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Genome-wide association study of platelet factor 4/heparin antibodies in heparin-induced thrombocytopenia. Blood Adv 2022; 6:4137-4146. [PMID: 35533259 PMCID: PMC9327558 DOI: 10.1182/bloodadvances.2022007673] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/02/2022] [Indexed: 11/20/2022] Open
Abstract
Heparin, a widely used anticoagulant, carries the risk of an antibody mediated adverse drug reaction, heparin-induced thrombocytopenia (HIT). A subset of heparin-treated patients produces detectable levels of antibodies against complexes of heparin bound to circulating platelet factor 4 (PF4). Using a genome-wide association study (GWAS) approach, we aimed to identify genetic variants associated with anti-PF4/heparin antibodies that account for the variable antibody response seen in HIT. We performed a GWAS on anti-PF4/heparin antibody levels determined via polyclonal enzyme-linked immunosorbent assays (ELISA). Our discovery cohort (n=4237) and replication cohort (n=807) constituted patients with European ancestry and clinical suspicion of HIT with cases confirmed via functional assay. Genome-wide significance was considered at α=5x10-8. No variants were significantly associated with anti-PF4/heparin antibody levels in the discovery cohort at a genome-wide significant level. Secondary GWAS analyses included identification of variants with suggestive associations in the discovery cohort (α=1x10-4). The top variant in both cohorts was rs1555175145 (discovery β=-0.112[0.018], p=2.50x10-5; replication β=-0.104[0.051], p=0.041). In gene set enrichment analysis (GSEA), three gene sets reached false discovery rate-adjusted significance (q<0.05) in both discovery and replication cohorts: "Leukocyte Transendothelial Migration," "Innate Immune Response," and "Lyase Activity." Our results indicate that genomic variation is not significantly associated with anti-PF4/heparin antibody levels. Given our power to identify variants with moderate frequencies and effect sizes, this evidence suggests genetic variation is not a primary driver of variable antibody response in heparin-treated patients with European ancestry.
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Miller E, Norwood C, Giles JB, Huddart R, Karnes JH, Whirl-Carrillo M, Klein TE. PharmGKB summary: heparin-induced thrombocytopenia pathway, adverse drug reaction. Pharmacogenet Genomics 2022; 32:117-124. [PMID: 35102073 PMCID: PMC8988468 DOI: 10.1097/fpc.0000000000000465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Elise Miller
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Charles Norwood
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Jason B. Giles
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Rachel Huddart
- Department of Biomedical Data Science, Stanford University, Stanford, CA
| | - Jason H. Karnes
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Teri E. Klein
- Department of Biomedical Data Science, Stanford University, Stanford, CA
- Department of Biomedical Informatics Research, Stanford University, Stanford, CA
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Giles JB, Miller EC, Steiner HE, Karnes JH. Elucidation of Cellular Contributions to Heparin-Induced Thrombocytopenia Using Omic Approaches. Front Pharmacol 2022; 12:812830. [PMID: 35126147 PMCID: PMC8814424 DOI: 10.3389/fphar.2021.812830] [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: 11/10/2021] [Accepted: 12/31/2021] [Indexed: 11/23/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is an unpredictable, complex, immune-mediated adverse drug reaction associated with a high mortality. Despite decades of research into HIT, fundamental knowledge gaps persist regarding HIT likely due to the complex and unusual nature of the HIT immune response. Such knowledge gaps include the identity of a HIT immunogen, the intrinsic roles of various cell types and their interactions, and the molecular basis that distinguishes pathogenic and non-pathogenic PF4/heparin antibodies. While a key feature of HIT, thrombocytopenia, implicates platelets as a seminal cell fragment in HIT pathogenesis, strong evidence exists for critical roles of multiple cell types. The rise in omic technologies over the last decade has resulted in a number of agnostic, whole system approaches for biological research that may be especially informative for complex phenotypes. Applying multi-omics techniques to HIT has the potential to bring new insights into HIT pathophysiology and identify biomarkers with clinical utility. In this review, we review the clinical, immunological, and molecular features of HIT with emphasis on key cell types and their roles. We then address the applicability of several omic techniques underutilized in HIT, which have the potential to fill knowledge gaps related to HIT biology.
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Affiliation(s)
- Jason B. Giles
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, United States
| | - Elise C. Miller
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, United States
| | - Heidi E. Steiner
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, United States
| | - Jason H. Karnes
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, United States,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States,*Correspondence: Jason H. Karnes,
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Heparin-induced thrombocytopenia: ELISA optical density value and 4T score in correlation with panel donor platelets activation in functional flow cytometric assay. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 19:77-84. [PMID: 33085589 DOI: 10.2450/2020.0120-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Serological assays for the diagnosis of heparin-induced thrombocytopenia (HIT) detect both platelet-activating and platelet non-activating anti-heparin/platelet factor 4 (PF4) antibodies and have therefore a limited positive predictive value. Functional assays confirm the presence of platelet-activating antibodies but require platelets from healthy donors, whose response to patient serum can differ. Our aim was to investigate the correlation between the level of anti-heparin/PF4 antibodies, 4T score, and the extent of panel donor platelet activation in the functional assay. MATERIALS AND METHODS In total, 38 sera from enzyme immunoassays (ELISA) positive patients were tested against panel platelets obtained from 10 healthy, randomly selected donors, using our routine flow cytometry functional test for CD62P expression. Levels of anti-heparin/PF4 antibodies from medical and surgical patients and 4T pretest probability scores (where available) were correlated with the number of activated panel platelets. RESULTS Sera with low ELISA optical density (OD) values (0.4-1) activated on average 5.6, sera with intermediate ELISA OD values (>1-2.5) activated on average 7.3, and sera with high ELISA OD values (>2.5) activated on average 8.6 out of 10 panel platelets. One serum with low 4T score did not activate donor platelets, 12 sera with intermediate 4T score activated on average 6.3 donors, 8 sera with high 4T score activated on average 8.5 panel platelets. DISCUSSION Sera with higher ELISA OD values activated platelets from a higher number of platelet donors, independently of patient type (medical or surgical). The average number of activated panel platelets increased with rising 4T score. Results indicate that both donor platelet reactivity and quantity of anti-heparin/PF4 antibodies affect the result of the functional assay, meaning special attention is needed in platelet donor selection when testing sera with low levels of antibodies.
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Fibronectin modulates formation of PF4/heparin complexes and is a potential factor for reducing risk of developing HIT. Blood 2018; 133:978-989. [PMID: 30573633 DOI: 10.1182/blood-2018-05-850370] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 12/10/2018] [Indexed: 11/20/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is caused by platelet-activating anti-platelet factor 4 (PF4)/heparin antibodies. Platelet activation assays that use "washed" platelets are more sensitive for detecting HIT antibodies than platelet-rich plasma (PRP)-based assays. Moreover, heparin-exposed patients vary considerably with respect to the risk of PF4/heparin immunization and, among antibody-positive patients, the risk of subsequent "breakthrough" of clinical HIT with manifestation of thrombocytopenia. We used washed platelets and PRP, standard laboratory HIT tests, and physicochemical methods to identify a plasma factor interfering with PF4/heparin complexes and anti-PF4/heparin antibody-platelet interaction, thus explaining differences in functional assays. To investigate a modulating risk for PF4/heparin immunization and breakthrough of HIT, we also tested 89 plasmas from 2 serosurveillance trials. Fibronectin levels were measured in 4 patient groups exhibiting different degrees of heparin-dependent immunization and expression of HIT. The heat-labile plasma protein, fibronectin, inhibited PF4 binding to platelets in a dose-dependent fashion, particularly in washed (vs PRP) systems. Fibronectin also inhibited PF4/heparin binding to platelets, anti-PF4/heparin antibody binding to PF4/heparin complexes, and anti-PF4/heparin antibody-induced platelet activation as a result of PF4/heparin complex disruption. In addition, plasma fibronectin levels increased progressively among the following 4 patient groups: enzyme-linked immunosorbent assay (ELISA)+/serotonin-release assay (SRA)+/HIT+ < ELISA+/SRA+/HIT- ∼ ELISA+/SRA-/HIT- < ELISA-/SRA-/HIT-. Altogether, these findings suggest that fibronectin interferes with PF4/heparin complex formation and anti-PF4/heparin antibody-induced platelet activation. Reduced fibronectin levels in washed platelet assays help to explain the greater sensitivity of washed platelet (vs PRP) assays for HIT. More importantly, lower plasma fibronectin levels could represent a risk factor for PF4/heparin immunization and clinical breakthrough of HIT.
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Karnes JH. Pharmacogenetics to prevent heparin-induced thrombocytopenia: what do we know? Pharmacogenomics 2018; 19:1413-1422. [PMID: 30398086 DOI: 10.2217/pgs-2018-0147] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a life-threatening, immune-mediated adverse reaction to heparin anticoagulants. The inability to predict HIT represents a considerable liability associated with heparin administration. Genetic studies of HIT are challenging due to the scarcity of true HIT cases, potential for misclassification, and many environmental risk factors. Genetic studies have not consistently identified risk alleles for HIT, the production of platelet factor 4/heparin antibodies or the thromboembolic complications of HIT. Genes implicated in HIT and platelet factor 4/heparin antibody levels include FCGR2A, TDAG8, HLA-DR and others. Compelling evidence also suggests that the FCGR2A H131R polymorphism is associated with HIT-related thrombosis. There is a need for well-powered, multiethnic studies with laboratory confirmation of HIT, detailed patient- and drug-specific data, and inclusion of both serologic and thromboembolic outcomes. Genomic biomarkers identified from such studies offer the possibility of shifting current clinical practice paradigms from early detection and treatment to prevention.
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Affiliation(s)
- Jason H Karnes
- Department of Pharmacy Practice & Science, University of Arizona College of Pharmacy, Tucson, AZ 85721, USA.,Sarver Heart Center, Department of Medicine, University of Arizona College of Medicine - Tucson, Tucson, AZ 85721, USA.,Division of Pharmacogenomics, Center for Applied Genetics & Genomic Medicine (TCAG2M), Department of Medicine, University of Arizona College of Medicine - Tucson, Tucson, AZ 85721, USA
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Witten A, Bolbrinker J, Barysenka A, Huber M, Rühle F, Nowak-Göttl U, Garbe E, Kreutz R, Stoll M. Targeted resequencing of a locus for heparin-induced thrombocytopenia on chromosome 5 identified in a genome-wide association study. J Mol Med (Berl) 2018; 96:765-775. [PMID: 29934777 DOI: 10.1007/s00109-018-1661-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 06/05/2018] [Accepted: 06/12/2018] [Indexed: 12/18/2022]
Abstract
Immune-mediated heparin-induced thrombocytopenia (HIT) is the clinically most important adverse drug reaction (ADR) in response to heparin therapy characterized by a prothrombotic state despite a decrease in platelet count. We conducted a genome-wide association study in 96 suspected HIT cases and 96 controls to explore the genetic predisposition for HIT within a case-control pharmacovigilance study followed by replication in additional 86 cases and 86 controls from the same study. One single nucleotide polymorphism (SNP, rs1433265, P = 6.5 × 10-5, odds ratio (OR) 2.79) from 16 identified SNPs was successfully replicated (P = 1.5 × 10-4, OR 2.77; combined data set P = 2.7 × 10-8, OR 2.77) and remained the most strongly associated SNP after imputing locus genotypes. Fine mapping revealed a significantly associated risk-conferring haplotype (P = 4.9 × 10-6, OR 2.41). In order to find rare variants contributing to the association signals, we applied a targeted resequencing approach in a subgroup of 73 HIT patients and 23 controls for the regions with the 16 most strongly HIT-associated SNPs. C-alpha testing was applied to test for the impact of rare variants and we detected two candidate genes, the discoidin domain receptor tyrosine kinase 1 (DDR1, P = 3.6 × 10-2) and the multiple C2 and transmembrane domain containing 2 (MCTP2, P = 4.5 × 10-2). For the genes interactor of little elongation complex ELL subunit 1 (ICE1) and a disintegrin-like and metalloproteinase with thrombospondin type 1 motif, 16 (ADAMTS16) nearby rs1433265, we identified several missense variants. Although replication in an independent population is warranted, these findings provide a basis for future studies aiming to identify and characterize genetic susceptibility factors for HIT. KEY MESSAGES: We identified and validated a HIT-associated locus on chromosome 5. Targeted NGS analysis for rare variants identifies DDR1 and MCTP2 as novel candidates. In addition, missense variants for ADAMTS16 and ICE1 were identified in the locus.
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Affiliation(s)
- Anika Witten
- Department of Genetic Epidemiology, Institute of Human Genetics, University Hospital Münster, Münster, Germany
| | - Juliane Bolbrinker
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Andrei Barysenka
- Department of Genetic Epidemiology, Institute of Human Genetics, University Hospital Münster, Münster, Germany
| | - Matthias Huber
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Frank Rühle
- Department of Genetic Epidemiology, Institute of Human Genetics, University Hospital Münster, Münster, Germany
| | - Ulrike Nowak-Göttl
- Thrombosis and Hemostasis Unit, Department of Clinical Chemistry, University Hospital of Kiel and Lübeck, Kiel, Germany
| | - Edeltraut Garbe
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany.,Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Monika Stoll
- Department of Genetic Epidemiology, Institute of Human Genetics, University Hospital Münster, Münster, Germany. .,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands.
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Staibano P, Arnold DM, Bowdish DME, Nazy I. The unique immunological features of heparin-induced thrombocytopenia. Br J Haematol 2017; 177:198-207. [DOI: 10.1111/bjh.14603] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Phillip Staibano
- 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
- Canadian Blood Services; Hamilton ON Canada
| | - Dawn M. E. Bowdish
- McMaster Immunology Research Centre; McMaster University; Hamilton ON Canada
| | - Ishac Nazy
- Department of Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton ON Canada
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Lioger B, Rollin J, Vayne C, Perret-Gallix K, Pouplard C, Godeau B, Michel M, Gruel Y. No impact of PTPN22, PTPRJ and ACP1 genes polymorphisms on the risk of immune thrombocytopenia in French adult patients. Thromb Res 2016; 144:76-8. [PMID: 27309885 DOI: 10.1016/j.thromres.2016.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 04/14/2016] [Accepted: 04/23/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Bertrand Lioger
- Service de Médecine Interne, Hôpital Bretonneau, Centre Hospitalier Universitaire (CHU) Tours, Tours, France; Unité Mixte de Recherche Centre National de la Recherche Scientifique 7292 and Université François Rabelais, Tours, France
| | - Jerome Rollin
- Unité Mixte de Recherche Centre National de la Recherche Scientifique 7292 and Université François Rabelais, Tours, France; Department of Hematology-Hemostasis, Trousseau hospital, Tours, France
| | - Caroline Vayne
- Unité Mixte de Recherche Centre National de la Recherche Scientifique 7292 and Université François Rabelais, Tours, France; Department of Hematology-Hemostasis, Trousseau hospital, Tours, France
| | - Kevin Perret-Gallix
- Unité Mixte de Recherche Centre National de la Recherche Scientifique 7292 and Université François Rabelais, Tours, France; Department of Hematology-Hemostasis, Trousseau hospital, Tours, France
| | - Claire Pouplard
- Unité Mixte de Recherche Centre National de la Recherche Scientifique 7292 and Université François Rabelais, Tours, France; Department of Hematology-Hemostasis, Trousseau hospital, Tours, France
| | - Bertrand Godeau
- Department of Internal Medicine, National Referral Centre for Adult's Immune Cytopenias, Henri Mondor University Hospital, Assistance Publique Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Marc Michel
- Department of Internal Medicine, National Referral Centre for Adult's Immune Cytopenias, Henri Mondor University Hospital, Assistance Publique Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Yves Gruel
- Unité Mixte de Recherche Centre National de la Recherche Scientifique 7292 and Université François Rabelais, Tours, France; Department of Hematology-Hemostasis, Trousseau hospital, Tours, France.
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Li T, Xu X, Li J, Xing S, Zhang L, Li W, Ma J, Fu X. Association of ACP1 gene polymorphisms and coronary artery disease in northeast Chinese population. J Genet 2016; 94:125-8. [PMID: 25846885 DOI: 10.1007/s12041-015-0475-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Tianbao Li
- National Engineering Laboratory for AIDS Vaccine, Jilin University, Changchun 130012, People's Republic of China.
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Karnes JH, Cronin RM, Rollin J, Teumer A, Pouplard C, Shaffer CM, Blanquicett C, Bowton EA, Cowan JD, Mosley JD, Van Driest SL, Weeke PE, Wells QS, Bakchoul T, Denny JC, Greinacher A, Gruel Y, Roden DM. A genome-wide association study of heparin-induced thrombocytopenia using an electronic medical record. Thromb Haemost 2014; 113:772-81. [PMID: 25503805 DOI: 10.1160/th14-08-0670] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 10/27/2014] [Indexed: 12/20/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is an unpredictable, potentially catastrophic adverse effect of heparin treatment resulting from an immune response to platelet factor 4 (PF4)/heparin complexes. No genome-wide evaluations have been performed to identify potential genetic influences on HIT. Here, we performed a genome-wide association study (GWAS) and candidate gene study using HIT cases and controls identified using electronic medical records (EMRs) coupled to a DNA biobank and attempted to replicate GWAS associations in an independent cohort. We subsequently investigated influences of GWAS-associated single nucleotide polymorphisms (SNPs) on PF4/heparin antibodies in non-heparin treated individuals. In a recessive model, we observed significant SNP associations (odds ratio [OR] 18.52; 95% confidence interval [CI] 6.33-54.23; p=3.18×10(-9)) with HIT near the T-Cell Death-Associated Gene 8 (TDAG8). These SNPs are in linkage disequilibrium with a missense TDAG8 SNP. TDAG8 SNPs trended toward an association with HIT in replication analysis (OR 5.71; 0.47-69.22; p=0.17), and the missense SNP was associated with PF4/heparin antibody levels and positive PF4/heparin antibodies in non-heparin treated patients (OR 3.09; 1.14-8.13; p=0.02). In the candidate gene study, SNPs at HLA-DRA were nominally associated with HIT (OR 0.25; 0.15-0.44; p=2.06×10(-6)). Further study of TDAG8 and HLA-DRA SNPs is warranted to assess their influence on the risk of developing HIT.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Dan M Roden
- Dan M. Roden, MD, MRB4 1285B, 2215B Garland Avenue, Nashville, TN, 37232-0575, USA, Tel.: +1 615 322 0067, Fax: +1 615 343 4522, E-mail:
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