DICHIARAZIONE Relatore: PAOLO GRESELE

Transcription

1 DICHIARAZIONE Relatore: PAOLO GRESELE Come da nuova regolamentazione della Commissione Nazionale per la Formazione Continua del Ministero della Salute, è richiesta la trasparenza delle fonti di finanziamento e dei rapporti con soggetti portatori di interessi commerciali in campo sanitario. Posizione di dipendente in aziende con interessi commerciali in campo sanitario: NIENTE DA DICHIARARE Consulenza ad aziende con interessi commerciali in campo sanitario: NIENTE DA DICHIARARE Fondi per la ricerca da aziende con interessi commerciali in campo sanitario: FIDIA, IMMUCOR Partecipazione ad Advisory Board: NIENTE DA DICHIARARE Titolarietà di brevetti in compartecipazione ad aziende con interessi commerciali in campo sanitario: NIENTE DA DICHIARARE Partecipazioni azionarie in aziende con interessi commerciali in campo sanitario: NIENTE DA DICHIARARE Altro

2 Dife% acquisi, della funzionalità piastrinica Paolo Gresele Department of Medicine Sec,on of Internal and Cardiovascular Medicine University of Perugia XIII Congresso Nazionale SIES Simposio congiunto SIES-SISET Rimini, October 2014

3 Platelet ac(va(on at a vascular wall damage area Gresele P et al., TiPS 2008;29:352

4 Ac(vatory signalling in platelets ADP thrombin ASPIRIN TxA2 Gα q β γ P2Y12 Gα q GTP β γ PLCβ TXA 2 X AA COX-1 IP3 DAG PLA 2 Ca 2+ PKC integrin α IIb β 3 GDP Gα i GDP β γ β γ PI-3K PLCγ2 CalDAG GEF I Rap1 FBG GPVI FcRγ Tyr Tyr Syk epinephrine collagen

5 Platelet Inhibitory Signalling PGI 2 PGD 2 adenosine NO IPr A2a Gα s GDP? β γ β γ Gα s GTP + ATP AC + + camp Gα s GTP Protein Kinasi A (PKA) AMP PDE _ NO cgmp GC GTP nitra(on nitrosyla(on of proteins PLATELET INHIBITION VASP MLCK ABP GPIbβ Rap1 IP3-R PLCβ P Protein Kinasi G (PKG)

6 Acquired disorders of platelet func,on A qualita,ve abnormality of platelet func,on in subjects with no personal or family history of bleeding Usually (not always) in persons with a normal platelet count OVen associated with mucocutaneous bleeding Are encountered commonly in clinical prac,ce (much more frequent than inherited platelet disorders)

7 Clinical importance of acquired disorders of platelet func,on The clinical importance of an acquired platelet disorder is defined primarily by the pa,ent s history In the majority of affected individuals the clinical significance is minor Serious bleeding may occur when acquired platelet dysfunc,on associates with other hemosta,c defects, during acute illness, and/or when the affected subjects undergo surgery/invasive procedures Most oven it is difficult to discern the role of platelet dysfunc,on from other concomitant altera,ons, especially in acutely ill pa,ents.

8 Clinical evalua,on of the pa,ent with a suspected acquired platelet func,on disorder Family bleeding history Drug and food history Sites of bleeding (easy bruising, epistaxis, gum bleeding, menorrhagia) Severity, recurrence (objec,ve assessment?) Concomitant systemic disorders

9 Approach (flow chart) to diagnosing an acquired platelet func,on disorder Hassan AA & Kroll MH, Hematology 2009, 403

10 Causes of acquired platelet func,on disorders Foods/Drugs Cirrhosis Uremia Hematologic disorders Myeloprolifera,ve disorders Myeloma/Paraproteinemias Myelodysplasia Cardiopulmonary bypass Blood bank platelets

11 Acquired platelet dysfunc,on in liver cirrhosis Prolonga,on in the skin bleeding,me and associa,on with GI bleeding 25 Bleeding (me (min) bleeding (me > 10 min previous bleeding no previous bleeding 21 (52%) 14 (22%) Violi F et al., Haematologica 1994, 79: 61

12 Prolonga,on of the PFA- 100 closure,me in liver cirrhosis PFA- 100 epinephrine, sec Pihusch R et al., J Hepatol 2002, 37:548

13 Platelet dysfunc,on in cirrhosis Aggrega,on in response to thrombin 100 Maximal amplitude (%) * * 0 Healthy controls Child A- B Child C Laffi G, Marra F, Gresele P et al., Gastroenterology 1992, 103:641

14 Exhausted platelets in cirrhosis Acquired storage pool defect Healthy controls Child A- B Child C 75 Platelet ATP 2500 Platelet βtg 21 Plasma βtg/pf4 ATP (mol/10 8 plts) ** ** Release * Total content βtg (ng/10 8 plts) * Release ** * ** Total content βtg/pf4 (ng/10 8 plts) RATIO ** Laffi G, Marra F, Gresele P et al., Gastroenterology 1992, 103:641

15 Defec(ve signal transduc(on in platelets from cirrho(c pa(ents controls IP 3 (cpm) cirrho,cs F (arbitrary units) controls cirrho,cs [Ca 2+ ] (nm) Thrombin (U/ml) Laffi G et al., Gastroenterology 1993; 105:148

16 Enhanced intraplatelet inhibitory signalling in cirrhosis control cirrhosis 3200 fmol/10 8 PLTS fmol/10 8 PLTS camp cgmp 0 Laffi G et al., Gastroenterology 1993; 105:148

17 Bleeding and thrombosis in pa,ents with myeloprolifera,ve neoplasms Thrombo,c and haemorrhagic events in essen,al thrombocythaemia (ET) and polycythaemia vera (PV) reported at diagnosis. Ellior MA & Tefferi A. Brit J Haematol 2005, 128,

18 Mechanisms of bleeding complica,ons in MPN Thrombocytosis and Qualitative Platelet Dysfunction Acquired von Willebrand Syndrome Iatrogenic: Aspirin, Anagrelide and Anticoagulation MPN- Associated Bleeding Anatomical Bleeding: Gastric and Esophageal Varices Quantitative Platelet Dysfunction: Myelofibrosis From McMahon B et al. Sem Thromb Hemost 2013; 39:

19 100 Platelet aggrega,on and granule release are defec,ve in MPN control MPD PLATELET AGGREGATION 30 β- TG RELEASE Platelet aggrega(on (maximal amplitude, %) * β- TG (% of total content) * 0 40 collagen 1.2 µg/ml ADP 10 µm epinephrine 100 µm collagen 1.2 µg/ml ADP 10 µm epinephrine 100 µm ATP (% of total content) HEX released (% of total content) * 40 * * 20 * 0 collagen 1.2 µg/ml ADP 10 µm epinephrine 100 µm 0 collagen 1.2 µg/ml ADP 10 µm epinephrine 100 µm Emiliani C et al., Platelets 2006; 17:20

20 Adjustement of platelet count in PRP reduces platelet aggrega,on Caraneo M et al., Haematologica 2007; 92: 694

21 Defec,ve in vivo platelet ac,va,on in MPN Two incisions are made and the (me for clo^ng to occur is recorded. Blood is collected and analyzed by flow cytometry. P- selec(n (% of posi(ve cells) MPD pa,ents healthy subjects minutes Emiliani C et al., Platelets 2006; 17:20

22 Platelet dysfunction in CML platelets receiving different tyrosine kinase inhibitors Ima,nib (n=15) Nilo,nib (n=7) Dasa,nib (n=27) Bosu,nib (n=26) % Maximal agonist- induced aggrega(on Quintas- Lardam et al., Blood 2009;114:261

23 Acquired Glanzmann Thrombasthenia in a pa,ent with non Hodgkin lymphoma Platelet aggrega,on Platelet adhesion at high shear (3000 sec - 1 ) Giannini S et al., Cytometry Part B 2008, 74B: 194

24 Acquired Glanzmann Thrombasthenia in a pa,ent with non Hodgkin lymphoma Mixing tests ADP- induced platelet aggrega(on Adhesion on a collagen surface Giannini S et al., Cytometry Part B 2008, 74B: 194

25 Acquired Glanzmann Thrombasthenia in a pa,ent with non Hodgkin lymphoma pa,ent purified an,body commercial an, GPIIb an,body Giannini S et al., Cytometry Part B 2008, 74B: 194

26 Therapeu,c approach to acquired disorders of platelet func,on Platelet transfusion Desmopressin (DDAVP) An,fibrinoly,c agents (Tranexamic acid) Recombinant ac,vated FVII Recombinant erythropoie,n (uremia) Conjugated estrogens (uremia) Apro,nin (CABG)

27 Conclusions Acquired disorders of platelet func,on represent a frequent cause of medical consulta,on Most of the,mes they are of limited clinical importance but in some condi,ons may cause serious bleeding Their iden,fica,on requires an accurate clinical evalua,on and a set of laboratory assays No laboratory test predicts bleeding in acquired platelet dysfunc,on Treatment approaches vary according to the severity of platelet dysfunc,on, to its cause and associated disease Further clinical research on the detec(on, prognos(c value and management of acquired platelet func(on defects is warranted

28 DDAVP shortens bleeding,me in acquired platelet dysfunc,on Bleeding (me (min) Liver Disease Non Uremic Renal Disease Pulmonary Hypertension Cause of defect Myelofibrosis Tangier s Disease Di Michele D et al., Am J Hematol 1990, 33: 39-45

29 Tranexamic acid shortens bleeding,me in chronic renal failure Mezzano D et al., Thromb Haemost 1999, 82: 1250

30 rfviia improves local fibrin forma,on but not platelet deposi,on in cirrhosis Tonda R et al., J Hepatol 2003, 39: 954

31 Acquired platelet dysfunc,on with selec,ve defect of GPVI mediated- platelet ac,va,on in malignant haemopathy Bellucci S et al., Thromb Haemost 2005, 93:130

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33 PFA-100 principle of the method Vacuum chuck Cup/Capillary assembly Coated membrane 0.8 ml anticoagulated whole blood High shear rate ( s -1 ) Membrane: COLL/EPI; COLL/ADP Membrane occlusion Capillary Blood sample Housing/ sample reservoir

34 Impaired platelet aggrega,on and acquired storage pool disease in uremia 100 controls chronic heart failure Platelet aggrega(on * * * Platelet granule content * * 0 ADP 4 µm Collagen 1 µg/ml Collagen 2 µg/ml 0 ATP (nmoles/10 9 platelets) PF4 (µg/10 9 platelets) from Mezzano D et al., Thromb Haemost 1996

35 NO produc,on and intracellular cgmp are increased in platelets from uremic pa,ents controls uremics controls uremics Noris M & Remuzzi G, Blood 1999, 94:2596

36 Impaired platelet adhesion in uremic rats is restored by the inhibi,on of NO- forma,on 100 Platelet adhesion (%) SHAM UREMICS UREMICS + L- NMMA Remuzzi G et al., J Clin Invest 1990, 86: 1768

37 Serum TPO levels regulate platelet function in MPN Concentra,ons of added TPO (ng/ml) Defec,ve aggrega,on normal circula,ng TPO 7/9 high circula,ng TPO 1/6 p=0.04 Usuki K et al. Br J Hematol 1997;97:530

38 Platelet adhesion to denuded arterial segments is impaired in uremia and restored by repo treatment Escolar G et al., Curr Hematol Rep 2005, 4:359

39 Heavy ethanol intake impairs platelet aggrega,on LIGHT TRANSMISSION adrenaline 0.4 µmol two weeks aier alchol absten(on collagen 1 µg/ml two weeks aier alchol absten(on ADP 2 µm two weeks aier alchol absten(on before before before 1 min 1 min 1 min Vermylen J & Blockmans D, Clin Haematol 1989, 2:729

40 Moderate wine intake reduces platelet aggrega,on white wine red wine Collagen induced platelet aggrega(on Seconds (lag phase) before aier WHITE WINE before aier RED WINE - 20 healthy volunteers - red and white wine: 300 ml/day - Intake: 2 weeks Pignatelli P et al., Pathophysiol Haemost Thromb 2002, 32: 356

41 Moderate wine intake increases NO-production by platelets NOx release by stimulated platelets before and after red or white wine consumption * p=0.01 vs before **p=0.037 vs before White wine Red wine ** * NOx (µm) Before After Gresele P et al., J Nutr 2008, 138:1602

42 Resveratrol increases platelet NO production NO (pmol/10 8 platelets) Resveratrol (µmol/l) Nitrite plus nitrate (µmol/l) ( 3 H)L- Citrulline (pmol/10 8 platelets) Resveratrol (µmol/l) Resveratrol (µmol/l) Gresele P et al., J Nutr 2008, 138:1602

43 α2β1 deficiency in MPN INCREASED LIGHT TRANSMITTANCE (%) INCREASED LIGHT TRANSMITTANCE (%) Handa M et al., Thromb Haemost 1995; 79: 521