VZHE-039, a novel antisickling agent that prevents erythrocyte sickling under both hypoxic and anoxic conditions.

Sickle cell disease (SCD) results from a hemoglobin (Hb) mutation ßGlu6 → ßVal6 that changes normal Hb (HbA) into sickle Hb (HbS). Under hypoxia, HbS polymerizes into rigid fibers, causing red blood cells (RBCs) to sickle; leading to numerous adverse pathological effects. The RBC sickling is made worse by the low oxygen (O2) affinity of HbS, due to elevated intra-RBC concentrations of the natural Hb effector, 2,3-diphosphoglycerate. This has prompted the development of Hb modifiers, such as aromatic aldehydes, with the intent of increasing Hb affinity for O2 with subsequent prevention of RBC sickling. One such molecule, Voxelotor was recently approved by U.S. FDA to treat SCD. Here we report results of a novel aromatic aldehyde, VZHE-039, that mimics both the O2-dependent and O2-independent antisickling properties of fetal hemoglobin. The latter mechanism of action-as elucidated through crystallographic and biological studies-is likely due to disruption of key intermolecular contacts necessary for stable HbS polymer formation. This dual antisickling mechanism, in addition to VZHE-039 metabolic stability, has translated into significantly enhanced and sustained pharmacologic activities. Finally, VZHE-039 showed no significant inhibition of several CYPs, demonstrated efficient RBC partitioning and high membrane permeability, and is not an efflux transporter (P-gp) substrate.

Inhibition of Band 3 tyrosine phosphorylation: a new mechanism for treatment of sickle cell disease.

Many hypotheses have been proposed to explain how a glutamate to valine substitution in sickle haemoglobin (HbS) can cause sickle cell disease (SCD). We propose and document a new mechanism in which elevated tyrosine phosphorylation of Band 3 initiates sequelae that cause vaso-occlusion and the symptoms of SCD. In this mechanism, denaturation of HbS and release of heme generate intracellular oxidants which cause inhibition of erythrocyte tyrosine phosphatases, thus permitting constitutive tyrosine phosphorylation of Band 3. This phosphorylation in turn induces dissociation of the spectrin-actin cytoskeleton from the membrane, leading to membrane weakening, discharge of membrane-derived microparticles (which initiate the coagulation cascade) and release of cell-free HbS (which consumes nitric oxide) and activates the endothelium to express adhesion receptors). These processes promote vaso-occlusive events which cause SCD. We further show that inhibitors of Syk tyrosine kinase block Band 3 tyrosine phosphorylation, prevent release of cell-free Hb, inhibit discharge of membrane-derived microparticles, increase sickle cell deformability, reduce sickle cell adhesion to human endothelial cells, and enhance sickle cell flow through microcapillaries. In view of reports that imatinib (a Syk inhibitor) successfully treats symptoms of sickle cell disease, we suggest that Syk tyrosine kinase inhibitors warrant repurposing as potential treatments for SCD.

The delay time in sickle cell disease after 40 years: A paradigm assessed.

Sickle hemoglobin polymerization commences with a striking latency period, called a "delay time" followed by abrupt polymer formation. The delay time is exceedingly concentration dependent. This discovery (40 years ago) led to the "kinetic hypothesis," that is, that the pathophysiology was related to the relationship between the delay time and the capillary transit. The delay time is well described by a double-nucleation mechanism of polymer formation. In macroscopic volumes, the delay time is highly reproducible, but in small volumes such as erythrocytes, under certain conditions, the intrinsic delay time can be augmented by a stochastic delay owing to random waiting times for the first nucleus to form. This lengthens the average delay and adds further protection from vaso-occlusion. When oxygen removal is not sudden, the growth of polymers after the delay time is limited by the rate of oxygen removal, further lengthening the time before occlusion may occur. This is important if some polymers have remained in the cell after pulmonary transit as their presence otherwise would obliterate any delay. The difficulty of deforming a cell once polymerized rationalizes the "two-step" model of vaso-occlusion in which a postcapillary adhesion event is followed by a sickling logjam. The delay time that is required is therefore generalized to be the delay time for an erythrocyte to move beyond regions in the venuoles where adherent cells have reduced the available lumen. The measurements of delay times correlate well with the severity of sickling syndromes. They also correlate with the improvements owing to the administration of hydroxyurea.

Discrimination of various thalassemia syndromes and iron deficiency and utilization of reticulocyte measurements in monitoring response to iron therapy.

Decreased hemoglobinization of red cells resulting in hypochromia and microcytosis are the main features of thalassemia syndromes, and also of iron deficiency anemia (IDA). A simple and reliable method is required to distinguish the two conditions in the routine laboratories. In this study we analyzed the red cell and reticulocyte parameters from 414 samples of various types of thalassemias and IDA and discovered a variety of discriminating criteria including a discrimination index (DI) which should be useful for differential diagnosis. Slightly decreased MCV and CH are suggestive of α-thalassemia 2, Hb CS, and Hb E heterozygotes whereas the increased Rbc counts are obvious in α-thalassemia 1 and ß-thalassemia. In Hb E, the number of microcytic red cells was greater than the number of hypochromic red cells resulting in an increased M/H ratio. Hb H diseases are characterized by a higher number of hypochromic red cells and decreased CHCM, while broadening of hemoglobin concentration histogram results in increased HDW in ß-thalassemia diseases. Iron deficiency anemia results in hypochromic-microcytic red cells and increased RDW. The number of reticulocyte with %High Retic and CHr value were increased in the first month of iron supplementation indicating the response to iron therapy.

Intravenous immunoglobulins reverse acute vaso-occlusive crises in sickle cell mice through rapid inhibition of neutrophil adhesion.

Previous studies using intravital microscopy in a sickle cell disease (SCD) mouse model suggest that adherent white blood cells (WBCs) play a key role in vaso-occlusion by capturing circulating red blood cells (RBCs) in venules. Commercial intravenous immunoglobulin (IVIG) given before the inflammatory stimuli increased microcirculatory blood flow and survival. To mimic the clinical situation in which SCD patients seek medical attention after the onset of symptoms, we developed an in vivo model in which the therapeutic intervention (eg, IVIG) was administered after in the inflammatory challenge. In this setting, IVIG rapidly (<10 minutes) reduced adherent leukocyte numbers and dramatically inhibited interactions between RBCs and WBCs, resulting in improved microcirculatory blood flow and survival of sickle cell "Berkeley" mice. Longer survival correlated positively with blood flow (P=.001) and negatively with the number of adherent leukocytes (P=.001) and RBC-WBC interactions (P=.002). Using multichannel digital fluorescence videomicroscopy, we found that IVIG affected specifically the recruitment of neutrophils. Moreover, further analyses of leukocyte behavior revealed that IVIG significantly increased rolling velocities, indicating that it alters adhesion pathways involved in slow rolling. These data suggest that the potential therapeutic benefits of IVIG in SCD crises should be evaluated in a clinical trial.

Protective effect of Ugni molinae Turcz against oxidative damage of human erythrocytes.

Ugni molinae Turcz, also known as "Murtilla", is a plant that grows in the south of Chile. Infusions of its leaves have long been used in traditional native herbal medicine. The chemical composition of the leaves indicates the presence of polyphenols, which have antioxidant properties. In the present work, the antioxidant properties of U. molinae were evaluated in human erythrocytes exposed in vitro to oxidative stress induced by HClO. The experiments were carried out by scanning electron microscopy (SEM) and hemolysis measurements. The SEM observations showed that HClO induced a morphological alteration in the red blood cells from a discoid to an echinocytic form. According to the bilayer couple hypothesis, the formation of echinocytes indicates that HClO was inserted in the outer leaflet of the erythrocyte membrane. However, a concentration as low as 10 microM gallic acid equivalents (GAE) U. molinae aqueous extract neutralized the shape change effect of HClO applied in a concentration as high as 0.25 mM. The significant protection of U. molinae aqueous extract was also shown in the hemolysis experiments. In fact, very low concentrations of the extract considerably reduced the deleterious capacity of HClO to induce hemolysis in red blood cells. It is concluded that the location of the extract components into the membrane bilayer and the resulting restriction on its fluidity might hinder the diffusion of HClO and its consequent damaging effects. This conclusion can also imply that this restriction could apply to the diffusion of free radicals into cell membranes and the subsequent decrease of the kinetics of free radical reactions.

Sickle cell disease: from membrane pathophysiology to novel therapies for prevention of erythrocyte dehydration.

Sickle cell anemia is characterized by the presence of dense dehydrated erythrocytes that have lost most of their K content. Due to the unique dependence of Hb S polymerization on intracellular Hb S concentration, preventing this dehydration should markedly reduce polymerization. The erythrocyte intermediate conductance Ca-activated K channel (hSK4 or KCNN4), first described by Gardos, has been shown to be a major pathway for sickle cell dehydration. Studies with the imidazole antimycotic clotrimazole have shown reduction of sickle cell dehydration in vivo in a small number of patients with sickle cell disease; dose-limiting gastrointestinal and liver toxicities were observed. Based on the chemical structure of clotrimazole metabolites, a novel Gardos channel inhibitor, ICA-17043, has been developed. It has shown substantial activity both in vitro and in vivo in transgenic sickle mice. ICA-17043 is currently in phase 2 human trials. Another potential therapeutic target is the K-Cl cotransport. When sickle erythrocytes are exposed to relatively acidic conditions, they undergo cell shrinkage via activation of this pathway. K-Cl cotransport can be blocked by increasing the abnormally low erythrocyte Mg content of sickle erythrocytes. Oral Mg supplementation has been shown to reduce sickle cell dehydration in vivo in transgenic sickle mice and in patients in two separate clinical trials. Oral Mg pidolate is being tested in clinical trials in homozygous sickle cell disease and in Hb S/HbC (SC) disease, either as a single agent or in combination with hydroxyurea. The ongoing trials will determine the clinical effectiveness of therapies aimed at preventing sickle erythrocyte dehydration.

Hydration of sickle erythrocytes using a herbal extract (Pfaffia paniculata) in vitro.

Pfaffia paniculata (PP) is a perennial wild plant that grows in South America. Its root powder has been used by South American Indians for a variety of ailments and has been reported to have a salutary effect on sickle cell disease in Brazil. Its mechanism of action, however, is unknown. In this report, we present experimental data showing that PP improves the deformability of sickle cells, increases their Na+ content and their mean corpuscular volume (MCV). These findings indicate that PP functions as a sodium ionophore on sickle cells and improves their hydration status and rheological properties.

Phosphorus-31 nuclear magnetic resonance studies of human red blood cells.

Phosphorus-31 nuclear magnetic resonance spectroscopy is used to monitor the changes in the concentrations of 2,3-diphosphoglycerate and adenosine-5' triphosphate as a function of time and to measure the intracellular pH of normal and abnormal red blood cells in the presence of 25% oxygen, 5.6% carbon dioxide, and 69.4% nitrogen at 37 degrees C. Under these conditions, the intracellular pH values of normal AA, sickle SS, AS, SC, AC, and CC red cells are 7.24 +/- 0.07, 7.13 +/- 0.04, 7.15 +/- 0.03, 7.16 +/- 0.03, 7.24 +/- 0.05, and 7.14 +/- 0.03, respectively. The intracellular pH of SS red cells is about 0.1 pH unit more acidic than that of AA red cells. Time-dependent changes in the concentration of 2,3-diphosphoglycerate of normal human red cells show an initial lag phase, followed by a slow linear decrease. The duration of the initial lag phase decreases in the following order: AA approximately equal to AS approximately equal to AC greater than SC greater than SS approximately equal to CC red cells. The decay of 2,3-diphosphoglycerate is much faster in SS and CC red cells compared to other red cells studied. The time-dependent depletion of adenosine-5' triphosphate in these red cells is similar in nature to that of 2,3-diphosphoglycerate. The linewidths of 2-P and 3-P resonances of 2,3-diphosphoglycerate for fully oxygenated SS red cells are broader (approximately 20 Hz) than those for other red cells (approximately 10 Hz). However, the linewidths of 2-P and 3-P resonances of 2,3-diphosphoglycerate in the lysates of these red cells are narrower (approximately 4.5 Hz) than those in the intact red cells and are very similar in all types of red cells studied. The linewidths of the 31P resonances of adenosine-5' triphosphate are also similar (approximately 30-40 Hz) in all red cells studied. In addition, we have investigated the effect of carbamylation on the metabolism of 2,3-diphosphoglycerate and the intracellular pH in SS and AA red cells and have found that neither one is affected by this process. Our results provide further evidence that phosphorus-31 nuclear magnetic resonance spectroscopy offers a direct, non-invasive way to investigate the intracellular environment and the metabolism of phosphorylated metabolites in intact red blood cells.

Monovalent cation composition and ATP and lipid content of irreversibly sickled cells.

Discontinuous Stractan gradients were used to separate heterogeneous populations of sickle cells into discrete subpopulations containing varying proportions of reticulocytes, mature discoid cells, and irreversibly sickled cells (ISC). The improved homogeneity of these preparations, together with an enhanced yield of ISC, allowed us to distinguish effects of cell maturation from those of irreversible sickling. With these cell preparations we have begun to define physical properties of ISC. We confirmed the marked abnormalities in cation composition of native ISC. Measurements of ATP in ISC did not substantiate prior reports of ATP deficits. Finally, no evidence for substantial loss of membrane lipids during the process of ISC formation could be demonstrated.

The effect of bicarbonate and distilled water on sickle cell trait hematuria and in vitro studies on the interaction of osmolality and pH on erythrocyte sickling in sickle cell trait.

The effect of intravenously administered distilled water was examined alone and during alkalization in a patient with gross hematuria associated with the sickle cell trait. On each of 4 occasions hematuria ceased promptly after the infusion of distilled water. Bicarbonate therapy also consistently decreased hematuria. In vitro studies on erythrocytes from another patient with sickle cell trait and hematuria demonstrated that slight increases in urinary pH similar to those that occur in the urine during alkalization can reverse or prevent erythrocyte sickling in the sicle cell trait. If patients with the sickle cell trait are hydrated adequately and have a good rate of urine flow distilled water can be given intravenously with virtually no danger of acute tubular necrosis secondary to erythrocyte hemolysis.

Irreversibly sickled erythrocytes: a consequence of the heterogeneous distribution of hemoglobin types in sickle-cell anemia.

THE AMOUNT OF FETAL HEMOGLOBIN (HB F) IN ERYTHROCYTES OF PATIENTS WITH SICKLE CELL ANEMIA (HB SS DISEASE) WAS MEASURED BY TWO METHODS: (a) photometry of individual cells stained for Hb F by the Kleihauer-Betke technique; and (b) chemical assay of alkali-resistant hemoglobin in cells distributed according to specific gravity by ultracentrifugation. Irreversibly sickled cells (ISC), which could be identified directly during photometry and which were found to gather in high concentration at the bottom of ultracentrifuged cell columns, contained significantly less Hb F than non-ISC. Cell content of total Hb was constant regardless of cell size, shape, or ultracentrifugal behavior: thus absolute amounts of Hb F and S varied reciprocally from cell to cell. In experiments designed to estimate age, at formation, and rate of destruction of ISC, Hb SS blood was incubated with selenomethionine-(75)Se (which labels reticulocytes) or (51)Cr (which labels erythrocytes at random) and reinfused. Sequential blood samples were separated by ultracentrifugation into fractions rich in reticulocytes, non-ISC, and ISC; and chronological changes in the specific activity of each fraction were determined. Analogous information was obtained from radioautography of sequential blood samples after reinfusion of whole blood labeled with amino acids-(3)H: this technique permitted direct visual characterization of labeled erythrocytes as ISC or non-ISC, all of which had been reticulocytes at the time of reinfusion. The transformation of non-ISC into ISC, presumably a manifestation of membrane damage, proved to begin soon after cell release from the marrow; and ISC subsequently underwent rapid removal from the circulating blood. IT IS THEREFORE APPARENT FROM THESE STUDIES THAT, IN HB SS DISEASE, RELATIVELY SMALL RECIPROCAL CHANGES IN THE AMOUNTS OF THE TWO MAJOR HEMOGLOBINS CARRY PREDICTIVE IMPORTANCE: (a) net synthesis of Hb F is least in erythroid cells destined to become ISC; and (b) these irreversibly deformed erythrocytes suffer preferential destruction.

Irreversibly sickled erythrocytes: a consequence of the heterogeneous distribution of hemoglobin types in sickle-cell anemia

The amount of fetal hemoglobin (Hb F) in erythrocytes of patients with sickle cell anemia (Hb SS disease) was measured by two methods: (a) photometry of individual cells strained for Hb F by the Kleihauer-Betke technique; and (b) chemical assay of alkali-resistant hemoglobin in cells distributed according to specific gravity by ultracentrifugation. Irreversibly sickled cells (ISC), which could be identified directly during photometry and which were found to gather in high concentration at the bottom of ultracentrifuged cell columns, contained significantly less Hb F than non-ISC. Cell content of total Hb was constant regardless of cell size, shape, or ultracentrifugal behavior: thus absolute amounts of Hb F and S varied reciprocally from cell to cell. In experiments designed to estimate age, at formation, and rate of destruction of ISC, Hb SS blood was incubated with selenomethionine-75Se (which labels reticulocytes) of 51Cr (which labels erythrocytes at random) and reinfused. Sequential blood samples were separated by ultracentrifugation into fractions rich in reticulocytes, non-ISC, ans ISC; and chronological changes in the specific activity of each fraction were determined. Analogous information was obtained from radioautography of sequential blood samples after reinfusion of whole blood labeled with amino acids-3H: this technique permitted direct visual characterization of labeled erythrocytes as ISC of non-ISC, all of which had been reticulocytes at the time of reinfusion. The transformation of non-ISC into ISC, presumably a manifestation of membrane damage, proved to begin soon after cell release from the marrow; and ISC subsequently underwent rapid removal from the circulating blood. It is therefore apparent from these studies that, in Hb SS disease, relatively small reciprocal changes in the amounts of the two major hemoglobins carry predictive importance: (a) net synthesis of Hb F is least in erythroid cells destined to become ISC; and (b) these irreversibly deformed erythrocytes suffer preferential destruction. (AU)

Membrane lipid depletion in hyperpermeable red blood cells: its role in the genesis of spherocytes in hereditary spherocytosis.

Hereditary spherocytosis (HS) red cells lose membrane lipids excessively during incubation in vitro. Individual phosphatides as well as cholesterol are lost in proportion to their content in membranes, suggesting that fragments of membrane are removed. Supplementation of HS red cells with glucose during incubation has no consistent protective effect, whereas diminishing the excessive sodium flux through these cells by suspending them in either sodium-free or hypertonic media prevents membrane fragmentation. The characteristic excessive increase in osmotic fragility which occurs in incubated HS red cells results both from inordinate accumulation of intracellular sodium ions which produces osmotic swelling, and from depletion of surface material which generates microspherocytosis. Inhibiting both of these processes by incubating HS red cells in sodium-free media completely prevents increases in osmotic fragility despite prolonged incubation. Normal red cells rendered hyperpermeable to cations by exposure either to n-butanol or to inhibitors of membrane sulfhydryl groups, lose membrane lipid upon incubation in a similar fashion to untreated HS red cells; perfectly smooth microspherocytes, akin to those seen in HS, are thereby generated.I conclude that depletion of membrane lipids in HS which leads to microspherocytosis is correlatable with the excessive cation flux and possibly to the stimulated metabolism of acidic phosphatides in these red cells. It is suggested that this relation is derived from the fact that these phosphatides are in some way involved in maintaining the proper alignment of repeating membrane lipoprotein units, and that this function is adversely affected when these molecules are turning over more rapidly in response to increased cation flux.