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Ala C, Joshi RP, Gupta P, Goswami SG, Ramalingam S, Kondapalli Venkata Gowri CS, Sankaranarayanan M. A critical review of therapeutic interventions in sickle cell disease: Progress and challenges. Arch Pharm (Weinheim) 2024:e2400381. [PMID: 39031925 DOI: 10.1002/ardp.202400381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 07/04/2024] [Accepted: 07/08/2024] [Indexed: 07/22/2024]
Abstract
Sickle cell disease (SCD) is an autosomal recessive genetic disorder that occurs due to the point mutation in the β-globin gene, which results in the formation of sickle hemoglobin (HbS) in the red blood cells (RBCs). When HbS is exposed to an oxygen-depleted environment, it polymerizes, resulting in hemolysis, vaso-occlusion pain, and impaired blood flow. Still, there is no affordable cure for this inherited disease. Approved medications held promise but were met with challenges due to limited patient tolerance and undesired side effects, thereby inhibiting their ability to enhance the quality of life across various individuals with SCD. Progress has been made in understanding the pathophysiology of SCD during the past few decades, leading to the discovery of novel targets and therapies. However, there is a compelling need for research to discover medications with improved efficacy and reduced side effects. Also, more clinical investigations on various drug combinations with different mechanisms of action are needed. This review comprehensively presents therapeutic approaches for SCD, including those currently available or under investigation. It covers fundamental aspects of the disease, such as epidemiology and pathophysiology, and provides detailed discussions on various disease-modifying agents. Additionally, expert insights are offered on the future development of pharmacotherapy for SCD.
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Affiliation(s)
- Chandu Ala
- Department of Pharmacy, Birla Institute of Technology and Science Pilani, Medicinal Chemistry Research Laboratory, Pilani Campus, Pilani, Rajasthan, India
| | - Renuka Parshuram Joshi
- Department of Pharmacy, Birla Institute of Technology and Science Pilani, Medicinal Chemistry Research Laboratory, Pilani Campus, Pilani, Rajasthan, India
| | - Pragya Gupta
- CSIR-Institute of Genomics and Integrative Biology, New Delhi, India
| | | | | | | | - Murugesan Sankaranarayanan
- Department of Pharmacy, Birla Institute of Technology and Science Pilani, Medicinal Chemistry Research Laboratory, Pilani Campus, Pilani, Rajasthan, India
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Pavitra E, Acharya RK, Gupta VK, Verma HK, Kang H, Lee JH, Sahu T, Bhaskar L, Raju GSR, Huh YS. Impacts of oxidative stress and anti-oxidants on the development, pathogenesis, and therapy of sickle cell disease: A comprehensive review. Biomed Pharmacother 2024; 176:116849. [PMID: 38823275 DOI: 10.1016/j.biopha.2024.116849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/17/2024] [Accepted: 05/27/2024] [Indexed: 06/03/2024] Open
Abstract
Sickle cell disease (SCD) is the most severe monogenic hemoglobinopathy caused by a single genetic mutation that leads to repeated polymerization and depolymerization of hemoglobin resulting in intravascular hemolysis, cell adhesion, vascular occlusion, and ischemia-reperfusion injury. Hemolysis causes oxidative damage indirectly by generating reactive oxygen species through various pathophysiological mechanisms, which include hemoglobin autoxidation, endothelial nitric oxide synthase uncoupling, reduced nitric oxide bioavailability, and elevated levels of asymmetric dimethylarginine. Red blood cells have a built-in anti-oxidant system that includes enzymes like sodium dismutase, catalase, and glutathione peroxidase, along with free radical scavenging molecules, such as vitamin C, vitamin E, and glutathione, which help them to fight oxidative damage. However, these anti-oxidants may not be sufficient to prevent the effects of oxidative stress in SCD patients. Therefore, in line with a recent FDA request that the focus to be placed on the development of innovative therapies for SCD that address the root cause of the disease, there is a need for therapies that target oxidative stress and restore redox balance in SCD patients. This review summarizes the current state of knowledge regarding the role of oxidative stress in SCD and the potential benefits of anti-oxidant therapies. It also discusses the challenges and limitations of these therapies and suggests future directions for research and development.
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Affiliation(s)
- Eluri Pavitra
- NanoBio High-Tech Materials Research Center, Department of Biological Sciences and Bioengineering, Inha University, Incheon 22212, Republic of Korea; 3D Convergence Center, Inha University, Incheon 22212, Republic of Korea
| | - Rakesh Kumar Acharya
- Department of Zoology, Guru Ghasidas Vishwavidyalaya, Bilaspur, Chhattisgarh 495009, India
| | - Vivek Kumar Gupta
- NanoBio High-Tech Materials Research Center, Department of Biological Sciences and Bioengineering, Inha University, Incheon 22212, Republic of Korea
| | - Henu Kumar Verma
- Department of Immunopathology, Institute of lungs health and Immunity, Comprehensive Pneumology Center, Helmholtz Zentrum, Neuherberg, Munich 85764, Germany
| | - Haneul Kang
- NanoBio High-Tech Materials Research Center, Department of Biological Sciences and Bioengineering, Inha University, Incheon 22212, Republic of Korea
| | - Jeong-Hwan Lee
- 3D Convergence Center, Inha University, Incheon 22212, Republic of Korea
| | - Tarun Sahu
- Department of Physiology, All Indian Institute of Medical Science, Raipur, Chhattisgarh, India
| | - Lvks Bhaskar
- Department of Zoology, Guru Ghasidas Vishwavidyalaya, Bilaspur, Chhattisgarh 495009, India.
| | - Ganji Seeta Rama Raju
- Department of Energy and Materials Engineering, Dongguk University-Seoul, Seoul 04620, Republic of Korea.
| | - Yun Suk Huh
- NanoBio High-Tech Materials Research Center, Department of Biological Sciences and Bioengineering, Inha University, Incheon 22212, Republic of Korea.
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Fortuna V, Lima J, Oliveira GF, Oliveira YS, Getachew B, Nekhai S, Aschner M, Tizabi Y. Ferroptosis as an emerging target in sickle cell disease. Curr Res Toxicol 2024; 7:100181. [PMID: 39021403 PMCID: PMC11252799 DOI: 10.1016/j.crtox.2024.100181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 06/13/2024] [Accepted: 06/17/2024] [Indexed: 07/20/2024] Open
Abstract
Sickle cell disease (SCD) is an inherited hemoglobin disorder marked by red blood cell sickling, resulting in severe anemia, painful episodes, extensive organ damage, and shortened life expectancy. In SCD, increased iron levels can trigger ferroptosis, a specific type of cell death characterized by reactive oxygen species (ROS) and lipid peroxide accumulation, leading to damage and organ impairments. The intricate interplay between iron, ferroptosis, inflammation, and oxidative stress in SCD underscores the necessity of thoroughly understanding these processes for the development of innovative therapeutic strategies. This review highlights the importance of balancing the complex interactions among various factors and exploitation of the knowledge in developing novel therapeutics for this devastating disease.
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Affiliation(s)
- Vitor Fortuna
- Department of Biochemistry and Biophysics, Health Sciences Institute, Federal University of Bahia, BA 40231-300, Brazil
- Postgraduate Program in Immunology, Health Sciences Institute, Federal University of Bahia, BA 40231-300, Brazil
| | - Jaqueline Lima
- Postgraduate Program in Immunology, Health Sciences Institute, Federal University of Bahia, BA 40231-300, Brazil
| | - Gabriel F. Oliveira
- Postgraduate Program in Immunology, Health Sciences Institute, Federal University of Bahia, BA 40231-300, Brazil
| | - Yasmin S. Oliveira
- Postgraduate Program in Immunology, Health Sciences Institute, Federal University of Bahia, BA 40231-300, Brazil
| | - Bruk Getachew
- Department of Pharmacology, Howard University College of Medicine, Washington, DC, USA
| | - Sergei Nekhai
- Center for Sickle Cell Disease, Departments of Microbiology and Medicine, Howard University College of Medicine, Washington, DC, USA
| | - Michael Aschner
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Yousef Tizabi
- Department of Pharmacology, Howard University College of Medicine, Washington, DC, USA
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Gonçalves E, Smaoui S, Brito M, Oliveira JM, Arez AP, Tavares L. Sickle Cell Disease: Current Drug Treatments and Functional Foods with Therapeutic Potential. Curr Issues Mol Biol 2024; 46:5845-5865. [PMID: 38921020 PMCID: PMC11202234 DOI: 10.3390/cimb46060349] [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: 05/14/2024] [Revised: 06/06/2024] [Accepted: 06/10/2024] [Indexed: 06/27/2024] Open
Abstract
Sickle cell anemia (SCA), the most common form of sickle cell disease (SCD), is a genetic blood disorder. Red blood cells break down prematurely, causing anemia and often blocking blood vessels, leading to chronic pain, organ damage, and increased infection risk. SCD arises from a single-nucleotide mutation in the β-globin gene, substituting glutamic acid with valine in the β-globin chain. This review examines treatments evaluated through randomized controlled trials for managing SCD, analyzes the potential of functional foods (dietary components with health benefits) as a complementary strategy, and explores the use of bioactive compounds as functional food ingredients. While randomized trials show promise for certain drugs, functional foods enriched with bioactive compounds also hold therapeutic potential. Further research is needed to confirm clinical efficacy, optimal dosages, and specific effects of these compounds on SCD, potentially offering a cost-effective and accessible approach to managing the disease.
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Affiliation(s)
- Elisângela Gonçalves
- Global Health and Tropical Medicine (GHTM), Associate Laboratory in Translation and Innovation Towards Global Health (LA-REAL), Institute of Hygiene and Tropical Medicine, (IHMT), NOVA University of Lisbon (UNL) 1349-008 Lisbon, Portugal; (E.G.); (A.P.A.)
| | - Slim Smaoui
- Laboratory of Microbial and Enzymes Biotechnology and Biomolecules (LBMEB), Centre of Biotechnology of Sfax (CBS), University of Sfax-Tunisia, Road of Sidi Mansour Km 6, P.O. Box 1177, Sfax 3018, Tunisia;
| | - Miguel Brito
- Health Research Centre of Angola (CISA), Caxito, Angola;
- H&TRC—Health & Technology Research Center, Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, 1990-092 Lisbon, Portugal
| | - J. M. Oliveira
- School of Design, Management and Production Technologies Northern Aveiro, University of Aveiro, Estrada do Cercal, 449, 3810-193 Oliveira de Azeméis, Portugal;
- EMaRT Group—Emerging Materials, Research, Technology, University of Aveiro, 3810-193 Aveiro, Portugal
- CICECO Aveiro—Institute of Materials, University of Aveiro, Campus Universitário de Santiago, 3810-193 Aveiro, Portugal
| | - Ana Paula Arez
- Global Health and Tropical Medicine (GHTM), Associate Laboratory in Translation and Innovation Towards Global Health (LA-REAL), Institute of Hygiene and Tropical Medicine, (IHMT), NOVA University of Lisbon (UNL) 1349-008 Lisbon, Portugal; (E.G.); (A.P.A.)
| | - Loleny Tavares
- School of Design, Management and Production Technologies Northern Aveiro, University of Aveiro, Estrada do Cercal, 449, 3810-193 Oliveira de Azeméis, Portugal;
- EMaRT Group—Emerging Materials, Research, Technology, University of Aveiro, 3810-193 Aveiro, Portugal
- CICECO Aveiro—Institute of Materials, University of Aveiro, Campus Universitário de Santiago, 3810-193 Aveiro, Portugal
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Costa-Júnior DA, Souza Valente TN, Belisário AR, Carvalho GQ, Madeira M, Velloso-Rodrigues C. Association of ZBTB38 gene polymorphism (rs724016) with height and fetal hemoglobin in individuals with sickle cell anemia. Mol Genet Metab Rep 2024; 39:101086. [PMID: 38800625 PMCID: PMC11127270 DOI: 10.1016/j.ymgmr.2024.101086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/18/2024] [Accepted: 04/21/2024] [Indexed: 05/29/2024] Open
Abstract
Objectives Our study evaluated the association of the polymorphism rs724016 in the ZBTB38 gene, previously associated with height in other populations, with predictors of height, clinical outcomes, and laboratory parameters in sickle cell anemia (SCA). Methods Cross-sectional study with individuals with SCA and aged between 3 and 20 years. Clinical, laboratory, molecular, and bone age (BA) data were evaluated. Levels of IGF-1 and IGFBP-3 were adjusted for BA, target height (TH) was calculated as the mean parental height standard deviation score (SDS), and predicted adult height (PAH) SDS was calculated using BA. Results We evaluated 80 individuals with SCA. The homozygous genotype of the G allele of rs724016 was associated with a lower height SDS (p < 0.001) and, in a additive genetic model, was negatively associated with HbF levels (p = 0.016). Lower adjusted IGF-1 levels were associated with co-inheritance of alpha-thalassemia and with the absence of HU therapy. Elevated HbF levels were associated with a lower deficit in adjusted growth potential (TH minus PAH). Conclusion Our analysis shows that SNP rs724016 in the ZBTB38 is associated with shorter height and lower HbF levels, an important modifier of SCA.
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Affiliation(s)
- Domício Antônio Costa-Júnior
- Department of Medicine, Federal University of Juiz de Fora - Governador Valadares Campus (UFJF-GV), Minas Gerais (MG), Brazil
| | | | | | | | - Miguel Madeira
- Division of Endocrinology, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
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Bolarinwa AB, Oduwole O, Okebe J, Ogbenna AA, Otokiti OE, Olatinwo AT. Antioxidant supplementation for sickle cell disease. Cochrane Database Syst Rev 2024; 5:CD013590. [PMID: 38775255 PMCID: PMC11110109 DOI: 10.1002/14651858.cd013590.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND Sickle cell disease (SCD) refers to a group of genetic disorders characterized by the presence of an abnormal haemoglobin molecule called haemoglobin S (HbS). When subjected to oxidative stress from low oxygen concentrations, HbS molecules form rigid polymers, giving the red cell the typical sickle shape. Antioxidants have been shown to reduce oxidative stress and improve outcomes in other diseases associated with oxidative stress. Therefore, it is important to review and synthesize the available evidence on the effect of antioxidants on the clinical outcomes of people with SCD. OBJECTIVES To assess the effectiveness and safety of antioxidant supplementation for improving health outcomes in people with SCD. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 15 August 2023. SELECTION CRITERIA We included randomized and quasi-randomized controlled trials comparing antioxidant supplementation to placebo, other antioxidants, or different doses of antioxidants, in people with SCD. DATA COLLECTION AND ANALYSIS Two authors independently extracted data, assessed the risk of bias and certainty of the evidence, and reported according to Cochrane methodological procedures. MAIN RESULTS The review included 1609 participants in 26 studies, with 17 comparisons. We rated 13 studies as having a high risk of bias overall, and 13 studies as having an unclear risk of bias overall due to study limitations. We used GRADE to rate the certainty of evidence. Only eight studies reported on our important outcomes at six months. Vitamin C (1400 mg) plus vitamin E (800 mg) versus placebo Based on evidence from one study in 83 participants, vitamin C (1400 mg) plus vitamin E (800 mg) may not be better than placebo at reducing the frequency of crisis (risk ratio (RR) 1.18, 95% confidence interval (CI) 0.64 to 2.18), the severity of pain (RR 1.33, 95% CI 0.40 to 4.37), or adverse effects (AE), of which the most common were headache, nausea, fatigue, diarrhoea, and epigastric pain (RR 0.56, 95% CI 0.31 to 1.00). Vitamin C plus vitamin E may increase the risk of SCD-related complications (acute chest syndrome: RR 2.66, 95% CI 0.77 to 9.13; 1 study, 83 participants), and increase haemoglobin level (median (interquartile range) 90 (81 to 96) g/L versus 93.5 (84 to 105) g/L) (1 study, 83 participants) compared to placebo. However, the evidence for all the above effects is very uncertain. The study did not report on quality of life (QoL) of participants and their caregivers, nor on frequency of hospitalization. Zinc versus placebo Zinc may not be better than placebo at reducing the frequency of crisis at six months (rate ratio 0.62, 95% CI 0.17 to 2.29; 1 study, 36 participants; low-certainty evidence). We are uncertain whether zinc is better than placebo at improving sickle cell-related complications (complete healing of leg ulcers at six months: RR 2.00, 95% CI 0.60 to 6.72; 1 study, 34 participants; very low-certainty evidence). Zinc may be better than placebo at increasing haemoglobin level (g/dL) (MD 1.26, 95% CI 0.44 to 1.26; 1 study, 36 participants; low-certainty evidence). The study did not report on severity of pain, QoL, AE, and frequency of hospitalization. N-acetylcysteine versus placebo N-acetylcysteine (NAC) 1200 mg may not be better than placebo at reducing the frequency of crisis in SCD, reported as pain days (rate ratio 0.99 days, 95% CI 0.53 to 1.84; 1 study, 96 participants; low-certainty evidence). Low-certainty evidence from one study (96 participants) suggests NAC (1200 mg) may not be better than placebo at reducing the severity of pain (MD 0.17, 95% CI -0.53 to 0.87). Compared to placebo, NAC (1200 mg) may not be better at improving physical QoL (MD -1.80, 95% CI -5.01 to 1.41) and mental QoL (MD 2.00, 95% CI -1.45 to 5.45; very low-certainty evidence), reducing the risk of adverse effects (gastrointestinal complaints, pruritus, or rash) (RR 0.92, 95% CI 0.75 to 1.14; low-certainty evidence), reducing the frequency of hospitalizations (rate ratio 0.98, 95% CI 0.41 to 2.38; low-certainty evidence), and sickle cell-related complications (RR 5.00, 95% CI 0.25 to 101.48; very low-certainty evidence), or increasing haemoglobin level (MD -0.18 g/dL, 95% CI -0.40 to 0.04; low-certainty evidence). L-arginine versus placebo L-arginine may not be better than placebo at reducing the frequency of crisis (monthly pain) (RR 0.71, 95% CI 0.26 to 1.95; 1 study, 50 participants; low-certainty evidence). However, L-arginine may be better than placebo at reducing the severity of pain (MD -1.41, 95% CI -1.65 to -1.18; 2 studies, 125 participants; low-certainty evidence). One participant allocated to L-arginine developed hives during infusion of L-arginine, another experienced acute clinical deterioration, and a participant in the placebo group had clinically relevant increases in liver function enzymes. The evidence is very uncertain whether L-arginine is better at reducing the mean number of days in hospital compared to placebo (MD -0.85 days, 95% CI -1.87 to 0.17; 2 studies, 125 participants; very low-certainty evidence). Also, L-arginine may not be better than placebo at increasing haemoglobin level (MD 0.4 g/dL, 95% CI -0.50 to 1.3; 2 studies, 106 participants; low-certainty evidence). No study in this comparison reported on QoL and sickle cell-related complications. Omega-3 versus placebo Very low-certainty evidence shows no evidence of a difference in the risk of adverse effects of omega-3 compared to placebo (RR 1.05, 95% CI 0.74 to 1.48; 1 study, 67 participants). Very low-certainty evidence suggests that omega-3 may not be better than placebo at increasing haemoglobin level (MD 0.36 g/L, 95% CI -0.21 to 0.93; 1 study, 67 participants). The study did not report on frequency of crisis, severity of pain, QoL, frequency of hospitalization, and sickle cell-related complications. AUTHORS' CONCLUSIONS There was inconsistent evidence on all outcomes to draw conclusions on the beneficial and harmful effects of antioxidants. However, L-arginine may be better than placebo at reducing the severity of pain at six months, and zinc may be better than placebo at increasing haemoglobin level. We are uncertain whether other antioxidants are beneficial for SCD. Larger studies conducted on each comparison would reduce the current uncertainties.
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Affiliation(s)
- Abiola B Bolarinwa
- Department of Haematology & Blood Transfusion Medicine, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Olabisi Oduwole
- Department of Medical Laboratory Science, Achievers University, Owo, Nigeria
| | - Joseph Okebe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Ann A Ogbenna
- Department of Haematology & Blood Transfusion Medicine, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Oluwakemi E Otokiti
- Department of Haematology & Blood Transfusion Medicine, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Adejoke T Olatinwo
- Department of Haematology & Blood Transfusion Medicine, Lagos University Teaching Hospital, Lagos, Nigeria
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Kaminski TW, Katoch O, Li Z, Hanway CB, Dubey RK, Alagbe A, Brzoska T, Zhang H, Sundd P, Kato GJ, Novelli EM, Pradhan-Sundd T. Impaired hemoglobin clearance by sinusoidal endothelium promotes vaso-occlusion and liver injury in sickle cell disease. Haematologica 2024; 109:1535-1550. [PMID: 37941440 PMCID: PMC11063870 DOI: 10.3324/haematol.2023.283792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 11/02/2023] [Indexed: 11/10/2023] Open
Abstract
Sickle cell disease (SCD) is a monogenic disorder that affects 100,000 African-Americans and millions of people worldwide. Intra-erythrocytic polymerization of sickle hemoglobin (HbS) promotes erythrocyte sickling, impaired rheology, ischemia and hemolysis, leading to the development of progressive liver injury in SCD. Liver-resident macrophages and monocytes are known to enable the clearance of HbS; however, the role of liver sinusoidal endothelial cells (LSEC) in HbS clearance and liver injury in SCD remains unknown. Using real-time intravital (in vivo) imaging in mice liver as well as flow cytometric analysis and confocal imaging of primary human LSEC, we show for the first time that liver injury in SCD is associated with accumulation of HbS and iron in the LSEC, leading to senescence of these cells. Hemoglobin uptake by LSEC was mediated by micropinocytosis. Hepatic monocytes were observed to attenuate LSEC senescence by accelerating HbS clearance in the liver of SCD mice; however, this protection was impaired in P-selectin-deficient SCD mice secondary to reduced monocyte recruitment in the liver. These findings are the first to suggest that LSEC contribute to HbS clearance and HbS-induced LSEC senescence promotes progressive liver injury in SCD mice. Our results provide a novel insight into the pathogenesis of hemolysis-induced chronic liver injury in SCD caused by LSEC senescence. Identifying the regulators of LSEC-mediated HbS clearance may lead to new therapies to prevent the progression of liver injury in SCD.
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Affiliation(s)
- Tomasz W Kaminski
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Omika Katoch
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ziming Li
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Corrine B Hanway
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Rikesh K Dubey
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Adekunle Alagbe
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Tomasz Brzoska
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Prithu Sundd
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA; Division of Pulmonary Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Enrico M Novelli
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Tirthadipa Pradhan-Sundd
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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8
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Ababio GK, Ekem I, Acquaye J, Oppong SY, Amoah AGB, Brandful J, Quaye IK. Detection of Transversions and Transitions in HBG2 Cis-Elements Associated with Sickle Cell Allele in Ghanaians. Biochem Genet 2024; 62:666-674. [PMID: 37395849 DOI: 10.1007/s10528-023-10438-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/20/2023] [Indexed: 07/04/2023]
Abstract
Short tandem repeats located 5' prime to the β-globin gene, have been observed to be in linkage disequilibrium with the HbS allele, and thought to affect the severity of sickle cell disease. Here, we report on new mutants within the HBG2 region that may impact sickle cell disease. To determine the cis-acting elements microsatellites, indels and single nucleotide polymorphisms (SNPs), within the HBG2 region by sequencing, in subjects with sickle cell disease. The case-control study was located at the Center for Clinical Genetics, Sickle cell unit, Korle-Bu Teaching Hospital. A questionnaire was used for demographic data and clinical information. Hematological profile (red blood cell, white blood cell, platelet, hemoglobin and mean corpuscular volume) were assessed in 83 subjects. A set of 45 samples comprising amplified DNA on the HBG2 gene from HbSS (22), HbSC (17) and 6 controls (HbAA) were sequenced. Differences in the microsatellite region between sickle cell disease (SCD) (HbSS and HbSC) genotypes and control subjects were identified by counting and assessed by Chi-square analysis. Red blood cells, hematocrit, platelets, white blood cells and hemoglobin indices differed in genotypic groups. HbSS subjects were affirmed to have severer hemolytic anemia than HbSC subjects. Two indels (T1824 and C905) were seen in both SS and SC genotypes. Two peculiar SNPs: G:T1860 (transition) and A:G1872 transversions were found within the HBG2 gene that were significantly associated with the HbSS genotype (Fisher's exact test, p = 0.006) and HbS allele respectively (Fisher's exact test, p = 0.006). Cis-acting elements in HbSS and HbSC were different and may contribute to the phenotype seen in the disease state.
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Affiliation(s)
- G K Ababio
- Department of Medical Biochemistry, University of Ghana Medical School, Accra, Ghana.
| | - I Ekem
- Department of Hematology, University of Cape Coast School of Medicine, Cape Coast, Ghana
| | - J Acquaye
- Department of Hematology, University of Ghana Medical School, Accra, Ghana
| | - S Y Oppong
- Department of Medical Biochemistry, University of Ghana Medical School, Accra, Ghana
- Department of Chemical Pathology, University of Ghana Medical School, Accra, Ghana
| | - A G B Amoah
- Department of Medicine, University of Ghana Medical School, Accra, Ghana
| | - J Brandful
- Department of Virology, Noguchi Memorial Institute of Medical Research, Legon, Ghana
| | - I K Quaye
- Department of Biochemistry, University of Namibia Medical School, Windhoek, Namibia.
- Regent University College of Science and Technology, Dansoman, Accra, Ghana.
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Alexandrova-Watanabe A, Abadjieva E, Giosheva I, Langari A, Tiankov T, Gartchev E, Komsa-Penkova R, Todinova S. Assessment of Red Blood Cell Aggregation in Preeclampsia by Microfluidic Image Flow Analysis-Impact of Oxidative Stress on Disease Severity. Int J Mol Sci 2024; 25:3732. [PMID: 38612543 PMCID: PMC11011533 DOI: 10.3390/ijms25073732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/25/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Preeclampsia (PE) is a hypertensive disease characterized by proteinuria, endothelial dysfunction, and placental hypoxia. Reduced placental blood flow causes changes in red blood cell (RBC) rheological characteristics. Herein, we used microfluidics techniques and new image flow analysis to evaluate RBC aggregation in preeclamptic and normotensive pregnant women. The results demonstrate that RBC aggregation depends on the disease severity and was higher in patients with preterm birth and low birth weight. The RBC aggregation indices (EAI) at low shear rates were higher for non-severe (0.107 ± 0.01) and severe PE (0.149 ± 0.05) versus controls (0.085 ± 0.01; p < 0.05). The significantly more undispersed RBC aggregates were found at high shear rates for non-severe (18.1 ± 5.5) and severe PE (25.7 ± 5.8) versus controls (14.4 ± 4.1; p < 0.05). The model experiment with in-vitro-induced oxidative stress in RBCs demonstrated that the elevated aggregation in PE RBCs can be partially due to the effect of oxidation. The results revealed that RBCs from PE patients become significantly more adhesive, forming large, branched aggregates at a low shear rate. Significantly more undispersed RBC aggregates at high shear rates indicate the formation of stable RBC clusters, drastically more pronounced in patients with severe PE. Our findings demonstrate that altered RBC aggregation contributes to preeclampsia severity.
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Affiliation(s)
| | - Emilia Abadjieva
- Institute of Mechanics, Bulgarian Academy of Sciences, 1113 Sofia, Bulgaria; (A.A.-W.); (E.A.); (T.T.)
| | - Ina Giosheva
- University Obstetrics and Gynecology Hospital “Maichin Dom”, 1431 Sofia, Bulgaria; (I.G.); (E.G.)
- Institute of Biophysics and Biomedical Engineering, Bulgarian Academy of Sciences, 1113 Sofia, Bulgaria;
| | - Ariana Langari
- Institute of Biophysics and Biomedical Engineering, Bulgarian Academy of Sciences, 1113 Sofia, Bulgaria;
| | - Tihomir Tiankov
- Institute of Mechanics, Bulgarian Academy of Sciences, 1113 Sofia, Bulgaria; (A.A.-W.); (E.A.); (T.T.)
| | - Emil Gartchev
- University Obstetrics and Gynecology Hospital “Maichin Dom”, 1431 Sofia, Bulgaria; (I.G.); (E.G.)
| | | | - Svetla Todinova
- Institute of Biophysics and Biomedical Engineering, Bulgarian Academy of Sciences, 1113 Sofia, Bulgaria;
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10
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Gupta P, Kumar R. Nitric oxide: A potential etiological agent for vaso-occlusive crises in sickle cell disease. Nitric Oxide 2024; 144:40-46. [PMID: 38316197 DOI: 10.1016/j.niox.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/27/2023] [Accepted: 01/29/2024] [Indexed: 02/07/2024]
Abstract
Nitric oxide (NO), a vasodilator contributes to the vaso-occlusive crisis associated with the sickle cell disease (SCD). Vascular nitric oxide helps in vasodilation, controlled platelet aggregation, and preventing adhesion of sickled red blood cells to the endothelium. It decreases the expression of pro-inflammatory genes responsible for atherogenesis associated with SCD. Haemolysis and activated endothelium in SCD patients reduce the bioavailability of NO which promotes the severity of sickle cell disease mainly causes vaso-occlusive crises. Additionally, NO depletion can also contribute to the formation of thrombus, which can cause serious complications such as stroke, pulmonary embolism etc. Understanding the multifaceted role of NO provides valuable insights into its therapeutic potential for managing SCD and preventing associated complications. Various clinical trials and studies suggested the importance of artificially induced nitric oxide and its supplements in the reduction of severity. Further research on the mechanisms of NO depletion in SCD is needed to develop more effective treatment strategies and improve the management of this debilitating disease.
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Affiliation(s)
- Parul Gupta
- ICMR-National Institute of Research in Tribal Health, India
| | - Ravindra Kumar
- ICMR-National Institute of Research in Tribal Health, India.
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11
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Obeagu EI. Red blood cells as biomarkers and mediators in complications of diabetes mellitus: A review. Medicine (Baltimore) 2024; 103:e37265. [PMID: 38394525 DOI: 10.1097/md.0000000000037265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2024] Open
Abstract
Red blood cells (RBCs), traditionally recognized for their oxygen transport role, have garnered increasing attention for their significance as crucial contributors to the pathophysiology of diabetes mellitus. In this comprehensive review, we elucidate the multifaceted roles of RBCs as both biomarkers and mediators in diabetes mellitus. Amidst the intricate interplay of altered metabolic pathways and the diabetic milieu, RBCs manifest distinct alterations in their structure, function, and lifespan. The chronic exposure to hyperglycemia induces oxidative stress, leading to modifications in RBC physiology and membrane integrity. These modifications, including glycation of hemoglobin (HbA1c), establish RBCs as invaluable biomarkers for assessing glycemic control over extended periods. Moreover, RBCs serve as mediators in the progression of diabetic complications. Their involvement in vascular dysfunction, hemorheological changes, and inflammatory pathways contributes significantly to diabetic microangiopathy and associated complications. Exploring the therapeutic implications, this review addresses potential interventions targeting RBC abnormalities to ameliorate diabetic complications. In conclusion, comprehending the nuanced roles of RBCs as biomarkers and mediators in diabetes mellitus offers promising avenues for enhanced diagnostic precision, therapeutic interventions, and improved patient outcomes. This review consolidates the current understanding and emphasizes the imperative need for further research to harness the full potential of RBC-related insights in the realm of diabetes mellitus.
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12
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Grüning NM, Ralser M. Monogenic Disorders of ROS Production and the Primary Anti-Oxidative Defense. Biomolecules 2024; 14:206. [PMID: 38397443 PMCID: PMC10887155 DOI: 10.3390/biom14020206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/25/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
Oxidative stress, characterized by an imbalance between the production of reactive oxygen species (ROS) and the cellular anti-oxidant defense mechanisms, plays a critical role in the pathogenesis of various human diseases. Redox metabolism, comprising a network of enzymes and genes, serves as a crucial regulator of ROS levels and maintains cellular homeostasis. This review provides an overview of the most important human genes encoding for proteins involved in ROS generation, ROS detoxification, and production of reduced nicotinamide adenine dinucleotide phosphate (NADPH), and the genetic disorders that lead to dysregulation of these vital processes. Insights gained from studies on inherited monogenic metabolic diseases provide valuable basic understanding of redox metabolism and signaling, and they also help to unravel the underlying pathomechanisms that contribute to prevalent chronic disorders like cardiovascular disease, neurodegeneration, and cancer.
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Affiliation(s)
- Nana-Maria Grüning
- Department of Biochemistry, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Markus Ralser
- Department of Biochemistry, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany;
- The Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
- Max Planck Institute for Molecular Genetics, 14195 Berlin, Germany
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13
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Bell V, Varzakas T, Psaltopoulou T, Fernandes T. Sickle Cell Disease Update: New Treatments and Challenging Nutritional Interventions. Nutrients 2024; 16:258. [PMID: 38257151 PMCID: PMC10820494 DOI: 10.3390/nu16020258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
Sickle cell disease (SCD), a distinctive and often overlooked illness in the 21st century, is a congenital blood disorder characterized by considerable phenotypic diversity. It comprises a group of disorders, with sickle cell anemia (SCA) being the most prevalent and serious genotype. Although there have been some systematic reviews of global data, worldwide statistics regarding SCD prevalence, morbidity, and mortality remain scarce. In developed countries with a lower number of sickle cell patients, cutting-edge technologies have led to the development of new treatments. However, in developing settings where sickle cell disease (SCD) is more prevalent, medical management, rather than a cure, still relies on the use of hydroxyurea, blood transfusions, and analgesics. This is a disease that affects red blood cells, consequently affecting most organs in diverse manners. We discuss its etiology and the advent of new technologies, but the aim of this study is to understand the various types of nutrition-related studies involving individuals suffering from SCD, particularly in Africa. The interplay of the environment, food, gut microbiota, along with their respective genomes collectively known as the gut microbiome, and host metabolism is responsible for mediating host metabolic phenotypes and modulating gut microbiota. In addition, it serves the purpose of providing essential nutrients. Moreover, it engages in direct interactions with host homeostasis and the immune system, as well as indirect interactions via metabolites. Nutrition interventions and nutritional care are mechanisms for addressing increased nutrient expenditures and are important aspects of supportive management for patients with SCD. Underprivileged areas in Sub-Saharan Africa should be accompanied by efforts to define and promote of the nutritional aspects of SCD. Their importance is key to maintaining well-being and quality of life, especially because new technologies and products remain limited, while the use of native medicinal plant resources is acknowledged.
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Affiliation(s)
- Victoria Bell
- Faculty of Pharmacy, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal;
| | - Theodoros Varzakas
- Department of Food Science and Technology, University of the Peloponnese, 24100 Kalamata, Greece
| | - Theodora Psaltopoulou
- Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Tito Fernandes
- CIISA, Faculty of Veterinary Medicine, University of Lisbon, 1649-004 Lisbon, Portugal
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14
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Gorur V, Kranc KR, Ganuza M, Telfer P. Haematopoietic stem cell health in sickle cell disease and its implications for stem cell therapies and secondary haematological disorders. Blood Rev 2024; 63:101137. [PMID: 37919142 DOI: 10.1016/j.blre.2023.101137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 10/04/2023] [Accepted: 10/04/2023] [Indexed: 11/04/2023]
Abstract
Gene modification of haematopoietic stem cells (HSCs) is a potentially curative approach to sickle cell disease (SCD) and offers hope for patients who are not eligible for allogeneic HSC transplantation. Current approaches require in vitro manipulation of healthy autologous HSC prior to their transplantation. However, the health and integrity of HSCs may be compromised by a variety of disease processes in SCD, and challenges have emerged in the clinical trials of gene therapy. There is also concern about increased susceptibility to haematological malignancies during long-term follow up of patients, and this raises questions about genomic stability in the stem cell compartment. In this review, we evaluate the evidence for HSC deficits in SCD and then discuss their potential causation. Finally, we suggest several questions which need to be addressed in order to progress with successful HSC manipulation for gene therapy in SCD.
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Affiliation(s)
- Vishaka Gorur
- William Harvey Research Institute, Queen Mary University of London, EC1M 6BQ, UK.
| | - Kamil R Kranc
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, EC1M 6BQ, UK.
| | - Miguel Ganuza
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, EC1M 6BQ, UK.
| | - Paul Telfer
- Blizard Institute, Queen Mary University of London, E1 2AT, UK.
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15
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Tahara U, Matsui T, Atsugi T, Fukuda K, Terooatea TW, Minoda A, Kubo A, Amagai M. Keratinocytes of the Upper Epidermis and Isthmus of Hair Follicles Express Hemoglobin mRNA and Protein. J Invest Dermatol 2023; 143:2346-2355.e10. [PMID: 37981423 DOI: 10.1016/j.jid.2023.08.008] [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: 05/08/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 11/21/2023]
Abstract
The epidermis, the keratinized stratified squamous epithelium surrounding the body surface, offers a valuable framework to investigate how terrestrial animals overcome environmental stresses. However, the mechanisms underlying epidermal barrier function remain nebulous. In this study, we examined genes highly expressed in the human and mouse upper epidermis, the outer frontier that induces various barrier-related genes. Transcriptome analysis revealed that the messenger RNA level of hemoglobin α (HBA), an oxygen carrier in erythroid cells, was enriched in the upper epidermis compared with that in the whole epidermis. Immunostaining analysis confirmed HBA protein expression in human and mouse keratinocytes (KCs) of the stratum spinosum and stratum granulosum. HBA was also expressed in hair follicle KCs in the isthmus region; its expression levels were more prominent than those in interfollicular KCs. HBA expression was not observed in noncutaneous keratinized stratified squamous epithelia of mice, for example, the vagina, esophagus, and forestomach. HBA expression was upregulated in human epidermal KC cultures after UV irradiation, a major cause of skin-specific oxidative stress. Furthermore, HBA knockdown increased UV-induced production of ROS in primary KCs. Our findings suggest that epidermal HBA expression is induced by oxidative stress and acts as an antioxidant, contributing to skin barrier function.
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Affiliation(s)
- Umi Tahara
- Laboratory for Skin Homeostasis, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan; Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Takeshi Matsui
- Laboratory for Skin Homeostasis, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan; Department of Dermatology, Keio University School of Medicine, Tokyo, Japan; Laboratory for Evolutionary Cell Biology of the Skin, School of Bioscience and Biotechnology, Tokyo University of Technology, Hachioji, Japan
| | - Toru Atsugi
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Keitaro Fukuda
- Laboratory for Skin Homeostasis, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan; Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Tommy W Terooatea
- Laboratory for Cellular Epigenomics, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
| | - Aki Minoda
- Laboratory for Cellular Epigenomics, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan; Department of Cell Biology, Faculty of Science, Radboud Institute for Molecular Life Sciences, Radboud University, Nijmegen, The Netherlands
| | - Akiharu Kubo
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan; Division of Dermatology, Department of Internal Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masayuki Amagai
- Laboratory for Skin Homeostasis, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan; Department of Dermatology, Keio University School of Medicine, Tokyo, Japan.
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16
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Giannaki A, Georgatzakou HΤ, Fortis SP, Anastasiadi AT, Pavlou EG, Nomikou EG, Drandaki MP, Kotsiafti A, Xydaki A, Fountzoula C, Papageorgiou EG, Tzounakas VL, Kriebardis AG. Stratification of β Sβ + Compound Heterozygotes Based on L-Glutamine Administration and RDW: Focusing on Disease Severity. Antioxidants (Basel) 2023; 12:1982. [PMID: 38001835 PMCID: PMC10669421 DOI: 10.3390/antiox12111982] [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: 10/06/2023] [Revised: 10/30/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
Sickle cell disease (SCD) is heterogeneous in terms of manifestation severity, even more so when in compound heterozygosity with beta-thalassemia. The aim of the present study was to stratify βSβ+ patient blood samples in a severity-dependent manner. Blood from thirty-two patients with HbS/β-thalassemia compound heterozygosity was examined for several parameters (e.g., hemostasis, inflammation, redox equilibrium) against healthy controls. Additionally, SCD patients were a posteriori (a) categorized based on the L-glutamine dose and (b) clustered into high-/low-RDW subgroups. The patient cohort was characterized by anemia, inflammation, and elevated coagulation. Higher-dose administration of L-glutamine was associated with decreased markers of inflammation and oxidation (e.g., intracellular reactive oxygen species) and an altered coagulation profile. The higher-RDW group was characterized by increased hemolysis, elevated markers of inflammation and stress erythropoiesis, and oxidative phenomena (e.g., membrane-bound hemoglobin). Moreover, the levels of hemostasis parameters (e.g., D-Dimers) were greater compared to the lower-RDW subgroup. The administration of higher doses of L-glutamine along with hydroxyurea seems to attenuate several features in SCD patients, probably by enhancing antioxidant power. Moreover, anisocytosis may alter erythrocytes' coagulation processes and hemolytic propensity. This results in the disruption of the redox and pro-/anti-inflammatory equilibria, creating a positive feedback loop by inducing stress erythropoiesis and, thus, the occurrence of a mixed erythrocyte population.
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Affiliation(s)
- Aimilia Giannaki
- Laboratory of Reliability and Quality Control in Laboratory Hematology (HemQcR), Department of Biomedical Sciences, School of Health & Caring Sciences, University of West Attica (UniWA), 12243 Egaleo, Greece; (A.G.); (H.T.G.); (S.P.F.); (A.T.A.); (E.G.P.); (E.G.P.)
| | - Hara Τ. Georgatzakou
- Laboratory of Reliability and Quality Control in Laboratory Hematology (HemQcR), Department of Biomedical Sciences, School of Health & Caring Sciences, University of West Attica (UniWA), 12243 Egaleo, Greece; (A.G.); (H.T.G.); (S.P.F.); (A.T.A.); (E.G.P.); (E.G.P.)
| | - Sotirios P. Fortis
- Laboratory of Reliability and Quality Control in Laboratory Hematology (HemQcR), Department of Biomedical Sciences, School of Health & Caring Sciences, University of West Attica (UniWA), 12243 Egaleo, Greece; (A.G.); (H.T.G.); (S.P.F.); (A.T.A.); (E.G.P.); (E.G.P.)
| | - Alkmini T. Anastasiadi
- Laboratory of Reliability and Quality Control in Laboratory Hematology (HemQcR), Department of Biomedical Sciences, School of Health & Caring Sciences, University of West Attica (UniWA), 12243 Egaleo, Greece; (A.G.); (H.T.G.); (S.P.F.); (A.T.A.); (E.G.P.); (E.G.P.)
- Department of Biochemistry, School of Medicine, University of Patras, 26504 Patras, Greece;
| | - Efthimia G. Pavlou
- Laboratory of Reliability and Quality Control in Laboratory Hematology (HemQcR), Department of Biomedical Sciences, School of Health & Caring Sciences, University of West Attica (UniWA), 12243 Egaleo, Greece; (A.G.); (H.T.G.); (S.P.F.); (A.T.A.); (E.G.P.); (E.G.P.)
- Blood Bank and Hemophilia Unit, Hippokration Hospital, 11527 Athens, Greece;
| | - Efrosyni G. Nomikou
- Blood Bank and Hemophilia Unit, Hippokration Hospital, 11527 Athens, Greece;
| | - Maria P. Drandaki
- Thalassemia and Sickle Cell Unit, Expertise Center of Hemoglobinopathies and Their Complications, Hippokration General Hospital, 11527 Athens, Greece; (M.P.D.); (A.K.); (A.X.)
| | - Angeliki Kotsiafti
- Thalassemia and Sickle Cell Unit, Expertise Center of Hemoglobinopathies and Their Complications, Hippokration General Hospital, 11527 Athens, Greece; (M.P.D.); (A.K.); (A.X.)
| | - Aikaterini Xydaki
- Thalassemia and Sickle Cell Unit, Expertise Center of Hemoglobinopathies and Their Complications, Hippokration General Hospital, 11527 Athens, Greece; (M.P.D.); (A.K.); (A.X.)
| | - Christina Fountzoula
- Laboratory of Chemistry, Biochemistry and Cosmetic Science (ChemBiochemCosm), Department of Biomedical Sciences, School of Health & Caring Sciences, University of West Attica (UniWA), 12243 Egaleo, Greece;
| | - Effie G. Papageorgiou
- Laboratory of Reliability and Quality Control in Laboratory Hematology (HemQcR), Department of Biomedical Sciences, School of Health & Caring Sciences, University of West Attica (UniWA), 12243 Egaleo, Greece; (A.G.); (H.T.G.); (S.P.F.); (A.T.A.); (E.G.P.); (E.G.P.)
| | - Vassilis L. Tzounakas
- Department of Biochemistry, School of Medicine, University of Patras, 26504 Patras, Greece;
| | - Anastasios G. Kriebardis
- Laboratory of Reliability and Quality Control in Laboratory Hematology (HemQcR), Department of Biomedical Sciences, School of Health & Caring Sciences, University of West Attica (UniWA), 12243 Egaleo, Greece; (A.G.); (H.T.G.); (S.P.F.); (A.T.A.); (E.G.P.); (E.G.P.)
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17
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Aboderin FI, Oduola T, Davison GM, Oguntibeju OO. A Review of the Relationship between the Immune Response, Inflammation, Oxidative Stress, and the Pathogenesis of Sickle Cell Anaemia. Biomedicines 2023; 11:2413. [PMID: 37760854 PMCID: PMC10525295 DOI: 10.3390/biomedicines11092413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/09/2023] [Accepted: 08/26/2023] [Indexed: 09/29/2023] Open
Abstract
Sickle cell anaemia (SCD) is a life-threatening haematological disorder which is predominant in sub-Saharan Africa and is triggered by a genetic mutation of the β-chain haemoglobin gene resulting in the substitution of glutamic acid with valine. This mutation leads to the production of an abnormal haemoglobin molecule called haemoglobin S (HbS). When deoxygenated, haemoglobin S (HbS) polymerises and results in a sickle-shaped red blood cell which is rigid and has a significantly shortened life span. Various reports have shown a strong link between oxidative stress, inflammation, the immune response, and the pathogenesis of sickle cell disease. The consequence of these processes leads to the development of vasculopathy (disease of the blood vessels) and several other complications. The role of the immune system, particularly the innate immune system, in the pathogenesis of SCD has become increasingly clear in recent years of research; however, little is known about the roles of the adaptive immune system in this disease. This review examines the interaction between the immune system, inflammation, oxidative stress, blood transfusion, and their effects on the pathogenesis of sickle cell anaemia.
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Affiliation(s)
- Florence Ifechukwude Aboderin
- Department of Biomedical Sciences, Faculty of Health and Wellness Sciences, Cape Peninsula University of Technology, Bellville 7535, South Africa;
| | - Taofeeq Oduola
- Department of Chemical Pathology, Usmanu Danfodiyo University, Sokoto 840004, Nigeria;
| | - Glenda Mary Davison
- SAMRC/CPUT Cardiometabolic Health Research Unit, Department of Biomedical Sciences, Faculty of Health and Wellness Sciences, Cape Peninsula University of Technology, Bellville 7535, South Africa;
| | - Oluwafemi Omoniyi Oguntibeju
- Department of Biomedical Sciences, Faculty of Health and Wellness Sciences, Cape Peninsula University of Technology, Bellville 7535, South Africa;
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18
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Banait S, Banait T, Shukla S, Mane S, Jain J. Bilateral Humeral Head Avascular Necrosis: A Rare Presentation in Sickle Cell Trait. Cureus 2023; 15:e44006. [PMID: 37746483 PMCID: PMC10517089 DOI: 10.7759/cureus.44006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 08/23/2023] [Indexed: 09/26/2023] Open
Abstract
Sickle cell disease (SCD) affects millions of people worldwide. It is an autosomal recessive hemoglobinopathy that occurs due to a point mutation in the sixth codon that replaces glutamic acid with valine in the beta-globin chain. Avascular necrosis (AVN), also known as osteonecrosis, is one of its complications. In this report, we present a case of a 25-year-old female with sickle cell trait without any comorbidities who presented to us with pain in both shoulder joints for three months and was diagnosed with AVN in bilateral shoulder joints. Appropriate treatment can dramatically reduce pain and improve the quality of life for these patients. This case drew our attention due to its rare presentation.
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Affiliation(s)
- Shashank Banait
- Department of Ophthalmology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research (DMIHER), Wardha, IND
| | - Tanvi Banait
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research (DMIHER), Wardha, IND
| | - Shivani Shukla
- Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Wardha, IND
| | - Supriya Mane
- Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Wardha, IND
| | - Jyoti Jain
- Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Wardha, IND
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19
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Trucas M, Burattini S, Porcu S, Simbula M, Ristaldi MS, Kowalik MA, Serra MP, Gobbi P, Battistelli M, Perra A, Quartu M. Multi-Organ Morphological Findings in a Humanized Murine Model of Sickle Cell Trait. Int J Mol Sci 2023; 24:10452. [PMID: 37445630 DOI: 10.3390/ijms241310452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Sickle cell disease (SCD) is caused by the homozygous beta-globin gene mutation that can lead to ischemic multi-organ damage and consequently reduce life expectancy. On the other hand, sickle cell trait (SCT), the heterozygous beta-globin gene mutation, is still considered a benign condition. Although the mechanisms are not well understood, clinical evidence has recently shown that specific pathological symptoms can also be recognized in SCT carriers. So far, there are still scant data regarding the morphological modifications referable to possible multi-organ damage in the SCT condition. Therefore, after genotypic and hematological characterization, by conventional light microscopy and transmission electron microscopy (TEM), we investigated the presence of tissue alterations in 13 heterozygous Townes mice, one of the best-known animal models that, up to now, was used only for the study of the homozygous condition. We found that endothelial alterations, as among which the thickening of vessel basal lamina, are ubiquitous in the lung, liver, kidney, and spleen of SCT carrier mice. The lung shows the most significant alterations, with a distortion of the general tissue architecture, while the heart is the least affected. Collectively, our findings contribute novel data to the histopathological modifications at microscopic and ultrastructural levels, underlying the heterozygous beta-globin gene mutation, and indicate the translational suitability of the Townes model to characterize the features of multiple organ involvement in the SCT carriers.
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Affiliation(s)
- Marcello Trucas
- Department of Biomedical Sciences, Section of Cytomorphology, University of Cagliari, Cittadella Universitaria di Monserrato, 09042 Monserrato, Italy
| | - Sabrina Burattini
- Department of Biomolecular Sciences, Campus Scientifico "Enrico Mattei", University of Urbino Carlo Bo, Via Ca' le Suore 2-Località Crocicchia, 61029 Urbino, Italy
| | - Susanna Porcu
- Italian National Research Council (CNR)-IRGB, Cittadella Universitaria Monserrato, 09042 Monserrato, Italy
| | - Michela Simbula
- Italian National Research Council (CNR)-IRGB, Cittadella Universitaria Monserrato, 09042 Monserrato, Italy
| | - Maria Serafina Ristaldi
- Italian National Research Council (CNR)-IRGB, Cittadella Universitaria Monserrato, 09042 Monserrato, Italy
| | - Marta Anna Kowalik
- Department of Biomedical Sciences, Unit of Oncology and Molecular Pathology, University of Cagliari, Cittadella Universitaria di Monserrato, 09042 Monserrato, Italy
| | - Maria Pina Serra
- Department of Biomedical Sciences, Section of Cytomorphology, University of Cagliari, Cittadella Universitaria di Monserrato, 09042 Monserrato, Italy
| | - Pietro Gobbi
- Department of Biomolecular Sciences, Campus Scientifico "Enrico Mattei", University of Urbino Carlo Bo, Via Ca' le Suore 2-Località Crocicchia, 61029 Urbino, Italy
| | - Michela Battistelli
- Department of Biomolecular Sciences, Campus Scientifico "Enrico Mattei", University of Urbino Carlo Bo, Via Ca' le Suore 2-Località Crocicchia, 61029 Urbino, Italy
| | - Andrea Perra
- Department of Biomedical Sciences, Unit of Oncology and Molecular Pathology, University of Cagliari, Cittadella Universitaria di Monserrato, 09042 Monserrato, Italy
| | - Marina Quartu
- Department of Biomedical Sciences, Section of Cytomorphology, University of Cagliari, Cittadella Universitaria di Monserrato, 09042 Monserrato, Italy
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20
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An R, Man Y, Cheng K, Zhang T, Chen C, Wang F, Abdulla F, Kucukal E, Wulftange WJ, Goreke U, Bode A, Nayak LV, Vercellotti GM, Belcher JD, Little JA, Gurkan UA. Sickle red blood cell-derived extracellular vesicles activate endothelial cells and enhance sickle red cell adhesion mediated by von Willebrand factor. Br J Haematol 2023; 201:552-563. [PMID: 36604837 PMCID: PMC10121869 DOI: 10.1111/bjh.18616] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 11/14/2022] [Accepted: 12/06/2022] [Indexed: 01/07/2023]
Abstract
Endothelial activation and sickle red blood cell (RBC) adhesion are central to the pathogenesis of sickle cell disease (SCD). Quantitatively, RBC-derived extracellular vesicles (REVs) are more abundant from SS RBCs compared with healthy RBCs (AA RBCs). Sickle RBC-derived REVs (SS REVs) are known to promote endothelial cell (EC) activation through cell signalling and transcriptional regulation at longer terms. However, the SS REV-mediated short-term non-transcriptional response of EC is unclear. Here, we examined the impact of SS REVs on acute microvascular EC activation and RBC adhesion at 2 h. Compared with AA REVs, SS REVs promoted human pulmonary microvascular ECs (HPMEC) activation indicated by increased von Willebrand factor (VWF) expression. Under microfluidic conditions, we found abnormal SS RBC adhesion to HPMECs exposed to SS REVs. This enhanced SS RBC adhesion was reduced by haeme binding protein haemopexin or VWF cleaving protease ADAMTS13 to a level similar to HPMECs treated with AA REVs. Consistent with these observations, haemin- or SS REV-induced microvascular stasis in SS mice with implanted dorsal skin-fold chambers that was inhibited by ADAMTS13. The adhesion induced by SS REVs was variable and was higher with SS RBCs from patients with increased markers of haemolysis (lactate dehydrogenase and reticulocyte count) or a concomitant clinical diagnosis of deep vein thrombosis. Our results emphasise the critical contribution made by REVs to the pathophysiology of SCD by triggering acute microvascular EC activation and abnormal RBC adhesion. These findings may help to better understand acute pathophysiological mechanism of SCD and thereby the development of new treatment strategies using VWF as a potential target.
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Affiliation(s)
- Ran An
- Mechanical and Aerospace Engineering Department, Case Western Reserve University, Cleveland, OH, USA
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
- Department of Biomedical Sciences, University of Houston, Houston, TX, USA
- indicates equal contribution
| | - Yuncheng Man
- Mechanical and Aerospace Engineering Department, Case Western Reserve University, Cleveland, OH, USA
- indicates equal contribution
| | - Kevin Cheng
- Mechanical and Aerospace Engineering Department, Case Western Reserve University, Cleveland, OH, USA
| | - Tianyi Zhang
- Physiology and Biophysics Department, Case Western Reserve University, Cleveland, OH, USA
| | - Chunsheng Chen
- Division of Hematology, Oncology and Transplantation, Vascular Biology Center, University of Minnesota, Minneapolis, MN, USA
| | - Fang Wang
- Mechanical and Aerospace Engineering Department, Case Western Reserve University, Cleveland, OH, USA
| | - Fuad Abdulla
- Division of Hematology, Oncology and Transplantation, Vascular Biology Center, University of Minnesota, Minneapolis, MN, USA
| | - Erdem Kucukal
- Mechanical and Aerospace Engineering Department, Case Western Reserve University, Cleveland, OH, USA
| | - William J. Wulftange
- Biomedical Engineering Department, Case Western Reserve University, Cleveland, OH, USA
| | - Utku Goreke
- Mechanical and Aerospace Engineering Department, Case Western Reserve University, Cleveland, OH, USA
| | - Allison Bode
- Mechanical and Aerospace Engineering Department, Case Western Reserve University, Cleveland, OH, USA
- Department of Hematology and Oncology, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Lalitha V. Nayak
- Department of Hematology and Oncology, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Gregory M. Vercellotti
- Division of Hematology, Oncology and Transplantation, Vascular Biology Center, University of Minnesota, Minneapolis, MN, USA
| | - John D. Belcher
- Division of Hematology, Oncology and Transplantation, Vascular Biology Center, University of Minnesota, Minneapolis, MN, USA
| | - Jane A. Little
- Divison of Hematology & UNC Blood Research Center, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Umut A. Gurkan
- Mechanical and Aerospace Engineering Department, Case Western Reserve University, Cleveland, OH, USA
- Division of Hematology, Oncology and Transplantation, Vascular Biology Center, University of Minnesota, Minneapolis, MN, USA
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA
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21
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Chauhan W, Zennadi R. Keap1-Nrf2 Heterodimer: A Therapeutic Target to Ameliorate Sickle Cell Disease. Antioxidants (Basel) 2023; 12:antiox12030740. [PMID: 36978988 PMCID: PMC10045360 DOI: 10.3390/antiox12030740] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/04/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023] Open
Abstract
Sickle cell disease (SCD) is a monogenic inheritable disease characterized by severe anemia, increased hemolysis, and recurrent, painful vaso-occlusive crises due to the polymerization of hemoglobin S (HbS)-generated oxidative stress. Up until now, only four drugs are approved for SCD in the US. However, each of these drugs affects only a limited array of SCD pathologies. Importantly, curative therapies, such as gene therapy, or hematopoietic stem cell transplantation are not available for every patient because of their high costs, availability of donor matching, and their serious adverse effects. Therefore, there is an unmet medical need for novel therapeutic strategies that target broader SCD sequelae. SCD phenotypic severity can be alleviated by increasing fetal hemoglobin (HbF) expression. This results in the inhibition of HbS polymerization and thus sickling, and a reduction in oxidative stress. The efficacy of HbF is due to its ability to dilute HbS levels below the threshold required for polymerization and to influence HbS polymer stability in RBCs. Nuclear factor-E2-related factor 2 (Nrf2)/Kelch-like ECH-associated protein-1 (Keap1)-complex signaling is one of the most important cytoprotective signaling controlling oxidative stress. Nrf2 is present in most organs and, after dissociation from Keap1, it accumulates in the cytoplasm, then translocates to the nucleus where it binds to the antioxidant response element (ARE) sequences and increases the expression of various cytoprotective antioxidant genes. Keeping this in mind, various researchers have proposed a role of multiple agents, more importantly tert-Butylhydroquinone (tBHQ), curcumin, etc., (having electrophilic properties) in inhibiting keap1 activity, so that Nrf2 can translocate to the nucleus to activate the gamma globin gene, thus maintaining alpha-hemoglobin-stabilizing protein (AHSP) and HbF levels. This leads to reduced oxidative stress, consequently minimizing SCD-associated complications. In this review, we will discuss the role of the Keap-1–Nrf2 complex in hemoglobinopathies, especially in SCD, and how this complex might represent a better target for more effective treatment options.
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22
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Ibrahim A, Muhammad SA. Antioxidant-Rich Nutraceutical as a Therapeutic Strategy for Sickle Cell Disease. JOURNAL OF THE AMERICAN NUTRITION ASSOCIATION 2022:1-10. [PMID: 36069788 DOI: 10.1080/27697061.2022.2108930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/23/2022] [Accepted: 07/29/2022] [Indexed: 06/15/2023]
Abstract
Sickle cell disease (SCD) is a genetically inherited disease in which the "SS" individual possesses two copies of the abnormal beta-globin gene. This disease is one of the most dominant genetic diseases in the world. SCD is marked by the propensity of red cell hemoglobin to polymerize and distort the red cell from a biconcave disk shape into a sickle shape, resulting in a typical vaso-occlusive episode and accelerated hemolysis. Plants are rich sources of bioactive compounds that are promising anti-sickling agents to scavenge free radicals, thereby ensuring oxidative balance. The current review highlights the potential therapeutic benefits of antioxidant-rich nutraceutical in the treatment and management of sickle cell disease. The anti-sickling potential of nutraceutical is attributed to the presence of antioxidant bioactive chemicals such as alkaloids, polyphenols, vitamins, and minerals, which acts as scavengers of free radicals that prevent oxidative damage of the hemoglobin and prevent hemolysis, facilitating longer erythrocyte lifespan. The challenges of current therapies for SCD and future directions are also discussed.KEY TEACHING POINTSSickle cell disease is a genetically inherited disease in which SS individuals possess two copies of the abnormal beta-globin gene.Oxidative stress contributes to the pathophysiology of secondary dysfunction in sickle cell patients.Antioxidants can play a vital role in maintaining a balance between oxidant and antioxidant defense systems.Nutraceutical rich in antioxidants such as alkaloids, polyphenols, vitamins, and minerals is potential therapeutic agents for sickle cell disease.An antioxidant-rich nutraceutical may act to reduce vaso-occlusive crises.
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Affiliation(s)
- Abdulwasiu Ibrahim
- Department of Biochemistry and Molecular Biology, Usmanu Danfodiyo University, Sokoto, Nigeria
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23
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Conran N, Costa FF. Sickle Cell Disease and Oxidative Stress: Implications for a Role of Diminished Endothelial SOD2 in Pulmonary Complications. FUNCTION (OXFORD, ENGLAND) 2022; 3:zqac021. [PMID: 36156896 PMCID: PMC9492249 DOI: 10.1093/function/zqac021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 01/07/2023]
Affiliation(s)
| | - Fernando F Costa
- Hematology and Transfusion Center, University of Campinas – UNICAMP, Campinas, São Paulo 13083-878, Brazil
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24
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Loh D, Reiter RJ. Melatonin: Regulation of Prion Protein Phase Separation in Cancer Multidrug Resistance. MOLECULES (BASEL, SWITZERLAND) 2022; 27:molecules27030705. [PMID: 35163973 PMCID: PMC8839844 DOI: 10.3390/molecules27030705] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/11/2022] [Accepted: 01/17/2022] [Indexed: 12/13/2022]
Abstract
The unique ability to adapt and thrive in inhospitable, stressful tumor microenvironments (TME) also renders cancer cells resistant to traditional chemotherapeutic treatments and/or novel pharmaceuticals. Cancer cells exhibit extensive metabolic alterations involving hypoxia, accelerated glycolysis, oxidative stress, and increased extracellular ATP that may activate ancient, conserved prion adaptive response strategies that exacerbate multidrug resistance (MDR) by exploiting cellular stress to increase cancer metastatic potential and stemness, balance proliferation and differentiation, and amplify resistance to apoptosis. The regulation of prions in MDR is further complicated by important, putative physiological functions of ligand-binding and signal transduction. Melatonin is capable of both enhancing physiological functions and inhibiting oncogenic properties of prion proteins. Through regulation of phase separation of the prion N-terminal domain which targets and interacts with lipid rafts, melatonin may prevent conformational changes that can result in aggregation and/or conversion to pathological, infectious isoforms. As a cancer therapy adjuvant, melatonin could modulate TME oxidative stress levels and hypoxia, reverse pH gradient changes, reduce lipid peroxidation, and protect lipid raft compositions to suppress prion-mediated, non-Mendelian, heritable, but often reversible epigenetic adaptations that facilitate cancer heterogeneity, stemness, metastasis, and drug resistance. This review examines some of the mechanisms that may balance physiological and pathological effects of prions and prion-like proteins achieved through the synergistic use of melatonin to ameliorate MDR, which remains a challenge in cancer treatment.
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Affiliation(s)
- Doris Loh
- Independent Researcher, Marble Falls, TX 78654, USA
- Correspondence: (D.L.); (R.J.R.)
| | - Russel J. Reiter
- Department of Cellular and Structural Biology, UT Health San Antonio, San Antonio, TX 78229, USA
- Correspondence: (D.L.); (R.J.R.)
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