Aekaterini Sfiridaki

Mean Platelet Volume: A Useful Marker of Inflammatory Bowel Disease Activity

OBJECTIVES:We investigated whether the mean platelet volume would be a useful marker in the evaluation of inflammatory bowel disease activity.METHODS:Complete blood count, C-reactive protein, erythrocyte sedimentation rate, serum thrombopoietin and erythropoietin, plasma β-thromboglobulin, and platelet factor 4 were measured in 93 patients with ulcerative colitis, 66 patients with Crohns disease, and 38 healthy blood donors. Disease activity was assessed by the Clinical Colitis Activity Index in patients with ulcerative colitis and by the Crohns Disease Activity Index in patients with Crohns disease.RESULTS:Mean platelet count was increased in patients with active compared to inactive ulcerative colitis (p < 0.05), and in patients with active compared to inactive Crohns disease (p = 0.0002) or healthy controls (p < 0.0001). On the other hand, mean platelet volume was significantly decreased in patients with active compared to inactive ulcerative colitis (p = 0.02) or healthy controls (p < 0.0001), and in patients with active compared to inactive Crohns disease (p = 0.0005) or healthy controls (p < 0.0001). Mean platelet volume was inversely correlated with the white blood cell count (r =−0.17, p = 0.02), C-reactive protein (r =−0.46, p = 0.009) and erythrocyte sedimentation rate (r =−0.28, p = 0.008). No significant correlations were found between mean platelet volume and serum thrombopoietin or erythropoietin levels; however, a strong negative correlation between mean platelet volume and β-thromboglobulin (r =−0.34, p < 0.0001) and platelet factor 4 (r =−0.30, p = 0.0002) was observed.CONCLUSIONS:Mean platelet volume is significantly reduced in active inflammatory bowel disease and is negatively correlated with the known inflammatory bowel disease activity markers and the platelet activation products. We propose that mean platelet volume provides a useful marker of activity in inflammatory bowel disease.

Serum hepcidin and prohepcidin concentrations in inflammatory bowel disease.

Background Anemia is an important complication of inflammatory bowel disease (IBD). Recent data suggest that hepcidin is a major mediator of anemia with a central role in iron homeostasis and metabolism. The aim of this study was to evaluate the serum levels of hepcidin and its prohormone, prohepcidin, in patients with IBD in comparison with healthy controls. Methods One hundred patients with IBD [49 ulcerative colitis (UC), 51 Crohns disease (CD)] and 102 healthy controls were enrolled. Serum hepcidin and prohepcidin levels were measured by commercially available enzyme-linked immunosorbent assays kits. Their relationship with clinical and laboratory parameters of UC and CD was assessed. Results Median hepcidin levels were significantly higher in both patients with UC and patients with CD compared with healthy controls (P<0.0001). Median prohepcidin levels were significantly lower in patients with IBD compared with healthy controls (P=0.03). In the univariate analysis, serum hepcidin was significantly negatively correlated (r=−0.36, P=0.0003), whereas serum prohepcidin was positively correlated (r=0.65, P<0.0001) with the hemoglobin levels. Significant correlations of both hepcidin (r=0.34, P=0.0007) and prohepcidin (r=−0.21, P=0.04) with ferritin levels were found in patients with IBD. Serum hepcidin was also correlated with disease activity (for UC, r=0.36, P=0.009) and C-reactive protein (r=0.29, P=0.004). After multivariate analysis serum hepcidin levels remained significantly correlated with ferritin (P=0.0008) and disease activity (for UC, P=0.004). Conclusion Serum hepcidin and prohepcidin levels are significantly altered in patients with IBD compared with healthy controls. This finding suggests a substantial role of these two hormones in the development of anemia in IBD.

Association between enhanced soluble CD40 ligand and prothrombotic state in inflammatory bowel disease.

Background Inflammatory bowel disease is associated with an increased incidence of thromboembolic complications. The aim of this study was to investigate the role of the soluble CD40 ligand (sCD40L), which displays prothrombotic properties, in patients with ulcerative colitis (UC) and Crohns disease (CD) in comparison with inflammatory and healthy controls. Methods Plasma levels of sCD40L, prothrombin fragment 1+2 (F1+2), thrombin–antithrombin (TAT) complex and soluble P-selectin were measured in 104 inflammatory bowel disease patients (54 ulcerative colitis and 50 Crohns disease), in 18 cases with other causes of intestinal inflammation and in 80 healthy controls using commercially available enzyme-linked immunosorbent assays. Plasma levels of sCD40L were correlated with disease activity, type, localization and treatment as well as with the measured thrombophilic parameters. Results CD patients had significantly higher sCD40L levels than both groups of controls (CD vs HC P < 0.001; CD vs non-IBD P < 0.05). UC patients had higher but not significantly different sCD40L levels compared with the controls. Both UC and CD patients with active disease had significantly higher sCD40L levels in comparison with patients with inactive disease. Plasma levels of sCD40L were correlated with platelet count (r = 0.27, P = 0.001). They also showed a correlation with prothrombin F1+2 (r = 0.16, r = 0.03) and TAT (r = 0.15, r = 0.04) as well as with P-selectin (r = 0.19, P = 0.01). Conclusions The increased sCD40L plasma levels may represent, at least in some degree, a molecular link between inflammatory bowel disease and the procoagualant state.

Hypercoagulable states in patients with hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) patients have an increased risk for venous thromboembolism, mainly portal venous thrombosis (PVT). The aim of this study was to assess the role of acquired and hereditary thrombotic risk factors in HCC patients. Thirty-one patients with HCC, 30 patients with cirrhosis but without HCC or PVT, and 48 matched healthy controls were studied. Mean levels of plasma protein C, protein S, antithrombin, and serum lipoprotein (a) were significantly lower in patients with HCC and in the cirrhotic group compared to the healthy controls. Mean serum homocysteine levels were significantly higher in patients with HCC compared to cirrhotics and healthy controls. The prevalence of activated protein C resistance, factor V Leiden mutation, prothrombin gene mutation G20210GA, and C677T methylenetetrahydrofolate reductase polymorphism was not significantly different among the three groups. In conclusion, thrombophilic defects are common in HCC patients and they might contribute to the observed thrombotic complications in this malignancy.

Elevated thrombopoietin serum levels in patients with inflammatory bowel disease

OBJECTIVES:Elevated platelet count is a well recognized marker of inflammatory bowel disease (IBD) activity. Thrombopoietin (TPO) is a critical cytokine in the physiological regulation of thrombopoiesis. The aim of this study was to investigate the serum levels of endogenous TPO in patients with IBD, the relationship between platelet counts and TPO levels, and the correlation of TPO with the clinical characteristics of the patients.METHODS:TPO levels in 40 patients with Crohns disease (CD), 63 patients with ulcerative colitis (UC), and in 42 healthy blood donors were assessed by ELISA. Platelet and white blood cell counts as well as C-reactive protein, and erythrocyte sedimentation rate were measured.RESULTS:TPO levels were significantly elevated in patients with CD (mean 124.3 ± SD 58.0 pg/ml, p < 0.0001) and in patients with UC (mean 152.2 ± SD 142.3 pg/ml, p < 0.0001), compared to controls (mean 53.4 ± SD 45.7 pg/ml). TPO levels remained significantly elevated in remission (mean 144.7 ± SD 131.1 pg/ml, p < 0.0001 compared to controls). Platelets were significantly elevated only in active CD, being normal in inactive disease as well as in all patients with UC. There was no significant correlation between TPO levels and various clinical characteristics of patients with IBD. No significant correlation was found between TPO levels and either platelet counts or white blood cell counts, erythrocyte sedimentation rate, and C-reactive protein.CONCLUSIONS:TPO levels are increased in IBD, irrespective of disease activity, platelet counts, and clinical characteristics of the patients. These observations indicate that TPO, apart from being a platelet producer, might have additional functions, probably related to the procoagulant state of IBD.

Plasma thrombin-activatable fibrinolysis inhibitor and plasminogen activator inhibitor-1 levels in inflammatory bowel disease.

Background Patients with inflammatory bowel disease (IBD) have an increased risk of thromboembolic events. Imbalance of fibrinolysis has been suggested as one of the possible pathogenetic mechanisms. As plasminogen activator inhibitor-1 (PAI-1) and thrombin-activatable fibrinolysis inhibitor (TAFI) are inhibitors of fibrinolysis, we studied TAFI as well as PAI-1 plasma levels in IBD patients compared with healthy controls. Methods A total of 132 IBD patients [68 ulcerative colitis (UC) and 64 Crohns disease (CD)] and 50 healthy controls were enrolled. PAI-1 and TAFI plasma levels were assessed by commercially available enzyme-linked immunosorbent assay kits. Their relationship with clinical parameters of UC and CD was assessed. Results Mean plasma PAI-1 levels were significantly higher in both UC patients (3.9±1.3 IU/ml) and CD patients (4.0±1.5 IU/ml) compared with healthy controls (3.1±1.1 IU/ml) (P=0.01). On the other hand, mean plasma TAFI levels were significantly lower in both UC patients (14.7±3.1 μg/ml) and CD patients (13.3±3.4 μg/ml) compared with healthy controls (17.4±3.0 μg/ml) (P<0.0001). Patients with active disease had significantly higher PAI-1 levels compared with patients with inactive disease for both diseases (P=0.03 and P=0.01, respectively). No significant association between plasma TAFI levels and disease activity was also found. Plasma TAFI levels were significantly lower in patients with ileal CD compared with patients with colonic CD. Conclusion PAI-1 plasma levels are increased whereas TAFI levels are decreased in IBD patients. These results suggest an imbalance of fibrinolysis in IBD.

Association between thrombocytosis and iron deficiency anemia in inflammatory bowel disease.

Background Thrombocytosis and iron deficiency anemia are frequent complications of inflammatory bowel disease (IBD). The aim of this study was to investigate the correlation between iron deficiency anemia and thrombocytosis in IBD patients. Methods A total of 198 consecutive IBD patients and 102 healthy controls participated in the study. The parameters investigated were: platelets (PLT), mean platelet volume, platelet distribution width, plateletcrit, hematocrit (HCT) levels, hemoglobulin (Hb) levels, mean corpuscular volume (MCV), red cell distribution width (RDW), ferritin levels, soluble transferrin receptor (sTfR) levels, the sTfR-F index (sTfR-F=sTfR/log10 ferritin), and vitamin B12 and folate levels. Thrombocytosis was defined as an absolute number of PLT greater than 400k/&mgr;l. Disease activity indices (Crohn’s Disease Activity Index for Crohn’s disease and Simple Clinical Colitis Activity Index for ulcerative colitis) as well as C-reactive protein (CRP) were also correlated with the study parameters. Results The IBD patients demonstrated decreased HCT levels, Hb levels, MCV, mean platelet volume, and ferritin levels and an increased absolute PLT count, RDW, platelet distribution width, plateletcrit, sTfR and sTfR-F index (P<0.0001) compared with healthy controls. Twenty-seven patients exhibited thrombocytosis (13.6%). The median value for PLT (interquartile range) was 289 (228–355)k/&mgr;l, for Hb levels was 13.4 (12.0–14.7) g/dl, for ferritin levels was 36.6 (19.7–80.7) ng/ml, and for sTfR-F was 0.82 (0.61–1.37) mg/l. The PLT in IBD patients correlated with HCT levels, Hb levels, MCV, RDW, Fe levels, ferritin levels, sTfR, sTfR-F, CRP levels, Simple Clinical Colitis Activity Index, and Crohn’s Disease Activity Index (Spearman’s &rgr; correlation). In the multivariate analysis, only Hb levels, RDW, CRP levels, ferritin levels, and sTfR-F remained significant (P<0.05). None of the aforementioned was observed in the control group. Conclusion The absolute PLT count seems to correlate with iron deficiency anemia parameters and disease activity in IBD patients. Controlling the inflammation and managing iron deficiency could lead to reversal of thrombocytosis in IBD patients.

Low Plasma Protein Z Levels in Patients with Ischemic Colitis

Hypercoagulable states have been suggested to play an important role in the pathogenesis of ischemic colitis. Since protein Z is, as recently demonstrated, important in the regulation of coagulation, we investigated the plasma levels of protein Z in connection to factor V Leiden (FVL) anti-phospholipid antibodies in patients with a definite diagnosis of ischemic colitis. The plasma levels of protein Z were measured using a commercially available enzyme-linked immunosorbent assay in 33 patients with ischemic colitis, 13 patients with diverticulitis, and 33 healthy controls. Mean plasma protein Z levels were 1.38 ± 0.52 μg/ml in patients with ischemic colitis and were significantly lower compared to healthy controls (1.86± 0.49 μg/ml) patients with diverticulitis (1.72 ± 0.53 μg/ml) (P = 0.001). Protein Z deficiency was found in patients cases with ischemic colitis (18.2%) compared to one with diverticulitis (7.7%) one healthy control (3.0%). In conclusion, our results suggest that low plasma protein Z levels may play a role in the disease development in some cases with ischemic colitis.

Acquired and hereditary thrombotic risk factors in patients with acute mesenteric vein thrombosis

Acquired and hereditary thrombotic risk factors in patients with acute mesenteric vein thrombosis

The Janus tyrosine kinase-2 V617F mutation is not implicated in the pathogenesis of ischemic colitis in young patients.

To the Editor: An acquired single nucleotide mutation affecting the Janus tyrosine kinase-2 (JAK2) V617F was first identified in 2005 in patients suffering from polycythemia vera.1 This mutation occurs in the autoinhibitory JH2 domain of JAK2 in hematopoietic cells leading to constitutive activation of proliferative signaling pathways, hypersensitivity to cytokines, uncontrolled proliferation of hematopoietic precursors, and eventually the development of myeloproliferative neoplasms (MPN). JAK2 mutations are found in almost all patients with polycythemia vera and in approximately 50% of patients with essential thrombocythemia and primary myelofibrosis.2 A common feature shared among the MPNs is the significant risk of thrombotic complications, which may be linked to the presence of JAK2 mutation.3 Moreover, the JAK2 V617F mutation has been associated with splanchnic vein thrombosis, cerebral thrombosis,4 and portal vein thrombosis5 in the absence of overt MPN. Ischemic colitis (IC) is the most common form of ischemic injury of the gastrointestinal tract and can present as an occlusive or nonocclusive form. The etiology of IC is multifactorial and the pathogenesis not fully understood. A plethora of conditions may predispose to the disease such as shock, colon cancer, or after surgery to the aorta or mesenteric vessels. Nevertheless, IC may spontaneously appear in apparently healthy individuals. Recently, a state of increased coagulability has been raised as a significant factor in the pathogenesis of IC, especially in young patients without any other predisposing illnesses. The most significant associations were found with the presence of antiphosopholipid antibodies, factor V R506Q (Leiden),6,7 plasminogen activator inhibitor gene polymorphisms,8 and protein Z deficiency.9 Moreover, the thrombophilic tendency may develop as a result of interaction between multiple genes and acquired factors. The aim of our study was to investigate the incidence and possible role of JAK2 V617F mutation in a group of 29 patients with nonocclusive IC, aged 55 years or younger, who were nonsurgically treated at 2 hospitals (Venizelion General Hospital and University Hospital of Heraklion). The clinical characteristics of the patients with IC are presented in Table 1. Disease subtypes were characterized according to the classification of Brandt and Boley (Table 2). No patient had overt MPN. The diagnosis of definitive IC was based on established clinical, endoscopic, and histologic criteria.6 Twenty sex-matched and age-matched healthy individuals were used as controls. Genomic DNA was extracted from whole blood and stored at 801C until analysis. For screening and quantification of JAK2 V617F mutation, we used a quantitative polymerase chain reaction based on the principle of double-dye hydrolysis oligonucleotide probes (JAK2 MutaQuant, Ipsogen, Marseille, France) on an ABI Prism 7500 analyzer. The JAK2 V617F mutation was found in only 1 of the 29 patients with IC and in 1 among 20 healthy controls (P=NS). Hypercoagulable states have been proposed to be involved in the pathogenesis of IC. However, their role remains under investigation. Arrhythmia and embolic conditions have been found in IC patients. Oral contraceptives, antiphospholipid antibodies, cocaine, and other medications may play a role. An inherited predisposition owing to 1 or more genes and an interaction between TABLE 1. Four Patients With Negative Seroconversion, But Subsequent Seropositivity and Small Bowel Villous Atrophy; Data Originally Published by Kurppa et al2