Диагностика тромбоцитопений - Журнал Терапевтический архив № 7 Вопросы гематологии 2018

Диагностика тромбоцитопений

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Аннотация

В статье рассмотрены методы лабораторной диагностики тромбоцитопений. Дифференциальный диагноз чаще всего проводится между иммунной и гипопродуктивной формами тромбоцитопении. Иммунные тромбоцитопении развиваются вследствие появления в кровотоке антитромбоцитарных антител и ускоренного разрушения сенсибилизированных антителами тромбоцитов, а гипопродуктивные тромбоцитопении − вследствие нарушения продукции тромбоцитов в костном мозге. Главные направления лабораторной диагностики тромбоцитопений связаны с анализом ауто- и аутоантител и оценкой продукции тромбоцитов и их оборота в кровотоке. Для исследования антитромбоцитарных антител применяют следующие методы: 1) измерение количества тромбоцит-ассоциированных иммуноглобулинов, 2) определение реагирующих с тромбоцитами циркулирующих в плазме антител и 3) определение антител антиген-специфическими методами – по их реакции с изолированными антигенами тромбоцитов. Эффективность продукции тромбоцитов можно определять по содержанию в крови «молодых» форм тромбоцитов (ретикулярные тромбоциты). Еще один метод для оценки продукции тромбоцитов, а также скорости их оборота в кровотоке – определение в плазме растворимого гликокалицина, фрагмента гликопротеина Ib, отщепляющегося с поверхности тромбоцитов при их разрушении в селезенке и печени. У больных с иммунной тромбоцитопенией всегда определяются аутоантитела против тромбоцитов, существенно повышено процентное содержание ретикулярных тромбоцитов, а количество плазменного гликокалицина – в пределах нормы или повышено. У больных с гипопродуктивной тромбоцитопенией аутоантитела не выявляются или выявляются на низком уровне, процентное содержание ретикулярных тромбоцитов в пределах нормы или умеренно повышено, а количество плазменного гликокалицина снижено. Отдельные разделы статьи посвящены диагностике гаптеновых форм иммунных тромбоцитопений (гепарин-индуцированная тромбоцитопения и др.) и аллоиммунных тромбоцитопений (в частности, неонатальной аллоиммунной тромбоцитопении).

Ключевые слова: тромбоциты, тромбоцитопении, иммунные тромбоцитопении, антитромбоцитарные антитела, ретикулярные тромбоциты, гликокалицин.

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Laboratory methods used for the diagnostics of thrombocytopenias are reviewed. Differential diagnosis is usually carried out between immune and hypoproductive forms of thrombocytopenia. Immune thrombocytopenias are caused by appearance in blood of antiplatelet abtibodies and accelerated destruction of platelets sensibilized by those antibodies, and hypoproductive thrombocytopenias – by impaired platelet production in the bone marrow. Main directions of the laboratory diagnostics of thrombocytopenias – analysis of auto- and alloautoantibodies and evaluation of platelet production and turnover in the blood stream. The following methods are used for the investigation of antiplatelet antibodies: 1) measurement of platelet associated immunoglobulins; 2) determination of circulating antibodies reacting with platelets; 3) determination of antibodies using antigen specific methods – by their reactivity with isolated platelet antigens (glycoproteins). Efficacy of platelet production could be assessed by measuring in blood the amount of “young” (reticulated) platelets. One more method for the evaluation of platelet production as well as the rate of platelet turnover – measurement of plasma soluble glycocalicin, glycoprotein Ib fragment shed from the surface of platelets upon their destruction in spleen and liver. In patients with immune thrombocytopenia autoantibodies are evaluated in all cases, the percentage of reticulated platelets is significantly increased and the amount of plasma glycocalicin is within the normal range or increased. In patients with hypoproductive thrombocytopenia autoantibodies are not detected or detected at low level, the percentage of reticulated platelets is within the normal range or slightly increased and the amount of plasma glycocalicin is lowered. Diagnostics of hapten forms of immune thromocytopenias (heparin-induced thrombocytopenia and others) and of alloimmune thrombocytopenias (neonatal alloimmune thrombocytopenia in particular) are considered in the separate sections of this review.

Keywords: platelets, thrombocytopenias, immune thrombocytopenias, antiplatelet antibodies, reticulated platelets, glycocalicin.

Список литературы

1. Segal JB, Moliterno AR. Platelet сounts differ by sex, ethnicity, and age in the United States. Ann Epidemiol. 2006; 16: 123-130.
2. Biino G, Santimone I, Minelli C, Sorice R, Frongia B, Traglia M et al. Age- and sex-related variations in platelet count in Italy: a proposal of reference ranges based on 40987 subjects’ data. PLoS ONE. 2013 ; 8 (1): e54289. doi:10.1371/journal.pone.0054289
3. Rodeghiero F, Stasi R, Gernsheimer T, Michel M, Provan D, Arnold DM et al. Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood. 2009; 113: 2386-2393.
4. Veneri D, Franchini M, Randon F, Nichele I, Pizzolo G, Ambrosetti A. Thrombocytopenias: a clinical point of view. Blood Transfus. 2009; 7: 75-85.
5. Psaila B, Bussel JB. Immune thrombocytopenia (ITP). In: Platelets. Third edition. (Michelson AD, ed.). Amsterdam, Boston, Heidelberg et al: Academic Press, Elsevier Inc. 2013: 819-833.
6. Мазуров А.В. Физиология и патология тромбоцитов. М.: Литтерра, 2011: 206-251. [Mazurov AV. Platelet physiology and pathology. M.:Litterra, 2011: 206-251. (In Russ.)].
7. Bizzaro N. Pseudothrombocytopenia. In: Platelets. Third edition. (Michelson AD, ed.). Amsterdam, Boston, Heidelberg et al: Academic Press, Elsevier Inc. 2013: 989-997.
8. Michelson AD. The clinical approach to disorders of platelet number and function. In: Platelets. Third edition. (Michelson AD, ed.). Amsterdam, Boston, Heidelberg et al: Academic Press, Elsevier Inc. 2013: 813-818.
9. Kienast J, Schmitz G. Flow cytometric analysis of thiazole orange uptake by platelets: a diagnostic aid in the evaluation of thrombocytopenic disorders. Blood. 1990; 75: 116-121.
10. Kurata Y, Hayashi S, Kiyoi T, Kosugi S, Kashiwagi H. Hoda S, Tomiyama Y. Diagnostic value of tests for reticulated platelets, plasma glycocalicin, and thrombopoietin for discriminating between hyperdestructive and hypoplastic thrombocytopenia. Am J Clin Pathol. 2001; 115: 656-664.
11. Steinberg MH, Kelton JG, Coller BS. Plasma glycocalicin. An aid in the classification of thrombocytopenic patients. N Engl J Med. 1987; 317: 1037-1042.
12. Beer JH, Buchi L, Steiner B. Glycocalicin: a new assay - the normal plasma levels and its potential usefulness in selected diseases. Blood. 1994; 83: 691-702.
13. Kunishima S, Tahara T, Kato T, Kobayashi S, Saito H, Naoe T. Serum thrombopoietin and plasma glycocalicin concentrations as useful diagnostic markers in thrombocytopenic disorders. Eur J Haematol. 1996; 57: 68-71.
14. Khaspekova SG, Shustova ON, Golubeva NV, Vasiliev SA, Mazurov AV. Relationships of mean platelet volume and plasma thrombopoietin with glycocalicin levels in thrombocytopenic patients. Acta Haematologica. 2015; 133: 295-299.
15. Ichikawa N, Ishida F, Shimodaira S, Tahara T, Kato T, Kitano K. Regulation of serum thrombopietin levels by platelets and megakaryocytes in patients with aplastic anaemia and idiopathic thrombocytopenic purpura. Thromb Haemost. 1996; 76: 156-160.
16. Kuznetsov AI, Ivanov AL, Idelson LI, Mazurov AV. Different mechanisms of thrombocytopenia in patients with lymphoproliferative disorders. Eur J Haematol. 1992; 49: 113-118.
17. Provan D, Stasi R, Newland AC, Blanchette VS, Bolton-Maggs P, James B. Bussel JB et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010; 115: 168-186.
18. Terrell DR, Beebe LA, Vesely SK, Neas BR, Segal JB, and James N. George JN. The incidence of immune thrombocytopenic purpura in children and adults: A critical review of published reports. Am J Hematol. 2010; 85: 174-180.
19. Савченко В.Г. Патогенез и методы диагностики идиопатической тромбоцитопенической пурпуры. Тер. Архив. 1979; 51(9): 122-131. [Savchenko VG. Pathogenesis and the methods of diagnosis of idiopathic thrombopenic purpura. Ter Arkh. 1979; 51 (9): 122-131. (In Russ.)].
20. Kelton JG. The serological investigation of patients with autoimmune thrombocytopenia. Thromb Haemost. 1995; 74: 228-233.
21. McMillan R. Clinical role of antiplatelet antibody assays. Semin Thromb Haemost. 1995; 21: 37-45.
22. Зотиков Е.А., Бабаева А. Г., Головкина Л.Л. Тромбоциты и антитромбоцитарные антитела. Монолит. М., 2003. [Zotikov EA, Babaeva AG, Golovkina LL. Platelets and antiplatelet antibodies. Monolit. Moscow, 2003. (In Russ.)].
23. McMillan R. The role of antiplatelet autoantibody assays in the diagnosis of immune thrombocytopenic purpura. Curr Hematol Rep. 2005; 4: 160-165.
24. Cines DB, Liebman H, Stasi R. Pathobiology of secondary immune thrombocytopenia. Semin Hematol. 2009; 46 (1 Suppl 2): S2-14.
25. Анфимова О.М., Хаспекова С.Г., Масчан А.А., Мазуров А.В. Аутоантитела против тромбоцитов при тромбоцитопениях у детей. Бюлл Эксп Биол Мед. 1995; 120 (12): 636-639. [Anfimova OM, Khaspekova SG, Maschan AA, Mazurov AV. Autoantibodies against platelets in thrombocytopenias in children. Biull Eksp Biol Med. 1995; 120 (12): 636-639. (In Russ.)].
26. Анфимова О.М., Хаспекова С.Г., Власова И.В., Мазуров А.В. Определение антигенов антитромбоцитарных антител у больных с различными формами тромбоцитопении. Бюлл Эксп Биол Мед. 1998; 125 (5): 596-600. [Anfimova OM, Khaspekova SG, Vlasova IV, Mazurov AV. Determination of antigens of anti-thrombocyte antibodies in patients with different forms of thrombocytopenia. Biull Eksp Biol Med. 1998; 125 (5): 596-600. (In Russ.)].
27. Penny J. Ballem PJ, Segal GM, Stratton JR, Gemsheimer T, Adamson JW, Slichter SJ. Mechanisms of thrombocytopenia in chronic autoimmune thrombocytopenic purpura. Evidence of both impaired platelet production and increased platelet clearance. J Clin Invest. 1987; 80: 33-40.
28. Kaito K, Otsubo H, Usui N, Yoshida M, Tanno J, Kurihara E, Matsumoto K, Hirata R, Domitsu K, Kobayashi M. Platelet size deviation width, platelet large cell ration, and mean platelet volume have sufficient sensitivity and specificity in the diagnosis of immune thrombocytopenia. Br J Haematol. 2005; 128: 698-702.
29. Aster RH, Curtis BR, McFarland JG, Bougie DW. Drug-induced immune thrombocytopenia: pathogenesis, diagnosis and management. J Thromb Haemost. 2009; 7: 911-918.
30. Greinacher A, Warkentin TE, Chong BH. Heparin-induced thrombocytopenia. In: Platelets. Third edition. (Michelson AD, ed.). Amsterdam, Boston, Heidelberg et al: Academic Press, Elsevier Inc. 2013: 851-882.
31. Kaplan C, Heyu N, Freedman J. Alloimmune thrombocytopenia. In: Platelets. Third edition. (Michelson AD, ed.). Amsterdam, Boston, Heidelberg et al: Academic Press, Elsevier Inc. 2013: 953-970.
32. Bussel JB, Primiani A. Fetal and neonatal alloimmune thrombocytopenia: progress and ongoing debates. Blood Reviews. 2008; 22: 33-52.
33. Koyama S, Tomimatsu T, Kanagawa T, Kumasawa K, Tsutsui T, Kimura T. Reliable predictors of neonatal immune thrombocytopenia in pregnant women with idiopathic thrombocytopenic purpura. Am J Hematol. 2012; 87: 15-21.
34. Lambert MP, Poncz M. Inherited thrombocytopenias. In: Platelets. Third edition. (Michelson AD, ed.). Amsterdam, Boston, Heidelberg et al: Academic Press, Elsevier Inc. 2013: 971-988.

________________________________________________

1. Segal JB, Moliterno AR. Platelet сounts differ by sex, ethnicity, and age in the United States. Ann Epidemiol. 2006; 16: 123-130.
2. Biino G, Santimone I, Minelli C, Sorice R, Frongia B, Traglia M et al. Age- and sex-related variations in platelet count in Italy: a proposal of reference ranges based on 40987 subjects’ data. PLoS ONE. 2013 ; 8 (1): e54289. doi:10.1371/journal.pone.0054289
3. Rodeghiero F, Stasi R, Gernsheimer T, Michel M, Provan D, Arnold DM et al. Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood. 2009; 113: 2386-2393.
4. Veneri D, Franchini M, Randon F, Nichele I, Pizzolo G, Ambrosetti A. Thrombocytopenias: a clinical point of view. Blood Transfus. 2009; 7: 75-85.
5. Psaila B, Bussel JB. Immune thrombocytopenia (ITP). In: Platelets. Third edition. (Michelson AD, ed.). Amsterdam, Boston, Heidelberg et al: Academic Press, Elsevier Inc. 2013: 819-833.
6. [Mazurov AV. Platelet physiology and pathology. M.:Litterra, 2011: 206-251. (In Russ.)].
7. Bizzaro N. Pseudothrombocytopenia. In: Platelets. Third edition. (Michelson AD, ed.). Amsterdam, Boston, Heidelberg et al: Academic Press, Elsevier Inc. 2013: 989-997.
8. Michelson AD. The clinical approach to disorders of platelet number and function. In: Platelets. Third edition. (Michelson AD, ed.). Amsterdam, Boston, Heidelberg et al: Academic Press, Elsevier Inc. 2013: 813-818.
9. Kienast J, Schmitz G. Flow cytometric analysis of thiazole orange uptake by platelets: a diagnostic aid in the evaluation of thrombocytopenic disorders. Blood. 1990; 75: 116-121.
10. Kurata Y, Hayashi S, Kiyoi T, Kosugi S, Kashiwagi H. Hoda S, Tomiyama Y. Diagnostic value of tests for reticulated platelets, plasma glycocalicin, and thrombopoietin for discriminating between hyperdestructive and hypoplastic thrombocytopenia. Am J Clin Pathol. 2001; 115: 656-664.
11. Steinberg MH, Kelton JG, Coller BS. Plasma glycocalicin. An aid in the classification of thrombocytopenic patients. N Engl J Med. 1987; 317: 1037-1042.
12. Beer JH, Buchi L, Steiner B. Glycocalicin: a new assay - the normal plasma levels and its potential usefulness in selected diseases. Blood. 1994; 83: 691-702.
13. Kunishima S, Tahara T, Kato T, Kobayashi S, Saito H, Naoe T. Serum thrombopoietin and plasma glycocalicin concentrations as useful diagnostic markers in thrombocytopenic disorders. Eur J Haematol. 1996; 57: 68-71.
14. Khaspekova SG, Shustova ON, Golubeva NV, Vasiliev SA, Mazurov AV. Relationships of mean platelet volume and plasma thrombopoietin with glycocalicin levels in thrombocytopenic patients. Acta Haematologica. 2015; 133: 295-299.
15. Ichikawa N, Ishida F, Shimodaira S, Tahara T, Kato T, Kitano K. Regulation of serum thrombopietin levels by platelets and megakaryocytes in patients with aplastic anaemia and idiopathic thrombocytopenic purpura. Thromb Haemost. 1996; 76: 156-160.
16. Kuznetsov AI, Ivanov AL, Idelson LI, Mazurov AV. Different mechanisms of thrombocytopenia in patients with lymphoproliferative disorders. Eur J Haematol. 1992; 49: 113-118.
17. Provan D, Stasi R, Newland AC, Blanchette VS, Bolton-Maggs P, James B. Bussel JB et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010; 115: 168-186.
18. Terrell DR, Beebe LA, Vesely SK, Neas BR, Segal JB, and James N. George JN. The incidence of immune thrombocytopenic purpura in children and adults: A critical review of published reports. Am J Hematol. 2010; 85: 174-180.
19. [Savchenko VG. Pathogenesis and the methods of diagnosis of idiopathic thrombopenic purpura. Ter Arkh. 1979; 51 (9): 122-131. (In Russ.)].
20. Kelton JG. The serological investigation of patients with autoimmune thrombocytopenia. Thromb Haemost. 1995; 74: 228-233.
21. McMillan R. Clinical role of antiplatelet antibody assays. Semin Thromb Haemost. 1995; 21: 37-45.
22. [Zotikov EA, Babaeva AG, Golovkina LL. Platelets and antiplatelet antibodies. Monolit. Moscow, 2003. (In Russ.)].
23. McMillan R. The role of antiplatelet autoantibody assays in the diagnosis of immune thrombocytopenic purpura. Curr Hematol Rep. 2005; 4: 160-165.
24. Cines DB, Liebman H, Stasi R. Pathobiology of secondary immune thrombocytopenia. Semin Hematol. 2009; 46 (1 Suppl 2): S2-14.
25. [Anfimova OM, Khaspekova SG, Maschan AA, Mazurov AV. Autoantibodies against platelets in thrombocytopenias in children. Biull Eksp Biol Med. 1995; 120 (12): 636-639. (In Russ.)].
26.[Anfimova OM, Khaspekova SG, Vlasova IV, Mazurov AV. Determination of antigens of anti-thrombocyte antibodies in patients with different forms of thrombocytopenia. Biull Eksp Biol Med. 1998; 125 (5): 596-600. (In Russ.)].
27. Penny J. Ballem PJ, Segal GM, Stratton JR, Gemsheimer T, Adamson JW, Slichter SJ. Mechanisms of thrombocytopenia in chronic autoimmune thrombocytopenic purpura. Evidence of both impaired platelet production and increased platelet clearance. J Clin Invest. 1987; 80: 33-40.
28. Kaito K, Otsubo H, Usui N, Yoshida M, Tanno J, Kurihara E, Matsumoto K, Hirata R, Domitsu K, Kobayashi M. Platelet size deviation width, platelet large cell ration, and mean platelet volume have sufficient sensitivity and specificity in the diagnosis of immune thrombocytopenia. Br J Haematol. 2005; 128: 698-702.
29. Aster RH, Curtis BR, McFarland JG, Bougie DW. Drug-induced immune thrombocytopenia: pathogenesis, diagnosis and management. J Thromb Haemost. 2009; 7: 911-918.
30. Greinacher A, Warkentin TE, Chong BH. Heparin-induced thrombocytopenia. In: Platelets. Third edition. (Michelson AD, ed.). Amsterdam, Boston, Heidelberg et al: Academic Press, Elsevier Inc. 2013: 851-882.
31. Kaplan C, Heyu N, Freedman J. Alloimmune thrombocytopenia. In: Platelets. Third edition. (Michelson AD, ed.). Amsterdam, Boston, Heidelberg et al: Academic Press, Elsevier Inc. 2013: 953-970.
32. Bussel JB, Primiani A. Fetal and neonatal alloimmune thrombocytopenia: progress and ongoing debates. Blood Reviews. 2008; 22: 33-52.
33. Koyama S, Tomimatsu T, Kanagawa T, Kumasawa K, Tsutsui T, Kimura T. Reliable predictors of neonatal immune thrombocytopenia in pregnant women with idiopathic thrombocytopenic purpura. Am J Hematol. 2012; 87: 15-21.
34. Lambert MP, Poncz M. Inherited thrombocytopenias. In: Platelets. Third edition. (Michelson AD, ed.). Amsterdam, Boston, Heidelberg et al: Academic Press, Elsevier Inc. 2013: 971-988.

Авторы

А.В. МАЗУРОВ 1, С.Г. ХАСПЕКОВА 1, С.А. ВАСИЛЬЕВ 2

1 Национальный медицинский исследовательский центр кардиологии Минздрава Российской Федерации, Москва, Россия;
2 Национальный медицинский исследовательский центр гематологии Минздрава Российской Федерации, Москва, Россия

________________________________________________

A.V. MAZUROV 1, S.G. KHASPEKOVA 1, S.A. VASILIEV 2

1 National Medical Research Center for Cardiology Russian Ministry of Health, Moscow, Russia;
2 National Medical Research Center for Hematology Russian Ministry of Health, Moscow, Russia

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