Prevention of garlic-induced hemolytic anemia using some tropical green leafy vegetables

Garlic (Allium sativum) is popularly consumed in Nigeria because of its health benefit in treatment and management of several disease conditions. However, excessive intake of garlic may cause hemolytic anemia. This project sought to investigate the ability of some commonly consumed tropical green leafy vegetables-namely, Amaranthus cruentus, Baselia alba, Solanum macrocarpon, Ocimum gratissimum, and Corchorus olitorius-to prevent garlic-induced hemolytic anemia. Wister strain albino rats were fed diet containing 4% garlic with or without 40% vegetable supplement. The study showed that there was a decrease in daily feed intake (6.7-7.2 g/rat/day), daily weight gain (0.7-1.5 g/rat/day), and digestibility (70.4-91.5%) of rats fed diet with garlic (4%), with or without vegetable (40%) supplement, compared with those rats fed the basal diet without garlic (4%) and vegetable (40%) supplement (digestibility, 95.5%; daily feed intake, 7.5 g/rat/day; and daily weight gain, 2.0 g/rat/day). However, there was a significant decrease (P < .05) in the packed cell volume (PCV) (31.0%), hemoglobin (Hb) (10.2 g/dL), red blood cells (RBCs) (4.3 x 10(6)/microL), and white blood cells (WBCs) (3.5 x 10(6)/microL) of rats fed diet with garlic (4%) but without vegetable compared with those rats fed diet without garlic (4%) and vegetable (40%) supplements (PCV, 38.2%; Hb, 13.0 g/dL; RBCs, 5.5 x 10(6)/microL; and WBCs, 4.0 x 10(6)/microL). Conversely, there was a significant increase in the PCV (33.5-35.6%), Hb (12.0-12.5 g/dL), and RBCs (4.9-5.3 x 10(6)/microL) of rats fed diet with garlic (4%) and vegetable (40%) supplement compared with rats fed diet with 4% garlic supplement (except S. macrocarpon and C. olitorius). Furthermore, there was a significant decrease (P < .05) in mean corpuscular volume (69.2-72.0 fL) of rats fed the basal and those fed diet with garlic and vegetable (except C. olitorus and S. macrocarpon) supplement compared with the rats fed diet with garlic but without vegetable supplement (74.5 fL). This therefore implies that garlic could induce hemolytic anemia in rats. However, such anemia could be prevented by some tropical green leafy vegetables such as A. cruentus, B. alba, and O. gratissimum.

Controlling the complement system for prevention of red cell destruction

PURPOSE OF REVIEW

Complement sensitization of red blood cells (RBCs) can lead to both intravascular and extravascular red cell destruction. Altered levels of naturally occurring complement regulatory proteins on red cells can result in hemolysis, while defective expression of these proteins on immune cells can cause breakdown of tolerance to self antigens and is associated with autoimmune disease.

RECENT FINDINGS

To date several complement inhibitors, including recombinant forms of complement regulatory proteins, humanized antibodies, and synthetic molecules have been described that limit complement activation by interfering with different steps in the complement cascade. However, few have been evaluated for prevention of complement-mediated RBC destruction. In this review, possible applications of these complement inhibitors for treatment of complement-mediated hemolysis in specific disease states are described. Furthermore, the implication of the regulatory role of complement in the development of autoimmune hemolytic anemia is discussed.

SUMMARY

Complement therapeutics has potential for effective and safe prophylactic use and treatment of hemolytic transfusion reactions and complement-mediated hemolytic diseases. Furthermore, the regulatory function of complement may be exploited to prevent and treat autoimmune hemolytic anemia.

Potential approaches to prevent uncommon hemolytic side effects of AB0 antibodies in plasma derivatives

Since hemolytic reactions in patients after administration of plasma derivatives like immunoglobulins or coagulation factor preparations have been described, titers of anti-A and anti-B-antibodies have to be below defined levels for batch release of these plasma-derived therapeutic products according to the European Pharmacopoeia. We have summarized clinical relevance of AB0 antibodies in plasma derivatives and related legal issues in the European Union, United States of America, and Japan. We have also discussed potential approaches for the prevention of hemolytic side effects with feasible steps in preparation of plasma derivatives, viz., (1) selection of donors, (2) exclusion of "dangerous donors", (3) optimizing ratio of the types of plasma, (4) removal of antibodies, (5) production of blood-group-specific plasma derivatives, (6) rejection of batches of plasma derivatives with high titers of antibodies, and (7) crossmatching before administration. For harmonization of standards for anti-A and anti-B in plasma-derived therapeutics the regulators and manufacturers will have to realistically deal with complex clinical, practical, and economic issues.

Prevention of complement-mediated immune hemolysis by a small molecule compound

Complement sensitization of red blood cells (RBCs) can result in transfusion reactions and hemolytic anemias. We hypothesized that manipulating the complement system using small organic molecules might prevent RBC destruction, thereby prolonging RBC survival in patients. Using a simple, rapid, large-scale hemolytic assay, we screened a 10,000 compound library, enriched in anti-inflammatory compounds at a final concentration of 25 microM, and identified a 549Da compound (C(34)H(24)N(6)O(2)) with a symmetrical structure containing two benzimidazole rings that, as compared to a known anti-complement molecule FUT-175, was more effective in reducing hemolysis by the classical pathway and had comparable anti-hemolytic activity against the alternative pathway. Furthermore, in a xenotransfusion mouse model, treatment of mice with 1.2mg/kg of the compound significantly prolonged the survival of transfused RBCs, reducing C3 deposition, but not the deposition of control IgG or IgM, for the first hour post-transfusion. These data suggest that further studies are warranted to determine if this compound has usefulness in a transfusion setting.

Orally administered Kampo medicine, Juzen-taiho-to, ameliorates anemia during interferon plus ribavirin therapy in patients with chronic hepatitis C

BACKGROUND

Interferon plus ribavirin (IFN/Rib) therapy is currently standard treatment for chronic hepatitis C. Hemolytic anemia, however, is a serious side effect of this treatment, requiring reductions in or complete withdrawal of ribavirin.

METHODS

We retrospectively investigated the effect of the Kampo medicine Juzen-taiho-to (TJ-48), which contains bone marrow-stimulating compounds, on anemia in 67 patients with chronic hepatitis C, who received IFN/Rib therapy.

RESULTS

The reduction in hemoglobin levels was significantly ameliorated in TJ-48-treated patients (P<0.05). Consequently, only 13% (4/32) of TJ-48-treated patients received altered doses of ribavirin, while the ribavirin dose had to be reduced or withdrawn in 43% (15/35) of patients in the absence of TJ-48 administration (P<0.001).

CONCLUSIONS

These results indicate the possibility that oral administration of TJ-48 supports IFN/Rib therapy without necessitating ribavirin reduction or withdrawal.

Significant numbers of apheresis-derived group O platelet units have "high-titer" anti-A/A,B: implications for transfusion policy

Transfusion of group O single-donor apheresis PLTs (SDP) to group A recipients has resulted in intravascular hemolysis and mortality. Owing to low availability of type-specific SDPs, transfusion services sometimes issue ABO-mismatched PLTs. After observing two cases of acute hemolysis following infusion of O SDPs to group A patients, where both recipient eluates revealed anti-A specificity, a prospective study to determine the prevalence of "high-titer" anti-A/A,B in group O SDPs was commenced. One hundred group O SDP samples were tested. Titers of at least 64 and/or 256 from either buffered (generally reflective of IgM antibodies) or anti-IgG gel cards, respectively, were considered critically high. Twenty-eight and 39 percent of samples revealed critically high anti-A/A,B IgM and IgG titers, respectively. IgM titers were at 1:64 (18%), 128 (6%), and 256 (4%), whereas IgG titers were at 1:256 (28%), 512 (7%), 1024 (2%), and 2048 (2%). The prevalence of critical anti-A/A,B titers in group O SDPs is relatively high. Thus, the risk of minor side ABO mismatch and potential intravascular hemolysis during group O SDP transfusion to group A recipients may be significant. Based on these data, a policy was instituted to test anti-A/A,B titers in O SDPs prior to "out-of-group" transfusion.

CR1-based inhibitors for prevention of complement-mediated immune hemolysis

Complement receptor 1 (CR1) is a single pass transmembrane glycoprotein that, through its ability to bind key components of the complement cascade, can inhibit both the classical and alternative pathways. Using several animal models, a recombinant form of CR1 has been documented to be effective in reducing tissue damage that occurs as a result of complement activation in various inflammatory conditions. This strategy is currently being explored in human clinical trials. Activation of complement cascade via the antibody-mediated classical pathway can initiate red blood cell destruction, causing transfusion reactions and hemolytic anemia. We discuss here our approach of using CR1 derivatives as therapeutic targets for prevention of complement-dependent immune hemolysis. Using a mouse model of hemolytic transfusion reaction, we have found that sCR1 treatment reduces complement activation and prolongs the survival of transfused red blood cells. Through structure-function analysis, we have identified a complement inhibitory domain located at the amino-terminal region of CR1 that mediates its antihemolytic activity in vivo. Collectively, our data highlight a potential use for CR1 to control complement-dependent immune hemolysis and identify its functional domains for the future design of CR1-based inhibitors.

[Immunomodulating activity of polyunsaturated phospholipids and regulators of energy metabolism in toxic anemia]

Possible potentiation of the immunomodulating effects of carbohydrate and lipid metabolism regulators by their use in combination with polyunsaturated phospholipids was studied. The polyunsaturated phospholipids in toxic anemia icreased the immunomodulating effects of thiamine and inosine which activated glucose catabolism in erythrocytes. The combined use of the polyunsaturated phospholipids and thiamine normalized the oxidation--energy status and lowered manifestation of the immunosuppressing properties of light erythrocytes in laboratory rats exposed to hemolytic poison. The use of the combination of the polyunsaturated phospholipids and inosine normalized the oxidation--energy status and induced manifestation of the immunomodulating properties in heavy erythrocytes of the poisoned rats. The globulin fraction of the rat serum containing antibodies to erythrocytes of the poisoned rats exposed to the polyunsaturated phospholipids and inosine increased the immunity status of the poisoned rats treated with the above mentioned agents. Carnitine and biotin in combination with the polyunsatured phospholipids showed no effect on the phagocytic and metabolic activity of leukocytes and the immunity status of the rats exposed to hemolytic poison.

Folic acid supplementation does not prevent ribavirin-induced anemia

Treatment of chronic hepatitis C consists of inteferon plus ribavirin. The major adverse effect of ribavirin is hemolytic anemia, a complication that limits therapy. Folic acid supplementation is used to improve erythropoiesis in chronic hemolytic anemia. The aim of this study was to evaluate the effectiveness of folic acid supplementation in the prevention of ribavirin-induced anemia in patients being treated for hepatitis C. Twenty one patients enrolled in treatment protocols for hepatitis C received folic acid 1 mg daily and 22 did not. Groups were similar in age, gender, ribavirin dose and baseline hemoglobin. Folic acid supplementation had no effect in the decrease in hemoglobin or the measured parameters of hemolysis. No difference between males and females was noted for hemoglobin decrease or lowest hemoglobin levels. In our study, folic acid showed no beneficial effect in the prevention of ribavirin-induced anemia.

Relationship between oxidative stress, pathology, and behavioral signs of lead poisoning in mallards

Some of the adverse effects of lead (Pb) may be associated with oxidative damage of lipids, proteins, or DNA. In a previous study a linkage was observed between the susceptibilities of waterfowl species to Pb poisoning with oxidative stress. To investigate this relationship among the individuals of a single species, for 3 wk 4 groups of 12 mallards were fed diets containing high or low levels of vitamin E (20 or 220 UI/kg) and high or low levels of Pb (0 or 2 g/kg). During the first week of Pb exposure, mallards developed hemolytic anemia, and during the second week, signs of neurological impairment. Histological findings in the Pb-exposed mallards were hemosiderosis, demyelinization of sciatic and brachial nerves, and tumefaction of renal tubular epithelium with the presence of intranuclear inclusion bodies. Lipid peroxidation increased with Pb exposure in blood, liver, bile, and brain, but decreased in nerves. Glutathione (GSH) increased with Pb exposure in liver and bile, and its oxidized/reduced ratio only increased in bile. Pb exposure inhibited GSH peroxidase activity (GPX) in plasma, liver, and brain, and decreased protein thiols (PSH) in blood and liver. Vitamin E resulted in significantly lower lipid peroxidation in nerves of control birds relative to unsupplemented controls, but did not alleviate any sign of lead posioning. Pb-induced pathological changes associated with hepatic and nervous functions were significantly correlated with lower GPX activity and PSH concentrations in these tissues rather than lipid peroxidation. Data suggest that inhibition of antioxidant enzymes and interaction with sulfhydryl groups of proteins may play a more important role in Pb poisoning of waterfowl than lipid peroxidation.

Influence on hazelnut oil administration on peroxidation status of erythrocytes and apolipoprotein B 100-containing lipoproteins in rabbits fed on a high cholesterol diet

Hazelnut oil (HO) is rich in monounsaturated fatty acids (MUFA). The effect of a high cholesterol (HC) diet with and without HO on lipids and lipid peroxide levels in plasma, apolipoprotein B 100-containing lipoproteins (VLDL + LDL), and erythrocytes as well as hematological data was investigated in rabbits. A HC diet caused significant increases in lipid peroxide levels in plasma and apo B-containing lipoproteins together with histopathological atherosclerotic findings in aorta. In addition, this diet resulted in hemolytic anemia associated with increased endogenous diene conjugate (DC) levels, but H(2)O(2)-induced malondialdehyde (MDA) levels remained unchanged in erythrocytes. HO supplementation reduced lipid peroxide levels in plasma and apolipoprotein B 100-containing lipoproteins as well as aortic atherosclerotic lesions in rabbits fed an HC diet without any decreasing effect on lipid levels. In addition, HO was found to reduce hemolytic anemia together with significant decreases in DC and H(2)O(2)-induced MDA levels.

Complement receptor 1 inhibitors for prevention of immune-mediated red cell destruction: potential use in transfusion therapy

Activation of complement cascade via the antibody-mediated classical pathway can initiate red blood cell (RBC) destruction, causing transfusion reactions and hemolytic anemia. In the present study, we have assessed the ability of a human recombinant soluble form of complement receptor 1 (sCR1) to inhibit complement-mediated RBC destruction in vitro and in vivo. Using an in vitro alloimmune incompatibility model, sCR1 inhibited complement activation and prevented hemolysis. Following transfusion of human group O RBCs into mice lacking detectable pre-existing antibodies against the transfused RBCs, systemic coadministration of 10 mg/kg sCR1, a dose well tolerated in human subjects for prevention of tissue injury, completely inhibited the in vivo clearance of the transfused RBCs and surface C3 deposition in the first hour after transfusion, correlating with the half-life of sCR1 in the circulation. Treatment with sCR1 increased the survival of transfused human group A RBCs in the circulation of mice with pre-existing anti-A for 2 hours after transfusion by 50%, reduced intravascular hemolysis, and lowered the levels of complement deposition (C3 and C4), but not immunoglobulin G (IgG) or IgM, on the transfused cells by 100-fold. We further identified potential functional domains in CR1 that can act to limit complement-mediated RBC destruction in vitro and in vivo. Collectively, our data highlight a potential use of CR1-based inhibitors for prevention of complement-dependent immune hemolysis.

Hemolytic transfusion reaction: safeguards for practice

Most hemolytic transfusion reactions result from administration of ABO-incompatible blood. Even a small amount of incompatible blood may initiate a reaction and cause devastating consequences leading to death. Careful monitoring of the anesthetized patient is important in recognizing symptoms of a transfusion reaction so that the reaction may be promptly detected and treatment quickly initiated. Many factors contribute to blood transfusion errors resulting from the misidentification of either the patient or the blood product. Nursing has opportunities to establish policies and procedures, design nursing practices, and educate staff to help avoid blood transfusion errors.

Glucose-6-phosphate dehydrogenase deficiency and hematopoietic stem cell transplantation

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked hemolytic enzymopathy affecting 3% of Southern Chinese males. Among 275 adult allogeneic hematopoietic stem cell transplantations (SCT), five cases (1.8%) each of donors and recipients were G6PD deficient. Among 107 autologous SCT, four patients (3.7%) were G6PD deficient. All subjects were male, except for two female patients with chronic myeloid leukemia (CML). The incidence of G6PD deficiency in female CML patients was significantly higher than the background female incidence (P = 0.004), but comparable with that in the males (P = 0.664). There was no significant hemolysis or delay in red cell engraftment, and all but one patient converted to donor G6PD screening status. One female patient achieved partial correction of her G6PD status and relapsed at 10 months. We suggest that G6PD deficiency should be tested for in all marrow donors and recipients in susceptible populations. From our data, there is a suggestion of increased clinical incidence of G6PD deficiency in female patients with multi-lineage clonal marrow disorders.

Erythropoietin can obviate the need for repeated heart valve replacement in high-risk patients with severe mechanical hemolytic anemia: case reports and literature review

BACKGROUND AND AIM OF THE STUDY

Brisk hemolysis due to perivalvular leak is usually an indication for valve re-replacement. Repeated surgery after multiple previous valve operations is associated with high mortality, morbidity and failure rates. The present study evaluated the role of erythropoietin (EPO) administration in deferring or obviating the need for repeated surgery.

METHODS

Three patients (two men, one woman; age range 62-76 years) with two mechanical valves each and two to four previous heart valve operations, who suffered from severe mechanical hemolytic anemia, were given subcutaneous EPO for 15-17 months.

RESULTS

A marked reduction in red blood cell consumption was achieved with a weekly EPO dose of 18,000 U in two patients, both of whom also had mild or moderate kidney malfunction. A third patient with normal renal function and extreme hemolysis showed a transient, partial response to 30,000 U of EPO per week, and eventually needed a fifth operation.

CONCLUSION

EPO may defer or even obviate the need for repeated valve surgery in patients with severe hemolysis due to perivalvular leak, especially those with inadequate EPO response, such as those with renal malfunction.

Antioxidant prevention of Heinz body formation and oxidative injury in cats

OBJECTIVE

To determine the effectiveness of 3 antioxidants in preventing Heinz body anemia in cats.

DESIGN

Prospective study.

ANIMALS

44 specific-pathogen-free healthy cats.

PROCEDURE

Cats were housed individually, divided randomly into 4 groups, and given the following orally every 12 hours: empty gelcaps (control cats), N-acetylcysteine (NAC, 100 mg/kg of body weight), vitamin E (d,l-alpha-tocopherol; 400 IU), or ascorbate (250 mg). After 2 weeks, Heinz bodies were induced by dietary onion powder (OP; 1% or 3% of dry matter) or propylene glycol (PG, 8% wt/vol in drinking water) for an additional 3 weeks. Intake of treated water or food was recorded daily. Body weight, PCV, Heinz body and reticulocyte percentages, reduced glutathione concentration, and total antioxidant status were measured twice weekly in all cats.

RESULTS

Heinz body percentage and degree of anemia did not differ significantly among cats receiving antioxidants and control cats except in cats that ingested water containing PG, in which antioxidant supplementation was associated with a decrease in water intake. Of cats that were fed a diet that contained OP, cats that received NAC had significantly higher reduced glutathione concentrations, compared with other cats in the experiment. Total antioxidant status did not consistently correlate with antioxidant supplementation or type of oxidant administered (ie, OP or PG).

CONCLUSIONS AND CLINICAL RELEVANCE

Although the effect of antioxidant supplementation on Heinz body anemia in cats was minimal, antioxidants may have subclinical biochemical effects such as GSH sparing that may be important against milder forms of oxidative stress.

Blood tacrolimus concentrations in bone marrow transplant patients undergoing plasmapheresis

Microangiopathic hemolytic anemia (MAHA) is a well-described complication of stem cell transplantation. Plasmapheresis is one modality utilized as therapy for patients who develop this complication. However, plasmapheresis may alter whole blood levels of certain medications and its effect on tacrolimus in bone marrow transplant patients is unknown. Because tacrolimus has a narrow therapeutic range, the effect of plasmapheresis on whole blood concentrations would be important to know. We report three allogeneic BMT patients who were receiving tacrolimus as acute GVHD therapy while undergoing plasmapheresis for MAHA. Tacrolimus levels seemed unaffected by plasmapheresis in these patients.

Perioperative management of glucose 6 phosphate dehydrogenase deficiency. A review of the literature

Glucose 6 phosphate dehydrogenase (G6PDH) deficiency is the most frequent cause of hemolytic anemias due to enzyme abnormality. Perioperative management must be careful to avoid the onset of hemolytic crisis. We present a complete review of the literature on this illness and describe the perioperative management of an adult with known G6PD deficiency and the pathogenesis and clinical manifestations of the disorder and its possible anesthetic implications are discussed. A 49-year-old patient had undergone varum osteotomy in her left knee due to genu valgum. She had been diagnosed as having G6PDH deficiency sixteen years earlier provoked by ingesting beans. The perioperative circumstances capable of causing autohemolysis are described and discussed. In spite of the fact that the pattern is self-limited, it provokes the onset of jaundice and anemia which can complicate the recovery. Simple elimination of those elements which precipitate with oxyhemoglobin will allow an uneventful anesthetic procedure.

Prophylactic splenectomy and cholecystectomy in mild hereditary spherocytosis: analyzing the decision in different clinical scenarios

OBJECTIVES

Patients with mild hereditary spherocytosis (HS), i.e. with haemolysis without anaemia. have an increased risk of gallstone formation, erythroid aplasia and haemolytic crisis. Since the effect of prophylactic splenectomy on life expectancy has not been established, we conducted a decision analysis comparing prophylactic splenectomy and cholecystectomy with no surgery.

DESIGN

The available data on surgery and disease outcomes were modelled to estimate the effects of the different interventions on the quality-adjusted life expectancy. The early phase outcomes depicted surgery-related mortality and incorporated compliance and the adverse effects of prophylaxis against post splenectomy infections. The late phase outcomes were framed by a Markov cohort analysis.

RESULTS

For patients without gallstones, surgery was of no benefit. For those with gallstones the preferred strategies were found to be splenectomy and cholecystectomy before the age of 39 when asymptomatic, and before 52 when accompanied by occasional biliary colic. Cholecystectomy alone proved to be the preferred strategy in older patients with occasional biliary colic. For patients of up to 52 years of age and candidates for cholecystectomy because of recurrent biliary colic, the best strategy was to combine this procedure with splenectomy. Sensitivity analysis showed that the results were sensitive to the incidence of post cholecystectomy syndrome. Most remarkably an extreme sensitivity to compliance with post splenectomy infection prophylaxis was demonstrated.

CONCLUSIONS

Our model suggested that combined prophylactic splenectomy and cholecystectomy provide a substantial gain in quality-adjusted life expectancy for young patients and adults with mild HS and gallstones.