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Ahmed A, Koster A, Lance M, Milojevic M. European guidelines on peri-operative venous thromboembolism prophylaxis: first update.: Chapter 1: Cardiovascular Surgery. Eur J Anaesthesiol 2024; 41:570-572. [PMID: 38957020 DOI: 10.1097/eja.0000000000002026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Affiliation(s)
- Aamer Ahmed
- From the Department of Anaesthesia and Critical Care, Glenfield Hospital, University Hospitals of Leicester, NHS, Trust, ESAIC (AA), Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicester, UK, ESAIC (AA), Sana Heart Centre Cottbus, Ruhr University Bochum, Germany, EACTAIC (AK), Aga Khan University Hospital Nairobi, Kenya, EACTAIC (ML) and Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia, EACTS (MM)
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Hollis IB, Jennings DL, Krim S, Ton VK, Ducharme A, Cowger J, Looby M, Eulert-Green JJ, Bansal N, Horn E, Byku M, Katz J, Michaud CJ, Rajapreyar I, Campbell P, Vale C, Cosgrove R, Hernandez-Montfort J, Otero J, Ingemi A, Raj S, Weeks P, Agarwal R, Martinez ES, Tops LF, Ahmed MM, Kiskaddon A, Kremer J, Keebler M, Ratnagiri RK. An ISHLT consensus statement on strategies to prevent and manage hemocompatibility related adverse events in patients with a durable, continuous-flow ventricular assist device. J Heart Lung Transplant 2024; 43:1199-1234. [PMID: 38878021 DOI: 10.1016/j.healun.2024.04.065] [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: 04/26/2024] [Accepted: 04/26/2024] [Indexed: 07/15/2024] Open
Abstract
Life expectancy of patients with a durable, continuous-flow left ventricular assist device (CF-LVAD) continues to increase. Despite significant improvements in the delivery of care for patients with these devices, hemocompatability-related adverse events (HRAEs) are still a concern and contribute to significant morbility and mortality when they occur. As such, dissemination of current best evidence and practices is of critical importance. This ISHLT Consensus Statement is a summative assessment of the current literature on prevention and management of HRAEs through optimal management of oral anticoagulant and antiplatelet medications, parenteral anticoagulant medications, management of patients at high risk for HRAEs and those experiencing thrombotic or bleeding events, and device management outside of antithrombotic medications. This document is intended to assist clinicians caring for patients with a CF-LVAD provide the best care possible with respect to prevention and management of these events.
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Affiliation(s)
- Ian B Hollis
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina; University of North Carolina Medical Center, Chapel Hill, North Carolina.
| | - Douglas L Jennings
- New York Presbyterian Columbia Irving Medical Center/Long Island University College of Pharmacy, New York, New York
| | - Selim Krim
- John Ochsner Heart and Vascular Institute, New Orleans, Louisiana
| | - Van-Khue Ton
- Massachusetts General Hospital, Boston, Massachusetts
| | - Anique Ducharme
- Montreal Heart Institute/Université de Montréal, Montreal, Quebec, Canada
| | | | - Mary Looby
- Inova Fairfax Medical Campus, Falls Church, Virginia
| | | | - Neha Bansal
- Mount Sinai Kravis Children's Hospital, New York, New York
| | - Ed Horn
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mirnela Byku
- University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Jason Katz
- Division of Cardiology, NYU Grossman School of Medicine & Bellevue Hospital, New York, New York
| | | | | | | | - Cassandra Vale
- The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Richard Cosgrove
- Cornerstone Specialty Hospital/University of Arizona College of Pharmacy, Tucson, Arizona
| | | | - Jessica Otero
- AdventHealth Littleton Hospital, Littleton, Colorado
| | | | | | - Phillip Weeks
- Memorial Hermann-Texas Medical Center, Houston, Texas
| | - Richa Agarwal
- Duke University Medical Center, Durham, North Carolina
| | | | - Laurens F Tops
- Leiden University Medical Center, Leiden, the Netherlands
| | | | - Amy Kiskaddon
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Mary Keebler
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Angeli M, Gialeraki A, Anastasopoulou I, Katsarou O, Politou M. Flow cytometry vs conventional methods for the evaluation of anti-PF4/heparin antibodies: a single center study. Bioanalysis 2024:1-11. [PMID: 39023297 DOI: 10.1080/17576180.2024.2373571] [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: 02/08/2024] [Accepted: 06/25/2024] [Indexed: 07/20/2024] Open
Abstract
Aim: Heparin-induced thrombocytopenia (HIT) is a rare, life-threatening, immune-mediated adverse effect of heparin administration. This study compares frequently used laboratory assays in terms of their effectiveness in HIT diagnosis. Materials & methods: Fifty patients with suspected HIT were tested by gel immunoassay and solid phase PF4/heparin antibody ELISA. On positive results, platelet activation markers P-selectin and Annexin V were assayed using flow cytometry. Results: Thirty/50 patients were negative for both immunoassays. Flow cytometry was performed in the 20 immunoassay positive patients. Platelet activation was observed in 7/20 in the presence of low heparin concentration (0.2 IU/ml). Conclusion: The results are in accordance with the currently available literature and flow cytometry seems a promising alternative in HIT laboratory investigation.
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Affiliation(s)
- Marina Angeli
- Department of Hematology, National & Kapodistrian University of Athens, General Hospital of Athens LAIKO, Athens, Greece
| | - Argyri Gialeraki
- Hematology Laboratory, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Anastasopoulou
- Blood Transfusion Service & National Reference Center for Congenital Bleeding Disorders, General Hospital of Athens LAIKO, Athens, Greece
| | - Olga Katsarou
- Blood Transfusion Service & National Reference Center for Congenital Bleeding Disorders, General Hospital of Athens LAIKO, Athens, Greece
| | - Marianna Politou
- Hematology Laboratory-Blood Bank, Aretaieio Hospital, School of Medicine,National & Kapodistrian University of Athens, Athens, Greece
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Giles JB, Martinez KL, Steiner HE, Klein A, Ooi A, Pryor J, Sweitzer N, Fuchs D, Karnes JH. Association of Metal Cations with the Anti-PF4/Heparin Antibody Response in Heparin-Induced Thrombocytopenia. Cardiovasc Toxicol 2024:10.1007/s12012-024-09895-w. [PMID: 39017812 DOI: 10.1007/s12012-024-09895-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/08/2024] [Indexed: 07/18/2024]
Abstract
Heparin-induced thrombocytopenia (HIT) is an antibody-mediated immune response against complexes of heparin and platelet factor 4 (PF4). The electrostatic interaction between heparin and PF4 is critical for the anti-PF4/heparin antibody response seen in HIT. The binding of metal cations to heparin induces conformational changes and charge neutralization of the heparin molecule, and cation-heparin binding can modulate the specificity and affinity for heparin-binding partners. However, the effects of metal cation binding to heparin in the context of anti-PF4/heparin antibody response have not been determined. Here, we utilized inductively coupled plasma mass spectrometry (ICP-MS) to quantify 16 metal cations in patient plasma and tested for correlation with anti-PF4/heparin IgG levels and platelet count after clinical suspicion of HIT in a cohort of heparin-treated patients. The average age of the cohort (n = 32) was 60.53 (SD = 14.31) years old, had a mean anti-PF4/heparin antibody optical density [OD405] of 0.93 (SD = 1.21) units, and was primarily female (n = 23). Patients with positive anti-PF4/heparin antibody test results (OD405 ≥ 0.5 units) were younger, had increased weight and BMI, and were more likely to have a positive serotonin release assay (SRA) result compared to antibody-negative patients. We observed statistical differences between antibody-positive and -negative groups for sodium and aluminum and significant correlations of anti-PF4/heparin antibody levels with sodium and silver. While differences in sodium concentrations were associated with antibody-positive status and correlated with antibody levels, no replication was performed. Additional studies are warranted to confirm our observed association, including in vitro binding studies and larger observational cohorts.
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Affiliation(s)
- Jason B Giles
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kiana L Martinez
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, 1295 N Martin AVE, Tucson, AZ, 85721, USA
| | - Heidi E Steiner
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, 1295 N Martin AVE, Tucson, AZ, 85721, USA
| | - Andrew Klein
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, 1295 N Martin AVE, Tucson, AZ, 85721, USA
| | - Aikseng Ooi
- Department of Pharmacology and Toxicology, University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Julie Pryor
- Banner University Medical Center-Tucson, Tucson, AZ, USA
| | - Nancy Sweitzer
- John T Milliken Department of Internal Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Deborah Fuchs
- Banner University Medical Center-Tucson, Tucson, AZ, USA
| | - Jason H Karnes
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, 1295 N Martin AVE, Tucson, AZ, 85721, USA.
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
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Huang Y, Dong D, Zhang W, Wang R, Lin YCD, Zuo H, Huang HY, Huang HD. DrugRepoBank: a comprehensive database and discovery platform for accelerating drug repositioning. Database (Oxford) 2024; 2024:baae051. [PMID: 38994794 PMCID: PMC11240114 DOI: 10.1093/database/baae051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 04/25/2024] [Accepted: 06/29/2024] [Indexed: 07/13/2024]
Abstract
In recent years, drug repositioning has emerged as a promising alternative to the time-consuming, expensive and risky process of developing new drugs for diseases. However, the current database for drug repositioning faces several issues, including insufficient data volume, restricted data types, algorithm inaccuracies resulting from the neglect of multidimensional or heterogeneous data, a lack of systematic organization of literature data associated with drug repositioning, limited analytical capabilities and user-unfriendly webpage interfaces. Hence, we have established the first all-encompassing database called DrugRepoBank, consisting of two main modules: the 'Literature' module and the 'Prediction' module. The 'Literature' module serves as the largest repository of literature-supported drug repositioning data with experimental evidence, encompassing 169 repositioned drugs from 134 articles from 1 January 2000 to 1 July 2023. The 'Prediction' module employs 18 efficient algorithms, including similarity-based, artificial-intelligence-based, signature-based and network-based methods to predict repositioned drug candidates. The DrugRepoBank features an interactive and user-friendly web interface and offers comprehensive functionalities such as bioinformatics analysis of disease signatures. When users provide information about a drug, target or disease of interest, DrugRepoBank offers new indications and targets for the drug, proposes new drugs that bind to the target or suggests potential drugs for the queried disease. Additionally, it provides basic information about drugs, targets or diseases, along with supporting literature. We utilize three case studies to demonstrate the feasibility and effectiveness of predictively repositioned drugs within DrugRepoBank. The establishment of the DrugRepoBank database will significantly accelerate the pace of drug repositioning. Database URL: https://awi.cuhk.edu.cn/DrugRepoBank.
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Affiliation(s)
- Yixian Huang
- School of Medicine, The Chinese University of Hong Kong, Shenzhen, Longgang District, Shenzhen, Guangdong 518172, China
- Warshel Institute for Computational Biology, School of Medicine, The Chinese University of Hong Kong, Shenzhen, Longgang District, Shenzhen, Guangdong 518172, China
| | - Danhong Dong
- School of Medicine, The Chinese University of Hong Kong, Shenzhen, Longgang District, Shenzhen, Guangdong 518172, China
- Warshel Institute for Computational Biology, School of Medicine, The Chinese University of Hong Kong, Shenzhen, Longgang District, Shenzhen, Guangdong 518172, China
| | - Wenyang Zhang
- School of Medicine, The Chinese University of Hong Kong, Shenzhen, Longgang District, Shenzhen, Guangdong 518172, China
- Warshel Institute for Computational Biology, School of Medicine, The Chinese University of Hong Kong, Shenzhen, Longgang District, Shenzhen, Guangdong 518172, China
| | - Ruiting Wang
- School of Medicine, The Chinese University of Hong Kong, Shenzhen, Longgang District, Shenzhen, Guangdong 518172, China
- Warshel Institute for Computational Biology, School of Medicine, The Chinese University of Hong Kong, Shenzhen, Longgang District, Shenzhen, Guangdong 518172, China
| | - Yang-Chi-Dung Lin
- School of Medicine, The Chinese University of Hong Kong, Shenzhen, Longgang District, Shenzhen, Guangdong 518172, China
- Warshel Institute for Computational Biology, School of Medicine, The Chinese University of Hong Kong, Shenzhen, Longgang District, Shenzhen, Guangdong 518172, China
| | - Huali Zuo
- School of Medicine, The Chinese University of Hong Kong, Shenzhen, Longgang District, Shenzhen, Guangdong 518172, China
- Warshel Institute for Computational Biology, School of Medicine, The Chinese University of Hong Kong, Shenzhen, Longgang District, Shenzhen, Guangdong 518172, China
| | - Hsi-Yuan Huang
- School of Medicine, The Chinese University of Hong Kong, Shenzhen, Longgang District, Shenzhen, Guangdong 518172, China
- Warshel Institute for Computational Biology, School of Medicine, The Chinese University of Hong Kong, Shenzhen, Longgang District, Shenzhen, Guangdong 518172, China
| | - Hsien-Da Huang
- School of Medicine, The Chinese University of Hong Kong, Shenzhen, Longgang District, Shenzhen, Guangdong 518172, China
- Warshel Institute for Computational Biology, School of Medicine, The Chinese University of Hong Kong, Shenzhen, Longgang District, Shenzhen, Guangdong 518172, China
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Minei V, Valesella P, Papandrea M, Sivera P, Insana A, Cosseddu D, Umurungi J, Montaruli B. Combination of 2 Quantitative Immunoassays and Clinical Score Algorithm to Reduce False-Negative Results in Heparin-Induced Thrombocytopenia: Prevalence Study of Mauriziano Hospital in Turin, Italy. J Appl Lab Med 2024:jfae062. [PMID: 38980803 DOI: 10.1093/jalm/jfae062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/15/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a serious adverse effect of heparin treatment caused by platelet-activating anti-platelet factor 4 (PF4)/heparin antibodies. Accurate diagnosis of HIT is essential but remains challenging. The aim of our study was to explore the performance of our optimized diagnostic laboratory algorithm, based on Chemiluminescence (CliA) and ELISA immunoassays, on suspected HIT patients. The study compared the prevalence of HIT diagnosis in A.O. Mauriziano with the literature. METHODS 163 consecutive patients were investigated for suspected HIT with CliA HemosIL Acustar HIT-IgG, Werfen. HIT was ruled out in all patients with CliA <0.13 U/mL. All patients with CliA >0.13 U/mL were further investigated with Zymutest-HIA anti-PF4 IgG ELISA immunoassay. In these patients, HIT was ruled out on the combination of CliA between 0.13 and 1.0 U/mL followed by ELISA assay <0.300 OD. HIT was ruled in patients whose plasma tested positive or doubtful with CliA and positive with ELISA immunoassay and confirmed positive with a platelet aggregation test (PAT). Suspicion of HIT was revealed with clinical 4Ts score or recent suggestive anamnestic history. RESULTS Our diagnostic algorithm ruled out HIT diagnosis in 144/163 patients (88%) and predicted a positive PAT in 5/19 (26%) of CliA positive (4/5) or ELISA positive and CliA doubtful (1/5) patients. CONCLUSIONS Our prevalence was 3.1%, comparable with the literature. The approach combining 2 quantitative immunoassays' (CliA and ELISA) results and 4Ts score probability was able to rule out the diagnosis within 1 h in 66% of patients with suspected HIT and within 24 h in 88% of patients. In the remaining 12% of cases, management decisions have to be based on individualized judgment while awaiting functional confirming results (48-72 h).
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Affiliation(s)
- Veronica Minei
- SC Laboratorio Analisi, Azienda Ospedaliera Ordine Mauriziano, Turin, Italy
| | - Paolo Valesella
- Dipartimento di patologia clinica e biochimica clinica, Unito, Turin, Italy
| | - Maria Papandrea
- SC Laboratorio Analisi, Azienda Ospedaliera Ordine Mauriziano, Turin, Italy
| | - Piera Sivera
- SC Ematologia, Azienda Ospedaliera Ordine Mauriziano, Turin, Italy
| | - Antonio Insana
- SC Laboratorio Analisi, Azienda Ospedaliera Ordine Mauriziano, Turin, Italy
| | - Domenico Cosseddu
- SC Laboratorio Analisi, Azienda Ospedaliera Ordine Mauriziano, Turin, Italy
| | - Johanna Umurungi
- SC Ematologia, Azienda Ospedaliera Ordine Mauriziano, Turin, Italy
| | - Barbara Montaruli
- SC Laboratorio Analisi, Azienda Ospedaliera Ordine Mauriziano, Turin, Italy
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Mukherjee A, Gentille C, Patel A, Ensor J, Rice L. Heparin-induced thrombocytopenia with very high antibody titer is associated with slower platelet recovery and higher risk of thrombosis. Int J Hematol 2024:10.1007/s12185-024-03811-2. [PMID: 38976179 DOI: 10.1007/s12185-024-03811-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 06/06/2024] [Accepted: 06/24/2024] [Indexed: 07/09/2024]
Abstract
Heparin-induced thrombocytopenia (HIT) is a prothrombotic disorder mediated by platelet-activating antibodies targeting platelet factor 4 (PF4) and heparin complex. A higher antibody titer is reflected in a higher optical density (OD) by enzyme-linked immunosorbent assay for heparin-PF4 antibodies. This single-institution retrospective study of 116 HIT patients examined the effect of heparin-PF4 OD on time to platelet recovery, vascular thrombosis, and in-hospital mortality. Patients were divided into 3 cohorts based on heparin-PF4 OD: cohort 1 had an OD ≥ 2 and ≤ 2.4, cohort 2 had an OD > 2.4 and ≤ 2.8, and cohort 3 had an OD > 2.8. A higher OD titer was associated with significantly increased time to platelet recovery when compared between cohorts 1 versus 2 (HR = 0.599, p = 0.0221) and 1 versus 3 (HR = 0.515, p = 0.0014), as well as an increased risk of thrombosis (79.4%-cohort 3 vs 53.8%-cohort 2 vs 46.1%-cohort 1, p = 0.04), but had no impact on mortality (2.62-alive vs 2.65-deceased, p = 0.7432). A higher OD titer can inform risk assessment and support decision-making in HIT patients; however, prospective studies are needed to further clarify the impact of heparin-PF4 OD on outcomes.
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Affiliation(s)
- Akash Mukherjee
- Department of Hematology and Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Cesar Gentille
- Department of Hematology and Oncology, Houston Methodist Hospital, Houston, TX, USA.
| | - Asmita Patel
- Department of Hematology and Oncology, Global Cancer Research Institute, San Jose, CA, USA
| | - Joe Ensor
- Department of Hematology and Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Lawrence Rice
- Department of Hematology and Oncology, Houston Methodist Hospital, Houston, TX, USA
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Warkentin TE. Limb Ischemic Necrosis Secondary to Microvascular Thrombosis: A Brief Historical Review. Semin Thromb Hemost 2024; 50:760-772. [PMID: 38688305 PMCID: PMC11167199 DOI: 10.1055/s-0044-1786356] [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] [Indexed: 05/02/2024]
Abstract
Ischemic limb injury can be broadly classified into arterial (absent pulses) and venous/microvascular (detectable pulses); the latter can be divided into two overlapping disorders-venous limb gangrene (VLG) and symmetrical peripheral gangrene (SPG). Both VLG and SPG feature predominant acral (distal) extremity ischemic necrosis, although in some instances, concomitant nonacral ischemia/skin necrosis occurs. Historically, for coagulopathic disorders with prominent nonacral ischemic necrosis, clinician-scientists implicated depletion of natural anticoagulants, especially involving the protein C (PC) system. This historical review traces the recognition of natural anticoagulant depletion as a key feature of nonacral ischemic syndromes, such as classic warfarin-induced skin necrosis, neonatal purpura fulminans (PF), and meningococcemia-associated PF. However, only after several decades was it recognized that natural anticoagulant depletion is also a key feature of predominantly acral ischemic microthrombosis syndromes-VLG and SPG-even when accompanying nonacral thrombosis is not present. These acquired acral limb ischemic syndromes typically involve the triad of (a) disseminated intravascular coagulation, (b) natural anticoagulant depletion, and (c) a localizing explanation for microthrombosis occurring in one or more limbs, either deep vein thrombosis (helping to explain VLG) or circulatory shock (helping to explain SPG). In most cases of VLG or SPG there are one or more events that exacerbate natural anticoagulant depletion, such as warfarin therapy (e.g., warfarin-associated VLG complicating heparin-induced thrombocytopenia or cancer hypercoagulability) or acute ischemic hepatitis ("shock liver") as a proximate factor predisposing to severe depletion of hepatically synthesized natural anticoagulants (PC, antithrombin) in the setting of circulatory shock.
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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
- Service of Benign Hematology, Hamilton Health Sciences, Hamilton General Hospital, Hamilton, Ontario, Canada
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Raymond C, Dell'Osso L, Golding C, Zahner C. Cost-Effectiveness and Return on Investment Analysis of an In-house HemosIL Heparin-Induced Thrombocytopenia Antibody Assay at a Mid-Sized Institution. Arch Pathol Lab Med 2024; 148:846-851. [PMID: 37756572 DOI: 10.5858/arpa.2023-0141-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2023] [Indexed: 09/29/2023]
Abstract
CONTEXT.— Laboratories face the challenge of providing quality patient care while managing costs and turnaround times (TATs). To this end, we brought the heparin-induced thrombocytopenia (HIT) antibody test in-house with the goal of reducing costs and the time to diagnosis. OBJECTIVES.— To determine the cost-effectiveness and return on investment of our in-house HIT antibody test by comparing it to send-out assays with TATs of 2, 3, or 4 days. DESIGN.— We performed a retrospective chart review of all patients with a HIT antibody assay and analysis of laboratory financial records. Analysis included the percentage of patients receiving alternative treatment, cost of treatment, startup costs of bringing the test in-house, and average TAT of the in-house test. RESULTS.— We found significant reductions in the cost of treatment for patients and the overall cost to the health care system. The in-house assay became cost-effective at between 8 and 20 tests, with a return on investment of up to 298%. CONCLUSIONS.— Bringing the HIT antibody assay in-house becomes cost-effective at a very low test volume with excellent return on investment. This novel analysis can provide a framework for other laboratory medicine professionals to analyze the benefits of bringing this and other assays in-house.
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Affiliation(s)
- Caitlin Raymond
- From the Departments of Pathology, University of Texas Medical Branch, Galveston(Raymond, Dell'Osso, Zahner)
| | - Liesel Dell'Osso
- From the Departments of Pathology, University of Texas Medical Branch, Galveston(Raymond, Dell'Osso, Zahner)
| | - Charles Golding
- From the Departments of Pharmacology, University of Texas Medical Branch, Galveston.(Golding)
| | - Christopher Zahner
- From the Departments of Pathology, University of Texas Medical Branch, Galveston(Raymond, Dell'Osso, Zahner)
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Song D, Jin Y, Zhang Y, Zhou Z. Heparin-induced thrombocytopenia in extracorporeal membrane oxygenation-supported patients: a systematic review and meta-analysis. Thromb J 2024; 22:55. [PMID: 38937784 PMCID: PMC11212165 DOI: 10.1186/s12959-024-00624-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/17/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND In recent years, extracorporeal membrane oxygenation (ECMO) has been increasingly used in critically ill patients with respiratory or cardiac failure. Heparin is usually used as anticoagulation therapy during ECMO support. However, heparin-induced thrombocytopenia (HIT) in ECMO-supported patients, which results in considerable morbidity and mortality, has not yet been well described. This meta-analysis and systematic review aimed to thoroughly report the incidence of HIT on ECMO, as well as the characteristics and outcomes of HIT patients. METHODS We searched the PubMed, Embase, Cochrane Library, and Scopus databases for studies investigating HIT in adult patients supported by ECMO. All studies conforming to the inclusion criteria were screened from 1975 to August 2023. Nineteen studies from a total of 1,625 abstracts were selected. The primary outcomes were the incidence of HIT and suspected HIT. RESULTS The pooled incidence of HIT in ECMO-supported patients was 4.2% (95% CI: 2.7-5.6; 18 studies). A total of 15.9% (95% CI: 9.0-22.8; 12 studies) of patients on ECMO were suspected of having HIT. Enzyme-linked immunosorbent assay (ELISA) is the most commonly used immunoassay. The median optical density (OD) of the ELISA in HIT-confirmed patients ranged from 1.08 to 2.10. In most studies, the serotonin release assay (SRA) was performed as a HIT-confirming test. According to the subgroup analysis, the pooled incidence of HIT in ECMO patients was 2.7% in studies whose diagnostic mode was functional assays, which is significantly lower than the incidence in studies in which the patients were diagnosed by immunoassay (14.5%). Argatroban was most commonly used as an alternative anticoagulation agent after the withdrawal of heparin. Among confirmed HIT patients, 45.5% (95% CI: 28.8-62.6) experienced thrombotic events, while 50.1% (95% CI: 24.9-75.4) experienced bleeding events. Overall, 46.6% (95% CI: 30.4-63.1) of patients on ECMO with HIT died. CONCLUSION According to our study, the pooled incidence of HIT in ECMO-supported patients is 4.2%, and it contributes to adverse outcomes. Inappropriate diagnostic methods can easily lead to misdiagnosis of HIT. Further research and development of diagnostic algorithms and laboratory assays are warranted.
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Affiliation(s)
- Danyu Song
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Fuwai Hospital, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Yu Jin
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Yang Zhang
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Fuwai Hospital, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
| | - Zhou Zhou
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Fuwai Hospital, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
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Nilius H, Hamzeh-Cognasse H, Hastings J, Studt JD, Tsakiris DA, Greinacher A, Mendez A, Schmidt A, Wuillemin WA, Gerber B, Vishnu P, Graf L, Kremer Hovinga JA, Bakchoul T, Cognasse F, Nagler M. Proteomic profiling for biomarker discovery in heparin-induced thrombocytopenia. Blood Adv 2024; 8:2825-2834. [PMID: 38588487 PMCID: PMC11176969 DOI: 10.1182/bloodadvances.2024012782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/19/2024] [Accepted: 03/19/2024] [Indexed: 04/10/2024] Open
Abstract
ABSTRACT New analytical techniques can assess hundreds of proteins simultaneously with high sensitivity, facilitating the observation of their complex interplay and role in disease mechanisms. We hypothesized that proteomic profiling targeting proteins involved in thrombus formation, inflammation, and the immune response would identify potentially new biomarkers for heparin-induced thrombocytopenia (HIT). Four existing panels of the Olink proximity extension assay covering 356 proteins involved in thrombus formation, inflammation, and immune response were applied to randomly selected patients with suspected HIT (confirmed HIT, n = 32; HIT ruled out, n = 38; and positive heparin/platelet factor 4 [H/PF4] antibodies, n = 28). The relative difference in protein concentration was analyzed using a linear regression model adjusted for sex and age. To confirm the test results, soluble P-selectin was determined using enzyme-linked immunosorbent assay (ELISA) in above mentioned patients and an additional second data set (n = 49). HIT was defined as a positive heparin-induced platelet activation assay (washed platelet assay). Among 98 patients of the primary data set, the median 4Ts score was 5 in patients with HIT, 4 in patients with positive H/PF4 antibodies, and 3 in patients without HIT. The median optical density of a polyspecific H/PF4 ELISA were 3.0, 0.9, and 0.3. Soluble P-selectin remained statistically significant after multiple test adjustments. The area under the receiver operating characteristic curve was 0.81 for Olink and 0.8 for ELISA. Future studies shall assess the diagnostic and prognostic value of soluble P-selectin in the management of HIT.
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Affiliation(s)
- Henning Nilius
- Department of Clinical Chemistry, Inselspital University Hospital Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Hind Hamzeh-Cognasse
- French Blood Establishment Auvergne-Rhone-Alpes, Saint-Etienne, France
- University Jean Monnet, Mines Saint-Etienne, INSERM, U 1059 SAINBIOSE, Saint-Etienne, France
| | - Janna Hastings
- Institute for Implementation Science in Health Care, Faculty of Medicine, University of Zurich, Zurich, Switzerland
- School of Medicine, University of St. Gallen, St. Gallen, Switzerland
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | | | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Adriana Mendez
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Adrian Schmidt
- Institute of Laboratory Medicine and Clinic of Medical Oncology and Hematology, Municipal Hospital Zurich Triemli, Zurich, Switzerland
| | - Walter A. Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne and University of Bern, Lucerne, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Prakash Vishnu
- Division of Hematology, Fred Hutchinson Cancer Center, University of Washington, Seattle, WA
| | - Lukas Graf
- Cantonal Hospital of St. Gallen, Center for Laboratory Medicine, St. Gallen, Switzerland
| | - Johanna A. Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital Bern University Hospital, Bern, Switzerland
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Fabrice Cognasse
- French Blood Establishment Auvergne-Rhone-Alpes, Saint-Etienne, France
- University Jean Monnet, Mines Saint-Etienne, INSERM, U 1059 SAINBIOSE, Saint-Etienne, France
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital University Hospital Bern, Bern, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
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12
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Salman G, Johannesmeyer HJ, Breen MJ. Key considerations in navigating ticagrelor's reported effect on heparin-induced thrombocytopenia functional assays in a landscape of limited data. Am J Health Syst Pharm 2024; 81:488-493. [PMID: 38365265 DOI: 10.1093/ajhp/zxae040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Indexed: 02/18/2024] Open
Abstract
PURPOSE This article discusses key considerations regarding ticagrelor's reported effect on heparin-induced thrombocytopenia functional assays, such as literature gaps and possible management strategies. SUMMARY Limited data indicate that ticagrelor may induce false-negative results in functional assays used in the diagnosis of heparin-induced thrombocytopenia. False-negative functional assays for heparin-induced thrombocytopenia could have catastrophic consequences. The manufacturer labeling of ticagrelor now includes a warning for this potential drug-laboratory interaction. This article suggests areas that would benefit from further research and strategies in navigating this possible interaction. CONCLUSION Clinicians should exercise caution when evaluating functional assays for heparin-induced thrombocytopenia in patients receiving ticagrelor. This article offers suggestions for future areas of research and potential management strategies.
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Affiliation(s)
- Genene Salman
- Department of Pharmacy Practice, College of Pharmacy, Marshall B. Ketchum University, Fullerton, CA, USA
| | - Herman J Johannesmeyer
- Department of Clinical Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University of California, Irvine, Irvine, CA, USA
| | - Martin J Breen
- Department of Pharmacy Services, St. Jude Medical Center, Fullerton, CA, USA
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13
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Sukumaran M, Cantrell DR, D'Agostino C, Jahromi BS, Ansari SA, Potts MB. Bivalirudin as a substitute for heparin in neurointervention for patients with heparin-induced thrombocytopenia. J Stroke Cerebrovasc Dis 2024; 33:107310. [PMID: 38636321 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/20/2023] [Accepted: 08/15/2023] [Indexed: 04/20/2024] Open
Abstract
OBJECTIVES Heparin-induced thrombocytopenia is a known complication of heparin exposure with potentially life-threatening sequelae. Direct thrombin inhibitors can be substituted for heparin in patients with heparin-induced thrombocytopenia that require anticoagulation. However, the use of direct thrombin inhibitors as a substitute for heparin has not been widely reported in the neuroendovascular literature. MATERIALS AND METHODS Here we report the first use of the direct thrombin inhibitor bivalirudin in a neuroendovascular procedure as a substitute for heparin in a patient with a ruptured pseudoaneurysm and heparin-induced thrombocytopenia, and review the literature on the use of bivalirudin and argatroban for such patients. RESULTS Bivalirudin was safely and effectively used in the case reported, with no thrombotic or hemorrhagic complications. Our literature review revealed a paucity of studies on the use of heparin alternatives, including bivalirudin, in neuroendovascular procedures in patients with heparin-induced thrombocytopenia. CONCLUSIONS Heparin-induced thrombocytopenia is an important iatrogenic disease process in patients undergoing neuroendovascular procedures, and developing protocols to diagnose and manage heparin-induced thrombocytopenia is important for healthcare systems. While further research needs to be done to establish the full range of anticoagulation options to substitute for heparin, our case indicates bivalirudin as a potential candidate.
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Affiliation(s)
- Madhav Sukumaran
- Clinical Fellow, Cerebrovascular and Endovascular Neurosurgery, Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02215, United States.
| | - Donald R Cantrell
- Departments of Radiology and Neurology, Northwestern Medicine, United States
| | | | - Babak S Jahromi
- Departments of Neurological Surgery, Neurology, and Radiology, Northwestern Medicine, United States
| | - Sameer A Ansari
- Departments of Neurological Surgery, Neurology, and Radiology, Northwestern Medicine, United States
| | - Matthew B Potts
- Departments of Neurological Surgery, Neurology, and Radiology, Northwestern Medicine, United States
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14
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Choi PYI, Uzun G, Bakchoul T. Results of an international survey of opinions on the definitions and treatments for heparin-induced thrombocytopenia: communication from the ISTH SSC Subcommittee on Platelet Immunology. J Thromb Haemost 2024; 22:1772-1778. [PMID: 38301999 DOI: 10.1016/j.jtha.2024.01.014] [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: 10/17/2023] [Revised: 01/08/2024] [Accepted: 01/20/2024] [Indexed: 02/03/2024]
Abstract
Heparin-induced thrombocytopenia (HIT) is rare, affecting fewer than 1 in 1500 hospital admissions. Despite the increasing adoption of new therapies in HIT, such as direct oral anticoagulants and pooled immunoglobulins, there is limited high-quality evidence to guide clinicians. Numerous uncommon presentations of HIT and HIT-like entities have recently been recognized, and a harmonized approach to their classification is required to study them better. We present the results of an international survey of opinions from experts and practitioners in the field of platelet immunology regarding the role of direct oral anticoagulants in HIT, novel definitions of subclassifications of HIT-like platelet factor 4 immune conditions (spontaneous autoimmune HIT, persistent autoimmune HIT, and treatment-refractory HIT), and the role for intravenous immunoglobulins in the treatment paradigm of HIT and these HIT-like conditions. From 102 survey responses, there was broad acceptance of rivaroxaban (74.5%) and apixaban (73.5%) even before platelet recovery, as well as for intravenous immunoglobulin in the management of spontaneous (85.6%), persistent (83.7%), and treatment-refractory HIT (87.4%). With this mandate for harmonizing terminologies and treatment approaches in special situations without robust clinical data owing to their rarity, we plan to conduct a robust survey, establish international consensus, and draft management guidelines for HIT and platelet factor 4 immune diseases in the near future.
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MESH Headings
- Humans
- Heparin/adverse effects
- Heparin/immunology
- Immunoglobulins, Intravenous/therapeutic use
- Immunoglobulins, Intravenous/adverse effects
- Thrombocytopenia/chemically induced
- Thrombocytopenia/immunology
- Thrombocytopenia/diagnosis
- Anticoagulants/adverse effects
- Platelet Factor 4/immunology
- Surveys and Questionnaires
- Pyrazoles/adverse effects
- Pyrazoles/therapeutic use
- Blood Platelets/immunology
- Blood Platelets/drug effects
- Blood Platelets/metabolism
- Pyridones/adverse effects
- Pyridones/therapeutic use
- Rivaroxaban/adverse effects
- Purpura, Thrombocytopenic, Idiopathic/chemically induced
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Health Care Surveys
- Terminology as Topic
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Affiliation(s)
- Philip Young-Ill Choi
- Haematology Department, the Canberra Hospital, Garran, Canberra, Australian Capital Territory, Australia; John Curtin School of Medical Research, Australian National University, Acton, Canberra, Australian Capital Territory, Australia
| | - Günalp Uzun
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany
| | - Tamam Bakchoul
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany.
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Mansour A, Berahou M, Odot J, Pontis A, Parasido A, Reizine F, Launey Y, Garlantézec R, Flecher E, Lecompte T, Nesseler N, Gouin-Thibault I. Antithrombin Levels and Heparin Responsiveness during Venoarterial Extracorporeal Membrane Oxygenation: A Prospective Single-center Cohort Study. Anesthesiology 2024; 140:1153-1164. [PMID: 38271619 PMCID: PMC11097948 DOI: 10.1097/aln.0000000000004920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/17/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Unfractionated heparin, administered during venoarterial extracorporeal membrane oxygenation to prevent thromboembolic events, largely depends on plasma antithrombin for its antithrombotic effects. Decreased heparin responsiveness seems frequent on extracorporeal membrane oxygenation; however, its association with acquired antithrombin deficiency is poorly understood. The objective of this study was to describe longitudinal changes in plasma antithrombin levels during extracorporeal membrane oxygenation support and evaluate the association between antithrombin levels and heparin responsiveness. The hypothesis was that extracorporeal membrane oxygenation support would be associated with acquired antithrombin deficiency and related decreased heparin responsiveness. METHODS Adults receiving venoarterial extracorporeal membrane oxygenation were prospectively included. All patients received continuous intravenous unfractionated heparin using a standardized protocol (target anti-Xa 0.3 to 0.5 IU/ml). For each patient, arterial blood was withdrawn into citrate-containing tubes at 11 time points (from hour 0 up to day 7). Anti-Xa (without dextran or antithrombin added) and antithrombin levels were measured. The primary outcome was the antithrombin plasma level. In the absence of consensus, antithrombin deficiency was defined as a time-weighted average of antithrombin less than or equal to 70%. Data regarding clinical management and heparin dosage were collected. RESULTS Fifty patients, including 42% postcardiotomy, were included between April 2020 and May 2021, with a total of 447 samples. Median extracorporeal membrane oxygenation duration was 7 (interquartile range, 4 to 12) days. Median antithrombin level was 48% (37 to 60%) at baseline. Antithrombin levels significantly increased throughout the follow-up. Time-weighted average of antithrombin levels was 63% (57 to 73%) and was less than or equal to 70% in 32 (64%) of patients. Overall, 45 (90%) patients had at least one antithrombin value less than 70%, and 35 (70%) had at least one antithrombin value less than 50%. Antithrombin levels were not significantly associated with heparin responsiveness evaluated by anti-Xa assay or heparin dosage. CONCLUSIONS Venoarterial extracorporeal membrane oxygenation support was associated with a moderate acquired antithrombin deficiency, mainly during the first 72 h, that did not correlate with heparin responsiveness. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Alexandre Mansour
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France; University of Rennes, National Institute of Health and Medical Research, Center of Clinical Investigation, Research Institute for Environmental and Occupational Health, University Hospital Federation Survival Optimization in Organ Transplantation, Univ Rennes, Rennes, France
| | - Mathilde Berahou
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Joscelyn Odot
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Adeline Pontis
- Department of Hematology, Pontchaillou, University Hospital of Rennes, Rennes, France; University of Rennes, National Institute of Health and Medical Research, Center of Clinical Investigation, Research Institute for Environmental and Occupational Health, University Hospital Federation Survival Optimization in Organ Transplantation, Univ Rennes, Rennes, France
| | - Alessandro Parasido
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Florian Reizine
- Department of Medical Intensive Care, University Hospital of Rennes, Rennes, France
| | - Yoann Launey
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Ronan Garlantézec
- Department of Epidemiology and Public Health, Pontchaillou, University Hospital of Rennes, Rennes, France; University of Rennes, National Institute of Health and Medical Research, Center of Clinical Investigation, Research Institute for Environmental and Occupational Health, University Hospital Federation Survival Optimization in Organ Transplantation, Univ Rennes, Rennes, France
| | - Erwan Flecher
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou, University Hospital of Rennes, University of Rennes, Signal and Image Treatment Laboratory, National Institute of Health and Medical Research U1099, Rennes, France
| | - Thomas Lecompte
- Department of Hematology, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Nicolas Nesseler
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France; University of Rennes, National Institute of Health and Medical Research, Center of Clinical Investigation, Nutrition, Metabolism, Cancer Mixed Research Unit, University Hospital Federation Survival Optimization in Organ Transplantation, Univ Rennes, Rennes, France
| | - Isabelle Gouin-Thibault
- Department of Hematology, Pontchaillou, University Hospital of Rennes, Rennes, France; University of Rennes, National Institute of Health and Medical Research, Research Institute for Environmental and Occupational Health, Rennes, France
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16
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Samimi MN, Hale A, Schults J, Fischer A, Roberts JA, Dhanani J. Clinical guidance for unfractionated heparin dosing and monitoring in critically ill patients. Expert Opin Pharmacother 2024; 25:985-997. [PMID: 38825778 DOI: 10.1080/14656566.2024.2364057] [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: 01/29/2024] [Accepted: 05/31/2024] [Indexed: 06/04/2024]
Abstract
INTRODUCTION Unfractionated heparin is a widely used anticoagulant in critically ill patients. It has a well-established safety profile and remains an attractive option for clinicians due to its short half-life and reversibility. Heparin has a unique pharmacokinetic profile, which contributes to significant inter-patient and intra-patient variability in effect. The variability in anticoagulant effect combined with heparin's short half-life mean close monitoring is required for clinical efficacy and preventing adverse effects. To optimize heparin use in critically ill patients, effective monitoring assays and dose adjustment strategies are needed. AREAS COVERED This paper explores the use of heparin as an anticoagulant and optimal approaches to monitoring in critically ill patients. EXPERT OPINION Conventional monitoring assays for heparin dosing have significant limitations. Emerging data appear to favor using anti-Xa assay monitoring for heparin anticoagulation, which many centers have successfully adopted as the standard. The anti-Xa assay appears have important benefits relative to the aPTT for heparin monitoring in critically ill patients, and should be considered for broader use.
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Affiliation(s)
- May N Samimi
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Andrew Hale
- Discipline of Pharmacy, School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Jessica Schults
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Andreas Fischer
- Pharmacy Department, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Jayesh Dhanani
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Sugraliyev AB. [Heparin-Induced Thrombocytopenia]. KARDIOLOGIIA 2024; 64:18-25. [PMID: 38841785 DOI: 10.18087/cardio.2024.5.n2186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 10/28/2022] [Indexed: 06/07/2024]
Abstract
The extensive use of therapeutic doses of heparin to prevent thrombosis in critically ill patients with COVID-19 during the pandemic has led to an increased incidence of bleeding and heparin-induced thrombocytopenia (HIT). In addition, the introduction of the AstraZeneca and Johnson&Johnson vaccines against COVID-19 into clinical practice was associated with the development of a rare but very severe, adverse thrombotic complication, vaccine-induced immune thrombotic thrombocytopenia (VITT). Thrombotic complications of VITT turned out to be similar to HIT both clinically and pathophysiologically. HIT is a potentially fatal immune-mediated adverse drug response that results in emergence of antibodies that activate platelets in the presence of heparin. HIT is characterized by a high incidence of venous and arterial thromboses, often with fatal outcomes. Currently, there are clearly defined international guidelines for the diagnosis, treatment and prevention of HIT. In case of thrombotic complications, non-heparin anticoagulants should be used.
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18
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Giles JB, Martinez KL, Steiner HE, Klein A, Ooi A, Pryor J, Sweitzer N, Fuchs D, Karnes JH. Association of Metal Cations with the Anti-PF4/Heparin Antibody Response in Heparin-Induced Thrombocytopenia. RESEARCH SQUARE 2024:rs.3.rs-4385055. [PMID: 38798628 PMCID: PMC11118685 DOI: 10.21203/rs.3.rs-4385055/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Heparin-induced thrombocytopenia (HIT) is an antibody-mediated immune response against complexes of heparin and platelet factor 4 (PF4). The electrostatic interaction between heparin and PF4 is critical for the anti-PF4/heparin antibody response seen in HIT. The binding of metal cations to heparin induces conformational changes and charge neutralization of the heparin molecule, and cation-heparin binding can modulate the specificity and affinity for heparin-binding partners. However, the effects of metal cation binding to heparin in the context of anti-PF4/heparin antibody response have not been determined. Here, we utilized inductively coupled plasma mass spectrometry (ICP-MS) to quantify 16 metal cations in patient plasma and tested for correlation with anti-PF4/heparin IgG levels and platelet count after clinical suspicion of HIT in a cohort of heparin-treated patients. The average age of the cohort (n = 32) was 60.53 (SD = 14.31) years old, had a mean anti-PF4/heparin antibody optical density [OD405] of 0.93 (SD = 1.21) units and was primarily female (n = 23). Patients with positive anti-PF4/heparin antibody test results (OD405 ≥ 0.5 units) were younger, had increased weight and BMI, and were more likely to have a positive serotonin release assay (SRA) result compared to antibody negative patients. We observed statistical differences between antibody positive and negative groups for sodium and aluminum and significant correlations of anti-PF4/heparin antibody levels with sodium and silver. While differences in sodium concentrations were associated with antibody positive status and correlated with antibody levels, no replication was performed. Additional studies are warranted to confirm our observed association, including in vitro binding studies and larger observational cohorts.
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19
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Attah A, Peterson C, Jacobs M, Bhagavatula R, Shah D, Kaplan R, Samhouri Y. Anti-PF4 ELISA-Negative, SRA-Positive Heparin-Induced Thrombocytopenia. Hematol Rep 2024; 16:295-298. [PMID: 38804282 PMCID: PMC11130879 DOI: 10.3390/hematolrep16020029] [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: 10/20/2022] [Revised: 01/31/2024] [Accepted: 02/19/2024] [Indexed: 05/29/2024] Open
Abstract
Heparin products are frequently used in the inpatient setting to prevent and treat venous thromboembolism, but they simultaneously put patients at risk of developing heparin-induced thrombocytopenia (HIT). The 4Ts score determines the pretest probability of HIT. Diagnosis is made with a screening antiplatelet factor (PF4) immunoassay and the serotonin-release assay (SRA) as a confirmatory test. Anti-PF4 assays have high sensitivity (98%) but lower specificity (50%) and result in frequent false-positive tests. We present a rare case from our institution of a patient with anti-PF4-Polyanion ELISA-negative, SRA-positive HIT and describe the challenges in making a timely diagnosis in this case.
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Affiliation(s)
- Abraham Attah
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15212, USA
| | - Chelsea Peterson
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA 15212, USA (Y.S.)
| | - Max Jacobs
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA 15212, USA
| | - Rama Bhagavatula
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA 15212, USA (Y.S.)
| | - Deep Shah
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA 15212, USA (Y.S.)
| | - Robert Kaplan
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA 15212, USA (Y.S.)
| | - Yazan Samhouri
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA 15212, USA (Y.S.)
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Bevilacqua S, Stefàno P, Berteotti M, Del Pace S, Pieri M, Mandarano R, Rogolino A, Cesari F, Gori AM, Giusti B, Marcucci R. Heparin-induced thrombocytopenia after cardiac surgery. A single-center, retrospective cohort study. Res Pract Thromb Haemost 2024; 8:102465. [PMID: 39036670 PMCID: PMC11260323 DOI: 10.1016/j.rpth.2024.102465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/17/2024] [Indexed: 07/23/2024] Open
Abstract
Background Cardiac surgery is a high-risk setting for heparin-induced thrombocytopenia (HIT). However, large differences in its incidence, rate of thrombotic complications, and mortality have been reported in this context. Few studies address the pharmacologic management of HIT specifically in this setting. Objectives To describe the incidence, outcomes, and management of patients with HIT in our cohort and to compare them with patients presenting platelet factor 4/heparin antibodies but without platelet-activating capacity. Methods A retrospective observational study was conducted over a period of 10 years and 6 months on 13,178 cardiac operations in a single high-volume cardiac surgery center. Results HIT was diagnosed in 0.22% of patients. HIT with associated thromboembolic complications occurred in 0.04% of cases. Two deaths at 30 days were registered, both in patients with associated thrombosis. The 4T score showed a 99.9% negative predictive value. The immunoglobulin G-specific chemiluminescence test positivity rate was highly predictive of HIT. Warfarin was often started early after surgery, and although it was rarely stopped when the diagnosis of HIT was made, no new thromboembolic complications subsequently occurred. Thrombocytopenia appeared to be a poor prognostic sign, whatever the cause. Conclusion Although rare, HIT is characterized by high mortality in this setting, especially if thrombotic complications occur. Large multicentric studies or an international registry should be created to enhance the scientific evidence on HIT diagnosis and management in this context.
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Affiliation(s)
- Sergio Bevilacqua
- Department of Anesthesia and Intensive Care, University Hospital Careggi, Firenze, Italy
| | - Pierluigi Stefàno
- Department of Cardiothoracic and Vascular Surgery, University Hospital Careggi, Firenze, Italy
| | - Martina Berteotti
- Department of Experimental and Clinical Medicine, Atherothrombotic Diseases Center, University Hospital Careggi, Firenze, Italy
| | - Stefano Del Pace
- Department of Cardiothoracic and Vascular Surgery, University Hospital Careggi, Firenze, Italy
| | - Matteo Pieri
- Department of Anesthesia and Intensive Care, University Hospital Careggi, Firenze, Italy
| | - Raffaele Mandarano
- Department of Anesthesia and Intensive Care, University Hospital Careggi, Firenze, Italy
| | - Angela Rogolino
- Department of Experimental and Clinical Medicine, Atherothrombotic Diseases Center, University Hospital Careggi, Firenze, Italy
| | - Francesca Cesari
- Department of Experimental and Clinical Medicine, Atherothrombotic Diseases Center, University Hospital Careggi, Firenze, Italy
| | - Anna Maria Gori
- Department of Experimental and Clinical Medicine, Atherothrombotic Diseases Center, University Hospital Careggi, Firenze, Italy
| | - Betti Giusti
- Department of Experimental and Clinical Medicine, Atherothrombotic Diseases Center, University Hospital Careggi, Firenze, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, Atherothrombotic Diseases Center, University Hospital Careggi, Firenze, Italy
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Zon RL, Sylvester KW, Rubins D, Grandoni J, Kelly J, Timilsina S, Akladious M, Patel R, Connors JM. Electronic alerts to improve management of heparin-induced thrombocytopenia. Res Pract Thromb Haemost 2024; 8:102423. [PMID: 38953054 PMCID: PMC11215413 DOI: 10.1016/j.rpth.2024.102423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/04/2024] [Accepted: 04/10/2024] [Indexed: 07/03/2024] Open
Abstract
Background Heparin-induced thrombocytopenia (HIT) is a difficult clinicopathologic diagnosis to make and to treat. Delays in identification and appropriate treatment can lead to increased morbidity and mortality. Objectives To use electronic health alert interventions to improve provider diagnosis and management of heparin-induced thrombocytopenia through guideline-based, accurate care delivery. Methods This quality improvement initiative developed 3 electronic health record-based interventions at our 750-bed academic medical center to improve the initial management of suspected HIT between 2018 and 2021: 1. an interruptive alert to recommend discontinuation of active heparin products when signing a heparin-platelet factor 4 test (PF4) order, 2. integrated 4T score calculation in the heparin-PF4 test order, and 3. interruptive alert suggesting not to order heparin-PF4 tests when the 4T score is <4. Changes in practice were assessed over defined time periods pre and post each intervention. Results Intervention 1 resulted in heparin discontinuation in more patients, with 65% (191 heparin orders/293 heparin-PF4 enzyme-linked immunosorbent assay tests) of cases continuing heparin prealert and only 54% (127 heparin orders/235 heparin-PF4 enzyme-linked immunosorbent assay tests) postinterruptive alert (95% CI 2.3-19.9; P = .015). Intervention 2 increased appropriate heparin-PF4 test ordering from 40.4% (110/272) preintervention to 79.1% (246/311) (95% CI 30.9-46.4; P < .00001) postintervention, with inappropriate PF4 ordering defined as testing when 4T score was <4. Intervention 3 did not lead to reduction in heparin-PF4 testing in the control group (96 inappropriate orders/402 total orders, 24%) compared to the randomized alert group (56 inappropriate orders/298 total orders; 19%) (95% CI -1.2 to 11.5; P = .13). Conclusion Implementation of unique electronic health record interventions, including both diagnostic and management interventions, led to improved guideline-based, accurate care delivery with 4T score calculation and cessation of heparin for patients with suspected HIT.
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Affiliation(s)
- Rebecca L. Zon
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Hematology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Katelyn W. Sylvester
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - David Rubins
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jessica Grandoni
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Julie Kelly
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Shreya Timilsina
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Mark Akladious
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Rajesh Patel
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jean M. Connors
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Hematology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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22
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Warkentin TE. A career in solving clinical-pathological conundrums: Heyde syndrome, anti-platelet factor 4 disorders, and microvascular limb ischemic necrosis. Int J Lab Hematol 2024; 46 Suppl 1:12-26. [PMID: 38432651 DOI: 10.1111/ijlh.14261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/14/2024] [Indexed: 03/05/2024]
Abstract
Hematology is a clinical specialty with strong roots in the laboratory; accordingly, the lab can help solve perplexing clinical problems. This review highlights clinical-pathological conundrums addressed during my 35-year hematology career at McMaster University. Heyde syndrome is the association between aortic stenosis and bleeding gastrointestinal (GI) angiodysplasia where the bleeding is usually cured by aortic valve replacement; the chance reading of a neonatal study showing reversible deficiency of high-molecular-weight (HMW) multimers of von Willebrand factor (vWF) following surgical correction of congenital heart disease provided the key insight that a subtle deficiency of HMW multimers of vWF explains Heyde syndrome. The unusual immunobiology of heparin-induced thrombocytopenia (HIT)-a highly prothrombotic, antibody-mediated, anti-platelet factor 4 (PF4) disorder featuring rapid appearance and then disappearance (seroreversion) of the pathological heparin-dependent platelet-activating antibodies-permitted identification of key clinical features that informed development of a scoring system (4Ts) to aid in HIT diagnosis. Atypical clinical presentations of HIT prompted identification of heparin-independent anti-PF4 antibodies, now recognized as the explanation for vaccine-induced immune thrombotic thrombocytopenia (VITT), as well as VITT-like disorders triggered by adenovirus infection. Another unusual feature of HIT is its strong association with limb ischemia, including limb necrosis secondary to deep-vein/microvascular thrombosis (venous limb gangrene). The remarkable observation that supratherapeutic warfarin anticoagulation predisposes to HIT- and cancer-associated venous limb gangrene provided insight into disturbed procoagulant/anticoagulant balance; these concepts are relevant to microvascular thrombosis in critical illness (symmetrical peripheral gangrene), including a pathophysiological role for proximate "shock liver" (impaired hepatic synthesis of natural anticoagulants).
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Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, and Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Yamada S, Asakura H. How We Interpret Thrombosis with Thrombocytopenia Syndrome? Int J Mol Sci 2024; 25:4956. [PMID: 38732176 PMCID: PMC11084439 DOI: 10.3390/ijms25094956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/16/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
Platelets play an important role in hemostasis, and a low platelet count usually increases the risk of bleeding. Conditions in which thrombosis occurs despite low platelet counts are referred to as thrombosis with thrombocytopenia syndrome, including heparin-induced thrombocytopenia, vaccine-induced immune thrombotic thrombocytopenia, paroxysmal nocturnal hemoglobinuria, antiphospholipid syndrome, thrombotic microangiopathy (TMA), and disseminated intravascular coagulation. TMA includes thrombotic thrombocytopenic purpura, Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (HUS), and atypical HUS. Patients with these pathologies present with thrombosis and consumptive thrombocytopenia associated with the activation of platelets and the coagulation system. Treatment varies from disease to disease, and many diseases have direct impacts on mortality and organ prognosis if therapeutic interventions are not promptly implemented. Underlying diseases and the results of physical examinations and general laboratory tests as part of a thorough workup for patients should promptly lead to therapeutic intervention before definitive diagnosis. For some diseases, the diagnosis and initial treatment must proceed in parallel. Utilization of not only laboratory tests but also various scoring systems is important for validating therapeutic interventions based on clinical information.
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Affiliation(s)
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, Takaramachi 13-1, Kanazawa City 920-8640, Ishikawa, Japan;
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24
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Tauzi P, Aubourg C, Dang Van S, Gros A, Sargentini C, Rineau E. A Case Report of Pulmonary Embolectomy Under Cardiopulmonary Bypass in a Patient with Intracranial Hemorrhage and History of Heparin-Induced Thrombocytopenia. A A Pract 2024; 18:e01767. [PMID: 38578015 DOI: 10.1213/xaa.0000000000001767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Pulmonary embolism is a common complication after intracranial hemorrhage. As thrombolysis is contraindicated in this situation, surgical pulmonary embolectomy may be indicated in case of high-risk pulmonary embolism but requires transient anticoagulation with heparin during cardiopulmonary bypass. We report the case of a patient with a history of heparin-induced thrombocytopenia who presented with a high-risk pulmonary embolism 10 days after the spontaneous onset of a voluminous intracerebral hematoma. Despite high doses of heparin required to run the cardiopulmonary bypass and subsequent anticoagulation by danaparoid sodium, the brain hematoma remained stable and the patient was discharged without complications 30 days after surgery.
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Affiliation(s)
- Paul Tauzi
- From the Departments of Department of Anaesthesia and Critical Care, Angers University Hospital, Angers, France
| | - Corentin Aubourg
- From the Departments of Department of Anaesthesia and Critical Care, Angers University Hospital, Angers, France
| | - Simon Dang Van
- Cardiac Surgery, Angers University Hospital, Angers, France
| | - Antoine Gros
- From the Departments of Department of Anaesthesia and Critical Care, Angers University Hospital, Angers, France
| | - Cyril Sargentini
- From the Departments of Department of Anaesthesia and Critical Care, Angers University Hospital, Angers, France
| | - Emmanuel Rineau
- From the Departments of Department of Anaesthesia and Critical Care, Angers University Hospital, Angers, France
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25
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Moriguchi G, Umehara T, Yano Y, Fujita T, Kishima H. Paradoxical Worsening of Cerebral Venous Sinus Thrombosis Due to Heparin-Induced Thrombocytopenia: A Case Report and Literature Review. Cureus 2024; 16:e58124. [PMID: 38738156 PMCID: PMC11088870 DOI: 10.7759/cureus.58124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2024] [Indexed: 05/14/2024] Open
Abstract
Development of cerebral venous sinus thrombosis (CVST) is a rare manifestation of heparin-induced thrombocytopenia (HIT). Herein, we present a case in which heparin administration for primary CVST caused paradoxical worsening of CVST secondary to HIT. A 53-year-old woman diagnosed with CVST was provided with intravenous unfractionated heparin therapy. After 12 days, the patient presented tonic convulsive seizures (TCS). Subsequent magnetic resonance image (MRI) scans revealed an exacerbation of cerebral edema with a subcortical hemorrhage on the left parietal lobe. Laboratory test results revealed a significant decline in platelet count. Heparin was immediately discontinued and replaced with argatroban. The definitive diagnosis of HIT was made through the presence of HIT antibodies. The present case, in which HIT caused the secondary CVST exacerbation, is distinctly rare. Our case provides an instructive example by highlighting the potential of TCS as the first sign of HIT development during CVST treatment.
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Affiliation(s)
- Gento Moriguchi
- Department of Neurosurgery, Hanwa Memorial Hospital, Osaka, JPN
| | - Toru Umehara
- Department of Neurosurgery, Hanwa Memorial Hospital, Osaka, JPN
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, JPN
| | - Yoshihiro Yano
- Department of Neurosurgery, Hanwa Memorial Hospital, Osaka, JPN
| | - Toshiaki Fujita
- Department of Neurosurgery, Hanwa Memorial Hospital, Osaka, JPN
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, JPN
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26
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Djulbegovic B, Hozo I, Cuker A, Guyatt G. Improving methods of clinical practice guidelines: From guidelines to pathways to fast-and-frugal trees and decision analysis to develop individualised patient care. J Eval Clin Pract 2024; 30:393-402. [PMID: 38073027 DOI: 10.1111/jep.13953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Current methods for developing clinical practice guidelines have several limitations: they are characterised by the "black box" operation-a process with defined inputs and outputs but an incomplete understanding of its internal workings; they have "the integration problem"-a lack of framework for explicitly integrating factors such as patient preferences and trade-offs between benefits and harms; they generate one recommendation at a time that typically are not connected in a coherent analytical framework; and they apply to "average" patients, while clinicians and their patients seek advice tailored to individual circumstances. METHODS We propose augmenting the current guideline development method by converting evidence-based pathways into fast-and-frugal decision trees (FFTs) and integrating them with generalised decision curve analysis to formulate clear, individualised management recommendations. RESULTS We illustrate the process by developing recommendations for the management of heparin-induced thrombocytopenia (HIT). We converted evidence-based pathways for HIT, developed by the American Society of Hematology, into an FFT. Here, we consider only thrombotic complications and major bleeding. We leveraged the predictive potential of FFTs to compare the effects of argatroban, bivalirudin, fondaparinux, and direct oral anticoagulants (DOACs) using generalised decision curve analysis. We found that DOACs were superior to other treatments if the FFT-predicted probability of HIT exceeded 3%. CONCLUSIONS The proposed analytical framework connects guidelines, pathways, FFTs, and decision analysis, offering risk-tailored personalised recommendations and addressing current guideline development critiques.
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Affiliation(s)
- Benjamin Djulbegovic
- Division of Medical Hematology and Oncology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Iztok Hozo
- Department of Mathematics, Indiana University Northwest, Gary, Indiana, USA
| | - Adam Cuker
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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27
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Bakkaloğlu SA, Ezgü D, Hari P, Boyer O, Schaefer F. Perception and knowledge of pediatric nephrologists on evidence-based guideline development methodology. Pediatr Nephrol 2024; 39:1015-1018. [PMID: 37648842 DOI: 10.1007/s00467-023-06139-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 08/11/2023] [Accepted: 08/11/2023] [Indexed: 09/01/2023]
Affiliation(s)
- Sevcan A Bakkaloğlu
- Division of Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine, Gazi University, Ankara, Turkey.
| | - Defne Ezgü
- Faculty of Medicine, Başkent University, Ankara, Turkey
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Olivia Boyer
- Néphrologie Pédiatrique, Centre de Référence MARHEA, Hôpital Necker-Enfants Malades, APHP, Institut Imagine, Université Paris Cité, Inserm U1163, Paris, France
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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28
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Yin Q, Han L, Wang Y, Kang F, Cai F, Wu L, Zheng X, Li L, Dong LE, Dong L, Liang S, Chen M, Yang Y, Bian Y. Unlocking the potential of fondaparinux: guideline for optimal usage and clinical suggestions (2023). Front Pharmacol 2024; 15:1352982. [PMID: 38529183 PMCID: PMC10961909 DOI: 10.3389/fphar.2024.1352982] [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: 12/15/2023] [Accepted: 02/12/2024] [Indexed: 03/27/2024] Open
Abstract
Background: Thromboembolic disease is associated with a high rate of disability or death and gravely jeopardizes people's health and places considerable financial pressure on society. The primary treatment for thromboembolic illness is anticoagulant medication. Fondaparinux, a parenteral anticoagulant medicine, is still used but is confusing due to its disparate domestic and international indications and lack of knowledge about its usage. Its off-label drug usage in therapeutic settings and irrational drug use are also common. Objective: The aim of this guideline is to enhance the judicious clinical application of fondaparinux by consolidating the findings of evidence-based research on the drug and offering superior clinical suggestions. Methods: Seventeen clinical questions were developed by 37 clinical pharmacy experts, and recommendations were formulated under the supervision of three methodologists. Through methodical literature searches and the use of recommendation, assessment, development and evaluation grading techniques, we gathered evidence. Results: This guideline culminated in 17 recommendations, including the use of fondaparinux for venous thromboembolism (VTE) prevention and treatment, perioperative surgical prophylaxis, specific diseases, special populations, bleeding and overdose management. For different types of VTE, we recommend first assessing thrombotic risk in hospitalized patients and then administering the drug according to the patient's body mass. In surgical patients in the perioperative period, fondaparinux may be used for VTE prophylaxis, but postoperative use usually requires confirmation that adequate hemostasis has been achieved. Fondaparinux may be used for anticoagulation prophylaxis in patients hospitalized for oncological purposes, in patients with atrial fibrillation (AF) after resuscitation, in patients with cirrhosis combined with portal vein thrombosis (PVT), in patients with antiphospholipid syndrome (APS), and in patients with inflammatory bowel disease (IBD). Fondaparinux should be used with caution in special populations, such as pregnant female patients with a history of heparin-induced thrombocytopenia (HIT) or platelet counts less than 50 × 109/L, pregnant patients with a prethrombotic state (PTS) combined with recurrent spontaneous abortion (RSA), and children. For bleeding caused by fondaparinux, dialysis may partially remove the drug. Conclusion: The purpose of this guideline is to provide all healthcare providers with high-quality recommendations for the clinical use of fondaparinux and to improve the rational use of the drug in clinical practice. Currently, there is a lack of a dedicated antidote for the management of fondaparinux. The clinical investigation of activated prothrombin complex concentrate (APCC) or recombinant activated factor VII (rFⅦa) as potential reversal agents is still pending. This critical gap necessitates heightened scrutiny and research emphasis, potentially constituting a novel avenue for future inquiries into fondaparinux sodium. A meticulous examination of adverse events and safety profiles associated with the utilization of fondaparinux sodium will contribute significantly to a more comprehensive understanding of its inherent risks and benefits within the clinical milieu.
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Affiliation(s)
- Qinan Yin
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Lizhu Han
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yin Wang
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Fengjiao Kang
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Fengqun Cai
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Liuyun Wu
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xingyue Zheng
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Lian Li
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Li e Dong
- Department of Pharmacy, The Third People’s Hospital of Chengdu, Sichuan, China
| | - Limei Dong
- Department of Pharmacy, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Shuhong Liang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Min Chen
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yong Yang
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yuan Bian
- Department of Pharmacy, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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29
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Genzen JR, Moser KA. The FDA's proposed rule on laboratory-developed tests: what happens next? Lab Med 2024; 55:109-110. [PMID: 38373253 DOI: 10.1093/labmed/lmae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024] Open
Affiliation(s)
- Jonathan R Genzen
- Department of Pathology, University of Utah Health, Salt Lake City, UT, US
- ARUP Laboratories, Salt Lake City, UT, US
| | - Karen A Moser
- Department of Pathology, University of Utah Health, Salt Lake City, UT, US
- ARUP Laboratories, Salt Lake City, UT, US
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30
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Larsen EL, Nilius H, Studt JD, Tsakiris DA, Greinacher A, Mendez A, Schmidt A, Wuillemin WA, Gerber B, Vishnu P, Graf L, Kremer Hovinga JA, Goetze JP, Bakchoul T, Nagler M. Accuracy of Diagnosing Heparin-Induced Thrombocytopenia. JAMA Netw Open 2024; 7:e243786. [PMID: 38530310 DOI: 10.1001/jamanetworkopen.2024.3786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
Importance Heparin-induced thrombocytopenia (HIT) is a life-threatening condition that requires urgent diagnostic clarification. However, knowledge of the diagnostic utility of the recommended diagnostic tests is limited in clinical practice. Objective To evaluate the current diagnostic practice for managing the suspicion of HIT. Design, Setting, and Participants This prospective diagnostic study was conducted from January 2018 to May 2021 among consecutive patients with suspected HIT from 11 study centers in Switzerland, Germany, and the United States. Detailed clinical data and laboratory information were recorded. Platelet factor 4/heparin antibodies were quantified using an automated chemiluminescent immunoassay (CLIA). A washed-platelet heparin-induced platelet activation (HIPA) test was used as a reference standard to define HIT. Exposures Suspicion of HIT. Main Outcomes and Measures The primary outcome was the diagnostic accuracy of the 4Ts score, the CLIA, and the recommended algorithm serially combining both tests. Results Of 1448 patients included between 2018 and 2021, 1318 were available for the current analysis (median [IQR] age, 67 [57-75] years; 849 [64.6%] male). HIPA was positive in 111 patients (prevalence, 8.4%). The most frequent setting was intensive care unit (487 [37.0%]) or cardiovascular surgery (434 [33.0%]). The 4Ts score was low risk in 625 patients (46.8%). By 2 × 2 table, the numbers of patients with false-negative results were 10 (9.0%; 4Ts score), 5 (4.5%; CLIA), and 15 (13.5%; recommended diagnostic algorithm). The numbers of patients with false-positive results were 592 (49.0%; 4Ts score), 73 (6.0%; CLIA), and 50 (4.1%; recommended diagnostic algorithm), respectively. Conclusions and Relevance In this diagnostic study of patients suspected of having HIT, when the recommended diagnostic algorithm was used in clinical practice, antibody testing was required in half the patients. A substantial number of patients were, however, still misclassified, which could lead to delayed diagnosis or overtreatment. Development of improved diagnostic algorithms for HIT diagnosis should be pursued.
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Affiliation(s)
- Emil List Larsen
- Department of Clinical Biochemistry, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Henning Nilius
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | | | - Andreas Greinacher
- Department of Transfusion Medicine, Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Adriana Mendez
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Adrian Schmidt
- Institute of Laboratory Medicine and Clinic of Medical Oncology and Hematology, Municipal Hospital Zurich Triemli, Zurich, Switzerland
| | - Walter A Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne and University of Bern, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Prakash Vishnu
- Fred Hutchinson Cancer Center, University of Washington, Seattle
| | - Lukas Graf
- Cantonal Hospital of St Gallen, St Gallen, Switzerland
| | - Johanna A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Jens P Goetze
- Department of Clinical Biochemistry, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health, Copenhagen University, Copenhagen, Denmark
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, Bern, Switzerland
- University of Bern, Bern, Switzerland
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31
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Zlamal J, Aliotta A, Alberio L, Chen V, Bakchoul T. Diagnostic value of antibody-induced procoagulant platelets in heparin-induced thrombocytopenia: communication from the ISTH SSC Subcommittee on Platelet Immunology. J Thromb Haemost 2024; 22:860-868. [PMID: 38065529 DOI: 10.1016/j.jtha.2023.11.019] [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: 07/27/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 12/30/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is an immune-mediated prothrombotic disorder characterized by a drop in platelet count and an increased risk of thromboembolic events. The accurate diagnosis of HIT involves clinical assessment and laboratory testing with well-characterized functional tests. Recent research has shown the potential of investigating procoagulant platelet formation induced by HIT antibodies. To successfully implement these assays in clinical laboratories, careful consideration of technical and preanalytical factors is crucial. In this communication from the SSC Platelet Immunology, we provide a consensus from experts on the use of flow cytometry in HIT diagnosis, highlighting the importance of standardized protocols.
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Affiliation(s)
- Jan Zlamal
- Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany
| | - Alessandro Aliotta
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Vivien Chen
- ANZAC Research Institute, Sydney Local Health District, Sydney, New South Wales, Australia; Department of Haematology, Concord Repatriation General Hospital and NSW Health Pathology, Sydney, New South Wales, Australia; Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Tamam Bakchoul
- Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany.
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32
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Nepal N, Patel D, Omosebi O, Shin Y. Type II Heparin-Induced Thrombocytopenia Manifesting As Cardiac Arrest Following Intravenous Heparin Bolus During an Elective Procedure: A Case Report and Literature Review. Cureus 2024; 16:e57072. [PMID: 38681320 PMCID: PMC11052637 DOI: 10.7759/cureus.57072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a rare and life-threatening autoimmune-mediated adverse drug reaction seen in patients who are exposed to various forms of pharmacological heparin, including unfractionated heparin (UFH) and low molecular weight heparin (LMWH). Despite the presence of thrombocytopenia, these patients face the risk of clot formation and bleeding simultaneously. Prompt cessation of heparin and the initiation of non-heparin anticoagulants are important for the patient's survival. Typically, clinical diagnosis of HIT is necessary, and waiting for lab test results, which can take days, may not be always feasible. Here, we present a case of an unusual presentation of type II HIT, complicated by significant thrombocytopenia, pulmonary hemorrhage, and cardiac arrest after receiving intravenous (IV) heparin bolus during an elective cardiac ablation procedure for paroxysmal atrial fibrillation.
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Affiliation(s)
- Nisha Nepal
- Internal Medicine, Danbury Hospital, Danbury, USA
| | - Dhiraj Patel
- Internal Medicine, University of Vermont, Burlington, USA
| | - Opeyemi Omosebi
- Internal Medicine, Connecticut Institute For Communities, Inc., Danbury, USA
| | - Yong Shin
- Medicine, Danbury Hospital, Danbury, USA
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Erdoes G, Koster A, Levy JH. Monitoring Argatroban Anticoagulation in the Critically Ill: All Tests Are Not Created Equal. Anesthesiology 2024; 140:189-191. [PMID: 38193739 DOI: 10.1097/aln.0000000000004814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Affiliation(s)
- Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Koster
- Institute of Anesthesiology and Pain Therapy, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina
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Heubner L, Oertel R, Tiebel O, Mehlig-Warnecke N, Beyer-Westendorf J, Mirus M, Roessler M, Renner B, Spieth PM. Monitoring of Argatroban in Critically Ill Patients: A Prospective Study Comparing Activated Partial Thromboplastin Time, Point-of-Care Viscoelastic Testing with Ecarin Clotting Time and Diluted Thrombin Time to Mass Spectrometry. Anesthesiology 2024; 140:261-271. [PMID: 37787760 DOI: 10.1097/aln.0000000000004787] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
BACKGROUND The direct thrombin inhibitor argatroban is indicated for the treatment of heparin-induced thrombocytopenia II, but it is also used off-label to treat critically ill patients presenting with heparin resistance, severe antithrombin deficiency, or hypercoagulability. Direct drug monitoring is not routinely available, and argatroban dosing is mainly based on global coagulation assays such as activated partial thromboplastin time (PTT) or diluted thrombin time (TT), both of which have limitations in patients with hypercoagulability. METHODS Blood samples were obtained from critically ill patients treated with argatroban. Activated PTT and diluted TT were measured with a STA R Max3 analyzer (STAGO Deutschland GmbH, Germany) using an argatroban-calibrated kit. Ecarin clotting time was measured using a point-of-care viscoelastic test device. Liquid chromatography with tandem mass spectrometry was performed using a reversed-phase column, a solvent gradient, and an API4000 mass spectrometer with electrospray. Correlation was described using Pearson correlation coefficient r and Bayesian multilevel regression to estimate relationships between outcomes and covariates. RESULTS From June 2021 to March 2022, 205 blood samples from 22 patients were analyzed, allowing for 195 activated PTT-liquid chromatography with tandem mass spectrometry comparisons, 153 ecarin clotting time-liquid chromatography with tandem mass spectrometry comparison, and 105 diluted TT-liquid chromatography with tandem mass spectrometry comparisons. Compared to liquid chromatography with tandem mass spectrometry, performance of argatroban quantification was best for diluted TT (r = 0.91), followed by ecarin clotting time (r = 0.58) and activated PTT (r = 0.48). Regression analysis revealed that patients with sepsis were more prone to argatroban overdosing (coefficient, 4.194; 95% credible interval, 2.220 to 6.792). CONCLUSIONS Although activated PTT monitoring of argatroban is the most commonly used test, in critically ill patients, diluted TT provides more precise measurements. Alternately, point-of-care viscoelastic ecarin clotting time also provides guidance for argatroban dosing to identify overdosing if available. The data also suggested that patients with sepsis are at greater risk for argatroban overdosing. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Lars Heubner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| | - Reinhard Oertel
- Institute of Clinical Pharmacology, Faculty of Medicine, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| | - Oliver Tiebel
- Institute of Clinical Chemistry, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| | - Nicole Mehlig-Warnecke
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| | - Jan Beyer-Westendorf
- Division of Hematology and Hemostasis, Department of Medicine I Thrombosis Research, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| | - Martin Mirus
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Martin Roessler
- BARMER Institut für Gesundheitssystemforschung, Berlin, Germany
| | - Bertold Renner
- Institute of Clinical Pharmacology, Faculty of Medicine, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| | - Peter Markus Spieth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
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Arachchillage DJ, Thachil J, Anderson JAM, Baker P, Poles A, Kitchen S, Laffan M. Diagnosis and management of heparin-induced thrombocytopenia: Third edition. Br J Haematol 2024; 204:459-475. [PMID: 38153164 DOI: 10.1111/bjh.19180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 12/29/2023]
Affiliation(s)
- Deepa J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Julia A M Anderson
- Department of Haematology, Edinburgh Royal Infirmary, Edinburgh, Scotland
| | - Peter Baker
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Anthony Poles
- Bristol NHS Blood and Transplant Centre, Bristol, UK
| | - Steve Kitchen
- Department of Haematology, Royal Hallamshire Hospital, Sheffield, UK
| | - Mike Laffan
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
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Müller L, Dabbiru VAS, Schönborn L, Greinacher A. Therapeutic strategies in FcγIIA receptor-dependent thrombosis and thromboinflammation as seen in heparin-induced thrombocytopenia (HIT) and vaccine-induced immune thrombocytopenia and thrombosis (VITT). Expert Opin Pharmacother 2024; 25:281-294. [PMID: 38465524 DOI: 10.1080/14656566.2024.2328241] [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: 01/18/2024] [Accepted: 03/05/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Fcγ-receptors (FcγR) are membrane receptors expressed on a variety of immune cells, specialized in recognition of the Fc part of immunoglobulin G (IgG) antibodies. FcγRIIA-dependent platelet activation in platelet factor 4 (PF4) antibody-related disorders have gained major attention, when these antibodies were identified as the cause of the adverse vaccination event termed vaccine-induced immune thrombocytopenia and thrombosis (VITT) during the COVID-19 vaccination campaign. With the recognition of anti-PF4 antibodies as cause for severe spontaneous and sometimes recurrent thromboses independent of vaccination, their clinical relevance extended far beyond heparin-induced thrombocytopenia (HIT) and VITT. AREAS COVERED Patients developing these disorders show life-threatening thromboses, and the outcome is highly dependent on effective treatment. This narrative literature review summarizes treatment options for HIT and VITT that are currently available for clinical application and provides the perspective toward new developments. EXPERT OPINION Nearly all these novel approaches are based on in vitro, preclinical observations, or case reports with only limited implementation in clinical practice. The therapeutic potential of these approaches still needs to be proven in larger cohort studies to ensure treatment efficacy and long-term patient safety.
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Affiliation(s)
- Luisa Müller
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Venkata A S Dabbiru
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Linda Schönborn
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Andreas Greinacher
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
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Tucker CM, Rhoades R, Sharma R, Gong JZ. Optimization of laboratory diagnosis of heparin-induced thrombocytopenia using HemosIL-AcuStar-HIT-IgG assay. Lab Med 2024; 55:34-39. [PMID: 37094798 DOI: 10.1093/labmed/lmad029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
OBJECTIVE The aim of this study was to determine an optimal cutoff value for the newly available HemosIL-AcuStar-HIT-IgG assay (AcuStar) for the diagnosis of heparin-induced thrombocytopenia (HIT). METHOD We evaluated the performance of AcuStar using serotonin release assay (SRA) as the gold standard and incorporated 4T score calculation in a cohort of suspected HIT cases. Statistical analysis was performed to determine optimal cutoff value for the diagnosis of HIT. RESULT A diagnosis of HIT can be excluded with a platelet factor 4 (PF4) value of <0.4 U/mL by AcuStar and 4T score in the low-risk category (≤3). All other cases will require confirmation with a functional test. CONCLUSION Our study resulted in the implementation of a diagnostic algorithm for laboratory diagnosis of HIT, which incorporates pretest calculation of 4T score and AcuStar as a screening test, with reflex confirmation by SRA. This new algorithm resulted in extended hours of test availability and a more rapid turnaround time in reporting PF4 results.
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Affiliation(s)
- Catherine M Tucker
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA, US
| | - Ruben Rhoades
- Department of Medicine, Division of Hematology, Thomas Jefferson University, Philadelphia, PA, US
| | - Ruchika Sharma
- Department of Pediatrics, Division of Hematology/Oncology/BMT, Medical College of Wisconsin, Versiti Blood Research Institute, Milwaukee, WI,US
| | - Jerald Z Gong
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA, US
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Habibi S, Hsieh TC, Khanna S. Perioperative Plasma Exchange and Intravenous Immunoglobulin Use for Refractory Heparin-Induced Thrombocytopenia in a Liver Transplant Recipient. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e941865. [PMID: 38158651 PMCID: PMC10765992 DOI: 10.12659/ajcr.941865] [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: 07/21/2023] [Revised: 12/20/2023] [Accepted: 12/06/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a serious adverse effect of heparin, which can lead to a prothrombotic state. Prompt cessation of heparin and initiation of non-heparin anticoagulation is the standard of care for HIT. Nevertheless, the treatment can pose challenges, particularly in refractory HIT, in patients with contraindications to anticoagulation, or those requiring urgent surgery. Additionally, in rare cases, conventional anticoagulation therapy is not effective, necessitating alternative treatments such as plasma exchange (PLEX) and intravenous immunoglobulin (IVIG). CASE REPORT Here, we report the case of a 57-year-old male patient who developed mild acute cellular rejection, refractory HIT, and disseminated intravascular coagulation after liver transplant surgery. Heparin was stopped and argatroban was initiated for thromboembolism treatment, but hepatic artery thrombosis occurred in the setting of refractory HIT and caused transplant failure. The patient underwent a second liver transplant 1 month after the first surgery. He had 2 sessions of PLEX and received 1 dose of IVIG before and 1 dose during the operation. Despite advanced treatment with PLEX and IVIG, the refractory HIT persisted. Hepatic artery thrombosis recurred within 2 weeks and the transplant failed again despite catheter-directed intra-arterial thrombolysis and argatroban therapy. CONCLUSIONS Recently perioperative PLEX and IVIG have been used a few times for the treatment of refractory HIT. This is the first reported case of a liver transplant recipient with refractory HIT who underwent this treatment strategy. Further investigation is required to determine the efficacy and safety of preoperative and intraoperative administration of PLEX and IVIG, especially in liver transplant recipients with HIT.
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Affiliation(s)
- Shaghayegh Habibi
- Department of Internal Medicine, Lucy Curci Cancer Center, Eisenhower Health, Rancho Mirage, CA, USA
| | - Tien-Chan Hsieh
- Division of Hematology and Oncology, Department of Medicine, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Shrinkhala Khanna
- Division of Hematology and Oncology, Department of Medicine, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
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Porres-Aguilar M, Najera C, Mares AC, Benzidia I, Prakash S, Crichi B. Successful Treatment With the Oral Factor Xa Inhibitor Edoxaban in Heparin-Induced Thrombocytopenia With Thrombosis. Angiology 2023:33197231225291. [PMID: 38153027 DOI: 10.1177/00033197231225291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Heparin-induced thrombocytopenia with thrombosis (HITT) is a rare immune reaction to the drug heparin that causes increased blood clotting, putting patients at risk for arterial and venous thromboembolism which can have severe consequences. We present a case of HITT successfully treated with the direct oral anticoagulant (DOAC), edoxaban. A 56-year-old man had surgery to remove a colorectal mass. After discharge, he developed chest discomfort, shortness of breath, and low oxygen levels and was diagnosed with a right-sided lobar pulmonary embolism. His platelet count dropped, his tests confirmed a diagnosis of HITT, and he was initially treated with fondaparinux. After showing clinical and laboratory improvement, he was switched to edoxaban. Despite being diagnosed with colonic adenocarcinoma during follow-up, the patient's platelet count returned to normal, and he did not experience any more blood clots or serious bleeding events. The use of DOACs like edoxaban as potential therapies for HITT is promising; further research is being conducted to evaluate their effectiveness, safety, and potential benefits for treating this acquired high-risk thrombophilia.
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Affiliation(s)
- Mateo Porres-Aguilar
- Department of Internal Medicine, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Carolina Najera
- Department of Internal Medicine, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, TX, USA
| | | | - Ilham Benzidia
- Vascular Medicine Unit, Department of Thoracic, Cardiovascular Surgery and Vascular Medicine, CHU Reunion-Site Nord, Saint Denis, France
| | - Swathi Prakash
- Department of Internal Medicine, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Benjamin Crichi
- Department of Internal Medicine, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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Rikken SAOF, van 't Hof AWJ, ten Berg JM, Kereiakes DJ, Coller BS. Critical Analysis of Thrombocytopenia Associated With Glycoprotein IIb/IIIa Inhibitors and Potential Role of Zalunfiban, a Novel Small Molecule Glycoprotein Inhibitor, in Understanding the Mechanism(s). J Am Heart Assoc 2023; 12:e031855. [PMID: 38063187 PMCID: PMC10863773 DOI: 10.1161/jaha.123.031855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
Thrombocytopenia is a rare but serious complication of the intravenous glycoprotein IIb/IIIa (GPIIb/IIIa; integrin αIIbβ3) receptor inhibitors (GPIs), abciximab, eptifibatide, and tirofiban. The thrombocytopenia ranges from mild (50 000-100 000 platelets/μL), to severe (20 000 to <50 000/μL), to profound (<20 000/μL). Profound thrombocytopenia appears to occur in <1% of patients receiving their first course of therapy. Thrombocytopenia can be either acute (<24 hours) or delayed (up to ~14 days). Both hemorrhagic and thrombotic complications have been reported in association with thrombocytopenia. Diagnosis requires exclusion of pseudothrombocytopenia and heparin-induced thrombocytopenia. Therapy based on the severity of thrombocytopenia and symptoms may include drug withdrawals and treatment with steroids, intravenous IgG, and platelet transfusions. Abciximab-associated thrombocytopenia is most common and due to either preformed antibodies or antibodies induced in response to abciximab (delayed). Readministration of abciximab is associated with increased risk of thrombocytopenia. Evidence also supports an immune basis for thrombocytopenia associated with the 2 small molecule GPIs. The latter bind αIIbβ3 like the natural ligands and thus induce the receptor to undergo major conformational changes that potentially create neoepitopes. Thrombocytopenia associated with these drugs is also immune-mediated, with antibodies recognizing the αIIbβ3 receptor only in the presence of the drug. It is unclear whether the antibody binding depends on the conformational change and whether the drug contributes directly to the epitope. Zalunfiban, a second-generation subcutaneous small molecule GPI, does not induce the conformational changes; therefore, data from studies of zalunfiban will provide information on the contribution of the conformational changes to the development of GPI-associated thrombocytopenia.
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Affiliation(s)
- Sem A. O. F. Rikken
- Department of CardiologySt. Antonius HospitalNieuwegeinThe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)MaastrichtThe Netherlands
| | - Arnoud W. J. van 't Hof
- Cardiovascular Research Institute Maastricht (CARIM)MaastrichtThe Netherlands
- Department of CardiologyMUMC+MaastrichtThe Netherlands
- Department of CardiologyZuyderland Medical CentreHeerlenThe Netherlands
| | - Jurriën M. ten Berg
- Department of CardiologySt. Antonius HospitalNieuwegeinThe Netherlands
- Cardiovascular Research Institute Maastricht (CARIM)MaastrichtThe Netherlands
- Department of CardiologyMUMC+MaastrichtThe Netherlands
| | - Dean J. Kereiakes
- The Christ Hospital Heart and Vascular Institute and Lindner Clinical Research CenterCincinnatiOHUSA
| | - Barry S. Coller
- Allen and Frances Adler Laboratory of Blood and Vascular BiologyRockefeller UniversityNew YorkNYUSA
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Jesudas R, Takemoto CM. Where have all the platelets gone? HIT, DIC, or something else? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:43-50. [PMID: 38066886 PMCID: PMC10727081 DOI: 10.1182/hematology.2023000465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Thrombocytopenia in ill children is common; accurately diagnosing the underlying etiology is challenging and essential for appropriate management. Triggers for accelerated consumption of platelets are numerous; common downstream mechanisms of clearance include platelet trapping in microvascular thrombi, phagocytosis, and platelet activation. Thrombocytopenia with microangiopathic hemolytic anemia (MAHA) is frequently due to disseminated intravascular coagulation. Thrombotic microangiopathy (TMA) is a subgroup of MAHA. Specific TMA syndromes include thrombotic thrombocytopenic purpura, complement-mediated TMA (CM-TMA), and Shiga toxin-mediated hemolytic uremic syndrome. Isolated thrombocytopenia is characteristic of immune thrombocytopenia; however, concomitant cytopenias are frequent in critically ill patients, making the diagnosis difficult. Immune thrombocytopenia with large vessel thrombosis is a feature of heparin-induced thrombocytopenia and antiphospholipid antibody syndrome. In addition, thrombocytopenia is common with macrophage activation, which is characteristic of hemophagocytic lymphohistiocytosis. While thrombocytopenia in ill patients can be driven by hypoproliferative processes such as myelosuppression and/or bone marrow failure, this review will focus on consumptive thrombocytopenia due to immune and nonimmune causes.
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Greinacher A. Thrombotic anti-PF4 immune disorders: HIT, VITT, and beyond. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:1-10. [PMID: 38066843 PMCID: PMC10727100 DOI: 10.1182/hematology.2023000503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Antibodies against the chemokine platelet factor 4 (PF4) occur often, but only those that activate platelets induce severe prothrombotic disorders with associated thrombocytopenia. Heparin-induced thrombocytopenia (HIT) is the prototypic anti-PF4 disorder, mediated by strong activation of platelets through their FcγIIa (immunoglobulin G [IgG]) receptors (FcγRIIa). Concomitant pancellular activation (monocytes, neutrophils, endothelium) triggers thromboinflammation with a high risk for venous and arterial thrombosis. The classic concept of HIT is that anti-PF4/heparin IgG, recognizing antigen sites on (cationic) PF4 that form in the presence of (anionic) heparin, constitute the heparin-dependent antibodies that cause HIT. Accordingly, HIT is managed by anticoagulation with a nonheparin anticoagulant. In 2021, adenovirus vector COVID-19 vaccines triggered the rare adverse effect "vaccine-induced immune thrombotic thrombocytopenia" (VITT), also caused by anti-PF4 IgG. VITT is a predominantly heparin-independent platelet-activating disorder that requires both therapeutic-dose anticoagulation and inhibition of FcγRIIa-mediated platelet activation by high-dose intravenous immunoglobulin (IVIG). HIT and VITT antibodies bind to different epitopes on PF4; new immunoassays can differentiate between these distinct HIT-like and VITT-like antibodies. These studies indicate that (1) severe, atypical presentations of HIT ("autoimmune HIT") are associated with both HIT-like (heparin-dependent) and VITT-like (heparin-independent) anti-PF4 antibodies; (2) in some patients with severe acute (and sometimes chronic, recurrent) thrombosis, VITT-like antibodies can be identified independent of proximate heparin exposure or vaccination. We propose to classify anti-PF4 antibodies as type 1 (nonpathogenic, non- platelet activating), type 2 (heparin dependent, platelet activating), and type 3 (heparin independent, platelet activating). A key concept is that type 3 antibodies (autoimmune HIT, VITT) require anticoagulation plus an adjunct treatment, namely high-dose IVIG, to deescalate the severe anti-PF4 IgG-mediated hypercoagulability state.
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Affiliation(s)
- Andreas Greinacher
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
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Lee J, Lindsley J, Chasler J, Streiff MB, Naik R, Shanbhag S, Dane KE. The Impact of an Antithrombotic Stewardship Program on Heparin-Induced Thrombocytopenia Management. J Pharm Pract 2023; 36:1343-1349. [PMID: 35848327 DOI: 10.1177/08971900221116185] [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] [Indexed: 11/16/2022]
Abstract
Background: An antithrombotic stewardship program was implemented to reduce IV DTI use and increase fondaparinux and direct oral anticoagulant (DOAC) use for suspected or confirmed Heparin-induced thrombocytopenia (HIT). Objectives: This study evaluated the impact of an antithrombotic stewardship program on IV DTI utilization in patients with HIT. Methods: A retrospective analysis of adults receiving IV DTIs or fondaparinux from July 2016 to July 2017 (pre-stewardship) and October 2017 to July 2019 (post-stewardship) was conducted. Results: The median duration of IV DTI administration was not significantly different in HIT-negative patients between the pre- and post-stewardship cohorts (1.6 days (25th percentile (p25), 75th percentile (p75): .5, 3.3) vs 1.7 days (p25, p75: .9, 3.9), P = .31). The median duration of IV DTI administration in HIT-positive patients was 9.9 days (p25, p75: 7.6, 21.0) pre-stewardship and 7.3 days (p25, p75: 4.8, 16.5) post-stewardship (P = .18). For HIT-positive patients, the time from HIT diagnosis to discharge was 12.8 days (p25, p75: 8.9, 24.9) and 9.2 days (p25, p75: 4.0, 18.1) in the pre- and post-stewardship cohorts, respectively (P = .07). Fondaparinux and DOAC prescribing rates were 40.7% and 62.2% in the pre- and post-stewardship cohorts, respectively (P = .09). The percentage of patients with no contraindications to IV DTI alternatives receiving these agents increased from 31.2% to 78.6% (P = .01) following stewardship implementation. Conclusions: Intravenous DTI alternative utilization increased significantly after stewardship implementation. Stewardship implementation was associated with a non-statistically significant trend towards decreased IV DTI utilization and decreased length of stay for HIT-positive patients.
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Affiliation(s)
- John Lee
- Department of Pharmacy, the Johns Hopkins Hospitaly, Baltimore, MD, USA
| | - John Lindsley
- Department of Pharmacy, the Johns Hopkins Hospitaly, Baltimore, MD, USA
| | - Jessica Chasler
- Department of Pharmacy, the Johns Hopkins Hospitaly, Baltimore, MD, USA
| | - Michael B Streiff
- Division of Hematology, the Johns Hopkins Hospital, Baltimore, MD, USA
| | - Rakhi Naik
- Department of Medicine, Division of Hematology, the Johns Hopkins Hospital, Baltimore, MD, USA
| | - Satish Shanbhag
- Hematologist/Oncologist, Cancer Specialists of North Florida, Fleming Island, FL, USA
| | - Kathryn E Dane
- Department of Pharmacy, the Johns Hopkins Hospitaly, Baltimore, MD, USA
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Shi D, Zhao H, Bu C, Fraser K, Wang H, Dordick JS, Linhardt RJ, Zhang F, Shi F, Chi L. New insights into the binding of PF4 to long heparin oligosaccharides in ultralarge complexes using mass spectrometry. J Thromb Haemost 2023; 21:3608-3618. [PMID: 37648114 DOI: 10.1016/j.jtha.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/18/2023] [Accepted: 08/18/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a serious complication caused by heparin drugs. The ultralarge complexes formed by platelet factor 4 (PF4) with heparin or low molecular weight heparins (LMWHs) are important participants in inducing the immune response and HIT. OBJECTIVES We aim at characterizing the interaction between PF4 and long-chain heparin oligosaccharides and providing robust analytical methods for the analysis of PF4-heparin complexes. METHODS In this work, the characteristics of PF4-enoxaparin complexes after incubation in different molar ratios and concentrations were analyzed by multiple analytical methods, especially liquid chromatography-mass spectrometry and liquid chromatography-tandem mass spectrometry with multiple reaction monitoring were developed to qualitatively and quantitatively monitor heparin oligosaccharides and PF4 in HIT-inducing complexes. RESULTS The results showed that the largest proportion of ultralarge complexes formed by PF4 and enoxaparin was at a specific molar ratio, ie, a PF4/enoxaparin ratio of 2:1, while the ultralarge complexes contained PF4 tetramer and enoxaparin at a molar ratio of approximately 2:1. CONCLUSION A binding model of PF4 and enoxaparin in ultralarge complexes is proposed with one heparin oligosaccharide chain (∼ dp18) bound to 2 PF4 tetramers in different morphologies to form ultralarge complexes, while PF4 tetramer is surrounded by multiple heparin chains in smaller complexes. Our study provides new insights into the structural mechanism of PF4-LMWH interaction, which help to further understand the mechanism of LMWH immunogenicity and develop safer heparin products.
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Affiliation(s)
- Deling Shi
- National Glycoengineering Research Center, Shandong University, Qingdao, Shandong Province, China; Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Huimin Zhao
- National Glycoengineering Research Center, Shandong University, Qingdao, Shandong Province, China
| | - Changkai Bu
- National Glycoengineering Research Center, Shandong University, Qingdao, Shandong Province, China
| | - Keith Fraser
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Biological Sciences, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Haoran Wang
- National Glycoengineering Research Center, Shandong University, Qingdao, Shandong Province, China
| | - Jonathan S Dordick
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Biological Sciences, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Biological Engineering, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Robert J Linhardt
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Biological Sciences, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Chemistry and Chemical Biology, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Fuming Zhang
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York, USA; Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, New York, USA.
| | - Feng Shi
- Shandong Institute for Food and Drug Control, Jinan, Shandong Province, China.
| | - Lianli Chi
- National Glycoengineering Research Center, Shandong University, Qingdao, Shandong Province, China.
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Pong T, Cyr K, Aparicio-Valenzuela J, Carlton C, Lee AM. A Modified 4Ts Score for Heparin-Induced Thrombocytopenia in the Mechanical Circulatory Support Population. J Cardiothorac Vasc Anesth 2023; 37:2499-2507. [PMID: 37407329 DOI: 10.1053/j.jvca.2023.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/16/2023] [Accepted: 06/21/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE To identify risk factors and develop a pretest scoring system to differentiate patients with heparin-induced thrombocytopenia (HIT) in the mechanical circulatory support (MCS) population. The authors present a modified "4TMCS" scoring system, which considers the "type of mechanical circulatory support" that may help identify patients at risk for developing postoperative HIT. DESIGN A retrospective cohort study. Patients who underwent cardiac surgery were categorized into 3 groups: (1) normal platelet count, (2) thrombocytopenia with a negative HIT test, and (3) thrombocytopenia with a positive HIT test. A comparison of diagnostic accuracy between the 4Ts and 4TMCS probability scores was performed. SETTING At a single adult tertiary-care center. PARTICIPANTS A total of 5,314 patients who underwent cardiac surgery between May 1, 2008 and December 31, 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In total, 125 out of 5,314 patients (2.4%) were diagnosed with HIT, of whom 75 out of 5,314 (1.4%) had clinical evidence of thrombosis. Overall, in-hospital mortality was 25.6%, 11.7%, and 1.5% in the HIT(+), HIT(-), and control groups, respectively (p < 0.001). Mechanical circulatory support was associated with a significantly increased risk for HIT, with an incidence of 5.9% in patients receiving MCS versus 1.9% in those without (p < 0.001). Area under the receiver operator curve (AUC) analysis demonstrated improved diagnostic accuracy of the 4TMCS score compared with the 4Ts (AUC = 0.83 v 0.77, p < 0.044). The 4TMCS score had higher sensitivity than the 4Ts, using the guideline-recommended score cutoff of ≥4 (95.2% v 85.7%). CONCLUSION Heparin-induced thrombocytopenia is associated with worse outcomes and increased morbidity and mortality in the MCS population. Awareness of patient risk factors and the application of a modified 4TMCS probability score may allow for more accurate screening and treatment of HIT in the MCS population.
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Affiliation(s)
- Terrence Pong
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Kevin Cyr
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Joy Aparicio-Valenzuela
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Cody Carlton
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Anson M Lee
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA.
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Foley K, Rao V, Djaiani G. Mechanical Circulatory Support and Heparin: Friends or Foes? J Cardiothorac Vasc Anesth 2023; 37:2508-2510. [PMID: 37778948 DOI: 10.1053/j.jvca.2023.08.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Karen Foley
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - George Djaiani
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada.
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Rottenstreich A, Bussel JB. Treatment of immune thrombocytopenia during pregnancy with thrombopoietin receptor agonists. Br J Haematol 2023; 203:872-885. [PMID: 37830251 DOI: 10.1111/bjh.19161] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 09/30/2023] [Accepted: 10/04/2023] [Indexed: 10/14/2023]
Abstract
The introduction of thrombopoietin receptor agonists (TPO-RAs) led to a paradigm shift in the management of immune thrombocytopenia (ITP). However, TPO-RAs are not approved for use during pregnancy due to the absence of evidence and concerns for possible effects on the fetus due to their expected transplacental transfer. This comprehensive review examines the safety and efficacy of TPO-RA in 45 pregnancies of women with ITP (romiplostim n = 22; eltrombopag n = 21; both in the same pregnancy n = 2). Mothers experienced failure of the median of three treatment lines during pregnancy prior to TPO-RA administration. A platelet response (>30 × 109 /L) was seen in 86.7% of cases (including a complete response >100 × 109 /L in 66.7%) and was similar between eltrombopag and romiplostim (87.0% and 83.3%, p = 0.99). The maternal safety profile was favourable, with no thromboembolic events encountered. Neonatal thrombocytopenia was noted in one third of cases, with one case of ICH grade 3, and neonatal thrombocytosis was observed in three cases. No other neonatal adverse events attributable to TPO-RAs were seen. This review suggests that the use of TPO-RA during pregnancy is associated with a high response rate and appears safe. Nevertheless, TPO-RA should not be routinely used in pregnancy and should be avoided in the first trimester until further evidence is accumulated.
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Affiliation(s)
- Amihai Rottenstreich
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
- Laboratory of Blood and Vascular Biology, Rockefeller University, New York, New York, USA
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - James B Bussel
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
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48
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van Oosterom N, De Guzman KR, Winckel K, Johnson A, Falconer N. Evaluation of the Quality and Safety of Venous Thromboembolism Prophylaxis Among Gastroenterology Inpatients at a Tertiary Hospital in Australia. Hosp Pharm 2023; 58:595-604. [PMID: 38560547 PMCID: PMC10977061 DOI: 10.1177/00185787231172385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background and objective: Hospital acquired venous thromboembolisms (VTEs) are common and preventable. The Queensland Health VTE prophylaxis guidelines, developed in 2018, provide guidance for risk assessment, and prescribing of anticoagulation for prophylaxis and treatment of hospital inpatients. Currently, there are limited recommendations for gastroenterology patients. This study investigated the completion of VTE risk assessments, and the appropriateness of VTE prophylaxis regimens, in accordance with Queensland Health guidelines for gastroenterology patients. The quality and safety of VTE prophylaxis regimens was assessed based on their VTE risk and bleeding risk. Method: A retrospective study was conducted by obtaining a random sample of gastroenterology patients admitted to a tertiary Australian hospital, from 1st May 2019 and 1st May 2020, to determine the compliance of VTE risk assessment and thromboprophylaxis prescribing with state-wide VTE guidelines. The quality and safety of thromboprophylaxis was evaluated using the modified Caprini and HASBLED scores, and subsequent thromboprophylaxis-related complications. Results: Of the 94 patients reviewed, 68 did not have contraindications to thromboprophylaxis. Of these 68 patients, 32 (47%) had no VTE risk assessment recorded in their clinical records and were not prescribed any thromboprophylaxis during the hospitalization. There was no significant difference between thromboprophylaxis prescribing for patients with low VTE risk, compared to moderate to high VTE risk (P = .075). There was a trend for decrease in thromboprophylaxis prescribing as HASBLED bleeding risk score increased, and patients with moderate-high bleed risk were less likely to be prescribed thromboprophylaxis (P = .006). There were no thromboprophylaxis related complications identified. Conclusion: It is essential that all patients have a clearly documented risk assessment and are prescribed thromboprophylaxis according to best practice guidelines. The prescription of venous thromboembolism prophylaxis should continue to be individualized, with each patient assessed holistically.
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Affiliation(s)
| | | | - Karl Winckel
- University of Queensland, Brisbane, QLD, Australia
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49
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Cheung MC, Kunkle R, Plovnick R, Lottenberg R, Rezende SM, Silverstein R, Pai M, Seftel M, Cuker A. ASH Clinical Practice Guidelines: strategies to stay up-to-date. Blood Adv 2023; 7:6707-6709. [PMID: 37738156 PMCID: PMC10641472 DOI: 10.1182/bloodadvances.2023011481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 09/07/2023] [Accepted: 09/10/2023] [Indexed: 09/24/2023] Open
Affiliation(s)
- Matthew C Cheung
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Rob Kunkle
- American Society of Hematology, Washington, DC
| | | | - Richard Lottenberg
- Division of Hematology and Oncology, University of Florida, Gainesville, FL
| | - Suely M Rezende
- Department of Internal Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Roy Silverstein
- Medical College of Wisconsin and Versiti Blood Research Institute, Milwaukee, WI
| | - Menaka Pai
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Matthew Seftel
- University of British Columbia and Canadian Blood Services, Vancouver, BC, Canada
| | - Adam Cuker
- Hematology, University of Pennsylvania, Philadelphia, PA
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50
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Santos A, Vega A, Davenport A. How to Ensure Patency of the Extracorporeal Circuit in Hemodialysis: Global Perspectives. Semin Nephrol 2023; 43:151476. [PMID: 38272778 DOI: 10.1016/j.semnephrol.2023.151476] [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] [Indexed: 01/27/2024]
Abstract
An adequate knowledge of anticoagulants used to prevent clotting in the extracorporeal circuit is crucial to provide optimal hemodialysis. Drugs can potentially prevent extracorporeal circuit clotting, but administration, half-life, and potential side effects differ. However, there is a lack of concise recommendations to guide anticoagulation and to avoid side effects. Because of the development of newer anticoagulant agents, direct thrombin inhibitors, and heparinoids, some of the side effects related to heparin may be overcome, but a deeper knowledge of these newer drugs is necessary. Moreover, types of heparin used, routes of administration, and health care economics vary around the world. We performed an extensive review of the literature, and the present article focuses on available anticoagulant drugs, exploring doses, side effects, particular use in hemodialysis, mechanism of action, pharmacokinetic properties, and use in special situations. Classical anticoagulants are still the standard of anticoagulation, but many questions remain unanswered; for example, is there real superiority of one treatment over another in terms of efficacy, safety, and health care economics? Anticoagulant protocols for hemodialysis need to be standardized and further studies performed to answer all of these questions.
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Affiliation(s)
- Alba Santos
- Nephrology Department, Hospital Universitario del Vinalopó, Elche, Spain.
| | - Almudena Vega
- Nephrology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Andrew Davenport
- Department of Renal Medicine, Division of Medicine, University College London, London, UK
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