Platelet Function Disorders

Prachi Jain Dr S Sirisha Rani Nita

Radhakrishnan
Rekha Harish

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 Introduction

• Primary physiological role of Platelets – hemostasis

at site of vascular injury by forming platalet plug

• Steps involved
1. Platelet Adhesion
2. Platelet Activation
3. Platelet Aggregation

• Platelet function disorders result from any defect in

these steps
Ref: Insert your references here

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 Normal Platelet
• Normal human platelets : Small in size (0.5 x 3.0 μm)
• Shape: - Discoid in shape have a mean volume
(MPV) 7–11 fL
• Anucleated
• Number: They circulate in relatively high numbers
(between 150 and 400 x 10^9 /L)
• Life span: approximately 7 to 10 days (7 – 12 days)

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 Ref: Platelets.2018;29:319-25

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 When to suspect

• Unexplained mucocutaneous bleeding, menorrhagia

or postop bleeding – usually mild bleeding or
bruising but variable in severity
• Recurrent Bleeding/bruising despite normal platelet
count and coagulation tests
• Family history of bleeding
• Bleeding manifestations with low platelet count and
large or small platelet size

Ref: Blood Rev.2005 Mar;19(2):111-23.

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 Acquired Platelet function disorders

• Drugs affecting platelet function

• Systemic disorders - Uraemia
Antiplatelet antibodies
Cardiopulmonary bypass
Liver disease
• Haematological disorders - Myeloproliferative disorders
Dysproteinaemias
Acquired von Willebrand disease
• Storage defect (transfused platelets)

Ref: Hematology Am Soc Hematol Educ Program.2005:403-8.

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 Acquired Platelet function disorders
• Drugs affecting platelet function
1. COX-1&2 inhibitors – Aspirin, other NSAIDs
2. Inhibitors of Platelet Receptors - Abciximab, tirofiban,
eptifibatide (αIIbβ3) Ticlopidine, clopidogrel, prasugrel
(irreversible), cangrelor (reversible), ticagrelor (reversible)
(P2Y12)
3. Phosphodiesterase Inhibitors - Dipyridamole Cilostazole
4. Anticoagulants -  Heparinoids, vitamin K antagonists and
direct thrombin inhibitors
5. Cardiovascular Agents β‐adrenergic blockers (propranolol) 
Vasodilators (nitroprusside, nitroglycerin) Diuretics (furosemide),
Calcium channel blockersCalcium channel blockers
Ref: Br J Hematol. 2011;155:30-44, Hematology Am Soc Hematol Educ Program.2005:403-8.

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 Acquired Platelet function disorders
6. Antimicrobials - β‐lactams (penicillins, cephalosporins) 
Amphotericin (antifungal) Hydroxychloroquine (antimalarial) 
Nitrofurantoin
7. Chemotherapeutic agents – Asparaginase, Plicamycin 
Vincristine
8. Psychotropics and Anaesthetics - Tricyclic antidepressants
(imipramine) Phenothiazines (chloropromazine) Local and
general anaesthesia (halothane)
9. Thrombolytic Agents Streptokinase Urokinase Tissue
Plasminogen Activator (TPA)
10. Food/Herbs (at high concentrations) Alcohol Caffeine
(methylxanthine) Cumin Dong quai Fenugreek Garlic,
onion, ginger Ginseng Fish Oil Tamarind
Ref: Br J Hematol. 2011;155:30-44, Hematology Am Soc Hematol Educ Program.2005:403-8.

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INHERITED DISORDERS OF PLATELET FUNCTION
 Inherited Disorders of Platelet Function
Abnormalites of Receptor for adhesive
proteins
Abnormalites of receptors for soluble
proteins
Abnormality of Platelet granules
Ref: Pediatr Blood Cancer 2011;56:975–983
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GPIb-IX (Bernard Soulier Syndrome*,
Platelet type von willebrand disease*)
GPIIb-IIIa (Glanzman thrombasthenia)
GPIa-IIa
GP IV
Thromboxane A2 receptor
P2Y12 receptor
α2 adrenergic receptor
Δ-granules (delta storage pool deficiency,
Hermansky-Pudlak syndrome, Chediak
higashi syndrome, TAR syndrome
α-granules (Gray platelet syndrome*,
Quebec platelet syndrome*, Paris Trousseau
Jacobsen syndrome*)
α and Δ storage pool deficiency
 Inherited Disorders of Platelet Function
Abnormalites of signal transduction
pathways
Abnormalites of cytoskeleton
Abnormality of membrane phospholipids
* Assocaited with thrombocytopenia
Ref: Pediatr Blood Cancer 2011;56:975–983
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Primary secretion defects
Arachidionic acid/thromboxane A2 pathway
defects
Gαq deficiency
Defects in pleckstrin phosphorylation
Defects in Calcium mobilization
MYH9-related disorders *(May–Hegglin
anomaly, Sebastian syndrome, Fechtner
syndrome, Epstein syndrome)
Wiskott–Aldrich syndrome*
X-linked thrombocytopenia*
Scott syndrome
 Diagnostic workup

• Detailed clinical history

• Platelet count and mean platelet volume (MPV)

• Blood smear - Always examine peripheral blood film
(Platelet count and size should be looked at)
• Coagulation profile – to rule out other causes of
bleeding manifestations
• Test for Von Willebrand disease (vWD)

Ref: Platelets. 2017;J14:1-7. Thromb Haemostat.2004;2:890-1. Br J Hematol. 2011;155:30-44

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 Diagnostic workup - Screening Tests

1. Template Bleeding time – oldest test of platelet

function. Described by Duke (1910)
Highly operator dependent and subjective
Influenced by age, gender, vascular pattern, skin
temperature and skin thickness
2. Ivy's “Method
More accurate
Done by inflating BP Cuff in arm and by making a lancet
wound in forearm
Not recommended in young children less than 2 years

Ref: Platelets. 2017;J14:1-7. Thromb Haemostat.2004;2:890-1. Br J Hematol. 2011;155:30-44

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 Diagnostic workup - Screening Tests

2. Platelet Function Analyser (PFA-100) – closure time

citrated whole blood is aspirated at high shear rates
(5000–6000/s) through disposable cartridges
containing an aperture - coated with either collagen
and epinephrine or collagen and ADP (CADP)
Agonists trigger platelet plug formation, leading to
rapid occlusion of the aperture and cessation of
blood flow  
• End point – Time to occlusion of blood flow
(Closure time CT) or non-closure if CT exceeds
300seconds
Ref: Platelets. 2017;J14:1-7. Thromb Haemostat.2004;2:890-1. Br J Hematol. 2011;155:30-44

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 Diagnostic workup - Screening Tests

Platelet Function Analyser (PFA-100) – closure time

Ref: Insert your references here

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 Diagnostic workup - Specific assays
Light Transmission aggregometry (LTA) – Gold
standard
Method
• Platelet rich plasma (PRP) and platelet poor plasma
(PPP) prepared from Citrated blood
• Baselone Panel of agonists - ADP, epinephrine,
collagen (type I, tendon), arachidonic acid and
ristocetin
• Extended panell - gamma Thrombin, Thrombin
Receptor Activating Peptides (TRAPs), Collagen‐Related
Peptide (CRP), endoperoxide analogue U46619 and
calcium ionophore A23187
Ref:Methods Mol Biol. 2013;992:227-40. Methods Mol Biol.2017;1646:321-331. Int J Mol Sci.2017 ;18: 1803

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 Diagnostic workup - LTA

• Change in optical density (or light transmittance) at

37°C after addition of the agonists is measured
• Aggregation curves are obtained for these agonists

• If the aggregation to ristocetin is normal then

retesting should additionally be performed with low
dose (0·5–0·7 mg/ml) ristocetin to check for
hyperfunction or gain of function (associated with
Type 2B and platelet type VWD).

Ref:Methods Mol Biol. 2013;992:227-40. Methods Mol Biol.2017;1646:321-331. Int J Mol Sci.2017 ;18: 1803

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 Diagnostic workup - LTA

Aggregation Curve

Ref: Insert your references here

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 Diagnostic workup - LTA

Aggregation Curve

Ref: Br J Hematol. 2011;155:30-44

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 LTA - GT vs BSS
Glanzmann Thrombasthenia
(GT)
Defect in GPIIb-IIIa
Absent response to all agonist
except Ristocetin

Bernard Soulier Syndrome

(BSS)
Defect in GPI
Absent response to Ristocetin
Abnormal large Platelets
Thrombocytopenia
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 LTA
Platelet storage pool disorder or a defect in nucleotide release

reversible, first wave aggregation is seen with ADP, adrenaline and collagen
and only partial agglutination with ristocetin

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 Diagnostic workup - LTA
Precautions
Samples should be freshly collected

Appropriate control samples to be run simultaneously

Platelet counts > 600 × 109/l in PRP should be diluted

Repeat all unexpected, abnormal light transmission

aggregometry tests with a fresh sample, in parallel with a

normal control sample

Only experienced individuals should interpret tracings and
Ref:
results
Br J Hematol. 2011;155:30-44

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 Diagnostic workup - Flowcytometry
• Quantification of glycoprotein receptor density in
the diagnosis of defects, such as GT and BSS, and
detecting their heterozygous states

• Also used to measure the collagen (GpIa/IIa and

GpVI) and PAR‐1 receptor densities if LTA testing
suggests any abnormalities in these receptors

• Expensive
• Time consuming
• Requires specialized training
Ref: Methods Mol Biol.2017;1646:369-89. Malays J Med Sci.2013;20:62-6

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 Treatment – General Measures
• Avoid NSAIDs and anti-platelet drugs
• Avoid injuries,Avoid IM injections

• Repeated transfusion may be required vaccination

against Hepatitis A and B

• HLA-matched transfusions preferred

• Patients should carry an emergency health card with

information about the disease, therapy,
contraindications (antiplatelet drugs)
Ref: Transfuse Med Hemother. 2010;37:237-46

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 Treatment – Local Measures
• Nose and Gum bleeds – nose pads, fibrin sealants

• Good Oral hygiene to prevent gum bleeding

• Tranexamic acid – local application, oral

• For Menorrhagia – progesterone only or combined

oral contraceptive pills, along with tranexamic acid.
Depo-medroxyprogesteone acetate (3 monthly) is an
alternative

Ref: Hemophilia.2012:;18:161-5. Br J Hematol. 2010.149;813-23.

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 Treatment – Drugs
• Systemic Antifibrinolytic Therapy – Tranaxemic acid (Oral
or IV @10-15 mg/kg/dose TDS)

• Desmopressin - shortens the bleeding time in storage

pool deficiencies. Can be administered parenterally either
via intravenous or subcutaneous injection or intranasally
as drops or spray.
Recommended parenteral dose is 0.3 μg/kg body weight,

intranasal dose is 150ug (wt 50kg), 300 μg (>50kg)

Response to desmopressin is highly variable
Not effective in GT
Ref: Transfuse Med Hemother. 2010;37:237-46

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 Treatment
• Platelet concentrates - bleeding complications in
inherited platelet disorders (e.g. GT, BSS)
prophylaxis in preoperative period

• Recombinant Activated Factor VIIa (rFVIIa) - Best

reported data concerning the efficacy of rFVIIa is
documented in thrombasthenic patients
Dose - at least 3 bolus doses of 80–120 μg/ kg rFVIIa
Used for the treatment of severe bleeding complications in
patients with GT, BSS, storage pool diseases, and several
acquired thrombocytopathies 

Ref: J Thromb Haemost. 2004;9:1096-103. Transfuse Med Hemother. 2010;37:237-46

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 Treatment – Specific
• Bone marrow transplant – successfully done for disorders
like GT, BSS

• Gene Therapy – ongoing research (eg: GT)

Ref: Br J Hematol. 2010.149;813-23

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