The autoimmune disease known as autoimmune thrombocytopenic purpura (ITP) is clinically defined by a low numbers of platelets in the circulation blood. Anti-platelet antibodies bind to glycoprotein molecules on the membranes of platelets and result in their dysfunction and destruction. Despite a growing body of information about ITP, it is difficult to isolate and characterise anti-platelet antibodies, because only limited monoclonal antibodies are available from ITP patients. This study used a phage display system to recognise Fab anti-platelet antibodies. Anti-platelet Fab-expressing phage was isolated by sequential panning of an ITP Fab library against normal non-ITP platelets. After isolation, the anti-platelet Fab-expressing phage was characterised by ELISA and Western blotting. The Fab-bearing phage pool obtained from five rounds of panning was analysed in order to determine its anti-platelet reactivity. Of the phage colonies obtained, 100 colonies of different sizes were randomly selected for reaction with whole platelets, using Ml3 phage as a negative control. 12 colonies of them had strong reactions against the whole platelet preparation, but only four colonies showed substantial reactivity against the lysed platelet preparation (lysate). Colony S7 showed highest the greatest degree of binding to both the lysate and the whole platelet preparation. The specificity of the four colonies (S2, S7, S8 and S9) that had strong positive reactions against platelet antigens was determined for the glycoprotein component GP Ilb/IIIa. Further characterisation of the proteins in the lysate preparation was carried out using blotting techniques. The protein content of the four Fab-bearing phage colonies was quantified under the non-reducing conditions of Western blotting to evaluate their ability to recognise platelet antigens. Three of the four colonies showed three bands representing proteins with different molecular weights. Each of these three colonies had one band that corresponded to a protein of molecular weight 92 kD. The fourth colony showed only a single band, but this band also corresponded to a 92-kD protein.

Neonatal alloimmune thrombocytopenia (NAIT) is caused by maternal alloantibodies against fetal platelet antigens inherited from the father and which are absent from maternal platelets. In Caucasians, antibodies against the Leu33 (HPA-1a) polymorphism of integrin β3 (part of the platelet αIIbβ3 complex) account for >70% of cases. Antenatal screening for these antibodies does not currently take place in the UK, partly because of the absence of sensitive, predictive tests. We hypothesized that the poor sensitivity and predictive abilities of current assays are due to the use of β3 in an inappropriate conformation, resulting in sub-optimal binding of HPA-1a antibodies. We hypothesized firstly that in vitro induced changes to αIIbβ3 might alter accessibility of the HPA-1a epitopes to alloantibodies, thus reducing assay sensitivity. Secondly, we hypothesized that HPA-1a antibodies are stimulated by, and preferentially recognise, β3 in association with αv, a molecule present on placental syncytiotrophoblasts, and that reactivity against platelet αIIbβ3 reflects only cross-reactivity with αvβ3. Our first hypothesis was proven by demonstrating that use of the cation chelating compound EDTA, used by many diagnostic laboratories as a component of assay reagents or present in blood samples as anticoagulant, resulted in significantly reduced assay sensitivity. These findings were confirmed in an international workshop. Support for our second hypothesis was provided by demonstrating enhanced reactivity of a small panel of examples of anti-HPA-1a against αvβ3 compared to αIIbβ3 and by molecular modelling data. We also showed that HPA-1a antibodies can inhibit platelet function by using a novel application of the ROTEM® delta thromboelastograph and an immunofluorescence assay in which we demonstrated blocking of platelet function using a monoclonal antibody, PAC-1, that binds only to activated αIIbβ3. These studies provide possible explanations for the poor sensitivity and predictive abilities of current assays and suggest further areas for research.

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