Identifying carriers of type 2N von Willebrand disease: procedures and significance.

The defective FVIII carrier function of von Willebrand factor (VWF) identifies type 2N von Willebrand disease (VWD), a variant with a pattern resembling hemophilia A. Type 2N characterization is based on the evaluation of the capacity of VWF to bind exogenous FVIII (VWF:FVIIIB). Here we report on a retrospective evaluation of hemostatic laboratory parameters most useful in detecting type 2N carriers. The diagnostic capacity of aPTT, FVIII, VWF:Ag, FVIII/VWF:Ag ratio, VWF:FVIIIB and VWF:FVIIIB/VWF:Ag ratio was evaluated in 21 type 2N VWD carriers. Twenty subjects were heterozygous for the R854Q mutation, one was heterozygous for the R760C missense mutation, which interferes with cleavage of the VWF propeptide. We found that prolongation of aPTT and decrease in FVIII and FVIII/VWF:Ag ratio were not frequent findings in type 2N carriers. The same was true for VWF:FVIIIB which was not always abnormal. On the contrary, VWF:FVIIIB/VWF:Ag ratio was always defective and its values were not related with FVIII and FVIII/VWF:Ag ratio or influenced by plasma VWF concentration. Given these results, we attribute the greatest significance to VWF:FVIIIB/VWF:Ag ratio in the diagnosis of type 2N defects, and only search for type 2N mutations, to validate the diagnosis, if the ratio proves abnormal.

A simple, rapid method for screening hybridomas producing monoclonal antibodies to platelet proteins.

Several parameters influence the outcome of somatic cell fusions based on the Köhler and Milstein technology, and a number of steps are of critical importance, including the screening strategy. The procedure chosen, appropriate for the type of antibody required, should be rapid and sensitive, in order to clone the relevant hybrids as quickly as possible. A simple and quick dot blot-based method is reported, suitable for screening hybridoma culture supernatants in order to identify clones producing monoclonal antibodies to platelet constituents.

Quantitative and qualitative evaluation of blood salvaged after extracorporeal circulation (ECC) in paediatric heart surgery. Study of biochemical, morphological and structural variations of RBC after ECC and after salvaging of ECC circuit priming blood.

The salvaging of ECC circuit priming blood is essential for reducing the morbidity related to homologous blood transfusions and the importance of this technique is inversely proportionate to the age and weight of the child. In infants, the washing and centrifugation of blood not only drastically reduce the risk of contracting blood-transmitted diseases and cut management costs, but are also of considerable hemodynamic importance, producing a rapid normalization of the patient's hematocrit and hemoglobin and balancing the O2 consumption/demand ratio. The marketing of miniaturized salvagin devices with 55 ml bowls by Dideco has made possible the recovery of small quantities of blood, so as to normalise the hematic crisis and permit the application of total hemodilution in low-weight patients. The salvaged blood shows an average hematocrit of 52.7+/-9.7% (max 68.1%) and an average hemoglobin of 17.6 +/- 2.9 g/dl (max 20.7 g/dl), and maintains its structural components, osmotic resistance, concentration of intraerythrocytic hemoglobin and mean corpuscular hemoglobin all intact. Washing with isoosmotic and isoionic hydroelectrolytic solutions normalizes the ionic situation in the post-operative period and activated blood salvaging after Extracorporeal Circulation. The use of solutions without nutritional substances results however in a considerable fall in the number of enzymes in the intraerythrocytic metabolic glucide chain (G6PDH: -40.7 +/- 14.3% p<0.001), (PK: -23.8 +/- 20.5% p<0.03). This drop may be responsible for erythrocytic morphological alterations (echinocytic change) and probably for the release of hemoglobin from the red blood cells. Washing with isoionic, isoosmotic solutions containing G5% and adenine could, at least in theory, improve the quality of the salvaged blood, by normalizing the morphology and the volume of the RBC and by increasing the hematocrit.

[Disintegrins: potent inhibitors of platelet aggregation]. / Le disintegrine: potenti inibitori dell'aggregazione piastrinica.

Disintegrins are a family of highly homologous polypeptides purified from snake venoms, which contain the arginine-glycine-aspartic acid (RGD) sequence. The RGD tripeptide acts as an integrin recognition sequence; it is also present on several proteins involved in cell adhesion such as fibrinogen, fibronectin, von Willebrand factor, and collagen. Disintegrins can therefore competitively inhibit integrin-ligand interactions: they block fibrinogen binding to its platelet receptor, alpha IIb beta 3: hence they are potent platelet aggregation inhibitors. Disintegrins are up to 2000 times more potent than short synthetic linear RGD-containing peptides in blocking fibrinogen-dependent platelet aggregation. Likely, the amino acids surrounding the RGD sequence and intrachain disulphide bridges force the RGD sequence in an appropriate conformation which accounts for the high, but variable, platelet inhibitory activity exhibited by disintegrin molecules. Disintegrins block the adhesive functions of the RGD-dependent integrins present on different cell types in different tissues: for this reason they are not alpha IIb beta 3-specific. A single disintegrin polypeptide, barbourin, was found to be a specific alpha IIb beta 3 antagonist: unlike all other disintegrins it contains the lysine-glycine-aspartic acid (KGD) sequence instead of the RGD one, which solely imparts alpha IIb beta 3 specificity to the molecule. This finding led to the synthesis of small, conformationally constrained KGD-containing peptides, which proven to be specific and potent inhibitors of alpha IIb beta 3 function; these compounds are presently undergoing evaluation in clinical trials as antithrombotic agents.

[Recovery of transplantable hematopoietic progenitor cells from the umbilical cord blood]. / Recupero di progenitori emopoietici trapiantabili da sangue di cordone ombelicale.

Cord blood (CB) is a source of transplantable hematopoietic progenitor cells (HPC); it represents an alternative to bone marrow to restore hematopoiesis in patients affected by malignant and non-malignant disease. Therefore, large-scale CB banks would be a natural complement to bone marrow donor registries. Storage of unmanipulated whole CB units requires a great number of liquid nitrogen containers. Separation of leukocytes allows CB storage in smaller space, thus lowering banking costs; unfortunately, CB processing may cause significant losses of stem/progenitor cells. We describe here a procedure for erythrocyte removal from CB units by 1 xg sedimentation on Emagel, a gelatin-based colloidal compound commonly used as plasma expander. The erythrocyte-depleted supernatant was collected and then centrifuged to recover the leukocyte pool. We evaluated erythrocyte depletion and leukocyte recovery after different sedimentation time (30, 45 and 60 min), on 139 CB units collected at delivery. All the considered parameters were improved by increasing sedimentation time. Erythrocyte depletion at 60 min was 86.0% and we recovered 93.3% of CD34+ cells. The proposed CB-processing method allowed us to collect a satisfactory amount of HPC in view of stem cell transplantation; it may have a potential role in UCB banking.

Interaction of the von Willebrand factor with platelets and thrombosis.

The human von Willebrand factor (vWf) is a multimeric glycoprotein present in plasma, platelets, endothelial cells and subendothelium and synthesized in endothelial cells and megakaryocytes. vWf plays a pivotal role in the mechanisms of blood clotting and platelet thrombus formation; quantitative and qualitative abnormalities of vWf cause the most common congenital bleeding disorder in man, the von Willebrand disease. vWf stabilizes factor VIII and interacts with subendothelial components and with platelet membrane receptors. The multimeric structure of vWf provides an array of binding sites which allows multivalent interactions with its ligands, thus supporting the formation of stable platelet aggregates at the site of vascular injury, particularly under flow conditions characterized by high shear stress. In the last years, remarkable progress has been made toward understanding the structure of vWf protein and gene, and the elucidation of many structure-function relationships, which may result in improved therapeutic intervention for vWD patients, and in the development of effective strategies for antithrombotic therapy.

[Glanzmann's thrombasthenia: a rare example of an integrin deficit]. / La tromboastenia di Glanzmann: un raro esempio di deficit di un'integrina.

Glanzmann's thrombasthenia is an autosomal recessive life-long bleeding disorder, originated from a quantitative or qualitative defect of the major platelet membrane receptor: the GPIIb/IIIa complex. The GPIIb/IIIa complex is a calcium-dependent heterodimer, belonging to the integrin superfamily. The complex of activated platelets can bind fibrinogen, von Willebrand factor, fibronectin and vitronectin, which are proteins playing an important role in platelet adhesion and aggregation. Thrombasthenic platelets are deficient in GPIIb, GPIIIa and GPIIb/IIIa complex; however, platelets from few thrombasthenic patients content near-normal amounts of functionally abnormal complex. The GPIIb/IIIa quantitative or functional defect leads to defective platelet hemostatic plug formation. Hemorrhagic symptoms consist of purpura, gingival hemorrhage, menorrhagia and epistaxis. Some cases of Glanzmann's thrombasthenia have been characterized at the molecular genetic level. Molecular abnormalities include: GPIIb or GPIIIa partial gene deletion, GPIIIa gene insertion, a point mutation resulting in an amino acid substitution within the GPIIIa molecule. In spite of the contemporary reduction of both GPIIb and GPIIIa in most cases of Glanzmann's thrombasthenia, it appears that a molecular abnormality affecting only one of the glycoprotein genes may result in a thrombasthenic phenotype.

[The glycoprotein IIb/IIIa complex of the platelets. An activation-dependent integrin]. / Il complesso glicoproteico IIb/IIIa delle piastrine. Un'integrina attivazione-dipendente.

The glycoprotein (GP) IIb/IIIa complex is the most abundant platelet membrane receptor (approximately 80,000 copies/platelet). The GP IIb/IIIa complex is an adhesion receptor belonging to the integrin superfamily; it can bind five adhesive proteins containing the arginine-glycine-aspartic acid (RGD) sequence in their structure: fibrinogen (Fg), von Willebrand factor (vWf), thrombospondin (Tsp), fibronectin (Fn) and vitronectin (Vn). Fg mediates platelet aggregation; vWf, Tsp and Fn are large molecules that support platelet adhesion to vessel wall; Vn is a molecular connection among hemostasis and others physiological processes. The complex is presents at any time on the platelet surface, but macromolecular ligands cannot access to their receptor because of steric hindrances intrinsic to the complex itself or its microenvironment. Adhesive proteins can bind to the complex only after platelets become activated; following platelet stimulation and ligand binding a conformational change takes place, accompanied by expression of new epitopes termed LIBS (ligand-induced binding sites). The complex-bound fibrinogen undergoes to a progressive rearrangement which increases the adhesive function of the molecule. The RGD sequence present in adhesive proteins, in addition to its receptor role, may serve as a trigger sequence that induces a high affinity ligand-binding state in the GP IIb/IIIa complex. The different domains of adhesive proteins can bind to platelet surface receptors, other than GP IIb/IIIa, so realizing multiple ligand-receptor interactions.

[Platelet hyperaggregation induced by an antiplatelet monoclonal antibody in a female patient with essential thrombocythemia of childhood]. / Iperaggregazione piastrinica indotta da un anticorpo monoclonale anti-piastrine in una paziente con trombocitemia essenziale in età pediatrica.

Essential thrombocythemia (ET) is a chronic myeloproliferative disease, rarely observed in pediatric age, characterized by a persistently increased platelet count. Abnormalities of platelet function observed in ET patients may be, at least in part, responsible for the thrombohemorrhagic complications. The authors report about a pediatric patient affected by ET, showing an abnormal platelet response following stimulation by anti-platelet monoclonal antibody. Such finding may be attributable to a structural abnormality of the platelet fibrinogen receptor or to post-receptor alterations.

[Epidemiologic research for thalassemia and hemoglobinopathy traits in the territory of a local health unit in Liguria]. / Indagine epidemiologica per traits talassemici ed emoglobinopatie nel territorio di una U.S.L. della Liguria.

The authors investigated the incidence of thalassemia traits and hemoglobinopathies in western Liguria, where up to 70% of people comes from other italian regions, particularly from the South. The authors screened 442 primary school pupils in Albenga and Andora (Savona). Laboratory investigations permitted to detect 19 thalassemia trait carrier subjects (4.30% of the total examined): 12 of them were diagnosed heterozygous for beta-thalassemia, 6 for alpha-thalassemia, and 1 for Hb S. Authors would underline that more than half of the screening positive subjects resulted carrier of beta-thalassemia or Hb S trait, both potentially able to give origin to severe diseases: homozygous beta-thalassemia, sickle cell anemia, and beta-thalassemia/Hb S double heterozygosity.

von Willebrand factor, von Willebrand factor-cleaving protease, and shear stress.

von Willebrand factor (VWF) is a multimeric plasma glycoprotein (GP) involved in platelet adhesion at the site of vascular damage, which acts as a bridge between the injured subendothelium and the platelet receptors. The multimeric structure of VWF allows it to support multiple interactions with platelets and endothelial components under high shear stress. Rapid flow conditions induce a conformational transition of the VWF molecule, thus allowing its functional binding domains to be exposed. A specific VWF-cleaving protease (ADAMTS-13) physiologically down regulates the multimeric size of newly released and circulating VWF in order to prevent unwanted platelet thrombus formation. The occurrence of microvascular platelet aggregation in thrombotic thrombocytopenic purpura, which is caused by an ADAMTS-13 deficiency, well-demonstrates the important role of the protease in regulating the adhesive activity of VWF. Better knowledge of VWF function would contribute to the development of novel anti-thrombotic strategies based on the selective inhibition of the VWF interaction with platelet receptors and endothelial components in areas of the circulation characterised by elevated fluid dynamic forces.

Leukocyte recovery from umbilical cord blood by poligeline.

Umbilical cord blood (UCB) collected at delivery is a source of transplantable stem/progenitor cells; it represents an alternative to bone marrow to restore hematopoiesis in patients affected by malignant and non-malignant disease. Therefore, large-scale UCB banks would be a natural complement to bone marrow donor registries. Storage of unmanipulated whole UCB units requires a great number of liquid nitrogen containers. Separation of leukocytes allows UCB storage in smaller space, thus lowering banking costs; unfortunately, UCB processing may cause significant losses of stem cells. We report about the use of poligeline to remove erythrocytes from UCB units. After erythrocyte sedimentation at 1xg (30' or 40') or 50xg, leukocyte-rich supernatant was collected and centrifuged to recover the leukocyte pool in view of stem cell transplantation. Erythrocyte depletion was always satisfactory, ranging from 82.6% to 88.9%, but 1xg sedimentation for 40' enabled us to achieve the best CD34+ cell recovery (mean value 80.5%). The proposed UCB-processing method allowed us to lower the final sample volume down to 1/10 of the initial one, in this way making UCB banking feasible. Erythrocyte depletion took place directly in the collection bag, thus reducing microbial contamination risk.

Activation of human platelets by monoclonal antibodies.

Some monoclonal antibodies (mAbs) are able to induce platelet activation and/or aggregation in vitro. Such mAbs show specificity to important platelet membrane glycoproteins (GPs), including GPIIb/IIIa, GPIV, and the HLA complex. Different mechanisms are implicated in mAb-mediated platelet activation: mAbs can interact contemporarily with the target antigen by means of their Fab portion, and with the platelet Fc receptor (Fc gamma RII) through their Fc portion. Frequently, cross-linking Fc gamma RII causes receptor oligomerization, which in turn leads to platelet activation. On the other hand, it has been demonstrated that the target antigen may entirely transduce the activation signal. The activation event sometimes results from a conformational shift of the target antigen. Investigation of the mechanisms leading to mAb-mediated platelet activation will presumably increase our knowledge about platelet activation pathways, and will help in the management of patients having serum platelet-aggregating autoantibodies or alloantibodies.

Adhesion of MNC to extracellular matrix proteins following in vitro photochemotherapy.

BACKGROUND: Photochemotherapy is a safe and effective treatment for patients with drug-resistant severe GvHD. The technique involves the exposure of MNC to psoralen and UVA light (PUVA). We have investigated the effect of in vitro PUVA on MNC adhesion to extracellular matrix (ECM) proteins. METHODS: MNC were isolated from peripheral blood (PB) and umbilical cord blood (UCB), and treated with PUVA. After labeling by a chemiluminescent probe, MNC were plated on ECM proteins (collagen, fibronectin, vitronectin and laminin) and the number of adherent cells was measured. RESULTS: Untreated MNC from both PB and UCB showed a similar adhesion to the substrates. As a consequence of exposure to PUVA, most of PB samples showed significantly enhanced adhesion to the ECM proteins; on the other hand, UCB-recovered MNC did not significantly modify their adhesion. DISCUSSION: MNC adhesion to ECM components is mediated by integrins, a family of cell membrane receptors; the ligand-binding affinity of certain integrins may be modulated by different stimuli. PUVA treatment of PB-recovered MNC may induce the up-regulation of the ligand-binding affinity of the integrins involved in the adhesion to ECM proteins. The finding of unmodified UCB cell adhesion after PUVA, may be related to the functional immaturity of lymphocytes at birth.

The human platelet membrane glycoprotein IIb/IIIa complex: a multi functional adhesion receptor.

The glycoprotein GPIIb/IIIa complex is a major constituent of the platelet membrane; it plays an important role in platelet adhesion and aggregation. The complex is a member of the integrin superfamily. Integrins are related membrane receptors which mediate the adhesive interactions of a variety of cells; they specifically recognize the arginine-glycine-aspartic acid (RGD) sequence present in several adhesive proteins. The GPIIb/IIIa complex of activated platelets can bind fibrinogen, von Willebrand factor, fibronectin, vitronectin and thrombospondin. Platelets are activated by a variety of signals including extracellular matrix molecules and soluble factors; upon platelet activation the complex undergoes a conformational change, thus permitting the macromolecular ligands access to their binding sites. In turn, fibrinogen binding results in a receptor modification and neoantigens exposure; such events may participate in signal transduction. The adhesive proteins compete reciprocally for binding to GPIIb/IIIa, and the complex binds to different domains of them, thus creating multiple interactions with the ligands.

Biochemical and molecular basis of Glanzmann's thrombasthenia.

Glanzmann's thrombasthenia is a rare autosomal recessive bleeding disorder characterized by a quantitative deficiency or a functional abnormality of the major platelet membrane integrin receptor: the glycoprotein (GP) IIb/IIIa complex. The GPIIb/IIIa complex functions as a platelet receptor for fibrinogen, von Willebrand factor, fibronectin and vitronectin; therefore it plays an important role in platelet adhesion and aggregation. Thrombasthenic platelets are severely deficient in GPIIb/IIIa content or function, and fail to aggregate and form the hemostatic plug at the site of vessel injury. On the other hand, heterozygous subjects (having about half the number of normal GPIIb/IIIa complexes) do not show bleeding problems. It has been demonstrated that a molecular defect affecting one of the two GP coding genes is sufficient to determine a contemporary deficit of both GPIIb and GPIIIa, and hence the thrombasthenic phenotype. Up to now, few molecular abnormalities giving rise to Glanzmann's thrombasthenia have been characterized. Large rearrangements within the GPIIb or GPIIIa coding genes appear to be unusual, whereas small modifications in the nucleotide sequence of the coding regions occur with higher frequency.

Platelet antibody detection in pediatric immune thrombocytopenic purpura: evaluation of three screening methods.

BACKGROUND AND OBJECTIVES: Immune thrombocytopenic purpura (ITP) is a common hematologic disorder, two forms of which occur in children. The detection of circulating platelet antibodies is helpful in diagnosis. MATERIALS AND METHODS: We evaluated three different immunological methods for detecting platelet antibodies in the serum of children with ITP. These were: a solid-phase red-cell adherence test (SPRCA), an enzyme immunoassay (EIA), and an immunofluorescence test (PSIF). RESULTS: The sensitivity of the methods in detecting IgG antibodies ranged from 28.1 (EIA) to 39.4% (SPRCA). We also looked for IgM antibodies by PSIF, thus raising the sensitivity of this test from 32.0 to 40.0%. A combination of two tests (SPRCA and EIA) allowed us to detect 61.8% positive samples. By doing all three tests, we obtained 71.3% positive samples. Finally, we reached 73.5% by adding PSIF for IgM. We found a higher frequency of circulating antibodies in both acute and chronic ITP at onset than in clinical remission. There were a few positive sera in chronic ITP, but not in the acute form in remission. CONCLUSION: The individual tests each have a relatively low sensitivity, but the combination of all three increases the diagnostic effectiveness. The finding of platelet antibodies during remission may predict evolution toward a systemic autoimmune state.