HEMATOLOGY# 14 -- Hemolytic Anemias I

Erythrocyte Membrane Disorders

I. Fluid mosaic model A. fluid: lipids & proteins move in plane of membrane bilayer B. mosaic: membrane composed of protein and lipid 1. phospholipid bilayer Phospholipids: PE,PC, PI Cholesterol Glycolipids 2. Integral Membrane Proteins/glycoproteins a. exposed to both outside and inside of bilayer b. antigenic (ABO, MN) or A receptors (glycophorin A&B) 3. Cytoplasmic membrane proteins (e.g. a. 4.1, spectrin, actin, ankyrin b. Confined to internal sites c. structural proteins of cytoskeleton (give cell its shape) d. spectrin i. dimers aligned parallel, entwine, ii.self associate head to head; iii. tails bind actin; iv. binding of actin strengthened by protein 4.1 e. 2D network ankyrin: anchors cytoskeleton to lipid bilayer via protein glycophorin

HEMATOLOGY# 14 -- Hemolytic Anemias I

4. Functions of cytoskeleton a. stabilizes asymmetry and integrity of membrane bilayer b. immobilizes and organizes integral membrane proteins c. provides restricted flexibility to bilayer C. Normal RBC volume and surface area diameter (um) Volume(fl) Normal RBC 7-8 90 EquivolSphere 5.5 90 Surface Area(um2) 140 95

1. increased surface/volume ratio gives cell its biconcavit 2. allows change in configuration without rupture 3. an optimal shape for respiratory gas exchange D. Functions of membrane 1. maintenance of cell volume i. selective permeability (doesn't allow passage passage of ions and large molecules (Hb) ii. Na+/K+ ATPase Pump (ATP from glycolysis) cntrls cationic gradient iii. inside cell pumps Na+ out of cell; pumps K+ into cell 2. maintenance of cell shape i. cations control water intake and loss ii. increased internal Na+ cell swells ==>spherocytosis==>Hb leaks out of stretched membrane iii. loss of Na+ internally, cell shrinks (dehydration) iv. second ATPase pump selectively control Ca++ cell levels a)pumps Ca++ out of cell b)accumulation of Ca++ ==> echinocyte c)concomitant w/ H2O and K+ loss==>crenated, dehydrated cell d)==>sequestration in spleen phagocytosis E. Altered permeability or dysfunction in active cation transport (or both)==>hemolysis 1. aging of cell i. Na+ K+ pump requires ATP ii. As cell ages and loses glycolytic enzymes (less ATP) ==>pump slows==>swelling-->hemolysis F. Osmotic fragility (resistance to hemolysis) 1. 0.85% NaCl = normal saline = serum salt conc 2. no shift of water or ions in or out of cell ==>no shape change 3. in distilled water or [salt] < 0. 44% Na/K-ATPase fails ==> water enters ==> cell swelling to 160% vol ==> hemolysis breakage 4. Osmotic fragility test: meas. ability of cells to swell in hypotonic medium a. spherocytosis: surface to volume ratio decreases(cell rounds up) b. observed in congenital sph., idiopathic sphero, aquired hemolytic, immunohemolytic ABO incompatibility anemia c. normal osmotic fragility : paroxysmyl nocturnal hemoglobinemia d. decreased osmotic fragility: i. target cells: S/V increases (cells flatten out) ii. sickle cell anemia some hemolytic anemias

HEMATOLOGY# 14 -- Hemolytic Anemias I

II. Hemolysis due to membrane defects A.Hereditary spherocytosis 1. First hemolytic disease described (1871) 2. Incidence 1/5000 people 3. Inherited as autosomal dominant defect in membrane stability ==> fragmentation(blebs)==>decreased surface to volume ratio 4. Increased osmotic fragility (inflated sandwich bag phenomena) 5. Defective cells destroyed by spleen a. spherocyte more rigid==>retained in spleen w/low glucose w/ low O2 ==>blebs==>destroyed by macrophage b. symptoms i. jaundice, mild to moderate anemia, splenomegaly ii. blood smear with spherocytes and high reticulocyte counts 6. Underlying defect: a. qualitative or quantitative spectrin deficiency b. membrane sleletal defect i. spectrin ii. ankyrin iii. 4.1 iv. Band III 7. Treatment a. splenectomy to halt red cell splenic conditioning and hemolysis b. spherocytosis persists and Howell-Jolly bodies (nuclear remnants), target cells become evident in blood smear

B. Hereditary elliptocytosis 1. inherited as autosomal dominant 2. incidence 1:2500 3. symptoms = no hemolysis to severe hemolysis 4. mild HE (most common form) a. >40% of blood cells elliptical b. defect in spectrin heads interferes with self-association

HEMATOLOGY# 14 -- Hemolytic Anemias I

c. no anemia, or splenomegaly, mild hemolysis 5. hereditary pyropoikilocytosis a. moderately severe hemolytic anemia b. cell fragmentation bizzare poikilocytosis .esp w/fever or burn trauma d. defect in spectrin self-association

C. Membrane defects secondary to acquired-extrinsic defects 1. acanthocytosis in liver disease a. result in spur cell (acanthocytes) in blood i.rounded RBC ii.thorny projections b. due to abnormal cholesterol-laden lipoproteins produced in liver==>loaded onto RBC to increase its membrane cholesterol/phospholipid c. cells initially flattened (leptocyte) conditioned (remodeled) in spleen i. loss of surface membrane and lipids ii. cell rigidity ==> acanthocytes 2. biliary obstruction (liver disease) a. patients develop target cells secondary to acquisition of both excess cholesterol and phospholipids b. membrane surface area expand c. cell deformability unchanged; no morbidity

HEMATOLOGY# 14 -- Hemolytic Anemias I

D. Defects in cation permeability 1. hereditary stomatocytosis(hydrocytosis) a. disease associated volume gain (hereditary defect of Na+ permeability) i. Na+ leak in> K+ loss (out) ii. overwhelms Na+K+ pump b. excess water intake c. stomatocytes appear ==>hemolysis 2.hereditary xerocytosis a. hereditary disease associated with water loss (volume loss) b. occurs in 3 situations i. when loss of K+>gain of Na+ f ii.when intracellular accumulation of Ca++ 6 is great iii. when ATP depletion is high (pyruvate kinase deficiency) c. target cells; spiculated cells i. cells have increased cytoplasmic viscosity ii. more rigid==>splenic sequestrations==>hemolysis 3. paroxysmal nocturnal hemoglobinuria a. hemoglobinuria upon awakening from intravascular hemolysis(mild acidosis) b. acquired disease associated with gain in volume of cell c. often follows as a consequence of aplastic anemia i. result of mutagenic effects of marrow hypoplasia

HEMATOLOGY# 14 -- Hemolytic Anemias I

d. defect derives from clones of abnormal stem cells i. membrane defect unknown but manifests as increased sensitivity to complement ii. membranes a+-RBC, WBC, and platelets affected -- all bind C3b more avidly -- all more susceptible to lysis by C5,9 e. mild acidosis during sleep enhances binding of complement e. No antibody involvement