Download PDF
Thromb Haemost 1999; 82(02): 448-456
DOI: 10.1055/s-0037-1615865
Research Article
Schattauer GmbH

Heparin-Induced Thrombocytopenia: Molecular Pathogenesis

Gian Paolo Visentin
1   Blood Research Institute, The Blood Center of Southeastern Wisconsin, Inc., Milwaukee, Wisconsin, USA
› Author Affiliations
Further Information

Publication History

Publication Date:
09 December 2017 (online)

    Permissions and Reprints

Introduction

Heparin-induced thrombocytopenia (HIT), a relatively common complication of heparin therapy, is characterized by an unexpected fall in platelet count occurring 5 days or more after the initiation of treatment.1,2 Patients who manifest only the thrombocytopenia rarely experience severe bleeding or other major adverse effects.3 Often, however, the thrombocytopenia is accompanied by arterial and/or venous thrombosis and thromboembolism, a complication which can be devastating.4 HIT, with or without thrombosis, is probably the most common cause of immunologically-mediated, drug-induced thrombocytopenia. HIT usually occurs in patients given standard therapeutic doses of heparin, especially of bovine origin.5 However, it has been reported following low-dose, subcutaneous heparin6 and in patients exposed to heparin “flushes” used to maintain the patency of intravenous lines.7 Even minute quantities of heparin released from heparin-bonded catheters appear to be capable of causing the disorder in previously sensitized patients.8 HIT has been induced by low molecular weight heparin (LMWH)9,10 and other heparin-like polysaccharides.11,12

HIT differs from most other forms of drug-induced immune thrombocytopenia in that the responsible antibodies activate platelets in the presence of pharmacologic doses of heparin (0.1-1 U/ml), rather than merely binding to platelets to promote their destruction in the reticuloendothelial system.3,13,14 The observation that heparin-induced platelet activation can be blocked in vitro by monoclonal antibodies specific for the platelet Fc receptor (FcγRIIA)15 suggests that antibodies associated with HIT somehow interact with heparin to form platelet-activating immune complexes. Attempts to demonstrate such complexes and their binding to intact platelets, however, have generally yielded negative or equivocal results.14,16,17 The association of HIT with thrombosis and disseminated intravascular coagulation (DIC) suggests that heparin-induced antibodies might react with endothelial cells (EC). Binding of IgG from the serum of patients with HIT to cultured human umbilical vein endothelial cells (HUVEC) observed in one study,18 but not confirmed in another,19 left open the question of whether immune-mediated vascular damage is important in pathogenesis.

In 1992, Amiral and coworkers obtained evidence that antibodies associated with HIT are specific for complexes of heparin and platelet factor 4 (PF4), a heparin-binding protein stored in platelet α granules.20 These findings were subsequently confirmed by several groups, including ours.21-23 We also provided the first direct evidence that HIT antibodies bind to HUVEC in the presence of PF4, but not in its absence, thus, suggesting that the antibodies also recognize PF4 complexed with the heparan sulfate molecules displayed on HUVEC.21 Furthermore, Greinacher et al22 showed, by adsorption/elution of total IgG derived from HIT patients on PF4-coated EC, that the eluted antibodies also caused heparin-dependent platelet activation, thus, indicating that they recognize epitope(s) present on both PF4-heparin and PF4-heparan complexes.

 

  • References

  • 1 Deykin D. Current status of anticoagulant therapy. Am J Med 1982; 72: 661.
    PubMedGoogle Scholar
  • 2 Warkentin TE, Kelton JG. Interaction of heparin with platelets, including heparin-induced thrombocytopenia. In: Low-Molecular-Weight-Heparins In Prophylaxis and Therapy of Thromboembolic Diseases. Bounameaux H. ed. New York: Marcel Dekker, Inc.; 1994: 75-127.
    Google Scholar
  • 3 Edson JR. Heparin-induced thrombocytopenia. J Lab Clin Med 1992; 120: 355-356.
    PubMedGoogle Scholar
  • 4 Weismann RE, Tobin RW. Arterial embolism occurring during systemic heparin therapy. Arch Surg 1958; 76: 219-227.
    CrossrefPubMedGoogle Scholar
  • 5 Lee DH, Warkentin TE. Frequency of heparin-induced thrombocytopenia. In: Heparin-Induced Thrombocytopenia. Warkentin TE, Greinacher A. eds. New York: Marcel Dekker, Inc.; In press.
    Google Scholar
  • 6 Husheksky WJ. Subcutaneous heparin-induced thrombocytopenia. Arch Intern Med 1978; 138: 1489-1491.
    CrossrefPubMedGoogle Scholar
  • 7 Heeger PS, Backstrom JR. Heparin flushes and thrombocytopenia. Ann Intern Med 1986; 105: 143.
    PubMedGoogle Scholar
  • 8 Laster JL, Nichols WK, Silver D. Thrombocytopenia associated with heparin-coated catheters in patients with heparin-associated antiplatelet antibodies. Arch Intern Med 1989; 149: 2285-2287.
    CrossrefPubMedGoogle Scholar
  • 9 Lecompte T. Thrombocytopenia associated with low-molecular-weight heparin (letter). Lancet 1991; 338: 1217.
    PubMedGoogle Scholar
  • 10 Tardy B. Thrombocytopenia associated with low-molecular-weight heparin (letter). Lancet 1991; 338: 1217.
    PubMedGoogle Scholar
  • 11 Tardy-Poncet B, Tardy B, Grelac F, Reynaud J, Mismetti P, Bertrand JC, Guyotat D. Pentosan polysulfate-induced thrombocytopenia and thrombosis. [Review]. Am J Haematol 1994; 45: 252-257.
    CrossrefPubMedGoogle Scholar
  • 12 Magnani HN. Heparin-induced thrombocytopenia (HITP): an overview of 230 patients treated with Orgaran (Org 10172). Thromb Haemost 1993; 70: 554-561.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Chong BH, Pitney WR, Castaldi PA. Heparin-induced thrombocytopenia: association of thrombotic complications with heparin-dependent IgG synthesis that induces thromboxane synthesis and platelet aggregation. Lancet 1982; 2: 1246-1248.
    PubMedGoogle Scholar
  • 14 Warkentin TE, Kelton JG. Heparin-induced thrombocytopenia. Prog Hemost Thromb 1991; 10: 1-34.
    PubMedGoogle Scholar
  • 15 Kelton JG, Sheridan D, Santos A, Smith J, Steeves K, Smith C, Brown C, Murphy WG. Heparin-induced thrombocytopenia: laboratory studies. Blood 1988; 72: 925-930.
    PubMedGoogle Scholar
  • 16 Greinacher A, Michels I, Mueller-Eckert C. Heparin-associated thrombocytopenia: the antibody is not heparin specific. Thromb Haemost 1992; 67: 545-549.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Green D, Harris K, Reynolds N, Roberts M, Patterson R. Heparin immune thrombocytopenia: evidence for heparin-platelet complex as the antigenic determinate. J Lab Clin Med 1978; 91: 167-175.
    PubMedGoogle Scholar
  • 18 Cines DB, Tomaski A, Tannenbaum S. Immune endothelial cell injury in heparin-associated thrombocytopenia. N Engl J Med 1987; 316: 581-589.
    CrossrefPubMedGoogle Scholar
  • 19 Foresti V, Guareschi G, Pediconi A, Scolari N, Vismara A, Confalonieri F. Platelet aggregating IgG without antibodies to endothelial cells in a case of heparin-induced thrombocytopenia with thrombotic complication. Hematologica 1988; 73: 125-127.
    PubMedGoogle Scholar
  • 20 Amiral J, Bridey Dreyfus M, Vissac AM, Fressinaud E, Wolf M, Meyer D. Platelet factor 4 complexed to heparin is the target for antibodies generated in heparin-induced thrombocytopenia (letter). Thromb Haemost 1992; 68: 95-96.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Visentin GP, Ford SE, Scott PJ, Aster RH. Antibodies from patients with heparin-induced thrombocytopenia/thrombosis are specific for platelet factor 4 complexed with heparin or bound to endothelial cells. J Clin Invest 1994; 93: 81-88.
    CrossrefPubMedGoogle Scholar
  • 22 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.
    PubMedGoogle Scholar
  • 23 Kelton JG, Smith JW, Warkentin TE, Hayward CPM, Denomme GA, Horsewood P. Immunoglobulin G from patients with heparin-induced thrombocytopenia binds to a complex of heparin and Platelet factor 4. Blood 1994; 83: 3232-3239.
    PubMedGoogle Scholar
  • 24 Visentin GP, Malik M, Cyganiak KA, Aster RH. Patients treated with unfractionated heparin during open heart surgery are at high risk to form antibodies reactive with heparin: platelet factor 4 complexes. J Lab Clin Med 1996; 128: 376-383.
    CrossrefPubMedGoogle Scholar
  • 25 Suh JS, Malik MI, Aster RH, Visentin GP. Characterization of the humoral immune response in heparin-induced thrombocytopenia. Am J Hematol 1997; 54: 196-201.
    CrossrefPubMedGoogle Scholar
  • 26 Amiral J, Bridey F, Wolf M. Antibodies to macromolecular platelet factor 4 heparin complexes in heparin-induced thrombocytopenia: a study of 44 cases. Thromb Haemost 1995; 73: 21-28.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 27 Arepally G, Reynolds C, Tomaski A, Amiral J, Jawad A, Poncz M, Cines DB. Comparison of PF4-heparin ELISA assay with the 14C-Serotonin release assay in the diagnosis of heparin-induced thrombocytopenia. Am J Clin Pathol 1995; 104: 648-654.
    CrossrefPubMedGoogle Scholar
  • 28 Luster AD. Chemokines: chemotactic cytokines that mediate inflammation. [Review]. N Engl J Med 1998; 338: 436-445.
    CrossrefPubMedGoogle Scholar
  • 29 Poncz M, Surrey S, LaRocco P, Weiss MJ, Rappaport EF, Conway TM, Schwartz E. Cloning and characterization of platelet factor 4 cDNA derived from a human erythroleukemic cell line. Blood 1987; 69: 219-223.
    PubMedGoogle Scholar
  • 30 Zhang X, Chen L, Bancroft DP, Lai CK, Maione TE. Crystal Structure of Recombinant Human Platelet Factor 4. Biochemistry 1994; 33: 8361-366.
    CrossrefPubMedGoogle Scholar
  • 31 Loscalzo J, Melnick B, Handin RI. The interaction of platelet factor 4 and glycosaminoglycans. Arch Biochem Biophys 1985; 240: 446-455.
    CrossrefPubMedGoogle Scholar
  • 32 Maccarana M, Linbahl U. Mode of interaction between platelet factor 4 and heparin. Glycobiology 1993; 3: 271-277.
    CrossrefPubMedGoogle Scholar
  • 33 Mayo KH, Ilyina E, Roongta V, Dundas M, Joseph J, Lai CK, Maione T, Daly TJ. Heparin binding to platelet factor-4. An NMR and site-directed mutagenesis study: arginine residues are crucial for binding. Biochem J 1995; 312: 357-365.
    CrossrefPubMedGoogle Scholar
  • 34 Höök M, Kjellén L, Johansson S, Robinson J. Cell surface gly cosaminoglycans. Annu Rev Biochem 1984; 53: 847-856.
    CrossrefPubMedGoogle Scholar
  • 35 Greinacher A, Alban S, Dummel V, Franz G, Mueller-Eckhardt C. Characterization of the structural requirements for a carbohydrate based anticoagulant with a reduced risk of inducing the immunological type of heparin-associated thrombocytopenia. Thromb Haemost 1995; 74: 886-892.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 36 Visentin GP, Moghaddam M, Aster RH. Antibodies associated with heparin-induced thrombo-cytopenia/thrombosis (HITP) recognize sites on platelet factor 4 (PF4) induced by the binding of linear polyanionic compounds (abstract). Thromb Haemost 1997; (Suppl.): 362.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 37 Horsewood P, Warkentin TE, Hayward CPM, Kelton JG. The epitope specificity of heparin-induced thrombocytopenia. Br J Haematology 1996; 95: 161-167.
    CrossrefPubMedGoogle Scholar
  • 38 Suh JS, Aster RH, Visentin GP. Antibodies from patients with heparin-induced thrombocytopenia/thrombosis (HITT) recognize diverse epitopes on heparin: PF4 complexes. Blood 1998; 91: 916-22.
    CrossrefPubMedGoogle Scholar
  • 39 St Charles R, Walz DA, Edwards BFP. The 3-dimensional structure of bovine platelet factor 4 at 3.0 A resolution. J Biol Chem 1989; 264: 2092-2099.
    PubMedGoogle Scholar
  • 40 Mayo KH, Roongta V, Ilyina E, Milius R, Barker S, Quinlan C, La Rosa G, Daly TJ. NMR solution structure of the 32-kDa platelet factor 4 ELR-motif N-terminal chimera: a symmetric tetramer. Biochemistry 1995; 34: 11399-11409.
    CrossrefPubMedGoogle Scholar
  • 41 Stuckey JA, St Charles R, Edwards DFP. A model of the platelet factor 4 complex with heparin. Proteins 1992; 14: 277-287.
    CrossrefPubMedGoogle Scholar
  • 42 Talpas CJ, Walz DA, Lee L. H-NMR studies of bovine platelet factor 4: histidine assignments and interactions with heparin. Biochimica Biophysica Acta 1991; 1078: 208-218.
    CrossrefPubMedGoogle Scholar
  • 43 Stringer SE, Gallagher JT. Specific binding of the chemokine platelet factor 4 to heparan sulfate. J Biol Chem 1997; 272: 20508-20514.
    CrossrefPubMedGoogle Scholar
  • 44 Nieduszynski I. General physical properties of heparin. In Heparin: Chemical and Biological Properties, Clinical Applications. Lane DA, Lindahl U. eds. Boca Raton, FL: CRC Press, Inc.; 1989: 51-63.
    Google Scholar
  • 45 Amiral J, Marfang-Koka A, Wolf M, Alessi MC, Tardy B, Boyer-Neumann C, Vissac AM, Fressinaud E, Poncz M, Meyer D. Presence of autoantibodies to interleukin-8 or neutrophil-activating peptide-2 in patients with heparin-associated thrombocytopenia. Blood 1996; 88: 410-416.
    PubMedGoogle Scholar
  • 46 Ziporen L, Li ZQ, Park KS, Sabnekar P, Liu WY, Arepally G, Shoenfeld Y, Kieber-Emmons T, Cines DB, Poncz M. Defining an antigenic epitopes on platelet factor 4 associated with heparin-induced thrombocytopenia. Blood 1998; 92: 3250-3259.
    PubMedGoogle Scholar
  • 47 Doit T, Greenberg SM, Rosenberg RD. Structure of the rat platelet factor 4 gene: a marker for megakaryocyte differentiation. Mol Cell Biol 1987; 7: 898-904.
    CrossrefPubMedGoogle Scholar
  • 48 Visentin GP, Aster RH, Geoffrey RA. Identification of critical amino acids in human platelet factor 4 (PF4)-heparin complex required for antibody recognition in heparin-induced thrombocytopenia/thrombosis (HITP) (abstract). Thromb Haemost 1997; (suppl.): 362.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 49 Amiral J, Wolf M, Fischer AM, Boyer-Neumann C, Vissac AM, Meyer D. Pathogenicity of IgA and/or IgM antibodies to heparin-PF4 complexes in patients with heparin-induced thrombocytopenia. Br J Haematol 1996; 92: 954-959.
    CrossrefPubMedGoogle Scholar
  • 50 Arepally G, McKenzie SE, Jiang XM, Poncz M, Cines DB. Fc gamma RIIA H/R 131 polymorphism, subclass-specific IgG anti-heparin/platelet factor 4 antibodies and clinical course in patients with heparin-induced thrombocytopenia and thrombosis. Blood 1997; 89: 370-375.
    PubMedGoogle Scholar
  • 51 Kelton JG, Warkentin TE. Heparin-induced thrombocytopenia. Diagnosis, natural history, and treatment options. [Review]. Postgrad Med J 1998; 103: 169-171 175-178.
    CrossrefPubMedGoogle Scholar
  • 52 Maslanka K, Piatek T, Gorski J, Yassai M, Gorski J. Molecular analysis of T cell repertoires. Spectratypes generated by multiplex polymerase chain reaction and evaluated by radioactivity or fluorescence. Hum Immunol 1995; 44: 28-34.
    PubMedGoogle Scholar
  • 53 Cochet M, Pannetier C, Regnault A, Darche S, Leclerc C, Kourilsky P. Molecular detection and in vivo analysis of the specific T cell response to a protein antigen. Eur J Immunol 1992; 22: 2639-2647.
    CrossrefPubMedGoogle Scholar
  • 54 Pannetier C, Cochet M, Darche S, Casrouge A, Zoller M, Kourilsky P. The sizes of the CDR3 hypervariable regions of the murine T-cell receptor beta chains vary as a function of the recombined germ-line segments. Proc Natl Acad Sci USA 1993; 90: 4319-4323.
    CrossrefPubMedGoogle Scholar
  • 55 Maslanka K, Yassai M, Gorski J. Molecular identification of T cells that respond in a primary bulk culture to a peptide derived from a platelet glycoprotein implicated in neonatal alloimmune thrombocytopenia. J Clin Invest 1996; 98: 1802-1808.
    CrossrefPubMedGoogle Scholar
  • 56 LaRoque R, Robinson MA. Diversity of the human T cell receptor beta chain. [Review]. Human Immunology 1996; 48: 3-11.
    CrossrefPubMedGoogle Scholar
  • 57 De Palma R, Gorski J, Aster RH, Visentin GP. The immune response in heparin-induced thrombocytopenia/thrombosis (HITP): Preferential use of the VB11 family of the T cell receptor (TCR) repertoire (abstract). Blood 1995; 86 (suppl.): 537a.
    PubMedGoogle Scholar
  • 58 Bacsi S, De Palma R, Visentin GP, Gorski J, Aster RH. Complexes of heparin and platelet factor 4 (PF4) drive the T cell receptor (TCR) repertoire in cultured PBMCs from heparin-induced Thrombocytopenia/thrombosis (HITP) patients (abstract). Blood 1996; 88 (Suppl.): 516a.
    PubMedGoogle Scholar
  • 59 Bacsi S, Geoffrey R, Gorksi J, Aster R. Antigen-specific expansion of T cell clonotypes in heparin-induced thrombocytopenia/thrombosis (HITT) patient cultured T cells (abstract). Blood 1997; 90: 403a.
    PubMedGoogle Scholar
  • 60 Greinacher A, Mueller-Eckhardt G. Heparin-associated thrombocytopenia: no association of immune response with HLA. Vox Sanguinis 1993; 65: 151-153.
    PubMedGoogle Scholar
  • 61 Warkentin TE, Chong BH, Greinacher A. Heparin-induced thrombocytopenia: towards consensus. [Review]. Thromb Haemost 1998; 79: 1-7.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 62 Marcum JA, Rosenberg RD. The biochemistry, cell biology, and pathophysiology of anticoagulantly active heparin-like molecules of the vessel wall. In Heparin: Chemical and Biological Properties Clinical Applications. Lane D.A., Lindal U.. eds. Boca Raton, FL: CRC Press, Inc.; 1989: 275-294.
    Google Scholar