Partially desulfated heparin modulates the interaction between anti-protamine/heparin antibodies and platelets

 

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Summary

Protamine (PRT) is the standard drug to neutralise heparin. PRT/heparin complexes induce an immune response similar to that observed in heparin-induced thrombocytopenia (HIT). Partially desulfated heparin (ODSH) was shown to interfere with anti-platelet factor 4/heparin antibodies (Abs), which are responsible for HIT. In this study, we analyse the impact of ODSH on the interaction between anti-PRT/heparin Abs and platelets. The ability of ODSH to prevent anti-PRT/heparin Ab-induced platelet destruction in vivo was investigated using the NOD/ SCID mouse model. ODSH improved platelet survival in the presence of PRT, heparin and anti-PRT/heparin Abs (median platelet survival after 300 minutes (min) with 20 μg/ml ODSH: 75 %, range 70–81 % vs without ODSH: 49%, range 44–59%, p=0.006). Furthermore, when ODSH was applied 60 min after Ab injection platelet survival was improved (median platelet survival after 300 min with ODSH: 83 %, range 77–93 % vs without ODSH: 59 %, range 29–61 %, p=0.02). In in vitro experiments ODSH inhibited platelet activation at concentrations > 16 μg/mL (p< 0.001), as well as PRT/heparin complex binding to platelets (mean fluorescence intensity [MFI] without ODSH: 85 ± 14 vs with ODSH: 15 ± 0.6, p=0.013). ODSH also displaced pre-bound complexes from the platelet surface (MFI without ODSH: 324 ± 43 vs with 32 μg/ml ODSH: 53 ± 9, p< 0.001). While interfering with platelet activation by anti-PRT/heparin Abs, up to a concentration of 16 μg/ml, ODSH had only minimal impact on neutralisation of heparin by PRT. In conclusion, our study shows that ODSH is able to inhibit platelet activation and destruction suggesting a potential clinical use to reduce anti-PRT/heparin Ab-mediated adverse effects.

• References

• 1 Weitz JI. Low-molecular-weight heparins. N Engl J Med 1997; 337: 688-698.
  CrossrefPubMedGoogle Scholar
• 2 Gray E, Hogwood J, Mulloy B. The anticoagulant and antithrombotic mechanisms of heparin. Handbook Exp Pharmacol 2012; 207: 43-61.
  PubMedGoogle Scholar
• 3 Bakchoul T, Zollner H, Amiral J. et al. Anti-protamine-heparin antibodies: incidence, clinical relevance, and pathogenesis. Blood 2013; 121: 2821-2827.
  CrossrefPubMedGoogle Scholar
• 4 Singla A, Sullivan MJ, Lee G. et al. Protamine-induced immune thrombocytopenia. Transfusion 2013; 53: 2158-2163.
  PubMedGoogle Scholar
• 5 Pouplard C, Leroux D, Rollin J. et al. Incidence of antibodies to protamine sulfate/heparin complexes incardiac surgery patients and impact on platelet activation and clinical outcome. Thromb Haemost 2013; 109: 1141-1147.
  Article in Thieme ConnectPubMedGoogle Scholar
• 6 Lee GM, Welsby IJ, Phillips-Bute B. et al. High incidence of antibodies to prota-mine and protamine/heparin complexes in patients undergoing cardiopulmon-ary bypass. Blood 2013; 121: 2828-2835.
  CrossrefPubMedGoogle Scholar
• 7 Panzer S, Schiferer A, Steinlechner B. et al. Serological features of antibodies to protamine inducing thrombocytopenia and thrombosis. Clinical chemistry and laboratory medicine : CCLM / FESCC 2015; 53: 249-255.
  PubMedGoogle Scholar
• 8 Sachs U, Bakchoul T, Wagner A. et al. Incidence, predictors and clinical relevance of protamine-heparin-antibodies in patients undergoing cardiac surgery with cardiopulmonary bypass. 47. Jahreskongress der Deutschen Gesellschaft für Transfusionsmedizin und Immunhämatologie (DGTI) Abstract. Transfus Med Hemother 2014; 41 (Suppl. 01) 2-108.
  PubMedGoogle Scholar
• 9 Rao NV, Argyle B, Xu X. et al. Low anticoagulant heparin targets multiple sites of inflammation, suppresses heparin-induced thrombocytopenia, and inhibits interaction of RAGE with its ligands. Am J Physiol Cell Physiol 2010; 299: C97-110.
  CrossrefPubMedGoogle Scholar
• 10 Fryer A, Huang YC, Rao G. et al. Selective O-desulfation produces nonantico-agulant heparin that retains pharmacological activity in the lung. J Pharmacol Exp Therap 1997; 282: 208-219.
  PubMedGoogle Scholar
• 11 Krauel K, Hackbarth C, Furll B. et al. Heparin-induced thrombocytopenia: in vitro studies on the interaction of dabigatran, rivaroxaban, and low-sulfated he-parin, with platelet factor 4 and anti-PF4/heparin antibodies. Blood 2012; 119: 1248-1255.
  CrossrefPubMedGoogle Scholar
• 12 Joglekar MV, Quintana Diez PM, Marcus S. et al. Disruption of PF4/H multi-molecular complex formation with a minimally anticoagulant heparin (ODSH). Thromb Haemost 2012; 107: 717-725.
  Article in Thieme ConnectPubMedGoogle Scholar
• 13 Boylan B, Berndt MC, Kahn ML. et al. Activation-independent, antibody-mediated removal of GPVI from circulating human platelets: development of a novel NOD/SCID mouse model to evaluate the in vivo effectiveness of antihuman platelet agents. Blood 2006; 108: 908-914.
  CrossrefPubMedGoogle Scholar
• 14 Newman PM, Swanson RL, Chong BH. Heparin-induced thrombocytopenia: IgG binding to PF4-heparin complexes in the fluid phase and cross-reactivity with low molecular weight heparin and heparinoid. Thromb Haemost 1998; 80: 292-297.
  Article in Thieme ConnectPubMedGoogle Scholar
• 15 Krauel K, Potschke C, Weber C. et al. Platelet factor 4 binds to bacteria, [corrected] inducing antibodies cross-reacting with the major antigen in heparin-induced thrombocytopenia. Blood 2011; 117: 1370-1378.
  CrossrefPubMedGoogle Scholar
• 16 Butterworth J, Lin YA, Prielipp R. et al. The pharmacokinetics and cardiovascular effects of a single intravenous dose of protamine in normal volunteers. An-esth Analg 2002; 94: 514-522.
  CrossrefPubMedGoogle Scholar
• 17 Butterworth J, Lin YA, Prielipp RC. et al. Rapid disappearance of protamine in adults undergoing cardiac operation with cardiopulmonary bypass. Ann Thoracic Surg 2002; 74: 1589-1595.
  CrossrefPubMedGoogle Scholar
• 18 Nurden P, Poujol C, Durrieu-Jais C. et al. Labeling of the internal pool of GP IIb-IIIa in platelets by c7E3 Fab fragments (abciximab): flow and endocytic mechanisms contribute to the transport. Blood 1999; 93: 1622-1633.
  PubMedGoogle Scholar