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Bhat V, Sheehan VA. Can we use biomarkers to identify those at risk of acute pain from sickle cell disease? Expert Rev Hematol 2024; 17:411-418. [PMID: 38949576 DOI: 10.1080/17474086.2024.2372322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 06/21/2024] [Indexed: 07/02/2024]
Abstract
INTRODUCTION Acute pain episodes, also known as vaso-occlusive crises (VOC), are a major symptom of sickle cell disease (SCD) and lead to frequent hospitalizations. The diagnosis of VOC can be challenging, particularly in adults with SCD, 50% of whom have chronic pain. Several potential biomarkers have been proposed for identifying individuals with VOC, including elevation above the baseline of various vascular growth factors, cytokines, and other markers of inflammation. However, none have been validated to date. AREAS COVERED We summarize prospective biomarkers for the diagnosis of acute pain in SCD, and how they may be involved in the pathophysiology of a VOC. Previous and current strategies for biomarker discovery, including the use of omics techniques, are discussed. EXPERT OPINION Implementing a multi-omics-based approach will facilitate the discovery of objective and validated biomarkers for acute pain.
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Affiliation(s)
- Varsha Bhat
- Center for Integrative Genomics, School of Biological Sciences, Georgia Institute of Technology, Atlanta, GA, USA
| | - Vivien A Sheehan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
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Ahmed B, Arigliani M, Gupta A. Respiratory management of acute chest syndrome in children with sickle cell disease. Eur Respir Rev 2024; 33:240005. [PMID: 39293855 PMCID: PMC11409057 DOI: 10.1183/16000617.0005-2024] [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: 01/08/2024] [Accepted: 07/01/2024] [Indexed: 09/20/2024] Open
Abstract
Acute chest syndrome (ACS) is a leading cause of respiratory distress and hospitalisation in children with sickle cell disease (SCD). The aetiology is multifactorial and includes fat embolism, venous thromboembolism, alveolar hypoventilation and respiratory infections, with the latter being particularly common in children. These triggers contribute to a vicious cycle of erythrocyte sickling, adhesion to the endothelium, haemolysis, vaso-occlusion and ventilation-perfusion mismatch in the lungs, resulting in the clinical manifestations of ACS. The clinical presentation includes fever, chest pain, dyspnoea, cough, wheeze and hypoxia, accompanied by a new pulmonary infiltrate on chest radiography. Respiratory symptoms may overlap with those of acute asthma, which may be difficult to distinguish. Patients with ACS may deteriorate rapidly; thus prevention, early recognition and aggressive, multidisciplinary team management is essential. In this narrative review, we highlight the current evidence regarding the epidemiology, pathophysiology, treatment and preventative strategies for ACS, focusing on the aspects of major interest for the paediatric pulmonologist and multidisciplinary team who manage children with SCD.
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Affiliation(s)
- Bushra Ahmed
- UCL GOS Institute of Child Health, University College London, London, UK
| | - Michele Arigliani
- UCL GOS Institute of Child Health, University College London, London, UK
| | - Atul Gupta
- King's College Hospital, King's College London, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
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Korman R, Hatabah D, Brown LA, Harris F, Wilkinson H, Rees CA, Bakshi N, Archer DR, Dampier C, Morris CR. Impact of arginine therapy on kyotorphin in children with sickle cell disease and vaso-occlusive pain. Blood Adv 2024; 8:3267-3271. [PMID: 38527291 PMCID: PMC11226964 DOI: 10.1182/bloodadvances.2023012209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/12/2024] [Accepted: 02/25/2024] [Indexed: 03/27/2024] Open
Affiliation(s)
- Rawan Korman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Dunia Hatabah
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Lou Ann Brown
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Frank Harris
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | | | - Chris A. Rees
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Children’s Healthcare of Atlanta, Atlanta, GA
| | - Nitya Bakshi
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Children’s Healthcare of Atlanta, Atlanta, GA
| | - David R. Archer
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Carlton Dampier
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Children’s Healthcare of Atlanta, Atlanta, GA
| | - Claudia R. Morris
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Children’s Healthcare of Atlanta, Atlanta, GA
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Rees CA, Brousseau DC, Cohen DM, Villella A, Dampier C, Brown K, Campbell A, Chumpitazi CE, Airewele G, Chang T, Denton C, Ellison A, Thompson A, Ahmad F, Bakshi N, Coleman KD, Leibovich S, Leake D, Hatabah D, Wilkinson H, Robinson M, Casper TC, Vichinsky E, Morris CR. Sickle Cell Disease Treatment with Arginine Therapy (STArT): study protocol for a phase 3 randomized controlled trial. Trials 2023; 24:538. [PMID: 37587492 PMCID: PMC10433602 DOI: 10.1186/s13063-023-07538-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/25/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Despite substantial illness burden and healthcare utilization conferred by pain from vaso-occlusive episodes (VOE) in children with sickle cell disease (SCD), disease-modifying therapies to effectively treat SCD-VOE are lacking. The aim of the Sickle Cell Disease Treatment with Arginine Therapy (STArT) Trial is to provide definitive evidence regarding the efficacy of intravenous arginine as a treatment for acute SCD-VOE among children, adolescents, and young adults. METHODS STArT is a double-blind, placebo-controlled, randomized, phase 3, multicenter trial of intravenous arginine therapy in 360 children, adolescents, and young adults who present with SCD-VOE. The STArT Trial is being conducted at 10 sites in the USA through the Pediatric Emergency Care Applied Research Network (PECARN). Enrollment began in 2021 and will continue for 5 years. Within 12 h of receiving their first dose of intravenous opioids, enrolled participants are randomized 1:1 to receive either (1) a one-time loading dose of L-arginine (200 mg/kg with a maximum of 20 g) administered intravenously followed by a standard dose of 100 mg/kg (maximum 10 g) three times a day or (2) a one-time placebo loading dose of normal saline followed by normal saline three times per day at equivalent volumes and duration as the study drug. Participants, research staff, and investigators are blinded to the participant's randomization. All clinical care is provided in accordance with the institution-specific standard of care for SCD-VOE based on the 2014 National Heart, Lung, and Blood Institute guidelines. The primary outcome is time to SCD-VOE pain crisis resolution, defined as the time (in hours) from study drug delivery to the last dose of parenteral opioid delivery. Secondary outcomes include total parental opioid use and patient-reported outcomes. In addition, the trial will characterize alterations in the arginine metabolome and mitochondrial function in children with SCD-VOE. DISCUSSION Building on the foundation of established relationships between emergency medicine providers and hematologists in a multicenter research network to ensure adequate participant accrual, the STArT Trial will provide definitive information about the efficacy of intravenous arginine for the treatment of SCD-VOE for children. TRIAL REGISTRATION The STArT Trial was registered in ClinicalTrials.gov on April 9, 2021, and enrollment began on June 21, 2021 (NCT04839354).
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Affiliation(s)
- Chris A Rees
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University School of Medicine, 1760 Haygood Drive NE, Atlanta, GA, W45830322, USA
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - David C Brousseau
- Department of Pediatrics, Nemours Children's Health Delaware and the Sidney Kimmel Medical College, Thomas Jefferson University, Wilmington, DE, USA
| | | | | | - Carlton Dampier
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University School of Medicine, 1760 Haygood Drive NE, Atlanta, GA, W45830322, USA
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kathleen Brown
- Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Andrew Campbell
- Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | | | - Gladstone Airewele
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Todd Chang
- Children's Hospital Los Angeles and Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Christopher Denton
- Children's Hospital Los Angeles and Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Angela Ellison
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Fahd Ahmad
- Washington University in St. Louis, St. Louis, MO, USA
| | - Nitya Bakshi
- Division of Pediatric Hematology/Oncology/BMT, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Keli D Coleman
- Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | | | | | - Dunia Hatabah
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University School of Medicine, 1760 Haygood Drive NE, Atlanta, GA, W45830322, USA
| | | | | | | | - Elliott Vichinsky
- Center for Maternal-Fetal Precision Medicine, University of California, San Francisco, CA, USA
- Department of Pediatrics, UCSF-Benioff Children's Hospital-Oakland, Oakland, CA, USA
| | - Claudia R Morris
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University School of Medicine, 1760 Haygood Drive NE, Atlanta, GA, W45830322, USA.
- Children's Healthcare of Atlanta, Atlanta, GA, USA.
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Reyes LZ, Winterberg PD, George RP, Kelleman M, Harris F, Jo H, Brown LAS, Morris CR. Arginine Dysregulation and Myocardial Dysfunction in a Mouse Model and Children with Chronic Kidney Disease. Nutrients 2023; 15:2162. [PMID: 37432321 PMCID: PMC10181438 DOI: 10.3390/nu15092162] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 07/12/2023] Open
Abstract
Cardiovascular disease is the leading cause of death in chronic kidney disease (CKD). Arginine, the endogenous precursor for nitric oxide synthesis, is produced in the kidneys. Arginine bioavailability contributes to endothelial and myocardial dysfunction in CKD. Plasma from 129X1/SvJ mice with and without CKD (5/6th nephrectomy), and banked plasma from children with and without CKD were analyzed for amino acids involved in arginine metabolism, ADMA, and arginase activity. Echocardiographic measures of myocardial function were compared with plasma analytes. In a separate experiment, a non-specific arginase inhibitor was administered to mice with and without CKD. Plasma citrulline and glutamine concentrations correlated with multiple measures of myocardial dysfunction. Plasma arginase activity was significantly increased in CKD mice at 16 weeks vs. 8 weeks (p = 0.002) and ventricular strain improved after arginase inhibition in mice with CKD (p = 0.03). In children on dialysis, arginase activity was significantly increased vs. healthy controls (p = 0.04). Increasing ADMA correlated with increasing RWT in children with CKD (r = 0.54; p = 0.003). In a mouse model, and children, with CKD, arginine dysregulation correlates with myocardial dysfunction.
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Affiliation(s)
- Loretta Z. Reyes
- Division of Pediatric Nephrology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Pamela D. Winterberg
- Division of Pediatric Nephrology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Roshan Punnoose George
- Division of Pediatric Nephrology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Michael Kelleman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Frank Harris
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Hanjoong Jo
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Lou Ann S. Brown
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Claudia R. Morris
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA
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Lowe M, Bambhroliya Z, Patel H, Patel VJ, Vudugula SA, Cheruvu NP, Raza S, Okunlola OI. Emerging Therapies for the Management of Pain and Vaso-Occlusive Crises in Patients With Sickle Cell Disease: A Systematic Review of Randomized Controlled Trials. Cureus 2023; 15:e38014. [PMID: 37223201 PMCID: PMC10204617 DOI: 10.7759/cureus.38014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 04/23/2023] [Indexed: 05/25/2023] Open
Abstract
Sickle cell disease (SCD) is an inherited disorder that impairs red blood cells (RBCs) and disrupts the delivery of oxygen to tissues. There is currently no cure. Symptoms can appear as early as six months of age and include anemia, acute episodes of pain, swelling, infections, delayed growth, and vision problems. A growing number of therapies are being investigated for reducing these episodes of pain, also known as vaso-occlusive crises (VOCs). The research literature evidence, however, currently includes far more approaches that have not shown superiority versus placebo than ones that have been proven effective. The purpose of this systematic review is to evaluate the body of randomized controlled trials (RCTs) to determine the quality of support for and against the use of a variety of current and emerging therapies for treading SCD VOCs. Several important new papers have emerged since previous systematic reviews with similar objectives were published. This review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and focused on PubMed exclusively. Only RCTs were sought, and no other filters, except for a five-year historical timeline cut-off, were used. Of the 46 publications that were returned in response to the query, 18 were ultimately accepted as meeting the pre-established inclusion criteria. The Cochrane risk-of-bias tool was utilized as a quality assessment measure, and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework was used to assess the certainty of the evidence. Among the included publications, five out of 18 featured positive results with superiority and statistical significance versus placebo for either reduction in pain score or number/duration of VOCs. The approaches featured therapies ranging from de novo molecules to currently available drugs approved for other indications to naturally occurring metabolites such as amino acids and vitamins. A single therapy, arginine, was supported for both clinical endpoints: pain score reduction and shortened VOC duration. Currently, two therapies are approved by the United States Food and Drug Administration (FDA) and are commercially available (crizanlizumab, ADAKVEO and L-glutamine, Endari). All other therapies are investigational only in nature. Several studies included measurement of biomarker endpoints as well as clinical outcomes. Generally, beneficial outcomes related to improving biomarker levels did not also translate into statistically significant reduction of pain scores or number/duration of VOCs. While measuring biomarkers may contribute to the understanding of pathophysiology, it does not appear to directly offer predictive value toward treatment success clinically. It can be concluded that there exists a specific opportunity to design, fund, and execute investigations that both compare emerging and existing therapies versus one another and compare combinational therapies versus placebo.
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Affiliation(s)
- Michael Lowe
- Seeking Anesthesiology, Ross University School of Medicine, Fort Lauderdale, USA
| | - Zarna Bambhroliya
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Hesha Patel
- Internal Medicine, Capital Health Medical Center, New Jersey, USA
| | - Vishva J Patel
- Medicine, Gujarat Medical Education and Research Society (GMERS) Medical College, Vadodara, IND
| | | | | | - Shafaat Raza
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Majumdar S, McKinley K, Chamberlain J, Thomas B, Margulies S, Nickel R, Darbari D, Campbell A, Berul C, Summar M, Kalsi G. Design of an adaptive randomized clinical trial of intravenous citrulline for sickle cell pain crisis in the emergency department. Contemp Clin Trials Commun 2023; 32:101077. [PMID: 36698745 PMCID: PMC9868327 DOI: 10.1016/j.conctc.2023.101077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 11/06/2022] [Accepted: 01/14/2023] [Indexed: 01/18/2023] Open
Abstract
Background Vaso-occlusive pain crisis (VOC) is the most frequent cause for Emergency Department (ED) visits and hospital admissions for patients with sickle cell disease (SCD). Nitric oxide plays a critical role in the pathogenesis of vaso-occlusion. The amino acid, citrulline, is the main endothelial nitric oxide booster that offers the potential to ameliorate vaso-occlusion and decrease the risk of hospitalization. Objective In this two-part study, the goal of the first part is to determine the pharmacokinetic profile of intravenous (IV) l-citrulline and optimal dose for the second part of the study, which is to determine the efficacy and tolerability of the intervention in patients with SCD. Design A phase I/IIA open-label dose-finding study with subsequent double-blind, placebo-controlled, randomized Study of l-citrulline in children and adolescents with SCD presenting to the ED in VOC. Methods Part 1: Subjects experiencing VOC are enrolled in an open-label, ascending dose of IV l-citrulline to identify the optimum dose with endpoints of pharmacokinetic parameters, pain scores, reduction of opioid use, quality of life, proportion admitted to the hospital for treatment of pain, readmission rates, and assessment of adverse events. Part 2 of the trial is a double-blind, placebo-controlled adaptive "pick-the-winner" design to evaluate the efficacy and tolerability of IV l-citrulline in patients with SCD while receiving standard of care therapy for VOC. Summary This ED based sickle cell adaptive trial will determine the optimal dose for IV citrulline and whether the intervention improves outcome as a potential novel therapy for VOC in SCD.
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Affiliation(s)
- S. Majumdar
- Departments of Hematology at Children's National Hospital, United States,Corresponding author. Center for Cancer & Blood Disorders, Washington DC, 20010, United States.
| | - K.W. McKinley
- Departments of Emergency Medicine at Children's National Hospital, United States
| | - J. Chamberlain
- Departments of Emergency Medicine at Children's National Hospital, United States
| | - B. Thomas
- Departments of Emergency Medicine at Children's National Hospital, United States
| | - S. Margulies
- Departments of Hematology at Children's National Hospital, United States
| | - R.S. Nickel
- Departments of Hematology at Children's National Hospital, United States
| | - D.S. Darbari
- Departments of Hematology at Children's National Hospital, United States
| | - A. Campbell
- Departments of Hematology at Children's National Hospital, United States
| | - C. Berul
- Departments of Cardiology at Children's National Hospital, United States
| | - M. Summar
- Departments of Genetics at Children's National Hospital, United States
| | - G. Kalsi
- Asklepion Pharmaceuticals, United States
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Correlation of Asymmetric Dimethyl Arginine Level to Sickle Retinopathy in Children With Sickle Cell Disease. J Pediatr Hematol Oncol 2023; 45:e48-e51. [PMID: 35180766 DOI: 10.1097/mph.0000000000002435] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/20/2022] [Indexed: 02/03/2023]
Abstract
Asymmetric dimethyl arginine (ADMA) is a competitive inhibitor of nitric oxide synthetase especially in L-arginine deficiency, which is the case in sickle cell disease (SCD). we aimed to assess the level of ADMA in children with sickle retinopathy and to correlate it to the degree of retinopathy. In this cross-sectional study 40 children with SCD were included, 20 of them with sickle cell retinopathy (SCR) (group I), 20 with normal fundus examination (group II), and another 20 healthy children served as controls (group III). We measured ADMA level by ELISA and performed fundus examination. Seventeen of the 20 children included in group I had Grade I retinopathy (85%), 2 children had Grade II retinopathy (10%), and 1 child had Grade III retinopathy (5%). ADMA was significantly higher in SCD than controls ( P -value <0.001), and it was even higher in patients with SCR compared those without retinopathy ( P -value <0.002), and there was positive linear correlation between ADMA and the grade of retinopathy. The type of retinopathy detect in the studied patients was the nonproliferative type. In conclusion, ADMA is elevated in children with SCD, and its level is even higher in those who develop SCR.
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Zhou Y, Yu X, Nicely A, Cunningham G, Challa C, McKinley K, Nickel R, Campbell A, Darbari D, Summar M, Majumdar S. Amino acid signature during sickle cell pain crisis shows significant alterations related to nitric oxide and energy metabolism. Mol Genet Metab 2022; 137:146-152. [PMID: 36030599 DOI: 10.1016/j.ymgme.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 08/15/2022] [Accepted: 08/17/2022] [Indexed: 11/20/2022]
Abstract
Nitric oxide depletion secondary to arginase induced arginine deficiency has been shown to be important in the pathophysiology of vaso-occlusion in sickle cell pain crisis. Our objective of this study was to perform a comprehensive amino acid evaluation during sickle cell pain crisis. In a total of 58 subjects (29 in steady-state sickle cell disease and 29 with sickle cell pain crisis), the amino acids related to nitric oxide pathway was significantly decreased during sickle cell pain crisis compared to steady-state sickle cell disease: arginine (p = 0.001), citrulline (p = 0.012), and ornithine (p = 0.03). In addition, the amino acids related to energy metabolism was significantly decreased during a pain crisis: asparagine (p < 0.001), serine (p = 0.002), histidine (p = 0.017), alanine (p = 0.004), tyrosine (p = 0.012), methionine (p = 0.007), cystine (p = 0.016), isoleucine (p = 0.016) and lysine (p = 0.006). The amino acid related to oxidative stress were significantly higher during a sickle cell pain crisis (glutamic acid (p < 0.001). Furthermore, multivariate analysis with partial least squares-discriminant analysis (PLS-DA) showed that deficiencies of the amino acids arginine, asparagine, citrulline, methionine and alanine were the most important related to sickle cell pain crisis.
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Affiliation(s)
- Yun Zhou
- Divisions of Genetics, Children's National Hospital, George Washington University of Health Sciences, United States of America
| | - Xue Yu
- Department of Data Science, University of Mississippi Medical Center, United States of America
| | - Ava Nicely
- Hematology, Children's National Hospital, George Washington University of Health Sciences, United States of America
| | - Gary Cunningham
- Divisions of Genetics, Children's National Hospital, George Washington University of Health Sciences, United States of America
| | - Chaitanya Challa
- Anesthesia, Children's National Hospital, George Washington University of Health Sciences, United States of America
| | - Kenneth McKinley
- Emergency Department, Children's National Hospital, George Washington University of Health Sciences, United States of America
| | - Robert Nickel
- Hematology, Children's National Hospital, George Washington University of Health Sciences, United States of America
| | - Andrew Campbell
- Hematology, Children's National Hospital, George Washington University of Health Sciences, United States of America
| | - Deepika Darbari
- Hematology, Children's National Hospital, George Washington University of Health Sciences, United States of America
| | - Marshall Summar
- Divisions of Genetics, Children's National Hospital, George Washington University of Health Sciences, United States of America
| | - Suvankar Majumdar
- Hematology, Children's National Hospital, George Washington University of Health Sciences, United States of America.
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Increasing nitric oxide bioavailability fails to improve collateral vessel formation in humanized sickle cell mice. J Transl Med 2022; 102:805-813. [PMID: 35354915 PMCID: PMC9329194 DOI: 10.1038/s41374-022-00780-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/28/2022] [Accepted: 03/04/2022] [Indexed: 11/08/2022] Open
Abstract
Sickle cell disease (SCD) is associated with repeated bouts of vascular insufficiency leading to organ dysfunction. Deficits in revascularization following vascular injury are evident in SCD patients and animal models. We aimed to elucidate whether enhancing nitric oxide bioavailability in SCD mice improves outcomes in a model of vascular insufficiency. Townes AA (wild type) and SS (sickle cell) mice were treated with either L-Arginine (5% in drinking water), L-NAME (N(ω)-nitro-L-arginine methyl ester; 1 g/L in drinking water) or NO-generating hydrogel (PA-YK-NO), then subjected to hindlimb ischemia via femoral artery ligation and excision. Perfusion recovery was monitored over 28 days via LASER Doppler perfusion imaging. Consistent with previous findings, perfusion was impaired in SS mice (63 ± 4% of non-ischemic limb perfusion in AA vs 33 ± 3% in SS; day 28; P < 0.001; n = 5-7) and associated with increased necrosis. L-Arginine treatment had no significant effect on perfusion recovery or necrosis (n = 5-7). PA-YK-NO treatment led to worsened perfusion recovery (19 ± 3 vs. 32 ± 3 in vehicle-treated mice; day 7; P < 0.05; n = 4-5), increased necrosis score (P < 0.05, n = 4-5) and a 46% increase in hindlimb peroxynitrite (P = 0.055, n = 4-5). Interestingly, L-NAME worsened outcomes in SS mice with decreased in vivo lectin staining following ischemia (7 ± 2% area in untreated vs 4 ± 2% in treated mice, P < 0.05, n = 5). Our findings demonstrate that L-arginine and direct NO delivery both fail to improve postischemic neovascularization in SCD. Addition of NO to the inflammatory, oxidative environment in SCD may result in further oxidative stress and limit recovery.
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Aboursheid T, Albaroudi O, Alahdab F. Inhaled nitric oxide for treating pain crises in people with sickle cell disease. Cochrane Database Syst Rev 2022; 7:CD011808. [PMID: 35802341 PMCID: PMC9266993 DOI: 10.1002/14651858.cd011808.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND In people with sickle cell disease, sickled red blood cells cause the occlusion of small blood vessels, which presents as episodes of severe pain known as pain crises or vaso-occlusive crises. The pain can occur in the bones, chest, or other parts of the body, and may last several hours to days. Pain relief during crises includes both pharmacologic and non-pharmacologic treatments. The efficacy of inhaled nitric oxide in pain crises has been a subject of controversy; hypotheses have been made suggesting a beneficial response due to its vasodilator properties, yet no conclusive evidence has been presented. This review aimed to evaluate the available randomised controlled studies addressing this topic. OBJECTIVES To capture the body of evidence evaluating the efficacy and safety of the use of inhaled nitric oxide in treating pain crises in people with sickle cell disease, and to assess the relevance, robustness, and validity of the treatment to better guide medical practice in the fields of haematology and palliative care (since the recent literature seems to favour the involvement of palliative care for such people). SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Trials Register. We searched for unpublished work in the abstract books of the European Haematology Association conference, the American Society of Hematology conference, the British Society for Haematology Annual Scientific Meeting, the Caribbean Health Research Council Meetings, and the National Sickle Cell Disease Program Annual Meeting. The most recent search was conducted on 1 September 2021. We also searched ongoing study registries on 19 November 2021. SELECTION CRITERIA Randomised and quasi-randomised trials comparing inhaled nitric oxide with placebo for treating pain crises in people with sickle cell disease. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data (including adverse event data), with any disagreements resolved by consulting a third review author. When the data were not reported in the text, we attempted to extract the data from available tables or figures. We contacted trial authors for additional information. We assessed the certainty of the evidence using the GRADE criteria. MAIN RESULTS We included three trials involving a total of 188 participants in the review. There were equal numbers of males and females. Most participants were adults, although one small trial was conducted in a children's hospital and recruited children over the age of 10 years. All three parallel trials compared inhaled nitric oxygen (80 parts per million (ppm)) to placebo (nitrogen gas mixed with oxygen or room air) for four hours; one trial continued administering nitric oxide (40 ppm) for a further four hours. This extended trial had an overall low risk of bias; however, we had concerns about risk of bias for the remaining two trials due to their small sample size, and additionally a high risk of bias due to financial conflicts of interest in one of these smaller trials. We were only able to analyse some limited data from the eight-hour trial, reporting the remaining results narratively. Evidence from one trial (150 participants) suggested that inhaled nitric oxide may not reduce the time to pain resolution: inhaled nitric oxide median 73.0 hours (95% confidence interval (CI) 46.0 to 91.0) and with placebo median 65.5 hours (95% CI 48.1 to 84.0) (low-certainty evidence). No trial reported on the duration of the initial pain crisis. Only one large trial reported on the frequency of pain crises in the follow-up period and found there may be little or no difference between the inhaled nitric oxide and placebo groups for return to the emergency department (risk ratio (RR) 0.73, 95% CI 0.31 to 1.71) and rehospitalisation (RR 0.53, 95% CI 0.25 to 1.11) (150 participants; low-certainty evidence). There may be little or no difference between treatment and placebo in terms of reduction in pain score at any time point up to eight hours (150 participants). The two smaller trials reported a beneficial effect of inhaled nitric oxide in reducing the visual analogue pain score after four hours of the intervention. Analgesic use was reported not to differ greatly between the inhaled nitric oxide group and placebo group in any of the three trials, but no analysable data were provided. Two trials reported the median duration of hospitalisation: in the largest trial the placebo group had the shorter duration, whilst in the second smaller (paediatric) trial hospitalisation was shorter in the treatment group. Only the largest trial (150 participants) reported serious adverse events, with no increase in the inhaled nitric oxide group during or after the intervention compared to the control group (acute chest syndrome occurred in 5 out of 75 participants from each group, pyrexia in 1 out of 75 participants from each group, and dysphagia and a drop in haemoglobin were each reported in 1 out of 75 participants in the inhaled nitric oxide group) (low-certainty evidence). AUTHORS' CONCLUSIONS The currently available evidence is insufficient to determine the effects (benefits or harms) of using inhaled nitric oxide to treat pain (vaso-occlusive) crises in people with sickle cell disease. Large-scale, long-term trials are needed to provide more robust data in this area. Patient-important outcomes (e.g. measures of pain and time to pain resolution and amounts of analgesics used), as well as use of healthcare services, should be measured and reported in a standardised manner.
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Affiliation(s)
| | - Omar Albaroudi
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | - Fares Alahdab
- Evidence-based Practice Center, Mayo Clinic, Rochester, MN, USA
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12
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Onalo R, Cilliers A, Cooper P, Morris CR. Arginine Therapy and Cardiopulmonary Hemodynamics in Hospitalized Children with Sickle Cell Anemia: A Prospective, Double-blinded, Randomized Placebo-controlled Clinical Trial. Am J Respir Crit Care Med 2022; 206:70-80. [PMID: 35426778 PMCID: PMC9954326 DOI: 10.1164/rccm.202108-1930oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Acute changes in cardiopulmonary hemodynamics that include tricuspid regurgitant jet velocity (TRV) elevation measured by Doppler echocardiography are often encountered during sickle cell vasoocclusive pain and acute chest syndrome (ACS). Arginine and nitric oxide depletion develop in patients with these complications. Arginine administration may therefore improve nitric oxide bioavailability and potentiate pulmonary vasodilatation. Objectives: To evaluate effects of l-arginine supplementation on Doppler indices of cardiopulmonary hemodynamics in children with sickle cell anemia experiencing pain. Methods: This was a prospective, double-blinded, randomized placebo-controlled trial of oral arginine in children with sickle cell anemia age 5-17 years hospitalized with severe pain and/or ACS. Measurements and Main Results: Blood biomarkers and Doppler echocardiographic indices of cardiopulmonary hemodynamics were measured before and after supplementation. The mean change in TRV, pulmonary artery systolic pressure, mean pulmonary artery pressure, and other indices of cardiopulmonary hemodynamics were tested with paired Student's t test and correlated with markers of arginine bioavailability using Pearson correlation. Sixty-six children were randomized into arginine versus placebo groups. An elevated TRV ⩾ 2.5 m/s was seen in 40 (61%) patients. A Day 5 Doppler echocardiogram was performed in 47 patients who remained hospitalized. A greater reduction in median TRV occurred in the arginine group than placebo (22.2%, n = 22 vs. 3.8%, n = 25; p < 0.01). A larger percentage increase in global arginine bioavailability was associated with a lower TRV after 5 days of supplementation (r = -0.533; P = 0.001). Significant differences in multiple indices of cardiopulmonary hemodynamics and mean N-terminal pro B-type brain natriuretic peptide were also noted after arginine therapy. Conclusions: Oral arginine supplementation improves cardiopulmonary hemodynamics during sickle cell disease vasoocclusive pain and ACS.Clinical trial registered with Pan African Clinical Trial Registry https://pactr.samrc.ac.za/Search.aspx (PACTR201611001864290).
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Affiliation(s)
- Richard Onalo
- Cardiology Unit, Department of Paediatrics, Faculty of Clinical Sciences, University of Abuja, Abuja, Nigeria
| | - Antoinette Cilliers
- Division of Paediatric Cardiology, Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, and
| | - Peter Cooper
- Department of Paediatrics and Child Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Claudia R. Morris
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia;,Children’s Healthcare of Atlanta, Atlanta, Georgia; and,Center for Clinical and Translational Research of Children’s Healthcare of Atlanta and Emory University, Atlanta, Georgia
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13
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Redaelli S, Magliocca A, Malhotra R, Ristagno G, Citerio G, Bellani G, Berra L, Rezoagli E. Nitric oxide: Clinical applications in critically ill patients. Nitric Oxide 2022; 121:20-33. [PMID: 35123061 PMCID: PMC10189363 DOI: 10.1016/j.niox.2022.01.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/19/2022] [Accepted: 01/31/2022] [Indexed: 12/19/2022]
Abstract
Inhaled nitric oxide (iNO) acts as a selective pulmonary vasodilator and it is currently approved by the FDA for the treatment of persistent pulmonary hypertension of the newborn. iNO has been demonstrated to effectively decrease pulmonary artery pressure and improve oxygenation, while decreasing extracorporeal life support use in hypoxic newborns affected by persistent pulmonary hypertension. Also, iNO seems a safe treatment with limited side effects. Despite the promising beneficial effects of NO in the preclinical literature, there is still a lack of high quality evidence for the use of iNO in clinical settings. A variety of clinical applications have been suggested in and out of the critical care environment, aiming to use iNO in respiratory failure and pulmonary hypertension of adults or as a preventative measure of hemolysis-induced vasoconstriction, ischemia/reperfusion injury and as a potential treatment of renal failure associated with cardiopulmonary bypass. In this narrative review we aim to present a comprehensive summary of the potential use of iNO in several clinical conditions with its suggested benefits, including its recent application in the scenario of the COVID-19 pandemic. Randomized controlled trials, meta-analyses, guidelines, observational studies and case-series were reported and the main findings summarized. Furthermore, we will describe the toxicity profile of NO and discuss an innovative proposed strategy to produce iNO. Overall, iNO exhibits a wide range of potential clinical benefits, that certainly warrants further efforts with randomized clinical trials to determine specific therapeutic roles of iNO.
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Affiliation(s)
- Simone Redaelli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Aurora Magliocca
- Department of Medical Physiopathology and Transplants, University of Milan, Milano, Italy
| | - Rajeev Malhotra
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Giuseppe Ristagno
- Department of Medical Physiopathology and Transplants, University of Milan, Milano, Italy; Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Neuroscience Department, NeuroIntensive Care Unit, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, ECMO Center, San Gerardo University Hospital, Monza, Italy
| | - Lorenzo Berra
- Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Respiratory Care Department, Massachusetts General Hospital, Boston, MA, USA
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, ECMO Center, San Gerardo University Hospital, Monza, Italy.
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14
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Okon IA, Atiang Bes J, S. Udoakag I, Pius Udia J, Udofia Owu D. L-Arginine Oral Supplementation Reverses Hematological and Electrolytes Imbalances in Adrenaline-Induced Myocardial Injury in Rats. JOURNAL OF MEDICAL SCIENCES 2022. [DOI: 10.3923/jms.2022.90.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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15
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Morris CR, Kuypers FA, Hagar R, Larkin S, Lavrisha L, Saulys A, Vichinsky EP, Suh JH. Implications for the Metabolic Fate of Oral Glutamine Supplementation within Plasma and Erythrocytes of Patients with Sickle Cell Disease: A Pharmacokinetics Study. Complement Ther Med 2022; 64:102803. [PMID: 35032556 DOI: 10.1016/j.ctim.2022.102803] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 11/13/2021] [Accepted: 01/10/2022] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES L-Glutamine is FDA-approved for sickle cell disease (SCD), yet the mechanism(s)-of-action are poorly understood. We performed a pharmacokinetics (pK) study to determine the metabolic fate of glutamine supplementation on plasma and erythrocyte amino acids in patients with SCD. DESIGN A pK study was performed where patients with SCD fasting for >8hours received oral L-glutamine (10 grams). Blood was analyzed at baseline, 30/60/90minutes/2/3/4/8 hrs. A standardized diet was administered to all participants at 3 established time-points (after 2/5/7hrs). A subset of patients also had pK studies performed without glutamine supplementation to follow normal diurnal fluctuations in amino acids. SETTING Comprehensive SCD Center in Oakland, California RESULTS: Five patients with SCD were included, three of whom performed pK studies both with and without glutamine supplementation. Average age was 50.6 ± 5.6 years, 60% were female, 40% SS, 60% SC. Plasma glutamine levels increased significantly after oral glutamine supplementation, compared to minimal fluctuations with diet. Plasma glutamine concentration peaked within 30-minutes of ingestion (p=0.01) before decreasing to a plateau by 2-hours that remained higher than baseline by 8hours. Oral glutamine also increased plasma arginine concentration, which peaked by 4-hrs (p=0.03) and remained elevated through 8-hrs. Erythrocyte glutamine levels began to increase by 8-hours, while erythrocyte arginine concentration peaked at 4-hours. CONCLUSIONS Oral glutamine supplementation acutely improved glutamine and arginine bioavailability in both plasma and erythrocytes. This is the first study to demonstrate that glutamine therapy increases arginine bioavailability and may provide insight into shared mechanisms-of-action between these conditionally-essential amino acids.
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Affiliation(s)
- Claudia R Morris
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA; Children's Healthcare of Atlanta, Atlanta, Georgia, USA.
| | - Frans A Kuypers
- Department of Hematology/Oncology, UCSF-Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - Robert Hagar
- Department of Hematology/Oncology, UCSF-Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - Sandra Larkin
- Department of Hematology/Oncology, UCSF-Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - Lisa Lavrisha
- Department of Hematology/Oncology, UCSF-Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - Augusta Saulys
- Department of Emergency Medicine, UCSF-Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - Elliott P Vichinsky
- Department of Hematology/Oncology, UCSF-Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - Jung H Suh
- Department of Hematology/Oncology, UCSF-Benioff Children's Hospital Oakland, Oakland, CA, USA
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16
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Knisely MR, Tanabe PJ, Walker JKL, Yang Q, Shah NR. Severe Persistent Pain and Inflammatory Biomarkers in Sickle Cell Disease: An Exploratory Study. Biol Res Nurs 2022; 24:24-30. [PMID: 34189962 PMCID: PMC9248289 DOI: 10.1177/10998004211027220] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Severe pain is among the most common and deleterious symptoms experienced by individuals with sickle cell disease (SCD), of whom more than 50% report chronic pain. Despite this, the understanding of the biological contributors to persistent severe SCD pain is limited. This exploratory study sought to describe pain phenotypes based on frequency of severe pain experienced over 6 months and identify inflammatory biomarkers associated with pain phenotypes among individuals with SCD. METHODS This study used self-report and electronic health record data collected from 74 individuals enrolled in the Duke Sickle Cell Disease Implementation Consortium Registry. Plasma from previously collected blood specimens was used to generate inflammatory biomarker data using the Inflammation 20-plex ProcartaPlexTM panel. Descriptive statistics were used to describe the occurrence of severe pain over the past 6 months, and bi-variate analyses were used to evaluate the relationship between inflammatory biomarkers and pain phenotypes. RESULTS Among the 74 participants included in this study, 33.8% reported severe pain occurring never or rarely, 40.5% reported severe pain occurring sometimes, and 25.7% reported severe pain occurring often or always. Soluble E-selectin (sE-selectin) was the only inflammatory biomarker significantly associated with the pain phenotype groups (p = 0.049). Post hoc comparisons identified that participants in the often/always severe pain group had significantly higher plasma concentrations of sE-selectin compared to those in the sometimes severe pain group (p = 0.040). CONCLUSIONS Our findings provide preliminary evidence of the frequent occurrence of severe pain and that sE-selectin may be an objective biomarker for the frequent occurrence of severe pain in this population.
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Affiliation(s)
| | | | | | - Qing Yang
- Duke University School of Nursing,
Durham, NC, USA
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17
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Reyes LZ, Figueroa J, Leake D, Khemani K, Kumari P, Bakshi N, Lane PA, Dampier C, Morris CR. Safety of intravenous arginine therapy in children with sickle cell disease hospitalized for vaso-occlusive pain: A randomized placebo-controlled trial in progress. Am J Hematol 2022; 97:E21-E24. [PMID: 34724240 PMCID: PMC8722015 DOI: 10.1002/ajh.26396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 10/25/2021] [Accepted: 10/28/2021] [Indexed: 01/03/2023]
Affiliation(s)
- Loretta Z. Reyes
- Department of Pediatrics, Emory University School of
Medicine, Atlanta, Georgia, USA,Children’s Healthcare of Atlanta, Atlanta, Georgia,
USA
| | - Janet Figueroa
- Department of Pediatrics, Emory University School of
Medicine, Atlanta, Georgia, USA,Children’s Healthcare of Atlanta, Atlanta, Georgia,
USA
| | - Deborah Leake
- Children’s Healthcare of Atlanta, Atlanta, Georgia,
USA
| | - Kirshma Khemani
- Department of Pediatrics, Emory University School of
Medicine, Atlanta, Georgia, USA,Children’s Healthcare of Atlanta, Atlanta, Georgia,
USA
| | - Polly Kumari
- Department of Pediatrics, Emory University School of
Medicine, Atlanta, Georgia, USA,Children’s Healthcare of Atlanta, Atlanta, Georgia,
USA
| | - Nitya Bakshi
- Department of Pediatrics, Emory University School of
Medicine, Atlanta, Georgia, USA,Children’s Healthcare of Atlanta, Atlanta, Georgia,
USA
| | - Peter A. Lane
- Department of Pediatrics, Emory University School of
Medicine, Atlanta, Georgia, USA,Children’s Healthcare of Atlanta, Atlanta, Georgia,
USA
| | - Carlton Dampier
- Department of Pediatrics, Emory University School of
Medicine, Atlanta, Georgia, USA,Children’s Healthcare of Atlanta, Atlanta, Georgia,
USA
| | - Claudia R. Morris
- Department of Pediatrics, Emory University School of
Medicine, Atlanta, Georgia, USA,Children’s Healthcare of Atlanta, Atlanta, Georgia,
USA
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18
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White J, Callaghan MU, Gao X, Liu K, Zaidi A, Tarasev M, Hines PC. Longitudinal assessment of adhesion to vascular cell adhesion molecule-1 at steady state and during vaso-occlusive crises in sickle cell disease. Br J Haematol 2021; 196:1052-1058. [PMID: 34850378 PMCID: PMC9299835 DOI: 10.1111/bjh.17954] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 10/18/2021] [Accepted: 10/28/2021] [Indexed: 01/01/2023]
Abstract
Sickle cell disease (SCD) is characterized by frequent and unpredictable vaso‐occlusive crises (VOCs). Sickle erythrocytes (SSRBCs) contribute to VOCs by participating in a series of adhesive events with blood cells and the vascular endothelium. Adhesion assays have been used to evaluate the relationship between SSRBC adhesion and SCD severity. We developed a standardized, clinical flow adhesion assay of whole blood to vascular cell adhesion molecule (FA‐WB‐VCAM). The objective of this study was to assess the variability and clinical predictive value of FA‐WB‐VCAM in a six‐month longitudinal, observational study (ELIPSIS) in SCD subjects during at‐home, steady‐state and self‐reported VOCs, and following VOC resolution. We observed a strong relationship between FA‐WB‐VCAM and SCD severity. Adhesion indices were significantly lower in SCD subjects on hydroxycarbamide and increased during VOCs; at‐home VOCs had significantly higher FA‐WB‐VCAM than steady‐state and contact VOCs. SCD subjects with a high frequency of self‐reported VOCs had a pro‐adhesive phenotype at steady state and were stratified into a high‐adhesive phenotype cohort; two years prospectively we observed a higher frequency of VOCs in the high‐adhesion cohort. This study supports stratifying SCD subjects based on steady‐state FA‐WB‐VCAM and suggests that FA‐WB‐VCAM may be a plausible surrogate end‐point for SCD severity.
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Affiliation(s)
- Jennell White
- Department of Pharmacology, Wayne State University School of Medicine, Detroit, MI, USA.,Functional Fluidics, Children's Hospital of Michigan, Detroit, MI, USA
| | - Michael U Callaghan
- Division of Pediatric Hematology and Oncology, Children's Hospital of Michigan, Detroit, MI, USA
| | - Xiufeng Gao
- Functional Fluidics, Children's Hospital of Michigan, Detroit, MI, USA
| | - Ke Liu
- Functional Fluidics, Children's Hospital of Michigan, Detroit, MI, USA
| | - Ahmar Zaidi
- Division of Pediatric Hematology and Oncology, Children's Hospital of Michigan, Detroit, MI, USA
| | - Michael Tarasev
- Functional Fluidics, Children's Hospital of Michigan, Detroit, MI, USA
| | - Patrick C Hines
- Functional Fluidics, Children's Hospital of Michigan, Detroit, MI, USA.,Division of Pediatric Critical Care Medicine, Children's Hospital of Michigan, Detroit, MI, USA
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19
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Impact of arginine therapy on mitochondrial function in children with sickle cell disease during vaso-occlusive pain. Blood 2021; 136:1402-1406. [PMID: 32384147 DOI: 10.1182/blood.2019003672] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 04/27/2020] [Indexed: 12/30/2022] Open
Abstract
Altered mitochondrial function occurs in sickle cell disease (SCD), due in part to low nitric oxide (NO) bioavailability. Arginine, the substrate for NO production, becomes acutely deficient in SCD patients with vaso-occlusive pain episodes (VOE). To determine if arginine improves mitochondrial function, 12 children with SCD-VOE (13.6 ± 3 years; 67% male; 75% hemoglobin-SS) were randomized to 1 of 3 arginine doses: (1) 100 mg/kg IV 3 times/day (TID); (2) loading dose (200 mg/kg) then 100 mg/kg TID; or (3) loading dose (200 mg/kg) followed by continuous infusion (300 mg/kg per day) until discharge. Platelet-rich plasma mitochondrial activity, protein expression, and protein-carbonyls were measured from emergency department (ED) presentation vs discharge. All VOE subjects at ED presentation had significantly decreased complex-V activity compared to a steady-state cohort. Notably, complex-V activity was increased at discharge in subjects from all 3 arginine-dosing schemes; greatest increase occurred with a loading dose (P < .001). Although complex-IV and citrate synthase activities were similar in VOE platelets vs steady state, enzyme activities were significantly increased in VOE subjects after arginine-loading dose treatment. Arginine also decreased protein-carbonyl levels across all treatment doses (P < .01), suggesting a decrease in oxidative stress. Arginine therapy increases mitochondrial activity and reduces oxidative stress in children with SCD/VOE. This trial was registered at www.clinicaltrials.gov as #NCT02536170.
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20
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Taylor CM, Kasztan M, Sedaka R, Molina PA, Dunaway LS, Pollock JS, Pollock DM. Hydroxyurea improves nitric oxide bioavailability in humanized sickle cell mice. Am J Physiol Regul Integr Comp Physiol 2021; 320:R630-R640. [PMID: 33624556 DOI: 10.1152/ajpregu.00205.2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite advancements in disease management, sickle cell nephropathy, a major contributor to mortality and morbidity in patients, has limited therapeutic options. Previous studies indicate hydroxyurea, a commonly prescribed therapy for sickle cell disease (SCD), can reduce renal injury in SCD but the mechanisms are uncertain. Because SCD is associated with reduced nitric oxide (NO) bioavailability, we hypothesized that hydroxyurea treatment would improve NO bioavailability in the humanized sickle cell mouse. Humanized male 12-wk-old sickle (HbSS) and genetic control (HbAA) mice were treated with hydroxyurea or regular tap water for 2 wk before renal and systemic NO bioavailability as well as renal injury were assessed. Untreated HbSS mice exhibited increased proteinuria, elevated plasma endothelin-1 (ET-1), and reduced urine concentrating ability compared with HbAA mice. Hydroxyurea reduced proteinuria and plasma ET-1 levels in HbSS mice. Untreated HbSS mice had reduced plasma nitrite and elevated plasma arginase concentrations compared with HbAA mice. Hydroxyurea treatment augmented plasma nitrite and attenuated plasma arginase in HbSS mice. Renal vessels isolated from HbSS mice also had elevated nitric oxide synthase 3 (NOS3) and arginase 2 expression compared with untreated HbAA mice. Hydroxyurea treatment did not alter renal vascular NOS3, however, renal vascular arginase 2 expression was significantly reduced. These data support the hypothesis that hydroxyurea treatment augments renal and systemic NO bioavailability by reducing arginase activity as a potential mechanism for the improvement on renal injury seen in SCD mice.
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Affiliation(s)
- Crystal M Taylor
- Section of Cardio-renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Malgorzata Kasztan
- Section of Cardio-renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Randee Sedaka
- Section of Cardio-renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Patrick A Molina
- Section of Cardio-renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Luke S Dunaway
- Section of Cardio-renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jennifer S Pollock
- Section of Cardio-renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - David M Pollock
- Section of Cardio-renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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21
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Onalo R, Cooper P, Cilliers A, Vorster BC, Uche N, Oluseyi OO, Onalo VD, Zubairu Y, Ayodele‐Kehinde AU, Damilare OM, Figueroa J, Morris CR. Randomized control trial of oral arginine therapy for children with sickle cell anemia hospitalized for pain in Nigeria. Am J Hematol 2021; 96:89-97. [PMID: 33075179 DOI: 10.1002/ajh.26028] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 10/16/2020] [Accepted: 10/17/2020] [Indexed: 12/15/2022]
Abstract
Low arginine bioavailability is associated with vaso-occlusive painful crisis (VOC) severity in sickle cell anemia (SCA) and predicts need for pediatric hospitalization. Intravenous arginine therapy has opioid-sparing effects and was found to significantly decrease pain scores in children hospitalized with SCA-VOC in a phase-two randomized placebo-controlled trial (RCT). Efficacy of oral arginine is unknown. Our objective was to determine the safety and efficacy of oral arginine therapy in Nigerian children with SCA. A double-blind RCT of oral L-arginine-hydrochloride (100 mg/kg TID) was conducted in children with SCA-VOC, aged 5-17 years, hospitalized at two Nigerian sites. The primary outcome measure was analgesic usage, quantified by difference in the mean Analgesic Medication Quantification Scale (MQS). Secondary outcomes included daily pain scores, time-to-crisis-resolution and length-of-hospital-stay. An intention-to-treat analysis was performed. Sixty-eight children (age 5-17 years, mean 10.6 ± 0.4 years; 56% male), were randomized to receive L-arginine (35 patients) or placebo (33 patients). The mean total MQS for the arginine group was 73.4 (95% CI, 62.4-84.3) vs 120.0 (96.7-143.3) for placebo (P < .001). The mean rate of decline in worst pain scores was faster in the arginine arm vs placebo (1.50 [1.23-1.77] vs 1.09 [0.94-1.24] point/d, P = .009). Children receiving arginine had a shorter time-to-crisis-resolution (P = .02), shorter hospital-stay (P = .002) and experienced no serious adverse event. Pain control was more rapid, total analgesic requirement was significantly reduced, and most notably, time-to-crisis-resolution and length-of-hospital-stay were shorter in children with SCA-VOC receiving arginine vs placebo. Given the established safety and low cost, oral arginine is a promising adjuvant therapy for SCA-VOC management.
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Affiliation(s)
- Richard Onalo
- Department of Paediatrics Faculty of Clinical Sciences, University of Abuja Gwagwalada Nigeria
- Department of Paediatrics Faculty of Clinical Sciences, University of the Witwatersrand Johannesburg South Africa
| | - Peter Cooper
- Department of Paediatrics Faculty of Clinical Sciences, University of the Witwatersrand Johannesburg South Africa
| | - Antoinette Cilliers
- Department of Paediatrics Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand Johannesburg South Africa
| | - Barend C. Vorster
- Centre for Human Metabolomics North West University Potchefstroom South Africa
| | - Nnebe‐Agumadu Uche
- Department of Paediatrics Faculty of Clinical Sciences, University of Abuja Gwagwalada Nigeria
| | | | - Victoria D. Onalo
- Emergency Paediatric Pharmacy University of Abuja Teaching Hospital Gwagwalada Nigeria
| | - Yunusa Zubairu
- Emergency Paediatric Pharmacy University of Abuja Teaching Hospital Gwagwalada Nigeria
| | | | | | - Janet Figueroa
- Department of Pediatrics Biostatistical Core, Emory University School of Medicine Atlanta Georgia USA
| | - Claudia R. Morris
- Division of Pediatric Emergency Medicine, Department of Pediatrics Emory University School of Medicine Atlanta Georgia USA
- Childrenʼs Healthcare of Atlanta Atlanta Georgia USA
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22
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Hallmark L, Almeida LE, Kamimura S, Smith M, Quezado ZM. Nitric oxide and sickle cell disease-Is there a painful connection? Exp Biol Med (Maywood) 2020; 246:332-341. [PMID: 33517776 DOI: 10.1177/1535370220976397] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Sickle cell disease is the most common hemoglobinopathy and affects millions worldwide. The disease is associated with severe organ dysfunction, acute and chronic pain, and significantly decreased life expectancy. The large body of work demonstrating that hemolysis results in rapid consumption of the endogenous vasodilator nitric oxide, decreased nitric oxide production, and promotion of vaso-occlusion provides the basis for the hypothesis that nitric oxide bioavailability is reduced in sickle cell disease and that this deficit plays a role in sickle cell disease pain. Despite initial promising results, large clinical trials using strategies to increase nitric oxide bioavailability in sickle cell disease patients yielded no significant change in duration or frequency of acute pain crises. Further, recent investigations showed that sickle cell disease patients and mouse models have elevated baseline levels of blood nitrite, a reservoir for nitric oxide formation and a product of nitric oxide metabolism, regardless of pain phenotype. These conflicting results challenge the hypotheses that nitric oxide bioavailability is decreased and that it plays a significant role in the pathogenesis in sickle cell disease acute pain crises. Conversely, a large body of work demonstrates that nitric oxide, as a neurotransmitter, has a complex role in pain neurobiology, contributes to the development of central sensitization, and can mediate hyperalgesia in inflammatory and neuropathic pain. These results support an alternative hypothesis: one proposing that altered nitric oxide signaling may contribute to the development of neuropathic and/or inflammatory pain in sickle cell disease through its role as a neurotransmitter.
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Affiliation(s)
- Lillian Hallmark
- Department of Perioperative Medicine, 2511National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Luis Ef Almeida
- Department of Perioperative Medicine, 2511National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Sayuri Kamimura
- Department of Perioperative Medicine, 2511National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Meghann Smith
- Department of Perioperative Medicine, 2511National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Zenaide Mn Quezado
- Department of Perioperative Medicine, 2511National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
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In vitro assessment of the anti-sickling properties of Buchholzia coriacea and Mucuna pruriens seed extracts. In Vitro Cell Dev Biol Anim 2020; 56:773-782. [PMID: 33025340 DOI: 10.1007/s11626-020-00512-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/13/2020] [Indexed: 02/02/2023]
Abstract
Sickle cell disease is a group of diseases inherited through the gene and it affects the haemoglobin in the red blood cell. This study investigated the methanol seed extract of Buchholzia coriacea for possible in vitro anti-sickling effects and also determined the effect of Mucuna pruriens seed extract on the solubility and oxygen-binding rate of sickle cell haemoglobin. Sickle cell blood was collected from sickle cell disease patients with subsequent addition of 2% sodium metabisulphite to cause more sickling. Varying concentrations of the seed extracts (50%, 25%, 12.5% and 6.25%) were added to the pre-treated blood for these in vitro assays. The results showed that the extract of Buchholzia coriacea significantly (P < 0.05) inhibited sickling at all concentrations with the highest percentage inhibition of 73.3 ± 5.8, reversed sickled erythrocytes at all concentrations with the highest percentage reversal of 83.3 ± 5.8 and significantly (P < 0.05) inhibited polymerisation at all concentrations used in comparison to the parallel control. The extract of Mucuna pruriens seed significantly (P < 0.05) increased the solubility of sickle haemoglobin at 50%, 25%, 12.5% and 6.25% concentrations, increased Fe2+/Fe3+ ratio from 1.7 (control) to 12.2 (50% concentration) and reduced osmotic fragility (at 12.5% and 6.25% concentrations) when compared with parallel control. The results indicate the feasibility of the seed extracts as promising agents in the management of sickle cell disease.
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Chaliha DR, Vaccarezza M, Takechi R, Lam V, Visser E, Drummond P, Mamo JCL. A Paradoxical Vasodilatory Nutraceutical Intervention for Prevention and Attenuation of Migraine-A Hypothetical Review. Nutrients 2020; 12:E2487. [PMID: 32824835 PMCID: PMC7468811 DOI: 10.3390/nu12082487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/14/2020] [Accepted: 08/15/2020] [Indexed: 02/07/2023] Open
Abstract
Studies suggest that migraine pain has a vascular component. The prevailing dogma is that peripheral vasoconstriction activates baroreceptors in central, large arteries. Dilatation of central vessels stimulates nociceptors and induces cortical spreading depression. Studies investigating nitric oxide (NO) donors support the indicated hypothesis that pain is amplified when acutely administered. In this review, we provide an alternate hypothesis which, if substantiated, may provide therapeutic opportunities for attenuating migraine frequency and severity. We suggest that in migraines, heightened sympathetic tone results in progressive central microvascular constriction. Suboptimal parenchymal blood flow, we suggest, activates nociceptors and triggers headache pain onset. Administration of NO donors could paradoxically promote constriction of the microvasculature as a consequence of larger upstream central artery vasodilatation. Inhibitors of NO production are reported to alleviate migraine pain. We describe how constriction of larger upstream arteries, induced by NO synthesis inhibitors, may result in a compensatory dilatory response of the microvasculature. The restoration of central capillary blood flow may be the primary mechanism for pain relief. Attenuating the propensity for central capillary constriction and promoting a more dilatory phenotype may reduce frequency and severity of migraines. Here, we propose consideration of two dietary nutraceuticals for reducing migraine risk: L-arginine and aged garlic extracts.
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Affiliation(s)
- Devahuti Rai Chaliha
- Curtin Health Innovation Research Institute, Curtin University, Kent St., Bentley 6102, Australia; (D.R.C.); (M.V.); (R.T.); (V.L.)
- School of Public Health, Faculty of Health Sciences, Curtin University, Kent St., Bentley 6102, Australia
| | - Mauro Vaccarezza
- Curtin Health Innovation Research Institute, Curtin University, Kent St., Bentley 6102, Australia; (D.R.C.); (M.V.); (R.T.); (V.L.)
- School of Pharmacy and Biomedical Sciences, Faculty of Health Sciences, Curtin University, Kent St., Bentley 6102, Australia
| | - Ryu Takechi
- Curtin Health Innovation Research Institute, Curtin University, Kent St., Bentley 6102, Australia; (D.R.C.); (M.V.); (R.T.); (V.L.)
- School of Public Health, Faculty of Health Sciences, Curtin University, Kent St., Bentley 6102, Australia
| | - Virginie Lam
- Curtin Health Innovation Research Institute, Curtin University, Kent St., Bentley 6102, Australia; (D.R.C.); (M.V.); (R.T.); (V.L.)
- School of Public Health, Faculty of Health Sciences, Curtin University, Kent St., Bentley 6102, Australia
| | - Eric Visser
- School of Medicine, University of Notre Dame, Fremantle 6160, Australia;
| | - Peter Drummond
- College of Science, Health, Engineering and Education (SHEE), Murdoch University, Murdoch 6150, Australia;
| | - John Charles Louis Mamo
- Curtin Health Innovation Research Institute, Curtin University, Kent St., Bentley 6102, Australia; (D.R.C.); (M.V.); (R.T.); (V.L.)
- School of Public Health, Faculty of Health Sciences, Curtin University, Kent St., Bentley 6102, Australia
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Takaoka K, Cyril AC, Jinesh S, Radhakrishnan R. Mechanisms of pain in sickle cell disease. Br J Pain 2020; 15:213-220. [PMID: 34055342 DOI: 10.1177/2049463720920682] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives The hallmark of sickle cell disease (SCD) is acute and chronic pain, and the pain dominates the clinical characteristics of SCD patients. Although pharmacological treatments of SCD targeting the disease mechanisms have been improved, many SCD patients suffer from pain. To overcome the pain of the disease, there have been renewed requirements to understand the novel molecular mechanisms of the pain in SCD. Methods We concisely summarized the molecular mechanisms of SCD-related acute and chronic pain, focusing on potential drug targets to treat pain. Results Acute pain of SCD is caused by vaso-occulusive crisis (VOC), impaired oxygen supply or infarction-reperfusion tissue injuries. In VOC, inflammatory cytokines include tryptase activate nociceptors and transient receptor potential vanilloid type 1. In tissue injury, the secondary inflammatory response is triggered and causes further tissue injuries. Tissue injury generates cytokines and pain mediators including bradykinin, and they activate nociceptive afferent nerves and trigger pain. The main causes of chronic pain are from extended hyperalgesia after a VOC and central sensitization. Neuropathic pain could be due to central or peripheral nerve injury, and protein kinase C might be associated with the pain. In central sensitization, neuroplasticity in the brain and the activation of glial cells may be related with the pain. Discussion In this review, we summarized the molecular mechanisms of SCD-related acute and chronic pain. The novel treatments targeting the disease mechanisms would interrupt complications of SCD and reduce the pain of the SCD patients.
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Affiliation(s)
- Kensuke Takaoka
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | - Asha Caroline Cyril
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | | | - Rajan Radhakrishnan
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
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26
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Blumberg AH, Ebelt ST, Liang D, Morris CR, Sarnat JA. Ambient air pollution and sickle cell disease-related emergency department visits in Atlanta, GA. ENVIRONMENTAL RESEARCH 2020; 184:109292. [PMID: 32179263 PMCID: PMC7847665 DOI: 10.1016/j.envres.2020.109292] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 02/20/2020] [Accepted: 02/21/2020] [Indexed: 06/01/2023]
Abstract
BACKGROUND Sickle cell disease (SCD) is an inherited, autosomal recessive blood disorder, among the most prevalent genetic diseases, globally. While the genetic and hemolytic dynamics of SCD have been well-characterized, the etiology of SCD-related pathophysiological processes is unclear. Although limited, observational evidence suggests that environmental factors, including urban air pollution, may play a role. OBJECTIVES We assessed whether daily ambient air pollution concentrations are associated with corresponding emergency department (ED) visit counts for acute SCD exacerbations in Atlanta, Georgia, during a 9-year (2005-2013) period. We also examined heterogeneity in response by age and sex. METHODS ED visit data were from 41 hospitals in the 20-county Atlanta, GA area. Associations between daily air pollution levels for 8 urban air pollutants and counts of SCD related ED visits were estimated using Poisson generalized linear models. RESULTS We observed positive associations between pollutants generally indicative of traffic emissions and corresponding SCD ED visits [e.g., rate ratio of 1.022 (95% CI: 1.002, 1.043) per interquartile range increase in carbon monoxide]. Age stratified analyses indicated stronger associations with traffic pollutants among children (0-18 years), as compared to older age strata. Associations involving other pollutants, including ozone and particulate matter and for models of individuals >18 years old, were consistent a null hypothesis of no association. DISCUSSION This analysis represents the first North American study to examine acute risk among individuals with SCD to urban air pollution and provide evidence of urban air pollution, especially from traffic sources, as a trigger for acute exacerbations. These findings are consistent with a hypothesis that biological pathways, including several centrally associated with oxidative stress, may contribute towards enhanced susceptibility in individuals with SCD.
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27
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Samarasinghe AE, Rosch JW. Convergence of Inflammatory Pathways in Allergic Asthma and Sickle Cell Disease. Front Immunol 2020; 10:3058. [PMID: 32038616 PMCID: PMC6992560 DOI: 10.3389/fimmu.2019.03058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 12/16/2019] [Indexed: 01/19/2023] Open
Abstract
The underlying pathologies of sickle cell disease and asthma share many characteristics in terms of respiratory inflammation. The principal mechanisms of pulmonary inflammation are largely distinct, but activation of common pathways downstream of the initial inflammatory triggers may lead to exacerbation of both disease states. The altered inflammatory landscape of these respiratory pathologies can differentially impact respiratory pathogen susceptibility in patients with sickle cell disease and asthma. How these two distinct diseases behave in a comorbid setting can further exacerbate pulmonary complications associated with both disease states and impact susceptibility to respiratory infection. This review will provide a concise overview of how asthma distinctly affects individuals with sickle cell disease and how pulmonary physiology and inflammation are impacted during comorbidity.
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Affiliation(s)
- Amali E Samarasinghe
- Division of Pulmonology, Allergy-Immunology, and Sleep, Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States.,Department of Microbiology Immunology and Biochemistry, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States.,Children's Foundation Research Institute, Memphis, TN, United States
| | - Jason W Rosch
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, United States
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28
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Farrell AT, Panepinto J, Carroll CP, Darbari DS, Desai AA, King AA, Adams RJ, Barber TD, Brandow AM, DeBaun MR, Donahue MJ, Gupta K, Hankins JS, Kameka M, Kirkham FJ, Luksenburg H, Miller S, Oneal PA, Rees DC, Setse R, Sheehan VA, Strouse J, Stucky CL, Werner EM, Wood JC, Zempsky WT. End points for sickle cell disease clinical trials: patient-reported outcomes, pain, and the brain. Blood Adv 2019; 3:3982-4001. [PMID: 31809538 PMCID: PMC6963237 DOI: 10.1182/bloodadvances.2019000882] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 09/26/2019] [Indexed: 12/12/2022] Open
Abstract
To address the global burden of sickle cell disease (SCD) and the need for novel therapies, the American Society of Hematology partnered with the US Food and Drug Administration to engage the work of 7 panels of clinicians, investigators, and patients to develop consensus recommendations for clinical trial end points. The panels conducted their work through literature reviews, assessment of available evidence, and expert judgment focusing on end points related to: patient-reported outcomes (PROs), pain (non-PROs), the brain, end-organ considerations, biomarkers, measurement of cure, and low-resource settings. This article presents the findings and recommendations of the PROs, pain, and brain panels, as well as relevant findings and recommendations from the biomarkers panel. The panels identify end points, where there were supporting data, to use in clinical trials of SCD. In addition, the panels discuss where further research is needed to support the development and validation of additional clinical trial end points.
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Affiliation(s)
| | - Julie Panepinto
- Pediatric Hematology, Medical College of Wisconsin/Children's Wisconsin, Milwaukee, WI
| | - C Patrick Carroll
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Ankit A Desai
- Krannert Institute of Cardiology, Indiana University, Bloomington, IN
| | - Allison A King
- Division of Hematology and Oncology in Pediatrics and Medicine, Washington University School of Medicine, St. Louis, MO
| | - Robert J Adams
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | | | - Amanda M Brandow
- Pediatric Hematology, Medical College of Wisconsin/Children's Wisconsin, Milwaukee, WI
| | - Michael R DeBaun
- Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, TN
| | - Manus J Donahue
- Department of Radiology and Radiological Sciences
- Department of Neurology, and
- Department of Psychiatry, School of Medicine, Vanderbilt University, Nashville, TN
| | - Kalpna Gupta
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN
| | - Jane S Hankins
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN
| | - Michelle Kameka
- Nicole Wertheim College of Nursing and Health Sciences, Florida International University, Miami, FL
| | - Fenella J Kirkham
- Developmental Neurosciences Unit and
- Biomedical Research Unit, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Harvey Luksenburg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | | | | | - David C Rees
- Department of Haematological Medicine, King's College Hospital, London, United Kingdom
- School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom
| | | | - Vivien A Sheehan
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - John Strouse
- Division of Hematology, Department of Medicine, and
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Cheryl L Stucky
- Department of Cell Biology, Neurobiology, and Anatomy, Medical College of Wisconsin, Milwaukee, WI
| | - Ellen M Werner
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - John C Wood
- Children's Hospital Los Angeles, Los Angeles, CA; and
| | - William T Zempsky
- Department of Pediatrics, Connecticut Children's/School of Medicine, University of Connecticut, Hartford, CT
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Powell-Roach KL, Yao Y, Jhun EH, He Y, Suarez ML, Ezenwa MO, Molokie RE, Wang ZJ, Wilkie DJ. Vasopressin SNP pain factors and stress in sickle cell disease. PLoS One 2019; 14:e0224886. [PMID: 31710639 PMCID: PMC6844466 DOI: 10.1371/journal.pone.0224886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/23/2019] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Frequencies of single nucleotide polymorphisms (SNPs) from pain related candidate genes are available for individuals with sickle cell disease (SCD). One of those genes, the arginine vasopressin receptor 1A gene (AVPR1A) and one of its SNPs, rs10877969, has been associated with pain and disability in other pain populations. In patients with SCD, clinical factors such as pain and stress have been associated with increased health care utilization, but it is not known if the presence of the AVPR1A SNP plays a role in this observation. The study purpose was to explore the relationships between rs10877969 and self-reported pain, stress, and acute care utilization events among individuals with SCD. METHODS In a cross-sectional investigation of outpatients with SCD, participants completed PAINReportIt®, a computerized pain measure, to describe their pain experience and contributed blood or saliva samples for genetic analysis. We extracted emergency department and acute care utilization from medical records. RESULTS The SNP genotype frequencies (%) for this sample were CC 30 (28%), CT 44 (41%), TT 33 (31%). Acute care utilization and stress as an aggravator of pain were significantly associated with the rs10877969 genotype (p = .02 and p = .002, respectively). The CT genotype had the highest mean utilization and CC genotype was associated with not citing stress as a pain aggravator. Chronic pain was not associated with rs10877969 (p = .41). CONCLUSION This study shows that rs10877969 is related to indicators of stress and acute pain. Further research is recommended with other measures of stress and acute pain.
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Affiliation(s)
- Keesha L. Powell-Roach
- Department of Community Dentistry and Behavioral Science, College of Dentistry, University of Florida, Gainesville, Florida, United States of America
- Center for Palliative Care Research and Education, University of Florida College of Nursing, Gainesville, Florida, United States of America
| | - Yingwei Yao
- Department of Biobehavioral Nursing Science, University of Florida College of Nursing, Gainesville, Florida, United States of America
- Department of Biobehavioral Health Sciences, University of Illinois at Chicago College of Nursing, Chicago, Illinois, United States of America
| | - Ellie H. Jhun
- Committee on Clinical Pharmacology and Pharmacogenetics, University of Chicago, Chicago, Illinois, United States of America
- Department of Biopharmaceutical Sciences, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Ying He
- Department of Biopharmaceutical Sciences, University of Illinois at Chicago, Chicago, Illinois, United States of America
- Cancer Center, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Marie L. Suarez
- Department of Biobehavioral Health Sciences, University of Illinois at Chicago College of Nursing, Chicago, Illinois, United States of America
| | - Miriam O. Ezenwa
- Department of Biobehavioral Nursing Science, University of Florida College of Nursing, Gainesville, Florida, United States of America
| | - Robert E. Molokie
- Department of Biopharmaceutical Sciences, University of Illinois at Chicago, Chicago, Illinois, United States of America
- Division of Hematology/Oncology, University of Illinois at Chicago College of Medicine, Chicago, Illinois, United States of America
- Jessie Brown Veteran’s Administration Medical Center, Chicago, Illinois, United States of America
| | - Zaijie Jim Wang
- Department of Biopharmaceutical Sciences, University of Illinois at Chicago, Chicago, Illinois, United States of America
- Cancer Center, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Diana J. Wilkie
- Center for Palliative Care Research and Education, University of Florida College of Nursing, Gainesville, Florida, United States of America
- Department of Biobehavioral Nursing Science, University of Florida College of Nursing, Gainesville, Florida, United States of America
- Department of Biobehavioral Health Sciences, University of Illinois at Chicago College of Nursing, Chicago, Illinois, United States of America
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Aboursheid T, Albaroudi O, Alahdab F. Inhaled nitric oxide for treating pain crises in people with sickle cell disease. Cochrane Database Syst Rev 2019; 10:CD011808. [PMID: 31603241 PMCID: PMC6788324 DOI: 10.1002/14651858.cd011808.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND In people with sickle cell disease, sickled red blood cells cause the occlusion of small blood vessels which presents as episodes of severe pain known as pain crises or vaso-occlusive crises. The pain can occur in the bones, chest, or other parts of the body, and may last several hours to days. Pain relief during crises includes both pharmacologic and non-pharmacologic treatments. The efficacy of inhaled nitric oxide in pain crises has been a controversial issue and hypotheses have been made suggesting a beneficial response due to its vasodilator properties. Yet no conclusive evidence has been presented.This review aims to evaluate the available randomised controlled studies which address this topic. OBJECTIVES To capture the available body of evidence evaluating the efficacy and safety of the use of inhaled nitric oxide in treating pain crises in people with sickle cell disease; and to assess the treatment's relevance, robustness, and validity, in order to better guide medical practice in the fields of haematology and palliative care (since recent literature seems to favour the involvement of palliative care for those people). SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register. Unpublished work is identified by searching the abstract books of the European Haematology Association conference; the American Society of Hematology conference; the British Society for Haematology Annual Scientific Meeting; the Caribbean Health Research Council Meetings; and the National Sickle Cell Disease Program Annual Meeting.Date of most recent search: 19 September 2019.We also searched ongoing study registries, date of most recent search: 26 September 2019. SELECTION CRITERIA Randomised and quasi-randomised trials comparing inhaled nitric oxide with placebo, or standardized way of treatment of pain crises in people with sickle cell disease. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data (including adverse event data). A third author helped clarify any disagreement. When the data were not reported in the text, we attempted to extract the data from any table or figure available. We contacted trial authors for additional information. We assessed the quality of the evidence using the GRADE criteria MAIN RESULTS: We identified six trials, three of which (188 participants) were eligible for inclusion in the review. There were equal numbers of males and females; and most participants were adults, although one small trial was conducted in a children's hospital and recruited children over the age of 10 years. All three parallel trials compared inhaled nitric oxygen (80 ppm) to placebo (room air) for four hours; one trial continued administering nitric oxide (40 ppm) for a further four hours. This extended trial had an overall low risk of bias; however, in the remaining two trials we had concerns about the risk of bias from the small sample size and additionally a high risk of bias due to financial conflicts of interest in one of these smaller trials. We were only able to analyse some limited data from the eight-hour trial and report the remaining results narratively.The time to pain resolution was only reported in one trial (150 participants), showing there may be little or no difference between the two groups: with inhaled nitric oxide median 73.0 hours (95% confidence interval (CI) 46.0 to 91.0) and with placebo median 65.5 hours (95% CI 48.1 to 84.0) (low-quality evidence). No trial reported on the duration of the initial pain crisis. Only one large trial reported on the frequency of pain crises in the follow-up period and found there may be little or no difference between the inhaled nitric oxide and placebo groups for a return to the ED, risk ratio 0.73 (95% CI 0.31 to 1.71) or for re-hospitalisation, risk ratio 0.53 (95% CI 0.25 to 1.11) (150 participants; low-quality evidence).There may be little or no difference between treatment and placebo in terms of reduction in pain score at any time point up to eight hours (150 participants). The two smaller trials reported a beneficial effect of inhaled nitric oxide in reducing the visual analogue pain score after four hours of the intervention, but these trials were small and limited compared to the first trial.Analgesic use was reported not to differ greatly between the inhaled nitric oxide group and placebo group in any of the three trials, but no analysable data were provided. The median duration of hospitalisation was reported by two trials, in the largest trial the placebo group had the shorter duration and in the second smaller (paediatric) trial hospitalisation was shorter in the treatment group.Only the largest trial (150 participants) reported serious adverse events, with no increase in the inhaled nitric oxide group during or after the intervention compared to the control group (acute chest syndrome occurred in 5 out of 75 participants from each group, pyrexia in 1 out of 75 participants from each group, dysphagia and a drop in haemoglobin were each reported in 1 out of 75 participants in the inhaled nitric oxide group, but not in the placebo group) (low-quality evidence). AUTHORS' CONCLUSIONS The currently available trials do not provide sufficient evidence to determine the effects (benefits or harms) of using inhaled nitric oxide to treat pain (vaso-occlusive) crises in people with sickle cell disease. Large-scale, long-term trials are needed to provide more robust data in this area. Patient-important outcomes (e.g. measures of pain and time to pain resolution and amounts of analgesics used), as well as use of healthcare services should be measured and reported in a standardized form.
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Affiliation(s)
| | | | - Fares Alahdab
- Mayo ClinicEvidence‐based Practice Center1919 3rd Ave NEApt 2RochesterMNUSA55906
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31
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Impact of ET-1 and sex in glomerular hyperfiltration in humanized sickle cell mice. Clin Sci (Lond) 2019; 133:1475-1486. [PMID: 31273050 DOI: 10.1042/cs20190215] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/01/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023]
Abstract
Hyperfiltration, highly prevalent early in sickle cell disease (SCD), is in part driven by an increase in ultrafiltration coefficient (Kf). The increase in Kf may be due to enlarged filtration surface area and/or increased glomerular permeability (Palb). Previous studies have demonstrated that endothelin-1 (ET-1) contributes to Palb changes in models of diabetes and SCD. Thus, we performed longitudinal studies of renal function to determine the relationship between ET-1 and glomerular size and Palb that may contribute to hyperfiltration in humanized sickle cell (HbSS) and control (HbAA) mice at 8-32 weeks of age. HbSS mice were characterized by significant increases in plasma and glomerular ET-1 expression in both sexes although this increase was significantly greater in males. HbSS glomeruli of both males and females presented with a progressive and significant increase in glomerular size, volume, and Kf During the onset of hyperfiltration, plasma and glomerular ET-1 expression were associated with a greater increase in glomerular size and Kf in HbSS mice, regardless of sex. The pattern of Palb augmentation during the hyperfiltration was also associated with an increase in glomerular ET-1 expression, in both male and female HbSS mice. However, the increase in Palb was significantly greater in males and delayed in time in females. Additionally, selective endothelin A receptor (ETA) antagonist prevented hyperfiltration in HbSS, regardless of sex. These results suggest that marked sex disparity in glomerular hyperfiltration may be driven, in part, by ET-1-dependent ultra-structural changes in filtration barrier components contributing to glomerular hyperfiltration in HbSS mice.
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Abstract
IMPACT STATEMENT Sickle cell disease (SCD) is one of the most common inherited diseases and is associated with a reduced life expectancy and acute and chronic complications, including frequent painful vaso-occlusive episodes that often require hospitalization. At present, treatment of SCD is limited to hematopoietic stem cell transplant, transfusion, and limited options for pharmacotherapy, based principally on hydroxyurea therapy. This review highlights the importance of intracellular cGMP-dependent signaling pathways in SCD pathophysiology; modulation of these pathways with soluble guanylate cyclase (sGC) stimulators or phosphodiesterase (PDE) inhibitors could potentially provide vasorelaxation and anti-inflammatory effects, as well as elevate levels of anti-sickling fetal hemoglobin.
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Affiliation(s)
- Nicola Conran
- Hematology Center, University of Campinas – UNICAMP,
Cidade Universitária, Campinas-SP 13083-878-SP, Brazil
| | - Lidiane Torres
- Hematology Center, University of Campinas – UNICAMP,
Cidade Universitária, Campinas-SP 13083-878-SP, Brazil
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Sharma D, Day ME, Stimpson SJ, Rodeghier M, Ghafuri D, Callaghan M, Zaidi AU, Hannan B, Kassim A, Zempsky W, Wellons M, James A, Bruehl S, DeBaun MR. Acute Vaso-Occlusive Pain is Temporally Associated with the Onset of Menstruation in Women with Sickle Cell Disease. J Womens Health (Larchmt) 2019; 28:162-169. [DOI: 10.1089/jwh.2018.7147] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Deva Sharma
- Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melissa E. Day
- Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah-Jo Stimpson
- Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark Rodeghier
- Department of Pediatrics, Rodeghier Consultants, Chicago, Illinois
| | - Djamila Ghafuri
- Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Callaghan
- Department of Pediatrics, Wayne State University Medical Center, Detroit, Michigan
| | - Ahmar Urooj Zaidi
- Department of Pediatrics, Wayne State University Medical Center, Detroit, Michigan
| | - Bryan Hannan
- Department of Pediatrics, Wayne State University Medical Center, Detroit, Michigan
| | - Adetola Kassim
- Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William Zempsky
- Connecticut Children's Medical Center, Hartford, Connecticut
| | - Melissa Wellons
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andra James
- Department of Obstetrics and Gynecology, Duke Hemostasis and Thrombosis Center, Duke University, Durham, North Carolina
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael R. DeBaun
- Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, Tennessee
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Correlation Between Soluble Endothelial Adhesion Molecules and Nitric Oxide Metabolites in Sickle Cell Disease. Med Sci (Basel) 2018; 7:medsci7010001. [PMID: 30577523 PMCID: PMC6359114 DOI: 10.3390/medsci7010001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/04/2018] [Accepted: 12/13/2018] [Indexed: 11/17/2022] Open
Abstract
Nitric Oxide (NO) and soluble adhesion molecules are promising biomarkers, which predict endothelial dysfunction in sickle cell disease (SCD). Several studies have investigated the relationship between NO (as well as its metabolites) and endothelial adhesion molecules in SCD. However, these studies were done mainly in the developed world, and it is difficult to extrapolate the findings to SCD populations in other geographical regions such as Africa due to significant disparities in the results. The aim of the current study was to determine the correlation between levels of nitric oxide metabolites (NOx) and adhesion molecules in SCD patients in a tertiary hospital in Ghana. A case control cross-sectional study involving 100 SCD (made up of HbSS and HbSC patients) and 60 healthy controls was conducted. Concentrations of NOx and soluble endothelial adhesion molecules (ICAM-1, VCAM-1 and E-selectin) were measured in all the study participants (n = 160) by the Griess reagent system and enzyme-linked immunosorbent assay (ELISA). Correlation analysis was performed to determine a possible link between the variables. Levels of soluble adhesion molecules were higher in the HbSS patients. Correlation of NOx with ICAM-1 almost approached significance (r = 0.565, p = 0.058) in the HbSS patients. There were no correlations between NOx and E-selectin in both HbSS and HbSC patients. There were no significant correlations between NOx and VCAM-1 in all the study participants (p > 0.05). Of the soluble adhesion molecules, ICAM-1 showed a significant positive correlation with VCAM-1 in the HbSC patients. There were no significant differences between the adhesion molecules and the age of participants in the various study groups. Whether or not a significant correlation exists between NOx and soluble adhesion molecules may not depend on the sickle cell genotype. The expression of adhesion molecules may not depend on age.
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Antwi-Boasiako C, Campbell AD. Low nitric oxide level is implicated in sickle cell disease and its complications in Ghana. Vasc Health Risk Manag 2018; 14:199-204. [PMID: 30233199 PMCID: PMC6134946 DOI: 10.2147/vhrm.s163228] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Nitric oxide (NO) plays a fundamental role in maintaining normal vasomotor tone. Recent clinical and experimental data suggest that NO may play a role in the pathogenesis and therapy of sickle cell disease (SCD). The aim of this study was to determine NO metabolites (NOx) in SCD patients at steady state and in vaso-occlusive crisis (VOC), as well as those with hemolytic clinical sub-phenotype that includes leg ulcers and priapism. METHODOLOGY This was a case-control cross-sectional study conducted on a total of 694 subjects including 148 comparison group HbAA, 208 HbSS SCD patients in steady state, 82 HbSC SCD patients in steady state, 156 HbSS SCD patients in VOC, 34 HbSC SCD patients in VOC, 34 HbSS SCD patients in post VOC, 21 HbSS SCD patients with leg ulcer and 11 HbSS SCD patients with priapism, with age ranging from 15 to 65 years. Laboratory diagnosis of SCD was done at the Sickle Cell Clinic of the Korle-Bu Teaching Hospital. Plasma nitric oxide metabolites were measured using Griess reagent system by ELISA method. RESULTS Mean NOx of 59.66±0.75 µMol/L in the comparison group was significantly different from those in steady state (P=0.02). During VOC, there was a significant reduction in mean NOx levels to 6.08±0.81 µMol/L (P<0.001). Mean NOx levels were however, significantly higher (50.97±1.68 µMol/L) (P<0.001) in the immediate postcrisis period. The mean NOx levels in the leg ulcer (21.70±1.18 µMol/L) (P<0.001) and priapism (28.97±1.27 µMol/L) (P<0.001) patients were significantly low as compared to the SCD patients in the steady state and comparison group. CONCLUSION This study presents the first report on plasma NOx levels in SCD complication in Ghanaian SCD patients and confirms reduced plasma NOx levels in SCD patients in general.
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Affiliation(s)
- Charles Antwi-Boasiako
- Department of Physiology, School of Biomedical and Allied Health Sciences, College of Health Sciences, University of Ghana, Accra, Ghana,
| | - Andrew D Campbell
- Comprehensive Sickle Cell Program Children's National Medical Center, Division of Hematology, School of Medicine and Health Sciences George Washington University, Washington, DC, USA
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Sadhu N, Jhun EH, Yao Y, He Y, Molokie RE, Wilkie DJ, Wang ZJ. Genetic variants of GCH1 associate with chronic and acute crisis pain in African Americans with sickle cell disease. Exp Hematol 2018; 66:42-49. [PMID: 30031848 DOI: 10.1016/j.exphem.2018.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 06/20/2018] [Accepted: 07/15/2018] [Indexed: 01/29/2023]
Abstract
The multidimensional nature of pain in sickle cell disease (SCD) has rendered its therapeutic management extremely challenging. In this study, we explored the role of five single nucleotide polymorphisms (SNPs) of candidate gene GCH1 in SCD pain. Composite pain index (CPI) scores and acute care utilization rates were used as phenotype markers. Rs8007267 was associated with chronic pain (additive model: B = -3.76, p = 0.037; dominant model: B = -5.61, p = 0.021) and rs3783641 (additive model: incident rate ratio [IRR] = 1.37, p = 0.024; recessive model: IRR = 1.81, p = 0.018) with utilization rate. These associations persisted when subjects with HbSS and HbSβ° genotype only were analyzed. We also identified two haploblocks (rs10483639[G>C]-rs752688[C>T]-rs4411417[T>C] and rs3783641[T>A]-rs8007267[T>C]) with SNPs in high linkage disequilibrium. Of these, haplotype T-C of haploblock rs3783641-rs8007267 showed significant association with rate of utilization (odds ratio [OR] = 0.31, p = 0.001). Our study indicates potential contribution of GCH1 polymorphisms to the variability of pain in African Americans with SCD.
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Affiliation(s)
- Nilanjana Sadhu
- Department of Biopharmaceutical Sciences, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
| | - Ellie H Jhun
- Department of Biopharmaceutical Sciences, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
| | - Yingwei Yao
- Department of Biobehavioral Nursing Science, University of Florida College of Nursing, Gainesville, FL, USA
| | - Ying He
- Department of Biopharmaceutical Sciences, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA; Comprehensive Sickle Cell Center, University of Illinois at Chicago, Chicago, IL, USA
| | - Robert E Molokie
- Department of Biopharmaceutical Sciences, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA; Comprehensive Sickle Cell Center, University of Illinois at Chicago, Chicago, IL, USA; Jesse Brown Veteran's Administration Medical Center, Chicago, IL, USA; Division of Hematology/Oncology, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
| | - Diana J Wilkie
- Department of Biobehavioral Nursing Science, University of Florida College of Nursing, Gainesville, FL, USA; Comprehensive Sickle Cell Center, University of Illinois at Chicago, Chicago, IL, USA
| | - Zaijie Jim Wang
- Department of Biopharmaceutical Sciences, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA; Comprehensive Sickle Cell Center, University of Illinois at Chicago, Chicago, IL, USA.
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Morrone K, Mitchell WB, Manwani D. Novel Sickle Cell Disease Therapies: Targeting Pathways Downstream of Sickling. Semin Hematol 2018; 55:68-75. [PMID: 30616808 DOI: 10.1053/j.seminhematol.2018.04.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/13/2018] [Indexed: 12/15/2022]
Abstract
Sickle cell disease is an inherited hemoglobinopathy characterized by hemolytic anemia, frequent painful episodes, poor quality of life, end organ damage and a shortened lifespan. Although the seminal event is the polymerization of the abnormal hemoglobin, the downstream pathophysiology of vaso-occlusion results from heterotypic interactions between the altered, adhesive sickle cell RBCs, neutrophils, endothelium, and platelets. Ischemia reperfusion injury, hemolysis and oxidant damage all contribute to heightened inflammation and activation of the hemostatic system. These downstream targets are the focus of emerging treatments with considerable potential to ameliorate disease manifestations. This review summarizes the progress on development of these agents.
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Affiliation(s)
- Kerry Morrone
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY
| | - William Beau Mitchell
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, New York, NY
| | - Deepa Manwani
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY.
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Cox SE, Ellins EA, Marealle AI, Newton CR, Soka D, Sasi P, Luca Di Tanna G, Johnson W, Makani J, Prentice AM, Halcox JP, Kirkham FJ. Ready-to-use food supplement, with or without arginine and citrulline, with daily chloroquine in Tanzanian children with sickle-cell disease: a double-blind, random order crossover trial. Lancet Haematol 2018; 5:e147-e160. [PMID: 29548623 PMCID: PMC5871644 DOI: 10.1016/s2352-3026(18)30020-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 01/15/2018] [Accepted: 01/15/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Sickle-cell disease increases the risk of malnutrition. Low arginine and nitric oxide bioavailability are implicated in morbidity related to sickle-cell disease. Simple interventions are required, especially in low-income settings. We aimed to test the hypotheses that: (1) supplementary arginine, citrulline, and daily chloroquine increase bioavailable arginine and flow-mediated dilatation (FMD; maximal diameter change; FMDmax%), a measure of nitric oxide-dependent endothelial function; and (2) protein energy supplementation in the form of ready-to-use supplementary food (RUSF) improves the height-for-age and body-mass index-for-age Z-scores in children with sickle-cell disease. METHODS We performed a double-blind, random order crossover trial with two 4-month intervention periods (each followed by 4-month washout periods) in Muhimbili National Hospital in Dar-es-Salaam, Tanzania. We enrolled 119 children from the Muhimbili Sickle Cohort who were aged 8-12 years, naive to hydroxyurea, and had documented HbSS phenotype. Two formulations of RUSF (providing 500 kcal/day) were tested: basic (RUSF-b), with which children also received weekly chloroquine (150 mg or 225 mg chloroquine base, dependent on bodyweight); and vascular (RUSF-v), which was fortified with arginine and citrulline (designed to achieve mean intakes of 0·2 g/kg per day of arginine and 0·1 g/kg per day of citrulline), and with which children received daily chloroquine (maximum 3 mg chloroquine base/kg per day). Children were randomly allocated to receive either RUSF-b first or RUSF-v first and, after a washout period, were then given the other treatment. The primary outcomes in comparing the two RUSF formulations were mean plasma arginine, arginine to ornithine ratio, and arginine to asymmetric dimethylarginine ratio, and mean FMDmax%. The primary outcomes of the combined effect of both RUSF interventions were mean height-for-age Z-score and body-mass index-for-age Z-score. Analyses were done on the eligible intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT01718054; and with ISRCTN74331412. FINDINGS Between Aug 9, 2012, and Feb 26, 2014, 145 children were randomised (71 children to RUSF-v first and 74 children to RUSF-b first) and 119 children were treated, of whom 114 children yielded complete data for all reported endpoints. The ratio of arginine to ornithine (mean of individual differences -8·67%, 95% CI -19·55 to 2·20; p=0·12) and the mean FMDmax% (1·00, -0·47 to 2·47; p=0·18) did not significantly differ between the RUSF-b and RUSF-v treatments. However, the arginine to asymmetric dimethylarginine ratio was significantly increased by RUSF-v compared with RUSF-b (56·26%, 31·13 to 81·38; p<0·0001). In planned analyses that used mixed effects models to estimate the effect of each intervention compared with the participants at baseline or during washout periods, the arginine to asymmetric dimethylarginine ratio increased following both RUSF-v treatment (86%; p<0·0001) and RUSF-b treatment (40%; p<0·0001). However, FMDmax% was higher after treatment with RUSF-v (0·92; p<0·0001) but not RUSF-b (0·39; p=0·22). Following either intervention (RUSF-b and RUSF-v, pooled) body-mass index-for-age Z-score (0·091; p=0·001) and height-for-age Z-score (0·013; p=0·081) increased compared with baseline and washout timepoints. In 83 participants in the treated population, there were 71 adverse events during the intervention, of which 21 (30%) were serious, and 81 adverse events during the washout periods, of which 26 (32%) were serious (p=0·31), including one patient who died in the second washout period. INTERPRETATION RUSF providing 500 kcal/day results in small weight gains in children with sickle-cell disease. However, even without arginine and citrulline fortification, RUSF seems to ameliorate arginine dysregulation and might improve endothelial function. Long-term studies are required to assess whether these physiological effects translate to improved clinical outcomes and better growth and development in patients with sickle-cell disease. FUNDING Wellcome Trust.
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Affiliation(s)
- Sharon E Cox
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK; School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan; Muhimbili Wellcome Programme, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Elizabeth A Ellins
- Institute of Life Sciences, Swansea University Medical School, Swansea University, Swansea, UK
| | - Alphonce I Marealle
- Muhimbili Wellcome Programme, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Charles R Newton
- Muhimbili Wellcome Programme, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Deogratias Soka
- Muhimbili Wellcome Programme, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Department of Haematology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Philip Sasi
- Department of Clinical Pharmacology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Gian Luca Di Tanna
- Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK; Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - William Johnson
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, Leicestershire, UK
| | - Julie Makani
- Muhimbili Wellcome Programme, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Department of Haematology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Andrew M Prentice
- Medical Research Council Unit The Gambia, London School of Hygiene & Tropical Medicine, London, UK
| | - Julian P Halcox
- Institute of Life Sciences, Swansea University Medical School, Swansea University, Swansea, UK
| | - Fenella J Kirkham
- Developmental Neurosciences Programme, UCL Great Ormond Street Institute of Child Health, London, UK; Clinical and Experimental Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK; University Child Health, University Hospital Southampton, Southampton, UK
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Pulmonary Vascular Dysfunction and Cor Pulmonale During Acute Respiratory Distress Syndrome in Sicklers. Shock 2018; 46:358-64. [PMID: 27206275 DOI: 10.1097/shk.0000000000000640] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute chest syndrome (ACS) is the most common cause of death among sickle cell disease (SCD) adult patients. Pulmonary vascular dysfunction (PVD) and acute cor pulmonale (ACP) are common during acute respiratory distress syndrome (ARDS) and their prevalence may be even more important during ARDS related to ACS (ACS-ARDS). The objective of this study was to evaluate the prevalence and prognosis of PVD and ACP during ACS-ARDS. PATIENTS AND METHODS This was a retrospective analysis over a 10-year period of patients with moderate-to-severe ARDS. PVD and ACP were assessed by echocardiography. ARDS episodes were assigned to ACS-ARDS or nonACS-ARDS group according to whether the clinical insult was ACS or not, respectively. To evaluate independent factors associated with ACP, significant univariable risk factors were examined using logistic regression and propensity score analyses. RESULTS A total of 362 patients were analyzed, including 24 ACS-ARDS. PVD and ACP were identified, respectively, in 24 (100%) and 20 (83%) ACS-ARDS patients, as compared with 204 (60%) and 68 (20%) nonACS-ARDS patients (P < 0.0001). The mortality did not differ between ACS-ARDS and nonACS-ARDS patients. Both the crude (odds ratio [OR], 19.9; 95% confidence interval [CI], 6.6-60; P < 0.0001), multivariable adjustment (OR, 27.4; 95% CI, 8.2-91.5; P < 0.001), and propensity-matched (OR, 11.7; 95% CI, 1.2-110.8; P = 0.03) analyses found a significant association between ACS-ARDS and ACP. CONCLUSIONS All SCD patients presenting with moderate-to-severe ARDS as a consequence of ACS experienced PVD and more than 80% of them exhibited ACP. These results suggest a predominant role for PVD in the pathogenesis of severe forms of ACS.
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Marealle AI, Siervo M, Wassel S, Bluck L, Prentice AM, Minzi O, Sasi P, Kamuhabwa A, Soka D, Makani J, Cox SE. A pilot study of a non-invasive oral nitrate stable isotopic method suggests that arginine and citrulline supplementation increases whole-body NO production in Tanzanian children with sickle cell disease. Nitric Oxide 2018; 74:19-22. [PMID: 29305240 PMCID: PMC5832986 DOI: 10.1016/j.niox.2017.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 11/25/2017] [Accepted: 12/29/2017] [Indexed: 12/24/2022]
Abstract
Background Low bioavailability of nitric oxide (NO) is implicated in the pathophysiology of sickle cell disease (SCD). We designed a nested pilot study to be conducted within a clinical trial testing the effects of a daily ready-to-use supplementary food (RUSF) fortified with arginine (Arg) and citrulline (Citr) vs. non-fortified RUSF in children with SCD. The pilot study evaluated 1) the feasibility of a non-invasive stable isotope method to measure whole-body NO production and 2) whether Arg+Citr supplementation was associated with increased whole-body NO production. Subjects Twenty-nine children (70% male, 9–11years, weight 16.3–31.3 kg) with SCD. Methods Sixteen children received RUSF+Arg/Citr (Arg, 0.2 g/kg/day; Citr, 0.1 g/kg/day) in combination with daily chloroquine (50 mg) and thirteen received the base RUSF in combination with weekly chloroquine (150 mg). Plasma amino acids were assessed using ion-exchange elution (Biochrom-30, Biochrom, UK) and whole-body NO production was measured using a non-invasive stable isotopic method. Results The RUSF+Arg/Citr intervention increased plasma arginine (P = .02) and ornithine (P = .003) and decreased the ratio of asymmetric dimethylarginine to arginine (P = .01), compared to the base RUSF. A significant increase in whole-body NO production was observed in the RUSF-Arg/Citr group compared to baseline (weight-adjusted systemic NO synthesis 3.38 ± 2.29 μmol/kg/hr vs 2.35 ± 1.13 μmol/kg/hr, P = .04). No significant changes were detected in the base RUSF group (weight-adjusted systemic NO synthesis 2.64 ± 1.14 μmol/kg/hr vs 2.53 ± 1.12 μmol/kg/hr, P = .80). Conclusions The non-invasive stable isotopic method was acceptable and the results provided supporting evidence that Arg/Citr supplementation may increase systemic NO synthesis in children with SCD. This method for measuring whole-body NO synthesis is feasible in young children. The isotopic decay of the stable isotope tracer demonstrated good linear fit. Arginine and citrulline supplementation may increase whole-body NO synthesis.
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Affiliation(s)
- Alphonce I Marealle
- Muhimbili Wellcome Programme, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; School of Pharmacy, Department of Clinical Pharmacy & Pharmacology, Muhimbili University of Health & Allied Sciences, Dar es Salaam, Tanzania
| | - Mario Siervo
- Human Nutrition Research Centre, Institute of Cellular Medicine, Newcastle University, Campus for Ageing and Vitality, Newcastle on Tyne, UK
| | | | - Les Bluck
- MRC Human Nutrition Research, Cambridge, UK
| | - Andrew M Prentice
- MRC Unit, The Gambia and MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Omary Minzi
- School of Pharmacy, Department of Clinical Pharmacy & Pharmacology, Muhimbili University of Health & Allied Sciences, Dar es Salaam, Tanzania
| | - Philip Sasi
- School of Medicine, Department of Clinical Pharmacology, Muhimbili University of Health & Allied Sciences, Dar es Salaam, Tanzania
| | - Appolinary Kamuhabwa
- School of Pharmacy, Department of Clinical Pharmacy & Pharmacology, Muhimbili University of Health & Allied Sciences, Dar es Salaam, Tanzania
| | - Deogratias Soka
- Muhimbili Wellcome Programme, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Julie Makani
- Muhimbili Wellcome Programme, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Sharon E Cox
- Muhimbili Wellcome Programme, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; School of Tropical Medicine & Global Health, Nagasaki University, Nagasaki, Japan; Dept of Population Health, London School of Hygiene & Tropical Medicine, London, UK.
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Targeting novel mechanisms of pain in sickle cell disease. Blood 2017; 130:2377-2385. [PMID: 29187376 DOI: 10.1182/blood-2017-05-782003] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 08/23/2017] [Indexed: 11/20/2022] Open
Abstract
Patients with sickle cell disease (SCD) suffer from intense pain that can start during infancy and increase in severity throughout life, leading to hospitalization and poor quality of life. A unique feature of SCD is vaso-occlusive crises (VOCs) characterized by episodic, recurrent, and unpredictable episodes of acute pain. Microvascular obstruction during a VOC leads to impaired oxygen supply to the periphery and ischemia reperfusion injury, inflammation, oxidative stress, and endothelial dysfunction, all of which may perpetuate a noxious microenvironment leading to pain. In addition to episodic acute pain, patients with SCD also report chronic pain. Current treatment of moderate to severe pain in SCD is mostly reliant upon opioids; however, long-term use of opioids is associated with multiple side effects. This review presents up-to-date developments in our understanding of the pathobiology of pain in SCD. To help focus future research efforts, major gaps in knowledge are identified regarding how sickle pathobiology evokes pain, pathways specific to chronic and acute sickle pain, perception-based targets of "top-down" mechanisms originating from the brain and neuromodulation, and how pain affects the sickle microenvironment and pathophysiology. This review also describes mechanism-based targets that may help develop novel therapeutic and/or preventive strategies to ameliorate pain in SCD.
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Tran H, Gupta M, Gupta K. Targeting novel mechanisms of pain in sickle cell disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:546-555. [PMID: 29222304 PMCID: PMC6142592 DOI: 10.1182/asheducation-2017.1.546] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Patients with sickle cell disease (SCD) suffer from intense pain that can start during infancy and increase in severity throughout life, leading to hospitalization and poor quality of life. A unique feature of SCD is vaso-occlusive crises (VOCs) characterized by episodic, recurrent, and unpredictable episodes of acute pain. Microvascular obstruction during a VOC leads to impaired oxygen supply to the periphery and ischemia reperfusion injury, inflammation, oxidative stress, and endothelial dysfunction, all of which may perpetuate a noxious microenvironment leading to pain. In addition to episodic acute pain, patients with SCD also report chronic pain. Current treatment of moderate to severe pain in SCD is mostly reliant upon opioids; however, long-term use of opioids is associated with multiple side effects. This review presents up-to-date developments in our understanding of the pathobiology of pain in SCD. To help focus future research efforts, major gaps in knowledge are identified regarding how sickle pathobiology evokes pain, pathways specific to chronic and acute sickle pain, perception-based targets of "top-down" mechanisms originating from the brain and neuromodulation, and how pain affects the sickle microenvironment and pathophysiology. This review also describes mechanism-based targets that may help develop novel therapeutic and/or preventive strategies to ameliorate pain in SCD.
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Affiliation(s)
- Huy Tran
- Vascular Biology Center, Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN; and
| | - Mihir Gupta
- Department of Neurosurgery, University of California San Diego, La Jolla, CA
| | - Kalpna Gupta
- Vascular Biology Center, Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN; and
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Raghunathan VM, Whitesell PL, Lim SH. Sleep-disordered breathing in patients with sickle cell disease. Ann Hematol 2017; 97:755-762. [PMID: 29214337 DOI: 10.1007/s00277-017-3199-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 11/29/2017] [Indexed: 01/18/2023]
Abstract
Sickle cell disease is one of the most common hereditary hemoglobinopathies worldwide, and its vaso-occlusive and hemolytic crises cause considerable patient morbidity. A growing body of evidence has shown that sleep-disordered breathing, and in particular, obstructive sleep apnea, occurs at high frequency in the sickle cell population, and that there is significant overlap in the underlying pathophysiology of these two conditions. Through a variety of mechanisms including nocturnal hypoxemia and increased oxidative stress, production of pro-inflammatory cytokines, and endothelial dysfunction, sickle cell anemia and sleep-disordered breathing potentiate each other's clinical effects and end-organ complications. Here, we will review the shared pathophysiologic mechanisms of these conditions and discuss their clinical sequelae. We will also examine the results of studies that have been carried out with clinical intervention of nocturnal hypoxemia in patients with sickle cell disease in the attempts to overcome the complications of the disease. Finally, we will propose the areas of investigation that merit further investigations in future in patients with sickle cell disease and sleep-disordered breathing.
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Affiliation(s)
- Vikram M Raghunathan
- Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Peter L Whitesell
- Department of Medicine, Howard University College of Medicine, Washington, DC, USA
| | - Seah H Lim
- Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI, USA. .,Rhode Island Hospital, Room 140, APC Building593 Eddy Street, Providence, RI, 02903, USA.
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45
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Husain M, Hartman AD, Desai P. Pharmacogenomics of sickle cell disease: steps toward personalized medicine. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2017; 10:261-265. [PMID: 29089781 PMCID: PMC5656342 DOI: 10.2147/pgpm.s123427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Sickle cell disease (SCD) is a monogenetic disease but has a wide range of phenotypic expressions. Some of these differences in phenotype can be explained by genetic polymorphisms in the human globin gene. These polymorphisms can result in different responses to typical treatment, sometimes leading to inadequate therapeutics. Research is revealing more polymorphisms, and therefore, new targets for intervention to improve outcomes in SCD. This area of pharmacogenomics is continuing to develop. We provide a brief review of the current literature on pharmacogenomics in SCD and possible targets for intervention.
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Affiliation(s)
| | | | - Payal Desai
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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46
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Degree of anemia, indirect markers of hemolysis, and vascular complications of sickle cell disease in Africa. Blood 2017; 130:2215-2223. [PMID: 28931524 DOI: 10.1182/blood-2016-12-755777] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 09/02/2017] [Indexed: 11/20/2022] Open
Abstract
The hyperhemolysis paradigm that describes overlapping "hyperhemolytic-endothelial dysfunction" and "high hemoglobin-hyperviscous" subphenotypes of sickle cell disease (SCD) patients is based on North American studies. We performed a transversal study nested in the CADRE cohort to analyze the association between steady-state hemolysis and vascular complications of SCD among sub-Saharan African patients. In Mali, Cameroon, and Ivory Coast, 2407 SCD patients (1751 SS or sickle β-zero-thalassemia [Sβ0], 495 SC, and 161 sickle β+-thalassemia [Sβ+]), aged 3 years old and over, were included at steady state. Relative hemolytic intensity was estimated from a composite index derived from principal component analysis, which included bilirubin levels or clinical icterus, and lactate dehydrogenase levels. We assessed vascular complications (elevated tricuspid regurgitant jet velocity [TRV], microalbuminuria, leg ulcers, priapism, stroke, and osteonecrosis) by clinical examination, laboratory tests, and echocardiography. After adjustment for age, sex, country, and SCD phenotype, a low hemoglobin level was significantly associated with TRV and microalbuminuria in the whole population and with leg ulcers in SS-Sβ0 adults. A high hemolysis index was associated with microalbuminuria in the whole population and with elevated TRV, microalbuminuria, and leg ulcers in SS-Sβ0 adults, but these associations were no longer significant after adjustment for hemoglobin level. In conclusion, severe anemia at steady state in SCD patients living in West and Central Africa is associated with elevated TRV, microalbuminuria, and leg ulcers, but these vascular complications are not independently associated with indirect markers of increased hemolysis. Other mechanisms leading to anemia, including malnutrition and infectious diseases, may also play a role in the development of SCD vasculopathy.
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Shilo NR, Morris CR. Pathways to pulmonary hypertension in sickle cell disease: the search for prevention and early intervention. Expert Rev Hematol 2017; 10:875-890. [PMID: 28817980 DOI: 10.1080/17474086.2017.1364989] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Pulmonary hypertension (PH) develops in a significant number of patients with sickle cell disease (SCD), resulting in increased morbidity and mortality. This review focuses on PH pathophysiology, risk stratification, and new recommendations for screening and treatment for patients with SCD. Areas covered: An extensive PubMed literature search was performed. While the pathophysiology of PH in SCD is yet to be fully deciphered, it is known that the etiology is multifactorial; hemolysis, hypercoagulability, hypoxemia, ischemic-reperfusion injury, oxidative stress, and genetic susceptibility all contribute in varying degrees to endothelial dysfunction. Hemolysis, in particular, seems to play a key role by inciting an imbalance in the regulatory axis of nitric oxide and arginine metabolism. Systematic risk stratification starting in childhood based on clinical features and biomarkers that enable early detection is necessary. Multi-faceted, targeted interventions, before irreversible vasculopathy develops, will allow for improved patient outcomes and life expectancy. Expert commentary: Despite progress in our understanding of PH in SCD, clinically proven therapies remain elusive and additional controlled clinical trials are needed. Prevention of disease starts in childhood, a critical window for intervention. Given the complex and multifactorial nature of SCD, patients will ultimately benefit from combination therapies that simultaneously targets multiple mechanisms.
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Affiliation(s)
- Natalie R Shilo
- a Department of Pediatrics, Division of Pulmonary Medicine , University of Connecticut Heath Center , Farmington , CT , USA
| | - Claudia R Morris
- b Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory-Children's Center for Cystic Fibrosis and Airways Disease Research , Emory University School of Medicine , Atlanta , GA , USA
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Nurain IO, Bewaji CO. Effects of Aqueous Bark Extracts of Khaya grandifoliola and Enantia chlorantha on Some Biochemical Parameters in Swiss Mice. IRANIAN JOURNAL OF TOXICOLOGY 2017. [DOI: 10.29252/arakmu.11.5.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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49
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Kang BY, Park K, Kleinhenz JM, Murphy TC, Sutliff RL, Archer D, Hart CM. Peroxisome Proliferator-Activated Receptor γ Regulates the V-Ets Avian Erythroblastosis Virus E26 Oncogene Homolog 1/microRNA-27a Axis to Reduce Endothelin-1 and Endothelial Dysfunction in the Sickle Cell Mouse Lung. Am J Respir Cell Mol Biol 2017; 56:131-144. [PMID: 27612006 DOI: 10.1165/rcmb.2016-0166oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Pulmonary hypertension (PH), a serious complication of sickle cell disease (SCD), causes significant morbidity and mortality. Although a recent study determined that hemin release during hemolysis triggers endothelial dysfunction in SCD, the pathogenesis of SCD-PH remains incompletely defined. This study examines peroxisome proliferator-activated receptor γ (PPARγ) regulation in SCD-PH and endothelial dysfunction. PH and right ventricular hypertrophy were studied in Townes humanized sickle cell (SS) and littermate control (AA) mice. In parallel studies, SS or AA mice were gavaged with the PPARγ agonist, rosiglitazone (RSG), 10 mg/kg/day, or vehicle for 10 days. In vitro, human pulmonary artery endothelial cells (HPAECs) were treated with vehicle or hemin for 72 hours, and selected HPAECs were treated with RSG. SS mice developed PH and right ventricular hypertrophy associated with reduced lung levels of PPARγ and increased levels of microRNA-27a (miR-27a), v-ets avian erythroblastosis virus E26 oncogene homolog 1 (ETS1), endothelin-1 (ET-1), and markers of endothelial dysfunction (platelet/endothelial cell adhesion molecule 1 and E selectin). HPAECs treated with hemin had increased ETS1, miR-27a, ET-1, and endothelial dysfunction and decreased PPARγ levels. These derangements were attenuated by ETS1 knockdown, inhibition of miR-27a, or PPARγ overexpression. In SS mouse lung or in hemin-treated HPAECs, activation of PPARγ with RSG attenuated reductions in PPARγ and increases in miR-27a, ET-1, and markers of endothelial dysfunction. In SCD-PH pathogenesis, ETS1 stimulates increases in miR-27a levels that reduce PPARγ and increase ET-1 and endothelial dysfunction. PPARγ activation attenuated SCD-associated signaling derangements, suggesting a novel therapeutic approach to attenuate SCD-PH pathogenesis.
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Affiliation(s)
- Bum-Yong Kang
- 1 Department of Medicine, Atlanta Veterans Affairs and Emory University Medical Centers, Atlanta, Georgia; and
| | - Kathy Park
- 1 Department of Medicine, Atlanta Veterans Affairs and Emory University Medical Centers, Atlanta, Georgia; and
| | - Jennifer M Kleinhenz
- 1 Department of Medicine, Atlanta Veterans Affairs and Emory University Medical Centers, Atlanta, Georgia; and
| | - Tamara C Murphy
- 1 Department of Medicine, Atlanta Veterans Affairs and Emory University Medical Centers, Atlanta, Georgia; and
| | - Roy L Sutliff
- 1 Department of Medicine, Atlanta Veterans Affairs and Emory University Medical Centers, Atlanta, Georgia; and
| | - David Archer
- 2 Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - C Michael Hart
- 1 Department of Medicine, Atlanta Veterans Affairs and Emory University Medical Centers, Atlanta, Georgia; and
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Khorshied MM, Mohamed NS, Hamza RS, Ali RM, El-Ghamrawy MK. Protein Z and Endothelin-1 genetic polymorphisms in pediatric Egyptian sickle cell disease patients. J Clin Lab Anal 2017; 32. [PMID: 28548215 DOI: 10.1002/jcla.22264] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 04/25/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Sickle cell disease (SCD) is a monogenic disease associated with multisystem morbidity. Vasculopathy caused by delicate imbalance between coagulation and endothelial systems plays a pivotal role in disease course. As Protein Z and Endothelin-1 genetic polymorphisms may increase the thrombotic risk, the aim of the current work was to verify the possible impact of Protein Z (PROZ G79A) and Endothelin-1 (EDN1 G5665T) polymorphisms on the clinic-laboratory features of the SCD in a cohort of Egyptian pediatric patients. METHODS Genotyping of Protein Z G79A and Endothelin-1 G5665T was carried out by polymerase chain reaction-restricted fragment length polymorphism (PCR-RFLP) assay for 100 SCD patients and 100 controls. RESULTS Protein -Z G79A polymorphism was not associated with vascular complications in the studied SCD patients. Endothelin-1 G5665T polymorphism was associated with pulmonary dysfunction (pulmonary artery hypertension and acute chest syndrome) and severe vaso-occlusive crises (VOC). CONCLUSION Endothelin-1 G5665T polymorphism could be considered as a molecular predictor for pulmonary dysfunction and severe VOC in SCD. Further researches with larger cohorts are recommended to understand the pathophysiology of SCD and to explain the inter-patients' variability of disease severity.
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Affiliation(s)
- Mervat M Khorshied
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nohair S Mohamed
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rania S Hamza
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rasha M Ali
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mona K El-Ghamrawy
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
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