Receiver operating characteristic analysis of plasma PDI levels in MPN patients who developed TE during follow up

Comparison of standard thrombosis risk factors with plasma PDI and development of thromboembolic events in MPN

Comparison of standard thrombosis risk factors with plasma PDI and development of thromboembolic events in MPN

PDI ELISA does not detect vascular thiol isomerases ERp5 and ERp57

<p>Details of the thromboembolic events in the study</p>

<p>Receiver operating characteristic analysis of plasma PDI levels in MPN patients who developed TE during follow up</p>

<p>PDI ELISA does not detect vascular thiol isomerases ERp5 and ERp57</p>

Details of the thromboembolic events in the study

Abstract Purpose: Thromboembolic events (TE) are the most common complications of myeloproliferative neoplasms (MPN). Clinical parameters, including patient age and mutation status, are used to risk-stratify patients with MPN, but a true biomarker of TE risk is lacking. Protein disulfide isomerase (PDI), an endoplasmic reticulum protein vital for protein folding, also possesses essential extracellular functions, including regulation of thrombus formation. Pharmacologic PDI inhibition prevents thrombus formation, but whether pathologic increases in PDI increase TE risk remains unknown. Experimental Design: We evaluated the association of plasma PDI levels and risk of TE in a cohort of patients with MPN with established diagnosis of polycythemia vera (PV) or essential thrombocythemia (ET), compared with healthy controls. Plasma PDI was measured at enrollment and subjects followed prospectively for development of TE. Results: A subset of patients, primarily those with JAK2-mutated MPN, had significantly elevated plasma PDI levels as compared with controls. Plasma PDI was functionally active. There was no association between PDI levels and clinical parameters typically used to risk-stratify patients with MPN. The risk of TE was 8-fold greater in those with PDI levels above 2.5 ng/mL. Circulating endothelial cells from JAK2-mutated MPN patients, but not platelets, demonstrated augmented PDI release, suggesting endothelial activation as a source of increased plasma PDI in MPN. Conclusions: The observed association between plasma PDI levels and increased risk of TE in patients with JAK2-mutated MPN has both prognostic and therapeutic implications.

AbstractVenous thromboembolism (VTE) with concurrent thrombocytopenia is frequently encountered in patients with cancer. Therapeutic anticoagulation in the setting of thrombocytopenia is associated with a high risk of hemorrhage. Retrospective analyses suggest the utility of modified-dose anticoagulation in this population. To assess the incidence of hemorrhage or thrombosis according to anticoagulation strategy, we performed a prospective, multicenter, observational study. Patients with active malignancy, acute VTE, and concurrent thrombocytopenia (platelet count <100 000/µL) were enrolled. The cumulative incidences of hemorrhage or recurrent VTE were determined considering death as a competing risk. Primary outcomes were centrally adjudicated and comparisons made according to initial treatment with full-dose or modified-dose anticoagulation. A total of 121 patients were enrolled at 6 hospitals. Seventy-five patients were initially treated with full-dose anticoagulation (62%) and 33 (27%) with modified-dose anticoagulation; 13 (11%) patients received no anticoagulation. Most patients who received modified-dose anticoagulation had a hematologic malignancy (31 of 33 [94%]) and an acute deep vein thrombosis (28 of 33 [85%]). In patients who initially received full-dose anticoagulation, the cumulative incidence of major hemorrhage at 60 days was 12.8% (95% confidence interval [CI], 4.9-20.8) and 6.6% (95% CI, 2.4-15.7) in those who received modified-dose anticoagulation (Fine-Gray hazard ratio, 2.18; 95% CI, 1.21-3.93). The cumulative incidence of recurrent VTE at 60 days in patients who initially received full-dose anticoagulation was 5.6% (95% CI, 0.2-11) and 0% in patients who received modified-dose anticoagulation. In conclusion, modified-dose anticoagulation appears to be a safe alternative to therapeutic anticoagulation in patients with cancer who develop deep vein thrombosis in the setting of thrombocytopenia.

Abstract Coronavirus disease 2019 (COVID-19) is associated with a prothrombotic state with a high incidence of thrombotic events during hospitalization; however, data examining rates of thrombosis after discharge are limited. We conducted a retrospective observational cohort study of discharged patients with confirmed COVID-19 not receiving anticoagulation. The cohort included 163 patients with median time from discharge to last recorded follow-up of 30 days (interquartile range [IQR], 17-46 days). The median duration of index hospitalization was 6 days (IQR, 3-12 days) and 26% required intensive care. The cumulative incidence of thrombosis (including arterial and venous events) at day 30 following discharge was 2.5% (95% confidence interval [CI], 0.8-7.6); the cumulative incidence of venous thromboembolism alone at day 30 postdischarge was 0.6% (95% CI, 0.1-4.6). The 30-day cumulative incidence of major hemorrhage was 0.7% (95% CI, 0.1-5.1) and of clinically relevant nonmajor bleeds was 2.9% (95% CI, 1.0-9.1). We conclude that the rates of thrombosis and hemorrhage appear to be similar following hospital discharge for COVID-19, emphasizing the need for randomized data to inform recommendations for universal postdischarge thromboprophylaxis.

Introduction: Factor XI (FXI) deficiency is a rare bleeding disorder with a prevalence of approximately one in one million in the general population but more prevalent in the Ashkenazi Jewish community, in whom 10% are heterozygous with mild deficiencies. An ever increasing number of women are referred to hematology specialists without a clear bleeding history but a mild FXI deficiency identified initially through genetic panel testing. For instance, direct-to-consumer genetic testing has become commonplace with certain platforms such as 23andMe receiving FDA authorization to specifically include genetic testing for the most common FXI polymorphisms (i.e. F283L, E117X, and IVS14+1G>A). Unlike other inherited bleeding disorders, FXI levels do not reliably correlate with bleeding severity. There is limited data to guide the appropriate management of mild FXI deficiency during delivery. Considering postpartum hemorrhage accounts for approximately 10% of maternal mortality, we evaluated delivery outcomes among women with mild factor XI deficiency. Methods We performed a matched, retrospective, case control single-institution analyses. Pregnant women were identified with mild factor XI deficiency with levels between 20-70%. The control population consisted of 200 women undergoing deliveries between 2016 and 2018 identified by successive medical record numbering. Primary postpartum hemorrhage (PPH) was defined as estimated blood loss (EBL) > 1000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after delivery. Results Among the 40 FXI deficient women there were 71 deliveries, and outcomes were compared with 200 controls deliveries. A similar percentage of deliveries in the FXI deficient women and controls were vaginal (63% versus 63%, P=1.0). The groups were well matched for age and number of primigravid deliveries. The median estimated blood loss were the same FXI and controls for vaginal deliveries (300 mL for both groups) and caesarean deliveries (800 mL for both groups). There were no PPH recorded among the 45 vaginal deliveries in women with factor XI deficiency compared with one of 125 deliveries in the control cohort. In contrast, women with mild factor XI deficiency undergoing cesarean delivery were approximately 2-fold more likely to develop PPH relative to controls (odds ratio 2.73, 95% CI 1.02-7.26). The overall rates of PPH among those FXI women who underwent cesarean delivery was 38.4% (10 of 26 deliveries) compared with 18.7% (14 of 75 deliveries, p=0.04). No women in the FXI deficient cohort required RBC transfusions, while three women in the control cohort required red cell transfusions. Prior history of hemorrhage was the best predictor of PPH following cesarean delivery. The majority of women who developed PPH following caesarean delivery had a prior history of hemorrhage (7 of 10). Only two of the women with PPH received prophylactic measures prior to delivery. Among the women 16 caesarean deliveries in the FXI deficiency group without PPH, significantly fewer had a history of bleeding (2 of 16, p=0.009). Conclusions: In this case control study, we did not observe any cases of PPH among women with FXI deficiency who underwent a vaginal delivery but noted a greater than 2-fold increase in PPH among those women who underwent a cesarean delivery. In those women with a bleeding history the risk of PPH following cesarean section the risk of PPH was nearly 10-fold higher compared to women without a history of hemorrhage supporting the role for prophylactic measures in this high-risk group. Disclosures Zwicker: Portola: Consultancy; Daiichi: Consultancy; Incyte: Research Funding; Seattle Genetics: Consultancy; Bayer: Consultancy; Parexel: Consultancy; Quercegen: Research Funding.

BACKGROUND: Myeloproliferative neoplasms (MPNs) including essential thrombocythemia (ET) and polycythemia vera (PV) are commonly diagnosed in the sixth decade, but as many as 20% of patients are younger than 40. This introduces the possibility of pregnancy and need for specialized management. ET/PV patients have a higher risk of pregnancy complications, with a reported 68.5% live birth rate (LBR), and 1.8% and 2.4% risk of major thrombotic and bleeding events respectively. Risk factors for pregnancy complications are conflicting, and further contemporary studies are needed. METHODS: We retrospectively analyzed 130 pregnancies in 58 ET/PV women seen at 3 affiliate hospitals from 1995-2019. Patients were identified using ICD-9/10 codes in the electronic medical record. We analyzed 12 input variables as risk factors associated with first pregnancy complications after MPN diagnosis by univariate logistic regression (α=0.1, type I error rate; Table 1a). Variables with p<0.10 were included in multivariate logistic regression modeling. Cell counts were averaged at baseline, each trimester, delivery, and the postpartum period. RESULTS: The analysis included 53 ET patients and 5 PV patients. Driver mutation status for JAK2, CALR, or MPL was available in 79% of all patients: 60.3% were JAK2+ and 12.1% were CALR+. 2 patients were high-risk by International Prognostic Score of thrombosis (IPSET). Median maternal age was 34, median year of delivery was 2010, and median time between MPN diagnosis and index pregnancy was 3 years. There were no complications in 46% of pregnancies. The LBR was 70%. Aspirin (ASA) and interferon were used in 58.5% and 1.5% of pregnancies, respectively. In the pregnancies that resulted in live birth, postpartum low-molecular-weight heparin (LMWH) was used in 23.5% of cases. Antepartum LMWH was used in 6.9% of cases. PV patients were more likely to be treated with ASA (p=0.039) or postpartum LMWH (p=0.013) compared to ET patients. The most common complication was spontaneous abortion (SAB), defined as fetal loss <20 weeks, which occurred in 24.6% of all cases. Thrombosis and hemorrhage occurred in 2.3% and 6.9% of pregnancies respectively. On univariate analysis, only history of miscarriage prior to MPN diagnosis (13.2% of women) and ASA use during pregnancy were significantly associated with outcomes. On multivariate analysis, history of prior miscarriage remained statistically significant (OR 8.82, p=0.023), while ASA use during pregnancy trended toward improved outcomes (OR 0.33, p=0.12). All other variables were not significantly associated with pregnancy outcomes (Table 1a). Cell counts throughout pregnancy were available in 53 ET patients (Figure 1). There was a significant decline in platelets (p<0.001) from baseline to delivery. The average percent platelet, hemoglobin (Hg), and white blood cell (WBC) change from baseline to delivery was -42.98%, -9.25%, and +35.65%, respectively. The median nadir was at delivery. In 12 women with postpartum labs drawn within one month of delivery, 7 had recovered their platelet counts to at least 75% of their baseline. CONCLUSIONS: In this contemporary analysis of pregnancy outcomes in 130 ET/PV women, we demonstrate that overall prognosis is good, with a LBR of 70%. However, pregnant ET/PV patients remain at high risk, with SAB and complication rates of 24.6% and 54%, and maternal thrombosis and hemorrhage occurring in 2.3% and 6.9% of pregnancies. We show for the first time that prior miscarriage is a significant predictor of pregnancy complication in MPN patients (OR 8.82). Cell counts have never been systematically evaluated in MPN patients throughout pregnancy. We found that platelet counts decrease dramatically, often to normal, in ET. Platelet recovery occurs quickly in the postpartum period, with most patients returning to 75% of their baseline platelet count by one month postpartum. The observed 43% platelet nadir from starting counts to the day of delivery is greater than the expected 20% platelet decrease in the normal pregnant population. This decrease is unlikely to be explained by hemodilution, as the observed Hg decrease in ET patients approximates that seen in normal women. While we found no effect of JAK2 or CALR mutation status on pregnancy complications, it is possible that changes in allele burden influence platelet trends and outcomes. Measuring these changes in available women is the next step in our investigation. Disclosures Bustoros, MD: Takeda: Honoraria. Connell:Michael H. Flanagan Foundation: Membership on an entity's Board of Directors or advisory committees. Connors:Bristol Myer-Squibb: Consultancy, Other: Scientific Ad boards; Portola: Other: scientific ad boards; Abbott: Consultancy; Eli Lilly: Consultancy. Kuter:Argenx: Consultancy, Honoraria, Research Funding; Alnylam: Consultancy, Honoraria, Research Funding; UCB: Consultancy, Honoraria; Takeda (Bioverativ): Consultancy, Honoraria, Research Funding; Actelion (Syntimmune): Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria; Shire: Consultancy, Honoraria; Shinogi: Consultancy, Honoraria; Agios: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Momenta: Consultancy, Honoraria; Momenta: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Platelet Disorder Support Association: Consultancy, Honoraria; Agios: Consultancy, Honoraria, Research Funding; Caremark: Consultancy, Honoraria; Daiichi Sankyo: Consultancy, Honoraria; Amgen: Consultancy, Honoraria, Research Funding; Dova: Consultancy, Honoraria; Dova: Consultancy, Honoraria; Kyowa-Kirin: Consultancy, Honoraria; Kezar: Research Funding; Bristol Myers Squibb (BMS): Consultancy, Honoraria, Research Funding; Actelion (Syntimmune): Consultancy, Honoraria, Research Funding; Daiichi Sankyo: Consultancy, Honoraria; Protalex: Consultancy, Honoraria, Research Funding; Kezar: Research Funding; Platelet Disorder Support Association: Consultancy, Honoraria; Up-to-Date: Consultancy, Honoraria, Patents & Royalties: 3 Up-to-Date chapters; Takeda (Bioverativ): Consultancy, Honoraria, Research Funding; Shire: Consultancy, Honoraria; Rigel: Consultancy, Honoraria, Research Funding; Sanofi: Consultancy, Honoraria; Rigel: Consultancy, Honoraria, Research Funding; Genzyme: Consultancy, Honoraria; Sanofi: Consultancy, Honoraria; Shinogi: Consultancy, Honoraria; Genzyme: Consultancy, Honoraria; Merck Sharp Dohme: Consultancy, Honoraria; Protalix: Consultancy, Honoraria; Protalix: Consultancy, Honoraria; Principia: Consultancy, Honoraria, Research Funding; Principia: Consultancy, Honoraria, Research Funding; Protalex: Consultancy, Honoraria, Research Funding; UCB: Consultancy, Honoraria; Up-to-Date: Consultancy, Honoraria, Patents & Royalties: 3 Up-to-Date chapters; Zafgen: Consultancy, Honoraria; Zafgen: Consultancy, Honoraria; Amgen: Consultancy, Honoraria, Research Funding; Alnylam: Consultancy, Honoraria, Research Funding; Argenx: Consultancy, Honoraria, Research Funding; Merck Sharp Dohme: Consultancy, Honoraria; Kyowa-Kirin: Consultancy, Honoraria; Caremark: Consultancy, Honoraria; Bristol Myers Squibb (BMS): Consultancy, Honoraria, Research Funding. Mullally:Janssen: Research Funding. Neuberg:Pharmacyclics: Research Funding; Madrigal Pharmaceuticals: Equity Ownership; Celgene: Research Funding. Zwicker:Daiichi: Consultancy; Quercegen: Research Funding; Parexel: Consultancy; Portola: Consultancy; Incyte: Research Funding; Seattle Genetics: Consultancy; Bayer: Consultancy. Hobbs:Jazz pharmaceuticals: Consultancy; Bayer: Research Funding; Merck: Research Funding; Celgene: Consultancy; Incyte: Consultancy, Research Funding; Agios: Consultancy.

Coronavirus disease 2019 (Covid-19) is associated with venous and arterial thrombotic complications, especially among those hospitalized with more severe disease. Disturbances in coagulation indices are commonly observed in severe Covid-19 including marked elevations of plasma D-dimer that portend a poor prognosis. Emerging evidence points to the inadequacy of standard thromboprophylaxis. And, in an attempt to prevent thrombotic events and potentially limit microvasculature fibrin deposition, more aggressive thromboprophylaxis anticoagulation regimens are considered, including therapeutic dosing of unfractionated heparin (UFH).1 Heparin induced thrombocytopenia (HIT) is an uncommon but potentially life-threatening complication of heparin exposure. Autoimmune hematologic phenomena have increasingly been recognized during the course of Covid-19.2, 3 Accordingly, we evaluated the incidence of HIT among hospitalized patients with Covid-19 treated with intravenous, therapeutic-dose heparin. Institutional Review Board approval was obtained. A retrospective cohort analysis was performed for patients hospitalized at Beth Israel Deaconess Medical Center with Covid-19 confirmed by PCR between February 1, 2020 to May 7, 2020 and received intravenous UFH for ≥5 days. A cut off of 5 days was selected based on the known natural history of HIT. The HIT antibody testing was ordered by the treating physicians and performed by latex immunoassay for anti-platelet factor 4/heparin antibodies (HemosIL HIT-Ab).4 Confirmatory testing performed by serotonin release assay (Versiti, Wisconsin). To account for death as a competing risk, estimation of the cumulative incidence of HIT was calculated by competing risk analyses (stcompet, Stata Corp, TX) along with 95% confidence intervals at 25 days from start of heparin infusion. Among 439 hospitalized patients with Covid-19, 88 patients who received at least 5 days of UFH were included in the analyses. The target partial thromboplastin time was above 60 seconds in 84 patients and the remaining four patients the target was above 50 seconds. Median duration of heparin exposure was 11 days (IQR 7-15 days). The most common indications for therapeutic heparin were Covid-19 coagulopathy (N = 58), confirmed or presumed venous thromboembolism (N = 15), and atrial fibrillation (N = 15). Among eight patients where there was suspicion for HIT, five patients tested positive for HIT by latex immunoassay (Table S1). The cumulative incidence of positive HIT immunoassay assay was 12% at 25 days (95% CI, 4% to 26%, Figure 1). Direct thrombin inhibitors were administered following HIT diagnosis (argatroban N = 4, bivalirudin N = 1). One patient was identified with thrombotic complications in the setting of HIT, this included evidence of acute cerebrovascular infarct as well as extensive areas of splenic infarction. Three patients developed major hemorrhagic events. Three patients died during hospitalization of progressive respiratory failure, one was discharged, and one remains hospitalized. Therapeutic UFH is commonly administered in order to mitigate the prothrombotic state in severe Covid-19. We report a cumulative incidence of detectable HIT antibodies of 12% at 25 days. In non-Covid-19 cohort analyses conducted in hospitalized medical populations, the rate of diagnosed HIT by antibody testing alone (ie, without serotonin release confirmation) is typically less than 3%.5, 6 For instance, in a cohort of 5415 patients receiving therapeutic heparin, the overall incidence was 0.76%.5 These results raise several important issues. First, while immunologic detection of auto-antibodies such as lupus anticoagulant appear to be prevalent among patients with Covid-19, whether or not these are pathologic is unclear. In our cohort, the majority of the positive HIT antibody tests were not definitively confirmed by serotonin release assay, which reinforces the importance of confirmatory testing. Second, while the benefit of empiric therapeutic heparin to mitigate the hypercoagulable state of Covid-19 is not established, the diagnosis of HIT necessitates the initiation of non-heparin anticoagulants. Three of the five patients diagnosed with HIT developed major hemorrhages after switching to direct thrombin inhibitors. Bleeding risks must be balanced in prothrombotic disorders and critically ill patients may have multiple risk factors, a recent paper showed that the rate of major bleeding in critically ill patients with Covid-19 was considerable.7 Lastly, the incidence of HIT commonly correlates with duration and intensity of heparin exposure. Even in the absence of immune hyperstimulation, prolonged hospitalizations are common with severe Covid-19 and thus an increased incidence of HIT would be expected. This study is the first to investigate the incidence of HIT in hospitalized patients with Covid-19 being treated with therapeutic unfractionated heparin, however we acknowledge limitations including the limited sample size given the single center design. Given the retrospective design of the study, HIT testing was only performed when considered indicated by the treating providers. However cytopenias and thrombosis are common in critically ill patients and given the widespread use of heparin in hospitalized Covid-19 patients, it is possible that screening serologies would detect higher rates of HIT antibodies. This would lead to an underestimate of the true prevalence of HIT antibodies by detecting unsuspected patients. The latex immune turbidimetric assay used in our center is semi-quantitative with operating characteristics superior to the more common ELISA.4 The serotonin release assay, which is the confirmatory test, was performed in all four of the patients with low positive values, and only one was negative, belying that the antibodies detected in a majority of the cases were not false positives. In this single center retrospective cohort study, we found a high incidence of HIT antibody positivity in critically ill Covid-19 patients being treated with therapeutic unfractionated heparin. Despite the limitations of the study design, our findings suggest that HIT may be an unrecognized clinical entity at least in a subpopulation of patients and merits further study. Considering the frequency of HIT following prolonged UFH exposure in the intensive care setting, we urge caution in the empiric use of intravenous UFH for the management of Covid-19 coagulopathy. JIZ reports research funding from Incyte and Quercegen; consultancy: Sanofi, CSL, Parexel; honoraria/advisory boards: Pfizer/BMS, Portola, Daiichi. KAB reports consultancy with Janssen. WCA is employed by DynaMed. Table S1 Characteristics of patients with COVID-19 receiving UFH who tested positive for HIT antibodies by latex immunoassay. 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Background Coronavirus disease-2019 (COVID-19) is a recognized prothrombotic state. Patients hospitalized with active cancer are predisposed to thrombosis but whether active cancer further amplifies thrombotic risk with COVID-19 is not known. Objectives To evaluate cumulative incidences of thrombotic and hemorrhagic events in hospitalized COVID-19 patients with and without active cancer at 28 days. Methods A retrospective cohort analysis of consecutive adults hospitalized with COVID-19 was performed. Active cancer required cancer-directed therapy within previous 6 months. The cumulative incidences of thrombosis or hemorrhage were estimated considering death as a competing risk. Results Patients without cancer (n = 353) and active cancer (n = 45) were comparable in terms of age, sex, antibiotics administered, length of hospitalization, and critical care. The most common malignancies were lymphoid (17.8%), gastrointestinal (15.6%), lung (13.3%), and genitourinary (13.3%). At day 28, the cumulative incidence of thrombotic events was 18.2% (95% confidence interval [CI], 10.2%-27.9%) in the non-cancer cohort and 14.2% (95% CI, 4.7%-28.7%) in the cancer cohort. The cumulative incidence of major and fatal bleeding at day 28 was 20.8% (95% CI, 12.1%-31.0%) in the non-cancer group and 19.5% (95% CI, 5.5%-39.8%) in the cancer cohort. Three patients experienced fatal bleeds, all of whom were in the non-cancer cohort. Survival was significantly shorter in the group with active cancer (P = .038). Conclusions We observed a similarly high incidence of thrombosis and bleeding among patients admitted with COVID-19 with or without active cancer.