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Fetal/neonatal alloimmune thrombocytopenia: a systematic review of impact of HLA-DRB3*01:01 on fetal/neonatal outcome. Blood Adv 2021; 4:3368-3377. [PMID: 32717028 DOI: 10.1182/bloodadvances.2020002137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/09/2020] [Indexed: 01/06/2023] Open
Abstract
The most common, severe cases of fetal and neonatal alloimmune thrombocytopenia among whites are caused by antibodies against human platelet antigen 1a (HPA-1a). The aims of this systematic review and meta-analysis are to determine the association between maternal HLA-DRB3*01:01 and: (1) HPA-1a-alloimmunization and (2) neonatal outcome in children born of HPA-1a-immunized women. A systematic literature search identified 4 prospective and 8 retrospective studies. Data were combined across studies to estimate pooled odds ratios (ORs) and the associated 95% confidence intervals (CIs). The population represented by the prospective studies was more than 150 000. In the prospective studies, there were 64 severely thrombocytopenic newborns (platelet count <50 × 109/L) of whom 3 had intracranial hemorrhage. The mothers of all 64 children were HLA-DRB3*01:01+. The number of severely thrombocytopenic children born of HPA-1a-alloimmunized women in the retrospective studies was 214; 205 of whom were born of HLA-DRB3*01:01+ women. For HLA-DRB3*01:01- women, the OR (95% CI) for alloimmunization was 0.05 (0.00-0.60), and for severe neonatal thrombocytopenia 0.08 (0.02-0.37). This meta-analysis demonstrates that the risk of alloimmunization and of having a child with severe thrombocytopenia are both very low for HPA-1a- women who are HLA-DRB3*01:01-.
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Kjeldsen-Kragh J, Bengtsson J. Fetal and Neonatal Alloimmune Thrombocytopenia-New Prospects for Fetal Risk Assessment of HPA-1a-Negative Pregnant Women. Transfus Med Rev 2020; 34:270-276. [PMID: 33039264 DOI: 10.1016/j.tmrv.2020.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 11/17/2022]
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a rare and potentially serious bleeding condition in the fetus/newborn. FNAIT is usually considered as the platelet counterpart of hemolytic disease of the fetus and newborn. In FNAIT, maternal alloantibodies against paternally inherited platelet antigens traverse the placenta and cause thrombocytopenia in the fetus/newborn. The most common and most serious cases of FNAIT among white people are caused by alloantibodies against the human platelet antigen 1a (HPA-1a), which is absent in 2.3% of women. Today, there is no screening for FNAIT, and for this reason, FNAIT is not suspected until an otherwise healthy child, born at term, presents with thrombocytopenia. Clinical management of subsequent pregnancies at risk of FNAIT is mostly based on the obstetric history. During the last 5 decades, hemolytic disease of the fetus and newborn caused by antibodies against RhD has successfully been prevented by administration of hyperimmune anti-D IgG drug products to RhD-negative women after delivery of an RhD-positive child. Similarly, a hyperimmune anti-HPA-1a IgG (NAITgam) is under development for the prevention of HPA-1a immunization and FNAIT. If NAITgam becomes licensed for FNAIT prophylaxis and national health authorities decide to include FNAIT screening in their antenatal health care programs, it will be necessary to improve today's tools for assessing the risk of FNAIT. Although the primary risk factor for HPA-1a immunization is platelet type HPA-1bb, not all HPA-1a-negative women develop anti-HPA-1a. The women who are HLA-DRB3:01:01 negative (72%) only rarely develop anti-HPA-1a, and for those few who become HPA-1a immunized, it is quite rare to have a child with severe thrombocytopenia. Determination of fetal HPA-1 type is important because 15% of HPA-1a-negative women will carry an HPA-1a-negative fetus and therefore not be at risk of FNAIT. The severity of FNAIT seems to be associated with the level of anti-HPA-1a. Hence, in Norway, for example, an Ab threshold of 3 IU/mL is used to distinguish between low- and high-risk pregnancies. The current review will discuss to what extent these analyses, as well as determination of subtypes of anti-HPA-1a (anti-β3, anti-αIIbβ3, and anti-αvβ3) and Fc core fucosylation of anti-HPA-1a IgG, can be used as risk stratification tools.
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Affiliation(s)
- Jens Kjeldsen-Kragh
- Department of Clinical Immunology and Transfusion Medicine, University and Regional Laboratories, Region Skåne, Lund, Sweden; Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway.
| | - Jesper Bengtsson
- Department of Clinical Immunology and Transfusion Medicine, University and Regional Laboratories, Region Skåne, Lund, Sweden
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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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Regan F, Lees CC, Jones B, Nicolaides KH, Wimalasundera RC, Mijovic A. Prenatal Management of Pregnancies at Risk of Fetal Neonatal Alloimmune Thrombocytopenia (FNAIT): Scientific Impact Paper No. 61. BJOG 2019; 126:e173-e185. [PMID: 30968555 DOI: 10.1111/1471-0528.15642] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
WHAT IS IT?: Fetal neonatal alloimmune thrombocytopenia (FNAIT), also known as neonatal alloimmune thrombocytopenia (NAIT) or fetomaternal alloimmune thrombocytopenia (FMAIT), is a rare condition which affects a baby's platelets. This can put them at risk of problems with bleeding, particularly into the brain. One baby per week in the UK may be seriously affected and milder forms can affect one in every 1000 births. HOW IS IT CAUSED?: Platelets are blood cells that are very important in helping blood to clot. All platelets have natural proteins on their surface called human platelet antigens (HPAs). In babies, half of these antigens are inherited from the mother and half from the father. During pregnancy, some of the baby's platelets can cross into the mother's bloodstream. In most cases, this does not cause a problem. But in cases of FNAIT, the mother's immune system does not recognise the baby's HPAs that were inherited from the father and develops antibodies, which can cross the placenta and attack the baby's platelets. These antibodies are called anti-HPAs, and the commonest antibody implicated is anti-HPA-1a, but there are other rarer antibody types. If this happens, the baby's platelets may be destroyed causing their platelet count to fall dangerously low. If the platelet count is very low there is a risk to the baby of bleeding into their brain before they are born. This is very rare but if it happens it can have serious effects on the baby's health. HOW IS IT INHERITED?: A baby inherits half of their HPAs from its mother and half from its father. Consequently, a baby may have different HPAs from its mother. As the condition is very rare, and even if the baby is at risk of the condition we have no way of knowing how severely they will be affected, routine screening is not currently recommended. WHAT CAN BE DONE?: FNAIT is usually diagnosed if a previous baby has had a low platelet count. The parents are offered blood tests and the condition can be confirmed or ruled out. There are many other causes of low platelets in babies, which may also need to be tested for. As the condition is so rare, expertise is limited to specialist centres and normally a haematologist and fetal medicine doctor will perform and interpret the tests together. Fortunately, there is an effective treatment for the vast majority of cases called immunoglobulin, or IVIg. This 'blood product' is given intravenously through a drip every week to women at risk of the condition. It may be started from as early as 16 weeks in the next pregnancy, until birth, which would be offered at around 36-37 weeks. Less common treatments that may be considered depending on individual circumstances include steroid tablets or injections, or giving platelet transfusions to the baby. WHAT DOES THIS PAPER TELL YOU?: This paper considers the latest evidence in relation to treatment options in the management of pregnancies at risk of FNAIT. Specifically, we discuss the role of screening, when IVIg should be started, what dose should be used, and what evidence there is for maternal steroids. We also consider in very rare selected cases, the use of fetal blood sampling and giving platelet transfusions to the baby before birth. Finally, we consider the approaches to blood testing mothers to tell if babies are at risk, which is offered in some countries, and development of new treatments to reduce the risk of FNAIT.
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MESH Headings
- Antigens, Human Platelet
- Female
- Fetal Diseases/genetics
- Fetal Diseases/prevention & control
- Fetal Diseases/therapy
- Genetic Testing
- Humans
- Immunoglobulins, Intravenous/therapeutic use
- Infant, Newborn
- Infant, Newborn, Diseases/genetics
- Infant, Newborn, Diseases/therapy
- Integrin beta3
- Mass Screening/methods
- Medical History Taking
- Platelet Count
- Pregnancy
- Prenatal Care/methods
- Thrombocytopenia, Neonatal Alloimmune/diagnosis
- Thrombocytopenia, Neonatal Alloimmune/genetics
- Thrombocytopenia, Neonatal Alloimmune/prevention & control
- Thrombocytopenia, Neonatal Alloimmune/therapy
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Bertrand G, Blouin L, Boehlen F, Levine E, Minon JM, Winer N. Management of neonatal thrombocytopenia in a context of maternal antiplatelet alloimmunization: Expert opinion of the French-speaking working group. Arch Pediatr 2019; 26:191-197. [PMID: 30827773 DOI: 10.1016/j.arcped.2019.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 12/13/2018] [Accepted: 02/03/2019] [Indexed: 01/07/2023]
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a potentially devastating disease, seen in 1/800-1000 neonates. FNAIT is the most common cause of early-onset isolated severe neonatal thrombocytopenia in maternity wards. The most feared complication of this disorder is intracranial hemorrhage, leading to death or neurological sequelae. There is no systematic screening of at-risk pregnancies and FNAIT is often discovered when fetal or neonatal bleeding is observed. A working group on fetomaternal platelet alloimmunization was created in 2017, under the auspices on the French Group of Thrombosis and Hemostasis (GFHT). The first objective of this group was to survey clinical practices for treatment of thrombocytopenic neonates in a context of suspected or confirmed FNAIT.
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Affiliation(s)
- G Bertrand
- laboratoire HLA-HPA, Établissement français du sang (EFS) Bretagne, rue Pierre-Jean-Gineste, BP 91614, 35016 Rennes cedex, France.
| | - L Blouin
- Laboratoire d'immunologie et immunogénétique, EFS Nouvelle Aquitaine, CHU de Bordeaux, place Amélie-Léon, 33076 Bordeaux cedex, France
| | - F Boehlen
- Service d'angiologie et d'hémostase, hôpitaux universitaires de Genève, 4, rue Gabrielle-Perret-Gentil, 1211 Genève 14, Switzerland
| | - E Levine
- Service de néonatologie soins intensifs, hôpital universitaire de Rennes, 16, boulevard de Bulgarie, 35000 Rennes, France
| | - J-M Minon
- Unité d'hémostase et de transfusion, département de médecine de laboratoire, centre hospitalier régional de la Citadelle, boulevard du XXII(e)-de-Ligne, 4000 Liège, Belgium
| | - N Winer
- INRA, UMR 1280, département de gynécologie et d'obstétrique, physiologie des adaptations nutritionnelles, hôpital universitaire de Nantes, 38, boulevard Jean-Monnet, 44093 Nantes cedex 1, France
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Kjeldsen-Kragh J, Olsen KJ. Risk of HPA-1a-immunization in HPA-1a-negative women after giving birth to an HPA-1a-positive child. Transfusion 2019; 59:1344-1352. [PMID: 30729532 DOI: 10.1111/trf.15152] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 12/15/2018] [Accepted: 12/15/2018] [Indexed: 01/11/2023]
Affiliation(s)
- Jens Kjeldsen-Kragh
- Department of Clinical Immunology and Transfusion Medicine, University and Regional Laboratories Region Skåne, Lund, Sweden.,Department of Laboratory Medicine, University Hospital of North-Norway, Tromsø, Norway
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8
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Winkelhorst D, Oepkes D. Foetal and neonatal alloimmune thrombocytopenia. Best Pract Res Clin Obstet Gynaecol 2019; 58:15-27. [PMID: 30827816 DOI: 10.1016/j.bpobgyn.2019.01.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 01/23/2019] [Accepted: 01/31/2019] [Indexed: 12/19/2022]
Abstract
Foetal or neonatal thrombocytopenia results from alloimmunisation during pregnancy. Maternal alloantibodies can be formed following exposure to paternally derived human platelet antigens (HPAs) on foetal platelets, in case of incompatible HPA type. These alloantibodies are of the immunoglobulin G subclass and can therefore enter the foetal circulation through active placental transport mediated by the neonatal Fc-receptor. After entering the foetal circulation, these alloantibodies can cause destruction of foetal platelets and potentially damage other foetal cells containing the specific antigen. Subsequent clinical presentation in foetuses or neonates can vary widely, from an asymptomatic thrombocytopenia to a broad spectrum of bleeding complications. Most frequently encountered are minor skin haemorrhages, such as hematomas or petechiae, but also more devastating haemorrhages can occur. Of these, an intracranial haemorrhage is the most feared complication because of its high risk of life-long major neurological handicaps or perinatal death.
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Affiliation(s)
- Dian Winkelhorst
- Department of Obstetrics, Leiden University Medical Center, K6-35, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, K6-35, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.
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10
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Zhi H, Ahlen MT, Thinn AMM, Weiler H, Curtis BR, Skogen B, Zhu J, Newman PJ. High-resolution mapping of the polyclonal immune response to the human platelet alloantigen HPA-1a (Pl A1). Blood Adv 2018; 2:3001-3011. [PMID: 30413435 PMCID: PMC6234362 DOI: 10.1182/bloodadvances.2018023341] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 10/10/2018] [Indexed: 12/11/2022] Open
Abstract
Antibodies to platelet-specific antigens are responsible for 2 clinically important bleeding disorders: posttransfusion purpura and fetal/neonatal alloimmune thrombocytopenia (FNAIT). The human platelet-specific alloantigen 1a/1b (HPA-1a/1b; also known as PlA1/A2) alloantigen system of human platelet membrane glycoprotein (GP) IIIa is controlled by a Leu33Pro polymorphism and is responsible for ∼80% of the cases of FNAIT. Local residues surrounding polymorphic residue 33 are suspected to have a profound effect on alloantibody binding and subsequent downstream effector events. To define the molecular requirements for HPA-1a alloantibody binding, we generated transgenic mice that expressed murine GPIIIa (muGPIIIa) isoforms harboring select humanized residues within the plexin-semaphorin-integrin (PSI) and epidermal growth factor 1 (EGF1) domains and examined their ability to support the binding of a series of monoclonal and polyclonal HPA-1a-specific antibodies. Humanizing the PSI domain of muGPIIIa was sufficient to recreate the HPA-1a epitope recognized by some HPA-1a-specific antibodies; however, humanizing distinct amino acids within the linearly distant but conformationally close EGF1 domain was required to enable binding of others. These results reveal the previously unsuspected complex heterogeneity of the polyclonal alloimmune response to this clinically important human platelet alloantigen system. High-resolution mapping of this alloimmune response may improve diagnosis of FNAIT and should facilitate the rational design and selection of contemplated prophylactic and therapeutic anti-HPA-1a reagents.
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Affiliation(s)
- Huiying Zhi
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | - Maria Therese Ahlen
- Immunology Research Group, Department of Medical Biology, The Arctic University of Norway, Tromsø, Norway
- Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Aye Myat Myat Thinn
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
- Department of Biochemistry
| | - Hartmut Weiler
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | - Brian R Curtis
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | - Bjørn Skogen
- Immunology Research Group, Department of Medical Biology, The Arctic University of Norway, Tromsø, Norway
- Department of Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Jieqing Zhu
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
- Department of Biochemistry
| | - Peter J Newman
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
- Department of Pharmacology, and
- Department of Cell Biology, Medical College of Wisconsin, Milwaukee, WI
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Kirkham FJ, Zafeiriou D, Howe D, Czarpran P, Harris A, Gunny R, Vollmer B. Fetal stroke and cerebrovascular disease: Advances in understanding from lenticulostriate and venous imaging, alloimmune thrombocytopaenia and monochorionic twins. Eur J Paediatr Neurol 2018; 22:989-1005. [PMID: 30467085 DOI: 10.1016/j.ejpn.2018.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 12/17/2022]
Abstract
Fetal stroke is an important cause of cerebral palsy but is difficult to diagnose unless imaging is undertaken in pregnancies at risk because of known maternal or fetal disorders. Fetal ultrasound or magnetic resonance imaging may show haemorrhage or ischaemic lesions including multicystic encephalomalacia and focal porencephaly. Serial imaging has shown the development of malformations including schizencephaly and polymicrogyra after ischaemic and haemorrhagic stroke. Recognised causes of haemorrhagic fetal stroke include alloimmune and autoimmune thrombocytopaenia, maternal and fetal clotting disorders and trauma but these are relatively rare. It is likely that a significant proportion of periventricular and intraventricular haemorrhages are of venous origin. Recent evidence highlights the importance of arterial endothelial dysfunction, rather than thrombocytopaenia, in the intraparenchymal haemorrhage of alloimmune thrombocytopaenia. In the context of placental anastomoses, monochorionic diamniotic twins are at risk of twin twin transfusion syndrome (TTTS), or partial forms including Twin Oligohydramnios Polyhydramnios Sequence (TOPS), differences in estimated weight (selective Intrauterine growth Retardation; sIUGR), or in fetal haemoglobin (Twin Anaemia Polycythaemia Sequence; TAPS). There is a very wide range of ischaemic and haemorrhagic injury in a focal as well as a global distribution. Acute twin twin transfusion may account for intraventricular haemorrhage in recipients and periventricular leukomalacia in donors but there are additional risk factors for focal embolism and cerebrovascular disease. The recipient has circulatory overload, with effects on systemic and pulmonary circulations which probably lead to systemic and pulmonary hypertension and even right ventricular outflow tract obstruction as well as the polycythaemia which is a risk factor for thrombosis and vasculopathy. The donor is hypovolaemic and has a reticulocytosis in response to the anaemia while maternal hypertension and diabetes may influence stroke risk. Understanding of the mechanisms, including the role of vasculopathy, in well studied conditions such as alloimmune thrombocytopaenia and monochorionic diamniotic twinning may lead to reduction of the burden of antenatally sustained cerebral palsy.
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Affiliation(s)
- Fenella J Kirkham
- Developmental Neurosciences Section and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom.
| | - Dimitrios Zafeiriou
- 1st Department of Pediatrics, "Hippokratio' General Hospital, Aristotle University, Thessaloniki, Greece
| | - David Howe
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom
| | - Philippa Czarpran
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom
| | - Ashley Harris
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom
| | - Roxanna Gunny
- Developmental Neurosciences Section and Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, United Kingdom; Department of Radiology, St George's hospital, London, United Kingdom
| | - Brigitte Vollmer
- Departments of Child Health, Obstetrics and Gynaecology and Radiology, University Hospital Southampton, United Kingdom; Clinical and Experimental Sciences, University of Southampton, United Kingdom
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Winkelhorst D, Kamphuis MM, Steggerda SJ, Rijken M, Oepkes D, Lopriore E, van Klink JMM. Perinatal Outcome and Long-Term Neurodevelopment after Intracranial Haemorrhage due to Fetal and Neonatal Alloimmune Thrombocytopenia. Fetal Diagn Ther 2018; 45:184-191. [PMID: 29730660 DOI: 10.1159/000488280] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 03/07/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate the perinatal and long-term neurodevelopmental outcome in a cohort of children with intracranial haemorrhage (ICH) due to fetal and neonatal alloimmune thrombocytopenia (FNAIT) and to clearly outline the burden of this disease. SUBJECTS AND METHODS We performed an observational cohort study and included all consecutive cases of ICH caused by FNAIT from 1993 to 2015 at Leiden University Medical Centre. Neurological, motor, and cognitive development were assessed at a minimum age of 1 year. The primary outcome was adverse outcome, defined as perinatal death or severe neurodevelopmental impairment (NDI). Severe NDI was defined as any of the following: cerebral palsy (Gross Motor Function Classification System [GMFCS] level ≥II), bilateral deafness, blindness, or severe motor and/or cognitive developmental delay (<-2 SD). RESULTS In total, 21 cases of ICH due to FNAIT were included in the study. The perinatal mortality rate was 10/21 (48%). Long-term outcome was assessed in 10 children (n = 1 lost to follow-up). Severe and moderate NDI were diagnosed in 6/10 (60%) and 1/10 (10%) of the surviving children. The overall adverse outcome, including perinatal mortality or severe NDI, was 16/20 (80%). CONCLUSIONS The risk of perinatal death or severe NDI in children with ICH due to FNAIT is high. Only screening and effective preventive treatment can avoid this burden.
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Affiliation(s)
- Dian Winkelhorst
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The
| | - Marije M Kamphuis
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Sylke J Steggerda
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Monique Rijken
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Enrico Lopriore
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jeanine M M van Klink
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
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13
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Sachs UJ, Santoso S. Bleeding or no bleeding? Anti-endothelial alphaVbeta3 antibodies as a major cause of intracranial haemorrhage in fetal-neonatal alloimmune thrombocytopenia. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- U. J. Sachs
- Institute for Clinical Immunology and Transfusion Medicine; Justus Liebig University; Giessen Germany
- Center for Transfusion Medicine and Hemotherapy; University Hospital Giessen and Marburg; Marburg Germany
- German Center for Fetomaternal Incompatibility (DZFI); University Hospital Giessen and Marburg; Giessen Germany
| | - S. Santoso
- Institute for Clinical Immunology and Transfusion Medicine; Justus Liebig University; Giessen Germany
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Kovanlikaya A, Tiwari P, Bussel JB. Imaging and management of fetuses and neonates with alloimmune thrombocytopenia. Pediatr Blood Cancer 2017; 64. [PMID: 28675682 DOI: 10.1002/pbc.26690] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 05/26/2017] [Accepted: 05/27/2017] [Indexed: 01/06/2023]
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is the most common cause of severe neonatal thrombocytopenia and intracranial bleeding in term newborns. Intracranial hemorrhage (ICH) commonly results in death or severe, lasting neurologic disability. The timing of ICH is also important for management of the next affected pregnancy in cases of FNAIT. This manuscript reviews the advantages and disadvantages of the different radiologic methodologies to identify and characterize ICH. It discusses the limits of ultrasound and the advantages of magnetic resonance imaging allowing avoidance of the radiation associated with computed tomography (CT) scans.
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Affiliation(s)
- Arzu Kovanlikaya
- Division of Pediatric Radiology, Department of Radiology, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York
| | - Priyanka Tiwari
- Division of Newborn Medicine, Department of Pediatrics, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York
| | - James B Bussel
- Division of Pediatric Hematology/Oncology, Department of Pediatrics and Medicine, New York Presbyterian Hospital/Weill Cornell Medical College, New York, New York
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Refsum E, Håkansson S, Mörtberg A, Wikman A, Westgren M. Intracranial hemorrhages in neonates born from 32 weeks of gestation-low frequency of associated fetal and neonatal alloimmune thrombocytopenia: a register-based study. Transfusion 2017; 58:223-231. [DOI: 10.1111/trf.14394] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 09/25/2017] [Accepted: 09/25/2017] [Indexed: 01/16/2023]
Affiliation(s)
- Erle Refsum
- Department of Laboratory Medicine; Karolinska Institutet; Stockholm Sweden
| | - Stellan Håkansson
- Department of Clinical Sciences, Pediatrics; Umeå University; Umeå Sweden
| | - Anette Mörtberg
- Department of Laboratory Medicine; Karolinska Institutet; Stockholm Sweden
- Department of Clinical Immunology and Transfusion Medicine; Karolinska University Hospital; Stockholm Sweden
| | - Agneta Wikman
- Department of Laboratory Medicine; Karolinska Institutet; Stockholm Sweden
- Department of Clinical Immunology and Transfusion Medicine; Karolinska University Hospital; Stockholm Sweden
| | - Magnus Westgren
- Department of Obstetrics and Gynecology; Karolinska University Hospital; Stockholm Sweden
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Kjeldsen-Kragh J. Screening for fetal and neonatal alloimmune thrombocytopenia: is it possible and what are the potential outcomes? ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J. Kjeldsen-Kragh
- Department of Clinical Immunology and Transfusion Medicine; University and Regional Laboratories Region Skåne; Lund Sweden
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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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Abstract
Thrombocytopenia in pregnant women is diagnosed frequently by obstetricians because platelet counts are included with automated complete blood cell counts (CBCs) obtained during routine prenatal screening (). Although most U.S. health care providers are trained using U.S. Conventional Units, most scientists, journals, and countries use Système International (SI) units. The laboratory results reported in U.S. Conventional Units can be converted to SI Units or vice versa by using a conversion factor. The conversion factor for platelet count results is 1.0 (ie, to convert from x 103/µL, multiply by 1.0, to get x 109/L). Thrombocytopenia, defined as a platelet count of less than 150 x 109/L, is common and occurs in 7-12% of pregnancies (). Thrombocytopenia can result from a variety of physiologic or pathologic conditions, several of which are unique to pregnancy. Some causes of thrombocytopenia are serious medical disorders that have the potential for maternal and fetal morbidity. In contrast, other conditions, such as gestational thrombocytopenia, are benign and pose no maternal or fetal risks. Because of the increased recognition of maternal and fetal thrombocytopenia, there are numerous controversies about obstetric management of this condition. Clinicians must weigh the risks of maternal and fetal bleeding complications against the costs and morbidity of diagnostic tests and invasive interventions.
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Tiller H, Husebekk A, Ahlen MT, Stuge TB, Skogen B. Current perspectives on fetal and neonatal alloimmune thrombocytopenia - increasing clinical concerns and new treatment opportunities. Int J Womens Health 2017; 9:223-234. [PMID: 28458583 PMCID: PMC5402885 DOI: 10.2147/ijwh.s90753] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Differences in platelet type between the fetus and the mother can lead to maternal immunization and destruction of the fetal platelets, a condition named fetal and neonatal alloimmune thrombocytopenia (FNAIT). FNAIT is reported to occur in ~1 per 1,000 live born neonates. The major risk is intracranial hemorrhage in the fetus or newborn, which is associated with severe neurological complications or death. Since no countries have yet implemented a screening program to detect pregnancies at risk, the diagnosis is typically established after the birth of a child with symptoms. Reports on broader clinical impact have increased clinical concern and awareness. Along with new treatment options for FNAIT, the debate around antenatal screening to detect pregnancies at risk of FNAIT has been revitalized.
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Affiliation(s)
- Heidi Tiller
- Immunology Research Group, Faculty of Health Sciences, UiT, The Arctic University of Norway
| | - Anne Husebekk
- Immunology Research Group, Faculty of Health Sciences, UiT, The Arctic University of Norway
| | | | - Tor B Stuge
- Immunology Research Group, Faculty of Health Sciences, UiT, The Arctic University of Norway
| | - Bjørn Skogen
- Department of Laboratory Medicine, Norwegian National Unit for Platelet Immunology, University Hospital of North Norway, Tromsø, Norway
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20
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Meler E, Porta R, Canals C, Serra B, Lozano M. Fatal alloimmune thrombocytopenia due to anti-HLA alloimmunization in a twin pregnancy: A very infrequent complication of assisted reproduction. Transfus Apher Sci 2017; 56:165-167. [DOI: 10.1016/j.transci.2016.10.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 10/25/2016] [Accepted: 10/31/2016] [Indexed: 01/18/2023]
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Kamphuis MM, Tiller H, van den Akker ES, Westgren M, Tiblad E, Oepkes D. Fetal and Neonatal Alloimmune Thrombocytopenia: Management and Outcome of a Large International Retrospective Cohort. Fetal Diagn Ther 2016; 41:251-257. [PMID: 27728915 DOI: 10.1159/000448753] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 07/14/2016] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To evaluate the management and outcome of a large international cohort of cases of pregnancies complicated by fetal and neonatal alloimmune thrombocytopenia (FNAIT). METHODS This was an observational prospective and retrospective cohort study of all cases of FNAIT entered into the international multicentre No IntraCranial Haemorrhage (NOICH) registry during the period of 2001-2010. We evaluated human platelet antigen (HPA) specificity, the antenatal and postnatal interventions performed, and clinical outcome. RESULTS A total of 615 pregnancies complicated by FNAIT from 10 countries were included. Anti-HPA-1a was the most commonly implicated antibody. Antenatal treatment was administered in 273 pregnancies (44%), varying from intrauterine platelet transfusion to maternal administration of immunoglobulins, steroids, or a combination of those. Intracranial haemorrhage was diagnosed in 23 fetuses or neonates (3.7%). Overall perinatal mortality was 1.14% (n = 7). CONCLUSION This study presents the largest cohort of cases of FNAIT published. Our data show that antenatal treatment for FNAIT results in favourable perinatal outcome. Over time, in most centres, treatment for FNAIT changed from an invasive to a complete non-invasive procedure.
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Affiliation(s)
- Marije M Kamphuis
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
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22
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Weng YJ, Husebekk A, Skogen B, Kjaer M, Lin LT, Burnouf T. Anti-Human Platelet Antigen-1a Immunoglobulin G Preparation Intended to Prevent Fetal and Neonatal Alloimmune Thrombocytopenia. PLoS One 2016; 11:e0162973. [PMID: 27627660 PMCID: PMC5023090 DOI: 10.1371/journal.pone.0162973] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 08/31/2016] [Indexed: 11/26/2022] Open
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a severe disease that is caused by maternal alloantibodies generated during pregnancy or at delivery as a result of incompatibility between maternal and fetal human platelet antigens (HPAs) inherited from the father. Antibody-mediated immune suppression using anti-HPA-1a immunoglobulins is thought to be able to prevent FNAIT caused by HPA-1a. A fractionation process to prepare anti-HPA-1a immunoglobulin (Ig) G (IgG) from human plasma was therefore developed. Anti-HPA-1a plasma was obtained from volunteer mothers who underwent alloimmunization against HPA-1a during a previous pregnancy. Plasma was cryoprecipitated and the supernatant treated with caprylic acid and solvent/detergent (S/D), purified by chromatography, nanofiltered, concentrated, and sterile-filtered. The anti-HPA-1a immunoglobulin fraction was characterized for purity and safety. PAK12 and quantitative monoclonal antibody immobilization of platelet antigen (MAIPA) assays were used to detect anti-HPA-1a IgG. Hepatitis C virus (HCV) removal during nanofiltration was assessed by spiking experiments, using cell culture-derived reporter HCV and luciferase analysis. The caprylic acid treatment precipitated non-Ig proteins yielding a 90% pure Ig supernatant. S-HyperCel chromatography of the S/D-treated supernatant followed by HyperCel STAR AX provided high IgG recovery (>80%) and purity (>99.5%), and efficient IgA and IgM removal. Concentrations of complement factors C3 and C4 were < 0.5 and < 0.4 mg/dL, respectively. The final IgG could be nanofiltered on Planova 20N under conditions removing more than 3 log HCV infectivity to baseline mock infection level, and concentrated to ca. 30 g/L. Proteolytic activity and thrombin generation were low in the final fraction. The Pak12 and MAIPA assays showed good recovery of anti-HPA-1a throughout the process. Clinical-grade HPA-1a IgG can be prepared using a process compliant with current quality requirements opening perspectives for the prevention of FNAIT.
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Affiliation(s)
- Ying-Jan Weng
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
| | - Anne Husebekk
- Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Björn Skogen
- Department of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
- Department of Laboratory Medicine, University Hospital North Norway, Tromsø, Norway
| | - Mette Kjaer
- Department of Laboratory Medicine, University Hospital North Norway, Tromsø, Norway
- Finnmark Hospital Trust, Hammerfest, Norway
| | - Liang-Tzung Lin
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Microbiology and Immunology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Thierry Burnouf
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
- * E-mail:
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Santoso S, Wihadmadyatami H, Bakchoul T, Werth S, Al-Fakhri N, Bein G, Kiefel V, Zhu J, Newman PJ, Bayat B, Sachs UJ. Antiendothelial αvβ3 Antibodies Are a Major Cause of Intracranial Bleeding in Fetal/Neonatal Alloimmune Thrombocytopenia. Arterioscler Thromb Vasc Biol 2016; 36:1517-24. [PMID: 27283740 DOI: 10.1161/atvbaha.116.307281] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 06/01/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Fetal/neonatal alloimmune thrombocytopenia is a severe bleeding disorder, which can result in intracranial hemorrhage (ICH), leading to death or neurological sequelae. In whites, maternal anti-human platelet antigen-1a (HPA-1a) antibodies are responsible for the majority of cases. No predictive factors for ICH are available to guide prophylactic treatment during pregnancy. In this study, we investigated antibodies from mothers with ICH-positive fetal/neonatal alloimmune thrombocytopenia and with ICH-negative fetal/neonatal alloimmune thrombocytopenia to identify serological and functional differences between the groups. APPROACH AND RESULTS In an antigen capture assay, we observed a stronger binding of +ICH antibodies to endothelial cell (EC)-derived αvβ3. By absorption experiments, we subsequently identified anti-HPA-1a antibodies of anti-αvβ3 specificity in the +ICH but not in the -ICH cohort. Only the anti-αvβ3 subtype, but not the anti-β3 subtype, induced EC apoptosis of HPA-1a-positive ECs by caspase-3/7 activation, and mediated by reactive oxygen species. In addition, only the anti-αvβ3 subtype, but not the anti-β3 subtype, interfered with EC adhesion to vitronectin and with EC tube formation. CONCLUSIONS We conclude that the composition of the anti-HPA-1a antibody subtype(s) of the mother may determine whether ICH occurs. Analysis of anti-HPA-1a antibodies of the anti-αvβ3 subtype in maternal serum has potential in the diagnostic prediction of ICH development and may allow for modification of prophylactic treatment in fetal/neonatal alloimmune thrombocytopenia.
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Affiliation(s)
- Sentot Santoso
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (S.S., H.W., S.W., G.B., B.B., U.J.S.); Department of Anatomy, Faculty of Veterinary Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia (H.W.); Institute for Immunology and Transfusion Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany (T.B.); Center for Transfusion Medicine and Hemotherapy (N.A.-F., U.J.S.) and German Center for Fetomaternal Incompatibility (DZFI) (G.B., U.J.S.), University Hospital Giessen and Marburg, Giessen, Germany; Institute for Transfusion Medicine, University of Rostock, Rostock, Germany (V.K.); and Blood Research Institute, BloodCenter of Wisconsin, Milwaukee (J.Z., P.J.N.).
| | - Hevi Wihadmadyatami
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (S.S., H.W., S.W., G.B., B.B., U.J.S.); Department of Anatomy, Faculty of Veterinary Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia (H.W.); Institute for Immunology and Transfusion Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany (T.B.); Center for Transfusion Medicine and Hemotherapy (N.A.-F., U.J.S.) and German Center for Fetomaternal Incompatibility (DZFI) (G.B., U.J.S.), University Hospital Giessen and Marburg, Giessen, Germany; Institute for Transfusion Medicine, University of Rostock, Rostock, Germany (V.K.); and Blood Research Institute, BloodCenter of Wisconsin, Milwaukee (J.Z., P.J.N.)
| | - Tamam Bakchoul
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (S.S., H.W., S.W., G.B., B.B., U.J.S.); Department of Anatomy, Faculty of Veterinary Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia (H.W.); Institute for Immunology and Transfusion Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany (T.B.); Center for Transfusion Medicine and Hemotherapy (N.A.-F., U.J.S.) and German Center for Fetomaternal Incompatibility (DZFI) (G.B., U.J.S.), University Hospital Giessen and Marburg, Giessen, Germany; Institute for Transfusion Medicine, University of Rostock, Rostock, Germany (V.K.); and Blood Research Institute, BloodCenter of Wisconsin, Milwaukee (J.Z., P.J.N.)
| | - Silke Werth
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (S.S., H.W., S.W., G.B., B.B., U.J.S.); Department of Anatomy, Faculty of Veterinary Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia (H.W.); Institute for Immunology and Transfusion Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany (T.B.); Center for Transfusion Medicine and Hemotherapy (N.A.-F., U.J.S.) and German Center for Fetomaternal Incompatibility (DZFI) (G.B., U.J.S.), University Hospital Giessen and Marburg, Giessen, Germany; Institute for Transfusion Medicine, University of Rostock, Rostock, Germany (V.K.); and Blood Research Institute, BloodCenter of Wisconsin, Milwaukee (J.Z., P.J.N.)
| | - Nadia Al-Fakhri
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (S.S., H.W., S.W., G.B., B.B., U.J.S.); Department of Anatomy, Faculty of Veterinary Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia (H.W.); Institute for Immunology and Transfusion Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany (T.B.); Center for Transfusion Medicine and Hemotherapy (N.A.-F., U.J.S.) and German Center for Fetomaternal Incompatibility (DZFI) (G.B., U.J.S.), University Hospital Giessen and Marburg, Giessen, Germany; Institute for Transfusion Medicine, University of Rostock, Rostock, Germany (V.K.); and Blood Research Institute, BloodCenter of Wisconsin, Milwaukee (J.Z., P.J.N.)
| | - Gregor Bein
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (S.S., H.W., S.W., G.B., B.B., U.J.S.); Department of Anatomy, Faculty of Veterinary Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia (H.W.); Institute for Immunology and Transfusion Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany (T.B.); Center for Transfusion Medicine and Hemotherapy (N.A.-F., U.J.S.) and German Center for Fetomaternal Incompatibility (DZFI) (G.B., U.J.S.), University Hospital Giessen and Marburg, Giessen, Germany; Institute for Transfusion Medicine, University of Rostock, Rostock, Germany (V.K.); and Blood Research Institute, BloodCenter of Wisconsin, Milwaukee (J.Z., P.J.N.)
| | - Volker Kiefel
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (S.S., H.W., S.W., G.B., B.B., U.J.S.); Department of Anatomy, Faculty of Veterinary Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia (H.W.); Institute for Immunology and Transfusion Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany (T.B.); Center for Transfusion Medicine and Hemotherapy (N.A.-F., U.J.S.) and German Center for Fetomaternal Incompatibility (DZFI) (G.B., U.J.S.), University Hospital Giessen and Marburg, Giessen, Germany; Institute for Transfusion Medicine, University of Rostock, Rostock, Germany (V.K.); and Blood Research Institute, BloodCenter of Wisconsin, Milwaukee (J.Z., P.J.N.)
| | - Jieqing Zhu
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (S.S., H.W., S.W., G.B., B.B., U.J.S.); Department of Anatomy, Faculty of Veterinary Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia (H.W.); Institute for Immunology and Transfusion Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany (T.B.); Center for Transfusion Medicine and Hemotherapy (N.A.-F., U.J.S.) and German Center for Fetomaternal Incompatibility (DZFI) (G.B., U.J.S.), University Hospital Giessen and Marburg, Giessen, Germany; Institute for Transfusion Medicine, University of Rostock, Rostock, Germany (V.K.); and Blood Research Institute, BloodCenter of Wisconsin, Milwaukee (J.Z., P.J.N.)
| | - Peter J Newman
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (S.S., H.W., S.W., G.B., B.B., U.J.S.); Department of Anatomy, Faculty of Veterinary Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia (H.W.); Institute for Immunology and Transfusion Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany (T.B.); Center for Transfusion Medicine and Hemotherapy (N.A.-F., U.J.S.) and German Center for Fetomaternal Incompatibility (DZFI) (G.B., U.J.S.), University Hospital Giessen and Marburg, Giessen, Germany; Institute for Transfusion Medicine, University of Rostock, Rostock, Germany (V.K.); and Blood Research Institute, BloodCenter of Wisconsin, Milwaukee (J.Z., P.J.N.)
| | - Behnaz Bayat
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (S.S., H.W., S.W., G.B., B.B., U.J.S.); Department of Anatomy, Faculty of Veterinary Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia (H.W.); Institute for Immunology and Transfusion Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany (T.B.); Center for Transfusion Medicine and Hemotherapy (N.A.-F., U.J.S.) and German Center for Fetomaternal Incompatibility (DZFI) (G.B., U.J.S.), University Hospital Giessen and Marburg, Giessen, Germany; Institute for Transfusion Medicine, University of Rostock, Rostock, Germany (V.K.); and Blood Research Institute, BloodCenter of Wisconsin, Milwaukee (J.Z., P.J.N.)
| | - Ulrich J Sachs
- From the Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany (S.S., H.W., S.W., G.B., B.B., U.J.S.); Department of Anatomy, Faculty of Veterinary Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia (H.W.); Institute for Immunology and Transfusion Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany (T.B.); Center for Transfusion Medicine and Hemotherapy (N.A.-F., U.J.S.) and German Center for Fetomaternal Incompatibility (DZFI) (G.B., U.J.S.), University Hospital Giessen and Marburg, Giessen, Germany; Institute for Transfusion Medicine, University of Rostock, Rostock, Germany (V.K.); and Blood Research Institute, BloodCenter of Wisconsin, Milwaukee (J.Z., P.J.N.).
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CRISPR/Cas9-mediated conversion of human platelet alloantigen allotypes. Blood 2015; 127:675-80. [PMID: 26634302 DOI: 10.1182/blood-2015-10-675751] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 11/27/2015] [Indexed: 01/28/2023] Open
Abstract
Human platelet alloantigens (HPAs) reside on functionally important platelet membrane glycoproteins and are caused by single nucleotide polymorphisms in the genes that encode them. Antibodies that form against HPAs are responsible for several clinically important alloimmune bleeding disorders, including fetal and neonatal alloimmune thrombocytopenia and posttransfusion purpura. The HPA-1a/HPA-1b alloantigen system, also known as the Pl(A1)/Pl(A2) polymorphism, is the most frequently implicated HPA among whites, and a single Leu33Pro amino acid polymorphism within the integrin β3 subunit is responsible for generating the HPA-1a/HPA-1b alloantigenic epitopes. HPA-1b/b platelets, like those bearing other low-frequency platelet-specific alloantigens, are relatively rare in the population and difficult to obtain for purposes of transfusion therapy and diagnostic testing. We used CRISPR/Cas9 (clustered regularly interspaced short palindromic repeats/CRISPR associated protein 9) gene-editing technology to transform Leu33 (+) megakaryocytelike DAMI cells and induced pluripotent stem cells (iPSCs) to the Pro33 allotype. CD41(+) megakaryocyte progenitors derived from these cells expressed the HPA-1b (Pl(A2)) alloantigenic epitope, as reported by diagnostic NciI restriction enzyme digestion, DNA sequencing, and western blot analysis using HPA-1b-specific human maternal alloantisera. Application of CRISPR/Cas9 technology to genetically edit this and other clinically-important HPAs holds great potential for production of designer platelets for diagnostic, investigative, and, ultimately, therapeutic use.
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Brojer E, Husebekk A, Dębska M, Uhrynowska M, Guz K, Orzińska A, Dębski R, Maślanka K. Fetal/Neonatal Alloimmune Thrombocytopenia: Pathogenesis, Diagnostics and Prevention. Arch Immunol Ther Exp (Warsz) 2015; 64:279-90. [PMID: 26564154 PMCID: PMC4939163 DOI: 10.1007/s00005-015-0371-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 08/31/2015] [Indexed: 01/10/2023]
Abstract
Fetal/neonatal alloimmune thrombocytopenia (FNAIT) is a relatively rare condition (1/1000–1/2000) that was granted orphan status by the European Medicines Agency in 2011. Clinical consequences of FNAIT, however, may be severe. A thrombocytopenic fetus or new-born is at risk of intracranial hemorrhage that may result in lifelong disability or death. Preventing such bleeding is thus vital and requires a solution. Anti-HPA1a antibodies are the most frequent cause of FNAIT in Caucasians. Its pathogenesis is similar to hemolytic disease of the newborn (HDN) due to anti-RhD antibodies, but is characterized by platelet destruction and is more often observed in the first pregnancy. In 75 % of these women, alloimmunization by HPA-1a antigens, however, occurs at delivery, which enables development of antibody-mediated immune suppression to prevent maternal immunization. As for HDN, the recurrence rate of FNAIT is high. For advancing diagnostic efforts and treatment, it is thereby crucial to understand the pathogenesis of FNAIT, including cellular immunity involvement. This review presents the current knowledge on FNAIT. Also described is a program for HPA-1a screening in identifying HPA-1a negative pregnant women at risk of immunization. This program is now performed at the Institute of Hematology and Transfusion Medicine in cooperation with the Department of Obstetrics and Gynecology of the Medical Centre of Postgraduate Education in Warsaw as well as the UiT The Arctic University of Norway.
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Affiliation(s)
- Ewa Brojer
- Department of Immunohematology and Immunology of Transfusion Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland.
| | - Anne Husebekk
- Institute of Medical Biology, UiT The Arctic University of Norway, Tromsø, Norway
| | - Marzena Dębska
- 2nd Department of Obstetrics and Gynecology, Medical Centre of Postgraduate Education, Warsaw, Poland
| | - Małgorzata Uhrynowska
- Department of Immunohematology and Immunology of Transfusion Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Katarzyna Guz
- Department of Immunohematology and Immunology of Transfusion Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Agnieszka Orzińska
- Department of Immunohematology and Immunology of Transfusion Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Romuald Dębski
- 2nd Department of Obstetrics and Gynecology, Medical Centre of Postgraduate Education, Warsaw, Poland
| | - Krystyna Maślanka
- Department of Immunohematology and Immunology of Transfusion Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
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Delbos F, Bertrand G, Croisille L, Ansart-Pirenne H, Bierling P, Kaplan C. Fetal and neonatal alloimmune thrombocytopenia: predictive factors of intracranial hemorrhage. Transfusion 2015; 56:59-66; quiz 58. [DOI: 10.1111/trf.13274] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 07/06/2015] [Accepted: 07/14/2015] [Indexed: 12/18/2022]
Affiliation(s)
- Florent Delbos
- Laboratoire HLA/ILP; Etablissement Français du Sang; Créteil
| | - Gérald Bertrand
- Platelet Immunology; Institut National de la Transfusion Sanguine; Paris France
| | - Laure Croisille
- Laboratoire HLA/ILP; Etablissement Français du Sang; Créteil
| | | | - Philippe Bierling
- Laboratoire HLA/ILP; Etablissement Français du Sang; Créteil
- IMRB, University Paris Est Créteil (UPEC); INSERM U955; Créteil, France
| | - Cécile Kaplan
- Platelet Immunology; Institut National de la Transfusion Sanguine; Paris France
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Chong W, Turro E, Metcalfe P, Yusuf R, Mérieux Y, Rigal D, Porcelijn L, Huiskes E, Lucas G, Bendukidze N, Green A, Fontão-Wendel R, Husebekk A, Dixey J, Guest A, Mushens R, Ouwehand WH, Navarrete CV. A multicenter validation of recombinant β3 integrin-coupled beads to detect human platelet antigen-1 alloantibodies in 498 cases of fetomaternal alloimmune thrombocytopenia. Transfusion 2015; 55:2742-51. [DOI: 10.1111/trf.13222] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 03/23/2015] [Accepted: 05/11/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Winnie Chong
- Histocompatibility and Immunogenetics Laboratories; National Health Service Blood and Transplant (NHSBT); Colindale, London UK
| | - Ernest Turro
- Department of Haematology; University of Cambridge and NHSBT Cambridge, Cambridge Biomedical Campus
- Medical Research Council Biostatistics Unit; Cambridge Biomedical Campus; Cambridge UK
| | - Paul Metcalfe
- National Institute for Biological Standards and Control Medicines and Healthcare Products Regulatory Agency; Potters Bar UK
| | - Rizwan Yusuf
- National Institute for Biological Standards and Control Medicines and Healthcare Products Regulatory Agency; Potters Bar UK
| | - Yves Mérieux
- Etablissement Français du Sang Rhône-Alpes (EFS); Lyon France
| | - Dominique Rigal
- Etablissement Français du Sang Rhône-Alpes (EFS); Lyon France
| | - Leendert Porcelijn
- Platelet and Leukocyte Serology Department; Sanquin Diagnostic Services; Amsterdam the Netherlands
| | - Elly Huiskes
- Platelet and Leukocyte Serology Department; Sanquin Diagnostic Services; Amsterdam the Netherlands
| | - Geoff Lucas
- Histocompatibility and Immunogenetics Laboratories; National Health Service Blood and Transplant (NHSBT); Filton, Bristol UK
| | - Nina Bendukidze
- Histocompatibility and Immunogenetics Laboratories; National Health Service Blood and Transplant (NHSBT); Filton, Bristol UK
| | - Ann Green
- Histocompatibility and Immunogenetics Laboratories; National Health Service Blood and Transplant (NHSBT); Filton, Bristol UK
| | | | | | - Jonathan Dixey
- International Blood Group Reference Laboratory (IBGRL); Filton Bristol UK
| | - Alan Guest
- International Blood Group Reference Laboratory (IBGRL); Filton Bristol UK
| | - Rosey Mushens
- International Blood Group Reference Laboratory (IBGRL); Filton Bristol UK
| | - Willem H. Ouwehand
- Department of Haematology; University of Cambridge and NHSBT Cambridge, Cambridge Biomedical Campus
| | - Cristina V. Navarrete
- Histocompatibility and Immunogenetics Laboratories; National Health Service Blood and Transplant (NHSBT); Colindale, London UK
- Division of Infection and Immunity; University College London; London UK
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Abstract
Key Points
CRP enhances IgG-mediated respiratory burst and phagocytosis of platelets in vitro and their clearance in vivo. CRP levels are increased in ITP patients and correlate with platelet counts and bleeding severity and predict time to recovery.
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Bertrand G, Conti F. Genotyping of Human Platelet Antigens by BeadChip Microarray Technology. Methods Mol Biol 2015; 1310:149-165. [PMID: 26024633 DOI: 10.1007/978-1-4939-2690-9_13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Human platelet antigen (HPA) typing plays a critical role in the diagnosis of fetal/neonatal alloimmune thrombocytopenia, and the prevention of posttransfusion purpura and refractoriness to platelet transfusions. The recent development of high-throughput genotyping methods, allowing simultaneous genotyping of as many as 17 HPAs, is of utmost interest for saving time and money. Here, we describe a microarray technology named "BeadChip," designed for HPA-1 to -9, -11, and -15 genotyping of up to 96 individuals, in approximately 5 h. This technology was used to study allele frequencies in Brazilian blood donors, considering the heterogeneous ethnic composition.
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Affiliation(s)
- Gerald Bertrand
- Histocompatibilty and Immunogenetics Laboratory, EFS Bretagne, Rue Pierre Jean-Gineste, 35000, Rennes, France,
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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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Kamphuis MM, Paridaans NP, Porcelijn L, Lopriore E, Oepkes D. Incidence and consequences of neonatal alloimmune thrombocytopenia: a systematic review. Pediatrics 2014; 133:715-21. [PMID: 24590747 DOI: 10.1542/peds.2013-3320] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Neonatal alloimmune thrombocytopenia (NAIT) is a potentially devastating disease that may lead to intracranial hemorrhage in the fetus or neonate, often with death or major neurologic damage. There are no routine screening programs for NAIT, preventive measures are taken only in a subsequent pregnancy. To estimate the population incidence of NAIT and its consequences, we conducted a review of the literature. Our results may aid in the design of a screening program. METHODS An electronic literature search included Medline, Embase, Cochrane database and references of retrieved articles. Eligible for inclusion were all prospective studies aimed at diagnosing NAIT in a general, nonselected newborn population, with sufficient information on platelet count at birth, bleeding complications, and treatment. Titles and abstracts were reviewed, followed by review of full text publications. Studies were independently assessed by 2 reviewers for methodologic quality. Disagreements were resolved by consensus, including a third reviewer. RESULTS From the initial 768 studies, 21 remained for full text analysis, 6 of which met the inclusion criteria. In total, 59,425 newborns were screened, with severe thrombocytopenia in 89 cases (0.15%). NAIT was diagnosed in 24 of these 89 newborns (27%). In 6 (25%) of these cases, an intracranial hemorrhage was found, all likely of antenatal origin. CONCLUSIONS NAIT is among the most important causes of neonatal thrombocytopenia. Intracranial hemorrhage due to NAIT occurs in 10 per 100 000 neonates, commonly before birth. Screening for NAIT might be effective but should be done antenatally.
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Yang WH, Cheng CS, Chang JB, Liu KT, Chang JL. Antibody formation in pregnant women with maternal-neonatal human platelet antigen mismatch from a hospital in northern Taiwan. Kaohsiung J Med Sci 2014; 30:25-8. [DOI: 10.1016/j.kjms.2013.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 04/29/2013] [Indexed: 10/26/2022] Open
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Edinur HA, Dunn PPJ, Lea RA, Chambers GK. Human platelet antigens frequencies in Maori and Polynesian populations. Transfus Med 2013; 23:330-7. [PMID: 23841727 DOI: 10.1111/tme.12061] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 06/11/2013] [Accepted: 06/17/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Allele frequencies of human platelet antigens (HPA) reflect population history and possibility of platelet-specific alloimmunization. Here, we report on screening of variants at HPA loci for Polynesian and Maori subjects. OBJECTIVES Our aims are to evaluate new HPA genotyping methods, compile and analyse new HPA datasets for these subjects, use HPA data for tracing ancestry, migration patterns, genetic admixture and its potential influence on health. MATERIALS AND METHODS A total of 75 Maori and 25 Polynesian DNA samples were genotyped using commercial BAGene HPA-TYPE DNA-SSP kits, BLOODchip hybridization SNP assays and DNA sequence based typing. RESULTS Genotyping was successful and cross validation of PCR-SSP and BLOODchip gave 100% agreement. Among the HPA loci tested, only six are dimorphic (HPA-1 to -3, -5, -6 and -15) and all others are monomorphic. The Polynesians and Maori have the 'a' allele form as the most common for all loci except HPA-15. CONCLUSIONS The newly observed HPA data as well as principal coordinate analysis clearly indicate genetic contributions from both, Asia and Australasia in Maori and Polynesian populations together with recent admixture with Europeans. In addition, different prevalences of HPA alleles among Polynesian, Maori and European populations contribute towards different risk profiles for platelet-specific alloimmunization. This is the first report for these populations and our findings are of direct practical relevance for blood transfusion centres, the management of pregnancies, assessment of neonatal alloimmune thrombocytopenia and management of multi-transfused patients.
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Affiliation(s)
- H A Edinur
- School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand
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Tiller H, Kamphuis MM, Flodmark O, Papadogiannakis N, David AL, Sainio S, Koskinen S, Javela K, Wikman AT, Kekomaki R, Kanhai HHH, Oepkes D, Husebekk A, Westgren M. Fetal intracranial haemorrhages caused by fetal and neonatal alloimmune thrombocytopenia: an observational cohort study of 43 cases from an international multicentre registry. BMJ Open 2013; 3:bmjopen-2012-002490. [PMID: 23524102 PMCID: PMC3612794 DOI: 10.1136/bmjopen-2012-002490] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To characterise pregnancies where the fetus or neonate was diagnosed with fetal and neonatal alloimmune thrombocytopenia (FNAIT) and suffered from intracranial haemorrhage (ICH), with special focus on time of bleeding onset. DESIGN Observational cohort study of all recorded cases of ICH caused by FNAIT from the international No IntraCranial Haemorrhage (NOICH) registry during the period 2001-2010. SETTING 13 tertiary referral centres from nine countries across the world. PARTICIPANTS 37 mothers and 43 children of FNAIT pregnancies complicated by fetal or neonatal ICH identified from the NOICH registry was included if FNAIT diagnosis and ICH was confirmed. PRIMARY AND SECONDARY OUTCOME MEASURES Gestational age at onset of ICH, type of ICH and clinical outcome of ICH were the primary outcome measures. General maternal and neonatal characteristics of pregnancies complicated by fetal/neonatal ICH were secondary outcome measures. RESULTS From a total of 592 FNAIT cases in the registry, 43 confirmed cases of ICH due to FNAIT were included in the study. The majority of bleedings (23/43, 54%) occurred before 28 gestational weeks and often affected the first born child (27/43, 63%). One-third (35%) of the children died within 4 days after delivery. 23 (53%) children survived with severe neurological disabilities and only 5 (12%) were alive and well at time of discharge. Antenatal treatment was not given in most (91%) cases of fetal/neonatal ICH. CONCLUSIONS ICH caused by FNAIT often occurs during second trimester and the clinical outcome is poor. In order to prevent ICH caused by FNAIT, at-risk pregnancies must be identified and prevention and/or interventions should start early in the second trimester.
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Affiliation(s)
- Heidi Tiller
- Department of Obstetrics and Gynaecology, University Hospital North Norway, Tromsø, Norway
| | - Marije M Kamphuis
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Olof Flodmark
- Neuroradiologiska kliniken, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Nikos Papadogiannakis
- Department of Laboratory Medicine, Division of Pathology, Section of Perinatal Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Anna L David
- Obstetrics and Maternal Foetal Medicine, Institute for Women's Health, University College, London, UK
| | | | | | - Kaija Javela
- Finnish Red Cross Blood Service, Helsinki, Finland
| | - Agneta Taune Wikman
- Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | | | - Humphrey H H Kanhai
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Anne Husebekk
- Institute of Medical Biology, University of Tromsø, Tromsø, Norway
| | - Magnus Westgren
- Department of Obstetrics and Gynaecology, Division of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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Peterson JA, McFarland JG, Curtis BR, Aster RH. Neonatal alloimmune thrombocytopenia: pathogenesis, diagnosis and management. Br J Haematol 2013; 161:3-14. [PMID: 23384054 DOI: 10.1111/bjh.12235] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Neonatal alloimmune thrombocytopenia, (NAIT) is caused by maternal antibodies raised against alloantigens carried on fetal platelets. Although many cases are mild, NAIT is a significant cause of morbidity and mortality in newborns and is the most common cause of intracranial haemorrhage in full-term infants. In this report, we review the pathogenesis, clinical presentation, laboratory diagnosis and prenatal and post-natal management of NAIT and highlight areas of controversy that deserve the attention of clinical and laboratory investigators.
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Affiliation(s)
- Julie A Peterson
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI 53226-3548, US.
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Towards a prophylactic treatment of HPA-related foetal and neonatal alloimmune thrombocytopenia. Curr Opin Hematol 2012; 19:469-74. [DOI: 10.1097/moh.0b013e328358f86c] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Madani K, Kamphuis MM, Lopriore E, Porcelijn L, Oepkes D. Delayed diagnosis of fetal and neonatal alloimmune thrombocytopenia: a cause of perinatal mortality and morbidity. BJOG 2012; 119:1612-6. [DOI: 10.1111/j.1471-0528.2012.03503.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Neonatal alloimmune thrombocytopenia (NAIT), with an incidence of one in 1000 live births, is the most common cause of severe thrombocytopenia and intra-cerebral haemorrhage in term neonates. NAIT results from trans-placental passage of maternal antibodies against a paternally derived fetal platelet alloantigen. Clinical presentation varies from unexpected thrombocytopenia on a blood film in a well newborn to intracranial haemorrhage (ICH). In contrast to haemolytic disease of the newborn, NAIT can present in a first pregnancy, and subsequent pregnancies are usually more severely affected. The role of antenatal screening for maternal alloantibodies instead of fetal blood sampling to identify at-risk fetuses remains uncertain, but there is a trend towards less invasive maternally directed treatment for at-risk pregnancies. Neonatal management is aimed at preventing or limiting thrombocytopenic bleeding with transfusion of antigen-matched platelets.
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Affiliation(s)
- David C Risson
- Grantley Stable Neonatal Unit, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
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Cook TJ, Qiu CC, Dickinson JE. A review of the contemporary management of fetal and neonatal alloimmune thrombocytopenia in an Australian tertiary obstetric hospital. Aust N Z J Obstet Gynaecol 2012; 52:321-6. [PMID: 22510050 DOI: 10.1111/j.1479-828x.2012.01438.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Accepted: 03/14/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is the most common cause of severe perinatal thrombocytopenia, arising from the transplacental passage of maternal antibodies directed at paternally inherited antigens on fetal platelets. AIM To review the occurrence, management and perinatal outcomes of pregnancies complicated by FNAIT from a single tertiary obstetric hospital in Western Australia. MATERIALS AND METHODS The study was conducted as a retrospective review of cases with prenatally recognised FNAIT between 2001 and 2011, with the treatment modalities and outcomes analysed. RESULTS Over the 10-year period, 20 cases of clinically significant FNAIT in 13 women were managed at our centre. Three cases were complicated by antenatal intracranial haemorrhage (15%), and in all 3, this was the presenting feature leading to diagnosis. In 17/20 (85%) cases, anti-HPA 1a was the responsible antibody, with the remainder being anti-HPA 5b. In 16/17 cases with pre-pregnancy recognition, intravenous gammaglobulin (IVGG) was administered antenatally (gestation at commencement ranging from 13 to 26 weeks) with adjuvant prednisolone in three cases. Postnatal treatment (IVGG or platelet transfusion) was provided in 4/16 cases. There was no intracranial haemorrhage or demise in any case receiving prenatal therapy. CONCLUSIONS FNAIT is a rare and serious condition. In our small single-centre study, there was variability in the therapeutic strategies, although IVGG was central to all prenatally managed pregnancies. None of the treated pregnancies was complicated by intracranial haemorrhage or fetal death. There is a need for ongoing refinement of FNAIT management protocols, both in the prenatal and in the postnatal period.
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Affiliation(s)
- Timothy J Cook
- School of Women's and Infants' Health, The University of Western Australia, Perth, Western Australia, Australia
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Preimplantation Genetic Diagnosis for Fetal Neonatal Alloimmune Thrombocytopenia Due to Antihuman Platelet Antigen Maternal Antibodies. Obstet Gynecol 2012; 119:338-43. [DOI: 10.1097/aog.0b013e318242a11d] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Egbor M, Knott P, Bhide A. Red-cell and platelet alloimmunisation in pregnancy. Best Pract Res Clin Obstet Gynaecol 2012; 26:119-32. [DOI: 10.1016/j.bpobgyn.2011.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 09/20/2011] [Accepted: 10/11/2011] [Indexed: 10/14/2022]
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Tiller H, Killie MK, Chen P, Eksteen M, Husebekk A, Skogen B, Kjeldsen-Kragh J, Ni H. Toward a prophylaxis against fetal and neonatal alloimmune thrombocytopenia: induction of antibody-mediated immune suppression and prevention of severe clinical complications in a murine model. Transfusion 2012; 52:1446-57. [DOI: 10.1111/j.1537-2995.2011.03480.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Stuge TB, Skogen B, Ahlen MT, Husebekk A, Urbaniak SJ, Bessos H. The cellular immunobiology associated with fetal and neonatal alloimmune thrombocytopenia. Transfus Apher Sci 2011; 45:53-9. [PMID: 21708486 DOI: 10.1016/j.transci.2011.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is caused by maternal antibodies that cross the placenta in connection with pregnancy and destroy fetal platelets. Recently, maternal T cell responses associated with FNAIT have been studied at the clonal level. These T cell clones recognize an integrin β3 epitope, which is anchored to the HLA-DRB3∗0101-encoded MHC molecule DR52a. The same MHC allele is strongly associated with FNAIT. As the production of pathological antibodies reactive with fetal platelets is likely dependent on these T cell responses, there exists a potential for preventing FNAIT by targeting these T cells.
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Affiliation(s)
- Tor B Stuge
- Laboratory Medicine, University Hospital of North Norway, Tromsø, Norway.
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Kamphuis MM, Oepkes D. Fetal and neonatal alloimmune thrombocytopenia: prenatal interventions. Prenat Diagn 2011; 31:712-9. [DOI: 10.1002/pd.2779] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 04/20/2011] [Accepted: 04/21/2011] [Indexed: 11/05/2022]
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Skogen B, Killie MK, Kjeldsen-Kragh J, Ahlen MT, Tiller H, Stuge TB, Husebekk A. Reconsidering fetal and neonatal alloimmune thrombocytopenia with a focus on screening and prevention. Expert Rev Hematol 2011; 3:559-66. [PMID: 21083473 DOI: 10.1586/ehm.10.49] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Uncertainty regarding the pathophysiology of fetal and neonatal alloimmune thrombocytopenia (FNAIT) has hampered the decision regarding how to identify, follow-up and treat the women and children with this potentially serious condition. Since knowledge of the condition is derived mainly from retrospective studies, understanding of the natural history of this condition remains incomplete. General screening programs for FNAIT have still not been introduced, mainly because of a lack of reliable risk factors and effective treatment. Now, several prospective screening studies involving up to 100,000 pregnant women have been published and the results have changed the understanding of the pathophysiology of FNAIT and, thereby, the approach toward diagnostics, prevention and treatment in a more appropriate way.
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Affiliation(s)
- Bjørn Skogen
- Laboratory Medicine, University Hospital of North Norway, N-9038 Tromsø, Norway.
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Abstract
Fetal/neonatal alloimmune thrombocytopenia is the most common cause of severe thrombocytopenia in the fetus and in an otherwise healthy newborn. To counter the consequences of severe fetal thrombocytopenia, antenatal therapies have been implemented. Predictive parameters for fetal severe thrombocytopenia are important for the development of noninvasive strategy and tailored intervention. We report here data concerning 239 pregnancies in 75 HPA-1bb women. Analysis of the index cases (diagnosis of fetal/neonatal alloimmune thrombocytopenia) did not show any significant correlation between the severity of the disease and the maternal genetic background (ABO blood group and HLA-DRB3 allele). Subsequent pregnancies were managed, and therapy effectiveness was evaluated. The highest mean newborn platelet count was observed for a combination of intravenous immunoglobulin and steroids (135 × 10⁹/L; 54 newborns) compared with intravenous immunoglobulin alone (89 × 10⁹/L; 27 newborns). The maternal anti-HPA-1a antibody concentration measured before any treatment and before 28 weeks of gestation was predictive of the fetal status. The weighted areas under curves of the maternal alloantibody concentrations were predictive of therapy response. To conclude, this large retrospective survey gives new insights on maternal predictive parameters for fetal status and therapy effectiveness allowing noninvasive strategies.
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