Hamostaseologie 2004; 24(01): 65-70
DOI: 10.1055/s-0037-1619608
Grußwort
Schattauer GmbH

Diagnose der thrombotischthrombozytopenischen Purpura

Diagnosis of thrombotic thrombocytopenic purpura
U. Budde
1   Coagulation Laboratory, Lab. Association Prof. Arndt and Partners, Hamburg
,
D. Angerhaus
1   Coagulation Laboratory, Lab. Association Prof. Arndt and Partners, Hamburg
,
T. Obser
2   Department of Paediatric Haematology & Oncology, University Children’s Hospital Hamburg-Eppendorf, Germany
,
R. Schneppenheim
2   Department of Paediatric Haematology & Oncology, University Children’s Hospital Hamburg-Eppendorf, Germany
› Author Affiliations
Further Information

Publication History

Publication Date:
22 December 2017 (online)

Zusammenfassung

Die TTP ist durch das generalisierte Auftreten von hyalinen Thromben in der Mikrozirkulation gekennzeichnet. Bei allen bekannten Fällen der angeborenen TTP ist die von-Willebrand-Faktor-spaltende Protease (VWF-CP) stark vermindert. Auch bei einem aktuell noch umstrittenen Prozentsatz von Patienten mit erworbener TTP ist diese Proteaseaktivität infolge Autoantikörperbildung nicht nachweisbar oder stark vermindert (T<5%). Daher gehört neben der konventionellen Diagnostik die Untersuchung der VWF-CP und der Nachweis gegen sie gerichteter Antikörper zur diagnostischen Aufarbeitung von Fällen mit thrombotischer Mikroangiopathie. Allen Methoden zum Nachweis der VWF-CP gemeinsam ist der initiale Verdau des Substrates (gereinigter VWF, rekombinanter VWF, Plasma ohne endogene VWF-CP, Fragmente mit spezifischer Spaltstelle oder Patientenplasma mit eigener endogener Protease). Der Nachweis des Verdaus erfolgt mittels Analyse der residualen Multimere, des Autretens spezifischer Spaltprodukte, der Bestimmung der residualen VWF:CB oder des residualen VWF:RCo, oder mit fragmentspezifischen monoklonalen Antikörpern. Wirklich schnell (<30 min) funktioniert die Messung im Cone-and-plate(let)-Aggregometer. Nach Zusatz einer geringen Plasmamenge eines TTP-Patienten kommt es zu starker Erhöhung von Thrombozytenadhäsion und -aggregation einer Normalperson, während beide Aktivitäten bei anderen thrombotischen Mikroangiopathien infolge Verdünnungseffekt geschwächt werden. Die Molekulargenetik spielt eine wichtige Rolle für die Unterscheidung zwischen angeborener und erworbener TTP.

Summary

As hallmark of TTP, generalized hyaline thrombi in the patient’s microcirculation is known. These thrombi are composed of platelets and VWF. A severe defect of the VWF cleaving protease (VWF-CP) was found in all known patients with the inherited form of TTP. In contrary, although a severe deficiency of VWF-CP is specific for the acquired form, too, only a fraction of these patients is characterized by a severe deficiency. In most patients with a severe deficiency autoantibodies directed against VWF-CP is detectable in plasma. However, many patients with acquired TTP do not show any severe deficiency. Because treatment differs in inherited and acquired forms and as persistance of autoantibodies during clinical remission is of prognostic value, the determination of the activity of VWF-CP and of antibodies against VWF-CP are important parts in the workup of patients with TTP. In all methods for the determination of the activity of VWF-CP the first step is proteolysis of a specific substrate for the protease. In the second step the activity of the protease is measured by analysis of the residual VWF multimers, by the generation of specific fragments, by using the residual VWF:CB or VWF:RCo as marker of the loss of multimers or with help of specific monoclonal antibodies. In less than 30 min the cone and plate(let) aggregometer helps to distinguish between different forms of thrombotic microangiopathies. While adhesion and aggregation of platelets from a healthy person are clearly enhanced after addition of a small amount of plasma from a TTP patient, both characteristics are weakened by plasma from patients with other forms of thrombotic microangiopathy (dilution effect). Molecular genetics are established methods in the differentiation between inherited and acquired forms of TTP in those cases without autoantibodies against VWF-CP.

 
  • Literatur

  • 1 Aronson DL, Krizek DM, Rick ME. A rapid assay for the VWF protease. Thromb Haemost 2001; 85: 184-5.
  • 2 Böhm M, Vigh T, Scharrer I. Evaluation and clinical application of a new method for measuring activity of von Willebrand factor-cleaving metalloprotease (ADAMTS13). Ann Hematol 2002; 81: 430-5.
  • 3 Furlan M, Robles R, Lämmle B. Partial purification and characterization of a protease from human plasma cleaving von Willebrand factor to fragments produced by in vivo proteolysis. Blood 1996; 87: 4223-34.
  • 4 Gerritsen HE, Turecek PL, Schwarz HP, Lämmle B, Furlan M. Assay of von Willebrand factor (vWF)-cleaving protease based on decreased collagen binding affinity of degraded vWF: a tool for the diagnosis of thrombotic thrombocytopenic purpura (TTP). Thromb Haemost 1999; 82: 1386-9.
  • 5 Kokame K, Matsumoto M, Fujimura Y, Miyata T. VWF73, a region from D1596-R1668 of von Willebrand factor provides a minimal substrate for ADAMTS-13. Blood. 2003 prepublished online (September 25, 2003).
  • 6 Levy GG, Nichols WC, Lian EC, Foroud T, McClintick JN, McGee BM, Yang AY, Siemieniak DR, Stark KR, Gruppo R, Sarode R, Shurin SB, Chandrasekaran V, Stabler SP, Sabio H, Bouhassira EE, Upshaw Jr JD, Ginsburg D, Tsai HM. Mutations in a member of the ADAMTS gene family cause thrombotic thrombocytopenic purpura. Nature 2001; 413: 488-94.
  • 7 Lian EC, Harkness DR, Byrnes JJ, Wallach H, Nunez R. Presence of aggregating factor in the plasma of patients with trombotic thrombocytopenic purpura and its inhibition by normal plasma. Blood 1979; 53: 333-8.
  • 8 Mannucci PM. Consistence of ADAMTS-13 activity assays: a moderately optimistic view. J Thromb Haemost 2003; 1: 1880-1.
  • 9 Moake JL, Rudy CK, Troll JH, Weinstein MJ, Colannino NM, Azocar J, Seder RH, Hong SL, Deykin D. Unusually large plasma factor VIII: von Willebrand factor multimers in chronic relapsing thrombotic thrombocytopenic purpura. N Engl J Med 1982; 307: 1432-5.
  • 10 Moore JC, Murphy WG, Kelton JG. Calpain proteolysis of von Willebrand factor enhances its binding to platelet membrane glycoprotein IIb/IIIa: an explanation for platelet aggregation in thrombotic thrombocytopenic purpura. Br J Haematol 1990; 74: 457-64.
  • 11 Moschcowitz E. Hyaline thrombosis of the terminal arterioles and capillaries: a hitherto undescribed disease. Proc N Y Pathol Soc 1924; 24: 21-4.
  • 12 O’Brien JR. “Exhausted” platelets continue to circulate. Lancet 1978; 2 (8103): 1316-7.
  • 13 Obert B, Tout H, Veyradier A, Fressinaud E, Meyer D, Girma JP. Estimation of the von Willebrand factor-cleaving protease in plasma using monoclonal antibodies to vWF. Thromb Haemost 1999; 82: 1382-5.
  • 14 Remuzzi G, Misani R, Livio M, Mecca G, de Gaetano G, Donati MD. Thrombotic thrombocytopenic purpura. A deficiency of plasma factors regulating platelet-vessel-wall interactions?. N Engl J Med 1978; 299: 311-4.
  • 15 Schneppenheim R, Budde U, Oyen F, Angerhaus D, Aumann V, Drewke E, Hassenpflug W, Häberle J, Kentouche K, Kohne E, Kurnik K, Müller-Wiefel D, Obser T, Santer R, Sykora KW. Von Willebrand factor cleaving protease and ADAMTS13 mutations in childhood TTP. Blood 2002; 101: 1845-50.
  • 16 Schulman I, Pierce M, Lukens A, Currimbhoy Z. Studies on thrombopoiesis. I. A factor in normal human plasma required for platelet production; chronic thrombocytopenia due to its deficiency. Blood 1960; 16: 943-57.
  • 17 Shenkman B, Budde U, Angerhaus D, Lubetsky S, Savion N, Seligson U, Varon D. Diagnosis of various types of thrombotic thrombocytopenic purpura by cone and plate(let) analyzer. Blood 2002; 100: 685a.
  • 18 Studt JM, Böhm M, Budde U, Girma JP, Varadi K, Lämmle B. Measurement of von Willebrand factor-cleaving protease (ADAMTS-13) activity in plasma: a multicenter comparison of different assay methods. J Thromb Haemost 2003; 1: 1882-7.
  • 19 Tandon NN, Rock G, Jamieson GA. Anti CD 36 antibodies in thrombotic thrombocytopenic pupura. Br J Haematol 1996; 88: 816-22.
  • 20 Tsai HM. Physiologic cleavage of von Willebrand factor by a plasma protease is dependent on its conformation and requires calcium ion. Blood 1996; 87: 4235-44.
  • 21 Upshaw Jr. JD. Congenital deficiency of a factor in normal plasma that reverses microangiopathic hemolysis and thrombocytopenia. N Engl J Med 1978; 298: 1350-2.