Heparin-induced thrombocytopenia – current options of laboratory diagnostics in the Czech Republic

Czech version

Authors: P. Sadílek; I. Fátorová; P. Ďulíček
Authors‘ workplace: IV. interní hematologická klinika FN Hradec Králové
Published in: Transfuze Hematol. dnes,28, 2022, No. 3, p. 152-162.
Category: Review/Educational Papers
doi: https://doi.org/10.48095/cctahd2022prolekare.cz11

Overview

Heparin-induced thrombocytopenia (HIT) is a serious complication of heparin treatment. It is caused by IgG class antibodies directed against the platelet factor 4 (PF4) /heparin complex with subsequent strong platelet activation. Despite anticoagulant therapy and thrombocytopenia, there is a high risk of venous and arterial thrombosis. Diagnosis of HIT requires both evidence of clinical symptoms and laboratory confirmation of pathogenic antibodies. We divide laboratory tests for the diagnosis of HIT into two groups, immunological and functional. Immunological (antigenic) tests are used to detect antibodies directed against the PF4/heparin complex. Functional assays are based on the ability of antibodies to activate donor platelets in the presence of heparin. The aim of this article is to present a brief overview of laboratory tests for the diagnosis of HIT available in the Czech Republic.

Keywords:

Immunoassays – Functional tests – heparin-induced thrombocytopenia (HIT) – laboratory diagnostics of HIT

Sources

1. Greinacher A, Juhl D, Strobel U, et al. Heparin-induced thrombocytopenia: a prospective study on the incidence, platelet-activating capacity and clinical signifikance of antiplatelet factor 4/heparin antibodies of the IgG, IgM and IgA classes. J Thromb Haemost. 2007; 5: 1666–1673.

2. Warkentin TE. Heparin-induced thrombocytopenia: A clinicopathologic syndrome. Thromb Haemost. 1999; 82: 439–447.

3. Amiral J, Bridey F, Dreyfus M, et al. Platelet factor 4 complexed to heparin is the target for antibodies generated in heparin-induced thrombocytopenia. Thromb Haemost. 1992; 68: 95–96.

4. Greinacher A, Potzsch B, Amiral J, Dummel V, Eichner A, Mueller-Eckhardt C. Heparin-associated thrombocytopenia: isolation of the antibody and characterization of a multimolecular PF4-heparin complex as the major antigen. Thromb Haemost. 1994; 71: 247–251.

5. Rauova L, Zhai L, Kowalska MA, Gowthami MA, Douglas BC, Mortimer P. Role of platelet surface PF4 antigenic complexes in heparin-induced thrombocytopenia pathogenesis: diagnostic and therapeutic implications. Blood. 2006; 107: 2346–2353.

6. Warkentin TE. Heparin-induced thrombocytopenia: IgG-mediated platelet activation, platelet microparticle generation, and altered procoagulant /anticoagulant balance in the pathogenesis of thrombosis and venous limb gangrene complicating heparin-induced thrombocytopenia. Transfus Med Rev. 1996; 10: 249–258.

7. Lo GK, Sigouin CS, Warkentin TE. What is the potential for overdiagnosis of heparin-induced thrombocytopenia? Am J Hematol. 2007; 82: 1037–1043.

8. Warkentin TE. Clinical picture of heparin-induced thrombocytopenia (HIT) and its differentiation from non-HIT thrombocytopenia. Thromb Haemost. 2016; 116 (5): 813–822.

9. Greinacher A, Farner B, Kroll H, Kohlmann T, Warkentin TE, Eichler P. Clinical features of heparin-induced thrombocytopenia including risk factor for thrombosis. Thromb Haemost. 2005; 94: 132–135.

10. Lo GK, Juhl D, Warkentin TE, Sigouin CS, Eichler P, Greinacher A. Evaluation of pretest clinical score (4 T’s) for the diagnosis of heparin-induced thrombocytopenia in two clinical settings. J Thromb Haemost. 2006; 4: 759–765.

11. Greinacher A. Heparin-induced thrombocytopenia. J Thromb Haemost. 2009; 7 (1): 9–12.

12. Pouplard C, Gueret P, Fouassier M, et al. Prospective evaluation of the ‚4Ts‘ score and particle gel immunoassay specific to heparin/PF4 for the diagnosis of heparin-induced thrombocytopenia. J Thromb Haemost. 2007; 5: 1373–1379.

13. Warkentin TE, Kelton JG. Temporal aspects of heparin-induced thrombocytopenia. N Engl J Med. 2001; 344: 1286–1292.

14. Warkentin TE. Laboratory diagnosis of heparin-induced thrombocytopenia. Int J Lab Hematol. 2019; 41 (1): 15–25.

15. 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 (5): 1044–1055.

16. Warkentin TE, Sheppard JI, Raschke R, Greinacher A. Performance characteristics of a rapid assay for anti-PF4/heparin antibodies, the Particle Immuno Filtration Assay. J Thromb Haemost. 2007; 5 (11): 2308‐2310.

17. Sachs UJ, von Hesberg J, Santoso S, Bein G, Bakchoul T. Evaluation of a new nanoparticle-based lateral-flow immunoassay for the exclusion of heparin-induced thrombocytopenia (HIT). Thromb Haemost. 2011; 106: 1197–1202.

18. https: //www.labmate-online.com/news/laboratory-products/3/stago-uk-ltd/launch-of-rapid-hit-exclusion-test-in-the-uk/20306 (staženo 20.3.2022)

19. Nagler M, Bachmann LM, ten Cate H, ten Cate-Hoek A. Diagnostic value of immunoassays for heparin-induced thrombocytopenia: a systematic review and meta-analysis. Blood. 2016; 127 (5): 546–557.

20. Eichler P, Raschke R, Lubenow N, Meyer O, Schwind P, Greinacher A. The new ID-heparin/PF4 antibody test for rapid detection of heparin-induced antibodies in comparison with functional and antigenic assays. Br J Haematol. 2002; 116: 887–891.

21. Meyer O, Salama A, Pittet N, Schwind P. Rapid detection of heparin-induced platelet antibodies with particle gel immunoassay (ID-HPF4). Lancet. 1999; 354: 1525–1526.

22. Schneiter S, Colucci G, Sulze I, Barizzi G, Lammle B, Alberio L. Variability of anti-PF4/heparin antibody results obtained by the rapid testing system ID-H/PF4-PaGIA. J Thromb Haemost. 2009; 7: 1649–1655.

23. Alhaliq AR, Joshua D, Kershaw G, Dunkley S. The Diamed assay has a poor positive predictive value for HIT in a tertiary hospital referral setting. Int J Lab Hematol. 2007; 29 (1): 69–70.

24. Warkentin TE, Sheppard JI. Testing for heparin-induced thrombocytopenia antibodies. Transfus Med Rev. 2006; 20 (4): 259–272.

25. Vissac AM, Catala M, Amiral J. Incidence of the various heparin dependent antibody isotypes in a group of patients with heparin induced thrombocytopenia. J Thromb Haemost. 2007; 5 Suppl: P-T-318.

26. Zwicker JI, Uhl L, Huang WY, Shaz BH, Bauer KA. Thrombosis and ELISA optical density values in hospitalized patients with heparin-induced thrombocytopenia. J Thromb Haemost. 2004; 2: 2133–2137.

27. Warkentin TE, Sheppard JI, Moore JC, Kelton JG. The use of well-characterized sera for the assessment of new diagnostic enzyme-immunoassay for the diagnosis of heparin-induced thrombocytopenia. J Thromb Haemost. 2010; 8: 216–218.

28. Warkentin TE, Sheppard JI, Moore JC, Moore KM, Sigouin CS, Kelton JG. Laboratory testing for the antibodies that cause heparin-induced thrombocytopenia: how much class do we need? J Lab Clin Med. 2005; 146 (6): 341–346.

29. Bakchoul T, Giptner A, Najaoui A, Bein G, Santoso S, Sachs UJH. Prospective evaluation of immunoassay for the diagnosis of heparin-induced thrombocytopenia. J Thromb Haemost. 2009; 7: 1260–1265.

30. Whitlatch NL, Perry SL, Ortel TL. Anti-heparin/platelet factor 4 antibody optical density values and the confirmatory procedure in the diagnosis of heparin-induced thrombocytopenia. Thromb Haemost. 2008; 100: 678–684.

31. Whitlatch NL, Kong DF, Metjian AD, Arepally GM, Ortel TL. Validation of the high-dose heparin confirmatory step for the diagnosis of heparin-induced thrombocytopenia. Blood. 2010; 116: 1761–1766.

32. Warkentin TE, Sheppard JI. No significant improvement in diagnostic specificity of an anti-PF4/polyanion immunoassay with use of high heparin confirmatory procedure. J Thromb Haemost. 2006; 4: 281–282.

33. Greinacher A, Ittermann T, Bagemuhl J, et al. Heparin-induced thrombocytopenia: towards standardization of platelet factor 4/heparin antigen tests. J Thromb Haemost. 2010; 8: 2025–2031.

34. Altuntas F, Matevosyan K, Burner J, Shen YM, Sarode R. Higher optical density of an antigen assay predicts thrombosis in patients with heparin-induced thrombocytopenia. Eur J Haematol. 2008; 80: 429–435.

35. Baroletti S, Hurwitz S, Conti NA, Fanikos J, Piazza G, Goldhaber SZ. Thrombosis in suspected heparin-induced thrombocytopenia occurs more often with high antibody levels. Am J Med. 2012; 125: 44–49.

36. Husseinzadeh HD, Gimotty PA, Pishko AM, Buckley M, Warkentin TE, Cuker A. Diagnostic accuracy of IgG-specific versus polyspecific enzyme-linked immunoassays in heparin-induced thrombocytopenia: a systematic review and meta-analysis. J Thromb Haemost. 2017; 15 (6): 1203–1212.

37. Warkentin TE, Sheppard JI, 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.

38. Warkentin TE, Greinacher A. Laboratory testing for heparin-induced thrombocytopenia. In: Warkentin TE, Greinacher A, eds. Heparin‐induced thrombocytopenia. 5th edn. Boca Raton, Florida, CRC Press, 2013; 272–314.

39. Warkentin TE, Sheppard JI, Linkins LA, Arnold DM, Nazy I. High sensitivity and specificity of an automated IgG-specific chemiluminescence immunoassay for diagnosis of HIT. Blood. 2018; 132 (12): 1345–1349.

40. Chong BH, Burgess J, Ismail F. The clinical usefulness of the platelet aggregation test for the diagnosis of heparin-induced thrombocytopenia. Thromb Haemost. 1993; 69: 344–350.

41. Galea V, Khaterchi A, Robert F, Gerotziafas G, Hatmi M, Elalamy I. Heparin-induced multiple electrode aggregometry is a promising and useful functional tool for heparin-induced thrombocytopenia diagnosis: confirmation in a prospective study. Platelets. 2013; 24 (6): 441–447.

42. Favaloro EJ, McCaughan G, Mohammed S, et al. HIT or miss? A comprehensive contemporary investigation of laboratory tests for heparin-induced thrombocytopenia. Pathology. 2018; 50 (4): 426–436.

43. Elalamy I, Galea V, Hatmi M, Gerotziafas GT. Heparin-induced multiple electrode aggregometry: a potential tool for improvement of heparin-induced thrombocytopenia diagnosis. J Thromb Haemost. 2009; 7: 1932–1934.

44. Jin J, Baker SA, Hall ET, Gombar S, Bao A, Zehnder JL. Implementation of whole-blood impedance aggregometry for heparin-induced thrombocytopenia functional assay and case discussion. Am J Clin Pathol. 2019; 152: 50–58.

45. Padmanabhan A, Jones CG, Curtis BR, et al. A novel PF4-dependent platelet activation assay identifies patients likely to have heparin-induced thrombocytopenia/thrombosis. Chest. 2016; 150 (3): 506–515.

46. Solano C, Mutsando H, Self M, Morel-Kopp MC, Mollee P. Using HitAlert flow cytometry to detect heparin-induced thrombocytopenia antibodies in a tertiary care hospital. Blood Coagul Fibrinolysis. 2013; 24 (4): 365–370.

47. Eichler P, Budde U, Haas S, et al. First workshop for detection of heparin-induced antibodies: validation of the heparin-induced platelet-activation test (HIPA) in comparison with a PF4/heparin ELISA. Thromb Haemost. 1999; 81: 625–629.

48. Tardy B, Lecompte T, Mullier F, Vayne C, Pouplard C. Detection of platelet-activating antibodies associated with heparin-induced thrombocytopenia. J Clin Med. 2020; 9 (4): 1226.

49. Greinacher A, Michels I, Kiefel V, Mueller-Eckhardt C. A rapid and sensitive test for diagnosis heparin-associated thrombocytopenia. Thromb Haemost. 1991; 66: 734–736.

50. Warkentin TE, Hayward CP, Smith CA, Kelly PM, Kelton JG. Determinants of donor platelet variability when testing for heparin-induced thrombocytopenia. J Lab Clin Med. 1992; 120: 371–379.

51. Sheridan D, Carter C, Kelton JG. A diagnostic test for heparin-induced thrombocytopenia. Blood. 1986; 67: 27–30.

52. Warkentin TE, Arnold DM, Nazi I, Kelton JG. The platelet serotonin-release assay. Am J Hematol. 2015; 90 (6): 564–572.

53. Moore JC, Arnold DM, Warkentin TE, Warkentin AE, Kelton JG. An algorithm for resolving indeterminate test results in the platelet serotonin release assay for investigation of heparin-induced thrombocytopenia. J Thromb Haemost. 2008; 6: 1595–1597.

54. Fouassier M, Bourgerette E, Libert F, Pouplard C, Marques-Verdier A. Determination of serotonin release from platelets by HPLC and ELISA in the diagnosis of heparin-induced thrombocytopenia: comparison with reference method by [14C]-serotonin release assay. J Thromb Haemost. 2006; 4: 1136–1139.

55. Lee DP, Warkentin TE, Denomme GA, Hayward CPM, Kelton JG. A diagnostic test for heparin-induced thrombocytopenia: detection of platelet microparticles using flow cytometry. Br J Haematol. 1996; 95: 724–731.

56. Gobbi G, Mirandola P, Tazzari PL, et al. Flow cytometry detection of serotonin content and release in resting and activated platelets. Br J Haematol. 2003; 121: 892–896.