Changes in erythropoiesis due to radiation or chemotherapy as studied by flow cytometric determination of peripheral blood reticulocytes

Effect of an Ayurveda antidote Dooshivishari Agada in carboplatin induced myelosuppression in Male Wistar rats

Background

Carboplatin is one of the common chemotherapeutic agents in the management of various malignant conditions. Myelosuppression remains one of the major adverse effects of it that leads to compromised quality of life and can procrastinate or cease the chemotherapy regimen. Increasing shreds of evidence suggest the role of Complementary and alternate medicine in palliative cancer care. Ayurveda has prescribed Dooshivishari Agada (DVA) as an anti-dote for similar conditions mentioned above which arise out of sub-lethal toxic substances called Dooshivisha (DV).

Objective

The present study was carried out to evaluate the role of DVA in myelosuppression among rats.

Method

Male Wistar rats weighing 250–275 g were divided into three groups, Group I was administered normal saline and acted as Normal control. Group II and III received a single dose of carboplatin (60 mg/kg through the tail vein) on day one and acted as disease control. Group III received experimental drug DVA 256 mg/kg orally for the next 18 days. Animals were bled on days 0, 3, 6, 9, 12, 15, 18 for hematological analysis.

Results

DVA prolonged the nadir time for Hb, RBC, and WBC counts from day 9 to day 12 when compared to the carboplatin group. In terms of Platelet count, there was no significant difference over carboplatin. Group III showed a significant increase in Total reticulocyte count in comparison to group II.

Conclusion

Present study showed that DVA may help in delaying the myelosuppression which needs further evaluation.

Cyclophosphamide induces a significant increase in iron content in the liver and spleen of mice

Objective:

Oxidative stress is one of the major mechanisms of cyclophosphamide (CPX)-induced toxicities. However, it is unknown how CPX induces oxidative stress. Based on the available information, we speculated that CPX could increase iron content in the tissues and then induce oxidative stress.

Method:

We tested this hypothesis by investigating the effects of CPX on iron and ferritin contents, expression of transferrin receptor 1 (TfR1), ferroportin 1 (Fpn1), iron regulatory proteins (IRPs), hepcidin, and nuclear factor erythroid 2-related factor-2 (Nrf2) in the liver and spleen, and also on reticulocyte count, immature reticulocyte fraction, and hemoglobin (Hb) in the blood in c57/B6 mouse.

Results:

We demonstrated that CPX could induce a significant increase in iron contents and ferritin expression in the liver and spleen, notably inhibit erythropoiesis and Hb synthesis and lead to a reduction in iron usage. The reduced expression in TfR1 and Fpn1 is a secondary effect of CPX-induced iron accumulation in the liver and spleen and also partly associated with the suppressed IRP/iron-responsive element system, upregulation of hepcidin, and downregulation of Nrf2.

Conclusions:

The reduced iron usage is one of the causes for iron overload in the liver and spleen and the increased tissue iron might be one of the mechanisms for CPX to induce oxidative stress and toxicities.

A protective role of heme-regulated eIF2α kinase in cadmium-induced toxicity in erythroid cells

Although a number of studies have demonstrated that cadmium (Cd) can incur damage to mature red cells, the potential injuries of Cd to erythroid progenitor cells have not been investigated thus far. Heme-regulated eIF2α kinase (Hri) is essential for translational regulation and survival of erythroid precursors in the setting of iron deficiency. Hri has been demonstrated to activate Atf4 signaling in reducing oxidative stress and in promoting erythroid differentiation during stress erythropoiesis. Here, we demonstrated that Cd significantly provoked cell death and suppressed erythroid differentiation of erythroid progenitor cells. Importantly, our results established a crucial role of Hri in ameliorating Cd-induced impairment to erythropoiesis. Upon Cd treatment, Hri-eIF2αP-Atf4 signaling was activated to protect cells from cell death and differentiation attenuation in Wt fetal liver erythroblasts; in contrast, Hri(-/-) erythroblasts suffered from enhanced oxidative stress, as evidenced by increased levels of reactive oxygen species (ROS) and consequentially elevated apoptosis. As for Cd administration in vivo, impaired erythropoiesis in bone marrow and dramatic extramedullary erythropoiesis in spleen were observed in Hri(-/-) mice. Taken together, our combined data highlighted a crucial role of Hri in protecting survival and differentiation of erythroid progenitor cells upon Cd treatment.

Pharmacodynamic model for chemotherapy-induced anemia in rats

Anticancer agents often cause bone marrow toxicity resulting in progressive anemia which may influence the therapeutic effects of erythropoietic-stimulating agents. The objective of this study was to develop a pharmacodynamic (PD) model to describe chemotherapy-induced anemia in rats. Anemia was induced in male Wistar rats with a single intravenous (i.v.) injection of 60 mg/kg carboplatin. Hematological responses including reticulocytes, red blood cells (RBC), hemoglobin, and endogenous rat erythropoietin (EPO) were measured for up to 4 weeks. A catenary, lifespan-based, indirect response model served as a basic PD model to represent erythroid cellular populations in the bone marrow and blood involved in erythropoiesis. The model assumed that actively proliferating progenitor cells in the bone marrow are sensitive to anti-cancer agents and subject to an irreversible removal process. The removal rate of the target cells is proportional to drug activity concentrations and the cell numbers. An additional RBC loss from the circulation resulting from thrombocytopenia was described by a first-order process. The turnover process of rat EPO and EPO-mediated feedback inhibition mechanism regulated by hemoglobin changes were incorporated. Reticulocyte counts decreased rapidly and reached a nadir by day 3 after administration of carboplatin and returned to the baseline by day 13. This was followed by a gradual increase and the rebound peak occurred at about day 15. The hemoglobin nadir was approximately 9 g/dl observed at about 11-13 days compared to its normal value of 13 g/dl and hemoglobin returned to the baseline by day 30. The increase in endogenous rat EPO mirrored inversely hemoglobin changes and the maximum increase was observed soon after the hemoglobin nadir. The carboplatin-treated rats exhibited progressive anemia. The proposed model adequately described the time course of hematological changes after carboplatin in rats and can be a useful tool to explore potential strategies for the management of anemia caused by chemotherapy.

Reticulocyte analysis by flow cytometry and other techniques

Enumeration of peripheral blood reticulocytes is an essential part of the diagnosis and management of anemic patients, since the number of reticulocytes in the peripheral blood reflects the erythrocytic activity of the bone marrow. Reticulocyte enumeration using flow cytometric methodology is rapidly replacing the inaccurate, imprecise manual counting technique used in the past. This article explores the pathophysiology of the reticulocyte, the various means of counting reticulocytes, and the diverse clinical applications of reticulocyte data.

Diagnostic advances in defining erythropoietic abnormalities and red blood cell diseases

The majority of clinical applications of flow cytometry begin with various approaches to remove red blood cells (RBCs) from the clinical sample. However, multiparameter cytometry has and will continue to contribute much to the understanding of the pathophysiology and diagnostic accuracy in the clinical evaluation of human diseases affecting erythroid cells. This review summarizes the diagnostic advances relating to erythroid cells in the areas of immunohematology, laboratory hematology, and infectious disease with particular emphasis on medical evaluation of the anemic patient and fetomaternal hemorrhage. Semin Hematol 38:148-159.

The effect of GM-CSF on reticulocytes, haemoglobin and haematocrit in patients receiving chemotherapy for solid tumours

The effect of granulocyte-macrophage colony stimulating factor (GM-CSF) on reticulocytes, haemoglobin and haematocrit levels of patients receiving chemotherapy for solid tumours was assessed. Forty-two patients were randomized into two groups who either did or did not receive GM-CSF 300 U/d on days 8 and 15 post-chemotherapy for neutropenia prophylaxis. Patients were stratified according to tumour type (non small-cell lung cancer, small-cell lung cancer, ovarian and breast cancer). Eight patients with progressive disease were excluded. The 34 patients evaluated completed six chemotherapeutic cycles of 21 days. They did not receive transfusions or erythropoietin. The estimated dose intensities (mg/m2/d) for each drug used were significantly higher in the group on GM-CSF compared to the group without. Haemoglobin and haematocrit were measured by the H * 1 (Bayer) haematology analyser and reticulocyte counts by the flow-cytometric reticulocyte analyser, R-1000 (Sysmex). Measurements were conducted on days 1 and 12 of every cycle for six cycles. At the beginning of therapy there were no significant differences between the two groups. However, red cell and reticulocyte counts fell significantly in the group without GM-CSF compared to the group on GM-CSF. Reticulocyte differences preceded those of haemoglobin and haematocrit. The data indicate a positive in vivo effect of GM-CSF on the erythroid tissue of patients receiving chemotherapy for solid tumours.

Flow cytometric reticulocyte maturity index: a useful laboratory parameter of erythropoietic activity in anemia

Flow cytometric reticulocyte analysis is superior to manual reticulocyte counting with respect to precision and sensitivity. Furthermore, because the fluorescence intensity of reticulocytes is directly proportional to the erythrocyte RNA content, flow cytometric analysis using thiazole orange gives a quantitative reticulocyte maturity index (RMI). Previous studies have demonstrated that the RMI parameter is the earliest indicator of bone marrow engraftment following transplantation. In the present study, we analyzed the correlation of the RMI to standard red cell parameters, reticulocyte percentage, and absolute reticulocyte count in 413 anemic patients. The correlation of RMI to serum erythropoietin (Epo) and serum transferrin receptor (TfR) was analyzed in a subset of anemic blood samples. We found weak correlations between the RMI and hemoglobin (r2 = 0.041), hematocrit (r2 = 0.038), reticulocyte percentage (r2 = 0.078), and absolute reticulocyte count (r2 = 0.087). Stronger correlations were observed between the RMI and Epo (r2 = 0.181) and the TfR (r2 = 0.191). The results indicate that the RMI represents a cost-effective measurement of erythropoietic activity and provides an additional parameter to classify anemic patients into categories of high and low erythropoietic activity, especially in hypoproductive anemias.

Automated measurement of reticulated platelets in estimating thrombopoiesis

We described a fully automated measurement of reticulated platelets using a fluorescent dye, auramine O, and a reticulocyte counter, the R-3000, equipped with special software. Reproducibility and linearity were shown to be good. In the normal subjects studied (n = 60), the mean value for reticulated platelets was 0.98% +/- 0.41% and the mean absolute count was 2.12 +/- 0.69 x 10(9)/l. The absolute count for reticulated platelets was significantly lower (p < 0.05) in patients with reduced thrombopoiesis as seen in acute myeloblastic leukemia, aplastic anemia or chemotherapy-induced thrombocytopenia and it was elevated (p < 0.05) in essential thrombocythemia and in chronic myelocytic leukemia with thrombocytosis. All 20 patients with chronic idiopathic thrombocytopenic purpura had a high percentage of reticulated platelets. The percentage of reticulated platelets was significantly increased (p < 0.05) in patients with impaired thrombopoiesis despite the reduction in the absolute count. In 2 leukemic patients, an apparent rise was noticed in the percentage of reticulated platelets which preceded by several days a progressive increase in the platelet count at the recovery phase of thrombocytopenia. The results suggest that an automated measurement of reticulated platelets can be applied to routine laboratories for clinical use.

Flow cytometric detection of abnormal fetal erythropoiesis: application to 5-fluorouracil-induced anemia

We sought to determine whether flow cytometric analysis of circulating fetal blood cells could be used to rapidly detect perturbations of fetal erythropoiesis. In addition, we wanted to determine whether this approach would allow sample collection by exsanguination instead of fetal cardiac puncture, a difficult technique used to prevent contamination of samples with maternal erythrocytes. To monitor fetal erythropoiesis from gestational day (GD) 14-20, we analyzed the cell size, RNA content, and percentage of circulating liver-derived reticulocytes relative to yolk-sac-derived erythroblasts. As a model toxicant, we chose 5-fluorouracil (5-FU), since we previously observed that maternal administration at 20-40 mg/kg on gestational day (GD) 14 produced fetal anemia on GD 16-17, as evidenced by dose-dependent decreases in the cell counts, hematocrit, and hemoglobin content of fetal blood obtained by cardiac puncture. We report herein that 48 hr after maternal 5-FU administration, both cardiac and peripheral blood samples exhibited a dose-dependent decrease in the relative percentage of reticulocytes, indicating a reduced rate of reticulocyte release from the fetal liver. Moreover, at 30 and 40 mg/kg, reticulocytes exhibited increased size and reduced RNA content on GD 16, but elevated RNA content (indicative of premature release) by GD 18. These data suggest that 5-FU inhibits both erythroid cell proliferation and RNA synthesis reversibly, resulting in an anemia that triggers compensatory release of immature reticulocytes.(ABSTRACT TRUNCATED AT 250 WORDS)

Reticulocyte maturity as an indicator for estimating qualitative abnormality of erythropoiesis

AIMS

To determine the maturity of reticulocytes in patients with anaemia as a result of various haematological disorders including those with qualitative abnormalities such as ineffective erythropoiesis or dyserythropoiesis.

METHODS

The number of mature reticulocytes was measured with flow cytometry in venous blood samples from 122 patients with haematological disorders and 100 healthy controls. Reticulocytes were classified into three categories by the fluorescence intensity of auramin O staining: low fluorescence ratio (LFR), medium fluorescence ratio (MFR), and high fluorescence ratio (HFR). Immature reticulocytes were determined as the aggregate of MFR and HFR (%).

RESULTS

The mean (2SD) number of immature reticulocytes in 100 normal subjects was 9.0 (7.0)%. Significantly high mean values of immature reticulocytes with a normal or reduced reticulocyte count were shown in 90 patients with dyserythropoietic or ineffective erythropoietic conditions, such as acute myeloid leukaemia (AML) (n = 37), myelodysplastic syndrome (MDS) (n = 35), aplastic anaemia (AA) (n = 8), or megaloblastic anaemia (MA), (n = 6). Reticulocyte ratios returned to normal after successful treatment of patients with AML (n = 10) and MA (n = 3). However, high percentages of immature reticulocytes with increased reticulocyte counts were consistently observed in patients with enhanced erythropoiesis such as those with acquired autoimmune haemolytic anaemias (AIHA) (n = 4) or acute blood loss (ABL) (n = 4). Reticulocyte maturity was within the normal range in patients with reduced erythropoiesis such as occurs in chronic renal failure (CRF) (n = 11), or in iron deficiency anaemia (IDA) (n = 13).

CONCLUSIONS

The evaluation of reticulocyte maturity with total reticulocyte count seems to be clinically useful for estimating the qualitative impairment of erythropoiesis, and so could help differentiate haematological disorders.

Flow cytometric reticulocyte analysis and the reticulocyte maturity index

Reticulocyte analysis has evolved to one of the accepted and routinely practiced clinical applications of flow cytometry technology. Similar to CD4 measurements, FCM technology has contributed to documented improvements in reticulocyte counting precision over previous microscope-based techniques. The ability to FCM instruments to quantitate fluorescence intensity has been utilized to derive a parameter of reticulocyte maturity, which we have termed the reticulocyte maturity index. The FCM-derived RMI parameter offers an additional perspective to assess the erythropoietic response in anemic patients over reticulocyte counting alone and provides further insight into the differential diagnosis of anemia. Clinical utility of the RMI has been reported in monitoring expensive, new-technology therapies, such as bone marrow transplantation and erythropoietin therapy. FCM reticulocyte analysis is still not fully mature, but is in a state of continued evolution. Needs exist for (i) improved software for data analysis, (ii) newer automation techniques to improve interlaboratory correlations, and (iii) further validation and refinement of the reticulocyte maturity index parameter.

Proposal for standardization of flow cytometric reticulocyte maturity index (RMI) measurements

Flow cytometric (FCM) reticulocyte analysis is more accurate, sensitive, and reproducible relative to previously employed manual microscopic methods in clinical laboratory hematology. FCM reticulocyte analysis using RNA binding fluorochromes additionally allows for the quantification of fluorescence intensity or population distribution of the reticulocyte RNA content. Viewed from the perspective of erythroid maturation, quantification of the fluorescence intensity distribution provides a reticulocyte maturation index (RMI). We performed a systematic study of 18 different methods to express thiazole orange stained reticulocyte fluorescence intensity, compared to standard mean fluorescence intensity quantification, using 185 anemic and non-anemic human blood samples. The method best correlating with the mean fluorescence intensity RMI on 2 different FCM instruments (R2 = 0.93 and 0.86) was a ratio of the highly fluorescent reticulocytes, defined using a normal adult population, and the total number of reticulocytes (HFR%). In contrast to mean fluorescence intensity measurements, a HFR% RMI parameter can provide similar units of expression (0.01-1.00) with good correlation between different FCM instruments (R2 = 0.76). We conclude the HFR% method of RMI expression provides a superior means of interlaboratory standardization and clinical comprehension of this useful diagnostic parameter in clinical laboratory hematology.