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Human platelets are known to have Fc receptors that are able to recognize soluble immune complexes and to respond to that stimulation by aggregating and releasing soluble factors. In diabetes, enhanced platelet aggregation has been proposed as one of the factors contributing to the development of microangiopathy. Soluble immune complexes isolated from seven diabetic patients were found to enhance ADP-induced platelet aggregation and release of ATP. This enhancement was proven not to be an artifact due to the isolation protocol, by comparison of purified immune complexes with nonspecific protein purified from normal sera by identical or slightly modified isolation protocols. Soluble immune complex appear to be the first well-characterized platelet aggregating factors form the sera of diabetic patients. The natural of the antigen involved in their formation does not appear relevant, since very similar results were obtained whether soluble immune complexes were purified from patients with insulin-anti-insulin complexes in their serum, or from those without such complexed but with positive results in nonspecific screening techniques.

A simplified approach for estimating free and total anti-insulin antibodies and soluble insulin-anti-insulin immune complexes in serum has been developed and evaluated. For determination of free anti-insulin antibodies, a binding ratio for 125I-labeled insulin at fivefold serum dilution is calculated; the binding ratios obtained are reproducible (run-to-run coefficient of variation, 7.3%) and correlate well with titration of anti-insulin antibodies by other techniques (correlation coefficient, 0.9327). Total anti-insulin antibody concentrations are determined by calculating the [125I]insulin binding ratio for a sample previously acidified, adsorbed with acid dextran-coated charcoal, and neutralized. The difference in binding ratios between two aliquots of the same serum, one diluted 10-fold without manipulation and the second studied at an identical dilution after acidification and removal of free insulin, is taken as an index of the presence of soluble insulin-anti-insulin immune complexes. Because the tests can be performed at a single dilution, both time and materials are conserved without apparent loss of discrimination between sera with high antibody titers and high concentrations of insulin-anti-insulin immune complexes and sera with negative titers or low concentrations.

In view of the tendency toward vascular disease in diabetes mellitus, we studied platelet aggregation in 15 normal, 7 prediabetic, 12 latent, and 20 frankly diabetic subjects. Platelets from latent and frank diabetics showed increased platelet aggregation 4 minutes after adding adenosine 5'-diphosphate (60% verus 29% at 1.0 mu-M), epinephrine (46% versus 14% at 0.25 mu-M), and collagen (72% versus 17% at 0.25 mu-g/ml). Three prediabetics had increased platelet aggregation. Platelet sensitivity to aggregating agents was most marked in frank diabetics, intermediate in latent diabetics, and least in prediabetics. Second-phase platelet aggregation was reversed with acetylsalicylic acid, intravenous tolbutamide, and oral glucose administration. We conclude that platelet aggregation may be increased early in diabetes mellitus and may be involved in the genesis of diabetic microangiopathy. Prospective studies on the effect of therapeutic agents such as acetylsalicylic acid on the natural course of diabetic vascular disease are indicated.

Irreversible second-phase aggregation of platelets in diabetic patients is prevented in vitro by 5, 8, 11, 14-eicosatetraynoic acid (TYA), a competitive inhibitor of the labile aggregation-stimulating substance (LASS) which is formed from arachidonic acid. Thus, inhibition of prostaglandin synthesis inhibits platelet aggregation in diabetic subjects. These findings indicate that platelets from diabetics are subject to control by intracellular mechanisms operative in the regulation of platelet function in normal individuals.

Second-phase platelet aggregation induced by adenosine diphosphate (ADP) and epinephrine was measured in fasting platelet-rich plasma in normals, "prediabetics," and diabetics with or without vascular disease. "Plasma factor" potentiation of ADP-induced second-phase platelet aggregation was also estimated, as were megathrombocyte numbers in the same patient groups. There was an increased sensitivity of second-phase platelet aggregation noted with both aggregating agents in all diabetic groups except for the prediabetics. This activity was paralleled by an increase in plasma factor activity. In vivo evidence of an increased turnover of platelets in frank diabetics was suggested by increased numbers of megathrombocytes. These studies demonstrate that platelets from diabetics are sensitive to aggregating agents and that this sensitivity may be related to plasma factor(s) present in diabetics. In vivo platelet aggregation may be present in diabetics. Longitudinal studies will be necessary to establish the relationship of these findings to the genesis of diabetic vascular disease.