Hypoxia Reoxygenation Treatment Induces Platelet Hyperactivity and Relieves Calpain-1-Mediated Inhibition of Platelet Aggregation in a Mouse Model of Severe Sickle Cell Disease
Authors: Nwankwo Jennifer O. , Warburton Rod R. , Gremmel Thomas , Gerrits Anja J. , Richey Lauren J. , Hill Nicholas S. , Rivera Alicia , Jakubowski Joseph A. , Frelinger Andrew L. , Chishti Athar H. 
Published: October 2019

Abstract
Introduction: With an estimated 15 million patients and no drug that addresses its etiology, sickle cell disease (SCD) remains an area of unmet need. Vaso-occlusive pain crisis (VOPC), the hallmark of SCD, is initiated by sickle RBCs (sRBCs) recruiting leukocytes and platelets to potentiate vessel occlusion. ADP released by sRBCs is a potent activator of platelets, and sickle cell patients are known to have activated platelets in circulation both at steady state and during VOPC. However, the mechanism underlying platelet dysfunction in SCD is not fully understood. Platelet activation mediated by the protease activated receptors (PAR1 and PAR4 in humans, PAR3 and PAR4 in mice), triggers PLC-β activation resulting in calcium mobilization. The increased calcium flux leads to activation of GPIIbIIIa/aIIbb3, GP1b, and P-selectin involved in platelet aggregation, adhesion, and rolling. Prior evidence has established a role of the calcium-activated cysteine protease, calpain-1 in platelet activation. Washed platelets from calpain-1 knockout C57BL/6 mice demonstrated impaired platelet aggregation. However, due to the critical contribution of sRBCs to platelet dysfunction in SCD, whole blood (impedance) aggregometry represents a physiological assessment of platelet aggregation.
Methods: Townes SCD mice (SS) were backcrossed with calpain-1 knockout (CKO) mice to generate SCD mice lacking calpain-1 (SSCKO). Humanized mice (AA) were used as controls. Using flow cytometry, we evaluated in vivo platelet activation following stimulation with ADP and Thrombin GPRP. Platelet counts were obtained via ADVIA 120 and flow cytometry. For platelet aggregation, 500 μL of blood was harvested from the vena cava of AA, SS, SSCKO, and CKO mice. Whole blood aggregation in response to PAR4 stimulation was assessed using the Roche Multiplate Analyzer. A separate group of mice were challenged with hypoxia/reoxygenation (H/R) treatment (3 hours of 10.5% O2, followed by 4 hours of 21% O2) prior to platelet aggregation testing. SCD mice are characterized by tissue infarcts suggestive of thrombus formation. To examine whether H/R treatment induces formation of fibrin thrombi, we harvested brain, lungs, heart, kidneys, liver, and spleen following blood collection, and performed histology.
Results: Compared to AA, SS and SSCKO mice are thrombocytopenic. Similar to Berkeley, Townes mouse platelets are activated in vivo, demonstrated by activated GPIIbIIIa on circulating platelets. At steady state, PAR4 agonist-induced platelet aggregation is similar in AA and SS mice (64 U v. 53 U, n = 6-10/group, p = 0.3). As depicted in Fig 1., SSCKO mice show significantly reduced platelet aggregation compared to SS mice (13 U v 53 U, p<0.001, n = 6-10 per group). As expected, H/R treatment induces platelet hyperactivity in SS, but not AA mice (71 U v. 59 U, p = 0.04, n = 6/group). Interestingly, the H/R-induced platelet hyperactivity partially relieves the calpain-1-mediated inhibition of platelet aggregation in SSCKO mice at steady state (Fig 2) (53 U v. 13 U, p<0.001, n = 6-8/group). Furthermore, CKO mice do not show defective platelet aggregation at both steady state, and following H/R treatment, indicating an important role for sRBCs and adhesion in whole blood aggregation. Despite attenuated platelet aggregation, SSCKO platelets at steady state show comparable expression of activated GPIIbIIIa relative to their AA and SS counterparts, indicating that the impaired aggregation at steady state is not due to defective integrin translocation. Since the Roche Multiplate Analyzer takes platelet adhesion into account in determining aggregation, we hypothesize that defective SSCKO whole blood aggregation at steady state is due to reduced cell adhesion. Finally, while silent infarcts were detected in all tissues, fibrin thrombi were not detected, a finding consistent with studies in the Berkeley model reporting minimal thrombi formation in tissues. In summary, we report that calpain-1 is required for platelet aggregation in steady state SCD but not following H/R treatment. This is the first study of H/R-induced platelet dysfunction in the Townes model, and raises the possibility of targeting calpain-1 as a treatment for platelet hyperactivity in SCD.
Figure 1. Impaired steady state whole blood platelet aggregation in SSCKO mice (panel 3). Figure 1. Impaired steady state whole blood platelet aggregation in SSCKO mice (panel 3). Figure 2. H/R relieves calpain-1-mediated inhibition of platelet aggregation in SS-CKO mice (panel 3). Figure 2. H/R relieves calpain-1-mediated inhibition of platelet aggregation in SS-CKO mice (panel 3).

Disclosures
Jakubowski: Eli Lilly and Company: Employment, Equity Ownership. Frelinger:GL Synthesis: Research Funding; Celerion: Research Funding; Megakaryon: Research Funding; Bristol-Myers Squibb: Research Funding; Sysmex: Research Funding; Eisai: Research Funding; Baxalta: Research Funding; Pfizer: Research Funding; GE Global Research: Research Funding; NIH: Research Funding.