Indications for transfusion in the management of sickle cell disease

Treating sickle cell disease in resource-limited sub-Saharan Africa: recent strategies and recommendations in addressing the gaps for the provision of evidence-based management

INTRODUCTION

The management of Sickle cell disease (SCD) in sub-Saharan Africa (SSA) suffers from the lack of universal infant and population screening, inadequate access to standard treatment and poor public health prioritization amidst unstable political systems.

AREAS COVERED

The state of evidencebased management of SCD in SSA was investigated including sustainability of international funding agencies.

EXPERT OPINION

Current efforts are fragmentary along languages lines; sometimes driven by the funder's objectives and not the national agenda. The review highlighted the role of internal and external partnerships such as SPARCO, ARISE, CONSA, as well as technology-based support for the implementation of evidence-based care for SCD. We advocate for increased funding to implement SCD comprehensive care in line with the WHO SCD Framework for Primary, Secondary, Tertiary and Specialist Comprehensive Care at state and national level. To achieve this objective, it is important that SCD, as a leading non-communicable disease in Africa, be mandated as a standing agenda for the National Council of Ministers at the African Union, WHO and other regional bodies in Africa.

Osivelotor for the treatment of sickle cell disease

INTRODUCTION

Despite advances in the treatment of sickle cell disease (SCD), an inherited disorder leading to abnormal sickle hemoglobin (HbS) polymerization, patients continue to have a shorter life expectancy comparatively to the general population. Increase in the concentration of oxygenated HbS in red blood cells (RBCs) has been considered as a novel approach to inhibit HbS polymerization and reduce RBC sickling and their complications, raising interest for novel oxygen affinity modulators.

AREAS COVERED

This review summarizes the characteristics and primary results obtained with osivelotor, a novel oxygen affinity modulator, for the treatment of SCD. Osivelotor is presented with improved pharmacokinetic properties comparatively to voxelotor. It may enable higher hemoglobin (Hb) occupancy at lower doses potentially leading to significant improvements of clinical outcomes.

EXPERT OPINION

The first clinical phase 2/3 trial with osivelotor reported increases of Hb levels and RBC counts, and decrease of RBC sickling. The treatment was apparently well tolerated. However, osivelotor shares the same mechanism of action as voxelotor, and therefore similar limitations regarding its efficacy for which the improvement in Hb level appears misleading. Several issues remain to be resolved before considering any drug approval.

Challenges and opportunities for conceiving genetically diverse sickle cell mice

A milestone in sickle cell disease (SCD) therapeutics was achieved in December 2023 with the FDA-approved gene therapy for patients aged 12 years and older. However, these therapies may only suit a fraction of patients because of cost or health risks. A better understanding of SCD outcome heterogeneity is needed to propose patient-specific pharmacological interventions. To achieve this, humanized and genetically diverse mouse models are essential for associating candidate genotypes with specific hematological traits, organ function, and disease resilience. Here, we discuss the challenges and opportunities in developing genetically diverse sickle cell mice (GDS mice). These models are expected to complement current approaches in SCD research and enhance our understanding of SCD heterogeneity and anemia.

Vasculopathy among children and adolescents with sickle cell disease: the crosstalk with annexin A1, vitamin D, and myocardial iron overload

BACKGROUND

Annexin A1 plays an important role in myocardial defense against ischemia-reperfusion injury. We aimed to evaluate the role of annexin A1 as a potential marker of vasculopathy in children and adolescents with sickle cell disease (SCD) and its relation to myocardial iron content (MIC) and vitamin D status.

RESEARCH DESIGN AND METHODS

Forty-one patients with SCD were compared with 40 age- and sex-matched healthy controls, and underwent assessment of serum annexin A1, vitamin D, Doppler echocardiography and cardiac magnetic resonance (CMR).

RESULTS

Six (14.6%) SCD patients had cardiac disease, five (12.2%) had abnormal MIC (≥1.16) and 10 (24.4%) had pulmonary hypertension risk. Annexin A1 levels were significantly lower among patients with SCD compared with healthy controls (p < 0.001). SCD patients with pulmonary hypertension risk, evidence of diastolic dysfunction, and nephropathy as well as those with serum ferritin ≥ 2500 µg/L and vitamin D deficiency had lower Annexin A1 levels than those without. Serum annexin A1 levels were negatively correlated to urinary albumin creatinine ratio (UACR) and Tei index while positively correlated to vitamin D among SCD patients.

CONCLUSIONS

Annexin A1 could be a promising marker of vasculopathy and may provide a biochemical explanation for vitamin D deficiency in SCD.

Clinical and Economic Burden of Managing Patients with Sickle Cell Disease Receiving Frequent Red Blood Cell Transfusions in the United States

Purpose

Standard of care for patients with sickle cell disease (SCD) includes red blood cell transfusions (RBCTs). Data on clinical and economic outcomes of patients with SCD receiving frequent RBCTs are limited.

Materials and Methods

This longitudinal, retrospective, claims-based analysis used the Merative™ MarketScan® Commercial, Medicare, and Multi-State Medicaid databases. Patients with SCD (identified using ICD-9/10 codes) receiving frequent RBCTs (≥6 RBCTs during any 12-month period) between January 1, 2015, and March 1, 2019, were included. The index date was the date of the sixth RBCT. Eligible patients were required to have ≥12 months of continuous enrollment pre- and post-index. Patients were followed from index to end of enrollment, death, or end of the study period (February 29, 2020), whichever came first. Clinical complications, all-cause healthcare resource utilization (HCRU), and healthcare costs were descriptively summarized during follow-up.

Results

A total of 919 patients with SCD receiving frequent RBCTs met the eligibility criteria for inclusion. Patients experienced a mean of 4.0 vaso-occlusive crises (VOCs) per patient per year (PPPY) and received a mean of 8.3 RBCTs PPPY during follow-up. The most common clinical complications were iron overload (77%), infections (66%), and cerebrovascular disease (48%). Patients had a mean of 2.3 inpatient admissions, 83.5 outpatient visits, and 37.4 outpatient prescriptions PPPY during follow-up. Mean total annual healthcare costs were $106,123 PPPY, including mean inpatient, outpatient medical, and outpatient pharmacy costs of $48,463, $28,307, and $29,353, respectively. Compared to those with <2 baseline VOCs, patients with ≥2 baseline VOCs had more HCRU and higher annual healthcare costs.

Conclusion

Despite utilizing available care with frequent RBCTs, patients with SCD experienced a variety of disease and transfusion-related complications, including frequent VOCs and iron overload, which led to substantial HCRU and costs. These findings highlight the need for novel therapies for this patient group.

O blood usage trends in the pediatric population 2015-2019: A multi-institutional analysis

BACKGROUND

In 2019, AABB released the bulletin "Recommendations on the Use of Group O Red Blood Cells" in which the recommendations about pediatric and neonatal blood transfusions were limited. Eight U.S. pediatric hospitals sought to determine trends in pediatric group O blood use and clarify which pediatric populations receive group O blood transfusions despite a non-group O blood type.

STUDY DESIGN AND METHODS

Eight U.S.-based institutions serving a pediatric population provided data from their respective Electronic Health Records. Data submitted included unit blood type, patient blood type, patient age, sex, and discharge diagnosis. If the discharge diagnosis was not available, the admitting diagnosis was substituted. GPT-4 was used to sort diagnoses into categories for analysis. Data were visualized using a series of alluvial plots, spaghetti plots, and tables. Tables were stratified on variables of interest (blood type, age, sex, diagnosis) to explore O blood type distribution among different patient populations.

RESULTS

A total of 142,227 discrete transfusion events were identified, of which 52,731 recipients were non-O blood type. Overall, 35,575 transfusion events of O blood went to A, B, or AB blood type recipients (67%). Additionally, 26% of Rh(D) negative transfusion events went to recipients who were Rh(D) positive. Top diagnostic categories for receiving O blood type were cardiovascular disorders (22%) and sickle cell anemia (15%).

DISCUSSION

This study highlights opportunities to address O blood supply challenges by identifying where non-O blood may be utilized safely in the vulnerable pediatric population.

Beyond Childhood: Adult and Adolescent Sickle Cell Disease and Outcomes in Northern Ghana

Background

Adults and adolescents face different barriers to healthcare utilization compared to children.

Objective

To describe adult and adolescent sickle cell disease (SCD) and outcomes in northern Ghana.

Methods

This was a retrospective cohort study of SCD patients aged 13 years and above, admitted between January 1, 2021 and December 31, 2022 at the Komfo Anokye Teaching Hospital. The data was summarized with descriptive statistics and a multivariate logistics regression analysis was fitted to identify factors independently associated with prolonged hospital stay of more than 4 days.

Results

Of the 326 admissions, 68.9% regularly attended their sickle cell clinics. Approximately 3% of all admissions into the internal medicine ward were due to SCD. Commonest complications observed were painful vaso-occlusive crisis (VOC) (78.1%), infection (51.2%), and hyperhemolysis (24.0%). Presented as adjusted odds ratio (95% CI), the predictors of prolonged hospital stay were: presence of comorbidities, 2.71 [(1.28, 5.97), p = 0.011]; infection, 1.78 [(1.08, 2.94), p = 0.024]; acute chest syndrome, 2.42 [(1.22, 4.970), p = 0.013]; hyperhemolysis, 2.02 [(1.08, 3.80), p = 0.028]; sequestration crisis, 3.80 [(1.50, 11.0), p = 0.008]; and requirement for transfusion, 3.58 [(1.80, 7.36), p < 0.001]. Mortality rate was 2.5%.

Conclusion

SCD and its related complications constitute a significant proportion of all admissions into the adult medical ward. Approximately one in every three Ghanaian adult and adolescent SCD patients does not regularly attend the SCD clinic.

Trial Registration

The authors have confirmed clinical trial registration is not needed for this submission.

The vaso-occlusive pain crisis in sickle cell patients: A focus on pathogenesis

Vaso-occlusive pain crisis (VOC) is recognized as a prominent complication of sickle cell disease, accompanied by debilitating pain and serious consequences for patients, making it the primary cause of visits to hospital emergency departments. In the etiology of VOC, the intricate interaction of endothelial cells, hypoxia, inflammation, and the coagulation system is pivotal. Hemoglobin S polymerization under hypoxic conditions leads to the formation of rigid and adhesive red blood cells that interact with vascular endothelial cells and other blood cells, causing occlusion and subsequent inflammation. Hemolysis of red blood cells results in anemia and heightened inflammation, whereas oxidative stress and involvement of the coagulation system further complicate matters. In this review, we strive to examine the pathophysiology of VOC from these mentioned aspects by consolidating findings from various studies, as a comprehensive understanding of the causes of VOC is essential for the development of targeted therapeutic interventions and the prevention and management of pain, ultimately improving the quality of life for patients.

Current and emerging drug treatment strategies to tackle sickle cell anemia

INTRODUCTION

Since its discovery in the early 1900s, sickle cell disease (SCD) has contributed significantly to the scientific understanding of hemoglobin and hemoglobinopathies. Despite this, now almost a century later, optimal medical management and even curative options remain limited. Encouragingly, in the last decade, there has been a push toward advancing the care for individuals with SCD and a diversifying interest in options to manage this disorder.

AREAS COVERED

Here, we review the current state of disease modifying therapies for SCD including fetal hemoglobin inducers, monoclonal antibodies, anti-inflammatory modulators, and enzyme activators. We also discuss current curative strategies with specific interest in transformative gene therapies.

EXPERT OPINION

SCD is a chronic, progressive disease that despite a century of clinical description, only now is seeing a growth and advance in therapeutic options to improve the lifespan and quality of life for individuals with SCD. We anticipate newly designed and even repurposed therapies that may work as a single agent or combination agents to tackle the progression of SCD. The vast majority of individuals living with SCD are unlikely to receive gene therapy, therefore improved disease management is critical even for those that may ultimately chose to pursue a potentially curative strategy.

Quality of Life and Out-of-Pocket Expenditures for Sickle Cell Disease Patients in Saudi Arabia: A Single-Center Study

Background: Sickle cell anemia (SCD) is a relatively uncommon health condition in many countries, but it is prevalent in Saudi Arabia mainly due to the high incidence of consanguineous marriages. Regrettably, there are elevated rates of vaso-occlusive crises (VOCs) and blood transfusions, leading to poor quality of life and significant financial strain. Objective(s): This study aimed to assess the frequency of blood transfusions, out-of-pocket expenditures (OOPEs), and health-related quality of life (HRQoL) in SCD patients. Methods: This was a questionnaire-based cross-sectional study that involved SCD patients at a university-affiliated tertiary care center in Riyadh, Saudi Arabia. The patients' medical and sociodemographic characteristics were obtained from the electronic medical records. Data on HRQoL and OOPEs were collected through a questionnaire-based interview. To present the baseline characteristics, descriptive statistics such as mean, standard deviation, frequency, and percentage were used. In addition, various statistical tests, including the Chi-Square test, Student t-test, one-way ANOVA, and multiple linear regression, were performed. Results: One hundred and eighteen patients consented to participate and were included in the analysis. Almost 53% of the patients were females. The mean age of the sample was 31 years, while the age-adjusted quality-adjusted life years (QALYs) was 24.33 years (p-value < 0.0001). Most patients (83.05%) reside in Riyadh with a monthly family income of less than USD 2666.67 (75.42%). Monthly OOPEs were, on average, USD 650.69 ± 1853.96, and one-third of the adult patients reported income loss due to illness, further exacerbating their financial strain. High frequency of blood transfusion (β = -0.0564, p-value = 0.0066) and higher number of comorbidities (β = -0.10367, p-value = 0.0244) were negatively associated with the HRQoL among adult patients. On the other hand, adult patients with higher levels of education had better HRQoL (β = 0.05378, p-value = 0.0377). Conclusions: The findings of this study highlight the negative impact of SCD on patients' HRQoL and financial well-being. This underscores the urgent need for comprehensive systemic approaches to address the challenges posed by SCD in Saudi Arabia.

Position paper on advancing sickle cell disease management in France by bridging the clinical practices and guidelines through expert insights

In France, sickle cell disease (SCD) is the most common rare disease and represents the most prevalent genetic disorder, with 19,800 to 32,400 patients diagnosed in 2016 and 1:714 newborns affected in 2019. SCD is caused by a single mutation in the β-globin gene, resulting in the production of abnormal hemoglobin (called HbS), chronic hemolytic anemia, and impaired red blood cell rheology. SCD patients face several severe acute and chronic complications, including stroke, acute chest syndrome (ACS), painful vaso-occlusive crisis (VOC), organ failure, and a high risk of infections. As patients' care pathway remains unclear in France, a roundtable advisory board meeting was organized in the country to provide insights into the management of SCD in alignment with clinical guidelines. The meeting brought together a panel of esteemed key opinion leaders (KOLs) in SCD management, encompassing both clinical practice and research. During the meeting, the KOLs discussed clinical practices and their alignment with French guidelines, identifying areas of concordance and discrepancy. They also addressed disparities in SCD clinical practices across regions and medical centers. The KOLs discussed the prophylactic and therapeutic options currently available for SCD patients in France, with a focus on transfusion therapies, especially automated red blood cell exchange (aRBCX). The results of this advisory board meeting provide a valuable platform for gathering expert perspectives on SCD management, clinical practices, guideline alignment, and the potential for contributions to guideline updates.

Fostering a healthier generation of children with sickle cell disease through advancements in care

Sickle cell disease (SCD) is an inherited disorder of hemoglobin that affects tens of millions of individuals worldwide. Without preventive and disease-modifying therapy, SCD results in many acute and chronic complications impacting both quality and length of life. We are currently in a new generation of SCD care in high resource settings due to recent advancements in care. Universal newborn screening (NBS) for SCD with associated parental education and preventive care significantly improved mortality rates. Beginning in the 1990s, hydroxyurea emerged as a promising pharmacologic treatment for SCD due to its ability to increase the amount of fetal hemoglobin. It is now the mainstay of treatment, with strong recommendations to begin as early as the first year of life with the goal of reducing most short- and long-term complications and allowing for a normalized quality of life. More recently, gene therapy has come to the forefront in SCD and brings the hope of a cure for many patients. In 2023, the FDA approved two cell-based gene therapies for patients with SCD. The future is bright for patients with SCD, and the current generation of affected children will expectantly be able to grow up free of suffering and severe, frequent pain.

Therapeutics for sickle cell disease intravascular hemolysis

Sickle cell disease (SCD) is a genetic disorder predominantly affecting individuals of African descent, with a significant global health burden. SCD is characterized by intravascular hemolysis, driven by the polymerization of mutated hemoglobin within red blood cells (RBCs), leading to vascular inflammation, organ damage, and heme toxicity. Clinical manifestations include acute pain crises, hemolytic anemia, and multi-organ dysfunction, imposing substantial morbidity and mortality challenges. Current therapeutic strategies mitigate these complications by increasing the concentration of RBCs with normal hemoglobin via transfusion, inducing fetal hemoglobin, restoring nitric oxide signaling, inhibiting platelet-endothelium interaction, and stabilizing hemoglobin in its oxygenated state. While hydroxyurea and gene therapies show promise, each faces distinct challenges. Hydroxyurea's efficacy varies among patients, and gene therapies, though effective, are limited by issues of accessibility and affordability. An emerging frontier in SCD management involves harnessing endogenous clearance mechanisms for hemolysis products. A recent work by Heggland et al. showed that CD-36-like proteins mediate heme absorption in hematophagous ectoparasite, a type of parasite that feeds on the blood of its host. This discovery underscores the need for further investigation into scavenger receptors (e.g., CD36, SR-BI, SR-BII) for their possible role in heme uptake and detoxification in mammalian species. In this review, we discussed current SCD therapeutics and the specific stages of pathophysiology they target. We identified the limitations of existing treatments and explored potential future developments for novel SCD therapies. Novel therapeutic targets, including heme scavenging pathways, hold the potential for improving outcomes and reducing the global burden of SCD.

First investigation of RH gene polymorphism in patients with sickle cell disease and associated blood donors in Cameroon, Central Africa

BACKGROUND

Although genetic polymorphism of the RH blood group system is well known in sub-Saharan Africa, national/regional specificities still remain to be described precisely. For the first time in Cameroon, Central Africa, and in order to better characterize the molecular basis driving RH phenotype variability, as well as to identify the main antigens that may be potentially responsible for alloimmunization, we sought 1) to study the RH genes in a cohort of 109 patients with sickle cell disease; 2) to study the same genes in the corresponding donors whose red blood cells (RBCs) were transfused to the patients (108 donors in 98 patients); 3) to predict RH phenotype on the basis of the molecular data and compare the results with serologic testing; and 4) to identify retrospectively patients at risk for alloimmunization.

MATERIALS AND METHODS

In order to generate an exhaustive dataset, the RH genes of all patient and donor samples were systematically investigated 1) by quantitative multiplex PCR of short fluorescent fragments (QMPSF) for characterization of RHD gene zygosity and potential structural variants (SVs), and 2) by Sanger sequencing for identification of single nucleotide variants (SNVs). Subsequent to molecular analysis, the genotypes and RH phenotype were deduced and predicted, respectively, from reference databases.

RESULTS

In a total of 217 Cameroonian individuals, as many as 24 and up to 22 variant alleles were identified in the RHD and RHCE genes, respectively, in addition to the reference alleles. Interestingly, 65 patients with SCD (66.3%) were assumed to be exposed to one or more undesirable RH antigen(s) with varying degrees of clinical relevance.

DISCUSSION

Beyond the comprehensive report of the nature and distribution of RH variant alleles in a subset of Cameroonian patients treated by transfusion therapy, this work highlights the need for an extensive review of current practice, including routine serologic typing procedures, preferably in the near future.

Study of the antigenic characteristics of red blood cells units and their sickle cell disease recipients and the G6PD activity of transfused red blood cells units

INTRODUCTION

Transfusion has a central place in the treatment of patients with sickle cell disease (SCD). Matching blood groups of red blood cell (RBC) units with the blood groups of the patient is essential to prevent alloimmunization and delayed hemolytic transfusion reaction. African ancestry donors have the best phenocompatibility with patients of the same origin, however their RBCs may present characteristic that can alter quality of the unit such as glucose-6-phosphate dehydrogenase (G6PD) deficiency. The objective is to analyze transfusion protocol, immunization rate and mismatch situations of SCD recipients and to evaluate the frequency of G6PD deficiency in RBCs units from African ancestry donors.

METHODS

Samples of units transfused to SCD patients were analyzed. Transfusion data were collected from institutional databases. The activity of G6PD was measured in the segment of the RBC units.

RESULTS

A total of 98 segments of units transfused to 37 SCD recipients in 41 transfusions episodes was collected. Among patients, 35.1% (n = 13) had no antibodies; 10.8% (n = 4) had antibodies against Fya/Fyb, Jka/Jkb, M/N, S/s; 21.6% (n = 8) against RH/K antigens. In all cases, the protocols were in line with the recommendations. G6PD deficiency was observed in 9 units, that were all collected from Afro-Caribbean donors.

CONCLUSION

The transfusion protocol is established to prevent immunological reactions due to disparities in blood group antigens between donors and SCD recipients. However, the units of African ancestry donors, which allowed the best compatibility, displayed a high rate of G6PD deficiency. The storage and recovery impact of this deficiency must be evaluated.

Modification of deglycerolization procedure improves processing and post-thaw quality of cryopreserved sickle trait red cell concentrates

Red blood cell (RBC) transfusion is a critical therapy for those with sickle cell disease (SCD). Alloimmunization is frequent for those with SCD and may limit the availability of matched RBC. Cryopreserved RBCs, from family members or donors with a similar RBC antigen profile could provide a viable alternative to avoid further alloimmunization and prevent hemolytic transfusion-related events. However, cryopreserved SCD and Sickle Cell trait (S-trait) donor RBC units suffer from reduced recovery following deglycerolization. This study proposes and tests a modified deglycerolization protocol using an automated cell processor to mitigate RBC loss. Six red cell concentrates (RCC) from donors with S-trait and six control RCCs were glycerolized, frozen (<-65 °C) and deglycerolized on the ACP 215 using modified parameters (decreased hypertonic solution flow rate (100 mL/min) and hypertonic equilibration delay (120 s), and increased NaCl dilution volumes (500 mL). Quality testing included: hematocrit (HCT), hemolysis, indices, extracellular potassium, morphology, osmotic fragility, osmotic gradient ektacytometry, hemoglobin (HGB), and recovery. Canadian standards (CS) indicate that acceptable deglycerolized units for transfusion require a HCT ≤0.80 L/L, HGB ≥35 g/unit, and hemolysis <0.8 % in 90 % of units tested. No significant differences in HGB or RBC recovery were observed between study groups. Significant differences between study groups were identified in osmotic fragility and osmotic gradient ektacytometry parameters. Of the 6 S-trait RCCs, 3/6 units were within the HCT, HGB and hemolysis thresholds set by the CS. The modified deglycerolization protocol provides a path for the routine cryopreservation of S-trait RBCs.

Rapid haemoglobin A and S quantification using Tosoh HLC-723G8 in variant mode for patients with sickle cell disease

The management of life-threatening complications in patients with sickle cell disease (SCD) requires an accurate and reproducible quantification of haemoglobin A (HbA) and S (HbS) with a short turnaround time and 24-7 availability. We propose a novel method for quantifying HbA and HbS using the glycated haemoglobin (HbA1c) assay on a Tosoh HLC-723G8 (G8) analyser in variant mode. HbA and HbS results obtained using our method highly correlated with results obtained using a reference method (r > 0.99 for 124 samples of patients with SCD or sickle cell trait). Our method met laboratory requirements for linearity (coefficient of variation [CV] and bias <5%), between-run and within-run reproducibility (CV <10%) and carryover (<0.5%) over the range of HbS and HbA values expected in a therapeutic context. Using the G8 analyser in variant mode is viable for monitoring HbA and HbS concentrations in dire situations. This method is easy to use, quick (1.6 min per sample), and automatable and produces highly reproducible results without significant bias. Finally, it does not require modifications to the analytical pipeline recommended by the supplier, enabling a 24-7 availability without disrupting routine monitoring of HbA1c in the laboratory.

Robotic-assisted versus laparoscopic splenectomy in children: a costeffectiveness study

Laparoscopic elective splenectomy is considered as a safe surgical treatment of spleen non-traumatic blood disorders. However, robotic assisted splenectomy is becoming a promising alternative, although there are scarce studies in pediatric patients. Our aim is to compare the effectiveness and associated costs of both procedures in children. A single-institution retrospective study was performed among consecutive children undergoing splenectomy between 2004 and 2021, who were divided according to the surgical approach: LAS group (laparoscopic splenectomy) and RAS group (robotic assisted splenectomy). Demographics, clinical features, intraoperative blood loss, surgery time, length of hospital stay (LOS), postoperative complications, need for postoperative blood transfusion, readmission rate and economic data were compared. A total of 84 patients were included (23 LAS group; 61 RAS group), without demographic or clinical differences between them. RAS patients presented lower intraoperative blood loss (42 ± 15 vs. 158 ± 39 ml; p < 0.021) and shorter surgery time (135 ± 39 vs. 182 ± 68 min; p = 0.043), with no differences in median LOS (3 days in both groups). No intraoperative complications or conversion was reported. Five postoperative complications were observed: 4 in LAS patients (17.4%) versus only one in RAS (1.6%; p = 0.021). One reintervention was required in LAS group due to hemoperitoneum 12 h after splenectomy. RAS patients had lower postoperative blood transfusion requirements (1.6% vs. 13.0%; p = 0.025) and lower readmission rate (3.3 vs. 17.4%; p = 0.042). No differences were observed when comparing the median economic costs ($25,645 LAS vs. $28,135 RAS; p = 0.215). Robotic assisted splenectomy may be considered as a safe and feasible option in children compared to the traditional laparoscopic approach. Level of evidence: III.

Sickle Cell Disease Update: New Treatments and Challenging Nutritional Interventions

Sickle cell disease (SCD), a distinctive and often overlooked illness in the 21st century, is a congenital blood disorder characterized by considerable phenotypic diversity. It comprises a group of disorders, with sickle cell anemia (SCA) being the most prevalent and serious genotype. Although there have been some systematic reviews of global data, worldwide statistics regarding SCD prevalence, morbidity, and mortality remain scarce. In developed countries with a lower number of sickle cell patients, cutting-edge technologies have led to the development of new treatments. However, in developing settings where sickle cell disease (SCD) is more prevalent, medical management, rather than a cure, still relies on the use of hydroxyurea, blood transfusions, and analgesics. This is a disease that affects red blood cells, consequently affecting most organs in diverse manners. We discuss its etiology and the advent of new technologies, but the aim of this study is to understand the various types of nutrition-related studies involving individuals suffering from SCD, particularly in Africa. The interplay of the environment, food, gut microbiota, along with their respective genomes collectively known as the gut microbiome, and host metabolism is responsible for mediating host metabolic phenotypes and modulating gut microbiota. In addition, it serves the purpose of providing essential nutrients. Moreover, it engages in direct interactions with host homeostasis and the immune system, as well as indirect interactions via metabolites. Nutrition interventions and nutritional care are mechanisms for addressing increased nutrient expenditures and are important aspects of supportive management for patients with SCD. Underprivileged areas in Sub-Saharan Africa should be accompanied by efforts to define and promote of the nutritional aspects of SCD. Their importance is key to maintaining well-being and quality of life, especially because new technologies and products remain limited, while the use of native medicinal plant resources is acknowledged.

Global burden of transfusion in sickle cell disease

Sickle cell disease (SCD) is the most common hereditary hemoglobinopathy. The underlying pathophysiology of the red blood cell (RBC) leads to pan-systemic complications which manifest at an early age. While curative and disease-modifying treatments exist for SCD, a key intervention in the management and treatment of SCD is RBC transfusion, which can alleviate or prevent many complications. SCD patients often require chronic RBC transfusion therapy which can result in complications, such as iron overload, alloimmunization and infection. In low- and middle-income countries (LMICs), SCD patients lack appropriate access to healthcare such as newborn screening, health education, prophylaxis for infection, and treatments to reduce both mortality and SCD-related adverse effects. Poor access to RBCs for transfusion, coupled with donated blood not meeting safety standards set by the World Health Organization, presents a significant barrier for patients requiring chronic transfusions in LMICs. Unmet needs associated with blood collection, blood component processing and recipient matching all pose a serious problem in many LMICs, although this varies depending on geographic location, political organizations and economy. This review aims to provide an overview of the global burden of SCD, focusing on the availability of current treatments and the burden of chronic RBC transfusions in patients with SCD.

The APC-EPCR-PAR1 axis in sickle cell disease

Sickle Cell Disease (SCD) is a group of inherited hemoglobinopathies. Sickle cell anemia (SCA) is caused by a homozygous mutation in the β-globin generating sickle hemoglobin (HbS). Deoxygenation leads to pathologic polymerization of HbS and sickling of erythrocytes. The two predominant pathologies of SCD are hemolytic anemia and vaso-occlusive episodes (VOE), along with sequelae of complications including acute chest syndrome, hepatopathy, nephropathy, pulmonary hypertension, venous thromboembolism, and stroke. SCD is associated with endothelial activation due to the release of danger-associated molecular patterns (DAMPs) such as heme, recurrent ischemia-reperfusion injury, and chronic thrombin generation and inflammation. Endothelial cell activation is mediated, in part, by thrombin-dependent activation of protease-activated receptor 1 (PAR1), a G protein coupled receptor that plays a role in platelet activation, endothelial permeability, inflammation, and cytotoxicity. PAR1 can also be activated by activated protein C (APC), which promotes endothelial barrier protection and cytoprotective signaling. Notably, the APC system is dysregulated in SCD. This mini-review will discuss activation of PAR1 by APC and thrombin, the APC-EPCR-PAR1 axis, and their potential roles in SCD.

Management of Older Adults with Sickle Cell Disease: Considerations for Current and Emerging Therapies

People with sickle cell disease (SCD) are living longer than ever before, with the median survival increasing from age 14 years in 1973, beyond age 40 years in the 1990s, and as high as 61 years in recent cohorts from academic centers. Improvements in survival have been attributed to initiatives, such as newborn screening, penicillin prophylaxis, vaccination against encapsulated organisms, better detection and treatment of splenic sequestration, and improved transfusion support. There are an estimated 100,000 people living with SCD in the United States and millions of people with SCD globally. Given that the number of older adults with SCD will likely continue to increase as survival improves, better evidence on how to manage this population is needed. When managing older adults with SCD (defined herein as age ≥ 40 years), healthcare providers should consider the potential pitfalls of extrapolating evidence from existing studies on current and emerging therapies that have typically been conducted with participants at mean ages far below 40 years. Older adults with SCD have historically had little to no representation in clinical trials; therefore, more guidance is needed on how to use current and emerging therapies in this population. This article summarizes the available evidence for managing older adults with SCD and discusses potential challenges to using approved and emerging drugs in this population.

Role of Serum Ferritin in Predicting Outcomes of COVID-19 Infection Among Sickle Cell Disease Patients: A Systematic Review and Meta-Analysis

Patients with sickle cell disease (SCD) are at higher risk of getting severe COVID-19 infection. This systematic review and meta-analysis aimed to determine the role of serum ferritin in predicting ICU admission and mortality among patients with SCD following COVID-19 infection. A systematic search was conducted in PubMed, Scopus, Web of Science, Embase, WHO COVID-19 database, ProQuest, and Cochrane Library for articles published between 1st December 2019 to 31st November 2021. Methodological quality was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklists. Eleven articles (7 cohorts and 4 case series) were included in this review. Pooled mean serum ferritin level on admission was 1581.62 ng/mL while pooled proportion of ICU admission and mortality were 0.10 (95% CI 0.06; 0.16, prediction interval 0.04; 0.23, p = 0.29, I 2 = 17%) and 0.07 (95% CI 0.05; 0.11, prediction interval 0.04; 0.12, p = 0.68, I 2 = 0%) respectively. Meta-regression showed that serum ferritin did not predict for both ICU admission (regression coefficient = 0.0001, p = 0.3523) and mortality (regression coefficient = 0.0001, p = 0.4029). Our analyses showed that serum ferritin may not be a useful marker to predict the outcomes of COVID-19 infection among patients with SCD. More data are required to identify a reliable tool to identify patients with SCD who are at risk of getting severe COVID-19 infection.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=287792, PROSPERO Registration: CRD42021287792.