The nature of anaemia in rheumatoid arthritis. V. Red Cell survival measured by radioactive chromium

Hepcidin antimicrobial peptide transgenic mice exhibit features of the anemia of inflammation

The anemia of inflammation is an acquired disorder affecting patients with a variety of medical conditions, and it is characterized by changes in iron homeostasis and erythropoiesis. Mounting evidence suggests that hepcidin antimicrobial peptide plays a primary role in the pathogenesis of the anemia of inflammation. To evaluate which features of this anemia can be attributed to hepcidin, we have generated mice carrying a tetracycline-regulated hepcidin transgene. Expression of the hepcidin transgene resulted in down-regulation of endogenous hepcidin mRNA. The transgenic mice developed a mild-to-moderate anemia associated with iron deficiency and iron-restricted erythropoiesis. Similar to the anemia of inflammation, iron accumulated in tissue macrophages, whereas a relative paucity of iron was found in the liver. Circulating erythrocytes in transgenic animals had normal survival rates, but transgenic animals had an impaired response to erythropoietin. Thus, hepcidin transgenic mice recapitulate each of the key features of anemia of inflammation in human patients and serve as a useful model of this prevalent disorder.

Inhibition by activated neutrophils of the Ca2+ pump ATPase of intact red blood cells

Human neutrophils, activated by phorbol myristate acetate in the presence of intact red blood cells (RBCs), caused inhibition of the Ca2+ pump ATPase of the RBCs and fragmentation of the enzyme as well as other membrane proteins. Inhibition of the Ca2+ pump ATPase of intact RBCs was directly related to the neutrophil concentration and the time of incubation. Ca2+ pump ATPase activity was partially protected by the addition of exogenous glutathione-glutathione peroxidase, but not by superoxide dismutase. The addition of sodium azide, a potent inhibitor of endogenous RBC catalase, enhanced inhibition of the Ca2+ pump ATPase of intact RBCs. Examination by SDS-polyacrylamide gel electrophoresis of membrane proteins isolated from RBCs preincubated with activated neutrophils showed gross changes in banding patterns as compared to controls. Thus, a significant amount of methemoglobin appeared to be associated with the membrane proteins, and, in general, protein bands appeared to be more diffuse and less defined than proteins in control lanes. In addition, there was an increase in the low molecular weight protein bands. Using a monoclonal antibody to the Ca2+ pump ATPase, it was shown that the 140 kDa band representing the Ca2+ pump ATPase decreased, with concomitant appearance of two low molecular weight bands running at 8.2 and 6.8 kDa in the membrane proteins from RBCs preincubated with activated neutrophils. The data are interpreted to suggest that inhibition of the Ca2+ pump ATPase in intact RBCs under these conditions occurred as a result of: neutrophil-derived superoxide, dismutation of superoxide, to H2O2, diffusion of H2O2 into RBCs, a Fenton type reaction between oxyhemoglobin, and H2O2 producing hydroxyl radical and/or a ferryl radical capable of promoting protein fragmentation of RBC membrane proteins, including the plasma membrane Ca2+ pump ATPase.

The pathogenesis of anemia in rheumatoid arthritis: a clinical and laboratory analysis

Principal concepts concerning the anemia of RA are summarized in Tables 7 and 8. These concepts have been validated by our analysis of 93 anemic RA patients and by our review of the literature. The fact that anemia in RA may have one or more etiologies, occasionally in the same patient, mandates a reasoned approach to the analysis of anemia in every RA patient in whom it may occur. In particular, iron deficiency is common and determination of bone marrow iron content via an aspirate may be required for a definitive diagnosis. In those RA patients with anemia of chronic disease, the best therapy remains control of the underlying disease, most commonly with second line drugs and/or corticosteroids. The place for recombinant erythropoietin in the therapy of this anemia has not been defined; one specific role for erythropoietin may be in the preparation of RA patients for elective surgery, particularly hip arthroplasty, where correction of the anemia may either obviate the need for transfusion or may allow for donation of blood for purposes of autologous transfusion perioperatively. The pathogenesis of the anemia of chronic disease, as seen in RA anemia, is not completely understood. Inflammatory mediators, particularly the cytokines, appear to be important factors in the impairment of erythropoiesis. The mechanism by which these cytokines impair erythroid progenitor growth and hemoglobin production in developing erythrocytes is an important area for future study.

Low selenium level in severe rheumatoid arthritis

Serum selenium concentrations were measured in 87 patients with rheumatoid arthritis. The serum selenium levels of the whole group of patients was significantly reduced (70.2 +/- 13.3 micrograms/l, p less than 0.001) when compared with the reference material (79.8 +/- 10.6 micrograms/l). However, the reduction was not equally pronounced in three groups of patients representing different courses of the disease. One group with an active, disabling disease of long duration had a very reduced serum selenium level (63.7 +/- 14.1 micrograms/l, p less than 0.001). Another group, with a protracted but mild disease had a slightly reduced level (74.1 +/- 10.8 micrograms/l, p less than 0.01), and a group with mild disease of short duration had a slightly but not significantly reduced selenium level (75.9 +/- 10.8 micrograms/l, p less than 0.1). Significant correlation was found between serum selenium and the number of joints with limitation of motion, number of joints with active arthritis, haemoglobin concentration and IgG concentration. No correlation was found between serum selenium and disease duration, morning stiffness, ESR, C-reactive protein, rheumatoid factor titre, serum albumin, IgM and IgA. Selenium is part of the enzyme glutathione peroxidase that catabolizes peroxides which are suggested to be actively involved in inflammation. A low selenium level may thus be a further factor in the pathogenesis of rheumatoid arthritis.

Anemia associated with rheumatoid disease. Inverse correlation between erythropoiesis and both IgM and rheumatoid factor levels

Cell culture techniques were used to evaluate the number of erythroid colonies formed by circulating progenitor cells from 24 patients with rheumatoid disease and controls. A highly significant inverse correlation was demonstrated between erythroid colony counts and serum IgM and rheumatoid factor concentrations in the rheumatoid patients. The potential role of these factors in the pathogenesis of the anemia of rheumatoid disease is discussed.

Glycosylated haemoglobin in rheumatoid arthritis

Shortened red cell survival has a role in the anaemia of rheumatoid arthritis (RA), but direct measurement of it is difficult. Glycosylated haemoglobin (HbA1) provides an index of red cell life span in normoglycaemic patients, because glycosylation depends on both the concentration of blood glucose and the duration of erythrocyte survival. HbA1 was significantly lower in 30 patients with RA (5.6 +/- 0.7%, mean +/- SD) than in 15 healthy controls (7.3 +/- 0.7%) and 14 patients with osteoarthritis (7.4 +/- 0.7%, p less than 0.001). HbA1 was depressed less in active RA than during remission, which is consistent with diminished red cell production in active RA. These data on HbA1 confirm that shortened red cell survival is common in RA, and point to diminished red cell production in active disease. Determination of HbA1 should prove to be of clinical value in the assessment of normoglycaemic patients with RA but is an inadequate index of glucose homoeostasis in diabetics with RA.

Erythropoiesis in the anaemia of rheumatoid arthritis

Erythropoietic activity and mean red-cell lifespan were measured using 59Fe-transferrin in 32 anaemic patients with active rheumatoid arthritis (RA) and in 20 haematologically normal subjects. Marrow iron turnover (MIT) in the patients was normal and in only 11 was red-cell lifespan less than 70 d. Ineffective iron turnover (IIT) was significantly increased in those patients in whom there was evidence of iron deficiency (serum ferritin less than 12 microgram/l) but in the remaining patients IIT was significantly less than in the normal subjects. In a further 19 patients with simple iron deficiency anaemia IIT was significantly increased. The marrow response to chronic inflammatory disease is clearly distinct from that seen in simple iron deficiency and this suggests different pathogenic mechanisms for these two anaemias.

Erythropoiesis and mean red-cell lifespan in normal subjects and in patients with the anaemia of active rheumatoid arthritis

Recently developed ferrokinetic methods offer a tool to measure effective and ineffective erythropoiesis and mean red-cell lifespan (Ricketts et al, 1975). We have used this tool to investigate erythropoiesis in normal subjects and in patients with the anaemia of active rheumatoid arthritis. In normal subjects the results are comparable with the results published by Cavill et al (1977). In patients with the anemia of active rheumatoid arthritis there appears to be a total and an effective red-cell production as in the normal subjects. The ineffective erythropoiesis in the patients is increased and the produced red cells have a shortened mean lifespan in the circulation. The increased ineffective erythropoiesis is probably due to inadequate supply of iron to the marrow and the shortened mean red-cell lifespan to an extra-corpuscular haemolytic factor. The impaired marrow response to the anaemia of active rheumatoid arthritis has been confirmed.

Anaemia of rheumatoid arthritis and iron therapy

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