Gordon W. Stewart

Disorders of the Red Cell Membrane

The red cell membrane is composed of a lipid bilayer, studded with transmembrane proteins, and the membrane skeleton, also termed the erythrocyte skeleton. The latter is a bidimensional network that laminates the inner surface of the bilayer. Skeleton proteins are connected to transmembrane proteins through anchoring proteins (Fig. 21-1). The main features of the proteins of interest and their genes are enumerated in Table 21-1. A number of hereditary hemolytic anemias, usually associated with red cell shape abnormalities, stem from mutations affecting a variety of genes that encode membrane, skeletal, or anchoring proteins. We will focus on hereditary spherocytosis (HS), hereditary elliptocytosis (HE), and its aggravated form, hereditary pyropoikilocytosis (HPP).

Thrombo-embolic disease after splenectomy for hereditary stomatocytosis.

Nine cases of hereditary stomatocytosis (HSt) are presented which show documented thrombotic complications after splenectomy. In three cases, patients became severely ill with pulmonary hypertension and a fourth developed portal hypertension. One unsplenectomized affected adult relative had suspected but unconfirmed thrombotic pathology; the six other affected unsplenectomized adults did not. Since splenectomy is of only limited therapeutic benefit in stomatocytosis, it should be not be performed without careful consideration. A tendency to iron overload, even without hypertransfusion and irrespective of splenectomy, is evident in many of these patients.

Multiple clinical forms of dehydrated hereditary stomatocytosis arise from mutations in PIEZO1

Autosomal dominant dehydrated hereditary stomatocytosis (DHSt) usually presents as a compensated hemolytic anemia with macrocytosis and abnormally shaped red blood cells (RBCs). DHSt is part of a pleiotropic syndrome that may also exhibit pseudohyperkalemia and perinatal edema. We identified PIEZO1 as the disease gene for pleiotropic DHSt in a large kindred by exome sequencing analysis within the previously mapped 16q23-q24 interval. In 26 affected individuals among 7 multigenerational DHSt families with the pleiotropic syndrome, 11 heterozygous PIEZO1 missense mutations cosegregated with disease. PIEZO1 is expressed in the plasma membranes of RBCs and its messenger RNA, and protein levels increase during in vitro erythroid differentiation of CD34(+) cells. PIEZO1 is also expressed in liver and bone marrow during human and mouse development. We suggest for the first time a correlation between a PIEZO1 mutation and perinatal edema. DHSt patient red cells with the R2456H mutation exhibit increased ion-channel activity. Functional studies of PIEZO1 mutant R2488Q expressed in Xenopus oocytes demonstrated changes in ion-channel activity consistent with the altered cation content of DHSt patient red cells. Our findings provide direct evidence that R2456H and R2488Q mutations in PIEZO1 alter mechanosensitive channel regulation, leading to increased cation transport in erythroid cells.

Epithelial Na+ channels and stomatin are expressed in rat trigeminal mechanosensory neurons

Abstract. Caenorhabditis elegans MEC-4 and MEC-10 are subunits of the degenerin/epithelial Na+ channel (DEG/ENaC) ion channel superfamily thought to be associated with MEC-2 (a stomatin-like protein) in a mechanotransducing molecular complex in specialized touch sensory neurons. A key question is whether analogous molecular complexes in higher organisms transduce mechanical signals. To address this question, we selected mechanoreceptors of the rat vibrissal follicle-sinus complex in the mystacial pad and the trigeminal ganglia for an immunocytochemical and molecular biological study. RT-PCR of poly(A+) mRNA of rat trigeminal ganglia indicated that α-, β-, and γ-ENaC and stomatin mRNA are expressed in rat trigeminal ganglia. Using immunocytochemistry, we found that α-, β-, and γ-ENaC subunits and stomatin are localized in the perikarya of the trigeminal neurons and in a minor fraction of their termination site in the vibrissal follicle-sinus complex, where longitudinal lanceolate endings are immunopositive. We conclude that α-, β-, and γ-ENaC subunits as well as the candidate interacting protein stomatin are coexpressed in a mammalian mechanoreceptor, a location consistent with a possible role in mechanotransduction.

Stomatocytic haemolysis and macrothrombocytopenia (Mediterranean stomatocytosis/macrothrombocytopenia) is the haematological presentation of phytosterolaemia

Phytosterolaemia (sitosterolaemia) is a recessively inherited metabolic condition in which the absorption of both cholesterol and plant‐derived cholesterol‐like molecules at the gut is unselective and unrestricted. In haematology, Mediterranean stomatocytosis or Mediterranean macrothrombocytopenia is a poorly understood haematological condition that combines stomatocytic haemolysis with the presence of very large platelets. Five pedigrees showing this haematology were identified. Gas chromatography mass spectrometry (GC‐MS) showed that all of the patients with this highly specific haematology had grossly elevated levels of phytosterols in the blood, diagnostic of phytosterolaemia. All showed mutations in the ABCG5 and ABCG8 previously linked to phytosterolaemia. Three pedigrees showed five new mutations, while two pedigrees showed the common W361X mutation in ABCG8. We draw the following four conclusions: (i) that Mediterranean stomatocytosis/macrothrombocytopenia is caused by an excess of phytosterols in the blood; (ii) that phytosterolaemia, which does not respond to standard statin treatment, can be diagnosed via the distinctive haematology described here, even when the cholesterol is normal; (iii) that phytosterolaemia should be considered in the differential diagnosis of all patients with large platelets; and (iv) that the platelet size should be noted in patients with hypercholesterolaemia.

Hemolytic disease due to membrane ion channel disorders

Purpose of reviewTo summarize recent findings in the study of the ′hereditary stomatocytoses and allied disorders’, diseases in which the red cell membrane leaks Na+ and K+, disturbing the osmotic homeostasis of the cell. Recent findingsRecent work has emphasized the diversity of these conditions, especially evident in the variations in temperature dependence of the cation leak. The association between the dehydrated, xerocytic form that maps to chromosome 16, with perinatal ascites is confirmed. Two cases that may represent a new hematoneurologic syndrome have been recognized. SummaryThese leaky-membrane diseases fall into three main categories. The ′dehydrated’ or xerocytic form maps to chromosome 16 and shows a minimal leak, and can show an excess of phosphatidylcholine in the membrane. Some of these xerocytic cases show a syndrome of self-limiting perinatal ascites of unknown cause. A second group shows very variable temperature dependence in the cation leak. The most severe ′overhydrated’ form shows very leaky cells and the 32kD stomatin protein is missing, although the gene is not mutated. This deficiency seems to be the result of a trafficking problem. The protein is associated with cholesterol and sphingomyelin-rich ′rafts’ and may be some kind of partner protein for a membrane-bound proteolytic system.

Hereditary dehydrated and overhydrated stomatocytosis: recent advances.

The hereditary stomatocytoses and allied disorders are genetic defects of the erythrocyte membrane that result in abnormal permeability to the univalent cations Na+ and K+. Although rare, these conditions reflect abnormalities in physiologic mechanisms that are of paramount interest. All cases (as defined here) show increased plasma membrane permeability to Na+ and K+ and, to a greater or lesser degree, stomatocytic morphology. Dehydrated hereditary stomatocytosis, the most common form of hereditary stomatocytosis, is more heterogeneous than previously thought and includes kindreds showing pseudohyperkalemia or perinatal edema, or both. The gene responsible for both dehydrated hereditary stomatocytosis and familial pseudohyperkalemia, a nonhemolytic variant that presents with high plasma K+ levels, has been mapped to 16q23-qter. The cause of overhydrated hereditary stomatocytosis remains elusive despite the manifest lack of the enigmatic protein stomatin in the erythrocyte membrane. In all cases where splenectomy has been performed, this procedure has conferred a marked risk for thrombosis in adult life. This finding stresses the importance of diagnostic distinction between these conditions and hereditary spherocytosis.

FAMILIAL PSEUDOHYPERKALÆMIA A New Syndrome

Inherited pseudohyperkalaemia due to an abnormal red-blood-cell potassium leak was discovered in 16 of 28 relatives of a woman with pseudohyperkalaemia. Autosomal dominance seemed to account for inheritance of this abnormality. Affected subjects were not anaemic and had normal in-vivo plasma-potassium concentrations.

Stomatin-deficient cryohydrocytosis results from mutations in SLC2A1: a novel form of GLUT1 deficiency syndrome

The hereditary stomatocytoses are a series of dominantly inherited hemolytic anemias in which the permeability of the erythrocyte membrane to monovalent cations is pathologically increased. The causative mutations for some forms of hereditary stomatocytosis have been found in the transporter protein genes, RHAG and SLC4A1. Glucose transporter 1 (glut1) deficiency syndromes (glut1DSs) result from mutations in SLC2A1, encoding glut1. Glut1 is the main glucose transporter in the mammalian blood-brain barrier, and glut1DSs are manifested by an array of neurologic symptoms. We have previously reported 2 cases of stomatin-deficient cryohydrocytosis (sdCHC), a rare form of stomatocytosis associated with a cold-induced cation leak, hemolytic anemia, and hepatosplenomegaly but also with cataracts, seizures, mental retardation, and movement disorder. We now show that sdCHC is associated with mutations in SLC2A1 that cause both loss of glucose transport and a cation leak, as shown by expression studies in Xenopus oocytes. On the basis of a 3-dimensional model of glut1, we propose potential mechanisms underlying the phenotypes of the 2 mutations found. We investigated the loss of stomatin during erythropoiesis and find this occurs during reticulocyte maturation and involves endocytosis. The molecular basis of the glut1DS, paroxysmal exercise-induced dyskinesia, and sdCHC phenotypes are compared and discussed.

A variant of hereditary stomatocytosis with marked pseudohyperkalaemia

A family with an unusual form of hereditary stomatocytosis is described. The affected members showed a mild, dominantly‐inherited, haemolytic anaemia with intracellular Na and K levels of 41–48 and 44–53 mmol/(l cells) respectively. This anaemia was associated with marked ‘pseudohyperkalaemia’: that is, loss of K from red cells on storage at room temperature. At 37°C, ‘leak’ tracer flux rates (assessed as the ouabain + bumetanide‐resistant K fluxes) showed a roughly 5‐fold acceleration compared to normal, and an abnormal temperature dependence with a shallow slope between 37 and 20°C (mean Q10 (ratio of reaction rates at temperature T and T − 10) over this interval, 1.6; normal 2.2). The pseudohyperkalaemia could be attributed to the disparity between pump and leak at 20°C. This is an identical mechanism to that previously shown for the haematologically trivial condition, ‘familial pseudohyperkalaemia’. No protein or lipid abnormality was found in the membrane of these cells.