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Sarfo FS, Paintsil V, Nyanor I, Asafo-Adjei EK, Ahmed EA, Nguah SB, Amuzu EX, Abubakar SY, Tutu LO, Mensah YGO, Nartey AK, Bediako AA, Osei L, Mantey AA, Acheampong E, Ansong D, Akoto AO. A contemporary evaluation of the frequency & factors associated with overt stroke across the lifespan: A Ghanaian sickle cell disease registry analysis. J Neurol Sci 2024; 466:123263. [PMID: 39368214 DOI: 10.1016/j.jns.2024.123263] [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: 05/26/2024] [Revised: 08/19/2024] [Accepted: 09/28/2024] [Indexed: 10/07/2024]
Abstract
BACKGROUND Stroke is a devastating complication of Sickle Cell Disease (SCD) with significant mortality and substantial morbidity. The burden of prevalent stroke in SCD is highest in sub-Saharan Africa and estimated at 4.2 % to 6.4 % in the era where evidence-based prevention strategies such as use of hydroxyurea therapy and transcranial doppler ultrasound were not routine care. PURPOSE To assess the contemporary frequency and factors associated with prevalent stroke across the lifespan in an SCD registry at the tertiary medical center in Ghana. METHODS This is a cross-sectional study conducted at the Komfo Anokye Teaching Hospital, a tertiary medical center in the middle belt of Ghana. The center has comprehensive Sickle Cell Clinics for children, adolescents, and adults with a patient registry established as part of the Sickle Pan-African Research Consortium (SPARCo)-Ghana study from 2017 to date. Data captured in the registry and analyzed for the present study include demographics, stroke status using the WHO criteria supplemented by the Questionnaire for Verifying Stroke Free Status (QVSFS), use of hydroxyurea, and complete blood count. Logistic regression modeling was utilized to assess factors associated with stroke. RESULTS Among a registry cohort of 4115 individuals with confirmed SCD, 35 (0.85 %, 95 % CI: 0.59-1.18 %) had overt or clinically confirmed stroke. The frequency of stroke differed significantly across the lifespan being 0.38 % (95 % CI: 0.12-0.64 %) among children <10 years, 1.23 % (95 % CI: 0.73-1.94 %) among adolescents aged 10 to 17 years, and 1.44 % (95 % CI: 0.66-2.71 %) among adults 18 years or more, p = 0.007. In adjusted analysis, each 10-year increase in age was associated with odds ratio, OR (95 % CI) of 1.90 (1.42-2.54) and hydroxyurea use, OR of 6.09 (2.65-13.99). The association between hydroxyurea and stroke observed in this cross-sectional study is not causal. CONCLUSION Approximately 1 in 120 SCD patients in this large Ghanaian cohort had clinically overt stroke. The gradual uptake of hydroxyurea therapy into routine care for SCD in this resource-limited setting, may partly explain the lower frequency of stroke.
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Affiliation(s)
- Fred Stephen Sarfo
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana.
| | - Vivian Paintsil
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | | | | | - Samuel Blay Nguah
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | | | | | | | | | | | - Leslie Osei
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | | | - Daniel Ansong
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Alex Osei Akoto
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana
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Monagel DA, Algahtani SS, Karawagh LA, Althubaity WD, Azab SA, Haneef DF, Elimam N. Renal outcomes in pediatric patients with sickle cell disease: a single center experience in Saudi Arabia. Front Pediatr 2023; 11:1295883. [PMID: 38161437 PMCID: PMC10755027 DOI: 10.3389/fped.2023.1295883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
Background Sickle cell nephropathy (SCN) is a significant complication of sickle cell disease (SCD) with an asymptomatic onset in childhood and potential progression to chronic kidney disease (CKD). The clinical findings of SCN include hyposthenuria, hematuria, proteinuria, hyperfiltration, and CKD. Data on renal manifestation among patients with SCD in Saudi Arabia is lacking. Therefore, this study aimed to evaluate renal outcomes in patients with SCD who visited a hematology clinic at the National Guard Hospital, Jeddah. Methods We conducted a retrospective chart review of renal complications in patients with SCD who are within 0-14 years of age and on regular follow-ups at the pediatric hematology clinic in King Abdulaziz Medical City-Jeddah, Saudi Arabia. Results Among the 140 patients with SCD, 99 met the inclusion criteria. The median age at diagnosis was 18 (1-108) months. Two SCD phenotypes were observed, with 82 (83%) patients having sickle cell anemia (HbSS) and 17 (17%) having HbS/B+ thalassemia. Of the total patients, 92 (93%) were administered hydroxyurea (HU), with a median starting age of 48 (9-168) months. The most common renal complication observed during routine urinalysis was hematuria (38%), followed by proteinuria (11%). After stratifying the sample into four age groups (0-3 years old, 4-7 years old, 8-11 years old, and 12-14 years old), the mean glomerular filtration rate (GFR) values were 96.16, 101.36, 112.69, and 120.11 ml/min/1.73 m2 respectively. Renal imaging revealed abnormal findings in 27 (29%) patients. The most common abnormality observed on US was increased echogenicity (43%). Conclusion SCN is a significant complication of SCD. In this study, we assessed the renal outcomes in pediatric patients with SCD. After analyzing the clinical findings of SCN, we concluded that the presence of renal complications in pediatric patients presented a progressive pattern.
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Affiliation(s)
- Dania A. Monagel
- College of Medicine, King Saud bin Abdul-Aziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- Department of Oncology, Ministry of the National Guard-Health Affairs, Jeddah, Saudi Arabia
| | - Shatha S. Algahtani
- College of Medicine, King Saud bin Abdul-Aziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Lian A. Karawagh
- College of Medicine, King Saud bin Abdul-Aziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Wafa D. Althubaity
- College of Medicine, King Saud bin Abdul-Aziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Sara A. Azab
- College of Medicine, King Saud bin Abdul-Aziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Deena F. Haneef
- Center of Excellence in Genomic Medicine Research (CEGMR), King Abdulaziz University, Jeddah, Saudi Arabia
| | - Naglla Elimam
- Department of Oncology, Ministry of the National Guard-Health Affairs, Jeddah, Saudi Arabia
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Prophylactic Hydroxyurea Treatment Is Associated with Improved Cerebral Hemodynamics as a Surrogate Marker of Stroke Risk in Sickle Cell Disease: A Retrospective Comparative Analysis. J Clin Med 2022; 11:jcm11123491. [PMID: 35743561 PMCID: PMC9225168 DOI: 10.3390/jcm11123491] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/10/2022] [Accepted: 06/15/2022] [Indexed: 11/21/2022] Open
Abstract
Sickle cell disease (SCD) increases the incidence of childhood stroke eighty-fold. Stroke risk can be estimated by measurement of the blood velocity through the middle cerebral artery (MCA) using transcranial doppler ultrasound (TCD). A high MCA blood velocity indicates increased stroke risk due to cerebral vasculopathy, and first-line treatment to prevent primary or recurrent strokes in high-risk children with SCD has classically been chronic blood transfusions. Research has more recently shown that many of these patients may safely transition from transfusions to oral hydroxyurea (HU) treatment while maintaining a decreased risk of stroke. However, the effect on stroke risk of truly prophylactic HU treatment beginning in infancy, prior to the onset of cerebral vasculopathy, is less well understood. Our retrospective study aimed to document the long-term effects of HU treatment compared with no HU treatment in children with SCD, using TCD measurements as our primary outcome and a surrogate marker of stroke risk. Our results showed that when accounting for age-related variability and duration of treatment, prophylactic HU treatment was independently associated with lower TCD MCA velocities compared with no HU treatment, providing further evidence supporting its early initiation for patients with SCD.
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Creary SE, Beeman C, Stanek J, King K, McGann PT, O’Brien SH, Liem RI, Holl J, Badawy SM. Impact of hydroxyurea dose and adherence on hematologic outcomes for children with sickle cell anemia. Pediatr Blood Cancer 2022; 69:e29607. [PMID: 35373884 PMCID: PMC9038671 DOI: 10.1002/pbc.29607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hydroxyurea is the primary treatment for sickle cell anemia (SCA), yet real-world implementation in high-income settings is suboptimal. Variation in prescribed hydroxyurea dose and patient adherence in these settings can both affect actual exposure to hydroxyurea. Quantifying the contributions of hydroxyurea dose and medication adherence to the relationship between hydroxyurea exposure and hematologic parameters could inform strategies to optimize exposure and improve outcomes. PROCEDURE We evaluated the relationship between hydroxyurea exposure, defined by average prescribed dose and adherence, and hematologic parameters using data from children with SCA who were enrolled in two prospective hydroxyurea adherence studies. Hydroxyurea adherence was assessed by video directly observed therapy or electronic pill bottle and medication administration record. Average prescribed dose was abstracted from prescriptions in patients' electronic medical record. Participants with a hydroxyurea exposure >20 mg/kg/day and ≤20 mg/kg/day were included in the higher and lower exposure groups, respectively. RESULTS Forty-five participants were included in the analysis (56% male; median age 12 years [range 2-19]; 98% Black). Higher exposed participants (n = 23) were prescribed a higher dose (27.2 vs. 24.4 mg/kg/day, p = .002) and had better adherence (0.92 vs. 0.71, p ≤ .001) compared to lower exposed participants (n = 22). Higher exposure was associated with higher fetal hemoglobin (p = .04) and mean corpuscular volume (p = .02). CONCLUSIONS Higher hydroxyurea exposure is associated with improved hematologic parameters in the high-income setting and is affected by both prescribed dose and adherence. Future studies are needed to optimize both adherence and hydroxyurea prescribing and confirm that increasing exposure improves clinical outcomes in this setting.
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Affiliation(s)
- Susan E. Creary
- Center for Child Health Equity and Outcomes, Research Institute Nationwide Children’s Hospital, Columbus, OH,Division of Pediatric Hematology/Oncology/BMT, Nationwide Children’s Hospital & The Ohio State University, Columbus, OH
| | - Chase Beeman
- Center for Child Health Equity and Outcomes, Research Institute Nationwide Children’s Hospital, Columbus, OH
| | - Joseph Stanek
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children’s Hospital & The Ohio State University, Columbus, OH
| | - Kathryn King
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Patrick T. McGann
- Department of Pediatrics, The Warren Alpert Medical School of Brown University, Hasbro Children’s Hospital and Rhode Island Hospital, Providence, RI
| | - Sarah H. O’Brien
- Center for Child Health Equity and Outcomes, Research Institute Nationwide Children’s Hospital, Columbus, OH,Division of Pediatric Hematology/Oncology/BMT, Nationwide Children’s Hospital & The Ohio State University, Columbus, OH
| | - Robert I. Liem
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Jane Holl
- Department of Neurology and Center for Healthcare Delivery Science and Innovation, University of Chicago, Chicago, IL
| | - Sherif M. Badawy
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
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Cucchiara BL, Kasner SE. Treatment of “Other” Stroke Etiologies. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00058-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Loggetto SR, Veríssimo MPDA, Darrigo-Junior LG, Simões RDS, Bernardo WM, Braga JAP. Guidelines on sickle cell disease: primary stroke prevention in children and adolescents. Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular Guidelines project: Associação Médica Brasileira - 2021. Hematol Transfus Cell Ther 2021; 44:85-94. [PMID: 34857507 PMCID: PMC8885378 DOI: 10.1016/j.htct.2021.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/16/2021] [Accepted: 09/26/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Sandra Regina Loggetto
- Hospital Infantil Sabará, São Paulo, SP, Brazil; Grupo Gestor de Serviços de Hematologia (GSH), São Paulo, SP, Brazil; Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular (ABHH), São Paulo, SP, Brazil.
| | - Mônica Pinheiro de Almeida Veríssimo
- Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular (ABHH), São Paulo, SP, Brazil; Centro Infantil de Investigações Hematológicas Dr. Domingos A. Boldrini, Campinas, SP, Brazil
| | - Luiz Guilherme Darrigo-Junior
- Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular (ABHH), São Paulo, SP, Brazil; Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP/USP), Ribeirão Preto, SP, Brazil
| | - Ricardo Dos Santos Simões
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, SP, Brazil; Associação Médica Brasileira (AMB), São Paulo, SP, Brazil
| | - Wanderley Marques Bernardo
- Associação Médica Brasileira (AMB), São Paulo, SP, Brazil; Faculdade de Medicina da Universidade de São Paulo (FM USP), São Paulo, SP, Brazil
| | - Josefina Aparecida Pellegrini Braga
- Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular (ABHH), São Paulo, SP, Brazil; Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM UNIFESP), São Paulo, SP, Brazil
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Hebbel RP, Vercellotti GM. Multiple inducers of endothelial NOS (eNOS) dysfunction in sickle cell disease. Am J Hematol 2021; 96:1505-1517. [PMID: 34331722 PMCID: PMC9292023 DOI: 10.1002/ajh.26308] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 12/26/2022]
Abstract
A characteristic aspect of the robust, systemic inflammatory state in sickle cell disease is dysfunction of endothelial nitric oxide synthase (eNOS). We identify 10 aberrant endothelial cell inputs, present in the specific sickle context, that are known to have the ability to cause eNOS dysfunction. These are: endothelial arginase depletion, asymmetric dimethylarginine, complement activation, endothelial glycocalyx degradation, free fatty acids, inflammatory mediators, microparticles, oxidized low density lipoproteins, reactive oxygen species, and Toll‐like receptor 4 signaling ligands. The effect of true eNOS dysfunction on clinical testing using flow‐mediated dilation can be simulated by two known examples of endothelial dysfunction mimicry (hemoglobin consumption of NO; and oxidation of smooth muscle cell soluble guanylate cyclase). This lends ambiguity to interpretation of such clinical testing. The presence of these multiple perturbing factors argues that a therapeutic approach targeting only a single injurious endothelial input (or either example of mimicry) would not be sufficiently efficacious. This would seem to argue for identifying therapeutics that directly protect eNOS function or application of multiple therapeutic approaches.
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Affiliation(s)
- Robert P. Hebbel
- Division of Hematology‐Oncology‐Transplantation, Department of Medicine University of Minnesota Medical School Minneapolis Minnesota USA
| | - Gregory M. Vercellotti
- Division of Hematology‐Oncology‐Transplantation, Department of Medicine University of Minnesota Medical School Minneapolis Minnesota USA
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Montalembert M, Voskaridou E, Oevermann L, Cannas G, Habibi A, Loko G, Joseph L, Colombatti R, Bartolucci P, Brousse V, Galactéros F. Real-Life experience with hydroxyurea in patients with sickle cell disease: Results from the prospective ESCORT-HU cohort study. Am J Hematol 2021; 96:1223-1231. [PMID: 34224583 DOI: 10.1002/ajh.26286] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 07/02/2021] [Indexed: 12/28/2022]
Abstract
Several controlled studies have evidenced good efficacy and short-term and mid-term safety profiles for hydroxyurea (HU), which has become the cornerstone for prevention of sickle-cell disease (SCD)-related vaso-occlusive crises. However, there are few large-scale reports on its long-term use and certain caregivers and patients have concerns about its safety. Following the licensing of HU in Europe for children and adults with severe forms of SCD, ESCORT-HU was designed as a Phase IV observational cohort study. It included 1906 participants, of whom 55% were adults. The most common hemoglobin (Hb) genotypes were HbSS (84.7%) and HbSβ+ (7.0%). The median duration of follow-up was 45 months, for a total of 7309 patient-years of observation. The dose of HU after 1 year was 20.6 mg/kg/d for children and 16.3 mg/kg/d for adults. There was a statistically significant decrease in the number of vaso-occlusive episodes lasting >48 h, acute chest syndrome episodes, hospitalizations, and the percentage of patients requiring blood transfusions within the first 12 months relative to the year before enrolment. Neutropenia and thrombocytopenia were the most commonly reported adverse effects. No new HU toxicity was identified. Overall, 125 pregnancies were reported in 101 women and no malformations were observed in the neonates. There were 12 pregnancies for partners of male patients treated with HU. One case of fatal myelodysplastic syndrome was reported, for which a causal association with HU could not be excluded. This cohort study of patients with SCD highlights the positive benefit-to-risk ratio of HU in children and adults.
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Affiliation(s)
- Mariane Montalembert
- Reference Centre for Sickle Cell Disease, Department of General Pediatrics and Pediatric Infectious Diseases Necker‐Enfants malades Hospital, Assistance Publique‐Hôpitaux de Paris (AP‐HP) Paris France
| | - Ersi Voskaridou
- Centre of Excellence in Rare Hematological Disease‐Hemoglobinopathies, Laiko General Hospital Athens Greece
| | - Lena Oevermann
- Department of Pediatric Oncology & Hematology Charité University Medicine, Berlin and Berlin Institute of Health Berlin Germany
| | - Giovanna Cannas
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Médecine Interne, Centre de Référence Constitutif: Syndromes Drépanocytaires Majeurs, Thalassémies et Autres Pathologies Rares du Globule Rouge et de l'Erythropoïèse Lyon France
| | - Anoosha Habibi
- Sickle Cell Referral Center, Department of Internal Medicine Henri‐Mondor University Hospital‐UPEC, AP‐HP Créteil France
| | - Gylna Loko
- Centre hospitalier de la Martinique Fort‐de‐France Martinique France
| | - Laure Joseph
- Biotherapy Department Necker Children's Hospital, Assistance Publique‐Hôpitaux de Paris Paris France
| | | | - Pablo Bartolucci
- Sickle Cell Referral Center, Department of Internal Medicine Henri‐Mondor University Hospital‐UPEC, AP‐HP Créteil France
| | - Valentine Brousse
- Reference Centre for Sickle Cell Disease, Department of General Pediatrics and Pediatric Infectious Diseases Necker‐Enfants malades Hospital, Assistance Publique‐Hôpitaux de Paris (AP‐HP) Paris France
| | - Frédéric Galactéros
- Sickle Cell Referral Center, Department of Internal Medicine Henri‐Mondor University Hospital‐UPEC, AP‐HP Créteil France
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Kirkham FJ, Lagunju IA. Epidemiology of Stroke in Sickle Cell Disease. J Clin Med 2021; 10:4232. [PMID: 34575342 PMCID: PMC8469588 DOI: 10.3390/jcm10184232] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 12/18/2022] Open
Abstract
Sickle cell disease is the most common cause of stroke in childhood, both ischaemic and haemorrhagic, and it also affects adults with the condition. Without any screening or preventative treatment, the incidence appears to fall within the range 0.5 to 0.9 per 100 patient years of observation. Newborn screening with Penicillin prophylaxis and vaccination leading to reduced bacterial infection may have reduced the incidence, alongside increasing hydroxyurea prescription. Transcranial Doppler screening and prophylactic chronic transfusion for at least an initial year has reduced the incidence of stroke by up to 10-fold in children with time averaged mean of the maximum velocity >200 cm/s. Hydroxyurea also appears to reduce the incidence of first stroke to a similar extent in the same group but the optimal dose remains controversial. The prevention of haemorrhagic stroke at all ages and ischaemic stroke in adults has not yet received the same degree of attention. Although there are fewer studies, silent cerebral infarction on magnetic resonance imaging (MRI), and other neurological conditions, including headache, epilepsy and cognitive dysfunction, are also more prevalent in sickle cell disease compared with age matched controls. Clinical, neuropsychological and quantitative MRI screening may prove useful for understanding epidemiology and aetiology.
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Affiliation(s)
- Fenella Jane Kirkham
- Developmental Neurosciences, UCL Great Ormond Street Institute of Child Health, Faculty of Population Health Sciences, 30 Guilford Street, London WC1N 1EH, UK
- Child Health, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton and University Hospital Southampton, Southampton SO16 6YD, UK
- Paediatric Neurosciences, King’s College Hospital, London SE5 9RS, UK
| | - Ikeoluwa A. Lagunju
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan PMB 3017, Nigeria;
- Department of Paediatrics, University College Hospital, Ibadan PMB 5116, Nigeria
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American Society of Hematology 2020 guidelines for sickle cell disease: prevention, diagnosis, and treatment of cerebrovascular disease in children and adults. Blood Adv 2021; 4:1554-1588. [PMID: 32298430 DOI: 10.1182/bloodadvances.2019001142] [Citation(s) in RCA: 208] [Impact Index Per Article: 69.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 02/03/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Central nervous system (CNS) complications are among the most common, devastating sequelae of sickle cell disease (SCD) occurring throughout the lifespan. OBJECTIVE These evidence-based guidelines of the American Society of Hematology are intended to support the SCD community in decisions about prevention, diagnosis, and treatment of the most common neurological morbidities in SCD. METHODS The Mayo Evidence-Based Practice Research Program supported the guideline development process, including updating or performing systematic evidence reviews. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE evidence-to-decision frameworks, to assess evidence and make recommendations. RESULTS The panel placed a higher value on maintaining cognitive function than on being alive with significantly less than baseline cognitive function. The panel developed 19 recommendations with evidence-based strategies to prevent, diagnose, and treat CNS complications of SCD in low-middle- and high-income settings. CONCLUSIONS Three of 19 recommendations immediately impact clinical care. These recommendations include: use of transcranial Doppler ultrasound screening and hydroxyurea for primary stroke prevention in children with hemoglobin SS (HbSS) and hemoglobin Sβ0 (HbSβ0) thalassemia living in low-middle-income settings; surveillance for developmental delay, cognitive impairments, and neurodevelopmental disorders in children; and use of magnetic resonance imaging of the brain without sedation to detect silent cerebral infarcts at least once in early-school-age children and once in adults with HbSS or HbSβ0 thalassemia. Individuals with SCD, their family members, and clinicians should become aware of and implement these recommendations to reduce the burden of CNS complications in children and adults with SCD.
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Gbotosho OT, Taylor M, Malik P. Cardiac pathophysiology in sickle cell disease. J Thromb Thrombolysis 2021; 52:248-259. [PMID: 33677791 DOI: 10.1007/s11239-021-02414-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Oluwabukola Temitope Gbotosho
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center and the University of Cincinnati, Cincinnati, OH, USA
| | - Michael Taylor
- Division of Cardiology, Heart Institute, Cincinnati Children's Hospital Medical Center and the University of Cincinnati, Cincinnati, OH, USA
| | - Punam Malik
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center and the University of Cincinnati, Cincinnati, OH, USA. .,Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center and the University of Cincinnati, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
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12
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John CC, Opoka RO, Latham TS, Hume HA, Nabaggala C, Kasirye P, Ndugwa CM, Lane A, Ware RE. Hydroxyurea Dose Escalation for Sickle Cell Anemia in Sub-Saharan Africa. N Engl J Med 2020; 382:2524-2533. [PMID: 32579813 DOI: 10.1056/nejmoa2000146] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Hydroxyurea has proven safety, feasibility, and efficacy in children with sickle cell anemia in sub-Saharan Africa, with studies showing a reduced incidence of vaso-occlusive events and reduced mortality. Dosing standards remain undetermined, however, and whether escalation to the maximum tolerated dose confers clinical benefits that outweigh treatment-related toxic effects is unknown. METHODS In a randomized, double-blind trial, we compared hydroxyurea at a fixed dose (approximately 20 mg per kilogram of body weight per day) with dose escalation (approximately 30 mg per kilogram per day). The primary outcome was a hemoglobin level of 9.0 g or more per deciliter or a fetal hemoglobin level of 20% or more after 24 months. Secondary outcomes included the incidences of malaria, vaso-occlusive crises, and serious adverse events. RESULTS Children received hydroxyurea at a fixed dose (94 children; mean [±SD] age, 4.6±1.0 years) or with dose escalation (93 children; mean age, 4.8±0.9 years); the mean doses were 19.2±1.8 mg per kilogram per day and 29.5±3.6 mg per kilogram per day, respectively. The data and safety monitoring board halted the trial when the numbers of clinical events were significantly lower among children receiving escalated dosing than among those receiving a fixed dose. At trial closure, 86% of the children in the dose-escalation group had reached the primary-outcome thresholds, as compared with 37% of the children in the fixed-dose group (P<0.001). Children in the dose-escalation group had fewer sickle cell-related adverse events (incidence rate ratio, 0.43; 95% confidence interval [CI], 0.34 to 0.54), vaso-occlusive pain crises (incidence rate ratio, 0.43; 95% CI, 0.34 to 0.56), cases of acute chest syndrome or pneumonia (incidence rate ratio, 0.27; 95% CI, 0.11 to 0.56), transfusions (incidence rate ratio, 0.30; 95% CI, 0.20 to 0.43), and hospitalizations (incidence rate ratio, 0.21; 95% CI, 0.13 to 0.34). Laboratory-confirmed dose-limiting toxic effects were similar in the two groups, and there were no cases of severe neutropenia or thrombocytopenia. CONCLUSIONS Among children with sickle cell anemia in sub-Saharan Africa, hydroxyurea with dose escalation had superior clinical efficacy to that of fixed-dose hydroxyurea, with equivalent safety. (Funded by the Doris Duke Charitable Foundation and the Cincinnati Children's Research Foundation; NOHARM MTD ClinicalTrials.gov number, NCT03128515.).
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Affiliation(s)
- Chandy C John
- From the Ryan White Center for Pediatric Infectious Diseases and Global Health, Department of Pediatrics, Indiana University, Indianapolis (C.C.J.); the Department of Pediatrics and Child Health, Makerere University (R.O.O., H.A.H., C.N., P.K., C.M.N.), Global Health Uganda (R.O.O., C.N.), and Mulago Hospital (P.K.) - all in Kampala, Uganda; the Division of Hematology, Department of Pediatrics (T.S.L., A.L., R.E.W.), and the Global Health Center (R.E.W.), Cincinnati Children's Hospital Medical Center, and the University of Cincinnati College of Medicine (A.L., R.E.W.) - all in Cincinnati; and the Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal (H.A.H.)
| | - Robert O Opoka
- From the Ryan White Center for Pediatric Infectious Diseases and Global Health, Department of Pediatrics, Indiana University, Indianapolis (C.C.J.); the Department of Pediatrics and Child Health, Makerere University (R.O.O., H.A.H., C.N., P.K., C.M.N.), Global Health Uganda (R.O.O., C.N.), and Mulago Hospital (P.K.) - all in Kampala, Uganda; the Division of Hematology, Department of Pediatrics (T.S.L., A.L., R.E.W.), and the Global Health Center (R.E.W.), Cincinnati Children's Hospital Medical Center, and the University of Cincinnati College of Medicine (A.L., R.E.W.) - all in Cincinnati; and the Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal (H.A.H.)
| | - Teresa S Latham
- From the Ryan White Center for Pediatric Infectious Diseases and Global Health, Department of Pediatrics, Indiana University, Indianapolis (C.C.J.); the Department of Pediatrics and Child Health, Makerere University (R.O.O., H.A.H., C.N., P.K., C.M.N.), Global Health Uganda (R.O.O., C.N.), and Mulago Hospital (P.K.) - all in Kampala, Uganda; the Division of Hematology, Department of Pediatrics (T.S.L., A.L., R.E.W.), and the Global Health Center (R.E.W.), Cincinnati Children's Hospital Medical Center, and the University of Cincinnati College of Medicine (A.L., R.E.W.) - all in Cincinnati; and the Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal (H.A.H.)
| | - Heather A Hume
- From the Ryan White Center for Pediatric Infectious Diseases and Global Health, Department of Pediatrics, Indiana University, Indianapolis (C.C.J.); the Department of Pediatrics and Child Health, Makerere University (R.O.O., H.A.H., C.N., P.K., C.M.N.), Global Health Uganda (R.O.O., C.N.), and Mulago Hospital (P.K.) - all in Kampala, Uganda; the Division of Hematology, Department of Pediatrics (T.S.L., A.L., R.E.W.), and the Global Health Center (R.E.W.), Cincinnati Children's Hospital Medical Center, and the University of Cincinnati College of Medicine (A.L., R.E.W.) - all in Cincinnati; and the Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal (H.A.H.)
| | - Catherine Nabaggala
- From the Ryan White Center for Pediatric Infectious Diseases and Global Health, Department of Pediatrics, Indiana University, Indianapolis (C.C.J.); the Department of Pediatrics and Child Health, Makerere University (R.O.O., H.A.H., C.N., P.K., C.M.N.), Global Health Uganda (R.O.O., C.N.), and Mulago Hospital (P.K.) - all in Kampala, Uganda; the Division of Hematology, Department of Pediatrics (T.S.L., A.L., R.E.W.), and the Global Health Center (R.E.W.), Cincinnati Children's Hospital Medical Center, and the University of Cincinnati College of Medicine (A.L., R.E.W.) - all in Cincinnati; and the Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal (H.A.H.)
| | - Phillip Kasirye
- From the Ryan White Center for Pediatric Infectious Diseases and Global Health, Department of Pediatrics, Indiana University, Indianapolis (C.C.J.); the Department of Pediatrics and Child Health, Makerere University (R.O.O., H.A.H., C.N., P.K., C.M.N.), Global Health Uganda (R.O.O., C.N.), and Mulago Hospital (P.K.) - all in Kampala, Uganda; the Division of Hematology, Department of Pediatrics (T.S.L., A.L., R.E.W.), and the Global Health Center (R.E.W.), Cincinnati Children's Hospital Medical Center, and the University of Cincinnati College of Medicine (A.L., R.E.W.) - all in Cincinnati; and the Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal (H.A.H.)
| | - Christopher M Ndugwa
- From the Ryan White Center for Pediatric Infectious Diseases and Global Health, Department of Pediatrics, Indiana University, Indianapolis (C.C.J.); the Department of Pediatrics and Child Health, Makerere University (R.O.O., H.A.H., C.N., P.K., C.M.N.), Global Health Uganda (R.O.O., C.N.), and Mulago Hospital (P.K.) - all in Kampala, Uganda; the Division of Hematology, Department of Pediatrics (T.S.L., A.L., R.E.W.), and the Global Health Center (R.E.W.), Cincinnati Children's Hospital Medical Center, and the University of Cincinnati College of Medicine (A.L., R.E.W.) - all in Cincinnati; and the Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal (H.A.H.)
| | - Adam Lane
- From the Ryan White Center for Pediatric Infectious Diseases and Global Health, Department of Pediatrics, Indiana University, Indianapolis (C.C.J.); the Department of Pediatrics and Child Health, Makerere University (R.O.O., H.A.H., C.N., P.K., C.M.N.), Global Health Uganda (R.O.O., C.N.), and Mulago Hospital (P.K.) - all in Kampala, Uganda; the Division of Hematology, Department of Pediatrics (T.S.L., A.L., R.E.W.), and the Global Health Center (R.E.W.), Cincinnati Children's Hospital Medical Center, and the University of Cincinnati College of Medicine (A.L., R.E.W.) - all in Cincinnati; and the Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal (H.A.H.)
| | - Russell E Ware
- From the Ryan White Center for Pediatric Infectious Diseases and Global Health, Department of Pediatrics, Indiana University, Indianapolis (C.C.J.); the Department of Pediatrics and Child Health, Makerere University (R.O.O., H.A.H., C.N., P.K., C.M.N.), Global Health Uganda (R.O.O., C.N.), and Mulago Hospital (P.K.) - all in Kampala, Uganda; the Division of Hematology, Department of Pediatrics (T.S.L., A.L., R.E.W.), and the Global Health Center (R.E.W.), Cincinnati Children's Hospital Medical Center, and the University of Cincinnati College of Medicine (A.L., R.E.W.) - all in Cincinnati; and the Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal (H.A.H.)
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de Montalembert M, Tshilolo L, Allali S. Sickle cell disease: a comprehensive program of care from birth. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:490-495. [PMID: 31808910 PMCID: PMC6913505 DOI: 10.1182/hematology.2019000053] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
As more children are appropriately being diagnosed, the burden of sickle cell disease is increasing greatly in Africa and in high-resource countries such as the United States and Europe. Early management is mandatory, but newborn screening is not implemented everywhere. Point-of-care testing devices are increasingly being used in low-resource countries, showing good sensitivity and specificity. Because the diagnosis is often traumatic for the families, the announcement should be made by an experienced person. The development of care networks is urgently required to facilitate daily life by defining the respective functions of nearby and highly specialized health care professionals, who should work in close collaboration. Comprehensive programs targeting the prevention of pneumococcal infections, malaria in infested zones, and stroke may substantially improve patient care. Hydroxyurea is increasingly being used, but whether it should be systematically prescribed in all children is debated, and its access is still limited in many African countries. Yearly checkups should be organized early in life in order to screen and then treat any organ impairment. Enhancing parents' and patients' knowledge and skills is mandatory.
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Affiliation(s)
- Mariane de Montalembert
- Reference Center for Sickle Cell Disease, Hôpital Necker-Enfants malades, AP-HP, Université Paris Descartes, Labex GR-Ex, Paris, France; and
| | - Léon Tshilolo
- Centre Hospitalier Mère-Enfant, CEFA/Monkole, Kinshasa, Democratic Republic of the Congo
| | - Slimane Allali
- Reference Center for Sickle Cell Disease, Hôpital Necker-Enfants malades, AP-HP, Université Paris Descartes, Labex GR-Ex, Paris, France; and
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14
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Regan S, Yang X, Finnberg NK, El-Deiry WS, Pu JJ. Occurrence of acute myeloid leukemia in hydroxyurea-treated sickle cell disease patient. Cancer Biol Ther 2019; 20:1389-1397. [PMID: 31423878 DOI: 10.1080/15384047.2019.1647055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Hydroxyurea (HU) has been widely used in sickle cell disease. Its potential long-term risk for carcinogenesis or leukemogenic risk remains undefined. Here, we report a 26 y old African-American female with Sickle Cell Disease (SCD) who developed refractory/relapsed acute myeloid leukemia (AML) 6 months after 26 months of HU use. That patient's cytogenetics and molecular genetics analyses demonstrated a complex mutation profile with 5q deletion, trisomy 8, and P53 deletion (deletion of 17p13.1). P53 gene sequence studies revealed a multitude of somatic mutations that most suggest a treatment-related etiology. The above-mentioned data indicates that the patient may have developed acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) as a direct result of HU exposure.
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Affiliation(s)
- Samuel Regan
- Department of Medicine, College of Medicine, SUNY Upstate Medical University , Syracuse , New York , USA
| | - Xuebin Yang
- Department of Pathology, Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA
| | | | - Wafik S El-Deiry
- Department of Pathology, Warren Alpert Medical School, Brown University , Providence , Rhode Island , USA
| | - Jeffrey J Pu
- Department of Medicine, College of Medicine, SUNY Upstate Medical University , Syracuse , New York , USA.,Upstate Cancer Center, Departments of Medicine, Pathology, and Pharmacology, SUNY Upstate Medical University , Syracuse , New York , USA.,Syracuse VA Medical Center, SUNY Upstate Medical University , Syracuse , New York , USA
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15
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Chambers TM, Kahan S, Camanda JF, Scheurer M, Airewele GE. Intermittent or uneven daily administration of low-dose hydroxyurea is effective in treating children with sickle cell anemia in Angola. Pediatr Blood Cancer 2018; 65:e27365. [PMID: 30051651 DOI: 10.1002/pbc.27365] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 05/30/2018] [Accepted: 06/18/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Although hydroxyurea is proven effective in treatment of sickle cell anemia (SCA) and is widely prescribed in high-income countries, due to questions about feasibility of treating large numbers of patients in resource-limited health systems, its use is limited in sub-Saharan Africa (SSA), where most children with SCA live. We assessed hematological response and toxicity of hydroxyurea treatment for SCA in Angola. METHODS Retrospective study of children with SCA (not selected for clinical severity) treated on a fixed dose of hydroxyurea for at least 6 months. Because only the 500 mg capsule was available, dose was averaged weekly. We evaluated toxicity events and magnitude of hydroxyurea-induced changes in blood counts and compared patients who received a uniform daily dose to those prescribed intermittent or uneven daily doses. RESULTS Only 13% of 303 patients received a uniform dose of hydroxyurea daily. Dose ranged from 16.5 to 22.8 mg/kg/day. Hydroxyurea increased HGB and mean cell volume values by 0.5 g/dL (P < 0.0001) and 8 fL (P < 0.0001), while ANC, PLT, and ARC decreased 1.1 × 109 /L (P < 0.0001), 34 × 109 /L (P = < 0.0001), and 19 × 109 /L (P = 0.0008), respectively. There were no differences in magnitude of hydroxyurea-induced changes between patients prescribed intermittent or uneven doses and uniform daily doses, or between those treated in the lower and higher dose quartiles. Hematological toxicity events were mild and reversible. CONCLUSION Intermittent or uneven daily dosing of hydroxyurea is as effective as fixed daily doses in treating SCA. This strategy may enable treatment of additional children with SCA in SSA.
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Affiliation(s)
- Tiffany M Chambers
- Department of Pediatrics-Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas
| | - Silvina Kahan
- Global Health Corps, Baylor College of Medicine, Houston, Texas
| | - Joao F Camanda
- Faculty of Medicine, Universidade 11 de Novembro, Cabinda, Angola
| | - Michael Scheurer
- Department of Pediatrics-Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas
| | - Gladstone E Airewele
- Department of Pediatrics-Section of Hematology and Oncology, Baylor College of Medicine, Houston, Texas
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16
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Casella JF, Adams RJ, Brambilla DJ, Strouse JJ, Maier P, Dlugash R, Avadhani R, Vermillion K, Tonascia J, Voeks JH, Hanley DF, Thompson RE, Lehmann HP. Developing a risk-based composite neurologic outcome for a trial of hydroxyurea in young children with sickle cell disease. Clin Trials 2018; 16:20-31. [PMID: 30426764 DOI: 10.1177/1740774518807160] [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: 11/16/2022]
Abstract
BACKGROUND Studies of interventions to prevent the many neurological complications of sickle cell disease must take into account multiple outcomes of variable severity, with limited sample size. The goals of the studies presented were to use investigator preferences across outcomes to determine an attitude-based weighting of relevant clinical outcomes and to establish a valid composite outcome for a clinical trial. METHODS In Study 1, investigators were surveyed about their practice regarding hydroxyurea therapy and opinions about outcomes for the "Hydroxyurea to Prevent the Central Nervous System Complications of Sickle Cell Disease Trial" (HU Prevent), and their minimally acceptable relative risk reduction for the two outcome components, motor and neurocognitive deficits. In Study 2, HU Prevent investigators provided overall weights for these two components. In Study 3, they provided more granular rankings, ratings, and maximum number acceptable to harm. A weighted composite outcome, the Stroke Consequences Risk Score, was constructed that incorporates the major neurologic complications of sickle cell disease. The Stroke Consequences Risk Score represents the 3-year risk of suffering the adverse consequences of stroke. In Study 4, the results of the Optimizing Primary Stroke Prevention in Sickle Cell Anemia (STOP2) and Silent Infarct Transfusion Trials were reanalyzed in light of the composite outcome. RESULTS In total, 22 to 27 investigators participated per study. In Study 1, across three samplings between 2009 and 2015, the average minimally acceptable relative risk reduction ranged from 0.36 to 0.50, at or below the target effect size of 0.50. In 2015, 21 (91%) reported that a placebo-controlled trial is reasonable; 23 (100%), that it is ethical; and 22 (96%), that they would change their practice, if the results of the trial were positive. In Studies 2 and 3, the weight elicited for a cognitive decline (of 10 IQ points) from the overall assessment was 0.67 (and for motor deficit, the complementary 0.33); from ranking, 0.6; from rating, 0.58; and from maximal number acceptable to harm, 0.5. Using data from two major clinical trials, Study 4 demonstrated the same conclusions as the original trials using the Stroke Consequences Risk Score, with smaller p-values for both reanalyses. An assessment of acceptability was performed as well. CONCLUSION This set of studies provides the rationale, justification, and validation for the use of a weighted composite outcome and confirms the need for the phase III HU Prevent study. Surveys of investigators in multi-center studies can provide the basis of clinically meaningful outcomes that foster the translation of study results into practice while increasing the efficiency of a study.
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Affiliation(s)
- James F Casella
- 1 Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert J Adams
- 2 Department of Neurology, Medical University of South Carolina, Charleston, SC, USA
| | | | - John J Strouse
- 1 Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,4 Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pia Maier
- 5 Heidelberg University School of Medicine, Heidelberg, Germany
| | - Rachel Dlugash
- 6 Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Radhika Avadhani
- 6 Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - James Tonascia
- 7 Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jenifer H Voeks
- 2 Department of Neurology, Medical University of South Carolina, Charleston, SC, USA
| | - Daniel F Hanley
- 8 Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard E Thompson
- 7 Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Harold P Lehmann
- 9 Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Marks LJ, Munube D, Kasirye P, Mupere E, Jin Z, LaRussa P, Idro R, Green NS. Stroke Prevalence in Children With Sickle Cell Disease in Sub-Saharan Africa: A Systematic Review and Meta-Analysis. Glob Pediatr Health 2018; 5:2333794X18774970. [PMID: 29785408 PMCID: PMC5954575 DOI: 10.1177/2333794x18774970] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 03/30/2018] [Indexed: 01/15/2023] Open
Abstract
Objectives. The prevalence of stroke among children with sickle cell disease (SCD) in sub-Saharan Africa was systematically reviewed. Methods. Comprehensive searches of PubMed, Embase, and Web of Science were performed for articles published between 1980 and 2016 (English or French) reporting stroke prevalence. Using preselected inclusion criteria, titles and abstracts were screened and full-text articles were reviewed. Results. Ten full-text articles met selection criteria. Cross-sectional clinic-based data reported 2.9% to 16.9% stroke prevalence among children with SCD. Using available sickle gene frequencies by country, estimated pediatric mortality, and fixed- and random-effects model, the number of affected individuals is projected as 29 800 (95% confidence interval = 25 571-34 027) and 59 732 (37 004-82 460), respectively. Conclusion. Systematic review enabled the estimation of the number of children with SCD stroke in sub-Saharan Africa. High disease mortality, inaccurate diagnosis, and regional variability of risk hamper more precise estimates. Adopting standardized stroke assessments may provide more accurate determination of numbers affected to inform preventive interventions.
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Affiliation(s)
- Lianna J Marks
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | | | - Zhezhen Jin
- Columbia University Medical Center, New York, NY, USA
| | | | | | - Nancy S Green
- Columbia University Medical Center, New York, NY, USA
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Qureshi A, Kaya B, Pancham S, Keenan R, Anderson J, Akanni M, Howard J. Guidelines for the use of hydroxycarbamide in children and adults with sickle cell disease: A British Society for Haematology Guideline. Br J Haematol 2018; 181:460-475. [PMID: 29732531 DOI: 10.1111/bjh.15235] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Amrana Qureshi
- Department of Paediatric Haematology and Oncology, Oxford Children's Hospital, Oxford University Hospital NHS Trust, Oxford, UK
| | - Banu Kaya
- Department of Paediatric Haematology and Oncology, Royal London Hospitals, Barts Health NHS Trust, London, UK
| | - Shivan Pancham
- Department of Haematology, Sandwell and West Birmingham NHS Trust, West Bromwich, UK
| | - Russell Keenan
- Department of Paediatric Haematology, Alderhey Children's Hospital NHS Trust, Liverpool, UK
| | - Jeremy Anderson
- Department of Clinical Psychology, Imperial College Healthcare NHS Trust, London, UK
| | - Magbor Akanni
- Department of Haematology, Milton Keynes Hospital NHS Trust, Milton Keynes, UK
| | - Jo Howard
- Department of Haematology, Guys and St Thomas's NHS Foundation Trust, London, UK
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Moeen SM, Thabet AF, Hasan HA, Saleh MA. Lower Transcranial Doppler Flow Velocities in Sickle Cell Anemia Patients on Hydroxyurea: Myth or Fact. Indian J Hematol Blood Transfus 2018; 34:97-103. [PMID: 29398806 DOI: 10.1007/s12288-017-0814-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 04/04/2017] [Indexed: 12/21/2022] Open
Abstract
Transcranial Doppler (TCD) detects stroke risk in patients with sickle cell anemia (SCA). Hydroxyurea therapy has the ability to induce increased levels of fetal hemoglobin in sickle cells thus decreasing tendency for red cell sickling. This study aimed to evaluate TCD findings in SCA patients on hydroxyurea and correlate the time-averaged mean velocity (TAMV) with their hematological parameters. Forty SCA patients of both sexes, aged 16-22 years with no history of stroke were screened with TCD for an elevated TAMV, divided into: Group T (20 patients on blood transfusion); and Group H (20 patients on daily hydroxyurea). For all, full medical history, clinical examination, hemoglobin, hematocrit, leukocytes, platelets, fetal hemoglobin and sickling test, in addition TCD to describe the pattern of cerebral blood flow abnormalities were done. TAMV in all cerebral arteries were significantly higher in Group T than Group H, the highest TAMV (147.5 ± 57.09 cm/s) was found in the right middle cerebral artery and correlated negatively with hematocrit in Groups H (P < 0.001). There were 2 (10%) abnormal TAMV results and 5 (25%) conditional in Group T, while all results were normal in Group H. Hydroxyurea therapy may lower TCD velocities and prevent the risk of primary stroke in SCA patients.
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Affiliation(s)
- Sawsan M Moeen
- 1Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmad F Thabet
- 1Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Hosam A Hasan
- 2Department of Radio-diagnosis, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Medhat A Saleh
- 3Department of Public Health and Community Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
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20
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Colombatti R, Palazzi G, Masera N, Notarangelo LD, Bonetti E, Samperi P, Barone A, Perrotta S, Facchini E, Miano M, Del Vecchio GC, Guerzoni ME, Corti P, Menzato F, Cesaro S, Casale M, Rigano P, Forni GL, Russo G, Sainati L. Hydroxyurea prescription, availability and use for children with sickle cell disease in Italy: Results of a National Multicenter survey. Pediatr Blood Cancer 2018; 65. [PMID: 28868627 DOI: 10.1002/pbc.26774] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 07/24/2017] [Accepted: 08/01/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND The number of patients with sickle cell disease (SCD) has increased in Italy in the past decade due to immigration. In spite of the established efficacy of hydroxyurea (HU) in childhood, population-based data regarding its prescription and effectiveness come mainly from studies performed in adults or outside Europe. POPULATION AND METHODS The Hydroxyurea in SCD: A Large Nation-wide Cohort Study from Italy was a retrospective cohort study of adult and pediatric patients with SCD attending 32 centers. Pediatric data are analyzed separately. RESULTS Out of 504 children followed in 11 centers, 206 (40%) were on HU (194 SS/Sβ°, 12 SC/Sß+); 74% came from Sub-Saharian Africa and 18% from Europe. HU therapy indications for SS/Sβ° patients were as follows: 57% painful vaso-occlusive crisis, acute chest syndrome or both, 24% anemia, 8% anemia, and other reasons (the majority had Hb ≤ 8-8.5 g/dl, revealing scarce acceptance of low Hb values by pediatric hematologist). Mean starting dose was 15.5 mg/kg, and dose at full regimen was 17.1 mg/kg. Mean age at HU therapy was 7.68 years, although it was lower for SS/Sβ° patients. Only 10% started HU before 3 years. In 92%, 500 mg capsule was used; in 6%, the galenic was used; and in 2%, 100 mg tablet was used. Significant reduction of clinical events and inpatients admissions, with improvement in hematological parameters, was observed for SS/Sβ° patients and a trend toward improvement for SC/Sß+ patients was also observed. CONCLUSIONS HU effectiveness is demonstrated in a national cohort of children with SCD living in Italy, even at a lower dose than recommended, revealing good adherence to a treatment program by a socially vulnerable group of patients such as immigrants.
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Affiliation(s)
- Raffaella Colombatti
- Department of Child and Maternal Health, Clinic of Pediatric Hematology Oncology, Azienda Ospedaliera-Università di Padova, Padova, Italy
| | - Giovanni Palazzi
- Department of Child and Maternal Health, Clinic of Pediatric Hematology Oncology, Azienda Ospedaliera-Università degli Studi di Modena, Modena, Italy
| | - Nicoletta Masera
- Department of Pediatric Clinic, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | | | - Elisa Bonetti
- Department of Pediatric Onco-Hematology, Azienda Ospedaliera Universitaria Integrata, Verona, Itlay
| | - Piera Samperi
- Department of Pediatric Hematology and Oncology, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Angelica Barone
- Department of Pediatric Onco-Hematology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Silverio Perrotta
- Department of Woman, Child and General and Specialist Surgery, Università degli Studi della Campania "Luigi Vanvitelli,", Napoli, Italy
| | - Elena Facchini
- Clinic of Pediatric Hematology Oncology, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Maurizio Miano
- Haematology Unit, I.R.C.C.S. Istituto Giannina Gaslini, Genoa, Italy
| | | | - Maria Elena Guerzoni
- Department of Child and Maternal Health, Clinic of Pediatric Hematology Oncology, Azienda Ospedaliera-Università degli Studi di Modena, Modena, Italy
| | - Paola Corti
- Department of Pediatric Clinic, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Federica Menzato
- Department of Child and Maternal Health, Clinic of Pediatric Hematology Oncology, Azienda Ospedaliera-Università di Padova, Padova, Italy
| | - Simone Cesaro
- Department of Pediatric Onco-Hematology, Azienda Ospedaliera Universitaria Integrata, Verona, Itlay
| | - Maddalena Casale
- Department of Woman, Child and General and Specialist Surgery, Università degli Studi della Campania "Luigi Vanvitelli,", Napoli, Italy
| | - Paolo Rigano
- Campus of Haematology Franco e Piera Cutino-A.O.O.R. "Villa Sofia-Cervello,", Palermo, Italy
| | - Gian Luca Forni
- Hematology-Thalassemia and Congenital Anemia Center, Galliera Hospital, Genoa, Italy
| | - Giovanna Russo
- Department of Pediatric Hematology and Oncology, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Laura Sainati
- Department of Child and Maternal Health, Clinic of Pediatric Hematology Oncology, Azienda Ospedaliera-Università di Padova, Padova, Italy
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Saunthararajah Y, Vichinsky EP. Sickle Cell Disease. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00042-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Abstract
Sickle cell disease (SCD) is a monogenetic disorder caused by a mutation in the β-globin gene HBB leading to polymerization of red blood cells causing damage to cell membranes, increasing its rigidity and intravascular hemolysis. Multiple lines of evidence suggest that SCD can be viewed as pan-vasculopathy associated with multiple mechanisms but driven by hemoglobin S polymerization. Here we review the pathophysiology, clinical manifestations and management strategies for cerebrovascular disease, pulmonary hypertension and renal disease associated with SCD. These "vascular phenotypes" reflect the systemic nature of the complications of SCD and are a major threat to the well-being of patients with the disorder.
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Affiliation(s)
- Ashar Usmani
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago, Chicago, IL, USA
| | - Roberto F. Machado
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University, Indianapolis, IN, USA
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Estepp JH, Smeltzer MP, Kang G, Li C, Wang WC, Abrams C, Aygun B, Ware RE, Nottage K, Hankins JS. A clinically meaningful fetal hemoglobin threshold for children with sickle cell anemia during hydroxyurea therapy. Am J Hematol 2017; 92:1333-1339. [PMID: 28913922 DOI: 10.1002/ajh.24906] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/09/2017] [Accepted: 09/11/2017] [Indexed: 02/03/2023]
Abstract
Hydroxyurea has proven clinical benefits and is recommended to be offered to all children with sickle cell anemia (SCA), but the optimal dosing regimen remains controversial. Induction of red blood cell fetal hemoglobin (HbF) by hydroxyurea appears to be dose-dependent. However, it is unknown whether maximizing HbF% improves clinical outcomes. HUSTLE (NCT00305175) is a prospective observational study with a primary goal of describing the long-term clinical effects of hydroxyurea escalated to maximal tolerated dose (MTD) in children with SCA. In 230 children, providing 610 patient-years of follow up, the mean attained HbF% at MTD was >20% for up to 4 years of follow-up. When HbF% values were ≤20%, children had twice the odds of hospitalization for any reason (P < .0001), including vaso-occlusive pain (P < .01) and acute chest syndrome (ACS) (P < .01), and more than four times the odds of admission for fever (P < .001). Thirty day readmission rates were not affected by HbF%. Neutropenia (ANC <1000 × 106 /L) was rare (2.3% of all laboratory monitoring), transient, and benign. Therefore, attaining HbF >20% was associated with fewer hospitalizations without significant toxicity. These data support the use of hydroxyurea in children, and suggest that the preferred dosing strategy is one that targets a HbF endpoint >20%.
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Affiliation(s)
- Jeremie H. Estepp
- Department of Hematology; St. Jude Children's Research Hospital; Memphis Tennessee
- Department of Pathology; St. Jude Children's Research Hospital; Memphis Tennessee
| | - Matthew P. Smeltzer
- Division of Epidemiology, Biostatistics, and Environmental Health; The University of Memphis School of Public Health; Memphis Tennessee
| | - Guolian Kang
- Department of Biostatistics; St. Jude Children's Research Hospital; Memphis Tennessee
| | - Chen Li
- Department of Biostatistics; St. Jude Children's Research Hospital; Memphis Tennessee
| | - Winfred C. Wang
- Department of Hematology; St. Jude Children's Research Hospital; Memphis Tennessee
| | - Christina Abrams
- Department of Pediatrics; University of Tennessee Health Sciences Center; Memphis Tennessee
| | - Banu Aygun
- Division of Hematology/; Oncology Steven and Alexandra Cohen Children's Medical Center; New Hyde Park New York
| | - Russell E. Ware
- Division of Hematology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | | | - Jane S. Hankins
- Department of Hematology; St. Jude Children's Research Hospital; Memphis Tennessee
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Adegoke SA, Macedo-Campos RDS, Braga JAP, Figueiredo MS, Silva GS. Changes in Transcranial Doppler Flow Velocities in Children with Sickle Cell Disease: The Impact of Hydroxyurea Therapy. J Stroke Cerebrovasc Dis 2017; 27:425-431. [PMID: 29056404 DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/30/2017] [Accepted: 09/17/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Hydroxyurea (HU) was recently described as a substitute for chronic transfusion for children with sickle cell disease (SCD) and abnormal transcranial Doppler (TCD) velocities who have received at least 1 year of transfusions. However, the role of HU in reverting elevated TCD velocities in patients not treated with transfusion is still debatable. The objective of the study was to examine whether HU influences the progression of TCD velocities in children with SCD. PATIENTS AND METHODS Children with SCD with at least 2 TCDs not less than 6 months apart were evaluated over 51 months. Time-averaged maximum mean (TAMM) velocities for the initial and the last transcranial Doppler examinations were noted and differences compared between HU and HU-naive groups. RESULTS Overall, 68.8% of the HU-group with elevated TCD velocities compared with 40.0% of the HU-naive experienced TCD reversal (P = .047). A higher proportion of the HU-naive group, 7 (14.3%) versus 9.8% of the HU group experienced TCD conversion. Those with initial conditional velocities in the HU-group experienced a significant reduction in TAMM velocities (from 176.8 ± 5.3 to 162.7 ± 13.9 cm/s, difference of 14.1 cm/s; P = .001) unlike those in the HU-naive group (176.3 ± 5.3 to 170.0 ± 18.6 cm/s, difference of 6.3 cm/s; P = .148). The change in the TAMM velocities was also significantly higher among the HU-group (14.1 ± 12.4 cm/s versus 6.3 ± 18.5 cm/s, P = .015). CONCLUSION Our data suggest a beneficial role of HU in TCD velocity reduction in patients not treated with chronic transfusions, particularly among those with initial conditional TCD velocities.
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Affiliation(s)
- Samuel Ademola Adegoke
- Haematology and Blood Transfusion Division, Universidade Federal de São Paulo, São Paulo, Brazil; Department of Pediatrics and Child Health, Obafemi Awolowo University, Ile-Ife, Nigeria.
| | | | | | - Maria Stella Figueiredo
- Haematology and Blood Transfusion Division, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil; Programa Integrado de Neurologia, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Abstract
BACKGROUND As previous studies had discordant results with regard to the correlation of transcranial Doppler (TCD) screening and brain MRI, the aim of this study was to find the correlation between TCD values and silent ischemia in sickle cell disease (SCD) patients. METHOD AND MATERIALS In this cross-sectional study, 50 patients with proven diagnosis of sickle cell hemoglobinopathies based on their hemoglobin electrophoresis were included. Demographic data, their physical exam, information with regard to crises history, and their laboratory data were recorded. Brain MRI and TCD were requested for all patients. RESULTS The mean age of the patients was 10.2±5.8 years. Only 3 patients (6%) showed evidence of ischemia on brain MRI. Normal and ischemic patients were not significantly different with respect to TCD values, sex, splenomegaly, aplastic crisis, and laboratory test results (P-value >0.05). Only platelet count was significantly higher in the ischemic group compared with that in the normal group (P=0.002). The pain crisis was significantly associated with the mean velocity values of RMCA, LMCA, RV, and LV arteries (P-value <0.05). CONCLUSION On the basis of our results, there was no significant difference in the mean velocity TCD values between patients with and without evidence of ischemic brain damage in brain MRI. The frequency of silent ischemia was much lower than expected. Further studies with larger sample sizes are needed to elucidate the positive predictive value of abnormal TCD in the prediction of silent ischemia in patients with sickle hemoglobinopathy in certain ethnic groups.
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Brewin J, Kaya B, Chakravorty S. How I manage sickle cell patients with high transcranial doppler results. Br J Haematol 2017; 179:377-388. [DOI: 10.1111/bjh.14850] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- John Brewin
- Department of Haematology; King's College London; London UK
| | - Banu Kaya
- Department of Haematology; Royal London Hospital; London UK
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Mazzucco S, Diomedi M, Qureshi A, Sainati L, Padayachee ST. Transcranial Doppler screening for stroke risk in children with sickle cell disease: a systematic review. Int J Stroke 2017; 12:580-588. [PMID: 28440126 DOI: 10.1177/1747493017706189] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Sickle cell disease (SCD) is one of the most common causes of stroke in children worldwide. Based on the results of the Stroke Prevention Trial in Sickle Cell Anemia (STOP), annual transcranial Doppler ultrasound (TCD) screening for affected children is standard practice. However, the need for TCD surveillance programs could override the accuracy of the screening, affecting the correct stratification of stroke risk and subsequent clinical management of the target population. Aims To shed light on this issue, a systematic review of the literature on TCD screening for children and adolescents with SCD was carried out (CRD42016050549), according to a list of clinically relevant questions, with a particular focus on screening practices in European countries. Quality of the evidence was rated using the grading of recommendations assessment, development and evaluation. Summary of review Thirty-three studies published in English or French were included (5 randomized controlled trials, 8 experimental non-randomized, and 20 observational studies). The quality of the retrieved evidence ranged between low and high, but was rated as moderate or high most of the times. TCD is effective as a screening tool for the primary prevention of stroke in SCD children. There is no high-quality evidence on the effectiveness of alternative screening methods, such as imaging-TCD with or without angle correction or magnetic resonance angiography. No evidence was found on effectiveness of the screening on children on hydroxyurea and with genotypes other than HbSS and HbS/β0. No European data were found on screening rates or adherence of screening practices to the STOP protocol. Conclusions High-quality studies on alternative screening methods that are currently used in real-world practice, and on screening applicability to specific subgroups of patients are urgently needed. Considering the low awareness of the disease in European countries and the lack of data on screening practices and adherence, clinicians need up-to-date guidelines for more uniform and evidence-based surveillance of children with SCD.
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Affiliation(s)
- Sara Mazzucco
- 1 Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- 2 Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Marina Diomedi
- 3 Stroke Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Amrana Qureshi
- 4 Paediatric Haematology and Oncology Service, Children's Hospital-Oxford University Hospital Foundation Trust, Oxford, UK
| | - Laura Sainati
- 5 Pediatric Haematology and Oncology Service, Dipartimento della Donna e del Bambino, Padua University, Padova, Italy
| | - Soundrie T Padayachee
- 6 Ultrasonic Angiology Department, Guy's & St Thomas' NHS Foundation Trust, London, UK
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Ware RE, de Montalembert M, Tshilolo L, Abboud MR. Sickle cell disease. Lancet 2017; 390:311-323. [PMID: 28159390 DOI: 10.1016/s0140-6736(17)30193-9] [Citation(s) in RCA: 572] [Impact Index Per Article: 81.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/11/2016] [Accepted: 11/18/2016] [Indexed: 01/08/2023]
Abstract
Sickle cell disease is a common and life-threatening haematological disorder that affects millions of people worldwide. Abnormal sickle-shaped erythrocytes disrupt blood flow in small vessels, and this vaso-occlusion leads to distal tissue ischaemia and inflammation, with symptoms defining the acute painful sickle-cell crisis. Repeated sickling and ongoing haemolytic anaemia, even when subclinical, lead to parenchymal injury and chronic organ damage, causing substantial morbidity and early mortality. Currently available treatments are limited to transfusions and hydroxycarbamide, although stem cell transplantation might be a potentially curative therapy. Several new therapeutic options are in development, including gene therapy and gene editing. Recent advances include systematic universal screening for stroke risk, improved management of iron overload using oral chelators and non-invasive MRI measurements, and point-of-care diagnostic devices. Controversies include the role of haemolysis in sickle cell disease pathophysiology, optimal management of pregnancy, and strategies to prevent cerebrovascular disease.
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Affiliation(s)
- Russell E Ware
- Division of Hematology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | | | - Léon Tshilolo
- Centre Hospitalier Monkole, Kinshasa, Democratic Republic of Congo
| | - Miguel R Abboud
- Department of Pediatrics, American University of Beirut, Beirut, Lebanon
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Ghafuri DL, Chaturvedi S, Rodeghier M, Stimpson SJ, McClain B, Byrd J, DeBaun MR. Secondary benefit of maintaining normal transcranial Doppler velocities when using hydroxyurea for prevention of severe sickle cell anemia. Pediatr Blood Cancer 2017; 64. [PMID: 28035747 DOI: 10.1002/pbc.26401] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 11/15/2016] [Accepted: 11/16/2016] [Indexed: 11/06/2022]
Abstract
In a retrospective cohort study, we tested the hypothesis that when prescribing hydroxyurea (HU) to children with sickle cell anemia (SCA) to prevent vaso-occlusive events, there will be a secondary benefit of maintaining low transcranial Doppler (TCD) velocity, measured by imaging technique (TCDi). HU was prescribed for 90.9% (110 of 120) of children with SCA ≥5 years of age and followed for a median of 4.4 years, with 70% (n = 77) receiving at least one TCDi evaluation after starting HU. No child prescribed HU had a conditional or abnormal TCDi measurement. HU initiation for disease severity prevention decreases the prevalence of abnormal TCDi velocities.
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Affiliation(s)
| | - Shruti Chaturvedi
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | | | - Sarah-Jo Stimpson
- Department of Pediatrics, Vanderbilt-Meharry Sickle Cell Center for Excellence, Vanderbilt University of Medicine, Nashville, Tennessee
| | - Brandi McClain
- Department of Pediatrics, Vanderbilt-Meharry Sickle Cell Center for Excellence, Vanderbilt University of Medicine, Nashville, Tennessee
| | - Jeannie Byrd
- Department of Pediatrics, Vanderbilt-Meharry Sickle Cell Center for Excellence, Vanderbilt University of Medicine, Nashville, Tennessee
| | - Michael R DeBaun
- Department of Pediatrics, Vanderbilt-Meharry Sickle Cell Center for Excellence, Vanderbilt University of Medicine, Nashville, Tennessee
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Cannas G, Poutrel S, Thomas X. Hydroxycarbamine: from an Old Drug Used in Malignant Hemopathies to a Current Standard in Sickle Cell Disease. Mediterr J Hematol Infect Dis 2017; 9:e2017015. [PMID: 28293403 PMCID: PMC5333733 DOI: 10.4084/mjhid.2017.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 01/20/2017] [Indexed: 01/31/2023] Open
Abstract
While hydroxycarbamide (hydroxyurea, HU) has less and fewer indications in malignant hemopathies, it represents the only widely used drug which modifies sickle cell disease pathogenesis. Clinical experience with HU for patients with sickle cell disease has been accumulated over the past 25 years in Western countries. The review of the literature provides increasing support for safety and efficacy in both children and adults for reducing acute vaso-occlusive events including pain episodes and acute chest syndrome. No increased incidence of leukemia and teratogenicity was demonstrated. HU has become the standard-of-care for sickle cell anemia but remains underused. Barriers to its use should be identified and overcome.
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Affiliation(s)
- Giovanna Cannas
- Hospices Civils de Lyon, Department of Internal Medicine, Edouard Herriot Hospital, Lyon, France
- Claude Bernard University Lyon 1, Laboratoire Interuniversitaire de Biologie de la Motricité EA7424, Equipe ‘Vascular biology and red blood cell’, Villeurbanne, France
| | - Solène Poutrel
- Hospices Civils de Lyon, Department of Internal Medicine, Edouard Herriot Hospital, Lyon, France
| | - Xavier Thomas
- Hospices Civils de Lyon, Hematology Department, Lyon-Sud Hospital, Pierre Bénite, France
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31
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DeBaun MR, King AA. Prevention of central nervous system sequelae in sickle cell disease without evidence from randomized controlled trials: the case for a team-based learning collaborative. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:632-639. [PMID: 27913539 PMCID: PMC6142474 DOI: 10.1182/asheducation-2016.1.632] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Since 1998, the National Institutes of Health has funded 5 randomized controlled trials (RCTs) for primary and secondary prevention of strokes in children with sickle cell anemia (SCA). In a systematic fashion, these trials have significantly advanced the care of children with SCA. In the absence of an RCT, clinicians are often compelled to make decisions at the bedside, based on experience, observational studies, and principles of hematology. We will provide an initial example that describes how a team-based, learning collaborative developed a multisite standard care protocol with a low budget (<$10 000 per year) to overcome the intrinsic limitations of advancing the care of neurologic complications in sickle cell disease (SCD). The critical components of this approach include: (1) regular meetings with the multidisciplinary team from multiple sites; (2) consensus regarding the best evidence-based neurologic management in multiple SCD centers; (3) an Institutional Review Board-approved protocol based on consensus standard care; (4) minimizing and ensuring accurate data collection; and most importantly, (5) a spirit of collaboration to improve the care of individuals with SCD. Four common neurologic problems and strategies for management in children and adults with SCD will be discussed: (1) secondary stroke prevention in high-income countries; (2) primary stroke prevention in low- and middle-income countries (LMICs); (3) poor academic performance in students; and (4) cognitive disability in adults. With a commitment to a team-based learning collaborative, incremental advances are possible for the neurologic care of children and adults with SCD.
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Affiliation(s)
- Michael R. DeBaun
- Vanderbilt-Meharry Sickle Cell Center for Excellence, Department of Pediatrics, Vanderbilt University of Medicine, Nashville, TN; and
| | - Allison A. King
- Program in Occupational Therapy, Departments of Surgery (Division of Public Health Sciences) and Pediatrics (Division of Hematology and Oncology), Washington University School of Medicine, St. Louis, MO
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Davis BA, Allard S, Qureshi A, Porter JB, Pancham S, Win N, Cho G, Ryan K. Guidelines on red cell transfusion in sickle cell disease Part II: indications for transfusion. Br J Haematol 2016; 176:192-209. [DOI: 10.1111/bjh.14383] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - Shubha Allard
- Barts Health NHS Trust & NHS Blood and Transplant; London UK
| | - Amrana Qureshi
- Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | - John B. Porter
- University College London Hospitals NHS Foundation Trust; London UK
| | - Shivan Pancham
- Sandwell and West Birmingham Hospitals NHS Trust; Birmingham UK
| | - Nay Win
- NHS Blood and Transplant; London UK
| | | | - Kate Ryan
- Central Manchester University Hospitals NHS Foundation Trust; Manchester UK
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Rankine-Mullings AE, Little CR, Reid ME, Soares DP, Taylor-Bryan C, Knight-Madden JM, Stuber SE, Badaloo AV, Aldred K, Wisdom-Phipps ME, Latham T, Ware RE. EXpanding Treatment for Existing Neurological Disease (EXTEND): An Open-Label Phase II Clinical Trial of Hydroxyurea Treatment in Sickle Cell Anemia. JMIR Res Protoc 2016; 5:e185. [PMID: 27619954 PMCID: PMC5037317 DOI: 10.2196/resprot.5872] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 07/21/2016] [Accepted: 08/08/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Cerebral vasculopathy in sickle cell anemia (SCA) begins in childhood and features intracranial arterial stenosis with high risk of ischemic stroke. Stroke risk can be reduced by transcranial doppler (TCD) screening and chronic transfusion therapy; however, this approach is impractical in many developing countries. Accumulating evidence supports the use of hydroxyurea for the prevention and treatment of cerebrovascular disease in children with SCA. Recently we reported that hydroxyurea significantly reduced the conversion from conditional TCD velocities to abnormal velocities; whether hydroxyurea can be used for children with newly diagnosed severe cerebrovascular disease in place of starting transfusion therapy remains unknown. OBJECTIVE The primary objective of the EXpanding Treatment for Existing Neurological Disease (EXTEND) trial is to investigate the effect of open label hydroxyurea on the maximum time-averaged mean velocity (TAMV) after 18 months of treatment compared to the pre-treatment value. Secondary objectives include the effects of hydroxyurea on serial TCD velocities, the incidence of neurological and non-neurological events, quality of life (QOL), body composition and metabolism, toxicity and treatment response, changes to brain magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA), genetic and serologic markers of disease severity, and cognitive and pulmonary function. METHODS This prospective Phase II trial will enroll children with SCA in Jamaica, between the ages of 2 and 17 years, with either conditional (170-199 cm/sec) or abnormal (≥ 200 cm/sec) TCD velocities. Oral hydroxyurea will be administered daily and escalated to the maximum tolerated dose (MTD). Participants will be seen in the Sickle Cell Unit (SCU) in Kingston, Jamaica monthly until achieving MTD, and then every 3 months. TCD will be performed every 6 months. RESULTS Currently, 43 participants have been enrolled out of a projected 50. There was one withdrawal due to immigration, with no permanent screen failures. Of the 43 enrolled, 37 participants have initiated study treatment. CONCLUSIONS This trial investigates the effects of hydroxyurea treatment at MTD in children with conditional or abnormal TCD velocities before transfusion therapy and may represent an important advance towards establishing a suitable non-transfusion protocol for stroke prevention in children with SCA. The trial outcomes will have profound significance in developing countries where the disease burden is highest. CLINICALTRIAL ClinicalTrials.gov NCT02556099; https://clinicaltrials.gov/ct2/show/NCT02556099 (Archived by WebCite at http://www.webcitation.org/6k1yMAa9G).
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Affiliation(s)
- Angela E Rankine-Mullings
- Sickle Cell Unit, Tropical Medicine Research Institute, University of the West Indies, Kingston, Jamaica.
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Chou ST, Fasano RM. Management of Patients with Sickle Cell Disease Using Transfusion Therapy. Hematol Oncol Clin North Am 2016; 30:591-608. [DOI: 10.1016/j.hoc.2016.01.011] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Central nervous system complications and management in sickle cell disease. Blood 2016; 127:829-38. [DOI: 10.1182/blood-2015-09-618579] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 12/25/2015] [Indexed: 02/07/2023] Open
Abstract
Abstract
With advances in brain imaging and completion of randomized clinical trials (RCTs) for primary and secondary stroke prevention, the natural history of central nervous system (CNS) complications in sickle cell disease (SCD) is evolving. In order of current prevalence, the primary CNS complications include silent cerebral infarcts (39% by 18 years), headache (both acute and chronic: 36% in children with sickle cell anemia [SCA]), ischemic stroke (as low as 1% in children with SCA with effective screening and prophylaxis, but ∼11% in children with SCA without screening), and hemorrhagic stroke in children and adults with SCA (3% and 10%, respectively). In high-income countries, RCTs (Stroke Prevention in Sickle Cell Anemia [STOP], STOP II) have demonstrated that regular blood transfusion therapy (typically monthly) achieves primary stroke prevention in children with SCA and high transcranial Doppler (TCD) velocities; after at least a year, hydroxycarbamide may be substituted (TCD With Transfusions Changing to Hydroxyurea [TWiTCH]). Also in high-income countries, RCTs have demonstrated that regular blood transfusion is the optimal current therapy for secondary prevention of infarcts for children with SCA and strokes (Stroke With Transfusions Changing to Hydroxyurea [SWiTCH]) or silent cerebral infarcts (Silent Infarct Transfusion [SIT] Trial). For adults with SCD, CNS complications continue to be a major cause of morbidity and mortality, with no evidence-based strategy for prevention.
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36
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Ware RE, Davis BR, Schultz WH, Brown RC, Aygun B, Sarnaik S, Odame I, Fuh B, George A, Owen W, Luchtman-Jones L, Rogers ZR, Hilliard L, Gauger C, Piccone C, Lee MT, Kwiatkowski JL, Jackson S, Miller ST, Roberts C, Heeney MM, Kalfa TA, Nelson S, Imran H, Nottage K, Alvarez O, Rhodes M, Thompson AA, Rothman JA, Helton KJ, Roberts D, Coleman J, Bonner MJ, Kutlar A, Patel N, Wood J, Piller L, Wei P, Luden J, Mortier NA, Stuber SE, Luban NLC, Cohen AR, Pressel S, Adams RJ. Hydroxycarbamide versus chronic transfusion for maintenance of transcranial doppler flow velocities in children with sickle cell anaemia-TCD With Transfusions Changing to Hydroxyurea (TWiTCH): a multicentre, open-label, phase 3, non-inferiority trial. Lancet 2016; 387:661-670. [PMID: 26670617 PMCID: PMC5724392 DOI: 10.1016/s0140-6736(15)01041-7] [Citation(s) in RCA: 320] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND For children with sickle cell anaemia and high transcranial doppler (TCD) flow velocities, regular blood transfusions can effectively prevent primary stroke, but must be continued indefinitely. The efficacy of hydroxycarbamide (hydroxyurea) in this setting is unknown; we performed the TWiTCH trial to compare hydroxyurea with standard transfusions. METHODS TWiTCH was a multicentre, phase 3, randomised, open-label, non-inferiority trial done at 26 paediatric hospitals and health centres in the USA and Canada. We enrolled children with sickle cell anaemia who were aged 4-16 years and had abnormal TCD flow velocities (≥ 200 cm/s) but no severe vasculopathy. After screening, eligible participants were randomly assigned 1:1 to continue standard transfusions (standard group) or hydroxycarbamide (alternative group). Randomisation was done at a central site, stratified by site with a block size of four, and an adaptive randomisation scheme was used to balance the covariates of baseline age and TCD velocity. The study was open-label, but TCD examinations were read centrally by observers masked to treatment assignment and previous TCD results. Participants assigned to standard treatment continued to receive monthly transfusions to maintain 30% sickle haemoglobin or lower, while those assigned to the alternative treatment started oral hydroxycarbamide at 20 mg/kg per day, which was escalated to each participant's maximum tolerated dose. The treatment period lasted 24 months from randomisation. The primary study endpoint was the 24 month TCD velocity calculated from a general linear mixed model, with the non-inferiority margin set at 15 cm/s. The primary analysis was done in the intention-to-treat population and safety was assessed in all patients who received at least one dose of assigned treatment. This study is registered with ClinicalTrials.gov, number NCT01425307. FINDINGS Between Sept 20, 2011, and April 17, 2013, 159 patients consented and enrolled in TWiTCH. 121 participants passed screening and were then randomly assigned to treatment (61 to transfusions and 60 to hydroxycarbamide). At the first scheduled interim analysis, non-inferiority was shown and the sponsor terminated the study. Final model-based TCD velocities were 143 cm/s (95% CI 140-146) in children who received standard transfusions and 138 cm/s (135-142) in those who received hydroxycarbamide, with a difference of 4·54 (0·10-8·98). Non-inferiority (p=8·82 × 10(-16)) and post-hoc superiority (p=0·023) were met. Of 29 new neurological events adjudicated centrally by masked reviewers, no strokes were identified, but three transient ischaemic attacks occurred in each group. Magnetic resonance brain imaging and angiography (MRI and MRA) at exit showed no new cerebral infarcts in either treatment group, but worsened vasculopathy in one participant who received standard transfusions. 23 severe adverse events in nine (15%) patients were reported for hydroxycarbamide and ten serious adverse events in six (10%) patients were reported for standard transfusions. The most common serious adverse event in both groups was vaso-occlusive pain (11 events in five [8%] patients with hydroxycarbamide and three events in one [2%] patient for transfusions). INTERPRETATION For high-risk children with sickle cell anaemia and abnormal TCD velocities who have received at least 1 year of transfusions, and have no MRA-defined severe vasculopathy, hydroxycarbamide treatment can substitute for chronic transfusions to maintain TCD velocities and help to prevent primary stroke. FUNDING National Heart, Lung, and Blood Institute, National Institutes of Health.
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Affiliation(s)
- Russell E Ware
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Barry R Davis
- University of Texas School of Public Health, Houston, TX, USA
| | | | | | - Banu Aygun
- Cohen Children's Medical Center, New Hyde Park, NY, USA
| | | | - Isaac Odame
- Hospital for Sick Children, Toronto, ON, Canada
| | - Beng Fuh
- East Carolina University, Greenville, NC, USA
| | - Alex George
- Baylor College of Medicine, Houston, TX, USA
| | - William Owen
- Children's Hospital of the King's Daughters, Norfolk, VA, USA
| | | | | | | | | | | | | | | | | | - Scott T Miller
- State University of New York-Downstate, Brooklyn, NY, USA
| | | | | | | | - Stephen Nelson
- Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | | | - Kerri Nottage
- St Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | - Alexis A Thompson
- Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | | | - Donna Roberts
- Medical University of South Carolina, Charleston, SC, USA
| | - Jamie Coleman
- St Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | - Niren Patel
- Georgia Regents University, Augusta, GA, USA
| | - John Wood
- Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Linda Piller
- University of Texas School of Public Health, Houston, TX, USA
| | - Peng Wei
- University of Texas School of Public Health, Houston, TX, USA
| | - Judy Luden
- Medical University of South Carolina, Charleston, SC, USA
| | - Nicole A Mortier
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Susan E Stuber
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Alan R Cohen
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sara Pressel
- University of Texas School of Public Health, Houston, TX, USA
| | - Robert J Adams
- Medical University of South Carolina, Charleston, SC, USA
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Crespi JSR, Braga JA, Figueiredo MS, Silva GS, Debieux P, da Silva EMK. Interventions for preventing silent cerebral infarcts in people with sickle cell disease. Hippokratia 2016. [DOI: 10.1002/14651858.cd010718.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Juliana SR Crespi
- Universidade Federal de São Paulo; Department of Pediatrics; Rua Botucatu, 598 São Paulo São Paulo Brazil 04023-062
| | - Josefina A.P Braga
- Universidade Federal de São Paulo; Department of Pediatrics; Rua Botucatu, 598 São Paulo São Paulo Brazil 04023-062
| | - Maria S Figueiredo
- Universidade Federal de São Paulo; Department of Clinical Oncology; Rua Dr Diogo de Faria, 824 - 3o andar CEP São Paulo São Paulo Brazil 04037-002
| | - Gisele S Silva
- Universidade Federal de São Paulo; Department of Neurology; Rua Pedro de Toledo, 598 669 - Edif. Pesquisa II - 2o. andar São Paulo Brazil 04039-032
| | - Pedro Debieux
- Universidade Federal de São Paulo; Department of Orthopaedics and Traumatology; Rua Borges Lagoa, 783 - 5th Floor São Paulo São Paulo Brazil 04038-032
| | - Edina MK da Silva
- Universidade Federal de São Paulo; Emergency Medicine and Evidence Based Medicine; Rua Borges Lagoa 564 cj 64 Vl. Clementino São Paulo São Paulo Brazil 04038-000
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Chaturvedi S, DeBaun MR. Evolution of sickle cell disease from a life-threatening disease of children to a chronic disease of adults: The last 40 years. Am J Hematol 2016; 91:5-14. [PMID: 26547630 DOI: 10.1002/ajh.24235] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 11/04/2015] [Accepted: 11/05/2015] [Indexed: 02/05/2023]
Abstract
Over the past 40 years, public health measures such as universal newborn screening, penicillin prophylaxis, vaccinations, and hydroxyurea therapy have led to an impressive decline in sickle cell disease (SCD)-related childhood mortality and SCD-related morbidity in high-income countries. We remain cautiously optimistic that the next 40 years will be focused on meeting current challenges in SCD by addressing chronic complications of SCD to reduce mortality and improve quality of life in a growing population of adults with SCD in high-income countries, while simultaneously decreasing the disparity of medical care between high and low-income countries.
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Affiliation(s)
- Shruti Chaturvedi
- Department of Medicine, Division of Hematology and Oncology; Vanderbilt University Medical Center; Nashville Tennessee
| | - Michael R. DeBaun
- Department of Pediatrics, Vanderbilt-Meharry Sickle Cell Disease Center of Excellence; Vanderbilt University Medical Center; Nashville Tennessee
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Kasner SE, Cucchiara BL. Treatment of “Other” Stroke Etiologies. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00056-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Hankins JS, McCarville MB, Rankine-Mullings A, Reid ME, Lobo CL, Moura PG, Ali S, Soares DP, Aldred K, Jay DW, Aygun B, Bennett J, Kang G, Goldsmith JC, Smeltzer MP, Boyett JM, Ware RE. Prevention of conversion to abnormal transcranial Doppler with hydroxyurea in sickle cell anemia: A Phase III international randomized clinical trial. Am J Hematol 2015; 90:1099-105. [PMID: 26414435 DOI: 10.1002/ajh.24198] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 09/23/2015] [Indexed: 11/08/2022]
Abstract
Children with sickle cell anemia (SCA) and conditional transcranial Doppler (TCD) ultrasound velocities (170-199 cm/sec) may develop stroke. However, with limited available clinical data, the current standard of care for conditional TCD velocities is observation. The efficacy of hydroxyurea in preventing conversion from conditional to abnormal TCD (≥200 cm/sec), which confers a higher stroke risk, has not been studied prospectively in a randomized trial. Sparing Conversion to Abnormal TCD Elevation (SCATE #NCT01531387) was a National Heart, Lung, and Blood Institute-funded Phase III multicenter international clinical trial comparing alternative therapy (hydroxyurea) to standard care (observation) to prevent conversion from conditional to abnormal TCD velocity in children with SCA. SCATE enrolled 38 children from the United States, Jamaica, and Brazil [HbSS (36), HbSβ(0) -thalassemia (1), and HbSD (1), median age = 5.4 years (range, 2.7-9.8)]. Because of the slow patient accrual and administrative delays, SCATE was terminated early. In an intention-to-treat analysis, the cumulative incidence of abnormal conversion was 9% (95% CI = 0-35%) in the hydroxyurea arm and 47% (95% CI = 6-81%) in observation arm at 15 months (P = 0.16). In post hoc analysis according to treatment received, significantly fewer children on hydroxyurea converted to abnormal TCD velocities when compared with observation (0% vs. 50%, P = 0.02). After a mean of 10.1 months, a significant change in mean TCD velocity was observed with hydroxyurea treatment (-15.5 vs. +10.2 cm/sec, P = 0.02). No stroke events occurred in either arm. Hydroxyurea reduces TCD velocities in children with SCA and conditional velocities.
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Affiliation(s)
- Jane S. Hankins
- Department of Hematology; St. Jude Children's Research Hospital; Memphis Tennessee
| | - Mary Beth McCarville
- Department of Hematology; St. Jude Children's Research Hospital; Memphis Tennessee
| | - Angela Rankine-Mullings
- Sickle Cell Unit; Tropical Medicine Research Institute (TMRI), University of the West Indies; Kingston Jamaica
| | - Marvin E. Reid
- Sickle Cell Unit; Tropical Medicine Research Institute (TMRI), University of the West Indies; Kingston Jamaica
| | - Clarisse L.C. Lobo
- Instituto De Hematologia Arthur Siqueira Cavalcanti (HEMORIO); Rio De Janeiro Brazil
| | - Patricia G. Moura
- Instituto De Hematologia Arthur Siqueira Cavalcanti (HEMORIO); Rio De Janeiro Brazil
| | - Susanna Ali
- Sickle Cell Unit; Tropical Medicine Research Institute (TMRI), University of the West Indies; Kingston Jamaica
| | - Deanne P. Soares
- Sickle Cell Unit; Tropical Medicine Research Institute (TMRI), University of the West Indies; Kingston Jamaica
| | - Karen Aldred
- Sickle Cell Unit; Tropical Medicine Research Institute (TMRI), University of the West Indies; Kingston Jamaica
| | - Dennis W. Jay
- Department of Hematology; St. Jude Children's Research Hospital; Memphis Tennessee
| | - Banu Aygun
- Division of Pediatric Hematology/Oncology and Stem Cell Transplantation; Cohen Children's Medical Center of New York; New Hyde Park New York
| | - John Bennett
- Wake Forest University School of Medicine; Winston-Salem North Carolina
| | - Guolian Kang
- Department of Hematology; St. Jude Children's Research Hospital; Memphis Tennessee
| | | | - Matthew P. Smeltzer
- Department of Hematology; St. Jude Children's Research Hospital; Memphis Tennessee
| | - James M. Boyett
- Department of Hematology; St. Jude Children's Research Hospital; Memphis Tennessee
| | - Russell E. Ware
- Division of Hematology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
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Lê PQ, Gulbis B, Dedeken L, Dupont S, Vanderfaeillie A, Heijmans C, Huybrechts S, Devalck C, Efira A, Dresse MF, Rozen L, Benghiat FS, Ferster A. Survival among children and adults with sickle cell disease in Belgium: Benefit from hydroxyurea treatment. Pediatr Blood Cancer 2015; 62:1956-61. [PMID: 26173735 DOI: 10.1002/pbc.25608] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 04/22/2015] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To evaluate the survival of patients with sickle cell disease (SCD) recorded in the Belgian SCD Registry and to assess the impact of disease-modifying treatments (DMT). METHOD The Registry created in 2008 included patients of eight centers. All available data in 2008 were retrospectively encoded in the database. After 2008 and until 2012, all data were recorded prospectively for already registered patients as well as newly diagnosed subjects. Data were registered from neonatal screening or from diagnosis (first contact) until last follow-up or death. Data included diagnosis, demography, and outcome data. RESULTS We collected data from 469 patients over a 5,110 patient years (PY) follow-up period. The global mortality rate was low (0.25/100 PY), although 13 patients died (2.8%) and was similar between children, adolescents (10-18 years), and young adults (P = 0.76). Out of the cohort, 185 patients received hydroxyurea at last follow-up (median duration of treatment: 10.3 years), 90 underwent hematopoietic stem cell transplantation (HSCT), 24 were chronically transfused, and 170 had never had any DMT. Hydroxyurea showed significant benefit on patients outcome as reflected by a lower mortality rate compared to transplanted individuals or people without DMT (0.14, 0.36, and 0.38 per 100 PY, respectively) and by higher Kaplan-Meier estimates of 15 year survival (99.4%) compared to HSCT (93.8%; P = 0.01) or no DMT groups (95.4%; P = 0.04). CONCLUSION SCD mortality in Belgium is low with no increase observed in young adults. Patients treated with hydroxyurea demonstrate a significant benefit in survival when compared to those without DMT or transplanted.
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Affiliation(s)
- Phu Quoc Lê
- Hemato-Oncology Unit, Hôpital Universitaire des Enfants Reine Fabiola, U.L.B., Brussels, Belgium
| | - Béatrice Gulbis
- Department of Clinical Chemistry, Hôpital Erasme, U.L.B., Brussels, Belgium
| | - Laurence Dedeken
- Hemato-Oncology Unit, Hôpital Universitaire des Enfants Reine Fabiola, U.L.B., Brussels, Belgium
| | - Sophie Dupont
- Hemato-Oncology Unit, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | | | - Catherine Heijmans
- Hemato-Oncology Unit, Hôpital Universitaire des Enfants Reine Fabiola, U.L.B., Brussels, Belgium.,Department of Pediatrics, Hôpital de Jolimont, La Louvière, Belgium
| | - Sophie Huybrechts
- Hemato-Oncology Unit, Hôpital Universitaire des Enfants Reine Fabiola, U.L.B., Brussels, Belgium
| | - Christine Devalck
- Hemato-Oncology Unit, Hôpital Universitaire des Enfants Reine Fabiola, U.L.B., Brussels, Belgium
| | - André Efira
- Hemato-Oncology Unit, Hôpital Universitaire Brugmann, U.L.B., Brussels, Belgium
| | | | - Laurence Rozen
- Laboratory of Hematology, CHU-Brugmann, Hôpital Universitaire des Enfants Reine Fabiola, U.L.B., Brussels, Belgium
| | | | - Alina Ferster
- Hemato-Oncology Unit, Hôpital Universitaire des Enfants Reine Fabiola, U.L.B., Brussels, Belgium
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Lagunju I, Brown BJ, Sodeinde O. Hydroxyurea lowers transcranial Doppler flow velocities in children with sickle cell anaemia in a Nigerian cohort. Pediatr Blood Cancer 2015; 62:1587-91. [PMID: 25847050 DOI: 10.1002/pbc.25529] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 03/03/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND Sickle cell anaemia (SCA) is the leading genetic disorder in Nigeria. Elevated velocities ≥170 cm/sec occur in about a third of Nigerian children with SCA. Chronic blood transfusion for stroke prevention is faced with a myriad of challenges in our practice. OBJECTIVES To evaluate the effectiveness of hydroxyurea (HU) in reducing flow velocities in a cohort of Nigerian children with SCA and elevated velocities treated with HU. METHODS An observational study was carried out on a cohort of Nigerian children with SCA and elevated velocities identified on routine transcranial Doppler (TCD) screening. HU was recommended in those with TCD velocities ≥ 170cm/sec as stipulated in our hospital protocol. Outcomes were compared after ≥12 months of observation. RESULTS Fifty children with elevated TCD velocities were studied; 31 consented to HU therapy and 19 declined. Children on HU showed a statistically significant decline in mean velocities from 199.7 [17.1] cm/sec to 165.8 [20.7] cm/sec (P < 0.001) with a significant increase in mean packed cell volume from 21.1 [3.4] to 25.0 [2.8]%. Children without treatment had a significant rise in mean velocities from 190.2 [10.8] cm/sec to 199.7 [14.9] cm/sec (P = 0.003). Children with conditional risk velocities on HU were less likely to convert to abnormal risk (P < 0.001). Two stroke events occurred, one in each group. No adverse effects of HU were recorded in the cohort. CONCLUSION HU appears to significantly reduce TCD velocities in Nigerian children with SCA and elevated velocities ≥170 cm/sec with beneficial effect on the haematological profile. HU may provide an effective approach to primary stroke prevention, particularly in Africa.
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Affiliation(s)
- IkeOluwa Lagunju
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Biobele J Brown
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Olugbemiro Sodeinde
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
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Brousse V, Kossorotoff M, de Montalembert M. How I manage cerebral vasculopathy in children with sickle cell disease. Br J Haematol 2015; 170:615-25. [DOI: 10.1111/bjh.13477] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Valentine Brousse
- Paediatrics and Sickle-Cell Centre; University Hospital Necker-Enfants Malades; APHP; Paris France
- UMR S-1134; INSERM; Paris France
- GR-Ex; Laboratory of Excellence; Paris France
- Paris Descartes University; Paris France
| | - Manoelle Kossorotoff
- Paediatric Neurology, French Centre for Paediatric Stroke; Necker-Enfants Malades University Hospital; APHP; Paris France
| | - Mariane de Montalembert
- Paediatrics and Sickle-Cell Centre; University Hospital Necker-Enfants Malades; APHP; Paris France
- GR-Ex; Laboratory of Excellence; Paris France
- Paris Descartes University; Paris France
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Dépistage de la vasculopathie cérébrale drépanocytaire par doppler transcrânien au Mali. Arch Pediatr 2015; 22:260-6. [DOI: 10.1016/j.arcped.2014.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Revised: 10/24/2014] [Accepted: 12/09/2014] [Indexed: 11/22/2022]
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Abstract
Abstract
A 27-year-old man with sickle cell disease (HbSS) presents to the sickle cell clinic for follow-up after a screening echocardiogram revealed an increased tricuspid regurgitant velocity of 2.7 m/s. He has a history of 2 painful crises per year and has been hospitalized 3 times over the past 10 years for management of painful crises. He had one episode of acute chest syndrome at age 15 that was treated with an RBC exchange transfusion, supplemental oxygen, and intravenous antibiotics; he did not require mechanical ventilation. He has not had additional episodes of acute chest syndrome and does not have a history of stroke, retinopathy, or leg ulcers. The patient has never been treated with hydroxyurea. He wants to know whether hydroxyurea will prevent future pulmonary complications related to sickle cell disease.
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Meschia JF, Bushnell C, Boden-Albala B, Braun LT, Bravata DM, Chaturvedi S, Creager MA, Eckel RH, Elkind MSV, Fornage M, Goldstein LB, Greenberg SM, Horvath SE, Iadecola C, Jauch EC, Moore WS, Wilson JA. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:3754-832. [PMID: 25355838 PMCID: PMC5020564 DOI: 10.1161/str.0000000000000046] [Citation(s) in RCA: 993] [Impact Index Per Article: 99.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.
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Aloni MN, Lê PQ, Heijmans C, Huybrechts S, Devalck C, Azzi N, Ngalula-Mujinga M, Ferster A. A pilot study of manual chronic partial exchange transfusion in children with sickle disease. ACTA ACUST UNITED AC 2014; 20:284-8. [PMID: 25133935 DOI: 10.1179/1607845414y.0000000191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Objective Red cell exchange transfusion is frequently used in the management of patients with sickle cell disease (SCD) either electively or chronically to maintain hemoglobin S (HbS) <30%. The purpose of this retrospective study was to evaluate the results of manual chronic partial exchange transfusion (MCPET) on level of Hb and HbS, on iron load and on the need for chelation, on risk of immunization, monitoring transfusion-transmitted viral infection, and clinical outcome. Methods We reviewed the long-term effect of MCPET in 10 children (six men and four women) with SCD and evaluated the iron balance during a median follow-up of 20 months (range: 6-36) in which 248 exchanges were performed. Results The pre-exchange median Hb value was 9.5 g/dl (range: 7.7-10.9 g/dl) and the median post-exchange value was 9.4 g/dl (range: 8.4-11.1 g/dl).The majority of patients reached an HbS of <50% with a median HbS value of 40.04% (range: 30-54). At start of the MCPET program, the median ferritin was 439 ng/ml (range: 80-1704 ng/ml). In the final evaluation, the median value of ferritin was 531 ng/ml (range: 84-3840 ng/ml). The annual calculated iron balance was 0. 28 ± 0.08 mg/kg/day. MCPET was well tolerated, and adverse effects were limited. Discussion MCPET in children with SCD is safe to prevent iron overload, and is effective and easy to use in our cohort. Conclusion Indication for chronic exchange blood transfusion is essential for patients with SCD with recurrent and frequent crises who do not respond to hydroxyurea. However, there is no consensual study for the period at which chronic transfusion can safely be stopped and further research in large population of patients with SCD will need to clarify this question.
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Wiczling P, Liem RI, Panepinto JA, Garg U, Abdel-Rahman SM, Kearns GL, Neville KA. Population pharmacokinetics of hydroxyurea for children and adolescents with sickle cell disease. J Clin Pharmacol 2014; 54:1016-22. [DOI: 10.1002/jcph.303] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 03/31/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Paweł Wiczling
- Department of Biopharmaceutics and Pharmacokinetics; Medical University of Gdansk; Gdansk Poland
| | - Robert I. Liem
- Hematology, Oncology & Stem Cell Transplant; Ann & Robert H. Lurie Children's Hospital of Chicago; Chicago IL
| | - Julie A. Panepinto
- Pediatrics; Medical College of Wisconsin/The Children's Research Institute of the Children's Hospital of Wisconsin; Milwaukee WI
| | - Uttam Garg
- Department of Pathology and Laboratory Medicine; Children's Mercy Hospitals and Clinics; Kansas City MO
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De Montalembert M, Wang W. Cerebrovascular complications in children with sickle cell disease. HANDBOOK OF CLINICAL NEUROLOGY 2014; 113:1937-43. [PMID: 23622417 DOI: 10.1016/b978-0-444-59565-2.00064-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Cerebrovascular accidents were until recently responsible for much mortality and morbidity in children with sickle cell disease; the likelihood of a child with HbSS having a stroke was 11% before age 20 years, with a peak incidence of ischemic stroke between 2 and 5 years of age, and of hemorrhagic strokes between 20 and 29 years of age. Vessels occlusion is likely initiated by intimal proliferation and amplified by inflammation, excessive adhesion of cells to activated endothelium, hypercoagulable state, and vascular tone dysregulation. Silent infarcts may occur and are associated with decreased cognitive functions. Transcranial Doppler ultrasonography (TCD) was more recently demonstrated able to achieve early detection of the children at high risk for clinical strokes. A randomized study demonstrated that a first stroke may be prevented by monthly transfusion in children with abnormal TCD, leading to a recommendation for annual TCD screening of children aged between 2 and 16 years and monthly transfusion for those with abnormal results. In children who have had a first stroke, the risk of recurrence is more than 50% and is greatly reduced by chronic transfusion, although not completely abolished. Hematopoietic stem cell transplant is indicated in children with cerebral vasculopathy who have an HLA-identical sibling.
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Affiliation(s)
- M De Montalembert
- Department of Pediatrics, Hôpital Necker Enfants Malades and Sickle Cell Reference Center, Paris, France.
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