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Yu Y, Song Y, Zhao Y, Wang N, Wei B, Linhardt RJ, Dordick JS, Zhang F, Wang H. Quality control, safety assessment and preparation approaches of low molecular weight heparin. Carbohydr Polym 2024; 339:122216. [PMID: 38823901 DOI: 10.1016/j.carbpol.2024.122216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/26/2024] [Accepted: 04/27/2024] [Indexed: 06/03/2024]
Abstract
Low Molecular Weight Heparins (LMWHs) are well-established for use in the prevention and treatment of thrombotic diseases, and as a substitute for unfractionated heparin (UFH) due to their predictable pharmacokinetics and subcutaneous bioavailability. LMWHs are produced by various depolymerization methods from UFH, resulting in heterogeneous compounds with similar biochemical and pharmacological properties. However, the delicate supply chain of UFH and potential contamination from animal sources require new manufacturing approaches for LMWHs. Various LMWH preparation methods are emerging, such as chemical synthesis, enzymatic or chemical depolymerization and chemoenzymatic synthesis. To establish the sameness of active ingredients in both innovator and generic LMWH products, the Food and Drug Administration has implemented a stringent scientific method of equivalence based on physicochemical properties, heparin source material and depolymerization techniques, disaccharide composition and oligosaccharide mapping, biological and biochemical properties, and in vivo pharmacodynamic profiles. In this review, we discuss currently available LMWHs, potential manufacturing methods, and recent progress for manufacturing quality control of these LMWHs.
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Affiliation(s)
- Yanlei Yu
- College of Pharmaceutical Science & Collaborative Innovation Center for Yangtze River Delta Region Green Pharmaceuticals, Key Laboratory of Marine Fishery Resources Exploitment & Utilization of Zhejiang Province, Zhejiang University of Technology, 310014 Hangzhou, China
| | - Yue Song
- College of Pharmaceutical Science & Collaborative Innovation Center for Yangtze River Delta Region Green Pharmaceuticals, Key Laboratory of Marine Fishery Resources Exploitment & Utilization of Zhejiang Province, Zhejiang University of Technology, 310014 Hangzhou, China
| | - Yunjie Zhao
- College of Pharmaceutical Science & Collaborative Innovation Center for Yangtze River Delta Region Green Pharmaceuticals, Key Laboratory of Marine Fishery Resources Exploitment & Utilization of Zhejiang Province, Zhejiang University of Technology, 310014 Hangzhou, China
| | - Ningning Wang
- College of Pharmaceutical Science & Collaborative Innovation Center for Yangtze River Delta Region Green Pharmaceuticals, Key Laboratory of Marine Fishery Resources Exploitment & Utilization of Zhejiang Province, Zhejiang University of Technology, 310014 Hangzhou, China
| | - Bin Wei
- College of Pharmaceutical Science & Collaborative Innovation Center for Yangtze River Delta Region Green Pharmaceuticals, Key Laboratory of Marine Fishery Resources Exploitment & Utilization of Zhejiang Province, Zhejiang University of Technology, 310014 Hangzhou, China; Binjiang Cyberspace Security Institute of ZJUT, Hangzhou 310056, China
| | - Robert J Linhardt
- Department of Chemical and Biological Engineering, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, NY 12180, United States
| | - Jonathan S Dordick
- Department of Chemical and Biological Engineering, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, NY 12180, United States
| | - Fuming Zhang
- Department of Chemical and Biological Engineering, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, NY 12180, United States.
| | - Hong Wang
- College of Pharmaceutical Science & Collaborative Innovation Center for Yangtze River Delta Region Green Pharmaceuticals, Key Laboratory of Marine Fishery Resources Exploitment & Utilization of Zhejiang Province, Zhejiang University of Technology, 310014 Hangzhou, China; Binjiang Cyberspace Security Institute of ZJUT, Hangzhou 310056, China.
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2
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Salman G, Johannesmeyer HJ, Breen MJ. Key considerations in navigating ticagrelor's reported effect on heparin-induced thrombocytopenia functional assays in a landscape of limited data. Am J Health Syst Pharm 2024; 81:488-493. [PMID: 38365265 DOI: 10.1093/ajhp/zxae040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Indexed: 02/18/2024] Open
Abstract
PURPOSE This article discusses key considerations regarding ticagrelor's reported effect on heparin-induced thrombocytopenia functional assays, such as literature gaps and possible management strategies. SUMMARY Limited data indicate that ticagrelor may induce false-negative results in functional assays used in the diagnosis of heparin-induced thrombocytopenia. False-negative functional assays for heparin-induced thrombocytopenia could have catastrophic consequences. The manufacturer labeling of ticagrelor now includes a warning for this potential drug-laboratory interaction. This article suggests areas that would benefit from further research and strategies in navigating this possible interaction. CONCLUSION Clinicians should exercise caution when evaluating functional assays for heparin-induced thrombocytopenia in patients receiving ticagrelor. This article offers suggestions for future areas of research and potential management strategies.
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Affiliation(s)
- Genene Salman
- Department of Pharmacy Practice, College of Pharmacy, Marshall B. Ketchum University, Fullerton, CA, USA
| | - Herman J Johannesmeyer
- Department of Clinical Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University of California, Irvine, Irvine, CA, USA
| | - Martin J Breen
- Department of Pharmacy Services, St. Jude Medical Center, Fullerton, CA, USA
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Pathak A, Verma N, Tripathi S, Mishra A, Poluri KM. Nanosensor based approaches for quantitative detection of heparin. Talanta 2024; 273:125873. [PMID: 38460425 DOI: 10.1016/j.talanta.2024.125873] [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: 12/25/2023] [Revised: 02/23/2024] [Accepted: 03/03/2024] [Indexed: 03/11/2024]
Abstract
Heparin, being a widely employed anticoagulant in numerus clinical complications, requires strict quantification and qualitative screening to ensure the safety of patients from potential threat of thrombocytopenia. However, the intricacy of heparin's chemical structures and low abundance hinders the precise monitoring of its level and quality in clinical settings. Conventional laboratory assays have limitations in sensitivity and specificity, necessitating the development of innovative approaches. In this context, nanosensors emerged as a promising solution due to enhanced sensitivity, selectivity, and ability to detect heparin even at low concentrations. This review delves into a range of sensing approaches including colorimetric, fluorometric, surface-enhanced Raman spectroscopy, and electrochemical techniques using different types of nanomaterials, thus providing insights of its principles, capabilities, and limitations. Moreover, integration of smart-phone with nanosensors for point of care diagnostics has also been explored. Additionally, recent advances in nanopore technologies, artificial intelligence (AI) and machine learning (ML) have been discussed offering specificity against contaminants present in heparin to ensure its quality. By consolidating current knowledge and highlighting the potential of nanosensors, this review aims to contribute to the advancement of efficient, reliable, and economical heparin detection methods providing improved patient care.
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Affiliation(s)
- Aakanksha Pathak
- Centre for Nanotechnology, Indian Institute of Technology Roorkee, Roorkee, 247667, Uttarakhand, India
| | - Nishchay Verma
- Centre for Nanotechnology, Indian Institute of Technology Roorkee, Roorkee, 247667, Uttarakhand, India
| | - Shweta Tripathi
- Department of Biosciences and Bioengineering, Indian Institute of Technology Roorkee, Roorkee, 247667, Uttarakhand, India
| | - Amit Mishra
- Cellular and Molecular Neurobiology Unit, Indian Institute of Technology Jodhpur, Jodhpur, 342011, Rajasthan, India
| | - Krishna Mohan Poluri
- Centre for Nanotechnology, Indian Institute of Technology Roorkee, Roorkee, 247667, Uttarakhand, India; Department of Biosciences and Bioengineering, Indian Institute of Technology Roorkee, Roorkee, 247667, Uttarakhand, India.
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Arachchillage DJ, Kitchen S. Pleiotropic Effects of Heparin and its Monitoring in the Clinical Practice. Semin Thromb Hemost 2024. [PMID: 38810964 DOI: 10.1055/s-0044-1786990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Unfractionated heparin (UFH) was uncovered in 1916, has been used as an anticoagulant since 1935, and has been listed in the World Health Organization's Model List of Essential Medicines. Despite the availability of many other anticoagulants, the use of heparin (either low molecular weight heparin [LMWH] or UFH) is still substantial. Heparin has pleotropic effects including anticoagulant and several nonanticoagulant properties such as antiproliferative, anti-inflammatory activity, and anticomplement effects. Although UFH has been widely replaced by LMWH, UFH is still the preferred anticoagulant of choice for patients undergoing cardiopulmonary bypass surgery, extracorporeal membrane oxygenation, and patients with high-risk mechanical cardiac valves requiring temporary bridging with a parenteral anticoagulant. UFH is a highly negatively charged molecule and binds many positively charged molecules, hence has unpredictable pharmacokinetics, and variable anticoagulant effect on an individual patient basis. Therefore, anticoagulant effects of UFH may not be proportional to the dose of UFH given to any individual patient. In this review, we discuss the anticoagulant and nonanticoagulant activities of UFH, differences between UFH and LMWH, when to use UFH, different methods of monitoring the anticoagulant effects of UFH (including activated partial thromboplastin time, heparin anti-Xa activity level, and activated clotting time), while discussing pros and cons related to each method and comparison of clinical outcomes in patients treated with UFH monitored with different methods based on available evidence.
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Affiliation(s)
- Deepa J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Department of Haematology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Steve Kitchen
- Department of Coagulation, Royal Hallamshire Hospital, Sheffield, United Kingdom
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Wan T, Garland SJ, Drury CT, Lambert J, Yoon J, Chan M. Anticoagulation stewardship: Improving adherence to clinical guidelines and reducing overuse of venous thromboembolism prophylaxis in hospitalized medical patients. Thromb Res 2024; 239:109036. [PMID: 38776611 DOI: 10.1016/j.thromres.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 05/02/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024]
Abstract
Adherence to guideline recommendations for venous thromboembolism prophylaxis (VTE) in hospitalized medical patients is suboptimal despite national policies and institutional interventions. The aim of this quality improvement project was to improve adherence to guidelines and decrease the overuse of VTE prophylaxis in order to reduce the institutional cost for heparins. A multidisciplinary anticoagulation stewardship program (ACSP) using the audit and feedback strategy was implemented on the medicine inpatient units at a teaching hospital in Canada. The primary outcome measure was a comparison, pre and post introduction of the ACSP, of the costs per 6-month period for prophylactic dose enoxaparin and unfractionated heparin on the medicine units. The balancing measures were the 90-day VTE rate and major bleeding rate during the hospitalization. Six months after the implementation of the ACSP, the cost was decreased by >50 % without any observed negative impact on patient safety. This study demonstrates the potential for anticoagulation stewardship programs to optimize the use of VTE prophylaxis and reduce the associated costs and risks.
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Affiliation(s)
- Tony Wan
- Division of General Internal Medicine, Department of Medicine, University of British Columbia, Canada.
| | - Stephanie J Garland
- Department of Pharmacy, St. Paul's Hospital, Vancouver, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Canada
| | - Chipman Taylor Drury
- Division of General Internal Medicine, Department of Medicine, University of British Columbia, Canada
| | - Justin Lambert
- General Internal Medicine Fellowship Program, Department of Medicine, University of British Columbia, Canada
| | - Joshua Yoon
- Doctors of Medicine Undergraduate Program, Department of Medicine, University of British Columbia, Canada
| | - Melissa Chan
- Doctors of Medicine Undergraduate Program, Department of Medicine, University of British Columbia, Canada
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Darok M, Daly A, Walter V, Krawiec C. Association of medical comorbidities in obese subjects diagnosed with heparin-induced thrombocytopenia. SAGE Open Med 2024; 12:20503121241247471. [PMID: 38711468 PMCID: PMC11072068 DOI: 10.1177/20503121241247471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/28/2024] [Indexed: 05/08/2024] Open
Abstract
Objectives Heparin-induced thrombocytopenia can occur in obese subjects. The medical comorbidities associated with obesity may contribute to the pathogenesis of this disease. It is unknown, however, which specific medical comorbidities and if higher odds of thrombosis are present in obese heparin-induced thrombocytopenia patients. We sought to determine whether obese heparin-induced thrombocytopenia subjects had higher odds of both comorbidities and thrombosis, hypothesizing that this patient population would have higher odds of both these conditions. Methods This was a multi-center retrospective study utilizing TriNetX©, an electronic health record database, in subjects aged 18-99 years diagnosed with heparin-induced thrombocytopenia. The cohort was divided into two groups (1) non-obese (body mass index < 30 kg/m2) and (2) obese (body mass index ⩾ 30 kg/m2). We evaluated patient characteristics, diagnostic, laboratory, medication, and procedure codes. Results A total of 1583 subjects (696 (44.0%) non-obese and 887 (56.0%) obese) were included. Obese subjects had higher odds of diabetes with complications (OR = 1.73, 95% CI = 1.35-2.22, p < 0.001) and without complications (OR = 1.81, 95% CI = 1.47-2.22, p < 0.001). This association was still present after correcting for demographic and clinical factors. There were no increased odds of thrombosis observed in the obesity group. Conclusions Our study found that obese heparin-induced thrombocytopenia subjects had higher odds of having a diabetes mellitus comorbidity, but did not have higher odds of thrombosis. Given obesity is considered a hypercoagulable state, further study may be needed to understand why obese subjects diagnosed with heparin-induced thrombocytopenia do not have higher rates of thrombosis.
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Affiliation(s)
- Matthew Darok
- Pediatrics, Department of Pediatrics, Penn State Hershey Children’s Hospital, Hershey, PA, USA
| | - Alexander Daly
- Hospital Pediatrics, Department of Pediatrics, Penn State Hershey Children’s Hospital, Hershey, PA, USA
| | - Vonn Walter
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Conrad Krawiec
- Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Hershey Children’s Hospital, Hershey, PA, USA
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Arachchillage DJ, Rajakaruna I, Makris M, Laffan M. Heparin-induced Thrombocytopenia with Thrombosis in COVID-19 versus Vaccine-induced Immune Thrombocytopenia and Thrombosis in the United Kingdom. Semin Thromb Hemost 2024. [PMID: 38593858 DOI: 10.1055/s-0044-1785484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Affiliation(s)
- Deepa J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Department of Haematology, Imperial College, Healthcare NHS Trust, London, United Kingdom
| | - Indika Rajakaruna
- Department of Computer Science, University of East London, London, United Kingdom
| | - Mike Makris
- School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Mike Laffan
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Department of Haematology, Imperial College, Healthcare NHS Trust, London, United Kingdom
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8
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Bösch J, Bachler M, Fries D. Thrombosis prophylaxis following trauma. Curr Opin Anaesthesiol 2024; 37:139-143. [PMID: 38390905 DOI: 10.1097/aco.0000000000001351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW This review explores the persistent occurrence of venous thromboembolic events (VTE) in major trauma patients despite standard thrombosis prophylaxis with low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH). It investigates the inadequacies of standard pharmacologic prophylaxis and proposes alternative approaches not covered in current trauma guidelines. RECENT FINDINGS Recent studies highlight the effectiveness of monitoring and adjusting subcutaneous LMWH doses based on anti-Xa levels for the purpose of reducing VTE in trauma patients. The need for dose adaptation arises due to factors like fluctuating organ function, varying antithrombin levels, interaction with plasma proteins, and altered bioavailability influenced by oedema or vasopressor use. Additionally, promising alternatives such as intravenous LMWH, UFH, and argatroban have shown success in intensive care settings. SUMMARY The standard dosing of subcutaneous LMWH is often insufficient for effective thrombosis prophylaxis in trauma patients. A more personalised approach, adjusting doses based on specific effect levels like anti-Xa or choosing an alternative mode of anticoagulation, could reduce the risk of insufficient prophylaxis and subsequent VTE.
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Affiliation(s)
- Johannes Bösch
- Department for Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Mirjam Bachler
- Institute for Sports Medicine, Alpine Medicine and Health Tourism, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Dietmar Fries
- Department for Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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Cross B, Turner RM, Zhang JE, Pirmohamed M. Being precise with anticoagulation to reduce adverse drug reactions: are we there yet? THE PHARMACOGENOMICS JOURNAL 2024; 24:7. [PMID: 38443337 PMCID: PMC10914631 DOI: 10.1038/s41397-024-00329-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 02/11/2024] [Accepted: 02/15/2024] [Indexed: 03/07/2024]
Abstract
Anticoagulants are potent therapeutics widely used in medical and surgical settings, and the amount spent on anticoagulation is rising. Although warfarin remains a widely prescribed oral anticoagulant, prescriptions of direct oral anticoagulants (DOACs) have increased rapidly. Heparin-based parenteral anticoagulants include both unfractionated and low molecular weight heparins (LMWHs). In clinical practice, anticoagulants are generally well tolerated, although interindividual variability in response is apparent. This variability in anticoagulant response can lead to serious incident thrombosis, haemorrhage and off-target adverse reactions such as heparin-induced thrombocytopaenia (HIT). This review seeks to highlight the genetic, environmental and clinical factors associated with variability in anticoagulant response, and review the current evidence base for tailoring the drug, dose, and/or monitoring decisions to identified patient subgroups to improve anticoagulant safety. Areas that would benefit from further research are also identified. Validated variants in VKORC1, CYP2C9 and CYP4F2 constitute biomarkers for differential warfarin response and genotype-informed warfarin dosing has been shown to reduce adverse clinical events. Polymorphisms in CES1 appear relevant to dabigatran exposure but the genetic studies focusing on clinical outcomes such as bleeding are sparse. The influence of body weight on LMWH response merits further attention, as does the relationship between anti-Xa levels and clinical outcomes. Ultimately, safe and effective anticoagulation requires both a deeper parsing of factors contributing to variable response, and further prospective studies to determine optimal therapeutic strategies in identified higher risk subgroups.
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Affiliation(s)
- Benjamin Cross
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Richard M Turner
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
- GSK, Stevenage, Hertfordshire, SG1 2NY, UK
| | - J Eunice Zhang
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK.
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Ramos L, Luxardo R, Crucelegui MS, Satera N, Jordán Ordoñez Y, Rosa-Diez G. Online hemodiafiltration without calcium replacement using citrate as an anticoagulant and dialysis fluid with 3.5 mEq of post dilutional calcium in patients with heparin-induced thrombocytopenia: Report of 2 cases. Nefrologia 2024; 44:299-301. [PMID: 38548583 DOI: 10.1016/j.nefroe.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024] Open
Affiliation(s)
- Lucas Ramos
- Nephrology, Hospital Italiano de Buenos Aires, Ciudad Autonóma de Buenos Aires, Buenos Aires, Argentina.
| | - Rosario Luxardo
- Nephrology, Hospital Italiano de Buenos Aires, Ciudad Autonóma de Buenos Aires, Buenos Aires, Argentina
| | - María Soledad Crucelegui
- Nephrology, Hospital Italiano de Buenos Aires, Ciudad Autonóma de Buenos Aires, Buenos Aires, Argentina
| | - Nadia Satera
- Nephrology, Hospital Italiano de Buenos Aires, Ciudad Autonóma de Buenos Aires, Buenos Aires, Argentina
| | - Yuliana Jordán Ordoñez
- Nephrology, Hospital Italiano de Buenos Aires, Ciudad Autonóma de Buenos Aires, Buenos Aires, Argentina
| | - Guillermo Rosa-Diez
- Nephrology, Hospital Italiano de Buenos Aires, Ciudad Autonóma de Buenos Aires, Buenos Aires, Argentina
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Watson C, Saaid H, Vedula V, Cardenas JC, Henke PK, Nicoud F, Xu XY, Hunt BJ, Manning KB. Venous Thromboembolism: Review of Clinical Challenges, Biology, Assessment, Treatment, and Modeling. Ann Biomed Eng 2024; 52:467-486. [PMID: 37914979 DOI: 10.1007/s10439-023-03390-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/17/2023] [Indexed: 11/03/2023]
Abstract
Venous thromboembolism (VTE) is a massive clinical challenge, annually affecting millions of patients globally. VTE is a particularly consequential pathology, as incidence is correlated with extremely common risk factors, and a large cohort of patients experience recurrent VTE after initial intervention. Altered hemodynamics, hypercoagulability, and damaged vascular tissue cause deep-vein thrombosis and pulmonary embolism, the two permutations of VTE. Venous valves have been identified as likely locations for initial blood clot formation, but the exact pathway by which thrombosis occurs in this environment is not entirely clear. Several risk factors are known to increase the likelihood of VTE, particularly those that increase inflammation and coagulability, increase venous resistance, and damage the endothelial lining. While these risk factors are useful as predictive tools, VTE diagnosis prior to presentation of outward symptoms is difficult, chiefly due to challenges in successfully imaging deep-vein thrombi. Clinically, VTE can be managed by anticoagulants or mechanical intervention. Recently, direct oral anticoagulants and catheter-directed thrombolysis have emerged as leading tools in resolution of venous thrombosis. While a satisfactory VTE model has yet to be developed, recent strides have been made in advancing in silico models of venous hemodynamics, hemorheology, fluid-structure interaction, and clot growth. These models are often guided by imaging-informed boundary conditions or inspired by benchtop animal models. These gaps in knowledge are critical targets to address necessary improvements in prediction and diagnosis, clinical management, and VTE experimental and computational models.
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Affiliation(s)
- Connor Watson
- Department of Biomedical Engineering, The Pennsylvania State University, 122 Chemical and Biomedical Engineering Building, University Park, PA, 16802-4400, USA
| | - Hicham Saaid
- Department of Biomedical Engineering, The Pennsylvania State University, 122 Chemical and Biomedical Engineering Building, University Park, PA, 16802-4400, USA
| | - Vijay Vedula
- Department of Mechanical Engineering, Fu Foundation School of Engineering and Applied Science, Columbia University, New York, NY, USA
| | - Jessica C Cardenas
- Department of Surgery and the Center for Translational Injury Research, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Franck Nicoud
- CNRS, IMAG, Université de Montpellier, Montpellier, France
- Institut Universitaire de France, Paris, France
| | - Xiao Yun Xu
- Department of Chemical Engineering, Imperial College London, London, UK
| | - Beverley J Hunt
- Department of Thrombosis and Haemostasis, King's College, London, UK
- Thrombosis and Haemophilia Centre, Guy's & St Thomas' NHS Trust, London, UK
| | - Keefe B Manning
- Department of Biomedical Engineering, The Pennsylvania State University, 122 Chemical and Biomedical Engineering Building, University Park, PA, 16802-4400, USA.
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA.
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Amin AN, Kartashov A, Ngai W, Steele K, Rosenthal N. Effectiveness, Safety, and Costs of Thromboprophylaxis with Enoxaparin or Unfractionated Heparin Among Medical Inpatients With Chronic Obstructive Pulmonary Disease or Heart Failure. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2024; 11:44-56. [PMID: 38390025 PMCID: PMC10883471 DOI: 10.36469/001c.92408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 01/12/2024] [Indexed: 02/24/2024]
Abstract
Background: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are risk factors for venous thromboembolism (VTE). Enoxaparin and unfractionated heparin (UFH) help prevent hospital-associated VTE, but few studies have compared them in COPD or HF. Objectives: To compare effectiveness, safety, and costs of enoxaparin vs UFH thromboprophylaxis in medical inpatients with COPD or HF. Methods: This retrospective cohort study included adults with COPD or HF from the Premier PINC AI Healthcare Database. Included patients received prophylactic-dose enoxaparin or UFH during a >6-day index hospitalization (the first visit/admission that met selection criteria during the study period) between January 1, 2010, and September 30, 2016. Multivariable regression models assessed independent associations between exposures and outcomes. Hospital costs were adjusted to 2017 US dollars. Patients were followed 90 days postdischarge (readmission period). Results: In the COPD cohort, 114 174 (69%) patients received enoxaparin and 51 011 (31%) received UFH. Among patients with COPD, enoxaparin recipients had 21%, 37%, and 10% lower odds of VTE, major bleeding, and in-hospital mortality during index admission, and 17% and 50% lower odds of major bleeding and heparin-induced thrombocytopenia (HIT) during the readmission period, compared with UFH recipients (all P <.006). In the HF cohort, 58 488 (58%) patients received enoxaparin and 42 726 (42%) received UFH. Enoxaparin recipients had 24% and 10% lower odds of major bleeding and in-hospital mortality during index admission, and 13%, 11%, and 51% lower odds of VTE, major bleeding, and HIT during readmission (all P <.04) compared with UFH recipients. Enoxaparin recipients also had significantly lower total hospital costs during index admission (mean reduction per patient: COPD, 1280 ; H F , 2677) and readmission (COPD, 379 ; H F , 1024). Among inpatients with COPD or HF, thromboprophylaxis with enoxaparin vs UFH was associated with significantly lower odds of bleeding, mortality, and HIT, and with lower hospital costs. Conclusions: This study suggests that thromboprophylaxis with enoxaparin is associated with better outcomes and lower costs among medical inpatients with COPD or HF based on real-world evidence. Our findings underscore the importance of assessing clinical outcomes and side effects when evaluating cost-effectiveness.
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Affiliation(s)
| | - Alex Kartashov
- PINC AI™ Applied Sciences, Premier Inc., Charlotte, North Carolina, USA
| | | | | | - Ning Rosenthal
- PINC AI™ Applied Sciences, Premier Inc., Charlotte, North Carolina, USA
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Hussein HR, Chang CY, Zheng Y, Yang CY, Li LH, Lee YT, Chen JY, Liang YC, Lin CJ, Chang YC, Geo HN, Noor SM, Kiew LV, Chen FR, Chang CC. Immune-stealth VP28-conjugated heparin nanoparticles for enhanced and reversible anticoagulation. NANOTECHNOLOGY 2024; 35:175102. [PMID: 38262054 DOI: 10.1088/1361-6528/ad21a2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/23/2024] [Indexed: 01/25/2024]
Abstract
Heparins are a family of sulfated linear negatively charged polysaccharides that have been widely used for their anticoagulant, antithrombotic, antitumor, anti-inflammatory, and antiviral properties. Additionally, it has been used for acute cerebral infarction relief as well as other pharmacological actions. However, heparin's self-aggregated macrocomplex may reduce blood circulation time and induce life-threatening thrombocytopenia (HIT) complicating the use of heparins. Nonetheless, the conjugation of heparin to immuno-stealth biomolecules may overcome these obstacles. An immunostealth recombinant viral capsid protein (VP28) was expressed and conjugated with heparin to form a novel nanoparticle (VP28-heparin). VP28-heparin was characterized and tested to determine its immunogenicity, anticoagulation properties, effects on total platelet count, and risk of inducing HIT in animal models. The synthesized VP28-heparin trimeric nanoparticle was non-immunogenic, possessed an average hydrodynamic size (8.81 ± 0.58 nm) optimal for the evasion renal filtration and reticuloendothelial system uptake (hence prolonging circulating half-life). Additionally, VP28-heparin did not induce mouse death or reduce blood platelet count when administered at a high dosein vivo(hence reducing HIT risks). The VP28-heparin nanoparticle also exhibited superior anticoagulation properties (2.2× higher prothrombin time) and comparable activated partial thromboplastin time, but longer anticoagulation period when compared to unfractionated heparin. The anticoagulative effects of the VP28-heparin can also be reversed using protamine sulfate. Thus, VP28-heparin may be an effective and safe heparin derivative for therapeutic use.
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Affiliation(s)
- Hussein Reda Hussein
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, 30068 Hsinchu, Taiwan
- Department of Botany and Microbiology, Faculty of Science, Al-Azhar University, Assiut branch 71524, Egypt
| | - Chia-Yu Chang
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, 30068 Hsinchu, Taiwan
| | - Yini Zheng
- Department of Materials Science and Engineering, City University of Hong Kong, Hong Kong
| | - Chih-Yu Yang
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Li-Hua Li
- Department of Pathology and laboratory medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Yi-Tzu Lee
- Department of Emergency, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Jun-Yi Chen
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Yu-Chaun Liang
- Agricultural Biotechnology Research Center, Academia Sinica, Taipei 11529, Taiwan
| | - Chuan-Ju Lin
- Agricultural Biotechnology Research Center, Academia Sinica, Taipei 11529, Taiwan
| | - Yu-Chia Chang
- Agricultural Biotechnology Research Center, Academia Sinica, Taipei 11529, Taiwan
| | - Hui Nee Geo
- Department of Pharmacology, Faculty of Medicine, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
| | - Suzita Mohd Noor
- Department of Biomedical Science, Faculty of Medicine, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
| | - Lik Voon Kiew
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, 30068 Hsinchu, Taiwan
- Department of Pharmacology, Faculty of Medicine, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
| | - Fu-Rong Chen
- Department of Materials Science and Engineering, City University of Hong Kong, Hong Kong
| | - Chia-Ching Chang
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, 30068 Hsinchu, Taiwan
- Department of Electrophysics, National Yang Ming Chiao Tung University, Hsinchu 30010, Taiwan
- Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), National Yang Ming Chiao Tung University, Hsinchu 30068, Taiwan
- International College of Semiconductor Technology, National Yang Ming Chiao Tung University, 30010 Hsinchu, Taiwan
- Institute of Physics, Academia Sinica, Taipei 10529, Taiwan
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14
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Arachchillage DJ, Thachil J, Anderson JAM, Baker P, Poles A, Kitchen S, Laffan M. Diagnosis and management of heparin-induced thrombocytopenia: Third edition. Br J Haematol 2024; 204:459-475. [PMID: 38153164 DOI: 10.1111/bjh.19180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 12/29/2023]
Affiliation(s)
- Deepa J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Julia A M Anderson
- Department of Haematology, Edinburgh Royal Infirmary, Edinburgh, Scotland
| | - Peter Baker
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Anthony Poles
- Bristol NHS Blood and Transplant Centre, Bristol, UK
| | - Steve Kitchen
- Department of Haematology, Royal Hallamshire Hospital, Sheffield, UK
| | - Mike Laffan
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
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15
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Tucker CM, Rhoades R, Sharma R, Gong JZ. Optimization of laboratory diagnosis of heparin-induced thrombocytopenia using HemosIL-AcuStar-HIT-IgG assay. Lab Med 2024; 55:34-39. [PMID: 37094798 DOI: 10.1093/labmed/lmad029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
OBJECTIVE The aim of this study was to determine an optimal cutoff value for the newly available HemosIL-AcuStar-HIT-IgG assay (AcuStar) for the diagnosis of heparin-induced thrombocytopenia (HIT). METHOD We evaluated the performance of AcuStar using serotonin release assay (SRA) as the gold standard and incorporated 4T score calculation in a cohort of suspected HIT cases. Statistical analysis was performed to determine optimal cutoff value for the diagnosis of HIT. RESULT A diagnosis of HIT can be excluded with a platelet factor 4 (PF4) value of <0.4 U/mL by AcuStar and 4T score in the low-risk category (≤3). All other cases will require confirmation with a functional test. CONCLUSION Our study resulted in the implementation of a diagnostic algorithm for laboratory diagnosis of HIT, which incorporates pretest calculation of 4T score and AcuStar as a screening test, with reflex confirmation by SRA. This new algorithm resulted in extended hours of test availability and a more rapid turnaround time in reporting PF4 results.
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Affiliation(s)
- Catherine M Tucker
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA, US
| | - Ruben Rhoades
- Department of Medicine, Division of Hematology, Thomas Jefferson University, Philadelphia, PA, US
| | - Ruchika Sharma
- Department of Pediatrics, Division of Hematology/Oncology/BMT, Medical College of Wisconsin, Versiti Blood Research Institute, Milwaukee, WI,US
| | - Jerald Z Gong
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA, US
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16
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McMains CJ, Mather TL, Adamson KA, Whitfield R, Doren EL, Hettinger PC, LoGiudice JA. Heparin-induced thrombocytopenia in lower extremity free tissue transfers. Microsurgery 2024; 44:e31075. [PMID: 37339917 DOI: 10.1002/micr.31075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 04/07/2023] [Accepted: 06/02/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) an immunologically mediated reaction to heparin products, can lead to severe thrombocytopenia and potentially life-threatening thrombotic events. In microsurgery, a missed or delayed diagnosis of HIT can cause complications requiring revision operations, flap loss, or limb loss. Surgeons must remain vigilant for this uncommon yet potentially devastating condition and keep abreast of management strategies. METHODS CPT and ICD-10 codes in electronic medical records were used to collect demographic information, clinical courses, and outcomes for patients with a HIT diagnosis who underwent lower extremity free tissue transfer in one institution. RESULTS The authors' institution performed 415 lower extremity free flaps in 411 patients during the 10-year study period. Flap salvage rate was 71% for compromised lower extremity flaps without HIT, and 25% in those with HIT. Four patients (four flaps) met study inclusion criteria during the study period. Three of the four flaps failed and were later debrided; one was rescued after a takeback for anastomosis revision. Two patients successfully underwent a delayed second free flap procedure after recovery, and one was salvaged with a pedicled muscle flap. CONCLUSIONS Surgeons should monitor for HIT by establishing coagulation panel and platelet count baselines and trending these values in the early post-operative period for patients treated with heparin products. The 4T score can be used to screen for HIT with high clinical suspicion. Arterial thrombosis or poor flap perfusion despite sound microvascular technique could suggest HIT. Surgical and medical management including strict heparin avoidance can prevent adverse events for these patients.
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Affiliation(s)
- Conner J McMains
- Department of Plastic Surgery, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Tara L Mather
- Department of Plastic Surgery, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Karri A Adamson
- Department of Plastic Surgery, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Robert Whitfield
- Department of Plastic Surgery, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Erin L Doren
- Department of Plastic Surgery, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Patrick C Hettinger
- Department of Plastic Surgery, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - John A LoGiudice
- Department of Plastic Surgery, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Shi D, Zhao H, Bu C, Fraser K, Wang H, Dordick JS, Linhardt RJ, Zhang F, Shi F, Chi L. New insights into the binding of PF4 to long heparin oligosaccharides in ultralarge complexes using mass spectrometry. J Thromb Haemost 2023; 21:3608-3618. [PMID: 37648114 DOI: 10.1016/j.jtha.2023.08.020] [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: 03/27/2023] [Revised: 08/18/2023] [Accepted: 08/18/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a serious complication caused by heparin drugs. The ultralarge complexes formed by platelet factor 4 (PF4) with heparin or low molecular weight heparins (LMWHs) are important participants in inducing the immune response and HIT. OBJECTIVES We aim at characterizing the interaction between PF4 and long-chain heparin oligosaccharides and providing robust analytical methods for the analysis of PF4-heparin complexes. METHODS In this work, the characteristics of PF4-enoxaparin complexes after incubation in different molar ratios and concentrations were analyzed by multiple analytical methods, especially liquid chromatography-mass spectrometry and liquid chromatography-tandem mass spectrometry with multiple reaction monitoring were developed to qualitatively and quantitatively monitor heparin oligosaccharides and PF4 in HIT-inducing complexes. RESULTS The results showed that the largest proportion of ultralarge complexes formed by PF4 and enoxaparin was at a specific molar ratio, ie, a PF4/enoxaparin ratio of 2:1, while the ultralarge complexes contained PF4 tetramer and enoxaparin at a molar ratio of approximately 2:1. CONCLUSION A binding model of PF4 and enoxaparin in ultralarge complexes is proposed with one heparin oligosaccharide chain (∼ dp18) bound to 2 PF4 tetramers in different morphologies to form ultralarge complexes, while PF4 tetramer is surrounded by multiple heparin chains in smaller complexes. Our study provides new insights into the structural mechanism of PF4-LMWH interaction, which help to further understand the mechanism of LMWH immunogenicity and develop safer heparin products.
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Affiliation(s)
- Deling Shi
- National Glycoengineering Research Center, Shandong University, Qingdao, Shandong Province, China; Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Huimin Zhao
- National Glycoengineering Research Center, Shandong University, Qingdao, Shandong Province, China
| | - Changkai Bu
- National Glycoengineering Research Center, Shandong University, Qingdao, Shandong Province, China
| | - Keith Fraser
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Biological Sciences, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Haoran Wang
- National Glycoengineering Research Center, Shandong University, Qingdao, Shandong Province, China
| | - Jonathan S Dordick
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Biological Sciences, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Biological Engineering, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Robert J Linhardt
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Biological Sciences, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Chemistry and Chemical Biology, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Fuming Zhang
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, New York, USA.
| | - Feng Shi
- Shandong Institute for Food and Drug Control, Jinan, Shandong Province, China.
| | - Lianli Chi
- National Glycoengineering Research Center, Shandong University, Qingdao, Shandong Province, China.
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18
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Pong T, Cyr K, Aparicio-Valenzuela J, Carlton C, Lee AM. A Modified 4Ts Score for Heparin-Induced Thrombocytopenia in the Mechanical Circulatory Support Population. J Cardiothorac Vasc Anesth 2023; 37:2499-2507. [PMID: 37407329 DOI: 10.1053/j.jvca.2023.06.033] [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: 02/16/2023] [Revised: 06/16/2023] [Accepted: 06/21/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE To identify risk factors and develop a pretest scoring system to differentiate patients with heparin-induced thrombocytopenia (HIT) in the mechanical circulatory support (MCS) population. The authors present a modified "4TMCS" scoring system, which considers the "type of mechanical circulatory support" that may help identify patients at risk for developing postoperative HIT. DESIGN A retrospective cohort study. Patients who underwent cardiac surgery were categorized into 3 groups: (1) normal platelet count, (2) thrombocytopenia with a negative HIT test, and (3) thrombocytopenia with a positive HIT test. A comparison of diagnostic accuracy between the 4Ts and 4TMCS probability scores was performed. SETTING At a single adult tertiary-care center. PARTICIPANTS A total of 5,314 patients who underwent cardiac surgery between May 1, 2008 and December 31, 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In total, 125 out of 5,314 patients (2.4%) were diagnosed with HIT, of whom 75 out of 5,314 (1.4%) had clinical evidence of thrombosis. Overall, in-hospital mortality was 25.6%, 11.7%, and 1.5% in the HIT(+), HIT(-), and control groups, respectively (p < 0.001). Mechanical circulatory support was associated with a significantly increased risk for HIT, with an incidence of 5.9% in patients receiving MCS versus 1.9% in those without (p < 0.001). Area under the receiver operator curve (AUC) analysis demonstrated improved diagnostic accuracy of the 4TMCS score compared with the 4Ts (AUC = 0.83 v 0.77, p < 0.044). The 4TMCS score had higher sensitivity than the 4Ts, using the guideline-recommended score cutoff of ≥4 (95.2% v 85.7%). CONCLUSION Heparin-induced thrombocytopenia is associated with worse outcomes and increased morbidity and mortality in the MCS population. Awareness of patient risk factors and the application of a modified 4TMCS probability score may allow for more accurate screening and treatment of HIT in the MCS population.
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Affiliation(s)
- Terrence Pong
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Kevin Cyr
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Joy Aparicio-Valenzuela
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Cody Carlton
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Anson M Lee
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA.
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19
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Foley K, Rao V, Djaiani G. Mechanical Circulatory Support and Heparin: Friends or Foes? J Cardiothorac Vasc Anesth 2023; 37:2508-2510. [PMID: 37778948 DOI: 10.1053/j.jvca.2023.08.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Karen Foley
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - George Djaiani
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada.
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20
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Thomas C, Ali R, Park I, Kim H, Short S, Kaunfer S, Durai L, Yilmam OA, Shenoy T, Battinelli EM, Al-Samkari H, Leaf DE. Platelet Factor 4 Antibodies and Severe AKI. KIDNEY360 2023; 4:1672-1679. [PMID: 37907435 PMCID: PMC10758522 DOI: 10.34067/kid.0000000000000287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/19/2023] [Indexed: 11/02/2023]
Abstract
Key Points Patients testing positive for platelet factor 4 antibodies have a >50% higher odds of developing severe AKI compared with those who test negative. The relationship between platelet factor 4 antibodies and severe AKI was independent of demographics, comorbidities, laboratory values, and severity-of-illness characteristics. Background Heparin-induced thrombocytopenia, which results from production of antibodies that bind to heparin-platelet factor 4 (PF4) complexes, is a hypercoagulable state associated with considerable morbidity and mortality due to thrombotic complications. We investigated whether PF4 antibodies are associated with an increased risk of AKI. Methods We conducted a cohort study of hospitalized adults who underwent testing for PF4 antibodies at two large medical centers in Boston between 2015 and 2021. The primary exposure was PF4 test positivity. The primary outcome was severe AKI, defined by Kidney Disease: Improving Global Outcomes stage 3 as a ≥3-fold increase in serum creatinine or receipt of KRT within 7 days after the PF4 test. We used multivariable logistic regression to adjust for potential confounders. Results A total of 4224 patients were included in our analysis, 469 (11.1%) of whom had a positive PF4 test. Severe AKI occurred in 50 of 469 patients (10.7%) with a positive PF4 test and in 235 of 3755 patients (6.3%) with a negative test (unadjusted odds ratio, 1.79 [95% confidence interval, 1.30 to 2.47]). In multivariable analyses adjusted for demographics, comorbidities, laboratory values, and severity-of-illness characteristics, PF4 test positivity remained associated with a higher risk of severe AKI (adjusted odds ratio, 1.56 [95% confidence interval, 1.10 to 2.20]). Conclusions Among hospitalized adults, the presence of PF4 antibodies is independently associated with a 56% higher odds of developing severe AKI. Additional studies are needed to investigate potential mechanisms that may underlie these findings, such as pathogenic effects of PF4 antibodies on the microvasculature of the kidneys.
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Affiliation(s)
- Charlotte Thomas
- Harvard Medical School, Boston, Massachusetts
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rafia Ali
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Isabel Park
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Helena Kim
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Samuel Short
- Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Sarah Kaunfer
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lavanya Durai
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Osman A. Yilmam
- Harvard Medical School, Boston, Massachusetts
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tushar Shenoy
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elisabeth M. Battinelli
- Harvard Medical School, Boston, Massachusetts
- Division of Hematology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, Massachusetts
- Division of Hematology, Massachusetts General Hospital, Boston, Massachusetts
| | - David E. Leaf
- Harvard Medical School, Boston, Massachusetts
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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21
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Warkentin TE. Immunologic Effects of Heparin Associated With Hemodialysis: Focus on Heparin-Induced Thrombocytopenia. Semin Nephrol 2023; 43:151479. [PMID: 38195304 DOI: 10.1016/j.semnephrol.2023.151479] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Intermittent hemodialysis (HD) is almost invariably performed with heparin, and thus HD patients are at risk of developing the immune-mediated adverse effect heparin-induced thrombocytopenia (HIT), caused by anti-platelet factor 4/heparin IgG, which strongly activates platelets. HIT patients develop hypercoagulability with greatly increased risk of thrombosis, both venous and arterial. Certain HIT-associated complications are more likely to develop among HD patients, including hemofilter thrombosis despite heparin, intravascular catheter and/or arteriovenous fistula-associated thrombosis, post-heparin bolus anaphylactoid/anaphylactic reactions, and thrombotic stroke and acute limb artery thrombosis (reflecting the high frequency of underlying arteriopathy in many patients with renal failure). Management of HIT in HD usually requires use of an alternative (non-heparin) anticoagulant; for example, danaparoid sodium (outside the USA) or argatroban (USA and elsewhere). Whether heparin-grafted hemodialyzers (without systemic heparin) can be used safely in acute HIT is unknown. The HIT immune response is remarkably transient and usually not retriggered by subsequent heparin administration. Accordingly, since renal failure patients often require long-term HD, there may be the opportunity-following seroreversion (loss of platelet-activating HIT antibodies)-to restart heparin for HD, a practice that appears to have a low likelihood of retriggering HIT.
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Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada; Transfusion Medicine, Hamilton Regional Laboratory Medicine Program, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Canada; Service of Benign Hematology, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Canada.
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22
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Cogan JC, McFarland MM, May JE, Lim MY. Quality improvement approaches to heparin-induced thrombocytopenia: a scoping review. Res Pract Thromb Haemost 2023; 7:102219. [PMID: 38077807 PMCID: PMC10704520 DOI: 10.1016/j.rpth.2023.102219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/18/2023] [Accepted: 09/21/2023] [Indexed: 02/12/2024] Open
Abstract
Background Heparin-induced thrombocytopenia (HIT) is a relatively uncommon condition characterized by 2 exceedingly common phenomena in hospitalized patients: thrombocytopenia and heparin exposure. Consequently, HIT is frequently overdiagnosed and inappropriately treated. These issues are the focus of many quality improvement (QI) initiatives. Objectives In this scoping review, we identified and characterized all published QI studies on improving the diagnosis and management of HIT. Methods We conducted a systematic literature search through April 2022 for studies reporting on QI interventions regarding the diagnosis, treatment, and/or prevention of HIT. Results Thirty studies were included in the final review. Studies were separated into 5 groups based on the focus of the interventions: increasing HIT recognition, reducing HIT incidence, reducing HIT overdiagnosis, promoting safer HIT management, and creating HIT task forces. Nine studies focused on the implementation of 4Ts score calculator into electronic medical record orders for HIT testing, while only 1 evaluated the impact of reducing unfractionated heparin use in favor of low-molecular-weight heparin. Six studies focused on the implementation of direct thrombin inhibitor management protocols, while none evaluated the use of alternative anticoagulants in HIT management. Conclusion The bulk of published HIT QI research focused on reducing overdiagnosis and promoting safer direct thrombin inhibitor therapy, while minimal attention has been devoted to HIT prevention and the use of evidence-based alternative HIT therapies.
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Affiliation(s)
- Jacob C. Cogan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mary M. McFarland
- Spencer S. Eccles Health Sciences Library, University of Utah, Salt Lake City, Utah, USA
| | - Jori E. May
- University of Alabama at Birmingham Medicine Birmingham, Alabama, USA
| | - Ming Y. Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
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23
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Cosmi B, Legnani C, Cini M, Borgese L, Sartori M, Palareti G. Incidence and clinical outcomes of heparin-induced thrombocytopenia: 11 year experience in a tertiary care university hospital. Intern Emerg Med 2023; 18:1971-1980. [PMID: 37568069 DOI: 10.1007/s11739-023-03379-5] [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: 03/16/2023] [Accepted: 07/12/2023] [Indexed: 08/13/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a rare immuno-mediated adverse reaction with high thrombotic and mortality risk. To evaluate incidence and outcomes of HIT cases diagnosed at a tertiary care hospital from 2007 to 2018. A retrospective study was conducted. Patients with suspected HIT underwent 4Ts score assessment and anti-heparin PF4 IgG antibodies ELISA screening test. If the latter was positive, platelet aggregation test (PAT) was performed. If the latter was positive, any form of heparin was stopped, alternative anticoagulants were started and then overlapped with warfarin. HIT incidence was calculated by dividing HIT cases by the mean yearly number of admitted patients over 11 years. Follow-up was 90 days. Among 2125 screening tests, 96 (4.5%) were positive with confirmatory PAT in 82/90 (3.8% for missing data in 6). Median age was 75; 39 patients were surgical and 51 medical. The median 4Ts score was 5. Unfractionated heparin was employed in 34 (37%). HIT incidence was 0.16/1000/patient/years (95% CI: 0.12-0.23) in surgical and 0.15/1000/patient/years (95%: 0.12-0.20) in medical patients. HIT with thrombosis (HIT-T) was observed in 31 patients (0.05/1000/patient/years 95% CI: 0.04-0.1), with venous thromboses in 25 (80%). HIT without thrombosis was observed in 59 patients (0.1/1000 patient/years; 95% CI: 0.08-0.13, twofold vs HIT-T). All cause mortality was 25.5% (95% CI: 17.6-35.4), major bleeding 7.7% (95% CI:3.2-15.3), and thromboembolic complications 3.3% (95% CI:1.1-9.3). HIT is a rare event with high mortality, despite the use of non heparin anticoagulants.
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Affiliation(s)
- Benilde Cosmi
- Angiology and Blood Coagulation Unit , IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
- Angiology and Blood Coagulation Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | | | | | - Laura Borgese
- Angiology and Blood Coagulation Unit , IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Angiology and Blood Coagulation Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Michelangelo Sartori
- Angiology and Blood Coagulation Unit , IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Howick V JF, Harmon DM, McBane RD. 44-Year-Old Woman With Cough and Shortness of Breath. Mayo Clin Proc 2023; 98:1557-1563. [PMID: 37793730 DOI: 10.1016/j.mayocp.2023.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/28/2023] [Accepted: 02/02/2023] [Indexed: 10/06/2023]
Affiliation(s)
- James F Howick V
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - David M Harmon
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Robert D McBane
- Advisor to residents and Consultant in Vascular Cardiology, Mayo Clinic, Rochester, MN.
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25
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Rytel A, Nowak M, Kukawska-Rytel M, Morawiec K, Niemczyk S. Different Types of Vasculitis Complicated by Heparin-Induced Thrombocytopenia-Analysis of Four Cases and Literature Review. J Clin Med 2023; 12:6176. [PMID: 37834820 PMCID: PMC10573553 DOI: 10.3390/jcm12196176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 09/22/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
Vasculitis and HIT have different etiologies, although both involve autoimmune mechanisms. Treatment of vasculitis often requires the use of an anticoagulant such as heparin, which can lead to the development of HIT and subsequent life-threatening complications. The analysis covered patients hospitalized in the Department of Internal Medicine, Nephrology and Dialysis in the period from September 2020 to March 2023. After analyzing the data, we selected four patients in whom vasculitis treatment was complicated by HIT. These included two patients with ANCA vasculitis and two patients with anti-GBM disease. We also described similar cases reported in the literature.
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Affiliation(s)
- Adam Rytel
- Department of Internal Diseases, Nephrology and Dialysis, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland (K.M.)
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Šoltés J, Skribuckij M, Říha H, Lipš M, Michálek P, Balík M, Pořízka M. Update on Anticoagulation Strategies in Patients with ECMO-A Narrative Review. J Clin Med 2023; 12:6067. [PMID: 37763010 PMCID: PMC10532142 DOI: 10.3390/jcm12186067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/14/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
The use of extracorporeal membrane oxygenation (ECMO) has recently increased exponentially. ECMO has become the preferred mode of organ support in refractory respiratory or circulatory failure. The fragile balance of haemostasis physiology is massively altered by the patient's critical condition and specifically the aetiology of the underlying disease. Furthermore, an application of ECMO conveys another disturbance of haemostasis due to blood-circuit interaction and the presence of an oxygenator. The purpose of this review is to summarise current knowledge on the anticoagulation management in patients undergoing ECMO therapy. The unfractionated heparin modality with monitoring of activated partial thromboplastin tests is considered to be a gold standard for anticoagulation in this specific subgroup of intensive care patients. However, alternative modalities with other agents are comprehensively discussed. Furthermore, other ways of monitoring can represent the actual state of coagulation in a more complex fashion, such as thromboelastometric/graphic methods, and might become more frequent. In conclusion, the coagulation system of patients with ECMO is altered by multiple variables, and there is a significant lack of evidence in this area. Therefore, a highly individualised approach is the best solution today.
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Affiliation(s)
- Ján Šoltés
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
- Emergency Service of Central Bohemia, Vančurova 1544, 27201 Kladno, Czech Republic
| | - Michal Skribuckij
- Department of Anaesthesia, Golden Jubilee University National Hospital, Clydebank G81 4DY, UK;
| | - Hynek Říha
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
- Department of Anaesthesiology and Intensive Care Medicine, Institute for Clinical and Experimental Medicine, 14021 Prague, Czech Republic
| | - Michal Lipš
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
| | - Pavel Michálek
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
- Department of Anaesthesia, Antrim Area Hospital, Antrim BT41 2RL, UK
| | - Martin Balík
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
| | - Michal Pořízka
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, 12808 Prague, Czech Republic; (J.Š.); (H.Ř.); (M.L.); (P.M.); (M.B.)
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Lv FF, Li MY, Qu W, Jiang ZS. Rivaroxaban for the treatment of heparin-induced thrombocytopenia with thrombosis in a patient undergoing artificial hip arthroplasty: A case report. World J Clin Cases 2023; 11:6147-6153. [PMID: 37731576 PMCID: PMC10507566 DOI: 10.12998/wjcc.v11.i26.6147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/13/2023] [Accepted: 07/19/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Anticoagulation treatment after lower limb surgery is one of the key methods to avoid thrombosis, and low-molecular-weight heparin is the treatment that is most frequently used in clinical practice. But one uncommon side effect of low-molecular-weight heparin is heparin-induced thrombocytopenia (HIT), which can develop into thrombosis if not caught early or managed incorrectly. CASE SUMMARY We present a case of a patient who underwent hip arthroplasty and experienced thrombocytopenia due to HIT on the 9th d following the application of low-molecular-weight heparin anticoagulation. We did not diagnose HIT in time and applied 1 unit of platelets to the patient, which led to thrombosis. Luckily, the patient recovered following effective and timely surgery and treatment with rivaroxaban. CONCLUSION Patients using low-molecular-weight heparin after lower limb surgery need to have their platelet counts regularly checked. If HIT develops, platelet treatment should be given with caution.
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Affiliation(s)
- Fang-Fang Lv
- Department of Endocrinology, 960th Hospital of PLA, Jinan 250014, Shandong Province, China
| | - Mei-Ye Li
- Department of Endocrinology, 960th Hospital of PLA, Jinan 250014, Shandong Province, China
| | - Wei Qu
- Department of Endocrinology, 960th Hospital of PLA, Jinan 250014, Shandong Province, China
| | - Zhao-Shun Jiang
- Department of Endocrinology, 960th Hospital of PLA, Jinan 250014, Shandong Province, China
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28
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Gbadamosi S, Feick KL. Update on the Treatment of Heparin-Induced Thrombocytopenia. AACN Adv Crit Care 2023; 34:173-178. [PMID: 37644631 DOI: 10.4037/aacnacc2023462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Affiliation(s)
- Sheriff Gbadamosi
- Sheriff Gbadamosi is Clinical Pharmacy Specialist-Critical Care, Temple University Hospital Main Campus, 3401 N Broad Street, Philadelphia, PA 19140
| | - Kristin L Feick
- Kristin L. Feick is Clinical Pharmacy Specialist-Critical Care, University of Pittsburgh Medical Center Central Pennsylvania Region
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Diaz D, Martinez J, Bushman G, Wolowich WR. Anticoagulation strategies in COVID-19 infected patients receiving ECMO support. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2023; 55:121-129. [PMID: 37682210 PMCID: PMC10487306 DOI: 10.1051/ject/2023027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/07/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Hospitalized COVID-19 patients with hypoxemic respiratory failure may deteriorate despite invasive mechanical ventilation and thus require extracorporeal membrane oxygenation (ECMO) support. Unfractionated heparin (UFH) is the antithrombotic of choice, however, bivalirudin may offer more predictable pharmacokinetics resulting in consistent anticoagulant effects with lower bleeding and thrombotic occurrences. The aim of this study was to evaluate efficacy and safety outcomes in patients undergoing venovenous (VV) ECMO receiving bivalirudin or UFH-based anticoagulation. METHODS This retrospective, single-center, observational cohort study included patients with confirmed COVID-19 infection requiring VV ECMO support receiving anticoagulation with UFH or bivalirudin. Primary endpoints were time to reach therapeutic aPTT, percent time spent in aPTT range, and the occurrence of thrombotic events over the entire course of ECMO support. Secondary endpoints included the incidence of major/minor bleeding, the ability to wean off ECMO support, in-hospital mortality, and length of stay. RESULTS Twenty-two patients were included in the study (n = 10 UFH, n = 12 bivalirudin). Time to therapeutic aPTT was achieved faster with UFH (10 h vs. 20 h). The percentage time spent within the goal aPTT range was similar between UFH and bivalirudin (50% vs. 52%). Thrombotic events were significantly higher in the UFH group (40% DVT, 40% PE, 80% oxygenator thrombus in ECMO machine, 10% ischemic stroke) versus bivalirudin (8% DVT, 17% PE, 33% oxygenator thrombus, no ischemic strokes) (CI 95%, p = 0.04). The overall bleeding incidence was higher in the UFH arm (90% vs. 75%). The mortality rate was 90% in the UFH group and 58% in the bivalirudin group. The length of stay was similar between the two study arms. CONCLUSION In hospitalized patients with COVID-19-associated acute respiratory distress syndrome (ARDS) on VV ECMO support, the use of bivalirudin showed to be a viable anticoagulation alternative in terms of efficacy compared to UFH and resulted in a favorable safety profile with lower rates of bleeding and thrombotic events.
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Affiliation(s)
- Dayne Diaz
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Department of Pharmacy, Mount Sinai Medical Center, Pharmacy Suite 2020 4300 Alton Rd. Miami Beach FL 33140 United States
| | - Jenny Martinez
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Department of Pharmacy, Mount Sinai Medical Center, Pharmacy Suite 2020 4300 Alton Rd. Miami Beach FL 33140 United States
| | - Grant Bushman
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Department of Pharmacy, Mount Sinai Medical Center, Pharmacy Suite 2020 4300 Alton Rd. Miami Beach FL 33140 United States
| | - William R. Wolowich
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Department of Pharmacy Practice, Nova Southeastern University 3300 S University Dr Fort Lauderdale FL 33328 United States
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Patel SV, Liberman SA, Burgess PL, Goldberg JE, Poylin VY, Messick CA, Davis BR, Feingold DL, Lightner AL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Reduction of Venous Thromboembolic Disease in Colorectal Surgery. Dis Colon Rectum 2023; 66:1162-1173. [PMID: 37318130 DOI: 10.1097/dcr.0000000000002975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Sunil V Patel
- Department of Surgery, Queen's University, Kingston, Canada
| | | | - Pamela L Burgess
- Department of Surgery, Uniformed Services University of the Health Sciences, Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Joel E Goldberg
- Division of Colorectal Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vitaliy Y Poylin
- Division of Gastrointestinal and Oncologic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Craig A Messick
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bradley R Davis
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Daniel L Feingold
- Department of Surgery, Rutgers University, New Brunswick, New Jersey
| | | | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati, Cincinnati, Ohio
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31
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Alhanshani AA. Heparin Induced Thrombocytopenia - Pathophysiology, Diagnosis and Treatment: A Narrative Review. Int J Gen Med 2023; 16:3947-3953. [PMID: 37667778 PMCID: PMC10475297 DOI: 10.2147/ijgm.s420327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 08/02/2023] [Indexed: 09/06/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a life-threatening, immune-mediated complication following heparin exposure and is considered to be the most severe adverse reaction to heparin treatment that is not associated with bleeding. Development of autoantibodies against platelet factor 4 (PF4) - heparin complex constitutes the basis of the pathophysiological changes in patients suffering from HIT, which then binds to the surface of platelets and monocytes, thus provoking their activation and subsequent aggregation, ultimately leading to the formation of thrombosis. Formation of arterial and venous thrombosis is aggravated by the simultaneous activation of platelets and monocytes with a substantial mortality rate. The incidence of HIT is reported to be significantly lower in pediatric patients compared with adults. Diagnosis of HIT in pediatric population remains a clinical entity supplemented by laboratory evaluation. The positive predictive value of laboratory evaluation is further elevated by the use of scoring systems and predictive models used for hastening the diagnosis of HIT. Use of alternative anticoagulants like direct thrombin inhibitors and factor Xa inhibitors form the mainstay of treatment in cases of HIT, however, more prospective studies would be required in the pediatric population to delineate definitive guidelines for proper management of patients in this age-group. This article delivers diagnostic and treatment approach in case of patients with HIT, wherein the pathophysiology, clinical manifestations, diagnostic approach and the management of patients with HIT has been described.
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Affiliation(s)
- Ahmad A Alhanshani
- Department of Child Health, College of Medicine, King Khalid University, Abha, Saudi Arabia
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32
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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.
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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
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Amin A, Kartashov A, Ngai W, Steele K, Rosenthal N. Effectiveness, safety, and costs of thromboprophylaxis with enoxaparin or unfractionated heparin in inpatients with obesity. Front Cardiovasc Med 2023; 10:1163684. [PMID: 37396589 PMCID: PMC10313352 DOI: 10.3389/fcvm.2023.1163684] [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: 02/11/2023] [Accepted: 05/08/2023] [Indexed: 07/04/2023] Open
Abstract
Background Obesity is a frequent and significant risk factor for venous thromboembolism (VTE) among hospitalized adults. Pharmacologic thromboprophylaxis can help prevent VTE, but real-world effectiveness, safety, and costs among inpatients with obesity are unknown. Objective This study aims to compare clinical and economic outcomes among adult medical inpatients with obesity who received thromboprophylaxis with enoxaparin or unfractionated heparin (UFH). Methods A retrospective cohort study was performed using the PINC AI™ Healthcare Database, which covers more than 850 hospitals in the United States. Patients included were ≥18 years old, had a primary or secondary discharge diagnosis of obesity [International Classification of Diseases (ICD)-9 diagnosis codes 278.01, 278.02, and 278.03; ICD-10 diagnosis codes E66.0x, E66.1, E66.2, E66.8, and E66.9], received ≥1 thromboprophylactic dose of enoxaparin (≤40 mg/day) or UFH (≤15,000 IU/day) during the index hospitalization, stayed ≥6 days in the hospital, and were discharged between 01 January 2010, and 30 September 2016. We excluded surgical patients, patients with pre-existing VTE, and those who received higher (treatment-level) doses or multiple types of anticoagulants. Multivariable regression models were constructed to compare enoxaparin with UFH based on the incidence of VTE, pulmonary embolism (PE)---------related mortality, overall in-hospital mortality, major bleeding, treatment costs, and total hospitalization costs during the index hospitalization and the 90 days after index discharge (readmission period). Results Among 67,193 inpatients who met the selection criteria, 44,367 (66%) and 22,826 (34%) received enoxaparin and UFH, respectively, during their index hospitalization. Demographic, visit-related, clinical, and hospital characteristics differed significantly between groups. Enoxaparin during index hospitalization was associated with 29%, 73%, 30%, and 39% decreases in the adjusted odds of VTE, PE-related mortality, in-hospital mortality, and major bleeding, respectively, compared with UFH (all p < 0.002). Compared with UFH, enoxaparin was associated with significantly lower total hospitalization costs during the index hospitalization and readmission periods. Conclusions Among adult inpatients with obesity, primary thromboprophylaxis with enoxaparin compared with UFH was associated with significantly lower risks of in-hospital VTE, major bleeding, PE-related mortality, overall in-hospital mortality, and hospitalization costs.
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Affiliation(s)
- Alpesh Amin
- Department of Medicine, University of California at Irvine, Irvine, CA, United States
| | - Alex Kartashov
- PINC AI™ Applied Sciences, Premier Inc., Charlotte, NC, United States
| | | | | | - Ning Rosenthal
- PINC AI™ Applied Sciences, Premier Inc., Charlotte, NC, United States
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Hein A, Wai SM. A Case Report of Native Coronary Artery Thrombosis With Heparin-Induced Thrombocytopenia. Cureus 2023; 15:e39220. [PMID: 37378150 PMCID: PMC10292049 DOI: 10.7759/cureus.39220] [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] [Accepted: 05/19/2023] [Indexed: 06/29/2023] Open
Abstract
Heparin is an anticoagulant which has been widely used in various clinical settings, from thromboprophylaxis to the treatment of thromboembolism. Heparin-induced thrombocytopenia (HIT) is a rare medical condition with severe complications if unrecognised, and it carries significant risks of co-morbidities and mortality. The incidence of HIT is relatively less common in low molecular weight heparin. HIT is more common in the venous system than the arterial circulatory system, and it is rare to see multi-vessel coronary artery thrombosis due to HIT. We hereby report a case of multi-vessel coronary thrombosis secondary to low molecular weight HIT, presenting as a case of ST-segment elevation myocardial infarction. We learned from the case that low molecular weight heparin can cause thrombosis secondary to HIT and HIT could be one of the differential diagnoses in those presenting with ST-elevation myocardial infarct and recent exposure to low molecular weight heparin.
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Affiliation(s)
- Aung Hein
- Department of Cardiology, University Hospitals Dorset, Bournemouth, GBR
| | - Su M Wai
- Department of Cardiology, University Hospitals Dorset, Bournemouth, GBR
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35
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Hogwood J, Mulloy B, Lever R, Gray E, Page CP. Pharmacology of Heparin and Related Drugs: An Update. Pharmacol Rev 2023; 75:328-379. [PMID: 36792365 DOI: 10.1124/pharmrev.122.000684] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 02/17/2023] Open
Abstract
Heparin has been used extensively as an antithrombotic and anticoagulant for close to 100 years. This anticoagulant activity is attributed mainly to the pentasaccharide sequence, which potentiates the inhibitory action of antithrombin, a major inhibitor of the coagulation cascade. More recently it has been elucidated that heparin exhibits anti-inflammatory effect via interference of the formation of neutrophil extracellular traps and this may also contribute to heparin's antithrombotic activity. This illustrates that heparin interacts with a broad range of biomolecules, exerting both anticoagulant and nonanticoagulant actions. Since our previous review, there has been an increased interest in these nonanticoagulant effects of heparin, with the beneficial role in patients infected with SARS2-coronavirus a highly topical example. This article provides an update on our previous review with more recent developments and observations made for these novel uses of heparin and an overview of the development status of heparin-based drugs. SIGNIFICANCE STATEMENT: This state-of-the-art review covers recent developments in the use of heparin and heparin-like materials as anticoagulant, now including immunothrombosis observations, and as nonanticoagulant including a role in the treatment of SARS-coronavirus and inflammatory conditions.
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Affiliation(s)
- John Hogwood
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Barbara Mulloy
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Rebeca Lever
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Elaine Gray
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Clive P Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
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Haut ER, Byrne JP, Price MA, Bixby P, Bulger EM, Lake L, Costantini T. Proceedings from the 2022 Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma. J Trauma Acute Care Surg 2023; 94:461-468. [PMID: 36534056 PMCID: PMC9974764 DOI: 10.1097/ta.0000000000003843] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
ABSTRACT On May 4 and 5, 2022, a meeting of multidisciplinary stakeholders in the prevention and treatment of venous thromboembolism (VTE) after trauma was convened by the Coalition for National Trauma Research, funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health, and hosted by the American College of Surgeons in Chicago, Illinois. This consensus conference gathered more than 40 in-person and 80 virtual attendees, including trauma surgeons, other physicians, thrombosis experts, nurses, pharmacists, researchers, and patient advocates. The objectives of the meeting were twofold: (1) to review and summarize the present state of the scientific evidence regarding VTE prevention strategies in injured patients and (2) to develop consensus on future priorities in VTE prevention implementation and research gaps.To achieve these objectives, the first part of the conference consisted of talks from physician leaders, researchers, clinical champions, and patient advocates to summarize the current state of knowledge of VTE pathogenesis and prevention in patients with major injury. Video recordings of all talks and accompanying slides are freely available on the conference website ( https://www.nattrauma.org/research/research-policies-templates-guidelines/vte-conference/ ). Following this curriculum, the second part of the conference consisted of a series of small-group breakout sessions on topics potentially requiring future study. Through this process, research priorities were identified, and plans of action to develop and undertake future studies were defined.The 2022 Consensus Conference to Implement Optimal VTE Prophylaxis in Trauma answered the National Trauma Research Action Plan call to define a course for future research into preventing thromboembolism after trauma. A multidisciplinary group of clinical champions, physicians, scientists, and patients delineated clear objectives for future investigation to address important, persistent key knowledge gaps. The series of papers from the conference outlines the consensus based on the current literature and a roadmap for research to answer these unanswered questions.
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Affiliation(s)
- Elliott R Haut
- From the Division of Acute Care Surgery, Department of Surgery (E.R.H., J.P.B.), Department of Anesthesiology and Critical Care Medicine (E.R.H.), and Department of Emergency Medicine (E.R.H.), Johns Hopkins University School of Medicine; Armstrong Institute for Patient Safety and Quality (E.R.H.), Johns Hopkins Medicine; Department of Health Policy and Management (E.R.H.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Coalition for National Trauma Research (M.A.P., P.B.), San Antonio, Texas; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington, DC; National Blood Clot Alliance (L.L.), Philadelphia, Pennsylvania; Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery (T.C.), University of California San Diego School of Medicine, San Diego, California
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Helms J, Frere C, Thiele T, Tanaka KA, Neal MD, Steiner ME, Connors JM, Levy JH. Anticoagulation in adult patients supported with extracorporeal membrane oxygenation: guidance from the Scientific and Standardization Committees on Perioperative and Critical Care Haemostasis and Thrombosis of the International Society on Thrombosis and Haemostasis. J Thromb Haemost 2023; 21:373-396. [PMID: 36700496 DOI: 10.1016/j.jtha.2022.11.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 01/26/2023]
Abstract
Anticoagulation of patients supported by extracorporeal membrane oxygenation is challenging because of a high risk of both bleeding and thrombotic complications, and often empirical. Practice in anticoagulation management is therefore highly variable. The scope of this guidance document is to provide clinicians with practical advice on the choice of an anticoagulant agent, dosing, and the optimal anticoagulant monitoring strategy during extracorporeal membrane oxygenation support in adult patients.
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Affiliation(s)
- Julie Helms
- Strasbourg University (UNISTRA), Strasbourg University Hospital, Medical Intensive Care Unit - NHC, INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France.
| | - Corinne Frere
- Sorbonne Université, UMRS 1166, AP-HP. Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Thomas Thiele
- Institut für Transfusionsmedizin, Universitätsmedizin Rostock, Schillingallee 36, Rostock, Germany
| | - Kenichi A Tanaka
- Department of Anesthesiology, Universit of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Matthew D Neal
- Department of Surgery, Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marie E Steiner
- Division of Hematology/Oncology and Division of Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
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38
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Selvadurai MV, Favaloro EJ, Chen VM. Mechanisms of Thrombosis in Heparin-Induced Thrombocytopenia and Vaccine-Induced Immune Thrombotic Thrombocytopenia. Semin Thromb Hemost 2023. [PMID: 36706782 DOI: 10.1055/s-0043-1761269] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) and vaccine-induced immune thrombotic thrombocytopenia (VITT) are rare, iatrogenic immune-mediated conditions with high rates of thrombosis-related morbidity and mortality. HIT is a long-recognized reaction to the administration of the common parenterally administered anticoagulant heparin (or its derivatives), while VITT is a new, distinct syndrome occurring in response to adenovirus-based vaccines against coronavirus disease 2019 and potentially other types of vaccines. A feature of both HIT and VITT is paradoxical thrombosis despite a characteristic low platelet count, mediated by the presence of platelet-activating antibodies to platelet factor 4. Several additional factors have also been suggested to contribute to clot formation in HIT and/or VITT, including monocytes, tissue factor, microparticles, endothelium, the formation of neutrophil extracellular traps, complement, procoagulant platelets, and vaccine components. In this review, we discuss the literature to date regarding mechanisms contributing to thrombosis in both HIT and VITT and explore the pathophysiological similarities and differences between the two conditions.
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Affiliation(s)
- Maria V Selvadurai
- The Alfred Hospital, Melbourne, VIC, Australia.,ANZAC Research Institute, University of Sydney, Sydney, NSW, Australia
| | - 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, NSW, Australia.,School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, NSW, Australia.,School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, NSW, Australia
| | - Vivien M Chen
- ANZAC Research Institute, University of Sydney, Sydney, NSW, Australia.,Department of Haematology, Concord Repatriation General Hospital and NSW Health Pathology, Sydney, NSW, Australia
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Abstract
Over 2 years have passed since the start of the COVID-19 pandemic, which has claimed millions of lives. Unlike the early days of the pandemic, when management decisions were based on extrapolations from in vitro data, case reports and case series, clinicians are now equipped with an armamentarium of therapies based on high-quality evidence. These treatments are spread across seven main therapeutic categories: anti-inflammatory agents, antivirals, antithrombotics, therapies for acute hypoxaemic respiratory failure, anti-SARS-CoV-2 (neutralizing) antibody therapies, modulators of the renin-angiotensin-aldosterone system and vitamins. For each of these treatments, the patient population characteristics and clinical settings in which they were studied are important considerations. Although few direct comparisons have been performed, the evidence base and magnitude of benefit for anti-inflammatory and antiviral agents clearly outweigh those of other therapeutic approaches such as vitamins. The emergence of novel variants has further complicated the interpretation of much of the available evidence, particularly for antibody therapies. Importantly, patients with acute and chronic kidney disease were under-represented in many of the COVID-19 clinical trials, and outcomes in this population might differ from those reported in the general population. Here, we examine the clinical evidence for these therapies through a kidney medicine lens.
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40
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Fabregues F, Antonio García-Velasco J, Llácer J, Requena A, Ángel Checa M, Bellver J, José Espinós J. The role of thrombophilias in reproduction: A swot analysis. Eur J Obstet Gynecol Reprod Biol 2023; 280:12-21. [PMID: 36375360 DOI: 10.1016/j.ejogrb.2022.10.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 10/25/2022] [Indexed: 12/27/2022]
Abstract
Thrombophilia is a group of inherited or acquired coagulation disorders that have been associated with reproductive failure. However, there are still no clear recommendations on whether its inclusion in the initial study of the infertile couple or patients with recurrent implantation failure is necessary. In this discussion paper, based on a SWOT (strengths, weaknesses, opportunities, threats) analysis, the different aspects of the repercussions of thrombophilia screening and treatment in reproduction are evaluated. To avoid possible subjectivity in the analysis and results of this study, researchers followed Oxford criteria for the evaluation of evidence. The results from the evaluation of the reviewed bibliography seem to indicate that, pending new evidence, it would be advisable not to include thrombophilia screening in the initial baseline study of the infertile couple. There is no evidence to support a clear association between thrombophilia and implantation failure or infertility. Thrombophilia testing in this setting may increase cost, with minimal potential benefit and lead to inappropriate use of anticoagulants with possible deleterious adverse effects. Future well-designed studies are needed to assess the possible benefit of anticoagulant therapy in infertile thrombophilic patients with implantation failure.
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Affiliation(s)
- Francisco Fabregues
- Institut Clinic Gynecology, Obstetrics and Neonatology (ICGON), Hospital Clinic, C/Villarroel 160, Barcelona 08036, Spain.
| | | | - Joaquín Llácer
- Ginefiv-GeneraLife, Calle José Silva 18, Madrid 28043, Spain
| | - Antonio Requena
- Ginefiv-GeneraLife, Calle José Silva 18, Madrid 28043, Spain
| | - Miguel Ángel Checa
- Hospital del Mar-Parc de Salut Mar, Paseo Maritimo 25-29, Barcelona 08005, Spain; Fundación Fertty, Ausiàs March 25, Barcelona 08010, Spain
| | - José Bellver
- Departamento de Pediatría, Obstetricia y Ginecología, Facultad de Medicina, Universidad de Valencia, Spain; Instituto Valenciano de Infertilidad (IVI-RMA) Valencia, Plaza de la Policía Local, 3, Valencia 46015, Spain; Fundación FIVI, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Valencia, Spain
| | - Juan José Espinós
- Fundación Fertty, Ausiàs March 25, Barcelona 08010, Spain; Universidad Autónoma de Barcelona. Campus de la UAB, Plaza Cívica, s/n, Bellaterra (Barcelona) 08193, Spain
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Lee CSM, Powell MC, Chen VM. Whole Blood Procoagulant Platelet Flow Cytometry Protocol for Heparin-Induced Thrombocytopenia (HIT) and Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT) Testing. Methods Mol Biol 2023; 2663:441-461. [PMID: 37204729 DOI: 10.1007/978-1-0716-3175-1_29] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a well-characterized, iatrogenic complication of heparin anticoagulation with significant morbidity. In contrast, vaccine-induced immune thrombotic thrombocytopenia (VITT) is a recently recognized severe prothrombotic complication of adenoviral vaccines, including the ChAdOx1 nCoV-19 (Vaxzevria, AstraZeneca) and Ad26.COV2.S (Janssen, Johnson & Johnson) vaccines against COVID-19. The diagnosis of HIT and VITT involve laboratory testing for antiplatelet antibodies by immunoassays followed by confirmation by functional assays to detect platelet-activating antibodies. Functional assays are critical to detect pathological antibodies due to the varying sensitivity and specificity of immunoassays. This chapter presents a protocol for a novel whole blood flow cytometry-based assay to detect procoagulant platelets in healthy donor blood in response to plasma from patients suspected of HIT or VITT. A method to identify suitable healthy donors for HIT and VITT testing is also described.
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Affiliation(s)
- Christine S M Lee
- ANZAC Research Institute, University of Sydney, Sydney, NSW, Australia
| | - Matthew C Powell
- Diagnostic Pathology Unit, NSW Health Pathology, Concord Hospital, Concord, NSW, Australia
| | - Vivien M Chen
- ANZAC Research Institute, University of Sydney, Sydney, NSW, Australia.
- Department of Haematology, Concord Hospital, Sydney Local Health District, Concord, NSW, Australia.
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42
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Anticoagulation Management during Extracorporeal Membrane Oxygenation-A Mini-Review. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121783. [PMID: 36556985 PMCID: PMC9782867 DOI: 10.3390/medicina58121783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/25/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) has been established as a life-saving technique for patients with the most severe forms of respiratory or cardiac failure. It can, however, be associated with severe complications. Anticoagulation therapy is required to prevent ECMO circuit thrombosis. It is, however, associated with an increased risk of hemocoagulation disorders. Thus, safe anticoagulation is a cornerstone of ECMO therapy. The most frequently used anticoagulant is unfractionated heparin, which can, however, cause significant adverse effects. Novel drugs (e.g., argatroban and bivalirudin) may be superior to heparin in the better predictability of their effects, functioning independently of antithrombin, inhibiting thrombin bound to fibrin, and eliminating heparin-induced thrombocytopenia. It is also necessary to keep in mind that hemocoagulation tests are not specific, and their results, used for setting up the dosage, can be biased by many factors. The knowledge of the advantages and disadvantages of particular drugs, limitations of particular tests, and individualization are cornerstones of prevention against critical events, such as life-threatening bleeding or acute oxygenator failure followed by life-threatening hypoxemia and hemodynamic deterioration. This paper describes the effects of anticoagulant drugs used in ECMO and their monitoring, highlighting specific conditions and factors that might influence coagulation and anticoagulation measurements.
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43
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Lin Y, Shao Y, Liu Y, Yang R, Liao S, Yang S, Xu M, He J. Efficacy and safety of nafamostat mesilate anticoagulation in blood purification treatment of critically ill patients: a systematic review and meta-analysis. Ren Fail 2022; 44:1263-1279. [PMID: 35930302 PMCID: PMC9359194 DOI: 10.1080/0886022x.2022.2105233] [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] [Indexed: 01/08/2023] Open
Abstract
Background Nafamostat mesilate (NM), a broad-spectrum and potent serine protease inhibitor, can be used as an anticoagulant during extracorporeal circulation, as well as a promising drug effective against coronavirus disease 2019 (COVID-19). We conducted a systematic meta-analysis to evaluate the safety and efficacy of NM administration in critically ill patients who underwent blood purification therapy (BPT). Methods The Cochrane Library, Web of Science and PubMed were comprehensively searched from inception to August 20, 2021, for potential studies. Results Four randomized controlled trials (RCTs) and seven observational studies with 2723 patients met the inclusion criteria. The meta-analysis demonstrated that conventional therapy (CT) significantly increased hospital mortality compared with NM administration (RR = 1.25, p = 0.0007). In subgroup analyses, the in-hospital mortality of the NM group was significantly lower than that of the anticoagulant-free (NA) group (RR = 1.31, p = 0.002). The CT interventions markedly elevated the risk ratio of bleeding complications by 45% (RR = 1.45, p = 0.010) compared with NM interventions. In another subgroup analysis, NM used exhibited a significantly lower risk of bleeding complications than those of the low-molecular-weight heparin (LMWH) used (RR = 4.58, p = 0.020). The filter lifespan was decreased significantly (MD = −10.59, p < 0.0001) in the NA groups compared with the NM groups. Due to the poor quality of the included RCTs, these results should be interpreted with caution. Conclusion Given the better survival outcomes, lower risk of bleeding, NM anticoagulation seems to be a safe and efficient approach for BPT patients and could yield a favorable filter lifespan. More multi-center RCTs with large samples are required for further validation of this study.
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Affiliation(s)
- Yao Lin
- Jieyang Medical Research Center, Jieyang People's Hospital, Jieyang, China
| | - Yiming Shao
- The Intensive Care Unit, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Yuchun Liu
- Jieyang Medical Research Center, Jieyang People's Hospital, Jieyang, China
| | - Ruoxuan Yang
- Jieyang Medical Research Center, Jieyang People's Hospital, Jieyang, China
| | - Shuanglin Liao
- The Intensive Care Unit, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Shuai Yang
- The Intensive Care Unit, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Mingwei Xu
- Jieyang Medical Research Center, Jieyang People's Hospital, Jieyang, China
| | - Junbing He
- Jieyang Medical Research Center, Jieyang People's Hospital, Jieyang, China
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44
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Tang B, Yang X, Zhang A, Wang Q, Fan L, Fang G. Polypseudorotaxane hydrogel based on Tween 80 and α-cyclodextrin for sustained delivery of low molecular weight heparin. Carbohydr Polym 2022; 297:120002. [DOI: 10.1016/j.carbpol.2022.120002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/13/2022] [Accepted: 08/16/2022] [Indexed: 11/26/2022]
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45
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Maruyama K, Miyata S, Kokame K. Alpha-HIT assay: A new assay for heparin-induced thrombocytopenia antibody detection using FcγRIIa-coated beads and Alpha technology. Res Pract Thromb Haemost 2022; 6:e12818. [PMID: 37602359 PMCID: PMC10439501 DOI: 10.1002/rth2.12818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 08/11/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Keiko Maruyama
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shigeki Miyata
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Koichi Kokame
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
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46
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Meher MK, Poluri KM. Bifunctional Dalteparin/Enoxaparin coated nanosilver formulation to prevent bloodstream infections during hemodialysis. Carbohydr Polym 2022; 291:119546. [DOI: 10.1016/j.carbpol.2022.119546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 04/04/2022] [Accepted: 04/25/2022] [Indexed: 11/02/2022]
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47
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Chopard R, Behr J, Vidoni C, Ecarnot F, Meneveau N. An Update on the Management of Acute High-Risk Pulmonary Embolism. J Clin Med 2022; 11:jcm11164807. [PMID: 36013046 PMCID: PMC9409943 DOI: 10.3390/jcm11164807] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 11/16/2022] Open
Abstract
Hemodynamic instability and right ventricular (RV) dysfunction are the key determinants of short-term prognosis in patients with acute pulmonary embolism (PE). High-risk PE encompasses a wide spectrum of clinical situations from sustained hypotension to cardiac arrest. Early recognition and treatment tailored to each individual are crucial. Systemic fibrinolysis is the first-line pulmonary reperfusion therapy to rapidly reverse RV overload and hemodynamic collapse, at the cost of a significant rate of bleeding. Catheter-directed pharmacological and mechanical techniques ensure swift recovery of echocardiographic parameters and may possess a better safety profile than systemic thrombolysis. Further clinical studies are mandatory to clarify which pulmonary reperfusion strategy may improve early clinical outcomes and fill existing gaps in the evidence.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
- F-CRIN, INNOVTE Network, 42055 Saint-Etienne, France
- Correspondence:
| | - Julien Behr
- Department of Radiology, University Hospital Besançon, 25000 Besancon, France
| | - Charles Vidoni
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
- F-CRIN, INNOVTE Network, 42055 Saint-Etienne, France
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48
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Chen LY, Khan N, Lindenbauer A, Nguyen TH. When Will Fondaparinux Induce Thrombocytopenia? Bioconjug Chem 2022; 33:1574-1583. [PMID: 35878320 PMCID: PMC9390334 DOI: 10.1021/acs.bioconjchem.2c00316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The pentasaccharide Fondaparinux, a synthetic selective factor Xa inhibitor, is one of the safest anticoagulants in the heparin family that is recommended as an alternative drug for patients with hypersensitivity to other drugs such as heparin-induced thrombocytopenia (HIT). However, some observations of Fondaparinux-induced thrombocytopenia (FIT) have been reported while others claimed that FIT does not occur in patients with fondaparinux therapy, indicating that the mechanism of FIT remains controversial. Here, we utilized different methodologies including dynamic light scattering, immunosorbent and platelet aggregation assays, confocal laser scanning microscopy, and flow cytometry to gain insights into FIT. We found that at a certain concentration, Fondaparinux formed sufficient large and stable complexes with PF4 that facilitated binding of the HIT-like monoclonal KKO antibody and enhanced platelet aggregation and activation. We proposed a model to describe the role of Fondaparinux concentration in the formation of complexes with platelet factor 4 and how it promotes the binding of KKO. Our results clarify controversial observations of FIT in patients as each contains a dissimilar PF4:Fondaparinux concentration ratio.
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Affiliation(s)
- Li-Yu Chen
- Institute for Bioprocessing and Analytical Measurement Techniques, 37308 Heiligenstadt, Germany.,Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, 07745 Jena, Germany
| | - Nida Khan
- Institute for Bioprocessing and Analytical Measurement Techniques, 37308 Heiligenstadt, Germany.,Faculty of Mathematics and Natural Sciences, Technische Universität Ilmenau, 98694 Ilmenau, Germany
| | - Annerose Lindenbauer
- Institute for Bioprocessing and Analytical Measurement Techniques, 37308 Heiligenstadt, Germany
| | - Thi-Huong Nguyen
- Institute for Bioprocessing and Analytical Measurement Techniques, 37308 Heiligenstadt, Germany.,Faculty of Mathematics and Natural Sciences, Technische Universität Ilmenau, 98694 Ilmenau, Germany
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49
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López-Briz E, Ruiz Garcia V, Cabello JB, Bort-Martí S, Carbonell Sanchis R. Heparin versus 0.9% sodium chloride locking for prevention of occlusion in central venous catheters in adults. Cochrane Database Syst Rev 2022; 7:CD008462. [PMID: 35849083 PMCID: PMC9291254 DOI: 10.1002/14651858.cd008462.pub4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Intermittent locking of central venous catheters (CVCs) is undertaken to help maintain their patency and performance. There are systematic variations in care: some practitioners use heparin (at different concentrations), whilst others use 0.9% sodium chloride (normal saline). This review looks at the effectiveness and safety of intermittent locking with heparin compared to normal saline, to see if the evidence establishes whether one is better than the other. This is an update of an earlier Cochrane Review. OBJECTIVES To evaluate the benefits and harms of intermittent locking of CVCs with heparin versus normal saline in adults to prevent occlusion. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 20 October 2021. SELECTION CRITERIA We included randomised controlled trials in adults ≥ 18 years of age with a CVC that compared intermittent locking with heparin at any concentration versus normal saline. We excluded studies on infants and children from this review. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were occlusion of CVCs and duration of catheter patency. Our secondary outcomes were CVC-related bloodstream infections and CVC-related colonisation, mortality, haemorrhage, heparin-induced thrombocytopaenia, CVC-related thrombosis, number of additional CVC insertions, abnormality of coagulation profile and allergic reactions to heparin. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We identified one new RCT with 30 participants for this update. We included a total of 12 RCTs with 2422 participants. Data for meta-analysis were available from all RCTs. We noted differences in methods used by the included studies and variation in heparin concentrations (10 to 5000 IU/mL), time to follow-up (1 to 251.8 days), and the unit of analysis used (participant, catheter, line access). Five studies included ICU (intensive care unit) patients, two studies included oncology patients, and the remaining studies included miscellaneous patients (chronic kidney disease, haemodialysis, home care patients, etc.). Primary outcomes Overall, combined results may show fewer occlusions with heparin compared to normal saline but this is uncertain (risk ratio (RR) 0.70, 95% confidence interval (CI) 0.51 to 0.95; 10 studies; 1672 participants; low-certainty evidence). We pooled studies that used participant or catheter as the unit of analysis. We carried out subgroup analysis by unit of analysis. No clear differences were detected after testing for subgroup differences (P = 0.23). We found no clear evidence of a difference in the duration of catheter patency with heparin compared to normal saline (mean difference (MD) 0.44 days, 95% CI -0.10 to 0.99; 6 studies; 1788 participants; low-certainty evidence). Secondary outcomes We found no clear evidence of a difference in the following outcomes: CVC-related bloodstream infections (RR 0.66, 95% CI 0.08 to 5.80; 3 studies; 1127 participants; very low-certainty evidence); mortality (RR 0.76, 95% CI 0.44 to 1.31; 3 studies; 1100 participants; very low-certainty evidence); haemorrhage (RR 1.54, 95% CI 0.41 to 5.74; 3 studies; 1197 participants; very low-certainty evidence); or heparin-induced thrombocytopaenia (RR 0.21, 95% CI 0.01 to 4.27; 3 studies; 443 participants; very low-certainty evidence). The main reasons for downgrading the certainty of evidence for the primary and secondary outcomes were unclear allocation concealment, suspicion of publication bias, imprecision and inconsistency. AUTHORS' CONCLUSIONS Given the low-certainty evidence, we are uncertain whether intermittent locking with heparin results in fewer central venous catheter occlusions than intermittent locking with normal saline in adults. Low-certainty evidence suggests that heparin may have little or no effect on catheter patency duration. Although we found no evidence of differences in safety (CVC-related bloodstream infections, mortality, or haemorrhage), the combined studies were not powered to detect rare adverse events such as heparin-induced thrombocytopaenia. Further research conducted over longer periods would reduce the current uncertainties.
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Affiliation(s)
- Eduardo López-Briz
- Department of Pharmacy & CASP Spain, La Fe University Hospital, Valencia, Spain
| | - Vicente Ruiz Garcia
- Hospital at Home Unit & CASPe Spain, La Fe University Hospital, Valencia, Spain
| | - Juan B Cabello
- Department of Cardiology & CASP Spain, Hospital General Universitario de Alicante, Alicante, Spain
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50
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A Rare Case of Extensive Cerebral Venous Sinus Thrombosis Complicated by Heparin-Induced Thrombocytopenia. Case Rep Hematol 2022; 2022:7845786. [PMID: 35707792 PMCID: PMC9192252 DOI: 10.1155/2022/7845786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 05/20/2022] [Indexed: 01/08/2023] Open
Abstract
Cerebral venous sinus thrombosis (CVST) is a rare but potentially life-threatening cause of stroke. Several risk factors have been identified including hypercoagulable state, malignancy, use of oral contraceptives, pregnancy, head injury, infection, and prothrombotic states such as heparin-induced thrombocytopenia (HIT). HIT is a prothrombotic state leading to thrombosis in several distinct locations including CVST requiring prompt discontinuation of heparin and initiation of nonheparin anticoagulation to prevent catastrophic consequences. Very rarely, HIT can complicate the ongoing CVST leading to worsening thrombosis and clinical deterioration. We here report an exceedingly rare case of CVST complicated by HIT in a 22-year-old female patient who showed remarkable clinical improvement after discontinuation of heparin and initiation of argatroban.
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