Scientific Comments

A novel strategy for the screening for platelet refractoriness: prospects and limitations

Valder R. Arruda Over the last decades the progressive increase in platelet use has coincided with
increasingly aggressive myelosuppressive therapy for malignancies or allogeneic hematopoietic
stem cell transplantation. The US National Marrow Donor Program predicts a doubling in
University of Pennsylvania, USA

allogeneic transplants between 2010 and 2015(1). More than three million Brazilian donors
were registered in the Bone Marrow Donors Worldwide program by 2010(2). Together, it is
anticipated that there will be a continuing growth in the number of allogeneic transfusions.
Although platelets were identified over 100 year ago, data accumulated from the last ten years
has provided a boost of novel information on platelet biology, and hope for the development
of therapy to improve platelet production and survival(3,4).
Current data suggest that platelets emerge from the tips of the proplatelet extension of
mature megakaryocytes, and individual platelets may be capable of dividing in the circulation(3).
The identification of thrombopoietin, the primary cytokine required for normal numbers of
marrow megakaryocytes and circulating platelets, resulted in the generation of its recombinant
derivatives, now used to minimize the duration of thrombocytopenia. Interleukin-11 the
only US Federal Food and Drug Agency (FDA) approved drug to treat thrombocytopenia
has a limited effect on platelet numbers after intensive myelosuppression. Other cell-based
therapies, such as the generation of megakaryocytes and the use of human embryonic/mature
pluripotent hematopoietic precursors, raise the possibility of a future supply of platelets(1).
To date, the platelet products available for transfusion are based on platelet concentrates
from whole blood or platelet apheresis. The main complication in the use of platelets is the
development of alloantibodies that precludes the improvement of severe thrombocytopenia,
which is associated with increased morbidity and mortality(5,6).
Platelet transfusion refractoriness (PTR) is characterized by the lack of adequate post-
transfusional platelet increments, with the underlying mechanisms being due to immune and
non-immune pathologies(4,6). The latter comprises the large majority (~70-80%) of PTR cases.
Platelet alloimmunization is the result of both the donor product transfused and the immune
status of the recipient. Platelets express a number of antigens that have been shown to influence
post-transfusion counts and platelet survival; these include ABO, human leukocyte antigens
(HLA) and human platelet antigens (HPA). Primary immunization against HLA-antigens,
which are also expressed in other cells, is caused mostly by contaminating leukocytes in
platelet products; HPA-specific immunization is less frequent.
The management of alloimmune PTR is clinically challenging and without consensus
on the ideal therapeutic approach(6). Thus, it is highly attractive to develop preventive
strategies to minimize the risk of PTR and to develop diagnostic and screening tests to
assess the risk of platelet alloimmunization and to guide the most appropriate therapy.
Conflict-of-interest disclosure: Currently, clinically suspected PRT is confirmed by using a series of laboratory tests such
The author declares no competing financial as those listed in Table 1(4,6). There is no clear gold standard, and the goal is to determine
interest a panel-reactive antibody (PRA) score in terms of the percentage of positive tests in the
panel and their specificity towards the antigen. The agreement of different tests in detecting
Submitted: 6/24/2013
Accepted: 6/28/2013 HLA antibodies varies considerably depending on the antigen source and purity, specific
technical design and laboratory experience.
Corresponding author: In this issue of the Revista Brasileira de Hematologia e Hemoterapia, Bub et al. sought to
determine whether screening for PTR using a simplified method based on the flow cytometry
Valder R. Arruda
Perelman School of Medicine
University of Pennsylvania immunofluorescence test (FC-PIFT) could be advantageous compared to standard tests using
The Children’s Hospital of Philadelphia anti-HLA antibody assays(7). The results showed an overall accuracy of the FC-PIFT of 80%,
3501 Civic Center Blvd
with sensitivity of 86% and specificity of 75%, and with a negative predictive rate of 86%.
5056 CTRB
Philadelphia, PA 19104, USA These results were comparable, yet not identical, with the data using anti-HLA antibody tests.
[email protected] The main concern is the relative discrepancy of FC-PIFT positive/anti-HLA negative results
that will require further tests to determine whether these findings represent the relative rare
www.rbhh.org or www.scielo.br/rbhh
HPA-restricted or non-clinically relevant antibodies. The limited number of patients tested
also imposes limitations on the overall impact of these findings. Nevertheless, this initial study
DOI: 10.5581/1516-8484.20130065 has the potential to provide an alternative screening detection method for clinically relevant

Rev Bras Hematol Hemoter. 2013;35(4):225-41 233

Table 1 - Tests for the diagnosis of anti-HLA or anti-HPA antibodies related Brazilian public health systems is unknown. Thus, in patients
to platelet transfusion refractoriness
with a high risk of PR, the costs of suboptimal transfusions (not
Assay Target Comments properly tested) and the delay in restoring hemostasis all may
Lymphocytotoxicity
Only detects cytotoxic favor the use of additional tests to improve the most beneficial
HLA antibodies, technically
test (LCT)
complex
platelet product to a specific patient population.
Platelet
immunofluorescence test HLA and HPA References
(PIFT)*
Lymphocyte
HLA
Detection by flow 1. Leavitt AD. Are there more tricks in the bag for treating thrombocytopenia?
immunofluorescence test cytometry is preferable J Clin Invest. 2010;120(11):3807-10. Comment in: J Clin Invest. 2010;
Antigen capture ELISA* HLA 120(11):3917-22.

Monoclonal antibody 2. Bone Marrow Donors Worlwide [Internet]. The Netherlands; BMDW
specific immobilization The most sensitive for [cited 2012 Nov 2]. Available from: www.bmdw.org
HPA or HPA-HLA
of platelet antigen HLA alloantibodies 3. Italiano JE Jr, Patel-Hett S, Hartwig JH. Mechanics of proplatelet
(MAIPA)
elaboration. J Thromb Haemost. 2007;5(Suppl 1):18-23.
Solid-phase red cell
agglutination test
HLA-HPA 4. Pavenski K, Freedman J, Semple JW. HLA alloimmunization against
platelet transfusions: pathophysiology, significance, prevention and
Multiple flow cytometric management. Tissue Antigens. 2012;79(4):237-45.
HLA
bead assays*
5. Leukocyte reduction and ultraviolet B irradiation of platelets to prevent
HLA: human leukocyte antigens; HPA: human platelet antigens; ELISA: enzyme-linked
alloimmunization and refractoriness to platelet transfusions. The Trial
immunosorbent assay
to Reduce Alloimmunization to Platelets Study Group. N Engl J Med.
* Methods used in some or in all samples in the report by Bud et al. as standard for anti-
1997;337(26):1861-9. Comment in: N Engl J Med. 1998;338(20):1468-
HLA alloantibodies.
9; author reply 1469-70. N Engl J Med. 1997;337(26):1914-5.
6. Hod E, Schwartz J. Platelet transfusion refractoriness. Br J Haematol.
2008;142(3):348-60.
platelet alloantibodies. It is possible that selecting a high-risk
7. Bub CB, Martinelli BM, Avelino TM, Gonçalez AC, Barjas-Castro ML,
population for PTR using a simplified and fast methodology Castro V. Platelet antibody detection by flow cytometry: an effective
may be an attractive strategy. Notably, studies in the Brazilian method for evaluation and support in platelet refractoriness. Rev Bras
pediatric and adolescent population are desired to define the best Hematol Hemoter. 2013;35(4):252-5.
approach to recognize PTR(8). 8. Luban NL, McBride E, Ford JC, Gupta S. Transfusion medicine problems
Finally, the cost assessment of an intermediary test also and solutions for the pediatric hematologist/oncologist. Pediatr Blood
needs to be taken into account. Although the total cost of a platelet Cancer. 2012;58(7):1106-11.
transfusion procedure is unclear, it is estimated that a standard 9. Benjamin RJ. The effect of various platelet dosing strategies on
clinical situation (i.e. no anticipated platelet refractoriness) in transfusion costs. Transfusion. 2012;52(9):1852-4. Comment on:
the US could range from ~470 to 760 dollars(9). The cost in the Transfusion. 2012;52(9):1957-67; Transfusion. 2010;50(4):753-65.

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234 Rev Bras Hematol Hemoter. 2013;35(4):225-41