Renal abnormalities among children with sickle cell conditions in highly resource-limited setting in Ghana

Sickle Cell Disease Related Vasculopathies and Early Evaluation in a Pediatric Population

BACKGROUND/AIM

Cardiovascular pathologies are ubiquitous in sickle cell disease (SCD). A targeted literature review was conducted to compare the overall epidemiology of selected vasculopathies seen in SCD (SCDVs) compared to the general population. Since many SCDV may originate in childhood, the study also focused on the retrospective investigation of SCDVs in a pediatric cohort at the Harbor-UCLA Medical Center.

PATIENTS AND METHODS

SCDVs were studied along patient age, β-globin genotypes, and fetal hemoglobin (HbF). Urine microalbumin/creatinine ratios (UM/Cr), trans-cranial doppler (TCD) and tricuspid regurgitant jet velocities (TRJV) were analyzed as well. Retinographies and overt vasculopathies were presented descriptively.

RESULTS

Among 20 females and 20 males [average 8.3 years (2.3-19 years)], 70% had HbSS/Sβ0, 22.5% HbSC and 7.5%-HbSβ+. The mean(±SD) HbF% was 17.4±12.7% (30% higher in <10 vs. ≥10 y/o, and 3 times higher in SS/Sβ0). Twenty-six patients received hydroxyurea and 13/26, L-glutamine. Thirty-six patients had TCDs within 1.4±0.9 years and all laboratory values were obtained within the last 12 months. TCDs showed low-normal velocities, but 2 were higher for HbSS/Sβ0 vs. HbSC/Sβ+ (MCA-96 vs. 86 cm/s, p=0.03; and PCA-50 vs. 41, p<0.001). Nineteen of 28 patients with echocardiograms had measurable TRJV (2.46±0.19 m/s); 9 had TRJV ≥2.5-2.8 m/s, but BNP ≤80 pg/ml. SS/Sβ0 was associated with higher UM/Cr. There were 2 cases with silent infarcts, 1-Moyamoya, 2-persistent macroalbuminuria, and 1-hematuria/renal papillary necrosis. Most ≥9 y/o patients had retinographies without SCD-related changes. There was no correlation among TCD (MCA), TRJV, and UM/Cr (n=17); thus, in this subpopulation, pathologies of cerebral, cardiopulmonary, and renal vasculatures evolved independently. Patients with higher TRJV and/or overt vasculopathy (n=14) were older than ones without (12.5±4.7 vs. 6.1±3.1 y/o, p<0.001), and had lower HbF (11.4±7.6 vs. 20.6±13.8%, p=0.026).

CONCLUSION

While overt SCDVs are less frequent in children, age-dependent trends/surrogate markers suggest their early origination in youth, justifying intense screening to prevent their progression with disease-modifying measures.

Urinogenital schistosomiasis knowledge, attitude, practices, and its clinical correlates among communities along water bodies in the Kwahu Afram Plains North District, Ghana

BACKGROUND

Adequate knowledge and proper practices coupled with knowledge of the burden of disease are necessary for the eradication of Schistosoma infection. This study assessed knowledge, attitude, and practice (KAP) as well as health outcomes related to Schistosoma haematobium infection at Kwahu Afram Plains North District (KAPND).

METHODS

A cross-sectional survey using a structured questionnaire was carried out among 140 participants from four local communities in KAPND in August 2021. From these participants, 10ml of urine was collected for determination of the presence of S. haematobium and urine routine examination. In addition, 4ml of blood was collected and used for haematological examination. Descriptive statistics and logistic regression analysis using IBM SPSS were used to describe and represent the data collected.

RESULTS

The study reports a gap in knowledge about schistosomiasis in the study area with the majority indicating that they have not heard of schistosomiasis (60.7%), do not know the mode of transmission (49.3%), and do not know how the disease could be spread (51.5%). The overall prevalence of urinary schistosomiasis was 52.9%. This was associated with age, occupation, perceived mode of Schistosoma transmission, knowledge of Schistosoma prevention, awareness that schistosomiasis can be treated, frequency of visits to water bodies, and water usage patterns. In multivariate analysis, factors that remained significantly associated with S. haematobium infection were age 21-40 (OR  =  0.21, 95% CI: 0.06-0.76), 41-60 (OR  =  0.01, 95% CI: 0.01-0.52) and ≥ 60 (OR  =  0.02, 95% CI: 0.02-0.87), informal employment (OR  =  0.01, 95% CI: 0.01-0.69) and awareness of transmission by drinking water from river body (OR  =  0.03, 95% CI: 0.03-0.92). In Schistosoma infection, reduced haemoglobin, haematocrit, mean corpuscular volume, mean corpuscular haemoglobin, lymphocytes and eosinophils were observed. White blood cells, neutrophils, and monocytes were significantly elevated in infected states. Urine analysis revealed high pus cells and red blood cells counts among Schistosoma-positive participants.

CONCLUSION

Schistosoma infection is endemic among inhabitants in KAPND, and is associated with a gap in knowledge, awareness, and practice possibly due to inadequate education in the area. Poor clinical outcomes associated with Schistosoma infection have been demonstrated in the area. A well-structured public education, nutritional intervention, and mass drug administration will be necessary to eradicate this menace.

Neutrophil gelatinase-associated lipocalin is elevated in children with acute kidney injury and sickle cell anemia, and predicts mortality

Urine neutrophil gelatinase-associated lipocalin (NGAL) is a biomarker of acute kidney injury that has been adapted to a urine dipstick test. However, there is limited data on its use in low-and-middle-income countries where diagnosis of acute kidney injury remains a challenge. To study this, we prospectively enrolled 250 children with sickle cell anemia aged two to 18 years encompassing 185 children hospitalized with a vaso-occlusive pain crisis and a reference group of 65 children attending the sickle cell clinic for routine care follow up. Kidney injury was defined using serial creatinine measures and a modified-Kidney Disease Improving Global Outcome definition for sickle cell anemia. Urine NGAL was measured using the NGAL dipstick and a laboratory reference. The mean age of children enrolled was 8.9 years and 42.8% were female. Among hospitalized children, 36.2% had kidney injury and 3.2% died. Measured urine NGAL levels by the dipstick were strongly correlated with the standard enzyme-linked immunosorbent assay for urine NGAL (hospitalized children, 0.71; routine care reference, 0.88). NGAL levels were elevated in kidney injury and significantly increased across injury stages. Hospitalized children with a high-risk dipstick test (300ng/mL and more) had a 2.47-fold relative risk of kidney injury (95% confidence interval 1.68 to 3.61) and 7.28 increased risk of death (95% confidence interval 1.10 to 26.81) adjusting for age and sex. Thus, urine NGAL levels were found to be significantly elevated in children with sickle cell anemia and acute kidney injury and may predict mortality.

Sickle cell nephropathy: A review of novel biomarkers and their potential roles in early detection of renal involvement

Whether the underlying mutations are homozygous, heterozygous, or co-inherited with other hemoglobinopathies, sickle cell disease is known to afflict the kidneys, leading to the clinical entity known as sickle cell nephropathy (SCN). Although common, SCN remains diagnostically elusive. Conventional studies performed in the context of renal disorders often fail to detect early stage SCN. This makes the quest for early diagnosis and treatment more challenging, and it increases the burden of chronic kidney disease-related morbidity among patients. Novel diagnostic tools have been employed to overcome this limitation. In this study, we discuss various biomarkers of SCN, including those employed in clinical practice and others recently identified in experimental settings, such as markers of vascular injury, endothelial dysfunction, tubulo-glomerular damage, and oxidative stress. These include kidney injury molecule-1, monocyte chemoattractant protein-1, N-acetyl-B-D-glucosaminidase, ceruloplasmin, orosomucoid, nephrin, and cation channels, among others. Furthermore, we explore the potential of novel biomarkers for refining diagnostic and therapeutic approaches and describe some obstacles that still need to be overcome. We highlight the importance of a collaborative approach to standardize the use of promising new biomarkers. Finally, we outline the limitations of conventional markers of renal damage as extensions of the pathogenic process occurring at the level of the organ and its functional subunits, with a discussion of the expected pattern of clinical and biochemical progression among patients with SCN.

Time trends, sociodemographic and health factors associated with discharge and length of stay of hospitalised patients with sickle cell disease in Ghana: a retrospective analysis of national routine health database

OBJECTIVE

Patients with sickle cell disease (SCD) are prone to multiple episodes resulting in frequent hospital visits. We determined the time trends, sociodemographic and health factors associated with length of stay (LoS) for patients with SCD in Ghana.

DESIGN, PARTICIPANTS, SETTING

We retrospectively analysed SCD hospitalisation records of 22 680 patients from a nationwide database of the Ghana Health Service from 2012 to 2017.

OUTCOME MEASURES

Factors associated with LoS were estimated using Cox regression, while the cumulative incidence of being discharged alive was estimated with in-hospital death as a competing risk.

RESULTS

Patients admitted for SCD over 6 years constituted 22 680 (0.8%) of nearly 3 million admissions. The median age and LoS for the patients were 16 years (IQR=8-24) and 3 days (IQR=2-4), representing 14 202 (62.6%) of the patients discharged alive by the third day. Patients with sickle cell anaemia (6139, 52.6%) with a crisis were more frequent than those without a crisis. Increasing age was associated with shorter LoS when comparing age groups 10-14 years (HR=1.08, 95% CI 1.01 to 1.14) and 25-29 years (HR=1.27, 95% CI 1.17 to 1.37) to patients aged 0-4 years. Patients with comorbidities had a longer LoS compared with those without (HR=0.88, 95% CI 0.86 to 0.90).

CONCLUSION

This is the largest study to date documenting factors associated with LoS for patients admitted for SCD. The association of younger age with increased LoS supports recent calls for early SCD screening, especially newborns. The emerging trends and factors accounting for SCD admission require a multisector approach as these patients already experience frequent episodes of pain and hospital visits.

Plasma Lipids and Lipoproteins in Sickle Cell Disease Patients in the Northern West Bank, Palestine

Background

Lipid metabolism may be altered in red cell genetic disorders. The erythrocyte and plasma lipids are defected which may increase the risk of cardiovascular disease. In the present study, we hypothesized a possible link between severity of anemia and altered lipid profile in SCD.

Methods

A total of 151 SCD patients, including 62 patients with sickle cell anemia (SS), 54 patients with sickle β-thalassemia (ST), and 35 individuals with sickle cell trait (AS), were studied. The control group consisted of 160 healthy individuals. Total cholesterol (TC), triglyceride (TG), and high-density lipoprotein cholesterol (HDL-C) were enzymatically measured.

Results

Total cholesterol and LDL-C were significantly lower (P value < 0.001) in SS and ST patients compared to AS individuals and AA controls. However, LDL-C was significantly lower in AS individuals (both males and female) compared to AA controls (P value < 0.001). The HDL-C in SS and ST patients (both males and females) was significantly lower than that in AS individuals (P value < 0.001). In addition, the HDL-C was significantly higher in SS and ST males and AS (males and females) compared to AA controls (P value < 0.001). The HDL-C was also significantly higher in SS males (P value < 0.001) and females (P value < 0.05) compared to ST patients. The HDL-C was significantly higher in AS individuals (P value < 0.001) compared to AA controls. The triglycerides in SS males was significantly lower than that in ST patients (P value < 0.001), but there was no significant difference when compared to AS individuals and AA controls. In contrast, triglycerides in SS females were significantly lower than those in ST (P value < 0.05), AS (P value < 0.001), and AA controls (P value < 0.001). In males of ST patients, triglycerides were significantly higher than those observed in AS males and AA males (P value < 0.001). In contrast, females of ST patients have a significantly lower triglycerides compared to AS and AA females (P value < 0.001).

Conclusions

In SCD, the plasma is affected in some way, especially the plasma cholesterol that was investigated in this study. Further prospective studies should examine the contribution of an altered lipid profile to the severity and clinical complications in SCD patients.

Investigations of Kidney Dysfunction-Related Gene Variants in Sickle Cell Disease Patients in Cameroon (Sub-Saharan Africa)

Background

Renal dysfunctions are associated with increased morbidity and mortality in sickle cell disease (SCD). Early detection and subsequent management of SCD patients at risk for renal failure and dysfunctions are essential, however, predictors that can identify patients at risk of developing renal dysfunction are not fully understood.

Methods

In this study, we have investigated the association of 31 known kidney dysfunctions-related variants detected in African Americans from multi-ethnic genome wide studies (GWAS) meta-analysis, to kidney-dysfunctions in a group of 413 Cameroonian patients with SCD. Systems level bioinformatics analyses were performed, employing protein-protein interaction networks to further interrogate the putative associations.

Results

Up to 61% of these patients had micro-albuminuria, 2.4% proteinuria, 71% glomerular hyperfiltration, and 5.9% had renal failure. Six variants are significantly associated with the two quantifiable phenotypes of kidney dysfunction (eGFR and crude-albuminuria): A1CF-rs10994860 (P = 0.02020), SYPL2-rs12136063 (P = 0.04208), and APOL1 (G1)-rs73885319 (P = 0.04610) are associated with eGFR; and WNT7A-rs6795744 (P = 0.03730), TMEM60-rs6465825 (P = 0.02340), and APOL1 (G2)-rs71785313 (P = 0.03803) observed to be protective against micro-albuminuria. We identified a protein-protein interaction sub-network containing three of these gene variants: APOL1, SYPL2, and WNT7A, connected to the Nuclear factor NF-kappa-B p105 subunit (NFKB1), revealed to be essential and might indirectly influence extreme phenotypes. Interestingly, clinical variables, including body mass index (BMI), systolic blood pressure, vaso-occlusive crisis (VOC), and haemoglobin (Hb), explain better the kidney phenotypic variations in this SCD population.

Conclusion

This study highlights a strong contribution of haematological indices (Hb level), anthropometric variables (BMI, blood pressure), and clinical events (i.e., vaso-occlusive crisis) to kidney dysfunctions in SCD, rather than known genetic factors. Only 6/31 characterised gene-variants are associated with kidney dysfunction phenotypes in SCD samples from Cameroon. The data reveal and emphasise the urgent need to extend GWAS studies in populations of African ancestries living in Africa, and particularly for kidney dysfunctions in SCD.