1
|
Schönborn L, Pavord S, Chen VMY, Pai M, Gwarzo DH, Buttery J, Munoz FM, Tran H, Greinacher A, Law B. Thrombosis with thrombocytopenia syndrome (TTS) and vaccine-induced immune thrombocytopenia and thrombosis (VITT): Brighton Collaboration case definitions and guidelines for data collection, analysis, and presentation of immunisation safety data. Vaccine 2024; 42:1799-1811. [PMID: 38302339 DOI: 10.1016/j.vaccine.2024.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/15/2024] [Indexed: 02/03/2024]
Abstract
This is a revision of the online November 2021 Brighton thrombosis with thrombocytopenia syndrome (TTS) case definition and a new Brighton Collaboration case definition for vaccine-induced immune thrombocytopenia and thrombosis (VITT). These case definitions are intended for use in clinical trials and post-licensure pharmacovigilance activities to facilitate safety data comparability across multiple settings. They are not intended to guide clinical management. The case definitions were developed by a group of subject matter and Brighton Collaboration process experts as part of the Coalition for Epidemic Preparedness Innovations (CEPI)-funded Safety Platform for Evaluation of vACcines (SPEAC). The case definitions, each with defined levels of diagnostic certainty, are based on relevant published evidence and expert consensus and are accompanied by specific guidelines for TTS and VITT data collection and analysis. The document underwent peer review by a reference group of vaccine safety stakeholders and haematology experts to ensure case definition useability, applicability and scientific integrity.
Collapse
Affiliation(s)
- Linda Schönborn
- University Medicine Greifswald, Institute for Transfusion Medicine, Greifswald, Germany.
| | - Sue Pavord
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Vivien Mun Yee Chen
- Department of Haematology, Concord Repatriation General Hospital and NSW Health Pathology, Concord, NSW, Australia; ANZAC Research Institute, Concord, NSW, Australia; Sydney Medical School, University of Sydney, Concord, NSW, Australia.
| | - Menaka Pai
- Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada.
| | - Dalha Haliru Gwarzo
- Institution: Bayero University, Kano, Nigeria; Aminu Kano Teaching Hospital, Kano, Nigeria.
| | - Jim Buttery
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.
| | - Flor M Munoz
- Department of Pediatrics, Division of Infectious Diseases, and Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, USA.
| | - Huyen Tran
- Clinical Haematology Department, Monash University, Melbourne, Victoria, Australia; The Alfred Hospital, Melbourne, Victoria, Australia.
| | - Andreas Greinacher
- University Medicine Greifswald, Institute for Transfusion Medicine, Greifswald, Germany.
| | - Barbara Law
- SPEAC, Brighton Collaboration, Independent Consultant, Stratford, Ontario, Canada.
| |
Collapse
|
2
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
3
|
Schönborn L, Esteban O, Wesche J, Dobosz P, Broto M, Puig SR, Fuhrmann J, Torres R, Serra J, Llevadot R, Palicio M, Wang JJ, Gordon TP, Lindhoff-Last E, Hoffmann T, Alberio L, Langer F, Boehme C, Biguzzi E, Grosse L, Endres M, Liman T, Thiele T, Warkentin TE, Greinacher A. Anti-PF4 immunothrombosis without proximate heparin or adenovirus vector vaccine exposure. Blood 2023; 142:2305-2314. [PMID: 37883798 PMCID: PMC10862238 DOI: 10.1182/blood.2023022136] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/28/2023] [Accepted: 10/11/2023] [Indexed: 10/28/2023] Open
Abstract
ABSTRACT Platelet-activating anti-platelet factor 4 (PF4)/heparin antibodies and anti-PF4 antibodies cause heparin-induced thrombocytopenia (HIT) and vaccine-induced immune thrombocytopenia and thrombosis (VITT), respectively. Diagnostic and treatment considerations differ somewhat between HIT and VITT. We identified patients with thrombocytopenia and thrombosis without proximate heparin exposure or adenovirus-based vaccination who tested strongly positive by PF4/polyanion enzyme-immunoassays and negative/weakly positive by heparin-induced platelet activation (HIPA) test but strongly positive by PF4-induced platelet activation (PIPA) test (ie, VITT-like profile). We tested these patients by a standard chemiluminescence assay that detects anti-PF4/heparin antibodies found in HIT (HemosIL AcuStar HIT-IgG(PF4-H)) as well as a novel chemiluminescence assay for anti-PF4 antibodies found in VITT. Representative control sera included an exploratory anti-PF4 antibody-positive but HIPA-negative/weak cohort obtained before 2020 (n = 188). We identified 9 patients with a clinical-pathological profile of a VITT-like disorder in the absence of proximate heparin or vaccination, with a high frequency of stroke (arterial, n = 3; cerebral venous sinus thrombosis, n = 4), thrombocytopenia (median platelet count nadir, 49 × 109/L), and hypercoagulability (greatly elevated D-dimer levels). VITT-like serological features included strong reactivity by PIPA (aggregation <10 minutes in 9/9 sera) and positive testing in the novel anti-PF4 chemiluminescence assay (3/9 also tested positive in the anti-PF4/heparin chemiluminescence assay). Our exploratory cohort identified 13 additional patient sera obtained before 2020 with VITT-like anti-PF4 antibodies. Platelet-activating VITT-like anti-PF4 antibodies should be considered in patients with thrombocytopenia, thrombosis, and very high D-dimer levels, even without a proximate exposure to heparin or adenovirus vector vaccines.
Collapse
Affiliation(s)
- Linda Schönborn
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | | | - Jan Wesche
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | | | | | | | - Jessica Fuhrmann
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | | | | | | | | | - Jing Jing Wang
- Department of Immunology, College of Medicine and Public Health, Flinders University and SA Pathology, Bedford Park, SA, Australia
| | - Tom Paul Gordon
- Department of Immunology, College of Medicine and Public Health, Flinders University and SA Pathology, Bedford Park, SA, Australia
| | - Edelgard Lindhoff-Last
- Cardioangiology Center Bethanien Hospital, CCB Coagulation Center and CCB Coagulation Research Center, Frankfurt, Hessen, Germany
| | - Till Hoffmann
- Institute for Transplantation Diagnostics and Cell Therapeutics, University Hospital Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Lorenzo Alberio
- Service and Central Laboratory of Hematology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Florian Langer
- Zentrum für Onkologie, II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Christian Boehme
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Eugenia Biguzzi
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Leonie Grosse
- Department of Pediatrics, Dr. von Hauner Children’s Hospital, Ludwig Maximilian University, Munich, Germany
| | - Matthias Endres
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Deutsches Zentrum für Neurodegenerative Erkrankungen, Partner site Berlin, Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Partner site Berlin, Berlin, Germany
| | - Thomas Liman
- Center for Stroke Research Berlin, Berlin, Germany
- Deutsches Zentrum für Neurodegenerative Erkrankungen, Partner site Berlin, Berlin, Germany
- Department of Neurology, Evangelical Hospital Oldenburg, Carl von Ossietzky University, Oldenburg, Germany
| | - Thomas Thiele
- Institut für Transfusionsmedizin, Universitätsmedizin Rostock, Rostock, Germany
| | - Theodore E. Warkentin
- Department of Pathology and Molecular Medicine and Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Andreas Greinacher
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| |
Collapse
|
4
|
|
5
|
Dabbiru VAS, Müller L, Schönborn L, Greinacher A. Vaccine-Induced Immune Thrombocytopenia and Thrombosis (VITT)-Insights from Clinical Cases, In Vitro Studies and Murine Models. J Clin Med 2023; 12:6126. [PMID: 37834770 PMCID: PMC10573542 DOI: 10.3390/jcm12196126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/15/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
An effective worldwide vaccination campaign started and is still being carried out in the face of the coronavirus disease 2019 (COVID-19) pandemic. While vaccines are great tools to confront the pandemic, predominantly adenoviral vector-based vaccines can cause a rare severe adverse effect, termed vaccine-induced immune thrombocytopenia and thrombosis (VITT), in about 1 in 100,000 vaccinated individuals. VITT is diagnosed 5-30 days post-vaccination and clinically characterized by thrombocytopenia, strongly elevated D-dimer levels, platelet-activating anti-platelet factor 4 (PF4) antibodies and thrombosis, especially at atypical sites such as the cerebral venous sinus and/or splanchnic veins. There are striking similarities between heparin-induced thrombocytopenia (HIT) and VITT. Both are caused by anti-PF4 antibodies, causing platelet and leukocyte activation which results in massive thrombo-inflammation. However, it is still to be determined why PF4 becomes immunogenic in VITT and which constituent of the vaccine triggers the immune response. As VITT-like syndromes are increasingly reported in patients shortly after viral infections, direct virus-PF4 interactions might be most relevant. Here we summarize the current information and hypotheses on the pathogenesis of VITT and address in vivo models, especially murine models for further studies on VITT.
Collapse
Affiliation(s)
| | | | | | - Andreas Greinacher
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, 17489 Greifswald, Germany; (V.A.S.D.); (L.M.); (L.S.)
| |
Collapse
|
6
|
Schönborn L, Seck SE, Thiele T, Kaderali L, Hoffmann T, Hlinka A, Lindhoff-Last E, Völker U, Selleng K, Buoninfante A, Cavaleri M, Greinacher A. Long-term outcome in vaccine-induced immune thrombocytopenia and thrombosis. J Thromb Haemost 2023; 21:2519-2527. [PMID: 37394120 DOI: 10.1016/j.jtha.2023.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/13/2023] [Accepted: 06/17/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Rapid diagnosis and treatment has improved outcome of patients with vaccine-induced immune thrombocytopenia and thrombosis (VITT). However, after the acute episode, many questions on long-term management of VITT remained unanswered. OBJECTIVES To analyze, in patients with VITT, the long-term course of anti-platelet factor 4 (PF4) antibodies; clinical outcomes, including risk of recurrent thrombosis and/or thrombocytopenia; and the effects of new vaccinations. METHODS 71 patients with serologically confirmed VITT in Germany were enrolled into a prospective longitudinal study and followed for a mean of 79 weeks from March 2021 to January 2023. The course of anti-PF4 antibodies was analyzed by consecutive anti-PF4/heparin immunoglobulin G enzyme-linked immunosorbent assay and PF4-enhanced platelet activation assay. RESULTS Platelet-activating anti-PF4 antibodies became undetectable in 62 of 71 patients (87.3%; 95% CI, 77.6%-93.2%). In 6 patients (8.5%), platelet-activating anti-PF4 antibodies persisted for >18 months. Five of 71 patients (7.0%) showed recurrent episodes of thrombocytopenia and/or thrombosis; in 4 of them (80.0%), alternative explanations beside VITT were present. After further COVID-19 vaccination with a messenger RNA vaccine, no reactivation of platelet-activating anti-PF4 antibodies or new thrombosis was observed. No adverse events occurred in our patients subsequently vaccinated against influenza, tick-borne encephalitis, varicella, tetanus, diphtheria, pertussis, and polio. No new thrombosis occurred in the 24 patients (33.8%) who developed symptomatic SARS-CoV-2 infection following recovery from acute VITT. CONCLUSION Once the acute episode of VITT has passed, patients appear to be at low risk for recurrent thrombosis and/or thrombocytopenia.
Collapse
Affiliation(s)
- Linda Schönborn
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Sabrina E Seck
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Thomas Thiele
- Institute of Transfusion Medicine, University Medicine Rostock, Rostock, Germany
| | - Lars Kaderali
- Institute of Bioinformatics, University Medicine Greifswald, Greifswald, Germany
| | - Till Hoffmann
- Institute for Transplantation Diagnostics and Cell Therapeutics, University Hospital Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Annalena Hlinka
- Institute for Transplantation Diagnostics and Cell Therapeutics, University Hospital Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Edelgard Lindhoff-Last
- Cardioangiology Center Bethanien Hospital, CCB Coagulation Center and CCB Coagulation Research Center, Frankfurt, Hessen, Germany
| | - Uwe Völker
- Interfaculty Institute of Genetics and Functional Genomics, University Medicine Greifswald, Greifswald, Germany
| | - Kathleen Selleng
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Alessandra Buoninfante
- Health Threats and Vaccines Strategy, European Medicines Agency, Amsterdam, The Netherlands
| | - Marco Cavaleri
- Health Threats and Vaccines Strategy, European Medicines Agency, Amsterdam, The Netherlands
| | - Andreas Greinacher
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany.
| |
Collapse
|
7
|
Edmonds R, Schönborn L, Habben S, Paparoupa M, Greinacher A, Schuppert F. Vaccine-induced immune thrombotic thrombocytopenia (VITT) after SARS-CoV-2 vaccination: Two cases from Germany with unusual presentation. Clin Case Rep 2023; 11:e6883. [PMID: 36698527 PMCID: PMC9859986 DOI: 10.1002/ccr3.6883] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 10/15/2022] [Accepted: 01/01/2023] [Indexed: 01/22/2023] Open
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare clinical condition that has emerged during the mass immunization against SARS-CoV-2. Reports indicate that VITT may also be induced by other vaccines, such as the human papillomavirus vaccine, or occur independently of vaccination. Its recognition requires a high index of suspicion, especially in patients presenting with thrombocytopenia and thrombosis several days after vaccination with an adenoviral vector-based vaccine against SARS-CoV-2. Bleeding manifestations do not exclude VITT, as initially assumed. It is of great importance to perform the appropriate diagnostic tests early in the course of the disease, as false-negative results may occur and many aspects of VITT are not fully understood. These two cases from Germany demonstrate unusual presentations of VITT.
Collapse
Affiliation(s)
- Rhea Edmonds
- Department of Gastroenterology, Endocrinology, Diabetology and General MedicineKlinikum KasselKasselGermany,Campus Kassel of the University of SouthamptonSouthamptonUK
| | - Linda Schönborn
- Department of Transfusion Medicine, Institute of Immunology and Transfusion MedicineUniversity of GreifswaldGreifswaldGermany
| | - Sunke Habben
- Department of Gastroenterology, Endocrinology, Diabetology and General MedicineKlinikum KasselKasselGermany,Campus Kassel of the University of SouthamptonSouthamptonUK
| | - Maria Paparoupa
- Department of Intensive Care MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Andreas Greinacher
- Department of Transfusion Medicine, Institute of Immunology and Transfusion MedicineUniversity of GreifswaldGreifswaldGermany
| | - Frank Schuppert
- Department of Gastroenterology, Endocrinology, Diabetology and General MedicineKlinikum KasselKasselGermany,Campus Kassel of the University of SouthamptonSouthamptonUK
| |
Collapse
|
8
|
Salih F, Schönborn L, Endres M, Greinacher A. Immunvermittelte Sinus- und Hirnvenenthrombosen: VITT und
prä-VITT als Modellerkrankung. AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1936-3123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ZusammenfassungIn diesem Übersichtsartikel beschreiben wir die klinischen und
paraklinischen Charakteristika der Vakzin-induzierten immunthrombotischen
Thrombozytopenie (VITT) und fassen den gegenwärtigen Kenntnisstand zur
Pathogenese zusammen. Bei der VITT bilden sich 5–20 Tage nach einer
Impfung mit einem Adenovirus-vektorbasiertem SARS-CoV-2-Vakzin (AstraZeneca oder
Johnson & Johnson) lebensbedrohliche Thrombosen aus, vor allem in den
zerebralen Sinus und Hirnvenen. Laborchemisch zeigt sich eine typische
Thrombozytopenie mit erhöhten D-Dimeren. Der Pathogenese liegen
immunologische Prozesse zugrunde, die Ähnlichkeiten mit der
Heparin-induzierten Thrombozytopenie aufweisen: so geht die VITT mit
hochtitrigem Immunoglobulin G gegen das thrombozytäre Protein
Plättchenfaktor 4 (PF4) einher. Durch die Interaktion mit dem Impfstoff
wird PF4 so verändert, dass es von Antikörper-produzierenden
Zellen des Immunsystems erkannt wird. Die so produzierten
Anti-PF4-Antikörper führen über thrombozytäre
FcγIIa-Rezeptoren zu einer Plättchenaktivierung. Der Nachweis
plättchenaktivierender Anti-PF4-Antikörper bestätigt die
Diagnose einer VITT. Antikoagulanzien, die die Bildung von Thrombin oder
Thrombin selbst blockieren und hochdosiertes i. v.-Immunglobulin G, das
die Fcγ-Rezeptor-vermittelte Zellaktivierung inhibiert, stellen die
wirksame und kausale Behandlung der VITT dar. Bei Patienten mit katastrophalem
Verlauf kann ein Plasmaaustausch versucht werden. Bei einigen Patienten ist ein
prä-VITT Syndrom als Prodromalstadium zu beoachten, das sich
typischerweise mit Kopfschmerzen manifestieren kann und dessen frühe
Behandlung hilft, thrombotische Komplikationen zu vermeiden. Die spezifische
Dynamik der VITT-assozierten Immunreaktion entspricht einer transienten,
sekundären Immunantwort. Aktuelle Studien gehen der Frage nach, wie PF4
an unterschiedliche adenovirale Proteine bindet und beleuchten die Rolle von
anderen Impfstoff-Bestandteilen als potentielle Liganden für die
PF4-Bindung. Einige dieser Faktoren sind auch an der Etablierung eines
proinflammatorischen Milieus („danger signal“) beteiligt, das
unmittelbar nach der Impfung die 1. Phase der VITT-Pathogenese triggert. Sobald
in der 2. Phase der VITT-Pathogenese hohe Titer von Anti-PF4-Antikörper
gebildet sind, aktivieren diese neben Thrombozyten auch Granulozyten. In einem
als NETose (von „neutrophil extracellular traps“) bezeichneten
Prozess setzen aktivierte Granulozyten dabei DNA frei, mit der PF4 weitere
Komplexe bildet, an die Anti-PF4-Antikörper binden. Dies
verstärkt die Fcγ-Rezeptor-vermittelte Zellaktivierung weiter
mit der Folge einer ausgeprägten Thrombin-Bildung. Zum Ende des Artikels
geben wir einen Ausblick, welchen Einfluss die bisherigen Erkenntnisse zur VITT
auf weitere globale Impfkampagnen gegen SARS-CoV-2 haben und beleuchten, wie
Anti-PF4-Antikörper jenseits von VITT und HIT auch eine Rolle bei
seltenen Erkrankungen spielen, die mit rezidivierenden venösen und
arteriellen Thrombosen einhergehen.
Collapse
Affiliation(s)
- Farid Salih
- Klinik für Neurologie mit Experimenteller Neurologie,
Charité Universitätsmedizin Berlin, Berlin,
Germany
| | - Linda Schönborn
- Institut für Transfusionsmedizin, Universitätsmedizin
Greifswald, Greifswald, Germany
| | - Matthias Endres
- Klinik für Neurologie mit Experimenteller Neurologie,
Charité Universitätsmedizin Berlin, Berlin,
Germany
| | - Andreas Greinacher
- Institut für Transfusionsmedizin, Universitätsmedizin
Greifswald, Greifswald, Germany
| |
Collapse
|
9
|
Schönborn L, Thiele T, Esefeld M, El Debuch K, Wesche J, Seck SE, Kaderali L, Wolff M, Warkentin TE, Greinacher A. Quantitative interpretation of PF4/heparin-EIA optical densities in predicting platelet-activating VITT antibodies. J Thromb Haemost 2022; 20:2579-2586. [PMID: 36006172 DOI: 10.1111/jth.15862] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a prothrombotic, heparin-induced thrombocytopenia (HIT)-mimicking, adverse reaction caused by platelet-activating anti-platelet factor 4 (PF4) antibodies that occurs rarely after adenovirus vector-based COVID-19 vaccination. Strength of PF4-dependent enzyme immunoassay (EIA) reactivity-judged by optical density (OD) measurements-strongly predicts platelet-activating properties of HIT antibodies in a functional test. Whether a similar relationship holds for VITT antibodies is unknown. OBJECTIVES To evaluate probability for positive platelet activation testing for VITT antibodies based upon EIA OD reactivity; and to investigate simple approaches to minimize false-negative platelet activation testing for VITT. METHODS All samples referred for VITT testing were systematically evaluated by semiquantitative in-house PF4/heparin-EIA (OD readings) and PF4-induced platelet activation (PIPA) testing within a cohort study. EIA-positive sera testing PIPA-negative were retested following 1/4 to 1/10 dilution. Logistic regression was performed to predict the probability of a positive PIPA per magnitude of EIA reactivity. RESULTS Greater EIA ODs in sera from patients with suspected VITT correlated strongly with greater likelihood of PIPA reactivity. Of 61 sera (with OD values >1.0) testing negative in the PIPA, a high proportion (27/61, 44.3%) became PIPA positive when tested at 1/4 to 1/10 dilution. CONCLUSIONS VITT serology resembles HIT in that greater EIA OD reactivity predicts higher probability of positive testing for platelet-activating antibodies. Unlike the situation with HIT antibodies, however, diluting putative VITT serum increases probability of a positive platelet activation assay, suggesting that optimal complex formation depends on the stoichiometric ratio of PF4 and anti-PF4 VITT antibodies.
Collapse
Affiliation(s)
- Linda Schönborn
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Thomas Thiele
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Max Esefeld
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Khalil El Debuch
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Jan Wesche
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Sabrina E Seck
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Lars Kaderali
- Institute of Bioinformatics, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Martina Wolff
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, and Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andreas Greinacher
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| |
Collapse
|
10
|
|
11
|
Raster J, Greinacher A, Schönborn L. Risk of Blood Bag Lesions Induced by Standard Transfusion Devices. Transfus Med Hemother 2022; 49:401-403. [PMID: 36654972 PMCID: PMC9768288 DOI: 10.1159/000524376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 03/29/2022] [Indexed: 01/21/2023] Open
|
12
|
Salih F, Kohler S, Schönborn L, Thiele T, Greinacher A, Endres M. Early recognition and treatment of pre-VITT syndrome after adenoviral vector-based SARS-CoV-2 vaccination may prevent from thrombotic complications: review of published cases and clinical pathway. Eur Heart J Open 2022; 2:oeac036. [PMID: 35919343 PMCID: PMC9242075 DOI: 10.1093/ehjopen/oeac036] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/30/2022] [Indexed: 11/26/2022]
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare but highly morbid complication after adenoviral vector-based SARS-CoV-2 vaccination. The pre-VITT syndrome is defined as vaccine-induced immune thrombocytopenia without thrombosis typically presenting with new-onset headache. This review aims to identify at-risk patients before complications such as cerebral venous sinus thrombosis occur. We review previously published reports of 19 patients (median age 35 years, range 23-74; 16 females) who met the diagnostic criteria for a pre-VITT syndrome. Seven patients progressed to VITT, 12 patients did not. Patients who experienced VITT received delayed treatment. The median interval between the onset of headache and VITT-treatment (i.e. anticoagulation, immune globulins, or corticosteroids) was 5 days (range 1-8 days) compared with 2 days (0-5 days) in those without subsequent VITT (P = 0.033). The interval from onset of headache to anticoagulation was longer in patients with VITT (median 7 vs. 2 days; range 3-9 vs. 0-7 days; P = 0.01). Anticoagulation was safe in all patients with a pre-VITT syndrome as no haemorrhagic complications occurred after anticoagulation was started despite low platelets. The transient decline of platelet count after admission was significantly more pronounced in patients who progressed to VITT (median 67 vs. 0 × 103/µL; range 0-77 × 103/µL vs. 0-10 × 103/µL; P = 0.005). d-dimers did not differ between groups. Pre-VITT syndrome is a 'red flag' and allows to identify and preemptively treat patients at-risk of further progression to VITT. However, it must be distinguished from post-vaccination immune thrombocytopenia.
Collapse
Affiliation(s)
| | | | - Linda Schönborn
- Universitätsmedizin Greifswald, Institute of Immunology and Transfusion Medicine, Sauerbruch-Straße, 17489 Greifswald, Germany
| | - Thomas Thiele
- Universitätsmedizin Greifswald, Institute of Immunology and Transfusion Medicine, Sauerbruch-Straße, 17489 Greifswald, Germany
| | | | - Matthias Endres
- Corresponding author. Tel: +49 30 450 560101, Fax: +49 30 450 7560 932,
| |
Collapse
|
13
|
Abstract
In hundreds of patients worldwide, vaccination against COVID-19 with adenovirus vector vaccines (ChAdOx1 nCoV-19; Ad26.COV2.S) triggered platelet-activating anti-platelet factor 4 (PF4) antibodies inducing vaccine-induced immune thrombotic thrombocytopenia (VITT). In most VITT patients, platelet-activating anti-PF4-antibodies are transient and the disorder is discrete and non-recurring. However, in some patients platelet-activating antibodies persist, associated with recurrent thrombocytopenia and sometimes with relapse of thrombosis despite therapeutic-dose anticoagulation. Anti-PF4 IgG antibodies measured by enzyme-immunoassay (EIA) are usually detectable for longer than platelet-activating antibodies in functional assays, but duration of detectability is highly assay-dependent. As more than 1 vaccination dose against COVID-19 is required to achieve sufficient protection, at least 69 VITT patients have undergone subsequent vaccination with an mRNA vaccine, with no relevant subsequent increase in anti-PF4 antibody titers, thrombocytopenia, or thrombotic complications. Also, re-exposure to adenoviral vector-based vaccines in 5 VITT patients was not associated with adverse reactions. Although data are limited, vaccination against influenza also appears to be safe. SARS-CoV-2 infection reported in 1 patient with preceding VITT did not influence anti-PF4 antibody levels. We discuss how these temporal characteristics of VITT provide insights into pathogenesis.
Collapse
Affiliation(s)
| | - Andreas Greinacher
- Corresponding author. Andreas Greinacher, Professor, Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Sauerbruchstraße, Greifswald, D-17489, Germany. Tel.: +49 3834 865482; Fax: +49 3834 865489
| |
Collapse
|
14
|
Greinacher A, Schönborn L, Siegerist F, Steil L, Palankar R, Handtke S, Reder A, Thiele T, Aurich K, Methling K, Lalk M, Völker U, Endlich N. Pathogenesis of vaccine-induced immune thrombotic thrombocytopenia (VITT). Semin Hematol 2022; 59:97-107. [PMID: 35512907 PMCID: PMC8863951 DOI: 10.1053/j.seminhematol.2022.02.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 02/16/2022] [Indexed: 02/06/2023]
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT; synonym, thrombosis with thrombocytopenia syndrome, is associated with high-titer immunoglobulin G antibodies directed against platelet factor 4 (PF4). These antibodies activate platelets via platelet FcγIIa receptors, with platelet activation greatly enhanced by PF4. Here we summarize the current concepts in the pathogenesis of VITT. We first address parallels between heparin-induced thrombocytopenia and VITT, and provide recent findings on binding of PF4 to adenovirus particles and non-assembled adenovirus proteins in the 2 adenovirus vector-based COVID-19 vaccines, ChAdOx1 nCoV-19 and Ad26.COV2.S. Further, we discuss the potential role of vaccine constituents such as glycosaminoglycans, EDTA, polysorbate 80, human cell-line proteins and nucleotides as potential binding partners of PF4. The immune response towards PF4 in VITT is likely triggered by a proinflammatory milieu. Human cell-line proteins, non-assembled virus proteins, and potentially EDTA may contribute to the proinflammatory state. The transient nature of the immune response towards PF4 in VITT makes it likely that-as in heparin-induced thrombocytopenia -marginal zone B cells are key for antibody production. Once high-titer anti-PF4 antibodies have been formed 5 to 20 days after vaccination, they activate platelets and granulocytes. Activated granulocytes undergo NETosis and the released DNA also forms complexes with PF4, which fuels the Fcγ receptor-dependent cell activation process, ultimately leading to massive thrombin generation. Finally, we summarize our initial observations indicating that VITT-like antibodies might also be present in rare patients with recurrent venous and arterial thrombotic complications, independent of vaccination.
Collapse
Affiliation(s)
- Andreas Greinacher
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany,Corresponding author: Prof. Dr Andreas Greinacher, Institut für Transfusions medizin, Universitätsmedizin Greifswald, Sauerbruchstraße, D-17489 Greifswald, Germany. Tel: +49 383 486 5482; fax: +49 383 486 5489
| | - Linda Schönborn
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Florian Siegerist
- Institute for Anatomy and Cell Biology, University Medicine Greifswald, Greifswald, Germany
| | - Leif Steil
- Interfaculty Institute of Genetics and Functional Genomics, Department Functional Genomics, University Medicine Greifswald, Greifswald, Germany
| | - Raghavendra Palankar
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Stefan Handtke
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Alexander Reder
- Interfaculty Institute of Genetics and Functional Genomics, Department Functional Genomics, University Medicine Greifswald, Greifswald, Germany
| | - Thomas Thiele
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Konstanze Aurich
- Institute of Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Karen Methling
- Institute of Biochemistry, University of Greifswald, Greifswald, Germany
| | - Michael Lalk
- Institute of Biochemistry, University of Greifswald, Greifswald, Germany
| | - Uwe Völker
- Interfaculty Institute of Genetics and Functional Genomics, Department Functional Genomics, University Medicine Greifswald, Greifswald, Germany
| | - Nicole Endlich
- Institute for Anatomy and Cell Biology, University Medicine Greifswald, Greifswald, Germany
| |
Collapse
|
15
|
Schönborn L, Thiele T, Kaderali L, Günther A, Hoffmann T, Seck SE, Selleng K, Greinacher A. Most anti-PF4 antibodies in vaccine-induced immune thrombotic thrombocytopenia are transient. Blood 2022; 139:1903-1907. [PMID: 35113987 PMCID: PMC8816791 DOI: 10.1182/blood.2021014214] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/26/2022] [Indexed: 11/20/2022] Open
Abstract
Vaccine-induced thrombotic thrombocytopenia (VITT) is triggered by vaccination against COVID-19 with adenovirus vector vaccines (ChAdOx1 nCoV-19; Ad26.COV2-S). In this observational study, we followed VITT patients for changes in their reactivity of platelet-activating antiplatelet factor 4 (PF4) immunoglobulin G (IgG) antibodies by an anti-PF4/heparin IgG enzyme immunoassay (EIA) and a functional test for PF4-dependent, platelet-activating antibodies, and new thrombotic complications. Sixty-five VITT patients (41 females; median, 51 years; range, 18-80 years) were followed for a median of 25 weeks (range, 3-36 weeks). In 48/65 patients (73.8%; CI, 62.0% to 83.0%) the functional assay became negative. The median time to negative functional test result was 15.5 weeks (range, 5-28 weeks). In parallel, EIA optical density (OD) values decreased from median 3.12 to 1.52 (P < .0001), but seroreversion to a negative result was seen in only 14 (21.5%) patients. Five (7.5%) patients showed persistent platelet-activating antibodies and high EIA ODs for >11 weeks. None of the 29 VITT patients who received a second vaccination dose with an mRNA COVID-19 vaccine developed new thromboses or relevant increase in anti-PF4/heparin IgG EIA OD, regardless of whether PF4-dependent platelet-activating antibodies were still present. PF4-dependent platelet-activating antibodies are transient in most patients with VITT. VITT patients can safely receive a second COVID-19 mRNA-vaccine shot.
Collapse
Affiliation(s)
| | - Thomas Thiele
- Institute of Immunology and Transfusion Medicine and
| | - Lars Kaderali
- Institute of Bioinformatics, University Medicine Greifswald, Greifswald, Germany
| | - Albrecht Günther
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany; and
| | - Till Hoffmann
- Institute for Transplantation Diagnostics and Cell Therapeutics, University Hospital Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | | | | | | |
Collapse
|
16
|
Platton S, Schönborn L, Charrot S, Badat M, Boot J, McDonald V, Sivapalaratnam S, Bariana T, Theodoulou A, Bowles L, MacCallum P. Vaccine-induced immune thrombocytopenia and thrombosis: The decline in anti-platelet factor 4 antibodies is assay-dependent. Br J Haematol 2021; 197:428-430. [PMID: 34970735 DOI: 10.1111/bjh.18022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/30/2021] [Accepted: 12/14/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Sean Platton
- The Royal London Haemophilia Centre, Barts Health NHS Trust, London, UK
| | - Linda Schönborn
- Institut für Immunologie und Transfusionsmedizin, Abteilung Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Sarah Charrot
- Department of Haematology, Barts Health NHS Trust, London, UK
| | - Mohsin Badat
- Department of Haematology, Barts Health NHS Trust, London, UK
| | - Jesca Boot
- Department of Haematology, Barts Health NHS Trust, London, UK
| | - Vickie McDonald
- Department of Haematology, Barts Health NHS Trust, London, UK
| | | | - Tadbir Bariana
- Department of Haematology, Barts Health NHS Trust, London, UK
| | | | - Louise Bowles
- Department of Haematology, Barts Health NHS Trust, London, UK
| | - Peter MacCallum
- Department of Haematology, Barts Health NHS Trust, London, UK.,Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| |
Collapse
|
17
|
Thiele T, Weisser K, Schönborn L, Funk MB, Weber G, Greinacher A, Keller-Stanislawski B. Laboratory confirmed vaccine-induced immune thrombotic thrombocytopenia: Retrospective analysis of reported cases after vaccination with ChAdOx-1 nCoV-19 in Germany. Lancet Reg Health Eur 2021; 12:100270. [PMID: 34901912 PMCID: PMC8645417 DOI: 10.1016/j.lanepe.2021.100270] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a severe adverse event of SARS-CoV-2 vaccination. We describe the characteristics of patients reported in Germany based on the Brighton Collaboration (BC) case definition criteria for Thrombosis and Thrombocytopenia Syndrome (TTS) and focus on patients with complete anti-platelet factor 4 (PF4)-antibody laboratory work up. Methods The adverse drug reaction database of the Paul-Ehrlich Institute was queried for TTS cases following ChAdOx1 nCoV-19 vaccination from February 1, until May 21, 2021. Cases with reports from the Greifswald laboratory were analysed in detail. Findings PF4 antibody tests were available for 69 suspected TTS cases reported to the Paul-Ehrlich Institute, of whom 52 patients fulfilled the BC case definition; 37 (71%) women, 15 (29%) men, median age 46·0 years (interquartile range 31·0-60·3 years). Cerebral venous sinus thrombosis was confirmed in 37 (71%), (additional) multiple thromboses in 19 (37%) patients. Twelve patients died. Non-survivors showed lower platelet counts compared to survivors (median nadir 15,000/µL vs 49,000/µL; p<0·0001). Combined anti-PF4/heparin IgG ELISA and PF4-dependent platelet activation testing yielded sensitivity of 96% (95% confidence interval 87-100%) and specificity of 77% (50-93%) for TTS. Four patients with thrombocytopenia but without thrombosis presented with severe headache or cerebral bleeding, explaining the lower specificity. Interpretation VITT has high mortality and can present with isolated thrombocytopenia, severe headache, and bleeding. Demonstration of platelet activating anti-PF4 IgG has high sensitivity for TTS and captures a wider spectrum of clinically relevant VITT than the current BC case definition. Funding Deutsche Forschungsgemeinschaft: 374031971-TRR240; Domagk-Programm Universitätsmedizin Greifswald
Collapse
Affiliation(s)
- Thomas Thiele
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald
| | - Karin Weisser
- Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Division Safety of Medicinal Products and Medical Devices, Langen, Germany
| | - Linda Schönborn
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald
| | - Markus B Funk
- Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Division Safety of Medicinal Products and Medical Devices, Langen, Germany
| | - Gabriele Weber
- Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Division Safety of Medicinal Products and Medical Devices, Langen, Germany
| | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald
| | - Brigitte Keller-Stanislawski
- Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Division Safety of Medicinal Products and Medical Devices, Langen, Germany
| |
Collapse
|
18
|
Salih F, Schönborn L, Kohler S, Franke C, Möckel M, Dörner T, Bauknecht HC, Pille C, Graw JA, Alonso A, Pelz J, Schneider H, Bayas A, Christ M, Kuramatsu JB, Thiele T, Greinacher A, Endres M. Vaccine-Induced Thrombocytopenia with Severe Headache. N Engl J Med 2021; 385:2103-2105. [PMID: 34525282 PMCID: PMC8522796 DOI: 10.1056/nejmc2112974] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Farid Salih
- Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | | | | | | | | | | | | | - Jan A Graw
- Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Johann Pelz
- University Hospital of Leipzig, Leipzig, Germany
| | | | | | | | | | | | | | | |
Collapse
|
19
|
|
20
|
Thiele T, Ulm L, Holtfreter S, Schönborn L, Kuhn SO, Scheer C, Warkentin TE, Bröker BM, Becker K, Aurich K, Selleng K, Hübner NO, Greinacher A. Frequency of positive anti-PF4/polyanion antibody tests after COVID-19 vaccination with ChAdOx1 nCoV-19 and BNT162b2. Blood 2021; 138:299-303. [PMID: 33988688 PMCID: PMC8129797 DOI: 10.1182/blood.2021012217] [Citation(s) in RCA: 108] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/11/2021] [Indexed: 11/20/2022] Open
Abstract
Vaccination using the adenoviral vector COVID-19 vaccine ChAdOx1 nCoV-19 (AstraZeneca) has been associated with rare vaccine-induced immune thrombotic thrombocytopenia (VITT). Affected patients test strongly positive in platelet factor 4 (PF4)/polyanion enzyme immunoassays (EIAs), and serum-induced platelet activation is maximal in the presence of PF4. We determined the frequency of anti-PF4/polyanion antibodies in healthy vaccinees and assessed whether PF4/polyanion EIA+ sera exhibit platelet-activating properties after vaccination with ChAdOx1 nCoV-19 (n = 138) or BNT162b2 (BioNTech/Pfizer; n = 143). In total, 19 of 281 participants tested positive for anti-PF4/polyanion antibodies postvaccination (All: 6.8% [95% confidence interval (CI), 4.4-10.3]; BNT162b2: 5.6% [95% CI, 2.9-10.7]; ChAdOx1 nCoV-19: 8.0% [95% CI, 4.5% to 13.7%]). Optical densities were mostly low (between 0.5 and 1.0 units; reference range, <0.50), and none of the PF4/polyanion EIA+ samples induced platelet activation in the presence of PF4. We conclude that positive PF4/polyanion EIAs can occur after severe acute respiratory syndrome coronavirus 2 vaccination with both messenger RNA- and adenoviral vector-based vaccines, but many of these antibodies likely have minor (if any) clinical relevance. Accordingly, low-titer positive PF4/polyanion EIA results should be interpreted with caution when screening asymptomatic individuals after vaccination against COVID-19. Pathogenic platelet-activating antibodies that cause VITT do not occur commonly following vaccination.
Collapse
Affiliation(s)
- Thomas Thiele
- Department of Transfusion Medicine, Institute of Immunology and Transfusion Medicine
| | - Lena Ulm
- Friedrich-Loeffler Institute of Medical Microbiology
| | - Silva Holtfreter
- Department of Immunology, Institute of Immunology and Transfusion Medicine, and
| | - Linda Schönborn
- Department of Transfusion Medicine, Institute of Immunology and Transfusion Medicine
| | - Sven Olaf Kuhn
- Department of Anaesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Christian Scheer
- Department of Anaesthesiology, University Medicine Greifswald, Greifswald, Germany
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine and
- Department of Medicine, McMaster University, Hamilton, ON, Canada; and
| | - Barbara M Bröker
- Department of Immunology, Institute of Immunology and Transfusion Medicine, and
| | | | - Konstanze Aurich
- Department of Transfusion Medicine, Institute of Immunology and Transfusion Medicine
| | - Kathleen Selleng
- Department of Transfusion Medicine, Institute of Immunology and Transfusion Medicine
| | - Nils-Olaf Hübner
- Central Unit for Infection Prevention and Control, University Medicine Greifswald, Greifswald, Germany
| | - Andreas Greinacher
- Department of Transfusion Medicine, Institute of Immunology and Transfusion Medicine
| |
Collapse
|
21
|
Greffin K, Schmidt S, Schönborn L, Muehlan H. "Blood for Blood"? Personal Motives and Deterrents for Blood Donation in the German Population. Int J Environ Res Public Health 2021; 18:4238. [PMID: 33923586 PMCID: PMC8072955 DOI: 10.3390/ijerph18084238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 11/16/2022]
Abstract
It is crucial to provide updated knowledge about blood (non-)donors, as it is necessary to design targeted interventions with the aim of retaining blood donors and thus contributing to a functioning health system. This study investigates the prevalence and socio-demographic patterning of lifetime blood donation, assessing blood donation intention within the next 12 months and exploring personal motives and deterrents of blood donation qualitatively in the German population. A face-to-face cross-sectional survey with 2531 respondents was conducted, representative of the German population in terms of age, gender, and residency. Closed as well as open questions were asked. Qualitative content analysis was used for coding the qualitative material. Basic descriptive statistics were conducted to address our research questions. More than one-third of the participants reported that they have donated blood at least once in their lifetime. Motives and deterrents were assigned to 10 domains with 50 main categories and 65 sub-categories. The most frequently stated motives for blood donation were "altruism", "social responsibility", and "charity", whereas the most frequently stated deterrents were "health status", "age", and "lack of time". This study provides information to tailor recruitment and reactivation strategies to address donors at different career steps-from non-donor to loyal donor.
Collapse
Affiliation(s)
- Klara Greffin
- Department of Psychology, University of Greifswald, 17489 Greifswald, Germany; (S.S.); (H.M.)
| | - Silke Schmidt
- Department of Psychology, University of Greifswald, 17489 Greifswald, Germany; (S.S.); (H.M.)
| | - Linda Schönborn
- Institute for Immunology & Transfusion Medicine, University Medicine Greifswald, 17489 Greifswald, Germany;
| | - Holger Muehlan
- Department of Psychology, University of Greifswald, 17489 Greifswald, Germany; (S.S.); (H.M.)
| |
Collapse
|
22
|
Eichler H, Feyer AK, Weitmann K, Hoffmann W, Henseler O, Opitz A, Patek A, Hans DN, Schönborn L, Greinacher A. Population-Based Analysis of the Impact of Demographics on the Current and Future Blood Supply in the Saarland. Transfus Med Hemother 2020; 48:175-182. [PMID: 34177423 DOI: 10.1159/000512645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 10/19/2020] [Indexed: 12/14/2022] Open
Abstract
Background The federal state of Saarland (SL) is experiencing the fastest demographic change in the western part of Germany. In this study, we analyzed retrospective data on the current and future supply of red blood cell concentrates (RBC) in this region and compared it to the current and future RBC demand in SL hospitals. Methods The projection of the SL blood supply in 2030 was modeled based on SL demographics for age distribution and donation frequency of donors, and the RBC transfusion data for in-house patients. These results were compared to published data on the transfusion demand from the state of Mecklenburg-Western Pomerania (MV). Results For the period January 1 to December 31, 2017, a total of 43,205 whole blood donations were collected. The donation frequency in SL never exceeded 80 per 1,000 inhabitants and was well below the numbers in MV. Thirty-one percent of the donors were responsible for 53.5% of the donations, and donors older than 45 years of age contributed highly to the total blood supply. In addition, 40,614 RBC transfusions at 10 SL hospitals were analyzed representing nearly all RBC transfusions for in-house patients in this region. RBC transfusions per 1,000 inhabitants increased with age from 24 (50-54) to 140 (80-84) years. Facing an already existing structural deficit of nearly 8,200 RBC in 2017, the projection predicts a dramatic increase in the regional deficit to >18,300 RBC in 2030. Conclusion Our results on RBC demand in SL are comparable but not identical to those projected for the region of MV in eastern Germany. Due to the ongoing demographic changes in Germany as a whole, regular regional monitoring of RBC demand and the age structure of blood recipients and donors should be implemented to allow for better strategic planning in blood transfusion services and hospitals.
Collapse
Affiliation(s)
- Hermann Eichler
- Universität des Saarlandes, Institut für Klinische Hämostaseologie und Transfusionsmedizin, Homburg, Germany
| | - Anna Katharina Feyer
- Universität des Saarlandes, Institut für Klinische Hämostaseologie und Transfusionsmedizin, Homburg, Germany
| | - Kerstin Weitmann
- Universitätsmedizin Greifswald, Institut für Community Medicine, Greifswald, Germany
| | - Wolfgang Hoffmann
- Universitätsmedizin Greifswald, Institut für Community Medicine, Greifswald, Germany
| | | | - Andreas Opitz
- DRK-Blutspendedienst Rheinland-Pfalz und Saarland, Bad Kreuznach, Germany
| | - Alexander Patek
- Blutspendezentrale Saar-Pfalz, Klinikum Saarbrücken, Saarbrücken, Germany
| | | | - Linda Schönborn
- Universitätsmedizin Greifswald, Institut für Immunologie und Transfusionsmedizin, Greifswald, Germany
| | - Andreas Greinacher
- Universitätsmedizin Greifswald, Institut für Immunologie und Transfusionsmedizin, Greifswald, Germany
| |
Collapse
|
23
|
Schönborn L, Weitmann K, Greinacher A, Hoffmann W. Characteristics of Recipients of Red Blood Cell Concentrates in a German Federal State. Transfus Med Hemother 2020; 47:370-377. [PMID: 33173455 PMCID: PMC7590768 DOI: 10.1159/000510207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 07/05/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Annual transfusion rates in many European countries range between 25 and 35 red blood cell concentrates (RBCs)/1,000 population. It is unclear why transfusion rates in Germany are considerably higher (approx. 50-55 RBCs/1,000 population). METHODS We assessed the characteristics of transfusion recipients at all hospitals of the German federal state Mecklenburg-Western Pomerania during a 10-year longitudinal study. RESULTS Although 75% of patients received ≤4 RBCs/patient in 2015 (1 RBC: 11.3%; 2 RBCs: 42.6%; 3 RBCs: 6.3%; 4 RBCs: 15.0%), the mean transfusion index was 4.6 RBCs due to a minority of patients with a high transfusion demand. Two thirds of all RBCs were transfused to only 25% of RBC recipients. Consistently, male patients received a higher number of RBCs (2005: 54.2%; 2015: 56.8%) and had a higher mean transfusion index than female patients (mean 5.1 ± 7.2; median 2; inter-quartile range [IQR] 2-4 vs. mean 4.0 ± 5.8; median 2; IQR 2-4). The absolute transfusion demand decreased between 2005 and 2015 by 13.5% due to a composite of active reduction (clinical practice change) and population decline in the 65- to 75-year age group (lower birth rate cohort 1940-1950); however, with major differences between hospitals (range from -61.0 to +41.4%). CONCLUSION Transfusion demand in a population could largely be driven by patients with high transfusion demand. Different treatment practices in this group of patients probably add to the major differences in transfusion demand per 1,000 individuals between countries. The available data cannot prove this hypothesis. Implementation of a diagnosis-related group-based monitoring system is urgently needed to allow informative monitoring on the population level and meaningful comparisons between transfusion practices.
Collapse
Affiliation(s)
- Linda Schönborn
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Kerstin Weitmann
- Institut für Community Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Wolfgang Hoffmann
- Institut für Community Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| |
Collapse
|
24
|
Schönborn L, Weitmann K, Greger N, Kiefel V, Hoffmann W, Greinacher A. Longitudinal Changes in the Blood Supply and Demand in North-East-Germany 2005-2015. Transfus Med Hemother 2017; 44:224-231. [PMID: 28924427 DOI: 10.1159/000479538] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 07/18/2017] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Securing future blood supply is a major issue of transfusion safety. In this prospective 10-year longitudinal study we enrolled all blood donation services and hospitals of the federal state Mecklenburg-Western Pomerania. METHODS AND RESULTS From 2005 to 2015 (time period with major demographic effects), whole blood donation numbers declined by 18%. In male donors this paralleled the demographic change, while donation rates of females declined 12.4% more than expected from demography. In parallel, red cell transfusion rates/1,000 population decreased from 2005 to 2015 from 56 to 51 (-8.4%), primarily due to less transfusions in patients >60 years. However, the transfusion demand declined much less than blood donation numbers: -13.5% versus -18%, and the population >65 years (highest transfusion demand) will further increase. The key question is whether the decline in transfusion demand observed over the previous years will further continue, hereby compensating for reduced blood donation numbers due to the demographic change. The population structure of Mecklenburg-Western Pomerania reflects all Eastern German federal states, while the Western German federal states will reach similar ratios of age groups 18-64 years / ≥65 years about 10 years later. CONCLUSIONS Regular monitoring of age- and sex-specific donation and transfusion data is urgently required to allow transfusion services strategic planning for securing future blood supply.
Collapse
Affiliation(s)
- Linda Schönborn
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Kerstin Weitmann
- Institut für Community Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Nico Greger
- Institut für Transfusionsmedizin, Universitätsmedizin Rostock, Rostock, Germany
| | - Volker Kiefel
- Institut für Transfusionsmedizin, Universitätsmedizin Rostock, Rostock, Germany
| | - Wolfgang Hoffmann
- Institut für Community Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| |
Collapse
|