1
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Moulinet T, Moussu A, Pierson L, Pagliuca S. The many facets of immune-mediated thrombocytopenia: Principles of immunobiology and immunotherapy. Blood Rev 2024; 63:101141. [PMID: 37980261 DOI: 10.1016/j.blre.2023.101141] [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] [Received: 08/30/2023] [Revised: 10/08/2023] [Accepted: 11/05/2023] [Indexed: 11/20/2023]
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune condition, due to peripheral platelet destruction through antibody-dependent cellular phagocytosis, complement-dependent cytotoxicity, cytotoxic T lymphocyte-mediated cytotoxicity, and megakaryopoiesis alteration. This condition may be idiopathic or triggered by drugs, vaccines, infections, cancers, autoimmune disorders and systemic diseases. Recent advances in our understanding of ITP immunobiology support the idea that other forms of thrombocytopenia, for instance, occurring after immunotherapy or cellular therapies, may share a common pathophysiology with possible therapeutic implications. If a decent pipeline of old and new agents is currently deployed for classical ITP, in other more complex immune-mediated thrombocytopenic disorders, clinical management is less harmonized and would deserve further prospective investigations. Here, we seek to provide a fresh overview of pathophysiology and current therapeutical algorithms for adult patients affected by this disorder with specific insights into poorly codified scenarios, including refractory ITP and post-immunotherapy/cellular therapy immune-mediated thrombocytopenia.
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Affiliation(s)
- Thomas Moulinet
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France; UMR 7365, IMoPA, Lorraine University, CNRS, Nancy, France
| | - Anthony Moussu
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Ludovic Pierson
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Simona Pagliuca
- UMR 7365, IMoPA, Lorraine University, CNRS, Nancy, France; Department of Hematology, Regional Competence Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Nancy University Hospital, Vandœuvre-lès-Nancy, France.
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2
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Satoh T, Uojima H, Wada N, Takiguchi H, Kaneko M, Nakamura M, Gonda N, Homma M, Hidaka H, Kusano C, Horie R. Introduction of direct-acting antiviral agents alters frequencies of anti-GPIIb/IIIa antibody-producing B cells in chronic hepatitis C patients with thrombocytopenia. Platelets 2023; 34:2161498. [PMID: 36597279 DOI: 10.1080/09537104.2022.2161498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The pathogenesis of thrombocytopenia in chronic hepatitis C (CHC) conceivably involves autoimmunity; however, the dynamics of autoantibodies and other autoimmune mechanisms remain unclear. In this study, we examined the changes in the frequency of anti-glycoprotein (GP) IIb/IIIa antibody-producing B cells and the levels of plasma B-cell-activating factor (BAFF), a proliferation-inducing ligand (APRIL), and interleukin (IL)-21 following treatment of CHC with direct-acting antiviral agents (DAA). We recruited 28 patients with CHC who underwent treatment with DAA for 8-12 weeks and subsequently tested negative for serum hepatitis C virus RNA. Thirty healthy controls were recruited for comparison. Platelet counts increased significantly (p = .016), and the frequency of anti-GPIIb/IIIa antibody-producing B cells decreased significantly (p = .002) in CHC patients with thrombocytopenia at the end of treatment (EOT) than before DAA treatment (baseline). However, these changes were not observed in CHC patients without thrombocytopenia. Plasma BAFF levels in CHC patients with thrombocytopenia significantly decreased from baseline to EOT (p = .002). Anti-GPIIb/IIIa antibody-producing B cells were positively correlated with plasma BAFF levels in these patients (r = 0.669, p = .039). These results suggest that DAA treatment suppresses the autoimmune response against platelets and improves thrombocytopenia.
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Affiliation(s)
- Takashi Satoh
- Division of Hematology, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan.,Division of Molecular Hematology, Kitasato University Graduate School of Medical Sciences, Sagamihara, anagawa, Japan.,Regenerative Medicine and Cell Design Research Facility, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan
| | - Haruki Uojima
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Naohisa Wada
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Hayato Takiguchi
- Division of Molecular Hematology, Kitasato University Graduate School of Medical Sciences, Sagamihara, anagawa, Japan
| | - Mei Kaneko
- Division of Hematology, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan
| | - Marina Nakamura
- Division of Hematology, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan
| | - Natsuki Gonda
- Division of Hematology, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan
| | - Michika Homma
- Division of Hematology, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan
| | - Hisashi Hidaka
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Chika Kusano
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Ryouichi Horie
- Division of Hematology, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan.,Division of Molecular Hematology, Kitasato University Graduate School of Medical Sciences, Sagamihara, anagawa, Japan
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3
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Roeser A, Lazarus AH, Mahévas M. B cells and antibodies in refractory immune thrombocytopenia. Br J Haematol 2023; 203:43-53. [PMID: 37002711 DOI: 10.1111/bjh.18773] [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] [Received: 02/16/2023] [Accepted: 03/11/2023] [Indexed: 04/03/2023]
Abstract
Immune thrombocytopenia (ITP) is an acquired bleeding disorder mediated by pathogenic autoantibodies secreted by plasma cells (PCs) in many patients. In refractory ITP patients, the persistence of splenic and bone marrow autoreactive long-lived PCs (LLPCs) may explain primary failure of rituximab and splenectomy respectively. The reactivation of autoreactive memory B cells generating new autoreactive PCs contributes to relapses after initial response to rituximab. Emerging strategies targeting B cells and PCs aim to prevent the settlement of splenic LLPCs with the combination of anti-BAFF and rituximab, to deplete autoreactive PCs with anti-CD38 antibodies, and to induce deeper B-cell depletion in tissues with novel anti-CD20 monoclonal antibodies and anti-CD19 therapies. Alternative strategies, focused on controlling autoantibody mediated effects, have also been developed, including SYK and BTK inhibitors, complement inhibitors, FcRn blockers and inhibitors of platelet desialylation.
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Affiliation(s)
- Anaïs Roeser
- Institut Necker Enfants Malades (INEM), INSERM U1151/CNRS UMS 8253, ATIP-Avenir TeamAI2B, Paris, France
- Service de Médecine Interne, Centre Hospitalier Universitaire Henri-Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Est Créteil (UPEC), Créteil, France
| | - Alan H Lazarus
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Departments of Medicine and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Innovation and Portfolio Management, Canadian Blood Services, Ottawa, Ontario, Canada
| | - Matthieu Mahévas
- Institut Necker Enfants Malades (INEM), INSERM U1151/CNRS UMS 8253, ATIP-Avenir TeamAI2B, Paris, France
- Service de Médecine Interne, Centre Hospitalier Universitaire Henri-Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Est Créteil (UPEC), Créteil, France
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4
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Weitz IC, Liebman HA. Complement in immune thrombocytopenia (ITP): The role of complement in refractory ITP. Br J Haematol 2023; 203:96-100. [PMID: 37735550 DOI: 10.1111/bjh.19070] [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] [Received: 07/03/2023] [Accepted: 07/31/2023] [Indexed: 09/23/2023]
Abstract
Immune thrombocytopenia (ITP) is a disorder characterized by low platelets due to increased clearance and decreased platelet production. While ITP has been characterized as an acquired disorder of the adaptive immune system, the resulting platelet autoantibodies provide ancillary links to the innate immune system via antibody interaction with the complement system. Most autoantibodies in patients with ITP are of the IgG1 subclass, which can be potent activators of the classical complement pathway. Antibody-coated platelets can initiate complement activation via the classical pathway leading to both direct platelet destruction and enhanced clearance of C3b-coated platelets by complement receptors. Similar autoantibody interactions with bone marrow megakaryocytes can also result in complement injury and ineffective thrombopoiesis. The development of novel therapeutic complement inhibitors has revived interest in the role of complement in autoantibody-mediated disorders, such as ITP. A recent early-phase clinical trial of a classical complement pathway inhibitor has demonstrated efficacy in a subset of ITP patients refractory to conventional immune modulation. In this review, we will analyse the role of complement in refractory ITP.
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Affiliation(s)
- Ilene Ceil Weitz
- Jane Anne Nohl Division of Hematology, University of Southern California-Keck School of Medicine, Los Angeles, California, USA
| | - Howard Allen Liebman
- Jane Anne Nohl Division of Hematology, University of Southern California-Keck School of Medicine, Los Angeles, California, USA
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5
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Norris PAA, Tawhidi Z, Sachs UJ, Cserti-Gazdewich CM, Lin Y, Callum J, Gil Gonzalez L, Shan Y, Branch DR, Lazarus AH. Serum from half of patients with immune thrombocytopenia trigger macrophage phagocytosis of platelets. Blood Adv 2023; 7:3561-3572. [PMID: 37042934 PMCID: PMC10368862 DOI: 10.1182/bloodadvances.2022009423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 03/21/2023] [Accepted: 04/05/2023] [Indexed: 04/13/2023] Open
Abstract
Humoral antiplatelet factors, such as autoantibodies, are thought to primarily clear platelets by triggering macrophage phagocytosis in immune thrombocytopenia (ITP). However, there are few studies characterizing the capacity and mechanisms of humoral factor-triggered macrophage phagocytosis of platelets using specimens from patients with ITP. Here, we assessed sera from a cohort of 24 patients with ITP for the capacity to trigger macrophage phagocytosis of normal donor platelets and characterized the contribution of humoral factors to phagocytosis. Sera that produced a phagocytosis magnitude greater than a normal human serum mean + 2 standard deviations were considered phagocytosis-positive. Overall, 42% (8/19) of MHC I alloantibody-negative ITP sera were phagocytosis-positive. The indirect monoclonal antibody immobilization of platelet antigens assay was used to detect immunoglobulin G (IgG) autoantibodies to glycoproteins (GP)IIb/IIIa, GPIb/IX, and GPIa/IIa. Autoantibody-positive sera triggered a higher mean magnitude of phagocytosis than autoantibody-negative sera. Phagocytosis correlated inversely with platelet counts among autoantibody-positive patients but not among autoantibody-negative patients. Select phagocytosis-positive sera were separated into IgG-purified and -depleted fractions via protein G and reassessed for phagocytosis. Phagocytosis was largely retained in the purified IgG fractions. In addition, we assessed serum concentrations of C-reactive protein, serum amyloid P, and pentraxin 3 as potential phagocytosis modulators. Pentraxin 3 concentrations correlated inversely with platelet counts among patients positive for autoantibodies. Taken together, sera from approximately half of the patients with ITP studied triggered macrophage phagocytosis of platelets beyond a normal level. An important role for antiplatelet autoantibodies in phagocytosis is supported; a role for pentraxins such as pentraxin 3 may be suggested.
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Affiliation(s)
- Peter A. A. Norris
- Innovation and Portfolio Management, Canadian Blood Services, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada
| | - Zoya Tawhidi
- Innovation and Portfolio Management, Canadian Blood Services, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada
| | - Ulrich J. Sachs
- Institute for Clinical Immunology, Transfusion Medicine, and Haemostasis, Justus Liebig University, Giessen, Germany
- Department of Thrombosis and Haemostasis, Giessen University Hospital, Giessen, Germany
| | - Christine M. Cserti-Gazdewich
- Innovation and Portfolio Management, Canadian Blood Services, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Laboratory Medicine Program, University Health Network, Toronto, ON, Canada
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, University of Toronto, Toronto, ON, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, University of Toronto, Toronto, ON, Canada
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jeannie Callum
- Innovation and Portfolio Management, Canadian Blood Services, Toronto, ON, Canada
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, University of Toronto, Toronto, ON, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen’s University, Kingston, ON, Canada
| | - Lazaro Gil Gonzalez
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada
| | - Yuexin Shan
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada
| | - Donald R. Branch
- Innovation and Portfolio Management, Canadian Blood Services, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Hematology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Alan H. Lazarus
- Innovation and Portfolio Management, Canadian Blood Services, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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6
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Nakajima-Kato Y, Komai M, Yoshida T, Kanai A. A novel monoclonal antibody with improved FcγR blocking ability demonstrated non-inferior efficacy compared to IVIG in cynomolgus monkey ITP model at considerably lower dose. Clin Exp Immunol 2023; 211:23-30. [PMID: 36480334 PMCID: PMC9993454 DOI: 10.1093/cei/uxac112] [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] [Received: 07/07/2022] [Revised: 11/04/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
Intravenous immunoglobulin (IVIG) is a well-established treatment for various autoimmune and inflammatory diseases. However, the standard dose prescribed for autoimmune diseases, including immune thrombocytopenic purpura (ITP), is 2 g/kg, which is markedly high and leads to a high treatment burden. In this study, we generated fragment crystallizable (Fc)-modified anti-haptoglobin (Hp) monoclonal antibodies with non-inferior efficacy compared to IVIG at considerably lower doses than IVIG, as shown by in vitro experiments. We evaluated binding activity of anti-Hp antibodies to Fc gamma receptors (FcγRs) with ELISA and inhibitory activity against the ADCC reaction. Furthermore, we successfully established a novel cynomolgus monkey ITP model and demonstrated that the anti-Hp antibody exerted its effect in this model with only a single dose. This Fc-modified anti-Hp monoclonal antibody could be a valuable therapeutic replacement for IVIG for the treatment of ITP.
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Affiliation(s)
- Yuko Nakajima-Kato
- Correspondence: Yuko Nakajima-Kato, Biomedical Science Research Laboratories 2, Research Unit, R&D Division, Kyowa Kirin Co., Ltd., Japan
| | - Masato Komai
- Biomedical Science Research Laboratories 2, Research Unit, R&D Division, Kyowa Kirin Co., Ltd., Japan
| | - Tadashi Yoshida
- Graduate School of Bio-Applications and Systems Engineering, Tokyo University of Agriculture and Technology, Tokyo, Japan
- Department of Applied Biological Science, Tokyo University of Agriculture and Technology, Tokyo, Japan
| | - Akiko Kanai
- Biomedical Science Research Laboratories 1, Research Unit, R&D Division, Kyowa Kirin Co., Ltd., Japan
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7
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Satoh T, Takiguchi H, Uojima H, Kubo M, Tanaka C, Yokoyama F, Wada N, Miyazaki K, Hidaka H, Kusano C, Kuwana M, Horie R. B cell-activating factor is involved in thrombocytopenia in patients with liver cirrhosis. Ann Hematol 2022; 101:2433-2444. [PMID: 36098792 DOI: 10.1007/s00277-022-04973-x] [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] [Received: 05/07/2022] [Accepted: 08/28/2022] [Indexed: 11/26/2022]
Abstract
Liver cirrhosis (LC) involves B cells that produce anti-glycoprotein (GP) IIb/IIIa antibodies, found in primary immune thrombocytopenia (ITP). The role of autoimmunity in the pathology of thrombocytopenia in LC was investigated using 25 LC patients with thrombocytopenia, 18 ITP patients, and 30 healthy controls. Anti-GPIIb/IIIa antibody-producing B cells were quantified using enzyme-linked immunospot assay. Platelet-associated and plasma anti-GPIIb/IIIa antibody, plasma B cell-activating factor (BAFF), and a proliferation-inducing ligand (APRIL) levels were measured using enzyme-linked immunosorbent assay. B cell subset fractions and regulatory T cells (Tregs) were quantified using flow cytometry.The number of anti-GPIIb/IIIa antibody-producing B cells was significantly higher in LC patients than in ITP patients and healthy controls (both p < 0.001). Platelet-associated anti-GPIIb/IIIa antibodies were significantly higher in LC patients than in ITP patients and healthy controls (p = 0.002, p < 0.001, respectively). BAFF levels were significantly higher in LC patients than in ITP patients and healthy controls (p = 0.001 and p < 0.001, respectively), and APRIL levels were significantly higher in LC patients than in healthy controls (p < 0.001). Anti-GPIIb/IIIa antibody-producing B cells and platelet-associated anti-GPIIb/IIIa antibodies were positively correlated with BAFF levels in LC patients. LC patients had more naïve B cells and plasmablasts than healthy controls (p = 0.005, p = 0.03, respectively); plasmablasts were positively correlated with BAFF levels. LC patients had similar Tregs levels as ITP patients and healthy controls. Therefore, excessive BAFF production in LC patients with thrombocytopenia is likely associated with autoimmune B cell response, inducing anti-GPIIb/IIIa antibody production.
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Affiliation(s)
- Takashi Satoh
- Division of Hematology, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan.
- Division of Molecular Hematology, Kitasato University Graduate School of Medical Sciences, Sagamihara, Kanagawa, Japan.
- Regenerative Medicine and Cell Design Research Facility, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan.
| | - Hayato Takiguchi
- Division of Molecular Hematology, Kitasato University Graduate School of Medical Sciences, Sagamihara, Kanagawa, Japan
| | - Haruki Uojima
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Makoto Kubo
- Regenerative Medicine and Cell Design Research Facility, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan
- Division of Immunology, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan
| | - Chisato Tanaka
- Division of Hematology, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan
| | - Fumiko Yokoyama
- Division of Hematology, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan
| | - Naohisa Wada
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Koji Miyazaki
- Department of Transfusion and Cell Transplantation, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Hisashi Hidaka
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Chika Kusano
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Ryouichi Horie
- Division of Hematology, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan
- Division of Molecular Hematology, Kitasato University Graduate School of Medical Sciences, Sagamihara, Kanagawa, Japan
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8
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Canales-Herrerias P, Crickx E, Broketa M, Sokal A, Chenon G, Azzaoui I, Vandenberghe A, Perima A, Iannascoli B, Richard-Le Goff O, Castrillon C, Mottet G, Sterlin D, Robbins A, Michel M, England P, Millot GA, Eyer K, Baudry J, Mahevas M, Bruhns P. High-affinity autoreactive plasma cells disseminate through multiple organs in patients with immune thrombocytopenic purpura. J Clin Invest 2022; 132:153580. [PMID: 35503254 PMCID: PMC9197514 DOI: 10.1172/jci153580] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 04/28/2022] [Indexed: 11/17/2022] Open
Abstract
The major therapeutic goal for immune thrombocytopenic purpura (ITP) is to restore normal platelet counts using drugs to promote platelet production or by interfering with mechanisms responsible for platelet destruction. Eighty percent of patients with ITP possess anti–integrin αIIbβ3 IgG autoantibodies that cause platelet opsonization and phagocytosis. The spleen is considered the primary site of autoantibody production by autoreactive B cells and platelet destruction. The immediate failure in approximately 50% of patients to recover a normal platelet count after anti-CD20 rituximab-mediated B cell depletion and splenectomy suggests that autoreactive, rituximab-resistant, IgG-secreting B cells (IgG-SCs) reside in other anatomical compartments. We analyzed more than 3,300 single IgG-SCs from spleen, bone marrow, and/or blood of 27 patients with ITP, revealing high interindividual variability in affinity for αIIbβ3, with variations over 3 logs. IgG-SC dissemination and range of affinities were, however, similar for each patient. Longitudinal analysis of autoreactive IgG-SCs upon treatment with the anti-CD38 mAb daratumumab demonstrated variable outcomes, from complete remission to failure with persistence of high-affinity anti–αIIbβ3 IgG-SCs in the bone marrow. This study demonstrates the existence and dissemination of high-affinity autoreactive plasma cells in multiple anatomical compartments of patients with ITP that may cause the failure of current therapies.
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Affiliation(s)
| | - Etienne Crickx
- INSERM U1151/CNRS UMS8253, Institut Necker-Enfants Malades, Paris, France
| | - Matteo Broketa
- Department of Immunology, Institut Pasteur, Paris, France
| | - Aurélien Sokal
- INSERM U1151/CNRS UMS8253, Institut Necker-Enfants Malades, Paris, France
| | - Guilhem Chenon
- Laboratoire Colloïdes et Matériaux Divisés (LCMD), ESPCI, Paris, France
| | - Imane Azzaoui
- Service de Médecine Interne, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Paris, France
| | - Alexis Vandenberghe
- Service de Médecine Interne, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Paris, France
| | - Angga Perima
- Department of Immunology, Institut Pasteur, Paris, France
| | | | | | | | | | | | - Ailsa Robbins
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunolo, Robert Debré Hospital, Reims University Hospitals, Reims, France
| | - Marc Michel
- Service de Médecine Interne, Centre Hospitalier Universitaire Henri-Mondor, Créteil, France
| | - Patrick England
- Plateforme de Biophysique Moléculaire, Institut Pasteur, Paris, France
| | - Gael A Millot
- Hub Bioinformatique et Biostatistique, Institut Pasteur, Paris, France
| | - Klaus Eyer
- Laboratory for Functional Immune Repertoire Analysis, ETH Zurich, Zurich, Switzerland
| | - Jean Baudry
- Laboratoire Colloïdes et Matériaux Divisés (LCMD), ESPCI, Paris, France
| | - Matthieu Mahevas
- INSERM U1151/CNRS UMS8253, Institut Necker-Enfants Malades, Paris, France
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9
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Nishizawa K, Yamashita T, Ogawa Y, Kobayashi H. Membranous nephropathy complicated by immune thrombocytopenia treated with low-density lipoprotein apheresis: a case report and literature review. CEN Case Rep 2021; 11:43-49. [PMID: 34287815 DOI: 10.1007/s13730-021-00630-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/15/2021] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) may lead to membranous nephropathy (MN). Here, we report a case of MN complicated by ITP and validate the hypothesis that circulating antiplatelet antibodies cause MN using immunofluorescence analysis for immunoglobulin (Ig) G subclass and anti-phospholipase A2 receptor (PLA2R) antibodies. A 39-year-old Japanese man with ITP, who had been treated with prednisolone for 10 months, achieved a stable disease condition. However, 4 months after tapering the dose down to 10 mg prednisolone, he developed nephrotic syndrome, with a urinary protein-to-creatinine ratio (U-PCR) of 10.6 g/g Cr and was admitted to our hospital. His platelet count, at 89,000/μL, was lower than the normal range, indicating the recurrence of ITP. Renal biopsy revealed the thickening of the glomerular basement membrane with the deposition of IgG and complement component 3. Predominant deposition of IgG1 and negativity for anti-PLA2R staining indicated secondary MN; however, no typical conditions of secondary MN were evident. Although oral prednisolone and cyclosporine A were administered, he was refractory to treatment. A total of 12 sessions of low-density lipoprotein apheresis (LDL-A) decreased his U-PCR to < 3 g/g Cr. Seven months after discharge, his U-PCR further decreased to 0.54 g/g Cr and platelet count recovered to > 200,000/μL. Our literature review reveals that this condition is refractory to steroid therapy. LDL-A can be an effective treatment in drug-resistant MN complicated by ITP.
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Affiliation(s)
- Keitaro Nishizawa
- Department of Nephrology, Asahikawa Red Cross Hospital, 1jo 1 chome, Akebono, Asahikawa, Hokkaido, Japan.
| | - Tomohisa Yamashita
- Department of Nephrology, Asahikawa Red Cross Hospital, 1jo 1 chome, Akebono, Asahikawa, Hokkaido, Japan
| | - Yayoi Ogawa
- Hokkaido Renal Pathology Center, Sapporo, Japan
| | - Hironori Kobayashi
- Department of Nephrology, Asahikawa Red Cross Hospital, 1jo 1 chome, Akebono, Asahikawa, Hokkaido, Japan
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10
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Gabe C, Sirotich E, Li N, Ivetic N, Nazy I, Smith J, Kelton JG, Arnold DM. Performance characteristics of platelet autoantibody testing for the diagnosis of immune thrombocytopenia using strict clinical criteria. Br J Haematol 2021; 194:439-443. [PMID: 34109621 DOI: 10.1111/bjh.17566] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/29/2021] [Indexed: 11/28/2022]
Abstract
Misclassification of immune thrombocytopenia (ITP) is common, which might undermine the value of platelet autoantibody testing. We determined the sensitivity and specificity of platelet autoantibody testing using the direct antigen capture assay for anti-glycoprotein (GP) IIb/IIIa or anti-GPIbIX in patients with 'definite ITP', defined as those with a documented treatment response. Sensitivity of platelet autoantiboody testing increased from 48·3% [95% confidence interval (CI) 43·5-53·2] for all ITP patients to 64·7% (95% CI 54·6-73·9) for definite ITP patients. Specificity was unchanged [75·3% (95% CI 67·5-82·1)]. High optical density values (>0·8) improved the specificity of platelet autoantibody testing but lowered sensitivity. In patients with a high pretest probability, platelet autoantibodies can aid in the diagnosis of ITP and may be most prevalent in certain patient subsets.
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Affiliation(s)
- Caroline Gabe
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Emily Sirotich
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Na Li
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Nikola Ivetic
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ishac Nazy
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - James Smith
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - John G Kelton
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Donald M Arnold
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
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11
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Immune Thrombocytopenia: Recent Advances in Pathogenesis and Treatments. Hemasphere 2021; 5:e574. [PMID: 34095758 PMCID: PMC8171374 DOI: 10.1097/hs9.0000000000000574] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/08/2021] [Indexed: 11/26/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune disease due to both a peripheral destruction of platelets and an inappropriate bone marrow production. Although the primary triggering factors of ITP remain unknown, a loss of immune tolerance-mostly represented by a regulatory T-cell defect-allows T follicular helper cells to stimulate autoreactive splenic B cells that differentiate into antiplatelet antibody-producing plasma cells. Glycoprotein IIb/IIIa is the main target of antiplatelet antibodies leading to platelet phagocytosis by splenic macrophages, through interactions with Fc gamma receptors (FcγRs) and complement receptors. This allows macrophages to activate autoreactive T cells by their antigen-presenting functions. Moreover, the activation of the classical complement pathway participates to platelet opsonization and also to their destruction by complement-dependent cytotoxicity. Platelet destruction is also mediated by a FcγR-independent pathway, involving platelet desialylation that favors their binding to the Ashwell-Morell receptor and their clearance in the liver. Cytotoxic T cells also contribute to ITP pathogenesis by mediating cytotoxicity against megakaryocytes and peripheral platelets. The deficient megakaryopoiesis resulting from both the humoral and the cytotoxic immune responses is sustained by inappropriate levels of thrombopoietin, the major growth factor of megakaryocytes. The better understanding of ITP pathogenesis has provided important therapeutic advances. B cell-targeting therapies and thrombopoietin-receptor agonists (TPO-RAs) have been used for years. New emerging therapeutic strategies that inhibit FcγR signaling, the neonatal Fc receptor or the classical complement pathway, will deeply modify the management of ITP in the near future.
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12
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A modern reassessment of glycoprotein-specific direct platelet autoantibody testing in immune thrombocytopenia. Blood Adv 2021; 4:9-18. [PMID: 31891657 DOI: 10.1182/bloodadvances.2019000868] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 11/21/2019] [Indexed: 12/30/2022] Open
Abstract
Platelet autoantibody (PA) testing has previously shown poor sensitivity for immune thrombocytopenia (ITP) diagnosis, but no previous study used both 2011 American Society of Hematology (ASH) guidelines for ITP diagnosis and 2012 International Society on Thrombosis and Haemostasis (ISTH) PA testing recommendations. We therefore performed a comprehensive retrospective study of PA testing in adult patients with ITP strictly applying these criteria. Of 986 PA assays performed, 485 assays in 368 patients met criteria and were included. Sensitivity and specificity of a positive test result for diagnosis of active ITP (n = 228 patients) were 90% and 78%, respectively. Sensitivity and specificity of a negative test result for clinical remission (n = 61 assays) were 87% and 91%. Antibodies against both glycoprotein IIb (GPIIb)/IIIa and GPIb/IX were required for the presence of antibodies against GPIa/IIa in patients with ITP. Logistic regression analysis revealed that more positive autoantibodies predicted more severe disease (relative to nonsevere ITP, relative risk ratio for severe ITP and refractory ITP was 2.27 [P < .001] and 3.09 [P < .001], respectively, per additional autoantibody); however, serologic testing did not meaningfully predict treatment response to glucocorticoids, intravenous immunoglobulin, or thrombopoietin receptor agonists. Sixty-four patients with ITP had multiple PA assays performed longitudinally: all 10 patients achieving remission converted from positive to negative serologic results, and evidence for epitope spreading was observed in 35% of patients with ongoing active disease. In conclusion, glycoprotein-specific direct PA testing performed using ISTH recommendations in patients meeting ASH diagnostic criteria is sensitive and specific for ITP diagnosis and reliably confirms clinical remission. More glycoproteins targeted by autoantibodies predicts for more severe disease.
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13
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Sandal R, Mishra K, Jandial A, Sahu KK, Siddiqui AD. Update on diagnosis and treatment of immune thrombocytopenia. Expert Rev Clin Pharmacol 2021; 14:553-568. [PMID: 33724124 DOI: 10.1080/17512433.2021.1903315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is a heterogeneous acquired disorder characterized by isolated thrombocytopenia whose exact pathogenesis is not yet clear. Depending upon the presence or absence of an underlying treatable cause, ITP can be categorized as primary or secondary. Primary ITP is a diagnosis of exclusion and there is no gold standard test for its confirmation. Recent drug intake, infections, lymphoproliferative disorders, and connective tissue disorders should be ruled out before labeling a patient as primary ITP. AREA COVERED This review summarizes a comprehensive update on the diagnostic and therapeutic modalities for ITP. We reviewed the literature using GOOGLE SCHOLAR, PUBMED and ClinicalTrial.gov databases as needed to support the evidence. We searched the literature using the following keywords: 'immune thrombocytopenia,' 'idiopathic thrombocytopenic purpura,' 'thrombocytopenia,' 'immune thrombocytopenic purpura,' and 'isolated thrombocytopenia'. EXPERT OPINION We believe that more detailed studies are required to understand the exact pathophysiology behind ITP. The first-line drugs like corticosteroids have both short-term and long-term adverse effects. This brings the need to explore effective alternative medications and to reconsider their role in ITP treatment algorithm if guidelines can be modified based on new studies.
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Affiliation(s)
- Rajeev Sandal
- Dept of Clinical Hematology, IGMC, Shimla, Himachal Pradesh, India
| | - Kundan Mishra
- Department of Internal Medicine (Adult Clinical Hematology Division), Postgraduate Institute of Medical Education and Research, Chandigarh (Union Territory), India
| | - Aditya Jandial
- Dept of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), Delhi, India
| | - Kamal Kant Sahu
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
| | - Ahmad Daniyal Siddiqui
- Division of Hematology and Oncology, Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
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14
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Porcelijn L, Schmidt DE, Oldert G, Hofstede-van Egmond S, Kapur R, Zwaginga JJ, de Haas M. Evolution and Utility of Antiplatelet Autoantibody Testing in Patients with Immune Thrombocytopenia. Transfus Med Rev 2020; 34:258-269. [PMID: 33046350 DOI: 10.1016/j.tmrv.2020.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 01/01/2023]
Abstract
To this day, immune thrombocytopenia (ITP) remains a clinical diagnosis made by exclusion of other causes for thrombocytopenia. Reliable detection of platelet autoantibodies would support the clinical diagnosis, but the lack of specificity and sensitivity of the available methods for platelet autoantibody testing limits their value in the diagnostic workup of thrombocytopenia. The introduction of methods for glycoprotein-specific autoantibody detection has improved the specificity of testing and is acceptable for ruling in ITP but not ruling it out as a diagnosis. The sensitivity of these assays varies widely, even between studies using comparable assays. A review of the relevant literature combined with our own laboratory's experience of testing large number of serum and platelet samples makes it clear that this variation can be explained by variations in the characteristics of the tests, including in the glycoprotein-specific monoclonal antibodies, the glycoproteins that are tested, the platelet numbers used in the assay and the cutoff levels for positive and negative results, as well as differences in the tested patient populations. In our opinion, further standardization and optimization of the direct autoantibody detection methods to increase sensitivity without compromising specificity seem possible but will still likely be insufficient to distinguish the often very weak specific autoantibody signals from background signals. Further developments of autoantibody detection methods will therefore be necessary to increase sensitivity to a level acceptable to provide laboratory confirmation of a diagnosis of ITP.
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Affiliation(s)
- Leendert Porcelijn
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, the Netherlands.
| | - David E Schmidt
- Sanquin Research, Department of Experimental Immunohematology, Amsterdam and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Gonda Oldert
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, the Netherlands
| | | | - Rick Kapur
- Sanquin Research, Department of Experimental Immunohematology, Amsterdam and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jaap Jan Zwaginga
- Department of Immuno-hematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands; Sanquin Research, Center for Clinical Transfusion Research, Leiden, the Netherlands; Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| | - Masja de Haas
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, the Netherlands; Sanquin Research, Center for Clinical Transfusion Research, Leiden, the Netherlands; Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
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15
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Zheng SS, Perdomo JS, Leung HHL, Yan F, Chong BH. Acquired Glanzmann thrombasthenia associated with platelet desialylation. J Thromb Haemost 2020; 18:714-721. [PMID: 31869497 DOI: 10.1111/jth.14722] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 11/30/2019] [Accepted: 12/17/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The notable discrepancy between platelet count and bleeding manifestations in immune thrombocytopenia (ITP) patients with acquired Glanzmann thrombasthenia (GT) has been described. OBJECTIVES We aimed to examine the mechanisms responsible for thrombocytopenia and the bleeding phenotype in a patient with acquired GT. PATIENT, METHODS, AND RESULTS A patient with primary ITP underwent splenectomy due to steroid intolerance. Despite platelet count normalization, bleeding continued. Platelet aggregometry was abnormal with all agonists except for ristocetin. Flow cytometry demonstrated the presence of antiplatelet antibody, which caused dose-dependent inhibition of fibrinogen and PAC-1 binding, induction of neuraminidase-1 expression as well as platelet desialylation in donor platelets. Indirect monoclonal antibody immobilization of platelet specific antigen assay (MAIPA) confirmed specificity to αIIb β3 only, corroborated by binding on Chinese hamster ovary (CHO) cells expressing human glycoprotein αIIb β3 but not GP Ib/IX. Both desialylation and neuraminidase expression were observed with plasma adsorbed on Ib/IX CHO cells and with the immunoglobulin G (IgG) fraction. Desialylation was inhibited in the presence of anti-Fc-gamma receptor IIa (FcγRIIa) antibody. A nonobese diabetic/severe combined immunodeficient ITP murine model was established, which showed rapid hepatic donor platelet clearance in the presence of patient IgG. Treatment of mice with the neuraminidase inhibitor oseltamivir significantly reduced antibody-induced platelet destruction. CONCLUSIONS We report the first case of a patient with acquired GT due to ITP with FcγRIIa mediated platelet desialylation, independent of platelet activation. Treatment with neuraminidase inhibitor may prevent platelet clearance by anti-αIIb β3 antibodies.
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Affiliation(s)
- Shiying Silvia Zheng
- Haematology Research Unit, St. George and Sutherland Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - José Sail Perdomo
- Haematology Research Unit, St. George and Sutherland Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Halina Hoi Laam Leung
- Haematology Research Unit, St. George and Sutherland Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Feng Yan
- Haematology Research Unit, St. George and Sutherland Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Beng Hock Chong
- Haematology Research Unit, St. George and Sutherland Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Haematology, St. George Hospital, Kogarah, NSW, Australia
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16
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Martellosio JP, Barra A, Roy-Peaud F, Souchaud-Debouverie O, Martin M, Lateur C, Gombert JM, Roblot P, Puyade M. Performance diagnostique des rapports κ/λ des chaines légères libres sériques (test Freelite®) et IgGκ/IgGλ (test Hevylite®) comme marqueurs pronostiques de chronicisation du purpura thrombopénique immunologique de l’adulte. Rev Med Interne 2020; 41:3-7. [DOI: 10.1016/j.revmed.2019.10.333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 10/08/2019] [Accepted: 10/21/2019] [Indexed: 10/25/2022]
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17
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Provan D, Arnold DM, Bussel JB, Chong BH, Cooper N, Gernsheimer T, Ghanima W, Godeau B, González-López TJ, Grainger J, Hou M, Kruse C, McDonald V, Michel M, Newland AC, Pavord S, Rodeghiero F, Scully M, Tomiyama Y, Wong RS, Zaja F, Kuter DJ. Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Adv 2019; 3:3780-3817. [PMID: 31770441 PMCID: PMC6880896 DOI: 10.1182/bloodadvances.2019000812] [Citation(s) in RCA: 549] [Impact Index Per Article: 109.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 09/18/2019] [Indexed: 01/19/2023] Open
Abstract
Over the last decade, there have been numerous developments and changes in treatment practices for the management of patients with immune thrombocytopenia (ITP). This article is an update of the International Consensus Report published in 2010. A critical review was performed to identify all relevant articles published between 2009 and 2018. An expert panel screened, reviewed, and graded the studies and formulated the updated consensus recommendations based on the new data. The final document provides consensus recommendations on the diagnosis and management of ITP in adults, during pregnancy, and in children, as well as quality-of-life considerations.
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Affiliation(s)
- Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Donald M Arnold
- McMaster Centre for Transfusion Research, Department of Medicine and Department of Pathology and Molecular Medicine, McMaster University and Canadian Blood Services, Hamilton, ON, Canada
| | - James B Bussel
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY
| | - Beng H Chong
- St. George Hospital, NSW Health Pathology, University of New South Wales, Sydney, NSW, Australia
| | - Nichola Cooper
- Department of Haematology, Hammersmith Hospital, London, United Kingdom
| | | | - Waleed Ghanima
- Departments of Research, Medicine and Oncology, Østfold Hospital Trust, Grålum, Norway
- Department of Hematology, Institute of Clinical Medicine, Oslo University, Oslo, Norway
| | - Bertrand Godeau
- Centre de Référence des Cytopénies Auto-Immunes de l'Adulte, Service de Médecine Interne, CHU Henri Mondor, AP-HP, Université Paris-Est Créteil, Créteil, France
| | | | - John Grainger
- Department of Haematology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Ming Hou
- Department of Haematology, Qilu Hospital, Shandong University, Jinan, China
| | | | - Vickie McDonald
- Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Marc Michel
- Centre de Référence des Cytopénies Auto-Immunes de l'Adulte, Service de Médecine Interne, CHU Henri Mondor, AP-HP, Université Paris-Est Créteil, Créteil, France
| | - Adrian C Newland
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Sue Pavord
- Haematology Theme Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Francesco Rodeghiero
- Hematology Project Foundation, Affiliated to the Department of Cell Therapy and Hematology, San Bortolo Hospital, Vicenza, Italy
| | - Marie Scully
- Department of Haematology, University College London Hospital, Cardiometabolic Programme-NIHR UCLH/UCL BRC, London, United Kingdom
| | - Yoshiaki Tomiyama
- Department of Blood Transfusion, Osaka University Hospital, Osaka, Japan
| | - Raymond S Wong
- Sir YK Pao Centre for Cancer and Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
| | - Francesco Zaja
- SC Ematologia, Azienda Sanitaria Universitaria Integrata, Trieste, Italy; and
| | - David J Kuter
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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18
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Hirokawa M, Fujishima N, Togashi M, Saga A, Omokawa A, Saga T, Moritoki Y, Ueki S, Takahashi N, Kitaura K, Suzuki R. High-throughput sequencing of IgG B-cell receptors reveals frequent usage of the rearranged IGHV4-28/IGHJ4 gene in primary immune thrombocytopenia. Sci Rep 2019; 9:8645. [PMID: 31201346 PMCID: PMC6570656 DOI: 10.1038/s41598-019-45264-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 06/04/2019] [Indexed: 11/26/2022] Open
Abstract
Primary immune thrombocytopenia (ITP) is an acquired form of thrombocytopenia caused by IgG anti-platelet autoantibodies and represents an organ-specific autoimmune disorder. Although the glycoprotein (GP)IIb/IIIa and GPIb/IX have been shown to be targets for autoantibodies, the antigen specificity of autoantibodies is not fully elucidated. To identify the characteristics of IgG B-cell receptor (BCR) repertoires in ITP, we took advantage of adaptor-ligation PCR and high-throughput DNA sequencing methods for analyzing the clone-based repertoires of IgG-expressing peripheral blood B cells. A total of 2,009,943 in-frame and 315,469 unique reads for IGH (immunoglobulin heavy) were obtained from twenty blood samples. Comparison of the IGHV repertoires between patients and controls revealed an increased usage of IGHV4–28 in ITP patients. One hundred eighty-six distinct IGHV4–28-carrying sequences were identified in ITP patients and the majority of these clones used an IGHJ4 segment. The IGHV4–28/IGHJ4-carrying B-cell clones were found in all ITP patients. Oligoclonal expansions of IGHV4–28/IGHJ4-carrying B cells were accompanied by multiple related clones with single amino substitution in the CDR3 region suggesting somatic hypermutation. Taken together, the expansion of IGHV4–28/IGHJ4-carrying IgG-expressing B cells in ITP may be the result of certain antigenic pressure and may provide a clue for the immune pathophysiology of ITP.
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Affiliation(s)
- Makoto Hirokawa
- Department of General Internal Medicine and Clinical Laboratory Medicine, Akita University Graduate School of Medicine, Akita, Japan.
| | - Naohito Fujishima
- Division of Blood Transfusion, Akita University Hospital, Akita, Japan.,Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Masaru Togashi
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Akiko Saga
- Department of General Internal Medicine and Clinical Laboratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Ayumi Omokawa
- Department of General Internal Medicine and Clinical Laboratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Tomoo Saga
- Department of General Internal Medicine and Clinical Laboratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Yuki Moritoki
- Department of General Internal Medicine and Clinical Laboratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Shigeharu Ueki
- Department of General Internal Medicine and Clinical Laboratory Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Naoto Takahashi
- Department of Hematology, Nephrology and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | | | - Ryuji Suzuki
- Repertoire Genesis Incorporation, Ibaraki, Japan.,Department of Rheumatology and Clinical Immunology, Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Japan
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19
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Vrbensky JR, Moore JE, Arnold DM, Smith JW, Kelton JG, Nazy I. The sensitivity and specificity of platelet autoantibody testing in immune thrombocytopenia: a systematic review and meta-analysis of a diagnostic test. J Thromb Haemost 2019; 17:787-794. [PMID: 30801909 DOI: 10.1111/jth.14419] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 02/15/2019] [Indexed: 11/30/2022]
Abstract
Essentials The diagnosis of ITP is based on a platelet count < 100 × 109 L-1 and exclusion of other causes. There are no standard tests or biomarkers to diagnose ITP. The sensitivity of platelet autoantibody testing is low (53%). The specificity is high (> 90%). A positive autoantibody test can be useful to rule in ITP but a negative does not rule out ITP. SUMMARY: Background Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by a low platelet count and an increased risk of bleeding. The sensitivity and specificity of platelet autoantibody tests is variable and their utility is uncertain. Objective The purpose of this study was to perform a systematic review and meta-analysis of platelet autoantibody tests in the diagnosis of ITP. Methods Ovid Medline, PubMed, and Web of Science were searched from inception until 31 May 2018. Two reviewers independently assessed studies for eligibility and extracted data. Studies that reported testing results for antiplatelet autoantibodies on platelets (direct tests) or in plasma/serum (indirect tests) for 20 or more ITP patients were included. Results Pooled estimates for sensitivity and specificity were calculated using a random effects model. Pooled estimates for the sensitivity and specificity of direct anti-platelet autoantibody testing for either anti-glycoprotein IIbIIIa or anti-glycoprotein IbIX were 53% (95% confidence interval [CI], 44-61%) and 93% (95% CI, 81-99%), respectively. For indirect testing, the pooled estimates for the sensitivity and specificity were 18% (95% CI, 12-24%) and 96% (95% CI, 87-100%), respectively. Conclusions Autoantibody testing in ITP patients has a high specificity but low sensitivity. A positive autoantibody test can be useful for ruling in ITP, but a negative test does not rule out ITP.
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Affiliation(s)
- John R Vrbensky
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Joyce E Moore
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Centre for Transfusion Research, Hamilton, Ontario, Canada
- Canadian Blood Services, Hamilton, Ontario, Canada
| | - James W Smith
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John G Kelton
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Centre for Transfusion Research, Hamilton, Ontario, Canada
| | - Ishac Nazy
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Centre for Transfusion Research, Hamilton, Ontario, Canada
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20
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Vollenberg R, Jouni R, Norris PAA, Burg-Roderfeld M, Cooper N, Rummel MJ, Bein G, Marini I, Bayat B, Burack R, Lazarus AH, Bakchoul T, Sachs UJ. Glycoprotein V is a relevant immune target in patients with immune thrombocytopenia. Haematologica 2019; 104:1237-1243. [PMID: 30923095 PMCID: PMC6545841 DOI: 10.3324/haematol.2018.211086] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 03/20/2019] [Indexed: 11/16/2022] Open
Abstract
Platelet autoantibody-induced platelet clearance represents a major pathomechanism in immune thrombocytopenia (ITP). There is growing evidence for clinical differences between anti-glycoprotein IIb/IIIa and anti-glycoprotein Ib/IX mediated ITP. Glycoprotein V is a well characterized target antigen in Varicella-associated and drug-induced thrombocytopenia. We conducted a systematic study assessing the prevalence and functional capacity of autoantibodies against glycoprotein V. A total of 1140 patients were included. In one-third of patients, platelet-bound autoantibodies against glycoproteins Ib/IX, IIb/IIIa, or V were detected in a monoclonal antibody immobilization of platelet antigen assay; platelet-bound autoantiglycoprotein V was present in the majority of samples (222 out of 343, 64.7%). Investigation of patient sera revealed the presence of free autoantibodies against glycoprotein V in 13.5% of these patients by an indirect monoclonal antibody immobilization of platelet antigen assay, but in 39.6% by surface plasmon resonance technology. These antibodies showed significantly lower avidity (association/dissociation ratio 0.32±0.13 vs. 0.73±0.14; P<0.001). High- and low-avidity antibodies induced comparable amounts of platelet uptake in a phagocytosis assay using CD14+ positively-selected human macrophages [mean phagocytic index, 6.81 (range, 4.75-9.86) vs. 6.01 (range, 5.00-6.98); P=0.954]. In a NOD/SCID mouse model, IgG prepared from both types of anti-glycoprotein V autoantibodies eliminated human platelets with no detectable difference between the groups from the murine circulation [mean platelet survival at 300 minutes, 40% (range, 27-55) vs. 35% (16-46); P=0.025]. Our data establish glycoprotein V as a relevant immune target in immune thrombocytopenia. We would suggest that further studies including glycoprotein V will be required before ITP treatment can be tailored according to platelet autoantibody specificity.
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Affiliation(s)
- Richard Vollenberg
- Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany
| | - Rabie Jouni
- Center for Clinical Transfusion Medicine, Medical Faculty of Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Peter A A Norris
- The Canadian Blood Services & The Keenan Research Centre of St. Michael's Hospital, Toronto, ON, Canada
| | - Monika Burg-Roderfeld
- Faculty for Chemistry and Biology, Fresenius University of Applied Sciences, Idstein, Germany
| | - Nina Cooper
- Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany
| | - Mathias J Rummel
- IVth Department of Internal Medicine (Hematology/Oncology), Justus Liebig University, Giessen, Germany
| | - Gregor Bein
- Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany
| | - Irene Marini
- Center for Clinical Transfusion Medicine, Medical Faculty of Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Behnaz Bayat
- Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany
| | - Richard Burack
- Department of Pathology and Laboratory Medicine, University of Rochester, NY, USA
| | - Alan H Lazarus
- The Canadian Blood Services & The Keenan Research Centre of St. Michael's Hospital, Toronto, ON, Canada
| | - Tamam Bakchoul
- Center for Clinical Transfusion Medicine, Medical Faculty of Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Ulrich J Sachs
- Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany .,Center for Transfusion Medicine and Hemotherapy and Hemostasis Center, University Hospital Giessen and Marburg, Marburg, Germany
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21
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Nurden AT. Acquired Glanzmann thrombasthenia: From antibodies to anti-platelet drugs. Blood Rev 2019; 36:10-22. [PMID: 31010659 DOI: 10.1016/j.blre.2019.03.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/15/2019] [Accepted: 03/19/2019] [Indexed: 02/06/2023]
Abstract
In contrast to the inherited platelet disorder given by mutations in the ITGA2B and ITGB3 genes, mucocutaneous bleeding from a spontaneous inhibition of normally expressed αIIbβ3 characterizes acquired Glanzmann thrombasthenia (GT). Classically, it is associated with autoantibodies or paraproteins that block platelet aggregation without causing a fall in platelet count. However, inhibitory antibodies to αIIbβ3 are widely associated with primary immune thrombocytopenia (ITP), occur in secondary ITP associated with leukemia and related disorders, solid cancers and myeloma, other autoimmune diseases, following organ transplantation while cytoplasmic dysregulation of αIIbβ3 function features in myeloproliferative and myelodysplastic syndromes. Antibodies to αIIbβ3 occur during viral and bacterial infections, while drug-dependent antibodies reacting with αIIbβ3 are a special case. Direct induction of acquired GT is a feature of therapies that block platelets in coronary artery disease. This review looks at these conditions, emphasizing molecular mechanisms, therapy, patient management and future directions for research.
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Affiliation(s)
- Alan T Nurden
- Institut de Rhythmologie et de Modélisation Cardiaque, Plateforme Technologique d'Innovation Biomédicale, Hôpital Xavier Arnozan, Pessac, France.
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22
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Brückner C, Lehmann C, Dudziak D, Nimmerjahn F. Sweet SIGNs: IgG glycosylation leads the way in IVIG-mediated resolution of inflammation. Int Immunol 2019; 29:499-509. [PMID: 29300958 DOI: 10.1093/intimm/dxx053] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 10/04/2017] [Indexed: 12/31/2022] Open
Abstract
A hallmark of many chronic inflammatory and autoimmune diseases is that there is an impaired resolution of inflammation and return to the steady state. The infusion of high doses of pooled serum IgG preparations from thousands of donors [intravenous immunoglobulin (IVIG) therapy] has been shown to induce resolution of inflammation in a variety of chronic inflammatory and autoimmune diseases, suggesting that IgG molecules can instruct the immune system to stop inflammatory processes and initiate the return to the steady state. The aim of this review is to discuss how insights into the mechanism of IVIG activity may help to understand the molecular and cellular pathways underlying resolution of inflammation. We will put a special emphasis on pathways dependent on the IgG FC domain and IgG sialylation, as several recent studies have provided new insights into how this glycosylation-dependent pathway modulates innate and adaptive immune responses through different sets of C-type or I-type lectins.
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Affiliation(s)
- Christin Brückner
- Chair of Genetics, Department of Biology, Friedrich Alexander University Erlangen Nürnberg (FAU), Germany
| | - Christian Lehmann
- Department of Dermatology, Laboratory of Dendritic Cell Biology, University Hospital Erlangen, Germany
| | - Diana Dudziak
- Department of Dermatology, Laboratory of Dendritic Cell Biology, University Hospital Erlangen, Germany.,Medical Immunology Campus Erlangen, Germany
| | - Falk Nimmerjahn
- Chair of Genetics, Department of Biology, Friedrich Alexander University Erlangen Nürnberg (FAU), Germany.,Medical Immunology Campus Erlangen, Germany
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23
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Dai L, He L, Wang Z, Bai X, He Y, Cao L, Zhu M, Ruan C. Altered circulating T follicular helper cells in patients with chronic immune thrombocytopenia. Exp Ther Med 2018; 16:2471-2477. [PMID: 30186484 PMCID: PMC6122441 DOI: 10.3892/etm.2018.6508] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 06/01/2018] [Indexed: 12/27/2022] Open
Abstract
The present study aimed to illuminate the role of circulating T follicular helper (TFH) cells in patients diagnosed with chronic immune thrombocytopenia (cITP). Fifty-four patients with cITP and 30 age-matched healthy control subjects were enrolled in the present study. TFH cell frequencies, expression of CD4+ TFH cell-associated cytokines, including interleukin (IL)-2, IL-4, IL-10 and IL-21 and associated regulatory mRNA expression levels including Bcl-6, c-Maf, Blimp-1 and PD-1 pre- and post-treatment with intravenous immunoglobulin and corticosteroids, were detected by flow cytometry, ELISA and reverse transcription-quantitative polymerase chain reaction, respectively. TFH cell frequencies of patients were significantly higher compared with healthy controls pre-treatment (P<0.05). Following treatment, significantly decreased percentages of TFH cells were present in cITP responders (P<0.05). Correlation analysis revealed that the number of TFH cells was negatively correlated with the platelet count in the peripheral blood. Furthermore, analysis of inflammatory cytokines indicated significant differences in serum interleukin (IL)-21 and IL-10 between pretreated patients and healthy controls (P<0.05). Additionally, transcription factor B-cell lymphoma (Bcl)-6, c-Maf and programmed death-ligand (PD)-1 mRNA expression levels were significantly different between cITP patients prior to treatment and the healthy controls (P<0.05). However, the expression levels of Bcl-6, C-Maf and PD-1 mRNA were significantly changed post-treatment (P<0.05). These data demonstrated that circulating TFH cells and CD4+ TFH cell-associated cytokines may serve a role in cITP. The findings suggest that the overactivation of TFH cells may contribute to the immunopathogenesis of cITP, thus blocking the pathway of TFH cells may be reasonable for therapeutic intervention.
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Affiliation(s)
- Lan Dai
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Linyan He
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Zhaoyue Wang
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Xia Bai
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Yang He
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Lijuan Cao
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Mingqing Zhu
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Changgeng Ruan
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu 215006, P.R. China
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24
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Guo L, Kapur R, Aslam R, Hunt K, Hou Y, Zufferey A, Speck ER, Rondina MT, Lazarus AH, Ni H, Semple JW. Antiplatelet antibody-induced thrombocytopenia does not correlate with megakaryocyte abnormalities in murine immune thrombocytopenia. Scand J Immunol 2018; 88:e12678. [DOI: 10.1111/sji.12678] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 05/29/2018] [Indexed: 11/29/2022]
Affiliation(s)
- L. Guo
- The Toronto Platelet Immunobiology Group; Toronto ON Canada
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital; Toronto ON Canada
- Institute of Medical Science; University of Toronto; Toronto ON Canada
- University of Utah; Salt Lake City UT USA
| | - R. Kapur
- The Toronto Platelet Immunobiology Group; Toronto ON Canada
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital; Toronto ON Canada
- Institute of Medical Science; University of Toronto; Toronto ON Canada
- Canadian Blood Services; Lund University; Canadian Blood Services; Toronto ON Canada
- Division of Hematology and Transfusion Medicine; Lund University; Lund Sweden
| | - R. Aslam
- The Toronto Platelet Immunobiology Group; Toronto ON Canada
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital; Toronto ON Canada
| | - K. Hunt
- The Toronto Platelet Immunobiology Group; Toronto ON Canada
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital; Toronto ON Canada
| | - Y. Hou
- The Toronto Platelet Immunobiology Group; Toronto ON Canada
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital; Toronto ON Canada
| | - A. Zufferey
- The Toronto Platelet Immunobiology Group; Toronto ON Canada
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital; Toronto ON Canada
| | - E. R. Speck
- The Toronto Platelet Immunobiology Group; Toronto ON Canada
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital; Toronto ON Canada
| | | | - A. H. Lazarus
- The Toronto Platelet Immunobiology Group; Toronto ON Canada
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital; Toronto ON Canada
- Institute of Medical Science; University of Toronto; Toronto ON Canada
- Department of Medicine; University of Toronto; Toronto ON Canada
- Department of Laboratory Medicine and Pathobiology; University of Toronto; Toronto ON Canada
| | - H. Ni
- The Toronto Platelet Immunobiology Group; Toronto ON Canada
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital; Toronto ON Canada
- Institute of Medical Science; University of Toronto; Toronto ON Canada
- Department of Medicine; University of Toronto; Toronto ON Canada
- Department of Laboratory Medicine and Pathobiology; University of Toronto; Toronto ON Canada
| | - J. W. Semple
- The Toronto Platelet Immunobiology Group; Toronto ON Canada
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital; Toronto ON Canada
- Institute of Medical Science; University of Toronto; Toronto ON Canada
- Canadian Blood Services; Lund University; Canadian Blood Services; Toronto ON Canada
- Division of Hematology and Transfusion Medicine; Lund University; Lund Sweden. Department of Medicine; University of Toronto; Toronto ON Canada. Department of Laboratory Medicine and Pathobiology; University of Toronto; Toronto ON Canada. Department of Pharmacology; University of Toronto; Toronto ON Canada
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25
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Swinkels M, Rijkers M, Voorberg J, Vidarsson G, Leebeek FWG, Jansen AJG. Emerging Concepts in Immune Thrombocytopenia. Front Immunol 2018; 9:880. [PMID: 29760702 PMCID: PMC5937051 DOI: 10.3389/fimmu.2018.00880] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 04/09/2018] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease defined by low platelet counts which presents with an increased bleeding risk. Several genetic risk factors (e.g., polymorphisms in immunity-related genes) predispose to ITP. Autoantibodies and cytotoxic CD8+ T cells (Tc) mediate the anti-platelet response leading to thrombocytopenia. Both effector arms enhance platelet clearance through phagocytosis by splenic macrophages or dendritic cells and by induction of apoptosis. Meanwhile, platelet production is inhibited by CD8+ Tc targeting megakaryocytes in the bone marrow. CD4+ T helper cells are important for B cell differentiation into autoantibody secreting plasma cells. Regulatory Tc are essential to secure immune tolerance, and reduced levels have been implicated in the development of ITP. Both Fcγ-receptor-dependent and -independent pathways are involved in the etiology of ITP. In this review, we present a simplified model for the pathogenesis of ITP, in which exposure of platelet surface antigens and a loss of tolerance are required for development of chronic anti-platelet responses. We also suggest that infections may comprise an important trigger for the development of auto-immunity against platelets in ITP. Post-translational modification of autoantigens has been firmly implicated in the development of autoimmune disorders like rheumatoid arthritis and type 1 diabetes. Based on these findings, we propose that post-translational modifications of platelet antigens may also contribute to the pathogenesis of ITP.
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Affiliation(s)
- Maurice Swinkels
- Department of Hematology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Maaike Rijkers
- Department of Plasma Proteins, AMC-Sanquin Landsteiner Laboratory, Amsterdam, Netherlands
| | - Jan Voorberg
- Department of Plasma Proteins, AMC-Sanquin Landsteiner Laboratory, Amsterdam, Netherlands
| | - Gestur Vidarsson
- Department of Experimental Immunohematology, AMC-Sanquin Landsteiner Laboratory, Amsterdam, Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - A J Gerard Jansen
- Department of Hematology, Erasmus University Medical Centre, Rotterdam, Netherlands.,Department of Plasma Proteins, AMC-Sanquin Landsteiner Laboratory, Amsterdam, Netherlands
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26
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Sakiyama C, Sullivan S. IgG4-Related Pancreatitis and Immune Thrombocytopenia: A Case Report and Literature Review. Cureus 2017; 9:e1724. [PMID: 29188168 PMCID: PMC5705167 DOI: 10.7759/cureus.1724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
A patient with a prior diagnosis of IgG4-related autoimmune pancreatitis (AIP) presented four years later with severe prednisone resistant immune thrombocytopenia (ITP). Her case is reported and the scant literature of the very unusual possible association of IgG4-related AIP and ITP is reviewed. It is suggested that investigation for IgG4-related disease be part of the work-up of ITP.
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Affiliation(s)
- Claire Sakiyama
- Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Stephen Sullivan
- Medicine/island Medical Program, University of Victoria, British Columbia, Canada
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27
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Nishimoto T, Okazaki Y, Numajiri M, Kuwana M. Mouse immune thrombocytopenia is associated with Th1 bias and expression of activating Fcγ receptors. Int J Hematol 2016; 105:598-605. [PMID: 28028748 DOI: 10.1007/s12185-016-2172-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 12/20/2016] [Accepted: 12/21/2016] [Indexed: 12/13/2022]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease mediated by anti-platelet autoantibodies. We recently established a mouse ITP model exhibiting regulatory T-cell (Treg) deficiency, although only one-third of the Treg-deficient mice developed ITP. To clarify mechanisms involved in the emergence of platelet-specific autoimmunity in this model, we examined the T helper (Th)-cell balance and macrophage Fcγ receptor (FcγR) expression profiles in Treg-deficient mice with and without ITP. Splenocytes from both populations of Treg-deficient mice and control BALB/c mice were subjected to flow cytometry-based analyses to evaluate Th cell subset proportions and the expression of activating and inhibitory FcγRs on macrophages. In addition, IgG subclass distribution of anti-platelet autoantibodies in splenocyte culture supernatants was determined by flow cytometry using IgG subclass-specific antibodies. Treg-deficient ITP mice exhibited a significantly higher proportion of Th1 cells than either Treg-deficient non-ITP or control mice. The predominant anti-platelet autoantibody subclasses in the ITP mice were Th1-associated IgG2a and IgG2b. Furthermore, the FcγRI/FcγRIIB expression ratio in splenic macrophages was higher in the Treg-deficient ITP than in the Treg-deficient non-ITP and control mice. In summary, Th1 polarization and macrophages' activating FcγR expression profile are associated with the development of ITP in Treg-deficient mice.
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Affiliation(s)
- Tetsuya Nishimoto
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yuka Okazaki
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Miku Numajiri
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Masataka Kuwana
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan. .,Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
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28
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Neschadim A, Kotra LP, Branch DR. Small molecule phagocytosis inhibitors for immune cytopenias. Autoimmun Rev 2016; 15:843-7. [PMID: 27296447 DOI: 10.1016/j.autrev.2016.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 06/07/2016] [Indexed: 01/19/2023]
Abstract
Immune cytopenias are conditions characterized by low blood cell counts, such as platelets in immune thrombocytopenia (ITP) and red blood cells in autoimmune hemolytic anemia (AIHA). Chronic ITP affects approximately 4 in 100,000 adults annually while AIHA is much less common. Extravascular phagocytosis and massive destruction of autoantibody-opsonized blood cells by macrophages in the spleen and liver are the hallmark of these conditions. Current treatment modalities for ITP and AIHA include the first-line use of corticosteroids; whereas, IVIg shows efficacy in ITP but not AIHA. One main mechanism of action by which IVIg treatment leads to the reduction in platelet destruction rates in ITP is thought to involve Fcγ receptor (FcγR) blockade, ultimately leading to the inhibition of extravascular platelet phagocytosis. IVIg, which is manufactured from the human plasma of thousands of donors, is a limited resource, and alternative treatments, particularly those based on bioavailable small molecules, are needed. In this review, we overview the pathophysiology of ITP, the role of Fcγ receptors, and the mechanisms of action of IVIg in treating ITP, and outline the efforts and progress towards developing novel, first-in-class inhibitors of phagocytosis as synthetic, small molecule substitutes for IVIg in ITP and other conditions where the pathobiology of the disease involves phagocytosis.
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Affiliation(s)
- Anton Neschadim
- Centre for Innovation, Canadian Blood Services, Toronto, ON, Canada
| | - Lakshmi P Kotra
- Center for Molecular Design and Preformulations, University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada; McLaughlin Center for Molecular Medicine, University of Toronto, Toronto, ON, Canada; Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Donald R Branch
- Centre for Innovation, Canadian Blood Services, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada; Division of Advanced Diagnostics, Infection and Immunity Group, Toronto General Hospital Research Institute, Toronto, ON, Canada.
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29
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Takasumi M, Miyata M, Kuroda M, Terashima K, Abe K, Takahashi A, Kobayashi H, Tazaki K, Watanabe H, Ohira H. Overlap of IgG4-related Disease and Primary Biliary Cirrhosis Complicated with Autoimmune Thrombocytopenia. Intern Med 2016; 55:1387-92. [PMID: 27181554 DOI: 10.2169/internalmedicine.55.6202] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 63-year-old woman was referred to Fukushima Red Cross Hospital with an enlargement of the left submandibular gland and subcutaneous bleeding in the chest and legs. A diffuse enlargement of the pancreas was also detected by abdominal computed tomography, and laboratory data showed severe thrombocytopenia. She was diagnosed with IgG4-related disease (IgG4-RD) complicated with autoimmune thrombocytopenia and was treated with methylprednisolone, after which the number of platelets favorably increased. Further investigation for liver dysfunction revealed underlying primary biliary cirrhosis (PBC). We herein report a rare case of IgG4-RD overlapping PBC complicated with autoimmune thrombocytopenia.
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Affiliation(s)
- Mika Takasumi
- Department of Internal Medicine and Gastroenterology, Fukushima Red Cross Hospital, Japan
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30
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Refractory thrombocytopenia and neutropenia: a diagnostic challenge. Mediterr J Hematol Infect Dis 2015; 7:e2015018. [PMID: 25745545 PMCID: PMC4344166 DOI: 10.4084/mjhid.2015.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 01/28/2015] [Indexed: 11/27/2022] Open
Abstract
The 2008 WHO classification identified refractory cytopenia with unilineage dysplasia (RCUD) as a composite entity encompassing refractory anemia, refractory thrombocytopenia (RT), and refractory neutropenia (RN), characterized by 10% or more dysplastic cells in the bone marrow respective lineage. The diagnosis of RT and RN is complicated by several factors. Diagnosing RT first requires exclusion of familial thrombocytopenia, chronic auto-immune thrombocytopenia, concomitant medications, viral infections, or hypersplenism. Diagnosis of RN should also be made after ruling out differential diagnoses such as ethnic or familial neutropenia, as well as acquired, drug-induced, infection-related or malignancy-related neutropenia. An accurate quantification of dysplasia should be performed in order to distinguish RT or RN from the provisional entity named idiopathic cytopenia of unknown significance (ICUS). Cytogenetic analysis, and possibly in the future somatic mutation analysis (of genes most frequently mutated in MDS), and flow cytometry analysis aberrant antigen expression on myeloid cells may help in this differential diagnosis. Importantly, we and others found that, while isolated neutropenia and thrombocytopenia are not rare in MDS, those patients can generally be classified (according to WHO 2008 classification) as refractory cytopenia with multilineage dysplasia or refractory anemia with excess blasts, while RT and RN (according to WHO 2008) are quite rare. These results suggest in particular that identification of RT and RN as distinct entities could be reconsidered in future WHO classification updates.
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31
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Cines DB, Cuker A, Semple JW. Pathogenesis of immune thrombocytopenia. Presse Med 2014; 43:e49-59. [DOI: 10.1016/j.lpm.2014.01.010] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 01/29/2014] [Indexed: 12/30/2022] Open
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32
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Kahraman C, Emre H, Gulcan E, Bilen Y, Uludag K, Uyanik A, Keleş M. Combined immune thrombocytopenic purpura and immunoglobulin A nephropathy: a similar pathophysiologic process? Ren Fail 2014; 36:464-5. [PMID: 24456575 DOI: 10.3109/0886022x.2013.872568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
IgA nephropathy is one of the most common forms of glomerulopathies. It is an immune complex-mediated glomerulonephritis diagnosed by the presence of mesangial IgA deposits that are often associated with mesangial cell proliferation. The IgG, C3, IgM, or other immunoglobulin light chains may be co-existed with IgA. Its pathogenesis suggested that it is responsible for enhancing the production of proinflammatory cytokines, chemokines, and growth factors. Platelet-derived growth factor (PDGF) has also been implicated as a modulator of disease activity. Immune thrombocytopenic purpura (ITP) is a bleeding disorder caused by thrombocytopenia that is not associated with a systemic disease. Its pathogenesis suggested an autoimmune disease in which IgG is thought to damage megakaryocytes, which are the precursors of platelet cells. Several studies reported that PDGF levels were higher in normal subjects than in patients with ITP. Moreover, ITP is a disease related to the antibody. Thus, our aim is to examine whether a similar pathophysiological relationship exist between ITP and IgAN that may be mediated by PDGF and/or IgG.
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Affiliation(s)
- Cüneyt Kahraman
- Department of Internal Medicine and Nephrology, Dumlupinar University School of Medicine , Kutahya , Turkey
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33
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Chen JF, Yang LH, Chang LX, Feng JJ, Liu JQ. The clinical significance of circulating B cells secreting anti-glycoprotein IIb/IIIa antibody and platelet glycoprotein IIb/IIIa in patients with primary immune thrombocytopenia. ACTA ACUST UNITED AC 2013; 17:283-90. [PMID: 22971534 DOI: 10.1179/1607845412y.0000000014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES The objective of the study is to evaluate the possible roles of the detection of circulating B cells secreting anti-glycoprotein IIb/IIIa antibody, platelet glycoprotein IIb/IIIa, and anti-glycoprotein IIb/IIIa antibody in the diagnosis of primary immune thrombocytopenia (ITP) patients. METHODS Circulating B cells secreting anti-glycoprotein IIb/IIIa antibody, platelet glycoprotein IIb/IIIa and anti-glycoprotein IIb/IIIa antibody in 64 patients with ITP, 33 non-ITP patients, and 32 controls were measured with enzyme-linked immunospot assay (ELISPOT), monoclonal antibody immobilization of platelet antigens assay (MAIPA) and flow cytometic analysis (FCM), respectively. RESULTS Compared with the controls and non-ITP patients, the frequency of circulating B cells secreting anti-glycoprotein IIb/IIIa antibody was significantly increased, whereas the positive rate of platelet glycoprotein IIb/IIIa was significantly decreased (P < 0.05) in ITP patients, respectively. The sensitivities for the diagnosis of ITP of ELISPOT and FCM were 68.8% and 57.8%, and the specificities of 90.9% and 90.9%, respectively. The sensitivities of ELISPOT and FCM were higher than MAIPA's sensitivity (39.1%) (P < 0.05). However, there was no apparent difference of the sensitivities of ELISPOT and FCM and the specificities of those three detections (MAIPA's specificity was 81.8%) (P > 0.05). DISCUSSION ELISPOT and FCM for detecting the circulating B cells secreting anti-glycoprotein IIb/IIIa antibody and the platelet glycoprotein IIb/IIIa were as specific as that of MAIPA for assay of anti-glycoprotein IIb/IIIa antibody, but ELISPOT and FCM had higher sensitivities. So ELISPOT and FCM were sensitive and specific for identifying patients with autoantibody-mediated thrombocytopenia and these should be used as diagnostic tests in clinic.
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Affiliation(s)
- Jian-fang Chen
- The Second Hospital of Shanxi Medical University, Taiyuan, People's Republic of China
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Hoemberg M, Stahl D, Schlenke P, Sibrowski W, Pachmann U, Cassens U. The isotype of autoantibodies influences the phagocytosis of antibody-coated platelets in autoimmune thrombocytopenic purpura. Scand J Immunol 2011; 74:489-95. [PMID: 21790706 DOI: 10.1111/j.1365-3083.2011.02600.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Autoimmune thrombocytopenic purpura (AITP) is an acquired autoimmune bleeding disorder, characterized by isolated thrombocytopenia because of destruction of auto-antibody-coated platelets by Fc-receptor-mediated phagocytosis. The destruction of autoantibody-sensitized platelets by FcγR-bearing phagocytic cells and the following antigen presentation are considered to play a key role for the pathophysiology of AITP. Although different isotypes of AITP-mediating autoantibodies, e.g. IgG, IgM and IgA, are frequently found in AITP patients, their role in the pathophysiology of AITP remains unclear. Using a flow cytometric monocyte-based phagocytosis assay, we investigated the impact of disease-associated autoantibody isotype in antibody-mediated phagocytosis of platelets. Platelets, labelled with 5-chloromethyl fluorescein diacetate (CMFDA), were incubated with AITP patients' serum characterized by pure IgG or IgM antiplatelet autoantibodies. Labelled platelets were incubated with monocytes. Phagocytosis was defined as the product of percentage of CMFDA-positive monocytes and mean fluorescence intensity of CMFDA. Adherence of platelets to monocytes was quantified by anti-CD61-PerCp in a CMFDA(+) CD14(+) gate. IgG-coated platelets showed a significantly higher phagocytic index than IgM-coated platelets (mean 796 ± 157 versus 539 ± 78, P < 0.01). There were no significant differences regarding platelet adherence to monocytes. The isotype of autoantibodies influences the quantity of in vitro phagocytosis of autologous platelets by monocytes. Therefore, the AITP-mediating autoantibody isotype should be considered more carefully in pathophysiologic models and furthermore in diagnostic, therapeutic and prognostic approaches in AITP.
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Affiliation(s)
- M Hoemberg
- Institute of Transfusion Medicine and Transplantation Immunology, University Hospital Muenster, Germany.
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Abstract
PURPOSE OF REVIEW Blood platelets are involved in primary and secondary hemostasis and thus maintain the integrity of the vasculature. They circulate with an average lifespan of 5-9 days in humans. Thus, the body must generate and clear platelets daily to maintain normal physiological blood platelet counts. Known platelet clearance mechanisms include antibody-mediated clearance by spleen macrophages, as in immune thrombocytopenia, and platelet consumption due to massive blood loss. RECENT FINDINGS New concepts in the clearance mechanisms of platelets have recently emerged. New evidence shows that platelets desialyted due to chilling or sepsis are cleared in the liver by macrophages, that is Kupffer cells, as well as hepatocytes, through lectin-mediated recognition of platelet glycans. On the contrary, platelet-associated antibodies normalize the clearance of platelets in a mouse model for Wiskott-Aldrich syndrome. SUMMARY The goal of this review is to summarize the latest findings in platelet clearance mechanisms with a focus on lectin-mediated recognition of platelet glycans. Transfusion medicine and treatments of hematopoietic disorders associated with severe thrombocytopenia may benefit from a better understanding of these mechanisms.
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High-dose dexamethasone shifts the balance of stimulatory and inhibitory Fcgamma receptors on monocytes in patients with primary immune thrombocytopenia. Blood 2010; 117:2061-9. [PMID: 21131591 DOI: 10.1182/blood-2010-07-295477] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The human Fcγ receptor (FcγR) system is composed of 2 opposing families, the activating FcγRs (FcγRI, FcγRIIa, and FcγRIII) and the inhibitory FcγR (FcγRIIb). The disturbed balance of the activating and inhibitory FcγRs has been implicated in the pathogenesis of many autoimmune diseases. In this study, the expression of FcγRs on monocytes was determined in 23 patients with primary immune thrombocytopenia (ITP) before and after high-dose dexamethasone (HD-DXM) treatment. The FcγRI expression was significantly higher in ITP patients and decreased after HD-DXM treatment. The ratio of FcγRIIa/IIb mRNA expression on monocytes was significantly higher in untreated patients than in healthy controls. After HD-DXM therapy, the ratio decreased and the increased expression of FcγRIIb mRNA and protein coincided with a remarkable decrease in the expression of FcγRIIa, FcγRI, and monocyte phagocytic capacity. There was no significant difference in FcγRIII expression on monocytes between patients and controls. In vitro cell-culture experiments showed that DXM could induce FcγRIIa and FcγRIIb expression in monocytes from ITP patients, with FcγRIIb at higher amplitudes. These findings suggested that the disturbed FcγR balance might play a role in the pathogenesis of ITP, and that HD-DXM therapy could shift monocyte FcγR balance toward the inhibitory FcγRIIb in patients with ITP.
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Rocha AMC, De Souza C, Rocha GA, De Melo FF, Saraiva ISB, Clementino NCD, Marino MCA, Queiroz DMM. research paper: IL1RN VNTR and IL2−330 polymorphic genes are independently associated with chronic immune thrombocytopenia. Br J Haematol 2010; 150:679-84. [DOI: 10.1111/j.1365-2141.2010.08318.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Pang SJY, Lazarus AH. Mechanisms of platelet recovery in ITP associated with therapy. Ann Hematol 2010; 89 Suppl 1:31-5. [PMID: 20179926 DOI: 10.1007/s00277-010-0916-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 01/29/2010] [Indexed: 02/07/2023]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease primarily characterized by increased clearance of auto-antibody-sensitized platelets by Fc-receptor-bearing macrophages in the spleen and liver. It has been classically accepted that antibody-mediated platelet destruction is Fc dependent. Recent studies, however, may also indicate the involvement of Fc-independent pathways of platelet destruction. Current treatment options work by immunosuppression (e.g., corticosteroids), immunomodulation (e.g., IVIg and anti-D), or removal of the platelet destruction site (splenectomy) in ITP. This review will discuss the mechanisms of action of these and other treatments for ITP.
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Black LV, Maheshwari A. Disorders of the fetomaternal unit: hematologic manifestations in the fetus and neonate. Semin Perinatol 2009; 33:12-9. [PMID: 19167577 PMCID: PMC4429289 DOI: 10.1053/j.semperi.2008.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Histoarchitectural characteristics of the human placenta place the fetus at a high risk of growth restriction, abnormal fetomaternal cell traffic, and vertical transmission of pathogens. These abnormalities of the fetomaternal unit are frequently associated with hematological abnormalities in the fetus/neonate and may be the first, most common, or the only clinical manifestations of these conditions. This article reviews the pathophysiology and characteristic hematological manifestations of these conditions in the fetus and the neonate.
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Affiliation(s)
- L. Vandy Black
- Instructor in Pediatric Hematology-Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Akhil Maheshwari
- Corresponding Author: Phone: (205) 934-4680; Fax: (205) 212-2014,
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Asahi A, Nishimoto T, Okazaki Y, Suzuki H, Masaoka T, Kawakami Y, Ikeda Y, Kuwana M. Helicobacter pylori eradication shifts monocyte Fcgamma receptor balance toward inhibitory FcgammaRIIB in immune thrombocytopenic purpura patients. J Clin Invest 2008; 118:2939-49. [PMID: 18654664 DOI: 10.1172/jci34496] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2007] [Accepted: 05/14/2008] [Indexed: 12/13/2022] Open
Abstract
Immune thrombocytopenia purpura (ITP) is a bleeding disorder in which platelet-specific autoantibodies cause a loss of platelets. In a subset of patients with ITP and infected with Helicobacter pylori, the number of platelets recovers after eradication of H. pylori. To examine the role of H. pylori infection in the pathogenesis of ITP, the response of 34 ITP patients to treatment with a standard H. pylori eradication regimen, irrespective of whether they were infected with H. pylori, was evaluated. Eradication of H. pylori was achieved in all H. pylori-positive patients, and a significant increase in platelets was observed in 61% of these patients. By contrast, none of the H. pylori-negative patients showed increased platelets. At baseline, monocytes from the H. pylori-positive patients exhibited an enhanced phagocytic capacity and low levels of the inhibitory Fcgamma receptor IIB (FcgammaRIIB). One week after starting the H. pylori eradication regimen, this activated monocyte phenotype was suppressed and improvements in autoimmune and platelet kinetic parameters followed. Modulation of monocyte FcgammaR balance was also found in association with H. pylori infection in individuals who did not have ITP and in mice. Our findings strongly suggest that the recovery in platelet numbers observed in ITP patients after H. pylori eradication is mediated through a change in FcgammaR balance toward the inhibitory FcgammaRIIB.
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Affiliation(s)
- Atsuko Asahi
- Division of Rheumatology, Department of Internal Medicine, and Institute for Advanced Medical Research, Keio University School of Medicine, Tokyo, Japan
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Madhusudhanan M, Yusuff AM. Unusual presentation of chronic idiopathic thrombocytopenic purpura. Oman Med J 2008; 23:48-49. [PMID: 22567212 PMCID: PMC3338995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Accepted: 07/27/2007] [Indexed: 05/31/2023] Open
Abstract
A snakebite victim presented with normal clotting profile and a low platelet count. A routine CBC in his past records (February 2004) showed a platelet count of 20,000/microlitre, but the patient was not symptomatic. We report a case of chronic idiopathic thrombocytopenic purpura, incidentally found in a patient presenting with snakebite. The patient also has acquired primary testicular failure. After the diagnosis the patient was on regular follow up. He caused trauma to the right external auditory canal and perforated his tympanic membrane. His left tympanic membrane was also scarred and retracted. Establishing a diagnosis of an ITP early is important so that the patient can take precaution to avoid undue trauma and monitor proper follow up.
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Affiliation(s)
- M. Madhusudhanan
- Address Correspondence and reprint request to: M. Madhusudhanan, MD, Specialist & HOD, Laboratory Medicine Department, Rustaq Hospital, Rustaq, Sultanate of Oman.
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Abdelmalek MF, Hellner LB, Zumberg M, Melgen VW, Lottenberg R. Acute liver failure occurring immediately following anti-D immune globulin infusion in a patient with chronic hepatitis B infection. Dig Dis Sci 2007; 52:914-9. [PMID: 17347887 DOI: 10.1007/s10620-006-9319-6] [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: 11/07/2005] [Accepted: 03/17/2006] [Indexed: 12/09/2022]
Affiliation(s)
- Manal F Abdelmalek
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL 32610, USA
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Tomer A. Autoimmune thrombocytopenia: determination of platelet-specific autoantibodies by flow cytometry. Pediatr Blood Cancer 2006; 47:697-700. [PMID: 16933272 DOI: 10.1002/pbc.20987] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Autoimmune thrombocytopenia is a disorder characterized by antibody-mediated accelerated platelet destruction. Despite its clinical importance, the diagnosis of which is one of exclusion, thus inevitably associated with potential difficulties. Current methods used to determine antigen-specific antibodies including MAIPA and the radioactive immunobead assay, are not routinely used due to methodological and practical limitations. To facilitate diagnosis, flow cytometric methods have been developed, suitable for testing a single or multiple samples. The feasible flow cytometric methods with their high sensitivity and specificity should facilitate the routine use of diagnostic methods for autoimmune thrombocytopenia and permit follow-up to determine immune remission.
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Affiliation(s)
- Aaron Tomer
- Blood Bank and Transfusion Medicine, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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Bloor AJC, Smith GA, Jaswon M, Parker NE, Ouwehand WH, Liesner R. Acquired thrombasthenia due to GPIIbIIIa platelet autoantibodies in a 4-yr-old child. Eur J Haematol 2006; 76:89-90. [PMID: 16343278 DOI: 10.1111/j.1600-0609.2005.00574.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sandler SG, Tutuncuoglu SO. Immune thrombocytopenic purpura – current management practices. Expert Opin Pharmacother 2005; 5:2515-27. [PMID: 15571469 DOI: 10.1517/14656566.5.12.2515] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The treatment of patients with immune thrombocytopenic purpura (ITP) is changing rapidly, as new agents demonstrate the capability of improving outcomes and decreasing toxicity. Prior to 1981, the only effective treatment options available to increase platelet counts in persons with ITP were corticosteroids and splenectomy. In recent years, intravenous immunoglobulin (IVIg) and intravenous Rh immunoglobulin (IV RhIg) have demonstrated efficacy comparable to that of corticosteroids for increasing platelet counts in ITP. In addition, IVIg and IV RhIg have demonstrated efficacy for maintaining corticosteroid-induced increased platelet counts by periodic infusion, causing a transient impairment of reticuloendothelial clearance function (medical splenectomy). Thus, the time-proven efficacy of corticosteroids for initial treatment of ITP (induction) may now be supplemented with IVIg or IV RhIg infusions for patients requiring ongoing treatment to support a timely and complete steroid taper, while sustaining the increased platelet count (maintenance) with less toxicity. Several investigators have reported that rituximab (anti-CD20) induced sustained remissions with minimal toxicity, in patients with chronic ITP. These reports are promising and, if confirmed, will provide another effective (spleen-sparing) option for managing acute ITP and a long-awaited option for patients who have had a splenectomy and are refractory to conventional agents. Other treatments, including danazol, azathioprine, cyclophosphamide, vinca alkaloids and cyclosporin A, have advocates, but evidence of their efficacy is limited to relatively small and mostly uncontrolled clinical trials. In our opinion, these agents should be reserved for symptomatic thrombocytopenia after refractoriness to corticosteroids, IVIg, IV RhIg, splenectomy and rituximab has been clearly established.
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Affiliation(s)
- S Gerald Sandler
- Georgetown University Hospital, Department of Laboratory Medicine, 3800 Reservoir Road, NW, Washington, DC 20007, USA.
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Abstract
Abstract
Hemolytic anemia due to immune function is one of the major causes of acquired hemolytic anemia. In recent years, as more is known about the immune system, these entities have become better understood and their treatment improved. In this section, we will discuss three areas in which this progress has been apparent.
In Section I, Dr. Peter Hillmen outlines the recent findings in the pathogenesis of paroxysmal nocturnal hemoglobinuria (PNH), relating the biochemical defect (the lack of glycosylphosphatidylinositol [GPI]-linked proteins on the cell surface) to the clinical manifestations, particularly hemolysis (and its effects) and thrombosis. He discusses the pathogenesis of the disorder in the face of marrow dysfunction insofar as it is known. His major emphasis is on innovative therapies that are designed to decrease the effectiveness of complement activation, since the lack of cellular modulation of this system is the primary cause of the pathology of the disease. He recounts his considerable experience with a humanized monoclonal antibody against C5, which has a remarkable effect in controlling the manifestations of the disease. Other means of controlling the action of complement include replacing the missing modulatory proteins on the cell surface; these studies are not as developed as the former agent.
In Section II, Dr. Alan Schreiber describes the biochemistry, genetics, and function of the Fcγ receptors and their role in the pathobiology of autoimmune hemolytic anemia and idiopathic thrombocytopenic purpura due to IgG antibodies. He outlines the complex varieties of these molecules, showing how they vary in genetic origin and in function. These variations can be related to three-dimensional topography, which is known in some detail. Liganding IgG results in the transduction of a signal through the tyrosine-based activation motif and Syk signaling. The role of these receptors in the pathogenesis of hematological diseases due to IgG antibodies is outlined and the potential of therapy of these diseases by regulation of these receptors is discussed.
In Section III, Dr. Wendell Rosse discusses the forms of autoimmune hemolytic anemia characterized by antibodies that react preferentially in the cold–cold agglutinin disease and paroxysmal cold hemoglobinuria (PCH). The former is due to IgM antibodies with a common but particular structure that reacts primarily with carbohydrate or carbohydrate-containing antigens, an interaction that is diminished at body temperature. PCH is a less common but probably underdiagnosed illness due to an IgG antibody reacting with a carbohydrate antigen; improved techniques for the diagnosis of PCH are described. Therapy for the two disorders differs somewhat because of the differences in isotype of the antibody. Since the hemolysis in both is primarily due to complement activation, the potential role of its control, as by the monoclonal antibody described by Dr. Hillmen, is discussed.
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MESH Headings
- Anemia, Hemolytic, Autoimmune/diagnosis
- Anemia, Hemolytic, Autoimmune/immunology
- Anemia, Hemolytic, Autoimmune/therapy
- Antigen-Antibody Complex/immunology
- Autoantibodies/immunology
- Hemoglobinuria, Paroxysmal/diagnosis
- Hemoglobinuria, Paroxysmal/physiopathology
- Hemoglobinuria, Paroxysmal/therapy
- Humans
- Receptors, IgG/immunology
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Affiliation(s)
- Wendell F Rosse
- Duke University, Department of Medicine, Durham, NC 27707, USA
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