THE INITIATION AND ENHANCEMENT OF HUMAN RED CELL LYSIS BY ACTIVATORS OF THE FIRST COMPONENT OF COMPLEMENT AND BY FIRST COMPONENT ESTERASE; STUDIES USING NORMAL RED CELLS AND RED CELLS FROM PATIENTS WITH PAROXYSMAL NOCTURNAL HEMOGLOBINURIA

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

He reshaped the forefront of xenotransplantation: Agustin Pasqual Dalmasso (1933-2021)

Agustin Pasqual Dalmasso died in December 2021. He was 88 years old and an Honorary Member of the International Xenotransplantation Association. Gus made seminal contributions to understanding and overcoming the barrier complement system poses to xenotransplantation. Those endeavoring to advance xenotransplantation to clinical application and those seeking the most topics in which to devote their life's work could do no better than examining how Gus approached the subjects of his life's work.

Bystander Immune Cytolysis

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

Complement sensitivity of erythroid and myeloid precursors in paroxysmal in nocturnal hemoglobinuria

To test the hypothesis that paroxysmal nocturnal hemoglobinuria (PNH) is a hematopoietic stem cell disorder, the growth of BFU-e and CFU-gm and the complement sensitivity of cultured cells from BFU-e and CFU-gm colonies, as well as of unipotential progenitor cells (CFU-gm and BFU-e), were examined in five PNH patients. BFU-e growth was reduced in the three patients examined, and poor CFU-gm growth was noted in three of the five patients. Compared to normals, BFU-e and CFU-gm colonies in all patients demonstrated an increased susceptibility to the lytic action of complement when the release of 59Fe and myeloperoxidase was measured as specific markers for monitoring membrane damage. Compared to the growth of normal bone marrow cells, CFU-gm growth was significantly inhibited by pretreatment of bone marrow mononuclear cells with monoclonal OKIal antibody and complement. These findings support the proposition that a membrane defect predisposing blood cells to complement-mediated lysis may occur at the level of unipotential progenitor cells.

Affected erythrocytes of patients with paroxysmal nocturnal hemoglobinuria are deficient in the complement regulatory protein, decay accelerating factor

Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired defect of bone marrow stem cells in which the affected clones produce erythrocytes (also granulocytes and platelets) with membranes that are abnormally sensitive to complement-mediated lysis. Abnormal erythrocytes (E) from patients with PNH (PNH-E) are 3-5 times more sensitive (type II PNH-E) or 15-25 times more sensitive (type III PNH-E) to lysis in vitro by human complement than normal E from unaffected individuals and the functionally normal E that arise from unaffected clones and the functionally normal E that arise from unaffected clones in PNH patients (type I PNH-E). After complement activation by either the classical or alternative pathway, abnormal amounts of C3b are deposited on the membranes of PNH-E compared with normal E, suggesting that the PNH-E membrane cannot regulate the events responsible for C3b deposition. Two proteins that decrease the stability of the classical and alternative pathway C3 convertases on target cells have been isolated from normal human E stroma: the 70,000 Mr decay accelerating factor of stroma (DAF) and the 250,000 Mr C3b receptor (C3bR). Specific immune precipitates of solubilized membranes from 125I-surface-labeled normal E demonstrate both proteins. In contrast, specific immune precipitates of PNH-E from three patients show C3bR but are deficient in DAF; type II PNH-E are relatively deficient and type III PNH-E are totally deficient in DAF. Antibody that neutralizes the activity of isolated DAF is adsorbed by intact normal E under conditions in which it is weakly adsorbed by type II PNH-E and not adsorbed by type III PNH-E. The deficiency of DAF antigen in PNH-E, as assessed by lack of immunoprecipitation and antibody adsorption, could explain the abnormal sensitivity of PNH-E to complement-mediated lysis and suggests that DAF may protect the membranes of normal E from damage resulting from autologous complement activation.

Interactions between polymerized human albumin, hepatitis B surface antigen, and complement: I. Binding of polyalbumin to Clq

There is considerable evidence that substances other than immunoglobulins can bind human Clq. Utilizing purified human Clq immobilized on polystyrene beads, we have demonstrated that polymerized human albumin (PHALB-125I) binds to human Clq in a direct binding assay. This interaction required a high degree of albumin polymerization as the percentage of binding was proportional to the polymer size and monomeric albumin was unreactive. Binding was species specific in the human Clq bound only human, and not xenogeneic, polyalbumins. Similarly, polymers of various other human plasma proteins were unreactive. To demonstrate that this interaction was not unique to immobilized Clq, soluble Clq was shown to inhibit PHALB-125I binding to solid phase Clq. Because aggregated IgG, poly(I):poly(C), dextran sulfate, polyglutamic acid, and polylysine have been previously shown to bind Clq, we used them in further blocking experiments and found them also to inhibit the interaction between Clq and PHALB. Anti-human Clq and, to a lesser extent, anti-PHALB antibodies inhibited the interaction. The Clq-PHALB binding was pH, ionic strength, and temperature dependent. In addition, human Clq was not observed to bind hepatitis B surface antigen (HBsAg) directly; however, in the presence of sufficiently polymerized human albumin a Clq-PHALB-HBsAg complex was formed. These interactions may be implicated in hepatocyte-HBsAg receptor function as well as in the host defense mechanisms involved in hepatitis B virus infection.

Complement-dependent platelet injury by staphylococcal protein A

A new example of complement-mediated platelet injury has been described. Staphylococcal protein A (SPA) causes rabbit platelet injury as manifested by release of platelet 5-hydroxytryptamine (5HT). This reaction is complement-dependent and occurs over a very small range of SPA concentration, larger amounts being inhibitory. Complement fixation by SPA demonstrates the same narrow SPA concentration requirement whereas precipitation of IgG by SPA is roughly proportional to SPA concentration over a wide concentration range. The reaction can be separated into a sensitization step which requires SPA and plasma but not complement, and a release step which does require complement. Complement-mediated platelet damage induced by SPA is a new biologic property of this common component of the cell wall of pathogenic staphylococci which may contribute to the development of inflammatory and thromboembolic reactions complicating intravascular staphylococcal infection.

Lysis of erythrocytes by complement in the absence of antibody

A new pathway of complement-mediated hemolysis has been described. It is independent of antibody and does not require binding of the first four complement components to the target-cell surface. The actual attack of the target cell begins with the attachment of C5, C6, and C7. The binding reaction is catalyzed by C4, 2, 3, an enzyme which may be formed in cell-free solution. C4, 2, 3 may effect binding of C5, 6, 7 by acting from the fluid phase or from the surface of another cell to which it is specifically bound (EAC 4, 2, 3). In either case, the resulting product is EC5, 6, 7 which is susceptible to lysis by C8 and C9. Erythrocytes from patients with paroxysmal nocturnal hemoglobinuria (PNH) were particularly susceptible to lysis by the above described mechanism. PNH cells, but not normal human erythrocytes, could also be lysed through activation of complement by cobra factor. These observations allow the operational distinction of an activation and an attack mechanism of complement.

The detection of cell-bound antibody on complement-coated human red cells

This study sought to elucidate the mechanism by which human red cells, in a variety of clinical settings, become coated in vivo with autologous complement components in the absence of anti-red cell autoantibodies demonstrable by standard methods. By means of a newly developed complement-fixing antibody consumption test, previously undetectable red cell-bound gammaG globulin could be detected and quantified. By this technique, the complement-coated red cells of 13 of 16 patients were shown to carry abnormally high numbers of gammaG molecules per cell, which were nevertheless below the level for detection by the direct antiglobulin test. Eluates were made from the red cells of seven of these patients and each eluate, when sufficiently concentrated, was capable of sensitizing normal human red cells (with gammaG antibodies) to give a positive indirect antiglobulin test with anti-gammaG serum. In the presence of fresh normal serum, six of the eluates so tested were capable of fixing complement to normal human red cells. The antibodies in the red cell eluates did not exhibit Rh specificity and did not react with nonprimate red cells. When studied by sucrose gradient ultracentrifugation, the gammaG antibodies to human red cells in these eluates sedimented in the 7S region. It is concluded that in many patients in whom direct antiglobulin tests reveal only cell-bound complement, the complement fixation is mediated in vivo by small quantities of "warm-reacting" erythrocyte autoantibodies of the gammaG class.

Reactive haemolysis--a distinctive form of red cell lysis

This paper describes a form of red cell lysis differentiated from classical complement haemolysis by its occurrence in the absence of antibody on the cells and in the presence of EDTA. This type of haemolysis has been called reactive haemolysis. It is the result of the interaction, in the presence of red cells, of at least two serum factors called `reactor' and `indicator', respectively.

Reactor only becomes active after incubation at 37° of serum with certain agents, notably antibody-coated bacteria, zymosan and agarose, in conditions similar to those required for complement activation. The potential for the formation of activated reactor could be demonstrated infrequently in healthy subjects but more frequently in sera from hospital patients. Activated reactor behaved as a protein sedimenting between 7S and 19S, and of α₂—β₁, electrophoretic mobility in agar.

Indicator factors were present in all human sera studied, as well as in the sera of a number of mammalian species. They were demonstrable at high dilutions of the serum and required no prior activation for their action. They occurred maximally in the 7S fractions of serum proteins and migrated in the β₂ position on electrophoresis.

Reactive haemolysis was first observed and can most conveniently be demonstrated in a red cell—agarose gel. It can also be demonstrated in the test tube following partial purification of activated reactor and indicator factors. Studies in the test tube indicated that a soluble labile lytic factor was responsible for this type of haemolysis.

Studies of paroxysmal nocturnal hemoglobinuria erythrocytes: increased lysis and lipid peroxide formation by hydrogen peroxide

When paroxysmal nocturnal hemoglobinuria (PNH) erythrocytes were exposed to H(2)O(2) they lysed excessively and formed greater than normal quantities of lipid peroxides when compared to red cells of normal subjects and patients with most types of hematologic disease. It was also shown that lytic sensitivity to acidified serum was related to the enhanced lytic sensitivity to H(2)O(2). If the lipid of PNH cells was first extracted then exposed to ultraviolet radiation more lipid peroxides were formed than in extracts of normal red blood cells. The possible explanations for these findings and their relationship to the PNH hemolytic mechanism are discussed.

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

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