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Nwosu CS, Nri-Ezedi CA, Okechukwu C, Ulasi TO, Umeh EO, Ebubedike UR, Aronu ME, Obi-Nwosu AL, Odita AO, Agu NV, Ngonadi SC, Emedike NC, Uke KM, Emegoakor AC. Two-Dimensional Ultrasound Assessment of Long-Term Intra-Abdominal Organ Changes in Children with Sickle Cell Anemia during Steady State: A Comparative Study. Niger J Clin Pract 2023; 26:1861-1867. [PMID: 38158354 DOI: 10.4103/njcp.njcp_411_23] [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: 05/30/2023] [Accepted: 09/18/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Sickle cell anemia (SCA) is a hereditary blood disorder with global prevalence, including in Nigeria. Despite advancements in SCA care management, understanding the long-term impact on organs during steady state has remained inconclusive. AIM This study aimed to investigate the long-term changes in intra-abdominal organs of SCA children compared with non-SCA children during steady state using two-dimensional ultrasound assessment. MATERIALS AND METHODS A total of 116 children (58 SCA and 58 controls) were enrolled between June 2021 and July 2022. Clinico-demographic data were collected through an interviewer-administered questionnaire. Two-dimensional ultrasound was used to measure the liver, spleen, kidneys, and inferior vena cava in all subjects. Age-matched controls had AA or AS genotypes. RESULTS Of the 58 patients with SCA, 65.5% were males with an overall mean age of 8.1 ± 3.4 years, while among the non-SCA cohort (n = 58), 48.3% were males with an overall mean age of 8.7 ± 3.9 years. There was no statistically significant difference in the age and gender distribution between the SCA and non-SCA cohorts (P = 0.390 and P = 0.091, respectively). SCA subjects had a larger mean hepatic size than non-SCA subjects (12.09 cm ± 2.23 vs. 11.67 cm ± 1.96; P = 0.276) but smaller mean splenic size (8.01 cm ± 1.89 vs. 8.19 cm ± 1.61; P = 0.577) and inferior vena cava diameter (1.16 cm ± 0.29 vs. 1.25 cm ± 0.33; P = 0.100). Left kidney length and breadth were significantly greater in SCA patients (8.91 ± 1.16 vs. 8.27 ± 1.30; P = 0.006 and 4.15 ± 0.92 vs. 3.79 ± 0.48; P = 0.008, respectively). CONCLUSION This study highlights the utility of two-dimensional ultrasound assessment in monitoring intra-abdominal organ changes in SCA children, suggesting its cost-effective benefits in monitoring health outcomes in SCA patients.
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Affiliation(s)
- C S Nwosu
- Department of Radiology, Faculty of Medicine, Nnamdi Azikiwe University Awka, Anambra State, Nigeria
| | - C A Nri-Ezedi
- Department of Paediatrics, Faculty of Medicine, Nnamdi Azikiwe University Awka, Anambra State, Nigeria
| | - C Okechukwu
- Department of Paediatrics and Child Health, Rivers State University Teaching Hospital, Port-Harcourt, Rivers State, Nigeria
| | - T O Ulasi
- Department of Paediatrics, Faculty of Medicine, Nnamdi Azikiwe University Awka, Anambra State, Nigeria
| | - E O Umeh
- Department of Radiology, Faculty of Medicine, Nnamdi Azikiwe University Awka, Anambra State, Nigeria
| | - U R Ebubedike
- Department of Radiology, Faculty of Medicine, Nnamdi Azikiwe University Awka, Anambra State, Nigeria
| | - M E Aronu
- Department of Radiology, Faculty of Medicine, Nnamdi Azikiwe University Awka, Anambra State, Nigeria
| | - A L Obi-Nwosu
- Department of Family Medicine, Faculty of Medicine, Nnamdi Azikiwe University Awka, Anambra State, Nigeria
| | - A O Odita
- Department of Paediatrics, Faculty of Medicine, Nnamdi Azikiwe University Awka, Anambra State, Nigeria
| | - N V Agu
- Department of Paediatrics, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - S C Ngonadi
- Department of Paediatrics, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - N C Emedike
- Department of Radiology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - K M Uke
- Department of Radiology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - A C Emegoakor
- Department of Radiology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
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2
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Farris N, Benoit SW, McNinch NL, Bodas P. Urinary Biomarkers for the Assessment of Acute Kidney Injury of Pediatric Sickle Cell Anemia Patients Admitted for Severe Vaso-occlusive Crises. J Pediatr Hematol Oncol 2023; 45:309-314. [PMID: 36898013 DOI: 10.1097/mph.0000000000002642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/20/2022] [Indexed: 03/12/2023]
Abstract
Sickle cell nephropathy is a progressive morbidity, beginning in childhood, which is incompletely understood partially due to insensitive measures. We performed a prospective pilot study of pediatric and young adult patients with sickle cell anemia (SCA) to assess urinary biomarkers during acute pain crises. Four biomarkers were analyzed with elevations potentially suggesting acute kidney injury: (1) neutrophil gelatinase-associated lipocalin (NGAL), (2) kidney injury molecule-1, (3) albumin, and (4) nephrin. Fourteen unique patients were admitted for severe pain crises and were found to be representative of a larger SCA population. Urine samples were collected at the time of admission, during admission, and at follow-up after discharge. Exploratory analyses compared cohort values to the best available population values; individuals were also compared against themselves at various time points. Albumin was found to be moderately elevated for an individual during admission compared with follow-up ( P = 0.006, Hedge g : 0.67). Albumin was not found to be elevated compared with population values. Neutrophil gelatinase-associated lipocalin, kidney injury molecule-1, and nephrin were not found to be significantly elevated compared with population values or comparing admission to follow-up. Though albumin was found to be minimally elevated, further research should focus on alternative markers in efforts to further understand kidney disease in patients with SCA.
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Affiliation(s)
- Nicholas Farris
- Division of Pediatric Hematology Oncology, University of Rochester, Rochester, NY
- Division of Hematology Oncology Akron Children's Hospital
| | - Stefanie W Benoit
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Neil L McNinch
- Division of Hematology Oncology Akron Children's Hospital
- Rebecca D. Considine Research Institute at Akron Children's Hospital, Akron
| | - Prasad Bodas
- Division of Hematology Oncology Akron Children's Hospital
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3
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Williams JD, Kumar R, Afolabi JM, Park F, Adebiyi A. Rhabdomyolysis aggravates renal iron accumulation and acute kidney injury in a humanized mouse model of sickle cell disease. Free Radic Res 2023; 57:404-412. [PMID: 37840281 DOI: 10.1080/10715762.2023.2269313] [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: 05/23/2023] [Accepted: 09/29/2023] [Indexed: 10/17/2023]
Abstract
Individuals with sickle cell disease (SCD) are at greater risk of rhabdomyolysis, a potentially life-threatening condition resulting from the breakdown of skeletal muscle fibers. Acute kidney injury (AKI) is one of the most severe complications of rhabdomyolysis. Chronic kidney and cardiovascular disease, which account for SCD mortality, are long-term consequences of AKI. Although SCD elevates the risks of rhabdomyolysis-induced sudden death, the mechanisms that underlie rhabdomyolysis-induced AKI in SCD are unclear. In the present study, we show that, unlike their control non-sickling (AA) counterparts, transgenic homozygous SCD (SS; Townes model) mice exhibited 100% mortality 8-24 h after intramuscular glycerol injection. Five hours after glycerol injection, SS mice showed a more significant increase in myoglobinuria and plasma creatine kinase levels than AA mice. Basal plasma heme and kidney tissue iron levels were significantly higher in SS than in AA mice. In contrast to AA, glycerol-induced rhabdomyolysis aggravated these parameters in SS mice. Rhabdomyolysis also amplified oxidative stress in SS compared to AA mice. Glycerol-treated SS mice exhibited worse renal function, exemplified by a reduction in GFR with a corresponding increase in plasma and urinary biomarkers of early AKI and renal tubular damage. The free radical scavenger and Fenton chemistry inhibitor, TEMPOL, ameliorated rhabdomyolysis-induced AKI in the SS mice. These findings demonstrate that oxidative stress driven by renal iron accumulation amplifies rhabdomyolysis-induced AKI in SCD mice.
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Affiliation(s)
- Jada D Williams
- Department of Physiology, University of TN Health Science Center, Memphis, Tennessee
| | - Ravi Kumar
- Department of Physiology, University of TN Health Science Center, Memphis, Tennessee
- Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, Missouri
| | - Jeremiah M Afolabi
- Department of Physiology, University of TN Health Science Center, Memphis, Tennessee
| | - Frank Park
- Department of Pharmaceutical Sciences, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Adebowale Adebiyi
- Department of Physiology, University of TN Health Science Center, Memphis, Tennessee
- Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, Missouri
- NextGen Precision Health, University of Missouri, Columbia, Missouri
- Department of Anesthesiology and Perioperative Medicine, University of Missouri, Columbia, Missouri
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4
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Adebayo OC, Van den Heuvel LP, Olowu WA, Levtchenko EN, Labarque V. Sickle cell nephropathy: insights into the pediatric population. Pediatr Nephrol 2022; 37:1231-1243. [PMID: 34050806 DOI: 10.1007/s00467-021-05126-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/10/2021] [Accepted: 05/06/2021] [Indexed: 12/13/2022]
Abstract
The life expectancy of individuals with sickle cell disease has increased over the years, majorly due to an overall improvement in diagnosis and medical care. Nevertheless, this improved longevity has resulted in an increased prevalence of chronic complications such as sickle cell nephropathy (SCN), which poses a challenge to the medical care of the patient, shortening the lifespan of patients by 20-30 years. Clinical presentation of SCN is age-dependent, with kidney dysfunction slowly beginning to develop from childhood, progressing to chronic kidney disease and kidney failure during the third and fourth decades of life. This review explores the epidemiology, pathology, pathophysiology, clinical presentation, and management of SCN by focusing on the pediatric population. It also discusses the factors that can modify SCN susceptibility.
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Affiliation(s)
- Oyindamola C Adebayo
- Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium.,Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Lambertus P Van den Heuvel
- Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Pediatric Nephrology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Wasiu A Olowu
- Pediatric Nephrology and Hypertension Unit, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria
| | - Elena N Levtchenko
- Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium. .,Department of Pediatric Nephrology, University Hospital Leuven, Herestraat 49, Bus 817, 3000, Leuven, Belgium.
| | - Veerle Labarque
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Pediatric Hematology, University Hospital Leuven, Leuven, Belgium
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5
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Sasongko TH, Nagalla S. Angiotensin-converting enzyme (ACE) inhibitors for proteinuria and microalbuminuria in people with sickle cell disease. Cochrane Database Syst Rev 2021; 12:CD009191. [PMID: 34932828 PMCID: PMC8691947 DOI: 10.1002/14651858.cd009191.pub4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Sickle cell disease is a group of disorders characterized by deformation of erythrocytes. Renal damage is a frequent complication in sickle cell disease as a result of long-standing anemia and disturbed circulation through the renal medullary capillaries. Due to the improvement in life expectancy of people with sickle cell disease, there has been a corresponding significant increase in the incidence of renal complications. Microalbuminuria and proteinuria are noted to be a strong predictor of subsequent renal failure. There is extensive experience and evidence with angiotensin-converting enzyme (ACE) inhibitors over many years in a variety of clinical situations for patients who do not have sickle cell disease, but their effect in people with this disease is unknown. It is common practice to administer ACE inhibitors for sickle nephropathy due to their renoprotective properties; however, little is known about their effectiveness and safety in this setting. This is an update of a Cochrane Review first published in 2013 and 2015. OBJECTIVES To determine the effectiveness of ACE inhibitor administration in people with sickle cell disease for decreasing intraglomerular pressure, microalbuminuria and proteinuria and to to assess the safety of ACE inhibitors as pertains to their adverse effects. SEARCH METHODS The authors searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Hameoglobinopathies Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of the most recent search: 18 October 2021. We also searched clinical trial registries. Date of the most recent search: 22 August 2021. SELECTION CRITERIA Randomized or quasi-randomized controlled trials of ACE inhibitors designed to reduce microalbuminuria and proteinuria in people with sickle cell disease compared to either placebo or standard treatment regimen. DATA COLLECTION AND ANALYSIS Three authors independently applied the inclusion criteria in order to select studies for inclusion in the review. Two authors assessed the risk of bias of studies and extracted data and the third author verified these assessments. MAIN RESULTS Seven studies were identified through the searches. Six studies were excluded. The included study randomized 22 participants (7 males and 15 females) having proteinuria or microalbuminuria with sickle cell disease and treated the participants for six months (median length of follow up of three months) with captopril or placebo. Overall, the certainty of the evidence provided in this review was very low, since most risk of bias domains were judged to have either an unclear or a high risk of bias. Because of this, we are uncertain whether captopril makes any difference, in total urinary albumin excretion (at six months) as compared to the placebo group, although it yielded a mean difference of -49.00 (95% confidence interval (CI) -124.10 to 26.10) or in the absolute change score, although it yielded a mean difference of -63.00 (95% CI -93.78 to -32.22). At six months albumin excretion in the captopril group was noted to decrease from baseline by a mean (standard deviation) of 45 (23) mg/day and the placebo group was noted to increase by 18 (45) mg/day. Serum creatinine and potassium levels were reported constant throughout the study (very low-certainty evidence). The potential for inducing hypotension should be highlighted; the study reported a decrease of 8 mmHg in systolic pressure and 5 mmHg in diastolic and mean blood pressure (very low-certainty evidence). AUTHORS' CONCLUSIONS Overall, we judged the certainty of the evidence to be very low. The included study selectively reported its results, was not powered to detect a group difference, should it exist, and otherwise did not offer enough information to allow us to judge the bias inherent in the study. Indirectness (in relation to the limited age and type of population included) and imprecision (wide confidence intervals around the effect estimate) were observed. More long-term studies involving multiple centers and larger cohorts using a randomized-controlled design are warranted, especially among the pediatric age group. Detailed reporting of each outcome measure is necessary to allow a clear cut interpretation in a systematic review. One of the difficulties encountered in this review was the lack of detailed data reported in the included study. Overall, we judged the certainty of this evidence to be very low.
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Affiliation(s)
- Teguh Haryo Sasongko
- Perdana University RCSI School of Medicine, Perdana University (PU), Selangor, Malaysia
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6
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Maurício L, Ribeiro S, Santos L, Miranda DBD. Predictors associated with sickle cell nephropathy: a systematic review. Rev Assoc Med Bras (1992) 2021; 67:313-317. [PMID: 34406259 DOI: 10.1590/1806-9282.67.02.20200676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 11/16/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Sickle cell anemia affects more than 30 million people worldwide. Chronic kidney disease develops in 40% of individuals. The death rate of patients with sickle nephropathy is still high, with little known predictors related to its development. To answer the question "What predictors are associated with the onset of chronic kidney disease in patients with sickle cell anemia?", this article seeks to contribute to a better understanding of sickle nephropathy, making possible a new look at the sickle cell anemia and its kidney complications. METHODS A systematic review was developed, using the PRISMA recommendation, for cohort studies on predictors related to the outcome of sickle nephropathy in patients with sickle cell anemia. RESULTS Initially 321 studies were identified in Pubmed, of which six were selected to compose this systematic review. Lower hemoglobin levels, increased ages and albuminuria were the most pointed predictors associated with chronic kidney disease. CONCLUSION The main predictors associated with the development of chronic kidney disease in individuals with sickle cell anemia were lower hemoglobin levels, increased ages, and albuminuria. New studies evaluating predictors for the development of chronic kidney disease in sickle cell anemia are needed to better understand its installation and prevent its progression.
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Affiliation(s)
- Lauana Maurício
- Pontifícia Universidade Católica de Goiás - Goiânia (GO), Brazil
| | - Sara Ribeiro
- Pontifícia Universidade Católica de Goiás - Goiânia (GO), Brazil
| | - Luciana Santos
- Pontifícia Universidade Católica de Goiás - Goiânia (GO), Brazil
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7
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Dubey SRK, Shrivastava N, Sharma T, Bhatt GC, Dhingra B, Pakhare AP, Goel SK, Joshi D. Abnormal Ambulatory Blood Pressure and Early Renal Dysfunction in Sickle Cell Disease. Indian J Pediatr 2021; 88:562-567. [PMID: 33175364 DOI: 10.1007/s12098-020-03558-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 10/26/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES There is sparsity of studies evaluating blood pressure in children with sickle cell disease (SCD), which have shown inconsistent results. Few of the studies have documented lower office blood pressure (BP) in SCD patients, whereas, others have shown presence of masked hypertension and abnormal ambulatory blood BP monitoring (ABPM). Thus, the present study was conducted to examine 24 h ABPM parameters and renal dysfunction in children with SCD and compare them with healthy controls. METHODS A cross-sectional study was conducted on 56 children (30 children having SCD and 26 controls). ABPM and evaluation of renal functions including serum creatinine, serum urea, urinary creatinine, urinary protein and specific gravity was performed. RESULTS Spot urinary protein to creatinine ratio was found to be higher in patients with SCD (63.3%) as compared to controls (p < 0.001). Proteinuria was observed in 1/4th of the SCD patients less than ten years of age. Masked hypertension was present in 2 (6.6%) patients, ambulatory hypertension in 4 (13.3%), ambulatory pre-hypertension in 1 (3.3%) and abnormal dipping in 60%. A statistically significant correlation of BMI for age Z-score and standard deviation score (SDS/Z) of 24 h systolic BP (r = 0.56, p = 0.002); estimated glomerular filtration rate (eGFR) with 24 h diastolic BP SDS (r = -0.52; p = 0.038) and age with e GFR (r = 0.54; p = 0.025) was found in the present study. CONCLUSIONS The present study corroborates that ABPM abnormalities (ambulatory hypertension, non-dipping pattern, ambulatory prehypertension) and early onset proteinuria are significant findings in patients with SCD. This underscores the importance of regular screening for proteinuria and ABPM in routine care, for early detection and prevention of progressive renal damage in SCD.
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Affiliation(s)
- Shiv Ram Krishna Dubey
- Department of Pediatrics, ISN-Sister Renal Center, All India Institute of Medical Sciences (AIIMS), Madhya Pradesh, Bhopal, India.,Department of Pediatrics, Government Medical College, Vidisha, Madhya Pradesh, India
| | - Neha Shrivastava
- Department of Pediatrics, ISN-Sister Renal Center, All India Institute of Medical Sciences (AIIMS), Madhya Pradesh, Bhopal, India.,Department of Pediatrics, Gandhi Medical College, Bhopal, Madhya Pradesh, India
| | - Tanya Sharma
- Department of Pathology & Lab Medicine, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Girish C Bhatt
- Department of Pediatrics, ISN-Sister Renal Center, All India Institute of Medical Sciences (AIIMS), Madhya Pradesh, Bhopal, India.
| | - Bhavna Dhingra
- Department of Pediatrics, ISN-Sister Renal Center, All India Institute of Medical Sciences (AIIMS), Madhya Pradesh, Bhopal, India
| | - Abhijit P Pakhare
- Department of Community & Family Medicine, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - S K Goel
- Department of Biochemistry, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Deepti Joshi
- Department of Pathology & Lab Medicine, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
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Meglic A, Debeljak M, Kovac J, Trampus Bakija A, Rajic V, Kojc N, Trebusak Podkrajsek K. SPTB related spherocytosis in a three-generation family presenting with kidney failure in adulthood due to co-occurrence of UMOD disease causing variant. Nefrologia 2020; 40:421-428. [PMID: 32113667 DOI: 10.1016/j.nefro.2019.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 08/14/2019] [Accepted: 10/27/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Hereditary spherocytosis is clinically and genetically heterogeneous disorder and its clinical characteristics are spherocytosis, anaemia, jaundice and splenomegaly. The aetiology is associated to the genes encoding proteins involved in the interaction between the erythrocyte membrane and the lipid bilayer. Causative variants in βI-spectrin (SPTB) gene presenting as mild to moderately severe disease are responsible for approximately 25% cases in the USA and Europe. Among kidney disease, isolated cases of nephrotic syndrome due to membranoproliferative glomerulonephritis and macroscopic haematuria with proteinuria due to IgA nephropathy were previously reported in patients with SPTB deficiency. OBJECTIVE Seven patients from the same family with spherocytosis were evaluated to assess the kidney failure presented in all affected adult patients. METHODS Clinical, radiological and laboratory investigations were issued to evaluate the spherocytosis and kidney disease. In selected patients, we also performed genetics testing with next generation sequencing of genes related to hereditary spherocytosis, inherited glomerular disorders and tubulo-interstitial kidney disease. RESULTS Among the family members with spherocytosis, two adults had end-stage kidney disease and one chronic kidney disease stage 4 with unspecific histopathological findings of interstitial fibrosis/tubular atrophy and glomerulosclerosis. At the time, there were no signs of kidney disease present in four paediatric patients. Novel nonsense variant in SPTB gene (NM_001024858; c.4796G>A; p.Trp1599Ter) was detected in all family members with spherocytosis and was predicted to be disease causing. Furthermore, all adult patients with kidney failure and two paediatric cousins of the index patients were heterozygous for the UMOD gene variant (NM_003361.3:c.552G>C, NP_003352.2:p.Trp184Cys) previously reported in patients with tubulo-interstitial kidney disease. UMOD variant was not present in the index patients. CONCLUSIONS The co-occurrence of any two rare inherited disorders is extremely rare, while to our knowledge the co-occurrence of genetically confirmed HS and autosomal dominant tubulo-interstitial kidney disease (ADTKD) has previously not been reported. It is not possibly to evaluate whether the haemolytic crises due to HS are influencing the progression of the UMOD related renal disease, since the UMOD related ADTKD characteristics in general and in here presented family are extremely variable. Nevertheless, the observed kidney disease in the family is warranting the regular nephrological examinations in UMOD positive paediatric patients in the family in order to recognise hyperuricemia and treat it as early as possible. This is emphasising the importance of serum uric acid detection in routine laboratory screening of paediatric patients in order to identify early signs of tubular injury indicating possible ADTKD.
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Affiliation(s)
- Anamarija Meglic
- University Medical Centre Ljubljana, University Children's Hospital, Department of Nephrology, Ljubljana, Slovenia
| | - Marusa Debeljak
- University Medical Centre Ljubljana, University Children's Hospital, Institute for Special Laboratory Diagnostics, Ljubljana, Slovenia
| | - Jernej Kovac
- University Medical Centre Ljubljana, University Children's Hospital, Institute for Special Laboratory Diagnostics, Ljubljana, Slovenia
| | - Alenka Trampus Bakija
- University Medical Centre Ljubljana, University Children's Hospital, Institute for Special Laboratory Diagnostics, Ljubljana, Slovenia
| | - Vladan Rajic
- University Medical Centre Ljubljana, University Children's Hospital, Department of Haematology and Oncology, Ljubljana, Slovenia
| | - Nika Kojc
- University of Ljubljana, Faculty of Medicine, Institute of Pathology, Ljubljana, Slovenia
| | - Katarina Trebusak Podkrajsek
- University Medical Centre Ljubljana, University Children's Hospital, Institute for Special Laboratory Diagnostics, Ljubljana, Slovenia; University of Ljubljana, Faculty of Medicine, Institute of Biochemistry, Ljubljana, Slovenia.
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9
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Van Avondt K, Nur E, Zeerleder S. Mechanisms of haemolysis-induced kidney injury. Nat Rev Nephrol 2019; 15:671-692. [PMID: 31455889 DOI: 10.1038/s41581-019-0181-0] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2019] [Indexed: 12/16/2022]
Abstract
Intravascular haemolysis is a fundamental feature of chronic hereditary and acquired haemolytic anaemias, including those associated with haemoglobinopathies, complement disorders and infectious diseases such as malaria. Destabilization of red blood cells (RBCs) within the vasculature results in systemic inflammation, vasomotor dysfunction, thrombophilia and proliferative vasculopathy. The haemoprotein scavengers haptoglobin and haemopexin act to limit circulating levels of free haemoglobin, haem and iron - potentially toxic species that are released from injured RBCs. However, these adaptive defence systems can fail owing to ongoing intravascular disintegration of RBCs. Induction of the haem-degrading enzyme haem oxygenase 1 (HO1) - and potentially HO2 - represents a response to, and endogenous defence against, large amounts of cellular haem; however, this system can also become saturated. A frequent adverse consequence of massive and/or chronic haemolysis is kidney injury, which contributes to the morbidity and mortality of chronic haemolytic diseases. Intravascular destruction of RBCs and the resulting accumulation of haemoproteins can induce kidney injury via a number of mechanisms, including oxidative stress and cytotoxicity pathways, through the formation of intratubular casts and through direct as well as indirect proinflammatory effects, the latter via the activation of neutrophils and monocytes. Understanding of the detailed pathophysiology of haemolysis-induced kidney injury offers opportunities for the design and implementation of new therapeutic strategies to counteract the unfavourable and potentially fatal effects of haemolysis on the kidney.
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Affiliation(s)
- Kristof Van Avondt
- Department of Immunopathology, Sanquin Research, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands. .,Institute for Cardiovascular Prevention (IPEK), Ludwig Maximilian University of Munich, Munich, Germany.
| | - Erfan Nur
- Department of Haematology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Sacha Zeerleder
- Department of Immunopathology, Sanquin Research, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands. .,Department of Haematology and Central Haematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland. .,Department for BioMedical Research, University of Bern, Bern, Switzerland.
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10
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Belisário AR, da Silva AAS, Silva CVM, de Souza LMG, Wakabayashi EA, Araújo SDA, Simoes-e-Silva AC. Sickle cell disease nephropathy: an update on risk factors and potential biomarkers in pediatric patients. Biomark Med 2019; 13:967-987. [DOI: 10.2217/bmm-2019-0105] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
One of the major chronic complications of sickle cell disease (SCD) is sickle cell nephropathy. The aim of this review is to discuss the pathophysiology, natural history, clinical manifestations, risk factors, biomarkers and therapeutic approaches for sickle cell nephropathy, focusing on studies with pediatric patients. The earliest manifestation of renal disease is an increase in the glomerular filtration rate. A finding that may also be observed in early childhood is microalbuminuria. Nephrin, KIM-1, VGFs, chemokines and renin-angiotensin system molecules have emerged as potential early markers of renal dysfunction in SCD. In regards to a therapeutic approach, renin-angiotensin system inhibitors and angiotensin receptor blockers seem to be effective for the control of albuminuria in adults with SCD, although new studies in children are needed. The precise moment to begin renoprotection in SCD patients who should be treated remains to be determined.
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Affiliation(s)
- André R Belisário
- Centro de Tecidos Biológicos de Minas Gerais, Fundação Hemominas, Rua das Goiabeiras, 779, Lagoa Santa, Minas Gerais 33400-000, Brazil
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Av Prof. Alfredo Balena, 190, Belo Horizonte, Minas Gerais 30130-100, Brazil
| | - Ariadna AS da Silva
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Av Prof. Alfredo Balena, 190, Belo Horizonte, Minas Gerais 30130-100, Brazil
| | - Cristiane VM Silva
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Av Prof. Alfredo Balena, 190, Belo Horizonte, Minas Gerais 30130-100, Brazil
| | - Larissa MG de Souza
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Av Prof. Alfredo Balena, 190, Belo Horizonte, Minas Gerais 30130-100, Brazil
| | - Eduarda A Wakabayashi
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Av Prof. Alfredo Balena, 190, Belo Horizonte, Minas Gerais 30130-100, Brazil
| | - Stanley de A Araújo
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Av Prof. Alfredo Balena, 190, Belo Horizonte, Minas Gerais 30130-100, Brazil
| | - Ana C Simoes-e-Silva
- Laboratório Interdisciplinar de Investigação Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Av Prof. Alfredo Balena, 190, Belo Horizonte, Minas Gerais 30130-100, Brazil
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11
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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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12
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Quinn CT, Saraf SL, Gordeuk VR, Fitzhugh CD, Creary SE, Bodas P, George A, Raj AB, Nero AC, Terrell CE, McCord L, Lane A, Ackerman HC, Yang Y, Niss O, Taylor MD, Devarajan P, Malik P. Losartan for the nephropathy of sickle cell anemia: A phase-2, multicenter trial. Am J Hematol 2017; 92:E520-E528. [PMID: 28589652 DOI: 10.1002/ajh.24810] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 05/26/2017] [Accepted: 05/29/2017] [Indexed: 01/26/2023]
Abstract
Nephropathy is a common and progressive complication of sickle cell anemia (SCA). In SCA mice, we found that hyperangiotensinemia in the absence of hypertension underlies nephropathy, and its downregulation by losartan, an angiotensin-II-receptor-1 blocker, reduced albuminuria and progression of nephropathy. Therefore, we performed a phase-2 trial of oral losartan, given for 6 months, to explore whether it reduced albuminuria in children and adults with SCA. Participants were allocated to groups defined by class of baseline urinary albumin-to-creatinine ratio (UACR): no albuminuria (NoA), microalbuminuria (MicroA), and macroalbuminuria (MacroA). The primary endpoint was a ≥25% reduction UACR from baseline. There were 32 evaluable participants (mean age 24 years; NoA = 14, MicroA = 12, MacroA = 6). The primary endpoint was met in 83% of the MacroA group (P < 0.0001) and 58% of the MicroA group (P < 0.0001). Median fold-change in UACR was -0.74 for MacroA and -0.46 for MicroA. In MacroA and MicroA, UACR classification improved in 50% but worsened in 11%. Urine osmolality and estimated glomerular filtration rate (eGFR) did not change significantly. Losartan was discontinued in three participants [leg cramps, N = 1; decline in eGFR >25% (142➝104 mL/minute/1.73 m2 ), N = 1; rise in serum creatinine >50% (0.2➝0.3 mg/dL), N = 1]. Albuminuria was associated with diastolic dysfunction and impaired functional capacity, although cardiopulmonary status was unchanged after 6 months of losartan therapy. In summary, losartan decreased urinary albumin excretion in most participants with albuminuria. Those with macroalbuminuria had the greatest benefit. This study forms the basis for a phase-3, randomized, placebo-controlled trial of losartan for the nephropathy of SCA.
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Affiliation(s)
- Charles T. Quinn
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Santosh L. Saraf
- Hematology/Oncology, University of Illinois at Chicago; Chicago Illinois
| | - Victor R. Gordeuk
- Hematology/Oncology, University of Illinois at Chicago; Chicago Illinois
| | - Courtney D. Fitzhugh
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health; Bethesda Maryland
| | - Susan E. Creary
- Hematology, Oncology & BMT, Nationwide Children's Hospital; Columbus Ohio
| | - Prasad Bodas
- Hematology and Oncology, Akron Children's Hospital; Akron Ohio
| | - Alex George
- Hematology Center, Texas Children's Hospital; Houston Texas
| | - Ashok B. Raj
- Pediatric Cancer & Blood Disorders, University of Louisville; Louisville Kentucky
| | - Alecia C. Nero
- Hematology-Oncology, UT Southwestern Medical Center; Dallas Texas
| | - Catherine E. Terrell
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Lisa McCord
- Clinical and Translational Research, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Adam Lane
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Hans C. Ackerman
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health; Bethesda Maryland
| | - Yu Yang
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health; Bethesda Maryland
| | - Omar Niss
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Michael D. Taylor
- Cardiology, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Prasad Devarajan
- Nephrology, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Punam Malik
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
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13
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Mammen C, Bissonnette ML, Matsell DG. Acute kidney injury in children with sickle cell disease-compounding a chronic problem. Pediatr Nephrol 2017; 32:1287-1291. [PMID: 28353009 DOI: 10.1007/s00467-017-3650-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 03/10/2017] [Indexed: 11/24/2022]
Abstract
In an article recently published in Pediatric Nephrology, Baddam and colleagues discuss the relatively underreported clinical problem of repeated episodes of acute kidney injury (AKI) in children with sickle cell disease (SCD). Their report is a cautionary note about the importance of repeated kidney injury on the background of underlying chronic kidney injury and its potential implications on long-term kidney outcome. In children and adults with SCD, this includes the effects of repeated vaso-occlusive crises and the management of these painful episodes with non-steroidal anti-inflammatory drugs. Here we review the scope of kidney involvement in SCD in children and discuss the potential short- and long-term consequences of AKI in children with SCD.
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Affiliation(s)
- Cherry Mammen
- Department of Pediatrics, University of British Columbia, Vancouver, Canada.,Division of Nephrology, British Columbia Children's Hospital, Vancouver, Canada
| | - Mei Lin Bissonnette
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Douglas G Matsell
- Department of Pediatrics, University of British Columbia, Vancouver, Canada. .,Division of Nephrology, British Columbia Children's Hospital, Vancouver, Canada.
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14
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Shatat IF, Qanungo S, Hudson S, Laken MA, Hailpern SM. Changes in Urine Microalbumin-to-Creatinine Ratio in Children with Sickle Cell Disease over Time. Front Pediatr 2016; 4:106. [PMID: 27774444 PMCID: PMC5053981 DOI: 10.3389/fped.2016.00106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 09/13/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Approximately 20% of children with sickle cell disease (SCD) have microalbuminuria (MA). Very little is known about the progression of MA in children and young adults with SCD. METHODS In this study, we analyzed 5-year EMR data of 373 children [with ≥2 microalbumin-to-creatinine (MA/Cr) ratio measurements] followed at the Medical University of South Carolina to determine the rate, direction, magnitude, and predictors of MA/Cr change over time. RESULTS Age range was 1-22 years; mean 10.2 ± 5.2 years, 49.5% were males. Median follow-up duration was 3.12 ± 1.16 years. At baseline, 328 children had normal (<20 mg/L) MA level. Forty-five (12.1%) of children had MA (≥20 mg/L), of which 91% were ≥8 years and 21 (47%) continued to have MA at the end of the study period. On the other hand, during the study period, 24 new patients developed MA and 24 normalized their MA to levels <20 mg/L. In multivariate logistic regression model, age and bilirubin levels were predictive of MA/Cr increase in patients who received at least one blood transfusion during the study period. Baseline MA level was not predictive of the change in MA/Cr. CONCLUSION In children and young adults, microalbuminuria is considered a marker of early renal injury. Over time, MA/Cr levels may increase or decrease. Further studies are needed to confirm our findings, assess the reliability of MA as marker of long-term renal injury, and identify high risk patients with SCD likely to have worsening of MA over time.
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Affiliation(s)
- Ibrahim F Shatat
- Pediatric Nephrology and Hypertension, Sidra Medical and Research Center, Doha, Qatar; College of Nursing, Medical University of South Carolina, Charleston, SC, USA; Weill Cornell Medical College, New York, NY, USA
| | - Suparna Qanungo
- College of Nursing, Medical University of South Carolina , Charleston, SC , USA
| | - Shannon Hudson
- College of Nursing, Medical University of South Carolina , Charleston, SC , USA
| | - Marilyn A Laken
- College of Nursing, Medical University of South Carolina , Charleston, SC , USA
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15
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Bartolucci P, Habibi A, Stehlé T, Di Liberto G, Rakotoson MG, Gellen-Dautremer J, Loric S, Moutereau S, Sahali D, Wagner-Ballon O, Remy P, Lang P, Grimbert P, Audureau E, Godeau B, Galacteros F, Audard V. Six Months of Hydroxyurea Reduces Albuminuria in Patients with Sickle Cell Disease. J Am Soc Nephrol 2015; 27:1847-53. [PMID: 26586692 DOI: 10.1681/asn.2014111126] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 09/07/2015] [Indexed: 12/22/2022] Open
Abstract
The earliest symptom of glomerular injury in patients with sickle cell disease (SCD) is microalbuminuria. The effect of hydroxyurea (HU) on urine albumin-to-creatinine ratio (ACR) is unclear and should be determined, because increasing numbers of patients with SCD take this drug to improve red blood cell function. In this cohort study of 58 SS-homozygous adults with SCD who initiated HU therapy, we evaluated ACR changes and relationships of these changes with demographic, clinical, and biologic parameters at HU initiation (baseline) and 6 months later (follow-up). Between baseline and follow-up, ACR declined significantly for the entire population (3.0-1.7 mg/mmol; P<0.01), but this was primarily driven by the ACR reduction in the microalbuminuria subgroup (8.1-2.3 mg/mmol; P=0.03; n=23). According to bivariate analyses on 39 patients who did not receive a blood transfusion during the study period, the baseline to follow-up ACR decline was strongly associated with decreases in levels of hemolysis markers, percentage of dense red blood cells, and systolic BP. Bivariate analysis also revealed a close association between the ACR decrease and high baseline levels of hemolysis markers and percentage of dense red blood cells. These results show that urine ACR decreased significantly after 6 months of HU and confirm a close relationship between ACR and hemolysis evolution in patients with SCD.
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Affiliation(s)
- Pablo Bartolucci
- Sickle Cell Referral Center, Department of Internal Medicine, Unité Institut National de la Santé Et de la Recherche Médicale (INSERM) U955, Equipe 2 and Laboratory of Excellence Globule Rouge Excellence (GR-Ex), Paris, France Groupe Hospitalier Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Creteil, France;
| | - Anoosha Habibi
- Sickle Cell Referral Center, Department of Internal Medicine, Groupe Hospitalier Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Creteil, France
| | - Thomas Stehlé
- Groupe Hospitalier Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Creteil, France; Department of Nephrology and Renal Transplantation
| | - Gaetana Di Liberto
- Unité Institut National de la Santé Et de la Recherche Médicale (INSERM) U955, Equipe 2 and Laboratory of Excellence Globule Rouge Excellence (GR-Ex), Paris, France Groupe Hospitalier Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Creteil, France
| | - Marie Georgine Rakotoson
- Unité Institut National de la Santé Et de la Recherche Médicale (INSERM) U955, Equipe 2 and Laboratory of Excellence Globule Rouge Excellence (GR-Ex), Paris, France Groupe Hospitalier Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Creteil, France
| | - Justine Gellen-Dautremer
- Sickle Cell Referral Center, Department of Internal Medicine, Groupe Hospitalier Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Creteil, France
| | - Sylvain Loric
- Groupe Hospitalier Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Creteil, France; Departement de Biochimie-Pharmacotoxicologie
| | - Stéphane Moutereau
- Groupe Hospitalier Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Creteil, France; Departement de Biochimie-Pharmacotoxicologie
| | - Dil Sahali
- Groupe Hospitalier Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Creteil, France; Department of Nephrology and Renal Transplantation, Unité INSERM U955, Equipe 21, Idiopathic Nephrotic Syndrome Referral Center, Université Paris-Est Créteil, Creteil, France; and
| | - Orianne Wagner-Ballon
- Groupe Hospitalier Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Creteil, France; Department of Hematology and Immunology Biology, and
| | - Philippe Remy
- Groupe Hospitalier Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Creteil, France; Department of Nephrology and Renal Transplantation, Unité INSERM U955, Equipe 21, Idiopathic Nephrotic Syndrome Referral Center, Université Paris-Est Créteil, Creteil, France; and
| | - Philippe Lang
- Groupe Hospitalier Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Creteil, France; Department of Nephrology and Renal Transplantation, Unité INSERM U955, Equipe 21, Idiopathic Nephrotic Syndrome Referral Center, Université Paris-Est Créteil, Creteil, France; and
| | - Philippe Grimbert
- Groupe Hospitalier Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Creteil, France; Department of Nephrology and Renal Transplantation, Unité INSERM U955, Equipe 21, Idiopathic Nephrotic Syndrome Referral Center, Université Paris-Est Créteil, Creteil, France; and
| | - Etienne Audureau
- Groupe Hospitalier Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Creteil, France; Public Health Unit EA (Equipe d'Accueil) 7376 CEpiA (Clinical Epidemiology And Ageing Unit, and
| | - Bertrand Godeau
- Department of Internal Medicine, Groupe Hospitalier Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Creteil, France
| | - Frédéric Galacteros
- Sickle Cell Referral Center, Department of Internal Medicine, Unité Institut National de la Santé Et de la Recherche Médicale (INSERM) U955, Equipe 2 and Laboratory of Excellence Globule Rouge Excellence (GR-Ex), Paris, France Groupe Hospitalier Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Creteil, France
| | - Vincent Audard
- Groupe Hospitalier Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Université Paris-Est Créteil, Creteil, France; Department of Nephrology and Renal Transplantation, Unité INSERM U955, Equipe 21, Idiopathic Nephrotic Syndrome Referral Center, Université Paris-Est Créteil, Creteil, France; and
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16
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Sasongko TH, Nagalla S, Ballas SK. Angiotensin-converting enzyme (ACE) inhibitors for proteinuria and microalbuminuria in people with sickle cell disease. Cochrane Database Syst Rev 2015; 2015:CD009191. [PMID: 26041152 PMCID: PMC6464711 DOI: 10.1002/14651858.cd009191.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Sickle cell disease is a group of disorders characterized by deformation of erythrocytes. Renal damage is a frequent complication in sickle cell disease as a result of long-standing anemia and disturbed circulation through the renal medullary capillaries. Due to the improvement in life expectancy of people with sickle cell disease, there has been a corresponding significant increase in the incidence of renal complications. Microalbuminuria and proteinuria are noted to be a strong predictor of subsequent renal failure. There is extensive experience and evidence with angiotensin-converting enzyme (ACE) inhibitors over many years in a variety of clinical situations for patients who do not have sickle cell disease, but their effect in people with this disease is unknown. It is common practice to administer ACE inhibitors for sickle nephropathy due to their renoprotective properties; however, little is known about their effectiveness and safety in this setting. This is an update of a Cochrane Review first published in 2013. OBJECTIVES To determine the effectiveness of ACE inhibitor administration in people with sickle cell disease for decreasing intraglomerular pressure, microalbuminuria and proteinuria and to to assess the safety of ACE inhibitors as pertains to their adverse effects. SEARCH METHODS The authors searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Hameoglobinopathies Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Date of the most recent search: 03 June 2015. SELECTION CRITERIA Randomized or quasi-randomized controlled trials of ACE inhibitors designed to reduce microalbuminuria and proteinuria in people with sickle cell disease compared to either placebo or standard treatment regimen. DATA COLLECTION AND ANALYSIS Three authors independently applied the inclusion criteria in order to select studies for inclusion in the review. Two authors assessed the risk of bias of studies and extracted data and the third author verified these assessments. MAIN RESULTS Five studies were identified through the searches, only one met our inclusion criteria. The included study randomized 22 participants (seven males and 15 females) having proteinuria or microalbuminuria with sickle cell disease and treated the participants for six months (median length of follow up of three months) with captopril or placebo. The overall quality of the outcomes reported was high, since most aspects that may contribute to bias were regarded to be of low risk, although allocation concealment was not reported. At six months, the study reported no significant difference in urinary albumin excretion between the captopril group and the placebo group, although the mean urinary albumin excretion in the captopril group was lower by a mean difference of -49.00 (95% confidence interval -124.10 to 26.10) compared to that of placebo. However, our analysis on the absolute change score showed significant changes between the two groups by a mean difference of -63.00 (95% confidence interval -93.78 to -32.22). At six months albumin excretion in the captopril group was noted to decrease from baseline by a mean of 45 ± 23 mg/day and the placebo group was noted to increase by 18 ± 45 mg/day. Serum creatinine and potassium levels were reported constant throughout the study. The potential for inducing hypotension should be highlighted; the study reported a decrease of 8 mmHg in systolic pressure and 5 mmHg in diastolic and mean blood pressure. AUTHORS' CONCLUSIONS There is not enough evidence to show that the administration of ACE inhibitors is associated with a reduction of microalbuminuria and proteinuria in people with sickle cell disease, although a potential for this was seen. More long-term studies involving multiple centers and larger cohorts using a randomized-controlled design are warranted, especially among the pediatric age group. Detailed reporting of each outcome measure is necessary to allow a clear cut interpretation in a systematic review. One of the difficulties encountered in this review was the lack of detailed data reported in the included study.
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Affiliation(s)
- Teguh H Sasongko
- International Medical UniversityHuman Biology Division, School of MedicineNo. 126, Jalan Jalil Perkasa 19, Bukit JalilKuala LumpurMalaysia57000
| | - Srikanth Nagalla
- Thomas Jefferson UniversityDepartment of Medicine, Division of HematologyMedical Center Boulevard1015 Walnut StreetPhiladelphiaPennsylvaniaUSAPA 19107‐5099
| | - Samir K Ballas
- Jefferson Medical College, Thomas Jefferson UniversityCardeza Foundation for Hematologic Research, Department of Medicine1015 Walnut StreetPhiladelphiaUSAPA 19107‐5099
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17
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Abstract
Sickle cell disease (SCD) substantially alters renal structure and function, and causes various renal syndromes and diseases. Such diverse renal outcomes reflect the uniquely complex vascular pathobiology of SCD and the propensity of red blood cells to sickle in the renal medulla because of its hypoxic, acidotic, and hyperosmolar conditions. Renal complications and involvement in sickle cell nephropathy (SCN) include altered haemodynamics, hypertrophy, assorted glomerulopathies, chronic kidney disease, acute kidney injury, impaired urinary concentrating ability, distal nephron dysfunction, haematuria, and increased risks of urinary tract infections and renal medullary carcinoma. SCN largely reflects an underlying vasculopathy characterized by cortical hyperperfusion, medullary hypoperfusion, and an increased, stress-induced vasoconstrictive response. Renal involvement is usually more severe in homozygous disease (sickle cell anaemia, HbSS) than in compound heterozygous types of SCD (for example HbSC and HbSβ(+)-thalassaemia), and is typically mild, albeit prevalent, in the heterozygous state (sickle cell trait, HbAS). Renal involvement contributes substantially to the diminished life expectancy of patients with SCD, accounting for 16-18% of mortality. As improved clinical care promotes survival into adulthood, SCN imposes a growing burden on both individual health and health system costs. This Review addresses the renal manifestations of SCD and focuses on their underlying mechanisms.
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Affiliation(s)
- Karl A Nath
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street S. W., Rochester, MN 55905, USA
| | - Robert P Hebbel
- Division of Haematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Mayo Mail Code 480, 420 Delaware Street S. E., Minneapolis, MN 55455, USA
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18
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Becker AM, Goldberg JH, Henson M, Ahn C, Tong L, Baum M, Buchanan GR. Blood pressure abnormalities in children with sickle cell anemia. Pediatr Blood Cancer 2014; 61:518-22. [PMID: 24424792 DOI: 10.1002/pbc.24843] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 10/07/2013] [Indexed: 11/06/2022]
Abstract
BACKGROUND Kidney disease is an important cause of morbidity and mortality in patients with sickle cell anemia (SCA). The factors that affect progression of renal disease are unknown, especially in children and adolescents. Alterations in blood pressure, including hypertension and lack of the normal nocturnal dip in blood pressure, are important determinants of diabetic nephropathy and other renal diseases and may play a role in sickle cell nephropathy. Our primary hypothesis was that children with SCA who have microalbuminuria will demonstrate less nocturnal dipping of blood pressure compared to patients without microalbuminuria. We also investigated other potential factors associated with microalbuminuria. PROCEDURE This prospective study of 52 adolescents with SCA followed in the Children's Medical Center Dallas Comprehensive Sickle Cell Center characterized 24-hour ambulatory blood pressure profiles and presence of microalbuminuria. Stepwise logistic regression was performed to identify significant independent factors that are associated with microalbuminuria. RESULTS Thirty-five percent of patients were identified as having previously unrecognized hypertension, and 17% had pre-hypertension (blood pressure greater than the 90th percentile but less than the 95th percentile). Fifty-six percent of patients lacked the normal nocturnal dip in blood pressure. In addition, 21% had microalbuminuria, and their percent nocturnal dip was significantly less than those without microalbuminuria (P = 0.01). CONCLUSIONS Blood pressure abnormalities are common in adolescents with SCA and are a possible modifiable risk factor in the progression of sickle cell nephropathy.
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19
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Cazenave M, Koehl B, Nochy D, Tharaux PL, Audard V. [Spectrum of renal manifestations in sickle cell disease]. Nephrol Ther 2013; 10:10-6. [PMID: 24113202 DOI: 10.1016/j.nephro.2013.07.366] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 07/18/2013] [Accepted: 07/21/2013] [Indexed: 01/13/2023]
Abstract
Sickle cell disease (SCD), the most common hemoglobinopathy, is an increasing cause of chronic kidney disease. In the last decade, we have witnessed a better understanding in the characterization of clinical manifestations and pathogenesis of sickle cell nephropathy. The spectrum of renal diseases during SCD includes various renal manifestations such as impairment of urinary concentrating ability, defect in urine acidification, renal papillary necrosis and proteinuria related to glomerular injury leading to progressive end-stage renal disease. Endothelial dysfunction related to chronic hemolysis and the relative renal hypoxia caused by vaso-occlusive sickle red blood cells are probably two key factors for SCN development. Optimal therapeutic management (including the use of blockers of the renin-angiotensin system) of patients with proteinuria remains to be determined. Renal replacement therapy with dialysis is required in SCD patients with end-stage renal disease but these patients should probably undergo kidney transplantation that requires careful management.
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Affiliation(s)
- Maud Cazenave
- Inserm U970, Paris cardiovascular centre (PARCC), université Paris Descartes, Sorbonne Paris cité, 75015 Paris, France
| | - Bérengère Koehl
- Service de pédiatrie générale, hôpital Robert-Debré, université Paris Diderot, AP-HP, 75019 Paris, France
| | - Dominique Nochy
- Service d'anatomopathologie, hôpital européen Georges-Pompidou, université Paris Descartes, AP-HP, 75015 Paris, France
| | - Pierre-Louis Tharaux
- Inserm U970, Paris cardiovascular centre (PARCC), université Paris Descartes, Sorbonne Paris cité, 75015 Paris, France; Service de néphrologie, hôpital européen Georges-Pompidou, université Paris Descartes, AP-HP, 75015 Paris, France
| | - Vincent Audard
- Inserm U 955, service de néphrologie et de transplantation, institut francilien de recherche en néphrologie et transplantation (IFRNT), hôpital Henri-Mondor, université Paris Est Créteil, AP-HP, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France.
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Sasongko TH, Nagalla S, Ballas SK. Angiotensin-converting enzyme (ACE) inhibitors for proteinuria and microalbuminuria in people with sickle cell disease. Cochrane Database Syst Rev 2013:CD009191. [PMID: 23543572 DOI: 10.1002/14651858.cd009191.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Sickle cell disease is a group of disorders characterized by deformation of erythrocytes. Renal damage is a frequent complication in sickle cell disease as a result of long-standing anemia and disturbed circulation through the renal medullary capillaries. Due to the improvement in life expectancy of people with sickle cell disease, there has been a corresponding significant increase in the incidence of renal complications. Microalbuminuria and proteinuria are noted to be a strong predictor of subsequent renal failure. There is extensive experience and evidence with angiotensin-converting enzyme (ACE) inhibitors over many years in a variety of clinical situations for patients who do not have sickle cell disease, but their effect in patients with this disease is unknown. It is common practice to administer ACE inhibitors for sickle nephropathy due to their renoprotective properties; however, little is known about their effectiveness and safety in this setting. OBJECTIVES To determine the effectiveness of ACE inhibitor administration in people with sickle cell disease for decreasing intraglomerular pressure, microalbuminuria and proteinuria and to to assess the safety of ACE inhibitors as pertains to their adverse effects. SEARCH METHODS The authors searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Hameoglobinopathies Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Date of the most recent search: 05 July 2012. SELECTION CRITERIA Randomized or quasi-randomized controlled trials of ACE inhibitors designed to reduce microalbuminuria and proteinuria in people with sickle cell disease compared to either placebo or standard treatment regimen. DATA COLLECTION AND ANALYSIS Three authors independently applied the inclusion criteria in order to select studies for inclusion in the review. Two authors assessed the risk of bias of studies and extracted data and the third author verified these assessments. MAIN RESULTS Five studies were identified through the searches, only one met our inclusion criteria. The included study randomized 22 participants (7 males and 15 females) having proteinuria or microalbuminuria with sickle cell disease and treated the participants for six months (median length of follow-up of three months) with captopril or placebo. At six months, the study reported no significant difference in urinary albumin excretion between the captopril group and the placebo group, although the mean urinary albumin excretion in the captopril group was lower by a mean difference of -49.00 (95% confidence interval -124.10 to 26.10) compared to that of placebo. However, our analysis on the absolute change score showed significant changes between the two groups by a mean difference of -63.00 (95% confidence interval -93.78 to -32.22). At six months albumin excretion in the captopril group was noted to decrease from baseline by a mean of 45 ± 23 mg/day and the placebo group was noted to increase by 18 ± 45 mg/day. Serum creatinine and potassium levels were reported constant throughout the study. The potential for inducing hypotension should be highlighted; the study reported a decrease of 8 mmHg in systolic pressure and 5 mmHg in diastolic and mean blood pressure. AUTHORS' CONCLUSIONS There is not enough evidence to show that the administration of ACE inhibitors is associated with a reduction of microalbuminuria and proteinuria in people with sickle cell disease, although a potential for this was seen. More long-term studies involving multiple centers and larger cohorts using a randomized-controlled design are warranted, especially among the pediatric age group. Detailed reporting of each outcome measure is necessary to allow a clear cut interpretation in a systematic review. One of the difficulties encountered in this review was the lack of detailed data reported in the included study.
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Affiliation(s)
- Teguh H Sasongko
- Human Genome Center, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia.
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Arlet JB, Ribeil JA, Chatellier G, Eladari D, De Seigneux S, Souberbielle JC, Friedlander G, de Montalembert M, Pouchot J, Prié D, Courbebaisse M. Determination of the best method to estimate glomerular filtration rate from serum creatinine in adult patients with sickle cell disease: a prospective observational cohort study. BMC Nephrol 2012; 13:83. [PMID: 22866669 PMCID: PMC3465224 DOI: 10.1186/1471-2369-13-83] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 07/28/2012] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Sickle cell disease (SCD) leads to tissue hypoxia resulting in chronic organ dysfunction including SCD associated nephropathy. The goal of our study was to determine the best equation to estimate glomerular filtration rate (GFR) in SCD adult patients. METHODS We conducted a prospective observational cohort study. Since 2007, all adult SCD patients in steady state, followed in two medical departments, have had their GFR measured using iohexol plasma clearance (gold standard). The Cockcroft-Gault, MDRD-v4, CKP-EPI and finally, MDRD and CKD-EPI equations without adjustment for ethnicity were tested to estimate GFR from serum creatinine. Estimated GFRs were compared to measured GFRs according to the graphical Bland and Altman method. RESULTS Sixty-four SCD patients (16 men, median age 27.5 years [range 18.0-67.5], 41 with SS-genotype were studied. They were Sub-Saharan Africa and French West Indies natives and predominantly lean (median body mass index: 22 kg/m2 [16-33]). Hyperfiltration (defined as measured GFR >110 mL/min/1.73 m2) was detected in 53.1% of patients. Urinary albumin/creatinine ratio was higher in patients with hyperfiltration than in patients with normal GFR (4.05 mg/mmol [0.14-60] versus 0.4 mg/mmol [0.7-81], p = 0.01). The CKD-EPI equation without adjustment for ethnicity had both the lowest bias and the greatest precision. Differences between estimated GFRs using the CKP-EPI equation and measured GFRs decreased with increasing GFR values, whereas it increased with the Cockcroft-Gault and MDRD-v4 equations. CONCLUSIONS We confirm that SCD patients have a high rate of glomerular hyperfiltration, which is frequently associated with microalbuminuria or macroalbuminuria. In non-Afro-American SCD patients, the best method for estimating GFR from serum creatinine is the CKD-EPI equation without adjustment for ethnicity. This equation is particularly accurate to estimate high GFR values, including glomerular hyperfiltration, and thus should be recommended to screen SCD adult patients at high risk for SCD nephropathy.
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Affiliation(s)
- Jean-Benoît Arlet
- Service de Médecine Interne, centre de référence des syndromes drépanocytaires majeurs, Faculté de médecine Paris Descartes et Assistance publique – Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Cedex 15, Paris, 75908, France
| | - Jean-Antoine Ribeil
- Département de Biothérapie, centre de référence des syndromes drépanocytaires majeurs, Faculté de médecine Paris Descartes et Assistance publique – Hôpitaux de Paris, Hôpital Necker Enfants Malades, 161, rue de Sèvres, 75015 Paris Cedex 15, Paris, France, 75908, France
| | - Gilles Chatellier
- Faculté de médecine Paris Descartes et CIC-EC4 INSERM, Assistance publique – Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Cedex 15, Paris, 75908, France
| | - Dominique Eladari
- Service d’Explorations Fonctionnelles. Faculté de médecine Paris Descartes, INSERM U872 et Assistance publique –Hôpitaux de Paris, Hôpital Européen Georges Pompidou, 20, rue Leblanc, Cedex 15, Paris, 75908, France
| | - Sophie De Seigneux
- Service de Néphrologie, Hôpital Cantonal de Genève, 4 rue Perret Gentil, Genève 4, Suisse, 1211, Switzerland
| | - Jean-Claude Souberbielle
- Service d’Explorations Fonctionnelles. Faculté de médecine Paris Descartes, INSERM U845 et Assistance publique –Hôpitaux de Paris, Hôpital Necker Enfants Malades, 161, rue de Sèvres, 75015 Paris, Cedex 15, France, Paris, 75908, France
| | - Gérard Friedlander
- Service d’Explorations Fonctionnelles. Faculté de médecine Paris Descartes, INSERM U845 et Assistance publique –Hôpitaux de Paris, Hôpital Européen Georges Pompidou, 20, rue Leblanc Cedex 15, Paris, 75908, France
| | - Marianne de Montalembert
- Service de Pédiatrie Générale, Assistance publique –Hôpitaux de Paris, Hôpital Necker Enfants Malades, 161, rue de Sèvres, 75015 Paris, Cedex 15, France, Paris, 75908, France
| | - Jacques Pouchot
- Service de Médecine Interne, centre de référence des syndromes drépanocytaires majeurs, Faculté de médecine Paris Descartes et Assistance publique – Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Cedex 15, Paris, 75908, France
| | - Dominique Prié
- Service d’Explorations Fonctionnelles. Faculté de médecine Paris Descartes, INSERM U845 et Assistance publique –Hôpitaux de Paris, Hôpital Necker Enfants Malades, 161, rue de Sèvres, 75015 Paris, Cedex 15, France, Paris, 75908, France
| | - Marie Courbebaisse
- Service d’Explorations Fonctionnelles. Faculté de médecine Paris Descartes, INSERM U845 et Assistance publique –Hôpitaux de Paris, Hôpital Necker Enfants Malades, 161, rue de Sèvres, 75015 Paris, Cedex 15, France, Paris, 75908, France
- Hôpital Européen Georges Pompidou, 20, rue Leblanc, Cedex 15, Paris, 75908, France
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Ballas SK, Kesen MR, Goldberg MF, Lutty GA, Dampier C, Osunkwo I, Wang WC, Hoppe C, Hagar W, Darbari DS, Malik P. Beyond the definitions of the phenotypic complications of sickle cell disease: an update on management. ScientificWorldJournal 2012; 2012:949535. [PMID: 22924029 PMCID: PMC3415156 DOI: 10.1100/2012/949535] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 04/01/2012] [Indexed: 12/25/2022] Open
Abstract
The sickle hemoglobin is an abnormal hemoglobin due to point mutation (GAG → GTG) in exon 1 of the β globin gene resulting in the substitution of glutamic acid by valine at position 6 of the β globin polypeptide chain. Although the molecular lesion is a single-point mutation, the sickle gene is pleiotropic in nature causing multiple phenotypic expressions that constitute the various complications of sickle cell disease in general and sickle cell anemia in particular. The disease itself is chronic in nature but many of its complications are acute such as the recurrent acute painful crises (its hallmark), acute chest syndrome, and priapism. These complications vary considerably among patients, in the same patient with time, among countries and with age and sex. To date, there is no well-established consensus among providers on the management of the complications of sickle cell disease due in part to lack of evidence and in part to differences in the experience of providers. It is the aim of this paper to review available current approaches to manage the major complications of sickle cell disease. We hope that this will establish another preliminary forum among providers that may eventually lead the way to better outcomes.
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Affiliation(s)
- Samir K Ballas
- Cardeza Foundation and Department of Medicine, Thomas Jefferson University, 1015 Walnut Street, Philadelphia, PA 19107, USA.
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Becker AM. Sickle cell nephropathy: challenging the conventional wisdom. Pediatr Nephrol 2011; 26:2099-109. [PMID: 21203778 DOI: 10.1007/s00467-010-1736-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 10/08/2010] [Accepted: 11/02/2010] [Indexed: 01/13/2023]
Abstract
This review explores the current model of sickle cell nephropathy and the limitations of the model. Renal abnormalities are common complications of sickle cell disease (SCD). Beginning in childhood, patients with SCD develop a urinary concentrating defect resulting in polyuria and a predisposition to nocturnal enuresis and dehydration. The current model of sickle cell nephropathy suggests that destruction of the renal medulla induces production of renal vasodilating substances that feedback to the glomerulus causing hyperfiltration. Hyperfiltration leads to glomerulosclerosis and proteinuria, with eventual reduction in kidney function. The crucial steps of vasodilating substance production and hyperfiltration in children with SCD have not been proven. Treatment of sickle cell nephropathy is aimed at the reduction of proteinuria with angiotensin converting enzyme inhibitors or angiotensin receptor blockers. Hydroxyurea and chronic transfusion therapy may also alter the progression of sickle cell nephropathy in children. Further studies are needed to identify an accurate model and effective treatments for sickle cell nephropathy.
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Affiliation(s)
- Amy M Becker
- Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9063, USA.
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Abstract
Despite its apparently simple molecular aetiology, sickle cell disease (SCD) has long been known to have a remarkably variable clinical course, with complications involving many organs including the kidneys. Whilst many affected individuals show no evidence of renal involvement into late adulthood, others develop renal dysfunction in childhood or early adult life with a significant proportion eventually requiring renal replacement therapy. This review explores the pathophysiology and clinical manifestations of sickle cell nephropathy (SCN) and discusses how each complication can be investigated, monitored and managed in the outpatient setting. We summarize current knowledge of genetic modulation of sickle-related renal dysfunction. We outline the evidence for various treatment options and discuss others for which little evidence currently exists.
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Sundaram N, Bennett M, Wilhelm J, Kim MO, Atweh G, Devarajan P, Malik P. Biomarkers for early detection of sickle nephropathy. Am J Hematol 2011; 86:559-66. [PMID: 21630304 DOI: 10.1002/ajh.22045] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Renal complications affect nearly 30-50% of adults with sickle cell anemia (SCA), causing significant morbidity and mortality. Standard renal function tests like serum creatinine and glomerular filtration rate become abnormal in this disease only when renal damage has become extensive and largely irreversible. Moreover, not all patients develop sickle nephropathy (SN). Therefore, noninvasive biomarkers that predict early onset of SN are necessary. We performed a cross-sectional analysis for nephropathy in 116 patients with sickle cell disease, analyzing urinary kidney injury molecule-1 (KIM-1), liver-type fatty acid binding protein (L-FABP), N-acetyl-b-D-glucosaminidase (NAG), neutrophil gelatinase-associated lipocalin (NGAL) and transforming growth factor-β1 (TGF-β), together with conventional renal biomarkers (urine albumin and osmolality, and serum creatinine and cystatin C estimated GFR) during routine clinic visits when patients were at steady-state/baseline. We observed a distinct biomarker pattern: KIM-1 and NAG emerged as biomarkers with a strong association with albuminuria. Surprisingly, and in contrast to other acute/chronic renal disorders, NGAL, L-FABP, and TGF-β levels did not show any relationship with albuminuria in patients with SCA. Our study identifies potential biomarkers for SN, and suggests longitudinal validation of these biomarkers for early detection of SN, so that therapeutic interventions can be applied before renal damage becomes irreversible.
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Affiliation(s)
- Nambirajan Sundaram
- Division of Experimental Hematology and Cancer Biology, University of Cincinnati, Ohio, USA
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Urinary transforming growth factor beta-1 as a marker of renal dysfunction in sickle cell disease. Pediatr Nephrol 2011; 26:275-80. [PMID: 21107986 DOI: 10.1007/s00467-010-1677-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Revised: 09/14/2010] [Accepted: 09/17/2010] [Indexed: 01/21/2023]
Abstract
Renal dysfunction affects 5-18% of patients with sickle cell disease (SCD). To date, no studies have described urinary levels of transforming growth factor β-1 (TGF-β1), a marker of fibrosis, and neutrophil gelatinase-associated lipocalin (NGAL), a marker of acute/chronic kidney disease, as biomarkers in identifying patients at risk of developing renal disease in SCD. We hypothesized that SCD subjects will have increased urinary excretion of TGF-β1 and NGAL compared with healthy controls (CTR). We examined 51 SCD subjects: 42 HbSS, 8 HbSC, and 1 HbSD. Sixteen out of 42 patients with HbSS were on hydroxyurea (HU). Urinary excretion of TGF-β1 was 26.4 ± 1.5 pg/mgCr in SCD subjects vs 15.0 ± 2.4 pg/mgCr in CTR (p<0.00001). SCD patients with hemoglobin < 9 g/dl had higher urinary TGF-β1 than patients with milder anemia (p=0.002). Urinary TGF-β1 trended lower in HbSS patients treated with HU (23.61 ± 2.6 pg/mgCr), vs patients not on HU (27.69 ± 1.8 pg/mgCr; p=0.055). There was no correlation between urinary TGF-β1 and microalbuminuria or estimated glomerular function. There was no difference in urinary NGAL in SCD patients vs CTR. We suggest that urinary TGF-β1 may serve as a marker of early renal injury in SCD.
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Gurkan S, Scarponi KJ, Hotchkiss H, Savage B, Drachtman R. Lactate dehydrogenase as a predictor of kidney involvement in patients with sickle cell anemia. Pediatr Nephrol 2010; 25:2123-7. [PMID: 20517617 DOI: 10.1007/s00467-010-1560-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Revised: 05/04/2010] [Accepted: 05/06/2010] [Indexed: 12/14/2022]
Abstract
A retrospective chart review of 40 patients with sickle cell anemia (SCA) between the ages of 5-19 years who were seen within a 1-year period was performed to determine clinical and laboratory correlates for microalbuminuria and proteinuria. Age, sex, height, body mass index (BMI), serum creatinine [and estimated glomerular filtration rate (eGFR) by Schwartz and MDRD formulas], type of SCA, hemoglobin (Hb) level [total Hb and hemoglobin F percentage (HbF%)], lactate dehydrogenase (LDH) level, reticulocyte count, blood pressure, history of splenectomy, history of hydroxyurea use, and history of transfusions were correlated with microalbuminuria and proteinuria by univariate and multivariate regression analysis. The prevalence of microalbuminuria and proteinuria among these patients was 15 and 5%, respectively. Univariate analyses revealed a significant correlation between LDH level and microalbuminuria (Pearson r=0.47, p=0.04) and between LDH level and proteinuria (Pearson r=0.48, p=0.035). Multivariate analysis revealed a significant correlation between microalbuminuria and LDH level (p = 0.04) when controlled for age, sex, eGFR, Hb level, HbF%, type of SCA, BMI, history of transfusions, and reticulocyte count. In this pediatric SCA population, LDH was found to correlate with the presence of microalbuminuria and proteinuria. Further studies are needed to confirm LDH as an early marker for the risk of kidney involvement among SCA patients.
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Affiliation(s)
- Sevgi Gurkan
- Pediatrics, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey (UMDNJ), New Brunswick, NJ 08901, USA.
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Prevalence and clinical correlates of microalbuminuria in children with sickle cell disease. Pediatr Nephrol 2010; 25:1505-11. [PMID: 20505954 DOI: 10.1007/s00467-010-1536-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Revised: 03/18/2010] [Accepted: 03/19/2010] [Indexed: 10/19/2022]
Abstract
Sickle cell disease (SCD) is associated with a large spectrum of renal abnormalities, one of which, microalbuminuria/proteinuria (MA/P), is a known predictor of end-stage renal disease. We studied 90 children with SCD (57% male; mean age 11.4 +/- 5.2 years) to determine the prevalence and examine clinical correlates of MA/P. The average of two spot urine microalbumin-to-creatinine samples obtained 6 months apart was recorded. Medical records were reviewed for demographic and biochemical data. Medication use, resting office blood pressures (BP), vaso-occlusive pain crises (VOC), and monthly transfusions were recorded. Fourteen children (15.5%) had MA/P. Hemoglobin (Hb) levels were significantly lower in the children with MA than in those without MA/P (8.8 +/- 1.1 vs. 9.8 +/- 1.4 g/dL, respectively) and were significantly correlated with MA (rho = 0.24, p = 0.03). Children with MA were more likely to have abnormal BP (p = 0.058), with 5/14 being hypertensive or pre-hypertensive. In a multivariate logistic regression model of MA, both Hb and BP classification remained in the final model. MA is a simple screening biomarker of early kidney injury in children with SCD. Larger studies to evaluate predictive factors of MA and the relationship to BP are needed.
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Maigne G, Ferlicot S, Galacteros F, Belenfant X, Ulinski T, Niaudet P, Ronco P, Godeau B, Durrbach A, Sahali S, Lang P, Lambotte O, Audard V. Glomerular lesions in patients with sickle cell disease. Medicine (Baltimore) 2010; 89:18-27. [PMID: 20075701 DOI: 10.1097/md.0b013e3181ca59b6] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Sickle cell disease (SCD) is an increasing cause of chronic kidney disease, but the spectrum of glomerular lesions and their underlying mechanisms remain poorly described. We reviewed 18 renal biopsies from patients with SCD and glomerular involvement and studied the expression of hypoxic markers in the biopsy specimens. Four histopathologic variants were distinguished: focal segmental glomerulosclerosis (FSGS) (39%), membranoproliferative glomerulonephritis (28%), thrombotic microangiopathy glomerulopathy (17%), and specific sickle cell disease glomerulopathy (17%). Chronic organ damage and history of acute chest syndrome were associated with the occurrence of SCD glomerulopathy. All patients exhibited macroalbuminuria but only 6 patients displayed impaired renal function. SCD was not associated with a specific FSGS histologic variant. Long-term follow-up analysis revealed that 50% of patients exhibited chronic kidney disease. Regardless of the histologic variants, immunohistochemistry did not reveal a specific induction of hypoxic markers (inducible nitric oxide synthase [iNOS], nitrotyrosine, hypoxia-inducible factor [HIF]-1 alpha) at the time of renal biopsy. This large study shows that a wide spectrum of glomerular lesions is associated with SCD. Whatever lesions are observed, the renal prognosis is poor, and early renoprotective treatment is necessary. Hypoxic state does not seem to play a key role in the progression of glomerular lesions, but its potential role at an early stage of glomerular injury requires further investigation.
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Affiliation(s)
- Gwenola Maigne
- From Internal Medicine Unit (GW, SS, OL), Pathology Department (SF), and Nephrology and Renal Transplantation Department (AD), APHP, Hôpital Kremlin Bicêtre, Université Paris 11, Le Kremlin Bicêtre; Sickle Cell Disease Center (FG) and Internal Medicine Unit (BG), APHP, Hôpital Henri Mondor, Université Paris 12, Créteil; Nephrology and Renal Transplantation Department (PL, VA), APHP, Hôpital Henri Mondor, and Institut Francilien de recherche en Néphrologie et Transplantation (IFRNT), INSERM U 955, Université Paris 12, Créteil; Nephrology Department (XB), Hôpital de Montreuil, Montreuil; Nephrology Department (TU), APHP, Hôpital Trousseau, UPMC Université Paris 06, Paris; Pediatric Nephrology Department (PN), APHP, Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris; Nephrology Department (PR), APHP, Hôpital Tenon, UPMC Université Paris 06, Paris; France
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Estimating glomerular filtration rate by measurement of cystatin C serum concentrations: A comparison with chrome-EDTA clearance. Clin Chim Acta 2008; 393:125-7. [DOI: 10.1016/j.cca.2008.03.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Revised: 03/26/2008] [Accepted: 03/26/2008] [Indexed: 11/23/2022]
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Pashankar FD, Ment LR, Pearson HA. Sickle cell disease complicated by post-streptococcal glomerulonephritis, cerebral hemorrhage and reversible posterior leucoencephalopathy syndrome. Pediatr Blood Cancer 2008; 50:864-6. [PMID: 17973321 DOI: 10.1002/pbc.21321] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A patient with homozygous hemoglobin SS disease presented with an intracerebral hemorrhage complicating reversible posterior leucoencephalopathy syndrome (RPLS), secondary to hypertension associated with acute post-streptococcal glomerulonephritis (APSGN). Distinguishing potentially reversible causes of central nervous system events from primary cerebral infarction or hemorrhage in patients with sickle cell disease is important because the management and prognosis of these complications is very different. Similarly, because of the difference in prognosis between APSGN and other forms of sickle cell nephropathy, it is also important to differentiate these conditions.
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Affiliation(s)
- Farzana D Pashankar
- Department of Pediatrics and Neurology, Yale University School of Medicine, New Haven, Connecticut, USA.
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McKie KT, Hanevold CD, Hernandez C, Waller JL, Ortiz L, McKie KM. Prevalence, prevention, and treatment of microalbuminuria and proteinuria in children with sickle cell disease. J Pediatr Hematol Oncol 2007; 29:140-4. [PMID: 17356390 DOI: 10.1097/mph.0b013e3180335081] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Microalbuminuria (MA) and proteinuria (P) are believed to be precursors of sickle cell nephropathy. We analyzed our longitudinal data on MA/P in children with sickle cell disease (SS) to define the age of onset, association with age, sex, and hemoglobin, and to explore the safety and efficacy of hydroxyurea and angiotensin converting enzyme inhibitor (ACEI) therapy. Data on 191 patients with SS (ages 3 to 20 y) with a mean follow up of 2.19 years+/-2.05 were available. Urine MA was measured yearly with follow-up testing if abnormal. Prevalence of MA/P was 19.4%. Increasing age and lower hemoglobin levels were related to MA/P but sex was not. Microalbumin excretion normalized in 44% of patients treated with hydroxyurea and 56% of patients treated with ACEI. Hyperkalemia developed in 4 ACEI patients resulting in discontinuation of treatment in 3 children. In summary, MA/P often develops in childhood and preventive and treatment strategies for sickle cell nephropathy should be a focus of pediatric programs. Our preliminary data suggest that although both hydroxyurea and ACEI therapy may be beneficial for MA/P, hyperkalemia may limit the utility of ACEI.
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Affiliation(s)
- Kathleen T McKie
- Department of Pediatrics, Medical College of Georgia, Augusta, GA 30912, USA.
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Audard V, Grimbert P, Kirsch M, Habibi MA, Lang P, Remy P, Abbou C, Loisance D, Benaiem N, Bachir D, Vermes E. Successful Combined Heart and Kidney Transplantation in a Patient With Sickle-cell Anemia. J Heart Lung Transplant 2006; 25:993-6. [PMID: 16890124 DOI: 10.1016/j.healun.2006.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2005] [Revised: 02/24/2006] [Accepted: 04/13/2006] [Indexed: 10/24/2022] Open
Abstract
Little is known about the management of dual-organ transplantation for sickle-cell disease (SCD)-related complications. In this case study, we report the successful outcome of combined heart and kidney transplantation in a patient with SCD. The recipient was a 33-year-old man with homozygous SCD, who developed end-stage heart and renal failure requiring combined heart and kidney transplantation. The patient was managed with pre-operative blood transfusion and moderate hypothermic cardiopulmonary bypass, with limited peri-operative complications. During the first 6 months there was one episode of acute heart rejection without concomitant renal rejection. Eighteen months after surgery, the patient is at home without vaso-occlusive crises or septic complications. Heart and renal allograft function is preserved, without coronary artery vasculopathy, but with asymptomatic moderate transplant renal artery stenosis. SCD is managed by periodic transfusion. This case study demonstrates that combined heart and kidney transplantation is feasible in patients with SCD. Careful attention to peri- and post-operative management is required.
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Affiliation(s)
- Vincent Audard
- Department of Nephrology and Transplantation, Henri Mondor Hospital, Université Paris XII, Créteil, France
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Fitzhugh CD, Wigfall DR, Ware RE. Enalapril and hydroxyurea therapy for children with sickle nephropathy. Pediatr Blood Cancer 2005; 45:982-5. [PMID: 15704213 DOI: 10.1002/pbc.20296] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Proteinuria in children with sickle cell anemia (SCA) is an early sign of sickle nephropathy, and portends the development of nephrotic syndrome and chronic renal failure. Enalapril has been shown to reduce proteinuria in adult patients with SCA, but the potential benefits of hydroxyurea in this clinical setting have not been reported. A single institution retrospective analysis was performed. Children with sickle nephropathy were identified, and the laboratory effects of enalapril and hydroxyurea therapy were evaluated in children with substantial proteinuria. Three children developed proteinuria at 8 +/- 1 years of age. Pre-treatment laboratory studies included a low serum albumin (2.8 +/- 0.8 g/dl) and a highly elevated urine protein/creatinine ratio (6.9 +/- 3.7, normal <0.2). Enalapril treatment for 3.0 +/- 1.3 years normalized serum albumin (3.9 +/- 0.3 g/dl) without significant changes in serum potassium, serum creatinine, or systolic blood pressure. However, urine protein/creatinine remained elevated in the nephrotic range (1.6 +/- 0.7). The addition of hydroxyurea therapy for 3.5 +/- 1.2 years increased fetal hemoglobin levels (7.0 +/- 3.6% to 21.0 +/- 3.2%) and was associated with a near-normal urine protein/creatinine ratio (0.5 +/- 0.1). Enalapril therapy for children with sickle nephropathy reduces urinary protein excretion and normalizes serum albumin. Hydroxyurea therapy may further normalize the urine protein/creatinine ratio. Combination therapy should be tested prospectively in children with sickle nephropathy.
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Affiliation(s)
- Courtney D Fitzhugh
- Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina, USA
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Nath KA, Grande JP, Croatt AJ, Frank E, Caplice NM, Hebbel RP, Katusic ZS. Transgenic sickle mice are markedly sensitive to renal ischemia-reperfusion injury. THE AMERICAN JOURNAL OF PATHOLOGY 2005; 166:963-72. [PMID: 15793278 PMCID: PMC1602372 DOI: 10.1016/s0002-9440(10)62318-8] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Ischemic injury is invoked as a mechanism contributing to end-organ damage and other complications of sickle cell disease (SCD). However, the intrinsic sensitivity of tissues in SCD to ischemic insults has never been addressed. We examined the effect of renal ischemia in a transgenic mouse expressing human sickle hemoglobin. Twenty-four hours after bilateral, total renal artery occlusion for 15 minutes, transgenic sickle mice exhibited worse renal function and more marked histological injury. With bilateral renal ischemia of greater duration (22.5 minutes), and after 6 hours, transgenic sickle mice exhibited massive vascular congestion, sickling of red blood cells, more marked histological injury in the kidney, and more prominent congestion in the capillary beds in the lungs and heart. Additionally, serum amyloid P-component, the murine homologue of C-reactive protein, was markedly increased in transgenic sickle mice as compared to wild-type mice. Twenty-four hours after bilateral renal ischemia for 22.5 minutes, transgenic sickle mice exhibited 28% mortality, with no mortality observed in any other group. With bilateral renal ischemia of short or long duration, renal expression of caspase-3 was most prominent in transgenic sickle mice subjected to ischemia. Thus, renal ischemia in this murine model induces more severe renal injury and extrarenal complications. We conclude that tissues in SCD exhibit heightened vascular congestion and sensitivity to ischemia and that clinically apparent or silent episodes of ischemia may contribute to the complications of SCD.
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Affiliation(s)
- Karl A Nath
- Division of Nephrology, Mayo Clinic College of Medicine, 200 First St., SW, Guggenheim 542, Rochester, MN 55905, USA.
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[Enuresis in children with sickle cell disease]. Arch Pediatr 2004; 11:1168-72. [PMID: 15475271 DOI: 10.1016/j.arcped.2004.05.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2003] [Accepted: 05/26/2004] [Indexed: 11/18/2022]
Abstract
POPULATIONS AND METHODS In order to analyze epidemiological and clinical characteristics of enuresis in children with sickle cell disease, and identify risk and aetiological factors, 987 subjects (aged 5-20 years) took part in a cross-sectional study. These children were divided into two groups: group 1 consisted of 456 homozygous children with sickle cell disease (haemoglobin SS), while group 2 consisted of 531 normal children. These groups were paired according to age and sex. RESULTS The prevalence of enuresis was 50.9% in group 1 and 16.4% in group 2, and was significantly higher (P < 0.05) in the girls. The frequency decreased significantly between the ages of 5-20. At age 16, frequency of enuretic children with sickle cell disease remained statistically greater (15.9% vs. 8.0%). The frequency of wet nights was higher (P < 0.05) in group 1. In addition, anaemia crisis and painful crisis were related to prevalence of enuresis. There was a significant (P < 0.01) negative correlation between haemoglobin F percentage and prevalence of enuresis. CONCLUSION Enuresis is frequent in children with sickle cell disease and its intensity is linked to severity of disease.
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Abdulrahman IS. The Kidney in Sickle Cell Disease: Pathophysiology and Clinical Review. Int J Organ Transplant Med 2004. [DOI: 10.1016/s1561-5413(09)60120-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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