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Stewart GW, Gibson JS, Rees DC. The cation-leaky hereditary stomatocytosis syndromes: A tale of six proteins. Br J Haematol 2023; 203:509-522. [PMID: 37679660 DOI: 10.1111/bjh.19093] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/13/2023] [Accepted: 08/22/2023] [Indexed: 09/09/2023]
Abstract
This review concerns a series of dominantly inherited haemolytic anaemias in which the membrane of the erythrocyte 'leaks' the univalent cations, compromising the osmotic stability of the cell. The majority of the conditions are explained by mutations in one of six genes, coding for multispanning membrane proteins of different structure and function. These are: RhAG, coding for an ammonium carrier; SLC4A1, coding for the band 3 anion exchanger; PIEZO1, coding for a mechanosensitive cation channel; GLUT1, coding for a glucose transporter; KCNN4, coding for an internal-calcium-activated potassium channel; and ABCB6, coding for a porphyrin transporter. This review describes the five clinical syndromes associated with genetic defects in these genes and their variable genotype/phenotype relationships.
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Affiliation(s)
- Gordon W Stewart
- Division of Medicine, Faculty of Medical Sciences, University College London, London, UK
| | - John S Gibson
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - David C Rees
- Haematological Medicine, Kings College London, London, UK
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2
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Kalamara TV, Dodos K, Vlachaki E. Splenectomy is significantly associated with thrombosis but not with pulmonary hypertension in patients with transfusion-dependent thalassemia: a meta-analysis of observational studies. Front Med (Lausanne) 2023; 10:1259785. [PMID: 37886361 PMCID: PMC10598854 DOI: 10.3389/fmed.2023.1259785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/27/2023] [Indexed: 10/28/2023] Open
Abstract
Introduction Thromboembolism (TE) and pulmonary hypertension (PH) constitute frequently occurring complications in patients with transfusion-dependent thalassemia and have been associated with splenectomy in different studies. Nevertheless, the size of the possible association varies greatly in literature. Herein, we sought to provide pooled effect estimates regarding the impact of splenectomy on TE and PH in transfusion dependent thalassemia (TDT) by retrieving relevant, available studies. Methods We systematically searched articles published in PubMed, Cochrane library, Scopus and gray literature from inception until the 30th of May, 2023. Pooled estimates in terms of odds ratios (OR) and 95% confidence intervals (CI) were calculated according to outcome measures. Risk of bias and quality of studies were evaluated. Results Regarding TE, 4 studies were selected for meta-analysis and the pooled data demonstrated that splenectomy was significantly associated with this outcome in TDT patients [OR = 4.08, 95% CI (1.03, 16.11), p = 0.04]. On the other hand, we pooled data from seven investigating PH, and, interestingly, the quantitative analysis revealed no association between splenectomy and PH [OR = 1.76, 95% CI (0.91, 3.41), p = 0.1]. Conclusion Splenectomy is associated with higher risks of TE, but not with PH in patients with TDT.
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Affiliation(s)
- Tsampika-Vasileia Kalamara
- Adults Thalassemia Unit, Hippokration General Hospital, Second Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Dodos
- Third Department of Pediatrics, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efthymia Vlachaki
- Adults Thalassemia Unit, Hippokration General Hospital, Second Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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3
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Jamwal M, Singh N, Sharma P, Duseja A, Lad DP, Malhotra P, Das R. Dehydrated hereditary stomatocytosis masquerading as primary haemochromatosis: a diagnostic challenge. Pathology 2023; 55:876-879. [PMID: 37393146 DOI: 10.1016/j.pathol.2023.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 03/15/2023] [Accepted: 03/28/2023] [Indexed: 07/03/2023]
Affiliation(s)
- Manu Jamwal
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Namrata Singh
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Prashant Sharma
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepesh P Lad
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Reena Das
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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4
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Glucose 6 Phosphate Isomerase Deficiency, a Rare Hemolytic Anemia Misdiagnosed as Hereditary Spherocytosis. J Pediatr Hematol Oncol 2023; 45:41-43. [PMID: 36161881 DOI: 10.1097/mph.0000000000002544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/26/2022] [Indexed: 02/03/2023]
Abstract
Hereditary hemolytic anemias are a heterogenous group of disorders that include membranopathies, enzymopathies, and hemoglobinopathies. Genetic testing is helpful in the diagnostic workup when the clinical and laboratory workup is not conclusive. Here, we present a case of a 21-month-old female who was initially diagnosed with hereditary spherocytosis based on the presence of a variant of unknown significance in the SPTB gene. Further genetic workup revealed a homozygous glucose 6 phosphate isomerase mutation and the patient was ultimately diagnosed with glucose 6 phosphate isomerase deficiency.
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5
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Hussein HA, Ibrahim A. B-mode and color Doppler ultrasonography of normal external jugular vein in donkeys (Equus asinus). BMC Vet Res 2022; 18:345. [PMID: 36104788 PMCID: PMC9472444 DOI: 10.1186/s12917-022-03441-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 09/07/2022] [Indexed: 11/18/2022] Open
Abstract
Background Although the jugular vein is a major important blood vessel in equine, the literature lacks this vessel's normal B-mode and Doppler ultrasonographic examinations in donkeys. Therefore, this study aimed to determine the reference ranges of B-mode and Doppler ultrasonographic indices of jugular veins in healthy adult donkeys (Equus asinus) and the possible effect of examination side (left and right), gender, and body condition on the ultrasonographic measurements of this vessel. B-mode and Doppler ultrasound imaging of the external jugular vein was conducted on 20 adult healthy donkeys of both sexes. Results In all donkeys, the jugular vein was 4.01 to 8.1 mm from the body surface. The longitudinal and transverse venous diameters ranged from 3.94 to 10.5 mm and from 0.88 to 1.9 cm, respectively. Moreover, the vein areas varied from 0.61 to 2.83 cm2. The reference values of superficial and deep wall thickness (SWT and DWT) were 0.56 ± 0.2 and 0.6 ± 0.13 mm, respectively. The blood velocity, blood follow rate, and congestion index of the external jugular vein can be expected in adult healthy donkeys as a range value from 8.4 to 13.5 cm/sec, from 0.33 to 1.78 ml/min, and from 0.06 to 0.27 cm.sec, respectively. Generally, the vein showed laminar monophasic waveforms. The examination side and gender have no significant effect on the ultrasound measurements of the vein (P > 0.05). Donkeys with a body condition score (BCS) ≥ 3 revealed increases in the depth of the vein (P < 0.05). Conclusions The results of this study can be used as reference values and provide a basis for comparison when evaluating donkeys with diseases that affect blood flow in the external jugular vein.
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6
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Kalfa TA. Diagnosis and clinical management of red cell membrane disorders. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:331-340. [PMID: 34889366 PMCID: PMC8791164 DOI: 10.1182/hematology.2021000265] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Heterogeneous red blood cell (RBC) membrane disorders and hydration defects often present with the common clinical findings of hemolytic anemia, but they may require substantially different management, based on their pathophysiology. An accurate and timely diagnosis is essential to avoid inappropriate interventions and prevent complications. Advances in genetic testing availability within the last decade, combined with extensive foundational knowledge on RBC membrane structure and function, now facilitate the correct diagnosis in patients with a variety of hereditary hemolytic anemias (HHAs). Studies in patient cohorts with well-defined genetic diagnoses have revealed complications such as iron overload in hereditary xerocytosis, which is amenable to monitoring, prevention, and treatment, and demonstrated that splenectomy is not always an effective or safe treatment for any patient with HHA. However, a multitude of variants of unknown clinical significance have been discovered by genetic evaluation, requiring interpretation by thorough phenotypic assessment in clinical and/or research laboratories. Here we discuss genotype-phenotype correlations and corresponding clinical management in patients with RBC membranopathies and propose an algorithm for the laboratory workup of patients presenting with symptoms and signs of hemolytic anemia, with a clinical case that exemplifies such a workup.
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MESH Headings
- Anemia, Hemolytic, Congenital/diagnosis
- Anemia, Hemolytic, Congenital/genetics
- Anemia, Hemolytic, Congenital/pathology
- Anemia, Hemolytic, Congenital/therapy
- Disease Management
- Elliptocytosis, Hereditary/diagnosis
- Elliptocytosis, Hereditary/genetics
- Elliptocytosis, Hereditary/pathology
- Elliptocytosis, Hereditary/therapy
- Erythrocyte Membrane/pathology
- Genetic Testing
- Humans
- Hydrops Fetalis/diagnosis
- Hydrops Fetalis/genetics
- Hydrops Fetalis/pathology
- Hydrops Fetalis/therapy
- Infant
- Male
- Mutation
- Spherocytosis, Hereditary/diagnosis
- Spherocytosis, Hereditary/genetics
- Spherocytosis, Hereditary/pathology
- Spherocytosis, Hereditary/therapy
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Affiliation(s)
- Theodosia A. Kalfa
- Correspondence Theodosia A. Kalfa, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 7015, Cincinnati, OH 45229-3039; e-mail:
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7
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Confounding factors in the diagnosis and clinical course of rare congenital hemolytic anemias. Orphanet J Rare Dis 2021; 16:415. [PMID: 34627331 PMCID: PMC8501562 DOI: 10.1186/s13023-021-02036-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/19/2021] [Indexed: 01/19/2023] Open
Abstract
Congenital hemolytic anemias (CHAs) comprise defects of the erythrocyte membrane proteins and of red blood cell enzymes metabolism, along with alterations of erythropoiesis. These rare and heterogeneous conditions may generate several difficulties from the diagnostic point of view. Membrane defects include hereditary spherocytosis and elliptocytosis, and the group of hereditary stomatocytosis; glucose-6-phosphate dehydrogenase and pyruvate kinase, are the most common enzyme deficiencies. Among ultra-rare forms, it is worth reminding other enzyme defects (glucosephosphate isomerase, phosphofructokinase, adenylate kinase, triosephosphate isomerase, phosphoglycerate kinase, hexokinase, and pyrimidine 5′-nucleotidase), and congenital dyserythropoietic anemias. Family history, clinical findings (anemia, hemolysis, splenomegaly, gallstones, and iron overload), red cells morphology, and biochemical tests are well recognized diagnostic tools. Molecular findings are increasingly used, particularly in recessive and de novo cases, and may be fundamental in unraveling the diagnosis. Notably, several confounders may further challenge the diagnostic workup, including concomitant blood loss, nutrients deficiency, alterations of hemolytic markers due to other causes (alloimmunization, infectious agents, rare metabolic disorders), coexistence of other hemolytic disorders (autoimmune hemolytic anemia, paroxysmal nocturnal hemoglobinuria, etc.). Additional factors to be considered are the possible association with bone marrow, renal or hepatic diseases, other causes of iron overload (hereditary hemochromatosis, hemoglobinopathies, metabolic diseases), and the presence of extra-hematological signs/symptoms. In this review we provide some instructive clinical vignettes that highlight the difficulties and confounders encountered in the diagnosis and clinical management of CHAs.
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8
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Jankovsky N, Caulier A, Demagny J, Guitton C, Djordjevic S, Lebon D, Ouled‐Haddou H, Picard V, Garçon L. Recent advances in the pathophysiology of PIEZO1-related hereditary xerocytosis. Am J Hematol 2021; 96:1017-1026. [PMID: 33848364 DOI: 10.1002/ajh.26192] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 02/06/2023]
Abstract
Hereditary xerocytosis is a rare red blood cell disease related to gain-of-function mutations in the FAM38A gene, encoding PIEZO1, in 90% of cases; PIEZO1 is a broadly expressed mechano-transducer that plays a major role in many cell systems and tissues that respond to mechanical stress. In erythrocytes, PIEZO1 adapts the intracellular ionic content and cell hydration status to the mechanical constraints induced by the environment. Until recently, the pathophysiology of hereditary xerocytosis was mainly believed to be based on the "PIEZO1-Gardos channel axis" in erythrocytes, according to which PIEZO1-activating mutations induce a calcium influx that secondarily activates the Gardos channel, leading to potassium and water efflux and subsequently to red blood cell dehydration. However, recent studies have demonstrated additional roles for PIEZO1 during early erythropoiesis and reticulocyte maturation, as well as roles in other tissues and cells such as lymphatic vessels, hepatocytes, macrophages and platelets that may affect the pathophysiology of the disease. These findings, presented and discussed in this review, broaden our understanding of hereditary xerocytosis beyond that of primarily being a red blood cell disease and identify potential therapeutic targets.
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Affiliation(s)
- Nicolas Jankovsky
- UR4666 HEMATIM Université Picardie Jules Verne Amiens France
- Service d'Hématologie Clinique, CHU Amiens‐Picardie Amiens France
| | - Alexis Caulier
- UR4666 HEMATIM Université Picardie Jules Verne Amiens France
- Service d'Hématologie Clinique, CHU Amiens‐Picardie Amiens France
| | - Julien Demagny
- UR4666 HEMATIM Université Picardie Jules Verne Amiens France
- Service d'Hématologie Biologique, CHU Amiens‐Picardie Amiens France
| | - Corinne Guitton
- Service de Pédiatrie Générale, CHU Bicêtre Le Kremlin‐Bicêtre France
- Centre de référence des maladies constitutionnelles du globule rouge et de l'érythropoïèse (Filière MCGRE) Créteil France
| | | | - Delphine Lebon
- UR4666 HEMATIM Université Picardie Jules Verne Amiens France
- Service d'Hématologie Clinique, CHU Amiens‐Picardie Amiens France
| | | | - Véronique Picard
- Centre de référence des maladies constitutionnelles du globule rouge et de l'érythropoïèse (Filière MCGRE) Créteil France
- Service d'Hématologie Biologique, CHU Bicêtre Le Kremlin‐Bicêtre France
- Faculté de Pharmacie Université Paris Saclay Châtenay‐Malabry France
| | - Loïc Garçon
- UR4666 HEMATIM Université Picardie Jules Verne Amiens France
- Service d'Hématologie Biologique, CHU Amiens‐Picardie Amiens France
- Centre de référence des maladies constitutionnelles du globule rouge et de l'érythropoïèse (Filière MCGRE) Créteil France
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9
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Steinberg-Shemer O, Tamary H. Impact of Next-Generation Sequencing on the Diagnosis and Treatment of Congenital Anemias. Mol Diagn Ther 2021; 24:397-407. [PMID: 32557003 DOI: 10.1007/s40291-020-00478-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Congenital anemias are a wide spectrum of diseases including hypoproliferative anemia syndromes, dyserythropoietic anemias, sideroblastic anemias, red blood cell membrane and enzymatic defects, hemoglobinopathies, and thalassemia syndromes. The various congenital anemia syndromes may have similar clinical and laboratory presentations, making the diagnosis challenging. The traditional work-up, which includes a complete blood count, blood smears, bone marrow studies, flow cytometry, and the osmotic fragility test, does not always lead to the diagnosis. Specialized tests such as red blood cell enzyme activity and ektacytometry are not widely available. In addition, red blood cell transfusions may mask some of the laboratory characteristics. Therefore, genetic testing is crucial for accurate diagnosis of patients with congenital anemias. However, gene-by-gene testing is labor intensive because of the large number of genes involved. Thus, targeted next-generation sequencing using custom-made gene panels has been increasingly utilized, with a high success rate of diagnosis. Accurate genetic diagnosis is important for determining specific therapeutic modalities, as well as for avoiding splenectomy when contraindicated. In addition, molecular diagnosis can allow for genetic counseling and prenatal diagnosis in severe cases. We suggest a work-up scheme for patients with congenital anemias, including early incorporation of targeted next-generation sequencing panels.
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Affiliation(s)
- Orna Steinberg-Shemer
- Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Hematology Laboratory, Felsenstein Medical Research Center, Petach Tikva, Israel
| | - Hannah Tamary
- Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Pediatric Hematology Laboratory, Felsenstein Medical Research Center, Petach Tikva, Israel.
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10
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Red cell membrane disorders: structure meets function. Blood 2021; 136:1250-1261. [PMID: 32702754 DOI: 10.1182/blood.2019000946] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 01/06/2020] [Indexed: 12/12/2022] Open
Abstract
The mature red blood cell (RBC) lacks a nucleus and organelles characteristic of most cells, but it is elegantly structured to perform the essential function of delivering oxygen and removing carbon dioxide from all other cells while enduring the shear stress imposed by navigating small vessels and sinusoids. Over the past several decades, the efforts of biochemists, cell and molecular biologists, and hematologists have provided an appreciation of the complexity of RBC membrane structure, while studies of the RBC membrane disorders have offered valuable insights into structure-function relationships. Within the last decade, advances in genetic testing and its increased availability have made it possible to substantially build upon this foundational knowledge. Although disorders of the RBC membrane due to altered structural organization or altered transport function are heterogeneous, they often present with common clinical findings of hemolytic anemia. However, they may require substantially different management depending on the underlying pathophysiology. Accurate diagnosis is essential to avoid emergence of complications or inappropriate interventions. We propose an algorithm for laboratory evaluation of patients presenting with symptoms and signs of hemolytic anemia with a focus on RBC membrane disorders. Here, we review the genotypic and phenotypic variability of the RBC membrane disorders in order to raise the index of suspicion and highlight the need for correct and timely diagnosis.
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11
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Fortugno C, Galea E, Cantaffa R, Gigliotti F, Fabiano RL, Talarico V, Raiola G, Galati MC. Hereditary red blood cell membrane defects. Detection of PIEZO1 mutations associated with SPTA1 mutations. An unusual clinical case of hereditary xerocytosis. Pediatr Hematol Oncol 2021; 38:184-190. [PMID: 33136529 DOI: 10.1080/08880018.2020.1829219] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Carmelo Fortugno
- Department of Pediatric Onco-Hematology, Pugliese Ciaccio Hospital, Catanzaro, Italy
| | - Eulalia Galea
- Department of Pediatric Onco-Hematology, Pugliese Ciaccio Hospital, Catanzaro, Italy
| | - Renato Cantaffa
- Department of Pediatric Onco-Hematology, Pugliese Ciaccio Hospital, Catanzaro, Italy
| | - Francesco Gigliotti
- Department of Pediatric Onco-Hematology, Pugliese Ciaccio Hospital, Catanzaro, Italy
| | - Rachele Lucia Fabiano
- Department of Pediatric Onco-Hematology, Pugliese Ciaccio Hospital, Catanzaro, Italy
| | | | - Giuseppe Raiola
- Department of Pediatrics, Pugliese Ciaccio Hospital, Catanzaro, Italy
| | - Maria Concetta Galati
- Department of Pediatric Onco-Hematology, Pugliese Ciaccio Hospital, Catanzaro, Italy
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12
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Russo R, Marra R, Rosato BE, Iolascon A, Andolfo I. Genetics and Genomics Approaches for Diagnosis and Research Into Hereditary Anemias. Front Physiol 2020; 11:613559. [PMID: 33414725 PMCID: PMC7783452 DOI: 10.3389/fphys.2020.613559] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/03/2020] [Indexed: 01/19/2023] Open
Abstract
The hereditary anemias are a relatively heterogeneous set of disorders that can show wide clinical and genetic heterogeneity, which often hampers correct clinical diagnosis. The classical diagnostic workflow for these conditions generally used to start with analysis of the family and personal histories, followed by biochemical and morphological evaluations, and ending with genetic testing. However, the diagnostic framework has changed more recently, and genetic testing is now a suitable approach for differential diagnosis of these patients. There are several approaches to this genetic testing, the choice of which depends on phenotyping, genetic heterogeneity, and gene size. For patients who show complete phenotyping, single-gene testing remains recommended. However, genetic analysis now includes next-generation sequencing, which is generally based on custom-designed targeting panels and whole-exome sequencing. The use of next-generation sequencing also allows the identification of new causative genes, and of polygenic conditions and genetic factors that modify disease severity of hereditary anemias. In the research field, whole-genome sequencing is useful for the identification of non-coding causative mutations, which might account for the disruption of transcriptional factor occupancy sites and cis-regulatory elements. Moreover, advances in high-throughput sequencing techniques have now resulted in the identification of genome-wide profiling of the chromatin structures known as the topologically associating domains. These represent a recurrent disease mechanism that exposes genes to inappropriate regulatory elements, causing errors in gene expression. This review focuses on the challenges of diagnosis and research into hereditary anemias, with indications of both the advantages and disadvantages. Finally, we consider the future perspectives for the use of next-generation sequencing technologies in this era of precision medicine.
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Affiliation(s)
- Roberta Russo
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, Naples, Italy.,CEINGE Biotecnologie Avanzate, Naples, Italy
| | - Roberta Marra
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, Naples, Italy.,CEINGE Biotecnologie Avanzate, Naples, Italy
| | - Barbara Eleni Rosato
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, Naples, Italy.,CEINGE Biotecnologie Avanzate, Naples, Italy
| | - Achille Iolascon
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, Naples, Italy.,CEINGE Biotecnologie Avanzate, Naples, Italy
| | - Immacolata Andolfo
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, Naples, Italy.,CEINGE Biotecnologie Avanzate, Naples, Italy
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13
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Zaninoni A, Fermo E, Vercellati C, Marcello AP, Barcellini W, Bianchi P. Congenital Hemolytic Anemias: Is There a Role for the Immune System? Front Immunol 2020; 11:1309. [PMID: 32655575 PMCID: PMC7324678 DOI: 10.3389/fimmu.2020.01309] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 05/22/2020] [Indexed: 01/19/2023] Open
Abstract
Congenital hemolytic anemias (CHAs) are a heterogeneous group of rare hereditary conditions including defects of erythrocyte membrane proteins, red cell enzymes, and disorders due to defective erythropoiesis. They are characterized by variable degree of anemia, chronic extravascular hemolysis, reduced erythrocyte life span, splenomegaly, jaundice, biliary lithiasis, and iron overload. Although few data are reported on the role of the immune system in CHAs, several immune-mediated mechanisms may be involved in the pathogenesis of these rare diseases. We reported in ~60% of patients with hereditary spherocytosis (HS), the presence of naturally-occurring autoantibodies (NAbs) directed against different membrane proteins (α- and β-spectrin, band 3, and dematin). Positive HS subjects showed a more hemolytic pattern and NAbs were more evident in aged erythrocytes. The latter is in line with the function of NAbs in the opsonization of damaged/senescent erythrocytes and their consequent removal in the spleen. Splenectomy, usually performed to reduce erythrocyte catheresis and improve Hb levels, has different efficacy in various CHAs. Median Hb increase is 3 g/dL in HS, 1.6–1.8 g/dL in pyruvate kinase deficiency (PKD), and 1 g/dL in congenital dyserythropoietic anemias (CDA) type II. Consistently with clinical severity, splenectomy is performed in 20% of HS, 45% of CDAII, and in 60% of PKD patients. Importantly, sepsis and thrombotic events have been registered, particularly in PKD with a frequency of ~7% for both. Furthermore, we analyzed the role of pro-inflammatory cytokines and found that interleukin 10 and interferon γ, and to a lesser extent interleukin 6, were increased in all CHAs compared with controls. Moreover, CDAII and enzymatic defects showed increased tumor necrosis factor-α and reduced interleukin 17. Finally, we reported that iron overload occurred in 31% of patients with membrane defects, in ~60% of CDAII cases, and in up to 82% of PKD patients (defined by MRI liver iron concentration >4 mg Fe/gdw). Hepcidin was slightly increased in CHAs compared with controls and positively correlated with ferritin and with the inflammatory cytokines interleukin 6 and interferon γ. Overall the results suggest the existence of a vicious circle between chronic hemolysis, inflammatory response, bone marrow dyserythropoiesis, and iron overload.
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Affiliation(s)
- Anna Zaninoni
- UOS Fisiopatologia delle Anemie, UOC Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa Fermo
- UOS Fisiopatologia delle Anemie, UOC Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Cristina Vercellati
- UOS Fisiopatologia delle Anemie, UOC Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Paola Marcello
- UOS Fisiopatologia delle Anemie, UOC Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Wilma Barcellini
- UOS Fisiopatologia delle Anemie, UOC Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Bianchi
- UOS Fisiopatologia delle Anemie, UOC Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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14
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Long B, Koyfman A, Gottlieb M. Complications in the adult asplenic patient: A review for the emergency clinician. Am J Emerg Med 2020; 44:452-457. [PMID: 32247651 DOI: 10.1016/j.ajem.2020.03.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/23/2020] [Accepted: 03/23/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The spleen performs several important physiologic functions. However, patients can have functional asplenia or have their spleen removed for a number of reasons, which can put them at risk for several dangerous complications. OBJECTIVE This narrative review provides a focused evaluation of adult asplenic patients and complications in the emergency departing setting. DISCUSSION The spleen plays integral roles in the immune and reticuloendothelial systems and also modulates the inflammatory and coagulation cascades. Asplenia refers to the anatomic or physiologic loss of splenic function, which may be due to trauma, immunological, hematological, or oncological etiologies. Asplenic patients are at risk for several complications including infection, arterial and venous thrombosis, and pulmonary hypertension. Fever in an asplenic patient and overwhelming post-splenectomy infection (OPSI) are medical emergencies with a high mortality and require rapid evaluation and management with broad-spectrum antibiotics. Asplenic patients are at increased risk of arterial thrombosis, such as coronary artery disease, and venous thrombosis including deep venous thrombosis, pulmonary embolism, and splenic and portal vein thrombosis. Management of venous thrombosis includes anticoagulation. Pulmonary hypertension with associated right ventricular dysfunction may also occur in asplenia. These patients require hemodynamic stabilization with an emphasis on inciting causes and treatment of the pulmonary hypertension. CONCLUSIONS The spleen is an integral organ involved in several physiologic functions. Asplenia, or absence of spleen function, is associated with severe complications. Knowledge of these complications can improve the care of these patients.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, United States
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15
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16
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Mechanosensitive Piezo1 ion channel protein (PIEZO1 gene): update and extended mutation analysis of hereditary xerocytosis in India. Ann Hematol 2020; 99:715-727. [PMID: 32112123 DOI: 10.1007/s00277-020-03955-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 02/06/2020] [Indexed: 12/24/2022]
Abstract
Hereditary xerocytosis (HX), also known as dehydrated stomatocytosis (DHSt) is a dominantly inherited genetic disorder exhibiting red cell membrane dehydration caused by the loss of the monovalent cation K+ and water. Variants in mechanosensitive Piezo ionic channels of the PIEZO1 gene are the primary cause of HX. We have utilized high throughput and highly precise next-generation sequencing (NGS) to make a diagnosis and examine the genotype-phenotype relationship in inflexible HX cases. Seven unrelated patients with unexplained hemolytic anemia were scrutinized with a panel probing 8000 genes related to congenital anemia. Targeted next-generation sequencing identified 8 missense variants in the PIEZO1 gene in 7 unrelated Indian patients. Three of the 8 variants are novel (c.1795G > C, c.2915G > A, c.7372 T > C) and the remaining five (c.4082A > G, c.6829C > A, c.7374C > G, c.7381G > A, c.7483_7488dup) are previously reported. The variants have been validated by Sanger sequencing. One patient with autosomal dominant mutation (c.7372 T > C) is associated with iron refractory iron deficiency anemia. Of the 7 patients, one has HX in combination with a novel homozygous variant (c.994G > A) in the PKLR gene causing PK deficiency resulting in severe clinical manifestations with phenotypic variability. In silico prediction using bioinformatics tools were used to study the possible damaging effects of the novel variants. Structural-functional analysis of the novel variants was investigated by molecular modeling software (PyMOL and Swiss PDB). These results encompass the heterogeneous behavior of mechano-sensitive Piezo1 protein observed in HX patients in India. Moreover, NGS imparted a subtle, economical, and quick tool for understanding the genetic cause of undiagnosed cases of congenital hemolytic anemia. NGS grants a potential technology integrating clinical history together with molecular report profiting in such patients and their families.
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Jamwal M, Aggarwal A, Palodhi A, Sharma P, Bansal D, Trehan A, Malhotra P, Maitra A, Das R. Next-Generation Sequencing-Based Diagnosis of Unexplained Inherited Hemolytic Anemias Reveals Wide Genetic and Phenotypic Heterogeneity. J Mol Diagn 2020; 22:579-590. [PMID: 32036089 DOI: 10.1016/j.jmoldx.2020.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 11/19/2019] [Accepted: 01/14/2020] [Indexed: 12/28/2022] Open
Abstract
Determination of the cause of inherited hemolysis is based on clinical and stepwise conventional laboratory tests. Patients with obscure etiology require genetic diagnosis, which is time-consuming, expensive, and laborious, mainly because of numerous causal genes. This study enrolled 43 patients with clinical and laboratory evidence of unexplained hemolytic anemia. Initially, 13 patients were tested using a commercial (TruSight One) panel, and remaining cases underwent targeted sequencing using a customized 55-gene panel. Pyruvate kinase deficiency was found in eight, glucose-6-phosphate dehydrogenase (G6PD) deficiency in three (G6PD Guadalajara in two and p.Tyr227Ser: novel, named as G6PD Chandigarh), and glucose-6-phosphate isomerase (GPI) deficiency in two (GPI:p.Arg347His and p.Phe304Leu: novel, named as GPI Chandigarh). Three patients had Mediterranean stomatocytosis/macrothrombocytopenia, and two had overhydrated stomatocytosis. Xerocytosis was found in three patients, whereas six had potentially pathogenic variants in membrane protein-coding genes. Overall, 63% cases received a definite diagnosis. Timely determination of etiology was helpful in diagnosis, genetic counseling, and offering a prenatal diagnosis. Therapeutic implications include performing or avoiding splenectomy that may ameliorate the anemia in many but also predispose to thrombosis in other groups of patients. This first study on the genetic spectrum of unexplained hemolytic anemia from the Indian subcontinent also represents, currently, one of the largest cohort worldwide of such patients.
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Affiliation(s)
- Manu Jamwal
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anu Aggarwal
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Prashant Sharma
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepak Bansal
- Hematology-Oncology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amita Trehan
- Hematology-Oncology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Arindam Maitra
- National Institute of Biomedical Genomics, Kalyani, India
| | - Reena Das
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
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Jamwal M, Sharma P, Das R. Laboratory Approach to Hemolytic Anemia. Indian J Pediatr 2020; 87:66-74. [PMID: 31823208 DOI: 10.1007/s12098-019-03119-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 11/04/2019] [Indexed: 12/12/2022]
Abstract
Hemolytic anemias are a group of disorders with varied clinical and molecular heterogeneity. They are characterized by decreased levels of circulating erythrocytes in blood. The pathognomic finding is a reduced red cell life span with severe anemia or, compensated hemolysis accompanied by reticulocytosis. The diagnostic workup or laboratory approach for hemolytic anemias is based on methodical step-wise testing which includes red blood cell morphology, hematological indices with increased reticulocyte count along with clinical features of hemolytic anemias. If conventional laboratory tests are unable to detect the underlying cause of hemolysis, genetic testing is recommended. Sanger sequencing along with conventional testing is the most efficient way to diagnose the underlying genetic causes, especially in thalassemias/hemoglobinopathies, if required. However, hemolytic anemias being highly heterogeneous disorders, next-generation sequencing-based screening is rapidly becoming an efficient way to decipher the etiologies where common causes have been excluded.
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Affiliation(s)
- Manu Jamwal
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Prashant Sharma
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Reena Das
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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Doppler ultrasonographic evaluation of brachial and femoral veins, and coagulation and lipid profiles in dogs following open splenectomy. Sci Rep 2019; 9:15377. [PMID: 31653942 PMCID: PMC6814893 DOI: 10.1038/s41598-019-51924-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 10/10/2019] [Indexed: 11/08/2022] Open
Abstract
In dogs, splenectomy is mandatory as an emergency following splenic rupture with resultant hemoperitoneum and hypotensive shock. The present work aimed to evaluate the Doppler ultrasonographic parameters of brachial and femoral veins in splenectomized dogs and to investigate the effect of splenectomy on the coagulation and lipid profiles. A total number of 9 dogs underwent clinical, abdominal ultrasonographic and laboratory examinations prior to the surgical operation and kept for 60-day observation period post-splenectomy. Follow-up ultrasonography revealed no serious complications post-splenectomy. Both brachial and femoral veins were imaged medial to their corresponding arteries. Doppler ultrasonographic parameters of both veins showed no significant changes throughout the study period (P > 0.05). Haematological analysis revealed development of anemia, leukocytosis, and thrombocytosis in dogs post-splenectomy. Coagulation profile exhibited no significant variations in prothrombin and activated partial thromboplastin times (P > 0.05). In comparison with their baseline values, the mean concentrations of total cholesterol, low-density lipoprotein, and triglycerides were significantly increased 30-day post-splenectomy. In conclusion, it may seem that open splenectomy has no influence on the Doppler ultrasonographic indices of brachial and femoral veins with no evidence of deep vein thrombosis in dogs. However, persistent leukocytosis and thrombocytosis, as well as altered lipid profile may increase the risk of vascular complications with the long run. Therefore, a further long-term study may be required.
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20
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Sinha AA, Adusumilli T, Cohen HW, Nouraie M, Little J, Manwani D. Splenectomy is not associated with a higher tricuspid regurgitant jet velocity in people with sickle cell anemia. Pediatr Blood Cancer 2019; 66:e27928. [PMID: 31322833 DOI: 10.1002/pbc.27928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Vascular complications such as pulmonary hypertension (PH) occur at an increased rate following splenectomy in patients with various hemolytic blood disorders including thalassemia. The goal of this retrospective cross-sectional analysis was to assess the independent association of splenectomy with an elevated tricuspid regurgitation velocity (TRV) in people with homozygous sickle cell disease (HbSS). TRV is a noninvasive screening test for PH and a surrogate marker of prognosis in sickle cell disease (SCD). PROCEDURE Data were obtained from the multicenter Walk-PHaSST (treatment of pulmonary hypertension and sickle cell disease with sildenafil therapy) study of PH (NCT00492531). We compared TRV in the cohort of patients with HbSS who were surgically splenectomized with patients who were not surgically splenectomized. RESULTS We found no significant differences in TRV between the two groups. CONCLUSIONS The lack of difference in TRV between the two groups is most likely because members of the comparator nonsurgical group in many cases experienced autoinfarction of the spleen in childhood. Splenectomy does not seem to confer additional risk for the development of a higher TRV in HbSS, unlike in patients with thalassemia or other hemolytic anemias. This could be an important consideration when weighing the risks and benefits of splenectomy in patients with HbSS.
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Affiliation(s)
- Arpan A Sinha
- Jimmy Everest Section of Pediatric Hematology/Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Tanvi Adusumilli
- Department of Pediatrics, Albert Einstein College of Medicine, New York
| | - Hillel W Cohen
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York
| | - Mehdi Nouraie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jane Little
- Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Deepa Manwani
- Department of Pediatrics, Albert Einstein College of Medicine, New York
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21
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Iolascon A, Andolfo I, Russo R. Advances in understanding the pathogenesis of red cell membrane disorders. Br J Haematol 2019; 187:13-24. [PMID: 31364155 DOI: 10.1111/bjh.16126] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hereditary erythrocyte membrane disorders are caused by mutations in genes encoding various transmembrane or cytoskeletal proteins of red blood cells. The main consequences of these genetic alterations are decreased cell deformability and shortened erythrocyte survival. Red blood cell membrane defects encompass a heterogeneous group of haemolytic anaemias caused by either (i) altered membrane structural organisation (hereditary spherocytosis, hereditary elliptocytosis, hereditary pyropoikilocytosis and Southeast Asian ovalocytosis) or (ii) altered membrane transport function (overhydrated hereditary stomatocytosis, dehydrated hereditary stomatocytosis or xerocytosis, familial pseudohyperkalaemia and cryohydrocytosis). Herein we provide a comprehensive review of the recent literature on the molecular genetics of erythrocyte membrane defects and their reported clinical consequences. We also describe the effect of low-expression genetic variants on the high inter- and intra-familial phenotype variability of erythrocyte structural defects.
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Affiliation(s)
- Achille Iolascon
- Department of Molecular Medicine and Medical Biotechnologies, Federico II" University of Naples, Naples, Italy.,CEINGE - Biotecnologie Avanzate, Naples, Italy
| | - Immacolata Andolfo
- Department of Molecular Medicine and Medical Biotechnologies, Federico II" University of Naples, Naples, Italy.,CEINGE - Biotecnologie Avanzate, Naples, Italy
| | - Roberta Russo
- Department of Molecular Medicine and Medical Biotechnologies, Federico II" University of Naples, Naples, Italy.,CEINGE - Biotecnologie Avanzate, Naples, Italy
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22
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Frederiksen H. Dehydrated hereditary stomatocytosis: clinical perspectives. J Blood Med 2019; 10:183-191. [PMID: 31308777 PMCID: PMC6613601 DOI: 10.2147/jbm.s179764] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 06/14/2019] [Indexed: 12/30/2022] Open
Abstract
Dehydrated hereditary stomatocytosis (DHSt) is a nonimmune congenital hemolytic disorder characterized by red blood cell (RBC) dehydration and lysis. It has been a recognized diagnostic entity for almost 50 years, and autosomal dominant inheritance has long been suspected, but it was not until 2011 that the first genetic alterations were identified. The current study reviews 73 articles published during 1971–2019 and focuses on clinical perspectives of the disease. All but one of the published clinical data in DHSt were either single case reports or case series. From these, it can be seen that patients with DHSt often have fully or partially compensated hemolysis with few symptoms. Despite this, iron overload is an almost universal finding even in patients without or with only sporadic blood transfusions, and this may lead to organ dysfunction. Other severe complications, such as thrombosis and perinatal fluid effusions unrelated to fetal hemoglobin concentration, may also occur. No specific treatment for symptomatic hemolysis exists, and splenectomy should be avoided as it seems to aggravate the risk of thrombosis. Recently, treatment with senicapoc has shown activity against RBC dehydration in vitro; however, it is not known if this translates into relevant clinical effects. In conclusion, despite recent advances in the understanding of pathophysiology in DHSt, options for clinical management have not improved. Entering data into international registries has the potential to fill gaps in knowledge and eventually care of these rare patients.
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23
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Yacobovich J, Tamary H. Splenectomy and emerging novel treatments in rare inherited hemolytic anemias. Hemasphere 2019; 3:HemaSphere-2019-0043. [PMID: 35309810 PMCID: PMC8925654 DOI: 10.1097/hs9.0000000000000190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 02/12/2019] [Indexed: 01/19/2023] Open
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24
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Rets A, Clayton AL, Christensen RD, Agarwal AM. Molecular diagnostic update in hereditary hemolytic anemia and neonatal hyperbilirubinemia. Int J Lab Hematol 2019; 41 Suppl 1:95-101. [DOI: 10.1111/ijlh.13014] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/27/2019] [Accepted: 03/01/2019] [Indexed: 01/19/2023]
Affiliation(s)
- Anton Rets
- Department of Pathology University of Utah Health Salt Lake City Utah
- ARUP Laboratories Salt Lake City Utah
| | | | - Robert D. Christensen
- Division of Neonatology and Hematology/Oncology University of Utah Health Salt Lake City Utah
| | - Archana M. Agarwal
- Department of Pathology University of Utah Health Salt Lake City Utah
- ARUP Laboratories Salt Lake City Utah
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25
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Risinger M, Emberesh M, Kalfa TA. Rare Hereditary Hemolytic Anemias: Diagnostic Approach and Considerations in Management. Hematol Oncol Clin North Am 2019; 33:373-392. [PMID: 31030808 DOI: 10.1016/j.hoc.2019.01.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Hereditary hemolytic anemias (HHAs) comprise a heterogeneous group of anemias caused by mutations in genes coding the globins, red blood cell (RBC) membrane proteins, and RBC enzymes. Congenital dyserythropoietic anemias (CDAs) are rare disorders of erythropoiesis characterized by binucleated and multinucleated erythroblasts in bone marrow. CDAs typically present with a hemolytic phenotype, as the produced RBCs have structural defects and decreased survival and should be considered in the differential of HHAs. This article discusses the clinical presentation, laboratory findings, and management considerations for rare HHAs arising from unstable hemoglobins, RBC hydration defects, the less common RBC enzymopathies, and CDAs.
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Affiliation(s)
- Mary Risinger
- College of Nursing, University of Cincinnati, 3110 Vine Street, Cincinnati, OH 45221-0038, USA
| | - Myesa Emberesh
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7018, Cincinnati, OH 45229-3039, USA
| | - Theodosia A Kalfa
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7015, Cincinnati, OH 45229-3039, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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26
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Picard V, Guitton C, Thuret I, Rose C, Bendelac L, Ghazal K, Aguilar-Martinez P, Badens C, Barro C, Bénéteau C, Berger C, Cathébras P, Deconinck E, Delaunay J, Durand JM, Firah N, Galactéros F, Godeau B, Jaïs X, de Jaureguiberry JP, Le Stradic C, Lifermann F, Maffre R, Morin G, Perrin J, Proulle V, Ruivard M, Toutain F, Lahary A, Garçon L. Clinical and biological features in PIEZO1-hereditary xerocytosis and Gardos channelopathy: a retrospective series of 126 patients. Haematologica 2019; 104:1554-1564. [PMID: 30655378 PMCID: PMC6669138 DOI: 10.3324/haematol.2018.205328] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/15/2019] [Indexed: 01/16/2023] Open
Abstract
We describe the clinical, hematologic and genetic characteristics of a retrospective series of 126 subjects from 64 families with hereditary xerocytosis. Twelve patients from six families carried a KCNN4 mutation, five had the recurrent p.Arg352His mutation and one had a new deletion at the exon 7-intron 7 junction. Forty-nine families carried a PIEZO1 mutation, which was a known recurrent mutation in only one-third of the cases and private sequence variation in others; 12 new probably pathogenic missense mutations were identified. The two dominant features leading to diagnosis were hemolysis that persisted after splenectomy and hyperferritinemia, with an inconstant correlation with liver iron content assessed by magnetic resonance imaging. PIEZO1-hereditary xerocytosis was characterized by compensated hemolysis in most cases, perinatal edema of heterogeneous severity in more than 20% of families and a major risk of post-splenectomy thrombotic events, including a high frequency of portal thrombosis. In KCNN4-related disease, the main symptoms were more severe anemia, hemolysis and iron overload, with no clear sign of red cell dehydration; therefore, this disorder would be better described as a ‘Gardos channelopathy’. These data on the largest series to date indicate that PIEZO1-hereditary xerocytosis and Gardos channelopathy are not the same disease although they share hemolysis, a high rate of iron overload and inefficient splenectomy. They demonstrate the high variability in clinical expression as well as genetic bases of PIEZO1-hereditary xerocytosis. These results will help to improve the diagnosis of hereditary xerocytosis and to provide recommendations on the clinical management in terms of splenectomy, iron overload and pregnancy follow-up.
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Affiliation(s)
- Véronique Picard
- Laboratoire d'Hématologie, Center Hospitalier Universitaire (CHU) Bicêtre, Assistance publique - Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre.,Université Paris Sud Paris Saclay, Faculté de Pharmacie, Chatenay Malabry
| | - Corinne Guitton
- Service de Pédiatrie Générale, CHU Bicêtre et Filière MCGRE, AP-HP, Le Kremlin-Bicêtre
| | - Isabelle Thuret
- Service de Pédiatrie, Hôpital La Timone, Aix Marseille University, Marseille
| | - Christian Rose
- Service d'Oncologie et d'Hématologie, Hôpital Saint Vincent de Paul, Lille
| | - Laurence Bendelac
- Laboratoire d'Hématologie, Center Hospitalier Universitaire (CHU) Bicêtre, Assistance publique - Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre
| | - Kaldoun Ghazal
- Laboratoire de Biochimie, CHU Bicêtre, AP-HP, Le Kremlin-Bicêtre
| | | | | | - Claire Barro
- Laboratoire d'Hématologie Biologique, CHU Grenoble, Grenoble
| | | | - Claire Berger
- Service d'Hématologie-Oncologie Pédiatrique, CHU, Saint-Etienne
| | | | | | | | | | - Nadia Firah
- Service de Pédiatrie, Centre Hospitaliere (CH) Pau
| | - Frédéric Galactéros
- Centre de Référence des Syndromes Drépanocytaires Majeurs, Hôpital Henri-Mondor, AP-HP, Créteil
| | - Bertrand Godeau
- Service de Médecine Interne, CHU Henri Mondor, AP-HP, Créteil
| | - Xavier Jaïs
- Service de Pneumologie, CHU Bicêtre, AP-HP, Le Kremlin-Bicêtre
| | | | | | | | - Robert Maffre
- Laboratoire d'Hématologie, Center Hospitalier Universitaire (CHU) Bicêtre, Assistance publique - Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre
| | | | | | - Valérie Proulle
- Laboratoire d'Hématologie, Center Hospitalier Universitaire (CHU) Bicêtre, Assistance publique - Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre
| | - Marc Ruivard
- Service de Médecine Interne, CHU Estaing, Clermont-Ferrand
| | | | | | - Loïc Garçon
- Laboratoire d'Hématologie, Center Hospitalier Universitaire (CHU) Bicêtre, Assistance publique - Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre .,Equipe d'Accueil 4666 HEMATIM Université de Picardie Jules Verne and Service d'Hématologie Biologique, CHU Amiens, France
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27
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Bianchi P, Fermo E, Glader B, Kanno H, Agarwal A, Barcellini W, Eber S, Hoyer JD, Kuter DJ, Maia TM, Mañu-Pereira MDM, Kalfa TA, Pissard S, Segovia JC, van Beers E, Gallagher PG, Rees DC, van Wijk R. Addressing the diagnostic gaps in pyruvate kinase deficiency: Consensus recommendations on the diagnosis of pyruvate kinase deficiency. Am J Hematol 2019; 94:149-161. [PMID: 30358897 DOI: 10.1002/ajh.25325] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/19/2018] [Accepted: 10/20/2018] [Indexed: 01/19/2023]
Abstract
Pyruvate kinase deficiency (PKD) is the most common enzyme defect of glycolysis and an important cause of hereditary, nonspherocytic hemolytic anemia. The disease has a worldwide geographical distribution but there are no verified data regarding its frequency. Difficulties in the diagnostic workflow and interpretation of PK enzyme assay likely play a role. By the creation of a global PKD International Working Group in 2016, involving 24 experts from 20 Centers of Expertise we studied the current gaps in the diagnosis of PKD in order to establish diagnostic guidelines. By means of a detailed survey and subsequent discussions, multiple aspects of the diagnosis of PKD were evaluated and discussed by members of Expert Centers from Europe, USA, and Asia directly involved in diagnosis. Broad consensus was reached among the Centers on many clinical and technical aspects of the diagnosis of PKD. The results of this study are here presented as recommendations for the diagnosis of PKD and used to prepare a diagnostic algorithm. This information might be helpful for other Centers to deliver timely and appropriate diagnosis and to increase awareness in PKD.
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Affiliation(s)
- Paola Bianchi
- UOC Ematologia, Fisiopatologia delle Anemie; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; Milan Italy
| | - Elisa Fermo
- UOC Ematologia, Fisiopatologia delle Anemie; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; Milan Italy
| | - Bertil Glader
- Lucile Packard Children's Hospital; Stanford University School of Medicine; Palo Alto California
| | - Hitoshi Kanno
- Department of Transfusion Medicine and Cell Processing; Faculty of Medicine, Tokyo Women's Medical University; Tokyo Japan
| | | | - Wilma Barcellini
- UOC Ematologia, Fisiopatologia delle Anemie; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; Milan Italy
| | - Stefan Eber
- Special Praxis for Pediatric Hematology and Childrens’ Hospital; Technical University; Munich Germany
| | - James D. Hoyer
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Rochester Minnesota
| | - David J. Kuter
- Hematology Division; Massachusetts General Hospital; Boston Massachusetts
| | | | | | - Theodosia A. Kalfa
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center and Department of Pediatrics; University of Cincinnati, College of Medicine; Cincinnati Ohio
| | - Serge Pissard
- APHP-University Hospital Henri Mondor and Inserm IMRB U955eq2; Creteil France
| | - José-Carlos Segovia
- Differentiation and Cytometry Unit. Hematopoietic Innovative Therapies Division, Centro de Investigaciones Energéticas; Medioambientales y Tecnológicas (CIEMAT) - Centro de Investigaciones Biomédicas en Red de Enfermedades Raras (CIBERER); Madrid Spain
- Advance Therapies Mixed Unit; Instituto de Investigación Sanitaria-Fundación Jimenez Díaz (IIS-FJD); Madrid Spain
| | - Eduard van Beers
- Van Creveldkliniek, University Medical Center Utrecht; University of Utrecht; Utrecht The Netherlands
| | - Patrick G. Gallagher
- Departments of Pediatrics, Pathology and Genetics; Yale University School of Medicine; New Haven Connecticut
| | - David C. Rees
- Department of Paediatric Haematology; King's College Hospital; London United Kingdom
| | - Richard van Wijk
- Department of Clinical Chemistry and Haematology, Division Laboratories, Pharmacy and Biomedical Genetics; University Medical Center Utrecht, Utrecht University; Utrecht The Netherlands
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Karami H, Darvishi-Khezri H, Kosaryan M, Akbarzadeh R, Dabirian M. The improvement of pulmonary artery pressure after bosentan therapy in patients with β-thalassemia and Doppler-defined pulmonary arterial hypertension. Int Med Case Rep J 2018; 12:1-7. [PMID: 30588128 PMCID: PMC6301293 DOI: 10.2147/imcrj.s180602] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction Pulmonary arterial hypertension (PAH) is relatively prevalent in patients with thalassemia. PAH treatment is necessary as the prevalence of Doppler-estimated PAH and the resultant mortality is high in such patients. Materials and methods This study aimed at evaluating the effect of bosentan therapy on patients with thalassemia suspected of PAH. Based on pulsed Doppler echocardiography, all the cases were suspected of severe PAH. Consequently, bosentan was initiated at a dose of 62.5 mg twice a day for 4 weeks, which was increased to 62.5–125 mg twice a day, if no adverse side effects were observed. Results The results of this study showed that pulmonary artery pressure (PAP) decreased after the administration of bosentan in three cases, from 160 to 120, 110 to 65, and 60 to 25 mmHg; in other words, the PAP reduced in the mentioned cases by 25%, 36.4%, and 58.4%, respectively. Conclusion In this study, PAP improved after bosentan therapy in patients with β-thalassemia suspected of PAH; however, further studies are required to confirm the findings.
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Affiliation(s)
- Hossein Karami
- Department of Pediatrics, Thalassemia Research Center (TRC), Hemoglobinopathy Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Hadi Darvishi-Khezri
- Student Research Committee, Thalassemia Research Center (TRC), Hemoglobinopathy Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mehrnoush Kosaryan
- Department of Pediatrics, Thalassemia Research Center (TRC), Hemoglobinopathy Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Rosetta Akbarzadeh
- Student Research Committee, Thalassemia Research Center (TRC), Hemoglobinopathy Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mojdeh Dabirian
- Department of Cardiology, Cardiovascular Research Center, Mazandaran University of Medical Sciences, Sari, Iran,
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29
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Mohandas N. Inherited hemolytic anemia: a possessive beginner's guide. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:377-381. [PMID: 30504335 PMCID: PMC6245988 DOI: 10.1182/asheducation-2018.1.377] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Significant advances have been made in diagnosis and clinical management of inherited red cell membrane disorders that result in hemolytic anemia. Membrane structural defects lead to hereditary spherocytosis (HS) and hereditary elliptocytosis (HE), whereas altered membrane transport function accounts for hereditary xerocytosis (HX) and hereditary overhydrated stomatocytosis (OHS). The degrees of membrane loss and resultant increases in cell sphericity determine the severity of anemia in HS and HE, and splenectomy leads to amelioration of anemia by increasing the circulatory red cell life span. Alterations in cell volume as a result of disordered membrane cation permeability account for reduced life span red cells in HX and OHS. Importantly, splenectomy is not beneficial in these 2 membrane transport disorders and is not recommended because it is ineffective and may lead to an increased risk of life-threatening thrombosis. Rational approaches are now available for the diagnosis and management of these inherited red cell disorders, and these will be discussed in this review.
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MESH Headings
- Anemia, Hemolytic, Congenital/genetics
- Anemia, Hemolytic, Congenital/metabolism
- Anemia, Hemolytic, Congenital/pathology
- Anemia, Hemolytic, Congenital/therapy
- Elliptocytosis, Hereditary/genetics
- Elliptocytosis, Hereditary/metabolism
- Elliptocytosis, Hereditary/pathology
- Elliptocytosis, Hereditary/therapy
- Erythrocyte Membrane/genetics
- Erythrocyte Membrane/metabolism
- Erythrocyte Membrane/pathology
- Humans
- Hydrops Fetalis/genetics
- Hydrops Fetalis/metabolism
- Hydrops Fetalis/pathology
- Hydrops Fetalis/therapy
- Risk Factors
- Spherocytosis, Hereditary/genetics
- Spherocytosis, Hereditary/metabolism
- Spherocytosis, Hereditary/pathology
- Spherocytosis, Hereditary/therapy
- Thrombosis/genetics
- Thrombosis/metabolism
- Thrombosis/pathology
- Thrombosis/therapy
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30
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Orvain C, Da Costa L, Van Wijk R, Pissard S, Picard V, Mansour-Hendili L, Cunat S, Giansily-Blaizot M, Cartron G, Schved JF, Aguilar-Martinez P. Inherited or acquired modifiers of iron status may dramatically affect the phenotype in dehydrated hereditary stomatocytosis. Eur J Haematol 2018; 101:566-569. [DOI: 10.1111/ejh.13135] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 06/29/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Corentin Orvain
- Department of Haematology Biology; Saint Eloi Hospital; Montpellier University Hospital; Montpellier France
- Department of Blood Diseases; Angers University Hospital; Angers France
- CRCINA, INSERM; Université de Nantes; Université d'Angers; Angers France
| | - Lydie Da Costa
- Department of Biological Haematology; AP-HP; Robert Debré University Hospital; Paris France
| | - Richard Van Wijk
- Department of Clinical Chemistry and Haematology; Utrecht University Medical Center; Utrecht The Netherlands
| | - Serge Pissard
- Department of Molecular Genetics; AP-HP; Henri Mondor University Hospital; Créteil France
| | - Véronique Picard
- Laboratory of Haematology; AP-HP; Bicêtre University Hospital; Le Kremlin-Bicêtre France
| | - Lamisse Mansour-Hendili
- Department of Haematology Biology; Saint Eloi Hospital; Montpellier University Hospital; Montpellier France
- Department of Molecular Genetics; AP-HP; Henri Mondor University Hospital; Créteil France
| | - Séverine Cunat
- Department of Haematology Biology; Saint Eloi Hospital; Montpellier University Hospital; Montpellier France
| | - Muriel Giansily-Blaizot
- Department of Haematology Biology; Saint Eloi Hospital; Montpellier University Hospital; Montpellier France
| | - Guillaume Cartron
- Department of Clinical Haematology; Saint Eloi Hospital; Montpellier University Hospital; Montpellier France
| | - Jean-François Schved
- Department of Haematology Biology; Saint Eloi Hospital; Montpellier University Hospital; Montpellier France
| | - Patricia Aguilar-Martinez
- Department of Haematology Biology; Saint Eloi Hospital; Montpellier University Hospital; Montpellier France
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31
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Shefer Averbuch N, Steinberg-Shemer O, Dgany O, Krasnov T, Noy-Lotan S, Yacobovich J, Kuperman AA, Kattamis A, Ben Barak A, Roth-Jelinek B, Chubar E, Shabad E, Dufort G, Ellis M, Wolach O, Pazgal I, Abu Quider A, Miskin H, Tamary H. Targeted next generation sequencing for the diagnosis of patients with rare congenital anemias. Eur J Haematol 2018; 101:297-304. [PMID: 29786897 DOI: 10.1111/ejh.13097] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Most patients with anemia are diagnosed through clinical phenotype and basic laboratory testing. Nonetheless, in cases of rare congenital anemias, some patients remain undiagnosed despite undergoing an exhaustive workup. Genetic testing is complicated by the large number of genes involved in rare anemias and the similarities in the clinical presentation of the different syndromes. OBJECTIVE We aimed to enhance the diagnosis of patients with congenital anemias by using targeted next-generation sequencing. METHODS Genetic diagnosis was performed by gene capture followed by next-generation sequencing of 76 genes known to cause anemia syndromes. RESULTS Genetic diagnosis was achieved in 13 out of 21 patients (62%). Six patients were diagnosed with pyruvate kinase deficiency, 4 with dehydrated hereditary stomatocytosis, 2 with sideroblastic anemia, and 1 with CDA type IV. Eight novel mutations were found. In 7 patients, the genetic diagnosis differed from the pretest presumed diagnosis. The mean lag time from presentation to diagnosis was over 13 years. CONCLUSIONS Targeted next-generation sequencing led to an accurate diagnosis in over 60% of patients with rare anemias. These patients do not need further diagnostic workup. Earlier incorporation of this method into the workup of patients with congenital anemia may improve patients' care and enable genetic counseling.
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Affiliation(s)
- Noa Shefer Averbuch
- Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orna Steinberg-Shemer
- Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Dgany
- Pediatric Hematology Laboratory, Felsenstein Medical Research Center, Sackler School of Medicine, Tel Aviv University, Petach Tikva, Israel
| | - Tanya Krasnov
- Pediatric Hematology Laboratory, Felsenstein Medical Research Center, Sackler School of Medicine, Tel Aviv University, Petach Tikva, Israel
| | - Sharon Noy-Lotan
- Pediatric Hematology Laboratory, Felsenstein Medical Research Center, Sackler School of Medicine, Tel Aviv University, Petach Tikva, Israel
| | - Joanne Yacobovich
- Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir A Kuperman
- Blood Coagulation Service and Pediatric Hematology Clinic, Galilee Medical Center, Nahariya, Israel.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Antonis Kattamis
- First Department of Pediatrics, National & Kapodistrian University of Athens, Athens, Greece
| | - Ayelet Ben Barak
- Pediatric Hematology/Oncology Department, Rambam Medical Center, Haifa, Israel
| | | | | | | | - Gustavo Dufort
- Pediatric Hemato-Oncology Department, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
| | - Martin Ellis
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Hematology Institute, Meir Medical Center, Kfar Saba, Israel
| | - Ofir Wolach
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
| | - Idit Pazgal
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Comprehensive Center of Thalassemia, Hemoglobinopathies & Rare Anemias, Institute of Hematology, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Abed Abu Quider
- Pediatric Hematology, Soroka University Medical Center, Ben-Gurion University, Beer Sheva, Israel
| | - Hagit Miskin
- Pediatric Hematology Unit, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Hannah Tamary
- Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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32
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Huisjes R, Bogdanova A, van Solinge WW, Schiffelers RM, Kaestner L, van Wijk R. Squeezing for Life - Properties of Red Blood Cell Deformability. Front Physiol 2018; 9:656. [PMID: 29910743 PMCID: PMC5992676 DOI: 10.3389/fphys.2018.00656] [Citation(s) in RCA: 187] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 05/14/2018] [Indexed: 12/25/2022] Open
Abstract
Deformability is an essential feature of blood cells (RBCs) that enables them to travel through even the smallest capillaries of the human body. Deformability is a function of (i) structural elements of cytoskeletal proteins, (ii) processes controlling intracellular ion and water handling and (iii) membrane surface-to-volume ratio. All these factors may be altered in various forms of hereditary hemolytic anemia, such as sickle cell disease, thalassemia, hereditary spherocytosis and hereditary xerocytosis. Although mutations are known as the primary causes of these congenital anemias, little is known about the resulting secondary processes that affect RBC deformability (such as secondary changes in RBC hydration, membrane protein phosphorylation, and RBC vesiculation). These secondary processes could, however, play an important role in the premature removal of the aberrant RBCs by the spleen. Altered RBC deformability could contribute to disease pathophysiology in various disorders of the RBC. Here we review the current knowledge on RBC deformability in different forms of hereditary hemolytic anemia and describe secondary mechanisms involved in RBC deformability.
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Affiliation(s)
- Rick Huisjes
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Anna Bogdanova
- Red Blood Cell Research Group, Institute of Veterinary Physiology, Vetsuisse Faculty and the Zurich Center for Integrative Human Physiology (ZIHP), University of Zurich, Zürich, Switzerland
| | - Wouter W van Solinge
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Raymond M Schiffelers
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Lars Kaestner
- Theoretical Medicine and Biosciences, Saarland University, Saarbrücken, Germany.,Experimental Physics, Saarland University, Saarbrücken, Germany
| | - Richard van Wijk
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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33
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Flatt JF, Bruce LJ. The Molecular Basis for Altered Cation Permeability in Hereditary Stomatocytic Human Red Blood Cells. Front Physiol 2018; 9:367. [PMID: 29713289 PMCID: PMC5911802 DOI: 10.3389/fphys.2018.00367] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 03/27/2018] [Indexed: 11/20/2022] Open
Abstract
Normal human RBCs have a very low basal permeability (leak) to cations, which is continuously corrected by the Na,K-ATPase. The leak is temperature-dependent, and this temperature dependence has been evaluated in the presence of inhibitors to exclude the activity of the Na,K-ATPase and NaK2Cl transporter. The severity of the RBC cation leak is altered in various conditions, most notably the hereditary stomatocytosis group of conditions. Pedigrees within this group have been classified into distinct phenotypes according to various factors, including the severity and temperature-dependence of the cation leak. As recent breakthroughs have provided more information regarding the molecular basis of hereditary stomatocytosis, it has become clear that these phenotypes elegantly segregate with distinct genetic backgrounds. The cryohydrocytosis phenotype, including South-east Asian Ovalocytosis, results from mutations in SLC4A1, and the very rare condition, stomatin-deficient cryohydrocytosis, is caused by mutations in SLC2A1. Mutations in RHAG cause the very leaky condition over-hydrated stomatocytosis, and mutations in ABCB6 result in familial pseudohyperkalemia. All of the above are large multi-spanning membrane proteins and the mutations may either modify the structure of these proteins, resulting in formation of a cation pore, or otherwise disrupt the membrane to allow unregulated cation movement across the membrane. More recently mutations have been found in two RBC cation channels, PIEZO1 and KCNN4, which result in dehydrated stomatocytosis. These mutations alter the activation and deactivation kinetics of these channels, leading to increased opening and allowing greater cation fluxes than in wild type.
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Affiliation(s)
- Joanna F Flatt
- Bristol Institute for Transfusion Sciences, NHS Blood and Transplant, Bristol, United Kingdom
| | - Lesley J Bruce
- Bristol Institute for Transfusion Sciences, NHS Blood and Transplant, Bristol, United Kingdom
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34
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Jamwal M, Aggarwal A, Sachdeva MUS, Sharma P, Malhotra P, Maitra A, Das R. Overhydrated stomatocytosis associated with a complex RHAG genotype including a novel de novo mutation. J Clin Pathol 2018; 71:648-652. [DOI: 10.1136/jclinpath-2018-205018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/01/2018] [Accepted: 03/02/2018] [Indexed: 11/04/2022]
Abstract
Overhydrated stomatocytosis is a rare autosomal dominant disorder known to cause variably severe haemolytic anaemia due to heterozygous mutations in the RHAG gene. We report a 26-year-old man with recurring jaundice, splenohepatomegaly and mild chronic haemolytic anaemia with significant stomatocytosis. Extensive haemolytic work-up including flow cytometry for eosin-5′-maleimide and CD47 expression levels was carried out. Targeted resequencing revealed two probably causative heterozygous mutations in RHAG (Leu336Ser and Ile149Met) and one heterozygous mutation in ANK1 (Glu1046Lys). RHAG involvement was confirmed by decreased RhAG macrocomplex component indicated by the reduced CD47 expression on erythrocytes. In silico analysis concordantly flagged RHAG:Leu336Ser and ANK1:Glu1046Lys as likely deleterious mutation, whereas RHAG:Ile149Met was reported as likely neutral by PROVEAN. Family screening by Sanger sequencing revealed RHAG:Leu336Ser in a mother and ANK1:Glu1046Lys in a father who were both asymptomatic, excluding them as causative dominant events, thus establishing RHAG:Ile149Met, novel de novo mutation as probably causative. This case illustrates the importance of family screening in interpreting next-generation sequencing (NGS) data, as in silico analysis alone can be misleading. Erudite generation of diagnostic possibilities based on a thorough baseline clinical and laboratory work-up remains as important as ever, even as NGS brings about a paradigm shift in the diagnostic work-up of rare haemolytic anaemias.
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35
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Clinical spectrum of pyruvate kinase deficiency: data from the Pyruvate Kinase Deficiency Natural History Study. Blood 2018; 131:2183-2192. [PMID: 29549173 DOI: 10.1182/blood-2017-10-810796] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 03/02/2018] [Indexed: 01/19/2023] Open
Abstract
An international, multicenter registry was established to collect retrospective and prospective clinical data on patients with pyruvate kinase (PK) deficiency, the most common glycolytic defect causing congenital nonspherocytic hemolytic anemia. Medical history and laboratory and radiologic data were retrospectively collected at enrollment for 254 patients with molecularly confirmed PK deficiency. Perinatal complications were common, including anemia that required transfusions, hyperbilirubinemia, hydrops, and prematurity. Nearly all newborns were treated with phototherapy (93%), and many were treated with exchange transfusions (46%). Children age 5 years and younger were often transfused until splenectomy. Splenectomy (150 [59%] of 254 patients) was associated with a median increase in hemoglobin of 1.6 g/dL and a decreased transfusion burden in 90% of patients. Predictors of a response to splenectomy included higher presplenectomy hemoglobin (P = .007), lower indirect bilirubin (P = .005), and missense PKLR mutations (P = .0017). Postsplenectomy thrombosis was reported in 11% of patients. The most frequent complications included iron overload (48%) and gallstones (45%), but other complications such as aplastic crises, osteopenia/bone fragility, extramedullary hematopoiesis, postsplenectomy sepsis, pulmonary hypertension, and leg ulcers were not uncommon. Overall, 87 (34%) of 254 patients had both a splenectomy and cholecystectomy. In those who had a splenectomy without simultaneous cholecystectomy, 48% later required a cholecystectomy. Although the risk of complications increases with severity of anemia and a genotype-phenotype relationship was observed, complications were common in all patients with PK deficiency. Diagnostic testing for PK deficiency should be considered in patients with apparent congenital hemolytic anemia and close monitoring for iron overload, gallstones, and other complications is needed regardless of baseline hemoglobin. This trial was registered at www.clinicaltrials.gov as #NCT02053480.
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36
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Risinger M, Glogowska E, Chonat S, Zhang K, Dagaonkar N, Joiner CH, Quinn CT, Kalfa TA, Gallagher PG. Hereditary xerocytosis: Diagnostic considerations. Am J Hematol 2018; 93:E67-E69. [PMID: 29210095 DOI: 10.1002/ajh.24996] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 11/30/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Mary Risinger
- College of Nursing; University of Cincinnati; Cincinnati Ohio
| | - Edyta Glogowska
- Department of Pediatrics; Yale University School of Medicine; New Haven Connecticut
- Department of Pathology; Yale University School of Medicine; New Haven Connecticut
- Department of Genetics; Yale University School of Medicine; New Haven Connecticut
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University School of Medicine; Atlanta Georgia
| | - Kejian Zhang
- Molecular Genetics Laboratory; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Neha Dagaonkar
- Molecular Genetics Laboratory; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Clinton H. Joiner
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University School of Medicine; Atlanta Georgia
| | - Charles T. Quinn
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine; Cincinnati Ohio
| | - Theodosia A. Kalfa
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine; Cincinnati Ohio
| | - Patrick G. Gallagher
- Department of Pediatrics; Yale University School of Medicine; New Haven Connecticut
- Department of Pathology; Yale University School of Medicine; New Haven Connecticut
- Department of Genetics; Yale University School of Medicine; New Haven Connecticut
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37
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Segraves JM, Cartin-Ceba R, Leise MD, Krowka MJ. Relationship between portopulmonary hypertension and splenectomy: Mayo Clinic experience and review of published works. Hepatol Res 2018; 48:E340-E346. [PMID: 28667665 DOI: 10.1111/hepr.12930] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 06/23/2017] [Indexed: 12/31/2022]
Abstract
AIM Portopulmonary hypertension is a serious complication of portal hypertension that can lead to right heart failure and death. To our knowledge, an association between portopulmonary hypertension and prior splenectomy has not been described previously. The goals of this study were to describe the frequency of splenectomy in portopulmonary hypertension and compare selected parameters between portopulmonary hypertension subgroups. METHODS This is a retrospective analysis of patients diagnosed with portopulmonary hypertension between 1 January 1988 and 30 June 2015 at Mayo Clinic (Rochester, MN, USA). We compared age, sex, right ventricle systolic pressure by echocardiography, and right heart catheterization measurements/calculations among subgroups of portopulmonary hypertension patients with splenectomy and/or autoimmune liver disease (autoimmune hepatitis/primary biliary cirrhosis/primary sclerosing cholangitis). RESULTS The cohort consisted of 141 patients, of whom 8 (6%) had a history of splenectomy prior to the development of portopulmonary hypertension. Twenty-seven (19%) portopulmonary hypertension patients had autoimmune liver disease, and 5 of 8 (62.5%) splenectomized portopulmonary hypertension patients had autoimmune liver disease. No significant difference was noted in right heart catheterization measurements/calculations between splenectomized and non-splenectomized portopulmonary hypertension patients. Right ventricle systolic pressure by echocardiography was significantly higher in those splenectomized. CONCLUSIONS Prior history of splenectomy in portopulmonary hypertension was 6% in this cohort. The combination of autoimmune liver disease and splenectomy in portopulmonary hypertension was not uncommon. History of splenectomy in patients with portal hypertension and/or autoimmune liver disease may have clinical implications.
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Affiliation(s)
- Justin M Segraves
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rodrigo Cartin-Ceba
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Michael D Leise
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Krowka
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
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38
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Review of the Association between Splenectomy and Chronic Thromboembolic Pulmonary Hypertension. Ann Am Thorac Soc 2018; 13:945-54. [PMID: 27058013 DOI: 10.1513/annalsats.201512-826fr] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Recent evidence suggests that there may be a link between splenectomy and the later development of pulmonary hypertension, in particular World Health Organization group IV pulmonary hypertension (chronic thromboembolic pulmonary hypertension). Epidemiological studies have demonstrated an odds ratio as high as 18 for the development of chronic thromboembolic pulmonary hypertension after splenectomy in comparison with matched control subjects who have not undergone splenectomy. The mechanisms governing the association between removal of the spleen and the subsequent development of chronic thromboembolic pulmonary hypertension remain incompletely understood; however, recent advances in understanding of coagulation homeostasis have shed some light on this association. Splenectomy increases the risk of venous thromboembolic disease, a necessary precursor of chronic thromboembolic pulmonary hypertension, by generating a prothrombotic state. This prothrombotic state likely results from a reduction in the removal of circulating procoagulant factors from the bloodstream after splenectomy. Although much is to be learned, circulating microparticles have emerged as the most likely mediator for the development of thrombosis after splenectomy. Apparently because of a reduction in reticuloendothelial cell clearance, microparticle levels are elevated in patients after splenectomy. Elevated circulating microparticle levels have been linked to thromboembolism and pulmonary hypertension in a dose-dependent fashion. It is important for health care providers to be aware of the link between splenectomy and chronic thromboembolic pulmonary hypertension. We are optimistic that clarification of the exact mechanisms that govern this association will yield clinical guidelines and potential treatments.
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39
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Abstract
The erythrocyte contains a network of pathways that regulate salt and water content in the face of extracellular and intracellular osmotic perturbations. This allows the erythrocyte to maintain a narrow range of cell hemoglobin concentration, a process critical for normal red blood cell function and survival. Primary disorders that perturb volume homeostasis jeopardize the erythrocyte and may lead to its premature destruction. These disorders are marked by clinical, laboratory, and physiologic heterogeneity. Recent studies have revealed that these disorders are also marked by genetic heterogeneity. They have implicated roles for several proteins, PIEZO1, a mammalian mechanosensory protein; GLUT1, the glucose transporter; SLC4A1, the anion transporter; RhAG, the Rh-associated glycoprotein; KCNN4, the Gardos channel; and ABCB6, an adenosine triphosphate-binding cassette family member, in the maintenance of erythrocyte volume homeostasis. Secondary disorders of erythrocyte hydration include sickle cell disease, thalassemia, hemoglobin CC, and hereditary spherocytosis, where cellular dehydration may be a significant contributor to disease pathology and clinical complications. Understanding the pathways regulating erythrocyte water and solute content may reveal innovative strategies to maintain normal volume in disorders associated with primary or secondary cellular dehydration. These mechanisms will serve as a paradigm for other cells and may reveal new therapeutic targets for disease prevention and treatment beyond the erythrocyte.
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40
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Llaudet-Planas E, Vives-Corrons JL, Rizzuto V, Gómez-Ramírez P, Sevilla Navarro J, Coll Sibina MT, García-Bernal M, Ruiz Llobet A, Badell I, Velasco-Puyó P, Dapena JL, Mañú-Pereira MM. Osmotic gradient ektacytometry: A valuable screening test for hereditary spherocytosis and other red blood cell membrane disorders. Int J Lab Hematol 2017; 40:94-102. [PMID: 29024480 DOI: 10.1111/ijlh.12746] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 08/29/2017] [Indexed: 12/01/2022]
Abstract
INTRODUCTION New generation osmotic gradient ektacytometry has become a powerful procedure for measuring red blood cell deformability and therefore for the diagnosis of red blood cell membrane disorders. In this study, we aim to provide further support to the usefulness of osmotic gradient ektacytometry for the differential diagnosis of hereditary spherocytosis by measuring the optimal cutoff values of the parameters provided by this technique. METHODS A total of 65 cases of hereditary spherocytosis, 7 hereditary elliptocytosis, 3 hereditary xerocytosis, and 171 normal controls were analyzed with osmotic gradient ektacytometry in addition to the routine red blood cell laboratory techniques. The most robust osmoscan parameters for hereditary spherocytosis diagnosis were determined using receiver operating characteristic curve analysis. RESULTS The best diagnostic criteria for hereditary spherocytosis were the combination of decreased minimal elongation index up to 3% and increased minimal osmolality point up to 5.2% when compared to the mean of controls. Using this established criterion, osmotic gradient ektacytometry reported a sensitivity of 93.85% and a specificity of 98.38% for the diagnosis of hereditary spherocytosis. CONCLUSION Osmotic gradient ektacytometry is an effective diagnostic test for hereditary spherocytosis and enables its differential diagnosis with other red blood cell membrane diseases based on specific pathology profiles.
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Affiliation(s)
- E Llaudet-Planas
- Red Cell Pathology Unit, Hospital Clínic de Barcelona, [Institut d'Investigacions Biomèdiques August Pi I Sunyer] IDIBAPS, [Universitat de Barcelona] UB, Barcelona, Spain.,Red Cell Pathology Unit, [Josep Carreras Leukemia Research Institute] IJC, [Universitat Autònoma de Barcelona] UAB, Badalona, Spain
| | - J L Vives-Corrons
- Red Cell Pathology Unit, Hospital Clínic de Barcelona, [Institut d'Investigacions Biomèdiques August Pi I Sunyer] IDIBAPS, [Universitat de Barcelona] UB, Barcelona, Spain.,Red Cell Pathology Unit, [Josep Carreras Leukemia Research Institute] IJC, [Universitat Autònoma de Barcelona] UAB, Badalona, Spain
| | - V Rizzuto
- Red Cell Pathology Unit, [Josep Carreras Leukemia Research Institute] IJC, [Universitat Autònoma de Barcelona] UAB, Badalona, Spain
| | - P Gómez-Ramírez
- Red Cell Pathology Unit, Hospital Clínic de Barcelona, [Institut d'Investigacions Biomèdiques August Pi I Sunyer] IDIBAPS, [Universitat de Barcelona] UB, Barcelona, Spain
| | - J Sevilla Navarro
- Servicio Hematología Pediátrica, [Hospital Infantil Universitario Niño Jesús] HIUNJ, [Fundación por la Investigación Biomédica] FIB, CIBERER, Madrid, Spain
| | - M T Coll Sibina
- Pediatric Department, Hospital General de Granollers, Granollers, Spain
| | - M García-Bernal
- Pediatric Hematology and Oncology Department, Hospital Universitari Mútua de Terrassa, Terrassa, Spain
| | - A Ruiz Llobet
- Pediatric Hematology and Oncology Department, Hospital Sant Joan de Déu de Barcelona, [University of Barcelona] UB, Barcelona, Spain
| | - I Badell
- Unidad de Hematología, Oncología y Trasplante Hematopoyético, Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona [UAB], Barcelona, Spain
| | - P Velasco-Puyó
- Pediatric Oncology and Hematology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona [UAB], Barcelona, Spain
| | - J L Dapena
- Pediatric Oncology and Hematology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona [UAB], Barcelona, Spain
| | - M M Mañú-Pereira
- Red Cell Pathology Unit, Hospital Clínic de Barcelona, [Institut d'Investigacions Biomèdiques August Pi I Sunyer] IDIBAPS, [Universitat de Barcelona] UB, Barcelona, Spain.,Red Cell Pathology Unit, [Josep Carreras Leukemia Research Institute] IJC, [Universitat Autònoma de Barcelona] UAB, Badalona, Spain
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41
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Narla J, Mohandas N. Red cell membrane disorders. Int J Lab Hematol 2017; 39 Suppl 1:47-52. [PMID: 28447420 DOI: 10.1111/ijlh.12657] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 02/21/2017] [Indexed: 11/30/2022]
Abstract
Significant advances have been made in our understanding of the structural basis for altered cell function in various inherited red cell membrane disorders with reduced red cell survival and resulting hemolytic anemia. The current review summarizes these advances as they relate to defining the molecular and structural basis for disorders involving altered membrane structural organization (hereditary spherocytosis [HS] and hereditary elliptocytosis [HE]) and altered membrane transport function (hereditary overhydrated stomatocytosis and hereditary xerocytosis). Mutations in genes encoding membrane proteins that account for these distinct red cell phenotypes have been identified. These molecular insights have led to improved understanding of the structural basis for altered membrane function in these disorders. Weakening of vertical linkage between the lipid bilayer and spectrin-based membrane skeleton leads to membrane loss in HS. In contrast, weakening of lateral linkages among different skeletal proteins leads to membrane fragmentation and decreased surface area in HE. The degrees of membrane loss and resultant increases in cell sphericity determine the severity of anemia in these two disorders. Splenectomy leads to amelioration of anemia by increasing the circulatory red cell life span of spherocytic red cells that are normally sequestered by the spleen. Disordered membrane cation permeability and resultant increase or decrease in red cell volume account for altered cellular deformability of hereditary overhydrated stomatocytosis and hereditary xerocytosis, respectively. Importantly, splenectomy is not beneficial in these two membrane transport disorders and in fact contraindicated due to severe postsplenectomy thrombotic complications.
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Affiliation(s)
- J Narla
- Regional Medical Center, San Jose, CA, USA
| | - N Mohandas
- New York Blood Center, New York, NY, USA
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42
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Iolascon A, Andolfo I, Barcellini W, Corcione F, Garçon L, De Franceschi L, Pignata C, Graziadei G, Pospisilova D, Rees DC, de Montalembert M, Rivella S, Gambale A, Russo R, Ribeiro L, Vives-Corrons J, Martinez PA, Kattamis A, Gulbis B, Cappellini MD, Roberts I, Tamary H. Recommendations regarding splenectomy in hereditary hemolytic anemias. Haematologica 2017; 102:1304-1313. [PMID: 28550188 PMCID: PMC5541865 DOI: 10.3324/haematol.2016.161166] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 05/22/2017] [Indexed: 01/19/2023] Open
Abstract
Hereditary hemolytic anemias are a group of disorders with a variety of causes, including red cell membrane defects, red blood cell enzyme disorders, congenital dyserythropoietic anemias, thalassemia syndromes and hemoglobinopathies. As damaged red blood cells passing through the red pulp of the spleen are removed by splenic macrophages, splenectomy is one possible therapeutic approach to the management of severely affected patients. However, except for hereditary spherocytosis for which the effectiveness of splenectomy has been well documented, the efficacy of splenectomy in other anemias within this group has yet to be determined and there are concerns regarding short- and long-term infectious and thrombotic complications. In light of the priorities identified by the European Hematology Association Roadmap we generated specific recommendations for each disorder, except thalassemia syndromes for which there are other, recent guidelines. Our recommendations are intended to enable clinicians to achieve better informed decisions on disease management by splenectomy, on the type of splenectomy and the possible consequences. As no randomized clinical trials, case control or cohort studies regarding splenectomy in these disorders were found in the literature, recommendations for each disease were based on expert opinion and were subsequently critically revised and modified by the Splenectomy in Rare Anemias Study Group, which includes hematologists caring for both adults and children.
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Affiliation(s)
- Achille Iolascon
- Department of Molecular Medicine and Medical Biotechnology, University Federico II Naples, Italy .,CEINGE Biotecnologie Avanzate, Naples, Italy
| | - Immacolata Andolfo
- Department of Molecular Medicine and Medical Biotechnology, University Federico II Naples, Italy.,CEINGE Biotecnologie Avanzate, Naples, Italy
| | - Wilma Barcellini
- Oncohematology Unit, IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Corcione
- Department of General Surgery, Monaldi Hospital A.O.R.N. dei Colli, Naples, Italy
| | - Loïc Garçon
- Service d'Hématologie Biologique, CHU Amiens Picardie, Amiens, France
| | | | - Claudio Pignata
- Department of Translational Medical Sciences, Federico II University of Naples, Italy
| | - Giovanna Graziadei
- Department of Clinical Science and Community Health, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, University of Milan, Italy
| | - Dagmar Pospisilova
- Department of Pediatrics, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - David C Rees
- Department of Paediatric Haematology, King's College Hospital, King's College London School of Medicine, UK
| | | | - Stefano Rivella
- Department of Pediatrics, Division of Hematology-Oncology, Children's Blood and Cancer Foundation Laboratories, Weill Cornell Medical College, New York, NY, USA; Department of Pediatrics, Division of Hematology, Children's Hospital of Philadelphia, PA, USA
| | - Antonella Gambale
- Department of Molecular Medicine and Medical Biotechnology, University Federico II Naples, Italy.,CEINGE Biotecnologie Avanzate, Naples, Italy
| | - Roberta Russo
- Department of Molecular Medicine and Medical Biotechnology, University Federico II Naples, Italy.,CEINGE Biotecnologie Avanzate, Naples, Italy
| | - Leticia Ribeiro
- Hematology Service, Hospital and University Center of Coimbra (CHUC), Portugal
| | | | | | | | - Beatrice Gulbis
- Department of Clinical Chemistry, Hôpital Erasme, U.L.B., Brussels, Belgium
| | - Maria Domenica Cappellini
- Department of Clinical Science and Community Health, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, University of Milan, Italy
| | - Irene Roberts
- Department of Paediatrics, Children's Hospital, University of Oxford, John Radcliffe Hospital, UK
| | - Hannah Tamary
- Pediatric Hematology Unit, Schneider Children's Medical Center of Israel, Petah Tiqva, Sackler Faculty of Medicine, Tel Aviv University, Israel
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43
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Fermo E, Bogdanova A, Petkova-Kirova P, Zaninoni A, Marcello AP, Makhro A, Hänggi P, Hertz L, Danielczok J, Vercellati C, Mirra N, Zanella A, Cortelezzi A, Barcellini W, Kaestner L, Bianchi P. 'Gardos Channelopathy': a variant of hereditary Stomatocytosis with complex molecular regulation. Sci Rep 2017; 7:1744. [PMID: 28496185 PMCID: PMC5431847 DOI: 10.1038/s41598-017-01591-w] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 03/31/2017] [Indexed: 11/17/2022] Open
Abstract
The Gardos channel is a Ca2+ sensitive, K+ selective channel present in several tissues including RBCs, where it is involved in cell volume regulation. Recently, mutations at two different aminoacid residues in KCNN4 have been reported in patients with hereditary xerocytosis. We identified by whole exome sequencing a new family with two members affected by chronic hemolytic anemia carrying mutation R352H in the KCNN4 gene. No additional mutations in genes encoding for RBCs cytoskeletal, membrane or channel proteins were detected. We performed functional studies on patients’ RBCs to evaluate the effects of R352H mutation on the cellular properties and eventually on the clinical phenotype. Gardos channel hyperactivation was demonstrated in circulating erythrocytes and erythroblasts differentiated ex-vivo from peripheral CD34+ cells. Pathological alterations in the function of multiple ion transport systems were observed, suggesting the presence of compensatory effects ultimately preventing cellular dehydration in patient’s RBCs; moreover, flow cytometry and confocal fluorescence live-cell imaging showed Ca2+ overload in the RBCs of both patients and hypersensitivity of Ca2+ uptake by RBCs to swelling. Altogether these findings suggest that the ‘Gardos channelopathy’ is a complex pathology, to some extent different from the common hereditary xerocytosis.
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Affiliation(s)
- Elisa Fermo
- UOC Oncoematologia, UOS. Fisiopatologia delle Anemie Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Anna Bogdanova
- Vetsuisse Faculty and the Zurich Center for Integrative Human Physiology (ZIHP), Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland
| | - Polina Petkova-Kirova
- Research Center for Molecular Imaging and Screening, Medical School, Institute for Molecular Cell Biology, Saarland University, Homburg/Saar, Germany
| | - Anna Zaninoni
- UOC Oncoematologia, UOS. Fisiopatologia delle Anemie Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Anna Paola Marcello
- UOC Oncoematologia, UOS. Fisiopatologia delle Anemie Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Asya Makhro
- Vetsuisse Faculty and the Zurich Center for Integrative Human Physiology (ZIHP), Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland
| | - Pascal Hänggi
- Vetsuisse Faculty and the Zurich Center for Integrative Human Physiology (ZIHP), Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland
| | - Laura Hertz
- Research Center for Molecular Imaging and Screening, Medical School, Institute for Molecular Cell Biology, Saarland University, Homburg/Saar, Germany
| | - Jens Danielczok
- Research Center for Molecular Imaging and Screening, Medical School, Institute for Molecular Cell Biology, Saarland University, Homburg/Saar, Germany
| | - Cristina Vercellati
- UOC Oncoematologia, UOS. Fisiopatologia delle Anemie Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Nadia Mirra
- UOC Pronto soccorso, Pediatria ambulatoriale e DH/MAC. Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Alberto Zanella
- UOC Oncoematologia, UOS. Fisiopatologia delle Anemie Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Agostino Cortelezzi
- UOC Oncoematologia, UOS. Fisiopatologia delle Anemie Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.,Universita' degli Studi di Milano, Milano, Italy
| | - Wilma Barcellini
- UOC Oncoematologia, UOS. Fisiopatologia delle Anemie Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Lars Kaestner
- Experimental Physics, Saarland University, Saarbruecken, Germany.,Theoretical Medicine and Biosciences, Saarland University, Homburg/Saar, Germany
| | - Paola Bianchi
- UOC Oncoematologia, UOS. Fisiopatologia delle Anemie Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.
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44
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Hereditary Xerocytosis due to Mutations in PIEZO1 Gene Associated with Heterozygous Pyruvate Kinase Deficiency and Beta-Thalassemia Trait in Two Unrelated Families. Case Rep Hematol 2017; 2017:2769570. [PMID: 28367341 PMCID: PMC5358460 DOI: 10.1155/2017/2769570] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 02/15/2017] [Indexed: 11/23/2022] Open
Abstract
Hereditary xerocytosis (HX) is a rare disorder caused by defects of RBC permeability, associated with haemolytic anaemia of variable degree and iron overload. It is sometimes misdiagnosed as hereditary spherocytosis or other congenital haemolytic anaemia. Splenectomy is contraindicated due to increased risk of thromboembolic complications. We report the clinical, haematological, and molecular characteristics of four patients from two unrelated Italian families affected by HX, associated with beta-thalassemia trait and heterozygous pyruvate kinase deficiency, respectively. Two patients had been splenectomised and displayed thrombotic episodes. All patients had iron overload in the absence of transfusion, two of them requiring iron chelation. The diagnosis of HX was confirmed by LoRRca Osmoscan analysis showing a left-shifted curve. PIEZO1 gene sequencing revealed the presence of mutation p.E2496ELE, showing that this is one of the most frequent mutations in this disease. The concomitant defects did not aggravate the clinical phenotype; however, in one patient, the initial diagnosis of pyruvate kinase deficiency delayed the correct diagnosis of HX for many years and resulted in splenectomy followed by thrombotic complications. The study underlines the importance of a precise diagnosis in HX, particularly in view of splenectomy, and the need of a molecular confirmation of suspected RBC enzymopathy.
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45
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Abstract
Mutations in the genes encoding the mechanosensitive cation channels PIEZO1 and PIEZO2 are responsible for multiple hereditary human diseases. Loss-of-function mutations in the human PIEZO1 gene cause autosomal recessive congenital lymphatic dysplasia. Gain-of-function mutations in the human PIEZO1 gene cause the autosomal dominant hemolytic anemia, hereditary xerocytosis (also known as dehydrated stomatocytosis). Loss-of-function mutations in the human PIEZO2 gene cause an autosomal recessive syndrome of muscular atrophy with perinatal respiratory distress, arthrogryposis, and scoliosis. Gain-of-function mutations in the human PIEZO2 gene cause three clinical types of autosomal dominant distal arthrogryposis. This chapter will review the hereditary diseases caused by mutations in the PIEZO genes and will discuss additional physiological systems in which PIEZO channel dysfunction may contribute to human disease pathophysiology.
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Affiliation(s)
- S L Alper
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States.
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46
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Mathew R, Huang J, Wu JM, Fallon JT, Gewitz MH. Hematological disorders and pulmonary hypertension. World J Cardiol 2016; 8:703-718. [PMID: 28070238 PMCID: PMC5183970 DOI: 10.4330/wjc.v8.i12.703] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/07/2016] [Accepted: 10/09/2016] [Indexed: 02/06/2023] Open
Abstract
Pulmonary hypertension (PH), a serious disorder with a high morbidity and mortality rate, is known to occur in a number of unrelated systemic diseases. Several hematological disorders such as sickle cell disease, thalassemia and myeloproliferative diseases develop PH which worsens the prognosis. Associated oxidant injury and vascular inflammation cause endothelial damage and dysfunction. Pulmonary vascular endothelial damage/dysfunction is an early event in PH resulting in the loss of vascular reactivity, activation of proliferative and antiapoptotic pathways leading to vascular remodeling, elevated pulmonary artery pressure, right ventricular hypertrophy and premature death. Hemolysis observed in hematological disorders leads to free hemoglobin which rapidly scavenges nitric oxide (NO), limiting its bioavailability, and leading to endothelial dysfunction. In addition, hemolysis releases arginase into the circulation which converts L-arginine to ornithine, thus bypassing NO production. Furthermore, treatments for hematological disorders such as immunosuppressive therapy, splenectomy, bone marrow transplantation, and radiation have been shown to contribute to the development of PH. Recent studies have shown deregulated iron homeostasis in patients with cardiopulmonary diseases including pulmonary arterial hypertension (PAH). Several studies have reported low iron levels in patients with idiopathic PAH, and iron deficiency is an important risk factor. This article reviews PH associated with hematological disorders and its mechanism; and iron homeostasis and its relevance to PH.
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47
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Andolfo I, Russo R, Gambale A, Iolascon A. New insights on hereditary erythrocyte membrane defects. Haematologica 2016; 101:1284-1294. [PMID: 27756835 PMCID: PMC5394881 DOI: 10.3324/haematol.2016.142463] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 06/16/2016] [Indexed: 01/02/2023] Open
Abstract
After the first proposed model of the red blood cell membrane skeleton 36 years ago, several additional proteins have been discovered during the intervening years, and their relationship with the pathogenesis of the related disorders have been somewhat defined. The knowledge of erythrocyte membrane structure is important because it represents the model for spectrin-based membrane skeletons in all cells and because defects in its structure underlie multiple hemolytic anemias. This review summarizes the main features of erythrocyte membrane disorders, dividing them into structural and altered permeability defects, focusing particularly on the most recent advances. New proteins involved in alterations of the red blood cell membrane permeability were recently described. The mechanoreceptor PIEZO1 is the largest ion channel identified to date, the fundamental regulator of erythrocyte volume homeostasis. Missense, gain-of-function mutations in the PIEZO1 gene have been identified in several families as causative of dehydrated hereditary stomatocytosis or xerocytosis. Similarly, the KCNN4 gene, codifying the so called Gardos channel, has been recently identified as a second causative gene of hereditary xerocytosis. Finally, ABCB6 missense mutations were identified in different pedigrees of familial pseudohyperkalemia. New genomic technologies have improved the quality and reduced the time of diagnosis of these diseases. Moreover, they are essential for the identification of the new causative genes. However, many questions remain to solve, and are currently objects of intensive studies.
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Affiliation(s)
- Immacolata Andolfo
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, Italy
- CEINGE Biotecnologie Avanzate, Napoli, Italy
| | - Roberta Russo
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, Italy
- CEINGE Biotecnologie Avanzate, Napoli, Italy
| | - Antonella Gambale
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, Italy
- CEINGE Biotecnologie Avanzate, Napoli, Italy
| | - Achille Iolascon
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, Italy
- CEINGE Biotecnologie Avanzate, Napoli, Italy
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48
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Lacy JN, Ulirsch JC, Grace RF, Towne MC, Hale J, Mohandas N, Lux SE, Agrawal PB, Sankaran VG. Exome sequencing results in successful diagnosis and treatment of a severe congenital anemia. Cold Spring Harb Mol Case Stud 2016; 2:a000885. [PMID: 27551681 PMCID: PMC4990811 DOI: 10.1101/mcs.a000885] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Whole-exome sequencing is increasingly used for diagnosis and identification of appropriate therapies in patients. Here, we present the case of a 3-yr-old male with a lifelong and severe transfusion-dependent anemia of unclear etiology, despite an extensive clinical workup. Given the difficulty of making the diagnosis and the potential side effects from performing interventions in patients with a congenital anemia of unknown etiology, we opted to perform whole-exome sequencing on the patient and his parents. This resulted in the identification of homozygous loss-of-function mutations in the EPB41 gene, encoding erythrocyte protein band 4.1, which therefore causes a rare and severe form of hereditary elliptocytosis in the patient. Based on prior clinical experience in similar patients, a surgical splenectomy was performed that resulted in subsequent transfusion independence in the patient. This case illustrates how whole-exome sequencing can lead to accurate diagnoses (and exclusion of diagnoses where interventions, such as splenectomy, would be contraindicated), thereby resulting in appropriate and successful therapeutic intervention—a major goal of precision medicine.
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Affiliation(s)
- Jessica N Lacy
- Division of Hematology/Oncology, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA;; Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts 02115, USA;; Broad Institute of MIT and Harvard, Cambridge, Massachusetts 02142, USA
| | - Jacob C Ulirsch
- Division of Hematology/Oncology, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA;; Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts 02115, USA;; Broad Institute of MIT and Harvard, Cambridge, Massachusetts 02142, USA
| | - Rachael F Grace
- Division of Hematology/Oncology, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA;; Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Meghan C Towne
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - John Hale
- New York Blood Center, New York, New York 10065, USA
| | | | - Samuel E Lux
- Division of Hematology/Oncology, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA;; Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Pankaj B Agrawal
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts 02142, USA;; Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA;; Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Vijay G Sankaran
- Division of Hematology/Oncology, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA;; Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts 02115, USA;; Broad Institute of MIT and Harvard, Cambridge, Massachusetts 02142, USA
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49
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Yawata Y, Kanzaki A, Yawata A, Nakanishi H, Kaku M. Hereditary Red Cell Membrane Disorders in Japan: Their Genotypic and Phenotypic Features in 1014 Cases Studied. Hematology 2016; 6:399-422. [DOI: 10.1080/10245332.2001.11746596] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Yoshihito Yawata
- The Division of Hematology, Department of Medicine, Kawasaki Medical School, 316 Matsushima, Kurashiki City, Japan
| | - Akio Kanzaki
- The Division of Hematology, Department of Medicine, Kawasaki Medical School, 316 Matsushima, Kurashiki City, Japan
| | - Ayumi Yawata
- The Division of Hematology, Department of Medicine, Kawasaki Medical School, 316 Matsushima, Kurashiki City, Japan
| | - Hidekazu Nakanishi
- The Division of Hematology, Department of Medicine, Kawasaki Medical School, 316 Matsushima, Kurashiki City, Japan
| | - Mayumi Kaku
- The Division of Hematology, Department of Medicine, Kawasaki Medical School, 316 Matsushima, Kurashiki City, Japan
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50
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Andolfo I, Russo R, Manna F, De Rosa G, Gambale A, Zouwail S, Detta N, Pardo CL, Alper SL, Brugnara C, Sharma AK, De Franceschi L, Iolascon A. Functional characterization of novel ABCB6 mutations and their clinical implications in familial pseudohyperkalemia. Haematologica 2016; 101:909-17. [PMID: 27151991 DOI: 10.3324/haematol.2016.142372] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/29/2016] [Indexed: 11/09/2022] Open
Abstract
Isolated familial pseudohyperkalemia is a dominant red cell trait characterized by cold-induced 'passive leak' of red cell potassium ions into plasma. The causative gene of this condition is ABCB6, which encodes an erythrocyte membrane ABC transporter protein bearing the Langereis blood group antigen system. In this study analyzing three new families, we report the first functional characterization of ABCB6 mutants, including the homozygous mutation V454A, heterozygous mutation R276W, and compound heterozygous mutations R276W and R723Q (in trans). All these mutations are annotated in public databases, suggesting that familial pseudohyperkalemia could be common in the general population. Indeed, we identified variant R276W in one of 327 random blood donors (0.3%). Four weeks' storage of heterozygous R276W blood cells resulted in massive loss of potassium compared to that from healthy control red blood cells. Moreover, measurement of cation flux demonstrated greater loss of potassium or rubidium ions from HEK-293 cells expressing ABCB6 mutants than from cells expressing wild-type ABCB6. The R276W/R723Q mutations elicited greater cellular potassium ion efflux than did the other mutants tested. In conclusion, ABCB6 missense mutations in red blood cells from subjects with familial pseudohyperkalemia show elevated potassium ion efflux. The prevalence of such individuals in the blood donor population is moderate. The fact that storage of blood from these subjects leads to significantly increased levels of potassium in the plasma could have serious clinical implications for neonates and infants receiving large-volume transfusions of whole blood. Genetic tests for familial pseudohyperkalemia could be added to blood donor pre-screening. Further study of ABCB6 function and trafficking could be informative for the study of other pathologies of red blood cell hydration.
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Affiliation(s)
- Immacolata Andolfo
- Department of Molecular Medicine and Medical Biotechnologies, "Federico II" University of Naples, Italy CEINGE, Biotecnologie Avanzate, Naples, Italy
| | - Roberta Russo
- Department of Molecular Medicine and Medical Biotechnologies, "Federico II" University of Naples, Italy CEINGE, Biotecnologie Avanzate, Naples, Italy
| | - Francesco Manna
- Department of Molecular Medicine and Medical Biotechnologies, "Federico II" University of Naples, Italy CEINGE, Biotecnologie Avanzate, Naples, Italy
| | - Gianluca De Rosa
- Department of Molecular Medicine and Medical Biotechnologies, "Federico II" University of Naples, Italy CEINGE, Biotecnologie Avanzate, Naples, Italy
| | - Antonella Gambale
- Department of Molecular Medicine and Medical Biotechnologies, "Federico II" University of Naples, Italy CEINGE, Biotecnologie Avanzate, Naples, Italy
| | - Soha Zouwail
- Department of Biochemistry and Immunology, Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK and Department of Medical Biochemistry, School of Medicine, Alexandria University, Egypt
| | | | - Catia Lo Pardo
- Servizio Immunotrasfusionale, "A. Cardarelli" Hospital, Naples, Italy
| | - Seth L Alper
- Division of Nephrology and Center for Vascular Biology Research, Beth Israel Deaconess Medical Center and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Carlo Brugnara
- Department of Laboratory Medicine, Boston Children's Hospital and Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Alok K Sharma
- Division of Nephrology and Center for Vascular Biology Research, Beth Israel Deaconess Medical Center and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Achille Iolascon
- Department of Molecular Medicine and Medical Biotechnologies, "Federico II" University of Naples, Italy CEINGE, Biotecnologie Avanzate, Naples, Italy
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