OMFScienceWednesdays-red blood cell deformability in ME/CFS

[Binkie4]

Low molecular weight heparin ( Fragmin I think) has been given to me for long distance air travel, and during and after hip surgery. I inject myself. It's been given to prevent blood clotting because a thrombophilia screen showed I had factor V Leiden, sticky blood, a genetic disorder. I have no reaction to them other than bruising which was pretty extensive after 6 weeks. This was the only medication offered on the NHS but I've been told a similar inexpensive treatment is available in pill form. I have forgotten the name- rivaroxaban? Or something like that. It would be more convenient if taken in pill form. Getting rid of sharps isn't always easy. I carry them back in my suitcase. @Nickster- I have wondered if it changes the shape of red blood cells too. And also wondered where low blood volume fits in.

I have not read Melissa Kaplan's article before, and had not been aware of a link between factor V and me/cfs. No doctor has pointed it out to me although factor V is becoming better known. Must read it carefully tomorrow. I have Dr Simpsons book and read it a couple of years ago, but his work seemed to have been forgotten until now. The haematologist I talked to about it looked blank. Very glad Prof Davies is onto it.

ETA: my O2 levels tend to be low at 92%, currently being investigated. Could sticky blood have impacted this?

 

[Binkie4]

I have to drink absurd quantities of water to feel normal. I also take potassium and magnesium. Here's some 1988 research on red blood cell deformability: (It basically says hydration is important for deformability, and so is potassium.)

View attachment 26553

I wonder if hydration could play a role in our deformability issues, and this "thick blood" that was mentioned recently by Ron.

Hydration is also a major treatment for POTS.

I recently had some tests under anaesthesia. Dr Bansal recommended I be hydrated with saline prior to anaesthesia to avoid an ME crash. I was utterly fine, no pem, despite 3 days of testing. I wish hydration/saline could also be sorted out for us.

 

[Sushi]

rivaroxaban

That is Xarelto (brand name), a new generation anti-coagulant similar to the one I am taking Eliquis. If this med will work for you, it is available in the UK as I know patients who are taking it.

I also injected low molecular weight heparin after my ISAC panel test.

 

[Binkie4]

That is Xarelto (brand name), a new generation anti-coagulant similar to the one I am taking Eliquis. If this med will work for you, it is available in the UK as I know patients who are taking it.

I also injected low molecular weight heparin after my ISAC panel test.

Do you take Eliquis daily? Is it for a coagulation disorder? I only knew of people taking it if immobilised for shortish periods.

 

[Sushi]

Do you take Eliquis daily? Is it for a coagulation disorder? I only knew of people taking it if immobilised for shortish periods.

Eliqius is a twice daily protocol while Xarelto is once daily I think. I take it because I have Afib which increases the risk of stroke. There are several new anticoagulants used by Afib patients: Pradaxa, Eliquis and Xarelto are the most common. These replace coumadin which requires careful monitoring while the newer ones don't.

 

[Cort]

Hi guys,

On this #OMFScienceWednesday, we present a new project that we are funding that will evaluate the ‘deformability’ of red blood cells as a potential biomarker for ME/CFS. Red blood cells (RBCs) are the most common cells in the blood. Their main role is to transport oxygen and carbon dioxide in the blood, and this role depends in part on their ‘deformability’ / elasticity as they flow through small blood vessels.

Alterations in RBC deformability have been associated with inflammation and diseases like sepsis, and some studies suggest that RBC damage occurs in ME/CFS. These observations along with new technology available for measuring RBC deformability prompted Dr. Ron Davis’ team at Stanford and their collaborators at San Jose State University to examine RBC deformability in ME/CFS.

In some very early data generated by this team, there are indications that RBC deformability is reduced in some ME/CFS patients. The ME/CFS RBCs tested so far seem to move more slowly and elongate less than healthy controls, according to tests with this new technology. We are funding a project to confirm these findings in additional patients, and to study RBCs using additional methods, including various types of advanced microscopy, to better understand why these differences exist.

If these experiments are successful, they may establish a new biomarker for ME/CFS that could assist in diagnosis and possibly finding new treatments! Stay tuned for more.

Learn more about RBCs in this Khan Academy video:

So interested in this research and so glad you're getting positive results. I just feel that something is impeding oxygen delivery to the muscles and this could be part of the picture.....And how interesting that inflammation and sepsis - two problems associated with ME/CFS - are associated with RBC deformability problem!

 

[Ben H]

So interested in this research and so glad you're getting positive results. I just feel that something is impeding oxygen delivery to the muscles and this could be part of the picture.....And how interesting that inflammation and sepsis - two problems associated with ME/CFS - are associated with RBC deformability problem!

I agree Cort-Julia Newton’s studies also suggest this of course. I’m thinking how AMPK comes into it too. Many moving parts.


B

 

[Cort]

My son was put on blood thinners. I wonder how this changes the shape of the blood. Does anyone else take blood thinners?

I heard Dr. Holtorf say at a conference that heparin is his secret weapon (!). I don't know if anyone else uses it. I haven't heard of it.

 

[Cort]

This is super exciting. Blood cells that don't deform properly could be very relevant.

I recently learned that one reason blood vessels relax is because when red blood cells go through tight points in the blood vessels, the red blood cells get squished and bumped, which causes them to release ATP, which acts as a vasodilatory signal.

(Another cause of vasodilation is when vessels are too narrow for the amount of blood going through, the vessels get bumped and pushed by the blood cells. This is called shear stress. In response, they are supposed to relax, which they do by releasing Nitric oxide (NO). You will remember that Fluge and Mella patented an NO supplement for ME/CFS.)

POTS is also related to problems with vasodilation and vasoconstriction, so there's clear evidence a lot of us have problems there.

Vasodilation (blood vessels getting wider) is crucial for getting enough blood (and the oxygen it carries) to muscles which are working. Without sufficient blood flow, you could get tired very quickly, and maybe end up doing anaerobic respiration, causing lactic acid buildup. [hopefully this all sounds like it's fitting together!]

Here's a good except of a paper from 2013

Controlled release of ATP from red blood cells (RBC) in response to mechanical deformation or hemoglobin desaturation is a key physiological process for matching oxygen supply with demand in both pulmonary and systemic tissues[8]. Released ATP binds to endothelial purinergic receptors and initiates signaling events that ultimately lead to increased vasodilator and/or decreased vasoconstrictor activity[9]; the net effect being increased blood flow.

Seminal studies over the last decade have mapped out elements of the signaling pathway in RBC that regulates ATP release and involves Gi-proteins, cAMP activation of PKA and key roles for CFTR and Pannexin proteins[8] and have done much to dispel the notion that RBC are ‘dead’ cellular bags whose sole function is to compartmentalize hemoglobin. Furthermore, dysfunction in this signaling pathway has been demonstrated in diabetic and pulmonary hypertensive patients with the concomitant loss of ATP dependent regulation of blood flow discussed as a possible mechanism underlying vascular complications that characterize these diseases​

Incidentally, it's interesting this mentions purinergic signalling, which is Robert Naviaux's pet theory. However it seems like a specific case, rater than the generic case (sickness behaviour/winter metabolism) that Naviaux is pursuing. Open to hearing if anyone can see a linkage there.

My personal case history suggests to me problems with vasodilation, because the things I can't stand are all things that would normally cause vasodilation - exercise, alcohol, warm weather, mental stress - and especially all of these at once. I also seem to do better with high iron supplementation. So I'm pretty interested in this hypothesis.

Thanks for all that information. I had no idea about the shear stress.

I think its Mayo that is testing intravenous iron supplementation in POTS. Anecdotally they're finding that it can help a lot - even in people with low normal ferritin levels. Apparently we all have our best iron set point which does not necessarily correspond with lab values. I did a blog on an adolescent with POTS who was finally able to exercise after iron infusions; his system reset at that point. (Iron supplementation by itself was not enough.) Hopefully that study will be out soon.

 

[alex3619]

I heard Dr. Holtorf say at a conference that heparin is his secret weapon (!). I don't know if anyone else uses it. I haven't heard of it.

The drug I react badly to, Clexane, is I think a modified form of Heparin. However its my neuropathic type pain that is worsened, its unclear if it has an effect on ME.

 

[Sushi]

I heard Dr. Holtorf say at a conference that heparin is his secret weapon (!). I don't know if anyone else uses it. I haven't heard of it.

Those of us who followed Dr. David Berg's protocol will have used heparin. I injected low molecular weight heparin for many months (my doctor was working with Dr. Berg) and did notice a significant change, but like everything we try, we can't be sure of the cause of the change.

I may be using Lovenox short term soon (another form of heparin). It will be interesting to see if I notice anything from it.

 

[FMMM1]

Repeating what others have said:
Wenzhong Xiao looked at gene expression and found that ME/CFS looks most similar to systemic inflammatory response syndrome [OMF community symposium September 2017]. Ben has pointed out that "Alterations in RBC deformability have been associated with inflammation and diseases like sepsis" (SIRS).

Fluge and Mella found a possible role of abnormal AMPK activation in ME/CFS (Metabolic profiling indicates impaired pyruvate dehydrogenase function in myalgic encephalopathy/chronic fatigue syndrome).
Naviaux proposed a role for ATP/purinergic receptors.
Cort has pointed out that "signaling pathway in RBC that regulates ATP release and involves Gi-proteins, cAMP activation of PKA".

However, as Alex has pointed out, we need to understand the biochemistry. Is there a signalling compound/compounds and if so what?

Also, how do you diagnose individual patients using red blood cells? On the face of you'd need a health (self) control (identical twin) or the differences would need to be very marked.

The general interest in sepsis may help to progress this research area.

From memory, Ron (and Wenzhong?) worked on sepsis; so this looks like a promising mix of experience and an interesting research area.

 

[Murph]

I agree Cort-Julia Newton’s studies also suggest this of course. I’m thinking how AMPK comes into it too. Many moving parts.

B

I found this to be an excellent question. I am very interested in the hypothesis of AMPK dysregulation (which is closely linked to mTor dysregulation.) AMPK is all about energy sensing that helps cells choose which energy sources to use. AMPK does catabolic things (eats up proteins) in response to low ATP. I know the Melbourne Bioanalytics guys are very interested in AMPK.

AMPK has potential linkages to the Naviaux purinergic signalling hypothesis and the Griffith Calcium work. It is also part of the Fluge Mella PDH blockage hypothesis. (The idea the body might be using some energy sources preferentially is very dear to me. As some people might be aware, I've got a lot of benefit from my doctor recommending to me massive amino acid supplementation. )

Now, Fluge and Mella do draw a link from AMPK to blood flow issues, but in their paper it is more about the endothelial cells of the blood vessels than the blood flowing through them:

"AMPK activates the endothelial nitric oxide synthase enzyme (eNOS) (49), and corrupted AMPK signaling may be a mechanism in endothelial dysfunction"

So is there any research on AMPK-red blood cell deformability linkages? I went looking, and I did not find heaps. But what research there is finds a link...

Maintenance of red blood cell integrity by AMP-activated protein kinase alpha1 catalytic subunit.
Foretz M1, Guihard S, Leclerc J, Fauveau V, Couty JP, Andris F, Gaudry M, Andreelli F, Vaulont S, Viollet B.
Author information
Abstract
AMP-activated protein kinase (AMPK) plays a pivotal role in regulating cellular energy metabolism. We previously showed that AMPKalpha1-/- mice develop moderate anemia associated with splenomegaly and high reticulocytosis. Here, we report that splenectomy of AMPKalpha1-/- mice worsened anemia supporting evidence that AMPKalpha1-/- mice developed a compensatory response through extramedullary erythropoiesis in the spleen. Transplantation of bone marrow from AMPKalpha1-/- mice into wild-type recipients recapitulated the hematologic phenotype. Further, AMPKalpha1-/- red blood cells (RBC) showed less deformability in response to shear stress limiting their membrane flexibility. Thus, our results highlight the crucial role of AMPK to preserve RBC integrity.


The AMPKγ1 subunit plays an essential role in erythrocyte membrane elasticity, and its genetic inactivation induces splenomegaly and anemia.
Foretz M1, Hébrard S, Guihard S, Leclerc J, Do Cruzeiro M, Hamard G, Niedergang F, Gaudry M, Viollet B.
Author information
Abstract
AMP-activated protein kinase (AMPK) is an αβγ heterotrimer conserved throughout evolution and important for energy sensing in all eukaryote cells. AMPK controls metabolism and various cellular events in response to both hormones and changes in cellular energy status. The γ subunit senses intracellular energy status through the competitive binding of AMP and ATP. We show here that targeted disruption of the mouse AMPKγ1 gene (Prkag1) causes regenerative hemolytic anemia by increasing the sequestration of abnormal erythrocytes. Prkag1(-/-) mice displayed splenomegaly and iron accumulation due to compensatory splenic erythropoiesis and erythrophagocytosis. Moreover, AMPKγ1-deficient erythrocytes were highly resistant to osmotic hemolysis and poorly deformable in response to increasing shear stress, consistent with greater membrane rigidity. No change in cytoskeletal protein composition was observed; however, the phosphorylation level of adducin, a protein promoting the binding of spectrin to actin, was higher in AMPKγ1-deficient erythrocytes. Together, these results demonstrate that AMPKγ1 subunit is required for the maintenance of erythrocyte membrane elasticity.

--

This is all extremely speculative at this stage but possibly, for anyone interested in top-down grand theory making, you could include rbc deformability problems as a result of AMPK issues?

 

[Binkie4]

"I may be using Lovenox short term soon (another form of heparin). It will be interesting to see if I notice anything from it"

Please can you feed back @Sushi when you try it. I have not heard of heparin being used as a treatment by any UK doctor ( please correct me if I am wrong) but would like to bring this up with my doctor especially since I know I can tolerate heparin.

EDIT: quote marks round Sushi's post

 

[aquariusgirl]

@Cort when did Holtorf say this? Was it recently? As you know back in the day, Dr Brewer was working with David Berg and they used antivirals plus heparin IIRC but then Brewer switched his focus away from viruses to mycotoxins.

Doctors are leery of prescribing Heparin long term I think.....

Berg told me I had a serious fibrin problem. He was right. I have to take a biofilm buster with antibiotics or they don't seem to work.

 

[Sushi]

Please can you feed back @Sushi when you try it.

Will do though it won't be until May.

I have not heard of heparin being used as a treatment by any UK doctor ( please correct me if I am wrong) but would like to bring this up with my doctor especially since I know I can tolerate heparin.

Heparin is an old drug that has been widely used so it is almost certain that it is used in the UK. The question will be, though, what conditions do they approve it for?

 

[Murph]

I think its Mayo that is testing intravenous iron supplementation in POTS. Anecdotally they're finding that it can help a lot - even in people with low normal ferritin levels. Apparently we all have our best iron set point which does not necessarily correspond with lab values. I did a blog on an adolescent with POTS who was finally able to exercise after iron infusions; his system reset at that point. (Iron supplementation by itself was not enough.) Hopefully that study will be out soon.

It would certainly be possible to implicate iron levels in a theory of ME/CFS that centred on AMPK.

Iron deficiency causes a shift in AMP-activated protein kinase (AMPK) subunit composition in rat skeletal muscle
John F Merrill,1 David M Thomson,1 Shalene E Hardman,1 Squire D Hepworth,2 Shelby Willie,1 and Chad R Hancock

2
Author information ► Article notes ► Copyright and License information ► Disclaimer
This article has been cited by other articles in PMC.
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Abstract
Background
As a cellular energy sensor, the 5’AMP-activated protein kinase (AMPK) is activated in response to energy stresses such as hypoxia and muscle contraction. To determine effects of iron deficiency on AMPK activation and signaling, as well as the AMPK subunit composition in skeletal muscle, rats were fed a control (C=50-58 mg/kg Fe) or iron deficient (ID=2-6 mg/kg Fe) diet for 6–8 wks.

Results
Their respective hematocrits were 47.5% ± 1.0 and 16.5% ± 0.6. Iron deficiency resulted in 28.3% greater muscle fatigue (p<0.01) in response to 10 min of stimulation (1 twitch/sec) and was associated with a greater reduction in phosphocreatine (C: Resting 24.1 ± 0.9 μmol/g, Stim 13.1 ± 1.5 μmol/g; ID: Resting 22.7 ± 1.0 μmol/g, Stim 3.2 ± 0.7 μmol/g; p<0.01) and ATP levels (C: Resting 5.89 ± 0.48 μmol/g, Stim 6.03 ± 0.35 μmol/g; ID: Resting 5.51 ± 0.20 μmol/g, Stim 4.19 ± 0.47 μmol/g; p<0.05). AMPK activation increased with stimulation in muscles of C and ID animals. A reduction in Cytochrome c and other iron-dependent mitochondrial proteins was observed in ID animals (p<0.01). The AMPK catalytic subunit (α) was examined because both isoforms are known to play different roles in responding to energy challenges. In ID animals, AMPKα2 subunit protein content was reduced to 71.6% of C (p<0.05), however this did not result in a significant difference in resting AMPKα2 activity. AMPKα1 protein was unchanged, however an overall increase in AMPKα1 activity was observed (C: 0.91 pmol/mg/min; ID: 1.63 pmol/mg/min; p<0.05). Resting phospho Acetyl CoA Carboxylase (pACC) was unchanged. In addition, we observed significant reductions in the β2 and γ3 subunits of AMPK in response to iron deficiency.

Conclusions
This study indicates that chronic iron deficiency causes a shift in the expression of AMPKα, β, and γ subunit composition. Iron deficiency also causes chronic activation of AMPK as well as an increase in AMPKα1 activity in exercised skeletal muscle.

--

Two tiny pieces of anecdata in support of the role of iron: I had a great big multi-year improvement in my health when I stopped being vegetarian; I now eat red meat a lot but still feel much worse if I stop taking iron tablets.

You could also ask if the higher number of women with me/cfs might be due to higher rates of anemia in women. This could allow us to explain me/cfs epidemiology without autoimmunity, if evidence for autoimmunity turned out to be weak.

And also in support of possible AMPK hyperactivation: me/cfs folk seem to have awful trouble putting on muscle. (even accounting for the fact we're stationary!)

 

[alex3619]

Will do though it won't be until May.
Heparin is an old drug that has been widely used so it is almost certain that it is used in the UK. The question will be, though, what conditions do they approve it for?

Anyone immobilised in bed for a long time, such as with a broken leg or back etc., will be on some form of blood thinner. Its also used after surgery for a while, until patients are mobile again. Heparin is only one option though, and I think perhaps not the most widely used, though others are often variants of Heparin. As soon as patients are over the worst of surgery, and are mobile again, blood thinners are stopped. Those with long term blood clot risk for any reason might however stay on blood thinners. Indeed the reason aspirin is often prescribed for heart attack survivors is in part because of its blood thinning action, it helps decrease risk of clots. There is another reason aspirin is prescribed, due to one of the eicosanoid hormones it induces, but I forget the details.

 

[Murph]

and extracellular ATP can activate mast cells.

if red blood cell deformabiity is reduced, wouldn't that reduce ATP loss from them?

 

[CFS_for_19_years]

My son was put on blood thinners. I wonder how this changes the shape of the blood. Does anyone else take blood thinners?

If he's on heparin, it won't change the shape of red blood cells. Heparin exerts its anti-clotting action by inactivating thrombin and activated factor X (Xa).
Mechanism of Action and Pharmacology of Unfractionated Heparin
http://atvb.ahajournals.org/content/21/7/1094

Heparin is a sulfated polysaccharide with a molecular weight range of 3000 to 30 000 Da (mean, 15 000 Da). It produces its major anticoagulant effect by inactivating thrombin and activated factor X (factor Xa) through an antithrombin (AT)-dependent mechanism. Heparin binds to AT through a high-affinity pentasaccharide, which is present on about a third of heparin molecules. For inhibition of thrombin, heparin must bind to both the coagulation enzyme and AT, whereas binding to the enzyme is not required for inhibition of factor Xa. Molecules of heparin with fewer than 18 saccharides lack the chain length to bridge between thrombin and AT and therefore are unable to inhibit thrombin. In contrast, very small heparin fragments containing the pentasaccharide sequence inhibit factor Xa via AT. By inactivating thrombin, heparin not only prevents fibrin formation but also inhibits thrombin-induced activation of platelets and of factors V and VIII.[---]

Clinical Use of Heparin
Heparin is effective for prevention and treatment of venous thrombosis and pulmonary embolism (PE), for prevention of mural thrombosis after myocardial infarction (MI), and for treatment of patients with unstable angina and MI.[...]


Prophylaxis of VTE (venous thromboembolism)

Heparin in a fixed, low dose of 5000 U subcutaneously (SC) every 8 or 12 hours reduces the risk of venous thrombosis and fatal PE by 60% to 70% and is an effective and safe form of prophylaxis in medical and surgical patients at risk of VTE. Although low-dose heparin is also effective in reducing deep-vein thrombosis after hip surgery, it is not as effective as LMWH (low molecular weight heparin) in this setting.

Low-Molecular-Weight Heparins
LMWHs are derived from heparin by chemical or enzymatic depolymerization to yield fragments approximately one third the size of heparin. LMWHs have a mean molecular weight of 4500 to 5000 Da with a distribution of 1000 to 10 000 Da.

All of the anticoagulant, pharmacokinetic, and other biological differences between unfractionated heparin (UFH) and LMWH can be explained by the relatively lower binding properties of LMWH. Compared with UFH, LMWHs have reduced ability to inactivate thrombin because the smaller fragments cannot bind simultaneously to AT and thrombin. In contrast, because bridging between AT and factor Xa is less critical for anti–factor Xa activity, the smaller fragments inactivate factor Xa almost as well as do larger molecules. Because virtually all heparin molecules contain at least 18 saccharide units, UFH has an anti–factor Xa to anti–factor IIa ratio of 1:1. In contrast, commercial LMWHs have anti–factor Xa to anti–factor IIa ratios between 2:1 and 4:1, depending on their molecular size distribution.

Reduced binding to plasma proteins and cells is responsible for the more predictable dose-response relationship of LMWH, longer plasma half-life (compared with UFH), and lower risk of heparin-induced thrombocytopenia and osteopenia. (my note: important).LMWHs are cleared principally by the renal route.[...]

Prevention of Venous Thrombosis
In general surgical patients and in medical patients at high risk of venous thrombosis, low doses of LMWH administered SC once daily are at least as effective and safe as low-dose UFH administered SC 2 or 3 times daily. LMWH has become the anticoagulant of choice for the prevention of venous thrombosis during major orthopedic surgery and in anticoagulant-eligible victims of major trauma. The risk of bleeding with LMWH is small and comparable to that with low-dose UFH.