Polycythaemia following splenectomy in myelofibrosis with myeloid metaplasia. A reorganization of erythropoiesis

3 patients with myelofibrosis with myeloid metaplasia were splenectomized because of anaemia and disturbing splenomegaly. In the course of the 6 months following splenectomy, a polycythaemia developed. Erythrokinetic studies demonstrated that in all cases a reduction in plasma volume and an increase in red cell volume was obtained. Total erythropoiesis decreased along with normalization of ineffective erythropoiesis and peripheral haemolysis. The reappearance of an erythropoietic activity measured over the sacrum was a constant finding, while in 1 patient, a depression of activity over the liver was observed. The new distribution and organization of erythropoiesis in the splenectomized patients is hypothesized as being due to the removal of the influence of an enlarged spleen on erythropoietic organs.     

Erythrokinetic Studies in Hairy-Cell Leukaemia

Erythrokinetics were studied in 29 patients with hairy-cell leukaemia. In all cases there was an increase in plasma volume, closely correlated to the size of the spleen, indicating that the true degree of anaemia can only be appreciated by red cell volume measurement. Moderately increased haemolysis was observed in most cases, which did not correlate with the spleen size. Simultaneous study of autologous and isologous red cell life-span suggested an extra-corpuscular mechanism for the haemolysis in most patients. A quantitative erythropoietic defect, either relative or absolute, was found in half the cases, without any qualitative defect. Only one case showed erythroid metaplasia of the spleen. Thus marrow failure appears to be largely responsible for the anaemia and granulocytopenia in hairy-cell leukaemia. A clear correlation was shown between the short-term prognosis after splenectomy and the degree of hypersplenism. However, long-term survival correlated chiefly with the degree of bone marrow failure, whether splenectomy had been carried out or not. The results indicate that isotope studies in hairy-cell leukaemia are useful both in determining the best form of treatment and predicting survival.     

Classification of anaemia on the basis of ferrokinetic parameters

Quantitative information on abnormalities of erythropoiesis and mechanisms of anaemia has been obtained in 136 anaemic patients by means of ferrokinetic studies. To derive a functional classification of anaemia based on ferrokinetic parameters, agglomerative hierarchical cluster analysis and principal coordinate analysis were utilized as techniques for unsupervised classification. Two main clusters were found and named anaemia with low potential erythropoiesis and with high potential erythropoiesis, since the most discriminant parameter between them was total erythroid iron turnover, a measure of total erythropoietic activity. A value of total erythropoiesis equal to 4 times the normal was found to discriminate these two types of anaemia in 94% of cases. Within the group with low potential erythropoiesis, three clusters showing different qualitative disturbances of erythropoiesis were singled out. Among patients with high potential erythropoiesis, two clusters were found. A value of effective erythropoiesis equal to 2.5 times the normal was shown to have a high discriminant power between these clusters. This threshold level distinguished between patients having ineffective erythropoiesis or peripheral haemolysis as the major mechanism of anaemia. The present functional classification of anaemia provides a complete picture of the different pathogenetic mechanisms and may represent the basis for a more rational diagnostic approach to erythroid disorders.     

Haematological Effects of the Idiopathic Splenomegaly Seen in Uganda

The haematological effects of idiopathic splenomegaly have been studied in a group of 15 Ugandan patients. The results of the main investigations were compared with those obtained in five patients with miscellaneous diseases and without palpable splenomegaly.
The splenic enlargement was mainly due to reticuloendothelial hyperplasia and not to sinusoidal congestion.
A normochromic anaemia was present in almost all the patients and a proportion had leucopenia and thrombocytopenia. One patient presented with a crisis of anaemia; she was later shown to have red cell G6PD deficiency which was believed to be coincidental.
Three aetiological factors were found in relation to the anaemia; reduction of red cell survival time, present in all the patients, haemodilution from expansion of the plasma volume, and the exclusion of a proportion of the red cell mass from the general circulation by the spleen. Six to 39 per cent of the red cell volume, the amount varying with spleen size, was sequestered in a slow mixing compartment, believed to be the extrasinusoidal spaces (the spleen pool) in the patients with splenomegaly. No spleen pool could be shown in any of the patients without splenomegaly.
Intrasplenic red cell destruction was not conspicuous and it has been suggested that the red cells, after damage from repeated stagnation in the spleen pool, are destroyed widely throughout the body.
The reasons for expansion of the plasma volume is not known. It relates to spleen size but cannot wholly be explained by plasma in the spleen pool.
A good result from splenectomy was obtained in six out of seven patients in whom this was undertaken. Two months after operation the red cell survival time was corrected in the patients in whom this was measured. The rise in the PCV could be explained only by substantial reduction in plasma volume.     

Effects of splenectomy on liver volume and prognosis of cirrhosis in patients with esophageal varices

BACKGROUND: Several previous studies have shown that hepatic regeneration after partial hepatic resection accelerates over time once a splenectomy has been performed. This was a retrospective study investigating whether a splenectomy has some beneficial effects for cirrhotic patients with esophageal varices. METHODS: Ninety-three patients underwent either esophageal transection, including splenectomy (splenectomy group), or endoscopic injection sclerotherapy (controls) for esophageal varices. No patient had hepatocellular carcinoma and the grades of their hepatic function were from mild to moderate. The changes in hepatic and splenic functions and liver volume were evaluated, as well as the probability of survival. RESULTS AND CONCLUSIONS: Both plasma white blood cell and platelet counts significantly increased in the splenectomy group compared to the controls (P < 0.05). The proportion of liver volume 1 year after the treatments compared to the volume before the treatments (which was 100%) was 96.4% in splenectomy group and 94.4% in controls. No patient had serious complications, such as severe infection caused by the splenectomy. The two groups showed no statistically significant differences in survival rates throughout this study. Although hypersplenism significantly was improved by splenectomy, no difference in changes in liver volume nor survival probability between the two groups was found. Further studies, such as those with a large number of patients, long-term volumetric analysis, or histopathological examination, are needed to clarify fully the effects of splenectomy on cirrhotic patients.     

The Assessment of Red Cell Survival in Normal Subjects and in Patients with Haemoly tic Disorders and Ineffective Erythropoiesis using the Radioiron Occupancy Method

A direct method for measuring red cell lifespan in vivo using the radioiron occupancy method (Dagg et al, 1972) has been applied to eight normal subjects. The mean red cell lifespan was 116 d with a range of 104-124 d. To establish the method clinically in the presence of haemolysis and ineffective erythropoiesis, 22 patients with haemolytic disease and six patients with megaloblastic and sideroblastic anaemia were studied. All 22 patients with haemolytic anaemia had shortening of the red cell lifespan, with a range from 62 to 10 d; the results were compared with red cell lifespan derived from simultaneous radiochromium studies (Bentley et al, 1974). A close agreement between the two methods was obtained (r = 0.87; P less than 0.001). To assess the validity of the method in the presence of ineffective erythropoiesis, double isotope studies were also carried out in three patients with megaloblastic anaemia and three with sideroblastic anaemia. Close agreement was again obtained between lifespan measurements obtained from radioiron occupancy data and those derived from radiochromium studies, suggesting that the presence of significant ineffective erythropoiesis does not invalidate the method. The theoretical considerations involved in the application of the radioiron occupancy method to haemolytic states are discussed.     

Risks and benefits of splenectomy versus no splenectomy for hereditary spherocytosis – a personal view

Splenectomy is indicated in hereditary spherocytosis to relieve symptoms due to anaemia or splenomegaly, reverse growth failure or skeletal changes due to over-robust erythropoiesis, and prevent recurrent gallstones. A life-long risk of bacterial infection has been recognised for many years as a concomitant cost of splenectomy. The scope of this risk has expanded to include a number of organisms beyond the triad of pneumococcus, meningococcus, and haemophilus influenzae. Recently, it has been demonstrated that splenectomy also confers a significant risk of delayed adverse vascular events in patients with hereditary spherocytosis, just as it does in patients undergoing splenectomy for other indications. Further, these same studies demonstrated a benefit of avoiding splenectomy: hereditary spherocytosis patients with a spleen have significantly fewer adverse vascular events than unaffected family members, probably because of the protective effect of chronic, mild anaemia. Accordingly, this review marshals the evidence favouring a conservative approach to splenectomy in spherocytosis.     

Evidence of parvovirus B19 infection in patients of pre-eclampsia and eclampsia with dyserythropoietic anaemia

Parvovirus B19 (PVB19) infection can induce transient anaemia in patients with increased erythropoiesis. However, the dynamic change within the bone marrow after PVB19 infection is not well understood. Increased erythropoiesis is a physiological phenomenon in puerperital women. Nevertheless, anaemia as a result of PVB19 infection in puerperital women has never been reported. We report one patient with eclampsia and two patients with pre-eclampsia who had transient, severe anaemia during the puerperital period because of PVB19 infection. Viral genomes were detected in the peripheral blood during the anaemic period by polymerase chain reaction and became undetectable after the anaemia was resolved. Viral genomes and protein could also be detected in bone marrow by in situ hybridization and immunohistochemical staining, respectively. Serial aspiration cytology of bone marrow showed severe dysplastic change involving erythroid precursors with a few apoptotic cells at the initial onset of anaemia, markedly increased apoptotic cells that was confirmed by the increased expression of activated caspase 3, around the nadir of anaemia, and a normal marrow picture without features of apoptosis after recovery from anaemia. Our data indicates that PVB19 infection can induce transient, severe dyserythropoietic anaemia in puerperital women with pre-eclampsia/eclampsia and the pathogenetic mechanism may probably involve the induction of apoptosis following PVB19 infection.     

In-vitro studies of ineffective erythropoiesis in rheumatoid arthritis

Ineffective erythropoiesis was assessed in a series of 32 patients with rheumatoid arthritis by means of a new in-vitro method which measures the release of haem from a labelled cohort of erythroblasts in culture. Haem release was significantly increased in patients with the anaemia of chronic disorders but was normal in those who were not anaemic or who had an iron-deficiency anaemia. In 2 patients with anaemia of chronic disorders haem release returned to normal after successful antirheumatic therapy. The increased ineffective erythropoiesis in patients with rheumatoid arthritis and anaemia of chronic disorders appeared to be unrelated to functional iron deficiency and was not attributable to a serum factor.     

Blood Volume Changes in Splenomegaly

S ummary . Blood volume changes have been measured in 65 patients with splenomegaly due to a miscellany of causes. The red-cell mass is often normal despite the fact that anaemia is present, and the anaemia is in part due to sequestration of red cells in a splenic pool and haemodilution of the red cells in an expanded plasma volume. Both factors may be relieved by splenectomy although the ultimate prognosis is dependent on the primary disease present.     

Regulation of erythropoiesis during rapid growth

High levels of plasma erythropoiesis stimulating factor(s) (ESF) have been found in neonatal WLO-mice during the period of rapid growth. If the high ESF activity is due to the concomitant physiological anaemia of infancy alone, it should be possible to block erythropoiesis by hypertransfusion. Mice were hypertransfused starting on day 14, and killed on day 20. Although hypertransfusion reduced the ESF levels by approximately 55% (P less than 0.001), ESF levels were still detectable in the cell culture assay used (P less than 0.001). Moreover, hypertransfused mice showed active erythropoiesis in the bone marrow, and none had a reticulocyte count below 2%. No correlation was found between PCV and ESF in the hypertransfused animals (r = 0.07, P greater than 0.5), nor was there any difference in weight gain between control and hypertransfused mice (P greater than 0.5). These results show that hypertransfusion did not totally supress erythropoiesis in neonatal WLO-mice, which is different from hypertransfused adult mice. The data indicate that the high plasma ESF found in neonatal WLO-mice during the growth period are not due to the anaemia alone. These findings support studies indicating that regulation of erythropoiesis in the neonate differs from the adult. Factors related to growth per se could be responsible for this difference.     

Recent insights into the pathogenesis of Diamond-Blackfan anaemia

Diamond-Blackfan anaemia (DBA) is a congenital anaemia and broad developmental disease that develops soon after birth. The anaemia is due to failure of erythropoiesis, with normal platelet and myeloid lineages, and it can be managed with steroids, blood transfusions, or stem cell transplantation. Normal erythropoiesis after transplantation shows that the defect is intrinsic to an erythroid precursor. DBA is inherited in about 10-20% of cases, and genetic studies have identified mutations in a ribosomal protein gene, RPS19, in 25% of cases; there is evidence for involvement of at least two other genes. In yeast, RPS19 deletion leads to a block in ribosomal RNA biogenesis. The critical question is how mutations in RPS19 lead to the failure of proliferation and differentiation of erythroid progenitors. While this question has not yet been answered, understanding the biology of DBA may provide insight not only into the defect in erythropoisis, but also into the other developmental abnormalities that are present in about 40% of patients, and into the cancer predisposition that is inherent to DBA.     

Measurement of Erythropoiesis using 52Fe

S ummary A method for determining erythropoiesis quantitatively with ⁵²Fe has been applied to 25 patients with anaemia. The data were derived from quantitative scanning of the erythropoietic areas and the measurement of the plasma iron turnover. We have assessed this ⁵²Fe measurement of erythropoiesis by comparing it with total marrow iron turnover studies. Both methods give similar estimates of erythropoiesis except in patients with severe ineffective erythropoiesis and in a patient with significant peripheral haemolysis, when erythropoiesis as measured with the ⁵²Fe technique gave higher results. In these conditions, the estimate of total erythropoiesis might be more reliable using the ⁵²Fe quantitative scanning technique. However, the measurement of erythropoiesis with ⁵²Fe does not distinguish effective from ineffective erythropoiesis and cannot be applied to patients with extramedullary erythropoiesis.     

Thrombotic thrombocytopenic purpura unresponsive to plasma infusion and plasma exchange, but responsive to splenectomy

A 60-yr-old female presented with typical thrombotic thrombocytopenic purpura (TTP). She remained in coma with frequent seizures for 1 wk, with persisting severe thrombocytopenia and microangiopathic haemolytic anaemia, despite treatment with prednisolone, plasma exchange, fresh frozen plasma, sulphinpyrazone and dipyridamole. Splenectomy induced haematological improvement within 1 d, there was cessation of fitting after 2 d, and full neurological recovery ensued over 3 wk. Laboratory studies did not reveal the presence of a platelet-aggregating factor (PAF), stated to be present in some two-thirds of cases. While plasma exchange and plasma infusion are beneficial in many cases, splenectomy appears still to be of value in unresponsive disease.     

Quantitation of Ineffective Erythropoiesis from the Incorporation of [15N]Delta-aminolaevulinic Acid and [15N]Glycine into Early Labelled Bilirubin: II. ANAEMIC PATIENTS

SUMMARY The incorporation of [¹⁵N]δ-aminolaevulinic acid and [¹⁵N]glycine into haemoglobin haem and early labelled bilirubin was measured in subjects with various haematological disorders. The clearance of [¹⁴C] bilirubin was used to measure bilirubin production rate, and the magnitude of the various sources of bilirubin production and the percentage ineffective erythropoiesis were calculated. Ineffective erythropoiesis was found to be a major factor in the production of the anaemia in patients with the following disorders: megaloblastic anaemia associated with the Lesch-Nyhan syndrome, thalassaemia intermedia, sideroblastic anaemia, and the anaemia of chronic disorders. In three patients with iron-deficiency anaemia ineffective erythropoiesis was increased, but was of minor importance in the production of the anaemia, while in two patients with aplastic anaemia and one with macrocytosis of alcoholism there was no increase in ineffective erythropoiesis.     

Ferrokinetic and erythrokinetic studies in alpha and beta thalassaemia

Ferrokinetic and erythrokinetic studies were performed in 25 non-splenectomized patients with alpha or beta thalassaemia. Nine of these had HbH disease and six had HbE/beta thalassaemia or homozygous beta thalassaemia. In HbH disease, a mild anaemia was associated with severe peripheral haemolysis, increased splenic sequestration and only a moderate degree of ineffective erythropoiesis. By contrast, in the beta thalassaemia syndromes, a more marked anaemia was associated with prominent ineffective erythropoiesis and mild peripheral haemolysis. These findings indicate that the pathogenesis of anaemia in alpha and beta thalassaemia is different, haemolysis dominating in HbH disease and ineffective erythropoiesis in HbE/beta thalassaemia and homozygous beta thalassaemia.     

Optimal management of β thalassaemia intermedia

Our understanding of the molecular and pathophysiological mechanisms underlying the disease process in patients with β thalassaemia intermedia (TI) has substantially increased over the past decade. The hallmark of disease process in patients with TI includes ineffective erythropoiesis, chronic haemolytic anaemia, and iron overload. There are a number of options currently available for managing patients with TI including splenectomy, transfusion therapy, iron chelation therapy, modulation of fetal haemoglobin production, and several other agents targeting specific clinical complications. Limited studies assessed the efficacy and safety of these modalities; hence, there are currently no clear guidelines for managing patients with TI. Until solid evidence-based guidelines are available, individualised treatment should be entertained.     

Cold haemagglutinin disease with severe anaemia, reticulocytopenia and erythroid bone marrow

A quantitative assessment of total, effective and ineffective erythropoiesis, and mean red cell life-span was performed in 2 patients with idiopathic cold-haemagglutinin disease (CHAD) who had severe anaemia, reticulocytopenia and erythroid bone marrow. In both cases, ineffective erythropoiesis represented the major factor in the pathogenesis of the anaemia. The most likely explanation of this was that cold antibodies had some effect on the maturing red-cell precursors. Ineffective erythropoiesis has already been shown in patients affected by auto-immune haemolytic anaemia due to warm antibodies with reticulocytopenia and erythroid bone marrow. Therefore, it is apparent that both warm and cold antibodies may cause not only peripheral destruction of mature red cells but also intramedullary death of red-cell precursors.     

A haemolytic syndrome associated with the complete absence of red cell membrane protein 4.2 in two Tunisian siblings

We report on the complete absence of protein 4.2 in two Tunisian siblings. The propositus presented with a haemolytic anaemia that evolved in an intermittent fashion until she was cured by splenectomy. Her red cells had a normal morphology, as well as normal deformability upon osmotic gradient ektacytometry. SDS-polyacrylamide gel electrophoresis failed to reveal any protein 4.2. Using anti-protein 4.2 polyclonal antibodies. Western blots were also unable to detect protein 4.2. Preparation of inside out vesicles resulted in no detectable loss of ankyrin. The propositus's sister presented with a haemolytic anaemia but had not undergone splenectomy; she showed the same biochemical features. The two cases presented of missing protein 4.2 are the first ones to be described outside the Japanese population. Considered as homozygotes for some defect that must alter the protein 4.2 gene itself, they exemplify a unique syndrome pertaining neither to elliptocytosis nor to spherocytosis, at least not closely. The parents, who are first cousins and whom we regarded as heterozygotes, were clinically and morphologically normal; they had a normal content of protein 4.2. Therefore, the 4.2 (-) haemolytic anaemia appears as entirely recessive.     

Studies of Ineffective Erythropoiesis and Peripheral Haemolysis in Congenital Dyserythropoietic Anaemia Type II

Erythrokinetic parameters were estimated in six patients suffering from congenital dyserythropoietic anaemia type II (CDA II) by means of a mathematical model of iron kinetics. A wide variation in effectiveness of erythroid activity was observed, and a significant negative correlation was found between ineffective erythropoiesis and peripheral haemolysis. In four patients with prominent peripheral haemolysis, splenectomy was carried out. Marked improvement in their clinical condition and in haemoglobin level resulted.