Effects of insulin on erythrocyte deformability in diabetics--relationship between erythrocyte deformability and platelet aggregation

Tissue oxygen demand in regulation of the behavior of the cells in the vasculature

The control of arteriolar diameters in microvasculature has been in the focus of studies on mechanisms matching oxygen demand and supply at the tissue level. Functionally, important vascular elements include EC, VSMC, and RBC. Integration of these different cell types into functional units aimed at matching tissue oxygen supply with tissue oxygen demand is only achieved when all these cells can respond to the signals of tissue oxygen demand. Many vasoactive agents that serve as signals of tissue oxygen demand have their receptors on all these types of cells (VSMC, EC, and RBC) implying that there can be a coordinated regulation of their behavior by the tissue oxygen demand. Such functions of RBC as oxygen carrying by Hb, rheology, and release of vasoactive agents are considered. Several common extra- and intracellular signaling pathways that link tissue oxygen demand with control of VSMC contractility, EC permeability, and RBC functioning are discussed.

Decreased red blood cell aggregation subsequent to improved glycaemic control in Type 2 diabetes mellitus

AIMS

Reports of rheological changes following intensification of metabolic control are limited and not concordant. The present study was designed to test the hypothesis that intensification of management of Type 2 diabetes (T2DM) with diet, exercise and insulin improves haemorheological behaviour by reducing red blood cell (RBC) aggregation.

METHODS

Blood was sampled from 55 subjects before and following 14 +/- 3 weeks of intensified management. RBC aggregation was measured in vitro for cells in plasma or in an aggregating 70 kD dextran solution. Plasma viscosity and whole blood viscosity were also measured.

RESULTS

During treatment, fasting glucose fell 27%, HbA1c fell 21%, and serum triglycerides and total cholesterol fell 28% and 12%, respectively (P < 0.0001 for each). The extent and strength of RBC aggregation in plasma fell by 10-13% (P < 0.002). Similar decreases of RBC aggregation were seen for cells suspended in dextran (P < 0.002). Plasma viscosity decreased by 3% (P < 0.02) and high shear blood viscosity by 6-7% (P < 0.0001). Changes of RBC aggregation in plasma and in dextran were significantly correlated, supporting a cellular rather than a plasmatic origin for these changes. However, there were no significant correlations between RBC aggregation changes and changes of fasting glucose, HbA1c, serum triglycerides, serum cholesterol, or plasma fibrinogen.

CONCLUSIONS

Intensified metabolic control results in a reduction of RBC aggregation that appears to be intrinsic to RBC. Since increased RBC aggregation can impair microcirculatory flow, it is possible that haemorheological factors may contribute to the reduction of microvascular complications resulting from improved metabolic control in T2DM.

The clinical importance of erythrocyte deformability, a hemorrheological parameter

Hemorheology, the science of the flow behavior of blood, has become increasingly important in clinical situations. The rheology of blood is dependent on its viscosity, which in turn is influenced by plasma viscosity, hematocrit, erythrocyte aggregation, and erythrocyte deformability. In recent years it has become apparent that the shape and elasticity of erythrocytes may be important in explaining the etiology of certain pathological situations. Thus, clinicians have become increasingly interested in hemorheology in general and erythrocyte deformability in particular. In the course of time, many clinical studies have been performed, but no concise review has thus far been published. This article encompasses a review of the clinically based literature on this subject.

Aldose reductase inhibitors and diabetic complications

Aldose reductase inhibitors impede flux of glucose through the sorbitol pathway in diabetes mellitus. They therefore reduce the accumulation of the pathway metabolites, sorbitol and fructose, reduce the impact of the flux on the cofactors used by the pathway and reduce other derived phenomena, such as osmotic stress and myo-inositol depletion. As drugs, their targets are the chronic complications of diabetes--neuropathy, retinopathy, nephropathy and vasculopathy. In experimental models there is proof of activity against biochemical, functional and structural defects in all of the involved tissues, but we await full clinical verification of this potential.

Effect of diabetes on photochemically induced thrombosis in femoral artery and platelet aggregation in rats

Effect of diabetes on thrombogenesis was examined by using a thrombus model with photochemical reaction in the rat femoral artery. In streptozotocin-induced diabetic rats for 8 weeks, the formation of thrombus following endothelial injury was significantly slower than that in non-diabetic rats. Insulin treatment normalized the abnormality of thrombogenesis. Aggregation in washed platelets from rats with diabetes was enhanced. However, platelet aggregation in whole blood was reduced in diabetic rats, and plasma from diabetic rats attenuated platelet aggregation. These results suggest that plasma factor(s) and/or other blood cells modify the hyperaggregability of platelets per se in vivo in diabetic rats. Treatment with insulin improved the aggregation in whole blood and washed platelets. In conclusion, diabetes induces the prolongation of thrombogenesis in the rat femoral artery. Hypoaggregability of whole blood is likely to be partly involved in the abnormal thrombogenesis.

Blood hyperviscosity and its relationship to progressive renal failure in patients with diabetic nephropathy

Blood rheology was investigated in patients with diabetic nephropathy and progressive renal insufficiency, and compared with similar non-diabetic patients and healthy control subjects. Plasma viscosity and whole blood viscosity at standardized haematocrit were elevated to a comparable degree in the two patient groups, but erythrocyte deformability was normal. In diabetic patients, the rate of progression of renal failure showed weak, but significant, correlations with plasma viscosity (rs = 0.50, p = 0.005), standardized whole blood viscosity (rs = 0.41, p = 0.021), plasma fibrinogen (rs = 0.46, p = 0.010), C reactive protein (rs = 0.40, p = 0.023), and proteinuria (rs = 0.52, p = 0.003). Both plasma viscosity and plasma fibrinogen correlated significantly with proteinuria (rs = 0.45, p = 0.012 and 0.40, p = 0.027, respectively). Rheological abnormality is probably a manifestation of increased acute phase proteins, but it remains to be determined whether these are the cause or the effect of the renal injury. Abnormal blood rheology may be a risk factor for the progression of renal failure in diabetic nephropathy.

Erythrocyte deformability in diabetes and erythrocyte membrane lipid composition

Erythrocyte deformability was assessed in 40 diabetic patients, 24 insulin-dependent (IDD) and 16 non-insulin-dependent (NIDD), by measuring the initial filtration flow rate of whole blood, isolated red blood cells (RBC), and isolated RBC membranes with the Hanss hemorheometer, and its relationship to the plasma and ghost membrane lipid composition was investigated. RBC deformability was significantly reduced, whereas the deformability of the isolated RBC membranes did not differ significantly from the controls. In the plasma, the triglycerides were high, the high-density lipoprotein (HDL) cholesterol was reduced, and the ratio of total cholesterol over HDL cholesterol was high as compared with the controls. The RBC lipid composition expressed in mumol lipids/10(10) RBC showed significantly lower levels of free cholesterol, sphingomyelines, and phosphatidylcholine, which are the lipids principally located on the outer layer of the RBC membranes. These data suggest that in both IDD and NIDD patients, there may be a relation between these modifications in the RBC lipid composition and rheological impairment of the RBC.

Blood rheology during an intensified conventional insulin treatment (ICIT) in insulin-dependent diabetes

Fifteen insulin-dependent diabetes mellitus (IDDM) patients with minor diabetic complications underwent an intensified conventional insulin treatment (ICIT) program consisting of multiple daily insulin injections with an insulin pen. Blood viscosity parameters were measured before the start, after 6 weeks, 1 and 2 years with a Contraves LS30 viscosimeter. At the start several rheological parameters were disturbed in the diabetic subjects. Mean total hemoglobin A1 (HbA1) significantly (at least P less than 0.05) decreased while the plasma free insulin level significantly increased (at least P less than 0.05) under ICIT. During the first 6 weeks hematocrit (P less than 0.01), plasma (P less than 0.05), whole blood (P less than 0.05) and erythrocyte (P less than 0.01) viscosities significantly decreased but they increased again at 1 year of ICIT. Only plasma viscosity (P less than 0.05) remained below the starting value after 1 and 2 years. Normalization of the blood sugar level improved plasma and whole blood viscosity by an insulin-induced dilution phenomenon after 6 weeks. The persisting decrease in plasma viscosity was accompanied by a significant alteration of the plasma protein profile. These findings suggest that metabolic status influences blood rheology in IDDM patients but by different mechanisms on a short- or long-term basis.

A reappraisal of the influence of blood rheology on glomerular filtration and its role in the pathogenesis of diabetic nephropathy

The basic assumptions concerning the mechanisms of normal glomerular filtration are discussed. Attention is drawn to blood rheologic changes that follow glomerular filtration and influence postglomerular blood flow adversely. It is proposed that the blood rheologic changes will increase the resistance to flow in the peritubular plexus commensurate with the dimensions of the capillaries and blood viscosity in accordance with the general principles of the Poiseuille formula, even though blood is a non-Newtonian fluid. For this reason, the conditions of flow in the plexus must be a determinant of intraglomerular capillary pressure. When blood rheology is abnormal, as in insulin-dependent diabetic patients, the abnormality will be amplified by glomerular filtration and it is suggested that the consequences will be manifest as problems of blood flow in the peritubular plexus. As the increase in postglomerular intravascular pressure needed to restore the rate of blood flow to normal necessitates dilation of the afferent arteriole and possibly more proximal vessels, such changes will result in an increase in intraglomerular pressure. The increase in pressure that increases filtration is therefore a direct consequence of abnormal blood rheology. This concept provides a basis for understanding the mechanism of diabetic proteinuria and for other proteinurias associated with abnormal blood rheology. A possible role for altered blood rheology in the pathogenesis of both focal and total glomerulosclerosis is discussed, and the potential benefits of agents that improve blood rheology are outlined.

Effects of hyperglycaemia and sorbitol accumulation on erythrocyte deformability in diabetes mellitus

Erythrocyte deformability was studied in a total of 83 poorly controlled diabetics (mean blood glucose 12.2 mmol/l) who were divided into three groups, each with matched healthy controls. There was no appreciable difference between diabetics and matched controls regarding the filtration of erythrocytes through 3 micron diameter straight channel pores (25 diabetics) or tortuous channel pores (28 diabetics), or for the measurement of erythrocyte elongation over a range of osmolalities in the Ektacytometer (30 diabetics). When erythrocytes from 17 additional diabetics and 17 healthy controls were incubated for two hours at 37 degrees C in hyperglycaemic (50 mmol glucose/l) buffer, however, there was a considerable reduction in erythrocyte filterability for both diabetics and controls in parallel with an increase in erythrocyte sorbitol concentration. This loss of filterability was prevented by the addition of an aldose reductase inhibitor (Sorbinil). High glucose concentrations (congruent to 50 mmol/l) impair the filterability of erythrocytes through 3 micron pores, and the intracellular accumulation of sorbitol in poorly controlled outpatients is therefore unlikely to have a major adverse effect on erythrocyte rheology in diabetes mellitus.

Modification of platelet adhesion by antiplatelet drugs helps prevent cardiovascular complications of diabetes mellitus

If it could be shown that: The abnormal platelet function in diabetes contributes to the development of cardiovascular complications of diabetes, the abnormal platelet function is a consequence of the diabetic state, the level of blood sugar control or insulin administration, antiplatelet drugs improve the abnormal platelet function independent of the diabetic state and its treatment, the altered platelet function induced by antiplatelet drugs diminishes the evolution of cardiovascular complications, the addition of antiplatelet drugs to the management of diabetes may be reasonable. Specifically designed animal experiments are necessary to provide the scientific basis for designing appropriate clinical trials.

Control of erythrocyte membrane microviscosity by insulin

The human erythrocyte membrane binds insulin through high-affinity, low-capacity binding sites (dissociation constant Kd1 2.45 X 10(-9)M; capacity n1 207 fmol/mg protein) and low-affinity, high-capacity binding sites (Kd2 0.63 X 10(-6) M; n2 37 pmol/mg protein). Treatment of the erythrocyte membrane or the intact cells with the physiological concentration of insulin, which is within the range of Kd value of the high-affinity sites, results in a significant reduction of the membrane microviscosity and the filtration time of the intact cells. Use of supraphysiological concentrations of the hormone reverses the effect of the lower concentration of insulin on the membrane microviscosity and the filtration time.

In vitro insulin action on different ATPases of erythrocyte membranes in normal and diabetic rats

The in vitro effect of porcine insulin on Na+ + K+, Ca2+- and Mg2+-ATPases of the rat erythrocyte membrane of normal and alloxan-induced diabetic rats was investigated. Na+ + K+- and Ca2+-stimulated enzyme activities were significantly decreased in diabetic rats in comparison to normal animals. The specific activities of both these ATPases in the latter group were markedly reduced on pre-incubating the ghosts with insulin. Similar treatment of the erythrocyte membranes of diabetic animals, however, resulted in a significant increase of these activities. These qualitatively different effects of the hormone in the two groups increased progressively with hormone concentration and duration of pre-incubation. Mg2+-stimulated ATPase activity was not significantly affected in diabetes or by insulin.

Changes in the rheologic properties of blood after a high altitude expedition

The changes in blood rheologic properties induced by exposure to high altitude plus heavy and prolonged physical strain were investigated in 14 climbers of an Italian expedition to Himalaya (maximum altitude reached m 7350). In blood samples collected immediately after return, alterations of some haemorheologic parameters were observed in comparison with baseline values, and namely an increase in relative blood viscosity, fibrinogen and erythrocyte filtration time along with a fall in platelet count. Treatment with a drug acting on the red cell deformability (Pentoxifylline) appeared to prevent the changes in blood viscosity and erythrocyte filterability. In the 9 climbers whom we were able to re-examine after three months, all altered parameters were found to be restored to baseline values. These results contribute to the knowledge of the pathogenesis of high altitude disease and stress the significance of altered haemorheology as one of the mechanisms possibly involved in the vascular events observed in this condition.

Doublet formation of diabetic erythrocytes as a model of impaired membrane viscous deformation

Erythrocyte deformation involves both viscous dissipation in the cell interior and viscoelastic motion of the cell membrane. Reports that describe reduced filterability of diabetic erythrocytes, altered response to oscillatory motion in a capillary-sized pipet, and impaired packing during centrifugation indicate a disturbance of red cell rheology in diabetes. We have selected conditions that minimize the macromolecule-mediated energy of attraction between erythrocytes and studied erythrocyte motion during doublet formation. Under such conditions, doublet formation frequency is strikingly reduced in diabetes. For nondiabetic erythrocytes the formation rate is 0.73 doublets per minute, whereas for diabetic erythrocytes the rate is 0.23 doublets per minute. In addition, mean velocity of doublet formation was found to be decreased to half of normal in diabetes. Completeness of doublet formation, regularly diminished when cell size of the two component cells was similar, was the same for diabetic and nondiabetic erythrocytes. Observation of several features of doublet formation gave a picture of the mechanical process. The initial cell making contact with the glass microscope slide was observed to remain fixed in position. The late arriving cell's ability to form a doublet was seen to decrease rapidly, apparently because it came to adhere to the glass surface. The attractive force between the cells overcomes the force of gravity, but cell deformation resistance slows doublet formation by balancing the tendency for cell-cell contact area to increase. An integral equation combining strain energy and viscous dissipation was applied to the doublet formation process. Slowing of doublet formation in diabetes appears to be produced by a doubling of resistance to rate of change of curvature of diabetic erythrocytes.