|
|
 Previous Article | Table of Contents | Next Article 
Blood, 15 August 2000, Vol. 96, No. 4, pp. 1602-1604
BRIEF REPORT
Severe hereditary spherocytosis and distal renal tubular acidosis
associated with the total absence of band 3
Maria Letícia Ribeiro,
Nicole Alloisio,
Helena Almeida,
Clara Gomes,
Pascale Texier,
Carlos Lemos,
Gabriela Mimoso,
Laurette Morlé,
Faïza Bey-Cabet,
René-Charles Rudigoz,
Jean Delaunay, and
Gabriel Tamagnini
From Unidade de Hematologia Molecular, Serviço de
Hematologia, Centro Hospitalar de Coimbra, Coimbra, Portugal;
Laboratoire de Génétique Humaine, CNRS URA 1171, and Centre
de Génétique Moléculaire et Cellulaire, CNRS UMR
5534, Villeurbanne, France; Unidade de Nefrologia, Hospital
Pediátrico de Coimbra, Coimbra, Portugal; Maternidade Bissaya
Barreto, Centro Hospitalar de Coimbra, Coimbra, Portugal; Service de
Biochimie, Hôpital Debrousse, Lyon, France; Service
d'Obstétrique, Hôpital de la Croix-Rousse, Lyon, France.
 |
Abstract |
Absence of band 3, associated with the mutation Coimbra (V488M) in
the homozygous state, caused severe hereditary spherocytosis in a young
child. Although prenatal testing was made available to the parents, it
was declined. Because the fetus stopped moving near term, an emergency
cesarean section was performed and a severely anemic, hydropic female
baby was delivered. She was resuscitated and initially kept alive with
respiratory assistance and hypertransfusion therapy. Cord blood smears
revealed erythroblastosis, poikilocytosis, and red cells with
stalk-like elongations. Band 3 and protein 4.2 were absent; spectrin,
ankyrin, and glycophorin A were significantly reduced. Renal tubular
acidosis was detected by the age of 3 months. Nephrocalcinosis appeared
soon thereafter. After 3 years of follow-up the child is doing
reasonably well on a regimen that includes regular blood transfusions
and daily bicarbonate supplements. The long-term prognosis remains
uncertain given the potential for hematologic and renal complications.
(Blood. 2000;96:1602-1604)
© 2000 by The American Society of Hematology.
| |
Introduction |
Band 3, also known as the red cell anion exchanger
1, is encoded by the EPB3 gene. Band 3 Coimbra (GTG ATG;
V488M) represents a mutation at the beginning of the fourth
transmembrane domain.1 Insertion of the fourth
transmembrane domain is a prerequisite for incorporation of
transmembrane domains 1 through 32 and therefore band 3 Coimbra must represent a membrane insertion defect. In addition, an
N-terminally truncated band 3 isoform exists in renal
tubular intercalar A cells.
In the heterozygous state, band 3 Coimbra causes typical
hereditary spherocytosis (HS) and is associated with partial deficiency of band 3 and of protein 4.2 (the latter is deficient as a secondary phenomenon).1 In addition, certain mutations of the
EPB3 gene are responsible for dominant distal renal tubular
acidosis (DRTA).3-5 In these cases, the amount of
erythrocyte band 3 is normal and hematologic manifestations are absent.
A mutation causing band 3 deficient-HS and partial DRTA,6
or a higher basal urinary pH,7 in the heterozygous state
has been observed.
Severe HS resulting from the absence of band 3 has been observed in a
natural strain of cattle8 and in 2 band 3 null mouse strains engineered through targeted recombination.9,10 In one strain glycophorin A was absent,10,11 and a
susceptibility with respect to thrombotic complications was
noted.12 Severe HS in humans was first reported by Ribeiro
and colleagues.13 We herein provide a full account of a
case of severe HS associated with total absence of band 3, as well as
follow-up over a subsequent 3-year period.
| |
Study design |
Several cousins were found to be heterozygous for band 3 Coimbra, including the patient's mother who has had 3 pregnancies. In
her first pregnancy (1989), the fetus stopped moving near term, and a
stillborn baby with hydrops fetalis was delivered. We have almost no
information on the fetus, but we may reasonably surmise that it was
homozygous for band 3 Coimbra. In her second pregnancy (1994), prenatal
diagnosis, taking advantage of an NlaIII site created by
mutation Coimbra (not shown), concluded that the fetus was homozygous
for the mutation. This led to medical termination of pregnancy after
approval by the Coimbra Maternity Ethical Committee. The placenta had a
normal appearance, but on histologic examination, a deficient formation
of the capillaries and a marked siderosis were observed. The male fetus
had cervical edema and no obvious malformation. Liver and spleen
samples were unsuitable for analysis.
The parents declined prenatal diagnosis in the third pregnancy
(1996). By week 34 of gestation, a pericardial effusion was recorded.
At week 36, there was significant ascites and anasarca, and the fetus
stopped moving. An emergency cesarean section was performed. The
hydropic female newborn had intense pallor, generalized edema,
prominent ascites, and massive hepatosplenomegaly (weight, 2445 g;
Apgar scores, 2, 8, and 9).
Red blood cell indices in cord blood were: red blood cells, 1.07 T/L; hemoglobin, 52 g/L; hematocrit, 15.7%; mean corpuscular volume,
147 fL; mean corpuscular hemoglobin, 49 pg; mean corpuscular hemoglobin
concentration, 31 g/dL; and reticulocytes, 9.57%. Red blood cells
exhibited a wide variety of abnormal morphologies, some presenting with
long spike-like elongations (Figure 1A). Blood transfusion, intensive resuscitation, and assisted respiratory ventilation were immediately initiated after birth. During 6 weeks in
the neonatal intensive care unit, the baby required continuous ventilation, drainage of the ascitic fluid, and exchange transfusion (taking severe hyperbilirubinemia into account). A hypertransfusion regimen was started because pretransfusion hemoglobin levels were rarely above 6.5 g/L. Erythroblasts and nucleated red blood cells with
scant and irregular cytoplasm were present. Iron chelating treatment
was initiated when the serum ferritin concentration reached 800 ng/L
(8-12 hours of intravenous infusion of desferroxiamine ([40 mg/kg]
twice a week).
View larger version (86K):
[in this window]
[in a new window]
| Figure 1.
Peripheral blood smear, red cell membrane proteins, and
glycophorins before transfusion.
(A) Red blood cells with bizarre shapes, spherocytes, and erythroblasts
with cytoplasmic elongations. (B) Coomassie blue staining. (C) Western
blotting of band 3 using a monoclonal antibody (Sigma, St Louis, MO).
(D) Western blotting of protein 4.2 using our own polyclonal antibody.
(E) Silver staining of glycophorins; a: control; b: patient (venous
blood prior to transfusion). (B) In the patient, band 3 and protein 4.2 were missing (denoted by  ); Spectrin  and  chains, ankyrin
were strongly reduced, as was band 6 (*). Unlike the membrane of mice
with targeted inactivation of the band 3 gene,9,10 the
patient's membrane retained negligible amounts (4%) of hemoglobin
(versus 1% in controls); residual hemoglobin would not significantly
alter the quantification of membrane proteins. The amounts of protein
4.1 and actin were found to be rather similar to those of controls. (C)
Band 3 was present and accompanied by known proteolytic fragments (60, 41, and 22 kd) in the control. In the patient, band 3 was totally
missing (). (D) Protein 4.2 was totally missing as well (). (E)
There was a strong reduction of the GPA dimer (**) and a less
pronounced decrease of the GPA monomer (*). The heterodimer GPA/GPB was
nearly undetectable (). No obvious differences were recorded as for
the other glycophorins.
|
|
Hyperchloremic metabolic acidosis was detected by the age of 3 months.
The infant received oral sodium bicarbonate (8 mEq/kg daily) and
subsequently also received monopotassium phosphate. Soon after the
discovery of blood acidosis, ultrasound showed the onset of
nephrocalcinosis. Correcting the acidosis led to the normalization of
calciuria. Nephrocalcinosis subsequently remained stable without
impairment of glomerular filtration.
Psychomotor development was slightly delayed, but there appeared to be
no increased susceptibility to infection, no neurologic abnormality, no
hearing impairment, and no thrombotic tendency. At the age of 3, the
child was doing reasonably well.
Red cells were obtained from umbilical cord and peripheral blood before
the first transfusion. Sodium dodecyl sulfate-polyacrylamide gel
electrophoresis and Western blotting of membrane proteins and DNA
analysis were carried out as described before,1 with minor
modifications. Characterizations of the renal acidosis were based on
standard methodologies.14-16
| |
Results and discussion |
Polymerase chain reaction amplification of DNA from the child's
white blood cells followed by NlaIII digestion demonstrated homozygosity for mutation Coimbra. Band 3 and protein 4.2 were absent.
Spectrin and chains and ankyrin were reduced (by about 43% and
57%, respectively) in comparison to protein 4.1, which was taken as a
reference (Figure 1B-D). Band 6 was strongly diminished (Figure 1B),
and glycophorin A was markedly decreased (Figure 1E). These features
matched those described in 1 band 3 null mouse strain with a number of
small differences.10,11
The urine anion gap was positive, and the value of plasma
K+ was normal to decreased. The lowest urine pH after
furosemide administration was 6.6. The urine/blood
PCO2 gradient was less than 20 mm Hg after
NaHCO3 loading, the fractional excretion of HCO3 at normal plasma HCO3
concentration was 4%, and there was a high Ca++
urinary excretion (urinary Ca++/creatinine ratio 1.2 mmol/mmol). These tests indicated a distal acidification defect (Table
1).
The child would probably have died had not an extensive knowledge of
the family history and of the underlying mutation led to preparation
for intensive care. The prognosis is uncertain, however. The
transfusion demand will remain the same, necessitating the control of
iron overload. Bone marrow transplantation with a compatible donor
would represent the most satisfactory solution. In the meantime, a
partial or total splenectomy is being considered to reduce transfusion
requirements. DRTA has been corrected with oral HCO3
supplementation, but nephrocalcinosis will persist and may cause renal failure.
A similar case of HS with missing band 3 has been
identified.17 No DRTA occurred in this instance because
the frameshift mutation only caused deletion of exon 2 and spared the
renal isoform of band 3. This work shows that intensive treatment may
keep a patient with total band 3 deficiency alive. Nevertheless,
potential hematologic and renal complications can be quite severe.
Thus, medical termination of pregnancy, as was done with the previous gestation, remains an alternative.
| |
Acknowledgments |
We thank the family studied here for their kind
cooperation, the Prenatal Diagnosis Unit of the Maternidade Bissaya
Barreto for assistance during the pregnancy, and Dr M. J. Julião for performing the postmortem examination of the fetus
after the second pregnancy.
| |
Footnotes |
Submitted April 2, 1999; accepted April 18, 2000.
Supported by the Forum Hematológico, the Centre National de la
Recherche Scientifique (URA 1171), the Institut National de la
Santé et de la Recherche Médicale (CRE 930405), the
Université Claude-Bernard Lyon-1', the Association pour la
Recherche sur le Cancer, the Association Française contre les
Myopathies, and the Conseil de la Région Rhône-Alpes.
Presented in part at the 39th Annual Meeting of the American Society of
Hematology, San Diego, December 5-9, 1997, and published by Blood
90:265a, 1997 (suppl, abstract).
The publication costs of this
article were defrayed in part by
page charge payment. Therefore,
and solely to indicate this fact,
this article is hereby marked
"advertisement"
in accordance with 18 U.S.C.
section 1734.
Reprints: M. L. Ribeiro, Unidade de Hematologia
Molecular, Serviço de Hematologia, Hospital Pediátrico,
Centro Hospitalar de Coimbra, 3001 Coimbra Codex, Portugal; e-mail:
leticiar{at}mail.telepac.pt.
| |
References |
1.
Alloisio N, Texier P, Vallier A, et al.
Modulation of clinical expression and band 3 deficiency in hereditary spherocytosis.
Blood
1997;90:414[Abstract/Free Full Text].
2.
Ota K, Sakaguchi M, Hamasaki N, Mihara K.
Assessment of topogenic functions of anticipated transmembrane segments of human band 3.
J Biol Chem.
1998;273:28286[Abstract/Free Full Text].
3.
Bruce LJ, Cope DL, Jones GK, et al.
Familial distal renal tubular acidosis is associated with mutations in the red cell anion exchanger (band 3, AE1) gene.
J Clin Invest.
1997;100:1693[Medline]
[Order article via Infotrieve].
4.
Jarolim P, Shayakul C, Prabakaran D, et al.
Autosomal dominant distal renal tubular acidosis is associated in three families with heterozygosity for the R589H mutation in the AE1 (band 3) Cl/CO3 exchanger.
J Biol Chem.
1998;273:6380[Abstract/Free Full Text].
5.
Karet FE, Gainza FJ, Györy AZ, et al.
Mutations in the chloride-bicarbonate exchanger gene exchanger gene AE1 cause autosomal dominant but not autosomal recessive distal renal tubular acidosis.
Proc Nat Acad Sci U S A.
1998;95:6337[Abstract/Free Full Text].
6.
Rysava R, Tesar V, Jiras M Jr, Brabec V, Jarolim P.
Incomplete distal renal tubular acidosis coinherited with a mutation in the band 3 (AE1) gene.
Nephrol Dial Transplant.
1997;12:1869[Abstract/Free Full Text].
7.
Lima PRM, Gontijo JAR, Lopes de Faria JB, Costa FF, Saad STO.
Band 3 Campinas: a novel splicing mutation in the band 3 gene (AE1) associated with hereditary spherocytosis. Hyperactivity of the Na+/Li+ countertransport and an abnormal renal bicarbonate handling.
Blood.
1997;90:2810[Abstract/Free Full Text].
8.
Inaba M, Yawata A, Koshino I, et al.
Defective anion transport and marked spherocytosis with membrane instability caused by hereditary total deficiency of red cell band 3 in cattle due to a nonsense mutation.
J Clin Invest.
1996;97:1804[Medline]
[Order article via Infotrieve].
9.
Peters LL, Shivdasani RA, Liu SC, et al.
Anion exchanger 1 (band 3) is required to prevent erythrocyte surface loss but not to form the membrane skeleton.
Cell.
1996;86:917[Medline]
[Order article via Infotrieve].
10.
Southgate CD, Chishti AH, Mitchell B, Yi SJ, Palek J.
Targeted disruption of the murine erythroid band 3 gene results in spherocytosis and severe hemolytic anemia despite a normal membrane skeleton.
Nature Genet.
1996;14:227[Medline]
[Order article via Infotrieve].
11.
Hassoun H, Hanada T, Lutchman M, et al.
Complete deficiency of glycophorin A in red blood cells from mice with targeted inactivation of the band 3 (AE1) gene.
Blood.
1998;91:2146[Abstract/Free Full Text].
12.
Hassoun H, Wang Y, Vassiliadis J, et al.
Targeted inactivation of murine band 3 (AE1) gene produces a hypercoagulable state causing widespread thrombosis in vivo.
Blood.
1998;92:1785[Abstract/Free Full Text].
13.
Ribeiro ML, Alloisio N, Almeida H, et al.
Hereditary spherocytosis with total absence of band 3 in a baby with mutation Coimbra (V488M) in the homozygous state (abstract).
Blood.
1997;90(suppl):265a.
14.
Rodriguez-Soriano J, Vallo A.
Renal tubular acidosis.
Pediatr Nephrol.
1990;4:268[Medline]
[Order article via Infotrieve].
15.
Dalton RN, Haycock GB.
Laboratory investigation. In:
Holliday MA,Barrat TM,Avner ED, eds.
Pediatric Nephrology. Baltimore: Williams & Wilkins; 1994:397.
16.
Rodriguez-Soriano J, Vallo A.
Renal tubular hyperkaliaemia in childhood.
Pediatr Nephrol.
1988;2:498[Medline]
[Order article via Infotrieve].
17.
Perrotta S.
Nigro V, Iolascon A, et al. Dominant hereditary spherocytosis due to band 3 Neapolis produces a life-threatening anemia at the homozygous state (abstract).
Blood.
1998;92(suppl):9a.
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
A. M. Toye, R. C. Williamson, M. Khanfar, B. Bader-Meunier, T. Cynober, M. Thibault, G. Tchernia, M. Dechaux, J. Delaunay, and L. J. Bruce
Band 3 Courcouronnes (Ser667Phe): a trafficking mutant differentially rescued by wild-type band 3 and glycophorin A
Blood,
June 1, 2008;
111(11):
5380 - 5389.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. A. Stehberger, B. E. Shmukler, A. K. Stuart-Tilley, L. L. Peters, S. L. Alper, and C. A. Wagner
Distal Renal Tubular Acidosis in Mice Lacking the AE1 (Band3) Cl-/HCO3- Exchanger (slc4a1)
J. Am. Soc. Nephrol.,
May 1, 2007;
18(5):
1408 - 1418.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Delaunay, A. Toye, R. Williamson, M. Khanfar, B. Bader-Meunier, T. Cynober, M. Thibault, G. J. Tchernia, M. Dechaux, and L. Bruce
Band 3 Courcouronne: Homozygous Mutation Ser667Phe Causes Severe Hereditary Spherocytosis and Incomplete Distal Renal Tubular Acidosis.
Blood (ASH Annual Meeting Abstracts),
November 16, 2006;
108(11):
1563 - 1563.
[Abstract]
[PDF]
|
|
|
|
|
|
|
A. Pushkin and I. Kurtz
SLC4 base (HCO3-, CO32-) transporters: classification, function, structure, genetic diseases, and knockout models
Am J Physiol Renal Physiol,
March 1, 2006;
290(3):
F580 - F599.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. L Alper
Molecular physiology of SLC4 anion exchangers
Exp Physiol,
January 1, 2006;
91(1):
153 - 161.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Perrotta, A. Borriello, A. Scaloni, L. De Franceschi, A. M. Brunati, F. Turrini, V. Nigro, E. Miraglia del Giudice, B. Nobili, M. L. Conte, et al.
The N-terminal 11 amino acids of human erythrocyte band 3 are critical for aldolase binding and protein phosphorylation: implications for band 3 function
Blood,
December 15, 2005;
106(13):
4359 - 4366.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. M. Toye, S. Ghosh, M. T. Young, G. K. Jones, R. B. Sessions, M. Ramauge, P. Leclerc, J. Basu, J. Delaunay, and M. J. A. Tanner
Protein-4.2 association with band 3 (AE1, SLCA4) in Xenopus oocytes: effects of three natural protein-4.2 mutations associated with hemolytic anemia
Blood,
May 15, 2005;
105(10):
4088 - 4095.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
N. Rungroj, M. A. J. Devonald, A. W. Cuthbert, F. Reimann, V. Akkarapatumwong, P.-t. Yenchitsomanus, W. M. Bennett, and F. E. Karet
A Novel Missense Mutation in AE1 Causing Autosomal Dominant Distal Renal Tubular Acidosis Retains Normal Transport Function but Is Mistargeted in Polarized Epithelial Cells
J. Biol. Chem.,
April 2, 2004;
279(14):
13833 - 13838.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. N. Dahl, R. Parthasarathy, C. M. Westhoff, D. M. Layton, and D. E. Discher
Protein 4.2 is critical to CD47-membrane skeleton attachment in human red cells
Blood,
February 1, 2004;
103(3):
1131 - 1136.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. J. Bruce, R.-j. Pan, D. L. Cope, M. Uchikawa, R. B. Gunn, R. J. Cherry, and M. J. A. Tanner
Altered Structure and Anion Transport Properties of Band 3 (AE1, SLC4A1) in Human Red Cells Lacking Glycophorin A
J. Biol. Chem.,
January 23, 2004;
279(4):
2414 - 2420.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Perrotta, L. Luzzatto, M. Carella, and A. Iolascon
Congenital dyserythropoietic anemia type II in human patients is not due to mutations in the erythroid anion exchanger 1
Blood,
October 1, 2003;
102(7):
2704 - 2705.
[Full Text]
[PDF]
|
|
|
|
|
|
|
V. Nicolas, C. Le Van Kim, P. Gane, C. Birkenmeier, J.-P. Cartron, Y. Colin, and I. Mouro-Chanteloup
Rh-RhAG/Ankyrin-R, a New Interaction Site between the Membrane Bilayer and the Red Cell Skeleton, Is Impaired by Rhnull-associated Mutation
J. Biol. Chem.,
July 3, 2003;
278(28):
25526 - 25533.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. J. Bruce, R. Beckmann, M. L. Ribeiro, L. L. Peters, J. A. Chasis, J. Delaunay, N. Mohandas, D. J. Anstee, and M. J.A. Tanner
A band 3-based macrocomplex of integral and peripheral proteins in the RBC membrane
Blood,
May 15, 2003;
101(10):
4180 - 4188.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. J. Bruce, S. Ghosh, M. J. King, D. M. Layton, W. J. Mawby, G. W. Stewart, P.-A. Oldenborg, J. Delaunay, and M. J. A. Tanner
Absence of CD47 in protein 4.2-deficient hereditary spherocytosis in man: an interaction between the Rh complex and the band 3 complex
Blood,
August 13, 2002;
100(5):
1878 - 1885.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. Garratty, M. J. Telen, and L. D. Petz
Red Cell Antigens as Functional Molecules and Obstacles to Transfusion
Hematology,
January 1, 2002;
2002(1):
445 - 462.
[Abstract]
[Full Text]
|
|
|
|
Top
Abstract
Introduction
