Pub Date : 2020-05-01DOI: 10.1164/ajrccm-conference.2020.201.1_meetingabstracts.a7215
R. Vats, T.W. Kaminski, T. Brzóska, E. Tutuncuoglu, J. Tejero, C. Hillery, Tirthadipa Pradhan‐Sundd, M. Gladwin, P. Sundd
{"title":"Circulating Neutrophil Extracellular Traps in the Pathogenesis of Acute Chest Syndrome of Sickle Cell Disease","authors":"R. Vats, T.W. Kaminski, T. Brzóska, E. Tutuncuoglu, J. Tejero, C. Hillery, Tirthadipa Pradhan‐Sundd, M. Gladwin, P. Sundd","doi":"10.1164/ajrccm-conference.2020.201.1_meetingabstracts.a7215","DOIUrl":"https://doi.org/10.1164/ajrccm-conference.2020.201.1_meetingabstracts.a7215","url":null,"abstract":"","PeriodicalId":348915,"journal":{"name":"D59. SICKLE CELL DISEASE","volume":"66 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134541516","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-13DOI: 10.1182/blood-2019-122199
R. Lawrence, Sarah L. Khan, V. K. Gupta, B. Scarpato, R. Strykowski, J. Newman, J. Sloan, R. Cohen, S. Nouraie, E. Klings
Introduction Patients with sickle cell disease (SCD) are at increased risk for venous thromboembolism (VTE). By age 40, 11-12% of SCD patients have experienced a VTE. VTE confers nearly a three-fold increase in mortality risk for individuals with SCD. We hypothesized that VTE increases subsequent SCD severity which may increase acute care utilization. We investigated the association between VTE and rates of vaso-occlusive events (VOE) and acute care utilization for individuals with SCD. Methods We performed a retrospective longitudinal chart review of 239 adults with SCD who received care at our institution between 2003 and 2018. VTE was defined as deep venous thrombosis (DVT) diagnosed by Duplex ultrasound or pulmonary embolism (PE) diagnosed by either ventilation-perfusion scanning or computed tomography angiography. Medical histories, laboratories and medication use for all subjects were obtained. For VTE patients, clinical data for 1- and 5- years post-VTE were obtained and compared to 1 year prior to the VTE. For non-VTE patients, data were obtained at baseline and compared to five years later. We evaluated all acute care visits for the presence of a SCD-related problem, specifically assessing if a VOE or acute chest syndrome (ACS) occurred. We calculated rates of VOE, ACS, Emergency Department (ED) visits and hospitalizations prior to and subsequent to a VTE and compared these to occurrence rates among those without VTE. Data were analyzed using Stata 14.2. Results In our cohort of 239 individuals with SCD, 153 (64%) were HbSS/HbSβ0 and 127(53%) were female. Fifty-six individuals (23%) had a history of VTE; 20 had a DVT (36%), 33 had a PE (59%), and 3 had both (5%). Patients with VTE had a higher frequency of prior history of ACS (p<0.001), stroke (p=0.013), splenectomy (p=0.033), and avascular necrosis (p<0.001) than those without a VTE. Prior to their VTE, these patients had higher white blood cell (11.8 x103 [9-15 x 103] vs 9.7 x103 [7-12 x 103], p=0.047) and platelet counts (378 x 103 [272-485 x 103] vs 322 x 103 [244-400 x 103], p=0.007) than those without a VTE. During five years of follow-up after a VTE, these patients had 6.32 (SD 14.97) ED visits per year compared to 2.84 (SD 5.93, p<0.03) ED visits per year in those without a VTE. Ninety two percent of these ED visits were SCD-related; 73% were for VOE and 4% for ACS. Additionally, SCD patients with a VTE had an increase in all-cause hospital admissions (2.84 [SD 3.26] vs 1.43 [SD 2.86], p=0.003) and SCD-related hospital admissions (2.61 [SD 3.13] vs 1.23 [SD 2.74], p=0.001) per year compared to those without VTE. Conclusion VTE is a frequent complication in patients with SCD. Our study suggests that patients who experience a VTE have greater SCD severity as evidenced by increased VOE, ED and hospital utilization. These data suggest that VTE is not merely an isolated event in SCD patients and that it may either serve as an indicator of disease severity or contribute to over
{"title":"Patients with Sickle Cell Disease and Venous Thromboembolism Experience Increased Frequency of Vasoocclusive Events","authors":"R. Lawrence, Sarah L. Khan, V. K. Gupta, B. Scarpato, R. Strykowski, J. Newman, J. Sloan, R. Cohen, S. Nouraie, E. Klings","doi":"10.1182/blood-2019-122199","DOIUrl":"https://doi.org/10.1182/blood-2019-122199","url":null,"abstract":"Introduction\u0000 Patients with sickle cell disease (SCD) are at increased risk for venous thromboembolism (VTE). By age 40, 11-12% of SCD patients have experienced a VTE. VTE confers nearly a three-fold increase in mortality risk for individuals with SCD. We hypothesized that VTE increases subsequent SCD severity which may increase acute care utilization. We investigated the association between VTE and rates of vaso-occlusive events (VOE) and acute care utilization for individuals with SCD.\u0000 Methods\u0000 We performed a retrospective longitudinal chart review of 239 adults with SCD who received care at our institution between 2003 and 2018. VTE was defined as deep venous thrombosis (DVT) diagnosed by Duplex ultrasound or pulmonary embolism (PE) diagnosed by either ventilation-perfusion scanning or computed tomography angiography. Medical histories, laboratories and medication use for all subjects were obtained. For VTE patients, clinical data for 1- and 5- years post-VTE were obtained and compared to 1 year prior to the VTE. For non-VTE patients, data were obtained at baseline and compared to five years later. We evaluated all acute care visits for the presence of a SCD-related problem, specifically assessing if a VOE or acute chest syndrome (ACS) occurred. We calculated rates of VOE, ACS, Emergency Department (ED) visits and hospitalizations prior to and subsequent to a VTE and compared these to occurrence rates among those without VTE. Data were analyzed using Stata 14.2.\u0000 Results\u0000 In our cohort of 239 individuals with SCD, 153 (64%) were HbSS/HbSβ0 and 127(53%) were female. Fifty-six individuals (23%) had a history of VTE; 20 had a DVT (36%), 33 had a PE (59%), and 3 had both (5%). Patients with VTE had a higher frequency of prior history of ACS (p<0.001), stroke (p=0.013), splenectomy (p=0.033), and avascular necrosis (p<0.001) than those without a VTE. Prior to their VTE, these patients had higher white blood cell (11.8 x103 [9-15 x 103] vs 9.7 x103 [7-12 x 103], p=0.047) and platelet counts (378 x 103 [272-485 x 103] vs 322 x 103 [244-400 x 103], p=0.007) than those without a VTE. During five years of follow-up after a VTE, these patients had 6.32 (SD 14.97) ED visits per year compared to 2.84 (SD 5.93, p<0.03) ED visits per year in those without a VTE. Ninety two percent of these ED visits were SCD-related; 73% were for VOE and 4% for ACS. Additionally, SCD patients with a VTE had an increase in all-cause hospital admissions (2.84 [SD 3.26] vs 1.43 [SD 2.86], p=0.003) and SCD-related hospital admissions (2.61 [SD 3.13] vs 1.23 [SD 2.74], p=0.001) per year compared to those without VTE.\u0000 Conclusion\u0000 VTE is a frequent complication in patients with SCD. Our study suggests that patients who experience a VTE have greater SCD severity as evidenced by increased VOE, ED and hospital utilization. These data suggest that VTE is not merely an isolated event in SCD patients and that it may either serve as an indicator of disease severity or contribute to over","PeriodicalId":348915,"journal":{"name":"D59. SICKLE CELL DISEASE","volume":"16 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127364010","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-13DOI: 10.1182/blood-2019-130592
T. Brzóska, M. Bennewitz, E. Tutuncuoglu, M. Ragni, M. Neal, M. Gladwin, P. Sundd
Hemolysis is a hallmark of various inherited or acquired blood disorders including sickle cell disease, thalassemia, paroxysmal nocturnal hemoglobinuria, thrombotic thrombocytopenic purpura and hemolytic-uremic syndrome. Epidemiological evidence suggests that in situ pulmonary thrombosis is a major pathological event contributing to cardiopulmonary morbidities affecting patients with hemolytic disorders. Intravascular hemolysis promotes the release of erythrocyte-derived damage associated molecular patterns (eDAMPs) molecules such as cell free hemoglobin (Hb), heme and adenosine diphosphate (ADP). Although these eDAMPS may activate platelets, promote endothelial dysfunction and drive sterile thrombo-inflammation, the pathogenesis of pulmonary thrombosis in hemolytic disorders and the role of platelets in this process remains unclear. Intravascular hemolysis in C57BL/6 (WT) mice was induced by intravenous (IV) administration of deionized water (H2O). Alternatively, eDAMPs or tissue derived DAMPs relevant to hemolysis or endothelial injury were administered IV to WT mice. The pulmonary microcirculation was visualized using quantitative intravital fluorescence lung microscopy (qFILM). Fluorochrome-conjugated anti-mouse CD49b Ab and dextran were administered IV for in vivo staining of circulating platelets and visualization of blood vessels, respectively. Time series of qFILM images were collected at baseline and post IV administration of agonists to assess pulmonary thrombosis. IV administration of H2O led to arrival of platelet-rich thrombi in the pulmonary arterioles that occluded the arteriolar bottle-necks located at the junction of pulmonary arterioles and capillaries leading to their transient obstruction. DAMPs such as ADP, collagen, thrombin and tissue factor also triggered dose-dependent PT in mice. Identical to IV H2O, DAMPs triggered pulmonary thrombosis also involved entrapment of platelet-rich thrombi in the arteriolar bottle-necks, which led to ischemia in the pulmonary arteriole and the down-stream capillaries. Interestingly, pretreatment with IV heparin (300 U/kg) prevented TF-induced but not ADP-triggered pulmonary thrombosis in mice. In contrast, IV administration of αIIbβ3 receptor inhibitor eptifibatide (10 mg/kg) completely abrogated TF-, collagen and ADP-dependent PT. Our current findings provide the first real-time in vivo visual evidence establishing that intravascular hemolysis directly induces pulmonary thrombosis, which involves entrapment of platelet-rich thrombi in the pre-capillary pulmonary arterioles. Our results are the first to identify that platelet activation and procoagulant activity contribute to pathogenesis of hemolysis induced pulmonary thrombosis. Ragni: OPKO: Research Funding; Bioverativ/Sanofi: Other: Advisory Board, Research Funding; Shire/Takeda: Other: Advisory Board, Research Funding; Sangamo: Research Funding; Spark Therapeutics: Other: Advisory Board, Research Funding; Alnylam/Sanofi: Other:
{"title":"Mechanism of Pulmonary Thrombosis in Hemolytic Disorders","authors":"T. Brzóska, M. Bennewitz, E. Tutuncuoglu, M. Ragni, M. Neal, M. Gladwin, P. Sundd","doi":"10.1182/blood-2019-130592","DOIUrl":"https://doi.org/10.1182/blood-2019-130592","url":null,"abstract":"Hemolysis is a hallmark of various inherited or acquired blood disorders including sickle cell disease, thalassemia, paroxysmal nocturnal hemoglobinuria, thrombotic thrombocytopenic purpura and hemolytic-uremic syndrome. Epidemiological evidence suggests that in situ pulmonary thrombosis is a major pathological event contributing to cardiopulmonary morbidities affecting patients with hemolytic disorders. Intravascular hemolysis promotes the release of erythrocyte-derived damage associated molecular patterns (eDAMPs) molecules such as cell free hemoglobin (Hb), heme and adenosine diphosphate (ADP). Although these eDAMPS may activate platelets, promote endothelial dysfunction and drive sterile thrombo-inflammation, the pathogenesis of pulmonary thrombosis in hemolytic disorders and the role of platelets in this process remains unclear.\u0000 Intravascular hemolysis in C57BL/6 (WT) mice was induced by intravenous (IV) administration of deionized water (H2O). Alternatively, eDAMPs or tissue derived DAMPs relevant to hemolysis or endothelial injury were administered IV to WT mice. The pulmonary microcirculation was visualized using quantitative intravital fluorescence lung microscopy (qFILM). Fluorochrome-conjugated anti-mouse CD49b Ab and dextran were administered IV for in vivo staining of circulating platelets and visualization of blood vessels, respectively. Time series of qFILM images were collected at baseline and post IV administration of agonists to assess pulmonary thrombosis.\u0000 IV administration of H2O led to arrival of platelet-rich thrombi in the pulmonary arterioles that occluded the arteriolar bottle-necks located at the junction of pulmonary arterioles and capillaries leading to their transient obstruction. DAMPs such as ADP, collagen, thrombin and tissue factor also triggered dose-dependent PT in mice. Identical to IV H2O, DAMPs triggered pulmonary thrombosis also involved entrapment of platelet-rich thrombi in the arteriolar bottle-necks, which led to ischemia in the pulmonary arteriole and the down-stream capillaries. Interestingly, pretreatment with IV heparin (300 U/kg) prevented TF-induced but not ADP-triggered pulmonary thrombosis in mice. In contrast, IV administration of αIIbβ3 receptor inhibitor eptifibatide (10 mg/kg) completely abrogated TF-, collagen and ADP-dependent PT.\u0000 Our current findings provide the first real-time in vivo visual evidence establishing that intravascular hemolysis directly induces pulmonary thrombosis, which involves entrapment of platelet-rich thrombi in the pre-capillary pulmonary arterioles. Our results are the first to identify that platelet activation and procoagulant activity contribute to pathogenesis of hemolysis induced pulmonary thrombosis.\u0000 \u0000 \u0000 Ragni: OPKO: Research Funding; Bioverativ/Sanofi: Other: Advisory Board, Research Funding; Shire/Takeda: Other: Advisory Board, Research Funding; Sangamo: Research Funding; Spark Therapeutics: Other: Advisory Board, Research Funding; Alnylam/Sanofi: Other: ","PeriodicalId":348915,"journal":{"name":"D59. SICKLE CELL DISEASE","volume":"20 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129221638","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-13DOI: 10.1182/blood-2019-130882
T. Brzóska, E. Tutuncuoglu, S. Tofovic, E. Jackson, M. Gladwin, P. Sundd
Acute systemic painful vaso-occlusive crisis (VOC) often serves as an antecedent to acute chest syndrome (ACS), which is a type of acute lung injury and the leading cause of mortality among sickle cell disease (SCD) patients. Thrombocytopenia secondary to pulmonary thrombosis is major risk factor for ACS, however, only 20% of ACS patients are diagnosed with pulmonary thrombosis as an underlying cause of ACS. Although clinical evidence supports the presence of prothrombotic state in subset of SCD patients, the molecular, cellular and genetic mechanisms that selectively render subset of SCD patients at either higher or lower risk of developing pulmonary thrombosis remains elusive. Adenosine diphosphate (ADP) released from lysed erythrocytes can activate platelets by stimulating their purinergic P2Y1 and P2Y12 receptors, however, P2Y12 receptor antagonists have not shown any benefit in clinical trials, justifying the need for better understanding of purinergic signaling in SCD. Here, we use intravital lung microscopy in transgenic humanized SCD mice to show that intravenous administration of ADP triggered pulmonary thrombosis in control mice but failed to trigger pulmonary thrombosis in SCD mice. In contrast, collagen evoked pulmonary thrombosis identically in both control and SCD mice. Identical to intravital findings, IV ADP administration also evoked transient thrombocytopenia in control but not SCD mice, while, IV collagen led to comparable drop in platelet count in both SCD and control mice. ADP is metabolized by the ecto-nucleoside-tri-phosphate-diphosphohydrolase-1 (E-NTPDase1) CD39. IV administration of fluorescent analogue of ADP, N⁶- ethenoadenosine- 5'- O- diphosphate (ε-ADP) followed by invivo microdialysis and HPLC analysis revealed impaired ε-ADP degradation in SCD mice, suggestive of decreased CD39 activity. Our current findings suggest that loss of CD39 activity in SCD possibly prevents ADP-mediated pulmonary thrombosis. Currently, experiments are underway to identify pathways contributing to loss of CD39 activity in SCD, how that affects purinergic signaling and whether selective activation vs deactivation of this pathway is responsible for risk of pulmonary thrombosis in only 20% of ACS patients. Gladwin: Globin Solutions, Inc: Patents & Royalties: Provisional patents for the use of recombinant neuroglobin and heme-based molecules as antidotes for CO poisoning; United Therapeutics: Patents & Royalties: Co-inventor on an NIH government patent for the use of nitrite salts in cardiovascular diseases ; Bayer Pharmaceuticals: Other: Co-investigator.
{"title":"CD39 as a Master Regulator of Pulmonary Thrombosis in Sickle Cell Disease","authors":"T. Brzóska, E. Tutuncuoglu, S. Tofovic, E. Jackson, M. Gladwin, P. Sundd","doi":"10.1182/blood-2019-130882","DOIUrl":"https://doi.org/10.1182/blood-2019-130882","url":null,"abstract":"Acute systemic painful vaso-occlusive crisis (VOC) often serves as an antecedent to acute chest syndrome (ACS), which is a type of acute lung injury and the leading cause of mortality among sickle cell disease (SCD) patients. Thrombocytopenia secondary to pulmonary thrombosis is major risk factor for ACS, however, only 20% of ACS patients are diagnosed with pulmonary thrombosis as an underlying cause of ACS. Although clinical evidence supports the presence of prothrombotic state in subset of SCD patients, the molecular, cellular and genetic mechanisms that selectively render subset of SCD patients at either higher or lower risk of developing pulmonary thrombosis remains elusive. Adenosine diphosphate (ADP) released from lysed erythrocytes can activate platelets by stimulating their purinergic P2Y1 and P2Y12 receptors, however, P2Y12 receptor antagonists have not shown any benefit in clinical trials, justifying the need for better understanding of purinergic signaling in SCD.\u0000 Here, we use intravital lung microscopy in transgenic humanized SCD mice to show that intravenous administration of ADP triggered pulmonary thrombosis in control mice but failed to trigger pulmonary thrombosis in SCD mice. In contrast, collagen evoked pulmonary thrombosis identically in both control and SCD mice. Identical to intravital findings, IV ADP administration also evoked transient thrombocytopenia in control but not SCD mice, while, IV collagen led to comparable drop in platelet count in both SCD and control mice. ADP is metabolized by the ecto-nucleoside-tri-phosphate-diphosphohydrolase-1 (E-NTPDase1) CD39. IV administration of fluorescent analogue of ADP, N⁶- ethenoadenosine- 5'- O- diphosphate (ε-ADP) followed by invivo microdialysis and HPLC analysis revealed impaired ε-ADP degradation in SCD mice, suggestive of decreased CD39 activity.\u0000 Our current findings suggest that loss of CD39 activity in SCD possibly prevents ADP-mediated pulmonary thrombosis. Currently, experiments are underway to identify pathways contributing to loss of CD39 activity in SCD, how that affects purinergic signaling and whether selective activation vs deactivation of this pathway is responsible for risk of pulmonary thrombosis in only 20% of ACS patients.\u0000 \u0000 \u0000 Gladwin: Globin Solutions, Inc: Patents & Royalties: Provisional patents for the use of recombinant neuroglobin and heme-based molecules as antidotes for CO poisoning; United Therapeutics: Patents & Royalties: Co-inventor on an NIH government patent for the use of nitrite salts in cardiovascular diseases ; Bayer Pharmaceuticals: Other: Co-investigator.\u0000","PeriodicalId":348915,"journal":{"name":"D59. SICKLE CELL DISEASE","volume":"41 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"133440000","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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