Clinical variability of ATP11C-related hemolytic anemia: expanding the phenotypic and diagnostic spectrum

The ATP11C gene, localized on X-chromosome, encodes the major phosphatidylserine flippase in human red blood cells (RBCs). Flippases actively transport phospholipids from the outer to the inner leaflet of the lipid bilayer, establishing and maintaining phospholipid asymmetry crucial for cell survival. Variants in ATP11C have been recently associated with a novel form of X-linked congenital hemolytic anemia. In this study, we identified 10 individuals from 7 unrelated families harboring 6 rare, novel variants in the ATP11C gene. Three of the variants were further characterized and functionally validated. Notably, the first variant, p.R467C, was identified in a male neonate presenting with mild hemolytic anemia. The second variant, c.2226-1G>C, was found in a 53-year-old male who was originally suspected of hereditary hemochromatosis. The third variant, p.D609V, was detected in a 68-year-old female with mild anemia. Functional studies revealed reduced ATP11C protein expression, as well as decreased flippase activity both in vitro and in ex vivo RBCs supporting a loss-of-function mechanism. Additionally, in the female patient, we identified skewed X-chromosome inactivation, because of which the pathogenic effect of the heterozygous ATP11C variant became clinically evident. Our study expands the clinical spectrum of ATP11C-related hemolytic anemia, highlighting its association with adult-onset disease and hepatic iron overload. We emphasize the importance of including ATP11C in genetic testing for the diagnosis of hereditary hemolytic anemia and iron metabolism alterations. These findings enhance our understanding of RBCs membrane homeostasis and elucidate the critical role of ATP11C in erythropoiesis and systemic iron regulation.