Recombinant human thrombopoietin: basic biology and evaluation of clinical studies

A novel therapeutic approach for thrombocytopenia by minibody agonist of the thrombopoietin receptor

Antibodies have brought valuable therapeutics in the clinical treatment of various diseases without serious adverse effects through their intrinsic features such as specific binding to the target antigen with high affinity, clinical safety as serum proteins, and long half-life. Agonist antibodies, furthermore, could be expected to maximize the value of therapeutic antibodies. Indeed, several IgG/IgM antibodies have been reported to induce cellular growth/differentiation and apoptosis. These agonist antibodies, however, should be further improved to exert more potent biologic activities and appropriate serum half-life depending upon the disease indications. Here, we report that IgG antibodies against the thrombopoietin receptor (Mpl), which have an absence or very weak agonist activity, can be engineered to be agonist minibodies, which include diabody or sc(Fv)2 as potent as natural ligand. Through this technological development, minibodies have been successfully constructed to bind and activate 2 types of dysfunctional mutant Mpls that cause congenital amegakaryocytic thrombocytopenia (CAMT). This drastic conversion of biologic activities by designing minibodies can be widely applicable to generate agonist minibodies for clinical application, which will constitute a new paradigm in antibody-based therapeutics.

Regulation of haematopoiesis by growth factors - emerging insights and therapies

Haematopoiesis is regulated by a wide variety of glycoprotein hormones, including stem cell factor, granulocyte-macrophage colony-stimulating factor, thrombopoietin and IL-3. These haematopoietic growth factors (HGFs) share a number of properties, including redundancy, pleiotropy, autocrine and paracrine effects, receptor subunit oligomerisation and similar signal transduction mechanisms, yet each one has a unique spectrum of haematopoietic activity. Ongoing studies with knockout mice have discovered previously unrecognised physiological roles for HGFs, linking haematopoiesis to innate immunity, pulmonary physiology and bone metabolism. The regulation of stem cells by HGFs within niches of the bone marrow microenvironment is now well recognised and similar mechanisms appear to exist in the regulation of other stem cell compartments. Alternative signalling strategies, other than tyrosine kinase activation and phosphotyrosine cascades, may account for some of the more subtle differences between HGFs. Accumulating evidence suggests that some, but not all, HGF receptors can transduce a genuine lineage-determining signal at certain points in haematopoiesis. Further studies, primarily at the receptor level, are needed to determine the mechanisms of instructive signalling, which may include phosphoserine cascades. Novel haematopoietic regulators, as well as the development of biological therapies, including growth factor antagonists and peptide mimetics, are also discussed.

Constitutively activated phosphatidylinositol 3-kinase primes platelets from patients with chronic myelogenous leukemia for thrombopoietin-induced aggregation

In this study, we examined the effect of thrombopoietin (TPO) on the aggregation of platelets from 40 patients with myeloproliferative disorders (MPDs), including 17 patients with chronic myelogenous leukemia in the chronic phase (CML-CP), 10 with polycythemia vera, 10 with essential thrombocythemia, and three with myelofibrosis. TPO by itself dose-dependently induced the aggregation of platelets from patients with CML-CP but not from those with other MPDs or with CML-CP in cytogenetical complete remission. The expression of CD63 in CML-CP platelets was induced by TPO treatment. Phosphatidylinositol 3-kinase (PI3-kinase) was constitutively activated in CML-CP platelets. Pretreatment with PI3-kinase inhibitors (wortmannin and LY294002) dose-dependently inhibited TPO-induced aggregation of CML-CP platelets. The Abl kinase inhibitor imatinib mesylate and the Jak inhibitor AG490 suppressed TPO-induced aggregation of CML-CP platelets. Pretreatment with imatinib mesylate, but not with AG490, inhibited the activity of PI3-kinase in CML-CP platelets. In addition, tyrosine phosphorylation of Jak2 was undetected in CML-CP platelets before TPO treatment. These findings indicate that the constitutive activation of PI3-kinase primes CML-CP platelets for the aggregation induced by TPO, and that Bcr-Abl, but not Jak family protein tyrosine kinases, are involved in the constitutive activation of PI3-kinase in CML-CP platelets.

Megakaryocyte growth and development factor is a potent growth factor for primitive hematopoietic progenitors in the human fetus

Megakaryocyte growth and development factor (MGDF), or thrombopoietin, has received considerable attention as a therapeutic agent for treating thrombocytopenia or for its use in the ex vivo culture of hematopoietic stem cells. MGDF is known to support the growth of a broad spectrum of hematopoietic precursors obtained from adult or neonatal tissues, but its effects on the growth of fetal progenitors and stem cells has not been studied. Human CD38(+)CD34(2+) progenitors and CD38(-)CD34(2+) cells, a population that contains stem cells, were isolated from midgestation liver and grown under defined conditions with MGDF and various cytokines known to support the growth of primitive hematopoietic precursors. In clonal assays of colony-forming cells (CFCs), MGDF supported the growth of 15-25% of candidate stem cells when combined with granulocyte colony-stimulating factor, granulocyte-macrophage colony-stimulating factor (GM-CSF), flk-2/flt3 ligand, or stem cell factor. MGDF was observed to strongly support the early stages of hematopoiesis and expansion of high proliferative potential CFCs. More mature progenitors were expanded nearly 78-fold in 1 wk of culture with MGDF+SCF+GM-CSF. MGDF alone was also found to support the short-term (2 d) survival of CD38(-)CD34(2+) high proliferative potential CFCs. The effects of MGDF were more modest on CD38(+)CD34(2+) progenitors with only additive increases in colony formation being observed. These findings suggest that MGDF administration in fetuses and neonates may strongly affect the growth and mobilization of primitive hematopoietic progenitors and that MGDF may find use in the ex vivo growth and expansion of fetal stem cells.

Analysis of remobilization success in patients undergoing autologous stem cell transplants who fail an initial mobilization: risk factors, cytokine use and cost

Inadequate stem cell mobilization is seen in approximately 25% of patients undergoing autotransplantation for hematologic malignancies. Remobilization strategies include chemotherapy/cytokine combinations or high-dose cytokines alone or in combination. From 1/1997 to 7/2002, we remobilized 86 patients who failed an initial mobilization (median total CD34=0.72 x 10(6)/kg) in sequential cohorts using high-dose G-CSF (32 microg/kg/day) or G-CSF(10 microg/kg/day)+GM-CSF (5 microg/kg/day). No difference in CD34/kg yields were seen (G-CSF alone: 2.2 x 10(6) and G-CSF+GM-CSF 1.6 x 10(6)) in the median 3 aphereses performed (P=0.333). Of the 86, 23 (27%) failed the second mobilization; 14 were remobilized again (yield=1.5 x 10(6) CD34/kg; three aphereses). Of the 86, 93% went to transplant: three progressed, and three had inadequate stem cells. Significant risk factors for a failed remobilization were: number of stem-cell-damaging regimens (P=0.015), time between last chemotherapy and first mobilization (P=0.028), and higher WBC at initiation of first mobilization (P=0.04). High-dose G-CSF (32 microg/kg/day) was more costly @ USD $9,016, vs $5,907 for the G-CSF+GM-CSF combination (P<0.001). Most patients failing an initial mobilization benefit from a cytokine only remobilization. Lower cost G-CSF+GM-CSF is as effective as high-dose G-CSF.

Neonatal transfusion practice

Many previously widely accepted neonatal transfusion practices are changing as neonatologists become more aware of the risks to their patients of multiple blood product transfusions. Recent literature and research on neonatal transfusion practice are here reviewed, and practical guidelines and trigger thresholds for blood products commonly used in neonatal medicine are proposed.

Leukemic cells and the cytokine patchwork

BACKGROUND

In leukemia, the clonal population is characterized by a hierarchical organization. Although the majority of the leukemic population is generated after post-determinic divisions, a subset of cells retain undifferentiated "blast" morphology. In addition, leukemic cells often have numerical or structural chromosomal abnormalities, aberrant gene expression patterns, and abnormal cell surface marker profiles. Despite these differences when compared to normal bone marrow and blood cells, leukemic cell survival and proliferation, just like that of normal progenitor cells, is influenced by hematopoietic growth factors. A major issue is whether differential regulation of normal and leukemic hematopoietic cells by cytokines can be exploited in antileukemic treatment or, in contrast, whether in vivo cytokine therapy may even be harmful to the patients.

PROCEDURE

Here we review the results of recent experimental and clinical observations that investigated the influence of cytokines on leukemic cell growth and differentiation in vitro and in vivo.

RESULTS

The majority of studies indicate that hematopoietic growth factors are involved in the regulation of proliferation and terminal differentiation of leukemic blast cells. Genetic aberrations involving cytokines or their receptors may contribute to leukemogenesis. Abundant interactions, cross-lineage stimulation, and aberrant response patterns seem to transform the complex cytokine network regulation of normal hematopoiesis into an even more interlaced "patchwork" that controls leukemic hematopoiesis.

CONCLUSIONS

Since hematopoietic growth factors are present in high serum concentrations in patients with acute leukemia and myelodysplastic syndromes, consequences of possible interactions should be kept in mind even when well-defined human recombinant factors in single application are to be involved in antileukemic protocols.

Role of apoptotic processes in platelet biogenesis

Platelets are anucleate cells that fragment from mature megakaryocytes and play an essential role in thrombosis and hemostasis. Platelets are among the first cell types to be recruited to an injured blood vessel, assisting in endothelial repair. Platelet hyperactivation contributes to the development of atherosclerosis, myocardial infarction, and ischemia of peripheral limbs. A fall in platelet counts, due to a variety of conditions, including disseminated intravascular coagulation, chemotherapy or genetic disorders, may lead, in most severe cases, to death from hemorrhage. This review focuses on the late stages of megakaryocyte differentiation and platelet fragmentation, including associated cytoskeletal changes, and on the importance of apoptotic events for these processes. Studies point to a unique biological system in which programmed cell death may be linked with biogenesis of new cells.

Chemokine-mediated interaction of hematopoietic progenitors with the bone marrow vascular niche is required for thrombopoiesis

The molecular pathways involved in the differentiation of hematopoietic progenitors are unknown. Here we report that chemokine-mediated interactions of megakaryocyte progenitors with sinusoidal bone marrow endothelial cells (BMECs) promote thrombopoietin (TPO)-independent platelet production. Megakaryocyte-active cytokines, including interleukin-6 (IL-6) and IL-11, did not induce platelet production in thrombocytopenic, TPO-deficient (Thpo(-/-)) or TPO receptor-deficient (Mpl(-/-)) mice. In contrast, megakaryocyte-active chemokines, including stromal-derived factor-1 (SDF-1) and fibroblast growth factor-4 (FGF-4), restored thrombopoiesis in Thpo(-/-) and Mpl(-/-) mice. FGF-4 and SDF-1 enhanced vascular cell adhesion molecule-1 (VCAM-1)- and very late antigen-4 (VLA-4)-mediated localization of CXCR4(+) megakaryocyte progenitors to the vascular niche, promoting survival, maturation and platelet release. Disruption of the vascular niche or interference with megakaryocyte motility inhibited thrombopoiesis under physiological conditions and after myelosuppression. SDF-1 and FGF-4 diminished thrombocytopenia after myelosuppression. These data suggest that TPO supports progenitor cell expansion, whereas chemokine-mediated interaction of progenitors with the bone marrow vascular niche allows the progenitors to relocate to a microenvironment that is permissive and instructive for megakaryocyte maturation and thrombopoiesis. Progenitor-active chemokines offer a new strategy to restore hematopoiesis in a clinical setting.

Sugar coating extends half-lives and improves effectiveness of cytokine hormones

Recombinant human erythropoietin (rhEPO) is an effective and widely used therapeutic agent that is produced by bioengineering. Modification of the rhEPO protein by glycoengineering increased its already abundant N-glycosylation, which enhances its erythropoietic activity in vivo by decreasing its metabolic clearance. Elliott et al. recently reported increased in vivo activities of thrombopoietin (Mpl ligand) and leptin following carbohydrate addition to both, which suggests that such glycoengineering could be applied to a variety of hormones, cytokines and growth factors.

Pathogenesis, classification, and treatment of myelodysplastic syndromes (MDS)

Myelodysplastic syndromes (MDS) comprise a heterogeneous group of clonal myeloid disorders characterized by morphologic dysplasia in one or more cell lineages. Dysplasia in MDS is associated with insufficient production of blood cells and consecutive cytopenia(s). The natural course and prognosis of MDS vary among patients and depend on genetic defects that occur during clonal evolution. In a significant group of patients (roughly 30%) progression to secondary leukemia is observed. These patients appear to have a grave prognosis. The treatment of patients with MDS has to be adjusted to the individual situation and age in each case. In many patients, control of blast cell production by palliative cytoreduction, continuous support with red blood cells, as well as other supportive measures, seem appropriate. In other patients, however, curative therapy (chemotherapy, stem cell transplantation) should be considered. The final decision to offer curative therapy must be based on many different factors including age and the overall situation of the patient. Recently established scoring systems aimed at predicting survival and evolution of leukemia in MDS may be helpful in this regard.