Original Article

Clinical and Applied

Thrombosis/Hemostasis
Platelet Hyperaggregability is Highly 2015, Vol. 21(2) 132-138
ª The Author(s) 2013

Prevalent in Patients With Chronic Kidney Reprints and permission:

sagepub.com/journalsPermissions.nav
DOI: 10.1177/1076029613490828
Disease: An Underestimated Risk Indicator cat.sagepub.com

of Thromboembolic Events

Eray Yagmur, MD1, Rolf Dario Frank, MD2, Joseph Neulen, MD3,
Jürgen Floege, MD4, and Anja Susanne Mühlfeld, MD4

Abstract
Background: Platelet hyperaggregation is known to be associated with arterial and venous thromboembolic events. The
prevalence of platelet hyperaggregation in patients with chronic kidney disease (CKD) has not been described to date.
Methods: Platelet hyperaggregation in patients with renal disease was defined by comparison of platelet aggregation patterns to
non-CKD patients without thromboembolic disorders and healthy controls. Results: Among the 30 hemodialysis patients and 34
renal transplant recipients, 20 (67%) and 28 (82%) showed significantly decreased median D-epinephrine aggregation and
increased 0.5 mol/L epinephrine response (65% and 54%) compared to healthy controls and non-CKD patients. In concordance to
the laboratory finding of platelet hyperaggregability, renal transplant recipients showed a high rate of thromboembolic events
(normal platelet aggregation: 0 events and platelet hyperaggregation: 30 events in 13 of 28 patients). Conclusions: Patients
with CKD exhibit a hitherto unappreciated high prevalence of platelet hyperaggregability indicating sticky platelet syndrome.
Laboratory testing of platelet hyperaggregability may supplement the assessment of thromboembolic complications in patients
with CKD.

Keywords
chronic kidney disease, embolism, platelet hyperaggregability, sticky platelet syndrome, thrombosis

Introduction G-protein b-3 polymorphism encoding the b-3 subunit of

In the laboratory setting, hyperaggregability of platelets is
characterized by light transmission aggregometry and dose-
independent platelet aggregation solely due to epinephrine
and/or adenosine diphosphate (ADP).1 In the early 1980s
Mammen and Bick suggested platelet hyperaggregation as the
underlying cause of thrombophilia in patients with unexplained
arterial and venous thromboembolism or recurrent spontaneous
abortions. The observation of so-called sticky platelet
syndromes (SPSs) has been proven by numerous clinical case
reports associated with acute myocardial infarction, throm-
boembolic kidney graft infarction, transient ischemic cerebral
attacks, and strokes.2,3
Family testing of the affected patients suggested an autoso-
mal pattern of heredity.4,5 Kotuličová et al recently reported the
prevalence of selected GP6 gene polymorphisms as indepen-
dent risk factors for deep vein thrombosis in patients with
platelet hyperaggregability.6,7 In addition, Johnson et al identi-
fied associations of 7 loci with platelet aggregation in response
to the agonists ADP and epinephrine.8 In contrast, Yee et al
showed in healthy individuals that epinephrine-mediated plate-
let activation and hyperaggregation are associated with
G proteins involved in platelet activation signaling pathways.9
Although the cause for platelet hyperaggregation is still
unknown, our group has published a mini series of 3 patients
with SPS exhibiting thromboembolic complications after kid-
ney transplantation.10 Based on these findings, we conducted
a case–control study in chronic hemodialysis (HD) patients and
renal transplant recipients to provide more information about
the prevalence of platelet hyperaggregation in patients with
1
Laboratory Diagnostics Center, RWTH-University Hospital Aachen, Aachen
and Medical Care Center, Dr Stein and colleagues, Mönchengladbach, Germany
2
Clinic for Internal Medicine and Clinical Intensive Care Medicine, Sankt Anto-
nius Hospital Eschweiler, Eschweiler, Germany
3
Department of Gynecological Endocrinology and Reproductive Medicine,
RWTH-University Hospital Aachen, Aachen, Germany
4
Division of Nephrology and Clinical Immunology, RWTH-University Hospital
Aachen, Aachen, Germany
Corresponding Author:
Anja Susanne Mühlfeld, Division of Nephrology and Clinical Immunology,
RWTH-University Hospital Aachen, Pauwelsstr 30, 52074 Aachen, Germany.
Email: amuehlfeld@ukaachen.de
Yagmur et al
chronic kidney disease (CKD). Detailed platelet aggregation
analysis was performed and compared to platelet response in
healthy controls and non-CKD patients with and without
thromboembolic events.
Patients and Methods
Patients and Healthy Control Collective
Platelet aggregation analysis was performed in 64 patients with
CKD (chronic HD patients: n ¼ 30, 15 males/15 females, med-
ian age 50 years, range 20-75 years; renal transplant recipients:
n ¼ 34, 11 males/13 females, median age 56 years, range 26-79
years) who were admitted to the Department of Nephrology at
the RWTH Aachen University Hospital. In addition, non-CKD
patients (n ¼ 79; median age 34 years, range 23-43 years) were
assessed for platelet hyperaggregability at the Department of
Gynecological Endocrinology and Reproductive Medicine at
the RWTH Aachen University as part of the evaluation for
infertility. At the time of laboratory investigation, all patients
had normal plasmatic coagulation (data not shown). The
healthy control population consisted of 44 volunteers (8 males/
36 females, median age 42 years, range 24-63 years).
None of the investigated study populations had disturbed
platelet function by neither antiplatelet medication nor physical
exertion at the time of blood draws. In patients receiving anti-
platelet therapy, the treatment was interrupted for 10 days
before platelet function testing. Moreover, patients and healthy
controls were questioned about recent ingestion of any nonpre-
scribed medication to exclude drugs that may interfere with
platelet aggregation.
Healthy controls were investigated to determine the decisio-
nal platelet hyperaggregability cutoffs. Platelet hyperaggreg-
ability in patients with CKD was assessed by comparison of
platelet function to healthy controls and non-CKD patients with
and without thromboembolic events.
The study protocol was approved by the local ethics com-
mittee and conducted in accordance with the ethical standards
laid down in the Declaration of Helsinki.
Platelet Aggregometry
To minimize preanalytical activation of platelets and clotting
proteins, citrated (sodium citrate 0.11 mol/L) whole blood sam-
ples were drawn by venopuncture through wide-bore needles
without a tourniquet. Platelet aggregation was performed within
4 hours after blood sample collection. All participating patients
and healthy controls had initial platelet counts within the refer-
ence range (data not shown).
Platelet function was evaluated by testing aggregation
responses to ADP and epinephrine by optical light transmission
aggregometry (PAP 8 Aggregometer; mölab, Langenfeld, Ger-
many) according to the method established by Born and
Cross11 and modified by Mammen.3 The aggregometry testing
was performed using native platelet-rich plasma (PRP; without
platelet count adjustment), because there is no accepted lower
limit of PRP platelet counts for aggregation testing.12-15
133
Microscopic assessment of platelet morphology in citrated
whole blood smear was carried out to exclude platelet plugs
and spontaneous aggregation prior to aggregation analysis.
Identification of Patients With Platelet Hyperaggregation
There are no validated reference intervals in the literature for
platelet aggregation by multiple concentrations of agonists.
Therefore, we evaluated dose-dependent platelet aggregation
patterns of ADP and epinephrine by stimulating native PRP
samples in 44 healthy controls (median platelet count 193/
nL). Furthermore, we investigated platelet aggregation in a
gynecological non-CKD patient group having infertility. This
collective, platelet hyperaggregability, referred to as SPS, is the
second most common thrombophilia that causes recurrent
spontaneous abortion or fetal loss syndrome.2,3 Patients were
clinically classified into thromboembolic (22 of 79; 28%) and
nonthromboembolic categories (57 of 79; 72%) determined
by medical history. Platelet aggregation was investigated in all
patients after stimulation with ADP and epinephrine at 4 differ-
ent concentrations according to the recommended concentra-
tions for testing, ADP (mmol/L): 10, 2, 1, and 0.5; epinephrine
(mmol/L): 50, 10, 1, and 0.5.15
The decisional platelet hyperaggregability cutoff for each
agonist in patients with CKD was established on the basis of
dose-dependent platelet function illustrated in Table 1. Platelet
aggregation patterns in patients with CKD compared to non-
CKD patients without thromboembolic complications and
healthy controls were determined as hyperaggregation under
the following conditions: (1) increased platelet aggregation at
low-dose epinephrine (0.5 mmol/L) greater than maximum
aggregation value in non-CKD patients without thromboem-
bolic events (>39%); (2) significantly increased median
aggregability when compared to median low-dose epinephrine
aggregation in healthy controls (>27%); (3) decreased D-aggre-
gation patterns (difference of platelet aggregation between the
highest versus the lowest concentration of each agonist) in
patients compared to healthy controls, median D-platelet aggre-
gation response significantly lower than 64% for ADP and 56%
for epinephrine.
The ADP-induced aggregation was not considered as signif-
icant for potential platelet hyperaggregability due to the pres-
ence of dose-dependent platelet aggregation patterns in all
the study collectives.
Statistical Analysis
Owing to the skewed distribution of the aggregation para-
meters, values are given as minimum, maximum, and median.
Comparisons between the subgroups are illustrated using Box
and -Whiskers plots. Differences between the 2 groups and
multiple comparisons among more than 2 groups were assessed
by the nonparametric Mann-Whitney U test. The statistical
significance level is determined by P < .05. Because multiple
comparisons were performed simultaneously, the significance
level is adapted by the Bonferroni method (P < .0021). All
134 Clinical and Applied Thrombosis/Hemostasis 21(2)

Table 1. Healthy Controls and Patient Characteristics.a

HD Patients Renal Transplant Patients Non-CKD Patients

Healthy Controls Normal Hyperreactive Normal Hyperreactive Normal Hyperreactive

Platelet Aggregation (n ¼ 44) (n ¼ 10) (n ¼ 20) (n ¼ 6) (n ¼ 28) (n ¼ 57) (n ¼ 22)

ADP 10 mmol/L 78 (50-120) 67 (53-74) 68 (42-84) 76 (63-80) 74 (48-108) 71 (41-94) 77 (64-94)

ADP 2 mmol/L 30 (11-92) 24 (5-49) 25 (14-56) 27 (17-50) 37 (12-66) 20 (1-81) 36 (17-82)
ADP 1 mmol/L 19 (9-37) 11 (5-32) 12 (4-44) 8 (1-36) 20 (9-37) 5 (1-56) 11 (5-28)
ADP 0.5 mmol/L 18 (10-47) 8 (2-16) 9 (1-32) 7 (1-17) 11 (1-21) 2 (1-21) 3 (1-17)
D-ADP 64 (37-109) 61 (46-70) 56 (37-77) 68 (55-78) 64 (36-95) 69 (35-89) 72 (61-85)
Epinephrine 50 mmol/L 82 (24-120) 70 (53-77) 68 (50-91) 64 (54-88) 79 (50-102) 72 (54-93) 72 (61-94)
Epinephrine 10 mmol/L 73 (18-120) 52 (39-71) 66 (43-87) 57 (37-68) 65 (40-88) 26 (1-86) 71 (45-80)
Epinephrine 1 mmol/L 35 (12-116) 40 (22-48) 66 (44-86) 42 (25-60) 62 (41-83) 16 (1-70) 67 (47-92)
Epinephrine 0.5 mmol/L 27 (8-55) 31 (17-39) 65 (40-86) 32 (20-38) 54 (40-78) 11 (1-39) 70 (41-82)
D-Epinephrine 56 (6-106) 38 (14-54) 5 (6-20) 32 (16-57) 13 (12-60) 64 (21- 85) 6 (9-32)
Abbreviations: ADP, adenosine diphosphate; CKD, chronic kidney disease; HD, hemodialysis.
a
Platelet aggregation data in response to different ADP and epinephrine concentrations. Platelet aggregation data in response to lowest ADP and epinephrine
concentration (0.5 mmol/L) as well as D-ADP and D-epinephrine differences formed the basis for the definition of platelet hyperaggregability in patients with renal
disease: decreased D-aggregation patterns (difference in platelet aggregation between the highest versus the lowest concentration of each agonist) and increased
aggregability at 0.5 mmol/L agonist associated with absence of dose dependence in patients with CKD compared to healthy controls and non-CKD patients. Min-
imum and maximum aggregations in parenthesis.

statistical analyses were performed using MedCalc version
11.4.2 (Mariakerke, Belgium) and SigmaStat version 3.1
(Systat Software Inc, San Jose, California).
Results
Dose-Dependent Platelet Aggregation in Healthy Controls
and Non-CKD Patients With and Without Thromboembolic
Events
In healthy controls, normal platelet aggregation in native PRP
(median platelet count: 193/nL) after stimulation by ADP (10
mmol/L) was determined as 78% (median aggregation; 95%
confidence interval: 71%-90%) and 82% (median aggregation;
95% confidence interval: 75%-89%) by 50 mmol/L epinephrine
stimulation, respectively (Figure 1A-C). The median platelet
aggregation responses to lowest ADP and epinephrine concen-
trations were significantly and dose dependently decreased (0.5
mmol/L ADP 18%; 95% confidence interval [CI]: 15%-19%;
P < .0001 [vs 10 mmol/L] and 0.5 mmol/L epinephrine 27%;
95% confidence interCIval: 23%-35%; P < .0001 [vs 50 mmol/
L]). The median D-platelet aggregation response defined by the
difference between highest and lowest concentrations of ADP
and epinephrine was 64% and 56%, respectively (Table 1).
To assess the prevalence of platelet hyperaggregability in a
best-characterized high-risk non-CKD population, we analyzed
the reports of platelet aggregation testing in the central labora-
tory at the RWTH Aachen University between March 2000 and
April 2007. During this time, platelet function tests were
ordered in 79 patients from the department of gynecological
endocrinology and reproductive medicine to assess platelet
aggregability as part of the evaluation for infertility. Of these
patients, 22 patients had a positive medical history of recurrent
spontaneous abortions or fetal loss syndrome, whereas 57
patients were negative for thrombophilia. All 79 patients were
negative for plasmatic hypercoagulopathy. Patients with posi-
tive medical history had increased and dose-independent 0.5
mmol/L epinephrine-induced platelet aggregation compared
to normal platelet aggregation (70%, range 41%-82% vs
11%, range 1%-39%; P < .0001; Fig. 1B and C). Patients with
normal dose-dependent platelet function demonstrated a med-
ian D-epinephrine (difference of the highest vs lowest epi-
nephrine stimulation) of 64% (range 21%-85%; median
D-ADP 69%; range 35%-89%). The median D-epinephrine
response in patients with dose-independent platelet hyperag-
gregation was significantly lower (6%, range 9%-39%; P <
.0001; median D-ADP 71%, range 61%-85%; P ¼ .0996).
Platelet aggregation response in these patients was used
together with the results in healthy controls to determine plate-
let hyperaggregation in patients with CKD (see Identification
of Patients With Platelet Hyperaggregation section and Tables 1
and 2).
Platelet Aggregation in Patients With CKD
Hemodialysis Patients. Platelet function was assessed in 30 HD
patients. Ten HD patients were found to have normal platelet
aggregation pattern compared to non-CKD and healthy con-
trols. In contrast, median low-dose epinephrine-induced plate-
let aggregation was significantly higher in 20 HD patients
compared to normal aggregation (65%, range 40%-86% vs
31%, range 17%-39%; P < .0001; Table 1 and Figure 1D). In
HD patients with normal platelet function, the median D-epi-
nephrine was 38% (range 14%-24%; median D-ADP 61%,
range 46%-70%), while the median D-epinephrine response
in patients with platelet hyperaggregability was decreased to
only 5% (range 6%-20%, P < .0001).
Low-dose epinephrine-induced platelet aggregation in
patients with identified hyperaggregability was significantly
Yagmur et al 135

140 100
A.
A B
120
Maximum Platelet Aggregation (%)

Maximum Platelet Aggregation (%)

80

100
60

80
40
60

20
40

0
20

0
µM M M µM M M M µM µM 2µ
M
1µ
M µM µM µM µM µM
10 2µ 1µ 0.5 0µ 0µ 1µ .5 10 P P 0.5 50 10 i1 0.5
P P P i5 i1 Pi i0 P AD AD P Pi Pi EP Pi
AD AD AD P E P E P E P AD D E E E
AD E A

100

B.
C D
Maximum Platelet Aggregation (%)

80

60

40

20

µM 2µ
M
1µ
M µM µM µM µM µM
10 P P 0.5 50 10 i1 i0
.5
P AD AD P Pi Pi EP P
AD A D E E E

Figure 1. Statistical summary of platelet aggregation by Box-and-Whiskers plots. Dose-dependent platelet aggregation in (A) to (C): (A) healthy
controls, (B) non-CKD patients without thromboembolic events, and (C) non-CKD patients with thromboembolic events. Interestingly, signif-
icant dose-independent platelet hyperaggregation is found in non-CKD patients with thromboembolic events compared with clearly dose-
dependent normal aggregation patterns in healthy controls and non-CKD patients without thromboembolic events. D, Low-dose
epinephrine-induced platelet aggregation in healthy controls, hemodialysis patients, and renal transplant patients. Similar to non-CKD patients,
platelet aggregation due to low-dose epinephrine is significantly elevated in patients with CKD and related to observed high number of
thromboembolic events in renal transplant patients. P values of nonparametric Mann-Whitney U tests are given in (D). Comparisons between
collectives are illustrated using Box-and-Whiskers-plots, where the vertical lines in the box indicate the median per group, the box represents
50% of the values, and horizontal lines show minimum and maximum values of the calculated nonoutlier values; dots indicate outlier values. CKD
indicates chronic kidney disease.

increased compared to healthy controls and non-CKD Renal Transplant Patients. Of the 34 patients tested, 6 (18%) were
patients without thromboembolic events (all P < .0001) and found to have normal platelet aggregation patterns (as
statistically comparable to platelet hyperaggregation in described previously) and 28 (82%) showed platelet hyperag-
non-CKD patients with thromboembolic events (P ¼ .5125; gregation (Table 1). Low-dose epinephrine-induced platelet
Table 2). aggregation was significantly higher compared to normal
To exclude activation of platelets during HD as a reason for aggregation (54%, range 40%-78% vs 32%, 20%-38%range;
the high prevalence of platelet hyperaggregation, we analyzed P < .0001; Figure 1D). In patients with normal dose-
platelet response in 10 patients immediately before and after a dependent platelet function, the median D-epinephrine was
HD session. In 8 cases, identical aggregation results were found 32% (range 16%-57%; median D-ADP 68%, range 55%-
before and after HD. In 2 patients, hyperreactive platelets chan- 78%). The median D-epinephrine response in renal transplant
ged into normal reactive platelets after HD (data not shown). patients with dose-independent platelet aggregation was signif-
Taken together, these results rule out mechanical induction of icantly decreased (13%, range 12%-60%; P < .0001; median
platelet aggregation through the process of HD. D-ADP 64, range 36%-95%; P ¼ .5569).
136 Clinical and Applied Thrombosis/Hemostasis 21(2)

Table 2. Significance Level of Platelet Aggregation of Low Agonist Concentration (0.5 mmol/L) in Healthy Controls and Non-CKD Patients
Compared to Patients With Renal Disease.a

Non-CKD Non-CKD
Non-CKD Patients Without Non-CKD Patients With
Healthy Controls Patients Without Thromboembolic Patients With Thromboembolic
Healthy Controls Versus Renal Thromboembolic Events Versus Thromboembolic Events Versus
Versus HD Transplant Events Versus HD NTX Events Versus HD NTX
Platelet Aggregation
P Values (Significance Hyper- Hyper- Hyper- Hyper- Hyper- Hyper-
Level P < .0021) Normal reactive Normal reactive Normal reactive Normal reactive Normal reactive Normal reactive

ADP 0.5 mmol/L <.0001 .0001 .0010 <.0001 .0018 <.0001 .2707 <.0001 .0629 .0030 .7568 .0021
Epinephrine 0.5 mmol/L .5852 <.0001 .5306 <.0001 <.0001 <.0001 .0007 <.0001 <.0001 .5125 .0002 .0185

Abbreviations: ADP, adenosine diphosphate; CKD, chronic kidney disease; HD, hemodialysis; NTX, renal transplant.
a
Platelet hyperaggregability in patients was supposed when the following conditions were present: (1) platelet aggregation in patients without similar decline as
reported in healthy controls and/or non-CKD patients without thromboembolic events; (2) dose-dependent median platelet aggregation response to lowest ADP
and epinephrine concentrations in patients significantly higher than platelet response in non-CKD patients without thromboembolic events and healthy controls
(single epinephrine aggregation > 39%). The statistical significance level is determined as P < .05 and corrected by the Bonferroni method to P < .0021. P values of
nonparametric Mann-Whitney U tests are given in the table (significant values are in bold; (hemodialysis patients; NTX patients).

Table 3. Use of Immunosuppressive Medication in Renal Transplant Patients.

Number of Immunosuppressive
CNI mTOR Antimetabolite Steroids Drugs

Platelet hyperaggregation n ¼ 28 21/28 (75%) 7/28 (25%) 20/28 (75%) 26/28 (93%) 2.7 + 0.5
Normal platelet aggregation n ¼ 6 4/6 (67%) 2/6 (33%) 5/6 (83%) 5/6 (83%) 2.7 + 0.5
Abbreviations: CNI, calcineurin inhibitor; mTOR, mammalian target of rapamycin.

Table 4. Thromboembolic Events in Renal Transplant Patients Due kidney transplantation who never gained sufficient transplant
to Platelet Aggregability.a function also tested positive for platelet hyperaggregability
Normal Hyper-
(CKD stage 5; data not shown).
Aggregation aggregation There was no difference in the kind of immunosuppressive
(n ¼ 6) (n ¼ 28) medications used or the amount of immunosuppression in
transplant patients with or without platelet hyperaggregability
Transitory ischemic attack/stroke 0 5 (Table 3).
Deep-vein thrombosis/pulmonary 0 12
embolism
Microinfarctions (colon, kidney) 0 2 Thromboembolic Complications in Patients With CKD
Kidney infarctions 0 6 Having SPS
Other thrombosis 0 5
a
There was a numerical trend toward more thromboembolic
In 28 patients with platelet hyperaggregability, there were 30 events in 13 complications in the cohort of renal transplant recipients that
patients, whereas none of the 6 patients without platelet hyperaggregability
showed thromboembolic events. tested positive for platelet hyperaggregability. Renal transplant
recipients with normal platelet aggregation had no history of
thromboembolic events while we could record 30 thromboem-
bolic events in 13 patients diagnosed with platelet hyperaggre-
Low-dose epinephrine-induced platelet aggregation in
gation (P ¼ .07; Table 4). On the other hand, 15 of the renal
patients with hyperaggregability was significantly increased
transplant recipients with platelet hyperaggregability had no
compared to healthy controls and non-CKD patients without
history of thromboembolic events.
thromboembolic events (all P < .0001) and statistically compa-
rable to platelet hyperaggregation in non-CKD patients with
thromboembolic events (P ¼ .0185; Table 2).
The degree of renal function impairment did not seem to Discussion
influence platelet aggregation as transplant patients with platelet We found a high prevalence of platelet hyperaggregability in
hyperaggregation were evenly distributed over the CKD stages 1 patients with CKD (82%; HD patients, 67% in renal transplant
to 3. By chance, no patients with CKD stage 4 were assessed. recipients). This prevalence markedly exceeded that of a high-
Two patients with thrombotic complications immediately after risk disease control, namely, women with recurrent spontaneous
Yagmur et al
abortion (28%). In addition, none of the healthy individuals
tested had dose-independent platelet hyperaggregability.
Currently, there is no other study available, which examines
platelet aggregation in patients with CKD using ADP and
epinephrine-induced light transmission aggregometry. Patients
with CKD have a high risk of thromboembolic complications
and cardiovascular events.16 In general, the increase in risk is
thought to be multifactorial. In part it might be the result of the
same underlying diseases causing vascular disease and CDK
(hypertension, diabetes, hyperlipidemia, etc) and in part sec-
ondary to CKD-induced disturbances in calcium and phosphate
homeostasis and uremic toxins. In addition, in the situation of
renal transplantation, there is a high incidence of deep-vein
thrombosis, probably due to mechanical alterations by the
surgical procedure and the transplant.17 Overall, our study sug-
gests that increased platelet aggregability might reflect these
factors and contribute to the increased risk of thromboembolic
events in patients with CKD.
So far, platelet hyperaggregability has been examined in the
setting of recurrent miscarriages and unexplained arterial and
venous thromboembolic events in non-CKD patients as a rea-
son for vascular morbidity. Bick et al examined 351 women
having recurrent miscarriages.2 Of this population, 20% was
found to have SPS. The same authors reported on 153 patients
referred for the evaluation of unexplained arterial or venous
events and found SPS prevalence of 21% for patients with
arterial events and 13% in those with venous events.18 Kubisz
et al investigated 64 patients with a history of arterial or venous
thromboembolic events and found SPS in 14% of those
patients.19 In contrast, Ruiz-Argüelles et al found 6 of 10
patients with primary hypercoagulable state to be affected by
SPS of which most patients had more than 1 thrombophilic
abnormality.20,21
The prevalence of platelet hyperaggregability in the form of
SPS in the general population has never been formally
assessed. So far, only patients with clinical events of throm-
boembolism have been tested for SPS, and no data is available
on the rate of thromboembolic events in patients with SPS. In
healthy controls without thromboembolic events, we could not
find platelet hyperaggregability. In addition, none of the
patients with recurrent miscarriages and SPS had any record
of clinical thromboembolism other than the gynecological
disease. In our study, the relationship between platelet hyperag-
gregability and thromboembolic events in patients with CKD
was not clear. Although there was a high number of throm-
boembolic events in renal transplant recipients with SPS (30
events in 13 of 28 patients with hyperreactive platelets) com-
pared to patients with normal platelet function (0 events in 6
patients with normal platelet function), it did not reach statisti-
cal significance. It is likely that platelet hyperaggregability
itself does not cause thromboembolic events, similar to APC
resistance or protein C deficiency, but only predisposes to them
and that a second hit may be required to develop overt clinical
disease. In the literature, it has already been proposed that
epinephrine release in vivo may act as an inducer of platelet
aggregation.22 In the case of renal transplant recipients,
137
endothelial injury caused by treatment with immunosuppres-
sive drugs such as cyclosporine A and tacrolimus23,24 might
represent a trigger for the induction of thrombosis. In addition,
renal transplant patients have many other risk factors for induc-
tion of the coagulation system such as perioperative stress with
the release of adrenalin, surgical damage to the vasculature,
rejection episodes, and uncontrolled hypertension. These
triggers might explain the higher incidence of thromboembolic
diseases in the renal transplant population. In the case of HD
patients, platelet hyperaggregability-induced thrombophilia
might be counteracted by uremic bleeding disorder. However,
although there was a numerical increase in thromboembolic
events in patients with CKD having platelet hyperaggregability
after renal transplantation, the number of patients assessed was
too small to allow a meaningful statistical analysis. Larger
prospective studies in patients with CKD will have to be per-
formed to assess the risk of thromboembolic complications
added by platelet hyperaggregability.
A limitation of this study is that from a methodological
standpoint, the definition of platelet hyperaggregability is not
standardized to date.9,14 Furthermore, interpretation of platelet
aggregability is heavily affected by preanalytical errors and, so
far, it depends on nonstandardized laboratory methods. There are
also uncertainties about the limits of acceptable platelet counts.
The PRP platelet count shows little relationship to maximum
aggregation in samples with normal platelet counts.12,13 Further-
more, there are no validated reference intervals for platelet
aggregation by multiple concentrations of agonists. However,
Yee et al reported in 2005 that light transmission aggregometry
using 0.4 mmol/L citrated PRP reliably identifies a distinct sub-
group of healthy individuals with platelet hyperaggregability.25
In conclusion, our study highlights that increased platelet
aggregability can be found in patients with CKD who are at a
high risk of thromboembolic events. This change in platelet
function might contribute to the increased rate of vascular
events in patients with CKD. Platelet function testing in patients
with CKD should be taken into clinical consideration and
might thus indicate a potentially increased risk of thromboem-
bolic events. Whether screening for platelet hyperaggregability
in patients with CKD and treatment with acetylic salicylic acid,
particularly in those patients with CKD and thromboembolic
events, will ultimately affect patient outcomes have to be tested
in prospective trials.
Acknowledgment
The authors gratefully acknowledge Mrs Claudia Brügmann for revis-
ing the manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
138
References
1. Frenkel EP, Mammen EF. Sticky platelet syndrome and thrombo-
cythemia. Hematol Oncol Clin North Am. 2003;17(1):63-83.
2. Bick RL, Hoppensteadt D. Recurrent miscarriage syndrome and
infertility due to blood coagulation protein/platelet defects: a
review and update. Clin Appl Thromb Hemost. 2005;11(1):1-13.
3. Mammen EF. Ten years’ experience with the ‘‘sticky platelet
syndrome". Clin Appl Thromb Hemost. 1995;1(1):66-72.
4. Mammen EF, Barnhart MI, Selik NR, Gilroy J, Klepach GL.
"Sticky platelet syndrome": a congenital platelet abnormality pre-
disposing to thrombosis? Folia Haematol Int Mag Klin Morphol
Blutforsch. 1988;115(3):361-365.
5. Simonova R, Bartosova L, Chudy P, et al. Nine kindreds of famil-
ial sticky platelet syndrome phenotype [published online March
19, 2012]. Clin Appl Thromb Hemost. 2012.
6. Kotuličová D, Chudý P, Škereňová M, Ivanková J, Dobrotová M,
Kubisz P. Variability of GP6 gene in patients with sticky platelet
syndrome and deep venous thrombosis and/or pulmonary embo-
lism. Blood Coagul Fibrinolysis. 2012;23(6):543-547.
7. Sokol J, Biringer K, Skerenova M, et al. Platelet aggregation
abnormalities in patients with fetal losses: the GP6 gene
polymorphism. Fertil Steril. 2012;98(5):1170-1174.
8. Johnson AD, Yanek LR, Chen MH, et al. Genome-wide
meta-analyses identifies seven loci associated with platelet aggre-
gation in response to agonists. Nat Genet. 2010;42(7):608-613.
9. Yee DL, Bergeron AL, Sun CW, Dong JF, Bray PF. Platelet
hyperreactivity generalizes to multiple forms of stimulation.
J Thromb Haemost. 2006;4(9):2043-2050.
10. Muhlfeld AS, Ketteler M, Schwamborn K, et al. Sticky platelet
syndrome: an underrecognized cause of graft dysfunction and
thromboembolic complications in renal transplant recipients.
Am J Transplant. 2007;7(7):1865-1868.
11. Born GV, Cross MJ. The Aggregation of blood platelets.
J Physiol. 1963;168:178-195.
12. Castilloux JF, Moffat KA, Liu Y, et al. A prospective cohort study
of light transmission platelet aggregometry for bleeding disorders:
is testing native platelet-rich plasma non-inferior to testing platelet
count adjusted samples? Thromb Haemost. 2011;106(4):675-682.
13. Hayward CP, Moffat KA, Pai M, et al. An evaluation of methods
for determining reference intervals for light transmission platelet
aggregation tests on samples with normal or reduced platelet
counts. Thromb Haemost. 2008;100(1):134-145.
Clinical and Applied Thrombosis/Hemostasis 21(2)
14. Hayward CP, Moffat KA, Raby A, et al. Development of
North American consensus guidelines for medical laboratories
that perform and interpret platelet function testing using light
transmission aggregometry. Am J Clin Pathol. 2010;134(6):
955-963.
15. Christie DJ, Avari T, Carrington LR, et al. Platelet Function Test-
ing by Aggregometry; Approved Guideline; vol 28. Wayne PA:
CLSI; 2008:1-45.
16. Mahmoodi BK, Gansevoort RT, Naess IA, et al. Association of
mild to moderate chronic kidney disease with venous thromboem-
bolism: pooled analysis of five prospective general population
cohorts. Circulation. 2012;126(16):1964-1971.
17. Poli D, Zanazzi M, Antonucci E, et al. Renal transplant recipients
are at high risk for both symptomatic and asymptomatic deep vein
thrombosis. J Thromb Haemost. 2006;4(5):988-992.
18. Bick RL. Sticky platelet syndrome: a common cause of unex-
plained arterial and venous thrombosis. Clin Appl Thromb
Hemost. 1998;4(2):77-81.
19. Kubisz P, Ivankov J, Holly P, Stasko JN, Musial J. The glycopro-
tein IIIa PL(A1/A2) polymorphism—a defect responsible for the
sticky platelet syndrome? Clin Appl Thromb Hemost. 2006;12(1):
117-119.
20. Ruiz-Argüelles GJ, López-Martı́nez B, Cruz-Cruz D, Esparza-
Silva L, Reyes-Aulis MB. Primary thrombophilia in Mexico III:
a prospective study of the sticky platelet syndrome. Clin Appl
Thromb Hemost. 2002;8(3):273-277.
21. Ruiz-Argüelles GJ, López-Martı́nez B, Valdés-Tapia P, Gómez-
Rangel JD, Reyes-Núñez V, Garcés-Eisele J. Primary thrombo-
philia in Mexico. V. A comprehensive prospective study indicates
that most cases are multifactorial. Am J Hematol. 2005;78(1):
21-26.
22. Mammen EF. Sticky platelet syndrome. Semin Thromb Hemost.
1999;25(4):361-365.
23. Benigni A, Morigi M, Perico N, et al. The acute effect of FK506
and cyclosporine on endothelial cell function and renal vascular
resistance. Transplantation. 1992;54(5):775-780.
24. Zoja C, Furci L, Ghilardi F, Zilio P, Benigni A, Remuzzi G.
Cyclosporin-induced endothelial cell injury. Lab Invest. 1986;
55(4):455-462.
25. Yee DL, Sun CW, Bergeron AL, Dong JF, Bray PF. Aggregome-
try detects platelet hyperreactivity in healthy individuals. Blood.
2005;106(8):2723-2729.