Physicochemical Characteristics of Platelet Factor 4 under Various Conditions are Relevant for Heparin-Induced Thrombocytopenia Testing.

Heparin-induced thrombocytopenia (HIT), an adverse drug effect, has gained much attention. Affected patients have a high risk of new thrombotic complications. In addition, HIT is also a model to study mechanisms of immune-mediated disorders. Platelet factor 4 (PF4) is the key protein involved. It is the basis for many diagnostic tests for HIT and is used for in vitro studies and in mouse models on the pathogenesis of HIT. Purified PF4 is known to easily form aggregates, which can cause artifacts in experiments. The impact of storage buffer, storage period, lyophilization, and temperature on the size of PF4 and PF4/heparin (H) complexes was assessed by dynamic light scattering (DLS), while enzyme immunoassay (EIA) was used to test the binding of anti-PF4/H antibodies (aPF4/H Abs) to PF4/H complexes. PF4 size was more stable in Hank's balanced salt solution (HBSS) compared to phosphate-buffered saline (PBS), especially during storage. Lyophilization further facilitated the formation of PF4 aggregates, while incubation of reconstituted lyophilized PF4 in PBS at 37 °C reduced PF4 aggregates. Complexes formed between lyophilized PF4 and heparin were larger, and they enhanced the binding of aPF4/H Abs in EIA compared to complexes between nonlyophilized PF4 and heparin, both in HBSS and PBS, possibly influencing in vitro test results. Our results may be helpful for mechanistic studies on the biological function of PF4 and for the improvement of assays for detecting aPF4/H Abs.

Characterization of the interaction between platelet factor 4 and homogeneous synthetic low molecular weight heparins.

BACKGROUND: Heparins are usually produced from animal tissues. It is now possible to synthesize heparins. This provides the abilities to overcome shortages of heparin, to optimize biological effects, and to reduce adverse drug effects. Heparins interact with platelet factor 4 (PF4), which can induce an immune response causing thrombocytopenia. This side effect is called heparin-induced thrombocytopenia (HIT). We characterized the interaction of PF4 and HIT antibodies with oligosaccharides of 6-, 8-, 10-, and 12-mer size and a hypersulfated 12-mer (S12-mer). METHODS: We utilized multiple methodologies including isothermal calorimetry, circular dichroism spectroscopy, single molecule force spectroscopy (SMFS), enzyme immunosorbent assay (EIA), and platelet aggregation test to characterize the interaction of synthetic heparin analogs with PF4 and anti-PF4/heparin antibodies. RESULTS: The synthetic heparin-like compounds display stronger binding characteristics to PF4 than animal-derived heparins of corresponding lengths. Upon complexation with PF4, 6-mer and S12-mer heparins showed much lower enthalpy, induced less conformational changes in PF4, and interacted with weaker forces than 8-, 10-, and 12-mer heparins. Anti-PF4/heparin antibodies bind more weakly to complexes formed between PF4 and heparins ≤ 8-mer than with complexes formed between PF4 and heparins ≥ 10-mer. Addition of one sulfate group to the 12-mer resulted in a S12-mer, which showed substantial changes in its binding characteristics to PF4. CONCLUSIONS: We provide a template for characterizing interactions of newly developed heparin-based anticoagulant drugs with proteins, especially PF4 and the resulting potential antigenicity.

Comparing the effects of fludioxonil on non-target soil invertebrates using ecotoxicological methods from single-species bioassays to model ecosystems.

The lower tier toxicity tests used for risk assessment of plant protection products are conducted with single species, only regarding direct effects of the tested substances. However, it is not clear, if lower tier tests are able to protect in situ soil communities, as these tests are not able to account for direct and indirect effects of chemicals on multi-species systems in natural soil communities. This knowledge gap between single-species tests and field studies can be bridged using model ecosystems (microcosms), which allow for the assessment of direct and indirect effects of the compounds under evaluation. In the present study, single-species toxicity tests and soil-spiked microcosms were used to comparatively investigate the toxicity of the non-systemic fungicide fludioxonil (FDO) on non-target soil organisms, with nematodes being the test organisms of choice. The potential effects of FDO on nematodes were investigated in two different test systems: (i) standardized toxicity tests using Caenorhabditis elegans exposed to FDO-spiked soil (FDO concentrations 50-1207 mg/kg soil dry weight) and (ii) in situ nematode communities sampled from microcosms containing FDO-spiked soil (FDO concentrations 75-600 mg/kg soil dry weight). FDO dose-dependently inhibited the reproduction of C. elegans, with an effect concentration (EC50) of 209.9 mg FDO/kg soil dry weight and a no observed effect concentration (NOEC) of 63.0 mg FDO/kg soil dry weight. In the microcosms, FDO significantly affected trait-based indices, such as the Maturity Index (MI25) and the Enrichment Index (EI), which responded already at FDO concentrations of 14.3 and 62.4 mg/kg dry soil. Overall, this study provides new insights into the impact of the non-systemic fungicide FDO on non-target soil organisms and demonstrates the suitability of nematode-based tools, that allow for a quick and cost-effective lower and higher tier risk assessment of plant protection products.

Reactivity of platelet-activating and nonplatelet-activating anti-PF4/heparin antibodies in enzyme immunosorbent assays under different conditions.

Essentials At low pH and low salt concentrations: Maximal conformational change of PF4 upon complexation with heparin occurs. Changing physicochemical conditions may become an approach to better discriminate the signal of platelet-activating- and nonactivating PF4/H Abs in antigen tests. BACKGROUND: Enzyme immunosorbent assays (EIA) are widely used to detect human antiplatelet factor 4/heparin antibodies (aPF4/H Abs) to rule out heparin-induced thrombocytopenia. EIAs cannot differentiate between clinically relevant, platelet-activating, and nonrelevant, nonplatelet-activating Abs and only ~50% of patients' sera testing positive by EIA contain antibodies that activate platelets. Recently, we have shown platelet-activating aPF4/H Abs bind more strongly to PF4/H complexes than nonplatelet-activating antibodies. Antigen-antibody interactions are known to depend on electrostatic interactions governed by pH, heat, and ionic strength. We tested whether changes in pH and ionic strength can improve the specificity of EIAs detecting aPF4/H Abs. METHODS: We investigated first the conformational change of PF4 when binding to heparin under various pH and salt conditions using circular dichroism spectroscopy, and then the binding of aPF4/H Abs to PF4/H complexes by EIA. RESULTS: Maximal conformational change of PF4 on complexation with heparin was identified at low pH and low salt concentrations. EIA tested with a large number of sera at 50 mmol/L NaCl, pH 6.0 shows a potential to increase the specificity for the detection of platelet-activating aPF4/H Abs. CONCLUSION: Changing physicochemical conditions may become an approach to better discriminate the signal of platelet-activating and nonactivating PF4/H Abs in antigen tests.

Prevalence and clinical implications of anti-PF4/heparin antibodies in intensive care patients: a prospective observational study.

Data on the frequency of anti-platelet factor 4/heparin (PF4/H) antibodies and their association with outcomes in intensive care unit (ICU) patients are sparse. In this prospective, observational study we screened 320 consecutive surgical/medical ICU patients for anti-PF4/H antibodies by enzyme-immunoassay (EIA) for immunoglobulin (Ig)G/A/M separately and heparin-induced platelet activation assay (HIPA) at ICU admission (=baseline), day 6, and day 10. HIPA-positive patients were additionally tested by serotonin-release assay (SRA). Patients tested positive by day 10: for anti-PF4/H-IgG = 17.2 % and for anti-PF4/H-IgM = 42.1 %. Within the first 10 ICU days, platelet counts decreased to <100 Gpt/L in 27.8 % patients. However, only seven patients (2.2 %) experienced a drop in the platelet count ≥50 % beginning after the fourth ICU day. These included the only two patients (0.6 %; 95 % confidence interval 0.08-2.2 %) with heparin-induced thrombocytopenia (HIT). Only strong reactions in the HIPA were reproducible by SRA. This study confirms that testing for anti-PF4/H IgG antibodies should be restricted to ICU-patients who develop a platelet count decrease of >50 % that begins after day four of heparin treatment (which may have started before ICU admission). Among patients testing positive by IgG-specific EIA a functional platelet activation assay should be performed (regarding only strong reactions as positive).

Immune heparin-induced thrombocytopenia can occur in patients receiving clopidogrel and aspirin.

Platelet adenosine diphosphate (ADP) receptors may play a role in potentiating platelet activation induced by IgG from patients with immune heparin-induced thrombocytopenia (HIT), as shown by previous studies using the ADP receptor antagonists AR-C66096 and ticlopidine. Consistent with these observations, we found that platelet activation by HIT sera is also significantly reduced in patients receiving clopidogrel, an ADP receptor antagonist prodrug now in wide clinical use. Despite these in vitro and ex vivo findings, we observed two patients develop acute HIT while receiving both clopidogrel and aspirin: both patients' sera tested strongly positive in a heparin-dependent washed platelet activation assay (100% serotonin release) and PF4/heparin-enzyme-immunoassay (2.594 and 2.190 absorbance units). Both patients also developed HIT-associated clinical sequelae (acute systemic reaction postintravenous heparin bolus; thrombotic stroke) in association with their episode of HIT. We conclude that combined therapy with aspirin and clopidogrel does not necessarily protect against clinical HIT, at least in patients with HIT antibodies that have strong platelet-activating characteristics.

Heparin-induced thrombocytopenia in children: 12 new cases and review of the literature.

Immune-mediated heparin-induced thrombocytopenia (HIT) is a rare but severe adverse effect of heparin therapy. Only few data are available on clinical presentation, diagnosis and management of HIT in children. Records of all patients sent to our laboratory between 1995 and November 2003 were reviewed. To identify literature reports a Medline search was performed, the reference lists of those publications were screened and the abstracts of meetings on thrombosis and hemostasis between 2000 and 2003 were assessed. We identified 12 new HIT patients between 13 months and 18 years of age from our laboratory and 71 reports on HIT in children in the literature. For the assessment of frequency of HIT all studies enrolling > 100 patients were analyzed. HIT is rare in children. In pediatric patients, there seem to be two risk groups: newborns and infants under 4 years of age undergoing cardiac surgery (incidence approximately 1-2%), and teenagers treated with heparin for thrombosis. For confirmation of HIT in children, antigen assays are most important. There are conflicting data on the optimal cut-off, with one randomized, double-blind trial indicating that the cut-off established in adults is appropriate. There are no systematic studies on alternative anticoagulants in children affected by HIT. Most data are available for lepirudin and danaparoid. Substitution of unfractionated heparin by low-molecular-weight heparins for regular anticoagulation may reduce the incidence of HIT.

The new ID-heparin/PF4 antibody test for rapid detection of heparin-induced antibodies in comparison with functional and antigenic assays.

Heparin-induced thrombocytopenia (HIT) is an immune-mediated complication of heparin treatment. Several in vitro assays are available to detect the causative HIT antibodies: functional assays, usually requiring freshly prepared platelets and immunological tests based on the enzyme-linked immunosorbent assay (ELISA) principle. We compared a new, simple and rapid test based on the ID-microtyping particle agglutination system with 14C-serotonin release assay, heparin-induced platelet activation (HIPA) test and two ELISAs. Sera from 100 confirmed HIT patients, 20 serologically negative suspected HIT patients and 20 healthy blood donors were used. The specificity and sensitivity of the new test was similar to the functional assays. Compared with the ELISAs, specificity was better at the cost of reduced sensitivity. As in all other immunological tests, HIT antibodies against less typical antigens, such as interleukin (IL)-8 or neutrophil-activating peptide (NAP) 2 could not be detected. Thus, although the ID-Heparin/PF4 antibody test seems to be a quick, reliable and robust test to determine the presence of HIT antibodies, it should still be combined with a functional assay if possible. Evaluation of the test in a prospective setting as well as interlaboratory variation should be assessed as a next step.