Definisi
Hereditary spherocytosis is a heterogeneous group of diseases affecting the
red blood cells (erythrocytes). Their common features are structural membrane
defects which result in an impairment of erythrocytic deformability. The highly
variable clinical manifestations of the disease depend on the various mutations of
genes encoding membrane proteins, their various functional consequences, and
the respective mode of inheritance.
The disease was first described in the second half of the nineteenth
century. In 1900 Oskar Minkowski published his observations on familial clusters
[1]. Hereditary spherocytosis belongs to the congenital hemolytic anemias, named
after the microscopic aspect of spherocytes in a blood smear.
Prevalensi
HS occurs in all ethnic groups. The highest frequency of 1: 5,000 is found
in Northern European countries. De novo mutations of ankyrin or other membrane
protein genes are a frequent cause of sporadic HS. In about two thirds of patients,
the disease is inherited in a dominant pattern and can be followed from generation
to generation, mostly with the same severity. In the remaining cases, both parents
are normal.
Prevalence in Germany is estimated to amount to approx. 1:2000 - 2500
[2]. Hereditary spherocytosis is by far the most common congenital hemolytic
anemia in persons of northern or central European descent.
Pathophysiological effects
The red blood cell or erythrocyte membrane is a dynamic and fluid
structure with the strength and fl exibility needed to survive 120 days in the
circulation. Its lipid bilayer is composed mainly of phospholipids and cholesterol,
with integral proteins embedded in the lipid bilayer that span the membrane and a
membrane skeleton on the cytoplasmic side (figure 1).1,1316 The polar heads of
the lipid bilayer are turned outward and their apolar fatty-acid chains face one
another and form the inner core. The band-3 complex, is centred by a band-3
tetramer; band 3 can also exist as a dimer. Each band-3 monomer consists of a
large transmembrane segment, with a long, branched polylactosaminoglycan
attached on the non-cytoplasmic side, and a stalk-like cytoplasmic domain that
anchors the ankyrin-1. The ankyrin-1 also binds to the C-terminal region of the -
spectrin chain and to protein 4.2. Glycophorin A exists as a dimer with several
short, sialic-acid-containing glycans attached to it. The Rhesus (Rh) complex
contains the Rh polypeptides, the Rh-associated glycoprotein (arranged as a
heterotetramer), CD47, the Landsteiner-Wiener glycoprotein, and glycophorin B
dimer. CD47 interacts with protein 4.2 and the Rh polypeptides to establish a
contact with ankyrin-1. The Rh complex and the band-3 complex are thought to
form a macrocomplex. In the junctional complex, protein 4.1R interacts with one
end of several spectrin tetramers in the -spectrin N-terminal, in a region
containing actin short fi laments and an array of actin-binding proteinsie,
dematin, tropomyosin, -adducin, and tropomodulin. Outside the junctional
complex, protein 4.1R interacts with transmembrane glycophorin C and p55. The
22 tetramer of spectrin forms a dense network, lining the inner surface of the
lipid bilayer. The -spectrin and -chains are antiparallel with the head-to-head
association of two dimersie, N-terminal region of -spectrin chains with the C-
terminal region of -spectrin chainsat the self-association site to generate
tetramers and higher-order oligomers (figure 1). The membrane and its skeleton
provide the erythrocyte with deformability ie, the ability to undergo substantial
distortion without fragmentation or loss of integrity during microcirculation and
the ability to withstand the shear stress of the arterial circulation.1,13,1719 Two
factors are implicated in the pathophysiological effects of hereditary
spherocytosisan intrinsic red blood cell membrane defect and an intact spleen
that selectively retains, damages, and removes the defective erythrocytes (figure
2).1,20,21
Although the main molecular defects in hereditary spherocytosis are
heterogeneous, one common feature of the erythrocytes in this disorder is
weakened vertical linkages between the membrane skeleton and the lipid bilayer
with its integral proteins (table 1). Vertical linkages include spectrin, ankyrin-1,
band-3, and protein-4.2 interactions; spectrin, protein-4.1R, glycophorin-C, and
p55 interactions; Rh-complex and ankyrin-1 interactions; and other, as yet not
fully defined lipid bilayer-membrane skeleton interactions (figure 1). When these
interactions are compromised, loss of cohesion between bilayer and membrane
skeleton occurs, leading to destabilisation of the lipid bilayer and release of
skeleton-free lipid vesicles.1,22 Two distinct pathways lead to reduced membrane
surface area: (1) defects in spectrin, ankyrin, or protein 4.2 reduce the density of
the membrane skeleton, destabilising the overlying lipid bilayer and releasing
band-3-containing microvesicles; and (2) defects of band 3 lead to its deficiency
and loss of the lipid-stabilising eff ect, which results in the loss of band-3-free
microvesicles from the membrane. Both pathways result in reduced membrane
surface area, a reduction in the ratio of surface area to volume, and the formation
of spherocytes with reduced deformability that are selectively retained and
damaged in the spleen (figure 2).1,2,22
Once trapped in the spleen, the abnormal erythrocytes undergo additional
damage or splenic conditioning shown by further loss of surface area and an
increase in cell density. Low pH, low concentrations of glucose and adenosine
triphosphate, contact of erythrocytes with macrophages, and high local
concentrations of oxidants contribute to conditioning. Some of these conditioned
erythrocytes escape the hostile environment of the spleen, re-enter the systemic
circulation, and are visable as the tail of cells on osmotic fragility tests (figure 2).1
Splenic destruction of abnormal erythrocytes is the main cause of haemolysis in
patients with hereditary spherocytosis.
Analysis of deformability profi les show that splenectomy is more
beneficial for spectrin-deficient or ankyrin-deficient than for band 3-deficient red
blood cells. Splenectomy prevents an early loss of immature cells in both types of
deficiencies but it has an additional beneficial effect on mature spectrin-defi cient
or ankyrin deficient cells, increasing their survival. Spectrin-deficient or ankyrin-
deficient erythrocytes escape opsonisation by releasing band-3-containing
vesicles. Hence, band-3 clusters needed for bivalent binding of low affinity,
naturally occurring IgG antibodies might be retained in band-3-deficient
erythrocytes with an excess of skeletal proteins but are released from spectrin-
deficient or ankyrin-deficient cells in which vesicle budding is facilitated by an
impaired skeleton.23
Cause
The common cause of the various forms of hereditary spherocytosis are
membrane defects. These defects decrease the deformability of the erythrocytes
and accelerate their degradation in the spleen. The genes encoding the membrane
proteins ankyrin, band 3, and spectrin are most frequently affected [3].
Modifications of the genes encoding protein 4.2, the RH complex and cases with
hitherto undefined defects are less frequent [4]. The disease follows an autosomal-
dominant trait in about 70 percent of all persons affected, whereas autosomal-
recessive inheritance prevails in only 15 percent. Other patients acquire the
disease on account of new mutations. Table 1 shows a classification based on
molecular features [3- 6]
Clinical Presentation
Symptoms
The clinical spectrum of hereditary spherocytosis ranges from severe
forms requiring transfusions in early childhood to asymptomatic patients with
incidental diagnosis by laboratory analysis or other indication. Characteristic
features and typical complications are compiled in Table 2 and 3.
Complications
Gallbladder disease
Chronic haemolysis leads to the formation of bilirubinate gallstones, which are the
most common complication of hereditary spherocytosis. Gallstones are noted in at
least 5% of children less than 10 years of age;7 the proportion increases to 40
50% in the second to fi fth decades, with most stones arising between 10 and 30
years of age.88 The co-inheritance of Gilberts syndrome increases the risk of
cholelithiasis by four-fold to fi ve-fold.89 Timely diagnosis and treatment will
help prevent complications of biliarytract disease, including biliary obstruction
with pancreatitis, cholecystitis, and cholangitis. The best method for detection of
gallstones is ultrasonography.88 We recommend an abdominal ultrasound every
third to fifth year in patients with hereditary spherocytosis, every year in those
with both hereditary spherocytosis and Gilberts syndrome, and before
splenectomy. Once the spleen is removed, individuals with hereditary
spherocytosis do not develop pigment stones.90
Klasifikasi
A classification of hereditary spherocytosis based on clinical severity grades is
shown in Table 4 [2, 7-10].
Table 4: Clinical Classification of Hereditary Spherocytosis*
Diagnosis
Diagnostics in Cases of Suspected Hereditary Spherocytosis
Meticulous medical history and physical examination provide the basis of
rational diagnostics. Further diagnostic steps to be taken in adults are shown in
Table 6and 7 and as an algorithm presented in Figure 1.
There is no single test that identifies all forms of hereditary spherocytosis.
For this reason it is recommended to combine two test procedures. A recent study
with 150 patients even achieved a sensitivity of 100 percent by combination of
AGLT and EMA test [12]. An examination of osmotic resistance with hypotonic
salt solutions has a distinctly lower sensitivity than AGLT and EMA test.
Ektacytometry
An exact determination of osmotic fragility (and thus a differentiation
between spherocytosis and macrocytic stomatocytosis) is possible by means of
osmotic-gradient ektacytometry. However, this method is currently available only
in Zurich and in Paris, Hospital Kremlin Bictre.
As the test can only be performed with fresh blood samples taken at the
site of analysis, ektacytometry remains reserved to few exceptional cases in which
the diagnosis cannot be obtained otherwise.
Membrane Analysis
Biochemical analysis by means of gel electrophoresis can be applied as a
quantitative method to prove a decrease in the number of membrane proteins, and
qualitatively to identify the particular proteins affected. Only seldom do these
methods contribute to diagnostics.
Genetic Analysis
Molecular genetic diagnostics identifies the genetic defect specific to the
patient and/or the family [3, 5]. These diagnostics remain reserved to special cases
on account of the numerous target genes showing heterogeneity of possible
mutations and the considerable costs arising therefrom.
All diagnostic methods produce false-positive and/or false-negative
results. As a rule, the diagnosis of patients without a positive family history
should therefore not just rely on one single method only (e.g. only osmotic
resistance, only EMA, only biochemical membrane diagnostics). For screening
purposes at least two different methods should be applied, preferentially the EMA
test and AGLT. The specificity and sensitivity of future diagnostic tests will have
to be compared with these two laboratory procedures.
Differential Diagnosis
Differential diagnostics of adult patients with hyperregenerative, normochromic
anemia and spherocytes can be classified into congenital and acquired disorders:
Congenital
Hereditary elliptocytosis: The findings in basic diagnostics are quite
identical to those belonging to hereditary spherocytosis, however, the osmotic
fragility of the RBC will be mostly increased if the course of the disease is
moderately severe to severe. Crucial is the microscopical analysis of the blood
smear. The same applies to spherocytic elliptocytosis, in which spherocytes are
found next to the elliptocytes.
Hereditary pyropoikilocytosis: The pathophysiological basis is
homozygosity of spectrin anomalies with a positive family history of hereditary
elliptocytosis. Flow cytometry (EMA Test) reveals significantly decreased
binding rate of the dye similar to Herediary Spherocytosis. Crucial is the
morphological examination of blood smears and, contrary to other membrane-
dependent diseases, a pronounced decrease of MCV values below 70fl.
Hereditary defects of the cation permeability of the RBC membrane:
Differential diagnostics are summarized in Table 8 [16].
Acquired
Autoimmune hemolytic anemia, in particular the rare forms with negative
Coombs test
Microangiopathic hemolytic anemia
Hemolyticuremic syndrome
Hypophosphatemia
(Delayed) hemolytic transfusion reaction
Hemolysis of toxic or infectious etiology
Terapi
There is no causal therapy of the genetic defect. The most effective symptomatic
therapy consists in splenectomy. Cholecystectomy is indicated in case of
cholelithiasis [17].
Splenectomy
Splenectomy often contributes to the elimination of anemia and to the
regression of increased hemolysis parameters. However, the alterations discovered
in blood smears will become more distinctive than they had been previously.
Splenectomy is mostly indicated in childhood, but should, if possible, not
performed before school age. Splenectomy also has to be considered in adults
with symptomatic disease. Splenectomy is an option for adults with
extramedullary hematopoiesis. It remains an open question whether
extramedullary hematopoiesis recedes afterwards.
If hemolysis persists after splenectomy the diagnosis will have to be
reconsidered. Accessory spleens must be searched for and, if they exist, they must
be removed. The indication for splenectomy depends on the degree of clinical
severity, see Table 9 [2]
The risk of splenectomy consists in the operation and in the life-long increased
rate of severe infections, particularly due to pneumococci with a mortality of 0.1
0.4 % [2, 18]. The risk is reduced by a partial instead of a complete splenectomy
[19, 20]. Subtotal splenectomy is recommended in patients with hereditary
spherocytosis. A mild anemic condition might persist in patients with a severe
variant of the disease, particularly in case of spectrin defects. Prior to and after
splenectomy recommendations concerning vaccinations and/or antibiotic
prophylaxis must be observed. [21, 22].
SIMPULAN