1
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Pfeffer MA, Kohs TC, Vu HH, Jordan KR, Wang JSH, Lorentz CU, Tucker EI, Puy C, Olson SR, DeLoughery TG, Hinds MT, Keshari RS, Gailani D, Lupu F, McCarty OJ, Shatzel JJ. Factor XI Inhibition for the Prevention of Catheter-Associated Thrombosis in Patients With Cancer Undergoing Central Line Placement: A Phase 2 Clinical Trial. Arterioscler Thromb Vasc Biol 2024; 44:290-299. [PMID: 37970718 PMCID: PMC10877270 DOI: 10.1161/atvbaha.123.319692] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/24/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Despite the ubiquitous utilization of central venous catheters in clinical practice, their use commonly provokes thromboembolism. No prophylactic strategy has shown sufficient efficacy to justify routine use. Coagulation factors FXI (factor XI) and FXII (factor XII) represent novel targets for device-associated thrombosis, which may mitigate bleeding risk. Our objective was to evaluate the safety and efficacy of an anti-FXI mAb (monoclonal antibody), gruticibart (AB023), in a prospective, single-arm study of patients with cancer receiving central line placement. METHODS We enrolled ambulatory cancer patients undergoing central line placement to receive a single dose of gruticibart (2 mg/kg) administered through the venous catheter within 24 hours of placement and a follow-up surveillance ultrasound at day 14 for evaluation of catheter thrombosis. A parallel, noninterventional study was used as a comparator. RESULTS In total, 22 subjects (n=11 per study) were enrolled. The overall incidence of catheter-associated thrombosis was 12.5% in the interventional study and 40.0% in the control study. The anti-FXI mAb, gruticibart, significantly prolonged the activated partial thromboplastin time in all subjects on day 14 compared with baseline (P<0.001). Gruticibart was well tolerated and without infusion reactions, drug-related adverse events, or clinically relevant bleeding. Platelet flow cytometry demonstrated no difference in platelet activation following administration of gruticibart. T (thrombin)-AT (antithrombin) and activated FXI-AT complexes increased following central line placement in the control study, which was not demonstrated in our intervention study. CRP (C-reactive protein) did not significantly increase on day 14 in those who received gruticibart, but it did significantly increase in the noninterventional study. CONCLUSIONS FXI inhibition with gruticibart was well tolerated without any significant adverse or bleeding-related events and resulted in a lower incidence of catheter-associated thrombosis on surveillance ultrasound compared with the published literature and our internal control study. These findings suggest that targeting FXI could represent a safe intervention to prevent catheter thrombosis. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04465760.
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Affiliation(s)
- Michael A. Pfeffer
- Division of Hematology and Medical Oncology, Oregon Health
& Science University, Portland, OR
| | - Tia C.L. Kohs
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Helen H. Vu
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Kelley R. Jordan
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Jenny Si Han Wang
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Christina U. Lorentz
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
- Aronora, Inc., Portland, OR
| | - Erik I. Tucker
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
- Aronora, Inc., Portland, OR
| | - Cristina Puy
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Sven R. Olson
- Division of Hematology and Medical Oncology, Oregon Health
& Science University, Portland, OR
| | - Thomas G. DeLoughery
- Division of Hematology and Medical Oncology, Oregon Health
& Science University, Portland, OR
| | - Monica T. Hinds
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Ravi S. Keshari
- Cardiovascular Biology Research Program, Oklahoma Medical
Research Foundation, Oklahoma City, OK
| | - David Gailani
- Department of Pathology, Microbiology and Immunology,
Vanderbilt University Medical Center, Nashville, TN
| | - Florea Lupu
- Cardiovascular Biology Research Program, Oklahoma Medical
Research Foundation, Oklahoma City, OK
| | - Owen J.T. McCarty
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology, Oregon Health
& Science University, Portland, OR
- Department of Biomedical Engineering, Oregon Health &
Science University, Portland, OR
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2
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Kohs TCL, Olson SR, Pang J, Jordan KR, Zheng TJ, Xie A, Hodovan J, Muller M, McArthur C, Johnson J, Sousa BB, Wallisch M, Kievit P, Aslan JE, Seixas JD, Bernardes GJL, Hinds MT, Lindner JR, McCarty OJT, Puy C, Shatzel JJ. Ibrutinib Inhibits BMX-Dependent Endothelial VCAM-1 Expression In Vitro and Pro-Atherosclerotic Endothelial Activation and Platelet Adhesion In Vivo. Cell Mol Bioeng 2022; 15:231-243. [PMID: 35611166 PMCID: PMC9124262 DOI: 10.1007/s12195-022-00723-1] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/24/2022] [Indexed: 12/22/2022] Open
Abstract
Introduction Inflammatory activation of the vascular endothelium leads to overexpression of adhesion molecules such as vascular cell adhesion molecule-1 (VCAM-1), contributing to the pro-thrombotic state underpinning atherogenesis. While the role of TEC family kinases (TFKs) in mediating inflammatory cell and platelet activation is well defined, the role of TFKs in vascular endothelial activation remains unclear. We investigated the role of TFKs in endothelial cell activation in vitro and in a nonhuman primate model of diet-induced atherosclerosis in vivo. Methods and Results In vitro, we found that ibrutinib blocked activation of the TFK member, BMX, by vascular endothelial growth factors (VEGF)-A in human aortic endothelial cells (HAECs). Blockade of BMX activation with ibrutinib or pharmacologically distinct BMX inhibitors eliminated the ability of VEGF-A to stimulate VCAM-1 expression in HAECs. We validated that treatment with ibrutinib inhibited TFK-mediated platelet activation and aggregation in both human and primate samples as measured using flow cytometry and light transmission aggregometry. We utilized contrast-enhanced ultrasound molecular imaging to measure platelet GPIbα and endothelial VCAM-1 expression in atherosclerosis-prone carotid arteries of obese nonhuman primates. We observed that the TFK inhibitor, ibrutinib, inhibited platelet deposition and endothelial cell activation in vivo. Conclusion Herein we found that VEGF-A signals through BMX to induce VCAM-1 expression in endothelial cells, and that VCAM-1 expression is sensitive to ibrutinib in vitro and in atherosclerosis-prone carotid arteries in vivo. These findings suggest that TFKs may contribute to the pathogenesis of atherosclerosis and could represent a novel therapeutic target.
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Affiliation(s)
- Tia C. L. Kohs
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
| | - Sven R. Olson
- Division of Hematology & Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
| | - Jiaqing Pang
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
| | - Kelley R. Jordan
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
| | - Tony J. Zheng
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
| | - Aris Xie
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR USA
| | - James Hodovan
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR USA
| | - Matthew Muller
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR USA
| | - Carrie McArthur
- Oregon National Primate Research Center, Oregon Health & Science University, Portland, OR USA
| | - Jennifer Johnson
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
| | - Bárbara B. Sousa
- Instituto de Medicina Molecular, João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Michael Wallisch
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA ,Aronora, Inc., Portland, OR USA
| | - Paul Kievit
- Oregon National Primate Research Center, Oregon Health & Science University, Portland, OR USA
| | - Joseph E. Aslan
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA ,Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR USA
| | - João D. Seixas
- Instituto de Medicina Molecular, João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Gonçalo J. L. Bernardes
- Instituto de Medicina Molecular, João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal ,Yusuf Hamied Department of Chemistry, University of Cambridge, Cambridge, UK
| | - Monica T. Hinds
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
| | - Jonathan R. Lindner
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR USA ,Oregon National Primate Research Center, Oregon Health & Science University, Portland, OR USA
| | - Owen J. T. McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA ,Division of Hematology & Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
| | - Cristina Puy
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA ,Division of Hematology & Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
| | - Joseph J. Shatzel
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA ,Division of Hematology & Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
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3
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Elstrott BK, Lakshmanan HH, Melrose AR, Jordan KR, Martens KL, Yang C, Peterson DF, McMurry HS, Lavasseur C, Lo JO, Olson SR, DeLoughery TG, Aslan JE, Shatzel JJ. Platelet reactivity and platelet count in women with iron deficiency treated with intravenous iron. Res Pract Thromb Haemost 2022; 6:e12692. [PMID: 35356666 PMCID: PMC8941679 DOI: 10.1002/rth2.12692] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/31/2022] [Accepted: 02/18/2022] [Indexed: 12/03/2022] Open
Abstract
Background Iron deficiency anemia (IDA) and heavy menstrual bleeding are prevalent, interrelated issues impacting over 300 million premenopausal women worldwide. IDA is generally associated with increased platelet counts; however, the effects of IDA and its correction on platelet function in premenopausal women remain unknown. Objectives We sought to determine how IDA and intravenous iron affect platelet count and platelet function in premenopausal women. Methods Hematologic indices were assessed in a multicenter, retrospective cohort of 231 women repleted with intravenous iron. Pre- and postinfusion blood samples were then obtained from a prospective cohort of 13 women to analyze the effect of intravenous iron on hematologic parameters as well as platelet function with flow cytometry and platelet aggregation assays under physiologic shear. Results Following iron replacement, anemia improved, and mean platelet counts decreased by 26.5 and 16.0 K/mm3 in the retrospective and prospective cohorts, respectively. Replacement reduced baseline platelet surface P-selectin levels while enhancing platelet secretory responses to agonists, including collagen-related peptide and ADP. Platelet adhesion and aggregation on collagen under physiologic shear also significantly increased following repletion. Conclusion We find that intravenous iron improves anemia while restoring platelet counts and platelet secretory responses in premenopausal women with iron deficiency. Our results suggest that iron deficiency as well as iron replacement can have a range of effects on platelet production and function. Consequently, platelet reactivity profiles should be further examined in women and other groups with IDA where replacement offers a promising means to improve anemia as well as quality of life.
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Affiliation(s)
- Benjamin K. Elstrott
- Division of Hematology‐Medical OncologySchool of MedicineKnight Cancer InstituteOregon Health & Science UniversityPortlandOregonUSA
| | - Hari H.S. Lakshmanan
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandOregonUSA
| | - Alexander R. Melrose
- Division of CardiologySchool of MedicineKnight Cardiovascular InstituteOregon Health & Science UniversityPortlandOregonUSA
| | - Kelley R. Jordan
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandOregonUSA
| | - Kylee L. Martens
- Division of Hematology‐Medical OncologySchool of MedicineKnight Cancer InstituteOregon Health & Science UniversityPortlandOregonUSA
| | - Chih‐Jen Yang
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandOregonUSA
| | - Danielle F. Peterson
- Department of Orthopedics and RehabilitationOregon Health & Science UniversityPortlandOregonUSA
| | - Hannah Stowe McMurry
- Division of Hematology‐Medical OncologySchool of MedicineKnight Cancer InstituteOregon Health & Science UniversityPortlandOregonUSA
| | - Corinne Lavasseur
- Division of Hematology‐Medical OncologySchool of MedicineKnight Cancer InstituteOregon Health & Science UniversityPortlandOregonUSA
| | - Jamie O. Lo
- Department of Obstetrics and GynecologyOregon Health & Science UniversityPortlandOregonUSA
| | - Sven R. Olson
- Division of Hematology‐Medical OncologySchool of MedicineKnight Cancer InstituteOregon Health & Science UniversityPortlandOregonUSA
| | - Thomas G. DeLoughery
- Division of Hematology‐Medical OncologySchool of MedicineKnight Cancer InstituteOregon Health & Science UniversityPortlandOregonUSA
| | - Joseph E. Aslan
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandOregonUSA,Division of CardiologySchool of MedicineKnight Cardiovascular InstituteOregon Health & Science UniversityPortlandOregonUSA
| | - Joseph J. Shatzel
- Division of Hematology‐Medical OncologySchool of MedicineKnight Cancer InstituteOregon Health & Science UniversityPortlandOregonUSA,Division of CardiologySchool of MedicineKnight Cardiovascular InstituteOregon Health & Science UniversityPortlandOregonUSA
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4
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Lindquist I, Olson SR, Li A, Al-Samkari H, Jou JH, McCarty OJT, Shatzel JJ. The efficacy and safety of thrombopoietin receptor agonists in patients with chronic liver disease undergoing elective procedures: a systematic review and meta-analysis. Platelets 2022; 33:66-72. [PMID: 33459573 PMCID: PMC8286270 DOI: 10.1080/09537104.2020.1859102] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 01/04/2023]
Abstract
Thrombopoietin receptor agonists (TPO-RAs) can mitigate preprocedural thrombocytopenia in patients with chronic liver disease (CLD) however their effects on procedural outcomes is unclear. In this meta-analysis, we aimed to better define the efficacy, thrombotic risk and bleeding mitigation associated with the use of preoperative TPO-RAs in patients with CLD. We performed a systematic review and meta-analysis of randomized placebo-controlled clinical trials to assess the use of preprocedural TPO-RAs in patients with CLD, searching MEDLINE, EMBASE and the Cochrane library database. Six publications comprising eight randomized trials (1229 patients; 717 received TPO-RAs, 512 received placebo) and three unique TPO-RAs were retrieved. The majority of the included procedures were endoscopic. TPO-RAs were significantly more likely to result in a preoperative platelet count greater than 50 x 109/L (72.1% vs 15.6%, RR 4.8, 95% CI 3.6-6.4 p < .00001. NNT 1.8) and reduced the incidence of platelet transfusions (22.5% vs 67.8%, RR 0.33, 95% CI 0.3-0.4 p < .00001. NNT 2.2). Total periprocedural bleeding was decreased in patients who received TPO-RAs (11.6% vs 15.6%, RR 0.64, 95% CI 0.5-0.9 p = .01. NNT 24.7) and there was no increase in the rate of thrombosis (2.2% vs 1.8% RR 1.25, 95% CI 0.6-2.9 p = .60. NNH 211.1). In patients with CLD the use of preprocedural TPO-RAs resulted in significant increased platelet counts, and decreased the incidence of platelet transfusions as compared to placebo. TPO use likewise decreased the incidence of total periprocedural bleeding without increasing the rate of thrombosis.
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Affiliation(s)
- Ingrid Lindquist
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, OR, USA
| | - Sven R Olson
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Ang Li
- Section of Hematology Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Janice H Jou
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, OR, USA
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Joseph J Shatzel
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
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5
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Kohs TCL, Liu P, Raghunathan V, Amirsoltani R, Oakes M, McCarty OJT, Olson SR, Masha L, Zonies D, Shatzel JJ. Severe thrombocytopenia in adults undergoing extracorporeal membrane oxygenation is predictive of thrombosis. Platelets 2021; 33:570-576. [PMID: 34355646 PMCID: PMC9089832 DOI: 10.1080/09537104.2021.1961707] [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] [Indexed: 12/18/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) provides lifesaving circulatory support and gas exchange, although hematologic complications are frequent. The relationship between ECMO and severe thrombocytopenia (platelet count <50 × 109/L) remains ill-defined. We performed a cohort study of 67 patients who received ECMO between 2016 and 2019, of which 65.7% received veno-arterial (VA) ECMO and 34.3% received veno-venous (VV) ECMO. All patients received heparin and 25.4% received antiplatelet therapy. In total, 23.9% of patients had a thrombotic event and 67.2% had a hemorrhagic event. 38.8% of patients developed severe thrombocytopenia. Severe thrombocytopenia was more common in patients with lower baseline platelet counts and increased the likelihood of thrombosis by 365% (OR 3.65, 95% CI 1.13-11.8, P = .031), while the type of ECMO (VA or VV) was not predictive of severe thrombocytopenia (P = .764). Multivariate logistic regression controlling for additional clinical variables found that severe thrombocytopenia predicted thrombosis (OR 3.65, CI 1.13-11.78, P = .031). Over a quarter of patients requiring ECMO developed severe thrombocytopenia in our cohort, which was associated with an increased risk of thrombosis and in-hospital mortality. Additional prospective observation is required to clarify the clinical implications of severe thrombocytopenia in the ECMO patient population.
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Affiliation(s)
- Tia C L Kohs
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, USA
| | - Patricia Liu
- Department of Medicine, Oregon Health & Science University, Portland, USA
| | - Vikram Raghunathan
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, USA
| | - Ramin Amirsoltani
- Department of Surgery, Oregon Health & Science University, Portland, USA
| | - Michael Oakes
- Department of Medicine, Oregon Health & Science University, Portland, USA
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, USA
| | - Sven R Olson
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, USA.,Division of Hematology and Oncology, Oregon Health & Science University, Portland, USA
| | - Luke Masha
- Department of Cardiology, Oregon Health & Science University, Portland, USA
| | - David Zonies
- Department of Cardiology, Oregon Health & Science University, Portland, USA
| | - Joseph J Shatzel
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, USA.,Division of Hematology and Oncology, Oregon Health & Science University, Portland, USA
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6
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Raghunathan V, Liu P, Kohs TCL, Amirsoltani R, Oakes M, McCarty OJT, Olson SR, Zonies D, Shatzel JJ. Heparin Resistance Is Common in Patients Undergoing Extracorporeal Membrane Oxygenation but Is Not Associated with Worse Clinical Outcomes. ASAIO J 2021; 67:899-906. [PMID: 33528163 PMCID: PMC9019066 DOI: 10.1097/mat.0000000000001334] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) protocols generally require systemic anticoagulation with heparin to prevent circuit thrombosis. The prevalence, risk factors, and outcomes of heparin resistance in this setting are ill-defined. To better understand the prevalence and clinical consequences of heparin resistance in this population, we conducted a retrospective analysis of all patients treated with ECMO at a single academic medical center between 2016 and 2019. Univariate and multivariate analyses were used to evaluate predictors and outcomes of heparin resistance. Of 67 patients in our study, 50.7% met the threshold for heparin resistance for at least 1 day, which was managed in all cases with increases in heparin dose. Patients with heparin resistance were more likely to be male (82.4% vs. 48.5%, p = 0.005) and to have a higher mean platelet count (132 vs. 104 × 103/mL, p = 0.027) compared with those without heparin resistance. Multivariate logistic regression found no significant association between the development of heparin resistance and rates of thrombosis, hemorrhage, or overall survival. Additional prospective studies are required to clarify the clinical implications of heparin resistance in this population.
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Affiliation(s)
- Vikram Raghunathan
- From the Division of Hematology and Oncology, Oregon Health & Science University, Portland, Oregon
| | - Patricia Liu
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Tia C L Kohs
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon
| | - Ramin Amirsoltani
- School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Michael Oakes
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon
| | - Sven R Olson
- From the Division of Hematology and Oncology, Oregon Health & Science University, Portland, Oregon
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon
| | - David Zonies
- Department of Surgery, Oregon Health & Science University, Portland, Oregon
| | - Joseph J Shatzel
- From the Division of Hematology and Oncology, Oregon Health & Science University, Portland, Oregon
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon
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7
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Silasi R, Keshari RS, Regmi G, Lupu C, Georgescu C, Simmons JH, Wallisch M, Kohs TCL, Shatzel JJ, Olson SR, Lorentz CU, Puy C, Tucker EI, Gailani D, Strickland S, Gruber A, McCarty OJT, Lupu F. Factor XII plays a pathogenic role in organ failure and death in baboons challenged with Staphylococcus aureus. Blood 2021; 138:178-189. [PMID: 33598692 PMCID: PMC8288658 DOI: 10.1182/blood.2020009345] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/26/2021] [Indexed: 12/29/2022] Open
Abstract
Activation of coagulation factor (F) XI promotes multiorgan failure in rodent models of sepsis and in a baboon model of lethal systemic inflammation induced by infusion of heat-inactivated Staphylococcus aureus. Here we used the anticoagulant FXII-neutralizing antibody 5C12 to verify the mechanistic role of FXII in this baboon model. Compared with untreated control animals, repeated 5C12 administration before and at 8 and 24 hours after bacterial challenge prevented the dramatic increase in circulating complexes of contact system enzymes FXIIa, FXIa, and kallikrein with antithrombin or C1 inhibitor, and prevented cleavage and consumption of high-molecular-weight kininogen. Activation of several coagulation factors and fibrinolytic enzymes was also prevented. D-dimer levels exhibited a profound increase in the untreated animals but not in the treated animals. The antibody also blocked the increase in plasma biomarkers of inflammation and cell damage, including tumor necrosis factor, interleukin (IL)-1β, IL-6, IL-8, IL-10, granulocyte-macrophage colony-stimulating factor, nucleosomes, and myeloperoxidase. Based on clinical presentation and circulating biomarkers, inhibition of FXII prevented fever, terminal hypotension, respiratory distress, and multiorgan failure. All animals receiving 5C12 had milder and transient clinical symptoms and were asymptomatic at day 7, whereas untreated control animals suffered irreversible multiorgan failure and had to be euthanized within 2 days after the bacterial challenge. This study confirms and extends our previous finding that at least 2 enzymes of the contact activation complex, FXIa and FXIIa, play critical roles in the development of an acute and terminal inflammatory response in baboons challenged with heat-inactivated S aureus.
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Affiliation(s)
- Robert Silasi
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Ravi S Keshari
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Girija Regmi
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Cristina Lupu
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Constantin Georgescu
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Joe H Simmons
- Michale E. Keeling Center for Comparative Medicine and Research, University of Texas MD Anderson Cancer Center, Bastrop, TX
| | - Michael Wallisch
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
- Aronora, Inc, Portland, OR
| | - Tia C L Kohs
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
| | - Joseph J Shatzel
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
- Division of Hematology & Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, OR
| | - Sven R Olson
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
- Division of Hematology & Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, OR
| | - Christina U Lorentz
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
- Aronora, Inc, Portland, OR
| | - Cristina Puy
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
| | - Erik I Tucker
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
- Aronora, Inc, Portland, OR
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Sidney Strickland
- Patricia and John Rosenwald Laboratory of Neurobiology and Genetics, The Rockefeller University, New York, NY; and
| | - András Gruber
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
- Aronora, Inc, Portland, OR
- Division of Hematology & Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, OR
| | - Owen J T McCarty
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
- Division of Hematology & Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, OR
| | - Florea Lupu
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
- Department of Cell Biology
- Department of Pathology, and
- Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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8
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Olson SR, Murphree CR, Zonies D, Meyer AD, McCarty OJ, DeLoughery TG, Shatzel JJ. Thrombosis and Bleeding in Extracorporeal Membrane Oxygenation (ECMO) Without Anticoagulation: A Systematic Review. ASAIO J 2021; 67:290-296. [PMID: 33627603 PMCID: PMC8623470 DOI: 10.1097/mat.0000000000001230] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) causes both thrombosis and bleeding. Major society guidelines recommend continuous, systemic anticoagulation to prevent thrombosis of the ECMO circuit, though this may be undesirable in those with active, or high risk of, bleeding. We aimed to systematically review thrombosis and bleeding outcomes in published cases of adults treated with ECMO without continuous systemic anticoagulation. Ovid MEDLINE, Cochrane CENTRAL and CDSR, and hand search via SCOPUS were queried. Eligible studies were independently reviewed by two blinded authors if they reported adults (≥18 years) treated with either VV- or VA-ECMO without continuous systemic anticoagulation for ≥24 hours. Patient demographics, clinical data, and specifics of ECMO technology and treatment parameters were collected. Primary outcomes of interest included incidence of bleeding, thrombosis of the ECMO circuit requiring equipment exchange, patient venous or arterial thrombosis, ability to wean off of ECMO, and mortality. Of the 443 total publications identified, 34 describing 201 patients met our inclusion criteria. Most patients were treated for either acute respiratory distress syndrome or cardiogenic shock. The median duration of anticoagulant-free ECMO was 4.75 days. ECMO circuity thrombosis and patient thrombosis occurred in 27 (13.4%) and 19 (9.5%) patients, respectively. Any bleeding and major or "severe" bleeding was reported in 66 (32.8%) and 56 (27.9%) patients, respectively. Forty patients (19%) died. While limited by primarily retrospective data and inconsistent reporting of outcomes, our systematic review of anticoagulant-free ECMO reveals an incidence of circuity and patient thrombosis comparable to patients receiving continuous systemic anticoagulation while on ECMO.
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Affiliation(s)
- Sven R. Olson
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland OR
| | - Catherine R. Murphree
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland OR
| | - David Zonies
- Division of Trauma & Critical Care, Department of Surgery, Oregon Health and Science University, Portland OR
| | - Andrew D. Meyer
- Division of Pediatric Critical Care, Department of Pediatrics, University of Texas Health, San Antonio TX
| | - Owen J.T. McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland OR
| | - Thomas G. DeLoughery
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland OR
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland OR
- Department of Biomedical Engineering, Oregon Health & Science University, Portland OR
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9
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Kato C, Oakes M, Kim M, Desai A, Olson SR, Raghunathan V, Shatzel JJ. Anticoagulation strategies in extracorporeal circulatory devices in adult populations. Eur J Haematol 2020; 106:19-31. [PMID: 32946632 DOI: 10.1111/ejh.13520] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [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: 06/07/2020] [Revised: 08/27/2020] [Accepted: 08/31/2020] [Indexed: 12/16/2022]
Abstract
Extracorporeal circulatory devices such as hemodialysis and extracorporeal membrane oxygenation can be lifesaving; however, they are also prone to pathologic events including device failure, venous and arterial thrombosis, hemorrhage, and an accelerated risk for atherosclerotic disease due to interactions between blood components and device surfaces of varying biocompatibility. While extracorporeal devices may be used acutely for limited periods of time (eg, extracorporeal membrane oxygenation, continuous venovenous hemofiltration, therapeutic apheresis), some patients require chronic use of these technologies (eg, intermittent hemodialysis and left ventricular assist devices). Given the substantial thrombotic risks associated with extracorporeal devices, multiple antiplatelet and anticoagulation strategies-including unfractionated heparin, low-molecular-weight heparin, citrate, direct thrombin inhibitors, and direct oral anticoagulants, have been used to mitigate the thrombotic milieu within the patient and device. In the following manuscript, we outline the current data on anticoagulation strategies for commonly used extracorporeal circulatory devices, highlighting the potential benefits and complications involved with each.
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Affiliation(s)
- Catherine Kato
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Michael Oakes
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Morris Kim
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Anish Desai
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Sven R Olson
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA.,Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Vikram Raghunathan
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Joseph J Shatzel
- Division of Hematology and Oncology, Oregon Health & Science University, Portland, OR, USA.,Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
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10
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Kohs TCL, Lorentz CU, Johnson J, Puy C, Olson SR, Shatzel JJ, Gailani D, Hinds MT, Tucker EI, Gruber A, McCarty OJT, Wallisch M. Development of Coagulation Factor XII Antibodies for Inhibiting Vascular Device-Related Thrombosis. Cell Mol Bioeng 2020; 14:161-175. [PMID: 33868498 DOI: 10.1007/s12195-020-00657-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/26/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction Vascular devices such as stents, hemodialyzers, and membrane oxygenators can activate blood coagulation and often require the use of systemic anticoagulants to selectively prevent intravascular thrombotic/embolic events or extracorporeal device failure. Coagulation factor (F)XII of the contact activation system has been shown to play an important role in initiating vascular device surface-initiated thrombus formation. As FXII is dispensable for hemostasis, targeting the contact activation system holds promise as a significantly safer strategy than traditional antithrombotics for preventing vascular device-associated thrombosis. Objective Generate and characterize anti-FXII monoclonal antibodies that inhibit FXII activation or activity. Methods Monoclonal antibodies against FXII were generated in FXII-deficient mice and evaluated for their binding and anticoagulant properties in purified and plasma systems, in whole blood flow-based assays, and in an in vivo non-human primate model of vascular device-initiated thrombus formation. Results A FXII antibody screen identified over 400 candidates, which were evaluated in binding studies and clotting assays. One non-inhibitor and six inhibitor antibodies were selected for characterization in functional assays. The most potent inhibitory antibody, 1B2, was found to prolong clotting times, inhibit fibrin generation on collagen under shear, and inhibit platelet deposition and fibrin formation in an extracorporeal membrane oxygenator deployed in a non-human primate. Conclusion Selective contact activation inhibitors hold potential as useful tools for research applications as well as safe and effective inhibitors of vascular device-related thrombosis.
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Affiliation(s)
- T C L Kohs
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
| | - C U Lorentz
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
- Aronora Inc., Portland, OR USA
| | - J Johnson
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
| | - C Puy
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
| | - S R Olson
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
- Division of Hematology& Medical Oncology, Department of Medicine, Oregon Health & Science University, Portland, OR USA
| | - J J Shatzel
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
- Division of Hematology& Medical Oncology, Department of Medicine, Oregon Health & Science University, Portland, OR USA
| | - D Gailani
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN USA
| | - M T Hinds
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
| | - E I Tucker
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
- Aronora Inc., Portland, OR USA
| | - A Gruber
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
- Aronora Inc., Portland, OR USA
- Division of Hematology& Medical Oncology, Department of Medicine, Oregon Health & Science University, Portland, OR USA
| | - O J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
- Division of Hematology& Medical Oncology, Department of Medicine, Oregon Health & Science University, Portland, OR USA
| | - M Wallisch
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239 USA
- Aronora Inc., Portland, OR USA
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11
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Lakshmanan HHS, Pore AA, Kohs TCL, Yazar F, Thompson RM, Jurney PL, Maddala J, Olson SR, Shatzel JJ, Vanapalli SA, McCarty OJT. Design of a Microfluidic Bleeding Chip to Evaluate Antithrombotic Agents for Use in COVID-19 Patients. Cell Mol Bioeng 2020; 13:331-339. [PMID: 32837586 PMCID: PMC7408976 DOI: 10.1007/s12195-020-00644-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 06/08/2020] [Accepted: 07/31/2020] [Indexed: 12/27/2022] Open
Abstract
Introduction Interventions that could prevent thrombosis, clinical decompensation, and respiratory compromise in patients with novel coronavirus disease (COVID-19) are key to decrease mortality rate. Studies show that profound cytokine release and excessive activation of blood coagulation appear to be key drivers of COVID-19 associated mortality. Since limited in vitro methods exist for assessing the effects of anticoagulants on hemostasis, the development of novel therapies to safely prevent thrombosis in COVID-19 patients relies on preclinical animal models and early phase human trials. Herein we present the design of a microfluidic “bleeding chip” to evaluate the effects of antithrombotic therapies on hemostatic plug formation in vitro. Methods The design of the microfluidic device consists of two orthogonal channels: an inlet that serves as a model blood vessel, and a bleeding channel to model hemostatic plug formation at sites of compromised endothelial barrier function. This is achieved by placing a series of 3 pillars spaced 10 μm apart at the intersection of the two channels. The pillars and bleeding channel are coated with the extracellular matrix protein collagen. Results Perfusion of human whole blood through the microfluidic bleeding chip led to initial platelet adhesion and aggregation at the pillars followed by hemostatic plug formation and occlusion of the bleeding channel. Conclusions Safe and effective mitigating agents are needed for treatment and prevention of thrombotic complications in COVID-19 patients. This simple microfluidic device holds potential to be developed into a tool for assessing the effects of anticoagulant therapy on hemostasis.
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Affiliation(s)
- Hari Hara Sudhan Lakshmanan
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 SW Bond Ave; CH13B, Portland, OR 97239 USA
| | - Adity A Pore
- Department of Chemical Engineering, Texas Tech University, Lubbock, TX USA
| | - Tia C L Kohs
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 SW Bond Ave; CH13B, Portland, OR 97239 USA
| | - Feyza Yazar
- Department of Biomedical Engineering, San José State University, San Jose, CA USA
| | - Rachel M Thompson
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 SW Bond Ave; CH13B, Portland, OR 97239 USA
| | - Patrick L Jurney
- Department of Biomedical Engineering, San José State University, San Jose, CA USA
| | - Jeevan Maddala
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 SW Bond Ave; CH13B, Portland, OR 97239 USA
| | - Sven R Olson
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 SW Bond Ave; CH13B, Portland, OR 97239 USA.,Division of Hematology & Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, OR USA
| | - Joseph J Shatzel
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 SW Bond Ave; CH13B, Portland, OR 97239 USA.,Division of Hematology & Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, OR USA
| | - Siva A Vanapalli
- Department of Chemical Engineering, Texas Tech University, Lubbock, TX USA
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 SW Bond Ave; CH13B, Portland, OR 97239 USA.,Division of Hematology & Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, OR USA
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12
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Tao DL, Olson SR, DeLoughery TG, Shatzel JJ. The efficacy and safety of DOACs versus LMWH for cancer-associated thrombosis: A systematic review and meta-analysis. Eur J Haematol 2020; 105:360-362. [PMID: 32441350 DOI: 10.1111/ejh.13453] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Derrick L Tao
- Department of Internal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Sven R Olson
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Thomas G DeLoughery
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Joseph J Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
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13
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Wallisch M, Olson SR, Crosby J, Johnson J, Murray SF, Shatzel JJ, Tucker EI, McCarty OJT, Hinds MT, Monia BP, Gruber A. Evaluation of the Antihemostatic and Antithrombotic Effects of Lowering Coagulation Factor VII Levels in a Non-human Primate. Cell Mol Bioeng 2020; 13:179-187. [PMID: 32426056 DOI: 10.1007/s12195-020-00613-4] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/12/2020] [Indexed: 12/19/2022] Open
Abstract
Introduction Tissue factor (TF) and factor (F) VII, components of the extrinsic pathway of blood coagulation, are essential for hemostatic plug formation in response to injury; less clear are their roles in propagating thrombosis, as observational data in humans with congenital FVII deficiency suggests persistent thrombotic and bleeding risk even at significantly decreased FVII levels. We aimed to define the contribution of FVII to thrombus formation and hemostasis using a non-human primate model. Methods We treated baboons with a FVII antisense oligonucleotide (ASO) and measured platelet and fibrin deposition inside and distal to collagen- or TF-coated vascular grafts. We assessed hemostasis by measuring bleeding time (BT) and prothrombin time (PT). Enoxaparin and vehicle treatments served as controls. Results FVII-ASO treatment reduced FVII levels by 95% and significantly increased both the PT and BT. Lowering FVII levels did not decrease platelet deposition in collagen- or TF-coated grafts, in thrombi distal to the grafts, or fibrin content of either collagen- and TF-coated grafts. Lowering FVII levels were associated with a modest 25% reduction in platelet deposition at 60 min in the distal thrombus tail of TF-coated grafts only. Conclusions FVII inhibition by way of ASO is feasible yet significantly impairs hemostasis while only exhibiting antithrombotic effects when thrombosis is initiated by vessel wall surface-associated TF exposure.
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Affiliation(s)
- Michael Wallisch
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR USA
- Aronora, Inc., Portland, OR 97239 USA
| | - Sven R Olson
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR USA
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
| | | | - Jennifer Johnson
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR USA
| | | | - Joseph J Shatzel
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR USA
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
| | - Erik I Tucker
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR USA
- Aronora, Inc., Portland, OR 97239 USA
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR USA
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
| | - Monica T Hinds
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR USA
| | | | - András Gruber
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR USA
- Aronora, Inc., Portland, OR 97239 USA
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR USA
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14
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Murphree CR, Nguyen NN, Raghunathan V, Olson SR, DeLoughery T, Shatzel JJ. Diagnosis and management of hereditary haemochromatosis. Vox Sang 2020; 115:255-262. [PMID: 32080859 DOI: 10.1111/vox.12896] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 09/24/2019] [Revised: 01/13/2020] [Accepted: 01/24/2020] [Indexed: 12/14/2022]
Abstract
Hereditary haemochromatosis, one of the most common genetic disorders in the United States, can produce systemic iron deposition leading to end-organ failure and death if untreated. The diagnosis of this condition can be challenging as elevated serum ferritin may be seen in a variety of conditions, including acute and chronic liver disease, a range of systemic inflammatory states, and both primary and secondary iron overload syndromes. Appropriate and timely diagnosis of haemochromatosis is paramount as simple interventions, such as phlebotomy, can prevent or reverse organ damage from iron overload. The recognition of other aetiologies of elevated ferritin is also vital to ensure that appropriate intervention is provided and phlebotomy only utilized in patients who require it. In this review, we summarize the existing data on the work up and management of hereditary haemochromatosis and present a practical algorithm for the diagnosis and management of this disease.
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Affiliation(s)
- Catherine R Murphree
- Division of Hematology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Nga N Nguyen
- Division of Hematology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Vikram Raghunathan
- Division of Hematology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Sven R Olson
- Division of Hematology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Thomas DeLoughery
- Division of Hematology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Joseph J Shatzel
- Division of Hematology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
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15
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Lorentz CU, Verbout NG, Wallisch M, Hagen MW, Shatzel JJ, Olson SR, Puy C, Hinds MT, McCarty OJT, Gailani D, Gruber A, Tucker EI. Contact Activation Inhibitor and Factor XI Antibody, AB023, Produces Safe, Dose-Dependent Anticoagulation in a Phase 1 First-In-Human Trial. Arterioscler Thromb Vasc Biol 2020; 39:799-809. [PMID: 30700130 DOI: 10.1161/atvbaha.118.312328] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Objective- Factor XI (FXI) contributes to thrombotic disease while playing a limited role in normal hemostasis. We generated a unique, humanized anti-FXI antibody, AB023, which blocks factor XIIa-mediated FXI activation without inhibiting FXI activation by thrombin or the procoagulant function of FXIa. We sought to confirm the antithrombotic activity of AB023 in a baboon thrombosis model and to evaluate the safety, tolerability, pharmacokinetics, and pharmacodynamics in healthy adult subjects. Approach and Results- In a primate model of acute vascular graft thrombosis, AB023 reduced platelet and fibrin accumulation within the grafts by >75%. To evaluate the safety of AB023, we performed a first-in-human study in healthy adult volunteers without any serious adverse events. Overall, 10 of 21 (48%) subjects experienced 20 treatment-emergent adverse events, with 7 of 16 (44%) subjects following active treatment and 3 of 5 (60%) subjects following placebo. AB023 did not increase bleeding or prothrombin times. Anticoagulation was verified by a saturable ≈2-fold prolongation of the partial thromboplastin time for over 1 month after the highest dose. Conclusions- AB023, which inhibits contact activation-initiated blood coagulation in vitro and experimental thrombus formation in primates, produced a dose-dependent duration of limited anticoagulation without drug-related adverse effects in a phase 1 trial. When put in context with earlier observations suggesting that FXI contributes to venous thromboembolism and cardiovascular disease, although contributing minimally to hemostasis, our data further justify clinical evaluation of AB023 in conditions where contact-initiated FXI activation is suspected to have a pathogenic role. Clinical Trial Registration- URL: http://www.clinicaltrials.gov . Unique identifier: NCT03097341.
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Affiliation(s)
- Christina U Lorentz
- From Aronora, Inc, Portland, OR (C.U.L., N.G.V., M.W., A.G., E.I.T.).,Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland
| | - Norah G Verbout
- From Aronora, Inc, Portland, OR (C.U.L., N.G.V., M.W., A.G., E.I.T.).,Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland
| | - Michael Wallisch
- From Aronora, Inc, Portland, OR (C.U.L., N.G.V., M.W., A.G., E.I.T.).,Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland
| | - Matthew W Hagen
- Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland
| | - Joseph J Shatzel
- Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland.,Division of Hematology and Medical Oncology (J.J.S., S.R.O., O.J.T.M., A.G.), Oregon Health & Science University, Portland
| | - Sven R Olson
- Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland.,Division of Hematology and Medical Oncology (J.J.S., S.R.O., O.J.T.M., A.G.), Oregon Health & Science University, Portland
| | - Cristina Puy
- Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland
| | - Monica T Hinds
- Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland
| | - Owen J T McCarty
- Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland.,Division of Hematology and Medical Oncology (J.J.S., S.R.O., O.J.T.M., A.G.), Oregon Health & Science University, Portland
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN (D.G.)
| | - András Gruber
- From Aronora, Inc, Portland, OR (C.U.L., N.G.V., M.W., A.G., E.I.T.).,Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland.,Division of Hematology and Medical Oncology (J.J.S., S.R.O., O.J.T.M., A.G.), Oregon Health & Science University, Portland
| | - Erik I Tucker
- From Aronora, Inc, Portland, OR (C.U.L., N.G.V., M.W., A.G., E.I.T.).,Department of Biomedical Engineering (C.U.L., N.G.V., M.W., M.W.H., J.J.S., S.R.O., C.P., M.T.H., O.J.T.M., A.G., E.I.T.), Oregon Health & Science University, Portland
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16
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Murphree CR, Nguyen NN, Shatzel JJ, Olson SR, Chung PD, Lockridge JB, Andeen NK, DeLoughery TG. Biopsy-proven thrombotic microangiopathy without schistocytosis on peripheral blood smear: A cautionary tale. Am J Hematol 2019; 94:E234-E237. [PMID: 31175815 DOI: 10.1002/ajh.25551] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 05/29/2019] [Accepted: 06/03/2019] [Indexed: 12/18/2022]
Affiliation(s)
| | - Nga N. Nguyen
- Division of HematologyOregon Health & Science University Portland Oregon
| | - Joseph J. Shatzel
- Division of HematologyOregon Health & Science University Portland Oregon
| | - Sven R. Olson
- Division of HematologyOregon Health & Science University Portland Oregon
| | - Paul D. Chung
- Division of HematologyOregon Health & Science University Portland Oregon
| | - Joseph B. Lockridge
- Division of Nephrology & HypertensionOregon Health & Science University Portland Oregon
| | - Nicole K. Andeen
- Department of PathologyOregon Health & Science University Portland Oregon
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17
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Thapa N, Shatzel J, Deloughery TG, Olson SR. Direct oral anticoagulants in gastrointestinal malignancies: is the convenience worth the risk? J Gastrointest Oncol 2019; 10:807-809. [PMID: 31392062 DOI: 10.21037/jgo.2019.02.07] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Namisha Thapa
- Department of Medicine, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Joseph Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Thomas G Deloughery
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Sven R Olson
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
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18
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Olson SR, Shatzel JJ, DeLoughery TG. Asymptomatic "breakthrough" thrombosis and anticoagulant "failure": Keep calm and carry on. Res Pract Thromb Haemost 2019; 3:498-502. [PMID: 31294334 PMCID: PMC6611361 DOI: 10.1002/rth2.12218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 04/25/2019] [Indexed: 11/10/2022] Open
Abstract
Despite therapeutic anticoagulation, patients with venous thromboembolism (VTE) not uncommonly present with findings of progressive thrombosis, sometimes within the first several weeks of treatment. While the prevailing strategy in these scenarios is to assume the current anticoagulant is ineffective and to switch to a different drug class, this practice may be unnecessary. Numerous trials of heparins and vitamin K antagonists for VTE have demonstrated that asymptomatic thrombus propagation despite therapeutic anticoagulation is common. While similar, serial imaging studies after initial VTE have not been replicated in trials of the direct oral anticoagulants, we reason that asymptomatic thrombus propagation detected within the first month of VTE diagnosis can be managed with continuation of the current anticoagulant strategy and close follow‐up for worsening or recurrent symptoms.
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Affiliation(s)
- Sven R Olson
- Division of Hematology and Medical Oncology Oregon Health and Science University Knight Cancer Institute Portland Oregon
| | - Joseph J Shatzel
- Division of Hematology and Medical Oncology Oregon Health and Science University Knight Cancer Institute Portland Oregon
| | - Thomas G DeLoughery
- Division of Hematology and Medical Oncology Oregon Health and Science University Knight Cancer Institute Portland Oregon
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19
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Raghunathan V, Zilberman‐Rudenko J, Olson SR, Lupu F, McCarty OJT, Shatzel JJ. The contact pathway and sepsis. Res Pract Thromb Haemost 2019; 3:331-339. [PMID: 31294319 PMCID: PMC6611366 DOI: 10.1002/rth2.12217] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 04/15/2019] [Indexed: 12/12/2022] Open
Abstract
The contact pathway factors XI (FXI) and XII (FXII) have been demonstrated to be largely dispensable for hemostasis, as their absence results in a mild to absent bleeding diathesis. A growing body of literature, however, suggests that the contact pathway contributes to the pathologic host response to certain infectious organisms that produces the often-fatal syndrome known as sepsis. The contact pathway factors serve as a central node connecting inflammation to coagulation, and may offer a potentially safe therapeutic target to mitigate the morbidity and mortality associated with sepsis. Herein, we summarize published in vivo and in vitro data that have explored the roles of the contact pathway in sepsis, and discuss potential clinical applications of novel FXI- and FXII-inhibiting drugs currently under investigation.
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Affiliation(s)
- Vikram Raghunathan
- Division of Hematology‐Medical OncologyKnight Cancer InstituteOregon Health & Science UniversityPortlandOregonUSA
| | | | - Sven R. Olson
- Division of Hematology‐Medical OncologyKnight Cancer InstituteOregon Health & Science UniversityPortlandOregonUSA
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandOregonUSA
| | - Florea Lupu
- Cardiovascular Biology Research ProgramOklahoma Medical Research FoundationOklahoma CityOklahomaUSA
| | - Owen J. T. McCarty
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandOregonUSA
| | - Joseph J. Shatzel
- Division of Hematology‐Medical OncologyKnight Cancer InstituteOregon Health & Science UniversityPortlandOregonUSA
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandOregonUSA
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20
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DeLoughery EP, Olson SR, Puy C, McCarty OJT, Shatzel JJ. The Safety and Efficacy of Novel Agents Targeting Factors XI and XII in Early Phase Human Trials. Semin Thromb Hemost 2019; 45:502-508. [PMID: 31216587 DOI: 10.1055/s-0039-1692439] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Although anticoagulation without hemorrhage is a primary aim, this vision has remained as yet out of reach. Even despite the superior safety profile of the direct oral anticoagulants, hemorrhage remains a major risk of anticoagulation. Selective inhibition of the contact pathway of coagulation, specifically coagulation factor XI (FXI) and/or factor XII (FXII), has now substantial epidemiologic and preclinical data supporting the notion that these factors contribute to pathologic thrombosis and are yet primarily dispensable for in vivo hemostasis. In this way, targeting FXI and FXII may revolutionize the future anticoagulation landscape. Several drugs are under development for this purpose, including: ISIS 416858, a FXI antisense oligonucleotide which impairs hepatic synthesis of FXI; MAA868, a monoclonal antibody that binds the procoagulant enzymatic site of both zymogen and activated FXI (FXIa); BAY 1213790, a monoclonal antibody that binds the procoagulant enzymatic site of FXIa only; and AB023, a monoclonal antibody that inhibits activated FXII-mediated activation of FXI, along with two small molecules in clinical trials. Each of these drugs have demonstrated favorable safety profiles in their phases 1 and 2 studies to date, with preclinical data also supporting efficacy of abrogating thrombosis in various animal models. Other benefits of some of these drugs include once-monthly dosing and safety in patients with renal or hepatic impairment, while others offer quickly metabolized parenteral options, thus providing more convenient and widely available anticoagulation options. Though still far from the marketplace, drugs targeting FXI and FXII have the potential to usher in a new era of anticoagulation therapy.
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Affiliation(s)
| | - Sven R Olson
- Division of Hematology and Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon.,Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon
| | - Cristina Puy
- Division of Hematology and Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon.,Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon
| | - Owen J T McCarty
- Division of Hematology and Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon.,Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon
| | - Joseph J Shatzel
- Division of Hematology and Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon.,Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon
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21
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Lakshmanan HHS, Shatzel JJ, Olson SR, McCarty OJT, Maddala J. Modeling the effect of blood vessel bifurcation ratio on occlusive thrombus formation. Comput Methods Biomech Biomed Engin 2019; 22:972-980. [PMID: 31066295 DOI: 10.1080/10255842.2019.1610744] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Vascular geometry is a major determinant of the hemodynamics that promote or prevent unnecessary vessel occlusion from thrombus formation. Bifurcations in the vascular geometry are repeating structures that introduce flow separation between parent and daughter vessels. We modelled the blood flow and shear rate in a bifurcation during thrombus formation and show that blood vessel bifurcation ratios determine the maximum shear rate on the surface of a growing thrombus. We built an analytical model that may aid in predicting microvascular bifurcation ratios that are prone to occlusive thrombus formation. We also observed that bifurcation ratios that adhere to Murray's law of bifurcations may be protected from occlusive thrombus formation. These results may be useful in the rational design of diagnostic microfluidic devices and microfluidic blood oxygenators.
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Affiliation(s)
- Hari Hara Sudhan Lakshmanan
- a Biomedical Engineering, School of Medicine , Oregon Health & Science University , Portland , OR , USA.,b Chemical and Biomedical Engineering , West Virginia University , Morgantown , WV , USA
| | - Joseph J Shatzel
- a Biomedical Engineering, School of Medicine , Oregon Health & Science University , Portland , OR , USA.,c Division of Hematology-Oncology, School of Medicine , Oregon Health & Science University , Portland , OR , USA
| | - Sven R Olson
- c Division of Hematology-Oncology, School of Medicine , Oregon Health & Science University , Portland , OR , USA
| | - Owen J T McCarty
- a Biomedical Engineering, School of Medicine , Oregon Health & Science University , Portland , OR , USA.,c Division of Hematology-Oncology, School of Medicine , Oregon Health & Science University , Portland , OR , USA
| | - Jeevan Maddala
- a Biomedical Engineering, School of Medicine , Oregon Health & Science University , Portland , OR , USA.,b Chemical and Biomedical Engineering , West Virginia University , Morgantown , WV , USA
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22
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Affiliation(s)
- Sven R. Olson
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland
| | - Thomas G. DeLoughery
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland
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23
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Olson SR, Koprowski S, Hum J, McCarty OJT, DeLoughery TG, Shatzel JJ. Chronic liver disease, thrombocytopenia and procedural bleeding risk; are novel thrombopoietin mimetics the solution? Platelets 2018; 30:796-798. [PMID: 30422039 DOI: 10.1080/09537104.2018.1542125] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Chronic liver disease (CLD) alters normal hemostatic and thrombotic systems via multiple mechanisms including reduced platelet function and number, leading to challenging peri-operative planning. Hepatic thrombopoietin (TPO) synthesis is reduced in CLD, leading to several recent randomized, placebo-controlled trials examining the utility of TPO-mimetics to increase platelet counts prior to surgery. While these trials do suggest that TPO-mimetics are efficacious at increasing platelet counts in patients with CLD and have led to several recent drug approvals in this space by the U.S. Food & Drug Administration, it remains unclear whether these results translate to the relevant clinical endpoint of reduced perioperative bleeding rate and severity. In this article, we review several recently-published, phase 3 trials on the TPO-mimetics eltrombopag, avatrombopag and lusutrombopag, and discuss the clinical significance of their results.
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Affiliation(s)
- Sven R Olson
- a Division of Hematology and Medical Oncology , Oregon Health and Science University, Knight Cancer Institute , Portland , OR , USA
| | - Steven Koprowski
- a Division of Hematology and Medical Oncology , Oregon Health and Science University, Knight Cancer Institute , Portland , OR , USA
| | - Justine Hum
- b Division of Gastroenterology and Hepatology , Oregon Health & Science University , Portland , OR , USA
| | - Owen J T McCarty
- a Division of Hematology and Medical Oncology , Oregon Health and Science University, Knight Cancer Institute , Portland , OR , USA.,c Department of Biomedical Engineering , Oregon Health & Science University , Portland , OR , USA
| | - Thomas G DeLoughery
- a Division of Hematology and Medical Oncology , Oregon Health and Science University, Knight Cancer Institute , Portland , OR , USA
| | - Joseph J Shatzel
- a Division of Hematology and Medical Oncology , Oregon Health and Science University, Knight Cancer Institute , Portland , OR , USA.,c Department of Biomedical Engineering , Oregon Health & Science University , Portland , OR , USA
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24
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Shatzel JJ, O'Donnell M, Olson SR, Kearney MR, Daughety MM, Hum J, Nguyen KP, DeLoughery TG. Venous thrombosis in unusual sites: A practical review for the hematologist. Eur J Haematol 2018; 102:53-62. [PMID: 30267448 DOI: 10.1111/ejh.13177] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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: 07/23/2018] [Revised: 09/20/2018] [Accepted: 09/21/2018] [Indexed: 12/13/2022]
Abstract
Thrombosis of unusual venous sites encompasses a large part of consultative hematology and is encountered routinely by practicing hematologists. Contrary to the more commonly encountered lower extremity venous thrombosis and common cardiovascular disorders, the various thromboses outlined in this review have unique presentations, pathophysiology, workup, and treatments that all hematologists should be aware of. This review attempts to outline the most up to date literature on cerebral, retinal, upper extremity, hepatic, portal, splenic, mesenteric, and renal vein thrombosis, focusing on the incidence, pathophysiology, provoking factors, and current recommended treatments for each type of unusual thrombosis to provide a useful and practical review for the hematologist.
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Affiliation(s)
- Joseph J Shatzel
- Division of Hematology-Oncology, Oregon Health & Science University, Portland, Oregon
| | - Matthew O'Donnell
- Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon
| | - Sven R Olson
- Division of Hematology-Oncology, Oregon Health & Science University, Portland, Oregon
| | - Matthew R Kearney
- Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon
| | - Molly M Daughety
- Division of Hematology-Oncology, Oregon Health & Science University, Portland, Oregon
| | - Justine Hum
- Division of Gastroenterology, Oregon Health & Science University, Portland, Oregon
| | - Khanh P Nguyen
- Division of Vascular Surgery, Oregon Health & Science University, Portland, Oregon
| | - Thomas G DeLoughery
- Division of Hematology-Oncology, Oregon Health & Science University, Portland, Oregon
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25
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O'Donnell M, Shatzel JJ, Olson SR, Daughety MM, Nguyen KP, Hum J, DeLoughery TG. Arterial thrombosis in unusual sites: A practical review. Eur J Haematol 2018; 101:728-736. [PMID: 30129979 DOI: 10.1111/ejh.13165] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 07/23/2018] [Revised: 08/13/2018] [Accepted: 08/14/2018] [Indexed: 12/19/2022]
Abstract
While cardiovascular disease is common, occasionally hematologists and other practitioners will encounter patients with arterial thrombosis/infarction in unusual sites, without clear cause or obvious diagnostic and treatment paradigms. Contrary to the more commonly encountered cerebrovascular accident and cardiovascular disorders, the various infarctions outlined in this review have unique presentations, pathophysiology, workup, and treatments that all hematologists should be aware of. This review outlines the current literature on arterial thrombosis, with consideration given to anatomic sources and hypercoagulable associations, while focusing on the epidemiology, pathophysiology, provoking factors, and current recommended treatments for intracardiac thrombus, primary aortic mural thrombus, visceral infarctions, and cryptogenic limb ischemia to provide a useful and practical review for the practitioner.
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Affiliation(s)
- Matthew O'Donnell
- Division of Hematology-Oncology, Oregon Health & Science University, Portland, Oregon
| | - Joseph J Shatzel
- Division of Hematology-Oncology, Oregon Health & Science University, Portland, Oregon.,Biomedical Engineering, Oregon Health & Science University, Portland, Oregon
| | - Sven R Olson
- Division of Hematology-Oncology, Oregon Health & Science University, Portland, Oregon
| | - Molly M Daughety
- Division of Hematology-Oncology, Oregon Health & Science University, Portland, Oregon
| | - Khanh P Nguyen
- Division of Vascular Surgery, Oregon Health & Science University, Portland, Oregon
| | - Justine Hum
- Division of Gastroenterology, Oregon Health & Science University, Portland, Oregon
| | - Thomas G DeLoughery
- Division of Hematology-Oncology, Oregon Health & Science University, Portland, Oregon
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26
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Olson SR, Lu E, Sulpizio E, Shatzel JJ, Rueda JF, DeLoughery TG. When to Stop Eculizumab in Complement-Mediated Thrombotic Microangiopathies. Am J Nephrol 2018; 48:96-107. [PMID: 30110670 DOI: 10.1159/000492033] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [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: 05/16/2018] [Accepted: 07/04/2018] [Indexed: 11/19/2022]
Abstract
The terminal complement-inhibitor eculizumab has dramatically changed the management of patients with atypical hemolytic uremic syndrome (aHUS), and has also shown promise for treating certain forms of secondary HUS (sHUS), including that caused by drugs and solid-organ/hematopoietic stem cell transplant. While effective, eculizumab is costly and inconvenient. In this review, we evaluate the literature on eculizumab cessation in these diseases to better inform clinicians who consider stopping therapy. Reported relapse rates in aHUS after stopping eculizumab are as high as 30%, suggesting indefinite therapy is reasonable and that patients who choose to stop should be closely monitored. In sHUS, relapse is rare, justifying short courses of eculizumab.
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Affiliation(s)
- Sven R Olson
- Division of Hematology and Medical Oncology, Oregon Health and Science University, Knight Cancer Institute, Portland, Oregon, USA
| | - Eric Lu
- Department of Internal Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Emilio Sulpizio
- Department of Internal Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Joseph J Shatzel
- Division of Hematology and Medical Oncology, Oregon Health and Science University, Knight Cancer Institute, Portland, Oregon, USA
| | - Jose F Rueda
- Division of Nephrology and Hypertension, Oregon Health and Science University, Portland, Oregon, USA
| | - Thomas G DeLoughery
- Division of Hematology and Medical Oncology, Oregon Health and Science University, Knight Cancer Institute, Portland, Oregon, USA
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27
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Shatzel JJ, Daughety MM, Olson SR, Beer TM, DeLoughery TG. Management of Anticoagulation in Patients With Prostate Cancer Receiving Enzalutamide. J Oncol Pract 2018; 13:720-727. [PMID: 29125921 DOI: 10.1200/jop.2017.022004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Enzalutamide, a novel, oral androgen receptor antagonist used for the treatment of metastatic, castration-resistant prostate cancer, has been shown to improve overall and progression-free survival, prolong time to initiation of chemotherapy, reduce skeletal-related events, and carry a favorable adverse effect profile. Metastatic prostate cancer is a disease of older men, a population with an increased incidence of medical comorbidities warranting anticoagulation. Prostate cancer itself, along with some of its therapies, is also prothrombotic. Enzalutamide interacts with several anticoagulants through various mechanisms, making their concurrent use clinically challenging. As such, complex decisions about anticoagulation in these patients are frequently encountered by treating physicians. In this review, we describe the potential interactions between enzalutamide and various anticoagulants, and suggest management paradigms based on the current body of knowledge for patients with atrial fibrillation, venous thromboembolism, and mechanical heart valves.
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Affiliation(s)
| | | | - Sven R Olson
- Oregon Health & Science University, Portland, OR
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28
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Shatzel JJ, Olson SR, Tao DL, McCarty OJT, Danilov AV, DeLoughery TG. Ibrutinib-associated bleeding: pathogenesis, management and risk reduction strategies. J Thromb Haemost 2017; 15:835-847. [PMID: 28182323 PMCID: PMC6152914 DOI: 10.1111/jth.13651] [Citation(s) in RCA: 163] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Indexed: 01/02/2023]
Abstract
Ibrutinib is an irreversible inhibitor of Bruton's tyrosine kinase (Btk) that has proven to be an effective therapeutic agent for multiple B-cell-mediated lymphoproliferative disorders. Ibrutinib, however, carries an increased bleeding risk compared with standard chemotherapy. Bleeding events range from minor mucocutaneous bleeding to life-threatening hemorrhage, due in large part to the effects of ibrutinib on several distinct platelet signaling pathways. There is currently a minimal amount of data to guide clinicians regarding the use of ibrutinib in patients at high risk of bleeding or on anticoagulant or antiplatelet therapy. In addition, the potential cardiovascular protective effects of ibrutinib monotherapy in patients at risk of vascular disease are unknown. Patients should be cautioned against using non-steroidal anti-inflammatory drugs, fish oils, vitamin E and aspirin-containing products, and consider replacing ibrutinib with a different agent if dual antiplatelet therapy is indicated. Patients should not take vitamin K antagonists concurrently with ibrutinib; direct oral anticoagulants should be used if extended anticoagulation is strongly indicated. In this review, we describe the pathophysiology of ibrutinib-mediated bleeding and suggest risk reduction strategies for common clinical scenarios associated with ibrutinib.
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Affiliation(s)
- Joseph J. Shatzel
- Division of Hematology and Medical Oncology, Oregon Health
& Science University, Knight Cancer Institute, Portland, Oregon
| | - Sven R. Olson
- Division of Hematology and Medical Oncology, Oregon Health
& Science University, Knight Cancer Institute, Portland, Oregon
| | - Derrick L. Tao
- Division of Hematology and Medical Oncology, Oregon Health
& Science University, Knight Cancer Institute, Portland, Oregon
| | - Owen J. T. McCarty
- Division of Hematology and Medical Oncology, Oregon Health
& Science University, Knight Cancer Institute, Portland, Oregon
- Department of Biomedical Engineering, School of Medicine,
Oregon Health & Science University, Portland, Oregon
| | - Alexey V. Danilov
- Division of Hematology and Medical Oncology, Oregon Health
& Science University, Knight Cancer Institute, Portland, Oregon
| | - Thomas G. DeLoughery
- Division of Hematology and Medical Oncology, Oregon Health
& Science University, Knight Cancer Institute, Portland, Oregon
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29
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Olson SR, Chu C, Shatzel JJ, Deloughery TG. The "platelet boilermaker": A treatment protocol to rapidly increase platelets in patients with immune-mediated thrombocytopenia. Am J Hematol 2016; 91:E330-1. [PMID: 27153241 DOI: 10.1002/ajh.24409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 04/26/2016] [Accepted: 05/03/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Sven R. Olson
- Department of Internal Medicine; Oregon Health and Science University; Portland Oregon
| | - Charles Chu
- School of Medicine; Oregon Health and Science University; Portland Oregon
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology; Oregon Health and Science University, Knight Cancer Institute; Portland Oregon
| | - Thomas G. Deloughery
- Division of Hematology and Medical Oncology; Oregon Health and Science University, Knight Cancer Institute; Portland Oregon
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30
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Ibarra V, Laffoon TA, Snyder M, Gambrall M, Olson SR. Clinical pathways in the perioperative setting. Nurs Case Manag 1997; 2:97-104; quiz 105-6. [PMID: 9197663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Clinical pathways have been implemented in a variety of health-care settings. They serve as a useful tool for case managers in acute care settings as well as ambulatory care settings, skilled care facilities, and long-term care facilities. The use of these tools in the perioperative setting, along with variance documentation and data feedback is presented here. By creating tangible definitions of quality in the perioperative setting, clinical pathways improve patient care and assure clinical consistency and continuity of care.
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Affiliation(s)
- V Ibarra
- University of Iowa Hospitals and Clinics, Iowa City, Iowa
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31
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Olson SR. HUD toasts assisted living ... Section 232 Mortgage Insurance program. Provider 1995; 21:31-2. [PMID: 10140826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
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Olson SR, McFadden TJ. Creative financing alternatives. Provider 1994; 20:55-6. [PMID: 10134634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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33
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Olson SR. Guaranteeing fair housing. Provider 1994; 20:57-8. [PMID: 10171826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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34
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Olson SR. Residential living. Linking service to standards. Provider 1994; 20:51-3. [PMID: 10171782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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35
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Abstract
Six newborn infants with necrotizing enterocolitis (NEC) were noted to have air confined to Morison pouch as an early sign of pneumoperitoneum. Air in Morison pouch appears as a triangular lucency in the right upper quadrant. Extraluminal air in this location is easily mistaken for air within a loop of bowel if its characteristic appearance is not specifically sought. Review of the literature revealed no reported cases of NEC in which air in Morison pouch was mentioned. The authors' observation of six patients suggests that air in Morison pouch may be more common than previously recognized. Air in Morison pouch has the same significance as more obvious signs of pneumoperitoneum, and its detection is an indication for surgery.
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Affiliation(s)
- P W Brill
- Department of Radiology, New York Hospital-Cornell Medical Center, NY 10021
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36
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Affiliation(s)
- S R Olson
- Department of Radiology, New York Hospital--Cornell Center, NY 10021
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