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Kruijt M, Smit N, van Ham J, Cobbaert C, Ruhaak L. Effects of sample matrix in the measurement of antithrombin by LC-MS: A role for immunocapture. J Mass Spectrom Adv Clin Lab 2023; 27:61-65. [PMID: 36691568 PMCID: PMC9860377 DOI: 10.1016/j.jmsacl.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 01/09/2023] Open
Abstract
Introduction The sample matrix composition, which is greatly affected by the type of blood collection tube used during phlebotomy, is of major importance in laboratory testing as it can influence test results. We developed an LC-MRM-MS test to molecularly characterize antithrombin in citrate plasma. The test principle differs greatly from traditional laboratory tests and the influence of varying plasma sample matrices is largely unknown. Objectives To identify whether variations in sample matrix affect the LC-MRM-MS test for antithrombin and assess whether sample pre-processing by immunocapture reduces matrix-specific effects. Methods Samples (n = 45) originating from four different blood collection tubes (sodium citrate, lithium heparin, K2-EDTA and K2-EDTA with protease inhibitors) were processed directly or after immunocapture. Antithrombin was digested into proteotypic peptides, which were monitored by LC-MRM-MS. Results from lithium heparin and the K2-EDTA matrices were compared to the standard sample matrix, sodium citrate, using Deming regression analysis and repeated measures one-way ANOVA. Results Deming regression analysis of directly processed samples revealed slopes deviating >5% from the line of identity for at least six out of 22 peptides in all matrices. Significant differences between all matrices were found upon analysis by ANOVA for at least 10 peptides. Pre-processing by immunocapture led to slopes within 5% of the line of identity for nearly all peptides of the matrices. Furthermore, significant differences between matrices after immunocapture were only observed for four peptides. Conclusion Variations in the sample matrix affect the measurement of antithrombin by LC-MRM-MS, but observed effects are greatly reduced upon pre-processing by immunocapture.
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Key Words
- AT, antithrombin
- Anticoagulants
- Antithrombin
- BD, Becton, Dickinson and Company
- CV, coefficient of variation
- FA, formic acid
- Immunocapture
- LC, liquid chromatography
- LUVDS, Leiden University Medical Center Voluntary Donor Service
- MRM, multiple reaction monitoring
- PIC, protease inhibitor cocktail
- QC, quality control
- Quantitative clinical chemistry proteomics
- SST, system suitability test
- Sample matrix
- VHH, single variable domain on a heavy chain
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Affiliation(s)
- M. Kruijt
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands,Corresponding author at: Leiden University Medical Center, Department of Clinical Chemistry and Laboratory Medicine, Office E2-27, Albinusdreef 2, 2333 ZA Leiden, The Netherlands.
| | - N.P.M. Smit
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - J.J. van Ham
- Biobank Facility, Leiden University Medical Center, Leiden, The Netherlands
| | - C.M. Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - L.R. Ruhaak
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Zanetto A, Campello E, Bulato C, Gavasso S, Saggiorato G, Shalaby S, Burra P, Angeli P, Senzolo M, Simioni P. Global hemostatic profiling in patients with decompensated cirrhosis and bacterial infections. JHEP Rep 2022; 4:100493. [PMID: 35647501 PMCID: PMC9131254 DOI: 10.1016/j.jhepr.2022.100493] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/13/2022] [Indexed: 02/08/2023] Open
Abstract
Background & Aims Bacterial infections in cirrhosis are associated with increased bleeding risk. To assess the factors responsible for bleeding tendency in patients with bacterial infections, we conducted a prospective study comparing all 3 aspects of hemostasis (platelets, coagulation, and fibrinolysis) in hospitalized patients with decompensated cirrhosis with vs. without bacterial infections. Methods Primary hemostasis assessment included whole blood platelet aggregation and von Willebrand factor (VWF). Coagulation assessment included procoagulant factors (fibrinogen, factor II, V, VII, VIII, IX, X, XI, XII, XIII), natural anticoagulants (protein C, protein S, antithrombin) and thrombomodulin-modified thrombin generation test. Fibrinolysis assessment included fibrinolytic factors (plasminogen, t-PA, PAI-1, α2-AP, TAFIa/ai) and plasmin-antiplasmin complex (PAP). Results Eighty patients with decompensated cirrhosis were included (40 with and 40 without bacterial infections). Severity of cirrhosis and platelet count were comparable between groups. At baseline, patients with cirrhosis and bacterial infections had significantly lower whole blood platelet aggregation, without significant differences in VWF. Regarding coagulation, bacterial infections were associated with reduced procoagulant factors VII and XII, and a significant reduction of all natural anticoagulants. However, thrombomodulin-modified thrombin generation was comparable between the study groups. Finally, although mixed potentially hypo-fibrinolytic (lower plasminogen) and hyper-fibrinolytic (higher t-PA) changes were present in bacterial infections, a comparable level of PAP was detected in both groups. Upon resolution of infection (n = 29/40), platelet aggregation further deteriorated whereas coagulation and fibrinolysis factors returned to levels observed in patients without bacterial infections. Conclusion In hospitalized patients with decompensated cirrhosis, bacterial infections are associated with reduced whole blood platelet aggregation and a significant decrease of all natural anticoagulants, which may unbalance hemostasis and potentially increase the risk of both bleeding and thrombosis. Lay summary Bacterial infections are a common issue in hospitalized patients with decompensated cirrhosis (i.e. patients hospitalized due to severe complications of advanced chronic liver disease). Patients with decompensated cirrhosis who acquire infections may be at increased risk of bleeding complications following invasive procedures (that is a procedure in which the body is penetrated or entered, for instance by a needle or a tube). As bleeding complications in decompensated cirrhosis are associated with a high risk of further decompensation and death, there is an urgent need to understand the factors responsible for such increased bleeding tendency. Herein, we investigated the alterations of hemostasis (that is the physiological process responsible for clot formation and stability) in patients with decompensated cirrhosis and bacterial infections. We found that development of bacterial infections in these patients is associated with alterations of hemostasis (particularly of platelets and clotting cascade) that may increase the risk of both bleeding and thrombotic complications.
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Key Words
- ACLF, acute-on-chronic liver failure
- AKI, acute kidney injury
- AT, antithrombin
- ETP, endogenous thrombin potential
- F, factor
- FXIII, fibrin-stabilizing factor XIII
- MELD, model for end-stage liver disease
- PAI-1, plasminogen activator inhibitor-1
- PAP, plasmin-antiplasmin complex
- PC, protein C
- PS, protein S
- TAFIa/ai, activated and inactivated thrombin-activatable fibrinolytic inhibitor
- TM, thrombomodulin
- VWF, von Willebrand factor
- cirrhosis
- coagulation
- fibrinolysis
- infections
- platelets
- t-PA, tissue-type plasminogen activator
- α2-AP, α2-antiplasmin
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Elena Campello
- General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Cristiana Bulato
- General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Sabrina Gavasso
- General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Graziella Saggiorato
- General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Sarah Shalaby
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Paolo Simioni
- General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, Padova, Italy
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Gervaso L, Dave H, Khorana AA. Venous and Arterial Thromboembolism in Patients With Cancer: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2021; 3:173-190. [PMID: 34396323 PMCID: PMC8352228 DOI: 10.1016/j.jaccao.2021.03.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 12/20/2022] Open
Abstract
Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, represents a major cause of morbidity and mortality in patients with cancer. Arterial thromboembolism, including myocardial infarction and stroke, is also prevalent. Risk differs in subgroups, with higher rates observed in specific cancers including pancreas, stomach, and multiple myeloma. Thromboprophylaxis is recommended for most patients with active cancer hospitalized for medical illnesses and after major cancer surgery. Outpatient thromboprophylaxis is not routinely recommended, but emerging data suggest that a high-risk population that benefits from pharmacological thromboprophylaxis can be identified using a validated risk tool. Direct oral anticoagulants are emerging as the preferred new option for the treatment of cancer-associated VTE, although low-molecular-weight heparin remains a standard for patients at high bleeding risk. Management of VTE beyond the first 6 months and challenging clinical situations including intracranial metastases and thrombocytopenia require careful management in balancing the benefits and risks of anticoagulation and remain major knowledge gaps in evidence.
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Key Words
- ASCO, American Society of Clinical Oncology
- ASH, American Society of Hematology
- AT, antithrombin
- ATE, arterial thromboembolism
- CAT, cancer-associated thrombosis
- CI, confidence interval
- CRNMB, clinically relevant nonmajor bleeding
- CVA, cerebrovascular event
- DOAC, direct oral anticoagulant
- DVT, deep venous thrombosis
- ESMO, European Society of Medical Oncology
- GI, gastrointestinal
- HR, hazard ratio
- ICH, intracranial hemorrhage
- ISTH, International Society on Thrombosis and Haemostasis
- KS, Khorana score
- LMWH, low-molecular-weight heparin
- MI, myocardial infarction
- MM, multiple myeloma
- NNT, number needed to treat
- PE, pulmonary embolism
- PPV, positive predictive value
- RAM, risk assessment model
- SPE, segmental pulmonary embolism
- SSC, Scientific and Standardization Committee
- SSPE, subsegmental pulmonary embolism
- UHF, unfractionated heparin
- VKA, vitamin K antagonist
- VTE, venous thromboembolism
- VVT, visceral vein thrombosis
- arterial thromboembolism
- cancer-associated thrombosis
- prophylaxis
- risk assessment models
- treatment
- venous thromboembolism
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Affiliation(s)
- Lorenzo Gervaso
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, Istituto Europeo di Oncologia, European Institute of Oncology, Milan, Italy
- Molecular Medicine Department, University of Pavia, Pavia, Italy
| | - Heloni Dave
- Maharaja Sayajirao University, Medical College, Vadodara, Gujarat, India
| | - Alok A. Khorana
- Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland, Ohio, USA
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Komori M, Hayata E, Nakata M, Yuzawa H, Oji A, Morita M. Apixaban therapy in a pregnant woman with heparin-induced thrombocytopenia and venous thromboembolic events caused by congenital antithrombin deficiency: A case report. Case Rep Womens Health 2020; 27:e00200. [PMID: 32300539 PMCID: PMC7152699 DOI: 10.1016/j.crwh.2020.e00200] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 03/29/2020] [Accepted: 04/02/2020] [Indexed: 11/30/2022] Open
Abstract
We report the case of a 35-year-old pregnant woman (gravida 3, para 1) with antithrombin deficiency who was successfully treated with apixaban. She had a history of heparin-induced thrombocytopenia and venous thromboembolic events. Pregnancy was confirmed while the patient was having anticoagulant therapy for a persistent thrombus. Choice of anticoagulation during her pregnancy was limited because of her antithrombin deficiency: heparin was not an option because of her history of heparin-induced thrombocytopenia; antithrombin-dependent anticoagulant drugs were not an option because of her antithrombin deficiency, and she preferred outpatient management. Despite the fact that there are no reports of its use in pregnant women, we selected apixaban (10 mg/day), a direct Xa inhibitor, as the best solution. No progression of thrombus was noted during the pregnancy. The newborn baby had no external congenital anomalies, intracranial hemorrhage, or bleeding tendency. Thus, apixaban may be a candidate for anticoagulant therapy in pregnant women with a history of venous thromboembolic events and heparin-induced thrombocytopenia. Pregnant women are at higher risk for venous thromboembolism than women who are not pregnant. Anticoagulant therapy is limited for a pregnant woman with heparin-induced thrombocytopenia caused by congenital antithrombin deficiency. Apixaban may be an alternative option of anticoagulant therapy during pregnancy.
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Affiliation(s)
- Mayuko Komori
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Japan
| | - Eijiro Hayata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Japan
| | - Hitomi Yuzawa
- Department of Cardiology, Toho University Omori Medical Center, Japan
| | - Ayako Oji
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Japan
| | - Mineto Morita
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Japan
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