1. Introduction
Gamma-aminobutyric acid (GABA) is a ubiquitous non-protein amino acid and its presence has been shown in bacteria, plants, and vertebrates [
1,
2,
3,
4]. It is produced by decarboxylation of glutamate by the enzyme glutamate decarboxylase and is metabolized by transamination via the catalyzing effects of GABA transaminase to yield succinic semialdehyde or succinic acid [
5,
6]. GABA is defined as an inhibitory neurotransmitter in the central nervous system [
7] and has various positive effects on mammalian physiology, including reducing blood pressure, relieving anxiety, and enhancing immunity [
8,
9,
10,
11].
The hormone erythropoietin (EPO) stimulates erythropoiesis, namely the process of red blood cell (RBC) production in the bone marrow [
12]. EPO is a hematopoietic growth factor that generally supports proliferation and differentiation of erythroid cells through interaction with the EPO receptor (EPOR) [
13,
14]. The liver is the main organ of EPO production in the fetus, while the kidney is the predominant organ for EPO production in adults [
15]. Approximately 90% of systemic EPO in adults is produced by peritubular interstitial fibroblasts in the renal cortex and outer medulla of renal tissue [
16].
Epo gene expression in response to reduced oxygen tension is controlled by the heterodimeric transcription factors, hypoxia-inducible factor (Hif), specifically Hif-1α and Hif-2α. Hif-2α has a more critical effect on
Epo expression than Hif-1α under physiological and hypoxic conditions in adults. Moreover, Hif-1α and Hif-2α have different physiological roles: for example, renal cancer cell growth is retarded and enhanced by Hif-1α and Hif-2α, respectively [
17].
Anemia with chronic kidney disease shows decreased production of EPO [
18]. Diseased kidneys do not release sufficient amounts of EPO, which may consequently lead to anemia, which is universal in end-stage renal disease [
19]. Exogenous recombinant human EPO is widely used for the treatment of anemia and generally has a good safety profile. Some potential acute side effects include transient flu-like symptoms, rash at the injection region, and headache, which are normally reported as mild and disappear within a few hours. However, long periods of recombinant EPO treatment can result in cardiovascular diseases including hypertension, polycythemia, stroke, and seizures [
20,
21,
22], with hypertension being the most common [
23]. Recombinant human EPO treatment for managing anemia can therefore be costly, have undesired side effects, and be painful to the patients.
Endogenous EPO produced in the body has a positive effect on various diseases such as nerve cell protection, chronic ocular hypertension, and juvenile chronic arthritis [
24,
25]. EPO levels in diabetic chronic kidney disease also serve as an indicator for predicting mortality, and increasing endogenous EPO levels is effective in the treatment of anemia in patients with chronic kidney disease [
26]. Furthermore, EPO levels predict the mortality rate of patients with heart failure, and consistently elevated EPO levels have independent prognostic value [
27,
28]. In our preliminary experiment, we found that GABA increases the absorption of organic iron in mice with iron deficiency anemia. Co-treatment by GABA and piperine induces
Epo and
Epor genes in kidney cells through p38/c-JUN N-terminal kinase (JNK) mitogen-activated protein kinase (MAPK) activation [
29]. Thus, we hypothesized that GABA treatment may improve anemia and increases endogenous EPO levels that stimulates erythropoiesis. To confirm the hypothesis, we investigated the effect of GABA administration on EPO levels and hematological parameter. We investigated expression levels of genes involved in erythropoiesis in rats, and identified proteins involved in EPO production by GABA. We also analyzed a network of identified proteins and found that GABA induces a hypoxic environment, which activates Hif resulted in the increase of EPO production.
2. Materials and Methods
2.1. Animals
Sprague–Dawley rats (five-week-old, male) were purchased from Koatech (Pyungtaek, Korea). Animals were acclimated for one week under 12 h light and 12 h dark conditions in a room at constant temperature (20 ± 2 °C) and humidity (50 ± 5%). Animals were fed a standard diet (Harlan Diet 2018S; Harlan Laboratories, Madison, WI, USA) with drinking water provided freely. The drinking water was changed every day. All experimental procedures were approved by the Korea University Institutional Animal Care and Use Committee (Approval No.: KUIACUC-2016-148), and animals were maintained in accordance with the Guide for the Care and Use of Laboratory Animals (NIH Publication No. 85-23, 1996). After a week of adaptation, rats were randomly divided into 4 groups (n = 8 per group), and the groups treated with 50, 100, or 200 ppm GABA for 3 weeks (Sigma-Aldrich, St. Louis, MO, USA), designated G50, G100, and G200, respectively. GABA was supplied via water. Clinical signs were monitored every 12 h.
2.2. Blood Analysis
Blood samples were collected by cardiac puncture under carbon dioxide gas anesthesia. Blood cell counts and serum EPO concentration were determined at the end of the trial (day 21). Whole blood was collected in vacutainer tubes (Becton Dickinson, Franklin Lakes, NJ, USA) coated with ethylenediaminetetraacetic acid (EDTA) anticoagulant. White blood cell (WBC), lymphocyte, monocyte, neutrophil, eosinophil, basophil, RBC, hemoglobin (Hb), hematocrit (Hct), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and platelets (PLT) concentrations were measured using an automatic blood cell counter (Cell counter analyzer, MS9-5V; Melet Schloesing Laboratoires, Osny, France). Whole blood samples were analyzed within 5 h. The remaining blood was collected in plain vacutainer tube (Becton Dickinson, Franklin Lakes, NJ, USA), and the serum separated by centrifugation (4000 rpm, 10 min). Serum EPO was measured using a rat EPO enzyme-linked immunosorbent assay (ELISA) kit (Cusabio, Houston, TX, USA). All serum samples were stored at −80 °C until analysis. Serum creatinine was determined using the hexokinase enzyme method using an AU680 automated chemistry analyzer (Beckman Coulter Inc., Pasadena, CA, USA).
2.3. Quantitative Real-Time Polymerase Chain Reaction and Data Analysis in Rat Kidney
Total ribonucleic acid (RNA) was extracted using Trizol reagent (Gibco BRL, Gaithersburg, MD, USA) according to the protocol of the manufacturer. Approximately 10 mg of renal cortex tissue was thawed and homogenized in 1 mL Trizol reagent. Concentration of RNA was quantified with a Nanodrop spectrophotometer (DS-11+; DeNovix Inc., Wilmington, DE, USA). Next, cDNA was prepared using a cDNA synthesis kit (Thermo Fisher Scientific, Waltham, MA, USA). Quantitative real-time polymerase chain reaction (qPCR) was performed using a RT-qPCR kit (Thermo Fisher Scientific, Waltham, MA, USA) and a StepOne Plus Real-time PCR system (Thermo Fisher Scientific, Waltham, MA, USA). Primer specific sequences are listed in
Table 1. Reactions were preheated for 10 min at 95 °C followed by 40 cycles at 95 °C for 20 s, 60 °C for 20 s, and 72 °C for 20 s. qPCR data were quantified based on the number of cycles needed for amplification-generated fluorescence to reach a specific threshold of detection (Ct value). Relative gene expression was quantified on the basis of equal amounts of RNA (1 μg) and average Ct values for each gene. Delta Ct (ΔCt = Ct
target gene − Ct
reference gene) was calculated using Ct values for genes in the same sample. Actin was used as the internal reference control gene. ΔΔCt value was calculated with the following equation: ΔΔCt = (ΔCt
treated − ΔCt
untreated). Normalized expression change was expressed as 2
−ΔΔCt (actin control was set to 1) [
30].
2.4. Histological Analysis
Kidney tissue was surgically removed, fixed in 10% paraformaldehyde, and then 5 μm paraffin sections were prepared. Hematoxylin–eosin (H&E) staining was used to observe general histopathological changes in tissue. Kidney biopsies were fixed in 4% paraformaldehyde (Sigma–Aldrich, St. Louis, MO, USA) for immunohistochemistry. Paraffin-embedded 3-µm-thick sections were cut, mounted on POLYSINE Slides (Thermo Fisher Scientific, Waltham, MA, USA), de-waxed in xylene, and then gradually dehydrated in 70%, 80%, 90%, and 100% ethanol for 5 min each. Antigen retrieval was performed by boiling in sodium citrate buffer (10 mM sodium citrate and 0.05% Tween 20, pH 6.0). Sections were blocked for 30 min with phosphate buffered saline (PBS) containing 1% horse serum (Sigma-Aldrich, St. Louis, MO, USA), and then incubated overnight at 4 °C with anti-Epo (1:200; rabbit polyclonal IgG N-19, sc-1310) and anti-Epor (1:200; goat polyclonal IgG H-194, sc-5624) (Santa Cruz Biotechnology, Dallas, TX, USA) antibodies. For Hif immunohistochemistry, anti-Hif-1α (1:200; rabbit polyclonal IgG, NB100-479) and anti-Hif-2α (1:100; rabbit polyclonal IgG, NB100-122) (Novus Biological, Centennial, CO, USA) were used as primary antibodies. Sections were rinsed three times in PBS and incubated for 1 h at room temperature with Alexa Fluor 488-conjugated goat anti-rabbit IgG (H+L) (1:1000; A27034) and Alexa Fluor 594-conjugated rabbit anti-goat IgG (H+L) secondary antibodies (1:1000; A27016) (Invitrogen, Carlsbad, CA, USA) for anti-Epo and anti-Epor, respectively. Goat anti-rabbit IgG (H+L) Alexa Fluor 488-conjugated antibody (1:200; A-11008) (Thermo Fisher Scientific, Waltham, MA, USA) was used as a secondary antibody for anti-Hif-1α and anti-Hif-2α. After further rinsing, nuclei were counterstained with 4′,6-diamidino-2-phenylindole (DAPI) (1:10,000, Thermo Fisher Scientific, Waltham, MA, USA) in PBS. Images were captured using a confocal microscope with a FV1000 Fluoview camera (Olympus, Tokyo, Japan). Relative intensity was measured using ImageJ.
2.5. RNA Microarray
Total RNA was extracted using Trizol reagent (Gibco BRL, Gaithersburg, MD, USA) according to the manufacturer’s protocol. Dissolved RNA was further treated with RNase-free DNase to digest contaminated genomic DNA, and then purified using Qiaquick Rneasy Mini kit (Qiagen, Valencia, CA, USA) according to the manufacturer’s instructions. Eluted RNA was quantified using a ND-1000 spectrophotometer (NanoDrop Technologies, Inc., Wilmington, DE, USA). RNA quality was verified using 1% agarose denaturing gels and an Agilent 2100 Bio-analyzer (Agilent Technologies, Santa Clara, CA, USA). For control and test RNAs, synthesis of target cRNA probes and hybridization were performed using Agilent’s Low RNA Input Linear Amplification kit (Agilent Technologies, Santa Clara, CA, USA) according to the manufacturer’s instructions. Amplified and labeled cRNA was purified on RNase mini columns (Qiagen, Valencia, CA, USA) according to the manufacturer’s protocol. Labeled cRNA targets were quantified using a ND-1000 spectrophotometer (NanoDrop Technologies, Inc., Wilmington, DE, USA). Arrays were hybridized at 65 °C for 17 h using an Agilent Hybridization oven (Agilent Technologies, Santa Clara, CA, USA). Hybridized microarrays were washed using the manufacturer’s washing protocol (Agilent Technologies, Santa Clara, CA, USA). Fluorescence images of the hybridized arrays were generated using the Agilent DNA Microarray Scanner, and intensities were extracted using Agilent Feature Extraction software ver. 10.7.3.1. Average fluorescence intensity was calculated for each spot and the local background subtracted. All data normalization and selection of fold-changed genes were performed using GeneSpring GX 7.3.1 (Agilent Technologies, Santa Clara, CA, USA). Differentially expressed genes were identified using a single t-test that assumes unequal variance between groups. The criterion for identification of significant genes was a value of p < 0.05. RNA sequencing data have been deposited in NCBI’s Gene Expression Omnibus (GEO) database (accession code: GSE146299). For pie char and Venn diagram, the ExDEGA software (Excel based Differentially Expressed Gene Analysis, ebiogen, Seoul, Korea), which is an analysis tool that facilitates the analysis of numerous data from microarray according to classified Gene Ontology (GO) terms, was used. The genes with a p-value < 0.05 and a fold change of 2.0 compared with the negative control were defined as significantly changed genes.
2.6. Two-Dimensional Electrophoresis
Isolated kidney tissue was directly homogenized using a motor-driven homogenizer (PowerGen 125; Fisher Scientific, Hampton, NH, USA) in sample lysis solution composed of 7 M urea and 2 M thiourea containing 4% (
w/
v) 3-3[(3-cholamidopropyl) dimethylammoniol]-1-benzamidine. Proteins were extracted for 1 h at room temperature by vortexing. After centrifugation at 15,000×
g for 1 h at 15 °C, insoluble material was discarded, and the soluble fraction used for two-dimensional gel electrophoresis (2DE) protein concentration was assayed by the Bradford method [
31]. Immobilized pH gradient (IPG) dry strips (4–10 NL IPG, 24 cm; Genomine, Pohang, Korea) were equilibrated for 12 to 16 h with 7 M urea and 2 M thiourea containing 2% 3-[(3-cholamidopropyl) dimethylammonio]-1-propanesulfonate (CHAPS), 1% dithiothreitol (DTT), and 1% pharmalyte, and loaded with 200 μg of protein. Isoelectric focusing (IEF) was performed at 20 °C using a Multiphor II electrophoresis unit and EPS 3500 XL power supply (Amersham Biosciences, Piscataway, NJ, USA), following the instructions of the manufacturer. During IEF, the voltage was linearly increased over 3 h from 150 to 3500 V for sample entry, followed by a constant 3500 V, with focusing complete after 96 kVh. Prior to the second dimension, strips were incubated for 10 min in equilibration buffer (50 mM Tris-Cl, pH 6.8 containing 6 M urea, 2% sodium dodecyl sulfate (SDS), and 30% glycerol), first with 1% DTT and second with 2.5% iodoacetamide. Equilibrated strips were inserted onto sodium dodecyl sulphate–polyacrylamide gel electrophoresis (SDS-PAGE) gels (20 × 24 cm, 10%–16%). SDS-PAGE was performed using the Hoefer DALT 2DE system (Amersham Bioscience, Piscataway, NJ, USA) following the instructions of the manufacturer. 2DE gels were run at 20 °C for 1700 Vh, and then silver stained (but without fixing and glutaraldehyde sensitization). Quantitative analysis of digitized images was performed using PDQuest software (version 7.0; Bio-Rad, Hercules, CA, USA), according to the protocols of the manufacturer. The quantity of each spot was normalized by total valid spot intensity. Protein spots expressed over two-fold in expression levels compared with controls from the normal sample were selected. The NCBInr database was searched using Mascot software, and identified spots were mapped onto gels stained with Coomassie brilliant blue. For protein identification, protein spots were excised, digested with trypsin (Promega, Madison, WI, USA), mixed with α-cyano-4-hydroxycinnamic acid (CHCA) in 50% acetonitrile (ACN)/0.1% trifluoroacetic acid (TFA), then subjected to matrix assisted laser desorption ionization–time of flight–mass spectrometry (MALDI-TOF-MS) analysis (Ettan MALDI-TOF; Amersham Bioscience, Piscataway, NJ, USA), as described previously [
32].
2.7. Protein Data Bioinformatics Analysis
Differentially expressed proteins were subjected to GO analysis, pathway enrichment, and protein–protein interaction (PPI) analysis. GO analysis was performed using the Database for Annotation, Visualization and Integrated Discovery (DAVID) and included biological processes (BP), cell components (CC), and molecular functions (MF). Pathway enrichment was performed using the Kyoto Encyclopedia of Genes and Genomes (KEGG) database, with significant pathways analyzed. Based on interactions among pathways in the KEGG database, PPI were built using the Search Tool for Retrieval of Interacting Genes/Protein (STRING) database.
2.8. ATP Measurement and NADH Dehydrogenase Assay in Mitochondria
Intact mitochondria were immediately isolated from the kidney by differential centrifugation using a Mitochondria Isolation kit (Thermo Fisher Scientific, Waltham, MA, USA). The pellet was re-suspended in PBS, and freshly isolated mitochondria immediately used for analysis of ATP content. Mitochondrial protein concentration was determined using the Bradford method. Mitochondrial ATP content was measured by a luminescence assay using the ATPlite ATP detection system (Perkin-Elmer, Waltham, MA, USA). For the NADH dehydrogenase activity assay, mitochondria were isolated, as described above, with contamination from cytosolic dehydrogenase prevented. Mitochondrial NADH dehydrogenase activity was measured using a mitochondrial complex I activity assay kit (BioVision, Milpitas, CA, USA).
2.9. Statistical Analysis
Statistical analysis was performed with SPSS 12.0 (IBM Corporation, Armonk, NY, USA). Results were expressed as mean ± standard deviation (SD) of three independent experiments. Statistical significance of differences was determined by Student’s t-test. A level of p < 0.05 was considered significant.
4. Discussion
The beneficial effects of GABA have been studied, and include lowering blood pressure, improving immunity, relieving anxiety, and stroke prevention [
35,
36,
37,
38]. Human recombinant EPO has one of the world’s top ten biopharmaceutical sales. Extensive research to develop erythropoiesis-stimulating agents and to produce biosimilar EPOs for anemia treatment has been studied [
39]. However, human recombinant EPO and exogenous EPO cannot be universal remedies because of their expense. Therefore, alternative strategies for EPO production in the kidney are promising methods for improving anemia. In this study, GABA stimulated EPO production in the rat kidney, with levels of serum EPO increasing in a dose-dependent manner.
Hif-1α is degraded at normal oxygen concentrations by binding of a hydroxyl group to the proline residue in the oxygen-dependent degradation domain (ODDD) by prolyl hydroxylase (Phd). This ultimately allows for recognition and ubiquitination by the von Hippel-Lindau protein (pVhl) and E3 ubiquitin ligase complex [
40,
41,
42]. When Phd loses its activity in a hypoxic state,
Hif-1α is stabilized and the gene transcribed for adaptation to hypoxia [
43]. In addition, Hif-2α is involved in erythropoiesis of adults and plays a different physiological role than Hif-1α [
44]. In this study, the
Hif-1α gene induced in only the hypoxic state was significantly increased after GABA intake, even in the normal oxygen state, compared with the control group. In addition, there was no significant difference in
Phd-2α gene expression, which should be increased in normal oxygen conditions. Moreover, the
Hif-2α gene is directly involved in erythropoiesis and was significantly increased after GABA intake. This suggests that GABA does not directly affect Phd to stabilize Hif-1α, instead GABA might directly affect Hif expression.
In this study, although RBC count in G100 group did not show a significant increase compared with the control group, RBC count showed a tendency to increase in the GABA-administered groups. Enhancement of RBC production is caused by a homeostatic mechanism of higher organisms [
45]. In addition, GABA increased EPO level but not Hb level. In a previous report, the administration of 5000 IU human EPO (rHuEpo) for 15 weeks in 8 healthy male volunteers significantly increased Hb after 8 weeks by increasing red blood cell volume and decreasing plasma volume [
46]. The recommended initial dose of epoetin alfa (rHuEpo) for chronic kidney disease adult patients is 50 to 100 U/kg three times weekly, intravenously or subcutaneously [
47], which have been approved by the U.S. Food and Drug Administration (FDA). Although the exact equivalent dose cannot be converted between human and rat, in this study, the increased concentration of EPO by GABA (50 to 200 ppm) treatment was 37 to 60 mIU, which might be not enough to significantly increase Hb in non-anemic rat within the experimental period. In this study, we used non-anemic animal model, which may be another reason why Hb level did not increase, even though EPO increased by GABA administration. Further studies are needed on the improvement effect of GABA on anemia in animal model of anemia.
GABA is approved and generally recognized as safe (GRAS) by the Food and Drug Administration (FDA), and is used as a food supplement [
48]. Kidney tissue from each group was examined, with H&E staining performed to determine kidney toxicity. No clinical symptoms such as tissue necrosis or inflammation were observed, and it was confirmed that ingestion of GABA does not act as a toxin in rats. Serum creatinine level suggested that GABA supplementation did not show toxicity as well.
Protein expression profile analysis comparing control and GABA administration groups found seven significantly increased proteins compared with the control group, with two proteins (DOPA decarboxylase and NADH dehydrogenase) greatly increased. DOPA decarboxylase decomposes 3,4-dihydroxyphenylalanine into carbon dioxide and amines, and is involved in dopamine biosynthesis [
49]. Dopamine is reported to increase in the brain when recombinant EPO is administered to mice [
50]. In addition, GABA can increase or decrease dopamine turnover depending on brain area analysis, duration of stimulation, and administration of dopamine antagonist [
51]. Although there may be differences in concentration from the present study, it is thought that increased EPO due to GABA may affect increased DOPA decarboxylase expression.
NADH dehydrogenase transfers electrons from NADH to ubiquinone [
52]. NADH supports ATP synthesis, which is dependent on electron route through the electron transport chain and homeostasis [
53]. Excess NADH in the citrate cycle significantly increases NADH dehydrogenase expression to maintain NAD and ATP homeostasis in mitochondria. Expression of the NADH dehydrogenase gene in human vascular cells is approximately 1.4-fold increased by human recombinant EPO [
54]. In the present study, NADH dehydrogenase protein was greatly increased by GABA, which may be due to differences in endogenous and exogenous EPO.
Leukemia inhibitory factor (Lif) is a remarkable polyfunctional regulator, with striking actions on a diverse range of cell types, although it has not yet been demonstrated to be a major proliferative factor for hematopoietic cells [
55]. It is not apparent that Lif alone activates differentiation into normal fetal cells or adult hematopoietic cells, but when combined with interleukin-3, Lif enhances proliferation of blast colonies [
56]. It is also known to be a proliferative stimulus for the continuous hematopoietic cell line, DA-1 [
57]. In this study, Lif protein was greatly elevated in GABA treated rats (
Table 7), which suggests that GABA might support erythropoiesis and hematopoiesis by elevating EPO and Lif. The isocitrate dehydrogenase (Idh) family of enzymes catalyzes oxidative decarboxylation of isocitrate to α-ketoglutarate and carbon dioxide. Idh plays a role in cell growth in the hypoxic condition [
58]. Indeed, GABA increases Idh expression, suggesting that GABA induces a hypoxic condition. Therefore, GABA increases the activity of the TCA cycle followed by development of hypoxia resulted in the increase of expression level of Hif or vice versa, which has to be explained with intense molecular study in our further study.
GO analysis and KEGG pathway analysis are the most reliable methods for providing greater understanding of BP, CC, and MF. In this study, overexpressed proteins were classified into different functional categories according to GO analysis. These categories included: citrate metabolic process, tricarboxylic acid cycle, mitochondrial respiratory chain complex, respiratory chain, cofactor binding, succinate dehydrogenase activity, and others (
Figure 5A). KEGG pathway analysis showed that the citrate cycle, metabolic pathway, and carbon metabolism were the top three most enriched pathways (
p < 0.05). These pathways are associated with carbohydrate metabolism, a series of chemical reactions, and carbon decomposition and synthesis. In RNA microarrays and 2DE analysis, the most significant pathway was the citrate cycle. The citrate cycle (or TCA cycle or Krebs cycle) is an important aerobic pathway for the final steps of carbohydrate and fatty acid oxidation. The cycle starts with acetyl-CoA, which is the activated form of acetate derived from glycolysis and pyruvate oxidation for carbohydrates, and from beta oxidation of fatty acids [
53]. It produces ATP in mitochondria and plays a variety of roles in intracellular energy supply.
mTORC exists as a two-cell complex with individual regulation and function. mTOR complex 1 is inhibited by the natural product rapamycin and contains a protein, raptor [
59,
60]. The ultimate role of mTORC1 is to regulate cell differentiation through cap-dependent translation, which affects cell size, with 4EBP1 regulating cell proliferation [
61,
62]. It is also reported that the mTORC1 pathway is an important regulator of RBC growth and proliferation, and that inhibiting mTORC can cause anemia [
63]. Moreover, erythroid mitochondria are regulated by mTORC1-mediated protein translation and may be directly related to blood disease associated with mitochondrial dysregulation [
64]. When erythrocytes are cleaved, EPO reactivity (which is an erythropoietic factor) is required, and iron is accumulated and highly proliferated [
64]. Both EPO and iron activate mTORC1 and phosphorylate 4EBP1 and p70S6K to promote protein synthesis in mitochondria [
63,
65]. In this study, mTORC1, 4EBP1, and p70S6K expression were significantly increased in kidney tissue.
Mitochondrial stimulation activity increases cellular processes, such as Hb synthesis, by increasing ATP and cellular metabolism. Mitochondrial dysfunction is a serious sign of disease, causing erythropoiesis dysfunction. In another aspect, the balance between ATP and RBC is very important. Changes in intracellular ATP in vitro alter the shape of RBCs, and increase RBC membrane fluctuation [
66,
67]. RBC fluctuations are directly linked to the membrane bilayer and cytoskeletal network, which suggests that critical binding between the lipid bilayer and spectrin network is actively controlled by ATP. The results of our protein expression and KEGG pathway analysis are consistent with our gene expression and RBC production results. Altogether, these results are a reliable basis for erythropoiesis concept.