Научно-практический журнал
«Клиническая физиология кровообращения»

Главный редактор

Лео Антонович Бокерия, доктор медицинских наук, профессор, академик РАН и РАМН, президент ФГБУ «НМИЦ ССХ им. А.Н. Бакулева» МЗ РФ


Патогенез гепарининдуцированной тромбоцитопении

Авторы: Самсонова Н.Н., Есаян Г.С., Рогальская Е.А., Ярустовский М.Б.

Организация:
ФГБУ «Национальный медицинский исследовательский центр сердечно-сосудистой хирургии им. А.Н. Бакулева» (президент – академик РАН и РАМН Л.А. Бокерия) Минздрава России, Рублевское ш., 135, Москва, 121552, Российская Федерация

Для корреспонденции: Сведения доступны для зарегистрированных пользователей.

Раздел: Обзоры

DOI: https://doi.org/10.24022/1814-6910-2020-17-4-294-298

УДК: 616.151.5:616.155.294

Библиографическая ссылка: Клиническая физиология кровообращения. 2020; 4 (17): 294-298

Цитировать как: Самсонова Н.Н., Есаян Г.С., Рогальская Е.А., Ярустовский М.Б.. Патогенез гепарининдуцированной тромбоцитопении. Клиническая физиология кровообращения. 2020; 4 (17): 294-298. DOI: 10.24022/1814-6910-2020-17-4-294-298

Ключевые слова: терапия гепарином, кардиохирургия, гепарининдуцированная тромбоцитопения, тромбоцитопения, тромбоз

Поступила / Принята к печати:  18.06.2020 / 26.06.2020

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Аннотация

Гепарином индуцированная тромбоцитопения (ГИТ) – грозное осложнение в кардиохирургии, возникающее при использовании гепарина. Клиническим проявлением ГИТ служит тромбоз на фоне тромбоцитопении. В основе патогенеза ГИТ лежит образование антител к комплексу тромбоцитарный фактор 4 (ТФ-4) и гепарин, которые, взаимодействуя с FcyRIIA-рецепторами клеток, индуцируют усиленную экспрессию тканевого фактора и интенсивное тромбинообразование. При запуске данных механизмов протромботический риск сохраняется от нескольких дней до недель, даже после прекращения применения гепарина. Установлено, что иммунный ответ на ТФ-4–гепарин проявляется гораздо чаще, чем клинические признаки тромбоцитопении или тромбоза. Инфекционно-воспалительные осложнения являются предпосылкой развития ГИТ. В обзоре отражены современные представления об антигене и антителах, а также механизмах тромбообразования при ГИТ.

Литература

  1. Бокерия Л.А., Чичерин И.Н. Гепарининдуцированная тромбоцитопения. М.: НЦССХ им. А.Н. Бакулева РАМН; 2007.
  2. Пирогов А.Л. Гепарин-индуцированная тромбоцитопения при сердечно-сосудистых вмешательствах. Механизмы развития, диагностики и методы коррекции. Комплексные проблемы сердечно-сосудистых заболеваний. 2014; 4: 95–103. DOI: 10.17802/ 2306-1278-2014-4-95-103
  3. Петрова О.В., Егорова Т.Г., Мурыгина О.И., Вавилова Т.В. Новые возможности диагностики гепарин-индуцированной тромбоцитопении у кардиохирургических больных. Медицинский алфавит. 2013; 3 (16): 41–4.
  4. Иванов А.В., Медведева Е.С., Ерофеичев В.Н., Воробьев С.А. Гепарин-индуцированная тромбоцитопения у кардиологических пациентов (клинические наблюдения). Тверской медицинский журнал. 2017; 5: 156–9.
  5. Arepally G.M. Heparin-induced thrombocytopenia. Blood. 2017; 129: 2864–72. DOI: 10.1182/blood-2016- 11-709873 6. Warkentin Т.E. Нeparin-induced thrombocytopeniа and anaesthesiology. Can. J. Anesth. 2002; 49 (6): 36–49.
  6. Warkentin T.E., Greinacher A. So, does low-molecular-weight heparin cause less heparin-induced thrombocytopenia than unfractionated heparin or not? Chect. 2007; 132 (4): 1108–10. DOI: 10.1378/chest.07-1553
  7. Linkins L.A., Dans A.L., Moores L.K., Bona R., Davidson B.L., Schulman S., Crowther M. Treatment and prevention of heparin-induced thrombocytopenia: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141 (2, Suppl.): e495S–e530S. DOI: 10.1378/ chest.11-2303
  8. Косырев А.Б. Современное решение диагностики синдрома «гепарининдуцированной тромбоцитопении». Медицинский алфавит. 2011; 1 (4): 44–6.
  9. Покутнев A.П., Ефремушкин А.Г., Косоухов А.П., Дуда А.И., Ефремушкина А.А., Бендриков О.А. Первый опыт применения прямого ингибитора тромбина бивалирудина во время коронарного шунтирования в условиях искусственного кровообращения в Алтайском краевом кардиологическом диспансере. Комплексные проблемы сердечнососудистых заболеваний. 2015; 1: 81–5.
  10. Chong B.H., Ismail F. The mechanism of heparininduced platelet aggregation. Eur. J. Haematol. 1989; 43 (3): 245–51. DOI: 10.1111/j.1600-0609.1989.tb00290.x
  11. Weismann R.E., Tobin R.W. Arterial embolism occurring during systemic heparin therapy. AMA Arch Surg. 1958; 76 (2): 219–27. DOI: 10.1001/archsurg.1958.01280200041005
  12. Warkentin T.E., Sheppard J.A., Moore J.C., Cook R.J., Kelton J.G. Studies of the immune response in heparin-induced thrombocytopenia. Blood. 2009; 113 (20): 4963–9. DOI: 10.1182/blood-2008-10-186064
  13. Amiral J., Bridey F., Dreyfus M., Vissoc A.M., Fressinaud E., Wolf M., Meyer D. Platelet factor 4 complexed 298 Reviews Clinical Physiology of Circulation. 2020; 17 (4). DOI: 10.24022/1814-6910-2020-17-4-294-298 to heparin is the target for antibodies generated in heparin-induced thrombocytopenia. Thromb Haemost. 1992; 68 (1): 95–6. DOI: 10.1055/s-0038-1656329
  14. Zucker M.B., Katz I.R. Platelet factor 4: production, structure, and physiologic and immunologic action. Proc. Soc. Exp. Biol. Med. 1991; 198 (2): 693–702. DOI: 10.3181/00379727-198-43309
  15. Климович Л.Г. Маркеры активации гемостаза при противотромботической терапии у больных ишемической болезнью сердца: Дис. … д-ра биол. наук. М.; 2000.
  16. Бокерия Л.А., Климович Л.Г., Потехина А.В., Путято Н.А., Самсонова Н.Н. Механизмы вовлечения ингибиторов свертывания в развитие воспалительной реакции и перспективные направления антикоагулянтной терапии. Клиническая физиология кровообращения. 2004; 1: 46–55.
  17. Marcum J.A., McKenney J.B., Rosenberg R.D. Acceleration of thrombin-antithrombin complex formation in rat hindquarters via heparinlike molecules bound to the endothelium. J. Clin. Invest. 1984; 74 (2): 341–50. DOI: 10.1172/jci111429
  18. Handin R.I., Cohen H.J. Purification and binding properties of human platelet factor four. J. Biol. Chem. 1976; 251 (14): 4273–82.
  19. Bock P.E., Luscombe M., Marshall S.E., Pepper D.S., Holbrook J.J. The multiple complexes formed by the interaction of platelet factor 4 with heparin. Biochem. J. 1980; 191 (3): 769–76. DOI: 10.1042/bj1910769
  20. Suvarna S., Espinasse B., Qi R., Lubica R., Poncz M., Cines D.B. et al. Determinants of PF4/heparin immunogeneicity. Blood. 2007; 110 (13): 4253–60. DOI: 10.1182/blood-2007-08-105098
  21. Greinacher A., Alban S., Omer-Adam M.A., Weitschies W., Warkentin T.E. Heparin-induced thrombocytopenia: a stoichiometry-based model to explain the differing immunogenicities of unfractionated heparin, low-molecular-weight heparin, and fondaparinux in different clinical settings. Thromb. Res. 2008; 122 (2): 211–20. DOI: 10.1016/j.thromres.2007.11.007
  22. Brandt S., Krauel K., Gottschalk K.E., Renné T., Helm C.A., Greinacher A., Block S. Characterisation of the conformational changes in platelet factor 4 induced by polyanions: towards in vitro prediction of antigenicity. Thromb. Haemost. 2014; 112 (1): 53–64. DOI: 10.1160/TH13-08-0634
  23. Kreimann M., Brandt S., Krauel K., Block S., Helm C.A., Weitschies W. et al. Binding of anti-platelet factor 4/heparin antibodies depends on the thermodynamics of conformational changes in platelet factor 4. Blood. 2014; 124 (15): 2442–9. DOI: 10.1182/blood2014-03-559518
  24. Bauer T.L., Arepally G., Konkle B.A., Mestichelli B., Shapiro S.S., Cines D.B. et al. Prevalence of heparinassociated antibodies without thrombosis in patients undergoing cardiopulmonary bypass surgery. Circulation. 1997; 95 (5): 1242–6. DOI: 10.1161/01.cir.95.5.1242
  25. Amiral J., Peynaud-Debayle E., Wolf M., Bridey F., Vissac A.M., Meyer D. Generation of antibodies to heparin-PF4 complexes without thrombocytopenia in patients treated with unfractionated or low-molecularweight heparin. Am. J. Hematol. 1996; 52 (2): 90–5. DOI: 10.1002/(sici)1096-8652(199606)52:2%3C90:: aid-ajh4%3E3.0.co;2-0
  26. Warkentin T.E., Sheppard J.A., Horsewood P., Simpson P.J., Moore J.C., Kelton J.G. Impact of the patient population on the risk for heparin-induced thrombocytopenia. Blood. 2000; 96 (5): 1703–8. DOI: 10.1182/blood.v96.5.1703.h8001703_1703_1708
  27. Warkentin T.E., Cook R.J., Marder V.J., Sheppard J.I., Moore J.C., Eriksson B. et al. Antiplatelet factor 4/heparin antibodies in orthopedic surgery patients receiving antithrombotic prophylaxis with fondaparinux or enoxaparin. Blood. 2005; 106 (12): 3791–6. DOI: 10.1182/blood-2005-05-1938
  28. Visentin G.P., Malik M., Cyganiak K.A., Aster R.H. 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 (4): 376–83. DOI: 10.1016/s0022-2143 (96)80009-6
  29. Krauel K., Schulze A., Jouni R., Hackbarth C., Hietkamp B., Selleng S. et al. Further insights into the antiPF4/heparin IgM immune response. Thromb. Haemost. 2016; 115 (4): 752–61. DOI: 10.1160/TH15-08-0654
  30. Khandelwal S., Lee G.M., Hester C.G., Poncz M., McKenzie S.E., Sachais B.S. et al. The antigenic complex in HIT binds to B cells via complement and complement receptor 2 (CD21). Blood. 2016; 128 (14): 1789–99. DOI: 10.1182/blood-2016-04-709634
  31. Zheng Y., Wang A.W., Yu M., Padmanabhan A., Tourdot B., Newman D.K. et al. B-cell tolerance regulates production of antibodies causing heparin-induced thrombocytopenia. Blood. 2014; 123 (6): 931–4. DOI: 10.1182/blood-2013-11-540781
  32. Reilly M.P., Taylor S.M., Hartman N.K., Arepally G.M., Sachais B.S., Cines D.B. et al. Heparininduced thrombocytopenia/thrombosis in a transgenic mouse model requires human platelet factor 4 and platelet activation through FcgRIIA. Blood. 2001; 98 (8): 2442–7. DOI: 10.1182/blood.v98.8.2442
  33. Warkentin T.E., Hayward C.P., Boshkov L.K., Santos A.V., Sheppard J.A., Bode A.P., Kelton J.G. Sera from patients with heparin-induced thrombocytopenia generate platelet-derived microparticles with procoagulant activity: an explanation for the thrombotic complications of heparin-induced thrombocytopenia. Blood. 1994; 84 (11): 3691–9. DOI: 10.1182/blood.v84.11.3691.bloodjournal84113691
  34. Arepally G.M., Mayer I.M. Antibodies from patients with heparin-induced thrombocytopenia stimulate monocytic cells to express tissue factor and secrete interleukin-8. Blood. 2001; 98 (4): 1252–4. DOI: 10.1182/blood.v98.4.1252
****
  1. Bockeria L.A., Chicherin I.N. Нeparin-induced thrombocytopenia. Moscow; 2007 (in Russ.)
  2. Pirogov A.L. Heparininduced thrombocytopenia in cardiovascular surgery. Pathogenesis, diagnostics and correction methods. Complex Issues of Cardiovascular Diseases. 2014; 4: 95–103 (in Russ.). DOI: 10.17802/ 2306-1278-2014-4-95-103
  3. Petrova O.V., Egorova T.G., Murygina O.I., Vavilova T.V. New possibilities of diagnostics of heparin-induced thrombocytopenia in cardiosurgical patients. Medical Alphabet. 2013; 3 (16): 41–4 (in Russ.)
  4. Ivanov A.V., Medvedeva E.S., Erofeichev V.N., Vorob'ev S.A. Heparin-induced thrombocytopenia in cardiac patients (clinical observations). Tver Medical Journal. 2017; 5: 156–9 (in Russ.)
  5. Arepally G.M. Heparin-induced thrombocytopenia. Blood. 2017; 129: 2864–72. DOI: 10.1182/blood-2016- 11-709873 6. Warkentin Т.E. Нeparin-induced thrombocytopeniа and anaesthesiology. Can. J. Anesth. 2002; 49 (6): 36–49.
  6. Warkentin T.E., Greinacher A. So, does low-molecular-weight heparin cause less heparin-induced thrombocytopenia than unfractionated heparin or not? Chect. 2007; 132 (4): 1108–10. DOI: 10.1378/chest.07-1553
  7. Linkins L.A., Dans A.L., Moores L.K., Bona R., Davidson B.L., Schulman S., Crowther M. Treatment and prevention of heparin-induced thrombocytopenia: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141 (2, Suppl.): e495S–e530S. DOI: 10.1378/ chest.11-2303
  8. Kosyrev A.B. A modern solution for diagnosing the syndrome of “heparin-induced thrombocytopenia”. Medical Alphabet. 2011; 1 (4): 44–6 (in Russ.)
  9. Pokutnev A.P., Efremushkin A.G., Kosoukhov A.P., Duda A.I., Efremushkina A.A., Bendrikov O.A. The first experience of application of inhibitor bivalirudin direct trombin during coronary bypass surgery under conditions of extracorporeal circulation in Altai regional cardiologic dispensary. Complex Issues of Cardiovascular Diseases. 2015; 1: 81–5 (in Russ.)
  10. Chong B.H., Ismail F. The mechanism of heparininduced platelet aggregation. Eur. J. Haematol. 1989; 43 (3): 245–51. DOI: 10.1111/j.1600-0609.1989.tb00290.x
  11. Weismann R.E., Tobin R.W. Arterial embolism occurring during systemic heparin therapy. AMA Arch Surg. 1958; 76 (2): 219–27. DOI: 10.1001/archsurg.1958.01280200041005
  12. Warkentin T.E., Sheppard J.A., Moore J.C., Cook R.J., Kelton J.G. Studies of the immune response in heparin-induced thrombocytopenia. Blood. 2009; 113 (20): 4963–9. DOI: 10.1182/blood-2008-10-186064
  13. Amiral J., Bridey F., Dreyfus M., Vissoc A.M., Fressinaud E., Wolf M., Meyer D. Platelet factor 4 complexed 298 Reviews Clinical Physiology of Circulation. 2020; 17 (4). DOI: 10.24022/1814-6910-2020-17-4-294-298 to heparin is the target for antibodies generated in heparin-induced thrombocytopenia. Thromb Haemost. 1992; 68 (1): 95–6. DOI: 10.1055/s-0038-1656329
  14. Zucker M.B., Katz I.R. Platelet factor 4: production, structure, and physiologic and immunologic action. Proc. Soc. Exp. Biol. Med. 1991; 198 (2): 693–702. DOI: 10.3181/00379727-198-43309
  15. Klimovich L.G. Markers of hemostasis activation in antithrombotic therapy in patients with ischemic heart disease: Dr. Biol. Sc. Diss. Moscow; 2000 (in Russ.)
  16. Bockeria L.A., Klimovich L.G., Potekhina A.V., Putyato N.A., Samsonova N.N. Mechanisms of the involvement of clotting inhibitors in the development of the inflammatory response and promising directions of anticoagulant therapy. Сlinical Physiology of Circulation. 2004; 1: 4–55 (in Russ.).]
  17. Marcum J.A., McKenney J.B., Rosenberg R.D. Acceleration of thrombin-antithrombin complex formation in rat hindquarters via heparinlike molecules bound to the endothelium. J. Clin. Invest. 1984; 74 (2): 341–50. DOI: 10.1172/jci111429
  18. Handin R.I., Cohen H.J. Purification and binding properties of human platelet factor four. J. Biol. Chem. 1976; 251 (14): 4273–82.
  19. Bock P.E., Luscombe M., Marshall S.E., Pepper D.S., Holbrook J.J. The multiple complexes formed by the interaction of platelet factor 4 with heparin. Biochem. J. 1980; 191 (3): 769–76. DOI: 10.1042/bj1910769
  20. Suvarna S., Espinasse B., Qi R., Lubica R., Poncz M., Cines D.B. et al. Determinants of PF4/heparin immunogeneicity. Blood. 2007; 110 (13): 4253–60. DOI: 10.1182/blood-2007-08-105098
  21. Greinacher A., Alban S., Omer-Adam M.A., Weitschies W., Warkentin T.E. Heparin-induced thrombocytopenia: a stoichiometry-based model to explain the differing immunogenicities of unfractionated heparin, low-molecular-weight heparin, and fondaparinux in different clinical settings. Thromb. Res. 2008; 122 (2): 211–20. DOI: 10.1016/j.thromres.2007.11.007
  22. Brandt S., Krauel K., Gottschalk K.E., Renné T., Helm C.A., Greinacher A., Block S. Characterisation of the conformational changes in platelet factor 4 induced by polyanions: towards in vitro prediction of antigenicity. Thromb. Haemost. 2014; 112 (1): 53–64. DOI: 10.1160/TH13-08-0634
  23. Kreimann M., Brandt S., Krauel K., Block S., Helm C.A., Weitschies W. et al. Binding of anti-platelet factor 4/heparin antibodies depends on the thermodynamics of conformational changes in platelet factor 4. Blood. 2014; 124 (15): 2442–9. DOI: 10.1182/blood2014-03-559518
  24. Bauer T.L., Arepally G., Konkle B.A., Mestichelli B., Shapiro S.S., Cines D.B. et al. Prevalence of heparinassociated antibodies without thrombosis in patients undergoing cardiopulmonary bypass surgery. Circulation. 1997; 95 (5): 1242–6. DOI: 10.1161/01.cir.95.5.1242
  25. Amiral J., Peynaud-Debayle E., Wolf M., Bridey F., Vissac A.M., Meyer D. Generation of antibodies to heparin-PF4 complexes without thrombocytopenia in patients treated with unfractionated or low-molecularweight heparin. Am. J. Hematol. 1996; 52 (2): 90–5. DOI: 10.1002/(sici)1096-8652(199606)52:2%3C90:: aid-ajh4%3E3.0.co;2-0
  26. Warkentin T.E., Sheppard J.A., Horsewood P., Simpson P.J., Moore J.C., Kelton J.G. Impact of the patient population on the risk for heparin-induced thrombocytopenia. Blood. 2000; 96 (5): 1703–8. DOI: 10.1182/blood.v96.5.1703.h8001703_1703_1708
  27. Warkentin T.E., Cook R.J., Marder V.J., Sheppard J.I., Moore J.C., Eriksson B. et al. Antiplatelet factor 4/heparin antibodies in orthopedic surgery patients receiving antithrombotic prophylaxis with fondaparinux or enoxaparin. Blood. 2005; 106 (12): 3791–6. DOI: 10.1182/blood-2005-05-1938
  28. Visentin G.P., Malik M., Cyganiak K.A., Aster R.H. 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 (4): 376–83. DOI: 10.1016/s0022-2143 (96)80009-6
  29. Krauel K., Schulze A., Jouni R., Hackbarth C., Hietkamp B., Selleng S. et al. Further insights into the antiPF4/heparin IgM immune response. Thromb. Haemost. 2016; 115 (4): 752–61. DOI: 10.1160/TH15-08-0654
  30. Khandelwal S., Lee G.M., Hester C.G., Poncz M., McKenzie S.E., Sachais B.S. et al. The antigenic complex in HIT binds to B cells via complement and complement receptor 2 (CD21). Blood. 2016; 128 (14): 1789–99. DOI: 10.1182/blood-2016-04-709634
  31. Zheng Y., Wang A.W., Yu M., Padmanabhan A., Tourdot B., Newman D.K. et al. B-cell tolerance regulates production of antibodies causing heparin-induced thrombocytopenia. Blood. 2014; 123 (6): 931–4. DOI: 10.1182/blood-2013-11-540781
  32. Reilly M.P., Taylor S.M., Hartman N.K., Arepally G.M., Sachais B.S., Cines D.B. et al. Heparininduced thrombocytopenia/thrombosis in a transgenic mouse model requires human platelet factor 4 and platelet activation through FcgRIIA. Blood. 2001; 98 (8): 2442–7. DOI: 10.1182/blood.v98.8.2442
  33. Warkentin T.E., Hayward C.P., Boshkov L.K., Santos A.V., Sheppard J.A., Bode A.P., Kelton J.G. Sera from patients with heparin-induced thrombocytopenia generate platelet-derived microparticles with procoagulant activity: an explanation for the thrombotic complications of heparin-induced thrombocytopenia. Blood. 1994; 84 (11): 3691–9. DOI: 10.1182/blood.v84.11.3691.bloodjournal84113691
  34. Arepally G.M., Mayer I.M. Antibodies from patients with heparin-induced thrombocytopenia stimulate monocytic cells to express tissue factor and secrete interleukin-8. Blood. 2001; 98 (4): 1252–4. DOI: 10.1182/blood.v98.4.1252

Об авторах

  • Самсонова Наталья Николаевна, доктор мед. наук, профессор, гл. науч. сотр.; ORCID
  • Есаян Галина Сергеевна, мл. науч. сотр.; ORCID
  • Рогальская Екатерина Анатольевна, канд. мед. наук, заведующая лабораторией гематологии; ORCID
  • Ярустовский Михаил Борисович, доктор мед. наук, профессор, чл.-корр. РАН, заведующий отделением гравитационной хирургии крови и эндоскопии, заместитель директора Института кардиохирургии им. В.И. Бураковского; ORCID

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