Diagnosis and treatment of patients refractory to platelet transfusions

Italian daily platelet transfusion practice for haematological patients undergoing high dose chemotherapy with or without stem cell transplantation: a survey by the GIMEMA Haemostasis and Thrombosis Working Party

BACKGROUND

Following high-dose chemotherapy/bone marrow transplantation, patients are routinely, prophylactically transfused with platelet concentrates (PC) if they have a platelet count ≤10×10⁹/L or higher in the presence of risk factors for bleeding. However, whether such transfusions are necessary in clinically stable patients with no bleeding, or whether a therapeutic transfusion strategy could be sufficient and safe, is still debated.

MATERIALS AND METHODS

The GIMEMA Haemostasis and Thrombosis Working Party sent a questionnaire to Italian haematology departments to survey several aspects of daily platelet transfusion practice, such as the cut-off platelet count for transfusion, the evaluation of refractoriness and the type of PC administered.

RESULTS

The questionnaire was answered by 18 out of 31 centres (58%). A total of 23,162 PC were transfused in 2,396 patients in 2013. The vast majority of centres (95%) transfused PC according to Italian and international guidelines; only a few transfused always at platelet counts ≤20×10⁹/L. The broad agreement on platelet count cut-off for transfusion (≤10×10⁹/L) was not confirmed when the World Health Organization (WHO) bleeding score was considered: only a third of centres (33%) used transfusions as recommended when the bleeding grade was ≥2. Platelet refractoriness was poorly monitored and most centres (89%) evaluated, mostly empirically (67%), response to transfusion only 24 hours later. Thirty percent of centres transfused platelets in asymptomatic refractory patients.

DISCUSSION

Although most Italian haematology departments transfuse PC according to Italian and international guidelines, our survey shows that in routine daily practice physicians do not comply closely with the WHO recommendations on platelet transfusions and monitoring platelet refractoriness. This causes excessive platelet transfusions, with a resulting increase of costs and waste of public health resources.

Consensus and controversies in platelet transfusion

Platelet transfusion therapy is the standard of care for thrombocytopenic patients with hemato-oncological disorders and bone marrow failure states due to intensive chemoradiotherapy. Guidelines to lower triggers for prophylactic and therapeutic transfusions are being developed based on better levels of evidence. The optimum transfusion dose, the choice of platelet concentrate and transfusion interval pose a challenge to balance scientific advances with cost-effective strategies. Platelet refractoriness requires "matched" platelets and is a difficult to treat phenomenon. Pathogen inactivation is a crucial issue in view of susceptibility of platelet concentrates to bacterial contamination. This article reviews the current developments and challenges in optimizing platelet transfusion therapy.

Discovery of novel non-peptide thrombopoietin mimetic compounds that induce megakaryocytopoiesis

We have identified a series of novel non-peptide compounds that activate the thrombopoietin-dependent cell line Ba/F3-huMPL. The compounds stimulated proliferation of Ba/F3-huMPL in the absence of other growth factors, but did not promote proliferation of the thrombopoietin-independent parent cell line Ba/F3. The thrombopoietin-mimetic compounds elicited signal-transduction responses comparable with recombinant human thrombopoietin, such as tyrosine phosphorylation of the thrombopoietin receptor, JAK (Janus kinase) 2, Tyk2 (tyrosine kinase 2), STAT (signal transducer and activator of transcription) 3, STAT5, MAPKs (mitogen-activated protein kinases), PLCγ (phospholipase Cγ), Grb2 (growth-factor-receptor-bound protein 2), Shc (Src homology and collagen homology), Vav, Cbl and SHP-2 (Src homology 2 domain-containing protein tyrosine phosphatase 2) and increased the number of CD41+ cells (megakaryocyte lineage) in cultures of human CD34+ bone-marrow cells (haematopoietic stem cells). These findings suggest that this series of compounds are novel agonists of the human thrombopoietin receptor and are possible lead compounds for the generation of anti-thrombocytopaenia drugs.

Study of gene expression profile during cord blood-associated megakaryopoiesis

AIMS

To study the gene profile in cord blood (CB)-associated megakaryopoiesis.

METHODS

In vitro differentiation of megakaryocytes (Mks) was carried out using human CB CD34(+) cells under the stimulation of recombinant human interleukin-3, stem cell factor and thrombopoietin for 7 d, followed by thrombopoietin only for further 3 d. Lineage-specific differentiation of Mk was examined by the expression of CD41 using flow cytometry and confocal microscopy. Total cellular RNA was extracted from day-0 CD34(+), day-10 CD41(+) and CD41(-) populations were isolated by immunomagnetic sorting respectively. Microarray was performed, and the data were analyzed using the GeneChip Operating System, Spotfire software and Genomatix BiblioSphere.

RESULTS

Flow cytometric analysis showed 19.44 +/- 3.05% CD41(+) cells at day 10 of culture. The purity of CD41(+) population was enriched to 95.70 +/- 4.19% after sorting. Gene expression profiling revealed an upregulation of 285 and downregulation of 53 unique genes in the CD41(+) cells compared with CD41(-) and CD34(+) cells. Platelet-associated genes, such as thrombospondin 1, platelet glycoprotein IIIa, etc., were highly expressed in CD41(+) cells but not in CD41(-) cells and CD34(+) cells. Moreover, some genes that have not been reported to be associated with CB-derived megakaryopoiesis, such as Cbl-interacting proteins Sts-1, protocadherin 21, etc., are found to be highly expressed in the CD41(+) cells from this study.

CONCLUSIONS

This study reveals a global gene expression profile of in vitro human CB-derived megakaryopoiesis at day 10. Some of these genes may play regulatory roles during the development of CB-derived megakaryopoiesis.

Recombinant human thrombopoietin: basic biology and evaluation of clinical studies

Thrombocytopenia is a common medical problem for which the main treatment is platelet transfusion. Given the increasing use of platelets and the declining donor population, identification of a safe and effective platelet growth factor could improve the management of thrombocytopenia. Thrombopoietin (TPO), the c-Mpl ligand, is the primary physiologic regulator of megakaryocyte and platelet development. Since the purification of TPO in 1994, 2 recombinant forms of the c-Mpl ligand--recombinant human thrombopoietin (rhTPO) and pegylated recombinant human megakaryocyte growth and development factor (PEG-rHuMGDF)--have undergone extensive clinical investigation. Both have been shown to be potent stimulators of megakaryocyte growth and platelet production and are biologically active in reducing the thrombocytopenia of nonmyeloablative chemotherapy. However, neither TPO has demonstrated benefit in stem cell transplantation or leukemia chemotherapy. Other clinical studies have investigated the use of TPO in treating chronic nonchemotherapy-induced thrombocytopenia associated with myelodysplastic syndromes, idiopathic thrombocytopenic purpura, thrombocytopenia due to human immunodeficiency virus, and liver disease. Based solely on animal studies, TPO may be effective in reducing surgical thrombocytopenia and bleeding, ex vivo expansion of pluripotent stem cells, and as a radioprotectant. Ongoing and future studies will help define the clinical role of recombinant TPO and TPO mimetics in the treatment of chemotherapy- and nonchemotherapy-induced thrombocytopenia.

Revisitation of the clinical indications for the transfusion of platelet concentrates

Platelet transfusion is indicated when the expected benefits of increasing the number of functional platelets in the patient's circulation outweigh the potential risks generated by exposing the patient to allogeneic, manipulated and stored blood products such as platelet concentrates. Although reassuring evidence has been collected indicating that current risks associated with blood transfusion are lower than those of several voluntary and involuntary human activities, balancing benefits and risks of platelet transfusion may not be easy in a proportion of patients and in a number of conditions. To facilitate this task, guidelines have been developed, with particular attention to cancer patients. As witnessed by the most recent guidelines, over the last few years there has been a progressive, although not absolute, consensus on: (i) the routine use of platelets as a tool to prevent hemorrhage in oncohematology (the so called 'prophylactic approach') as opposed to limiting platelet transfusion to actual bleeding episodes (the so-called 'therapeutic approach') and (ii) lowering the trigger for prophylactic platelet transfusion in stable oncohematology recipients from 20 x 109 to 10 x 109 platelets/L. This has been accompanied by a reduction of platelet use per oncohematology patient of about 20%, an important outcome in view of the progressive increase of platelet demand due to more aggressive therapy in cancer patients. In selected clinical conditions, specific triggers ranging from 30 x 10(9) to 100 x 10(9) platelets/L have been recommended, with higher values when surgical procedures are required for the patient's treatment. Indications and trigger values proposed in the guidelines must be considered within the context of careful clinical evaluation of each patient, with a clear appreciation of the power of discrimination of automated platelet counters at low counts, and of the quality and local availability of platelet products for emergency.

Pharmacologic treatment options in patients with thrombocytopenia

Thrombocytopenia that results from chemotherapy has become an increasingly important issue in the treatment of cancer and remains a difficult clinical problem. The identification of a safe and effective platelet growth factor could significantly improve the management of severe chemotherapy-induced thrombocytopenia. Over the past decade, a number of hematopoietic growth factors with thrombopoietic activity have been identified, including stem-cell factor (c-kit ligand), interleukin (IL)-1, IL-3, IL-6, and IL-11, as well as thrombopoietin (TPO) and its derivatives. Only a few of these agents have shown acceptable tolerability and sufficient ability to stimulate thrombopoiesis to justify testing in randomized clinical trials. Currently, IL-11 is the only cytokine licensed in the United States for treatment of chemotherapy-induced thrombocytopenia. However, its thrombopoietic activity is modest and its use is often associated with unfavorable side effects. Identification of TPO, the c-Mpl ligand, as the primary physiologic regulator of megakaryocyte and platelet development offers important promise for treatment of thrombocytopenia. Preliminary clinical studies of recombinant human TPO (rhTPO), a full-length glycosylated molecule, indicate that it is safe and biologically active in reducing severe chemotherapy-induced thrombocytopenia. In addition to rhTPO, the future may see the development of novel genetically engineered, high-affinity cytokine receptor agonists and c-Mpl ligand mimetic peptides.