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Casella JF, Furstenau DK, Adams RJ, Brambilla DJ, Lebensburger JD, Fehr JJ, Jordan LC, King AA, Ichord RN, McKinstry RC, Kraut MA, Shaw DW, White DA, Whyte-Stewart DA, Avadhani R, Barron-Casella EA, Cannon AD, Eaton CK, Riekert KA, Shay JE, Smith-Seidel CA, Weiss DC, Ostapkovich ND, Vermillion K, Treine KE, Kingsbury CE, Strouse JJ, Thompson RE, Hanley DF. Hydroxyurea to prevent brain injury in children with sickle cell disease (HU Prevent)-A randomized, placebo-controlled phase II feasibility/pilot study. Am J Hematol 2024. [PMID: 38953438 DOI: 10.1002/ajh.27423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/17/2024] [Accepted: 06/15/2024] [Indexed: 07/04/2024]
Abstract
Central nervous system (CNS) injury is common in sickle cell disease (SCD) and occurs early in life. Hydroxyurea is safe and efficacious for treatment of SCD, but high-quality evidence from randomized trials to estimate its neuroprotective effect is scant. HU Prevent was a randomized (1:1), double-blind, phase II feasibility/pilot trial of dose-escalated hydroxyurea vs. placebo for the primary prevention of CNS injury in children with HbSS or HbS-β0-thalassemia subtypes of SCD age 12-48 months with normal neurological examination, MRI of the brain, and cerebral blood flow velocity. We hypothesized that hydroxyurea would reduce by 50% the incidence of CNS injury. Two outcomes were compared: primary-a composite of silent cerebral infarction, elevated cerebral blood flow velocity, transient ischemic attack, or stroke; secondary-a weighted score estimating the risk of suffering the consequences of stroke (the Stroke Consequences Risk Score-SCRS), based on the same outcome events. Six participants were randomized to each group. One participant in the hydroxyurea group had a primary outcome vs. four in the placebo group (incidence rate ratio [90% CI] 0.216 [0.009, 1.66], p = .2914) (~80% reduction in the hydroxyurea group). The mean SCRS score was 0.078 (SD 0.174) in the hydroxyurea group, 0.312 (SD 0.174) in the placebo group, p = .072, below the p-value of .10 often used to justify subsequent phase III investigations. Serious adverse events related to study procedures occurred in 3/41 MRIs performed, all related to sedation. These results suggest that hydroxyurea may have profound neuroprotective effect in children with SCD and support a definitive phase III study to encourage the early use of hydroxyurea in all infants with SCD.
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Affiliation(s)
- James F Casella
- Department of Pediatrics, Division of Hematology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dana K Furstenau
- Department of Pediatrics, Division of Hematology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robert J Adams
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Donald J Brambilla
- Research Triangle Institute (RTI) International, Rockville, Maryland, USA
| | - Jeffrey D Lebensburger
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James J Fehr
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Lori C Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Allison A King
- Division of Pediatric Hematology/Oncology, Washington University and St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Rebecca N Ichord
- Department of Neurology and Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert C McKinstry
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael A Kraut
- Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dennis W Shaw
- Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Desiree A White
- Department of Psychological Brain Sciences, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Donna A Whyte-Stewart
- Division of Nonmalignant Hematology, Food and Drug Administration (FDA), Silver Spring, Maryland, USA
| | - Radhika Avadhani
- Department of Neurology and Neurosurgery, BIOS Clinical Trials Coordinating Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emily A Barron-Casella
- Department of Pediatrics, Division of Hematology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alicia D Cannon
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Cyd K Eaton
- Biostatistics, Epidemiology, and Data Management Core, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Kristin A Riekert
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joanne E Shay
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Cynthia A Smith-Seidel
- Department of Psychology, Martinsburg Veterans Affairs Medical Center (VAMC), Martinsburg, West Virginia, USA
| | - Diane C Weiss
- Department of Pediatrics, Division of Hematology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Noeleen D Ostapkovich
- Department of Neurology and Neurosurgery, BIOS Clinical Trials Coordinating Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Krista Vermillion
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kevin E Treine
- Department of Neurology and Neurosurgery, BIOS Clinical Trials Coordinating Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Claire E Kingsbury
- Department of Pediatrics, Division of Hematology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - John J Strouse
- Department of Medicine and Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Richard E Thompson
- Department of Biostatistics, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Daniel F Hanley
- Department of Neurology and Neurosurgery, BIOS Clinical Trials Coordinating Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Brothers RO, Turrentine KB, Akbar M, Triplett S, Zhao H, Urner TM, Goldman-Yassen A, Jones RA, Knight-Scott J, Milla SS, Bai S, Tang A, Brown RC, Buckley EM. The influence of voxelotor on cerebral blood flow and oxygen extraction in pediatric sickle cell disease. Blood 2024; 143:2145-2151. [PMID: 38364110 DOI: 10.1182/blood.2023022011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 01/23/2024] [Accepted: 02/01/2024] [Indexed: 02/18/2024] Open
Abstract
ABSTRACT Voxelotor is an inhibitor of sickle hemoglobin polymerization that is used to treat sickle cell disease. Although voxelotor has been shown to improve anemia, the clinical benefit on the brain remains to be determined. This study quantified the cerebral hemodynamic effects of voxelotor in children with sickle cell anemia (SCA) using noninvasive diffuse optical spectroscopies. Specifically, frequency-domain near-infrared spectroscopy combined with diffuse correlation spectroscopy were used to noninvasively assess regional oxygen extraction fraction (OEF), cerebral blood volume, and an index of cerebral blood flow (CBFi). Estimates of CBFi were first validated against arterial spin-labeled magnetic resonance imaging (ASL-MRI) in 8 children with SCA aged 8 to 18 years. CBFi was significantly positively correlated with ASL-MRI-measured blood flow (R2 = 0.651; P = .015). Next, a single-center, open-label pilot study was completed in 8 children with SCA aged 4 to 17 years on voxelotor, monitored before treatment initiation and at 4, 8, and 12 weeks (NCT05018728). By 4 weeks, both OEF and CBFi significantly decreased, and these decreases persisted to 12 weeks (both P < .05). Decreases in CBFi were significantly correlated with increases in blood hemoglobin (Hb) concentration (P = .025), whereas the correlation between decreases in OEF and increases in Hb trended toward significance (P = .12). Given that previous work has shown that oxygen extraction and blood flow are elevated in pediatric SCA compared with controls, these results suggest that voxelotor may reduce cerebral hemodynamic impairments. This trial was registered at www.ClinicalTrials.gov as #NCT05018728.
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Affiliation(s)
- Rowan O Brothers
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA
| | - Katherine B Turrentine
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA
| | - Mariam Akbar
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA
| | - Sydney Triplett
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA
| | - Hongting Zhao
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA
| | - Tara M Urner
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA
| | - Adam Goldman-Yassen
- Department of Radiology and Imaging Sciences, Children's Healthcare of Atlanta and Emory University, Atlanta, GA
| | - Richard A Jones
- Department of Radiology, Children's Healthcare of Atlanta, Atlanta, GA
| | - Jack Knight-Scott
- Department of Radiology, Children's Healthcare of Atlanta, Atlanta, GA
| | - Sarah S Milla
- Department of Pediatric Radiology, Children's Hospital Colorado, Aurora, CO
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Shasha Bai
- Pediatric Biostatistics Core, Emory University School of Medicine, Atlanta, GA
| | - Amy Tang
- Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, GA
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - R Clark Brown
- Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, GA
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Erin M Buckley
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
- Children's Research Scholar, Children's Healthcare of Atlanta, Atlanta, GA
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de Castro JNP, da Silva Costa SM, Camargo ACL, Ito MT, de Souza BB, de Haidar E Bertozzo V, Rodrigues TAR, Lanaro C, de Albuquerque DM, Saez RC, Saad STO, Ozelo MC, Cendes F, Costa FF, de Melo MB. Comparative transcriptomic analysis of circulating endothelial cells in sickle cell stroke. Ann Hematol 2024; 103:1167-1179. [PMID: 38386032 DOI: 10.1007/s00277-024-05655-6] [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: 10/11/2023] [Accepted: 02/08/2024] [Indexed: 02/23/2024]
Abstract
Ischemic stroke (IS) is one of the most impairing complications of sickle cell anemia (SCA), responsible for 20% of mortality in patients. Rheological alterations, adhesive properties of sickle reticulocytes, leukocyte adhesion, inflammation and endothelial dysfunction are related to the vasculopathy observed prior to ischemic events. The role of the vascular endothelium in this complex cascade of mechanisms is emphasized, as well as in the process of ischemia-induced repair and neovascularization. The aim of the present study was to perform a comparative transcriptomic analysis of endothelial colony-forming cells (ECFCs) from SCA patients with and without IS. Next, to gain further insights of the biological relevance of differentially expressed genes (DEGs), functional enrichment analysis, protein-protein interaction network (PPI) construction and in silico prediction of regulatory factors were performed. Among the 2469 DEGs, genes related to cell proliferation (AKT1, E2F1, CDCA5, EGFL7), migration (AKT1, HRAS), angiogenesis (AKT1, EGFL7) and defense response pathways (HRAS, IRF3, TGFB1), important endothelial cell molecular mechanisms in post ischemia repair were identified. Despite the severity of IS in SCA, widely accepted molecular targets are still lacking, especially related to stroke outcome. The comparative analysis of the gene expression profile of ECFCs from IS patients versus controls seems to indicate that there is a persistent angiogenic process even after a long time this complication has occurred. Thus, this is an original study which may lead to new insights into the molecular basis of SCA stroke and contribute to a better understanding of the role of endothelial cells in stroke recovery.
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Affiliation(s)
- Júlia Nicoliello Pereira de Castro
- Laboratory of Human Genetics, Center for Molecular Biology and Genetic Engineering-CBMEG, Universidade Estadual de Campinas-UNICAMP, Campinas, São Paulo, 13083-875, Brazil
| | - Sueli Matilde da Silva Costa
- Laboratory of Human Genetics, Center for Molecular Biology and Genetic Engineering-CBMEG, Universidade Estadual de Campinas-UNICAMP, Campinas, São Paulo, 13083-875, Brazil
| | - Ana Carolina Lima Camargo
- Laboratory of Human Genetics, Center for Molecular Biology and Genetic Engineering-CBMEG, Universidade Estadual de Campinas-UNICAMP, Campinas, São Paulo, 13083-875, Brazil
| | - Mirta Tomie Ito
- Laboratory of Human Genetics, Center for Molecular Biology and Genetic Engineering-CBMEG, Universidade Estadual de Campinas-UNICAMP, Campinas, São Paulo, 13083-875, Brazil
| | - Bruno Batista de Souza
- Laboratory of Human Genetics, Center for Molecular Biology and Genetic Engineering-CBMEG, Universidade Estadual de Campinas-UNICAMP, Campinas, São Paulo, 13083-875, Brazil
| | - Victor de Haidar E Bertozzo
- Laboratory of Human Genetics, Center for Molecular Biology and Genetic Engineering-CBMEG, Universidade Estadual de Campinas-UNICAMP, Campinas, São Paulo, 13083-875, Brazil
| | - Thiago Adalton Rosa Rodrigues
- Laboratory of Human Genetics, Center for Molecular Biology and Genetic Engineering-CBMEG, Universidade Estadual de Campinas-UNICAMP, Campinas, São Paulo, 13083-875, Brazil
| | - Carolina Lanaro
- Hematology and Hemotherapy Center, Universidade Estadual de Campinas-UNICAMP, Campinas, São Paulo, Brazil
| | | | - Roberta Casagrande Saez
- Hematology and Hemotherapy Center, Universidade Estadual de Campinas-UNICAMP, Campinas, São Paulo, Brazil
| | - Sara Teresinha Olalla Saad
- Hematology and Hemotherapy Center, Universidade Estadual de Campinas-UNICAMP, Campinas, São Paulo, Brazil
| | - Margareth Castro Ozelo
- Hematology and Hemotherapy Center, Universidade Estadual de Campinas-UNICAMP, Campinas, São Paulo, Brazil
| | - Fernando Cendes
- Neuroimaging Laboratory, Department of Neurology, Universidade Estadual de Campinas-UNICAMP, Campinas, São Paulo, Brazil
| | - Fernando Ferreira Costa
- Hematology and Hemotherapy Center, Universidade Estadual de Campinas-UNICAMP, Campinas, São Paulo, Brazil
| | - Mônica Barbosa de Melo
- Laboratory of Human Genetics, Center for Molecular Biology and Genetic Engineering-CBMEG, Universidade Estadual de Campinas-UNICAMP, Campinas, São Paulo, 13083-875, Brazil.
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Light J, Boucher M, Baskin-Miller J, Winstead M. Managing the Cerebrovascular Complications of Sickle Cell Disease: Current Perspectives. J Blood Med 2023; 14:279-293. [PMID: 37082003 PMCID: PMC10112470 DOI: 10.2147/jbm.s383472] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/31/2023] [Indexed: 04/22/2023] Open
Abstract
The importance of protecting brain function for people with sickle cell disease (SCD) cannot be overstated. SCD is associated with multiple cerebrovascular complications that threaten neurocognitive function and life. Without screening and preventive management, 11% of children at 24% of adults with SCD have ischemic or hemorrhagic strokes. Stroke screening in children with SCD is well-established using transcranial Doppler ultrasound (TCD). TCD velocities above 200 cm/s significantly increase the risk of stroke, which can be prevented using chronic red blood cell (RBC) transfusion. RBC transfusion is also the cornerstone of acute stroke management and secondary stroke prevention. Chronic transfusion requires long-term management of complications like iron overload. Hydroxyurea can replace chronic transfusions for primary stroke prevention in a select group of patients or in populations where chronic transfusions are not feasible. Silent cerebral infarction (SCI) is even more common than stroke, affecting 39% of children and more than 50% of adults with SCD; management of SCI is individualized and includes careful neurocognitive evaluation. Hematopoietic stem cell transplant prevents cerebrovascular complications, despite the short- and long-term risks. Newer disease-modifying agents like voxelotor and crizanlizumab, as well as gene therapy, may treat cerebrovascular complications, but these approaches are investigational.
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Affiliation(s)
- Jennifer Light
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maria Boucher
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jacquelyn Baskin-Miller
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mike Winstead
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Correspondence: Mike Winstead, Division of Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC, USA, Tel +1 919-966-1178, Fax +1 919-966-7629, Email
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