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Gillespie M, Afolabi-Brown O, Machogu E, Willen S, Kopp BT. Updates in Pediatric Sickle Cell Lung Disease. Clin Chest Med 2024; 45:749-760. [PMID: 39069335 DOI: 10.1016/j.ccm.2024.02.022] [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] [Indexed: 07/30/2024]
Abstract
Sickle cell lung disease presents a challenging care paradigm involving acute and chronic lower airway disease, sleep-disordered breathing, pulmonary vascular disease, and modification by environmental factors. Understanding the presentation, pathophysiology, and diagnostic approaches is essential for accurate identification and management. While significant progress has been made, there remains a need for research to develop effective treatments and interventions to decrease disease burden in these children. Additionally, the long-term impact of interventions on cardiopulmonary outcomes is unknown. Collaborative efforts among health care providers, researchers, advocacy groups, and policy makers are crucial to improving the lives of children with SCD.
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Affiliation(s)
- Michelle Gillespie
- Division of Pulmonary Medicine, The Ohio State University Wexner Medical Center, Nationwide Children's Hospital, 2050 Kenny Road, Suite 2200, Columbus, OH, USA
| | - Olufunke Afolabi-Brown
- Division of Pulmonary and Sleep Medicine, Children' Hospital of Philadelphia, 3500 Civic Center Boulevard, Philadelphia, PA, USA
| | - Evans Machogu
- Division of Pediatric Pulmonary, Allergy and Sleep Medicine, Riley Hospital for Children, Indiana University School of Medicine, 705 Riley Hospital, ROC 4270 Indianapolis, IN 46202, USA
| | - Shaina Willen
- Division of Pulmonology, Department of Pediatrics, UC Davis Medical Center, 2516 Stockton Boulevard, Sacramento, CA, USA; Division of Hematology/Oncology, Department of Pediatrics, UC Davis Medical Center, 2516 Stockton Boulevard, Sacramento, CA, USA
| | - Benjamin T Kopp
- Division of Pulmonology, Asthma, Cystic Fibrosis, and Sleep, Emory Children's Center, 2015 Uppergate Drive, Atlanta, GA 30322, USA; Children's Healthcare of Atlanta, Emory Children's Center, 2015 Uppergate Drive, Atlanta, GA 30322, USA.
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Pavan AR, Terroni B, Dos Santos JL. Endothelial dysfunction in Sickle Cell Disease: Strategies for the treatment. Nitric Oxide 2024; 149:7-17. [PMID: 38806107 DOI: 10.1016/j.niox.2024.05.003] [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: 02/15/2024] [Revised: 04/15/2024] [Accepted: 05/25/2024] [Indexed: 05/30/2024]
Abstract
Sickle Cell Anemia (SCA), is an inherited hemoglobinopathy characterized by the presence of an abnormal hemoglobin (HbS), being the most prevalent sickle cell disease (SCD). SCA is characterized by vascular endothelial dysfunction, which contributes significantly to various clinical conditions, including but not limited to pulmonary hypertension, priapism, cutaneous leg ulceration, and stroke. The pathophysiology of endothelial dysfunction (ED) in SCA is a multifaceted process involving a chronic inflammatory and hypercoagulable state. Key factors include hemolysis-associated elements like reduced arginine and nitric oxide (NO) availability, elevated levels of vascular adhesion molecules, the uncoupling effect of NO synthase, heightened arginase activity, an environment characterized by oxidative stress with the production of reactive oxygen and nitrogen species, and occurrences of ischemia-reperfusion injury, along with apolipoprotein A-1 depletion. The urgency for novel interventions addressing ED is evident. Presently, there is a focus on investigating small molecules that disrupt the arginine-nitric oxide pathway, exhibiting anti-inflammatory and antioxidant properties while diminishing levels of cellular and vascular adhesion molecules. In this mini-review article, we delve into the progress made in strategies for treating ED in SCD with the aim of cultivating insights for drug design.
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Affiliation(s)
- Aline Renata Pavan
- São Paulo State University (UNESP), School of Pharmaceutical Sciences, Araraquara, Brazil; São Paulo State University (UNESP), Institute of Chemistry, Araraquara, Brazil.
| | - Barbara Terroni
- São Paulo State University (UNESP), School of Pharmaceutical Sciences, Araraquara, Brazil
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Hersi K, Ramani GV, Law JY, Sadek AS, Vaidya A, Gladwin MT, Cassady SJ. Diagnosis and management of chronic thromboembolic pulmonary hypertension (CTEPH) in sickle cell disease: A review. Pulm Circ 2024; 14:e12362. [PMID: 38803827 PMCID: PMC11128985 DOI: 10.1002/pul2.12362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 02/13/2024] [Accepted: 03/11/2024] [Indexed: 05/29/2024] Open
Abstract
Pulmonary hypertension in sickle cell disease (SCD) is a complex phenomenon resulting from multiple overlapping etiologies, including pulmonary vasoconstriction in the setting of chronic hemolytic anemia, diastolic dysfunction, and chronic thromboembolic disease. The presence of pulmonary hypertension of any cause in SCD confers a significant increase in mortality risk. Evidence to guide the management of patients with sickle cell disease and chronic thromboembolic pulmonary hypertension (CTEPH) is scant and largely the realm of case reports and small case series. Centered on a discussion of a complex young patient with hemoglobin hemoglobin SC who ultimately underwent treatment with pulmonary thromboendarterectomy, we review the available literature to guide management and discuss and overview of treatment of CTEPH in SCD, considering the unique considerations and challenges facing patients suffering from this multisystem disease.
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Affiliation(s)
- Kadija Hersi
- Division of Pulmonary and Critical Care Medicine, Department of MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
- National Heart, Lung, and Blood InstituteNational Institutes of HealthBethesdaMarylandUSA
| | - Gautam V. Ramani
- Division of Cardiology, Department of MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Jennie Y. Law
- Division of Hematology and Oncology, Department of MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Ahmed S. Sadek
- Division of Cardiology, Department of MedicineLewis Katz School of Medicine at TemplePhiladelphiaPennsylvaniaUSA
| | - Anjali Vaidya
- Division of Cardiology, Department of MedicineLewis Katz School of Medicine at TemplePhiladelphiaPennsylvaniaUSA
| | - Mark T. Gladwin
- Division of Pulmonary and Critical Care Medicine, Department of MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Steven J. Cassady
- Division of Pulmonary and Critical Care Medicine, Department of MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
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Roy NB, Carpenter A, Dale-Harris I, Dorée C, Estcourt LJ. Interventions for chronic kidney disease in people with sickle cell disease. Cochrane Database Syst Rev 2023; 8:CD012380. [PMID: 37539955 PMCID: PMC10404133 DOI: 10.1002/14651858.cd012380.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: 08/05/2023]
Abstract
BACKGROUND Sickle cell disease (SCD), one of the commonest severe monogenic disorders, is caused by the inheritance of two abnormal haemoglobin (beta-globin) genes. SCD can cause severe pain, significant end-organ damage, pulmonary complications, and premature death. Kidney disease is a frequent and potentially severe complication in people with SCD. Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function present for more than three months. Sickle cell nephropathy refers to the spectrum of kidney complications in SCD. Glomerular damage is a cause of microalbuminuria and can develop at an early age in children with SCD, with increased prevalence in adulthood. In people with sickle cell nephropathy, outcomes are poor as a result of the progression to proteinuria and chronic kidney insufficiency. Up to 12% of people who develop sickle cell nephropathy will develop end-stage renal disease. This is an update of a review first published in 2017. OBJECTIVES To assess the effectiveness of any intervention for preventing or reducing kidney complications or chronic kidney disease in people with sickle cell disease. Possible interventions include red blood cell transfusions, hydroxyurea, and angiotensin-converting enzyme inhibitors (ACEIs), either alone or in combination. SEARCH METHODS We searched for relevant trials in the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, CENTRAL, MEDLINE, Embase, seven other databases, and two other trials registers. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing interventions to prevent or reduce kidney complications or CKD in people with SCD. We applied no restrictions related to outcomes examined, language, or publication status. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility, extracted data, assessed the risk of bias, and assessed the certainty of the evidence (GRADE). MAIN RESULTS We included three RCTs with 385 participants. We rated the certainty of the evidence as low to very low across different outcomes according to GRADE methodology, downgrading for risk of bias concerns, indirectness, and imprecision. Hydroxyurea versus placebo One RCT published in 2011 compared hydroxyurea to placebo in 193 children aged nine to 18 months. We are unsure if hydroxyurea compared to placebo reduces or prevents progression of kidney disease assessed by change in glomerular filtration rate (mean difference (MD) 0.58 mL/min /1.73 m2, 95% confidence interval (CI) -14.60 to 15.76; 142 participants; very low certainty). Hydroxyurea compared to placebo may improve the ability to concentrate urine (MD 42.23 mOsm/kg, 95% CI 12.14 to 72.32; 178 participants; low certainty), and may make little or no difference to SCD-related serious adverse events, including acute chest syndrome (risk ratio (RR) 0.39, 99% CI 0.13 to 1.16; 193 participants; low certainty), painful crisis (RR 0.68, 99% CI 0.45 to 1.02; 193 participants; low certainty); and hospitalisations (RR 0.83, 99% CI 0.68 to 1.01; 193 participants; low certainty). No deaths occurred in either trial arm and the RCT did not report quality of life. Angiotensin-converting enzyme inhibitors versus placebo One RCT published in 1998 compared an ACEI (captopril) to placebo in 22 adults with normal blood pressure and microalbuminuria. We are unsure if captopril compared to placebo reduces proteinuria (MD -49.00 mg/day, 95% CI -124.10 to 26.10; 22 participants; very low certainty). We are unsure if captopril reduces or prevents kidney disease as measured by creatinine clearance; the trial authors stated that creatinine clearance remained constant over six months in both groups, but provided no comparative data (very low certainty). The RCT did not report serious adverse events, all-cause mortality, or quality of life. Angiotensin-converting enzyme inhibitors versus vitamin C One RCT published in 2020 compared an ACEI (lisinopril) with vitamin C in 170 children aged one to 18 years with normal blood pressure and microalbuminuria. It reported no data we could analyse. We are unsure if lisinopril compared to vitamin C reduces proteinuria in this population: the large drop in microalbuminuria in both arms of the trial after only one month on treatment may have been due to an overestimation of microalbuminuria at baseline rather than a true effect. The RCT did not report serious adverse events, all-cause mortality, or quality of life. AUTHORS' CONCLUSIONS We are unsure if hydroxyurea improves glomerular filtration rate or reduces hyperfiltration in children aged nine to 18 months, but it may improve their ability to concentrate urine and may make little or no difference to the incidence of acute chest syndrome, painful crises, and hospitalisations. We are unsure if ACEI compared to placebo has any effect on preventing or reducing kidney complications in adults with normal blood pressure and microalbuminuria. We are unsure if ACEI compared to vitamin C has any effect on preventing or reducing kidney complications in children with normal blood pressure and microalbuminuria. No RCTs assessed red blood cell transfusions or any combined interventions to prevent or reduce kidney complications. Due to lack of evidence, we cannot comment on the management of children aged over 18 months or adults with any known genotype of SCD. We have identified a lack of adequately designed and powered studies, although we found four ongoing trials since the last version of this review. Only one ongoing trial addresses renal function as a primary outcome in the short term, but such interventions have long-term effects. Trials of hydroxyurea, ACEIs or red blood cell transfusion in older children and adults are urgently needed to determine any effect on prevention or reduction of kidney complications in people with SCD.
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Affiliation(s)
- Noemi Ba Roy
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
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Ettinger NA, Guffey D, Anum SJ, Fasipe T, Katkin J, Bhar S, Airewele G, Saini A, Tubman VN. Multi-center retrospective study of children with sickle cell disease admitted to pediatric intensive care units in the United States. Sci Rep 2023; 13:6758. [PMID: 37185357 PMCID: PMC10130031 DOI: 10.1038/s41598-023-32651-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 03/30/2023] [Indexed: 05/17/2023] Open
Abstract
Data on outcomes and interventions for children with sickle cell disease (SCD) admitted to a pediatric intensive care units (PICU) are unknown. We provide the first comprehensive multi-center report on PICU interventions associated with death, the need for invasive respiratory support or stroke among critically ill children with SCD. We collected retrospective multi-center cohort data from January 1, 2012 to December 31, 2019 utilizing the Virtual Pediatric Systems, LLC database. We identified 3388 unique children with SCD, accounting for a total of 5264 PICU admissions from 138 PICUs. The overall mortality rate for the PICU admissions cohort was 1.8% (95/5264 PICU admissions, 95/3388 [2.8%] of all unique patients), the rate of needing of needing Invasive Respiratory Support (IRS, a composite category of exposure) was 21.3% (872/4093 PICU admissions with complete data) and the overall rate of stroke (ischemic or hemorrhagic) was 12.5% (657/5264 PICU admissions). In multivariable analysis adjusting for admission age category, sex, race/ethnicity, PRISM-3 score at admission, exposure to IRS, quartile of unit volume of patients with SCD, and patient origin, admitted children who needed invasive respiratory support (IRS) had higher adjusted odds ratios for mortality (adjusted odds ratio [aOR], 19.72; 95% confidence interval [CI] 8.98-43.29; p < 0.001), although admitted children > 2 years old had decreased aOR for needing IRS (aOR 0.25-0.62; 95% CI 0.16-0.94; p < 0.001-0.025). By contrast, admitted children > 2 years old had a strikingly increased aOR for stroke (aOR 7.57-16.32; 95% CI 2.25-52.15; p < 0.001). These groups may represent PICU-specific subsets of patients with SCD who are at higher risk for more serious illness and should deserve early consideration for referral to a pediatric institution providing comprehensive care for patients with SCD.
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Affiliation(s)
- Nicholas A Ettinger
- Division of Pediatric Critical Care, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, 6651 Main Street, MC: E1420, Houston, TX, 77030, USA.
| | - Danielle Guffey
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | - Shaniqua J Anum
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Titilope Fasipe
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Julie Katkin
- Division of Pulmonology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Saleh Bhar
- Division of Pediatric Critical Care, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, 6651 Main Street, MC: E1420, Houston, TX, 77030, USA
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Gladstone Airewele
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Arun Saini
- Division of Pediatric Critical Care, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, 6651 Main Street, MC: E1420, Houston, TX, 77030, USA
| | - Venée N Tubman
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
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Hamzaoui A, Louhaichi S, Hamdi B. [Lung manifestations of sickle-cell disease]. Rev Mal Respir 2023:S0761-8425(23)00107-9. [PMID: 37059617 DOI: 10.1016/j.rmr.2023.03.002] [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: 07/23/2022] [Accepted: 03/04/2023] [Indexed: 04/16/2023]
Abstract
Sickle-cell disease is an autosomal recessive genetic disorder of hemoglobin that causes systemic damage. Hypoxia is the main actor of sickle-cell disease. It initiates acutely the pathogenic cascade leading to tissue damages that in turn induce chronic hypoxia. Lung lesions represent the major risk of morbidity and mortality. Management of sickle-cell disease requires a tight collaboration between hematologists, intensivists and chest physicians. Recurrent episodes of thrombosis and hemolysis characterize the disease. New therapeutic protocols, associating hydroxyurea, transfusion program and stem cell transplantation in severe cases allow a prolonged survival until the fifth decade. However, recurrent pain, crisis, frequent hospital admissions due to infection, anemia or acute chest syndrome and chronic complications leading to organ deficiencies degrade the patients' quality of life. In low-income countries where the majority of sickle-cell patients are living, the disease is still associated with a high mortality in childhood. This paper focuses on acute chest syndrome and chronic lung manifestations.
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Affiliation(s)
- A Hamzaoui
- Pavillon B/LR19SP02, hôpital Abderrahmen-Mami, 2080 Ariana, Tunisie; Faculté de médecine de Tunis, 1006 Tunis, Tunisie.
| | - S Louhaichi
- Pavillon B/LR19SP02, hôpital Abderrahmen-Mami, 2080 Ariana, Tunisie; Faculté de médecine de Tunis, 1006 Tunis, Tunisie
| | - B Hamdi
- Pavillon B/LR19SP02, hôpital Abderrahmen-Mami, 2080 Ariana, Tunisie; Faculté de médecine de Tunis, 1006 Tunis, Tunisie
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Sleep disordered breathing and its relation to stroke and pulmonary hypertension in children with sickle cell disease: a single-center cross-sectional study. Ann Hematol 2023; 102:271-281. [PMID: 36645459 PMCID: PMC9889484 DOI: 10.1007/s00277-023-05099-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 01/03/2023] [Indexed: 01/17/2023]
Abstract
Sleep disordered breathing (SDB) is a common underdiagnosed sequela of sickle cell disease (SCD) that has been linked to the frequency of vaso-occlusive crises. To determine the frequency of SDB in children with SCD and its association to SCD-related complications, thirty children and adolescents with SCD at their steady state underwent clinical, laboratory, and radiological assessment using transcranial duplex (TCD) and echo assessment of tricuspid regurge velocity (TRV). All participants had an overnight polysomnography after completing the modified STOP-Bang questionnaire. The mean age of the studied cohort was 10.2 years, with male: female ratio 1.7:1. Six children (20%) had high-risk for obstructive sleep apnea (OSA), while nine (30%) were at intermediate risk. Sleep apnea defined as apnea (AHI) > 1 event/hour was found among 18/30 (60%) subjects (14 males and 4 females). Children with AHI > 5 (moderate to severe OSA) had significantly higher TRV (p = 0.007) and left MCA flow velocity (p = 0.049) when compared to those with AHI < 5. Children with AHI > 5 were at higher risk of OSA according to the modified STOP-Bang questionnaire (p = 0.02). AHI positively correlated with TRV (r = 0.53, p = 0.003), right MCA flow velocity (r = 0.45, p = 0.013), and left MCA flow velocity (r = 0.55, p = 0.002), and negatively correlated to BMI-SDS (r = - 0.48, p = 0.008). The high frequency of OSA in the studied cohort with SCD and its association with increasing risk of PH and TCD changes highlights the importance of early detection and management of OSA in children with SCD.
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Lao TT. The obstetric implications of pulmonary hypertension and lung transplant. Best Pract Res Clin Obstet Gynaecol 2022; 85:70-82. [PMID: 35868979 DOI: 10.1016/j.bpobgyn.2022.06.002] [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: 05/31/2022] [Accepted: 06/20/2022] [Indexed: 12/14/2022]
Abstract
Pulmonary hypertension (PH) is present when the mean pulmonary artery pressure is elevated to >20 mmHg as determined by right heart catheterization. It is categorized into five groups according to the underlying causes. Its presence is considered a contraindication to pregnancy for which therapeutic termination is usually advised due to grave maternal prognosis and pregnancy outcome. Nevertheless, pregnancies in affected women are increasingly reported, about half of which were unplanned, and two-thirds resulted in live births without increased foetal anomalies, notwithstanding increased risks of preterm birth, low birth weight, pre-eclampsia, other obstetric complications, and medical comorbidities, when managed under a multidisciplinary team in specialized centres. Successful lung transplant, the ultimate treatment for PH and other progressive lung diseases, restores fertility, and pregnancy is increasingly encountered, but there is a higher risk of graft rejection and mortality, compared with recipients of other organs. Preconception assessment is vital in optimizing maternal and pregnancy outcomes.
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Affiliation(s)
- Terence T Lao
- Department of Obstetrics & Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong.
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Gillespie ML, Spring MR, Cohen RT, Klings ES. The interplay of sleep disordered breathing, nocturnal hypoxemia, and endothelial dysfunction in sickle cell disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Khan MI, Patel N, Meda RT, Nuguru SP, Rachakonda S, Sripathi S. Sickle Cell Disease and Its Respiratory Complications. Cureus 2022; 14:e28528. [PMID: 36185937 PMCID: PMC9517690 DOI: 10.7759/cureus.28528] [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] [Accepted: 08/29/2022] [Indexed: 11/10/2022] Open
Abstract
Sickle cell disease (SCD) is a hematological disorder that is inherited in an autosomal recessive (AR) fashion. It is caused by mutations in the genes encoding for the globin apoprotein of hemoglobin (Hb), leading to diminished oxygen-carrying ability. Its pathophysiologic mechanism affects multiple organ systems, making it crucial to understand the complications of SCD and find the best ways to prevent and treat them. Some important ways that SCD manifests in the respiratory system are acute chest syndrome (ACS), pulmonary hypertension (PH), asthma, and venous thromboembolism (VTE). This article summarizes their salient features, including pathogenesis related to the adverse outcomes, screening practices, and management guidelines, with the intent to provide greater insight into forming better practices that increase the quality of life in SCD patients.
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Ross JM, Forté S, Soulières D. Emerging drugs for the treatment of sickle cell disease: a review of phase II/III trials. Expert Opin Emerg Drugs 2022; 27:211-224. [PMID: 35912835 DOI: 10.1080/14728214.2022.2105835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The substitution of glutamic acid by valine on the ß-globin gene produces the hemoglobin S variant responsible for sickle cell disease (SCD), a disorder that affects millions of people worldwide and leads to acute and cumulative organ damage. Even though life expectancy has significantly improved where the best medical care is available, there are still few therapeutic options for SCD and those are limited by their availability, cost, and individual toxicities. AREAS COVERED This review summarizes the clinical data on current treatments for SCD and emerging therapies studied in the acute setting as well as potential disease-modifying agents, with an emphasis on the FDA-approved agents. EXPERT OPINION Hydroxyurea has been a gold standard for two decades, showing benefits in acute complications and overall survival in sickle cell anemia, although data is lacking for certain genotypes such as hemoglobin SC. As progress is made in our understanding of the pathophysiological networks characterizing SCD, numerous pathways appear to be targetable, with L-glutamine, Crizanlizumab and Voxelotor now approved by the FDA. Pursuing a multi-agent approach could alter the disease course in a more effective fashion and provide an alternative option to curative therapies, but longer clinical studies are needed.
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Affiliation(s)
- Jules M Ross
- Centre Universitaire de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Stéphanie Forté
- Centre Universitaire de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Denis Soulières
- Centre Universitaire de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
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Azbell RCG, Desai PC. Treatment dilemmas: strategies for priapism, chronic leg ulcer disease, and pulmonary hypertension in sickle cell disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:411-417. [PMID: 34889382 PMCID: PMC8791181 DOI: 10.1182/hematology.2021000275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Sickle cell disease is a disorder characterized by chronic hemolytic anemia and multiorgan disease complications. Although vaso-occlusive episodes, acute chest syndrome, and neurovascular disease frequently result in complication and have well-documented guidelines for management, the management of chronic hemolytic and vascular-related complications, such as priapism, leg ulcers, and pulmonary hypertension, is not as well recognized despite their increasing reported prevalence and association with morbidity and mortality. This chapter therefore reviews the current updates on diagnosis and management of priapism, leg ulcers, and pulmonary hypertension.
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Affiliation(s)
- Roberta C G Azbell
- The Ohio State University Wexner Medical Center, Department of Internal Medicine, Columbus, OH
- Division of Hospital Medicine, Columbus, OH
| | - Payal Chandarana Desai
- The Ohio State University Wexner Medical Center, Department of Internal Medicine, Columbus, OH
- Division of Hematology and Oncology, Columbus, OH
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Madu A, Madu K, Anigbogu I, Ugwu AO, Okwulehie VA, Ololo U, Ugwu C, Chikezie K. Phenotypic characterisation and associations of leg ulcers in adult sickle cell patients. Wound Repair Regen 2021; 30:126-131. [PMID: 34738694 DOI: 10.1111/wrr.12970] [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: 01/15/2021] [Revised: 07/23/2021] [Accepted: 08/24/2021] [Indexed: 11/30/2022]
Abstract
Sickle leg ulcer (SLU) occurs as a result chronic occlusion of the vasculature with consequent necrosis of the skin and subcutaneous tissue usually in proximity of the malleoli. The description of clinical associations and the simultaneous occurrence of SLU and other complications of SCD compared to the non-SLU patients was the aim of this work. A total of 272 (60.8% males and 39.2% females) patients were captured during this time period out of which 68 (51 males and 17 females) had SLU out of whom 20 patients had bilateral leg ulcers. Prevalence of SLU was 25% and the median age of patients was 25 years, frequency of crisis 2 per annum and 44 (74.6%) had been transfused in the past. Median Hb of the group was 7.6 g/dl and 25% had values lower than 6.5. The occurrence of other complications in SLU patients was as follows; 10 had AVN, 9 priapism, 8 had osteomyelitis, 6 nephropathy, stroke 2, osteoarthritis 4 and cholelithiasis 4. There was a significant relationship between the occurrence of SLU and gender of the patient being more in 67males-Likelihood ratio 4.610 (p = 0.032) and the occurrence of pulmonary hypertension-Likelihood ratio 4.762 (p = 0.029). There was no significant association between the occurrence of SLU and other complications of SCD. Leg ulcer patients have a median age of 25 years with a prevalence of 25% but do not necessarily show other features of severe disease phenotypes. SLU patients were more likely to develop pulmonary hypertension. Further studies on impact of environmental factors on the occurrence of SLU are needed to further evaluate its aetiology.
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Affiliation(s)
- Anazoeze Madu
- Department of Haematology and Immunology, University of Nigeria, Ituku-Ozalla Campus, Enugu State, Nigeria
| | | | - Ikechukwu Anigbogu
- Department of Haematology and Immunology, University of Nigeria, Ituku-Ozalla Campus, Enugu State, Nigeria
| | - Angela Ogechukwu Ugwu
- Department of Haematology and Immunology, University of Nigeria, Ituku-Ozalla Campus, Enugu State, Nigeria
| | - Vincent A Okwulehie
- Department of Surgery, University of Nigeria, Ituku-Ozalla Campus, Enugu State, Nigeria
| | - Uchenna Ololo
- Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, Nigeria
| | - Chioma Ugwu
- Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, Nigeria
| | - Kelechi Chikezie
- Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, Nigeria
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14
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Stembridge M, Hoiland RL, Williams AM, Howe CA, Donnelly J, Dawkins TG, Drane A, Tymko MM, Gasho C, Anholm J, Simpson LL, Moore JP, Bailey DM, MacLeod DB, Ainslie PN. The influence of hemoconcentration on hypoxic pulmonary vasoconstriction in acute, prolonged, and lifelong hypoxemia. Am J Physiol Heart Circ Physiol 2021; 321:H738-H747. [PMID: 34448634 DOI: 10.1152/ajpheart.00357.2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Hemoconcentration can influence hypoxic pulmonary vasoconstriction (HPV) via increased frictional force and vasoactive signaling from erythrocytes, but whether the balance of these mechanism is modified by the duration of hypoxia remains to be determined. We performed three sequential studies: 1) at sea level, in normoxia and isocapnic hypoxia with and without isovolumic hemodilution (n = 10, aged 29 ± 7 yr); 2) at altitude (6 ± 2 days acclimatization at 5,050 m), before and during hypervolumic hemodilution (n = 11, aged 27 ± 5 yr) with room air and additional hypoxia [fraction of inspired oxygen ([Formula: see text])= 0.15]; and 3) at altitude (4,340 m) in Andean high-altitude natives with excessive erythrocytosis (EE; n = 6, aged 39 ± 17 yr), before and during isovolumic hemodilution with room air and hyperoxia (end-tidal Po2 = 100 mmHg). At sea level, hemodilution mildly increased pulmonary artery systolic pressure (PASP; +1.6 ± 1.5 mmHg, P = 0.01) and pulmonary vascular resistance (PVR; +0.7 ± 0.8 wu, P = 0.04). In contrast, after acclimation to 5,050 m, hemodilution did not significantly alter PASP (22.7 ± 5.2 vs. 24.5 ± 5.2 mmHg, P = 0.14) or PVR (2.2 ± 0.9 vs. 2.3 ± 1.2 wu, P = 0.77), although both remained sensitive to additional acute hypoxia. In Andeans with EE at 4,340 m, hemodilution lowered PVR in room air (2.9 ± 0.9 vs. 2.3 ± 0.8 wu, P = 0.03), but PASP remained unchanged (31.3 ± 6.7 vs. 30.9 ± 6.9 mmHg, P = 0.80) due to an increase in cardiac output. Collectively, our series of studies reveal that HPV is modified by the duration of exposure and the prevailing hematocrit level. In application, these findings emphasize the importance of accounting for hematocrit and duration of exposure when interpreting the pulmonary vascular responses to hypoxemia.NEW & NOTEWORTHY Red blood cell concentration influences the pulmonary vasculature via direct frictional force and vasoactive signaling, but whether the magnitude of the response is modified with duration of exposure is not known. By assessing the pulmonary vascular response to hemodilution in acute normobaric and prolonged hypobaric hypoxia in lowlanders and lifelong hypobaric hypoxemia in Andean natives, we demonstrated that a reduction in red cell concentration augments the vasoconstrictive effects of hypoxia in lowlanders. In high-altitude natives, hemodilution lowered pulmonary vascular resistance, but a compensatory increase in cardiac output following hemodilution rendered PASP unchanged.
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Affiliation(s)
- Mike Stembridge
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom
| | - Ryan L Hoiland
- Centre for Heart, Lung and Vascular Health, University of British Columbia Okanagan, Kelowna, British Columbia, Canada.,Department of Anesthesiology, Pharmacology, and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexandra M Williams
- Centre for Heart, Lung and Vascular Health, University of British Columbia Okanagan, Kelowna, British Columbia, Canada.,Faculty of Medicine, Department of Cellular and Physiological Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Connor A Howe
- Centre for Heart, Lung and Vascular Health, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Joseph Donnelly
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Tony G Dawkins
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom
| | - Aimee Drane
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom
| | - Michael M Tymko
- Centre for Heart, Lung and Vascular Health, University of British Columbia Okanagan, Kelowna, British Columbia, Canada.,Neurovascular Health Laboratory, Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Alberta, Canada
| | - Christopher Gasho
- Division of Pulmonary and Critical Care, School of Medicine, Loma Linda University, Loma Linda, California
| | - James Anholm
- Division of Pulmonary and Critical Care, School of Medicine, Loma Linda University, Loma Linda, California
| | - Lydia L Simpson
- Extremes Research Group, School of Sport, Health and Exercise Sciences, Bangor University, Wales, United Kingdom
| | - Jonathan P Moore
- Extremes Research Group, School of Sport, Health and Exercise Sciences, Bangor University, Wales, United Kingdom
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, United Kingdom
| | - David B MacLeod
- Human Pharmacology and Physiology Laboratory, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Philip N Ainslie
- Centre for Heart, Lung and Vascular Health, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
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15
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Cramer-Bour C, Ruhl AP, Nouraie SM, Emeh RO, Ruopp NF, Thein SL, Weir NA, Klings ES. Long-term tolerability of phosphodiesterase-5 inhibitors in pulmonary hypertension of sickle cell disease. Eur J Haematol 2021; 107:54-62. [PMID: 33650125 PMCID: PMC8730705 DOI: 10.1111/ejh.13612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Sickle cell disease-related pulmonary hypertension (SCD-PH) is a complex disorder with multifactorial contributory mechanisms. Previous trials have evaluated the efficacy of pulmonary arterial hypertension (PAH) therapies in SCD-PH with mixed results. We hypothesized that a subset of patients with right heart catheterization (RHC) confirmed disease may benefit from PAH therapy. METHODS We performed a retrospective chart review of patients with SCD-PH diagnosed by RHC who were treated with phosphodiesterase 5 inhibitor (PDE5-I) therapy for ≥4 months between 2008 and 2019 at two institutions. RESULTS Thirty-six patients were included in the analysis. The median age (IQR) upon PDE5-I initiation was 47.5 years (35-51.5 years); 58% were female and twenty-nine (81%) had HbSS disease. Of these, 53% of patients had a history of acute chest syndrome, 42% had a history of venous thromboembolism, and 38% had imaging consistent with chronic thromboembolic PH. Patients were treated for a median duration of 25 months (IQR 13-60 months). Use of PDE5-I was associated with a significant improvement in symptoms as assessed by NYHA Class (P = .002). CONCLUSIONS In SCD patients with PH defined by RHC, PDE5-I therapy was tolerated long-term and may improve physical activity.
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Affiliation(s)
- Cassondra Cramer-Bour
- Department of Medicine, Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118
| | - A. Parker Ruhl
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
- Pulmonary Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - S. Mehdi Nouraie
- Division of Pulmonary, Asthma and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213
| | - Robert O. Emeh
- Howard University College of Medicine, 520 W St NW, Washington, DC 20059
| | - Nicole F. Ruopp
- Division of Pulmonary, Critical Care, and Sleep Medicine, Tufts Medical Center, Boston, MA
| | - Swee Lay Thein
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Nargues A. Weir
- Pulmonary Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Elizabeth S. Klings
- Department of Medicine, Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118
- The Pulmonary Center, Boston University School of Medicine, 72 East Concord Street, R‐304, Boston, MA 02118
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16
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Ex Vivo Activation of Red Blood Cell Senescence by Plasma from Sickle-Cell Disease Patients: Correlation between Markers and Adhesion Consequences during Acute Disease Events. Biomolecules 2021; 11:biom11070963. [PMID: 34208829 PMCID: PMC8301992 DOI: 10.3390/biom11070963] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND: Blood transfusion remains a key treatment for managing occlusive episodes and painful crises in sickle-cell disease (SCD). In that clinical context, red blood cells (RBCs) from donors and transfused to patients, may be affected by plasma components in the recipients’ blood. Senescence lesion markers appear on the red cells after transfusion, shortening the RBC lifespan in circulation. In the specific context of SCD, senescence signals can also trigger the occlusive painful events, typical of the disease. This work follows through our previous data that described a RBC senescence process, rapidly detected after challenge with SCD pathological plasmas. In this clinical context, we wanted here to further explore the characteristics and physiologic consequences of AA RBC lesions associated with senescence, as lesions caused by RBCs after transfusion may have adverse consequences for SCD patients. METHODS: Plasma samples from SCD patients, with acute symptoms (n = 20) or steady-state disease (n = 34) were co-incubated with donor AA RBCs from blood units for 24 to 48 h. Specific markers signing RBC senescence were quantified after the incubation with SCD plasma samples. The physiologic in-flow adhesion was investigated on senescent RBCs, an in vitro technic into biochips that mimic adherence of RBCs during the occlusive events of SCD. RESULTS: Senescence markers on AA RBCs, together with their in-flow adhesion to the plasma-bridging protein thrombospondin, were associated with the clinical status of the SCD patients from whom plasma was obtained. In these experiments, the highest values were obtained for SCD acute plasma samples. Adhesion of senescent RBCs into biochips, which is not reversed by a pre-treatment with recombinant Annexin V, can be reproduced with the use of chemical agents acting on RBC membrane channels that regulate either Ca2+ entry or modulating RBC hydration. CONCLUSION: We found that markers on red cells are correlated, and that the senescence induced by SCD plasma provokes the adhesion of RBCs to the vessel wall protein thrombospondin. In-flow adhesion of senescent red cells after plasma co-incubations can be reproduced with the use of modulators of RBC membrane channels; activating the Piezo1 Ca2+ mechanosensitive channel provokes RBC adhesion of normal (non-senescent) RBCs, while blocking the Ca2+-dependent K+ Gardos channel, can reverse it. Clinically modulating the RBC adhesion to vascular wall proteins might be a promising avenue for the treatment of painful occlusive events in SCD.
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17
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Sange I, Cherukuri PB, Parchuri V, Srinivas N, Ramanan SP, Sange AH, Modi S, Khot FA. Sickle Cell Disease and the Respiratory System: A Tangential Perspective to the Hematopulmonological Dilemma. Cureus 2021; 13:e15562. [PMID: 34277185 PMCID: PMC8271619 DOI: 10.7759/cureus.15562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/10/2021] [Indexed: 11/05/2022] Open
Abstract
Sickle cell disease (SCD) is a genetically inherited hematological condition that predominantly affects the African-American subset of the population. It leads to the precipitation of multi-systematic manifestations throughout the course of the life of the patient leading to an increased rate of inpatient admissions and decreased quality of life. This article has reviewed some of the most common pulmonary complications of SCD with a brief overview of the clinical features and their management and has also highlighted the fatality of the complications placing a strong focus on screening, monitoring, and the treatment of the disease. The article has also discussed the management of SCD from a pulmonological perspective rather than hematological alone.
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Affiliation(s)
- Ibrahim Sange
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Research, K. J. Somaiya Medical College, Mumbai, IND
| | | | | | - Natasha Srinivas
- Research, B.G.S. Global Institute of Medical Sciences, Bangalore, IND
| | - Sruthi Priyavadhana Ramanan
- Neurology, California Institute of Behavioral Neurosciences & Psychology, California, USA.,Medicine/Surgery, Saveetha Medical College, Chennai, IND
| | | | - Srimy Modi
- Research, K. J. Somaiya Medical College, Mumbai, IND
| | - Farhat A Khot
- Research, Maharashtra Institute of Medical Education and Research (MIMER) Medical College, Pune, IND
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18
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Nader E, Conran N, Romana M, Connes P. Vasculopathy in Sickle Cell Disease: From Red Blood Cell Sickling to Vascular Dysfunction. Compr Physiol 2021; 11:1785-1803. [PMID: 33792905 DOI: 10.1002/cphy.c200024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Sickle cell disease (SCD) is a hereditary disorder that leads to the production of an abnormal hemoglobin, hemoglobin S (HbS). HbS polymerizes in deoxygenated conditions, which can prompt red blood cell (RBC) sickling and leaves the RBCs more rigid, fragile, and prone to hemolysis. SCD patients suffer from a plethora of complications, ranging from acute complications, such as characteristic, frequent, and debilitating vaso-occlusive episodes to chronic organ damage. While RBC sickling is the primary event at the origin of vaso-occlusive processes, other factors that can further increase RBC transit times in the microcirculation may also be required to precipitate vaso-occlusive processes. The adhesion of RBC and leukocytes to activated endothelium and the formation of heterocellular aggregates, as well as increased blood viscosity, are among the mechanisms involved in slowing the progress of RBCs in deoxygenated vascular areas, favoring RBC sickling and promoting vascular occlusion. Chronic inflammatory processes and oxidative stress, which are perpetuated by hemolytic events and ischemia-reperfusion injury, result in this pan cellular activation and some acute events, such as stroke and acute chest syndrome, as well as chronic end-organ damage. Furthermore, impaired vasodilation and vasomotor hyperresponsiveness in SCD also contribute to vaso-occlusive processes. Treating SCD as a vascular disease in addition to its hematological perspective, the present article looks at the interplay between abnormal RBC physiology/integrity, vascular dysfunction and clinical severity in SCD, and discusses existing therapies and novel drugs in development that may ameliorate vascular complications in the disease. © 2021 American Physiological Society. Compr Physiol 11:1785-1803, 2021.
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Affiliation(s)
- Elie Nader
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Team Vascular Biology and Red Blood Cell, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France.,Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), PRES Sorbonne, Paris, France
| | - Nicola Conran
- Hematology Center, University of Campinas - UNICAMP, Cidade Universitária, Campinas-SP, Brazil
| | - Marc Romana
- Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), PRES Sorbonne, Paris, France.,Université des Antilles, UMR_S1134, BIGR, Pointe-à-Pitre, France.,Université de Paris, UMR_S1134, BIGR, INSERM, Paris, France
| | - Philippe Connes
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Team Vascular Biology and Red Blood Cell, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France.,Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), PRES Sorbonne, Paris, France
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19
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Vona R, Sposi NM, Mattia L, Gambardella L, Straface E, Pietraforte D. Sickle Cell Disease: Role of Oxidative Stress and Antioxidant Therapy. Antioxidants (Basel) 2021; 10:antiox10020296. [PMID: 33669171 PMCID: PMC7919654 DOI: 10.3390/antiox10020296] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 02/08/2021] [Accepted: 02/12/2021] [Indexed: 12/11/2022] Open
Abstract
Sickle cell disease (SCD) is the most common hereditary disorder of hemoglobin (Hb), which affects approximately a million people worldwide. It is characterized by a single nucleotide substitution in the β-globin gene, leading to the production of abnormal sickle hemoglobin (HbS) with multi-system consequences. HbS polymerization is the primary event in SCD. Repeated polymerization and depolymerization of Hb causes oxidative stress that plays a key role in the pathophysiology of hemolysis, vessel occlusion and the following organ damage in sickle cell patients. For this reason, reactive oxidizing species and the (end)-products of their oxidative reactions have been proposed as markers of both tissue pro-oxidant status and disease severity. Although more studies are needed to clarify their role, antioxidant agents have been shown to be effective in reducing pathological consequences of the disease by preventing oxidative damage in SCD, i.e., by decreasing the oxidant formation or repairing the induced damage. An improved understanding of oxidative stress will lead to targeted antioxidant therapies that should prevent or delay the development of organ complications in this patient population.
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Affiliation(s)
- Rosa Vona
- Biomarkers Unit, Center for Gender-Specific Medicine, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy; (R.V.); (N.M.S.); (L.G.)
| | - Nadia Maria Sposi
- Biomarkers Unit, Center for Gender-Specific Medicine, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy; (R.V.); (N.M.S.); (L.G.)
| | - Lorenza Mattia
- Department of Clinical and Molecular Medicine, “La Sapienza” University, 00161 Rome, Italy;
- Endocrine-Metabolic Unit, Sant’Andrea University Hospital, 00189 Rome, Italy
| | - Lucrezia Gambardella
- Biomarkers Unit, Center for Gender-Specific Medicine, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy; (R.V.); (N.M.S.); (L.G.)
| | - Elisabetta Straface
- Biomarkers Unit, Center for Gender-Specific Medicine, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy; (R.V.); (N.M.S.); (L.G.)
- Correspondence: ; Tel.: +39-064-990-2443; Fax: +39-064-990-3690
| | - Donatella Pietraforte
- Core Facilities, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy;
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20
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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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21
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Pandarakutty S, Murali K, Arulappan J, Al Sabei SD. Health-Related Quality of Life of Children and Adolescents with Sickle Cell Disease in the Middle East and North Africa Region: A systematic review. Sultan Qaboos Univ Med J 2021; 20:e280-e289. [PMID: 33414931 PMCID: PMC7757932 DOI: 10.18295/squmj.2020.20.04.002] [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: 12/02/2019] [Revised: 04/02/2020] [Accepted: 05/15/2020] [Indexed: 11/16/2022] Open
Abstract
Sickle cell disease (SCD) can significantly impair the health-related quality of life (HRQOL) of children and adolescents. This review aimed to assess current evidence regarding the HRQOL of children and adolescents with SCD in the Middle East and North Africa region. A systematic search of various databases was conducted to identify relevant articles, including MEDLINE® (National Library of Medicine, Bethesda, Maryland, USA), Scopus® (Elsevier, Amsterdam, the Netherlands), Cumulative Index to Nursing and Allied Health Literature®, Masader (Oman Virtual Science Library, Muscat, Oman) and EBSCOhost (EBSCO Information Services, Ipswich, Massachusetts, USA). A total of 533 articles were identified; however, only 10 were eligible for inclusion in the final analysis. Results from these studies showed that children and adolescents with SCD had compromised HRQOL compared to their healthy peers, particularly in terms of physical, psychosocial, familial, financial and academic functioning. Therefore, interventions are necessary to improve overall HRQOL outcomes for this population.
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Affiliation(s)
- Suthan Pandarakutty
- Department of Nursing, College of Health Sciences, University of Buraimi, Al Buraimi, Oman
| | - Kamala Murali
- Department of Paediatric Nursing, Rani Meyyammai College of Nursing, Annamalai University, Chidambaram, Tamil Nadu, India
| | | | - Sulaiman D Al Sabei
- Fundamentals & Administration, College of Nursing, Sultan Qaboos University, Muscat, Oman
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22
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Schreier DA, Hacker TA, Tabima DM, Platt MO, Chesler NC. Effects of Red Blood Cell Sickling on Right Ventricular Afterload in vivo. EXPERIMENTAL MECHANICS 2021; 61:229-235. [PMID: 33776073 PMCID: PMC7992815 DOI: 10.1007/s11340-020-00669-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 09/28/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Hemolysis in sickle cell disease (SCD) releases cell free hemoglobin, which scavenges nitric oxide (NO), leading to pulmonary vascular vasoconstriction, increased pulmonary vascular resistance (PVR), and the development of PH. However, PVR is only one component of right ventricular (RV) afterload. Whether sickled red blood cells increase the total RV afterload, including compliance and wave reflections, is unclear. OBJECTIVE Patients with SCD and pulmonary hypertension (PH) have a significantly increased risk of sudden death compared to patients with SCD alone. Sickled red blood cells (RBCs) are fragile and lyse easily. Here, we sought to determine the acute effects of SCD RBCs and increased cell free hemoglobin on RV afterload. METHODS Main pulmonary artery pressures and flows were measured in C57BL6 mice before and after exchanges of whole blood (~200 uL, Hct=45%) with an equal volume of SCD RBCs in plasma (Hct=45%) or cell free hemoglobin (Hb+) in solution. After transfusions, animals were additionally stressed with acute hypoxia (AH; 10% O2). RESULTS SCD RBCs increased PVR only compared to control RBCs; cell free hemoglobin increased PVR and wave reflections. These increases in RV afterload increased further with AH. CONCLUSIONS The release of cell free hemoglobin from fragile SCD RBCs in vivo increases the total RV afterload and may impair RV function more than the SCD RBCs themselves.
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Affiliation(s)
- D A Schreier
- Department of Biomedical Engineering University of Wisconsin, 2146 ECB, 1550 Engineering Dr., Madison, WI 53706
| | - T A Hacker
- Department of Medicine 1685 Highland Avenue, 5158 Medical Foundation Centennial Building, Madison, WI 53705-2281
| | - D M Tabima
- Department of Biomedical Engineering University of Wisconsin, 2146 ECB, 1550 Engineering Dr., Madison, WI 53706
| | - M O Platt
- Department of Biomedical Engineering University of Georgia Tech, Engineered Biosystems Building, 950 Atlantic Drive, Suite 3015, Atlanta, GA 30332
| | - N C Chesler
- Department of Biomedical Engineering University of Wisconsin, 2146 ECB, 1550 Engineering Dr., Madison, WI 53706
- Department of Medicine 1685 Highland Avenue, 5158 Medical Foundation Centennial Building, Madison, WI 53705-2281
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23
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Ajibare AO, Olabode OP, Fagbemiro EY, Akinlade OM, Akintunde AA, Akinpelu OO, Olatunji LA, Soladoye AO, Opadijo OG. Assessment of Ventricular Repolarization in Sickle Cell Anemia Patients: The Role of QTc Interval, Tp-e Interval and Tp-e/QTc Ratio and Its Gender Implication. Vasc Health Risk Manag 2020; 16:525-533. [PMID: 33324066 PMCID: PMC7733033 DOI: 10.2147/vhrm.s259766] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 10/01/2020] [Indexed: 12/21/2022] Open
Abstract
Background Many specific and non-specific electrocardiographic abnormalities including ventricular arrhythmias have been reported in subjects with sickle cell anemia (SCA). In SCA patients, cardiac electrical abnormalities may be the leading cause of increased risk of arrhythmias. The corrected QT (QTc) interval, peak to the end of the T wave (Tp-e) interval and associated Tp-e/QTc ratio are promising measures of altered ventricular repolarization and increased arrhythmogenesis risk. Aim This study assessed ventricular repolarization abnormalities in subjects with SCA using the QTc interval, Tp-e interval and Tp-e/QTc ratio, and also evaluated the gender differences in these parameters, as well as their determinants. Methods Sixty subjects with SCA and 60 healthy control subjects, matched for age and gender, were studied. All participants underwent physical examination, hematological and biochemical evaluation, and 12-lead electrocardiography (ECG) recording. QT and Tp-e intervals were measured from the ECG, and the QTc interval was calculated using Bazett’s formula. Tp-e/QT and Tp-e/QTc ratios were also derived. Results QT and QTc intervals were prolonged in subjects with SCA. Tp-e interval, Tp-e/QT ratio and Tp-e/QTc ratio were prolonged in male SCA subjects, with a paradoxical shortening in female SCA subjects. Plasminogen activator inhibitor-1 (PAI-1) was an independent determinant of QTc, while body mass index (BMI) was an independent determinant of both Tp-e interval and Tp-e/QTc ratio. Conclusion Our results suggest an elevated risk for ventricular arrhythmogenesis in male SCA subjects. Furthermore, increased BMI and PAI-1 level are possible markers of ventricular repolarization abnormalities in SCA subjects.
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24
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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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25
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Vinhaes CL, Teixeira RS, Monteiro-Júnior JAS, Tibúrcio R, Cubillos-Angulo JM, Arriaga MB, Sabarin AG, de Souza AJ, Silva JJ, Lyra IM, Ladeia AM, Andrade BB. Hydroxyurea treatment is associated with reduced degree of oxidative perturbation in children and adolescents with sickle cell anemia. Sci Rep 2020; 10:18982. [PMID: 33149225 PMCID: PMC7642412 DOI: 10.1038/s41598-020-76075-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/16/2020] [Indexed: 01/16/2023] Open
Abstract
Sickle cell anemia (SCA) is the most common inherited hemolytic anemia worldwide. Here, we performed an exploratory study to investigate the systemic oxidative stress in children and adolescents with SCA. Additionally, we evaluated the potential impact of hydroxyurea therapy on the status of oxidative stress in a case–control study from Brazil. To do so, a panel containing 9 oxidative stress markers was measured in plasma samples from a cohort of 47 SCA cases and 40 healthy children and adolescents. Among the SCA patients, 42.5% were undertaking hydroxyurea. Multidimensional analysis was employed to describe disease phenotypes. Our results demonstrated that SCA is associated with increased levels of oxidative stress markers, suggesting the existence of an unbalanced inflammatory response in peripheral blood. Subsequent analyses revealed that hydroxyurea therapy was associated with diminished oxidative imbalance in SCA patients. Our findings reinforce the idea that SCA is associated with a substantial dysregulation of oxidative responses which may be dampened by treatment with hydroxyurea. If validated by larger prospective studies, our observations argue that reduction of oxidative stress may be a main mechanism through which hydroxyurea therapy attenuates the tissue damage and can contribute to improved clinical outcomes in SCA.
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Affiliation(s)
- Caian L Vinhaes
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz (FIOCRUZ), Salvador, 40296-710, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, 41810-710, Brazil.,School of Medicine, Faculdade de Tecnologia E Ciências (UniFTC), Salvador, 41741-590, Brazil
| | - Rozana S Teixeira
- Bahiana School of Medicine and Public Health, Bahia Foundation for the Development of Sciences, Salvador, 40290-000, Brazil.,School of Medicine, Federal University of Bahia, Salvador, 40110-100, Brazil
| | - Jay A S Monteiro-Júnior
- Bahiana School of Medicine and Public Health, Bahia Foundation for the Development of Sciences, Salvador, 40290-000, Brazil
| | - Rafael Tibúrcio
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz (FIOCRUZ), Salvador, 40296-710, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, 41810-710, Brazil.,School of Medicine, Federal University of Bahia, Salvador, 40110-100, Brazil
| | - Juan M Cubillos-Angulo
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz (FIOCRUZ), Salvador, 40296-710, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, 41810-710, Brazil.,School of Medicine, Federal University of Bahia, Salvador, 40110-100, Brazil
| | - María B Arriaga
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz (FIOCRUZ), Salvador, 40296-710, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, 41810-710, Brazil.,School of Medicine, Federal University of Bahia, Salvador, 40110-100, Brazil
| | - Adrielle G Sabarin
- Bahiana School of Medicine and Public Health, Bahia Foundation for the Development of Sciences, Salvador, 40290-000, Brazil
| | - Amâncio J de Souza
- Bahiana School of Medicine and Public Health, Bahia Foundation for the Development of Sciences, Salvador, 40290-000, Brazil
| | - Jacqueline J Silva
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz (FIOCRUZ), Salvador, 40296-710, Brazil.,Bahiana School of Medicine and Public Health, Bahia Foundation for the Development of Sciences, Salvador, 40290-000, Brazil
| | - Isa M Lyra
- University Salvador (UNIFACS), Laureate International Universities, Salvador, 41720-200, Brazil
| | - Ana Marice Ladeia
- Bahiana School of Medicine and Public Health, Bahia Foundation for the Development of Sciences, Salvador, 40290-000, Brazil.,Catholic University of Salvador, Salvador, 41740-090, Brazil
| | - Bruno B Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz (FIOCRUZ), Salvador, 40296-710, Brazil. .,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, 41810-710, Brazil. .,School of Medicine, Faculdade de Tecnologia E Ciências (UniFTC), Salvador, 41741-590, Brazil. .,Bahiana School of Medicine and Public Health, Bahia Foundation for the Development of Sciences, Salvador, 40290-000, Brazil. .,School of Medicine, Federal University of Bahia, Salvador, 40110-100, Brazil. .,University Salvador (UNIFACS), Laureate International Universities, Salvador, 41720-200, Brazil.
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26
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Albinni S, Marx M, Lang IM. Focused Update on Pulmonary Hypertension in Children-Selected Topics of Interest for the Adult Cardiologist. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E420. [PMID: 32825190 PMCID: PMC7559541 DOI: 10.3390/medicina56090420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/13/2020] [Accepted: 08/16/2020] [Indexed: 11/16/2022]
Abstract
Pulmonary hypertensive vascular disease (PHVD), and pulmonary hypertension (PH), which is a broader term, are severe conditions associated with high morbidity and mortality at all ages. Treatment guidelines in childhood are widely adopted from adult data and experience, though big differences may exist regarding aetiology, concomitant conditions and presentation. Over the past few years, paediatric aspects have been incorporated into the common guidelines, which currently address both children and adults with pulmonary hypertension (PH). There are multiple facets of PH in the context of cardiac conditions in childhood. Apart from Eisenmenger syndrome (ES), the broad spectrum of congenital heart disease (CHD) comprises PH in failing Fontan physiology, as well as segmental PH. In this review we provide current data and novel aspects on the pathophysiological background and individual management concepts of these conditions. Moreover, we focus on paediatric left heart failure with PH and its challenging issues, including end stage treatment options, such as mechanical support and paediatric transplantation. PH in the context of rare congenital disorders, such as Scimitar Syndrome and sickle cell disease is discussed. Based on current data, we provide an overview on multiple underlying mechanisms of PH involved in these conditions, and different management strategies in children and adulthood. In addition, we summarize the paediatric aspects and the pros and cons of the recently updated definitions of PH. This review provides deeper insights into some challenging conditions of paediatric PH in order to improve current knowledge and care for children and young adults.
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Affiliation(s)
- Sulaima Albinni
- Paediatric Heart Centre Vienna, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, 1090 Wien, Austria;
| | - Manfred Marx
- Paediatric Heart Centre Vienna, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, 1090 Wien, Austria;
| | - Irene M. Lang
- AKH-Vienna, Department of Cardiology, Medical University of Vienna, 1090 Wien, Austria;
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27
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Ghali MGZ, Styler MJ. Etiologies, Cerebral Vasomotion, and Endothelial Dysfunction in the Pathophysiology of Posterior Reversible Encephalopathy Syndrome in Pediatric Patients. JOURNAL OF PEDIATRIC NEUROLOGY 2020. [DOI: 10.1055/s-0040-1702934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AbstractThe posterior reversible encephalopathy syndrome was characterized by Hinchey and colleagues in the 1990s. The condition frequently afflicts patients suffering from hematologic and solid organ malignancy and individuals undergoing transplantation. Cases are more frequently described in the adult population compared with children. In the pediatric population, malignancy, transplantation, renal disease, and hypertension represent the most common etiologies. Theories on pathogenesis have centered upon cerebrovascular dysautoregulation with increases in blood–brain barrier permeability. This generates vasogenic edema of the cerebral parenchyma and consequent neurologic deficits. The parietal and occipital lobes are affected with greatest prevalence, though frontal and temporal lobe involvement is frequent, and that of the contents of the infratentorial posterior cranial fossa are occasionally described. The clinical presentation involves a characteristic constellation of neurologic signs and symptoms, most typically inclusive of headache, visual-field disturbances, abnormalities of visual acuity, and seizures. Supportive care, withdrawal of the offending agent, antihypertensive therapy, and prophylactic anticonvulsants affect convalescence in majority of cases. The principal challenge lies in identifying the responsible agent precipitating the condition in patients with malignancy and those having undergone transplantation and thus deciding which medication among a multidrug treatment regimen to withhold, the duration of drug cessation required to effect clinical resolution, and the safety of resuming treatment with the compound. We accordingly reviewed and evaluated the literature discussing the posterior reversible encephalopathy syndrome in children.
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Affiliation(s)
- Michael G. Z. Ghali
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, United States
| | - Michael J. Styler
- Department of Hematology and Oncology, Hahnemann University Hospital, Philadelphia, Pennsylvania, United States
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28
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Noronha SA. Cardiac causes of hypoxia in sickle cell disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2019.101192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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29
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Wood KC, Durgin BG, Schmidt HM, Hahn SA, Baust JJ, Bachman T, Vitturi DA, Ghosh S, Ofori-Acquah SF, Mora AL, Gladwin MT, Straub AC. Smooth muscle cytochrome b5 reductase 3 deficiency accelerates pulmonary hypertension development in sickle cell mice. Blood Adv 2019; 3:4104-4116. [PMID: 31821458 PMCID: PMC6963246 DOI: 10.1182/bloodadvances.2019000621] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/29/2019] [Indexed: 01/26/2023] Open
Abstract
Pulmonary and systemic vasculopathies are significant risk factors for early morbidity and death in patients with sickle cell disease (SCD). An underlying mechanism of SCD vasculopathy is vascular smooth muscle (VSM) nitric oxide (NO) resistance, which is mediated by NO scavenging reactions with plasma hemoglobin (Hb) and reactive oxygen species that can oxidize soluble guanylyl cyclase (sGC), the NO receptor. Prior studies show that cytochrome b5 reductase 3 (CYB5R3), known as methemoglobin reductase in erythrocytes, functions in VSM as an sGC heme iron reductase critical for reducing and sensitizing sGC to NO and generating cyclic guanosine monophosphate for vasodilation. Therefore, we hypothesized that VSM CYB5R3 deficiency accelerates development of pulmonary hypertension (PH) in SCD. Bone marrow transplant was used to create SCD chimeric mice with background smooth muscle cell (SMC)-specific tamoxifen-inducible Cyb5r3 knockout (SMC R3 KO) and wild-type (WT) control. Three weeks after completing tamoxifen treatment, we observed 60% knockdown of pulmonary arterial SMC CYB5R3, 5 to 6 mm Hg elevated right-ventricular (RV) maximum systolic pressure (RVmaxSP) and biventricular hypertrophy in SS chimeras with SMC R3 KO (SS/R3KD) relative to WT (SS/R3WT). RV contractility, heart rate, hematological parameters, and cell-free Hb were similar between groups. When identically generated SS/R3 chimeras were studied 12 weeks after completing tamoxifen treatment, RVmaxSP in SS/R3KD had not increased further, but RV hypertrophy relative to SS/R3WT persisted. These are the first studies to establish involvement of SMC CYB5R3 in SCD-associated development of PH, which can exist in mice by 5 weeks of SMC CYB5R3 protein deficiency.
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Affiliation(s)
- Katherine C Wood
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
| | - Brittany G Durgin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
| | - Heidi M Schmidt
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
- Department of Pharmacology and Chemical Biology
| | - Scott A Hahn
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
| | - Jeffrey J Baust
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
| | - Tim Bachman
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
| | - Dario A Vitturi
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
- Department of Pharmacology and Chemical Biology
| | - Samit Ghosh
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
| | - Solomon F Ofori-Acquah
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
- Division of Hematology and Oncology, Department of Medicine, and
| | - Ana L Mora
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Mark T Gladwin
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Adam C Straub
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Department of Medicine
- Department of Pharmacology and Chemical Biology
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30
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Ribeiro TO, Silveira BM, Meira MC, Carreira ACO, Sogayar MC, Meyer R, Fortuna V. Investigating the potential of the secretome of mesenchymal stem cells derived from sickle cell disease patients. PLoS One 2019; 14:e0222093. [PMID: 31665139 PMCID: PMC6821040 DOI: 10.1371/journal.pone.0222093] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 08/21/2019] [Indexed: 02/07/2023] Open
Abstract
Sickle cell disease (SCD) is a monogenic red cell disorder associated with multiple vascular complications, microvessel injury and wound-healing deficiency. Although stem cell transplantation with bone marrow-derived mesenchymal stem cells (BMSC) can promote wound healing and tissue repair in SCD patients, therapeutic efficacy is largely dependent on the paracrine activity of the implanted BM stromal cells. Since in vitro expansion and culture conditions are known to modulate the innate characteristics of BMSCs, the present study investigated the effects of normoxic and hypoxic cell-culture preconditioning on the BMSC secretome, in addition to the expression of paracrine molecules that induce angiogenesis and skin regeneration. BMSCs derived from SCD patients were submitted to culturing under normoxic (norCM) and hypoxic (hypoCM) conditions. We found that hypoxically conditioned cells presented increased expression and secretion of several well-characterized trophic growth factors (VEGF, IL8, MCP-1, ANG) directly linked to angiogenesis and tissue repair. The hypoCM secretome presented stronger angiogenic potential than norCM, both in vitro and in vivo, as evidenced by HUVEC proliferation, survival, migration, sprouting formation and in vivo angiogenesis. After local application in a murine wound-healing model, HypoCM showed significantly improved wound closure, as well as enhanced neovascularization in comparison to untreated controls. In sum, the secretome of hypoxia-preconditioned BMSC has increased expression of trophic factors involved in angiogenesis and skin regeneration. Considering that these preconditioned media are easily obtainable, this strategy represents an alternative to stem cell transplantation and could form the basis of novel therapies for vascular regeneration and wound healing in individuals with sickle cell disease.
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Affiliation(s)
- Tiago O. Ribeiro
- Health Science Institute, Federal University of Bahia, Salvador, BA, Brazil
| | - Brysa M. Silveira
- Health Science Institute, Federal University of Bahia, Salvador, BA, Brazil
| | - Mercia C. Meira
- Health Science Institute, Federal University of Bahia, Salvador, BA, Brazil
| | - Ana C. O. Carreira
- Cell and Molecular Therapy Center NUCEL-NETCEM, School of Medicine, Internal Medicine Department, University of São Paulo, São Paulo, SP, Brazil
| | - Mari Cleide Sogayar
- Cell and Molecular Therapy Center NUCEL-NETCEM, School of Medicine, Internal Medicine Department, University of São Paulo, São Paulo, SP, Brazil
- Chemistry Institute, Biochemistry Department, University of São Paulo, São Paulo, SP, Brazil
| | - Roberto Meyer
- Health Science Institute, Federal University of Bahia, Salvador, BA, Brazil
| | - Vitor Fortuna
- Health Science Institute, Federal University of Bahia, Salvador, BA, Brazil
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31
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Suliman HB, Nozik-Grayck E. Mitochondrial Dysfunction: Metabolic Drivers of Pulmonary Hypertension. Antioxid Redox Signal 2019; 31:843-857. [PMID: 30604624 PMCID: PMC6751393 DOI: 10.1089/ars.2018.7705] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Significance: Pulmonary hypertension (PH) is a progressive disease characterized by pulmonary vascular remodeling and lung vasculopathy. The disease displays progressive dyspnea, pulmonary artery uncoupling and right ventricular (RV) dysfunction. The overall survival rate is ranging from 28-72%. Recent Advances: The molecular events that promote the development of PH are complex and incompletely understood. Metabolic impairment has been proposed to contribute to the pathophysiology of PH with evidence for mitochondrial dysfunction involving the electron transport chain proteins, antioxidant enzymes, apoptosis regulators, and mitochondrial quality control. Critical Issues: It is vital to characterize the mechanisms by which mitochondrial dysfunction contribute to PH pathogenesis. This review focuses on the currently available publications that supports mitochondrial mechanisms in PH pathophysiology. Future Directions: Further studies of these metabolic mitochondrial alterations in PH could be viable targets of diagnostic and therapeutic intervention.
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Affiliation(s)
- Hagir B Suliman
- Department of Anesthesiology, Duke University Medical Centers, Durham, North Carolina
| | - Eva Nozik-Grayck
- Department of Pediatrics, Cardiovascular Pulmonary Research Labs and Pediatric Critical Care Medicine, University of Colorado Denver, Aurora, Colorado
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32
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Potoka KP, Wood KC, Baust JJ, Bueno M, Hahn SA, Vanderpool RR, Bachman T, Mallampalli GM, Osei-Hwedieh DO, Schrott V, Sun B, Bullock GC, Becker-Pelster EM, Wittwer M, Stampfuss J, Mathar I, Stasch JP, Truebel H, Sandner P, Mora AL, Straub AC, Gladwin MT. Nitric Oxide-Independent Soluble Guanylate Cyclase Activation Improves Vascular Function and Cardiac Remodeling in Sickle Cell Disease. Am J Respir Cell Mol Biol 2019; 58:636-647. [PMID: 29268036 DOI: 10.1165/rcmb.2017-0292oc] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Sickle cell disease (SCD) is associated with intravascular hemolysis and oxidative inhibition of nitric oxide (NO) signaling. BAY 54-6544 is a small-molecule activator of oxidized soluble guanylate cyclase (sGC), which, unlike endogenous NO and the sGC stimulator, BAY 41-8543, preferentially binds and activates heme-free, NO-insensitive sGC to restore enzymatic cGMP production. We tested orally delivered sGC activator, BAY 54-6544 (17 mg/kg/d), sGC stimulator, BAY 41-8543, sildenafil, and placebo for 4-12 weeks in the Berkeley transgenic mouse model of SCD (BERK-SCD) and their hemizygous (Hemi) littermate controls (BERK-Hemi). Right ventricular (RV) maximum systolic pressure (RVmaxSP) was measured using micro right-heart catheterization. RV hypertrophy (RVH) was determined using Fulton's index and RV corrected weight (ratio of RV to tibia). Pulmonary artery vasoreactivity was tested for endothelium-dependent and -independent vessel relaxation. Right-heart catheterization revealed higher RVmaxSP and RVH in BERK-SCD versus BERK-Hemi, which worsened with age. Treatment with the sGC activator more effectively lowered RVmaxSP and RVH, with 90-day treatment delivering superior results, when compared with other treatments and placebo groups. In myography experiments, acetylcholine-induced (endothelium-dependent) and sodium-nitroprusside-induced (endothelium-independent NO donor) relaxation of the pulmonary artery harvested from placebo-treated BERK-SCD was impaired relative to BERK-Hemi but improved after therapy with sGC activator. By contrast, no significant effect for sGC stimulator or sildenafil was observed in BERK-SCD. These findings suggest that sGC is oxidized in the pulmonary arteries of transgenic SCD mice, leading to blunted responses to NO, and that the sGC activator, BAY 54-6544, may represent a novel therapy for SCD-associated pulmonary arterial hypertension and cardiac remodeling.
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Affiliation(s)
- Karin P Potoka
- 1 Division of Newborn Medicine, Department of Pediatrics.,2 Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine
| | - Katherine C Wood
- 2 Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine.,3 University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jeffrey J Baust
- 2 Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine
| | - Marta Bueno
- 2 Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine.,4 Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Scott A Hahn
- 2 Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine
| | | | - Tim Bachman
- 2 Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine
| | - Grace M Mallampalli
- 2 Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine.,3 University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Valerie Schrott
- 2 Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine
| | - Bin Sun
- 2 Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine
| | - Grant C Bullock
- 2 Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine
| | | | | | | | | | | | - Hubert Truebel
- 5 Bayer AG, Wuppertal, Germany.,6 University of Witten/Herdecke, Witten, Germany
| | - Peter Sandner
- 5 Bayer AG, Wuppertal, Germany.,8 Hannover Medical School, Hannover, Germany; and
| | - Ana L Mora
- 2 Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine.,4 Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Adam C Straub
- 2 Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine.,9 Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark T Gladwin
- 2 Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine.,4 Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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33
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Novelli EM, Little-Ihrig L, Knupp HE, Rogers NM, Yao M, Baust JJ, Meijles D, St Croix CM, Ross MA, Pagano PJ, DeVallance ER, Miles G, Potoka KP, Isenberg JS, Gladwin MT. Vascular TSP1-CD47 signaling promotes sickle cell-associated arterial vasculopathy and pulmonary hypertension in mice. Am J Physiol Lung Cell Mol Physiol 2019; 316:L1150-L1164. [PMID: 30892078 PMCID: PMC6620668 DOI: 10.1152/ajplung.00302.2018] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 03/07/2019] [Accepted: 03/14/2019] [Indexed: 02/08/2023] Open
Abstract
Pulmonary hypertension (PH) is a leading cause of death in sickle cell disease (SCD) patients. Hemolysis and oxidative stress contribute to SCD-associated PH. We have reported that the protein thrombospondin-1 (TSP1) is elevated in the plasma of patients with SCD and, by interacting with its receptor CD47, limits vasodilation of distal pulmonary arteries ex vivo. We hypothesized that the TSP1-CD47 interaction may promote PH in SCD. We found that TSP1 and CD47 are upregulated in the lungs of Berkeley (BERK) sickling (Sickle) mice and patients with SCD-associated PH. We then generated chimeric animals by transplanting BERK bone marrow into C57BL/6J (n = 24) and CD47 knockout (CD47KO, n = 27) mice. Right ventricular (RV) pressure was lower in fully engrafted Sickle-to-CD47KO than Sickle-to-C57BL/6J chimeras, as shown by the reduced maximum RV pressure (P = 0.013) and mean pulmonary artery pressure (P = 0.020). The afterload of the sickle-to-CD47KO chimeras was also lower, as shown by the diminished pulmonary vascular resistance (P = 0.024) and RV effective arterial elastance (P = 0.052). On myography, aortic segments from Sickle-to-CD47KO chimeras showed improved relaxation to acetylcholine. We hypothesized that, in SCD, TSP1-CD47 signaling promotes PH, in part, by increasing reactive oxygen species (ROS) generation. In human pulmonary artery endothelial cells, treatment with TSP1 stimulated ROS generation, which was abrogated by CD47 blockade. Explanted lungs of CD47KO chimeras had less vascular congestion and a smaller oxidative footprint. Our results show that genetic absence of CD47 ameliorates SCD-associated PH, which may be due to decreased ROS levels. Modulation of TSP1-CD47 may provide a new molecular approach to the treatment of SCD-associated PH.
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Affiliation(s)
- Enrico M Novelli
- Heart, Lung, Blood, and Vascular Medicine Institute and Division of Hematology/Oncology, UPMC Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Lynda Little-Ihrig
- Heart, Lung, Blood, and Vascular Medicine Institute and Division of Hematology/Oncology, UPMC Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Heather E Knupp
- UPMC Children's Hospital of Pittsburgh , Pittsburgh, Pennsylvania
| | - Natasha M Rogers
- Department of Medicine, Westmead Clinical School, University of Sydney , Sydney, New South Wales , Australia
| | - Mingyi Yao
- Department of Pharmaceutical Science, Midwestern University , Glendale, Arizona
| | - Jeffrey J Baust
- Heart, Lung, Blood, and Vascular Medicine Institute and Division of Hematology/Oncology, UPMC Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Daniel Meijles
- School of Biological Sciences, University of Reading , Reading , United Kingdom
| | - Claudette M St Croix
- Center for Biologic Imaging, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Mark A Ross
- Center for Biologic Imaging, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Patrick J Pagano
- Heart, Lung, Blood, and Vascular Medicine Institute and Division of Hematology/Oncology, UPMC Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Evan R DeVallance
- Heart, Lung, Blood, and Vascular Medicine Institute and Division of Hematology/Oncology, UPMC Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - George Miles
- Department of Molecular and Human Genetics, Baylor College of Medicine , Houston, Texas
| | - Karin P Potoka
- Heart, Lung, Blood, and Vascular Medicine Institute and Division of Hematology/Oncology, UPMC Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
- UPMC Children's Hospital of Pittsburgh , Pittsburgh, Pennsylvania
| | - Jeffrey S Isenberg
- Heart, Lung, Blood, and Vascular Medicine Institute and Division of Hematology/Oncology, UPMC Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Mark T Gladwin
- Heart, Lung, Blood, and Vascular Medicine Institute and Division of Hematology/Oncology, UPMC Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
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Houwing ME, de Pagter PJ, van Beers EJ, Biemond BJ, Rettenbacher E, Rijneveld AW, Schols EM, Philipsen JNJ, Tamminga RYJ, van Draat KF, Nur E, Cnossen MH. Sickle cell disease: Clinical presentation and management of a global health challenge. Blood Rev 2019; 37:100580. [PMID: 31128863 DOI: 10.1016/j.blre.2019.05.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 05/17/2019] [Accepted: 05/17/2019] [Indexed: 01/12/2023]
Abstract
Sickle cell disease is an autosomal recessive, multisystem disorder, characterised by chronic haemolytic anaemia, painful episodes of vaso-occlusion, progressive organ failure and a reduced life expectancy. Sickle cell disease is the most common monogenetic disease, with millions affected worldwide. In well-resourced countries, comprehensive care programs have increased life expectancy of sickle cell disease patients, with almost all infants surviving into adulthood. Therapeutic options for sickle cell disease patients are however, still scarce. Predictors of sickle cell disease severity and a better understanding of pathophysiology and (epi)genetic modifiers are warranted and could lead to more precise management and treatment. This review provides an extensive summary of the pathophysiology and management of sickle cell disease and encompasses the characteristics, complications and current and future treatment options of the disease.
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Affiliation(s)
- M E Houwing
- Department of Paediatric Haematology, Erasmus University Medical Center - Sophia Children's Hospital, Wytemaweg 80, 3015, CN, Rotterdam, the Netherlands.
| | - P J de Pagter
- Department of Paediatric Haematology, Erasmus University Medical Center - Sophia Children's Hospital, Wytemaweg 80, 3015, CN, Rotterdam, the Netherlands.
| | - E J van Beers
- Department of Internal Medicine and Dermatology, Van Creveldkliniek, University Medical Center Utrecht, Internal mail no C.01.412, 3508, GA, Utrecht, the Netherlands.
| | - B J Biemond
- Department of Internal Medicine and Clinical Haematology, Amsterdam University Medical Centers, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands.
| | - E Rettenbacher
- Department of Paediatric Haematology, Radboud University Medical Center - Amalia Children's Hospital, Geert Grooteplein Zuid 10, 6500, HB, Nijmegen, the Netherlands.
| | - A W Rijneveld
- Department of Haematology, Erasmus University Medical Center, Wytemaweg 80, 3015, CN, Rotterdam, the Netherlands.
| | - E M Schols
- Department of Haematology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, the Netherlands.
| | - J N J Philipsen
- Department of Cell Biology, Erasmus University Medical Center, Wytemaweg 80, 3015, CN, Rotterdam, the Netherlands.
| | - R Y J Tamminga
- Department of Paediatric Oncology and Haematology, University Medical Center Groningen - Beatrix Children's Hospital, Postbus 30001, 9700, RB, Groningen, the Netherlands..
| | - K Fijn van Draat
- Department of Paediatric Haematology, Amsterdam University Medical Centers - Emma Children's Hospital, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Department of Plasma Proteins, Sanquin Research, the Netherlands.
| | - E Nur
- Department of Internal Medicine and Clinical Haematology, Amsterdam University Medical Centers, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands.
| | - M H Cnossen
- Department of Paediatric Haematology, Erasmus University Medical Center - Sophia Children's Hospital, Wytemaweg 80, 3015, CN, Rotterdam, the Netherlands.
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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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Galadanci AA, DeBaun MR, Galadanci NA. Neurologic complications in children under five years with sickle cell disease. Neurosci Lett 2019; 706:201-206. [PMID: 31039424 DOI: 10.1016/j.neulet.2019.04.030] [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] [Received: 09/01/2018] [Revised: 02/27/2019] [Accepted: 04/12/2019] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Sickle Cell Disease (SCD) is one of the most common genetic diseases in the world affecting every organ. The major challenge in the medical care of children with SCD is preventing end-organ dysfunction, particularly the brain. Major neurologic complications in children less than five years with SCD include, but are not limited to, Silent cerebral infarct, cerebral sinus thrombosis, epilepsy, reversible encephalopathy syndrome, and ischemic and hemorrhagic stroke. Recurrent headaches and migraine are not rare in children under five years with SCD. This review will focus on the neurologic complications and the description of the modifiable risk factors in children less than 5 years of age with emphasis on differences between high and low resource settings. AREAS COVERED Neurologic complications of children under 5 years of age and the modifiable risk factors. The PUBMED database was searched using medical subject headings (MeSH) and keywords for articles regarding neurologic complications in children under 5 years of age. CONCLUSION Neurologic complications in children under five years of age with SCD may be more frequent than currently reported, among which Silent cerebral infarct and cognitive impairment are the most common.
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Affiliation(s)
- Aisha A Galadanci
- Department of Hematology and Blood Transfusion, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Michael R DeBaun
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Najibah A Galadanci
- Department of Epidemiology, UAB School of Public Health, University of Alabama at Birmingham, 1665 University Blvd, Birmingham, AL 35233, USA.
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Lung Function Abnormalities in Sickle Cell Anaemia. Adv Hematol 2019; 2019:1783240. [PMID: 31057625 PMCID: PMC6463674 DOI: 10.1155/2019/1783240] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/31/2019] [Accepted: 02/26/2019] [Indexed: 01/03/2023] Open
Abstract
Background Abnormalities in lung function tests have been shown to commonly occur in a majority of patients with sickle cell disease (SCD) even at steady state. The prevalence and pattern of these lung function abnormalities have been described in other populations but this is unknown among our sickle cell cohort. There is generally little information available on risk factors associated with the lung function abnormalities and its relevance in patient care. Method This was an analytical cross-sectional study involving 76 clinically stable, hydroxyurea-naive adult Hb-SS participants and 76 nonsickle cell disease (non-SCD) controls. A structured questionnaire was used to obtain sociodemographic data and clinical history of the participants. Investigations performed included spirometry, pulse oximetry, tricuspid regurgitant jet velocity (TRV) measurements via echocardiogram, complete blood counts, free plasma haemoglobin, serum urea, and creatinine. Results Weight, BMI, mean FVC, and FEV1% predicted values were comparatively lower among the Hb-SS patients (p < 0.001). Abnormal spirometry outcome occurred in 70.4% of Hb-SS patients, predominantly restrictive defects (p < 0.001), and showed no significant association with steady-state Hb, WBC count, free plasma haemoglobin, frequency of sickling crisis, chronic leg ulcers, and TRV measurements (p > 0.05). The mean oxygen saturation was comparatively lower among Hb-SS patients (p < 0.001). Conclusion Measured lung volumes were significantly lower in Hb-SS patients when compared to non-SCD controls and this difference was not influenced by anthropometric variance. Lung function abnormalities, particularly restrictive defects, are prevalent in Hb-SS patients but showed no significant association with recognized markers of disease severity.
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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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Ramos-Machado V, Ladeia AM, dos Santos Teixeira R, da Anunciação Ferreira T, Terse-Ramos R. Sleep disorders and endothelial dysfunction in children with sickle cell anemia. Sleep Med 2019; 53:9-15. [DOI: 10.1016/j.sleep.2018.08.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 07/12/2018] [Accepted: 08/06/2018] [Indexed: 10/28/2022]
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Xu JZ, Garrett ME, Soldano KL, Chen ST, Clish CB, Ashley-Koch AE, Telen MJ. Clinical and metabolomic risk factors associated with rapid renal function decline in sickle cell disease. Am J Hematol 2018; 93:1451-1460. [PMID: 30144150 DOI: 10.1002/ajh.25263] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/16/2018] [Accepted: 08/20/2018] [Indexed: 12/22/2022]
Abstract
Sickle cell disease (SCD) nephropathy and lower estimated glomerular filtration rate (eGFR) are risk factors for early mortality. Furthermore, rate of eGFR decline predicts progression to end-stage renal disease in many clinical settings. However, factors predicting renal function decline in SCD are poorly documented. Using clinical, laboratory, genetic, and metabolomic data, we evaluated predictors of renal function decline in a longitudinal cohort of 288 adults (mean age 33.0 years). In 193 subjects with 5-year follow-up data, mean rate of eGFR decline was 2.35 mL/min/1.73 m2 /year, nearly twice that of African American adults overall. Hyperfiltration was prevalent at baseline (61.1%), and 36.8% of subjects experienced rapid eGFR decline (≥3 mL/min/1.73 m2 /year). Severe Hb genotype; proteinuria; higher platelet and reticulocyte counts, and systolic BP; and lower Hb level and BMI were associated with rapid decline. A risk scoring system was created using these 7 variables and was highly predictive of rapid eGFR decline, with odds of rapid decline increasing 1.635-fold for every point increment (P < 0.0001). Rapid eGFR decline was also associated with higher organ system severity score and peak creatinine. Additionally, two metabolites (asymmetric dimethylarginine and quinolinic acid) were associated with rapid decline. Further investigation into longitudinal SCD nephropathy (SCDN) trajectory, early markers of SCDN, and tools for risk stratification should inform interventional studies targeted to slowing GFR decline and improving SCD outcomes.
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Affiliation(s)
- Julia Z Xu
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Melanie E Garrett
- Department of Medicine, Division of Nephrology and Duke Molecular Physiology Institute, Duke University Medical Center, Durham, North Carolina
| | - Karen L Soldano
- Department of Medicine, Division of Nephrology and Duke Molecular Physiology Institute, Duke University Medical Center, Durham, North Carolina
| | - Sean T Chen
- Duke University School of Medicine, Durham, North Carolina
| | - Clary B Clish
- Metabolite Profiling, Broad Institute, Massachusetts Institute of Technology and Harvard University, Cambridge, Massachusetts
| | - Allison E Ashley-Koch
- Department of Medicine, Division of Nephrology and Duke Molecular Physiology Institute, Duke University Medical Center, Durham, North Carolina
| | - Marilyn J Telen
- Department of Medicine, Division of Hematology and Duke Comprehensive Sickle Cell Center, Duke University Medical Center, Durham, North Carolina
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Kurdyukov S, Eccles CA, Desai AA, Gonzalez-Garay M, Yuan JXJ, Garcia JGN, Rafikova O, Rafikov R. New cases of Glucose-6-Phosphate Dehydrogenase deficiency in Pulmonary Arterial Hypertension. PLoS One 2018; 13:e0203493. [PMID: 30161219 PMCID: PMC6117081 DOI: 10.1371/journal.pone.0203493] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 08/21/2018] [Indexed: 11/19/2022] Open
Abstract
Pulmonary Arterial Hypertension (PAH) is a fatal disorder with limited treatment options and reduced life expectancy after diagnosis. Complex genetic backgrounds in PAH complicates identification of causative mutations that is essential for an understanding of the disease diagnostics and etiology especially for idiopathic PAH (iPAH). Hemolysis has been implicated as contributing to the pathobiology of PAH. Glucose-6-Phosphate Dehydrogenase (G6PD) expression and activity define erythrocyte's antioxidant capacity, and its decrease contributes to erythrocyte fragility. As G6PD deficiency was previously reported in a limited number of PAH cases, we tested whether iPAH patients exhibit underlying G6PD alterations in erythrocytes. A cohort of 22 PAH patients and 8 non-PAH patients were recruited for this study. DNA isolated from Peripheral Blood Mononuclear Cells (PBMC) was used for detection of mutations in the coding region of the G6PD gene. RNA isolated from PBMC was used for determination of G6PD mRNA expression level. G6PD activity was measured in Red Blood Cell (RBC) pellets. Three patients had missense mutations in G6PD (Val291Met, Asn126Asp, Asp194Glu), however, only one mutation (Val291Met) results in a severe G6PD deficiency. A single patient with mutation (Asn126Asp) showed a 21% decrease in G6PD activity, two subjects showed G6PD deficiency without mutations, and one patient had a decreased level of G6PD mRNA and reduced enzyme levels. This study demonstrates that a moderate decrease in G6PD activity is associated with PAH. Screening for G6PD activity and mutations in the G6PD gene may provide early detection of individuals predisposed to PAH.
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Affiliation(s)
- Sergey Kurdyukov
- Division of Endocrinology, Department of Medicine, College of Medicine, The University of Arizona, Tucson, Arizona, United States of America
| | - Cody A. Eccles
- Division of Endocrinology, Department of Medicine, College of Medicine, The University of Arizona, Tucson, Arizona, United States of America
| | - Ankit A. Desai
- Division of Cardiology, Department of Medicine, College of Medicine, The University of Arizona, Tucson, Arizona, United States of America
| | - Manuel Gonzalez-Garay
- Division of Translational and Regenerative Medicine, Department of Medicine, College of Medicine, The University of Arizona, Tucson, Arizona, United States of America
| | - Jason X.-J. Yuan
- Division of Translational and Regenerative Medicine, Department of Medicine, College of Medicine, The University of Arizona, Tucson, Arizona, United States of America
| | - Joe G. N. Garcia
- Division of Pulmonary and Critical Care Medicine; Department of Medicine, College of Medicine, The University of Arizona, Tucson, Arizona, United States of America
| | - Olga Rafikova
- Division of Endocrinology, Department of Medicine, College of Medicine, The University of Arizona, Tucson, Arizona, United States of America
| | - Ruslan Rafikov
- Division of Endocrinology, Department of Medicine, College of Medicine, The University of Arizona, Tucson, Arizona, United States of America
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Culley MK, Chan SY. Mitochondrial metabolism in pulmonary hypertension: beyond mountains there are mountains. J Clin Invest 2018; 128:3704-3715. [PMID: 30080181 DOI: 10.1172/jci120847] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Pulmonary hypertension (PH) is a heterogeneous and fatal disease of the lung vasculature, where metabolic and mitochondrial dysfunction may drive pathogenesis. Similar to the Warburg effect in cancer, a shift from mitochondrial oxidation to glycolysis occurs in diseased pulmonary vessels and the right ventricle. However, appreciation of metabolic events in PH beyond the Warburg effect is only just emerging. This Review discusses molecular, translational, and clinical concepts centered on the mitochondria and highlights promising, controversial, and challenging areas of investigation. If we can move beyond the "mountains" of obstacles in this field and elucidate these fundamental tenets of pulmonary vascular metabolism, such work has the potential to usher in much-needed diagnostic and therapeutic approaches for the mitochondrial and metabolic management of PH.
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Affiliation(s)
- Miranda K Culley
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Stephen Y Chan
- Center for Pulmonary Vascular Biology and Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Vanderpool RR, Naeije R. Hematocrit-corrected Pulmonary Vascular Resistance. Am J Respir Crit Care Med 2018. [DOI: 10.1164/rccm.201801-0081pp] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Rebecca R. Vanderpool
- Department of Translational and Regenerative Medicine, University of Arizona, Tucson, Arizona; and
| | - Robert Naeije
- Department of Cardiology, Erasmus University Hospital, Brussels, Belgium
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Yalamanoglu A, Deuel JW, Hunt RC, Baek JH, Hassell K, Redinius K, Irwin DC, Schaer DJ, Buehler PW. Depletion of haptoglobin and hemopexin promote hemoglobin-mediated lipoprotein oxidation in sickle cell disease. Am J Physiol Lung Cell Mol Physiol 2018; 315:L765-L774. [PMID: 30047285 DOI: 10.1152/ajplung.00269.2018] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Intravascular sickling and lysis of red blood cells, a hallmark feature of sickle cell disease (SCD), releases hemoglobin (Hb) into the circulation. Increased cell-free Hb has been linked to vasculopathy and in vitro lipid oxidation. Scavenger plasma proteins haptoglobin (Hp) and hemopexin (Hpx) can attenuate cell-free Hb and total plasma heme lipid-oxidative capacity but are depleted in SCD. Here, we isolated lipids from BERK-SS mice, guinea pigs (GP) infused with heme-albumin, and patients with SCD undergoing regular exchange transfusion therapy and evaluated the level of lipid oxidation. Malondialdehyde formation, an end product of lipid peroxidation, was increased in BERK-SS mice, purified lipid fractions of the heme-albumin infused GP, and patients with SCD compared with controls. In humans, the extent of lipid oxidation was associated with the absence of Hp as well as decreased Hpx in plasma samples. Postmortem pulmonary tissue obtained from patients with SCD demonstrated oxidized LDL deposition in the pulmonary artery. The relationship between no Hp and low Hpx levels with greater LDL and HDL oxidation demonstrates the loss of protection against cell-free Hb and total plasma heme-mediated lipid oxidation and tissue injury in SCD. Strategies to protect against plasma lipid oxidation by cell-free Hb and total plasma heme (e.g., therapeutic Hp and Hpx replacement) may diminish the deleterious effects of cell-free Hb and total plasma heme toward the vascular system in SCD.
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Affiliation(s)
- Ayla Yalamanoglu
- Laboratory of Biochemistry and Vascular Biology, United States Food and Drug Administration, Silver Spring, Maryland
| | - Jeremy W Deuel
- Division of Internal Medicine, University Hospital of Zurich , Zurich , Switzerland
| | - Ryan C Hunt
- Division of Plasma Protein Therapeutics, United States Food and Drug Administration , Silver Spring, Maryland
| | - Jin Hyen Baek
- Laboratory of Biochemistry and Vascular Biology, United States Food and Drug Administration, Silver Spring, Maryland
| | - Kathryn Hassell
- Division of Hematology, University of Colorado , Aurora, Colorado
| | - Katie Redinius
- Cardiovascular and Pulmonary Research Laboratory, University of Colorado, Aurora, Colorado
| | - David C Irwin
- Cardiovascular and Pulmonary Research Laboratory, University of Colorado, Aurora, Colorado
| | - Dominik J Schaer
- Division of Internal Medicine, University Hospital of Zurich , Zurich , Switzerland
| | - Paul W Buehler
- Laboratory of Biochemistry and Vascular Biology, United States Food and Drug Administration, Silver Spring, Maryland
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Weir NA, Conrey A, Lewis D, Mehari A. Riociguat use in sickle cell related chronic thromboembolic pulmonary hypertension: A case series. Pulm Circ 2018; 8:2045894018791802. [PMID: 30033820 PMCID: PMC6083805 DOI: 10.1177/2045894018791802] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Adults with sickle cell disease can develop pulmonary hypertension from a multitude of etiologies. Classified as WHO Group 5, there are no therapies approved for the treatment of sickle cell disease-pulmonary hypertension. Thromboembolic disease is prevalent in sickle cell disease and can lead to pulmonary hypertension. The only approved medical therapy for chronic thromboembolic pulmonary hypertension is riociguat. We report the experience, safety and tolerability of riociguat use in a series of sickle cell disease patients with chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
- Nargues A Weir
- 1 Cardiovascular and Pulmonary Branch and Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, USA.,2 Inova Advanced Lung Disease Program, Falls Church, USA
| | - Anna Conrey
- 1 Cardiovascular and Pulmonary Branch and Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, USA
| | - Denise Lewis
- 2 Inova Advanced Lung Disease Program, Falls Church, USA
| | - Alem Mehari
- 3 Howard University College of Medicine, Washington DC, USA
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Mehari A, Igbineweka N, Allen D, Nichols J, Thein SL, Weir NA. Abnormal Ventilation-Perfusion Scan Is Associated with Pulmonary Hypertension in Sickle Cell Adults. J Nucl Med 2018; 60:86-92. [PMID: 29880507 DOI: 10.2967/jnumed.118.211466] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/23/2018] [Indexed: 02/02/2023] Open
Abstract
Pulmonary hypertension (PH) in adults with sickle cell disease (SCD) is associated with early mortality. Chronic thromboembolic PH (CTEPH) is an important complication and contributor to PH in SCD but is likely underappreciated. Guidelines recommend ventilation-perfusion (V/Q) scintigraphy as the imaging modality of choice to exclude CTEPH. Data on V/Q scanning are limited in SCD. Our objective was to compare the performance of V/Q scanning with that of CT pulmonary angiography (CTPA) and to report clinical outcomes associated with abnormal V/Q findings. Methods: Laboratory data, echocardiography, 6-min-walk testing, V/Q scanning, CTPA, and right heart catheterization (RHC) were prospectively obtained. High-probability and intermediate-probability V/Q findings were considered to be abnormal. Included for analysis were 142 SCD adults (aged 40.1 ± 13.7 y, 83 women, 87% hemoglobin SS) in a stable state enrolled consecutively between March 13, 2002, and June 8, 2017. Results: V/Q results were abnormal in 65 of 142 patients (45.8%). CTPA was positive for pulmonary embolism in 16 of 60 (26.7%). RHC confirmed PH (mean pulmonary artery pressure ≥ 25 mmHg) in 46 of 64 (71.9%), of whom 34 (73.9%) had abnormal V/Q findings. Among those without PH by RHC (n = 18), 2 of 18 patients had abnormal V/Q findings. Thirty-three patients had a complete dataset (V/Q scanning, CTPA, and RHC); 29 of 33 had abnormal RHC findings, of whom 26 had abnormal V/Q findings, compared with 11 who had abnormal CTPA findings. There was greater concordance between V/Q findings and RHC (κ-value = 0.53; P < 0.001) than between CTPA and RHC (κ-value = 0.13; P = 0.065). The sensitivity and specificity for V/Q scanning was 89.7% and 75.0%, respectively, whereas CTPA had sensitivity of 37.3% and specificity of 100%. Abnormal V/Q finding swere associated with hemodynamic severity (mean pulmonary artery pressure, 35.2 ± 9.6 vs. 26.9 ± 10.5 mm Hg, P = 0.002; transpulmonary gradient, 21.5 ± 9.7 vs. 12.16 ± 11 mmHg, P = 0.005; and pulmonary vascular resistance, 226.5 ± 135 vs. 140.7 ± 123.7 dynes⋅s⋅cm-5, P = 0.013) and exercise capacity (6-min-walk distance, 382.8 ± 122.3 vs. 442.3 ± 110.6 m, P < 0.010). Thirty-four deaths were observed over 15 y. All-cause mortality was higher in the abnormal-V/Q group (21 [61.8%]) than in the normal-V/Q group (13 [38.2%]) (log-rank test, P = 0.006; hazard ratio, 2.54). Conclusion: V/Q scanning is superior to CTPA in detecting thrombotic events in SCD. Abnormal V/Q findings are associated with PH, worse hemodynamics, lower functional capacity, and higher mortality. Despite high sensitivity in detecting CTEPH, V/Q scanning is underutilized. We recommend the use of V/Q scanning in the evaluation of dyspnea in adult SCD patients given the important implications toward management.
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Affiliation(s)
- Alem Mehari
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland .,Division of Pulmonary Diseases, Howard University College of Medicine, Washington, District of Columbia; and
| | - Norris Igbineweka
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Darlene Allen
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Jim Nichols
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Swee Lay Thein
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Nargues A Weir
- Sickle Cell Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.,Inova Advanced Lung Disease Program, Falls Church, Virginia
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Ramakrishnan L, Pedersen SL, Toe QK, Quinlan GJ, Wort SJ. Pulmonary Arterial Hypertension: Iron Matters. Front Physiol 2018; 9:641. [PMID: 29904352 PMCID: PMC5990599 DOI: 10.3389/fphys.2018.00641] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 05/11/2018] [Indexed: 12/16/2022] Open
Abstract
The interplay between iron and oxygen is longstanding and central to all aerobic life. Tight regulation of these interactions including homeostatic regulation of iron utilization ensures safe usage of this limited resource. However, when control is lost adverse events can ensue, which are known to contribute to an array of disease processes. Recently, associations between disrupted iron homeostasis and pulmonary artery hypertension (PAH) have been described with the suggestion that there is a contributory link with disease. This review provides a background for iron regulation in humans, describes PAH classifications, and discusses emerging literature, which suggests a role for disrupted iron homeostatic control in various sub-types of PAH, including a role for decompartmentalization of hemoglobin. Finally, the potential for therapeutic options to restore iron homeostatic balance in PAH are discussed.
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Abstract
The primary β-globin gene mutation that causes sickle cell disease (SCD) has significant pathophysiological consequences that result in hemolytic events and the induction of the inflammatory processes that ultimately lead to vaso-occlusion. In addition to their role in the initiation of the acute painful vaso-occlusive episodes that are characteristic of SCD, inflammatory processes are also key components of many of the complications of the disease including autosplenectomy, acute chest syndrome, pulmonary hypertension, leg ulcers, nephropathy and stroke. We, herein, discuss the events that trigger inflammation in the disease, as well as the mechanisms, inflammatory molecules and cells that propagate these inflammatory processes. Given the central role that inflammation plays in SCD pathophysiology, many of the therapeutic approaches currently under pre-clinical and clinical development for the treatment of SCD endeavor to counter aspects or specific molecules of these inflammatory processes and it is possible that, in the future, we will see anti-inflammatory drugs being used either together with, or in place of, hydroxyurea in those SCD patients for whom hematopoietic stem cell transplants and evolving gene therapies are not a viable option.
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Affiliation(s)
- Nicola Conran
- Hematology Center, University of Campinas - UNICAMP, Cidade Universitária, Campinas-SP, Brazil
| | - John D Belcher
- Department of Medicine, Division of Hematology, Oncology and Transplantation, Vascular Biology Center, University of Minnesota, Minneapolis, MN, USA
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Chiadika S, Lim-Fung M, Llanos-Chea F, Serauto Canache A, Yang W, Paruthi C, Zhang X, McPherson DD, Idowu M. Echocardiographic parameters to identify sickle cell patients with cardio-pathology. Echocardiography 2018; 35:1271-1276. [PMID: 29756358 DOI: 10.1111/echo.14028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Sickle cell disease (SCD) affects millions of people and causes chronic hemolytic anemia leading to vasculopathies such as pulmonary hypertension and abnormalities in cardiac function that increase complications and mortality. It is therefore crucial to identify cardiac abnormalities in SCD. We aimed to assess the prevalence of echocardiographic parameters in SCD to help identify cardiopulmonary risk. METHODS Ninety-one patients (53% male), median age of 30, body surface area (BSA) of 1.79 m2 , hemoglobin of 8.8 g/dL, and creatinine of 0.7 mg/dL identified. We retrospectively measured laboratory and echocardiographic parameters in patients with SCD : left ventricular (LV) dimensions, LV ejection fraction (LVEF), LV Myocardial Performance Index (MPI), LV Mass Index (MI), Left Atrial Volume Index (LAVI), Tricuspid Regurgitation Velocity (TRV), tricuspid annular plane systolic excursion (TAPSE), right heart dimensions. RESULTS Prevalence of left heart abnormalities was 32%: increased LV end-diastolic diameter (EDD), 78%: LV MPI, 21%: diastolic dysfunction, 38%: decreased LVEF, 24%: increased LVMI, and 47%: increased LAVI. Right heart abnormalities were 39%: TAPSE, 38%: increased TRV, and 59%: increased pulmonary systolic pressure (PASP). Multivariate logistic regression analysis was significant for increased LVMI and LAVI in those with hemoglobin ≤8 g/dL (odds ratio (OR) 7.4, 95% confidence interval (CI) 2.23-24.6, P = .001) and (OR 3.32, 95% CI 1.18-9.33, P = .023). CONCLUSIONS We confirmed increased prevalence of abnormal LVEDD, LVMI, diastolic function, LAVI, and PASP in SCD. In addition, we identified abnormal LV MPI (78%), TAPSE (29%). These parameters may be useful and readily accessible echocardiographic prognostic tools in this population.
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Affiliation(s)
- Simbo Chiadika
- Division of Cardiology, Department of Internal Medicine, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
| | - Mary Lim-Fung
- Division of Cardiology, Department of Internal Medicine, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
| | - Fiorella Llanos-Chea
- Department of Internal Medicine, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
| | - Astrid Serauto Canache
- Department of Internal Medicine, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
| | - Wei Yang
- Department of Internal Medicine, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
| | - Christina Paruthi
- Division of Cardiology, Department of Internal Medicine, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
| | - Xu Zhang
- Division of Clinical and Translational Sciences, Department of Internal Medicine, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
| | - David D McPherson
- Division of Cardiology, Department of Internal Medicine, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
| | - Modupe Idowu
- Division of Hematology, Department of Internal Medicine, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
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