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Hamdy M, Shaheen IA, Khallaf M, Selim YMM. Thrombin activatable fibrinolysis inhibitor plasma levels and TAFI Thr325Ile genetic polymorphism in a cohort of Egyptian sickle cell disease patients and impact on disease severity. Pediatr Blood Cancer 2024; 71:e30959. [PMID: 38520679 DOI: 10.1002/pbc.30959] [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] [Received: 11/07/2023] [Revised: 02/07/2024] [Accepted: 02/28/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Thrombin is a critical protease modulating thrombosis as well as inflammation, which are one of the main pathophysiological mechanisms in sickle vasculopathy, and its levels were reported to be high in sickle cell disease (SCD). The thrombin-thrombomodulin complex activates the TAFI inhibitor of fibrinolysis, which acts by reducing plasmin affinity for its substrate thus hindering fibrinolysis. OBJECTIVE We aimed to determine the influence of the Thr325Ile single nucleotide polymorphism (SNP) on TAFI antigen levels and potential effects on the severity of SCD in a cohort of Egyptian patients. METHODS Genotyping of Thr325lle polymorphism using Taq-Man SNP genotyping assay and TAFI level measurement using an enzyme-linked immunosorbent assay were performed for 80 SCD patients (45 homozygous HbSS, 16 S/β0 and 19 Sβ+) as well as 80 age- and gender-matched healthy control subjects. RESULTS Plasma TAFI levels were higher in SCD patients with Thr325Ile polymorphism, yet the difference was not statistically significant (p = .204). SCD patients with polymorphic genotypes had a greater number of hospital admissions (p = .03). Ten patients with acute chest syndrome had the homozygous polymorphic genotype (GG), and all patients with pulmonary hypertension had the polymorphic genotype (six were homozygous [GG] and five were heterozygous [GA]). Patients with SCD complicated with pulmonary hypertension showed significantly higher plasma TAFI levels (p = .044). CONCLUSION The analysis of Thr325Ile polymorphisms combined with plasma TAFI levels suggests that the analyzed SNP could influence plasma TAFL levels and SCD disease severity and hospitalization rates, which could be predictors for complex disease.
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Affiliation(s)
- Mona Hamdy
- Department of Pediatrics, Pediatric Hematology and BMT Unit, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Iman A Shaheen
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Khallaf
- Department of Pediatrics, Pediatric Hematology and BMT Unit, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Yasmeen M M Selim
- Department of Pediatrics, Pediatric Hematology and BMT Unit, Faculty of Medicine, Cairo University, Cairo, Egypt
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Bathla T, Lotfollahzadeh S, Quisel M, Mehta M, Malikova M, Chitalia VC. End Organ Affection in Sickle Cell Disease. Cells 2024; 13:934. [PMID: 38891066 DOI: 10.3390/cells13110934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 05/21/2024] [Accepted: 05/24/2024] [Indexed: 06/20/2024] Open
Abstract
Sickle cell disease is an orphan disease affecting ethnic minorities and characterized by profound systemic manifestations. Although around 100,000 individuals with SCD are living in the US, the exact number of individuals is unknown, and it is considered an orphan disease. This single-gene disorder leads to red blood cell sickling and the deoxygenation of hemoglobin, resulting in hemolysis. SCD is associated with acute complications such as vaso-occlusive crisis, infections, and chronic target organ complications such as pulmonary disease and renal failure. While genetic therapy holds promise to alter the fundamental disease process, the major challenge in the field remains the target end organ damage and ways to mitigate or reverse it. Here, we provide an overview of the clinical manifestations and pathogenesis with a focus on end-organ damage and current therapeutic options, including recent FDA-approved stem cell and gene editing therapies.
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Affiliation(s)
- Tanvi Bathla
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Saran Lotfollahzadeh
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Matthew Quisel
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Mansi Mehta
- Saint Vincent's Medical Hospital, Worcester, MA 01608, USA
| | - Marina Malikova
- Department of Surgery, Boston University School of Medicine, Boston, MA 02118, USA
| | - Vipul C Chitalia
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA
- Veterans Affairs Boston Healthcare System, Boston, MA 02118, USA
- Institute of Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Center of Cross-Organ Vascular Pathology, Department of Medicine, Boston University Medical Center, Evans Biomedical Research Center, X-530, Boston, MA 02118, USA
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M A A, O AI, M S A, A BR, O O. Assessment of hypoxemia among young adults with sickle cell anaemia in steady state in southwestern Nigeria: a crosssectional study. BMC Res Notes 2024; 17:100. [PMID: 38589908 PMCID: PMC11003092 DOI: 10.1186/s13104-024-06765-0] [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: 07/03/2023] [Accepted: 04/02/2024] [Indexed: 04/10/2024] Open
Abstract
OBJECTIVES Hypoxia is a known feature of sickle cell anaemia (SCA) which results from chronic anaemia and recurrent vaso-occlusive crisis (VOC) which can cause tissue ischaemia that leads to an end organ damage. The hallmark of SCA is chronic anaemia and recurrent vaso-occlusive crisis. The aim of this study is to compare the oxygen saturation of sickle cell anaemic individuals with the normal haemoglobin type (Hb AA) control and also to determine the prevalence of hypoxemia among SCA. RESULTS Two-hundred and twenty-two (136 Hb SS and 86 Hb AA) participated in the study. The mean ± SD of age (years), oxygen saturation (%) and pulse rate (bpm) of participants with sickle cell anaemia and Hb AA control were 21.85 ± 3.04 and 22.14 ± 3.18 (t = 0.701, p = 0.436), 95.21 ± 3.02 and 98.07 ± 0.81 (t=-8.598, p < 0.0001) and 77.10 ± 9.28 and 73.16 ± 8.52 (t = 3.173, p = 0.002) respectively. The prevalence of hypoxemia among SCA participants was 47.1%. Prevalence of hypoxemia in males with SCA was 60.9% while 39.1% of the females had hypoxemia.
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Affiliation(s)
- Asafa M A
- Department of Physiological Sciences, Faculty of Basic Medical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria.
| | - Ahmed I O
- Department of Haematology and Blood Transfusion, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria
| | - Afolabi M S
- Respiratory Unit, Department of Internal Medicine, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria
| | - Bolarinwa R A
- Department of Haematology and Blood Transfusion, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria
- Department of Haematology and Immunology, Faculty of Basic Medical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Ogunlade O
- Department of Physiological Sciences, Faculty of Basic Medical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
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Al Kahf S, Roche A, Baron A, Chantalat-Auger C, Savale L. Pulmonary hypertension in sickle cell disease. Presse Med 2023; 52:104209. [PMID: 37967611 DOI: 10.1016/j.lpm.2023.104209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
Sickle cell disease (SCD) is a complex genetic disorder that has long challenged both patients and healthcare professionals. One of its chronic and debilitating complications is pulmonary hypertension (PH). SCD-associated PH is often post-capillary, secondary to left heart disease. It can also sometimes be pre-capillary with multiple and often interrelated mechanisms including obstructive remodeling of the pulmonary vascular bed secondary to hemolysis, endothelial dysfunction, thrombosis, hypoxia, or associated risk factors like portal hypertension. Screening symptomatic patients with echocardiographic signs of PH is crucial to determine those who should undergo right heart catheterization, the cornerstone exam to diagnose and categorize patients with PH. The workup following the diagnosis relies on identifying the cause of PH to personalize treatment. Ongoing efforts are made to treat this complex condition, starting with treating the underlying disease with hydroxyurea or chronic blood exchange transfusion. Robust data on the efficacy of PAH-specific therapies are lacking in this specific population. Initiation of such therapies must be made by an expert center after a case-by-case assessment of the benefit-risk ratio according to the phenotype and the mechanisms involved in the development of PH. Efforts are also poured into studying the interventional and medical therapies used on chronic thromboembolic PH for patients presenting with a thrombotic form. The management of those patients requires a multidisciplinary approach, with conjoint efforts from PH and SCD specialists.
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Affiliation(s)
- Salma Al Kahf
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France; Université Paris-Saclay, Faculté de Médecine, Pulmonary Hypertension: Pathophysiology and Novel Therapies 94276 Le Kremlin-Bicêtre, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 94270 Le Kremlin-Bicêtre, France
| | - Anne Roche
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France; Université Paris-Saclay, Faculté de Médecine, Pulmonary Hypertension: Pathophysiology and Novel Therapies 94276 Le Kremlin-Bicêtre, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 94270 Le Kremlin-Bicêtre, France
| | - Audrey Baron
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France; Université Paris-Saclay, Faculté de Médecine, Pulmonary Hypertension: Pathophysiology and Novel Therapies 94276 Le Kremlin-Bicêtre, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 94270 Le Kremlin-Bicêtre, France
| | - Christelle Chantalat-Auger
- Université Paris-Saclay, Faculté de Médecine, Pulmonary Hypertension: Pathophysiology and Novel Therapies 94276 Le Kremlin-Bicêtre, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Service de médecine interne, Hôpital Bicêtre, 94270 Le Kremlin-Bicêtre, France
| | - Laurent Savale
- INSERM UMR_S 999 "Pulmonary Hypertension: Pathophysiology and Novel Therapies", Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France; Université Paris-Saclay, Faculté de Médecine, Pulmonary Hypertension: Pathophysiology and Novel Therapies 94276 Le Kremlin-Bicêtre, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 94270 Le Kremlin-Bicêtre, France.
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Gbotosho OT, Gollamudi J, Hyacinth HI. The Role of Inflammation in The Cellular and Molecular Mechanisms of Cardiopulmonary Complications of Sickle Cell Disease. Biomolecules 2023; 13:381. [PMID: 36830749 PMCID: PMC9953727 DOI: 10.3390/biom13020381] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/09/2023] [Accepted: 02/13/2023] [Indexed: 02/19/2023] Open
Abstract
Cardiopulmonary complications remain the major cause of mortality despite newer therapies and improvements in the lifespan of patients with sickle cell disease (SCD). Inflammation has been identified as a major risk modifier in the pathogenesis of SCD-associated cardiopulmonary complications in recent mechanistic and observational studies. In this review, we discuss recent cellular and molecular mechanisms of cardiopulmonary complications in SCD and summarize the most recent evidence from clinical and laboratory studies. We emphasize the role of inflammation in the onset and progression of these complications to better understand the underlying pathobiological processes. We also discuss future basic and translational research in addressing questions about the complex role of inflammation in the development of SCD cardiopulmonary complications, which may lead to promising therapies and reduce morbidity and mortality in this vulnerable population.
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Affiliation(s)
- Oluwabukola T. Gbotosho
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45267-0525, USA
| | - Jahnavi Gollamudi
- Division of Hematology & Oncology, Department of Internal Medicine, 3125 Eden Avenue, ML 0562, Cincinnati, OH 45219-0562, USA
| | - Hyacinth I. Hyacinth
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45267-0525, USA
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Lamarre Y, Nader E, Connes P, Romana M, Garnier Y. Extracellular Vesicles in Sickle Cell Disease: A Promising Tool. Bioengineering (Basel) 2022; 9:bioengineering9090439. [PMID: 36134985 PMCID: PMC9495982 DOI: 10.3390/bioengineering9090439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 08/25/2022] [Accepted: 08/31/2022] [Indexed: 12/12/2022] Open
Abstract
Sickle cell disease (SCD) is the most common hemoglobinopathy worldwide. It is characterized by an impairment of shear stress-mediated vasodilation, a pro-coagulant, and a pro-adhesive state orchestrated among others by the depletion of the vasodilator nitric oxide, by the increased phosphatidylserine exposure and tissue factor expression, and by the increased interactions of erythrocytes with endothelial cells that mediate the overexpression of adhesion molecules such as VCAM-1, respectively. Extracellular vesicles (EVs) have been shown to be novel actors involved in SCD pathophysiological processes. Medium-sized EVs, also called microparticles, which exhibit increased plasma levels in this pathology, were shown to induce the activation of endothelial cells, thereby increasing neutrophil adhesion, a key process potentially leading to the main complication associated with SCD, vaso-occlusive crises (VOCs). Small-sized EVs, also named exosomes, which have also been reported to be overrepresented in SCD, were shown to potentiate interactions between erythrocytes and platelets, and to trigger endothelial monolayer disruption, two processes also known to favor the occurrence of VOCs. In this review we provide an overview of the current knowledge about EVs concentration and role in SCD.
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Affiliation(s)
- Yann Lamarre
- Université Paris Cité and Université des Antilles, Inserm, BIGR, F-75015 Paris, France
| | - Elie Nader
- Laboratoire Inter-Universitaire de Biologie de la Motricité EA7424, Team “Vascular Biology and Red Blood Cell”, Université Claude Bernard Lyon 1, Université de Lyon, 69622 Lyon, France
| | - Philippe Connes
- Laboratoire Inter-Universitaire de Biologie de la Motricité EA7424, Team “Vascular Biology and Red Blood Cell”, Université Claude Bernard Lyon 1, Université de Lyon, 69622 Lyon, France
| | - Marc Romana
- Université Paris Cité and Université des Antilles, Inserm, BIGR, F-75015 Paris, France
| | - Yohann Garnier
- Université Paris Cité and Université des Antilles, Inserm, BIGR, F-75015 Paris, France
- Correspondence: ; Tel.: +590-590-891530
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7
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Okoye HC, Ezekekwu C, Nwagha TU, Korubo K, Omunakwe HE, Nnachi OC, Madu AJ, Nwogoh B, Efobi CC, Muoghalu EA, Nonyelu C, Okoye AE, Obodo OI, Ugwu CS, Egolum MC, Nnachi OA, Okpala I. Prevalence of venous thromboembolism and its associations in a large racially homogenous population of sickle cell disease patients. Eur J Haematol Suppl 2022; 109:321-326. [PMID: 35687045 DOI: 10.1111/ejh.13811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/26/2022] [Accepted: 05/30/2022] [Indexed: 11/30/2022]
Abstract
To determine the prevalence of venous thromboembolism (VTE) among adult sickle cell disease (SCD) patients in Nigeria. METHODS This was a multicentre retrospective study in which the medical records of adult SCD patients were reviewed. Information on demographics, steady-state haemogram, clinical phenotypes, duration of follow-up, history of VTE including risk factors and management was collected. RESULTS Of the 509 SCD patients with a median (IQR) duration of follow-up of 2 years, 10 (2.0%) had VTE (9 DVT and 1 PE). Their median (IQR) age was 27 (22.8-30.3) years. Identifiable risk factors for VTE included positive family history (2, 20%) surgery, splenectomy, paraplegia and cancer (1, 10% each). No risk factor was identifiable in four persons. VTE had no significant association with age and gender. VTE was significantly associated with the following events: acute chest syndrome [p = .002, odds ratio (OR) 8, 95% CI 2.2-28.9], osteonecrosis [p = .012, OR 5.24, 95% CI, 1.45-18.91] and vaso-occlusive crisis [p = .035]. Also significantly associated with VTE were pulmonary hypertension [p = .001, OR 23.3, 95%CI 5.18-105.06] and stroke [p = .032, OR 9.35, 95%CI 0.87-53.25]. CONCLUSION The prevalence of VTE among SCD patients in Nigeria is low. It is significantly associated with vaso-occlusive crisis, pulmonary hypertension and stroke.
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Affiliation(s)
- Helen Chioma Okoye
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Chinedu Ezekekwu
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Theresa Ukamaka Nwagha
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Kaladada Korubo
- Department of Haematology and Blood Transfusion, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
| | - Hannah E Omunakwe
- Department of Haematology, Rivers State University Teaching Hospital, Port Harcourt, Nigeria
| | - Oluomachi Charity Nnachi
- Department of Haematology and Blood Transfusion, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
| | - Anazoeze Jude Madu
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Benedict Nwogoh
- Department of Haematology, University of Benin Teaching Hospital, Benin City, Nigeria
| | - Chilota Chibuife Efobi
- Department of Haematology and Blood Transfusion, College of Health Sciences, Nnamdi Azikiwe University, Nnewi, Nigeria
| | - Ebele Adaobi Muoghalu
- Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Charles Nonyelu
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Augustine E Okoye
- Department of Haematology and Blood Transfusion, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
| | - Onochie Ikenna Obodo
- Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Chioma Sandra Ugwu
- Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Michael C Egolum
- Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Oji Anya Nnachi
- Department of Haematology and Blood Transfusion, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
| | - Iheanyi Okpala
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Enugu, Nigeria
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8
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Niazi MRK, Chukkalore D, Jahangir A, Sahra S, Macdougall K, Rehan M, Odaimi M. Management of acute chest syndrome in patients with sickle cell disease: a systematic review of randomized clinical trials. Expert Rev Hematol 2022; 15:547-558. [PMID: 35666654 DOI: 10.1080/17474086.2022.2085089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Acute chest syndrome (ACS) accounts for the highest mortality in Sickle cell disease patients. Early diagnosis and timely management of ACS results in better outcomes. However, the effectiveness of most treatment modalities for ACS management has not been established. AREAS COVERED To review the treatment modalities management protocols and highlight the effectiveness of each option a literature search was done. Randomized controlled trials that assessed the efficacy of different treatment modalities in ACS management in SCD patients were chosen and reviewed. EXPERT OPINION 11 randomized controlled trials were found that evaluated the efficacy of incentive spirometry, positive expiratory pressure device, intravenous dexamethasone, oral vs. intravenous morphine, inhaled nitric oxide, unfractionated heparin, and blood transfusion in the prevention or treatment of ACS. Although there are guidelines for ACS treatment, the available evidence is very limited to delineating the effectiveness of various interventions in ACS management. More high-quality studies and trials with a larger patient population can benefit this area to support the recommendations with stronger evidence.
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Affiliation(s)
- Muhammad Rafay Khan Niazi
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Divya Chukkalore
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Abdullah Jahangir
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Syeda Sahra
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Kira Macdougall
- Department of Hematology and Medical Oncology, Oklahoma University of Health and Science, Oklahoma, OK, USA
| | - Maryam Rehan
- Department of Hematology and Medical Oncology, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Marcel Odaimi
- Department of Hematology and Medical Oncology, Staten Island University Hospital/Northwell Health, New York, NY, USA
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Feugray G, Kasonga F, Grall M, Benhamou Y, Bobée-Schneider V, Buchonnet G, Daliphard S, Le Cam Duchez V, Lahary A, Billoir P. Assessment of Reticulocyte and Erythrocyte Parameters From Automated Blood Counts in Vaso-Occlusive Crisis on Sickle Cell Disease. Front Med (Lausanne) 2022; 9:858911. [PMID: 35492334 PMCID: PMC9044919 DOI: 10.3389/fmed.2022.858911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/21/2022] [Indexed: 12/18/2022] Open
Abstract
Sickle cell disease is a complex genetic disease involving cell adhesion between red blood cells, white blood cells, platelets and endothelial cells, inducing painful vaso-occlusive crisis (VOC). We assessed reticulocyte and erythrocyte parameters in a cohort of confirmed SCD patients, and investigated whether a combination of these routine laboratory biomarkers of haemolysis could be used to predict VOC development. Reticulocyte and erythrocyte parameters were evaluated using the Sysmex XN-9000 analyser. A total of 98 patients with SCD were included, 72 in steady state and 26 in VOC. Among the 72 patients in steady state, 22 developed a VOC in the following year (median: 3 months [2-6]). The following parameters were increased in SCD patients with VOC development compared to SCD patients without VOC development in the following year: reticulocyte count (94.6 109/L [67.8-128] vs. 48.4 109/L [24.9-87.5]), immature reticulocyte count (259 109/L [181-334] vs. 152 109/L [129-208]) reticulocyte/immature reticulocyte fraction (IRF) ratio (6.63 109/(L*%) [4.67-9.56] vs. 4.94 109/(L*%) [3.96-6.61]), and medium fluorescence reticulocytes (MFR) (19.9% [17.4-20.7] vs. 17.1% [15.95-19.75]). The association of a reticulocyte count of >189.4 109/L and an MFR of >19.75% showed a sensitivity of 81.8% and a specificity of 88% to predict VOC development in the following year. Based on our findings, a combination of routine laboratory biomarkers, as reticulocyte count, immature reticulocyte count and fluorescent reticulocyte fraction at steady state, could be used to predict VOC development in SCD.
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Affiliation(s)
- Guillaume Feugray
- General Biochemistry, Normandie Univ, Rouen University, INSERM U1096, CHU Rouen, Rouen, France
| | | | | | - Ygal Benhamou
- Department of Internal Medecine, Normandie Univ, Rouen University, INSERM U1096, CHU Rouen, Rouen, France
| | | | | | | | - Véronique Le Cam Duchez
- Normandie Univ, Rouen University, INSERM U1096, CHU Rouen, Vascular Hemostasis Unit, Rouen, France
| | | | - Paul Billoir
- Normandie Univ, Rouen University, INSERM U1096, CHU Rouen, Vascular Hemostasis Unit, Rouen, France
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Masese RV, Bulgin D, Knisely MR, Preiss L, Stevenson E, Hankins JS, Treadwell MJ, King AA, Gordeuk VR, Kanter J, Gibson R, Glassberg JA, Tanabe P, Shah N. Sex-based differences in the manifestations and complications of sickle cell disease: Report from the Sickle Cell Disease Implementation Consortium. PLoS One 2021; 16:e0258638. [PMID: 34714833 PMCID: PMC8555833 DOI: 10.1371/journal.pone.0258638] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 10/04/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Sex-based clinical outcome differences in sickle cell disease (SCD) remain largely unknown despite evidence that female sex is associated with an increased lifespan. To better characterize sex-based differences in SCD, we assessed pain, treatment characteristics, laboratory measures and complications among males and females currently enrolled in the Sickle Cell Disease Implementation Consortium (SCDIC) registry. METHODS The SCDIC consists of eight comprehensive SCD centers and one data coordinating center that received funding from the National Heart Lung and Blood Institute to improve outcomes for individuals with SCD. Eligibility criteria included: 15 to 45 years of age and a confirmed diagnosis of SCD. Self-report surveys were completed and data were also abstracted from the participants' medical records. RESULTS A total of 2,124 participants were included (mean age: 27.8 years; 56% female). The majority had hemoglobin SS SCD genotype. Females had worse reports of pain severity (mean (SD) T-score 51.6 (9.6) vs 49.3 (10), p<0.001), more vaso-occlusive episodes (p = 0.01) and a higher occurrence of 3 or more hospital admissions in the past year (30.9% vs. 25.5, p = 0.03). On multivariable analysis, males had higher odds of acute chest syndrome (odds ratio (OR) 1.4, p = 0.002), cardiovascular (OR 1.70, p<0.001) and musculoskeletal (OR 1.33, p = 0.0034) complications and lower odds of depression (OR 0.77, p = 0.0381). Females had higher fetal hemoglobin levels with and without hydroxyurea use (9.6% vs 8.5%, p = 0.03 and 3% vs 2.2%, p = 0.0005, respectively). CONCLUSION Our data suggests that sex differences in clinical outcomes do occur among individuals with SCD. Future research needs to explore the mechanisms underlying these differences.
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Affiliation(s)
- Rita V. Masese
- School of Nursing, Duke University, Durham, North Carolina, United States of America
| | - Dominique Bulgin
- College of Nursing, University of Tennessee Knoxville, Knoxville, Tennessee, United States of America
| | - Mitchell R. Knisely
- School of Nursing, Duke University, Durham, North Carolina, United States of America
| | - Liliana Preiss
- RTI International, Research Triangle Park, North Carolina, United States of America
| | - Eleanor Stevenson
- School of Nursing, Duke University, Durham, North Carolina, United States of America
| | - Jane S. Hankins
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Marsha J. Treadwell
- Department of Pediatrics, University of California San Francisco Benioff Children’s Hospital, Oakland, California, United States of America
| | - Allison A. King
- School of Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Victor R. Gordeuk
- University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Julie Kanter
- University of Alabama, Birmingham, Alabama, United States of America
| | - Robert Gibson
- Department of Emergency Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia, United States of America
| | - Jeffrey A. Glassberg
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Paula Tanabe
- School of Nursing, Duke University, Durham, North Carolina, United States of America
| | - Nirmish Shah
- School of Nursing, Duke University, Durham, North Carolina, United States of America
- School of Medicine, Duke University, Durham, North Carolina, United States of America
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11
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Nader E, Garnier Y, Connes P, Romana M. Extracellular Vesicles in Sickle Cell Disease: Plasma Concentration, Blood Cell Types Origin Distribution and Biological Properties. Front Med (Lausanne) 2021; 8:728693. [PMID: 34490315 PMCID: PMC8417591 DOI: 10.3389/fmed.2021.728693] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/30/2021] [Indexed: 01/08/2023] Open
Abstract
Prototype of monogenic disorder, sickle cell disease (SCD) is caused by a unique single mutation in the β-globin gene, leading to the production of the abnormal hemoglobin S (HbS). HbS polymerization in deoxygenated condition induces the sickling of red blood cells (RBCs), which become less deformable and more fragile, and thus prone to lysis. In addition to anemia, SCD patients may exhibit a plethora of clinical manifestations ranging from acute complications such as the frequent and debilitating painful vaso-occlusive crisis to chronic end organ damages. Several interrelated pathophysiological processes have been described, including impaired blood rheology, increased blood cell adhesion, coagulation, inflammation and enhanced oxidative stress among others. During the last two decades, it has been shown that extracellular vesicles (EVs), defined as cell-derived anucleated particles delimited by a lipid bilayer, and comprising small EVs (sEVs) and medium/large EVs (m/lEVs); are not only biomarkers but also subcellular actors in SCD pathophysiology. Plasma concentration of m/lEVs, originated mainly from RBCs and platelets (PLTs) but also from the other blood cell types, is higher in SCD patients than in healthy controls. The concentration and the density of externalized phosphatidylserine of those released from RBCs may vary according to clinical status (crisis vs. steady state) and treatment (hydroxyurea). Besides their procoagulant properties initially described, RBC-m/lEVs may promote inflammation through their effects on monocytes/macrophages and endothelial cells. Although less intensely studied, sEVs plasma concentration is increased in SCD and these EVs may cause endothelial damages. In addition, sEVs released from activated PLTs trigger PLT-neutrophil aggregation involved in lung vaso-occlusion in sickle mice. Altogether, these data clearly indicate that EVs are both biomarkers and bio-effectors in SCD, which deserve further studies.
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Affiliation(s)
- Elie Nader
- Laboratoire Inter-Universitaire de Biologie de la Motricité EA7424, Team "Vascular Biology and Red Blood Cell", Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France.,Laboratoire d'Excellence du Globule Rouge, PRES Sorbonne, Paris, France
| | - Yohann Garnier
- Laboratoire d'Excellence du Globule Rouge, PRES Sorbonne, Paris, France.,Université des Antilles, UMR_S1134, BIGR, Pointe-à-Pitre, France.,Université de Paris, UMR_S1134, BIGR, INSERM, Paris, France
| | - Philippe Connes
- Laboratoire Inter-Universitaire de Biologie de la Motricité EA7424, Team "Vascular Biology and Red Blood Cell", Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France.,Laboratoire d'Excellence du Globule Rouge, PRES Sorbonne, Paris, France
| | - Marc Romana
- Laboratoire d'Excellence du Globule Rouge, PRES Sorbonne, Paris, France.,Université des Antilles, UMR_S1134, BIGR, Pointe-à-Pitre, France.,Université de Paris, UMR_S1134, BIGR, INSERM, Paris, France
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12
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Mathur T, Flanagan JM, Jain A. Tripartite collaboration of blood-derived endothelial cells, next generation RNA sequencing and bioengineered vessel-chip may distinguish vasculopathy and thrombosis among sickle cell disease patients. Bioeng Transl Med 2021; 6:e10211. [PMID: 34589594 PMCID: PMC8459595 DOI: 10.1002/btm2.10211] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/24/2020] [Accepted: 12/29/2020] [Indexed: 12/15/2022] Open
Abstract
Sickle cell disease (SCD) is the most prevalent inherited blood disorder in the world. But the clinical manifestations of the disease are highly variable. In particular, it is currently difficult to predict the adverse outcomes within patients with SCD, such as, vasculopathy, thrombosis, and stroke. Therefore, for most effective and timely interventions, a predictive analytic strategy is desirable. In this study, we evaluate the endothelial and prothrombotic characteristics of blood outgrowth endothelial cells (BOECs) generated from blood samples of SCD patients with known differences in clinical severity of the disease. We present a method to evaluate patient-specific vaso-occlusive risk by combining novel RNA-seq and organ-on-chip approaches. Through differential gene expression (DGE) and pathway analysis we find that BOECs from SCD patients exhibit an activated state through cell adhesion molecule (CAM) and cytokine signaling pathways among many others. In agreement with clinical symptoms of patients, DGE analyses reveal that patient with severe SCD had a greater extent of endothelial activation compared to patient with milder symptoms. This difference is confirmed by performing qRT-PCR of endothelial adhesion markers like E-selectin, P-selectin, tissue factor, and Von Willebrand factor. Finally, the differential regulation of the proinflammatory phenotype is confirmed through platelet adhesion readouts in our BOEC vessel-chip. Taken together, we hypothesize that these easily blood-derived endothelial cells evaluated through RNA-seq and organ-on-chips may serve as a biotechnique to predict vaso-occlusive episodes in SCD patients and will ultimately allow better therapeutic interventions.
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Affiliation(s)
- Tanmay Mathur
- Department of Biomedical EngineeringTexas A&M UniversityCollege StationTexasUSA
| | - Jonathan M. Flanagan
- Department of Pediatrics, Section of Hematology‐OncologyBaylor College of MedicineHoustonTexasUSA
| | - Abhishek Jain
- Department of Biomedical EngineeringTexas A&M UniversityCollege StationTexasUSA
- Department of Medical PhysiologyCollege of Medicine, Texas A&M Health Science CenterBryanTexasUSA
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13
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Abstract
PURPOSE OF REVIEW Sickle cell disease (SCD), one of the most common genetic diseases in the world, is characterized by repeated episodes of hemolysis and vaso-occlusion. Hemolytic anemia is a risk factor for the development of pulmonary hypertension, and currently SCD-related pulmonary hypertension is classified as World Health Organization group 5 pulmonary hypertension. Patients with SCD-related pulmonary hypertension have unique hemodynamics, multiple comorbidities, and distinct phenotypes that may contribute to the development of pulmonary hypertension. RECENT FINDINGS SCD-related pulmonary hypertension is defined as a mean pulmonary artery pressure >20 mmHg, a pulmonary artery occlusion pressure ≤15 mmHg and relatively low pulmonary vascular resistance (>2 Wood units) rather than the traditional definition of ≥3 Wood units, an important distinction due to a baseline high-cardiac output state in the setting of chronic anemia and low vascular resistance. Diastolic dysfunction is frequently identified in this patient population and right heart catheterization is essential to determine if combined pre- and postcapillary pulmonary hypertension is present. Thromboembolism is common among patients with SCD, and screening for chronic thromboembolic pulmonary hypertension is essential. Data regarding advanced therapies are limited. Primary treatment options include targeting correction of their primary hemoglobinopathy as well as aggressive management of underlying comorbid conditions. SUMMARY SCD-related pulmonary hypertension is common among patients with SCD and is associated with increased mortality. A high index of suspicion is warranted during evaluation to identify all potential factors that may be contributing to disease.
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Affiliation(s)
- Clare C Prohaska
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University, Indianapolis, Indiana, USA
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14
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Dufu K, Williams AT, Muller CR, Walser CM, Lucas A, Eaker AM, Alt C, Cathers BE, Oksenberg D, Cabrales P. Increased hemoglobin affinity for oxygen with GBT1118 improves hypoxia tolerance in sickle cell mice. Am J Physiol Heart Circ Physiol 2021; 321:H400-H411. [PMID: 34213392 DOI: 10.1152/ajpheart.00048.2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Therapeutic agents that increase the Hb affinity for oxygen (O2) could, in theory, lead to decreased O2 release from Hb and impose a hypoxic risk to tissues. In this study, GBT1118, an allosteric modifier of Hb affinity for O2, was used to assess the impact of increasing Hb affinity for O2 on brain tissue oxygenation, blood pressure, heart rate, O2 delivery, and tolerance to hypoxia in Townes transgenic sickle cell disease (SCD) mice. Brain oxygenation and O2 delivery were studied during normoxia and severe hypoxic challenges. Chronic treatment with GBT1118 increased Hb affinity for O2, reducing the Po2 for 50% HbO2 saturation (P50) in SCD mice from 31 mmHg to 18 mmHg. This treatment significantly reduced anemia, increasing hematocrit by 33%, improved cardiac output (CO), and O2 delivery and extraction. Chronically increasing Hb affinity for O2 with GBT1118 preserved cortical O2 tension during normoxia, improved cortical O2 tension during hypoxia, and increased tolerance to severe hypoxia in SCD mice. Independent of hematological changes induced by chronic treatment, a single dose of GBT1118 significantly improved tolerance to hypoxia, highlighting the benefits of increasing Hb affinity for O2 and consequently reducing sickling of RBCs in blood during hypoxia in SCD.NEW & NOTEWORTHY Chronic pharmacologically increased hemoglobin affinity for oxygen in sickle cell disease mice alleviated hematological consequences of sickle cell disease, increasing RBC half-life, hematocrit, and hemoglobin concentration, while also decreasing reticulocyte count. Additionally, chronically increased hemoglobin affinity for oxygen significantly improved survival as well as cortical tissue oxygenation in sickle cell disease mice during hypoxia, suggesting that oxygen delivery and utilization is improved by increased hemoglobin affinity for oxygen.
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Affiliation(s)
- Kobina Dufu
- Global Blood Therapeutics, Inc., San Francisco, California
| | - Alexander T Williams
- Department of Bioengineering, University of California San Diego, La Jolla, California
| | - Cynthia R Muller
- Department of Bioengineering, University of California San Diego, La Jolla, California
| | - Cynthia M Walser
- Department of Bioengineering, University of California San Diego, La Jolla, California
| | - Alfredo Lucas
- Department of Bioengineering, University of California San Diego, La Jolla, California
| | - Allyn M Eaker
- Department of Bioengineering, University of California San Diego, La Jolla, California
| | - Carsten Alt
- Global Blood Therapeutics, Inc., San Francisco, California
| | | | | | - Pedro Cabrales
- Department of Bioengineering, University of California San Diego, La Jolla, California
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15
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Dako F, Hossain R, Jeudy J, White C. Dual-energy CT evidence of pulmonary microvascular occlusion in patients with sickle cell disease experiencing acute chest syndrome. Clin Imaging 2021; 78:94-97. [PMID: 33773449 DOI: 10.1016/j.clinimag.2021.03.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/01/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Acute chest syndrome (ACS), defined by the presence of a chest radiographic opacity in sickle cell disease patients experiencing respiratory symptoms is a leading cause of death in these patients. The etiology is ACS is not well understood however pulmonary microvascular occlusion has been postulated to be a major pathophysiologic driver. Our study aims to assess the value of dual-energy CT (DECT) as a marker of pulmonary microvascular occlusion. MATERIALS/METHODS A search tool was used to identify CT angiography studies from 1/1/2017 to 9/15/2019 with any variation of the phrases "Acute chest syndrome" and "Sickle cell". These studies were manually reviewed for the use of DECT technique. An age-matched control group was created. DECT pulmonary blood volume (PBV) maps were reviewed semi-quantitatively for the presence of iodine defects and the number of involved bronchopulmonary segments were scored. Other recorded values included type of parenchymal opacities, diameter of main pulmonary artery (MPA) and presence of right ventricular dilatation. Mean values between cases and controls were compared using a two-sample t-test. RESULTS Nine sickle cell DECT cases with PBV maps and nine age-matched controls were evaluated. Bronchopulmonary segments with iodine defects were significantly higher in cases vs controls (mean: 4.7 vs 0.3, p < 0.003). PBV defects were more extensive than parenchymal findings. MPA diameter was higher in cases (2.9 cm) vs control (2.4 cm), P < 0.03. CONCLUSIONS DECT demonstrates abnormal PBV in sickle cell patients, often the predominant abnormality identified early, and likely reflects the presence of pulmonary microvascular occlusion.
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Affiliation(s)
- Farouk Dako
- Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, PA 19102, United States of America.
| | - Rydhwana Hossain
- Department of Radiology, University of Maryland School of Medicine, Baltimore, MD 21201, United States of America
| | - Jean Jeudy
- Department of Radiology, University of Maryland School of Medicine, Baltimore, MD 21201, United States of America
| | - Charles White
- Department of Radiology, University of Maryland School of Medicine, Baltimore, MD 21201, United States of America
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16
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ADAMTS-13-VWF axis in sickle cell disease patients. Ann Hematol 2021; 100:375-382. [PMID: 33404693 DOI: 10.1007/s00277-020-04385-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
Sickle cell disease (SCD) comprises a group of genetic disorders characterized by the presence of the hemoglobin (Hb) S in homozygosis or in heterozygosis with some other Hb variant or in interaction with thalassemia. SCD is characterized by a very complex pathophysiology, which determines a wide variability of clinical manifestations, including a chronic state of hypercoagulability responsible for the increased risk of thromboembolic events. ADAMTS13 and von Willebrand factor (VWF) play an important role in arterial and venous thrombosis. Thus, the aim of this study was to understand how the ADAMTS13-VWF axis behaves in sickle cell disease, as well as whether there is an association of these markers with the use of hydroxyurea (HU). This is a cross-sectional study conducted with 40 patients diagnosed with SCD and 40 healthy individuals. The analysis of the ADAMTS13-VWF axis was comparatively performed between groups of patients and controls and, afterwards, between patients with SCD who were users and non-users of HU. ADAMTS13 activity, ADAMTS13 activity/VWF:Ag, and ADAMTS13:Ag/VWF:Ag ratios were significantly lower and VWF:Ag levels significantly higher in SCD patients when compared to the controls. There was no statistically significant difference in ADAMTS13:Ag and VWF collagen binding (VWF:CB) levels between the groups evaluated. Among the categories of HU use, there was no statistically significant difference in any of the evaluated markers. As a conclusion, we could observe that the ADAMTS13-VWF axis is altered in SCD when compared to healthy individuals and that there is no association between these markers and the use of HU.
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17
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Ladeira VS, de Oliveira Toledo SL, Ferreira LGR, Oliveira MM, Silva APF, de Oliveira WV, Duarte RCF, Renó CDO, Dusse LMS, Dos Santos HL, Carvalho MDG, Pinheiro MDB, Rios DRA. Thrombin generation in vivo and ex vivo in sickle cell disease patients. Thromb Res 2020; 197:165-171. [PMID: 33221576 DOI: 10.1016/j.thromres.2020.10.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/26/2020] [Accepted: 10/29/2020] [Indexed: 12/18/2022]
Abstract
Activation of coagulation is an important hallmark of sickle cell disease (SCD) and it is believed that hypercoagulability plays a role to the disease pathophysiology. Studies have sought to identify how hemostatic biomarkers are expressed in SCD, however, the results are inconclusive. In this context, our objective was to evaluate the thrombin generation in vivo and ex vivo in SCD patients and the association between these biomarkers and the use of HU. This cross-sectional study was carried out with patients diagnosed with SCD, users or not of Hydroxyurea (HU), and healthy individuals as controls. D dimer (D-Di) was evaluated by ELISA and (TGT) thrombin generation test by CAT method. D-Di plasma levels were significantly higher in SCD patients when compared to the controls. TGT parameters such as peak, ETP and normalized ETP at low TF concentration and time-to-peak, peak, ETP and normalized ETP values at high TF concentration were lower in SCD patients than in controls. In contrast, the normalized activated protein C sensitivity ratio (nAPCsr) was higher in patients compared to controls, indicating resistance to the action of this natural anticoagulant. Regarding the use of HU, comparing users and non-users of this drug, no difference was observed in D-Di levels and in most TGT parameters. Our data analyzed together allow us to conclude that patients with SCD present a state of hypercoagulability in vivo due to the higher levels of D-Di and resistance to APC assessed ex vivo which is consistent with the coagulation imbalance described in SCD patients.
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Affiliation(s)
- Valéria Sutana Ladeira
- Universidade Federal de São João del-Rei, Campus Centro Oeste Dona Lindu, Brazil; Fundação Hemominas, Minas Gerais, Brazil
| | | | | | - Marina Mendes Oliveira
- Universidade Federal de São João del-Rei, Campus Centro Oeste Dona Lindu, Brazil; Fundação Hemominas, Minas Gerais, Brazil
| | | | | | | | | | | | | | - Maria das Graças Carvalho
- Universidade Federal de São João del-Rei, Campus Centro Oeste Dona Lindu, Brazil; Faculdade de Farmácia, Universidade Federal de Minas Gerais, Brazil
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18
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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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19
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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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20
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Role of the coagulation system in the pathogenesis of sickle cell disease. Blood Adv 2020; 3:3170-3180. [PMID: 31648337 DOI: 10.1182/bloodadvances.2019000193] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 09/16/2019] [Indexed: 01/12/2023] Open
Abstract
Sickle cell disease (SCD) is an inherited monogenic red blood cell disorder affecting millions worldwide. SCD causes vascular occlusions, chronic hemolytic anemia, and cumulative organ damage such as nephropathy, pulmonary hypertension, pathologic heart remodeling, and liver necrosis. Coagulation system activation, a conspicuous feature of SCD that causes chronic inflammation, is an important component of SCD pathophysiology. The key coagulation factor, thrombin (factor IIa [FIIa]), is both a central protease in hemostasis and thrombosis and a key modifier of inflammation. Pharmacologic or genetic reduction of circulating prothrombin in Berkeley sickle mice significantly improves survival, ameliorates vascular inflammation, and results in markedly reduced end-organ damage. Accordingly, factors both upstream and downstream of thrombin, such as the tissue factor-FX complex, fibrinogen, platelets, von Willebrand factor, FXII, high-molecular-weight kininogen, etc, also play important roles in SCD pathogenesis. In this review, we discuss the various aspects of coagulation system activation and their roles in the pathophysiology of SCD.
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21
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Lizarralde-Iragorri MA, Shet AS. Sickle Cell Disease: A Paradigm for Venous Thrombosis Pathophysiology. Int J Mol Sci 2020; 21:ijms21155279. [PMID: 32722421 PMCID: PMC7432404 DOI: 10.3390/ijms21155279] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/23/2020] [Accepted: 07/24/2020] [Indexed: 02/06/2023] Open
Abstract
Venous thromboembolism (VTE) is an important cause of vascular morbidity and mortality. Many risk factors have been identified for venous thrombosis that lead to alterations in blood flow, activate the vascular endothelium, and increase the propensity for blood coagulation. However, the precise molecular and cellular mechanisms that cause blood clots in the venous vasculature have not been fully elucidated. Patients with sickle cell disease (SCD) demonstrate all the risk factors for venous stasis, activated endothelium, and blood hypercoagulability, making them particularly vulnerable to VTE. In this review, we will discuss how mouse models have elucidated the complex vascular pathobiology of SCD. We review the dysregulated pathways of inflammation and coagulation in SCD and how the resultant hypercoagulable state can potentiate thrombosis through down-regulation of vascular anticoagulants. Studies of VTE pathogenesis using SCD mouse models may provide insight into the intersection between the cellular and molecular processes involving inflammation and coagulation and help to identify novel mechanistic pathways.
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22
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Biochemical and therapeutic effects of Omega-3 fatty acids in sickle cell disease. Complement Ther Med 2020; 52:102482. [PMID: 32951732 DOI: 10.1016/j.ctim.2020.102482] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/02/2020] [Accepted: 06/08/2020] [Indexed: 01/29/2023] Open
Abstract
Sickle cell disease (SCD) is a hematologic disorder with complex pathophysiology that includes chronic hemolysis, vaso-occlusion and inflammation. Increased leukocyte-erythrocyte-endothelial interactions, due to upregulated expression of adhesion molecules and activated endothelium, are thought to play a primary role in initiation and progression of SCD vaso-occlusive crisis and end-organ damage. Several new pathophysiology-based therapeutic options for SCD are being developed, chiefly targeting the inflammatory pathways. Omega-3 fatty acids are polyunsaturated fatty acids that are known to have effects on diverse physiological processes. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are the principal biologically active omega-3 fatty acids. The therapeutic effects of DHA and EPA on chronic inflammatory disorders and cardiovascular diseases are well recognized. The therapeutic effects of omega-3 fatty acids are attributed to their anti-inflammatory and anti-thrombotic eicosanoids, and the novel class of EPA and DHA derived lipid mediators: resolvins, protectins and maresins. Blood cell membranes of patients with SCD have abnormal fatty acids composition characterized by high ratio of pro-inflammatory arachidonic acid (AA) to anti-inflammatory DHA and EPA (high omega-6/omega-3 ratio). In addition, experimental and clinical studies provide evidence that treatment with DHA does confer improvement in rheological properties of sickle RBC, inflammation and hemolysis. The clinical studies have shown improvements in VOC rate, markers of inflammation, adhesion, and hemolysis. In toto, the results of studies on the therapeutic effects of omega-3 fatty acids in SCD provide good body of evidence that omega-3 fatty acids could be a safe and effective treatment for SCD.
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23
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Elimination of the fibrinogen integrin α Mβ 2-binding motif improves renal pathology in mice with sickle cell anemia. Blood Adv 2020; 3:1519-1532. [PMID: 31076408 DOI: 10.1182/bloodadvances.2019032342] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 04/12/2019] [Indexed: 01/17/2023] Open
Abstract
Sickle cell anemia (SCA) is caused by a point mutation in the β-globin gene that leads to devastating downstream consequences including chronic hemolytic anemia, episodic vascular occlusion, and cumulative organ damage resulting in death. SCA patients show coagulation activation and inflammation even in the absence of vascular occlusion. The coagulation factor fibrinogen is not only central to hemostasis but also plays important roles in pathologic inflammatory processes, in part by engaging neutrophils/macrophages through the αMβ2 integrin receptor. To determine whether fibrin(ogen)-mediated inflammation is a driver of SCA-associated pathologies, hematopoietic stem cells from Berkeley sickle mice were transplanted into homozygous Fibγ390-396A mice that express normal levels of a mutant form of fibrin(ogen) that does not engage αMβ2 Fibγ390-396A mice with SCA displayed an impressive reduction of reactive oxygen species (ROS) in white blood cells (WBCs), decreased circulating inflammatory cytokines/chemokines, and significantly improved SCA-associated glomerular pathology highlighted by reduced glomerulosclerosis, inflammatory cell infiltration, ischemic lesions, mesangial thickening, mesangial hypercellularity, and glomerular enlargement. In addition, Fibγ390-396A mice with SCA had improved glomerular protective responses and podocyte/mesangial transcriptional signatures that resulted in reduced albuminuria. Interestingly, the fibrinogen γ390-396A mutation had a negligible effect on cardiac, lung, and liver functions and pathologies in the context of SCA over a year-long observation period. Taken together, our data support that fibrinogen significantly contributes to WBC-driven inflammation and ROS production, which is a key driver of SCA-associated glomerulopathy, and may represent a novel therapeutic target against irreversible kidney damage in SCA.
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24
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Laboratory Biomarkers, Cerebral Blood Flow Velocity, and Intellectual Function in Children with Sickle Cell Disease. Adv Hematol 2020; 2020:8181425. [PMID: 32158473 PMCID: PMC7061118 DOI: 10.1155/2020/8181425] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 12/26/2019] [Accepted: 01/06/2020] [Indexed: 11/17/2022] Open
Abstract
Objective The aim of this preliminary study was to describe putative markers of cerebral vasculopathy and investigate relationships among these markers, demographic factors, and cognitive function in a young sample of neurologically normal children with SCD. Study Design. Thirty-eight children with homozygous HbS, aged 4-11 years, were included. Estimated IQ and markers of coagulation and endothelial activation, hemolysis, and inflammation, as well as transcranial Doppler velocities, hydroxyurea use, and demographic information were obtained. Results Using multiple regression analyses, there were few significant independent associations between biomarkers or blood flow velocity and estimated IQ. Lactic dehydrogenase (LDH) independently predicted cognitive function, but blood flow velocity did not mediate this relationship. Maternal education, patient age, and hydroxyurea status were independent predictors of cognition. Given the small sample size, a LASSO statistical model was employed to further identify potential predictors of IQ, which identified LDH, absolute neutrophil count (ANC), platelet count, thrombin-antithrombin (TAT), tissue factor (TF), maternal education, age, and hydroxyurea as potential predictors of cognition. Conclusions In addition to effects of age and maternal education, some vasculopathic markers are associated with cognitive function in young children with SCD, and these relationships do not appear to be mediated through blood flow velocity. Although the lack of association among certain variables was not as predicted, results provide support for further research regarding the influence of vasculopathic markers on cognitive function in children with SCD without stroke, especially intravascular hemolysis and coagulation/endothelial activation, and a possible role for HU treatment in preventing or reversing cognitive decline.
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Zhu XJ, Wei JK, Zhang CM. Evaluation of endothelial microparticles as a prognostic marker in hemolytic disease of the newborn in China. J Int Med Res 2019; 47:5732-5739. [PMID: 31516072 PMCID: PMC6862913 DOI: 10.1177/0300060519870947] [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] [Indexed: 11/26/2022] Open
Abstract
Objective This study aimed to evaluate endothelial microparticles (EMPs) as a potential prognostic marker in hemolytic disease of the Chinese neonate. Methods We compared 29 newborns with ABO hemolytic disease of the newborn (ABO HDN), 22 newborns with Rh HDN, and 21 healthy newborns with matched mother and infant blood groups (controls). Markers of hemolysis and von Willebrand factor antigen (vWF Ag) were analyzed. EMP (CD144+) levels were measured before and after therapy. Results vWF Ag and pretherapy EMP levels were higher in the ABO HDN and Rh HDN groups than in the control group. Additionally, vWF Ag and pretherapy EMP levels were significantly higher in the ABO HDN group than in the Rh HDN group. Posttherapy EMP levels were decreased compared with pretherapy levels in the ABO HDN and Rh HDN groups. Moreover, hemoglobin and indirect bilirubin levels were independently correlated with pretherapy EMP levels in the ABO HDN group. Conclusion Our findings indicate that EMP measurement in neonates with HDN may provide a novel method of monitoring possible severe vascular dysfunction in patients in China. An external validation in larger datasets is necessary for further study.
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Affiliation(s)
- Xiao-Jing Zhu
- Department of Pediatrics, Baoding First Central Hospital, Baoding, Hebei, China
| | - Jin-Kai Wei
- Department of Pediatrics, Baoding First Central Hospital, Baoding, Hebei, China
| | - Cong-Min Zhang
- Department of Pediatrics, Baoding First Central Hospital, Baoding, Hebei, China
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Yates AM, Joshi VM, Aygun B, Moen J, Smeltzer MP, Govindaswamy D, Dowdy J, Cotton A, Kang G, Ware RE, Hankins JS. Elevated tricuspid regurgitation velocity in congenital hemolytic anemias: Prevalence and laboratory correlates. Pediatr Blood Cancer 2019; 66:e27717. [PMID: 30907497 DOI: 10.1002/pbc.27717] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/03/2019] [Accepted: 03/05/2019] [Indexed: 01/26/2023]
Abstract
Elevated tricuspid valve regurgitation jet velocity (TRV ≥ 2.5 m/s) is associated with mortality among adults with sickle cell disease (SCD), but correlative biomarkers are not studied according to treatment exposure or genotypes. To investigate the associations between biomarkers and TRV elevation, we examined the relationship between TRV and hemolytic, inflammatory, and cardiac biomarkers, stratified by disease-modifying treatments and SCD genotype. In total, 294 participants with SCD (mean age, 11.0 ± 3.7 years) and 49 hereditary spherocytosis (HS; mean age, 22.9 ± 19.75 years) were included for comparison and enrolled. TRV was elevated in 30.7% of children with SCD overall: 18.8% in HbSC/HbSβ+ -thalassemia, 28.9% in untreated HbSS/HbSβ0 -thalassemia, 34.2% in HbSS/HbSβ0 -thalassemia hydroxyurea-treated, and 57% in HbSS/HbSβ0 -thalassemia chronic transfusion treated. TRV was elevated in 10.7% and 27.8% in HS children and adults, respectively. In children with SCD, elevated TRV was correlated with hemoglobin (odds ratio [OR] = 0.78, P = 0.004), lactate dehydrogenase (LDH; OR = 2.52, P = 0.005), and N-terminal pro-brain natriuretic peptide (NT-pro BNP; OR = 1.003, P = 0.004). In multivariable logistic regression, adjusting for genotype, sex, hemolytic index, and treatment, hemoglobin concentration remained the only significant variable associated with elevated TRV in untreated HbSS/HbSβ0 -thalassemia participants. TRV was not associated with inflammatory markers, other markers of hemolysis, or NT-pro BNP in untreated HbSS/HbSβ0 -thalassemia. Neither hemoglobin nor LDH was associated with TRV in HbSC/HbSβ+ -thalassemia. These results suggest that elevated TRV is influenced by the degree of anemia, possibly reflecting sickling as part of the disease pathophysiology. Prospective studies should monitor hemoglobin concentration as children with SCD age into adulthood, prompting initiation of TRV screening and monitoring.
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Affiliation(s)
- Amber M Yates
- Division of Pediatric Hematology Oncology, Texas Children's Hospital, Houston, Texas
| | - Vijaya M Joshi
- Division of Pediatric Cardiology, Le Bonheur Children's Hospital, Memphis, Tennessee.,Cardiopulmonary Services, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Banu Aygun
- Cohen Children's Medical Center of New York, New Hyde Park, New York
| | - Joseph Moen
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Matthew P Smeltzer
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tennessee
| | - Devi Govindaswamy
- Cardiopulmonary Services, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Jola Dowdy
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Alyssa Cotton
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Guolian Kang
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Russell E Ware
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jane S Hankins
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee
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Houwing ME, de Pagter PJ, van Beers EJ, Biemond BJ, Rettenbacher E, Rijneveld AW, Schols EM, Philipsen JNJ, Tamminga RYJ, van Draat KF, Nur E, Cnossen MH. Sickle cell disease: Clinical presentation and management of a global health challenge. Blood Rev 2019; 37:100580. [PMID: 31128863 DOI: 10.1016/j.blre.2019.05.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 05/17/2019] [Accepted: 05/17/2019] [Indexed: 01/12/2023]
Abstract
Sickle cell disease is an autosomal recessive, multisystem disorder, characterised by chronic haemolytic anaemia, painful episodes of vaso-occlusion, progressive organ failure and a reduced life expectancy. Sickle cell disease is the most common monogenetic disease, with millions affected worldwide. In well-resourced countries, comprehensive care programs have increased life expectancy of sickle cell disease patients, with almost all infants surviving into adulthood. Therapeutic options for sickle cell disease patients are however, still scarce. Predictors of sickle cell disease severity and a better understanding of pathophysiology and (epi)genetic modifiers are warranted and could lead to more precise management and treatment. This review provides an extensive summary of the pathophysiology and management of sickle cell disease and encompasses the characteristics, complications and current and future treatment options of the disease.
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Affiliation(s)
- M E Houwing
- Department of Paediatric Haematology, Erasmus University Medical Center - Sophia Children's Hospital, Wytemaweg 80, 3015, CN, Rotterdam, the Netherlands.
| | - P J de Pagter
- Department of Paediatric Haematology, Erasmus University Medical Center - Sophia Children's Hospital, Wytemaweg 80, 3015, CN, Rotterdam, the Netherlands.
| | - E J van Beers
- Department of Internal Medicine and Dermatology, Van Creveldkliniek, University Medical Center Utrecht, Internal mail no C.01.412, 3508, GA, Utrecht, the Netherlands.
| | - B J Biemond
- Department of Internal Medicine and Clinical Haematology, Amsterdam University Medical Centers, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands.
| | - E Rettenbacher
- Department of Paediatric Haematology, Radboud University Medical Center - Amalia Children's Hospital, Geert Grooteplein Zuid 10, 6500, HB, Nijmegen, the Netherlands.
| | - A W Rijneveld
- Department of Haematology, Erasmus University Medical Center, Wytemaweg 80, 3015, CN, Rotterdam, the Netherlands.
| | - E M Schols
- Department of Haematology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, the Netherlands.
| | - J N J Philipsen
- Department of Cell Biology, Erasmus University Medical Center, Wytemaweg 80, 3015, CN, Rotterdam, the Netherlands.
| | - R Y J Tamminga
- Department of Paediatric Oncology and Haematology, University Medical Center Groningen - Beatrix Children's Hospital, Postbus 30001, 9700, RB, Groningen, the Netherlands..
| | - K Fijn van Draat
- Department of Paediatric Haematology, Amsterdam University Medical Centers - Emma Children's Hospital, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Department of Plasma Proteins, Sanquin Research, the Netherlands.
| | - E Nur
- Department of Internal Medicine and Clinical Haematology, Amsterdam University Medical Centers, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands.
| | - M H Cnossen
- Department of Paediatric Haematology, Erasmus University Medical Center - Sophia Children's Hospital, Wytemaweg 80, 3015, CN, Rotterdam, the Netherlands.
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Toledo SLDO, Guedes JVM, Alpoim PN, Rios DRA, Pinheiro MDB. Sickle cell disease: Hemostatic and inflammatory changes, and their interrelation. Clin Chim Acta 2019; 493:129-137. [PMID: 30825426 DOI: 10.1016/j.cca.2019.02.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/26/2019] [Accepted: 02/26/2019] [Indexed: 12/23/2022]
Abstract
Sickle cell disease, the most common genetic blood disorder in the world, has high clinical variability, negatively impacts quality of life and contributes to early mortality. Sickled erythrocytes cause blood flow obstruction, hemolysis, and several hemostatic changes that promote coagulation. These events, in turn, induce chronic inflammation, characterized by elevated plasma levels of pro-inflammatory markers, which aggravates the already unfavorable state of the circulatory system. Empirical evidence indicates that the hemostatic and inflammatory systems continuously interact with each other and thereby further propagate the hypercoagulability and inflammatory conditions. In this review article, we discuss the pathophysiological aspects of sickle cell disease and the hemostatic and inflammatory changes that underlie its pathogenesis.
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Affiliation(s)
- Sílvia L de O Toledo
- Federal University of São João del-Rei (UFSJ), Dona Lindu Center-West Campus, Sebastião Gonçalves Coelho Street, 400, Chanadour, 35501-296 Divinópolis, MG, Brazil
| | - João V M Guedes
- Federal University of São João del-Rei (UFSJ), Dona Lindu Center-West Campus, Sebastião Gonçalves Coelho Street, 400, Chanadour, 35501-296 Divinópolis, MG, Brazil
| | - Patrícia N Alpoim
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais (MG), Brazil
| | - Danyelle R A Rios
- Federal University of São João del-Rei (UFSJ), Dona Lindu Center-West Campus, Sebastião Gonçalves Coelho Street, 400, Chanadour, 35501-296 Divinópolis, MG, Brazil
| | - Melina de B Pinheiro
- Federal University of São João del-Rei (UFSJ), Dona Lindu Center-West Campus, Sebastião Gonçalves Coelho Street, 400, Chanadour, 35501-296 Divinópolis, MG, Brazil.
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29
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Frelinger AL. Platelet Function Testing in Clinical Research Trials. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00037-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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30
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Torres L, Conran N. Emerging pharmacotherapeutic approaches for the management of sickle cell disease. Expert Opin Pharmacother 2018; 20:173-186. [DOI: 10.1080/14656566.2018.1548610] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Lidiane Torres
- Hematology Center, University of Campinas – UNICAMP, Campinas, Brazil
| | - Nicola Conran
- Hematology Center, University of Campinas – UNICAMP, Campinas, Brazil
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31
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Abstract
The primary β-globin gene mutation that causes sickle cell disease (SCD) has significant pathophysiological consequences that result in hemolytic events and the induction of the inflammatory processes that ultimately lead to vaso-occlusion. In addition to their role in the initiation of the acute painful vaso-occlusive episodes that are characteristic of SCD, inflammatory processes are also key components of many of the complications of the disease including autosplenectomy, acute chest syndrome, pulmonary hypertension, leg ulcers, nephropathy and stroke. We, herein, discuss the events that trigger inflammation in the disease, as well as the mechanisms, inflammatory molecules and cells that propagate these inflammatory processes. Given the central role that inflammation plays in SCD pathophysiology, many of the therapeutic approaches currently under pre-clinical and clinical development for the treatment of SCD endeavor to counter aspects or specific molecules of these inflammatory processes and it is possible that, in the future, we will see anti-inflammatory drugs being used either together with, or in place of, hydroxyurea in those SCD patients for whom hematopoietic stem cell transplants and evolving gene therapies are not a viable option.
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Affiliation(s)
- Nicola Conran
- Hematology Center, University of Campinas - UNICAMP, Cidade Universitária, Campinas-SP, Brazil
| | - John D Belcher
- Department of Medicine, Division of Hematology, Oncology and Transplantation, Vascular Biology Center, University of Minnesota, Minneapolis, MN, USA
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32
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Abstract
Sickle cell disease (SCD) is a monogenetic disorder caused by a mutation in the β-globin gene HBB leading to polymerization of red blood cells causing damage to cell membranes, increasing its rigidity and intravascular hemolysis. Multiple lines of evidence suggest that SCD can be viewed as pan-vasculopathy associated with multiple mechanisms but driven by hemoglobin S polymerization. Here we review the pathophysiology, clinical manifestations and management strategies for cerebrovascular disease, pulmonary hypertension and renal disease associated with SCD. These "vascular phenotypes" reflect the systemic nature of the complications of SCD and are a major threat to the well-being of patients with the disorder.
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Affiliation(s)
- Ashar Usmani
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago, Chicago, IL, USA
| | - Roberto F Machado
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University, Indianapolis, IN, USA
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Behling-Kelly EL, Wakshlag J. A commercial soy-based phospholipid emulsion accelerates clot formation in normal canine whole blood and induces hemolysis in whole blood from normal and dogs with inflammatory leukograms. J Vet Emerg Crit Care (San Antonio) 2018; 28:252-260. [PMID: 29631333 DOI: 10.1111/vec.12716] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 10/07/2016] [Accepted: 12/14/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To compare lipid emulsion-induced hemolysis in blood from dogs with inflammatory leukograms to blood from healthy dogs, and determine the impact of a prototypical soy-based phospholipid emulsion on coagulation in whole blood from healthy dogs. DESIGN Ex vivo study using EDTA and citrated whole blood from healthy dogs and EDTA anticoagulated whole blood from dogs with inflammatory leukograms. SETTING University research laboratory. ANIMALS Healthy dogs (total of 16, 9 for hemolysis assays and 6 for thromboelastography) included student- and staff-owned animals. Blood samples from dogs with inflammatory leukograms (8) were obtained from the clinical pathology laboratory after the complete blood count was performed as part of patient care. For the purposes of this study, an inflammatory leukogram was defined as a neutrophilia with a left-shift (minimum of 3% band neutrophils) and evidence of toxic change. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Hemolysis was measured via spectrophotometric quantification of released hemoglobin and expressed as a percent of a water-lysed control. The soy emulsion caused hemolysis in blood from healthy dogs, ranging from 3.6% to 16.4% as the dose increased, and 4.1% to 25.0% in blood from dogs with inflammatory leukograms. Hemolysis between these patient groups was significantly different at the highest dose. Coagulation was assessed by native thromboelastography. Treatment of whole blood with the lipid emulsion caused a significant decrease in the time to clot formation (R) and a shorter time to reach a clot amplitude of 20 mm (K). CONCLUSIONS Soy-based lipid emulsions cause hemolysis that is more severe in blood from dogs with inflammatory leukograms and accelerate clot formation in canine blood. The in vivo significance of these findings is not clear at this time, but warrants additional investigation given the use of these emulsions in clinical practice.
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Affiliation(s)
- Erica L Behling-Kelly
- Departments of Population Medicine and Diagnostic Sciences (Behling-Kelly) and Department of Clinical Sciences (Wakshlag), Cornell University, Ithaca, 14853, NY
| | - Joseph Wakshlag
- Departments of Population Medicine and Diagnostic Sciences (Behling-Kelly) and Department of Clinical Sciences (Wakshlag), Cornell University, Ithaca, 14853, NY
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34
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Belisário AR, Silva CM, Velloso-Rodrigues C, Viana MB. Genetic, laboratory and clinical risk factors in the development of overt ischemic stroke in children with sickle cell disease. Hematol Transfus Cell Ther 2018; 40:166-181. [PMID: 30057991 PMCID: PMC6003005 DOI: 10.1016/j.bjhh.2017.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 08/30/2017] [Indexed: 12/22/2022] Open
Abstract
Cerebrovascular disease, particularly stroke, is one of the most severe clinical complications associated with sickle cell disease and is a significant cause of morbidity in both children and adults. Over the past two decades, considerable advances have been made in the understanding of its natural history and enabled early identification and treatment of children at the highest risk. Transcranial Doppler screening and regular blood transfusions have markedly reduced the risk of stroke in children. However, transcranial Doppler has a limited positive predictive value and the pathophysiology of cerebrovascular disease is not completely understood. In this review, we will focus on the current state of knowledge about risk factors associated with ischemic stroke in patients with sickle cell disease. A search of PubMed was performed to identify studies. Full texts of the included articles were reviewed and data were summarized in a table. The coinheritance of alpha-thalassemia plays a protective role against ischemic stroke. The influence of other genetic risk factors is controversial, still preliminary, and requires confirmatory studies. Recent advances have established the reticulocyte count as the most important laboratory risk factor. Clinical features associated with acute hypoxemia as well as silent infarcts seem to influence the development of strokes in children. However, transcranial Doppler remains the only available clinical prognostic tool to have been validated. If our understanding of the many risk factors associated with stroke advances further, it may be possible to develop useful tools to detect patients at the highest risk early, improving the selection of children requiring intensification therapy.
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Affiliation(s)
- André Rolim Belisário
- Centro de Tecidos Biológicos de Minas Gerais, Fundação Hemominas, Lagoa Santa, MG, Brazil
- Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
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Faes C, Sparkenbaugh EM, Pawlinski R. Hypercoagulable state in sickle cell disease. Clin Hemorheol Microcirc 2018; 68:301-318. [DOI: 10.3233/ch-189013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Camille Faes
- Interuniversity Laboratory of Human Movement Biology EA7424, Vascular biology and Red Blood Cell Team, University Claude Bernard Lyon1, Villeurbanne, France; Laboratory of Excellence “GR-Ex, ” Paris, France
| | - Erica M. Sparkenbaugh
- McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rafal Pawlinski
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Ansari J, Moufarrej YE, Pawlinski R, Gavins FNE. Sickle cell disease: a malady beyond a hemoglobin defect in cerebrovascular disease. Expert Rev Hematol 2017; 11:45-55. [PMID: 29207881 DOI: 10.1080/17474086.2018.1407240] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Sickle cell disease (SCD) is a devastating monogenic disorder that presents as a multisystem illness and affects approximately 100,000 individuals in the United States alone. SCD management largely focuses on primary prevention, symptomatic treatment and targeting of hemoglobin polymerization and red blood cell sickling. Areas covered: This review will discuss the progress of SCD over the last few decades, highlighting some of the clinical (mainly cerebrovascular) and psychosocial challenges of SCD in the United States. In addition, focus will also be made on the evolving science and management of this inherited disease. Expert commentary: Until recently hydroxyurea (HU) has been the only FDA approved therapy for SCD. However, advancing understanding of SCD pathophysiology has led to multiple clinical trials targeting SCD related thrombo-inflammation, abnormal endothelial biology, increased oxidant stress and sickle cell mutation. Yet, despite advancing understanding, available therapies are limited. SCD also imposes great psychosocial challenges for the individual and the affected community, which has previously been under-recognized. This has created a pressing need for complementary adjuvant therapies with repurposed and novel drugs, in addition to the establishment of comprehensive clinics focusing on both the medical treatment and the psychosocial issues associated with SCD.
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Affiliation(s)
- Junaid Ansari
- a Department of Molecular and Cellular Physiology , Louisiana State University Health Sciences Center - Shreveport , Shreveport , LA , USA
| | - Youmna E Moufarrej
- b Louisiana State University School of Medicine - Shreveport , Shreveport , LA , USA
| | - Rafal Pawlinski
- c Department of Medicine , University of North Carolina , Chapel Hill , NC , USA
| | - Felicity N E Gavins
- a Department of Molecular and Cellular Physiology , Louisiana State University Health Sciences Center - Shreveport , Shreveport , LA , USA
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Nwankwo JO, Gremmel T, Gerrits AJ, Mithila FJ, Warburton RR, Hill NS, Lu Y, Richey LJ, Jakubowski JA, Frelinger AL, Chishti AH. Calpain-1 regulates platelet function in a humanized mouse model of sickle cell disease. Thromb Res 2017; 160:58-65. [PMID: 29101791 DOI: 10.1016/j.thromres.2017.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 10/02/2017] [Accepted: 10/26/2017] [Indexed: 12/18/2022]
Abstract
One of the major contributors to sickle cell disease (SCD) pathobiology is the hemolysis of sickle red blood cells (RBCs), which release free hemoglobin and platelet agonists including adenosine 5'-diphosphate (ADP) into the plasma. While platelet activation/aggregation may promote tissue ischemia and pulmonary hypertension in SCD, modulation of sickle platelet dysfunction remains poorly understood. Calpain-1, a ubiquitous calcium-activated cysteine protease expressed in hematopoietic cells, mediates aggregation of platelets in healthy mice. We generated calpain-1 knockout Townes sickle (SSCKO) mice to investigate the role of calpain-1 in steady state and hypoxia/reoxygenation (H/R)-induced sickle platelet activation and aggregation, clot retraction, and pulmonary arterial hypertension. Using multi-electrode aggregometry, which measures platelet adhesion and aggregation in whole blood, we determined that steady state SSCKO mice exhibit significantly impaired PAR4-TRAP-stimulated platelet aggregation as compared to Townes sickle (SS) and humanized control (AA) mice. Interestingly, the H/R injury induced platelet hyperactivity in SS and SSCKO, but not AA mice, and partially rescued the aggregation defect in SSCKO mice. The PAR4-TRAP-stimulated GPIIb-IIIa (αIIbβ3) integrin activation was normal in SSCKO platelets suggesting that an alternate mechanism mediates the impaired platelet aggregation in steady state SSCKO mice. Taken together, we provide the first evidence that calpain-1 regulates platelet hyperactivity in sickle mice, and may offer a viable pharmacological target to reduce platelet hyperactivity in SCD.
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Affiliation(s)
- Jennifer O Nwankwo
- Graduate Program in Pharmacology and Experimental Therapeutics, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
| | - Thomas Gremmel
- Center for Platelet Research Studies, Division of Hematology/Oncology, Boston Children's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Anja J Gerrits
- Center for Platelet Research Studies, Division of Hematology/Oncology, Boston Children's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Farha J Mithila
- Department of Developmental, Molecular and Chemical Biology, Tufts University School of Medicine, Boston, MA, USA
| | - Rod R Warburton
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - Yunzhe Lu
- Department of Developmental, Molecular and Chemical Biology, Tufts University School of Medicine, Boston, MA, USA
| | - Lauren J Richey
- Division of Laboratory Animal Medicine, Tufts University, Boston, MA, USA
| | | | - Andrew L Frelinger
- Center for Platelet Research Studies, Division of Hematology/Oncology, Boston Children's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Athar H Chishti
- Graduate Program in Pharmacology and Experimental Therapeutics, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA; Department of Developmental, Molecular and Chemical Biology, Tufts University School of Medicine, Boston, MA, USA.
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Association of silent infarcts in sickle cell anemia with decreased annexin A5 resistance. Blood Cells Mol Dis 2017; 69:53-56. [PMID: 28911832 DOI: 10.1016/j.bcmd.2017.09.001] [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: 04/18/2017] [Revised: 08/31/2017] [Accepted: 09/01/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Sickle cell anemia (SCA) is characterized by abnormally shaped, adhesive RBCs that interact with white blood cells and the endothelium, leading to chronic hemolysis, vasculopathy and a prothrombotic state. About 10% of subjects with a thrombotic event in the general population will have an associated antiphospholipid (aPL) antibody. One proposed mechanism for the thrombophilic nature of aPL antibodies is the disruption of the potent anticoagulant annexin A5 or Annexin A5 resistance (A5R). We designed a pilot study assessing the presence of aPL antibodies and disruption of A5R in pediatric sickle cell subjects. METHODS 39 subjects with SCA participated in this study. A5R, DRVVT, anti-β2GP1, anti-β2GP1, anti-phosphatidylserine and anti-cardiolipin antibody assays were performed. RESULTS There was a high prevalence of abnormal A5R despite a low prevalence of antiphospholipid antibodies. Multivariate logistic regression analyses showed an association with silent infarcts (p=0.015), lower hemoglobin (p=0.037), older age (p=0.047) and abnormal A5R. CONCLUSION We report an association between annexin A5 resistance and presence of silent infarct, low hemoglobin, and older age in a subgroup of SCA subjects. A potential role for perturbed A5R in the pathophysiology of SCA needs to be evaluated further.
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Molokie R, Lavelle D, Gowhari M, Pacini M, Krauz L, Hassan J, Ibanez V, Ruiz MA, Ng KP, Woost P, Radivoyevitch T, Pacelli D, Fada S, Rump M, Hsieh M, Tisdale JF, Jacobberger J, Phelps M, Engel JD, Saraf S, Hsu LL, Gordeuk V, DeSimone J, Saunthararajah Y. Oral tetrahydrouridine and decitabine for non-cytotoxic epigenetic gene regulation in sickle cell disease: A randomized phase 1 study. PLoS Med 2017; 14:e1002382. [PMID: 28880867 PMCID: PMC5589090 DOI: 10.1371/journal.pmed.1002382] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 08/03/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Sickle cell disease (SCD), a congenital hemolytic anemia that exacts terrible global morbidity and mortality, is driven by polymerization of mutated sickle hemoglobin (HbS) in red blood cells (RBCs). Fetal hemoglobin (HbF) interferes with this polymerization, but HbF is epigenetically silenced from infancy onward by DNA methyltransferase 1 (DNMT1). METHODS AND FINDINGS To pharmacologically re-induce HbF by DNMT1 inhibition, this first-in-human clinical trial (NCT01685515) combined 2 small molecules-decitabine to deplete DNMT1 and tetrahydrouridine (THU) to inhibit cytidine deaminase (CDA), the enzyme that otherwise rapidly deaminates/inactivates decitabine, severely limiting its half-life, tissue distribution, and oral bioavailability. Oral decitabine doses, administered after oral THU 10 mg/kg, were escalated from a very low starting level (0.01, 0.02, 0.04, 0.08, or 0.16 mg/kg) to identify minimal doses active in depleting DNMT1 without cytotoxicity. Patients were SCD adults at risk of early death despite standard-of-care, randomized 3:2 to THU-decitabine versus placebo in 5 cohorts of 5 patients treated 2X/week for 8 weeks, with 4 weeks of follow-up. The primary endpoint was ≥ grade 3 non-hematologic toxicity. This endpoint was not triggered, and adverse events (AEs) were not significantly different in THU-decitabine-versus placebo-treated patients. At the decitabine 0.16 mg/kg dose, plasma concentrations peaked at approximately 50 nM (Cmax) and remained elevated for several hours. This dose decreased DNMT1 protein in peripheral blood mononuclear cells by >75% and repetitive element CpG methylation by approximately 10%, and increased HbF by 4%-9% (P < 0.001), doubling fetal hemoglobin-enriched red blood cells (F-cells) up to approximately 80% of total RBCs. Total hemoglobin increased by 1.2-1.9 g/dL (P = 0.01) as reticulocytes simultaneously decreased; that is, better quality and efficiency of HbF-enriched erythropoiesis elevated hemoglobin using fewer reticulocytes. Also indicating better RBC quality, biomarkers of hemolysis, thrombophilia, and inflammation (LDH, bilirubin, D-dimer, C-reactive protein [CRP]) improved. As expected with non-cytotoxic DNMT1-depletion, platelets increased and neutrophils concurrently decreased, but not to an extent requiring treatment holds. As an early phase study, limitations include small patient numbers at each dose level and narrow capacity to evaluate clinical benefits. CONCLUSION Administration of oral THU-decitabine to patients with SCD was safe in this study and, by targeting DNMT1, upregulated HbF in RBCs. Further studies should investigate clinical benefits and potential harms not identified to date. TRIAL REGISTRATION ClinicalTrials.gov, NCT01685515.
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Affiliation(s)
- Robert Molokie
- Department of Medicine, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, United States of America
- Jesse Brown VA Medical Center, Chicago, Illinois, United States of America
| | - Donald Lavelle
- Department of Medicine, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, United States of America
- Jesse Brown VA Medical Center, Chicago, Illinois, United States of America
| | - Michel Gowhari
- Department of Medicine, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, United States of America
| | - Michael Pacini
- Department of Medicine, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, United States of America
| | - Lani Krauz
- Department of Medicine, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, United States of America
| | - Johara Hassan
- Department of Medicine, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, United States of America
| | - Vinzon Ibanez
- Jesse Brown VA Medical Center, Chicago, Illinois, United States of America
| | - Maria A. Ruiz
- Jesse Brown VA Medical Center, Chicago, Illinois, United States of America
| | - Kwok Peng Ng
- Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Philip Woost
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Tomas Radivoyevitch
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Daisy Pacelli
- Department of Medicine, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, United States of America
| | - Sherry Fada
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Matthew Rump
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Matthew Hsieh
- Molecular and Clinical Hematology Section, National Institutes of Health, Bethesda, Maryland, United States of America
| | - John F. Tisdale
- Molecular and Clinical Hematology Section, National Institutes of Health, Bethesda, Maryland, United States of America
| | - James Jacobberger
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Mitch Phelps
- College of Pharmacy, The Ohio State University, Columbus, Ohio, United States of America
| | - James Douglas Engel
- Cell and Developmental Biology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Santhosh Saraf
- Department of Medicine, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, United States of America
| | - Lewis L. Hsu
- Department of Medicine, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, United States of America
| | - Victor Gordeuk
- Department of Medicine, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, United States of America
| | - Joseph DeSimone
- Department of Medicine, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, United States of America
| | - Yogen Saunthararajah
- Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
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Shilo NR, Morris CR. Pathways to pulmonary hypertension in sickle cell disease: the search for prevention and early intervention. Expert Rev Hematol 2017; 10:875-890. [PMID: 28817980 DOI: 10.1080/17474086.2017.1364989] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Pulmonary hypertension (PH) develops in a significant number of patients with sickle cell disease (SCD), resulting in increased morbidity and mortality. This review focuses on PH pathophysiology, risk stratification, and new recommendations for screening and treatment for patients with SCD. Areas covered: An extensive PubMed literature search was performed. While the pathophysiology of PH in SCD is yet to be fully deciphered, it is known that the etiology is multifactorial; hemolysis, hypercoagulability, hypoxemia, ischemic-reperfusion injury, oxidative stress, and genetic susceptibility all contribute in varying degrees to endothelial dysfunction. Hemolysis, in particular, seems to play a key role by inciting an imbalance in the regulatory axis of nitric oxide and arginine metabolism. Systematic risk stratification starting in childhood based on clinical features and biomarkers that enable early detection is necessary. Multi-faceted, targeted interventions, before irreversible vasculopathy develops, will allow for improved patient outcomes and life expectancy. Expert commentary: Despite progress in our understanding of PH in SCD, clinically proven therapies remain elusive and additional controlled clinical trials are needed. Prevention of disease starts in childhood, a critical window for intervention. Given the complex and multifactorial nature of SCD, patients will ultimately benefit from combination therapies that simultaneously targets multiple mechanisms.
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Affiliation(s)
- Natalie R Shilo
- a Department of Pediatrics, Division of Pulmonary Medicine , University of Connecticut Heath Center , Farmington , CT , USA
| | - Claudia R Morris
- b Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory-Children's Center for Cystic Fibrosis and Airways Disease Research , Emory University School of Medicine , Atlanta , GA , USA
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41
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Placenta growth factor mediated gene regulation in sickle cell disease. Blood Rev 2017; 32:61-70. [PMID: 28823762 DOI: 10.1016/j.blre.2017.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/08/2017] [Accepted: 08/15/2017] [Indexed: 01/07/2023]
Abstract
Sickle cell anemia (SCA) is an autosomal recessive disorder caused by mutation in the β-globin gene. Pulmonary hypertension (PH), a complication of SCA, results in severe morbidity and mortality. PH is a multifactorial disease: systemic vasculopathy, pulmonary vasoconstriction, and endothelial dysfunction and remodeling. Placenta growth factor (PlGF), an angiogenic growth factor, elaborated from erythroid cells, has been shown to contribute to inflammation, pulmonary vasoconstriction and airway hyper-responsiveness (AH) in mouse models of sickle cell disease. In this review, we summarize the cell-signaling mechanism(s) by which PlGF regulates the expression of genes involved in inflammation, PH and AH in cell culture and corroborate these findings in mouse models of SCA and in individuals with SCA. The role of microRNAs (miRNAs) in the post-transcriptional regulation of these genes is presented and how these miRNAs located in their host genes are transcriptionally regulated. An understanding of the transcriptional regulation of these miRNAs provides a new therapeutic approach to ameliorate the clinical manifestations of SCA.
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Abstract
Sickle cell disease (SCD) is a hematologic disorder caused by a well-characterized point mutation in the β-globin gene. Abnormal polymerization of hemoglobin tetramers results in the formation of sickle red blood cells that leads to vascular occlusions, hemolytic anemia, vascular inflammation and cumulative, multiple organ damage. Ongoing activation of coagulation is another hallmark of SCD. Recent studies strongly suggested that hypercoagulation in SCD is not just a secondary event but contributes directly to the disease pathophysiology. In this article we summarize mechanisms leading to the activation of coagulation, review data indicating direct contribution of coagulation to the pathology of SCD and, we discuss the anticoagulation as a possible treatment strategy to attenuate the disease progression.
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Affiliation(s)
- E Sparkenbaugh
- University of North Carolina, School of Medicine, Division of Hematology and Oncology, Chapel Hill, NC, USA
| | - R Pawlinski
- University of North Carolina, School of Medicine, Division of Hematology and Oncology, Chapel Hill, NC, USA
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43
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Telen MJ. Developing new pharmacotherapeutic approaches to treating sickle-cell disease. ACTA ACUST UNITED AC 2016; 12:239-247. [PMID: 28484512 DOI: 10.1111/voxs.12305] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Survival for patients with SCD has been prolonged by improvements in supportive care, including vaccinations, antibiotic prophylaxis, and overall medical management, including tra nsfusion. However, there remains only one approved, partially effective drug for sickle cell disease-hydroxyurea (hydroxycarbamide). The world desperately needs better ways of both treating and preventing the recurrent painful vaso-occlusive episodes pathognomonic of sickle cell disease as well as the end-organ damage that still leads inexorably to severely shortened life expectancies throughout the world. Based on accumulating knowledge about how the abnormal red blood cells of sickle cell disease cause the double scourge of acute painful episodes and progressive end-organ damage, both pharmaceutical enterprises and individual investigators are now pursuing multiple new avenues for treating sickle cell disease. As a result, many compounds are in active development, both in preclinical models as well as in phase I, II, and III clinical trials. These agents target many pathophysiologic processes thought to be critical in sickle cell disease, including the chemical and physical behavior of haemoglobin S, cell adhesion, coagulation pathways, platelet activation, inflammatory pathways, and upregulation of haemoglobin F expression. In addition, recent explorations of the genetic variations that predispose to certain types of sickle cell disease-related tissue injury, such as stroke or nephropathy, are expected to lead to identification of drugs targeting the pathways uncovered by such work. Thus, the next five to ten years holds a promise of new treatments for sickle cell disease.
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Affiliation(s)
- Marilyn J Telen
- Division of Hematology, Department of Medicine, Duke Comprehensive Sickle Cell Center, Duke University, Durham, NC, USA, Box 2615 DUMC, Durham, NC 27710, TEL: +1 919 684 5378, FAX: +1 919 681 7688,
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44
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Charrin E, Ofori-Acquah SF, Nader E, Skinner S, Connes P, Pialoux V, Joly P, Martin C. Inflammatory and oxidative stress phenotypes in transgenic sickle cell mice. Blood Cells Mol Dis 2016; 62:13-21. [DOI: 10.1016/j.bcmd.2016.10.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/18/2016] [Accepted: 10/26/2016] [Indexed: 11/25/2022]
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45
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Whelihan MF, Lim MY, Mooberry MJ, Piegore MG, Ilich A, Wogu A, Cai J, Monroe DM, Ataga KI, Mann KG, Key NS. Thrombin generation and cell-dependent hypercoagulability in sickle cell disease. J Thromb Haemost 2016; 14:1941-1952. [PMID: 27430959 DOI: 10.1111/jth.13416] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Indexed: 02/03/2023]
Abstract
Essentials Sickle cell disease is increasingly being recognized as a chronic hypercoagulable state. Thrombin generation is elevated in the whole blood, but not the plasma of sickle cell patients. Whole blood thrombin generation inversely correlates to erythrocyte phosphatidylserine exposure. Acquired protein S deficiency is likely explained by binding of protein S to sickle red cells. Click to hear Dr Hillery discuss coagulation and vascular pathologies in mouse models of sickle cell disease. SUMMARY Introduction Sickle cell disease (SCD) is a hypercoagulable state with chronic activation of coagulation and an increased incidence of thromboembolic events. However, although plasma pre-thrombotic markers such as thrombin-anithrombin complexes and D-dimer are elevated, there is no consensus on whether global assays of thrombin generation in plasma are abnormal in patients with SCD. Based on our recent observation that normal red blood cells (RBCs) contribute to thrombin generation in whole blood, we hypothesized that the cellular components in blood (notably phosphatidylserine-expressing erythrocytes) contribute to enhanced thrombin generation in SCD. Methods Whole blood and plasma thrombin generation assays were performed on blood samples from 25 SCD patients in a non-crisis 'steady state' and 25 healthy race-matched controls. Results Whole blood thrombin generation was significantly elevated in SCD, whereas plasma thrombin generation was paradoxically reduced compared with controls. Surprisingly, whole blood and plasma thrombin generation were both negatively correlated with phosphatidylserine exposure on RBCs. Plasma thrombin generation in the presence of exogenous activated protein C or soluble thrombomodulin revealed deficiencies in the protein C/S anticoagulant pathway in SCD. These global changes were associated with significantly lower plasma protein S activity in SCD that correlated inversely with RBC phosphatidylserine exposure. Conclusion Increased RBC phosphatidylserine exposure in SCD is associated with acquired protein S deficiency. In addition, these data suggest a cellular contribution to thrombin generation in SCD (other than RBC phosphatidylserine exposure) that explains the elevated thrombin generation in whole blood.
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Affiliation(s)
| | - M Y Lim
- Department of Medicine, Chapel Hill, NC, USA
| | | | - M G Piegore
- Department of Medicine, Chapel Hill, NC, USA
| | - A Ilich
- Department of Medicine, Chapel Hill, NC, USA
| | - A Wogu
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - J Cai
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - D M Monroe
- Department of Medicine, Chapel Hill, NC, USA
| | - K I Ataga
- Department of Medicine, Chapel Hill, NC, USA
| | - K G Mann
- Department of Biochemistry, University of Vermont, Burlington, VT, USA
| | - N S Key
- Department of Medicine, Chapel Hill, NC, USA.
- Department of Pathology and Laboratory Medicine, Chapel Hill, NC, USA.
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46
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Al-Faris L, Al-Rukhayes M, Al-Humood S. Expression pattern of CD55 and CD59 on red blood cells in sickle cell disease. ACTA ACUST UNITED AC 2016; 22:105-113. [PMID: 27667587 DOI: 10.1080/10245332.2016.1231988] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To investigate the pattern of CD55 and CD59 expression on RBCs of SCD patients, and its association with anemia, biochemical parameters of hemolysis, level of erythropoietin, and pro-inflammatory markers. METHODS Flow cytometric analysis was performed on RBCs from 71 adult SCD patients and 53 healthy controls, using the commercial REDQUANT kit. RESULTS CD59 deficiency was significantly higher among SCD patients than among healthy controls. The proportions of CD55-deficient and CD59-deficient RBCs from SCD patients were significantly higher when compared with those from healthy controls (0.17 vs. 0.09 and 2.1 vs. 1.2, respectively). The MFI of CD55 and CD59 expression on RBCs in SCD was significantly reduced when compared to the expression in healthy controls (5.2 vs. 6.4 and 19.4 vs 20.3, respectively). The pattern of CD55 and CD59 expression was not correlated with anemia, biomarkers of hemolysis, erythropoietin level, or other pro-inflammatory markers. DISCUSSION There is an altered pattern of CD55 and CD59 expression on RBCs of SCD Patients; however, it does not seem to play a causal role in the pathophysiology of anemia, and is unlikely to be influenced by the level of erythropoietin or other inflammatory mediators.
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Affiliation(s)
- Lama Al-Faris
- a Department of Pathology, Faculty of Medicine , Kuwait University , Safat , Kuwait
| | - Monera Al-Rukhayes
- a Department of Pathology, Faculty of Medicine , Kuwait University , Safat , Kuwait
| | - Salah Al-Humood
- a Department of Pathology, Faculty of Medicine , Kuwait University , Safat , Kuwait
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47
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Cita KC, Ferdinand S, Connes P, Brudey L, Tressières B, Etienne-Julan M, Lemonne N, Tarer V, Elion J, Romana M. Association of adenylyl cyclase 6 rs3730070 polymorphism and hemolytic level in patients with sickle cell anemia. Blood Cells Mol Dis 2016; 58:21-5. [PMID: 27067484 DOI: 10.1016/j.bcmd.2016.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 11/17/2022]
Abstract
A recent study suggested that adenosine signaling pathway could promote hemolysis in patients with sickle cell anemia (SCA). This signaling pathway involves several gene coding enzymes for which variants have been described. In this study, we analyzed the genotype-phenotype relationships between functional polymorphisms or polymorphisms associated with altered expression of adenosine pathway genes, namely adenosine deaminase (ada; rs73598374), adenosine A2b receptor (adora2b; rs7208480), adenylyl cyclase6 (adcy6; rs3730071, rs3730070, rs7300155), and hemolytic rate in SCA patients. One hundred and fifty SCA patients were genotyped for adcy6, ada, and adora2b variants as well as alpha-globin gene, a genetic factor known to modulate hemolytic rate. Hematological and biochemical data were obtained at steady-state. Lactate dehydrogenase, aspartate aminotransferase, reticulocytes and total bilirubin were used to calculate a hemolytic index. Genotype-phenotype relationships were investigated using parametric tests and multivariate analysis. SCA patients carrying at least one allele of adcy6 rs3730070-G exhibited lower hemolytic rate than non-carriers in univariate analysis (p=0.006). The presence of adcy6 rs3730070-G variant was associated with a decreased hemolytic rate in adjusted model for age and alpha-thalassemia (p=0.032). Our results support a protective effect of adcy6 rs3730070-G variant on hemolysis in SCA patients.
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Affiliation(s)
- Kizzy-Clara Cita
- Inserm UMR 1134, Hôpital Ricou, CHU de Pointe-à-Pitre, F-97157 Guadeloupe, France; Laboratoire d'Excellence du Globule Rouge (LABEX GR-Ex), PRES Sorbonne Paris Cité, F-a, Paris, France
| | - Séverine Ferdinand
- Inserm UMR 1134, Hôpital Ricou, CHU de Pointe-à-Pitre, F-97157 Guadeloupe, France; Laboratoire d'Excellence du Globule Rouge (LABEX GR-Ex), PRES Sorbonne Paris Cité, F-a, Paris, France
| | - Philippe Connes
- Inserm UMR 1134, Hôpital Ricou, CHU de Pointe-à-Pitre, F-97157 Guadeloupe, France; Laboratoire d'Excellence du Globule Rouge (LABEX GR-Ex), PRES Sorbonne Paris Cité, F-a, Paris, France; Institut Universitaire de France, F-75006 Paris, France; Laboratoire CRIS EA647, Equipe "Biologie Vasculaire et du Globule Rouge", Université Lyon 1, F-69100 Villeurbanne, France
| | - Laura Brudey
- Inserm UMR 1134, Hôpital Ricou, CHU de Pointe-à-Pitre, F-97157 Guadeloupe, France; Laboratoire d'Excellence du Globule Rouge (LABEX GR-Ex), PRES Sorbonne Paris Cité, F-a, Paris, France
| | - Benoit Tressières
- Centre d'Investigation Clinique Antilles Guyane CIC 14-24 Inserm, CHU de Pointe-à-Pitre, Guadeloupe, France
| | - Maryse Etienne-Julan
- Unité Transversale de la Drépanocytose, Centre de référence maladies rares pour la drépanocytose aux Antilles-Guyane, CHU de Pointe-à-Pitre, F-97157 Pointe-à-Pitre, Guadeloupe, France
| | - Nathalie Lemonne
- Unité Transversale de la Drépanocytose, Centre de référence maladies rares pour la drépanocytose aux Antilles-Guyane, CHU de Pointe-à-Pitre, F-97157 Pointe-à-Pitre, Guadeloupe, France
| | - Vanessa Tarer
- Unité Transversale de la Drépanocytose, Centre de référence maladies rares pour la drépanocytose aux Antilles-Guyane, CHU de Pointe-à-Pitre, F-97157 Pointe-à-Pitre, Guadeloupe, France
| | - Jacques Elion
- Laboratoire d'Excellence du Globule Rouge (LABEX GR-Ex), PRES Sorbonne Paris Cité, F-a, Paris, France; Inserm UMR 1134, F-75739 Paris, France
| | - Marc Romana
- Inserm UMR 1134, Hôpital Ricou, CHU de Pointe-à-Pitre, F-97157 Guadeloupe, France; Laboratoire d'Excellence du Globule Rouge (LABEX GR-Ex), PRES Sorbonne Paris Cité, F-a, Paris, France.
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Thrombin-independent contribution of tissue factor to inflammation and cardiac hypertrophy in a mouse model of sickle cell disease. Blood 2016; 127:1371-3. [PMID: 26817955 DOI: 10.1182/blood-2015-11-681114] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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49
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Pathophysiology and treatment of pulmonary hypertension in sickle cell disease. Blood 2016; 127:820-8. [PMID: 26758918 DOI: 10.1182/blood-2015-08-618561] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 10/21/2015] [Indexed: 12/11/2022] Open
Abstract
Pulmonary hypertension affects ∼10% of adult patients with sickle cell disease (SCD), particularly those with the homozygous genotype. An increase in pulmonary artery systolic pressure, estimated noninvasively by echocardiography, helps identify SCD patients at risk for pulmonary hypertension, but definitive diagnosis requires right-heart catheterization. About half of SCD-related pulmonary hypertension patients have precapillary pulmonary hypertension with potential etiologies of (1) a nitric oxide deficiency state and vasculopathy consequent to intravascular hemolysis, (2) chronic pulmonary thromboembolism, or (3) upregulated hypoxic responses secondary to anemia, low O2 saturation, and microvascular obstruction. The remainder have postcapillary pulmonary hypertension secondary to left ventricular dysfunction. Although the pulmonary artery pressure in SCD patients with pulmonary hypertension is only moderately elevated, they have a markedly higher risk of death than patients without pulmonary hypertension. Guidelines for diagnosis and management of SCD-related pulmonary hypertension were published recently by the American Thoracic Society. Management of adults with sickle-related pulmonary hypertension is based on anticoagulation for those with thromboembolism; oxygen therapy for those with low oxygen saturation; treatment of left ventricular failure in those with postcapillary pulmonary hypertension; and hydroxyurea or transfusions to raise the hemoglobin concentration, reduce hemolysis, and prevent vaso-occlusive events that cause additional increases in pulmonary pressure. Randomized trials have not identified drugs to lower pulmonary pressure in SCD patients with precapillary pulmonary hypertension. Patients with hemodynamics of pulmonary arterial hypertension should be referred to specialized centers and considered for treatments known to be effective in other forms of pulmonary arterial hypertension. There have been reports that some of these treatments improve SCD-related pulmonary hypertension.
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50
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Novelli EM, Gladwin MT. Crises in Sickle Cell Disease. Chest 2015; 149:1082-93. [PMID: 26836899 DOI: 10.1016/j.chest.2015.12.016] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 12/04/2015] [Accepted: 12/11/2015] [Indexed: 12/16/2022] Open
Abstract
In spite of significant strides in the treatment of sickle cell disease (SCD), SCD crises are still responsible for high morbidity and early mortality. While most patients initially seek care in the acute setting for a seemingly uncomplicated pain episode (pain crisis or vaso-occlusive crisis), this initial event is the primary risk factor for potentially life-threatening complications. The pathophysiological basis of these illnesses is end-organ ischemia and infarction combined with the downstream effects of hemolysis that results from red blood cell sickling. These pathological changes can occur acutely and lead to a dramatic clinical presentation, but are frequently superimposed over a milieu of chronic vasculopathy, immune dysregulation, and decreased functional reserve. In the lungs, acute chest syndrome is a particularly ominous lung injury syndrome with a complex pathogenesis and potentially devastating sequelae, but all organ systems can be affected. It is, therefore, critical to understand the SCD patients' susceptibility to acute complications and their risk factors so that they can be recognized promptly and managed effectively. Blood transfusions remain the mainstay of therapy for all severe acute crises. Recommendations and indications for the safest and most efficient implementation of transfusion strategies in the critical care setting are therefore presented and discussed, together with their pitfalls and potential future therapeutic alternatives. In particular, the importance of extended phenotypic red blood cell matching cannot be overemphasized, due to the high prevalence of severe complications from red cell alloimmunization in SCD.
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Affiliation(s)
- Enrico M Novelli
- Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA; Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA; Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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