210 Chapter 16 Under normal circumstances, approximately 1 x 10!" platelets are pro- duced every day. After circulating for 7-10 days, platelets lose their surface receptors (e.g., collagen receptor, GPVI, CD42b) and senescent platelets are removed by phagocytic cells of the reticuloendothelial system. Previ- ously thought to be a passive process, senescence and apoptosis likely involve intrinsic signals as well [2]. Thrombopoiesis parallels consumption and is tightly regulated by cytokines such as thrombopoietin (TPO) and interleukins 6 and 11 (IL-6 and IL-11) ‘Thrombopoietin is the principal regulator of platelet production. Binding to its receptor ¢-Mpl, thrombopoietin promotes differentiation of meg- akaryocyte progenitors, endomitosis, and platelet production. Inherited defects in the c-Mpl receptor lead to a severe thrombocytopenic condition called congenital amegakaryocytic thrombocytopenia (CAMT). Similar to megakaryocytes, platelets also express ¢-Mpl and regulate free TPO levels by binding and removing it from the circulation. TPO is produced consti- tutively by the liver but circulating TPO levels depend on the platelet and megakaryocyte mass. When platelet counts are low, less TPO is removed and more is available to stimulate thrombopoiesis. The converse is true when platelet counts are high. Normal bone marrow has significant reserve and, if needed, platelet production can increase eightfold. Synthetic ago- nists of ¢-Mpl are now available and approved for treatment of immune thrombocytopenia (ITP). Platelet structure The deceptively simple-appearing platelets are minute anucleate blood cells measuring 1.5-2.5 ym. Their plasma membrane forms a unique open canalicular system by invaginating deep into the platelet. It provides a large surface area for adsorption and activation of the coagulation protein, complexes (prothrombinase and Xase). Upon platelet activation, the nega- tively charged phospholipid, phosphatidylserine, translocates from the inner leaflet to the external surface to interact with the coagulation proteins, Embedded in the plasma membrane are the numerous glycopro- teins including Gp-Ib/IX/V and integrin allb/83 (formerly Gp-HIb/IIla) involved in platelet adhesion and aggregation, respectively. Just beneath the plasma membrane lies an elaborate cytoskeleton responsible for main- taining the discoid shape of resting platelets and inducing shape change upon activation. Platelets contain alpha-granules (a-), dense-granules (6-), lysosomes, peroxisomes, and organelles such as mitochondria and the dense tubular system (DTS), a derivative of the smooth endoplasmic reticulum, The DTS sequesters intracellular calcium and is the major site of thromboxaneInherited and Acquired Platelet Disorders 211 production [3]. Once activated, platelet «- and §-granules release their contents resulting in a secondary wave of amplified aggregation. Alpha- granules contain more than 280 proteins including von Willebrand factor (VWF), platelet-derived growth factor (PDGF), and the platelet-specific proteins ~ platelet factor 4 (PF4) and -thromboglobulin [4]. Coagulation factors V, VIL, and XU and fibrinogen are also found in o-granules but, rather than being synthesized by platelets, they are endocytosed from the blood. Dense-granules contain adenosine diphosphate (ADP), adenosine triphosphate (ATP), serotonin, and calcium, responsible for the dense appearance on electron microscopy. Platelet physiology Primary hemostasis, the formation of a platelet plug at the site of endothe- lial injury, occurs in the following phases: adhesion and activation, aggre- gation, and release reaction (Figure 16.1). Adhesion and activation Platelets possess unique glycoproteins (Gp) that adhere to exposed suben- dothelium following vessel injury. The particular glycoprotein involved is dictated by blood flow patterns. Under high shear (e.g,, in arterioles) VWF first coats exposed collagen. Platelet surface Gp-Ib/IX/V complex then. binds collagen through VWF. Deficiency of either VWF (von Willebrand” disease; VWD) or Gp-Ib/IX/V (Bernard-Soulier syndrome) leads to a bleeding disorder. In addition to tethering the platelet, this interaction exposes and activates Gp-IIb/IIla which then more firmly binds the plate- let to collagen (also through VWF). Integrin 0281 (formerly Gp-Ia/Ila) and Gp-VI further strengthen this interaction by directly binding collagen. In low flow states, Gp-la/Ila is primarily responsible for initiating adhesion and activation Once activated, the cytoskeleton induces a shape change and platelets become more flattened. They extend filopodia in an attempt to bridge the endothelial defect. The cytoskeleton later also mediates clot retraction. Gregation Inactivated Gp-IIb/Ila cannot bind circulating fibrinogen, but a confor mational change during activation allows it to bind fibrinogen. As more platelets are activated they cross-link fibrinogen through Gp-IIb/IIla and aggregate. The platelet plug is further strengthened after agonists are released from granules, more platelets are recruited, and the coagulation cascade is complete with formation of fibrin. Gp-Ib/Illa is defective in