THE HEMOLYSIS OF RED CELLS FROM PATIENTS WITH PAROXYSMAL NOCTURNAL HEMOGLOBINURIA BY PARTIALLY PURIFIED SUB-COMPONENTS OF THE THIRD COMPLEMENT COMPONENT

What is the role of complement in bystander hemolysis? Old concept, new insights

INTRODUCTION

Bystander hemolysis occurs when antigen-negative red blood cells (RBCs) are lysed by the complement system. Many clinical entities including passenger lymphocyte syndrome, hyperhemolysis following blood transfusion, and paroxysmal nocturnal hemoglobinuria are complicated by bystander hemolysis.

AREAS COVERED

The review provides data about the role of the complement system in the pathogenesis of bystander hemolysis. Moreover, future perspectives on the understanding and management of this syndrome are described.

EXPERT OPINION

Complement system can be activated via classical, alternative, and lectin pathways. Classical pathway activation is mediated by antigen-antibody (autoantibodies and alloantibodies against autologous RBCs, infectious agents) complexes. Alternative pathway initiation is triggered by heme, RBC microvesicles, and endothelial injury that is a result of intravascular hemolysis. Thus, C5b is formed, binds with C6-C9 compomers, and MAC (C5b-9) is formulated in bystander RBCs membranes, leading to cell lysis. Intravascular hemolysis, results in activation of the alternative pathway, establishing a vicious cycle between complement activation and bystander hemolysis. C5 inhibitors have been used effectively in patients with hyperhemolysis syndrome and other entities characterized by bystander hemolysis.

Bystander Immune Cytolysis

In addition to alloimmune and autoimmune cell lysis, a third category of immune destruction of blood cells should be recognized. This additional immunologic response occurs when cells or tissues are injured by immunologic reactions in which the cells act as "innocent bystanders." One mechanism by which an immune response to an exogenous antigen leads to the destruction of autologous blood cells is the temporary development of autoantibodies. This is actually an alloimmune reaction which results in a temporary state of "pseudo"-autoimmunity. Although originally described as a type of hemolysis of autologous cells, the concept of bystander immune cytolysis has been extended to include other instances in which immune destruction of cells is caused by antibody that is not developed in response to intrinsic antigens on the cell being lysed. In recent years, compelling data have been presented documenting bystander immune cytolysis in a number of different clinical settings, and efforts have been made to define the mechanisms by which this occurs. Physicians must be aware that some examples of immune lysis of autologous cells are, in reality, examples of temporary bystander immune cytolysis rather than true autoimmune disease. Furthermore, some alloimmune hemolytic reactions can result in lysis of bystander cells.

Percutaneous transluminal coronary angioplasty in a patient with paroxysmal nocturnal hemoglobinuria

Paroxysmal nocturnal hemoglobinuria (PHN) is an acquired chronic hemolytic anemia associated with an unusual susceptibility to hemolytic crisis, infection, and venous thrombosis which would be aggravated by a number of factors including surgery. We report a case of PHN undergoing percutaneous transluminal coronary angioplasty and discuss the corresponding perioperative management.

The low ionic strength reaction of human blood: relationship between the binding of serum immunoglobulin and complement of red blood cells and surface charge of the cells

Using the sucrose haemolysis reaction of Hartmann & Jenkins (1966) as a basic model, the low ionic strength reaction (LISR) of human blood was studied to determine: (1) serum Ig uptake by RBC with saline elution and 125I-IgG uptake, and (2) complement fixation (CF) to RBC with lysis of PNH cells and C3H/C4 antiglobulin haemagglutination (AH) of normal cells. The saline eluates were found to contain IgG and IgM with traces of IgA; their pH optima for the uptake by RBC were 6.0 +/- 0.5, 5.5 +/- 0.5 and c 5.0 respectively. The ratio of bound IgG to IgM was linearly related to the uptake pH. Both C4 AH and lysis were found to be optimum at pH 6.0--7.5, whereas the maximum C3 AH was at pH 6.0 +/- 0.5. The LISR performed at a constant pH (6.1 +/- 0.1) showed that an increasing concentration of neuraminidase (VCN) used in pretreatment of RBC was associated with a decrease in both IgG uptake and CF activity. A maximum VCN effect reduced the Ig uptake to c 20% of normal and abolished almost all the CF activity. An impaired LISR to various degrees was also observed with RBC pretreated with ficin, papain, bromelin, trypsin or protamine, and RBC from two individuals of En(a-) type. Preincubation of serum at LIS with and without RBC resulted in respectively a 'complete' and partial consumption of C in the fluid phase. The latter was not enhanced or inhibited by the addition of VCN-treated RBC for preincubation. A hypothesis is proposed suggesting that in the LSR the Ig uptake by RBC is an electrostatic interaction of the oppositely charged RBC and Ig and the CF to RBC results from C activation by the cell-bound IgG and IgM. In addition, a pH-dependent inactivation of the cell-bound C3 in the LISR is demonstrated.

An examination of complement proteins on membranes of paroxysmal nocturnal haemoglobinuria (PNH) and PNH-like red cells

Proteins obtained from membranes of PNH erythrocytes and of red cells treated with 2-aminoethylisothiouronium bromide (AET) following lysis in acidified serum (Ham's test) were compared by sodium dodecylsulphate-polyacrylamide gel electrophoresis. The peptide patterns were identical, providing support that AET-treated red cells afford a suitable experimental substitute for PNH red cells in studies involving complement fixation.

Reduction by cobra venom factor of myocardial necrosis after coronary artery occlusion

Components of the complement system are known to play an important role in the cytolytic process and in chemotaxis of leukocytes. Cobra venom factor specifically cleaves C3 activity via activation of the alternative (properdin) complement pathway. It does not act directly on C3. If C3 is involved in tissue necrosis after ischemic injury, cobra venom factor might reduce tissue damage after acute coronary occlusion. Accordingly, in 14 control dogs occlusion of the left anterior descending artery was carried out for 24 h. Epicardial electrograms were recorded 15 min after occlusion, and 24 h later transmural specimens for creatine phosphokinase activity (CPK) and for histological analysis were obtained from the same sites. In another 14 experimental dogs, 20 U/kg cobra venom factor was given intravenously 30 min after occlusion. Serum complement levels fell within 2-4 h to <20% of normal. In the control dogs, the relationship between ST-segment elevation and CPK activity 24 h later was: log CPK = -0.06 ST + 1.48 (n = 111 specimens, 14 dogs, r = 0.77). In the experimental dogs, log CPK = -0.024 ST + 1.46 (n = 111 specimens, 14 dogs, r = 0.60), showing significantly different slopes (P < 0.001), i.e., less CPK depression for any level of ST-segment elevation. Histologically, 69 of 71 sites (97%) with ST-segment elevation exceeding 2 mV in the control dogs showed signs of necrosis 24 h later, whereas in the experimental group only 43 of 79 sites (54%) with abnormal ST-segment elevations showed signs of necrosis (P < 0.0005). At the same time, it was shown that the administration of cobra venom factor did not alter cardiac performance, collateral blood flow to the ischemic myocardium or the clotting system, but infiltration of polymorphonuclear leukocytes into the myocardium was decreased. It is concluded that cobra venom factor, by reducing the amount of C3 and C5 substrate available for chemotactic factor generation, or other as yet undefined mechanisms, protects the ischemic myocardium from undergoing necrosis, as judged by histology and local CPK activity. Hence, a new approach to limiting the extent of myocardial infarcts after experimental coronary occlusion, based upon inhibition of complement-dependent inflammatory processes, is demonstrated.

Homozygous human C3 deficiency. The role of C3 in antibody production, C-1s-induced vasopermeability, and cobra venom-induced passive hemolysis

Studies of the family of a patient with marked deficiency of the third component of complement (C3) demonstrated that the patient was homozygous for a blank allele at the C3 locus, C3-. Metabolic studies with purified radiolabeled C3 in the patient revealed a mildly elevated fractional catabolic rate and a markedly reduced synthesis rate, consistent with a lack of C3 synthesis as the patient's primary defect. There was also a mild increase in the rate of conversion of purified C3 added to her serum and incubated at 37 degrees C in vitro. Major blood group-compatible erythrocytes from a patient with paroxysmal nocturnal hemoglobinuria had the same shortened survival in the C3-deficient patient as in a normal control. Although no leukocytosis developed in the patient in spontaneous infection by pyogenic organisms, there was a normal leukocytosis in response to the injection of thyphoid vaccine. The intradermal injection of C-1s, which produces a marked increase in vasopermeability in the skin of normal subjects, produced no definite change in the patient, possibly implicating C3 or a protein in the alternative pathway as the normal mediator of this response. The patient's serum exhibited near-normal immune adherence activity, confirming the lack of requirement of C3 for this function. C5 inactivation and passive hemolysis of unsensitized guinea pig erythrocytes occurred normally in C3-deficient serum on incubation with cobra venom factor, indicating that C3 is not required for these reactions. The patient's humoral antibody response to both protein and carbohydrate antigens was entirely normal, making it unlikely that C3 is required for antigen processing.

Mechanisms of immune lysis of red blood cells in vitro. I. Paroxysmal nocturnal hemoglobinuria cells

The effect of five different reactions which activate complement (antibody activation, reduction in ionic strength, acidification, cobra venom factor (CoF) activation, and inulin activation) upon normal and PNH cells was investigated, using normal serum and serum devoid of the fourth component of complement (C4) activity from patients with hereditary angioneurotic edema (HANE) as a source of complement. Both normal and HANE serum lysed paroxysmal nocturnal hemoglobinuria (PNH) cells when complement was activated by acidification, CoF and inulin, indicating that the terminal steps of complement were activated in the absence of C4, presumably by the alternate or properdin pathway. Normal but not HANE serum lysed cells coated with anti-I, indicating that complement was activated by the C1-dependent classic pathway. HANE serum partially supported lysis by serum at reduced ionic strength, indicating that the activation of terminal complement components had occurred through both of the pathways of activation. The amount of the third component of human complement (C3) which was bound to the membrane of lysed and unlysed cells by these procedures was determined by anti-C3 absorption and was found to differ for each method of complement activation. In general, more C3 was bound to lysed cells than to unlysed cells. For given conditions, more was bound to PNH cells than to normal cells. However, very much less bound C3 was required for lysis of the PNH cells than for lysis of normal cells. These two phenomena, especially the latter, account for the marked lysis of PNH cells when complement is activated. Normal cells treated with AET (aminoethylisothiouronium bromide) did not bind more C3 than untreated cells and the lysed cells had less bound C3 than lysed PNH cells.

Reactive lysis: the complement-mediated lysis of unsensitized cells. II. The characterization of activated reactor as C56 and the participation of C8 and C9

It has been shown that the "activated reactor" that is produced in certain human sera by complement activation is a stable complex of the fifth and sixth component of complement (C56). On interaction with C7, the indicator factor, a complex C567 is formed which for a short time (half-life less than 1 min) has an activated binding site and can attach itself to normal red cell membranes, conferring on them the hemolytic properties of the "heat stable" complement intermediate EC 1 approximately 7, the capacity to be lysed by C8 and C9. These cells have neither antibody nor the complement components up to C3 bound on them. The binding site-activated C567c-can similarly bind to other hydrophobic surfaces, including agarose gel where it forms a "stainable line". If the complex is not bound to a surface, the binding site decays and the resulting complex will no longer give rise to lysis. However it will still inactivate C8 and C9 in solution. The sera that can generate activated reactor apparently do so because they have an excess of C5 and C6, compared to their content of C7. The phenomenon of reactive lysis thus represents complement-mediated lysis of unsensitized cells initiated at the C5 stage by a stable complex (C56) which was generated by complement activation at a distance. The immunochemistry of the phenomenon is described and some of its implications discussed.

Effect of the cationic environment on immune haemolysis of high potassium and low potassium sheep erythrocytes

Immune haemolysis was studied with the two types of genetically controlled sheep erythrocytes (E) which contain either high potassium (K) and low sodium (Na) (HK E) or low K and high Na (LK E). It was found that the susceptibility of HK and LK E to lysis by guinea-pig and human complement is influenced by the cationic environment. In veronal buffer containing 0.140 M sodium, caesium, choline or Tris, HK E were less susceptible to immune lysis than LK E. No difference was observed in potassium and in lithium(Li). Immune lysis of HK E was stimulated by the cationic series: K>Li>Rb>Cs>Na. Immune lysis of LK E was less dependent on the cationic environment, but K had a slight stimulatory effect. HK and LK E had similar reactivity with haemolytic antibody and in immune adherence. The enhancing effect of potassium was demonstrable upon E^* (an erythrocyte which has been damaged by complement but has not yet undergone lysis), suggesting that the cationic effect is produced in the final steps of immune lysis. The data suggest that the different reactivity of HK and LK E with complement in a sodium medium might be independent of the cationic permeability properties of the membrane. Inhibition of active transport by ouabain did not modify the reactivity of HK and LK E with complement in a sodium medium.

Passive hemolysis by serum and cobra venom factor: a new mechanism inducing membrane damage by complement

The studies presented here indicate that activation of the complement (C') system by a foreign protein will cause membrane injury and passive lysis of unsensitized erythrocytes present at the time of the reaction. These observations suggest that in addition to the classical antibody-C'-induced cytolysis, there are alternative pathways or mechanisms for activation and participation of the terminal C' components in the production of cell membrane injury. We have shown that a substance derived from cobra venom and eluted from a single protein band on polyacrylamide can promote lysis of unsensitized autologous or heterologous erythrocytes in the presence of fresh guinea pig serum and that this lysis-inducing activity and C'-inhibiting activity appear to reside in the same fractions. The lytic activity is prevented by several agents known to impair classical C'3 activity, but is unaffected by certain procedures which interfere with the function of C' components C'1 and C'2, a suggestion that this reaction involves chiefly C'3-C'9. Further, the cobra venom (CV) factor depletes C' activity in cobra serum, and the CV factor (with its 5S serum cofactor) converts purified C'3 to its inactive form,(1) indicating that the reaction of this complex with the complement system occurs without participation of antibody. Therefore, since the lysis-inducing and C'-inhibiting activity of the CV factor appear to result from similar interactions with the complement system, these observations suggest that cell membrane damage and cell lysis can be accomplished through activation of the complement system by a mechanism involving little or no participation of classical antibody or C' components C'1, 4, or 2.

In vivo metabolism of complement. I. Metabolism of the third component (C'3) in acquired hemolytic anemia

The in vivo metabolism of purified third component of complement labeled with (125)-iodine (C'3-(125)I) was studied in normal subjects and in patients with acquired hemolytic anemias. 27 such studies were performed; in addition, three studies were performed using C'3i, the biologically inactive reaction product of C'3. In normal subjects the mean fractional catabolic rate of C'3 was 2.12%/hr and the normal range (defined throughout as the mean +/- 2 SD) was from 1.56 to 2.68. The mean percentage of C'3 that was intravascular was 66.6% and the normal range was from 51 to 83. The C'3 synthesis rate averaged 1.16 mg/kg per hr with a normal range of from 0.90 to 1.42. The mean serum concentration of C'3 was 1.43 mg/ml with a normal range of from 1.00 to 1.87. The fractional catabolic rate and synthesis rate of C'3 were at the upper limit of normal or were increased above normal in patients who had warm antibody autoimmune hemolytic anemia with complement on their erythrocytes and in patients with paroxysmal nocturnal hemoglobinuria studied during periods of active hemolysis. An increased C'3 synthesis rate was also found in one patient who was hematologically normal but had an active peptic ulcer and elevated serum concentration of C'3.A normal fractional catabolic rate and C'3 synthesis rate were found in patients with autoimmune hemolytic anemia associated with alpha-methyldopa administration, atypical cold antibody autoimmune hemolytic anemia, and in paroxysmal nocturnal hemoglobinuria during an asymptomatic interval. The three studies with C'3i-(125)I revealed a very rapid removal of the labeled protein from the plasma with less than 10% remaining after 2 hr and with a corresponding increase in urinary excretion rate of the label. The fractional catabolic rate of C'3i averaged 37%/hr. The findings are consistent with the previously elucidated in vitro reaction mechanism of C'3 and strengthen the concept that serum complement participates in immune reactions in vivo.

Disorders of the red cell membrane: a review of biochemical and physiologic alterations of erythrocyte membranes which may lead to morphologic changes and shortened cell survival

Morphologically similar cells can be seen in such varied conditions as liver disease, renal disease, a-betalipoproteinemia, malab sorption states, congenital nonspherocytic anemias, thalassemia, iron deficiency, pykno cytosis, hemolytic-uremic syndrome, erythro cyte enzyme deficiencies, etc.

The common denominator in these condi tions may be an increase in membrane rigid ity, resulting from a diversity of causes. These would include altered protein-lipid- carbohydrate composition, abnormally struc tured hemoglobins, the presence of Heinz bodies due to altered glycolysis or unstable hemoglobins. The end result of such altered membrane elasticity, regardless of cause, would be fragmentation and destruction of the red cells during passage through small vascular channels, particularly in the spleen. Changes in erythrocyte stromal composi tion often seem to reflect more generalized systemic metabolic disorders. Whether any of the alterations of membrane composition are causally related to either the morpho logic changes or the shortened cell survival still remains to be proven.

Alper CA, Rosen FS: Studies of the in vivo behavior of human C'3 in normal subjects and patients

The metabolic behavior of C'3 labeled with radioactive iodine was investigated in 10 normal subjects and in 20 patients with diseases in which complement is thought to play a pathophysiological role. The mean fractional catabolic rate of C'3 in normal subjects was 2.3 +/- 1.0% of the plasma pool per hr, whereas the fractional catabolic rate of C'3(i), the inactive conversion product of C'3 produced by complement activation, was at least five times as great. Increased catabolic rates were found in some patients with acute glomerulonephritis, systemic lupus erythematosus, idiopathic nephrotic syndrome of childhood, and progressive glomerulonephritis. Depressed synthesis was found in each of four studies of patients with progressive glomerulonephritis and seemed to be the major factor in the lowering of plasma C'3 concentrations regularly observed in patients with this disease. Of three patients with acute glomerulonephritis, synthesis rates of C'3 were markedly depressed in one subject, at the lower limit of normal in another, and entirely normal in the third. Increased extravascular: plasma pool ratios were observed in the studies of C'3(i) metabolism in a normal subject, and of C'3 metabolism in two of three patients with acute glomerulonephritis, in one of four patients with systemic lupus erythematosus, and in one patient with idiopathic nephrotic syndrome. The increased pool ratios are possibly compatible with tissue attachment of part of the injected C'3 or its conversion products. No important abnormalities of metabolism were found in patients with acquired hemolytic anemia, paroxysmal nocturnal hemoglobinuria, hereditary angioneurotic edema, or rheumatoid arthritis.By means of antigen-antibody crossed electrophoresis, C'3(i) could be demonstrated in the fresh plasma of three of eight patients who had acute glomerulonephritis. This finding was used as evidence for in vivo complement activation in this disease. Since C'3(i) was demonstrated only in plasma from patients with very low plasma concentrations whose onset of symptoms was very recent, there may be two phases in the metabolism of C'3: early complement activation with resultant increased catabolism and later depressed synthesis, both of which lead to lowered serum concentrations.

Complement as a mediator of inflammation. II. Biological properties of anaphylatoxin prepared with purified components of human complement

Interaction in free solution of highly purified preparations of human C'1 esterase, C'4, C'2, and C'3, in the presence of Mg(2+), resulted in rapid generation of an activity indistinguishable by biological criteria from anaphylatoxin. The formation of anaphylatoxin was associated with immunoelectrophoretic conversion of C'3 to anodically faster migrating proteins and was unaffected by the presence or absence of added C'5. The biological properties of human anaphylatoxin prepared in this manner include: contraction and desensitization of isolated guinea pig ileum, failure to contract isolated rat uterus, enhancement of vascular permeability in guinea pig skin, degranulation of mast cells in guinea pig mesentery preparations, and liberation of histamine from suspensions of rat peritoneal mast cells. The smooth muscle-contracting and permeability enhancing properties were fully blocked by an antihistaminic drug, triprolidine. No cross-desensitizing activity on guinea pig ileum was demonstrable between rat and human or guinea pig and human anaphylatoxins but a closer biological relationship between rat and guinea pig anaphylatoxins was observed. It is concluded that anaphylatoxin is a product of the complement system. Its possible relationship to apparently similar activities currently being obtained in other laboratories has been discussed.

Serum-red cell interactions at low ionic strength: erythrocyte complement coating and hemolysis of paroxysmal nocturnal hemoglobinuria cells

Complement coating and hemolysis were observed when erythrocytes from patients with paroxysmal nocturnal hemoglobinuria (PNH) were incubated in isotonic sucrose solution in the presence of small amounts of serum. Normal cells were likewise coated with complement components but did not hemolyze. Both normal and PNH erythrocytes reduced the hemolytic complement activity of the serum used in this reaction. Experience with other simple saccharides and related compounds suggests that the low ionic strength of the sucrose solution is the feature that permitted complement coating of red cells and hemolysis of PNH erythrocytes. Isotonic solutions of other sugars or sugar alcohols that do not readily enter human erythrocytes could be substituted for sucrose. The mechanism for these reactions may possibly relate to the agglutination observed with erythrocytes tested in the serum-sucrose system. Even though PNH hemolytic activity could be removed by prior heating of serum or barium sulfate treatment of plasma, the agglutination phenomenon still persisted. The in vitro conditions necessary for optimal sucrose hemolysis of PNH erythrocytes were described and compared with those of the classical acid hemolysis test. The requirement for less serum in the sucrose hemolysis system than needed in the standard acid hemolysis reaction makes certain experiments, especially those using large amounts of autologous PNH serum, much more feasible. Additional advantages of the sucrose hemolysis test are that it can be carried out at room temperature in the presence of oxalate and citrate and that critical pH control is not essential. To date, the sucrose hemolysis test has been a sensitive and specific one for PNH. A modified test used for screening purposes, the "sugar water" test, is very easy to perform.

Formation and functional significance of a molecular complex derived from the second and the fourth component of human complement

A functional unit of the human complement system has been delineated. It is composed of two subunits which are derived from the second (C'2) and from the fourth (C'4) component of complement. Purified C'2 and C'4 were found to interact in free solution and to form a reversible protein-protein complex. When acted upon by C'1 esterase in the presence of Mg ions, the reversible complex acquires stability and the ability to act enzymatically on the third component of complement. The trivial name C'3 convertase has been selected to denote the enzyme. Molecular weight determinations suggest that the entire C'4 molecule, but probably only a fragment of the C'2 molecule, are incorporated into C'3 convertase. Prior treatment of C'2 with iodine led to enhanced stability and activity of the enzyme. It was shown that the cell-bound form of C'3 convertase is cytolytically active and that the free enzyme is able to induce lysis from the fluid phase of erythrocytes from patients with paroxysmal nocturnal hemoglobinuria. Evidence was presented that action of C'3 convertase on C'3 results in fragmentation of the molecule.