Assessment of the red cell proteome of young patients with unexplained hemolytic anemia by two-dimensional differential in-gel electrophoresis (DIGE)

Erythrocyte cytosolic protein expression profiles of children with unexplained hemolytic anemia were compared with profiles of close relatives and controls by two-dimensional differential in-gel electrophoresis (2D-DIGE). The severity of anemia in the patients varied from compensated (i.e., no medical intervention required) to chronic transfusion dependence. Common characteristics of all patients included chronic elevation of reticulocyte count and a negative workup for anemia focusing on hemoglobinopathies, morphologic abnormalities that would suggest a membrane defect, immune-mediated red cell destruction, and evaluation of the most common red cell enzyme defects, glucose-6-phosphate dehydrogenase and pyruvate kinase deficiency. Based upon this initial workup and presentation during infancy or early childhood, four patients classified as hereditary nonspherocytic hemolytic anemia (HNSHA) of unknown etiology were selected for proteomic analysis. DIGE analysis of red cell cytosolic proteins clearly discriminated each anemic patient from both familial and unrelated controls, revealing both patient-specific and shared patterns of differential protein expression. Changes in expression pattern shared among the four patients were identified in several protein classes including chaperons, cytoskeletal and proteasome proteins. Elevated expression in patient samples of some proteins correlated with high reticulocyte count, likely identifying a subset of proteins that are normally lost during erythroid maturation, including proteins involved in mitochondrial metabolism and protein synthesis. Proteins identified with patient-specific decreased expression included components of the glutathione synthetic pathway, antioxidant pathways, and proteins involved in signal transduction and nucleotide metabolism. Among the more than 200 proteins identified in this study are 21 proteins not previously described as part of the erythrocyte proteome. These results demonstrate the feasibility of applying a global proteomic approach to aid characterization of red cells from patients with hereditary anemia of unknown cause, including the identification of differentially expressed proteins as potential candidates with a role in disease pathogenesis.     

Hemoglobin deficit: an inherited hypochromic anemia in the mouse

The character and pathogenesis of hemoglobin deficit (gene symbol, hbd), an autosomal recessive trait in the mouse, were studied. The main hematological features of hemoglobin deficit are anemia, red cell hypochromia and microcytosis, and reticulocytosis. The absence of raised fecal urobilinogen excretion and frank hyperbilirubinemia and bilirubinuria suggests that excess hemolysis is not the primary cause of the anemia. The raised plasma iron concentration and the failure of the anemia to respond to parenteral iron treatment indicate that the anemia is not due to iron deficiency. The absence of siderocytes and sideroblasts suggests that anemia is probably not due to ferrochelatase deficiency. Thalassemia is excluded by the finding of balanced reticulocyte globin chain synthesis. The markedly elevated levels of free red cell protoporphyrin taken together with the other findings already noted suggest that the anemia of hemoglobin deficit is due to a defect in the erythroid cell iron procurement mechanisms leading in turn to diminished heme and hemoglobin synthesis.     

Hemorrhage-Adjusted Iron Requirements,Hematinics and Hepcidin Define Hereditary Hemorrhagic Telangiectasia as a Model of Hemorrhagic Iron Deficiency

Background

Iron deficiency anemia remains a major global health problem. Higher iron demands provide the potential for a targeted preventative approach before anemia develops. The primary study objective was to develop and validate a metric that stratifies recommended dietary iron intake to compensate for patient-specific non-menstrual hemorrhagic losses. The secondary objective was to examine whether iron deficiency can be attributed to under-replacement of epistaxis (nosebleed) hemorrhagic iron losses in hereditary hemorrhagic telangiectasia (HHT).

Methodology/Principal Findings

The hemorrhage adjusted iron requirement (HAIR) sums the recommended dietary allowance, and iron required to replace additional quantified hemorrhagic losses, based on the pre-menopausal increment to compensate for menstrual losses (formula provided). In a study population of 50 HHT patients completing concurrent dietary and nosebleed questionnaires, 43/50 (86%) met their recommended dietary allowance, but only 10/50 (20%) met their HAIR. Higher HAIR was a powerful predictor of lower hemoglobin (p = 0.009), lower mean corpuscular hemoglobin content (p<0.001), lower log-transformed serum iron (p = 0.009), and higher log-transformed red cell distribution width (p<0.001). There was no evidence of generalised abnormalities in iron handling Ferritin and ferritin² explained 60% of the hepcidin variance (p<0.001), and the mean hepcidinferritin ratio was similar to reported controls. Iron supplement use increased the proportion of individuals meeting their HAIR, and blunted associations between HAIR and hematinic indices. Once adjusted for supplement use however, reciprocal relationships between HAIR and hemoglobin/serum iron persisted. Of 568 individuals using iron tablets, most reported problems completing the course. For patients with hereditary hemorrhagic telangiectasia, persistent anemia was reported three-times more frequently if iron tablets caused diarrhea or needed to be stopped.

Conclusions/significance

HAIR values, providing an indication of individuals’ iron requirements, may be a useful tool in prevention, assessment and management of iron deficiency. Iron deficiency in HHT can be explained by under-replacement of nosebleed hemorrhagic iron losses.     

The clinical utility of discriminant functions for the differential diagnosis of microcytic anemias

Several groups of authors have derived discriminant functions (DFs) based on red cell indices (primarily MCH, MCV, and RDW) that can be used to differentiate iron deficiency from thalassemia minor. The Technicon H*1 analyzer provides a direct MCHC measurement (termed the CHCM), in addition to the conventional computed value (Hgb/PCV). To evaluate the clinical utility of red cell discriminant analysis, chart review was performed in 176 cases for which hemoglobin characterization and quantitation studies had been requested. Six published discriminants were evaluated for cases of clearly defined iron deficiency anemia and thalassemia minor. Overall diagnostic efficiency ranged from 50%-82%, and the diagnostic performance of three of the discriminants failed to achieve statistical significance. Mean values for both MCHC and CHCM were significantly lower in patients with iron deficiency than in patients with other causes of microcytic anemia. It was also observed that MCHC was significantly greater than CHCM in patients with iron deficiency anemia, but not in patients with other causes of microcytic anemia. Both MCHC and the difference between MCHC and CHCM showed potential value as parameters for the differential diagnosis of iron deficiency from other causes of microcytic anemia. It was noted, however, that in 67% of the cases studied, the use of a DF could not have resolved the diagnosis to the extent that hemoglobin characterization and quantitation studies were no longer indicated.     

Assessment of erythrocyte deformability with the laser-assisted optical rotational cell analyzer (LORCA)

The erythrocyte deformability of 28 patients with anemia was evaluated with the laser-assisted optical rotational cell analyzer (LORCA), an image analyzer that converts into numerical form the degree of refraction of a laser beam induced by red cells subjected to a range of torsional stresses. The patients were 10 thalassemics, including three with intermediate forms (1 HbC/beta degree, 1 homozygote beta for Orkin's haplotype VI, 1 beta degree/beta delta Sicilian type) and seven heteroygotes for beta Th; six with hereditary spherocytosis (including 2 with structural alteration of the spectrin beta chain); three with type II congenital dyserythropoietic anemia (HEMPAS), two hemizygotes and one heterozygote for G-6PD deficiency, and six with severe hypochromic hyposideremic anemia. Red cell deformability was reduced in intermediate thalassemia, hereditary spherocytosis and HEMPAS, normal in heterozygous beta thalassemia and G-6PD deficiency, and increased in hypochromic hyposideremic anemia. These results show that erythrocyte deformability can be impaired by an Hb chain imbalance, membrane and cyto skeleton structure anomalies and changes in the red cell area/volume ratio.     

Reference blood values of iron metabolism in cynomolgus macaques.

Iron deficiency anemia is a human health problem of global significance, particularly as it affects pregnant women and infants. While the study of nonhuman primates has resulted in valuable knowledge about iron metabolism, hematologic and biochemical reference ranges for the parameters of iron metabolism are difficult to document in healthy monkeys. At our institution, we maintain a large breeding colony of healthy cynomolgus monkeys (Macaca fascicularis). Data compiled after sampling nonpregnant females and male members of this colony are presented as reference ranges for red cell number, hemoglobin, hematocrit, mean cellular volume, mean cellular hemoglobin, mean cellular hemoglobin concentration, serum iron, total iron-binding capacity, serum transferrin, and serum ferritin.     

A new red cell discriminant incorporating volume dispersion for differentiating iron deficiency anemia from thalassemia minor

A novel red cell discriminant function [MCV2 x RDW/(Hgb x 100)] was compared to six other discriminants in 102 patients with established mild iron deficiency anemia and 33 patients with beta-thalassemia minor. The discriminant incorporates the two key measurements of erythrocyte cell volume distribution, namely the mean (MCV) and standard deviation (RDW), which are known to be helpful for distinguishing between these two frequent causes of microcytic hypochromic anemia. Data used for the learning set to develop the new discriminant were obtained using an electrical impedance automated whole blood analyzer (Coulter S + IV) and were applied as a validation set for six other discriminants. The discriminant was also tested on smaller subsets of the patients groups using data obtained on either an alternate electrical impedance instrument (Sysmex E-5000) or a laser light scattering based system (Technicon H*1). From the comparison it was concluded that use of a discriminant function that incorporates a measurement of red cell volume dispersion results in enhanced accuracy for distinguishing iron deficiency anemia from thalassemia minor.     

Nondiscrete heterogeneity of human erythrocytes: comparison of Coulter-principle flow cytometry and Soret-hemoglobinometry image analysis

In the blood of normal subjects, the volumes of single erythrocytes are distributed with a coefficient of variation (CV) of 10.8 +/- 1.8%; while in hemoglobinopathies, CV increases proportionately to the degree of anemia produced. Using single cell Soret-band hemoglobinometry and focused-aperture impedance counting, we compared the distribution of red cell volume, area, hemoglobin content, and hemoglobin concentration in normals and subjects with anemic disorders. The CV, nondiscrete heterogeneity, is first, a general characteristic of biologic measurement, second, a sensitive indicator of abnormality of erythropoiesis, and third, consistently less for hemoglobin concentration than for volume, area, or hemoglobin content of the same cells.     

Image processing for automated erythrocyte classification.

Digital image processing and pattern recognition techniques were applied to determine the feasibility of a natural n-space subgrouping of normal and abnormal peripheral blood erythrocytes into well separated categories. The data consisted of 325 digitized red cells from 11 different cell classes. The analysis resulted in five features: (a) size, (b) roundness, (c) spicularity, (d) eccentricity and (e) central gray level distribution. These features separated the data into six distinct condensed subgroups of red cells. Each subgroup consisted of morphologically similar cells: (a) macrocytes, (b) normocytes, (c) schistocytes, acanthocytes and burr cells, (d) microcytes and spherocytes, (e) elliptocytes, sickle cells and pencil forms and (f) target cells. The concept of a quantitative "red cell differential" was introduced, utilizing these subgroup definitions to establish subpopulations of red cells, with quantifiable indices for the diagnosis of anemia, at the specimen level.     

Anemia,differentiating between thalassemia minor and iron deficiency

Many of the conditions noted in examination of the blood of patients with thalassemia minor are much like those observed in patients with iron deficiency anemia. A study was made of similarities and contrasts between blood and bone marrow features in both conditions for purposes of differential diagnosis. A salient distinction is that bone marrow hemosiderin is present in normal amount in patients with thalassemia minor, but not in those with iron deficiency anemia. If therapy with iron does not restore hemoglobin values to normal, thalassemia minor is strongly suspect. Even in the latter disease, however, there may be small fluctuations in hemoglobin values, particularly in pregnancy. One must be alert to this possibility lest a slight, fleeting increase in hemoglobin be mistakenly ascribed to iron therapy.     

ANEMIA—Differentiating Between Thalassemia Minor and Iron Deficiency

Many of the conditions noted in examination of the blood of patients with thalassemia minor are much like those observed in patients with iron deficiency anemia. A study was made of similarities and contrasts between blood and bone marrow features in both conditions for purposes of differential diagnosis. A salient distinction is that bone marrow hemosiderin is present in normal amount in patients with thalassemia minor, but not in those with iron deficiency anemia. If therapy with iron does not restore hemoglobin values to normal, thalassemia minor is strongly suspect. Even in the latter disease, however, there may be small fluctuations in hemoglobin values, particularly in pregnancy. One must be alert to this possibility lest a slight, fleeting increase in hemoglobin be mistakenly ascribed to iron therapy.     

The binding of hemoglobin to membranes of normal and sickle erythrocytes.

The binding of hemoglobins A, S, and A2 to red cell membranes prepared by hypotonic lysis from normal blood and blood from persons with sickle cell anemia was quantified under a variety of conditions using hemoglobin labelled by alkylation with 14C-labelled Nitrogen Mustard. Membrane morphology was examined by electron microscopy. Normal membranes were found capable of binding native hemoglobin A and hemoglobin S in similar amounts when incubated at low hemoglobin: membrane ratios, but at high ratios hemoglobin saturation levels of the membranes increased progressively for hemoglobin A, hemoglobin S and hemoglobin A2, respectively, in order of increasing electropositivity. Binding was unaffected by variations in temperature (4-22 degrees C) and altered little by the presence of sulfhydryl reagents, but was inhibited at pH levels above 7.35; disrupted at high ionic strength; and dependent on the ionic composition of the media. These findings suggest that electrostatic, but not hydrophobic or sulfhydryl bonds are important in membrane binding of the hemoglobin under the conditions studied. An increased retention of hemoglobin in preparations of membranes from red cells of patients with sickle cell anemia (homozygote S) was attributable to the dense fraction of homozygote S red cells rich in irreversibly sickled cells, and the latter membranes had a smaller residual binding capacity for new hemoglobin. This suggests that in homozygote S cells which have become irreversibly sickled cells in vivo, there are membrane changes which involve alteration and/or blockade of hemoglobin binding sites. These findings support the notion that hemoglobin participates in the dynamic structure of the red cell membrane in a manner which differs in normal and pathological states.     

Prosthetic heart valves' mechanical loading of red blood cells in patients with hereditary membrane defects

Implantable cardiovascular devices such as prosthetic heart valves (PHVs) are widely applied clinical tools. Upon implantation, the patient can suffer from anemia as a result of red cell destruction and hemolysis can be more relevant whenever the patient is also affected by red cell disorders in which erythrocytes are more susceptible to mechanical stress such as hereditary spherocytosis (HS) and hereditary elliptocytosis (HE). Considering the typical morphological alterations observed in HS and HE, a study of the influence of cell geometry on the distribution of the shear stress on red cells in biological fluids was carried out. A numerical simulation of the loading caused by Reynolds shear stresses on a prolate spheroid was performed, with the ellipticity of the particle as the independent parameter. The average shear stress on a particle in the blood stream was found to depend on the particle's geometry, besides the stress field produced by the prosthetic device. The relevance of an increasing particle ellipticity on the global load is discussed. The model was applied to erythrocytes from implanted patients with HE or HS, enabling to explain the occurrence of moderate or severe anemia, respectively. The clinical data support the relevance of the proposed global parameter as erythrocyte trauma predictor with regard to the fluid dynamics of artificial organs.     

Physicochemical properties and inhibition effect on iron deficiency anemia of a novel polysaccharide-iron complex (LPPC)

Porphyran (P) was extracted from red algae Porphyra by boiling water. A novel polysaccharide-iron complex (LPPC) was prepared under the alkaline condition by adding a ferric chloride solution to the low molecular weight porphyran (LP) solution. Physicochemical properties and inhibition effect on iron deficiency anemia of this complex were studied. The content of iron(III) in the complex is 21.57% determined with iodometry. The results indicate that LPPC was product required. The complex can increase red blood cell count (RBC), hemoglobin (Hb), Serum iron (SI), spleen index, spleen mass and mass of mice with iron deficiency anemia (IDA). Although the structure and deeper mechanisms on hemolytic anemia of LPPC should be further studied, LPPC is hoped to be developed as a late-model iron supplement which has a synergism on anemia.     

The binding of hemoglobin to membranes of normal and sickle erythrocytes

The binding of hemoglobins A, S, and A₂ to red cell membranes prepared by hypotonic lysis from normal blood and blood from persons with sickle cell anemia was quantified under a variety of conditions using hemoglobin labelled by alkylation with ¹⁴C-labelled Nitrogen Mustard. Membrane morphology was examined by electron microscopy. Normal membranes were found capable of binding native hemoglobin A and hemoglobin S in similar amounts when incubated at low hemoglobin: membrane ratios, but at high ratios hemoglobin saturation levels of the membranes increased progressively for hemoglobin A, hemoglobin S and hemoglobin A₂, respectively, in order of increasing electropositivity. Binding was unaffected by variations in temperature (4–22 °C) and altered little by the presence of sulfhydryl reagents, but was inhibited at pH levels above 7.35; disrupted at high ionic strength; and dependent on the ionic composition of the media. These findings suggest that electrostatic, but not hydrophobic or sulfhydryl bonds are important in membrane binding of the hemoglobin under the conditions studied.An increased retention of hemoglobin in preparations of membranes from red cells of patients with sickle cell anemia (homozygote S) was attributable to the dense fraction of homozygote S red cells rich in irreversibly sickled cells, and the latter membranes had a smaller residual binding capacity for new hemoglobin. This suggests that in homozygote S cells which have become irreversibly sickled cells in vivo, there are membrane changes which involve alteration and/or blockade of hemoglobin binding sites.These findings support the notion that hemoglobin participates in the dynamic structure of the red cell membrane in a manner which differs in normal and pathological states.     

Abnormal folate metabolism in feed-related anemia of cultured channel catfish

"No-blood disease" is a severe, feed-related anemia of channel catfish. Pathological features in advanced cases include almost total absence of circulating red blood cells, hepatic fatty change, megaloblastic arrest of hematopoiesis, and intussusceptions of the small intestine. In view of similarities to folate deficiency in man studies were made regarding the intake and metabolism of folic acid. When a bacterial culture medium, containing inorganic salts and folic acid as the sole carbon source, was inoculated with a small sample of anemia-producing feed, over 95% of the folate was destroyed. A yellow precipitate formed and had the characteristic uv spectrum of pteroic acid; it represented 32% of the folate originally present. Differential microbiological assays revealed that the same anemia-producing feed contained 20 times as much folate activity for Streptococcus fecalis as for Lactobacillus casei (59 micrograms/g vs 2.6 micrograms/g). This growth response is compatible with an excess of pteroic acid and/or formyl-pteroic acid which support the former but not the latter organism. Plasma folate activity (mean +/- SD, ng/ml) assayed with L. casei and S. fecalis in 22 normal catfish (hematocrit range 32-43) was 17.2 +/- 6.2 and 23.4 +/- 13.8, respectively. Comparable values in 15 anemic catfish (hematocrit range 0 to 30) were 35.5 +/- 33.7 and 58.7 +/- 76.5. The mean plasma pteroate activity, estimated by subtraction, was 6.2 and 23.2 ng/ml, respectively, in normal and anemic fish. Fingerling catfish raised under controlled conditions on feed containing 130 mg/kg of pteroic acid failed to gain weight and developed anemia with the characteristic red cell morphologic features that are seen in the naturally occurring disease. We conclude that severe anemia in channel catfish can be caused by abnormal folate metabolism and may be due to ingestion of folic acid-breakdown products, such as pteroic acid. It is postulated that microorganisms in contaminated feed synthesize folate which, in turn, is converted to pteroate by a pseudomonad or similar organism.     

Ocular manifestations of sickle hemoglobinopathies

Sickle cell disease is a hereditary disorder that is characterized by the production of structurally abnormal hemoglobin molecules. Clinical manifestations depend upon the amount and types of abnormal hemoglobin present. This paper reviews the genetic and molecular basis of sickle hemoglobinopathies and thalassemias including sickle cell anemia, SC disease, sickle cell-Beta Thalassemia and sickle trait. The systemic and ocular manifestations of these diseases are presented. Treatment regimens pertaining to hyphema, proliferative retinopathy, vitreous hemorrhage and retinal detachment are also discussed.     

Advances in hereditary red cell enzyme anomalies

Conclusions From the above report we can observe that recent advances in hereditary disorders of red cell enzymes concern molecular mechanisms of the defect and relationship between molecular anomalies and pathologic consequences. Moreover, congenital nonspherocytic hemolytic anemias of undertermined cause are becoming fewer.It seems to us that the perspectives opened in this field could develop in two ways. Firstly, the current possibility of obtaining homogeneous mutant enzymes (for pyruvate kinase, glucose phosphate isomerase, glucose-6-phosphate dehydrogenase, phosphoglycerate kinase) should enable the study of the structure-function relationship, as was done for hemoglobin. Secondly, the recent progress in genetic analysis and genetic engineering could provide a direct approach of the nature of the genetic defect at the DNA level. This should be fundamental to understand the nature of some enzyme deficiencies without any detectable abnormal product of a mutant gene (e.g., glucose phosphate isomerase deficiencies with silent gene and M-type phosphofructokinase deficiency).     

The accumulation of basic nonhemoglobin proteins during the differentiation of primitive (embryonic) red cells of amphibia

The preferential accumulation of hemoglobin is a characteristic of the differentiation of definitive (adult) red blood cells. Since primitive (embryonic or larval) red blood cells have many properties which contrast with definitive red cells, the accumulation of red cell proteins was analyzed during the differentiation of primtive red cells to determine whether or not hemoglobin was the only protein which showed a substantial increase in amount. Primitive red cells of amphibia were used because the mature circulating cell retains large amounts (13%) of specific, well characterized, nonhemoglobin proteins (CP). Preparations of primitive red cells enriched in immature cells were obtained from the circulation of bullfrog tadpoles recovering from phenylhydrazine-induced anemia. The amount of CP, determined by electrophoresis, imunodiffusion, and ion-exchange chromatography, was compared for red cells from normal animals and anemic animals. Mature cells contained three to six times the amount of CP and three times the amount of hemoglobin found in the population of red cells enriched in immature cells. The accumulation of CP during maturation of primitive red cells indicates that differentiation of primitive red cells is less restrictive than differentiation of definitive red cells. Since the primitive red cell is less specialized than the definitive red cell, it is possible that primitive red cells have several roles in the developing animal, in contrast to the single role of synthesizing and maintaining hemoglobin in the adult animal.