Molecular diagnosis of hereditary spherocytosis by multi-gene target sequencing in Korea: matching with osmotic fragility test and presence of spherocyte.

BACKGROUND: Current diagnostic tests for hereditary spherocytosis (HS) focus on the detection of hemolysis or indirectly assessing defects of membrane protein, whereas direct methods to detect protein defects are complicated and difficult to implement. In the present study, we investigated the patterns of genetic variation associated with HS among patients clinically diagnosed with HS. METHODS: Multi-gene targeted sequencing of 43 genes (17 RBC membrane protein-encoding genes, 20 RBC enzyme-encoding genes, and six additional genes for the differential diagnosis) was performed using the Illumina HiSeq platform. RESULTS: Among 59 patients with HS, 50 (84.7%) had one or more significant variants in a RBC membrane protein-encoding genes. A total of 54 significant variants including 46 novel mutations were detected in six RBC membrane protein-encoding genes, with the highest number of variants found in SPTB (n = 28), and followed by ANK1 (n = 19), SLC4A1 (n = 3), SPTA1 (n = 2), EPB41 (n = 1), and EPB42 (n = 1). Concurrent mutations of genes encoding RBC enzymes (ALDOB, GAPDH, and GSR) were detected in three patients. UGT1A1 mutations were present in 24 patients (40.7%). Positive rate of osmotic fragility test was 86.8% among patients harboring HS-related gene mutations. CONCLUSIONS: This constitutes the first large-scaled genetic study of Korean patients with HS. We demonstrated that multi-gene target sequencing is sensitive and feasible that can be used as a powerful tool for diagnosing HS. Considering the discrepancies of clinical and molecular diagnoses of HS, our findings suggest that molecular genetic analysis is required for accurate diagnosis of HS.

Hereditary Spherocytosis - Diagnosis, Surgical Treatment and Outcomes. A Literature Review.

Hereditary spherocytosis (HS) is a disease affecting the red blood cells membrane and belongs to the congenital hemolytic anemias. The clinical spectrum ranges from asymptomatic patients to severe forms requiring transfusions in early childhood. The diagnosis can be based on the physical examination, complete red blood cell count, reticulocytes count, medical history and specific tests, preferentially the EMA test (eosin-5-maleimide binding) test and AGLT (Acidified Glycerol Lysis Time). Splenectomy is considered the standard surgical treatment in moderate and severe forms of hereditary spherocytosis. Total splenectomy exposes the patient to a life - long risk of potentially lethal infections and thus, its usage was reconsidered. Because of this reason, a feasible alternative is the partial splenectomy. The use of partial splenectomy aims to retain splenic immunologic function, while at the same time to decrease the rate of hemolysis. The long - term outcomes of patients with total or subtotal splenectomy for congenital hemolytic anemia, still remain unclear, but the majority of the studies showed a qualitative resolution of anemia and reduction of transfusion rate. Despite the well known advantages of conservative surgery, the optimal choice of treatment and outcomes should be confirmed with the patient.

Spherocytic shift of red blood cells during storage provides a quantitative whole cell-based marker of the storage lesion.

BACKGROUND: Storage lesion may explain the rapid clearance of up to 25% of transfused red blood cells (RBCs) in recipients. Several alterations affect stored RBC but a quantitative, whole cell-based predictor of transfusion yield is lacking. Because RBCs with reduced surface area are retained by the spleen, we quantified changes in RBC dimensions during storage. STUDY DESIGN AND METHODS: Using imaging flow cytometry we observed the dimension and morphology of RBCs upon storage, along with that of conventional biochemical and mechanical markers of storage lesion. We then validated these findings using differential interference contrast (DIC) microscopy and quantified the accumulation of microparticles (MPs). RESULTS: Mean projected surface area of the whole RBC population decreased from 72.4 to 68.4 µm2 , a change resulting from the appearance of a well-demarcated subpopulation of RBCs with reduced mean projected surface (58 µm2 , 15.2%-19.9% reduction). These "small RBCs" accounted for 4.9 and 23.6% of all RBCs on Days 3 and 42 of storage, respectively. DIC microscopy confirmed that small RBCs had shifted upon storage from discocytes to echinocytes III, spheroechinocytes, and spherocytes. Glycophorin A-positive MPs and small RBCs appeared after similar kinetics. CONCLUSION: The reduction in surface area of small RBCs is expected to induce their retention by the spleen. We propose that small RBCs generated by MP-induced membrane loss are preferentially cleared from the circulation shortly after transfusion of long-stored blood. Their operator-independent quantification using imaging flow cytometry may provide a marker of storage lesion potentially predictive of transfusion yield.

Early postnatal diagnosis of hereditary spherocytosis by combining light microscopy, acidified glycerol lysis test and eosin-5'-maleimide binding assay.

Exact diagnosis of hereditary spherocytosis (HS) is widely considered unreliable around birth. However, early postnatal diagnosis at the beginning of congenital hemolysis may be essential for managing neonatal anemia and hemolytic icterus, identifying those at high risk for severe hyperbilirubinemia, irreversible kernicterus, or sudden need for red cell transfusion. We analyzed 37 blood samples from neonates or infants up to six weeks of life that had been collected in-house or shipped to our laboratory due to suspected red cell membrane disorder. By combining assessment of red cell morphology, acidified glycerol lysis test (AGLT), and eosin-5'-maleimide (EMA) binding assay, we were able to clearly exclude HS in 22 and confirm HS in 10 patients, of which one had undergone red cell transfusion prior to blood sampling. Assessment of red cell morphology and normal test results allowed diagnosis of infantile pyknocytosis or Heinz body anemia in three neonates. Re-evaluation of five patients with inconsistent results of AGLT and EMA binding led to confirmation of HS in two cases. Automated analysis of hematologic parameters revealed elevated proportion of hyperdense cells to be a highly significant indicator for HS in neonatal infants. We showed that assessment of red cell morphology in combination with AGLT and EMA binding assay is a reliable basis for confirming or rejecting suspected diagnosis of HS even in neonates. Our data underline the necessity for blood sampling and laboratory exploration in suspected red cell membrane or enzyme defects at the earliest occasion.

Targeted deletion of alpha-adducin results in absent beta- and gamma-adducin, compensated hemolytic anemia, and lethal hydrocephalus in mice.

In the red blood cell (RBC), adducin is present primarily as tetramers of alpha- and beta-subunits at spectrin-actin junctions, or junctional complexes. Mouse RBCs also contain small amounts of gamma-adducin. Platelets contain alpha- and gamma-adducin only. Adducin functions as a barbed-end actin capping protein to regulate actin filament length and recruits spectrin to the ends of actin filaments. To further define adducin's role in vivo, we generated alpha-adducin knockout mice. alpha-Adducin is absent in all tissues examined in homozygous null mice. In RBCs, beta- and gamma-adducin are also absent, indicating that alpha-adducin is the limiting subunit in tetramer formation at the spectrin-actin junction. Similarly, gamma-adducin is absent in alpha-null platelets. alpha-Adducin-null mice display compensated hemolytic anemia with features characteristic of RBCs in hereditary spherocytosis (HS), including spherocytes with significant loss of surface area, decreased mean corpuscular volume (MCV), cell dehydration, and increased osmotic fragility. Platelets maintain their normal discoid shape, and bleeding times are normal. alpha-Adducin-null mice show growth retardation at birth and throughout adulthood. Approximately 50% develop lethal communicating hydrocephalus with striking dilation of the lateral, third, and fourth ventricles. These data indicate that adducin plays a role in RBC membrane stability and in cerebrospinal fluid homeostasis.

Functional interaction between Rh proteins and the spectrin-based skeleton in erythroid and epithelial cells.

We summarize the different experimental approaches which provide evidence that direct interaction of Rh and RhAG to ankyrin-R constitutes, together with the AE-1 (Band 3)-ankyrin-protein 4.2 and GPC-protein 4.1-p55 complexes, another major anchoring site between the red cell membrane bilayer and the underlying spectrin-based skeleton. The observations that some residues of the ankyrin binding site are mutated in Rh and RhAG proteins from some weak D and Rh(null) variants, respectively, suggest that the Rh-RhAG/ankyrin-R interaction plays a crucial role in the biosynthesis and/or the stability of the Rh complex in the red cell membrane. Similarly, binding to ankyrin G is required for cell surface expression of the non-erythroid member of the Rh protein family, RhBG, at the basolateral membrane domain of polarized epithelial cells. The next challenge will be to determine whether binding to the membrane skeleton may be critical for the emerging ammonium transport function of Rh proteins in erythroid and non-erythroid cells.

Decreased content of protein 4.2 in ankyrin-deficient normoblastosis (nb/nb) mouse red blood cells: evidence for ankyrin enhancement of protein 4.2 membrane binding.

Homozygous normoblastosis (nb/nb) mice, whose red blood cell (RBC) membranes are nearly completely deficient in full-length 210-kD ankyrin, were used to study interactions between ankyrin and protein 4.2 (P4.2). Although it is unclear whether or not these proteins interact in the membrane, both ankyrin and P4.2 bind to the cytoplasmic domain of band 3 (cdb3). In addition to the complete deficiency of full-length ankyrin, nb/nb RBC membranes are also partially spectrin deficient, resulting in morphologically spherocytic and mechanically fragile cells. A new finding was that nb/nb RBC membranes are severely (approximately 73%) P4.2 deficient compared with wild type (+/+) or high reticulocyte mouse RBC membranes. Metabolic labeling of nb/nb reticulocytes showed active P4.2 synthesis at levels comparable with high reticulocyte controls suggesting that the nb/nb P4.2 deficiency was not the result of defective P4.2 synthesis. Reconstitution of nb/nb inside-out vesicles (IOVs) with human RBC ankyrin restored ankyrin levels to approximately 80% of +/+ IOV levels and increased binding of exogenously added human RBC P4.2 by approximately 60%. These results suggest that ankyrin is required for normal associations of P4.2 with the RBC membrane.

Hereditary spherocytosis (HS) due to loss of anion exchange transporter.

BACKGROUND: Hereditary spherocytosis encompasses a heterogenous group of inherited disorders due to alteration of r.b.c. surface/volume ratio. Spectrin deficiency is the most common observed defect. We analyzed a case of HS associated with band 3 deficiency without spectrin reduction. METHODS: In the study of a family originating from southern Italy, we show that a 20% deficiency of band 3 with normal spectrin content may be responsible for dominantly inherited hereditary spherocytosis (HS). The proband is a 12 years old girl consulting for jaundice, chronic anaemia and splenomegaly. Her mother had a similar haematologic phenotype. RESULTS: Electrophoretic analysis of erythrocyte membrane proteins showed a deficiency in band 3 protein. Band 3 protein chymotryptic fragments, deglycosylated band 3, and its isolated cytoplasmic domain, all displayed normal electrophoretic migrations. Furthermore, the tryptic peptides profile of the cytoplasmic domain of the protein did not demonstrate any abnormality, nor did the amino acid composition of the peptides. Analysis of the membrane proteins during erythrocyte ageing, evaluated in density-fractionated red cells, showed that band 3 content was normal in the lighter fraction, whereas in the denser fraction band 3 deficiency was more pronounced than in membranes from non fractionated red blood cells. CONCLUSIONS: This case describes HS due to anion exchange transporter deficiency. Our results on fractioned red cells support the hypothesis that the defect was probably due to a band 3 protein loss during cell ageing and not to a primitive quantitative defect.

Transbilayer asymmetry of pyrene mobility in human spherocytic red cell membranes.

The diffusion-dependent formation of pyrene excimers (excited dimers) was studied in normal and spherocytic red cell membranes. Pyrene emission was alternatively quenched in either bilayer half by non radiative energy transfer to haemoglobin. Pyrene excimer to monomer fluorescence intensity ratio, I'/I, was 0.35 +/- 0.03 (S.E.) in washed red blood cells obtained from normal donors (n = 8) and 0.45 + 0.03 (n = 13) in the corresponding isolated, haemoglobin-free resealed membranes (P less than 0.02). In the spherocytic condition the respective values were 0.28 +/- 0.01 (n = 9) and 0.53 +/- 0.03 (n = 9), P less than 0.001. In contrast to the decrease of I'/I in red cells as compared to isolated membranes, being 22% in normal cells and 47% in spherocytic ones, haemoglobin added to the exofacial side of isolated membranes, respectively, reduced I'/I by 18% and 5%. In normal red cell membranes, pyrene mobility appears to be higher in the inner monolayer than in the outer one. In spherocytic membranes our results indicate an enhanced transmembrane asymmetry in lipid monolayer fluidity, probably due to a defect of the membrane protein skeleton organization.

Ca2+ influx in normal and spherocytic red cells.

The influx of 45Ca2+ into normal red cells and various types of spherocytic red cells was studied after blocking active Ca2+ extrusion by vanadate. The measurements were performed with and without verapamil, a calcium antagonist. The influx of Ca2+ into red cells from unsplenectomized persons was 22 +/- 7 mumol/l packed red cells/h (mean +/- SD), and 17 +/- 7 mumol/l per h when incubated with verapamil. The influx of Ca2+ into red cells from four splenectomized normal controls was of the same magnitude as in the unsplenectomized controls but there was no effect of verapamil on the influx rate. The influx of Ca2+ into red cells from nine splenectomized patients with hereditary spherocytosis (HS) was 27 +/- 9 mumol/l per h without and 24 +/- 9 mumol/l per h with verapamil. In 9 normal red cell samples made spherocytic by thermal damage the corresponding values were 32 +/- 16 and 31 +/- 19 mumol/l per h, respectively. The uptake of Ca2+ in chlorpromazine-induced spherocytic red cells was 20 +/- 4 mumol/l per h without and 19 +/- 5 mumol/l per h with verapamil in 9 experiments. These results indicate that although in HS erythrocytes changes in the cell membrane lead to an increased Ca2+ influx, the slow calcium channels are not affected, whereas in spherocytes induced by thermal damage or by incubation with chlorpromazine the channels are blocked, at least partly.

Biodegradability of inhaled organic particles in patients with chronic bronchitis.

2 h after the inhalation of monodispersed 99mTc-labeled autologous spherocytes and of commercial human albumin microspheres (HAM), 7 patients with chronic bronchitis underwent bronchofibroscopy. The fate of organic particles along the tracheobronchial tree was verified by scanning electron microscopy and the proteolytic activity (trypsin and PZ peptidase) in mucus samples was assessed. Significant proteolytic activity was detected in bronchial secretions. Thereafter in vitro digestion of labeled spherocytes and HAM was verified after exposure to increasing concentrations of trypsin. While in vitro a similar time-course of tryptic digestion of both particles was observed, in vivo spherocytes seem to be less vulnerable to enzymatic digestion. These findings add another unexpected variable, which may influence the reproducibility of radioaerosol lung mucociliary clearance measurements, and improve its standardization.

Adenosine triphosphate restoration and discocytic transformation of stored human erythrocytes.

Erythrocytes in human blood stored for 120 days were collected by centrifugation after dispersion in buffered physiological saline. The aged erythrocytes thus collected were incubated with inosine, adenine, glucose or other media, and their shapes and ATP levels were studied by scanning electron microscopy and a luciferine-luciferase method. The aged erythrocytes incubated in a mixture of adenine and inosine markedly regained their ATP levels, and also showed a marked transformation from spiked spherocytes to normal discocytes. Incubation with inosine alone restored ATP levels of the aged erythrocytes to some extent, but did not result in morphological rejuvenation. Incubation in a mixture of citrate and glucose caused morphological rejuvenation, though it restored ATP levels less effectively than incubation in inosine alone. Incubation with adenine alone neither restored ATP levels nor resulted in morphological rejuvenation of the stored erythrocytes.

Does an unfavorable metabolic environment for red cells develop within the cat spleen when abnormal cells become trapped?

Intrasplenic pH, blood gas tensions, and glucose concentration were deduced from measurements of blood drained from cat spleen during contraction with the inflow occluded. During this procedure the hematocrit of the outflow rises gradually from 35% to 40% (arterial) to 75% to 80%, the last fraction representing a pure sample of blood from the splenic pulp. In normoxic animals no evidence was found of an unfavorable metabolic environment for red cells within the spleen on account of low pH, low O2 tension, and substrate deprivation, as is generally believed. However, red cell flow through the red pulp can be impeded rheologically after sequestration of 10(9) heat-treated (HT) autologous red cells, and we have tested the hypothesis that under these conditions the availability of O2 and glucose might be reduced and a decline in pH might occur. One hour after injection of the HT cells into the splenic artery, splenic contraction was induced with the arterial inflow occluded; the blood expelled from the splenic vein was collected anaerobically as successive 1 ml fractions. Values of pH, O2 tension, and glucose concentration in the final samples expelled were not significantly different from those in corresponding samples from control spleens. Thus, even when stasis of 50% of intrasplenic red cells occurs, caused by the sequestration of 10(9) abnormal cells, no hostile metabolic environment develops within the red pulp. Presumably the residual plasma flow through the pulp is sufficient to maintain a normal metabolic environment.

[Hereditary diseases of the human erythrocyte membrane skeleton (author's transl)]. / Les maladies héréditaires du squelette membranaire du globule rouge humain.

The shape and, to some extent, the deformability of the human erythrocyte are dependent upon a proteinic cytoskeleton arranged as a net on the inner side of the membrane. The meshes of the net are composed of spectrin, a fibrillar protein, and the knots of protofilaments of actin and of a protein called 4.1 from its position a electrophoresis. The cytoskeleton is attached to the other proteins and lipids of the membrane, and on its stability depends that of the whole red cell. Several abnormalities of this formation, involving the structure and/or functions of spectrin and protein 4.1, have recently be detected by new techniques. These techniques have shown that different molecular disorders may results in spherical or elliptical erythrocytes, thereby demonstrating the heterogeneous biochemistry of inherited spherocytes and elliptocytes.

Reconstitution of spectrin-deficient, spherocytic mouse erythrocyte membranes.

To study directly the role of spectrin in erythrocyte membrane function, we have designed a reconstituted membrane system using erythrocyte membranes from spectrin-deficient mice and purified spectrin from normal mice. The normal spectrin is inserted into the spectrin-deficient spherocytes by exchange hemolysis. Thereafter, raising the ionic strength and temperature reseals the cells and, with time, facilitates binding of the spectrin to the spectrin-deficient membranes. The binding is apparently specific as shown by its dependence upon the concentration of undenatured spectrin and the concentration of salt used, as well as by the immunofluorescent appearance of the reconstituted cells after treatment with specific antispectrin antibody. In terms of in vitro cellular behavior, the reconstituted preparations show marked changes in comparison to the untreated spherocytes. In particular, membrane stability, as measured by the reduction of myelin figure formation and lipid loss, is considerably enhanced. In addition, membrane fusion, which occurs readily with the untreated spherocytes, is virtually eliminated. Finally, the osmotic behavior of the native spherocytes is appreciably altered, such that the early phase of osmotically induced swelling, as measured in a high-speed stop-flow apparatus, is delayed and modified. Taken together, these findings indicate specific roles for spectrin in the stabilization of the erythrocyte membrane, in the limitation of membrane fusion, and in the modulation of the membrane's response to osmotic stress.

31P-NMR study on nucleotides and intracellular pH of hereditary spherocytes.

As determined by 31p-NMR spectroscopy, intracellular pH of hereditary spherocytes was lower (pH 6.7-6.9) than that of normal red cells. The level of adenosine diphosphate in hereditary spherocytes was found to be persistently high. The metabolism of nucleotides and other phosphoryl compounds in human red blood cells have been studied in detail by 31p-MNR spectroscopy. However, to our knowledge, there seems to be no report describing the result of 31p-NMR spectroscopy on red blood cells from hereditary spherocytosis.