Reduced Red Blood Cell Deformability Research Articles

COVID-19 impairs oxygen delivery by altering red blood cell hematological, hemorheological, and oxygen transport properties.

Introduction: Coronavirus disease 2019 (COVID-19) is characterized by impaired oxygen (O2) homeostasis, including O2 sensing, uptake, transport/delivery, and consumption. Red blood cells (RBCs) are central to maintaining O2 homeostasis and undergo direct exposure to coronavirus in vivo. We thus hypothesized that COVID-19 alters RBC properties relevant to O2 homeostasis, including the hematological profile, Hb O2 transport characteristics, rheology, and the hypoxic vasodilatory (HVD) reflex. Methods: RBCs from 18 hospitalized COVID-19 subjects and 20 healthy controls were analyzed as follows: (i) clinical hematological parameters (complete blood count; hematology analyzer); (ii) O2 dissociation curves (p50, Hill number, and Bohr plot; Hemox-Analyzer); (iii) rheological properties (osmotic fragility, deformability, and aggregation; laser-assisted optical rotational cell analyzer (LORRCA) ektacytometry); and (iv) vasoactivity (the RBC HVD; vascular ring bioassay). Results: Compared to age- and gender-matched healthy controls, COVID-19 subjects demonstrated 1) significant hematological differences (increased WBC count-with a higher percentage of neutrophils); RBC distribution width (RDW); and reduced hematocrit (HCT), Hb concentration, mean corpuscular volume (MCV), and mean corpuscular hemoglobin concentration (MCHC); 2) impaired O2-carrying capacity and O2 capacitance (resulting from anemia) without difference in p50 or Hb-O2 cooperativity; 3) compromised regulation of RBC volume (altered osmotic fragility); 4) reduced RBC deformability; 5) accelerated RBC aggregation kinetics; and (6) no change in the RBC HVD reflex. Discussion: When considered collectively, homeostatic compensation for these RBC impairments requires that the cardiac output in the COVID cohort would need to increase by ∼135% to maintain O2 delivery similar to that in the control cohort. Additionally, the COVID-19 disease RBC properties were found to be exaggerated in blood-type O hospitalized COVID-19 subjects compared to blood-type A. These data indicate that altered RBC features in hospitalized COVID-19 subjects burden the cardiovascular system to maintain O2 delivery homeostasis, which appears exaggerated by blood type (more pronounced with blood-type O) and likely plays a role in disease pathogenesis.

Evaluation of the Impact of a Naturally Occurring Beta Hemoglobin Variant, Hb G-Makassar, on Mature Red Blood Cell Function and Pathology in a Sickle Cell Disease Mouse Model

Background: Gene based therapy may provide a cure for individuals with sickle cell disease (SCD); base editing is a novel strategy with the ability to directly edit the mutation responsible for disease. The sickle hemoglobin (HbS) point mutation cannot be converted to wild-type HBB by an adenine base editor, however it can be converted to a naturally occurring hemoglobin variant, HbG-Makassar (HbG). HbG is a non-pathogenic, non-sickling hemoglobin variant. In vitro crystal structure analysis of HbG shows that it is highly similar to that of wildtype hemoglobin (HbA). However, few HbGG individuals (with no overt red cell disease) and no HbSG individuals have been identified; thus, the red blood cells (RBCs) of HbGG and HbSG individuals have not been evaluated functionally. The Makassar base editing strategy produces greater than 80% homozygous Hb-G product and has been evaluated in vitro, however erythroid culture of edited hematopoietic stem cells do not produce fully mature, enucleated red cells. Therefore, mouse models of HbGG and HbSG could be used to evaluate the function of mature, enucleated HbGG or HbSG RBCs. Methods: A humanized beta globin locus mouse (Townes) with the Makassar allele was created at by knocking-in the Makassar point mutation to generated WT/Makassar heterozygotes (HbAG) which were backcrossed to generated HbGG homozygotes. HbSG genotypes were subsequently generated by crossing to HbSS Townes mice. We analyzed the red cell function of HbAA, HbAS, HbSS, HbGG, and HbSG mice. Whole blood was collected through terminal enucleation. Complete blood counts were measured on a hematology analyzer (Heska and, ADVIA). Red cell deformability (elongation index, EI) was measured using oxygen gradient ektacytometry (LoRRCA) under normoxic (EImax) and hypoxic (EImin) conditions. Viscosity measurements were obtained on a Beckman cone and plate viscometer. Percent sickle cells were quantified through chemically induced sickling with sodium metabisulfite and counted by an individual blinded to genotype using light microscopy. Kidney, liver, and spleen were fixed, preserved in paraffin, stained using hematoxylin and eosin stains and imaged using a Keyence microscope. Flow cytometry was performed on bone marrow and whole blood to determine the erythroid maturation and mitochondrial retention of RBCs. Analysis was performed with Stata 18.0 (College Station) across genotypes using Dunn Pairwise test with statistically significant values being selected at adjusted p < 0.05. Results Homozygous HbG mice (HbGG) had comparable white blood cell count (WBC) and absolute reticulocyte count (ARC) to that of mice with homozygous HbA (HbAA). HbGG mice had lower hemoglobin and mean corpuscular volume (MCV) in comparison to mice with HbAA. HbGG mice had a higher percentage of dense RBCs than HbAA mice. HbSG mice had comparable values to HbAS mice for MCV but had significantly lower hemoglobin and ARC. HbSG mice had significantly higher values for WBC, and % dense RBCs against HbAS mice. HbSS and HbSG mice had comparable values for hemoglobin, and ARC. Hematocrit to viscosity ratio (HVR) shows comparable oxygen transport effectiveness of HbGG, HbSG, HbAS and HbSS RBC. Further red cell function testing is shown in Figure 1 and Figure 2. Mitochondrial retention was highest in HbSS mice, followed by HbSG, while HbAS, HbAA, and HbGG had similar values. Microscopy analysis of renal sections of HbGG and HbSG mice sacrificed at 24-28 weeks did not show the characteristic morphologic changes seen in HbSS mice at 24-28 weeks. Conclusions- HbGG appears functionally similar to HbAA, with minimal sickling under hypoxia, no anemia, normal spleen size, and no organ damage at 24 weeks of age. HbGG does exhibit signs of dehydration, as evidenced by elevated %DRBC and reduced RBC deformability. RBC function, sickling under hypoxia, Hb, WBC, ARC, and mitochondrial retention measures places HbSG as intermediate in severity between HbAS and HbSS. However, organ pathology, spleen and liver weights for HbSG were more comparable to HbAS than HbSS. Base editing strategies to install Makassar therefore can potentially lead to >90% of RBCs that have therapeutic benefit due to rheological properties comparable to HbAA and can be seen as a promising treatment strategy for patients with sickle cell disease.

Plasmodium knowlesi (Pk) Malaria: A Review & Proposal of Therapeutically Rational Exchange (T-REX) of Pk-Resistant Red Blood Cells.

Plasmodium knowlesi (Pk) causes zoonotic malaria and is known as the "fifth human malaria parasite". Pk malaria is an emerging threat because infections are increasing and can be fatal. While most infections are in Southeast Asia (SEA), especially Malaysia, travelers frequently visit this region and can present with Pk malaria around the world. So, clinicians need to know (1) patients who present with fever after recent travel to SEA might be infected with Pk and (2) Pk is often misdiagnosed as P. malariae (which typically causes less severe malaria). Here we review the history, pathophysiology, clinical features, diagnosis, and treatment of Pk malaria. Severe disease is most common in adults. Signs and symptoms can include fever, abdominal pain, jaundice, acute kidney injury, acute respiratory distress syndrome, hyponatremia, hyperparasitemia, and thrombocytopenia. Dengue is one of the diseases to be considered in the differential. Regarding pathophysiologic mechanisms, when Pk parasites invade mature red blood cells (RBCs, i.e., normocytes) and reticulocytes, changes in the red blood cell (RBC) surface can result in life-threatening cytoadherence, sequestration, and reduced RBC deformability. Since molecular mechanisms involving the erythrocytic stage are responsible for onset of severe disease and lethal outcomes, it is biologically plausible that manual exchange transfusion (ET) or automated RBC exchange (RBCX) could be highly beneficial by replacing "sticky" parasitized RBCs with uninfected, deformable, healthy donor RBCs. Here we suggest use of special Pk-resistant donor RBCs to optimize adjunctive manual ET/RBCX for malaria. "Therapeutically-rational exchange transfusion" (T-REX) is proposed in which Pk-resistant RBCs are transfused (instead of disease-promoting RBCs). Because expression of the Duffy antigen on the surface of human RBCs is essential for parasite invasion, T-REX of Duffy-negative RBCs-also known as Fy(a-b-) RBCs-could replace the majority of the patient's circulating normocytes with Pk invasion-resistant RBCs (in a single procedure lasting about 2 h). When sequestered or non-sequestered iRBCs rupture-in a 24 h Pk asexual life cycle-the released merozoites cannot invade Fy(a-b-) RBCs. When Fy(a-b-) RBC units are scarce (e.g., in Malaysia), clinicians can consider the risks and benefits of transfusing plausibly Pk-resistant RBCs, such as glucose-6-phosphate dehydrogenase deficient (G6PDd) RBCs and Southeast Asian ovalocytes (SAO). Patients typically require a very short recovery time (<1 h) after the procedure. Fy(a-b-) RBCs should have a normal lifespan, while SAO and G6PDd RBCs may have mildly reduced half-lives. Because SAO and G6PDd RBCs come from screened blood donors who are healthy and not anemic, these RBCs have a low-risk for hemolysis and do not need to be removed after the patient recovers from malaria. T-REX could be especially useful if (1) antimalarial medications are not readily available, (2) patients are likely to progress to severe disease, or (3) drug-resistant strains emerge. In conclusion, T-REX is a proposed optimization of manual ET/RBCX that has not yet been utilized but can be considered by physicians to treat Pk malaria patients.

PSUN168 The relationship between vitamin C concentrations and reduced red blood cell deformability in diabetes

Abstract Background Microvascular angiopathy is a common complication for patients with diabetes. Reduced red blood cell (RBC) deformability in diabetes has been associated with micro- and macrovascular complications such as diabetic nephropathy and coronary artery disease. Preliminary studies in mice have shown an inverse relationship between RBC vitamin C concentrations and RBC deformability measures. This study investigated the relationship between RBC vitamin C concentration and cell deformability measures. Methods We analyzed RBC deformability and vitamin C level in a cross-sectional cohort study of individuals with diabetes (n=82) and non-diabetic controls (n=80). Subjects were studied outpatient, with samples obtained following an overnight fast. RBC rigidity parameters defined as SS1/2 (shear stress at which half of the maximum deformability occurs) was assessed using the laser diffraction viscometry ektacytometer (LORRCA, Mechatronics, Netherland). We also quantified osmotic sensitivity by measuring deformability under an osmotic gradient (osmoScan, o-hyper; osmolality corresponding to 50% of the Elmax). Vitamin C in plasma was measured using coulometric electrochemical detection with high performance liquid chromatography. We evaluated the association between these deformability parameters, vitamin C concentration. Results Compared to the non-diabetic cohort, the diabetes cohort had significantly lower RBC vitamin C concentration, respectively 28.1µM and 42.9µM (p=0.0013). Low RBC vitamin C concentration was significantly associated with reduce RBC deformability measured by increased SS1/2 (p=0.009). Additionally, low RBC vitamin C was associated with decreased o-hyper, suggesting a decrease dehydration of RBC (p=0.0250). Conclusion Our data demonstrate reduced vitamin c levels in the diabetic cohort. Reduced RBC deformability is associated with reduced RBC vitamin C concentration. Thus, reduced vitamin C levels in diabetic patients might increase red blood cell rigidity and reduce deformability. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

FEATURES OF THE PARAMETERS OF RED BLOOD CELLS AND HEMOSTASIS IN PATIENTS WITH STROKES ASSOCIATED WITH CORONAVIRUS INFECTION

Objective: The purpose is to identify the peculiarities of the parameters of red blood cells (RBC) and hemostasis in patients with strokes associated with coronavirus infection. Design and method: A total of 124 patients (48.5 + 1.9 years) with impairments of cerebral circulation due to COVID-19 (confirmed by positive PCR test) had been examined. Among them, 74 patients had ischemic stroke, 25– transient ischaemic attack, 17– intracerebral hemorrhage, 8– subarachnoid hemorrhage. The parameters of hemostasis were measured by standard methods, electrical, viscoelastic parameters of RBC - by dielectrophoresis. Results: 71 patients (the 1st group) showed signs of intravascular coagulation and thrombosis: accelerated platelet-leukocyte aggregation, increased levels of coagulation products, reduced fibrinolysis activity (p = 0.001–0.04). The levels of D-dimer, fibrinogen, ESR, platelet count were higher in this group compared to the second one (p &lt; 0.01). A moderate increase of RBC summarized rigidity, viscosity was noted. The level of RBC hemolysis was associated with platelet count (r = 0.735,p = 0.03), D-dimer (r = 0.482, p &lt; 0.05), fibrinogen level (r = 0.374, p = 0.04). In 2nd group (53 persons), the markers of thrombosis had moderate deviations. Sharply reduced RBC deformability with increased summarized rigidity, viscosity was dominant coupled with the background of high electrical conductivity of cell membranes compared to the indicators in the 1st group (p &lt; 0.01). There was a decrease of membrane capacity, surface charge, cell dipole moment, polarizability than those in the 1st group (p = 0.0001–0.05). A sharp decrease of RBC deformability creates obstacles to overcoming small-diameter capillaries, leading to violations of microcirculatory blood flow. RBC deformability was associated with levels of ferritin (r = 0.451, p = 0.02), HbA1c (r = 0.480, p = 0.03), uric acid (r = -0.371, p &lt; 0.05), LDL cholesterol (r = 0.461, p = 0.02). Incubation of blood samples in vitro for 10 min with riboflavin, nicotinamide, inosine, which ensures RBC energy metabolism, restored the reduced RBC deformability (p &lt; 0.01), altered cell morphology (p = 0.04), decreased RBC aggregation (p &lt; 0.001). Conclusions: The revealed features of parameters of RBC hemostasis in stroke patients with coronavirus infection are associated with two independent pathogenetic mechanisms: thrombotic and hemorheologic. The thrombotic variant is due to procoagulant state and an activity of inflammation. The hemorheologic variant is caused by decrease of RBC energy metabolism, activity of enzymes.

A computational study of red blood cell deformability effect on hemodynamic alteration in capillary vessel networks

Capillary blood vessels, the smallest vessels in the body, form an intricate network with constantly bifurcating, merging and winding vessels. Red blood cells (RBCs) must navigate through such complex microvascular networks in order to maintain tissue perfusion and oxygenation. Normal, healthy RBCs are extremely deformable and able to easily flow through narrow vessels. However, RBC deformability is reduced in many pathological conditions and during blood storage. The influence of reduced cell deformability on microvascular hemodynamics is not well established. Here we use a high-fidelity, 3D computational model of blood flow that retains exact geometric details of physiologically realistic microvascular networks, and deformation of every one of nearly a thousand RBCs flowing through the networks. We predict that reduced RBC deformability alters RBC trafficking with significant and heterogeneous changes in hematocrit. We quantify such changes along with RBC partitioning and lingering at vascular bifurcations, perfusion and vascular resistance, and wall shear stress. We elucidate the cellular-scale mechanisms that cause such changes. We show that such changes arise primarily due to the altered RBC dynamics at vascular bifurcations, as well as cross-stream migration. Less deformable cells tend to linger less at majority of bifurcations increasing the fraction of RBCs entering the higher flow branches. Changes in vascular resistance also seen to be heterogeneous and correlate with hematocrit changes. Furthermore, alteration in RBC dynamics is shown to cause localized changes in wall shear stress within vessels and near vascular bifurcations. Such heterogeneous and focal changes in hemodynamics may be the cause of morphological abnormalities in capillary vessel networks as observed in several diseases.

Stroke mechanisms associated with coronavirus disease (COVID-19)

The purpose is to identify the pathophysiological mechanisms of stroke development in patients with COVID-19.MethodsA total of 92 patients (46.72+1.72 years) with impairments of cerebral circulation due to COVID-19 (confirmed by positive PCR test results) had been examined. Among them, 67 patients had an ischemic stroke, 14–a transient ischaemic attack, 11–an intracerebral hemorrhage, 3– a subarachnoid hemorrhage.The parameters of hemostasis were measured by standard methods, electrical and viscoelastic parameters of red blood cells (RBC) by the dielectrophoresis method was carried out.ResultsMost of the surveyed persons (60 patients) showed signs of an intravascular coagulation and thrombosis: accelerated platelet-leukocyte aggregation, increased levels of coagulation products, reduced fibrinolysis activity (p=0.002–0.04). The levels of D-dimer, fibrinogen, ESR, platelet count were significantly higher in this group compared to patients in the second one (p<0.01). A moderate increase in summarized rigidity, viscosity of RBC was noted. The level of RBC hemolysis was associated with platelet count (r=0.727, p<0.05), D-dimer level (r=0.422, p=0.04), and fibrinogen level (r=0.318, p<0.05).In the second group of patients (32 persons with a predominance of men - 25 male subjects), the markers of thrombosis had moderate deviations. A sharply reduced RBC deformability with increased summarized rigidity and viscosity was dominant coupled with the background of high electrical conductivity of cell membranes compared to the indicators in the first group (p<0.01). There was a decrease in membrane capacity, surface charge, electrical dipole moment of the cells and polarizability at all frequencies of the electric field than those in the first group (p=0.0001–0.05). A sharp decrease in RBC deformability creates obstacles to overcoming small-diameter capillaries, leading to violations of microcirculatory blood flow.The RBC deformability was associated with levels of ferritin (r=0.407, p=0.024), HbA1c (r=0.419, p=0.033), uric acid (r=−0.303, p<0.05), and LDL cholesterol (r=0.426, p=0.029).Incubation of blood samples in vitro for 10 min with riboflavin, nicotinamide, inosine, which ensures RBC energy metabolism (anaerobic glycolysis and pentose phosphate pathway) restored the reduced the RBC deformability (p<0.01), and decreased the RBC aggregation (p<0.001). Similar changes were obtained when coenzymes were administered to patients in vivo.ConclusionTwo independent mechanisms of cerebral circulatory disturbances have been identified in COVID-19 stroke patients: both thrombotic and hemorheologic. The thrombotic variant is associated with a procoagulant state and with an activity of inflammation. The hemorheologic variant is caused by a decrease in the activity of the RBC energy metabolism enzymes; it is associated with the presence of metabolic disorders and is to be eliminated by an administration of coenzymes and metabolites.FUNDunding AcknowledgementType of funding sources: Other. Main funding source(s): This research was done within the framework of the topic “Epidemiological monitoring of the population state of health and studies on molecular genetic and molecular biological mechanisms of the development of common internal diseases in Siberia for improvement of the relevant diagnostic, preventive, and therapeutic methods” in State Assignment No. 0324-2018-0001, registration No. AAAA-A17-117112850280-2

Peripartum Investigation of Red Blood Cell Properties in Women Diagnosed with Early-Onset Preeclampsia.

We investigated peripartum maternal red blood cell (RBC) properties in early-onset preeclampsia (PE). Repeated blood samples were taken prospectively for hemorheological measurements at PE diagnosis (n = 13) or during 26–34 weeks of gestation in healthy pregnancies (n = 24), then at delivery, and 72 h postpartum. RBC aggregation was characterized by M index (infrared light transmission between the aggregated RBCs in stasis) and aggregation index (AI—laser backscattering from the RBC aggregates). We observed significantly elevated RBC aggregation (M index = 9.8 vs. 8.5; AI = 72.9% vs. 67.5%; p < 0.001) and reduced RBC deformability in PE (p < 0.05). A positive linear relationship was observed between AI and gestational age at birth in PE by regression analysis (R2 = 0.554; p = 0.006). ROC analysis of AI showed an AUC of 0.84 (0.68–0.99) (p = 0.001) for PE and indicated a cutoff of 69.4% (sensitivity = 83.3%; specificity = 62.5%), while M values showed an AUC of 0.75 (0.58–0.92) (p = 0.019) and indicated a cutoff of 8.39 (sensitivity = 90.9% and specificity = 50%). The predicted probabilities from the combination of AI and M variables showed increased AUC = 0.90 (0.79–1.00) (p < 0.001). Our results established impaired microcirculation in early-onset PE manifesting as deteriorated maternal RBC properties. The longer the pathologic pregnancy persists, the more pronounced the maternal erythrocyte aggregation. AI and M index could help in the prognostication of early-onset PE, but further investigations are warranted to confirm the prognostic role before the onset of symptoms.

Proteinuric chronic kidney disease is associated with altered red blood cell lifespan, deformability and metabolism

Anemia is a common complication of chronic kidney disease, affecting the quality of life of patients. Among various factors, such as iron and erythropoietin deficiency, reduced red blood cell (RBC) lifespan has been implicated in the pathogenesis of anemia. However, mechanistic data on invivo RBC dysfunction in kidney disease are lacking. Herein, we describe the development of chronic kidney disease-associated anemia in mice with proteinuric kidney disease resulting from either administration of doxorubicin or an inducible podocin deficiency. In both experimental models, anemia manifested at day 10 and progressed at day 30 despite increased circulating erythropoietin levels and erythropoiesis in the bone marrow and spleen. Circulating RBCs in both mouse models displayed altered morphology and diminished osmotic-sensitive deformability together with increased phosphatidylserine externalization on the outer plasma membrane, a hallmark of RBC death. Fluorescence-labelling of RBCs at day 20 of mice with doxorubicin-induced kidney disease revealed premature clearance from the circulation. Metabolomic analyses of RBCs from both mouse models demonstrated temporal changes in redox recycling pathways and Lands' cycle, a membrane lipid remodeling process. Anemic patients with proteinuric kidney disease had an increased proportion of circulating phosphatidylserine-positive RBCs. Thus, our observations suggest that reduced RBC lifespan, mediated by altered RBC metabolism, reduced RBC deformability, and enhanced cell death contribute to the development of anemia in proteinuric kidney disease.

Hemorheological Alterations and Oxidative Damage in Sickle Cell Anemia.

Sickle cell anemia (SCA) is the most common hereditary disorder of hemoglobin (Hb) characterized by a mutation in the β globin gene, which leads to synthesis of HbS a hemoglobin which, under hypoxic conditions, gels and leading to the sickling of the red blood cells (RBC). The dehydration of the RBC increases the concentration of the intracellular Hb with an increase in the internal viscosity and consequently a decrease in the erythrocyte deformability. Sickle red blood cells due to their difficulty to flow through the microcirculation cause frequent vaso-occlusive episodes, tissue ischemia, and infarctions. Moreover, the reduced RBC deformability causes cell fragility leading to hemolysis and recently a key role of hemolysis and oxidative stress in the development of vascular dysfunction has been demonstrated. The aim of this study was to evaluate the hemorheological profiles of patients with SCA in order to point out new indices of vascular impairment, and to characterize the membrane oxidative damage of sickled RBC. Blood viscosities, erythrocyte aggregation, and viscoelastic profiles of SCA patients were determined, and the RBC oxidative damage was investigated by comparing metabolic capability and RBC membrane proteins from SCA patients with and without transfusion dependence. The hemorheological profile of SCA subjects demonstrated high blood viscosity, increased RBC aggregation, and decreased RBC deformability. These impaired flow properties were associated with RBC membrane protein oxidation, with degradation of spectrin and increased membrane-bound globin. The comparison between SCA patients with and without transfusion dependence showed metabolic and structural RBC oxidative damage significantly different.

Effect of acute exercise on RBC deformability and RBC nitric oxide synthase signalling pathway in young sickle cell anaemia patients

Sickle cell anaemia (SCA) is characterized by reduced red blood cell (RBC) deformability and nitric oxide (NO) bioavailability. The aim of the study was to investigate whether exercise might affect these parameters in SCA. SCA patients and healthy controls (AA) performed an acute submaximal exercise test until subjects reached the first ventilatory threshold (VT 1). Blood was sampled at rest and at VT 1. At rest, free haemoglobin level was higher and RBC count, haemoglobin and haematocrit were lower in SCA compared to AA. RBC deformability was lower in SCA. Exercise had no effect on the tested parameters. RBC NO level was higher in SCA compared to AA at rest and significantly decreased after exercise in SCA. This might be related to a reduction in RBC-NO synthase (RBC-NOS) activation which was only observed in SCA after exercise. Free radical levels were higher in SCA at rest but concentration was not affected by exercise. Marker for lipid peroxidation and antioxidative capacity were similar in SCA and AA and not affected by exercise. In conclusion, a single acute submaximal bout of exercise has no deleterious effects on RBC deformability or oxidative stress markers in SCA, and seems to modulate RBC-NOS signalling pathway.

Use of Computational Fluid Dynamics to Analyze Blood Flow, Hemolysis and Sublethal Damage to Red Blood Cells in a Bileaflet Artificial Heart Valve

Artificial heart valves may expose blood to flow conditions that lead to unnaturally high stress and damage to blood cells as well as issues with thrombosis. The purpose of this research was to predict the trauma caused to red blood cells (RBCs), including hemolysis, from the stresses applied to them and their exposure time as determined by analysis of simulation results for blood flow through both a functioning and malfunctioning bileaflet artificial heart valve. The calculations provided the spatial distribution of the Kolmogorov length scales that were used to estimate the spatial and size distributions of the smallest turbulent flow eddies in the flow field. The number and surface area of these eddies in the blood were utilized to predict the amount of hemolysis experienced by RBCs. Results indicated that hemolysis levels are low while suggesting stresses at the leading edge of the leaflet may contribute to subhemolytic damage characterized by shortened circulatory lifetimes and reduced RBC deformability.

Nitric oxide pathology and therapeutics in sickle cell disease.

Sickle cell disease is caused by a mutant form of hemoglobin that polymerizes under hypoxic conditions which leads to red blood cell (RBC) distortion, calcium-influx mediated RBC dehydration, increased RBC adhesivity, reduced RBC deformability, increased RBC fragility, and hemolysis. These impairments in RBC structure and function result in multifaceted downstream pathology including inflammation, endothelial cell activation, platelet and leukocyte activation and adhesion, and thrombosis, all of which contribute vascular occlusion and substantial morbidity and mortality. Hemoglobin released upon RBC hemolysis scavenges nitric oxide (NO) and generates reactive oxygen species (ROS) and thereby decreases bioavailability of this important signaling molecule. As the endothelium-derived relaxing factor, NO acts as a vasodilator and also decreases platelet, leukocyte, and endothelial cell activation. Thus, low NO bioavailability contributes to pathology in sickle cell disease and its restoration could serve as an effective treatment. Despite its promise, clinical trials based on restoring NO bioavailability have so far been mainly disappointing. However, particular "NO donating" agents such as nitrite, which unlike some other NO donors can improve sickle RBC properties, may yet prove effective.

Reduced red blood cell deformability in Plasmodium knowlesi malaria

AbstractThe simian parasite Plasmodium knowlesi can cause severe and fatal human malaria. However, little is known about the pathogenesis of this disease. In falciparum malaria, reduced red blood cell deformability (RBC-D) contributes to microvascular obstruction and impaired organ perfusion. In P knowlesi infection, impaired microcirculatory flow has been observed in Macaca mulatta (rhesus macaques), unnatural hosts who develop severe and fatal disease. However, RBC-D has not been measured in human infection or in the natural host M fascicularis (long-tailed macaques). Using ektacytometry, we measured RBC-D in adults with severe and non-severe knowlesi and falciparum malaria and in healthy controls. In addition, we used micropipette aspiration to determine the relative stiffness of infected RBCs (iRBCs) and uninfected RBCs (uRBCs) in P knowlesi–infected humans and M fascicularis. Ektacytometry demonstrated that RBC-D overall was reduced in human knowlesi malaria in proportion to disease severity, and in severe knowlesi malaria, it was comparable to that of severe falciparum malaria. RBC-D correlated inversely with parasitemia and lactate in knowlesi malaria and HRP2 in falciparum malaria, and it correlated with hemoglobin nadir in knowlesi malaria. Micropipette aspiration confirmed that in humans, P knowlesi infection increased stiffness of both iRBCs and uRBCs, with the latter mostly the result of echinocytosis. In contrast, in the natural host M fascicularis, echinocyte formation was not observed, and the RBC-D of uRBCs was unaffected. In unnatural primate hosts of P knowlesi, including humans, reduced deformability of iRBCs and uRBCs may represent a key pathogenic mechanism leading to microvascular accumulation, impaired organ perfusion, and anemia.

A novel ENU-induced ankyrin-1 mutation impairs parasite invasion and increases erythrocyte clearance during malaria infection in mice.

Genetic defects in various red blood cell (RBC) cytoskeletal proteins have been long associated with changes in susceptibility towards malaria infection. In particular, while ankyrin (Ank-1) mutations account for approximately 50% of hereditary spherocytosis (HS) cases, an association with malaria is not well-established, and conflicting evidence has been reported. We describe a novel N-ethyl-N-nitrosourea (ENU)-induced ankyrin mutation MRI61689 that gives rise to two different ankyrin transcripts: one with an introduced splice acceptor site resulting a frameshift, the other with a skipped exon. Ank-1(MRI61689/+) mice exhibit an HS-like phenotype including reduction in mean corpuscular volume (MCV), increased osmotic fragility and reduced RBC deformability. They were also found to be resistant to rodent malaria Plasmodium chabaudi infection. Parasites in Ank-1(MRI61689/+) erythrocytes grew normally, but red cells showed resistance to merozoite invasion. Uninfected Ank-1(MRI61689/+) erythrocytes were also more likely to be cleared from circulation during infection; the “bystander effect”. This increased clearance is a novel resistance mechanism which was not observed in previous ankyrin mouse models. We propose that this bystander effect is due to reduced deformability of Ank-1(MRI61689/+) erythrocytes. This paper highlights the complex roles ankyrin plays in mediating malaria resistance.

The red-vine-leaf extract AS195 increases nitric oxide synthase-dependent nitric oxide generation and decreases oxidative stress in endothelial and red blood cells.

The red‐vine‐leaf extract AS195 improves cutaneous oxygen supply and the microcirculation in patients suffering from chronic venous insufficiency. Regulation of blood flow was associated to nitric oxide synthase (NOS)‐dependent NO (nitric oxide) production, and endothelial and red blood cells (RBC) have been shown to possess respective NOS isoforms. It was hypothesized that AS195 positively affects NOS activation in human umbilical vein endothelial cells (HUVECs) and RBC. Because patients with microvascular disorders show increased oxidative stress which limits NO bioavailability, it was further hypothesized that AS195 increases NO bioavailability by decreasing the content of reactive oxygen species (ROS) and increasing antioxidant capacity. Cultured HUVECs and RBCs from healthy volunteers were incubated with AS195 (100 μmol/L), tert‐butylhydroperoxide (TBHP, 1 mmol/L) to induce oxidative stress and with both AS195 and TBHP. Endothelial and red blood cell–nitric oxide synthase (RBC‐NOS) activation significantly increased after AS195 incubation. Nitrite concentration, a marker for NO production, increased in HUVEC but decreased in RBC after AS195 application possibly due to nitrite scavenging potential of flavonoids. S‐nitrosylation of RBC cytoskeletal spectrins and RBC deformability were increased after AS195 incubation. TBHP‐induced ROS were decreased by AS195, and antioxidative capacity was significantly increased in AS195‐treated cells. TBHP also reduced RBC deformability, but reduction was attenuated by parallel incubation with AS195. Adhesion of HUVEC was also reduced after AS195 treatment. Red‐vine‐leaf extract AS195 increases NOS activation and decreases oxidative stress. Both mechanisms increase NO bioavailability, improve cell function, and may thus account for enhanced microcirculation in both health and disease.

Reduced erythrocyte deformability associated with hypoargininemia during Plasmodiumfalciparum malaria

The mechanisms underlying reduced red blood cell (RBC) deformability during Plasmodium falciparum (Pf) malaria remain poorly understood. Here, we explore the possible involvement of the L-arginine and nitric oxide (NO) pathway on RBC deformability in Pf-infected patients and parasite cultures. RBC deformability was reduced during the acute attack (day0) and returned to normal values upon convalescence (day28). Day0 values correlated with plasma L-arginine levels (r = 0.69; p = 0.01) and weakly with parasitemia (r = −0.38; p = 0.006). In vitro, day0 patient's plasma incubated with ring-stage cultures at 41°C reduced RBC deformability, and this effect correlated strongly with plasma L-arginine levels (r = 0.89; p < 0.0001). Moreover, addition of exogenous L-arginine to the cultures increased deformability of both Pf-free and trophozoite-harboring RBCs. NO synthase activity, evidenced in Pf-infected RBCs, induced L-arginine-dependent NO production. These data show that hypoargininemia during P. falciparum malaria may altogether impair NO production and reduce RBC deformability, particularly at febrile temperature.

Red blood cell deformability is very slightly decreased in erythropoietin deficient mice

The present study compared the hemorheological properties between Epo-TAgh mice (a model of erythropoietin deficient mice) and wild-type (WT) control mice. Blood viscosity was determined at several shear rates using a cone-plate viscometer at native and adjusted hematocrit (i.e. 40%). Red blood cell (RBC) deformability was measured by ecktacytometry at several shear stresses and RBC aggregation properties by backscattered technique at adjusted hematocrit (i.e. 40%). Epo-TAgh mice had severe anemia (very low hematocrit), decreased blood viscosity at native hematocrit and slightly reduced RBC deformability at high shear stresses in comparison with WT mice. Blood viscosity at adjusted hematocrit (i.e. 40%) was not different between WT and Epo-TAgh mice. RBC aggregation did not differ between the two mice models. These findings suggest a role of erythropoietin in the regulation of RBC deformability.

The relationship between red blood cell deformability metrics and perfusion of an artificial microvascular network

The ability of red blood cells (RBC) to undergo a wide range of deformations while traversing the microvasculature is crucial for adequate perfusion. Interpretation of RBC deformability measurements performed in vitro in the context of microvascular perfusion has been notoriously difficult. This study compares the measurements of RBC deformability performed using micropore filtration and ektacytometry with the RBC ability to perfuse an artificial microvascular network (AMVN). Human RBCs were collected from healthy consenting volunteers, leukoreduced, washed and exposed to graded concentrations (0-0.08%) of glutaraldehyde (a non-specific protein cross-linker) and diamide (a spectrin-specific protein cross-linker) to impair the deformability of RBCs. Samples comprising cells with two different levels of deformability were created by adding non-deformable RBCs (hardened by exposure to 0.08% glutaraldehyde) to the sample of normal healthy RBCs. Ektacytometry indicated a nearly linear decline in RBC deformability with increasing glutaraldehyde concentration. Micropore filtration showed a significant reduction only for concentrations of glutaraldehyde higher than 0.04%. Neither micropore filtration nor ektacytometry measurements could accurately predict the AMVN perfusion. Treatment with diamide reduced RBC deformability as indicated by ektacytometry, but had no significant effect on either micropore filtration or the AMVN perfusion. Both micropore filtration and ektacytometry showed a linear decline in effective RBC deformability with increasing fraction of non-deformable RBCs in the sample. The corresponding decline in the AMVN perfusion plateaued above 50%, reflecting the innate ability of blood flow in the microvasculature to bypass occluded capillaries. Our results suggest that in vitro measurements of RBC deformability performed using either micropore filtration or ektacytometry may not represent the ability of same RBCs to perfuse microvascular networks. Further development of biomimetic tools for measuring RBC deformability (e.g. the AMVN) could enable a more functionally relevant testing of RBC mechanical properties.

P70: Molecular and physiological aspects connecting red cell eNOS, red blood cell deformability and decreased microvascular function in patients with essential hypertension

Background Arterial hypertension (HT) is a complex multifactorial condition associated with cardiovascular disease. Independent studies show that HT is associated with microcirculatory and hemorheological alterations, such as decreased red blood cell (RBC) deformability, as well as decreased endothelial function and nitric oxide (NO) bioavailability. Recently we found RBC carry an active endothelial nitric oxide synthase (eNOS), which is decreased in cardiovascular disease.Hypothesis: We hypothesized that a reduced RBC deformability may contribute to induce a hypertensive phenotype via impairment of microcirculatory conductance. Methods To evaluate hemorehological alterations in HT, patients ( n = 10) with HT and age-and risk factors-matched subjects ( n = 10) without HT (control) were recruited. High BP was defined as systolic BP > 135 mm Hg and diastolic BP > 85 mm in 24 h BP measurements. RBC deformability was measured by laser-assisted optical rotational cell analyzer (LORCA) and assessed as elongation index (EI) at 1.73 Pa. RBC redox state (ROS, GSH) was assessed by labeling with diclorodihydrofluorescein and thiol-tracker and flow cytometry. Cutaneous microvascular function as post-occlusion reactive hyperemia was measured by noninvasive laser Doppler Perfusion imaging and quantified as area under the curve (AUC). Endothelial function of the brachial artery was assessed as flow-mediated dilatation (FMD) by high resolution ultrasound. Deformability of RBC from eNOS −/− mice was evaluated and compared to wild type (WT) C57Bl/6 mice. To evaluate NO and NOS-dependent changes in RBC deformability, RBC from healthy individuals ( n = 6) were treated with NO donors, NOS inhibitors and guanylate cyclase inhibitors. Measurements of cGMP production in RBC were assessed by ELISA. A stepwise linear regression as well as a multivariate linear regression model were performed to identify independent predictors for systolic BP. Results In the HT group EI (0.300 ± 0.007 vs. 0.326 ± 0.007, p = 0.013), AUC (1657 ± 422 vs. 2313 ± 473 PU; p = 0.009). and FMD (6.2% ± 0.7% vs. 5.0% ± 0.3 % p = 0.010) was reduced in the HT group, suggesting decreased deformability, shorter lasting vasodilation of microvessels and endothelial dysfunction. In RBC from HT patients the ROS levels increased and the GSH levels decreased, indicating increased oxidative stress. Univariate inverse correlations were found between systolic BP and AUC ( r = −0.485; p r = 0.726; p R 2 = 0.607, p = 0.004). In a translational approach we analyzed deformability in eNOS −/− mice, characterized by a dysfunctional endothelium and hypertension. eNOS −/− RBC are less deformable than WT RBC, show increased ROS and decreased GSH, similarly to the HT grouP Moreover, NO donors increased EI of RBC from healthy individuals, while NOS inhibition as well as guanlyte cyclase inhibition decreased cGMP levels and EI indicating that NO/NOS/cGMP dependent pathways control deformability in RBC. Conclusion The NO/NOS/cGMP pathway controls RBC mechanoproperties, and RBC deformability is an independent predictor of increased blood pressure in patients with arterial hypertension. Disclosure Nothing to disclose.