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Effects of Oral Supplementation of Vitamin E on Fragility of RBC in
Hemolytic Anemic Patients with G6PD Deficiency
Nayma Sultana1,  Noorzahan Begum2, Shelina Begum3, Sultana Ferdousi4, Taskina Ali4
1Assistant Professor, Department of Physiology, Sir Salimullah Medical College, Dhaka, 2Professor and Chairman, Department of Physiology,
Bangabandhu Sheikh Mujib Medical University, Dhaka, 3Professor, Department of Physiology, Bangabandhu Sheikh Mujib Medical University,
Dhaka, 4Assistant Professor, Department of Physiology,   Bangabandhu Sheikh Mujib Medical University, Dhaka.

Abstract:
Background: Vitamin E has role in maintaining the integrity of red cell membrane by preventing oxidation of
polyunsaturated fatty acids and thereby protects cells from oxidative stress- induced lysis in G6PD deficiency, which
can be reflected by changes in osmotic fragility of RBC and some absolute values like MCV, MCH & MCHC.
Objective: To observe the effects of vitamin E supplementation on fragility of RBC in order to evaluate role of this anti-
oxidant vitamin in reducing chronic hemolysis in G6PD deficient patients. Methods: For this, a total number of 102
subjects with age ranged from 5 to 40 years of both sexes were included in the study. Among them 68 were G6PD
enzyme deficient patients, of whom 34 were in supplemented group (study group) and 34 were in non-supplemented
group (control group).  The supplemented group received vitamin E supplementation for 60 consecutive days at a dose
of 800 IU/day for adult and 400 IU/day for children <  12 years (in a divided dose i,e. 4 times daily). Age and sex
matched 34 apparently healthy subjects with normal blood G6PD level were taken to observe the base line data (healthy
control) and also for comparison. All the G6PD deficient patients were selected from Out Patient Department (OPD) of
Hematology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh during the period of July
2005 to June 2006 and all the healthy subjects were selected from personal contact. Blood G6PD level, osmotic fragility
of RBC were measured by standard techniques and MCV, MCH, and MCHC were obtained by calculation. All the
parameters were measured on day 1 (one) of their first visit and also were on day 60 in deficient group. Data were
compared among the deficient groups, also in supplemented group just before and after supplementation. Analysis of
data was done by appropriate statistical method. Results: Mean starting and completing points of osmotic fragility of
RBC were significantly higher but MCV, MCH, MCHC were significantly lower in patients suffering from hemolytic
anemia due to G6PD deficiency in comparison to those of the healthy control. After supplementation with vitamin E
starting and completing points of osmotic fragility of RBC were significantly decreased whereas, MCV, MCH, MCHC
were significantly increased  towards those of healthy control in supplemented group of patients in comparison to those
of their pre-supplemented (day-1) and non-supplemented groups both on day 1 and day 60. Conclusion: From this
study it may be concluded that, disturbances of some of the hematological parameter like higher osmotic fragility of
RBC and lower MCV, MCH, MCHC occur in G6PD deficient hemolytic anemic patients, which returned towards
normal after supplementation of vitamin E, which clearly indicates the role of this anti-oxidant vitamin in maintaining
red cell membrane integrity and thereby decreases the rate of hemolysis in this group of patients. So, vitamin E can be
supplemented along with other drugs for better management of the patients.

Key words: Osmotic fragility, G6PD,  hemolytic anemia, vitamin E.

[BSMMU J 2008; 1(1): 6-10]

Address for Correspondence: Dr. Nayma Sultana, Assistant Professor,
Department of Physiology, Sir Salimullah Medical College, Dhaka,
Bangladesh, E-mail:nayma_sultana@yahoo.com

Introduction:
Glucose 6-posphate dehydrogenase (G6PD) deficiency is
the most common clinically significant enzyme defect in
human biology and the common clinical manifestation of
this enzyme defect is hemolytic anemia 1 . Acute hemolytic
crisis may occur in G6PD deficiency due to some oxidative
stress, such as intake of some anti-malarial drugs, ingestion
of fava beans, various types of bacterial and viral infection2-4.

Hemolysis of RBC may also occur even without prior
administration of drugs in G6PD deficiency 5-7.

Vitamin E is one of the major lipid soluble antioxidant. It
prevents oxidation of polyunsaturated fatty acids and thus
protects red blood cells from oxidative stress-induced
lyses8.  Again, deficiency of vitamin E is a common feature
in genetic anemia, including G6PD deficiency hemolytic
anemia due to its increased consumption 8,9 .
Supplementation of vitamin E may have an important role
in maintaining red cell membrane integrity by reducing
osmotic fragility of erythrocyte10,11 and can minimize the



12

severity of hemolysis in G6PD deficient patients12. Again,
vitamin E supplementation can restore the required amount
of vitamin E level in this group of patients, and thus may
prevent hemolysis by improving red blood cells survival
5,6,13. Normal red blood cell indices like MCV, MCH and
MCHC may also be found in peripheral blood film by
oral supplementation of vitamin E 11 .

An increase in osmotic fragility of RBC may occur in
hemolytic anemia with G6PD deficiency 14 . Mean
corpuscular volume (MCV), mean corpuscular
hemoglobin (MCH) and mean corpuscular hemoglobin
concentration (MCHC) may also decrease in this group
of hemolytic anemic patients 15,16.

However the common clinical consequences of this
enzyme deficiency are neonatal jaundice and sporadic
hemolytic crisis2, can be minimized by vitamin E
supplementation. In our country many people are suffering
from hemolytic anemia due to G6PD deficiency.
Unfortunately, most of them are treated without knowing
the actual cause. Study of the changes in osmotic fragility
of RBC and MCV, MCH, MCHC is important  as it may
reflect the hemolytic crisis in G6PD deficient patients.
Evaluation of supplementation of vitamin is equally
important in these cases 10,11.

In Bangladesh there is lack of adequate information about
deficiency of G6PD enzyme among the anemic patients.
Only one study regarding the hematological parameters
of G6PD enzyme deficient patients has been reported in
our country17. But no published data regarding effects of
vitamin E supplementation in these G6PD enzyme
deficient patients are available. For this, the present study
was aimed at to observe some aspects of hematological
parameters in G6PD deficient hemolytic anemic patients
both before and after supplementation of vitamin E, in
order to explore its role in preventing red cell lyses and
thereby maintains the normal hematological status in these
enzyme deficient patients.  The output of the study may
be helpful to create awareness about the deficiency of
G6PD enzyme in anemic patients as well as the role of
vitamin E in minimizing the risk of complications.
Moreover it can provide information to clinicians for better
management of these patients.

Methods:
The present prospective interventional study was carried
out in the Department of Physiology, BSMMU, Dhaka
from July 2005 to June 2006. In this study, a total number
of 102 subjects with age ranged from 5 to 40 years of
both sexes were included. Among them 68 were patients

of hemolytic anemia with blood G6PD level below the
normal reference range 18 , of whom 34 were in
supplemented group (experimental group) and 34 were
without supplementation and was considered as non-
supplemented group (control group). The supplemented
group received vitamin E supplementation for 60
consecutive days at a dose of 800 IU/day for adult and
400 IU/day for children < 12 years; in a divided dose i,e.
4 times daily6,19. Age and sex matched 34 apparently
healthy subjects with normal blood G6PD level were taken
to observe the baseline data (healthy control) and also for
comparison. All the G6PD deficient patients were selected
from Out Patient Department (OPD) of Hematology,
Bangabandhu Sheikh Mujib Medical University
(BSMMU), Dhaka, and all the healthy subjects were
selected from personal contact. Blood G6PD level,
osmotic fragility of RBC and red cell indices (MCV, MCH,
MCHC) were done in all the subjects on day 1(one) of
their 1st visit and in G6PD enzyme deficient groups of
subjects also on day-60. Data were compared among
healthy control, supplemented, non-supplemented and also
within supplemented groups just before and after
supplementation. All the subjects belonged to middle and
lower middle socio-economic status. Patients with acute
hemolytic episode or received blood transfusion in the
last two months and β thalassemia trait were excluded
from the study. The objectives and benefits of the study
were explained to all the subjects to ensure their voluntary
participation and a written informed consent was taken
from each subject prior to the study.

Two (2) ml of blood was taken in an EDTA test tube for
determination of erythrocyte G6PD level and the
hematological parameters..

Erythrocyte G6PD enzyme level was determined by
spectrophotometric method 20 and the hematological
parameters were estimated by standard laboratory
technique21,22. All of these tests were done in the
Department of Physiology, BSMMU, Dhaka. Data were
expressed as Mean + SD. Independent-samples(unpaired)
‘t’ test and paired-samples ‘t’ test were done as the tests of
significance wherever applicable. The statistical analysis
was done by using SPSS programme version 12. p value
<0.05 was considered as significant.

Results:
Mean erythrocyte G6PD levels were significantly
(p<0.001) lower in G6PD enzyme deficient group of
patients when compared to that of healthy control (table-
I). The mean starting and completing points of osmotic
fragility of RBC were significantly (p<0.001) higher in

Effects of Oral Supplementation of Vitamin E on Fragility of RBC in Hemolytic Anemic Patients Nayma Sultana et al

7



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both the G6PD deficient groups in comparison to those of
healthy control group on day-1. After supplementation of
vitamin E (i,e. on day-60) starting and completing points
of osmotic fragility of RBC were significantly (p<0.001)
decreased in comparison to those of their pre-
supplemented (day-1) and also of non-supplemented
groups both on day-1 and day-60 and returned almost
toward the values of healthy control (table-II).

Patients with G6PD deficiency had significantly (p<0.001)
lower MCV, MCH and MCHC compared to those of
healthy control. These values were increased significantly
(p<0.001) toward the values of healthy control in G6PD
deficient group following vitamin E supplementation.
(table-III).

Table-I
Mean (±SD) Erythrocyte G6PD level in different study

groups (n = 102).

Groups n U/1012 RBC U/g Hb

A 34 191 + 18.8 6.69 + 1.19

(161 – 226) (5.00 – 9.60)

B1 34 105 + 9.38 3.29 + 0.34

(90 – 121) (2.38 – 3.90)

C1 34 105 + 10.09 3.31 + 0.33

(85 – 122) (2.60 – 3.84)

Statistical analysis:

Groups p                           value
A vs B1 0.000

*** 0.000***

A vs C1 0.000
*** 0.000***

B1 vs C1 0.747
ns 0.893ns

Group   A = Healthy subjects for baseline and control.

Group   B = Hemolytic anemic patients with G6PD
deficiency (Control)
- nonsupplemented group.

Group  C = Hemolytic anemic patients with G6PD
deficiency (study groupl)
- supplemented group.

B1 and C1 = On day 1; B2 and C2 = On day 60
Values in parentheses indicate ranges

Table-II
Mean (±SD) Osmotic fragility of RBC in different study

groups (n=102)

Groups n Starting Completing

point (%) point (%)

A 34 0.48 + 0.03 0.31 + 0.04

(0.45 – 0.55) (0.25 – 0.35)

B1 34 0.6 + 0.04 0.42 + 0.032

(0.5 – 0.65) (0.35 – 0.45)

B2 34 0.6 + 0.04 0.41 + 0.03

(0.5 – 0.65) (0.35 – 0.45)

C1 34 0.59 + 0.04 0.42 + 0.028

(0.5 – 0.65) (0.35 – 0.45)

C2 34 0.5 + 0.04 0.32 + 0.04

(0.4 – 0.55) (0.25 – 0.35)

Statistical analysis:

Groups                    p value

A vs B1 0.000
*** 0.000***

A vs C1 0.000
*** 0.000***

A vs B2 0.000
*** 0.000***

A vs C2 0.245
 ns 0.295 ns

B1 vs C1 0.314 
ns 0.546 ns

B2 vs C2 0.000
*** 0.000***

B1 vs B2 0.374
 ns 0.711 ns

C1 vs C2 0.000
*** 0.000***

Group   A = Healthy subjects for baseline and control.

Group   B = Hemolytic anemic patients with G6PD
deficiency (Control)
- nonsupplemented group.

Group  C = Hemolytic anemic patients with G6PD
deficiency (study group)
- supplemented group.
B1 and C1  = On day 1.  B2 and C2 = On
day 60.

Values in parentheses indicate ranges.

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Table-III
Mean (+ SD) MCV, MCH and MCHC in different study

groups (n = 102).

Groups n MCV (fl) MCH (pg) MCHC (g/dl)

A 34 91 + 6.65 31 + 1.53 34 + 2.13

(73 – 105) (26 – 34) (28.5 – 40)

B1 34 85 + 10.78 27 + 2.94 32 + 2.1

(65 – 104) (22 – 33) (26 – 33)

B2 34 85 + 9.37 27+ 2.72 32 + 2.24

(67 – 100) (22 – 31) (26 – 35)

C1 34 85 + 9.01 28 + 2.83 32 + 1.87

(65 – 101) (22 – 34) (28 – 33)

C2 34 90 + 6.64 30 + 2.42 33.5 + 0.76

(77– 104) (26 – 35) (32.5 – 36)

Statistical analysis:

Groups p value
A vs B1 0.025

 * 0.000 *** 0.010*

A vs C1 0.015
 * 0.000 *** 0.018*

A vs B2 0.019
* 0.000 *** 0.000***

A vs C2 0.967
 ns 0.851 ns 0.773ns

B1 vs C1 0.895
 ns 0.773 ns 0.842 ns

B2 vs C2 0.012
 * 0.000*** 0.000 ***

B1 vs B2 0.615
 ns 0.397ns 0.136 ns

C1 vs C2 0.002
 ** 0.000 *** 0.002 **

Group A = Healthy subjects for baseline and control.
Group B = Hemolytic anemic patients with G6PD

deficiency (Control)
- nonsupplemented group.

Group C = Hemolytic anemic patients with G6PD
deficiency (study group)
- supplemented group.

B1 and C1 = On day 1; B2 and C2 = On day 60

Values in parentheses indicate ranges.

Discussion:
The present study revealed that patients with G6PD
deficiency have significantly higher osmotic fragility of
RBC along with significantly lower values of red cell
indices like MCV, MCH, MCHC in comparison to those
of healthy control. These findings are in consistent with
those of some other researchers of different countries14-
16. On the contrary, no remarkable change in osmotic
fragility of RBC and red cell indices were reported.15,23 .

Again, in this study after 60 days supplementation of
vitamin E osmotic fragility in G6PD deficient patients was
significantly decreased and it was almost close to those of
healthy control. Similar observations were also reported24.
Red cell indices ( MCV, MCH, MCHC) were significantly
increased and moved towards normal value in the present
series of patients. This finding is similar to those of some
other researchers 11,13. On the other hand, no remarkable
changes in these values were observed in other studies 25,
which might be due to short duration and low dose of
vitamin E supplementation in their studies.

In G6PD deficiency oxidation of polyunsaturated fatty acid
on the RBC membrane may increase its susceptibility to
hemolysis25. In addition, abnormal degradation of
hemoglobin, disordered cellular metabolism may also be
responsible for early destruction of RBC in G6PD deficient
patients11. Therefore, early destruction of RBC is the
consequence of higher osmotic fragility of RBC in
oxidative stress26,27. In addition, decreased level of MCV,
MCH, MCHC in hemolytic anemia with G6PD deficiency
is a consequence of excessive hemolysis, more marked
under oxidative stress 27,28 .

Therefore, increased osmotic fragility of RBC in G6PD
deficiency indicates the presence of membrane defect in
the present series of patients. Moreover, decreased MCV,
MCH and MCHC might be due to nutritional deficiency
resulting from increased nutritional demand imposed by
fragile RBC in this type of patients.

Vitamin E acts as an anti-oxidant by scavenging free
radicals, thus prevents premature destruction of RBC19,25.
Therefore, supplementation of vitamin E restores osmotic
fragility of RBC and thus increases RBC survival9,24.
However, following vitamin E supplementation decreased
osmotic fragility of RBC and shifting of MCV, MCH and
MCHC towards normal in the patients of present study
are suggestive of protective role of vitamin E
supplementation in this group of patients.

Therefore, this study concludes that increase in osmotic
fragility and decrease in red cell indices may occur in
G6PD deficiency and vitamin E supplementation helps to
return these values towards normal. Determination of
vitamin E level, red cell half-life and long time
supplementation of vitamin E with larger sample size may
be helpful to draw any definite conclusion.

Acknowledgement:
This work was supported by Department of Physiology
BSMMU, Dhaka.

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