Platelet Factor 4 and Von Willebrand Factor Form an Immunogenic, Prothrombotic Complex in Heparin-Induced Thrombocytopenia

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Platelet Factor 4 and Von Willebrand Factor Form an Immunogenic, Prothrombotic Complex in Heparin-Induced Thrombocytopenia University of Pennsylvania ScholarlyCommons Publicly Accessible Penn Dissertations 2018 Platelet Factor 4 And Von Willebrand Factor Form An Immunogenic, Prothrombotic Complex In Heparin-Induced Thrombocytopenia Ian Johnston University of Pennsylvania, [email protected] Follow this and additional works at: https://repository.upenn.edu/edissertations Part of the Pharmacology Commons Recommended Citation Johnston, Ian, "Platelet Factor 4 And Von Willebrand Factor Form An Immunogenic, Prothrombotic Complex In Heparin-Induced Thrombocytopenia" (2018). Publicly Accessible Penn Dissertations. 2907. https://repository.upenn.edu/edissertations/2907 This paper is posted at ScholarlyCommons. https://repository.upenn.edu/edissertations/2907 For more information, please contact [email protected]. Platelet Factor 4 And Von Willebrand Factor Form An Immunogenic, Prothrombotic Complex In Heparin-Induced Thrombocytopenia Abstract Heparin-induced thrombocytopenia (HIT) is a prothrombotic, thrombocytopenic disorder that occurs in patients exposed to heparin due to the development of antibodies directed against complexes of platelet factor 4 (PF4) with heparin with other polyanions . We have recently shown that the perithrombus endothelium is targeted in HIT. Using a photochemical injury model and an endothelialized microfluidic system, we now show that PF4 binds to elongated strands of von Willebrand factor (VWF) released from injured endothelium. This binding appears to be periodic along the VWF strand and to favor larger VWF strands, suggesting formation of oligomers that may cross-link individual VWF subunits. KKO, a monoclonal HIT-like antibody, and HIT patient plasma form PF4-VWF-HIT antibody complexes that may stabilize the complexes which, in turn, avidly bind platelets, exacerbating thrombus growth in a human whole blood microfluidic system. This increase in platelet binding is attenuated by blocking either the platelet FcRIIA or the glycoprotein Ib/IX receptor. Charge-based as well as VWF-binding drugs can disrupt the PF4-VWF-HIT complexes. Dynamic light scattering studies provide additional support for the concept that PF4 and VWF form complexes in vitro. In vivo studies in a passive immunization model of HIT indicate a potential role for VWF in the prothrombotic nature of HIT. Thus, these studies newly identify VWF as a potentially important polymer involved in the formation of HIT antigenic complexes that contribute to the prothrombotic nature of HIT and offer a potential new therapeutic target to mitigate the thrombotic complications of affected patients. Degree Type Dissertation Degree Name Doctor of Philosophy (PhD) Graduate Group Pharmacology First Advisor Mortimer Poncz Second Advisor Lawrence F. Brass Subject Categories Pharmacology This dissertation is available at ScholarlyCommons: https://repository.upenn.edu/edissertations/2907 PLATELET FACTOR 4 AND VON WILLEBRAND FACTOR FORM AN IMMUNOGENIC, PROTHROMBOTIC COMPLEX IN HEPARIN-INDUCED THROMBOCYTOPENIA Ian Johnston A DISSERTATION in Pharmacology Presented to the Faculties of the University of Pennsylvania in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy 2018 Supervisor of Dissertation _________________________ Mortimer Poncz M.D., Professor of Pharmacology and Pediatrics Graduate Group Chairperson _________________________ Julie A. Blendy, Ph.D., Professor of Pharmacology Dissertation Committee Lawrence F. Brass, M.D., PhD., Professor of Pharmacology and Medicine (Chair) John W. Weisel, PhD., Professor of Cell and Developmental Biology Doug B. Cines, M.D., Professor of Pathology and Laboratory Medicine Robert J. Levy, M.D., Professor of Pediatric Cardiology i Dedication page I dedicate this work to my wife, Courtney, whose love and support made all of this possible. ii ACKNOWLEDGMENT I’d like to thank Dr. Mortimer Poncz for his guidance and support. He allowed me to integrate my engineering background with the biology of the lab and venture into very interesting scientific realms. This translated into various conference presentations and collaborations that weren’t always available to other graduate students. So I thank him for these opportunities as I know they will be valuable to my future career. I’d also like to thank my thesis committee members, Dr. Skip Brass, Dr. Doug Cines, Dr. John Weisel, and Dr. Robert Levy. Their input provided the extra push which helped me overcome the challenges of graduate school and helped me hone the skills I’ll use for years to come. I’d also like to thank Dr. Carlos Villa, Dr. Colin Greineder, and Dr. Jacob Myerson from the Muzykantov Lab. Their collaborations helped broaden my view of science and research and were essential to the development of the microfluidic model. Lastly, I’d like to thank a few members of the Poncz lab. I’d like to thank Dr. Randy Lyde and Vincent Hayes for their friendship and support during graduate school. iii ABSTRACT PLATELET FACTOR 4 AND VON WILLEBRAND FACTOR FORM AN IMMUNOGENIC, PROTHROMBOTIC COMPLEX IN HEPARIN-INDUCED THROMBOCYTOPENIA Ian H. Johnston Mortimer Poncz, M.D. Heparin-induced thrombocytopenia (HIT) is a prothrombotic, thrombocytopenic disorder that occurs in patients exposed to heparin due to the development of antibodies directed against complexes of platelet factor 4 (PF4) with heparin with other polyanions . We have recently shown that the perithrombus endothelium is targeted in HIT. Using a photochemical injury model and an endothelialized microfluidic system, we now show that PF4 binds to elongated strands of von Willebrand factor (VWF) released from injured endothelium. This binding appears to be periodic along the VWF strand and to favor larger VWF strands, suggesting formation of oligomers that may cross-link individual VWF subunits. KKO, a monoclonal HIT-like antibody, and HIT patient plasma form PF4-VWF-HIT antibody complexes that may stabilize the complexes which, in turn, avidly bind platelets, exacerbating thrombus growth in a human whole blood microfluidic system. This increase in platelet binding is attenuated by blocking either the platelet FcRIIA or the glycoprotein Ib/IX receptor. Charge-based as well as VWF-binding drugs can disrupt the PF4-VWF-HIT complexes. Dynamic light scattering studies provide additional support for the concept that PF4 and VWF form complexes in vitro. In vivo studies in a passive immunization model of HIT indicate a potential role for VWF in the prothrombotic nature of HIT. Thus, these studies newly identify VWF as a potentially important polymer involved in the formation of HIT antigenic complexes that contribute to the prothrombotic nature of HIT and offer a potential new therapeutic target to mitigate the thrombotic complications of affected patients. iv TABLE OF CONTENTS ACKNOWLEDGMENT ............................................................................................................. III ABSTRACT .................................................................................................................................. IV TABLE OF CONTENTS .............................................................................................................. V LIST OF TABLES ..................................................................................................................... VIII LIST OF ILLUSTRATIONS ....................................................................................................... IX CHAPTER 1 - INTRODUCTION .............................................................................................. 1 Hemostasis: Pro-coagulative Factors .......................................................................................... 2 Hemostasis: Anti-coagulative Factors ......................................................................................... 3 Thrombosis ..................................................................................................................................... 4 Heparin-Induced Thrombocytopenia (HIT): An Iatrogenic Prothrombotic Disease ................ 5 HIT Modeling ................................................................................................................................... 7 Sepsis: An Immune-Based Systemic Disorder ........................................................................... 8 Summary ......................................................................................................................................... 9 Figures .......................................................................................................................................... 12 CHAPTER 2 – MICROFLUIDIC SYSTEM MODELING ...................................................... 18 Motivation for Developing an Endothelialized Microfluidic System ....................................... 19 Microfluidic Device and Setup .................................................................................................... 19 Injury Settings: Hematoporphyrin-Induced Endothelial Injury ............................................... 21 Injury Settings: TNFα-Induced Endothelial Injury .................................................................... 22 Discussion .................................................................................................................................... 22 Figures .......................................................................................................................................... 23 v CHAPTER 3 – ENDOTHELIAL ANTIGEN ASSEMBLY LEADS TO
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