Pre-operative therapeutic plasma Exchange and intravenous immune globulin for the treatment of heparin induced thrombocytopenia in a lung transplant recipient

Mandernach, Molly W.; Nandavaram, Sravanthi; Salame, Bilal Khameze; Machuca, Tiago; Peláez, Andrés

doi:10.1016/j.transci.2019.05.010

Cited by 6 publications

(5 citation statements)

References 7 publications

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“…Post‐treatment HIT antibody testing was performed in 25 cases (83%) with findings of decreased or negative OD in 22 cases, unspecified positive OD in one case, 60 equivocal PF4 ELISA screen in one case, 62 and decrease in anti‐heparin antibody titer in one case 70 . Other laboratory outcomes in five cases include a negative SRA (n = 4), 6,64,68 negative HIPA (n = 1), 71 and negative washed platelet activation assay (WPA; n = 1) 69 …”

Section: Resultsmentioning

confidence: 99%

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Therapeutic plasma exchange and intravenous immune globulin in the treatment of heparin‐induced thrombocytopenia: A systematic review

et al. 2020

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Background: Immunomodulatory strategies in heparin-induced thrombocytopenia (HIT) include the use of intravenous immune globulin (IVIG) and therapeutic plasma exchange (TPE). The optimal application of these therapies is unknown and outcomes data are limited. We investigated treatment categories and laboratory and clinical outcomes of IVIG and/or TPE in HIT with a systematic literature review. Study Design and Methods: We searched MEDLINE, Embase, and Web of Science through December 2019 for studies combining controlled vocabulary and keywords related to thrombocytopenia, heparin, TPE, and IVIG. The primary outcome was treatment indication. Secondary outcomes were platelet recovery, HIT laboratory parameters, heparin re-exposure, and post-treatment course. Case-level data were analyzed by qualitative synthesis. Results: After 4241 references were screened, we identified 60 studies with four main categories of IVIG and/or TPE use as follows: (a) treatment of refractory HIT (n = 35; 31%); (b) initial therapy (n = 45; 40%); (c) cardiopulmonary bypass surgery (CPB; n = 30; 27%); and (d) other (n = 2; 2%). IVIG was most commonly used for the treatment of refractory HIT while TPE was primarily used to facilitate heparin exposure during CPB. Both IVIG and TPE were

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Section: Resultsmentioning

confidence: 99%

“…Two therapies aimed at targeting the immune mechanism of HIT include intravenous immune globulin (IVIG) and therapeutic plasma exchange (TPE). 5,6 TPE removes antibodies against heparin/PF4 large molecular weight complexes. 7 IVIG may interrupt the HIT immune response by blocking Fcγ-mediated platelet activation.…”

Section: Introductionmentioning

confidence: 99%

Therapeutic plasma exchange and intravenous immune globulin in the treatment of heparin‐induced thrombocytopenia: A systematic review

et al. 2020

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“…Mandernach et al, 66 Ibrahim and Rice, 30 Vender et al, 67 and Warkentin et al 68 describe administration of IVIG prophylactically prior to or around the time of surgery. None of these cases reported the patient’s actual body weight.…”

Section: Discussionmentioning

confidence: 99%

Intravenous Immune Globulin (IVIG) for Treatment of Autoimmune Heparin-Induced Thrombocytopenia: A Systematic Review

Dougherty

Yarsley

2020

Ann Pharmacother

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Objective: To evaluate intravenous immune globulin (IVIG) for autoimmune heparin-induced thrombocytopenia (aHIT), including platelet recovery, IVIG dose, dosing weight, IVIG product used, and complications reported. Data Sources: PubMed and EMBASE were searched from inception through June 21, 2020. Search terms included heparin-induced thrombocytopenia, HIT, intravenous immune globulin, IVIG, autoimmune HIT, aHIT, and immune globulin. Study Selection and Data Extraction: Patients administered IVIG for HIT and diagnosed by immunoassay (optical density ≥2) or positive activation assay were included. Data Synthesis: Twenty-four cases were reviewed; 92% had persistent aHIT. Time to IVIG administration post–nonheparin anticoagulant initiation was 9 days (median). Most common IVIG cumulative dose was 2 g/kg (dosed as 1 g/kg/d for 2 consecutive days); 75% had a favorable platelet increase (≥50 × 109/L) within 5 days of initial IVIG dosing. Relevance to Patient Care and Clinical Practice: aHIT is characterized by critically low platelets, thrombosis, and a persistent delay in platelet recovery despite treatment with a nonheparin anticoagulant. An immunoassay and subsequent confirmatory activation assay (at low, high, and 0 IU/mL unfractionated heparin levels) is recommended to confirm diagnosis. Patients nonresponsive to nonheparin anticoagulants within 5 days of initiation should be evaluated for IVIG treatment (2 g/kg cumulative dose). More data are needed to clarify appropriate IVIG dosing weight, although based on current published literature, it is recommended to use actual body weight. Conclusions: Data reported support use of IVIG as adjunctive therapy for patients with aHIT. Judicious IVIG use based on key clinical and laboratory findings is critical.

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“…Treatment of refractory HIT in patients undergoing urgent surgery is even more challenging since it requires a careful balance of bleeding and thrombotic risks. Recently IVIG has been used in patients with HIT undergoing various surgeries such as lung transplants [ 21 ], left ventricular assist device (LVAD) placement [ 3 , 22 ], vascular surgery [ 20 ], and heart transplant [ 11 ]. In 2018, Warkentin et al [ 20 ] presented the case of a 59-year-old man who developed refractory HIT after heparin exposure during vascular surgery, and he later required an urgent revascularization.…”

Section: Discussionmentioning

confidence: 99%

“…The surgery was successful, without thrombotic complications or recurrent thrombocytopenia. Later, Mandernach et al [ 21 ] described another case of HIT in a patient with end-stage lung disease who needed an urgent lung transplant and intraoperative heparin use. Preoperative treatment with PLEX and IVIG led to successful lung transplantation without the development of subsequent HIT.…”

Section: Discussionmentioning

confidence: 99%

Perioperative Plasma Exchange and Intravenous Immunoglobulin Use for Refractory Heparin-Induced Thrombocytopenia in a Liver Transplant Recipient

Habibi,

Hsieh,

Khanna

2023

Am J Case Rep

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Patient: Male, 57-year-old Final Diagnosis: Disseminated intravascular coagulation • heparin-induced thrombocytopenia • liver artery thrombosis • liver transplant rejection Symptoms: Weakness Clinical Procedure: — Specialty: Hematology • Transplantology Objective: Unusual clinical course Background: Heparin-induced thrombocytopenia (HIT) is a serious adverse effect of heparin, which can lead to a prothrombotic state. Prompt cessation of heparin and initiation of non-heparin anticoagulation is the standard of care for HIT. Nevertheless, the treatment can pose challenges, particularly in refractory HIT, in patients with contra-indications to anticoagulation, or those requiring urgent surgery. Additionally, in rare cases, conventional anticoagulation therapy is not effective, necessitating alternative treatments such as plasma exchange (PLEX) and intravenous immunoglobulin (IVIG). Case Report: Here, we report the case of a 57-year-old male patient who developed mild acute cellular rejection, refractory HIT, and disseminated intravascular coagulation after liver transplant surgery. Heparin was stopped and argatroban was initiated for thromboembolism treatment, but hepatic artery thrombosis occurred in the setting of refractory HIT and caused transplant failure. The patient underwent a second liver transplant 1 month after the first surgery. He had 2 sessions of PLEX and received 1 dose of IVIG before and 1 dose during the operation. Despite advanced treatment with PLEX and IVIG, the refractory HIT persisted. Hepatic artery thrombosis recurred within 2 weeks and the transplant failed again despite catheter-directed intra-arterial thrombolysis and argatroban therapy. Conclusions: Recently perioperative PLEX and IVIG have been used a few times for the treatment of refractory HIT. This is the first reported case of a liver transplant recipient with refractory HIT who underwent this treatment strategy. Further investigation is required to determine the efficacy and safety of preoperative and intraoperative administration of PLEX and IVIG, especially in liver transplant recipients with HIT.

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Pre-operative therapeutic plasma Exchange and intravenous immune globulin for the treatment of heparin induced thrombocytopenia in a lung transplant recipient

Cited by 6 publications

References 7 publications

Therapeutic plasma exchange and intravenous immune globulin in the treatment of heparin‐induced thrombocytopenia: A systematic review

Therapeutic plasma exchange and intravenous immune globulin in the treatment of heparin‐induced thrombocytopenia: A systematic review

Intravenous Immune Globulin (IVIG) for Treatment of Autoimmune Heparin-Induced Thrombocytopenia: A Systematic Review

Perioperative Plasma Exchange and Intravenous Immunoglobulin Use for Refractory Heparin-Induced Thrombocytopenia in a Liver Transplant Recipient

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