? The?Journal?of?Clinical?Investigation http://www.jci.org Volume 115 Number 12 December 2005
The molecular mechanisms
that control thrombopoiesis
Department of Medicine, Division of Hematology/Oncology, University of California, San Diego, San Diego, California, USA.
Overview of platelets and thrombopoiesis
An adequate supply of platelets is essential to repair the minute
vascular damage that occurs with daily life, and to initiate throm-
bus formation in the event of overt vascular injury. Accumulating
evidence also indicates vital roles for platelets in wound repair, the
innate immune response, and metastatic tumor cell biology. The
average platelet count in humans ranges from 150 × 109 to 400 × 109
per liter, although the level for any individual is maintained within
fairly narrow limits from day to day. While 150 × 109 to 400 × 109
per liter is considered “normal,” the values derived from the
mean ± 2 SDs of a group of “healthy” individuals, epidemiological
evidence indicates that individuals who display platelet counts in
the highest quartile of the normal range have a 2-fold increased
risk of adverse cardiovascular events (1), and, in both experimen-
tal animal models of metastatic cancer and patients with tumors,
higher platelet levels carry an unfavorable prognosis (2).
With a lifespan of approximately 10 days, a blood volume of
5 liters, and one-third of platelets pooled in the spleen, the average
adult must produce each day approximately 1 × 1011 platelets to
maintain a normal platelet count under steady-state conditions,
a level of production that can increase more than 10-fold under
conditions of increased demand. The primary regulator of platelet
production is thrombopoietin, an acidic glycoprotein produced
primarily in the liver, kidney, and BM. The biochemistry and struc-
ture-activity relationships of thrombopoietin have been carefully
evaluated, as have the binding sites to its receptor, the product of
the cellular protooncogene c-Mpl (3, 4). This Review will focus on
the regulation of platelet production, how thrombopoietin stimu-
lates thrombopoiesis under normal and pathological conditions,
and the molecular mechanisms through which the hormone pro-
duces its biological effects. In addition to providing an understand-
ing of normal physiology, the discovery of the biological effects of
thrombopoietin and its receptor provides a platform on which to
understand a number of clinical disorders of hematopoiesis and
serves to suggest novel therapeutic approaches to several diseases.
Discovery of thrombopoietin and the c-Mpl receptor
Evidence for a humoral regulator of thrombopoiesis was first pro-
vided in the late 1950s when plasma from bleeding or thrombocy-
topenic rats was found to induce thrombocytosis when transfused
into secondary animals. Based on ongoing work in erythropoiesis,
the term “thrombopoietin” was first coined in 1958 to describe the
humoral substance responsible for increasing platelet production
(5). In the late 1960s, in vivo assays were developed to detect throm-
bopoietin (6) but were cumbersome, hampering its purification.
In the 1980s, in vitro megakaryocyte colony–forming assays were
developed, allowing the identification of megakaryocyte colony–
stimulating factors, but whether the identified substances, such
as IL-3, GM-CSF, IL-6, or IL-11, were the same as thrombopoietin
remained controversial (7).
Occasionally in science, findings from one discipline spur an
entirely distinct field of investigation. The description of the
murine myeloproliferative leukemia virus in 1986 (8) and its
corresponding oncogene (v-Mpl) and cellular protooncogene
(c-Mpl) in the early 1990s (9, 10) had such an effect on the search
for thrombopoietin. Based on a number of shared primary and
secondary structural features, c-Mpl was identified as an orphan
member of the hematopoietic cytokine receptor family of pro-
teins, leading to the cloning of its ligand, thrombopoietin, 2 years
later (reviewed in ref. 11). Initial experiments with the recombi-
nant protein established thrombopoietin as the primary physi-
ological regulator of thrombopoiesis, as its levels were inversely
related to platelet or megakaryocyte mass and its infusion mas-
sively increased platelet production (12).
Regulation of thrombopoietin production
Investigators have found that blood and marrow levels of thrombo-
poietin are inversely related to platelet count. Patients with aplas-
tic anemia or thrombocytopenia secondary to myelosuppressive
therapy display high levels of the hormone (13, 14). However, there
are some notable exceptions to this relationship. The first is seen in
states of platelet destruction, where levels of the hormone are not
as high as would be anticipated from the degree of thrombocytope-
nia (15, 16). Such instances, seen in most patients with idiopathic
thrombocytopenic purpura, are characterized by megakaryocyte
hypertrophy, which likely contributes to thrombopoietin regulation
(17). A second instance in which thrombopoietin levels are not accu-
rately predicted by blood platelet count is in patients with inflam-
Nonstandard?abbreviations?used: ET, essential thrombocythemia; GSK3β, glycogen
synthase kinase-3β; IMF, idiopathic myelofibrosis; ORF, open reading frame; PV, poly-
cythemia vera; SDF-1, stromal cell–derived factor-1.
Conflict?of?interest: The author has declared that no conflict of interest exists.
Citation?for?this?article: J. Clin. Invest. 115:3339–3347 (2005).
3340? The?Journal?of?Clinical?Investigation http://www.jci.org Volume 115 Number 12 December 2005
matory, reactive thrombocytosis, where levels of the hormone are
higher than expected (18–21). However, an important unanswered
question is whether alterations in thrombopoietin production
explain the thrombocytosis associated with iron deficiency.
A major component of thrombopoietin regulation is achieved by
receptor-mediated uptake and destruction (Figure 1), a mechanism
of hematopoietic growth factor regulation first established for
M-CSF (22). Platelets bear high-affinity thrombopoietin receptors
that remove the hormone from solution (23), thereby establishing
an autoregulatory loop; as platelet counts rise, they remove more of
the hormone from the circulation, driving levels down, whereas in
thrombocytopenic states there are less platelets to adsorb throm-
bopoietin, allowing levels to rise and drive increased thrombopoi-
esis. However, not all thrombopoietin receptors contribute to this
effect; while endothelial cells display c-Mpl receptors (24) and some
endothelial cell types proliferate or migrate in response to the hor-
mone (25), transplantation studies have shown that endothelial cell
c-Mpl does not materially affect thrombopoietin levels despite a
100-fold more expansive cell surface (and predicted greater c-Mpl
mass) than that displayed by the totality of megakaryocytes and
platelets (26). Therefore, the mere presence of c-Mpl does not guar-
antee that it is involved in regulating thrombopoietin blood levels.
A second exception to the relatively simple platelet-adsorption-
and-destruction model of platelet homeostasis is illustrated by the
physiological response to severe thrombocytopenia; studies in both
mice and humans show that while marrow stromal cells display very
little thrombopoietin mRNA under normal conditions, transcripts
for the cytokine greatly increase in the presence of thrombocyto-
penia (Figure 1) (27). The precise humoral or cellular mediators of
this effect are under intense study. For example, in one report, the
platelet α-granule proteins PDGF and FGF-2 increased, but platelet
factor 4, thrombospondin, and TGF-β decreased thrombopoietin
production from primary human BM stromal cells (28). However,
others have reported that HGF is responsible for thrombopoietin
production from hepatocytes (29).
A third mechanism of thrombopoietin regulation occurs in
states of reactive thrombocytosis, where hormone concentrations
are higher than that predicted by the degree of thrombocytosis. For
example, inflammatory stimuli affect thrombopoietin production,
with the acute-phase response mediator IL-6 increasing thrombo-
poietin transcription from the liver (30). These in vitro effects are
also seen in vivo; administration of IL-6 to mice or cancer patients
increases thrombopoietin-specific mRNA in the liver and levels of
the hormone in the blood. Since an anti-thrombopoietin antibody
neutralizes the thrombopoietic effects of administered IL-6 (30), it
is now clear that thrombopoietin is the final mediator of inflam-
Additional modes of thrombopoietic regulation
In addition to thrombopoietin, additional factors likely influence
thrombopoiesis, as the genetic elimination of thrombopoietin or
its receptor leads to profound but not absolute thrombocytopenia
(the platelet counts in these settings are about 10% of a normal
level). In order to determine whether any of the known hema-
topoietic cytokines contributes to the residual thrombopoiesis
in the c-Mpl–null state, such mice have been crossed with other
cytokine- or cytokine receptor–deficient animals; from these stud-
ies it is clear that IL-3 (31, 32), IL-6, IL-11, and LIF (33) are not
basal, physiological mediators of thrombopoiesis. However, the
chemokine stromal cell–derived factor-1 (SDF-1) exerts numerous
influences on megakaryopoiesis, and studies indicate that it may
be responsible for thrombopoiesis not related to thrombopoietin.
The regulation of thrombopoietin levels. A steady-state amount of
hepatic thrombopoietin (TPO) is regulated by platelet c-Mpl receptor–
mediated uptake and destruction of the hormone. Hepatic production
of the hormone is depicted. Upon binding to platelet c-Mpl receptors,
the hormone is removed from the circulation and destroyed, which
reduces blood levels. In the presence of inflammation, IL-6 is released
from macrophages and, through TNF-α stimulation, from fibroblasts
and circulates to the liver to enhance thrombopoietin production.
Thrombocytopenia also leads to enhanced marrow stromal cell pro-
duction of thrombopoietin, although the molecular mediator(s) of this
effect is not yet completely understood.
? The?Journal?of?Clinical?Investigation http://www.jci.org Volume 115 Number 12 December 2005
For example, SDF-1 acts alone and in synergy with thrombopoietin
to enhance megakaryocyte colony formation in serum-free culture
(34). The chemokine also affects the motility of megakaryocytes,
driving their migration toward stromal cells (35), with which they
productively interact in an integrin α4β1–dependent manner (36).
The administration of SDF-1, along with FGF-4, can nearly nor-
malize the platelet count of c-Mpl–deficient mice and can enhance
platelet recovery following myelosuppression (37). Thus, accu-
mulating evidence points to SDF-1 and marrow stromal cells as
important influences on thrombopoiesis, but whether levels of the
chemokine or surface expression of integrins can be modulated in
response to thrombocytopenia remains unknown.
Hematopoietic and other activities of thrombopoietin
Although thrombopoietin was initially postulated to exclusively
promote the maturation of megakaryocytes and their fragmenta-
tion into platelets, its biological effects are more wide ranging than
was initially thought. Thrombopoietin supports the survival and
expansion of HSCs and all types of progenitor cells that display
megakaryocyte potential, promotes the maturation of megakaryo-
cytes, and enhances the platelet response to activating events.
Thrombopoietin is the most potent single stimulus of the
growth of hematopoietic progenitor cells committed to the mega-
karyocyte lineage. It also acts in synergy with other hematopoietic
cytokines, including SCF, IL-11, and erythropoietin, to promote
progenitor cell proliferation (38). In suspension culture, thrombo-
poietin stimulates the formation of large, highly polyploid mega-
karyocytes that can form proplatelet processes that then fragment
into immature and mature platelets (39). The hormone also affects
mature platelets, reducing the level of ADP, collagen, or thrombin
needed to induce aggregation (40, 41), and enhances platelet adhe-
sion to fibrinogen, fibronectin, and vWF in parallel plate perfusion
chamber assays (42).
In addition to its stimulation of most, if not all, aspects of mega-
karyopoiesis, thrombopoietin displays profound and nonredun-
dant effects on HSCs. Using highly purified marrow-derived cells,
2 groups showed that, by itself, the hormone affects the survival
of HSCs and works in synergy with IL-3 or SCF to promote pro-
liferation in vitro in both murine and human cells (43, 44). Subse-
quent in vivo studies confirmed the physiological relevance of these
findings; genetic elimination of thrombopoietin or its receptor in
mice, or congenital absence of c-Mpl in children, leads to profound
thrombocytopenia, and to equivalent reductions in the levels of
HSCs and progenitor cells of all hematopoietic lineages (45–48).
While thrombopoietin clearly plays an important role in the
maintenance of HSC numbers, it is not responsible for determina-
tion of the lineage fate of these cells. The distribution of hemato-
poietic progenitor cell types that emerge from cultures of HSCs is
identical whether thrombopoietin is present or not (43). Rather,
it is likely that the balance of transcription factors present in the
HSC is responsible for commitment to one or another hemato-
poietic lineage. Recently, based on commitment to either the ery-
throid or the myeloid lineage, a model of mutual transcription
factor antagonism has developed that can explain much of the
stochastic commitment to one or another cell lineage (49, 50). For
megakaryocytes, c-Myb seems particularly important; hypomorph-
ic alleles of the gene result in megakaryocytic expansion (51), and 2
mutant c-Myb?alleles, identified in a chemical mutagenesis screen,
have been shown to skew lineage commitment toward megakaryo-
poiesis and alter cell responsiveness to hematopoietic growth fac-
tors (52). The transcription factors known to affect megakaryocyte
commitment have been recently reviewed (53) and include GATA1,
AML1/RUNX1, FOG1, FLI1, MYB, and NF-E2.
Mpl receptor expression, regulation, and signaling
The type I hematopoietic growth factor receptor family, of which
c-Mpl is a member, consists of more than 20 molecules that bear
1 or 2 cytokine receptor motifs, an approximately 200–amino acid
module containing 4 spatially conserved Cys residues, 14 β-sheets,
and a juxtamembrane Trp-Ser-Xaa-Trp-Ser sequence (54). In addi-
tion to the cytokine receptor motif(s), type I receptors contain a
20- to 25-residue transmembrane domain and a 70– to 500–amino
acid intracellular domain containing short sequences that bind
intracellular kinases and other signal-transducing molecules. The
thrombopoietin receptor is expressed primarily in hematopoietic
tissues, specifically in megakaryocytes, their precursors, and their
progeny. For the most part, c-Mpl is constitutively expressed in
these tissues, although receptor display is modulated by thrombo-
poietin binding and receptor internalization. A second potential
level of c-Mpl regulation exists; multiple spliceoforms of the recep-
tor have been described that vary in their biological activity, and
1 form can alter receptor catabolism. Although the proportion of
the various isoforms of the receptor differs in different tissues,
they have not yet been shown to exert a regulatory effect.
The c-Mpl gene contains 12 exons and is organized like other
members of the hematopoietic cytokine receptor family (55). A
site for initiation of c-Mpl transcription resides 13 nucleotides
upstream of the translation initiation codon, and although the
promoter lacks conventional TATA and CAAT motifs, the 5′
flanking sequence contains consensus binding sequences for Ets
and GATA transcription factors, proteins vital for the regulation
of many megakaryocyte-specific genes. Analysis of c-Mpl tran-
scripts has identified several alternately spliced forms, including
extracellular domain deletions (56), an alternate intracellular
domain (the K isoform; ref. 8), and a prematurely truncated
isoform containing a unique carboxyl terminus (the Mpl-tr
isoform; ref. 57). While potentially acting as a dominant-negative
form of the receptor, and differentially expressed in certain cell
types, the K isoform does not affect thrombopoietin signaling,
as it does not interact with the wild-type receptor (58). Howev-
er, Mpl-tr may play a physiological role, as it is the only isoform
expressed in both human and murine cells. Of note, expression
levels of c-Mpl are low, with only 25–100 surface receptors present
per platelet (59, 60). The origin of the poor expression of c-Mpl
appears to be related to the c-Mpl-tr isoform, as its coexpression
with full-length c-Mpl leads to rapid degradation of the latter
(57). However, whether this physiology is reflected in thrombo-
poietin signal regulation is, at present, only speculative.
Another aspect of c-Mpl regulation under intense study is its
expression on hematopoietic cells of patients with myeloprolifera-
tive disorders (MPDs). While easily detectable on normal marrow
megakaryocytes and platelets, the receptor is decreased on cells
from patients with polycythemia vera and other myeloproliferative
diseases (61, 62). While the molecular basis for this is not under-
stood, it could be related to the hypersensitivity to cytokines and
signaling abnormalities seen in these disorders. Another clue to
this finding may lie in 2 recent observations, that coexpression of
the signaling kinase JAK2 is vital for hematopoietic cytokine recep-
tor expression (63), and that the activity of this kinase is altered in
a substantial number of patients with MPDs.
3342? The?Journal?of?Clinical?Investigation http://www.jci.org Volume 115 Number 12 December 2005
Upon binding, cognate ligand hematopoietic cytokine receptors
such as c-Mpl are activated to transmit numerous biochemical
signals. The molecular details of this process are now well under-
stood based on studies of the erythropoietin receptor (EpoR). The
EpoR exists in a homodimeric state in the absence of ligand, in
a conformation that holds the cytoplasmic domains 73 Å apart
(64). Upon ligand binding, receptor conformation shifts, bringing
the cytoplasmic domains within 39 Å of one another. Additional
studies indicate that the membrane-proximal box1 and box2 cyto-
plasmic domains constitutively bind JAK family kinases, even in an
inactive state. Upon ligand binding, the closer juxtaposition of the
2 tethered kinases allows their cross-activation, initiating signal
transduction. The active JAK kinase then phosphorylates (a) tyro-
sine residues within the receptor itself; (b) molecules that promote
cell survival and proliferation, including the STATs, PI3K, and the
MAPKs; and (c) those that limit cell signaling, including the SHP1
and SHIP1 phosphatases and SOCSs (Figures 2 and 3).
Additional insights into how the JAK kinases are regulated come
from domain analysis of the proteins. All 4 members of the family
(JAK1, JAK2, JAK3, and TYK2) display 3 major domains, JH1 (JAK
homology 1), JH2, and FERM (four-point-one, ezrin, radixin, moe-
sin), the latter responsible for binding to the cytoplasmic domain
of the cytokine receptors (Figure 2). The JH1 domain carries the
kinase activity of JAKs, and while JH2 bears significant homology
to JH1, its active site is altered and inactivated and is thus termed
the pseudokinase fK domain. The function of JH2 was identified
by differential expression studies; the JH1 domain is an active
kinase when expressed alone, whereas the activity of a JH1/JH2
polypeptide is greatly blunted (65). Thus, the JH2 domain regu-
lates the kinase activity of JH1, a physiology put into structural
terms by homology modeling of JH1/JH2; the JH2 domain inter-
acts with the inactive, but not the active, conformation of the acti-
vation loop of JH1 (Figure 4; ref. 66), in a region of JH2 shown to
be vital for kinase regulatory activity.
Once c-Mpl is activated by thrombopoietin engagement, its mul-
tiple effects on HSCs, megakaryocytes, and platelets are mediated
by a series of biochemical signaling events. Thrombopoietin acti-
vates both JAK2 and TYK2 in c-Mpl–bearing cell lines, although
only JAK2 is essential for signaling and is the predominant isoform
activated in primary megakaryocytes (67). By generating a com-
plex composed of the phosphatase SHP2, a scaffolding Gab/IRS
protein, and the p85 regulatory subunit of PI3K, thrombopoietin
stimulation of megakaryocytes and their precursors activates PI3K
and its immediate downstream effector Akt (PKB) (Figure 3) (68,
69). Blocking this pathway inhibits thrombopoietin-induced cell
survival and proliferation (70). In the mature platelet, the hormone
enhances α-granule secretion and aggregation induced by throm-
bin in a PI3K-dependent fashion (71). The pathways downstream
of Akt in megakaryocytes and platelets are under study and include
the transcription factor FOXO3a, the cell cycle inhibitor p27, and
glycogen synthase kinase-3β (GSK3β). In addition to PI3K, throm-
bopoietin stimulates 2 of the MAPK pathways (Figure 3), p42/p44
ERK1 and ERK2 (72) and p38 MAPK (73), events mediated by
receptor phosphorylation, binding and phosphorylation of Grb2,
SHC, and SOS, and exchange of GDP for GTP on Ras (74). The
functional consequences of these events include induction of the
transcription factor HoxB4 and expansion of HSCs mediated by
p38 MAPK (73); translocation of the transcription factor HoxA9
from cytoplasm to nucleus, which also favorably affects HSC
expansion (75); the ERK1/2–induced proliferation and polyploidi-
zation of megakaryocytes (76); and augmented thrombin-induced
liberation of phospholipase A2 and platelet activation (77).
Implications of thrombopoietin/Mpl signaling
in clinical disorders of hematopoiesis
Two primary reasons to generate a detailed map of the signaling cir-
cuitry used by hematopoietic growth factors are to understand dis-
orders of hematopoietic growth and to intervene in these processes
for therapeutic benefit (either enhancing or blunting signaling). A
number of human diseases in which blood cell production is altered
can now be understood as disorders of growth factor signaling.
One of the most common abnormalities of the blood count is
elevated platelet levels, and the most common cause of thrombo-
Hematopoietic cytokine receptor architecture and mechanism of ini-
tial signaling. A stylized hematopoietic cytokine receptor is shown,
depicting the 1 or 2 cytokine receptor motifs (C, Cys; WS, Trp-Ser-
Xaa-Trp-Ser), the transmembrane domain, and the box1 sequence to
which JAK kinases bind. Also shown are the 3 major domains of JAK
kinases, the FERM domain, which binds to box1, and the kinase JH1
and regulatory JH2 domains. Finally, upon JAK activation, the site of
receptor tyrosine phosphorylation is shown, which then serves as a
docking site for STATs and adapter proteins (SHC or SHP2).
? The?Journal?of?Clinical?Investigation http://www.jci.org Volume 115 Number 12 December 2005
cytosis is reaction to an inflammatory insult (20). A number of
cytokines are released from activated monocytes and macrophages,
including IL-1, TNF-α, and IL-6. While IL-1 and TNF-α have
mixed effects on hematopoiesis, in vitro IL-6 appears to act as a
megakaryocyte maturation factor (78). Intravenous infusion of
IL-6, in mice and during clinical trials in humans, leads to modest
thrombocytosis (79, 80). While this initially suggested that inflam-
matory thrombocytosis is due to IL-6, several investigators have
more recently shown that IL-6 induces hepatic thrombopoietin
production and that the thrombocytosis associated with IL-6 is
eliminated by blockade of thrombopoietin action (Figure 1) (30).
Much less common than inflammatory thrombocytosis is
familial thrombocytosis. At least 4 different genetic alterations
of the thrombopoietin gene have been shown to enhance produc-
tion of the hormone and drive polyclonal thrombocytosis. The
basis of all these cases is enhanced translation efficiency of the
Unlike most structural genes, in which protein translation initi-
ates from the first AUG codon in the transcript, the open read-
ing frame (ORF) encoding thrombopoietin begins with the eighth
AUG present in the mRNA (Figure 5); the previous 7 ORFs encode
short, apparently functionless polypeptides, if they are translated
Signaling pathways activated by thrombopoietin. A stylized drawing of c-Mpl is shown in the activated (phosphorylated) form. Once
phosphorylated, Tyr112 serves as a docking site for STAT3 and STAT5, both activated by thrombopoietin in megakaryocytes, which leads to
production of Bcl-xL, among other antiapoptotic and pro-proliferative signaling molecules. The same site also serves to recruit SHC, which in
turn recruits Grb2 and SOS (the latter a guanine nucleotide exchange factor for Ras), exchanging GTP for GDP, and thereby activating Ras.
In succession, a MAPKKK (MAPK kinase kinase, e.g., Raf), a MAPKK (MAPK kinase), and the MAPK ERK1/2 or p38 MAPK are recruited and
activated. As shown, Raf activation also contributes to PI3K activation. At a site proximal to Tyr112, a complex containing the phosphatase SHP2,
the adapter protein Gab1, and the regulatory subunit of PI3K (p85) forms upon phosphorylation by JAK2, which recruits the kinase subunit of
PI3K (p110), leading to phosphorylation of cell membrane–bound phosphoinositol4,5 biphosphate (PIP2) and thus generating phosphoinositol3,4,5
triphosphate (PIP3). PIP3 then recruits pleckstrin homology domain–containing proteins, including the Ser/Thr protein tyrosine kinase Akt. Once
activated at the cell membrane, Akt phosphorylates (and inactivates) GSK3β, which also promotes cell proliferation. Akt also phosphorylates the
transcription factor FOXO3a, leading to its nuclear exit and thus precluding its induction of the cell cycle inhibitor p27. Inhibition of cell signaling
is also initiated by JAK activation; shown in red is the transcriptional regulation of SOCS proteins by STATs, and their subsequent blockade of
signaling by preclusion of signaling molecule docking to P-Tyr residues of the receptor or their JAK-induced phosphorylation.
3344? The?Journal?of?Clinical?Investigation http://www.jci.org Volume 115 Number 12 December 2005
at all. Since the thrombopoietin initiation codon (AUG8) is embed-
ded within the out-of-frame, seventh ORF, and since post-termina-
tion ribosomes cannot scan backward to initiate at upstream AUG
codons (81), should a ribosome initiate at ORF7, it will terminate
downstream of AUG8 and hence fail to translate thrombopoietin.
Because of this alignment, thrombopoietin production is normally
very inefficient. In 4 separate pedigrees displaying autosomal
dominant thrombocytosis, the region surrounding the eighth
AUG carries a single-nucleotide mutation that greatly enhances
thrombopoietin translational efficiency (Figure 5; ref. 82). In 2
cases, a splice donor site mutation eliminates the exon carrying
the seventh and eighth AUG codons, and the translation termina-
tion codon for the fifth and sixth ORFs, and results in an in-frame
fusion of the fifth AUG to the thrombopoietin ORF. As the fifth
AUG is a highly efficient initiation codon, thrombopoietin pro-
duction rises, enhancing thrombopoiesis. The other 2 mutations
within exon 3 of the thrombopoietin gene eliminate the reason
for the unfavorable translation efficiency of the gene, the embed-
ding of AUG8 within the seventh ORF (Figure 5), again resulting
in greatly enhanced thrombopoietin production.
Disorders of the c-Mpl receptor
Thrombopoietin is the primary regulator of platelet production;
thus, abnormalities of the hormone or its receptor might also be
responsible for thrombocytopenia. In numerous instances of con-
genital amegakaryocytic thrombocytopenia, either severe homozy-
gous or mixed heterozygous, missense or nonsense mutations of
the c-Mpl gene have been identified (46, 83, 84). Loss of the recep-
tor leads to severe congenital thrombocytopenia (platelet counts
∼20 × 109 per liter), and within 1–3 years of birth nearly every
patient harboring 2 severely mutant alleles develops aplastic ane-
mia (46, 85), due to stem cell exhaustion. Stem cell transplantation
is the only known treatment for the disease. Of note, while humans
carrying inactivating mutations in the thrombopoietin receptor
develop stem cell failure, despite a 10-fold reduction in stem cell
numbers in both c-Mpl–null and thrombopoietin-null mice, the
animals maintain hematopoiesis and live a normal lifespan. The
difference between mice and humans likely resides in different
stem cell kinetics, although this issue has yet to be addressed.
The c-Mpl receptor was first recognized as a viral oncogene,
in which most of the extracellular domain of the receptor was
replaced by a viral gag gene sequence (7). It is likely that the uncon-
trolled myeloproliferation seen in mice expressing v-Mpl reflects
the loss of the amino terminus of the receptor; simple truncation
of the membrane-distal domain of c-Mpl eliminates its capacity
to bind thrombopoietin, and its expression leads to thrombo-
poietin-independent growth of cells (86). This and other studies
have spurred the concept that the membrane-distal domain puts
a brake on constitutive signaling by the membrane-proximal and
transmembrane domains, a block relieved by thrombopoietin
binding. Several clinical observations are consistent with this
model of c-Mpl activation. For example, an activating Ser-to-Asn
mutation of the transmembrane domain of the c-Mpl receptor,
first recognized by random mutagenesis of the receptor (87), has
now been found to cause thrombocytosis in a large family (88). A
second disorder of the c-Mpl receptor associated with thrombocy-
tosis has been found in African Americans, termed MplBaltimore, a
single-nucleotide polymorphism causing an amino acid alteration
at position Asn34 of the receptor (89). While this alteration in the
membrane-distal extracellular domain of c-Mpl associated with
thrombocytosis also supports the developing model of c-Mpl acti-
vation, it remains possible that MplBaltimore leads to thrombocytosis
through another mechanism, or that the single-nucleotide poly-
A molecular model of JAK2 JH1 and JH2 domains. Based on the ter-
tiary structure of the dimer receptor tyrosine kinase FGF receptor-4,
the model depicts the ATP-binding site (yellow), the kinase active site
(orange), the activation loop of JH1 in both inactive (purple) and active
(red) conformations, and the location of JH2 residue Val617 (V617).
Adapted with permission from Protein Engineering (66).
Genetic alterations in thrombopoietin that lead to enhanced translation
efficiency. The normal thrombopoietin mRNA (light blue) is spliced from
7 exons, of which 3 are shown (A). The numbered initiation codons
found in the primary thrombopoietin transcript are shown as within
their corresponding ORFs (e.g., the thrombopoietin ORF is dark blue
and initiates from AUG8). The sites of mutation that lead to enhanced
translation of the thrombopoietin transcript do so (B) by eliminating
exon 3 by altered splicing (∆E3) to create a new thrombopoietin ORF
initiated by a highly efficient initiation codon (AUG5); (C) by nonsense
mutation, prematurely truncating ORF7, which embeds the normal
thrombopoietin ORF; or (D) by shifting the efficiently initiated ORF7
(by a single-nucleotide insertion) to now include the thrombopoietin
polypeptide. Adapted with permission from Blood (82).
? The?Journal?of?Clinical?Investigation http://www.jci.org Volume 115 Number 12 December 2005
morphism lies in linkage disequilibrium with a distinct, causative,
non–c-Mpl coding mutation in these individuals.
Disorders of hematopoietic cell signal transduction
The classic chronic MPDs polycythemia vera (PV), idiopathic
myelofibrosis (IMF), and essential thrombocythemia (ET) share
several clinical features, including overproduction of 1 or more
hematopoietic cell lineages, a propensity for pathological hemor-
rhage or thrombosis, an excess or abnormality of megakaryocytes,
which elaborate cytokines responsible for myelofibrosis, and a
modestly elevated risk of progression to leukemia, a risk greatly
hastened by exposure to alkylating agents (90). Several molecu-
lar features of the chronic MPDs suggest that they represent
disorders of hematopoietic cell signaling. First, overexpression
of numerous growth factor signaling mediators leads to chronic
MPDs in mice — for example, unregulated expression of c-Mpl
(91) or thrombopoietin (92), loss of either of the signal-inhibi-
tory phosphatases SHP1 (93) and SHIP1 (94), conditional loss of
the Ras regulator NF-1 (95), or expression of an activated form
of K-Ras (96). Second, hematopoietic cells from patients with
chronic MPDs express constitutively activated signaling mol-
ecules, including STAT3 (97), Bcl-xL (98), and Akt (99). Third,
hematopoietic progenitor cells are hypersensitive to several differ-
ent hematopoietic growth factors in PV, IMF, and ET (100–102),
including erythropoietin and thrombopoietin; this implies a
resetting of the molecular pathways that transduce growth fac-
tor signals. Based on these and other observations, several groups
hypothesized that abnormalities in JAK2 kinase might underlie
the chronic MPDs, and multiple groups reported this to be the
case; 65–97% of patients with PV, 35–57% of patients with IMF,
and 23–57% of patients with ET carry 1 or 2 mutant JAK2 alleles
(overall, two-thirds are heterozygous and one-third homozygous,
the latter because of mitotic recombination). Remarkably, every
patient studied displays the same acquired mutation, Val-to-Phe
substitution of amino acid 617, which leads to constitutive JAK2
activation in vitro, and polycythemia when introduced into hema-
topoietic cells in vivo (102–107). This region of the pseudokinase
domain of JAK2 is necessary for proper JAK2 regulation (65) and,
in a molecular model, interacts with the activation loop of the
JH1 kinase domain of the molecule (Figure 4) (66). While of great
interest, the finding of an activated signaling kinase in patients
with chronic myeloproliferative diseases has also raised several
questions: why is overexpression of the kinase necessary to pro-
duce cytokine hypersensitivity in vitro and polycythemia in vivo
(since levels equivalent to wild-type JAK2 do not suffice); why are
3 distinct clinical disorders associated with the same mutation;
are second “hits” necessary to generate disease; and what, if any,
hematopoietic cytokine receptor does the mutant JAK2 kinase
interact with to produce its effects? Regardless of these questions,
it is almost certain that this discovery in chronic myeloprolifera-
tive diseases will yield new insights in patients with PV, IMF, and
ET and spur research into identifying a therapeutic agent that can
inhibit the mutant, but not the wild-type, form of JAK2 kinase.
Future research directions
Our understanding of the molecular basis of thrombopoiesis
has progressed substantially in the past 100 years, beginning
with James Homer Wright, who in 1906 provided evidence that
megakaryocytes give rise to blood platelets (108). Until this time,
little attention had been paid to platelets, then referred to as the
“dust of the blood.” But despite great progress, many questions
remain: What is the mechanistic basis for proplatelet formation,
a massive cytoplasmic reorganization of actin and tubulin that,
upon fragmentation, generates platelets, and what, if any, are the
exogenous signals that trigger the process? What is the reason for
megakaryocyte polyploidy, and what are the mechanisms by which
these cells uncouple DNA synthesis and cell division, one of the
most closely guarded links in cell physiology? What is being sensed
in marrow stromal cells that alter their production of thrombopoi-
etin in thrombocytopenia, and what are the signals that accom-
plish this? How can an alteration in the JAK2 kinase lead to PV in
some patients and ET in others? And how are stem cell decisions
of lineage commitment orchestrated? Research in thrombopoiesis
is presently in a logarithmic growth phase. The years to come will
provide many new insights into how platelets develop and how
that process is regulated.
Address correspondence to: Kenneth Kaushansky, Department of
Medicine, Division of Hematology/Oncology, University of Cali-
fornia, San Diego, 402 Dickinson Street, Suite 380, San Diego,
California 92103-8811, USA. Phone: (619) 543-2259; Fax: (619)
543-3931; E-mail: email@example.com.
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