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Bathla T, Lotfollahzadeh S, Quisel M, Mehta M, Malikova M, Chitalia VC. End Organ Affection in Sickle Cell Disease. Cells 2024; 13:934. [PMID: 38891066 PMCID: PMC11174153 DOI: 10.3390/cells13110934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 05/21/2024] [Accepted: 05/24/2024] [Indexed: 06/20/2024] Open
Abstract
Sickle cell disease is an orphan disease affecting ethnic minorities and characterized by profound systemic manifestations. Although around 100,000 individuals with SCD are living in the US, the exact number of individuals is unknown, and it is considered an orphan disease. This single-gene disorder leads to red blood cell sickling and the deoxygenation of hemoglobin, resulting in hemolysis. SCD is associated with acute complications such as vaso-occlusive crisis, infections, and chronic target organ complications such as pulmonary disease and renal failure. While genetic therapy holds promise to alter the fundamental disease process, the major challenge in the field remains the target end organ damage and ways to mitigate or reverse it. Here, we provide an overview of the clinical manifestations and pathogenesis with a focus on end-organ damage and current therapeutic options, including recent FDA-approved stem cell and gene editing therapies.
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Affiliation(s)
- Tanvi Bathla
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA; (T.B.); (S.L.); (M.Q.)
| | - Saran Lotfollahzadeh
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA; (T.B.); (S.L.); (M.Q.)
| | - Matthew Quisel
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA; (T.B.); (S.L.); (M.Q.)
| | - Mansi Mehta
- Saint Vincent’s Medical Hospital, Worcester, MA 01608, USA;
| | - Marina Malikova
- Department of Surgery, Boston University School of Medicine, Boston, MA 02118, USA;
| | - Vipul C. Chitalia
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA; (T.B.); (S.L.); (M.Q.)
- Veterans Affairs Boston Healthcare System, Boston, MA 02118, USA
- Institute of Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Center of Cross-Organ Vascular Pathology, Department of Medicine, Boston University Medical Center, Evans Biomedical Research Center, X-530, Boston, MA 02118, USA
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2
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Kamimura S, Smith M, Vogel S, Almeida LEF, Thein SL, Quezado ZMN. Mouse models of sickle cell disease: Imperfect and yet very informative. Blood Cells Mol Dis 2024; 104:102776. [PMID: 37391346 PMCID: PMC10725515 DOI: 10.1016/j.bcmd.2023.102776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/16/2023] [Indexed: 07/02/2023]
Abstract
The root cause of sickle cell disease (SCD) has been known for nearly a century, however, few therapies to treat the disease are available. Over several decades of work, with advances in gene editing technology and after several iterations of mice with differing genotype/phenotype relationships, researchers have developed humanized SCD mouse models. However, while a large body of preclinical studies has led to huge gains in basic science knowledge about SCD in mice, this knowledge has not led to the development of effective therapies to treat SCD-related complications in humans, thus leading to frustration with the paucity of translational progress in the SCD field. The use of mouse models to study human diseases is based on the genetic and phenotypic similarities between mouse and humans (face validity). The Berkeley and Townes SCD mice express only human globin chains and no mouse hemoglobin. With this genetic composition, these models present many phenotypic similarities, but also significant discrepancies that should be considered when interpreting preclinical studies results. Reviewing genetic and phenotypic similarities and discrepancies and examining studies that have translated to humans and those that have not, offer a better perspective of construct, face, and predictive validities of humanized SCD mouse models.
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Affiliation(s)
- Sayuri Kamimura
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Meghann Smith
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Sebastian Vogel
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Luis E F Almeida
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Swee Lay Thein
- Sickle Cell Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Zenaide M N Quezado
- Department of Perioperative Medicine, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA; Sickle Cell Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA.
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3
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Allali S, Marquant F, Rignault-Bricard R, Taylor M, Brice J, de Montalembert M, Maciel TT, Elie C, Hermine O. Oral famotidine reduces the plasma level of soluble P-selectin in children with sickle cell disease. Br J Haematol 2024; 204:346-351. [PMID: 37722599 DOI: 10.1111/bjh.19111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/30/2023] [Accepted: 09/07/2023] [Indexed: 09/20/2023]
Abstract
Plasma histamine levels are increased in patients with sickle cell disease (SCD), potentially promoting endothelial P-selectin expression and vaso-occlusion via histamine type 2 (H2) receptors. We conducted a prospective, non-comparative, single-centre study to determine whether famotidine, a H2 receptor antagonist, reduces P-selectin expression in SCD children. The median plasma P-selectin level was significantly reduced after 29 days of oral famotidine (53.2 ng/mL [IQR: 46.7-63.4] vs. 69.9 ng/mL [IQR: 53.6-84.2], median difference -10.2 ng/mL [IQR: -21.8 to -2.7], p = 0.005) in 28 patients. No effect was observed on other adhesion molecules, inflammation or haemolysis markers, except decreased reticulocyte count. No adverse events deemed related to famotidine were observed. Randomized controlled trials are now needed to assess the efficacy of famotidine in preventing vaso-occlusion in SCD.
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Affiliation(s)
- Slimane Allali
- Department of General Paediatrics and Paediatric Infectious Diseases, Sickle Cell Centre, Assistance Publique - Hôpitaux de Paris (AP-HP), Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
- Laboratory of Cellular and Molecular Mechanisms of Haematological Disorders and Therapeutical Implications, Imagine Institute, Inserm U1163, Université Paris Cité, Paris, France
- Laboratory of Excellence GR-Ex, Paris, France
| | - Fabienne Marquant
- Unité de Recherche Clinique/Centre d'investigation Clinique, Necker-Enfants Malades Hospital, AP-HP, Paris, France
| | - Rachel Rignault-Bricard
- Laboratory of Cellular and Molecular Mechanisms of Haematological Disorders and Therapeutical Implications, Imagine Institute, Inserm U1163, Université Paris Cité, Paris, France
| | - Melissa Taylor
- Department of General Paediatrics and Paediatric Infectious Diseases, Sickle Cell Centre, Assistance Publique - Hôpitaux de Paris (AP-HP), Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
- Laboratory of Excellence GR-Ex, Paris, France
| | - Joséphine Brice
- Department of General Paediatrics and Paediatric Infectious Diseases, Sickle Cell Centre, Assistance Publique - Hôpitaux de Paris (AP-HP), Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
- Laboratory of Excellence GR-Ex, Paris, France
| | - Mariane de Montalembert
- Department of General Paediatrics and Paediatric Infectious Diseases, Sickle Cell Centre, Assistance Publique - Hôpitaux de Paris (AP-HP), Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
- Laboratory of Excellence GR-Ex, Paris, France
| | - Thiago Trovati Maciel
- Laboratory of Cellular and Molecular Mechanisms of Haematological Disorders and Therapeutical Implications, Imagine Institute, Inserm U1163, Université Paris Cité, Paris, France
- Laboratory of Excellence GR-Ex, Paris, France
| | - Caroline Elie
- Unité de Recherche Clinique/Centre d'investigation Clinique, Necker-Enfants Malades Hospital, AP-HP, Paris, France
| | - Olivier Hermine
- Laboratory of Cellular and Molecular Mechanisms of Haematological Disorders and Therapeutical Implications, Imagine Institute, Inserm U1163, Université Paris Cité, Paris, France
- Laboratory of Excellence GR-Ex, Paris, France
- Department of Haematology, Necker-Enfants Malades Hospital, AP-HP, Université Paris Cité, Paris, France
- Reference Centre for Mastocytosis, Necker-Enfants Malades Hospital, AP-HP, Université Paris Cité, Paris, France
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Silva M, Faustino P. From Stress to Sick(le) and Back Again-Oxidative/Antioxidant Mechanisms, Genetic Modulation, and Cerebrovascular Disease in Children with Sickle Cell Anemia. Antioxidants (Basel) 2023; 12:1977. [PMID: 38001830 PMCID: PMC10669666 DOI: 10.3390/antiox12111977] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/30/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023] Open
Abstract
Sickle cell anemia (SCA) is a genetic disease caused by the homozygosity of the HBB:c.20A>T mutation, which results in the production of hemoglobin S (HbS). In hypoxic conditions, HbS suffers autoxidation and polymerizes inside red blood cells, altering their morphology into a sickle shape, with increased rigidity and fragility. This triggers complex pathophysiological mechanisms, including inflammation, cell adhesion, oxidative stress, and vaso-occlusion, along with metabolic alterations and endocrine complications. SCA is phenotypically heterogeneous due to the modulation of both environmental and genetic factors. Pediatric cerebrovascular disease (CVD), namely ischemic stroke and silent cerebral infarctions, is one of the most impactful manifestations. In this review, we highlight the role of oxidative stress in the pathophysiology of pediatric CVD. Since oxidative stress is an interdependent mechanism in vasculopathy, occurring alongside (or as result of) endothelial dysfunction, cell adhesion, inflammation, chronic hemolysis, ischemia-reperfusion injury, and vaso-occlusion, a brief overview of the main mechanisms involved is included. Moreover, the genetic modulation of CVD in SCA is discussed. The knowledge of the intricate network of altered mechanisms in SCA, and how it is affected by different genetic factors, is fundamental for the identification of potential therapeutic targets, drug development, and patient-specific treatment alternatives.
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Affiliation(s)
- Marisa Silva
- Departamento de Genética Humana, Instituto Nacional de Saúde Doutor Ricardo Jorge (INSA), Av. Padre Cruz, 1649-016 Lisboa, Portugal;
| | - Paula Faustino
- Departamento de Genética Humana, Instituto Nacional de Saúde Doutor Ricardo Jorge (INSA), Av. Padre Cruz, 1649-016 Lisboa, Portugal;
- Grupo Ecogenética e Saúde Humana, Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, 1649-028 Lisboa, Portugal
- Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, 1649-028 Lisboa, Portugal
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Kaur K, Kennedy K, Liles D. Crizanlizumab in sickle cell disease. Pain Manag 2023. [PMID: 37850353 DOI: 10.2217/pmt-2023-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023] Open
Abstract
Vaso-occlusion in sickle cell disease (SCD) leads to a myriad of manifestations driving morbidity and mortality in patients with SCD. Increased leucocyte adhesion and P-selectin expression on platelets and endothelial cells is an inciting event that leads to obstruction of microcirculation by adhesion with rigid sickled red blood cells. Crizanlizumab is a first-in-class monoclonal antibody that inhibits P-selectin and has been shown to decrease the frequency of vaso-occlusive pain crises in patients with SCD in clinical trials. The role of crizanlizumab in other manifestations of SCD still needs further investigation.
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Affiliation(s)
- Kiranveer Kaur
- Division of Hematology/Oncology, East Carolina University, Greenville, NC 27834, USA
| | - Katie Kennedy
- Division of Hematology/Oncology, East Carolina University, Greenville, NC 27834, USA
| | - Darla Liles
- Division of Hematology/Oncology, East Carolina University, Greenville, NC 27834, USA
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Gbotosho OT, Li W, Joiner CH, Brown LAS, Hyacinth HI. The inflammatory profiles of pulmonary alveolar macrophages and alveolar type 2 cells in SCD. Exp Biol Med (Maywood) 2023; 248:1013-1023. [PMID: 37012678 PMCID: PMC10581160 DOI: 10.1177/15353702231157940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 01/15/2023] [Indexed: 04/05/2023] Open
Abstract
The lung microenvironment plays a crucial role in maintaining lung homeostasis as well as the initiation and resolution of both acute and chronic lung injury. Acute chest syndrome (ACS) is a complication of sickle cell disease (SCD) like acute lung injury. Both the endothelial cells and peripheral blood mononuclear cells are known to secrete proinflammatory cytokines elevated during ACS episodes. However, in SCD, the lung microenvironment that may favor excessive production of proinflammatory cytokines and the contribution of other lung resident cells, such as alveolar macrophages and alveolar type 2 epithelial (AT-2) cells, to ACS pathogenesis is not completely understood. Here, we sought to understand the pulmonary microenvironment and the proinflammatory profile of lung alveolar macrophages (LAMs) and AT-2 cells at steady state in Townes sickle cell (SS) mice compared to control mice (AA). In addition, we examined lung function and micromechanics molecules essential for pulmonary epithelial barrier function in these mice. Our results showed that bronchoalveolar lavage (BAL) fluid in SS mice had elevated protein levels of pro-inflammatory cytokines interleukin (IL)-1β and IL-12 (p ⩽ 0.05) compared to AA controls. We showed for the first time, significantly increased protein levels of inflammatory mediators (Human antigen R (HuR), Toll-like receptor 4 (TLR4), MyD88, and PU.1) in AT-2 cells (1.4 to 2.2-fold) and LAM (17-21%) isolated from SS mice compared to AA control mice at steady state. There were also low levels of anti-inflammatory transcription factors (Nrf2 and PPARy) in SS mice compared to AA controls (p ⩽ 0.05). Finally, we found impaired lung function and a dysregulated composition of surfactant proteins (B and C). Our results demonstrate that SS mice at steady state had a compromised lung microenvironment with elevated expression of proinflammatory cytokines by AT-2 cells and LAM, as well as dysregulated expression of surfactant proteins necessary for maintaining the alveolar barrier integrity and lung function.
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Affiliation(s)
- Oluwabukola T Gbotosho
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Wei Li
- Aflac Cancer & Blood Disorders Center of Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Clinton H Joiner
- Aflac Cancer & Blood Disorders Center of Children’s Healthcare of Atlanta, Department of Pediatrics, 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
| | - Hyacinth I Hyacinth
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
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Gbotosho OT, Gollamudi J, Hyacinth HI. The Role of Inflammation in The Cellular and Molecular Mechanisms of Cardiopulmonary Complications of Sickle Cell Disease. Biomolecules 2023; 13:381. [PMID: 36830749 PMCID: PMC9953727 DOI: 10.3390/biom13020381] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/09/2023] [Accepted: 02/13/2023] [Indexed: 02/19/2023] Open
Abstract
Cardiopulmonary complications remain the major cause of mortality despite newer therapies and improvements in the lifespan of patients with sickle cell disease (SCD). Inflammation has been identified as a major risk modifier in the pathogenesis of SCD-associated cardiopulmonary complications in recent mechanistic and observational studies. In this review, we discuss recent cellular and molecular mechanisms of cardiopulmonary complications in SCD and summarize the most recent evidence from clinical and laboratory studies. We emphasize the role of inflammation in the onset and progression of these complications to better understand the underlying pathobiological processes. We also discuss future basic and translational research in addressing questions about the complex role of inflammation in the development of SCD cardiopulmonary complications, which may lead to promising therapies and reduce morbidity and mortality in this vulnerable population.
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Affiliation(s)
- Oluwabukola T. Gbotosho
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45267-0525, USA
| | - Jahnavi Gollamudi
- Division of Hematology & Oncology, Department of Internal Medicine, 3125 Eden Avenue, ML 0562, Cincinnati, OH 45219-0562, USA
| | - Hyacinth I. Hyacinth
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45267-0525, USA
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Zheng Z, Chang Z, Chen Y, Li J, Huang T, Huang Y, Fan Z, Gao J. Total bilirubin is associated with all-cause mortality in patients with acute respiratory distress syndrome: a retrospective study. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:1160. [PMID: 36467346 PMCID: PMC9708468 DOI: 10.21037/atm-22-1737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 09/19/2022] [Indexed: 11/09/2022]
Abstract
Background Acute respiratory distress syndrome (ARDS) is a life-threatening disease for which biomarkers to predict mortality are needed. Total bilirubin (TBIL), an end-product of hemoglobin catabolism in mammals reflecting liver dysfunction, has been demonstrated as an independent risk indicator for critically ill patients. This study aimed to examine whether TBIL on intensive care unit (ICU) admission is associated with ARDS mortality. Methods We analyzed the data of patients diagnosed with ARDS according to the Berlin definition from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The primary endpoint was 30-day ICU mortality after admission to the ICU, and the second endpoint was in-hospital mortality. Multivariable logistic analysis adjusted for potential confounders was used to determine the association between TBIL and short-term mortality. Results Of 1,539 ARDS patients enrolled, 261 patients died within 30 days of admission to the ICU. In the multivariable logistic analysis, each 1 g/dL increase in TBIL levels led to a 4% increase in the odds of 30-day ICU mortality [adjusted odds ratio (OR) =0.04; 95% confidence interval (CI): 0.01 to 0.08] and a 4% increase in the odds of in-hospital mortality (adjusted OR =0.04; 95% CI: 0.01 to 0.07). Furthermore, TBIL levels ≥2 mg/dL were significantly associated with 30-day ICU mortality (adjusted OR =1.51, 95% CI: 1.02 to 1.07) and in-hospital mortality (OR =1.41; 95% CI: 1.01 to 1.87). Similarly, associations between serum TBIL levels and 30-day ICU mortality were found in all subgroups stratified by comorbidities, the severity of ARDS, and other variables. Conclusions A higher serum TBIL on ICU admission was independently associated with mortality in ARDS patients. Intensive care and observation should be provided to ARDS patients with increased TBIL.
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Affiliation(s)
- Zhoude Zheng
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Zhen’ge Chang
- Department of Respiratory Medicine, Civil Aviation General Hospital, Beijing, China;,Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Yuxiong Chen
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jia Li
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Tingting Huang
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Yilin Huang
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Zhongjie Fan
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jinming Gao
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
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Vallelian F, Buehler PW, Schaer DJ. Hemolysis, free hemoglobin toxicity, and scavenger protein therapeutics. Blood 2022; 140:1837-1844. [PMID: 35660854 PMCID: PMC10653008 DOI: 10.1182/blood.2022015596] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/27/2022] [Indexed: 11/20/2022] Open
Abstract
During hemolysis, erythrophagocytes dispose damaged red blood cells. This prevents the extracellular release of hemoglobin, detoxifies heme, and recycles iron in a linked metabolic pathway. Complementary to this process, haptoglobin and hemopexin scavenge and shuttle the red blood cell toxins hemoglobin and heme to cellular clearance. Pathological hemolysis outpaces macrophage capacity and scavenger synthesis across a diversity of diseases. This imbalance leads to hemoglobin-driven disease progression. To meet a void in treatment options, scavenger protein-based therapeutics are in clinical development.
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Affiliation(s)
- Florence Vallelian
- Division of Internal Medicine, University Hospital, University of Zurich, Zurich, Switzerland
| | - Paul W. Buehler
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
- Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, Baltimore, MD
| | - Dominik J. Schaer
- Division of Internal Medicine, University Hospital, University of Zurich, Zurich, Switzerland
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Jones NM, Sysol JR, Singla S, Smith P, Sandusky GE, Wang H, Natarajan V, Dudek SM, Machado RF. Cortactin loss protects against hemin-induced acute lung injury in sickle cell disease. Am J Physiol Lung Cell Mol Physiol 2022; 322:L890-L897. [PMID: 35503995 PMCID: PMC9169831 DOI: 10.1152/ajplung.00274.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 04/28/2022] [Accepted: 04/28/2022] [Indexed: 11/22/2022] Open
Abstract
In patients with sickle cell disease (SCD), acute chest syndrome (ACS) is a common form of acute lung injury and a major cause of morbidity and mortality. The pathophysiology of ACS is complex, and hemin, the prosthetic moiety of hemoglobin, has been implicated in endothelial cell (EC) activation and subsequent acute lung injury (ALI) and ACS in vitro and in animal studies. Here, we examined the role of cortactin (CTTN), a cytoskeletal protein that regulates EC function, in response to hemin-induced ALI and ACS. Cortactin heterozygous (Cttn+/-) mice (n = 8) and their wild-type siblings (n = 8) were irradiated and subsequently received bone marrow cells (BMCs) extruded from the femurs of SCD mice (SS) to generate SS Cttn+/- and SS CttnWT chimeras. Following hemoglobin electrophoretic proof of BMC transplantation, the mice received 35 µmol/kg of hemin. Within 24 h, surviving mice were euthanized, and bronchoalveolar fluid (BAL) and lung samples were analyzed. For in vitro studies, human lung microvascular endothelial cells (HLMVECs) were used to determine hemin-induced changes in gene expression and reactive oxygen species (ROS) generation in cortactin deficiency and control conditions. When compared with wild-type littermates, the mortality for SS Cttn+/- mice trended to be lower after hemin infusion and these mice exhibited less severe lung injury and less necroptotic cell death. In vitro studies confirmed that cortactin deficiency is protective against hemin-induced injury in HMLVECs, by decreasing protein expression of p38/HSP27, improving cell barrier function, and decreasing the production of ROS. Further studies examining the role of CTTN in ACS are warranted and may open a new avenue of potential treatment for this devastating disease.
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Affiliation(s)
- Nicole M Jones
- Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Justin R Sysol
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Sunit Singla
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Patricia Smith
- Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - George E Sandusky
- Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Huashan Wang
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Viswanathan Natarajan
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
- Department of Pharmacology & Regenerative Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Steven M Dudek
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Roberto F Machado
- Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Karki NR, Saunders K, Kutlar A. A critical evaluation of crizanlizumab for the treatment of sickle cell disease. Expert Rev Hematol 2021; 15:5-13. [PMID: 34942078 DOI: 10.1080/17474086.2022.2023007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION P-selectin is a key adhesion molecule in the pathogenesis of sickle cell disease, including acute painful event(s). Many of the mediators activated in prototypical pain crisis are also involved in other complications seen in this population. Crizanlizumab is a monoclonal antibody approved in the US in 2019 for patients of all genotypes of sickle cell disease. By blocking P-selectin, it effectively prevents acute painful event(s) and has a manageable safety profile. AREAS COVERED In this review, we provide an overview of the (i) biology of P-selectin in sickle cell disease, (ii) various agents inhibiting P-selectin, (iii) pharmacology of crizanlizumab, (iv) preclinical and clinical data on crizanlizumab, and (v) its potential for other indications, ongoing studies, regulatory status, and cost issues. Further, we describe its position among other approved agents in sickle cell disease and project future directions as well. EXPERT OPINION Crizanlizumab holds great promise in modulating the natural history of sickle cell disease and may have pleotropic effects. Studies are ongoing to define its role in preventing other sickle cell-related complications, non-sickle cell inflammatory states, and thrombotic disorders.
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Affiliation(s)
- Nabin Raj Karki
- Division of Hematology/Oncology, Augusta University, Augusta, GA, USA
| | | | - Abdullah Kutlar
- Division of Hematology/Oncology, Augusta University, Augusta, GA, USA
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12
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Ryter SW. Significance of Heme and Heme Degradation in the Pathogenesis of Acute Lung and Inflammatory Disorders. Int J Mol Sci 2021; 22:ijms22115509. [PMID: 34073678 PMCID: PMC8197128 DOI: 10.3390/ijms22115509] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 02/07/2023] Open
Abstract
The heme molecule serves as an essential prosthetic group for oxygen transport and storage proteins, as well for cellular metabolic enzyme activities, including those involved in mitochondrial respiration, xenobiotic metabolism, and antioxidant responses. Dysfunction in both heme synthesis and degradation pathways can promote human disease. Heme is a pro-oxidant via iron catalysis that can induce cytotoxicity and injury to the vascular endothelium. Additionally, heme can modulate inflammatory and immune system functions. Thus, the synthesis, utilization and turnover of heme are by necessity tightly regulated. The microsomal heme oxygenase (HO) system degrades heme to carbon monoxide (CO), iron, and biliverdin-IXα, that latter which is converted to bilirubin-IXα by biliverdin reductase. Heme degradation by heme oxygenase-1 (HO-1) is linked to cytoprotection via heme removal, as well as by activity-dependent end-product generation (i.e., bile pigments and CO), and other potential mechanisms. Therapeutic strategies targeting the heme/HO-1 pathway, including therapeutic modulation of heme levels, elevation (or inhibition) of HO-1 protein and activity, and application of CO donor compounds or gas show potential in inflammatory conditions including sepsis and pulmonary diseases.
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Integrin VLA-4 as a PET imaging biomarker of hyper-adhesion in transgenic sickle mice. Blood Adv 2021; 4:4102-4112. [PMID: 32882004 DOI: 10.1182/bloodadvances.2020002642] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/15/2020] [Indexed: 12/12/2022] Open
Abstract
In sickle cell disease (SCD), very late antigen-4 (VLA-4 or integrin α4β1) mediates the adhesion of reticulocytes to inflamed, proinflammatory endothelium, a key process in promoting vaso-occlusive episodes (VOEs). We hypothesized that a radionuclide tracer targeting VLA-4 could be harnessed as a positron emission tomography (PET) imaging biomarker of VOEs. We tested the VLA-4 peptidomimetic PET tracer 64Cu-CB-TE1A1P-PEG4-LLP2A (64Cu-LLP2A) for imaging hyper-adhesion-associated VOEs in the SCD Townes mouse model. With lipopolysaccharide (LPS)-induced VOEs, 64Cu-LLP2A uptake was increased in the bone marrow of the humeri and femurs, common sites of VOEs in SCD mice compared with non-SCD mice. Treatment with a proven inhibitor of VOEs (the anti-mouse anti-P-selectin monoclonal antibody [mAb] RB40.34) during LPS stimulation led to a reduction in the uptake of 64Cu-LLP2A in the humeri and femurs to baseline levels, implying blockade of VOE hyper-adhesion. Flow cytometry with Cy3-LLP2A demonstrated an increased percentage of VLA-4-positive reticulocytes in SCD vs non-SCD mice in the bone and peripheral blood after treatment with LPS, which was abrogated by anti-P-selectin mAb treatment. These data, for the first time, show in vivo imaging of VLA-4-mediated hyper-adhesion, primarily of SCD reticulocytes, during VOEs. PET imaging with 64Cu-LLP2A may serve as a valuable, noninvasive method for identifying sites of vaso-occlusion and may provide an objective biomarker of disease severity and anti-P-selectin treatment efficacy in patients with SCD.
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Karki NR, Kutlar A. P-Selectin Blockade in the Treatment of Painful Vaso-Occlusive Crises in Sickle Cell Disease: A Spotlight on Crizanlizumab. J Pain Res 2021; 14:849-856. [PMID: 33833562 PMCID: PMC8019662 DOI: 10.2147/jpr.s278285] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/13/2021] [Indexed: 01/01/2023] Open
Abstract
Microvascular vaso-occlusion driven pain crisis is the hallmark of sickle cell disease with profound morbidity and increased mortality. Selectins, most notably P-selectins have an integral role in this phenomenon. P-selection was first identified in 1989. In 2019, after 3 decades of basic, translational, and clinical work with this pathway, the US Food and Drug Administration approved a P-selectin antibody, crizanlizumab to reduce frequency of pain crisis in patients more than 16 years with sickle cell disease. We review the fundamentals of P-selectin pathobiology, P-selectin blocking agents, clinical data with the use of crizanlizumab and prospects of this novel class of drugs in the context of other treatments for painful vaso-occlusive episodes.
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Affiliation(s)
- Nabin Raj Karki
- Division of Hematology/Oncology, Augusta University, Augusta, GA, USA
| | - Abdullah Kutlar
- Division of Hematology/Oncology, Augusta University, Augusta, GA, USA
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Vinchi F, Sparla R, Passos ST, Sharma R, Vance SZ, Zreid HS, Juaidi H, Manwani D, Yazdanbakhsh K, Nandi V, Silva AMN, Agarvas AR, Fibach E, Belcher JD, Vercellotti GM, Ghoti H, Muckenthaler MU. Vasculo-toxic and pro-inflammatory action of unbound haemoglobin, haem and iron in transfusion-dependent patients with haemolytic anaemias. Br J Haematol 2021; 193:637-658. [PMID: 33723861 PMCID: PMC8252605 DOI: 10.1111/bjh.17361] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/19/2021] [Indexed: 02/06/2023]
Abstract
Increasing evidence suggests that free haem and iron exert vasculo‐toxic and pro‐inflammatory effects by activating endothelial and immune cells. In the present retrospective study, we compared serum samples from transfusion‐dependent patients with β‐thalassaemia major and intermedia, hereditary spherocytosis and sickle cell disease (SCD). Haemolysis, transfusions and ineffective erythropoiesis contribute to haem and iron overload in haemolytic patients. In all cohorts we observed increased systemic haem and iron levels associated with scavenger depletion and toxic ‘free’ species formation. Endothelial dysfunction, oxidative stress and inflammation markers were significantly increased compared to healthy donors. In multivariable logistic regression analysis, oxidative stress markers remained significantly associated with both haem‐ and iron‐related parameters, while soluble vascular cell adhesion molecule 1 (sVCAM‐1), soluble endothelial selectin (sE‐selectin) and tumour necrosis factor α (TNFα) showed the strongest association with haem‐related parameters and soluble intercellular adhesion molecule 1 (sICAM‐1), sVCAM‐1, interleukin 6 (IL‐6) and vascular endothelial growth factor (VEGF) with iron‐related parameters. While hereditary spherocytosis was associated with the highest IL‐6 and TNFα levels, β‐thalassaemia major showed limited inflammation compared to SCD. The sVCAM1 increase was significantly lower in patients with SCD receiving exchange compared to simple transfusions. The present results support the involvement of free haem/iron species in the pathogenesis of vascular dysfunction and sterile inflammation in haemolytic diseases, irrespective of the underlying haemolytic mechanism, and highlight the potential therapeutic benefit of iron/haem scavenging therapies in these conditions.
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Affiliation(s)
- Francesca Vinchi
- Iron Research Program, New York Blood Center, New York, NY, USA.,Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, Cornell University, New York, NY, USA.,Molecular Medicine Partnership Unit (MMPU), European Molecular Biology Laboratory (EMBL), Heidelberg University, Heidelberg, Germany
| | - Richard Sparla
- Center for Translational Biomedical Iron Research, Department of Pediatric Oncology, Hematology, Immunology and Pulmonology, University of Heidelberg, Heidelberg, Germany
| | - Sara T Passos
- Iron Research Program, New York Blood Center, New York, NY, USA
| | - Richa Sharma
- Iron Research Program, New York Blood Center, New York, NY, USA
| | - S Zebulon Vance
- Iron Research Program, New York Blood Center, New York, NY, USA
| | - Hala S Zreid
- Department of Internal Medicine, Al Shifa Hospital, Gaza, Palestine
| | - Hesham Juaidi
- Department of Internal Medicine, Al Shifa Hospital, Gaza, Palestine
| | - Deepa Manwani
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA.,Pediatric Hematology, The Children's Hospital at Montefiore, New York, NY, USA
| | | | - Vijay Nandi
- Laboratory of Data Analytic Services, New York Blood Center, New York, NY, USA
| | - André M N Silva
- REQUIMTE-LAQV, Departamento de Química e Bioquímica, Faculdade de Ciências, University of Porto, Porto, Portugal
| | - Anand R Agarvas
- Center for Translational Biomedical Iron Research, Department of Pediatric Oncology, Hematology, Immunology and Pulmonology, University of Heidelberg, Heidelberg, Germany
| | - Eitan Fibach
- Department of Hematology, The Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - John D Belcher
- Department of Medicine, Division of Hematology, Oncology and Transplantation, Vascular Biology Center, University of Minnesota, Minneapolis, MN, USA
| | - Gregory M Vercellotti
- Department of Medicine, Division of Hematology, Oncology and Transplantation, Vascular Biology Center, University of Minnesota, Minneapolis, MN, USA
| | - Husam Ghoti
- European Center for Cancer and Cell Therapy (ECCT), Nicosia, Cyprus
| | - Martina U Muckenthaler
- Molecular Medicine Partnership Unit (MMPU), European Molecular Biology Laboratory (EMBL), Heidelberg University, Heidelberg, Germany.,Center for Translational Biomedical Iron Research, Department of Pediatric Oncology, Hematology, Immunology and Pulmonology, University of Heidelberg, Heidelberg, Germany.,German Center for Cardiovascular Research, Partner Site Heidelberg/Mannheim, Heidelberg, Germany.,Translational Lung Research Center (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
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16
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Gbotosho OT, Kapetanaki MG, Kato GJ. The Worst Things in Life are Free: The Role of Free Heme in Sickle Cell Disease. Front Immunol 2021; 11:561917. [PMID: 33584641 PMCID: PMC7873693 DOI: 10.3389/fimmu.2020.561917] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 12/04/2020] [Indexed: 12/15/2022] Open
Abstract
Hemolysis is a pathological feature of several diseases of diverse etiology such as hereditary anemias, malaria, and sepsis. A major complication of hemolysis involves the release of large quantities of hemoglobin into the blood circulation and the subsequent generation of harmful metabolites like labile heme. Protective mechanisms like haptoglobin-hemoglobin and hemopexin-heme binding, and heme oxygenase-1 enzymatic degradation of heme limit the toxicity of the hemolysis-related molecules. The capacity of these protective systems is exceeded in hemolytic diseases, resulting in high residual levels of hemolysis products in the circulation, which pose a great oxidative and proinflammatory risk. Sickle cell disease (SCD) features a prominent hemolytic anemia which impacts the phenotypic variability and disease severity. Not only is circulating heme a potent oxidative molecule, but it can act as an erythrocytic danger-associated molecular pattern (eDAMP) molecule which contributes to a proinflammatory state, promoting sickle complications such as vaso-occlusion and acute lung injury. Exposure to extracellular heme in SCD can also augment the expression of placental growth factor (PlGF) and interleukin-6 (IL-6), with important consequences to enthothelin-1 (ET-1) secretion and pulmonary hypertension, and potentially the development of renal and cardiac dysfunction. This review focuses on heme-induced mechanisms that are implicated in disease pathways, mainly in SCD. A special emphasis is given to heme-induced PlGF and IL-6 related mechanisms and their role in SCD disease progression.
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Affiliation(s)
- Oluwabukola T. Gbotosho
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Maria G. Kapetanaki
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Gregory J. Kato
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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Curative vs targeted therapy for SCD: does it make more sense to address the root cause than target downstream events? Blood Adv 2020; 4:3457-3465. [PMID: 32722787 DOI: 10.1182/bloodadvances.2020001469] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/15/2020] [Indexed: 12/14/2022] Open
Abstract
Sickle cell disease (SCD) places a heavy burden on a global and increasing population predominantly resident in resource-poor and developing countries. Progress continues to be made in preventing childhood mortality, and increasing numbers of chronically ill adults with disease are requiring care for disease sequelae. Curative therapies for SCD are therefore attractive to physicians and investigators focused on SCD. Gene therapies are being developed, and several are now in various stages of early-phase human clinical trials. However, we must also pursue avenues through which we can do the most good for the most people alive today. Such efforts include improving our understanding of disease mechanisms and which disease sequelae most strongly affect survival and interfere with quality of life. The pathways leading to disease sequelae are multiple, complex, and highly interactive. Four drugs have now been approved by the US Food and Drug Administration for SCD; however, each has a distinct mechanism and a measurable but limited effect on the many clinical sequelae of SCD. We therefore need to learn how to approach multi-agent therapy for SCD. The order of addition of each agent to treat a specific patient will need to be guided by response to previous therapy, risk factors identified for specific disease outcomes, and clinical studies to determine more comprehensively how the 4 currently approved drugs might interact and produce (or not) additive effects. Moreover, this will have to be accomplished with defined end points in mind, according to which pose the greatest threats to quality of life as well as survival.
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Abstract
INTRODUCTION In sickle cell disease (SCD), hemoglobin S (HbS) red blood cells (RBCs) are characteristically deformed and inflexible. Often breaking down in the circulation, they exhibit increased adhesive properties with the endothelium and activated neutrophils and platelets, increasing the risk of occlusion of the microcirculation. SCD is categorized into two sub-phenotypes: hyperhemolytic, associated with priapism, leg ulcers, pulmonary hypertension, and stroke, and high hemoglobin/viscosity, which may promote vaso-occlusion-associated pain, acute chest syndrome, and osteonecrosis. AREAS COVERED The sub-phenotypes are not completely distinct. Hemolysis may trigger vaso-occlusion, contributing to vascular complications. Targeting P-selectin, a key mediator of cross-talk between hyperhemolysis and vaso-occlusion, may be beneficial for vascular and vaso-occlusion-associated complications. English-language articles from PubMed on the topic of SCD and vaso-occlusive crises (VOCs) were reviewed from 1 January 2000 to 1 January 2019 using the search terms 'sickle cell disease,' 'vaso-occlusive crises,' and 'selectin.' EXPERT OPINION Besides targeting P-selectin, other strategies to counter VOCs and RBC sickling are being pursued. These include platelet inhibition to counter aggregation, intercellular adhesion, and thrombosis during VOCs; gene therapy to correct the homozygous missense mutation in the β-globin gene, causing polymerization of HbS; L-glutamine, possibly reducing oxidative stress in sickled RBCs; and fetal hemoglobin inducers.
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Affiliation(s)
- Solomon F Ofori-Acquah
- Department of Medicine, University of Pittsburgh , Pittsburgh, USA.,School of Biomedical and Allied Health Sciences, College of Health Sciences, University of Ghana , Accra, Ghana.,West African Genetic Medicine Centre (WAGMC), College of Health Sciences, University of Ghana , Accra, Ghana
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Nolfi-Donegan D, Pradhan-Sundd T, Pritchard KA, Hillery CA. Redox Signaling in Sickle Cell Disease. CURRENT OPINION IN PHYSIOLOGY 2019; 9:26-33. [PMID: 31240269 DOI: 10.1016/j.cophys.2019.04.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Sickle cell disease (SCD) is characterized by chronic hemolysis and repeated episodes of vascular occlusion leading to progressive organ injury. SCD is characterized by unbalanced, simultaneous pro-oxidant and anti-oxidant processes at the molecular, cellular and tissue levels, with the majority of reactions tipped in favor of pro-oxidant pathways. In this brief review we discuss new findings regarding how oxidized hemin, hemolysis, mitochondrial dysfunction and the innate immune system generate oxidative stress while hemopexin, haptoglobin, heme oxygenase-1 (HO-1) and nuclear factor erythroid 2-related factor 2 (Nrf2) may provide protection in human and murine SCD. We will also describe recent clinical trials showing beneficial effects of antioxidant therapy in SCD.
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Affiliation(s)
- Deirdre Nolfi-Donegan
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Tirthadipa Pradhan-Sundd
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Kirkwood A Pritchard
- Department of Surgery, Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Cheryl A Hillery
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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