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Liu L, Xu H, Wang J, Wang H, Ren S, Huang Q, Zhang M, Zhou H, Yang C, Jia L, Huang Y, Zhang H, Tao Y, Li Y, Min Y. Trimethylamine-N-oxide (TMAO) and basic fibroblast growth factor (bFGF) are possibly involved in corticosteroid resistance in adult patients with immune thrombocytopenia. Thromb Res 2024; 233:25-36. [PMID: 37988847 DOI: 10.1016/j.thromres.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 10/22/2023] [Accepted: 11/02/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE Immune thrombocytopenia (ITP) is an autoimmune disease characterized by accelerated platelet clearance. Gut dysbiosis was associated with its pathogenesis, but the underlying mechanisms have not been fully elucidated. Patients with ITP exhibit varying degrees of responsiveness to corticosteroid treatment. Therefore, prognostic indexes for corticosteroid responsiveness in ITP could offer valuable guidance for clinical practices. METHODS The present study examined the signature of six types of gut-microbiota metabolites and forty-eight types of cytokines, chemokines, and growth factors and their clinical significance in patients with ITP. RESULTS Both patients with good and poor corticosteroid responsiveness exhibited significantly elevated/suppressed secretion of twenty-two cyto(chemo)kins/growth factors in comparison to healthy controls. Additionally, patients with ITP demonstrated a significant decrease in plasma levels of trimethylamine-N-oxide (TMAO), which was found to be negatively correlated to circulating platelet counts, and positively correlated with Interleukin (IL)-1β and IL-18. Notably, patients who exhibited poor response to corticosteroid treatment displayed elevated levels of TMAO and basic fibroblast growth factor (bFGF) in comparison to responders. Additionally, we found that the amalgamation of TMAO, bFGF and interleukin (IL)-13 could serve as a valuable prognostic tool for predicting CS responsiveness. CONCLUSION Patients with ITP were characterized overall by an imbalanced secretion of cyto(cheo)kins/growth factors and inadequate levels of TMAO. The varying degrees of responsiveness to corticosteroid treatment can be attributed to different profiles of basic FGF and TMAO that might be related to overburdened oxidative stress and inflammasome overactivation, and ultimately mediate corticosteroid resistance.
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Affiliation(s)
- Lei Liu
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Huifang Xu
- Department of Clinical Medicine, Jining Medical University, Jining, China; Department of Pediatric Hematology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Jian Wang
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Haiyan Wang
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Saisai Ren
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Qian Huang
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Mingyan Zhang
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Hui Zhou
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Chunyan Yang
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Lu Jia
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Yu Huang
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Hao Zhang
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Yanling Tao
- Department of Pediatric Hematology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Ying Li
- Department of Pediatric Hematology, Affiliated Hospital of Jining Medical University, Jining, China.
| | - Yanan Min
- Department of Hematology, Affiliated Hospital of Jining Medical University, Jining, China; Shandong University of Traditional Chinese Medicine, Jinan, China.
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Kashiwagi H, Kuwana M, Murata M, Shimada N, Takafuta T, Yamanouchi J, Kato H, Hato T, Tomiyama Y. Reference guide for the diagnosis of adult primary immune thrombocytopenia, 2023 edition. Int J Hematol 2024; 119:1-13. [PMID: 37957517 PMCID: PMC10770234 DOI: 10.1007/s12185-023-03672-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 11/15/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia due to accelerated platelet destruction and impaired platelet production. Diagnosis of ITP is still challenging because ITP has been diagnosed by exclusion. Exclusion of thrombocytopenia due to bone marrow failure is especially important in Japan because of high prevalence of aplastic anemia compared to Western countries. Hence, we propose a new diagnostic criteria involving the measurement of plasma thrombopoietin (TPO) levels and percentage of immature platelet fraction (RP% or IPF%); 1) isolated thrombocytopenia with no morphological evidence of dysplasia in any blood cell type in a blood smear, 2) normal or slightly increased plasma TPO level (< cutoff), 3) elevated RP% or IPF% (> upper limit of normal), and 4) absence of other conditions that potentially cause thrombocytopenia including secondary ITP. A diagnosis of ITP is made if conditions 1-4 are all met. Cases in which criterion 2 or 3 is not met or unavailable are defined as "possible ITP," and diagnosis of ITP can be made mainly by typical clinical course. These new criteria enable us to clearly differentiate ITP from aplastic anemia and other forms of hypoplastic thrombocytopenia and can be highly useful in clinical practice for avoiding unnecessary bone marrow examination as well as for appropriate selection of treatments.
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Affiliation(s)
- Hirokazu Kashiwagi
- Department of Blood Transfusion, Osaka University Hospital, Suita, Osaka, 565-0871, 2-15, Yamadaoka, Japan.
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Mitsuru Murata
- Center for Clinical Medical Research, International University of Health and Welfare, Ohtawara, Tochigi, Japan
| | - Naoki Shimada
- Center for Basic Medical Research, International University of Health and Welfare, Ohtawara, Tochigi, Japan
| | - Toshiro Takafuta
- Department of Internal Medicine, Hiroshima City Funairi Citizens Hospital, Hiroshima, Hiroshima, Japan
| | - Jun Yamanouchi
- Division of Blood Transfusion and Cell Therapy, Ehime University Hospital, Toon, Ehime, Japan
| | - Hisashi Kato
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Takaaki Hato
- Japanese Red Cross Ehime Blood Center, Matsuyama, Ehime, Japan
| | - Yoshiaki Tomiyama
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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Wang Y, Sheng L, Han F, Guo Q, Zhang Z, Hou Y, Feng Q, Zhou H, Ji X, Peng J, Hou M, Xu M. Efficacy and safety of treatments in newly diagnosed adult primary immune thrombocytopenia: A systematic review and network meta-analysis. EClinicalMedicine 2023; 56:101777. [PMID: 36578882 PMCID: PMC9791309 DOI: 10.1016/j.eclinm.2022.101777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Immune thrombocytopenia is an autoimmune disease characterised by decreased platelet count. In recent years, novel therapeutic regimens have been investigated in randomised controlled trials (RCTs). We aimed to compare the efficacy and safety of different treatments in newly diagnosed adult primary immune thrombocytopenia. METHODS We did a systematic review and network meta-analysis of RCTs involving treatments for newly diagnosed primary immune thrombocytopenia. PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched up to April 31, 2022. The primary outcomes were 6-month sustained response and early response. Secondary outcome was grade 3 or higher adverse events. This study is registered with PROSPERO (CRD42022296179). FINDINGS Eighteen RCTs (n = 1944) were included in this study. Pairwise meta-analysis showed that the percentage of patients achieving early response was higher in the dexamethasone-containing doublet group than in the dexamethasone group (79.7% vs 68.7%, odds ratio [OR] 1.82, 95% CI 1.10-3.02). The difference was more profound for sustained response (60.5% vs 37.4%, OR 2.57, 95% CI 1.95-3.40). Network meta-analysis showed that dexamethasone plus recombinant human thrombopoietin ranked first for early response, followed by dexamethasone plus oseltamivir or tacrolimus. Rituximab plus prednisolone achieved highest sustained response, followed by dexamethasone plus all-trans retinoic acid or rituximab. Rituximab plus dexamethasone showed 15.3% of grade 3 or higher adverse events, followed by prednis(ol)one (4.8%) and all-trans retinoic acid plus dexamethasone (4.7%). INTERPRETATION Our findings suggested that compared with monotherapy dexamethasone or prednis(ol)one, the combined regimens had better early and sustained responses. rhTPO plus dexamethasone ranked top in early response, while rituximab plus corticosteroids obtained the best sustained response, but with more adverse events. Adding oseltamivir, all-trans retinoic acid or tacrolimus to dexamethasone reached equally encouraging sustained response, without compromising safety profile. Although this network meta-analysis compared all the therapeutic regimens up to date, more head-to-head RCTs with larger sample size are warranted to make direct comparison among these strategies. FUNDING National Natural Science Foundation of China, Major Research Plan of National Natural Science Foundation of China, Shandong Provincial Natural Science Foundation and Young Taishan Scholar Foundation of Shandong Province.
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Key Words
- AEs, adverse events
- ASH, American Society of Hematology
- All-trans retinoic acid
- Anti-D, Rho(D) immune globulin
- CI, confidence interval
- CrI, credible intervals
- DEX, dexamethasone
- Dexamethasone
- ITP, primary immune thrombocytopenia
- IVIg, intravenous immunoglobulin
- NMA, network meta-analysis
- Network meta-analysis
- OR, odds ratio
- OSE, oseltamivir
- Oseltamivir
- PRD, prednis(ol)one
- Prednis(ol)one
- Primary immune thrombocytopenia
- QoL, quality of life
- RA, all-trans retinoic acid
- RCTs, randomised controlled trials
- RTX, rituximab
- Randomized controlled trials
- Rituximab
- SUCRA, the surface under the cumulative ranking curve
- TAC, tacrolimus
- TPO-RAs, thrombopoietin receptor agonists
- Tacrolimus
- mPRD, methylprednisolone
- rhTPO
- rhTPO, recombinant human thrombopoietin
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Affiliation(s)
- Yun Wang
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Lei Sheng
- Department of General Surgery, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Fengjiao Han
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Qiuyu Guo
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Zihan Zhang
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Yu Hou
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Qi Feng
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Hai Zhou
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Xuebin Ji
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Jun Peng
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
- Advanced Medical Research Institute, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
- Corresponding author. Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Wenhuaxi Road, Jinan, China.
| | - Miao Xu
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
- Corresponding author. Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Wenhuaxi Road, Jinan, China.
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Bone marrow remodelling supports hematopoiesis in response to immune thrombocytopenia progression. Blood Adv 2021; 5:4877-4889. [PMID: 34428275 PMCID: PMC9153055 DOI: 10.1182/bloodadvances.2020003887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/10/2021] [Indexed: 11/20/2022] Open
Abstract
Sustained ITP activates and increases the number of functional LT-HSCs. The remodeled ITP bone marrow enhances hematopoiesis.
Immune thrombocytopenia (ITP) is an acquired autoimmune condition characterized by both reduced platelet production and the destruction of functionally normal platelets by sustained attack from the immune system. However, the effect of prolonged ITP on the more immature hematopoietic progenitors remains an open area of investigation. By using a murine in vivo model of extended ITP, we revealed that ITP progression drives considerable progenitor expansion and bone marrow (BM) remodeling. Single-cell assays using Lin–Sca1+c-Kit+CD48–CD150+ long-term hematopoietic stem cells (LT-HSCs) revealed elevated LT-HSC activation and proliferation in vitro. However, the increased activation did not come at the expense of LT-HSC functionality as measured by in vivo serial transplantations. ITP progression was associated with considerable BM vasodilation and angiogenesis, as well as a twofold increase in the local production of CXCL12, a cytokine essential for LT-HSC function and BM homing expressed at high levels by LepR+ BM stromal cells. This was associated with a 1.5-fold increase in LepR+ BM stromal cells and a 5.5-fold improvement in progenitor homing to the BM. The increase in stromal cells was transient and reverted back to baseline after platelet count returned to normal, but the vasculature changes in the BM persisted. Together, our data demonstrate that LT-HSCs expand in response to ITP and that LT-HSC functionality during sustained hematopoietic stress is maintained through an adapting BM microenvironment.
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Hitchcock IS, Hafer M, Sangkhae V, Tucker JA. The thrombopoietin receptor: revisiting the master regulator of platelet production. Platelets 2021; 32:770-778. [PMID: 34097561 PMCID: PMC8292222 DOI: 10.1080/09537104.2021.1925102] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 12/25/2022]
Abstract
Thrombopoietin (TPO) and its receptor, MPL, are the primary regulators of platelet production and critical for hematopoietic stem cell (HSC) maintenance. Since TPO was first cloned in 1994, the physiological and pathological roles of TPO and MPL have been well characterized, culminating in the first MPL agonists being approved for the treatment of chronic immune thrombocytopenia in 2008. Dysregulation of the TPO-MPL signaling axis contributes to the pathogenesis of hematological disorders: decreased expression or function results in severe thrombocytopenia progressing to bone marrow failure, while hyperactivation of MPL signaling, either by mutations in the receptor or associated Janus kinase 2 (JAK2), results in pathological myeloproliferation. Despite its importance, it was only recently that the long-running debate over the mechanism by which TPO binding activates MPL has been resolved. This review will cover key aspects of TPO and MPL structure and function and their importance in receptor activation, discuss how these are altered in hematological disorders and consider how a greater understanding could lead to the development of better-targeted and more efficacious therapies.
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Affiliation(s)
- Ian S. Hitchcock
- York Biomedical Research Institute, Department of Biology, University of York, York, UK
| | - Maximillian Hafer
- Department of Biology and Center of Cellular Nanoanalytics, University of Osnabrück, Osnabrück, Germany
| | - Veena Sangkhae
- Center for Iron Disorders, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Julie A. Tucker
- York Biomedical Research Institute, Department of Biology, University of York, York, UK
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6
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Märklin M, Tandler C, Kopp HG, Hoehn KL, Quintanilla-Martinez L, Borst O, Müller MR, Saur SJ. C-Cbl regulates c-MPL receptor trafficking and its internalization. J Cell Mol Med 2020; 24:12491-12503. [PMID: 32954656 PMCID: PMC7687000 DOI: 10.1111/jcmm.15785] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/10/2020] [Accepted: 07/31/2020] [Indexed: 01/11/2023] Open
Abstract
Thrombocyte formation from megakaryocyte and their progenitor cells is tightly regulated by thrombopoietin (TPO) and its receptor c‐MPL, thereby maintaining physiological functionality and numbers of circulating platelets. In patients, dysfunction of this regulation could cause thrombocytopenia or myeloproliferative syndromes. Since regulation of this pathway is still not completely understood, we investigated the role of the ubiquitin ligase c‐Cbl which was previously shown to negatively regulated c‐MPL signalling. We developed a new conditional mouse model using c‐Cblfl/flPf4Cre mice and demonstrated that platelet‐specific knockout of c‐Cbl led to severe microthrombocytosis and impaired uptake of TPO and c‐MPL receptor internalization. Furthermore, we characterized a constitutive STAT5 activation c‐Cbl KO platelets. This study identified c‐Cbl as a potential player in causing megakaryocytic and thrombocytic disorders.
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Affiliation(s)
- Melanie Märklin
- Clinical Collaboration Unit Translational Immunology, German Cancer Consortium (DKTK), German Cancer Research Centre (DKFZ), University Hospital Tübingen, Tübingen, Germany
| | - Claudia Tandler
- Clinical Collaboration Unit Translational Immunology, German Cancer Consortium (DKTK), German Cancer Research Centre (DKFZ), University Hospital Tübingen, Tübingen, Germany
| | - Hans-Georg Kopp
- Department of Molecular Oncology and Thoracic Oncology, Robert-Bosch-Hospital Stuttgart, Stuttgart, Germany
| | - Kyle L Hoehn
- School of Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney, NSW, Australia
| | | | - Oliver Borst
- Department of Kardiology and Angiology, University Hospital Tübingen, Tübingen, Germany
| | - Martin R Müller
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, University Hospital Tübingen, Tübingen, Germany.,Department of Hematology, Oncology and Immunology, Klinikum Region Hannover, KRH Klinikum Siloah, Hannover, Germany
| | - Sebastian J Saur
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology, University Hospital Tübingen, Tübingen, Germany
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Mahat U, Rotz SJ, Hanna R. Use of Thrombopoietin Receptor Agonists in Prolonged Thrombocytopenia after Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2020; 26:e65-e73. [DOI: 10.1016/j.bbmt.2019.12.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 01/09/2023]
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8
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Bussel J, Kulasekararaj A, Cooper N, Verma A, Steidl U, Semple JW, Will B. Mechanisms and therapeutic prospects of thrombopoietin receptor agonists. Semin Hematol 2019; 56:262-278. [PMID: 31836033 DOI: 10.1053/j.seminhematol.2019.09.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 07/30/2019] [Accepted: 09/30/2019] [Indexed: 12/13/2022]
Abstract
The second-generation thrombopoietin (TPO) receptor agonists eltrombopag and romiplostim are potent activators of megakaryopoiesis and represent a growing treatment option for patients with thrombocytopenic hematological disorders. Both TPO receptor agonists have been approved worldwide for the treatment of children and adults with chronic immune thrombocytopenia. In the EU and USA, eltrombopag is approved for the treatment of patients with severe aplastic anemia who have had an insufficient response to immunosuppressive therapy and in the USA for the first-line treatment of severe aplastic anemia in combination with immunosuppressive therapy. Eltrombopag has also shown efficacy in several other disease settings, for example, chemotherapy-induced thrombocytopenia, selected inherited thrombocytopenias, and myelodysplastic syndromes. While both TPO receptor agonists stimulate TPO receptor signaling and enhance megakaryopoiesis, their vastly different biochemical structures bestow upon them markedly different molecular and functional properties. Here, we review and discuss results from preclinical and clinical studies on the functional and molecular mechanisms of action of this new class of drug.
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Affiliation(s)
- James Bussel
- Pediatric Hematology/Oncology, Weill Cornell Medicine, New York, NY.
| | | | | | - Amit Verma
- Albert Einstein College of Medicine, New York, NY
| | | | - John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
| | - Britta Will
- Albert Einstein College of Medicine, New York, NY.
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Kanhai D, Mulder R, Ploos van Amstel HK, Schutgens R, Lukens M, Tamminga RYJ. Familial macrothrombocytopenia due to a double mutation in cis in the alpha-actinin 1 gene (ACTN1), previously considered to be chronic immune thrombocytopenic purpura. Pediatr Blood Cancer 2018; 65:e27418. [PMID: 30124235 DOI: 10.1002/pbc.27418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 07/10/2018] [Accepted: 07/29/2018] [Indexed: 11/07/2022]
Abstract
Congenital thrombocytopenia can easily be misdiagnosed as immune thrombocytopenic purpura, as is illustrated by this case of a woman and her two children. Doubts arose when steroid/IVIG therapy failed in the mother and the thrombocytopenia in the children persisted. By means of next-generation sequencing, two missense variants in cis in the ACTN1 gene of the affected family members were identified, both of unknown significance. We conclude, after further analysis of these mutations with, among others, in silico prediction tools, that the thrombocytopenia has a genetic cause, in particular the ACTN1 mutations, and is not immune mediated.
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Affiliation(s)
- Danny Kanhai
- Department of Pediatric Hematology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, the Netherlands
| | - René Mulder
- Department of Laboratory Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Roger Schutgens
- Department of Hematology, Van Creveldkliniek, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Michael Lukens
- Department of Laboratory Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Rienk Y J Tamminga
- Department of Pediatric Hematology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, the Netherlands
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10
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Zufferey A, Kapur R, Semple JW. Pathogenesis and Therapeutic Mechanisms in Immune Thrombocytopenia (ITP). J Clin Med 2017; 6:jcm6020016. [PMID: 28208757 PMCID: PMC5332920 DOI: 10.3390/jcm6020016] [Citation(s) in RCA: 281] [Impact Index Per Article: 40.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 02/04/2017] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is a complex autoimmune disease characterized by low platelet counts. The pathogenesis of ITP remains unclear although both antibody-mediated and/or T cell-mediated platelet destruction are key processes. In addition, impairment of T cells, cytokine imbalances, and the contribution of the bone marrow niche have now been recognized to be important. Treatment strategies are aimed at the restoration of platelet counts compatible with adequate hemostasis rather than achieving physiological platelet counts. The first line treatments focus on the inhibition of autoantibody production and platelet degradation, whereas second-line treatments include immunosuppressive drugs, such as Rituximab, and splenectomy. Finally, third-line treatments aim to stimulate platelet production by megakaryocytes. This review discusses the pathophysiology of ITP and how the different treatment modalities affect the pathogenic mechanisms.
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Affiliation(s)
- Anne Zufferey
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
- The Toronto Platelet Immunobiology Group, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
| | - Rick Kapur
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
- The Toronto Platelet Immunobiology Group, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
- Canadian Blood Services, Toronto, ON M5B 1W8, Canada.
| | - John W Semple
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
- The Toronto Platelet Immunobiology Group, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
- Canadian Blood Services, Toronto, ON M5B 1W8, Canada.
- Department of Pharmacology, Medicine, and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5B 1W8, Canada.
- Division of Hematology and Transfusion Medicine, Lund University, 221 84 Lund, Sweden.
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11
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Zhang X, Zhao Y, Li X, Han P, Jing F, Kong Z, Zhou H, Qiu J, Li L, Peng J, Hou M. Thrombopoietin: a potential diagnostic indicator of immune thrombocytopenia in pregnancy. Oncotarget 2016; 7:7489-96. [PMID: 26840092 PMCID: PMC4884934 DOI: 10.18632/oncotarget.7106] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 01/24/2016] [Indexed: 12/13/2022] Open
Abstract
To evaluate whether the serum thrombopoietin levels in pregnancy-associated immune thrombocytopenia (ITP) differ from those in gestational thrombocytopenia, and reveal the possibility of thrombopoietin serving as a marker for differential diagnosis. Serum thrombopoietin concentration was determined in ITP in pregnancy (n = 35), gestational thrombocytopenia (n = 31), healthy pregnancy (n = 32), age-matched nonpregnant ITP (n = 32) and nonpregnant healthy controls (n = 35) by ELISA. The serum thrombopoietin level of ITP in pregnancy (1283 ± 646 pg/mL) was significantly higher than gestational thrombocytopenia (187 ± 64 pg/mL) (P < 0.01), although the platelet counts of these two disorders may overlap. Twenty-nine of 35 patients with ITP in pregnancy had thrombopoietin values >500 pg/mL, whereas none of the gestational thrombocytopenia patients' thrombopoietin levels exceeded 500 pg/mL. In addition, ITP in pregnancy presented a markedly higher thrombopoietin level than nonpregnant ITP (88 ± 41 pg/mL) (P < 0.01), indicating that the pathogenesis of pregnant and nonpregnant ITP was different. Our findings suggest that measurement of serum thrombopoietin concentration provides valuable diagnostic information for differentiating ITP in pregnancy from gestational thrombocytopenia. Thrombopoietin represents a reliable marker for ITP in pregnancy.
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Affiliation(s)
- Xu Zhang
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Yajing Zhao
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Xiaoqing Li
- School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Panpan Han
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Fangmiao Jing
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Zhangyuan Kong
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Hai Zhou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Jihua Qiu
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Lizhen Li
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, Shandong, China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, Shandong, China.,Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Shandong University, Jinan, Shandong, China
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Saito C, Ishiyama K, Yamazaki H, Zaimoku Y, Nakao S. Hypomegakaryocytic thrombocytopenia (HMT): an immune-mediated bone marrow failure characterized by an increased number of PNH-phenotype cells and high plasma thrombopoietin levels. Br J Haematol 2016; 175:246-251. [PMID: 27351867 DOI: 10.1111/bjh.14210] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 05/04/2016] [Indexed: 01/29/2023]
Abstract
Patients with mild hypomegakaryocytic thrombocytopenia (HMT) that does not meet the diagnostic criteria for a definite disease entity may potentially progress to aplastic anaemia (AA) that is refractory to therapy. To clarify the clinical picture of HMT, we prospectively followed 25 HMT patients with white blood cell count >3·0 × 109 /l, haemoglobin level >100 g/l and platelet count of <100·0 × 109 /l in the absence of morphological and karyotypic abnormalities in the bone marrow. Glycosylphosphatidylinositol-anchored protein-deficient blood cells [paroxysmal nocturnal haemoglobinuria (PNH)-type cells] were detected in 7 of the 25 (28%) patients and elevated plasma thrombopoietin (TPO, also termed THPO) levels (>320 pg/ml) were observed in 11 (44%) patients. Five (four PNH+ and one PNH-) of six TPOhigh patients who were treated with ciclosporin (CsA) showed improvement. Among the 21 patients who were followed without treatment, thrombocytopenia progressed in four of ten TPOlow patients and four of 11 TPOhigh patients. The 3-year failure-free survival rate of the CsA-treated TPOhigh patients (100%) was significantly higher than that of the untreated TPOhigh patients (20%). These results suggest that a significant population of HMT patients has an immune pathophysiology that is similar to AA and may be improved by early therapeutic intervention with CsA.
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Affiliation(s)
- Chizuru Saito
- Department of Haematology, Kanazawa University Hospital, Kanazawa, Japan
| | - Ken Ishiyama
- Department of Haematology, Kanazawa University Hospital, Kanazawa, Japan
| | - Hirohito Yamazaki
- Division of Transfusion Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Yoshitaka Zaimoku
- Division of Transfusion Medicine, Kanazawa University Hospital, Kanazawa, Japan.,Cellular Transplantation Biology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Shinji Nakao
- Cellular Transplantation Biology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan.
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13
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Zhang J, Wu Q, Zheng Y. Persistent elevated bone marrow plasma levels of thrombopoietin in patients with aplastic anemia. Cytokine 2016; 85:11-3. [PMID: 27269179 DOI: 10.1016/j.cyto.2016.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 05/21/2016] [Accepted: 05/24/2016] [Indexed: 11/24/2022]
Abstract
Acquired aplastic anemia (AA) is an immune-mediated bone marrow (BM) failure syndrome. Plasma thrombopoietin (TPO) levels are elevated in AA patients with reduced blood counts. However, whether elevated TPO can recover to normal level in AA patients in complete remission (CR) after efficient immunosuppressive therapy (IST) is unknown. We measured TPO levels of BM plasma in a large cohort of AA patients with focusing on patients in CR after IST. Our data showed that BM plasma TPO levels were still high in patients who had reached normal blood counts levels for a long time. We speculate that downregulated expression of MPL (TPO receptor) in HSPC (hematopoietic stem and progenitor cells) may be related to the upregulated TPO in AA.
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Affiliation(s)
- Jizhou Zhang
- Severe Aplastic Anemia Studying Program, Institute of Hematology & Blood Diseases Hospital, State Key Laboratory of Experimental Hematology, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, PR China
| | - Qingqing Wu
- Severe Aplastic Anemia Studying Program, Institute of Hematology & Blood Diseases Hospital, State Key Laboratory of Experimental Hematology, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, PR China
| | - Yizhou Zheng
- Severe Aplastic Anemia Studying Program, Institute of Hematology & Blood Diseases Hospital, State Key Laboratory of Experimental Hematology, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, PR China.
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14
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Bone marrow niche in immune thrombocytopenia: a focus on megakaryopoiesis. Ann Hematol 2016; 95:1765-76. [PMID: 27236577 DOI: 10.1007/s00277-016-2703-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 05/23/2016] [Indexed: 12/18/2022]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by increased bleeding tendency and thrombocytopenia. In fact, the precise pathogenesis of this disease is still not clear. Megakaryopoiesis involves complete differentiation of megakaryocyte (MK) progenitors to functional platelets. This complex process occurs in specific bone marrow (BM) niches composed of several hematopoietic and non-hematopoietic cell types, soluble factors, and extracellular matrix proteins. These specialized microenvironments sustain MK maturation and localization to sinusoids as well as platelet release into circulation. However, MKs in ITP patients show impaired maturation and signs of degradation. Intrinsic defects in MKs and their extrinsic environment have been implicated in altered megakaryopoiesis in this disease. In particular, aberrant expression of miRNAs directing MK proliferation, differentiation, and platelet production; defective MK apoptosis; and reduced proliferation and differentiation rate of the MSC compartment observed in these patients may account for BM defects in ITP. Furthermore, insufficient production of thrombopoietin is another likely reason for ITP development. Therefore, identifying the signaling pathways and transcription factors influencing the interaction between MKs and BM niche in ITP patients will contribute to increased platelet production in order to prevent incomplete MK maturation and destruction as well as BM fibrosis and apoptosis in ITP. In this review, we will examine the interaction and role of BM niches in orchestrating megakaryopoiesis in ITP patients and discuss how these factors can be exploited to improve the quality of patient treatment and prognosis.
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15
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ACTN1-related thrombocytopenia: identification of novel families for phenotypic characterization. Blood 2014; 125:869-72. [PMID: 25361813 DOI: 10.1182/blood-2014-08-594531] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Inherited thrombocytopenias (ITs) are a heterogeneous group of syndromic and nonsyndromic diseases caused by mutations affecting different genes. Alterations of ACTN1, the gene encoding for α-actinin 1, have recently been identified in a few families as being responsible for a mild form of IT (ACTN1-related thrombocytopenia; ACTN1-RT). To better characterize this disease, we screened ACTN1 in 128 probands and found 10 (8 novel) missense heterozygous variants in 11 families. Combining bioinformatics, segregation, and functional studies, we demonstrated that all but 1 amino acid substitution had deleterious effects. The clinical and laboratory findings of 31 affected individuals confirmed that ACTN1-RT is a mild macrothrombocytopenia with low risk for bleeding. Low reticulated platelet counts and only slightly increased serum thrombopoietin levels indicated that the latest phases of megakaryopoiesis were affected. Given its relatively high frequency in our cohort (4.2%), ACTN1-RT has to be taken into consideration in the differential diagnosis of ITs.
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16
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Minowa K, Arai K, Kasahara M, Sakamoto S, Shimizu H, Nakano N, Ito R, Obayashi N, Nakazawa A, Ishiguro A. Romiplostim treatment allows for platelet transfusion-free liver transplantation in pediatric thrombocytopenic patient with primary sclerosing cholangitis. Pediatr Transplant 2014; 18:E212-5. [PMID: 25041553 DOI: 10.1111/petr.12308] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2014] [Indexed: 01/30/2023]
Abstract
Thrombocytopenia is a major risk factor for cirrhotic liver disease. Patients with thrombocytopenia may have esophageal or gastric varices secondary to portal hypertension, leading to variceal bleeding which exposes the liver to further damage. Here, we present a female pediatric patient with PSC and CD, whose progressive thrombocytopenia was successfully controlled by romiplostim, a TPO receptor agonist. The patient developed bloody diarrhea at four yr of age, and was subsequently diagnosed with PSC and CD when seven yr old. While CD was well-controlled by immunomodulators, the patient's thrombocytopenia gradually progressed resulting in petechiae (platelet count of 11 × 10(9) /L) when she was 10 yr and four months old. She responded poorly to immunoglobulin and corticosteroids. Weekly subcutaneous injection of romiplostim was therefore initiated, and platelet counts were maintained over at 50 × 10(9) /L. She was able to undergo successful LDLT without platelet transfusion seven months after the initiation of romiplostim. Romiplostim was not required after LDLT with improved platelet counts. This case report suggests that romiplostim may be effective in the treatment of thrombocytopenic children with liver cirrhosis and portal hypertension, and in eliminating the need for platelet transfusion during the peri-transplant period.
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Affiliation(s)
- Kei Minowa
- Division of Gastroenterology, National Center for Child Health and Development (NCCHD), Tokyo, Japan
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17
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Makar RS, Zhukov OS, Sahud MA, Kuter DJ. Thrombopoietin levels in patients with disorders of platelet production: diagnostic potential and utility in predicting response to TPO receptor agonists. Am J Hematol 2013; 88:1041-4. [PMID: 23913253 DOI: 10.1002/ajh.23562] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 07/24/2013] [Accepted: 07/26/2013] [Indexed: 11/06/2022]
Abstract
Thrombopoietin (TPO) is the major regulator of megakaryopoiesis. Measurement of serum TPO levels may help distinguish between various causes of thrombocytopenia and predict treatment response to TPO receptor agonists. Serum TPO levels from 118 healthy volunteers and 88 patients with abnormal platelet counts were measured using a quantitative ELISA assay. The mean (range) TPO level in healthy volunteers was 39 (7-99) pg/mL. TPO values were correlated with the patient's diagnosis, platelet count, and response to TPO receptor agonists. 88 patients with history of consumptive thrombocytopenia (39) or hypoproliferative thrombocytopenia (49) were analyzed. Median (interquartile range) TPO level for consumptive thrombocytopenia patients was 63 (48-98) pg/mL with a corresponding median (interquartile range) platelet count of 73 (28-146) × 10(9) /L. In contrast, hypoproliferative thrombocytopenia patients had platelet counts [59 (30-117) × 10(9) /L] comparable with consumptive thrombocytopenia patients, but significantly higher serum TPO levels [706 (358-1546) pg/mL, P < 0.0001]. Analysis of 21 ITP patients treated with TPO receptor agonists demonstrated that a TPO level >95 pg/mL was associated with lack of clinical response (P < 0.002). TPO levels may have diagnostic utility in discriminating between patients with hypoproliferative and consumptive thrombocytopenia. Elevated TPO levels in ITP patients may predict a poor clinical response to treatment with TPO receptor agonists.
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Affiliation(s)
- Robert S. Makar
- Department of Pathology, Massachusetts General Hospital, Harvard Medical SchoolBoston Massachusetts
| | - Olga S. Zhukov
- Coagulation Department, Quest Diagnostics Nichols InstituteSan Juan Capistrano California
| | - Mervyn A. Sahud
- Coagulation Department, Quest Diagnostics Nichols InstituteSan Juan Capistrano California
| | - David J. Kuter
- Division of Hematology, Massachusetts General Hospital, Harvard Medical SchoolBoston Massachusetts
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18
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Yamazaki H, Nakao S. Border between aplastic anemia and myelodysplastic syndrome. Int J Hematol 2013; 97:558-63. [PMID: 23613266 DOI: 10.1007/s12185-013-1324-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 04/03/2013] [Accepted: 04/03/2013] [Indexed: 11/26/2022]
Abstract
Distinguishing between acquired aplastic anemia (AA) and myelodysplastic syndrome (MDS) with a low blast cell percentage is often difficult and problematic, as both diseases are syndromes primarily defined by morphological findings, and their diagnostic criteria do not necessarily reflect the pathophysiology of their bone marrow (BM) failure. As a result, many patients with benign BM failure that should be managed as AA are diagnosed as having MDS, due to the absence of BM hypocellularity and the presence of dysplastic signs in the BM, and are treated inappropriately with toxic therapies, such as hypomethylating agents, and stem cell transplantation from unrelated donors. BM failure syndromes need to be managed in ways appropriate to their pathophysiology, which is more accurately determined by using markers such as the presence of glycosylphosphatidylinositol-anchored protein-deficient cells and HLA-A lacking leukocytes. We recently found that plasma thromobopoietin level is one of the most useful markers for distinguishing benign and pre-leukemic BM failure syndromes.
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Affiliation(s)
- Hirohito Yamazaki
- Cellular Transplantation Biology, Kanazawa University Graduate School of Medical Science, 13-1, Takaramachi, Kanazawa, Ishikawa 920-8641, Japan
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19
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Seiki Y, Sasaki Y, Hosokawa K, Saito C, Sugimori N, Yamazaki H, Takami A, Nakao S. Increased plasma thrombopoietin levels in patients with myelodysplastic syndrome: a reliable marker for a benign subset of bone marrow failure. Haematologica 2013; 98:901-7. [PMID: 23403320 DOI: 10.3324/haematol.2012.066217] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Although myelodysplastic syndromes are heterogeneous disorders comprising a benign subset of bone marrow failure similar to aplastic anemia, no laboratory test has been established to distinguish it from bone marrow failures that can evolve into acute myeloid leukemia. Plasma thrombopoietin levels were measured in 120 patients who had myelodysplastic syndrome with thrombocytopenia (< 100 × 10(9)/L) to determine any correlation to markers associated with immune pathophysiology and outcome. Thrombopoietin levels were consistently low for patients with refractory anemia with excess of blasts, while patients with other myelodysplatic syndrome subsets had more variable results. Patients with thrombopoietin levels of 320 pg/mL and over had increased glycosylphosphatidylinositol-anchored protein-deficient blood cells (49.1% vs. 0%), were more likely to have a low International Prognostic Scoring System (IPSS) score (≤1.0, 100% vs. 65.5%), a higher response rate to immunosuppressive therapy (84.2% vs. 14.3%), and a better 5-year progression-free survival rate (94.1% vs. 63.6% for refractory cytopenia with unilineage dysplasia; 100.0% vs. 44.4% for refractory cytopenia with multilineage dysplasia). In conclusion, increased plasma thrombopoietin levels were associated with a favorable prognosis of bone marrow failure and could, therefore, represent a reliable marker for a benign subset of myelodysplastic syndrome.
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Affiliation(s)
- Yu Seiki
- Cellular Transplantation Biology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
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20
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Noris P, Perrotta S, Bottega R, Pecci A, Melazzini F, Civaschi E, Russo S, Magrin S, Loffredo G, Di Salvo V, Russo G, Casale M, De Rocco D, Grignani C, Cattaneo M, Baronci C, Dragani A, Albano V, Jankovic M, Scianguetta S, Savoia A, Balduini CL. Clinical and laboratory features of 103 patients from 42 Italian families with inherited thrombocytopenia derived from the monoallelic Ala156Val mutation of GPIbα (Bolzano mutation). Haematologica 2011; 97:82-8. [PMID: 21933849 DOI: 10.3324/haematol.2011.050682] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Bernard-Soulier syndrome is a very rare form of inherited thrombocytopenia that derives from mutations in GPIbα, GPIbβ, or GPIX and is typically inherited as a recessive disease. However, some years ago it was shown that the monoallelic c.515C>T transition in the GPIBA gene (Bolzano mutation) was responsible for macrothrombocytopenia in a few Italian patients. DESIGN AND METHODS Over the past 10 years, we have searched for the Bolzano mutation in all subjects referred to our institutions because of an autosomal, dominant form of thrombocytopenia of unknown origin. RESULTS We identified 42 new Italian families (103 cases) with a thrombocytopenia induced by monoallelic Bolzano mutation. Analyses of the geographic origin of affected pedigrees and haplotypes indicated that this mutation originated in southern Italy. Although the clinical expression was variable, patients with this mutation typically had a mild form of Bernard-Soulier syndrome with mild thrombocytopenia and bleeding tendency. The most indicative laboratory findings were enlarged platelets and reduced GPIb/IX/V platelet expression; in vitro platelet aggregation was normal in nearly all of the cases. CONCLUSIONS Our study indicates that monoallelic Bolzano mutation is the most frequent cause of inherited thrombocytopenia in Italy, affecting 20% of patients recruited at our institutions during the last 10 years. Because many people from southern Italy have emigrated during the last century, this mutation may have spread to other countries.
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Affiliation(s)
- Patrizia Noris
- Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy.
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21
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Mutations in ANKRD26 are responsible for a frequent form of inherited thrombocytopenia: analysis of 78 patients from 21 families. Blood 2011; 117:6673-80. [PMID: 21467542 DOI: 10.1182/blood-2011-02-336537] [Citation(s) in RCA: 194] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Until recently, thrombocytopenia 2 (THC2) was considered an exceedingly rare form of autosomal dominant thrombocytopenia and only 2 families were known. However, we recently identified mutations in the 5'-untranslated region of the ANKRD26 gene in 9 THC2 families. Here we report on 12 additional pedigrees with ANKRD26 mutations, 6 of which are new. Because THC2 affected 21 of the 210 families in our database, it has to be considered one of the less rare forms of inherited thrombocytopenia. Analysis of all 21 families with ANKRD26 mutations identified to date revealed that thrombocytopenia and bleeding tendency were usually mild. Nearly all patients had no platelet macrocytosis, and this characteristic distinguishes THC2 from most other forms of inherited thrombocytopenia. In the majority of cases, platelets were deficient in glycoprotein Ia and α-granules, whereas in vitro platelet aggregation was normal. Bone marrow examination and serum thrombopoietin levels suggested that thrombocytopenia was derived from dysmegakaryopoiesis. Unexplained high values of hemoglobin and leukocytes were observed in a few cases. An unexpected finding that warrants further investigation was a high incidence of acute leukemia. Given the scarcity of distinctive characteristics, the ANKRD26-related thrombocytopenia has to be taken into consideration in the differential diagnosis of isolated thrombocytopenias.
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Contributions of TRAIL-mediated megakaryocyte apoptosis to impaired megakaryocyte and platelet production in immune thrombocytopenia. Blood 2010; 116:4307-16. [PMID: 20671119 DOI: 10.1182/blood-2010-02-267435] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Recent in vitro studies provide evidence for autoantibody-induced suppression of megakaryocytopoiesis and show a reduction in megakaryocyte production and maturation in the presence of immune thrombocytopenia (ITP) plasma. Here, we present CD34(+) cells from healthy umbilical cord blood mononuclear cells cultured in medium containing thrombopoietin, stem cell factor, interleukin-3, and 10% plasma from either ITP patients or healthy subjects. The quantity, quality, and apoptosis of megakaryocytes were measured. We observed that most ITP plasma boosted megakaryocyte quantity but impaired quality, resulting in significantly less polyploidy cells (N ≥ 4) and platelet release. In these megakaryocytes, we found a lower percentage of cell apoptosis, a lower expression of tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), and a higher expression of Bcl-xL. Furthermore, there was a decrease of sTRAIL in ITP plasma and in cell culture supernatants of this group compared with the control group. Our findings suggest that decreased apoptosis of megakaryocytes also contributes to in vitro dysmegakaryocytopoiesis and reduced platelet production. The abnormal expression of sTRAIL in plasma and TRAIL and Bcl-xL in megakaryocytes may play a role in the pathogenesis of impaired megakaryocyte apoptosis in ITP.
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23
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Wadenvik H, Olsson B. Moving towards a new era in the management of chronic immune thrombocytopenia. Ann Hematol 2010; 89 Suppl 1:87-93. [DOI: 10.1007/s00277-009-0873-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Accepted: 11/23/2009] [Indexed: 11/29/2022]
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24
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ASANUMA M, SEINO K, MIZUNO T, NASU M, YAMAUCHI F, FUJISHIMA M. Plasma thrombopoietin level and platelet indices in hemodialysis patients receiving recombinant human erythropoietin. Int J Lab Hematol 2010; 32:312-9. [DOI: 10.1111/j.1751-553x.2009.01191.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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25
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Unklare Thrombozytopenie. Hamostaseologie 2010. [DOI: 10.1007/978-3-642-01544-1_42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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26
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Nugent D, McMillan R, Nichol JL, Slichter SJ. Pathogenesis of chronic immune thrombocytopenia: increased platelet destruction and/or decreased platelet production. Br J Haematol 2009; 146:585-96. [PMID: 19466980 DOI: 10.1111/j.1365-2141.2009.07717.x] [Citation(s) in RCA: 174] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Chronic immune thrombocytopenia (ITP) is a haematological disorder in which patients predominantly develop skin and mucosal bleeding. Early studies suggested ITP was primarily due to immune-mediated peripheral platelet destruction. However, increasing evidence indicates that an additional component of this disorder is immune-mediated decreased platelet production that cannot keep pace with platelet destruction. Evidence for increased platelet destruction is thrombocytopenia following ITP plasma infusions in normal subjects, in vitro platelet phagocytosis, and decreased platelet survivals in ITP patients that respond to therapies that prevent in vivo platelet phagocytosis; e.g., intravenous immunoglobulin G, anti-D, corticosteroids, and splenectomy. The cause of platelet destruction in most ITP patients appears to be autoantibody-mediated. However, cytotoxic T lymphocyte-mediated platelet (and possibly megakaryocyte) lysis, may also be important. Studies supporting suppressed platelet production include: reduced platelet turnover in over 80% of ITP patients, morphological evidence of megakaryocyte damage, autoantibody-induced suppression of in vitro megakaryocytopoiesis, and increased platelet counts in most ITP patients following treatment with thrombopoietin receptor agonists. This review summarizes data that indicates that the pathogenesis of chronic ITP may be due to both immune-mediated platelet destruction and/or suppressed platelet production. The relative importance of these two mechanisms undoubtedly varies among patients.
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Affiliation(s)
- Diane Nugent
- Department of Hematology, Children's Hospital of Orange County, Orange, CA, USA
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27
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Peeters K, Stassen JM, Collen D, Van Geet C, Freson K. Emerging treatments for thrombocytopenia: Increasing platelet production. Drug Discov Today 2008; 13:798-806. [DOI: 10.1016/j.drudis.2008.06.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Revised: 06/03/2008] [Accepted: 06/04/2008] [Indexed: 12/29/2022]
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28
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Li X, Hou M. Emerging drugs for idiopathic thrombocytopenic purpura in adults. Expert Opin Emerg Drugs 2008; 13:237-54. [DOI: 10.1517/14728214.13.2.237] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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29
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Wang L, Li Y, Hou M. Idiopathic thrombocytopenic purpura and dysmegakaryocytopoiesis. Crit Rev Oncol Hematol 2007; 64:83-9. [PMID: 17900920 DOI: 10.1016/j.critrevonc.2007.05.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2006] [Revised: 05/22/2007] [Accepted: 05/23/2007] [Indexed: 10/22/2022] Open
Abstract
Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder characterized with thrombocytopenia, primarily caused by platelet destruction. However, the studies of platelet kinetics show platelet turn over are normal or decreased, suggesting that reduced platelet production may lead to severity of ITP. We review recent research progress on abnormal cell events involved in megakaryocytopoiesis contributing to thrombocytopenia.
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Affiliation(s)
- Lin Wang
- Hematology Oncology Center, Qilu Hospital, Shandong University, 107 West Wenhua Rd, Jinan, Shandong 250012, PR China
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30
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Roberts IA, Murray NA. Thrombocytopenia in the Newborn. Platelets 2007. [DOI: 10.1016/b978-012369367-9/50814-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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31
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Yamazaki R, Kuwana M, Mori T, Okazaki Y, Kawakami Y, Ikeda Y, Okamoto S. Prolonged thrombocytopenia after allogeneic hematopoietic stem cell transplantation: associations with impaired platelet production and increased platelet turnover. Bone Marrow Transplant 2006; 38:377-84. [PMID: 16915226 DOI: 10.1038/sj.bmt.1705444] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
To evaluate the mechanisms underlying prolonged thrombocytopenia after allogeneic hematopoietic stem cell transplantation (SCT), an index for plasma glycocalicin normalized for the individual platelet count (GCI), plasma thrombopoietin (TPO), and circulating B cells producing anti-GPIIb-IIIa antibodies were measured in 50 SCT recipients with or without prolonged thrombocytopenia, 42 patients with idiopathic thrombocytopenic purpura, nine patients with aplastic anemia, and 22 healthy individuals. All three indices were significantly higher in the SCT recipients with thrombocytopenia than in those without (P < 0.01 for all comparisons), and were significantly correlated with the platelet count in SCT recipients. Stepwise multiple regression analysis of the samples from the SCT recipients revealed that GCI and TPO independently pointed to specific mechanisms of thrombocytopenia. The GCI and TPO status in SCT recipients with thrombocytopenia had a pattern similar to that seen in aplastic anemia, suggesting a major role for impaired thrombopoiesis. An antiplatelet antibody response was frequently detected in SCT recipients, but the development of thrombocytopenia is likely to depend on additional factors, such as reticuloendothelial function. In summary, post transplant prolonged thrombocytopenia is associated with complex mechanisms, including impaired thrombopoiesis and increased platelet turnover.
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Affiliation(s)
- R Yamazaki
- Division of Hematology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Lonial S, Waller EK, Richardson PG, Jagannath S, Orlowski RZ, Giver CR, Jaye DL, Francis D, Giusti S, Torre C, Barlogie B, Berenson JR, Singhal S, Schenkein DP, Esseltine DLW, Anderson J, Xiao H, Heffner LT, Anderson KC. Risk factors and kinetics of thrombocytopenia associated with bortezomib for relapsed, refractory multiple myeloma. Blood 2005; 106:3777-84. [PMID: 16099887 PMCID: PMC1895114 DOI: 10.1182/blood-2005-03-1173] [Citation(s) in RCA: 267] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Bortezomib, a proteasome inhibitor with efficacy in multiple myeloma, is associated with thrombocytopenia, the cause and kinetics of which are different from those of standard cytotoxic agents. We assessed the frequency, kinetics, and mechanism of thrombocytopenia following treatment with bortezomib 1.3 mg/m2 in 228 patients with relapsed and/or refractory myeloma in 2 phase 2 trials. The mean platelet count decreased by approximately 60% during treatment but recovered rapidly between treatments in a cyclic fashion. Among responders, the pretreatment platelet count increased significantly during subsequent cycles of therapy. The mean percent reduction in platelets was independent of baseline platelet count, M-protein concentration, and marrow plasmacytosis. Plasma thrombopoietin levels inversely correlated with platelet count. Murine studies demonstrated a reduction in peripheral platelet count following a single bortezomib dose without negative effects on megakaryocytic cellularity, ploidy, or morphology. These data suggest that bortezomib-induced thrombocytopenia is due to a reversible effect on megakaryocytic function rather than a direct cytotoxic effect on megakaryocytes or their progenitors. The exact mechanism underlying bortezomib-induced thrombocytopenia remains unknown but it is unlikely to be related to marrow injury or decreased thrombopoietin production.
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Affiliation(s)
- Sagar Lonial
- Winship Cancer Institute, Emory University, Atlanta, GA, USA.
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Affiliation(s)
- Paul T Jubinsky
- Section of Pediatric Hematology/Oncology, Albert Einstein College of Medicine, Bronx, New York 10461, USA.
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Abstract
Recent developments in genomics and basic immunology have provided a new set of tools for investigation into the etiology and treatment of childhood immune thrombocytopenia purpura (ITP). The genomic revolution is generating a catalog of germ-line common genetic variants, some of which could influence the susceptibility or outcome of ITP. Similarly, in vitro analyses and animal models have been employed to probe the basic alterations underlying ITP. The emergence of a more refined understanding of complex diseases such as ITP has important implications for prevention, therapy, and follow-up. The relative contribution of the genetic component and its interaction with the strong environmental stimulus, such as an acute, antecedent viral infection, remains to be determined.
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Affiliation(s)
- Stephen Chanock
- Section on Genomic Variation, Pediatric Oncology Branch, National Cancer Institute, Advanced Technology Center, 8717 Grovemont Circle, Gaithersburg, MD 20892-4605, USA.
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35
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Tamary H, Yaniv I, Stein J, Dgany O, Shalev Z, Shechter T, Resnitzky P, Shaft D, Zoldan M, Kornreich L, Levy R, Cohen A, Moser RA, Kapelushnik J, Shalev H. A clinical and molecular study of a Bedouin family with dysmegakaryopoiesis, mild anemia, and neutropenia cured by bone marrow transplantation. Eur J Haematol 2003; 71:196-203. [PMID: 12930321 DOI: 10.1034/j.1600-0609.2003.00126.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Familial thrombocytopenia is a relatively rare and heterogeneous group of clinical and genetic syndromes of unknown etiology. Recently, mutations in a few hematopoietic transcription factors were implicated in dysmegakaryopoiesis with and without dyserythropoietic anemia. The aim of the present study was to describe the clinical and hematologic picture of members of a Bedouin family with severe congenital thrombocytopenia associated with neutropenia and anemia and to determine the possible involvement of hematopoietic transcription factor genes in their disease. PATIENTS AND METHODS Four members of a Bedouin family presented with severe bleeding tendency, including intracranial hemorrhage in three. Three of the four were successfully treated with allogenic human leukocyte antigen (HLA)-matched bone marrow transplants. Measurements of serum erythropoietin and thrombopoietin levels, bone marrow electron microscopy, and megakaryocytic colony were grown for each patient in addition to DNA amplification and single-strand conformation polymorphism of each exon of the NF-E2, Fli-1, FOG-1, and Gfi-1b in genes. RESULTS Bone marrow studies revealed dysmegakaryopoiesis and mild dyserythropoiesis. A low number of bone marrow megakaryocyte colony-forming units was found, as well as a slightly elevated serum thrombopoietin level. No mutation was identified in any of the transcription factor genes examined. CONCLUSIONS A unique autosomal recessive bone marrow disorder with prominent involvement of megakaryocytes is described. Defects were not identified in transcription factors affecting the common myeloid progenitor.
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Affiliation(s)
- H Tamary
- Pediatric Hematology-Oncology Center and Imaging Department, Schneider Children's Medical Center of Israel, Petah Tiqva, Israel.
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Dahlen DD, Broudy VC, Drachman JG. Internalization of the thrombopoietin receptor is regulated by 2 cytoplasmic motifs. Blood 2003; 102:102-8. [PMID: 12623841 DOI: 10.1182/blood-2002-11-3468] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Receptor-mediated internalization appears to be the primary mean of regulating the plasma level of thrombopoietin (TPO). However, the processes that regulate Mpl internalization have not previously been described. Using the cytokine-dependent cell line BaF3, we have identified 2 distinct motifs within the cytoplasmic domain of Mpl that underlie ligand-dependent internalization. Removal of the fourth cytoplasmic tyrosine residue by deletion or truncation results in a significant decrease in maximal internalization. The remaining receptor internalization is abrogated by deletion of cytoplasmic residues 54-69, which include the core box2 region (L54L55E56I57L58) and the only dileucine motifs (L54L55 and I57L58) within the cytoplasmic domain of Mpl. Receptor internalization mediated by this latter subdomain does not require Jak2 activation. Furthermore, TPO-stimulated cellular proliferation appears to be directly correlated with receptor internalization, indicating that internalization of the TPO/Mpl complex may be essential for normal signal transduction. Finally, we have demonstrated that upon removal of TPO from the supernatant, Mpl promptly reappears on the cell surface, suggesting that a pool of intracellular Mpl can be rapidly recycled to the cell surface. These data help identify the receptor motifs involved in TPO-induced internalization of Mpl and suggest that Mpl translocation may be necessary for normal cellular proliferation.
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Affiliation(s)
- Debra D Dahlen
- Division of Hematology, University of Washington, Seattle, WA 98104, USA.
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37
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Tefferi A. Thrombopoietin expression and plasma concentrations in chronic myeloproliferative disorders. Leuk Res 2003; 27:121-3. [PMID: 12526917 DOI: 10.1016/s0145-2126(02)00088-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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38
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Abstract
More than a century has elapsed since the appearance of the modern descriptions of polycythemia vera (PV). During this time, much has been learned regarding disease pathogenesis and PV-associated molecular aberrations. New information has allowed amendments to traditional diagnostic criteria. Phlebotomy remains the cornerstone treatment of PV, whereas myelosuppressive agents may augment the benefit of using phlebotomy for thrombosis prevention in high-risk patients. Excessive aspirin use is contraindicated in PV, although the use of lower-dose aspirin has been shown to be safe and effective in alleviating microvascular symptoms including erythromelalgia and headaches. Recent studies have shown the utility of selective serotonin receptor antagonists for treating PV-associated pruritus. Nevertheless, many questions remain unanswered. What is the specific genetic mutation or altered molecular pathway that is causally related to the disease? In the absence of a specific molecular marker, how is a working diagnosis of PV made? What evidence supports current practice in the management of PV? This article summarizes both old and new information on PV; proposes a modern diagnostic algorithm to formulate a working diagnosis; and provides recommendations for patient management, relying whenever possible on an evidence-based approach.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA.
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39
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Wang JC, Hashmi G. Elevated thrombopoietin levels in patients with myelofibrosis may not be due to enhanced production of thrombopoietin by bone marrow. Leuk Res 2003; 27:13-7. [PMID: 12479847 DOI: 10.1016/s0145-2126(02)00069-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Thrombopoietin (TPO) is recognized as the primary regulator of megakaryocyte and platelet production. Two alternative hypotheses for the mechanism of regulation have been proposed: (1) platelet and/or megakaryocyte mass regulate circulating TPO levels by binding to TPO through TPO receptors (c-MPL), with subsequent internalization and degradation of the protein; (2) TPO mRNA produced by bone marrow (BM) stromal cells or BM cells modulates blood TPO levels or platelet counts. In myeloproliferative disorders (MPD), including primary myelofibrosis (MF) and essential thrombocythemia (ET), elevated blood TPO levels occur despite increased platelet and megakaryocyte mass. Therefore, in these diseases, elevated blood TPO levels cannot be explained by the first mechanism. The present study, was designed to measure TPO mRNA production by BM mononuclear cells and BM stromal cells using a relative RT-PCR technique, to verify the second mechanism. We found no increase of TPO mRNA production in either BM cells or in BM stromal cells in patients with MF and ET. Furthermore, in those patients with MF who had elevated plasma TPO levels, TPO mRNA levels in bone marrow fibroblasts (BMFs) or BM cells were not elevated as compared with controls. Therefore, we concluded that in patients with MF, the elevated plasma TPO levels are not due to enhanced production of TPO mRNA either by BMF, or BM cells. The TPO receptor (c-MPL) abnormalities including reduced MPL protein levels or defective TPO induced signal transduction pathways are the likely mechanisms.
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Affiliation(s)
- Jen C Wang
- Division of Medical Oncology and Hematology, Brookdale University Hospital and Medical Center, Brooklyn, NY 11219, USA.
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40
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Sarmiento MA, Stanganelli C, Cabrera J, Gonzalez E, Bengió RM. Anti-Epo and anti-Tpo antibodies in myelodysplastic syndromes. Eur J Haematol 2002; 69:189-90. [PMID: 12406016 DOI: 10.1034/j.1600-0609.2002.02829.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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41
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Louwes H, De Wolf JTM, Houwerzijl E, Vellenga E. Evaluation assays measuring platelet kinetics in bone marrow and peripheral blood. An overview. Nucl Med Commun 2002; 23:581-90. [PMID: 12029215 DOI: 10.1097/00006231-200206000-00012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Platelets play an important role in haemostasis and thrombosis. For an understanding of the pathophysiology and treatment of thrombocytopenia, it is not sufficient to measure only the platelet count. Platelet kinetic parameters, such as platelet survival and turnover, might be useful because many thrombocytopenia related disorders result from the interaction between production, utilization or destruction, and sequestration of platelets. Therefore, measuring platelet turnover with radiolabelled platelets could be a sensitive and qualitative tool for clinicians. However, the method does not enjoy widespread use because it has some serious drawbacks, such as the problems associated with the manipulation of blood and platelets, and the use of radioactivity. Recently, other useful assays for measuring platelet fluxes have been described in the literature, including plasma thrombopoietin and glycocalicin. In this review, these new tests will be described, compared with the classical method using radiolabelled platelets, and finally evaluated for their usefulness in clinical practice.
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Affiliation(s)
- H Louwes
- Department of Nuclear Medicine, Martini Hospital, Groningen, the Netherlands.
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42
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Tacke F, Trautwein C, Zhao S, Andreeff M, Manns MP, Ganser A, Schöffski P. Quantification of hepatic thrombopoietin mRNA transcripts in patients with chronic liver diseases shows maintained gene expression in different etiologies of liver cirrhosis. LIVER 2002; 22:205-12. [PMID: 12100570 DOI: 10.1034/j.1600-0676.2002.01642.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND/AIMS Platelet production is regulated by thrombopoietin (TPO), which is primarily synthesized in the liver. The TPO in patients with liver diseases could possibly be owing to impaired hepatic TPO production. As we reported previously, TPO serum levels are not decreased in patients with liver diseases compared with healthy controls and do not depend on the stage of cirrhosis or platelet count, but are highly elevated in patients with chronic virus hepatitis. METHODS To study possible mechanisms, we measured hepatic TPO mRNA levels in liver tissue samples from 31 liver cirrhosis patients by quantitative TaqMan real-time RT-PCR and corresponding serum TPO concentrations by ELISA. RESULTS Median TPO serum levels were elevated in patients with viral hepatitis (n = 12) compared with patients with a biliary (n = 10), alcoholic (n = 6) or other (n = 3) disease etiology, while hepatic TPO mRNA levels did not differ. The TPO mRNA levels in patients with chronic liver diseases were not different from normal liver tissue sample. The TPO mRNA and TPO serum level did not correlate. CONCLUSIONS We conclude that hepatic TPO gene expression appears to be maintained on a constitutive transcriptional level in patients with liver diseases and does not change dependent on disease etiology.
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Affiliation(s)
- Frank Tacke
- Department of Gastroenterology and Hepatology, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625 Hannover, Germany
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43
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McFarland J. Pathophysiology of platelet destruction in immune (idiopathic) thrombocytopenic purpura. Blood Rev 2002; 16:1-2. [PMID: 11913982 DOI: 10.1054/blre.2001.0169] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The mechanism of platelet destruction in immune (idiopathic) thrombocytopenic purpura (ITP) is thought to involve production of autoantibody to platelet surface antigens. Once coated with antibody, circulating platelets undergo sequestration via interaction with Fc receptors of macrophages in the reticuloendothelial system. A number of questions remain about the mechanism of platelet destruction in this disease: 1) What is the nature of the stimulus to the immune system that generates antiplatelet antibodies? 2) What is the role of interactions between T-helper lymphocytes and antigen-presenting cells in ITP? 3) What role, if any, is played by the targeting of single or multiple platelet surface glycoproteins by the autoimmune response? 4) Is the site of platelet destruction, intravascular or extravascular, or the state of activation of platelets important in the destruction of platelets?
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Affiliation(s)
- J McFarland
- Platelet and Antibody laboratory, Blood Center of Southeastern Wisconsin, Milwaukee, 53201-2178, USA
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44
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von dem Borne A, Folman C, van den Oudenrijn S, Linthorst G, de Jong S, de Haas M. The potential role of thrombopoietin in idiopathic thrombocytopenic purpura. Blood Rev 2002; 16:57-9. [PMID: 11913997 DOI: 10.1054/blre.2001.0184] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Thrombopoietin (TPO) plays a central role in the pathogenesis of idiopathic thrombocytopenic purpura (ITP), as it does in other immune-mediated thrombocytopenias. Because TPO is bound and internalized by platelets, it is destroyed together with platelets at an accelerated rate in the macrophage system. Because the spleen acts as a TPO sink, compensation of the decreased platelet count by an increased production in the bone marrow is insufficient. This aspect of ITP, as well as the use of TPO in the treatment of ITP, will be the focus of this article.
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Affiliation(s)
- A von dem Borne
- Department of Medicine, Clinical Hematology, University of Amsterdam, Amsterdam, The Netherlands.
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45
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Lin XY, Hanada S, Uozumi K, Utsunomiya A, Suzuki S, Shimotakahara S, Takeuchi S, Takatsuka Y, Arima T. Serum levels of endogenous thrombopoietin and granulocyte-colony stimulating factor in patients with acute or lymphoma type adult T-cell leukemia during multicycle chemotherapy. Leuk Lymphoma 2002; 43:343-9. [PMID: 11999567 DOI: 10.1080/10428190290006134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Recent multidrug chemotherapy for adult T-cell leukemia (ATL) showed improved findings, however, these protocols often induced persistent myelosuppression. Among 67 patients with acute and lymphoma type ATL treated between January 1996 and December 1998, 42 patients died during this period and showed chemotherapy-induced myelosuppression. To characterize the relation between the severity of myelosuppression and the endogenous thrombopoietin (TPO) or granulocyte-colony stimulating factor (G-CSF) levels in ATL patients, we measured these hematopoietic factors using ELISA method. Nineteen patients with acute or lymphoma type ATL and 16 healthy individuals were examined. During thrombocytopenia, the serum TPO levels were significantly higher than that of controls (P < 0.0001) and were inversely correlated with the platelet counts (r = -0.687 P < 0.001). Later in the chemotherapy cycle, severe persistent thrombocytopenia occurred and TPO levels elevated and remained at a high level approximating the TPO levels of exogenous TPO administration (0.3 microg/kg body weight). On the other hand, the serum G-CSF levels with absolute neutrophil counts (ANC) below 0.5 x 10(9)/L were significantly higher than controls (P = 0.009) and inversely correlated with ANC (r = -0.382 P = 0.0034). However, G-CSF levels in six samples obtained after 6 h of G-CSF (100-150 microg per body) administration was approximately 50-fold higher than that in the neutropenic states. These findings suggested that G-CSF can effectively reduce the severity and duration of intensified chemotherapy-induced neutropenia and higher dose exogenous TPO (higher than 0.6 microg/kg per day) therapy may be required to enhance platelet recovery after intensive chemotherapy in ATL patients.
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Affiliation(s)
- Xiao-Yan Lin
- The Second Department of Internal Medicine, Faculty of Medicine, Kagoshima University, Japan
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46
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Kappers-Klunne MC, de Haan M, Struijk PC, van Vliet HH. Serum thrombopoietin levels in relation to disease status in patients with immune thrombocytopenic purpura. Br J Haematol 2001; 115:1004-6. [PMID: 11843841 DOI: 10.1046/j.1365-2141.2001.03184.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pre- and post-treatment serum thrombopoietin (TPO) concentration was measured in 35 patients with immune thrombocytopenic purpura (ITP). Mean post-treatment levels were significantly lower (P = 0.02) than pretreatment and not different for treatment modality. No significant correlation between pre- or post-treatment TPO and platelet counts was demonstrable (R = -0.325, P = 0.056 and R = -0.227, P = 0.190 respectively). In patients with very low platelet counts (< or =20 x 10(9)/l), pretreatment serum TPO was significantly higher than in patients with higher counts (P = 0.033). The logarithm of the platelet turnover rate, measured in 15 patients, correlated with pretreatment TPO levels (R = 0.64). These findings suggest a contributory role for TPO in the mechanism of ITP.
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Affiliation(s)
- M C Kappers-Klunne
- Department of Haematology, University Hospital Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
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47
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Abstract
Thrombocytosis is caused by three major pathophysiological mechanisms: (1) reactive or secondary thrombocytosis; (2) familial thrombocytosis; and (3) clonal thrombocytosis, including essential thrombocythemia and related myeloproliferative disorders. Recent work has begun to elucidate the abnormal megakaryocytopoiesis of essential thrombocythemia, which is associated with paradoxically elevated plasma levels of thrombopoietin. The clonal nature of all cases of essential thrombocythemia has been challenged. Thrombotic complications are the major causes of morbidity and mortality in this disease. Indications for platelet cytoreduction and antiplatelet therapy, as well as complications of treatment, are being clarified.
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Affiliation(s)
- A I Schafer
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
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48
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Gouin-Thibault I, Cassinat B, Chomienne C, Rain JD, Najean Y, Schlageter MH. Is the Thrombopoietin Assay Useful for Differential Diagnosis of Thrombocytopenia? Analysis of a Cohort of 160 Patients with Thrombocytopenia and Defined Platelet Life Span. Clin Chem 2001. [DOI: 10.1093/clinchem/47.9.1660] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Background: Thrombopoietin (TPO), the major hormone controlling platelet production, has been measured in thrombocytopenias with discordant results. The aim of our work was to assess the value of the TPO assay for differential diagnosis of thrombocytopenias in a large cohort of patients classified according to the results of their platelet isotopic study.
Methods: We measured TPO (R&D Systems) in serum of 160 thrombocytopenic patients referred to our department for platelet life span isotopic studies. We classified patients as follows: (a) idiopathic or autoimmune thrombocytopenia group (ITP; patients with increased platelet destruction and shortened platelet life span; n = 67); (b) pure genetic thrombocytopenia group (patients with decreased platelet production, normal platelet life span, and without bone marrow aplasia; n = 55); (c) bone marrow aplasia group (BM; patients with decreased platelet production, normal platelet life span, and bone marrow aplasia; n = 13).
Results: In patients with pure genetic thrombocytopenia, TPO (median, 55 ng/L) was not different from TPO in patients with ITP (median, 58 ng/L) or controls (n = 54; median, 51 ng/L). Only in patients with bone marrow aplasia was TPO significantly higher (median, 155 ng/L) and negatively correlated to the platelet count (r2 = 0.5014).
Conclusions: Although the median serum TPO is increased in thrombocytopenia with decreased platelet production from bone marrow aplasia, it does not differentiate patients with pure genetic thrombocytopenia from those with ITP.
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Affiliation(s)
- Isabelle Gouin-Thibault
- Service de Médecine Nucléaire, Hôpital Saint-Louis, Assistance Publique, Hôpitaux de Paris, 1, Avenue Claude Vellefaux, 75475 Paris Cedex 10, France
- Laboratoire d’Hématologie, Groupe Hospitalier Charles Foix-Jean Rostand, Assistance Publique, Hôpitaux de Paris, 7, Avenue de la République, 94205 Ivry Sur Seine Cedex 5, France
| | - Bruno Cassinat
- Service de Médecine Nucléaire, Hôpital Saint-Louis, Assistance Publique, Hôpitaux de Paris, 1, Avenue Claude Vellefaux, 75475 Paris Cedex 10, France
| | - Christine Chomienne
- Service de Médecine Nucléaire, Hôpital Saint-Louis, Assistance Publique, Hôpitaux de Paris, 1, Avenue Claude Vellefaux, 75475 Paris Cedex 10, France
| | - Jean-Didier Rain
- Service de Médecine Nucléaire, Hôpital Saint-Louis, Assistance Publique, Hôpitaux de Paris, 1, Avenue Claude Vellefaux, 75475 Paris Cedex 10, France
| | - Yves Najean
- Service de Médecine Nucléaire, Hôpital Saint-Louis, Assistance Publique, Hôpitaux de Paris, 1, Avenue Claude Vellefaux, 75475 Paris Cedex 10, France
| | - Marie-Hélène Schlageter
- Service de Médecine Nucléaire, Hôpital Saint-Louis, Assistance Publique, Hôpitaux de Paris, 1, Avenue Claude Vellefaux, 75475 Paris Cedex 10, France
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49
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Mi JQ, Blanc-Jouvan F, Wang J, Sotto MF, Cousin F, Castinel A, Chauvet M, Sotto JJ, Polack B, Mossuz P. Endogenous megakaryocytic colony formation and thrombopoietin sensitivity of megakaryocytic progenitor cells are useful to distinguish between essential thrombocythemia and reactive thrombocytosis. JOURNAL OF HEMATOTHERAPY & STEM CELL RESEARCH 2001; 10:405-9. [PMID: 11454315 DOI: 10.1089/152581601750289000] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Diagnosis of essential thrombocythemia (ET) is controversial and remains mainly an exclusion diagnosis. Endogenous megakaryocyte colony (EMC) formation have been largely evaluated to identify specific criteria for ET, but results are impeded by the lack of medium standardization. We evaluated megakaryocyte (MK) colony formation in a serum-free collagen-based medium, without cytokine and in the presence of various concentrations of thrombopoietin (TPO). Thirty-six bone marrows from patients diagnosed with ET (n = 11), polycythemia vera (PV; n = 12), reactive thrombocytosis (RT; n = 6) and healthy donors (n = 7) were assessed. We demonstrate that 11 out 11 of the ET patients had spontaneous megakaryocyte colony-forming unit (CFU-MK) formation, in contrast to none of the RT patients and healthy donors. MK progenitors from ET patients remained responsive to TPO, because exogenous addition of TPO significantly increased cloning efficiency. Moreover, at low doses of TPO (0.5 ng/ml and 5 ng/ml), the number of positive cultures and mean number of TPO stimulated CFU-MK were significantly higher in cultures of cells from patients with ET than in patients with RT. In summary, we have described a standardized serum-free, collagen-based assay that allows differential diagnosis of ET and RT, according to endogenous CFU-MK formation and sensitivity to TPO.
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Affiliation(s)
- J Q Mi
- Department of Hematology, CHU Grenoble, BP217-38043 Grenoble cedex, France
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50
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Abstract
In the last decade, the diagnosis of essential thrombocythemia (ET) has been refined by appreciation of the occurrence of karyotypically occult but molecularly evident chronic myelogenous leukemia and morphologically subtle myelodysplastic syndrome (MDS) and cellular-phase agnogenic myeloid metaplasia (AMM). Although ET continues to be defined by the presence of nonreactive thrombocythemia that is not accounted for by another chronic myeloid disorder, recent studies of clonality and other laboratory parameters have suggested clinically relevant biologic heterogeneity among affected patients. Furthermore, randomized, prospective, and controlled retrospective data have provided additional clinical information that has resulted in the development of risk categories and risk-adjusted treatment recommendations.
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Affiliation(s)
- A Tefferi
- Mayo Clinic, Division of Hematology and Internal Medicine, 200 First Street SW, Rochester, MN 55095, USA.
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