Aurelio Santos

Detection of a Platelet-Agglutinating Factor in Thrombotic Thrombocytopenic Purpura

A sensitive and specific test was used to identify a platelet-agglutinating factor in sera from patients with thrombotic thrombocytopenic purpura. Serum from patients plus a preparation rich in large multimers of factor VIII: von Willebrand factor were added to target platelets, and agglutination occurred in 41 of 48 samples. Edetic acid, heparin, or heating, but not aspirin, monomeric IgG, or dansylarginine N-(3-ethyl-1,5-pentanediyl)amide inhibited the platelet-agglutinating factor. In-vitro agglutination requires the presence of a platelet-agglutinating factor and large multimers of von Willebrand factor. High concentrations of either component lowers the amount of the other required for platelet agglutination. Some patients may be more susceptible to the agglutinating factor because of a congenital or acquired abnormality in processing unusually large multimers of von Willebrand factor or because of infections or inflammatory disorders that lead to increased synthesis of large multimers of von Willebrand factor.

A prospective comparison of four techniques for measuring platelet-associated IgG.

We describe a prospective study comparing four different assays for PAIgG. Platelets from patients with a variety of thrombocytopenic disorders were collected into ACD, washed, and the PAIgG then measured using three assays for surface PAIgG. These included: (a) a direct binding assay using 125I‐monoclonal anti‐IgG (MoAb); (b) a direct binding assay using 125I‐staphylococcal protein A (SPA); and (c) a two‐stage assay. PAIgG also was measured using an assay for ‘total’ PAIgG following platelet lysis. The mean ± SD number of molecules of IgG per platelet on washed platelets from 29 healthy, non‐thrombocytopenic controls was: 86 ± 80 (125I‐MoAb); 94 ± 96 (125I‐SPA); 3520 ± 1890 (two‐stage surface assay); and 10 850 ± 3720 (total PAIgG). A total of 62 different patients with idiopathic thrombocytopenic purpura or thrombocytopenia complicating systematic lupus erythematosus, and 73 different patients with‘non‐immune’ thrombocytopenia, were tested using each of the four assays. These ‘non‐immune’ thrombocytopenic patients included patients with carcinoma, septicaemia, pre‐eclampsia, chronic leukaemia, thrombotic thrombocytopenic purpura, haemolytic uraemic syndrome, acute leukaemia and myelodysplasia. All four essays gave similar results for both the immune and non‐immune thrombocytopenic patients. The sensitivity of the assays for the most severely thrombocytopenic patients with immune thrombocytopenia was: MoAb 60%; SPA 88%; two‐stage 82%; and‘total’ PAIgG 88%. The specificity of the four assays in the non‐immune thrombocytopenic patients was 57%‘total’ PAIgG; 63% two‐stage surface; 25% SPA; 38% MoAb. There was no quantitative cut‐off point that could be used to segregate the non‐immune thrombocytopenic patients from the immune thrombocytopenic patients. These results indicate that all of these assays share a similar high sensitivity but low specificity for ITP.

Combination immunosuppressant therapy for patients with chronic refractory immune thrombocytopenic purpura

Treatment options for patients with chronic refractory immune thrombocytopenic purpura (ITP) are limited. Because combination immunosuppressant therapy appeared to be effective in ITP and other disorders, we used this approach in patients with particularly severe and refractory ITP. In this retrospective, observational study, we determined the response (platelet count above 30 x 10(9)/L and doubling of baseline) among 19 refractory ITP patients. Treatment consisted of azathioprine, mycophenolate mofetil, and cyclosporine. The patients had failed a median of 6 prior treatments, including splenectomy (in all except 1). Of 19 patients, 14 (73.7%) achieved a response lasting a median of 24 months, after which time 8 (57.1%) relapsed. Of the 8 relapsing patients, 6 responded to additional treatments. Of the 14 patients who achieved an initial response, 2 (14.3%) remained in remission after eventually stopping all medications. Severe adverse events did not occur. Combination immunosuppressant therapy can produce a rise in the platelet count that is sometimes sustained in refractory ITP patients.

Analyses of cellular multimerin 1 receptors: in vitro evidence of binding mediated by αIibβ3 and αvβ3

Multimerin 1 (MMRN1) is a large, soluble, polymeric, factor V binding protein and member of the EMILIN protein family. In vivo, MMRN1 is found in platelets, megakaryocytes, endothelium and extracellular matrix fibers, but not in plasma. To address the mechanism of MMRN1 binding to activated platelets and endothelial cells, we investigated the identity of the major MMRN1 receptors on these cells using wild-type and RGE-forms of recombinant MMRN1.Ligand capture,cell adhesion,ELISA and flow cytometry analyses of platelet-MMRN1 binding, indicated that MMRN1 binds to integrins αIibβ 3 and αvβ3. Endothelial cell binding to MMRN1 was predominantly mediated by αvβ3 and did not require the MMRN1 RGD site or cellular activation.Like many other αvβ3 ligands, MMRN1 had the ability to support adhesion of additional cell types, including stimulated neutrophils. Expression studies, using a cell line capable of endothelial-like MMRN1 processing, indicated that MMRN1 adhesion to cellular receptors enhanced its extracellular matrix fiber assembly. These studies implicate integrin-mediated binding in MMRN1 attachment to cells and indicate that MMRN1 is a ligand for aIibβ 3 and αvβ3.

The interaction of ancrod with human platelets

Ancrod, a serine protease purified from the venom of Agkistrodon rhodostoma, has been used as a therapeutic anticoagulant for a number of indications, including replacement of heparin in patients with heparin-induced thrombocytopenia. Ancrod has similar fibrinolytic activity to thrombin, but ancrod specifically cleaves only the alpha chain of fibrinogen, producing the characteristic fibrinopeptides A, AP and AY. Because ancrod has been used in patients with heparin-induced thrombocytopenia, it is important to ensure that ancrod does not directly affect the platelets and potentially increase the hemostatic effect. The effect of ancrod on platelets has not been well established, and there is not agreement in published studies. Additionally, some of the studies are over 15 years old and pre-date sensitive assays such as glycoprotein analysis. For these reasons, we investigated the interaction of ancrod with human platelets using direct and indirect, functional and biochemical techniques. Incubation of platelets with ancrod alone did not induce platelet aggregation or the release of dense-granule contents. Pre-incubation of platelets with ancrod did not augment or inhibit the maximal aggregation achieved with thrombin, nor did it affect the amount of serotonin release from dense granules caused by activation by thrombin. Studies of ancrod-treated platelets using monoclonal antibody-mediated radioimmunoprecipitation demonstrated that high concentrations of ancrod did not cause measurable cleavage of either the glycoproteins Ib-IX or IIb-IIIa. Incubation of radiolabeled platelets with ancrod-treated plasma also had no effect on the platelet glycoproteins, indicating that ancrod does not indirectly affect the major surface receptors. Direct binding studies using radiolabeled ancrod did not demonstrate specific binding to the platelet surface. Together these studies indicate that ancrod does not directly affect nor bind to platelets in vitro. The hypo-coagulant state and subsequent platelet function defect resulting from the use of ancrod appears to be limited to the removal of fibrinogen from the circulation.