Thrombocytopenia, VWD and platelet disorders Flashcards

1
Q

Outline the steps in thrombopoiesis

A
  • Megakaryocytes are the bone marrow precursors
  • programmed via transcription factors to express platelet cell surface proteins and form platelet-specific organelles
  • Final stages of maturation - long pseudopodia develop
    • Forms a protoplatelet process
    • organelles move along microtubules to the end of the proplatelet
    • Proplatelets branch and formed bead like constrictions
    • The proplatelets fragment and for smooth disc like platelets
  • The platelets are released from the marrow into the vascular space as quiescient non-adhesive platelets.
  • Platelets have a life span of 6-10 days in the blood stream
  • ~ 100 billion are release each day!
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2
Q

Briefly describe the process of primary haemostasis

A
  • Vessel wall injury leads to exposure of subendothelial collagen and VWD
  • Platelets interact with collagen and VWD triggering activation
  • Platelet granules are released via cell signalling pathways
    • adenine nucleotides, calcium, serotonin, fibrinogen, VWF, fibronectin and P-selectin
  • Granules recruit additional platelets
  • Fibrin mesh helps to strengthen platelet plug
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3
Q

Discuss how activated platelets up-regulate and amplify clot formation, consolidation and retraction

A
  • Platelets are activated via exposure to subendothelial collagen and VWF
  • Platelet granules are released - recruiting more platelets and liberating fibrinogen
  • coated platelets act as a scaffolding for tenase and prothrombinase (FXa and Va) which binds to the phospholipid surface
  • thrombin and fibrin are produced locally to enhance clot maturation
  • Platelet cytoskeletal elements linked to fibrin receptors contract resulting in retraction of the growing clot
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4
Q

Clopidogrel: Mechanism of action

A
  • Platelet aggregation inhibitor
  • Effects via an active, highly unstable, unidentified compound
  • Compound selectively binds to platelet surface low-affinity ADP receptors - irreversibly alters ADP receptor
  • Inhibits activation of the platelet-glycoprotein Ib/IIIa complex necessary for platelet-fibrinogen binding
  • Also inhibits granule release - decreasing serotonin, calcium, fibrinogen, ADP, thrombospondin, all necessary for up-regulation of clot formation.
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5
Q

Aspirin: mechanism of action

  • in thromboprophylaxis
  • Analgesia
  • Anti-inflammatory
  • Anti-pyretic
A
  • Inhibits COX-1 (prostaglandin synthetase)
    • Reduces synthesis of prostaglandin and thromboxanes
  • Platelets cannot synthesize new COX-1, so the effect on platelets is irreversible
  • Doses of 1-2 mg/kg/day inhibit platelet function and aggregation (current recommendation is ~ 2 mg/kg/day
  • Prostaglandin E2 responsible for pyrogen effec
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6
Q

Heparin: Mechanism of action and use

A
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7
Q

Discuss the interaction between platelets and VWF

A
  • VWF and subendothelial collagen are exposed with vascular damage.
    • VWF binds with collagen and undergoes a conformational change. The strength of the bond is dependent on VWF multimer size
    • The largest multimeric form of VWF is stored within endothelial cells.
  • Platelets adhere to VWF once exposed. This adherance causes platelet activation.
    • Platelets adhere to VWF and slowly roll and become activated by interactions with collagen
  • Activated platelets release alpha-granules
    • These granules store ~ 20% of the total blood VWF (humans).
    • calcium released in the granules catalyses binding of GPIIb and IIIa to form the fibrinogen receptor
  • VWF then binds to GPIIb/IIIa receptors (fibrinogen receptor) on activated platelets allowing further adhesion and aggregation.
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8
Q

List causes of primary haemostatic disorders.

A
  1. Severe thrombocytopenia
  2. Von Willebrand disease
  3. Thrombopathia
  4. Vasculopathy
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9
Q

Discuss potential clinical signs cause by primary haemostatic disorders

A
  • Surface mucosal bleeding is the hallmark with petechiae most often seen
  • Epistaxis, haematuria and melena can be severe enough to warrant blood transfusion
  • Bleeding into the brain and lungs is uncommon but can be life-threatening
  • Cavity bleeding, haemarthrosis and haematoma are rarely reported
  • Excessive bleeding after trauma / surgery may be first sign
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10
Q

Describe the pathophysiological mechanisms that lead to immune mediated thrombocytopenia

A
  • ITP is mediated by the humoral immune system.
  • There may be a reduction in Treg activity leading to development of auto-antibodies
  • Antibodies bind to various platelet surface antigens
    • Abs directed against the fibrinogen receptor have been identified
    • A monoclonal antibody directed against GPIIb causes dose depended thjrombocytopenia
  • Antibody binding leads to opsinisation and subsequent removal by the reticuloendothelial system
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11
Q

List known causes of secondary ITP

A
  1. Drug reaction
    • sulphonamides and cephalosporins most common
  2. Infectious agents
    • Babesia
    • Anaplasma phagocytophilium
    • Ehrlichia canis
    • Leptospira
    • Leishmania infantum
  3. Neoplasia
    • Thrombocytopenia can also be caused by tumour bleeding, platelet consumption, DIC, splenic sequestration, decreased production (with myelophthisis)
    • histiocytic sarcoma, lymphoma, haemangiosarcoma
  4. Inflammatory disease
    • Chronic hepatitis
    • Pancreatitis
    • SIRS
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12
Q

Describe the diagnostic pathway for a dog with suspected severe thrombocytopenia

A
  • Clinical exam - surface bleeding (petechiae, ecchymoses, epistaxis), pallor, splenomegaly, fever
  • CBC and blood smear evaluation
    • Care to assess for clumped platelets
  • Always a presumptive diagnosis
  • Consider imaging
  • Consider infectious disease screening
  • In clinical practice - document SEVERE thrombcytopenia, exclude underlying disease, assess response to immunosuppression
  • detection of platelet bound antibody - Platelet surface associated IGg - flow cytometry assay. Sensitive but not specific for idiopathic IMT
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13
Q

List potential treatment options for IMT

A
  1. Corticosteroids
  2. Vincristine
  3. hIVIG
  4. Mycophenolate
  5. Azathioprine / cyclosporine
  6. Transfusion - pRBC or whole blood
    • fresh PRP, platelet concentrate or cryopreserved platelets not readily available in clinical practice
  7. lyophilised platelets???
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14
Q

Discuss the treatment approach for IMT

A
  • Ensure any offending medications are stopped
  • Assess for and treat infectious diseases (especially when endemic)
  • Blood or PRBC tansfusion as needed
  • Immunosuppression for idiopathic and if anti-microbials are not working
  • Vincristine been shown to reduce duration of severe thrmobocytopenia
  • hIVIG has also shown reduced time to platelet recovery compared to prednisolone alone (3.5 d vs 7.5 d)
  • Vincristine vs hIVIG showed not difference in platelet recovery in a further study.
  • Concurrent immunomodulatory drugs
    • no prospective studies comparing efficacy
    • azathioprine, cyclosporine and mycophenolate
    • Mycophenolate - platelet recovery in 2-6 days in 5 dogs as a single agent
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15
Q

Discuss the implications of concurrent IMHA and IMT in dogs

A
  • In one study of 21 dog with concurrent IMHA and IMT (< 50k/uL), 16 died or were euthanised within 30 days of hospital admission.
  • Another study, 12 dogs (Orcutt 2010) with IMHA and thrombocytopenia, but platelet count < 15 k/uL had an in-hospital mortality rate of 25% - similar to the individual diseases.
    • Looking closer, 2 further dogs died or were lost to follow up at 7 days and 2 more at 30 days and 30 day survival was 58% (but 2 were then lost to follow up at 30 days…)
  • Definition of IMT component was more stringent in the second paper and was more likely to exclude dogs with DIC
  • The clinical inplications and treatment options are the same as for each disease.
  • Immunosuppressive treatment and supportive care is similar.
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16
Q

Describe the classifications of Von Willebrand Disease

A
  • 3 types based on the quantitative and qualitative VWF multimers present.
  • Type 1: Low plasma VWF, full arraw of multimers present.
    • mild to moderate bleeding tendency
  • Type 2: Variable reduction in plasma VWF, but absence of high molecular weight VWF multimers
    • Moderate to severe bleeding tendencies
  • Type 3: Complete absence of plasma VWF
    • Severe bleeding tendency.
17
Q

List and discuss available screening tests for VWD

A
  1. Basic CBC profile is unremarkable
  2. PT, APTT and platelet count will be normal unless there has been recent bleeding / consumption
  3. BMBT: > 4 minutes when platelet count is > 100 k/uL and PCV > 30%
    • Consistent with VWD, thrombopathia or vasculopathy
  4. VWF:Ag - quantitative assay
    • Compared to pooled plasma (70%-180% is normal)
    • 50-69% - borderline / intermediate
    • 0-49% - abnormal
      • Sick/septic dogs could have increased VWF due to endothelial injury
  5. DNA testing
  6. Qualitative VWF Assay
    • ELISA measuring VWF:collagen binding activity
    • collagen binding is dependent on the presence of the high molecular weight muiltimer
18
Q

Discuss therapeutic options for dogs with VWD

A
  1. Requirement for treatment depends on disease type and severity (ie. spontaneous bleeding?) and the need for surgery
  2. Desmopressin acetate (DDAVP) - improvement in {VWF:Ag} 2-5 fold in people, but only mild in dogs.
    • A study looking at 16 dobermans (Callan 2005) showed improvement in mean plasma VWF from 10% to 17%, 1 hour after 1 mcg/kg SC DDAVP.
    • Proportional increases in all multimers was observe d
    • Can be used at 1 mcg/kg SC q 24 hours for prophylaxis
    • 30 minutes prior to surgery
  3. Blood component therapy - VWF plasma half life 12 hours
    • Whole blood
    • FFP
    • Cryoprecipitate - best choice -~37ml from 250-300 ml of FFP
19
Q

List known hereditary platelet function disorders and their pathophysiological mechanisms

A
  1. Glanzmann thrombasthenia
    1. absence or deficiency in the fibrinogen receptor (GPIIb-IIIa)
  2. Basset thrombopathia
  3. Platelet procoagulant deficiency (Scott Syndrome)
    • Autosomal-recessive in GSD
    • impaired platelet membrane phosphatidylsterine externalisation - decreased coated platelets
    • Decreased thrombinase activity
    • Decreased thrombin production
    • Nb. platelet function tests are normal.
    • Diagnosed via flow cytometry / DNA test
  4. P2Y12 Receptor Disorder
    • present in ~ 60% Greater Swiss Mountain dogs
20
Q

List potential causes for acquired platelet dysfunction

A
  1. Uraemia
  2. Hepatobiliary disease
  3. Paraproteinaemia
  4. Anaemia - altered rheological properties and decreased ADP quantity
  5. Drugs:
    • NSAIDS, especially aspirin
    • cephalosporins
    • Voluven
    • Clopidogrel (platelet P2Y12 ADP receptor antagonist)