151
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Cid AR, Montesinos P, Sánchez‐Guiu I, Haya S, Lorenzo JI, Sanz J, Moscardo F, Puig N, Planelles D, Bonanad S, Sanz GF, Vicente V, González‐Manchón C, Lozano ML, Rivera J, Sanz MA. Allogeneic hematopoietic cell transplantation in an adult patient with Glanzmann thrombasthenia. Clin Case Rep 2017; 5:1887-1890. [PMID: 29152293 PMCID: PMC5676254 DOI: 10.1002/ccr3.1206] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 07/27/2017] [Accepted: 08/19/2017] [Indexed: 11/17/2022] Open
Abstract
Glanzmann thrombasthenia is a rare bleeding disorder that can present life‐threatening bleeding. Our patients develop antiplatelet antibodies that become refractory to any pharmacological treatment. Allogeneic hematopoietic stem‐cell transplantation is the only currently curative procedure, but has major risks mainly in adult; indeed, our patient died.
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Affiliation(s)
- Ana R. Cid
- Unidad de Hemostasia y TrombosisServicio de HematologíaHospital Universitario y Politécnico La FeValenciaSpain
| | - Pau Montesinos
- Unidad de Trasplante de Células HematopoyéticasServicio de HematologíaHospital Universitario y Politécnico La FeValenciaSpain
| | - Isabel Sánchez‐Guiu
- Servicio de Hematología y Oncología MédicaHospital Universitario Morales MeseguerCentro Regional de HemodonaciónUniversidad de Murcia, IMIB‐Arrixaca, CIBERERMurciaSpain
| | - Saturnino Haya
- Unidad de Hemostasia y TrombosisServicio de HematologíaHospital Universitario y Politécnico La FeValenciaSpain
| | - Jose I. Lorenzo
- Unidad de Trasplante de Células HematopoyéticasServicio de HematologíaHospital Universitario y Politécnico La FeValenciaSpain
| | - Jaime Sanz
- Unidad de Trasplante de Células HematopoyéticasServicio de HematologíaHospital Universitario y Politécnico La FeValenciaSpain
| | - Federico Moscardo
- Unidad de Trasplante de Células HematopoyéticasServicio de HematologíaHospital Universitario y Politécnico La FeValenciaSpain
| | - Nieves Puig
- Centro de Transfusión de la Comunidad ValencianaValenciaSpain
| | | | - Santiago Bonanad
- Unidad de Hemostasia y TrombosisServicio de HematologíaHospital Universitario y Politécnico La FeValenciaSpain
| | - Guillermo F. Sanz
- Unidad de Trasplante de Células HematopoyéticasServicio de HematologíaHospital Universitario y Politécnico La FeValenciaSpain
| | - Vicente Vicente
- Servicio de Hematología y Oncología MédicaHospital Universitario Morales MeseguerCentro Regional de HemodonaciónUniversidad de Murcia, IMIB‐Arrixaca, CIBERERMurciaSpain
| | - Consuelo González‐Manchón
- Departament Cellular and Molecular MedicineCentro de Investigaciones Biológicas (C.S.I.C.)MadridSpain
| | - María L. Lozano
- Servicio de Hematología y Oncología MédicaHospital Universitario Morales MeseguerCentro Regional de HemodonaciónUniversidad de Murcia, IMIB‐Arrixaca, CIBERERMurciaSpain
| | - José Rivera
- Servicio de Hematología y Oncología MédicaHospital Universitario Morales MeseguerCentro Regional de HemodonaciónUniversidad de Murcia, IMIB‐Arrixaca, CIBERERMurciaSpain
| | - Miguel A. Sanz
- Unidad de Hemostasia y TrombosisServicio de HematologíaHospital Universitario y Politécnico La FeValenciaSpain
- Unidad de Trasplante de Células HematopoyéticasServicio de HematologíaHospital Universitario y Politécnico La FeValenciaSpain
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152
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Bastida JM, Lozano ML, Benito R, Janusz K, Palma-Barqueros V, Del Rey M, Hernández-Sánchez JM, Riesco S, Bermejo N, González-García H, Rodriguez-Alén A, Aguilar C, Sevivas T, López-Fernández MF, Marneth AE, van der Reijden BA, Morgan NV, Watson SP, Vicente V, Hernández-Rivas JM, Rivera J, González-Porras JR. Introducing high-throughput sequencing into mainstream genetic diagnosis practice in inherited platelet disorders. Haematologica 2017; 103:148-162. [PMID: 28983057 PMCID: PMC5777202 DOI: 10.3324/haematol.2017.171132] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 09/29/2017] [Indexed: 12/30/2022] Open
Abstract
Inherited platelet disorders are a heterogeneous group of rare diseases, caused by inherited defects in platelet production and/or function. Their genetic diagnosis would benefit clinical care, prognosis and preventative treatments. Until recently, this diagnosis has usually been performed via Sanger sequencing of a limited number of candidate genes. High-throughput sequencing is revolutionizing the genetic diagnosis of diseases, including bleeding disorders. We have designed a novel high-throughput sequencing platform to investigate the unknown molecular pathology in a cohort of 82 patients with inherited platelet disorders. Thirty-four (41.5%) patients presented with a phenotype strongly indicative of a particular type of platelet disorder. The other patients had clinical bleeding indicative of platelet dysfunction, but with no identifiable features. The high-throughput sequencing test enabled a molecular diagnosis in 70% of these patients. This sensitivity increased to 90% among patients suspected of having a defined platelet disorder. We found 57 different candidate variants in 28 genes, of which 70% had not previously been described. Following consensus guidelines, we qualified 68.4% and 26.3% of the candidate variants as being pathogenic and likely pathogenic, respectively. In addition to establishing definitive diagnoses of well-known inherited platelet disorders, high-throughput sequencing also identified rarer disorders such as sitosterolemia, filamin and actinin deficiencies, and G protein-coupled receptor defects. This included disease-causing variants in DIAPH1 (n=2) and RASGRP2 (n=3). Our study reinforces the feasibility of introducing high-throughput sequencing technology into the mainstream laboratory for the genetic diagnostic practice in inherited platelet disorders.
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Affiliation(s)
- José M Bastida
- Servicio de Hematología, Hospital Universitario de Salamanca-IBSAL-USAL, Spain .,On behalf of the Project "Functional and Molecular Characterization of Patients with Inherited Platelet Disorders" of the Hemorrhagic Diathesis Working Group of the Spanish Society of Thrombosis and Haemostasis
| | - María L Lozano
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CB15/00055-CIBERER, Spain.,On behalf of the Project "Functional and Molecular Characterization of Patients with Inherited Platelet Disorders" of the Hemorrhagic Diathesis Working Group of the Spanish Society of Thrombosis and Haemostasis
| | - Rocío Benito
- IBSAL, IBMCC, CIC, Universidad de Salamanca-CSIC, Spain
| | - Kamila Janusz
- IBSAL, IBMCC, CIC, Universidad de Salamanca-CSIC, Spain
| | - Verónica Palma-Barqueros
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CB15/00055-CIBERER, Spain
| | | | | | - Susana Riesco
- Servicio de Pediatría, Hospital Universitario de Salamanca-IBSAL, Spain
| | - Nuria Bermejo
- Servicio de Hematología, Complejo Hospitalario San Pedro Alcántara, Cáceres, Spain
| | | | - Agustín Rodriguez-Alén
- Servicio de Hematología y Hemoterapia, Hospital Virgen de la Salud, Complejo Hospitalario de Toledo, Spain
| | - Carlos Aguilar
- Servicio de Hematología, Complejo Asistencial de Soria, Spain
| | - Teresa Sevivas
- Serviço de Imunohemoterapia, Sangue e Medicina Transfusional do Centro Hospitalar e Universitário de Coimbra, EPE, Portugal
| | | | - Anna E Marneth
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Bert A van der Reijden
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Neil V Morgan
- Birmingham Platelet Group, Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Steve P Watson
- Birmingham Platelet Group, Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Vicente Vicente
- On behalf of the Project "Functional and Molecular Characterization of Patients with Inherited Platelet Disorders" of the Hemorrhagic Diathesis Working Group of the Spanish Society of Thrombosis and Haemostasis
| | - Jesús M Hernández-Rivas
- Servicio de Hematología, Hospital Universitario de Salamanca-IBSAL-USAL, Spain.,IBSAL, IBMCC, CIC, Universidad de Salamanca-CSIC, Spain
| | - José Rivera
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CB15/00055-CIBERER, Spain.,On behalf of the Project "Functional and Molecular Characterization of Patients with Inherited Platelet Disorders" of the Hemorrhagic Diathesis Working Group of the Spanish Society of Thrombosis and Haemostasis
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153
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Al Ghaithi R, Drake S, Watson SP, Morgan NV, Harrison P. Comparison of multiple electrode aggregometry with lumi-aggregometry for the diagnosis of patients with mild bleeding disorders. J Thromb Haemost 2017; 15:2045-2052. [PMID: 28762630 DOI: 10.1111/jth.13784] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Indexed: 08/31/2023]
Abstract
Essentials There is a clinical need for new technologies to measure platelet function in whole blood. Mild bleeding disorders were evaluated using multiple electrode aggregometry (MEA). MEA is insensitive at detecting patients with mild platelet function and secretion defects. More studies are required to investigate MEA in patients with a defined set of platelet disorders. SUMMARY Background Multiple electrode aggregometry (MEA) measures changes in electrical impedance caused by platelet aggregation in whole blood. This approach is faster, more convenient and offers the advantage over light transmission aggregometry (LTA) of assessing platelet function in whole blood and reducing preanalytical errors associated with preparation of platelet-rich plasma (PRP). Several studies indicate the utility of this method in assessing platelet inhibition in individuals taking antiplatelet agents (e.g. aspirin and clopidogrel). Objective Our current study sought to evaluate the ability of MEA in diagnosing patients with mild bleeding disorders by comparison with light transmission lumi-aggregometry (lumi-LTA). Methods Forty healthy subjects and 109 patients with a clinical diagnosis of a mild bleeding disorder were recruited into the UK Genotyping and Phenotyping of Platelets study (GAPP, ISRCTN 77951167). MEA was performed on whole blood using one or two concentrations of ADP, PAR-1 peptide, arachidonic acid and collagen. Lumi-LTA was performed in PRP using several concentrations of ADP, adrenaline, arachidonic acid, collagen, PAR-1 peptide and ristocetin. Results Of 109 patients tested, 54 (49%) patients gave abnormal responses by lumi-LTA to one or more agonists. In contrast, only 16 (15%) patients were shown to have abnormal responses to one or more agonists by MEA. Conclusions In this study we showed that MEA is less sensitive in identifying patients with abnormal platelet function relative to lumi-LTA.
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Affiliation(s)
- R Al Ghaithi
- Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, UK
- Institute of Cardiovascular Sciences University of Birmingham, University of Birmingham, Edgbaston, Birmingham, UK
| | - S Drake
- Institute of Cardiovascular Sciences University of Birmingham, University of Birmingham, Edgbaston, Birmingham, UK
| | - S P Watson
- Institute of Cardiovascular Sciences University of Birmingham, University of Birmingham, Edgbaston, Birmingham, UK
| | - N V Morgan
- Institute of Cardiovascular Sciences University of Birmingham, University of Birmingham, Edgbaston, Birmingham, UK
| | - P Harrison
- Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, UK
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154
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Boknäs N, Ramström S, Faxälv L, Lindahl TL. Flow cytometry-based platelet function testing is predictive of symptom burden in a cohort of bleeders. Platelets 2017; 29:512-519. [PMID: 28895772 DOI: 10.1080/09537104.2017.1349305] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Platelet function disorders (PFDs) are common in patients with mild bleeding disorders (MBDs), yet the significance of laboratory findings suggestive of a PFD remain unclear due to the lack of evidence for a clinical correlation between the test results and the patient phenotype. Herein, we present the results from a study evaluating the potential utility of platelet function testing using whole-blood flow cytometry in a cohort of 105 patients undergoing investigation for MBD. Subjects were evaluated with a test panel comprising two different activation markers (fibrinogen binding and P-selectin exposure) and four physiologically relevant platelet agonists (ADP, PAR1-AP, PAR4-AP, and CRP-XL). Abnormal test results were identified by comparison with reference ranges constructed from 24 healthy controls or with the fifth percentile of the entire patient cohort. We found that the abnormal test results are predictive of bleeding symptom severity, and that the greatest predictive strength was achieved using a subset of the panel, comparing measurements of fibrinogen binding after activation with all four agonists with the fifth percentile of the patient cohort (p = 0.00008, hazard ratio 8.7; 95% CI 2.5-40). Our results suggest that whole-blood flow cytometry-based platelet function testing could become a feasible alternative for the investigation of MBDs. We also show that platelet function testing using whole-blood flow cytometry could provide a clinically relevant quantitative assessment of platelet-related hemostasis.
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Affiliation(s)
- Niklas Boknäs
- a Department of Hematology and Department of Clinical and Experimental Medicine , Linköping University , Linköping , Sweden
| | - Sofia Ramström
- b Department of Clinical Chemistry and Department of Clinical and Experimental Medicine , Linköping University , Linköping , Sweden.,c School of Medical Sciences , Örebro University , Örebro , Sweden
| | - Lars Faxälv
- d Department of Clinical and Experimental Medicine , Linköping University , Linköping , Sweden
| | - Tomas L Lindahl
- b Department of Clinical Chemistry and Department of Clinical and Experimental Medicine , Linköping University , Linköping , Sweden
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155
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Bidlingmaier C, Olivieri M, Hütker S, Dietl S, Kurnik K. Perioperative management of hemostasis in children and adolescents. Blood Cells Mol Dis 2017; 67:91-95. [DOI: 10.1016/j.bcmd.2017.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 01/13/2017] [Accepted: 01/15/2017] [Indexed: 12/14/2022]
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156
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Freson K, Turro E. High-throughput sequencing approaches for diagnosing hereditary bleeding and platelet disorders. J Thromb Haemost 2017; 15:1262-1272. [PMID: 28671349 DOI: 10.1111/jth.13681] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Hereditary bleeding and platelet disorders (BPDs) are characterized by marked genetic heterogeneity, far greater than previously appreciated. The list of genes involved in the regulation of megakaryopoiesis, platelet formation, platelet function and bleeding has been growing rapidly since the introduction of high-throughput sequencing (HTS) approaches in research. Thanks to the gradual adoption of HTS in diagnostic practice, these discoveries are improving the diagnostic yield for BPD patients, who may or may not present with bleeding problems and often have other clinical symptoms unrelated to the blood system. However, it was previously found that screening for all known etiologies gives a diagnostic yield of over 90% when the phenotype closely matches a known BPD but drops to 10% when the phenotype is indicative of a novel disorder. Thus, further research is needed to identify currently unknown etiologies for BPDs. Novel genes are likely to be found to be implicated in BPDs. New modes of inheritance, including digenic inheritance, are likely to play a role in some cases. Additionally, identifying and interpreting pathogenic variants outside exons is a looming challenge that can only be tackled with an improved understanding of the regulatory landscape of relevant cell types and with the transition from targeted sequencing to whole-genome sequencing in the clinic.
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Affiliation(s)
- K Freson
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - E Turro
- Department of Haematology and MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
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157
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Germanovich K, Femia EA, Cheng CY, Dovlatova N, Cattaneo M. Effects of pH and concentration of sodium citrate anticoagulant on platelet aggregation measured by light transmission aggregometry induced by adenosine diphosphate. Platelets 2017. [PMID: 28643541 DOI: 10.1080/09537104.2017.1327655] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The 2013 ISTH-SSC guidelines for the standardization of light transmission aggregometry (LTA) were largely based on expert consensus, as studies directly comparing LTA methodologies were lacking. We experimentally tested the cogency of ISTH-SSC recommendations pertaining to use of anticoagulant, in particular whether: (1) buffered citrate (BC) is preferable to unbuffered citrate (C); (2) the two recommended concentrations of sodium citrate (109 and 129 mM) are equivalent in terms of platelet aggregation (PA). Blood from 16 healthy volunteers was collected into BC and C (109 and 129 mM). PA was measured by LTA in platelet-rich plasma (PRP) stimulated by adenosine diphosphate (ADP) (2 μM) immediately after PRP preparation and up to 4 hr after blood collection; pH and platelet counts in PRP were measured in parallel. pH in PRP increased with time up to about 8 for all anticoagulants, although it was lower in BC than in C at all times. In BC, PA was lower at 45 min, but equivalent at all other times. PA was higher and more stable in sodium citrate 109 mM than in 129 mM at all times. The extent of PA did not change for up to 2 hr after blood collection, and subsequently dramatically decreased. In contrast with ISTH-SSC recommendations, (1) BC does not show advantages compared to C; (2) 109 mM citrate is preferable to 129 mM, because it better supports PA; and (3) LTA studies should be completed within 2 hr of blood collection, instead of the recommended 4 hr.
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Affiliation(s)
- Ksenia Germanovich
- a Medicina III, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute , Università degli Studi di Milano , Milan , Italy
| | - Eti Alessandra Femia
- a Medicina III, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute , Università degli Studi di Milano , Milan , Italy
| | - Chun Yan Cheng
- a Medicina III, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute , Università degli Studi di Milano , Milan , Italy
| | - Natalia Dovlatova
- b Thrombosis and Haemostasis Group, Clinical Neurosciences , University of Nottingham , Nottingham , UK
| | - Marco Cattaneo
- a Medicina III, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute , Università degli Studi di Milano , Milan , Italy
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158
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Abstract
Heritable platelet function disorders (PFDs) are genetically heterogeneous and poorly characterized. Pathogenic variants in RASGRP2, which encodes calcium and diacylglycerol-regulated guanine exchange factor I (CalDAG-GEFI), have been reported previously in 3 pedigrees with bleeding and reduced platelet aggregation responses. To better define the phenotype associated with pathogenic RASGRP2 variants, we compared high-throughput sequencing and phenotype data from 2042 cases in pedigrees with unexplained bleeding or platelet disorders to data from 5422 controls. Eleven cases harbored 11 different, previously unreported RASGRP2 variants that were biallelic and likely pathogenic. The variants included 5 high-impact variants predicted to prevent CalDAG-GEFI expression and 6 missense variants affecting the CalDAG-GEFI CDC25 domain, which mediates Rap1 activation during platelet inside-out αIIbβ3 signaling. Cases with biallelic RASGRP2 variants had abnormal mucocutaneous, surgical, and dental bleeding from childhood, requiring ≥1 blood or platelet transfusion in 78% of cases. Platelets displayed reduced aggregation in response to adenosine 5'-diphosphate and epinephrine, but variable aggregation defects with other agonists. There were no other consistent clinical or laboratory features. These data enable definition of human CalDAG-GEFI deficiency as a nonsyndromic, recessive PFD associated with a moderate or severe bleeding phenotype and complex defects in platelet aggregation.
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159
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Sivapalaratnam S, Collins J, Gomez K. Diagnosis of inherited bleeding disorders in the genomic era. Br J Haematol 2017; 179:363-376. [PMID: 28612396 DOI: 10.1111/bjh.14796] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Inherited bleeding disorders affect between 1 in 1000 individuals for the most common disorder, von Willebrand Disease, to only 8 reported cases worldwide of alpha-2-antiplasmin deficiency. Those with an identifiable abnormality can be divided into disorders of coagulation factors (87%), platelet count and function (8%) and the fibrinolytic system (3%). Of the patients registered in the UK with a bleeding disorder, the remaining 2% are unclassifiable. In addition to bleeding symptoms, patients with an inherited bleeding disorder can manifest other abnormalities, making an accurate and complete diagnosis that reflects the underlying molecular pathology important. Although some inherited bleeding disorders can still be easily diagnosed through a combination of careful clinical assessment and laboratory assays of varying degrees of complexity, there are many where conventional approaches are inadequate. Improvements in phenotyping assays have enhanced our diagnostic armoury but genotyping now offers the most accurate and complete diagnosis for some of these conditions. The advent of next generation sequencing technology has meant that many genes can now be analysed routinely in clinical practice. Here, we discuss the different diagnostic tools currently available for inherited bleeding disorders and suggest that genotyping should be incorporated at an early stage in the diagnostic pathway.
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Affiliation(s)
- Suthesh Sivapalaratnam
- Department of Haematology, University of Cambridge, Cambridge, UK.,The Royal London Haemophilia Centre, The Royal London Hospital, London, UK
| | - Janine Collins
- Department of Haematology, University of Cambridge, Cambridge, UK.,The Royal London Haemophilia Centre, The Royal London Hospital, London, UK
| | - Keith Gomez
- Katherine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
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160
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161
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Practice patterns in the diagnosis of inherited platelet disorders within a single institution. Blood Coagul Fibrinolysis 2017; 28:303-308. [DOI: 10.1097/mbc.0000000000000596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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162
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Orsini S, Noris P, Bury L, Heller PG, Santoro C, Kadir RA, Butta NC, Falcinelli E, Cid AR, Fabris F, Fouassier M, Miyazaki K, Lozano ML, Zúñiga P, Flaujac C, Podda GM, Bermejo N, Favier R, Henskens Y, De Maistre E, De Candia E, Mumford AD, Ozdemir GN, Eker I, Nurden P, Bayart S, Lambert MP, Bussel J, Zieger B, Tosetto A, Melazzini F, Glembotsky AC, Pecci A, Cattaneo M, Schlegel N, Gresele P. Bleeding risk of surgery and its prevention in patients with inherited platelet disorders. Haematologica 2017; 102:1192-1203. [PMID: 28385783 PMCID: PMC5566025 DOI: 10.3324/haematol.2016.160754] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 04/04/2017] [Indexed: 11/16/2022] Open
Abstract
Excessive bleeding at surgery is a feared complication in patients with inherited platelet disorders. However, very few studies have evaluated the frequency of surgical bleeding in these hemorrhagic disorders. We performed a worldwide, multicentric, retrospective study to assess the bleeding complications of surgery, the preventive and therapeutic approaches adopted, and their efficacy in patients with inherited platelet disorders: the Surgery in Platelet disorders And Therapeutic Approach (SPATA) study. We rated the outcome of 829 surgical procedures carried out in 423 patients with well-defined forms of inherited platelet disorders: 238 inherited platelet function disorders and 185 inherited platelet number disorders. Frequency of surgical bleeding was high in patients with inherited platelet disorders (19.7%), with a significantly higher bleeding incidence in inherited platelet function disorders (24.8%) than in inherited platelet number disorders (13.4%). The frequency of bleeding varied according to the type of inherited platelet disorder, with biallelic Bernard Soulier syndrome having the highest occurrence (44.4%). Frequency of bleeding was predicted by a pre-operative World Health Organization bleeding score of 2 or higher. Some types of surgery were associated with a higher bleeding incidence, like cardiovascular and urological surgery. The use of pre-operative pro-hemostatic treatments was associated with a lower bleeding frequency in patients with inherited platelet function disorders but not in inherited platelet number disorders. Desmopressin, alone or with antifibrinolytic agents, was the preventive treatment associated with the lowest bleedings. Platelet transfusions were used more frequently in patients at higher bleeding risk. Surgical bleeding risk in inherited platelet disorders is substantial, especially in inherited platelet function disorders, and bleeding history, type of disorder, type of surgery and female sex are associated with higher bleeding frequency. Prophylactic pre-operative pro-hemostatic treatments appear to be required and are associated with a lower bleeding incidence.
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Affiliation(s)
- Sara Orsini
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Patrizia Noris
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Italy
| | - Loredana Bury
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Paula G Heller
- Hematología Investigación, Instituto de Investigaciones Médicas Alfredo Lanari, Universidad de Buenos Aires, CONICET, Argentina
| | | | - Rezan A Kadir
- Haemophilia Centre and Haemostasis Unit, Royal Free Hospital, London, UK
| | - Nora C Butta
- Unidad de Hematología, Hospital Universitario La Paz-IDIPaz, Madrid, Spain
| | - Emanuela Falcinelli
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Ana Rosa Cid
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - Fabrizio Fabris
- Clinica Medica 1 - Medicina Interna CLOPD, Dipartimento Assistenziale Integrato di Medicina, Azienda-Ospedale Università di Padova and Dipartimento di Medicina, Università di Padova, Italy
| | | | - Koji Miyazaki
- Department of Hematology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Maria Luisa Lozano
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguery Centro Regional de Hemodonación, IMIB-Arrixaca, Universidad de Murcia, Murcia 30003 and Grupo de Investigación CB15/00055 del Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Pamela Zúñiga
- Department of Hematology-Oncology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Claire Flaujac
- Service d'Hématologie Biologique Cochin Hospital, Paris, France
| | - Gian Marco Podda
- Medicina III, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Italy
| | - Nuria Bermejo
- Department of Hematology, Hospital San Pedro de Alcántara, Cáceres, Spain
| | - Remi Favier
- Assistance Publique-Hôpitaux de Paris, Armand Trousseau Children's Hospital, French Reference Centre for Inherited Platelet Disorders, Paris, France
| | - Yvonne Henskens
- Hematological Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Emmanuel De Maistre
- Department of Biology and Haematology, Centre Hospitalier Universitaire Dijon, France
| | - Erica De Candia
- Hemostasis and Thrombosis Unit, Institute of Internal Medicine, Policlinico Agostino Gemelli-Università Cattolica Sacro Cuore, Rome, Italy
| | | | - Gul Nihal Ozdemir
- Cerrahpasa Medical Faculty, Pediatric Hematology Department, Istanbul, Turkey
| | - Ibrahim Eker
- Gülhane Military Medical Faculty, Pediatric Hematology Department, Ankara, Turkey
| | - Paquita Nurden
- Reference Centre for Platelet Disorders, Bordeaux University Hospital Centre, Rythmology and Cardiac Modeling Institute (LIRYC), Xavier Arnozan Hospital, Pessac, France
| | - Sophie Bayart
- Centre Régional de Traitement des Hémophiles, Centre Hospitalier Universitaire de Rennes, France
| | - Michele P Lambert
- 1 Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PN, USA
| | - James Bussel
- Department of Pediatrics, Division of Hematology, Weill Cornell Medicine, New York, NY, USA
| | - Barbara Zieger
- Department of Pediatrics and Adolescent Medicine, University Medical Center Freiburg, Germany
| | | | - Federica Melazzini
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Italy
| | - Ana C Glembotsky
- Hematología Investigación, Instituto de Investigaciones Médicas Alfredo Lanari, Universidad de Buenos Aires, CONICET, Argentina
| | - Alessandro Pecci
- Department of Internal Medicine, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Italy
| | - Marco Cattaneo
- Medicina III, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Italy
| | - Nicole Schlegel
- Centre de Référence des Pathologies Plaquettaires (CRPP), Service d'Hématologie Biologique, CHU Robert Debré, AP-HP, Paris, France
| | - Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
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163
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Bariana TK, Ouwehand WH, Guerrero JA, Gomez K. Dawning of the age of genomics for platelet granule disorders: improving insight, diagnosis and management. Br J Haematol 2016; 176:705-720. [PMID: 27984638 DOI: 10.1111/bjh.14471] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Inherited disorders of platelet granules are clinically heterogeneous and their prevalence is underestimated because most patients do not undergo a complete diagnostic work-up. The lack of a genetic diagnosis limits the ability to tailor management, screen family members, aid with family planning, predict clinical progression and detect serious consequences, such as myelofibrosis, lung fibrosis and malignancy, in a timely manner. This is set to change with the introduction of high throughput sequencing (HTS) as a routine clinical diagnostic test. HTS diagnostic tests are now available, affordable and allow parallel screening of DNA samples for variants in all of the 80 known bleeding, thrombotic and platelet genes. Increased genetic diagnosis and curation of variants is, in turn, improving our understanding of the pathobiology and clinical course of inherited platelet disorders. Our understanding of the genetic causes of platelet granule disorders and the regulation of granule biogenesis is a work in progress and has been significantly enhanced by recent genomic discoveries from high-powered genome-wide association studies and genome sequencing projects. In the era of whole genome and epigenome sequencing, new strategies are required to integrate multiple sources of big data in the search for elusive, novel genes underlying granule disorders.
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Affiliation(s)
- Tadbir K Bariana
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK.,Department of Haematology, University College London Cancer Institute, London, UK.,Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Willem H Ouwehand
- Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.,NHS Blood and Transplant, Cambridge Biomedical Campus, Cambridge, UK.,NIHR BioResource, Cambridge University Hospitals, Cambridge Biomedical Campus, Cambridge, UK.,Human Genetics, Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, UK
| | - Jose A Guerrero
- Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.,NHS Blood and Transplant, Cambridge Biomedical Campus, Cambridge, UK
| | - Keith Gomez
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
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164
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Magnette A, Chatelain M, Chatelain B, Ten Cate H, Mullier F. Pre-analytical issues in the haemostasis laboratory: guidance for the clinical laboratories. Thromb J 2016; 14:49. [PMID: 27999475 PMCID: PMC5154122 DOI: 10.1186/s12959-016-0123-z] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 12/01/2016] [Indexed: 11/10/2022] Open
Abstract
Ensuring quality has become a daily requirement in laboratories. In haemostasis, even more than in other disciplines of biology, quality is determined by a pre-analytical step that encompasses all procedures, starting with the formulation of the medical question, and includes patient preparation, sample collection, handling, transportation, processing, and storage until time of analysis. This step, based on a variety of manual activities, is the most vulnerable part of the total testing process and is a major component of the reliability and validity of results in haemostasis and constitutes the most important source of erroneous or un-interpretable results. Pre-analytical errors may occur throughout the testing process and arise from unsuitable, inappropriate or wrongly handled procedures. Problems may arise during the collection of blood specimens such as misidentification of the sample, use of inadequate devices or needles, incorrect order of draw, prolonged tourniquet placing, unsuccessful attempts to locate the vein, incorrect use of additive tubes, collection of unsuitable samples for quality or quantity, inappropriate mixing of a sample, etc. Some factors can alter the result of a sample constituent after collection during transportation, preparation and storage. Laboratory errors can often have serious adverse consequences. Lack of standardized procedures for sample collection accounts for most of the errors encountered within the total testing process. They can also have clinical consequences as well as a significant impact on patient care, especially those related to specialized tests as these are often considered as "diagnostic". Controlling pre-analytical variables is critical since this has a direct influence on the quality of results and on their clinical reliability. The accurate standardization of the pre-analytical phase is of pivotal importance for achieving reliable results of coagulation tests and should reduce the side effects of the influence factors. This review is a summary of the most important recommendations regarding the importance of pre-analytical factors for coagulation testing and should be a tool to increase awareness about the importance of pre-analytical factors for coagulation testing.
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Affiliation(s)
- A Magnette
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NARILIS, Haematology Laboratory, B-5530 Yvoir, Belgium
| | - M Chatelain
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NARILIS, Haematology Laboratory, B-5530 Yvoir, Belgium
| | - B Chatelain
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NARILIS, Haematology Laboratory, B-5530 Yvoir, Belgium
| | - H Ten Cate
- Maastricht University Medical Centre and Cardiovascular Research Institute (CARIM), Department of Internal Medicine, Maastricht, The Netherlands
| | - F Mullier
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NARILIS, Haematology Laboratory, B-5530 Yvoir, Belgium
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165
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Urban D, Pluthero FG, Christensen H, Baidya S, Rand ML, Das A, Shah PS, Chitayat D, Blanchette VS, Kahr WHA. Decreased numbers of dense granules in fetal and neonatal platelets. Haematologica 2016; 102:e36-e38. [PMID: 27810994 DOI: 10.3324/haematol.2016.152421] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Denisa Urban
- Department of Biochemistry, University of Toronto, ON, Canada.,Cell Biology Program, Research Institute, The Hospital for Sick Children, University of Toronto, ON, Canada
| | - Fred G Pluthero
- Cell Biology Program, Research Institute, The Hospital for Sick Children, University of Toronto, ON, Canada
| | - Hilary Christensen
- Cell Biology Program, Research Institute, The Hospital for Sick Children, University of Toronto, ON, Canada
| | - Shoma Baidya
- Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto, ON, Canada
| | - Margaret L Rand
- Department of Biochemistry, University of Toronto, ON, Canada.,Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto, ON, Canada.,Physiology & Experimental Medicine Program, Research Institute, The Hospital for Sick Children, University of Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, ON, Canada
| | - Animitra Das
- Mount Sinai Hospital, University of Toronto, ON, Canada
| | - Prakeshkumar S Shah
- Department of Paediatrics, University of Toronto, ON, Canada.,Mount Sinai Hospital, University of Toronto, ON, Canada
| | - David Chitayat
- Department of Paediatrics, University of Toronto, ON, Canada.,Division of Clinical and Metabolic Genetics, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada.,Department of Molecular Genetics, University of Toronto, ON, Canada.,The Prenatal Diagnosis and Medical Genetics Program, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, ON, Canada
| | - Victor S Blanchette
- Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, ON, Canada.,The Child Health Evaluative Sciences Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Walter H A Kahr
- Department of Biochemistry, University of Toronto, ON, Canada .,Cell Biology Program, Research Institute, The Hospital for Sick Children, University of Toronto, ON, Canada.,Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, ON, Canada
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166
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Pfeiffer H, Herbst L, Schwarze B, Eckstein R, Weisbach V. Massive intoxication with rivaroxaban, phenprocoumon, and diclofenac: A case report. Medicine (Baltimore) 2016; 95:e5343. [PMID: 27858919 PMCID: PMC5591167 DOI: 10.1097/md.0000000000005343] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 10/10/2016] [Accepted: 10/11/2016] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Oral anticoagulants and painkillers, some with an additional effect on the coagulation system, are widely used and are therefore prone to abuse and (intentional) overdose. We report the case of a patient with a massive mixed anticoagulant intoxication. PATIENT CONCERNS The patient had ingested 1960 mg rivaroxaban, 31.5 mg phenprocoumon, 1425 mg diclofenac, and 21,000 mg metamizole in suicidal intention. DIAGNOSES Massive mixed anticoagulant overdose. INTERVENTIONS The patient was closely monitored. The phenprocoumon overdose was treated by the administration of vitamin K and PCC. OUTCOMES Despite the massive inhibition of the coagulation system, the patient did not experience bleeding apart from a slight gross hematuria. LESSONS Despite the ingestion of a massive amount of rivaroxaban, the plasma levels were not as high as feared, due to the ceiling effect of rivaroxaban absorption. Elimination occurred according to the half-life of rivaroxaban and was not unduly prolonged by the ingested quantity.
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Affiliation(s)
| | | | - Bernd Schwarze
- Department of Forensic Medicine, University Hospital Erlangen, Erlangen, Germany
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167
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Bastida Bermejo JM, Hernández-Rivas JM, González-Porras JR. Novel approaches for diagnosing inherited platelet disorders. Med Clin (Barc) 2016; 148:71-77. [PMID: 28218058 DOI: 10.1016/j.medcli.2016.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 09/02/2016] [Accepted: 09/05/2016] [Indexed: 12/20/2022]
Abstract
Inherited platelet disorders diagnosis is based on the clinical history and bleeding assessment tools. The laboratory functional assays as well as the molecular test to identify the pathogenic genetic variant are essential to confirm the accurate diagnosis of these disorders. Nowadays, the main challenges to developing a new diagnostic system are involved in reducing the samples' volume, and faster and more helpful analysis. Moreover, there are no widely available and standardised global tests. High throughput genetic testing such as next-generation sequencing has revolutionised DNA sequencing technologies as it allows the simultaneous and faster investigation of multiple genes at a manageable cost. This technology has improved the molecular characterisation of inherited platelet disorders and has been implemented in the research studies and the clinical routine practice.
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Affiliation(s)
- José María Bastida Bermejo
- Servicio de Hematología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Universidad de Salamanca (USAL), Salamanca, España.
| | - Jesús María Hernández-Rivas
- Servicio de Hematología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Universidad de Salamanca (USAL), Salamanca, España
| | - José Ramón González-Porras
- Servicio de Hematología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Universidad de Salamanca (USAL), Salamanca, España
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168
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Jurk K. Platelet granules - secretory and secretive. Hamostaseologie 2016; 37:208-210. [PMID: 27656707 DOI: 10.5482/hamo-16-07-0023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 09/07/2016] [Indexed: 11/05/2022] Open
Abstract
The article reviews three recent publications addressing physiological and pathological aspects of platelet granules and release as well as limitations of recent screening tests for diagnosis of non-syndromic inherited δ-storage pool disease (1-3).
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Affiliation(s)
- Kerstin Jurk
- PD Dr. rer. nat. Kerstin Jurk Center for Thrombosis and Hemostasis (CTH) University Medical Center Mainz Langenbeckstr. 1, 55131 Mainz, Germany E-Mail:
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169
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Badin MS, Graf L, Iyer JK, Moffat KA, Seecharan JL, Hayward CPM. Variability in platelet dense granule adenosine triphosphate release findings amongst patients tested multiple times as part of an assessment for a bleeding disorder. Int J Lab Hematol 2016; 38:648-657. [PMID: 27571881 DOI: 10.1111/ijlh.12553] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 06/07/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Lumi-aggregometry quantification of platelet dense granule adenosine triphosphate (ATP) release is commonly used for diagnosing platelet function disorders. As the test findings show considerable variability for healthy controls, we postulated that patient findings might also be variable and investigated patients who were assessed for dense granule ATP release defects more than once. METHODS Analyses were performed on prospectively collected data for first and second tests for subjects tested for dense granule ATP release defects more than once by the Hamilton Regional Laboratory Program (HRLMP) between January 2007 and June 2013 (cohort I). Similar analyses were performed for subjects who were recruited to a platelet disorder study (cohort II) and were assessed for ATP release defects more than once before October 2015. RESULTS A total of 150 unique subjects had multiple ATP release tests. Results with individual agonists were variable for many subjects. While normal findings with all tested agonists were often confirmed by the second test (cohort I: 83%; cohort II: 100%), impaired release with multiple agonists was confirmed in only some subjects (cohort I: 34%; cohort II: 54%). Inconsistent findings were common (cohort I: 36%; cohort II: 39%). ISTH bleeding scores showed no relationship to the test findings. The finding of impaired ATP release with 2 or more agonists on both tests was not associated with an increased likelihood of a definite bleeding disorder. CONCLUSION The variability in platelet dense granule ATP release findings amongst patients assessed for diagnostic purposes suggests that the test has limited value for diagnosing platelet disorders.
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Affiliation(s)
- M S Badin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - L Graf
- Centre for Laboratory Medicine and Hemophilia and Hemostasis Centre, St. Gallen, Switzerland
| | - J K Iyer
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - K A Moffat
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Hamilton Regional Laboratory Medicine Program, Hamilton, ON, Canada
| | - J L Seecharan
- Hamilton Regional Laboratory Medicine Program, Hamilton, ON, Canada
| | - C P M Hayward
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada.,Hamilton Regional Laboratory Medicine Program, Hamilton, ON, Canada
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170
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Gresele P, Falcinelli E, Bury L. Inherited platelet function disorders. Diagnostic approach and management. Hamostaseologie 2016; 36:265-278. [PMID: 27484722 DOI: 10.5482/hamo-16-02-0002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 07/16/2016] [Indexed: 12/25/2022] Open
Abstract
Inherited platelet function disorders (IPFDs) make up a significant proportion of congenital bleeding diatheses, but they remain poorly understood and often difficult to diagnose. Therefore, a rational diagnostic approach, based on a standardized sequence of laboratory tests, with consecutive steps of increasing level of complexity, plays a crucial role in the diagnosis of most IPFDs. In this review we discuss a diagnostic approach through platelet phenotyping and genotyping and we give an overview of the options for the management of bleeding in these disorders and an account of the few systematic studies on the bleeding risk associated with invasive procedures and its treatment.
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Affiliation(s)
- Paolo Gresele
- Paolo Gresele, MD, PhD, Division of Internal and Cardiovascular Medicine Department of Medicine, University of Perugia, Via E. dal Pozzo, 06126 Perugia, Italy, Tel. +39/07 55 78 39 89, Fax +39/07 55 71 60 83, E-Mail:
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171
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Eneman B, Levtchenko E, van den Heuvel B, Van Geet C, Freson K. Platelet abnormalities in nephrotic syndrome. Pediatr Nephrol 2016; 31:1267-79. [PMID: 26267676 DOI: 10.1007/s00467-015-3173-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 07/03/2015] [Accepted: 07/03/2015] [Indexed: 01/08/2023]
Abstract
Nephrotic syndrome (NS) is a common kidney disease associated with a significantly increased risk of thrombotic events. Alterations in plasma levels of pro- and anti-coagulant factors are involved in the pathophysiology of venous thrombosis in NS. However, the fact that the risk of both venous and arterial thrombosis is elevated in NS points to an additional role for blood platelets. Increased platelet counts and platelet hyperactivity have been observed in nephrotic children. Platelet hyperaggregability, increased release of active substances, and elevated surface expression of activation-dependent platelet markers have been documented. The mechanisms underlying those platelet alterations are multifactorial and are probably due to changes in plasma levels of platelet-interfering proteins and lipid changes, as a consequence of nephrosis. The causal relationship between platelet alterations seen in NS and the occurrence of thromboembolic phenomena remains unclear. Moreover, the efficiency of prophylactic treatment using antiplatelet agents for the prevention of thrombotic complications in nephrotic patients is also unknown. Thus, antiplatelet medication is currently not generally recommended for routine prophylactic therapy.
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Affiliation(s)
- Benedicte Eneman
- Pediatric Nephrology, Department of Pediatrics, University hospital of Leuven, Leuven, Belgium.
- Laboratory of Pediatric Nephrology, Department of Development & Regeneration, KU Leuven, Leuven, Belgium.
| | - Elena Levtchenko
- Pediatric Nephrology, Department of Pediatrics, University hospital of Leuven, Leuven, Belgium
- Laboratory of Pediatric Nephrology, Department of Development & Regeneration, KU Leuven, Leuven, Belgium
| | - Bert van den Heuvel
- Laboratory of Pediatric Nephrology, Department of Development & Regeneration, KU Leuven, Leuven, Belgium
| | - Chris Van Geet
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium
| | - Kathleen Freson
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium
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172
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Boender J, Kruip MJHA, Leebeek FWG. A diagnostic approach to mild bleeding disorders. J Thromb Haemost 2016; 14:1507-16. [PMID: 27208505 DOI: 10.1111/jth.13368] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Indexed: 01/02/2023]
Abstract
Mild inherited bleeding disorders are relatively common in the general population. Despite recent advances in diagnostic approaches, mild inherited bleeding disorders still pose a significant diagnostic challenge. Hemorrhagic diathesis can be caused by disorders in primary hemostasis (von Willebrand disease, inherited platelet function disorders), secondary hemostasis (hemophilia A and B, other (rare) coagulant factor deficiencies) and fibrinolysis, and in connective tissue or vascular formation. This review summarizes the currently available diagnostic methods for mild bleeding disorders and their pitfalls, from structured patient history to highly specialized laboratory diagnosis. A comprehensive framework for a diagnostic approach to mild inherited bleeding disorders is proposed.
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Affiliation(s)
- J Boender
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - M J H A Kruip
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - F W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
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173
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Scharf RE. Do we need antiplatelet therapy in thrombocytosis? Contra. Proposal for an individualized risk-adapted treatment. Hamostaseologie 2016; 36:241-260. [PMID: 27414763 DOI: 10.5482/hamo-16-06-0016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 07/04/2016] [Indexed: 01/08/2023] Open
Abstract
Thrombocytosis is a frequent laboratory finding but not a diagnosis. Therefore, elevated platelet counts (>450 x 109/l) require careful diagnostic work-up to differentiate between reactive thrombocytosis (RT), caused by various conditions, and essential thrombocythemia (ET), a myeloproliferative neoplasm (MPN). In either setting, aspirin is widely used in clinical practice. However, RT (even at platelet counts >1000 x 109/l) has never been shown to cause thrombosis or bleeding due to acquired von Willebrand factor defects in association with high platelet counts. Identification of reactive conditions and appropriate therapy of the underlying disorder are most relevant. By contrast to RT, ET and related MPN can be associated with thrombosis and/or hemorrhage. Current recommendations suggest the use of low-dose aspirin in all patients with ET unless contraindicated. However, the strength of this recommendation is weak, i. e. evidence level IIb grade B. A potential benefit of aspirin used for primary thromboprophylaxis in ET is mostly derived from the ECLAP study in polycythemia vera (PV). However, translating study results from PV to ET appears to be highly questionable and may be biased. In the absence of robust data regarding the benefit-risk balance of aspirin in ET, it appears reasonable (1) to stratify patients according to their individual thrombotic and bleeding risk, (2) to restrict the use of aspirin to high-risk categories and patients with microcirculatory disturbances, (3) to test for pharmacological efficacy (COX-1 inhibition; measurement of TXB2), and (4) to modify the aspirin dosing regimen (twice instead of once daily) if required.
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Affiliation(s)
- Rüdiger E Scharf
- Rüdiger E. Scharf, M.D., Ph.D., F.A.H.A., Dept. of Experimental and Clinical Hemostasis, Hemotherapy and Transfusion Medicine and Hemophilia Comprehensive Care Center, Heinrich Heine, Univ. Medical Center Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany, Tel. +49/( 0)211/ 811 73-44 / -45, Fax +49/( 0)211/ 811 62 21,
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174
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Peyvandi F, Hayward CPM. Genomic approaches to bleeding disorders. Haemophilia 2016; 22 Suppl 5:42-5. [DOI: 10.1111/hae.12998] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2016] [Indexed: 12/30/2022]
Affiliation(s)
- F. Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; Milan Italy
- Department of Pathophysiology and Transplantation; Università degli Studi di Milano; Milan Italy
| | - C. P. M. Hayward
- Department of Pathology and Molecular Medicine; McMaster University; Hamilton ON Canada
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175
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The utility of International Society on Thrombosis and Haemostasis-Bleeding Assessment Tool and other bleeding questionnaires in assessing the bleeding phenotype in two platelet function defects. Blood Coagul Fibrinolysis 2016; 27:589-93. [DOI: 10.1097/mbc.0000000000000496] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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176
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Inherited platelet disorders: toward DNA-based diagnosis. Blood 2016; 127:2814-23. [PMID: 27095789 DOI: 10.1182/blood-2016-03-378588] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 04/13/2016] [Indexed: 12/11/2022] Open
Abstract
Variations in platelet number, volume, and function are largely genetically controlled, and many loci associated with platelet traits have been identified by genome-wide association studies (GWASs).(1) The genome also contains a large number of rare variants, of which a tiny fraction underlies the inherited diseases of humans. Research over the last 3 decades has led to the discovery of 51 genes harboring variants responsible for inherited platelet disorders (IPDs). However, the majority of patients with an IPD still do not receive a molecular diagnosis. Alongside the scientific interest, molecular or genetic diagnosis is important for patients. There is increasing recognition that a number of IPDs are associated with severe pathologies, including an increased risk of malignancy, and a definitive diagnosis can inform prognosis and care. In this review, we give an overview of these disorders grouped according to their effect on platelet biology and their clinical characteristics. We also discuss the challenge of identifying candidate genes and causal variants therein, how IPDs have been historically diagnosed, and how this is changing with the introduction of high-throughput sequencing. Finally, we describe how integration of large genomic, epigenomic, and phenotypic datasets, including whole genome sequencing data, GWASs, epigenomic profiling, protein-protein interaction networks, and standardized clinical phenotype coding, will drive the discovery of novel mechanisms of disease in the near future to improve patient diagnosis and management.
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177
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A high-throughput sequencing test for diagnosing inherited bleeding, thrombotic, and platelet disorders. Blood 2016; 127:2791-803. [PMID: 27084890 DOI: 10.1182/blood-2015-12-688267] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 04/07/2016] [Indexed: 12/17/2022] Open
Abstract
Inherited bleeding, thrombotic, and platelet disorders (BPDs) are diseases that affect ∼300 individuals per million births. With the exception of hemophilia and von Willebrand disease patients, a molecular analysis for patients with a BPD is often unavailable. Many specialized tests are usually required to reach a putative diagnosis and they are typically performed in a step-wise manner to control costs. This approach causes delays and a conclusive molecular diagnosis is often never reached, which can compromise treatment and impede rapid identification of affected relatives. To address this unmet diagnostic need, we designed a high-throughput sequencing platform targeting 63 genes relevant for BPDs. The platform can call single nucleotide variants, short insertions/deletions, and large copy number variants (though not inversions) which are subjected to automated filtering for diagnostic prioritization, resulting in an average of 5.34 candidate variants per individual. We sequenced 159 and 137 samples, respectively, from cases with and without previously known causal variants. Among the latter group, 61 cases had clinical and laboratory phenotypes indicative of a particular molecular etiology, whereas the remainder had an a priori highly uncertain etiology. All previously detected variants were recapitulated and, when the etiology was suspected but unknown or uncertain, a molecular diagnosis was reached in 56 of 61 and only 8 of 76 cases, respectively. The latter category highlights the need for further research into novel causes of BPDs. The ThromboGenomics platform thus provides an affordable DNA-based test to diagnose patients suspected of having a known inherited BPD.
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178
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Engert A, Balduini C, Brand A, Coiffier B, Cordonnier C, Döhner H, de Wit TD, Eichinger S, Fibbe W, Green T, de Haas F, Iolascon A, Jaffredo T, Rodeghiero F, Salles G, Schuringa JJ. The European Hematology Association Roadmap for European Hematology Research: a consensus document. Haematologica 2016; 101:115-208. [PMID: 26819058 PMCID: PMC4938336 DOI: 10.3324/haematol.2015.136739] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 01/27/2016] [Indexed: 01/28/2023] Open
Abstract
The European Hematology Association (EHA) Roadmap for European Hematology Research highlights major achievements in diagnosis and treatment of blood disorders and identifies the greatest unmet clinical and scientific needs in those areas to enable better funded, more focused European hematology research. Initiated by the EHA, around 300 experts contributed to the consensus document, which will help European policy makers, research funders, research organizations, researchers, and patient groups make better informed decisions on hematology research. It also aims to raise public awareness of the burden of blood disorders on European society, which purely in economic terms is estimated at €23 billion per year, a level of cost that is not matched in current European hematology research funding. In recent decades, hematology research has improved our fundamental understanding of the biology of blood disorders, and has improved diagnostics and treatments, sometimes in revolutionary ways. This progress highlights the potential of focused basic research programs such as this EHA Roadmap.The EHA Roadmap identifies nine 'sections' in hematology: normal hematopoiesis, malignant lymphoid and myeloid diseases, anemias and related diseases, platelet disorders, blood coagulation and hemostatic disorders, transfusion medicine, infections in hematology, and hematopoietic stem cell transplantation. These sections span 60 smaller groups of diseases or disorders.The EHA Roadmap identifies priorities and needs across the field of hematology, including those to develop targeted therapies based on genomic profiling and chemical biology, to eradicate minimal residual malignant disease, and to develop cellular immunotherapies, combination treatments, gene therapies, hematopoietic stem cell treatments, and treatments that are better tolerated by elderly patients.
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Affiliation(s)
| | | | - Anneke Brand
- Leids Universitair Medisch Centrum, Leiden, the Netherlands
| | | | | | | | | | | | - Willem Fibbe
- Leids Universitair Medisch Centrum, Leiden, the Netherlands
| | - Tony Green
- Cambridge Institute for Medical Research, United Kingdom
| | - Fleur de Haas
- European Hematology Association, The Hague, the Netherlands
| | | | | | | | - Gilles Salles
- Hospices Civils de Lyon/Université de Lyon, Pierre-Bénite, France
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179
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Othman M, Kaur H, Favaloro EJ, Lillicrap D, Di Paola J, Harrison P, Gresele P. Platelet type von Willebrand disease and registry report: communication from the SSC of the ISTH. J Thromb Haemost 2016; 14:411-4. [PMID: 26882161 DOI: 10.1111/jth.13204] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 11/10/2015] [Indexed: 02/06/2023]
Affiliation(s)
- M Othman
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
- School of Baccalaureate Nursing, St. Lawrence College, Kingston, ON, Canada
| | - H Kaur
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
| | - E J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Pathology West, Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW, Australia
- NSW Health Pathology, Westmead, NSW, Australia
| | - D Lillicrap
- Department of Pathology & Molecular Medicine, Richardson Laboratory, Queen's University, Kingston, ON, Canada
| | - J Di Paola
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - P Harrison
- School of Immunity and Infection, University of Birmingham Medical School, Birmingham, UK
| | - P Gresele
- Division of Internal and Cardiovascular Medicine, Department of Medicine, University of Perugia, Perugia, Italy
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180
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Abstract
The International Federation of Gynecology and Obstetrics and the American Congress of Obstetricians and Gynecologists support the use of new terminology for abnormal uterine bleeding (AUB) to consistently categorize AUB by etiology. The term AUB can be further classified as AUB/heavy menstrual bleeding (HMB) (replacing the term "menorrhagia") or AUB/intermenstrual bleeding (replacing the term "metrorrhagia"). Although many cases of AUB in adolescent women are attributable to immaturity of the hypothalamic-pituitary-ovarian axis, underlying bleeding disorders should be considered in women with AUB/HMB. This article reviews the new terminology for AUB, discusses important relevant features of history and examination, presents the laboratory evaluation of HMB, and describes hormonal (oral contraceptive pills, progestin-only methods, long-acting reversible contraceptives including intrauterine systems), hematologic (tranexamic acid and desmopressin), and surgical management options for AUB/HMB.
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181
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Favier R, Raslova H. Progress in understanding the diagnosis and molecular genetics of macrothrombocytopenias. Br J Haematol 2015; 170:626-39. [DOI: 10.1111/bjh.13478] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Remi Favier
- Institut National de la Santé et de la Recherche Médicale; U1170; Equipe Labellisée Ligue Contre le Cancer; Villejuif France
- Assistance Publique-Hôpitaux de Paris; Armand Trousseau Children Hospital; French Reference Center for Platelet Disorders; Haematological Laboratory; Paris France
| | - Hana Raslova
- Institut National de la Santé et de la Recherche Médicale; U1170; Equipe Labellisée Ligue Contre le Cancer; Villejuif France
- Faculté de Médecine; University Paris Saclay and University Paris-Sud 11; Le Kremlin-Bicêtre France
- Gustave Roussy; Villejuif France
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182
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Dovlatova N. Current status and future prospects for platelet function testing in the diagnosis of inherited bleeding disorders. Br J Haematol 2015; 170:150-61. [PMID: 25920378 DOI: 10.1111/bjh.13405] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Platelets play a crucial role in haemostasis by preventing bleeding at the site of vascular injury. Several defects in platelet morphology and function have been identified and described over the years. Although a range of methodologies is available to assess platelet function, a significant proportion of subjects with bleeding symptoms and normal coagulation parameters still appear to have normal results on platelet function testing. This might suggest that the reason for bleeding is multifactorial and is due to a combination of several minor defects in platelet function and/or other parts of the haemostatic system or might indicate that the currently available platelet function tests do not provide optimal diagnostic power. This review will summarize the established platelet function tests used for diagnosing inherited platelet abnormalities in adults and children, and discuss the newly developed methodologies as well as unmet challenges and potential areas for further improvement in this field.
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Affiliation(s)
- Natalia Dovlatova
- Division of Clinical Neuroscience, Thrombosis and Haemostasis Research Group, Queens Medical Centre, University of Nottingham, Nottingham, UK
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