I am the 9%: Making the case for whole‐blood platelets

Over the last 15 years, there has been a trend in the United States towards the increasing use of apheresis platelet (AP) concentrates over whole‐blood‐derived platelets (WBP). Although 1‐h‐ and 24‐h‐corrected count increments tend to be higher with AP, this does not translate into improved haemostatic efficiency when used to prevent bleeding in haematology/oncology patients. WBP expose the recipient to more donors than apheresis products. However, recent studies have shown no significant differences in the rates of bacterial contamination, human leukocyte antigen alloimmunisation, RhD alloimmunisation, transfusion‐related acute lung injury or febrile non‐haemolytic transfusion reactions between these two products. Given the overall low rates of virally contaminated units in the era of nucleic acid testing and rigorous donor screening, the difference in donor exposures of 4–6 vs 1 has minimal clinical relevance. Although studies point to a marginally increased risk of donor adverse events associated with WBP, the absolute risk is too miniscule to act as a deterrent to making whole‐blood donations. Both types of platelet concentrates should therefore be considered clinically equivalent; in this light, the most responsible use of the community donor resource pool, which both optimises the utility of a whole‐blood donation and meets the clinical needs of thrombocytopenic recipients, is to have a mix of both types of platelet products so as to mitigate the risk of shortages.     

An αIIbβ3 antagonist prevents thrombosis without causing Fc receptor γ‐chain IIa‐mediated thrombocytopenia

Essentials

• FcγRIIa‐mediated thrombocytopenia is associated with drug‐dependent antibodies (DDAbs).
• We investigated the correlation between α_IIbβ₃ binding epitopes and induction of DDAbs.
• An FcγRIIa‐transgenic mouse model was used to evaluate thrombocytopenia among anti‐thrombotics.
• An antithrombotic with binding motif toward α_IIbβ‐propeller domain has less bleeding tendency.

Summary

Background

Thrombocytopenia, a common side effect of Arg‐Gly‐Asp‐mimetic antiplatelet drugs, is associated with drug‐dependent antibodies (DDAbs) that recognize conformation‐altered integrin α_IIbβ₃.

Objective

To explore the correlation between α_IIbβ₃ binding epitopes and induction of DDAb binding to conformation‐altered α_IIbβ₃, we examined whether two purified disintegrins, TMV‐2 and TMV‐7, with distinct binding motifs have different effects on induction of α_IIbβ₃ conformational change and platelet aggregation in the presence of AP2, an IgG₁ inhibitory mAb raised against α_IIbβ₃.

Methods

We investigated the possible mechanisms of intrinsic platelet activation of TMV‐2 and TMV‐7 in the presence of AP2 by examining the signal cascade, tail bleeding time and immune thrombocytopenia in Fc receptor γ‐chain IIa (FcγRIIa) transgenic mice.

Results

TMV‐7 has a binding motif that recognizes the α_IIb β‐propeller domain of α_IIbβ₃, unlike that of TMV‐2. TMV‐7 neither primed the platelets to bind ligand, nor caused a conformational change of α_IIbβ₃ as identified with the ligand‐induced binding site mAb AP5. In contrast to eptifibatide and TMV‐2, cotreatment of TMV‐7 with AP2 did not induce FcγRIIa‐mediated platelet aggregation and the downstream activation cascade. Both TMV‐2 and TMV‐7 efficaciously prevented occlusive thrombosis in vivo. Notably, both eptifibatide and TMV‐2 caused severe thrombocytopenia mediated by FcγRIIa, prolonged tail bleeding time in vivo, and repressed human whole blood coagulation indexes, whereas TMV‐7 did not impair hemostatic capacity.

Conclusions

TMV‐7 shows antiplatelet and antithrombotic activities resulting from a mechanism different from that of all other tested α_IIbβ₃ antagonists, and may offer advantages as a therapeutic agent with a better safety profile.