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Kashiwagi H, Kuwana M, Murata M, Shimada N, Takafuta T, Yamanouchi J, Kato H, Hato T, Tomiyama Y. Reference guide for the diagnosis of adult primary immune thrombocytopenia, 2023 edition. Int J Hematol 2024; 119:1-13. [PMID: 37957517 PMCID: PMC10770234 DOI: 10.1007/s12185-023-03672-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 11/15/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia due to accelerated platelet destruction and impaired platelet production. Diagnosis of ITP is still challenging because ITP has been diagnosed by exclusion. Exclusion of thrombocytopenia due to bone marrow failure is especially important in Japan because of high prevalence of aplastic anemia compared to Western countries. Hence, we propose a new diagnostic criteria involving the measurement of plasma thrombopoietin (TPO) levels and percentage of immature platelet fraction (RP% or IPF%); 1) isolated thrombocytopenia with no morphological evidence of dysplasia in any blood cell type in a blood smear, 2) normal or slightly increased plasma TPO level (< cutoff), 3) elevated RP% or IPF% (> upper limit of normal), and 4) absence of other conditions that potentially cause thrombocytopenia including secondary ITP. A diagnosis of ITP is made if conditions 1-4 are all met. Cases in which criterion 2 or 3 is not met or unavailable are defined as "possible ITP," and diagnosis of ITP can be made mainly by typical clinical course. These new criteria enable us to clearly differentiate ITP from aplastic anemia and other forms of hypoplastic thrombocytopenia and can be highly useful in clinical practice for avoiding unnecessary bone marrow examination as well as for appropriate selection of treatments.
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Affiliation(s)
- Hirokazu Kashiwagi
- Department of Blood Transfusion, Osaka University Hospital, Suita, Osaka, 565-0871, 2-15, Yamadaoka, Japan.
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Mitsuru Murata
- Center for Clinical Medical Research, International University of Health and Welfare, Ohtawara, Tochigi, Japan
| | - Naoki Shimada
- Center for Basic Medical Research, International University of Health and Welfare, Ohtawara, Tochigi, Japan
| | - Toshiro Takafuta
- Department of Internal Medicine, Hiroshima City Funairi Citizens Hospital, Hiroshima, Hiroshima, Japan
| | - Jun Yamanouchi
- Division of Blood Transfusion and Cell Therapy, Ehime University Hospital, Toon, Ehime, Japan
| | - Hisashi Kato
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Takaaki Hato
- Japanese Red Cross Ehime Blood Center, Matsuyama, Ehime, Japan
| | - Yoshiaki Tomiyama
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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Akuta K, Fukushima K, Nakata K, Hayashi S, Toda J, Shingai Y, Tsutsumi K, Machida T, Hino A, Kusakabe S, Doi Y, Fujita J, Kato H, Maeda T, Yokota T, Tomiyama Y, Hosen N, Kashiwagi H. Autoimmune-mediated thrombocytopenia after allogeneic hematopoietic stem cell transplantation: significance of detecting reticulated platelets and glycoprotein-specific platelet autoantibodies. Int J Hematol 2022; 115:322-328. [PMID: 35037230 DOI: 10.1007/s12185-021-03272-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 10/19/2022]
Abstract
Autoimmune hematological disorders are rare complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Diagnosis of immune thrombocytopenia (ITP) is challenging, especially after allo-HSCT, because various complications such as graft-versus-host disease, disease relapse, viral infection, thrombotic microangiopathy, and drug side effects can also cause thrombocytopenia. Assessment of reticulated platelets (RP) and plasma thrombopoietin (TPO) levels may be useful to distinguish between ITP and hypoplastic thrombocytopenia. ITP is generally characterized by an increased percentage of RP, and a normal or slightly increased plasma TPO level. We now report three cases of thrombocytopenia after allo-HSCT. RP% was elevated in these patients, as it is in primary ITP. However, in contrast to primary ITP, plasma TPO levels were high in two of three patients. Anti-αIIbβ3 and anti-GPIb/IX-specific direct IgG antibodies were detected as well, suggesting occurrence of immune-mediated platelet destruction in addition to bone marrow suppression in two patients. All three patients were successfully treated with corticosteroids and/or thrombopoietin receptor agonists (TPO-RAs). These results suggest that increased RP% and detection of glycoprotein-specific platelet autoantibodies are useful for the diagnosis of ITP after HSCT.
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Affiliation(s)
- Keigo Akuta
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Kentaro Fukushima
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Keiichi Nakata
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Satoru Hayashi
- Department of Blood Transfusion, Osaka University Hospital, Suita, Japan
| | - Jun Toda
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Yasuhiro Shingai
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Kazuhito Tsutsumi
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Tomohisa Machida
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Akihisa Hino
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Shinsuke Kusakabe
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Yukiko Doi
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Jiro Fujita
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Hisashi Kato
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Tetsuo Maeda
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Takafumi Yokota
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Yoshiaki Tomiyama
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Naoki Hosen
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Hirokazu Kashiwagi
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, Japan. .,Department of Blood Transfusion, Osaka University Hospital, Suita, Japan.
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Biner B, Devecioğlu O, Demir M. Pitfalls in the Diagnosis of Immune Thrombocytopenic Purpura in Children: 4 Case Reports. Clin Appl Thromb Hemost 2016; 13:329-33. [PMID: 17636197 DOI: 10.1177/1076029607302444] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Acute idiopathic thrombocytopenic purpura is the most common cause of thrombocytopenia in childhood, and diagnosis of idiopathic thrombocytopenic purpura is made clinically based on the exclusion of other causes of thrombocytopenia. Patients with diverse causes of thrombocytopenia are sometimes erroneously diagnosed as having idiopathic thrombocytopenic purpura. However, for the prevention of misdiagnoses, careful inspection of peripheral blood smear is of utmost importance. This report presents 4 cases presumed as acute idiopathic thrombocytopenic purpura that were finally identified as pseudothrombocytopenia, inherited macrothrombocytopenia (MHY9 disorders) possibly Epstein syndrome, Bernard-Soulier syndrome, and drug-induced thrombocytopenia. They draw attention to the importance of platelet morphology to exclude inherited macrothrombocytopenia and history to exclude drug-induced thrombocytopenia. Better diagnostic approaches would be possible by the awareness of these relatively rare causes of isolated thrombocytopenia.
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Affiliation(s)
- Betül Biner
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, School of Medicine, Trakya University, Edirne, Turkey.
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van der Linden N, Klinkenberg LJJ, Meex SJR, Beckers EAM, de Wit NCJ, Prinzen L. Immature platelet fraction measured on the Sysmex XN hemocytometer predicts thrombopoietic recovery after autologous stem cell transplantation. Eur J Haematol 2014; 93:150-6. [PMID: 24660761 PMCID: PMC4232898 DOI: 10.1111/ejh.12319] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2014] [Indexed: 01/02/2023]
Abstract
Objectives A period of thrombocytopenia is common after stem cell transplantation (SCT). To prevent serious bleeding complications, prophylactic platelet transfusions are administered. Previous studies have shown that a rise in immature platelets precedes recovery of platelet count. Our aim was to define a cutoff value for immature platelets predicting thrombopoietic recovery within 2 d. Methods Hematological parameters were measured on the Sysmex XN hemocytometer. We calculated reference change values (RCV) for platelets in eight healthy individuals as marker for platelet recovery. To define a cutoff value, we performed ROC analysis using data from 16 autologous SCT patients. Results RCV for platelet concentration was 14.1%. Platelet recovery was observed 13 (median; range 9–31) days after SCT. Increase in immature platelet fraction (IPF) before platelet recovery was seen in all autologous SCT patients. Optimal cutoff IPF was found to be 5.3% for platelet recovery within 2 d (specificity 0.98, sensitivity 0.47, positive predictive value 0.93). Conclusions We identified an optimal cutoff value for IPF 5.3% to predict platelet recovery after autologous SCT within 2 d. Implementing this cutoff value in transfusion strategy may reduce the number of prophylactic platelet transfusions.
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Affiliation(s)
- Noreen van der Linden
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, the Netherlands
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Measurement of thrombopoietic activity through the quantification of megakaryocytes in bone marrow cytology and reticulated platelets. Res Vet Sci 2012; 93:313-7. [DOI: 10.1016/j.rvsc.2011.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Revised: 05/16/2011] [Accepted: 07/10/2011] [Indexed: 11/21/2022]
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The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood 2011; 117:4190-207. [PMID: 21325604 DOI: 10.1182/blood-2010-08-302984] [Citation(s) in RCA: 1254] [Impact Index Per Article: 96.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is commonly encountered in clinical practice. In 1996 the American Society of Hematology published a landmark guidance paper designed to assist clinicians in the management of this disorder. Since 1996 there have been numerous advances in the management of both adult and pediatric ITP. These changes mandated an update in the guidelines. This guideline uses a rigorous, evidence-based approach to the location, interpretation, and presentation of the available evidence. We have endeavored to identify, abstract, and present all available methodologically rigorous data informing the treatment of ITP. We provide evidence-based treatment recommendations using the GRADE system in those areas in which such evidence exists. We do not provide evidence in those areas in which evidence is lacking, or is of lower quality--interested readers are referred to a number of recent, consensus-based recommendations for expert opinion in these clinical areas. Our review identified the need for additional studies in many key areas of the therapy of ITP such as comparative studies of "front-line" therapy for ITP, the management of serious bleeding in patients with ITP, and studies that will provide guidance about which therapy should be used as salvage therapy for patients after failure of a first-line intervention.
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Ruisi MM, Psaila B, Ward MJ, Villarica G, Bussel JB. Stability of measurement of the immature platelet fraction. Am J Hematol 2010; 85:622-4. [PMID: 20658593 DOI: 10.1002/ajh.21748] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Unklare Thrombozytopenie. Hamostaseologie 2010. [DOI: 10.1007/978-3-642-01544-1_42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Prognostic value of immature platelet fraction and plasma thrombopoietin in disseminated intravascular coagulation. Blood Coagul Fibrinolysis 2009; 20:409-14. [PMID: 19528793 DOI: 10.1097/mbc.0b013e32832b1866] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Although platelet count is a good parameter for the diagnosis of disseminated intravascular coagulation (DIC), a single measurement of platelet is not enough to reflect the ongoing platelet consumption because of compensatory synthesis of circulating platelet number. Increased thrombopoiesis owing to peripheral destruction is expected in patients with DIC. Reticulated platelet, measured as immature platelet fraction (IPF), and plasma thrombopoietin (TPO) are markers of platelet production. We investigated the potential usefulness of circulating IPF and TPO in 222 patients suspected of having DIC. Both IPF and TPO levels were significantly increased in overt DIC patients and well correlated with DIC score. IPF also correlated with fibrin-related marker such as fibrinogen degradation product and D-dimer. Both IPF and TPO showed better mortality prediction than platelet count with the multivariate logistic regression and Kaplan-Meier survival analysis. These results suggest that IPF and TPO are new potential candidates to detect the severity of DIC and to predict DIC mortality.
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Abstract
Criteria for distinguishing among etiologies of thrombocytosis are limited in their capacity to delineate clonal (essential thrombocythemia [ET]) from nonclonal (reactive thrombocytosis [RT]) etiologies. We studied platelet transcript profiles of 126 subjects (48 controls, 38 RT, 40 ET [24 contained the JAK2V(617)F mutation]) to identify transcript subsets that segregated phenotypes. Cross-platform consistency was validated using quantitative real-time polymerase chain reaction (RT-PCR). Class prediction algorithms were developed to assign phenotypic class between the thrombocytosis cohorts, and by JAK2 genotype. Sex differences were rare in normal and ET cohorts (< 1% of genes) but were male-skewed for approximately 3% of RT genes. An 11-biomarker gene subset using the microarray data discriminated among the 3 cohorts with 86.3% accuracy, with 93.6% accuracy in 2-way class prediction (ET vs RT). Subsequent quantitative RT-PCR analysis established that these biomarkers were 87.1% accurate in prospective classification of a new cohort. A 4-biomarker gene subset predicted JAK2 wild-type ET in more than 85% patient samples using either microarray or RT-PCR profiling, with lower predictive capacity in JAK2V(617)F mutant ET patients. These results establish that distinct genetic biomarker subsets can predict thrombocytosis class using routine phlebotomy.
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Abstract
In the first report of the concurrent immunodeficiency, thrombocytopenia, and eczema that we now call the Wiskott-Aldrich Syndrome (WAS), Alfred Wiskott asked whether it could be a familial form of Werlhof's disease (now called ITP). This review summarizes what is known about platelet production, consumption, and function in clinical and murine WAS. Both platelet production and consumption are affected by WASP deficiency. Likely molecular mechanisms have been identified for the former process, but remain problematic for the latter. Recent data in a murine model suggest that WASP deficiency could increase both the incidence of antiplatelet antibodies and susceptibility to their enhancement of platelet consumption. Wiskott's original speculation about the relationship between WAS and ITP may need to be reconsidered.
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Monteagudo M, Amengual MJ, Muñoz L, Soler JA, Roig I, Tolosa C. Reticulated platelets as a screening test to identify thrombocytopenia aetiology. QJM 2008; 101:549-55. [PMID: 18400777 DOI: 10.1093/qjmed/hcn047] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Thrombocytopenia is a common haematological abnormality and no simple diagnostic test is available to diagnose thrombocytopenia pathogenesis. AIM To evaluate sensitivity and specificity of reticulated platelets (RP) as a diagnostic test for thrombocytopenia with increased thrombopoietic activity. DESIGN Prospective observational study in thrombocytopenic patients. METHODS A direct, whole-blood, dual-labelling flow cytometric method was used. Direct, whole-blood double coverage was achieved using a monoclonal anti-glycoprotein (GP)-III antibody (CD61 PerCP) for platelet identification and thiazole orange (Retic-count) as platelet mARN stain. RESULTS RP were measured in 101 thrombocytopenic patients and 104 non-thrombocytopenic controls. The mean RP percentage in 60 thrombocytopenic patients with no increased thrombopoietic activity was 7.5% (CI for 95%: 5.2-9.7) and RP absolute number was 3.2 x 10(9)/l (CI for 95%: 2.1-4.3). The mean RP percentage in 41 thrombocytopenic patients with increased thrombopoietic activity was 30.3% (CI for 95%: 25.1-35.5) and RP absolute number was 6.2 (CI for 95%: 4.8-7.7). The RP percentage cut-off for a diagnosis of thrombocytopenia with increased thrombopoietic activity was 11% [sensitivity 93%, specificity 85%, positive predictive value (PPV) 83%, negative predictive value (NPV) 95%]. CONCLUSION RP measurement by flow cytometry, directly from whole-blood, is a useful screening test to differentiate between thrombocytopenia with high or low thrombopoietic activity. A RP percentage in excess of 11%, has a high sensitivity and good specificity for a diagnosis of thrombocytopenia with increased thrombopoietic activity.
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Affiliation(s)
- M Monteagudo
- Internal Medicine Department, Hospital de Sabadell, Parc Taulí S/N, 08208 Sabadell, Barcelona, Spain.
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Diquattro M, Gagliano F, Calabrò GM, Tommasi M, Scott CS, Mancuso G, Palma B, Menozzi I. Relationships between platelet counts, platelet volumes and reticulated platelets in patients with ITP: evidence for significant platelet count inaccuracies with conventional instrument methods. Int J Lab Hematol 2008; 31:199-206. [PMID: 18190589 DOI: 10.1111/j.1751-553x.2007.01025.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The platelet count has a primary role in the diagnosis and treatment of idiopathic thrombocytopenic purpura (ITP). This study analysed the accuracy of ITP patient platelet counts determined by Abbott CD-Sapphire (impedance/optical) and Bayer Advia 120 (optical) analyses, compared with a reference immunoplatelet method. Instrument platelet estimates showed broad equivalence in the higher range of observed values, but significant discrepancies against the immunoplatelet count were seen when platelet counts were <10 x 10(9)/l. CD-Sapphire mean platelet volume (MPV) results revealed increased (>12 fl) platelet volumes in eight of eight ITP patients with counts of <20 x 10(9)/l compared with 6/6 and 5/13 patients with platelet counts of 20-50 and >50 x 10(9)/l. In contrast, Bayer Advia MPV values showed no relationship with the platelet count. Increased reticulated platelets were associated with an increasing CD-Sapphire MPV (R(2) = 0.61) and a decreasing platelet count. High (>40%) reticulated platelet values were seen in 9/9 patients with immunoplatelet counts of <20 x 10(9)/l compared with 0/19 patients with platelet counts above 20 x 10(9)/l. There may be a need for caution in the interpretation of platelet counts in ITP patients obtained with conventional instrument methods, and therapeutic decisions should ideally be validated by reference immunoplatelet procedures.
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Affiliation(s)
- M Diquattro
- Laboratory Analysis ARNAS Civico, Palermo, Italy.
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Thomas-Kaskel AK, Mattern D, Köhler G, Finke J, Behringer D. Reticulated platelet counts correlate with treatment response in patients with idiopathic thrombocytopenic purpura and help identify the complex causes of thrombocytopenia in patients after allogeneic hematopoietic stem cell transplantation. CYTOMETRY PART B-CLINICAL CYTOMETRY 2007; 72:241-8. [PMID: 17266149 DOI: 10.1002/cyto.b.20163] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND In thrombocytopenic conditions of unknown origin, quantification of reticulated platelets (RP) in the peripheral blood by flow cytometry has been shown to differentiate increased platelet (Plt) turnover from insufficient Plt production. METHODS We used a whole blood flow cytometry method combining thiazole orange and anti-CD41a-staining to assess RP in 71 healthy subjects, six with thrombocytopenic myelodysplastic syndrome (MDS), nine with liver cirrhosis, 14 patients with idiopathic thrombocytopenic purpura (ITP), and 12 patients who had undergone hematopoietic stem cell transplantation (HSCT). RESULTS Patients with MDS had normal, patients with liver cirrhosis had slightly elevated RP counts compared to healthy subjects. ITP patients had elevated RP counts, and RP >15% were associated with treatment response (P = 0.015). In 7/10 patients after HSCT, an increase of RP preceded Plt recovery, whereas in patients with secondary thrombocytopenia after normal regeneration, the assessment of RP allowed the differentiation between conditions with high Plt turnover, such as GvHD and microangiopathy, indicated by high RP counts, and graft failure, indicated by low RP counts. CONCLUSIONS Our data provide the rationale for prospective studies on the diagnostic and prognostic value of RP counts in larger patient populations with ITP and after HSCT.
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