Johara Hassan

Haemoglobinuria is associated with chronic kidney disease and its progression in patients with sickle cell anaemia.

To evaluate the association between haemoglobinuria and chronic kidney disease (CKD) in sickle cell anaemia (SCA), we analysed 356 adult haemoglobin SS or Sβo thalassaemia patients from the University of Illinois at Chicago (UIC) and 439 from the multi‐centre Walk‐Treatment of Pulmonary Hypertension and Sickle Cell Disease with Sildenafil Therapy (Walk‐PHaSST) cohort. CKD was classified according to National Kidney Foundation Kidney Disease Outcomes Quality Initiatives guidelines. Haemoglobinuria, defined as positive haem on urine dipstick with absent red blood cells on microscopy, was confirmed by enzyme‐linked immunosorbent assay in a subset of patients. The prevalence of CKD was 58% in the UIC cohort and 54% in the Walk‐PHaSST cohort, and haemoglobinuria was observed in 36% and 20% of the patients, respectively. Pathway analysis in both cohorts indicated an independent association of lactate dehydrogenase with haemoglobinuria and, in turn, independent associations of haemoglobinuria and age with CKD (P < 0·0001). After a median of 32 months of follow‐up in the UIC cohort, haemoglobinuria was associated with progression of CKD [halving of estimated glomerular filtration rate or requirement for dialysis; Hazard ratio (HR) 13·9, 95% confidence interval (CI) 1·7–113·2, P = 0·0012] and increasing albuminuria (HR 3·1, 95% CI: 1·3–7·7; logrank P = 0·0035). In conclusion haemoglobinuria is common in SCA and is associated with CKD, consistent with a role for intravascular haemolysis in the pathogenesis of renal dysfunction in SCA.

Nonmyeloablative Stem Cell Transplantation with Alemtuzumab/Low-Dose Irradiation to Cure and Improve the Quality of Life of Adults with Sickle Cell Disease

Allogeneic hematopoietic stem cell transplantation (HSCT) is rarely performed in adult patients with sickle cell disease (SCD). We utilized the chemotherapy-free, alemtuzumab/total body irradiation 300 cGy regimen with sirolimus as post-transplantation immunosuppression in 13 high-risk SCD adult patients between November 2011 and June 2014. Patients received matched related donor (MRD) granulocyte colony-stimulating factor-mobilized peripheral blood stem cells, including 2 cases that were ABO incompatible. Quality-of-life (QoL) measurements were performed at different time points after HSCT. All 13 patients initially engrafted. A stable mixed donor/recipient chimerism was maintained in 12 patients (92%), whereas 1 patient not compliant with sirolimus experienced secondary graft failure. With a median follow-up of 22 months (range, 12 to 44 months) there was no mortality, no acute or chronic graft-versus-host disease (GVHD), and no grades 3 or 4 extramedullary toxicities. At 1 year after transplantation, patients with stable donor chimerism have normalized hemoglobin concentrations and improved cardiopulmonary and QoL parameters including bodily pain, general health, and vitality. In 4 patients, sirolimus was stopped without rejection or SCD-related complications. These results underscore the successful use of a chemotherapy-free regimen in MRD HSCT for high-risk adult SCD patients and demonstrates a high cure rate, absence of GVHD or mortality, and improvement in QoL including the applicability of this regimen in ABO mismatched cases (NCT number 01499888).

APOL1,α-thalassemia, and BCL11A variants as a genetic risk profile for progression of chronic kidney disease in sickle cell anemia

Sickle cell anemia (SCA) is caused by a mutation in the β-globin gene that results in hemoglobin polymerization and affects approximately 1 in 500 African Americans and 25 million people worldwide. Chronic kidney disease (CKD) is observed in up to 58% of adults, and is associated with a 3-fold increased risk for early mortality in SCA. Multiple genetic modifiers of clinical complications in SCA have been reported, and combining these genetic factors into a risk profile may strengthen the predictive value as compared to the individual factors alone. Homozygosity or compound heterozygosity for APOL1 G1/G2 (G1=S342G/I384M substitutions, G2=N388/Y389 deletions) is observed in 10-15% of African Americans, and is the strongest genetic association for CKD in African Americans in general. APOL1 G1/G2 is also associated with proteinuria and albumin-

Oral tetrahydrouridine and decitabine for non-cytotoxic epigenetic gene regulation in sickle cell disease: A randomized phase 1 study

Background Sickle cell disease (SCD), a congenital hemolytic anemia that exacts terrible global morbidity and mortality, is driven by polymerization of mutated sickle hemoglobin (HbS) in red blood cells (RBCs). Fetal hemoglobin (HbF) interferes with this polymerization, but HbF is epigenetically silenced from infancy onward by DNA methyltransferase 1 (DNMT1). Methods and findings To pharmacologically re-induce HbF by DNMT1 inhibition, this first-in-human clinical trial (NCT01685515) combined 2 small molecules—decitabine to deplete DNMT1 and tetrahydrouridine (THU) to inhibit cytidine deaminase (CDA), the enzyme that otherwise rapidly deaminates/inactivates decitabine, severely limiting its half-life, tissue distribution, and oral bioavailability. Oral decitabine doses, administered after oral THU 10 mg/kg, were escalated from a very low starting level (0.01, 0.02, 0.04, 0.08, or 0.16 mg/kg) to identify minimal doses active in depleting DNMT1 without cytotoxicity. Patients were SCD adults at risk of early death despite standard-of-care, randomized 3:2 to THU–decitabine versus placebo in 5 cohorts of 5 patients treated 2X/week for 8 weeks, with 4 weeks of follow-up. The primary endpoint was ≥ grade 3 non-hematologic toxicity. This endpoint was not triggered, and adverse events (AEs) were not significantly different in THU-decitabine—versus placebo-treated patients. At the decitabine 0.16 mg/kg dose, plasma concentrations peaked at approximately 50 nM (Cmax) and remained elevated for several hours. This dose decreased DNMT1 protein in peripheral blood mononuclear cells by >75% and repetitive element CpG methylation by approximately 10%, and increased HbF by 4%–9% (P < 0.001), doubling fetal hemoglobin-enriched red blood cells (F-cells) up to approximately 80% of total RBCs. Total hemoglobin increased by 1.2–1.9 g/dL (P = 0.01) as reticulocytes simultaneously decreased; that is, better quality and efficiency of HbF-enriched erythropoiesis elevated hemoglobin using fewer reticulocytes. Also indicating better RBC quality, biomarkers of hemolysis, thrombophilia, and inflammation (LDH, bilirubin, D-dimer, C-reactive protein [CRP]) improved. As expected with non-cytotoxic DNMT1-depletion, platelets increased and neutrophils concurrently decreased, but not to an extent requiring treatment holds. As an early phase study, limitations include small patient numbers at each dose level and narrow capacity to evaluate clinical benefits. Conclusion Administration of oral THU-decitabine to patients with SCD was safe in this study and, by targeting DNMT1, upregulated HbF in RBCs. Further studies should investigate clinical benefits and potential harms not identified to date. Trial registration ClinicalTrials.gov, NCT01685515

Risk factors for vitamin D deficiency in sickle cell disease

Vitamin D deficiency (VDD), 25‐OHD levels <20 ng/ml, is prevalent among patients with sickle cell disease (SCD) and is linked to acute and chronic pain and bone fracture in this population. There is limited literature regarding VDD‐associated risk factors for SCD. We examined potential clinical and genomic parameters associated with VDD in 335 adults with SCD in a cross‐sectional study. VDD was present in 65% of adult SCD patients, and 25‐OHD levels independently and positively correlated with older age (P < 0·001) and vitamin D supplementation (P < 0·001). 25‐OHD levels were higher in SCD patients over 40 years of age compared to the general African‐American population. Both lower 25‐OHD levels and increased pain frequency were associated with increased expression of SLC6A5 encoding glycine transporter‐2 (GlyT2), a protein involved in neuronal pain pathways. Lower 25‐OHD levels were also associated with increased expression of CYP3A4, and with decreased expression of GC (also termed DBP) and VDR, three genes involved in vitamin D metabolism. We conclude that vitamin D supplementation should be an almost universal feature of the care of young adults with SCD, and that further research is warranted into genomic factors that regulate vitamin D metabolism in SCD.

Platelets decline during Vaso-occlusive crisis as a predictor of acute chest syndrome in sickle cell disease.

Cell Leukemia/Lymphoma, an extremely rare stem cell disorder characterized by very poor prognosis and association of myeloproliferative neoplasm with T/B-cell lymphoma. Notably, this fusion causes constitutive activation of the FGFR1 kinase and, therefore, it is potentially targetable using drugs such as ponatinib [6]. Indeed, in vitro treatment of patient’s cells with nanomolar concentration of ponatinib caused a potent and specific growth inhibition (Supporting Information Fig. 2). A total of three NPM1 insertions were reported by both standard techniques and RNA-Seq; FLT3-ITD was detected in six samples by RNA-Seq and in four by standard PCR-based techniques (not tested in the remaining two). Although the numbers are too limited to drive definitive conclusions, this suggests comparable sensitivity of standard techniques and RNA-Seq in detecting these variants (Table I). A total of 23 SNV were also identified by RNA-Seq with a median of one variant per patient (range 0–4). Globally, 22/23 SNV have been confirmed by Sanger sequencing, suggesting that the accuracy of our pipeline for SNV detection is 96%. Of the 22 confirmed SNV, 10 were new and 12 were known variants (Table I). Taken globally, these data suggest that a single RNA-Seq analysis performed at diagnosis in AML patients, even in absence of a matched control sample, allows to quickly detect a large number of abnormalities that are not detected using standard clinical tests. This analysis will allow to achieve a better prognostic assessment and to identify potentially new treatment options, such as ponatinib for the patient carrying the ZMYM2-FGFR1 translocation. This is of paramount importance, as the list of clinically available selective inhibitors keeps growing at very fast pace and the discovery of new driver variants may lead to the development of novel targeted therapies (Supporting Information Table I).

Erythropoiesis-stimulating agents in sickle cell anaemia

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Program expansion of a day hospital dedicated to manage sickle cell pain

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