Coagulation changes in individuals with sickle cell trait.

Sickle cell disorders, such as Hb SS and Hb SC, are associated with a hypercoagulable state that may contribute to the vaso-occlusive episodes observed in the disorders. To what extent increased coagulation activity occurs in individuals with sickle cell trait has had limited study. Because such information may help clarify clinical and pathologic findings that may occur in these individuals and may be useful in clarifying the hypercoagulable state in sickle cell disease, we have examined individuals with Hb AS to determine the extent that increased coagulation activity does occur. We measured d-dimers, thrombin-antithrombin (TAT) complexes, prothrombin fragment 1.2 (F1.2), absolute blood monocyte levels, proteins C and S, and isotypes of antiphospholipid antibodies in individuals with Hb AS and in matched controls (Hb AA). Results showed that d-dimers, TAT, and F1.2 were increased significantly above normal levels. Absolute blood monocyte levels were increased. The d-dimers, TAT, F1.2, and monocyte counts showed significant increasing trends through groups of increasing severity (Hb AA, Hb AS, Hb SC, and Hb SS). Our study shows that individuals with Hb AS have increased coagulation activity, with d-dimers, TAT, and F1.2 being consistent indicators. The measures of coagulation activity in Hb AS are lower than in patients with Hb SC and Hb SS disease. These results extend our previous observation that the degree of coagulation activation parallels the degree of disease severity among sickle cell genotypes. The findings suggest that monocytosis, with the possible expression of monocyte-derived tissue factor, and the associated hypercoagulable state are driven by disease severity.

Ascorbate levels in red blood cells and urine in patients with sickle cell anemia.

UNLABELLED: Ascorbic acid can be important in sickle cell anemia (SCA) because significant oxidative stress occurs in the disease. Ascorbate could contribute to reduction of the increased oxygen free radicals generated in sickle red blood cells (SRBC) and to the recycling of vitamin E in the cells, while renal loss could contribute to the low plasma levels. Evaluation of red blood cell (RBC) and urine ascorbate in SCA has not been reported. Results showed (1) ascorbate levels in SRBC were similar to those in normals; (2) urine ascorbate excretion was increased in 36% of patients; (3) plasma levels of ascorbate were decreased. CONCLUSIONS: (1) Ascorbate is present in SRBC, most likely due to ascorbate recycling, despite increased free-radical generation. (2) The increase in renal excretion may contribute to the low plasma levels of ascorbate. (3) The presence of ample ascorbate in SRBC and decreased plasma ascorbate suggests that ascorbate movement across the SRBC membrane may differ from normal RBC.

Expression of regeneration and tolerance factor correlates directly with human immunodeficiency virus infection and inversely with hepatitis C virus infection.

Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) cause two of the most prevalent debilitating viral infections. HIV appears to induce a skewing toward a Th2 response, while in HCV infection a Th1 response appears to dominate. Regeneration and tolerance factor (RTF) may participate in driving or sustaining a Th2 cytokine response. The expression of RTF on CD3(+) T cells of HIV-seropositive (HIV(+)) individuals is increased. The purpose of this study was to compare the expression of RTF during HIV infections with that during HCV infections. Three-color flow-cytometric analysis of peripheral blood collected from HIV(+) HCV-seropositive (HCV(+)), HIV- and HCV-seropositive (HIV(+) HCV(+)), and HIV- and HCV-seronegative (HIV(-) HCV(-)) individuals was performed. Levels of RTF expression on T-lymphocyte subsets from these groups were compared, as were levels of RTF expression on activated T cells expressing CD38 and HLA-DR, to determine the relationship of RTF expression to these infections. We demonstrated that the expression of RTF on surfaces of T cells from HIV(+) individuals is upregulated and that its expression on T cells from HCV(+) individuals is downregulated. A twofold increase in the mean channel fluorescence of RTF on CD3(+) T cells was seen in both HIV(+) and HIV(+) HCV(+) individuals compared to HIV(-) HCV(-) individuals. HCV(+) individuals had lower levels of RTF expression than HIV(-) HCV(-) individuals (P < 0.005 for CD4(+); P < 0.0005 for CD8(+)). In terms of percentages of T cells expressing RTF, the groups were ranked as follows: HIV(+) > HIV(+) HCV(+) > HIV(-) HCV(-) > HCV(+). The results indicate that RTF expression correlates with HIV-associated immune activation and may be associated with Th2-type responses.

Regeneration and tolerance factor: a correlate of human immunodeficiency virus-associated T-cell activation.

Human immunodeficiency virus (HIV) infection causes extensive phenotypic alterations in lymphocytes. Cellular markers that are normally absent or expressed at low levels on quiescent cells are upregulated throughout the disease course. The transmembrane form of regeneration and tolerance factor (RTF) is expressed at negligible levels on resting T cells but is quickly upregulated following in vitro stimulation and activation. Recently, we reported that expression of RTF was significantly higher in cells from HIV-seropositive (HIV(+)) individuals than in cells from HIV-seronegative (HIV(-)) individuals. Because T cells from HIV(+) individuals express markers reflecting chronic activation, we hypothesized that these in vivo-activated cells would coexpress RTF. Flow cytometry was used to assess RTF expression on activated (CD38(+) and HLA-DR(+)) CD4(+) and CD8(+) T cells. HIV(+) individuals had higher percentages of RTF(+) CD38(+) (P < 0.0001) or RTF(+) HLA-DR(+) (P = 0.0001) CD4(+) T cells than HIV(-) individuals. In HIV(+) individuals, increased percentages of CD4(+) T cells that were RTF(+), RTF(+) CD38(+), and RTF(+) HLA-DR(+) correlated inversely with the absolute number and percentage of CD4(+) T cells and correlated positively with plasma beta(2)-microglobulin concentrations. HIV(+) individuals had higher percentages of CD8(+) T cells that were RTF(+) CD38(+) (P = 0.0001) or RTF(+) HLA-DR(+) (P = 0.0010). In HIV(+) individuals, increased percentages of CD8(+) T cells that were RTF(+) HLA-DR(+) correlated inversely with the percentage of CD4(+) T cells, and high percentages of CD8(+) T cells that were RTF(+) CD38(+) correlated positively with plasma beta(2)-microglobulin levels. These findings strongly suggest that increased RTF expression is a correlate of HIV-associated immune system activation.

Antiphospholipid antibodies, proteins C and S, and coagulation changes in sickle cell disease.

The significance, interactions, and sources of coagulation abnormalities and their relationship to clinical severity and painful episodes in sickle cell disease are not clear. To evaluate this, we have examined various measures of coagulation in 37 patients with sickle cell disease (20 patients with HbSS disease and 17 patients with HbSC disease). Measurements have included isotypes of antiphospholipid antibodies (IgG, IgM, IgA) to specific phospholipids; proteins C (activity, total antigen) and S (activity, total and free antigen); measures of coagulation activation (prothrombin fragment 1.2, thrombin-antithrombin, fibrinopeptide A, d-dimers); indicators of clinical severity; and studies obtained during steady states and painful episodes. Results in HbSS disease showed that antiphospholipid antibodies were increased, with IgG phosphatidylserine showing the highest and most frequently increased levels (37% of patients). Protein C (activity) and protein S (activity, total, free antigen) were decreased (P<.01), and all measures of coagulation activation were increased (P<.001). In HbSC disease, antiphospholipid antibodies were normal, protein C (activity) and protein S (free antigen) were decreased (P<.001), and all measures of coagulation activation were increased (P<.02). A strong correlation was observed in HbSS disease between IgG-PS and d-dimers. Moderate correlations occurred between protein C activity and thrombin-antithrombin and fibrinopeptide A, between protein S activity and prothrombin fragment 1.2 and d-dimers, and between protein C and protein S activity. In HbSC disease, moderate and fewer correlations occurred. Significant differences between HbSS disease and HbSC disease were observed in aPLs, proteins C and S, and measures of coagulation activation. Measurements during steady states and during painful episodes were not significantly different. We conclude that the antiphospholipid antibody IgG-PS may contribute to coagulation activation in HbSS disease and that IgG-PS, protein C, and protein S relate to each other and jointly to measures of coagulation activation. The increased level of IgG-PS in HbSS disease most likely reflects exposure of the procoagulant phosphatidylserine on the surfaces of red cell-shed vesicles and sickle red cells, which would further affect coagulation activation. The significant differences in coagulation measures between HbSS disease and HbSC disease are consistent with differences in clinical severity between the diseases. The development of painful episodes does not appear to be related to the coagulation changes.

Increased expression of regeneration and tolerance factor in individuals with human immunodeficiency virus infection.

Regeneration and tolerance factor (RTF) plays a pivotal role in successful pregnancy outcome and has potent immunomodulating properties. During pregnancy, it is abundantly expressed in the placenta and on peripheral B lymphocytes. Several lines of evidence suggest that both successful pregnancy outcome and progression from human immunodeficiency virus (HIV) infection to AIDS are associated with a Th2-type response. As a result, we hypothesized that the cellular expression of RTF may also be increased during infection with HIV. Using flow cytometric analysis, we showed a significantly (P < 0.01) increased expression of RTF on CD3(+) cells obtained from individuals with HIV over that for individuals without HIV. On average, 32.1% of the CD3(+) cells from individuals with HIV expressed high levels of RTF. In contrast, an average of only 6.7% of the CD3(+) cells from individuals without HIV expressed high levels of RTF. Similar results were obtained when CD19(+) cells from individuals with (mean, 44.1%) and without (mean, 25.8%) HIV were evaluated. Linear regression analysis suggested that high levels of RTF expression by CD3(+) cells correlated better with viral load (r value, 0.46) than with absolute CD4 count (r value, 0.09). While additional experiments are necessary to delineate the precise immunologic role of RTF, our current data suggest that RTF expression during HIV infection may be a useful marker of immune activation.

Phase changes in membrane lipids in sickle red cell shed-vesicles and sickle red cells.

Lipid phase transformations may occur in the membranes of sickle red cell shed-vesicles and sickle red cells. The presence of such phase changes could be important in sickle cell disease since membrane phase changes appear to contribute to the generation of antiphospholipid antibodies that are thrombophilic and occur in sickle cell disease. In the present study, we have evaluated sickle red cell shed-vesicles and sickle red cells for the presence of non-bilayer lipid phases using 31P-NMR spectroscopy. Results show that the spectra of both the shed-vesicles and the sickle red cells are compatible with the occurrence of non-bilayer phases in the membrane bilayers. The findings support the concept that these membranes could contribute to the generation of antiphospholipid antibodies in sickle cell disease.

Assessment of painful episode frequency in sickle-cell disease.

Frequency of painful episodes in sickle-cell disease is considered to be related to clinical severity and possibly to other aspects of the disease. Measurements of frequency often include only hospital-related or more severe, longer-lasting episodes. Since painful episodes, however, may regularly occur in nonhospital settings or be shorter-lasting with possible different pathologic effects, we measured all painful episodes in 10 adults with sickle-cell disease for 1.0-3.8 years, using a daily questionnaire. The results were related to other indices of disease severity and to possible precipitating factors, such as cold weather and menses. Sixty-one percent (on average) of the total number of episodes (243) were nonhospital-related, and 33% (on average) were shorter-lasting. Episode frequencies, whether determined as total, hospital-related, nonhospital-related, or shorter-lasting, were not related to each other or to other indicators of disease severity. The highest incidence of episode frequency occurred in the winter. The association of episodes with menses was moderately close in individual patients. The findings suggest that nonhospital-related painful episodes and shorter-lasting episodes may contribute significantly to episode frequency. Measurement of frequency of all painful episodes would require consideration when evaluating episode frequency and its relationship to disease severity, to possible precipitating factors of episodes, and to treatment of the disease, and for study of the natural course of the disease.

Real-time X-ray diffraction study at different scan rates of phase transitions for dipalmitoylphosphatidylcholine in KSCN.

Multibilayer arrays of dipalmitoylphosphatidylcholine (DPPC) in 1 M KSCN were characterized using real-time X-ray diffraction and differential scanning calorimetry. A phase transition sequence was observed as a function of increasing temperature which involved changes from the interdigitated subgel (Lc(inter)) to interdigitated gel (L beta(inter)) to disordered (L alpha) bilayer states. The phase transition mechanisms were unambiguously determined by comparison of results from fast and slow scans. The Lc(inter)-->L beta(inter) phase transition was shown to involve a continuous change in acyl chain spacing between the rectangular subgel acyl chain unit cell into an hexagonal gel acyl chain unit cell. The mechanism is similar to that for subgel to gel state transitions involving non-interdigitated DPPC bilayers.

Sterols stabilize the ripple phase structure in dihexadecylphosphatidylcholine.

The presence of various sterols in mixtures with dihexadecylphosphatidylcholine (DHPC) was studied using static X-ray diffraction of temperature equilibrated samples, and real-time X-ray diffraction of samples undergoing temperature scans. It was found that these sterols eliminate the interdigitation of the alkyl chains in the DHPC sub-gel and gel-state bilayers while stabilizing the ripple gel-state at the expense of the gel-state bilayer phase. The ripple-ripple phase transition previously observed for dipalmitoylphosphatidylcholine in the presence of low molar concentrations of sterols (Wolfe et al. (1992) Phys. Rev. Lett. 68, 1085-1088) was also observed for similar DHPC-sterol mixtures. In addition, we show the first evidence that the presence of 5 alpha-cholestane-3 beta,5,6 beta-triol will cause the lipid mixtures to continue to adopt a ripple mesophase structure even after the DHPC alkyl chain becomes disordered.

Inhibition of cytolytic T lymphocyte activity by oxysterols.

The objective of this study was to investigate the effects of oxysterols (OS), namely 5 alpha-hydroxy-6-ketocholestanol, 6-ketocholestanol and 25-hydroxycholesterol, on specific cell-mediated cytotoxicity by C57BL/6 spleen cells against P815-X2 (a DBA/2 mastocytoma) target cells. Cytolytic T lymphocytes (CTL) were generated by intraperitoneally injecting C57BL/6 mice with P815-X2 tumor cells 10 d prior to the cytotoxicity experiments. Preincubation of CTL with 10(-5) M 5 alpha-hydroxy-6-ketocholestanol and 6-ketocholestanol for 45 min in lipoprotein-depleted medium resulted in an inhibition of cytolytic activity (73 and 43%, respectively) as measured by 4-h 51Cr release. At a concentration of 5 x 10(-6) M, 5 alpha-hydroxy-6-ketocholestanol inhibited CTL activity by 65%, whereas 6-ketocholestanol did not elicit any inhibition. By contrast, 25-hydroxycholesterol did not inhibit CTL at either concentration, although it is known to be a potent inhibitor of 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase, the rate-limiting enzyme in the cholesterol biosynthetic pathway. When CTL were preincubated with OS in lipoprotein-replete medium, there was no inhibition of CTL activity at the respective concentrations. The results suggest that the inhibition of CTL activity upon short-term incubation with OS is not due to the inhibition of cholesterol synthesis, but may be due to the insertion of OS into the plasma membrane to replace cholesterol and alteration of membrane physical properties.

Intracellular Ca(2+)-containing vesicles in sickle cell disorders.

The frequency of red blood cells harboring Ca(2+)-containing vesicles was determined in patients with various sickle cell disorders; vesicles were identified by microscopy after the cells were stained with the fluorescent probe chlortetracycline. Specimens from 49 patients were studied. The highest frequencies of vesicle-containing cells were observed in samples from adults with homozygous sickle cell (SS) disease and in patients with S beta zero and SS(-alpha/alpha alpha) thalassemias. The frequency of cells with vesicles was less elevated in patients with SS(-alpha/-alpha) thalassemia and in patients with SS disease (Saudi Arabia high hemoglobin F), whereas a normal low frequency of positive cells was seen in patients with sickle cell-hereditary persistence of fetal hemoglobin and in patients with sickle trait. Deoxygenation induced an increase in the number of vesicle-containing cells that was proportional to the frequency of such cells in the oxygenated population. The frequency of Ca(2+)-containing vesicles in sickle red cells is associated with the clinical, hematologic, or clinical and hematologic severity of the sickle cell disorder.

Effects of fibrinogens on phase transitions in lipid model membrane systems.

An abnormal fibrinogen that caused aggregation of red blood cells (RBC) in a patient with gangrene was examined by real-time X-ray diffraction to determine its effects on dipalmitoylphosphatidylcholine (DPPC) and 1-palmitoyl-2-oleoylphosphatidylethanolamine (POPE) phase transitions. Similar studies were done with normal fibrinogen and results were compared. Both types of fibrinogen slightly increased the L alpha-->HII phase transition temperature and the HII phase parameters for POPE, while neither fibrinogen significantly affected the order-disordered acyl chain transitions in the lipid bilayer phase. However, fibrinogen differentially influenced the bilayer unit cell parameter of the gel and disordered bilayer and the gel state ripple phase. These results can be interpreted as indicating that fibrinogen has little effect on the balance of gel and disordered acyl chains in the lipid bilayer, but may influence membrane functions dependent on non-bilayer phases.

Intratumor heterogeneity of DNA ploidy and correlations with clinical stage and histologic grade in prostate cancer.

Paraffin blocks from 60 patients with prostate cancer were used to study the DNA ploidy patterns by flow cytometry. Nineteen patients had stage A disease, 11 had stage B, 9 had stage C, 20 had stage D, and 1 was of unknown stage. Histologically, 32 of the cancers were well differentiated, 21 were moderately differentiated, and 7 were poorly differentiated. Eighteen patients had an aneuploid or tetraploid (A/T) pattern and 42 had a diploid pattern. Seventy-one percent (5/7) of patients with poorly differentiated, 48% (10/21) with moderately differentiated, and 9% (3/32) with well-differentiated histology had A/T patterns (P < 0.01). Forty-five percent (9/20) of patients with stage D, 44% (4/9) with stage C, 27% (3/11) with stage B, and 5% (1/19) with stage A had A/T patterns (P < 0.05). Nine patients with an A/T pattern also had DNA ploidy studies done on the "benign" part of the specimen. These specimens showed diploid patterns although three of these patients had well-differentiated tumor in the "benign" designated part of the specimen. One patient with mixed histology had an aneuploid pattern on the poorly differentiated section and a diploid pattern on the well-differentiated section of the "malignant" designated part of the same specimen. We conclude that prostate cancer patients with non-diploid tumors have more advanced disease and less differentiated tumors than patients with diploid tumors and that considerable histological and ploidy heterogeneity may be present in different parts of the same paraffin-embedded specimen.

Antiphospholipid antibodies in sickle cell disease.

Antiphospholipid antibody formation can be induced in mice by phospholipid in a hexagonal II phase but not by phospholipid in a bilayer phase. Since sickle red cell membranes have increased hexagonal II phase content, we have measured serum antiphospholipid antibody levels in 25 patients with sickle cell disease to determine whether anti-phospholipid antibody may similarly be induced in these patients. Seventeen of the 25 patients (68%) had increased levels of antiphospholipid antibodies. Eleven patients (65%) had IgG and six each (35%) had IgM and IgA isotypes. Antiphosphatidylethanolamine, antiphosphatidylserine, antiphosphatidylinositol, and antiphosphatidic acid were the most frequently increased antibodies. The finding of increased antiphospholipid antibodies in these patients is compatible with the concept that antiphospholipid antibody formation is associated with structural changes in the red cell membrane and that such structural changes occur in the red cells of patients with sickle cell disease.

Functional studies on long-term cryopreserved peripheral blood mononuclear cells from patients with lung cancer and from healthy subjects.

To determine the functional abilities of long-term cryopreserved peripheral blood mononuclear cells (PBMCs) from patients with lung cancer and from healthy subjects, we assayed the proliferative and plaque-forming cell (PFC) responses of cells from these individuals after the cells had been cryopreserved for up to 31 months. The stability of these cells for B and T cell quantitative assays was also determined by using their respective monoclonal antibodies. The patients' results were compared with those in healthy subjects to ascertain whether the conclusions derived from the assay of cryopreserved cells are consistent with our earlier studies on fresh cells from similar patients. The results show that proliferative and PFC responses of the frozen cells were not significantly affected by further storage, despite an initial, irreversible functional loss in some subsets of T lymphocytes and monocytes during the process of freezing. They also demonstrate that cryopreserved PBMCs from both patients and controls can be successfully utilized for B and T cell quantitative assays. The conclusions derived from the assay of cryopreserved cells are also consistent with our earlier observations on fresh cells from patients with lung cancer; those studies indicated a B cell functional abnormality caused in part by increased suppressor T cell and monocyte activity.

Ca2+ accumulation and loss by aberrant endocytic vesicles in sickle erythrocytes.

Sickle cells contain internal vesicles which accumulate Ca2+. As shown here, the membrane enclosing the vesicles contains the plasma membrane Ca(2+)-ATPase, or Ca2+ pump, as judged by staining with an antibody directed against the protein. Moreover, the number of cells containing such vesicles increases upon deoxygenation. These findings argue strongly that the vesicles arise by endocytosis from the plasma membrane, and explain how they accumulate Ca2+. When sickle cells are depleted of ATP, Ca2+ is lost from the vesicles, as judged by the disappearance of staining with the Ca2+/membrane probe chlortetracycline (CTC), without a corresponding loss of antibody staining. This loss of Ca2+ can be inhibited by nitrendipine, a Ca2+ channel blocker. These results suggest that the vesicle membrane allows outward passage of Ca2+ by a nitrendipine-sensitive pathway, which can be overcome by the inward-directed activity of the Ca2+ pump of the vesicle membrane. If so, the Ca2+ which vesicles contain is in dynamic equilibrium with the cytoplasm of the sickle erythrocyte.

Inhibition of NK cell-mediated cytotoxicity by oxysterols.

Some of the oxidation products of cholesterol (oxysterols) have profound effects on plasma membrane structure and function. The present studies were undertaken to determine the effects of oxysterols on NK cell-mediated cytotoxicity. When mouse spleen cells were preincubated with certain oxysterols, NK cell cytotoxicity was inhibited without loss of effector cell viability. The strongest inhibition was observed with oxysterols that are oxidized at the C-5, C-6, or C-7 positions of the sterol nucleus. Among these, 7 beta-hydroxycholesterol caused more inhibition than 7 alpha-hydroxycholesterol suggesting that the spatial orientation of the hydroxyl group in the beta-position results in a greater perturbation in plasma membrane structure than that oriented in the alpha-position. In contrast, oxysterols that are oxidized at the C-20 and C-25 positions that are located on the C-17 acyl chain had little or no inhibitory effect, suggesting that oxidation in the cholesterol nucleus which is situated closer to the phospholipid headgroups at the lipid bilayer-aqueous interface results in a more profound effect on the plasma membrane physical structure. These results suggest that the lytic function of NK cell is sensitive to alterations in the physical state of its plasma membrane induced by oxysterols.

The effects of cholesterol oxidation products in sickle and normal red blood cell membranes.

The oxysterol content in normal and sickle red blood cell (RBC) membranes was assessed using thin-layer chromatography and capillary gas chromatography/mass spectrometry. Several more oxysterols were present in sickle RBCs compared to normal RBCs. Sickle RBC membranes had a higher concentration of 5 alpha,6 alpha-epoxycholesterol, 5 alpha-cholestane-3 beta,5,6 beta-triol, 7-ketocholesterol and 19-hydroxycholesterol than normal RBC membranes. The increased oxysterols in sickle RBC may be an effect of the increased oxidative stress which occurs in sickle RBC membranes. Physical characteristics of normal and sickle RBC membrane ghosts with and without inserted oxysterols were examined by Fourier transform infrared spectroscopy. The data are consistent with a greater sterol content in sickle cells compared to normal RBC membranes, and a possible oxysterol-cholesterol synergism.