Interleukin-37 reduces inflammation and impairs phagocytosis of platelets in immune thrombocytopenia (ITP).

Immune thrombocytopenia (ITP) is an autoimmune disease characterized by low platelet count with heterogeneous bleeding manifestations. Severe bleeding in ITP is not completely related with low platelet count. Fcγ receptor (FcγR)-mediated platelet destruction is one of the major mechanisms of ITP. Interleukin-37 (IL-37) is a fundamental natural suppressor of innate immunity and inflammatory responses in several autoimmune diseases. However, the role of IL-37 in the pathogenesis of ITP is unknown. In the present study, we identified that IL-37 expression was elevated in ITP patients, which was correlated with platelet count and the severity of bleeding in ITP, indicating that IL-37 could be a candidate in evaluating disease severity of ITP. In the in vitro study, IL-37 initiated an anti-inflammatory effect on monocytes/macrophages from ITP patients by down-regulating the phosphorylation of MAPK, AKT, and NF-κB signaling pathways. Moreover, IL-37 restored the balance of activating and inhibitory FcγRs and decreased antibody-mediated platelet phagocytosis by monocytes/macrophages. Our findings suggest that IL-37 may be a promising indicator of the disease severity and supplementation of IL-37 may be therapeutically beneficial for ITP patients.

High-dose dexamethasone vs prednisone for treatment of adult immune thrombocytopenia: a prospective multicenter randomized trial.

This study compared the efficacy and safety of high-dose dexamethasone (HD-DXM) and conventional prednisone (PDN) on the largest cohort to date as first-line strategies for newly diagnosed adult primary immune thrombocytopenia (ITP). Patients enrolled were randomized to receive DXM 40 mg/d for 4 days (n = 95, nonresponders received an additional 4-day course of DXM) or prednisone 1.0 mg/kg daily for 4 weeks and then tapered (n = 97). One or 2 courses of HD-DXM resulted in a higher incidence of overall initial response (82.1% vs 67.4%, P = .044) and complete response (50.5% vs 26.8%, P = .001) compared with prednisone. Time to response was shorter in the HD-DXM arm (P < .001), and a baseline bleeding score ≥8 was associated with a decreased likelihood of initial response. Sustained response was achieved by 40.0% of patients in the HD-DXM arm and 41.2% in the PDN arm (P = .884). Initial complete response was a positive indicator of sustained response, whereas presence of antiplatelet autoantibodies was a negative indicator. HD-DXM was generally tolerated better. We concluded that HD-DXM could be a preferred corticosteroid strategy for first-line management of adult primary ITP. This study is registered at www.clinicaltrials.gov as #NCT01356511.

Efficacy and safety of treatments in newly diagnosed adult primary immune thrombocytopenia: A systematic review and network meta-analysis.

Background: Immune thrombocytopenia is an autoimmune disease characterised by decreased platelet count. In recent years, novel therapeutic regimens have been investigated in randomised controlled trials (RCTs). We aimed to compare the efficacy and safety of different treatments in newly diagnosed adult primary immune thrombocytopenia. Methods: We did a systematic review and network meta-analysis of RCTs involving treatments for newly diagnosed primary immune thrombocytopenia. PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched up to April 31, 2022. The primary outcomes were 6-month sustained response and early response. Secondary outcome was grade 3 or higher adverse events. This study is registered with PROSPERO (CRD42022296179). Findings: Eighteen RCTs (n = 1944) were included in this study. Pairwise meta-analysis showed that the percentage of patients achieving early response was higher in the dexamethasone-containing doublet group than in the dexamethasone group (79.7% vs 68.7%, odds ratio [OR] 1.82, 95% CI 1.10-3.02). The difference was more profound for sustained response (60.5% vs 37.4%, OR 2.57, 95% CI 1.95-3.40). Network meta-analysis showed that dexamethasone plus recombinant human thrombopoietin ranked first for early response, followed by dexamethasone plus oseltamivir or tacrolimus. Rituximab plus prednisolone achieved highest sustained response, followed by dexamethasone plus all-trans retinoic acid or rituximab. Rituximab plus dexamethasone showed 15.3% of grade 3 or higher adverse events, followed by prednis(ol)one (4.8%) and all-trans retinoic acid plus dexamethasone (4.7%). Interpretation: Our findings suggested that compared with monotherapy dexamethasone or prednis(ol)one, the combined regimens had better early and sustained responses. rhTPO plus dexamethasone ranked top in early response, while rituximab plus corticosteroids obtained the best sustained response, but with more adverse events. Adding oseltamivir, all-trans retinoic acid or tacrolimus to dexamethasone reached equally encouraging sustained response, without compromising safety profile. Although this network meta-analysis compared all the therapeutic regimens up to date, more head-to-head RCTs with larger sample size are warranted to make direct comparison among these strategies. Funding: National Natural Science Foundation of China, Major Research Plan of National Natural Science Foundation of China, Shandong Provincial Natural Science Foundation and Young Taishan Scholar Foundation of Shandong Province.

The effects of BAFF and BAFF-R-Fc fusion protein in immune thrombocytopenia.

Elevated level of B-cell activating factor (BAFF) has been implicated in the pathogenesis of some autoimmune diseases. Blockade of receptor and ligand binding by decoy receptor has demonstrated a clinical benefit in both oncologic and immunologic diseases. In this report, we have detected plasma BAFF and BAFF mRNA expression in immune thrombocytopenia (ITP) patients by enzyme-linked immunosorbent assay (ELISA) and real-time quantitative reverse-transcription polymerase chain reaction (RT-PCR). The effects of recombinant human BAFF (rhBAFF) and BAFF-R-Fc fusion protein (BR3-Fc) on B cells, T cells, platelets, secretion of interferon gamma (IFNgamma), and interleukin-4 (IL-4) were measured by flow cytometry and ELISA. Patients with active disease had higher levels of plasma BAFF and BAFF mRNA than patients in remission and controls. In in vitro assays, rhBAFF promoted the survival of CD19(+) and CD8(+) cells, and increased the apoptosis of platelets and the secretion of IFN-gamma. BR3-Fc successfully corrected the effects of rhBAFF on lymphocytes, platelets, and cytokines. These findings suggest that BAFF may play a pathogenic role in ITP by promoting the survival of CD19(+) and CD8(+) cells, and increasing the apoptosis of platelets and the secretion of IFN-gamma. Blockade of BAFF by BR3-Fc might be a promising therapeutic approach for ITP.

Determination of platelet-bound glycoprotein-specific autoantibodies by flow cytometric immunobead assay in primary immune thrombocytopenia.

OBJECTIVES: Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by premature platelet destruction induced by autoantibodies directed against platelet glycoproteins (GPs). Despite being a clinically important disorder, ITP lacks a feasible diagnostic assay for routine clinical use. This study was meant to evaluate a newly developed flow cytometric immunobead assay for determination of platelet-bound GP-specific autoantibodies in comparison with indirect monoclonal antibody-specific immobilization of platelet antigen (MAIPA) in the diagnosis of ITP. METHODS: Platelet-bound and plasma GPIIb/IIIa and GPIb/IX autoantibodies were determined by flow cytometric immunobead assay and indirect modified MAIPA, respectively. The average fluorescence level for platelet-bound, GP-specific autoantibodies was given as a ratio to three normal controls tested simultaneously. RESULTS: The median value of platelet-bound GPIIb/IIIa and GPIb/IX autoantibodies in ITP group were 3.09 (range 0.78, 30.2) and 3.09 (range 0.72, 19.2), respectively, which were significantly higher than non-ITP group [1.01 (0.67, 5.59) and 1.01 (0.79, 5.56), respectively, P<0.001] and normal controls [1.02 (0.72, 1.76) and 1.03 (0.79, 1.73), respectively, P<0.001]. The receiver-operating characteristics curve analysis showed an area under the curve of 0.895 for GPIIb/IIIa autoantibody and 0.859 for GPIb/IX autoantibody, respectively. Combined detection of GPIIb/IIIa or GPIb/IX autoantibodies by flow cytometric immunobead assay showed a sensitivity of 82.11% for ITP diagnosis. CONCLUSION: This study demonstrated that determination of platelet-bound, GP-specific autoantibodies by flow cytometric immunobead assay was a convenient, sensitive, and specific test for the differential diagnosis of thrombocytopenic patients.

Tumor Necrosis Factor-α Blockade Corrects Monocyte/Macrophage Imbalance in Primary Immune Thrombocytopenia.

Primary immune thrombocytopenia (ITP) is an acquired autoimmune bleeding disorder. Monocytes and macrophages are the major cells involved in autoantibody-mediated platelet clearance in ITP. In the present study, we found increased percentages of peripheral blood proinflammatory CD16+ monocytes and elevated frequencies of splenic tumor necrosis factor-α (TNF-α)-expressing macrophages in ITP patients compared with healthy controls. Concurrently, we observed elevated TNF-α secretion in plasma as well as higher TNF-α mRNA expression in total peripheral blood mononuclear cells and CD14+ monocytes of ITP patients. Of note, in vitro TNF-α blockade with neutralizing antibody remarkably reduced polarization to M1 macrophages by inhibiting the nuclear factor kappa B (NF-κB) signaling pathway. Moreover, TNF-α blockade dampened macrophage phagocytosis and T cell stimulatory capacity. Finally, in passive and active murine models of ITP, anti-TNF-α therapy reduced the number of nonclassical monocytes and M1 macrophages, ameliorated the retention of platelets in spleen and liver, and increased the platelet count of ITP mice. Taken together, TNF-α blockade decreased the number and function of proinflammatory subsets of monocytes and macrophages by inhibiting the NF-κB signaling pathway, leading to remarkable attenuation of antibody-mediated platelet destruction. Thus, TNF-α blockade may be a promising therapeutic strategy for the management of ITP.

Abnormalities of bone marrow B cells and plasma cells in primary immune thrombocytopenia.

Primary immune thrombocytopenia (ITP) is an autoantibody-mediated hemorrhagic disorder in which B cells play an essential role. Previous studies have focused on peripheral blood (PB), but B cells in bone marrow (BM) have not been well characterized. We aimed to explore the profile of B-cell subsets and their cytokine environments in the BM of patients with ITP to further clarify the pathogenesis of the disease. B-cell subpopulations and their cytokine/chemokine receptors were detected by using flow cytometry. Plasma concentrations of cytokines/chemokines were measured by using enzyme-linked immunosorbent assay. Messenger RNA levels of B cell-related transcription factors were determined by using quantitative polymerase chain reaction. Regulatory B cell (Breg) function was assessed by quantifying their inhibitory effects on monocytes and T cells in vitro. Decreased proportions of total B cells, naive B cells, and defective Bregs were observed in patients with ITP compared with healthy controls (HCs), whereas an elevated frequency of long-lived plasma cells was found in BM of autoantibody-positive patients. No statistical difference was observed in plasmablasts or in short-lived plasma cells between patients with ITP and HCs. The immunosuppressive capacity of BM Bregs from patients with ITP was considerably weaker than HCs. An in vivo study using an active ITP murine model revealed that Breg transfusion could significantly alleviate thrombocytopenia. Moreover, overactivation of CXCL13-CXCR5 and BAFF/APRIL systems were found in ITP patient BM. Taken together, B-cell subsets in BM were skewed toward a proinflammatory profile in patients with ITP, suggesting the involvement of dysregulated BM B cells in the development of the disease.

[Expression of interleukin-18 and interleukin-18 receptor alpha chain of the peripheral white blood cells in immune thrombocytopenia].

OBJECTIVE: To detect the expression of interleukin (IL)-18 of the peripheral blood cells and IL-18 receptor alpha chain (IL-18Ralpha) on the surface of CD(3)(+) cells in patients newly diagnosed as immune thrombocytopenia (ITP) before medication and to explore the roles of IL-18 and IL-18Ralpha in the development of ITP. METHODS: Eighteen out-patients or inpatients with acute ITP accepting treatment in Qilu Hospital were enrolled in this study and 15 matching healthy subjects were taken as control. Plasma IL-18 level was detected with enzyme linked immunosorbent assay (ELISA), the expression of IL-18Ralpha on CD(3)(+) lymphocytes and total lymphocytes were measured with flow cytometry;T-bet and GATA-3 mRNA were measured with reverse transcriptase polymerase chain reaction (RT-PCR). RESULTS: The expression of IL-18 in acute ITP plasma was (468.57 + or - 141.62) ng/L and IL-18Ralpha on the surface of CD(3)(+) cells and lymphocytes were (8.50 + or - 3.16)% and (9.16 + or - 2.98)% respectively. The levels of IL-18 and IL-18Ralpha were increased in active ITP patients as compared with those in the controls (P < 0.05). The levels of IL-18 mRNA (0.12 + or - 0.02) and T-bet mRNA (0.07 + or - 0.02) were significantly increased in patients with active ITP as compared with those in the controls (P < 0.05), while GATA-3 mRNA (0.0039 + or - 0.0014) were significantly decreased in patients with active ITP (P < 0.05). The balance between T-bet and GATA-3 was significantly disturbed in ITP. CONCLUSIONS: Through the variation of the levels of gene and protein, our study showed that IL-18 and IL-18Ralpha might upregulate the expression of Th1-cytokines in ITP patients. It is also suggested that IL-18 has potential association with the development of ITP. Especially, it may provide a new treatment method for ITP by regulating the ratio of T-bet and GATA-3 and resuming the balance of Th1/Th2.

The different effects of indirubin on effector and CD4+CD25+ regulatory T cells in mice: potential implication for the treatment of autoimmune diseases.

CD4(+)CD25(+) regulatory T (Treg) cells play an essential role in the induction and maintenance of peripheral self-tolerance. Indirubin, a traditional Chinese medicine, was clinically used in the treatment of chronic myelocytic leukemia as well as some autoimmune diseases, including Alzheimer's disease, diabetes, and so on. The effects of indirubin on CD4(+)CD25(+)Treg cells, which play a critical role in controlling autoimmunity, have not been addressed. In the present study, we observed the cell levels, phenotypes, and immunoregulatory function of CD4(+)CD25(+)Treg cells in indirubin-treated mice. Treatment with indirubin significantly enhanced the ratios of CD4(+)CD25(+)Treg cells or CD4(+)CD25(+)Foxp3(+)Treg cells to CD4(+)T cells in peripheral blood, lymph nodes, and spleens (P < 0.01 compared with control mice). CD4(+)CD25(+)Foxp3(+)Treg cells to CD4 single positive cells in the thymi of indirubin-treated mice were significantly higher than those in control mice. Furthermore, splenic CD4(+)CD25(+)Treg cells in indirubin-treated mice showed immunosuppressive ability on the immune response of T effector cells to alloantigens or mitogen as efficiently as the control CD4(+)CD25(+)Treg cells in vitro. The present studies indicate that CD4(+)CD25(+)Treg cells are more resistant to indirubin than effector T cells in vivo. The selectively enhanced CD4(+)CD25(+)Treg cell levels by indirubin made host to be more favorable for immune tolerance induction, which opened one possibility for indirubin to treat autoimmune diseases.

Broadband unidirectional behavior of electromagnetic waves based on transformation optics.

High directive antennas are fundamental elements for microwave communication and information processing. Here, inspired by the method of transformation optics, we propose and demonstrate a transformation medium to control the transmission path of a point source, resulting in the unidirectional behavior of electromagnetic waves (directional emitter) without any reflectors. The network of inductor-capacitor transmission lines is designed to experimentally realize the transformation medium. Furthermore, the designed device can work in a broadband frequency range. The unidirectional-manner-based device demonstrated in this work will be an important step forward in developing a new type of directive antennas.

Identification of human platelet glycoprotein VI-specific IgG autoantibody and its fragments.

Glycoprotein VI (GPVI), as a major receptor for collagen on the platelet surface, mediates the initial platelet contact with collagen, and causes platelet aggregation and thrombosis. Agents of anti-GPVI can inhibit the adhesion, activation and aggregation function of platelets, which can be used for preventing thrombotic diseases. To make humanized monoclonal antibodies by phage surface display technology, we studied plasmas from 44 patients with chronic idiopathic thrombocytopenic purpura using modified monoclonal antibody immobilization of platelet antigen assays. GPVI-specific antibodies were found in six (13.6%) patients. Among these, only one showed significant inhibition of platelet aggregation induced by collagen. The IgG antibody and F(ab')2 fragments of this patient's plasma were further purified and their immunoreactivities and effects on platelet aggregation were reanalyzed. It was found that purified IgG and its F(ab')2 fragments from the patient not only retained the ability to bind to platelet GPVI, but also inhibited collagen-induced platelet aggregation. In this study, therefore, the specific anti-platelet GPVI autoantibody that inhibits collagen-induced platelet aggregation has been successfully screened out, which can be used to develop completely humanized anti-GPVI phage antibody.

Study of a humanized inhibitory anti-platelet glycoprotein VI phage antibody from a phage antibody library.

Objective The aims of the study were to study the effect of anti-platelet glycoprotein (GP) VI auto-antibodies on platelet aggregation and use phage surface display technology to produce anti-platelet GPVI phage antibody fragment, which may be developed to inhibit platelet aggregation in the treatment of cardiovascular disease. Methods Plasma samples from patients with immune thrombocytopenia (ITP) were screened by monoclonal antibody immobilization of the platelet antigen assay and the platelet aggregation test for anti-platelet GPVI auto-antibody with an inhibitory effect. The humanized anti-platelet GPVI phage antibody was produced by phage surface display technology. The function of the phage antibody fragment against platelet aggregation was examined by the platelet aggregation test. Results Of 726 ITP patients, 2 (0.27%) patients' plasma significantly inhibited platelet aggregation induced by collagen-1. After five rounds of selection, enrichment, and purification, a soluble phage antibody fragment was produced, which can inhibit platelet aggregation induced by collagen-1. The results demonstrate that only a few of the screened anti-platelet GPVI auto-antibodies showed an inhibitory effect on platelet aggregation. Discussion A completely humanized anti-GPVI soluble phage antibody can be produced by phage surface display technology. The antibody was able to specifically block collagen-induced platelet aggregation without influencing the aggregation responses to other agonists. Conclusions Results of the present study suggest that very few anti-platelet GPVI auto-antibodies inhibit the aggregation function of platelet. The humanized anti-platelet GPVI produced by phage surface display technology is promising to be used to inhibit platelet aggregation in the treatment of cardiovascular disease.

A series of Keggin-based compounds constructed by conjugate ring-rich pyrazine and quinoxaline derivatives.

Through the use of conjugate ring-rich pyrazine and quinoxaline derivatives, five new Keggin polymolybdate based compounds, [Ag(I)3L(1)2(H2O)2(PMo12O40)] (1), [Ag(I)4L(1)5(SiMo12O40)] (2), [Ag(I)6L(2)6(PMo12O40)2] (3), [Ag(I)2L(2)2(C16H36N)2](SiMo12O40)] (4), [Cu(I)3L(2)3(PMo12O40)] (5) (L(1) = 2,3-diphenylpyrazine, L(2) = 2,3-diphenylquinoxaline, C16H36N = tetrabutylammonium), were synthesized under hydrothermal conditions and characterized by single-crystal X-ray diffraction. In compound 1, three Ag(I) ions are fused by two L(1) molecules to form a [Ag3L(1)2](3+) subunit, and these subunits link the PMo12 anions to construct two kinds of 1D chains (I and II). Chains I and II connect to each other by sharing the same PMo12 anions and a 2D grid-like layer is built. The asymmetric unit of compound 2 is linked to form a dimer by sharing Ag ions, and a 1D double strand is formed. The SiMo12 anions connect adjacent 1D double strands through Ag3-O23 bonds and a 2D network is built. In compound 3, there exists a 1D ladder-like double chain with PMo12 anions as linking bars. A 2D layer is formed by linkage Ag2-O24 between adjacent chains. In compound 4, the PMo12 anions act as inorganic linkages to connect adjacent zigzag chains through Ag1-O3 bonds to construct a 2D grid-like layer. In compound 5 two Cu(I)-L(2) lines are fused by PMo12 anions to build a 1D ladder-like chain. Additionally, the electrochemical and photocatalytic properties of the title compounds have been studied.

[Construction and clinical applications of a humanized phage library of platelet GPIIb/IIIa single chain Fv antibody].

OBJECTIVE: To screen out the anti-platelet GPIIb/IIIa autoantibody which can inhibit with aggregation function of platelet and construct a humanized anti-platelet GPIIb/IIIa single chain Fv library by phage surface display technology. METHODS: Idiopathic thrombocytopenic purpura (ITP) patients whose plasma contains anti-platelet GPIIb/IIIa autoantibodies were screened out. The antibodies can inhibit the aggregation function of platelet by using MAIPA assay and platelet aggregation test. The heavy chain and light chain variable region genes of human immunoglobulin were amplified by RT-PCR from peripheral blood lymphocytes mRNA of the patients screened out and randomly combined through a DNA linker encoding the peptide (Gly(4)Ser)(3) to construct single chain Fv gene. ScFv gene was digested with SfiI/NotI restricted digest enzyme to ligate the pHEN2 cloning vector, then were electrically transformed to E.coli TG1. The TG1 containing ScFv-pHEN2 was rescued by helper phage M13K07 to produce ScFv phage antibody. RESULTS: Of 95 chronic ITP patients, 41 (43.2%) were found positive for anti-platelet GPIIb/IIIa autoantibody, 5 (5.3%) were markedly positive. 2 (2.1%) patients plasma significantly inhibited the aggregation function of platelet. The lengths of VH and VL were about 380 to 400 bp. They were successfully linked by DNA linker to form ScFv fragment of about 780 bp. After cloning ScFv to phagemid pHEN2 and transforming ScFv-pHEN2 to TG1, 2.1 x 10(7) clones formed. After M13K07 rescue, 1.62 x 10(10) cfu/ml ScFv phage antibodies were produced. CONCLUSION: Few anti-platelet GPIIb/IIIa antibodies can inhibit the aggregation function of platelet. A phage antibody library has been constructed by phage surface display technology. Humanized anti-platelet GPIIb/IIIa ScFv phage antibody can be screened from this library.

[Identification of human platelet specific functional antibody and its fragments].

OBJECTIVE: To study the immunoreactivity of the specific anti-platelet glycoprotein (GP) IgG antibody and its F(ab')2 fragments from patients with chronic idiopathic thrombocytopenic purpura (ITP) and to investigate their effects on platelet aggregation function. METHODS: Peripheral blood samples were collected from 84 patients with ITP. Modified monoclonal antibody immobilization of platelet antigen assays was used to detect the IgG antibodies specific for GP I b/II a, GP I b/IX and GP VI. The IgG antibody and its F(ab')2 fragments in the positive plasma inhibiting platelet aggregation function were prepared and purified. Plate-rich Peripheral blood sample was collected from a normal person with O type blood and platelet-rich plasma (PRP) and platelet-poor plasma (PPP) were prepared. Plasma pf ITP patient or purified IgG or F(ab')2 fragments of different concentrations were added into PRP, and then inducers of platelet aggregation ADP, ristocetin, or collagen were added. The platelet aggregation was measured. Platelet GP II b/III a specific human-rat chimeric antibody 7E3 and GP I b specific antibody SZ2 were used as positive controls and PBS was used as negative control. RESULTS: GP II b/III a and/or GP I b/IX and/or GP VI specific antibodies were found in 48 (57.1%) patients. The plasma, purified IgG and F(ab')2 fragments of 7 of these 48 patients (14.6%) with positive autoantibody showed significant activity against GP II b/III a (4 patients), GP I b/IX (2 patients), or GP VI (one patient). The purified IgG and F(ab')2 fragments of 2 patients positive in GP II b/ III a autoantibody out of the 7 patients significantly inhibited the platelet aggregation induced by ADP, the purified IgG and F(ab')2 fragments of 1 patients positive in GP I b/IX out of the 7 patients significantly inhibited the platelet aggregation induced by ristocetin, and the purified IgG and F(ab')2 fragments of 1 patients positive in GP VI out of the 7 patients significantly inhibited the platelet aggregation induced by collagen. CONCLUSION: A functional fragment, F(ab')2 portion of IgG is responsible for the autoantibody interaction with platelet GPs in ITP, and some of them also affect the platelet function. It can be used to develop completely humanized anti-GP small molecular phage antibody.

Biomarkers for immune thrombocytopenia.

Immune thrombocytopenia is an autoimmune disease with abnormal biomarkers. Immune thrombocytopenia pathogenesis is a complicated process in which the patient's immune system is activated by platelet autoantigens resulting in immune mediated platelet destruction or suppression of platelet production. The autoantibodies produced by autoreactive B cells against self antigens are considered to play a crucial role. In addition, biomarkers such as transforming growth factor-beta1,Toll-like receptors,T helper 1 andT helper 2 cytokine bias, Notch signaling and abnormal biomarker in megakaryocyte maturation are involved in the pathogenesis of this disease. With the genomewide association study on immune thrombocytopenia, more biomarkers will be founded in the future. They may provides a theoretical basis for the mechanism and treatment of immune thrombocytopenia.

Both splenic CD5(+) B and CD5(-) B cells produce platelet glycoprotein-specific autoantibodies in chronic ITP.

The objective of the present study is to determine splenic B-cell subsets and the ability of splenic CD5(+) B and CD5(-) B cells to produce platelet glycoprotein-specific autoantibodies in chronic idiopathic thrombocytopenic purpura (ITP). Splenic CD5(+) B cells were identified by two-color flow cytometric analysis in eight ITP patients. Magnetic activated cell sorting (MACS) purified splenic CD5(+) B cells and CD5(-) B cells were cultured separately in vitro. Glycoprotein-specific autoantibodies in culture supernatants and plasma were measured by modified monoclonal antibody immobilization of platelet antigen (MAIPA) assay. The percentage of splenic CD5(+) B cells in ITP patients was slightly higher than that in controls, with no statistical significance. Four ITP patients displayed plasma IgG autoantibodies against both GPIIb/IIIa and GPIb. Moreover, splenic CD5(+) B cells and CD5(-) B cells from these four ITP patients also produced high level of IgG anti-GPII(b)/III(a) and anti-GPI(b) antibodies. However, we were unable to detect IgM GP-specific autoantibodies in culture supernatant and plasma in these ITP patients. It is concluded that both splenic CD5(+) B cells and CD5(-) B cells produce platelet IgG GP-specific autoantibodies, and may all play a role in the pathogenic process of ITP.

T cell immune abnormalities in immune thrombocytopenia.

Immune thrombocytopenia is an autoimmune disease with abnormal T cell immunity. Cytotoxic T cells, abnormal T regulatory cells, helper T cell imbalance, megakaryocyte maturation abnormalities and abnormal T cell anergy are involved in the pathogenesis of this condition. The loss of T cell-mediated immune tolerance to platelet auto-antigens plays a crucial role in immune thrombocytopenia. The induction of T cell tolerance is an important mechanism by which the pathogenesis and treatment of immune thrombocytopenia can be studied. Studies regarding the roles of the new inducible costimulator signal transduction pathway, the ubiquitin proteasome pathway, and the nuclear factor kappa B signal transduction pathway in the induction of T cell tolerance can help improve our understanding of immune theory and may provide a new theoretical basis for studying the pathogenesis and treatment of immune thrombocytopenia.

Novel agents for anti-platelet therapy.

Anti-platelet therapy plays an important role in the treatment of patients with thrombotic diseases. The most commonly used anti-platelet drugs, namely, aspirin, ticlopidine, and clopidogrel, are effective in the prevention and treatment of cardio-cerebrovascular diseases. Glycoprotein IIb/IIIa antagonists (e.g., abciximab, eptifibatide and tirofiban) have demonstrated good clinical benefits and safety profiles in decreasing ischemic events in acute coronary syndrome. However, adverse events related to thrombosis or bleeding have been reported in cases of therapy with glycoprotein IIb/IIIa antagonists. Cilostazol is an anti-platelet agent used in the treatment of patients with peripheral ischemia, such as intermittent claudication. Presently, platelet adenosine diphosphate P2Y(12) receptor antagonists (e.g., clopidogrel, prasugrel, cangrelor, and ticagrelor) are being used in clinical settings for their pronounced protective effects. The new protease-activated receptor antagonists, vorapaxar and atopaxar, potentially decrease the risk of ischemic events without significantly increasing the rate of bleeding. Some other new anti-platelet drugs undergoing clinical trials have also been introduced. Indeed, the number of new anti-platelet drugs is increasing. Consequently, the efficacy of these anti-platelet agents in actual patients warrants scrutiny, especially in terms of the hemorrhagic risks. Hopefully, new selective platelet inhibitors with high anti-thrombotic efficiencies and low hemorrhagic side effects can be developed.