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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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2
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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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Favaloro EJ, Pasalic L. Heparin-Induced Thrombotic Thrombocytopenia (HITT) and Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT): Similar but Different. Methods Mol Biol 2023; 2663:405-415. [PMID: 37204726 DOI: 10.1007/978-1-0716-3175-1_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) represents an autoimmune process whereby antibodies are formed against heparin in complex with platelet factor 4 (PF4) after heparin administration. These antibodies can be detected by a variety of immunological assays, including ELISA (enzyme-linked immunosorbent assay) and by chemiluminescence on the AcuStar instrument. However, pathological HIT antibodies are those that activate platelets in a platelet activation assay and cause thrombosis in vivo. We would tend to call this condition heparin-induced thrombotic thrombocytopenia (HITT), although some workers instead use the truncated abbreviation HIT. Vaccine-induced (immune) thrombotic thrombocytopenia (VITT) instead reflects an autoimmune process whereby antibodies are formed against PF4 after administration of a vaccine, most notably adenovirus-based vaccines directed against COVID-19 (coronavirus disease 2019). Although both VITT and HITT reflect similar pathological processes, they have different origins and are detected in different ways. Most notable is that anti-PF4 antibodies in VITT can only be detected immunologically by ELISA assays, tending to be negative in rapid assays such as that using the AcuStar. Moreover, functional platelet activation assays otherwise used for HITT may need to be modified to detect platelet activation in VITT.
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Affiliation(s)
- Emmanuel J Favaloro
- School of Medical Sciences, Faculty of Medicine and Health University of Sydney, Westmead Hospital, Westmead, NSW, Australia.
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga, Wagga, NSW, Australia.
| | - Leonardo Pasalic
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
- Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW, Australia
- Westmead Clinical School, University of Sydney, Westmead Hospital, Westmead, NSW, Australia
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4
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Favaloro EJ, Pasalic L, Henry B, Lippi G. Laboratory testing for platelet factor 4 antibodies: differential utility for diagnosis/exclusion of heparin induced thrombocytopenia versus suspected vaccine induced thrombotic thrombocytopenia. Pathology 2022; 54:254-261. [PMID: 35125202 DOI: 10.1016/j.pathol.2021.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/12/2021] [Accepted: 10/20/2021] [Indexed: 12/13/2022]
Abstract
Platelet factor 4 (PF4), a protein stored in the alpha-granules of platelets and released upon activation, forms cationic tetramers that bind with various polymeric anions, including heparin. Some individuals develop antibodies against PF4 in complex with heparin (PF4/H), which potentially lead to the onset of heparin induced thrombocytopenia (HIT). In some patients, this may cause activation and aggregation of platelets, promoting pathological thrombosis, in a process called heparin induced thrombocytopenia with thrombosis ('HITT'). Laboratories can assess for the presence of these antibodies using many PF4 antibody tests, including by enzyme linked immunosorbent assay (ELISA), latex immunoassay (LIA), chemiluminescence immunoassay (CLIA) and even rapid nanoparticle based lateral flow immunoassays. All these assays can identify such antibodies with high sensitivity, but methods may have variable specificity. For example, several studies have shown CLIA assays to have higher specificity to HITT than ELISA assays. Very recently, a new 'HITT-like' syndrome has been described in some individuals receiving adenovirus based COVID-19 (coronavirus disease 2019) vaccines. This condition has been given several names, including vaccine induced thrombotic thrombocytopenia (VITT) and thrombosis with thrombocytopenia syndrome (TTS), and also involves a mechanism mediated by antibodies formed against PF4. These antibodies can also be detected by PF4 antibody tests, but detection sensitivity appears to favour ELISA assays, with most other tests (including CLIA and LIA) not generally capable of detecting such antibodies. Additional functional assays assessing for PF4 mediated platelet activation may also be performed. The current review is focussed on laboratory testing for PF4 antibodies, in particular to distinguishing patterns in HITT versus VITT.
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Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, Westmead, NSW, Australia; Sydney Centres for Thrombosis and Haemostasis, Westmead, NSW, Australia; Faculty of Science and Health, Charles Sturt University, Wagga Wagga, NSW, Australia.
| | - Leonardo Pasalic
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, Westmead, NSW, Australia; Sydney Centres for Thrombosis and Haemostasis, Westmead, NSW, Australia
| | - Brandon Henry
- Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children's Hospital Medical Center, Ohio, USA; Host-Pathogens Interactions and Population Health Programs, Texas Biomedical Research Institute, San Antonio, TX, USA
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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5
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Antibodies against Platelet Factor 4 and Their Associated Pathologies: From HIT/HITT to Spontaneous HIT-Like Syndrome, to COVID-19, to VITT/TTS. Antibodies (Basel) 2022; 11:antib11010007. [PMID: 35225866 PMCID: PMC8883896 DOI: 10.3390/antib11010007] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/20/2021] [Accepted: 01/19/2022] [Indexed: 02/06/2023] Open
Abstract
Antibodies against platelet factor 4 (PF4), a protein released from alpha-granules of activated platelets, may cause a number of pathophysiological conditions. The most commonly known is heparin-induced thrombocytopenia (HIT), which develops in a small proportion of people treated with the anticoagulant drug heparin. Notably, PF4 binds with high affinity to heparin, and in HIT, complexes of PF4/H may, in a small proportion of susceptible patients, trigger the development of anti-PF4 antibodies and subsequent platelet activation and aggregation, ultimately leading to the development of pathological thrombosis at sites of vessel occlusion. Of more modern interest, antibodies against PF4 may also arise in patients with COVID-19 (Coronavirus Disease 2019) or in patients who have been vaccinated against COVID-19, especially in recipients of adenovirus-based vaccines. For this latter group of patients, the terms VITT (vaccine-induced [immune] thrombotic thrombocytopenia) and TTS (thrombotic thrombocytopenia syndrome) have been coined. Another category associated with this pathophysiology comprises those in whom a precipitating event is not clear; this category is referred to as ‘spontaneous HIT-like syndrome’. Despite its name, it arises as an HIT-mimicking disorder but without antecedent heparin exposure. In this narrative review, we describe the development of antibodies against PF4, and associated pathophysiology, in such conditions.
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Halprin C, Czer LS, Cole R, Emerson D, Esmailian F, Hayes C, Kitahara S, Lam L, Martin-Stone S, Megna D, Moriguchi J, Okwan-Duodu D, Ramzy D, Yur J, Volod O. Diagnosing heparin-induced thrombocytopenia in mechanical circulatory support device patients. J Heart Lung Transplant 2021; 41:80-85. [PMID: 34656418 DOI: 10.1016/j.healun.2021.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 09/09/2021] [Accepted: 09/09/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Mechanical circulatory support device (MCSD) patients with positive heparin-induced thrombocytopenia (HIT) screening pose a unique challenge, as clinicians must make rapid decisions about their anticoagulation and whether they can safely undergo cardiopulmonary bypass. We identified screening practices at our institution and other institutions nationwide that differed from American Society of Hematology (ASH) guidelines. This discovery prompted a data review to confirm the applicability of guidelines to this unique population and to highlight complications of "gestalt" screening. METHODS Our study included MCSD patients with HIT testing from April 2014 to August 2020. We evaluated 510 PF4 IgG ELISA results. RESULTS HIT was confirmed in 4.2% of patients. There was an increased prevalence of HIT in patients with nondurable (5.3%) vs durable devices (2.9%) or those in the preimplantation setting (1.3%), however this difference was not statistically significant (p = 0.26). None of the patients with a low probability 4T Score had HIT. All patients with a high probability 4T Score and PF4 immunoassay OD >2.0 had HIT. False positive results occurred in 22% of assays ordered for patients with a low probability 4T Score. Twelve patients with a low probability 4T Score and a false positive immunoassay were switched to a direct thrombin inhibitor (DTI) while awaiting confirmatory results. Two patients experienced clinically significant bleeding after conversion to a DTI. An organ was refused in one patient with false positive HIT screening. CONCLUSIONS Our findings demonstrate that an opportunity exists to improve clinical outcomes by re-emphasizing the utility of established guidelines and highlighting their safe use in the MCSD patient population.
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Affiliation(s)
- Chelsea Halprin
- Pathology, Cedars Sinai Medical Center, Los Angeles, California.
| | - Lawrence S Czer
- Cedars Sinai Comprehensive Transplant Center, Cedars Sinai Medical Center, Los Angeles, California
| | - Robert Cole
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Dominic Emerson
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Fardad Esmailian
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Chelsea Hayes
- Pathology, Cedars Sinai Medical Center, Los Angeles, California
| | - Sumire Kitahara
- Pathology, Cedars Sinai Medical Center, Los Angeles, California
| | - Lee Lam
- Cedars Sinai Comprehensive Transplant Center, Cedars Sinai Medical Center, Los Angeles, California
| | - Sylvia Martin-Stone
- Department of Pharmacy Services, Cedars Sinai Medical Center, Los Angeles, California
| | - Dominick Megna
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Jaime Moriguchi
- Cedars Sinai Comprehensive Transplant Center, Cedars Sinai Medical Center, Los Angeles, California
| | | | - Danny Ramzy
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Justin Yur
- Department of Pharmacy Services, Cedars Sinai Medical Center, Los Angeles, California
| | - Oksana Volod
- Pathology, Cedars Sinai Medical Center, Los Angeles, California.
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Datta P, Zhang F, Dordick JS, Linhardt RJ. Platelet factor 4 polyanion immune complexes: heparin induced thrombocytopenia and vaccine-induced immune thrombotic thrombocytopenia. Thromb J 2021; 19:66. [PMID: 34526009 PMCID: PMC8443112 DOI: 10.1186/s12959-021-00318-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/01/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This is a review article on heparin-induced thrombocytopenia, an adverse effect of heparin therapy, and vaccine-induced immune thrombotic thrombocytopenia, occurring in some patients administered certain coronavirus vaccines. MAIN BODY/TEXT Immune-mediated thrombocytopenia occurs when specific antibodies bind to platelet factor 4 /heparin complexes. Platelet factor 4 is a naturally occurring chemokine, and under certain conditions, may complex with negatively charged molecules and polyanions, including heparin. The antibody-platelet factor 4/heparin complex may lead to platelet activation, accompanied by other cascading reactions, resulting in cerebral sinus thrombosis, deep vein thrombosis, lower limb arterial thrombosis, myocardial infarction, pulmonary embolism, skin necrosis, and thrombotic stroke. If untreated, heparin-induced thrombocytopenia can be life threatening. In parallel, rare incidents of spontaneous vaccine-induced immune thrombotic thrombocytopenia can also occur in some patients administered certain coronavirus vaccines. The role of platelet factor 4 in vaccine-induced thrombosis with thrombocytopenia syndrome further reinforces the importance the platelet factor 4/polyanion immune complexes and the complications that this might pose to susceptible individuals. These findings demonstrate, how auxiliary factors can complicate heparin therapy and drug development. An increasing interest in biomanufacturing heparins from non-animal sources has driven a growing interest in understanding the biology of immune-mediated heparin-induced thrombocytopenia, and therefore, the development of safe and effective biosynthetic heparins. SHORT CONCLUSION In conclusion, these findings further reinforce the importance of the binding of platelet factor 4 with known and unknown polyanions, and the complications that these might pose to susceptible patients. In parallel, these findings also demonstrate how auxiliary factors can complicate the heparin drug development.
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Affiliation(s)
- Payel Datta
- Heparin Applied Research Center, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, NY, 12180, USA
| | - Fuming Zhang
- Heparin Applied Research Center, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, NY, 12180, USA
| | - Jonathan S Dordick
- Heparin Applied Research Center, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, NY, 12180, USA
| | - Robert J Linhardt
- Heparin Applied Research Center, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, NY, 12180, USA.
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Mehdizade T, Kelahmetoglu O, Gurkan V, Çetin G, Guneren E. Early Suspicion of Heparin-Induced Thrombocytopenia for Successful Free Flap Salvage: Reports of Two Cases. J Hand Microsurg 2021; 13:178-180. [PMID: 34511835 DOI: 10.1055/s-0040-1713692] [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: 10/24/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is an underestimated complication of heparin treatment. Flap loss and related morbidity (even mortality) are caused by occlusion of the capillary vessels by a highly immunogenic complex formed by adherence of antiheparin antibodies to platelet factor 4. Early suspicion and effective treatment of HIT developing in two free flaps are described. We report on the management of two patients with HIT. Both patients were treated successfully by early suspicion and hematology consultation. Heparin products were discontinued; the patients were switched to a nonheparin anticoagulant. We emphasize the importance of early diagnosis, hematologist assessment, and a change to a nonheparin anticoagulant to prevent flap failure and possibly the catastrophic consequences of such failure.
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Affiliation(s)
- Turan Mehdizade
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Osman Kelahmetoglu
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Volkan Gurkan
- Department of Orthopedic and Traumatology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Güven Çetin
- Department of Haemotology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Ethem Guneren
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
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Páramo JA, Lozano ML, González-Porras JR, Mateo J. Current status of diagnosis and treatment of heparin-induced thrombocytopenia (HIT). Med Clin (Barc) 2021; 158:82-89. [PMID: 34311973 DOI: 10.1016/j.medcli.2021.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/21/2021] [Accepted: 05/21/2021] [Indexed: 12/01/2022]
Affiliation(s)
- José A Páramo
- Servicio de Hematología Clínica, Universidad de Navarra, Pamplona, España; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, España; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, España.
| | - Mª Luisa Lozano
- Departmento de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Murcia, España; Universidad de Murcia, IMIB-Arrixaca, CB15/00055-CIBERER, Murcia, España
| | | | - José Mateo
- Unidad de Hemostasia y Trombosis, Servicio de Hematología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
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10
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Favaloro EJ, Henry BM, Lippi G. The complicated relationships of heparin-induced thrombocytopenia and platelet factor 4 antibodies with COVID-19. Int J Lab Hematol 2021; 43:547-558. [PMID: 34000089 PMCID: PMC8239595 DOI: 10.1111/ijlh.13582] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/20/2021] [Accepted: 04/27/2021] [Indexed: 12/20/2022]
Abstract
COVID‐19 (coronavirus disease 2019) represents a prothrombotic disorder, and there have been several reports of platelet factor 4/heparin antibodies being present in COVID‐19‐infected patients. This has thus been identified in some publications as representing a high incidence of heparin‐induced thrombocytopenia (HIT), whereas in others, findings have been tempered by general lack of functional reactivity using confirmation assays of serotonin release assay (SRA) or heparin‐induced platelet aggregation (HIPA). Moreover, in at least two publications, data are provided suggesting that antibodies can arise in heparin naïve patients or that platelet activation may not be heparin‐dependent. From this literature, we would conclude that platelet factor 4/heparin antibodies can be observed in COVID‐19‐infected patients, and they may occur at higher incidence than in historical non‐COVID‐19‐infected cohorts. However, the situation is complex, since not all platelet factor 4/heparin antibodies may lead to platelet activation, and not all identified antibodies are heparin‐dependent, such that they do not necessarily reflect “true” HIT. Most recently, a “HIT‐like” syndrome has reported in patients who have been vaccinated against COVID‐19. Accordingly, much more is yet to be learnt about the insidious disease that COVID‐19 represents, including autoimmune outcomes in affected patients.
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Affiliation(s)
- Emmanuel J Favaloro
- Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia.,School of Biomedical Sciences, Charles Sturt University, Westmead, NSW, Australia
| | - Brandon Michael Henry
- Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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Zhang X, Jin Q, Kong D, Pan C, Zhang X, Zhou D, Shen Z, Zhou D, Ge J. Clinical outcomes of bivalirudin versus heparin in atrial fibrillation patients undergoing percutaneous left atrial appendage occlusion. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:629. [PMID: 33987327 PMCID: PMC8106030 DOI: 10.21037/atm-20-4755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Prior studies have suggested that patients with atrial fibrillation (AF) referred for left atrial appendage occlusion (LAAO) are confronted with considerable risk of periprocedural thromboembolism and hemmorhagic events. The purpose of this study was to evaluate the safety and feasibility of bivalirudin during LAAO. Methods This retrospective, observational study included 420 AF patients who were evaluated as being at high risk of stroke or bleeding and indicated for LAAO at our center between June 2018 and June 2019 (158 with bivalirudin and 262 with heparin). The primary outcome was the incidence of any bleeding within 48 hours of LAAO. Secondary outcomes were major adverse cardiac events (MACE) between 48 hours and 60 days post-procedure and overall bleeding events during follow up. Results No significant difference was observed between bivalirudin and heparin for major periprocedural bleeding (1.27% for bivalirudin vs. 2.29% for heparin, P=0.716) or minor bleeding (1.27% vs. 1.15%, P>0.9). At 48 hours post-procedure, strokes occurred at a rate of 0.63% in the bivalirudin group and 1.15% in the heparin group (P>0.9), and one case treated with bivalirudin developed systemic embolization. At 60 days, the rates of MACE (1.90% vs. 2.29%, P>0.9), a device-related thrombus (DRT) (1.27% vs. 1.52%, P>0.9), and overall bleeding events (5.06% vs. 4.96%, P=0.963) were comparable between the 2 cohorts. Upon Kaplan-Meier survival analysis, early safety during the 60-day follow-up was 93.67% in the bivalirudin group and 91.60% in the heparin group (P=0.570). Conclusions Bivalirudin has a comparable safety and efficacy profile to heparin as an intraprocedural anticoagulant, but currently, it should still be reserved for patients in which heparin is contraindicated.
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Affiliation(s)
- Xiaochun Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Research Unit of Cardiovascular Techniques and Devices, Chinese Academy of Medical Sciences, Shanghai, China
| | - Qinchun Jin
- Department of Cardiology, Zhongshan Hospital, Fudan University, Research Unit of Cardiovascular Techniques and Devices, Chinese Academy of Medical Sciences, Shanghai, China
| | - Dehong Kong
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Cuizhen Pan
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Xian Zhang
- Department of Cardiac Echocardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dan Zhou
- Department of Cardiac Echocardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhiyun Shen
- Department of Cardiac Echocardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Daxin Zhou
- Department of Cardiology, Zhongshan Hospital, Fudan University, Research Unit of Cardiovascular Techniques and Devices, Chinese Academy of Medical Sciences, Shanghai, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Research Unit of Cardiovascular Techniques and Devices, Chinese Academy of Medical Sciences, Shanghai, China
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12
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Warkentin TE, Smythe MA, Ali MA, Aslam N, Sheppard JI, Smith JW, Moore JC, Arnold DM, Nazy I. Serotonin-release assay-positive but platelet factor 4-dependent enzyme-immunoassay negative: HIT or not HIT? Am J Hematol 2021; 96:320-329. [PMID: 33326124 DOI: 10.1002/ajh.26075] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/07/2020] [Accepted: 12/14/2020] [Indexed: 12/28/2022]
Abstract
IgG-specific and polyspecific PF4-dependent enzyme-immunoassays (EIAs) have exceptionally high sensitivity (≥99%) for diagnosis of heparin-induced thrombocytopenia (HIT), a drug reaction caused by platelet-activating antibodies detectable by serotonin-release assay (SRA). The IgG-specific EIAs are recommended for screening, as their high sensitivity is accompanied by relatively high specificity vis-à-vis polyspecific EIAs. We investigated the frequency of SRA-positive/EIA-negative (SRA+/EIA-) HIT, prompted by referral to our reference HIT laboratory of serial blood samples from a patient ("index case") with false-negative IgG-specific EIAs. Despite initial clinical suspicion for HIT, repeat negative IgG-specific EIAs prompted heparin resumption, which triggered recurrent thrombocytopenia and near-fatal cardiac arrest, indicating likely post-heparin HIT-associated anaphylactoid reaction. Further investigations revealed a strong-positive SRA, whether performed with heparin alone, PF4 alone, or PF4/heparin, with inhibition by Fc receptor-blocking monoclonal antibody (indicating IgG-mediated platelet activation); however, five different IgG-specific immunoassays yielded primarily negative (or weak-positive) results. To investigate the frequency of SRA+/EIA- HIT, we reviewed the laboratory and clinical features of patients with this serological profile during a 6-year period in which our reference laboratory investigated for HIT using both SRA and IgG-specific EIA. Although ~0.2% of 8546 patients had an SRA+/EIA- profile, further review of 15 such cases indicated clerical/laboratory misclassification or false-positive SRA in all, with no SRA+/EIA- HIT case identified. We conclude that while SRA+/EIA- HIT is possible-as shown by our index case-this clinical picture is exceptionally uncommon. Moreover, the requirement for a positive EIA is a useful quality control maneuver that reduces risk of reporting a false-positive SRA result.
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Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine Michael G. DeGroote School of Medicine Hamilton Ontario Canada
- Department of Medicine Michael G. DeGroote School of Medicine Hamilton Ontario Canada
- McMaster Centre for Transfusion Research Hamilton Ontario Canada
| | - Maureen A. Smythe
- Department of Pharmaceutical Services Beaumont Hospital Royal Oak Michigan USA
- Department of Pharmacy Practice Wayne State University Detroit Michigan USA
- Oakland University William Beaumont School of Medicine Rochester Michigan USA
| | - Mona A. Ali
- Department of Pharmaceutical Services Beaumont Hospital Royal Oak Michigan USA
| | - Naveed Aslam
- Oakland University William Beaumont School of Medicine Rochester Michigan USA
| | - Jo‐Ann I. Sheppard
- Department of Pathology and Molecular Medicine Michael G. DeGroote School of Medicine Hamilton Ontario Canada
| | - James W. Smith
- Department of Medicine Michael G. DeGroote School of Medicine Hamilton Ontario Canada
| | - Jane C. Moore
- Department of Medicine Michael G. DeGroote School of Medicine Hamilton Ontario Canada
| | - Donald M. Arnold
- Department of Medicine Michael G. DeGroote School of Medicine Hamilton Ontario Canada
- McMaster Centre for Transfusion Research Hamilton Ontario Canada
| | - Ishac Nazy
- Department of Medicine Michael G. DeGroote School of Medicine Hamilton Ontario Canada
- McMaster Centre for Transfusion Research Hamilton Ontario Canada
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13
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Favaloro EJ, Mohammed S, Donikian D, Kondo M, Hamdam S, Hocker N, Brighton T. Effect of sample heat inactivation on test levels of HIT-IgG (PF4-H) detected by the ACL AcuStar. Thromb Res 2021; 200:12-15. [PMID: 33508737 DOI: 10.1016/j.thromres.2021.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/17/2020] [Accepted: 01/04/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia; Sydney Centres for Thrombosis and Haemostasis, Westmead, NSW, Australia; School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, New South Wales, Australia.
| | - Soma Mohammed
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia.
| | - Dea Donikian
- Prince of Wales Hospital, NSW Health Pathology, Randwick, NSW, Australia.
| | - Mayuko Kondo
- Prince of Wales Hospital, NSW Health Pathology, Randwick, NSW, Australia.
| | - Sayed Hamdam
- NSW Health Pathology, Blacktown Hospital, Blacktown, NSW, Australia.
| | - Naomi Hocker
- NSW Health Pathology, Wagga Wagga Hospital, Wagga Wagga, NSW, Australia.
| | - Timothy Brighton
- Prince of Wales Hospital, NSW Health Pathology, Randwick, NSW, Australia.
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14
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Han X, Li C, Zhang S, Hou X, Chen Z, Zhang J, Zhang Y, Sun J, Wang Y. Why thromboembolism occurs in some patients with thrombocytopenia and treatment strategies. Thromb Res 2020; 196:500-509. [PMID: 33091704 DOI: 10.1016/j.thromres.2020.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/02/2020] [Accepted: 10/05/2020] [Indexed: 12/31/2022]
Abstract
Platelets play such an important role in the process of thrombosis that patients with thrombocytopenia generally have an increased risk of bleeding. However, abnormal thrombotic events can sometimes occur in patients with thrombocytopenia, which is unusual and inexplicable. The treatments for thrombocytopenia and thromboembolism are usually contradictory. This review introduces the mechanisms of thromboembolism in patients with different types of thrombocytopenia and outlines treatment recommendations for the prevention and treatment of thrombosis. According to the cause of thrombocytopenia, this article addresses four etiologies, including inherited thrombocytopenia (Myh9-related disease, ANKRD26-associated thrombocytopenia, Glanzmann thrombasthenia, Bernard-Soulier syndrome), thrombotic microangiopathy (thrombotic thrombocytopenic purpura, atypical hemolytic uremic syndrome, hemolytic uremic syndrome, Hemolysis Elevated Liver enzymes and Low Platelets syndrome, disseminated intravascular coagulation), autoimmune-related thrombocytopenia (immune thrombocytopenic purpura, antiphospholipid syndrome, systemic lupus erythematosus), and acquired thrombocytopenia (Infection-induced thrombocytopenia and drug-induced thrombocytopenia, heparin-induced thrombocytopenia). We hope to provide more evidence for clinical applications and future research.
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Affiliation(s)
- Xiaorong Han
- Department of Cardiovascular Center, Jilin University First Hospital, China.
| | - Cheng Li
- Department of Cardiovascular Center, Jilin University First Hospital, China.
| | - Shuai Zhang
- Department of Cardiovascular Center, Jilin University First Hospital, China.
| | - Xiaojie Hou
- Department of Cardiovascular Surgery, The Affiliated Hospital of Southwest Medical University, China.
| | - Zhongbo Chen
- Department of Cardiovascular Center, Jilin University First Hospital, China.
| | - Jin Zhang
- Department of Cardiovascular Center, Jilin University First Hospital, China.
| | - Ying Zhang
- Department of Cardiovascular Center, Jilin University First Hospital, China.
| | - Jian Sun
- Department of Cardiovascular Center, Jilin University First Hospital, China.
| | - Yonggang Wang
- Department of Cardiovascular Center, Jilin University First Hospital, China.
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15
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Cai Z, Greene MI, Zhu Z, Zhang H. Structural Features and PF4 Functions that Occur in Heparin-Induced Thrombocytopenia (HIT) Complicated by COVID-19. Antibodies (Basel) 2020; 9:E52. [PMID: 33050376 PMCID: PMC7709132 DOI: 10.3390/antib9040052] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/10/2020] [Accepted: 09/29/2020] [Indexed: 01/08/2023] Open
Abstract
Platelet factor 4 (PF4, CXCL4) is a small chemokine protein released by activated platelets. Although a major physiological function of PF4 is to promote blood coagulation, this cytokine is involved in innate and adaptive immunity in events when platelets are activated in response to infections. Coronavirus disease 2019 (COVID-19) patients have abnormal coagulation activities, and severe patients develop higher D-dimer levels. D-dimers are small protein products present in the blood after blood clots are degraded by fibrinolysis. To prevent clotting, heparin is often clinically used in COVID-19 patients. Some clinical procedures for the management of COVID-19 patients may include extracorporeal membrane oxygenation (ECMO) and renal replacement therapy (CRRT), which also require the use of heparin. Anti-PF4 antibodies are frequently detected in severe patients and heparin-induced thrombocytopenia (HIT) can also be observed. PF4 and its role in HIT as well as in pathologies seen in COVID-19 patients define a potential therapeutic option of using blocking antibodies in the treatment of COVID-19.
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Affiliation(s)
| | | | | | - Hongtao Zhang
- Departments of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19301, USA; (Z.C.); (M.I.G.); (Z.Z.)
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16
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Favaloro EJ, Mohammed S, Donikian D, Kondo M, Duncan E, Yacoub O, Zebeljan D, Ng S, Malan E, Yuen A, Beggs J, Moosavi S, Coleman R, Klose N, Chapman K, Cavanaugh L, Pasalic L, Motum P, Tan CW, Brighton T. A multicentre assessment of contemporary laboratory assays for heparin induced thrombocytopenia. Pathology 2020; 53:247-256. [PMID: 33032809 DOI: 10.1016/j.pathol.2020.07.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/25/2020] [Accepted: 07/23/2020] [Indexed: 12/27/2022]
Abstract
Heparin induced thrombocytopenia (HIT) is a rare but potentially fatal complication of heparin therapy. In some patients, HIT causes platelet activation and thrombosis (sometimes abbreviated HITT), which leads to adverse clinical sequalae ('pathological HIT'). The likelihood of HIT is initially assessed clinically, typically using a scoring system, of which the 4T score is that most utilised. Subsequent laboratory testing to confirm or exclude HIT facilitates exclusion or diagnosis and management. The current investigation comprises a multicentre (n=9) assessment of contemporary laboratory testing for HIT, as performed over the past 1-3 years in each site and comprising testing of over 1200 samples. The primary laboratory test used by study participants (n=8) comprised a chemiluminescence procedure (HIT-IgG(PF4-H)) performed on an AcuStar instrument. Additional immunological testing performed by study sites included lateral flow (STiC, Stago), enzyme linked immunosorbent assay (ELISA), Asserachrom (HPIA IgG), PaGIA (BioRad), plus functional assays, primarily serotonin release assay (SRA) or platelet aggregation methods. The chemiluminescence procedure yielded a highly sensitive screening method for identifying functional HIT, given high area under the curve (AUC, generally ≥0.9) in a receiver operator characteristic (ROC) analysis against SRA as gold standard. ELISA testing resulted in lower ROC AUC scores (<0.8) and higher levels of false positives. Although there is clear association with the likelihood of HIT, the 4T score had less utility than literature suggests, and was comparable to a previous study reported by some of the authors.
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Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW, Australia; NSW Health Pathology, NSW, Australia; School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW, Australia.
| | - Soma Mohammed
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW, Australia; NSW Health Pathology, NSW, Australia
| | - Dea Donikian
- NSW Health Pathology, NSW, Australia; Prince of Wales Hospital, Randwick, NSW, Australia
| | - Mayuko Kondo
- NSW Health Pathology, NSW, Australia; Prince of Wales Hospital, Randwick, NSW, Australia
| | | | | | - Diane Zebeljan
- NSW Health Pathology, NSW, Australia; Liverpool Hospital, Liverpool, NSW, Australia
| | - Sara Ng
- NSW Health Pathology, NSW, Australia; Liverpool Hospital, Liverpool, NSW, Australia
| | | | - Agnes Yuen
- Monash Health, Melbourne, Vic, Australia
| | | | | | - Robyn Coleman
- Sullivan Nicolaides Pathology, Brisbane, Qld, Australia
| | - Nathan Klose
- Sullivan Nicolaides Pathology, Brisbane, Qld, Australia
| | - Kent Chapman
- NSW Health Pathology, NSW, Australia; John Hunter Hospital, Newcastle, NSW, Australia
| | - Lauren Cavanaugh
- NSW Health Pathology, NSW, Australia; St George Hospital, Kogarah, NSW, Australia
| | - Leonardo Pasalic
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW, Australia; NSW Health Pathology, NSW, Australia; School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW, Australia
| | - Penelope Motum
- NSW Health Pathology, NSW, Australia; Liverpool Hospital, Liverpool, NSW, Australia
| | - Chee Wee Tan
- South Australia Pathology, Adelaide, SA, Australia; Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Timothy Brighton
- NSW Health Pathology, NSW, Australia; Prince of Wales Hospital, Randwick, NSW, Australia
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17
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Favaloro EJ, Mohammed S. Plasma vs serum as test sample for the chemiluminescent AcuStar HemosIL HIT-IgG (PF4-H) assay. Int J Lab Hematol 2020; 43:e41-e44. [PMID: 32996703 DOI: 10.1111/ijlh.13353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/09/2020] [Accepted: 09/11/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead, NSW, Australia.,Westmead Hospital, Westmead, NSW, Australia.,Sydney Centres for Thrombosis and Haemostasis, Westmead, NSW, Australia.,School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW, Australia
| | - Soma Mohammed
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead, NSW, Australia.,Westmead Hospital, Westmead, NSW, Australia
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18
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Webb M, Sidebotham D. Bayes' formula: a powerful but counterintuitive tool for medical decision-making. BJA Educ 2020; 20:208-213. [PMID: 33456952 PMCID: PMC7808025 DOI: 10.1016/j.bjae.2020.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2020] [Indexed: 01/19/2023] Open
Affiliation(s)
- M.P.K. Webb
- Auckland City Hospital, Auckland, New Zealand
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19
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Heparininduzierte Thrombopenie in der Kardiochirurgie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2020. [DOI: 10.1007/s00398-019-00345-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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