Blood transfusion rate in Congolese patients with sickle cell anemia

Partial Splenic Embolization in Paediatric Sickle Cell Disease Patients with Hypersplenism

PURPOSE

To assess the safety and efficacy of partial splenic embolization (PSE) to reduce the need of transfusions and improve hematologic parameters in patients with hypersplenism and sickle cell disease (SCD).

MATERIAL AND METHODS

This prospective study includes 35 homozygous hemoglobin S patients with SCD and hypersplenism who underwent PSE from 2015 until 2021 in Kinshasa. Patients were evaluated, before and after PSE (1, 3 and 6 months), using clinical, laboratory and ultrasonographic methods. PSE was performed with the administration of gelatin sponge particles embolizing 60-70% of the splenic parenchyma.

RESULTS

The mean age was 10 (± 4) years and (21/35, 60%) were male. After PSE Leucocytes decreased at 3 months (16 692.94 vs 13 582.86, p = 0.02) and at six months Erythrocytes increased 2 004 000 vs. 2 804 142 (p < 0.001), Platelets increased (168 147 vs. 308 445, p < 0.001) and Hemoglobin increased (5.05 g/dL vs. 6.31 g/dL, p < 0.001) There was a significant dicrease in the need of transfusions from 6 (2-20) before PSE to 0.06 (0-1) after PSE (p < 0.001). The most frequent complication was splenic rupture (4/35, 11.4%), seen only and in all patients with hypoechogenic nodules at baseline.

CONCLUSION

PSE is a safe procedure in patients with SCD and hypersplenism, that do not have hypoechogenic nodules in the spleen. PSE improves the hematological parameters and reduces the frequency of blood transfusions.

Models of care for sickle cell disease in low-income and lower-middle-income countries: a scoping review

Sickle cell disease has a growing global burden falling primarily on low-income countries (LICs) and lower-middle-income countries (LMICs) where comprehensive care is often insufficient, particularly in rural areas. Integrated care models might be beneficial for improving access to care in areas with human resource and infrastructure constraints. As part of the Centre for Integration Science's ongoing efforts to define, systematise, and implement integrated care delivery models for non-communicable diseases (NCDs), this Review explores models of care for sickle cell disease in LICs and LMICs. We identified 99 models from 136 studies, primarily done in tertiary, urban facilities in LMICs. Except for two models of integrated care for concurrent treatment of other conditions, sickle cell disease care was mostly provided in specialised clinics, which are low in number and accessibility. The scarcity of published evidence of models of care for sickle cell disease and integrated care in rural settings of LICs and LMICs shows a need to implement more integrated models to improve access, particularly in rural areas. PEN-Plus, a model of decentralised, integrated care for severe chronic non-communicable diseases, provides an approach to service integration that could fill gaps in access to comprehensive sickle cell disease care in LICs and LMICs.

Genotypic and Phenotypic Composition of Sickle Cell Disease in the Arab Population - A Systematic Review

Sickle cell disease (SCD) is a genetic disease influenced by ethnicity and regional differences in its clinical course. Recent advances in the management of SCD with newer therapies are being introduced to the Western population. However, many of these treatments are yet to be used in the Arabic SCD population. Understanding the genetic variations of SCD regionally is essential to anticipate the utilization of new treatments. This systematic review's main objective is to pool the available data on the genetic composition of SCD in the Arabic population. Data for 44,034 patients was extracted from 184 studies (11 case reports, 8 case series, 56 retrospectives, 107 prospective observational studies, and 2 clinical trials) using PubMed, Scopus, and Google Scholar. Male (49%) and female (51%) patients were equally reported wherever gender was available (N=13105). Various SCD genotypes were reported in a total of 14,257 patients, including Hb SS (77%) Hb Sβ0 (9.9%), and Hb Sβ+ (7.2%), while the rest of the genotypes, including HbSC, HbSD, HbSE, HbSO Arab, Hb S/α-Thal, Hb Sβ0 + α-Thal, and HBS Oman were individually reported in <4% of the cases. Major SCD complications in the Arab population included pain crises (48.25%) followed by neurological complications (33.46%), hepatobiliary complications (25.53%), musculoskeletal complications (24.73%), and hemolytic anemia (23.57%). The treatments reported for SCD included hydroxyurea (20%), blood transfusion (14.32%), and Deferasirox (3.03%). We did not find the use of stem cell transplantation or newer treatments such as L-Glutamine, Voxelotor, Crizanlizumab, or gene therapy reported in any of the studies included in our review. This review highlights the genetic makeup of SCD in Arab countries and its common phenotypic manifestations and will help direct further research on SCD in this region, especially concerning genetic therapy.

Systematic Review Registration

The protocol has been registered in the International Prospective Register of Systematic Reviews(PROSPERO):CRD42020218,666. https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=218666.

The prevalence of human immunodeficiency and of hepatitis B viral infections is not increased in patients with sickle cell disease in Tanzania

BACKGROUND

Tanzania ranks as the fourth country in the world with respect to the number of sickle cell disease (SCD) births; it is also endemic to the human immunodeficiency virus (HIV) and the hepatitis B virus (HBV). This study was done to determine the prevalence of HIV and HBV infections among SCD patients in Dar es Salaam, Tanzania.

METHODS

A multicenter hospital-based descriptive cross sectional study was carried out among participants aged ≥ 16 years with a proven diagnosis of SCD. Socio-demographic and clinical data were recorded. Blood samples were drawn for HIV and HBV diagnosis. All categorical variables were summarized into frequencies.

RESULTS

There were 185/325 (56.9 %) females. The mean age (SD) was 23.0 ± 7.5 years. The prevalence of HIV was 1.8 %; the prevalence of HBV was 1.2 %.

CONCLUSIONS

The prevalence of both HIV and HBV in SCD patients is no greater than in the general population of Dar es Salaam or Tanzania. For associations, a large study would be needed. From a detailed blood transfusion history of SCD patients we found no evidence that HIV or HBV infection was transmitted through blood transfusion.

Blood Transfusion Frequency and Indications in Yemeni Children with Sickle Cell Disease

Background

Blood transfusion is an essential component in the care of patients with sickle cell disease (SCD), but it might be associated with serious acute and delayed complications. This study was aimed to describe red cell transfusion patterns and indications among hospitalized SCD children in a low-resource setting. Patients and Methods. A retrospective, descriptive study of all children (≤16 years) with SCD who received blood transfusion therapy during their hospital admissions in the pediatric department at Al-Sadaqa Teaching Hospital in Aden, Yemen, for a period of one year.

Results

Out of 217 hospitalized children with SCD, 169 (77.9%) were transfused and received 275 RBC transfusion episodes. The mean age of transfused children was 6.9 ± 4.6 years and 103 (60.9%) were males, with a male/female ratio of 1.6 : 1 (p=0.004). Hemoglobin (Hb) levels were significantly lower in the transfused than in the nontransfused (Hb 5.5 ± 1.5 vs. 7.7 ± 1.5 g/dL, p=0.03). Pretransfusion Hb levels were ˂7.0 g/dL in 86.2% and ˂5.0 g/dL in 39.3% of patients. Single transfusion was given to 122 (72.2%) and 5 or more transfusions in 9 (4.15%) of patients on different occasions. Simple (top-up) transfusion was used in all transfusion events. Commonest indications for transfusion were anemic crises (41.1%), vasoocclusive crises (VOC) (13.8%), VOC with anemic event (11.3%), acute chest syndrome (8.7%), and stroke (7.3%).

Conclusion

Intermittent blood transfusion remains a common practice for the management of children with acute SCD complications. Main indications were acute anemic crises, severe pain crises, ACS, and stroke. In limited resource settings, such as Yemen, conservative transfusion policy appears to be appropriate.

The clinical characteristics of Congolese children and adolescents suffering from sickle-cell anemia are marked by the high frequencies of epistaxis compared to Western series

Background: Sickle cell anaemia (SCA) is the most common genetic diseases in the Democratic Republic of Congo (DRC). It is estimated 30,000 to 40,000 neonates with SCA are born annually. Despite this high incidence rate, and the severity of the Bantu haplotype found in Congolese patients, major clinical characteristics remain poorly defined. The objective of this study was to assess the clinical and haematological profile of the SCA in patients less than 24 years of age. Methods: A cross-sectional study was conducted in Kinshasa, the large city of the DRC. Patients were consecutively selected in three health institutions. Results: The study includes 256 sickle cell patients. The mean age of 8.4 (SD = 4.9) years. The Hand-foot syndrome was most common (52.7%) first presentation revealing the disease in our series. The most prevalent crises found in our series were vaso-occlusive crises (VOC) in 170 cases (66.4%) and severe hemolysis in 136 cases (53.1%). Splenic sequestration was noted in 19 cases (7.4%). The age at the first pain crisis was 18.2±15.2 months-of-age and the age at the first transfusions was 29.2±27.6 months-of -age. The most common signs associated with sickle cell disease in our series were hepatomegaly (53.9%), splenomegaly (41.7%), and adenotonsillar hypertrophy (34.8%). Epistaxis was reported in 9.4%. Conclusion: The clinical course of patients in DRC was comparable to reports from Western countries, with the notable exception of epistaxis which was significantly higher in patients in the DRC.

Magnitude of elevated iron stores and risk associated in steady state sickle cell anemia Congolese children: a cross sectional study

Background

The serum ferritin assay is recommended in Sickle Cell Anemia (SCA) patients receiving regular transfusions. According to several authors, elevated iron stores indicating iron chelation corresponds to hyperferritinemia ≥500 ng/ml, and becomes detectable after twenty blood transfusions. The objectives of the study were to determine the prevalence of elevated iron stores and identify associated risk factors in a case series of Steady state SCA Congolese children.

Material and methods

Serum ferritin was assayed in Steady state SCA children followed in 2 specialized hospitals in Kinshasa. Elevated iron stores was defined as serum ferritin level ≥ 500 ng/ml, and the associated risk factors were identified using univariate analysis.

Results

Seventy patients (median age 9 years, 56% boys, 53% receiving hydroxyurea) were selected in the study. Serum ferritin levels ranged from 24 to 2584 ng / ml with 21.4% of children having elevated iron stores. Mean levels of LDH, indirect bilirubin, plasma free Hb and CRP were similar between the 2 groups whereas history of polytransfusions (> 3 during the last year) was more frequent among patients with elevated iron stores (73% vs. 44%, p = 0.078). Receiving > 3 transfusions in a year vs. 0 was the main risk factor associated with elevated iron stores [OR 6.17 (95% CI: 1.81–20.96)].

Conclusion

In SCA children, hyperferritinemia requiring iron chelation is most strongly related to blood transfusion. This situation concerned almost one in five children in present study; this shows the magnitude of the problem which is underestimated.

Possible Risk Factors for Severe Anemia in Hospitalized Sickle Cell Patients at Muhimbili National Hospital, Tanzania: Protocol for a Cross-Sectional Study

Background

Sickle cell disease (SCD) is the most common inherited disorder worldwide, with the highest burden in sub-Saharan Africa. The natural history of SCD is characterized by periods of steady state interspersed by acute episodes. The acute anemic crises may be transient and are precipitated by treatable factors like infections, nutritional deficiencies, and sequestration. Anemia is almost always present, although it occurs at different levels of severity.

Objective

This paper describes the protocol of a cross-sectional study to determine the prevalence of severe anemia and associated factors among sickle cell patients hospitalized at the Muhimbili National Hospital.

Methods

This is an ongoing, descriptive, cross-sectional, hospital-based study among individuals with SCD, admitted to the Muhimbili National Hospital in Dares Salaam, Tanzania. A minimum sample size of 369 was calculated based on the previous prevalence of hospitalizations due to severe anemia (20%) in the same cohort. We are using a piloted standardized case report form to document clinical and laboratory parameters following informed consent. Data analysis will be performed using Stata software. Severe anemia is defined as Hb<5g/dL. Chi-square or Fisher’s exact test will be used to ascertain association between categorical variables, and t-test will be used for numerical variables. Regression models for severe anemia against explanatory and confounding variables will be run, and results will be presented as adjusted odds ratio with 95% confidence intervals. A P value of <.05 will be considered significant.

Results

Enrolment commenced in January 2015 and concluded in September 2016. Complete data analysis will begin in February 2018. The study results are expected to be published in May 2018.

Conclusions

This protocol paper will provide a useful and practical model for conducting cross-sectional studies in hospitalized patients that cover a wide ranging of clinical and laboratory variables.

Acute Crises and Complications of Sickle Cell Anemia Among Patients Attending a Pediatric Tertiary Unit in Kinshasa, Democratic Republic Of Congo

In the Democratic Republic of Congo, the incidence of sickle cell anemia (SCA) is estimated to affect 30,000 to 40,000 neonates per year. However, there is paucity of data on acute clinical manifestations in sickle cell children. In these circumstances, it is difficult to develop a health care policy for an adequate management of sickle cell patients. This was a seven years’ retrospective study of children admitted with acute sickle cell crisis in the Department of Pediatrics in University Hospital of Kinshasa, Kinshasa, the Democratic Republic of Congo. A total of 108 patients were identified as having SCA. There were 56 (51%) girls and 52 (49%) boys. Median age was 10.5 years (range 1-24 years). No child was diagnosed by neonatal screening. The median age of diagnosis of sickle cell anemia was 90 months (range: 8-250 months). The median age at the first transfusion was 36 months (range 4-168). In this series, 61 (56.5%) patients were eligible for hydroxyurea. However, this treatment was only performed in 4 (6.6%) of them. Pain episodes, acute anemic crisis and severe infection represent respectively 38.2%, 34.3% and 21.9% of events. Altered sensorium and focal deficit were encountered occasionally and represented 3.4% of acute events. Acute renal manifestations, cholelithiasis and priapism were rarely reported, in this cohort. In Kinshasa, the care of patients suffering from sickle cell anemia is characterized by the delayed diagnosis and low detection of organ complications compared to reports of Western countries. This situation is due to resources deficiencies.

Characteristics, behaviors and association between Human African Trypanosomiasis and HIV seropositivity among volunteer blood donors in a semi-rural area: A survey from Kikwit, the Democratic Republic of Congo

Blood safety is a major element in the strategy to control the HIV epidemic. The aim of this study was to determine the prevalence and the associated factors of a positive HIV test among blood donors and its association between Human African Trypanosomiasis in Kikwit, the Democratic Republic of Congo. A cross-sectional study was conducted between November 2012 and May 2013. An anonymous questionnaire was designed to extract relevant data. The average mean age of participants was 30 years. The majority were man (67.8%). The overall prevalence of HIV, syphilis, hepatitis B, hepatitis C and human African trypanosomiasis was respectively 3.2%, 1.9%, 1.6%, 1.3% and 1.3%. Alcohol intake, casual unprotected sex, not using condoms during casual sex, sex after alcohol intake and seroprevalence of human African trypanosomiasis were significantly associated with a positive HIV test result ( p<0.05). In this study, sexual risk behaviors were the major risk factors associated with positive HIV tests in blood donors living in Kikwit. It is important to raise awareness about HIV and voluntary blood donation in response to some observations noted in this study such as the low educational level of the blood donors, the low level of knowledge of HIV prevention methods.

High rate of sickle cell anaemia in Sub-Saharan Africa underlines the need to screen all children with severe anaemia for the disease

AIM

Neonatal screening for sickle cell anaemia is not common practice in the Democratic Republic of Congo, and we determined the prevalence in children with unknown electrophoresis of haemoglobin and anaemia.

METHODS

A cross-sectional study was conducted in four hospitals in the country's capital Kinshasa.

RESULTS

We screened 807 patients with anaemia (Hb < 6 g/dL) for sickle cell disease. The overall mean age at presentation was 42.7 months ± 29.7 months, and most patients (76.3%) were less than five years of age, with a peak incidence at seven to 36 months of age (45%). The median age at the first transfusion was 29 months (range 4-159 months). Of these 807 children, 36 (4.5%) were homozygous for haemoglobin S disease and 45 (5.6%) were heterozygotes. The proportion of patients with homozygous sickle cell anaemia was slightly higher in children with a medical history of hand foot syndrome, in children who had received more than three transfusions and in children up to 36 months of age at their first transfusion.

CONCLUSION

The high prevalence of sickle cell anaemia in children in Sub-Saharan Africa underlines the need for neonatal screening or, if that is not possible, screening of all children with severe anaemia to identify patients with the disease and provide early management.

[Psychosocial impact of sickle cell disease in the parents of children living in Kinshasa, Democratic Republic of Congo: a qualitative study]

Introduction

L'insuffisance des moyens de base pour le dépistage et la prise en charge de la socioculturel Africain. D'où la nécessité de réaliser un travail de mise en sens du vécu et des émotions en vue d'information et de soutien psychologique des familles des drépanocytaires. Cette étude a eu pour objectif d'identifier la nature des répercussions psychosociales de la drépanocytose chez les parents et chez les malades.

Méthodes

Une approche qualitative a été utilisée. Des entretiens ont été menés auprès des parents et des patients drépanocytaires. Nos résultats ont fait l'objet d'une analyse thématique articulée sur les circonstances de découvertes de la maladie, les répercussions de la maladie et la perception de la prise en charge.

Résultats

Nos interviews ont montré des répercussions psychosociales importantes chez les parents d'enfants drépanocytaires et de stigmatisation des difficultés d'insertion sociale et scolaire pour les enfants drépanocytaires. Ces derniers sont les grands oubliés des récits de parents. La prise en charge est uniquement médicale avec des ressources très limitées et aucun accompagnement psychologique de la famille n'est assuré.

Conclusion

La prise en charge de cette maladie nécessite la mise en place d'une politique de prise en charge basée sur une approche globale de la maladie.

The interaction between sickle cell disease and HIV infection: a systematic review

Human immunodeficiency virus (HIV) and sickle cell disease (SCD) are regarded as endemic in overlapping geographic areas; however, for most countries only scarce data on the interaction between HIV and SCD and disease burden exist. HIV prevalence in SCD patients varies between 0% and 11.5% in published studies. SCD has been suggested to reduce disease progression of HIV into AIDS. Various interactions of antiretroviral therapy with SCD exist. Both SCD and HIV act as common risk factors for stroke, avascular necrosis, severe splenic dysfunction, pulmonary arterial hypertension, and sepsis, which may result in synergistic increase in risk of developing these diseases. No treatment guidelines regarding SCD with HIV coinfection were identified. Available evidence is mainly based on small clinical studies, thus making strong recommendations difficult. An increased effort to elucidate the precise interactions is warranted to better understand both diseases and effect more adequate treatment approaches, especially in view of their geographical coprevalence.

[Sickle cell disease in stationary phase in 6-59 months children in Lubumbashi: epidemiology and clinical features]

Introduction

Méthodes

Résultats

Conclusion

Malaria, clinical features and acute crisis in children suffering from sickle cell disease in resource-limited settings: a retrospective description of 90 cases

BACKGROUND

The prevalence of sickle cell disease (SCD) is extremely high in the Democratic Republic of Congo (DRC). Despite the high prevalence of this disease in our midst, there has been no report on the clinical features in the sickle cell pediatric population suffering from malaria in our midst.

METHODS

A retrospective survey of records from the Department of Paediatrics of the University Hospital of Kinshasa, Kinshasa, Democratic Republic of Congo, was done for the period 1998–2008. For the 10 years studied, 108 children with SCD were reviewed and the data of those who developed malaria during admission were retrieved and analyzed.

RESULTS

Of the 90 homozygous sickle cell children with malaria, fever, pallor, and jaundice were the commonly-found symptoms. Lethargy, severe anemia, respiratory distress, splenomegaly, hepatomegaly,digestive disorders, and prostration were common in children under 5 years, with significant difference (P, 0.05) to the older children. Transfusion because of to severe anemia was found necessary in 54.4% of cases. No case of cerebral malaria was found. Blackwater fever was a rare event. Hand–foot syndrome was present in 12.8% of patients, exclusively in those less than 5 years old. Pain crisis was associated in 46 cases (51.1%). Pain crisis was particularly present in SCD children less than 5 years of age (74.5% vs 25.6%, P , 0.001). No death was observed in this series.

CONCLUSION

We conclude that the acute crisis related to SCD is more common in children less than 5 years of age. High risk of a requirement for blood transfusion was found in young children. Anti-malarial prophylaxis is advocated in Kinshasa.

Sickle cell disease: new opportunities and challenges in Africa

Sickle cell disease (SCD) is one of the most common genetic causes of illness and death in the world. This is a review of SCD in Africa, which bears the highest burden of disease. The first section provides an introduction to the molecular basis of SCD and the pathophysiological mechanism of selected clinical events. The second section discusses the epidemiology of the disease (prevalence, morbidity, and mortality), at global level and within Africa. The third section discusses the laboratory diagnosis and management of SCD, emphasizing strategies that been have proven to be effective in areas with limited resources. Throughout the review, specific activities that require evidence to guide healthcare in Africa, as well as strategic areas for further research, will be highlighted.

Prevalence and risk factors for hepatitis C virus, hepatitis B virus, and human immunodeficiency virus in transfused children in Kinshasa

OBJECTIVE

To determine seroprevalence of hepatitis C virus (HCV), human immunodeficiency virus (HIV), and hepatitis B virus (HBV) and associated factors among transfused children.

METHODS

A multicenter cross-sectional study of transfused children aged between 18 mo and 13 y old was conducted in 4 hospitals in Kinshasa. Blood samples were collected for the detection of Hepatitis B surface antigen (HBsAg) and antibodies to HCV, HIV 1 and 2.

RESULTS

A total of 177 (47.7 %) boys and 194 (52.3 %) girls participated in the study. The median age was 59.5 mo (Interquartile range IQR = 60.6). The prevalence rates of HCV, HBV, and HIV infection were 13.5 %, 1.6 %, and 1.3 %, respectively. Frequency of transfusion events were significantly associated with HCV (p < 0.001) and HIV (p < 0.05) infections.

CONCLUSIONS

HCV infection was by far more frequently identified than HBV and HIV infections among Congolese transfused children. Frequency of transfusion events was the only significant risk factor associated with HCV and HIV infections but not for HBV.

Mortality in sickle cell anemia in Africa: a prospective cohort study in Tanzania

BACKGROUND

The World Health Organization has declared Sickle Cell Anemia (SCA) a public health priority. There are 300,000 births/year, over 75% in Africa, with estimates suggesting that 6 million Africans will be living with SCA if average survival reaches half the African norm. Countries such as United States of America and United Kingdom have reduced SCA mortality from 3 to 0.13 per 100 person years of observation (PYO), with interventions such as newborn screening, prevention of infections and comprehensive care, but implementation of interventions in African countries has been hindered by lack of locally appropriate information. The objective of this study was to determine the incidence and factors associated with death from SCA in Dar-es-Salaam.

METHODS AND FINDINGS

A hospital-based cohort study was conducted, with prospective surveillance of 1,725 SCA patients recruited from 2004 to 2009, with 209 (12%) lost to follow up, while 86 died. The mortality rate was 1.9 (95%CI 1.5, 2.9) per 100 PYO, highest under 5-years old [7.3 (4.8-11.0)], adjusting for dates of birth and study enrollment. Independent risk factors, at enrollment to the cohort, predicting death were low hemoglobin (<5 g/dL) [3.8 (1.8-8.2); p = 0.001] and high total bilirubin (≥102 µmol/L) [1.7 (1.0-2.9); p = 0.044] as determined by logistic regression.

CONCLUSIONS

Mortality in SCA in Africa is high, with the most vulnerable period being under 5-years old. This is most likely an underestimate, as this was a hospital cohort and may not have captured SCA individuals with severe disease who died in early childhood, those with mild disease who are undiagnosed or do not utilize services at health facilities. Prompt and effective treatment for anemia in SCA is recommended as it is likely to improve survival. Further research is required to determine the etiology, pathophysiology and the most appropriate strategies for management of anemia in SCA.