Consumption of larger platelets with decrease in adenine nucleotide content in thrombosis, disseminated intravascular coagulation, and postoperative state

Thrombomodulin alfa prevents the decrease in platelet aggregation in rat models of disseminated intravascular coagulation

INTRODUCTION

Disseminated intravascular coagulation (DIC), a deadly complication characterized by uncontrolled hypercoagulation, causes a decrease in the platelet count and impairs platelet aggregation. Thrombomodulin (TM) alfa, a recombinant human soluble TM, reduces hypercoagulation in DIC patients. However, the effects of TM alfa on impaired platelet aggregation remain to be determined. In this study, we aim to investigate the effects of TM alfa on platelet aggregation using lipopolysaccharide (LPS)-induced and tissue factor (TF)-induced DIC rat models.

MATERIALS AND METHODS

Sprague-Dawley rats were administered TF or LPS intravenously, with or without TM alfa before the injection. Six hours after LPS injection or 1 h after TF infusion, blood samples were obtained, and platelet-rich plasma was prepared. Collagen or adenosine diphosphate-induced platelet aggregation was measured using an aggregometer. In the other experiments, platelets were transfused 1 h after the TF infusion. Five minutes after transfusion, collagen-induced platelet aggregation was also measured.

RESULTS

The amplitude of platelet aggregation in platelet-rich plasma was decreased in LPS- and TF-treated rats. TM alfa inhibited the decrease in platelet aggregation in a dose-dependent manner. The washed platelet aggregation amplitude was not decreased in TF-treated rats. Suspension of normal platelets in plasma obtained from TF-treated rats reduced platelet aggregation. Platelet transfusion for TF-treated rats increased the platelet count but was unable to improve platelet aggregation.

CONCLUSIONS

TM alfa attenuated impairment of platelet aggregation in LPS- and TF-induced DIC rat models. The changes in plasma composition played a role in the decrease of platelet aggregation in TF-treated rats.

Platelet and other tests followed sequentially for 14 days after operation

Nineteen patients were studied twice before and sequentially from 1 h to 14 days after operations lasting about 1 h. Eighteen tests were carried out, ideally on all the nine occasions blood collections were planned. Only significant changes are summarized. Immediately after the operation the plasma PF4 and beta TG were raised in parallel suggesting some platelet 'release' had occurred. At this time platelet aggregation to ADP and collagen had decreased by 57% to 64% and the plasma cyclic AMP had doubled. Next day these abnormalities had returned towards normal. By day 2 the fibrinogen and the heparin neutralizing activity were maximal; they returned towards normal by day 14. On day 14, when presumably all platelets present at operation had been removed the new platelets were 53% more numerous and 9.5% smaller; they contained 23% less PF4 and 42% less serotonin and 5-HT uptake was decreased, but the total amount of 5-HT and PF4 in the circulation probably remained constant. In summary these operations transitorily upset platelet function for a few hours and the platelets formed postoperatively were abnormal.

Changes in platelet ATP secretion and aggregation during pregnancy and in preeclampsia

BACKGROUND

Platelet secretion plays an important role in the aggregation of platelets. However, the quantitative relationship between platelet aggregation and secretion of ATP during pregnancy and in pre-eclampsia has yet to be clarified. This study is designed to determine whether platelet count, volume, aggregation, and the amount of secreted ATP change in healthy, nonpregnant women, nonpreeclamptic pregnant women, and preeclamptic pregnant women and whether beta-thromboglobulin (BTG) and platelet factor 4 (PF-4) concentrations alter in nonpreeclamptic and pre-eclamptic women.

METHODS

Peripheral blood was collected from 114 women. Nonpreeclamptic pregnant women were divided into four groups (gestational weeks 10, 20, 30, and 35). Platelet aggregation and ATP secretion were investigated with the use of a lumi-aggregometer. BTG and PF-4 concentrations in peripheral blood were determined in 12 pregnant and 11 preeclamptic women.

RESULTS

The amount of secreted ATP upon induction by 5 microM ADP increased significantly (P < 0.05-0.01) with gestational age. On the other hand, the amount of secreted ATP induced by 5 microg/mL collagen reached the maximal value from gestational weeks 20 to 35 in nonpreeclamptic women. Significantly more platelet aggregation was induced by the ADP and collagen in nonpreeclamptic women in gestational weeks 20 and 30 than in the gestational weeks 10 or 35 (P < 0.05-0.005). The amount of secreted ATP and platelet count were significantly lower (P < 0.05) in preeclampsia than in normal pregnancy. The BTG and PF-4 concentrations were significantly higher (P < 0.05) in preeclampsia than in normal pregnancy.

CONCLUSIONS

The sensitivity of platelets for ATP secretion may intensify with progression of pregnancy. In normal pregnancy, around gestational week 35, the platelets may exhibit weaker ability to aggregate but maintain the capacity to secrete ATP. In preeclampsia, secreted ATP decreased because platelets may be stimulated to undergo a partial secretion.

Increased but highly dispersed levels of plasma glycocalicin in patients with disseminated intravascular coagulation

Thrombocytopenia is one of the most common laboratory manifestations of disseminated intravascular coagulation (DIC). To investigate whether thrombocytopenia in DIC is indeed due to platelet consumption, we measured the plasma levels of glycocalicin, a proteolytic fragment of the platelet membrane glycoprotein (GP) Ib alpha, a component of the GPIb/IX complex, in patients with solid tumors either with DIC(n=18) or without DIC (n=18). Patients with DIC had significantly elevated levels of glycocalicin(2.53 +/- 1.59 mg/1;n=18,p<0.05) compared to those without DIC (1.50 +/- 0.41 mg/1;n=18), indicating enhanced platelet consumption, or destruction, in patients with DIC. However, glycocalicin concentrations had a wide range (0.18-5.74 mg/1), and 3 DIC patients had levels lower than the normal lower limit. These findings suggest that, in patients with DIC, thrombocytopenia is not always due to increased platelet consumption, but it may be due to decreased production of platelets. Determination of plasma glycocalicin concentrations is an easy way to identify thrombocytopenia, due to bone marrow insufficiency in these patients.

Platelet activation in major surgical stress: influence of combined epidural and general anaesthesia

Platelets are activated in surgery releasing vasoactive substances such as serotonin and thromboxane. Platelets become temporarily hypoaggregable during surgery followed by a postoperative hyperaggregability. Local anaesthetics are known to inhibit platelet function but earlier reports are conflicting. In order to study the impact of the combined use of general and regional anaesthesia on platelet function during major surgery 16 otherwise healthy patients were randomised to either general anaesthesia (GA) (n = 8) or GA combined with epidural anaesthesia (GA+EPI) (n = 8) for elective upper abdominal surgery. Cyclic 3',5' adenosine monophosphate, plasma glucose, plasma cortisol and the rate pressure product (RPP) were markers of the stress response. ADP-induced platelet aggregation and the release products beta-thromboglobulin, serotonin and thromboxane 2 were measured in plasma before and during as well as for 3 days after surgery. A marked stress response was noted in both groups and epidural anaesthesia (EPI) only reduced the rate pressure product (RPP). Platelet aggregation was reduced during surgery, a little more so in the GA+EPI group. Postoperatively both groups showed significant hyperaggregability. The release products were not significantly influenced by regional anaesthesia. In conclusion epidural as combined with general anaesthesia affects platelet responses to major abdominal surgery only to a minor extent, although it may attenuate the haemodynamic response.

Characterization of platelet hypofunctions in rats under SART stress (repeated cold stress)

Platelet hypoaggregability has been reported in rats exposed to a chronic form of environmental stress induced by long-lasting fluctuation in air temperature, known as SART (specific alternation of rhythm in temperature) stress. This study examines functional characteristics of platelets from stressed rats in more detail. Exposure to stress reduced aggregation and ATP release in platelets stimulated with collagen, as determined using platelet-rich plasma (PRP). The resting levels of ATP but not ADP in platelets from stressed rats were lower than those from unstressed ones. Collagen-induced release and resting level of serotonin also decreased in platelets from stressed rats. In contrast, stress failed to cause hypoaggregability of washed platelets. Circulating platelet aggregates were detected in stressed rats. From these data, SART stress appears to cause intravascular activation of platelets in spite of in vitro hypofunctions. Alteration in plasma milieu may be associated with stress-induced platelet hypofunctions in PRP.

Adhesion efficiency, platelet density and size

We have previously shown that adhesion of human platelets to immobilized collagen is extremely rapid, with initial rates approaching 3% of single particles adhering per 10 ms. Here, we have investigated adhesion efficiency to collagen as a function of platelet density. Platelet subpopulations: low-density (1.040 < d < 1.065 g/ml), intermediate-density (1.065 < d < 1.070 g/ml) and high-density (1.070 < d < 1.080 g/ml) were separated by Percoll density gradient centrifugation. They constituted 24%, 47% and 29% of the total platelet population and had mean volumes of 6.01, 7.37 and 8.21 fl, respectively. Using a continuous-flow, micro-affinity column, we found that the most dense (large) platelets exhibited initial rate of adhesion 4 times greater than the least dense (small) platelets. They were also less sensitive to inhibition by prostacyclin (PGI2). In contrast, there was no significant difference in aggregation induced by high doses of ADP and collagen, indicating that the most dense platelets were not preferentially involved in aggregation induced by high doses of agonists. These results suggest that normal circulating platelets can be distinctly heterogeneous in their ability to adhere to collagen under arterial-flow conditions. The greater efficiency of high-density platelets may be related to increased content of the glycoprotein Ia/IIa (GPIa/IIa) complex.

Platelet hypoaggregability in rats exposed to SART stress (repeated cold stress)

A prolongation of bleeding time accompanied by thrombocytopenia and abnormalities in coagulation-fibrinolysis systems has been observed in laboratory animals exposed to a chronic form of environmental stress induced by severe fluctuations of air temperature, known as SART (specific alternation of rhythm in temperature) stress. In order to clarify the hemostatic profile under SART stress in more detail, the present study examined platelet aggregability in vitro as well as in vivo in stressed rats. During exposure to stress, thrombocytopenia developed from day 5, and remained up to at least day 14. In vitro aggregation of platelets stimulated by ADP or collagen was markedly decreased in stressed rats, compared with unstressed rats. Furthermore, stressed rats exhibited in vivo hypoaggregability of platelets, as estimated by the magnitude of the drop in circulating platelet counts following intravenous injection of ADP and collagen. Protein and cholesterol content in platelets remained constant after stress exposure. These results indicate that SART-stressed rats exhibit platelet dysfunctions in addition to thrombocytopenia. Considering the previous findings, the hemostatic system under SART stress appears to show a general tendency toward hemorrhage.

Disseminated Intravascular Coagulation: Pathogenesis and Management

Disseminated intravascular coagulation (DIC) is a clini-copathological syndrome secondary to an underlying disease. Characteristic laboratory abnormalities of DIC should suggest, much like the recognition of fever, anemia, or congestive heart failure, that an inciting disease process must be searched for. The clinical and laboratory consequences of DIC can be ascribed to the unregulated and unbalanced formation of thrombin, the main clot-forming enzyme, and plasmin, the main clot-lysing enzyme. If too much plasmin is formed in relation to thrombin, a hemorrhagic state, which appears in 60 to 75% of patients with deep vein thrombosis, will occur. Alternatively, if too much thrombin is formed in relation to the degree of secondary fibrinolysis, a thrombotic condition, which appears in 25 to 40% of patients with DIC, will become manifest. The diagnosis of DIC is dependent on the presence of an appropriate clinical situation with concurrent laboratory evidence of thrombin and plasmin formation. Thrombin formation, plasmin formation, or both, can be assessed by detection of fibrin monomer, fibrin/fibrinogen degradation products, and D-dimer or E fragment, respectively. Treatment of DIC should initially be addressed to treatment of the primary, underlying condition inciting the disorder. If treatment for DIC is specifically needed, blood product replacement is the first order of therapy. This replacement should be tailored to each patient's specific needs (i.e., platelets, fibrinogen, or plasma proteins). Heparin has a definite but limited use in conditions associated with acral cyanosis and dermal ischemia. Other specific therapies for DIC may be of use in individualized situations.

Platelet volume, aggregation, and adenosine triphosphate release in cerebral thrombosis

We compared whole blood platelet aggregation, adenosine triphosphate release, platelet count, platelet crit (percentage volume of platelets), and mean platelet volume during the acute, subacute, and chronic periods of cerebral thrombosis in 22 patients with value in 29 controls. During the acute and subacute periods, platelet aggregation, platelet count, platelet crit, and mean platelet volume were significantly less in the patients than in the controls (p less than 0.05-0.01) while the adenosine triphosphate release rate per volume of platelets was significantly greater (p less than 0.05). During the acute period, infarct size showed a significant positive correlation with platelet aggregation (r = 0.59, p less than 0.01) and adenosine triphosphate release rate (r = 0.70, p less than 0.001) but a negative correlation with platelet count (r = -0.44, p less than 0.05). Our results suggest that platelet aggregation is reduced during the acute period due to the consumption of platelets during thrombogenesis but that the remaining individual platelets are hyperactive. Platelet consumption during the acute period increases with infarct size. During the chronic period, platelet crit and mean platelet volume were significantly less in the patients than in the controls (p less than 0.01) while the adenosine triphosphate release rate was significantly greater (p less than 0.01), suggesting sustained platelet consumption and chronically enhanced secretion of individual platelets.

Selective decrease in platelet dense granule adenine nucleotides during recovery from acute experimental thrombocytopenia and ensuing thrombocytosis in baboons

Serial measurements of platelet volume, platelet content of adenine nucleotides, beta-thromboglobulin (beta-TG), platelet factor 4 (PF4) and ex vivo platelet aggregation were made in baboons under basal, steady-state conditions of normal platelet production, and during recovery from acute thrombocytopenia induced by the exposure of flowing blood to spherical glass microbeads. The mean basal platelet count of 509 +/- 107 X 10(9)/l (+/- 1 SD; n = 4) fell acutely to 36.8 +/- 12.6 X 10(9)/l after the insertion of glass bead columns and blood filters, placed distally, for 60 min into surgically implanted arteriovenous-shunts in heparinized baboons. After the irreversible removal of up to 90% of the baseline circulating platelet population, recovery from thrombocytopenia was characterized by a constant rate of increase in circulating platelet counts (115 +/- 11 X 10(9)/l/d) and a rebound thrombocytosis to 1.5 times the basal platelet count after 7 d. Steadystate thrombocytopoiesis was achieved by 3-4 weeks after the onset of thrombocytopenia. Platelet dense granule ADP and ATP decreased significantly from 3.89 +/- 0.20 and 2.33 +/- 0.25 mumol/10(11) platelets respectively at baseline to 2.17 +/- 0.37 and 1.68 +/- 0.37 mumol/10(11) platelets respectively after 7 d (P less than 0.001 in both cases) and normalization was achieved only after 4 weeks. By contrast, the mean platelet volume and platelet content of beta-TG and PF4 did not change significantly throughout the course of study (P greater than 0.1 in both cases). Platelet function, assessed by platelet aggregation ex vivo, demonstrated that platelet function was not impaired despite the significant decrease in dense granule ADP. We conclude that a selective, temporal reduction in platelet dense granule adenine nucleotides reflects changes in the thrombocytopoietic control mechanism secondary to induction of acute thrombocytopenia.

Platelet aggregability and platelet volume in the postoperative course: problems in the platelet aggregation test derived from the measurement of platelet volume

Platelet count, aggregability and volume in the postoperative course of 20 patients were examined. Platelet count was decreased on the 1st postoperative d, and increased on the 7th and 14th d compared with the preoperative value. The maximal aggregation rate of platelets induced by ADP was decreased on the 3rd postoperative d, and then recovered to the preoperative level. In contrast, platelet volume was only slightly increased on the 3rd postoperative d. In this study, there was no correlation between platelet aggregability and platelet volume in PRP. We have proposed one parameter, 'platelet concentration ratio' (platelet concentration in PRP/platelet concentration in whole blood). In the postoperative course, this concentration ratio changed depending on platelet volume, and possibly on other conditions of blood such as hematocrit, viscosity and specific gravity. The concentration ratio influenced the subpopulations of platelets in PRP. Platelet aggregation tests may be performed using PRP in which platelet subpopulations differ from those in whole blood, especially in the postoperative state.

Effects of nifedipine on platelet function

Effects of nifedipine on platelet aggregation were studied both in vitro and in vivo. From in vitro experiments, nifedipine inhibited platelet aggregation in a dose-dependent manner. The inhibition by nifedipine (final concentration 10 micrograms/ml) on epinephrine-induced and collagen-induced platelet aggregation was more than 90%, greater than that on adenosine diphosphate (ADP)-induced aggregation. The consumption ratio of small platelets (less than or equal to 6.4 fL) was higher than that of large platelets (greater than 6.4 fL), suggesting that nifedipine inhibits the aggregation of large platelets more effectively. Changes in the effects of nifedipine on platelet aggregation associated with exercise were also studied in six healthy volunteers. While platelet aggregability increased after exercise without administration of nifedipine, it was inhibited 90 minutes after the drug's administration (10 mg). The inhibition of collagen-induced and ADP-induced (2 microM) aggregation by nifedipine was particularly significant.

Platelet adenine nucleotide levels in patients with Dacron vascular prostheses

Platelets adenine nucleotide levels were determined in 11 patients with Dacron bifemoral aortic prostheses using high performance liquid chromatography. Total platelet and dense granule adenine nucleotide levels were measured in neutralized perchloric acid extracts prepared from gel-filtered platelet suspensions and from platelet supernatants following thrombin-induced release of granule constituents respectively. Dense granule adenine nucleotide levels were significantly decreased in the patient group compared with age and sex-matched controls (p less than 0.01), whereas no differences in cytoplasmic adenine nucleotide levels were observed (p greater than 0.2). Platelet survival measurements were made on 3 patients; when grouped with control subjects, a positive correlation was observed between platelet survival and platelet dense granule ADP (r = 0.96; p less than 0.01). These results suggest that platelet dense granule adenine nucleotide content may be a clinically significant indicator of vascular graft thrombogenesis.

Evidence against enhanced platelet activity in sickle cell anaemia

Although numerous studies have provided indirect evidence for enhanced platelet activity in sickle cell anaemia, little attention has been directed to examination of platelet alpha and dense granule release in the sickling disorders. We simultaneously measured by radioimmunoassay plasma levels of the alpha granule constituents beta-thromboglobulin (beta-TG) and platelet factor 4 (PF4) in 43 children with sickle cell anaemia in steady state and 24 patients during severe vaso-occlusive crisis. beta-TG levels during steady state (50 +/- 3.6 ng/ml, mean +/- SEM) were greater (P less than 0.001) than in normal controls (36 +/- 1.6), but there was no additional significant rise during crisis (55 +/- 5.9). PF4 levels were similar (P = 0.12) in both steady state (10 +/- 1.2 ng/ml) and crisis (9.3 +/- 2.3) to those of normal controls (6.0 +/- 0.8). The similarity of beta-TG/PF4 ratios in normal and sickle cell anaemia patients as well as the positive correlation (P less than 0.05) between platelet count and beta-TG and PF4 suggested that an artefactual in vitro platelet activation was responsible for some of the observed increased beta-TG and PF4 levels. Further evidence against enhanced platelet activity in these sickle cell patients included normal intraplatelet content of the dense granule constituent 5-HT and a normal ATP/ADP ratio. From this data we conclude that platelet activation in children with sickle cell anaemia appears minimal.

Platelet alpha granule depletion: findings in patients with prosthetic heart valves and following cardiopulmonary bypass surgery

The alpha granule content of platelets, as indicated by the amount of beta-thromboglobulin (beta-TG) in lysed platelet rich plasma was measured to determine whether platelet stimulation resulted in a circulating population of granule-depleted platelets. In 101 normal controls, with a mean platelet count of 242.6 +/- 6.5 X 10(9)/1, the mean platelet beta-TG content was 55.9 +/- 1.2 ng/10(6) platelets. There was a significant reduction in both these parameters (mean platelet count 195.5 +/- 5.8 X 10(9)/1 (P less than 0.001), mean platelet beta-TG 50.0 +/- 1.2 ng/10(6) platelets (P less than 0.01)) in 74 patients with prosthetic cardiac valves. In 24 patients, cardiopulmonary bypass surgery caused a much greater reduction in median platelet count from 210 X 10(9)/1 to 11.1 X 10(9)/1, two hours after surgery (P less than 0.001) but no overall change in platelet beta-TG. However, five patients who experienced diffuse haemorrhage in the postoperative period had a lower median platelet beta-TG (35.5 ng/10(6) platelets) than the other 19 patients (51.0 ng/10(6) platelets) (P less than 0.05).

In vivo platelet activation with in vitro hyperaggregability to arachidonic acid in renal allograft recipients

Renal allograft recipients were investigated to determine the extent and possible nature of in vivo platelet activation. In 92 allografted patients stable for more than 4 months' duration, intraplatelet serotonin in circulating platelets was depleted significantly. In a further 16 patients studied serially for 12 to 16 weeks following transplantation, intraplatelet serotonin fell abruptly within 4 days from transplantation to very low levels, and remained thus for 10 weeks, rising toward normal at about 12 weeks. Although some patients showed abrupt falls in intraplatelet serotonin coincident with acute rejection episodes, there was no difference in intraplatelet serotonin in seven patients whose grafts functioned well immediately and remained stable, and seven in whom repeated rejection led to graft loss within 3 months. Thus, these tests of platelet function do not permit diagnosis of rejection or prediction of graft outcome. Plasma platelet factor 4 (PF4) concentrations, in contrast, were normal in most patients during the first 6 weeks after grafting, then rose and remained abnormal up to 13 years following the allograft in the long-term stable graft recipients. This discrepancy suggests a different mode of platelet activation in the first few weeks after grafting from subsequent months. Despite universal depletion of intraplatelet amines and alpha-granule contents only four out of 14 early allograft recipients had an abnormal bleeding time, and platelet aggregation thresholds with adenosine-5'-diphosphate and collagen were not different from controls. However, thresholds for platelet aggregation with arachidonic acid were reduced significantly (P less than 0.01) and thromboxane B2 generation was increased in vitro. There was no correlation between depletion of intraplatelet serotonin and circulating platelet-agglutinating material, but nine of 17 biopsy specimens from rejecting allografts taken during the first 3 months showed extensive glomerular localization of platelet membrane antigens and PF4.

Activation of platelets in cancer, especially with reference to genesis of disseminated intravascular coagulation

Seventy-five cancer patients were evaluated on a scale of coagulation abnormalities related to DIC, one point given for each of the following criteria fulfilled and the score (0 to 4) being used. 1. Platelet count less than 150 x 10(3)/mu 1. 2. PT prolonged more than 1 sec over control or APTT prolonged more than 10 sec over control. 3. Fibrinogen less than 250 mg/dl (mean fibrinogen value of the cancer patients minus 1SD). 4. FDP greater than or equal to 20 micrograms/ml. The patients were distributed with 27% for score 0, 38% for 1, 20% for 2, 7% for 3 and 8% for 4. Platelet mode volume in score 4 was smaller than that of the other groups. Platelet aggregation by epinephrine was decreased in score 3 and 4 (P less than 0.01), while it was increased in score 0 (P less than 0.05). ADP-induced aggregation was increased in score 0 and 1 (P less than 0.01 - 0.05). The mean value of beta-thromboglobulin in cancer patients (44 +/- 24 ng/ml) was significantly higher than that of control (22 +/- 13 ng/ml) (P less than 0.01). These results suggest the existence of hyperfunction of platelets in cancer patients and possibility of a triggering mechanism of such activated platelets in the genesis of DIC in cancer.

Vitamin E and total parenteral nutrition

Vitamin E and essential fatty acid status were examined in two groups of patients, one receiving fat-free total parenteral nutrition (TPN) with intravenous all-rac-alpha-tocopherol for vitamin E deficiency and the other receiving routine intravenous fat (Intralipid, 10%) emulsions with TPN to supply both fatty acid and vitamin E requirements. Initial evaluation of both groups revealed a 50% incidence of vitamin E deficiency, platelet hyperaggregation, or in vitro H2O2-induced hemolysis. Only platelet hyperaggregation correlated significantly with vitamin E deficiency. Supplementation with all-rac-alpha-tocopherol corrected platelet hyperaggregation and H2O2-induced hemolysis; daily dosage requirements of 25-50 mg (fat-free TPN) or more (with intravenous fat) suggest increased vitamin E requirements during TPN. Intravenous fat emulsion did not correct the platelet and red blood cell abnormalities, a result of either increased vitamin E requirements or low alpha-tocopherol-equivalent content of the emulsion. Essential fatty acid deficiency (EFAD) was observed in seven patients with an associated platelet hyperaggregation independent of vitamin E deficiency. Prolonged TPN for enterocutaneous fistulae in three patients was associated with persistent EFAD and platelet hyperaggregation despite up to 2.0 liters of intravenous fat emulsion weekly.