Guidelines on neonatal screening and painful vaso-occlusive crisis in sickle cell disease: Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular: Project guidelines: Associação Médica Brasileira - 2016

Sickle Cell Disease in Brazil: Current Management

Sickle cell disease (SCD) comprises inherited red blood cell disorders due to a mutation in the β-globin gene (c20A > T, pGlu6Val) and is characterized by the presence of abnormal hemoglobin, hemoglobin S, hemolysis, and vaso-occlusion. This mutation, either in a homozygous configuration or in compound states with other β-globin mutations, leads to polymerization of hemoglobin S in deoxygenated conditions, causing modifications in red blood cell shape, particularly sickling. Vaso-occlusive crisis (VOC) is the hallmark of the disease, but other severe complications may arise from repeated bouts of VOCs. SCD is considered a global health problem, and its incidence has increased in some areas of the world, particularly the Americas and Africa. Management of the disease varies according to the region of the world, mainly due to local resources and socioeconomic status. This review aimed to describe more recent data on SCD regarding available treatment options, especially in Brazil. New treatment options are expected to be available to all patients, particularly crizanlizumab, which is already approved in the country.

Self-Report for Assessment of Pain and Quality of Life in Children with Sickle Cell Anemia in a Developing Country

Purpose

The specific assessment of pain and quality of life in children with sickle cell anemia (SCA) is still the subject of few studies and is traditionally evaluated through perception of their parents or guardians. Thus, this study aimed to evaluate pain, its characteristics, and impact on the quality of life (QoL) in children diagnosed with SCA, valuing their self-report.

Patients and Methods

This study was conducted on hematology and hemotherapy outpatient clinic in São Luís, Brazil, with children between 7 years and 12 years with SCA, of both genders. The instruments used were Numeric Pain Rating Scale, Faces Pain Scale and Autoquestionnaire Qualité de Vie Enfante Imagé (AUQEI) for the assessment of pain and QoL from the children’s self-report. The association between pain intensity and QoL was verified through the Chi-square test and the relationship between pain and the domains of AUQEI was verified through Pearson’s correlation, using Stata 10.0^®.

Results

The sample consisted of 104 children with a mean age of 8.97 years, 51.9% were male and 94.2% non-white. Pain was characterized predominately moderate to strong, stabbing (37.5%) and burning (31.7%), with greater frequency in the limbs, and reported simultaneously in two or more locations. The average pain score was 9.26 at the worst time and in the general context was 6.02. As a result of pain, 93.3% reported school absence, averaging 8.57 days of absence; 63.5% had sleep disturbance and 86.5% failed to perform your daily activities. QoL results were negative in 48.08% and 56.25% of these had severe pain. About 74% of children with positive QoL had mild pain.

Conclusion

Pain in children with SCA has a negative impact on their QoL based on their point of view, affecting their daily life. These findings highlight the importance of valuing children’s self-report of the disease, especially in a restricted resource scenario.

Sickle Cell Anemia Patients Display an Intricate Cellular and Serum Biomarker Network Highlighted by TCD4+CD69+ Lymphocytes, IL-17/MIP-1β, IL-12/VEGF, and IL-10/IP-10 Axis

BACKGROUND

Sickle cell anemia (SCA) is associated with a chronic proinflammatory state characterized by elevated leukocyte count, mortality from severe recurrent infections, and subsequent vasoocclusive complications with leukocyte adhesion to the endothelium and increased plasma levels of inflammatory cytokines. The immune system has a close connection with morbidity in SCA, but further studies are needed to uncover the involvement of innate and adaptive immunities in modulating the SCA physiopathology. We performed measurements of the frequency of innate and adaptive immunity cells, cytokines, chemokines, and growth factors and immunophenotyping of Toll-like receptor and adhesion molecule expression in the blood of SCA patients and healthy donors to evaluate the different profiles of these biomarkers, the relationship among them, and their correlation to laboratory records and death risk. Material and Methods. Immunophenotyping of cells, Toll-like receptors, and adhesion molecules were performed from peripheral blood samples of SCA patients and healthy donors by flow cytometry and cytokine/chemokine/growth factor measurement by the Luminex technique performed from the serum of the same subjects.

RESULTS

Cells of adaptive immunity such as IL-12, IL-17, and IL-10 cytokines; IL-8, IP-10, MIP-1α, MIP-1β, and RANTES chemokines; and VEGF, FGF-basic, and GM-CSF growth factors were higher in SCA patients than healthy donors regardless of any laboratorial and clinical condition. However, high death risk appears to have relevant biomarkers.

CONCLUSION

In the SCA pathophysiology at steady state, there is a broad immunological biomarker crosstalk highlighted by TCD4+CD69+ lymphocytes, IL-12 and IL-17 inflammatory and IL-10 regulatory cytokines, MIP-1α, MIP-1β, and IP-10 chemokines, and VEGF growth factor. High expression of TLR2 in monocytes and VLA-4 in TCD8+ lymphocytes and high levels of MIP-1β and RANTES appear to be relevant in high death risk conditions. The high reticulocytosis and high death risk conditions present common correlations, and there seems to be a balance by the Th2 profile.

Sickle cell disease

Sickle cell disease (SCD) is a group of inherited disorders caused by mutations in HBB, which encodes haemoglobin subunit β. The incidence is estimated to be between 300,000 and 400,000 neonates globally each year, the majority in sub-Saharan Africa. Haemoglobin molecules that include mutant sickle β-globin subunits can polymerize; erythrocytes that contain mostly haemoglobin polymers assume a sickled form and are prone to haemolysis. Other pathophysiological mechanisms that contribute to the SCD phenotype are vaso-occlusion and activation of the immune system. SCD is characterized by a remarkable phenotypic complexity. Common acute complications are acute pain events, acute chest syndrome and stroke; chronic complications (including chronic kidney disease) can damage all organs. Hydroxycarbamide, blood transfusions and haematopoietic stem cell transplantation can reduce the severity of the disease. Early diagnosis is crucial to improve survival, and universal newborn screening programmes have been implemented in some countries but are challenging in low-income, high-burden settings.