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Red Blood Cell Rheology in Sepsis K

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Red Blood Cell Rheology in Sepsis K M. Piagnerelli Red blood cell rheology in sepsis K. Zouaoui Boudjeltia M. Vanhaeverbeek J.-L. Vincent Abstract Changes in red blood cell membrane components such as sialic (RBC) function can contribute to acid, and an increase in others such alterations in microcirculatory blood as 2,3 diphosphoglycerate. Other flow and cellular dysoxia in sepsis. factors include interactions with Decreases in RBC and neutrophil white blood cells and their products deformability impair the passage of (reactive oxygen species), or the these cells through the microcircula- effects of temperature variations. tion. While the role of leukocytes Understanding the mechanisms of has been the focus of many studies altered RBC rheology in sepsis, and in sepsis, the role of erythrocyte the effects on blood flow and oxygen rheological alterations in this syn- transport, may lead to improved drome has only recently been inves- patient management and reductions tigated. RBC rheology can be influ- in morbidity and mortality. enced by many factors, including alterations in intracellular calcium Keywords Erythrocyte · and adenosine triphosphate (ATP) Deformability · Nitric oxide · concentrations, the effects of nitric Sialic acid · Multiple organ failure · oxide, a decrease in some RBC Oxygen transport Introduction ogy of microcirculatory alterations and, perhaps, the treatment of sepsis. Severe sepsis and septic shock are the commonest causes This review evaluates alterations occurring in RBC of death in intensive care units (ICUs), with associated rheology during sepsis and possible underlying mecha- mortality rates of 30–50% [1]. Sepsis is a complex nisms. The potential implications of blood transfusion pathophysiological process that involves both alterations and erythropoietin administration in sepsis will not be in the microcirculation and changes in the biochemical discussed. and physiological characteristics of the blood constitu- ents. Microvascular damage plays a crucial role in the Major determinants of RBC rheology impairment of tissue oxygenation that can contribute to multiple organ failure and death [2]. Viscosity Microcirculatory alterations include slowing of capil- lary blood flow as a result of decreased perfusion pres- Haemorheology is the study of deformation and flow of sure and local arteriolar constriction [2, 3], viscosity al- blood and blood cells. The prime function of blood is terations [4, 5], and disturbances of red (RBC) and white transport by flow, and the most important rheological (WBC) blood cell rheology [6, 7]. property of blood is its resistance to flow, or viscosity. Some recent studies [8, 9, 10] have also defined the The definition of viscosity is explained in Fig. 1. Plasma RBC as a possible oxygen sensor and regulator of vascu- viscosity is about 1.6 times that of water (normal range lar tone, opening new perspectives into the pathophysiol- 1.15–1.35 mPa/s). Blood is a non-Newtonian fluid and 1053 230 viscometers. Serum viscosity (i.e., plasma viscosity less the effect of fibrinogen) and whole blood viscosity can be measured. Aggregation At low shear rates, blood evolves from a low viscosity emulsion to a high viscosity suspension. The electrostat- ic repulsion of RBC is overcome by the presence of mac- romolecules which aggregate the cells. In inflammatory states, acute phase proteins (especially fibrinogen and large serum proteins such as a2 macroglobulin) increase RBC aggregation. Rouleaux of cells bind together in a side-by-side fashion and, together with the continuous uptake of individual cells, networks of larger aggregates are formed. Fig. 1 Blood viscosity. Schematic representation of a vessel lu- RBC aggregation is reversible by shear forces. At men. The curved line represents the flow velocity profile in lami- -1 nar flow. The viscosity (unit: Poise) is expressed as a ratio of shear shear rates of 7–10 s , the aggregates in normal blood stress to shear rate, where the shear stress (unit: dynes/cm2) is the are dispersed, cells become orientated with flow stream- force (F) parallel to the direction of flow per unit area of fluid lines, and blood viscosity is reduced as the shear rates in- sheared (A), and the shear rate (unit: second-1) is the velocity gra- crease further. In vitro, this process of aggregation and dient between adjacent layers in laminar flow. [dv velocity differ- ence of adjacent fluid laminae, dx distance between the fluid lami- disaggregation can continue for hours. nae (adapted from [5], with permission)] In addition to the plasma protein pattern, RBC aggre- gation is primarily determined by cellular properties; re- duction in cell size increases aggregation as does RBC its viscosity is therefore variable at any given tempera- ageing. The haematocrit shows a biphasic effect on red ture, depending on the shear rate. Haematocrit has a cell aggregation, with a peak effect at around 40–45%. large effect on blood viscosity and blood flow. For ex- Conditions of low shear rate in vivo are found primari- ample, hyperviscosity syndromes, such as polycythae- ly in the post-capillary venules. An increase in RBC ag- mia, are associated with profound perfusion problems gregation would increase blood viscosity at this level [11]; in contrast, anaemia favours an increase in cardiac [12]. The increased viscosity may promote blood stasis, output. In physiological conditions, changes in blood which may induce local hypoxia and endothelial damage. viscosity do not have a pronounced effect on blood flow. There are several methods of estimating RBC aggre- However, in low flow states, a reduction in shear rate gation other than low shear rate viscometry, for example, will cause an increase in viscosity. Blood viscosity, erythrocyte sedimentation rate and direct microscopic therefore, has the potential to reduce flow under low observation of aggregation. Microscopic techniques with flow, low shear conditions [3, 4, 5]. image analysis have also been developed [13], but the When RBCs are added to plasma, blood viscosity in- most widely used technique is the light scattering analy- creases logarithmically with a linear increase in hae- sis of RBC suspensions that employs light transmission matocrit over the range 20–60%. At high shear rates, through a RBC suspension to obtain indices of RBC ag- bulk blood viscosity is low because RBC aggregates are gregation. This is expressed mainly as the average aggre- dispersed and deformed into ellipsoids, oriented in paral- gate size at a certain shear stress. lel with flow streamlines, and with the membrane sliding around its cytoplasm. As shear rates are reduced, blood viscosity rises exponentially. In low flow states, when Deformability the shear stress acting on the cell is reduced, the RBC is less deformed; furthermore, the RBCs aggregate to form ‘Cellular deformability’ is the term generally used to rouleaux, increasing blood viscosity. In the normal circu- characterize the RBC’s ability to undergo deformation lation the shear stress is generally sufficient to disperse during flow [14]. The deformation response of a RBC to the rouleaux, allowing RBC deformation and facilitating fluid forces is a complex phenomenon that depends on a blood flow [3, 4, 5]. Therefore, the major determinants number of different cell characteristics including mem- of whole blood viscosity are shear rate, plasma viscosity, brane material properties [15], cell geometry, and cyto- haematocrit, RBC deformability, and RBC aggregation. plasmic viscosity [16]. It is possible to measure plasma and whole blood vis- As measures of cellular deformability are dependent cosity over a wide range of shear rates in a variety of on the technique used, quoted values are not comparable. 1054 231 Methods to measure cellular deformability have been de- scribed in detail elsewhere [17, 18]. Briefly, micropipette aspiration provides the most detailed characterization of membrane properties. Single RBCs are aspirated into mi- cropipettes with diameters in the range 1–2 µm; the rela- tionship between the applied negative pressure and the membrane tongue extension is then quantitated. Using ektacytometry, RBCs are subjected to a laminar shear stress field in a cuvette viscometer; the resultant change in cell shape is continuously monitored by laser dif- fractometry. Unstressed discoid cells generate a circular diffraction pattern. By measuring optical densities at two points along the major and minor axes of the elliptical diffraction pattern, a parameter termed “deformability Fig. 2 RBC membrane. Schematic representation of protein orien- tations in the human RBC. The membrane is composed of a phos- index” is generated which is a direct measure of cell pholipid membrane bilayer and transmembrane proteins including ellipticity. A numerical value of zero corresponds to non- glycophorin A and Band 3 proteins. Glycophorin A is the major deformable cells, while increasingly positive values cor- sialoglycoprotein of the RBC. SA bound to glycophorin A is re- respond to increasing cellular deformability. The mem- sponsible for the negative charge of the RBC membrane. The in- tracellular compartment (IC) is constituted by spectrin ( and brane fragmentation assay using the ektacytometer is subunits), actin, protein 4.1, protein 4.2, and ankyrin particularly useful for documenting decreased mechani- cal integrity of the membrane due to protein defects. Micropore filtration is limited by the possible occlu- Reversible deformation of the RBC membrane occurs sion of the filter pores by WBCs [6]. This technique with a change
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