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Nwosu CS, Nri-Ezedi CA, Okechukwu C, Ulasi TO, Umeh EO, Ebubedike UR, Aronu ME, Obi-Nwosu AL, Odita AO, Agu NV, Ngonadi SC, Emedike NC, Uke KM, Emegoakor AC. Two-Dimensional Ultrasound Assessment of Long-Term Intra-Abdominal Organ Changes in Children with Sickle Cell Anemia during Steady State: A Comparative Study. Niger J Clin Pract 2023; 26:1861-1867. [PMID: 38158354 DOI: 10.4103/njcp.njcp_411_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/18/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Sickle cell anemia (SCA) is a hereditary blood disorder with global prevalence, including in Nigeria. Despite advancements in SCA care management, understanding the long-term impact on organs during steady state has remained inconclusive. AIM This study aimed to investigate the long-term changes in intra-abdominal organs of SCA children compared with non-SCA children during steady state using two-dimensional ultrasound assessment. MATERIALS AND METHODS A total of 116 children (58 SCA and 58 controls) were enrolled between June 2021 and July 2022. Clinico-demographic data were collected through an interviewer-administered questionnaire. Two-dimensional ultrasound was used to measure the liver, spleen, kidneys, and inferior vena cava in all subjects. Age-matched controls had AA or AS genotypes. RESULTS Of the 58 patients with SCA, 65.5% were males with an overall mean age of 8.1 ± 3.4 years, while among the non-SCA cohort (n = 58), 48.3% were males with an overall mean age of 8.7 ± 3.9 years. There was no statistically significant difference in the age and gender distribution between the SCA and non-SCA cohorts (P = 0.390 and P = 0.091, respectively). SCA subjects had a larger mean hepatic size than non-SCA subjects (12.09 cm ± 2.23 vs. 11.67 cm ± 1.96; P = 0.276) but smaller mean splenic size (8.01 cm ± 1.89 vs. 8.19 cm ± 1.61; P = 0.577) and inferior vena cava diameter (1.16 cm ± 0.29 vs. 1.25 cm ± 0.33; P = 0.100). Left kidney length and breadth were significantly greater in SCA patients (8.91 ± 1.16 vs. 8.27 ± 1.30; P = 0.006 and 4.15 ± 0.92 vs. 3.79 ± 0.48; P = 0.008, respectively). CONCLUSION This study highlights the utility of two-dimensional ultrasound assessment in monitoring intra-abdominal organ changes in SCA children, suggesting its cost-effective benefits in monitoring health outcomes in SCA patients.
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Affiliation(s)
- C S Nwosu
- Department of Radiology, Faculty of Medicine, Nnamdi Azikiwe University Awka, Anambra State, Nigeria
| | - C A Nri-Ezedi
- Department of Paediatrics, Faculty of Medicine, Nnamdi Azikiwe University Awka, Anambra State, Nigeria
| | - C Okechukwu
- Department of Paediatrics and Child Health, Rivers State University Teaching Hospital, Port-Harcourt, Rivers State, Nigeria
| | - T O Ulasi
- Department of Paediatrics, Faculty of Medicine, Nnamdi Azikiwe University Awka, Anambra State, Nigeria
| | - E O Umeh
- Department of Radiology, Faculty of Medicine, Nnamdi Azikiwe University Awka, Anambra State, Nigeria
| | - U R Ebubedike
- Department of Radiology, Faculty of Medicine, Nnamdi Azikiwe University Awka, Anambra State, Nigeria
| | - M E Aronu
- Department of Radiology, Faculty of Medicine, Nnamdi Azikiwe University Awka, Anambra State, Nigeria
| | - A L Obi-Nwosu
- Department of Family Medicine, Faculty of Medicine, Nnamdi Azikiwe University Awka, Anambra State, Nigeria
| | - A O Odita
- Department of Paediatrics, Faculty of Medicine, Nnamdi Azikiwe University Awka, Anambra State, Nigeria
| | - N V Agu
- Department of Paediatrics, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - S C Ngonadi
- Department of Paediatrics, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - N C Emedike
- Department of Radiology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - K M Uke
- Department of Radiology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - A C Emegoakor
- Department of Radiology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
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Roy NB, Carpenter A, Dale-Harris I, Dorée C, Estcourt LJ. Interventions for chronic kidney disease in people with sickle cell disease. Cochrane Database Syst Rev 2023; 8:CD012380. [PMID: 37539955 PMCID: PMC10404133 DOI: 10.1002/14651858.cd012380.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
BACKGROUND Sickle cell disease (SCD), one of the commonest severe monogenic disorders, is caused by the inheritance of two abnormal haemoglobin (beta-globin) genes. SCD can cause severe pain, significant end-organ damage, pulmonary complications, and premature death. Kidney disease is a frequent and potentially severe complication in people with SCD. Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function present for more than three months. Sickle cell nephropathy refers to the spectrum of kidney complications in SCD. Glomerular damage is a cause of microalbuminuria and can develop at an early age in children with SCD, with increased prevalence in adulthood. In people with sickle cell nephropathy, outcomes are poor as a result of the progression to proteinuria and chronic kidney insufficiency. Up to 12% of people who develop sickle cell nephropathy will develop end-stage renal disease. This is an update of a review first published in 2017. OBJECTIVES To assess the effectiveness of any intervention for preventing or reducing kidney complications or chronic kidney disease in people with sickle cell disease. Possible interventions include red blood cell transfusions, hydroxyurea, and angiotensin-converting enzyme inhibitors (ACEIs), either alone or in combination. SEARCH METHODS We searched for relevant trials in the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, CENTRAL, MEDLINE, Embase, seven other databases, and two other trials registers. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing interventions to prevent or reduce kidney complications or CKD in people with SCD. We applied no restrictions related to outcomes examined, language, or publication status. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility, extracted data, assessed the risk of bias, and assessed the certainty of the evidence (GRADE). MAIN RESULTS We included three RCTs with 385 participants. We rated the certainty of the evidence as low to very low across different outcomes according to GRADE methodology, downgrading for risk of bias concerns, indirectness, and imprecision. Hydroxyurea versus placebo One RCT published in 2011 compared hydroxyurea to placebo in 193 children aged nine to 18 months. We are unsure if hydroxyurea compared to placebo reduces or prevents progression of kidney disease assessed by change in glomerular filtration rate (mean difference (MD) 0.58 mL/min /1.73 m2, 95% confidence interval (CI) -14.60 to 15.76; 142 participants; very low certainty). Hydroxyurea compared to placebo may improve the ability to concentrate urine (MD 42.23 mOsm/kg, 95% CI 12.14 to 72.32; 178 participants; low certainty), and may make little or no difference to SCD-related serious adverse events, including acute chest syndrome (risk ratio (RR) 0.39, 99% CI 0.13 to 1.16; 193 participants; low certainty), painful crisis (RR 0.68, 99% CI 0.45 to 1.02; 193 participants; low certainty); and hospitalisations (RR 0.83, 99% CI 0.68 to 1.01; 193 participants; low certainty). No deaths occurred in either trial arm and the RCT did not report quality of life. Angiotensin-converting enzyme inhibitors versus placebo One RCT published in 1998 compared an ACEI (captopril) to placebo in 22 adults with normal blood pressure and microalbuminuria. We are unsure if captopril compared to placebo reduces proteinuria (MD -49.00 mg/day, 95% CI -124.10 to 26.10; 22 participants; very low certainty). We are unsure if captopril reduces or prevents kidney disease as measured by creatinine clearance; the trial authors stated that creatinine clearance remained constant over six months in both groups, but provided no comparative data (very low certainty). The RCT did not report serious adverse events, all-cause mortality, or quality of life. Angiotensin-converting enzyme inhibitors versus vitamin C One RCT published in 2020 compared an ACEI (lisinopril) with vitamin C in 170 children aged one to 18 years with normal blood pressure and microalbuminuria. It reported no data we could analyse. We are unsure if lisinopril compared to vitamin C reduces proteinuria in this population: the large drop in microalbuminuria in both arms of the trial after only one month on treatment may have been due to an overestimation of microalbuminuria at baseline rather than a true effect. The RCT did not report serious adverse events, all-cause mortality, or quality of life. AUTHORS' CONCLUSIONS We are unsure if hydroxyurea improves glomerular filtration rate or reduces hyperfiltration in children aged nine to 18 months, but it may improve their ability to concentrate urine and may make little or no difference to the incidence of acute chest syndrome, painful crises, and hospitalisations. We are unsure if ACEI compared to placebo has any effect on preventing or reducing kidney complications in adults with normal blood pressure and microalbuminuria. We are unsure if ACEI compared to vitamin C has any effect on preventing or reducing kidney complications in children with normal blood pressure and microalbuminuria. No RCTs assessed red blood cell transfusions or any combined interventions to prevent or reduce kidney complications. Due to lack of evidence, we cannot comment on the management of children aged over 18 months or adults with any known genotype of SCD. We have identified a lack of adequately designed and powered studies, although we found four ongoing trials since the last version of this review. Only one ongoing trial addresses renal function as a primary outcome in the short term, but such interventions have long-term effects. Trials of hydroxyurea, ACEIs or red blood cell transfusion in older children and adults are urgently needed to determine any effect on prevention or reduction of kidney complications in people with SCD.
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Affiliation(s)
- Noemi Ba Roy
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
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Tennenbaum J, Volle G, Buffet P, Ranque B, Pouchot J, Arlet JB. [Splenic dysfunction in sickle cell disease: An update]. Rev Med Interne 2023:S0248-8663(23)00005-X. [PMID: 36710088 DOI: 10.1016/j.revmed.2023.01.005] [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: 10/18/2022] [Revised: 01/01/2023] [Accepted: 01/08/2023] [Indexed: 01/30/2023]
Abstract
The spleen filters blood cells and contributes to the immune defense. The red pulp clears the blood from altered red blood cells via its unique microcirculatory network ; while the white pulp is a secondary lymphoid organ, directly connected to the bloodstream, whose specificity is the defense against encapsulated bacteria through the production of "natural" IgM in the marginal zone. Various health conditions can cause acquired impairment of the splenic function (or hyposplenism) directly and/or through therapeutic splenectomy. Hypo/asplenia is complicated by an increased susceptibility to encapsulated germ infections, but an increased risk of thrombosis and pulmonary hypertension has also been reported after surgical splenectomy. Homozygous sickle cell disease is the most common disease associated with functional asplenia. The latter appears early in childhood likely through repeated ischemic alterations caused by the sickling of red blood cells. In addition, specific complications such as hypersplenism and acute splenic sequestration can occur and may be life-threatening. We provide here an update on the role and physiology of the spleen, which will allow a better understanding of the pathophysiology of spleen damage and its consequences in sickle cell disease.
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Affiliation(s)
- J Tennenbaum
- Service de médecine interne, Centre de référence national de la drépanocytose de l'adulte, Hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, Paris, France.
| | - G Volle
- Service de médecine interne, Hôpital Henri-Mondor, Assistance publique-Hôpitaux de Paris, Créteil, France
| | - P Buffet
- Laboratoire d'Excellence GR-Ex, Biologie intégrée du globule rouge (BIGR), Université Paris Cité, Inserm, Paris, France
| | - B Ranque
- Service de médecine interne, Centre de référence national de la drépanocytose de l'adulte, Hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, Paris, France; Laboratoire d'Excellence GR-Ex, Biologie intégrée du globule rouge (BIGR), Université Paris Cité, Inserm, Paris, France; Faculté de médecine Paris Cité, Paris, France
| | - J Pouchot
- Service de médecine interne, Centre de référence national de la drépanocytose de l'adulte, Hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, Paris, France; Faculté de médecine Paris Cité, Paris, France
| | - J-B Arlet
- Service de médecine interne, Centre de référence national de la drépanocytose de l'adulte, Hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, Paris, France; Laboratoire d'Excellence GR-Ex, Biologie intégrée du globule rouge (BIGR), Université Paris Cité, Inserm, Paris, France; Faculté de médecine Paris Cité, Paris, France; Inserm U1163, CNRS 8254, Institut IMAGINE, Hôpital Necker, Assistance publique-Hôpitaux de Paris, Paris, France
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4
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Nardo‐Marino A, Glenthøj A, Brewin JN, Petersen J, Braunstein TH, Kurtzhals JAL, Williams TN, Rees DC. The significance of spleen size in children with sickle cell anemia. Am J Hematol 2022; 97:1520-1528. [PMID: 36054667 PMCID: PMC9827862 DOI: 10.1002/ajh.26703] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/21/2022] [Accepted: 08/23/2022] [Indexed: 01/31/2023]
Abstract
It is well established that splenic dysfunction occurs in early childhood in sickle cell anemia (SCA), although the determinants and consequences of splenic injury are not fully understood. In this study, we examined spleen size and splenic function in 100 children with SCA aged 0-16 years at King's College Hospital in London. Spleen size was assessed by abdominal ultrasound (US) and splenic function by pitted red blood cells (PIT counts). In our cohort, 5.6% of children aged 6-10 years and 19.4% of children aged 11-16 years had no visible spleen on US (autosplenectomy). Splenomegaly was common in all age groups, with 28% of children overall having larger spleens than the average for their age. Only one child had a PIT count suggesting preserved splenic function. We found no correlation between hemoglobin F levels and spleen size, nor was there any difference in spleen size between children treated with or without hydroxyurea. Although there was a trend toward increased spleen length in children with co-inherited α-thalassemia, this did not reach statistical significance. Finally, we found a strong association between erythrocyte deformability measured with oxygen gradient ektacytometry, spleen size, and PIT counts. In conclusion, our results do not agree with the general perception that most children with SCA undergo autosplenectomy within the first decade of life and indicate that loss of erythrocyte deformability contributes to loss of splenic filtration capacity in SCA, as well as phenotypical variations in spleen size.
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Affiliation(s)
- Amina Nardo‐Marino
- Danish Centre for Haemoglobinopathies, Department of HaematologyCopenhagen University Hospital, RigshospitaletCopenhagenDenmark,Department of Immunology and Microbiology, Centre for Medical ParasitologyUniversity of CopenhagenCopenhagenDenmark,Department of Haematological MedicineKing's College HospitalLondonUnited Kingdom,Comprehensive Cancer Centre, School of Cancer and Pharmaceutical SciencesKing's College LondonLondonUnited Kingdom
| | - Andreas Glenthøj
- Danish Centre for Haemoglobinopathies, Department of HaematologyCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - John N. Brewin
- Department of Haematological MedicineKing's College HospitalLondonUnited Kingdom,Comprehensive Cancer Centre, School of Cancer and Pharmaceutical SciencesKing's College LondonLondonUnited Kingdom
| | - Jesper Petersen
- Danish Centre for Haemoglobinopathies, Department of HaematologyCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - Thomas H. Braunstein
- Core Facility for Integrated Microscopy, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Jørgen A. L. Kurtzhals
- Department of Immunology and Microbiology, Centre for Medical ParasitologyUniversity of CopenhagenCopenhagenDenmark,Department of Clinical MicrobiologyCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - Thomas N. Williams
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya,Department of Surgery and CancerInstitute of Global Health Innovation, Imperial College LondonLondonUnited Kingdom
| | - David C. Rees
- Department of Haematological MedicineKing's College HospitalLondonUnited Kingdom,Comprehensive Cancer Centre, School of Cancer and Pharmaceutical SciencesKing's College LondonLondonUnited Kingdom
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5
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Abstract
BACKGROUND Sickle cell disease (SCD) is one of the most common inherited diseases worldwide. It is associated with lifelong morbidity and a reduced life expectancy. Hydroxyurea (hydroxycarbamide), an oral chemotherapeutic drug, ameliorates some of the clinical problems of SCD, in particular that of pain, by raising foetal haemoglobin (HbF). This is an update of a previously published Cochrane Review. OBJECTIVES The aims of this review are to determine through a review of randomised or quasi-randomised studies whether the use of hydroxyurea in people with SCD alters the pattern of acute events, including pain; prevents, delays or reverses organ dysfunction; alters mortality and quality of life; or is associated with adverse effects. In addition, we hoped to assess whether the response to hydroxyurea in SCD varies with the type of SCD, age of the individual, duration and dose of treatment, and healthcare setting. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Haemoglobinopathies Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also searched online trial registries. The date of the most recent search was 17 February 2022. SELECTION CRITERIA Randomised and quasi-randomised controlled trials (RCTs and quasi-RCTs), of one month or longer, comparing hydroxyurea with placebo or standard therapy in people with SCD. DATA COLLECTION AND ANALYSIS Authors independently assessed studies for inclusion, carried out data extraction, assessed the risk of bias and assessed the quality of the evidence using GRADE. MAIN RESULTS We included nine RCTs recruiting 1104 adults and children with SCD (haemoglobin SS (HbSS), haemoglobin SC (HbSC) or haemoglobin Sβºthalassaemia (HbSβºthal) genotypes). Studies lasted from six to 30 months. We judged the quality of the evidence for the first two comparisons below as moderate to low as the studies contributing to these comparisons were mostly large and well-designed (and at low risk of bias); however, the evidence was limited and imprecise for some outcomes such as quality of life, deaths during the studies and adverse events, and the results are applicable only to individuals with HbSS and HbSβºthal genotypes. We judged the quality of the evidence for the third and fourth comparisons to be very low due to the limited number of participants, the lack of statistical power (both studies were terminated early with approximately only 20% of their target sample size recruited) and the lack of applicability to all age groups and genotypes. Hydroxyurea versus placebo Five studies (784 adults and children with HbSS or HbSβºthal) compared hydroxyurea to placebo; four recruited individuals with only severe disease and one recruited individuals with all disease severities. Hydroxyurea probably improves pain alteration (using measures such as pain crisis frequency, duration, intensity, hospital admissions and opoid use) and life-threatening illness, but we found no difference in death rates (10 deaths occurred during the studies, but the rates did not differ by treatment group) (all moderate-quality evidence). Hydroxyurea may improve measures of HbF (low-quality evidence) and probably decreases neutrophil counts (moderate-quality evidence). There were no consistent differences in terms of quality of life and adverse events (including serious or life-threatening events) (low-quality evidence). There were fewer occurrences of acute chest syndrome and blood transfusions in the hydroxyurea groups. Hydroxyurea and phlebotomy versus transfusion and chelation Two studies (254 children with HbSS or HbSβºthal also with risk of primary or secondary stroke) contributed to this comparison. There were no consistent differences in terms of pain alteration, death or adverse events (low-quality evidence) or life-threatening illness (moderate-quality evidence). Hydroxyurea with phlebotomy probably increased HbF and decreased neutrophil counts (moderate-quality evidence), but there were more occurrences of acute chest syndrome and infections. Quality of life was not reported. In the primary prevention study, no strokes occurred in either treatment group but in the secondary prevention study, seven strokes occurred in the hydroxyurea and phlebotomy group (none in the transfusion and chelation group) and the study was terminated early. Hydroxyurea versus observation One study (22 children with HbSS or HbSβºthal also at risk of stoke) compared hydroxyurea to observation. Pain alteration and quality of life were not reported. There were no differences in life-threatening illness, death (no deaths reported in either group) or adverse events (very low-quality evidence). We are uncertain if hydroxyurea improves HbF or decreases neutrophil counts (very low-quality evidence). Treatment regimens with and without hydroxyurea One study (44 adults and children with HbSC) compared treatment regimens with and without hydroxyurea. Pain alteration, life-threatening illness and quality of life were not reported. There were no differences in death rates (no deaths reported in either group), adverse events or neutrophil levels (very low-quality evidence). We are uncertain if hydroxyurea improves HbF (very low-quality evidence). AUTHORS' CONCLUSIONS There is evidence to suggest that hydroxyurea may be effective in decreasing the frequency of pain episodes and other acute complications in adults and children with sickle cell anaemia of HbSS or HbSβºthal genotypes and in preventing life-threatening neurological events in those with sickle cell anaemia at risk of primary stroke by maintaining transcranial Doppler velocities. However, there is still insufficient evidence on the long-term benefits of hydroxyurea, particularly with regard to preventing chronic complications of SCD, or recommending a standard dose or dose escalation to maximum tolerated dose. There is also insufficient evidence about the long-term risks of hydroxyurea, including its effects on fertility and reproduction. Evidence is also limited on the effects of hydroxyurea on individuals with the HbSC genotype. Future studies should be designed to address such uncertainties.
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Affiliation(s)
- Angela E Rankine-Mullings
- Sickle Cell Unit, Caribbean Institute for Health Research, University of the West Indies, Kingston, Jamaica
| | - Sarah J Nevitt
- Department of Health Data Science, University of Liverpool, Liverpool, UK
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6
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Kyrana E, Rees D, Lacaille F, Fitzpatrick E, Davenport M, Heaton N, Height S, Samyn M, Mavilio F, Brousse V, Suddle A, Chakravorty S, Verma A, Gupte G, Velangi M, Inusa B, Drasar E, Hadzic N, Grammatikopoulos T, Hind J, Deheragoda M, Sellars M, Dhawan A. Clinical management of sickle cell liver disease in children and young adults. Arch Dis Child 2021; 106:315-320. [PMID: 33177052 PMCID: PMC7610372 DOI: 10.1136/archdischild-2020-319778] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/02/2020] [Accepted: 08/30/2020] [Indexed: 11/03/2022]
Abstract
Liver involvement in sickle cell disease (SCD) is often referred to as sickle cell hepatopathy (SCH) and is a complication of SCD which may be associated with significant mortality. This review is based on a round-table workshop between paediatric and adult hepatologists and haematologists and review of the literature. The discussion was prompted by the lack of substantial data and guidance in managing these sometimes very challenging cases. This review provides a structured approach for the diagnosis and management of SCH in children and young adults. The term SCH describes any hepatobiliary dysfunction in the context of SCD. Diagnosis and management of biliary complications, acute hepatic crisis, acute hepatic sequestration and other manifestations of SCH are discussed, as well as the role of liver transplantation and haemopoietic stem cell transplantation in the management of SCH.
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Affiliation(s)
- Eirini Kyrana
- Children’s Live Unit, Leeds General Infirmary, Leeds, UK
| | - David Rees
- King’s College London, Department of Haematological Medicine, King’s College Hospital, Denmark Hill, London
| | - Florence Lacaille
- Gastroenterology-Hepatology-Nutrition Unit, Hôpital Universitaire Necker-Enfants Malades, 149 rue de Sèvres, 75015 Paris
| | - Emer Fitzpatrick
- Institute of Liver Studies, King’s College London, Denmark Hill, London, UK
| | - Mark Davenport
- Department of Paediatric Surgery, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Nigel Heaton
- Hepatobiliary and Pancreatic Surgery/Liver Transplantation, King’s College Hospital NHS Trust, Denmark Hill, SE9 5RS, London, UK
| | - Sue Height
- Paediatric Haematology, King’s College Hospital NHS Trust, London
| | - Marianne Samyn
- Paediatric Liver, GI and Nutrition Centre, King’s College Hospital NHS Trust, London, UK
| | - Fulvio Mavilio
- Department of Life Sciences, University of Modena and Reggio Emilia Via Campi, 287; 41125 Modena – Italy
| | - Valentine Brousse
- Service de Pédiatrie Générale et Maladies Infectieuses, Hôpital Necker-Enfants Malades, 149 rue de Sèvres, 75015 Paris
| | - Abid Suddle
- Institute of Liver Studies, King’s College Hospital NHS Trust, Denmark Hill, SE9 5RS, London, UK
| | - Subarna Chakravorty
- Paediatric Haematology, King’s College Hospital NHS Trust, Denmark Hill, London, UK
| | - Anita Verma
- Institute of Liver Studies, Kings College Hospital, Denmark Hill, SE9 5RS, London UK
| | - Girish Gupte
- Liver Unit (including small bowel transplantation), Birmingham Women’s and Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH
| | - Mark Velangi
- Department of Haematology, Birmingham Women’s and Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH
| | - Baba Inusa
- Children's sickle cell and thalassaemia centre at Evelina London Children’s Hospital, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH
| | - Emma Drasar
- Department of Clinical Haematology, University College London Hospitals, 250 Euston Roads Bloomsbury, London NW1 2PG
| | - Nedim Hadzic
- Paediatric Centre for Hepatology, Gastroenterology and Nutrition, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Tassos Grammatikopoulos
- Paediatric Liver, GI & Nutrition Centre and MowatLabs King's College Hospital NHS Foundation Trust, London and Institute of Liver Studies, King’s College London, Denmark Hill, London, SE5 9RS
| | - Jonathan Hind
- Paediatric Liver, GI and Nutrition Centre, King’s College Hospital NHS Trust, London, UK
| | - Maesha Deheragoda
- Liver Histopathology Laboratory, Institute of Liver Studies, King’s College Hospital, London, UK
| | - Maria Sellars
- Department of Radiology, Kings College Hospital, Denmark Hill, London, UK
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre and MowatLabs, King's College Hospital NHS Foundation Trust, London, UK
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7
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Abstract
Introduction: In human physiology, the spleen is generally neglected, and its role is considered anecdotal. In sickle cell disease, splenic dysfunction is the main cause of life-threatening complications, particularly in early childhood with the risk of pneumococcal overwhelming sepsis and acute splenic sequestration crisis, notably. During the course of the disease, the spleen functionally declines and anatomically disappears, albeit with great individual variability depending on modulating genetic and environmental factors. Areas covered: The present review aims to provide an overview of spleen structure and function in order to highlight its role in sickling disorders. The clinical features of spleen damage in sickle cell disease, as well as complications and short- and long-term consequences, are reviewed, along with the main therapeutic options. Expert opinion: Management of acute splenic sequestration recurrence and timing of splenectomy in children with sickling disorders are two main areas in which clinical studies are needed.
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Affiliation(s)
- Sara El Hoss
- a Université de Paris, Biologie Intégrée du Globule Rouge, UMR_S1134, BIGR, INSERM, F-75015 , Paris , France.,b Institut National de la Transfusion Sanguine , Paris , France.,c Laboratoire d'Excellence GR-Ex , Paris , France
| | - Valentine Brousse
- a Université de Paris, Biologie Intégrée du Globule Rouge, UMR_S1134, BIGR, INSERM, F-75015 , Paris , France.,b Institut National de la Transfusion Sanguine , Paris , France.,c Laboratoire d'Excellence GR-Ex , Paris , France.,d Service de Pédiatrie Générale et Maladies Infectieuses, Hôpital Necker-Enfants Malades, Centre de Référence de la Drépanocytose, AP-HP , Paris , France
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8
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Araújo NC, Neves MB, Mandarim-de-Lacerda CA, Orlando MMC. Assessment of Spleen Filtrate Function in Renal Transplant Recipients Using Technetium-99m Stannous Colloid Liver-Spleen Scan. Transplant Proc 2017; 49:1301-1306. [PMID: 28735998 DOI: 10.1016/j.transproceed.2017.02.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 02/07/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Functional hyposplenism (FH) is indicated by an anatomically present spleen that fails to take up radiolabeled colloid. The occurrence of FH has been reported in a small group of renal transplant recipients based on hematologic parameters. The aim of this study was to replicate this association in a larger group of renal transplant recipients with the use of technetium-99m-stannous colloid liver-spleen scan to assess the spleen function. METHODS This survey based on single samples enrolled 101 unselected adult patients with functional kidney grafts >180 days after transplantation. All patients underwent 99mTc-stannous colloid scan to assess spleen function as well as bone marrow uptake of radiocolloid along with an anatomic and blood flow study of the spleen and kidney with the use of Doppler sonography. RESULTS The prevalence of hyposplenism was 32.7% (33/101) for the cohort, and increased uptake of radiocolloid by the bone marrow was seen in 9.9% (10/101). According to the multivariate analysis, the frequency of hyposplenism was significantly influenced by indirect bilirubin and hemoglobin, and direct bilirubin and neutrophil count remained as independent predictors of bone marrow uptake. CONCLUSIONS This study demonstrated that a group of renal transplant recipients has FH. In addition, bone marrow uptake might be interpreted as liver dysfunction. In this situation, the small amount of contrast (spleen compared with liver) would leave hyposplenism undiagnosed. Further prospective and longitudinal clinical studies are needed to determine the clinical impact of this condition on the management of renal transplant recipients.
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Affiliation(s)
- N C Araújo
- Division of Nephrology, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - M B Neves
- Division of Nuclear Medicine, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - M M C Orlando
- Division of Nuclear Medicine, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
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Roy NBA, Fortin PM, Bull KR, Doree C, Trivella M, Hopewell S, Estcourt LJ. Interventions for chronic kidney disease in people with sickle cell disease. Cochrane Database Syst Rev 2017; 7:CD012380. [PMID: 28672087 PMCID: PMC5544118 DOI: 10.1002/14651858.cd012380.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Sickle cell disease (SCD) is one of the commonest severe monogenic disorders in the world, due to the inheritance of two abnormal haemoglobin (beta-globin) genes. SCD can cause severe pain, significant end-organ damage, pulmonary complications, and premature death. Kidney disease is a frequent and potentially severe complication in people with SCD.Chronic kidney disease is defined as abnormalities of kidney structure or function, present for more than three months. Sickle cell nephropathy refers to the spectrum of kidney complications in SCD.Glomerular damage is a cause of microalbuminuria and can develop at an early age in children with SCD, and increases in prevalence in adulthood. In people with sickle cell nephropathy, outcomes are poor as a result of the progression to proteinuria and chronic kidney insufficiency. Up to 12% of people who develop sickle cell nephropathy will develop end-stage renal disease. OBJECTIVES To assess the effectiveness of any intervention in preventing or reducing kidney complications or chronic kidney disease in people with SCD (including red blood cell transfusions, hydroxyurea and angiotensin-converting enzyme inhibitor (ACEI)), either alone or in combination with each other. SEARCH METHODS We searched for relevant trials in the Cochrane Library, MEDLINE (from 1946), Embase (from 1974), the Transfusion Evidence Library (from 1980), and ongoing trial databases; all searches current to 05 April 2016. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register: 13 April 2017. SELECTION CRITERIA Randomised controlled trials comparing interventions to prevent or reduce kidney complications or chronic kidney disease in people with SCD. There were no restrictions by outcomes examined, language or publication status. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial eligibility, extracted data and assessed the risk of bias. MAIN RESULTS We included two trials with 215 participants. One trial was published in 2011 and included 193 children aged 9 months to 18 months, and compared treatment with hydroxyurea to placebo. The second trial was published in 1998 and included 22 adults with normal blood pressure and microalbuminuria and compared ACEI to placebo.We rated the quality of evidence as low to very low across different outcomes according to GRADE methodology. This was due to trials having: a high or unclear risk of bias including attrition and detection bias; indirectness (the available evidence was for children aged 9 months to 18 months in one trial and a small and select adult sample size in a second trial); and imprecise outcome effect estimates of significant benefit or harm. Hydroxyurea versus placebo We are very uncertain if hydroxyurea reduces or prevents progression of kidney disease (assessed by change in glomerular filtration rate), or reduces hyperfiltration in children aged 9 to 18 months, mean difference (MD) 0.58 (95% confidence interval (CI) -14.60 to 15.76 (mL/min per 1.73 m²)) (one study; 142 participants; very low-quality evidence).In children aged 9 to 18 months, hydroxyurea may improve the ability to concentrate urine, MD 42.23 (95% CI 12.14 to 72.32 (mOsm/kg)) (one study; 178 participants; low-quality evidence).Hydroxyurea may make little or no difference to SCD-related serious adverse events including: incidence of acute chest syndrome, risk ratio (RR) 0.39 (99% CI 0.13 to 1.16); painful crisis, RR 0.68 (99% CI 0.45 to 1.02); and hospitalisations, RR 0.83 (99% CI 0.68 to 1.01) (one study, 193 participants; low-quality evidence).No deaths occurred in the trial. Quality of life was not reported. ACEI versus placeboWe are very uncertain if ACEI reduces proteinuria in adults with SCD who have normal blood pressure and microalbuminuria, MD -49.00 (95% CI -124.10 to 26.10 (mg per day)) (one study; 22 participants; very low-quality evidence). We are very uncertain if ACEI reduce or prevent kidney disease as measured by creatinine clearance. The authors state that creatinine clearance remained constant over six months in both groups, but no comparative data were provided (very low-quality evidence).All-cause mortality, serious adverse events and quality of life were not reported. AUTHORS' CONCLUSIONS In young children aged 9 months to 18 months, we are very uncertain if hydroxyurea improves glomerular filtration rate or reduces hyperfiltration, but it may improve young children's ability to concentrate urine and may make little or no difference on the incidence of acute chest syndrome, painful crises and hospitalisations.We are very uncertain if giving ACEI to adults with normal blood pressure and microalbuminuria has any effect on preventing or reducing kidney complications.This review identified no trials that looked at red cell transfusions nor any combinations of interventions to prevent or reduce kidney complications.Due to lack of evidence this review cannot comment on the management of either children aged over 18 months or adults with any known genotype of SCD.We have identified a lack of adequately-designed and powered studies, and no ongoing trials which address this critical question. Trials of hydroxyurea, ACEI or red blood cell transfusion in older children and adults are urgently needed to determine any effect on prevention or reduction kidney complications in people with SCD.
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Affiliation(s)
- Noemi BA Roy
- University of OxfordWeatherall Institute of Molecular MedicineJohn Radcliffe HospitalHeadley WayOxfordUKOX3 9DU
| | - Patricia M Fortin
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Katherine R Bull
- Oxford University Hospitals Trust and the University of OxfordOxford Kidney Unit and Nuffield Department of MedicineCornall Group, Henry Wellcome Building for Molecular PhysiologyRoosevelt DriveOxfordUKOX3 7BN
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Marialena Trivella
- University of OxfordCentre for Statistics in MedicineBotnar Research CentreWindmill RoadOxfordUKOX3 7LD
| | - Sally Hopewell
- University of OxfordOxford Clinical Trials Research UnitNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal SciencesWindmill RoadOxfordOxfordshireUKOX3 7LD
| | - Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
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Saied DA, El-Raziky MS, El-Ghamrawy MK, Mahmoud MA. The pattern of hepatobiliary complications among Egyptian sickle cell disease children. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2017. [DOI: 10.1016/j.epag.2017.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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11
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Abstract
BACKGROUND Sickle cell disease (SCD) is one of the most common inherited diseases worldwide. It is associated with lifelong morbidity and a reduced life expectancy. Hydroxyurea (hydroxycarbamide), an oral chemotherapeutic drug, ameliorates some of the clinical problems of SCD, in particular that of pain, by raising fetal haemoglobin. This is an update of a previously published Cochrane Review. OBJECTIVES To assess the effects of hydroxyurea therapy in people with SCD (all genotypes), of any age, regardless of setting. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Register, comprising of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also searched online trial registries.Date of the most recent search: 16 January 2017. SELECTION CRITERIA Randomised and quasi-randomised controlled trials, of one month or longer, comparing hydroxyurea with placebo, standard therapy or other interventions for people with SCD. DATA COLLECTION AND ANALYSIS Authors independently assessed studies for inclusion, carried out data extraction and assessed the risk of bias. MAIN RESULTS Seventeen studies were identified in the searches; eight randomised controlled trials were included, recruiting 899 adults and children with SCD (haemoglobin SS (HbSS), haemoglobin SC (HbSC) or haemoglobin Sβºthalassaemia (HbSβºthal) genotypes). Studies lasted from six to 30 months.Four studies (577 adults and children with HbSS or HbSβºthal) compared hydroxyurea to placebo; three recruited individuals with only severe disease and one recruited individuals with all disease severities. There were statistically significant improvements in terms of pain alteration (using measures such as pain crisis frequency, duration, intensity, hospital admissions and opoid use), measures of fetal haemoglobin and neutrophil counts and fewer occurrences of acute chest syndrome and blood transfusions in the hydroxyurea groups. There were no consistent statistically significant differences in terms of quality of life and adverse events (including serious or life-threatening events). Seven deaths occurred during the studies, but the rates by treatment group were not statistically significantly different.Two studies (254 children with HbSS or HbSβºthal also with risk of primary or secondary stroke) compared hydroxyurea and phlebotomy to transfusion and chelation; there were statistically significant improvements in terms of measures of fetal haemoglobin and neutrophil counts, but more occurrences of acute chest syndrome and infections in the hydroxyurea and phlebotomy group. There were no consistent statistically significant differences in terms of pain alteration and adverse events (including serious or life-threatening events). Two deaths occurred during the studies (one in a the hydroxyurea treatment arm and one in the control arm), but the rates by treatment group were not statistically significantly different. In the primary prevention study, no strokes occurred in either treatment group but in the secondary prevention study, seven strokes occurred in the hydroxyurea and phlebotomy group (none in the transfusion and chelation group) and the study was terminated early.The quality of the evidence for the above two comparisons was judged as moderate to low as the studies contributing to these comparisons were mostly large and well designed (and at low risk of bias); however evidence was limited and imprecise for some outcomes such as quality of life, deaths during the studies and adverse events and results are applicable only to individuals with HbSS and HbSβºthal genotypes.Of the remaining two studies, one (22 children with HbSS or HbSβºthal also at risk of stoke) compared hydroxyurea to observation; there were statistically significant improvements in terms of measures of fetal haemoglobin and neutrophil counts but no statistically significant differences in terms of adverse events (including serious or life-threatening events).The final study (44 adults and children with HbSC) compared treatment regimens with and without hydroxyurea - there was statistically significant improvement in terms of measures of fetal haemoglobin, but no statistically significant differences in terms of adverse events (including serious or life-threatening events). No participants died in either of these studies and other outcomes relevant to the review were not reported.The quality of the evidence for the above two comparisons was judged to be very low due to the limited number of participants, the lack of statistical power (as both studies were terminated early with approximately only 20% of their target sample size recruited) and the lack of applicability to all age groups and genotypes. AUTHORS' CONCLUSIONS There is evidence to suggest that hydroxyurea is effective in decreasing the frequency of pain episodes and other acute complications in adults and children with sickle cell anaemia of HbSS or HbSβºthal genotypes and in preventing life-threatening neurological events in those with sickle cell anaemia at risk of primary stroke by maintaining transcranial doppler velocities. However, there is still insufficient evidence on the long-term benefits of hydroxyurea, particularly in preventing chronic complications of SCD, recommending a standard dose or dose escalation to maximum tolerated dose. There is also insufficient evidence about the long-term risks of hydroxyurea, including its effects on fertility and reproduction. Evidence is also limited on the effects of hydroxyurea on individuals with HbSC genotype. Future studies should be designed to address such uncertainties.
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Affiliation(s)
- Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Ashley P Jones
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Jo Howard
- Guy's and St Thomas' Hospitals NHS Foundation TrustDepartment of HaematologyGreat Maze PondLondonUKSE1 9RT
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12
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Abstract
Sickle cell disease (SCD) substantially alters renal structure and function, and causes various renal syndromes and diseases. Such diverse renal outcomes reflect the uniquely complex vascular pathobiology of SCD and the propensity of red blood cells to sickle in the renal medulla because of its hypoxic, acidotic, and hyperosmolar conditions. Renal complications and involvement in sickle cell nephropathy (SCN) include altered haemodynamics, hypertrophy, assorted glomerulopathies, chronic kidney disease, acute kidney injury, impaired urinary concentrating ability, distal nephron dysfunction, haematuria, and increased risks of urinary tract infections and renal medullary carcinoma. SCN largely reflects an underlying vasculopathy characterized by cortical hyperperfusion, medullary hypoperfusion, and an increased, stress-induced vasoconstrictive response. Renal involvement is usually more severe in homozygous disease (sickle cell anaemia, HbSS) than in compound heterozygous types of SCD (for example HbSC and HbSβ(+)-thalassaemia), and is typically mild, albeit prevalent, in the heterozygous state (sickle cell trait, HbAS). Renal involvement contributes substantially to the diminished life expectancy of patients with SCD, accounting for 16-18% of mortality. As improved clinical care promotes survival into adulthood, SCN imposes a growing burden on both individual health and health system costs. This Review addresses the renal manifestations of SCD and focuses on their underlying mechanisms.
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Affiliation(s)
- Karl A Nath
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street S. W., Rochester, MN 55905, USA
| | - Robert P Hebbel
- Division of Haematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Mayo Mail Code 480, 420 Delaware Street S. E., Minneapolis, MN 55455, USA
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Dinan D, Epelman M, Guimaraes CV, Donnelly LF, Nagasubramanian R, Chauvin NA. The current state of imaging pediatric hemoglobinopathies. Semin Ultrasound CT MR 2014; 34:493-515. [PMID: 24332202 DOI: 10.1053/j.sult.2013.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The hemoglobinopathies are a group of genetic disorders with a broad spectrum of clinical manifestations and radiologic findings. The imaging of pediatric hemoglobinopathies, which is influenced by concomitant hemosiderosis and the sequela of chelation therapy, has evolved over the years along with ever-improving technology. This article reviews and illustrates the most common radiographic and cross-sectional imaging findings of the 2 best known and clinically relevant hemoglobinopathies in pediatric patients, sickle cell disease and β-thalassemia.
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Affiliation(s)
- David Dinan
- Department of Medical Imaging, Nemours Children's Hospital, Orlando, FL
| | - Monica Epelman
- Department of Medical Imaging, Nemours Children's Hospital, Orlando, FL.
| | | | | | | | - Nancy A Chauvin
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA
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14
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Brousse V, Buffet P, Rees D. The spleen and sickle cell disease: the sick(led) spleen. Br J Haematol 2014; 166:165-76. [DOI: 10.1111/bjh.12950] [Citation(s) in RCA: 148] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 03/31/2014] [Indexed: 12/01/2022]
Affiliation(s)
- Valentine Brousse
- Department of Paediatrics; Reference Centre for Sickle Cell Disease; Hôpital Universitaire Necker-Enfants Malades; APHP; Paris France
- Université Paris Descartes; Paris France
- Laboratory of Excellence GR-Ex; Paris France
| | - Pierre Buffet
- Laboratory of Excellence GR-Ex; Paris France
- Centre d'Immunologie et des Maladies Infectieuses de Paris; CIMI-PARIS; U 1135 INSERM/UPMC Université Paris VI; Paris France
- Service de Parasitologie; AP-HP; Hôpital Pitié-Salpêtrière; Paris France
| | - David Rees
- Department of Paediatric Haematology; King's College Hospital NHS Foundation Trust; King's Health Partners; Denmark Hill London UK
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Sheehan VA, Luo Z, Flanagan JM, Howard TA, Thompson BW, Wang WC, Kutlar A, Ware RE. Genetic modifiers of sickle cell anemia in the BABY HUG cohort: influence on laboratory and clinical phenotypes. Am J Hematol 2013; 88:571-6. [PMID: 23606168 DOI: 10.1002/ajh.23457] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 03/29/2013] [Accepted: 04/03/2013] [Indexed: 01/01/2023]
Abstract
The recently completed BABY HUG trial investigated the safety and efficacy of hydroxyurea in infants with sickle cell anemia (SCA). To investigate the effects of known genetic modifiers, genomic DNA on 190 randomized subjects were analyzed for alpha thalassemia, beta-globin haplotype, polymorphisms affecting endogenous fetal hemoglobin (HbF) levels (XmnI, BCL11A, and HBS1L-MYB), UGT1A1 promoter polymorphisms, and the common G6PD A(-) mutation. At study entry, infants with alpha thalassemia trait had significantly lower mean corpuscular volume, total bilirubin, and absolute reticulocyte count. Beta-globin haplotypes associated with milder disease had significantly higher hemoglobin and %HbF. BCL11A and XmnI polymorphisms had significant effects on baseline HbF, while UGT1A1 promoter polymorphisms significantly influenced baseline serum bilirubin. At study exit, subjects randomized to placebo still exhibited laboratory effects of alpha thalassemia and other modifiers, while those assigned hydroxyurea had treatment effects that exceeded most genetic influences. The pain phenotype was influenced by HbF modifiers in both treatment groups. These data document that genetic polymorphisms do modify laboratory and clinical phenotypes even in very young patients with SCA. The hydroxyurea effects are more potent, however, indicating that treatment criteria should not be limited to certain genetic subsets, and supporting the use of hydroxyurea for all young patients with SCA.
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Affiliation(s)
- Vivien A. Sheehan
- Department of Pediatrics; Hematology Center, Baylor College of Medicine; Houston Texas
| | - Zhaoyu Luo
- Clinical Trials and Surveys Corporation; Owings Mills Maryland
| | - Jonathan M. Flanagan
- Department of Pediatrics; Hematology Center, Baylor College of Medicine; Houston Texas
| | - Thad A. Howard
- Department of Pediatrics; Hematology Center, Baylor College of Medicine; Houston Texas
| | | | - Winfred C. Wang
- Department of Hematology; St. Jude Children's Research Hospital; Memphis Tennessee
| | - Abdullah Kutlar
- Division of Hematology/Oncology; Georgia Health Sciences Center; Augusta Georgia
| | - Russell E. Ware
- Department of Pediatrics; Hematology Center, Baylor College of Medicine; Houston Texas
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Abstract
Sickle cell disease (SCD) is caused by a mutation in both beta globin genes, resulting in chronic hemolysis and multiorgan disease that ultimately leads to premature death. Although hemoglobin S (HbS) polymerization and vaso-occlusion are central to the pathogenesis of SCD, overlapping pathways implicated in SCD-related endothelial dysfunction include hemolysis, defects in nitric oxide metabolism, ischemia-reperfusion injury, oxidative stress, increased cell-to-cell adhesion, and proinflammatory and coagulation mediators. Progression of organ-specific vasculopathy often precedes organ dysfunction and may provide targets for therapeutic intervention. SCD-related vasculopathies include, but are not limited to, moyamoya that often precedes cerebral infarcts or hemorrhage, proliferative retinopathy prior to loss of eyesight, pulmonary vasculopathy associated with pulmonary hypertension, and renal vasculopathy prior to the onset of chronic renal disease. This review evaluates evidence that SCD vasculopathy is a harbinger for organ dysfunction and reviews the potential for targeted antivasculopathy therapies.
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Affiliation(s)
- Adetola A Kassim
- Department of Medicine, Hematology/Stem Cell Transplant, Vanderbilt and Meharry Center for Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.
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Alvarez O, Miller ST, Wang WC, Luo Z, McCarville MB, Schwartz GJ, Thompson B, Howard T, Iyer RV, Rana SR, Rogers ZR, Sarnaik SA, Thornburg CD, Ware RE. Effect of hydroxyurea treatment on renal function parameters: results from the multi-center placebo-controlled BABY HUG clinical trial for infants with sickle cell anemia. Pediatr Blood Cancer 2012; 59:668-74. [PMID: 22294512 PMCID: PMC3396762 DOI: 10.1002/pbc.24100] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Accepted: 01/09/2012] [Indexed: 11/09/2022]
Abstract
BACKGROUND Children with sickle cell anemia (SCA) often develop hyposthenuria and renal hyperfiltration at an early age, possibly contributing to the glomerular injury and renal insufficiency commonly seen later in life. The Phase III randomized double-blinded Clinical Trial of Hydroxyurea in Infants with SCA (BABY HUG) tested the hypothesis that hydroxyurea can prevent kidney dysfunction by reducing hyperfiltration. PROCEDURE 193 infants with SCA (mean age 13.8 months) received hydroxyurea 20 mg/kg/day or placebo for 24 months. (99m) Tc diethylenetriaminepentaacetic acid (DTPA) clearance, serum creatinine, serum cystatin C, urinalysis, serum and urine osmolality after parent-supervised fluid deprivation, and renal ultrasonography were obtained at baseline and at exit to measure treatment effects on renal function. RESULTS At exit children treated with hydroxyurea had significantly higher urine osmolality (mean 495 mOsm/kg H(2) O compared to 452 in the placebo group, P = 0.007) and a larger percentage of subjects taking hydroxyurea achieved urine osmolality >500 mOsm/kg H(2) O. Moreover, children treated with hydroxyurea had smaller renal volumes (P = 0.007). DTPA-derived glomerular filtration rate (GFR) was not significantly different between the two treatment groups, but was significantly higher than published norms. GFR estimated by the Chronic Kidney Disease in Children (CKiD) Schwartz formula was the best non-invasive method to estimate GFR in these children, as it was the closest to the DTPA-derived GFR. CONCLUSION Treatment with hydroxyurea for 24 months did not influence GFR in young children with SCA. However, hydroxyurea was associated with better urine concentrating ability and less renal enlargement, suggesting some benefit to renal function.
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Affiliation(s)
- Ofelia Alvarez
- Division of Pediatric Hematology, University of Miami, Miami, Florida 33136, USA.
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McCarville MB, Rogers ZR, Sarnaik S, Scott P, Aygun B, Hilliard L, Lee MT, Kalinyak K, Owen W, Garro J, Schultz W, Yovetich N, Ware RE. Effects of chronic transfusions on abdominal sonographic abnormalities in children with sickle cell anemia. J Pediatr 2012; 160:281-285.e1. [PMID: 21907352 PMCID: PMC3237893 DOI: 10.1016/j.jpeds.2011.07.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 07/01/2011] [Accepted: 07/29/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess the effects of chronic erythrocyte transfusions on prevalence of sonographic incidence of organ damage in children with sickle cell anemia (SCA). STUDY DESIGN Children (N=148; mean age, 13.0 years) with SCA, receiving chronic transfusions (average, 7 years), underwent abdominal sonography at 25 institutions. After central imaging review, spleen, liver, and kidney measurements were compared with published normal values. Potential relations between ultrasound, clinical, and laboratory data were explored via analysis of variance, Student t test, and Cochran-Mantel-Haenzel tests of non-zero correlation. RESULTS Average spleen length was similar to normal children, but over one-third had spleen volumes >300 mL, 15 had previous splenectomy for splenomegaly, and 24 had abnormal splenic echotexture. Two-thirds had hepatobiliary disease; 37 had prior cholecystectomy, 46 had gallstones, and 16 had gallbladder sludge. Gallbladder disease correlated with older age (P=.002), longer liver length (P<.001), longer duration of transfusions (P=.034), and higher total bilirubin (P<.001). Liver (P<.001) and renal lengths (P≤.005) were larger than published norms. CONCLUSIONS In children with SCA, long-term transfusion therapy may not prevent development or progression of abdominal organ dysfunction.
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Affiliation(s)
- Mary Beth McCarville
- Department of Radiological Sciences, St Jude Children's Research Hospital, Memphis, TN 38105, USA.
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Rogers ZR, Wang WC, Luo Z, Iyer RV, Shalaby-Rana E, Dertinger SD, Shulkin BL, Miller JH, Files B, Lane PA, Thompson BW, Miller ST, Ware RE. Biomarkers of splenic function in infants with sickle cell anemia: baseline data from the BABY HUG Trial. Blood 2011; 117:2614-7. [PMID: 21217080 PMCID: PMC3062353 DOI: 10.1182/blood-2010-04-278747] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Accepted: 12/07/2010] [Indexed: 11/20/2022] Open
Abstract
We evaluated spleen function in 193 children with sickle cell anemia 8 to 18 months of age by (99m)Tc sulfur-colloid liver-spleen scan and correlated results with clinical and laboratory parameters, including 2 splenic biomarkers: pitted cell counts (PIT) and quantitative Howell-Jolly bodies (HJB) enumerated by flow cytometry. Loss of splenic function began before 12 months of age in 86% of infants in association with lower total or fetal hemoglobin and higher white blood cell or reticulocyte counts, reinforcing the need for early diagnosis and diligent preventive care. PIT and HJB correlated well with each other and liver-spleen scan results. Previously described biomarker threshold values did define patients with abnormal splenic function, but our data suggest that normal spleen function is better predicted by PIT of ≤1.2% or HJB ≤55/10(6) red blood cells and absent function by PIT ≥4.5% or HJB ≥665/10(6). HJB is methodologically advantageous compared with PIT, but both are valid biomarkers of splenic function. This trial was registered at www.clinicaltrials.gov as #NCT00006400.
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Affiliation(s)
- Zora R Rogers
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX 75390-9063, USA.
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