Hemorheology in cerebrovascular diseases: approaches to drug development

Altered Hemorheology in Fontan Patients in Normoxia and After Acute Hypoxic Exercise

Background

The Fontan circulation is a unique palliation procedure for several congenital heart defects. Impaired exercise capacity has previously been demonstrated in these patients and also a higher risk for cardiopulmonary mortality. Hemorheology was shown to affect cardiopulmonary capacity and in turn to be affected by regular exercise and hypoxia but none of these have been investigated in Fontan patients so far. The aim of this study was to detect general differences in hemorheology in normoxia as well as possible altered hemorheological responses to hypoxia exposure and hypoxic exercise between Fontan patients and healthy controls.

Methods and Findings

26 Fontan patients and 20 healthy controls performed an acute exercise test (AET) on a bicycle ergometer under hypoxia with ambient 15.2% oxygen saturation (sO₂). Blood samples were taken at rest in normoxia (T0), at rest in hypoxia (T1), after maximum exhaustion in hypoxia (T2), and after 50 min recovery in normoxia (T3). Hemorheological and blood parameters were investigated. Additionally, arterial stiffness was tested at T0. Red blood cell (RBC) deformability, NOx, erythropoietin (EPO) concentration, RBC count, hemoglobin (Hb) concentration and hematocrit (hct) were significantly increased in Fontan patients compared to controls. Same was observed for arterial stiffness. No changes were observed for RBC aggregation, fibrinogen concentration, free radical levels and vascular endothelial growth factor (VEGF). Hypoxia exposure did not change parameters, whereas exercise in hypoxia increased aggregation and hct significantly in both groups. Fontan patients showed significantly increased aggregation-disaggregation balance compared to controls.

Conclusion

Acute hypoxia exposure and exercise under hypoxia might have similar impact on hemorheology in Fontan patients and controls and was clinically well tolerated. Nevertheless, exercise alters aggregation and possibly hemodynamics which requires special attention in Fontan patients.

Continuum modeling of deformation and aggregation of red blood cells

In order to gain better understanding for rheology of an isolated red blood cell (RBC) and a group of multiple RBCs, new continuum models for describing mechanical properties of cellular structures of an RBC and inter-cellular interactions among multiple RBCs are developed. The viscous property of an RBC membrane, which characterizes dynamic behaviors of an RBC under stress loading and unloading processes, is determined using a generalized Maxwell model. The present model is capable of predicting stress relaxation and stress-strain hysteresis, of which prediction is not possible using the commonly used Kelvin-Voigt model. Nonlinear elasticity of an RBC is determined using the Yeoh hyperelastic material model in a framework of continuum mechanics using finite-element approximation. A novel method to model inter-cellular interactions among multiple adjacent RBCs is also developed. Unlike the previous modeling approaches for aggregation of RBCs, where interaction energy for aggregation is curve-fitted using a Morse-type potential function, the interaction energy is analytically determined. The present aggregation model, therefore, allows us to predict various effects of physical parameters such as the osmotic pressure, the thickness of a glycocalyx layer, the penetration depth, and the permittivity, on the depletion and electrostatic energy among RBCs. Simulations for elongation and recovery deformation of an RBC and for aggregation of multiple RBCs are conducted to evaluate the efficacy of the present continuum modeling methods.

Cell-cell affinity of senescent human erythrocytes

During their 120-day life span, human red blood cells (RBC) undergo several physicochemical changes, including an increased tendency to aggregate in plasma or polymer solutions. This study was designed to examine potential associations between age-related differences in RBC mobility, aggregation, and membrane glycocalyx properties for cells suspended in buffer and in 3 g/dl solutions of 70.3 kDa dextran. A recent model for depletion-mediated RBC aggregation was employed to calculate the changes of glycocalyx properties that were consistent with experimental electrophoretic mobility (EPM) and aggregation data. Young and old cells were obtained by density separation, after which aggregation and EPM were determined versus ionic strength; old cells exhibited a two- to threefold greater aggregation in dextran. EPM of old cells was identical to young cells in polymer-free media yet was 4% greater in dextran. The greater EPM for old RBC indicates a larger polymer depletion layer, which could be explained either by a 10-15% decrease of their glycocalyx thickness or a similar percentage decrease of polymer penetration into their glycocalyx. The larger depletion layer leads to markedly elevated cell-cell affinities for old cells, with the computed affinity increases consistent with enhanced old RBC aggregation. These results provide a rational explanation for the aggregation and EPM behavior of old RBC, and raise the possibility of depletion-mediated interactions contributing to senescent cell removal from the circulation.

Altered leukocyte rheology in patients with chronic cerebrovascular disease

Erythrocyte and leukocyte suspensions were prepared from 28 patients with chronic cerebrovascular disease and 30 age- and concomitant disease-matched control subjects. Cell filterability was studied with the new St. George's filtrometer, which can discriminate between initial filtration rate as an erythrocyte parameter and filter clogging as a leukocyte parameter. Compared with control subjects, a significant increase of filter clogging was found in the patients, suggesting decreased deformability or increased adhesiveness of leukocytes or both in chronic cerebrovascular disease.