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Medina-González R, Zaragoza JJ, Hernández-Barajas EM, Correa-de Leon J, Claure-Del Granado R, Vazquez-Rangel A, Pineda-Segura LM, Franco-Garcia MK, Chávez-Alonso G, Gómez-Fregoso JA, Rodríguez-García FG, Navarro-Blackaller G, Alcantar-Vallin L, Gallardo-González AM, Abundis-Mora GJ, García-García G, Chávez-Iñiguez JS. Decrease in platelet count in patients with AKI and its association with major adverse kidney events. Ren Fail 2024; 46:2359643. [PMID: 38869010 DOI: 10.1080/0886022x.2024.2359643] [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: 12/28/2023] [Accepted: 05/20/2024] [Indexed: 06/14/2024] Open
Abstract
INTRODUCTION A reduction in platelet count in critically ill patients is a marker of severity of the clinical condition. However, whether this association holds true in acute kidney injury (AKI) is unknown. We analyzed the association between platelet reduction in patients with AKI and major adverse kidney events (MAKE). METHODS In this retrospective cohort, we included AKI patients at the Hospital Civil of Guadalajara, in Jalisco, Mexico. Patients were divided according to whether their platelet count fell >21% during the first 10 days. Our objectives were to analyze the associations between a platelet reduction >21% and MAKE at 10 days (MAKE10) or at 30-90 days (MAKE30-90) and death. RESULTS From 2017 to 2023, 400 AKI patients were included, 134 of whom had a > 21% reduction in platelet count. The mean age was 54 years, 60% were male, and 44% had sepsis. The mean baseline platelet count was 194 x 103 cells/µL, and 65% of the KDIGO3 patients met these criteria. Those who underwent hemodialysis (HD) had lower platelet counts. After multiple adjustments, a platelet reduction >21% was associated with MAKE10 (OR 4.2, CI 2.1-8.5) but not with MAKE30-90. The mortality risk increased 3-fold (OR 2.9, CI 1.1-7.7, p = 0.02) with a greater decrease in the platelets (<90 x 103 cells/µL). As the platelets decreased, the incidence of MAKE was more likely to increase. These associations lost significance when accounting for starting HD. CONCLUSION In our retrospective cohort of patients with AKI, a > 21% reduction in platelet count was associated with MAKE. Our results are useful for generating hypotheses and motivating us to continue studying this association with a more robust design.
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Affiliation(s)
- Ramón Medina-González
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | | | - Eduardo M Hernández-Barajas
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
| | - Juarez Correa-de Leon
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
| | - Rolando Claure-Del Granado
- Division of Nephrology, Hospital Obrero No 2 - CNS. IIBISMED, Facultad de Medicina, Universidad Mayor de San Simon, Cochabamba, Bolivia
| | - Armando Vazquez-Rangel
- Department of Nephrology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | | | | | - Gael Chávez-Alonso
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
| | - Juan A Gómez-Fregoso
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | | | - Guillermo Navarro-Blackaller
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
| | - Luz Alcantar-Vallin
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
| | - Alejandro Martínez Gallardo-González
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
| | - Gabriela J Abundis-Mora
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | | | - Jonathan S Chávez-Iñiguez
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Jalisco, Mexico
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Beheshtizadeh N, Mohammadzadeh M, Mostafavi M, Seraji AA, Esmaeili Ranjbar F, Tabatabaei SZ, Ghafelehbashi R, Afzali M, Lolasi F. Improving hemocompatibility in tissue-engineered products employing heparin-loaded nanoplatforms. Pharmacol Res 2024; 206:107260. [PMID: 38906204 DOI: 10.1016/j.phrs.2024.107260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/21/2024] [Accepted: 06/10/2024] [Indexed: 06/23/2024]
Abstract
The enhancement of hemocompatibility through the use of nanoplatforms loaded with heparin represents a highly desirable characteristic in the context of emerging tissue engineering applications. The significance of employing heparin in biological processes is unquestionable, owing to its ability to interact with a diverse range of proteins. It plays a crucial role in numerous biological processes by engaging in interactions with diverse proteins and hydrogels. This review provides a summary of recent endeavors focused on augmenting the hemocompatibility of tissue engineering methods through the utilization of nanoplatforms loaded with heparin. This study also provides a comprehensive review of the various applications of heparin-loaded nanofibers and nanoparticles, as well as the techniques employed for encapsulating heparin within these nanoplatforms. The biological and physical effects resulting from the encapsulation of heparin in nanoplatforms are examined. The potential applications of heparin-based materials in tissue engineering are also discussed, along with future perspectives in this field.
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Affiliation(s)
- Nima Beheshtizadeh
- Department of Tissue Engineering, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran; Regenerative Medicine group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran.
| | - Mahsa Mohammadzadeh
- Department of Materials Engineering, Isfahan University of Technology, Isfahan 84156-83111, Iran; Regenerative Medicine group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Mehrnaz Mostafavi
- Faculty of Allied Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Abbas Seraji
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Canada; Department of Polymer Engineering and Color Technology, Amirkabir University of Technology, Tehran, Iran
| | - Faezeh Esmaeili Ranjbar
- Molecular Medicine Research Center, Research Institute of Basic Medical Sciences, Rafsanjan University of Medical Sciences, Rafsanjan, Iran; Regenerative Medicine group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Seyedeh Zoha Tabatabaei
- Cardiogenetic Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Robabehbeygom Ghafelehbashi
- Dental Materials Research Center, Dental Research Institute, School of Dentistry, Isfahan University of Medical Sciences, Isfahan 81746-73461, Iran; Department of Materials and Textile Engineering, College of Engineering, Razi University, Kermanshah, Iran; Regenerative Medicine group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Maede Afzali
- Department of Tissue Engineering, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran; Regenerative Medicine group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Farshad Lolasi
- Department of pharmaceutical biotechnology, Faculty of Pharmacy And Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran; Regenerative Medicine group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
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3
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Song D, Jin Y, Zhang Y, Zhou Z. Heparin-induced thrombocytopenia in extracorporeal membrane oxygenation-supported patients: a systematic review and meta-analysis. Thromb J 2024; 22:55. [PMID: 38937784 PMCID: PMC11212165 DOI: 10.1186/s12959-024-00624-5] [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: 02/06/2024] [Accepted: 06/17/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND In recent years, extracorporeal membrane oxygenation (ECMO) has been increasingly used in critically ill patients with respiratory or cardiac failure. Heparin is usually used as anticoagulation therapy during ECMO support. However, heparin-induced thrombocytopenia (HIT) in ECMO-supported patients, which results in considerable morbidity and mortality, has not yet been well described. This meta-analysis and systematic review aimed to thoroughly report the incidence of HIT on ECMO, as well as the characteristics and outcomes of HIT patients. METHODS We searched the PubMed, Embase, Cochrane Library, and Scopus databases for studies investigating HIT in adult patients supported by ECMO. All studies conforming to the inclusion criteria were screened from 1975 to August 2023. Nineteen studies from a total of 1,625 abstracts were selected. The primary outcomes were the incidence of HIT and suspected HIT. RESULTS The pooled incidence of HIT in ECMO-supported patients was 4.2% (95% CI: 2.7-5.6; 18 studies). A total of 15.9% (95% CI: 9.0-22.8; 12 studies) of patients on ECMO were suspected of having HIT. Enzyme-linked immunosorbent assay (ELISA) is the most commonly used immunoassay. The median optical density (OD) of the ELISA in HIT-confirmed patients ranged from 1.08 to 2.10. In most studies, the serotonin release assay (SRA) was performed as a HIT-confirming test. According to the subgroup analysis, the pooled incidence of HIT in ECMO patients was 2.7% in studies whose diagnostic mode was functional assays, which is significantly lower than the incidence in studies in which the patients were diagnosed by immunoassay (14.5%). Argatroban was most commonly used as an alternative anticoagulation agent after the withdrawal of heparin. Among confirmed HIT patients, 45.5% (95% CI: 28.8-62.6) experienced thrombotic events, while 50.1% (95% CI: 24.9-75.4) experienced bleeding events. Overall, 46.6% (95% CI: 30.4-63.1) of patients on ECMO with HIT died. CONCLUSION According to our study, the pooled incidence of HIT in ECMO-supported patients is 4.2%, and it contributes to adverse outcomes. Inappropriate diagnostic methods can easily lead to misdiagnosis of HIT. Further research and development of diagnostic algorithms and laboratory assays are warranted.
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Affiliation(s)
- Danyu Song
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Fuwai Hospital, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Yu Jin
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Yang Zhang
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Fuwai Hospital, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
| | - Zhou Zhou
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Fuwai Hospital, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
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High-frequency Contactless Sensor for the Detection of Heparin-Induced Thrombocytopenia Antibodies via Platelet Aggregation. Int J Mol Sci 2022; 23:ijms232214395. [PMID: 36430873 PMCID: PMC9694871 DOI: 10.3390/ijms232214395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 11/22/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT), a severe autoimmune disorder, occurs in patients undergoing heparin therapy. The presence of platelet-activating antibodies against platelet factor 4/Heparin in the blood confirms patients suffering from HIT. The most widely used methods for HIT diagnosis are immunoassays but the results only suit to rule out HIT as the assays provide only around 50% specificity. To confirm HIT, samples with positive results in immunoassays are retested in functional assays (>98% specificity) that track platelet-activating antibodies via platelet aggregation. However, the protocols in functional assays are either time-consuming (due to the requirement of the detection of serotonin release) or require highly trained staff for the visualization of platelets. Here, we applied a cheap and easy-to-use contactless sensor, which employs high-frequency microwaves to detect the changes in the resonant frequency caused by platelet aggregation/activation. Analysis of change in conductivity and permittivity allowed us to distinguish between HIT-like (KKO) and non-HIT-like (RTO) antibodies. KKO caused a stronger reduction of conductivity of platelet samples than RTO. Our results imply that the high-frequency contactless sensor can be a promising approach for the development of a better and easier method for the detection of HIT.
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5
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Heparin-induced thrombocytopenia post-cardiovascular interventional therapy: a case report. BMC Cardiovasc Disord 2022; 22:351. [PMID: 35922765 PMCID: PMC9351125 DOI: 10.1186/s12872-022-02796-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 07/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background Heparin-induced thrombocytopenia (HIT) is an antibody-mediated adverse drug reaction characterized by thrombocytopenia and thromboembolism. Herein, we present a case of HIT with subcutaneous hemorrhage after cardiovascular interventional therapy. Case presentation A 74-year-old man was admitted to the hospital for elective atrial fibrillation (AF) catheter ablation and left atrial appendage closure because of intermittent dizziness and palpitations. At presentation, the routine laboratory test results showed no abnormalities. He received subcutaneous enoxaparin for stroke prevention and unfractionated heparin for intraprocedural anticoagulation during coronary angiography and the AF procedure. On the second day after the AF procedure, the patient developed profound thrombocytopenia, moderate anemia, and mild subcutaneous hematoma. Blood tests and imaging examinations excluded acute hemolysis and other active bleeding. A 4Ts score of 5 and markedly positive platelet factor 4 IgG antibody established the diagnosis of HIT. Due to progressive subcutaneous hemorrhage in the thighs that could not be suppressed by pressure dressing, the patient received platelet transfusion and rivaroxaban for anticoagulation. The following days, the patient remained clinically stable from the hemorrhage, and his platelet count recovered. No thrombotic events occurred during hospitalization or follow-up. Conclusion This case emphasizes the significance of suspecting HIT in patients with unexplained rapid thrombocytopenia after frequent heparin exposure. Decision-making regarding alternative anticoagulation and platelet transfusion in HIT with hemorrhage must be based on unique patient characteristics.
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6
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Elrashdy F, Tambuwala MM, Hassan SS, Adadi P, Seyran M, Abd El-Aziz TM, Rezaei N, Lal A, Aljabali AAA, Kandimalla R, Bazan NG, Azad GK, Sherchan SP, Choudhury PP, Serrano-Aroca Á, Takayama K, Chauhan G, Pizzol D, Barh D, Panda PK, Mishra YK, Palù G, Lundstrom K, Redwan EM, Uversky VN. Autoimmunity roots of the thrombotic events after COVID-19 vaccination. Autoimmun Rev 2021; 20:102941. [PMID: 34508917 PMCID: PMC8426137 DOI: 10.1016/j.autrev.2021.102941] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 06/06/2021] [Indexed: 02/03/2023]
Abstract
Although vaccination represents the most promising way to stop or contain the coronavirus disease 2019 (COVID-19) pandemic and safety and effectiveness of available vaccines were proven, a small number of individuals who received anti-SARS-CoV-2 vaccines developed a prothrombotic syndrome. Vaccine-induced immune thrombotic thrombocytopenia (VITT) can be triggered by the adenoviral vector-based vaccine, whereas lipid nanoparticle-mRNA-based vaccines can induce rare cases of deep vein thrombosis (DVT). Although the main pathogenic mechanisms behind this rare phenomenon have not yet been identified, both host and vaccine factors might be involved, with pathology at least in part being related to the vaccine-triggered autoimmune reaction. In this review, we are considering some aspects related to pathogenesis, major risk factors, as well as peculiarities of diagnosis and treatment of this rare condition.
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Affiliation(s)
- Fatma Elrashdy
- Department of Endemic Medicine and Hepatogastroenterology, Kasr Alainy, Cairo University, Cairo, Egypt.
| | - Murtaza M Tambuwala
- School of Pharmacy and Pharmaceutical Sciences, Ulster University, Coleraine, BT52 1SA, Northern Ireland, United Kingdom.
| | - Sk Sarif Hassan
- Department of Mathematics, Pingla Thana Mahavidyalaya, Maligram, 722140 Paschim Medinipur, West Bengal, India
| | - Parise Adadi
- Department of Food Science, University of Otago, Dunedin, New Zealand
| | - Murat Seyran
- Doctoral Student in Natural and Technical Sciences (SPL 44), University of Vienna, Währinger Straße, A-1090 Vienna, Austria.
| | - Tarek Mohamed Abd El-Aziz
- Zoology Department, Faculty of Science, Minia University, El-Minia 61519, Egypt; Department of Cellular and Integrative Physiology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229-3900, USA.
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran; Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Stockholm, Sweden
| | - Amos Lal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, USA
| | - Alaa A A Aljabali
- Department of Pharmaceutics and Pharmaceutical Technology, Yarmouk University, Irbid 21163, P. O. BOX 566, Jordan.
| | - Ramesh Kandimalla
- Applied Biology, CSIR-Indian Institute of Chemical Technology, Uppal Road, Tarnaka, Hyderabad 500007, India; Department of Biochemistry, Kakatiya Medical College, Warangal, India
| | - Nicolas G Bazan
- Neuroscience Center of Excellence, School of Medicine, Louisiana State University Health New Orleans, New Orleans, Louisiana, 70112, USA.
| | | | - Samendra P Sherchan
- Department of Environmental Health Sciences, Tulane University, New Orleans, LA 70112, USA.
| | - Pabitra Pal Choudhury
- Applied Statistics Unit, Indian Statistical Institute, Kolkata, 700108, West Bengal, India
| | - Ángel Serrano-Aroca
- Biomaterials and Bioengineering Lab, Centro de Investigación Traslacional San Alberto Magno, Universidad Católica de Valencia San Vicente Mártir, c/Guillem de Castro 94, Valencia 46001, Spain.
| | - Kazuo Takayama
- Center for iPS Cell Research and Application (CiRA), Kyoto University, Kyoto 606-8507, Japan.
| | - Gaurav Chauhan
- School of Engineering and Sciences, Tecnológico de Monterrey, Av. Eugenio Garza Sada 2501 Sur, 64849 Monterrey, Nuevo León, Mexico.
| | - Damiano Pizzol
- Italian Agency for Development Cooperation -, Khartoum, Sudan Street 33, Al Amarat, Sudan
| | - Debmalya Barh
- Institute of Integrative Omics and Applied Biotechnology (IIOAB), Nonakuri, Purba Medinipur, WB-721172, India; and Departamento de Genética, Ecologia e Evolução, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte 31270-901, Brazil.
| | - Pritam Kumar Panda
- Condensed Matter Theory Group, Materials Theory Division, Department of Physics and Astronomy, Uppsala University, Box 516, SE-751 20 Uppsala, Sweden.
| | - Yogendra K Mishra
- University of Southern Denmark, Mads Clausen Institute, NanoSYD, Alsion 2, 6400 Sønderborg, Denmark.
| | - Giorgio Palù
- Department of Molecular Medicine, University of Padova, Italy.
| | | | - Elrashdy M Redwan
- Biological Science Department, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia.
| | - Vladimir N Uversky
- Department of Molecular Medicine, University of South Florida, Tampa, FL, United States.
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Hafeez MU, Ikram M, Shafiq Z, Sarfraz A, Sarfraz Z, Jaiswal V, Sarfraz M, Chérrez-Ojeda I. COVID-19 Vaccine-Associated Thrombosis With Thrombocytopenia Syndrome (TTS): A Systematic Review and Post Hoc Analysis. Clin Appl Thromb Hemost 2021; 27:10760296211048815. [PMID: 34698582 PMCID: PMC8552386 DOI: 10.1177/10760296211048815] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background A new clinical syndrome has been recognized following the COVID-19 vaccine,
termed thrombosis with thrombocytopenia syndrome (TTS). The following
systematic review focuses on extrapolating thrombotic risk factors, clinical
manifestations, and outcomes of patients diagnosed with TTS following the
COVID-19 vaccine. Methods We utilized the World Health Organization's criteria for a confirmed and
probable case of TTS following COVID-19 vaccination and conducted a
systematic review and posthoc analysis using the PRISMA 2020 statement. Data
analysis was conducted using SPSS V25 for factors associated with mortality,
including age, gender, anti-PF4/heparin antibodies, platelet nadir, D-dimer
peak, time to event diagnosis, arterial or venous thrombi. Results Of the 175 studies identified, a total of 25 studies with 69 patients were
included in this systematic review and post hoc analysis. Platelet nadir
(P < .001), arterial or venous thrombi
(χ2 = 41.911, P = .05), and chronic
medical conditions (χ2 = 25.507, P = .041)
were statistically associated with death. The ROC curve analysis yielded
D-dimer (AUC = .646) and platelet nadir (AUC = .604) as excellent models for
death prediction. Conclusion Adenoviral COVID-19 vaccines have been shown to trigger TTS, however, reports
of patients having received mRNA COVID-19 vaccines are also present.
Healthcare providers are recommended to maintain a high degree of suspicion
among individuals who have received the COVID-19 vaccine within the last 4
weeks.
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Affiliation(s)
| | - Maha Ikram
- 427002Shalamar Medical and Dental College, Lahore, Pakistan
| | | | | | | | | | - Muzna Sarfraz
- 66886King Edward Medical University, Lahore, Pakistan
| | - Ivan Chérrez-Ojeda
- 27890Universidad Espíritu Santo, Samborondón, Ecuador.,Respiralab Research Center, Guayaquil, Ecuador
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8
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See I, Su JR, Lale A, Woo EJ, Guh AY, Shimabukuro TT, Streiff MB, Rao AK, Wheeler AP, Beavers SF, Durbin AP, Edwards K, Miller E, Harrington TA, Mba-Jonas A, Nair N, Nguyen DT, Talaat KR, Urrutia VC, Walker SC, Creech CB, Clark TA, DeStefano F, Broder KR. US Case Reports of Cerebral Venous Sinus Thrombosis With Thrombocytopenia After Ad26.COV2.S Vaccination, March 2 to April 21, 2021. JAMA 2021; 325:2448-2456. [PMID: 33929487 PMCID: PMC8087975 DOI: 10.1001/jama.2021.7517] [Citation(s) in RCA: 402] [Impact Index Per Article: 134.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Cerebral venous sinus thrombosis (CVST) with thrombocytopenia, a rare and serious condition, has been described in Europe following receipt of the ChAdOx1 nCoV-19 vaccine (Oxford/AstraZeneca), which uses a chimpanzee adenoviral vector. A mechanism similar to autoimmune heparin-induced thrombocytopenia (HIT) has been proposed. In the US, the Ad26.COV2.S COVID-19 vaccine (Janssen/Johnson & Johnson), which uses a human adenoviral vector, received Emergency Use Authorization (EUA) on February 27, 2021. By April 12, 2021, approximately 7 million Ad26.COV2.S vaccine doses had been given in the US, and 6 cases of CVST with thrombocytopenia had been identified among the recipients, resulting in a temporary national pause in vaccination with this product on April 13, 2021. OBJECTIVE To describe reports of CVST with thrombocytopenia following Ad26.COV2.S vaccine receipt. DESIGN, SETTING, AND PARTICIPANTS Case series of 12 US patients with CVST and thrombocytopenia following use of Ad26.COV2.S vaccine under EUA reported to the Vaccine Adverse Event Reporting System (VAERS) from March 2 to April 21, 2021 (with follow-up reported through April 21, 2021). EXPOSURES Receipt of Ad26.COV2.S vaccine. MAIN OUTCOMES AND MEASURES Clinical course, imaging, laboratory tests, and outcomes after CVST diagnosis obtained from VAERS reports, medical record review, and discussion with clinicians. RESULTS Patients' ages ranged from 18 to younger than 60 years; all were White women, reported from 11 states. Seven patients had at least 1 CVST risk factor, including obesity (n = 6), hypothyroidism (n = 1), and oral contraceptive use (n = 1); none had documented prior heparin exposure. Time from Ad26.COV2.S vaccination to symptom onset ranged from 6 to 15 days. Eleven patients initially presented with headache; 1 patient initially presented with back pain and later developed headache. Of the 12 patients with CVST, 7 also had intracerebral hemorrhage; 8 had non-CVST thromboses. After diagnosis of CVST, 6 patients initially received heparin treatment. Platelet nadir ranged from 9 ×103/µL to 127 ×103/µL. All 11 patients tested for the heparin-platelet factor 4 HIT antibody by enzyme-linked immunosorbent assay (ELISA) screening had positive results. All patients were hospitalized (10 in an intensive care unit [ICU]). As of April 21, 2021, outcomes were death (n = 3), continued ICU care (n = 3), continued non-ICU hospitalization (n = 2), and discharged home (n = 4). CONCLUSIONS AND RELEVANCE The initial 12 US cases of CVST with thrombocytopenia after Ad26.COV2.S vaccination represent serious events. This case series may inform clinical guidance as Ad26.COV2.S vaccination resumes in the US as well as investigations into the potential relationship between Ad26.COV2.S vaccine and CVST with thrombocytopenia.
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Affiliation(s)
- Isaac See
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| | - John R. Su
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| | - Allison Lale
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| | - Emily Jane Woo
- Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, Maryland
| | - Alice Y. Guh
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| | - Tom T. Shimabukuro
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| | | | - Agam K. Rao
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| | | | - Suzanne F. Beavers
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| | | | | | - Elaine Miller
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| | | | - Adamma Mba-Jonas
- Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, Maryland
| | - Narayan Nair
- Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, Maryland
| | - Duong T. Nguyen
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| | | | | | | | | | - Thomas A. Clark
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| | - Frank DeStefano
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
| | - Karen R. Broder
- Centers for Disease Control and Prevention COVID-19 Response Team, Atlanta, Georgia
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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.
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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
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Guo Q, Lou Y, Liu L, Luo P. How Can I Manage Thrombocytopenia in Hemodialysis Patient? A Review. Ther Apher Dial 2019; 24:352-360. [PMID: 31661590 DOI: 10.1111/1744-9987.13448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/24/2019] [Accepted: 10/25/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Qiaoyan Guo
- Department of NephrologyJilin University Second Hospital Changchun China
| | - Yan Lou
- Department of NephrologyJilin University Second Hospital Changchun China
| | - Lihua Liu
- Department of NephrologyJilin University Second Hospital Changchun China
| | - Ping Luo
- Department of NephrologyJilin University Second Hospital Changchun China
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Nevzorova TA, Mordakhanova ER, Daminova AG, Ponomareva AA, Andrianova IA, Le Minh G, Rauova L, Litvinov RI, Weisel JW. Platelet factor 4-containing immune complexes induce platelet activation followed by calpain-dependent platelet death. Cell Death Discov 2019; 5:106. [PMID: 31263574 PMCID: PMC6591288 DOI: 10.1038/s41420-019-0188-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 05/29/2019] [Accepted: 06/05/2019] [Indexed: 01/23/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a complication of heparin therapy sometimes associated with thrombosis. The hallmark of HIT is antibodies to the heparin/platelet factor 4 (PF4) complex that cause thrombocytopenia and thrombosis through platelet activation. Despite the clinical importance, the molecular mechanisms and late consequences of immune platelet activation are not fully understood. Here, we studied immediate and delayed effects of the complexes formed by human PF4 and HIT-like monoclonal mouse anti-human-PF4/heparin IgG antibodies (named KKO) on isolated human platelets in vitro. Direct platelet-activating effect of the KKO/PF4 complexes was corroborated by the overexpression of phosphatidylserine (PS) and P-selectin on the platelet surface. The immune platelet activation was accompanied by a decrease of the mitochondrial transmembrane potential (ΔΨm), concurrent with a significant gradual reduction of the ATP content in platelets, indicating disruption of energy metabolism. A combination of PS expression and mitochondrial depolarization induced by the PF4-containing immune complexes observed in a substantial fraction of platelets was considered as a sign of ongoing platelet death, as opposed to a subpopulation of activated live platelets with PS on the plasma membrane but normal ΔΨm. Both activated and dying platelets treated with KKO/PF4 formed procoagulant extracellular microvesicles bearing PS on their surface. Scanning and transmission electron microscopy revealed dramatic morphological changes of KKO/PF4-treated platelets, including their fragmentation, another indicator of cell death. Most of the effects of KKO/PF4 were prevented by an anti-FcγRII monoclonal antibody IV.3. The adverse functional and structural changes in platelets induced by the KKO/PF4 complexes were associated with strong time-dependent activation of calpain, but only trace cleavage of caspase 3. The results indicate that the pathogenic PF4-containing HIT-like immune complexes induce direct prothrombotic platelet activation via FcγRIIA receptors followed by non-apoptotic calpain-dependent death of platelets, which can be an important mechanism of thrombocytopenia during HIT development.
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Affiliation(s)
- Tatiana A. Nevzorova
- Institute of Fundamental Medicine and Biology, Kazan Federal University, 18 Kremlyovskaya St., Kazan, Russian Federation 420008 Russia
| | - Elmira R. Mordakhanova
- Institute of Fundamental Medicine and Biology, Kazan Federal University, 18 Kremlyovskaya St., Kazan, Russian Federation 420008 Russia
| | - Amina G. Daminova
- Institute of Fundamental Medicine and Biology, Kazan Federal University, 18 Kremlyovskaya St., Kazan, Russian Federation 420008 Russia
- Kazan Institute of Biochemistry and Biophysics, FRC Kazan Scientific Center of RAS, 2/31 Lobachevsky str., Kazan, Russian Federation 420111 Russia
| | - Anastasia A. Ponomareva
- Institute of Fundamental Medicine and Biology, Kazan Federal University, 18 Kremlyovskaya St., Kazan, Russian Federation 420008 Russia
- Kazan Institute of Biochemistry and Biophysics, FRC Kazan Scientific Center of RAS, 2/31 Lobachevsky str., Kazan, Russian Federation 420111 Russia
| | - Izabella A. Andrianova
- Institute of Fundamental Medicine and Biology, Kazan Federal University, 18 Kremlyovskaya St., Kazan, Russian Federation 420008 Russia
| | - Giang Le Minh
- Institute of Fundamental Medicine and Biology, Kazan Federal University, 18 Kremlyovskaya St., Kazan, Russian Federation 420008 Russia
| | - Lubica Rauova
- Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104 USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Blvd, Philadelphia, PA 19104 USA
| | - Rustem I. Litvinov
- Institute of Fundamental Medicine and Biology, Kazan Federal University, 18 Kremlyovskaya St., Kazan, Russian Federation 420008 Russia
- Department of Cell and Developmental Biology, University of Pennsylvania Perelman School of Medicine, 421 Curie Boulevard, Philadelphia, PA 19104 USA
| | - John W. Weisel
- Institute of Fundamental Medicine and Biology, Kazan Federal University, 18 Kremlyovskaya St., Kazan, Russian Federation 420008 Russia
- Department of Cell and Developmental Biology, University of Pennsylvania Perelman School of Medicine, 421 Curie Boulevard, Philadelphia, PA 19104 USA
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Onwuemene OA, Zantek ND, Rollins-Raval MA, Raval JS, Kiss JE, Ipe TS, Kuchibhatla M, Pagano MB, Wong ECC. Therapeutic plasma exchange for management of heparin-induced thrombocytopenia: Results of an international practice survey. J Clin Apher 2019; 34:545-554. [PMID: 31116461 DOI: 10.1002/jca.21709] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 04/23/2019] [Accepted: 05/06/2019] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Anti-heparin/platelet factor 4 antibody immune complexes resulting from heparin-induced thrombocytopenia (HIT) are removed by therapeutic plasma exchange (TPE). We sought to define TPE in HIT practice patterns using an international survey. METHODS A 31-item online survey was disseminated through the American Society for Apheresis. After institutional duplicate responses were eliminated, a descriptive analysis was performed. RESULTS The survey was completed by 94 respondents from 78 institutions in 18 countries. Twenty-nine institutions (37%) used TPE for HIT (YES cohort) and 49 (63%) did not (NO cohort). Most NO respondents (65%) cited "no requests received" as the most common reason for not using TPE. Of the 29 YES respondents, 10 (34%) gave incomplete information and were excluded from the final analysis, leaving 19 responses. Of these, 18 (95%) treated ≤10 HIT patients over a 2-year period. The most common indications were cardiovascular surgery (CS; 63%) and HIT-associated thrombosis (HT; 26%). The typical plasma volume processed was 1.0 (63% CS and 58% HT). For CS, the typical replacement fluid was plasma (42%) and for HT, it was determined on an individual basis (32%). For CS, patients were treated with a set number of TPE procedures (37%) or laboratory/clinical response (37%). For HT, the number of TPE procedures typically depended on laboratory/clinical response (42%). CONCLUSION In a minority of responding institutions, TPE is most commonly used in HIT to prophylactically treat patients who will undergo heparin re-exposure during CS. Prospective studies are needed to more clearly define the role of TPE in HIT.
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Affiliation(s)
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | | | - Jay S Raval
- Department of Pathology, University of New Mexico, Albuquerque, New Mexico
| | - Joseph E Kiss
- Vitalant Northeast Division Blood Services, and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tina S Ipe
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Monica B Pagano
- Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Edward C C Wong
- Department of Coagulation, Quest Diagnostics, Nichols Institute, Chantilly, Virginia.,Department of Pediatrics and Pathology, George Washington School of Medicine and Health Sciences, Washington, District of Columbia
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Skaadel H, Bruserud Ø. Thrombotic complications in adult patients with severe single coagulation factor or platelet defects – an overview. Expert Rev Hematol 2019; 12:119-128. [DOI: 10.1080/17474086.2019.1570126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Hanne Skaadel
- Section for Hematology, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Øystein Bruserud
- Section for Hematology, Department of Clinical Science, University of Bergen, Bergen, Norway
- Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Abstract
There are numerous congenital and acquired causes of thrombocytopenia. Thrombocytopenia could be a result of decreased bone marrow production, increased consumption, increased destruction, splenic sequestration or a combination of these causes. In this review, we have focused on some of the serious acquired causes of thrombocytopenia. There have been some significant advances in our understanding of the pathophysiology, diagnostic testing, and treatment of immune thrombocytopenia, heparin-induced thrombocytopenia, thrombotic thrombocytopenic purpura, and atypical hemolytic uremic syndrome over the past five years. These advances have resulted in a significant decrease in mortality and morbidity of patients with these disorders. Despite these advances, we are still faced with numerous unanswered questions in the pathophysiology and management of these complex thrombocytopenic disorders.
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Affiliation(s)
- Srikanth Nagalla
- Division of Hematology/Oncology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Ravindra Sarode
- Division of Transfusion Medicine and Hemostasis, Department of Pathology, UT Southwestern Medical Center, Dallas, TX, USA
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Ibrahim IF, Rice L. Intravenous Immunoglobulin for Heparin-Induced Thrombocytopenia. Chest 2017; 152:906-907. [DOI: 10.1016/j.chest.2017.05.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 05/01/2017] [Accepted: 05/04/2017] [Indexed: 11/29/2022] Open
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Anti-Platelet Factor 4/Heparin Antibody Formation Occurs Endogenously and at Unexpected High Frequency in Polycythemia Vera. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9876819. [PMID: 28698883 PMCID: PMC5494054 DOI: 10.1155/2017/9876819] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/05/2017] [Accepted: 04/24/2017] [Indexed: 12/23/2022]
Abstract
Background Myeloproliferative neoplasms (MPN) encounter thromboses due to multiple known risk factors. Heparin-induced thrombocytopenia (HIT) is a thrombotic syndrome mediated by anti-platelet factor 4 (PF4)/heparin antibodies with undetermined significance for thrombosis in MPN. We hypothesized that anti-PF4/heparin Ab might occur in MPN and promote thrombosis. Methods Anti-PF4/heparin antibodies were analyzed in 127 MPN patients including 76 PV and 51 ET. Screening, validation testing, and isotype testing of anti-PF4/heparin Ab were correlated with disease characteristics. Results Anti-PF4/heparin antibodies were detected in 21% of PV and 12% of ET versus 0.3–3% in heparin-exposed patients. Validation testing confirmed anti-PF4/heparin immunoglobulins in 15% of PV and 10% of ET. Isotype testing detected 9.2% IgG and 5.3% IgM in PV and exclusively IgM in ET. IgG-positive PV patients encountered thromboses in 57.1% suggesting anti-PF4/heparin IgG may contribute to higher risk for thrombosis in MPN. Overall, 45% of PV patients experienced thromboses with 11.8% positive for anti-PF4/heparin IgG versus 7.1% in PV without thrombosis. Conclusion Anti-PF4/heparin antibodies occur endogenously and more frequently in MPN than upon heparin exposure. Thrombotic risk increases in anti-PF4/heparin IgG-positive PV reflecting potential implications and calling for larger, confirmatory cohorts. Anti-PF4/heparin IgG should be assessed upon thrombosis in PV to facilitate avoidance of heparin in anti-PF4/heparin IgG-positive PV.
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