1
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Baker RI, Choi P, Curry N, Gebhart J, Gomez K, Henskens Y, Heubel-Moenen F, James P, Kadir RA, Kouides P, Lavin M, Lordkipanidze M, Lowe G, Mumford A, Mutch N, Nagler M, Othman M, Pabinger I, Sidonio R, Thomas W, O'Donnell JS. Standardization of definition and management for bleeding disorder of unknown cause: communication from the SSC of the ISTH. J Thromb Haemost 2024; 22:2059-2070. [PMID: 38518896 DOI: 10.1016/j.jtha.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/08/2024] [Accepted: 03/08/2024] [Indexed: 03/24/2024]
Abstract
In many patients referred with significant bleeding phenotype, laboratory testing fails to define any hemostatic abnormalities. Clinical practice with respect to diagnosis and management of this patient cohort poses significant clinical challenges. We recommend that bleeding history in these patients should be objectively assessed using the International Society on Thrombosis and Haemostasis (ISTH) bleeding assessment tool. Patients with increased bleeding assessment tool scores should progress to hemostasis laboratory testing. To diagnose bleeding disorder of unknown cause (BDUC), normal complete blood count, prothrombin time, activated partial thromboplastin time, thrombin time, von Willebrand factor antigen, von Willebrand factor function, coagulation factors VIII, IX, and XI, and platelet light transmission aggregometry should be the minimum laboratory assessment. In some laboratories, additional specialized hemostasis testing may be performed to identify other rare causes of bleeding. We recommend that patients with a significant bleeding phenotype but normal laboratory investigations should be registered with a diagnosis of BDUC in preference to other terminology. Global hemostatic tests and markers of fibrinolysis demonstrate variable abnormalities, and their clinical significance remains uncertain. Targeted genomic sequencing examining candidate hemostatic genes has a low diagnostic yield. Underlying BDUC should be considered in patients with heavy menstrual bleeding since delays in diagnosis often extend to many years and negatively impact quality of life. Treatment options for BDUC patients include tranexamic acid, desmopressin, and platelet transfusions.
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Affiliation(s)
- Ross I Baker
- Western Australia Centre for Thrombosis and Haemostasis, Murdoch University, Perth, Australia; Clinical Research Unit, Perth Blood Institute, Perth, Australia; Hollywood Hospital Haemophilia Centre, Haematology Academic Unit, Perth, Australia; Irish-Australian Blood Collaborative Network, Dublin, Ireland and Perth, Australia.
| | - Philip Choi
- Haematology Department, The Canberra Hospital, Canberra, Australia; Division of Genome Sciences and Cancer, John Curtin School of Medical Research, Australian National University, Canberra, Australia
| | - Nicola Curry
- Department of Clinical Haematology, Haemophilia & Thrombosis Centre, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom; Radcliffe Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Johanna Gebhart
- Department of Medicine, Division of Hematology and Hemostaseology, Medical University Vienna, Vienna, Austria
| | - Keith Gomez
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London National Health Service Foundation Trust, London, United Kingdom
| | - Yvonne Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Biochemistry, Institute for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Floor Heubel-Moenen
- Department of Hematology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Paula James
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rezan Abdul Kadir
- Department of Obstetrics and Gynaecology, Katharine Dormandy Haemophilia and Thrombosis Centre, The Royal Free National Health Service Hospital, London, United Kingdom; Institute for Women's Health, University College, London, United Kingdom
| | - Peter Kouides
- Mary M. Gooley Hemophilia Center, Rochester, New York, USA
| | - Michelle Lavin
- Irish-Australian Blood Collaborative Network, Dublin, Ireland and Perth, Australia; National Coagulation Centre, St. James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Marie Lordkipanidze
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada; Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - Gillian Lowe
- West Midlands Adult Comprehensive Care Haemophilia Centre, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Andrew Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Nicola Mutch
- Aberdeen Cardiovascular and Diabetes Centre, Institute of Medical Sciences, School of Medicine, United Kingdom; Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, Bern, Switzerland; Department of Clinical Chemistry, Inselspital University Hospital Bern, Bern, Switzerland
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, Ontario, Canada; School of Baccalaureate Nursing, St Lawrence College, Kingston, Ontario, Canada; Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ingrid Pabinger
- Department of Medicine, Division of Hematology and Hemostaseology, Medical University Vienna, Vienna, Austria
| | - Robert Sidonio
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Will Thomas
- Department of Haematology, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - James S O'Donnell
- Irish-Australian Blood Collaborative Network, Dublin, Ireland and Perth, Australia; National Coagulation Centre, St. James's Hospital, Dublin, Ireland; Irish Centre for Vascular Biology, School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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2
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Verstraete A, Freson K, Verhamme P, Vanassche T. Thrombophilia Testing: from Genetic Predisposition to Discrimination. TH OPEN 2024; 8:e177-e180. [PMID: 38596262 PMCID: PMC11001463 DOI: 10.1055/a-2284-4285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/05/2024] [Indexed: 04/11/2024] Open
Affiliation(s)
- Andreas Verstraete
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, KU Leuven, Leuven, Belgium
| | - Kathleen Freson
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, KU Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, KU Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, KU Leuven, Leuven, Belgium
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3
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Zaninetti C, Baschin M, Vater L, Karastaneva A, Holzhauer S, Leinøe E, Ørslev Rasmussen A, Wesche J, Freyer C, Seidel MG, Greinacher A. Platelet expression of the transcription factor ETV6 associates with ETV6-related thrombocytopenia and can be detected by immunofluorescence on the blood film. Br J Haematol 2024; 204:710-714. [PMID: 37985135 DOI: 10.1111/bjh.19211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023]
Affiliation(s)
- Carlo Zaninetti
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Marcel Baschin
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
- Pädiatrischen Onkologie und Hämatologie der Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Leonard Vater
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Anna Karastaneva
- Division of Pediatric Hematology and Oncology, Department of Pediatric and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Susanne Holzhauer
- Klinik für Pädiatrie mit Schwerpunkt Onkologie und Hämatologie, Universitätsmedizin Berlin, Berlin, Germany
| | - Eva Leinøe
- Department of Haematology and Department of Genomic Medicine, Rigshospitalet University Hospital, Copenhagen, Denmark
| | | | - Jan Wesche
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Carmen Freyer
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Markus G Seidel
- Division of Pediatric Hematology and Oncology, Department of Pediatric and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Andreas Greinacher
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
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4
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Gebetsberger J, Mott K, Bernar A, Klopocki E, Streif W, Schulze H. State-of-the-Art Targeted High-Throughput Sequencing for Detecting Inherited Platelet Disorders. Hamostaseologie 2023; 43:244-251. [PMID: 37611606 DOI: 10.1055/a-2099-3266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Abstract
Inherited platelet disorders (IPDs) are a heterogeneous group of rare entities caused by molecular divergence in genes relevant for platelet formation and function. A rational diagnostic approach is necessary to counsel and treat patients with IPDs. With the introduction of high-throughput sequencing at the beginning of this millennium, a more accurate diagnosis of IPDs has become available. We discuss advantages and limitations of genetic testing, technical issues, and ethical aspects. Additionally, we provide information on the clinical significance of different classes of variants and how they are correctly reported.
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Affiliation(s)
- Jennifer Gebetsberger
- Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Tirol, Austria
| | - Kristina Mott
- Institute of Experimental Biomedicine, University Hospital Würzburg, Würzburg, Germany
| | - Aline Bernar
- Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Tirol, Austria
| | - Eva Klopocki
- Institute of Human Genetics, University of Würzburg, Würzburg, Germany
| | - Werner Streif
- Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Tirol, Austria
| | - Harald Schulze
- Institute of Experimental Biomedicine, University Hospital Würzburg, Würzburg, Germany
- Center for Rare Blood Cell Disorders, Center for Rare Diseases, University Hospital Würzburg, Würzburg, Germany
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5
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Heubel-Moenen FCJI, Ansems LEM, Verhezen PWM, Wetzels RJH, van Oerle RGM, Straat RJMHE, Megy K, Downes K, Henskens YMC, Beckers EAM, Joore MA. Effectiveness and costs of a stepwise versus an all-in-one approach to diagnose mild bleeding disorders. Br J Haematol 2023; 200:792-801. [PMID: 36444397 DOI: 10.1111/bjh.18570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 12/02/2022]
Abstract
The diagnostic work-up of patients referred to the haematologist for bleeding evaluation is performed in a stepwise way: bleeding history and results of screening laboratory tests guide further diagnostic evaluation. This can be ineffective, time-consuming and burdensome for patients. To improve this strategy, the initial laboratory investigation can be extended. In a model-based approach, effectiveness and costs of a conventional stepwise versus a newly proposed all-in-one diagnostic approach for bleeding evaluation were evaluated and compared, using data from an observational patient cohort study, including adult patients referred for bleeding evaluation. In the all-in-one approach, specialized platelet function tests, coagulation factors, and fibrinolysis tests were included in the initial investigation. Final diagnosis, hospital resource use and costs and patient burden were compared. A total of 150 patients were included. Compared to the stepwise approach, in the all-in-one approach, 19 additional patients reached a diagnosis and patient burden was lower, but total costs per patient were higher [€359, 95% bootstrapped confidence interval (BCI) 283-518, p = 0.001]. For bleeding evaluation of patients referred to the haematologist, an all-in-one diagnostic approach has a higher diagnostic yield and reduces patient burden, at a higher cost. This raises the question what costs justify the diagnosis of a bleeding disorder and a less burdensome diagnostic strategy.
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Affiliation(s)
- Floor C J I Heubel-Moenen
- Department of Hematology, Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Loes E M Ansems
- Department of Hematology, Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Paul W M Verhezen
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Rick J H Wetzels
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Rene G M van Oerle
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Ron J M H E Straat
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Karyn Megy
- National Institute for Health Research (NIHR) BioResource, Cambridge University Hospitals NHS Foundation, Cambridge Biomedical Campus, Cambridge, UK.,Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Kate Downes
- National Institute for Health Research (NIHR) BioResource, Cambridge University Hospitals NHS Foundation, Cambridge Biomedical Campus, Cambridge, UK.,Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.,Cambridge University Hospitals Genomic Laboratory, Cambridge University Hospitals Foundation Trust, Cambridge Biomedical Campus, UK
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Erik A M Beckers
- Department of Hematology, Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Manuela A Joore
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
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6
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Zaninetti C, Leinøe E, Lozano ML, Rossing M, Bastida JM, Zetterberg E, Rivera J, Greinacher A. Validation of immunofluorescence analysis of blood smears in patients with inherited platelet disorders. JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2023; 21:1010-1019. [PMID: 36732160 DOI: 10.1016/j.jtha.2022.12.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 12/08/2022] [Accepted: 12/27/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Inherited platelet disorders (IPDs) are rare diseases characterized by reduced blood platelet counts and/or impaired platelet function. Recognizing IPDs is advisable but often challenging. The diagnostic tools include clinical evaluation, platelet function tests, and molecular analyses. Demonstration of a pathogenic genetic variant confirms IPDs. We established a method to assess the platelet phenotype on blood smears using immunofluorescence microscopy as a diagnostic tool for IPDs. OBJECTIVES The aim of the present study was to validate immunofluorescence microscopy as a screening tool for IPDs in comparison with genetic screening. METHODS We performed a blinded comparison between the diagnosis made using immunofluorescence microscopy on blood smears and genetic findings in a cohort of 43 families affected with 20 different genetically confirmed IPDs. In total, 76% of the cases had inherited thrombocytopenia. RESULTS Immunofluorescence correctly predicted the underlying IPD in the vast majority of patients with 1 of 9 IPDs for which the typical morphologic pattern is known. Thirty of the 43 enrolled families (70%) were affected by 1 of these 9 IPDs. For the other 11 forms of IPD, we describe alterations of platelet structure in 9 disorders and normal findings in 2 disorders. CONCLUSION Immunofluorescence microscopy on blood smears is an effective screening tool for 9 forms of IPD, which include the most frequent forms of inherited thrombocytopenia. Using this approach, typical changes in the phenotype may also be identified for other rare IPDs.
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Affiliation(s)
- Carlo Zaninetti
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany. https://twitter.com/ZaninettiCarlo
| | - Eva Leinøe
- Department of Haematology, Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Genomic Medicine, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - María Luisa Lozano
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Pascual Parrilla, CIBERER-U765, Murcia, Spain
| | - Maria Rossing
- Centre for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jose Maria Bastida
- Department of Hematology, Complejo Asistencial Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Universidad de Salamanca, Salamanca, Spain; Grupo Español de Alteraciones Plaquetarias Congénitas, Spanish Society of Thrombosis and Haemostasis, Madrid, Spain
| | - Eva Zetterberg
- Clinical Coagulation Research Unit, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Jose Rivera
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Pascual Parrilla, CIBERER-U765, Murcia, Spain; Grupo Español de Alteraciones Plaquetarias Congénitas, Spanish Society of Thrombosis and Haemostasis, Madrid, Spain
| | - Andreas Greinacher
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany.
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7
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Freson K. Diagnostic value of multigene sequencing for inherited thrombocytopenia. Br J Haematol 2022; 199:645-646. [PMID: 36245319 DOI: 10.1111/bjh.18501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 09/24/2022] [Accepted: 09/25/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Kathleen Freson
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, KULeuven, Leuven, Belgium
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8
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Sullivan MJ, Palmer EL, Botero JP. ANKRD26-Related Thrombocytopenia and Predisposition to Myeloid Neoplasms. Curr Hematol Malig Rep 2022; 17:105-112. [PMID: 35751752 DOI: 10.1007/s11899-022-00666-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW This review describes ANKRD26-related thrombocytopenia (RT) from a molecular, clinical, and laboratory perspective, with a focus on the clinical decision-making that takes place in the diagnosis and management of families with ANKRD26-RT. RECENT FINDINGS ANKRD26-related thrombocytopenia (ANKRD26-RT) is a non-syndromic autosomal dominant thrombocytopenia with predisposition to hematologic neoplasm. The clinical presentation is variable with moderate thrombocytopenia with normal platelet size and absent to mild bleeding being the hallmark which makes it difficult to distinguish from other inherited thrombocytopenias. The pathophysiology involves overexpression of ANKRD26 through loss of inhibitory control by transcription factors RUNX1 and FLI1. The great majority of disease-causing variants are in the 5' untranslated region. Acute myeloid leukemia, myelodysplastic syndrome, and chronic myelomonocytic leukemia have been reported to occur in the context of germline variants in ANKRD26, with the development of somatic driver mutations in hematopoietic regulators playing an important role in malignant transformation. In the absence of clear risk estimates of development of malignancy, optimal surveillance strategies and interventions to reduce risk of evolution to a myeloid disorder, multidisciplinary evaluation, with a strong genetic counseling framework is essential in the approach to these patients and their families. Gene-specific expertise and a multidisciplinary approach are important in the diagnosis and treatment of patients and families with ANKRD26-RT. These strategies help overcome the challenges faced by clinicians in the evaluation of individuals with a rare, non-syndromic, inherited disorder with predisposition to hematologic malignancy for which large data to guide decision-making is not available.
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Affiliation(s)
- Mia J Sullivan
- Diagnostic Laboratories, Versiti, 638 N 18th St, Milwaukee, WI, 53233, USA
| | - Elizabeth L Palmer
- Diagnostic Laboratories, Versiti, 638 N 18th St, Milwaukee, WI, 53233, USA
| | - Juliana Perez Botero
- Diagnostic Laboratories, Versiti, 638 N 18th St, Milwaukee, WI, 53233, USA. .,Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA.
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9
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Warren JT, Di Paola J. Genetics of inherited thrombocytopenias. Blood 2022; 139:3264-3277. [PMID: 35167650 PMCID: PMC9164741 DOI: 10.1182/blood.2020009300] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 02/04/2022] [Indexed: 01/19/2023] Open
Abstract
The inherited thrombocytopenia syndromes are a group of disorders characterized primarily by quantitative defects in platelet number, though with a variety demonstrating qualitative defects and/or extrahematopoietic findings. Through collaborative international efforts applying next-generation sequencing approaches, the list of genetic syndromes that cause thrombocytopenia has expanded significantly in recent years, now with over 40 genes implicated. In this review, we focus on what is known about the genetic etiology of inherited thrombocytopenia syndromes and how the field has worked to validate new genetic discoveries. We highlight the important role for the clinician in identifying a germline genetic diagnosis and strategies for identifying novel causes through research-based endeavors.
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Affiliation(s)
- Julia T Warren
- Division of Hematology-Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Jorge Di Paola
- Division of Hematology-Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
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10
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Gomez K. Advances in the diagnosis of heritable platelet disorders. Blood Rev 2022; 56:100972. [PMID: 35595614 DOI: 10.1016/j.blre.2022.100972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/09/2022] [Accepted: 05/10/2022] [Indexed: 11/02/2022]
Abstract
The last decade has seen large increases in the number of patients registered with heritable platelet disorders in national databases of bleeding disorders. Although individually rare, collectively they are a relatively common cause of heritable bleeding. This revolution has come about through the application of high-throughput sequencing strategies and efforts to standardize diagnostic testing. There is renewed interest in established parameters such as platelet volume and utilising simple tools such as blood smears. The diagnostic yield from peripheral blood smears can be improved with new microscopy techniques that could potentially assist in determining which patients need to be referred to tertiary centres for specialist testing. A better understanding of the other clinical features that can accompany abnormalities of platelet number or function, can lead to better clinical management and prevention of serious complications. There are challenges for clinicians who need to be aware of these developments, understand the limitations of new diagnostic techniques and keep abreast of strategies for incorporation into clinical practice. This review discusses some of these approaches, the limitations that clinicians need to be aware of and techniques that may enter clinical use in the future.
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Affiliation(s)
- Keith Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK.
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11
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Bourguignon A, Tasneem S, Hayward CP. Screening and diagnosis of inherited platelet disorders. Crit Rev Clin Lab Sci 2022; 59:405-444. [PMID: 35341454 DOI: 10.1080/10408363.2022.2049199] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Inherited platelet disorders are important conditions that often manifest with bleeding. These disorders have heterogeneous underlying pathologies. Some are syndromic disorders with non-blood phenotypic features, and others are associated with an increased predisposition to developing myelodysplasia and leukemia. Platelet disorders can present with thrombocytopenia, defects in platelet function, or both. As the underlying pathogenesis of inherited thrombocytopenias and platelet function disorders are quite diverse, their evaluation requires a thorough clinical assessment and specialized diagnostic tests, that often challenge diagnostic laboratories. At present, many of the commonly encountered, non-syndromic platelet disorders do not have a defined molecular cause. Nonetheless, significant progress has been made over the past few decades to improve the diagnostic evaluation of inherited platelet disorders, from the assessment of the bleeding history to improved standardization of light transmission aggregometry, which remains a "gold standard" test of platelet function. Some platelet disorder test findings are highly predictive of a bleeding disorder and some show association to symptoms of prolonged bleeding, surgical bleeding, and wound healing problems. Multiple assays can be required to diagnose common and rare platelet disorders, each requiring control of preanalytical, analytical, and post-analytical variables. The laboratory investigations of platelet disorders include evaluations of platelet counts, size, and morphology by light microscopy; assessments for aggregation defects; tests for dense granule deficiency; analyses of granule constituents and their release; platelet protein analysis by immunofluorescent staining or flow cytometry; tests of platelet procoagulant function; evaluations of platelet ultrastructure; high-throughput sequencing and other molecular diagnostic tests. The focus of this article is to review current methods for the diagnostic assessment of platelet function, with a focus on contemporary, best diagnostic laboratory practices, and relationships between clinical and laboratory findings.
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Affiliation(s)
- Alex Bourguignon
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Subia Tasneem
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Catherine P Hayward
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
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12
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Ver Donck F, Labarque V, Freson K. Hemostatic phenotypes and genetic disorders. Res Pract Thromb Haemost 2021; 5:e12637. [PMID: 34964017 PMCID: PMC8677882 DOI: 10.1002/rth2.12637] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 10/26/2021] [Accepted: 11/10/2021] [Indexed: 11/16/2022] Open
Abstract
This review is focused on genetic regulators of bleeding and thrombosis with a focus on next-generation sequencing (NGS) technologies for diagnosis and research of patients with inherited disorders. The molecular diagnosis of hemostatic phenotypes relies on the detection of genetic variants in the 99 curated disease-causing genes implicated for bleeding, platelet, and thrombotic disorders through the use of multigene panel tests. In this review, we will provide an overview of the advantages and disadvantages of using such multigene panel tests for diagnostics. During the past decade, NGS technologies have also been used for the gene discovery of 32 novel genes involved in inherited hemostatic phenotypes. We will provide a brief overview of these genes and discuss what information (eg, linkage, consanguinity, multiple index cases with similar phenotypes, mouse models, and more) was used to support the gene discovery process. Next, we provide examples on how RNA sequencing is useful to explore disease mechanisms of novel and often unexpected genes. This review will summarize the important findings concerning NGS technologies for diagnostics and gene discovery that were presented at the ISTH 2021 conference. Finally, future perspectives in our field mainly deal with finding the needle in the haystack for some still unexplained patients and the need for exploring the noncoding gene space and rapid disease validation models.
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Affiliation(s)
- Fabienne Ver Donck
- Department of Cardiovascular SciencesCenter for Molecular and Vascular BiologyUniversity of LeuvenLeuvenBelgium
| | - Veerle Labarque
- Department of Cardiovascular SciencesCenter for Molecular and Vascular BiologyUniversity of LeuvenLeuvenBelgium
- Department of Pediatrics, Pediatric Hemato‐OncologyUniversity Hospitals LeuvenLeuvenBelgium
| | - Kathleen Freson
- Department of Cardiovascular SciencesCenter for Molecular and Vascular BiologyUniversity of LeuvenLeuvenBelgium
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13
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Megy K, Downes K, Morel‐Kopp M, Bastida JM, Brooks S, Bury L, Leinoe E, Gomez K, Morgan NV, Othman M, Ouwehand WH, Perez Botero J, Rivera J, Schulze H, Trégouët D, Freson K. GoldVariants, a resource for sharing rare genetic variants detected in bleeding, thrombotic, and platelet disorders: Communication from the ISTH SSC Subcommittee on Genomics in Thrombosis and Hemostasis. J Thromb Haemost 2021; 19:2612-2617. [PMID: 34355501 PMCID: PMC9291976 DOI: 10.1111/jth.15459] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/22/2021] [Accepted: 07/09/2021] [Indexed: 02/05/2023]
Abstract
The implementation of high-throughput sequencing (HTS) technologies in research and diagnostic laboratories has linked many new genes to rare bleeding, thrombotic, and platelet disorders (BTPD), and revealed multiple genetic variants linked to those disorders, many of them being of uncertain pathogenicity when considering the accepted evidence (variant consequence, frequency in control datasets, number of reported patients, prediction models, and functional assays). The sequencing effort has also resulted in resources for gathering disease-causing variants associated with specific genes, but for BTPD, such well-curated databases exist only for a few genes. On the other hand, submissions by individuals or diagnostic laboratories to the variant database ClinVar are hampered by the lack of a submission process tailored to capture the specific features of hemostatic diseases. As we move toward the implementation of HTS in the diagnosis of BTPD, the Scientific and Standardization Committee for Genetics in Thrombosis and Haemostasis has developed and tested a REDCap-based interface, aimed at the community, to submit curated genetic variants for diagnostic-grade BTPD genes. Here, we describe the use of the interface and the initial submission of 821 variants from 30 different centers covering 14 countries. This open-access variant resource will be shared with the community to improve variant classification and regular bulk data transfer to ClinVar.
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Affiliation(s)
- Karyn Megy
- Department of HaematologyUniversity of CambridgeCambridge Biomedical CampusCambridgeUK
- NIHR BioResourceCambridge University HospitalsCambridge Biomedical CampusCambridgeUK
- Present address:
Centre for Genomics ResearchDiscovery SciencesBioPharmaceuticals R&DAstraZenecaCambridgeUK
| | - Kate Downes
- Department of HaematologyUniversity of CambridgeCambridge Biomedical CampusCambridgeUK
- NIHR BioResourceCambridge University HospitalsCambridge Biomedical CampusCambridgeUK
- East Genomic Laboratory HubCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Marie‐Christine Morel‐Kopp
- Department of Haematology and Transfusion MedicineRoyal North Shore HospitalSydneyNew South WalesAustralia
- Northern Blood Research CentreKolling InstituteThe University of SydneySydneyNew South WalesAustralia
| | - José M. Bastida
- Department of HematologyIBSAL‐Hospital Universitario de SalamancaSalamancaSpain
| | - Shannon Brooks
- International Society on Thrombosis and Haemostasis (ISTH)CarrboroNorth CarolinaUSA
| | - Loredana Bury
- Section of Internal and Cardiovascular MedicineDepartment of MedicineUniversity of PerugiaPerugiaItaly
| | - Eva Leinoe
- Department of HaematologyRigshospitaletNational University HospitalCopenhagenDenmark
| | - Keith Gomez
- Haemophilia Centre and Thrombosis UnitRoyal Free London NHS Foundation TrustLondonUK
| | - Neil V. Morgan
- Institute of Cardiovascular SciencesCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
| | - Maha Othman
- Biomedical and Molecular Sciences School of Medicine Queen’s UniversityKingstonOntario,Canada
- School of Baccalaureate Nursing, St. Lawrence CollegeKingstonOntarioCanada
| | - Willem H. Ouwehand
- Department of HaematologyUniversity of CambridgeCambridge Biomedical CampusCambridgeUK
- NIHR BioResourceCambridge University HospitalsCambridge Biomedical CampusCambridgeUK
- East Genomic Laboratory HubCambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - Juliana Perez Botero
- Division of Hematology/OncologyMedical College of Wisconsin and Versiti Diagnostic LaboratoriesMilwaukeeWisconsinUSA
| | - José Rivera
- Servicio de Hematología y Oncología MédicaHospital Universitario Morales MeseguerCentro Regional de HemodonaciónUniversidad de MurciaIMIB‐ArrixacaCIBERER‐U765MurciaSpain
| | - Harald Schulze
- Institute of Experimental BiomedicineUniversity Hospital WuerzburgWuerzburgGermany
| | | | - Kathleen Freson
- Department of Cardiovascular SciencesCenter for Molecular and Vascular BiologyKU LeuvenLeuvenBelgium
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14
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Gomez K, Anderson J, Baker P, Biss T, Jennings I, Lowe G, Platton S. Clinical and laboratory diagnosis of heritable platelet disorders in adults and children: a British Society for Haematology Guideline. Br J Haematol 2021; 195:46-72. [PMID: 34435350 DOI: 10.1111/bjh.17690] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Keith Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London
| | - Julia Anderson
- Haemophilia Thrombosis and Immunology Centre, Royal Infirmary, NHS Lothian, Edinburgh
| | - Peter Baker
- Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - Tina Biss
- Haemophilia Comprehensive Care Centre, Royal Victoria Infirmary, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne
| | - Ian Jennings
- UK NEQAS for Blood Coagulation, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | - Gillian Lowe
- Haemophilia Comprehensive Care Centre, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sean Platton
- Haemophilia Centre, The Royal London Hospital, Barts Health NHS Trust, London, UK
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15
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Bussel JB, Peerschke E. Heritable platelet disorders: an enigma even guidelines can't unravel. Br J Haematol 2021; 195:13-14. [PMID: 34494258 DOI: 10.1111/bjh.17809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/16/2021] [Indexed: 11/27/2022]
Affiliation(s)
| | - Ellinor Peerschke
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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16
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17
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An Update on Pediatric Immune Thrombocytopenia (ITP): Differentiating Primary ITP, IPD, and PID. Blood 2021; 140:542-555. [PMID: 34479363 DOI: 10.1182/blood.2020006480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/20/2021] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is the most common acquired thrombocytopenia in children and is caused by both immune-mediated decreased platelet production and increased platelet destruction. In the absence of a diagnostic test, ITP must be differentiated from other thrombocytopenic disorders, including inherited platelet disorders (IPD). In addition, a diagnosis of secondary ITP due to a primary immune deficiency (PID) with immune dysregulation may not be apparent at diagnosis but can alter management and should be considered in an expanding number of clinical scenarios. The diagnostic evaluation of children with thrombocytopenia will vary based on the clinical history and laboratory features. Access to genotyping has broadened the ability to specify the etiology of thrombocytopenia, while increasing access to immunophenotyping, functional immunologic and platelet assays, and biochemical markers has allowed for more in-depth evaluation of patients. With this greater availability of testing, diagnostic algorithms in patients with thrombocytopenia have become complex. In this article, we highlight the diagnostic evaluation of thrombocytopenia in children with a focus on ITP, including consideration of underlying genetic and immune disorders, and utilize hypothetical patient cases to describe disease manifestations and strategies for treatment of pediatric ITP.
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18
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Perez Botero J, Di Paola J. Diagnostic approach to the patient with a suspected inherited platelet disorder: Who and how to test. J Thromb Haemost 2021; 19:2127-2136. [PMID: 34347927 DOI: 10.1111/jth.15484] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/02/2021] [Indexed: 11/30/2022]
Abstract
Bleeding and thrombocytopenia are common referrals to the pediatric and adult hematology practice. The differential diagnosis encompasses a wide spectrum of entities that vary in acuity, severity, and etiology. Most will be acquired (especially in adult patients), but many can be inherited, and some may have manifestations affecting other organ systems. The first step: defining whether the symptoms and/or laboratory findings are clinically significant and warrant additional work-up, can be equally as challenging as reaching the diagnosis itself. How much bleeding is too much to be considered normal? How low of a platelet count is too low? Once the decision has been made to pursue additional studies, considering the increasing number of laboratory tests available, the diagnostic process can be complex. In this article, we outline a general approach for the evaluation of patients in whom an inherited platelet disorder is being considered. We present two clinical vignettes as introduction to the diagnostic approach to inherited platelet disorders. We describe the rationale for the different types of tests that are clinically available, their limitations, and finally the challenges that are frequently encountered in the interpretation of results. We also intend to provide some guidance on the expected phenotype in terms of severity of bleeding and/or thrombocytopenia according to the etiology of the inherited disorder. Our goal is to provide the practicing hematologist with a practical framework that is clinically applicable in their daily practice.
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Affiliation(s)
- Juliana Perez Botero
- Versiti and Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jorge Di Paola
- Division of Pediatric Hematology Oncology, Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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19
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Zaninetti C, Wolff M, Greinacher A. Diagnosing Inherited Platelet Disorders: Modalities and Consequences. Hamostaseologie 2021; 41:475-488. [PMID: 34391210 DOI: 10.1055/a-1515-0813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Inherited platelet disorders (IPDs) are a group of rare conditions featured by reduced circulating platelets and/or impaired platelet function causing variable bleeding tendency. Additional hematological or non hematological features, which can be congenital or acquired, distinctively mark the clinical picture of a subgroup of patients. Recognizing an IPD is challenging, and diagnostic delay or mistakes are frequent. Despite the increasing availability of next-generation sequencing, a careful phenotyping of suspected patients-concerning the general clinical features, platelet morphology, and function-is still demanded. The cornerstones of IPD diagnosis are clinical evaluation, laboratory characterization, and genetic testing. Achieving a diagnosis of IPD is desirable for several reasons, including the possibility of tailored therapeutic strategies and individual follow-up programs. However, detailed investigations can also open complex scenarios raising ethical issues in case of IPDs predisposing to hematological malignancies. This review offers an overview of IPD diagnostic workup, from the interview with the proband to the molecular confirmation of the suspected disorder. The main implications of an IPD diagnosis are also discussed.
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Affiliation(s)
- Carlo Zaninetti
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany.,Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Martina Wolff
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
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20
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Inherited Platelet Disorders: An Updated Overview. Int J Mol Sci 2021; 22:ijms22094521. [PMID: 33926054 PMCID: PMC8123627 DOI: 10.3390/ijms22094521] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/17/2021] [Accepted: 04/21/2021] [Indexed: 02/06/2023] Open
Abstract
Platelets play a major role in hemostasis as ppwell as in many other physiological and pathological processes. Accordingly, production of about 1011 platelet per day as well as appropriate survival and functions are life essential events. Inherited platelet disorders (IPDs), affecting either platelet count or platelet functions, comprise a heterogenous group of about sixty rare diseases caused by molecular anomalies in many culprit genes. Their clinical relevance is highly variable according to the specific disease and even within the same type, ranging from almost negligible to life-threatening. Mucocutaneous bleeding diathesis (epistaxis, gum bleeding, purpura, menorrhagia), but also multisystemic disorders and/or malignancy comprise the clinical spectrum of IPDs. The early and accurate diagnosis of IPDs and a close patient medical follow-up is of great importance. A genotype-phenotype relationship in many IPDs makes a molecular diagnosis especially relevant to proper clinical management. Genetic diagnosis of IPDs has been greatly facilitated by the introduction of high throughput sequencing (HTS) techniques into mainstream investigation practice in these diseases. However, there are still unsolved ethical concerns on general genetic investigations. Patients should be informed and comprehend the potential implications of their genetic analysis. Unlike the progress in diagnosis, there have been no major advances in the clinical management of IPDs. Educational and preventive measures, few hemostatic drugs, platelet transfusions, thrombopoietin receptor agonists, and in life-threatening IPDs, allogeneic hematopoietic stem cell transplantation are therapeutic possibilities. Gene therapy may be a future option. Regular follow-up by a specialized hematology service with multidisciplinary support especially for syndromic IPDs is mandatory.
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21
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Bastida JM, Gonzalez-Porras JR, Rivera J, Lozano ML. Role of Thrombopoietin Receptor Agonists in Inherited Thrombocytopenia. Int J Mol Sci 2021; 22:ijms22094330. [PMID: 33919295 PMCID: PMC8122256 DOI: 10.3390/ijms22094330] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 04/16/2021] [Accepted: 04/17/2021] [Indexed: 01/05/2023] Open
Abstract
In the last decade, improvements in genetic testing have revolutionized the molecular diagnosis of inherited thrombocytopenias (ITs), increasing the spectrum of knowledge of these rare, complex and heterogeneous disorders. In contrast, the therapeutic management of ITs has not evolved in the same way. Platelet transfusions have been the gold standard treatment for a long time. Thrombopoietin receptor agonists (TPO-RA) were approved for immune thrombocytopenia (ITP) ten years ago and there is evidence for the use of TPO-RA not only in other forms of ITP, but also in ITs. We have reviewed in the literature the existing evidence on the role of TPO-RAs in ITs from 2010 to February 2021. A total of 24 articles have been included, 4 clinical trials, 3 case series and 17 case reports. A total of 126 patients with ITs have received TPO-RA. The main diagnoses were Wiskott–Aldrich syndrome, MYH9-related disorder and ANKRD26-related thrombocytopenia. Most patients were enrolled in clinical trials and were treated for short periods of time with TPO-RA as bridging therapies towards surgical interventions, or other specific approaches, such as hematopoietic stem cell transplantation. Here, we have carried out an updated and comprehensive review about the efficacy and safety of TPO-RA in ITs.
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Affiliation(s)
- José María Bastida
- Department of Hematology, Instituto de Investigación Biomédica de Salamanca (IBSAL), Complejo Asistencial Universitario de Salamanca (CAUSA), Universidad de Salamanca (USAL), 37007 Salamanca, Spain;
- Correspondence:
| | - José Ramón Gonzalez-Porras
- Department of Hematology, Instituto de Investigación Biomédica de Salamanca (IBSAL), Complejo Asistencial Universitario de Salamanca (CAUSA), Universidad de Salamanca (USAL), 37007 Salamanca, Spain;
| | - José Rivera
- Department of Hematology and Oncology, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CIBERER-U765, 30008 Murcia, Spain; (J.R.); (M.L.L.)
| | - María Luisa Lozano
- Department of Hematology and Oncology, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CIBERER-U765, 30008 Murcia, Spain; (J.R.); (M.L.L.)
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22
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Learning the Ropes of Platelet Count Regulation: Inherited Thrombocytopenias. J Clin Med 2021; 10:jcm10030533. [PMID: 33540538 PMCID: PMC7867147 DOI: 10.3390/jcm10030533] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 02/06/2023] Open
Abstract
Inherited thrombocytopenias (IT) are a group of hereditary disorders characterized by a reduced platelet count sometimes associated with abnormal platelet function, which can lead to bleeding but also to syndromic manifestations and predispositions to other disorders. Currently at least 41 disorders caused by mutations in 42 different genes have been described. The pathogenic mechanisms of many forms of IT have been identified as well as the gene variants implicated in megakaryocyte maturation or platelet formation and clearance, while for several of them the pathogenic mechanism is still unknown. A range of therapeutic approaches are now available to improve survival and quality of life of patients with IT; it is thus important to recognize an IT and establish a precise diagnosis. ITs may be difficult to diagnose and an initial accurate clinical evaluation is mandatory. A combination of clinical and traditional laboratory approaches together with advanced sequencing techniques provide the highest rate of diagnostic success. Despite advancement in the diagnosis of IT, around 50% of patients still do not receive a diagnosis, therefore further research in the field of ITs is warranted to further improve patient care.
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23
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Downes K, Borry P, Ericson K, Gomez K, Greinacher A, Lambert M, Leinoe E, Noris P, Van Geet C, Freson K. Clinical management, ethics and informed consent related to multi-gene panel-based high throughput sequencing testing for platelet disorders: Communication from the SSC of the ISTH. J Thromb Haemost 2020; 18:2751-2758. [PMID: 33079472 PMCID: PMC7589386 DOI: 10.1111/jth.14993] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 12/22/2022]
Abstract
Molecular diagnostics of inherited platelet disorders (IPD) has been revolutionized by the implementation of high-throughput sequencing (HTS) approaches. A conclusive diagnosis using HTS tests can be obtained quickly and cost-effectively in many, but not all patients. The expanding use of HTS tests has raised concerns regarding complex variant interpretation and the ethical implications of detecting unsolicited findings such as variants in IPD genes RUNX1, ETV6, and ANKRD26, which are associated with increased leukemic risk. This guidance document has been developed and written by a multidisciplinary team of researchers and clinicians, with expertise in hematology, clinical and molecular genetics, and bioethics, alongside a RUNX1 patient advocacy representative. We recommend that for clinical diagnostics, HTS for IPD should use a multigene panel of curated diagnostic-grade genes. Critically, we advise that an HTS test for clinical diagnostics should only be ordered by a clinical expert that is: (a) fully aware of the complexity of genotype-phenotype correlations for IPD; (b) able to discuss these complexities with a patient and family members before the test is initiated; and (c) able to interpret and appropriately communicate the results of a HTS diagnostic report, including the implication of variants of uncertain clinical significance. Each patient should know what an HTS test could mean for his or her clinical management before initiating a test. We hereby propose an exemplified informed consent document that includes information on these ethical concerns and can be used by the community for implementation of HTS of IPD in a clinical diagnostic setting. This paper does not include recommendations for HTS of IPD in a research setting.
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Affiliation(s)
- Kate Downes
- East Genomic Laboratory HubCambridge University Hospitals NHS Foundation TrustCambridgeUK
- Department of HaematologyUniversity of CambridgeCambridge Biomedical CampusCambridgeUK
| | - Pascal Borry
- Department of Public Health and Primary CareKU LeuvenLeuvenBelgium
| | | | - Keith Gomez
- Haemophilia Centre and Thrombosis UnitRoyal Free London NHS Foundation TrustLondonUK
| | - Andreas Greinacher
- Institut für Immunologie und TransfusionsmedizinUniversitätsmedizin GreifswaldGreifswaldGermany
| | - Michele Lambert
- Division of HematologyThe Children’s Hospital of PhiladelphiaPhiladelphiaPAUSA
- Department of PediatricsPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPAUSA
| | - Eva Leinoe
- Department of HaematologyRigshospitaletNational University HospitalCopenhagenDenmark
| | - Patrizia Noris
- IRCCS Policlinico San Matteo Foundation and University of PaviaPaviaItaly
| | - Chris Van Geet
- Department of Cardiovascular SciencesCenter or Molecular and Vascular BiologyKU LeuvenLeuvenBelgium
| | - Kathleen Freson
- Department of Cardiovascular SciencesCenter or Molecular and Vascular BiologyKU LeuvenLeuvenBelgium
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