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Heparin resistance in severe thermal injury: a prospective cohort study

BACKGROUND: Low molecular-weight heparin (LMWH) is routinely administered to burn patients for thromboprophylaxis. Some studies have reported heparin resistance, yet the mechanism(s) and prevalence have not been systematically studied. We hypothesized that nucleosomes, composed of histone structures...

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Autores principales: Cato, Liam D, Bailiff, Benjamin, Price, Joshua, Ermogeneous, Christos, Hazeldine, Jon, Lester, William, Lowe, Gillian, Wearn, Christopher, Bishop, Jonathan R B, Lord, Janet M, Moiemen, Naiem, Harrison, Paul
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Oxford University Press 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8528639/
https://www.ncbi.nlm.nih.gov/pubmed/34692855
http://dx.doi.org/10.1093/burnst/tkab032
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author Cato, Liam D
Bailiff, Benjamin
Price, Joshua
Ermogeneous, Christos
Hazeldine, Jon
Lester, William
Lowe, Gillian
Wearn, Christopher
Bishop, Jonathan R B
Lord, Janet M
Moiemen, Naiem
Harrison, Paul
author_facet Cato, Liam D
Bailiff, Benjamin
Price, Joshua
Ermogeneous, Christos
Hazeldine, Jon
Lester, William
Lowe, Gillian
Wearn, Christopher
Bishop, Jonathan R B
Lord, Janet M
Moiemen, Naiem
Harrison, Paul
author_sort Cato, Liam D
collection PubMed
description BACKGROUND: Low molecular-weight heparin (LMWH) is routinely administered to burn patients for thromboprophylaxis. Some studies have reported heparin resistance, yet the mechanism(s) and prevalence have not been systematically studied. We hypothesized that nucleosomes, composed of histone structures with associated DNA released from injured tissue and activated immune cells in the form of neutrophil extracellular traps (NETs or NETosis), neutralize LMWH resulting in suboptimal anticoagulation, assessed by reduction in anti-factor Xa activity. METHODS: Blood was sampled from >15% total body surface area (TBSA) burn patients receiving LMWH on days 5, 10 and 14. Peak anti-factor Xa (AFXa) activity, anti-thrombin (ATIII) activity, cell-free DNA (cfDNA) levels and nucleosome levels were measured. Mixed effects regression was adjusted for multiple confounders, including injury severity and ATIII activity, and was used to test the association between nucleosomes and AFXa. RESULTS: A total of 30 patients with severe burns were included. Mean TBSA 43% (SD 17). Twenty-three (77%) patients were affected by heparin resistance (defined by AFXa activity <0.2 IU/mL). Mean peak AFXa activity across samples was 0.18 IU/mL (SD 0.11). Mean ATIII was 81.9% activity (SD 20.4). Samples taken at higher LWMH doses were found to have significantly increased AFXa activity, though the effect was not observed at all doses, at 8000 IU no samples were heparin resistant. Nucleosome levels were negatively correlated with AFXa (r = −0.29, p = 0.050) consistent with the hypothesis. The final model, with peak AFXa as the response variable, was adjusted for nucleosome levels (p = 0.0453), ATIII activity (p = 0.0053), LMWH dose pre-sample (p = 0.0049), drug given (enoxaparin or tinzaparin) (p = 0.03), and other confounders including severity of injury, age, gender, time point of sample. CONCLUSIONS: Heparin resistance is a prevalent issue in severe burns. Nucleosome levels were increased post-burn, and showed an inverse association with AFXa consistent with the hypothesis that they may interfere with the anticoagulant effect of heparin in vivo and contribute to heparin resistance. Accurate monitoring of AFXa activity with appropriate therapy escalation plans are recommended with dose adjustment following severe burn injury.
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spelling pubmed-85286392021-10-21 Heparin resistance in severe thermal injury: a prospective cohort study Cato, Liam D Bailiff, Benjamin Price, Joshua Ermogeneous, Christos Hazeldine, Jon Lester, William Lowe, Gillian Wearn, Christopher Bishop, Jonathan R B Lord, Janet M Moiemen, Naiem Harrison, Paul Burns Trauma Research Article BACKGROUND: Low molecular-weight heparin (LMWH) is routinely administered to burn patients for thromboprophylaxis. Some studies have reported heparin resistance, yet the mechanism(s) and prevalence have not been systematically studied. We hypothesized that nucleosomes, composed of histone structures with associated DNA released from injured tissue and activated immune cells in the form of neutrophil extracellular traps (NETs or NETosis), neutralize LMWH resulting in suboptimal anticoagulation, assessed by reduction in anti-factor Xa activity. METHODS: Blood was sampled from >15% total body surface area (TBSA) burn patients receiving LMWH on days 5, 10 and 14. Peak anti-factor Xa (AFXa) activity, anti-thrombin (ATIII) activity, cell-free DNA (cfDNA) levels and nucleosome levels were measured. Mixed effects regression was adjusted for multiple confounders, including injury severity and ATIII activity, and was used to test the association between nucleosomes and AFXa. RESULTS: A total of 30 patients with severe burns were included. Mean TBSA 43% (SD 17). Twenty-three (77%) patients were affected by heparin resistance (defined by AFXa activity <0.2 IU/mL). Mean peak AFXa activity across samples was 0.18 IU/mL (SD 0.11). Mean ATIII was 81.9% activity (SD 20.4). Samples taken at higher LWMH doses were found to have significantly increased AFXa activity, though the effect was not observed at all doses, at 8000 IU no samples were heparin resistant. Nucleosome levels were negatively correlated with AFXa (r = −0.29, p = 0.050) consistent with the hypothesis. The final model, with peak AFXa as the response variable, was adjusted for nucleosome levels (p = 0.0453), ATIII activity (p = 0.0053), LMWH dose pre-sample (p = 0.0049), drug given (enoxaparin or tinzaparin) (p = 0.03), and other confounders including severity of injury, age, gender, time point of sample. CONCLUSIONS: Heparin resistance is a prevalent issue in severe burns. Nucleosome levels were increased post-burn, and showed an inverse association with AFXa consistent with the hypothesis that they may interfere with the anticoagulant effect of heparin in vivo and contribute to heparin resistance. Accurate monitoring of AFXa activity with appropriate therapy escalation plans are recommended with dose adjustment following severe burn injury. Oxford University Press 2021-10-20 /pmc/articles/PMC8528639/ /pubmed/34692855 http://dx.doi.org/10.1093/burnst/tkab032 Text en © The Author(s) 2021. Published by Oxford University Press. https://creativecommons.org/licenses/by/4.0/This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
spellingShingle Research Article
Cato, Liam D
Bailiff, Benjamin
Price, Joshua
Ermogeneous, Christos
Hazeldine, Jon
Lester, William
Lowe, Gillian
Wearn, Christopher
Bishop, Jonathan R B
Lord, Janet M
Moiemen, Naiem
Harrison, Paul
Heparin resistance in severe thermal injury: a prospective cohort study
title Heparin resistance in severe thermal injury: a prospective cohort study
title_full Heparin resistance in severe thermal injury: a prospective cohort study
title_fullStr Heparin resistance in severe thermal injury: a prospective cohort study
title_full_unstemmed Heparin resistance in severe thermal injury: a prospective cohort study
title_short Heparin resistance in severe thermal injury: a prospective cohort study
title_sort heparin resistance in severe thermal injury: a prospective cohort study
topic Research Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8528639/
https://www.ncbi.nlm.nih.gov/pubmed/34692855
http://dx.doi.org/10.1093/burnst/tkab032
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