AA Red Blood Cells Research Articles

Identifying Inflammatory Pathways That Promote RBC Alloimmunization in Patients with Sickle Cell Disease

Introduction: During red blood cell (RBC) transfusion, exposure to unmatched non-ABO antigens can lead to production of alloantibodies that promote potentially fatal hemolytic events. Patients with Sickle Cell Disease (SCD) have the highest incidence of RBC alloimmunization. Prior studies indicate that an altered immuno-regulatory and/or pro-inflammatory state may determine the risk of RBC alloimmunization. For example, one study reported that patients with SCD have inflammatory cytokine gene polymorphisms that could be associated with diverse disease presentations and alloimmunization. We previously reported that inflammatory type 1 interferons (IFNα/β) produced by innate immune cells are required for RBC alloimmunization in mice, while others have suggested that NFkB-induced cytokines play a role in murine transfusion models. However, the inflammatory factors that regulate RBC alloimmunization in patients with SCD are poorly understood. Alloimmunized patients with SCD also have elevated levels of anti-RBC autoantibodies, which facilitate erythrophagocytosis. Given the role of erythrophagocytosis by spleen macrophages in processing RBC antigens, we hypothesized that erythrophagocytosis of SCD RBCs may promote inflammatory pathways that regulate alloimmune responses. Methods: RBCs from control subjects (AA), and reticulocytes and mature RBCs from patients with SCD, were opsonized or not with anti-RBC antibodies (anti-RhD) and co-cultured for 3 hrs with human macrophages (hMac) differentiated from monocytes of healthy subjects. Phagocytosis of labeled RBCs was analyzed by flow cytometry. Bulk mRNA sequencing of co-cultured macrophages was performed to identify differential gene expression. Ingenuity Pathway Analysis (IPA) software was used to identify relevant pathways and upstream regulators of differentially expressed genes. To validate sequencing results, cytokine levels from co-culture supernatants were measured by multiplex cytokine assays. Results: Flow cytometric analysis revealed that opsonization was required for erythrophagocytosis in an FcR dependent manner. RNA-seq Differential Expression analysis of macrophages co-cultured with AA opsonized RBCs vs. non-opsonized RBCs identified 166 significantly upregulated and 24 downregulated genes (p<0.0001). IPA analysis revealed that the top 12 canonical pathways were related to inflammation, including TNF, IL-17, NF-kappa-B and NOD-like receptor signaling pathways. TNF signaling was the top predicted upstream regulator pathway with a fold enrichment score of 10.3 (16 genes) (p<0.0001). Co-cultures of mature RBCs from patients with SCD showed comparable results. When comparing macrophages from co-cultures of opsonized reticulocytes vs. non-opsonized reticulocytes from patients with SCD, 174 genes were upregulated and 31 were downregulated (p<0.0001). Pathway analysis also revealed unique signatures for opsonized reticulocytes from patients with SCD. The top 12 canonical pathways included TNF, NF-kappa-B and NOD-like receptor signaling pathways (Figure 1). The top predicted upstream regulators were TNF and the NF-kappa B signaling pathway with a fold enrichment score of 12.3 (22 genes) (p<0.0001) and 10.9 (18 genes), respectively (Figure 1). Finally, to validate the sequencing results, cytokines levels from supernatants of hMac co-cultures with the RBCs from the patients with SCD and control subjects were measured. Erythrophagocytosis of opsonized reticulocytes and AA RBCs, compared to non-opsonized co-cultures, led to production of NFκB-mediated cytokines, including TNF. Our results show that erythrophagocytosis of SCD RBCs promote NFκB-mediated TNF production. These results warrant further investigation of the role of NFκB-mediated inflammation in RBC alloimmunization in patients with SCD.

Non-O ABO blood group genotypes differ in their associations with Plasmodium falciparum rosetting and severe malaria.

Blood group O is associated with protection against severe malaria and reduced size and stability of P. falciparum-host red blood cell (RBC) rosettes compared to non-O blood groups. Whether the non-O blood groups encoded by the specific ABO genotypes AO, BO, AA, BB and AB differ in their associations with severe malaria and rosetting is unknown. The A and B antigens are host RBC receptors for rosetting, hence we hypothesized that the higher levels of A and/or B antigen on RBCs from AA, BB and AB genotypes compared to AO/BO genotypes could lead to larger rosettes, increased microvascular obstruction and higher risk of malaria pathology. We used a case-control study of Kenyan children and in vitro adhesion assays to test the hypothesis that "double dose" non-O genotypes (AA, BB, AB) are associated with increased risk of severe malaria and larger rosettes than "single dose" heterozygotes (AO, BO). In the case-control study, compared to OO, the double dose genotypes consistently had higher odds ratios (OR) for severe malaria than single dose genotypes, with AB (OR 1.93) and AO (OR 1.27) showing most marked difference (p = 0.02, Wald test). In vitro experiments with blood group A-preferring P. falciparum parasites showed that significantly larger rosettes were formed with AA and AB host RBCs compared to OO, whereas AO and BO genotypes rosettes were indistinguishable from OO. Overall, the data show that ABO genotype influences P. falciparum rosetting and support the hypothesis that double dose non-O genotypes confer a greater risk of severe malaria than AO/BO heterozygosity.

In vivo evaluation of the effect of sickle cell hemoglobin S, C and therapeutic transfusion on erythrocyte metabolism and cardiorenal dysfunction.

Despite a wealth of exploratory plasma metabolomics studies in sickle cell disease (SCD), no study to date has evaluate a large and well phenotyped cohort to compare the primary erythrocyte metabolome of hemoglobin SS, SC and transfused AA red blood cells (RBCs) in vivo. The current study evaluates the RBC metabolome of 587 subjects with sickle cell sickle cell disease (SCD) from the WALK-PHaSST clinical cohort. The set includes hemoglobin SS, hemoglobin SC SCD patients, with variable levels of HbA related to RBC transfusion events. Here we explore the modulating effects of genotype, age, sex, severity of hemolysis, and transfusion therapy on sickle RBC metabolism. Results show that RBCs from patients with Hb SS genotypes-compared to AA RBCs from recent transfusion events or SC RBCs-are characterized by significant alterations of RBC acylcarnitines, pyruvate, sphingosine 1-phosphate, creatinine, kynurenine and urate metabolism. Surprisingly, the RBC metabolism of SC RBCs is dramatically different from SS, with all glycolytic intermediates significantly elevated in SS RBCs, with the exception of pyruvate. This result suggests a metabolic blockade at the ATP-generating phosphoenolpyruvate to pyruvate step of glycolysis, which is catalyzed by redox-sensitive pyruvate kinase. Metabolomics, clinical and hematological data were collated in a novel online portal. In conclusion, we identified metabolic signatures of HbS RBCs that correlate with the degree of steady state hemolytic anemia, cardiovascular and renal dysfunction and mortality.

Sickle red blood cell-derived extracellular vesicles activate endothelial cells and enhance sickle red cell adhesion mediated by von Willebrand factor.

Endothelial activation and sickle red blood cell (RBC) adhesion are central to the pathogenesis of sickle cell disease (SCD). Quantitatively, RBC-derived extracellular vesicles (REVs) are more abundant from SS RBCs compared with healthy RBCs (AA RBCs). Sickle RBC-derived REVs (SS REVs) are known to promote endothelial cell (EC) activation through cell signalling and transcriptional regulation at longer terms. However, the SS REV-mediated short-term non-transcriptional response of EC is unclear. Here, we examined the impact of SS REVs on acute microvascular EC activation and RBC adhesion at 2 h. Compared with AA REVs, SS REVs promoted human pulmonary microvascular ECs (HPMEC) activation indicated by increased von Willebrand factor (VWF) expression. Under microfluidic conditions, we found abnormal SS RBC adhesion to HPMECs exposed to SS REVs. This enhanced SS RBC adhesion was reduced by haeme binding protein haemopexin or VWF cleaving protease ADAMTS13 to a level similar to HPMECs treated with AA REVs. Consistent with these observations, haemin- or SS REV-induced microvascular stasis in SS mice with implanted dorsal skin-fold chambers that was inhibited by ADAMTS13. The adhesion induced by SS REVs was variable and was higher with SS RBCs from patients with increased markers of haemolysis (lactate dehydrogenase and reticulocyte count) or a concomitant clinical diagnosis of deep vein thrombosis. Our results emphasise the critical contribution made by REVs to the pathophysiology of SCD by triggering acute microvascular EC activation and abnormal RBC adhesion. These findings may help to better understand acute pathophysiological mechanism of SCD and thereby the development of new treatment strategies using VWF as a potential target.

Extracellular Vesicles from Sickle Red Blood Cells Activate Endothelial Cells and Trigger Von Willebrand Factor-Mediated Sickle Red Cell Adhesion

Introduction: The sickle mutation of hemoglobin (HbS) afflicts millions of people worldwide and is characterized by hemolytic anemia, inflammation, painful vaso-occlusive crises, significant morbidity, and early mortality. In sickle cell disease (SCD), HbS polymerization under deoxygenation increases red blood cell (RBC) rigidity, adhesivity and susceptibility to lysis. Products of intravascular hemolysis including heme and RBC-released extracellular vesicles (REVs) promote acute and chronic inflammation triggering endothelial activation and abnormal RBC adhesion. Extracellular vesicles (EVs) are nano- or micro-particles composed of a lipid bilayer, comprised of transmembrane proteins, and enclosing intracellular remnants, including cytosolic proteins and miRNAs. EVs are known to exchange biomaterial between cells, and may serve as surrogate markers for the activated state of the parent cell thus are of high clinical significance. Quantitatively, REVs are more abundant from sickle RBCs (SS RBCs) compared with normal HbA-containing RBCs (AA RBCs). SS REVs are known to promote endothelial cell (EC) activation through cell signaling and transcriptional regulation at longer terms. However, the SS REV-mediated short term non transcriptional response of EC is unclear. Methods: Here, we have developed the SCD-EV-BioChip using microfluidic technology. SCD-EV-BioChip assesses RBC adhesion as a biomarker for REV-mediated human pulmonary microvascular endothelial cells (HPMECs) dysfunction using functional biomarker of RBC adhesion. Utilizing SCD-EV-BioChip, Here, we examined the impact of SS REVs on acute microvascular EC activation and RBC adhesion at 2 hours. For in vitro studies, SS REVs and AA REVs were collected from pooled human SS RBCs and AA RBCs activated using calcium ionophore. The generated REVs were characterized using scanning electron microscopy (SEM) and nanoparticle tracking analyzer (NTA). HPMECs were cultured in microfluidic channels under controlled shear stress for more than 72 hours then treated with REVs at 37 ºC for 2 hours. Von Willebrand factor (vWF) expression on REVs-treated HPMECs were quantified. RBC adhesion tests were conducted with and without vWF protease ADAMTS13 and heme-binding protein hemopexin under shear stress at 1 dyne/cm2 followed by a rinse step and quantification of adhered RBCs. For in vivo study, HbSS-Townes mice and a dorsal skin-fold chamber model was used to determine if ADAMTS13 would reduce microvascular stasis in response to hemin. Results: Within 2 hours, SS REVs, but not AA REVs, promoted increased levels of vWF expression on HPMECs, indicating HPMEC activation (Fig. 1A-C). VWF is known to trigger SRBC adhesion and vaso-occlusion. Using SCD-EV-BioChip, we found significantly increased SS RBC adhesion to HPMECs exposed to SREVs, compared to SRBC adhesion to HPMECs exposed to AA REVs, and AA RBC adhesion to HPMECs exposed to SS REVs (Fig. 1D-G). SS RBC adhesion was significantly reduced on HPMECs treated with SS REVs pre-incubated with hemopexin. ADAMTS13 is a regulator which is responsible for cleaving ultra large vWF. In this study, SS RBC adhesion was significantly reduced by vWF cleaving protease ADAMTS13 to a level similar to HPMECs treated with AA REVs (Fig. 1G). Consistent with these observations, studies in SS mice with implanted dorsal skin-fold chambers found hemin-induced stasis was inhibited by ADAMTS13 (Fig. 1F). SRBC adhesion was variable within a total of 15 test subjects with SCD, and was higher with SRBCs from patients with increased markers of hemolysis (LDH and reticulocyte count) or a concomitant clinical diagnosis of deep vein thrombosis. Conclusions: This work demonstrated the acute, non-transcriptional contribution made by REVs to the microvascular EC activation and vWF-mediated SRBC adhesion. Results from SCD-EV-BioChip indicated the effect of hemopexin in mitigating SREV-mediated HPMEC activation. Additionally, results from in vitro SCD-EV BioChip tests agreed with in vivo stasis tests using SS mice, both of which indicated the effect of ADAMTS13 in mitigating SS RBC adhesion and vaso-occlusion. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Ex Vivo Activation of Red Blood Cell Senescence by Plasma from Sickle-Cell Disease Patients: Correlation between Markers and Adhesion Consequences during Acute Disease Events.

BACKGROUND: Blood transfusion remains a key treatment for managing occlusive episodes and painful crises in sickle-cell disease (SCD). In that clinical context, red blood cells (RBCs) from donors and transfused to patients, may be affected by plasma components in the recipients’ blood. Senescence lesion markers appear on the red cells after transfusion, shortening the RBC lifespan in circulation. In the specific context of SCD, senescence signals can also trigger the occlusive painful events, typical of the disease. This work follows through our previous data that described a RBC senescence process, rapidly detected after challenge with SCD pathological plasmas. In this clinical context, we wanted here to further explore the characteristics and physiologic consequences of AA RBC lesions associated with senescence, as lesions caused by RBCs after transfusion may have adverse consequences for SCD patients. METHODS: Plasma samples from SCD patients, with acute symptoms (n = 20) or steady-state disease (n = 34) were co-incubated with donor AA RBCs from blood units for 24 to 48 h. Specific markers signing RBC senescence were quantified after the incubation with SCD plasma samples. The physiologic in-flow adhesion was investigated on senescent RBCs, an in vitro technic into biochips that mimic adherence of RBCs during the occlusive events of SCD. RESULTS: Senescence markers on AA RBCs, together with their in-flow adhesion to the plasma-bridging protein thrombospondin, were associated with the clinical status of the SCD patients from whom plasma was obtained. In these experiments, the highest values were obtained for SCD acute plasma samples. Adhesion of senescent RBCs into biochips, which is not reversed by a pre-treatment with recombinant Annexin V, can be reproduced with the use of chemical agents acting on RBC membrane channels that regulate either Ca2+ entry or modulating RBC hydration. CONCLUSION: We found that markers on red cells are correlated, and that the senescence induced by SCD plasma provokes the adhesion of RBCs to the vessel wall protein thrombospondin. In-flow adhesion of senescent red cells after plasma co-incubations can be reproduced with the use of modulators of RBC membrane channels; activating the Piezo1 Ca2+ mechanosensitive channel provokes RBC adhesion of normal (non-senescent) RBCs, while blocking the Ca2+-dependent K+ Gardos channel, can reverse it. Clinically modulating the RBC adhesion to vascular wall proteins might be a promising avenue for the treatment of painful occlusive events in SCD.

Breast milk and erythrocyte fatty acid composition of lactating women residing in a peri‑urban South African township

Data on breast milk fatty acid (FA) composition in South African lactating women in relation to their FA status, as well as on potential compositional changes within feed, are limited.The aim of this study was to assess the FA composition of breast milk sampled at three time points within feed, and to determine associations with red blood cell (RBC) total phospholipid FA levels in lactating South African mothers of 2–4-month-old breastfed infants.FA composition (% total FAs) was analyzed in RBC total phospholipids, and in fore-, mid-feed and hind-milk samples of lactating mothers (n = 100) of Black African descent living in a peri‑urban township.The mean age of the lactating women was 27.8 ± 6.8 years. Geometric mean (95% CI) breast milk SFA, MUFA and PUFA contents were 37.7 (37.3,38.1), 28.5 (27.9, 28.8), and 23.5 (23.2, 24.5)%, respectively. Breast milk DHA and AA contents were 0.25 (0.24, 3.71) and 0.81 (0.79, 0.83)%, respectively, in fore-, mid- and hind-milk combined. Maternal RBC EPA, DHA and AA levels were 0.37 (0.34, 0.40), 3.8 (3.6, 4.0) and 15.4 (14.8, 16.1)%, respectively. Women who reported to consume fish often (n = 3) had significantly higher RBC EPA levels than women who consumed fish sometimes (n = 56), never (n = 14) or rarely (n = 19). Breast milk DHA positively correlated with maternal RBC DHA, while no correlations were found between breast milk AA and maternal RBC AA. Breast milk ALA and DHA contents were significantly higher in mid-feed [ALA= 0.8 (0.2, 0.2), DHA=0.3 (0.2, 0.3)] and hind-milk [ALA=0.8 (0.8, 0.9), DHA=0.3 (0.3, 0.3)] than foremilk [ALA=0.8 (0.7, 0.9), DHA=0.2 (0.2, 0.3)]. In contrast, LA and AA contents remained constant within feed.In this sample of peri‑urban South African lactating mothers, breast milk was low in DHA and high in AA compared to global means. Breast milk DHA was associated with maternal RBC status, while breast milk AA was not. We further showed that breast milk ALA and DHA increased, while LA and AA remained unchanged within feed. This suggests that n-3 PUFA maybe preferentially transferred to breast milk within feed through biomagnification.

Multi-Modal Mechanisms and Anti-Sickling of Novel Sulfated Non-Anticoagulant Low Molecular Weight Heparin in Sickle Cell Disease

The pathogenesis of Sickle Cell Disease (SCD) comprises a complex interplay of factors associated with vascular endothelial activation, intense inflammation, and increased sickle cell adhesion. Microvascular occlusion in SCD is initiated by adhesion of sickle red blood cells (RBCs) to the endothelium, leading to acute painful vasoocclusive crisis (VOC) and clinical morbidity. Current treatment strategies remain sub-optimal and are limited by significant side effects. The inherent complexity of SCD makes it unlikely that a single therapeutic strategy will be universally beneficial. We have previously shown that the low molecular weight heparin (LMWH) tinzaparin significantly shortened both duration of VOC crisis and hospitalizations by ~40%, and resulted in statistically significant and rapid reduction of pain). However, safety concerns associated with the narrow therapeutic index (bleeding risks) of LMWH are a major barrier to dose escalation/optimization of treatments.We have developed a novel sulfated non-anticoagulant LMWH, named S-NACH, with an extensive range of bioactivities that would constitute a multi-modal approach to management of SCD. We generated and significantly optimized S-NACH for VOC to: 1) exert its beneficial activities without causing hemostatic (bleeding) side effects that are associated with the clinical use of LMWHs; and 2) incorporate an additional, potent direct anti-sickling property besides its anti-selectin and anti-inflammatory activities.We conducted in vitro and in vivo investigations on the efficacy of S-NACH on the biophysical properties of RBCs. For the in vitro study, 21 subjects comprising 12 SCD patients with hemoglobin (Hb) SS on hydroxurea and 9 normal subjects with Hb AA of both sexes and of different ages were randomly recruited. To assess the effects of S-NACH on the sickling, the SS blood samples were incubated under hypoxia (2% O2 gas, balance N2 gas) at 37°C for 1.5 h, in the absence (control) or presence of 1, 5, or 10 ug/mL of S-NACH or LMWH. For the in vivo study, we obtained pre-treatment samples from Townes' SCD mice (n=6 mice/treatment group) and treated the mice subcutaneously with PBS or 30-100 mg/kg S-NACH. Two hours after treatment, blood samples were evaluated for the percentage of sickled cells in pre- and post-administration samples using Leishman's stain and wet smears.Incubation with S-NACH in vitro under hypoxia showed a dose-dependent, significant inhibition of sickling (up to 80%) in samples from all subjects while LMWH showed no anti-sickling effect. S-NACH had no effect on the osmotic fragility of both AA and SS RBCs. Importantly, we observed a 40-50% decrease in levels of circulating sickled cells in treated SCD mice, an effect that persisted for up to 6 h. Our in vitro studies show that the direct anti-sickling effect is partly due to dose-dependent modification of Hb S to the high-affinity adduct form and the corresponding increase in oxygen affinity, as demonstrated with cation HPLC and oxygen equilibrium analyses. Summarily, our previous findings showed the efficacy of S-NACH as anti-adhesive and anti-inflammatory in SCD, and our current results demonstrate the direct anti-polymerization action of S-NACH on sickle RBCs. Our data document for the first time the supplemental direct anti-sickling effects of a novel S-NACH derivative, suggesting a rational mode of action for these effects and make a compelling case for future studies. Planned detailed structural studies of our S-NACH derivatives complexed with Hb are expected to further illuminate the anti-sickling properties. Our novel Nanoformulated S-NACH for subcutaneous and oral administration would facilitate broader investigation of this promising molecule with multiple modes of action in animal models, with relatively quick translation to successful studies in individuals with SCD. DisclosuresMousa:Vascular Vision Pharmaceuticals Co.: Patents & Royalties: Patent Holder.

Shear-Mediated Erythrocyte Nitric Oxide Production Is Differentially Regulated in Patients with Sickle Cell Disease

Introduction: Sickle cell disease (SCD) is an inherited hemoglobinopathy in which hemoglobin polymerizes when deoxygenated, causing increased red blood cell (RBC) stiffness and RBC sickling. This leads to microcirculatory slowing and occlusion, in turn causing vaso-occlusive crises acutely and microcirculatory damage chronically. RBC are known to signal blood vessels in the microcirculation, regulating vessel tone. Nitric oxide (NO) is a potent vasodilator and key regulator of vascular smooth muscle tone throughout the vasculature. However, the possibility that RBC make NO and that this might contribute to vascular tone, particularly in arterioles is controversial. Modulation of RBC NO production due to deformation of RBC by shear stress could have important physiological consequences in SCD where RBC deformability is decreased and dependent on the polymerization state of hemoglobin S.Objective: To determine if shear stress induced deformation induces change in NO production in individual RBC and if the magnitude and time course of this NO differs between RBC from patients with sickle cell disease and normal controls.Methods: NO production was measured using imaging microscopy of fluorescently labeled RBC exposed to shear after being allowed to adhere to a flow chamber attached to the microscope stage. Four SCD patients on simple chronic transfusion therapy, 4 SCD patients not on chronic transfusion therapy and 4 healthy control subjects were recruited from the hematology clinics at Children's Hospital Los Angeles under an IRB approved protocol. RBC underwent histopaque separation then washed 3x and resuspended in KRP buffer. The RBC were then incubated with 4 micromolar DAF-FM Diacetate (4-Amino-5-Methylamino-2',7'-Difluorofluorescein Diacetate, ThermoFisher Scientific), a fluorescent indicator related to NO production. RBC were then exposed to three experimental conditions: 1. buffer alone; 2. 1 milimolar arginine (substrate for NOS NO production); 3. 1 milimolar arginine and 1 milimolar L-NAME (a non-specific NOS inhibitor). The RBC were placed in poly L-lysine coated microfluidic chambers and placed under no shear conditions for 30 minutesk, then sheared at 0.5Pa for 30minutes. Individual cell analysis was performed using Image J analysis software (FIJI).Results: There is a slow baseline rise of NO fluorescent signal without exposure to shear and there is a large, acute increase in NO fluorescent signal with exposure to shear stress. (figure 1) The baseline fluorescent rate of rise is increased in non-transfused sickle cell subjects (p<0.0001) compared to transfused SCD patients and healthy control subjects, suggesting higher basal rate of NO production. (figure 2) We found a significant increase in fluorescence in response to shear in all three groups, with the transfused SCD patients showing a higher rate of change and higher magnitude fluorescence response. (figure 1) Addition of arginine increased the shear induced NO production in all three groups (P<0.05). The baseline NO related fluorescence was blunted with the addition of L-NAME in healthy subjects, whereas it was unchanged in both the transfused and non-transfused SCD groups. There was no significant change in shear-mediated NO related DAF fluorescence after L-NAME was added.Discussion: The results here indicate that RBC produce NO upon shear and the basal rate of NO production is higher in non-transfused patients with sickle cell disease. Addition of arginine increases both the magnitude and rate of NO production in all three groups. SCD patients on chronic transfusion therapy demonstrate a larger increase in NO response to shear. The increased response of NO related fluorescence with the addition of arginine suggests NOS has a role in shear mediated RBC NO production; however, L-NAME blockade does not significantly blunt the response in the presence of arginine. Shear induced RBC NO production may play an important role in regulation of microvascular profusion and would likely be modulated by the RBC deformability differences due to HbS polymerization.Conclusion: There is basal and shear dependent NO production in both AA and SCD RBC, and RBC NOS is differentially regulated in SCD and AA RBC. [Display omitted] [Display omitted] DisclosuresWood:Ionis Pharmaceuticals: Consultancy; Ionis Pharmaceuticals: Consultancy; Vifor: Consultancy; Vifor: Consultancy; World Care Clinical: Consultancy; World Care Clinical: Consultancy; Celgene: Consultancy; Celgene: Consultancy; AMAG: Consultancy; AMAG: Consultancy; Apopharma: Consultancy; Apopharma: Consultancy; Biomed Informatics: Consultancy; Biomed Informatics: Consultancy.

Alteration of the Structure and Dynamics of Venous Clot Formation in Human and Murine Sickle Cell Disease

Sickle cell disease (SCD) is associated with chronic activation of coagulation and an increased risk of venous thromboembolism. Traditionally, it is believed that during venous thrombosis, red blood cells (RBC) are simply trapped within fibrin-rich thrombi and do not actively affect thrombosis. However, a study from our group showed that factor XIII (FXIII) activity is critical for the retention of RBC within clots and directly affects thrombus size. Others reported that during clot contraction polyhedral shaped RBC formed a densely packed core and that SCD alters the formation of polyhedrocytes which may affect clot stability (Strauss et al, 2015, ASH abstract).We further investigated if SCD affects the structure and the dynamics of clot formation. Ex vivo clot retraction was performed using blood from sickle cell patients and Townes mice (a model of SCD). Citrated blood was added to siliconized wells of 96-well plates containing CaCl2 (10mM) and tissue factor (1pM) and incubated for 2 hours at 37°C. The number of RBC extruded from the clot was counted in serum by Hemavet™ and expressed as a percentage of initial RBC number in the anticoagulated blood. Morphology of the clots was evaluated using scanning and transmission electron microscopy (EM). Thrombosis in Townes SS (sickle) and AA (control) mice was studied using femoral vein thrombosis induced by electrolytic injury and inferior vena cava stenosis models.The number of mouse SS RBC in the serum extruded during clot contraction was dramatically reduced compared to the number of AA RBC (0.8±0.8% vs. 19.4±0.8%, n=3, p<0.0001, Fig. A). A similar result was observed for human RBC. Since SS mice and sickle patients have a lower hematocrit (HCT), we investigated if the number of RBC affects the extrusion of these cells during clot retraction. Indeed, lowering HCT in AA mouse blood reduced RBC extrusion from the clots. However, increasing HCT in SS mouse blood to that of AA blood did not increase the number of SS RBC extruded from the clot. Furthermore, inhibition of FXIIIa activity with T101 (10µM) increased the release of AA (by 64%, n=6, p<0.05) but not SS RBC from mouse clots. These data indicate that the entrapment of SS RBCs within the clot is not simply caused by lower RBC number, and is FXIII-independent. Mixing the platelet poor plasma (PPP) and cellular fraction of AA and SS mouse blood revealed that the entrapment of SS RBC is not mediated by PPP (AA blood recombined = 6.9±3.6%; SS blood recombined = 0.4±0.4%; AA cells/SS PPP = 6.7±6.4%; SS cells/AA PPP = 0.1±0.2%, n=3 per group).Clots formed ex vivo from AA blood had a gel-like, soft structure, whereas SS clots were more firm and stiff. EM demonstrated that RBC within AA clots had polyhedral shapes and were tightly packed in the central part of the clot. In contrast, most of the mouse SS RBC did not have polyhedral shapes, underwent sickling and were not compacted within the clot. They also formed long "spicule-like" processes that intertwined with fibrin fibers (Fig. C). Similar results were observed in blood of sickle patients; however, the sickled RBC phenotype was less prominent. Importantly, sickling of RBC was observed in clots formed in the inferior vena cava of SS mice, 2 hours after vessel stenosis (Fig. D). We also performed a tPA challenge assay on clots formed ex vivo from human blood and showed that SS clots challenged with low tPA concentration (0.6nM) were more resistant to fibrinolysis compared to AA clots (clot lysis time, 714±6 vs. 388.3±120.7 minutes, n=6, p=0.08).The electrolytic injury model of venous thrombosis was used to investigate the dynamics of clot formation in SS mice in vivo. Mice were infused with fluorescently labeled antibodies for fibrin (green) and platelets (red). Electrolytic injury was applied to the femoral vein; a relative intensity of fibrin and platelet accumulation was assessed by fluorescence microscopy for one hour at 10-minute intervals. SS mice have increased platelet and fibrin accumulation compared to AA mice (~ 2 fold, n=5-7, p<0.05 for 40, 50 and 60 minute time points). Interestingly, in the AA clots, platelets were mostly localized on the surface, in contrast to their widespread distribution throughout the clot in SS mice (Fig. E, yellow color).Our data demonstrated that SCD alters the structure and dynamics of venous clot formation. Experiments investigating the consequence of these observations in mouse models of stroke and pulmonary embolism are currently ongoing. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Effect of inositol hexaphosphate–loaded red blood cells (RBCs) on the rheology of sickle RBCs

The recent in vitro demonstration that inositol hexaphosphate-loaded red blood cells (IHP-RBCs) may reduce the risks of sickling of sickle RBCs (SS RBCs) exposed to hypoxia make these modified RBCs potentially useful in transfused sickle cell anemia (SCA) patients. Hemorheologic properties of IHP-RBCs, normal RBCs (AA RBCs), SS RBCs, SS RBCs plus AA RBCs, and SS RBCs plus IHP-RBCs were compared under normoxia and/or after hypoxic challenges. Although IHP-RBCs have reduced deformability compared with SS RBCs or AA RBCs, IHP-RBCs exhibited lower aggregability than AA RBCs and SS RBCs and, when mixed with SS RBCs, the aggregation level was below the one of SS RBCs alone or SS RBCs plus AA RBCs. Blood viscosity of SS RBC plus IHP-RBC suspension was lower than the viscosity of SS RBCs alone and greater than viscosity of SS RBCs plus AA RBCs. The hypoxic challenge was detrimental for deformability and viscosity of SS RBCs alone or SS plus AA RBC suspension but not for SS plus IHP-RBC suspension. Our results support the fact that IHP-RBCs could be useful in SCA by decreasing RBC aggregation and blunting the adverse effects of hypoxia on RBC deformability and blood viscosity.

Sickle Red Blood Cell Induced Adhesion of Neutrophils to Endothelial Cells and Biologic Correlates of Leukocyte Activation

Abstract 1055 In sickle cell disease (SCD), any event that slows the passage of red blood cells (RBCs) in the microcirculation can promote hemoglobin polymerization, red cell sickling, and vaso-occlusion. Homozygous (SS) RBCs have a sticky surface and, compared to normal (AA) RBCs, attach readily to both endothelial cells and other blood cells. Furthermore, the adhesive function of SS RBCs is up-regulated by the stress hormone epinephrine, resulting in significant vaso-occlusion and increased mononuclear leukocyte adhesion to the vascular endothelium in a mouse model. We therefore postulated that direct interaction between SS RBCs and neutrophils may also lead to activation and adhesion of neutrophils to endothelial cells. In order to explore whether SS RBCs can induce adhesion of neutrophils to endothelial cells independent of exogenous cytokine stimulation, neutrophils were isolated from healthy donors using density gradient media and then labeled with fluorescent dye. Fluorescent neutrophils were then co-incubated with epinephrine-treated SS or sham-treated (untreated) SS, AA or no added RBCs (control) at 37°C. Graduated height flow chambers were used to quantify adhesion of neutrophils to human umbilical vein endothelial cells (HUVECs) grown on glass slides coated with gelatin. We then also examined markers of hematologic status and endothelial activation to determine if any of these were correlated with the ability of SS RBCs to induce neutrophil adhesion. Enzyme linked immunosorbent assays (ELISAs) were used to quantify inflammatory markers (IL-1B, IL-6, IL-8), soluble L selectin (sL-SEL) and soluble P selectin (sP-SEL) in the plasma of the SS patient samples used in adhesion assays. We found that neither sham-treated nor epi-treated AA RBCs (n=3) significantly increased neutrophil adhesion to HUVECs, while both sham-treated and epinephrine-stimulated (epi) SS RBCs significantly increased neutrophil adhesion to endothelial cells (n=17, 42.0% adhesion for epi-SS RBCs vs 20.0% for no RBCs and 27.2% for untreated SS RBCs, with p values as shown in Figure 1). ELISA immunoassays confirmed elevated levels of sP-SEL and sL-SEL in SS patients, and levels of sL-SEL correlated with total leukocyte count (p=0.005). However, neither these biomarkers nor leukocyte count correlated with the ability of patient RBCs to stimulate normal leukocyte adhesion. Levels of IL-1B, IL-6 and IL-8 also did not correlate with the ability of patients' RBCs to stimulate neutrophil adhesion. However, we also found that HbF levels correlated inversely with sL-SEL levels (P=0.014), suggesting that HbF not only helps prevent RBC sickling but also reduces leukocyte activation. Other hematologic markers (Hb level, platelet count, reticulocyte count, LDH) also did not correlate with the ability of epi-SS RBCs to induce neutrophil adhesion. Therefore, we conclude that SS RBCs are able to stimulate neutrophil adhesion, especially under conditions that activate the adhesion receptors responsible for RBC-neutrophil interaction. In addition, we found that sL-SEL was increased in the presence of higher WBC counts, while it was inversely related to HbF levels. Taken together, these data suggest that the effect of HbF on SS RBCs reduces leukocyte activation, and this may occur in part through reduction of SS RBC-leukocyte interaction. Disclosures: No relevant conflicts of interest to declare.

Volume regulation and KCl cotransport in reticulocyte populations of sickle and normal red blood cells

The potassium chloride co-transporter (KCC) is a member of the electroneutral cation chloride family of cotransporters found in multiple tissues that are involved in transepithelial ion transport and regulation of intracellular ion content and cell volume. We have shown previously that three of the four KCC genes – KCC1, KCC3, and KCC4 – are expressed in red blood cells (RBC) (Exp. Hem. 33:624, 2005). Functionally, the KCC mediates volume reduction of reticulocytes that establishes the higher cellular hemoglobin concentration (CHC) of mature RBC. KCC activity is higher in reticulocytes and diminishes with age. KCC activity in RBC containing sickle hemoglobin (SS RBC) is elevated compared to normal (AA RBC) in part due to reticulocytosis in SS blood. However, we have demonstrated that SS reticulocytes have abnormal regulation of KCC activity leading to increased CHC upon activation of KCC compared to AA reticulocytes (Blood 104:2954, 2004; Blood 109:1734, 2007). These findings implicate KCC as a factor in the dehydration of SS RBC, which leads to elevated Hb S concentration and enhances Hb S polymerization and hemolysis. Because KCC activity correlates with cell age, standard flux measurements on blood samples with different numbers of reticulocytes or young non-reticulocytes are not comparable. The Advia automated cell counter measures cell volume (MCV) and cellular hemoglobin concentration (CHC) in reticulocytes, an age-defined population of cells, and thus circumvents the problem of variable reticulocyte counts among SS and AA blood samples. In this study, reticulocyte CHC measurements on fresh blood demonstrated a clear difference between AA and SS cells, reflecting in vivo dehydration of SS reticulocytes, although there was significant inter-individual variation, and the CHC distributions of the two groups overlapped. After KCC activation in vitro by cell swelling using the nystatin method, the initial changes in reticulocyte MCV and CHC with time were used to estimate flux rates mediated by KCC, assuming that changes were associated with isotonic KCl movements. After 20–30 min a final steady state MCV/CHC (set point) was achieved and maintained, reflecting inactivation of the transporter. CHC set points were 26.5–29 g/dl in SS reticulocytes compared to 25–26.5 g/dl in AA reticulocytes, reflecting abnormal regulation in SS cells. These results were reproducible in the same individual over time. KCC flux derived from CHC ranged from 5 to 10.3 mmolK/kgHb/min in SS reticulocytes, compared to 2.9–7.2 mmolK/kgHb/min in AA reticulocytes. Such measures of KCC activity in red cell populations controlled for cell age will facilitate further studies correlating KCC activity with phenotypic or genetic variability in sickle cell disease.

Rheologic behavior of sickle and normal red blood cell mixtures in sickle plasma: implications for transfusion therapy

Guidelines for transfusion in sickle cell disease usually define an upper hematocrit (Hct) limit of 0.30 to 0.35 to avoid blood hyperviscosity. In vitro viscosity studies of normal (AA) and sickle (SS) red blood cell (RBC) mixtures in buffer appear to confirm that this Hct limit is optimal for oxygen delivery to vascular beds as judged by the ratio of Hct to viscosity, with this ratio often termed "oxygen or RBC transport effectiveness." In the absence of plasma, however, effects due to RBC-RBC interactions mediated by plasma proteins cannot be assessed. To investigate the optimal Hct-to-viscosity ratio of RBCs in plasma, the rheologic effects of Hct (0.20-0.40), the proportion of SS RBCs (0-100%), and shear rate (1-1000/sec) for mixtures of oxygenated and deoxygenated SS and AA RBCs were evaluated in sickle plasma at 37 degrees C. RBC suspension viscosity was shear-dependent (i.e., viscosity decreased with increasing shear rate) and increased with Hct and proportion of SS RBCs. An "optimal" Hct level (defined as a maximal of the Hct-to-viscosity ratio) was seen only at shear rates above 50/sec. At lower shear rates (e.g., 5/sec), where plasma-mediated RBC-RBC interactions predominate, any increment in Hct was offset by a proportionally greater increase in viscosity, thus leading to a lower Hct-to-viscosity ratio. These results indicate the importance of plasma-mediated RBC interactions and suggest that the benefits of transfusion may vary depending on local flow rates (i.e., shear rates) and organ-specific hemodynamics.

Adhesive Characteristics of Hemoglobin SC Red Blood Cells.

Hemoglobin (Hb)-S containing red blood cells (RBCs) adhere abnormally to the vascular wall; this phenomenon is postulated to contribute to vaso-occlusive crisis and serious tissue damage. Patients homozygous for Hb S experience the most severe form of SCD, whereas heterozygous patients carrying Hb S and another hemoglobin variant, Hb C, experience somewhat milder clinical courses. Laminin is the extracellular matrix protein to which SS RBCs bind most avidly and is the ligand for the BCAM/Lu receptor. αvβ3 integrin is one of the major integrins on endothelial cells (ECs) and is the counter-receptor for LW on SS RBCs. Epinephrine activates both LW and BCAM/Lu on SS RBCs and thereby induces increased SS RBC adhesion to both ECs and laminin via a cAMP-dependent pathway. We have now compared the adhesive properties of Hb SC RBCs to SS RBCs. We measured the expression of RBC adhesion receptors, BCAM/Lu and LW, and assayed adhesion of SC RBCs to laminin and ECs (with and without prior stimulation of RBCs by epinephrine). Blood samples from Hb SC and SS patients in steady state and from normal controls (Hb AA) were collected into citrate tubes and were washed to remove plasma and buffy coat before use. The levels of BCAM/Lu and LW expression on RBCs were measured by flow cytometry using monoclonal antibodies to BCAM/Lu and anti-LW. SC RBCs expressed higher levels of BCAM/Lu (MFI 476.2, n=13) than did SS RBCs (MFI 332.3, n=33) and AA RBCs (MFI=225.5, n=16), but none of these differences were statistically significant (all p values >0.05). The levels of LW expression were also similar on AA, SC, and SS RBCs. Adhesion to laminin and ECs was measured as previously described, in a graduated height flow chamber. Non-treated, sham-treated, and epinephrine-treated RBCs were each infused into a flow chamber fitted with a slide coated with laminin or ECs. After washing at a constant rate, adherent RBCs were quantitated at points of different shear stresses. Adhesion of SC RBCs to laminin (mean of 53.1 cells/mm2 at 1 dyne/cm2, n=9) was lower than that of SS RBCs (mean of 69.0 cells/mm2 at 1 dyne/cm2, n=6, p=0.459) but was markedly higher than the adhesion seen with AA RBCs (mean of 0.03 cells/mm2 at 1 dyne/cm2, n=3, SC vs AA p=0.011). A positive correlation was found between BCAM/Lu expression and SC RBC adhesion to laminin (r=0.638, p=0.047). While epinephrine induced an increase in SC RBC adhesion to laminin in only 10% of all SC patient samples tested (compared to 50% of SS patients), epinephrine upregulated SC RBC adhesion to ECs approximately 10-fold in all samples tested (n=3). We conclude that SC RBCs represent an intermediate adhesive phenotype compared to AA and SS RBCs. While BCAM/Lu-mediated adhesion to laminin was lower on SC RBCs than on SS RBCs, unstimulated BCAM/Lu adhesive function was strikingly enhanced in relation to AA RBCs. Most importantly, epinephrine uniformly increased SC RBC adhesion to ECs, suggesting that in Hb SC disease, physiological stress may induce SC RBC adhesion and vaso-occlusive crises by mechanisms similar to those postulated to occur as a result of stress in Hb SS disease.

Distribution of dehydration rates generated by maximal Gardos-channel activation in normal and sickle red blood cells

AbstractThe Ca2+-activated K+ channels of human red blood cells (RBCs) (Gardos channels, hIK1, hSK4) can mediate rapid cell dehydration, of particular relevance to the pathophysiology of sickle cell disease. Previous investigations gave widely discrepant estimates of the number of Gardos channels per RBC, from as few as 1 to 3 to as many as 300, with large cell-to-cell differences, suggesting that RBCs could differ extensively in their susceptibility to dehydration by elevated Ca2+. Here we investigated the distribution of dehydration rates induced by maximal and uniform Ca2+ loads in normal (AA) and sickle (SS) RBCs by measuring the time-dependent changes in osmotic fragility and RBC volume distributions. We found a remarkable conservation of osmotic lysis and volume distribution profiles during Ca2+-induced dehydration, indicating overall uniformity of dehydration rates among AA and SS RBCs. In light of these results, alternative interpretations were suggested for the previously proposed low estimates and heterogeneity of channel numbers per cell. The results support the view that stochastic Ca2+ permeabilization rather than Gardos-channel variation is the main determinant selecting which SS cells dehydrate through Gardos channels in each sickling episode. (Blood. 2005;105:361-367)

Novel epinephrine and cyclic AMP-mediated activation of BCAM/Lu-dependent sickle (SS) RBC adhesion

AbstractThe vasoocclusive crisis is the major clinical feature of sickle cell anemia, which is believed to be initiated or sustained by sickle (SS) red blood cell (RBC) adhesion to the vascular wall. SS RBCs, but not unaffected (AA) RBCs, adhere avidly to multiple components of the vascular wall, including laminin. Here we report a novel role for epinephrine and cyclic adenosine monophosphate (cAMP) in the regulation of human SS RBC adhesiveness via the laminin receptor, basal cell adhesion molecule/Lutheran (BCAM/Lu). Our data demonstrate that peripheral SS RBCs contain greater than 4-fold more cAMP than AA RBCs under basal conditions. Forskolin or the stress mediator epinephrine further elevates cAMP in SS RBCs and increases adhesion of SS RBCs to laminin in a protein kinase A (PKA)–dependent manner, with the low-density population being the most responsive. Epinephrine-stimulated adhesion to laminin, mediated primarily via the β2-adrenergic receptor, occurred in SS RBC samples from 46% of patients and was blocked by recombinant, soluble BCAM/Lu, implicating this receptor as a target of cAMP signaling. Thus, these studies demonstrate a novel, rapid regulation of SS RBC adhesion by a cAMP-dependent pathway and suggest that components of this pathway, particularly PKA, the β2-adrenergic receptor, and BCAM/Lu, should be further explored as potential therapeutic targets to inhibit SS RBC adhesion.

Integrin-associated protein is an adhesion receptor on sickle red blood cells for immobilized thrombospondin

AbstractThe adhesive protein thrombospondin (TSP) potentially mediates sickle (SS) red blood cell (RBC) adhesion to the blood vessel wall, thereby contributing to vaso-occlusive crises in sickle cell disease. We previously reported that SS RBCs bind to immobilized TSP under flow conditions, whereas normal (AA) red cells do not. However, the SS RBC receptors that mediate this interaction are largely unknown. Here it is reported that integrin-associated protein (IAP), or CD47, mediates the adhesion of these cells to immobilized TSP under both flow and static conditions. A peptide derived from the C-terminal IAP binding site of TSP also supports sickle cell adhesion; adhesion to this peptide or to TSP is inhibited specifically by the anti-IAP monoclonal antibody, 1F7. Furthermore, these data suggest that IAP on SS RBCs is structurally different from that expressed on AA RBCs but that IAP expression levels do not vary between AA and SS RBCs. This structural difference may contribute to the enhanced adhesion of SS RBCs to immobilized TSP. These results identify IAP as a TSP receptor on SS RBCs and suggest that this receptor and its binding site within TSP represent potential therapeutic targets to decrease vaso-occlusion.

Molecular cloning and expression of a chloride channel-associated protein pICln in human young red blood cells: association with actin.

We report the cloning and sequencing from human reticulocytes of cDNA coding for the Cl- channel-associated protein, pICln. Human reticulocyte pICln (HRpICln) cDNA encodes a protein (predicted molecular mass 26293Da) identical with human non-pigmented ciliary epithelial cell pICln. By using full-length HRpICln cDNA (approx. 1.2 kb) to probe human lymphocyte metaphase-chromosome spreads, the location of the human ICln gene was mapped to 11q13 by fluorescence in situ hybridization analysis. Polyclonal antibodies to recombinant HRpICln detected bands at approx. 43 kDa and approx. 37 kDa in both normal (AA) and sickle (SS) red blood cell (RBC) ghost membranes. In SS ghosts, and in ghosts from a patient with autoimmune haemolytic anaemia with 9.8% reticulocytes, the amount of HRpICln was increased compared with AA ghosts, suggesting that the expression or membrane assembly of HRpICln is cell age-dependent. Laser scanning confocal fluorescent microscopy immunolocalized HRpICln largely to the RBC membrane. The increased staining intensity of HRpICln in a reticulocyte-enriched AA RBC density-separated fraction is consistent with a dependence of HRpICln membrane content on cell age. HRpICln and beta-actin form stable complexes in vivo, demonstrated with the yeast two-hybrid system. Low-ionic-strength extraction of ghost membranes, which results in the extraction of the spectrin-actin cytoskeleton, also results in the extraction of HRpICln, consistent with the possibility for the association of these proteins in RBCs in vivo. The results presented here establish the presence of the Cl- channel-associated protein, pICln, in human RBCs, and raises the possibility that this protein has a role in RBC Cl- transport and volume regulation in young RBCs. Moreover the association of RBC pICln with actin offers a model in which to test interactions between RBC ion channels and the cytoskeleton.

The accumulation of malonyldialdehyde, an end product of membrane lipid peroxidation, can cause potassium leak in normal and sickle red blood cells

This study has examined the effect of malonyldialdehyde (MDA), an end product of lipid peroxidation, on the K + leak in normal (AA) and sickle (SS) red blood cells (RBCs). In vitro MDA accumulation in human RBCs was accomplished by treating them with exogenous standard MDA. MDA accumulation assessed by the thiobarbituric acid reactivity of in vitro MDA-treated RBCs was comparable to the RBCs in hemolytic anemias. There was a significant K + leak in AA RBCs after in vitro treatment with MDA. The effect of MDA on the K + leak was greater in SS RBCs. The increase in cellular K + leak was significantly positively correlated with the extent of MDA accumulation as assessed by thiobarbituric acid reactivity.