The CD47 antigen is a transmembrane glycoprotein ubiquitously expressed on hematopoietic and non-hematopoietic cells. It serves as a receptor for Thrombospondin (TSP) and a ligand for signal regulatory protein-alpha (SIRP-alpha) receptor, acting, respectively, as a regulator of apoptosis and as antagonistic to phagocyte activity. Ligation of CD47 with antibodies, its natural physiological ligand TSP or the specific CD47-binding peptide 41NK induces apoptosis in nucleated blood cells. This apoptosis is characterized by mitochondrial damage and the exposure of phosphatydilserine on the outerleaflet of the plasma membrane. Interaction of SIRP-alpha with CD47 is important also for the regulation of phagocytosis. SIRP-alpha is an immunoglobulin superfamily member and is predominantly expressed in neurons, dendritic cells (DCs) and monocytes/macrophages. Phagocytes engulf foreign cells but not “self” in part because “self” cells express CD47 as a ligand for SIRP-alpha, which inhibits phagocytosis. Thus CD47 functions as a “don't eat me” signal. Based on studies in mice, a novel mechanism of platelet destruction involving the CD47/SIRP-alpha system has been recently suggested in Immune Thrombocytopenia (ITP). Specifically, it has been demonstrated that: 1) platelet homeostasis is regulated by platelet expression of CD47 under normal conditions and in immune thrombocytopenia in a mouse model; 2) interaction between platelet CD47 and macrophage SIRP-alpha is important in regulating normal platelet turnover and FcgammaR-mediated clearance of IgG-sensitized platelets; 3) CD47-deficient platelets have a shortened half-life in the circulation of CD47 wild-type mice and are also more sensitive to Fcgamma receptor-mediated clearance, both in vivo and in vitro. However, the role of CD47 pathway in the pathogenesis of human ITP has not yet been studied. Therefore, the main purpose of the present study was to evaluate whether alterations of this system (platelets/phagocytes) might play a pathogenetic role in human ITP. In particular, we investigated whether in ITP: i) platelets are more susceptible to CD47-induced cell death; ii) expression of CD47 on fresh and in vitro aged platelets is reduced; iii) the platelet phagocytic capacity of CD14-derived DCs and macrophages is differentially modulated in the presence or absence of antibodies against CD47 and SIRP-alpha. Phenotypical and functional analysis of the expression of CD47 on platelets and SIRP-αlpha on CD14-derived/circulating DCs and on CD14-derived macrophages was performed in 32 ITP patients. Patients were newly diagnosed (14 cases) or with persistent (15 cases) or chronic (3 cases) ITP. At the time of the study, patients with persistent or chronic ITP were off therapy by at least two months. None of the patients were splenectomized. The median platelet count at the time of the study was 49×109/L (range 14–98). We found that in healthy subjects CD47 expression increased in in vitro aged platelets and ligation of CD47 with anti-CD47 antibody induced a dose-dependent increase of platelet apoptosis. Immature and mature CD14-derived DCs and circulating myeloid DCs were strongly positive for SIRP-α. Conversely, we demonstrated that in ITP: 1) CD47 expression was unchanged in freshly isolated and in vitro aged platelets; 2) increased platelet apoptosis was not due to the activation of the CD47-induced cell death pathway, which instead was shown to be blocked; 3) the blockage of SIRP-αlpha on immature CD14-derived DCs or CD47 on platelets by specific antibodies failed to modify platelet uptake/phagocytosis of DCs; in contrast, targeting platelet CD47 with specific antibody significantly increases platelet phagocytosis of CD14-derived macrophages. In conclusion, our data demonstrate that in ITP the increased platelet clearance is not due to reduced CD47 expression on platelets. However, platelets from ITP patients are not healthy because 1) apoptosis is increased; 2) platelet apoptosis is independent from CD47 death signal; 3) CD47 expression is not modified by in vitro ageing/apoptosis. In addition, we show that the CD47 pathway plays a role in platelet phagocytosis of macrophages, but not in DCs. We conclude that in ITP patients platelet homeostasis is differentially modulated by the CD47 pathway.
No relevant conflicts of interest to declare.
Asterisk with author names denotes non-ASH members.