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Delvasto-Núñez L, Roem D, Bakhtiari K, van Mierlo G, Meijers JCM, Jongerius I, Zeerleder SS. Iron-Driven Alterations on Red Blood Cell-Derived Microvesicles Amplify Coagulation during Hemolysis via the Intrinsic Tenase Complex. Thromb Haemost 2021. [PMID: 34171935 DOI: 10.1055/s-0041-1731051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Hemolytic disorders characterized by complement-mediated intravascular hemolysis, such as autoimmune hemolytic anemia and paroxysmal nocturnal hemoglobinuria, are often complicated by life-threatening thromboembolic complications. Severe hemolytic episodes result in the release of red blood cell (RBC)-derived proinflammatory and oxidatively reactive mediators (e.g., extracellular hemoglobin, heme, and iron) into plasma. Here, we studied the role of these hemolytic mediators in coagulation activation by measuring factor Xa (FXa) and thrombin generation in the presence of RBC lysates. Our results show that hemolytic microvesicles (HMVs) formed during hemolysis stimulate thrombin generation through a mechanism involving FVIII and FIX, the so-called intrinsic tenase complex. Iron scavenging during hemolysis using deferoxamine decreased the ability of the HMVs to enhance thrombin generation. Furthermore, the addition of ferric chloride (FeCl3) to plasma propagated thrombin generation in a FVIII- and FIX-dependent manner suggesting that iron positively affects blood coagulation. Phosphatidylserine (PS) blockade using lactadherin and iron chelation using deferoxamine reduced intrinsic tenase activity in a purified system containing HMVs as source of phospholipids confirming that both PS and iron ions contribute to the procoagulant effect of the HMVs. Finally, the effects of FeCl3 and HMVs decreased in the presence of ascorbate and glutathione indicating that oxidative stress plays a role in hypercoagulability. Overall, our results provide evidence for the contribution of iron ions derived from hemolytic RBCs to thrombin generation. These findings add to our understanding of the pathogenesis of thrombosis in hemolytic diseases.
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Affiliation(s)
- Laura Delvasto-Núñez
- Sanquin Research, Department of Immunopathology, Amsterdam, The Netherlands, and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Hematology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Dorina Roem
- Sanquin Research, Department of Immunopathology, Amsterdam, The Netherlands, and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kamran Bakhtiari
- Department of Molecular Hematology, Sanquin Research, Amsterdam, The Netherlands
| | - Gerard van Mierlo
- Sanquin Research, Department of Immunopathology, Amsterdam, The Netherlands, and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joost C M Meijers
- Department of Molecular Hematology, Sanquin Research, Amsterdam, The Netherlands.,Department of Experimental Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ilse Jongerius
- Sanquin Research, Department of Immunopathology, Amsterdam, The Netherlands, and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Pediatric Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
| | - Sacha S Zeerleder
- Sanquin Research, Department of Immunopathology, Amsterdam, The Netherlands, and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Hematology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Hematology and Central Hematology Laboratory, Inselspital - Bern University Hospital, University of Bern, Bern, Switzerland.,Department for BioMedical Research, University of Bern, Bern, Switzerland
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2
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Delvasto L, Roem D, Bakhtiari K, van Mierlo GJ, Meijers J, Jongerius I, Zeerleder SS. Iron-driven alterations on red blood cell-derived microvesicles amplify coagulation during hemolysis via the intrinsic tenase complex. Thromb Haemost 2021; 122:80-91. [PMID: 33940654 DOI: 10.1055/a-1497-9573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Hemolytic disorders characterized by complement-mediated intravascular hemolysis, such as autoimmune hemolytic anemia and paroxysmal nocturnal hemoglobinuria, are often complicated by life-threatening thromboembolic complications. Severe hemolytic episodes result in the release of red blood cell (RBC)-derived pro-inflammatory and oxidatively reactive mediators (e.g. extracellular hemoglobin, heme and iron) into plasma. Here, we studied the role of these hemolytic mediators in coagulation activation by measuring FXa and thrombin generation in the presence of RBC lysates. Our results show that hemolytic microvesicles (HMVs) formed during hemolysis stimulate thrombin generation through a mechanism involving FVIII and FIX, the so-called intrinsic tenase complex. Iron scavenging during hemolysis using deferoxamine decreased the ability of the HMVs to enhance thrombin generation. Furthermore, the addition of ferric chloride (FeCl3) to plasma propagated thrombin generation in a FVIII and FIX-dependent manner suggesting that iron positively affects blood coagulation. Phosphatidylserine (PS) blockade using lactadherin and iron chelation using deferoxamine reduced intrinsic tenase activity in a purified system containing HMVs as source of phospholipids confirming that both PS and iron ions contribute to the procoagulant effect of the HMVs. Finally, the effects of FeCl3 and HMVs decreased in the presence of ascorbate and glutathione indicating that oxidative stress plays a role in hypercoagulability. Overall, our results provide evidence for the contribution of iron ions derived from hemolytic RBCs to thrombin generation. These findings add to our understanding of the pathogenesis of thrombosis in hemolytic diseases.
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Affiliation(s)
| | | | | | | | | | - Ilse Jongerius
- Sanquin Research, Amsterdam, Netherlands.,Department of Pediatric Immunology, Rheumatology and Infectious Diseases, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Sacha S Zeerleder
- Department of Immunopathology, Sanquin-AMC Landsteiner Laboratory, Amsterdam, Netherlands.,Department of Hematology, Academic Medical Center, Amsterdam, Netherlands
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3
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Delvasto-Nuñez L, Jongerius I, Zeerleder S. It takes two to thrombosis: Hemolysis and complement. Blood Rev 2021; 50:100834. [PMID: 33985796 DOI: 10.1016/j.blre.2021.100834] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 01/12/2023]
Abstract
Thromboembolic events represent the most common complication of hemolytic anemias characterized by complement-mediated hemolysis such as paroxysmal nocturnal hemoglobinuria and autoimmune hemolytic anemia. Similarly, atypical hemolytic uremic syndrome is characterized by hemolysis and thrombotic abnormalities. The main player in the development of thrombosis in hemolytic diseases is suggested to be the complement system. However, the release of extracellular hemoglobin and heme by hemolysis itself can also drive procoagulant responses. Both, complement activation and hemolysis promote the activation of neutrophils resulting in the formation of neutrophil extracellular traps and induce inflammation and vascular damage which all together might (synergistically) lead to hypercoagulability. In this review we aim to summarize the current knowledge on the role of complement activation and hemolysis in the onset of thrombosis in hemolytic diseases. This review will discuss the interplay between different biological systems and neutrophil activation contributing to the pathogenesis of thrombosis. Finally, we will combine this fundamental knowledge and address the pathophysiology of hemolysis in prototypical complement-driven diseases.
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Affiliation(s)
- Laura Delvasto-Nuñez
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Hematology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ilse Jongerius
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Pediatric Immunology, Amsterdam UMC, University of Amsterdam, Rheumatology and Infectious Diseases, Emma Children's Hospital, Amsterdam, the Netherlands
| | - Sacha Zeerleder
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Switzerland; Department for BioMedical Research, University of Bern, Switzerland.
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4
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Lapping-Carr G, Gemel J, Mao Y, Beyer EC. Circulating Extracellular Vesicles and Endothelial Damage in Sickle Cell Disease. Front Physiol 2020; 11:1063. [PMID: 33013455 PMCID: PMC7495019 DOI: 10.3389/fphys.2020.01063] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/31/2020] [Indexed: 12/12/2022] Open
Abstract
Endothelial damage is central to the pathogenesis of many of the complications of sickle cell disease. Circulating extracellular vesicles (EVs) have been implicated in modulating endothelial behavior in a variety of different, diseases with vascular pathologies. As seen in other hemolytic diseases, the plasma of sickle cell patients contains EVs of different sizes and cellular sources. The medium-sized vesicles (microparticles) primarily derive from mature red blood cells and platelets; some of these EVs have procoagulant properties, while others stimulate inflammation or endothelial adhesiveness. Most of the small EVs (including exosomes) derive from erythrocytes and erythrocyte precursors, but some also originate from platelets, white blood cells, and endothelial cells. These small EVs may alter the behavior of target cells by delivering cargo including proteins and nucleic acids. Studies in model systems implicate small EVs in promoting vaso-occlusion and disruption of endothelial integrity. Thus, both medium and small EVs may contribute to the increased endothelial damage in sickle cell disease. Development of a detailed understanding of the composition and roles of circulating EVs represents a promising approach toward novel predictive diagnostics and therapeutic approaches in sickle cell disease.
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Affiliation(s)
| | - Joanna Gemel
- Department of Pediatrics, The University of Chicago, Chicago, IL, United States
| | - Yifan Mao
- Department of Pediatrics, The University of Chicago, Chicago, IL, United States
| | - Eric C Beyer
- Department of Pediatrics, The University of Chicago, Chicago, IL, United States
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5
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Freitas Leal JK, Preijers F, Brock R, Adjobo-Hermans M, Bosman G. Red Blood Cell Homeostasis and Altered Vesicle Formation in Patients With Paroxysmal Nocturnal Hemoglobinuria. Front Physiol 2019; 10:578. [PMID: 31156458 PMCID: PMC6529780 DOI: 10.3389/fphys.2019.00578] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 04/24/2019] [Indexed: 12/26/2022] Open
Abstract
A subset of the red blood cells (RBCs) of patients with paroxysmal nocturnal hemoglobinuria (PNH) lacks GPI-anchored proteins. Some of these proteins, such as CD59, inhibit complement activation and protect against complement-mediated lysis. This pathology thus provides the possibility to explore the involvement of complement in red blood cell homeostasis and the role of GPI-anchored proteins in the generation of microvesicles (MVs) in vivo. Detailed analysis of morphology, volume, and density of red blood cells with various CD59 expression levels from patients with PNH did not provide indications for a major aberration of the red blood cell aging process in patients with PNH. However, our data indicate that the absence of GPI-anchored membrane proteins affects the composition of red blood cell-derived microvesicles, as well as the composition and concentration of platelet-derived vesicles. These data open the way toward a better understanding on the pathophysiological mechanism of PNH and thereby to the development of new treatment strategies.
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Affiliation(s)
| | - Frank Preijers
- Laboratory for Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Roland Brock
- Department of Biochemistry, Radboud University Medical Center, Nijmegen, Netherlands
| | - Merel Adjobo-Hermans
- Department of Biochemistry, Radboud University Medical Center, Nijmegen, Netherlands
| | - Giel Bosman
- Department of Biochemistry, Radboud University Medical Center, Nijmegen, Netherlands
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6
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Ben-Zeev B, Tabib A, Nissenkorn A, Garti BZ, Gomori JM, Nass D, Goldshmidt H, Fellig Y, Anikster Y, Nevo Y, Elpeleg O, Mevorach D. Devastating recurrent brain ischemic infarctions and retinal disease in pediatric patients with CD59 deficiency. Eur J Paediatr Neurol 2015; 19:688-93. [PMID: 26233519 DOI: 10.1016/j.ejpn.2015.07.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 07/01/2015] [Accepted: 07/07/2015] [Indexed: 12/17/2022]
Abstract
Identification of CD59 p.Cys89Tyr mutation in 5 patients from North-African Jewish origin presenting with chronic inflammatory demyelinating polyradiculoneuropathy like disease and chronic hemolysis, led us to reinvestigate an unsolved disease in 2 siblings from the same origin who died 17 years ago. The two patients carried the same CD59 gene mutation previously described by our group. These children had quiet similar disease course but in addition developed devastating recurrent brain infarctions, retinal and optic nerve involvement. Revising the brain autopsy of one of these patients confirmed the finding of multiple brain infarctions of different ages. CD59 protein expression was missing on brain endothelial cells by immunohistochemical staining. This new data expands the clinical spectrum of CD59 mutations and further emphasizes the need for its early detection and treatment.
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Affiliation(s)
- Bruria Ben-Zeev
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Israel.
| | - Adi Tabib
- Rheumatology Research Center and Department of Medicine, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Andreea Nissenkorn
- Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Israel
| | - Ben-Zion Garti
- Sackler School of Medicine, Tel-Aviv University, Israel; Pediatric B Department, Shneider Pediatric Hospital, Belinson Medical Center, Petach Tikva, Israel
| | - John Moshe Gomori
- Neuroimaging Unit, Department of Radiology, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Dvora Nass
- Pathology Department, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel
| | - Hanoch Goldshmidt
- Clinical Laboratory, Hadassah Medical Center, Hebrew University Medical Center, Jerusalem, Israel
| | - Yakov Fellig
- Department of Pathology, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Yair Anikster
- Sackler School of Medicine, Tel-Aviv University, Israel; Pediatric Metabolic Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel
| | - Yoram Nevo
- Pediatric Neurology Institute, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Orly Elpeleg
- Monique and Jacques Roboh Department of Genetic Research, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Dror Mevorach
- Department of Medicine B Director, Center for Research in Rheumatology, Hadassah Medical Center, Hebrew University, Jerusalem, Israel.
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7
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Fibach E, Dana M. Oxidative stress in paroxysmal nocturnal hemoglobinuria and other conditions of complement-mediated hemolysis. Free Radic Biol Med 2015; 88:63-9. [PMID: 25937178 DOI: 10.1016/j.freeradbiomed.2015.04.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 02/23/2015] [Accepted: 04/21/2015] [Indexed: 12/11/2022]
Abstract
The complement (C') system and redox status play important roles in the physiological functioning of the body, such as the defense system, but they are also involved in various pathological conditions, including hemolytic anemia. Herein, we review the interaction between the C' and the redox systems in C'-mediated hemolytic anemias, paroxysmal nocturnal hemoglobinuria (PNH) and autoimmune hemolytic anemia, including acute hemolytic transfusion reaction. Blood cells in these diseases have been shown to have increased oxidative status, which was further elevated by interaction with activated C'. The results suggest that oxidative stress, in conjunction with activated C', may cause the underlying symptoms of these diseases, such as intra- and extravascular hemolysis and thrombotic complications. Antioxidants ameliorate oxidative stress by preventing generation of free radicals, by scavenging and preventing their accumulation, and by correcting their cellular damage. Antioxidants have been shown to reduce the oxidative stress and inhibit hemolysis as well as platelet activation mediated by activated C'. This raises the possibility that treatment with antioxidants might be considered as a potential therapeutic modality for C'-mediated hemolytic anemias. Currently, eculizumab, a humanized monoclonal antibody that specifically targets the C' protein C5, is the main treatment modality for PNH. However, because antioxidants are well tolerated and relatively inexpensive, they might be considered as potential adjuvants or an alternative therapeutic modality for PNH and other C'-mediated hemolytic anemias.
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Affiliation(s)
- Eitan Fibach
- Department of Hematology, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel.
| | - Mutaz Dana
- Department of Hematology, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel
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8
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van Bijnen STA, Østerud B, Barteling W, Verbeek-Knobbe K, Willemsen M, van Heerde WL, Muus P. Alterations in markers of coagulation and fibrinolysis in patients with Paroxysmal Nocturnal Hemoglobinuria before and during treatment with eculizumab. Thromb Res 2015; 136:274-81. [PMID: 26143713 DOI: 10.1016/j.thromres.2015.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 06/04/2015] [Accepted: 06/08/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Paroxysmal Nocturnal Hemoglobinuria is characterized by complement-mediated hemolysis and an increased thrombosis risk. Eculizumab, an antibody to complement factor C5, reduces thrombotic risk via unknown mechanisms. Clinical observations suggest that eculizumab has an immediate effect. OBJECTIVES A better understanding of the mechanism via which eculizumab reduces thrombotic risk by studying its pharmacodynamic effect on coagulation and fibrinolysis. METHODS We measured microparticles (MP), tissue factor (TF) activity, prothrombin fragment 1+2 (F1+2), D-dimer and simultaneously thrombin and plasmin generation in 55 PNH patients. In 20 patients, parameters were compared before and during eculizumab treatment (at 1 and 2hours, 1, 4 and≥12weeks after commencement). RESULTS Patients with a history of thrombosis had elevated D-dimers (p=0.02) but not MP. Among patients on anticoagulants, those with thrombosis had higher F1+2 concentrations (p=0.003). TF activity was undetectable in plasma MP. Unexpectedly, thrombin peak height and thrombin potential were significantly lower in PNH patients than in healthy controls. Fibrinolysis parameters were normal. During eculizumab treatment D-dimer levels significantly decreased after 1hour (p=0.008) and remained decreased at≥12weeks (p=0.03). F1+2 (p=0.03) and thrombin peak height (p=0.02) in patients not on anticoagulants significantly decreased at≥week 12. MP remained unchanged. CONCLUSIONS Eculizumab induces an immediate decrease of D-dimer levels but not of other markers. The decrease in thrombin peak height and F1+2 suggests that eculizumab reduces thrombin generation. Elevated D-dimer levels in untreated PNH patients with a history of thrombosis suggest possible value in predicting thrombotic risk.
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Affiliation(s)
| | - B Østerud
- Department of Laboratory Medicine, Laboratory of Hematology, Radboudumc, Nijmegen, The Netherlands
| | - W Barteling
- Department of Medical Biology, Faculty of Health Sciences, University of Tromsø, Norway
| | - K Verbeek-Knobbe
- Department of Medical Biology, Faculty of Health Sciences, University of Tromsø, Norway
| | - M Willemsen
- Department of Medical Biology, Faculty of Health Sciences, University of Tromsø, Norway
| | - W L van Heerde
- Department of Medical Biology, Faculty of Health Sciences, University of Tromsø, Norway
| | - P Muus
- Department of Hematology, Radboudumc, Nijmegen, The Netherlands.
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9
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Kidd L, Geddings J, Hisada Y, Sueda M, Concannon T, Nichols T, Merricks E, Mackman N. Procoagulant microparticles in dogs with immune-mediated hemolytic anemia. J Vet Intern Med 2015; 29:908-16. [PMID: 25871966 PMCID: PMC4895429 DOI: 10.1111/jvim.12583] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 12/04/2014] [Accepted: 03/03/2015] [Indexed: 12/12/2022] Open
Abstract
Background Studies of some human prothrombotic diseases suggest that phosphatidylserine‐positive (PS+) and tissue factor‐positive (TF+) microparticles (MPs) might play a role in the pathogenesis of thrombosis or serve as biomarkers of thrombotic risk. Hypothesis/Objectives To determine if circulating levels of PS+MP and procoagulant activity (PCA) associated with PS+MPs and TF+ MPs are increased in dogs with IMHA. Animals Fifteen dogs with primary or secondary IMHA and 17 clinically healthy dogs. Methods Prospective case‐controlled observational study. Circulating PS+MPs were measured by flow cytometry. PCA associated with PS+MPs and TF+MPs was measured by thrombin and Factor Xa generating assays, respectively. Results Circulating numbers of PS+MPs were not significantly higher in dogs with IMHA [control median 251,000/μL (36,992–1,141,250/μL); IMHA median 361,990/μL (21,766–47,650,600/μL) P = .30]. However, PS+MP PCA [control median 2.2 (0.0–16.8) nM PS eq; IMHA median 8.596, (0–49.33 nM PS eq) P = .01] and TF+MP PCA [control median 0.0, (0.0–0.0 pg/mL); IMHA median 0.0; (0–22.34 pg/mL], P = .04) were increased. Intravascular hemolysis, which we showed might increase PS+ and TF+MP PCA, was evident in 3 of 5 dogs with PS+MP PCA and 2 of 4 dogs with TF+MP PCA higher than controls. Underlying disease in addition to IMHA was detected in 1 of 5 dogs with PS+PCA and 3 of 4 dogs with TF+MP PCA higher than controls. Conclusions and Clinical Importance TF+ and PS+MP PCA is increased in some dogs with IMHA. Further studies that determine if measuring TF+ and PS+ MP PCA can help identify dogs at risk for thrombosis are warranted.
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Affiliation(s)
- L Kidd
- Western University of Health Sciences College of Veterinary Medicine, Pomona, CA
| | - J Geddings
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Y Hisada
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - M Sueda
- California Veterinary Specialists, Ontario, CA
| | - T Concannon
- California Veterinary Specialists, Ontario, CA
| | - T Nichols
- Francis Owen Blood Research Laboratory Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - E Merricks
- Francis Owen Blood Research Laboratory Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - N Mackman
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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10
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Abstract
The most frequent and feared complication of paroxysmal nocturnal hemoglobinuria (PNH) is thrombosis. Recent research has demonstrated that the complement and coagulation systems are closely integrated with each influencing the activity of the other to the extent that thrombin itself has recently been shown to activate the alternative pathway of complement. This may explain some of the complexity of the thrombosis in PNH. In this review, the recent changes in our understanding of the pathophysiology of thrombosis in PNH, as well as the treatment of thrombosis, will be discussed. Mechanisms explored include platelet activation, toxicity of free hemoglobin, nitric oxide depletion, absence of other glycosylphosphatidylinositol-linked proteins such as urokinase-type plasminogen activator receptor and endothelial dysfunction. Complement inhibition with eculizumab has a dramatic effect in PNH and has a major impact in the prevention of thrombosis as well as its management in this disease.
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11
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12
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Van Bijnen STA, Van Heerde WL, Muus P. Mechanisms and clinical implications of thrombosis in paroxysmal nocturnal hemoglobinuria. J Thromb Haemost 2012; 10:1-10. [PMID: 22077430 DOI: 10.1111/j.1538-7836.2011.04562.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired disease characterized by a clone of blood cells lacking glycosyl phosphatidylinositol (GPI)-anchored proteins at the cell membrane. Deficiency of the GPI-anchored complement inhibitors CD55 and CD59 on erythrocytes leads to intravascular hemolysis upon complement activation. Apart from hemolysis, another prominent feature is a highly increased risk of thrombosis. Thrombosis in PNH results in high morbidity and mortality. Often, thrombosis occurs at unusual locations, with the Budd–Chiari syndrome being the most frequent manifestation. Primary prophylaxis with vitamin K antagonists reduces the risk but does not completely prevent thrombosis. Eculizumab, a mAb against complement factor C5, effectively reduces intravascular hemolysis and also thrombotic risk. Therefore, eculizumab treatment has dramatically improved the prognosis of PNH. The mechanism of thrombosis in PNH is still unknown, but the highly beneficial effect of eculizumab on thrombotic risk suggests a major role for complement activation. Additionally, a deficiency of GPI-anchored proteins involved in hemostasis may be implicated.
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Affiliation(s)
- S T A Van Bijnen
- Department of Hematology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
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13
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Kozuma Y, Sawahata Y, Takei Y, Chiba S, Ninomiya H. Procoagulant properties of microparticles released from red blood cells in paroxysmal nocturnal haemoglobinuria. Br J Haematol 2011; 152:631-9. [DOI: 10.1111/j.1365-2141.2010.08505.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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14
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Zhou J, Zheng Y, Shi J, Lu C, Hou J, Yu H, Qiao X, Qi S, Gilbert GE. Daunorubicin induces procoagulant response through phosphatidylserine exposure in red blood cells. Thromb Res 2010; 125:178-83. [DOI: 10.1016/j.thromres.2009.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2009] [Revised: 08/04/2009] [Accepted: 09/08/2009] [Indexed: 11/29/2022]
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15
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Oxidative status of red blood cells, neutrophils, and platelets in paroxysmal nocturnal hemoglobinuria. Exp Hematol 2008; 36:369-77. [DOI: 10.1016/j.exphem.2007.12.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2007] [Revised: 11/27/2007] [Accepted: 12/05/2007] [Indexed: 02/01/2023]
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16
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Mannari D, Liu C, Hughes D, Mehta A. The role of heparin in alleviating complement-mediated acute intravascular haemolysis. Acta Haematol 2008; 119:166-8. [PMID: 18493118 DOI: 10.1159/000134221] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Accepted: 03/05/2008] [Indexed: 11/19/2022]
Abstract
Heparin is commonly used as an anticoagulant but its many other pharmacologic properties are less well known. It has an important effect on complement regulation and has been shown in vitro to inhibit complement-mediated lysis of red cells. Although the beneficial effects of heparin for treatment of haemolytic anaemia were described many decades ago, its use in this scenario is not standard practice. Here we report a case where the use of heparin had a beneficial effect on a life-threatening episode of intravascular haemolysis. We also show unfractionated heparin to be more beneficial than low molecular weight heparin. We suggest that heparin has an important role to play in the management of complement-mediated haemolytic episodes.
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Affiliation(s)
- Deepak Mannari
- Department of Haematology, Royal Free Hospital, London, UK.
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17
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Noji H, Shichishima T, Okamoto M, Shichishima-Nakamura A, Matsumoto H, Tajima H, Ogawa K, Maruyama Y. Microvascular thrombosis in the hepatic vein of a patient with paroxysmal nocturnal hemoglobinuria. Int J Hematol 2007; 86:216-21. [PMID: 17988986 DOI: 10.1532/ijh97.07064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by complement-mediated hemolysis, venous thrombosis, and bone marrow failure. In May 2003, a 33-year-old man was admitted to a hospital with right hypochondralgia and fever. He had a history of aplastic anemia. The patient's diagnosis of diffuse microvessel thrombosis in the hepatic vein due to an unknown cause was derived from the findings of a contrast-enhanced computed tomography examination of the abdominal region, angiographic evaluation of abdominal vessels, and pathohistologic examination of a liver biopsy sample. The patient was subsequently treated with warfarin. The abdominal pain and fever continued, however, and anemia gradually appeared. In April 2004, the patient was referred to our hospital to examine the cause of the thrombosis. On admission, slight anemia and a low serum haptoglobin level were observed. A flow cytometry evaluation of CD55 and/or CD59, CD59, and CD48 expression in erythrocytes, granulocytes, and monocytes, respectively, showed that the respective proportions of negative populations were 5.6%, 97.1%, and 96.2%. The patient then received a diagnosis of aplastic anemia/PNH syndrome, which had caused the hemolytic anemia and thrombosis, although no hemoglobinuria had been observed during his clinical course. This patient is, to our knowledge, the first reported case of a PNH patient with thrombosis present only in hepatic microvessels and not in hepatic large vessels, in spite of the presence of few hemolytic events.
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Affiliation(s)
- Hideyoshi Noji
- First Department of Internal Medicine, Fukushima Medical University, Fukushima, Japan
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Microvascular thrombosis in the hepatic vein of a patient with paroxysmal nocturnal hemoglobinuria. Int J Hematol 2007. [DOI: 10.1007/bf03006923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Chung SM, Bae ON, Lim KM, Noh JY, Lee MY, Jung YS, Chung JH. Lysophosphatidic Acid Induces Thrombogenic Activity Through Phosphatidylserine Exposure and Procoagulant Microvesicle Generation in Human Erythrocytes. Arterioscler Thromb Vasc Biol 2007; 27:414-21. [PMID: 17110600 DOI: 10.1161/01.atv.0000252898.48084.6a] [Citation(s) in RCA: 195] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Although erythrocytes have been suggested to play a role in blood clotting, mediated through phosphatidylserine (PS) exposure and/or PS-bearing microvesicle generation, an endogenous substance that triggers the membrane alterations leading to a procoagulant activity in erythrocytes has not been reported. We now demonstrated that lysophosphatidic acid (LPA), an important lipid mediator in various pathophysiological processes, induces PS exposure and procoagulant microvesicle generation in erythrocytes, which represent a biological significance resulting in induction of thrombogenic activity. METHODS AND RESULTS In human erythrocytes, LPA treatment resulted in PS exposure on remnant cells and PS-bearing microvesicle generation in a concentration-dependent manner. Consistent with the microvesicle generation, scanning electron microscopic study revealed that LPA treatment induced surface changes, alteration of normal discocytic shape into echinocytes followed by spherocytes. Surprisingly, chelation of intracellular calcium did not affect LPA-induced PS exposure and microvesicle generation. On the other hand, protein kinase C (PKC) inhibitors significantly reduced PS exposure and microvesicle generation induced by LPA, reflecting the role of calcium-independent PKC. Activation of PKC was confirmed by Western blot analysis showing translocation of calcium-independent isoform, PKCzeta, to erythrocyte membrane. The activity of flippase, which is important in the maintenance of membrane asymmetry, was also inhibited by LPA. Furthermore, LPA-exposed erythrocytes actually potentiated the thrombin generation as determined by prothrombinase assay and accelerated the coagulation process initiated by recombinant human tissue factor in plasma. The adherence of erythrocytes to endothelial cells, another important feature of thrombogenic process, was also stimulated by LPA treatment. CONCLUSIONS These results suggested that LPA-exposed erythrocytes could make an important contribution to thrombosis mediated through PS exposure and procoagulant microvesicle generation.
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Affiliation(s)
- Seung-Min Chung
- College of Pharmacy, Seoul National University, Seoul 151-742, Korea
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Shin JH, Lim KM, Noh JY, Bae ON, Chung SM, Lee MY, Chung JH. Lead-Induced Procoagulant Activation of Erythrocytes through Phosphatidylserine Exposure May Lead To Thrombotic Diseases. Chem Res Toxicol 2007; 20:38-43. [PMID: 17226925 DOI: 10.1021/tx060114+] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Lead (Pb) is a ubiquitous heavy metal pollutant in various environmental media, especially in food and drinking water. In human blood, about 95% of lead is associated with erythrocytes, suggesting that erythrocytes could be an important target of lead toxicity in the cardiovascular system. Recent studies suggested that erythrocytes could contribute to blood coagulation via phosphatidylserine (PS) exposure and resultant procoagulant activation. We investigated the effects of lead on the procoagulant activity of erythrocytes using in vitro human erythrocyte and in vivo rat models. In a flow cytometric analysis, lead (Pb2+) enhanced PS exposure on human erythrocytes in a concentration- and time-dependent manner. The concentration of lead (1-5 microM) used in the current investigation is well within the ranges observed in blood from lead-exposed populations. PS exposure by lead appeared to be mediated by increased intracellular calcium levels as shown by 19F-NMR and intracellular ATP depletion. Consistent with these findings, the activity of scramblase, which is important in the induction of PS exposure, was enhanced, whereas the activity of flippase, which translocates exposed PS to inner membrane, was inhibited by lead treatment. Furthermore, lead-exposed erythrocytes increased thrombin generation as determined by a prothrombinase assay and accelerated the coagulation process initiated by tissue factor in plasma. These procoagulant activations by lead were also confirmed in vivo. Administration of lead significantly enhanced PS exposure on erythrocytes and, more importantly, elevated thrombus formation in a rat venous thrombosis model. These results suggest that lead exposure can provoke procoagulant activity in erythrocytes by PS exposure, contributing to enhanced clot formation. These data will provide new insights into the mechanism of lead-induced cardiovascular diseases.
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Affiliation(s)
- Jung-Hun Shin
- College of Pharmacy, Seoul National University, Seoul 151-742, Korea
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Olteanu H, Xu Y. The Use of Flow Cytometry in Diagnosis of Paroxysmal Nocturnal Hemoglobinuria. Lab Med 2006. [DOI: 10.1309/naah5j8dv43c0h7n] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Nishimura JI, Kanakura Y, Ware RE, Shichishima T, Nakakuma H, Ninomiya H, Decastro CM, Hall S, Kanamaru A, Sullivan KM, Mizoguchi H, Omine M, Kinoshita T, Rosse WF. Clinical course and flow cytometric analysis of paroxysmal nocturnal hemoglobinuria in the United States and Japan. Medicine (Baltimore) 2004; 83:193-207. [PMID: 15118546 DOI: 10.1097/01.md.0000126763.68170.46] [Citation(s) in RCA: 164] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
: To determine and directly compare the clinical course of white and Asian patients with paroxysmal nocturnal hemoglobinuria (PNH), data were collected for epidemiologic analysis on 176 patients from Duke University and 209 patients from Japan. White patients were younger with significantly more classical symptoms of PNH including thrombosis, hemoglobinuria, and infection, while Asian patients were older with more marrow aplasia. The mean fraction of CD59-negative polymorphonuclear cells (PMN) at initial analysis was higher among Duke patients than Japanese patients. In both cohorts, however, a larger PNH clone was associated with classical PNH symptoms, while a smaller PNH clone was associated with marrow aplasia. Thrombosis was significantly more prevalent in white patients than Asian patients, and was associated with a significantly higher proportion of CD59-negative PMN. For individual patients, CD59-negative populations varied considerably over time, but a decreasing PNH clone portended hematopoietic failure. Survival analysis revealed a similar death rate in each group, although causes of death were different and significantly more Duke patients died from thrombosis. Japanese patients had a longer mean survival time (32.1 yr vs. 19.4 yr), although Kaplan-Meier survival curves were not significantly different. Poor survival in both groups was associated with age over 50 years, severe leukopenia/neutropenia at diagnosis, and severe infection as a complication; additionally, thrombosis at diagnosis or follow-up for Duke patients and renal failure for Japanese patients were poor prognostic factors. These data identify important differences between white and Asian patients with PNH. Identification of prognostic factors will help the design of prospective clinical trials for PNH.
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Affiliation(s)
- Jun-Ichi Nishimura
- From the PNH Research Committee (JN, REW, CMD, SH, KMS, WFR), Duke University Medical Center, Durham, North Carolina, United States; the Research Committee for the Idiopathic Hematopoietic Disorders, Ministry of Health, Labour and Welfare, Government of Japan (JN, YK, AK, HM, MO, TK); the Department of Hematology, Tokyo Women's Medical College (HM), Tokyo; the Department of Immunoregulation, Research Institute for Microbial Diseases, Osaka University (JN, TK); the Department of Hematology and Oncology, Osaka University Graduate School of Medicine (JN, YK); the Third Department of Internal Medicine, Kinki University Medical School (AK), Osaka; the Division of Hematology, Department of Medicine, Showa University Fujigaoka Hospital (MO), Kanagawa; the First Department of Internal Medicine, Fukushima Medical University (TS), Fukushima; the Department of Hematology/Oncology, Wakayama Medical University (HNakakuma), Wakayama; the Division of Hematology, College of Medical Technology, University of Tsukuba (HNinomiya), Ibaraki, Japan
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Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) arises in the setting of bone marrow injury. Thus, management decisions must take into account whether symptoms are a consequence of the underlying marrow failure or of the expansion of the clone of the PIG-A mutant hematopoietic cells. The primary clinical manifestations of PNH are intravascular hemolysis and thrombophilia. Currently available options for treatment of the hemolysis of PNH are unsatisfactory, but the recent development of specific inhibitors of complement for use in treating human disease should make possible effective management of this pathology. The fundamental basis of the thrombophilia of PNH has not been elucidated. Currently, empiric anticoagulant therapy is the foundation for treating the thromboembolic complications of PNH. The role of warfarin prophylaxis, however, remains an area of active debate. Pregnancy in a patient with PNH presents special concerns about fetal/maternal well-being because of the high potential for thromboembolic complications. Bone marrow transplantation can be considered curative, but the decision to recommend this treatment must take into account factors related both to PNH and to comorbid conditions. Refining the technology for both gene therapy (by transducing stem cells with a functional PIG-A gene) and autotransplantation (by using stem cells selected for the expression of glycosyl phosphatidylinositol-anchored proteins) remain challenges for the future.
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Affiliation(s)
- Gabrielle Meyers
- Division of Hematology, University of Utah School of Medicine and VA Medical Center, Salt Lake City, Utah 84148, USA
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Ninomiya H, Kawashima Y, Nagasawa T. Inhibition of complement-mediated haemolysis in paroxysmal nocturnal haemoglobinuria by heparin or low-molecular weight heparin. Br J Haematol 2000; 109:875-81. [PMID: 10929045 DOI: 10.1046/j.1365-2141.2000.02125.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Complement (C')-mediated haemolysis in paroxysmal nocturnal haemoglobinuria (PNH) is mainly due to the deficiency of glycosyl phosphatidylinositol-anchored membrane proteins with C'-regulatory activities CD55 and CD59 in PNH-affected red blood cells (RBCs). Hydrophobic insertion of C5b-7 to RBC membranes, initiating the formation of a membrane attack complex, readily results in lysis of PNH RBCs due to the deficiency of CD59. We studied the significance of the electrostatic interactions between C5b-6 and RBC membranes preceding the insertion of C5b-7. In vitro, C'-mediated lysis of PNH RBCs (assessed by sucrose haemolytic assay) was inhibited by heparin, low-molecular weight heparin (LMWH) or protamine, indicating the significance of the electrostatic interactions between C' components and RBC membranes in the process of C'-mediated haemolysis. Neuraminidase-treated PNH RBCs became resistant to C' activation, suggesting that the sialic acid moieties on RBC membranes are involved in the interactions of RBC with C' components. By using biotin-labelled C7, we demonstrated that LMWH as well as heparin inhibited the insertion of C5b-7 to RBCs, although they did not inhibit the incorporation of C7 into membrane-associated C5b-6. Neither heparin nor LMWH could inhibit the procoagulant alteration of PNH RBC membranes induced by C' activation even at concentrations which inhibited the haemolysis completely. Because LMWH inhibited the C'-mediated lysis of PNH RBCs in vitro at the range which induced a limited prolongation of activated partial thromboplastin time of normal plasma, we consider that LMWH may be useful for both the inhibition of haemolysis and the prevention of thrombosis, which often follow a haemolytic attack in PNH.
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Affiliation(s)
- H Ninomiya
- College of Medical Technology, and Institute of Clinical Medicine, University of Tsukuba, Japan.
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