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Jerman H, Chang YS. Sickle cell disease: healthcare professionals' views of patients in the emergency department. Emerg Nurse 2024; 32:22-27. [PMID: 37580998 DOI: 10.7748/en.2023.e2171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2023] [Indexed: 08/16/2023]
Abstract
Most patients with sickle cell disease (SCD) need support from healthcare services to manage their condition, including painful vaso-occlusive crises. Vaso-occlusive crises should be treated as a medical emergency, but the quality of the care patients receive when they present to the emergency department (ED) is often suboptimal. This article reports the findings of a literature review on the views of ED nurses and doctors about patients with SCD. The review included four studies, all of which had been conducted in the US, demonstrating that research on the topic is limited. The review found mostly negative views, including the belief that patients misuse pain medicines and demonstrate drug-seeking behaviours. Racial bias, widely recognised as a negative influence on the care of patients with SCD, was not mentioned in any of the studies. Staff education regarding SCD is required to ensure patients receive the care they need when they present to the ED.
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Affiliation(s)
- Hannah Jerman
- Guy's and St Thomas' NHS Foundation Trust, London, England
| | - Yan-Shing Chang
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, England
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2
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Chi G, AlKhalfan F, Lee JJ, Montazerin SM, Fitzgerald C, Korjian S, Omar W, Barnathan E, Plotnikov A, Gibson CM. Factors associated with early, late, and very late stent thrombosis among patients with acute coronary syndrome undergoing coronary stent placement: analysis from the ATLAS ACS 2-TIMI 51 trial. Front Cardiovasc Med 2024; 10:1269011. [PMID: 38259304 PMCID: PMC10800486 DOI: 10.3389/fcvm.2023.1269011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024] Open
Abstract
Background Stent thrombosis (ST) is an uncommon but serious complication of stent implantation. This study aimed to explore factors associated with early, late, and very late ST to help guide risk assessment and clinical decision-making on ST. Methods The analysis included patients who received stent placement for the index acute coronary syndrome (ACS). Cumulative incidence of ST was assessed at 30 days (early ST), 31-360 days (late ST), 361-720 days (very late ST), and up to 720 days. Cox proportional hazards models were used to assess associations between ST and various factors, including patient characteristics [i.e., age, sex, ACS presentation, history of hypertension, smoking, diabetes, prior myocardial infarction (MI), heart failure, prior ischemic stroke, and cancer], laboratory tests [i.e., positive cardiac biomarker, hemoglobin, platelet count, white blood cell (WBC) count], and treatment [i.e., drug-eluting stent (DES) vs. bare-metal stent (BMS) and anticoagulant with rivaroxaban vs. placebo]. Results Among the 8,741 stented patients, 155 ST events (2.25%) occurred by Day 720. The cumulative incidences of early, late, and very late ST were 0.80%, 0.81%, and 0.77%, respectively. After multivariable adjustment, age ≥ 75 [hazard ratio (HR) = 2.13 (95% confidence interval, CI: 1.26-3.60)], a history of prior MI [HR = 1.81 (95% CI: 1.22-2.68)], low hemoglobin level [HR = 2.34 (95% CI: 1.59-3.44)], and high WBC count [HR = 1.58 (95% CI: 1.02-2.46)] were associated with a greater risk of overall ST, whereas DES [HR = 0.56 (95% CI: 0.38-0.83)] and rivaroxaban therapy [HR = 0.63 (95% CI: 0.44-0.88)] were associated with a lower risk of overall ST up to 720 days. Low hemoglobin level and high WBC count were associated with early ST (low hemoglobin: HR = 2.35 [95% CI: 1.34-4.12]; high WBC count: HR = 2.11 [95% CI: 1.17-3.81]). Low hemoglobin level and prior MI were associated with a greater risk of late ST (low hemoglobin: HR = 2.32 [95% CI: 1.26-4.27]; prior MI: HR = 2.98 [95% CI: 1.67-5.31]), whereas DES was associated with a lower risk of late ST [HR = 0.33 (95% CI: 0.16-0.67)]. Age ≥75 years was associated with very late ST. Conclusion The study identified positive and negative associations with early, late, and very late ST. These variables may be useful in constructing risk assessment models for ST. Clinical Trial Registration http://www.clinicaltrials.gov, identifier NCT00809965.
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Affiliation(s)
- Gerald Chi
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Fahad AlKhalfan
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Jane J. Lee
- Department of Trial Design and Development, Baim Institute for Clinical Research, Boston, MA, United States
| | - Sahar Memar Montazerin
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Clara Fitzgerald
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Serge Korjian
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Wally Omar
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Elliot Barnathan
- Cardiovascular, Metabolism, Retina and Pulmonary Hypertension, Johnson & Johnson Pharmaceutical Research and Development, Raritan, NJ, United States
| | - Alexei Plotnikov
- Cardiovascular, Metabolism, Retina and Pulmonary Hypertension, Johnson & Johnson Pharmaceutical Research and Development, Raritan, NJ, United States
| | - C. Michael Gibson
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
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3
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Silva M, Faustino P. From Stress to Sick(le) and Back Again-Oxidative/Antioxidant Mechanisms, Genetic Modulation, and Cerebrovascular Disease in Children with Sickle Cell Anemia. Antioxidants (Basel) 2023; 12:1977. [PMID: 38001830 PMCID: PMC10669666 DOI: 10.3390/antiox12111977] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/30/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023] Open
Abstract
Sickle cell anemia (SCA) is a genetic disease caused by the homozygosity of the HBB:c.20A>T mutation, which results in the production of hemoglobin S (HbS). In hypoxic conditions, HbS suffers autoxidation and polymerizes inside red blood cells, altering their morphology into a sickle shape, with increased rigidity and fragility. This triggers complex pathophysiological mechanisms, including inflammation, cell adhesion, oxidative stress, and vaso-occlusion, along with metabolic alterations and endocrine complications. SCA is phenotypically heterogeneous due to the modulation of both environmental and genetic factors. Pediatric cerebrovascular disease (CVD), namely ischemic stroke and silent cerebral infarctions, is one of the most impactful manifestations. In this review, we highlight the role of oxidative stress in the pathophysiology of pediatric CVD. Since oxidative stress is an interdependent mechanism in vasculopathy, occurring alongside (or as result of) endothelial dysfunction, cell adhesion, inflammation, chronic hemolysis, ischemia-reperfusion injury, and vaso-occlusion, a brief overview of the main mechanisms involved is included. Moreover, the genetic modulation of CVD in SCA is discussed. The knowledge of the intricate network of altered mechanisms in SCA, and how it is affected by different genetic factors, is fundamental for the identification of potential therapeutic targets, drug development, and patient-specific treatment alternatives.
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Affiliation(s)
- Marisa Silva
- Departamento de Genética Humana, Instituto Nacional de Saúde Doutor Ricardo Jorge (INSA), Av. Padre Cruz, 1649-016 Lisboa, Portugal;
| | - Paula Faustino
- Departamento de Genética Humana, Instituto Nacional de Saúde Doutor Ricardo Jorge (INSA), Av. Padre Cruz, 1649-016 Lisboa, Portugal;
- Grupo Ecogenética e Saúde Humana, Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, 1649-028 Lisboa, Portugal
- Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, 1649-028 Lisboa, Portugal
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Elendu C, Amaechi DC, Alakwe-Ojimba CE, Elendu TC, Elendu RC, Ayabazu CP, Aina TO, Aborisade O, Adenikinju JS. Understanding Sickle cell disease: Causes, symptoms, and treatment options. Medicine (Baltimore) 2023; 102:e35237. [PMID: 37746969 PMCID: PMC10519513 DOI: 10.1097/md.0000000000035237] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/08/2023] [Accepted: 08/24/2023] [Indexed: 09/26/2023] Open
Abstract
Sickle cell disease (SCD) is a hereditary blood disorder characterized by the production of abnormal hemoglobin molecules that cause red blood cells to take on a crescent or sickle shape. This condition affects millions of people worldwide, particularly those of African, Mediterranean, Middle Eastern, and South Asian descent. This paper aims to provide an overview of SCD by exploring its causes, symptoms, and available treatment options. The primary cause of SCD is a mutation in the gene responsible for producing hemoglobin, the protein that carries oxygen in red blood cells. This mutation has abnormal hemoglobin called hemoglobin S, which causes red blood cells to become stiff and sticky, leading to various health complications. Patients with SCD may experience recurrent pain, fatigue, anemia, and increased infection susceptibility. Treatment options for SCD focus on managing symptoms and preventing complications. This includes pain management with analgesics, hydration, and blood transfusions to improve oxygen delivery. Hydroxyurea, a medication that increases the production of fetal hemoglobin, is commonly used to reduce the frequency and severity of pain crises. Additionally, bone marrow or stem cell transplants can cure select individuals with severe SCD. Finally, understanding the causes, symptoms, and treatment options for SCD is crucial for healthcare professionals, patients, and their families. It enables early diagnosis, effective symptom management, and improved quality of life for individuals with this chronic condition.
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Affiliation(s)
| | | | | | | | - Rhoda C. Elendu
- van Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
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5
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Roy NB, Carpenter A, Dale-Harris I, Dorée C, Estcourt LJ. Interventions for chronic kidney disease in people with sickle cell disease. Cochrane Database Syst Rev 2023; 8:CD012380. [PMID: 37539955 PMCID: PMC10404133 DOI: 10.1002/14651858.cd012380.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
BACKGROUND Sickle cell disease (SCD), one of the commonest severe monogenic disorders, is caused by the inheritance of two abnormal haemoglobin (beta-globin) genes. SCD can cause severe pain, significant end-organ damage, pulmonary complications, and premature death. Kidney disease is a frequent and potentially severe complication in people with SCD. Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function present for more than three months. Sickle cell nephropathy refers to the spectrum of kidney complications in SCD. Glomerular damage is a cause of microalbuminuria and can develop at an early age in children with SCD, with increased prevalence in adulthood. In people with sickle cell nephropathy, outcomes are poor as a result of the progression to proteinuria and chronic kidney insufficiency. Up to 12% of people who develop sickle cell nephropathy will develop end-stage renal disease. This is an update of a review first published in 2017. OBJECTIVES To assess the effectiveness of any intervention for preventing or reducing kidney complications or chronic kidney disease in people with sickle cell disease. Possible interventions include red blood cell transfusions, hydroxyurea, and angiotensin-converting enzyme inhibitors (ACEIs), either alone or in combination. SEARCH METHODS We searched for relevant trials in the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, CENTRAL, MEDLINE, Embase, seven other databases, and two other trials registers. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing interventions to prevent or reduce kidney complications or CKD in people with SCD. We applied no restrictions related to outcomes examined, language, or publication status. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility, extracted data, assessed the risk of bias, and assessed the certainty of the evidence (GRADE). MAIN RESULTS We included three RCTs with 385 participants. We rated the certainty of the evidence as low to very low across different outcomes according to GRADE methodology, downgrading for risk of bias concerns, indirectness, and imprecision. Hydroxyurea versus placebo One RCT published in 2011 compared hydroxyurea to placebo in 193 children aged nine to 18 months. We are unsure if hydroxyurea compared to placebo reduces or prevents progression of kidney disease assessed by change in glomerular filtration rate (mean difference (MD) 0.58 mL/min /1.73 m2, 95% confidence interval (CI) -14.60 to 15.76; 142 participants; very low certainty). Hydroxyurea compared to placebo may improve the ability to concentrate urine (MD 42.23 mOsm/kg, 95% CI 12.14 to 72.32; 178 participants; low certainty), and may make little or no difference to SCD-related serious adverse events, including acute chest syndrome (risk ratio (RR) 0.39, 99% CI 0.13 to 1.16; 193 participants; low certainty), painful crisis (RR 0.68, 99% CI 0.45 to 1.02; 193 participants; low certainty); and hospitalisations (RR 0.83, 99% CI 0.68 to 1.01; 193 participants; low certainty). No deaths occurred in either trial arm and the RCT did not report quality of life. Angiotensin-converting enzyme inhibitors versus placebo One RCT published in 1998 compared an ACEI (captopril) to placebo in 22 adults with normal blood pressure and microalbuminuria. We are unsure if captopril compared to placebo reduces proteinuria (MD -49.00 mg/day, 95% CI -124.10 to 26.10; 22 participants; very low certainty). We are unsure if captopril reduces or prevents kidney disease as measured by creatinine clearance; the trial authors stated that creatinine clearance remained constant over six months in both groups, but provided no comparative data (very low certainty). The RCT did not report serious adverse events, all-cause mortality, or quality of life. Angiotensin-converting enzyme inhibitors versus vitamin C One RCT published in 2020 compared an ACEI (lisinopril) with vitamin C in 170 children aged one to 18 years with normal blood pressure and microalbuminuria. It reported no data we could analyse. We are unsure if lisinopril compared to vitamin C reduces proteinuria in this population: the large drop in microalbuminuria in both arms of the trial after only one month on treatment may have been due to an overestimation of microalbuminuria at baseline rather than a true effect. The RCT did not report serious adverse events, all-cause mortality, or quality of life. AUTHORS' CONCLUSIONS We are unsure if hydroxyurea improves glomerular filtration rate or reduces hyperfiltration in children aged nine to 18 months, but it may improve their ability to concentrate urine and may make little or no difference to the incidence of acute chest syndrome, painful crises, and hospitalisations. We are unsure if ACEI compared to placebo has any effect on preventing or reducing kidney complications in adults with normal blood pressure and microalbuminuria. We are unsure if ACEI compared to vitamin C has any effect on preventing or reducing kidney complications in children with normal blood pressure and microalbuminuria. No RCTs assessed red blood cell transfusions or any combined interventions to prevent or reduce kidney complications. Due to lack of evidence, we cannot comment on the management of children aged over 18 months or adults with any known genotype of SCD. We have identified a lack of adequately designed and powered studies, although we found four ongoing trials since the last version of this review. Only one ongoing trial addresses renal function as a primary outcome in the short term, but such interventions have long-term effects. Trials of hydroxyurea, ACEIs or red blood cell transfusion in older children and adults are urgently needed to determine any effect on prevention or reduction of kidney complications in people with SCD.
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Affiliation(s)
- Noemi Ba Roy
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
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Akivis Y, Seidman I, Salciccioli L, Mcfarlane SI, Wengrofsky P, Muthu J, Budzikowski A, Khatun N, John S. Sickle Cell Disease and the Heart.. [DOI: 10.21203/rs.3.rs-3040535/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Abstract
Purpose
The objective of this study was to explore the relationship between cardiac structure, cardiac index (CI), and diastolic function parameters, and laboratory values in patients with Sickle Cell Disease (SCD), and to characterize the distinct SCD cardiomyopathy phenotype
Methods
We conducted a retrospective review of 202 adult patients with SCD (mean age 41.02 ± 13.36) at our hospital who underwent outpatient echocardiographic screening from 2019–2022.
Results
Our study identified cardiac hypertrophy, chamber dilatation with preserved ejection fraction, elevated TRV, increased cardiac output, and diastolic dysfunction as defining echocardiographic features in SCD. There was a negative correlation between CI and lateral e’ (R = -0.182, P = 0.012), and a positive correlation between CI and E/e’ (R = 0.274, P = 0.0001).
Conclusions
Our study identified a unique cardiomyopathy in patients with SCD characterized by cardiac hypertrophy with preserved systolic function, abnormal mitral inflow patterns, and elevated cardiac output. These features are indicative of restrictive physiology, as evidenced by left atrial enlargement and diastolic dysfunction, superimposed on hyperdynamic physiology. Further research is needed to elucidate the pathophysiological mechanisms underlying these observations and determine their prognostic significance in vulnerable populations with an elevated burden of cardiovascular disease, including the risk of sudden cardiac death.
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Dahi M, Moshari M, Dabir S, Vosoghian M, Tabashi S, Tavakoli N, Madadi F. Effect of Vitamin C Infusion on Cerebral Oximetry During General Anesthesia for Carotid Endarterectomy in Diabetic Patients. Anesth Pain Med 2023; 13:e134000. [PMID: 37404261 PMCID: PMC10317028 DOI: 10.5812/aapm-134000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 01/22/2023] [Accepted: 01/25/2023] [Indexed: 07/20/2023] Open
Abstract
Background There is conflicting information about the effect of vitamin C on brain oxygenation during anesthesia. Objectives The current study was designed and performed to assess the effect of vitamin C infusion and brain oxygenation with cerebral oximetry on improving brain perfusion during general anesthesia in vascular surgery of diabetic patients. Methods This randomized clinical trial was performed on patients candidates for endarterectomy under general anesthesia and referred to Taleghani Hospital in Tehran, Iran, during 2019 - 2020. Considering inclusion criteria, the patients were divided into placebo and intervention groups. The patients in the placebo group received 500 mL of isotonic saline. In the intervention group, the patients received 1 g of vitamin C diluted in 500 mL of isotonic saline by infusion half an hour before anesthesia induction. Patients' oxygen levels were continuously measured by a cerebral oximetry sensor. The patients were put in a supine position for 10 minutes before and after anesthesia. At the end of the surgery, the indicators considered in the study were evaluated. Results No considerable difference was observed between systolic and diastolic blood pressure, heart rate, mean arterial pressure, partial pressure of carbon dioxide, oxygen saturation, regional oxygen saturation, supercritical carbon dioxide, and end-tidal carbon dioxide in total and between the two groups in the three stages before and after anesthesia induction and at the end of surgery (P > 0.05). Additionally, there was no significant difference between blood sugar (BS) levels in the study groups (P > 0.05) but in BS levels at three stages before and after anesthesia induction and at the end of the surgery, with a significant difference (P < 0.05). Conclusions The amount of perfusion in the two groups and, therefore, in total at the three stages before and after anesthesia induction and at the end of surgery is not different.
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Affiliation(s)
- Mastaneh Dahi
- Department of Anesthesiology and Critical Care, Anesthesiology Research Center, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Moshari
- Department of Anesthesiology and Critical Care, Anesthesiology Research Center, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shideh Dabir
- Department of Anesthesiology and Critical Care, Anesthesiology Research Center, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Vosoghian
- Department of Anesthesiology and Critical Care, Anesthesiology Research Center, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Soodeh Tabashi
- Department of Anesthesiology and Critical Care, Anesthesiology Research Center, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Navid Tavakoli
- Department of Anesthesiology and Critical Care, Anesthesiology Research Center, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Firoozeh Madadi
- Department of Anesthesiology and Critical Care, Anesthesiology Research Center, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Light J, Boucher M, Baskin-Miller J, Winstead M. Managing the Cerebrovascular Complications of Sickle Cell Disease: Current Perspectives. J Blood Med 2023; 14:279-293. [PMID: 37082003 PMCID: PMC10112470 DOI: 10.2147/jbm.s383472] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/31/2023] [Indexed: 04/22/2023] Open
Abstract
The importance of protecting brain function for people with sickle cell disease (SCD) cannot be overstated. SCD is associated with multiple cerebrovascular complications that threaten neurocognitive function and life. Without screening and preventive management, 11% of children at 24% of adults with SCD have ischemic or hemorrhagic strokes. Stroke screening in children with SCD is well-established using transcranial Doppler ultrasound (TCD). TCD velocities above 200 cm/s significantly increase the risk of stroke, which can be prevented using chronic red blood cell (RBC) transfusion. RBC transfusion is also the cornerstone of acute stroke management and secondary stroke prevention. Chronic transfusion requires long-term management of complications like iron overload. Hydroxyurea can replace chronic transfusions for primary stroke prevention in a select group of patients or in populations where chronic transfusions are not feasible. Silent cerebral infarction (SCI) is even more common than stroke, affecting 39% of children and more than 50% of adults with SCD; management of SCI is individualized and includes careful neurocognitive evaluation. Hematopoietic stem cell transplant prevents cerebrovascular complications, despite the short- and long-term risks. Newer disease-modifying agents like voxelotor and crizanlizumab, as well as gene therapy, may treat cerebrovascular complications, but these approaches are investigational.
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Affiliation(s)
- Jennifer Light
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maria Boucher
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jacquelyn Baskin-Miller
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mike Winstead
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Correspondence: Mike Winstead, Division of Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC, USA, Tel +1 919-966-1178, Fax +1 919-966-7629, Email
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Genetic Modifiers of Sickle Cell Disease. Hematol Oncol Clin North Am 2022; 36:1097-1124. [DOI: 10.1016/j.hoc.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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10
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Nelson MD, Bennett DM, Lehman ME, Okonji AI. Dizziness, Falls, and Hearing Loss in Adults Living With Sickle Cell Disease. Am J Audiol 2022; 31:1178-1190. [DOI: 10.1044/2022_aja-22-00059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Objective:
The aim of this study was to assess the prevalence of reported dizziness/imbalance, frequency of falls, and hearing loss in adults with sickle cell disease (SCD) and determine the relationship of these self-reported problems both during and in the absence of an SCD crisis. Also, the impact of educational level and health insurance on seeking treatment services, as well as the relationship of falls to stroke, legal blindness, and other orthopedic problems, was assessed. Interrupted blood flow to shared vestibular and auditory arteries supports the notion of increased likelihood of balance deficits and increased falls in this population.
Design:
A cross-sectional survey study design was used. Adults living with SCD responded to a questionnaire that was distributed online and through traditional mail.
Study Sample:
Adults living with SCD (
N
= 135) participated in the study.
Results:
Responses revealed 70% of participants with SCD experienced dizziness/imbalance and 23% reported hearing loss. Furthermore, 33% of participants reported falling one or more times in the last year. The prevalence of dizziness/imbalance, falling, and hearing loss in the respondents with SCD was much higher than that of the general population of the United States. Additionally, for dizziness and falling, the prevalence was higher not only than the national average but also for persons over 65 years of age. A significant association was demonstrated between dizziness/imbalance and hearing loss as well as dizziness/imbalance and falls for adults living with SCD. In fact, participants with self-reported hearing loss were 5.2 times more likely to also report dizziness/imbalance. They were 4.9 times more likely to fall if they also reported dizziness/imbalance. Numbness of the feet was revealed to significantly impact the likelihood of falling in this disease population and should be further studied. Regarding SCD crisis status, dizziness/imbalance and falls were more likely to occur outside of SCD crisis than during a crisis. Furthermore, pain levels were significantly associated with dizziness/imbalance only when respondents were in crisis and not in the absence of a crisis. In crisis, higher pain levels were reported from respondents who also reported dizziness/imbalance than from those who did not report dizziness. No significant relationship was revealed between hearing loss and falls.
Discussion:
These results provide justification for patient and health care provider education regarding appropriate referrals for vestibular/balance assessments and provision of fall prevention strategies. Future studies on balance and SCD are encouraged.
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Altered VWF:ADAMTS13 homeostasis is a target for therapeutic intervention in sickle cell disease. Proc Natl Acad Sci U S A 2022; 119:e2213079119. [PMID: 36170252 PMCID: PMC9546592 DOI: 10.1073/pnas.2213079119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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12
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Palomarez A, Jha M, Medina Romero X, Horton RE. Cardiovascular consequences of sickle cell disease. BIOPHYSICS REVIEWS 2022; 3:031302. [PMID: 38505276 PMCID: PMC10903381 DOI: 10.1063/5.0094650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/11/2022] [Indexed: 03/21/2024]
Abstract
Sickle cell disease (SCD) is an inherited blood disorder caused by a single point mutation within the beta globin gene. As a result of this mutation, hemoglobin polymerizes under low oxygen conditions causing red blood cells to deform, become more adhesive, and increase in rigidity, which affects blood flow dynamics. This process leads to enhanced red blood cell interactions with the endothelium and contributes to vaso-occlusion formation. Although traditionally defined as a red blood cell disorder, individuals with SCD are affected by numerous clinical consequences including stroke, painful crisis episodes, bone infarctions, and several organ-specific complications. Elevated cardiac output, endothelium activation along with the sickling process, and the vaso-occlusion events pose strains on the cardiovascular system. We will present a review of the cardiovascular consequences of sickle cell disease and show connections with the vasculopathy related to SCD. We will also highlight biophysical properties and engineering tools that have been used to characterize the disease. Finally, we will discuss therapies for SCD and potential implications on SCD cardiomyopathy.
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Affiliation(s)
- Alexis Palomarez
- Department of Biomedical Engineering, Cullen College of Engineering, University of Houston, Houston, Texas 77204, USA
| | - Manisha Jha
- Department of Biomedical Engineering, Cullen College of Engineering, University of Houston, Houston, Texas 77204, USA
| | - Ximena Medina Romero
- Department of Biomedical Engineering, Cullen College of Engineering, University of Houston, Houston, Texas 77204, USA
| | - Renita E. Horton
- Department of Biomedical Engineering, Cullen College of Engineering, University of Houston, Houston, Texas 77204, USA
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Torres LS, Asada N, Weiss MJ, Trumpp A, Suda T, Scadden DT, Ito K. Recent advances in "sickle and niche" research - Tribute to Dr. Paul S Frenette. Stem Cell Reports 2022; 17:1509-1535. [PMID: 35830837 PMCID: PMC9287685 DOI: 10.1016/j.stemcr.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 10/27/2022] Open
Abstract
In this retrospective, we review the two research topics that formed the basis of the outstanding career of Dr. Paul S. Frenette. In the first part, we focus on sickle cell disease (SCD). The defining feature of SCD is polymerization of the deoxygenated mutant hemoglobin, which leads to a vicious cycle of hemolysis and vaso-occlusion. We survey important discoveries in SCD pathophysiology that have led to recent advances in treatment of SCD. The second part focuses on the hematopoietic stem cell (HSC) niche, the complex microenvironment within the bone marrow that controls HSC function and homeostasis. We detail the cells that constitute this niche, and the factors that these cells use to exert control over hematopoiesis. Here, we trace the scientific paths of Dr. Frenette, highlight key aspects of his research, and identify his most important scientific contributions in both fields.
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Affiliation(s)
- Lidiane S Torres
- Ruth L. and David S. Gottesman Institute for Stem Cell and Regenerative Medicine Research, Albert Einstein College of Medicine, Bronx, New York, NY 10461, USA; Department of Cell Biology, Albert Einstein College of Medicine, Bronx, New York, NY 10461, USA; Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, NY 10461, USA
| | - Noboru Asada
- Department of Hematology and Oncology, Okayama University Hospital, Okayama 700-8558, Japan
| | - Mitchell J Weiss
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Andreas Trumpp
- Division of Stem Cells and Cancer, German Cancer Research Center (DKFZ) and DKFZ-ZMBH Alliance, 69120 Heidelberg, Germany; Heidelberg Institute for Stem Cell Technology and Experimental Medicine (HI-STEM gGmbH), 69120 Heidelberg, Germany; Faculty of Biosciences, Heidelberg University, 69117 Heidelberg, Germany; German Cancer Consortium (DKTK), 69120 Heidelberg, Germany
| | - Toshio Suda
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore; International Research Center for Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - David T Scadden
- Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, MA, USA; Harvard Stem Cell Institute, Harvard University, Cambridge, MA, USA; Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Keisuke Ito
- Ruth L. and David S. Gottesman Institute for Stem Cell and Regenerative Medicine Research, Albert Einstein College of Medicine, Bronx, New York, NY 10461, USA; Department of Cell Biology, Albert Einstein College of Medicine, Bronx, New York, NY 10461, USA; Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, NY 10461, USA; Montefiore Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, New York, NY 10461, USA; Einstein Diabetes Research Center, Albert Einstein College of Medicine, Bronx, NY, USA.
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14
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Al-Eyadhy A, Al-Jelaify MR. Suboptimal vancomycin levels in critically ill children with sickle cell disease and acute chest syndrome. J Infect Chemother 2022; 28:1304-1309. [DOI: 10.1016/j.jiac.2022.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/24/2022] [Accepted: 05/29/2022] [Indexed: 10/18/2022]
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TGF-β1 Reduces Neutrophil Adhesion and Prevents Acute Vaso-Occlusive Processes in Sickle Cell Disease Mice. Cells 2022; 11:cells11071200. [PMID: 35406764 PMCID: PMC8998040 DOI: 10.3390/cells11071200] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 12/26/2022] Open
Abstract
Sickle cell disease (SCD) patients experience chronic inflammation and recurrent vaso-occlusive episodes during their entire lifetime. Inflammation in SCD occurs with the overexpression of several inflammatory mediators, including transforming growth factor beta-1 (TGF-β1), a major immune regulator. In this study, we aimed to investigate the role played by TGF-β1 in vascular inflammation and vaso-occlusion in an animal model of SCD. Using intravital microscopy, we found that a daily dose of recombinant TGF-β1 administration for three consecutive days significantly reduced TNFα-induced leukocyte rolling, adhesion, and extravasation in the microcirculation of SCD mice. In contrast, immunological neutralization of TGF-β, in the absence of inflammatory stimulus, considerably increased these parameters. Our results indicate, for the first time, that TGF-β1 may play a significant ameliorative role in vascular SCD pathophysiology, modulating inflammation and vaso-occlusion. The mechanisms by which TGF-β1 exerts its anti-inflammatory effects in SCD, however, remains unclear. Our in vitro adhesion assays with TNFα-stimulated human neutrophils suggest that TGF-β1 can reduce the adhesive properties of these cells; however, direct effects of TGF-β1 on the endothelium cannot be ruled out. Further investigation of the wide range of the complex biology of this cytokine in SCD pathophysiology and its potential therapeutical use is needed.
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Silva M, Coelho A, Vargas S, Faustino P. VCAM1, HMOX1 and NOS3 differential endothelial expression may impact sickle cell anemia vasculopathy. Blood Cells Mol Dis 2022; 93:102639. [PMID: 34999313 DOI: 10.1016/j.bcmd.2021.102639] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 12/21/2021] [Accepted: 12/21/2021] [Indexed: 10/19/2022]
Abstract
Endothelial dysfunction plays a major role in sickle cell anemia (SCA) systemic vasculopathy, with upregulation of adhesion molecules (e.g., VCAM-1), decreased nitric oxide bioavailability, and oxidative stress. We aimed to assess the modulation role of pro-inflammatory and pro-oxidative stimuli on endothelial VCAM1, NOS3, and HMOX1 expression. We also evaluated the effect of the main SCA therapeutic agent, hydroxyurea, on that modulation. Our results showed that two VCAM1 promoter haplotypes, we previously associated with pediatric cerebral vasculopathy and severe hemolysis in SCA, increased promoter activity in TNF-α-stimulated transfected EA.hy926 and HBEC cell lines, consistent with a higher VCAM1 expression in macro and microvascular settings. In non-transfected cells, we also observed TNF-α-induced VCAM1 overexpression as well as heme-induced overexpression of HMOX1 in both cell models. Heme did not affect VCAM1 nor NOS3 expression and the latter was also not affected by TNF-α stimulus. Hydroxyurea treatment lowered TNF-induced VCAM1 and NOS3 expression but did not affect heme-induced HMOX1 expression. These data further indicate that VCAM1 haplotypes we studied lead to higher VCAM1 expression affecting not only cerebral but also systemic vasculopathy risk. The differential endothelial expression of VCAM1, NOS3, and HMOX1 also confirms their genetic modulation role in SCA systemic vasculopathy.
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Affiliation(s)
- Marisa Silva
- Departamento de Genética Humana, Instituto Nacional de Saúde Dr. Ricardo Jorge, Lisbon, Portugal
| | - Andreia Coelho
- Departamento de Genética Humana, Instituto Nacional de Saúde Dr. Ricardo Jorge, Lisbon, Portugal
| | - Sofia Vargas
- Departamento de Genética Humana, Instituto Nacional de Saúde Dr. Ricardo Jorge, Lisbon, Portugal
| | - Paula Faustino
- Departamento de Genética Humana, Instituto Nacional de Saúde Dr. Ricardo Jorge, Lisbon, Portugal; Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal; Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.
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Hu Z, Bie L, Gao J, Wang X. Insights into Selectin Inhibitor Design from Endogenous Isomeric Ligands of SLe a and SLe x. J Chem Inf Model 2021; 61:6085-6093. [PMID: 34905361 DOI: 10.1021/acs.jcim.1c01356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Selectins interact with cell-surface glycans to promote the initial tethering and rolling of leukocytes, and these interactions are targets for designs of inhibitors to neutralize diseases related to excessive inflammatory responses in many cardiovascular and immune dysfunctions, as well as tumor markers in different cancers. The isomeric endogenous tetrasaccharides, sialyl Lewis X (sLex) and sialyl Lewis A (sLea), are minimal sugar structures required for selectin binding. Understanding their subtle structural variances and significant advanced binding strengths of sLea over sLex could benefit the rational designs for selectin inhibitors. Modeling based on the E-selectin-sLex crystal structure in the present study demonstrated that the N-acetyl group of GlcNAc in sLex could form steric hindrances in the E-selectin-sLex complex, but the hydroxy methylene group of GlcNAc in sLea at the same position allows for stronger binding interactions. The subsequent designed inhibitor with a synthetic accessible linker molecule that has no exo-cyclic moieties replacing GlcNAc displayed comparable dynamic and energetic binding features to sLea. The present study deciphered the clues from endogenous isomeric sLea and sLex and provided insights into designing selectin inhibitors with simplified synthesis.
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Affiliation(s)
- Zhicheng Hu
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Lihua Bie
- Hubei Key Laboratory of Agricultural Bioinformatics, College of Informatics, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Jun Gao
- Hubei Key Laboratory of Agricultural Bioinformatics, College of Informatics, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Xiaocong Wang
- Hubei Key Laboratory of Agricultural Bioinformatics, College of Informatics, Huazhong Agricultural University, Wuhan, Hubei 430070, China
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Biassi TP, Guerra-Shinohara EM, Moretti PNS, de Freitas Dutra V, Cabañas-Pedro AC, Mecabo G, Colleoni GWB, Figueiredo MS. miRNA profile and disease severity in patients with sickle cell anemia. Ann Hematol 2021; 101:27-34. [PMID: 34677646 DOI: 10.1007/s00277-021-04665-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 09/12/2021] [Indexed: 11/26/2022]
Abstract
Identification of biomarkers associated with severity in sickle cell anemia is desirable. Circulating serum microRNAs (miRNA) are targets studied as diagnostic or prognostic markers, but few studies have been conducted in sickle cell anemia. The purpose of this study is to identify specific signatures of miRNAs in plasma samples from sickle cell anemia patients according to severity indexes. Screening of the miRNAs expression was performed in 8 patients, classified by tricuspid regurgitation velocity (TRV) measure: 4 with TRV ≥ 2.5 m/s and 4 with TRV < 2.5 m/s. The samples were analyzed by real-time PCR using Megaplex RT Human Pool A and Pool B comprising 667 distinct miRNAs. Seventeen miRNAs were differentially expressed between the two groups (p < 0.05). Five differentially expressed miRNAs (miR15b, miR502, miR510, miR544, miR629) were selected for validation in a cohort of 52 patient samples, 26 with TRV ≥ 2.5 m/s. Another two severity scores were also used: organ injury score (OIS) and Bayesian score (BS). Univariate binary logistic regressions were performed to analyze the data. Five out of 17 differentially expressed miRNAs were selected for validation in 52 patient samples: miR15b, miR502, miR510, miR544, and miR629. Two miRNAs (miR510 and miR629) were significantly decreased in cases of greater severity. Whereas miR510 expression discriminated the patients according to TRV and OIS, miR629 expression did it according to BS. This is the first study investigating plasma miRNAs as possible biomarkers for SCA severity. Our data suggest that low levels of miR510 and miR629 expression are associated with greater SCA disease severity. Further studies are still necessary to elucidate mechanism of these miRNAs and their related proteins.
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Affiliation(s)
- Thaís Priscila Biassi
- Hematology and Blood Transfusion Division, Universidade Federal de São Paulo UNIFESP, Sao Paulo, Brazil.
| | | | | | - Valeria de Freitas Dutra
- Hematology and Blood Transfusion Division, Universidade Federal de São Paulo UNIFESP, Sao Paulo, Brazil
| | | | - Grazielle Mecabo
- Hematology and Blood Transfusion Division, Universidade Federal de São Paulo UNIFESP, Sao Paulo, Brazil
| | | | - Maria Stella Figueiredo
- Hematology and Blood Transfusion Division, Universidade Federal de São Paulo UNIFESP, Sao Paulo, Brazil
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19
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Knisely MR, Tanabe PJ, Yang Q, Masese R, Jiang M, Shah NR. Severe Pain Profiles and Associated Sociodemographic and Clinical Characteristics in Individuals With Sickle Cell Disease. Clin J Pain 2021; 37:669-677. [PMID: 34265788 PMCID: PMC8373671 DOI: 10.1097/ajp.0000000000000957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 03/18/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to identify classes of individuals with sickle cell disease (SCD) who share distinct severe pain profiles and evaluate differences in demographic, clinical, and psychosocial characteristics between classes. METHODS This exploratory, cross-sectional study used data collected for the SCD Implementation Consortium Research Registry at Duke University. Using Adult Sickle Cell Quality of Life-Measurement System pain-item data from 291 adults with SCD, latent class analysis was used to determine classes of individuals sharing distinct severe pain profiles. Bivariate analyses and logistic regression models were used to assess the relationships between pain profile classes and demographic, clinical, and psychosocial characteristics. RESULTS Three classes sharing distinct severe pain profiles were identified: Low Frequency and Impact class (n=73), Moderate Frequency and Impact class (n=94), and High Frequency and Impact class (n=124). When compared with the Low Frequency and Impact class and controlling for age and sex, individuals in the Moderate Frequency and Impact class were more likely to: be female (P=0.031) and unemployed (P=0.013); report worse sleep (P=0.005) and social functioning (P=0.005); have less emotional distress (P=0.004); describe pain as "sore" (P=0.002); and have previous SCD-related lung complications (P=0.016). When compared with the Low Frequency and Impact class, individuals in the High Frequency and Impact class: had worse social functioning (P<0.001) and previous SCD-related lung complications (P=0.006); described pain as "sore" (P<0.001); and were taking pain medication daily for SCD (P=0.001). DISCUSSION Severe pain experiences in SCD are complex; however, there are subgroups of people who report similar experiences of severe pain.
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Affiliation(s)
| | - Paula J Tanabe
- Duke University School of Nursing
- Duke University School of Medicine, Durham, NC
| | | | | | - Meilin Jiang
- Department of Biostatistics, University of Florida, Gainesville, FL
| | - Nirmish R Shah
- Duke University School of Nursing
- Duke University School of Medicine, Durham, NC
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20
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Conran N, Embury SH. Sickle cell vaso-occlusion: The dialectic between red cells and white cells. Exp Biol Med (Maywood) 2021; 246:1458-1472. [PMID: 33794696 DOI: 10.1177/15353702211005392] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The pathophysiology of sickle cell anemia, a hereditary hemoglobinopathy, has fascinated clinicians and scientists alike since its description over 100 years ago. A single gene mutation in the HBB gene results in the production of abnormal hemoglobin (Hb) S, whose polymerization when deoxygenated alters the physiochemical properties of red blood cells, in turn triggering pan-cellular activation and pathological mechanisms that include hemolysis, vaso-occlusion, and ischemia-reperfusion to result in the varied and severe complications of the disease. Now widely regarded as an inflammatory disease, in recent years attention has included the role of leukocytes in vaso-occlusive processes in view of the part that these cells play in innate immune processes, their inherent ability to adhere to the endothelium when activated, and their sheer physical and potentially obstructive size. Here, we consider the role of sickle red blood cell populations in elucidating the importance of adhesion vis-a-vis polymerization in vaso-occlusion, review the direct adhesion of sickle red cells to the endothelium in vaso-occlusive processes, and discuss how red cell- and leukocyte-centered mechanisms are not mutually exclusive. Given the initial clinical success of crizanlizumab, a specific anti-P selectin therapy, we suggest that it is appropriate to take a holistic approach to understanding and exploring the complexity of vaso-occlusive mechanisms and the adhesive roles of the varied cell types, including endothelial cells, platelets, leukocytes, and red blood cells.
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Affiliation(s)
- Nicola Conran
- Hematology Center, University of Campinas-UNICAMP, Barão Geraldo 13083-8, Campinas, SP, Brazil
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21
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Lapping-Carr G, Gemel J, Mao Y, Sparks G, Harrington M, Peddinti R, Beyer EC. Circulating extracellular vesicles from patients with acute chest syndrome disrupt adherens junctions between endothelial cells. Pediatr Res 2021; 89:776-784. [PMID: 32454519 PMCID: PMC8261277 DOI: 10.1038/s41390-020-0923-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 03/28/2020] [Accepted: 04/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Small cell-derived extracellular vesicles (EVs) can affect endothelial function. We previously found that patients with sickle cell disease (SCD) have greater numbers of circulating EVs than subjects without the disease, and the EVs differentially disrupt endothelial integrity in vitro. Because endothelial disruption is a critical component of acute chest syndrome (ACS), we hypothesized that EVs isolated during ACS would induce greater endothelial damage than those isolated at baseline. METHODS Nine pediatric subjects had plasma isolated at baseline and during ACS from which EVs were isolated. Cultured microvascular endothelial cells were treated with EVs and then studied by immunofluorescence microscopy to localize VE-cadherin and F-actin. RESULTS The EVs had a diameter of 95 nm. They contained CD63 and flotillin-1, which were increased in SCD patients (5-13-fold compared to control) and further increased between baseline and ACS (24-57%). The EVs contained hemoglobin, glycophorin A, and ferritin. Treatment with baseline EVs caused modest separation of endothelial cells, while ACS EVs caused substantial disruptions of the endothelial cell monolayers. EVs from subjects with ACS also caused a 50% decrease in protein levels of VE-cadherin. CONCLUSIONS These results suggest that circulating EVs can modulate endothelial integrity contributing to the development of ACS in SCD patients by altering cadherin-containing intercellular junctions. IMPACT Sickle cell disease patients have circulating extracellular vesicles (EVs) that modulate endothelial integrity by altering cadherin-containing intercellular junctions. Disruption is more severe by EVs obtained during acute chest syndrome (ACS). These results expand our knowledge of the pathophysiology of acute chest syndrome and the vasculopathies of sickle cell disease.
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Affiliation(s)
| | - Joanna Gemel
- Department of Pediatrics, University of Chicago, Chicago, IL, USA
| | - Yifan Mao
- Department of Pediatrics, University of Chicago, Chicago, IL, USA
| | - Gianna Sparks
- Department of Pediatrics, University of Chicago, Chicago, IL, USA
| | | | - Radhika Peddinti
- Department of Pediatrics, University of Chicago, Chicago, IL, USA
| | - Eric C. Beyer
- Department of Pediatrics, University of Chicago, Chicago, IL, USA
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Khaibullina A, Almeida LEF, Kamimura S, Zerfas PM, Smith ML, Vogel S, Wakim P, Vasconcelos OM, Quezado MM, Horkayne-Szakaly I, Quezado ZMN. Sickle cell disease mice have cerebral oxidative stress and vascular and white matter abnormalities. Blood Cells Mol Dis 2021; 86:102493. [PMID: 32927249 PMCID: PMC7686096 DOI: 10.1016/j.bcmd.2020.102493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 02/06/2023]
Abstract
Strokes are feared complications of sickle cell disease (SCD) and yield significant neurologic and neurocognitive deficits. However, even without detectable strokes, SCD patients have significant neurocognitive deficits in domains of learning and memory, processing speed and executive function. In these cases, mechanisms unrelated to major cerebrovascular abnormalities likely underlie these deficits. While oxidative stress and stress-related signaling pathways play a role in SCD pathophysiology, their role in cerebral injury remains unknown. We have shown that Townes and BERK SCD mice, while not having strokes, recapitulate neurocognitive deficits reported in humans. We hypothesized that cognitive deficits in SCD mice are associated with cerebral oxidative stress. We showed that SCD mice have increased levels of reactive oxygen species, protein carbonylation, and lipid peroxidation in hippocampus and cortex, thus suggesting increased cerebral oxidative stress. Further, cerebral oxidative stress was associated with caspase-3 activity alterations and vascular endothelial abnormalities, white matter changes, and disruption of the blood brain barrier, similar to those reported after ischemic/oxidative injury. Additionally, after repeated hypoxia/reoxygenation exposure, homozygous Townes had enhanced microglia activation. Our findings indicate that oxidative stress and stress-induced tissue damage is increased in susceptible brain regions, which may, in turn, contribute to neurocognitive deficits in SCD mice.
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Affiliation(s)
- Alfia Khaibullina
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, United States of America
| | - Luis E F Almeida
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, United States of America
| | - Sayuri Kamimura
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, United States of America
| | - Patricia M Zerfas
- Office of Research Services, Office of the Director, National Institutes of Health, Bethesda, MD 20892, United States of America
| | - Meghann L Smith
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, United States of America
| | - Sebastian Vogel
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, United States of America
| | - Paul Wakim
- Biostatistics and Clinical Epidemiology Service, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, United States of America
| | - Olavo M Vasconcelos
- Neuromuscular Clinic, Electromyography Laboratory, Intraoperative Neurophysiology Monitoring Sections, Veterans Health Administration Medical Center, Virginia Commonwealth University, Richmond, VA 23249, United States of America
| | - Martha M Quezado
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, United States of America
| | - Iren Horkayne-Szakaly
- Neuropathology and Ophthalmic Pathology, Joint Pathology Center, Defense Health Agency, Silver Spring, MD 20910, United States of America
| | - Zenaide M N Quezado
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, United States of America.
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Argueta DA, Aich A, Muqolli F, Cherukury H, Sagi V, DiPatrizio NV, Gupta K. Considerations for Cannabis Use to Treat Pain in Sickle Cell Disease. J Clin Med 2020; 9:E3902. [PMID: 33271850 PMCID: PMC7761429 DOI: 10.3390/jcm9123902] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/22/2020] [Accepted: 11/26/2020] [Indexed: 12/18/2022] Open
Abstract
Pain in Sickle Cell Disease (SCD) is a major comorbidity and unique with acute pain due to recurrent and episodic vaso-occlusive crises as well as chronic pain, which can span an individual's entire life. Opioids are the mainstay treatment for pain in SCD. Due to recent health crises raised by adverse effects including deaths from opioid use, pain management in SCD is adversely affected. Cannabis and its products are most widely used for pain in multiple conditions and also by patients with SCD on their own. With the availability of "Medical Cannabis" and approval to use cannabis as medicine across majority of States in the United States as well as over-the-counter preparations, cannabis products are being used increasingly for SCD. The reliability of many of these products remains questionable, which poses a major health risk to the vulnerable individuals seeking pain relief. Therefore, this review provides up to date insights into available categories of cannabis-based treatment strategies, their mechanism of action and pre-clinical and clinical outcomes in SCD. It provides evidence for the benefits and risks of cannabis use in SCD and cautions about the unreliable and unvalidated products that may be adulterated with life-threatening non-cannabis compounds.
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Affiliation(s)
- Donovan A. Argueta
- Hematology/Oncology, Department of Medicine, University of California, Irvine, CA 92868, USA; (D.A.A.); (A.A.); (F.M.); (H.C.)
| | - Anupam Aich
- Hematology/Oncology, Department of Medicine, University of California, Irvine, CA 92868, USA; (D.A.A.); (A.A.); (F.M.); (H.C.)
| | - Fjolla Muqolli
- Hematology/Oncology, Department of Medicine, University of California, Irvine, CA 92868, USA; (D.A.A.); (A.A.); (F.M.); (H.C.)
| | - Hemanth Cherukury
- Hematology/Oncology, Department of Medicine, University of California, Irvine, CA 92868, USA; (D.A.A.); (A.A.); (F.M.); (H.C.)
| | - Varun Sagi
- Department of Hematology, Oncology, and Transplantation, University of Minnesota, Twin Cities, MN 55455, USA;
| | - Nicholas V. DiPatrizio
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, CA 92521, USA;
| | - Kalpna Gupta
- Hematology/Oncology, Department of Medicine, University of California, Irvine, CA 92868, USA; (D.A.A.); (A.A.); (F.M.); (H.C.)
- Southern California Institute for Research and Education, Long Beach VA Medical Center, Long Beach, CA 90822, USA
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Hebbel RP, Belcher JD, Vercellotti GM. The multifaceted role of ischemia/reperfusion in sickle cell anemia. J Clin Invest 2020; 130:1062-1072. [PMID: 32118586 DOI: 10.1172/jci133639] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Sickle cell anemia is a unique disease dominated by hemolytic anemia and vaso-occlusive events. The latter trigger a version of ischemia/reperfusion (I/R) pathobiology that is singular in its origin, cyclicity, complexity, instability, perpetuity, and breadth of clinical consequences. Specific clinical features are probably attributable to local I/R injury (e.g., stroke syndromes) or remote organ injury (e.g., acute chest syndrome) or the systematization of inflammation (e.g., multifocal arteriopathy). Indeed, by fashioning an underlying template of endothelial dysfunction and vulnerability, the robust inflammatory systematization no doubt contributes to all sickle pathology. In this Review, we highlight I/R-targeting therapeutics shown to improve microvascular blood flow in sickle transgenic mice undergoing I/R, and we suggest how such insights might be translated into human therapeutic strategies.
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25
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Shet AS, Lizarralde-Iragorri MA, Naik RP. The molecular basis for the prothrombotic state in sickle cell disease. Haematologica 2020; 105:2368-2379. [PMID: 33054077 PMCID: PMC7556662 DOI: 10.3324/haematol.2019.239350] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/22/2020] [Indexed: 12/15/2022] Open
Abstract
The genetic and molecular basis of sickle cell disease (SCD) has long since been characterized but the pathophysiological basis is not entirely defined. How a red cell hemolytic disorder initiates inflammation, endothelial dysfunction, coagulation activation and eventually leads to vascular thrombosis, is yet to be elucidated. Recent evidence has demonstrated a high frequency of unprovoked/recurrent venous thromboembolism (VTE) in SCD, with an increased risk of mortality among patients with a history of VTE. Here, we thoroughly review the molecular basis for the prothrombotic state in SCD, specifically highlighting emerging evidence for activation of overlapping inflammation and coagulation pathways, that predispose to venous thromboembolism. We share perspectives in managing venous thrombosis in SCD, highlighting innovative therapies with the potential to influence the clinical course of disease and reduce thrombotic risk, while maintaining an acceptable safety profile.
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Affiliation(s)
- Arun S. Shet
- Laboratory of Sickle Thrombosis and Vascular Biology, National Heart, Lung, and Blood Institute, NIH, Bethesda
| | | | - Rakhi P. Naik
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Conran N, De Paula EV. Thromboinflammatory mechanisms in sickle cell disease - challenging the hemostatic balance. Haematologica 2020; 105:2380-2390. [PMID: 33054078 PMCID: PMC7556678 DOI: 10.3324/haematol.2019.239343] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/19/2020] [Indexed: 11/11/2022] Open
Abstract
Sickle cell disease (SCD) is an inherited hemoglobinopathy that is caused by the presence of abnormal hemoglobin S (HbS) in red blood cells, leading to alterations in red cell properties and shape, as the result of HbS dexoygenation and subsequent polymerization. SCD pathophysiology is characterized by chronic inflammatory processes, triggered by hemolytic and vaso-occlusive events, which lead to the varied complications, organ damage and elevated mortality seen in individuals with the disease. In association with activation of the endothelium and leukocytes, hemostatic alterations and thrombotic events are well-documented in SCD. Here we discuss the role for inflammatory pathways in modulating coagulation and inducing platelet activation in SCD, due to tissue factor activation, adhesion molecule expression, inflammatory mediator production and the induction of innate immune responses, amongst other mechanisms. Thromboinflammatory pathways may play a significant role in some of the major complications of SCD, such as stroke, venous thromboembolism and possibly acute chest syndrome, besides exacerbating the chronic inflammation and cellular interactions that trigger vaso-occlusion, ischemia-reperfusion processes, and eventually organ damage.
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Affiliation(s)
- Nicola Conran
- Hematology Center, University of Campinas, UNICAMP, Cidade Universitária, Campinas-SP, Brazil
| | - Erich V. De Paula
- Hematology Center, University of Campinas, UNICAMP, Cidade Universitária, Campinas-SP, Brazil
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Wang X, Bie L, Fei J, Gao J. Insights into the Loop at the E-Selectin Binding Site: From Open to Close Conformation. J Chem Inf Model 2020; 60:5153-5161. [DOI: 10.1021/acs.jcim.0c00939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Xiaocong Wang
- Hubei Key Laboratory of Agricultural Bioinformatics, College of Informatics, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Lihua Bie
- Hubei Key Laboratory of Agricultural Bioinformatics, College of Informatics, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Junwen Fei
- Hubei Key Laboratory of Agricultural Bioinformatics, College of Informatics, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Jun Gao
- Hubei Key Laboratory of Agricultural Bioinformatics, College of Informatics, Huazhong Agricultural University, Wuhan, Hubei 430070, China
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Lapping-Carr G, Gemel J, Mao Y, Beyer EC. Circulating Extracellular Vesicles and Endothelial Damage in Sickle Cell Disease. Front Physiol 2020; 11:1063. [PMID: 33013455 PMCID: PMC7495019 DOI: 10.3389/fphys.2020.01063] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/31/2020] [Indexed: 12/12/2022] Open
Abstract
Endothelial damage is central to the pathogenesis of many of the complications of sickle cell disease. Circulating extracellular vesicles (EVs) have been implicated in modulating endothelial behavior in a variety of different, diseases with vascular pathologies. As seen in other hemolytic diseases, the plasma of sickle cell patients contains EVs of different sizes and cellular sources. The medium-sized vesicles (microparticles) primarily derive from mature red blood cells and platelets; some of these EVs have procoagulant properties, while others stimulate inflammation or endothelial adhesiveness. Most of the small EVs (including exosomes) derive from erythrocytes and erythrocyte precursors, but some also originate from platelets, white blood cells, and endothelial cells. These small EVs may alter the behavior of target cells by delivering cargo including proteins and nucleic acids. Studies in model systems implicate small EVs in promoting vaso-occlusion and disruption of endothelial integrity. Thus, both medium and small EVs may contribute to the increased endothelial damage in sickle cell disease. Development of a detailed understanding of the composition and roles of circulating EVs represents a promising approach toward novel predictive diagnostics and therapeutic approaches in sickle cell disease.
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Affiliation(s)
| | - Joanna Gemel
- Department of Pediatrics, The University of Chicago, Chicago, IL, United States
| | - Yifan Mao
- Department of Pediatrics, The University of Chicago, Chicago, IL, United States
| | - Eric C Beyer
- Department of Pediatrics, The University of Chicago, Chicago, IL, United States
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29
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CXCR4 hi effector neutrophils in sickle cell anemia: potential role for elevated circulating serotonin (5-HT) in CXCR4 hi neutrophil polarization. Sci Rep 2020; 10:14262. [PMID: 32868775 PMCID: PMC7459317 DOI: 10.1038/s41598-020-71078-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 08/07/2020] [Indexed: 01/01/2023] Open
Abstract
Leukocyte recruitment and heterocellular aggregate formation drive the inflammatory vaso-occlusive processes associated with sickle cell anemia (SCA). We characterized neutrophils in a population of patients with SCA and investigated whether platelet-derived molecules can induce phenotypic alterations in this cell type. Imaging flow cytometry analysis demonstrated that the frequency of circulating CXCR4hi neutrophils was significantly higher in steady-state SCA individuals than in healthy control individuals and that these cells presented increased CD11b activation and toll-like receptor-4 expression. SCA neutrophils display increased neutrophil-platelet aggregation, and CXCR4hi neutrophils demonstrated augmented neutrophil-platelet aggregate frequency with a higher mean number of platelets adhered per neutrophil. Importantly, incubation of neutrophils with platelets significantly elevated their CXCR4 expression, while SCA plasma was found to induce CXCR4hi neutrophil polarization significantly more than control plasma. SCA individuals had significantly increased plasma levels of serotonin (5-HT), and serotonin molecule and SCA plasma induced neutrophil CXCR4 expression in a serotonin-receptor-dependent manner. Thus, the augmented CXCR4hi neutrophil population may contribute to mechanisms that promote vaso-occlusion in SCA; furthermore, circulating serotonin, derived from platelet activation, may play a role in the polarization of neutrophils, suggesting that serotonin-receptor antagonists or serotonin reuptake inhibitors could represent therapeutic approaches to reduce neutrophil activation in SCA.
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30
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Relationship of polymorphism rs3800231 in FOXO3 gene and clinical severity with oxidative stress markers in sickle cell disease. Meta Gene 2020. [DOI: 10.1016/j.mgene.2020.100660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Abstract
INTRODUCTION In sickle cell disease (SCD), hemoglobin S (HbS) red blood cells (RBCs) are characteristically deformed and inflexible. Often breaking down in the circulation, they exhibit increased adhesive properties with the endothelium and activated neutrophils and platelets, increasing the risk of occlusion of the microcirculation. SCD is categorized into two sub-phenotypes: hyperhemolytic, associated with priapism, leg ulcers, pulmonary hypertension, and stroke, and high hemoglobin/viscosity, which may promote vaso-occlusion-associated pain, acute chest syndrome, and osteonecrosis. AREAS COVERED The sub-phenotypes are not completely distinct. Hemolysis may trigger vaso-occlusion, contributing to vascular complications. Targeting P-selectin, a key mediator of cross-talk between hyperhemolysis and vaso-occlusion, may be beneficial for vascular and vaso-occlusion-associated complications. English-language articles from PubMed on the topic of SCD and vaso-occlusive crises (VOCs) were reviewed from 1 January 2000 to 1 January 2019 using the search terms 'sickle cell disease,' 'vaso-occlusive crises,' and 'selectin.' EXPERT OPINION Besides targeting P-selectin, other strategies to counter VOCs and RBC sickling are being pursued. These include platelet inhibition to counter aggregation, intercellular adhesion, and thrombosis during VOCs; gene therapy to correct the homozygous missense mutation in the β-globin gene, causing polymerization of HbS; L-glutamine, possibly reducing oxidative stress in sickled RBCs; and fetal hemoglobin inducers.
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Affiliation(s)
- Solomon F Ofori-Acquah
- Department of Medicine, University of Pittsburgh , Pittsburgh, USA.,School of Biomedical and Allied Health Sciences, College of Health Sciences, University of Ghana , Accra, Ghana.,West African Genetic Medicine Centre (WAGMC), College of Health Sciences, University of Ghana , Accra, Ghana
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Haploidentical bone marrow transplant with posttransplant cyclophosphamide for sickle cell disease: An update. Hematol Oncol Stem Cell Ther 2020; 13:91-97. [PMID: 32202252 PMCID: PMC7118612 DOI: 10.1016/j.hemonc.2020.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 01/28/2020] [Indexed: 12/04/2022] Open
Abstract
Hematopoietic cell transplant (HCT) can cure both children and adults with sickle cell disease. Outcomes have historically been poor for the vast majority of patients who lack a matched sibling donor. However, the development of haploidentical HCT (haplo-HCT) with high doses of posttransplant cyclophosphamide (PTCy) has allowed for curative long-term potential with favorable transplant-related outcomes, though this has not obviated the potential for graft rejection from human leukocyte antigen mismatch and repeated red blood cell transfusions. Accordingly, multiple strategies have been developed to improve outcomes, the majority of which are based on the Johns Hopkins platform from 2012. Presently, we aim to discuss results from pertinent studies and compare outcomes with the two most recent approaches involving either thiotepa plus 200-cGy total body irradiation or 400-cGy total body irradiation. Direct comparisons are required to determine the optimized curative potential. Transplant-eligible patients must be referred to tertiary medical centers for consideration of haplo-HCT.
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Adelekan OO, Uche EI, Balogun TM, Osunkalu VO, Akinbami AA, Ismail KA, Badiru MA, Dosunmu AO, Kamson OR. Methylene tetrahydrofolate reductase gene mutation in sickle cell anaemia patients in Lagos, Nigeria. Pan Afr Med J 2019; 34:213. [PMID: 32201547 PMCID: PMC7065652 DOI: 10.11604/pamj.2019.34.213.19524] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 12/12/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction The significant causes of mortality among individuals with sickle cell anaemia (SCA) such as acute chest syndrome and cerebrovascular disease are related to vascular occlusion. Polymorphisms of the methylene tetrahydrofolate reductase (MTHFR) gene in persons with sickle cell anaemia have been suggested as a potential risk for vaso-occlusive events, with the C677T and A1298C polymorphisms being the commonest. This study therefore aimed to establish the pattern of MTHFR C677T and A1298C gene mutations among adults with HbSS phenotype attending the Haematology Clinic in Lagos State University Teaching Hospital Lagos, Nigeria. Methods A cross-sectional study was done among SCA patients attending the Haematology Clinic of the Lagos State University Teaching Hospital (LASUTH), using age and sex matched HbAA controls. DNA extraction and gene analysis were done. The selective amplification of a particular segment of the DNA by polymerase chain reaction (PCR) was done and subsequent digestion of the amplified MTHFR gene into its various fragments. Results The overall prevalence of the C677T mutation among participants was 19.3% (37 of 192), while the prevalence of A1298C was 15% (29 of 192). Conclusion The prevalence of MTHFR C677T was higher than A1298C mutations among sickle cell anaemia subjects.
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Affiliation(s)
| | - Ebele Ifeyinwa Uche
- Department of Haematology and Blood Transfusion, Lagos State University College of Medicine, Lagos, Nigeria
| | - Taiwo Modupe Balogun
- Department of Haematology and Blood Transfusion, Lagos State University Teaching Hospital, Lagos, Nigeria
| | - Vincent Oluseye Osunkalu
- Department of Haematology and Blood Transfusion, College of Medicine, University of Lagos, Idiaraba, Lagos, Nigeria
| | | | - Kamal Ayobami Ismail
- Department of Haematology and Blood Transfusion, Lagos State University College of Medicine, Lagos, Nigeria
| | - Mulikat Adesola Badiru
- Department of Haematology and Blood Transfusion, General Hospital Marina, Lagos, Nigeria
| | - Adedoyin Owolabi Dosunmu
- Department of Haematology and Blood Transfusion, Lagos State University College of Medicine, Lagos, Nigeria
| | - Omolara Risqat Kamson
- Department of Haematology and Blood Transfusion, Lagos State University Teaching Hospital, Lagos, Nigeria
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Ansari J, Gavins FNE. Ischemia-Reperfusion Injury in Sickle Cell Disease: From Basics to Therapeutics. THE AMERICAN JOURNAL OF PATHOLOGY 2019; 189:706-718. [PMID: 30904156 DOI: 10.1016/j.ajpath.2018.12.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/17/2018] [Accepted: 12/07/2018] [Indexed: 12/17/2022]
Abstract
Sickle cell disease (SCD) is one of the most common hereditary hemoglobinopathies worldwide, affecting almost 400,000 newborns globally each year. It is characterized by chronic hemolytic anemia and endothelial dysfunction, resulting in a constant state of disruption of the vascular system and leading to recurrent episodes of ischemia-reperfusion injury (I/RI) to multiple organ systems. I/RI is a fundamental vascular pathobiological paradigm and contributes to morbidity and mortality in a wide range of conditions, including myocardial infarction, stroke, acute kidney injury, and transplantation. I/RI is characterized by an initial restriction of blood supply to an organ, which can lead to ischemia, followed by the subsequent restoration of perfusion and concomitant reoxygenation. Recent advances in the pathophysiology of SCD have led to an understanding that many of the consequences of this disease can be explained by mechanisms associated with I/RI. The following review focuses on the evolving pathobiology of SCD, how various complications of SCD can be attributed to I/RI, and the role of timely therapeutic intervention(s) based on targeting mediators or pathways that influence I/R insult.
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Affiliation(s)
- Junaid Ansari
- Department of Molecular & Cellular Physiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana
| | - Felicity N E Gavins
- Department of Molecular & Cellular Physiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana.
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35
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Decreased erythrocyte binding of Siglec-9 increases neutrophil activation in sickle cell disease. Blood Cells Mol Dis 2019; 81:102399. [PMID: 31901888 DOI: 10.1016/j.bcmd.2019.102399] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 12/19/2019] [Accepted: 12/19/2019] [Indexed: 01/29/2023]
Abstract
Oxidative stress and inflammation promote vaso-occlusion in sickle cell disease (SCD). CD33-related Sialic acid-binding immunoglobulin-type lectins (CD33rSiglecs) are cell surface proteins that recognize sialic acids inhibit innate immune cell functions. We have shown that Siglec-9 on human neutrophils interact with erythrocyte sialic acids (prominently glycophorin-A (GYPA) to suppress neutrophil reactive oxygen species (ROS). We hypothesized that altered sickle erythrocyte membrane sialic acid leads to decreased Siglec-9 binding capability, and thus a decreased neutrophil oxidative burst. SS erythrocytes express significantly more sialic acid than AA erythrocytes (p = 0.02). SS erythrocytes displayed significantly less Siglec-9-Fc binding 39% ± 11 (mean ± SEM) compared to AA erythrocytes 78% ± 5 (p = 0.009). Treatment of AA erythrocytes with sialidase to remove sialic acid decreased binding to 3% ± 7.9 (p ≤ 0.001). When freshly isolated neutrophils were incubated with AA erythrocytes, neutrophils achieved 16% ± 6 of the oxidative burst exhibited by a stimulated neutrophil without erythrocytes. In contrast, neutrophils incubated with SS erythrocytes achieved 47% ± 6 of the oxidative burst (AA versus SS, p = 0.03). Stimulated neutrophils incubated with AA erythrocytes showed minimal NET formation while with SS erythrocytes NETs increased. SS erythrocytes are deficient in binding to neutrophil Siglec-9 which may contribute to the increased oxidative stress in SCD.
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Wood KC, Durgin BG, Schmidt HM, Hahn SA, Baust JJ, Bachman T, Vitturi DA, Ghosh S, Ofori-Acquah SF, Mora AL, Gladwin MT, Straub AC. Smooth muscle cytochrome b5 reductase 3 deficiency accelerates pulmonary hypertension development in sickle cell mice. Blood Adv 2019; 3:4104-4116. [PMID: 31821458 PMCID: PMC6963246 DOI: 10.1182/bloodadvances.2019000621] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/29/2019] [Indexed: 01/26/2023] Open
Abstract
Pulmonary and systemic vasculopathies are significant risk factors for early morbidity and death in patients with sickle cell disease (SCD). An underlying mechanism of SCD vasculopathy is vascular smooth muscle (VSM) nitric oxide (NO) resistance, which is mediated by NO scavenging reactions with plasma hemoglobin (Hb) and reactive oxygen species that can oxidize soluble guanylyl cyclase (sGC), the NO receptor. Prior studies show that cytochrome b5 reductase 3 (CYB5R3), known as methemoglobin reductase in erythrocytes, functions in VSM as an sGC heme iron reductase critical for reducing and sensitizing sGC to NO and generating cyclic guanosine monophosphate for vasodilation. Therefore, we hypothesized that VSM CYB5R3 deficiency accelerates development of pulmonary hypertension (PH) in SCD. Bone marrow transplant was used to create SCD chimeric mice with background smooth muscle cell (SMC)-specific tamoxifen-inducible Cyb5r3 knockout (SMC R3 KO) and wild-type (WT) control. Three weeks after completing tamoxifen treatment, we observed 60% knockdown of pulmonary arterial SMC CYB5R3, 5 to 6 mm Hg elevated right-ventricular (RV) maximum systolic pressure (RVmaxSP) and biventricular hypertrophy in SS chimeras with SMC R3 KO (SS/R3KD) relative to WT (SS/R3WT). RV contractility, heart rate, hematological parameters, and cell-free Hb were similar between groups. When identically generated SS/R3 chimeras were studied 12 weeks after completing tamoxifen treatment, RVmaxSP in SS/R3KD had not increased further, but RV hypertrophy relative to SS/R3WT persisted. These are the first studies to establish involvement of SMC CYB5R3 in SCD-associated development of PH, which can exist in mice by 5 weeks of SMC CYB5R3 protein deficiency.
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Affiliation(s)
- Katherine C Wood
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
| | - Brittany G Durgin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
| | - Heidi M Schmidt
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
- Department of Pharmacology and Chemical Biology
| | - Scott A Hahn
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
| | - Jeffrey J Baust
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
| | - Tim Bachman
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
| | - Dario A Vitturi
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
- Department of Pharmacology and Chemical Biology
| | - Samit Ghosh
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
| | - Solomon F Ofori-Acquah
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
- Division of Hematology and Oncology, Department of Medicine, and
| | - Ana L Mora
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Adam C Straub
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
- Department of Pharmacology and Chemical Biology
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Faes C, Juban G, Aufradet E, Desgeorges T, Charrin E, Connes P, Mury P, Mattè A, De Franceschi L, Martin C, Pialoux V. Effects of hypoxia-reoxygenation stimuli on renal redox status and nuclear factor erythroid 2-related factor 2 pathway in sickle cell SAD mice. Exp Physiol 2019; 105:357-369. [PMID: 31805612 DOI: 10.1113/ep087969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 12/02/2019] [Indexed: 11/08/2022]
Abstract
NEW FINDINGS What is the central question of this study? What are the effects of repeated subclinical vaso-occlusions on nuclear factor erythroid 2 related factor 2 (Nrf2) and oxidative stress balance regulation in the kidney of transgenic SAD mice? What is the main finding and its importance? In response to hypoxia-reoxygenation, nuclear Nrf2 protein expression decreased in the kidney of SAD mice while haem oxygenase transcripts were increased. This suggest that in SAD mice, other transcription factors than Nrf2 could be involved in renal antioxidant gene regulation in response to hypoxia-reoxygenation. ABSTRACT Hypoxia-reoxygenation (H/R) stress is known to increase oxidative stress in transgenic sickle mice and can cause organ failure. Here we described the effects of H/R on nuclear factor erythroid 2-related factor 2 (Nrf2) as a putative regulator of redox status in the kidneys of SAD mice investigating Nrf2-regulated antioxidant enzymes. Transgenic SAD mice and healthy C57Bl/6J mice were exposed to 4 h of hypoxia followed by various times of reoxygenation at ambient air (2 or 6 h). Regardless of the conditions (i.e. normoxia or H/R), SAD mice expressed higher renal oxidative stress levels. Nuclear Nrf2 protein expression decreased after 2 h post-hypoxia only in the medulla region of the kidney and only in SAD mice. Simultaneously, haem oxygenase transcripts were affected by H/R stimulus with a significant enhancement after 2 h post-hypoxia. Similarly, hypoxia inducible factor-1α staining increased after 2 h post-hypoxia in SAD mice in both cortex and medulla areas. Our data confirm that the kidneys are organs that are particularly sensitive to H/R stimuli in sickle cell SAD mice. Also, these results suggest an effect of the duration of recovery period (short vs. long) and specific responses according to kidney areas, medulla vs. cortex, on Nrf2 expression in response to H/R stimuli in SAD mice.
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Affiliation(s)
- Camille Faes
- Interuniversity Laboratory of Human Movement Biology EA7424, Univ Lyon - University Claude Bernard Lyon 1, Villeurbanne, France.,Labex GR-Ex, Paris, France
| | - Gaëtan Juban
- Institut NeuroMyoGène CNRS UMR 5510, INSERM U1217, Univ Lyon - University Claude Bernard Lyon 1, Lyon, France
| | - Emeline Aufradet
- Interuniversity Laboratory of Human Movement Biology EA7424, Univ Lyon - University Claude Bernard Lyon 1, Villeurbanne, France
| | - Thibaut Desgeorges
- Institut NeuroMyoGène CNRS UMR 5510, INSERM U1217, Univ Lyon - University Claude Bernard Lyon 1, Lyon, France
| | - Emmanuelle Charrin
- Interuniversity Laboratory of Human Movement Biology EA7424, Univ Lyon - University Claude Bernard Lyon 1, Villeurbanne, France.,Labex GR-Ex, Paris, France
| | - Philippe Connes
- Interuniversity Laboratory of Human Movement Biology EA7424, Univ Lyon - University Claude Bernard Lyon 1, Villeurbanne, France.,Labex GR-Ex, Paris, France.,Institut Universitaire de France, Paris, France
| | - Pauline Mury
- Interuniversity Laboratory of Human Movement Biology EA7424, Univ Lyon - University Claude Bernard Lyon 1, Villeurbanne, France.,Labex GR-Ex, Paris, France
| | - Alessandro Mattè
- Department of Medicine, University of Verona and AOUI-Verona, Verona, Italy
| | | | - Cyril Martin
- Interuniversity Laboratory of Human Movement Biology EA7424, Univ Lyon - University Claude Bernard Lyon 1, Villeurbanne, France.,Labex GR-Ex, Paris, France
| | - Vincent Pialoux
- Interuniversity Laboratory of Human Movement Biology EA7424, Univ Lyon - University Claude Bernard Lyon 1, Villeurbanne, France.,Labex GR-Ex, Paris, France.,Institut Universitaire de France, Paris, France
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Almeida LEF, Kamimura S, de Souza Batista CM, Spornick N, Nettleton MY, Walek E, Smith ML, Finkel JC, Darbari DS, Wakim P, Quezado ZMN. Sickle cell disease subjects and mouse models have elevated nitrite and cGMP levels in blood compartments. Nitric Oxide 2019; 94:79-91. [PMID: 31689491 DOI: 10.1016/j.niox.2019.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 10/20/2019] [Accepted: 10/30/2019] [Indexed: 11/26/2022]
Abstract
The hypothesis of decreased nitric oxide (NO) bioavailability in sickle cell disease (SCD) proposes that multiple factors leading to decreased NO production and increased consumption contributes to vaso-occlusion, pulmonary hypertension, and pain. The anion nitrite is central to NO physiology as it is an end product of NO metabolism and serves as a reservoir for NO formation. However, there is little data on nitrite levels in SCD patients and its relationship to pain phenotype. We measured nitrite in SCD subjects and examined its relationship to SCD pain. In SCD subjects, median whole blood, red blood cell and plasma nitrite levels were higher than in controls, and were not associated with pain burden. Similarly, Townes and BERK homozygous SCD mice had elevated blood nitrite. Additionally, in red blood cells and plasma from SCD subjects and in blood and kidney from Townes homozygous mice, levels of cyclic guanosine monophosphate (cGMP) were higher compared to controls. In vitro, hemoglobin concentration, rather than sickle hemoglobin, was responsible for nitrite metabolism rate. In vivo, inhibition of NO synthases and xanthine oxidoreductase decreased nitrite levels in homozygotes but not in control mice. Long-term nitrite treatment in SCD mice further elevated blood nitrite and cGMP, worsened anemia, decreased platelets, and did not change pain response. These data suggest that SCD in humans and animals is associated with increased nitrite/NO availability, which is unrelated to pain phenotype. These findings might explain why multiple clinical trials aimed at increasing NO availability in SCD patients failed to improve pain outcomes.
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Affiliation(s)
- Luis E F Almeida
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Sayuri Kamimura
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, 20892, USA
| | | | - Nicholas Spornick
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Margaret Y Nettleton
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Elizabeth Walek
- The Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Research Institute, School of Medicine and Health Sciences, George Washington University, Washington, DC, 20010, USA
| | - Meghann L Smith
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Julia C Finkel
- The Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Research Institute, School of Medicine and Health Sciences, George Washington University, Washington, DC, 20010, USA
| | - Deepika S Darbari
- Division of Hematology, Center for Cancer and Blood Disorders, Children's National Hospital, Department of Pediatrics, George Washington University School of Medicine, Washington, DC, 20010, USA
| | - Paul Wakim
- Biostatistics and Clinical Epidemiology Service, National Institutes of Health Clinical Center, Bethesda, MD, 20892, USA
| | - Zenaide M N Quezado
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, 20892, USA.
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Carden MA, Little J. Emerging disease-modifying therapies for sickle cell disease. Haematologica 2019; 104:1710-1719. [PMID: 31413089 PMCID: PMC6717563 DOI: 10.3324/haematol.2018.207357] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/10/2019] [Indexed: 12/20/2022] Open
Abstract
Sickle cell disease afflicts millions of people worldwide and approximately 100,000 Americans. Complications are myriad and arise as a result of complex pathological pathways ‘downstream’ to a point mutation in DNA, and include red blood cell membrane damage, inflammation, chronic hemolytic anemia with episodic vaso-occlusion, ischemia and pain, and ultimately risk of cumulative organ damage with reduced lifespan of affected individuals. The National Heart, Lung, and Blood Institute’s 2014 evidence-based guideline for sickle cell disease management states that additional research is needed before investigational curative therapies will be widely available to most patients with sickle cell disease. To date, sickle cell disease has been cured by hematopoietic stem cell transplantation in approximately 1,000 people, most of whom were children, and significantly ameliorated by gene therapy in a handful of subjects who have only limited follow-up thus far. During a timespan in which over 20 agents were approved for the treatment of cystic fibrosis by the Food and Drug Administration, similar approval was granted for only two drugs for sickle cell disease (hydroxyurea and L-glutamine) despite the higher prevalence of sickle cell disease. This trajectory appears to be changing, as the lack of multimodal agent therapy in sickle cell disease has spurred engagement among many in academia and industry who, in the last decade, have developed new drugs poised to prevent complications and alleviate suffering. Identified therapeutic strategies include fetal hemoglobin induction, inhibition of intracellular HbS polymerization, inhibition of oxidant stress and inflammation, and perturbation of the activation of the endothelium and other blood components (e.g. platelets, white blood cells, coagulation proteins) involved in the pathophysiology of sickle cell disease. In this article, we present a crash-course review of disease-modifying approaches (minus hematopoietic stem cell transplant and gene therapy) for patients with sickle cell disease currently, or recently, tested in clinical trials in the era following approval of hydroxyurea.
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Affiliation(s)
- Marcus A Carden
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of North Carolina Chapel Hill School of Medicine.,Department of Medicine, Division of Hematology, University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Jane Little
- Department of Medicine, Division of Hematology, University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC, USA
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Abstract
Introduction: Acute pain from episodic vaso-occlusion (VOC) spans the lifespan of almost everyone with sickle cell disease (SCD), while additional chronic pain develops in susceptible individuals in early adolescences. Frequent acute pain with chronic pain causes significant physical and psychological morbidity, and frequent health-care utilization. Available pharmacologic therapies reduce acute pain frequency but few evidence-based therapies are available for chronic pain. Areas covered: An extensive PubMed literature search was performed with appropriate search criteria. The pathophysiology of acute pain from VOC in SCD is very complex with many events subsequent to sickle polymer formation. Sensitization of pain pathways and alterations of brain networks contributes to the experience of chronic pain. Numerous therapies targeting putative VOC mechanisms are in clinical trials, and show considerable promise. Alternative analgesic treatments for acute and chronic pain have been examined in small patient cohorts, but formal clinical trials are lacking. Expert opinion: Childhood is likely a critical window for prevention of acute and later chronic pain. New multimodal analgesic therapies are needed, particularly for chronic pain, and should be examined in clinical trials. Given the multifactorial nature of both pain and VOC, simultaneously targeting multiple mechanisms may be the optimal approach for effective preventive therapies.
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Affiliation(s)
- Carlton Dampier
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta , Atlanta , GA , USA
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41
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Belisário AR, da Silva AAS, Silva CVM, de Souza LMG, Wakabayashi EA, Araújo SDA, Simoes-e-Silva AC. Sickle cell disease nephropathy: an update on risk factors and potential biomarkers in pediatric patients. Biomark Med 2019; 13:967-987. [DOI: 10.2217/bmm-2019-0105] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
One of the major chronic complications of sickle cell disease (SCD) is sickle cell nephropathy. The aim of this review is to discuss the pathophysiology, natural history, clinical manifestations, risk factors, biomarkers and therapeutic approaches for sickle cell nephropathy, focusing on studies with pediatric patients. The earliest manifestation of renal disease is an increase in the glomerular filtration rate. A finding that may also be observed in early childhood is microalbuminuria. Nephrin, KIM-1, VGFs, chemokines and renin-angiotensin system molecules have emerged as potential early markers of renal dysfunction in SCD. In regards to a therapeutic approach, renin-angiotensin system inhibitors and angiotensin receptor blockers seem to be effective for the control of albuminuria in adults with SCD, although new studies in children are needed. The precise moment to begin renoprotection in SCD patients who should be treated remains to be determined.
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Affiliation(s)
- André R Belisário
- Centro de Tecidos Biológicos de Minas Gerais, Fundação Hemominas, Rua das Goiabeiras, 779, Lagoa Santa, Minas Gerais 33400-000, Brazil
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Av Prof. Alfredo Balena, 190, Belo Horizonte, Minas Gerais 30130-100, Brazil
| | - Ariadna AS da Silva
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Av Prof. Alfredo Balena, 190, Belo Horizonte, Minas Gerais 30130-100, Brazil
| | - Cristiane VM Silva
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Av Prof. Alfredo Balena, 190, Belo Horizonte, Minas Gerais 30130-100, Brazil
| | - Larissa MG de Souza
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Av Prof. Alfredo Balena, 190, Belo Horizonte, Minas Gerais 30130-100, Brazil
| | - Eduarda A Wakabayashi
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Av Prof. Alfredo Balena, 190, Belo Horizonte, Minas Gerais 30130-100, Brazil
| | - Stanley de A Araújo
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Av Prof. Alfredo Balena, 190, Belo Horizonte, Minas Gerais 30130-100, Brazil
| | - Ana C Simoes-e-Silva
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Av Prof. Alfredo Balena, 190, Belo Horizonte, Minas Gerais 30130-100, Brazil
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42
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Patel DA, Akinsete AM, Connelly JA, Kassim AA. T-cell deplete versus T-cell replete haploidentical hematopoietic stem cell transplantation for sickle cell disease: where are we? Expert Rev Hematol 2019; 12:733-752. [DOI: 10.1080/17474086.2019.1642103] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Dilan A. Patel
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt-Meharry Center for Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Adeseye M. Akinsete
- College of Medicine, Division of Pediatric Hematology & Oncology, Lagos University Teaching Hospital, Lagos, Nigeria
| | - James A. Connelly
- Department of Pediatrics, Pediatric Hematopoietic Cell Transplant, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Adetola A. Kassim
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt-Meharry Center for Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN, USA
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43
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Inusa BPD, Hsu LL, Kohli N, Patel A, Ominu-Evbota K, Anie KA, Atoyebi W. Sickle Cell Disease-Genetics, Pathophysiology, Clinical Presentation and Treatment. Int J Neonatal Screen 2019; 5:20. [PMID: 33072979 PMCID: PMC7510211 DOI: 10.3390/ijns5020020] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 04/24/2019] [Indexed: 12/28/2022] Open
Abstract
Sickle cell disease (SCD) is a monogenetic disorder due to a single base-pair point mutation in the β-globin gene resulting in the substitution of the amino acid valine for glutamic acid in the β-globin chain. Phenotypic variation in the clinical presentation and disease outcome is a characteristic feature of the disorder. Understanding the pathogenesis and pathophysiology of the disorder is central to the choice of therapeutic development and intervention. In this special edition for newborn screening for haemoglobin disorders, it is pertinent to describe the genetic, pathologic and clinical presentation of sickle cell disease as a prelude to the justification for screening. Through a systematic review of the literature using search terms relating to SCD up till 2019, we identified relevant descriptive publications for inclusion. The scope of this review is mainly an overview of the clinical features of pain, the cardinal symptom in SCD, which present following the drop in foetal haemoglobin as young as five to six months after birth. The relative impact of haemolysis and small-vessel occlusive pathology remains controversial, a combination of features probably contribute to the different pathologies. We also provide an overview of emerging therapies in SCD.
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Affiliation(s)
- Baba P. D. Inusa
- Paediatric Haematology, Evelina London Children’s Hospital, Guy’s and St Thomas NHS Trust, London SE1 7EH, UK
- Correspondence:
| | - Lewis L. Hsu
- Pediatric Hematology-Oncology, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Neeraj Kohli
- Haematology, Guy’s and St Thomas NHS Trust, London SE1 7EH, UK
| | | | - Kilali Ominu-Evbota
- Paediatrics Department, Basildon and Thurrock University Hospitals, NHS Foundation Trust, Basildon SS16 5NL, UK
| | - Kofi A. Anie
- Haematology and Sickle Cell Centre, London North West University Healthcare NHS Trust, London NW10 7NS, UK
| | - Wale Atoyebi
- Department of Clinical Haematology, Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford OX3 9DU, UK
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44
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Park F, Soni H, Pressly JD, Adebiyi A. Acute hydroxyurea treatment reduces tubular damage following bilateral ischemia-reperfusion injury in a mouse model of sickle cell disease. Biochem Biophys Res Commun 2019; 515:72-76. [PMID: 31128920 DOI: 10.1016/j.bbrc.2019.05.116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 05/17/2019] [Indexed: 12/11/2022]
Abstract
Ischemic injury is a primary contributor to the initiation of renal tubular epithelial cell damage in sickle cell disease (SCD). In this study, we investigated the effects of bilateral ischemia-reperfusion injury, which is a common type of acute kidney injury (AKI), in male and female genetic mouse model of SCD. Bilateral occlusion of both renal hila for 21 min led to a significantly higher detection of established serum markers of AKI (creatinine, KIM-1 and NGAL) compared to sham-operated male SCD mice. Severe damage to the outer medullary tubules was determined in the ischemia-reperfision injury (IRI)-treated SCD male mice. In female SCD mice with a longer ischemic time (23 min), the serum markers of AKI were not as highly elevated compared to their male counterparts, and the extent of outer medullary tubular injury was less severe. To assess the potential benefit in the use of hydroxyurea (50 mg/kg IP) following bilateral renal IRI, we observed that the serum markers of AKI and the outer medullary tubular damage were markedly improved compared to male SCD mice that were not treated with hydroxyurea. In this study, we confirmed that male SCD mice were more susceptible to increased tubular damage and a loss in renal function compared to female SCD mice, and that hydroxyurea may partially prevent the extent of tubular injury following severe ischemia-reperfusion injury in SCD.
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Affiliation(s)
- Frank Park
- Department of Pharmaceutical Sciences, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Hitesh Soni
- Department of Physiology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jeffrey D Pressly
- Department of Pharmaceutical Sciences, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Adebowale Adebiyi
- Department of Physiology, University of Tennessee Health Science Center, Memphis, TN, USA
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Jabbarli R, Dinger TF, Pierscianek D, Oppong MD, Chen B, Dammann P, Wrede KH, Kaier K, Köhrmann M, Forsting M, Kleinschnitz C, Sure U. Intracranial Aneurysms in Sickle Cell Disease. Curr Neurovasc Res 2019; 16:63-76. [DOI: 10.2174/1567202616666190131160847] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 01/16/2019] [Accepted: 01/21/2019] [Indexed: 11/22/2022]
Abstract
Background:
The exact causes of intracranial aneurysms (IAs) are still unknown. However,
certain diseases are known to be associated with IAs.
Objective:
To analyze the differences in IA characteristics in the general population and in
individuals with sickle-cell disease (SCD).
Methods:
We systematically searched PubMed, Scopus, Web of Science, and Cochrane Library
for Data on SCD patients with IAs. We compared IA characteristics of SCD patients with those
from 2451 healthy IA carriers from our observational cohort.
Results:
129 SCD patients with IAs were identified in 42 studies. The SCD patient cohort was
characterized by younger age (mean 27.1 vs 54.9 years, p<0.0001) and lower female prevalence
(57.7% vs 68.4%, p=0.0177). The prevalence (47% vs 34.5%, p=0.004) and the number (3.02 vs
2.56 IAs/patient, p=0.004) of multiple IAs were also higher in the SCD cohort. Unruptured IAs
(3.27 vs 6.16 mm, p<0.0001), but not ruptured IAs (7.8 vs 7.34 mm, p=0.9086) were significantly
smaller in the SCD cohort. In addition, IAs were more frequently located in the internal carotid artery
(45% vs 29%, p<0.0001) or posterior circulation (43% vs 20%, p<0.0001). Higher age (≥30
years, p=0.007), IA size ≥7 mm (p=0.008), and location in posterior circulation (p=0.01) were independently
associated with subarachnoid hemorrhage in SCD.
Conclusion:
There is a distinct demographic and radiographic pattern of IA in SCD. Risk factors
for IA rupture in SCD are mostly congruent with those in healthy individuals.
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Affiliation(s)
- Ramazan Jabbarli
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | - Thiemo F. Dinger
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | | | - Marvin D. Oppong
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | - Bixia Chen
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | - Karsten H. Wrede
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
| | - Klaus Kaier
- Institute for Medical Biometry and Statistics, University of Freiburg, Freiburg Breisgau, Germany
| | - Martin Köhrmann
- Clinic for Neurology, University Hospital of Essen, Essen, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology, University Hospital of Essen, Essen, Germany
| | | | - Ulrich Sure
- Department of Neurosurgery, University Hospital of Essen, Essen, Germany
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46
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Uche E, Adelekan O, Akinbami A, Osunkalu V, Ismail K, Ogbenna AA, Badiru M, Dosunmu A, Oluwole E, Kamson O. Serum homocysteine and disease severity in sickle cell anemia patients in Lagos. J Blood Med 2019; 10:127-134. [PMID: 31191063 PMCID: PMC6520594 DOI: 10.2147/jbm.s198316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 04/01/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose: Hypercoagulability in sickle cell anemia (SCA) may be responsible for the increased development of vascular occlusion in certain organs as well as acute pain episodes. The causes of hypercoagulability in SCA are multifactorial and include raised homocysteine levels. This study, therefore, aimed to determine serum homocysteine levels in SCA patients in steady state and to correlate its levels with SCA disease severity. Patients and Methods: This was a cross-sectional study done among SCA patients in steady state attending the Haematology Clinic of the Lagos State University Teaching Hospital (LASUTH). Matched age and sex HbAA controls were also recruited. Serum homocysteine of each participant was done with enzyme-linked immunosorbent assay and disease severity score assessed in every SCA patient using clinical and laboratory parameters. Results: The mean value for homocysteine in the study group (SCA patients) was 19.80±19.75 µmol/L whilst that of the control group was 9.16±4.29 µmol/L. Thirty-nine out of 96 (46.6%) SCA patients had elevated homocysteine levels (>15 µmol/L) whilst all 96 participants in the control group had normal homocysteine levels. The difference in the means in the two groups was statistically significant with p=0.001. Majority (62.5%) of the SCA patients had a mild disease (severity score ≤3). There was a significant correlation between serum homocysteine levels and disease severity scores with p=0.04; χ2=4.04. Conclusion: Homocysteine levels were significantly higher in HbSS patients compared with matched HbAA controls and showed a positive correlation with disease severity scores in the SCA patients.
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Affiliation(s)
- Ebele Uche
- Department of Haematology and Blood Transfusion, Lagos State University College of Medicine, Lagos, Nigeria
| | - Oluwaseun Adelekan
- Department of Haematology and Blood Transfusion, General Hospital Marina, Lagos, Nigeria
| | - Akinsegun Akinbami
- Department of Haematology and Blood Transfusion, Lagos State University College of Medicine, Lagos, Nigeria
| | - Vincent Osunkalu
- Department of Haematology and Blood Transfusion, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Kamal Ismail
- Department of Haematology and Blood Transfusion, Lagos State University College of Medicine, Lagos, Nigeria
| | - Ann Abiola Ogbenna
- Department of Haematology and Blood Transfusion, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Mulikat Badiru
- Department of Haematology and Blood Transfusion, Lagos State University College of Medicine, Lagos, Nigeria
| | - Adedoyin Dosunmu
- Department of Haematology and Blood Transfusion, Lagos State University College of Medicine, Lagos, Nigeria
| | - Esther Oluwole
- Department of Community Health and Primary Care, College of Medicine University of Lagos, Lagos, Nigeria
| | - Omolara Kamson
- Department of Haematology and Blood Transfusion, Lagos State University Teaching Hospital, Lagos, Nigeria
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47
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Gupta K, Chen C, Lutty GA, Hebbel RP. Morphine promotes neovascularizing retinopathy in sickle transgeneic mice. Blood Adv 2019; 3:1073-1083. [PMID: 30944099 PMCID: PMC6457224 DOI: 10.1182/bloodadvances.2018026898] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 02/28/2019] [Indexed: 12/11/2022] Open
Abstract
Neovascularizing retinopathy is a significant complication of sickle cell disease (SCD), occurring more frequently in HbSC than HbSS disease. This risk difference is concordant with a divergence of angiogenesis risk, as identified by levels of pro- vs anti-angiogenic factors in the sickle patient's blood. Because our prior studies documented that morphine promotes angiogenesis in both malignancy and wound healing, we tested whether chronic opioid treatment would promote retinopathy in NY1DD sickle transgenic mice. After 10 to 15 months of treatment, sickle mice treated with morphine developed neovascularizing retinopathy to a far greater extent than either of the controls (sickle mice treated with saline and wild-type mice treated identically with morphine). Our dissection of the mechanistic linkage between morphine and retinopathy revealed a complex interplay among morphine engagement with its μ opioid receptor (MOR) on retinal endothelial cells (RECs); morphine-induced production of tumor necrosis factor α and interleukin-6 (IL-6), causing increased expression of both MOR and vascular endothelial growth factor receptor 2 (VEGFR2) on RECs; morphine/MOR engagement transactivating VEGFR2; and convergence of MOR, VEGFR2, and IL-6 activation on JAK/STAT3-dependent REC proliferation and angiogenesis. In the NY1DD mice, the result was increased angiogenesis, seen as neovascularizing retinopathy, similar to the retinal pathology occurring in humans with SCD. Therefore, we conclude that chronic opioid exposure, superimposed on the already angiogenic sickle milieu, might enhance risk for retinopathy. These results provide an additional reason for development and application of opioid alternatives for pain control in SCD.
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Affiliation(s)
- Kalpna Gupta
- Vascular Biology Center, and
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN; and
| | - Chunsheng Chen
- Vascular Biology Center, and
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN; and
| | - Gerard A Lutty
- Wilmer Ophthalmological Institute, John Hopkins School of Medicine, Baltimore, MD
| | - Robert P Hebbel
- Vascular Biology Center, and
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN; and
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48
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Strader MB, Liang H, Meng F, Harper J, Ostrowski DA, Henry ER, Shet AS, Eaton WA, Thein SL, Alayash AI. Interactions of an Anti-Sickling Drug with Hemoglobin in Red Blood Cells from a Patient with Sickle Cell Anemia. Bioconjug Chem 2019; 30:568-571. [PMID: 30794381 DOI: 10.1021/acs.bioconjchem.9b00130] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The pathophysiology associated with sickle cell disease (SCD) includes hemolytic anemia, vaso-occlusive events, and ultimately end organ damage set off by the polymerization of deoxygenated hemoglobin S (HbS) into long fibers and sickling of red blood cells (RBCs). One approach toward mitigating HbS polymerization is to pharmacologically stabilize the oxygenated (R) conformation of HbS and thereby reduce sickling frequency and SCD pathology. GBT440 is an α-subunit-specific modifying agent that has recently been reported to increase HbS oxygen binding affinity and consequently delay in vitro polymerization. In addition, animal model studies have demonstrated the potential for GBT440 to be a suitable therapeutic for daily oral dosing in humans. Here, we report an optimized method for detecting GBT440 intermediates in human patient hemolysate using a combination of HPLC and mass spectrometry analysis. First, oxygen dissociation curves (ODCs) analyzed from patient blood showed that oxygen affinity increased in a dose dependent manner. Second, HPLC and integrated mass spectrometric analysis collectively confirmed that GBT440 labeling was specific to the α N-terminus thereby ruling out other potential ligand binding sites. Finally, the results from this optimized analytical approach allowed us to detect a stable α-specific GBT440 adduct in the patient's hemolysate in a dose dependent manner. The results and methods presented in this report could therefore potentially help therapeutic monitoring of GBT440 induced oxygen affinity and reveal critical insight into the biophysical properties of GBT440 Hb complexes.
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Affiliation(s)
- Michael Brad Strader
- Laboratory of Biochemistry and Vascular Biology, Center for Biologics Evaluation and Research , Food and Drug Administration (FDA) , Silver Spring , Maryland 20993 , United States
| | - Hongying Liang
- Laboratory of Biochemistry and Vascular Biology, Center for Biologics Evaluation and Research , Food and Drug Administration (FDA) , Silver Spring , Maryland 20993 , United States
| | - Fantao Meng
- Laboratory of Biochemistry and Vascular Biology, Center for Biologics Evaluation and Research , Food and Drug Administration (FDA) , Silver Spring , Maryland 20993 , United States
| | - Julia Harper
- Laboratory of Chemical Physics, National Institute of Diabetes and Digestive and Kidney Disease , National Institutes of Health , Bethesda , Maryland 20892-0520 , United States
| | - David A Ostrowski
- Laboratory of Chemical Physics, National Institute of Diabetes and Digestive and Kidney Disease , National Institutes of Health , Bethesda , Maryland 20892-0520 , United States
| | - Eric R Henry
- Laboratory of Chemical Physics, National Institute of Diabetes and Digestive and Kidney Disease , National Institutes of Health , Bethesda , Maryland 20892-0520 , United States
| | - Arun S Shet
- Sickle Cell Branch, National Heart Lung and Blood Institute , National Institutes of Health , Bethesda , Maryland 20892 , United States
| | - William A Eaton
- Laboratory of Chemical Physics, National Institute of Diabetes and Digestive and Kidney Disease , National Institutes of Health , Bethesda , Maryland 20892-0520 , United States
| | - Swee L Thein
- Sickle Cell Branch, National Heart Lung and Blood Institute , National Institutes of Health , Bethesda , Maryland 20892 , United States
| | - Abdu I Alayash
- Laboratory of Biochemistry and Vascular Biology, Center for Biologics Evaluation and Research , Food and Drug Administration (FDA) , Silver Spring , Maryland 20993 , United States
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49
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Telen MJ, Malik P, Vercellotti GM. Therapeutic strategies for sickle cell disease: towards a multi-agent approach. Nat Rev Drug Discov 2019; 18:139-158. [PMID: 30514970 PMCID: PMC6645400 DOI: 10.1038/s41573-018-0003-2] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
For over 100 years, clinicians and scientists have been unravelling the consequences of the A to T substitution in the β-globin gene that produces haemoglobin S, which leads to the systemic manifestations of sickle cell disease (SCD), including vaso-occlusion, anaemia, haemolysis, organ injury and pain. However, despite growing understanding of the mechanisms of haemoglobin S polymerization and its effects on red blood cells, only two therapies for SCD - hydroxyurea and L-glutamine - are approved by the US Food and Drug Administration. Moreover, these treatment options do not fully address the manifestations of SCD, which arise from a complex network of interdependent pathophysiological processes. In this article, we review efforts to develop new drugs targeting these processes, including agents that reactivate fetal haemoglobin, anti-sickling agents, anti-adhesion agents, modulators of ischaemia-reperfusion and oxidative stress, agents that counteract free haemoglobin and haem, anti-inflammatory agents, anti-thrombotic agents and anti-platelet agents. We also discuss gene therapy, which holds promise of a cure, although its widespread application is currently limited by technical challenges and the expense of treatment. We thus propose that developing systems-oriented multi-agent strategies on the basis of SCD pathophysiology is needed to improve the quality of life and survival of people with SCD.
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Affiliation(s)
- Marilyn J Telen
- Division of Hematology, Department of Medicine and Duke Comprehensive Sickle Cell Center, Duke University, Durham, NC, USA.
| | - Punam Malik
- Division of Experimental Hematology and Cancer Biology and the Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Gregory M Vercellotti
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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50
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Abstract
IMPACT STATEMENT Sickle cell disease (SCD) is one of the most common inherited diseases and is associated with a reduced life expectancy and acute and chronic complications, including frequent painful vaso-occlusive episodes that often require hospitalization. At present, treatment of SCD is limited to hematopoietic stem cell transplant, transfusion, and limited options for pharmacotherapy, based principally on hydroxyurea therapy. This review highlights the importance of intracellular cGMP-dependent signaling pathways in SCD pathophysiology; modulation of these pathways with soluble guanylate cyclase (sGC) stimulators or phosphodiesterase (PDE) inhibitors could potentially provide vasorelaxation and anti-inflammatory effects, as well as elevate levels of anti-sickling fetal hemoglobin.
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Affiliation(s)
- Nicola Conran
- Hematology Center, University of Campinas – UNICAMP,
Cidade Universitária, Campinas-SP 13083-878-SP, Brazil
| | - Lidiane Torres
- Hematology Center, University of Campinas – UNICAMP,
Cidade Universitária, Campinas-SP 13083-878-SP, Brazil
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