Studies of neutrophil and monocyte oxidative responses in polycythaemia vera and related myeloproliferative disorders

Evaluation of superoxide dismutase enzyme activity of polymorphonuclear leucocytes, erythrocytes and thrombocytes in patients with chronic myeloproliferative disorders

This study aimed to investigate the activity of the antioxidant enzyme superoxide dismutase (SOD) in the three main cell types in chronic myeloproliferative disorders (CMPD) patients, i.e. polymorphonuclear leucocytes (PMNLs), erythrocytes and thrombocytes, prior to therapy. Patients with reactive neutrophilia (RN) and healthy volunteers were included as controls. The SOD activity of PMNLs was significantly decreased in CMPD and RN patients compared with healthy volunteers, whereas the SOD activity of erythrocytes was found to be significantly increased in patients with CMPD and RN compared with healthy volunteers. There were no significant differences in the SOD activity of thrombocytes between CMPD patients, RN patients or healthy volunteers. This study indicates that the activity of the SOD enzyme in two cell types is different in CMPD patients compared with healthy subjects. Thus, SOD activity may be altered dependent on cell type and due to specific cell function.

Pathogenetic mechanisms of polycythemia vera and congenital polycythemic disorders

The absolute polycythemias--those with increased red blood cell mass--can be divided into two groups: primary, caused by acquired or inherited mutations leading to a "gain-of-function" abnormalities expressed within the erythroid progenitors; and secondary, due to circulating serum factors, typically erythropoietin, stimulating erythropoiesis. This overview concentrates on the molecular biology of polycythemia vera (PV) discussed in the context of other polycythemic disorders. Recent advances in the regulation of erythropoiesis, as they may relate to polycythemic states, are discussed as a background for those well-defined polycythemic states wherein the molecular defect has not yet been elucidated. A number of cellular abnormalities associated with PV, including the hyperresponsiveness of PV progenitors to many cytokines as well as decreased expression of the thrombopoietin receptor on platelets and increased expression of Bcl-xL, suggest that the PV defect alters a number of cellular functions and is not restricted to cytokine receptor signal transduction. The increasing number of recognized instances of familial incidence of PV suggests that in these families the predisposition for PV is inherited as a dominant trait, and that PV is acquired as a new mutation that leads to a clonal hematopoiesis and may be due to loss of heterozygosity. The existence of these families provides a unique opportunity for isolation of the mutations in the gene leading to PV. Semin Hemaol 38(suppl 2):10-20.

Molecular basis for polycythemia

This overview concentrates on familial and congenital polycythemias in the context of other polycythemic disorders, with emphasis on those with established molecular lesions. Recent advances in the regulation of erythropoiesis, as they may relate to polycythemic states, are discussed as a background for those well-defined polycythemic states wherein the molecular defect has not yet been elucidated. Primary familial congenital polycythemias and congenital and familial secondary polycythemias, including hemoglobin mutants, methemoglobinemias and congenital 2,3-bisphosphoglycerate deficiency, are discussed. The most common primary polycythemia, polycythemia vera, as well as the only likely endemic congenital secondary polycythemia, known as Chuvash polycythemia, are discussed.

Leukocyte function in chronic myeloproliferative disorders

The myeloproliferative disorders (MPD) are clonal diseases that originate from a transformed stem cell and involve all myeloid lineage. The affected cells have both proliferative and functional impairment. Therefore, we evaluated and compared neutrophil function in 31 patients with polycythemia vera (PV), idiopathic myelofibrosis (MF), chronic myeloid leukemia (CML), and essential thrombocytosis (ET). Neutrophil chemotaxis, random migration, bactericidal activity and superoxide anion release in these patients were simultaneously compared to those of 31 healthy controls. In this study, chemotactic activity was significantly impaired in patients with PV and CML as compared to controls (M+/-SE: 42 +/- 6 vs. 69+/- 5 cells/field; p<0.005 and 47+/-7 vs. 68+/- 5; p<0.05, respectively). The assessment of the bactericidal activity of neutrophils showed no impairment in most of the patients. In the CML group, the serum had a very strong "lytic" effect on bacteria, possibly due to the high levels of serum lysozyme (22 +/- 2 microgram/ml). The superoxide anion release was found to be normal in most of the patients. Nevertheless, in 25% of PV patients the superoxide production was impaired (less than 60% of the simultaneous controls). In ET most patients had normal neutrophil function. Regarding the effect of treatment, neutrophil chemotactic activity was found to be significantly reduced in the hydrea-treated patients, as compared to the non- treated patients (p<0.001) or healthy controls (<0.0001). We conclude that disturbances in neutrophil function are present in patients with various MPDs, except ET. This probably reflects abnormal maturation of ancessors of the damaged stem cells. Nevertheless, we should keep in mind that therapy itself could affect neutrophil functions. This matter should be studied more extensively. Although infections are not common in MPD disorders, they occasionally occur. It is possible that impairment in the phagocytic function contribute to the development of infections in patients with myeloproliferative disorders.

Haematopoietic progenitors and signal transduction in polycythaemia vera and primary thrombocythaemia

While significant progress has been made in understanding the cellular defect and molecular basis of polycythaemia vera (PV), elucidation of the primary mutation leading to PV remains elusive. While clinically useful, the PV diagnostic criteria put forward by the Polycythemia Vera Study Group are not based on the pathophysiology of this disorder and in some instances may lead to false diagnosis or may not be sufficient to diagnose an early PV. In diagnostically unclear situations, clinical and laboratory findings must take into account the acquired nature of PV, its clonality, and the presence of endogenous erythroid colony formation in serum-containing media. It is likely that other simpler assays may be developed based on the rapidly emerging knowledge of the cellular pathology of PV. Several intriguing observations of abnormalities pertaining to the erythroid signal transduction have been recently reported; these remain to be validated in other laboratories and to be proven specific for PV. The clinical concept of primary thrombocythaemia (PT) lags behind what we know about PV. While the diagnosis of PT is still based on the exclusion of other known causes of thrombocytosis, new knowledge is emerging. Recent clonality studies of a large number of PT females show that the majority are clonal. It is our belief that thrombocythaemic subjects who are not found to be clonal are those with secondary thrombocytosis. Multiple in vitro-based assays of megakaryocytic and erythroid progenitors have been developed and conflicting data published. It is likely that standardized assays of megakaryocytic progenitors will soon become available and a reproducible PT specific defect will be found. Such a specific test would be of immense diagnostic value in this most elusive of all myeloproliferative disorders.

Impaired platelet binding of fibrinogen due to a lower number of GPIIB/IIIA receptors in polycythemia vera

We have previously described a stimulus-specific defect in platelet aggregation in polycythaemia vera (PV) after stimulation with surface receptor dependent agonists such as platelet activating factor (PAF). In contrast, responses to phorbol myristate acetate (PMA) were normal. We now report that after PAF stimulation, using flow cytometry, the amount of fibrinogen bound to its receptor was significantly lower in PV platelets with a median MFI of 6.0 (range 4.1-17.3) compared to controls, 12.8 (range 8-21.3; n=11; p<0.01). We found no evidence of preactivation of PV platelets. Quantitative analysis of GPIIIa gave a significantly lower number of GPIIIa on resting PV platelets, 14300 subunits of GPIIIa (range 8500-15500) vs. 19800 for controls (range 13400-26800; n=12; p<0.01). Both patients and controls increased their number of receptors on the cell surface after stimulation with PAF and PMA, but the significant difference in the number of receptors per cell remained. Indirect evaluation of PAF receptor function showed that activation of CD 62 did not differ in PV and controls after PAF stimulation. Additionally, although the basal level of serotonin in platelet-rich plasma was significantly lower in PV, there was a threefold increase of the basal level after stimulation with PAF for both PV and control platelets, also indicating a normal interaction of PAF with its receptor. Although our results indicate both an impaired PAF induced aggregation in PV and a lower number of GPIIb/IIIa complexes on single platelets, whether these phenomena are related remains uncertain.

Interactions between platelets and neutrophils in essential thrombocythaemia. Effects on neutrophil chemiluminescence and superoxide anion generation

Essential thrombocythaemia (ET) is frequently associated with neutrophil and platelet dysfunction, and with increased incidence of vascular complications (thrombosis, haemorrhage). Several interactions between platelets and neutrophils have been reported, and the reciprocal actions between these cells may have an important role both in thromboregulation and in diseases such as those caused by uncontrolled neutrophil activation. In the current paper the authors studied 15 patients affected by ET and 10 normal subjects as controls. Circulating neutrophils and platelets were purified and were recombined in constant ratios (50:1, 100:1 and 200:1) and the individual platelet to neutrophil ratio. Superoxide anion (O2-) generation and luminol-enhanced chemiluminescence (CL) were studied after neutrophil stimulation with fMLP. In normal subjects both O2- generation and CL were inhibited by autologous platelets in a dose-dependent manner. In ET patients, on the contrary, platelet-dependent inhibition of O2- generation did not occur, while a dose-dependent inhibition of CL was observed. Two groups of ET patients were found: patients with neutrophil O2- generation and CL within the normal range, and patients with significantly reduced neutrophil respiratory burst. However, no differences were found between these two groups of patients in terms of platelet effects towards fMLP-stimulated neutrophils. Therefore, platelets from ET patients were not able to exert the homeostatic control towards neutrophil O2- generation shown by platelets from normal subjects, and this phenomenon may have a role in the clinical setting. In fact, O2- has been shown to be a very strong direct platelet activator, is able to inactivate nitric oxide (which is a powerful inhibitor of platelet aggregation and adhesion to endothelium), and is directly involved in neutrophil-mediated tissue damage.

Impaired activation of phospholipase D in polycythaemia vera-implications for the pathogenesis of the disease?

A series of studies have demonstrated a stimulus-specific defect in PMN oxidative metabolism after stimulation with surface receptor dependent stimuli such as fMLP, leukotriene B4 and platelet activating factor (PAF), whereas the response to phorbol myristate acetate was normal. Having discovered this defect, studies of the stimulus response coupling for oxidative responses were performed showing a normal interaction of fMLP with it's receptor, as well as an intact activation of phospholipase C, as measured by the generation of 1,4,5-inositoltrisphosphate, and the subsequent rise of intracellular calcium. In contrast, the formation of diacylglycerol and phosphatidylethanol was decreased in PV PMN, denoting an impaired activation of phospholipase D (PLD). It was shown by flow cytometry analyses that the hampered oxidative response was present both in single PMN and monocytes. Moreover, platelets from PV patients, whose PMN exhibit a lower oxidative response to PAF, also have a diminished aggregatory response to PAF. Thus three different cell lineages in PV have been revealed to respond abnormally to surface receptor dependent stimuli, indicating that the proposed impairment of PLD might be relevant for changes in the malignant stem cell clone. Since phosphatidic acid, produced as a result of PLD activation, may be implicated in the regulation of several oncogenes, perturbations of the PLD system could theoretically be important for the development of PV.

Stimulus-specific defect in platelet aggregation in polycythemia vera

We have previously reported that polymorphonuclear granulocyte (PMN) and monocyte oxidative metabolism is reduced in polycythemia vera (PV) patients compared to healthy control subjects, after stimulation with cell surface receptor-dependent stimuli such as n-formyl-methionyl-leucyl-phenylalanine, leukotriene B4 and platelet-activating factor (PAF). In contrast, the oxidative response to phorbol myristate acetate (PMA) is normal. We now show that, in PV patients exhibiting significantly reduced PMN chemiluminescence after PAF stimulation, PAF induced platelet aggregation was also reduced--40 +/- 3% compared to 50 +/- 2% in controls (p < 0.01). The defective aggregatory response to PAF in PV remained over a wide range of stimuli concentrations. Platelet aggregation induced by PMA and ADP, however, was similar in PV and controls. In contrast, platelet aggregation induced by PAF (or by ADP and PMA) was not significantly reduced in patients with chronic myeloid leukemia, essential thrombocythemia and multiple myeloma. Furthermore, the release of beta-thromboglobulin was slightly but not significantly higher after PAF stimulation in PV and this argues against an abnormal PAF receptor as the cause of the defective function. Thus, not only PV neutrophils, but also PV platelets show a discrete defect of the stimulus response coupling for PAF, indicating a disease-specific abnormality that appears to be of clonal origin.