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Runge A, Brazel D, Pakbaz Z. Stroke in sickle cell disease and the promise of recent disease modifying agents. J Neurol Sci 2022; 442:120412. [PMID: 36150233 DOI: 10.1016/j.jns.2022.120412] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 09/01/2022] [Accepted: 09/04/2022] [Indexed: 10/31/2022]
Abstract
Sickle cell disease (SCD) is an inherited hemoglobinopathy affecting approximately 100,000 individuals in the United States. Cerebrovascular disease is among the most common and debilitating complications of SCA, with 53% experiencing silent cerebral infarct by age 30 and 3.8% experiencing overt stroke by age 40 years. This review highlights the burden of cerebrovascular disease in SCD, including both stroke and silent cerebral infarct (SCI). We then discuss the pathophysiology of stroke and cerebral fat embolism in the absence of a patent foramen ovale. This review also reveals that options for primary and secondary stroke prevention in SCD are still limited to hydroxyurea and blood transfusion, and that the role of aspirin and anticoagulation in SCD stroke has not been adequately studied. Limited data suggest that the novel disease-modifying agents for SCD management may improve renal dysfunction, leg ulcers, and lower the abnormally high TCD flow velocity. Further research is urgently needed to investigate their role in stroke prevention in SCD, as these novel agents target the main stroke contributors in SCD - hemolysis and vaso-occlusion. This literature review also explores the role of healthcare disparities in slowing progress in SCD management and research in the United States, highlighting the need for more investment in patient and clinician education, SCD management, and research.
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Affiliation(s)
- Ava Runge
- University of California Irvine School of Medicine, CA, USA
| | - Danielle Brazel
- University of California Irvine Medical Center, Department of Medicine, Orange California, CA, USA
| | - Zahra Pakbaz
- University of California Irvine School of Medicine, CA, USA; University of California Irvine Medical Center, Department of Medicine, Orange California, CA, USA; University of California Irvine Medical Center, Division of Hematology Oncology, CA, USA.
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2
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Abstract
Sickle cell disease (SCD) is characterized by variable clinical outcomes, with some patients suffering life-threatening complications during childhood, and others living relatively symptom-free into old age. Because of this variability, there is an important potential role for precision medicine, in which particular different treatments are selected for different groups of patients. However, the application of precision medicine in SCD is limited by difficulties in identifying different prognostic groups and the small number of available treatments. The main genetic determinant of outcomes in SCD is the underlying β-globin genotype, with sickle cell anemia (HbSS) and hemoglobin SC disease (HbSC) forming the 2 major forms of the disease in most populations of African origin. Although there are clear differences in clinical outcomes between these conditions, treatments approaches are very similar, with little evidence on how to treat HbSC in particular. Other genomic information, such as the co-inheritance of α-thalassemia, or high fetal hemoglobin (HbF) levels, is of some prognostic value but insufficient to determine treatments. Precision medicine is further limited by the fact that the 2 main drugs used in SCD, penicillin and hydroxyurea, are currently recommended for all patients. Newer treatments, such as crizanlizumab and voxelotor, raise the possibility that groups will emerge who respond best to particular drugs or combinations. Perhaps the best current example of precision medicine in SCD is the selective use of blood transfusions as primary stroke prevention in children with evidence of cerebral vasculopathy. More precise treatments may emerge as we understand more about the pathology of SCD, including problems with erythropoiesis.
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Insights into determinants of spleen injury in sickle cell anemia. Blood Adv 2020; 3:2328-2336. [PMID: 31391165 DOI: 10.1182/bloodadvances.2019000106] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 05/23/2019] [Indexed: 11/20/2022] Open
Abstract
Spleen dysfunction is central to morbidity and mortality in children with sickle cell anemia (SCA). The initiation and determinants of spleen injury, including acute splenic sequestration (ASS) have not been established. We investigated splenic function longitudinally in a cohort of 57 infants with SCA enrolled at 3 to 6 months of age and followed up to 24 months of age and explored the respective contribution of decreased red blood cell (RBC) deformability and increased RBC adhesion on splenic injury, including ASS. Spleen function was evaluated by sequential 99mTc heated RBC spleen scintigraphy and high-throughput quantification of RBCs with Howell-Jolly bodies (HJBs). At 6 and 18 months of age, spleen filtration function was decreased in 32% and 50% of infants, respectively, whereas the median %HJB-RBCs rose significantly (from 0.3% to 0.74%). An excellent correlation was established between %HJB-RBCs and spleen scintigraphy results. RBC adhesion to laminin and endothelial cells increased with time. Adhesion to endothelial cells negatively correlated with splenic function. Irreversibly sickled cells (ISCs), used as a surrogate marker of impaired deformability, were detected at enrollment and increased significantly at 18 months. %ISCs correlated positively with %HJB-RBCs and negatively with splenic uptake, indicating a relationship between their presence in the circulation and spleen dysfunction. In the subgroup of 8 infants who subsequently experienced ASS, %ISCs at enrollment were significantly higher compared with the asymptomatic group, suggesting a major role of impaired deformability in ASS. Higher levels of %HJB-RBCs were observed after the occurrence of ASS, demonstrating its negative impact on splenic function.
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Brousse V, El Hoss S, Bouazza N, Arnaud C, Bernaudin F, Pellegrino B, Guitton C, Odièvre-Montanié MH, Mames D, Brouzes C, Picard V, Nguyen-Khoa T, Pereira C, Lapouméroulie C, Pissard S, Gardner K, Menzel S, Le Van Kim C, Colin-Aronovicz Y, Buffet P, Mohandas N, Elie C, Maier-Redelsperger M, El Nemer W, de Montalembert M. Prognostic factors of disease severity in infants with sickle cell anemia: A comprehensive longitudinal cohort study. Am J Hematol 2018; 93:1411-1419. [PMID: 30132969 DOI: 10.1002/ajh.25260] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 08/15/2018] [Indexed: 12/31/2022]
Abstract
In order to identify very early prognostic factors that can provide insights into subsequent clinical complications, we performed a comprehensive longitudinal multi-center cohort study on 57 infants with sickle cell anemia (55 SS; 2 Sβ°) during the first 2 years of life (ClinicalTrials.gov: NCT01207037). Time to first occurrence of a severe clinical event-acute splenic sequestration (ASS), vaso-occlusive (VOC) event requiring hospitalization, transfusion requirement, conditional/ abnormal cerebral velocities, or death-was used as a composite endpoint. Infants were recruited at a mean age of 4.4 ±1 months. Median follow-up was 19.4 months. During the study period, 38.6% of infants experienced ≥1 severe event: 14% ASS, 22.8% ≥ 1 VOC (median age: 13.4 and 12.8 months, respectively) and 33.3% required transfusion. Of note, 77% of the cohort was hospitalized, with febrile illness being the leading cause for admission. Univariate analysis of various biomarkers measured at enrollment showed that fetal hemoglobin (HbF) was the strongest prognostic factor of subsequent severe outcome. Other biomarkers measured at enrolment including absolute neutrophil or reticulocyte counts, expression of erythroid adhesion markers, % of dense red cells, cellular deformability or ϒ-globin genetic variants, failed to be associated with severe clinical outcome. Multivariate analysis demonstrated that higher Hb concentration and HbF level are two independent protective factors (adjusted HRs (95% CI) 0.27 (0.11-0.73) and 0.16 (0.06-0.43), respectively). These findings imply that early measurement of HbF and Hb levels can identify infants at high risk for subsequent severe complications, who might maximally benefit from early disease modifying treatments.
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Affiliation(s)
- Valentine Brousse
- Service de Pédiatrie et Maladies Infectieuses; Hôpital Universitaire Necker-Enfants Malades; Paris France
- UMR_S 1134 Biologie Intégrée du Globule Rouge; Université Sorbonne Paris Cité/Université Paris Diderot/INSERM/INTS/Laboratoire d'Excellence GR-Ex; Paris France
| | - Sara El Hoss
- UMR_S 1134 Biologie Intégrée du Globule Rouge; Université Sorbonne Paris Cité/Université Paris Diderot/INSERM/INTS/Laboratoire d'Excellence GR-Ex; Paris France
| | - Naïm Bouazza
- Unité de Recherche Clinique/Centre d'investigation clinique Paris Descartes Necker-Cochin; Assistance Publique-Hôpitaux de Paris; Paris France
- Université Paris Descartes; EA7323, Sorbonne Paris Cité; Paris France
| | - Cécile Arnaud
- Service de Pédiatrie; Centre Hospitalier Intercommunal de Créteil; Créteil France
| | - Francoise Bernaudin
- Service de Pédiatrie; Centre Hospitalier Intercommunal de Créteil; Créteil France
| | - Béatrice Pellegrino
- Service de Pediatrie; Centre Hospitalier Poissy-Saint Germain; Poissy France
| | - Corinne Guitton
- Service de Pédiatrie, Hôpital Universitaire Kremlin-Bicêtre; Le Kremlin Bicêtre France
| | | | - David Mames
- Laboratoire d'Hématologie; Hôpital Universitaire Tenon; Paris France
| | - Chantal Brouzes
- Laboratoires d'Hématologie et de Biochimie; Hôpital Universitaire Necker-Enfants Malades; Paris France
| | - Véronique Picard
- Laboratoire d'Hématologie; Hôpital Universitaire Kremlin Bicêtre; Le Kremlin Bicêtre France
| | - Thao Nguyen-Khoa
- Laboratoires d'Hématologie et de Biochimie; Hôpital Universitaire Necker-Enfants Malades; Paris France
| | - Catia Pereira
- UMR_S 1134 Biologie Intégrée du Globule Rouge; Université Sorbonne Paris Cité/Université Paris Diderot/INSERM/INTS/Laboratoire d'Excellence GR-Ex; Paris France
| | - Claudine Lapouméroulie
- UMR_S 1134 Biologie Intégrée du Globule Rouge; Université Sorbonne Paris Cité/Université Paris Diderot/INSERM/INTS/Laboratoire d'Excellence GR-Ex; Paris France
| | - Serge Pissard
- Laboratoire de Biochimie Génétique; Hôpital Universitaire Henri Mondor; Créteil France
| | - Kate Gardner
- King's College London; Division of Cancer Studies; London UK
- King's College Hospital NHS Foundation Trust; London UK
| | - Stephan Menzel
- King's College London; Division of Cancer Studies; London UK
| | - Caroline Le Van Kim
- UMR_S 1134 Biologie Intégrée du Globule Rouge; Université Sorbonne Paris Cité/Université Paris Diderot/INSERM/INTS/Laboratoire d'Excellence GR-Ex; Paris France
| | - Yves Colin-Aronovicz
- UMR_S 1134 Biologie Intégrée du Globule Rouge; Université Sorbonne Paris Cité/Université Paris Diderot/INSERM/INTS/Laboratoire d'Excellence GR-Ex; Paris France
| | - Pierre Buffet
- UMR_S 1134 Biologie Intégrée du Globule Rouge; Université Sorbonne Paris Cité/Université Paris Diderot/INSERM/INTS/Laboratoire d'Excellence GR-Ex; Paris France
| | - Narla Mohandas
- Red Cell Physiology Laboratory; New York Blood Center; New York New York
| | - Caroline Elie
- Unité de Recherche Clinique/Centre d'investigation clinique Paris Descartes Necker-Cochin; Assistance Publique-Hôpitaux de Paris; Paris France
| | | | - Wassim El Nemer
- UMR_S 1134 Biologie Intégrée du Globule Rouge; Université Sorbonne Paris Cité/Université Paris Diderot/INSERM/INTS/Laboratoire d'Excellence GR-Ex; Paris France
| | - Mariane de Montalembert
- Service de Pédiatrie et Maladies Infectieuses; Hôpital Universitaire Necker-Enfants Malades; Paris France
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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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Shores DR, Everett AD. Children as Biomarker Orphans: Progress in the Field of Pediatric Biomarkers. J Pediatr 2018; 193:14-20.e31. [PMID: 29031860 PMCID: PMC5794519 DOI: 10.1016/j.jpeds.2017.08.077] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/04/2017] [Accepted: 08/30/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Darla R Shores
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD.
| | - Allen D Everett
- Division of Cardiology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
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Chaudhari H, Goyal S, Patil C. Neonates with sickle cell disease are vulnerable to blue light phototherapy-induced oxidative stress and proinflammatory cytokine elevations. Med Hypotheses 2016; 96:78-82. [PMID: 27959283 DOI: 10.1016/j.mehy.2016.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 09/27/2016] [Indexed: 11/24/2022]
Abstract
Sickle cell disease is a frequent genetic anomaly characterized by altered molecular structure of hemoglobin resulting into crescent-like deformation of the red blood corpuscles. Neonatal jaundice is a frequent co-morbidity in sickle cell disease. Phototherapy induces isomerization of bilirubin rendering it extractable through urine and hence it is used as a routine treatment of neonatal jaundice. An exposure to light phototherapy as a treatment of neonatal jaundice induces oxidative stress. It is hypothesized that such exposure of neonates with sickle cell disease to the blue light phototherapy as a treatment of neonatal jaundice induces severe oxidative stress and increases the levels of proinflammatory cytokines. This hypothesis is supported with two case studies of sickle cell disease suffering neonates who were exposed to blue light phototherapy to treat jaundice. In both these cases, exposure to phototherapy induced oxidative stress (increased lipid peroxidation and superoxide dismutase, slight change in activity of catalase and GSH) and elevated the levels of proinflammatory cytokine (TNFα, IL-1, and IL-6) in the sickle cell disease suffering neonates. These observations warrant further investigations to determine the consequences and clinical significance of the blue phototherapy-induced oxidative and proinflammatory stress in Sickle cell disease suffering neonates exposed to phototherapy as a treatment of jaundice.
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Affiliation(s)
- Hemakshi Chaudhari
- Department of Clinical Pharmacy, R. C. Patel Institute of Pharmaceutical Education and Research, Shirpur, Dist - Dhulia, Maharashtra, India
| | - Sameer Goyal
- Department of Pharmacology, R. C. Patel Institute of Pharmaceutical Education and Research, Shirpur, Dist- Dhulia, Maharashtra, India
| | - Chandragouda Patil
- Department of Pharmacology, R. C. Patel Institute of Pharmaceutical Education and Research, Shirpur, Dist- Dhulia, Maharashtra, India.
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8
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Conran N. High Foetal Haemoglobin in Sickle Cell Disease: Not so Protective? EBioMedicine 2015; 2:102-3. [PMID: 26137548 PMCID: PMC4485491 DOI: 10.1016/j.ebiom.2015.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 01/13/2015] [Indexed: 11/01/2022] Open
Affiliation(s)
- Nicola Conran
- INCT de Sangue, Hematology Center, School of Medicine, University of Campinas - UNICAMP, Campinas, Sao Paulo, Brazil
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