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Antineutrophil cytoplasmic autoantibodies with specificity for myeloperoxidase (MPO) were found in 53 patient sera that were routinely submitted for antineutrophil cytoplasmic antibody determination. Based on clinical and histologic criteria, 15 of these 53 patients were classified as having systemic necrotizing vasculitis of the polyarteritis group, 11 patients were classified as having Wegener's granulomatosis (WG), and 14 were classified as having idiopathic crescentic glomerulonephritis. The remaining 13 patients did not fulfill the diagnostic criteria for these disorders, although most of these patients had clinical symptoms compatible with these disorders. While all patients with WG had renal involvement, only 4 of the 15 patients with systemic necrotizing vasculitis of the polyarteritis group had glomerulonephritis. The sensitivity of autoantibodies to MPO for either systemic necrotizing vasculitis of the polyarteritis group, WG, or idiopathic crescentic glomerulonephritis was further tested in all our patients with these disorders (n = 104). Twenty-seven of 104 patients had autoantibodies to MPO. Furthermore, 69 of the remaining 77 patients had autoantibodies specific for the 29-kd serine protease, which has been reported to be specifically associated with WG. Sera from 8 patients were negative for either of these antibodies (92% sensitivity of autoantibodies to MPO and/or the 29-kd serine protease). The specificity of autoantibodies to MPO for either systemic necrotizing vasculitis of the polyarteritis group, WG, or idiopathic crescentic glomerulonephritis was also tested in selected groups of patients who had closely related diseases. Two of 144 patients had autoantibodies to MPO (specificity 99%). We conclude that these antibodies are not only associated with idiopathic and vasculitis-associated crescentic glomerulonephritis, but also with classic polyarteritis nodosa, Churg-Strauss syndrome, and the polyangiitis overlap syndrome without renal involvement. The presence of autoantibodies to MPO or the 29-kd serine protease is highly sensitive and specific for systemic necrotizing vasculitis of the polyarteritis group, WG, and idiopathic crescentic glomerulonephritis.

A case of a 32-year-old male negro is reported in whom acute renal failure was the first manifestation of a diffuse lymphocplasmocytic infiltrative disorder. The malignant cells only produced immunoglobulin light chain (lambda-type). A description of the pathological findings is given. The case presented can be considered an intermediate form between macroglobulinaemia and multiple myeloma.

Summary. Two murine monoclonal antibodies specific for human platelets were prepared and characterized by immunofluorescence, immunoprecipitation and by studying their effect on platelet function. Immunoprecipitation with lysates of normal platelets and platelets from a patient with Glanzmann's thrombasthenia revealed that the monoclonal antibodies were directed against glycoprotein GP IIIa. One of these anti-GP-IIIa antibodies (C17) inhibited both ADP- and collagen-induced platelet aggregation as well as ADP-induced fibrinogen binding to platelets. The other anti-GP-IIIa antibody (C15) also caused a complete inhibition of aggregation with collagen. However, a small, and fully reversible, ‘primary wave’ was observed if the platelets were stimulated with ADP when platelet-rich plasma was used. The ability to bind fibrinogen was unimpaired for platelets incubated with C15. These findings show that C15 and C17 probably recognize different determinants on GP IIIa. Neither of the monoclonal anti-GP-IIIa antibodies blocked the binding to Zwa-positive platelets of human polyclonal anti-Zwa antibodies. This implies that Zwa is different from the epitopes recognized by C15 and C17.

Summary. The purpose of this study was to determine whether quantitative or qualitative factors are of major importance in the destruction of red cells sensitized with incomplete warm autoantibodies of subclass IgG1. To that end, the relative amount of IgG1 antibody present on the red cells of patients with autoantibodies of this subclass only, was measured by means of continuous flow cytofluorometry. This method appeared to give an idea of the amount of antibody on red cells and was reproducible. The intensity of the fluorescence of patient's red cells, measured after incubation with a FITC-labelled anti-IgG1, was compared with the presence or absence of signs of increased haemolysis in vivo and the cytotoxic activity of normal monocytes towards these red cells in vitro. It appeared that it was predominantly the amount of IgGl autoantibody that determined whether or not these antibodies induced haemolysis in vivo or cytotoxicity of monocytec in vitro. This was also true with methyldopa-induced IgG1 autoantibodies.

Summary. The Rh blood group system represents a major immunodominant protein complex on red blood cells (RBC). Recently, the Rh homologues RhAG and RhCG were shown to promote ammonium ion transport in yeast. In this study, we showed that also in RBC the human Rh complex functions as an exporter of ammonium ions. We measured ammonium import during the incubation of RBC in a solution containing a radiolabelled analogue of NH4Cl (14C-methyl-NH3Cl). Rhnull cells of the regulator type (expressing no Rh complex proteins) accumulated significantly higher levels (P = 0·05) of radiolabelled methyl-ammonium ions than normal RBC, at room temperature. Rhnull cells of the amorph type (expressing limited amounts of Rh complex proteins) accumulated an intermediate amount of methyl-ammonium ions. To show that decreased ammonium export contributes to its accumulation, the release of intracellular methyl-ammonium from the cells was measured over time. In 30 s, normal RBC released 87% of the intracellular methyl-ammonium ions, whereas Rhnull cells of the regulator type released only 46%. We conclude that the Rh complex is involved in the export of ammonium from RBC.

Purpose To determine whether serum levels of soluble Fcγ receptor III and granulocyte colony-stimulating factor (G-CSF) are associated with the risk of infection in patients with neutropenia due to Felty's syndrome or systemic lupus erythematosus. Subjects and methods Serum levels of G-CSF and soluble Fcγ receptor III were measured by enzyme-linked immunosorbent assays in 13 patients with neutropenia due to Felty's syndrome, 10 patients with neutropenia due to systemic lupus erythematosus, and 41 controls with normal leukocyte counts (25 with systemic lupus erythematosus, 16 with rheumatoid arthritis). We calculated the area under the receiver operating characteristic (ROC) curves for the absolute neutrophil count, soluble Fcγ receptor III levels, and G-CSF levels. Results Nine of the neutropenic patients (7 with Felty's syndrome, 2 with lupus) had one or more infections within 3 months before and after blood samples were obtained. Absolute neutrophil counts were similar in neutropenic patients who did or did not have infections. However, the median level of soluble Fcγ receptor III (63 vs. 126 arbitrary units, P = 0.005) was significantly lower among patients who developed infections, whereas the median level of G-CSF (90.9 vs. 53.3 pg/mL, P = 0.04) was significantly higher compared with patients without infections. The area under the ROC curve was 0.58 ( P = 0.49) for the absolute neutrophil count, 0.84 ( P = 0.007) for soluble Fcγ receptor III levels, and 0.73 ( P = 0.03) for G-CSF levels. Conclusion In patients with chronic neutropenia due to rheumatic diseases, low soluble Fcγ receptor III levels and elevated G-CSF levels are better indicators of the risk of infection than is the neutrophil count.

Fourteen children with congenital thrombocytopenia were analysed in order to unravel the mechanisms underlying their thrombocytopenia and to evaluate the value of new laboratory tests, namely measurement of plasma thrombopoietin (Tpo) and glycocalicin (GC) levels and analysis of megakaryocytopoiesis in vitro. Three groups of patients were included. The first group (n = 6) was diagnosed with congenital amegakaryocytic thrombocytopenia. They had no megakaryocytes in the bone marrow, three out of four patients showed no megakaryocyte formation in vitro, and all had high Tpo and low GC levels. Mutations in the thrombopoietin receptor gene, c-mpl, were the cause. The second group of patients (n = 3) had normal Tpo and severely decreased GC levels. In bone marrow, normal to increased numbers of atypical, dysmature megakaryocytes were present. In vitro megakaryocyte formation was quantitatively normal. A defect in final megakaryocyte maturation and subsequent (pro-)platelets may be the cause of the thrombocytopenia. The patients in the third group (n = 5) had Wiskott-Aldrich syndrome (WAS). They had normal Tpo and GC levels and normal megakaryocyte formation both in vivo and in vitro. This corresponded with the generally accepted hypothesis that thrombocytopenia in WAS is due to increased platelet turnover. In conclusion, different causes of congenital thrombocytopenia can be distinguished using three parameters: Tpo and GC plasma levels and in vitro analysis of megakaryocytopoiesis. Therefore, these parameters may be helpful in early diagnosis of different forms of congenital thrombocytopenia.

Thrombopoietin (Tpo), the main regulator of thrombocytopoiesis, is a probable candidate to play a role in the increase in platelet counts that is frequently seen after surgery. In the current study, serial blood samples of patients that underwent major surgery were analysed with respect to Tpo kinetics, platelet turnover and inflammatory cytokines. Platelet Tpo content and plasma Tpo levels rose before platelet counts increased, suggesting that Tpo was indeed responsible for the elevation in platelet counts. In addition, an increase in interleukin 6 (IL-6) levels, but not in IL-11 and tumour necrosis factor alpha levels, was seen before the rise in Tpo concentration. In vitro, IL-6 was shown to enhance Tpo production by the HepG2 liver cell line. Thus, increased Tpo levels after surgery, possibly resulting from enhanced Tpo production under the influence of IL-6 or other inflammatory cytokines, are involved in an enhanced thrombocytopoiesis.

In multiple myeloma (MM), suppression of haematopoiesis occurs as a result of expansion of malignant cells in the bone marrow. Thrombopoietin (Tpo) levels in patients with impaired platelet production are generally found to be highly elevated. To examine the circulating Tpo levels in patients with MM, Tpo levels were measured in 50 serum samples from 34 patients. Tpo levels were subsequently related to disease stage, and cell numbers and markers, i.e. platelet count, leukocyte count and haemoglobin (Hb) concentration. Elevated Tpo levels were found in association with decreased platelet counts (n=8), but also in patients with normal platelet counts (n=14). The latter group included patients without and with signs of impaired haematopoiesis, i.e. with decreased Hb concentration and decreased leukocyte count. These results show that neither platelet counts nor Tpo levels are reliable parameters to judge bone-marrow failure in patients with MM. Furthermore, in patients with MM, increased Tpo levels may play a role in the maintenance of thrombocytopoiesis. The origin of the increased Tpo levels remains to be determined.

BACKGROUND: It has been shown in several studies that platelets play a role in the removal of TPO from the circulation. For instance, in vitro studies have shown that platelets can bind and internalize TPO, and transfusion studies have shown that the concentration of circulating TPO decreased after platelet transfusion. In the current study, the in vivo kinetics of plasma TPO levels and TPO uptake by transfused platelets is analyzed in more detail. STUDY DESIGN AND METHODS: Serial blood samples from patients who received a platelet transfusion were analyzed with respect to platelet count, plasma TPO concentration, and TPO content per platelet. In addition, the capacity of transfused platelets to bind TPO in vitro was assessed. RESULTS: Platelet counts increased immediately after transfusion, but subsequently started to decrease. Conversely, TPO levels decreased significantly but then returned to baseline level by 44 hours after transfusion. Platelet count and plasma TPO concentration were inversely correlated (rp = −0.9; p

Several lines of evidence suggest that coagulation may induce the release of thrombopoietin (TPO) into plasma and that TPO levels are higher in disseminated intravascular coagulation. Therefore we set out to illuminate the mechanism of TPO release in the setting of experimental endotoxemia, which induces activation of coagulation and platelets. Endotoxin (lipopolysachharide [LPS], 2 ng/kg) was infused into a total of 54 healthy men in two subsequent studies. Volunteers received infusions of unfractionated heparin, low-molecular-weight heparin, lepirudin, or placebo in a randomized, placebo-controlled fashion after bolus injection of LPS. TPO levels increased on average by 27% to 38% in all groups at 6 hours (P.05 vs baseline), although all active drugs effectively blocked coagulation. Platelet counts dropped by about 15% at 1 hour after LPS infusion, recovered after 2 days, and exceeded baseline values by 8% to 18% after 7 days (P.001 vs baseline for all groups). Yet lepirudin blunted the LPS-induced increase in circulating P-selectin by one half (P.005 vs placebo), whereas both heparins did not diminish the increase in this platelet or endothelial activation marker as compared with placebo. Endotoxemia enhances TPO plasma levels independent of the degree of coagulation induction, which eventually results in increased platelet numbers. Of potential clinical interest is the observation that the direct thrombin inhibitor lepirudin, in contrast to heparins, mitigated LPS-induced platelet activation.

Objective Reinfusion of ex vivo expanded autologous megakaryocytes together with stem cell transplantation may be useful to prevent or reduce the period of chemotherapy-induced thrombocytopenia. We compared the megakaryocyte expansion potential of CD34 + stem cells derived from different sources: cord blood (CB), peripheral blood (PB), bone marrow from adults (ABM), and bone marrow from children (ChBM). Three different growth factor combinations were tested to identify the best combination for each of the sources. Materials and Methods CD34 + cells were isolated from CB, PB, ABM, or ChBM and cultured in an in vitro liquid culture system in the presence of thrombopoietin (Tpo), Tpo + interleukin (IL-1), or Tpo + IL-3. After 8 days, proliferation was determined and the cultured cells were identified with lineage-specific surface markers by flow cytometry. Results Cultures with ChBM-derived CD34 + cells showed the lowest level of expansion of megakaryocytes and gave rise to more profound formation of myeloid and monocytic cells. In cultures with BM- or PB-derived cells, presence of IL-3 reduced the number of immature megakaryocytes (CD34 + CD41 + cells). However, in CB cultures, the number of CD34 + CD41 + cells was highest in cultures with Tpo + IL-3. Overall, cultures with CB CD34 + cells yielded the highest number of megakaryocytes, but these cells showed reduced ploidization and lower level of CD41 expression, suggesting less maturation. Conclusions Each of the different CD34 + cell sources responded differently to cytokine stimulation. For PB and ABM, the cytokine combination Tpo + IL-1 is most suitable to obtain high numbers of both immature and mature megakaryocytes for transfusion purposes. For CB, Tpo + IL-3 is better.

The applicability of different PCR-based assays for fetal RHD and K1 genotyping using DNA isolated from uncultured amniotic fluid cells has been tested prospectively: cord blood serotyping served as a control. For RHD genotyping, DNA was amplified with PCRs specific for RHD exon 7, the 3'-non-coding region and intron 4, using standard conditions. The results of these three separate assays were compared to those of a newly-developed multiplex PCR, simultaneously amplifying six regions of RHD. The PCRs analysing the 3'-non-coding region or intron 4 often yielded false-negative results or no results at all. Results of the exon 7 PCR and of the multiplex PCR always corresponded with postnatal serotyping, the multiplex PCR having the advantage of analysing six RHD-specific exons simultaneously. For K1 genotyping, two different PCR-based assays, both analysing the presence of T578C in the KEL gene, were applied. With the first method, a consensus 740-bp product of the KEL gene was amplified and subsequently specifically digested. As we were not able to obtain any PCR product from amniotic fluid DNA, we developed a new K1-specific PCR, amplifying a fragment of 91 bp only in cases of K1-positivity. With this PCR, all K1 genotyping results (n=30) correctly predicted the phenotypes. We conclude that fetal RHD and K1 genotyping can be performed reliably with DNA from uncultured amniotic fluid cells.

Hematopoietic progenitor cells (CD34+ cells) migrate to the bone marrow after reinfusion into peripheral veins. Stromal cell-derived factor-1 (SDF-1) is a chemokine produced by bone marrow stromal cells that induces migration of CD34+ cells. In this study we compared spontaneous and SDF-1-induced migration of CD34+ cells from bone marrow (BM), peripheral blood (PB), and cord blood (CB) across Transwell filters. Under all circumstances, CB CD34+ cells showed significantly more migration than did BM or PB CD34+ cells. SDF-1 induced migration of BM CD34+ cells was higher than that of PB CD34+ cells, possibly due to differences in sensitivity towards SDF-1. Indeed, PB CD34+ cells showed a significantly lower expression of the receptor for SDF-1 (CXCR-4) than did BM and CB CD34+ cells. The sensitivity to SDF-1, as measured by migration towards different concentrations of SDF-1, was identical for BM and CB-derived CD34+ cells and correlated with their equal CXCR-4 receptor expression. Coating of the filters with the extracellular matrix protein fibronectin (FN) strongly enhanced the SDF-1-induced migration of PB CD34+ cells (2.5 times) and of BM CD34+ cells (1.5 times). SDF-1 induced migration of PB CD34+ cells over FN-coated filters was blocked by antibodies against beta1 integrins. Subsequently, analysis was performed to determine whether SDF-1 preferentially promoted migration of subsets of CD34+ cells. Actively cycling CD34+ cells, which were present in BM (14%) but hardly in PB (2.2%) or CB (1.2%), were found to migrate preferentially towards SDF-1. In the input, 14%+/-2.5% of the BM CD34+ cells were in G2/M and S phase, whereas in the migrated fraction 20%+/-5.7% of the cells were actively cycling (p < 0.05). We did not observe preferential migration of phenotypically recognizable primitive CD34+ subsets, despite the fact that CB CD34+ cells are thought to contain a higher percentage of immature subsets. In conclusion, the relatively lower migration of PB CD34+ cells seems to be due to a lower sensitivity towards SDF-1, and the higher migrational capacity of CB CD34+ cells, in comparison to BM and PB CD34+ cells, seems to have an as yet unknown intrinsic cause. The increased migration of CB CD34+ cells may favor homing of these cells to the bone marrow, which might reduce the number of cells required for hematological reconstitution after transplantation.

Summary Background. Febrile conditions are often associated with increased platelet turnover and refractoriness to platelet transfusions, although several pyrogenic cytokines enhance thrombopoiesis. This study aimed to characterize the effects of experimental human endotoxemia on platelet turnover and thrombopoiesis. Methods. Endotoxin (4 ng/kg) was infused into 30 healthy men to study the regulation of thrombopoiesis in systemic human inflammation. Platelet counts, plasma thrombopoietin (TPO) and glycocalicin levels, and reticulated platelets (RP) were measured to evaluate the effect of acute endotoxemia on thrombopoiesis. Ten subjects received pretreatment with 1000 mg aspirin po. to evaluate possible effects of aspirin on platelet turnover, and ten subjects received paracetamol to control for effects of anti-pyresis. Results. Platelet counts dropped by about 15% (p 0.05). The number of circulating platelet-neutrophil aggregates increased more than 100% at 6 h (p

Acute idiopathic or autoimmune thrombocytopenic purpura (AITP) is a disorder found mainly in children, usually preceded by a viral infection, with a higher incidence in the autumn and winter. The platelet-specific autoantibodies in acute childhood AITP are more often of the IgM class. Chronic AITP occurs mostly in adults. The platelet immunofluorescence test (PIFT) detects platelet-specific autoantibodies with a sensitivity of 65–75%. The autoantibodies in chronic AITP are classified as IgG in 95%, IgM in 26% and IgA in 4% of cases. The antibodies are usually bound to platelets and are detectable as free circulating antibodies in about 40%. AITP in pregnancy may cause neonatal AITP by autoantibodies of the IgG class which pass the placenta barrier. The rare neonatal alloimmune thrombocytopenic purpura (NAITP) are caused by IgG alloantibodies against HPA-1a in 75–90%, HPA1b in 3–5%, HPA 3a in 4–5%, HPA5b in 6–19% and against private platelet antigens in 3%. To confirm the diagnosis of NAITP requires extensive serological testing of the child, and the parents have to be typed for the important platelet-specific antigens by PIFT, monoclonal antibody immobilisation of platelet antigens (MAIPA) and/or enzyme-linked immunosorbent assay (ELISA) techniques. Three mechanisms of drug-induced thrombocytopenias are described. Platelets of both the donor and the patient are destroyed in post-transfusion thrombocytopenic purpura (PTP) but PTP does not occur again if incompatible platelets are re-administered.

Although thrombopoietin (Tpo) was already described in the early sixties, it took more than 30 years before it was cloned. It became possible after the recognition and cloning of its receptor, Mpl. In the past few years new information about Tpo and Mpl has accumulated rapidly. Structure, biosynthesis and tissue expression have been elucidated. The central role of Tpo in the regulation of megakaryocytopoiesis and platelet production has become clear, as has the way in which this is accomplished. Tpo appears to be an important growth factor for haematopoietic stem cells as well. Thus, it may become one of the most important factors in stem cell transplantation. Finally, the signal transduction mechanisms involved and the way in which Tpo affects platelets and their precursors functionally have been studied in detail. The cloning and characterization of thrombopoietin and its receptor Mpl is one of the most important advances in the haematology of the nineties.

The cloning and characterization of thrombopoietin and its receptor Mpl in the past few years has been a major advance in haematology. It opens new ways of studying congenital and acquired platelet disorders, leading to new insights in the pathogenesis and treatment of this group of diseases. The Tpo level of the blood appears to be a useful marker for the differentiation between thrombocytopenia due to peripheral destruction and that due to thrombocytopoietic failure. No simple clinical parameter exist for this important differential diagnostic problem. When recombinant thrombopoietin becomes available for therapy it will rapidly become the drug of choice for many of our patients. However, because of all the legal and commercial issues at stake it is expected that it will still take a few more years before general availability is realized. Short peptides with Tpo activity ( Cwirla et al, 1997 ; Kimura et al, 1997 ), which can be synthesized chemically, may form a more easily obtainable alternative.

Recently, a new alloantigen on IgG Fc receptor type IIIb (FcγRIIIb), SH, was described (Bux et al, Blood 89:1027, 1997). We identified three healthy individuals whose neutrophils reacted positively with the SH antiserum. The neutrophil antigen (NA) phenotype of all three donors was NA(1+,2+). Analysis of genomic DNA showed that the three donors were positive for the described SH-encoding mutation in the NA2-FcγRIIIB gene, 266C→A. However, NA(1,2) genotyping and nucleotide sequencing of an NA2-specific fragment amplified from the genomic DNA fragment showed that these individuals carried three FcγRIIIBgenes, namely, NA1-FcγRIIIB, NA2-FcγRIIIB, andSH-FcγRIIIB, encoding NA1-FcγRIIIb, NA2-FcγRIIIb, and SH-FcγRIIIb, respectively. Southern blot analysis confirmed these findings. Furthermore, all three transcripts were isolated from neutrophil mRNA. To investigate whether the presence of threeFcγRIIIB genes resulted in a higher membrane expression of FcγRIIIb, we measured the reactivity of neutrophils from NA(1+,2+)SH(+) individuals with a panel of CD16 monoclonal antibodies (MoAbs) in comparison with neutrophils from NA(1+,2+)SH(−) controls. Reactivity of four different anti–pan-FcγRIII MoAbs and NA2-specific MoAb GRM1 was higher with SH(+) neutrophils compared with controls, whereas that of NA1-specific MoAbs was similar, which is in concordance with the results from the genomic analysis. We observed that reactivity with NA2-specific CD16 MoAb PEN1 was sixfold higher in SH(+) individuals compared with controls. Apparently, the 60Ala→Asp substitution in SH-FcγRIIIb influences the epitope recognized by PEN1. In conclusion, we identified three NA(1+,2+)SH(+) individuals carrying three FcγRIIIB genes and observed a clear gene-dosage effect on the level of expression of neutrophil FcγRIIIb.

Objective. To study whether the Fc gamma RIIIA-158V/F polymorphism, which affects IgG binding affinity, is a risk factor for systemic lupus erythematosus (SLE), Methods. We genotyped a group of 70 Caucasian SLE patients for all known Fc gamma R polymorphisms. Of this group, 45 patients (64%) had nephritis, In 35 patients, this diagnosis was confirmed by renal biopsy, Results, In the total group of 70 SLE patients, the frequency of the Fc gamma RIIIA-158F allele was 0.74, versus 0.57 in healthy controls (P = 0.003), The genotype distribution of the Fc gamma RIIIA-158V/F polymorphism was also significantly different from that of the control population (P = 0.004). The distribution of the other Fc gamma R polymorphisms-Fc gamma RIIA-131R/H, Fc gamma RIIIB-NA(1/2), and Fc gamma RIIIA-48L/R/H-was similar in SLE patients and controls, Conclusion. In our group of SLE patients, only the distribution of the alleles of the Fc gamma RIII4-158V/F polymorphism nas significantly different from that in the control group. This might indicate that macrophage expression of the Fc gamma RIIIA-158F isoform is involved in the disturbed clearance of immune complexes in patients with SLE.

SummaryIt has been reported that blood trombopoietin (TPO) levels can discriminate between thrombocytopenia due to increased platelet destruction and decreased platelet production. With our TPO ELISA and a glycocalicin ELISA we analysed a large group of patients in detail and could confirm and amplify the above notion in detail.TPO levels were determined in plasma from 178 clinically and serologically well-defined thrombocytopenic patients: 72 patients with idiopathic autoimmune thrombocytopenia (AITP), 29 patients with secondary AITP, 5 patients with amegakaryocytic thrombocytopenia and 72 patients who suffered from various diseases (46 in whom megakaryocyte deficiency was not and 26 in whom it was expected). In addition, we measured the level of glycocalicin as a marker of total body mass of platelets.In all patients with primary AITP and secondary AITP, TPO levels were within the normal range or in some (n = 7) cases only slightly increased. The level of glycocalicin was not significantly different from that of the controls (n = 95). The patients with amegakaryocytic thrombocytopenia had strongly elevated TPO levels and significantly decreased glycocalicin levels. Similarly, among the 72 thrombocytopenic patients with various disorders, elevated TPO levels were only found in patients in whom platelet production was depressed. The mean level of glycocalicin in these patients was decreased compared to that in controls and patients with AITP, but was not as low as in patients with amegakaryocytic thrombocytopenia.In conclusion, all patients with depressed platelet production had elevated levels of circulating TPO, whereas the TPO levels in patients with an immune-mediated thrombocytopenia were mostly within the normal range. Therefore, measurement of plasma TPO levels provides valuable diagnostic information for the analysis of thrombocytopenia in general.Moreover, treatment with TPO may be an option in AITP.

In our laboratory, a two-step procedure is used for purging precursor B ALL from autologous bone marrow grafts of children in second bone marrow remission. An immunorosette depletion method with CD19 and CD22 MAbs is followed by one cycle of complement-mediated cell lysis with CD9 and CD10 MAbs. The aim of the present study was to determine if the efficacy of this procedure could be further enhanced by including CD20 and CD72 MAbs in the current protocol. Leukemia-contaminated remission bone marrow was simulated by mixing cell line cells and normal bone marrow cells. The efficacy of purging of malignant cells was determined by culturing the cells in a limiting dilution assay. The effect of including CD20 and CD72 in the immunorosette depletion was limited. In contrast, when these MAbs were added during complement-mediated cell lysis, a significant increase in depletion of tumor cells was observed. This was true when complement lysis was carried out alone (0.4 versus 3.0 log depletion for Ros cells) and when it was preceded by immunorosette depletion (2.7 versus 4.1 log depletion for Ros cells). The loss of hematopoietic progenitor cells was not greater than with the current purging protocol.

We have previously described the private or family platelet antigen. Gro a , which was identified in a case of neonatal alloimmune thrombocytopenia. The Gro a antigen was found to be located on the GP IIIa (β 3 ) subunit of the GP IIb/IIIa complex, the most prominent fibrinogen receptor of platelets. Initial experiments to characterize the Gro a antigen at the molecular genetic level were unsuccessful. We therefore decided to use a different strategy to unravel the molecular basis of this antigen. Platelet GP IIIa mRNA of a Gro(a + ) and a Gro(a - ) donor was amplified with suitable primers in a reverse transcriptase-polymerase chain reaction (RT-PCR) and subjected to single-strand conformational polymorphism (SSCP) analysis. Three regions of the amplified GP IIIa cDNA derived from the Gro(a + ) donor showed a different SSCP pattern when compared to that of the Gro(a - ) donor. Direct nucleotide sequence analysis of these three segments revealed that two of them contained silent substitutions, A1163C, A1553G and G1565A. The first and the latter changes were described previously. In the third segment a G1996A mutation was found, predicting an arginine → histidine substitution at position 633 of the mature glycoprotein. PCR-ASRA (allele-specific restriction enzyme analysis) performed on cDNA as well as on genomic DNA with the restriction enzyme MaeIII showed that the His633 form of GPIIIa is restricted to the Gro(a + ) phenotype. The observed mutation is three amino acids upstream of the mutation underlying the HPA-8/Sr system (Arg636Cys), suggesting this region of GP IIIa to be susceptible for mutations. Moreover, the presence of a silent mutation and two low-frequency forms of the silent polymorphisms strongly suggests that the G1996A mutation did not occur in a direct ancestral allele.

Platelet-associated and plasma autoantibodies against platelet glycoproteins (GP) have been demonstrated in patients with autoimmune thrombocytopenia (AITP) using various methods. Eight laboratories in seven countries participated in this international study to evaluate the interlaboratory agreement using glycoprotein-specific immunoassays for these autoantibodies. The participating laboratories received blind samples of frozen washed platelets and plasma from 22 normal donors and 22 AITP patients. Platelet-associated and plasma autoantibodies against GPIIb-IIIa and GPIb-IX were measured by MAIPA, immunobead assay or modified antigen capture assay. Of the control samples, 96.0% and 97.2% of all results for platelet-associated and plasma autoantibodies to GPIIb-IIIa/ GPIb-IX, respectively, were negative. The mean variation coefficient of the control samples of platelet-associated and plasma autoantibodies was 89.5% (range 11.1-272.9%) and 46.5% (range 21.0-78.0%), respectively. In 20/22 patient samples, platelet-associated autoantibodies to either glycoprotein were noted by at least two laboratories. The mean degree of agreement in these samples was 74.0%. There was a significant correlation in the individual antibody measurements between all laboratories (Kendall coefficient of concordance 0.60 and 0.38, P < 0.001; Spearman rank order test, range of correlation coefficient 52.3-94.0% and 42.2-85.0%, P < 0.05, for anti-GPIIb-IIIa and anti-GPIb-IX, respectively). In contrast, plasma autoantibodies to either glycoprotein were noted by at least two laboratories in only 13/22 patient samples. Moreover, the degree of agreement was poor (50.1%) and a significant correlation was noted between only six pairs of laboratories. We conclude that methods used in this study yield good interlaboratory agreement in measuring platelet-associated autoantibodies against GPIIb-IIIa and GPIb-IX. In contrast, poor agreement was found in detecting plasma autoantibodies to the same glycoproteins.

Immunoglobulin heavy chain (IgH) oligoclonality in childhood B precursor ALL arises from the malignant transformation B precursor acute lymphoblastic leukemia (ALL) as determined and clonal expansion of a single B precursor cell which is in by Southern analysis is found in 30‐50% of patients and has the process of IgH recombination. This should lead to monobeen shown to be the result of ongoing IgH rearrangement clonal IgH rearrangement patterns by Southern analysis. How(mostly VH-replacement and VH to D‐JH joining) after malignant ever, in 30 to 50% of childhood B precursor ALL multiple transformation. It is unknown however, what determines the type of secondary rearrangement. Also the biological basis of rearranged bands (ie more bands than chromosome 14 copies the variable degree of oligoclonality observed in childhood ALL per cell) are observed at diagnosis. 8‐10 We and others have is poorly understood. We analyzed in detail the IgH rearrange- shown that IgH oligoclonality by Southern analysis is mechanment status of the leukemic cells for a random panel of 18 istically due to ongoing recombination (VH-replacement, VH childhood B precursor ALL patients by polymerase chain reac- to D‐J H joining, or de novo rearrangement of a germline tion (PCR)/sequencing analysis and by Southern analysis. By allele) of the IgH loci in the leukemic cell population. 11‐14 It Southern analysis 10/18 (55.6%) patients were considered oligoclonal and 8/18 (44.4%) monoclonal. In contrast, by PCR is unknown however, what determines the type of secondary minor clonal rearrangements were detected in 14/18 (77.8%) rearrangement. This issue is important for the monitoring of patients. VH-replacement was found in 7/14 patients, VH to D‐ minimal residual disease (MRD) by polymerase chain reaction JH joining in 6/14 patients and an unusual type of secondary (PCR) as the usefulness of this approach depends largely on rearrangement, VH‐D to JH joining, in one patient. Only a single the stability of the chosen tumor marker(s). Secondly, it is also type of secondary rearrangement was detected in each patient. unknown what determines the variable degree of IgH oligoThe type of secondary rearrangement (VH-replacement or VH to D‐JH joining) depended on the rearrangement status (VDJ/VDJ clonality in childhood ALL. Possibly, in some patients clones or VDJ/DJ, respectively) of the dominant leukemic clone as marked by different IgH rearrangements also possess a relative determined by Southern analysis. We found that in addition to growth advantage. Alternatively, the variable degree of oligoa more ‘advanced’ IgH rearrangement status patients with VH- clonality observed between patients may merely reflect differreplacements also have a more ‘advanced’ TCRd rearrange- ences in kinetic behavior of the leukemic cell populations. A ment status, which possibly reflects exposure of both the IgH better understanding of the nature of oligoclonality may prolocus and the TCRd locus to recombinase activity in a preleukemic clone. Finally, we investigated a putative relationship vide a rational basis for the choice of optimal tumor markers between oligoclonality by Southern analysis and S-phase frac- in case of multiple rearrangements at diagnosis. tion of the leukemic cell population. We found a significantly We previously analyzed IgH rearrangements in four seleclower percentage cells in S-phase for oligoclonal patients as ted patients that all presented with an oligoclonal IgH compared to monoclonal patients. Our data add to the under- rearrangement pattern by Southern analysis. 14 The data we standing of ongoing rearrangement of antigen receptor loci in obtained suggested that only a single type of secondary childhood ALL and have implications for the monitoring of minimal residual disease by PCR. rearrangement occurs in each patient and that the type

The platelet membrane glycoprotein (GP) Ib-IX-V complex, the major von Willebrand factor receptor on platelets, is absent or dysfunctional in patients with the Bernard-Soulier syndrome (BSS). The four single subunits of the GPIb-IX-V complex (GPIb alpha, Ib beta, IX and V) are molecular products of different genes. Several point mutations and deletions affecting the GPIb alpha gene have been identified as the cause of BSS, whilst in four BSS families a GPIX gene defect has been reported. Moreover, a single case of BSS has been associated with a genetic defect of GPIb beta. We investigated the molecular basis of another case of BSS with a deficient expression of GPIX, as detected by immunofluorescence studies. After amplification of the entire GPIX coding region, nucleotide sequence analysis showed a homozygous single point mutation predicting a phenylalanine to serine substitution at position 55 of the mature GPIX within its unique leucine-rich repeat. By allele-specific oligonucleotide hybridization we confirmed the homozygosity of the patient as well as the carrier state of two out of three of his children studied. Although the parents of the patient, who were first cousins, were no longer alive and thus not available for study, we speculate that the molecular defect observed in the proband was inherited from both parents, who probably were heterozygous for this GPIX gene defect. This study confirms that BSS may be caused by many different subtle molecular defects that often prevent the assembly and expression of a functional GPIb-IX-V complex.

SUMMARY. Allele-specific PCR using sequence specific primers (PCR-SSP) is a simple and reliable technique to detect point mutations in genes. We have developed a PCR-SSP to enable the detection of a C-T mutation at position 482 of the GPIb gene and a T-G mutation at position 13962 in exon 26 of the GPIIb gene. These point mutations are at the basis of the HPA alloantigens 2a, 2b and 3a, 3b respectively. One primer of each primer set has a 3′ nucleotide complementary to the DNA sequence coding for one allele. PCR product is only produced when the corresponding DNA is present and thus the genotype is determined by the presence or absence of a band in agarose electrophoresis of PCR products. A second set of primers in the same reaction yields a product regardless of the HPA genotype to control the efficiency of the PCR amplification. The HPA-2 and -3 genotypes determined in this way were in strict concordance with those established by conventional genotyping using PCR followed by restriction enzyme digestion (PCR-ASRA). PCR-SSP is a rapid and reliable technique that can be used for the determination of alleles which code for platelet alloantigens.

Molecular genetic analysis has been performed on a patient with Bernard-Soulier syndrome (BSS). The patient had characteristically giant platelets and was deficient in the glycoprotein (GP) Ib/IX/V complex, the von Willebrand factor (vWf) receptor on platelets. Previous studies with monoclonal antibodies directed against GP Ib alpha (CD 42b) and GP IX (CD 42a) demonstrated the absence of GP Ib alpha and presence of small amounts of GP IX on the surface of the patient's platelets. In this study the presence of GP V (CD 42d) is also demonstrated. This indicates a defect in the alpha-subunit of glycoprotein Ib. Therefore polymerase chain reaction (PCR)-amplification of the genomic DNA coding for GP Ib alpha was performed. Nucleotide sequence analysis of the entire coding region of GP Ib alpha revealed a homozygous single base pair mutation T--A, leading to a single amino acid substitution cysteine--serine at position 209 of the mature protein. We took advantage of the Mse I target site in the mutant allele, created by the T--A mutation, to analyse all available family members. PCR-ASRA (allele-specific restriction enzyme analysis) using the restriction enzyme Mse I, revealed the heterozygosity of the mother and the two children of the patient, whereas homozygosity of the patient for the Cys209Ser mutation was confirmed. The sister of the patient was not found to be a carrier of the mutant allele. The mutation identified in the family studied, responsible for the deficiency of the GP Ib/IX/V complex, suggests that the cysteine at amino acid position 209 may be involved in disulphide bonding.

A patient is described who developed symptoms of paroxysmal nocturnal hemoglobinuria (PNH) in her first pregnancy. This was uneventful except for a spontaneous preterm delivery. The second pregnancy was complicated by severe anemia and a hemolytic crisis with Budd-Chiari syndrome at 31 weeks' amenorrhoea. Delivery was again preterm and was the result of induced labour after premature rupture of membranes at 34 weeks. Literature shows a high maternal mortality among PNH patients (5.8%). The most common cause of death is liver vein thrombosis (Budd-Chiari syndrome). Fetal wastage (30%) and prematurity rate (16%) are also high. Recommendations for follow-up and therapy are given such as anticoagulation therapy, platelets and washed erythocytes transfusions, screening for Budd-Chiari syndrome and infections.

The serum of a Caucasian woman who gave birth to a child with neonatal alloimmune thrombocytopenia contained antibodies directed against a platelet antigen of the newborn. There was no incompatibility for the known platelet alloantigens HPA-1 to HPA-7 or for the private or low-frequency antigens Sra and Vaa, between the platelets of the parents. However, crossmatching with the serum of the mother and the platelets of the child and the father was strongly positive, suggesting a new platelet antibody specificity. To investigate the inheritance of the 'Groa' antigen involved, the available family members were tested in the platelet immunofluorescence test (PIFT) and the monoclonal antibody-specific immobilization of platelet antigens (MAIPA) assay. The Groa antigen was found to be inherited in an autosomal-codominant fashion. In the MAIPA, we localized the Groa antigen on the glycoprotein IIb/IIIa complex (alpha IIb beta 3). The GP IIb/IIIa localization was confirmed in immunoprecipitation studies. In Western blotting experiments, we further localized the Groa antigen on the GP IIIa (beta 3) subunit of the GP IIb/IIIa complex. Until now we have tested approximately 400 unrelated donors. None of these appeared to be positive for the Groa antigen, suggesting a phenotype frequency in the Dutch population of less than 0.01.

To characterize fetal thrombopoiesis, we determined plasma thrombopoietin (TPO) and glycocalicin levels, platelet counts and reticulated platelets (RP) of fetuses and compared them with the respective values of their mothers. Percutaneous umbilical vein sampling in abnormal pregnancies revealed twofold higher thrombopoietin levels and 20-fold higher reticulated platelet counts, but lower levels of glycocalicin in fetuses compared with their mothers (P < 0.05). Neither the expression of platelet glycoprotein Ib and IIb on platelets nor the platelet counts were different between mothers and their fetuses. These data indicate enhanced thrombopoiesis and/or increased platelet turnover in fetuses.

A 12-week-old fetus and one 17-week-old fetus + placenta were obtained after spontaneous abortions from two women of blood group p. The 17-week-old fetus was dissected into intestine, liver, brain and residual tissue. Nonacid glycosphingolipid fractions were prepared from the tissues. Glycolipid characterization was carried out using thin layer chromatography immunostained with monoclonal antibodies and bacteria and by 1H NMR spectroscopy and mass spectrometry. In the placental fraction substantial amounts of globotetraosylceramide (P-antigen) and globotriaosylceramide (Pk-antigen) were identified. In contrast, the fetuses contained only trace amounts of these structures, as revealed by immunostaining. These results indicate that the primary target for the antibodies of the anti-Tja serum is the placenta tissue, resulting in termination of the pregnancy.

Alloantibody formation against HPA-1a (Zwa/PIA1) has, to date, only been found in HLA-DRw52(a+) (Dw24) individuals. Alloimmunization against the product of the other HPA-1 allele, HPA-1b, is rare. We have been able to evaluate ten cases of HPA-1b alloimmunization in Europe in order to study whether there is an association between HLA phenotype and anti-HPA-1b antibody formation. HLA typing of these patients was performed with particular attention to the DRw52a specificity using specific T-cell clones. No association with DRw52a or any other known HLA phenotype was found. This finding implies that the amino acid substitution leucine33-proline33 in GPIIIa, responsible for HPA-1a/b, is of primary importance for the association of anti-HPA-1a antibody formation with DRw52a. These data show that the amino acid polymorphism affects the presentation of the immunogenic oligopeptides of HPA-1a and -1b in the HLA class-II groove.

Various amino acid and peptide thioesters were tested as substrates for human proteinase 3 and the best substrate is Boc-Ala-Ala-Nva-SBzl with a k cal / K m value of 1.0 × 10 6 nM it-1 s it-1 Boc-Ala-Ala-AA-SBzl (AA = Val, Ala, or Met) are also good substrates with k cal / K m values of (1-4) × 10 5 M −1 s −1 . Substituted isocoumarins are potent inhibitors of proteinase 3 and the best inhibitors are 7-amino-4-chloro-3-(2-bromoethoxy)isocoumarin and 3.4-dichloroisocoumarin (DCI) with k obs /[I] values of 4700 and 2600 M −1 s −1 , respectively. Substituted isocoumarins. peptide phosphonates and chloromethyl ketones inhibited proteinase 3 less potently than human neutrophil elastase (HNE) by 1-2 orders of magnitude.

The demonstration of autoantibodies to neutrophil cytoplasmic antigens (ANCA) in (1) systemic vasculitides such as Wegner's granulomatosis, classic polyarteritis nodosa and the Churg Strauss syndrome and (2) idiopathic crescentic glomerulonephritis has placed these disorders within the spectrum of autoimmune diseases. The target antigens have been identified as myeloid lysosomal enzymes that are involved in tissue destruction by neutrophils. Recent data suggest a pathogenetic role for these autoimmune responses. The autoantibodies may activate neutrophils, resulting in extensive tissue necrosis. Alternatively, T-cell-mediated immunity to these positively-charged enzymes that localize to polyanionic basement membranes may, in concert with the presence of autoantibodies, result in glomerulonephritis and vasculitis.

Summary. Quantification of platelet-bound immunoglobulins (PBIg) with radiolabelled murine monoclonal antibodies (mAbs) has been described only for IgG so far. Here we describe some modifications of this mAb radioimmunoassay (MARIA) and show that by using a panel of radiolabelled specific mAbs it is possible to quantify not only PBIgG but also PBIgG subclasses and PBIgM. Analysis by gel filtration showed that all anti-IgG and anti-IgG-subclass mAbs bound to their respective antigens in a ratio of about 1:1. However, the binding ratio for the anti-IgM Mab could not be established. There was a good correlation between the antibody-density per platelet as determined with the anti-IgG mAb and determined as the sum of the IgG molecules of different subclass per platelet (r= 0·90). Platelet fragments did not interfere in the assay. 89 normal healthy controls had 140 IgG molecules per platelet and bound 269 anti-IgM molecules per platelet (geometric means). In a study on the detection of PBIg in 147 thrombocytopenic patients, it appeared that the MARIA had a sensitivity of 61% and a specificity of 45% for the diagnosis of idiopathic thrombocytopenic purpura (ITP). Both in ITP and in secondary thrombocytopenia (STP), PBIgG1 and PBIgG3 were found more frequently (60% and 61%, respectively) than PBIgG2and PBIgG4 (13% and 9%, respectively). There was no relation between the amount of total PBIgG or PBIgM and the platelet count in either ITP or STP. Also, if IgG antibodies of only one subclass were found, there was no relation between the severity of the thrombocytopenia and the amount of PBIgG. By applying the MARIA, it is possible to quantify PBIgG, all four PBIgG-subclasses and PBIgM in ITP and STP in a reliable way.

To the Editor: The Rhesus (RH) blood group system, one of the most complex polymorphic systems in humans, encompasses at least 45 antigens. These antigens are carried by at least two red blood cell membrane proteins that are encoded by two homologous genes, RHD and RHCE.[1][1] The RHD antigen is a

The Rh blood group system represents a major immunodominant protein complex on red blood cells (RBC). Recently, the Rh homologues RhAG and RhCG were shown to promote ammonium ion transport in yeast. In this study, we showed that also in RBC the human Rh complex functions as an exporter of ammonium ions. We measured ammonium import during the incubation of RBC in a solution containing a radiolabelled analogue of NH4Cl (14C-methyl-NH3Cl). Rhnull cells of the regulator type (expressing no Rh complex proteins) accumulated significantly higher levels (P = 0.05) of radiolabelled methyl-ammonium ions than normal RBC, at room temperature. Rhnull cells of the amorph type (expressing limited amounts of Rh complex proteins) accumulated an intermediate amount of methyl-ammonium ions. To show that decreased ammonium export contributes to its accumulation, the release of intracellular methyl-ammonium from the cells was measured over time. In 30 s, normal RBC released 87% of the intracellular methyl-ammonium ions, whereas Rhnull cells of the regulator type released only 46%. We conclude that the Rh complex is involved in the export of ammonium from RBC.