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Bhat V, Sheehan VA. Can we use biomarkers to identify those at risk of acute pain from sickle cell disease? Expert Rev Hematol 2024; 17:411-418. [PMID: 38949576 DOI: 10.1080/17474086.2024.2372322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 06/21/2024] [Indexed: 07/02/2024]
Abstract
INTRODUCTION Acute pain episodes, also known as vaso-occlusive crises (VOC), are a major symptom of sickle cell disease (SCD) and lead to frequent hospitalizations. The diagnosis of VOC can be challenging, particularly in adults with SCD, 50% of whom have chronic pain. Several potential biomarkers have been proposed for identifying individuals with VOC, including elevation above the baseline of various vascular growth factors, cytokines, and other markers of inflammation. However, none have been validated to date. AREAS COVERED We summarize prospective biomarkers for the diagnosis of acute pain in SCD, and how they may be involved in the pathophysiology of a VOC. Previous and current strategies for biomarker discovery, including the use of omics techniques, are discussed. EXPERT OPINION Implementing a multi-omics-based approach will facilitate the discovery of objective and validated biomarkers for acute pain.
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Affiliation(s)
- Varsha Bhat
- Center for Integrative Genomics, School of Biological Sciences, Georgia Institute of Technology, Atlanta, GA, USA
| | - Vivien A Sheehan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
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Bodla ZH, Hashmi M, Niaz F, Auyeung AB, Oyetoran A, Khalil MJ, Faisal MS, Khalid F, Zakieh AR, Bazikian Y, Bray CL. Double Trouble: COVID-19 Infection Exacerbates Sickle Cell Crisis Outcomes in Hospitalized Patients-Insights from National Inpatient Sample 2020. Hematol Rep 2024; 16:421-430. [PMID: 39051414 PMCID: PMC11270312 DOI: 10.3390/hematolrep16030041] [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: 11/13/2023] [Revised: 03/17/2024] [Accepted: 04/16/2024] [Indexed: 07/27/2024] Open
Abstract
Background: This study investigated the impact of COVID-19 on patients with sickle cell crisis (SCC) using National Inpatient Sample (NIS) data for the year 2020. Methods: A retrospective cohort analysis was conducted utilizing International Classification of Diseases (ICD-10) codes to identify adults who were admitted with a principal diagnosis of sickle cell crisis. The primary outcomes examined were inpatient mortality, while the secondary outcomes assessed included morbidity, hospital length of stay, and resource utilization. Analyses were conducted with STATA. Multivariate logistic and linear regression analyses were used to adjust for confounding variables. Results: Of 66,415 adult patients with a primary SCC diagnosis, 875 were identified with a secondary diagnosis of COVID-19 infection. Unadjusted mortality rate was higher for SCC patients with COVID-19 (2.28%) compared to those without (0.33%), with an adjusted odds ratio (aOR) of 8.49 (p = 0.001). They also showed increased odds of developing acute respiratory failure (aOR = 2.37, p = 0.003) and acute kidney injury requiring dialysis (aOR = 8.66, p = 0.034). Additionally, these patients had longer hospital stays by an adjusted mean of 3.30 days (p < 0.001) and incurred higher hospitalization charges by an adjusted mean of USD 35,578 (p = 0.005). Conclusions: The SCC patients with COVID-19 presented higher mortality rates, increased morbidity indicators, longer hospital stays, and substantial economic burdens.
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Affiliation(s)
- Zubair Hassan Bodla
- Department of Internal medicine, Graduate Medical Education, College of Medicine, University of Central Florida (UCF), Orlando, FL 32827, USA
- Internal Medicine Residency Program, HCA Florida North Florida Hospital, Gainesville, FL 33328, USA
| | - Mariam Hashmi
- Department of Internal medicine, Graduate Medical Education, College of Medicine, University of Central Florida (UCF), Orlando, FL 32827, USA
- Internal Medicine Residency Program, HCA Florida North Florida Hospital, Gainesville, FL 33328, USA
| | - Fatima Niaz
- Department of Internal Medicine, King Edward Medical University, Lahore 54000, Punjab, Pakistan
| | - Austin B. Auyeung
- Department of Internal medicine, Graduate Medical Education, College of Medicine, University of Central Florida (UCF), Orlando, FL 32827, USA
- Internal Medicine Residency Program, HCA Florida North Florida Hospital, Gainesville, FL 33328, USA
| | - Anuoluwa Oyetoran
- Department of Internal medicine, Graduate Medical Education, College of Medicine, University of Central Florida (UCF), Orlando, FL 32827, USA
- Internal Medicine Residency Program, HCA Florida North Florida Hospital, Gainesville, FL 33328, USA
| | | | | | - Farhan Khalid
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ 07740, USA
| | - Abdel-Rahman Zakieh
- Department of Internal medicine, Graduate Medical Education, College of Medicine, University of Central Florida (UCF), Orlando, FL 32827, USA
- Internal Medicine Residency Program, HCA Florida North Florida Hospital, Gainesville, FL 33328, USA
| | - Yvette Bazikian
- Department of Internal medicine, Graduate Medical Education, College of Medicine, University of Central Florida (UCF), Orlando, FL 32827, USA
- Internal Medicine Residency Program, HCA Florida North Florida Hospital, Gainesville, FL 33328, USA
| | - Christopher L. Bray
- Department of Internal medicine, Graduate Medical Education, College of Medicine, University of Central Florida (UCF), Orlando, FL 32827, USA
- Internal Medicine Residency Program, HCA Florida North Florida Hospital, Gainesville, FL 33328, USA
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Hakami F, Alhazmi E, Busayli WM, Althurwi S, Darraj AM, Alamir MA, Hakami A, Othman RA, Moafa AI, Mahasi HA, Madkhali MA. Overview of the Association Between the Pathophysiology, Types, and Management of Sickle Cell Disease and Stroke. Cureus 2023; 15:e50577. [PMID: 38107212 PMCID: PMC10723021 DOI: 10.7759/cureus.50577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2023] [Indexed: 12/19/2023] Open
Abstract
Sickle cell disease (SCD) is a genetic blood disorder that affects hemoglobin and increases stroke risk, particularly in childhood. This review examines the pathophysiological association between SCD and stroke, the classification of stroke types, risk factors, diagnosis, management, prevention, and prognosis. A comprehensive literature search was conducted via PubMed, Scopus, and Cochrane databases. Relevant studies on SCD and stroke pathophysiology, classification, epidemiology, diagnosis, treatment, and prevention were identified. Sickle cell disease causes red blood cells to become rigid and sickle-shaped, obstructing blood vessels. Recurrent sickling alters cerebral blood flow and damages vessel walls, often leading to ischemic or hemorrhagic strokes (HS). These occur most frequently in childhood, with ischemic strokes (IS) being more common. Key risk factors include a prior transient ischemic attack (TIA), low hemoglobin, and a high leukocyte count. Neuroimaging is essential for diagnosis and determining stroke type. Primary prevention centers on blood transfusions and hydroxyurea for those at high risk. Acute treatment involves promptly restoring blood flow and managing complications. However, significant knowledge gaps remain regarding stroke mechanisms, optimizing screening protocols, and improving long-term outcomes. This review synthesizes current evidence on SCD and stroke to highlight opportunities for further research and standardizing care protocols across institutions. Ultimately, a holistic perspective is critical for mitigating the high risk of debilitating strokes in this vulnerable patient population.
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Affiliation(s)
- Faisal Hakami
- Medicine, Faculty of Medicine, Jazan University, Jazan, SAU
| | - Essam Alhazmi
- Medicine, Faculty of Medicine, Jazan University, Jazan, SAU
| | - Wafa M Busayli
- Medicine, Faculty of Medicine, Jazan University, Jazan, SAU
| | | | | | | | - Alyaj Hakami
- Medicine, Faculty of Medicine, Jazan University, Jazan, SAU
| | - Renad A Othman
- Medicine, Faculty of Medicine, Jazan University, Jazan, SAU
| | - Amal I Moafa
- Medicine, Faculty of Medicine, Jazan University, Jazan, SAU
| | | | - Mohammed Ali Madkhali
- Internal Medicine, and Hematology and Oncology, Faculty of Medicine, Jazan University, Jazan, SAU
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Ziyadah MS, Mansory EM, Alahwal HM, Bahashwan SM, Almohammadi AT, Radhwi OO, Alghamdi T, Khan SA, Almashjary MN, Barefah AS. Predisposing Factors and Incidence of Venous Thromboembolism among Hospitalized Patients with Sickle Cell Disease. J Clin Med 2023; 12:6498. [PMID: 37892636 PMCID: PMC10607487 DOI: 10.3390/jcm12206498] [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: 09/12/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Though patients with sickle cell disease (SCD) are at risk of developing venous thromboembolism (VTE), clear estimates of its incidence and predisposing factors in hospitalized SCD patients are not available. Therefore, this issue was addressed to facilitate an early diagnosis and initiate appropriate prophylactic and treatment strategies. A retrospective observational study was conducted on patients with SCD who were admitted to an academic center in Saudi Arabia over a 10-year period. We identified 1054 admissions of 394 patients with SCD. Of the 3% of patients identified with VTE, 50% experienced pulmonary embolism (PE), 34.3% exhibited deep vein thrombosis (DVT), 6.3% exhibited cerebral vein thrombosis, and 9.4% showed other forms of VTE. In pregnant SCD patients, 6.4% developed a VTE event during their hospital admission. Of the risk factors, high white blood cell count, length of stay, and presence of any additional risk factor for VTE was associated significantly with higher risk of VTE. In our study, this risk seems to be much lower, which is likely attributed to the use of VTE prophylactic strategies implemented in our center. Nevertheless, further studies are needed to establish the ideal prophylactic strategy in patients with SCD.
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Affiliation(s)
- Mohammed S. Ziyadah
- Department of Internal Medicine, Faculty of Medicine, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (M.S.Z.); (T.A.)
| | - Eman M. Mansory
- Hematology Department, Faculty of Medicine, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (E.M.M.); (H.M.A.); (S.M.B.); (A.T.A.); (O.O.R.)
- Hematology Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
| | - Hatem M. Alahwal
- Hematology Department, Faculty of Medicine, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (E.M.M.); (H.M.A.); (S.M.B.); (A.T.A.); (O.O.R.)
- Hematology Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
| | - Salem M. Bahashwan
- Hematology Department, Faculty of Medicine, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (E.M.M.); (H.M.A.); (S.M.B.); (A.T.A.); (O.O.R.)
- Hematology Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
| | - Abdullah T. Almohammadi
- Hematology Department, Faculty of Medicine, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (E.M.M.); (H.M.A.); (S.M.B.); (A.T.A.); (O.O.R.)
- Hematology Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
| | - Osman O. Radhwi
- Hematology Department, Faculty of Medicine, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (E.M.M.); (H.M.A.); (S.M.B.); (A.T.A.); (O.O.R.)
- Hematology Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
| | - Talal Alghamdi
- Department of Internal Medicine, Faculty of Medicine, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (M.S.Z.); (T.A.)
| | - Shahida A. Khan
- Applied Medical Nutrition Group, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Majed N. Almashjary
- Hematology Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Ahmed S. Barefah
- Hematology Department, Faculty of Medicine, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (E.M.M.); (H.M.A.); (S.M.B.); (A.T.A.); (O.O.R.)
- Hematology Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
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Chen M, Ataga KI, Hankins JS, Zhang M, Gatwood JD, Wan JY, Bailey JE. Age-related differences in risks and outcomes of 30-day readmission in adults with sickle cell disease. Ann Hematol 2023; 102:2329-2342. [PMID: 37450055 DOI: 10.1007/s00277-023-05365-5] [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: 05/09/2023] [Accepted: 07/09/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Literature on 30-day readmission in adults with sickle cell disease (SCD) is limited. This study examined the overall and age-stratified rates, risk factors, and healthcare resource utilization associated with 30-day readmission in this population. METHODS Using the Nationwide Readmissions Database, a retrospective cohort study was conducted to identify adult patients (aged ≥ 18) with SCD in 2016. Patients were stratified by age and followed for 30 days to assess readmission following an index discharge. The primary outcome was 30-day unplanned all-cause readmission. Secondary outcomes included index hospitalization costs and readmission outcomes (e.g., time to readmission, readmission costs, and readmission lengths of stay). Separate generalized linear mixed models estimated the adjusted odds ratios (aORs) for associations of readmission with patient and hospital characteristics, overall and by age. RESULTS Of 15,167 adults with SCD, 2,863 (18.9%) experienced readmission. Both the rates and odds of readmission decreased with increasing age. The SCD complications vaso-occlusive crisis and end-stage renal disease (ESRD) were significantly associated with increased likelihood of readmission (p < 0.05). Age-stratified analyses demonstrated that diagnosis of depression significantly increased risk of readmission among patients aged 18-to-29 years (aOR = 1.537, 95%CI: 1.215-1.945) but not among patients of other ages. All secondary outcomes significantly differed by age (p < 0.05). CONCLUSION This study demonstrates that patients with SCD are at very high risk of 30-day readmission and that younger adults and those with vaso-occlusive crisis and ESRD are among those at highest risk. Multifaceted, age-specific interventions targeting individuals with SCD on disease management are needed to prevent readmissions.
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Affiliation(s)
- Ming Chen
- Institute of Health Outcomes and Policy, University of Tennessee Health Science Center, Memphis, TN, 38163, USA.
- Center for Health System Improvement, University of Tennessee Health Science Center, Memphis, TN, 38163, USA.
| | - Kenneth I Ataga
- Center for Sickle Cell Disease, University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jane S Hankins
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Min Zhang
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Justin D Gatwood
- Institute of Health Outcomes and Policy, University of Tennessee Health Science Center, Memphis, TN, 38163, USA
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Nashville, TN, USA
| | - Jim Y Wan
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - James E Bailey
- Center for Health System Improvement, University of Tennessee Health Science Center, Memphis, TN, 38163, USA
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
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Ramadas N, Sparkenbaugh EM. The APC-EPCR-PAR1 axis in sickle cell disease. Front Med (Lausanne) 2023; 10:1141020. [PMID: 37497271 PMCID: PMC10366386 DOI: 10.3389/fmed.2023.1141020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 06/26/2023] [Indexed: 07/28/2023] Open
Abstract
Sickle Cell Disease (SCD) is a group of inherited hemoglobinopathies. Sickle cell anemia (SCA) is caused by a homozygous mutation in the β-globin generating sickle hemoglobin (HbS). Deoxygenation leads to pathologic polymerization of HbS and sickling of erythrocytes. The two predominant pathologies of SCD are hemolytic anemia and vaso-occlusive episodes (VOE), along with sequelae of complications including acute chest syndrome, hepatopathy, nephropathy, pulmonary hypertension, venous thromboembolism, and stroke. SCD is associated with endothelial activation due to the release of danger-associated molecular patterns (DAMPs) such as heme, recurrent ischemia-reperfusion injury, and chronic thrombin generation and inflammation. Endothelial cell activation is mediated, in part, by thrombin-dependent activation of protease-activated receptor 1 (PAR1), a G protein coupled receptor that plays a role in platelet activation, endothelial permeability, inflammation, and cytotoxicity. PAR1 can also be activated by activated protein C (APC), which promotes endothelial barrier protection and cytoprotective signaling. Notably, the APC system is dysregulated in SCD. This mini-review will discuss activation of PAR1 by APC and thrombin, the APC-EPCR-PAR1 axis, and their potential roles in SCD.
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Affiliation(s)
- Nirupama Ramadas
- Department of Medicine, Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Erica M. Sparkenbaugh
- Department of Medicine, Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Ibrahim R, Fadel A, Sawli N, Mecheik A. A Challenging Case of Severe Sickle Cell Crisis With Multiorgan Involvement: A Case Report. Cureus 2023; 15:e42437. [PMID: 37637522 PMCID: PMC10448915 DOI: 10.7759/cureus.42437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
Sickle cell anemia is a chronic and debilitating hemoglobinopathy characterized by the presence of abnormal hemoglobin, resulting in the formation of sickle-shaped red blood cells. This case report presents an unusual case of a 32-year-old female patient with sickle cell anemia who had not experienced any previous sickle cell crises since her diagnosis at the age of four years. Despite a stable clinical history, the patient's condition rapidly deteriorated, leading to septic shock, multiorgan failure, and atypical complications such as neurological impairment and acute kidney injury. Intensive management strategies, including blood exchange, mechanical ventilation, and aggressive antibiotic therapy, were implemented but unfortunately failed to reverse the progressive clinical deterioration. This case underscores the importance of early recognition and a multidisciplinary approach in managing atypical sickle cell crises to optimize patient outcomes. Further research is needed to improve our understanding and management of such presentations.
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Affiliation(s)
- Rana Ibrahim
- Research Department, Saint George Hospital-Hadath, Beirut, LBN
| | - Abbas Fadel
- Infectious Diseases Department, Saint George Hospital-Hadath, Beirut, LBN
| | - Nour Sawli
- Pharmacy Department, Saint George Hospital-Hadath, Beirut, LBN
| | - Ali Mecheik
- Intensive Care Unit Department, Saint George Hospital-Hadath, Beirut, LBN
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An R, Man Y, Cheng K, Zhang T, Chen C, Wang F, Abdulla F, Kucukal E, Wulftange WJ, Goreke U, Bode A, Nayak LV, Vercellotti GM, Belcher JD, Little JA, Gurkan UA. Sickle red blood cell-derived extracellular vesicles activate endothelial cells and enhance sickle red cell adhesion mediated by von Willebrand factor. Br J Haematol 2023; 201:552-563. [PMID: 36604837 PMCID: PMC10121869 DOI: 10.1111/bjh.18616] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 11/14/2022] [Accepted: 12/06/2022] [Indexed: 01/07/2023]
Abstract
Endothelial activation and sickle red blood cell (RBC) adhesion are central to the pathogenesis of sickle cell disease (SCD). Quantitatively, RBC-derived extracellular vesicles (REVs) are more abundant from SS RBCs compared with healthy RBCs (AA RBCs). Sickle RBC-derived REVs (SS REVs) are known to promote endothelial cell (EC) activation through cell signalling and transcriptional regulation at longer terms. However, the SS REV-mediated short-term non-transcriptional response of EC is unclear. Here, we examined the impact of SS REVs on acute microvascular EC activation and RBC adhesion at 2 h. Compared with AA REVs, SS REVs promoted human pulmonary microvascular ECs (HPMEC) activation indicated by increased von Willebrand factor (VWF) expression. Under microfluidic conditions, we found abnormal SS RBC adhesion to HPMECs exposed to SS REVs. This enhanced SS RBC adhesion was reduced by haeme binding protein haemopexin or VWF cleaving protease ADAMTS13 to a level similar to HPMECs treated with AA REVs. Consistent with these observations, haemin- or SS REV-induced microvascular stasis in SS mice with implanted dorsal skin-fold chambers that was inhibited by ADAMTS13. The adhesion induced by SS REVs was variable and was higher with SS RBCs from patients with increased markers of haemolysis (lactate dehydrogenase and reticulocyte count) or a concomitant clinical diagnosis of deep vein thrombosis. Our results emphasise the critical contribution made by REVs to the pathophysiology of SCD by triggering acute microvascular EC activation and abnormal RBC adhesion. These findings may help to better understand acute pathophysiological mechanism of SCD and thereby the development of new treatment strategies using VWF as a potential target.
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Affiliation(s)
- Ran An
- Mechanical and Aerospace Engineering Department, Case Western Reserve University, Cleveland, OH, USA
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
- Department of Biomedical Sciences, University of Houston, Houston, TX, USA
- indicates equal contribution
| | - Yuncheng Man
- Mechanical and Aerospace Engineering Department, Case Western Reserve University, Cleveland, OH, USA
- indicates equal contribution
| | - Kevin Cheng
- Mechanical and Aerospace Engineering Department, Case Western Reserve University, Cleveland, OH, USA
| | - Tianyi Zhang
- Physiology and Biophysics Department, Case Western Reserve University, Cleveland, OH, USA
| | - Chunsheng Chen
- Division of Hematology, Oncology and Transplantation, Vascular Biology Center, University of Minnesota, Minneapolis, MN, USA
| | - Fang Wang
- Mechanical and Aerospace Engineering Department, Case Western Reserve University, Cleveland, OH, USA
| | - Fuad Abdulla
- Division of Hematology, Oncology and Transplantation, Vascular Biology Center, University of Minnesota, Minneapolis, MN, USA
| | - Erdem Kucukal
- Mechanical and Aerospace Engineering Department, Case Western Reserve University, Cleveland, OH, USA
| | - William J. Wulftange
- Biomedical Engineering Department, Case Western Reserve University, Cleveland, OH, USA
| | - Utku Goreke
- Mechanical and Aerospace Engineering Department, Case Western Reserve University, Cleveland, OH, USA
| | - Allison Bode
- Mechanical and Aerospace Engineering Department, Case Western Reserve University, Cleveland, OH, USA
- Department of Hematology and Oncology, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Lalitha V. Nayak
- Department of Hematology and Oncology, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Gregory M. Vercellotti
- Division of Hematology, Oncology and Transplantation, Vascular Biology Center, University of Minnesota, Minneapolis, MN, USA
| | - John D. Belcher
- Division of Hematology, Oncology and Transplantation, Vascular Biology Center, University of Minnesota, Minneapolis, MN, USA
| | - Jane A. Little
- Divison of Hematology & UNC Blood Research Center, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Umut A. Gurkan
- Mechanical and Aerospace Engineering Department, Case Western Reserve University, Cleveland, OH, USA
- Division of Hematology, Oncology and Transplantation, Vascular Biology Center, University of Minnesota, Minneapolis, MN, USA
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA
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Saxena P, Muthu J. COVID-19 and Sickle Cell Disease: Two Independent Risk Factors for Venous Thromboembolism. Cureus 2023; 15:e37226. [PMID: 37159776 PMCID: PMC10163976 DOI: 10.7759/cureus.37226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 04/08/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been widely documented as a multi-systemic illness and associated with an increased incidence of thromboses. Likewise, sickle cell disease (SCD) is a hematologic disease responsible for widespread effects on the vasculature and is also associated with elevated thrombotic risk. In this review, we examine the incidence rates of venous thromboembolism (VTE) in SCD and COVID-19 independently and review the mechanisms of coagulopathy associated with both diseases. We describe the possible associations and commonalities between VTE mechanisms, as both diseases cause widespread inflammation that influences each tenet of Virchow's triad. We also discuss current anticoagulation guideline recommendations for the prevention of VTE events in each of these diseases. We report on current literature to date describing rates of VTE in SCD-COVID-19 patients and outline prospective areas of research to further understand the possible synergistic influence of coagulopathy in these patients. The association between SCD and COVID-19 remains a largely under-researched area of coagulopathy in current hematology and thrombotic literature, and our report lays out potential future prospects in the field.
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Light J, Boucher M, Baskin-Miller J, Winstead M. Managing the Cerebrovascular Complications of Sickle Cell Disease: Current Perspectives. J Blood Med 2023; 14:279-293. [PMID: 37082003 PMCID: PMC10112470 DOI: 10.2147/jbm.s383472] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/31/2023] [Indexed: 04/22/2023] Open
Abstract
The importance of protecting brain function for people with sickle cell disease (SCD) cannot be overstated. SCD is associated with multiple cerebrovascular complications that threaten neurocognitive function and life. Without screening and preventive management, 11% of children at 24% of adults with SCD have ischemic or hemorrhagic strokes. Stroke screening in children with SCD is well-established using transcranial Doppler ultrasound (TCD). TCD velocities above 200 cm/s significantly increase the risk of stroke, which can be prevented using chronic red blood cell (RBC) transfusion. RBC transfusion is also the cornerstone of acute stroke management and secondary stroke prevention. Chronic transfusion requires long-term management of complications like iron overload. Hydroxyurea can replace chronic transfusions for primary stroke prevention in a select group of patients or in populations where chronic transfusions are not feasible. Silent cerebral infarction (SCI) is even more common than stroke, affecting 39% of children and more than 50% of adults with SCD; management of SCI is individualized and includes careful neurocognitive evaluation. Hematopoietic stem cell transplant prevents cerebrovascular complications, despite the short- and long-term risks. Newer disease-modifying agents like voxelotor and crizanlizumab, as well as gene therapy, may treat cerebrovascular complications, but these approaches are investigational.
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Affiliation(s)
- Jennifer Light
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maria Boucher
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jacquelyn Baskin-Miller
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mike Winstead
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Correspondence: Mike Winstead, Division of Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC, USA, Tel +1 919-966-1178, Fax +1 919-966-7629, Email
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11
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Nwagha TU, Nweke M, Ezigbo ED. Contributions of von Willebrand factor to clinical severity of sickle cell disease: a systematic review and metanalysis. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2022; 27:860-866. [PMID: 35938970 DOI: 10.1080/16078454.2022.2107908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To evaluate the contributions of VWF to the clinical manifestation and severity of SCD. DESIGN A systematic review of peer-reviewed articles published in English. The review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. METHODS The data sources for the review included MEDLINE, PubMed, CINAHL, and Academic Search Complete. Articles that applied a quantitative approach to the investigation of the relationship of vWF with clinical manifestations and severity indices were included. The risk of bias assessment was carried out with a mixed-method appraisal tool. We computed I 2 to estimate the degree of heterogeneity. RESULT There was a significantly higher level of VWF in SCD than in the control (d = 2.7, Z = 4.865, P < 0.001, I 2 = 96.41%). Significant positive correlations were obtained for the relationship of VWF with vasoocclusive crisis (r= 0.277, Z= 5.077, P < 0.001, 1 2 =15.62), rate of hemolysis (r=0.441; Z= 4.440, I 2 = <1%), extracellular haemoglobin (r=-0.397, Z=-4.155, I 2 =<1%) and CRP (r = 0.331, Z = 4.566, P < 0.001, I 2 < 1%).The VWF is important in determining the clinical severity of sickle cell disease, which constitutes a putative therapeutic target. More work is required to understand the causal direction underlying the association between VWF levels and the clinical severity of sickle cell disease and the potential role that VWF plays in the clinical manifestations of sickle cell disease. PROTOCOL REGISTRATION The protocol was registered with PROSPERO (CRD42021262625).
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Affiliation(s)
- T U Nwagha
- Department of Haematology, Faculty of Medicine, University of Nigeria /University of Nigeria Teaching Hospital Ituku Ozalla, Nsukka, Nigeria
| | | | - E D Ezigbo
- Department of Medical Laboratory Science, Faculty of Health Sciences, University of Nigeria Enugu Campus, Nsukka, Nigeria
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12
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An R, Gurkan UA. Emerging functional microfluidic assays for the study of thromboinflammation in sickle cell disease. Curr Opin Hematol 2022; 29:327-334. [PMID: 35916533 PMCID: PMC10440906 DOI: 10.1097/moh.0000000000000731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review briefly summarizes the significant impact of thromboinflammation in sickle cell disease in relation to recent advances in biomarkers that are used in functional microfluidic assays. RECENT FINDINGS Sickle cell disease (SCD) is an inherited hemoglobinopathy that affects 100 000 Americans and millions worldwide. Patients with SCD exhibit chronic haemolysis, chronic inflammation and thrombosis, and vaso-occlusion, triggering various clinical complications, including organ damage and increased mortality and morbidity. Recent advances in functional microfluidic assays provide direct biomarkers of disease, including abnormal white blood cell and red blood cell adhesion, cell aggregation, endothelial degradation and contraction, and thrombus formation. SUMMARY Novel and emerging functional microfluidic assays are a promising and feasible strategy to comprehensively characterize thromboinflammatory reactions in SCD, which can be used for personalized risk assessment and tailored therapeutic decisions.
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Affiliation(s)
- Ran An
- Department of Mechanical and Aerospace Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Umut A. Gurkan
- Department of Mechanical and Aerospace Engineering, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
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13
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Mustafa AEM, Tahir NM, Ahmed Mohamed NAE, Mohammed AA, Mohammed SI. Deep Vein Thrombosis of the Left Lower Limb in a Sudanese Child with Sickle Cell Disease. MEDICINES (BASEL, SWITZERLAND) 2022; 9:52. [PMID: 36355057 PMCID: PMC9697196 DOI: 10.3390/medicines9110052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/13/2022] [Accepted: 10/20/2022] [Indexed: 06/16/2023]
Abstract
This is a case of an eleven-year-old female Sudanese child, a known Sickle Cell Anemia (SCA) patient, who presented with fever, as well as left thigh and leg swelling that was associated with pain and warmness, which was diagnosed as Deep Vein Thrombosis (DVT) of her left lower limb. She had a previous history of admissions to the emergency room, during which she once received blood. The patient was managed by carrying out a basic routine initial laboratory investigation. A Doppler ultrasound scan showed features consistent with DVT. Based on the clinical findings and investigation results, management began by providing the patient with intravenous fluid, analgesia, packed Red Blood Cells (RBCs), intravenous antibiotics, and low-molecular-weight heparin. Further consultations showed that there was no need for vascular surgery or surgical intervention. This case highlights the need for more studies on DVT and Venous Thromboembolism (VTE) complications in children with SCA, so as to develop strategies for diagnosis and management in order to reduce the risk of life-threatening complications of VTE in patients with Sickle Cell Disease SCD.
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Affiliation(s)
- Alam Eldin Musa Mustafa
- Department of Child Health, College of Medicine, King Khalid University, P.O. Box 641, Abha 61421, Saudi Arabia
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Kordofan University, P.O. Box 160, El Obeid 51111, Sudan
| | - Niemat Mohammed Tahir
- Department of Child Health, College of Medicine, King Khalid University, P.O. Box 641, Abha 61421, Saudi Arabia
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14
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Feugray G, Kasonga F, Grall M, Dumesnil C, Benhamou Y, Brunel V, Le Cam Duchez V, Lahary A, Billoir P. Investigation of thrombin generation assay to predict vaso-occlusive crisis in adulthood with sickle cell disease. Front Cardiovasc Med 2022; 9:883812. [PMID: 36277754 PMCID: PMC9579298 DOI: 10.3389/fcvm.2022.883812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Sickle cell disease (SCD) is an inherited hemoglobinopathy disorder. The main consequence is synthesis of hemoglobin S leading to chronic hemolysis associated with morbidity. The aim of this study was to investigate Thrombin Generation Assay (TGA) to assess hypercoagulability in SCD and TGA parameters as biomarkers of vaso-occlusive crisis (VOC) risk and hospitalization within 1 year. Materials and methods We performed TGA in platelet poor plasma (PPP) with 1 pM of tissue factor and 4 μM of phospholipid-standardized concentration, in duplicate for patients and controls. We measured thrombomodulin (TM), soluble endothelial Protein C Receptor and Tissue Factor Pathway Inhibitor (TFPI). Results A total of 113 adult patients with SCD, 83 at steady state and 30 during VOC, and 25 healthy controls matched on age and gender were included. Among the 83 patients at steady state, (36 S/S-1 S/β0, 20 S/Sα3.7, and 19 S/C-7 S/β+) 28 developed a VOC within 1 year (median: 4 months [2.25–6]). We observed an increase of peak and velocity associated with a shortening of lagtime and time to peak (TTP) and no difference of endogenous thrombin potential (ETP) in patients compared to controls. TFPI (p < 0.001) and TM (p = 0.006) were significantly decreased. TGA confirmed hypercoagulability in all SCD genotypes and clinical status. The association of ETP > 1,207 nM.min and peak >228.5 nM presented a sensitivity of 73.5% and a specificity of 93.9% to predict VOC development within 1 year. Conclusion We have demonstrated a hypercoagulable state in SCD associated with chronic hemolysis. These preliminary findings suggest that TGA parameters, as ETP and peak, could be used to predict VOC development within 1 year.
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Affiliation(s)
- Guillaume Feugray
- Vascular Hemostasis Unit, CHU Rouen, Normandie Université, UNIROUEN, INSERM U1096, Rouen, France
| | | | | | - Cécile Dumesnil
- Department of Pediatric Onco-Hematology, CHU Rouen, Rouen, France
| | - Ygal Benhamou
- Department of Internal Medicine, CHU Rouen, Normandie Université, UNIROUEN, INSERM U1096, Rouen, France
| | - Valery Brunel
- Department of General Biochemistry, CHU Rouen, Rouen, France
| | - Véronique Le Cam Duchez
- Vascular Hemostasis Unit, CHU Rouen, Normandie Université, UNIROUEN, INSERM U1096, Rouen, France
| | | | - Paul Billoir
- Vascular Hemostasis Unit, CHU Rouen, Normandie Université, UNIROUEN, INSERM U1096, Rouen, France,*Correspondence: Paul Billoir, ; orcid.org/0000-0001-5632-7713
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15
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Lamarre Y, Nader E, Connes P, Romana M, Garnier Y. Extracellular Vesicles in Sickle Cell Disease: A Promising Tool. Bioengineering (Basel) 2022; 9:bioengineering9090439. [PMID: 36134985 PMCID: PMC9495982 DOI: 10.3390/bioengineering9090439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 08/25/2022] [Accepted: 08/31/2022] [Indexed: 12/12/2022] Open
Abstract
Sickle cell disease (SCD) is the most common hemoglobinopathy worldwide. It is characterized by an impairment of shear stress-mediated vasodilation, a pro-coagulant, and a pro-adhesive state orchestrated among others by the depletion of the vasodilator nitric oxide, by the increased phosphatidylserine exposure and tissue factor expression, and by the increased interactions of erythrocytes with endothelial cells that mediate the overexpression of adhesion molecules such as VCAM-1, respectively. Extracellular vesicles (EVs) have been shown to be novel actors involved in SCD pathophysiological processes. Medium-sized EVs, also called microparticles, which exhibit increased plasma levels in this pathology, were shown to induce the activation of endothelial cells, thereby increasing neutrophil adhesion, a key process potentially leading to the main complication associated with SCD, vaso-occlusive crises (VOCs). Small-sized EVs, also named exosomes, which have also been reported to be overrepresented in SCD, were shown to potentiate interactions between erythrocytes and platelets, and to trigger endothelial monolayer disruption, two processes also known to favor the occurrence of VOCs. In this review we provide an overview of the current knowledge about EVs concentration and role in SCD.
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Affiliation(s)
- Yann Lamarre
- Université Paris Cité and Université des Antilles, Inserm, BIGR, F-75015 Paris, France
| | - Elie Nader
- Laboratoire Inter-Universitaire de Biologie de la Motricité EA7424, Team “Vascular Biology and Red Blood Cell”, Université Claude Bernard Lyon 1, Université de Lyon, 69622 Lyon, France
| | - Philippe Connes
- Laboratoire Inter-Universitaire de Biologie de la Motricité EA7424, Team “Vascular Biology and Red Blood Cell”, Université Claude Bernard Lyon 1, Université de Lyon, 69622 Lyon, France
| | - Marc Romana
- Université Paris Cité and Université des Antilles, Inserm, BIGR, F-75015 Paris, France
| | - Yohann Garnier
- Université Paris Cité and Université des Antilles, Inserm, BIGR, F-75015 Paris, France
- Correspondence: ; Tel.: +590-590-891530
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16
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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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17
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Arisz RA, de Vries JJ, Schols SEM, Eikenboom JCJ, de Maat, MPM. Interaction of von Willebrand factor with blood cells in flow models: a systematic review. Blood Adv 2022; 6:3979-3990. [PMID: 35816358 PMCID: PMC9278308 DOI: 10.1182/bloodadvances.2021006405] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 05/02/2022] [Indexed: 11/29/2022] Open
Abstract
The presence of blood flow influences the interaction between von Willebrand factor (VWF) and blood cells, affecting characteristics of forming blood clots. The interactions between coagulation and inflammation have mainly been studied in thrombosis models, but it remains unclear whether these interactions might also play a role in reduced bleeding in patients with bleeding disorders. In this systematic review, we provide an overview of the literature investigating the interactions between VWF and blood cells in flow models. For article selection, a systematic search was performed in Embase, Medline-Ovid, Cochrane Library, Web of Science databases, and Google Scholar. After selection, 24 articles were included. These articles describe direct or platelet-dependent interactions between VWF and neutrophils, monocytes, erythrocytes, or lymphocytes under different flow conditions. Almost all the described interactions required the presence of activated platelets. Only erythrocytes, monocytes, and natural killer cells were capable of directly binding the VWF multimers. Overall, interactions between VWF and blood cells mainly occurred in the presence of platelets. Because of the large variation in study design and used flow rates, further research is necessary to compare the results between studies and draw firm conclusions on when and under what conditions these interactions can occur. After our findings, many questions remained unanswered. This review might provide a starting point for future research. Extended knowledge on the influence of blood flow on VWF and blood cell interactions can contribute to improved understanding of the variation in bleeding in patients with bleeding disorders.
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Affiliation(s)
- Ryanne A. Arisz
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Judith J. de Vries
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Saskia E. M. Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
- Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands; and
| | - Jeroen C. J. Eikenboom
- Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Moniek P. M. de Maat,
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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18
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Okoye HC, Ezekekwu C, Nwagha TU, Korubo K, Omunakwe HE, Nnachi OC, Madu AJ, Nwogoh B, Efobi CC, Muoghalu EA, Nonyelu C, Okoye AE, Obodo OI, Ugwu CS, Egolum MC, Nnachi OA, Okpala I. Prevalence of venous thromboembolism and its associations in a large racially homogenous population of sickle cell disease patients. Eur J Haematol Suppl 2022; 109:321-326. [PMID: 35687045 DOI: 10.1111/ejh.13811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/26/2022] [Accepted: 05/30/2022] [Indexed: 11/30/2022]
Abstract
To determine the prevalence of venous thromboembolism (VTE) among adult sickle cell disease (SCD) patients in Nigeria. METHODS This was a multicentre retrospective study in which the medical records of adult SCD patients were reviewed. Information on demographics, steady-state haemogram, clinical phenotypes, duration of follow-up, history of VTE including risk factors and management was collected. RESULTS Of the 509 SCD patients with a median (IQR) duration of follow-up of 2 years, 10 (2.0%) had VTE (9 DVT and 1 PE). Their median (IQR) age was 27 (22.8-30.3) years. Identifiable risk factors for VTE included positive family history (2, 20%) surgery, splenectomy, paraplegia and cancer (1, 10% each). No risk factor was identifiable in four persons. VTE had no significant association with age and gender. VTE was significantly associated with the following events: acute chest syndrome [p = .002, odds ratio (OR) 8, 95% CI 2.2-28.9], osteonecrosis [p = .012, OR 5.24, 95% CI, 1.45-18.91] and vaso-occlusive crisis [p = .035]. Also significantly associated with VTE were pulmonary hypertension [p = .001, OR 23.3, 95%CI 5.18-105.06] and stroke [p = .032, OR 9.35, 95%CI 0.87-53.25]. CONCLUSION The prevalence of VTE among SCD patients in Nigeria is low. It is significantly associated with vaso-occlusive crisis, pulmonary hypertension and stroke.
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Affiliation(s)
- Helen Chioma Okoye
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Chinedu Ezekekwu
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Theresa Ukamaka Nwagha
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Kaladada Korubo
- Department of Haematology and Blood Transfusion, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
| | - Hannah E Omunakwe
- Department of Haematology, Rivers State University Teaching Hospital, Port Harcourt, Nigeria
| | - Oluomachi Charity Nnachi
- Department of Haematology and Blood Transfusion, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
| | - Anazoeze Jude Madu
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Benedict Nwogoh
- Department of Haematology, University of Benin Teaching Hospital, Benin City, Nigeria
| | - Chilota Chibuife Efobi
- Department of Haematology and Blood Transfusion, College of Health Sciences, Nnamdi Azikiwe University, Nnewi, Nigeria
| | - Ebele Adaobi Muoghalu
- Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Charles Nonyelu
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Augustine E Okoye
- Department of Haematology and Blood Transfusion, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
| | - Onochie Ikenna Obodo
- Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Chioma Sandra Ugwu
- Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Michael C Egolum
- Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Oji Anya Nnachi
- Department of Haematology and Blood Transfusion, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
| | - Iheanyi Okpala
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Haematology and Immunology, University of Nigeria Teaching Hospital, Enugu, Nigeria
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19
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Niazi MRK, Chukkalore D, Jahangir A, Sahra S, Macdougall K, Rehan M, Odaimi M. Management of acute chest syndrome in patients with sickle cell disease: a systematic review of randomized clinical trials. Expert Rev Hematol 2022; 15:547-558. [PMID: 35666654 DOI: 10.1080/17474086.2022.2085089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Acute chest syndrome (ACS) accounts for the highest mortality in Sickle cell disease patients. Early diagnosis and timely management of ACS results in better outcomes. However, the effectiveness of most treatment modalities for ACS management has not been established. AREAS COVERED To review the treatment modalities management protocols and highlight the effectiveness of each option a literature search was done. Randomized controlled trials that assessed the efficacy of different treatment modalities in ACS management in SCD patients were chosen and reviewed. EXPERT OPINION 11 randomized controlled trials were found that evaluated the efficacy of incentive spirometry, positive expiratory pressure device, intravenous dexamethasone, oral vs. intravenous morphine, inhaled nitric oxide, unfractionated heparin, and blood transfusion in the prevention or treatment of ACS. Although there are guidelines for ACS treatment, the available evidence is very limited to delineating the effectiveness of various interventions in ACS management. More high-quality studies and trials with a larger patient population can benefit this area to support the recommendations with stronger evidence.
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Affiliation(s)
- Muhammad Rafay Khan Niazi
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Divya Chukkalore
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Abdullah Jahangir
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Syeda Sahra
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Kira Macdougall
- Department of Hematology and Medical Oncology, Oklahoma University of Health and Science, Oklahoma, OK, USA
| | - Maryam Rehan
- Department of Hematology and Medical Oncology, Staten Island University Hospital/Northwell Health, New York, NY, USA
| | - Marcel Odaimi
- Department of Hematology and Medical Oncology, Staten Island University Hospital/Northwell Health, New York, NY, USA
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20
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Ilonze C, Anderson M, Stubblefield A, Journeycake J, Sinha AA. Use of infusion ports in patients with sickle cell disease: Indications and complications. Pediatr Blood Cancer 2022; 69:e29445. [PMID: 34786823 DOI: 10.1002/pbc.29445] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/27/2021] [Accepted: 10/15/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Peripheral venous access in patients with sickle cell disease (SCD) can become difficult over time due to frequent access and scarring. Infusion ports provide reliable central venous access. Deep venous thrombosis (DVT) and infections are complications associated with SCD and infusion ports. METHODS We performed a 17.5-year single-institution retrospective chart review (January 2000 to July 2018) with literature review regarding use of infusion ports in patients with SCD. RESULTS We identified 32 patients with infusion ports placed for a total of 63 devices (48 for chronic transfusion [CT] and 15 for poor venous access [PVA], not on CT) for a total of 99,272 catheter days. The mean age at first insertion was 8 years (range 1-20 years). Complications included malfunction, infection, thrombosis, difficult access, and pain over infusion port site. The rate of infection was 0.2 per 1000 catheter days. Thrombosis was identified in three devices (5%) in three patients (9%), with a rate of 0.03 per 1000 catheter days. There was no difference in complications by site in either the left or right subclavian vein (p = 1). The rate of premature removal was 0.36 per 1000 catheter days, which was higher among patients with infusion ports solely for PVA (0.87 per 1000 catheter days) compared with those placed for CT (0.29 per 1000 catheter days). CONCLUSION Infusion ports in patients with SCD was associated with low rates of thrombosis, infection, and malfunction, and may be considered as an alternative to frequent intravenous access, especially in patients requiring CT.
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Affiliation(s)
- Chibuzo Ilonze
- Division of Pediatric Hematology Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Jimmy Everest Section of Pediatric Hematology Oncology, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Michael Anderson
- Department of Epidemiology & Biostatistics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Alex Stubblefield
- Department of Epidemiology & Biostatistics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.,Department of Economics, Michigan State University, East Lansing, Michigan, USA
| | - Janna Journeycake
- Jimmy Everest Section of Pediatric Hematology Oncology, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Arpan A Sinha
- Jimmy Everest Section of Pediatric Hematology Oncology, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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21
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Kingsley A, Ofonime E, Edakabasi A. ADAMTS13 levels in sickle cell anaemia: is there a change between steady-state and vaso-occlusive crisis? THE EGYPTIAN JOURNAL OF HAEMATOLOGY 2022. [DOI: 10.4103/ejh.ejh_24_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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22
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Kingsley A, Ofonime E, Enobong U, Iquo I. Determination of the level of von willebrand factor and ADAMTS13 in sickle cell anaemia patients in steady state. Niger J Clin Pract 2022; 25:1393-1397. [DOI: 10.4103/njcp.njcp_110_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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23
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Rozi W, Ali EAH, Al-Mashdali AF, Abdelrazek M, Yassin MA. Use of rivaroxaban in sickle cell disease and venous thromboembolism: A case report. Medicine (Baltimore) 2021; 100:e27988. [PMID: 34941038 PMCID: PMC8702265 DOI: 10.1097/md.0000000000027988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/07/2021] [Accepted: 11/11/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Sickle cell disease (SCD) is a hematological disorder characterized by sickling of red blood cells. Patients are at increased risk of venous thromboembolism. There are no guidelines for the management of venous thromboembolism in sickle cell disease specifically in terms of the anticoagulant of choice. PATIENT CONCERNS Here, we report a case of a 30-year-old lady with past medical history of sickle cell disease who came with chest pain and shortness of breath. DIAGNOSIS We found that she has bilateral pulmonary embolism (PE). INTERVENTION She was started on rivaroxaban. OUTCOME The patient was followed for 18 months, she did not suffer from recurrence of PE, and she did not develop any complications related to rivaroxaban. CONCLUSION We concluded that rivaroxaban is effective in treating PE in sicklers and also it is safe.
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Affiliation(s)
- Waail Rozi
- Internal Medicine, Hamad Medical Corporation, Doha, Qatar
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24
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Cook O, Cervi A, Laureano M, Gangji AS, Verhovsek M. Combined preoperative plasma exchange and red blood cell exchange transfusion in a renal transplant patient with protein S deficiency and hemoglobin SC disease. Transfus Apher Sci 2021; 61:103345. [DOI: 10.1016/j.transci.2021.103345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 11/30/2021] [Accepted: 12/13/2021] [Indexed: 10/19/2022]
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25
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Delicou S, Aggeli K, Magganas K, Patsourakos D, Xydaki A, Koskinas J. Acute Chest Syndrome in Sickle Cell Disease: Clinical Presentation and Outcomes. The Experience of a Single Thalassemia and Sickle Cell Unit in a University Hospital. Hemoglobin 2021; 45:303-308. [PMID: 34814798 DOI: 10.1080/03630269.2021.2006690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Acute chest syndrome (ACS) is a common cause of death for sickle cell disease patients. This syndrome is defined as: respiratory symptoms, new X-ray findings developed and/or fever; ACS requires prompt treatment to avoid clinical deterioration and death in adults with sickle cell disease. Sixteen episodes of acute chest syndrome were studied in 16 adults with sickle cell disease. The clinical and radiological findings, treatment, response and outcome of the episode were evaluated respectively. The patient's past history and comorbidities were taken into account in the outcome and days of hospitalization. Fourteen patients recovered with no sequelae; one patient who required mechanical ventilation also recovered; one patient died due to pulmonary emboli. The mean hospitalization days were 7.43.
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Affiliation(s)
- Sophia Delicou
- Thalassemia and Sickle Cell Unit, Hippocration General Hospital, Athens, Greece
| | - Konstantina Aggeli
- First Department of Cardiology, National and Kapodistrian University of Athens School of Medicine, Athens, Greece.,First Department of Cardiology, Hippocration General Hospital Athens, University of Athens, Athens, Greece
| | | | | | - Aikaterini Xydaki
- Thalassemia and Sickle Cell Unit, Hippocration General Hospital, Athens, Greece
| | - John Koskinas
- Second Department of Internal Medicine, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
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26
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Martins SR, Toledo SLDO, da Silva AJ, Mendes FS, de Oliveira MM, Ferreira LGR, Dusse LMS, Carvalho MDG, Rios DRA, Alpoim PN, Pinheiro MDB. Endothelial dysfunction biomarkers in sickle cell disease: is there a role for ADMA and PAI-1? Ann Hematol 2021; 101:273-280. [PMID: 34665295 DOI: 10.1007/s00277-021-04695-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 10/10/2021] [Indexed: 01/26/2023]
Abstract
Within the spectrum of sickle cell disease (SCD) are sickle cell anemia (SCA), presence of hemoglobin SS (HbSS), hemoglobin SC disease (HbSC), and sickle cell β-thalassemia (Sβ-thal). Asymmetric dimethylarginine (ADMA) competitively inhibits the binding of arginine to NOS, reducing NO production. In patients with HbSS, increased levels of ADMA have been reported, as well as changes in many hemostatic biomarkers, including the plasminogen activator inhibitor type 1 (PAI-1). We hypothesized that high levels of ADMA and PAI-1 may be associated with more severe SCD. Thus, ADMA and PAI-1 levels were determined in 78 individuals including 38 adult patients with SCD and 40 control subjects. Higher levels of ADMA were shown in HbSS and Sβ-thal patients compared to controls. Concerning PAI-1, all patients showed high levels of PAI-1 compared to controls. As a role of NO in the pathogenesis of SCD has already been established, we concluded that high levels of ADMA should compromise, at least in part, NO synthesis, resulting in endothelial dysfunction. Elevated plasma levels of PAI-1 in all patients may indicate not only endothelial dysfunction but also a hypofibrinolytic state favoring thrombotic complications. Finally, high levels of ADMA and PAI-1 may be associated with more severe SCD.
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Affiliation(s)
- Suellen Rodrigues Martins
- Department of Clinical and Toxicological Analysis, Faculty of Pharmacy, Federal University of Minas Gerais, Avenida Antonio Carlos, 6627, Pampulha, Belo Horizonte, Minas Gerais, 31270901, Brazil
| | - Sílvia Letícia de Oliveira Toledo
- Federal University of São João del-Rei (UFSJ), Campus Centro-Oeste Dona Lindu, Sebastião Gonçalves Coelho Street, 400, Building: D, Room: 308.1, ChanadourDivinópolis, MG, 35501-296, Brazil
| | - Aislander Junio da Silva
- Department of Clinical and Toxicological Analysis, Faculty of Pharmacy, Federal University of Minas Gerais, Avenida Antonio Carlos, 6627, Pampulha, Belo Horizonte, Minas Gerais, 31270901, Brazil
| | - Fernanda Santos Mendes
- Department of Clinical and Toxicological Analysis, Faculty of Pharmacy, Federal University of Minas Gerais, Avenida Antonio Carlos, 6627, Pampulha, Belo Horizonte, Minas Gerais, 31270901, Brazil
| | - Marina Mendes de Oliveira
- Federal University of São João del-Rei (UFSJ), Campus Centro-Oeste Dona Lindu, Sebastião Gonçalves Coelho Street, 400, Building: D, Room: 308.1, ChanadourDivinópolis, MG, 35501-296, Brazil.,Fundação Centro de Hematologia E Hemoterapia Do Estado de Minas Gerais, (Hemominas), Divinópolis, MG, Brazil
| | - Leticia Gonçalves Resende Ferreira
- Federal University of São João del-Rei (UFSJ), Campus Centro-Oeste Dona Lindu, Sebastião Gonçalves Coelho Street, 400, Building: D, Room: 308.1, ChanadourDivinópolis, MG, 35501-296, Brazil
| | - Luci Maria Sant'Ana Dusse
- Department of Clinical and Toxicological Analysis, Faculty of Pharmacy, Federal University of Minas Gerais, Avenida Antonio Carlos, 6627, Pampulha, Belo Horizonte, Minas Gerais, 31270901, Brazil
| | - Maria das Graças Carvalho
- Department of Clinical and Toxicological Analysis, Faculty of Pharmacy, Federal University of Minas Gerais, Avenida Antonio Carlos, 6627, Pampulha, Belo Horizonte, Minas Gerais, 31270901, Brazil.,Federal University of São João del-Rei (UFSJ), Campus Centro-Oeste Dona Lindu, Sebastião Gonçalves Coelho Street, 400, Building: D, Room: 308.1, ChanadourDivinópolis, MG, 35501-296, Brazil
| | - Danyelle Romana Alves Rios
- Federal University of São João del-Rei (UFSJ), Campus Centro-Oeste Dona Lindu, Sebastião Gonçalves Coelho Street, 400, Building: D, Room: 308.1, ChanadourDivinópolis, MG, 35501-296, Brazil
| | - Patrícia Nessralla Alpoim
- Department of Clinical and Toxicological Analysis, Faculty of Pharmacy, Federal University of Minas Gerais, Avenida Antonio Carlos, 6627, Pampulha, Belo Horizonte, Minas Gerais, 31270901, Brazil.
| | - Melina de Barros Pinheiro
- Federal University of São João del-Rei (UFSJ), Campus Centro-Oeste Dona Lindu, Sebastião Gonçalves Coelho Street, 400, Building: D, Room: 308.1, ChanadourDivinópolis, MG, 35501-296, Brazil.
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27
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Wang Q, Zennadi R. The Role of RBC Oxidative Stress in Sickle Cell Disease: From the Molecular Basis to Pathologic Implications. Antioxidants (Basel) 2021; 10:antiox10101608. [PMID: 34679742 PMCID: PMC8533084 DOI: 10.3390/antiox10101608] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 01/14/2023] Open
Abstract
Sickle cell disease (SCD) is an inherited monogenic disorder and the most common severe hemoglobinopathy in the world. SCD is characterized by a point mutation in the β-globin gene, which results in hemoglobin (Hb) S production, leading to a variety of mechanistic and phenotypic changes within the sickle red blood cell (RBC). In SCD, the sickle RBCs are the root cause of the disease and they are a primary source of oxidative stress since sickle RBC redox state is compromised due to an imbalance between prooxidants and antioxidants. This imbalance in redox state is a result of a continuous production of reactive oxygen species (ROS) within the sickle RBC caused by the constant endogenous Hb autoxidation and NADPH oxidase activation, as well as by a deficiency in the antioxidant defense system. Accumulation of non-neutralized ROS within the sickle RBCs affects RBC membrane structure and function, leading to membrane integrity deficiency, low deformability, phosphatidylserine exposure, and release of micro-vesicles. These oxidative stress-associated RBC phenotypic modifications consequently evoke a myriad of physiological changes involved in multi-system manifestations. Thus, RBC oxidative stress in SCD can ultimately instigate major processes involved in organ damage. The critical role of the sickle RBC ROS production and its regulation in SCD pathophysiology are discussed here.
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28
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Nader E, Garnier Y, Connes P, Romana M. Extracellular Vesicles in Sickle Cell Disease: Plasma Concentration, Blood Cell Types Origin Distribution and Biological Properties. Front Med (Lausanne) 2021; 8:728693. [PMID: 34490315 PMCID: PMC8417591 DOI: 10.3389/fmed.2021.728693] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/30/2021] [Indexed: 01/08/2023] Open
Abstract
Prototype of monogenic disorder, sickle cell disease (SCD) is caused by a unique single mutation in the β-globin gene, leading to the production of the abnormal hemoglobin S (HbS). HbS polymerization in deoxygenated condition induces the sickling of red blood cells (RBCs), which become less deformable and more fragile, and thus prone to lysis. In addition to anemia, SCD patients may exhibit a plethora of clinical manifestations ranging from acute complications such as the frequent and debilitating painful vaso-occlusive crisis to chronic end organ damages. Several interrelated pathophysiological processes have been described, including impaired blood rheology, increased blood cell adhesion, coagulation, inflammation and enhanced oxidative stress among others. During the last two decades, it has been shown that extracellular vesicles (EVs), defined as cell-derived anucleated particles delimited by a lipid bilayer, and comprising small EVs (sEVs) and medium/large EVs (m/lEVs); are not only biomarkers but also subcellular actors in SCD pathophysiology. Plasma concentration of m/lEVs, originated mainly from RBCs and platelets (PLTs) but also from the other blood cell types, is higher in SCD patients than in healthy controls. The concentration and the density of externalized phosphatidylserine of those released from RBCs may vary according to clinical status (crisis vs. steady state) and treatment (hydroxyurea). Besides their procoagulant properties initially described, RBC-m/lEVs may promote inflammation through their effects on monocytes/macrophages and endothelial cells. Although less intensely studied, sEVs plasma concentration is increased in SCD and these EVs may cause endothelial damages. In addition, sEVs released from activated PLTs trigger PLT-neutrophil aggregation involved in lung vaso-occlusion in sickle mice. Altogether, these data clearly indicate that EVs are both biomarkers and bio-effectors in SCD, which deserve further studies.
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Affiliation(s)
- Elie Nader
- Laboratoire Inter-Universitaire de Biologie de la Motricité EA7424, Team "Vascular Biology and Red Blood Cell", Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France.,Laboratoire d'Excellence du Globule Rouge, PRES Sorbonne, Paris, France
| | - Yohann Garnier
- Laboratoire d'Excellence du Globule Rouge, 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 Inter-Universitaire de Biologie de la Motricité EA7424, Team "Vascular Biology and Red Blood Cell", Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France.,Laboratoire d'Excellence du Globule Rouge, PRES Sorbonne, Paris, France
| | - Marc Romana
- Laboratoire d'Excellence du Globule Rouge, PRES Sorbonne, Paris, France.,Université des Antilles, UMR_S1134, BIGR, Pointe-à-Pitre, France.,Université de Paris, UMR_S1134, BIGR, INSERM, Paris, France
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29
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Clinical, laboratory, and genetic risk factors for thrombosis in sickle cell disease. Blood Adv 2021; 4:1978-1986. [PMID: 32384541 DOI: 10.1182/bloodadvances.2019001384] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/31/2020] [Indexed: 12/15/2022] Open
Abstract
Sickle cell disease (SCD) patients are at a four- to 100-fold increased risk for thrombosis compared with the general population, although the mechanisms and risk factors are not clear. We investigated the incidence and predictors for thrombosis in a retrospective, longitudinal cohort of 1193 pediatric and adult SCD patients treated at our institution between January 2008 and December 2017. SCD diagnosis and thrombotic complications were identified using International Classification of Diseases coding and verified through medical chart review. Clinical and laboratory data were extracted from the medical records. With a median follow-up of 6.4 years, 208 (17.4%) SCD patients experienced 352 thrombotic events (64 strokes, 288 venous thromboembolisms [VTE]). Risk factors for stroke included older age and HbSS/Sβ0-genotype and a lower hemoglobin (Hb) F% in the subset of HbSS/Sβ0-genotype patients (P < .05). VTE risk was independently associated with lower estimated glomerular filtration rate, hydroxyurea (HU) use, HbSS/Sβ0 genotype, and higher white blood cell (WBC) counts and Hb (P ≤ .03). Two thrombomodulin gene variants previously associated with thrombosis in the general African American population, THBD rs2567617 (minor allele frequency [MAF] 0.25; odds ratio [OR], 1.5; P = .049) and THBD rs1998081 (MAF, 0.24; OR, 1.5; P = .059), were associated with thrombosis in this cohort. In summary, thrombotic complications are common, and several traditional and SCD-specific risk factors are associated with thrombotic risk. Future studies integrating clinical, laboratory, and genetic risk factors may improve our understanding of thrombosis and guide intervention practices in SCD.
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30
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Conran N, Embury SH. Sickle cell vaso-occlusion: The dialectic between red cells and white cells. Exp Biol Med (Maywood) 2021; 246:1458-1472. [PMID: 33794696 DOI: 10.1177/15353702211005392] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The pathophysiology of sickle cell anemia, a hereditary hemoglobinopathy, has fascinated clinicians and scientists alike since its description over 100 years ago. A single gene mutation in the HBB gene results in the production of abnormal hemoglobin (Hb) S, whose polymerization when deoxygenated alters the physiochemical properties of red blood cells, in turn triggering pan-cellular activation and pathological mechanisms that include hemolysis, vaso-occlusion, and ischemia-reperfusion to result in the varied and severe complications of the disease. Now widely regarded as an inflammatory disease, in recent years attention has included the role of leukocytes in vaso-occlusive processes in view of the part that these cells play in innate immune processes, their inherent ability to adhere to the endothelium when activated, and their sheer physical and potentially obstructive size. Here, we consider the role of sickle red blood cell populations in elucidating the importance of adhesion vis-a-vis polymerization in vaso-occlusion, review the direct adhesion of sickle red cells to the endothelium in vaso-occlusive processes, and discuss how red cell- and leukocyte-centered mechanisms are not mutually exclusive. Given the initial clinical success of crizanlizumab, a specific anti-P selectin therapy, we suggest that it is appropriate to take a holistic approach to understanding and exploring the complexity of vaso-occlusive mechanisms and the adhesive roles of the varied cell types, including endothelial cells, platelets, leukocytes, and red blood cells.
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Affiliation(s)
- Nicola Conran
- Hematology Center, University of Campinas-UNICAMP, Barão Geraldo 13083-8, Campinas, SP, Brazil
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31
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Abdulmalik O, Darwish NHE, Muralidharan-Chari V, Taleb MA, Mousa SA. Sulfated non-anticoagulant heparin derivative modifies intracellular hemoglobin, inhibits cell sickling in vitro, and prolongs survival of sickle cell mice under hypoxia. Haematologica 2021; 107:532-540. [PMID: 33567814 PMCID: PMC8804574 DOI: 10.3324/haematol.2020.272393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Indexed: 11/09/2022] Open
Abstract
Sickle cell disease (SCD) is an autosomal recessive genetic disease caused by a single point mutation, resulting in abnormal sickle hemoglobin (HbS). During hypoxia or dehydration, HbS polymerizes to form insoluble aggregates and induces sickling of red blood cells, which increases the adhesiveness of the cells, thereby altering the rheological properties of the blood, and triggers inflammatory responses, leading to hemolysis and vaso-occlusive crises. Unfractionated heparin and low-molecular weight heparins have been suggested as treatments to relieve coagulation complications in SCD. However, they are associated with bleeding complications after repeated dosing. An alternative sulfated non-anticoagulant heparin derivative (S-NACH) was previously reported to have no to low systemic anticoagulant activity and no bleeding side effects, and it interfered with P-selectin-dependent binding of sickle cells to endothelial cells, with concomitant decrease in the levels of adhesion biomarkers in SCD mice. S-NACH has been further engineered and structurally enhanced to bind with and modify HbS to inhibit sickling directly, thus employing a multimodal approach. Here, we show that S-NACH can: (i) directly engage in Schiff-base reactions with HbS to decrease red blood cell sickling under both normoxia and hypoxia in vitro, (ii) prolong the survival of SCD mice under hypoxia, and (iii) regulate the altered steady state levels of pro- and anti-inflammatory cytokines. Thus, our proof-of-concept, in vitro and in vivo preclinical studies demonstrate that the multimodal S-NACH is a highly promising candidate for development into an improved and optimized alternative to low-molecular weight heparins for the treatment of patients with SCD.
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Affiliation(s)
- Osheiza Abdulmalik
- Division of Hematology, the Children's Hospital of Philadelphia, Philadelphia, PA
| | - Noureldien H E Darwish
- The Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, Rensselaer, NY, USA; Clinical Pathology (Hematology Section), Faculty of Medicine, Mansoura University, Mansoura
| | | | - Maii Abu Taleb
- The Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, Rensselaer, NY
| | - Shaker A Mousa
- The Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, Rensselaer, NY, USA; Vascular Vison Pharmaceuticals Co., 7 University Place, Rensselaer, NY.
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32
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Kasinathan S, Mohammad Ashraf H, Minkowitz S, Adeyinka A, Bailey-Correa K. COVID-19 Infection and Acute Pulmonary Embolism in an Adolescent Female With Sickle Cell Disease. Cureus 2020; 12:e12348. [PMID: 33520543 PMCID: PMC7840446 DOI: 10.7759/cureus.12348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/28/2020] [Indexed: 12/24/2022] Open
Abstract
A previously healthy 20-year-old female presented to the emergency room in April 2020 with complaints of shortness of breath, chest pain, and cough. She was diagnosed with coronavirus disease 2019 (COVID-19) infection and pulmonary embolism (PE). Workup for anemia led to the diagnosis of sickle cell disease (SCD). Patients diagnosed with COVID-19 are at an increased risk for the development of PE and venous thromboembolism (VTE). Anticoagulation prophylaxis and escalation to treatment dosing are recommended in patients admitted with moderate to severe symptoms of COVID-19. PE and VTE are relatively uncommon in the pediatric and adolescent population. Most commonly, patients are diagnosed with thrombophilia or have an underlying hypercoagulable state such as with SCD. Also, symptoms of COVID-19 infection, acute chest syndrome (ACS), and PE can have overlapping features. In this report, we present a case of a late adolescent female with SCD, who was diagnosed with COVID-19, and whose condition was complicated with PE.
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33
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Sackey D, Dei-Adomakoh Y, Olayemi E. Enhanced Hypercoagulability in Sickle Cell Anaemia Patients with Chronic Leg Ulcers. Adv Hematol 2020; 2020:5157031. [PMID: 33299420 PMCID: PMC7704197 DOI: 10.1155/2020/5157031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 11/18/2022] Open
Abstract
Sickle Cell Anaemia (SCA) is associated with a hypercoagulable state resulting in a predisposition to venous thromboembolism. With improvements in the quality of care, more patients with SCA survive into adulthood with an associated increase in the frequency of end-organ damage and chronic complications such as chronic leg ulcers (CLUs). These ulcers rarely occur in the first decade of life and are recurrent, painful, and slow-to-heal. This study tested the hypothesis that coagulation is enhanced in SCA patients with CLU. 145 participants (50 SCA with CLU, 50 SCA without CLU, and 45 with haemoglobin AA) were assessed to determine their coagulation profile using selected tests of coagulation. The SCA with the CLU group had the lowest mean haemoglobin (Hb) concentration. SCA patients with and without CLUs had elevated mean platelet counts, shorter mean aPTT, and marginally prolonged mean PT compared to HbAA patients. SCA with CLUs patients had a significantly shortened aPTT than those without CLUs (p = 0.035) and HbAA (p = 0.009). There were significant differences in the mean PT between SCA with CLUs patients and HbAA (p = 0.017); SCA without CLU and HbAA (p = 0.014). SCA with and without CLUs patients had higher mean D-dimer levels compared to HbAA. There was a negative correlation between Hb concentration and duration of CLU (r = -0.331, p = 0.021). In conclusion, our study demonstrates a heightened hypercoagulability in SCA patients with CLUs. We did not test for platelet activation, and it is not clear what role, if any, the enhanced hypercoagulability plays in the pathogenesis of CLUs in SCA. It will be useful to ascertain if antiplatelet agents or/and anticoagulants quicken the healing of CLUs in SCA patients.
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Affiliation(s)
- David Sackey
- Haematology Unit, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | - Edeghonghon Olayemi
- Department of Haematology, University of Ghana Medical School, Accra, Ghana
- Ghana Institute of Clinical Genetics, Korle Bu, Accra, Ghana
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34
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Seaman CD, Novelli E, De Castro L, Ragni MV. Unfractionated heparin in acute chest syndrome: a pilot feasibility randomized controlled trial of unfractionated heparin vs. standard of care in acute chest syndrome. Pilot Feasibility Stud 2020; 6:174. [PMID: 33292674 PMCID: PMC7654047 DOI: 10.1186/s40814-020-00715-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/27/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Acute chest syndrome (ACS) is the leading cause of mortality in sickle cell disease (SCD). The pathogenesis of ACS is complex and not entirely understood with multiple etiologies likely contributing simultaneously. One particular etiology is pulmonary vascular occlusion due to thrombosis. Thus, anticoagulation is an attractive therapeutic modality. METHODS This was a single-center, randomized controlled, open-label, pilot study to determine the feasibility of performing a larger multicenter phase III trial to assess the effects of unfractionated heparin (UFH) in ACS. Subjects were randomized within 24 h of diagnosis of ACS to one of two treatment arms, UFH, and standard of care (SOC), or no UFH and SOC. UFH was given intravenously for 7 days, or until discharge, if discharge was shorter than 7 days. SOC consisted of intravenous fluids, antibiotics, supplemental oxygen, analgesia, red blood cell transfusion, and exchange transfusion. RESULTS From July 2014 to June 2018, a total of 7 patients underwent randomization (four patients received UFH in addition to SOC and 3 patients received SOC only). Two of the prespecified feasibility criteria were not met: the capacity to consent eligible individuals and the timely notification of hospitalized patients with ACS necessary to permit randomization within 24 h of diagnosis; thus, as a result of poor enrollment, the study was terminated early. The duration of hospitalization was 279.43 (SD 267.98) and 127.31 (SD 137.70) h in the UFH and SOC arms, respectively. The duration of hypoxemia, leukocytosis, fever, and moderate to severe pain was 117.52 (SD 60.52), 24.90 (SD 29.69), 117.52 (SD 60.52), and 117.52 (SD 60.52) h, respectively, in the UFH group, and 51.49 (SD 44.79), 0, 53.11 (SD 25.06), and 88.68 (SD 72.77) h, respectively, in the SOC group. No major bleeding was noted in either group. CONCLUSIONS Our study did not achieve prespecified feasibility criteria, resulting in poor enrollment and early termination, and serves to highlight some of the pitfalls experienced in clinical research in SCD. It did show the use of UFH without any major adverse events in 7 subjects. No future large-scale study is planned. TRIALS REGISTRATION Registered at ClinicalTrials.gov (NCT #02098993) on March 28, 2014.
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Affiliation(s)
- Craig D Seaman
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. .,Hemophilia Center of Western Pennsylvania, 3636 Boulevard of the Allies, Pittsburgh, PA, USA.
| | - Enrico Novelli
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Laura De Castro
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Margaret V Ragni
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Hemophilia Center of Western Pennsylvania, 3636 Boulevard of the Allies, Pittsburgh, PA, USA
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35
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Ladeira VS, de Oliveira Toledo SL, Ferreira LGR, Oliveira MM, Silva APF, de Oliveira WV, Duarte RCF, Renó CDO, Dusse LMS, Dos Santos HL, Carvalho MDG, Pinheiro MDB, Rios DRA. Thrombin generation in vivo and ex vivo in sickle cell disease patients. Thromb Res 2020; 197:165-171. [PMID: 33221576 DOI: 10.1016/j.thromres.2020.10.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/26/2020] [Accepted: 10/29/2020] [Indexed: 12/18/2022]
Abstract
Activation of coagulation is an important hallmark of sickle cell disease (SCD) and it is believed that hypercoagulability plays a role to the disease pathophysiology. Studies have sought to identify how hemostatic biomarkers are expressed in SCD, however, the results are inconclusive. In this context, our objective was to evaluate the thrombin generation in vivo and ex vivo in SCD patients and the association between these biomarkers and the use of HU. This cross-sectional study was carried out with patients diagnosed with SCD, users or not of Hydroxyurea (HU), and healthy individuals as controls. D dimer (D-Di) was evaluated by ELISA and (TGT) thrombin generation test by CAT method. D-Di plasma levels were significantly higher in SCD patients when compared to the controls. TGT parameters such as peak, ETP and normalized ETP at low TF concentration and time-to-peak, peak, ETP and normalized ETP values at high TF concentration were lower in SCD patients than in controls. In contrast, the normalized activated protein C sensitivity ratio (nAPCsr) was higher in patients compared to controls, indicating resistance to the action of this natural anticoagulant. Regarding the use of HU, comparing users and non-users of this drug, no difference was observed in D-Di levels and in most TGT parameters. Our data analyzed together allow us to conclude that patients with SCD present a state of hypercoagulability in vivo due to the higher levels of D-Di and resistance to APC assessed ex vivo which is consistent with the coagulation imbalance described in SCD patients.
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Affiliation(s)
- Valéria Sutana Ladeira
- Universidade Federal de São João del-Rei, Campus Centro Oeste Dona Lindu, Brazil; Fundação Hemominas, Minas Gerais, Brazil
| | | | | | - Marina Mendes Oliveira
- Universidade Federal de São João del-Rei, Campus Centro Oeste Dona Lindu, Brazil; Fundação Hemominas, Minas Gerais, Brazil
| | | | | | | | | | | | | | - Maria das Graças Carvalho
- Universidade Federal de São João del-Rei, Campus Centro Oeste Dona Lindu, Brazil; Faculdade de Farmácia, Universidade Federal de Minas Gerais, Brazil
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36
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Conran N, De Paula EV. Thromboinflammatory mechanisms in sickle cell disease - challenging the hemostatic balance. Haematologica 2020; 105:2380-2390. [PMID: 33054078 PMCID: PMC7556678 DOI: 10.3324/haematol.2019.239343] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/19/2020] [Indexed: 11/11/2022] Open
Abstract
Sickle cell disease (SCD) is an inherited hemoglobinopathy that is caused by the presence of abnormal hemoglobin S (HbS) in red blood cells, leading to alterations in red cell properties and shape, as the result of HbS dexoygenation and subsequent polymerization. SCD pathophysiology is characterized by chronic inflammatory processes, triggered by hemolytic and vaso-occlusive events, which lead to the varied complications, organ damage and elevated mortality seen in individuals with the disease. In association with activation of the endothelium and leukocytes, hemostatic alterations and thrombotic events are well-documented in SCD. Here we discuss the role for inflammatory pathways in modulating coagulation and inducing platelet activation in SCD, due to tissue factor activation, adhesion molecule expression, inflammatory mediator production and the induction of innate immune responses, amongst other mechanisms. Thromboinflammatory pathways may play a significant role in some of the major complications of SCD, such as stroke, venous thromboembolism and possibly acute chest syndrome, besides exacerbating the chronic inflammation and cellular interactions that trigger vaso-occlusion, ischemia-reperfusion processes, and eventually organ damage.
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Affiliation(s)
- Nicola Conran
- Hematology Center, University of Campinas, UNICAMP, Cidade Universitária, Campinas-SP, Brazil
| | - Erich V. De Paula
- Hematology Center, University of Campinas, UNICAMP, Cidade Universitária, Campinas-SP, Brazil
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Sparkenbaugh EM, Kasztan M, Henderson MW, Ellsworth P, Davis PR, Wilson KJ, Reeves B, Key NS, Strickland S, McCrae K, Pollock DM, Pawlinski R. High molecular weight kininogen contributes to early mortality and kidney dysfunction in a mouse model of sickle cell disease. J Thromb Haemost 2020; 18:2329-2340. [PMID: 32573897 PMCID: PMC8043232 DOI: 10.1111/jth.14972] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Sickle cell disease (SCD) is characterized by chronic hemolytic anemia, vaso-occlusive crises, chronic inflammation, and activation of coagulation. The clinical complications such as painful crisis, stroke, pulmonary hypertension, nephropathy and venous thromboembolism lead to cumulative organ damage and premature death. High molecular weight kininogen (HK) is a central cofactor for the kallikrein-kinin and intrinsic coagulation pathways, which contributes to both coagulation and inflammation. OBJECTIVE We hypothesize that HK contributes to the hypercoagulable and pro-inflammatory state that causes end-organ damage and early mortality in sickle mice. METHODS We evaluated the role of HK in the Townes mouse model of SCD. RESULTS/CONCLUSIONS We found elevated plasma levels of cleaved HK in sickle patients compared to healthy controls, suggesting ongoing HK activation in SCD. We used bone marrow transplantation to generate wild type and sickle cell mice on a HK-deficient background. We found that short-term HK deficiency attenuated thrombin generation and inflammation in sickle mice at steady state, which was independent of bradykinin signaling. Moreover, long-term HK deficiency attenuates kidney injury, reduces chronic inflammation, and ultimately improves survival of sickle mice.
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Affiliation(s)
- Erica M. Sparkenbaugh
- UNC Blood Research Center, Division of Hematology & Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Malgorzata Kasztan
- Section of Cardio-Renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael W. Henderson
- UNC Blood Research Center, Division of Hematology & Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Patrick Ellsworth
- UNC Blood Research Center, Division of Hematology & Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Parker Ross Davis
- Section of Cardio-Renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kathryn J. Wilson
- UNC Blood Research Center, Division of Hematology & Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Brandi Reeves
- UNC Blood Research Center, Division of Hematology & Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nigel S. Key
- UNC Blood Research Center, Division of Hematology & Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sidney Strickland
- Patricia and John Rosenwald Laboratory of Neurobiology and Genetics, The Rockefeller University, New York, NY, USA
| | - Keith McCrae
- Department of Hematology Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - David M. Pollock
- Section of Cardio-Renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rafal Pawlinski
- UNC Blood Research Center, Division of Hematology & Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Brzoska T, Vats R, Bennewitz MF, Tutuncuoglu E, Watkins SC, Ragni MV, Neal MD, Gladwin MT, Sundd P. Intravascular hemolysis triggers ADP-mediated generation of platelet-rich thrombi in precapillary pulmonary arterioles. JCI Insight 2020; 5:139437. [PMID: 32544100 DOI: 10.1172/jci.insight.139437] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/11/2020] [Indexed: 12/17/2022] Open
Abstract
Patients with hereditary or acquired hemolytic anemias have a high risk of developing in situ thrombosis of the pulmonary vasculature. While pulmonary thrombosis is a major morbidity associated with hemolytic disorders, the etiological mechanism underlying hemolysis-induced pulmonary thrombosis remains largely unknown. Here, we use intravital lung microscopy in mice to assess the pathogenesis of pulmonary thrombosis following deionized water-induced acute intravascular hemolysis. Acute hemolysis triggered the development of αIIbβ3-dependent platelet-rich thrombi in precapillary pulmonary arterioles, which led to the transient impairment of pulmonary blood flow. The hemolysis-induced pulmonary thrombosis was phenocopied with intravascular ADP- but not thrombin-triggered pulmonary thrombosis. Consistent with a mechanism involving ADP release from hemolyzing erythrocytes, the inhibition of platelet P2Y12 purinergic receptor signaling attenuated pulmonary thrombosis and rescued blood flow in the pulmonary arterioles of mice following intravascular hemolysis. These findings are the first in vivo studies to our knowledge to suggest that acute intravascular hemolysis promotes ADP-dependent platelet activation, leading to thrombosis in the precapillary pulmonary arterioles, and that thrombin generation most likely does not play a significant role in the pathogenesis of acute hemolysis-triggered pulmonary thrombosis.
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Affiliation(s)
- Tomasz Brzoska
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ravi Vats
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Margaret F Bennewitz
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Chemical and Biomedical Engineering, West Virginia University, Morgantown, West Virginia, USA
| | - Egemen Tutuncuoglu
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Simon C Watkins
- Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Margaret V Ragni
- Department of Medicine, University of Pittsburgh, Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania, USA
| | | | - Mark T Gladwin
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Prithu Sundd
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Pulmonary Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Akaba K, Nwogoh B, Oshatuyi O. Determination of von Willebrand factor level in patient with sickle cell diseasein vaso-occlusive crisis. Res Pract Thromb Haemost 2020; 4:902-905. [PMID: 32685901 PMCID: PMC7354399 DOI: 10.1002/rth2.12378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/10/2020] [Accepted: 04/17/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Sickle cell anemia (SCA) is a hypercoagulable state characterized by a significant alteration in hemostatic parameters that may predispose to increased risk of vaso-occlusive crisis (VOC). The role of von Willebrand factor (VWF) in the pathogenesis of VOC has not been fully investigated in Nigeria. OBJECTIVE The objective of this study was to evaluate the level of VWF in subjects with sickle cell disease (SCD) in Calabar, Nigeria, to determine its role in the pathogenesis of VOC. METHODS This was a comparative study carried out at the University of Calabar Teaching Hospital, Calabar, Nigeria. Sixty patients with SCA in VOC and 50 healthy controls were included. VWF levels were measured using Assaypro enzyme-linked immunosorbent assay kits. RESULTS The mean age of patients with SCA in VOC and controls was 23.5 ± 7.2 years and 26.5 ± 5.6 years, respectively. The means (standard deviations) of VWF in patients in VOC and controls were 2.52 ± 0.34 IU/mL and 1.41 ± 0.23 IU/mL, respectively. There was no correlation of hematocrit and VWF in VOC (r = -0.034; P = .80), while there was a modest inverse correlation in controls. CONCLUSIONS Levels of VWFare elevated in a VOC state and thus may be implicated in the pathogenesis of VOC.
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Affiliation(s)
- Kingsley Akaba
- Department of HaematologyUniversity of Calabar Teaching HospitalCalabarNigeria
| | - Benedict Nwogoh
- Department of HaematologyUniversity of Benin Teaching HospitalBeninNigeria
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Thrombin generation in children with sickle cell Anemia is Higher in the presence of platelets ⋆ and ⋆. Transfus Apher Sci 2020; 59:102852. [PMID: 32576489 DOI: 10.1016/j.transci.2020.102852] [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: 11/01/2019] [Revised: 03/31/2020] [Accepted: 06/03/2020] [Indexed: 11/19/2022]
Abstract
Cellular and plasma interactions underlie hypercoagulability in sickle cell anemia (SCA). In healthy adults, thrombin generation (TG), a biomarker of hypercoagulability, is similar in plasma with and without platelets. Studies investigating TG in SCA using platelet-poor plasma (PPP) show conflicting results. There are no studies in SCA simultaneously comparing TG using platelet rich plasma (PRP) and PPP. This prospective study compares TG in children with SCA, at steady state, in PPP versus PRP and investigates the association of predefined clinical variables with the difference between PRP and PPP. Our secondary aim was to investigate derangements in the protein C and S pathway measuring TG with and without thrombomodulin (TM). In forty-three paired samples from SCA patients, aged 2-15 years, TG in the presence of platelets was 5.9 % higher [1239 nmol/(min*L) (SD: 224.1) vs. 1151 nmol/(min*L) (SD 223.3); p = 0.026]. The difference was highest in the 6-10 year age group (9.5 %; SD 14.1) followed by the 2-5 year age group (5.4 %; SD 21.4). In a multiple linear regression model, age, gender, current use of hydroxyurea, degree of hemolysis and severity of pain crises were not predictive of the difference between PRP and PPP. In PPP, TG reduction after TM addition was 7.4 % (SD 16.8), signifying activated protein C resistance. In conclusion, TG in children with SCA aged 2-10 years is higher in the presence of platelets. TG using PRP along with TM addition may be a useful biomarker of hypercoagulability in this population.
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Abstract
Sickle cell disease (SCD) afflicts millions of people worldwide but is referred to as an orphan disease in the United States. Over the past several decades, there has been an increasing understanding of the pathophysiology of SCD and its complications. While most individuals with SCD in resource-rich countries survive into adulthood, the life expectancy of patients with SCD remains substantially shorter than for the general African-American population. SCD can be cured using hematopoietic stem cell transplantation and possibly gene therapy, but these treatment approaches are not available to most patients, the majority of whom reside in low- and middle-income countries. Until relatively recently, only one drug, hydroxyurea, was approved by the US Food and Drug Administration to ameliorate disease severity. Multiple other drugs (L-glutamine, crizanlizumab, and voxelotor) have recently been approved for the treatment of SCD, with several others at various stages of clinical testing. The availability of multiple agents to treat SCD raises questions related to the choice of appropriate drug therapy, combination of multiple agents, and affordability of recently approved products. The enthusiasm for new drug development provides opportunities to involve patients in low- and middle-income nations in the testing of potentially disease-modifying therapies and has the potential to contribute to capacity building in these environments. Demonstration that these agents, alone or in combination, can prevent or decrease end-organ damage would provide additional evidence for the role of drug therapies in improving outcomes in SCD.
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Affiliation(s)
- Parul Rai
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kenneth I. Ataga
- Center for Sickle Cell Disease, University of Tennessee Health Science Center, Memphis, TN, USA
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42
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Sickle cell vaso-occlusion: the clot thickens. Blood 2020; 135:1726-1727. [PMID: 32407525 DOI: 10.1182/blood.2020005034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Ansari J, Gavins FNE. Ischemia-Reperfusion Injury in Sickle Cell Disease: From Basics to Therapeutics. THE AMERICAN JOURNAL OF PATHOLOGY 2019; 189:706-718. [PMID: 30904156 DOI: 10.1016/j.ajpath.2018.12.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/17/2018] [Accepted: 12/07/2018] [Indexed: 12/17/2022]
Abstract
Sickle cell disease (SCD) is one of the most common hereditary hemoglobinopathies worldwide, affecting almost 400,000 newborns globally each year. It is characterized by chronic hemolytic anemia and endothelial dysfunction, resulting in a constant state of disruption of the vascular system and leading to recurrent episodes of ischemia-reperfusion injury (I/RI) to multiple organ systems. I/RI is a fundamental vascular pathobiological paradigm and contributes to morbidity and mortality in a wide range of conditions, including myocardial infarction, stroke, acute kidney injury, and transplantation. I/RI is characterized by an initial restriction of blood supply to an organ, which can lead to ischemia, followed by the subsequent restoration of perfusion and concomitant reoxygenation. Recent advances in the pathophysiology of SCD have led to an understanding that many of the consequences of this disease can be explained by mechanisms associated with I/RI. The following review focuses on the evolving pathobiology of SCD, how various complications of SCD can be attributed to I/RI, and the role of timely therapeutic intervention(s) based on targeting mediators or pathways that influence I/R insult.
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Affiliation(s)
- Junaid Ansari
- Department of Molecular & Cellular Physiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana
| | - Felicity N E Gavins
- Department of Molecular & Cellular Physiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana.
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Gibson CM, Yuet WC. Racial and Ethnic Differences in Response to Anticoagulation: A Review of the Literature. J Pharm Pract 2019; 34:685-693. [PMID: 31875763 DOI: 10.1177/0897190019894142] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Anticoagulants are among the most frequently prescribed medications in the United States. Racial and ethnic disparities in incidence and outcomes of thrombotic disorders are well-documented, but differences in response to anticoagulation are incompletely understood. OBJECTIVE The objective of this review is to describe the impact of race and ethnicity on surrogate and clinical end points related to anticoagulation and discuss racial or ethnic considerations for prescribing anticoagulants. METHODS A PubMed and MEDLINE search of clinical trials published between 1950 and May 2018 was conducted using search terms related to anticoagulation, specific anticoagulant drugs, race, and ethnicity. References of identified studies were also reviewed. English-language human studies on safety or efficacy of anticoagulants reporting data for different races or ethnicities were eligible for inclusion. RESULTS Seventeen relevant studies were identified. The majority of major trials reviewed for inclusion either did not include representative populations or did not report on the racial breakdown of participants. Racial differences in pharmacokinetics, dosing requirements, drug response, and/or safety end points were identified for unfractionated heparin, enoxaparin, argatroban, warfarin, rivaroxaban, and edoxaban. CONCLUSIONS Race appears to influence drug concentrations, dosing, or safety for some but not all direct oral anticoagulants. This information should be considered when selecting anticoagulant therapy for nonwhite individuals.
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Affiliation(s)
- Caitlin M Gibson
- Department of Pharmacotherapy, University of North Texas System College of Pharmacy, Fort Worth, TX, USA
| | - Wei C Yuet
- Department of Pharmacotherapy, University of North Texas System College of Pharmacy, Fort Worth, TX, USA
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Antwi-Baffour S, Kyeremeh R, Annison L. Severity of Anaemia Has Corresponding Effects on Coagulation Parameters of Sickle Cell Disease Patients. Diseases 2019; 7:E59. [PMID: 31861183 PMCID: PMC6956179 DOI: 10.3390/diseases7040059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/18/2019] [Accepted: 10/18/2019] [Indexed: 12/25/2022] Open
Abstract
Sickle cell disease (SCD) is an inherited condition characterized by chronic haemolytic anaemia. SCD is associated with moderate to severe anaemia, hypercoagulable state and inconsistent platelet count and function. However, studies have yielded conflicting results with regards to the effect of anaemia on coagulation in SCD. The purpose of this study was to determine the effect of anaemia severity on selected coagulation parameters of SCD patients. Four millilitres of venous blood samples were taken from the participants (SCD and non-SCD patients) and used for analysis of full blood count and coagulation parameters. Data was analysed using SPSS version-16. From the results, it was seen that individuals with SCD had a prolonged mean PT, APTT and high platelet count compared to the controls. There was also significant difference in the mean PT (p = 0.039), APTT (p = 0.041) and platelet count (p = 0.010) in HbSS participants with severe anaemia. Mean APTT also showed significant difference (p = 0.044) with severe anaemia in HbSC participants. It can be concluded that SCD patients have prolonged PT, APTT and increased platelet count which might predispose them to bleeding episodes and thrombocytosis. Significant difference was also seen between severity of anaemia and mean PT, APTT and platelet count in HbSS individuals.
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Affiliation(s)
- Samuel Antwi-Baffour
- Department of Medical Laboratory Sciences, School of Allied Health Sciences, College of Health Sciences, University of Ghana, P.O. Box KB 143 Accra, Ghana;
| | - Ransford Kyeremeh
- Department of Medical Laboratory Sciences, School of Allied Health Sciences, College of Health Sciences, University of Ghana, P.O. Box KB 143 Accra, Ghana;
| | - Lawrence Annison
- Department of Medical Laboratory Sciences, School of Allied Health Sciences, Narh-Bita College, P.O. Box Co1061 Tema, Ghana;
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Abstract
Identification of novel therapeutic targets has improved diagnostics and treatment of many diseases. Many innovative treatment strategies have been developed based on the newly identified biomarkers and key molecules. Most of the research focused on ways to manipulate signaling pathways by activating or suppressing them, validate new therapeutic targets for treatment, and epigenetic treatment of diseases. With the identification of aberrations in multiple growth pathways, the focus then shifted to the small molecules involved in these pathways for targeted therapy. In this communication/short review, we highlight the importance of identification of abnormal activation of the mitogen-activated protein kinase (MAPK), ERK1/2, and its upstream mediator MEK1/2, in erythrocytes in patients with sickle cell disease (SCD) critical for the adhesive interactions of these cells with the endothelium, and leukocytes promoting circulatory obstruction leading to tissue ischemia and infraction. We also discuss how targeting this signaling cascade with MEK1/2 inhibitors can reverse acute vasoocclusive crises in SCD.
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Affiliation(s)
- Rahima Zennadi
- Division of Hematology and Duke Comprehensive Sickle Cell Center, Department of Medicine, Duke University Medical Center, North Carolina, USA
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Rozen L, Noubouossie DF, Dedeken L, Lê PQ, Ferster A, Demulder A. Is There Any Improvement of the Coagulation Imbalance in Sickle Cell Disease after Hematopoietic Stem Cell Transplantation? J Clin Med 2019; 8:jcm8111796. [PMID: 31717804 PMCID: PMC6912463 DOI: 10.3390/jcm8111796] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/16/2019] [Accepted: 10/23/2019] [Indexed: 12/21/2022] Open
Abstract
Several components of the clotting system are modified towards hypercoagulability in sickle cell disease (SCD). To date, hematopoietic stem cell transplantation (HSCT) is the only validated curative treatment of SCD. Here, we investigated the changes in the hemostatic potential of SCD children who've received a successful HSCT. Seventeen children with severe SCD were enrolled in the study. Thrombin generation (TG) was performed on citrated platelet-poor plasma, obtained before and 3, 6, 9, 12 and 15 months after HSCT. TG was triggered using 1 pM tissue factor and 4 µM phospholipids with or without thrombomodulin (TM). Before the HSCT, SCD children showed a higher endogenous thrombin potential (ETP), higher peak, higher velocity and shorter time-to-peak of TG than the normal controls (NC). ETP did not significantly change following the HSCT. However, the peak, velocity and time-to-peak of TG reversed to normal ranges from 3 months post-HSCT and remained so up to 15 months post-HSCT. The reduction of ETP after the addition of thrombomodulin (RETP) was dramatically reduced in SCD children before HSCT as compared with the NC. A partial reversal of RETP was observed from 3 months through 15 months post-HSCT. No statistical difference was observed for patient age or donor hemoglobinopathy status. In summary, successful HSCT improves the kinetics of TG but not the total thrombin capacity in SCD children.
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Affiliation(s)
- Laurence Rozen
- Laboratory of Hematology LHUB-ULB ULB Université Libre de Bruxelles, 1020 Brussels, Belgium; (D.F.N.); (A.D.)
- Correspondence: ; Tel.: +32-2477-2921
| | - Denis F. Noubouossie
- Laboratory of Hematology LHUB-ULB ULB Université Libre de Bruxelles, 1020 Brussels, Belgium; (D.F.N.); (A.D.)
| | - Laurence Dedeken
- Hematology Oncology Unit, Hôpital and niversitaire des Enfants Reine Fabiola, ULB Université Libre de Bruxelles, 1020 Brussels, Belgium; (L.D.); (P.Q.L.); (A.F.)
| | - Phu Quoc Lê
- Hematology Oncology Unit, Hôpital and niversitaire des Enfants Reine Fabiola, ULB Université Libre de Bruxelles, 1020 Brussels, Belgium; (L.D.); (P.Q.L.); (A.F.)
| | - Alina Ferster
- Hematology Oncology Unit, Hôpital and niversitaire des Enfants Reine Fabiola, ULB Université Libre de Bruxelles, 1020 Brussels, Belgium; (L.D.); (P.Q.L.); (A.F.)
| | - Anne Demulder
- Laboratory of Hematology LHUB-ULB ULB Université Libre de Bruxelles, 1020 Brussels, Belgium; (D.F.N.); (A.D.)
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Carden MA, Little J. Emerging disease-modifying therapies for sickle cell disease. Haematologica 2019; 104:1710-1719. [PMID: 31413089 PMCID: PMC6717563 DOI: 10.3324/haematol.2018.207357] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/10/2019] [Indexed: 12/20/2022] Open
Abstract
Sickle cell disease afflicts millions of people worldwide and approximately 100,000 Americans. Complications are myriad and arise as a result of complex pathological pathways ‘downstream’ to a point mutation in DNA, and include red blood cell membrane damage, inflammation, chronic hemolytic anemia with episodic vaso-occlusion, ischemia and pain, and ultimately risk of cumulative organ damage with reduced lifespan of affected individuals. The National Heart, Lung, and Blood Institute’s 2014 evidence-based guideline for sickle cell disease management states that additional research is needed before investigational curative therapies will be widely available to most patients with sickle cell disease. To date, sickle cell disease has been cured by hematopoietic stem cell transplantation in approximately 1,000 people, most of whom were children, and significantly ameliorated by gene therapy in a handful of subjects who have only limited follow-up thus far. During a timespan in which over 20 agents were approved for the treatment of cystic fibrosis by the Food and Drug Administration, similar approval was granted for only two drugs for sickle cell disease (hydroxyurea and L-glutamine) despite the higher prevalence of sickle cell disease. This trajectory appears to be changing, as the lack of multimodal agent therapy in sickle cell disease has spurred engagement among many in academia and industry who, in the last decade, have developed new drugs poised to prevent complications and alleviate suffering. Identified therapeutic strategies include fetal hemoglobin induction, inhibition of intracellular HbS polymerization, inhibition of oxidant stress and inflammation, and perturbation of the activation of the endothelium and other blood components (e.g. platelets, white blood cells, coagulation proteins) involved in the pathophysiology of sickle cell disease. In this article, we present a crash-course review of disease-modifying approaches (minus hematopoietic stem cell transplant and gene therapy) for patients with sickle cell disease currently, or recently, tested in clinical trials in the era following approval of hydroxyurea.
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Affiliation(s)
- Marcus A Carden
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of North Carolina Chapel Hill School of Medicine.,Department of Medicine, Division of Hematology, University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Jane Little
- Department of Medicine, Division of Hematology, University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC, USA
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Brunson A, Keegan T, Mahajan A, White R, Wun T. High incidence of venous thromboembolism recurrence in patients with sickle cell disease. Am J Hematol 2019; 94:862-870. [PMID: 31074115 DOI: 10.1002/ajh.25508] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 11/07/2022]
Abstract
Previous reports show increased incidence of venous thromboembolism [VTE, deep-vein thrombosis (DVT) and pulmonary embolus (PE)] in sickle cell disease (SCD) patients. The incidence, time course, and risk factors for VTE recurrence have been less well described. We determined the cumulative incidence of first VTE recurrence and bleeding in a cohort of SCD patients with incident VTE. Risk factors for recurrence and bleeding were also determined using multivariable Cox regression models, adjusting for gender, race/ethnicity, era of incident VTE, location and hospitalization-associated status of incident VTE, and SCD-related complications. Results are presented as adjusted hazard ratios (HR) and 95% confidence intervals (CI). Among 877 SCD patients with an incident VTE, the 1-year and 5-year cumulative incidence of recurrence was 13.2% (95% CI 11.0%-15.5%) and 24.1% (95% CI 21.2%-27.1%). Risk factors for VTE recurrence included more severe SCD (HR = 2.41; CI: 1.67-3.47), lower extremity DVT as the incident event (HR = 1.64; CI: 1.17-2.30), and pneumonia/acute chest syndrome (HR = 1.68; CI: 1.15-2.45). The cumulative incidence of bleeding was 4.9% (CI 3.5%-6.4%) at 6 months and 7.9% (CI: 6.2%-9.8%) at 1 year. More severe SCD (HR = 1.61; CI: 1.11-2.35) was associated with bleeding. The high incidence of VTE recurrence in patients with SCD suggests that extended anticoagulation may be indicated; however, this must be weighed against a relatively high risk of bleeding. Prospective, randomized studies of anticoagulation in SCD patients with VTE are needed.
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Affiliation(s)
- Ann Brunson
- Center for Oncology and Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, UC Davis School of Medicine, Sacramento, California
| | - Theresa Keegan
- Center for Oncology and Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, UC Davis School of Medicine, Sacramento, California
| | - Anjlee Mahajan
- Center for Oncology and Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, UC Davis School of Medicine, Sacramento, California
| | - Richard White
- Division of General Internal Medicine, UC Davis School of Medicine, Sacramento, California
| | - Ted Wun
- Center for Oncology and Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, UC Davis School of Medicine, Sacramento, California
- UC Davis Clinical and Translational Science Center, Sacramento, California
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Patel A, Williams H, Baer MR, Zimrin AB, Law JY. Decreased Bleeding Incidence with Direct Oral Anticoagulants Compared to Vitamin K Antagonist and Low-Molecular-Weight Heparin in Patients with Sickle Cell Disease and Venous Thromboembolism. Acta Haematol 2019; 142:233-238. [PMID: 31108496 DOI: 10.1159/000500223] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/08/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a recognized complication of sickle cell disease (SCD), yet the optimal pharmacologic anticoagulant is unknown. METHODS A retrospective single-institution cohort study of patients with SCD complicated by first VTE from January 2009 through July 2017 was performed using ICD 9/10 codes. Data collected included the anticoagulant used, VTE recurrence, and incidence of bleeding. RESULTS 109 patients with VTE were identified. SCD genotypes included HbSS in 92 (84%), HbSC in 13 (12%), and HbS-β+ thalassemia in 4 (4%). After the initial VTE event, 32 patients received a vitamin K antagonist (VKA), 34 for low-molecular-weight heparin (LMWH), and 43 for direct oral anticoagulants (DOACs). 16 patients (15%) experienced a clinically significant bleeding event, including 9 on VKA, 5 on LMWH, and 2 on DOACs. At a median follow-up of 11.8 (range, 3.4-60) months, 33 patients had a recurrent VTE, including 10 on VKA, 10 on LMWH, and 13 on DOACs (p = 0.833). Bleeding incidence was least with the DOACs, which were associated with fewer bleeding events (OR 0.22), and greatest with VKA (OR 1.55) (p < 0.05). CONCLUSION There was no difference between VTE recurrence and choice of anticoagulation in SCD patients with VTE. Bleeding events were lower for DOACs compared to VKA or LMWH.
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Affiliation(s)
- Ameet Patel
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA,
| | - Hants Williams
- University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Maria R Baer
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Division of Hematology/Oncology, Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ann B Zimrin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Division of Hematology/Oncology, Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jennie Y Law
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Division of Hematology/Oncology, Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
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