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Flaherty S, Strauch P, Maktabi M, Pybus BS, Reichard G, Walker LA, Rochford R. Mechanisms of 8-aminoquinoline induced haemolytic toxicity in a G6PDd humanized mouse model. J Cell Mol Med 2022; 26:3675-3686. [PMID: 35665597 PMCID: PMC9258708 DOI: 10.1111/jcmm.17362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 11/29/2022] Open
Abstract
Primaquine (PQ) and Tafenoquine (TQ) are clinically important 8‐aminoquinolines (8‐AQ) used for radical cure treatment of P. vivax infection, known to target hepatic hypnozoites. 8‐AQs can trigger haemolytic anaemia in individuals with glucose‐6‐phosphate dehydrogenase deficiency (G6PDd), yet the mechanisms of haemolytic toxicity remain unknown. To address this issue, we used a humanized mouse model known to predict haemolytic toxicity responses in G6PDd human red blood cells (huRBCs). To evaluate the markers of eryptosis, huRBCs were isolated from mice 24–48 h post‐treatment and analysed for effects on phosphatidylserine (PS), intracellular reactive oxygen species (ROS) and autofluorescence. Urinalysis was performed to evaluate the occurrence of intravascular and extravascular haemolysis. Spleen and liver tissue harvested at 24 h and 5–7 days post‐treatment were stained for the presence of CD169+ macrophages, F4/80+ macrophages, Ter119+ mouse RBCs, glycophorin A+ huRBCs and murine reticulocytes (muRetics). G6PDd‐huRBCs from PQ/TQ treated mice showed increased markers for eryptosis as early as 24 h post‐treatment. This coincided with an early rise in levels of muRetics. Urinalysis revealed concurrent intravascular and extravascular haemolysis in response to PQ/TQ. Splenic CD169+ macrophages, present in all groups at day 1 post‐dosing were eliminated by days 5–7 in PQ/TQ treated mice only, while liver F4/80 macrophages and iron deposits increased. Collectively, our data suggest 8‐AQ treated G6PDd‐huRBCs have early physiological responses to treatment, including increased markers for eryptosis indicative of oxidative stress, resulting in extramedullary haematopoiesis and loss of splenic CD169+ macrophages, prompting the liver to act as the primary site of clearance.
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Affiliation(s)
- Siobhan Flaherty
- Department of Immunology and Microbiology, The University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Pamela Strauch
- Department of Immunology and Microbiology, The University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Mahdi Maktabi
- Department of Immunology and Microbiology, The University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Brandon S Pybus
- Division of Experimental Therapeutics, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Gregory Reichard
- Department of Drug Discovery, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Larry A Walker
- National Center for Natural Products Research and Department of Biomolecular Sciences, School of Pharmacy, The University of Mississippi, University, Mississippi, USA
| | - Rosemary Rochford
- Department of Immunology and Microbiology, The University of Colorado School of Medicine, Aurora, Colorado, USA
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Abstract
We report a case of a 91-year-old Caucasian woman with a history of chronic lymphocytic leukaemia who developed acute hypoxic respiratory failure (AHRF) requiring intubation for less than 24 hours after receiving rasburicase. Laboratory workup was significant for methemoglobinemia and acute anaemia, and blood film demonstrated evidence of oxidative haemolysis with bite cells. The patient was given a presumptive diagnosis of glucose-6-phosphate dehydrogenase (G6PD) deficiency and was managed conservatively with successful resolution of AHRF and stabilisation of haemoglobin level. Seven days after admission, she passed away due to subsequent complications; hence, follow-up G6PD level could not be obtained. Haemolytic anaemia and methemoglobinemia in the setting of recent rasburicase administration should raise clinical suspicion for G6PD deficiency. In non-emergent cases, patients should be screened prior to receiving rasburicase regardless of risk factors. Because rasburicase is often needed emergently, patients at high risk of tumour lysis syndrome should be screened early for G6PD deficiency.
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Affiliation(s)
- Luai Madanat
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Daniel Schoenherr
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Elizabeth Wey
- Department of Pathology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Ruby Gupta
- Department of Hematology and Oncology, William Beaumont Hospital, Royal Oak, Michigan, USA
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Akande M, Audino AN, Tobias JD. Rasburicase-induced Hemolytic Anemia in an Adolescent With Unknown Glucose-6-Phosphate Dehydrogenase Deficiency. J Pediatr Pharmacol Ther 2017; 22:471-475. [PMID: 29290749 DOI: 10.5863/1551-6776-22.6.471] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Rasburicase, used in the prevention and treatment of tumor lysis syndrome (TLS), may cause hemolytic anemia and methemoglobinemia in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Although routine screening for G6PD deficiency has been recommended, given the turnaround time for test results and the urgency to treat TLS, such screening may not be feasible. We report a case of rasburicase-induced hemolytic anemia without methemoglobinemia in an adolescent with T-cell lymphoblastic lymphoma, TLS, and previously unrecognized G6PD deficiency. Previous reports of hemolytic anemia with rasburicase are reviewed, mechanisms discussed, and preventative strategies presented.
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Affiliation(s)
- Manzilat Akande
- Division of Pediatric Critical Care Medicine (MA), Nationwide Children's Hospital, Columbus, Ohio, Department of Pediatrics (MA, ANA), The Ohio State University College of Medicine, Columbus, Ohio, Division of Pediatric Hematology/Oncology/BMT (ANA), Nationwide Children's Hospital, Columbus Ohio, Department of Anesthesiology & Pain Medicine (JTD), Nationwide Children's Hospital, Columbus, Ohio, and Department of Anesthesiology & Pain Medicine (JTD), The Ohio State University College of Medicine, Columbus, Ohio
| | - Anthony N Audino
- Division of Pediatric Critical Care Medicine (MA), Nationwide Children's Hospital, Columbus, Ohio, Department of Pediatrics (MA, ANA), The Ohio State University College of Medicine, Columbus, Ohio, Division of Pediatric Hematology/Oncology/BMT (ANA), Nationwide Children's Hospital, Columbus Ohio, Department of Anesthesiology & Pain Medicine (JTD), Nationwide Children's Hospital, Columbus, Ohio, and Department of Anesthesiology & Pain Medicine (JTD), The Ohio State University College of Medicine, Columbus, Ohio
| | - Joseph D Tobias
- Division of Pediatric Critical Care Medicine (MA), Nationwide Children's Hospital, Columbus, Ohio, Department of Pediatrics (MA, ANA), The Ohio State University College of Medicine, Columbus, Ohio, Division of Pediatric Hematology/Oncology/BMT (ANA), Nationwide Children's Hospital, Columbus Ohio, Department of Anesthesiology & Pain Medicine (JTD), Nationwide Children's Hospital, Columbus, Ohio, and Department of Anesthesiology & Pain Medicine (JTD), The Ohio State University College of Medicine, Columbus, Ohio
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Maffi D, Pasquino MT, Mandarino L, Tortora P, Girelli G, Meo D, Grazzini G, Caprari P. Glucose-6-phosphate dehydrogenase deficiency in Italian blood donors: prevalence and molecular defect characterization. Vox Sang 2013; 106:227-33. [PMID: 24134566 DOI: 10.1111/vox.12096] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 08/14/2013] [Accepted: 08/21/2013] [Indexed: 01/13/2023]
Abstract
BACKGROUND In the countries with high G6PD deficiency prevalence, blood donors are not routinely screened for this genetic defect. G6PD deficiency is often asymptomatic, blood donors may be carriers of the deficiency without being aware of it. The aim of the study was to evaluate the prevalence of G6PD deficiency among the Italian blood donors. DESIGN AND METHODS From October 2009 to April 2011, 3004 blood donors from a large hospital transfusion centre were screened for G6PD deficiency using differential pH-metry and the characterization of G6PD mutations was performed on G6PD-deficient subjects. The haematological features of G6PD-deficient and normal donors were also compared. RESULTS Thirty-three subjects (25 men and 8 women) with low G6PD activity were identified, corresponding to 1·1% of the examined blood donor population. The frequencies of class II severe alleles (Mediterranean, Valladolid, Chatham and Cassano) and class III mild alleles (Seattle, A- and Neapolis) were 48% and 43%, respectively. The haematological parameters of G6PD- donors were within normal range; however, the comparison between normal and G6PD- class II donors showed significant differences. CONCLUSION In Italy, the presence of blood donors with G6PD deficiency is not a rare event and the class II severe variants are frequent. The identification of G6PD-deficient donors and the characterization of the molecular variants would prevent the use of G6PD-deficient RBC units when the haemolytic complications could be relevant especially for high risk patients as premature infants and neonates and patients with sickle cell disease submitted to multiple transfusions.
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Affiliation(s)
- D Maffi
- Department of Hematology Oncology and Molecular Medicine, Istituto Superiore di Sanità, Rome, Italy
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Francis RO, Jhang JS, Pham HP, Hod EA, Zimring JC, Spitalnik SL. Glucose-6-phosphate dehydrogenase deficiency in transfusion medicine: the unknown risks. Vox Sang 2013; 105:271-82. [PMID: 23815264 DOI: 10.1111/vox.12068] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 05/05/2013] [Accepted: 06/05/2013] [Indexed: 12/21/2022]
Abstract
The hallmark of glucose-6-phosphate dehydrogenase (G6PD) deficiency is red blood cell (RBC) destruction in response to oxidative stress. Patients requiring RBC transfusions may simultaneously receive oxidative medications or have concurrent infections, both of which can induce haemolysis in G6PD-deficient RBCs. Although it is not routine practice to screen healthy blood donors for G6PD deficiency, case reports identified transfusion of G6PD-deficient RBCs as causing haemolysis and other adverse events. In addition, some patient populations may be more at risk for complications associated with transfusions of G6PD-deficient RBCs because they receive RBCs from donors who are more likely to have G6PD deficiency. This review discusses G6PD deficiency, its importance in transfusion medicine, changes in the RBC antioxidant system (of which G6PD is essential) during refrigerated storage and mechanisms of haemolysis. In addition, as yet unanswered questions that could be addressed by translational and clinical studies are identified and discussed.
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Affiliation(s)
- R O Francis
- Department of Pathology and Cell Biology, Laboratory of Transfusion Biology, Columbia University Medical Center-New York Presbyterian Hospital, New York, NY, USA
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Raciti PM, Francis RO, Spitalnik PF, Schwartz J, Jhang JS. Acquired hemoglobin variants and exposure to glucose-6-phosphate dehydrogenase deficient red blood cell units during exchange transfusion for sickle cell disease in a patient requiring antigen-matched blood. J Clin Apher 2013; 28:325-9. [PMID: 23450789 DOI: 10.1002/jca.21255] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 11/07/2012] [Accepted: 11/09/2012] [Indexed: 01/04/2023]
Abstract
Red blood cell exchange (RBCEx) is frequently used in the management of patients with sickle cell disease (SCD) and acute chest syndrome or stroke, or to maintain target hemoglobin S (HbS) levels. In these settings, RBCEx is a category I or II recommendation according to guidelines on the use of therapeutic apheresis published by the American Society for Apheresis. Matching donor red blood cells (RBCs) to recipient phenotypes (e.g., C, E, K-antigen negative) can decrease the risk of alloimmunization in patients with multi-transfused SCD. However, this may select for donors with a higher prevalence of RBC disorders for which screening is not performed. This report describes a patient with SCD treated with RBCEx using five units negative for C, E, K, Fya, Fyb (prospectively matched), four of which were from donors with hemoglobin variants and/or glucose-6-phosphate dehydrogenase (G6PD) deficiency. Pre-RBCEx HbS quantification by high performance liquid chromatography (HPLC) demonstrated 49.3% HbS and 2.8% hemoglobin C, presumably from transfusion of a hemoglobin C-containing RBC unit during a previous RBCEx. Post-RBCEx HPLC showed the appearance of hemoglobin G-Philadelphia. Two units were G6PD-deficient. The patient did well, but the consequences of transfusing RBC units that are G6PD-deficient and contain hemoglobin variants are unknown. Additional studies are needed to investigate effects on storage, in-vivo RBC recovery and survival, and physiological effects following transfusion of these units. Post-RBCEx HPLC can monitor RBCEx efficiency and detect the presence of abnormal transfused units.
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Affiliation(s)
- Patricia M Raciti
- Department of Pathology and Cell Biology, Columbia University Medical Center-NewYork-Presbyterian Hospital, New York, NY, USA
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Cheah CY, Lew TE, Seymour JF, Burbury K. Rasburicase causing severe oxidative hemolysis and methemoglobinemia in a patient with previously unrecognized glucose-6-phosphate dehydrogenase deficiency. Acta Haematol 2013; 130:254-9. [PMID: 23860572 DOI: 10.1159/000351048] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 03/17/2013] [Indexed: 11/19/2022]
Abstract
Rasburicase is frequently used in tumor lysis syndrome (TLS). Although it is very well tolerated, it can cause severe oxidative hemolytic anemia and methemoglobinemia in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. We report another case of rasburicase-induced methemoglobinemia in a patient with previously unrecognized G6PD deficiency and review the cases of methemoglobinemia and oxidative hemolysis reported in the literature to date. Patients from ethnicities in which G6PD deficiency is prevalent at high risk of TLS should be screened for G6PD deficiency prior to administration of rasburicase where practical. Asymptomatic decrease in oxygen saturation by oximetry and cyanosis are signs of methemoglobinemia; patients recover with conservative measures including supplemental oxygen and packed red cell transfusion.
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Affiliation(s)
- Chan Y Cheah
- Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, Vic., Australia
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Francis RO, Jhang J, Hendrickson JE, Zimring JC, Hod EA, Spitalnik SL. Frequency of glucose-6-phosphate dehydrogenase-deficient red blood cell units in a metropolitan transfusion service. Transfusion 2012; 53:606-11. [PMID: 22738400 DOI: 10.1111/j.1537-2995.2012.03765.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Glucose-6-phosphate dehydrogenase (G6PD) deficiency is characterized by red blood cell (RBC) destruction in response to oxidative stress. Although blood donors are not routinely screened for G6PD deficiency, the transfusion of stored G6PD-deficient RBCs may have serious adverse outcomes. By measuring G6PD enzyme activity of RBC units from a large metropolitan hospital transfusion service, we sought to determine 1) the prevalence of G6PD-deficient RBC units, 2) if G6PD activity changes during storage, and 3) if G6PD activity in segments correlates with its activity in the bags. STUDY DESIGN AND METHODS Quantitative G6PD activity was measured in 301 randomly selected RBC units and 73 D+C-E- (i.e., R r or R R ) RBC units, all stored in additive solutions. G6PD deficiency was defined as activity less than 60% of the normal mean. RESULTS The frequency of G6PD-deficient units in the general inventory was 0.3% (1/301; 95% confidence interval [CI], <0.01%-2.1%). In contrast, its frequency in D+C-E- RBC units was 12.3% (9/73; 95% CI, 6.4%-22.0%). G6PD activity did not significantly change during the 42-day storage period, and G6PD activity measured in RBC storage bags and attached segments correlated well (r=0.7-0.9, p ≤ 0.001, Spearman rank correlation). CONCLUSIONS Although the frequency of G6PD-deficient RBC units in the transfusion service general inventory was relatively low, it was significantly higher among a subset of R r or R R units. The latter are preferentially allocated for transfusion to patients with sickle cell disease to decrease the risk of RBC alloimmunization, possibly allowing more of these units to be inadvertently targeted to these patients.
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Affiliation(s)
- Richard O Francis
- Department of Pathology and Cell Biology, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York 10032, USA.
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Abstract
Dapsone, an old drug introduced and used almost exclusively for the treatment of leprosy, is now utilized in an increasing number of therapeutic situations. However, its hemotoxicity is potentially severe and is often dose limiting. Effective countermeasures, based on resolution of the mechanisms underlying dapsone-induced hemotoxicity, could significantly enhance the therapeutic value of the drug. In studies on rat red cells, we have established that the N-hydroxy metabolites of dapsone, DDS-NOH and MADDS-NOH, are direct-acting hemolytic agents, that they are formed in amounts sufficient to account for the hemotoxicity of the parent drug, and that the action of these toxic metabolites in the red cell induces premature sequestration by the spleen. Incubation of rat red cells with hemolytic concentrations of arylhydroxylamines leads to the generation of hydroxyl, glutathiyl, and hemoglobinthiyl radicals, and the formation of protein-glutathione mixed disulfides. Disulfide-linked adducts are also formed between membrane skeletal proteins and hemoglobin monomers, as well as between the monomeric hemoglobin units forming dimers, trimers, tetramers, and pentamers. Profound morphological changes are seen with change from normal discoidocity to an extreme nonspherocytic enchinocyte shape. Parallel studies with human red cells indicate that the response of human cells is qualitatively similar but that there are notable differences in regard to skeletal membrane effects. A working hypothesis for the mechanism underlying dapsone hemolytic activity is proposed.
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Affiliation(s)
- D J Jollow
- Departments of Cell and Molecular Pharmacology, Medical University of South Carolina, Charleston 29425, USA
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Abstract
Approximately 13 percent of American Negro males carry a mutant [A-variant] glucose-6-phosphate dehydrogenase enzyme in their red blood cells that predisposes them to hemolytic episodes following exposure to oxidant drugs such as primaquine. Most hemolytic episodes to standard prophylactic treatment are mild and self-limited, but as many as 2 percent of Negro males develop severe hemolysis when similarly treated. The exaggerated response may be due in part to the combination of G-6-PD deficiency and hypertension since hypertension can cause red cell fragmentation, and the stressed cells of G-6-PD deficient person would be more sensitive to such fragmentation.
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Abstract
Chlorination of potable water supplies high in organics may yield carcinogenic compounds such as trihalomethanes. Chlorine dioxide has been proposed as an alternative disinfectant to chlorine. However, chlorine dioxide is a strong oxidant that forms significant amounts of chlorite when added to potable water supplies, and chlorite is similar to nitrite in its molecular structure and may be similar in its mechanism of methemoglobin production. Nitrites and chlorites are thought to act synergistically to produce MetHb. Neonates and persons with G-*-PD deficiency are likely to be unusually susceptible to MetHb formation from these compounds because their red cells lack the metabolic machinery to adequately protect against oxidant stress. Since male blacks represent the largest population in the U.S. to be G-6PD deficient, Black male neonates may represent the group at highest risk to the use of chlorine dioxide as a disinfectant in the nations water supplies.
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