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Lynch K, Mega A, Daves M, Sadiq A, Fogarty H, Piccin A. Liver Disease and Sickle Cell Disease: Auto-Immune Hepatitis more than a Coincidence; A Systematic Review of the Literature. Mediterr J Hematol Infect Dis 2023; 15:e2023060. [PMID: 38028400 PMCID: PMC10631714 DOI: 10.4084/mjhid.2023.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/14/2023] [Indexed: 12/01/2023] Open
Abstract
In patients with SCD, chronic liver damage is a common manifestation. More than 50% of SCD patients have elevated liver enzymes. Common underlying aetiologies include sickle cell hepatic crisis, viral hepatitis, sickle cell intrahepatic cholestasis and hepatic sequestration in the acute setting, and cholelithiasis and iron overload in the chronic setting. Autoimmune hepatitis (AIH) is a rare disease that appears to occur more commonly in the sickle cell disease (SCD) population than in the general population. There are many schools of thought as to why this is the case, including the phosphatidylserine hypothesis, the heme inflammatory hypothesis, the complement generation hypothesis, and the transfusion alloimmunization hypothesis. Due to the natural history of the two illnesses, SCD is almost always diagnosed first in cases of dual pathology. Symptoms such as jaundice, fatigue, and abdominal pain are common in SCD, as are abnormal liver function tests (LFTs). These abnormalities, attributed to the other more frequent liver involvements in SCD, can lead to delays in AIH diagnosis in this population. Corticosteroids, sometimes with other immunosuppressive agents, such as azathioprine, are the cornerstone of acute AIH treatment. However, corticosteroid use in the SCD population has been shown to carry an increased risk of vaso-occlusive crises, providing a treatment dilemma. The following is a review of AIH in the SCD population, where we explore the pathophysiology behind the association between the two disorders, discuss an approach to investigating abnormal LFTs in SCD, and examine treatment options in this population with co-existing diseases.
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Affiliation(s)
- Kelvin Lynch
- Dept of Gastroenterology, Cork University Hospital, Cork, Ireland
| | - Andrea Mega
- Dept of Gastroenterology, Provincial Hospital of Bolzano (SABES-ASDAA), Bolzano, Italy
| | - Massimo Daves
- Dept of Laboratory Medicine, Provincial Hospital of Bolzano (SABES-ASDAA), Bolzano, Italy
| | - Asma Sadiq
- Northern Ireland Blood Transfusion Service, Belfast, UK
| | - Helen Fogarty
- Department of Haematology, Children's Health Ireland at Crumlin, Dublin
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin
| | - Andrea Piccin
- Northern Ireland Blood Transfusion Service, Belfast, UK
- Dept of Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria
- Dept of Industrial Engineering, University of Trento, Trento, Italy
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Aboderin FI, Oduola T, Davison GM, Oguntibeju OO. A Review of the Relationship between the Immune Response, Inflammation, Oxidative Stress, and the Pathogenesis of Sickle Cell Anaemia. Biomedicines 2023; 11:2413. [PMID: 37760854 PMCID: PMC10525295 DOI: 10.3390/biomedicines11092413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/09/2023] [Accepted: 08/26/2023] [Indexed: 09/29/2023] Open
Abstract
Sickle cell anaemia (SCD) is a life-threatening haematological disorder which is predominant in sub-Saharan Africa and is triggered by a genetic mutation of the β-chain haemoglobin gene resulting in the substitution of glutamic acid with valine. This mutation leads to the production of an abnormal haemoglobin molecule called haemoglobin S (HbS). When deoxygenated, haemoglobin S (HbS) polymerises and results in a sickle-shaped red blood cell which is rigid and has a significantly shortened life span. Various reports have shown a strong link between oxidative stress, inflammation, the immune response, and the pathogenesis of sickle cell disease. The consequence of these processes leads to the development of vasculopathy (disease of the blood vessels) and several other complications. The role of the immune system, particularly the innate immune system, in the pathogenesis of SCD has become increasingly clear in recent years of research; however, little is known about the roles of the adaptive immune system in this disease. This review examines the interaction between the immune system, inflammation, oxidative stress, blood transfusion, and their effects on the pathogenesis of sickle cell anaemia.
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Affiliation(s)
- Florence Ifechukwude Aboderin
- Department of Biomedical Sciences, Faculty of Health and Wellness Sciences, Cape Peninsula University of Technology, Bellville 7535, South Africa;
| | - Taofeeq Oduola
- Department of Chemical Pathology, Usmanu Danfodiyo University, Sokoto 840004, Nigeria;
| | - Glenda Mary Davison
- SAMRC/CPUT Cardiometabolic Health Research Unit, Department of Biomedical Sciences, Faculty of Health and Wellness Sciences, Cape Peninsula University of Technology, Bellville 7535, South Africa;
| | - Oluwafemi Omoniyi Oguntibeju
- Department of Biomedical Sciences, Faculty of Health and Wellness Sciences, Cape Peninsula University of Technology, Bellville 7535, South Africa;
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Piccin A, O'Connor-Byrne N, Daves M, Lynch K, Farshbaf AD, Martin-Loeches I. Autoimmune disease and sickle cell anaemia: 'Intersecting pathways and differential diagnosis'. Br J Haematol 2022; 197:518-528. [PMID: 35244209 DOI: 10.1111/bjh.18109] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 12/12/2022]
Abstract
Sickle cell disease (SCD) is an inherited disorder, which occurs due to a single gene mutation. It has multisystemic manifestations, affecting millions of people worldwide. The effect of SCD on joints and musculature can overlap with clinical features of autoimmune disease (AD). It is therefore difficult for clinical haematologists and physicians treating SCD patients to discriminate between these two conditions clinically. A delay in diagnosis leads to untreated symptoms and treatment differs considerably. An accurate knowledge of clinical findings and laboratory results of AD and SCD can help physicians avoid this. In the review that follows, we examine the existing literature on SCD and AD, and describe the features that may distinguish SCD and autoimmune disease such as systemic lupus erythematosus and rheumatoid arthritis. We aim to guide clinical haematologists and physicians towards a more rapid diagnosis of AD in sickle cell anaemia patients, by correct interpretation of the clinical assessment and commonly available diagnostics.
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Affiliation(s)
- Andrea Piccin
- Northern Ireland Blood Transfusion Service, Belfast, UK.,Department of Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria.,Department of Industrial Engineering, University of Trento, Trento, Italy
| | | | - Massimo Daves
- Clinical Biochemistry Laboratory, Bolzano General Hospital, Bolzano, Italy
| | - Kelvin Lynch
- Department of Haematology, Cork University Hospital, Cork, Ireland
| | | | - Ignacio Martin-Loeches
- Trinity College Dublin, School of Medicine, Dublin, Ireland.,Intensive Care Medicine, St James's Hospital, Dublin, Ireland
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Pecker LH, Patel N, Creary S, Darbari A, Meier ER, Darbari DS, Fasano RM. Diverse manifestations of acute sickle cell hepatopathy in pediatric patients with sickle cell disease: A case series. Pediatr Blood Cancer 2018; 65:e27060. [PMID: 29667721 DOI: 10.1002/pbc.27060] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 02/09/2018] [Accepted: 03/01/2018] [Indexed: 12/15/2022]
Abstract
The hepatic complications of sickle cell disease (SCD) are associated with increased morbidity and mortality in adults; children usually survive but may suffer significant sequelae. Few diagnostic tools differentiate the various hepatic manifestations of SCD. Why patients exhibit one hepatic pathology versus another is unclear. We report four pediatric patients with hemoglobin SS disease with diverse manifestations of acute hepatic involvement including acute sickle hepatic crisis, hepatic sequestration, sickle cell intrahepatic cholestasis, and a non-SCD cause of hepatopathy in a patient with viral hepatitis. These complications require a systematic approach to extensive evaluation and coordinated multidisciplinary care.
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Affiliation(s)
- Lydia H Pecker
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nidhi Patel
- Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, California
| | - Susan Creary
- Center for Innovation in Pediatric Practice, Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, Ohio
| | - Anil Darbari
- Division of Gastroenterology, Hepatology, and Nutrition, Children's National Health System, Washington, District of Columbia
| | | | - Deepika S Darbari
- Division of Hematology, Children's National, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Ross M Fasano
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
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Ballas SK. Comorbidities in aging patients with sickle cell disease. Clin Hemorheol Microcirc 2018; 68:129-145. [DOI: 10.3233/ch-189003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Samir K. Ballas
- Cardeza Foundation for Hematologic Research, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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Li-Thiao-Te V, Uettwiller F, Quartier P, Lacaille F, Bader-Meunier B, Brousse V, de Montalembert M. Coexistent sickle-cell anemia and autoimmune disease in eight children: pitfalls and challenges. Pediatr Rheumatol Online J 2018; 16:5. [PMID: 29343274 PMCID: PMC5772694 DOI: 10.1186/s12969-017-0221-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 12/26/2017] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Patients with sickle cell disease (SCD) present a defective activation of the alternate complement pathway that increases the risk of infection and is thought to predispose to autoimmune disease (AID). However, coexisting AID and SCD is rarely reported, suggesting possible underdiagnosis due to an overlapping of the symptoms. STUDY DESIGN Among 603 patients with SCD followed between 1999 and June 2016, we retrospectively searched for patients with coexisting SCD and AID. RESULTS We identified 8 patients aged from 7 to 17 years diagnosed with AID; juvenile idiopathic arthritis (n = 3), systemic lupus erythematosus (n = 2), Sjögren's syndrome (n = 1) and autoimmune hepatitis (n = 2). The diagnosis of AID was often delayed due to similarities of the symptoms with those of SCD. Patients treated with steroids experienced multiple vaso-occlusive crises and received prophylactic chronic blood transfusions when it was possible. Tolerance to other immunosuppressive and biological treatments, such as anti-TNF agents, was good. A remission of AID was achieved in 4 patients, without worsening the course of the SCD. One patient underwent a geno-identical hematopoietic stem cell transplantation that cured both diseases. Another one underwent a successful liver transplantation. CONCLUSION Coexistence of AID and SCD generates diagnostic and therapeutic challenges. Early diagnosis of AID is important to define the best treatment, which may include targeted biological therapy.
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Affiliation(s)
- Valerie Li-Thiao-Te
- Onco-Hématologie Pédiatrique, Centre Hospitalier Universitaire Amiens, Amiens, France.
| | - Florence Uettwiller
- 0000 0004 0593 9113grid.412134.1Unité d’Immunologie-Hématologie et Rhumatologie Pédiatrique, Centre de référence pour la Rhumatologie et les maladies Auto-immunes Systémiques de l’Enfant, Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Pierre Quartier
- 0000 0004 0593 9113grid.412134.1Unité d’Immunologie-Hématologie et Rhumatologie Pédiatrique, Centre de référence pour la Rhumatologie et les maladies Auto-immunes Systémiques de l’Enfant, Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France ,0000 0001 2188 0914grid.10992.33Université Paris-Descartes, Paris, France ,grid.462336.6IMAGINE Institute, Paris, France
| | - Florence Lacaille
- 0000 0004 0593 9113grid.412134.1Hépatologie-Gastroentérologie-Nutrition Pédiatrique, Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Brigitte Bader-Meunier
- 0000 0004 0593 9113grid.412134.1Unité d’Immunologie-Hématologie et Rhumatologie Pédiatrique, Centre de référence pour la Rhumatologie et les maladies Auto-immunes Systémiques de l’Enfant, Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris, Paris, France ,0000 0001 2188 0914grid.10992.33Université Paris-Descartes, Paris, France ,grid.462336.6IMAGINE Institute, Paris, France
| | - Valentine Brousse
- 0000 0004 0593 9113grid.412134.1Pédiatrie Générale, Centre de Référence des Hémoglobinopathies, Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris Labex-GR-Ex, Paris, France
| | - Mariane de Montalembert
- 0000 0004 0593 9113grid.412134.1Pédiatrie Générale, Centre de Référence des Hémoglobinopathies, Hôpital Necker-Enfants Malades, Assistance Publique Hôpitaux de Paris Labex-GR-Ex, Paris, France
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Jitraruch S, Fitzpatrick E, Deheragoda M, Deganello A, Mieli-Vergani G, Height S, Rees D, Hadzic N, Samyn M. Autoimmune Liver Disease in Children with Sickle Cell Disease. J Pediatr 2017; 189:79-85.e2. [PMID: 28735981 DOI: 10.1016/j.jpeds.2017.06.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 04/19/2017] [Accepted: 06/14/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the incidence, clinical features, and outcome of autoimmune liver disease (AILD) in patients with sickle cell disease (SCD). STUDY DESIGN Single center retrospective review of patients with SCD with AILD referred between 1999 and 2015. RESULTS Thirteen of 77 (17%) patients with SCD with hepatic dysfunction were diagnosed with AILD (median age 11, range, 3.4-16 years) with a female preponderance (77%). Acute hepatitis and insidious onset were the commonest presentations. Two patients (15%) presented with acute liver failure. In 2 patients (15%), parvovirus B19-induced transient red cell aplasia preceded the diagnosis of AILD. All patients were positive for antinuclear and/or smooth muscle autoantibodies. Six of 12 patients (50%) had cholangiopathy on cholangiogram suggesting autoimmune sclerosing cholangitis (ASC). Liver biopsy, performed in 11 patients without complications, showed interface hepatitis in 90%. Patients with AILD were treated with standard immunosuppression. After a median follow-up of 3.8 years (range, 0.2-14.3), 10 patients are alive (1 was transplanted 6.4 years after diagnosis); 2 are lost to follow-up; 1 died of subdural hemorrhage before starting treatment for AILD. Five (42%) achieved full and 4 (33%) partial biochemical remission. Ulcerative colitis, present in 4 patients (2 male patients, 3 with ASC) was diagnosed in 2 patients before and in 2 patients after the diagnosis of AILD. CONCLUSIONS AILD is not uncommon in patients with SCD, affecting mainly female patients and responding satisfactorily to immunosuppressive treatment. Liver biopsy is helpful in confirming the diagnosis and can be safely performed in the absence of acute vaso-occlusive sickling episodes. Ulcerative colitis is common in the presence of ASC.
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Affiliation(s)
- Suttiruk Jitraruch
- Pediatric Liver, GI, and Nutrition Center, King's College Hospital, London, United Kingdom; Department of Pediatrics, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Emer Fitzpatrick
- Pediatric Liver, GI, and Nutrition Center, King's College Hospital, London, United Kingdom
| | - Maesha Deheragoda
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | | | - Giorgina Mieli-Vergani
- Pediatric Liver, GI, and Nutrition Center, King's College Hospital, London, United Kingdom
| | - Susan Height
- Department of Pediatric Hematology, King's College Hospital, London, United Kingdom
| | - David Rees
- Department of Pediatric Hematology, King's College Hospital, London, United Kingdom
| | - Nedim Hadzic
- Pediatric Liver, GI, and Nutrition Center, King's College Hospital, London, United Kingdom
| | - Marianne Samyn
- Pediatric Liver, GI, and Nutrition Center, King's College Hospital, London, United Kingdom.
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Girard M, Franchi-Abella S, Lacaille F, Debray D. Specificities of sclerosing cholangitis in childhood. Clin Res Hepatol Gastroenterol 2012; 36:530-5. [PMID: 22633198 DOI: 10.1016/j.clinre.2012.04.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 04/15/2012] [Accepted: 04/17/2012] [Indexed: 02/04/2023]
Abstract
Sclerosing cholangitis (SC) is a chronic cholestatic disease characterized by inflammation and obliterative fibrosis of the bile ducts, leading to biliary cirrhosis and ultimately to liver failure. Four main clinical forms can be distinguished in children: i) neonatal SC, most probably a genetic disease transmitted by autosomal recessive inheritance; ii) SC associated with strong features of autoimmunity (referred as autoimmune sclerosing cholangitis) with quite good response to immuno-suppression iii) primary SC of unknown etiology (i.e. without features of autoimmunity) and iv) SC secondary to various diseases, including Langerhans cell histiocytosis and immunodeficiencies. Ursodesoxycholic acid is considered the treatment of choice for all forms of SC but without proof of its effectiveness in preventing progression to secondary biliary cirrhosis. In patients with immunodeficiencies, early bone marrow transplantation is the only way to prevent secondary SC. Liver transplantation remains the only validated treatment in children with biliary cirrhosis. Recurrence of SC after liver transplantation has not been clearly demonstrated in children; however, recurrence of Langerhans cell histiocytosis with bile duct injury has been reported. For patients with severe immunodeficiency, a two-step liver then bone marrow transplantation protocol may be proposed.
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Affiliation(s)
- Muriel Girard
- Pôle médicochirurgical, Hépatologie Pédiatrique, Hôpital Universitaire Necker-Enfants-Malades, AP-HP, 149, rue de Sèvres, 75015 Paris, France
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A randomized, controlled clinical trial of ketoprofen for sickle-cell disease vaso-occlusive crises in adults. Blood 2009; 114:3742-7. [DOI: 10.1182/blood-2009-06-227330] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Vaso-occlusive crisis (VOC) is the primary cause of hospitalization of patients with sickle-cell disease. Treatment mainly consists of intravenous morphine, which has many dose-related side effects. Nonsteroidal antiinflammatory drugs have been proposed to provide pain relief and decrease the need for opioids. Nevertheless, only a few underpowered trials of nonsteroidal antiinflammatory drugs for sickle-cell VOC have been conducted, and conflicting results were reported. We conducted a phase 3, double-blind, randomized, placebo-controlled trial with ketoprofen (300 mg/day for 5 days), a nonselective cyclooxygenase inhibitor, for severe VOC in adults. A total of 66 VOC episodes were included. The primary efficacy outcome was VOC duration. The secondary end points were morphine consumption, pain relief, and treatment failure. Seven VOC episodes in each group were excluded from the analysis because of treatment failures. No significant between-group differences were observed for the primary outcome or the secondary end points. Thus, although ketoprofen was well-tolerated, it had no significant efficacy as treatment of VOC requiring hospitalization. These findings argue against its systematic use in this setting.
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Severe neurologic complication after delayed hemolytic transfusion reaction in 2 children with sickle cell anemia: significant diagnosis and therapeutic challenges. J Pediatr Hematol Oncol 2008; 30:928-30. [PMID: 19131783 DOI: 10.1097/mph.0b013e31818c9172] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although delayed hemolytic transfusion reaction (DHTR) has been widely recognized as a serious complication of red blood cell transfusion in patients with sickle cell disease (SCD), there is no consensus on its optimal management. Discontinuation of transfusion is recommended, whereas corticosteroids and immunoglobulins are considered to be beneficial. We report 2 children with sickle cell anemia who were diagnosed with DHTR and experienced a subsequent neurologic event in the course of treatment with corticosteroids. The role of corticosteroids as possible precipitating factors of neurologic complications is discussed. Pending a better understanding of the chain of events of DHTR, SCD children with DHTR should receive steroids with great caution.
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