Contaminated heparin associated with adverse clinical events and activation of the contact system

N Engl J Med. 2008 Jun 5;358(23):2457-67. doi: 10.1056/NEJMoa0803200. Epub 2008 Apr 23.


Background: There is an urgent need to determine whether oversulfated chondroitin sulfate (OSCS), a compound contaminating heparin supplies worldwide, is the cause of the severe anaphylactoid reactions that have occurred after intravenous heparin administration in the United States and Germany.

Methods: Heparin procured from the Food and Drug Administration, consisting of suspect lots of heparin associated with the clinical events as well as control lots of heparin, were screened in a blinded fashion both for the presence of OSCS and for any biologic activity that could potentially link the contaminant to the observed clinical adverse events. In vitro assays for the activation of the contact system and the complement cascade were performed. In addition, the ability of OSCS to recapitulate key clinical manifestations in vivo was tested in swine.

Results: The OSCS found in contaminated lots of unfractionated heparin, as well as a synthetically generated OSCS reference standard, directly activated the kinin-kallikrein pathway in human plasma, which can lead to the generation of bradykinin, a potent vasoactive mediator. In addition, OSCS induced generation of C3a and C5a, potent anaphylatoxins derived from complement proteins. Activation of these two pathways was unexpectedly linked and dependent on fluid-phase activation of factor XII. Screening of plasma samples from various species indicated that swine and humans are sensitive to the effects of OSCS in a similar manner. OSCS-containing heparin and synthetically derived OSCS induced hypotension associated with kallikrein activation when administered by intravenous infusion in swine.

Conclusions: Our results provide a scientific rationale for a potential biologic link between the presence of OSCS in suspect lots of heparin and the observed clinical adverse events. An assay to assess the amidolytic activity of kallikrein can supplement analytic tests to protect the heparin supply chain by screening for OSCS and other highly sulfated polysaccharide contaminants of heparin that can activate the contact system.

Publication types

  • Case Reports
  • Research Support, N.I.H., Extramural

MeSH terms

  • Anaphylaxis / chemically induced*
  • Animals
  • China
  • Chondroitin Sulfates / adverse effects
  • Chondroitin Sulfates / analysis*
  • Chondroitin Sulfates / pharmacology*
  • Complement Activation / drug effects*
  • Complement C3a / biosynthesis
  • Complement C3a / drug effects
  • Complement C5a / biosynthesis
  • Complement C5a / drug effects
  • Drug Contamination*
  • Drug Industry
  • Female
  • Germany
  • Heparin / adverse effects
  • Heparin / chemistry*
  • Humans
  • Hypotension / chemically induced
  • Kallikreins / drug effects*
  • Kallikreins / metabolism
  • Middle Aged
  • Sus scrofa
  • United States
  • United States Food and Drug Administration


  • Complement C3a
  • Complement C5a
  • Heparin
  • Chondroitin Sulfates
  • Kallikreins