1
|
Bissola AL, Zhang Y, Cranstone M, Moore JC, Warkentin TE, Arnold DM, Nazy I. Evaluating Diagnostic Algorithms for Heparin-Induced Thrombocytopenia using Two Combined Automated Rapid Immunoassays. Semin Thromb Hemost 2024. [PMID: 38733981 DOI: 10.1055/s-0044-1786749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
Heparin-induced thrombocytopenia (HIT) is an autoimmune disorder caused by antibodies against platelet factor 4 (PF4) and heparin complexes. Rapid immunoassays (IAs) for detection of these antibodies mark a milestone in HIT diagnosis, despite a higher false-positive rate compared with functional platelet-activation assays. However, combining different rapid IAs may help to improve their diagnostic specificity. Here, we compared the individual performance of the latex immunoturbidimetric assay (LIA; HemosIL HIT-Ab [PF4-H]; sensitivity 91.7%, specificity 68.4%) and chemiluminescence immunoassay (CLIA; HemosIL AcuStarHIT-Ab [PF4-H]; sensitivity 92.4%, specificity 85.8%) with their combined performance using two unique diagnostic algorithms in a single prospective cohort of suspected HIT patients. Using the simultaneous algorithm adapted from Warkentin et al, the combined LIA-CLIA had a sensitivity of 99.0% and specificity of 64.3%. The sequential algorithm adapted from Rittener-Ruff et al was applied in two theoretical scenarios to reflect real-world circumstances in diagnostic laboratories where access to clinical information is limited: (1) assuming all patients had an intermediate 4Ts score and (2) assuming all patients had a high 4Ts score. This algorithm correctly predicted HIT in 94.5% (high 4Ts) and 96.0% (intermediate 4Ts) and excluded HIT in 82.6% (high 4Ts) and 80.1% (intermediate 4Ts) of patients in either scenario, respectively. Although both combined algorithms improved diagnostic performance of individual IAs, the simultaneous algorithm showed fewer false predictions (7.9%) than the sequential algorithm (intermediate 4Ts: 37.6% and high 4Ts: 41.5%) and proved more practical as it does not rely on physician evaluations. Our findings highlight the importance of accounting for clinician and interlaboratory variability when evaluating diagnostic tests for HIT.
Collapse
Affiliation(s)
- Anna-Lise Bissola
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Yi Zhang
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
- Department of Biochemistry and Biomedical Sciences, McMaster University Hamilton, Ontario, Canada
| | - Madison Cranstone
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, Ontario, Canada
| | - Jane C Moore
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Transfusion Medicine, Hamilton Regional Laboratory Medicine Program, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Donald M Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Ishac Nazy
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
- Department of Biochemistry and Biomedical Sciences, McMaster University Hamilton, Ontario, Canada
| |
Collapse
|
2
|
Pelzl L, Uzun G, Marini I, Zlamal J, Trumpp PN, Karakuyu A, Bakchoul T, Althaus K. Heparin-activated procoagulant platelet assay: a flow cytometry-based functional test for heparin-induced thrombocytopenia. J Thromb Haemost 2024; 22:470-479. [PMID: 37838242 DOI: 10.1016/j.jtha.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 09/04/2023] [Accepted: 10/05/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Functional platelet activation assays are required for the diagnosis of heparin-induced thrombocytopenia (HIT). Due to their sophisticated methodology, they are only available in reference centers. OBJECTIVES To evaluate the diagnostic accuracy of the flow cytometry-based heparin-activated procoagulant platelet (HAPP) assay in the laboratory diagnosis of HIT. METHODS Procoagulant platelets (PCP), defined by the expression of phosphatidylserine and CD62-P, were evaluated by flow cytometry in platelet-rich plasma from healthy donors after incubation with patient sera in the absence and presence of heparin. A sample was considered positive in HAPP assay, if the following 3 criteria were met: 1) the percentage of PCPs was ≥10.3% after incubation with 0.2 IU/mL heparin, 2) the fold increase in presence of 0.2 IU/mL heparin compared with buffer was ≥1.5, and 3) 100 IU/mL of heparin resulted in ≥50% inhibition of PCP. HAPP assay was validated in a prospective cohort (n = 202) of consecutive specimens submitted to our laboratory for serologic diagnosis of HIT. Heparin-induced platelet activation (HIPA) assay was used as the reference standard. RESULTS HIT-positive sera induced PCPs in the presence of 0.2 IU/mL heparin, which was inhibited with 100 IU/mL of heparin. In the prospective validation cohort, there were 15 HIPA+ and 187 HIPA- sera. HAPP was positive in 20 samples in this cohort. Using optimized cut-offs, HAPP assay had a sensitivity of 93.3% and specificity of 96.8%. CONCLUSION HAPP assay is promising as a simple and reliable functional assay for HIT; however, further studies are needed to confirm our results in larger cohorts.
Collapse
Affiliation(s)
- Lisann Pelzl
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany
| | - Günalp Uzun
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany
| | - Irene Marini
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany
| | - Jan Zlamal
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany
| | - Pascal N Trumpp
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Aleyna Karakuyu
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Tamam Bakchoul
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany.
| | - Karina Althaus
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany
| |
Collapse
|
3
|
Arachchillage DJ, Thachil J, Anderson JAM, Baker P, Poles A, Kitchen S, Laffan M. Diagnosis and management of heparin-induced thrombocytopenia: Third edition. Br J Haematol 2024; 204:459-475. [PMID: 38153164 DOI: 10.1111/bjh.19180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 12/29/2023]
Affiliation(s)
- Deepa J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Julia A M Anderson
- Department of Haematology, Edinburgh Royal Infirmary, Edinburgh, Scotland
| | - Peter Baker
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Anthony Poles
- Bristol NHS Blood and Transplant Centre, Bristol, UK
| | - Steve Kitchen
- Department of Haematology, Royal Hallamshire Hospital, Sheffield, UK
| | - Mike Laffan
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| |
Collapse
|
4
|
Tucker CM, Rhoades R, Sharma R, Gong JZ. Optimization of laboratory diagnosis of heparin-induced thrombocytopenia using HemosIL-AcuStar-HIT-IgG assay. Lab Med 2024; 55:34-39. [PMID: 37094798 DOI: 10.1093/labmed/lmad029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
OBJECTIVE The aim of this study was to determine an optimal cutoff value for the newly available HemosIL-AcuStar-HIT-IgG assay (AcuStar) for the diagnosis of heparin-induced thrombocytopenia (HIT). METHOD We evaluated the performance of AcuStar using serotonin release assay (SRA) as the gold standard and incorporated 4T score calculation in a cohort of suspected HIT cases. Statistical analysis was performed to determine optimal cutoff value for the diagnosis of HIT. RESULT A diagnosis of HIT can be excluded with a platelet factor 4 (PF4) value of <0.4 U/mL by AcuStar and 4T score in the low-risk category (≤3). All other cases will require confirmation with a functional test. CONCLUSION Our study resulted in the implementation of a diagnostic algorithm for laboratory diagnosis of HIT, which incorporates pretest calculation of 4T score and AcuStar as a screening test, with reflex confirmation by SRA. This new algorithm resulted in extended hours of test availability and a more rapid turnaround time in reporting PF4 results.
Collapse
Affiliation(s)
- Catherine M Tucker
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA, US
| | - Ruben Rhoades
- Department of Medicine, Division of Hematology, Thomas Jefferson University, Philadelphia, PA, US
| | - Ruchika Sharma
- Department of Pediatrics, Division of Hematology/Oncology/BMT, Medical College of Wisconsin, Versiti Blood Research Institute, Milwaukee, WI,US
| | - Jerald Z Gong
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA, US
| |
Collapse
|
5
|
Warkentin TE, Greinacher A. Laboratory Testing for Heparin-Induced Thrombocytopenia and Vaccine-Induced Immune Thrombotic Thrombocytopenia Antibodies: A Narrative Review. Semin Thromb Hemost 2023; 49:621-633. [PMID: 36455619 PMCID: PMC10421650 DOI: 10.1055/s-0042-1758818] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) and vaccine-induced immune thrombotic thrombocytopenia (VITT) are highly prothrombotic (thrombosis frequency ≥50%). Both are caused by platelet-activating anti-platelet factor 4 (PF4) antibodies, forming PF4/IgG-containing immune complexes that engage platelet FcγIIa receptors, producing strong platelet activation. In HIT, heparin crosslinks several PF4 molecules, whereas in VITT, anti-PF4 antibodies alone crosslink PF4. Sufficient levels of circulating anti-PF4 antibodies are needed to create the pathogenic immune complexes on platelet surfaces; this explains why certain serum (plasma)-based assays are highly sensitive for detecting HIT/VITT antibodies. Accordingly, HIT and VITT are "clinical-pathological" disorders, that is, positive testing for such antibodies-together with a compatible clinical picture-is integral for diagnosis. Heparin (low concentrations) enhances HIT antibody-induced platelet activation, but platelet activation by VITT sera is usually inhibited by heparin. For both HIT and VITT, high sensitivity (>99% and >95%, respectively) characterizes PF4-dependent enzyme immunoassays (EIAs) and PF4-enhanced platelet activation assays; in contrast, certain rapid immunoassays have high sensitivity for HIT (>90-97%) but poor sensitivity (<25%) for VITT. HIT and VITT antibodies are directed at distinct sites on PF4: solid-phase EIAs and platelet activation assays are indifferent to these distinct antigen targets, but rapid immunoassays are not. We discuss a conceptual model where PF4 is viewed as a "globe," with the heparin-binding site the "equator"; in this model, HIT antibodies are primarily directed at antigen site(s) at the north and south "poles" of PF4 (formed when PF4 binds to heparin), whereas VITT antibodies recognize sites on the equator.
Collapse
Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Transfusion Medicine, Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
- Service of Benign Hematology, Hamilton Health Sciences, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Andreas Greinacher
- Institute for Transfusion Medicine, University Medicine Greifswald, Greifswald, Germany
| |
Collapse
|
6
|
Nguyen TA, Kim Do AN, Hoang Lo TN, Park I, Vo KQ. Single-step controlled synthesis of flower-like gold nanoparticles stabilized by chitosan for sensitive detection of heparin using a surface-enhanced Raman scattering method. RSC Adv 2022; 12:34831-34842. [PMID: 36540228 PMCID: PMC9724128 DOI: 10.1039/d2ra06528b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 11/30/2022] [Indexed: 07/30/2023] Open
Abstract
A novel single-step and template-free procedure, including controlled synthesis of gold flowers (AuNFs), conjugation to a 4-MBA reporter, and stabilization with chitosan, is proposed to develop the SERS tags-based nanoparticles for trace detection of heparin. This SERS detection assay is based on the aggregation/non-aggregation balance of AuNFs-4-MBA@chitosan nanoparticles, which was induced by adding a very low concentration of heparin in the as-synthesized colloidal solutions. SERS-tag colloids are prepared by mixing chitosan with HAuCl4 and 4-mercapto benzoic acid before being reduced with ascorbic acid under appropriate pH conditions. The formed AuNFs-4-MBA@chitosan nanoparticles were positively charged with high stability and well-dispersed in aqueous media. Based on understanding each reaction component's role in the preparation of the SERS tag colloid, we aim to simplify the controlled synthesis and Raman probe conjugation process. The average size of AuNFs is below 90 nm, fine-tuned in shape and effectively conjugated to the Raman reporter molecules 4-MBA. These as-prepared SERS tag-based AuNFs have good biocompatibility and are virtually non-toxic, as studied with fibroblast and MCF-7 cells. Through these SERS-tag colloids, the trace detection of heparin is improved, with a wide detection window (0.01 to 100 ppm), high reproducibility (RSD value of 3.56%), limit of detection (LOD) of 0.054 ppm, and limit of quantification (LOQ) of 0.17 ppm. Comparison experiments show that the SERS-tag colloids possess good selectivity over other ions, and organic and amino acid substances. The results provide the capability and the potential for application under complex biological conditions and future biosensing based on SERS signal amplification.
Collapse
Affiliation(s)
- Thu Anh Nguyen
- Faculty of Chemistry, University of Science, Vietnam National University - Ho Chi Minh City 227 Nguyen Van Cu Street, Ward 4, District 5 Ho Chi Minh City 70000 Vietnam
| | - Anh Nguyen Kim Do
- Faculty of Chemistry, University of Science, Vietnam National University - Ho Chi Minh City 227 Nguyen Van Cu Street, Ward 4, District 5 Ho Chi Minh City 70000 Vietnam
| | - Tien Nu Hoang Lo
- Research Institute of Clean Manufacturing System, Korea Institute of Industrial Technology (KITECH) 89 Yangdaegiro-Gil, Ipjang-myeon Cheonan 31056 South Korea
| | - In Park
- Research Institute of Clean Manufacturing System, Korea Institute of Industrial Technology (KITECH) 89 Yangdaegiro-Gil, Ipjang-myeon Cheonan 31056 South Korea
- KITECH School, University of Science and Technology (UST) 176 Gajeong-dong, Yuseong-gu Daejeon 34113 South Korea
| | - Khuong Quoc Vo
- Faculty of Chemistry, University of Science, Vietnam National University - Ho Chi Minh City 227 Nguyen Van Cu Street, Ward 4, District 5 Ho Chi Minh City 70000 Vietnam
| |
Collapse
|
7
|
Jevtic SD, Arnold DM, Modi D, Ivetic N, Bissola AL, Nazy I. Vaccine-induced immune thrombotic thrombocytopenia: Updates in pathobiology and diagnosis. Front Cardiovasc Med 2022; 9:1040196. [PMID: 36352844 PMCID: PMC9637757 DOI: 10.3389/fcvm.2022.1040196] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/04/2022] [Indexed: 11/12/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a viral respiratory infection caused by the severe acute respiratory syndrome virus (SARS-CoV-2). Vaccines that protect against SARS-CoV-2 infection have been widely employed to reduce the incidence of symptomatic and severe disease. However, adenovirus-based SARS-CoV-2 vaccines can cause a rare, thrombotic disorder termed vaccine-induced immune thrombotic thrombocytopenia (VITT). VITT often develops in the first 5 to 30 days following vaccination and is characterized by thrombocytopenia and thrombosis in unusual locations (e.g., cerebral venous sinus thrombosis). The diagnosis is confirmed by testing for anti-PF4 antibodies, as these antibodies are capable of platelet activation without any cofactor. It can be clinically challenging to differentiate VITT from a similar disorder called heparin-induced thrombocytopenia (HIT), since heparin is commonly used in hospitalized patients. VITT and HIT have similar pathobiology and clinical manifestations but important differences in testing including the need for PF4-enhanced functional assays and the poor reliability of rapid immunoassays for the detection of anti-platelet factor 4 (PF4) antibodies. In this review we summarize the epidemiology of VITT; highlight similarities and differences between HIT and VITT; and provide an update on the clinical diagnosis of VITT.
Collapse
Affiliation(s)
- Stefan D. Jevtic
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Donald M. Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
- Canadian Blood Services, Hamilton, ON, Canada
| | - Dimpy Modi
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Nikola Ivetic
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anna-Lise Bissola
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
| | - Ishac Nazy
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
8
|
Murakami Y, Okazaki S, Yamamoto M, Sakurai R, Jinno J, Ozono T, Ikenaka K, Gon Y, Todo K, Sasaki T, Hirata H, Uchiyama A, Mochizuki H. Ischemic Stroke Due to Heparin-induced Thrombocytopenia during Severe COVID-19 Infection. Intern Med 2022; 61:2797-2801. [PMID: 35793954 PMCID: PMC9556234 DOI: 10.2169/internalmedicine.9531-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A 53-year-old woman with severe coronavirus disease 2019 (COVID-19) pneumonia was admitted and treated with intravenous unfractionated heparin for thromboprophylaxis under general anesthesia with mechanical ventilation. She developed right hemiparesis after hospitalization due to a large hemorrhagic infarction. Her platelet count decreased from 243,000/μL at administration to 121,000/μL. Anti-platelet factor 4-heparin antibody testing was positive according to a latex immunoturbidimetric assay. She was therefore diagnosed with heparin-induced thrombocytopenia. We immediately stopped the heparin and started argatroban; the platelet count recovered, and thrombosis did not relapse. Physicians should consider heparin-induced thrombocytopenia as a cause of ischemic stroke in patients with COVID-19 infection.
Collapse
Affiliation(s)
- Yasutaka Murakami
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Makoto Yamamoto
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Japan
| | - Rei Sakurai
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Jyunki Jinno
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Tatsuhiko Ozono
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Kensuke Ikenaka
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Yasufumi Gon
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| | - Haruhiko Hirata
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Japan
| | - Akinori Uchiyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan
| |
Collapse
|
9
|
Warkentin TE, Greinacher A. Seminars in Hematology Laboratory testing for VITT antibodies. Semin Hematol 2022; 59:80-88. [DOI: 10.1053/j.seminhematol.2022.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 01/07/2023]
|
10
|
Development and validation of a liquid chromatography‐tandem mass spectrometry method for the simultaneous analysis of androgens, estrogens, glucocorticoids and progestagens in human serum. Biomed Chromatogr 2022; 36:e5344. [DOI: 10.1002/bmc.5344] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 12/27/2021] [Accepted: 01/18/2022] [Indexed: 11/07/2022]
|
11
|
Khan NZ, Chen LY, Lindenbauer A, Pliquett U, Rothe H, Nguyen TH. Label-Free Detection and Characterization of Heparin-Induced Thrombocytopenia (HIT)-like Antibodies. ACS OMEGA 2021; 6:25926-25939. [PMID: 34660955 PMCID: PMC8515375 DOI: 10.1021/acsomega.1c02496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 09/16/2021] [Indexed: 05/04/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) antibodies (Abs) can mediate and activate blood cells, forming blood clots. To detect HIT Abs, immunological assays with high sensitivity (≥95%) and fast response are widely used, but only about 50% of these tests are accurate as non-HIT Abs also bind to the same antigens. We aim to develop biosensor-based electrical detection to better differentiate HIT-like from non-HIT-like Abs. As a proof of principle, we tested with two types of commercially available monoclonal Abs including KKO (inducing HIT) and RTO (noninducing HIT). Platelet factor 4/Heparin antigens were immobilized on gold electrodes, and binding of antibodies on the chips was detected based on the change in the charge transfer resistance (R ct). Binding of KKO on sensors yielded a significantly lower charge transfer resistance than that of RTO. Bound antibodies and their binding characteristics on the sensors were confirmed and characterized by complementary techniques. Analysis of thermal kinetics showed that RTO bonds are more stable than those of KKO, whereas KKO exhibited a higher negative ζ potential than RTO. These different characteristics made it possible to electrically differentiate these two types of antibodies. Our study opens a new avenue for the development of sensors for better detection of pathogenic Abs in HIT patients.
Collapse
Affiliation(s)
- Nida Zaman Khan
- Institute
for Bioprocessing and Analytical Measurement Techniques (iba), 37308 Heiligenstadt, Germany
- Institute
for Chemistry and Biotechnology, Faculty of Mathematics and Natural
Sciences, Technische Universität
Ilmenau, 98694 Ilmenau, Germany
| | - Li-Yu Chen
- Institute
for Bioprocessing and Analytical Measurement Techniques (iba), 37308 Heiligenstadt, Germany
- Institute
of Microbiology, Friedrich Schiller University, 07745 Jena, Germany
| | - Annerose Lindenbauer
- Institute
for Bioprocessing and Analytical Measurement Techniques (iba), 37308 Heiligenstadt, Germany
| | - Uwe Pliquett
- Institute
for Bioprocessing and Analytical Measurement Techniques (iba), 37308 Heiligenstadt, Germany
| | - Holger Rothe
- Institute
for Bioprocessing and Analytical Measurement Techniques (iba), 37308 Heiligenstadt, Germany
| | - Thi-Huong Nguyen
- Institute
for Bioprocessing and Analytical Measurement Techniques (iba), 37308 Heiligenstadt, Germany
- Institute
for Chemistry and Biotechnology, Faculty of Mathematics and Natural
Sciences, Technische Universität
Ilmenau, 98694 Ilmenau, Germany
| |
Collapse
|
12
|
Furuto Y, Kawamura M, Yamashita J, Yoshikawa T, Namikawa A, Isshiki R, Takahashi H, Shibuya Y. Anti-neutrophil cytoplasmic antibody-associated vasculitis accompanied by type II heparin-induced thrombocytopenia resulting in asymptomatic cerebral infarction: a case report. BMC Nephrol 2021; 22:220. [PMID: 34126959 PMCID: PMC8204417 DOI: 10.1186/s12882-021-02433-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 06/08/2021] [Indexed: 11/11/2022] Open
Abstract
Background Heparin-induced thrombocytopenia (HIT) involves platelet activation and aggregation caused by heparin or HIT antibodies associated with poor survival outcomes. We report a case of HIT that occurred after hemodialysis was started for rapidly progressive glomerulonephritis (RPGN), which was caused by anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV), and ultimately resulted in asymptomatic cerebral infarction. Case presentation A 76-year-old Japanese man was urgently admitted to our hospital for weight loss and acute kidney injury (serum creatinine: 12 mg/dL). Hemodialysis therapy was started using heparin for anticoagulation. Blood testing revealed elevated titers of myeloperoxidase anti-neutrophil cytoplasmic antibodies, and renal biopsy revealed crescentic glomerulonephritis with broad hyalinization of most of the glomeruli and a pauci-immune staining pattern. These findings fulfilled the diagnostic criteria for microscopic polyangiitis, and the patient was diagnosed with RPGN caused by AAV. Steroid pulse therapy, intermittent pulse intravenous cyclophosphamide, and oral steroid therapy failed to improve the patient’s renal function, and maintenance dialysis was started. However, on day 15, his platelet count had decreased to 47,000/µL, with clotting observed in the hemodialysis catheter. Magnetic resonance imaging of the head identified acute asymptomatic brain infarction in the left occipital lobe, and a positive HIT antibody test result supported a diagnosis of type II HIT. During hemodialysis, the anticoagulant treatment was changed from heparin to argatroban. Platelet counts subsequently normalized, and the patient was discharged. A negative HIT antibody test result was observed on day 622. Conclusions There have been several similar reports of AAV and HIT co-existence. However, this is a rare case report on cerebral infarction with AAV and HIT co-existence. Autoimmune diseases are considered risk factors for HIT, and AAV may overlap with other systemic autoimmune diseases. To confirm the relationship between these two diseases, it is necessary to accumulate more information from future cases with AAV and HIT co-existence. If acute thrombocytopenia and clotting events are observed when heparin is used as an anticoagulant, type II HIT should always be considered in any patient due to its potentially fatal thrombotic complications.
Collapse
Affiliation(s)
- Yoshitaka Furuto
- Department of Hypertension and Nephrology, NTT Medical Centre, 5-9-22, Higasi- Gotanda, Shinagawa-ku, 141-8625, Tokyo, Japan.
| | - Mariko Kawamura
- Department of Hypertension and Nephrology, NTT Medical Centre, 5-9-22, Higasi- Gotanda, Shinagawa-ku, 141-8625, Tokyo, Japan
| | - Jumpei Yamashita
- Department of Hypertension and Nephrology, NTT Medical Centre, 5-9-22, Higasi- Gotanda, Shinagawa-ku, 141-8625, Tokyo, Japan
| | - Takahiro Yoshikawa
- Department of Hypertension and Nephrology, NTT Medical Centre, 5-9-22, Higasi- Gotanda, Shinagawa-ku, 141-8625, Tokyo, Japan
| | - Akio Namikawa
- Department of Hypertension and Nephrology, NTT Medical Centre, 5-9-22, Higasi- Gotanda, Shinagawa-ku, 141-8625, Tokyo, Japan
| | - Rei Isshiki
- Department of Hypertension and Nephrology, NTT Medical Centre, 5-9-22, Higasi- Gotanda, Shinagawa-ku, 141-8625, Tokyo, Japan
| | - Hiroko Takahashi
- Department of Hypertension and Nephrology, NTT Medical Centre, 5-9-22, Higasi- Gotanda, Shinagawa-ku, 141-8625, Tokyo, Japan
| | - Yuko Shibuya
- Department of Hypertension and Nephrology, NTT Medical Centre, 5-9-22, Higasi- Gotanda, Shinagawa-ku, 141-8625, Tokyo, Japan
| |
Collapse
|
13
|
Doi Y, Koga K, Sugioka S, Inoue Y, Arisato T, Nishioka K, Ishihara T, Sugawara A. Heparin-induced thrombocytopenia among incident hemodialysis patients anticoagulated with low molecular weight heparin: A single-center retrospective study. Nefrologia 2021; 41:356-358. [PMID: 36165343 DOI: 10.1016/j.nefroe.2020.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 05/20/2020] [Indexed: 06/16/2023] Open
Affiliation(s)
- Yohei Doi
- Department of Nephrology, Osaka Red Cross Hospital, Japan.
| | - Kenichi Koga
- Department of Nephrology, Osaka Red Cross Hospital, Japan
| | - Sayaka Sugioka
- Department of Nephrology, Osaka Red Cross Hospital, Japan
| | - Yui Inoue
- Department of Nephrology, Osaka Red Cross Hospital, Japan
| | | | | | - Takeshi Ishihara
- Department of Clinical Engineering, Osaka Red Cross Hospital, Japan
| | - Akira Sugawara
- Department of Nephrology, Osaka Red Cross Hospital, Japan
| |
Collapse
|
14
|
Marcucci R, Berteotti M, Gori AM, Giusti B, Rogolino AA, Sticchi E, Liotta AA, Ageno W, De Candia E, Gresele P, Marchetti M, Marietta M, Tripodi A. Heparin induced thrombocytopenia: position paper from the Italian Society on Thrombosis and Haemostasis (SISET). BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2021; 19:14-23. [PMID: 33370230 PMCID: PMC7850929 DOI: 10.2450/2020.0248-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/14/2020] [Indexed: 12/21/2022]
Abstract
Heparin induced thrombocytopenia (HIT) is a rare immune mediated adverse drug reaction occurring after exposure to heparin. It is a serious and potentially fatal condition, which may be associated with the development of arterial or venous thrombotic events. Although known for many years, HIT is still often misdiagnosed. Pre- test clinical probability, screening for anti-PF4/heparin antibodies and documentation of their platelet activating capacity are the cornerstones of diagnosis. However, both clinical algorithms and test modalities have limited predictive values and limited diffusion so that the diagnosis and management is challenging in the clinical practice. For this reason, there is an unmet need for novel rational non-anticoagulant therapies based on the pathogenesis of HIT.The present paper reports the position of the Italian Society on Haemostasis and Thrombosis (SISET) in order to increase awareness of HIT among clinicians and other health care professionals and to provide information on the most appropriate management.
Collapse
Affiliation(s)
- Rossella Marcucci
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Martina Berteotti
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Anna M. Gori
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Betti Giusti
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Angela A. Rogolino
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Elena Sticchi
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Agatina Alessandrello Liotta
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Erica De Candia
- Department of Translational Medicine and Surgery, Catholic University of Rome, Rome, Italy
- Department of Image Diagnostics, Radiotherapy and Haematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Marina Marchetti
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Marco Marietta
- Department of Oncology and Haematology, University Hospital, Modena, Italy
| | - Armando Tripodi
- IRCCS “Ca’ Granda Maggiore” Hospital Foundation, “Angelo Bianchi Bonomi” Haemophilia and Thrombosis Center and “Fondazione Luigi Villa”, Milan, Italy
| |
Collapse
|
15
|
Marashi-Sabouni Z, Vayne C, Ibrahim-Kosta M, Guidon C, Loundou A, Guery EA, Morange PE, Camoin-Jau L. Clinical validation of immunoassay HemosIL® AcuStar HIT-IgG (PF4-H) in the diagnosis of Heparin-induced thrombocytopenia. J Thromb Thrombolysis 2021; 52:601-609. [PMID: 33386560 DOI: 10.1007/s11239-020-02349-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 11/25/2022]
Abstract
Heparin induced thrombocytopenia (HIT) is a life and limb-threatening complication of heparin exposure. The misdiagnosis of this disease can have major consequences on the patients. The objective of this study was to evaluate a diagnostic strategy that combines the 4Ts score with the result of HemosIL® AcuStar HIT-IgG (PF4-H) to confirm the diagnosis of HIT. Citrated plasmas from 1300 patients with suspicion of HIT were analyzed with a fully automated quantitative chemiluminescent immunoassay (HemosIL® AcuStar HIT-IgG (PF4/H)). If the IgG anti-PF4/H antibodies were positive (cut-off, 1 U/mL), HIT diagnosis was confirmed using functional tests. In total, 1300 samples of consecutive patients were enrolled, 94 (7.2%) of which gave positive results in HemosIL® AcuStar-IgG. HIT was diagnosed in 65 out of these patients, corresponding to a prevalence of 5%. Using ROC curve analysis, patients were divided into three groups according to their titer of antibodies. Higher values of the IgG (PF4-H) were associated with increased probability of HIT, and the diagnostic specificity was greatly increased using the combination of a 4Ts score > 3 and a positive titer ≥ 3.25 U/mL. Importantly, the diagnostic specificity is 100% when the titer is > 12.40 U/mL. We demonstrated that higher values of Anti PF4/H Antibodies were associated with a high probability of having HIT. A titer of HemosIL® IgG (PF4-H) > 12.40 U/mL has a specificity of 100% which should no require a functional test to confirm the diagnosis of HIT.
Collapse
Affiliation(s)
- Zeina Marashi-Sabouni
- Laboratoire d'Hématologie, La Timone Hospital, APHM, Boulevard Jean- Moulin, 13005, Marseille, France
| | - Caroline Vayne
- Service d'Hématologie Hémostase, Hôpital Trousseau, CHU de Tours, 37044, Tours, France
- EA7501 GICC, Université de Tours, Tours, France
| | - Manal Ibrahim-Kosta
- Laboratoire d'Hématologie, La Timone Hospital, APHM, Boulevard Jean- Moulin, 13005, Marseille, France
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
| | - Catherine Guidon
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Marseille, France
| | - Anderson Loundou
- Biostatistic and Public Health Department, La Timone Hospital, Marseille, France
| | - Eve Anne Guery
- Service d'Hématologie Hémostase, Hôpital Trousseau, CHU de Tours, 37044, Tours, France
| | - Pierre-Emmanuel Morange
- Laboratoire d'Hématologie, La Timone Hospital, APHM, Boulevard Jean- Moulin, 13005, Marseille, France
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
| | - Laurence Camoin-Jau
- Laboratoire d'Hématologie, La Timone Hospital, APHM, Boulevard Jean- Moulin, 13005, Marseille, France.
- Aix Marseille Univ, IRD, APHM, MEPHI, IHU Méditerranée Infection, Marseille, France.
| |
Collapse
|
16
|
Althaus K, Westphal A, Strobel U, Bakchoul T, Greinacher A. Real-life evaluation of an automated immunoassay for diagnosis of heparin-induced thrombocytopenia. Thromb Res 2020; 196:400-403. [DOI: 10.1016/j.thromres.2020.09.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/06/2020] [Accepted: 09/23/2020] [Indexed: 01/06/2023]
|
17
|
Jousselme E, Guéry EA, Nougier C, Sobas F, Rollin J, Gruel Y, Vayne C, Pouplard C. Prospective evaluation of two specific IgG immunoassays (HemosIL ® AcuStar HIT-IgG and HAT45G ® ) for the diagnosis of heparin-induced thrombocytopenia: A Bayesian approach. Int J Lab Hematol 2020; 43:468-476. [PMID: 33244896 DOI: 10.1111/ijlh.13404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/30/2020] [Accepted: 10/21/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The accurate diagnosis of heparin-induced thrombocytopenia (HIT) is essential to ensure adequate treatment and prevent complications. First step diagnosis test are immunoassays including enzyme-linked immunosorbent assays (ELISAs) and rapid immunoassays. METHODS Using a Bayesian approach, we prospectively evaluated the performance of the IgG PF4/polyvinylsulfonate ELISA and a chemiluminescent immunoassay (CLIA), which are specific for IgG and use the same antigenic target to detect HIT antibodies. RESULTS One hundred and eighty-four 184 consecutive patients with an intermediate (n = 159) or high (n = 25) clinical pretest probability of HIT based on the 4Ts score or platelet pattern were included. Both immunoassays (IAs) were performed on all 184 samples, and definite HIT was confirmed with a positive serotonin release assay in 29 patients (12.7%). The sensitivity (Ss) and negative predictive value (NPV) of ELISA were excellent (100%) allowing HIT to be excluded with good confidence when the test was negative. In addition, the Ss and NPV of the CLIA equalled 93.1% and 98.6%, respectively, as it was negative in two definite HIT. When the CLIA was negative, the post-test probability of HIT was 0.7% in case of intermediate risk. Although there was excellent agreement between CLIA and ELISA results, the quantitative values provided by the two IAs were not correlated. CONCLUSION AcuStar HIT® detects more than 90% of HIT, as do all rapid IAs, and appears to be a good tool for excluding HIT when the pretest probability is intermediate. A chemiluminescent signal higher than 10 IU/mL is highly predictive of definite HIT with a PPV of 100%.
Collapse
Affiliation(s)
- Emilie Jousselme
- Department of Haematology-Haemostasis, Civil Hospices of Lyon, Bron, France
| | - Eve-Anne Guéry
- Department of Haematology-Haemostasis, Regional University Hospital of Tours, Tours, France
| | - Christophe Nougier
- Department of Haematology-Haemostasis, Civil Hospices of Lyon, Bron, France
| | - Frédéric Sobas
- Department of Haematology-Haemostasis, Civil Hospices of Lyon, Bron, France
| | - Jérôme Rollin
- Department of Haematology-Haemostasis, Regional University Hospital of Tours, Tours, France.,EA 7501 GICC, University of Tours, Tours, France
| | - Yves Gruel
- Department of Haematology-Haemostasis, Regional University Hospital of Tours, Tours, France.,EA 7501 GICC, University of Tours, Tours, France
| | - Caroline Vayne
- Department of Haematology-Haemostasis, Regional University Hospital of Tours, Tours, France.,EA 7501 GICC, University of Tours, Tours, France
| | - Claire Pouplard
- Department of Haematology-Haemostasis, Regional University Hospital of Tours, Tours, France.,EA 7501 GICC, University of Tours, Tours, France
| |
Collapse
|
18
|
Favaloro EJ, Mohammed S, Donikian D, Kondo M, Duncan E, Yacoub O, Zebeljan D, Ng S, Malan E, Yuen A, Beggs J, Moosavi S, Coleman R, Klose N, Chapman K, Cavanaugh L, Pasalic L, Motum P, Tan CW, Brighton T. A multicentre assessment of contemporary laboratory assays for heparin induced thrombocytopenia. Pathology 2020; 53:247-256. [PMID: 33032809 DOI: 10.1016/j.pathol.2020.07.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/25/2020] [Accepted: 07/23/2020] [Indexed: 12/27/2022]
Abstract
Heparin induced thrombocytopenia (HIT) is a rare but potentially fatal complication of heparin therapy. In some patients, HIT causes platelet activation and thrombosis (sometimes abbreviated HITT), which leads to adverse clinical sequalae ('pathological HIT'). The likelihood of HIT is initially assessed clinically, typically using a scoring system, of which the 4T score is that most utilised. Subsequent laboratory testing to confirm or exclude HIT facilitates exclusion or diagnosis and management. The current investigation comprises a multicentre (n=9) assessment of contemporary laboratory testing for HIT, as performed over the past 1-3 years in each site and comprising testing of over 1200 samples. The primary laboratory test used by study participants (n=8) comprised a chemiluminescence procedure (HIT-IgG(PF4-H)) performed on an AcuStar instrument. Additional immunological testing performed by study sites included lateral flow (STiC, Stago), enzyme linked immunosorbent assay (ELISA), Asserachrom (HPIA IgG), PaGIA (BioRad), plus functional assays, primarily serotonin release assay (SRA) or platelet aggregation methods. The chemiluminescence procedure yielded a highly sensitive screening method for identifying functional HIT, given high area under the curve (AUC, generally ≥0.9) in a receiver operator characteristic (ROC) analysis against SRA as gold standard. ELISA testing resulted in lower ROC AUC scores (<0.8) and higher levels of false positives. Although there is clear association with the likelihood of HIT, the 4T score had less utility than literature suggests, and was comparable to a previous study reported by some of the authors.
Collapse
Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW, Australia; NSW Health Pathology, NSW, Australia; School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW, Australia.
| | - Soma Mohammed
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW, Australia; NSW Health Pathology, NSW, Australia
| | - Dea Donikian
- NSW Health Pathology, NSW, Australia; Prince of Wales Hospital, Randwick, NSW, Australia
| | - Mayuko Kondo
- NSW Health Pathology, NSW, Australia; Prince of Wales Hospital, Randwick, NSW, Australia
| | | | | | - Diane Zebeljan
- NSW Health Pathology, NSW, Australia; Liverpool Hospital, Liverpool, NSW, Australia
| | - Sara Ng
- NSW Health Pathology, NSW, Australia; Liverpool Hospital, Liverpool, NSW, Australia
| | | | - Agnes Yuen
- Monash Health, Melbourne, Vic, Australia
| | | | | | - Robyn Coleman
- Sullivan Nicolaides Pathology, Brisbane, Qld, Australia
| | - Nathan Klose
- Sullivan Nicolaides Pathology, Brisbane, Qld, Australia
| | - Kent Chapman
- NSW Health Pathology, NSW, Australia; John Hunter Hospital, Newcastle, NSW, Australia
| | - Lauren Cavanaugh
- NSW Health Pathology, NSW, Australia; St George Hospital, Kogarah, NSW, Australia
| | - Leonardo Pasalic
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW, Australia; NSW Health Pathology, NSW, Australia; School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW, Australia
| | - Penelope Motum
- NSW Health Pathology, NSW, Australia; Liverpool Hospital, Liverpool, NSW, Australia
| | - Chee Wee Tan
- South Australia Pathology, Adelaide, SA, Australia; Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Timothy Brighton
- NSW Health Pathology, NSW, Australia; Prince of Wales Hospital, Randwick, NSW, Australia
| |
Collapse
|
19
|
Sahu KK, Jindal V, Anderson J, Siddiqui AD, Jaiyesimi IA. Current Perspectives on Diagnostic Assays and Anti-PF4 Antibodies for the Diagnosis of Heparin-Induced Thrombocytopenia. J Blood Med 2020; 11:267-277. [PMID: 32884385 PMCID: PMC7443028 DOI: 10.2147/jbm.s232648] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 07/27/2020] [Indexed: 12/12/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a recognized clinical entity in patients receiving unfractionated heparin and low–molecular weight heparin. Currently, diagnosing HIT includes the combination of a physician’s clinical suspicion based on a clinical scoring system and a series of laboratory tests. In the present article, we discuss challenges in suspecting and diagnosing HIT in consideration of the turnaround time of available tests and recent advances in techniques and methodologies of newer immunoassays and functional assays.
Collapse
Affiliation(s)
- Kamal K Sahu
- Hemato-oncology Division, Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, USA
| | - Vishal Jindal
- Department of Hematology and Oncology, Oakland University William Beaumont School of Medicine, Royal Oak, MI 48073, USA
| | - Joseph Anderson
- Department of Hematology and Oncology, Oakland University William Beaumont School of Medicine, Royal Oak, MI 48073, USA
| | - Ahmad D Siddiqui
- Hemato-oncology Division, Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, USA
| | - Ishmael A Jaiyesimi
- Department of Hematology and Oncology, Oakland University William Beaumont School of Medicine, Royal Oak, MI 48073, USA
| |
Collapse
|
20
|
Doi Y, Koga K, Sugioka S, Inoue Y, Arisato T, Nishioka K, Ishihara T, Sugawara A. Heparin-induced thrombocytopenia among incident hemodialysis patients anticoagulated with low molecular weight heparin: A single-center retrospective study. Nefrologia 2020; 41:356-358. [PMID: 32807578 DOI: 10.1016/j.nefro.2020.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 05/13/2020] [Accepted: 05/20/2020] [Indexed: 10/23/2022] Open
Affiliation(s)
- Yohei Doi
- Department of Nephrology, Osaka Red Cross Hospital, Japan.
| | - Kenichi Koga
- Department of Nephrology, Osaka Red Cross Hospital, Japan
| | - Sayaka Sugioka
- Department of Nephrology, Osaka Red Cross Hospital, Japan
| | - Yui Inoue
- Department of Nephrology, Osaka Red Cross Hospital, Japan
| | | | | | - Takeshi Ishihara
- Department of Clinical Engineering, Osaka Red Cross Hospital, Japan
| | - Akira Sugawara
- Department of Nephrology, Osaka Red Cross Hospital, Japan
| |
Collapse
|
21
|
Adrenal failure secondary to bilateral adrenal haemorrhage in heparin-induced thrombocytopenia. Ann Hematol 2020; 99:657-659. [PMID: 31938810 DOI: 10.1007/s00277-019-03851-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 11/12/2019] [Indexed: 10/25/2022]
|
22
|
Mandryk Y, Czesla M, Mogilansky C, Stefkova K, Drees A, Massoudy P. Massive Left Atrial Thrombus in Two Patients with Heparin-Induced Thrombocytopenia Type II after Cardiac Surgery. TH OPEN 2019; 2:e334-e337. [PMID: 31249958 PMCID: PMC6524892 DOI: 10.1055/s-0038-1672188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 08/16/2018] [Indexed: 11/04/2022] Open
Abstract
Heparin-induced thrombocytopenia type II (HIT type II) can have devastating consequences in cardiac surgical patients. We report two cases of massive left atrial thrombus after mitral valve replacement and endocardial cryoablation in patients with HIT type II.
Collapse
Affiliation(s)
- Yuriy Mandryk
- Department of Cardiac Surgery, Klinikum Passau, Passau, Germany
| | - Markus Czesla
- Department of Cardiac Surgery, Klinikum Passau, Passau, Germany
| | | | - Kristina Stefkova
- Department for Laboratory Medicine, Klinikum Passau, Passau, Germany
| | - Aloys Drees
- Department for Laboratory Medicine, Klinikum Passau, Passau, Germany
| | - Parwis Massoudy
- Department of Cardiac Surgery, Klinikum Passau, Passau, Germany
| |
Collapse
|
23
|
Joseph J, Rabbolini D, Enjeti AK, Favaloro E, Kopp M, McRae S, Pasalic L, Tan CW, Ward CM, Chong BH. Diagnosis and management of heparin‐induced thrombocytopenia: a consensus statement from the Thrombosis and Haemostasis Society of Australia and New ZealandHITWriting Group. Med J Aust 2019; 210:509-516. [DOI: 10.5694/mja2.50213] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Joanne Joseph
- St Vincent's Hospital Sydney NSW
- St Vincent's Clinical SchoolUniversity of New South Wales Sydney NSW
| | - David Rabbolini
- Royal North Shore Hospital Sydney NSW
- Northern Blood Research CentreKolling Institute of Medical Research Sydney NSW
| | | | - Emmanuel Favaloro
- Institute of Clinical Pathology and Medical Research Sydney NSW
- Westmead Hospital Sydney NSW
| | | | | | - Leonardo Pasalic
- Institute of Clinical Pathology and Medical Research Sydney NSW
- Westmead Hospital Sydney NSW
| | | | - Christopher M Ward
- Royal North Shore Hospital Sydney NSW
- Northern Blood Research CentreKolling Institute of Medical Research Sydney NSW
| | | |
Collapse
|
24
|
Evaluation of a flow cytometer-based functional assay using platelet-rich plasma in the diagnosis of heparin-induced thrombocytopenia. Thromb Res 2019; 180:55-61. [PMID: 31220752 DOI: 10.1016/j.thromres.2019.05.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/07/2019] [Accepted: 05/20/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is caused by platelet-activating antibodies that recognize platelet factor 4/heparin (PF4/hep)-complexes. The in vitro demonstration of PF4/hep antibodies using functional assays is essential for an optimal management of patients suspected to have HIT. However, conventional functional assays are technically challenging and limited to specialized laboratories. In contrast, flow cytometers are commonly used in routine laboratories. The aim of this study is to investigate the performance characteristics of a commercially available, flow cytometer based assay in the diagnosis of HIT. STUDY DESIGN Sera of consecutive patients with suspected HIT were investigated using the Emo-test HIT Confirm® assay and compared to the standard method consisting of an IgG-specific enzyme immunoassay (EIA) for anti-PF4/hep antibodies and the heparin induced platelet aggregation (HIPA) test. RESULTS 390 sera were included in the study, 164 sera tested IgG EIA-positive, of which 33 also tested HIPA-positive. No HIPA-positive samples were EIA-negative. In the Emo-test HIT Confirm® assay, 112 sera revealed positive results (%Hepla > 13); however, 51 (45.5%) were EIA-negative. Of the 33 HIPA-positive/EIA-positive HIT sera, 23 tested positive in the Emo-test HIT Confirm® assay, 2 gave ambiguous results, and 8 sera yielded false-negative results. Accordingly, the HIT Confirm® assay showed a sensitivity of 69.7% with a slightly better specificity of 75.4% compared to the EIA (sensitivity 100%, specificity 63.3%). An increase in diagnostic specificity for HIT to 85% was found when positive results were obtained in both the Emo-test HIT Confirm® assay and EIA. CONCLUSION The Emo-Test HIT Confirm® assay may improve the specificity of laboratory investigations of HIT. However, the assay can only be recommended in combination with an immunoassay due to the high rate of false negativity. Our observation indicates a need to establish external quality assessment for functional assays to avoid such clinically relevant pitfalls.
Collapse
|
25
|
Li S, Fan LK, Wu W, Zhao YQ, Wang SJ. [Diagnostic value of two immunoassays for detecting heparin/PF4 complex antibodies in heparin-induced thrombocytopenia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:411-416. [PMID: 31207707 PMCID: PMC7342243 DOI: 10.3760/cma.j.issn.0253-2727.2019.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Indexed: 11/05/2022]
Abstract
Objectives: To assess the diagnostic values of latex immunoturbidimetric assay (LIA) and particle immunofiltration assay (PIFA) for heparin-induced thrombocytopenia (HIT) . Methods: Samples from 94 patients with suspected HIT from May 2016 to July 2018 in our hospital were prospectively analyzed by the two immunoassays. Their medical records and further follow-up data were also collected and analyzed by our hematologists to make the 4Ts scores and confirm the diagnosis of HIT, respectively. Performance characteristics of the two immunoassays were assessed, including sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) . Their post-test probabilities (PTP) were also calculated based on the 4Ts score. Results: Among 94 cases, 15 (16.0%) had a positive HIT, including 6 of 37 (16.2%) with an intermediate, and 9 of 15 (60.0%) with a high 4Ts score. PIFA operating characteristics were: sensitivity 100.0% (15/15) , specificity 51.9% (41/80) , PPV 28.3% (15/53) , NPV 100.0% (41/41) . The positive PTP in intermediate and high 4Ts score group were 28.7% and 75.7%, respectively, while negative PTP were all 0. At manufacturers' cutoffs, LIA operating characteristics were: sensitivity 66.7% (10/15) , specificity 94.9% (75/79) , PPV 71.4% (10/14) and NPV 93.8% (75/80) . The positive and negative PTP in intermediate 4Ts score group were 71.8% and 6.3%, while 95.2% and 34.4% in high 4Ts score group, respectively. Receiver operating characteristic (ROC) analysis manifested that LIA was preferable than PIFA, and combining the 2 assays together was significantly better than single test. Conclusions: 4Ts score is still an important tool for the diagnosis of HIT. Combining clinical score with heparin/PF4 antibody assay can increase the accuracy of confirming or excluding HIT. Although PIFA is inferior to LIA in the diagnostic value, its user friendliness and 100% NPV have major advantages. Combining the 2 assays together can achieve a higher diagnostic value.
Collapse
Affiliation(s)
- S Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences, Beijing 100730, China
| | - L K Fan
- Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences, Beijing 100730, China
| | - W Wu
- Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences, Beijing 100730, China
| | - Y Q Zhao
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences, Beijing 100730, China
| | - S J Wang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences, Beijing 100730, China
| |
Collapse
|
26
|
Heparin-Induced Thrombocytopenia. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00041-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
|
27
|
Wines BD, Tan CW, Duncan E, McRae S, Baker RI, Andrews RK, Esparon S, Gardiner EE, Hogarth PM. Dimeric FcγR ectodomains detect pathogenic anti-platelet factor 4-heparin antibodies in heparin-induced thromobocytopenia. J Thromb Haemost 2018; 16:2520-2525. [PMID: 30269432 PMCID: PMC6635755 DOI: 10.1111/jth.14306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Indexed: 11/28/2022]
Abstract
Essentials FcγRIIa mediates life-threatening heparin-induced thrombocytopenia (HIT). Most anti-platelet factor (PF)4-heparin IgGs are not pathogenic so diagnosis of HIT is challenging. Dimeric rsFcγRIIa was used to quantify receptor-binding activity of anti-PF4-heparin antibodies. Dimeric rsFcγRIIa binding specifically correlated with occurrence of HIT. SUMMARY: Background Heparin-induced thrombocytopenia (HIT) is a major and potentially fatal consequence of antibodies produced against platelet factor 4 (PF4)-heparin complexes following heparin exposure. Not all anti-PF4-heparin antibodies are pathogenic, so overdiagnosis can occur, with resulting inappropriate use of alternative anticoagulation therapies that have associated risks of bleeding. However, definitive platelet functional assays are not widely available for routine analysis. Objectives To assess the utility of dimeric recombinant soluble FcγRIIa (rsFcγRIIa) ectodomains for detecting HIT antibodies. Patients/Methods Plasma from 27 suspected HIT patients were tested for pathogenic anti-PF4-heparin antibodies by binding of a novel dimeric FcγRIIa ectodomain probe. Plasmas were also tested by the use of PF4-heparin IgG ELISA, the HemosIL AcuStar HIT IgG-specific assay, and a serotonin release assay (SRA). Results The dimeric rsFcγRIIa test produced no false positives and excluded four samples that were positive by IgG ELISA. In this small patient cohort, the novel assay correctly assigned 93% of the suspected HIT patients, with two of the HIT patients being scored as false negatives. The improved discrimination of the novel assay over the IgG ELISA, which scored four false positives, supports the mechanistic interpretation that binding of dimeric rsFcγRIIa detects pairs of closely spaced IgG antibodies in PF4-heparin immune complexes. Conclusions This study found the cell-free, function-based dimeric rsFcγRIIa assay to be convenient, simple, and potentially predictive of HIT. The assay had improved specificity over the IgG ELISA, and correlated strongly with the AcuStar HIT IgG-specific assay, warranting further evaluation of its potential to identify HIT in larger patient cohorts.
Collapse
Affiliation(s)
- B. D. Wines
- Immune Therapies GroupBurnet InstituteMelbourneVictoriaAustralia
- Department of ImmunologyMonash University Central Clinical SchoolMelbourneVictoriaAustralia
- Department of PathologyThe University of MelbourneMelbourneVictoriaAustralia
| | - C. W. Tan
- SA PathologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - E. Duncan
- SA PathologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - S. McRae
- SA PathologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - R. I. Baker
- Murdoch UniversityPerthWestern AustraliaAustralia
| | - R. K. Andrews
- Australian Centre for Blood DiseasesMonash UniversityMelbourneVictoriaAustralia
| | - S. Esparon
- Immune Therapies GroupBurnet InstituteMelbourneVictoriaAustralia
- Department of ImmunologyMonash University Central Clinical SchoolMelbourneVictoriaAustralia
- Department of PathologyThe University of MelbourneMelbourneVictoriaAustralia
| | - E. E. Gardiner
- ACRF Department of Cancer Biology and TherapeuticsJohn Curtin School of Medical ResearchAustralian National UniversityCanberraAustralia
| | - P. M. Hogarth
- Immune Therapies GroupBurnet InstituteMelbourneVictoriaAustralia
- Department of ImmunologyMonash University Central Clinical SchoolMelbourneVictoriaAustralia
- Department of PathologyThe University of MelbourneMelbourneVictoriaAustralia
| |
Collapse
|
28
|
HIT or miss? A comprehensive contemporary investigation of laboratory tests for heparin induced thrombocytopenia. Pathology 2018; 50:426-436. [DOI: 10.1016/j.pathol.2017.11.089] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 11/16/2017] [Accepted: 11/21/2017] [Indexed: 11/17/2022]
|
29
|
Nagler M, Bakchoul T. Clinical and laboratory tests for the diagnosis of heparin-induced thrombocytopenia. Thromb Haemost 2017; 116:823-834. [DOI: 10.1160/th16-03-0240] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 08/16/2016] [Indexed: 12/27/2022]
Abstract
SummaryA rapid diagnostic work-up is required in patients with suspected heparin-induced thrombocytopenia (HIT). However, diagnosis of HIT is challenging due to a number of practical issues and methodological limitations. Many laboratory tests and a few clinical scoring systems are available but the individual characteristics and the diagnostic accuracy of these are hard to appraise. The 4Ts score is a well evaluated clinical assessment tool with the potential to rule out HIT in many patients. Still, it requires experience and is subject to a relevant inter-observer variability. Immunoassays such as enzyme-linked immunosorbent assays or recently developed rapid assays are able to exclude HIT in a number of patients. But, accuracy of immunoassays differs depending on type of assay, threshold, antibody specificity and even manufacturer. Due to a comparatively low positive predictive value, HIT cannot be confirmed by immunoassays alone. In addition, only some of them are immediately accessible, particularly in small laboratories. While functional assays such as the serotonin release assay (SRA) and the heparin-induced platelet activation assay (HIPA) are considered as gold standard for diagnosis of HIT, they require a highly specialised laboratory. In addition, some of them are not adequately evaluated. In clinical practice, we recommend an integrated diagnostic approach combining not only clinical assessment (the 4Ts score) but immunoassays and functional assays as well. We propose a clear diagnostic algorithm supporting clinical decision-making. Furthermore, we provide an overview of all current laboratory techniques for HIT and discuss diagnostic pathways and strategies to reduce diagnostic errors, and future perspectives.
Collapse
|
30
|
Besser MW, Vuylsteke A. Heparin-Induced Thrombocytopenia and Vascular Surgery. J Cardiothorac Vasc Anesth 2017; 31:1758-1759. [DOI: 10.1053/j.jvca.2017.06.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Indexed: 11/11/2022]
|
31
|
Implementation of a rapid HIT immunoassay at a university hospital - Retrospective analysis of HIT laboratory orders in patients with thrombocytopenia. Thromb Res 2017; 158:65-70. [PMID: 28843825 DOI: 10.1016/j.thromres.2017.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/19/2017] [Accepted: 08/15/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a rare cause of thrombocytopenia and a potentially life-threatening adverse drug reaction. Clinical overdiagnosis of HIT results in costly laboratory tests and anticoagulation. Criteria and algorithms for diagnosis are established, but their translation into clinical practice is still challenging. STUDY DESIGN AND METHODS In a retrospective approach we studied all HIT related laboratory test requests within four years and evaluated data before (1st period, 24month) and after (2nd period, 24month) replacing particle gel immunoassay (PaGIA) and enzyme-linked immunosorbent assay (ELISA) by a chemiluminescent immunoassay (CLIA). HIT was confirmed by heparin-induced platelet activation (HIPA) test. Clinical pretest probability for HIT using an implemented simplified 4Ts score and platelet count were evaluated. Costs for laboratory tests and alternative anticoagulation were calculated. RESULTS In 1850 patients with suspected HIT, 2327 laboratory orders were performed. In 87.2% of these orders an intermediate/high simplified 4Ts score was found. Thrombocytopenia was present in 87.1%. After replacing PaGIA and ELISA by CLIA the number of immunological and functional laboratory tests was reduced by 38.2%. The number of positive HIT immunoassays declined from 22.6% to 6.0%, while the number of positive HIPA tests among positive immunological tests increased by 19%. Altogether, acute HIT was confirmed in 59 patients. A decline in the use of alternative anticoagulants was observed in the 2nd period. CONCLUSION Our study shows that in a university hospital setting HIT is well-known, but diagnosis requires a precise laboratory confirmation. Replacing PaGIA and ELISA by CLIA did not influence laboratory order behavior but results in reduced overall costs for laboratory diagnostics and alternative anticoagulation.
Collapse
|
32
|
Platelet factor 4/heparin complexes present epitopes differently on solid-phase vs platelet surfaces. Blood 2017; 129:3498-3501. [DOI: 10.1182/blood-2017-02-769786] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
33
|
Rapid immunoassays for diagnosis of heparin-induced thrombocytopenia: Comparison of diagnostic accuracy, reproducibility, and costs in clinical practice. PLoS One 2017; 12:e0178289. [PMID: 28594835 PMCID: PMC5464550 DOI: 10.1371/journal.pone.0178289] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 05/10/2017] [Indexed: 01/01/2023] Open
Abstract
Background Immunoassays are crucial in the work-up of patients with suspected heparin-induced thrombocytopenia (HIT) and rapid tests have been recently developed. However, comparative data on diagnostic accuracy, reproducibility, and analytical costs of different immunoassays in clinical practice are limited. Methods Samples of 179 consecutive patients evaluated for suspected HIT in clinical practice using a polyspecific enzyme-linked immunoabsorbent assay (GTI diagnostics; ELISA) and a rapid particle gel immunoassay (PaGIA), were additionally analysed with a IgG-specific chemiluminescent immunoassay (AcuStar HIT-IgG). Presence of HIT was defined as a positive functional heparin-induced platelet aggregation test. Diagnostic accuracy was determined for low, intermediate and high thresholds as previously established (ELISA: optical density 0.4, 1.3, and 2.0 respectively; PaGIA: positive/negative, titre of 4, titre of 32; AcuStar HIT-IgG: 1.0 U/ml, 2.8, 9.4) and reproducibility was assessed by repeated measurements. Costs of test determination were calculated taking reagents, controls, and working time of technicians according to Swiss health care system into account. Results Data on PaGIA results were available for 171 patients (95.5%), ELISA for 144 patients (80.4%), and AcuStar HIT-IgG for 179 patients (100%). Sensitivity was above 95% for all assays at low and intermediate thresholds. Specificity increased with higher thresholds and was above 90% for all assays with intermediate and high thresholds. Specificity of AcuStar HIT-IgG (92.8%; 95% CI 87.7, 96.2) was significantly higher than PaGIA (83.0%; 95% CI 76.3, 88.5) and higher than ELISA (81.8%, 95% CI 74.2, 88.0) at low threshold (p<0.05). Reproducibility was adequate for all assays. Total costs per test were CHF 51.02 for ELISA, 117.70 for AcuStar HIT-IgG, and 83.13 for PaGIA. Conclusions We observed favourable diagnostic accuracy measures and a high reproducibility for PaGIA and AcuStar HIT-IgG. Implementation into 24-hours-service might improve patient care but the results must be confirmed in other settings and larger populations as well.
Collapse
|
34
|
Favaloro EJ, McCaughan G, Pasalic L. Clinical and laboratory diagnosis of heparin induced thrombocytopenia: an update. Pathology 2017; 49:346-355. [DOI: 10.1016/j.pathol.2017.02.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 02/17/2017] [Accepted: 02/26/2017] [Indexed: 10/19/2022]
|
35
|
Warkentin TE, Sheppard JAI, Linkins LA, Arnold DM, Nazy I. Performance characteristics of an automated latex immunoturbidimetric assay [HemosIL ® HIT-Ab (PF4-H) ] for the diagnosis of immune heparin-induced thrombocytopenia. Thromb Res 2017; 153:108-117. [DOI: 10.1016/j.thromres.2017.03.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/14/2017] [Accepted: 03/09/2017] [Indexed: 12/13/2022]
|
36
|
Nagler M, Cuker A. Profile of Instrumentation Laboratory's HemosIL® AcuStar HIT-Ab(PF4-H) assay for diagnosis of heparin-induced thrombocytopenia. Expert Rev Mol Diagn 2017; 17:419-426. [PMID: 28271738 DOI: 10.1080/14737159.2017.1304213] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Immunoassays play an essential role in the diagnosis of heparin-induced thrombocytopenia (HIT). The objective of this article is to review HemosIL® AcuStar HIT-Ab(PF4-H) (Instrumentation Laboratory, Bedford, MA, USA), a new chemiluminescent immunoassay for HIT. Areas covered: The authors searched the published literature for evaluation studies of HemosIL® AcuStar HIT-Ab(PF4-H) and sought information from the manufacturer. In this paper, the authors discuss the analytical principle and technical aspects of the assay; describe its diagnostic performance in validation studies; report on its reproducibility, cost-effectiveness, and regulatory status; and discuss the implications of the assay on clinical practice and means of integrating it in diagnostic pathways. HemosIL® AcuStar HIT-Ab(PF4-H) is compared with other rapid assays and widely used enzyme-linked immunoassays for the diagnosis of HIT. Expert commentary: HemosIL® AcuStar HIT-Ab(PF4-H) is automatable, can be performed 24 h per day, offers a rapid turnaround time, and appears to have favorable diagnostic accuracy, particularly at thresholds above that listed in the label. These advantages could lead to improved patient outcomes through rapid provision of results at the point of care, enhancing the accuracy of initial diagnosis.
Collapse
Affiliation(s)
- Michael Nagler
- a Department of Haematology and Central Haematology Laboratory , University of Bern , Bern , Switzerland
| | - Adam Cuker
- b Departments of Medicine and Pathology & Laboratory Medicine , University of Pennsylvania , Philadelphia , PA , USA
| |
Collapse
|
37
|
Bakchoul T. An update on heparin-induced thrombocytopenia: diagnosis and management. Expert Opin Drug Saf 2016; 15:787-97. [DOI: 10.1517/14740338.2016.1165667] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Tamam Bakchoul
- Institute for Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| |
Collapse
|
38
|
Demand on-demand testing for the diagnosis of heparin-induced thrombocytopenia. Thromb Res 2016; 140:163-164. [DOI: 10.1016/j.thromres.2016.02.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 02/13/2016] [Indexed: 12/31/2022]
|
39
|
Sun L, Gimotty PA, Lakshmanan S, Cuker A. Diagnostic accuracy of rapid immunoassays for heparin-induced thrombocytopenia. A systematic review and meta-analysis. Thromb Haemost 2016; 115:1044-55. [PMID: 26763074 DOI: 10.1160/th15-06-0523] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 12/03/2015] [Indexed: 01/15/2023]
Abstract
The platelet factor 4/heparin ELISA has limited specificity for heparin-induced thrombocytopenia (HIT) and frequently does not provide same-day results. Rapid immunoassays (RIs) have been developed which provide results in 30 minutes or less. We conducted a systematic review and meta-analysis to evaluate the diagnostic accuracy of RIs for HIT. We searched the literature for studies in which samples from patients with suspected HIT were tested using a RI and a functional assay against which the performance of the RI could be measured. We performed sensitivity analyses of studies that directly compared different RIs with each other and with ELISAs. Estimates of sensitivity and specificity for each RI were calculated. Twenty-three articles, collectively involving six different RIs, met eligibility criteria. All RIs exhibited high sensitivity (0.96 to 1.00); there was wider variability in specificity (0.68 to 0.94). Specificity of the IgG-specific chemiluminescent assay (IgG-CA) was greater than the polyspecific chemiluminescent assay [0.94 (95 %CI 0.89-0.99) vs 0.82 (0.77-0.87)]. The particle gel immunoassay demonstrated greater specificity than the polyspecific ELISA [0.96 (0.95-0.97) vs 0.91 (0.89-0.92)]. The IgG-CA and lateral flow immunoassay [0.94 (0.91-0.97)] exhibited greater specificity than the IgG-specific ELISA [0.86 (0.82-0.90)]. Given their high sensitivity and rapid turnaround time, RIs are a reliable means of excluding HIT at the point-of-care in patients with low or intermediate clinical probability. Additionally, some RIs have greater specificity than HIT ELISAs. In summary, IgG-specific RIs appear to have improved diagnostic accuracy compared with ELISAs in patients with suspected HIT and may reduce misdiagnosis and overtreatment.
Collapse
Affiliation(s)
| | | | | | - Adam Cuker
- Adam Cuker, MD, MS, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA, Tel.: +1 215 615 6555, Fax: +1 215 615 6599, E-mail:
| |
Collapse
|
40
|
Detection of HIT antibody dependent platelet aggregation using novel surface imprinting approach. Talanta 2016; 147:1-7. [DOI: 10.1016/j.talanta.2015.09.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 09/08/2015] [Accepted: 09/11/2015] [Indexed: 11/19/2022]
|
41
|
Diagnostic value of immunoassays for heparin-induced thrombocytopenia: a systematic review and meta-analysis. Blood 2015; 127:546-57. [PMID: 26518436 DOI: 10.1182/blood-2015-07-661215] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 10/27/2015] [Indexed: 01/20/2023] Open
Abstract
Immunoassays are essential in the workup of patients with suspected heparin-induced thrombocytopenia. However, the diagnostic accuracy is uncertain with regard to different classes of assays, antibody specificities, thresholds, test variations, and manufacturers. We aimed to assess diagnostic accuracy measures of available immunoassays and to explore sources of heterogeneity. We performed comprehensive literature searches and applied strict inclusion criteria. Finally, 49 publications comprising 128 test evaluations in 15 199 patients were included in the analysis. Methodological quality according to the revised tool for quality assessment of diagnostic accuracy studies was moderate. Diagnostic accuracy measures were calculated with the unified model (comprising a bivariate random-effects model and a hierarchical summary receiver operating characteristics model). Important differences were observed between classes of immunoassays, type of antibody specificity, thresholds, application of confirmation step, and manufacturers. Combination of high sensitivity (>95%) and high specificity (>90%) was found in 5 tests only: polyspecific enzyme-linked immunosorbent assay (ELISA) with intermediate threshold (Genetic Testing Institute, Asserachrom), particle gel immunoassay, lateral flow immunoassay, polyspecific chemiluminescent immunoassay (CLIA) with a high threshold, and immunoglobulin G (IgG)-specific CLIA with low threshold. Borderline results (sensitivity, 99.6%; specificity, 89.9%) were observed for IgG-specific Genetic Testing Institute-ELISA with low threshold. Diagnostic accuracy appears to be inadequate in tests with high thresholds (ELISA; IgG-specific CLIA), combination of IgG specificity and intermediate thresholds (ELISA, CLIA), high-dose heparin confirmation step (ELISA), and particle immunofiltration assay. When making treatment decisions, clinicians should be a aware of diagnostic characteristics of the tests used and it is recommended they estimate posttest probabilities according to likelihood ratios as well as pretest probabilities using clinical scoring tools.
Collapse
|
42
|
Abstract
PURPOSE OF REVIEW To review the recent developments in understanding the pathophysiology of heparin-induced thrombocytopenia (HIT) and in applying this knowledge to the treatment of patients with suspected and proven HIT. RECENT FINDINGS HIT pathophysiology is dynamic and complex. HIT pathophysiology is initiated by four essential components--heparin (Hep), platelet factor 4 (PF4), IgG antibodies against the Hep-PF4 complex, and platelet FcγRIIa. HIT is propagated by activated platelets, monocytes, endothelial cells, and coagulation proteins. Insights into the unique HIT antibody response continue to emerge, but without consensus as to the relative roles of B cells, T cells, and antigen-presenting cells. Platelet activation via FcγRIIa, the sine qua non of HIT, has become much better appreciated. Therapy remains challenging for several reasons. Suspected HIT is more frequent than proven HIT, because of the widespread use of Hep and the inadequacies of current diagnostic tests and scoring systems. In proven HIT, approved treatments reduce but do not eliminate thrombosis, and have substantial bleeding risk. Rational novel therapeutic strategies, directed at the initiating steps in HIT pathophysiology and with potential combinations staged over time, are in various phases of development. SUMMARY Progress continues in understanding the breadth of molecular and cellular players in HIT. Translation to improved diagnosis and treatment is needed.
Collapse
|
43
|
Jourdy Y, Nougier C, Rugeri L, Bordet JC, Sobas F, Negrier C. Prospective evaluation of automatized PF4/heparin immunoassays HemosIL HIT-ab (PF4-H) for the diagnosis of heparin-induced thrombocytopenia. Int J Lab Hematol 2014; 37:244-52. [DOI: 10.1111/ijlh.12275] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 06/16/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Y. Jourdy
- Hemostasis Laboratory; Edouard Herriot Hospital; Lyon France
| | - C. Nougier
- Hemostasis Laboratory; Edouard Herriot Hospital; Lyon France
| | - L. Rugeri
- Hemostasis Laboratory; Edouard Herriot Hospital; Lyon France
| | - J. C. Bordet
- Hemostasis Laboratory; Edouard Herriot Hospital; Lyon France
| | - F. Sobas
- Hemostasis Laboratory; Edouard Herriot Hospital; Lyon France
| | - C. Negrier
- Hemostasis Laboratory; Edouard Herriot Hospital; Lyon France
| |
Collapse
|
44
|
Prevalence and clinical implications of anti-PF4/heparin antibodies in intensive care patients: a prospective observational study. J Thromb Thrombolysis 2014; 39:60-7. [DOI: 10.1007/s11239-014-1105-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
45
|
New insights in heparin-induced thrombocytopenia by the use of fluid-phase assays to detect specifically platelet factor 4/heparin complex antibodies and antibody-secreting cells. Thromb Res 2014; 134:174-81. [DOI: 10.1016/j.thromres.2014.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 04/13/2014] [Accepted: 04/17/2014] [Indexed: 01/08/2023]
|
46
|
Minet V, Baudar J, Bailly N, Douxfils J, Laloy J, Lessire S, Gourdin M, Devalet B, Chatelain B, Dogné J, Mullier F. Rapid exclusion of the diagnosis of immune HIT by AcuStar HIT and heparin-induced multiple electrode aggregometry. Thromb Res 2014; 133:1074-8. [DOI: 10.1016/j.thromres.2014.01.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/13/2014] [Accepted: 01/13/2014] [Indexed: 02/07/2023]
|
47
|
Bakchoul T, Zöllner H, Greinacher A. Current insights into the laboratory diagnosis of HIT. Int J Lab Hematol 2014; 36:296-305. [DOI: 10.1111/ijlh.12236] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 03/12/2014] [Indexed: 11/30/2022]
Affiliation(s)
- T. Bakchoul
- Department of Immunology and Transfusion Medicine; Universitätsmedizin Greifswald; Greifswald Germany
| | - H. Zöllner
- Department of Immunology and Transfusion Medicine; Universitätsmedizin Greifswald; Greifswald Germany
| | - A. Greinacher
- Department of Immunology and Transfusion Medicine; Universitätsmedizin Greifswald; Greifswald Germany
| |
Collapse
|
48
|
An instrument-based immunoassay with an appropriate normal range: minimizing HIT overdiagnosis. Thromb Res 2014; 133:961-2. [PMID: 24508450 DOI: 10.1016/j.thromres.2014.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 01/21/2014] [Accepted: 01/23/2014] [Indexed: 11/23/2022]
|
49
|
|
50
|
Chen Z, Wang Z, Chen X, Xu H, Liu J. Chitosan-capped gold nanoparticles for selective and colorimetric sensing of heparin. JOURNAL OF NANOPARTICLE RESEARCH : AN INTERDISCIPLINARY FORUM FOR NANOSCALE SCIENCE AND TECHNOLOGY 2013; 15:1930. [PMID: 24078791 PMCID: PMC3782634 DOI: 10.1007/s11051-013-1930-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 08/10/2013] [Indexed: 06/02/2023]
Abstract
In this contribution, novel chitosan-stabilized gold nanoparticles (AuNPs) were prepared by mixing chitosan with citrate-reductive AuNPs under appropriate conditions. The as-prepared chitosan-stabilized AuNPs were positively charged and highly stably dispersed in aqueous solution. They exhibited weak resonance light scattering (RLS) intensity and a wine red color. In addition, the chitosan-stabilized AuNPs were successfully utilized as novel sensitive probes for the detection of heparin for the first time. It was found that the addition of heparin induced a strong increase of RLS intensity for AuNPs and the color change from red to blue. The increase in RLS intensity and the color change of chitosan-stabilized AuNPs caused by heparin allowed the sensitive detection of heparin in the range of 0.2-60 μM (~6.7 U/mL). The detection limit for heparin is 0.8 μM at a signal-to-noise ratio of 3. The present sensor for heparin detection possessed a low detection limit and wide linear range. Additionally, the proposed method was also applied to the detection of heparin in biological media with satisfactory results.
Collapse
Affiliation(s)
- Zhanguang Chen
- Department of Chemistry, Shantou University, Shantou, 515063 China
| | - Zhen Wang
- Department of Chemistry, Shantou University, Shantou, 515063 China
| | - Xi Chen
- Department of Chemistry, Shantou University, Shantou, 515063 China
- Shantou Central Hospital, Affiliated Shantou Hospital of SUN YAT-SEN University, Shantou, 515031 China
| | - Haixiong Xu
- Shantou Central Hospital, Affiliated Shantou Hospital of SUN YAT-SEN University, Shantou, 515031 China
| | - Jinbin Liu
- Department of Chemistry, University of Texasat Dallas, Richardson, TX 75080 USA
| |
Collapse
|