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Renna SA, Zhao X, Kunapuli SP, Ma P, Holinstat M, Boxer MB, Maloney DJ, Michael JV, McKenzie SE. Novel Strategy to Combat the Procoagulant Phenotype in Heparin-Induced Thrombocytopenia Using 12-LOX Inhibition. Arterioscler Thromb Vasc Biol 2023; 43:1808-1817. [PMID: 37345522 DOI: 10.1161/atvbaha.123.319434] [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: 04/12/2023] [Accepted: 06/13/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a major concern for all individuals that undergo cardiac bypass surgeries or require prolonged heparin exposure. HIT is a life- and limb-threatening adverse drug reaction with an immune response following the formation of ultra-large immune complexes that drive platelet activation through the receptor FcγRIIA. Thrombotic events remain high following the standard of care treatment with anticoagulants, while increasing risk of bleeding complications. This study sought to investigate a novel approach to treatment of HIT. Recent reports demonstrate increased procoagulant activity in HIT; however, these reports required analysis ex vivo, and relevance in vivo remains unclear. METHODS Using human and mouse model systems, we investigated the cooperativity of PARs (protease-activated receptors) and FcγRIIA in HIT. We challenged humanized FcγRIIA transgenic mice with or without endogenous mouse Par4 (denoted as IIA-Par4+/+ or IIA-Par4-/-, respectively) with a well-established model IgG immune complex (anti [α]-CD9). Furthermore, we assessed the procoagulant phenotype and efficacy to treat HIT utilizing inhibitor of 12-LOX (12[S]-lipoxygenase), VLX-1005, previously reported to decrease platelet activation downstream of FcγRIIA and PAR4, using the triple allele HIT mouse model. RESULTS IIA-Par4+/+ mice given αCD9 were severely thrombocytopenic, with extensive platelet-fibrin deposition in the lung. In contrast, IIA-Par4-/- mice had negligible thrombocytopenia or pulmonary platelet-fibrin thrombi. We observed that pharmacological inhibition of 12-LOX resulted in a significant reduction in both platelet procoagulant phenotype ex vivo, and thrombocytopenia and thrombosis in our humanized mouse model of HIT in vivo. CONCLUSIONS These data demonstrate for the first time the need for dual platelet receptor (PAR and FcγRIIA) stimulation for fibrin formation in HIT in vivo. These results extend our understanding of HIT pathophysiology and provide a scientific rationale for targeting the procoagulant phenotype as a possible therapeutic strategy in HIT.
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Affiliation(s)
- Stephanie A Renna
- The Cardeza Foundation for Hematologic Research, Center for Hemostasis, Thrombosis and Vascular Biology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA (S.A.R., X.Z., P.M., J.V.M., S.E.M.)
| | - Xuefei Zhao
- The Cardeza Foundation for Hematologic Research, Center for Hemostasis, Thrombosis and Vascular Biology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA (S.A.R., X.Z., P.M., J.V.M., S.E.M.)
| | - Satya P Kunapuli
- Sol Sherry Thrombosis Center and the Department of Physiology, Temple University School of Medicine, Philadelphia, PA (S.P.K.)
| | - Peisong Ma
- The Cardeza Foundation for Hematologic Research, Center for Hemostasis, Thrombosis and Vascular Biology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA (S.A.R., X.Z., P.M., J.V.M., S.E.M.)
| | - Michael Holinstat
- Department of Pharmacology, University of Michigan, Ann Arbor (M.H.)
| | | | | | - James V Michael
- The Cardeza Foundation for Hematologic Research, Center for Hemostasis, Thrombosis and Vascular Biology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA (S.A.R., X.Z., P.M., J.V.M., S.E.M.)
| | - Steven E McKenzie
- The Cardeza Foundation for Hematologic Research, Center for Hemostasis, Thrombosis and Vascular Biology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA (S.A.R., X.Z., P.M., J.V.M., S.E.M.)
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2
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Warkentin TE, Greinacher A. Laboratory Testing for Heparin-Induced Thrombocytopenia and Vaccine-Induced Immune Thrombotic Thrombocytopenia Antibodies: A Narrative Review. Semin Thromb Hemost 2023; 49:621-633. [PMID: 36455619 PMCID: PMC10421650 DOI: 10.1055/s-0042-1758818] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) and vaccine-induced immune thrombotic thrombocytopenia (VITT) are highly prothrombotic (thrombosis frequency ≥50%). Both are caused by platelet-activating anti-platelet factor 4 (PF4) antibodies, forming PF4/IgG-containing immune complexes that engage platelet FcγIIa receptors, producing strong platelet activation. In HIT, heparin crosslinks several PF4 molecules, whereas in VITT, anti-PF4 antibodies alone crosslink PF4. Sufficient levels of circulating anti-PF4 antibodies are needed to create the pathogenic immune complexes on platelet surfaces; this explains why certain serum (plasma)-based assays are highly sensitive for detecting HIT/VITT antibodies. Accordingly, HIT and VITT are "clinical-pathological" disorders, that is, positive testing for such antibodies-together with a compatible clinical picture-is integral for diagnosis. Heparin (low concentrations) enhances HIT antibody-induced platelet activation, but platelet activation by VITT sera is usually inhibited by heparin. For both HIT and VITT, high sensitivity (>99% and >95%, respectively) characterizes PF4-dependent enzyme immunoassays (EIAs) and PF4-enhanced platelet activation assays; in contrast, certain rapid immunoassays have high sensitivity for HIT (>90-97%) but poor sensitivity (<25%) for VITT. HIT and VITT antibodies are directed at distinct sites on PF4: solid-phase EIAs and platelet activation assays are indifferent to these distinct antigen targets, but rapid immunoassays are not. We discuss a conceptual model where PF4 is viewed as a "globe," with the heparin-binding site the "equator"; in this model, HIT antibodies are primarily directed at antigen site(s) at the north and south "poles" of PF4 (formed when PF4 binds to heparin), whereas VITT antibodies recognize sites on the equator.
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Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Transfusion Medicine, Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
- Service of Benign Hematology, Hamilton Health Sciences, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Andreas Greinacher
- Institute for Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
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3
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Mongirdienė A, Liuizė A, Kašauskas A. Novel Knowledge about Molecular Mechanisms of Heparin-Induced Thrombocytopenia Type II and Treatment Targets. Int J Mol Sci 2023; 24:ijms24098217. [PMID: 37175923 PMCID: PMC10179321 DOI: 10.3390/ijms24098217] [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: 02/28/2023] [Revised: 04/04/2023] [Accepted: 04/07/2023] [Indexed: 05/15/2023] Open
Abstract
Heparin-induced thrombocytopenia type II (HIT II), as stated in the literature, occurs in about 3% of all patients and in 0.1-5% of surgical patients. Thrombosis develops in 20-64% of patients with HIT. The mortality rate in HIT II has not decreased using non-heparin treatment with anticoagulants such as argatroban and lepirudin. An improved understanding of the pathophysiology of HIT may help identify targeted therapies to prevent thrombosis without subjecting patients to the risk of intense anticoagulation. The review will summarize the current knowledge about the pathogenesis of HIT II, potential new therapeutic targets related to it, and new treatments being developed. HIT II pathogenesis involves multi-step immune-mediated pathways dependent on the ratio of PF4/heparin and platelet, monocyte, neutrophil, and endothelium activation. For years, only platelets were known to take part in HIT II development. A few years ago, specific receptors and signal-induced pathways in monocytes, neutrophils and endothelium were revealed. It had been shown that the cells that had become active realised different newly formed compounds (platelet-released TF, TNFα, NAP2, CXCL-7, ENA-78, platelet-derived microparticles; monocytes-TF-MPs; neutrophils-NETs), leading to additional cell activation and consequently thrombin generation, resulting in thrombosis. Knowledge about FcγIIa receptors on platelets, monocytes, neutrophils and FcγIIIa on endothelium, chemokine (CXCR-2), and PSGL-1 receptors on neutrophils could allow for the development of a new non-anticoagulant treatment for HIT II. IgG degradation, Syk kinase and NETosis inhibition are in the field of developing new treatment possibilities too. Accordingly, IdeS and DNases-related pathways should be investigated for better understanding of HIT pathogenesis and the possibilities of being the HIT II treatment targets.
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Affiliation(s)
- Aušra Mongirdienė
- Department of Biochemistry, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania
| | - Agnė Liuizė
- Medicine Academy, Lithuanian University of Health Sciences, Eiveniu Str. 4, LT-50103 Kaunas, Lithuania
| | - Artūras Kašauskas
- Department of Biochemistry, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania
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4
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Abstract
Acute thrombosis and thrombocytopenia pose challenges to the clinician. Thrombocytopenia is naturally viewed as a risk factor for bleeding, and an association with acute thrombosis appears paradoxical. It presents typically as a medical emergency and requires treatment to be started before having confirmatory results. This review supports the attending clinician to recognise and manage conditions that are part of the thrombotic thrombocytopenic syndrome through four illustrative clinical cases. Common themes linking the underlying pathology and treatment are explored to highlight the continued relevance of this rare, but often devastating, presentation.
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Affiliation(s)
| | - Cheng-Hock Toh
- University of Liverpool, Liverpool, UK, and consultant in haematology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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5
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McFadyen JD, Sharma P, Moon MJ, Noonan J, Goodall E, Tran HA, Peter K. Activation of circulating platelets in vaccine-induced thrombotic thrombocytopenia and its reversal by intravenous immunoglobulin. Br J Haematol 2021; 196:234-237. [PMID: 34402057 PMCID: PMC8444744 DOI: 10.1111/bjh.17750] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- James D McFadyen
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Department of Clinical Hematology, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Prerna Sharma
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Mitchell J Moon
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Jonathan Noonan
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth Goodall
- Department of Clinical Hematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Huyen A Tran
- Department of Clinical Hematology, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Department of Medicine, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
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6
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Chan M, Zhao X, Zheng XL. Low ADAMTS-13 predicts adverse outcomes in hospitalized patients with suspected heparin-induced thrombocytopenia. Res Pract Thromb Haemost 2021; 5:e12581. [PMID: 34553121 PMCID: PMC8444283 DOI: 10.1002/rth2.12581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/13/2021] [Accepted: 07/24/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a life-threatening thrombotic complication after heparin exposure. However, the role of ADAMTS-13 and von Willebrand factor (VWF) in the disease process and outcomes of HIT is not known. OBJECTIVE To determine the potential role of ADAMTS-13 and VWF in hospitalized patients suspected with HIT. METHODS Associations of the HIT tests, ADAMTS-13 activity, and VWF antigen or activity with other clinical parameters and outcomes in the patients suspected with HIT were determined. RESULTS Of 261 patients, 87 (33.3%) were positive and 174 (66.7%) were negative for a HIT antibody determined by an enzyme immunoassay (EIA). Of these 87 EIA+ patients, 31 (35.6%) were also positive but 56 (64.4%) were negative for serotonin-releasing assay (SRA). There was no statistically significant difference among all three groups (i.e., EIA-, EIA+/SRA+, and EIA+/SRA-) as to their demographic features, reasons for admission to the hospital, type of procedures performed, and in-hospital mortality. Compared to those in the healthy controls, plasma ADAMTS-13 activity in patients suspected with HIT was significantly lower but plasma VWF antigen (VWFAg) and activity (VWFAc) in these patients were significantly higher. While there was no statistically significant difference among all three groups regarding plasma levels of ADAMTS-13 activity, VWFAg, and VWFAc, plasma levels of ADAMTS-13 activity <50% or the low ratios of ADAMTS-13 activity to VWFAg (or VWFAc) are highly predictive for a 90-day mortality rate, particularly in the EIA+SRA+ group. CONCLUSIONS These results demonstrate that relative deficiency of plasma ADAMTS-13 activity in hospitalized patients suspected with HIT is common, which may contribute at least in part to the adverse outcomes in this patient population, particularly in those with true HIT.
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Affiliation(s)
- Meng Chan
- Departments of Pathology and Laboratory MedicineThe University of Kansas Medical CenterKansas CityKSUSA
| | - Xinyang Zhao
- Departments of Biochemistry and Molecular GeneticsThe University of Alabama at BirminghamBirminghamALUSA
| | - X. Long Zheng
- Departments of Pathology and Laboratory MedicineThe University of Kansas Medical CenterKansas CityKSUSA
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7
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Abstract
Motivation Single-cell RNA-sequencing has grown massively in scale since its inception, presenting substantial analytic and computational challenges. Even simple downstream analyses, such as dimensionality reduction and clustering, require days of runtime and hundreds of gigabytes of memory for today’s largest datasets. In addition, current methods often favor common cell types, and miss salient biological features captured by small cell populations. Results Here we present Hopper, a single-cell toolkit that both speeds up the analysis of single-cell datasets and highlights their transcriptional diversity by intelligent subsampling, or sketching. Hopper realizes the optimal polynomial-time approximation of the Hausdorff distance between the full and downsampled dataset, ensuring that each cell is well-represented by some cell in the sample. Unlike prior sketching methods, Hopper adds points iteratively and allows for additional sampling from regions of interest, enabling fast and targeted multi-resolution analyses. In a dataset of over 1.3 million mouse brain cells, Hopper detects a cluster of just 64 macrophages expressing inflammatory genes (0.004% of the full dataset) from a Hopper sketch containing just 5000 cells, and several other small but biologically interesting immune cell populations invisible to analysis of the full data. On an even larger dataset consisting of ∼2 million developing mouse organ cells, we show Hopper’s even representation of important cell types in small sketches, in contrast with prior sketching methods. We also introduce Treehopper, which uses spatial partitioning to speed up Hopper by orders of magnitude with minimal loss in performance. By condensing transcriptional information encoded in large datasets, Hopper and Treehopper grant the individual user with a laptop the analytic capabilities of a large consortium. Availability and implementation The code for Hopper is available at https://github.com/bendemeo/hopper. In addition, we have provided sketches of many of the largest single-cell datasets, available at http://hopper.csail.mit.edu.
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Affiliation(s)
- Benjamin DeMeo
- Department of Bioinformatics, Harvard University, Cambridge, MA 02138, USA.,Computer Science and Artificial Intelligence Laboratory
| | - Bonnie Berger
- Computer Science and Artificial Intelligence Laboratory.,Department of Mathematics, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
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8
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Heparin-Induced Thrombocytopenia: A Review of New Concepts in Pathogenesis, Diagnosis, and Management. J Clin Med 2021; 10:jcm10040683. [PMID: 33578859 PMCID: PMC7916628 DOI: 10.3390/jcm10040683] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/29/2021] [Accepted: 01/30/2021] [Indexed: 12/17/2022] Open
Abstract
Knowledge on heparin-induced thrombocytopenia keeps increasing. Recent progress on diagnosis and management as well as several discoveries concerning its pathogenesis have been made. However, many aspects of heparin-induced thrombocytopenia remain partly unknown, and exact application of these new insights still need to be addressed. This article reviews the main new concepts in pathogenesis, diagnosis, and management of heparin-induced thrombocytopenia.
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9
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Chong BH. Evolving concepts of pathogenesis of heparin-induced thrombocytopenia: Diagnostic and therapeutic implications. Int J Lab Hematol 2021; 42 Suppl 1:25-32. [PMID: 32543064 DOI: 10.1111/ijlh.13223] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/08/2020] [Accepted: 04/10/2020] [Indexed: 01/09/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is an immune reaction to heparin. It often causes severe thrombosis which may lead to limb gangrene and thrombosis-associated death. The concept of its pathogenesis has been evolving during the past five decades. Initially, HIT was thought to be caused by disseminated intravascular coagulation. Later it became clear that HIT was mediated by an immune mechanism whereby an IgG antibody induced platelet aggregation, release of procoagulant materials and consequently thrombus formation. The antigen comprises Platelet Factor 4 (PF4) and heparin which have a tendency to form ultralarge complexes. The HIT immune response has atypical features. IgG antibody appears early without IgM precedence and lasts transiently. One explanation is that there is prior priming by bacterial infection. Another unique characteristic is that it is processed as if it is a particulate antigen involving complement activation and B cells. Antigen-presenting cells/monocytes are also involved but the role of T cells is controversial. Recent advances have provided new insights into the underlying mechanisms of HIT-related thrombosis. Previously, platelets were believed to play a central role; their activation and consequently the induction of blood coagulation was the basis of the hypercoagulability in HIT. More recently, several studies have provided clear evidence that neutrophil and NETosis, monocytes and endothelial cells contribute significantly to the thrombosis in HIT. These new insights may result in development of better diagnostic laboratory assays and more effective treatments for HIT.
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Affiliation(s)
- Beng H Chong
- Heamatology Department, New South Wales Health Pathology, Kogarah and Sutherland Campuses, Sydney, NSW, Australia.,Heamatolgy Department, St George and Sutherland Hospitals, Sydney, NSW, Australia.,St George Clinical School, University of New South Wales, Sydney, NSW, Australia
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10
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Gaunt ER, Mabbott NA. The clinical correlates of vaccine-induced immune thrombotic thrombocytopenia after immunisation with adenovirus vector-based SARS-CoV-2 vaccines. IMMUNOTHERAPY ADVANCES 2021; 1:ltab019. [PMID: 34557868 PMCID: PMC8385946 DOI: 10.1093/immadv/ltab019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/04/2021] [Accepted: 08/16/2021] [Indexed: 12/13/2022] Open
Abstract
We are at a critical stage in the COVID-19 pandemic where vaccinations are being rolled out globally, in a race against time to get ahead of the SARS-CoV-2 coronavirus and the emergence of more highly transmissible variants. A range of vaccines have been created and received either emergency approval or full licensure. To attain the upper hand, maximum vaccine synthesis, deployment, and uptake as rapidly as possible is essential. However, vaccine uptake, particularly in younger adults is dropping, at least in part fuelled by reports of rare complications associated with specific vaccines. This review considers how vaccination with adenovirus vector-based vaccines against the SARS-CoV-2 coronavirus might cause rare cases of thrombosis and thrombocytopenia in some recipients. A thorough understanding of the underlying cellular and molecular mechanisms that mediate this syndrome may help to identify methods to prevent these very rare, but serious side effects. This will also help facilitate the identification of those at highest risk from these outcomes, so that we can work towards a stratified approach to vaccine deployment to mitigate these risks.
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Affiliation(s)
- Eleanor R Gaunt
- The Roslin Institute & Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush, Midlothian EH25 9RG, UK
| | - Neil A Mabbott
- The Roslin Institute & Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush, Midlothian EH25 9RG, UK
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11
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Warkentin TE. Challenges in Detecting Clinically Relevant Heparin-Induced Thrombocytopenia Antibodies. Hamostaseologie 2020; 40:472-484. [PMID: 33091948 PMCID: PMC7581458 DOI: 10.1055/a-1223-3329] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is an antibody-mediated hypercoagulable state featuring high thrombosis risk and distinct pathogenesis involving immunoglobulin G-mediated platelet activation. The target of the immune response is a cationic “self” protein, platelet factor 4 (PF4), rendered antigenic by heparin. A key problem is that only a minority of anti-PF4/polyanion antibodies induced by heparin are pathogenic, i.e., capable of causing platelet activation and thereby clinical HIT. Since thrombocytopenia occurs frequently in hospitalized, heparin-treated patients, testing for “HIT antibodies” is common; thus, the problem of distinguishing between pathogenic and nonpathogenic antibodies is important. The central concept is that those antibodies that have platelet-activating properties demonstrable in vitro correlate well with pathogenicity, as shown by platelet activation tests such as the serotonin-release assay (SRA) and heparin-induced platelet activation assay. However, in most circumstances, immunoassays are used for first-line testing, and so it is important for clinicians to appreciate which immunoassay result profiles—in the appropriate clinical context—predict the presence of platelet-activating antibodies (Bayesian analysis). Clinicians with access to rapid, on-demand HIT immunoassays (e.g., particle gel immunoassay, latex immunoturbidimetric assay, chemiluminescent immunoassay) can look beyond simple dichotomous result interpretation (“negative”/“positive”) and incorporate semiquantitative interpretation, where, for example, a strong-positive immunoassay result (or even combination of two immunoassays) points to a greater probability of detecting platelet-activating antibodies, and hence supporting a diagnosis of HIT. Recent recognition of “SRA-negative HIT” has increased the importance of semiquantitative interpretation of immunoassays, given that strong immunoassay reactivity is a potential clue indicating possible HIT despite a (false) negative platelet activation assay.
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Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,Transfusion Medicine, Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada.,Service of Clinical Hematology, Hamilton Health Sciences, Hamilton General Hospital, Hamilton, Ontario, Canada.,McMaster Centre for Transfusion Research, Hamilton, Ontario, Canada
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12
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Lax M, Pesonen E, Hiippala S, Schramko A, Lassila R, Raivio P. Heparin Dose and Point-of-Care Measurements of Hemostasis in Cardiac Surgery—Results of a Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2020; 34:2362-2368. [DOI: 10.1053/j.jvca.2019.12.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/23/2019] [Accepted: 12/30/2019] [Indexed: 12/29/2022]
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13
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The role of fluid-phase immune complexes in the pathogenesis of heparin-induced thrombocytopenia. Thromb Res 2020; 194:135-141. [PMID: 32788105 DOI: 10.1016/j.thromres.2020.06.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 11/24/2022]
Abstract
Immune complexes assemble on the platelet surface and cause Fc-mediated platelet activation in heparin-induced thrombocytopenia (HIT); however, it is not known if fluid-phase immune complexes contribute to HIT. The objective of this study was to understand the role of fluid-phase immune complexes in platelet activation and HIT. Binding of wild-type and 15 platelet factor 4 (PF4) mutants to platelets was measured using flow cytometry. Platelet activation was measured using the PF4-dependent 14C-serotonin release assay (PF4-SRA) with KKO and a HIT-patient plasma in the presence of wild-type or PF4 mutants. To activate platelets, we found that a minimal level of wild-type PF4 is required to bind the platelet surface in the presence of KKO (2.67 relative MFI) or HIT-patient plasma (1.71 relative MFI). Only a subset of PF4 mutants was able to support platelet activation, despite having lower surface binding than the minimum binding required of wild-type PF4 (9 mutants with KKO and 2 mutants with HIT-patient plasma). Using individual PF4 mutants, we identified that HIT immune complexes can be formed in fluid-phase and induce platelet activation. Further studies are required to investigate the role of fluid-phase HIT immune complexes in the development of thrombocytopenia and thrombosis associated with clinical HIT.
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14
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Tardy B, Lecompte T, Mullier F, Vayne C, Pouplard C. Detection of Platelet-Activating Antibodies Associated with Heparin-Induced Thrombocytopenia. J Clin Med 2020; 9:jcm9041226. [PMID: 32344682 PMCID: PMC7230370 DOI: 10.3390/jcm9041226] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/17/2020] [Accepted: 04/19/2020] [Indexed: 12/13/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a prothrombotic immune drug reaction caused by platelet-activating antibodies that in most instances recognize platelet factor 4 (PF4)/polyanion complexes. Platelet activation assays (i.e., functional assays) are more specific than immunoassays, since they are able to discern clinically relevant heparin-induced antibodies. All functional assays used for HIT diagnosis share the same principle, as they assess the ability of serum/plasma from suspected HIT patients to activate fresh platelets from healthy donors in the presence of several concentrations of heparin. Depending on the assay, donors’ platelets are stimulated either in whole blood (WB), platelet-rich plasma (PRP), or in a buffer medium (washed platelets, WP). In addition, the activation endpoint studied varies from one assay to another: platelet aggregation, membrane expression of markers of platelet activation, release of platelet granules. Tests with WP are more sensitive and serotonin release assay (SRA) is considered to be the current gold standard, but functional assays suffer from certain limitations regarding their sensitivity, specificity, complexity, and/or accessibility. However, the strict adherence to adequate preanalytical conditions, the use of selected platelet donors and the inclusion of positive and negative controls in each run are key points that ensure their performances.
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Affiliation(s)
- Brigitte Tardy
- Inserm U1059 Sainbiose, University of Lyon St Etienne, CIC 1408, FCRIN-INNOVTE, Hémostase Clinique CHU, 42055 Saint Etienne, France
| | - Thomas Lecompte
- Department of Medicine, Geneva University Hospitals, and Geneva Platelet Group (GpG), Faculty of Medicine, University of Geneva, CH-1211 Genève 14
| | - François Mullier
- CHU UCL Namur, Namur Thrombosis and Hemostasis center (NTHC), Hematology Laboratory, Université Catholique de Louvain, 5530 Yvoir, Belgium
| | - Caroline Vayne
- Department of Hemostasis, University Hospital of Tours, 37044 Tours, France
- University of Tours, EA 7501 GICC, 37000 Tours, France
| | - Claire Pouplard
- Department of Hemostasis, University Hospital of Tours, 37044 Tours, France
- University of Tours, EA 7501 GICC, 37000 Tours, France
- Correspondence:
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Zhang Z, Jayakumar MKG, Zheng X, Shikha S, Zhang Y, Bansal A, Poon DJJ, Chu PL, Yeo ELL, Chua MLK, Chee SK, Zhang Y. Upconversion superballs for programmable photoactivation of therapeutics. Nat Commun 2019; 10:4586. [PMID: 31594932 PMCID: PMC6783568 DOI: 10.1038/s41467-019-12506-w] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 09/09/2019] [Indexed: 12/31/2022] Open
Abstract
Upconversion nanoparticles (UCNPs) are the preferred choice for deep-tissue photoactivation, owing to their unique capability of converting deep tissue-penetrating near-infrared light to UV/visible light for photoactivation. Programmed photoactivation of multiple molecules is critical for controlling many biological processes. However, syntheses of such UCNPs require epitaxial growth of multiple shells on the core nanocrystals and are highly complex/time-consuming. To overcome this bottleneck, we have modularly assembled two distinct UCNPs which can individually be excited by 980/808 nm light, but not both. These orthogonal photoactivable UCNPs superballs are used for programmed photoactivation of multiple therapeutic processes for enhanced efficacy. These include sequential activation of endosomal escape through photochemical-internalization for enhanced cellular uptake, followed by photocontrolled gene knockdown of superoxide dismutase-1 to increase sensitivity to reactive oxygen species and finally, photodynamic therapy under these favorable conditions. Such programmed activation translated to significantly higher therapeutic efficacy in vitro and in vivo in comparison to conventional, non-programmed activation.
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Affiliation(s)
- Zhen Zhang
- Faculty of Engineering, Department of Biomedical Engineering, National University of Singapore, Singapore, 117583, Singapore
| | | | - Xiang Zheng
- Faculty of Engineering, Department of Biomedical Engineering, National University of Singapore, Singapore, 117583, Singapore
- NUS Graduate School for Integrative Sciences and Engineering, National University of Singapore, Singapore, 117456, Singapore
| | - Swati Shikha
- Faculty of Engineering, Department of Biomedical Engineering, National University of Singapore, Singapore, 117583, Singapore
| | - Yi Zhang
- Faculty of Engineering, Department of Biomedical Engineering, National University of Singapore, Singapore, 117583, Singapore
| | - Akshaya Bansal
- Faculty of Engineering, Department of Biomedical Engineering, National University of Singapore, Singapore, 117583, Singapore
| | - Dennis J J Poon
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, 169610, Singapore
| | - Pek Lim Chu
- Oncology Academic Program, Duke-NUS Medical School, Singapore, 169857, Singapore
| | - Eugenia L L Yeo
- Division of Medical Sciences, National Cancer Centre Singapore, Singapore, 169610, Singapore
| | - Melvin L K Chua
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, 169610, Singapore
- Oncology Academic Program, Duke-NUS Medical School, Singapore, 169857, Singapore
- Division of Medical Sciences, National Cancer Centre Singapore, Singapore, 169610, Singapore
| | - Soo Khee Chee
- Oncology Academic Program, Duke-NUS Medical School, Singapore, 169857, Singapore
- Division of Medical Sciences, National Cancer Centre Singapore, Singapore, 169610, Singapore
- Division of Surgical Oncology, National Cancer Centre Singapore, Singapore, 169610, Singapore
| | - Yong Zhang
- Faculty of Engineering, Department of Biomedical Engineering, National University of Singapore, Singapore, 117583, Singapore.
- NUS Graduate School for Integrative Sciences and Engineering, National University of Singapore, Singapore, 117456, Singapore.
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Maličev E. The use of flow cytometry in the diagnosis of heparin-induced thrombocytopenia (HIT). Transfus Med Rev 2019; 34:34-41. [PMID: 31575433 DOI: 10.1016/j.tmrv.2019.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 06/21/2019] [Accepted: 08/07/2019] [Indexed: 11/25/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) affects some of the patients exposed to heparin. It is mediated by antibodies that recognize neoepitopes on platelet factor 4 (PF4)/heparin complexes. A HIT diagnosis requires both clinical and laboratory evaluation and remains a challenge. Since many patients develop antibodies in response to heparin, but only a few of them generate anti-PF4/heparin antibodies capable of activating platelets which consequently cause clinical complications, the performance of serologic assays is not enough to diagnose HIT. Functional assays can identify pathogenic antibodies capable of platelet activation, but they are more demanding and their limited availability contributes to the problem of diagnosing HIT. Restricted laboratories usually collect sera of multiple patients to perform functional assays only once or twice a week; hence, a HIT diagnosis can take several days. The use of flow cytometry appears to be a promising alternative in the confirmation of pathogenic anti-PF4/heparin antibodies. Flow cytometric assays detect either activation markers on a healthy donor's platelet surfaces or platelet derived microparticles formed after platelet incubation with a patient's serum. Flow cytometers are readily available in many clinical laboratories, so this technology introduces the possibility of an earlier HIT diagnosis. The objective of this review was to collect findings on flow cytometric HIT confirmations to the present date, and to review the currently available flow cytometric assays used in the diagnosis of HIT.
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Affiliation(s)
- Elvira Maličev
- Blood Transfusion Center of Slovenia, Ljubljana, Slovenia.
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Manji F, Warkentin TE, Sheppard JAI, Lee A. Fondaparinux cross-reactivity in heparin-induced thrombocytopenia successfully treated with high-dose intravenous immunoglobulin and rivaroxaban. Platelets 2019; 31:124-127. [DOI: 10.1080/09537104.2019.1652263] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Farheen Manji
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Theodore E. Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Jo-Ann I. Sheppard
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Adrienne Lee
- Department of Medicine, University of Calgary, Calgary, AB, Canada
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Warkentin TE, Sheppard JI, Smith JW, Arnold DM, Nazy I. Timeline of heparin-induced thrombocytopenia seroconversion in serial plasma samples tested using an automated latex immunoturbidimetric assay. Int J Lab Hematol 2019; 41:493-502. [PMID: 31050876 PMCID: PMC6850468 DOI: 10.1111/ijlh.13031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/22/2019] [Accepted: 03/23/2019] [Indexed: 01/22/2023]
Abstract
INTRODUCTION HIT is caused by platelet-activating IgG that recognize multimolecular PF4/heparin complexes. HIT antibodies are generally detectable by PF4-dependent enzyme immunoassay (EIA) and by platelet serotonin-release assay (SRA) at the beginning of the HIT-related platelet count fall. We determined whether an automated immunoassay for HIT, the latex immunoturbidimetric assay (LIA), also detects antibodies early during the course of HIT. The LIA was also used to evaluate a patient with putative SRA-negative HIT. METHODS We evaluated the timing and magnitude of LIA reactivity in serial plasma samples obtained from 19 SRA-positive patients (17 with abnormal platelet count changes indicating HIT; two with subclinical seroconversion) and one putative SRA-negative HIT patient, all obtained from patients who participated in a clinical trial of heparin thromboprophylaxis. We determined LIA status at the onset of the HIT-related platelet count fall. RESULTS The LIA was positive in all 19 SRA-positive patients (median value, 7.3 U/mL [range, 1.2-35.5]; cutoff, 1.0 U/mL); for all 13 evaluable patients for whom an informative plasma sample was available at (or shortly before) the onset of the HIT-related platelet count fall, LIA reactivity was positive. Heterogeneity in seroconversion using the LIA was observed; some patients exhibited gradual increases in reactivity, whereas other patients showed rapid increase in reactivity over a few days. The single clinical trial patient who met clinical-pathological criteria for "SRA-negative HIT" tested LIA-positive. CONCLUSION The LIA detects HIT antibodies at the beginning of the HIT-associated platelet count fall. The LIA was also positive in a patient with SRA-negative HIT.
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Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine, Michael G. DeGroote School of MedicineMcMaster UniversityHamiltonOntarioCanada
- Department of Medicine, Michael G. DeGroote School of MedicineMcMaster UniversityHamiltonOntarioCanada
- McMaster Centre for Transfusion ResearchHamiltonOntarioCanada
- Hamilton Regional Laboratory Medicine ProgramHamilton Health SciencesHamiltonOntarioCanada
| | - Jo‐Ann I. Sheppard
- Department of Pathology and Molecular Medicine, Michael G. DeGroote School of MedicineMcMaster UniversityHamiltonOntarioCanada
| | - James W. Smith
- Department of Medicine, Michael G. DeGroote School of MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Donald M. Arnold
- Department of Medicine, Michael G. DeGroote School of MedicineMcMaster UniversityHamiltonOntarioCanada
- McMaster Centre for Transfusion ResearchHamiltonOntarioCanada
| | - Ishac Nazy
- Department of Medicine, Michael G. DeGroote School of MedicineMcMaster UniversityHamiltonOntarioCanada
- McMaster Centre for Transfusion ResearchHamiltonOntarioCanada
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Warkentin TE. High-dose intravenous immunoglobulin for the treatment and prevention of heparin-induced thrombocytopenia: a review. Expert Rev Hematol 2019; 12:685-698. [DOI: 10.1080/17474086.2019.1636645] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Regional Laboratory Medicine Program, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada
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Warkentin TE. Laboratory diagnosis of heparin-induced thrombocytopenia. Int J Lab Hematol 2019; 41 Suppl 1:15-25. [PMID: 31069988 DOI: 10.1111/ijlh.12993] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/25/2019] [Accepted: 02/01/2019] [Indexed: 12/18/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is a clinical-pathological disorder; thus, laboratory testing for the pathogenic platelet-activating antiplatelet factor 4 (PF4)/heparin antibodies is central for diagnosis. The "iceberg" model summarizes the inter-relationship between platelet activation assays and PF4-dependent immunoassays, with platelet-activating antibodies comprising a subset of anti-PF4/heparin antibodies. The platelet serotonin-release assay (SRA), performed by reference laboratories, has high sensitivity and specificity for HIT (~95% each), and is especially suited for detecting highly pathogenic HIT sera containing both heparin-dependent and heparin-independent platelet-activating antibodies; this latter subgroup of antibodies explains "autoimmune HIT" disorders (delayed-onset, persisting, spontaneous, heparin "flush," fondaparinux-associated). Recently, SRA-negative HIT has become recognized, in which serum from some HIT patients contains subthreshold levels of platelet-activating antibodies (by SRA) that become detectable using a PF4-enhanced platelet activation assay. Unusual immunologic features of HIT include early antibody detectability (at onset of platelet count fall) and antibody transience (seroreversion). Widely available PF4-dependent enzyme immunoassays (EIAs) have high sensitivity but poor specificity for HIT, although specificity is enhanced with IgG-specific EIAs and strong positive results; unfortunately, EIA results are usually not available in real time. Automated rapid immunoassays, such as the chemiluminescence immunoassay (CLIA) and latex immunoturbidimetric assay (LIA), facilitate real-time laboratory diagnosis. Recently available likelihood ratio (LR) data for positive (LR+) and negative (LR-) test results allow clinicians to adjust their pretest probabilities for HIT, using Bayesian analysis, into real-time posttest probabilities that are dramatically increased (test positive) or decreased (test negative). Moreover, (semi-)quantitative CLIA- and LIA-positive results (weak, moderate, strong positive) can further refine the posttest probability of HIT.
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Affiliation(s)
- Theodore E Warkentin
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,Hamilton Regional Laboratory Medicine Program, Hamilton Health Sciences, Hamilton General Hospital, Hamilton, Ontario, Canada.,McMaster Centre for Transfusion Research, Hamilton, Ontario, Canada
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Haughton B, Haughton J, George Norman J, Navid A, Allport K, Andrews M, Mannan K, Livesey J. Routine monitoring for heparin-induced thrombocytopenia following lower limb arthroplasty: Is it necessary? A prospective study in a UK district general hospital. Orthop Traumatol Surg Res 2019; 105:497-501. [PMID: 30878232 DOI: 10.1016/j.otsr.2018.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/10/2018] [Accepted: 12/17/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Heparin-induced thrombocytopenia (HIT) is a potentially life-threatening condition associated with heparin administration. Many orthopaedic units routinely prescribe low-molecular-weight heparins as thromboprophylaxis after hip and knee arthroplasty. HYPOTHESIS We postulated that routine platelet monitoring following heparin administration is of no clinical benefit. We therefore asked: firstly, what was the rate of thrombocytopenia in a large population of patients undergoing lower limb arthroplasty? Secondly, did this rate justify routine platelet monitoring? MATERIALS AND METHODS Unless contraindicated, all patients (n=1999, 53.05% female, mean age 69.23 years) at a UK district general hospital undergoing hip and knee arthroplasty were given daily prophylactic enoxaparin. Platelet counts were obtained between the 8th and 10th postoperative days and compared to preoperative baseline. A > 50% fall in platelet count was classified as "possible HIT". The minimal acceptable risk of thrombocytopenia was defined using The American College of Chest Physicians (ACCP) 2012 guidelines, which recommend monitoring platelet counts in patients receiving heparin where the expected risk of HIT is>1% and by descriptive cost-benefit analysis based on the cost of routine platelet monitoring in the clinical setting. RESULTS Complete results were available for 1361 (68.1%) patients, comprising: 653 primary hips, 22 revision hips, 1 hip resurfacing, 665 primary knees, 19 revision knees and 1 unicompartmental knee replacement. Mean platelet level was 281.9×109/L preoperatively and 527.83×109/L postoperatively. Forty-four patients (3.2%) experienced a postoperative fall in platelet levels. However, no patient experienced a drop in platelets to less than 50% of the preoperative value. DISCUSSION The incidence of HIT in the elective arthroplasty population is low. Therefore, routine postoperative monitoring of platelets is not necessary in this population of patients. LEVEL OF EVIDENCE II, prospective study.
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Affiliation(s)
- Benjamin Haughton
- York Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE, United Kingdom
| | - Joanna Haughton
- The Mid Yorkshire Hospitals NHS Trust, Aberford Road, Wakefield, WF1 4DG, United Kingdom
| | - John George Norman
- Hull York Medical School, John Hughlings Jackson Building, University of York, Heslington, York, YO10 5DD, United Kingdom.
| | - Ahmad Navid
- Health Education England: West Midlands, St Chads Court, 213 Hagley Road, Edgbaston, Birmingham, B16 9RG, United Kingdom
| | - Kathy Allport
- York Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE, United Kingdom
| | - Mark Andrews
- York Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE, United Kingdom
| | - Ken Mannan
- York Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE, United Kingdom
| | - Jonathan Livesey
- York Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE, United Kingdom
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Manikappa S, Benfield K, Gan TE, Butler J, Malan E, Tran HAM, Tucker A. Heparin-induced Thrombocytopenia and the Use of r-Hirudin during Cardiopulmonary Bypass. Anaesth Intensive Care 2019; 33:388-92. [PMID: 15973924 DOI: 10.1177/0310057x0503300316] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We report the successful use of r-hirudin (lepirudin) for cardiopulmonary bypass in a 67-year-old man who developed heparin-induced thrombocytopenia type II during heparin treatment of an extensive deep venous thrombosis. Lepirudin was monitored by the modified ecarin clotting time in a “mobile laboratory” set up next to the cardiac theatre, aiming for lepirudin levels of 3.5 to 4.5 μg/ml during bypass.
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Affiliation(s)
- S Manikappa
- Department of Anaesthesia, Monash Medical Centre, Clayton, Victoria
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Heparin-Induced Thrombocytopenia. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00041-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Amiral J, Seghatchian J. An update on evidence based diagnostic and confirmatory testing strategies for heparin induced thrombocytopenia using combined immunological and functional assays. Transfus Apher Sci 2018; 57:804-811. [PMID: 30401517 DOI: 10.1016/j.transci.2018.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
This manuscript aims to provide a concise review on current diagnostic/ confirmatory strategies of Heparin Induced Thrombocytopenia (HIT) with the combined use of immunological / functional assays in addition to the clinical probability. Laboratory diagnosis of HIT is of primordial importance as the related complications could become rapidly severe and life-threatening and can provoke limb amputation in some cases. The first action in the presence of HIT suspicion is to withdraw heparin and to initiate an alternative anticoagulant. Whilst vitamin K antagonists are not appropriate, anticoagulant options include Fondaparinux, Sodium Danaparoid, DOACs, Argatroban, and Bivalirudin. However, if HIT is excluded, patients can benefit again from the high therapeutic and antithrombotic efficacy of this drug, which remains superior to all the substitutive anticoagulant treatments. HIT is suspected in the presence of a platelet count drop > 50% on 2 successive counts, or a platelet count < 100 G/L, and of a significant clinical probability (4 Ts score). Testing patients' plasma is required for establishing the diagnosis. Laboratory investigation involves first the immunological measurement of heparin dependent IgG antibodies (mainly targeted to Heparin-Platelet Factor 4 complexes). When positive, a functional assay for platelet activation, performed at a low and high heparin concentration, allows confirming this disease. In any case, if the immuno-assay is negative, HIT can be excluded with a high probability, and heparin can be continued (if clinical examination favors this decision). Conversely, the higher the IgG antibody concentration is (and affinity), the higher is the probability of developing HIT. The functional assay has now become for confirming the platelet activation capacity of antibodies, and therefore confirming the presence of HIT. Up to now, the gold reference method for testing antibody-dependent platelet activation is the C14-Serotonin Release Assay, available only in very few laboratories working with radio-isotopes. A simple, sensitive, and accurate flow cytometry assay becomes now available to all clinical sites, and it can be easily used for testing the capacity of heparin dependent-antibodies to activate platelets, at low heparin concentration. This technique can be performed in any laboratory equipped with a flow cytometer and can make the HIT confirmation diagnosis rapidly available, which introduces a great improvement for management of patients with HIT. We believe that an evidence-based update on this topic is timely and well warranted.
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Affiliation(s)
- Jean Amiral
- SH-Consulting, Scientific Director and Consultant in Hemostasis, Andrésy France.
| | - Jerard Seghatchian
- International Consultancy in Blood Components Quality/Safety Improvement, Audit/ Inspection and DDR Strategies, London, UK.
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Palankar R, Kohler TP, Krauel K, Wesche J, Hammerschmidt S, Greinacher A. Platelets kill bacteria by bridging innate and adaptive immunity via platelet factor 4 and FcγRIIA. J Thromb Haemost 2018; 16:1187-1197. [PMID: 29350833 DOI: 10.1111/jth.13955] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Indexed: 12/15/2022]
Abstract
Essentials Human platelets specifically interact with IgG opsonized bacteria through FcγRIIA. Platelet factor 4 (PF4) binds to polyanions (P) and undergoes a conformational change. Anti-PF4/P IgG opsonizes PF4-coated Gram-positive and Gram-negative bacteria. Platelets specifically kill E.coli opsonized with PF4 and human anti-PF4/P IgG. SUMMARY Background Activated platelets release the chemokine platelet factor 4 (PF4) stored in their granules. PF4 binds to polyanions (P) on bacteria, undergoes a conformational change and exposes neoepitopes. These neoepitopes induce production of anti-PF4/P antibodies. As PF4 binds to a variety of bacteria, anti-PF4/P IgG can bind and opsonize several bacterial species. Objective Here we investigated whether platelets are able to kill bacteria directly after recognizing anti-PF4/P IgG opsonized bacteria in the presence of PF4 via their FcγRIIA. Methods Using platelet-bacteria suspension co-culture experiments and micropatterns with immobilized viable bacteria, in combination with pharmacological inhibitors and human anti- PF4/P IgG we analyzed the role of platelet-mediated killing of bacteria. Results In the presence of PF4, human anti-PF4/P IgG and platelets, E. coli killing (> 50%) with colony forming units (CFU mL-1 ) 0.71 × 104 ± 0.19 was observed compared with controls incubated only with anti-PF4/P IgG (CFU mL-1 3.4 × 104 ± 0.38). Blocking of platelet FcγRIIA using mAb IV.3 (CFU mL-1 2.5 × 104 ± 0.45), or integrin αIIbβ3 (CFU mL-1 2.26 × 104 ± 0.31), or disruption of cytoskeletal functions (CFU mL-1 2.7 × 104 ± 0.4) markedly reduced E. coli killing by this mechanism. Our observation of E. coli killing by platelets on micropatterned arrays is compatible with the model that platelets kill bacteria by covering them, actively concentrating them into the area under their granulomere and then releasing antimicrobial substances of platelet α-granules site directed towards bacteria. Conclusion These findings collectively indicate that by bridging of innate and adaptive immune mechanisms, platelets and anti-PF4/polyanion antibodies cooperate in an antibacterial host response.
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Affiliation(s)
- R Palankar
- Institute for Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - T P Kohler
- Department of Molecular Genetics and Infection Biology, Interfaculty Institute for Genetics and Functional Genomics, University of Greifswald, Greifswald, Germany
| | - K Krauel
- Institute for Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - J Wesche
- Institute for Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - S Hammerschmidt
- Department of Molecular Genetics and Infection Biology, Interfaculty Institute for Genetics and Functional Genomics, University of Greifswald, Greifswald, Germany
| | - A Greinacher
- Institute for Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
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Phan T, Mcmillan R, Skiadopoulos L, Walborn A, Hoppensteadt D, Fareed J, Bansal V. Elevated extracellular nucleosomes and their relevance to inflammation in stage 5 chronic kidney disease. INT ANGIOL 2018; 37:419-426. [PMID: 29644836 DOI: 10.23736/s0392-9590.18.03987-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Chronic kidney disease is a disorder characterized by a pro-inflammatory state that is associated with increased morbidity and mortality. Endogenous damage-associated molecular patterns, including nucleosomes, may contribute to this persistent inflammation. The aim of this study was to profile and evaluate the clinical significance of circulating nucleosomes in patients with Stage 5 chronic kidney disease (CKD5) on hemodialysis (HD). METHODS Under institutional review board approval, plasma samples were collected from 90 CKD5-HD patients (45 male and 45 female) prior to hemodialysis. Normal human plasma samples (25 male and 25 female) were used as a control group. Commercial enzyme-linked immunosorbent and colorimetric assays were used to profile nucleosome levels and biochemical markers of kidney injury, inflammation, thrombosis, and renal function in CKD5-HD and control groups. Clinical laboratory parameters were documented from the electronical medical record and correlated to nucleosome levels in the CKD5-HD cohort. RESULTS In comparison to healthy volunteers, the plasma from CKD5-HD patients exhibited markedly elevated nucleosomes (P<0.0001). Furthermore, nucleosome levels correlated with WBC count (P=0.025, R=0.243) and CRP (P=0.019, R=0.266) levels. No correlation was found between nucleosomes and the other parameters studied. CONCLUSIONS Our findings indicate extracellular nucleosomes are significantly elevated in CKD5-HD, suggesting increased cell death and/or inflammation. The observed correlations between nucleosomes and parameters of inflammation is suggestive of a complex, systemic inflammatory process underlying renal deterioration, consistent with the literature. Thus, nucleosomes may play a role in the pathogenesis and outcome of CKD5-HD.
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Affiliation(s)
- Trung Phan
- Stritch School of Medicine, Loyola University of Chicago, Maywood, IL, USA
| | - Ryan Mcmillan
- Stritch School of Medicine, Loyola University of Chicago, Maywood, IL, USA
| | | | - Amanda Walborn
- Stritch School of Medicine, Loyola University of Chicago, Maywood, IL, USA
| | - Debra Hoppensteadt
- Unit of Hemostasis and Thrombosis, Department of Pathology, Loyola University Medical Center, Maywood, IL, USA
| | - Jawed Fareed
- Unit of Hemostasis and Thrombosis, Department of Pathology, Loyola University Medical Center, Maywood, IL, USA -
| | - Vinod Bansal
- Unit of Nephrology, Department of Internal Medicine, Loyola University Medical Center, Maywood, IL, USA
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McMillan R, Skiadopoulos L, Hoppensteadt D, Guler N, Bansal V, Parasuraman R, Fareed J. Biomarkers of Endothelial, Renal, and Platelet Dysfunction in Stage 5 Chronic Kidney Disease Hemodialysis Patients With Heart Failure. Clin Appl Thromb Hemost 2018; 24:235-240. [PMID: 28990414 PMCID: PMC6707716 DOI: 10.1177/1076029617729216] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The aim of this study was to determine the role of endothelial, renal, and inflammatory biomarkers in the pathogenesis of heart failure (HF) in patients with stage 5 chronic kidney disease (CKD5) undergoing maintenance hemodialysis (HD). Plasma levels of biomarkers-kidney injury molecule 1 (KIM-1), N-terminal pro brain natriuretic peptide (NT-proBNP), glycated hemoglobin, neutrophil gelatinase-associated lipocalin, interleukin-18,platelet-derived growth factor, platelet factor 4 (PF4), 25-OH vitamin D, parathyroid hormone (PTH), endothelin, and endocan-were measured in CKD5-HD patients at the Loyola University Ambulatory Dialysis facility. The HF (+) CKD5-HD patients, as compared to HF (-) CKD5-HD patients, exhibited significantly elevated NT-proBNP ( P = .0194) and KIM-1 ( P = .0485). The NT-proBNP in HF (+) CKD5-HD patients was found to correlate with the levels of serum potassium ( P = .023, R = -.39), calcium ( P = .029, R = -.38), and PF4 ( P = .045, R = -.35). The KIM-1 in HF (+) CKD5-HD patients was found to correlate with PTH ( P = .043, R = -.36) and 25-OH vitamin D ( P = .037, R = .36). Elevated plasma NT-proBNP and KIM-1 in CKD5-HD and HF (+) CKD5-HD patients suggest that natriuretic peptides and KIM-1 may contribute to the pathogenesis of HF in CKD5-HD patients.
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Affiliation(s)
- Ryan McMillan
- Stritch School of Medicine, Loyola University of Chicago, Maywood, IL, USA
| | | | - Debra Hoppensteadt
- Department of Pathology, Loyola University Medical Center, Maywood, IL, USA
| | - Nil Guler
- Department of Pathology, Loyola University Medical Center, Maywood, IL, USA
| | - Vinod Bansal
- Department of Nephrology, Loyola University Medical Center, Maywood, IL, USA
| | | | - Jawed Fareed
- Department of Pathology, Loyola University Medical Center, Maywood, IL, USA
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Vayne C, Guery EA, Kizlik-Masson C, Rollin J, Bauters A, Gruel Y, Pouplard C. Beneficial effect of exogenous platelet factor 4 for detecting pathogenic heparin-induced thrombocytopenia antibodies. Br J Haematol 2017; 179:811-819. [DOI: 10.1111/bjh.14955] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 08/09/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Caroline Vayne
- Department of Haematology-Haemostasis; University Hospital of Tours; Tours France
- University François Rabelais; UMR CNRS 7292; Tours France
| | - Eve-Anne Guery
- Department of Haematology-Haemostasis; University Hospital of Tours; Tours France
- University François Rabelais; UMR CNRS 7292; Tours France
| | | | - Jérôme Rollin
- Department of Haematology-Haemostasis; University Hospital of Tours; Tours France
- University François Rabelais; UMR CNRS 7292; Tours France
| | - Anne Bauters
- Institute of Haematology-Transfusion; University Hospital of Lille; Lille France
| | - Yves Gruel
- Department of Haematology-Haemostasis; University Hospital of Tours; Tours France
- University François Rabelais; UMR CNRS 7292; Tours France
| | - Claire Pouplard
- Department of Haematology-Haemostasis; University Hospital of Tours; Tours France
- University François Rabelais; UMR CNRS 7292; Tours France
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Golden T, Ghazala S, Wadeea R, Junna S. Abciximab-induced acute profound thrombocytopenia postpercutaneous coronary intervention. BMJ Case Rep 2017; 2017:bcr-2017-221182. [PMID: 28710245 DOI: 10.1136/bcr-2017-221182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Abciximab (c7E3 Fab) is one of the three potent intravenous glycoprotein IIb/IIIa receptor inhibitors (along with eptifibatide and tirofiban) that have shown significant positive outcomes when used in patients with intracoronary thrombus. However, major side effects have been reported with its use including hypotension, major bleeding and thrombocytopenia. This case is a 53-year-old man presenting with acute chest pain diagnosed with non-ST-elevation myocardial infarction, who underwent percutaneous coronary intervention with abciximab and heparin infusion and developed acute profound thrombocytopenia (platelet count <20,000/L) within 9 hours of infusion. This case demonstrates the importance of routinely monitoring the platelet count prior to and 2-4 hours following abciximab infusion and differentiating other causes of acute profound thrombocytopenia, particularly pseudothrombocytopenia and heparin-induced thrombocytopenia.
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Affiliation(s)
- Todd Golden
- Department of Medicine, College of Medicine, University of Arizona, Tucson, USA
| | - Sehem Ghazala
- Department of Internal Medicine, University of Arizona, Tucson, USA
| | - Rita Wadeea
- Department of Medicine, Arizona Center on Aging, University of Arizona, Tucson, USA
| | - Shilpa Junna
- Department of Internal Medicine, University of Arizona, Tucson, USA
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Abstract
Due to familiarity, short half-life, ease of monitoring, and the availability of a reversal agent, heparin remains the anticoagulant of choice for cardiac operations requiring cardiopulmonary bypass (CPB). However, occasionally patients require CPB but should not receive heparin, most often because of acute or subacute heparin-induced thrombocytopenia (HIT). In these cases, if it is not feasible to wait for the disappearance of HIT antibodies, an alternative anticoagulant must be selected. A number of non-heparin anticoagulant options have been explored. However, current recommendations suggest the use of a direct thrombin inhibitor such as bivalirudin. This review describes the use of heparin alternatives for the conduct of CPB with a focus on the direct thrombin inhibitors.
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Lei BZ, Shatzel JJ, Sendowski M. Rapid and durable response to intravenous immunoglobulin in delayed heparin-induced thrombocytopenia: a case report. Transfusion 2016; 57:919-923. [DOI: 10.1111/trf.13960] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 10/31/2016] [Accepted: 11/08/2016] [Indexed: 12/16/2022]
Affiliation(s)
- Brandon Z. Lei
- Division of Hematology and Medical Oncology; Oregon Health and Science University, Knight Cancer Institute; Portland Oregon
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology; Oregon Health and Science University, Knight Cancer Institute; Portland Oregon
| | - Merav Sendowski
- Division of Hematology and Medical Oncology; Oregon Health and Science University, Knight Cancer Institute; Portland Oregon
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Davenport A. Management of Heparin-Induced Thrombocytopenia During Renal Replacement Therapy. Hemodial Int 2016; 5:81-85. [DOI: 10.1111/hdi.2001.5.1.81] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Heparin-induced thrombocytopenia (HIT) is an under-recognized, limb- and life-threatening complication of pharmacologic heparin administration. Antibody formation against heparin complexed to platelet factor 4 (PF4) is central to the pathogenesis of HIT. Heparin: PF4 antibodies promote platelet activation and aggregation as well as excess thrombin generation which may lead to clinical thrombosis. HIT should be suspected in patients who develop thrombocytopenia with or without associated arterial or venous thrombosis while on heparin. HIT is a clinical diagnosis. Specialized HIT assays should be interpreted with care. The cornerstone of HIT management is the discontinuation of all forms of heparin exposure and the institution of anticoagulation with an alternative agent. The direct thrombin inhibitors lepirudin and argatroban are currently available and approved for use in patients with HIT.
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Izumi M, Sakai T, Shirakawa A, Kozuru H, Jiuchi Y, Izumi Y, Asahara T, Kumagai K, Mawatari M, Osaki M, Motokawa S, Migita K. Reduced induction of anti-PF4/heparin antibody in RA patients after total knee arthroplasty. Arthritis Res Ther 2016; 18:191. [PMID: 27558507 PMCID: PMC4997690 DOI: 10.1186/s13075-016-1090-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 08/05/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Heparin-induced thrombocytopenia is caused by antibodies (Abs) specific to platelet factor 4 (PF4)/heparin complexes. In this study, we evaluated the rates of seroconversion of anti-PF4/heparin Ab between patients with rheumatoid arthritis (RA) and with osteoarthritis (OA) who underwent total knee arthroplasty. METHODS The subjects of this randomized controlled trial were 124 patients who underwent total knee arthroplasty (TKA) and received edoxaban with or without a foot pump as thromboprophylaxis. We measured anti-PF4/heparin Abs before and 10 days after surgery, as well as preoperative PF4, using commercially available ELISAs. We also used the database of J-PSVT, a hospital-based, prospective cohort study designed to document the effectiveness of thromboprophylactic agents during arthroplasty. RESULTS The rates of seroconversion to anti-PF4/heparin Ab were lower in RA patients (4.0 %) than in OA patients (25.5 %). The anti-PF4/heparin IgG optical density (OD) values did not differ before and after surgery in RA patients. In contrast, there was a significant increase in anti-PF4/heparin IgG OD values in OA patients after TKA. In the J-PSVT data, the postoperative seroconversion rates of anti-PF4/heparin Ab were lower in RA patients (10.4 %) than in OA patients (21.8 %) who received fondaparinux. The titers of anti-CCP Ab were significantly lower in RA patients with postoperative ant-PF4/heparin Ab compared with those without postoperative ant-PF4/heparin Ab There was no significant difference in preoperative PF4 levels between RA patients and OA patients. The heparin-binding affinity of the circulating PF4 was similar between RA patients and OA patients; however, the IgG fractions isolated from the sera of RA patients contained PF4 more frequently (69.2 %) than those from OA patients (10.2 %). CONCLUSIONS Our results showed a reduced likelihood of postoperative anti-PF/heparin Ab production in RA patients compared with OA patients. This suggests that the mechanisms underlying the anti-PF4 immune response in RA patients differ from the mechanisms of the anti-PF4/heparin immune response seen in OA patients after joint replacement. TRIAL REGISTRATION ISRCTN 18090286. Registered 8 July 2016.
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Affiliation(s)
- Masahiro Izumi
- Department of Molecular Immunology, Unit of Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-7-1, Nagasaki, 852-8501, Japan.,Department of Orthopedic Surgery, NHO Nagasaki Medical Center, Kubara 2-1001-1, Omura, Nagasaki, 856-8562, Japan
| | - Tatsuya Sakai
- Department of Molecular Immunology, Unit of Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-7-1, Nagasaki, 852-8501, Japan.,Department of Orthopedic Surgery, NHO Nagasaki Medical Center, Kubara 2-1001-1, Omura, Nagasaki, 856-8562, Japan
| | - Atsunori Shirakawa
- Department of Pharmacy, NHO Nagasaki Medical Center, Kubara 2-1001-1, Omura, Nagasaki, 856-8562, Japan
| | - Hideko Kozuru
- Department of Rheumatology, Clinical Research Center, NHO Nagasaki Medical Center, Kubara 2-1001-1, Omura, Nagasaki, 856-8562, Japan
| | - Yuka Jiuchi
- Department of Rheumatology, Clinical Research Center, NHO Nagasaki Medical Center, Kubara 2-1001-1, Omura, Nagasaki, 856-8562, Japan
| | - Yasumori Izumi
- Department of Rheumatology, Clinical Research Center, NHO Nagasaki Medical Center, Kubara 2-1001-1, Omura, Nagasaki, 856-8562, Japan
| | - Tomohiko Asahara
- Department of Orthopedic Surgery, NHO Nagasaki Medical Center, Kubara 2-1001-1, Omura, Nagasaki, 856-8562, Japan
| | - Kenji Kumagai
- Department of Orthopedic Surgery, NHO Nagasaki Medical Center, Kubara 2-1001-1, Omura, Nagasaki, 856-8562, Japan
| | - Masaaki Mawatari
- Department of Orthopedic Surgery, Saga University Hospital, Nabeshima 5-1-1, Saga, 849-8501, Japan
| | - Makoto Osaki
- Department of Orthopedic Surgery, Nagasaki University Hospital, Sakamoto 1-7-1, Nagasaki, 852-8501, Japan
| | | | - Kiyoshi Migita
- Department of Rheumatology, Clinical Research Center, NHO Nagasaki Medical Center, Kubara 2-1001-1, Omura, Nagasaki, 856-8562, Japan. .,Department of Rheumatology, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima, Fukushima, 960-1295, Japan.
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McMasters J, Panitch A. Prevention of Collagen-Induced Platelet Binding and Activation by Thermosensitive Nanoparticles. AAPS J 2015; 17:1117-25. [PMID: 26070443 PMCID: PMC4540739 DOI: 10.1208/s12248-015-9794-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 05/30/2015] [Indexed: 01/12/2023] Open
Abstract
Peripheral artery disease is an atherosclerotic occlusion in the peripheral vasculature that is typically treated via percutaneous transluminal angioplasty. Unfortunately, deployment of the angioplasty balloon damages the endothelial layer, exposing the underlying collagen and allowing for the binding and activation of circulating platelets, which initiate an inflammatory cascade leading to eventual restenosis. Here, we report on the development of poly(NIPAm-MBA-AMPS-AAc) nanoparticles that have a collagen I-binding peptide crosslinked to their surface allowing them to bind to exposed collagen. Once bound, these particles mask the exposed collagen from circulating platelets, effectively reducing collagen-mediated platelet activation. Using collagen I-coated plates, we demonstrate that these particles are able to bind to collagen at concentrations above 0.5 mg/mL. Once bound, these particles inhibit collagen-mediated platelet activation by over 60%. Using light scattering and zeta potential measurements, we investigated the potential of the nanoparticles as a drug delivery platform. We have verified that the collagen-binding nanoparticles retain the temperature sensitivity common to poly(NIPAm)-based nanoparticles while remaining colloidally stable in aqueous environments. We also demonstrate that they are able to passively load and release anti-inflammatory cell penetrating peptides. Combined, we have developed a collagen-binding nanoparticle that has dual therapy potential, preventing collagen-mediated platelet activation while delivering water-soluble therapeutics directly to the damaged area.
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Affiliation(s)
- James McMasters
- Weldon School of Biomedical Engineering, Purdue University, 206 S. Martin Jischke Dr., West Lafayette, Indiana 47907 USA
| | - Alyssa Panitch
- Weldon School of Biomedical Engineering, Purdue University, 206 S. Martin Jischke Dr., West Lafayette, Indiana 47907 USA
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Warkentin TE, Arnold DM, Nazi I, Kelton JG. The platelet serotonin-release assay. Am J Hematol 2015; 90:564-72. [PMID: 25775976 DOI: 10.1002/ajh.24006] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 03/05/2015] [Accepted: 03/08/2015] [Indexed: 12/24/2022]
Abstract
Few laboratory tests are as clinically useful as The platelet serotonin-release assay (SRA): a positive SRA in the appropriate clinical context is virtually diagnostic of heparin-induced thrombocytopenia (HIT), a life- and limb-threatening prothrombotic disorder caused by anti-platelet factor 4 (PF4)/heparin antibodies that activate platelets, thereby triggering serotonin-release. The SRA's performance characteristics include high sensitivity and specificity, although caveats include indeterminate reaction profiles (observed in ∼4% of test sera) and potential for false-positive reactions. As only a subset of anti-PF4/heparin antibodies detectable by enzyme-immunoassay (EIA) are additionally platelet-activating, the SRA has far greater diagnostic specificity than the EIA. However, requiring a positive EIA, either as an initial screening test or as an SRA adjunct, will reduce risk of a false-positive SRA (since a negative EIA in a patient with a "positive" SRA should prompt critical evaluation of the SRA reaction profile). The SRA also provides useful information on whether a HIT serum produces strong platelet activation even in the absence of heparin: such heparin-"independent" platelet activation is a marker of unusually severe HIT, including delayed-onset HIT and severe HIT complicated by consumptive coagulopathy with risk for microvascular thrombosis.
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Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
- Department of Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
| | - Donald M. Arnold
- Department of Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
| | - Ishac Nazi
- Department of Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
| | - John G. Kelton
- Department of Pathology and Molecular Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
- Department of Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
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Pinelli DF, Ford ML. Novel insights into anti-CD40/CD154 immunotherapy in transplant tolerance. Immunotherapy 2015; 7:399-410. [PMID: 25917630 PMCID: PMC5441999 DOI: 10.2217/imt.15.1] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Since the discovery of the CD40-CD154 costimulatory pathway and its critical role in the adaptive immune response, there has been considerable interest in therapeutically targeting this interaction with monoclonal antibodies in transplantation. Unfortunately, initial promise in animal models gave way to disappointment in clinical trials following a number of thromboembolic complications. However, recent mechanistic studies have identified the mechanism of these adverse events, as well as detailed a myriad of interactions between CD40 and CD154 on a wide variety of immune cell types and the critical role of this pathway in generating both humoral and cell-mediated alloreactive responses. This has led to resurgence in interest and the potential resurrection of anti-CD154 and anti-CD40 antibodies as clinically viable therapeutic options.
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Affiliation(s)
| | - Mandy L. Ford
- Emory Transplant Center, Emory University, Atlanta, GA
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39
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Abstract
Heparin is widely used for the prevention and treatment of thrombotic and particularly cardiovascular disorders. Unfortunately, 0.5 to 3.0% of patients given heparin develop an immune reaction, commonly termed Type II heparin-induced thrombocytopenia (HIT). This is characterized by a moderate thrombocytopenia and in some patients, a venous or arterial thrombosis. This frequently leads to disastrous sequelae, such as limb amputation and death. The pathophysiological basis of this serious adverse drug reaction is the production of an immunoglobulin G antibody that reacts with an antigenic complex consisting of heparin and platelet factor 4. A significant risk factor for the development of HIT is recent surgery, and the frequency of developing an antiheparin-platelet factor 4 or HIT antibody is particularly high in cardiac surgery patients, although surprisingly, only a few of these patients actually develop the clinical syndrome of HIT. This review will discuss the frequency, pathophysiology, clinical features, diagnosis and management of HIT.
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Affiliation(s)
- Beng H Chong
- Department of Medicine, St George Clinical School and Centre of Vascular Research, University of New South Wales, Sydney, New South Wales, USA.
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40
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Everds NE, Tarrant JM. Unexpected hematologic effects of biotherapeutics in nonclinical species and in humans. Toxicol Pathol 2013; 41:280-302. [PMID: 23471185 DOI: 10.1177/0192623312467400] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Biotherapeutics are expanding the arsenal of therapeutics available for treating and preventing disease. Although initially thought to have limited side effects due to the specificity of their binding, these drugs have now been shown to have potential for adverse drug reactions including effects on peripheral blood cell counts or function. Hematotoxicity caused by a biotherapeutic can be directly related to the activity of the biotherapeutic or can be indirect and due to autoimmunity, biological cascades, antidrug antibodies, or other immune system responses. Biotherapeutics can cause hematotoxicity primarily as a result of cellular activation, cytotoxicity, drug-dependent and independent immune responses, and sequelae from initiating cytokine and complement cascades. The underlying pathogenesis of biotherapeutic-induced hematotoxicity often is poorly understood. Nonclinical studies have generally predicted clinical hematotoxicity for recombinant cytokines and growth factors. However, most hematologic liabilities of biotherapeutics are not based on drug class but are species specific, immune-mediated, and of low incidence. Despite the potential for unexpected hematologic toxicity, the risk-benefit profile of most biotherapeutics is favorable; hematologic effects are readily monitorable and managed by dose modification, drug withdrawal, and/or therapeutic intervention. This article reviews examples of biotherapeutics that have unexpected hematotoxicity in nonclinical or clinical studies.
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Tessler O, Vorstenbosch J, Jones D, Lalonde S, Zadeh T. Heparin-induced thrombocytopenia and thrombosis as an under-diagnosed cause of flap failure in heparin-naive patients: A case report and systematic review of the literature. Microsurgery 2013; 34:157-63. [DOI: 10.1002/micr.22190] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Revised: 08/22/2013] [Accepted: 09/04/2013] [Indexed: 11/08/2022]
Affiliation(s)
- Oren Tessler
- Division of Plastic and Reconstructive Surgery; McGill University; Montreal QC
- Division of Plastic and Reconstructive Surgery; Massachusetts General Hospital; Boston MA
| | | | - Daniel Jones
- Faculty of Medicine; McGill University; Montreal QC
| | | | - Teanoosh Zadeh
- Division of Plastic and Reconstructive Surgery; McGill University; Montreal QC
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Warkentin TE. Anticoagulant failure in coagulopathic patients: PTT confounding and other pitfalls. Expert Opin Drug Saf 2013; 13:25-43. [DOI: 10.1517/14740338.2013.823946] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton Regional Laboratory Medicine Program, Hamilton General Hospital, Hamilton Health Sciences, 237 Barton St. E, Hamilton, Ontario L8L 2X2, Canada
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Walenga JM, Prechel M, Hoppensteadt D, Escalante V, Chaudhry T, Jeske WP, Bakhos M. Apixaban as an alternate oral anticoagulant for the management of patients with heparin-induced thrombocytopenia. Clin Appl Thromb Hemost 2013; 19:482-7. [PMID: 23780399 DOI: 10.1177/1076029613492876] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Due to the pronounced hypercoagulable state in heparin-induced thrombocytopenia (HIT), alternatives to heparin that do not interact with HIT antibodies are needed for anticoagulation management. This study was designed to determine whether the oral factor Xa inhibitor apixaban could be used. Functional platelet activation with apixaban in the presence of HIT antibodies was evaluated by the (14)C-serotonin release assay (SRA; washed platelets) and the heparin-induced platelet aggregation assay (PA-HIT; platelet-rich plasma). A consistent absence of platelet activation by apixaban (0.05-50 μg/mL) was observed: SRA (n = 35) 11 ± 4% and PA-HIT (n = 37) 8 ± 3% (mean ± standard error of the mean; positive is >20%) versus heparin (0.1 U/mL) 82 ± 3% SRA and 78 ± 6% PA-HIT (P < 0.01) versus enoxaparin (10 μg/mL) 73 ± 5% SRA and 62 ± 7% PA-HIT. Apixaban may provide an option for oral anticoagulation in patients with HIT, particularly for extended management and prevention.
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Affiliation(s)
- Jeanine M Walenga
- 1Department of Thoracic & Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL, USA
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Erratum. Clin Appl Thromb Hemost 2013; 19:344-9. [DOI: 10.1177/1076029613491346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Nazi I, Arnold DM, Smith JW, Horsewood P, Moore JC, Warkentin TE, Crowther MA, Kelton JG. FcγRIIa proteolysis as a diagnostic biomarker for heparin-induced thrombocytopenia. J Thromb Haemost 2013; 11:1146-53. [PMID: 23551961 DOI: 10.1111/jth.12208] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND A significant challenge in the management of heparin-induced thrombocytopenia (HIT) patients is making a timely and accurate diagnosis. The readily available enzyme immunoassays (EIAs) have low specificities. In contrast, platelet activation assays have higher specificities, but they are technically demanding and not widely available. In addition, ~ 10% of samples referred for HIT testing are initially classified as indeterminate by the serotonin release assay (SRA), which further delays accurate diagnosis. HIT is characterized by platelet activation, which leads to FcγRIIa proteolysis. This raises the possibility that identification of the proteolytic fragment of FcγRIIa could serve as a surrogate marker for HIT. OBJECTIVES To determine the specificity of platelet FcγRIIa proteolysis induced by sera from patients with HIT, and to correlate the results with those of the SRA. METHODS/PATIENTS Sera from HIT patients and control patients with other thrombocytopenic/prothrombotic disorders were tested for their ability to proteolyse FcγRIIa. The results were correlated with anti-platelet factor 4 (PF4)/heparin antibodies (EIA), and heparin-dependent platelet activation (SRA). RESULTS Only HIT patient samples (20/20) caused heparin-dependent FcγRIIa proteolysis, similar to what was shown by the SRA. None of the samples from the other patient groups or hospital controls caused FcγRIIa proteolysis. Among nine additional samples that tested indeterminate in the SRA, FcγRIIa proteolysis resolved five samples that had a positive anti-PF4/heparin EIA result; three had no FcγRIIa proteolysis, and two were shown to have heparin-dependent FcγRIIa proteolysis CONCLUSIONS This study suggests that heparin-dependent FcγRIIa proteolysis is at least as specific as the SRA for the diagnosis of HIT.
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Affiliation(s)
- I Nazi
- Department of Medicine, Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.
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46
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Nicolaides A, Fareed J, Kakkar AK, Comerota AJ, Goldhaber SZ, Hull R, Myers K, Samama M, Fletcher J, Kalodiki E, Bergqvist D, Bonnar J, Caprini JA, Carter C, Conard J, Eklof B, Elalamy I, Gerotziafas G, Geroulakos G, Giannoukas A, Greer I, Griffin M, Kakkos S, Lassen MR, Lowe GDO, Markel A, Prandoni P, Raskob G, Spyropoulos AC, Turpie AG, Walenga JM, Warwick D. Heparin-Induced Thrombocytopenia. Clin Appl Thromb Hemost 2013; 19:208-13. [DOI: 10.1177/1076029612474840s] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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47
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Heparin-Induced Thrombocytopenia. Platelets 2013. [DOI: 10.1016/b978-0-12-387837-3.00042-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Patel IJ, Davidson JC, Nikolic B, Salazar GM, Schwartzberg MS, Walker TG, Saad WA. Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions. J Vasc Interv Radiol 2012; 23:727-36. [PMID: 22513394 DOI: 10.1016/j.jvir.2012.02.012] [Citation(s) in RCA: 411] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 02/22/2012] [Accepted: 02/22/2012] [Indexed: 12/12/2022] Open
Affiliation(s)
- Indravadan J Patel
- Department of Radiology, University Hospitals Case Medical Center, Cleveland, OH, USA
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Results of a consensus meeting on the use of argatroban in patients with heparin-induced thrombocytopenia requiring antithrombotic therapy - a European Perspective. Thromb Res 2011; 129:426-33. [PMID: 22178575 DOI: 10.1016/j.thromres.2011.11.041] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 11/22/2011] [Accepted: 11/24/2011] [Indexed: 02/07/2023]
Abstract
Argatroban has been introduced as an alternative parenteral anticoagulant for HIT-patients in several European countries in 2005. In 2009 a panel of experts discussed their clinical experience with argatroban balancing risks and benefits of argatroban treatment in managing the highly procoagulant status of HIT-patients. This article summarizes the main conclusions of this round table discussion. An ongoing issue is the appropriate dosing of argatroban in special patient groups. Therefore, dosing recommendations for different HIT-patient groups (ICU patients; non-ICU patients, paediatric patients, and for patients undergoing renal replacement therapies) are summarized in this consensus statement. Because of the strong correlation between argatroban dosing requirements and scores used to characterize the severity of illness (APACHE; SAPS, SOFA) suitable dosing nomograms are given. This consensus statement contributes to clinically relevant information on the appropriate use and monitoring of argatroban based on the current literature, and provides additional information from clinical experience. As the two other approved drugs for HIT, danaparoid and lepirudin are either currently not available due to manufacturing problems (danaparoid) or will be withdrawn from the market in 2012 (lepirudin), this report should guide physicians who have limited experience with argatroban how to use this drug safely in patients with HIT.
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Contribution of Surface Localization to Platelet Activation by CD154 Antibodies and Introduction of a Novel Approach for Studying Immune Complex Activity. Thromb Res 2011; 127:571-5. [DOI: 10.1016/j.thromres.2009.12.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Revised: 12/18/2009] [Accepted: 12/30/2009] [Indexed: 11/19/2022]
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