Role of platelet TLR4 expression in pathogensis of septic thrombocytopenia

Abstract

Abstract:

BACKGROUND: Infection-induced thrombocytopenia (TCP) is an independent risk factor for death of patients with sepsis, but its mechanism is unknown. This study aimed to explore the underlying mechanism of TCP based on the relationship between TLR4 expression and platelet activation in septic patients.
METHODS: A total of 64 patients with sepsis were prospectively studied. Platelet count (PC), mean platelet volume (MPV), platelet distribution width (PDW), platelet TLR4 expression, platelet PAC-1 expression, sCD40L and TNF-α concentrations were compared between the healthy control group (15 volunteers) and sepsis group (64 patients) at admission and on the 3, 5, and 9 days after admission. The changes of MPV and PDW in the TCP and non-TCP subgroups of sepsis before and after treatment were recorded. Prognostic index was analyzed.
RESULTS: PC was lower in the sepsis group (P=0.006), and MPV and PDW were higher in the sepsis group than those in the healthy control group (P=0.046, P=0.001). Platelet TLR4 and PAC-1 expressions, and sCD40L and TNF-α levels increased more significantly in the sepsis group (P<0.001). PAC-1 expression and TNF-α level were higher in the TCP group than in the non-TCP group before and after treatment (P=0.023, P=0.011). sCD40L concentration and platelet TLR4 expression were significantly higher in the treated TCP group than in the non-TCP group (P=0.047, P=0.001). Compared to the non-TCP group, the rate of bleeding was higher (P=0.024) and the length of ICU stay was longer (P=0.013). The APACHE II score and the 28-day mortality were higher in the TCP group (P<0.01, P=0.048).
CONCLUSIONS: The elevation of platelet TLR4 expression in sepsis along with platelet activation is closely related to the incidence of thrombocytopenia. The occurrence of TCP is a sign of poor prognosis in sepsis patients.

Key words: Sepsis, Thrombocytopenia, Toll-like receptor, Platelet activation, Glycoprotein IIb/IIIa, Soluble CD40 ligand, β-Thromboglobulin, Tumor necrosis factor-α, Interleukin-8

Yong-qiang Wang, Bing Wang, Yong Liang, Shu-hua Cao, Li Liu, Xin-nv Xu. Role of platelet TLR4 expression in pathogensis of septic thrombocytopenia[J]. World Journal of Emergency Medicine, 2011, 2(1): 13-17.

Figures/Tables 3

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Table 3

References 35

1	Levi M, Lowenberg EC. Thrombocytopenia in critically ill patients. Seminars in Thrombosis & Hemostasis 2008; 34:417-424. doi: 10.1055/s-0028-1092871 pmid: 18956281
2	Vandijck DM, Blot SI, De Waele JJ, Hoste EA, Vandewoude KH, Decruyenaere JM. Thrombocytopenia and outcome in critically ill patients with bloodstream infection. Heart Lung 2010; 39: 21-26. Epub 2009 Oct 15. doi: 10.1016/j.hrtlng.2009.07.005 pmid: 20109983
3	Guo YL, Liu DQ, Bian Z, Zhang CY, Zen K. Down-regulation of platelet surface CD47 expression in Escherichia coli O157:H7 infection-induced thrombocytopenia. PLoS One 2009; 4:e7131. pmid: 19771158
4	Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference 1. Intensive Care Med 2003; 29:530-538. pmid: 12664219
5	Torgersen C, Dünser MW, Schmittinger CA, Pettilä V, Ruokonen E, Wenzel V, et al. Current approach to the haemodynamic management of septic shock patients in European intensive care units: a cross-sectional, self-reported questionnaire-based survey. Eur J Anaesthesiol 2010 Nov 17. [Epub ahead of print]
6	Strauss R, Wehler M, Mehler K, Kreutzer D, Koebnick C, Hahn EG. Thrombocytopenia in patients in the medical intensive care unit: bleeding prevalence, transfusion requirements, and outcome. Crit Care Med 2002; 30:1765-1771. doi: 10.1097/00003246-200208000-00015 pmid: 12163790
7	Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004; 32:858-873. doi: 10.1097/01.ccm.0000117317.18092.e4 pmid: 15090974
8	Strauss R, Wehler M, Mehler K, Kreutzer D, Koebnick C, Hahn EG. Thrombocytopenia in patients in the medical intensive care unit: bleeding prevalence, transfusion requirements, and outcome. Crit Care Med 2002; 30:1765-1771. doi: 10.1097/00003246-200208000-00015 pmid: 12163790
9	Inwald DP, Faust SN, Lister P, Peters MJ, Levin M, Heyderman R, et al. Platelet and soluble CD40L in meningococcal sepsis. Intensive Care Med 2006; 32: 1432-1437. Epub 2006 Jun 30. pmid: 16810523
10	Vanderschueren S, De Weerdt A, Malbrain M, Vankersschaever D, Frans E, Wilmer A, et al. Thrombocytopenia and prognosis in intensive care. Crit Care Med 2000; 28:1871-1876. pmid: 10890635
11	Nijsten MW, ten Duis HJ, Zijlstra JG, Porte RJ, Zwaveling JH, Paling JC, et al. Blunted rise in platelet count in critically ill patients is associated with worse outcome. Crit Care Med 2000; 28:3843-3846. pmid: 11153624
12	Stéphan F, Hollande J, Richard O, Cheffi A, Maier-Redelsperger M, Flahault A. Thrombocytopenia in a surgical ICU. Chest 1999; 115:1363-1370. doi: 10.1378/chest.115.5.1363 pmid: 10334154
13	Von Hundelshausen P, Weber C. Platelets as immune cells bridging inflammation and cardiovascular disease. Circulation Research 2007; 5:27-40. pmid: 13396959
14	McEver RP. P-selectin/PSGL-1 and other interactions between platelets, leukocytes, and endothelium. In: Michelson AD. Platelet. New York: Academic/ Elsevier Science, 2002: 139-155.
15	Ogura H, Kawasaki T, Tanaka H, Koh T, Tanaka R, Ozeki Y, et al. Activated platelets enhance microparticle formation and platelet-leukocyte interaction in severe trauma and sepsis. J Trauma 2001; 50:801-809. pmid: 11371835
16	André P, Nannizzi-Alaimo L, Prasad SK, Phillips DR. Platelet-derived CD40L: The switch-hitting player of cardiovascular disease. Circulation 2002; 106:896-899. doi: 10.1161/01.cir.0000028962.04520.01 pmid: 12186789
17	Inwald DP, Faust SN, Lister P, Peters MJ, Levin M, Heyderman R, et al. Platelet and soluble CD40L in meningococcal sepsis. Intensive Care Med 2006; 32: 1432-1437. Epub 2006 Jun 30. doi: 10.1007/s00134-006-0250-2 pmid: 16810523
18	Furman MI, Krueger LA, Linden MD, Barnard MR, Frelinger AL 3rd, Michelson AD. Release of soluble CD40L from platelets is regulated by glycoprotein IIb/IIIa and actin polymerization. J Am Coil Cardiol 2004; 43:2319-2325. doi: 10.1016/j.jacc.2003.12.055
19	Larkin D, Murphy D, Reilly DF, Cahill M, Sattler E, Harriott P, et al. ICln, a novel integrin alphaIIbbeta3-associated protein, functionally regulates platelet activation. J Biol Chem 2004; 279:272-286.
20	Bennett JS, Berger BW, Billings PC. The structure and function of platelet integrins. Thromb Haemost 2009; 7:200-205.
21	Mitsios JV, Tambaki AP, Abatzis M, Biris N, Sakarellos-Daitsiotis M, Sakarellos C, et al. Effect of synthetic peptides corresponding to residues 313-332 of the alphaIIb subunit on platelet activation and fibrinogen binding to alphaIIbbeta3. Eur J Biochem 2004; 271:855-862. doi: 10.1111/j.1432-1033.2004.03990.x pmid: 14764102
22	Mangiafico S, Cellerini M, Nencini P, Gensini G, Inzitari D. Intravenous glycoproteinGPIIb/IIIa inhibitor (tirofiban)followed by intra-arterial urokinase and mechanical thrombolysis in stroke CJ3. Am J Neuroradiol 2005; 26:2595-2601. pmid: 16286408
23	McGuire K, Jones M, Werling D, Williams JL, Glass EJ, Jann O. Radiation hybrid mapping of all 10 characterized bovine Toll-like receptors. Anim Genet 2006; 37:47-50. pmid: 16441295
24	Goldstein DR. Toll-like receptors and other links between innate and acquired alloimmunity. Curr Opin Immunol 2004; 16:538-544. doi: 10.1016/j.coi.2004.08.001 pmid: 15341996
25	Schilling JD, Mulvey MA, Vincent CD, Lorenz RG, Hultgren SJ. Bacterial invasion augments epithelial cytokine responses to Escherichia coli through a lipopolysaccharide-dependent mechanism. J Immunol 2001; 166:1148-1155. pmid: 11145696
26	Akashi S, Shimazu R, Ogata H, Nagai Y, Takeda K, Kimoto M, et al. Cutting edge: cell surface expression and lipopolysaccharide signaling via the toll-like receptor 4-MD-2 complex on mouse peritoneal macrophages. J Immunol 2000; 164:3471-3475. doi: 10.4049/jimmunol.164.7.3471 pmid: 10725698
27	Cognasse F, Hamzeh H, Chavarin P. Evidence of Toll-like receptor molecules on human platelets. Immunol Cell Bio 2005; 83:196-198.
28	Elzey BD, Tian J, Jensen RJ, Swanson AK, Lees JR, Lentz SR, et al. Platelet-mediated modulation of adaptive immunity A communication link between innate and adaptive immune compartments. Immunity 2003; 19:9-19. pmid: 12871635
29	Nakamura T, Ebihara I, Shoji H, Ushiyama C, Suzuki S, Koide H. Treatment with polymyxin B-immobilized fiber reduces platelet activation in septic shock patients: decrease in plasma levels of soluble P-selectin, platelet factor 4 and beta-thromboglobulin. Inflamm Res 1999; 48:171-175. doi: 10.1007/s000110050442 pmid: 10344466
30	Montrucchio G, Bosco O, Del Sorbo L, Fascio Pecetto P, Lupia E, Goffi A, et al. Mechanisms of the priming effect of low doses of lipopoly-saccharides on leukocyte-dependent platelet aggregation in whole blood. Thromb Haemost 2003; 90:872-881. doi: 10.1160/TH03-02-0085 pmid: 14597983
31	Ward JR, Bingle L, Judge HM, Brown SB, Storey RF, Whyte MK, et al. Agonists of Toll-like receptor (TLR)2 and TLR4 are unable tomodulate platelet activation by adenosine diphosphate and platelet activation factor. Thromb Haemost 2005; 94:831-834. pmid: 16270639
32	Cognasse F, Hamzeh-Cognasse H, Lafarge S, Delezay O, Pozzetto B, McNicol A, et al. Toll-like receptor 4 ligand can differentially modulate the release of cytokines by human platelets. Br J Haematol 2008; 141:84-91. pmid: 18279456
33	Buduneli N, Ozçaka O, Nalbantsoy A. Salivary and Plasma Levels of Toll-like Receptor 2 and Toll-Like Receptor 4 in Chronic Periodontitis. J Periodontol 2010 Dec 7. [Epub ahead of print] pmid: 33246354
34	Yang FL, Li CH, Hsu BG, Tsai NM, Lin SZ, Harn HJ, et al. The reduction of tumor necrosis factor-alpha release and tissue damage by pentobarbital in the experimental endotoxemia model. Shock 2007; 28:309-316. pmid: 17545946
35	Hashimoto N, Kawabe T, Imaizumi K, Hara T, Okamoto M, Kojima K, et al. CD40 plays a crucial role in lipopolysaccharide induced acute lung injury. Am J Respir Cell Mol Biol 2004; 30:808. pmid: 14693668

Platelet parameters	Control group (n=15)	Sepsis group
Platelet parameters	Control group (n=15)	Admission (n=64)	3rd day (n=58)	5th day (n=53)	9th day (n=50)
PC(×10⁹/L)	272.33±34.23	211.37±77.25^#	213.65±80.06^#	226.52±67.89^*	245.68±59.48^*★
MPV(fL)	9.64±0.66	10.23±0.82^*	10.07±0.82	9.98±0.88	9.92±0.64
PDW(fL)	15.61±1.54	17.83±1.66^#	16.91±1.77^*	16.51±1.36	16.27±1.46^※

Parameters	Control group (n=15)	Sepsis group
Parameters	Control group (n=15)	Admission (n=64)	3rd day (n=58)	5th day (n=53)	9th day (n=50)
TLR4(%)	23.50±4.68	39.93±9.07^*	36.99±7.52^*	31.93±6.16^*	28.46±5.78^※
PAC-1(%)	21.02±3.49	42.21±8.74^*	39.84±7.95^*	34.54±7.02^*	28.38±6.14^▲※
sCD40L(ng/ml)	3.27±0.41	6.94±1.05^*	5.61±1.16^*	4.83±0.88^*	4.12±0.71^▲※
TNF-α (pg/ml)	4.08±3.08	60.10±9.77^*	44.53±11.28^**	37.36±10.58^*	25.16±8.09^*※

Groups	sCD40L (ng/ml)	TNF-α (pg/ml)	TLR4 (%)	PAC-1 (%)
Non-TCP
Pre-treatment (n=37)	6.67±1.29	56.97±9.39	38.62±9.21	33.24±5.45
Post-treatment (n=29)	3.79±0.59	26.21±7.02	27.17±5.50	26.56±5.12
TCP
Pre-treatment (n=27)	7.09±1.35	62.96±8.41^*	41.76±8.94	45.42±9.39^*
Post-treatment (n=15)	4.12±0.67^Δ	30.64±7.52^Δ	31.48±4.31^▲	32.80±5.46^▲

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