MINI SYNTHESIS PAPER

Almera A. Limpao II

Mindanao State University – Iligan institute of Technology

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Keywords
red cell membrane, erythrocytes, bio-
logical defects, lipids, molecular biol-
ogy
Correspondence
CSM Department of Biology, Minda-
nao State University – Iligan Institute
of Technology, Iligan City, Philippines
9200
almeraii.limpao@g.msuiiit.edu.ph
Tel.: +63 930 4643 090
Summary
In this paper, various scientific journals and articles are synthesized
in order to discuss the pathophysiological mutations that can occur
to certain genes, as well as the underlying connection of these mu-
tations to many red cell membrane disorders, specifically hereditary
spherocytosis (HS) and other similar diseases such as hereditary el-
liptocytosis (HE), hereditary ovalocytosis (SAO), both types of he-
reditary stomatocytosis (HSt), and hereditary pyropoikilocytosis
(HPP).

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The red blood cell, also known as erythrocyte, is
the highly specialized cellular component of
blood that gives it its characteristic red color. Its
primary function is to carry oxygen from the
lungs to all the body tissues, and to carry carbon
dioxide waste to the lungs for exhalation. A ma-
ture red blood cell is round and small, approxi-
mately 7 to 8 micrometers (μm) in diameter. It
also takes the form of biconcave disks, a shape
that provides a large surface-to-volume ratio by
which gas exchange can occur. All red blood
cells are covered with a thin, selectively perme-
able membrane composed of two chemically
complex domains: a lipid bilayer and a protein-
based cytoskeleton (Smith, 1987). The lipid do-
main is composed of phospholipids, specifically
phosphatidylcholine and sphingomyelin in the
outer layer and phosphatidylethanolamine and
phosphatidylserine in the inner layer, with
unesterified cholesterol in the intervening space.
The cholesterol may be equally distributed be-
tween the two halves of the lipid bilayer but, the
other lipids must be asymmetrically distributed.
The membrane skeleton, on the other hand, is a
pseudo hexagonal meshwork made up of actin,
spectrin, pallidin, ankyrin and many other pro-
teins, all of which are responsible for strengthen-
ing the lipid bilayer and maintaining the mem-
brane’s elasticity and stability. This organized
structure of the membrane is what allows it to
account for all of the cell’s antigenic, transport,
and mechanical characteristics, particularly its
flexibility and extreme tolerance to bending,
folding, and distortion during repeated passage
through the narrow capillaries of the microvas-
culature (Samuel, 2016). But despite their appar-
ent complexity in structure, their limited meta-
bolic capability makes them vulnerable to a va-
riety of endogenous and exogenous chemicals
that can cause several unrecognized mutations in
the genes encoding the cell membrane and skel-
etal proteins. Some of the negative consequences
include decreased red cell deformability, re-
duced life span, and premature removal of the
erythrocytes from the circulation. In this paper,
various scientific journals and articles are syn-
thesized in order to discuss the pathophysiologi-
cal mutations that can occur to certain genes, as
well as the underlying connection of these muta-
tions to many red cell membrane disorders, spe-
cifically hereditary spherocytosis (HS) and other
similar diseases such as hereditary elliptocytosis
(HE), hereditary ovalocytosis (SAO), both types
of hereditary stomatocytosis (HSt), and heredi-
tary pyropoikilocytosis (HPP).

Hereditary spherocytosis (HS)
With an estimated prevalence ranging from 1:
2,000 to 1: 3,000, Hereditary spherocytosis or
the Minkowski Chauffard disease is known to be
the most common congenital red cell membrane
disorder in the world (Delaunay et al., 1996). Ac-
cording to many studies, the inheritance exhibits
a dominant autosomal pattern in approximately
75% of the cases, while the remaining are at-
tributed to the recessive forms and de novo mu-
tations. It is often manifested in newborn infants
and clinically characterized by pallor due to var-
iable anemia, jaundice due to hyperbiliru-
binemia, splenomegaly, cholelythiasis, and
phagocytosis of inflexible HS red blood cells. In
fact, Hereditary spherocytosis is actually a heter-
ogeneous disorder brought by either a quantita-
tive or a qualitative defect in the membrane pro-
teins anchoring to the cytoskeletal network of the
red blood cell. The vertical linkage between the
spectrin network and the lipid bilayer of the
cell’s membrane is heavily dependent on differ-
ent linker proteins with associated binding sites,
specifically band 3 and glycophorin C for the cy-
toplasmic domains and ankyrin, protein 4.1, and
spectrin for the cytoskeleton region. As such, de-
ficiencies of these transmembrane proteins can
disrupt the connection between the two layers
and subsequently result to the formation of an
unstable cell membrane. At a molecular level,
blood smear results show a loss of membrane
surface area in red blood cells, thus leading to a
reduced surface to volume ratio, osmotic fragil-
ity, decreased flexibility, increased cell spheric-
ity, and a shortened lifespan of 20 to 30 days
(Gallagher, 2004). The splenic trapping of the
misshapen red blood cells also leads to amplified
membrane injury and earlier ingestion of old
RBCs by the monocyte-macrophage system, ul-
timately resulting to chronic anemia and other
red blood cell disorders. It is important to note
then that most of these cases are due to mutations
in the following genes: ANK1, SPTB, SPTA1,
EPB42 and SLC4A1 which encodes the mem-
brane proteins ankyrin, spectrin beta-chain,
spectrin alpha-chain, protein 4.2, and the anion
exchanger 1 (band 3) respectively (Iolascon, Per-
rotta & Stewart, 2003). These proteins are re-
sponsible for carrying molecules in and out of
cells, keeping cell structure, and maintaining ho-
meostasis, and so, alterations in the gene func-
tion that encodes for these proteins can reduce
and/or negatively affect the structure of the cell
membrane and the interactions that keeps the cell
normal and functioning in the first place. The
most common is the ANK1 mutations that ac-
count for approximately 50 to 60% of HS cases,
while SPTA1 or SPTB accounts for 20%,
SLC4A1 for 15 to 20%, and EPB42 for only less
than 5% (Eber & Lux, 2004; Yawata et al, 2000;
Tanner, 2002).
Hereditary elliptocytosis (HE), ovalocytosis
(SAO), dehydrated hereditary stomatocytosis
(DHst), overhydrated hereditary stomatocyto-
sis (OHS), and pyropoikilocytosis (HPP)
Aside from clinical anemia, all forms of heredi-
tary spherocytosis are associated with polychro-
matophilia, loss of membrane surface area, and
resultant cell shape abnormalities ranging from
spherocytes, elliptocytes, ovalocytes, stomato-
cytes, and pyropoikilocytes. Another relatively
common and genetically heterogeneous red cell
membrane disorder is hereditary elliptocytosis
(HE). Like HS, it is commonly characterized by
a mechanically unstable membrane which
causes the cell shape’s progressive transfor-
mation from the normal discocytes to the irregu-
lar elliptocyte. Specifically, the mechanical in-
stability is largely due to a defect in the vertical
protein connections network including the spec-
trin dimer–dimer interaction and the spectrin–
actin–protein 4.1R junctional complex (Delau-
nay et al., 1996). The genes mutated in HE are
thus the α-spectrin (SPTA1), the β-spectrin
(SPTB) or protein 4.1R genes (Gallagher, 2004).
In severe cases, the large decrease in the surface
area of the membrane can cause extensive red
cell fragmentation. On another note, individuals
that are genetically heterozygous for an HE var-
iant are asymptomatic, while individuals that are
genetically homozygous or compound heterozy-
gous experience a varying range of mild to se-
vere anemia. Hereditary ovalocytosis (SAO), on
the other hand, has a distinguishing feature that
separates it from HS and HE, that is to say their
cell membrane is in fact very rigid and mechan-
ically more stable compared to spherocytes and
elliptocytes. SAO is a result of a mutation in the
SLC4A1 gene that encodes for the band 3 pro-
tein, specifically a deletion of the 27 nucleotides
associated with amino acids 400 to 408 (Mohan-
das et al., 1984). Phenotypically, the deformation
resulted to oval-shaped red cells called ovalo-
cytes with 1 or 2 transverse ridges around the
middle. The inheritance has an observed pattern
of autosomal dominant and only heterozygous
2
individuals have been reported as of to-date. For
hereditary stomatocytosis, defects in the anion
and cation transport across the cell membrane is
at play, which makes it the rarest among all the
other previously mentioned red cell membrane
disorders (Barcellinni et al., 2011). It is catego-
rized into two: dehydrated hereditary stomatocy-
tosis (DHst) and overhydrated hereditary
stomatocytosis (OHS). Both forms of stomato-
cytosis are mainly due to the abnormality in the
cell membrane’s permeability to monovalent
cations Na+ and K+, resulting in an alteration in
the intracellular cation and water volume con-
tent. The distinctive feature of DHst is the loss of
K+ and cell water, which causes the subsequent
increase in hemoglobin concentration and de-
creased osmotic resistance. OHS, in contrast, is
due to a 20 to 40-fold increase in cell hydration
with a resultant increase in volume, a decrease in
hemoglobin concentration, and an increased os-
motic fragility. However, unlike HS, HE, and
SAO, the increased osmotic fragility and insta-
bility is not because of a reduced cell surface
area, but because of the subsequent increase in
cell volume despite having a normal surface area
(Narla, 2017). The inheritance pattern of
stomatocytosis is autosomal dominant and its
clinical phenotype can vary from asymptomatic
to severe hemolytic anemia (Da Costa et al.,
2013). Majority of the patients diagnosed with
the previously mentioned disorders have few he-
matologic abnormalities. Indeed, RBC survival
time is decreased which causes a mild hemoly-
sis, however, the loss is well compensated for by
the bone marrow in the absence of anemia. But
hereditary pyropoikilocytosis (HPP), on the
other hand, is usually characterized by severe he-
molytic anemia at birth. If HE is caused by a de-
fect in the vertical protein and lipid interactions
within the cell’s membrane, HPP is more associ-
ated with the horizontal defects concerning the
head-to-head associations between the spectrin
heterodimers that form spectrin tetramers, and
the irregular interactions between the junctional
complexes of the membrane (Payne, Bell &
Hamby, 1995). The resulting loss in skeletal in-
tegrity causes RBCs to be fragmented and mis-
shapen, the morphology taking the shape similar
to extensive burns or pyropoikilocytes. In HPP,
the cell has two abnormalities: an alpha-spectrin
deficiency that causes defective vertical interac-
tions, and a mutant spectrin that causes abnormal
horizontal interactions (Palek, 1992). Moreover,
unlike the other mutations, HPP defects are all
recessive, which means the patient diagnosed
with HPP must have inherited the mutation from
both parents. The HPP phenotype is also seen in
patients who are homozygous or doubly hetero-
zygous for one or two HE mutations, respec-
tively (McKenzie, 1996).
Conclusion
In conclusion, the effects of defective structural
proteins and irregular cation permeability on the
cell membrane of red blood cells can easily man-
ifest as hereditary RBC disorders. The infor-
mation synthesized calls attention to the various
clinical and laboratory characterization of He-
reditary spherocytosis and many other red cell
membrane defects. Therefore, to ensure correct
diagnosis, it is important to take note of changes
in RBC morphology as accurately as possible.
This discovery is particularly significant in the
subject of molecular biology as it proves to show
how a simple disordered membrane structural
organization can lead to common diseases that
affect the entire human population. Much is yet
to be understood regarding the role of proteins
within the existing framework of understanding
the cell membrane, however, important discov-
eries have already been made which can help the
identification and target treatment of their related
diseases. It seems likely that potentially many
mutations might preclude to other rare and uni-
dentified diseases, which makes the study of all
these underlying and intracellular mechanisms
more important and relevant in the near future.
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