1
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Ahlen MT, Bussel JB. Desialylation unmasks HPA-9B alloantibodies. Blood 2023; 142:1853-1854. [PMID: 38032672 DOI: 10.1182/blood.2023022495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
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2
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Ouzegdouh Mammasse Y, Chenet C, Drubay D, Martageix C, Cartron JP, Vainchenker W, Petermann R. A new efficient tool for non-invasive diagnosis of fetomaternal platelet antigen incompatibility. Br J Haematol 2020; 190:787-798. [PMID: 32266719 DOI: 10.1111/bjh.16593] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/02/2020] [Indexed: 12/23/2022]
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is the consequence of platelet destruction by maternal alloantibodies against fetal human platelet antigens (HPA). This may result in intracranial haemorrhages (ICH) or even fetal death. Currently, fetal HPA genotyping is performed using invasive procedures. Here, we carried out a proof-of-concept study for non-invasive prenatal diagnosis of fetal platelet genotyping in four HPA systems (HPA-1, -3, -5 and-15) by droplet digital polymerase chain reaction (ddPCR) using cell-free DNA extracts from the plasma of 47 pregnant women with suspected, or history of, FNAIT. Results showed that 74% (35/47) of pregnant women presented incompatibility in at least one HPA system, and 38% (18/47) of cases presented HPA-1 incompatibility, including nine women with multiple incompatibilities. ICH occurred in one case of profound fetal thrombocytopenia with HPA-15 incompatibility, confirming the need for non-invasive prenatal genotyping in systems other than HPA-1. Fetal HPA genotypes predicted by ddPCR were confirmed in all FNAIT cases after amniocentesis or delivery. Fetal HPA genotyping on maternal plasma based on ddPCR is a fast, safe and reliable non-invasive method. This technique will be useful for the early identification of pregnancies at high risk of FNAIT requiring antenatal management to minimize the risk of fetal/neonatal haemorrhage.
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Affiliation(s)
- Yasmine Ouzegdouh Mammasse
- Institut National de la Transfusion Sanguine (INTS), Département d'Immunologie Plaquettaire, Paris, France
| | - Christophe Chenet
- Institut National de la Transfusion Sanguine (INTS), Département d'Immunologie Plaquettaire, Paris, France
| | - Damien Drubay
- INSERM, U1018, CESP, Faculté de Médecine - Université Paris-Sud - UVSQ, INSERM, Université Paris-Saclay, Villejuif, France.,Service de Biostatistique et d'Epidémiologie, Gustave Roussy, Villejuif, France
| | - Corinne Martageix
- Institut National de la Transfusion Sanguine (INTS), Département d'Immunologie Plaquettaire, Paris, France
| | | | - William Vainchenker
- Institut National de la Transfusion Sanguine (INTS), Département d'Immunologie Plaquettaire, Paris, France.,INSERM, UMR 1287, Gustave Roussy, Villejuif, France.,Université Paris-Saclay, UMR1287, Gustave Roussy, Villejuif, France
| | - Rachel Petermann
- Institut National de la Transfusion Sanguine (INTS), Département d'Immunologie Plaquettaire, Paris, France.,Centre de Recherche des Cordeliers, UMRS 1138, INSERM, Sorbonne Université, Université de Paris, Equipe ETRES (Ethics, Research, Translations), Paris, France
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3
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Bioengineered iPSC-derived megakaryocytes for the detection of platelet-specific patient alloantibodies. Blood 2020; 134:e1-e8. [PMID: 31697836 DOI: 10.1182/blood.2019002225] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 09/10/2019] [Indexed: 01/02/2023] Open
Abstract
Human platelet membrane glycoprotein polymorphisms can be immunogenic in man and are frequently the cause of clinically important immune reactions responsible for disorders such as neonatal alloimmune thrombocytopenia. Platelets from individuals carrying rare polymorphisms are often difficult to obtain, making diagnostic testing and transfusion of matched platelets challenging. In addition, class I HLA antibodies frequently present in maternal sera interfere with the detection of platelet-reactive alloantibodies. Detection of alloantibodies to human platelet antigen 3 (HPA-3) and HPA-9 is especially challenging, in part because of the presence of cell type-specific glycans situated near the polymorphic amino acid that together form the alloepitope. To overcome these limitations, we generated a series of HLA class I-negative blood group O induced pluripotent stem cell (iPSC) lines that were gene edited to sequentially convert their endogenous HPA-3a alloantigenic epitope to HPA-3b, and HPA-9a to HPA-9b. Subjecting these cell lines, upon differentiation into CD41+/CD42b+ human megakaryocytes (MKs), to flow cytometric detection of suspected anti-HPA-3 and HPA-9 alloantisera revealed that the HPA-3a-positive MKs specifically reacted with HPA-3a patient sera, whereas the HPA-3b MKs lost reactivity with HPA-3a patient sera while acquiring reactivity to HPA-3b patient sera. Importantly, HPA-9b-expressing MKs specifically reacted with anti-HPA-9b-suspected patient samples that had been undetectable using conventional techniques. The provision of specialized iPSC-derived human MKs expressing intact homozygous glycoprotein alloantigens on the cell surface that carry the appropriate endogenous carbohydrate moieties should greatly enhance detection of clinically important and rare HPA-specific alloantibodies that, to date, have resisted detection using current methods.
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4
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Baker JM, Shehata N, Bussel J, Murphy MF, Greinacher A, Bakchoul T, Massey E, Lieberman L, Landry D, Tanael S, Arnold DM, Baidya S, Bertrand G, Kjaer M, Kaplan C, Kjeldsen-Kragh J, Oepkes D, Savoia H, Ryan G, Hume H. Postnatal intervention for the treatment of FNAIT: a systematic review. J Perinatol 2019; 39:1329-1339. [PMID: 30971767 DOI: 10.1038/s41372-019-0360-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 02/26/2019] [Accepted: 03/01/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is associated with life-threatening bleeding. This systematic review of postnatal management of FNAIT examined transfusion of human platelet antigen (HPA) selected or unselected platelets, and/or IVIg on platelet increments, hemorrhage and mortality. STUDY DESIGN MEDLINE, EMBASE and Cochrane searches were conducted until 11 May 2018. RESULT Of 754 neonates, 382 received platelet transfusions (51%). HPA-selected platelets resulted in higher platelet increments and longer response times than HPA-unselected platelets. However, unselected platelets generally led to sufficient platelet increments to 30 × 109/L, a level above which intracranial hemorrhage or other life-threatening bleeding rarely occurred. Platelet increments were not improved with the addition of IVIg to platelet transfusion. CONCLUSION Overall, HPA-selected platelet transfusions were more effective than HPA-unselected platelets but unselected platelets were often effective enough to achieve clinical goals. Available studies do not clearly demonstrate a benefit for addition of IVIg to platelet transfusion.
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Affiliation(s)
- Jillian M Baker
- St. Michael's Hospital and The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Nadine Shehata
- Departments of Medicine and Obstetric Medicine, Mount Sinai Hospital, Toronto, Canada.,Center for Innovation, Canadian Blood Services, Toronto, Canada
| | | | - Michael F Murphy
- NHS Blood & Transplant, Oxford National Institute for Health Research (NIHR) Biomedical Research Centre, Oxford University Hospitals and University of Oxford, Oxford, UK
| | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Tamam Bakchoul
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany.,University Hospital of Tuebingen, Tuebingen, Germany
| | - Edwin Massey
- Diagnostic and Therapeutic Services, NHS Blood and Transplant, Bristol, UK
| | - Lani Lieberman
- University Health Network, University of Toronto, Toronto, Canada
| | - Denise Landry
- Center for Innovation, Canadian Blood Services, Ottawa, Canada
| | - Susano Tanael
- Center for Innovation, Canadian Blood Services, Toronto, Canada
| | - Donald M Arnold
- McMaster Centre for Transfusion Research, McMaster University and Canadian Blood Services, Hamilton, Canada
| | - Shoma Baidya
- Australian Red Cross Blood Service, Brisbane, QLD, Australia
| | - Gerald Bertrand
- BloodCenter of Brittany - (EFS) Établissement Français du Sang, Rennes, France
| | - Mette Kjaer
- Finnmark Hospital Trust, Hammerfest, Norway.,University Hospital of North Norway, Tromsø, Norway
| | - Cécile Kaplan
- Retired and formerly Institut National de la Transfusion Sanguine, Paris, France
| | - Jens Kjeldsen-Kragh
- University Hospital of North Norway, Tromsø, Norway.,University and Regional Laboratories Region Skåne, Lund, Sweden
| | - Dick Oepkes
- Leiden University Medical Center, Leiden, The Netherlands
| | | | - Greg Ryan
- Mount Sinai Hospital, Toronto, Canada
| | - Heather Hume
- Division of Haematology/Oncology, CHU Sainte-Justine, University of Montreal, Montreal, Canada
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5
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Yang Q, Lv X, Kong Y, Liu X, Shao M, Zhao Y, Xia N, Wang S, Li H. Timely diagnosis and treatment of neonatal alloimmune thrombocytopenia caused by anti HPA-3a antibody: A case report. Medicine (Baltimore) 2019; 98:e15440. [PMID: 31083173 PMCID: PMC6531177 DOI: 10.1097/md.0000000000015440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Neonatal alloimmune thrombocytopenia (NAIT) caused by anti HPA-3a antibody is rare, and the clinical features of the syndrome are not specific. PATIENT CONCERNS A male infant was noted to be irritable and physical examination revealed the presence of petechiae and bruising on the right arm and thigh after born. DIAGNOSES Platelet antibodies were investigated using the monoclonal antibody-specific immobilization of platelet antigens (MAIPA) assay, platelet genotyping (HPA 1-17) was performed by polymerase chain reaction technique with sequence-specific primers (PCR-SSP). The HPA genotype of the newborn was HPA-3a/b, while that of his mother and his father were HPA-3b/b and HPA-3a/a, respectively. The sera of newborn contained antibody against the platelet of newborn's father. The HPA antibody of the newborn was identified as anti HPA-3a. The newborn was confirmed as a patient of NAIT caused by anti HPA-3a antibody. INTERVENTIONS A single dose of intravenous immunoglobulin (IVIG) 1 g/kg was administered from day 3 to day 7. OUTCOMES At follow-up 3 months after discharge from the hospital, the baby was developing normally and had a normal platelet count (361 × 109/L). LESSONS NAIT caused by anti HPA-3a antibody is rare, and we believe this study can provide insights for diagnosing prospective cases. Prognosis of NAIT caused by HPA3a seems to be favorable if diagnosed and treated in a timely manner.
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Affiliation(s)
| | | | | | - Xin Liu
- Department of Blood Transfusion
| | | | | | | | | | - Huidong Li
- Department of Surgical Clinic, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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7
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Jallu V, Beranger T, Bianchi F, Casale C, Chenet C, Ferre N, Philippe S, Quesne J, Martageix C, Petermann R. Cab4b, the first human platelet antigen carried by glycoprotein IX discovered in a context of severe neonatal thrombocytopenia. J Thromb Haemost 2017; 15:1646-1654. [PMID: 28561420 DOI: 10.1111/jth.13744] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Indexed: 11/28/2022]
Abstract
Essentials Life-threatening maternofetal thrombocytopenias mostly depend on αIIb β3 antigens. We performed serological, genomic and in vitro studies of two life-threatening thrombocytopenias. Identification of a c.368C>T variation leading to Pro123Leu substitution in GPIX. A rare GPIX variant reported in a genomic database define a new alloantigen. SUMMARY Background After three miscarriages, a 39-year-old woman gave birth, with a 1-year interval, to two severely thrombocytopenic neonates (4 ×109 L-1 and 33 ×109 L-1 ) with intracranial hemorrhages. Transfusion of platelet concentrates corrected the thrombocytopenia. The outcome was favorable for the first child, but the second one died 10 days after cesarean delivery (31 weeks of gestation + 6 days). Methods Serologic studies were performed with mAb-specific immobilization of platelet antigens and flow cytometry techniques. Human platelet alloantigen (HPA) genotyping was performed with the BioArray HPA BeadChip and PCR-sequence-specific primer techniques. Genomic DNA was studied by direct sequencing of PCR products. The mutant glycoprotein (GP) was expressed in transiently transfected HEK293 cells. Results In MAIPA assay, the maternal serum faintly reacted with GPIbIX from paternal and child 1 platelets, but not with maternal or panel platelets. No maternofetal incompatibility was found in the 22 known HPA systems, tested except for HPA-1b in child 2. A new alloantigen carried by GPIbIX was suspected. Genomic sequencing revealed a paternal GPIX variation (NM_000174.4:c.368C>T). The father and children were heterozygous and incompatible with the mother, who was NM_000174.4:c.368C homozygous. The maternal serum reacted with the GPIX NP_000165.1:p.Leu123 form coexpressed with GPIb in transfected HEK293 cells. The NM_000174.4:c.368T allele (rs202229101) has a minor allele frequency of 0.0002, and was not detected in 120 French subjects (families with fetal and neonatal alloimmune thrombocytopenia [FNAIT]), suggesting that it is rarely implicated in alloimmunization. Conclusion The NP_000165.1:p.Leu123 allele named Cab4b is the first platelet alloantigen described on GPIX. In the absence of other known maternofetal incompatibility, the child 1 case suggests that anti-Cab4b alloantibodies can induce severe thrombocytopenias.
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Affiliation(s)
- V Jallu
- Département d'Immunologie Plaquettaire, Institut National de la Transfusion Sanguine (INTS), Paris, France
| | - T Beranger
- Département d'Immunologie Plaquettaire, Institut National de la Transfusion Sanguine (INTS), Paris, France
| | - F Bianchi
- Département d'Immunologie Plaquettaire, Institut National de la Transfusion Sanguine (INTS), Paris, France
| | - C Casale
- Département d'Immunologie Plaquettaire, Institut National de la Transfusion Sanguine (INTS), Paris, France
| | - C Chenet
- Département d'Immunologie Plaquettaire, Institut National de la Transfusion Sanguine (INTS), Paris, France
| | - N Ferre
- Département d'Immunologie Plaquettaire, Institut National de la Transfusion Sanguine (INTS), Paris, France
| | - S Philippe
- Département d'Immunologie Plaquettaire, Institut National de la Transfusion Sanguine (INTS), Paris, France
| | - J Quesne
- Département d'Immunologie Plaquettaire, Institut National de la Transfusion Sanguine (INTS), Paris, France
| | - C Martageix
- Département d'Immunologie Plaquettaire, Institut National de la Transfusion Sanguine (INTS), Paris, France
| | - R Petermann
- Département d'Immunologie Plaquettaire, Institut National de la Transfusion Sanguine (INTS), Paris, France
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8
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[Thirty years of platelet immunology in fetal and neonatal alloimmune thrombocytopenia management, current situation]. Transfus Clin Biol 2017; 24:166-171. [PMID: 28673503 DOI: 10.1016/j.tracli.2017.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 05/30/2017] [Indexed: 11/21/2022]
Abstract
Fetal and neonatal allo-immune thrombocytopenia (FNAIT) is considered as a rare disease due to the incidence (1/1000-1/2000 births). The major complication of severe thrombocytopenia is bleeding and particularly intra-cranial hemorrhage and neurologic sequelae following. Serology and molecular biology developments have reconfigured the platelet immunology diagnosis. Anti-HPA-1a allo-immunisation is responsible for more than 80% FNAIT cases with a high recurrence rate of severe bleeding complications. Therapeutic management has changed over the coming years from an invasive concept associating fetal blood sampling and in utero platelet transfusion to a non invasive treatment by intravenous immunoglobulins injection (IVIg). The purpose of this article is to provide an update on FNAIT management in the light of current developments over the past 30years.
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9
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Petermann R. [Platelet transfusion role in neonatal immune thrombocytopenia]. Transfus Clin Biol 2016; 23:217-221. [PMID: 27592154 DOI: 10.1016/j.tracli.2016.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 07/28/2016] [Indexed: 10/21/2022]
Abstract
Neonatal immune thrombocytopenia represent less than 5% of cases of early thrombocytopenia (early-onset<72hours post-delivery). As in adults, thrombocytopenia in neonates is defined as a platelet count less than 150G/L. They are either auto- or allo-immune. Thrombocytopenia resulting from transplacental passage of maternal antibodies directed to platelet membrane glycoproteins can be severe. The major complication of severe thrombocytopenia is bleeding and particularly intra-cranial haemorrhage and neurologic sequelea following. However, auto- and allo-immune thrombocytopenia have very different characteristics including the treatment management. In fact, this treatment is based on platelet transfusion associated or not to intravenous immunoglobulin administration. The purpose of this article is to remind platelet transfusion's place in neonatal immune thrombocytopenia in terms of recently published French guidelines and international practices.
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Affiliation(s)
- R Petermann
- Département d'immunologie plaquettaire, Institut national de la transfusion sanguine, 75015 Paris, France.
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10
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Bussel JB. What do we know about intracranial hemorrhage in fetal and neonatal alloimmune thrombocytopenia? Transfusion 2016; 56:17-8. [PMID: 26756707 DOI: 10.1111/trf.13412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 10/14/2015] [Indexed: 11/27/2022]
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Cooper N, Bein G, Heidinger K, Santoso S, Sachs UJ. A bead-based assay in the work-up of suspected platelet alloimmunization. Transfusion 2015; 56:115-8. [DOI: 10.1111/trf.13351] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 07/10/2015] [Accepted: 07/30/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Nina Cooper
- Institute for Clinical Immunology and Transfusion Medicine; Justus Liebig University
| | - Gregor Bein
- Institute for Clinical Immunology and Transfusion Medicine; Justus Liebig University
- German Center for Fetomaternal Incompatibility (DZFI); University Hospital Giessen and Marburg; Giessen Germany
| | - Kathrin Heidinger
- Institute for Clinical Immunology and Transfusion Medicine; Justus Liebig University
| | - Sentot Santoso
- Institute for Clinical Immunology and Transfusion Medicine; Justus Liebig University
| | - Ulrich J. Sachs
- Institute for Clinical Immunology and Transfusion Medicine; Justus Liebig University
- German Center for Fetomaternal Incompatibility (DZFI); University Hospital Giessen and Marburg; Giessen Germany
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12
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Vadasz B, Chen P, Yougbaré I, Zdravic D, Li J, Li C, Carrim N, Ni H. Platelets and platelet alloantigens: Lessons from human patients and animal models of fetal and neonatal alloimmune thrombocytopenia. Genes Dis 2015; 2:173-185. [PMID: 28345015 PMCID: PMC5362271 DOI: 10.1016/j.gendis.2015.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Platelets play critical roles in hemostasis and thrombosis. Emerging evidence indicates that they are versatile cells and also involved in many other physiological processes and disease states. Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a life threatening bleeding disorder caused by fetal platelet destruction by maternal alloantibodies developed during pregnancy. Gene polymorphisms cause platelet surface protein incompatibilities between mother and fetus, and ultimately lead to maternal alloimmunization. FNAIT is the most common cause of intracranial hemorrhage in full-term infants and can also lead to intrauterine growth retardation and miscarriage. Proper diagnosis, prevention and treatment of FNAIT is challenging due to insufficient knowledge of the disease and a lack of routine screening as well as its frequent occurrence in first pregnancies. Given the ethical difficulties in performing basic research on human fetuses and neonates, animal models are essential to improve our understanding of the pathogenesis and treatment of FNAIT. The aim of this review is to provide an overview on platelets, hemostasis and thrombocytopenia with a focus on the advancements made in FNAIT by utilizing animal models.
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Affiliation(s)
- Brian Vadasz
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada; Department of Laboratory Medicine, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Pingguo Chen
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada; Department of Laboratory Medicine, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada; Canadian Blood Services, Toronto, ON, Canada
| | - Issaka Yougbaré
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada; Department of Laboratory Medicine, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada; Canadian Blood Services, Toronto, ON, Canada
| | - Darko Zdravic
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada; Department of Laboratory Medicine, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada; Canadian Blood Services, Toronto, ON, Canada
| | - June Li
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada; Department of Laboratory Medicine, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Conglei Li
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada; Department of Laboratory Medicine, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada; Canadian Blood Services, Toronto, ON, Canada
| | - Naadiya Carrim
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada; Department of Laboratory Medicine, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada
| | - Heyu Ni
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada; Department of Laboratory Medicine, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada; Canadian Blood Services, Toronto, ON, Canada; Department of Physiology, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
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13
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Bertrand G, Kaplan C. How do we treat fetal and neonatal alloimmune thrombocytopenia? Transfusion 2014; 54:1698-703. [DOI: 10.1111/trf.12671] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 02/27/2014] [Accepted: 02/27/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Gérald Bertrand
- Platelet Immunology Department; Institut National de la Transfusion Sanguine; Paris France
| | - Cécile Kaplan
- Platelet Immunology Department; Institut National de la Transfusion Sanguine; Paris France
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Smock KJ, Agarwal AM, Lim MS, Tripp SR, Miles RR, Patel JL, Abromowitch M, Lones MA, Cairo MS, Perkins SL. Expression of Notch1 and mTOR pathway proteins in pediatric lymphoblastic lymphoma; a Children’s Oncology Group report. J Hematop 2014. [DOI: 10.1007/s12308-014-0200-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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15
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Heikal NM, Smock KJ. Laboratory testing for platelet antibodies. Am J Hematol 2013; 88:818-21. [PMID: 23757218 DOI: 10.1002/ajh.23503] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 05/24/2013] [Accepted: 05/28/2013] [Indexed: 12/21/2022]
Abstract
Laboratory testing for immune-mediated thrombocytopenias involves identification and classification of antibodies present in patient sera or attached to patient platelets. This article summarizes the available types of platelet antibody testing and applications in disorders such as neonatal alloimmune thrombocytopenia, post-transfusion purpura, multiple platelet transfusion refractoriness, immune thrombocytopenia, and drug-induced thrombocytopenia.
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Affiliation(s)
- Nahla M. Heikal
- Department of Pathology; University of Utah Health Sciences Center, and ARUP Laboratories Institute for Clinical and Experimental Pathology; Salt Lake City; Utah
| | - Kristi J. Smock
- Department of Pathology; University of Utah Health Sciences Center, and ARUP Laboratories Institute for Clinical and Experimental Pathology; Salt Lake City; Utah
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Jallu V, Bertrand G, Bianchi F, Chenet C, Poulain P, Kaplan C. The αIIb p.Leu841Met (Cab3(a+) ) polymorphism results in a new human platelet alloantigen involved in neonatal alloimmune thrombocytopenia. Transfusion 2012; 53:554-63. [PMID: 22738334 DOI: 10.1111/j.1537-2995.2012.03762.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fetal-neonatal alloimmune thrombocytopenia (FNAIT) diagnosis relies on maternofetal incompatibility and alloantibody identification. Genotyping for rare platelet (PLT) polymorphisms allowed the identification of three families with suspected or confirmed maternofetal incompatibility for the αIIb-c.2614C>A mutation (Halle et al., Transfusion 2008;48:14-15). STUDY DESIGN AND METHODS A polymerase chain reaction-sequence-specific primers amplification assay was designed to genotype the αIIb-c.2614C>A mutation. HEK293 cells expressing αIIb-Leu841 or αIIb-Met841 αIIbβ3 forms were used to probe the reactivity of maternal sera from these families and to study the effects of the substitution on αIIbβ3 expression and functions. RESULTS Tested by flow cytometry (FCM), one serum sample specifically reacted with αIIb-Met841 but not with αIIb-Leu841 αIIbβ3. This specificity revealed the αIIb-Leu841 polymorphism as a new alloantigen named Cab3(a+) . Cross-match testing using FCM also showed the Cab3(a+) antigen to be expressed at the PLT surface. As for anti-human PLT alloantigen (HPA)-3a (or -3b) and anti-HPA-9bw, detection of anti-Cab3(a+) alloantibodies appeared difficult and required whole PLT assays when classical monoclonal antibody-specific immobilization of PLT antigen test failed. In our FNAIT set, the immune response to Cab3(a+) maternofetal incompatibility could induce severe thrombocytopenias and life-threatening hemorrhages. The p.Leu841Met substitution has limited effects, if any, on local αIIb structure, preserving both αIIbβ3 expression and functions. CONCLUSION The Cab3(a+) polymorphism is a new rare alloantigen (allelic frequency <1%) carried by αIIb that might result in severe life-threatening thrombocytopenias. In Sub-Saharan African populations, higher Cab3(a+) gene frequencies (up to 8.2%; Halle et al., Transfusion 2008;48:14-15) and homozygous people are observed.
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Affiliation(s)
- Vincent Jallu
- Platelet Immunology Laboratory, INTS; DSIMB, INSERM, U665, France
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Lee AI, Kaufman RM. Transfusion Medicine and the Pregnant Patient. Hematol Oncol Clin North Am 2011; 25:393-413, ix. [DOI: 10.1016/j.hoc.2011.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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McQuilten ZK, Wood EM, Savoia H, Cole S. A review of pathophysiology and current treatment for neonatal alloimmune thrombocytopenia (NAIT) and introducing the Australian NAIT registry. Aust N Z J Obstet Gynaecol 2011; 51:191-8. [PMID: 21631435 DOI: 10.1111/j.1479-828x.2010.01270.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Fetomaternal or neonatal alloimmune thrombocytopenia (NAIT) is a rare but serious condition associated with significant fetal and neonatal morbidity and mortality. The most useful predictor of severe disease is a history of a sibling with an antenatal intracranial haemorrhage. However, NAIT can occur during the first pregnancy and may not be diagnosed until the neonatal period. Antenatal treatment options include maternal intravenous immunoglobulin (IVIG) and corticosteroid treatment, fetal blood sampling (FBS) and intrauterine platelet transfusion (IUT) and early delivery. FBS (with or without IUT) can be used to direct and monitor response to therapy, and to inform mode and timing of delivery. However, this procedure is associated with significant risks, including fetal death, and is generally now reserved for high-risk pregnancies. This review highlights the current understanding of the epidemiology and pathophysiology of NAIT and summarises current approaches to investigation and management. It also introduces the newly established Australian NAIT registry. Owing to the relative rarity of NAIT, accruing sufficient patient numbers for studies and clinical trials at an institutional level is difficult. This national registry will provide an opportunity to collect valuable information and inform future research on this condition.
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Affiliation(s)
- Zoe K McQuilten
- Transfusion Medicine Services, Australian Red Cross Blood Service, South Melbourne, Victoria 3205, Australia.
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20
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Boumahni B, Kaplan C, Clabé A, Randrianaivo H, Lanza F. [Maternal-fetal chikungunya infection associated with Bernard-Soulier syndrome]. Arch Pediatr 2011; 18:272-5. [PMID: 21269816 DOI: 10.1016/j.arcped.2010.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2009] [Revised: 09/09/2010] [Accepted: 12/12/2010] [Indexed: 11/29/2022]
Abstract
Neonatal thrombocytopenia may stem from several origins. A newborn was hospitalized on the 3rd day of life with thrombocytopenia likely due to maternofetal autoimmune thrombocytopenia. Two days later, he displayed a chikungunya virus infection, during a severe epidemic on Reunion Island. The characterization of human platelet antigen (HPA) in the parents showed incompatibility in the HPA-3 system; however, no detectable antiHPA-3a antibody was found in the mother's serum. The persistence of moderate thrombocytopenia led to the diagnosis, using flow cytometry, of Bernard-Soulier syndrome (BSS), with no detectable GPIbIX. This case shows that neonatal inherited thrombocytopenia may be difficult to characterize, especially when it is associated with an acquired cause.
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Affiliation(s)
- B Boumahni
- Service de réanimation néonatale et pédiatrique, groupe hospitalier Sud-Réunion, 97410 Saint-Pierre, Réunion.
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Barba P, Pallarés P, Nogués N, Canals C, Gracia M, Vinyets I, Muñiz-Diaz E. Post-transfusion purpura caused by anti-HPA-3a antibodies that are only detectable using whole platelets in the platelet immunofluorescence test. Transfus Med 2010; 20:200-2. [DOI: 10.1111/j.1365-3148.2009.00978.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Brouk H, Halle L, Bertrand G, Neche FZ, Ouelaa H, Kaplan C. Human platelet antigen allele frequencies in different Algerian populations. ACTA ACUST UNITED AC 2010; 75:673-8. [DOI: 10.1111/j.1399-0039.2009.01429.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Fetal and neonatal alloimmune thrombocytopenia (AIT) is the commonest cause of severe thrombocytopenia in neonates, and of intracranial hemorrhage (ICH) in term neonates [1] (J Trop Pediatr, 1999; 45: 237). If a newborn is affected with AIT, the next child will likely be more severely affected, and therefore fetal thrombocytopenia will begin early in gestation [2, 3] (Arch Neurol, 1984; 41: 30; N Engl J Med 1997; 337: 22). This creates a risk of in utero ICH even if there was not one in the previous pregnancy. There are new developments in AIT in regard to diagnosis, treatment, and screening which will be the focus of this review.
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Affiliation(s)
- J Bussel
- Platelet Research & Treatment Program, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY 10065, USA.
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Zhong XY, Holzgreve W. MALDI-TOF MS in Prenatal Genomics. ACTA ACUST UNITED AC 2009; 36:263-272. [PMID: 21049077 DOI: 10.1159/000223098] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Accepted: 05/14/2009] [Indexed: 12/23/2022]
Abstract
Prenatal diagnosis aims either to provide the reassurance to the couples at risk of having an affected child by timely appropriate therapy or to give the parents a chance to decide the fate of the unborn babies with health problems. Invasive prenatal diagnosis (IPD) is accurate, however, carrying a risk of miscarriage. Non-invasive prenatal diagnosis (NIPD) has been developed based on the existing of fetal genetic materials in maternal circulation; however, a minority fetal DNA in majority maternal background DNA hinders the detections of fetal traits. Different protocols and assays, such as homogenous MassEXTEND (hME), single allele base extension reaction (SABER), precise measuring copy number variation of each allele, and quantitative methylation and expression analysis using the high-throughput sensitive matrix-assisted laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF MS), allow NIPD for single gene disorders, fetal blood group genotyping and fetal aneuploidies as well as the development of fetal gender-independent biomarkers in maternal circulation for management of pathological pregnancies. In this review, we summarise the use of MALDI-TOF MS in prenatal genomics.
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Affiliation(s)
- Xiao Yan Zhong
- Laboratory for Prenatal Medicine and Gynaecological Oncology, University Women's Hospital /Department Research, University of Basel, Switzerland
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Bertrand G, Jallu V, Saillant D, Kervran D, Martageix C, Kaplan C. The new platelet alloantigen Cab a: a single point mutation Gln 716 His on the alpha 2 integrin. Transfusion 2009; 49:2076-83. [PMID: 19500323 DOI: 10.1111/j.1537-2995.2009.02240.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Fetal/neonatal alloimmune thrombocytopenia (FNAIT) is caused by maternal alloimmunization against fetal platelet (PLT) antigens, inherited from the father and absent from maternal PLTs. STUDY DESIGN AND METHODS A 29-year-old mother gave birth to a severely thrombocytopenic newborn (16 x 10(9) PLTs/L) leading to PLT transfusion therapy associated with intravenous immunoglobulins. The outcome was uneventful. Maternal serum showed a specific positive reaction with the antigen-capture assay (monoclonal antibody [MoAb]-specific immobilization of PLT antigens) only when it was tested with the paternal PLTs and a panel of MoAbs against glycoprotein (GP)Ia-IIa (alpha(2)beta(1) integrin) suggesting the implication of a new PLT antigen. RESULTS Nucleotide sequence analysis of GPIa cDNA of the father and newborn showed a nucleotide substitution at position 2235 (2235G > T according to the international nomenclature). This substitution induces a Q716H amino acid change in the GPIa mature protein, located outside the I domain involved in cell adhesion for collagen. In vitro analysis of recombinant Chinese hamster ovary (CHO) cells expressing wild-type or mutant (Q716H) human GPIa allowed us to demonstrate that this single amino acid substitution is responsible and sufficient for inducing Cab(a) antigen expression. Adhesion of CHO cells to collagen was not modified by the Cab polymorphism, nor by the maternal anti-Cab(a) alloantibodies, indicating that the mutation does not affect the function of integrin alpha(2)beta(1). In a Caucasian population study, none of the 104 unrelated blood donors was found to be Cab(a)(+). CONCLUSION We describe here a new PLT alloantigen Cab(a) involved in a severe case of FNAIT. Laboratory investigation for the "common" PLT alloantigens is no longer sufficient to evaluate neonatal alloimmune thrombocytopenia in suspected cases.
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Kaplan C. Les thrombopénies fœtales et néonatales allo-immunes. Transfus Clin Biol 2009; 16:214-7. [DOI: 10.1016/j.tracli.2009.03.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2009] [Accepted: 03/18/2009] [Indexed: 10/20/2022]
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Bussel JB, Sola-Visner M. Current approaches to the evaluation and management of the fetus and neonate with immune thrombocytopenia. Semin Perinatol 2009; 33:35-42. [PMID: 19167580 DOI: 10.1053/j.semperi.2008.10.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Fetal and neonatal alloimmune thrombocytopenia is not a well-known disease, except among specialists in maternal-fetal medicine, neonatologists, and certain pediatricians (ie, hematologists). However, this is by far the most common cause of early severe thrombocytopenia in neonates and of intracranial hemorrhage in term neonates. In addition, if a newborn is affected with alloimmune thrombocytopenia, the next child in the family will likely be more severely affected. Thus, the accurate diagnosis and appropriate management of this disorder are of extreme importance in perinatal medicine and will constitute the focus of this review.
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Affiliation(s)
- James B Bussel
- Division of Pediatric Hematology Oncology, Weill Cornell Medical College/New York-Presbyterian Hospital, New York, NY 10065, USA.
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van Gils JM, Stutterheim J, van Duijn TJ, Zwaginga JJ, Porcelijn L, de Haas M, Hordijk PL. HPA-1a alloantibodies reduce endothelial cell spreading and monolayer integrity. Mol Immunol 2008; 46:406-15. [PMID: 19038456 DOI: 10.1016/j.molimm.2008.10.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Revised: 10/13/2008] [Accepted: 10/14/2008] [Indexed: 12/01/2022]
Abstract
Maternal human platelet antigen (HPA)-1a alloantibodies causing neonatal alloimmune thrombocytopenia can bind also to endothelium, via the beta3-integrin (CD61). The aim of this study was to investigate the effect of HPA-1a Abs on endothelial cell function, with emphasis on monolayer integrity. We used a CD61 mAb as a model for the HPA-1a alloantibodies and confirmed the results with purified IgG fractions from HPA-1a alloimmunized women. The effect of these antibodies was examined by monitoring the adhesion, spreading, and monolayer integrity of primary HUVECs with conventional adhesion assays as well as electrical cell-substrate impedance sensing. We found that both the mAb CD61 and the HPA-1a antibodies caused a significant reduction in HUVEC spreading. Moreover, addition of the mAb CD61 and the HPA-1a antibodies prior to or following formation of a stable endothelial monolayer negatively affected endothelial monolayer integrity, which was accompanied by a redistribution of junctional proteins. Our data suggest that HPA-1a alloantibodies have a direct effect on endothelial cell spreading and monolayer integrity, which could contribute to the increased bleeding tendency in children with neonatal alloimmune thrombocytopenia.
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Affiliation(s)
- Janine M van Gils
- Department of Molecular Cell Biology, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Arnold DM, Smith JW, Kelton JG. Diagnosis and Management of Neonatal Alloimmune Thrombocytopenia. Transfus Med Rev 2008; 22:255-67. [DOI: 10.1016/j.tmrv.2008.05.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Fetal/Neonatal Allo-Immune Thrombocytopenia (FNAIT): Past, Present, and Future. Obstet Gynecol Surv 2008; 63:239-52. [DOI: 10.1097/ogx.0b013e31816412d3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Socher I, Zwingel C, Santoso S, Kroll H. Heterogeneity of HPA-3 alloantibodies: consequences for the diagnosis of alloimmune thrombocytopenic syndromes. Transfusion 2008; 48:463-72. [DOI: 10.1111/j.1537-2995.2007.01550.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Bussel JB, Primiani A. Fetal and neonatal alloimmune thrombocytopenia: progress and ongoing debates. Blood Rev 2007; 22:33-52. [PMID: 17981381 DOI: 10.1016/j.blre.2007.09.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Fetal and neonatal alloimmune thrombocytopenia (AIT) is a result of a parental incompatibility of platelet-specific antigens and the transplacental passage of maternal alloantibodies against the platelet antigen shared by the father and the fetus. It occurs in approximately 1 in 1000 live births and is the most common cause of severe thrombocytopenia in fetuses and term neonates. As screening programs are not routinely performed, most affected fetuses are identified after birth when neonatal thrombocytopenia is recognized. In severe cases, the affected fetus is identified as a result of suffering from an in utero intracranial hemorrhage. Once diagnosed, AIT must be treated antenatally as the disease can be more severe in subsequent pregnancies. While there have been many advances regarding the diagnosis and treatment of AIT, it is still difficult to predict the severity of disease and which therapy will be effective.
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Affiliation(s)
- James B Bussel
- Division of Hematology, Department of Pediatrics, Weill Medical College of Cornell University, New York, NY 10021-4853, United States.
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33
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Kaplan C, Freedman J. Alloimmune Thrombocytopenia. Platelets 2007. [DOI: 10.1016/b978-012369367-9/50815-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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35
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Kaplan C. Foetal and neonatal alloimmune thrombocytopaenia. Orphanet J Rare Dis 2006; 1:39. [PMID: 17032445 PMCID: PMC1624806 DOI: 10.1186/1750-1172-1-39] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2006] [Accepted: 10/10/2006] [Indexed: 12/03/2022] Open
Abstract
Foetal/neonatal alloimmune thrombocytopaenia (NAIT) results from maternal alloimmunisation against foetal platelet antigens inherited from the father and different from those present in the mother, and usually presents as a severe isolated thrombocytopaenia in otherwise healthy newborns. The incidence has been estimated at 1/800 to 1/1000 live births. NAIT has been considered to be the platelet counterpart of Rh Haemolytic Disease of the Newborn (RHD). Unlike RHD, NAIT can occur during a first pregnancy. The spectrum of the disease may range from sub-clinical moderate thrombocytopaenia to life-threatening bleeding in the neonatal period. Mildly affected infants may be asymptomatic. In those with severe thrombocytopaenia, the most common presentations are petechiae, purpura or cephalohaematoma at birth, associated with major risk of intracranial haemorrhage (up to 20% of reported cases), which leads to death or neurological sequelae. Alloimmune thrombocytopaenia is more often unexpected and is usually diagnosed after birth. Once suspected, the diagnosis is confirmed by demonstration of maternal antiplatelet alloantibodies directed against a paternal antigen inherited by the foetus/neonate. Post-natal management involves transfusion of platelets devoid of this antigen, and should not be delayed by biological confirmation of the diagnosis (once the diagnosis is suspected), especially in case of severe thrombocytopaenia. Prompt diagnosis and treatment are essential to reduce the chances of death and disability due to haemorrhage. Due to the high rate of recurrence and increased severity of the foetal thrombocytopaenia in successive pregnancies, antenatal therapy should be offered. However, management of high-risk pregnancies is still a matter of discussion.
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Affiliation(s)
- Cecile Kaplan
- Unité d'Immunologie Plaquettaire, Institut National de Transfusion Sanguine, 6 rue Alexandre Cabanel, 75015 Paris, France.
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36
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Berkowitz RL, Bussel JB, McFarland JG. Alloimmune thrombocytopenia: state of the art 2006. Am J Obstet Gynecol 2006; 195:907-13. [PMID: 16875656 DOI: 10.1016/j.ajog.2006.05.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2006] [Revised: 04/26/2006] [Accepted: 05/04/2006] [Indexed: 10/24/2022]
Abstract
In alloimmune thrombocytopenia maternal immunoglobulin G anti-platelet alloantibodies cross the placenta and cause fetal thrombocytopenia. The diagnosis requires laboratory demonstration of incompatibility between a maternal and paternal platelet alloantigen, and detection of maternal antibody to the discordant paternal alloantigen. This disorder should be treated in utero because of its propensity to cause fetal intracranial bleeding. Administration of intravenous immunoglobulin 1 gm/kg/wk to the mother is successful in substantially raising the platelet count in many fetuses, but this is most successful if the count is >20,000/mL3 at the time that the therapy is initiated. The addition of prednisone administered daily to the mother and/or increasing the dose of intravenous immunoglobulin has a therapeutic benefit in cases that have failed to respond to initial therapy with intravenous immunoglobulin alone. The only reliable noninvasive indicator of the potential for severe fetal thrombocytopenia is a history of an antenatal intracranial hemorrhage in a prior affected sibling. Because fetal blood sampling to determine the fetal platelet count may be associated with significant fetal morbidity, attempts are being made to derive a rational, non-invasive, stratified approach to patient-specific therapy of this disorder in affected pregnancies.
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Affiliation(s)
- Richard L Berkowitz
- Department of Obstetrics and Gynecology, Columbia Presbyterian Medical Center, New York, NY 10032, USA.
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Socher I, Kroll H, Santoso S. Heterogeneity of Platelet Alloantigens and Alloantibodies: New Insights into Structure and Function. Transfus Med Hemother 2006. [DOI: 10.1159/000092578] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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38
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Kaplan C, Porcelijn L, Vanlieferinghen P, Julien E, Bianchi F, Martageix C, Bertrand G, Jallu V. Anti-HPA-9bw (Maxa) fetomaternal alloimmunization, a clinically severe neonatal thrombocytopenia: difficulties in diagnosis and therapy and report on eight families. Transfusion 2005; 45:1799-803. [PMID: 16271107 DOI: 10.1111/j.1537-2995.2005.00606.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Fetal or neonatal alloimmune thrombocytopenia (FMAIT) results from a maternal alloimmunization against fetal platelet (PLT) antigens. In Caucasian persons, HPA-1a is the most frequently implicated antigen. During the past few years, FMAIT has been reported associated with rare or private antigens. STUDY DESIGN AND METHODS Since the first documented case of FMAIT due to anti-HPA-9bw (Max(a)), no additional cases have been reported. Here a retrospective analysis is presented of the cases referred to our laboratories in recent years. The diagnosis was performed by genotyping and identification of the maternal alloantibody by the monoclonal antibody-specific immobilization of PLT antigens (MAIPA) technique. RESULTS Parental genotyping showed HPA-9bw (Max(a)) mismatch as the sole antigenic incompatibility in seven of eight families. Because the father was found to be HPA-9bw (Max(a)) heterozygous in all the cases, the infant or fetus was genotyped to ascertain the diagnosis. The maternal alloantibody was identified in the MAIPA technique. These data strongly suggest, however, that recognition of the HPA-9bw (Max(a)) epitope is not uniform. The neonatal thrombocytopenia was severe in most cases with bleeding. The outcome was good in all the cases but one. CONCLUSION This analysis confirms that anti-HPA-9bw (Max(a)) FMAIT is not uncommon and was found to be approximately 2 percent of our confirmed FMAIT cases. It is a clinically severe syndrome that requires prompt diagnosis, albeit difficult, and maternal PLT transfusion therapy. Laboratory investigation of a suspected FMAIT case should be carried out in a specialist laboratory well-experienced in optimal testing. Appropriate management and antenatal therapy should be considered for successive pregnancies to prevent fetal bleeding.
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MESH Headings
- Antigens, Human Platelet/immunology
- Diagnosis, Differential
- Female
- Fetal Diseases/blood
- Fetal Diseases/diagnosis
- Fetal Diseases/etiology
- Fetal Diseases/therapy
- Humans
- Immunoglobulins, Intravenous/therapeutic use
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/etiology
- Infant, Newborn, Diseases/therapy
- Isoantibodies/blood
- Maternal-Fetal Exchange/immunology
- Platelet Count
- Platelet Transfusion
- Pregnancy
- Retrospective Studies
- Severity of Illness Index
- Thrombocytopenia/blood
- Thrombocytopenia/diagnosis
- Thrombocytopenia/etiology
- Thrombocytopenia/therapy
- Treatment Outcome
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Bussel JB, Zacharoulis S, Kramer K, McFarland JG, Pauliny J, Kaplan C. Clinical and diagnostic comparison of neonatal alloimmune thrombocytopenia to non-immune cases of thrombocytopenia. Pediatr Blood Cancer 2005; 45:176-83. [PMID: 15828027 DOI: 10.1002/pbc.20282] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Affected patients with neonatal alloimmune thrombocytopenia (AIT) are often severely thrombocytopenic and, if so, may suffer an intracranial hemorrhage (ICH). This study was undertaken to compare the outcome of cases of AIT to cases of neonatal thrombocytopenia shown not to be AIT and to identify clinical features that would facilitate the diagnosis. PROCEDURE Two hundred twenty two cases of neonatal thrombocytopenia for which serologic testing was obtained by the referring physician were accrued for this study from 11 testing laboratories. The relevant clinical information was pursued. RESULTS The mean birth platelet count in 110 neonates with AIT was 26,000/mm(3) x 10(9)/L and the rate of ICH was 11% (not all neonates had head sonos). Three criteria distinguished cases of AIT from other causes of neonatal thrombocytopenia (n = 56): (1) severe thrombocytopenia <50,000/mm(3) x 10(9)/L; (2) ICH associated with 1 or more of: a 1-min Apgar score >5, birthweight >2,200 g, grade >1, antenatal occurrence, or signs of bleeding, that is, petechiae, ecchymoses; and (3) no additional, non-hemorrhagic neonatal medical problems. CONCLUSIONS AIT is a unique type of neonatal thrombocytopenia with significant hemorrhagic consequences. Identification of AIT at the bedside should guide institution of appropriate treatment and lead to serologic testing for confirmation.
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Affiliation(s)
- James B Bussel
- Department of Pediatrics, The New York Hospital, Cornell University Medical Center, New York, New York 10021, USA.
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40
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Kaplan C. Les thrombopénies fœtales et néonatales allo-immunes : problèmes en suspens. Transfus Clin Biol 2005; 12:131-4. [PMID: 15950890 DOI: 10.1016/j.tracli.2005.04.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2005] [Indexed: 12/01/2022]
Abstract
The allo-immune thrombocytopenias are the major cause of severe thrombocytopenia in the fetus and the neonate. The frequency of this affection has been evaluated to be 1 out of 800 to 1000 live births. The deleterious consequences of severe thrombocytopenia are intracranial hemorrhages leading to death or neurological sequelae. Progress in platelet immunology and antenatal medicine has allowed a better diagnosis of this affection and development of the antenatal management of high-risk pregnancies. Nevertheless there are unsolved questions, particularly concerning the mechanism of the maternal immunization, the laboratory difficulties for the identification of the alloantibodies, the absence of antenatal management standardization.
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Affiliation(s)
- C Kaplan
- Laboratoire d'immunologie plaquettaire, INTS, 6, Paris, France.
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41
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Ertel K, Al-Tawil M, Santoso S, Kroll H. Relevance of the HPA-15 (Gov) polymorphism on CD109 in alloimmune thrombocytopenic syndromes. Transfusion 2005; 45:366-73. [PMID: 15752154 DOI: 10.1111/j.1537-2995.2005.04281.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Alloantibodies against the human platelet (PLT) alloantigen (HPA)-15 system residing on CD109 can cause fetal and neonatal alloimmune thrombocytopenia (FNAIT), posttransfusion purpura, and PLT transfusion refractoriness. The detection of antibodies against HPA-15, however, is hampered by the variable low expression and instability of the CD109 molecule during preparation and storage. STUDY DESIGN AND METHODS This study analyzed the occurrence of HPA-15 alloantibodies in 1403 patients: 930 FNAIT and 473 polytransfused (PT) patients by modified monoclonal antibody specific immobilization of PLT antigens (MAIPA) assay with well-defined phenotyped PLTs. A DNA typing technique was developed to confirm the phenotypes of PLT donors. B-cell lines were established as sources of reference DNA. RESULTS Genotyping of 407 unrelated blood donors revealed the gene frequencies 0.512 and 0.488 for HPA-15a and -15b, respectively. Based on the selection of PLTs expressing high amounts of CD109 on the surface (mean fluorescence intensity ratio 4-5 on expression peak on Days 2-4 after apheresis) antibody screening by the MAIPA assay was performed. In total, 16 (1.1%) HPA-15 alloantibodies were found comprising four anti-HPA-15a and 12 anti-HPA-15b. Anti-HPA-15b without other PLT-reactive antibodies were detectable in three serum samples of PT patients. The incidence of HPA-15 alloimmunization in PT patients was significantly higher than in mothers with FNAIT (3.0% vs. 0.22%). In relation to all detected HPA-specific antibodies, HPA-15 is responsible for 6.2 percent of alloimmunizations. CONCLUSION These observations indicate that alloimmunization against HPA-15 should be considered as a cause for immune thrombocytopenia, particularly in patients receiving multiple PLT transfusions.
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MESH Headings
- Antibodies, Monoclonal/immunology
- Antigens, CD/immunology
- Antigens, Human Platelet/genetics
- Antigens, Human Platelet/immunology
- Female
- GPI-Linked Proteins
- Genotype
- Humans
- Infant, Newborn
- Isoantibodies/immunology
- Male
- Neoplasm Proteins
- Pedigree
- Phenotype
- Polymerase Chain Reaction
- Polymorphism, Restriction Fragment Length
- Pregnancy
- Purpura, Thrombocytopenic, Idiopathic/genetics
- Purpura, Thrombocytopenic, Idiopathic/immunology
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Affiliation(s)
- Katharina Ertel
- Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany
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42
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Manno CS. Management of bleeding disorders in children. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2005:416-22. [PMID: 16304413 DOI: 10.1182/asheducation-2005.1.416] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Diagnosis and management of congenital and acquired bleeding disorders in children requires not only an understanding of the unique characteristics of pediatric hemostasis but also the natural course of bleeding disorders in children, which may differ substantially from the course observed in adult patients. In this article, three bleeding disorders of great importance to the pediatric hematologist are reviewed: neonatal alloimmune thrombocytopenia (NAIT), hemophilia and immune-mediated thrombocytopenic purpura (ITP). Current aspects of management are outlined. The unique physiology of transplacental transfer of maternally derived anti-platelet antibodies can result in neonatal immune thrombocytopenia, a significant cause of morbidity and mortality from bleeding in affected infants. For patients with hemophilia, approaches to treatment have shifted over the past decade from on-demand therapy to prophylaxis, either primary of secondary, resulting in delay of onset or complete avoidance of hemophilic arthropathy. Hemophilic inhibitors often develop in young children, prompting the need for a thorough understanding of the use of bypassing agents as well as immune tolerance induction in the young child. Finally, although several management strategies for ITP of childhood have been shown to improve the platelet count, side effects associated with corticosteroids, IVIg, anti-D and splenectomy force the practitioner to also consider the option of carefully observing, but not treating, the child with ITP.
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MESH Headings
- Antigens/immunology
- Blood Platelets/immunology
- Child
- Female
- Hemophilia A/blood
- Hemophilia A/immunology
- Hemophilia A/therapy
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/blood
- Infant, Newborn, Diseases/immunology
- Infant, Newborn, Diseases/therapy
- Maternal-Fetal Exchange
- Platelet Count
- Pregnancy
- Purpura, Thrombocytopenic/blood
- Purpura, Thrombocytopenic/therapy
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Thrombocytopenia, Neonatal Alloimmune/blood
- Thrombocytopenia, Neonatal Alloimmune/therapy
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Affiliation(s)
- Catherine S Manno
- The Children's Hospital of Philadelphia, 34th & Civic Center Blvd., Rm. 9518 Main Bldg., Philadelphia, PA 19104, USA.
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43
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Ohto H, Miura S, Ariga H, Ishii T, Fujimori K, Morita S. The natural history of maternal immunization against foetal platelet alloantigens. Transfus Med 2004; 14:399-408. [PMID: 15569234 DOI: 10.1111/j.1365-3148.2004.00535.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Foetomaternal alloimmune thrombocytopenia (FMAIT) occurs when maternal antibodies of an antigen-negative mother cause destruction of sensitized foetal platelets. In Caucasian populations, 6-12% of human platelet antigen (HPA)-1a-negative women develop anti-HPA-1a, and the incidence of clinically affected cases is estimated to be 10-20% of immunized women. This study was performed in order to elucidate the rate of maternal immunization, incidence of FMAIT and the likely outcome of the condition in Asians. Excluding two or more pregnancies during the period, serum samples from 24 630 pregnant women, mainly Japanese, were screened for antibodies against platelet alloantigens by means of mixed passive haemagglutination (MPHA) (Anti-HPA-MPHA, Olympus, Tokyo). Antibodies were detected in 0.91% (223/24 630) of the women's samples and the immunization rate was correlated with the number of pregnancies. Antibody specificity included anti-HPA-4b (49), anti-HPA-5a (three), anti-HPA-5b (168), anti-HPA-4b + 5b (one) and anti-Nak(a) (CD36) (two). No alloimmunization was observed within the HPA-1, HPA-2, HPA-3 or HPA-6 systems. Among HPA-4b- or HPA-5b-negative women, 24% or 14% estimated, respectively, had antibodies and 26% (10/38) or 10% (12/125) of neonates, respectively, born to these mothers developed thrombocytopenia. Two neonates born to mothers having anti-HPA-4b developed generalized purpura. No cases of intracranial bleeding or death due to FMAIT were recorded. Generalized purpura due to FMAIT occurs in one in 9359 (95% CI: 1 in 77 519-1 in 2591) pregnancies solely because of HPA-4b incompatibility.
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Affiliation(s)
- H Ohto
- Division of Blood Transfusion and Transplantation Immunology, Fukushima Medical University School of Medicine, Hikariga-oka, Fukushima City, Fukushima 960-1295, Japan.
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44
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Halle L, Bach K H, Martageix C, Bianchi F, Lê T Kim T, Morel-Kopp MC, Soulier J, Tetaria C, Kaplan C. Eleven human platelet systems studied in the Vietnamese and Ma'ohis Polynesian populations. ACTA ACUST UNITED AC 2004; 63:34-40. [PMID: 14651521 DOI: 10.1111/j.1399-0039.2004.00149.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The frequencies of human platelet antigens (HPA) are variable among different ethnic groups. Platelet phenotyping and genotyping in different populations are important to the clinical implications of antiplatelet alloimmunization. No report on HPA prevalence has been published concerning the Vietnamese Kinh and Ma'ohis Polynesian populations. Recent anthropological and genetic marker studies suggest that these two groups have a common origin in East Asia, so we have conducted a combined study concerning the frequency of HPA-1 to HPA-11w systems (excluding HPA-8w) and Gov in these two populations. The results demonstrate a similar pattern of prevalence between Ma'ohis and most of the Asian populations. However, it should be noted that the frequency of HPA-2 is closer to northern Caucasian frequencies than to Asian frequencies. The population of Kinh shows an HPA distribution that is closer to the Chinese population than to the northeastern Thais except for HPA-3, closer to the Indonesian population. Given HPA-3 gene frequency distribution fetomaternal incompatibility could occur more frequently with the risk of alloantibody production.
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Affiliation(s)
- L Halle
- Institut National de la Transfusion Sanguine (INTS), Laboratoire d'Immunologie Plaquettaire, Paris, France
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45
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Harrison CR, Curtis BR, McFarland JG, Huff RW, Aster RH. Severe neonatal alloimmune thrombocytopenia caused by antibodies to human platelet antigen 3a (Baka) detectable only in whole platelet assays. Transfusion 2003; 43:1398-402. [PMID: 14507271 DOI: 10.1046/j.1537-2995.2003.00533.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Maternal antibodies that cause neonatal alloimmune thrombocytopenia are commonly identified by solid-phase assays that detect the causative antibodies on the basis of their reactions with specific PLT glycoproteins. Two cases of severe neonatal alloimmune thrombocytopenia caused by maternal antibodies specific for human PLT antigen 3a (HPA-3a [Baka]) that failed to give the expected reactions in some solid-phase assays were recently encountered. STUDY DESIGN AND METHODS PLT-reactive antibodies were characterized by three different solid-phase assays and by flow cytometry. RESULTS The two maternal antibodies gave negative reactions in the antigen capture ELISA, modified antigen capture ELISA, and MoAb immobilization of PLT antigens tests but reacted strongly in flow cytometry with intact PLTs that were HPA-3a+. Other sera samples specific for HPA-3a reacted equally well in all assays. CONCLUSIONS The two antibodies appear to recognize an epitope on the HPA-3a+ form of glycoprotein IIb that is lost when PLTs are solubilized in detergent, as required for solid-phase assays. The diagnosis was made in these cases because no HLA antibodies were present, allowing an HPA-3a-specific reaction to be identified with intact PLTs as targets. Such antibodies are likely to be overlooked when HLA antibodies are also present.
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Affiliation(s)
- C R Harrison
- Department of Pathology, University of Texas Health Sciences Center, San Antonio, Texas 78284-7750, USA.
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46
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Abstract
Neonatal thrombocytopenia is a common clinical problem. Thrombocytopenia presenting in the first 72 hours of life is usually secondary to placental insufficiency and caused by reduced platelet production; fortunately most episodes are mild or moderate and resolve spontaneously. Thrombocytopenia presenting after 72 hours of age is usually secondary to sepsis or necrotising enterocolitis and is usually more severe and prolonged. Platelet transfusion remains the only treatment. There is a need for trials to define the safe lower limit for platelet count and which neonates will benefit from treatment.
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Affiliation(s)
- I Roberts
- Imperial College, Hammersmith Campus, London W12 0NN, UK.
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47
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Abstract
Fetal alloimmune thrombocytopenia (AIT) affects only a small number of fetuses but the consequences may be devastating. Outcomes range from mild thrombocytopenia without signs or symptoms to intracranial hemorrhage (ICH) and fetal or neonatal death. Antenatal screening is available but not used routinely in the United States. The most frequent method of AIT identification is its diagnosis in the neonatal period (index neonate). AIT may be diagnosed antenatally if an ICH is noted on routine obstetric ultrasound. There are accurate predictors of AIT, as well as antenatal therapies, to prevent the occurrence of severe disease and ICH.
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Affiliation(s)
- Mary Ellen Burke Sosa
- Division of Maternal-Fetal Medicine, Women & Infants' Hospital, Providence, Rhode Island 02905, USA.
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48
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Abstract
Fetal-neonatal alloimmune thrombocytopenia is the commonest cause of severe thrombocytopenia in the newborn. This disorder is due to the destruction of fetal platelets by a maternal platelet-specific antibody caused by fetal-maternal incompatibility. The most serious complication is intracranial hemorrhage (10-30 % of newborns), which may cause death (10 % of the reported cases) or irreversible neurological sequelae (20 %). The diagnosis is usually made after birth when most affected neonates have petechiae, purpura or overt bleeding. The degree of severity varies according to platelet count. Current methods allow detection of maternal platelet alloantibodies (usually HPA-1a). Clinical grounds and the exclusion of other causes of neonatal thrombocytopenia are required to establish an accurate diagnosis. Recurrence of this disease is very high and has prompted clinicians to develop antenatal prophylactic programs in subsequent pregnancies. However, the optimal treatment of at-risk pregnancies remains controversial. The early diagnosis of this process allows effective therapy based on the infusion of compatible platelets and IgG immunoglobulins when hemorrhage is not obvious. Antenatal management of subsequent pregnancies can prevent recurrence of thrombocytopenia and intracranial hemorrhage. The aim of this review is to draw pediatricians' attention to the importance of this probably under-diagnosed disease in which early diagnosis can prevent potentially severe complications.
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MESH Headings
- Antigens, Human Platelet/classification
- Antigens, Human Platelet/immunology
- Diagnosis, Differential
- HLA-DR Antigens/immunology
- HLA-DRB3 Chains
- Humans
- Immunoglobulin G/administration & dosage
- Immunoglobulins, Intravenous
- Infant, Newborn
- Integrin beta3
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/immunology
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Affiliation(s)
- E Muñiz-Díaz
- Banco de Sangre. Departamento de Hematología. Hospital Sant Pau-Creu Roja. Universidad Autónoma de Barcelona. España.
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49
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Abstract
Thrombocytopenia remains a common problem in sick newborns. A quarter of all neonates admitted to neonatal intensive care units develop thrombocytopenia, and in 20% of episodes the thrombocytopenia is severe (platelets <50 x 10(9)/L). Practical and clinically relevant classifications of neonatal thrombocytopenia have now been developed which, by highlighting the principal conditions precipitating severe thrombocytopenia (eg, sepsis, necrotizing enterocolitis, perinatal asphyxia, and the immune thrombocytopenias), aid the practicing neonatologist. Recent reviews demonstrate that many neonates with severe thrombocytopenia receive repeated platelet transfusions, although evidence of their clinical benefit is lacking, and there exists a significant variation in platelet transfusion practice between centers. These facts support the need for the development of evidence-based protocols for platelet transfusion in the newborn and stimulate continued interest in the potential of hemopoietic growth factors (, thrombopoietin and interleukin-11) to prevent or treat neonatal thrombocytopenia.
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Affiliation(s)
- Irene A G Roberts
- Pediatric Hematology, Imperial College, Faculty of Medicine, Hammersmith Hospital, London, United Kingdom.
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50
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Engelfriet CP, Reesink HW, Kroll H, Giers G, Bald R, Kanhai H, Kekomäki R, Teramo K, Panzer S, Jilma P, Ulm B, Bock J, Taaning E, Rodeck C, Goldman M, David M, Kaplan C. Prenatal management of alloimmune thrombocytopenia of the fetus. Vox Sang 2003; 84:142-9. [PMID: 12609023 DOI: 10.1046/j.1423-0410.2003.00269.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- C P Engelfriet
- Sanquin Diagnostic Services, Amsterdam, the Netherlands.
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