1
|
Lundy KA, Rabatin A, Davidson ER, Li J, Snider MJ, Kraut EH. Experience With Pre-procedural Hemostatic Medications versus Platelet Transfusion in Patients With Platelet Storage Pool Deficiency. J Pharm Pract 2023; 36:1412-1418. [PMID: 35976764 DOI: 10.1177/08971900221119167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BackgroundStorage pool deficiency (SPD) is a rare bleeding disorder characterized by reduction in the number of delta granules within platelets, interfering with hemostasis. Current literature lacks well-designed studies from which to draw concrete conclusions regarding pre-procedural management of bleeding complications. Objective: The purpose of this study is to describe bleeding and safety outcomes of SPD patients receiving either pre-procedural platelet transfusions or platelet-sparing regimens. Methods: An exploratory retrospective cohort study was conducted among SPD patients, comparing major bleeding events between those who received platelet transfusion and those who received desmopressin, tranexamic acid, and/or aminocaproic acid within 24 hours prior to procedure. Results: Rates of major bleeding were not found to be higher among patients who received a platelet-sparing regimen [platelet-sparing: 2/25 (8%); platelet transfusion: 2/29 (6.9%); P = .99]. Incidence of non-major bleeding was higher in the platelet transfusion group, but this was not statistically significant [platelet-sparing: 0/25 (0%); platelet transfusion: 3/29 (10.3%); P = .24]. Treatment-related adverse effects were observed following 8 of 54 procedures (14.8%). Conclusion: Use of a platelet-sparing regimen was not associated with a significantly higher incidence of major or non-major bleeding events. Future prospective trials are recommended to compare outcomes between therapies.
Collapse
Affiliation(s)
- Katharine A Lundy
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Abigail Rabatin
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Erica R Davidson
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Junan Li
- The Ohio State University College of Pharmacy, Columbus, OH, USA
| | - Melissa J Snider
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Eric H Kraut
- Division of Hematology & Oncology, The James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| |
Collapse
|
2
|
Sidonio RF, Bryant PC, Di Paola J, Hale S, Heiman M, Horowitz GS, Humphrey C, Jaffray J, Joyner LC, Kasthuri R, Konkle BA, Kouides PA, Montgomery R, Neeves K, Randi AM, Scappe N, Tarango C, Tickle K, Trapane P, Wang M, Waters B, Flood VH. Building the foundation for a community-generated national research blueprint for inherited bleeding disorders: research priorities for mucocutaneous bleeding disorders. Expert Rev Hematol 2023; 16:39-54. [PMID: 36920856 DOI: 10.1080/17474086.2023.2171983] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Excessive or abnormal mucocutaneous bleeding (MCB) may impact all aspects of the physical and psychosocial wellbeing of those who live with it (PWMCB). The evidence base for the optimal diagnosis and management of disorders such as inherited platelet disorders, hereditary hemorrhagic telangiectasia (HHT), hypermobility spectrum disorders (HSD), Ehlers-Danlos syndromes (EDS), and von Willebrand disease (VWD) remains thin with enormous potential for targeted research. RESEARCH DESIGN AND METHODS National Hemophilia Foundation and American Thrombosis and Hemostasis Network initiated the development of a National Research Blueprint for Inherited Bleeding Disorders with extensive all-stakeholder consultations to identify the priorities of people with inherited bleeding disorders and those who care for them. They recruited multidisciplinary expert working groups (WG) to distill community-identified priorities into concrete research questions and score their feasibility, impact, and risk. RESULTS WG2 detailed 38 high priority research questions concerning the biology of MCB, VWD, inherited qualitative platelet function defects, HDS/EDS, HHT, bleeding disorder of unknown cause, novel therapeutics, and aging. CONCLUSIONS Improving our understanding of the basic biology of MCB, large cohort longitudinal natural history studies, collaboration, and creative approaches to novel therapeutics will be important in maximizing the benefit of future research for the entire MCB community.
Collapse
Affiliation(s)
- Robert F Sidonio
- Department of Pediatrics, Aflac Cancer and Blood Disorders, Atlanta, Georgia, USA.,Hemophilia of Georgia Center for Bleeding and Clotting Disorders, Atlanta, Georgia, USA
| | - Paulette C Bryant
- Pediatric Hematology Oncology, St. Jude Affiliate Clinic at Novant Health Hemby Children's Hospital, Charlotte, North Carolina, USA.,National Hemophilia Foundation, New York, New York, USA
| | - Jorge Di Paola
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA.,Hematology/Oncology Department, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Sarah Hale
- Takeda Pharmaceuticals U.S.A, Lexington, Massachusetts, USA
| | - Meadow Heiman
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | | | | | - Julie Jaffray
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lora C Joyner
- East Carolina University Hemophilia Treatment Center, Greenville, North Carolina, USA
| | - Raj Kasthuri
- Division of Hematology, UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Barbara A Konkle
- Washington Center for Bleeding Disorders, Seattle, Washington, USA
| | | | - Robert Montgomery
- Blood Center of Wisconsin, Versiti, Milwaukee, Wisconsin, USA.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Keith Neeves
- Hemophilia and Thrombosis Center, University of Colorado Denver, Denver, Colorado, USA.,Department of Bioengineering, University of Colorado Denver, Denver, Colorado, USA.,Department of Pediatrics, University of Colorado Denver, Denver, Colorado, USA.,Department of pediatrics, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Anna M Randi
- National Heart and Lung Institute, Imperial College, London, UK
| | - Nikole Scappe
- National Hemophilia Foundation, New York, New York, USA
| | - Cristina Tarango
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kelly Tickle
- Department of Pediatrics, Aflac Cancer and Blood Disorders, Atlanta, Georgia, USA.,Hemophilia of Georgia Center for Bleeding and Clotting Disorders, Atlanta, Georgia, USA.,Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Pamela Trapane
- Division of Pediatric Genetics, Department of Pediatrics, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Michael Wang
- Department of pediatrics, Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Veronica H Flood
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| |
Collapse
|
3
|
Massey G, Tyrrell L, Diab Y, Gunning WT. Medich Giant Platelet Syndrome: An Evolving Qualitative and Quantitative Platelet Disorder. Hematol Rep 2022; 14:349-357. [PMID: 36547233 PMCID: PMC9779152 DOI: 10.3390/hematolrep14040049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/26/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022] Open
Abstract
Qualitative platelet disorders remain rare and varied. We describe here 2 additional patients with giant platelets, thrombocytopenia, deficiency in alpha granules and the presence of membranous inclusions within the cytoplasm. Collectively known as Medich syndrome, we further elucidated structural and clinical features of this rare syndrome. Platelets obtained from 2 patients with macro-thrombocytopenia were evaluated by electron microscopy. Structural findings were correlated with clinical characteristics. The defining morphologic feature found in the platelets of these patients is the presence of long, tubular inclusions consisting of several layers of membrane wrapped around a core of cytoplasm. These inclusions may deform the discoid shape of the platelet. In addition, abnormal giant alpha granules are present. Clinically all patients in the current report and review of the literature had mucosal bleeding and were often misdiagnosed as having immune related thrombocytopenia. To date five cases of Medich giant platelet syndrome have been reported. The cases are unified by the ultrastructural findings of abnormal alpha granules and unusual cytoplasmic scrolls. All patients experienced mucosal bleeding, however many clinical, biologic and genetic characteristics of this rare disorder remain to be determined.
Collapse
Affiliation(s)
- Gita Massey
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Virginia Commonwealth University School of Medicine, Richmond, VA 23298, USA
| | - Laura Tyrrell
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Virginia Commonwealth University School of Medicine, Richmond, VA 23298, USA
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN 46260, USA
| | - Yaser Diab
- Division of Pediatric Hematology, Children’s National Medical Center, Washington, DC 20010, USA
| | - William T. Gunning
- Department of Pathology, University of Toledo College of Medicine and Life Sciences, Toledo, OH 43614, USA
- Correspondence: ; Tel.: +1-419-383-4918
| |
Collapse
|
4
|
Diagnosing Czech Patients with Inherited Platelet Disorders. Int J Mol Sci 2022; 23:ijms232214386. [PMID: 36430862 PMCID: PMC9695320 DOI: 10.3390/ijms232214386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/13/2022] [Accepted: 11/15/2022] [Indexed: 11/22/2022] Open
Abstract
A single-center study was conducted on 120 patients with inherited disorders of primary hemostasis followed at our hematological center. These patients presented a variety of bleeding symptoms; however, they had no definitive diagnosis. Establishing a diagnosis has consequences for the investigation of probands in families and for treatment management; therefore, we aimed to improve the diagnosis rate in these patients by implementing advanced diagnostic methods. According to the accepted international guidelines at the time of study, we investigated platelet morphology, platelet function assay, light-transmission aggregometry, and flow cytometry. Using only these methods, we were unable to make a definitive diagnosis for most of our patients. However, next-generation sequencing (NGS), which was applied in 31 patients, allowed us to establish definitive diagnoses in six cases (variants in ANKRD26, ITGA2B, and F8) and helped us to identify suspected variants (NBEAL2, F2, BLOC1S6, AP3D1, GP1BB, ANO6, CD36, and ITGB3) and new suspected variants (GFI1B, FGA, GP1BA, and ITGA2B) in 11 patients. The role of NGS in patients with suspicious bleeding symptoms is growing and it changes the diagnostic algorithm. The greatest disadvantage of NGS, aside from the cost, is the occurrence of gene variants of uncertain significance.
Collapse
|
5
|
Li J, Rong L, Wang J, Fang Y. Umbilical cord blood transplantation for MYH9-related disorders. Pediatr Blood Cancer 2022; 69:e29711. [PMID: 35441449 DOI: 10.1002/pbc.29711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/23/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Jian Li
- Department of Hematology and Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University Nanjing, Nanjing, China
| | - Liucheng Rong
- Department of Hematology and Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University Nanjing, Nanjing, China
| | - Jun Wang
- Department of Hematology and Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University Nanjing, Nanjing, China
| | - Yongjun Fang
- Department of Hematology and Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University Nanjing, Nanjing, China
| |
Collapse
|
6
|
Gomez K. Advances in the diagnosis of heritable platelet disorders. Blood Rev 2022; 56:100972. [PMID: 35595614 DOI: 10.1016/j.blre.2022.100972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/09/2022] [Accepted: 05/10/2022] [Indexed: 11/02/2022]
Abstract
The last decade has seen large increases in the number of patients registered with heritable platelet disorders in national databases of bleeding disorders. Although individually rare, collectively they are a relatively common cause of heritable bleeding. This revolution has come about through the application of high-throughput sequencing strategies and efforts to standardize diagnostic testing. There is renewed interest in established parameters such as platelet volume and utilising simple tools such as blood smears. The diagnostic yield from peripheral blood smears can be improved with new microscopy techniques that could potentially assist in determining which patients need to be referred to tertiary centres for specialist testing. A better understanding of the other clinical features that can accompany abnormalities of platelet number or function, can lead to better clinical management and prevention of serious complications. There are challenges for clinicians who need to be aware of these developments, understand the limitations of new diagnostic techniques and keep abreast of strategies for incorporation into clinical practice. This review discusses some of these approaches, the limitations that clinicians need to be aware of and techniques that may enter clinical use in the future.
Collapse
Affiliation(s)
- Keith Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK.
| |
Collapse
|
7
|
Absi HA, Stein D. Circumcision bleeding rates in patients diagnosed with delta-storage pool deficiency later in life. Pediatr Blood Cancer 2022; 69:e29622. [PMID: 35234338 DOI: 10.1002/pbc.29622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 01/21/2022] [Accepted: 02/01/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Male circumcision is a common procedure, generally performed during the newborn period. Bleeding is an uncommon but feared complication of circumcision. Few reports have evaluated circumcision bleeding rates in patients with bleeding disorders. OBJECTIVES To study circumcision bleeding rates in male subjects who were diagnosed later in life with delta-storage pool deficiency (δ-SPD). METHODS We retrospectively reviewed the medical records of male subjects (≤18 years of age) who were circumcised without hemostatic prophylaxis prior to δ-SPD diagnosis from 2000 to 2020. Bleeding rates and severity were the main outcomes evaluated. We collected demographic data, bleeding scores using a validated assessment tool, laboratory data, and platelet electron microscopy results. A descriptive analysis was performed. RESULTS Twenty-five male subjects were included. The median bleeding score at presentation was 3.5 (range: 2-9). The diagnosis was confirmed using platelet electron microscopy. A value of <2 dense granules/platelet was considered abnormal. Circumcision was performed at a median age of 2 days (range: 1 day to 4 months). None of the subjects had intraoperative or postoperative bleeding. With a bleeding rate of zero, we suggest that newborn males with a family history of δ-SPD may be safely circumcised without hemostatic prophylaxis.
Collapse
Affiliation(s)
- Hebah Al Absi
- Department of Pediatrics, University of Toledo, Toledo, Ohio, USA
| | - Dagmar Stein
- Division of Pediatric Hematology and Oncology, Russell J. Ebeid Children's hospital, Toledo, Ohio, USA
| |
Collapse
|
8
|
An Update on Pediatric Immune Thrombocytopenia (ITP): Differentiating Primary ITP, IPD, and PID. Blood 2021; 140:542-555. [PMID: 34479363 DOI: 10.1182/blood.2020006480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/20/2021] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is the most common acquired thrombocytopenia in children and is caused by both immune-mediated decreased platelet production and increased platelet destruction. In the absence of a diagnostic test, ITP must be differentiated from other thrombocytopenic disorders, including inherited platelet disorders (IPD). In addition, a diagnosis of secondary ITP due to a primary immune deficiency (PID) with immune dysregulation may not be apparent at diagnosis but can alter management and should be considered in an expanding number of clinical scenarios. The diagnostic evaluation of children with thrombocytopenia will vary based on the clinical history and laboratory features. Access to genotyping has broadened the ability to specify the etiology of thrombocytopenia, while increasing access to immunophenotyping, functional immunologic and platelet assays, and biochemical markers has allowed for more in-depth evaluation of patients. With this greater availability of testing, diagnostic algorithms in patients with thrombocytopenia have become complex. In this article, we highlight the diagnostic evaluation of thrombocytopenia in children with a focus on ITP, including consideration of underlying genetic and immune disorders, and utilize hypothetical patient cases to describe disease manifestations and strategies for treatment of pediatric ITP.
Collapse
|
9
|
Zaninetti C, Wolff M, Greinacher A. Diagnosing Inherited Platelet Disorders: Modalities and Consequences. Hamostaseologie 2021; 41:475-488. [PMID: 34391210 DOI: 10.1055/a-1515-0813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Inherited platelet disorders (IPDs) are a group of rare conditions featured by reduced circulating platelets and/or impaired platelet function causing variable bleeding tendency. Additional hematological or non hematological features, which can be congenital or acquired, distinctively mark the clinical picture of a subgroup of patients. Recognizing an IPD is challenging, and diagnostic delay or mistakes are frequent. Despite the increasing availability of next-generation sequencing, a careful phenotyping of suspected patients-concerning the general clinical features, platelet morphology, and function-is still demanded. The cornerstones of IPD diagnosis are clinical evaluation, laboratory characterization, and genetic testing. Achieving a diagnosis of IPD is desirable for several reasons, including the possibility of tailored therapeutic strategies and individual follow-up programs. However, detailed investigations can also open complex scenarios raising ethical issues in case of IPDs predisposing to hematological malignancies. This review offers an overview of IPD diagnostic workup, from the interview with the proband to the molecular confirmation of the suspected disorder. The main implications of an IPD diagnosis are also discussed.
Collapse
Affiliation(s)
- Carlo Zaninetti
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany.,Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Martina Wolff
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| |
Collapse
|
10
|
Karasneh J, Christoforou J, Walker JS, Dios PD, Lockhart PB, Patton LL. World Workshop on Oral Medicine VII: Bleeding control interventions for invasive dental procedures in patients with inherited functional platelet disorders: A systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol 2021; 133:412-431. [PMID: 34758941 DOI: 10.1016/j.oooo.2021.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVES The objective of this study was to determine bleeding control interventions (BCIs) that were reported to be effective in controlling postoperative bleeding in patients with inherited functional platelet disorders (IFPDs) undergoing invasive dental procedures. STUDY DESIGN We searched MEDLINE/PubMed, Embase, Cochrane Library (Wiley), and Scopus from 1960 through April 2020 for studies on patients with IFPD undergoing invasive dental procedures. Two reviewers conducted assessments independently. RESULTS We found a total of 620 nonduplicate published articles, of which 32 studies met our inclusion criteria. Management with BCI in patients with IFPD included in this systematic review was effective in 80.7% of treatment sessions. Local measures used intraoperatively were found to be effective. Three different protocols of BCI were noted; the most effective protocol consisted of antifibrinolytics, scaffold/matrix agents, and sutures (P < .01). An adjunct protocol consisting of a tissue sealant was also effective (P < .01). A third protocol of platelet transfusion and antifibrinolytics was ineffective in controlling postoperative bleeding in 4 of 6 dental sessions. CONCLUSIONS This systematic review supports the use of local measures intraoperatively and antifibrinolytics postoperatively. It also supports making decision regarding platelet transfusion based on the clinician's clinical judgment and medical history of the individual patient.
Collapse
Affiliation(s)
- Jumana Karasneh
- Department of Oral Medicine and Oral Surgery; School of Dentistry, Jordan University of Science and Technology, Irbid, Jordan.
| | - Janina Christoforou
- Faculty of Health and Medical Sciences, Dental School, University of Western Australia, Perth, Australia
| | - Jennifer S Walker
- Health Sciences Library, University of North Carolina at Chapel Hill, NC, USA
| | - Pedro Diz Dios
- Medical-Surgical Dentistry Research Group (OMEQUI), Health Research Institute of Santiago de Compostela (IDIS), University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Peter B Lockhart
- Department of Oral Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Lauren L Patton
- Department of Dental Ecology, School of Dentistry, University of North Carolina at Chapel Hill, NC, USA
| |
Collapse
|
11
|
Alpha-Delta Platelet Storage Pool Deficiency in a Child and Successful Treatment by Umbilical Cord Blood Transplantation: A Case Report and Literature Review. J Pediatr Hematol Oncol 2021; 43:e749-e753. [PMID: 32694497 DOI: 10.1097/mph.0000000000001883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
12
|
Nurden P, Stritt S, Favier R, Nurden AT. Inherited platelet diseases with normal platelet count: phenotypes, genotypes and diagnostic strategy. Haematologica 2021; 106:337-350. [PMID: 33147934 PMCID: PMC7849565 DOI: 10.3324/haematol.2020.248153] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 08/12/2020] [Indexed: 12/16/2022] Open
Abstract
Inherited platelet disorders resulting from platelet function defects and a normal platelet count cause a moderate or severe bleeding diathesis. Since the description of Glanzmann thrombasthenia resulting from defects of ITGA2B and ITGB3, new inherited platelet disorders have been discovered, facilitated by the use of high throughput sequencing and genomic analyses. Defects of RASGRP2 and FERMT3 responsible for severe bleeding syndromes and integrin activation have illustrated the critical role of signaling molecules. Important are mutations of P2RY12 encoding the major ADP receptor causal for an inherited platelet disorder with inheritance characteristics that depend on the variant identified. Interestingly, variants of GP6 encoding the major subunit of the collagen receptor GPVI/FcRassociate only with mild bleeding. The numbers of genes involved in dense granule defects including Hermansky-Pudlak and Chediak Higashi syndromes continue to progress and are updated. The ANO6 gene encoding a Ca2+-activated ion channel required for phospholipid scrambling is responsible for the rare Scott syndrome and decreased procoagulant activity. A novel EPHB2 defect in a familial bleeding syndrome demonstrates a role for this tyrosine kinase receptor independent of the classical model of its interaction with ephrins. Such advances highlight the large diversity of variants affecting platelet function but not their production, despite the difficulties in establishing a clear phenotype when few families are affected. They have provided insights into essential pathways of platelet function and have been at the origin of new and improved therapies for ischemic disease. Nevertheless, many patients remain without a diagnosis and requiring new strategies that are now discussed.
Collapse
Affiliation(s)
| | - Simon Stritt
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala
| | - Remi Favier
- French National Reference Center for Inherited Platelet Disorders, Armand Trousseau Hospital, Assistance Publique-Hôpitaux de Paris, Paris
| | | |
Collapse
|
13
|
Al-Hebshi A. Inherited Platelet Function Disorder From Novel Mutations in RAS Guanyl-Releasing Protein-2 Confirmed by Sanger Sequencing. Cureus 2020; 12:e11708. [PMID: 33391941 PMCID: PMC7769792 DOI: 10.7759/cureus.11708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Inherited platelet disorders (IPDs) are genetically heterogeneous rare disorders due to quantitative and/or qualitative abnormalities of the platelet. IPDs are often predisposed to significant medical complications. RAS guanyl-releasing protein-2 (RASGRP2) was recently identified as a gene affected in patients with platelet function defects and a bleeding complication. RASGRP2 codes for the protein CalDAG-GEFI RAS (guanyl-releasing protein-2), a guanine nucleotide exchange factor for small guanosine triphosphate(GTP)ase Rap1. We used Sanger sequencing to identify a novel function-disrupting homozygous mutation in RASGRP2 responsible for bleeding diathesis and platelet dysfunction in a patient.
Collapse
Affiliation(s)
- Abdulqader Al-Hebshi
- Pediatric Hematology Oncology, Prince Mohammed Bin Abdulaziz Hospital, Medina, SAU.,Pediatric Hematology Oncology, Ministry of National Guard Health Affairs, Medina, SAU.,Pediatric Hematology Oncology, King Abdullah International Medical Research Center, Riyadh, SAU.,Pediatric Hematology Oncology, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| |
Collapse
|
14
|
Schorling DC, Müller CK, Pechmann A, Borell S, Rosenfelder S, Kölbel H, Schara U, Zieger B, Kirschner J. Impaired secretion of platelet granules in patients with Duchenne muscular dystrophy - results of a prospective diagnostic study. Neuromuscul Disord 2020; 31:35-43. [PMID: 33309480 DOI: 10.1016/j.nmd.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/29/2020] [Accepted: 11/09/2020] [Indexed: 01/14/2023]
Abstract
A tendency to bleed during scoliosis surgery has been reported repeatedly in Duchenne muscular dystrophy (DMD) and diagnostic studies show a prolonged bleeding time. The pathophysiological background is still not fully understood. The short dystrophin isoform dp71 is expressed in platelets and mediates contractile properties. We performed a bicentric, non-blinded, prospective diagnostic study in 53 patients with confirmed DMD. Extensive laboratory analyses included platelet aggregometry and platelet flow cytometry, as well as routine coagulation analyses. Results of laboratory diagnostics were correlated with clinical data. Patients were subgrouped and analyzed according to ambulatory status and cardiac involvement. Platelet aggregation was reduced after stimulation with ADP (adenosine triphosphate) [60%; reference range 66-84%]. In addition, in the DMD cohort the expression of platelet activation markers CD62 and CD63 (flow cytometry analyses) was significantly lower than in healthy controls, most prominent in non-ambulatory patients with cardiac involvement. There was no clear association with the location of the underlying mutations in the dystrophin gene. No further abnormalities were identified regarding primary or secondary hemostasis. This study shows that platelets of patients with DMD have decreased expression of CD62 and CD63 which are markers for platelet granule release. This may indicate that patients with DMD have an impaired platelet granule secretion which may explain to some extent the increased bleeding, especially in mucocutaneous areas and perioperatively.
Collapse
Affiliation(s)
- D C Schorling
- Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Mathildenstraße 1, 79106 Freiburg, Germany.
| | - C K Müller
- Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Mathildenstraße 1, 79106 Freiburg, Germany
| | - A Pechmann
- Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Mathildenstraße 1, 79106 Freiburg, Germany
| | - S Borell
- Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Mathildenstraße 1, 79106 Freiburg, Germany
| | - S Rosenfelder
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine - University of Freiburg, Faculty of Medicine, University of Freiburg, Mathildenstraße 1, 79106 Freiburg, Germany
| | - H Kölbel
- Department of Pediatric Neurology, Developmental Neurology and Social Pediatrics, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - U Schara
- Department of Pediatric Neurology, Developmental Neurology and Social Pediatrics, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - B Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine - University of Freiburg, Faculty of Medicine, University of Freiburg, Mathildenstraße 1, 79106 Freiburg, Germany
| | - J Kirschner
- Department of Neuropediatrics and Muscle Disorders, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Mathildenstraße 1, 79106 Freiburg, Germany; Department of Neuropediatrics, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| |
Collapse
|
15
|
Downes K, Borry P, Ericson K, Gomez K, Greinacher A, Lambert M, Leinoe E, Noris P, Van Geet C, Freson K. Clinical management, ethics and informed consent related to multi-gene panel-based high throughput sequencing testing for platelet disorders: Communication from the SSC of the ISTH. J Thromb Haemost 2020; 18:2751-2758. [PMID: 33079472 PMCID: PMC7589386 DOI: 10.1111/jth.14993] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 12/22/2022]
Abstract
Molecular diagnostics of inherited platelet disorders (IPD) has been revolutionized by the implementation of high-throughput sequencing (HTS) approaches. A conclusive diagnosis using HTS tests can be obtained quickly and cost-effectively in many, but not all patients. The expanding use of HTS tests has raised concerns regarding complex variant interpretation and the ethical implications of detecting unsolicited findings such as variants in IPD genes RUNX1, ETV6, and ANKRD26, which are associated with increased leukemic risk. This guidance document has been developed and written by a multidisciplinary team of researchers and clinicians, with expertise in hematology, clinical and molecular genetics, and bioethics, alongside a RUNX1 patient advocacy representative. We recommend that for clinical diagnostics, HTS for IPD should use a multigene panel of curated diagnostic-grade genes. Critically, we advise that an HTS test for clinical diagnostics should only be ordered by a clinical expert that is: (a) fully aware of the complexity of genotype-phenotype correlations for IPD; (b) able to discuss these complexities with a patient and family members before the test is initiated; and (c) able to interpret and appropriately communicate the results of a HTS diagnostic report, including the implication of variants of uncertain clinical significance. Each patient should know what an HTS test could mean for his or her clinical management before initiating a test. We hereby propose an exemplified informed consent document that includes information on these ethical concerns and can be used by the community for implementation of HTS of IPD in a clinical diagnostic setting. This paper does not include recommendations for HTS of IPD in a research setting.
Collapse
Affiliation(s)
- Kate Downes
- East Genomic Laboratory HubCambridge University Hospitals NHS Foundation TrustCambridgeUK
- Department of HaematologyUniversity of CambridgeCambridge Biomedical CampusCambridgeUK
| | - Pascal Borry
- Department of Public Health and Primary CareKU LeuvenLeuvenBelgium
| | | | - Keith Gomez
- Haemophilia Centre and Thrombosis UnitRoyal Free London NHS Foundation TrustLondonUK
| | - Andreas Greinacher
- Institut für Immunologie und TransfusionsmedizinUniversitätsmedizin GreifswaldGreifswaldGermany
| | - Michele Lambert
- Division of HematologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPAUSA
- Department of PediatricsPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPAUSA
| | - Eva Leinoe
- Department of HaematologyRigshospitaletNational University HospitalCopenhagenDenmark
| | - Patrizia Noris
- IRCCS Policlinico San Matteo Foundation and University of PaviaPaviaItaly
| | - Chris Van Geet
- Department of Cardiovascular SciencesCenter or Molecular and Vascular BiologyKU LeuvenLeuvenBelgium
| | - Kathleen Freson
- Department of Cardiovascular SciencesCenter or Molecular and Vascular BiologyKU LeuvenLeuvenBelgium
| | | |
Collapse
|
16
|
Abdelmoumen K, Fabre M, Ducastelle-Lepretre S, Favier R, Ballerini P, Bordet JC, Dargaud Y. Eltrombopag for the Treatment of Severe Inherited Thrombocytopenia. Acta Haematol 2020; 144:308-313. [PMID: 32987389 DOI: 10.1159/000509922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/06/2020] [Indexed: 12/12/2022]
Abstract
Inherited thrombocytopenias correspond to a group of hereditary disorders characterized by a reduced platelet count, platelet dysfunction, and a family history of thrombocytopenia. It is commonly associated with mucocutaneous bleeding. Thrombocytopenia results from mutations in genes involved in megakaryocyte differentiation, platelet formation, and clearance. Here we report on a patient presenting with severe syndromic inherited thrombocytopenia manifesting as spontaneous mucocutaneous bleeds, requiring frequent platelet transfusions. Thrombocytopenia was explained by the presence of 4 mutations in 3 hematopoietic transcription factor genes: FLI1, RUNX1, and ETV6. The patient was successfully treated with high-dose eltrombopag at 150 mg/day, an orally available non-peptide thrombopoietin receptor agonist. Since the start of treatment 23 months ago, the manifestations of bleeding have resolved, and no platelet transfusions or corticosteroids have been required. The patient has no clinical or laboratory evidence of myeloid malignancy so far.
Collapse
Affiliation(s)
- Karim Abdelmoumen
- Unite d'Hemostase Clinique, Hopital Cardiologique Louis Pradel, Lyon, France
| | - Marc Fabre
- Service de Medecine Interne, Centre Hospitalier Pierre Oudot, Bourgoin-Jallieu, France
| | | | - Remi Favier
- Assistance Publique Hôpitaux de Paris, Service d'Hématologie Biologique, CRPP, Hôpital Armand Trousseau, Paris, France
| | - Paola Ballerini
- Assistance Publique Hôpitaux de Paris, Service d'Hématologie Biologique, CRPP, Hôpital Armand Trousseau, Paris, France
| | - Jean Claude Bordet
- Laboratoire d'Hemostase, Groupement Hospitalier Est, CHU de Lyon, Lyon, France
| | - Yesim Dargaud
- Unite d'Hemostase Clinique, Hopital Cardiologique Louis Pradel, Lyon, France,
- Laboratoire d'Hemostase, Groupement Hospitalier Est, CHU de Lyon, Lyon, France,
| |
Collapse
|
17
|
Cowan J, Parikh T, Waghela R, Mora R. Thrombocytopenia with Absent Radii (TAR) Syndrome Without Significant Thrombocytopenia. Cureus 2020; 12:e10557. [PMID: 33101804 PMCID: PMC7575318 DOI: 10.7759/cureus.10557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Thrombocytopenia with absent radii (TAR) syndrome is a rare genetic syndrome that occurs with a frequency of about 0.42 cases per 100,000 live births. It is characterized by hypo-megakaryocytic thrombocytopenia with bilateral absent radii and the presence of both thumbs. The thrombocytopenia is initially very severe, manifesting in the first few weeks to months of life, but subsequently improves with time to reach near normal values by one to two years of age. We present a case of a newborn with TAR syndrome with an atypical presentation of mild thrombocytopenia in the first week of life, with early normalization of platelet counts in the neonatal period. The patient deviates from the normal pattern in which 95% of patients with TAR syndrome usually develop significant thrombocytopenia (platelet counts of less than 50 x 10 9 platelets/L) within the first four months of life. Additionally, the absence of hypo-megakaryocytes on peripheral smear sets this patient apart from the typical cases of TAR syndrome. TAR syndrome is often associated with significant morbidity and mortality secondary to severe thrombocytopenia, which occurs with the highest frequency in the first 14 months of life. The most common cause of mortality is due to a severe hemorrhagic event occurring in the brain, gastrointestinal tract, and other organs. Therefore, all patients with TAR syndrome should be monitored closely for symptomatic thrombocytopenia with platelet transfusions being implemented as the first-line therapy for the treatment of severe or symptomatic disease.
Collapse
Affiliation(s)
- Jael Cowan
- Pediatrics, Woodhull Medical Center, Brooklyn, USA
| | - Taral Parikh
- Pediatrics, Woodhull Medical Center, Brooklyn, USA
| | | | - Ricardo Mora
- Neonatology, Woodhull Medical Center, Brooklyn, USA
| |
Collapse
|
18
|
Seddiq M, Gadgeel M, Persaud Y, Lafferty J, Savaşan S. Severe macrothrombocytopenia with platelet CD9 deficiency responsive to romiplostim. Br J Haematol 2020; 190:e239-e242. [PMID: 32515038 DOI: 10.1111/bjh.16812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Marjilla Seddiq
- Division of Hematology/Oncology, Children's Hospital of Michigan, Detroit, MI, USA
| | - Manisha Gadgeel
- Hematology/Oncology Flow Cytometry Laboratory, Children's Hospital of Michigan, Detroit, MI, USA
| | - Yogindra Persaud
- Division of Hematology/Oncology, Children's Hospital of Michigan, Detroit, MI, USA
| | - Jennifer Lafferty
- Division of Hematology/Oncology, Children's Hospital of Michigan, Detroit, MI, USA
| | - Süreyya Savaşan
- Division of Hematology/Oncology, Children's Hospital of Michigan, Detroit, MI, USA.,Hematology/Oncology Flow Cytometry Laboratory, Children's Hospital of Michigan, Detroit, MI, USA.,Pediatric Bone Marrow Transplant Program, Children's Hospital of Michigan, Barbara Ann Karmanos Cancer Center, Wayne State University School of Medicine, Detroit, MI, USA
| |
Collapse
|
19
|
Zhao Y, Li J. A new NOTCH3 damaging variant in a thrombocytopenia family of Miao ethnic group. J Gene Med 2019; 21:e3130. [PMID: 31729093 DOI: 10.1002/jgm.3130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/15/2019] [Accepted: 10/01/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Pediatric inherited thrombocytopenia, also known as a deficiency of platelets in children, is caused by genetic factors and it is hard to obtain an effective treatment. Thus, it is necessary to identify the possible genetic variants that are responsible for thrombocytopenia. METHODS Whole exome sequencing was used to detect genetic variants in two members of a thrombocytopenia family of Miao ethnic group. Multiple in silico analyses were performed to evaluate the effects of the novel missense variants. RESULTS Finally, a novel variant (chr19: g.15170364G>A) in the NOTCH3 gene was found, as confirmed with Sanger sequencing, which could result in a R1694Q substitution in the protein. This variant was consistently suggested to be damaging by sift (Sorting Tolerant From Intolerant; http://sift.jcvi.org), polyphen (Polymorphism Phenotyping, version 2.0; http://genetics.bwh.harvard.edu/pph2) and mutationtaster (http://www.mutationtaster.org) software. By building the 3D model of the key region of NOTCH3 protein and performing the structure simulation, we found that (i) this variant affected the 3D structure model with a root-mean-square deviation = 0.46 between wild-type and mutant type; (ii) this variant caused the protein to reduce the solvent accessible surface area by 421 Å2 ; and (iii) compared to the wild-type protein, the mutant protein had two less amino acids to maintain protein stability. CONCLUSIONS A novel damaging variant in the NOTCH3 gene was identified in a thrombocytopenia family with respect to decreasing the stability of NOTCH3, which may help with the prognosis and therapy of inherited thrombocytopenia.
Collapse
Affiliation(s)
- Yingling Zhao
- Department of Hematology, Longgang District Central Hospital of Shenzhen, Guangdong Province, China
| | - Juheng Li
- Department of Hematology, People's Hospital of Longgang District of Shenzhen, Guangdong Province, China
| |
Collapse
|
20
|
Rost MS, Shestopalov I, Liu Y, Vo AH, Richter CE, Emly SM, Barrett FG, Stachura DL, Holinstat M, Zon LI, Shavit JA. Nfe2 is dispensable for early but required for adult thrombocyte formation and function in zebrafish. Blood Adv 2018; 2:3418-3427. [PMID: 30504234 PMCID: PMC6290098 DOI: 10.1182/bloodadvances.2018021865] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 10/31/2018] [Indexed: 12/20/2022] Open
Abstract
The NFE2 transcription factor is expressed in multiple hematopoietic lineages with a well-defined role in regulating megakaryocyte biogenesis and platelet production in mammals. Mice deficient in NFE2 develop severe thrombocytopenia with lethality resulting from neonatal hemorrhage. Recent data in mammals reveal potential differences in embryonic and adult thrombopoiesis. Multiple studies in zebrafish have revealed mechanistic insights into hematopoiesis, although thrombopoiesis has been less studied. Rather than platelets, zebrafish possess thrombocytes, which are nucleated cells with similar functional properties. Using transcription activator-like effector nucleases to generate mutations in nfe2, we show that unlike mammals, zebrafish survive to adulthood in the absence of Nfe2. Despite developing severe thrombocytopenia, homozygous mutants do not display overt hemorrhage or reduced survival. Surprisingly, quantification of circulating thrombocytes in mutant 6-day-old larvae revealed no significant differences from wild-type siblings. Both wild-type and nfe2 null larvae formed thrombocyte-rich clots in response to endothelial injury. In addition, ex vivo thrombocytic colony formation was intact in nfe2 mutants, and adult kidney marrow displayed expansion of hematopoietic progenitors. These data suggest that loss of Nfe2 results in a late block in adult thrombopoiesis, with secondary expansion of precursors: features consistent with mammals. Overall, our data suggest parallels with erythropoiesis, including distinct primitive and definitive pathways of development and potential for a previously unknown Nfe2-independent pathway of embryonic thrombopoiesis. Long-term homozygous mutant survival will facilitate in-depth study of Nfe2 deficiency in vivo, and further investigation could lead to alternative methodologies for the enhancement of platelet production.
Collapse
Affiliation(s)
- Megan S Rost
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI
| | - Ilya Shestopalov
- Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Yang Liu
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI
| | - Andy H Vo
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI
| | - Catherine E Richter
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI
| | - Sylvia M Emly
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI
| | | | - David L Stachura
- Department of Biological Sciences, California State University Chico, Chico, CA
| | - Michael Holinstat
- Department of Pharmacology, University of Michigan, Ann Arbor, MI; and
| | - Leonard I Zon
- Boston Children's Hospital and Harvard Medical School, Boston, MA
- Stem Cell Program and Division of Hematology/Oncology, Harvard Stem Cell Institute, Stem Cell and Regenerative Biology Department, Dana-Farber Cancer Institute and Howard Hughes Medical Institute, Boston, MA
| | - Jordan A Shavit
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI
| |
Collapse
|