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Thonon H, Van Nieuwenhove M, Thachil J, Lippi G, Hardy M, Mullier F. Hemostasis Testing in the Emergency Department: A Narrative Review. Semin Thromb Hemost 2024. [PMID: 38897223 DOI: 10.1055/s-0044-1787661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Routine laboratory screening is typically performed at initial evaluation of the vast majority of presentations to the emergency department (ED). These laboratory results are crucial to the diagnostic process, as they may influence up to 70% of clinical decisions. However, despite the usefulness of biological assessments, many tests performed are inappropriate or of doubtful clinical relevance. This overutilization rate of laboratory testing in hospitals, which represents a significant medical-economic burden, ranges from 20 to 67%, with coagulation tests at the top of the list. While reviews frequently focus on nonintensive care units, there are few published assessments of emergency-specific interventions or guidelines/guidance to date. The aim of this review is to highlight current recommendations for hemostasis evaluation in the emergency setting with a specific analysis of common situations leading to ED admissions, such as suspected venous thrombosis or severe bleeding. We revisit the evidence related to the assessment of patient's hemostatic capacity based on comprehensive history taking and physical examination as well as best practice recommendations for blood sample collection to ensure the reliability of results. This review also includes an examination of various currently available point of care tests and a comprehensive discussion on indications, limitations, and interpretation of these tests.
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Affiliation(s)
- Henri Thonon
- Emergency Department, Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Yvoir, Belgium
| | | | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, United Kingdom
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Michael Hardy
- Department of Anesthesiology, Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Yvoir, Belgium
| | - François Mullier
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Hematology Laboratory, Yvoir, Belgium
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle Mont, Université catholique de Louvain (UCLouvain), Yvoir, Belgium
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2
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Thomas-Rüddel D, Bauer M, Moita LF, Helbig C, Schlattmann P, Ehler J, Rahmel T, Meybohm P, Gründling M, Schenk H, Köcher T, Brunkhorst FM, Gräler M, Heger AJ, Weis S. Epirubicin for the Treatment of Sepsis and Septic Shock (EPOS-1): study protocol for a randomised, placebo-controlled phase IIa dose-escalation trial. BMJ Open 2024; 14:e075158. [PMID: 38653508 PMCID: PMC11043739 DOI: 10.1136/bmjopen-2023-075158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 03/28/2024] [Indexed: 04/25/2024] Open
Abstract
INTRODUCTION Sepsis remains the major cause of death among hospitalised patients in intensive care. While targeting sepsis-causing pathogens with source control or antimicrobials has had a dramatic impact on morbidity and mortality of sepsis patients, this strategy remains insufficient for about one-third of the affected individuals who succumb. Pharmacological targeting of mechanisms that reduce sepsis-defining organ dysfunction may be beneficial. When given at low doses, the anthracycline epirubicin promotes tissue damage control and lessens the severity of sepsis independently of the host-pathogen load by conferring disease tolerance to infection. Since epirubicin at higher doses can be myelotoxic, a first dose-response trial is necessary to assess the potential harm of this drug in this new indication. METHODS AND ANALYSIS Epirubicin for the Treatment of Sepsis and Septic Shock-1 is a randomised, double-blind, placebo-controlled phase 2 dose-escalation phase IIa clinical trial to assess the safety of epirubicin as an adjunctive in patients with sepsis. The primary endpoint is the 14-day myelotoxicity. Secondary and explorative outcomes include 30-day and 90-day mortality, organ dysfunction, pharmacokinetic/pharmacodynamic (PK/PD) and cytokine release. Patients will be randomised in three consecutive phases. For each study phase, patients are randomised to one of the two study arms (epirubicin or placebo) in a 4:1 ratio. Approximately 45 patients will be recruited. Patients in the epirubicin group will receive a single dose of epirubicin (3.75, 7.5 or 15 mg/m2 depending on the study phase. After each study phase, a data and safety monitoring board will recommend continuation or premature stopping of the trial. The primary analyses for each dose level will report the proportion of myelotoxicity together with a 95% CI. A potential dose-toxicity association will be analysed using a logistic regression model with dose as a covariate. All further analyses will be descriptive. ETHICS AND DISSEMINATION The protocol is approved by the German Federal Institute for Drugs and Medical Devices. The results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05033808.
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Affiliation(s)
- Daniel Thomas-Rüddel
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Michael Bauer
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | | | - Christiane Helbig
- Center for Clinical Studies, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Peter Schlattmann
- Institute of Medical Statistics, Computer Sciences, and Data Science, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Johannes Ehler
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Tim Rahmel
- Clinic for Anesthesiology, Intensive Care and Pain Therapy, University Medical Center Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Matthias Gründling
- Department of Anesthesiology, Greifswald, University Hospital of Greifswald, Greifswald, Germany
| | - Heiko Schenk
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Thomas Köcher
- Vienna BioCenter Core Facilities GmbH, Wien, Austria
| | - Frank M Brunkhorst
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Markus Gräler
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Ann-Julika Heger
- Center for Clinical Studies, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Sebastian Weis
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
- Institute for Infectious Disease and Infection Control, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
- Leibniz Institute for Infection Biology and Natural Products Research, Hans-Knöll Institute - HKI, Jena, Germany
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3
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Kanda M, Kitamura K, Saito A, Hayashi K, Suzuki T. A Case of Thrombocytopenia, Anasarca (Edema, Pleural Effusion, and Ascites), Fever, Reticulin Fibrosis/Renal Dysfunction, and Organomegaly (TAFRO) Syndrome Initially Not Presenting With Thrombocytopenia: A Role of Immature Platelet Fraction. Cureus 2024; 16:e58772. [PMID: 38779246 PMCID: PMC11111282 DOI: 10.7759/cureus.58772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2024] [Indexed: 05/25/2024] Open
Abstract
Thrombocytopenia, anasarca (edema, pleural effusion, and ascites), fever, reticulin fibrosis/renal dysfunction, and organomegaly (TAFRO) syndrome is a rare and severe systemic disease. The emergence of thrombocytopenia, however, may be preceded by other signs or symptoms, which could delay the diagnosis of the disease. We reported a case in which an increased immature platelet fraction (IPF), a surrogate marker for megakaryocytic activity, preceded the development of thrombocytopenia, and finally, we diagnosed the patient with TAFRO syndrome. A 79-year-old male with a previous history of uninephrectomy due to bladder and ureteral cancer was admitted to our hospital because of massive edema and progressive impairment in renal function. On admission, inguinal lymphadenopathy, elevated C-reactive protein (CRP), bilateral pleural effusion, and ascites were observed, and the lymph node biopsy showed that atrophic lymphoid follicles and germinal centers were observed along with prominent glomeruloid vascular proliferation and the expansion of the interfollicular spaces consistent with the feature of Castleman's disease. The peripheral platelet count did not reach the level of the criteria for TAFRO syndrome (13.9×104/µL), but the immature platelet fraction was increased (11.6%), and bone marrow biopsy revealed hyperplasia of megakaryocytes. During the course of the preemptive treatment with prednisolone and tocilizumab, thrombocytopenia was uncovered, and the patient was finally diagnosed as having TAFRO syndrome. Thus, the present case may offer valuable information on the role of the immature platelet fraction in the establishment of the early diagnosis of TAFRO syndrome.
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Affiliation(s)
- Mutsuo Kanda
- Department of Nephrology, Tokyo Medical University, Tokyo, JPN
| | - Koichi Kitamura
- Department of Nephrology, Diabetes, and Endocrinology, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, JPN
| | - Akira Saito
- Department of Pathology, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, JPN
| | - Koichi Hayashi
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kawasaki, JPN
| | - Toshihiko Suzuki
- Department of Nephrology, Diabetes, and Endocrinology, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, JPN
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Kashiwagi H, Kuwana M, Murata M, Shimada N, Takafuta T, Yamanouchi J, Kato H, Hato T, Tomiyama Y. Reference guide for the diagnosis of adult primary immune thrombocytopenia, 2023 edition. Int J Hematol 2024; 119:1-13. [PMID: 37957517 PMCID: PMC10770234 DOI: 10.1007/s12185-023-03672-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 11/15/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia due to accelerated platelet destruction and impaired platelet production. Diagnosis of ITP is still challenging because ITP has been diagnosed by exclusion. Exclusion of thrombocytopenia due to bone marrow failure is especially important in Japan because of high prevalence of aplastic anemia compared to Western countries. Hence, we propose a new diagnostic criteria involving the measurement of plasma thrombopoietin (TPO) levels and percentage of immature platelet fraction (RP% or IPF%); 1) isolated thrombocytopenia with no morphological evidence of dysplasia in any blood cell type in a blood smear, 2) normal or slightly increased plasma TPO level (< cutoff), 3) elevated RP% or IPF% (> upper limit of normal), and 4) absence of other conditions that potentially cause thrombocytopenia including secondary ITP. A diagnosis of ITP is made if conditions 1-4 are all met. Cases in which criterion 2 or 3 is not met or unavailable are defined as "possible ITP," and diagnosis of ITP can be made mainly by typical clinical course. These new criteria enable us to clearly differentiate ITP from aplastic anemia and other forms of hypoplastic thrombocytopenia and can be highly useful in clinical practice for avoiding unnecessary bone marrow examination as well as for appropriate selection of treatments.
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Affiliation(s)
- Hirokazu Kashiwagi
- Department of Blood Transfusion, Osaka University Hospital, Suita, Osaka, 565-0871, 2-15, Yamadaoka, Japan.
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Mitsuru Murata
- Center for Clinical Medical Research, International University of Health and Welfare, Ohtawara, Tochigi, Japan
| | - Naoki Shimada
- Center for Basic Medical Research, International University of Health and Welfare, Ohtawara, Tochigi, Japan
| | - Toshiro Takafuta
- Department of Internal Medicine, Hiroshima City Funairi Citizens Hospital, Hiroshima, Hiroshima, Japan
| | - Jun Yamanouchi
- Division of Blood Transfusion and Cell Therapy, Ehime University Hospital, Toon, Ehime, Japan
| | - Hisashi Kato
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Takaaki Hato
- Japanese Red Cross Ehime Blood Center, Matsuyama, Ehime, Japan
| | - Yoshiaki Tomiyama
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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5
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Butt AJ, Zaidi U, Munawar Ali R, Zafar S, Ali MS, Shamsi T. Reticulated Platelet Count as a Diagnostic Tool in Immune Thrombocytopenia (ITP). Cureus 2023; 15:e41346. [PMID: 37546153 PMCID: PMC10398611 DOI: 10.7759/cureus.41346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2023] [Indexed: 08/08/2023] Open
Abstract
OBJECTIVE This study aimed to compare the reticulated platelet count between patients having thrombocytopenia secondary to autoimmune destruction (immune thrombocytopenia {ITP}), bone marrow failure, and healthy controls who presented to a tertiary care hospital in Karachi, Pakistan. METHODOLOGY A cross-sectional study was conducted from February 2021 to October 2022 in the Department of Hematology, National Institute of Blood Disease (NIBD) Hospital in Karachi, Pakistan, that involved examining three groups: 30 patients with immune thrombocytopenia, 30 patients with thrombocytopenia secondary to reduced production from bone marrow, and 30 healthy controls. The study utilized the Sysmex XN-1000 (Hyogo, Japan: Sysmex Corporation) automated hematology analyzer to perform a complete blood count (CBC) test. Additionally, peripheral blood was stained with Leishman stain and examined under a microscope to eliminate pseudo thrombocytopenia and identify any abnormal cells or dysplasia. The immature platelet fraction (IPF) was then performed on Sysmex XN 1000 after ensuring adequate quality control. Finally, the data were analyzed using DATAtab (Graz, Austria: DATAtab) and SPSS version 25 (Armonk, NY: IBM Corp.). RESULTS Of the ninety participants, the median age was 33 years with a range of 18-71 years. Patients with ITP had a significantly higher median IPF% (median=26.65, IQR=15-39.4) than thrombocytopenia due to bone marrow failure (median=9.25, IQR=4.55-14.30) and healthy controls (median=7, IQR=4.40-9.90), with a p-value of 0.001. The immune thrombocytopenia group demonstrated an increase in IPF% as platelet counts increased, indicating a significant moderate correlation between IPF% and platelets in these patients (r=0.438, p=0.016) and confirming that IPF% was an independent predictor for the detection of ITP. CONCLUSION Reticulated platelet count may be a useful diagnostic tool to differentiate between ITP and thrombocytopenia caused by bone marrow failure. Because of its non-invasive nature, IPF is a valuable tool for expediting the management of thrombocytopenia associated with increased IPF.
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Affiliation(s)
- Aqsa Javed Butt
- Clinical Hematology, National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, PAK
| | - Uzma Zaidi
- Clinical Hematology, National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, PAK
| | - Rabeea Munawar Ali
- Clinical Hematology, National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, PAK
| | - Sidra Zafar
- Research and Development, National Institute of Blood Diseases and Bone marrow Transplantation, Karachi, PAK
| | - Muhammad Shujat Ali
- Clinical Hematology, National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, PAK
| | - Tahir Shamsi
- Clinical Hematology, National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, PAK
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6
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Allegra A, Cicero N, Mirabile G, Giorgianni CM, Gangemi S. Novel Biomarkers for Diagnosis and Monitoring of Immune Thrombocytopenia. Int J Mol Sci 2023; 24:ijms24054438. [PMID: 36901864 PMCID: PMC10003036 DOI: 10.3390/ijms24054438] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/12/2023] [Accepted: 02/21/2023] [Indexed: 03/12/2023] Open
Abstract
Lower-than-normal platelet counts are a hallmark of the acquired autoimmune illness known as immune thrombocytopenia, which can affect both adults and children. Immune thrombocytopenia patients' care has evolved significantly in recent years, but the disease's diagnosis has not, and it is still only clinically achievable with the elimination of other causes of thrombocytopenia. The lack of a valid biomarker or gold-standard diagnostic test, despite ongoing efforts to find one, adds to the high rate of disease misdiagnosis. However, in recent years, several studies have helped to elucidate a number of features of the disease's etiology, highlighting how the platelet loss is not only caused by an increase in peripheral platelet destruction but also involves a number of humoral and cellular immune system effectors. This made it possible to identify the role of immune-activating substances such cytokines and chemokines, complement, non-coding genetic material, the microbiome, and gene mutations. Furthermore, platelet and megakaryocyte immaturity indices have been emphasized as new disease markers, and prognostic signs and responses to particular types of therapy have been suggested. Our review's goal was to compile information from the literature on novel immune thrombocytopenia biomarkers, markers that will help us improve the management of these patients.
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Affiliation(s)
- Alessandro Allegra
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, 98100 Messina, Italy
- Correspondence:
| | - Nicola Cicero
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences (BIOMORF), University of Messina, 98100 Messina, Italy
| | - Giuseppe Mirabile
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, 98100 Messina, Italy
| | - Concetto Mario Giorgianni
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences (BIOMORF), University of Messina, 98100 Messina, Italy
| | - Sebastiano Gangemi
- Allergy and Clinical Immunology Unit, Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
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7
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Takeshita S, Kakita H, Asai S, Asai T, Mori M, Ueda H, Aoki H, Aoyama M, Yamada Y. Thrombocytopenia and insufficient thrombopoietin production in human small-for-gestational-age infants. Pediatr Res 2023; 93:619-624. [PMID: 35568734 PMCID: PMC9988681 DOI: 10.1038/s41390-022-02107-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 04/26/2022] [Accepted: 05/02/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Small-for-gestational-age (SGA) infants are at increased risk for transient thrombocytopenia. The aim of this study was to determine whether thrombocytopenia in human SGA infants is due to insufficient thrombopoietin (TPO) production. METHODS A prospective study of 202 infants with gestational age less than 37 weeks was conducted; 30 of them were SGA infants, and 172 were non-SGA infants. Thrombocytopenia was seen in 17 of 30 SGA infants and 40 of 172 non-SGA infants. RESULTS Platelet counts were significantly lower in the SGA group than in the non-SGA group at the time of the lowest platelet count within 72 h of birth. The platelet count and immature platelet fraction (IPF) were negatively correlated in non-SGA infants, but not in SGA infants. In addition, the platelet count and TPO were negatively correlated in non-SGA infants. IPF and TPO were significantly lower in SGA than in non-SGA infants with thrombocytopenia. CONCLUSION IPF increased with thrombocytopenia to promote platelet production in non-SGA infants due to increasing TPO, but not in SGA infants. This study found an association between insufficient TPO production and thrombocytopenia in SGA infants. In addition, this study is important for understanding the etiology of thrombocytopenia in SGA infants. IMPACT The immature platelet fraction was low, and serum thrombopoietin was not increased in small-for-gestational-age (SGA) infants with thrombocytopenia. Thrombocytopenia in SGA infants is due to insufficient thrombopoietin production. This study is important for understanding the etiology of thrombocytopenia in SGA infants.
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Affiliation(s)
- Satoru Takeshita
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan.,Department of Pathobiology, Nagoya City University Graduate School of Pharmaceutical Sciences, 3-1 Tanabedori, Mizuho-ku, Nagoya, Aichi, 467-8603, Japan
| | - Hiroki Kakita
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan. .,Department of Pathobiology, Nagoya City University Graduate School of Pharmaceutical Sciences, 3-1 Tanabedori, Mizuho-ku, Nagoya, Aichi, 467-8603, Japan.
| | - Shimpei Asai
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Takafumi Asai
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Mari Mori
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Hiroko Ueda
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Hiromasa Aoki
- Department of Pathobiology, Nagoya City University Graduate School of Pharmaceutical Sciences, 3-1 Tanabedori, Mizuho-ku, Nagoya, Aichi, 467-8603, Japan
| | - Mineyoshi Aoyama
- Department of Pathobiology, Nagoya City University Graduate School of Pharmaceutical Sciences, 3-1 Tanabedori, Mizuho-ku, Nagoya, Aichi, 467-8603, Japan
| | - Yasumasa Yamada
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
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8
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Li N, Mahamad S, Parpia S, Iorio A, Foroutan F, Heddle NM, Hsia CC, Sholzberg M, Rimmer E, Shivakumar S, Sun HL, Refaei M, Hamm C, Arnold DM. Development and internal validation of a clinical prediction model for the diagnosis of immune thrombocytopenia. J Thromb Haemost 2022; 20:2988-2997. [PMID: 36121734 DOI: 10.1111/jth.15885] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/15/2022] [Accepted: 09/15/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is a diagnosis of exclusion that can resemble other thrombocytopenic disorders. OBJECTIVES To develop a clinical prediction model (CPM) for the diagnosis of ITP to aid hematogists in investigating patients presenting with undifferentiated thrombocytopenia. METHODS We designed a CPM for ITP diagnosis at the time of the initial hematology consultation using penalized logistic regression based on data from patients with thrombocytopenia enrolled in the McMaster ITP registry (n = 523) called the Predict-ITP Tool. The case definition for ITP was a platelet count less than 100 × 109 /L and a platelet count response after high-dose corticosteroids or intravenous immune globulin, defined as the achievement of a platelet count above 50 × 109 /L and at least a doubling of baseline. Internal validation was done using bootstrap resampling. Model discrimination was assessed by the c-statistic, and calibration was assessed by the calibration slope, calibration-in-the-large, and calibration plot. RESULTS The final model included the following variables: (1) platelet count variability (based on three or more platelet count values), (2) lowest platelet count value, (3) maximum mean platelet volume, and (4) history of major bleeding (defined by the ITP bleeding scale). The optimism-corrected c-statistic was 0.83, the calibration slope was 0.88, and calibration-in-the-large for all performance measures was <0.001 with standard error <0.001, indicating good discrimination and excellent calibration. CONCLUSIONS The Predict-ITP Tool can estimate the likelihood of ITP for a given patient with thrombocytopenia at the time of the initial hematology consultation. The tool had high predictive accuracy for the diagnosis of ITP.
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Affiliation(s)
- Na Li
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Syed Mahamad
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sameer Parpia
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Farid Foroutan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Nancy M Heddle
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Canadian Blood Services, Hamilton, Ontario, Canada
| | - Cyrus C Hsia
- Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Michelle Sholzberg
- Departments of Medicine and Laboratory Medicine and Pathobiology, St. Michael's Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
| | - Emily Rimmer
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Sudeep Shivakumar
- Department of Medicine, Division of Hematology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Haowei Linda Sun
- Department of Medicine, Division of Hematology, University of Alberta, Edmonton, Alberta, Canada
| | - Mohammad Refaei
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Caroline Hamm
- Department of Biomedical Sciences, University of Windsor, Windsor, Ontario, Canada
- Division of Oncology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University - Windsor Campus, Windsor, Ontario, Canada
| | - Donald M Arnold
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
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9
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Chen SH, Tsai SC, Lu HC. Platelets as a Gauge of Liver Disease Kinetics? Int J Mol Sci 2022; 23:ijms231911460. [PMID: 36232759 PMCID: PMC9569526 DOI: 10.3390/ijms231911460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/22/2022] [Accepted: 09/25/2022] [Indexed: 11/18/2022] Open
Abstract
A multitude of laboratory and clinical interferences influence the utility of platelet-based diagnostic indices, including immature platelet fraction, in longitudinal monitoring and prognostication of patients with chronic liver disease (CLD). The complex yet highly regulated molecular basis of platelet production and clearance kinetics becomes dysregulated in liver pathogenesis. These underlying molecular mechanisms, including premature platelet clearance and bone marrow suppression in parallel with the progressive (e.g., treatment-naïve) or regressive (e.g., on-treatment and off-treatment) disease courses, involved in CLDs, may further confound the changes in platelet–liver correlations over time. Platelet count and function are commonly and secondarily altered in vivo in CLDs. However, the precise characterization of platelet functions during cirrhosis, including in vitro platelet aggregation, has proven challenging due to interferences such as thrombocytopenia. A flow cytometric approach may help monitor the unstably rebalanced hyper- and hypoaggregable states in patients with cirrhosis at risk of hyperaggregable, prothrombotic, or bleeding events. Studies have attempted to stratify patients with cirrhosis by substages and prognosis through the use of novel indices such as the ratio of in vitro endogenous platelet aggregation to platelet count. This review attempts to highlight clinical and laboratory precautions in the context of platelet-assisted CLD monitoring.
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Affiliation(s)
- Sheng-Hung Chen
- Department of Medicine, China Medical University, No. 91, Xueshi Road, Taichung 404333, Taiwan
- Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, No. 2, Yude Road, Taichung 404327, Taiwan
- Correspondence:
| | - Shih-Chang Tsai
- Department of Biological Science and Technology, China Medical University, Taichung 404333, Taiwan
| | - Hsiu-Chen Lu
- Department of Education, China Medical University Hospital, Taichung 404327, Taiwan
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10
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Akyol Ş, Tüfekçi Ö, Yilmaz Ş, Ören H. Evaluation of paediatric immune thrombocytopenia patients with clinical and laboratory findings: emphasizing the role of monocytosis. Blood Coagul Fibrinolysis 2022; 33:315-321. [PMID: 35834725 DOI: 10.1097/mbc.0000000000001146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
We aimed to investigate the relationship between demographics, clinical features, laboratory findings including monocytosis and clinical course in children with immune thrombocytopenia (ITP). Data of 100 ITP patients were analysed. Complete blood count findings of the patients at certain time points were evaluated to classify the disease as acute, persistent and chronic. An effect of sex on chronicity was not observed ( P = 0.166). Of the patients enrolled in the study, 38% ( n = 38) had chronic course. The mean age of patients with the chronic course was 7 ± 4.1 years, which was significantly higher than the other groups ( P = 0.007). Sixty-five percent ( n = 13) of the patients presenting with mucosal bleeding and 27.4% ( n = 20) of the patients presenting with skin bleeding became chronic ( P = 0.008). MPV was found to be significantly high in chronic ITP patients ( P = 0.049). Monocytosis was noted in 80% of the patients at diagnosis. Intravenous immunoglobulin was used in 84% of the patients with acute ITP; 33% of them developed chronic ITP. The age at diagnosis, presence of mucosal bleeding and increased MPV on admission were high-risk factors for the development of the chronic course. Monocytosis was detected in 80% of the patients on admission, and it may play a role in the pathogenesis of ITP.
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Affiliation(s)
- Şefika Akyol
- Dokuz Eylul University, Department of Pediatric Hematology, Izmir, Turkey
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11
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Huang WJ, Wang GY, Liu ZY, Zhang ML, Wang W, Zhang X, Wang RT. Preoperative PDW levels predict pulmonary metastasis in patients with hepatocellular carcinoma. BMC Cancer 2022; 22:683. [PMID: 35729523 PMCID: PMC9215007 DOI: 10.1186/s12885-022-09754-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/10/2022] [Indexed: 12/03/2022] Open
Abstract
Background In hepatocellular carcinoma (HCC), pulmonary metastasis (PM) after hepatectomy is associated with poor clinical outcomes. The crucial phases of tumour cell proliferation, angiogenesis, and metastasis all entail platelet activation. In HCC, platelet distribution width (PDW) suggests platelet size changes and predicts a worse prognosis. The aim of this study was to assess the association between PDW and PMs in HCC patients receiving hepatectomy. Material/methods From January 2013 to December 2015, a cohort of patients who underwent hepatectomy for HCC at the Harbin Medical University Cancer Hospital in China were retrospectively evaluated. The relationship between PDW levels and clinical and demographic parameters was examined. To investigate the relationships between predicted factors and PM, a competing risk model was used. From January 2016 to December 2018, a validation cohort of 109 patients from the First Affiliated Hospital of Harbin Medical University was studied independently. Results In the primary cohort, 19 out of 214 patients had postoperative PMs. In HCC patients with PM, PDW levels were lower than in those without PM. There was a significant difference in the cumulative incidence of 2-year PM between the high-PDW and low-PDW groups after controlling for competing risk events (death prior to the development of PM) (p < 0.001). In addition, PDW was also found to be an independent predictor for PM in a multivariable competing risk analysis. The results were externally validated in another cohort. Conclusions In HCC, preoperative PDW is significantly associated with PM. PDW could be a biomarker for post-operative PM in HCC patients.
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Affiliation(s)
- Wen-Juan Huang
- Department of Internal Medicine, Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin, Heilongjiang, 150081, China
| | - Guang-Yu Wang
- Department of Digestive Internal Medicine, Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin, Heilongjiang, 150081, China
| | - Zeng-Yao Liu
- Department of Interventional Medicine, The First Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang, 150001, China
| | - Meng-Lin Zhang
- Department of Internal Medicine, Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin, Heilongjiang, 150081, China
| | - Wen Wang
- Department of Internal Medicine, Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin, Heilongjiang, 150081, China
| | - Xin Zhang
- Department of Internal Medicine, Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin, Heilongjiang, 150081, China.
| | - Rui-Tao Wang
- Department of Internal Medicine, Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin, Heilongjiang, 150081, China.
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12
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Kim B. Diagnostic workup of inherited platelet disorders. Blood Res 2022; 57:11-19. [PMID: 35483920 PMCID: PMC9057669 DOI: 10.5045/br.2022.2021223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/17/2022] [Accepted: 01/27/2022] [Indexed: 11/17/2022] Open
Abstract
Inherited platelet disorders (IPDs) can cause mucocutaneous bleeding due to impaired primary hemostatic function of platelets, thrombocytopenia, or both. Recent advances in molecular technology can help identify many genes related to platelet biology, control the overall steps of megakaryopoiesis, and cause IPD. In this article, currently available laboratory tools for diagnosing IPDs with the characteristic laboratory features of each IPD are reviewed, and a general diagnostic approach for the evaluation of IPD patients is presented.
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Affiliation(s)
- Bohyun Kim
- Department of Laboratory Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
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13
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Bobircă A, Bobircă F, Ancuța I, Florescu A, Bojincă M, Muscă A, Florescu DN, Florescu LM, Sima RM, Florescu A, Mușetescu AE. COVID-19-A Trigger Factor for Severe Immune-Mediated Thrombocytopenia in Active Rheumatoid Arthritis. LIFE (BASEL, SWITZERLAND) 2022; 12:life12010077. [PMID: 35054471 PMCID: PMC8780601 DOI: 10.3390/life12010077] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/23/2021] [Accepted: 01/04/2022] [Indexed: 12/13/2022]
Abstract
Thrombocytopenia is defined as a platelet count below 150,000/mm3 for adults. There is still controversy about whether individuals with platelet counts of 100,000/mm3 to 150,000/mm3 should be classified as having genuine thrombocytopenia or borderline thrombocytopenia. Thrombocytopenia is considered mild when the platelet count is between 70,000 and 150,000/mm3 and severe if the count is less than 20,000/mm3. Thrombocytopenia in rheumatoid arthritis is a rare complication, with an incidence estimated between 3 and 10%. The main etiological aspects include drug-induced thrombocytopenia and immune thrombocytopenic purpura. The most common hematological abnormalities in SARS-CoV-2 infection are lymphopenia and thrombocytopenia. It has been observed that the severity of thrombocytopenia correlates with the severity of the infection, being a poor prognosis indicator and a risk factor for mortality. COVID-19 can stimulate the immune system to destroy platelets by increasing the production of autoantibodies and immune complexes. Autoimmunity induced by viral infections can be related to molecular mimicry, cryptic antigen expression and also spreading of the epitope. During the COVID-19 pandemic, it is of great importance to include the SARS-CoV-2 infection in differential diagnoses, due to the increased variability in forms of presentation of this pathology. In this review, our aim is to present one of the most recently discovered causes of thrombocytopenia, which is the SARS-CoV-2 infection and the therapeutic challenges it poses in association with an autoimmune disease such as rheumatoid arthritis.
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Affiliation(s)
- Anca Bobircă
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.B.); (I.A.); (M.B.)
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Florin Bobircă
- Department of General Surgery, Carol Davila University of Medicine and Pharmacy, Dr I. Cantacuzino Clinical Hospital, 050474 Bucharest, Romania;
| | - Ioan Ancuța
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.B.); (I.A.); (M.B.)
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Anca Florescu
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Mihai Bojincă
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.B.); (I.A.); (M.B.)
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Alice Muscă
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Dan Nicolae Florescu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Lucian Mihai Florescu
- Department of Radiology and Medical Imaging, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Romina Marina Sima
- Department of Obstetrics and Gynecology, “Bucur” Maternity, “Saint John” Clinical Emergency Hospital, 077160 Bucharest, Romania;
| | - Alesandra Florescu
- Department of Rheumatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
- Correspondence:
| | - Anca Emanuela Mușetescu
- Department of Rheumatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
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14
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Voigtlaender M, Langer F. Management of Vascular Thrombosis in Patients with Thrombocytopenia. Hamostaseologie 2021; 42:19-28. [PMID: 34933376 DOI: 10.1055/a-1675-7824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Platelets play critical roles in hemostasis and thrombosis. While low platelet counts increase the risk of bleeding, antithrombotic drugs, including anticoagulants and antiplatelet agents, are used to treat thromboembolic events. Thus, the management of thrombosis in patients with low platelet counts is challenging with hardly any evidence available to guide treatment. Recognition of the underlying cause of thrombocytopenia is essential for assessing the bleeding risk and tailoring therapeutic options. A typical clinical scenario is the occurrence of venous thromboembolism (VTE) in cancer patients experiencing transient thrombocytopenia during myelosuppressive chemotherapy. In such patients, the severity of thrombocytopenia, thrombus burden, clinical symptoms, and the timing of VTE relative to thrombocytopenia must be considered. In clinical practice, distinct hematological disorders characterized by low platelet counts and a thrombogenic state require specific diagnostics and treatment. These include the antiphospholipid syndrome, heparin-induced thrombocytopenia (HIT) and (spontaneous) HIT syndromes, disseminated intravascular coagulation, and paroxysmal nocturnal hemoglobinuria.
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Affiliation(s)
- Minna Voigtlaender
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Florian Langer
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
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15
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Goel G, Semwal S, Khare A, Joshi D, Amerneni CK, Pakhare A, Kapoor N. Immature Platelet Fraction: Its Clinical Utility in Thrombocytopenia Patients. J Lab Physicians 2021; 13:214-218. [PMID: 34602784 PMCID: PMC8478497 DOI: 10.1055/s-0041-1729471] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Objectives Etiology of thrombocytopenia is multifactorial and its pathogenesis should be distinguished for appropriate management. Newly formed immature platelets are called reticulated platelets (RPs) and can be estimated in peripheral blood using automated hematology analyzers, which express them as immature platelet fraction (IPF). In the present study we intend to assess and establish the clinical utility of IPF in differentiating the two major causes of thrombocytopenia-decreased production and increased destruction of platelets-along with determining its significance in monitoring patients with thrombocytopenia. Materials and Methods Sixty-one cases of thrombocytopenia and 101 healthy controls with normal platelet count were included in the study. IPF and all the other usual blood cell parameters were measured using a fully automated hematology analyzer. Based on the pathogenesis of thrombocytopenia, the cases were divided into groups and the difference in IPF value between the groups was evaluated. Results The reference range of IPF among healthy controls was estimated to be 0.7 to 5.7%. The mean IPF was significantly higher in patients with increased peripheral destruction of platelets (13.4%) as compared to patients with decreased production of platelets (4.6%). The optimal cutoff value of IPF for differentiating patients with increased peripheral destruction of platelets from patients with decreased production of platelets was 5.95% with a sensitivity of 88% and specificity of 75.9%. Conclusion Measurement of IPF is useful for detecting evidence of increased platelet production and helps in the initial evaluation of thrombocytopenia patients. It is a novel diagnostic method which can be used to differentiate patients with thrombocytopenia due to increased destruction of platelets from patients with thrombocytopenia due to bone marrow failure/suppression.
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Affiliation(s)
- Garima Goel
- Department of Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Shruti Semwal
- Department of Pathology, L.N. Medical College and J.K. Hospital, Bhopal, Madhya Pradesh, India
| | - Akriti Khare
- Department of Hematology, All India Institute of Medical Sciences, Delhi, India
| | - Deepti Joshi
- Department of Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Chaitanya K Amerneni
- Department of Pathology and Lab Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Abhijit Pakhare
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Neelkamal Kapoor
- Department of Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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16
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Abstract
Neonatal megakaryopoiesis and platelet turnover form a developmentally unique pattern by generating a pool of newly released reticulated platelets from the bone marrow into the circulation. Reticulated platelets are more reactive and hyperaggregable compared to mature platelets, due to their high residual mRNA content, large size, increased expression of platelet surface receptors, and degranulation. The proportion of reticulated platelets in neonates is higher compared to that in adults. Due to the emergence of an uninhibited platelet subpopulation, the newly formed reticulated platelet pool is inherently hyporesponsive to antiplatelets. An elevated population of reticulated platelets is often associated with increased platelet reactivity and is inversely related to high on-treatment platelet reactivity, which can contribute to ischemia. Measurements of the reticulated platelet subpopulation could be a useful indicator of increased tendency for platelet aggregation. Future research is anticipated to define the distinct functional properties of newly formed reticulated or immature platelets in neonates, as well as determine the impact of enhanced platelet turnover and high residual platelet reactivity on the response to antiplatelet agents.
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Affiliation(s)
- Belay Tesfamariam
- Division of Pharmacology and Toxicology, 372792Center for Drug Evaluation and Research, Silver Spring, MD, USA
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17
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Chen F, McDonald V, Newland A. Experts' review: the emerging roles of romiplostim in immune thrombocytopenia (ITP). Expert Opin Biol Ther 2021; 21:1383-1393. [PMID: 34313512 DOI: 10.1080/14712598.2021.1960979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The management of ITP has in recent years been transformed from reliance on immunosuppressants and splenectomy to targeted therapy with thrombopoietin receptor agonists (TPO-RA) that directly stimulate platelet production in the bone marrow. This has reduced the long-term infective complications and toxicities associated with the use of potent immunosuppressants and splenectomy. The welltolerated romiplostim, itself a novel drug construct called peptibody, has established itself, alongside other TPO-RA as the preferred 2nd line therapy in major international guidelines on treatment of ITP. AREAS COVERED This review summarizes the data from early licensing trials of romiplostim and discusses the real-world experience to date, the unexpected emerging data on treatment-free long-term remission achieved using TPO-RA, and the case for its early introduction in the therapeutic pathway. The emerging risk of thrombosis is also discussed. EXPERT OPINION The use of romiplostim and other TPO-RA will be increasingly brought forward in the management pathway of ITP with the prospect of modifying the long-term outcome of the disease by increasing sustained treatment-free remission. With the prospect of several new targeted therapies been introduced into clinical practice, TPO-RA will likely be a key component of future combination therapies for difficult cases.
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Affiliation(s)
- Frederick Chen
- Department of Clinical Haematology, the Royal London Hospital, Barts Health NHS Trust, London, UK.,Academic Haematology Unit, Barts & the London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | - Vickie McDonald
- Department of Clinical Haematology, the Royal London Hospital, Barts Health NHS Trust, London, UK.,Academic Haematology Unit, Barts & the London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry,QMUL, London, UK
| | - Adrian Newland
- Department of Clinical Haematology, the Royal London Hospital, Barts Health NHS Trust, London, UK.,Academic Haematology Unit, Barts & the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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18
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Hanata N, Shoda H, Kono M, Komai T, Natsumoto B, Tsuchida Y, Tsuchiya H, Nagafuchi Y, Taoka K, Kurokawa M, Fujio K. Immature platelet levels correlate with disease activity and predict treatment response of thrombocytopenia in lupus patients. Lupus 2021; 30:1764-1772. [PMID: 34304626 DOI: 10.1177/09612033211034233] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The immature platelet fraction (IPF) represents recently produced platelets in bone marrow and this parameter is increased in patient with primary immune thrombocytopenia (ITP). We investigated the associations between IPF and absolute immature platelet count (AIPC), and clinical parameters in systemic lupus erythematosus (SLE), which has more complex pathological mechanisms than in primary ITP. METHODS Patients with SLE were retrospectively reviewed at the University of Tokyo Hospital from May, 2012 to January, 2021. The correlations between clinical parameters and the number of immature platelets were assessed with Spearman's rank correlation coefficients. A multiple logistic regression model was used to identify the independent clinical parameters for IPF and AIPC. The difference in the distribution of time for a complete response (CR) after prednisolone (PSL) administration was also evaluated by log-rank test. RESULTS A total of 282 SLE patients were enrolled, and 12.41% of those patients showed thrombocytopenia. IPF correlated with clinical parameters such as platelet count (r = -0.58), AIPC (r = 0.64) and systemic lupus erythematosus disease activity index 2000 (SLEDAI-2K) (r = 0.24). SLEDAI-2K [odds ratio (OR) (per unit increase), 1.07; 95% CI, 1.013 - 1.13] and thrombocytopenia (OR, 32.23; 95% CI, 11.072 - 93.80) were independent clinical parameters to account for IPF increase. IPF correlated with the number of bone marrow megakaryocytes (n = 19, r = 0.57). Notably, the probability of CR in response to PSL in AIPC-high patients was higher than in AIPC-low patients (hazard ratio, 4.62; 95% CI, 1.07 - 20.02). CONCLUSION IPF correlated with disease activity of SLE and represented platelet production in the bone marrow, whereas AIPC predicted a rapid response to steroids in thrombocytopenic patients with SLE.
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Affiliation(s)
- Norio Hanata
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Shoda
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masanori Kono
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshihiko Komai
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Bunki Natsumoto
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yumi Tsuchida
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Haruka Tsuchiya
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasuo Nagafuchi
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuki Taoka
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mineo Kurokawa
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keishi Fujio
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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19
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Pereira KN, de Carvalho JAM, Paniz C, Moresco RN, da Silva JEP. Diagnostic characteristics of immature platelet fraction for the assessment of immune thrombocytopenia. Thromb Res 2021; 202:125-127. [PMID: 33831665 DOI: 10.1016/j.thromres.2021.03.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/18/2021] [Accepted: 03/20/2021] [Indexed: 10/21/2022]
Abstract
The diagnosis of immune thrombocytopenia (ITP) remains an exclusion, as a specific biomarker is missing. We aimed to investigate the diagnostic characteristics, establish a cut-off point for reticulated platelets, and compare it with the clinical exclusion diagnosis used in the assessment of ITP. Forty-one patients with ITP and 187 healthy individuals were enrolled in Santa Maria, Brazil. Sysmex XE-5000 was used to measure IPF. We obtained an IPF cut-off point of 6.3% with a sensitivity of 92.7% (95% CI: 80.1-98.5) and a specificity of 92.5% (95% CI: 87.8-95.8). The area under the curve was 0.97. The kappa coefficient was 0.85 (95% CI: 0.75-0.95), which shows high agreement between methods. The positive (PPV) and negative predictive values (NPV) were 81.25% and 96.42%, respectively. From the cut-off point, kappa index, PPV, and NPV obtained, it is possible to conclude that IPF can be an efficient laboratory marker for diagnosing ITP.
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Affiliation(s)
- Karla Nunes Pereira
- Postgraduate Program in Pharmaceutical Sciences, Center of Health Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil; University Hospital, Santa Maria, RS, Brazil
| | - José Antonio Mainardi de Carvalho
- University Hospital, Santa Maria, RS, Brazil; Department of Clinical and Toxicological Analysis, Center of Health Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil.
| | - Clóvis Paniz
- Postgraduate Program in Pharmaceutical Sciences, Center of Health Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil; Department of Clinical and Toxicological Analysis, Center of Health Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - Rafael Noal Moresco
- Postgraduate Program in Pharmaceutical Sciences, Center of Health Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil; Department of Clinical and Toxicological Analysis, Center of Health Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - José Edson Paz da Silva
- Postgraduate Program in Pharmaceutical Sciences, Center of Health Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil; Department of Clinical and Toxicological Analysis, Center of Health Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil
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20
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The molecular basis of immune-based platelet disorders. Clin Sci (Lond) 2021; 134:2807-2822. [PMID: 33140828 DOI: 10.1042/cs20191101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/12/2020] [Accepted: 10/23/2020] [Indexed: 12/17/2022]
Abstract
Platelets have a predominant role in haemostasis, the maintenance of blood volume and emerging roles as innate immune cells, in wound healing and in inflammatory responses. Platelets express receptors that are important for platelet adhesion, aggregation, participation in inflammatory responses, and for triggering degranulation and enhancing thrombin generation. They carry a cargo of granules bearing enzymes, adhesion molecules, growth factors and cytokines, and have the ability to generate reactive oxygen species. The platelet is at the frontline of a host of cellular responses to invading pathogens, injury, and infection. Perhaps because of this intrinsic responsibility of a platelet to rapidly respond to thrombotic, pathological and immunological factors as part of their infantry role; platelets are susceptible to targeted attack by the adaptive immune system. Such attacks are often transitory but result in aberrant platelet activation as well as significant loss of platelet numbers and platelet function, paradoxically leading to elevated risks of both thrombosis and bleeding. Here, we discuss the main molecular events underlying immune-based platelet disorders with specific focus on events occurring at the platelet surface leading to activation and clearance.
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21
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Sato Y, Yoshihisa A, Watanabe K, Hotsuki Y, Kimishima Y, Yokokawa T, Misaka T, Sato T, Kaneshiro T, Oikawa M, Kobayashi A, Takeishi Y. Association between platelet distribution width and prognosis in patients with heart failure. PLoS One 2020; 15:e0244608. [PMID: 33373413 PMCID: PMC7771660 DOI: 10.1371/journal.pone.0244608] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/11/2020] [Indexed: 11/18/2022] Open
Abstract
Background The prognostic impact of platelet distribution width (PDW), which is a specific marker of platelet activation, has been unclear in patients with heart failure (HF). Methods and results We conducted a prospective observational study enrolling 1,746 hospitalized patients with HF. Patients were divided into tertiles based on levels of PDW: 1st (PDW < 15.9 fL, n = 586), 2nd (PDW 15.9–16.8 fL, n = 617), and 3rd (PDW ≥ 16.9, n = 543) tertiles. We compared baseline patients’ characteristics and post-discharge prognosis: all-cause death; cardiac death; and cardiac events. The 3rd tertile showed the highest age and levels of B-type natriuretic peptide compared to other tertiles (1st, 2nd, and 3rd tertiles; age, 69.0, 68.0, and 70.0 years old, P = 0.038; B-type natriuretic peptide, 235.2, 171.9, and 241.0 pg/mL, P < 0.001). Left ventricular ejection fraction was equivalent among the tertiles. In the Kaplan-Meier analysis, rates of all endpoints were the highest in the 3rd tertile (log-rank P < 0.001, respectively). The Cox proportional hazard analysis revealed that the 3rd tertile was associated with adverse prognosis (all-cause death, hazard ratio [HR] 1.716, P < 0.001; cardiac death, HR 1.919, P < 0.001; cardiac event, HR 1.401, P = 0.002). Conclusions High PDW is a novel predictor of adverse prognosis in patients with HF.
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Affiliation(s)
- Yu Sato
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Akiomi Yoshihisa
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
- Department of Advanced Cardiac Therapeutics, Fukushima Medical University, Fukushima, Japan
- * E-mail:
| | - Koichiro Watanabe
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yu Hotsuki
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yusuke Kimishima
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Tetsuro Yokokawa
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Tomofumi Misaka
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
- Department of Advanced Cardiac Therapeutics, Fukushima Medical University, Fukushima, Japan
| | - Takamasa Sato
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Takashi Kaneshiro
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Masayoshi Oikawa
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Atsushi Kobayashi
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
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Reeves HM, Maitta RW. Immature Platelet Dynamics in Immune-Mediated Thrombocytopenic States. Front Med (Lausanne) 2020; 7:597734. [PMID: 33392220 PMCID: PMC7775312 DOI: 10.3389/fmed.2020.597734] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 11/24/2020] [Indexed: 01/19/2023] Open
Abstract
A major challenge encountered by clinicians is differentiating presentations characterized by significant thrombocytopenia due to overlapping clinical symptoms and signs in the setting of ambiguous laboratory results. Immature platelets represent the youngest platelets that can be measured in peripheral blood by current hematology analyzers. These young platelets are larger, with higher RNA content recently released from the bone marrow. Thrombocytopenic presentations caused directly or indirectly by immune responses can lead to compensatory bone marrow responses seeking to normalize the platelet count; thus obtaining absolute immature platelet counts may be informative while triaging patients. Over the last decade, their use has expanded beyond being an early biomarker of bone marrow reconstitution post-hematopoietic stem cell transplantation to being used to establish bone marrow responses to infection and thrombocytopenias due to immune etiologies. Its accessibility as part of more detailed platelet indices obtained with routine laboratories makes it a promising option to understand the bone marrow's real-time response to disease states characterized by thrombocytopenia. This review will look at the immature platelet count as a biomarker, while presenting current attempts trying to understand how it could be used in thrombocytopenias occurring secondary to a given immune etiology.
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Affiliation(s)
- Hollie M Reeves
- Department of Pathology, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, United States
| | - Robert W Maitta
- Department of Pathology, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, United States
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