Presentation on theme: "SICKLE CELL DISEASE JOHN M KAUFFMAN JR DO"— Presentation transcript:
1SICKLE CELL DISEASE JOHN M KAUFFMAN JR DO ASSOCIATE DEAN FOR POSTGRADUATE AFFAIRSVIA COLLEGE OF OSTEOPATHIC MEDICINE
2Goals and ObjectivesAt the conclusion of this program, the attendee will have a better understanding of:The genetics and transmission of Sickle Cell DiseaseThe Diagnosis and pathophysiology of Sickle Cell DiseaseThe management of the complications of Sickle Cell DiseaseThe current treatment of Sickle Cell Disease
3Sickle Cell Disease: A Case A 22yo AA woman is transferred to your hospital with respiratory failure. You are asked to see her in the emergency department. In the ED the patient is in obvious distress with a RR of 45 and an O2sat of 72%. Her ABG revealed 7.34/44/59/23/76% on 3 liters O2 by nasal canula.
4Sickle Cell Disease: A Case The patient had been diagnosed with Sickle Cell Anemia at age 6 and was hospitalized for a sickle cell crisis at age hours prior to admission in your hospital she was seen in another ED with severe pain (10/10) in her back thighs and knees. She was nauseated and had vomited once. She denied chest pain, SOB, fever, chills, abdominal pain, dysuria, constipation or diarrhea.
5Sickle Cell Disease: A Case Within 10 hours of admission to your hospital, the patients O2 sat dropped to 40% and she was intubated. Her ABG revealed: 7.35/44/80/22/94% on the vent with 100% O2 TV=350, and 22cm of peep.What is your diagnosis?
6DefinitionsSickle-Cell Disease: A group of blood disorders caused by a mutation in the hemoglobin gene.Common Sickle Cell Diseases Include:Sickle Cell AnemiaHemoglobin SC DiseaseSickle Beta ThalasemiaSickling and sickle cell disease also confer some resistance to malaria
7DefinitionsSickle-Cell Anemia : Sickle-cell anemia is the name of a specific form of sickle-cell disease in which the individual is homozygous for the mutation that causes HbS. Normal hemoglobin is called hemoglobin A, but people with sickle cell anemia have only hemoglobin S, which in the homozygous form, turns normal, round red blood cells into abnormally curved (sickle) shapes. Sickling decreases the cells' flexibility and predisposes the carrier to potentially serious complications. Sickle-cell anemia is also referred to as "HbSS", "SS disease", "hemoglobin S" etc.
9DefinitionsSickle Cell Trait: condition in which a person has one abnormal allele of the hemoglobin beta gene ( heterozygous), but does not display the severe symptoms of sickle cell disease that occur in individuals who have two copies of the abnormal Hb S allele ( homozygous)About 2 million Americans have sickle cell trait. The condition occurs in about 1 in 12 African Americans.
10Sickle Cell DiseaseSickle cell disease (SCD) is the most common genetic disorder identified in African Americans,Also found in people from South and Central America, the Mediterranean and the Middle East.
11Sickle Cell DiseaseIn the United States, it’s estimated that sickle cell anemia affects around 50,000 people, mainly African Americans. The disease occurs in about 1 out of every 700 African American births.Before the era of Hydroxyurea, the average life expectancy was in the 40’s
12Clinical Hallmarks of Sickle Cell Disease (SCD) Vaso-occlusionHemolysis
13Diagnostic Testing:Cellulose acetate electrophoresis is a standard method of separating Hb S from other hemoglobin variants. However Hb S, G, and D have the same electrophoretic mobility with this method.
15Diagnostic Testing:Citrate agar electrophoresis seperates Hb S from Hb D and GThin-layer isoelectric focusing and high performance liquid chomatography (HPLC) are highly accurate tools for the diagnosis of sickle or other hemoglobin variants
16Diagnostic TestingIn Summary: Cellulose acetate electrophoresis with either citrate agar electrophoresis or a solubility test allows a definitive diagnosis of sickle cell syndromeAlternatively, thin layer isoelectric focusing will separate Hb S, D, and G and can replace the two electrophoretic methods.However, thin-layer isoelectric focusing still requires a confirmatory solubility test for Hb S
17Newborn ScreeningMandated in all 50 states and the District of Columbia.Most states use either thin-layer isoelectric focusing (IEF) or high performance liquid chromatography (HPLC) as the initial screening test.Both methods have extremely high sensitivity and specificity for sickle cell anemia. Specimens must be drawn prior to any blood transfusion (false negative)Extremely premature infants may have false positive results when adult hemoglobin is undetectable
18Screening Programs Selective screening of infants of high-risk parents Universal testing of newbornsSelective screening misses up to 20% of AA newborns with SCDsickle cell diagnoses doubled when screening was changed from targeted to universal
20Laboratory Findings in Sickle Cell Disease Chronic Hemolysis with mild to moderate anemia (Hct 20-30%)Reticulocytosis of 3-15% ( % RBCs)Unconjugated hyperbilirubinemiaSickled RBCs on peripheral smearLow serum erythropoietin secondary to progressive renal diseaseFolate and Iron deficiency secondary to increased utilizaton of folate and urinary excretion of iron
21Peripheral Blood Smear Sickled red cellsPolychromasia indicative of reticulocytosisHowell-Jolly bodies secondary to splenic infarctsNormochromic, normocytic RBCs
24Findings in Sickle Cell Disease The Cooperative Study of Sickle Cell Disease looked at Lab Data in 2600 people with SCDMean WBC counts elevated especially in children < age 10Thrombocytosis seen individuals < age 18Serum Alk Phos elevated until puberty
25TIMING OF SCREENING Test all newborns at the time of birth Verify screening results at first office visitPerform confirmatory tests no later than 2 months of age.
26Most common types of sickle cell disease Hemoglobin SS disease (also called Sickle Cell Anemia)Hemoglobin Sickle-C diseaseSickle Beta-Thalassemia.
27Hemoglobin Hemoglobin: Definition and Structure Hemoglobin carries oxygen from the lungs to tissues and CO2 from the tissues to the lungs for excretion.Hemoglobin molecule consists of two parts:Porphyrin group or hemeProtein or globin portion.Globin is made up of four polypeptide chains attached to the porphyrin ringFour types: alpha, beta, delta and gamma.
29Sickle Cell Hemoglobin In normal Hemoglobin A, glutamic acid is on the 6th position of the beta chain, while in sickle-cell disease, this glutamic acid is replaced by valine (point mutation) leading to the formation of sickle cells.Polymerization: the two beta chains fit into each other forming a longitudinal polymer (or lock and key) causing the cell to become deformed and very rigid leading to vessel occlusion.Polymerization: activated by infections, hypoxia, acidosis, physical exercise, vasoocclusion due to cold as well as dehydration.
30Sickle Cell Hemoglobin In sickle cell hemoglobin (HbS) glutamic acid in position 6 (in beta chain) is mutated to valine. This change allows the deoxygenated form of the hemoglobin to stick to each other.
32Normal Adult Hemoglobin Primarily Hemoglobin A2 alpha chains and 2 beta chainsBeta chain synthesis begins early in fetal developmentSixth week of gestation, hemoglobin A composes about 7% of the total hemoglobin; the percentages slowly increase throughout the pregnancyThirtieth week there is a switch from gamma chain to beta chain production.
33Fetal Hemoglobin At birth babies have mostly fetal or F hemoglobin falls to the normal level of less than 3 to 5% by the time the infant is 5-6 months of ageAdults have less than 2% fetal hemoglobin.Fetal hemoglobin is made up of two alpha and two gamma chains.
34STRUCTURAL FORMULA FOR NORMAL HEMOGLOBIN A Major Adult Hemoglobin2 Alpha Chains + 2 Beta ChainsF Fetal Hemoglobin2 Alpha Chains + 2 Gamma ChainsA2 Minor Adult Hemoglobin2 Alpha Chains + 2 Delta Chain
35HEMOGLOBINOPATHIESHemoglobinopathy: disease or trait caused by a defect in the genetic code for hemoglobin synthesisOver 600 known hemoglobin variants reportedVast majority of abnormal hemoglobin result from the mutation of a single polypeptide chain.
36Genetics of Sickle Cell Trait Heterozygous subject (sickle cell trait (A/S), an abnormal gene is inherited from one parent and it directs the formation of abnormal hemoglobin.A normal gene is inherited from the other parent and it directs the formation of normal hemoglobin.
37Example of an Inheritance Pattern for Sickle Cell Trait
38Genetics of Sickle Cell Disease Homozygous subject, identical abnormal genes are inherited; one from each parent, and the majority of the hemoglobin is abnormal, such as in sickle cell anemia (S/S).
39Example of an Inheritance Pattern for Sickle Cell Trait
40HEMOGLOBIN A/S SICKLE CELL TRAIT GENOTYPE: ASBeta chain variantEach red cell contains a mixture of A (60%) and S (40%).Amount of A in each cell is enough to prevent sickling under most physiological conditions.
41POPULATIONS AFFECTED African Americans: 8-10% Hispanic Americans: 2% Occurs frequently in Greeks, Italians, Saudi Arabians, East indians and Middle Easterners
42CLINICAL SYMPTOMS of Sickle Cell Trait NOT associated with anemia.Offers some protection against malaria.Occasional hematuria and hyposthenia (impaired renal concentrating ability)Splenic infarction reported to occur at altitudes greater than 7,000 feetGreater risk for sudden death under extreme conditions such as those that might occur during basic training in the military.severe dehydration, malnutrition, physical overexertion and exhaustion. This risk though increased, is small.
43PRECAUTIONSAvoid hypoxic situations: deep sea diving, flying in unpressurized aircraft, strenuous physical activity over a prolonged period of time.
44COUNSELING POINTS TO BE MADE • Person is a healthy carrier• Person is not sick.• Sickle cell trait is not a disease.• Sickle cell trait will not cause you to be anemic.• There is a small amount of hemoglobin S, but not enough to change the shape of the red blood cell.• The red blood cells of a person with sickle cell trait remain round and flexible.
45SICKLE CELL ANEMIA GENOTYPE: S/S Hemoglobin S (90-100%) Hemoglobin F may be slightly elevated
46SICKLE CELL ANEMIAMost common form of sickle cell disease identified in African Americans
47SICKLE CELL ANEMIA Clinical Symptoms Most severe form of sickle cell diseaseClinical course variableSevere anemiaVaso-occlusion, pain episodes, organ damageAplastic episode, splenic sequestration, increased risk for infectionIf HbF is greater than 10% there is a decreased risk of stroke
48SICKLE CELL ANEMIA PRECAUTIONS Genetic counseling and screening to clarify risk for child born with sickle cell diseaseReferral to High Risk OB Clinic for pregnancy.Avoid Hypoxia, dehydration
49Clinical Manifestations of Sickle Cell Disease Vasoocclusion and hemolysis are the hallmarks of sickle cell diseaseVasoocclusion results in recurrent painful episodes (sickle cell crisis)Dactylitis (acute pain in the hands and feet) is the most common initial symptom
50Most Common Complications of Sickle Cell Disease Acute Painful Crisis (Sickle Cell Crisis)Acute Chest SyndromeStrokeChronic Lung DiseaseAvascular NecrosisLeg Ulcers
51Clinical Manifestations of Sickle Cell Disease Hemoglobin S (HbS) results results form the substitution of a valine for glutamic acid as the sixth amino acid of the beta globin chain, that produces a hemoglobin tetramer (alpha 2/beta S2) that is poorly soluble when deoxygenated.
52Clinical Manifestations of Sickle Cell Disease Sickle Cell Disease is used to describe those conditions associated with “ Sickling”Patients who are homozygous for HbS have the most severe form of the disease
53Pathophysiology of Vasoocclusion Sickle cells (Hb SS) lose deformability when deoxygenatedCauses vascular obstruction and ischemiaCritical factor underlying painful crises, acute chest syndrome, functional asplenia, and stroke
54Pathophysiology of Vasoocclusion Membrane damage shortens the lifespan of RBCsCausing chronic intravascular and extravascular hemolysisIntravascular hemolysis causes:Decreased nitric oxide, Increased vascular tone, and pulmonary artery hypertension
55Pathophysiology of Vasoocclusion Damaged RBCs have irregular surfaces that cause them to adhere to the vascular endotheliumpromotes acute vascular occlusion leading to a proliferative “lesion” made up of WBCs, platelets, smooth muscle cells and coagulation proteinsLeading to strokes and possibly Pulm HTN
56Gladwin and Vichinsky n engl j med November 20, (21): 2254
57Acute Painful Crisis (Sickle Cell Crisis) Acute pain (previously know as “sickle cell crisis”)Most common type of vasoocclusive eventsFirst symptom noted in over 25% of patientsMost frequent symptom after the age of two
58Clinical Manifestations of Sickle Cell Disease Dactylitis (acute pain in the hands and feet) most common symptom before the age of twoPain was the most common symptom after the age of twoSplenic sequestration is the third major symptom
59Clinical Manifestations of Sickle Cell Disease Significant predictors of adverse outcomeDactylitis before the age of 1Hemoglobin level <7 g/dlLeukocytosis in the absence of infection
61Acute Chest SyndromePresentation: Chest pain, pulmonary infiltrate and feverMost common form of acute pulmonary disease in Sickle Cell DiseaseMost common cause of death in SCDEtiology: pneumonia, infarction/thrombosis, fat embolus
62Acute Chest SyndromePresentation: Chest pain, pulmonary infiltrate and feverMost common form of acute pulmonary disease in Sickle Cell DiseaseMost common cause of death in SCDEtiology: pneumonia, infarction/thrombosis, fat embolus
63Gladwin and Vichinsky n engl j med November 20, 2008 359 (21): 2254
64Acute Chest SyndromeThe Acute Chest Syndrome occurs in the majority of patients with sickle cell disease at least once during their livesSecond most common cause of hospital admission after “painful vaso-occlusive crises”
65Acute Chest SyndromeThe Acute Chest Syndrome is a life-threatening disorderLeading cause of death in people with sickle cell anemia.Defined as the presence of a new pulmonary infiltrate on Chest Xray, with chest pain, fever, cough, dyspnea, or an elevated WBC count in a patient with sickle cell anemia.
66Acute Chest SyndromeCaused by occlusion of the pulmonary vessels by sickled red cells. Since hypoxia is the chief stimulus for polymerization of hemoglobin S, lung disease of any type poses a particular threat to the patient with sickle cell anemia.
67Four Major Precipitants of Acute Chest Syndrome InfectionBone Marrow EmboliThromboembolismAtelectasis
68Acute Severe Anemia Splenic Sequestration Crisis Aplastic Crisis Hyperhemoytic Crisis
69Splenic Sequestration Crisis Vaso-occlusion within the spleen and pooling of RBCs leads to a marked fall in Hg and an increase in reticulocytes
70Aplastic CrisisTransient cessation of erythropoiesis secondary to infection with parvovirusCan also occur after infection with Strep pneumoniae, salmonella, and EBV
71Hyperhemolytic Crisis Associated with multiple transfusionsAlso associated with certain drugs, infections and glucose-six-phostate dehydrogenase deficiency
72Growth and Development Growth retardation and delayed puberty are common in children with SCD
73Infection Impairment of the spleen Patients are susecptable to encapsulated organisms such as Strep pneumo, and H fluBacteremiaMeningitisPneumoniaOsteomyelitis
74FeverMedical emergency requiring immediate attention and treatment with antibiotics
76Bone Complications Bone infarction and necrosis Osteomyelitis OsteoporosisOsteonecrosis (avascular or ischemic necrosis)Bone marrow infarctionPulmonary fat embolism (secondary to bone marrow infarction)
77Cardiac Complications Increased Cardiac Output (secondary to chronic anemia)Myocardial Infarction (caused by increased oxygen demand that cannot be met due to the anemia and decreased oxygen carrying capacity of the RBCs)
78Dermatolgic Complications Leg Ulcers (secondary to vasoocclusion in the skin
79Hepatobiliary Complications Acute Hepatic IschemiaCholestasisHepatic sequestration crisisIron overload secondary to multiple transfusionsAcute and chronic cholelithiasis secondary to pigmented gallstonesHepatitis C secondary to blood transfusion
80Obstetrical Complications Fetal complications: Spontaneous abortion, intrauterine growth retardation, fetal demise, low birth weight secondary to compromised placental blood flowMaternal complications: acute chest syndrome, UTI, pyelonephritis, endometritis, preeclampsia, thromboembolic events, which occur in up to 50% of pregnancies
81Renal Complications Hematuria Proteinuria Hypertension Renal Infarction, Papillary necrosisNephrogenic DIFocal GlomerulosclerosisRenal Medullary carcinoma, seen in black patients with sickle cell trait
82Retinopathy Proliferative retinopathy Retinal artery occlusion Retinal detachment and hemorrhage
83TREATMENT COMPREHENSIVE CARE — Upon diagnosis of SCD implement a Comprehensive Care program for the affected child and his\her familyBecause of the many manifestations of the acute and chronic complications of SCDCritical to involve specialists with expertiseMultidisciplinary teams: social workers, psychologists, nurses, genetic counselors, and nutritionists.
84TREATMENT Universal screening of newborns Prophylactic Penicillin Improved medical careHave reduced the mortality of Sickle Cell Disease from 25% to less than 3%
85TREATMENTBegin prophylactic penicillin 125mg BID by 2-3 months of age and continue until two to three years of age. At this time increase dose to 250mg BID until the age of 5.After age 5 some clinicians elect to stop the penicillin prophylaxisImmunize against, Streptococcus pneumoniae, Haemophilus influenza,Hepatitis B and influenza
86TREATMENT Folic Acid 1mg daily Children 16 or younger should be evaluated with transcranial doppler (TCD) to identify those children at risk for cerebrovascular accidents.Begin TCDs at age two and continue every 12 to 24 months.The risk of stroke can be reduced
87TREATMENT Hydroxyurea Hematopoietic Stem-cell Transplantation Long Term Transfusion Therapy
88TreatmentHydroxyurea: Only FDA approved therapy to prevent episodes of pain in SCD. Interferes with the sickle hemoglobin polymerization process by increasing the production of fetal hemoglobin
89CureHematopoietic stem cell transplant. Limited to individuals less than 16 years of age
90HydroxyureaCytotoxic drug that can bind metals. Used in polyc ythemia vera to decreas the elevated Hct and platelet countInhibits ribonucleotide reductase by bindings its 2 main iron molecules and inactivating a critical tyrosyl radical that reduces the production of RBCs with a high level of HbSSFavors production of fetal Hb which arises from precursor cells that divide at a slower rate
91HydroxyureaA major breakthrough that shifts hemoglobin production from sickle hemoglobin to fetal hemoglobin by altering the bone marrow to favor fetal hemoglobin production
93HydroxyureaDose: Single daily oral dose 15 mg/kg (adjust for decreased creatinine clearance)Monitor CBC every 2 weeksContraindicated in: pregnancy, breast feeding, severe anemia, leukopenia and thrombocytopeniaDiscontinue if CBC counts drop below the acceptable range
99ReferencesAmerican Academy of Pediatrics. (2002). Health supervision for children with sickle cell disease. Pediatrics, 109(3), Dew, A., & van Besien, K. (2010). Stem-cell transplantation for sickle cell disease. The New England Journal of Medicine, 362(10), Feld, J. J., DeBaun, M. R., & Vichinsky, E. P. (2009). Overview of the management of sickle cell disease. UpToDate. Retrieved from Firth, P. G. (2009). Pulmonary complications of sickle cell disease. The New England Journal of Medicine, 360(10), Gladwin, M. T., Sachdev, V., Jison, M. L., Shizukuda, Y., Plehn, J. F., Minter, K., … Ognibene, F. P. (2004). Pulmonary hypertension as a risk factor for death in patients with sickle cell disease. The New England Journal of Medicine, 350(9), Gladwin, M. T., & Vichinsky, E. (2010). Pulmonary complications of sickle-cell disease. The New England Journal of Medicine, 359(21), Khan, S., & Rodgers, G. P. (2010). Hematopoietic cell transplantation in sickle cell disease.UpToDate. Retrieved from Lee, M. T., Piomelli, S., Granger, S., Miller, S. T., Harkness, S., Brambilla, D. J., & Adams, R. J.(2006). Stroke prevention trial in sickle cell anemia (STOP): Extended follow- up and final results. Blood, 108, doi: /blood Lunzer, M. M., Yekkirala, A., Hebbel, R. P., & Portoghese, P. S. (2007). Naloxone acts as a potent analgesic in transgenic mouse models of sickle cell anemia. Proceedings of the National Academy of Sciences, 104(14), doi: /pnas
100ReferencesMedoff, B. D., Shepard, J. O., Smith, R. N., & Kratz, A. (2005). Case : A 22-year-old woman with back and leg pain and respiratory failure. The New England Journal ofMedicine, 352(23),National Guideline Clearinghouse. (2007). Hemoglobinopathies in pregnancy. Retrieved fromNational Guideline Clearinghouse. (2007). Screening for sickle cell disease in newborns: U.S. Preventive Services Task Force recommendation.Retrieved fromPlatt, O. S. (2008). Hydroxyurea for the treatment of sickle cell anemia. The New England Journal of Medicine, 358(13),Rodgers, G. P. (2010). Specific therapies for sickle cell disease. UpToDate. Retrieved fromStrouse, J. J., Takemoto, C. M., Keefer, J. R., Kato, G. J., & Casella, J. F. (2008). Corticosteroids and increased risk of readmission after acute chest syndrome in children with sickle celldisease. Pediatric Blood Cancer, 50(5), doi: /pbc.21336Vinchinsky, E. (2009). Overview of the clinical manifestations of sickle cell disease. UpToDate. Retrieved fromVirginia Department of Health. (2005). Sickle cell anemia (Hb SS Disease). Retrieved fromVirginia Department of Health Division of Women’s and Infant Health. (n.d.). A counseling guide for sickle cell and other hemoglobin variants. The Virginia Sickle Cell Awareness Program. Retrieved from
101ReferencesYanni, E., Grosse, S. D., Yang, Q., & Olney, R. S. (2009). Trends in pediatric sickle cell disease-Related mortality in the United States, The Journal of Pediatrics, doi: /j.peds Ye, L., Chang, J. C., Lin, C., Sun, X., Yu, J., & Wai Kan, Y. (2009). Induced pluripotent stem cells offer new approach to therapy in thalassemia and sickle cell anemia and option in Prenatal diagnosis in genetic diseases. Proceedings of the National Academy of Sciences, 106(24), doi: /pnas West, MS, Wethers, D, Smith, J, et al. The Cooperative Study of Sickle Cell Disease: Laboratory profile of sickle cell disease: A cross-sectional analysis. J Clin Epidemiol 1992; 45:893.