Red blood cell metabolome maps disease burden, mutation class, and splenectomy status in hereditary spherocytosis.

Hereditary spherocytosis (HS) is caused by inherited defects in red blood cell (RBC) membrane and membrane-skeletal proteins, but the metabolic features associated with genotype, splenic selection, RBC injury, and clinical burden remain incompletely resolved. We performed RBC metabolomics in the VASCUSPHERO cohort, including 16 controls and 22 HS samples, and integrated omics data with splenectomy status, RBC deformability, microparticles, phosphatidylserine exposure, reactive oxygen species, calcium, CD47, complete blood count traits, and leukocyte subsets. The HS cohort included 12 spectrin beta, erythrocytic (SPTB)-only cases, 5 solute carrier family 4 member 1 (SLC4A1)/band 3 cases, 4 ankyrin 1 (ANK1)-only cases, and 1 combined ANK1/SPTB case. HS and control samples differed in global metabolomic space, with changes involving acylcarnitines, polyamines, pantothenate metabolism, gamma-glutamyl metabolites, sulfur metabolism, bile acids, and glutathione-related pathways. Metabolite and pathway scores correlated with reticulocytosis, deformability, RBC injury markers, and hematologic traits. Mutation-stratified analyses identified genotype-associated structure, whereas a cross-sectional analysis within SPTB-mutant HS identified splenectomy-associated metabolic and phenotypic differences. An exploratory, phenotype-derived burden score prioritized pantothenate, N1-acetylspermidine, N1-acetylspermine, gamma-glutamylputrescine, and selected acylcarnitines as candidate metabolic reporters. These findings position the RBC metabolome as an integrated, but not yet clinically validated, readout of membrane genetics, hemolytic stress, and splenectomy-associated remodeling. The Vascusphero project is a registered trail in ClinicalTrials.gov with identifier: NCT04451785 (https://clinicaltrials.gov/study/NCT04451785).