The Erythrocyte Sedimentation Rate and Its Relation to Cell Shape and Rigidity of Red Blood Cells from Chorea-Acanthocytosis Patients in an Off-Label Treatment with Dasatinib

Morphology, repulsion, and ordering of red blood cells in viscoelastic flows under confinement

Red blood cells (RBC), the primary carriers of oxygen in the body, play a crucial role across several biomedical applications, while also being an essential model system of a deformable object in the microfluidics and soft matter fields. However, RBC behavior in viscoelastic liquids, which holds promise in enhancing microfluidic diagnostic applications, remains poorly studied. We here show that using viscoelastic polymer solutions as a suspending carrier causes changes in the clustering and shape of flowing RBC in microfluidic flows when compared to a standard Newtonian suspending liquid. Additionally, when the local RBC concentration increases to a point where hydrodynamic interactions take place, we observe the formation of equally-spaced RBC structures, resembling the viscoelasticity-driven ordered particles observed previously in the literature, thus providing the first experimental evidence of viscoelasticity-driven cell ordering. The observed RBC ordering, unaffected by polymer molecular architecture, persists as long as the surrounding medium exhibits shear-thinning, viscoelastic properties. Complementary numerical simulations reveal that viscoelasticity-induced repulsion between RBCs leads to equidistant structures, with shear-thinning modulating this effect. Our results open the way for the development of new biomedical technologies based on the use of viscoelastic liquids while also clarifying fundamental aspects related to multibody hydrodynamic interactions in viscoelastic microfluidic flows.

Physiological and Pathogenesis Significance of Chorein in Health and Disease

This comprehensive review explores the physiological and pathophysiological significance of VPS13A, a protein encoded by the VPS13A gene. The VPS13A gene is associated with Chorea-acanthocytosis (ChAc), a rare hereditary neurodegenerative disorder. The review covers essential aspects, beginning with the genetics of VPS13A, highlighting its role in the pathogenesis of ChAc, and addressing the spectrum of genetic variants involved. It delves into the structure and function of the VPS13A protein, emphasizing its presence in various tissues and its potential involvement in protein trafficking and lipid homeostasis. Molecular functions of VPS13A in the brain tissue and other cell types or tissues with respect to their role in cytoskeletal regulation and autophagy are explored. Finally, it explores the intriguing link between VPS13A mutations, lipid imbalances, and neurodegeneration, shedding light on future research directions. Overall, this review serves as a comprehensive resource for understanding the pivotal role of VPS13A in health and disease, particularly in the context of ChAc. Key words: Chorein , Tumor, Actin, Microfilament, Gene expression, Chorea-acanthocytosis.

Confinement effect on the microcapillary flow and shape of red blood cells

The ability to change shape is essential for the proper functioning of red blood cells (RBCs) within the microvasculature. The shape of RBCs significantly influences blood flow and has been employed in microfluidic lab-on-a-chip devices, serving as a diagnostic biomarker for specific pathologies and enabling the assessment of RBC deformability. While external flow conditions, such as the vessel size and the flow velocity, are known to impact microscale RBC flow, our comprehensive understanding of how their shape-adapting ability is influenced by channel confinement in biomedical applications remains incomplete. This study explores the impact of various rectangular and square channels, each with different confinement and aspect ratios, on the in vitro RBC flow behavior and characteristic shapes. We demonstrate that rectangular microchannels, with a height similar to the RBC diameter in combination with a confinement ratio exceeding 0.9, are required to generate distinctive well-defined croissant and slipper-like RBC shapes. These shapes are characterized by their equilibrium positions in the channel cross section, and we observe a strong elongation of both stable shapes in response to the shear rate across the different channels. Less confined channel configurations lead to the emergence of unstable other shape types that display rich shape dynamics. Our work establishes an experimental framework to understand the influence of channel size on the single-cell flow behavior of RBCs, providing valuable insights for the design of biomicrofluidic single-cell analysis applications.

Advances in Red Blood Cells Research

This Editorial 'Advances in Red Blood Cell Research' is the preface for the special issue with the same title which files 14 contributions listed in Table 1 [...].

Early stage of erythrocyte sedimentation rate test: Fracture of a high-volume-fraction gel

Erythrocyte sedimentation rate (ESR) is a clinical parameter used as a nonspecific marker for inflammation, and recent studies have shown that it is linked to the collapse of the gel formed by red blood cells (RBCs) at physiological hematocrits (i.e. RBC volume fraction). Previous research has suggested that the observation of a slower initial dynamics is related to the formation of fractures in the gel. Moreover, RBC gels present specific properties due to the anisotropic shape and flexibility of the RBCs. Namely, the onset of the collapse is reached earlier and the settling velocity of the gel increases with increasing attraction between the RBCs, while the gel of spherical particles shows the opposite trend. Here, we report experimental observations of the gel structure during the onset of the collapse. We suggest an equation modeling this initial process as fracturing of the gel. We demonstrate that this equation provides a model for the motion of the interface between blood plasma and the RBC gel, along the whole time span. We also observe that the increase in the attraction between the RBCs modifies the density of fractures in the gel, which explains why the gel displays an earlier onset when the aggregation energy between the RBCs increases. Our work uncovers the detailed physical mechanism underlying the ESR and provides insights into the fracture dynamics of an RBC gel. These results can improve the accuracy of clinical measurements.

Erythrocyte sedimentation rate and red blood cell indices association in pediatrics patients with fever and cough: A cross-sectional study

Background and Aims

The erythrocyte sedimentation rate (ESR) is an essential inflammatory marker in treating some patients, particularly children. The level of ESR can be affected by red blood cell (RBC) indices, and not considering this can complicate the interpretation of ESR and the treatment and follow-up of patients. The study aimed to assess the association between ESR and RBC indices in children hospitalized with fever and cough in the pediatric ward of Imam Khomeini Hospital, Jiroft, in 2023.

Methods

A cross-sectional study was conducted to measure the association between ESR and RBC indices in children hospitalized with fever and cough in the pediatric ward of Imam Khomeini Hospital, Jiroft, in 2023. A total of 156 patients participated in the study. SPSS software was used for statistical analysis.

Results

The mean age of participants was 27.26 ± 3.14 months. The results showed that there is a significant negative correlation between ESR and RBC, r = -0.282 (p < 0.001), and ESR and hematocrit (HCT), r = -0.215 (p = 0.007). Also, the results demonstrated that there is a significant positive correlation between ESR and mean corpuscular volume (MCV), r = 0.159 (p = 0.048), ESR and mean corpuscular hemoglobin (MCH), r = 0.214 (p = 0.007), and ESR and mean cell hemoglobin concentration (MCHC), r = 0.209 (p = 0.009). There was a negative correlation between ESR and hemoglobin (Hb), r = -0.98 (p = 0.225), but this correlation was insignificant.

Conclusion

This study showed an association between ESR and RBC indices in hospitalized children with complaints of fever and cough. So, it is necessary that physicians and treatment staff pay attention to the RBC indices while interpreting and following up the results of ESR to complete the treatment process of patients.

Cell-free layer development and spatial organization of healthy and rigid red blood cells in a microfluidic bifurcation

Bifurcations and branches in the microcirculation dramatically affect blood flow as they determine the spatiotemporal organization of red blood cells (RBCs). Such changes in vessel geometries can further influence the formation of a cell-free layer (CFL) close to the vessel walls. Biophysical cell properties, such as their deformability, which is impaired in various diseases, are often thought to impact blood flow and affect the distribution of flowing RBCs. This study investigates the flow behavior of healthy and artificially hardened RBCs in a bifurcating microfluidic T-junction. We determine the RBC distribution across the channel width at multiple positions before and after the bifurcation. Thus, we reveal distinct focusing profiles in the feeding mother channel for rigid and healthy RBCs that dramatically impact the cell organization in the successive daughter channels. Moreover, we experimentally show how the characteristic asymmetric CFLs in the daughter vessels develop along their flow direction. Complimentary numerical simulations indicate that the buildup of the CFL is faster for healthy than for rigid RBCs. Our results provide fundamental knowledge to understand the partitioning of rigid RBC as a model of cells with pathologically impaired deformability in complex in vitro networks.

Effect of Cell Age and Membrane Rigidity on Red Blood Cell Shape in Capillary Flow

Blood flow in the microcirculatory system is crucially affected by intrinsic red blood cell (RBC) properties, such as their deformability. In the smallest vessels of this network, RBCs adapt their shapes to the flow conditions. Although it is known that the age of RBCs modifies their physical properties, such as increased cytosol viscosity and altered viscoelastic membrane properties, the evolution of their shape-adapting abilities during senescence remains unclear. In this study, we investigated the effect of RBC properties on the microcapillary in vitro flow behavior and their characteristic shapes in microfluidic channels. For this, we fractioned RBCs from healthy donors according to their age. Moreover, the membranes of fresh RBCs were chemically rigidified using diamide to study the effect of isolated graded-membrane rigidity. Our results show that a fraction of stable, asymmetric, off-centered slipper-like cells at high velocities decreases with increasing age or diamide concentration. However, while old cells form an enhanced number of stable symmetric croissants at the channel centerline, this shape class is suppressed for purely rigidified cells with diamide. Our study provides further knowledge about the distinct effects of age-related changes of intrinsic cell properties on the single-cell flow behavior of RBCs in confined flows due to inter-cellular age-related cell heterogeneity.

Red blood cell lingering modulates hematocrit distribution in the microcirculation

The distribution of red blood cells (RBCs) in the microcirculation determines the oxygen delivery and solute transport to tissues. This process relies on the partitioning of RBCs at successive bifurcations throughout the microvascular network, and it has been known since the last century that RBCs partition disproportionately to the fractional blood flow rate, therefore leading to heterogeneity of the hematocrit (i.e., volume fraction of RBCs in blood) in microvessels. Usually, downstream of a microvascular bifurcation, the vessel branch with a higher fraction of blood flow receives an even higher fraction of RBC flux. However, both temporal and time-average deviations from this phase-separation law have been observed in recent studies. Here, we quantify how the microscopic behavior of RBC lingering (i.e., RBCs temporarily residing near the bifurcation apex with diminished velocity) influences their partitioning, through combined in vivo experiments and in silico simulations. We developed an approach to quantify the cell lingering at highly confined capillary-level bifurcations and demonstrate that it correlates with deviations of the phase-separation process from established empirical predictions by Pries et al. Furthermore, we shed light on how the bifurcation geometry and cell membrane rigidity can affect the lingering behavior of RBCs; e.g., rigid cells tend to linger less than softer ones. Taken together, RBC lingering is an important mechanism that should be considered when studying how abnormal RBC rigidity in diseases such as malaria and sickle-cell disease could hinder the microcirculatory blood flow or how the vascular networks are altered under pathological conditions (e.g., thrombosis, tumors, aneurysm).

Red blood cell sedimentation rate measurements in a high aspect ratio microchannel

BACKGROUND

The erythrocyte sedimentation rate (ESR) test is commonly used in clinical practice for monitoring, screening and diagnosing pathological conditions and diseases related to the inflammatory response of the immune system. Several ESR techniques have been developed over the years improving the reliability, the precision and the duration of the measurement.

OBJECTIVE

In the present study a new low cost micro-ESR technique is described providing the major advantage of reducing the measurement time and the blood sample volume by multiple times compared to the commercial methods.

METHODS

Blood samples were obtained from healthy donors within the age group of 24-28 years and the haematocrit was adjusted to 30%, 40% and 50%. The ESR of the samples was measured utilizing a surface tension driven (STD) microfluidic chip and a monitoring device.

RESULTS

The evaluation of the method showed a high correlation (0.94, p < 10-5) at all haematocrit levels with the commercial instrument indicating the feasibility of the technique.

CONCLUSIONS

This micro-ESR technique provides the potential for a simple, low cost and fast tool for ESR measurement using low blood volume acquired by finger prick.

Contributions of Red Blood Cell Sedimentation in a Driving Syringe to Blood Flow in Capillary Channels

The erythrocyte sedimentation rate (ESR), which has been commonly used to detect physiological and pathological diseases in clinical settings, has been quantified using an interface in a vertical tube. However, previous methods do not provide biophysical information on blood during the ESR test. Therefore, it is necessary to quantify the individual contributions in terms of viscosity and pressure. In this study, to quantify RBC sedimentation, the image intensity (Ib) and interface (β) were obtained by analyzing the blood flow in the microfluidic channels. Based on threshold image intensity, the corresponding interfaces of RBCs (Ib > 0.15) and diluent (Ib < 0.15) were employed to obtain the viscosities (µb, µ0) and junction pressures (Pb, P0). Two coefficients (CH1, CH2) obtained from the empirical formulas (µb = µ0 [1 + CH1], Pb = P0 [1 + CH2]) were calculated to quantify RBC sedimentation. The present method was then adopted to detect differences in RBC sedimentation for various suspended blood samples (healthy RBCs suspended in dextran solutions or plasma). Based on the experimental results, four parameters (µ0, P0, CH1, and CH2) are considered to be effective for quantifying the contributions of the hematocrit and diluent. Two coefficients exhibited more consistent trends than the conventional ESR method. In conclusion, the proposed method can effectively detect RBC sedimentation.

The VES-Matic 5 system: performance of a novel instrument for measuring erythrocyte sedimentation rate

OBJECTIVES

The VES-Matic 5 is an automated analyzer that assesses erythrocyte sedimentation rate based on a modified Westergren sedimentation technique. Instrument performance was established by addressing the recommendations of the International Council for Standardization in Haematology.

METHODS

Comparison against the reference Westergren method was performed for all samples, and further for the low, middle, and upper third of the analytical range. Intra-run precision, inter-run precision, and interference studies were further assessed. This study included the evaluation of reference ranges.

RESULTS

The comparison of methods by Passing-Bablok analysis has shown a good agreement without systematic or proportional differences. The regression equation was y=-0.646 + 0.979x. The mean bias of -0.542 was obtained by Bland-Altman analysis and the upper limit of 8.03 with the lower limit of -9.11 can be considered clinically acceptable. Intra-run and inter-run precision were good for each parameter and interference studies did not show any significant bias with exception of anemia samples, which showed a proportional difference when comparing high erythrocyte sedimentation rate values. Using the local adult reference population, we verified the reference ranges in comparison to those available in the literature, and according to the Clinical Laboratory Standards Institute (CLSI) EP28-A3C document. We determined the upper limit partitioned by gender and the following age groups: from 18 to 50, from 50 to 70, and over 70.

CONCLUSIONS

The VES-Matic 5 analyzer presented good comparability with the reference method. As there are commercial quality control and suitable external quality assessment (EQA) material and programs, the VES-Matic 5 can be employed appropriately for routine purposes.

Erysense, a Lab-on-a-Chip-Based Point-of-Care Device to Evaluate Red Blood Cell Flow Properties With Multiple Clinical Applications

In many medical disciplines, red blood cells are discovered to be biomarkers since they "experience" various conditions in basically all organs of the body. Classical examples are diabetes and hypercholesterolemia. However, recently the red blood cell distribution width (RDW), is often referred to, as an unspecific parameter/marker (e.g., for cardiac events or in oncological studies). The measurement of RDW requires venous blood samples to perform the complete blood cell count (CBC). Here, we introduce Erysense, a lab-on-a-chip-based point-of-care device, to evaluate red blood cell flow properties. The capillary chip technology in combination with algorithms based on artificial neural networks allows the detection of very subtle changes in the red blood cell morphology. This flow-based method closely resembles in vivo conditions and blood sample volumes in the sub-microliter range are sufficient. We provide clinical examples for potential applications of Erysense as a diagnostic tool [here: neuroacanthocytosis syndromes (NAS)] and as cellular quality control for red blood cells [here: hemodiafiltration (HDF) and erythrocyte concentrate (EC) storage]. Due to the wide range of the applicable flow velocities (0.1-10 mm/s) different mechanical properties of the red blood cells can be addressed with Erysense providing the opportunity for differential diagnosis/judgments. Due to these versatile properties, we anticipate the value of Erysense for further diagnostic, prognostic, and theragnostic applications including but not limited to diabetes, iron deficiency, COVID-19, rheumatism, various red blood cell disorders and anemia, as well as inflammation-based diseases including sepsis.

Changes in Blood Cell Deformability in Chorea-Acanthocytosis and Effects of Treatment With Dasatinib or Lithium

Misshaped red blood cells (RBCs), characterized by thorn-like protrusions known as acanthocytes, are a key diagnostic feature in Chorea-Acanthocytosis (ChAc), a rare neurodegenerative disorder. The altered RBC morphology likely influences their biomechanical properties which are crucial for the cells to pass the microvasculature. Here, we investigated blood cell deformability of five ChAc patients compared to healthy controls during up to 1-year individual off-label treatment with the tyrosine kinase inhibitor dasatinib or several weeks with lithium. Measurements with two microfluidic techniques allowed us to assess RBC deformability under different shear stresses. Furthermore, we characterized leukocyte stiffness at high shear stresses. The results showed that blood cell deformability–including both RBCs and leukocytes - in general was altered in ChAc patients compared to healthy donors. Therefore, this study shows for the first time an impairment of leukocyte properties in ChAc. During treatment with dasatinib or lithium, we observed alterations in RBC deformability and a stiffness increase for leukocytes. The hematological phenotype of ChAc patients hinted at a reorganization of the cytoskeleton in blood cells which partly explains the altered mechanical properties observed here. These findings highlight the need for a systematic assessment of the contribution of impaired blood cell mechanics to the clinical manifestation of ChAc.

Sequential quantification of blood and diluent using red cell sedimentation-based separation and pressure-induced work in a microfluidic channel

The erythrocyte sedimentation method has been widely used to detect inflammatory diseases. However, this conventional method still has several drawbacks, such as a large blood volume (∼1 mL) and difficulty in continuous monitoring. Most importantly, image-based methods cannot quantify RBC-rich blood (blood) and RBC-free blood (diluent) simultaneously. In this study, instead of visualizing interface movement in the blood syringe, a simple method is proposed to quantify blood and diluent in microfluidic channels sequentially. The hematocrit was set to 25% to enhance RBC sedimentation and form two layers (blood and diluent) in the blood syringe. An air cavity (∼300 μL) inside the blood syringe was secured to completely remove dead volumes (∼200 μL) in fluidic paths (syringe needle and tubing). Thus, a small blood volume (V_b = 50 μL) suctioned into the blood syringe is sufficient for supplying blood and diluent in the blood channel sequentially. The relative ratio of blood resident time (RBC-to-diluent separation) was quantified using λ_b, which was obtained by quantifying the image intensity of blood flow. After the junction pressure (P_j) and blood volume (V) were obtained by analyzing the interface in the coflowing channel, the averaged work (W_p [Pa mm³]) was calculated and adopted to detect blood and diluent, respectively. The proposed method was then applied with various concentrations of dextran solution to detect aggregation-elevated blood. The W_p of blood and diluent exhibited substantial differences with respect to dextran solutions ranging from C_dex = 10 to C_dex = 40 mg mL^-1. Moreover, λ_b did not exhibit substantial differences in blood with C_dex > 10 mg mL^-1. The variations in λ_b were comparable to those of the previous method based on interface movement in the blood syringe. In conclusion, the W_P could detect blood as well as diluents more effectively than λ_b. Furthermore, the proposed method substantially reduced the blood volume from 1 mL to 50 μL.

XK-Associated McLeod Syndrome: Nonhematological Manifestations and Relation to VPS13A Disease

BACKGROUND

McLeod syndrome (MLS) is an X-linked multisystemic progressive disorder caused by loss of function mutations in the XK gene. The rare blood group phenotype of MLS patients with absent Kx antigen requires the support of specialized transfusion institutions because of the risk of transfusion complications. Acanthocytosis of red blood cells occurs in almost all patients. Nonhematological manifestations of MLS are very similar to those of VPS13A disease (chorea-acanthocytosis), an autosomal-recessive condition. Their shared phenotype apart from acanthocytosis includes movement disorders such as chorea and dystonia, epilepsy, peripheral neuropathy, and muscle involvement, typically with creatine kinase (CK) elevation, cardiomyopathy included.

SUMMARY

In this review, we describe the nonhematological manifestations of MLS in comparison with those of VPS13A disease. While there are many similarities, differences such as mode of inheritance, sex distribution, age at manifestation, severity of heart involvement, frequency of feeding dystonia or of involuntary head drops may help to distinguish these disorders in the clinic. Immunohematological demonstration of the McLeod-Kell phenotype or detection of pathogenic mutations of XK (or VPS13A, respectively) is the gold standard for distinction. "Neuroacanthocytosis" was often used as an overarching term, but is potentially misleading, as the term does not refer to a defined disease entity. Its use, if continued, must not prevent clinicians to seek a final diagnosis on the basis of molecular findings. The clinical similarity of MLS and VPS13A disease has long suggested some shared pathophysiology. Evidence for molecular interaction between XK, the McLeod protein, and chorein, the VPS13A gene product, has recently been put forward: XK forms a complex with chorein/VPS13A, a bulk lipid transporter located at various membrane contact sites. The exact role of XK in this complex needs to be further elucidated. Impairment of bulk lipid transport appears as the common denominator of both MLS and VPS13A disease. A variety of further conditions may in time be added to the "bulk lipid transport diseases," such as the recently recognized disorders caused by mutations in the VPS13B, VPS13C, and VPS13D genes.

KEY MESSAGES

(1) Patients diagnosed with the rare red cell McLeod phenotype (McLeod syndrome, MLS) require interdisciplinary collaboration of transfusion medicine specialists, neurologists, and cardiologists for both their hematological and nonhematological disease manifestations. (2) The phenotypical similarity of MLS and VPS13A disease, often leading to either confusion or insufficient diagnostic depth (under the label of "neuroacanthocytosis"), is based on interaction of the respective proteins, XK and chorein, within the cellular machinery for bulk lipid transport. (3) Overall, the term "bulk lipid transport diseases" seems useful for further research on a group of conditions that may not only share pathophysiology, but may also share treatment approaches.

Imaging Erythrocyte Sedimentation in Whole Blood

The erythrocyte sedimentation rate (ESR) is one of the oldest medical diagnostic tools. However, currently there is some debate on the structure formed by the cells during the sedimentation process. While the conventional view is that erythrocytes sediment as separate aggregates, others have suggested that they form a percolating gel, similar to other colloidal suspensions. However, visualization of aggregated erythrocytes, which would settle the question, has always been challenging. Direct methods usually study erythrocytes in 2D situations or low hematocrit (∼1%). Indirect methods, such as scattering or electric measurements, provide insight on the suspension evolution, but cannot directly discriminate between open or percolating structures. Here, we achieved a direct probing of the structures formed by erythrocytes in blood at stasis. We focused on blood samples at rest with controlled hematocrit of 45%, from healthy donors, and report observations from three different optical imaging techniques: direct light transmission through thin samples, two-photon microscopy and light-sheet microscopy. The three techniques, used in geometries with thickness from 150 μm to 3 mm, highlight that erythrocytes form a continuous network with characteristic cracks, i.e., a colloidal gel. The characteristic distance between the main cracks is of the order of ∼100 μm. A complete description of the structure then requires a field of view of the order of ∼1 mm, in order to obtain a statistically relevant number of structural elements. A quantitative analysis of the erythrocyte related processes and interactions during the sedimentation need a further refinement of the experimental set-ups.