QUANDO SI CONTA IL NUMERO DI PIASTRINE E LEUCOCITI IN

UNIVERSITA’ DEGLI STUDI DI MILANO V CORSO NAZIONALEDI AGGIORNAMENTO PIASTRINE 2015 MILANO, 11 NOVEMBRE 2015 QUANDO SI CONTA IL NUMERO DI PIASTRINE E LEUCOCITI IN UNA POPOLAZIONE: L’ESPERIENZA DEL PROGETTO MOLI-­‐SANI GIOVANNI de GAETANO, MD, PhD Dire<ore Dipar@mento di Epidemiologia e Prevenzione IRCCS Is@tuto Neurologico Mediterraneo NEUROMED Pozzilli (Isernia) IRCCS NEUROMED Parco Scien@fico Pozzilli (Isernia) “Every time the vascular wall is damaged, the earliest
phenomenon which can be observed is the accumulation
of blood platelets. Among aggregated platelets a few white
blood corpuscules are also captured…”
Giulio Bizzozero, 1882
Two small mural thrombi which have
formed within a small artery of the
omentum of a guinea pig. The larger
one contains, among blood platelets,
a white blood corpuscule.
FINO AGLI ANNI ’50 LA PIASTRINA CENERENTOLA DELL’EMOSTASI Receptor-­‐mediated signalling pathways in platelets Li et al, Cell Mol Life Sci 2015 Receptor-­‐mediated signalling pathways in neutrophils Li et al, Cell Mol Life Sci 2015 Li et al, Cell Mol Life Sci 2015 BLOOD CELL INDICES
VARIABILITY
PLATELET COUNT
LEUKOCYTE COUNT
Progetto
Uno studio di coorte prospettico
sui fattori di rischio e protezione,
genetici e acquisiti,
delle malattie cardiovascolari e dei tumori
The Moli-sani Study
ü  25,000 living in the Molise region
ü  Aged ≥ 35 years
ü  Recruitment phase: 2005-2010
ü  Follow-up: presently at 2011
ü  Study duration….. years…
ü  End points: cardiovascular and cancer
events
Moli-sani: distribution of platelet count
in men and women
Men
Women
Santimone et al, Haematologica, 2011
Moli-­‐sani: platelet count by age and sex 300 Platelet count 275 250 225 200 175 150 35-­‐39 40-­‐49 50-­‐59 MEN 60-­‐69 70-­‐79 >=80 WOMEN San@mone et al, Haematologica, 2011 VARIABLES ASSOCIATED WITH PLATELET COUNT 280 270 260 250 240 230 220 210 200 1 2 3 4 5 White blood cells 1 2 3 4 5 C-­‐ R eac@ve Protein 1 2 3 4 5 D-­‐dimer San@mone et al, Haematologica, 2011 VARIABLES ASSOCIATED WITH PLATELET COUNT
Santimone et al, Haematologica 2011
PLATELET COUNT IN 25 MOLISE VILLAGES Mean values adjusted for age and sex San@mone et al, Haematologica, 2011 Segni zodiacali Zodiaco delle piastrine
256,0
254,0
252,0
250,0
248,0
246,0
244,0
242,0
240,0
PLATELET COUNTS IN DIFFERENT OGLIASTRA VILLAGES Biino et al. Haematologica, 2011 Sud-Tirolo
Parco genetico Friuli
Val Borbera
Moli-sani
Carlantino
Cilento
Ogliastra
SEVEN ITALIAN STUDIES: ENROLLED SUBJECTS REGION VILLAGES (N) Molise 30 22,969 Ogliastra (Sardegna) 10 12,517 Cilento (Campania) 3 2,128 Val Borbera (Piemonte) 7 1,785 Carlan@no (Puglia) 1 1,478 Friuli-­‐Venezia Giulia 5 1,650 Sud Tirolo (Tren@no AA) 3 1,280 TOTAL 59 SUBJECTS (N) 43,807 Biino et al, submiDed SOME CHARACTERISTICS OF THE POOLED POPULATION SAMPLE • 
• 
• 
• 
• 
Enrolled individuals: 43,807 Studied individuals: 40,987 Men: 46.2% Mean age: 50.7 years (± 17.5) Mean platelet count: women 261,000; men 237,000 PLATELET COUNT BY AGE 340 320 Platelet count (x109/L) 300 280 M F 260 240 220 200 <5 5-­‐9 10-­‐14 15-­‐17 18-­‐34 Age (years) 35-­‐49 50-­‐64 65-­‐74 >=75 PLATELET COUNT BY AGE AND POPULATION 350
Platelet count (×10
9
/L)
380
320
290
260
230
200
<5
5-9
10-14
15-17
18-34
35-49
50-64
65-74
Age (years)
Carlantino
Borbera valley
Molise
Others Ogliastra
West Ogliastra
North Ogliastra
FVG
Cilento
South Tyrol
Lines represent age trend of platelet count in the inves@gated popula@ons >=75
Mean platelet count in the nine sub-­‐populaUons along with 95% CI Biino et al, PLoS ONE 2013 AGE-­‐ AND SEX-­‐SPECIFIC REFERENCE INTERVALS FOR PLATELET COUNT mean (SD) 2.5th-­‐97.5th 2.5th (95%CI) 97.5th (95%CI) 1702 299 (71.6) 176 -­‐ 452 166-­‐181 441-­‐467 Men 13789 238 (57.9) 141 -­‐ 362 140-­‐144 358-­‐365 Women 16358 264 (65.3) 156 -­‐ 405 153-­‐158 401-­‐410 Men 4303 220 (59.5) 122 -­‐ 350 119-­‐126 343-­‐360 Women 4835 245 (61.2) 140 -­‐ 379 137-­‐144 372-­‐390 Age n <15 years All 15-­‐64 years >64 years PLATELET COUNTS’ REFERENCE INTERVALS FOR CLINICAL PRACTICE 500
473
450
452
Platelet c ount (x109 /L)
400
436
405
350
369
362
396
379
361
350
300
250
200
150
100
176
165
156
136
141
120
140
119
122
112
Numbers inside bars represent reference intervals es@mated on the overall sample; numbers outside bars represent extended reference intervals es@mated stra@fying by geographical area. Taking into account the new normal ranges, is platelet count a marker of low-­‐grade inflamma@on, associated to the cardiovascular risk in a general popula@on? Low-grade inflammation
•  Low-grade inflammation is a subclinical
(systemic or local, often chronic) condition
characterized by increased levels of plasmatic
and/or cellular biomarkers of inflammation (e.g.
CRP, platelet or White Blood Cell counts)
without any apparent clinical sign.
•  It is an underlying patho-physiological
mechanism linking risk factors or metabolic
disorders (e.g., oxidative stress, obesity,
diabetes, dyslipidemia, etc.) to increased risk of
chronic degenerative disease
VARIABLES ASSOCIATED WITH PLATELET COUNT 280 270 260 250 240 230 220 210 200 1 2 3 4 5 White blood cells 1 2 3 4 5 C-­‐ R eac@ve Protein 1 2 3 4 5 D-­‐dimer San@mone et al, Haematologica, 2011 Am J Cardiol 2010
255 Moli-­‐sani: PLATELET COUNT AND 10-­‐YEAR CARDIOVASCULAR RISK IN HEALTHY MEN PLT count (109/L) 250 245 240 235 230 225 Low (<3) Medium (3-­‐20) CARDIOVASCULAR RISK (MEN) High (>20) Bonaccio et al. Blood, 2014 Moli-­‐sani: WHITE BLOOD CELL COUNT AND 10-­‐YEAR CARDIOVASCULAR RISK IN HEALTHY MEN 9 WBC count (109/L) 8,5 8 7,5 7 6,5 6 5,5 5 4,5 4 Low (<3) Medium (3-­‐20) High (>20) CARDIOVASCULAR RISK (MEN) Bonaccio et al. Blood, 2014 •  Low-­‐grade (subclinical) inflamma@on has been linked to increased risk for coronary heart disease. •  A Mediterranean dietary pa<ern has been associated with a reducUon of mortality for major chronic diseases. •  Does Mediterranean Diet modulate platelet and leukocyte counts? ?
LOW-GRADE INFLAMMATION AND
DIETARY PATTERNS
q Positive association between
Western-type / meat-based diets and
bio-markers of low-grade chronic
inflammation
q Inverse association between
vegetable-and fruit-based dietary
patterns and bio-markers of low-grade
chronic inflammation
Centritto F and Moli-sani study Investigators. NMCD 2009
Barbaresko J et al. Nutr Rev. 2013
PLATELET AND WBC COUNTS ACCORDING TO ADHERENCE TO THE MEDITERRANEAN DIET WBC 254 6,35 252 6,3 250 6,25 248 6,2 246 6,15 244 6,1 242 6,05 Low (0-­‐2) Low-­‐Medium (3-­‐4) Medium-­‐high (5-­‐6) WBC count (109/L) PLT count (109/L PLT High (7-­‐9) Adherence to Mediterranean diet (Greek score) Bonaccio M et al, Blood, 2014 Platelet count and adherence to the Mediterranean diet 254
Platelet count (109xL)
253
252
251
250
249
248
247
246
245
Low (0-2)
Low-Medium (3-4) Medium-high (5-6)
Adherence to the Mediterranean diet
High (7-9)
Bonaccio M et al. Blood. 2014;123:3037-44
ODDS RATIO OF BEING IN THE HIGHEST NORMAL PLT COUNT CATEGORY ACCORDING TO ADHERENCE TO THE MD (GREEK SCORE) 1,2 1,1 Odds ra@o (095%CI) 1 0,9 0,8 0,7 0,6 0,5 0,4 0,3 0,2 Low (0-­‐2) Low-­‐Medium (3-­‐4) Medium-­‐high (5-­‐6) High (7-­‐9) Adherence to the Mediterranean diet (Greek score) Bonaccio et al, Blood, 2014 ODDS RATIO OF BEING IN THE LOWEST NORMAL WBC COUNT CATEGORY ACCORDING TO ADHERENCE TO THE MEDITERRANEAN DIET 2 1,8 Odds ra@o (95%CI) 1,6 1,4 1,2 1 0,8 0,6 0,4 0,2 Low (0-­‐2) Low-­‐Medium (3) Medium-­‐high (4-­‐5) High (≥6) Adherence to the Mediterranean diet (Italian score) Bonaccio et al, Blood, 2014 PLATELET AND WHITE BLOOD CELL COUNTS AND 10-­‐YEAR CARDIOVASCULAR RISK IN HEALTHY MEN PLT WBC 251 8 7,5 247 245 7 243 6,5 241 239 6 237 WBC count (109/L) PLT count (109/L ) 249 5,5 235 233 5 Low (<3) Medium (3-­‐20) High (>20) CARDIOVASCULAR RISK (MEN) Bonaccio et al. Blood, 2014 The associa@on between WBC count and Mediterranean Diet disappeared when further adjusted for PLATELET count . On the contrary, the associa@on between PLATELET count and dietary scores remained significant aqer further controlling for WBC count. Bonaccio et al, Blood, 2014 A “low-­‐grade inflamma@on” score ü  The score was obtained by 10-­‐@les of 4 biomarkers • 
• 
• 
• 
C-reactive protein
Platelet count
Leukocyte count
Granulocyte/lymphocyte
ratio
ü The INFLA-score ranged between -16 and 16 and came up as
the sum of the 4 components
INFLA-­‐score for the evaluaUon of “low-­‐grade inflamma@on” Pounis G et al. Thromb & Haemostasis 2015
INFLA-­‐score: to evaluate “low-­‐grade inflamma@on” Pounis G et al., Thromb & Haemostasis, 2015
Odds of being in the highest category of the
“low grade inflammation” score
according to the adherence to Mediterranean Diet
1,1 Odds ra@o (95%CI) 1 0,9 0,8 0,7 0,6 0,5 Low Low-­‐medium Medium Categories of adherence to the MD High Odds ratios from the model adjusted for age, sex, energy intake, education, smoking,
leisure-time PA, BMI, diabetes, hypercholesterolemia, hypertension.
Bonaccio et al, unpublished
Odds of being in the top category of inflamma@on score according to a 2-­‐point increase in the adherence to Mediterranean Diet and contribu@on of single food items High vs Low quar@le of inflamma@on score P value Reduc@on in the effect (%) <.0001 -­‐ OR (95%CI) 2-­‐point increase in MDS 0.874 (0.827-­‐0.924) Aqer alternate removal of food items Meat and meat products (low intake) 0.898 (0.853-­‐0.946) <.0001 -­‐18.8 Fruits and nuts 0.892 (0.847-­‐0.940) <.0001 -­‐14.5 Cereals 0.889 (0.846-­‐0.935) <.0001 -­‐11.6 Moderate alcohol 0.886 (0.841-­‐0.933) <.0001 -­‐9.4 Vegetables 0.883 (0.836-­‐0.934) <.0001 -­‐7.2 Fish 0.881 (0.836-­‐0.930) <.0001 -­‐5.8 Monounsaturated/saturated fats 0.879 (0.831-­‐0.931) <.0001 -­‐4.3 Dairy products (low intake) 0.874 (0.829-­‐0.921) <.0001 0.0 Legumes 0.865 (0.820-­‐0.913) <.0001 7.3 “Low grade inflammation” score according to
categories of alcohol intake
3 Inflamma@on score (mean) 2,5 2 1,5 1 0,5 0 Abstainers -­‐0,5 Occasional Light Moderate Categories of alcohol intake Heavy Means (±SE) and P value <.0001 from the model adjusted for age, sex, energy intake,
education, smoking, leisure-time, PA, BMI, diabetes, hypercholesterolemia,
hypertension and adherence to MD without alcohol intake.
Abstainers: no alcohol consumption / Occasional: up to 1 gr/day/ Light: Women ≤12 gr/
day; Men ≤24 gr/day. / Moderate: Women 12-24 gr/day; Men 24-48 gr/day
Heavy: Women > 24 gr/day; Men > 48 gr/day
Bonaccio et al, unpublished
Thromb Haemost 2016
Polyphenol intake (score)
and adherence to the Mediterranean Diet
by Moli-sani participants.
Mediterranean
Diet adherence FLAVO
NOLS
Low
adherence
(n=17,655) High
adherence
(n=6,374) ANTH
OCYAN
IDIN
FLAVON
ES
FLAVA
NONS
FLAVA
NOLS
14.6
0.60
28.4
44.0
(10.6,
20.2) (0.41,
0.85) (20.8,
38.3) (23.9,
86.2) (86, 179) (15.5,
26.1) 19.9
0.84
37.5
59.2
171
27.0
(14.9,
27.1) (0.59,
1.18) (29.0,
48.5) (34.2,
100) (123,
240) (21.4,
34.3) 123
ISOFLA
VONES
20.2
LIGNANS
score
68.3
-5
(51.6, 88.8) (-14, 4) 95.8
6
(75.2, 123) (-3, 15) Pounis et al, 2015, Thromb Haemost., in press
INFLA-­‐score in associa@on with Polyphenol-­‐score Main outcome: INFLA-score, Independent variable: PAC-score
Pounis G et al. Thromb & Haemostasis 2015, in press
Thromb Haemost , 2015
IS PLATELET INDICES MICRO-­‐HETEROGENEITY A NEW INDEPENDENT DETERMINANT OF HAEMORRHAGIC AND/OR THROMBOTIC RISK AND/OR OF OTHER CLINICAL CONDITIONS? Ming-Tsun Tsai et al, Blood 2015 September 24
CONTRIBUTION OF PLATELET COUNT TO THE ASSOCIATION BETWEEN MEDITERRANEAN DIET AND “LOW-­‐GRADE INFLAMMATION” High vs Low Inflamma@on score P value Reduc@on in the effect (%) <.0001 -­‐ OR (95%CI) 2-­‐POINT INCREASE IN MDS 0.902 (0.857-­‐0.949) Without PLATELET COUNT 0.914 (0.872-­‐0.959) 0.0002 -­‐18.9 Without C-­‐reac@ve Protein 0.923 (0.883-­‐0.965) 0.0004 -­‐27.4 Without Granul/Lymphoc R 0.934 (0.895-­‐0.973) 0.0012 -­‐37.7 Without WBC count 0.937 (0.899-­‐0.978) 0.0026 -­‐40.6 * P value from the model adjusted for age, sex, educa@on, BMI, smoking, energy intake, exercise, income, hypertension, hypercholesterolemia. Bonaccio et al, This Congress “Every time the vascular wall is damaged, the earliest
phenomenon which can be observed is the accumulation
of blood platelets. Among aggregated platelets a few white
blood corpuscules are also captured…”
Giulio Bizzozero, 1882
Two small mural thrombi which have
formed within a small artery of the
omentum of a guinea pig. The larger
one contains, among blood platelets,
a white blood corpuscule.
1978 Mean platelet volume by age and sex Mean platelet volume
8,80
8,70
8,60
8,50
8,40
8,30
35-39
40-49
MEN
50-59
60-69
WOMEN
70-79
>=80
245
BMI associated with platelet count in men and women 240
235
230
Men 225
220
(<24) (24-26) (27-29) (30-31) (>31) BMI
270
265
260
255
Women 250
245
(<24) (24-26) (27-29) (30-31) (>31)
BMI
PLATELET COUNT DENSITIES BY POPULATION .008
kdensity plt
.006
.004
.002
0
0
50
100 150 200 250 300 350 400 450 500 550 600
9
Platelet count (×10 /L)
Carlantino
Borbera valley
Molise
Remainders Ogliastra
West Ogliastra
North Ogliastra
FVG
Cilento
South Tirolo
Each line represents the platelet count distribuUon of a populaUon. Ogliastra villages have been clustered in three groups following their genotype and phenotype characterisUcs. VerUcal lines represent the reference intervals currently in use. ODDS OF BEING IN THE TOP CATEGORY OF LOW-­‐GRADE INFLAMMATION ACCORDING TO A 2-­‐POINT INCREASE IN THE ADHERENCE TO MD. CONTRIBUTION OF SINGLE FOOD ITEMS High vs Low Inflamma@on score P value Reduc@on in the effect (%) <.0001 -­‐ 0.0022 -­‐27.2 OR (95%CI) 2-­‐point increase in MDS 0.902 (0.857-­‐0.949) Low meat and meat products 0.929 (0.886-­‐0.974) Fish 0.915 (0.871-­‐0.961) 0.0004 -­‐13.3 Fruits and nuts 0.912 (0.868-­‐0.958) 0.0002 -­‐10.5 MS ra@o 0.911 (0.865-­‐0.961) 0.0006 -­‐9.5 Cereals 0.907 (0.866-­‐0.950) <.0001 -­‐4.9 Moderate alcohol 0.905 (0.863-­‐0.949) <.0001 -­‐3.0 Vegetables 0.903 (0.858-­‐0.950) <.0001 -­‐1.2 Low Dairy products 0.901 (0.858-­‐0.946) <.0001 0.7 Legumes 0.897 (0.853-­‐0.943) <.0001 5.3 Bonaccio et al, This Congress LABORATORI DI RICERCA, UNIVERSITA’ CATTOLICA, CAMPOBASSO 245
BMI associated with platelet count in men and women 240
235
230
Men 225
220
(<24) (24-26) (27-29) (30-31) (>31) BMI
270
265
260
255
Women 250
245
(<24) (24-26) (27-29) (30-31) (>31)
BMI
OGLIASTRA REGION Biino, G. et al. Haematologica 2011;96:96-­‐101 Gruppo di Studio delle Piastrine XIII riunione nazionale Concordia Sagi<aria (VE) 7-­‐ 9 O<obre 2012 AGE-­‐ AND SEX-­‐RELATED VARIATIONS IN PLATELET COUNT IN ITALY: A PROPOSAL OF REFERENCE RANGES BASED ON 40,987 SUBJECTS' DATA Chiara Cerlex Giovanni de Gaetano, and Carlo Balduini on behalf of…. Ginevra Biino,1,2 Iolanda Santimone,3 Cosetta Minelli,4 Rossella Sorice,5
Bruno Frongia,2 Michela Traglia, 6 Sheila Ulivi,7 Augusto Di Castelnuovo,
3 Martin Gögele,4 Teresa Nutile,5 Marcella Francavilla,2 Cinzia Sala,6
Nicola Pirastu,7,8 Chiara Cerletti,9 Licia Iacoviello,3 Paolo Gasparini,7,8
Daniela Toniolo,6 Marina Ciullo,5 Peter Pramstaller,4 Mario Pirastu,2,10
Giovanni de Gaetano11 and Carlo L Balduini12
1
Institute of Molecular Genetics, National Research Council of Italy, Pavia;
2 Institute of Population Genetics, National Research Council of Italy, Sassari;
3,9, 11 Research Laboratories, Fondazione di Ricerca e Cura "Giovanni Paolo II", Università
Cattolica, Campobasso;
4 Institute of Genetic Medicine, EURAC Research, Bolzano;
5 Institute of Genetics and Biophysics A. Buzzati-Traverso, National Research Council of Italy,
Naples;
6 Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milano;
7 Institute for Maternal and Child Health - IRCCS “Burlo Garofolo” – Trieste;
8 Medical Genetics, Department of Reproductive Sciences, University of Trieste;
10 Shardna Life Sciences, Cagliari;
12 Department of Internal Medicine, IRCCS Foundation Policlinico S. Matteo, University of
Pavia.
Acknowledgments The Authors would like to thank the members of the Italian “Platelet Study Group” (GSP) for the useful discussion of the ini@al idea of this study Table 2. Age-­‐, sex-­‐ and popula@on-­‐ specific reference intervals for platelet count Low platelets areas Age <15 y n mean (SD) 2.5th-­‐97.5th Medium platelets areas mean (SD) 2.5th-­‐97.5th n All 15-­‐64 y 426 277 (65.7) Men 1032 212 (52.6) 120 -­‐ 343 11614 Women 1347 234 (54.2) >64 y 136 -­‐ 358 13577 Men 279 201 (54.4) 112 -­‐ 332 Women 408 217 (50.9) 119 -­‐ 325 165 -­‐ 412 995 301 (72.8) 239 (58) 265 (65) 220 3746 (59.5) 247 4013 (61.4) High platelet areas mean (SD) 2.5th-­‐97.
5th 179 -­‐ 459 281 322 (66.6) 196 -­‐ 473 143 -­‐ 362 1143 253 (54.9) 157 -­‐ 369 157 -­‐ 405 1434 284 (68.6) 176 -­‐ 436 123 -­‐ 350 278 239 (58.8) 133 -­‐ 361 143 -­‐ 381 414 254 (60.5) 144 -­‐ 396 n Grouping of disUnct geographical areas, according to their genotype and phenotype features, is as follows: Low (CarlanUno and North Ogliastra), Medium (Borbera valley, FVG, Others Ogliastra, Cilento and Molise) and High platelets areas (South Tyrol and West Ogliastra).