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Schoenaker JM, Nelson VS, Henderickx JGE, Terveer EM, Jansen AJG, Porcelijn L, Netelenbos T, Schipperus MR, Kapur R. The intestinal flora: The key to unraveling heterogeneity in immune thrombocytopenia? Blood Rev 2025; 69:101252. [PMID: 39672701 DOI: 10.1016/j.blre.2024.101252] [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: 10/16/2024] [Revised: 11/22/2024] [Accepted: 12/01/2024] [Indexed: 12/15/2024]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder characterized by enhanced platelet destruction and impaired platelet production, due to a loss of immune tolerance that leads to targeting of platelets and megakaryocytes by glycoprotein-autoantibodies and/or cytotoxic T cells. There is a high degree of heterogeneity in ITP patients signified by unpredictable disease trajectories and treatment responses. Initial studies in humans have identified intestinal microbiota perturbance in ITP. Recently, gut microbial perturbance has been linked to other autoimmune diseases. Based on these findings, we hypothesize that intestinal microbiota may influence ITP pathophysiology through several mechanisms, including induction of platelet-autoantibody production, increasing complement-dependent platelet cytotoxicity, disturbing T cell homeostasis, impairing megakaryocyte function, and increasing platelet-desialylation and -clearance. The pathophysiological heterogeneity of ITP may, at least in part, be attributed to a perturbed intestinal microbiota. Therefore, a better understanding of intestinal microbiota in ITP may result in a more personalized therapeutic approach.
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MESH Headings
- Humans
- Gastrointestinal Microbiome/immunology
- Purpura, Thrombocytopenic, Idiopathic/microbiology
- Purpura, Thrombocytopenic, Idiopathic/etiology
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Purpura, Thrombocytopenic, Idiopathic/metabolism
- Purpura, Thrombocytopenic, Idiopathic/pathology
- Blood Platelets/immunology
- Blood Platelets/metabolism
- Blood Platelets/pathology
- Animals
- Disease Susceptibility
- Autoantibodies/immunology
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Affiliation(s)
- Jente M Schoenaker
- Department of Experimental Immunohematology, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, 1066 CX Amsterdam, the Netherlands.
| | - Vivianne S Nelson
- Department of Experimental Immunohematology, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, 1066 CX Amsterdam, the Netherlands; Department of Hematology, HagaZiekenhuis, 2545 AA The Hague, the Netherlands; Department of Hematology, Leiden University Medical Center, 2333 ZA Leiden, the Netherlands.
| | - Jannie G E Henderickx
- Center for Microbiome Analyses and Therapeutics, Leiden University Center of Infectious Diseases (LU-CID), Leiden University Medical Center, 2333 ZA Leiden, the Netherlands; Department of Medical Microbiology, Leiden University Center of Infectious Diseases (LU-CID) Research, Leiden University Medical Center, 2333 ZA Leiden, the Netherlands.
| | - Elisabeth M Terveer
- Department of Medical Microbiology, Leiden University Center of Infectious Diseases (LU-CID) Research, Leiden University Medical Center, 2333 ZA Leiden, the Netherlands; Netherlands Donor Feces Bank, LUCID Medical Microbiology & Infection Prevention, Leiden University Medical Center, 2333 ZA Leiden, the Netherlands.
| | - A J Gerard Jansen
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, 3015 GD Rotterdam, the Netherlands.
| | - Leendert Porcelijn
- Sanquin Diagnostic Services, Department of Immunohematology Diagnostics, Sanquin, 1066 CX Amsterdam, the Netherlands.
| | - Tanja Netelenbos
- Department of Hematology, HagaZiekenhuis, 2545 AA The Hague, the Netherlands.
| | | | - Rick Kapur
- Department of Experimental Immunohematology, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, 1066 CX Amsterdam, the Netherlands.
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Semple JW, Schifferli A, Cooper N, Saad H, Mytych DT, Chea LS, Newland A. Immune thrombocytopenia: Pathophysiology and impacts of Romiplostim treatment. Blood Rev 2024; 67:101222. [PMID: 38942688 DOI: 10.1016/j.blre.2024.101222] [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: 04/21/2024] [Revised: 06/04/2024] [Accepted: 06/18/2024] [Indexed: 06/30/2024]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune bleeding disease caused by immune-mediated platelet destruction and decreased platelet production. ITP is characterized by an isolated thrombocytopenia (<100 × 109/L) and increased risk of bleeding. The disease has a complex pathophysiology wherein immune tolerance breakdown leads to platelet and megakaryocyte destruction. Therapeutics such as corticosteroids, intravenous immunoglobulins (IVIg), rituximab, and thrombopoietin receptor agonists (TPO-RAs) aim to increase platelet counts to prevent hemorrhage and increase quality of life. TPO-RAs act via stimulation of TPO receptors on megakaryocytes to directly stimulate platelet production. Romiplostim is a TPO-RA that has become a mainstay in the treatment of ITP. Treatment significantly increases megakaryocyte maturation and growth leading to improved platelet production and it has recently been shown to have additional immunomodulatory effects in treated patients. This review will highlight the complex pathophysiology of ITP and discuss the usage of Romiplostim in ITP and its ability to potentially immunomodulate autoimmunity.
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Affiliation(s)
- John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden, Clinical Immunology and Transfusion Medicine, Office of Medical Services, Region Skåne, Lund, Sweden; Departments of Pharmacology, Medicine and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, USA.
| | - Alexandra Schifferli
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
| | | | | | | | | | - Adrian Newland
- Barts and The London School of Medicine and Dentistry, London, UK.
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Crickx E, Mahévas M. B-cell responses to ITP treatments. Br J Haematol 2024; 204:397-398. [PMID: 38155442 DOI: 10.1111/bjh.19199] [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: 10/20/2023] [Revised: 10/29/2023] [Accepted: 10/30/2023] [Indexed: 12/30/2023]
Abstract
Deficiency in regulatory B cells has been suggested in immune thrombocytopenia. In this study, Stimpson et al. emphasize the importance of considering the treatments received for immunological analyses. Commentary on: Stimpson et al. Systemic immunosuppression depletes peripheral blood regulatory B cells in patients with immune thrombocytopenia. Br J Haematol 2024;204:644-648.
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Affiliation(s)
- Etienne Crickx
- Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
| | - Matthieu Mahévas
- Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
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