Blood destruction in the polycythemia induced by hypoxia

The hemoglobin catabolism during the development and during the disappearance of polycythemia induced by hypoxia was studied by measuring the totalcirculating hemoglobin and the daily bile pigment excretion in bile-fistula dogsbefore, during, and after prolonged periods of exposure to 20,000 feet simulatedaltitude.

1. The inscreased erythropoiesis during the first weeks of altitude exposure wasaccompanied by a signiflcant increase in bile pigment output. The possible sourcesof this pigment excretion are discussed.

2. The life spans of the red cells during altitude exposure was found to be about115 days. No differences were observed in the longevity of the cells in animals atground level and at altitude.

3. The normalization of the polycythemic blood levels took place within sixto eight weeks after returns to ground level, and was achieved by the combinedeffect of a depressed erythropoiesis and of an increased blood destruction. Theincrease in red cell destruction observed under these conditions demonstratesthe existence of an "active" mechanism of blood destrunction by which the organism is able to destroy normal blood cells before their life span is exhausted. Thisincreased red cell destruction, however, accounted for only 21 to 39 per cent ofthe hemoglobin which disappeared from circulation after return to ground level.The major part of the normalization of altitude polycythemia was brought aboutby a temporary depression of erythropoiesis which was estimated to amount to30 or 40 per cent of the normal cell production in the six weeks after the discontinuation of the altitude exposure.

Submitted on September 15, 1951 Accepted on October 25, 1951     

Studies on Congenital Hemolytic Syndromes. IV. Gastrointestinal Absorption of Iron

1. Results of studies of gastrointestinal absorption of ferrous iron in normalchildren and those with heterozygous thalassemia were similar.

2. In one patient with absent erythropoiesis but severe anemia, no increasein the amount of iron absorbed was noted.

3. In sickle cell-hemoglobin C disease and hereditary spherocytosis havingonly slight anemia in the presence of increased erythropoiesis, normal amountsof iron were absorbed.

4. Patients with sickle cell anemia and thalassemia major in whom therewas active erythropoiesis and marked anemia absorbed abnormally largeamounts of iron. The amount absorbed by individuals with the latter diseasecould be reduced by administration of transfusions and concomitant suppression of erythropoiesis.

5. Usual values for serum iron and latent iron-binding capacity in severalcongenital hemolytic syndromes have been presented and their significancediscussed.

6. No specific effect on absorption was noted by increased or reducedamounts of tissue or serum iron or by reduced or increased latent iron-bindingprotein.

Submitted on June 20, 1961 Accepted on October 30, 1961     

Studies of the production and life span of erythrocytes in myeloid metaplasia

1. Four patients with agnogenic myeloid metaplasia and one patient withpolycythemia vera and myeloid metaplasia were studied with Fe⁵⁹, Cr⁵¹ andglycine-2-C¹⁴.

2. Three of the patients with agnogenic myeloid metaplasia had activesplenic, hepatic or renal erythropoiesis. One had deficient erythropoiesis.

3. The red cell life span was short in all of the patients with agnogenicmyeloid metaplasia, definite splenic sequestration occurring in two patients.The red cell life span was normal in the patient with polycythemia vera andmyeloid metaplasia.

4. The possible indications for splenectomy were discussed.

Submitted on July 25, 1958 Accepted on October 12, 1958     

Erythrokinetics in pernicious anemia

Quantitative measurements of the erythropoietic activity of the marrow, ofcirculating red cell production and destruction have been made in patients withpernicious anemia in relapse and during response to vitamin B₁₂ therapy.

Total erythropoietic marrow activity as reflected by turnover of heme components proceeds at a rate of approximately 3 times normal. The delivery ofviable red cells to the circulating blood, however, does not increase above normal. This would indicate that the greater portion of marrow activity is ineffective in terms of blood production. This marrow dysfunction coupled with anincreased rate of cell destruction of approximately 3 times normal is responsiblefor the anemia. Total erythropoiesis is somewhat less, and effective erythropoiesisconsiderably less, than that which may be expected of the normal marrow underthe sustained stimulus of anemia.

The reticulocyte count is shown to be an unreliable index of blood productionin untreated pernicious anemia due to loss of reticulum from cytoplasma ofmany red cells before their delivery into circulation.

During the response to vitamin B₁₂ the ineffective erythropoiesis is convertedto effective erythropoiesis, whereas total erythropoiesis remains unchanged.The rate of blood production during recovery is 3 to 4 times normal.

Submitted on January 23, 1956 Accepted on May 3, 1956     

Leukopenia following administration of nicotinic acid

1. Intravenous nicotinic acid produces an immediate and marked neutropenia,which disappears within 15 minutes. The lymphocytes frequently show a slightreduction; but the red cell count, hematocrit and platelet count reveal no significant variation.

2. This response was similar in splenectomized and nonsplenectomized subjects.

3. In 2 patients with leukemia the white cell count was reduced in 5 minutesby nicotinic acid from 177,800 to 146,400 and 73,300 to 33,600.

4. The mechanism of the granulocytopenia after nicotinic acid is discussedin relation to its vasodilatation action and the distribution of leukocytes in thevascular system. This concept is outlined in table 5.

Submitted on December 11, 1951 Accepted on March 3, 1952     

Mediterranean anemia in a Negro complicated by pernicious anemia of pregnancy: report of a case

1. A case is presented of a Negro woman with Mediterranean anemia whodeveloped megaloblastic anemia of pregnancy in each of three pregnancies.

2. The possibility that Mediterranean anemia predisposes to the developmentof pernicious anemia of pregnancy is discussed.

3. With megaloblastic erythropoiesis, anemia became more severe, but thecharacteristic red cell hypochromia of Mediterranean disease was masked.

4. Purified liver extract failed to protect against the development of megaloblastic anemia of pregnancy but folic acid produced a satisfactory therapeuticresponse.

Submitted on August 12, 1953 Accepted on November 9, 1953     

Studies on Iron Absorption. I. The Relationships Between the Rate of Erythropoiesis, Hypoxia and Iron Absorption

(1) Evidence is presented that the augmentation of iron absorption fromthe gastro-intestinal tract produced by hypoxia can occur independently ofacceleration of erythropoiesis.

(2) It is demonstrated that the hormone erythropoietin is capable of enhancing iron absorption; and that this property of erythropoietin is indirect,being dependent on acceleration of erythropoiesis.

(3) An experimental model for the study of those factors that affect ironabsorption and are independent of increased red cell production is presented.

Submitted on July 21, 1961 Accepted on September 14, 1961     

Transmission of antianemic principle across the placenta and its influence on embryonic erythropoiesis; II. Comparison of the effect of liver extract and pteroylglutamic acid (PGA)

1. Prehepatic embryonic erythropoiesis is influenced when normal pregnant ratsare injected with potent antianemic substances.

2. Both liver extract and PGA (folic acid) cause a reduction in mean cell diameters, but the former is slightly more effective.

3. The rate of mitosis is increased and the relative proportions of individualphases altered.

4. The distribution of light areas in the cytoplasm—negative images of organoids as seen in dry smears—is altered to a greater extent by PGA than by liverextract.

5. The in vitro and in vivo action of drugs on erythropoietic cells are discussed.

     

The effect of acute protein deprivation upon erythropoiesis in rats

1. Hemoglobin concentration, blood volume, and erythrocyte radioiron uptake were measured in rats subjected to acute protein deficiency.

2. Removal of protein from the diet was followed promptly by hemoconcentration, diminution in blood volume, and drastic reduction in erythropoiesis.These changes were reversible, after 35 days, upon addition of protein tothe diet.

3. Protein intake is more essential for maintenance of normal erythropoiesisthan is total caloric intake.

4. The data suggest that hemoglobin concentration within the vascularsystem is more important than red cell volume in regulating erythropoieticrate.

Submitted on June 27, 1957 Accepted on September 15, 1957     

Factors Stimulating Erythropoiesis in Frogs

1. Sublethal levels of hypoxia do not stimulate erythropoiesis in the frogas measured by the incorporation of thymidine-2-C¹⁴ into peripheral erythrocytes, whereas bleeding of approximately one-third of the blood volume increases erythropoiesis 70-fold as judged by this criterion. This is taken as evidence that for the frog, the fundamental stimulus for erythropoiesis may notbe hypoxia.

2. Cobaltous ion administration does not increase erythropoiesis in the frog.

3. The serum of bled frogs increases the incorporation of thymidine-2-C¹⁴into the erythrocytes of frogs into which it is injected. This serum does notstimulate erythropoiesis in the polycythemic mouse. Serum from an anemicpatient which contains large amounts of erythropoietin as measured in thepolycythemic mouse does not stimulate erythropoiesis in the frog.

Submitted on January 9, 1963 Accepted on March 16, 1963     

Hematologic changes with ACTH and cortisone therapy of rheumatoid arthritis

1. Detailed hematologic observations, bone marrow aspirations and bloodvolume determinations were made on 20 patients with rheumatoid arthritis andallied disorders before, during and after the administration of either ACTH orcortisone.

2. Significant reticulocytosis occurred in every patient during therapy, butits magnitude was poorly correlated with either the initial degree of anemia orsubsequent increase in circulating red cell mass.

3. There was an increase in hematocrit and total circulating red cell mass ofall anemic patients who responded clinically to either ACTH or cortisone. Therewas little or no improvement of anemia when the clinical response was poor.

4. Polycythemia did not occur in any patient during prolonged therapy orwith repeated courses of either ACTH or cortisone.

5. Hemodilution and hemoconcentration were much more profound duringand after ACTH administration than they were with cortisone.

6. Bone marrow studies revealed moderate depression of the erythroid seriesbefore treatment. At the end of therapy erythroid elements were normal.

7. Significant polymorphonuclear leukocytosis occurred its all patients duringtherapy while lymphopenia was inconstant and unsustained. Circulating eosinophils were depressed more with ACTH than with cortisone treatment.

8. Before treatment eosinophils and their precursors were present in thebone marrow its normal or increased numbers. During therapy the number ofthese cells was unchanged in the marrow, even when there was profound peripheral eosinopenia

9. The role of ACTH and cortisone in the physiologic mechanism of hematopoiesis is discussed.

10. The improvement in the anemia associated with inflammatory disease inresponse to ACTH or cortisone therapy probably is a reflection of the controlof the underlying disease rather than a primary "stimulation" of the bonemarrow.

Submitted on February 14, 1951 Accepted on April 23, 1951     

The Effect of Splenic X-Irradiation on the Ferrokinetics of Chronic Leukemia with a Clinical Study

The usefulness of splenic x-irradiation in the palliative treatment of chronicleukemia is illustrated by the results obtained in the treatment of 18 patients.This form of therapy was generally followed by reduction in organ size, improvement in blood levels, and control of associated anemia.

Abnormalities of iron kinetics were defined in nearly all patients prior totherapy. A second ferrokinetic study was performed after remissions wereinduced by splenic irradiation.

In the majority of patients, some evidence of increased red cell sequestration in the spleen could be demonstrated before therapy. The reaction of theerythropoietic tissue to this hemolytic process varied. In a number of patientswith chronic lymphatic leukemia, there was an absolute hypoactivity. In thechronic myeloid group, erythropoiesis was either normal or slightly increased.In three cases of CLL with marked hemolytic activity, the erythropoietic activity was increased approximately twofold. However, in none of the anemiccases was erythropoiesis adequate to maintain a normal red cell mass. Extramedullary erythropoiesis was demonstrated in all patients of the myeloidgroup.

Submitted on February 4, 1966 Accepted on August 6, 1966     

Erythrokinetics. IV. The plasma iron turnover as a measure of erythropoiesis

Experimental and clinical studies have been performed to define more clearlythe significance of the plasma iron turnover.

It has been shown that the plasma iron turnover is not affected by the rate ofred cell destruction and to only a limited extent by increased body stores. Itdoes, however, reflect the degree of erythroid marrow activity and is a sensitiveindicator for measuring changes in such activity.

A series of 85 studies in normal subjects and in patients with various hematologic disorders were carried out to define the range of response with anemia andto assess the clinical value of the plasma iron turnover as an index of erythropoiesis. In states of marrow hyperfunction it is increased from 3 to 6 times normaland may be depressed to approximately half normal with marrow hypofunction.The plasma iron turnover is increased with marrow dyspoiesis. This increase is ameasure of total erythropoiesis and does not indicate the production of viablered cells.

Submitted on July 30, 1956 Accepted on November 4, 1956     

Studies of the rate of production and life span of erythrocytes in acute leukemia

The rate of red cell formation and the red cell life span were determinedin six adult patients with acute myelogenous leukemia by the use of Fe⁵⁹,Cr⁵¹ and glycine-2-C¹⁴. One patient with acute monocytic leukemia wasstudied with Fe⁵⁹ alone.

Erythropoiesis was normal or increased in two patients, deficient in fourpatients and absent in one. The data indicate that in the cases of deficienterythropoiesis a decreased number of red cells were produced in the marrow, but that they were released at a rapid rate.

The red cell life span appeared to be normal in one patient, short but finitein four patients, and short owing to random destruction in one patient. Onestudy did not include the measurement of red cell life span.

The liver removed an abnormally large proportion of the plasma iron whenmarrow erythropoiesis was deficient.

The bone marrow examination may be an unreliable indicator of the rateof erythropoiesis.

Submitted on August 7, 1958 Accepted on February 21, 1959     

The plasma erythropoietic stimulating factor; observations on circulating erythrocytes and bone marrow of rats receiving protein-free extracts of rabbit plasma

1. Boiled plasma extracts from anemic rabbits are capable of stimulatingerythropoiesis in normal rats as demonstrated by reticulocytosis, erythrocytosis,and increased marrow erythropoietic activity.

2. In the nonanemic rat recipient the increased erythropoiesis is manifestedby the production of cells of decreased size without associated increase in thehemoglobin or hematocrit determinations. The cells probably have a greatlyshortened life span.

3. The factor in anemic rabbit plasma is not destroyed by prolonged boilingand is not precipitated by perchloric acid. On the basis of these observations itwould seem to be nonprotein in nature.

4. Further investigations concerning the role of the erythrocyte stimulatingfactor in normal and abnormal erythropoiesis should be facilitated by the use ofnonprotein plasma extracts which may be administered to small laboratoryanimals.

Submitted on August 19, 1955 Accepted on October 1, 1955     

Genetic aspects of sickle cell anemia and microdrepanocytic disease

1. A brief review is presented of the genetic theories of sickle cell anemia andthe sickle cell trait.

2. The genetic data on 2 families of asymptomatic individuals with the sicklecell trait and of 3 families of patients with sickle cell anemia are reported. Thesedata confirm the heterozygous-homozygous theory of Neel.

3. The possibility is considered that many of the cases of sickle cell anemiadescribed in the white race are actually examples of "microdrepanocytic disease."

4. Microdrepanocytic disease is a new syndrome, first described by the authorsfrom Italy. It has some of the characteristics of both sickle cell anemia andMediterranean anemia. On the basis of studies in 11 families, the presence ofthe sickle cell trait in one parent and of microcythemia (Mediterranean anemiatrait) in the other, results in microdrepanocytic disease in some of the offspring.Hematologic studies in these patients indicate the simultaneous presence of bothsickle cell and microcythemic genes.

5. Genetic studies of these families suggests that the genes for microcythemiaand for sicklemia are located on different chromosomes and are inherited independently of each other. On the other hand, their simultaneous presence leadsto a disease of a moderate degree of severity having many of the features ofsickle cell anemia.

Submitted on May 3, 1951 Accepted on January 23, 1952     

Erythrokinetics: quantitative measurements of red cell production and destruction in normal subjects and patients with anemia

Red cell turnover of 19 normal subjects and 25 anemic patients was measuredwith the following technique: erythroid-myeloid ratio of the marrow, reticulocytecounts, plasma iron turnover, red cell utilization of radioiron, and urobilinogendeterminations. Measurements of blood production and destruction were so expressed as to allow comparison between normal and anemic individuals of different size and different red cell mass. The usefulness and disadvantages of eachprocedure in the study of anemia are discussed.

From studies of various types of anemia, it has become apparent that erythropoiesis must be defined in terms of total quantity of red cells produced and interms of the portion of red cells produced in the marrow which are delivered tothe circulating blood (effective versus ineffective erythropoiesis). A quantitativedefect alone exists when a normal ratio is maintained between effective andtotal erythropoiesis. Here, there are changes of similar magnitude of all erythrokinetic indices, although reticulocyte and urobilinogen values are occasionallydisproportionately high. The normal marrow appears to be able to increase itseffective red cell production to three times normal in acute anemia and six timesnormal in chronic anemia. In many disease states this maximal quantitativeresponse is impaired.

Dyspoiesis of the marrow is characterized by a dissociation of erythrokineticindices. Values which reflect total erythropoiesis (i.e., plasma iron turnover,fecal urobilinogen and erythroid-myeloid ratio of the marrow) are considerablygreater than the reticulocyte level and red cell utilization of radioiron whichrepresent effective erythropoiesis. Such defects may result in the pattern of ahemolytic process or aregenerative anemia, depending on their severity.

Submitted on October 26, 1955 Accepted on December 7, 1955     

Coexistent chronic lymphatic leukemia and polycythemia vera; morphologic and clinical studies with particular reference to unusual iron metabolism

1. A case of coexistenst chronic lymphatic leukemia and polycythemia verais described.

2. The source of the erythrocytosis was not apparent. Erythroid hypoplasiawas seen in the bone marrow, and there was no apparent extramedullary hematopoiesis in specimens of liver or spleen.

3. Plasma iron contenst was inordinately low, and this was confirmed by acorrespondingly high plasma iron-binding capacity. No stainable iron could bedemonstrated in the tissues examined.

4. The curve for plasma iron clearance was best satisfied by two componentsof different negative slopes. The more rapid had a half-time of 0.2 hours andprobably represented removal of iron for erythropoiesis. The slower had a half-time of 10.2 and probably represented extrahematopoietic iron utilization.

5. Erythrocyte radioiron utilization was greater than normal and approximated 100 per cent within nine days. This could have been a manifestation ofdepleted iron stores, accelerated erythropoiesis, or both.

Submitted on February 25, 1953 Accepted on May 28, 1953     

Chronic hemolytic anemia associated with thalassemia and sickling traits

The family history, case history and genealogy of a 6 year old girl sufferingfrom a chronic hemolytic anemia is presented. The disease, resulting from herinheritance of both the gene for sickle trait and that for thalassemia trait, iscompared to a similar case in a 38 year old male reported by Powell, et al.

To date the child has had no clinical evidence of an hemolytic anemia, exceptfor an enlarged spleen. Hematologically, however, all findings indicate the presence of a brisk hemolytic process.

Electrophoretic analysis of the patienst’s hemoglobin reveals a unique patternintermediate between the usual sickle cell trait and sickle anemia patterns.

Submitted on August 20, 1951 Accepted on November 7, 1951     

Paroxysmal nocturnal hemoglobinuria with two new case reports

1. Two patients with paroxysmal nocturnal hemoglobinuria are reported. Thechronicity of the hemolytic process is stressed.

2. Venous blood pH was found to be generally more alkaline during sleep andwe believe that the nocturnal hemolytic process is not due to increased acidityper se.

3. A trial with (1) oral prostigmine bromide for two months, and (2) witin subcutaneous pilocarpine nitrate and pilocarpine hydrochloride showed no evidenceof reduced erythrocyte destruction and the anemia was unaffected.

4. There was no effect with hapten upon in vitro hemolysis.

5. The hemoglobin structure of the erythrocyte in this disease is normal asmeasured by the electrophoretic method.

Submitted on October 17, 1950 Accepted on April 3, 1951