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Martínez-Carballeira D, Bernardo Á, Caro A, Soto I, Gutiérrez L. Pathophysiology, Clinical Manifestations and Diagnosis of Immune Thrombocytopenia: Contextualization from a Historical Perspective. Hematol Rep 2024; 16:204-219. [PMID: 38651450 PMCID: PMC11036214 DOI: 10.3390/hematolrep16020021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/29/2024] [Accepted: 04/01/2024] [Indexed: 04/25/2024] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease characterized by an isolated decrease in the platelet count and an increased risk of bleeding. The pathogenesis is complex, affecting multiple components of the immune system and causing both peripheral destruction of platelets and impaired central megakaryopoiesis and platelet production in the bone marrow. Here, we intend to contextualize the current knowledge on the pathophysiology, terminology, epidemiology, clinical manifestations, diagnosis, and prognosis of ITP from a historical perspective and the first references to the never-stopping garnering of knowledge about this entity. We highlight the necessity to better understand ITP in order to be able to provide ITP patients with personalized treatment options, improving disease prognosis and reducing the incidence or frequency of refractoriness.
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Affiliation(s)
- Daniel Martínez-Carballeira
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Ángel Bernardo
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Alberto Caro
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Inmaculada Soto
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Laura Gutiérrez
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
- Department of Medicine, University of Oviedo, 33006 Oviedo, Spain
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2
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Moulinet T, Moussu A, Pierson L, Pagliuca S. The many facets of immune-mediated thrombocytopenia: Principles of immunobiology and immunotherapy. Blood Rev 2024; 63:101141. [PMID: 37980261 DOI: 10.1016/j.blre.2023.101141] [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: 08/30/2023] [Revised: 10/08/2023] [Accepted: 11/05/2023] [Indexed: 11/20/2023]
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune condition, due to peripheral platelet destruction through antibody-dependent cellular phagocytosis, complement-dependent cytotoxicity, cytotoxic T lymphocyte-mediated cytotoxicity, and megakaryopoiesis alteration. This condition may be idiopathic or triggered by drugs, vaccines, infections, cancers, autoimmune disorders and systemic diseases. Recent advances in our understanding of ITP immunobiology support the idea that other forms of thrombocytopenia, for instance, occurring after immunotherapy or cellular therapies, may share a common pathophysiology with possible therapeutic implications. If a decent pipeline of old and new agents is currently deployed for classical ITP, in other more complex immune-mediated thrombocytopenic disorders, clinical management is less harmonized and would deserve further prospective investigations. Here, we seek to provide a fresh overview of pathophysiology and current therapeutical algorithms for adult patients affected by this disorder with specific insights into poorly codified scenarios, including refractory ITP and post-immunotherapy/cellular therapy immune-mediated thrombocytopenia.
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Affiliation(s)
- Thomas Moulinet
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France; UMR 7365, IMoPA, Lorraine University, CNRS, Nancy, France
| | - Anthony Moussu
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Ludovic Pierson
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Simona Pagliuca
- UMR 7365, IMoPA, Lorraine University, CNRS, Nancy, France; Department of Hematology, Regional Competence Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Nancy University Hospital, Vandœuvre-lès-Nancy, France.
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3
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Kimura H, Onozawa M, Hashiguchi J, Hidaka D, Kanaya M, Matsukawa T, Okada H, Kondo T, Matsuno Y, Teshima T. Hereditary thrombocythemia due to splicing donor site mutation of THPO in a Japanese family. Ann Hematol 2024; 103:89-96. [PMID: 37962621 DOI: 10.1007/s00277-023-05523-9] [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: 09/14/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023]
Abstract
Thrombopoietin (THPO) is an essential factor for platelet production. Hereditary thrombocythemia (HT) is caused by a germline mutation of THPO, MPL, or JAK2 and is inherited in an autosomal-dominant manner. We identified a Japanese family with HT due to a point mutation of the splicing donor site of the THPO gene (THPO c.13 + 1G > A). Bone marrow biopsy showed increased megakaryocytes mimicking essential thrombocythemia. One affected family member developed chronic myeloid leukemia. We cloned the mutation and developed mutated and wild type THPO expression vectors. Molecular analysis showed that the mutation causes an exon 3 skipping transcript of THPO that abrogates a suppressive untranslated upstream open reading frame. Although the transcript levels of THPO mRNA were comparable, mutated transcripts were more efficiently translated and THPO protein expression was significantly higher than that of the wild type.
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Affiliation(s)
- Hiroyuki Kimura
- Department of Hematology, Hokkaido University Faculty of Medicine, Graduate School of Medicine, Kita 15, Nishi 7, Kita-Ku, Sapporo, Japan
| | - Masahiro Onozawa
- Department of Hematology, Hokkaido University Faculty of Medicine, Graduate School of Medicine, Kita 15, Nishi 7, Kita-Ku, Sapporo, Japan.
| | - Junichi Hashiguchi
- Department of Hematology, Hokkaido University Faculty of Medicine, Graduate School of Medicine, Kita 15, Nishi 7, Kita-Ku, Sapporo, Japan
| | - Daisuke Hidaka
- Department of Hematology, Hokkaido University Faculty of Medicine, Graduate School of Medicine, Kita 15, Nishi 7, Kita-Ku, Sapporo, Japan
| | - Minoru Kanaya
- Blood Disorders Center, Aiiku Hospital, Sapporo, Japan
| | - Toshihiro Matsukawa
- Department of Hematology, Hokkaido University Faculty of Medicine, Graduate School of Medicine, Kita 15, Nishi 7, Kita-Ku, Sapporo, Japan
| | - Hiromi Okada
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Japan
| | - Takeshi Kondo
- Blood Disorders Center, Aiiku Hospital, Sapporo, Japan
| | - Yoshihiro Matsuno
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Japan
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Faculty of Medicine, Graduate School of Medicine, Kita 15, Nishi 7, Kita-Ku, Sapporo, Japan
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4
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Fu H, Lv M, Liu H, Sun Y, Zhang Y, Mo X, Han T, Wang F, Yan C, Wang Y, Kong J, Han W, Chen H, Chen Y, Chen Y, Xu L, Liu K, Huang X, Zhang X. Thrombopoietin level predicts the response to avatrombopag treatment for persistent thrombocytopenia after haploidentical haematopoietic stem cell transplantation. Bone Marrow Transplant 2023; 58:1368-1376. [PMID: 37679646 DOI: 10.1038/s41409-023-02100-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 08/12/2023] [Accepted: 08/23/2023] [Indexed: 09/09/2023]
Abstract
Persistent thrombocytopenia (PT) has an unsatisfactory response to therapy after haploidentical haematopoietic stem cell transplantation (haplo-HSCT). We retrospectively evaluated the safety and efficacy of avatrombopag treatment in 69 patients with PT following haplo-HSCT and assessed whether baseline thrombopoietin (TPO) levels could predict treatment response. Overall response (OR) and complete response (CR) were defined as increased platelet levels to over 20 × 109/L or 50 × 109/L independent of platelet transfusion during or within 7 days of the end of avatrombopag treatment, respectively. The incidences of OR and CR were 72.5% and 58.0%, with a median of 11 and 29 days to OR and CR, respectively. ROC analysis suggested that the optimally discriminant baseline TPO level threshold for both OR and CR to avatrombopag was ≤ 1714 pg/mL. In multivariate analysis, a lower baseline TPO level (P = 0.005) was a significant independent factor of response to avatrombopag. For patients resistant to other TPO receptor agonists (TPO-RAs), 9/16 (56.3%) exhibited a response after switching to avatrombopag. Avatrombopag was well tolerated, and responders achieved improved overall survival (79.0% vs. 91.1%, P = 0.001). In conclusion, avatrombopag is a potential safe and effective treatment for PT after haplo-HSCT, and lower baseline TPO levels predicted a better response.
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Affiliation(s)
- Haixia Fu
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, China
- Collaborative Innovation Center of Haematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Haematologic Disease, Beijing, China
| | - Meng Lv
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, China
- Collaborative Innovation Center of Haematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Haematologic Disease, Beijing, China
| | - Huixin Liu
- Peking University People's Hospital, Department of Clinical Epidemiology and Biostatistics, Beijing, China
| | - Yuqian Sun
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, China
- Collaborative Innovation Center of Haematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Haematologic Disease, Beijing, China
| | - Yuanyuan Zhang
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, China
- Collaborative Innovation Center of Haematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Haematologic Disease, Beijing, China
| | - Xiaodong Mo
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, China
- Collaborative Innovation Center of Haematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Haematologic Disease, Beijing, China
| | - Tingting Han
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, China
- Collaborative Innovation Center of Haematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Haematologic Disease, Beijing, China
| | - Fengrong Wang
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, China
- Collaborative Innovation Center of Haematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Haematologic Disease, Beijing, China
| | - Chenhua Yan
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, China
- Collaborative Innovation Center of Haematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Haematologic Disease, Beijing, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, China
- Collaborative Innovation Center of Haematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Haematologic Disease, Beijing, China
| | - Jun Kong
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, China
- Collaborative Innovation Center of Haematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Haematologic Disease, Beijing, China
| | - Wei Han
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, China
- Collaborative Innovation Center of Haematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Haematologic Disease, Beijing, China
| | - Huan Chen
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, China
- Collaborative Innovation Center of Haematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Haematologic Disease, Beijing, China
| | - Yao Chen
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, China
- Collaborative Innovation Center of Haematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Haematologic Disease, Beijing, China
| | - Yuhong Chen
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, China
- Collaborative Innovation Center of Haematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Haematologic Disease, Beijing, China
| | - Lanping Xu
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, China
- Collaborative Innovation Center of Haematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Haematologic Disease, Beijing, China
| | - Kaiyan Liu
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, China
- Collaborative Innovation Center of Haematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Haematologic Disease, Beijing, China
| | - Xiaojun Huang
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, China
- Collaborative Innovation Center of Haematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Haematologic Disease, Beijing, China
| | - Xiaohui Zhang
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, China.
- Collaborative Innovation Center of Haematology, Peking University, Beijing, China.
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.
- National Clinical Research Center for Haematologic Disease, Beijing, China.
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Wang Z, Wang L, Liu Y, Meng J, Dong S, Ma J, Hu Y, Chen Z, Cheng X, Wu R. Sustained response off treatment in eltrombopag for children with persistent/chronic primary immune thrombocytopenia: A multicentre observational retrospective study in China. Br J Haematol 2023. [PMID: 37128832 DOI: 10.1111/bjh.18842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/17/2023] [Accepted: 04/20/2023] [Indexed: 05/03/2023]
Abstract
Eltrombopag (ELT) is effective and safe in adult persistent/chronic immune thrombocytopenia (p/cITP); a proportion could achieve a sustained response off treatment (SRoT); however, data on children are lacking. We attempted to analyse SRoT of ELT in children with p/cITP in this study. A multicentre retrospective observational study was performed in November 2022 for children with p/cITP who used ELT alone for >2 months between January 2017 and November 2021. Clinical data of pre-, during and post-ELT were collected. SRoT was defined as maintaining a platelet count of ≥30 × 109 /L without rescue therapy for at least 6 months off ELT. There were 143 patients enrolled; 69.2% (99/143) achieved an overall response of 43.3% and 25.9% achieved complete response (CR) and response (R). Among the 35 patients analysed from whom ELT was withdrawn, 71.4% (25/35) showed SRoT after discontinuing ELT without additional ITP therapy, with a median follow-up of 0.94 (range, 0.53-3.8) years, equal to 17.5% (25/143) in all patients treated with ELT. Compared with the patients with relapse (n = 10), the SRoT patients (n = 25) had a higher rate of CR (80% [20/25] vs. 40% [4/10]), shorter interval time from initiation to taper (6.4 months vs. 9.4 months), longer time from taper to withdrawal (1.1 years vs. 0.3 years) and a longer duration of ELT treatment (1.6 years vs. 0.5 years) with p < 0.05. Patients who achieved CR could attain SRoT more easily (p = 0.02). ELT had a response in 69.2% of children with p/cITP and 17.5% of them attained SRoT with good tolerance. The patients who achieved CR and began ELT treatment as early as possible, with a longer treatment duration and slower tapering, had a higher probability of SRoT.
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Affiliation(s)
- Zhifa Wang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Lijuan Wang
- Department of Hematology, Henan Province Children's Hospital, Zhengzhou, Henan, China
| | - Yan Liu
- Department of Hematology, Baoding Children's Hospital, Baoding, Hebei, China
| | - Jinxi Meng
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Shuyue Dong
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jingyao Ma
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yu Hu
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhenping Chen
- Department of Hematology Research, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaoling Cheng
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Runhui Wu
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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6
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Ou Y, Zhan Y, Zhuang X, Shao X, Xu P, Li F, Chen H, Ji L, Cheng Y. A bibliometric analysis of primary immune thrombocytopenia from 2011 to 2021. Br J Haematol 2023; 201:954-970. [PMID: 36807900 DOI: 10.1111/bjh.18692] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 01/21/2023] [Accepted: 01/27/2023] [Indexed: 02/22/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia. This bibliometric analysis was applied to identify the characteristics of global scientific output, the hotspots, and frontiers of ITP over the past 10 years. We retrieved publications from 2011 to 2021 from the Web of Science Core Collection (WoSCC). Bibliometrix package, VOSviewer, and Citespace were used to analyse and visualize the trend, distribution, and hotspots of research on ITP. Altogether, there were 2084 papers, written by 9080 authors from 410 organizations in 70 countries/regions, published in 456 journals with 37 160 co-cited references. In the last decades, the most productive journal was British Journal of Haematology, China was the most productive country. and the most cited journal was Blood. Shandong University was the most productive institution in the field of ITP. NEUNERT C, 2011, BLOOD, CHENG G, 2011, LANCET, and PATEL VL, 2012, BLOOD were the top three most cited documents. "Thrombopoietin receptor agonist", "regulatory T cell" and "sialic acid" were three hotspots of the last decade. And "immature platelet fraction", "Th17", and "fostamatinib" would be research frontiers in the feature. The present study provided a novel insight for future research directions and scientific decision-making.
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Affiliation(s)
- Yang Ou
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China
| | - Yanxia Zhan
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xibing Zhuang
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xia Shao
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Pengcheng Xu
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Feng Li
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China.,Zhongshan Hospital Qingpu Branch, Department of Hematology, Fudan University, Shanghai, China
| | - Hao Chen
- Zhongshan Hospital Xuhui Branch, Department of Thoracic Surgery, Fudan University, Shanghai, China
| | - Lili Ji
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yunfeng Cheng
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China.,Zhongshan Hospital Qingpu Branch, Department of Hematology, Fudan University, Shanghai, China.,Institute of Clinical Science, Zhongshan Hospital, Fudan University, Shanghai, China
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7
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Chen W, Zhu L, Wang L, Zeng J, Wen M, Xu X, Zou L, Huang F, Huang Q, Qin D, Mei Q, Yang J, Wang Q, Wu J. A Novel Antithrombocytopenia Agent, Rhizoma cibotii, Promotes Megakaryopoiesis and Thrombopoiesis through the PI3K/AKT, MEK/ERK, and JAK2/STAT3 Signaling Pathways. Int J Mol Sci 2022; 23:ijms232214060. [PMID: 36430539 PMCID: PMC9694118 DOI: 10.3390/ijms232214060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cibotii rhizoma (CR) is a famous traditional Chinese medicine (TCM) used to treat bleeding, rheumatism, lumbago, etc. However, its therapeutic effects and mechanism against thrombocytopenia are still unknown so far. In the study, we investigated the effects of aqueous extracts of Cibotii rhizoma (AECRs) against thrombocytopenia and its molecular mechanism. METHODS Giemsa staining, phalloidin staining, and flow cytometry were performed to measure the effect of AECRs on the megakaryocyte differentiation in K562 and Meg-01 cells. A radiation-induced thrombocytopenia mouse model was constructed to assess the therapeutic actions of AECRs on thrombocytopenia. Network pharmacology and experimental verification were carried out to clarify its mechanism against thrombocytopenia. RESULTS AECRs promoted megakaryocyte differentiation in K562 and Meg-01 cells and accelerated platelet recovery and megakaryopoiesis with no systemic toxicity in radiation-induced thrombocytopenia mice. The PI3K/AKT, MEK/ERK, and JAK2/STAT3 signaling pathways contributed to AECR-induced megakaryocyte differentiation. The suppression of the above signaling pathways by their inhibitors blocked AERC-induced megakaryocyte differentiation. CONCLUSIONS AECRs can promote megakaryopoiesis and thrombopoiesis through activating PI3K/AKT, MEK/ERK, and JAK2/STAT3 signaling pathways, which has the potential to treat radiation-induced thrombocytopenia in the clinic.
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Affiliation(s)
- Wang Chen
- School of Pharmacy, Southwest Medical University, Luzhou 646000, China
| | - Linjie Zhu
- School of Pharmacy, Southwest Medical University, Luzhou 646000, China
| | - Long Wang
- School of Pharmacy, Southwest Medical University, Luzhou 646000, China
| | - Jing Zeng
- School of Pharmacy, Southwest Medical University, Luzhou 646000, China
| | - Min Wen
- School of Pharmacy, Southwest Medical University, Luzhou 646000, China
| | - Xiyan Xu
- School of Basic Medical Sciences, Southwest Medical University, Luzhou 646000, China
| | - LiLe Zou
- School of Basic Medical Sciences, Southwest Medical University, Luzhou 646000, China
| | - Feihong Huang
- School of Pharmacy, Southwest Medical University, Luzhou 646000, China
| | - Qianqian Huang
- School of Pharmacy, Southwest Medical University, Luzhou 646000, China
| | - Dalian Qin
- School of Pharmacy, Southwest Medical University, Luzhou 646000, China
- Education Ministry Key Laboratory of Medical Electrophysiology, Southwest Medical University, Luzhou 646000, China
| | - Qibing Mei
- School of Pharmacy, Southwest Medical University, Luzhou 646000, China
- Education Ministry Key Laboratory of Medical Electrophysiology, Southwest Medical University, Luzhou 646000, China
| | - Jing Yang
- School of Pharmacy, Southwest Medical University, Luzhou 646000, China
- Education Ministry Key Laboratory of Medical Electrophysiology, Southwest Medical University, Luzhou 646000, China
| | - Qiaozhi Wang
- School of Basic Medical Sciences, Southwest Medical University, Luzhou 646000, China
- Correspondence: (Q.W.); (J.W.); Tel.: 86-18015728611 (Q.W.); 86-13982416641 (J.W.)
| | - Jianming Wu
- School of Basic Medical Sciences, Southwest Medical University, Luzhou 646000, China
- Education Ministry Key Laboratory of Medical Electrophysiology, Southwest Medical University, Luzhou 646000, China
- Correspondence: (Q.W.); (J.W.); Tel.: 86-18015728611 (Q.W.); 86-13982416641 (J.W.)
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8
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Provan D, Newland AC. Investigational drugs for immune thrombocytopenia. Expert Opin Investig Drugs 2022; 31:715-727. [DOI: 10.1080/13543784.2022.2075340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Drew Provan
- Centre for Immunology, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London UK
| | - Adrian C Newland
- Centre for Immunology, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London UK
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9
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Eltrombopag in pediatric chronic and refractory ITP: data from a retrospective multicenter study from Lebanon. Ann Hematol 2022; 101:991-997. [DOI: 10.1007/s00277-022-04804-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 02/18/2022] [Indexed: 12/24/2022]
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10
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Cheney A, Woolcock AD, Mukhopadhyay A, Knapp D, Moore GE. Interleukin-6 and thrombopoietin concentrations in dogs with carcinoma with and without thrombocytosis. J Vet Intern Med 2022; 36:227-233. [PMID: 34881459 PMCID: PMC8783347 DOI: 10.1111/jvim.16317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 11/04/2021] [Accepted: 11/05/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Carcinoma-associated thrombocytosis involves tumor production of mediators such as interleukin-6 (IL-6) and thrombopoietin (TPO) that increase thrombopoiesis and may play a role in tumor evasion and metastasis. Carcinoma-associated thrombocytosis is described in people, but has not been described in dogs. HYPOTHESIS/OBJECTIVES Evaluate the concentrations of IL-6 and TPO in dogs diagnosed with carcinoma with or without thrombocytosis. We hypothesized that IL-6 and TPO concentrations would be higher in dogs with carcinoma compared to healthy dogs, and that IL-6 and TPO concentrations would be higher in dogs with carcinoma and thrombocytosis when compared to dogs with carcinoma and normal platelet counts. ANIMALS One-hundred sixteen dogs: 63 with carcinoma and 53 healthy control dogs. METHODS Complete blood count was performed in all dogs, and they were stratified for sub-group analysis based on the presence or absence of thrombocytosis (platelet count > 500 103/µL). Serum TPO and IL-6 concentrations were measured by ELISA. Results of selected numeric variables were compared using Wilcoxon rank sum tests for pairwise comparisons. A value of P < .05 was considered significant. RESULTS Twelve of the dogs with carcinoma (12/63, 19.0%) and none of the healthy control dogs (0%) had thrombocytosis. Thrombopoietin concentrations (median [range]) were significantly higher in dogs with carcinoma when compared to controls (87.42 pg/mL [0 to >600] vs 15.99 pg/mL [0 to >600], P < .001). Interleukin-6 concentrations (median [range]) were not different between dogs with carcinoma and healthy control dogs (9.70 pg/mL [0-181.53] vs 3.03 pg/mL [0-280.77], P = .15). In dogs with carcinoma, the TPO and IL-6 concentrations were not different between dogs with thrombocytosis and dogs with normal platelet count. CONCLUSIONS AND CLINICAL IMPORTANCE Thrombopoietin concentrations were significantly higher in dogs with carcinoma, regardless of platelet count. Thrombopoietin is likely to be 1 of multiple factors that can impact platelet number, production, and consumption in dogs with carcinoma.
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Affiliation(s)
- Adrienne Cheney
- Department of Veterinary Clinical Sciences, College of Veterinary MedicinePurdue UniversityWest LafayetteIndianaUSA
| | - Andrew D. Woolcock
- Department of Veterinary Clinical Sciences, College of Veterinary MedicinePurdue UniversityWest LafayetteIndianaUSA
| | - Abhijit Mukhopadhyay
- Department of Veterinary Clinical Sciences, College of Veterinary MedicinePurdue UniversityWest LafayetteIndianaUSA
| | - Deborah Knapp
- Department of Veterinary Clinical Sciences, College of Veterinary MedicinePurdue UniversityWest LafayetteIndianaUSA
| | - George E. Moore
- Department of Veterinary Administration, College of Veterinary MedicinePurdue UniversityWest LafayetteIndianaUSA
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11
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Figueiredo C, Blasczyk R. Generation of HLA Universal Megakaryocytes and Platelets by Genetic Engineering. Front Immunol 2021; 12:768458. [PMID: 34777386 PMCID: PMC8579098 DOI: 10.3389/fimmu.2021.768458] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/11/2021] [Indexed: 11/13/2022] Open
Abstract
Patelet transfusion refractoriness remains a relevant hurdle in the treatment of severe alloimmunized thrombocytopenic patients. Antibodies specific for the human leukocyte antigens (HLA) class I are considered the major immunological cause for PLT transfusion refractoriness. Due to the insufficient availability of HLA-matched PLTs, the development of new technologies is highly desirable to provide an adequate management of thrombocytopenia in immunized patients. Blood pharming is a promising strategy not only to generate an alternative to donor blood products, but it may offer the possibility to optimize the therapeutic effect of the produced blood cells by genetic modification. Recently, enormous technical advances in the field of in vitro production of megakaryocytes (MKs) and PLTs have been achieved by combining progresses made at different levels including identification of suitable cell sources, cell pharming technologies, bioreactors and application of genetic engineering tools. In particular, use of RNA interference, TALEN and CRISPR/Cas9 nucleases or nickases has allowed for the generation of HLA universal PLTs with the potential to survive under refractoriness conditions. Genetically engineered HLA-silenced MKs and PLTs were shown to be functional and to have the capability to survive cell- and antibody-mediated cytotoxicity using in vitro and in vivo models. This review is focused on the methods to generate in vitro genetically engineered MKs and PLTs with the capacity to evade allogeneic immune responses.
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Affiliation(s)
- Constanca Figueiredo
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Rainer Blasczyk
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
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12
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Kuter DJ. The structure, function, and clinical use of the thrombopoietin receptor agonist avatrombopag. Blood Rev 2021; 53:100909. [PMID: 34815110 DOI: 10.1016/j.blre.2021.100909] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/05/2021] [Accepted: 11/11/2021] [Indexed: 01/14/2023]
Abstract
Thrombopoietin regulates platelet production through activation of the thrombopoietin receptor (TPO-R). TPO-R agonists (TPO-RAs) are available to treat thrombocytopenia in chronic immune thrombocytopenia (ITP), chronic liver disease (CLD) patients who are undergoing a procedure, severe aplastic anemia (SAA), and hepatitis C virus (HCV) infection. There are four TPO-RAs approved in the US and Europe: romiplostim (ITP), eltrombopag (ITP, SAA, HCV), avatrombopag (ITP, CLD), and lusutrombopag (CLD). It is important to understand pharmacological characteristics of these agents when evaluating treatment options. Avatrombopag interacts with the transmembrane domain of the TPO-RA and does not compete with endogenous thrombopoietin for TPO-R binding. Structural differences between avatrombopag and other TPO-RAs may impart differential downstream effects on cell signaling pathways, potentially resulting in clinically relevant differences in outcome. Avatrombopag has a favorable pharmacological profile with similar exposure in Japanese, Chinese, or Caucasian patients and no drug-drug interactions, food interactions, or potential for chelation.
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Affiliation(s)
- David J Kuter
- Center for Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
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13
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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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14
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Immune Thrombocytopenia: Recent Advances in Pathogenesis and Treatments. Hemasphere 2021; 5:e574. [PMID: 34095758 PMCID: PMC8171374 DOI: 10.1097/hs9.0000000000000574] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/08/2021] [Indexed: 11/26/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune disease due to both a peripheral destruction of platelets and an inappropriate bone marrow production. Although the primary triggering factors of ITP remain unknown, a loss of immune tolerance-mostly represented by a regulatory T-cell defect-allows T follicular helper cells to stimulate autoreactive splenic B cells that differentiate into antiplatelet antibody-producing plasma cells. Glycoprotein IIb/IIIa is the main target of antiplatelet antibodies leading to platelet phagocytosis by splenic macrophages, through interactions with Fc gamma receptors (FcγRs) and complement receptors. This allows macrophages to activate autoreactive T cells by their antigen-presenting functions. Moreover, the activation of the classical complement pathway participates to platelet opsonization and also to their destruction by complement-dependent cytotoxicity. Platelet destruction is also mediated by a FcγR-independent pathway, involving platelet desialylation that favors their binding to the Ashwell-Morell receptor and their clearance in the liver. Cytotoxic T cells also contribute to ITP pathogenesis by mediating cytotoxicity against megakaryocytes and peripheral platelets. The deficient megakaryopoiesis resulting from both the humoral and the cytotoxic immune responses is sustained by inappropriate levels of thrombopoietin, the major growth factor of megakaryocytes. The better understanding of ITP pathogenesis has provided important therapeutic advances. B cell-targeting therapies and thrombopoietin-receptor agonists (TPO-RAs) have been used for years. New emerging therapeutic strategies that inhibit FcγR signaling, the neonatal Fc receptor or the classical complement pathway, will deeply modify the management of ITP in the near future.
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15
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Bussel JB, Soff G, Balduzzi A, Cooper N, Lawrence T, Semple JW. A Review of Romiplostim Mechanism of Action and Clinical Applicability. Drug Des Devel Ther 2021; 15:2243-2268. [PMID: 34079225 PMCID: PMC8165097 DOI: 10.2147/dddt.s299591] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/06/2021] [Indexed: 12/17/2022] Open
Abstract
Thrombocytopenia results from a variety of conditions, including radiation, chemotherapy, autoimmune disease, bone marrow disorders, pathologic conditions associated with surgical procedures, hematopoietic stem cell transplant (HSCT), and hematologic disorders associated with severe aplastic anemia. Immune thrombocytopenia (ITP) is caused by immune reactions that accelerate destruction and reduce production of platelets. Thrombopoietin (TPO) is a critical component of platelet production pathways, and TPO receptor agonists (TPO-RAs) are important for the management of ITP by increasing platelet production and reducing the need for other treatments. Romiplostim is a TPO-RA approved for use in patients with ITP in the United States, European Union, Australia, and several countries in Africa and Asia, as well as for use in patients with refractory aplastic anemia in Japan and Korea. Romiplostim binds to and activates the TPO receptor on megakaryocyte precursors, thus promoting cell proliferation and viability, resulting in increased platelet production. Through this mechanism, romiplostim reduces the need for other treatments and decreases bleeding events in patients with thrombocytopenia. In addition to its efficacy in ITP, studies have shown that romiplostim is effective in improving platelet counts in various settings, thereby highlighting the versatility of romiplostim. The efficacy of romiplostim in such disorders is currently under investigation. Here, we review the structure, mechanism, pharmacokinetics, and pharmacodynamics of romiplostim. We also summarize the clinical evidence supporting its use in ITP and other disorders that involve thrombocytopenia, including chemotherapy-induced thrombocytopenia, aplastic anemia, acute radiation syndrome, perisurgical thrombocytopenia, post-HSCT thrombocytopenia, and liver disease.
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Affiliation(s)
- James B Bussel
- Department of Pediatrics, Division of Hematology, Weill Cornell Medicine, New York, NY, USA
| | - Gerald Soff
- Department of Medicine, Hematology Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Adriana Balduzzi
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Ospedale San Gerardo, Monza, Italy
| | | | | | - John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
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16
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Bush LM, Healy CP, Marvin JE, Deans TL. High-throughput enrichment and isolation of megakaryocyte progenitor cells from the mouse bone marrow. Sci Rep 2021; 11:8268. [PMID: 33859294 PMCID: PMC8050096 DOI: 10.1038/s41598-021-87681-2] [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: 11/05/2020] [Accepted: 03/17/2021] [Indexed: 11/17/2022] Open
Abstract
Megakaryocytes are a rare population of cells that develop in the bone marrow and function to produce platelets that circulate throughout the body and form clots to stop or prevent bleeding. A major challenge in studying megakaryocyte development, and the diseases that arise from their dysfunction, is the identification, classification, and enrichment of megakaryocyte progenitor cells that are produced during hematopoiesis. Here, we present a high throughput strategy for identifying and isolating megakaryocytes and their progenitor cells from a heterogeneous population of bone marrow samples. Specifically, we couple thrombopoietin (TPO) induction, image flow cytometry, and principal component analysis (PCA) to identify and enrich for megakaryocyte progenitor cells that are capable of self-renewal and directly differentiating into mature megakaryocytes. This enrichment strategy distinguishes megakaryocyte progenitors from other lineage-committed cells in a high throughput manner. Furthermore, by using image flow cytometry with PCA, we have identified a combination of markers and characteristics that can be used to isolate megakaryocyte progenitor cells using standard flow cytometry methods. Altogether, these techniques enable the high throughput enrichment and isolation of cells in the megakaryocyte lineage and have the potential to enable rapid disease identification and diagnoses ahead of severe disease progression.
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Affiliation(s)
- Lucas M Bush
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, 84112, USA
| | - Connor P Healy
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, 84112, USA
| | - James E Marvin
- Flow Cytometry Core Facility, University of Utah Health Sciences Center, Salt Lake City, UT, 84112, USA
| | - Tara L Deans
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, 84112, USA.
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17
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Drexler B, Passweg J. Current evidence and the emerging role of eltrombopag in severe aplastic anemia. Ther Adv Hematol 2021; 12:2040620721998126. [PMID: 33747425 PMCID: PMC7940771 DOI: 10.1177/2040620721998126] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 02/02/2021] [Indexed: 12/12/2022] Open
Abstract
Acquired aplastic anemia (AA) is characterized by a reduced stem cell reserve. Several preclinical studies have confirmed the beneficial effect of thrombopoietin (TPO) on the expansion and maintenance of hematopoietic stem cells (HSCs). Thus, TPO receptor agonists seem to be an ideal therapeutic agent for AA to augment marrow function. First studies with eltrombopag as a single agent at 150 mg/day showed an overall response rate of 40–50% in patients with refractory severe AA (rSAA). Subsequent studies examined the first-line use of eltrombopag together with horse antithymocyte globulin and cyclosporine, reaching response rates up to 94%. Although used at high doses, known adverse events in the form of skin, gastrointestinal, or hepatic impairment are feasible in AA, however first data show a relatively high rate of clonal evolution in the form of karyotypic aberrations in patients with rAA. Nonetheless, there is a strong rationale that eltrombopag can contribute to restoring hematopoiesis in SAA by stimulating HSCs. Further studies are needed to decide if eltrombopag is clearly superior to current established treatments and to determine optimal treatment duration, dosage, and long-term effects.
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Affiliation(s)
- Beatrice Drexler
- Division of Hematology, University Hospital Basel, Petersgraben 4, Basel, 4031, Switzerland
| | - Jakob Passweg
- Division of Hematology, University Hospital Basel, Basel, Switzerland
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18
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Lucchini E, Palandri F, Volpetti S, Vianelli N, Auteri G, Rossi E, Patriarca A, Carli G, Barcellini W, Celli M, Consoli U, Valeri F, Santoro C, Crea E, Vignetti M, Paoloni F, Gigliotti CL, Boggio E, Dianzani U, Giardini I, Carpenedo M, Rodeghiero F, Fanin R, Zaja F. Eltrombopag second-line therapy in adult patients with primary immune thrombocytopenia in an attempt to achieve sustained remission off-treatment: results of a phase II, multicentre, prospective study. Br J Haematol 2021; 193:386-396. [PMID: 33618438 DOI: 10.1111/bjh.17334] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 12/17/2020] [Indexed: 01/09/2023]
Abstract
Up to 30% immune thrombocytopenia (ITP) patients achieve a sustained remission off-treatment (SROT) after discontinuation of thrombopoietin receptor agonists (TPO-RAs). Factors predictive of response are lacking. Patients aged ≥18 years with newly diagnosed or persistent ITP were treated with eltrombopag for 24 weeks. Primary end-point was SROT: the proportion of responders that were able to taper and discontinue eltrombopag maintaining the response during a period of observation (PO) of six months. Secondary end-points included the association between some immunological parameters (TPO serum levels, cytokines and lymphocyte subsets) and response. Fifty-one patients were evaluable. Primary end-point was achieved in 13/51 (25%) treated patients and 13/34 (38%) patients who started the tapering. Baseline TPO levels were not associated with response at week 24 nor with SROT. Higher baseline levels of IL-10, IL-4, TNF-α and osteopontin were negative factors predictive of response (P = 0·001, 0·008, 0·02 and 0·03 respectively). This study confirms that SROT is feasible for a proportion of ITP patients treated with eltrombopag. Some biological parameters were predictive of response.
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Affiliation(s)
- Elisa Lucchini
- S.C. Ematologia, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Francesca Palandri
- Azienda Ospedaliero-Universitaria di Bologna, IRCCS Policlinico S.Orsola-Malpighi, DAI, Dipartimento di Oncologia e di Ematologia, Bologna, Italy
| | - Stefano Volpetti
- Clinica Ematologica, Centro Trapianti e Terapie Cellulari "C. Melzi", DAME, Università degli Studi, Udine, Italy
| | - Nicola Vianelli
- Azienda Ospedaliero-Universitaria di Bologna, IRCCS Policlinico S.Orsola-Malpighi, DAI, Dipartimento di Oncologia e di Ematologia, Bologna, Italy
| | - Giuseppe Auteri
- Azienda Ospedaliero-Universitaria di Bologna, IRCCS Policlinico S.Orsola-Malpighi, DAI, Dipartimento di Oncologia e di Ematologia, Bologna, Italy
| | - Elena Rossi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico A. Gemelli IRCCS, Roma, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
| | | | - Giuseppe Carli
- Hematology Department, Ospedale San Bortolo, Vicenza, Italy
| | - Wilma Barcellini
- UOC Ematologia, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Ugo Consoli
- UOC Ematologia ARNAS Garibaldi, Catania, Italy
| | - Federica Valeri
- Regional Center for Hemorrhagic and Thrombotic Diseases, Haematology Unit, City of Health and Science University Hospital of Molinette, Turin, Italy
| | - Cristina Santoro
- Hematology, University Hospital Policlinico Umberto I, Rome, Italy
| | | | | | | | - Casimiro Luca Gigliotti
- Laboratory of Immunology, Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Elena Boggio
- Laboratory of Immunology, Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Umberto Dianzani
- Laboratory of Immunology, Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Ilaria Giardini
- Clinical and Experimental Pharmacokinetics Lab, Diagnostic Medicine Dep, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Monica Carpenedo
- Hematology and Transplant Dept, ASST Ospedale San Gerardo di Monza, Monza, Italy
| | - Francesco Rodeghiero
- Hematology Project Foundation, Vicenza, Italy - affiliated to the Dept. of Hematology of the San Bortolo Hospital, Vicenza, Italy
| | - Renato Fanin
- Clinica Ematologica, Centro Trapianti e Terapie Cellulari "C. Melzi", DAME, Università degli Studi, Udine, Italy
| | - Francesco Zaja
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
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19
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Ono‐Uruga Y, Ikeda Y, Matsubara Y. Platelet production using adipose-derived mesenchymal stem cells: Mechanistic studies and clinical application. J Thromb Haemost 2021; 19:342-350. [PMID: 33217130 PMCID: PMC7898515 DOI: 10.1111/jth.15181] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/29/2020] [Accepted: 11/12/2020] [Indexed: 12/12/2022]
Abstract
Megakaryocytes (MKs) are platelet progenitor stem cells found in the bone marrow. Platelets obtained from blood draws can be used for therapeutic applications, especially platelet transfusion. The needs for platelet transfusions for clinical situation is increasing, due in part to the growing number of patients undergoing chemotherapy. Platelets obtained from donors, however, have the disadvantages of a limited storage lifespan and the risk of donor-related infection. Extensive effort has therefore been directed at manufacturing platelets ex vivo. Here, we review ex vivo technologies for MK development, focusing on human adipose tissue-derived mesenchymal stem/stromal cell line (ASCL)-based strategies and their potential clinical application. Bone marrow and adipose tissues contain mesenchymal stem/stromal cells that have an ability to differentiate into MKs, which release platelets. Taking advantage of this mechanism, we developed a donor-independent system for manufacturing platelets for clinical application using ASCL established from adipose-derived mesenchymal stem/stromal cells (ASCs). Culture of ASCs with endogenous thrombopoietin and its receptor c-MPL, and endogenous genes such as p45NF-E2 leads to MK differentiation and subsequent platelet production. ASCs compose heterogeneous cells, however, and are not suitable for clinical application. Thus, we established ASCLs, which expand into a more homogeneous population, and fulfill the criteria for mesenchymal stem cells set by the International Society for Cellular Therapy. Using our ASCL culture system with MK lineage induction medium without recombinant thrombopoietin led to peak production of platelets within 12 days, which may be sufficient for clinical application.
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Affiliation(s)
- Yukako Ono‐Uruga
- Clinical and Translational Research CenterKeio University School of MedicineTokyoJapan
| | - Yasuo Ikeda
- Department of HematologyKeio University School of MedicineTokyoJapan
- Life Science and Medical BioscienceWaseda UniversityTokyoJapan
| | - Yumiko Matsubara
- Clinical and Translational Research CenterKeio University School of MedicineTokyoJapan
- Department of Laboratory MedicineKeio University School of MedicineTokyoJapan
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20
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Zeng X, Jiao Y, Li Z, Zhang Y, Ye J. [Thrombopoietin promotes megakaryopoiesis via protecting bone marrow endothelial function in patients undergoing chemotherapy for hematological malignancies]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2020; 40:1134-1140. [PMID: 32895184 DOI: 10.12122/j.issn.1673-4254.2020.08.10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To explore whether thrombopoietin (TPO) can rescue megakaryopoiesis by protecting bone marrowderived endothelial progenitor cells (BM-EPCs) in patients receiving chemotherapy for hematological malignancies. METHODS Bone marrow samples were collected from 23 patients with hematological malignancies 30 days after chemotherapy and from 10 healthy volunteers. BM-EPCs isolated from the samples were identified by staining for CD34, CD309 and CD133, and their proliferation in response to treatment with TPO was assessed using CCK8 assay. DiL-Ac-LDL uptake and FITC-UEA-I binding assay were performed to evaluate the amount of BM-EPCs from the subjects. Tube-formation and migration experiments were used for functional assessment of the BM-EPCs. The BM-EPCs with or without TPO treatment were co-cultured with human megakaryocytes, and the proliferation of the megakaryocytes was detected with flow cytometry. RESULTS Flow cytometry indicated that the TPO-treated cells had high expressions of CD34, CD133, and CD309. CCK8 assay demonstrated that TPO treatment enhanced the proliferation of the BM-EPCs, and the optimal concentration of TPO was 100 μg/L. Double immunofluorescence assay indicated that the number of BM-EPC was significantly higher in TPO-treated group than in the control group. The TPO-treated BM-EPCs exhibited stronger tube-formation and migration abilities (P < 0.05) and more significantly enhanced the proliferation of co-cultured human megakaryocytes than the control cells (P < 0.05). CONCLUSIONS TPO can directly stimulate megakaryopoiesis and reduce hemorrhage via protecting the function of BM-EPCs in patients following chemotherapy for hematological malignancies.
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Affiliation(s)
- Xiaoyuan Zeng
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Yingying Jiao
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Zongpeng Li
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Yujiao Zhang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Jieyu Ye
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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21
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Audia S, Mahevas M, Bonnotte B. [Immune thrombocytopenia: From pathogenesis to treatment]. Rev Med Interne 2020; 42:16-24. [PMID: 32741715 DOI: 10.1016/j.revmed.2020.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/29/2020] [Accepted: 06/20/2020] [Indexed: 12/13/2022]
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune disease due to an immune peripheral destruction of platelets and an inappropriate platelet production. The pathogenesis of ITP is now better understood: it involves a humoral immune response which dependents on the stimulation of B cells by specific T cells called T follicular helper cells, leading to their differentiation into plasma cells that produce antiplatelet antibodies thus promoting the phagocytosis of platelets mainly by splenic macrophages. The deciphering of ITP pathogenesis has led to a better understanding of the inefficiency of treatments such as rituximab, although it has not provided yet the determination of biological predictive factor of response to treatments. Moreover, new therapeutic perspectives have been opened in the last few years with the development of molecules targeting Fcγ receptor signalling such as Syk inhibitor, or molecules increasing the clearance of pathogenic autoantibodies such as inhibitors of the neonatal Fc receptor (FcRn).
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Affiliation(s)
- S Audia
- Service de Médecine Interne et Immunologie Clinique, Médecine 1-SOC 1, Hôpital François Mitterrand, Centre de référence des cytopénies auto-immunes de l'adulte, CHU Dijon-Bourgogne, 14 rue Paul Gaffarel, 21079 Dijon, France; Unité RIGHT, INSERM UMR 1098, Équipe "Immunorégulation et immunopathologie", Bâtiment B3, 15 rue Maréchal de Lattre de Tassigny, 21000 Dijon, France.
| | - M Mahevas
- 1 Service de Médecine Interne, Centre National de Référence des Cytopénies Auto-Immunes de l'Adulte, Centre Hospitalier Universitaire Henri-Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France; IMRB - U955 - Equipe n°2 "Transfusion et maladies du globule rouge" EFS Île-de-France, Hôpital Henri-Mondor, AP-HP, 51, avenue du Maréchal-de-Lattre-de-Tassigny, France
| | - B Bonnotte
- Service de Médecine Interne et Immunologie Clinique, Médecine 1-SOC 1, Hôpital François Mitterrand, Centre de référence des cytopénies auto-immunes de l'adulte, CHU Dijon-Bourgogne, 14 rue Paul Gaffarel, 21079 Dijon, France; Unité RIGHT, INSERM UMR 1098, Équipe "Immunorégulation et immunopathologie", Bâtiment B3, 15 rue Maréchal de Lattre de Tassigny, 21000 Dijon, France
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22
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Ebbo M, Rivière E, Godeau B. [Adult immune thrombocytopenia and thrombopoietin receptor agonist: Ten years later]. Rev Med Interne 2020; 42:38-45. [PMID: 32712041 DOI: 10.1016/j.revmed.2020.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 05/22/2020] [Indexed: 12/24/2022]
Abstract
Ten years after their licence in France, the use of the two thrombopoietin receptor agonists (TPO-RA), eltrombopag and romiplostim, has deeply modified the landscape of immune thrombocytopenia (ITP) treatment. In this review, we summarise data on efficacy and safety of these treatments during ITP, as well as their use in clinical practice. Their place in therapeutic strategy, the recent description of persistant remission after discontinuation of TPO-RA, and future new thrombopoietic agents are also discussed. Their use has progressively increased and early use at a newly diagnosed stage of the disease is under evaluation. However physician have to keep in mind that thromboembolism rates appear to be higher with TPO-RA treatment in ITP patients at high risk of thrombosis, and that data from "real-life" studies with very long term follow up are not available. Finally, the cost of these treatments should also be evaluated in future therapeutic strategies comparisons.
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Affiliation(s)
- M Ebbo
- Département de Médecine Interne, Hôpital de la Timone, AP-HM, Marseille, France; Aix Marseille Université, CNRS, INSERM, Centre d'Immunologie de Marseille Luminy, Marseille, France
| | - E Rivière
- Université de Bordeaux, Faculté de Médecine, 232 rue Léo Saignat, 33000 Bordeaux, France; CHU de Bordeaux, Service de Médecine Interne et Maladies Infectieuses, Hôpital Haut-Lévêque, 33604 Pessac, France
| | - B Godeau
- Service de médecine interne, Centre de référence des cytopénies autoimmunes de l'adulte, CHU Henri Mondor, APHP, UPEC, 94010 Créteil, France.
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23
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Dos-Santos JCK, Silva-Filho JL, Judice CC, Kayano ACAV, Aliberti J, Khouri R, de Lima DS, Nakaya H, Lacerda MVG, De Paula EV, Lopes SCP, Costa FTM. Platelet disturbances correlate with endothelial cell activation in uncomplicated Plasmodium vivax malaria. PLoS Negl Trop Dis 2020; 14:e0007656. [PMID: 32687542 PMCID: PMC7392343 DOI: 10.1371/journal.pntd.0007656] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 07/30/2020] [Accepted: 05/30/2020] [Indexed: 12/14/2022] Open
Abstract
Platelets drive endothelial cell activation in many diseases. However, if this occurs in Plasmodium vivax malaria is unclear. As platelets have been reported to be activated and to play a role in inflammatory response during malaria, we hypothesized that this would correlate with endothelial alterations during acute illness. We performed platelet flow cytometry of PAC-1 and P-selectin. We measured platelet markers (CXCL4, CD40L, P-selectin, Thrombopoietin, IL-11) and endothelial activation markers (ICAM-1, von Willebrand Factor and E-selectin) in plasma with a multiplex-based assay. The values of each mediator were used to generate heatmaps, K-means clustering and Principal Component analysis. In addition, we determined pair-wise Pearson’s correlation coefficients to generate correlation networks. Platelet counts were reduced, and mean platelet volume increased in malaria patients. The activation of circulating platelets in flow cytometry did not differ between patients and controls. CD40L levels (Median [IQ]: 517 [406–651] vs. 1029 [732–1267] pg/mL, P = 0.0001) were significantly higher in patients, while P-selectin and CXCL4 showed a nonsignificant trend towards higher levels in patients. The network correlation approach demonstrated the correlation between markers of platelet and endothelial activation, and the heatmaps revealed a distinct pattern of activation in two subsets of P. vivax patients when compared to controls. Although absolute platelet activation was not strong in uncomplicated vivax malaria, markers of platelet activity and production were correlated with higher endothelial cell activation, especially in a specific subset of patients. Endothelial cell activation is a key process in the pathogenesis of Plasmodium vivax malaria. Platelets are classically involved in endothelial cell activation in several diseases, but their role in the context of vivax malaria remains unclear. Thrombocytopenia is the most common hematological disturbance in P. vivax-infected patients, and platelets have been implicated in parasitemia control. In this work, we studied the activation of platelets in association with endothelial cell activation in vivax malaria. Platelets retrieved from infected peripheral blood were non-activated when analyzed by flow cytometry; however, they displayed higher mean volume and significantly reduced counts. We also found higher levels of circulating factors associated with platelet activation (especially soluble CD40L), thrombopoiesis and endothelial cell activation in infected patients. Further, through pair-wise correlation and clustering analysis, we found a subgroup of patients showing significant associations between markers of platelet and endothelial activation in a pattern different from that of endemic controls. Collectively, our findings indicate a role of platelets in endothelial cell activation in vivax malaria and indicate a heterogeneous host response in the setting of uncomplicated disease, a finding to be further explored in future studies.
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Affiliation(s)
- João Conrado Khouri Dos-Santos
- Laboratório de Doenças Tropicais–Prof. Luiz Jacintho da Silva. Instituto de Biologia, Universidade Estadual de Campinas, Campinas, Brazil
- Pós-graduação em Fisiopatologia Médica, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, Brazil
| | - João Luiz Silva-Filho
- Laboratório de Doenças Tropicais–Prof. Luiz Jacintho da Silva. Instituto de Biologia, Universidade Estadual de Campinas, Campinas, Brazil
| | - Carla C. Judice
- Laboratório de Doenças Tropicais–Prof. Luiz Jacintho da Silva. Instituto de Biologia, Universidade Estadual de Campinas, Campinas, Brazil
| | - Ana Carolina Andrade Vitor Kayano
- Laboratório de Doenças Tropicais–Prof. Luiz Jacintho da Silva. Instituto de Biologia, Universidade Estadual de Campinas, Campinas, Brazil
| | - Júlio Aliberti
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, United States of America
| | - Ricardo Khouri
- Instituto Gonçalo Moniz, Fiocruz Bahia, Salvador, Brazil
| | - Diógenes S. de Lima
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, São Paulo, Brazil
| | - Helder Nakaya
- Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences, University of Sao Paulo, São Paulo, Brazil
| | - Marcus Vinicius Guimarães Lacerda
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
- Instituto Leônidas & Maria Deane, Fiocruz Amazônia, Manaus, Brazil
| | - Erich Vinicius De Paula
- Centro de Hematologia e Hemoterapia–Hemocentro, Universidade Estadual de Campinas, Campinas, Brazil
| | | | - Fabio Trindade Maranhão Costa
- Laboratório de Doenças Tropicais–Prof. Luiz Jacintho da Silva. Instituto de Biologia, Universidade Estadual de Campinas, Campinas, Brazil
- * E-mail:
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24
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Kanagasabapathy D, Blosser RJ, Maupin KA, Hong JM, Alvarez M, Ghosh J, Mohamad SF, Aguilar-Perez A, Srour EF, Kacena MA, Bruzzaniti A. Megakaryocytes promote osteoclastogenesis in aging. Aging (Albany NY) 2020; 12:15121-15133. [PMID: 32634116 PMCID: PMC7425434 DOI: 10.18632/aging.103595] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 06/13/2020] [Indexed: 01/26/2023]
Abstract
Megakaryocytes (MKs) support bone formation by stimulating osteoblasts (OBs) and inhibiting osteoclasts (OCs). Aging results in higher bone resorption, leading to bone loss. Whereas previous studies showed the effects of aging on MK-mediated bone formation, the effects of aging on MK-mediated OC formation is poorly understood. Here we examined the effect of thrombopoietin (TPO) and MK-derived conditioned media (CM) from young (3-4 months) and aged (22-25 months) mice on OC precursors. Our findings showed that aging significantly increased OC formation in vitro. Moreover, the expression of the TPO receptor, Mpl, and circulating TPO levels were elevated in the bone marrow cavity. We previously showed that MKs from young mice secrete factors that inhibit OC differentiation. However, rather than inhibiting OC development, we found that MKs from aged mice promote OC formation. Interestingly, these age-related changes in MK functionality were only observed using female MKs, potentially implicating the sex steroid, estrogen, in signaling. Further, RANKL expression was highly elevated in aged MKs suggesting MK-derived RANKL signaling may promote osteoclastogenesis in aging. Taken together, these data suggest that modulation in TPO-Mpl expression in bone marrow and age-related changes in the MK secretome promote osteoclastogenesis to impact skeletal aging.
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Affiliation(s)
- Deepa Kanagasabapathy
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Rachel J Blosser
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Kevin A Maupin
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Jung Min Hong
- Department of Biomedical Sciences and Comprehensive Care, Indiana University School of Dentistry, Indianapolis, IN 46202, USA
| | - Marta Alvarez
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Joydeep Ghosh
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Safa F Mohamad
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Alexandra Aguilar-Perez
- Department of Biomedical Sciences and Comprehensive Care, Indiana University School of Dentistry, Indianapolis, IN 46202, USA
| | - Edward F Srour
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Melissa A Kacena
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Angela Bruzzaniti
- Department of Biomedical Sciences and Comprehensive Care, Indiana University School of Dentistry, Indianapolis, IN 46202, USA
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25
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Al-Samkari H, Grace RF, Kuter DJ. The role of romiplostim for pediatric patients with immune thrombocytopenia. Ther Adv Hematol 2020; 11:2040620720912992. [PMID: 32523658 PMCID: PMC7236573 DOI: 10.1177/2040620720912992] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/18/2020] [Indexed: 01/19/2023] Open
Abstract
The thrombopoietin receptor agonists (TPO-RAs) are a class of platelet growth factors used to treat immune thrombocytopenia (ITP) in children and adults. Romiplostim is a peptide TPO-RA approved for over a decade to treat adults with ITP but was just recently US Food and Drug Administration approved to manage ITP in children 1 year of age and older who have had an inadequate response to corticosteroids, intravenous immunoglobulin, or splenectomy. Like the small molecule TPO-RA eltrombopag, romiplostim offers a high clinical response rate in pediatric patients with ITP, but requires use over an extended, and possibly indefinite, duration. This review is a critical appraisal of the role of romiplostim in pediatric ITP, discussing the safety and efficacy of this agent in clinical trials of children and adults and defining the patients most likely to benefit from romiplostim treatment. The treating hematologist is additionally provided guidance with treatment goals, dosing strategies, toxicity management, and indications for discontinuation.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical chool, Suite 118, Room 112, Zero Emerson Place, Boston, MA 02114, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - David J Kuter
- Division of Hematology, Harvard Medical School, Boston, MA, USA
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26
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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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27
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Gilbert MM, Grimes AB, Kim TO, Despotovic JM. Romiplostim for the Treatment of Immune Thrombocytopenia: Spotlight on Patient Acceptability and Ease of Use. Patient Prefer Adherence 2020; 14:1237-1250. [PMID: 32801654 PMCID: PMC7383044 DOI: 10.2147/ppa.s192481] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 04/28/2020] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is an immune-mediated disorder resulting in platelet destruction and subsequent thrombocytopenia. Bleeding symptoms range from mild cutaneous bleeding to life-threatening hemorrhage. Romiplostim, a peptide-antibody fusion product, is a thrombopoietin receptor agonist (TPO-RA) indicated for use in patients with ITP. Romiplostim is US Food and Drug Administration (FDA) approved in children ≥1 year of age with ITP of >6 months' duration who have had an inadequate response to first-line therapies or splenectomy. FDA approval in adults with chronic ITP was expanded in October 2019 to include adults with newly diagnosed (<3 months' duration) and persistent (3-12 months' duration) ITP who demonstrated an inadequate response to first-line therapies, including corticosteroids and immunoglobulins, or splenectomy. The newly published 2019 American Society of Hematology ITP Guidelines place TPO-RAs, including romiplostim, as second-line therapies in both children and adults. Here, we review the use of romiplostim as second-line therapy with a spotlight on health-related quality of life, ease of use, and patient preference.
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Affiliation(s)
- Megan M Gilbert
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
- Correspondence: Megan M Gilbert Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin Suite 1510, Houston, TX77030, USATel +1 (832) 824-4736Fax +1 (832) 825-4846 Email
| | - Amanda B Grimes
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Taylor Olmsted Kim
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Jenny M Despotovic
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
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28
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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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29
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Activity of eltrombopag in severe aplastic anemia. Blood Adv 2019; 2:3054-3062. [PMID: 30425070 DOI: 10.1182/bloodadvances.2018020248] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 09/24/2018] [Indexed: 12/22/2022] Open
Abstract
Since the approval of horse antithymocyte globulin (ATG) decades ago, there was a long hiatus in therapies with activity in severe aplastic anemia (SAA). This scenario changed in 2014 when eltrombopag, a thrombopoietin receptor agonist, was approved for SAA after an insufficient response to initial immunosuppressive therapy (IST). The basis for this approval was the observation of single-agent activity of eltrombopag in this patient population, where 40% to 50% recovered blood counts at times involving >1 lineage. The achievement of transfusion independence confirmed the clinical benefit of this approach. Increase in marrow cellularity and CD34+ cells suggested a recovery to a more functioning bone marrow. Further in its development, eltrombopag was associated with standard horse ATG plus cyclosporine in first line, producing increases in overall (at about 90%) and complete response rates (at about 40%) and leading to transfusion independence and excellent survival. Interestingly, best results were observed when all drugs were started simultaneously. The cumulative incidence of clonal cytogenetic abnormalities to date has compared favorably with the vast experience with IST alone in SAA. Longer follow-up will help in define these long-term risks. In this review, the development of eltrombopag in SAA will be discussed.
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30
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Nakamura-Ishizu A, Suda T. Multifaceted roles of thrombopoietin in hematopoietic stem cell regulation. Ann N Y Acad Sci 2019; 1466:51-58. [PMID: 31292976 DOI: 10.1111/nyas.14169] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 05/09/2019] [Accepted: 05/24/2019] [Indexed: 12/21/2022]
Abstract
Thrombopoietin (Thpo) and its receptor myeloid proliferative leukemia (Mpl) were initially identified as the cytokine signaling that stimulates megakaryopoiesis and platelet production. However, Thpo-Mpl signaling has also been widely characterized as one of the few cytokine systems that directly regulates hematopoietic stem and progenitor cells. The ability of Thpo signaling to stimulate hematopoietic stem cell (HSC) self-renewal has led to the development and utilization of Thpo mimetic drugs to treat hematopoietic diseases with restricted function of HSCs, such as aplastic anemia. This review will cover the mechanisms by which Thpo-Mpl signaling regulates HSCs.
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Affiliation(s)
| | - Toshio Suda
- International Research Center for Medical Sciences, Kumamoto University, Kumamoto City, Japan
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31
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Noetzli LJ, French SL, Machlus KR. New Insights Into the Differentiation of Megakaryocytes From Hematopoietic Progenitors. Arterioscler Thromb Vasc Biol 2019; 39:1288-1300. [PMID: 31043076 PMCID: PMC6594866 DOI: 10.1161/atvbaha.119.312129] [Citation(s) in RCA: 140] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 04/22/2019] [Indexed: 02/07/2023]
Abstract
Megakaryocytes are hematopoietic cells, which are responsible for the production of blood platelets. The traditional view of megakaryopoiesis describes the cellular journey from hematopoietic stem cells, through a hierarchical series of progenitor cells, ultimately to a mature megakaryocyte. Once mature, the megakaryocyte then undergoes a terminal maturation process involving multiple rounds of endomitosis and cytoplasmic restructuring to allow platelet formation. However, recent studies have begun to redefine this hierarchy and shed new light on alternative routes by which hematopoietic stem cells are differentiated into megakaryocytes. In particular, the origin of megakaryocytes, including the existence and hierarchy of megakaryocyte progenitors, has been redefined, as new studies are suggesting that hematopoietic stem cells originate as megakaryocyte-primed and can bypass traditional lineage checkpoints. Overall, it is becoming evident that megakaryopoiesis does not only occur as a stepwise process, but is dynamic and adaptive to biological needs. In this review, we will reexamine the canonical dogmas of megakaryopoiesis and provide an updated framework for interpreting the roles of traditional pathways in the context of new megakaryocyte biology. Visual Overview- An online visual overview is available for this article.
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Affiliation(s)
- Leila J Noetzli
- Division of Hematology, Brigham and Women’s Hospital and Department of Medicine, Harvard Medical School, Boston, MA, 02115, USA
| | - Shauna L French
- Division of Hematology, Brigham and Women’s Hospital and Department of Medicine, Harvard Medical School, Boston, MA, 02115, USA
| | - Kellie R Machlus
- Division of Hematology, Brigham and Women’s Hospital and Department of Medicine, Harvard Medical School, Boston, MA, 02115, USA
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32
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Koride S, Nayak S, Banfield C, Peterson MC. Evaluating the Role of Janus Kinase Pathways in Platelet Homeostasis Using a Systems Modeling Approach. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2019; 8:478-488. [PMID: 31044523 PMCID: PMC6656939 DOI: 10.1002/psp4.12419] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 03/02/2019] [Indexed: 02/06/2023]
Abstract
Maintaining platelet homeostasis is important to avoid spontaneous bleeding and organ damage. Thrombopoietin, the primary regulator of platelet production, is affected by and acts in part via Janus kinase (JAK)‐signal transducer and activator of transcription (STAT)–mediated mechanisms. Interleukin‐6 is also partly responsible for inducing thrombopoietin production via the JAK‐STAT pathway. Although current understanding suggests that JAK2 is a primary mediator of platelet regulation, the emerging data show that a JAK1‐specific inhibitor resulted in the modulation of platelet numbers following dosing. To gain a mechanistic understanding, a model describing platelet regulation based on known physiology and JAK‐STAT pathways was built. The model provides a tool to coalesce biological understanding of platelet physiology and an in silico experimental platform to explore drug effects on platelet homeostasis. In this article, we explain the model construction and demonstrate the use of JAK‐inhibitor programs as informing probes of the physiology, gaining insights on dosing paradigms that avoid platelet‐related safety concerns.
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Affiliation(s)
- Sarita Koride
- Early Clinical Development, Clinical Pharmacology, Pfizer Inc., Cambridge, Massachusetts, USA
| | - Satyaprakash Nayak
- Global Product Development, Pharmacometrics, Pfizer Inc., Cambridge, Massachusetts, USA
| | - Christopher Banfield
- Early Clinical Development, Clinical Pharmacology, Pfizer Inc., Cambridge, Massachusetts, USA
| | - Mark C Peterson
- Global Product Development, Pharmacometrics, Pfizer Inc., Cambridge, Massachusetts, USA
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33
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Eltrombopag for use in children with immune thrombocytopenia. Blood Adv 2019; 2:454-461. [PMID: 29487060 DOI: 10.1182/bloodadvances.2017010660] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 01/22/2018] [Indexed: 01/19/2023] Open
Abstract
Eltrombopag is currently the only US Food and Drug Administration-approved thrombopoietin receptor agonist for the treatment of chronic immune thrombocytopenia (ITP) in children. This oral, once-per-day therapy has shown favorable efficacy and adverse effect profiles in children. Two multicenter, double-blind, placebo controlled clinical trials (PETIT [Efficacy and Safety Study of Eltrombopag in Pediatric Patients With Thrombocytopenia From Chronic Idiopathic Thrombocytopenic Purpura (ITP)] and PETIT2 [Study of a New Medication for Childhood Chronic Immune Thrombocytopenia (ITP), a Blood Disorder of Low Platelet Counts That Can Lead to Bruising Easily, Bleeding Gums, and/or Bleeding Inside the Body]) demonstrated efficacy in raising platelet counts, reducing bleeding, and reducing the need for concomitant ITP therapies with relatively few adverse effects. The most commonly reported drug-related adverse effects include headache, nausea, and hepatobiliary laboratory abnormalities. Long-term safety data in children are limited, and studies in adults have not revealed a clinically significant increased incidence of thrombosis, marrow fibrosis, or cataract formation. Eltrombopag has also been approved for treating refractory severe aplastic anemia (AA) and has potential for expanded use in ITP and severe AA as well as in other conditions associated with thrombocytopenia.
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34
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Enhancing functional platelet release in vivo from in vitro-grown megakaryocytes using small molecule inhibitors. Blood Adv 2019; 2:597-606. [PMID: 29545255 DOI: 10.1182/bloodadvances.2017010975] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 02/14/2018] [Indexed: 12/17/2022] Open
Abstract
In vitro-grown megakaryocytes for generating platelets may have value in meeting the increasing demand for platelet transfusions. Remaining challenges have included the poor yield and quality of in vitro-generated platelets. We have shown that infusing megakaryocytes leads to intrapulmonary release of functional platelets. A Src kinase inhibitor (SU6656), a Rho-associated kinase inhibitor (Y27632), and an aurora B kinase inhibitor (AZD1152) have been shown to increase megakaryocyte ploidy and in vitro proplatelet release. We now tested whether megakaryocytes generated from CD34+ hematopoietic cells in the presence of these inhibitors could enhance functional platelet yield following megakaryocyte infusion. As expected, all inhibitors increased megakaryocyte ploidy, size, and granularity, but these inhibitors differed in whether they injured terminal megakaryocytes: SU6656 was protective, whereas Y27632 and AZD1152 increased injury. Upon infusion, inhibitor-treated megakaryocytes released threefold to ninefold more platelets per initial noninjured megakaryocyte relative to control, but only SU6656-treated megakaryocytes had a significant increase in platelet yield when calculated based on the number of initial CD34+ cells; this was fourfold over nontreated megakaryocytes. The released platelets from drug-treated, but healthy, megakaryocytes contained similar percentages of young, uninjured platelets that robustly responded to agonists and were well incorporated into a growing thrombus in vivo as controls. These studies suggest that drug screens that select megakaryocytes with enhanced ploidy, cell size, and granularity may include a subset of drugs that can enhance the yield and function of platelets, and may have clinical application for ex vivo-generated megakaryocytes and platelet transfusion.
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Thrombopoietin Receptor Agonists. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00061-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Scheinberg P. Activity of eltrombopag in severe aplastic anemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:450-456. [PMID: 30504345 PMCID: PMC6245975 DOI: 10.1182/asheducation-2018.1.450] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Since the approval of horse antithymocyte globulin (ATG) decades ago, there was a long hiatus in therapies with activity in severe aplastic anemia (SAA). This scenario changed in 2014 when eltrombopag, a thrombopoietin receptor agonist, was approved for SAA after an insufficient response to initial immunosuppressive therapy (IST). The basis for this approval was the observation of single-agent activity of eltrombopag in this patient population, where 40% to 50% recovered blood counts at times involving >1 lineage. The achievement of transfusion independence confirmed the clinical benefit of this approach. Increase in marrow cellularity and CD34+ cells suggested a recovery to a more functioning bone marrow. Further in its development, eltrombopag was associated with standard horse ATG plus cyclosporine in first line, producing increases in overall (at about 90%) and complete response rates (at about 40%) and leading to transfusion independence and excellent survival. Interestingly, best results were observed when all drugs were started simultaneously. The cumulative incidence of clonal cytogenetic abnormalities to date has compared favorably with the vast experience with IST alone in SAA. Longer follow-up will help in define these long-term risks. In this review, the development of eltrombopag in SAA will be discussed.
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Affiliation(s)
- Phillip Scheinberg
- Division of Hematology, Hospital A Beneficência Portuguesa, Sao Paulo, Brazil
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Megakaryocytes and platelets from a novel human adipose tissue-derived mesenchymal stem cell line. Blood 2018; 133:633-643. [PMID: 30487128 DOI: 10.1182/blood-2018-04-842641] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 10/02/2018] [Indexed: 12/24/2022] Open
Abstract
The clinical need for platelet transfusions is increasing; however, donor-dependent platelet transfusions are associated with practical problems, such as the limited supply and the risk of infection. Thus, we developed a manufacturing system for platelets from a donor-independent cell source: a human adipose-derived mesenchymal stromal/stem cell line (ASCL). The ASCL was obtained using an upside-down culture flask method and satisfied the minimal criteria for defining mesenchymal stem cells (MSCs) by The International Society for Cellular Therapy. The ASCL showed its proliferation capacity for ≥2 months without any abnormal karyotypes. The ASCL was cultured in megakaryocyte induction media. ASCL-derived megakaryocytes were obtained, with a peak at day 8 of culture, and ASCL-derived platelets (ASCL-PLTs) were obtained, with a peak at day 12 of culture. We observed that CD42b+ cells expressed an MSC marker (CD90) which is related to cell adhesion. Compared with peripheral platelets, ASCL-PLTs exhibit higher levels of PAC1 binding, P-selectin surface exposure, ristocetin-induced platelet aggregation, and ADP-induced platelet aggregation, as well as similar levels of fibrinogen binding and collagen-induced platelet aggregation. ASCL-PLTs have lower epinephrine-induced platelet aggregation. The pattern of in vivo kinetics after infusion into irradiated immunodeficient NOD.Cg-PrkdcscidIl2rgtm1Wjl/SzJ mice was similar to that of platelet concentrates. ASCL-PLTs have similar characteristics to those of peripheral platelets and might have an additional function as MSCs. The establishment of the ASCL and its differentiation into ASCL-PLTs do not require gene transfer, and endogenous thrombopoietin is used for differentiation. The present protocol is a simple method that does not require feeder cells, further enhancing the clinical application of our approach.
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Nagareddy PR, Noothi SK, Flynn MC, Murphy AJ. It's reticulated: the liver at the heart of atherosclerosis. J Endocrinol 2018; 238:R1-R11. [PMID: 29720539 PMCID: PMC7065032 DOI: 10.1530/joe-18-0082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 05/02/2018] [Indexed: 12/28/2022]
Abstract
Platelets play a critical role in both the initiation and progression of atherosclerosis, and even more so in the ensuing atherothrombotic complications. Low-dose aspirin remains the mainstay of antiplatelet therapy in high-risk patients by reducing the risk of myocardial ischemia, stroke or death due to cardiovascular disease. However, antiplatelet therapies lose their efficacy in people with diabetes mellitus, increasing the risk of future atherothrombotic events. The molecular mechanisms that promote platelet hyperactivity remain unclear but could be due to glycation-induced conformational changes of platelet membranes resulting in impaired aspirin entry or less-efficient acetylation/compensatory increase in COX-2 expression in newborn platelets. Emerging evidence from our laboratory and elsewhere suggest that enhanced platelet turnover (thrombopoiesis), particularly the production of immature reticulated platelets from the bone marrow, could contribute to atherosclerotic complications. We have identified a major role for neutrophil-derived S100A8/A9, a damage-associated molecular pattern, in driving reticulated thrombopoiesis by directly interacting with its receptors on Kupffer cells in the liver. In this review, we discuss the role of hepatic inflammation in driving reticulated platelet production and suggest potential targets to control their production, improve efficacy of current antiplatelet therapies and reduce the risk of atherothrombotic complications.
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Affiliation(s)
| | - Sunil K Noothi
- Department of Nutrition SciencesUniversity of Alabama, Birmingham, UK
| | - Michelle C Flynn
- Division of ImmunometabolismBaker Heart and Diabetes Institute, Melbourne, Australia
- Department of ImmunologyMonash University, Melbourne, Australia
| | - Andrew J Murphy
- Division of ImmunometabolismBaker Heart and Diabetes Institute, Melbourne, Australia
- Department of ImmunologyMonash University, Melbourne, Australia
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GPIbα is required for platelet-mediated hepatic thrombopoietin generation. Blood 2018; 132:622-634. [PMID: 29794068 DOI: 10.1182/blood-2017-12-820779] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 05/18/2018] [Indexed: 12/17/2022] Open
Abstract
Thrombopoietin (TPO), a hematopoietic growth factor produced predominantly by the liver, is essential for thrombopoiesis. Prevailing theory posits that circulating TPO levels are maintained through its clearance by platelets and megakaryocytes via surface c-Mpl receptor internalization. Interestingly, we found a two- to threefold decrease in circulating TPO in GPIbα-/- mice compared with wild-type (WT) controls, which was consistent in GPIbα-deficient human Bernard-Soulier syndrome (BSS) patients. We showed that lower TPO levels in GPIbα-deficient conditions were not due to increased TPO clearance by GPIbα-/- platelets but rather to decreased hepatic TPO mRNA transcription and production. We found that WT, but not GPIbα-/-, platelet transfusions rescued hepatic TPO mRNA and circulating TPO levels in GPIbα-/- mice. In vitro hepatocyte cocultures with platelets or GPIbα-coupled beads further confirm the disruption of platelet-mediated hepatic TPO generation in the absence of GPIbα. Treatment of GPIbα-/- platelets with neuraminidase caused significant desialylation; however, strikingly, desialylated GPIbα-/- platelets could not rescue impaired hepatic TPO production in vivo or in vitro, suggesting that GPIbα, independent of platelet desialylation, is a prerequisite for hepatic TPO generation. Additionally, impaired hepatic TPO production was recapitulated in interleukin-4/GPIbα-transgenic mice, as well as with antibodies targeting the extracellular portion of GPIbα, demonstrating that the N terminus of GPIbα is required for platelet-mediated hepatic TPO generation. These findings reveal a novel nonredundant regulatory role for platelets in hepatic TPO homeostasis, which improves our understanding of constitutive TPO regulation and has important implications in diseases related to GPIbα, such as BSS and auto- and alloimmune-mediated thrombocytopenias.
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Gilreath JA, Wei M, Paul S, Parker CJ, Stenehjem DD, Rodgers GM. Dynamic dosing of romiplostim in patients with immune thrombocytopenia purpura: Two case reports. J Oncol Pharm Pract 2018; 25:719-723. [PMID: 29357781 DOI: 10.1177/1078155217752536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Romiplostim is a thrombopoietin receptor agonist approved for the treatment of immune thrombocytopenia purpura. When following FDA-approved romiplostim prescribing recommendations to withhold treatment for platelet counts above 400k/µL, some patients exhibit a precipitous decline in their platelet count potentially causing patient harm. We present two cases where stable platelet counts were achieved only through persistent weekly dosing of romiplostim despite platelet counts above 400k/µL on the day of administration. Therefore, continuous weekly dosing of romiplostim despite platelet count being above 400k/µL combined with twice weekly vigilant monitoring is an alternative method of romiplostim dosing that mitigates severe fluctuations in platelets. We also discuss important details, postulated mechanisms, and evidence-based mitigation strategies.
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Affiliation(s)
- Jeffrey A Gilreath
- 1 Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.,2 Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
| | - Mei Wei
- 3 Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Shilpa Paul
- 4 Department of Clinical Pharmacy Services, University of Texas at MD Anderson Cancer Center, Houston, TX, USA
| | - Charles J Parker
- 3 Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - David D Stenehjem
- 2 Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA.,5 Department of Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota, Duluth, MN, USA
| | - George M Rodgers
- 3 Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
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Qian J, Lu W, Yang L, Zhang YP, Yang X, Lin ZH, Liu H. [Efficacy and safety of recombinant human thrombopoietin combined with hormonal and cyclosporine in 20 patients with newly diagnosed immune-related pancytopenia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2017; 38:1078-1081. [PMID: 29365407 PMCID: PMC7342188 DOI: 10.3760/cma.j.issn.0253-2727.2017.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | | | | | | | - H Liu
- Affilicated Hospital of Nantong University, Nantong 226001, China
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Wang S, Shen M, Chen S, Wang C, Chen F, Chen M, Zhao G, Ran X, Cheng T, Su Y, Xu Y, Wang J. Development of a sandwich enzyme-linked immunosorbent assay for dTMP-GH fusion protein by rational immunogen selection. AMB Express 2017; 7:152. [PMID: 28724261 PMCID: PMC5514005 DOI: 10.1186/s13568-017-0454-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 07/11/2017] [Indexed: 11/10/2022] Open
Abstract
dTMP-GH is a chimeric protein containing a tandem dimer of thrombopoietin mimetic peptide (dTMP) fused to human growth hormone (hGH) prepared previously by our team. It shows significant bioactivity in promoting thrombocytopoiesis, but detection of intact dTMP-GH in plasma is still a challenge due to the presence of endogenous hGH. In this study, a rabbit polyclonal antibody with high affinity to dTMP was obtained with a BSA-conjugated immunogen composed of 20 amino acids sequence spanning two TMP and the linker. A monoclonal antibody termed as 3B2 was screened out by using immunizing mice with whole dTMP-GH, which was proved to simultaneously interact with rhGH, TMP-GH, and dTMP-GH, respectively. In this study, we developed a specific and sensitive sandwich enzyme-linked immunosorbent assay (ELISA) with two antibodies (one polyclonal and one HRP-conjugated monoclonal) to quantify dTMP-GH. The polyclonal antibody and HRP-conjugated monoclonal antibody 3B2 were applied as the capture antibody and detection antibody, respectively. A good correlation between ELISA and bicinchoninic acid (BCA) assay in the quantification of diluted dTMP-GH was observed (r2 = 0.996). Meanwhile, the standard curve of this ELISA method was found in a linear relationship between 0.2 and 10 ng/mL in the presence of rabbit plasma. In vivo experiments demonstrate that the newly developed method is effective to detect dTMP-GH in rabbits, which paves the way for further pharmacokinetic evaluation.
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Affiliation(s)
- Song Wang
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, 400038 People’s Republic of China
| | - Mingqiang Shen
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, 400038 People’s Republic of China
| | - Shilei Chen
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, 400038 People’s Republic of China
| | - Cheng Wang
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, 400038 People’s Republic of China
| | - Fang Chen
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, 400038 People’s Republic of China
| | - Mo Chen
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, 400038 People’s Republic of China
| | - Gaomei Zhao
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, 400038 People’s Republic of China
| | - Xinze Ran
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, 400038 People’s Republic of China
| | - Tianmin Cheng
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, 400038 People’s Republic of China
| | - Yongping Su
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, 400038 People’s Republic of China
| | - Yang Xu
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, 400038 People’s Republic of China
| | - Junping Wang
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Combined Injury, Chongqing Engineering Research Center for Nanomedicine, College of Preventive Medicine, Third Military Medical University, Chongqing, 400038 People’s Republic of China
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Audia S, Mahévas M, Samson M, Godeau B, Bonnotte B. Pathogenesis of immune thrombocytopenia. Autoimmun Rev 2017; 16:620-632. [DOI: 10.1016/j.autrev.2017.04.012] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 03/17/2017] [Indexed: 01/19/2023]
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Lusutrombopag increases hematocytes in a compensated liver cirrhosis patient. Clin J Gastroenterol 2017; 10:261-264. [PMID: 28324272 PMCID: PMC5429890 DOI: 10.1007/s12328-017-0735-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 03/09/2017] [Indexed: 01/07/2023]
Abstract
A 56-year-old Japanese man with liver cirrhosis (LC) due to hepatitis C virus was admitted to our hospital for radiofrequency ablation of residual tumor following lusutrombopag administration. Laboratory tests revealed thrombocytopenia and leukopenia. The patient's LC was managed, and he was classified as Child-Pugh A. After admission, lusutrombopag was administered for 7 days. The platelet count increased to over 50,000/mm3 after 7-14 days and returned to previous levels 50 days after administration. Leukocyte and erythrocyte counts also increased in response to the treatment and stayed elevated for over 120 days. Lusutrombopag acts selectively on human thrombopoietin (TPO) receptors and activates signaling pathways that promote the proliferation and differentiation of bone marrow progenitor cells into megakaryocytes, consequently increasing the blood platelet count. However, the patient treated with lusutrombopag in our case study showed increased blood leukocyte and erythrocyte counts as well. Given that TPO receptors are reportedly expressed in not only megakaryocyte progenitor cells but also hematopoietic progenitors, lusutrombopag may potentially improve pancytopenia caused by LC and can be used for the recovery of blood counts before other treatments.
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Gill H, Wong RSM, Kwong YL. From chronic immune thrombocytopenia to severe aplastic anemia: recent insights into the evolution of eltrombopag. Ther Adv Hematol 2017; 8:159-174. [PMID: 28473904 DOI: 10.1177/2040620717693573] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Thrombopoietin (TPO) is the most potent cytokine stimulating thrombopoiesis. Therapy with exogenous TPO is limited by the formation of antibodies cross-reacting with endogenous TPO. Mimetics of TPO are compounds with no antigenic similarity to TPO. Eltrombopag is an orally-active nonpeptide small molecule that binds to the transmembrane portion of the TPO receptor MPL. Initial trials of eltrombopag have centered on immune thrombocytopenia (ITP), which is due to both increased destruction and decreased production of platelets. Eltrombopag at 25-75 mg/day has been shown to be highly effective in raising the platelet count in ITP with suboptimal response to immunosuppression and splenectomy. These successful results led to the exploration of eltrombopag in other thrombocytopenic disorders. In hepatitis C viral infection, eltrombopag raises the platelet count sufficiently enough to allow treatment with ribavirin and pegylated interferon. Because MPL is expressed on hematopoietic cells, eltrombopag use in myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) might enhance leukemic proliferation. Clinical trials of eltrombopag in MDS and AML, however, have shown amelioration of thrombocytopenia without promoting disease progression. In severe aplastic anemia (SAA) not responding to immunosuppression with anti-thymocyte globulin (ATG) and cyclosporine, eltrombopag as a single agent at 150-300 mg/day results in an overall response rate of 40-70%. At high doses, adverse effects including pigmentation, gastrointestinal upset and hepatic derangement have become evident. Current studies have examined the first-line use of eltrombopag in combination with ATG in SAA. In a recent study, eltrombopag used at 150 mg/day with horse ATG resulted in an overall response rate of 90% in newly diagnosed SAA patients, with a complete response rate of about 50%. Clonal karyotypic aberrations are, however, found in 10-20% of SAA patients treated with eltrombopag. The safety and efficacy of eltrombopag in SAA require further evaluation, particularly when it is used with less intensive immunosuppression.
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Affiliation(s)
- Harinder Gill
- Department of Medicine, Queen Mary Hospital, Hong Kong, China
| | - Raymond S M Wong
- Sir Y.K. Pao Centre for Cancer and Department of Medicine and Therapeutics, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong, China
| | - Yok-Lam Kwong
- Department of Medicine, Queen Mary Hospital, Pokfulam Road, Hong Kong, China
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Hematopoietic Growth Factors in Transfusion Medicine. Transfus Med 2016. [DOI: 10.1002/9781119236504.ch17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
OBJECTIVES Classically, immune thrombocytopenia (ITP) was thought to be caused by the destruction and insufficient production of platelets, as mediated by autoantibodies. More recently other immune mechanisms that contribute to the disease have been discovered. This review attempts to address the main unresolved questions in ITP. METHODS We review the most current knowledge of the pathophysiology of ITP. Immunological effects of available therapies are also described. DISCUSSION The trigger may be a loss of tolerance due to molecular mimicry with cross-reaction of antibodies arising from infectious agents or drugs, genetic factors, and/or platelet Toll receptors. This loss of tolerance activates autoreactive effector B and T lymphocytes, which in turn initiates platelet destruction, mediated by cytotoxic T lymphocytes and the release of pro-inflammatory cytokines (IL-2/IL-17) by T helper (Th) cells (Th1/Th17). Th2 (anti-inflammatory) and regulatory B (Breg) and Treg cells are also inhibited (with decrease in IL-10/TGF-β), which leads to the disease becoming chronic. Some isotypes of autoantibodies may increase the bleeding risk. Corticosteroids, rituximab, and thrombopoietin receptor agonists (A-TPOs) all increase levels of Tregs and TGF-β. The A-TPOs also increase Breg levels, which could explain why complete remission has been seen in some cases. CONCLUSION A better understanding of the immunomodulatory effects of each ITP therapy is needed to best manage the disease.
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Affiliation(s)
- María Perera
- a Haematology Service , University Hospital Doctor Negrín , Las Palmas de Gran Canaria, Spain
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48
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Abstract
Aplastic anemia (AA) is a potential life-threatening hematopoietic stem cell (HSC) disorder resulting in cytopenia. The mainstays of treatment for AA are definitive therapy to restore HSCs and supportive measures to ameliorate cytopenia-related complications. The standard definitive therapy is HSC transplantation for young and medically fit patients with suitable donors and immunosuppressive therapy (IST) with antithymocyte globulin and cyclosporine for the remaining patients. A significant proportion of patients are refractory to IST or relapse after IST. Various strategies have been explored in these patients, including second course of antithymocyte globulin, high-dose cyclophosphamide, and alemtuzumab. Eltrombopag, a thrombopoietin mimetic, has recently emerged as an encouraging and promising agent for patients with refractory AA. It has demonstrated efficacy in restoring trilineage hematopoiesis, and this positive effect continues after discontinuation of the drug. There are ongoing clinical trials exploring the role of eltrombopag as a first-line therapy in moderate to severe AA and a combination of eltrombopag with IST in severe AA.
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Affiliation(s)
- Su Han Lum
- Department of Blood and Marrow Transplant, Royal Manchester Children’s Hospital, Manchester, UK
| | - John D Grainger
- Department of Blood and Marrow Transplant, Royal Manchester Children’s Hospital, Manchester, UK
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Singh VK, Kumar N, Kalsan M, Saini A, Chandra R. A Novel Peptide Thrombopoietin Mimetic Designing and Optimization Using Computational Approach. Front Bioeng Biotechnol 2016; 4:69. [PMID: 27630985 PMCID: PMC5006622 DOI: 10.3389/fbioe.2016.00069] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 08/10/2016] [Indexed: 01/22/2023] Open
Abstract
Thrombopoietin receptor (TPOR) is a cytokine receptor protein present on the cell surface. The activation of TPOR by thrombopoietin (TPO) (a glycoprotein hormone) triggers an intracellular cascade of megakaryocytopoiesis for the formation of platelets. Recent studies on ex vivo megakaryocytopoiesis have evolved the possibilities of therapeutics uses. These findings have paved the way for the development of various TPO alternatives (recombinant TPO, peptide, and non-peptide TPO mimetics), which are useful in regenerative medicine. However, these alternatives possess various limitations such as induction of autoimmune effects, high production cost, low specificity, and hence activity. In the present study, a novel peptidic TPO mimetic was designed through computational studies by studying the binding sites of TPO and TMP to TPOR and analogs of known mimetics. Screening of combinatorial library was done through molecular docking using ClusPro. These studies indicated mimetic-9 as a significant molecule since it was found to have better binding score of −938.8 kcal/mol with seven hydrogen bonds and a high number of hydrophobic interactions, than known mimetic TMP with docking score of −798.4 kcal/mol and TMP dimer with docking score of −811.9 kcal/mol for TPOR. Mimetic9-TPOR complex was further assessed by the molecular dynamics simulation, and their complex was found to be stable with an RMSD value of 0.091 Å. While studying the parameters, mimetic-9 was found to have overall good physiochemical properties with positive grand average hydropathy (GRAVY) score and high instability index score and was found to be localized in the extracellular region. The designed mimetic-9 might prove to be a useful lead molecule for mimicking the role of TPO for in vitro platelet production with higher efficiency.
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Affiliation(s)
- Vimal Kishor Singh
- Founder and O/I Stem Cell Research Laboratory, Department of Biotechnology, INSPIRE Faculty, Delhi Technological University , Delhi , India
| | - Neeraj Kumar
- Department of Chemistry, University of Delhi , Delhi , India
| | - Manisha Kalsan
- Department of Chemistry, University of Delhi , Delhi , India
| | - Abhishek Saini
- Stem Cell Research Laboratory, Department of Biotechnology, Delhi Technological University , Delhi , India
| | - Ramesh Chandra
- Department of Chemistry, University of Delhi , Delhi , India
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Ono-Uruga Y, Tozawa K, Horiuchi T, Murata M, Okamoto S, Ikeda Y, Suda T, Matsubara Y. Human adipose tissue-derived stromal cells can differentiate into megakaryocytes and platelets by secreting endogenous thrombopoietin. J Thromb Haemost 2016; 14:1285-97. [PMID: 26990635 DOI: 10.1111/jth.13313] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Indexed: 12/13/2022]
Abstract
UNLABELLED Essentials Manufacturing platelets from a donor-independent source is highlighted in transfusion medicine. We examined the differentiation of adipose tissue-derived stromal cells (ASCs) into platelets. Endogenous thrombopoietin (TPO) induced ASCs differentiation into megakaryocytes and platelets. TPO secretion from ASCs was due to an interaction of transferrin with its receptor CD71. SUMMARY Background Ex vivo production of megakaryocytes (MKs) and platelets from a donor-independent source is currently of intense interest in transfusion medicine. Adipose tissue-derived stromal cells (ASCs) constitute an attractive candidate cell source, because inducing these cells into MK lineages requires no gene transfer and only endogenous transcription factors containing p45NF-E2/Maf, an MK-inducing factor. Objectives To examine whether ASCs differentiate into MK lineages by using endogenous thrombopoietin (TPO), a primary cytokine that drives MK lineages. Methods TPO levels were measured by quantitative real-time PCR and ELISA. To investigate the effects of endogenous TPO on MK and platelet production, surface marker expression and functions for platelets were analyzed in ASC-derived cells cultured in the presence or absence of recombinant TPO. Based on a screening test, the role of transferrin receptor CD71 in TPO production and MK differentiation was examined with anti-CD71 antibody, small interfering RNA (siRNA) against CD71 (siRNA-CD71), and CD71-positive/negative cells. Results ASCs secreted TPO during MK differentiation, and the endogenous TPO facilitated MK and platelet production from ASCs. TPO secretion from ASCs occurred in a transferrin-dependent manner. ASCs treated with anti-CD71 antibody or transfected with siRNA-CD71 produced markedly less TPO. The TPO levels and MK yield were significantly higher when CD71-positive ASCs were used than when CD71-negative ASCs were used. Conclusions CD71 might be an appropriate marker for MK progenitor cells among human ASCs, because of the higher capacity of CD71-positive cells to produce TPO and their ability to differentiate into MKs. These findings could help to establish an efficient method for platelet production.
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Affiliation(s)
- Y Ono-Uruga
- Clinical and Translational Research Center, Keio University School of Medicine, Tokyo, Japan
- Kanagawa Academy of Science and Technology, Kanagawa, Japan
- Division of Hematology, Keio University School of Medicine, Tokyo, Japan
| | - K Tozawa
- Division of Hematology, Keio University School of Medicine, Tokyo, Japan
| | - T Horiuchi
- Clinical and Translational Research Center, Keio University School of Medicine, Tokyo, Japan
- Kanagawa Academy of Science and Technology, Kanagawa, Japan
| | - M Murata
- Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan
| | - S Okamoto
- Division of Hematology, Keio University School of Medicine, Tokyo, Japan
| | - Y Ikeda
- Division of Hematology, Keio University School of Medicine, Tokyo, Japan
- Faculty of Science and Engineering, Life Science and Medical Bioscience, Waseda University, Tokyo, Japan
| | - T Suda
- International Research Center for Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Y Matsubara
- Clinical and Translational Research Center, Keio University School of Medicine, Tokyo, Japan
- Kanagawa Academy of Science and Technology, Kanagawa, Japan
- Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan
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