Biology of anemia,differential diagnosis,and treatment options in human immunodeficiency virus infection

Anemia is the most common hematologic manifestation of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome. The causes of HIV-related anemia are multifactorial and include direct and indirect effects of HIV infection. HIV-related anemia generally is due to reduced red blood cell (RBC) production, secondary to a variety of causes, but it may also involve nutritional deficiencies, increased RBC destruction, or a combination of these problems. Evaluation of hemoglobin level, reticulocyte count, bilirubin, and mean corpuscular volume value and review of the peripheral blood smear are necessary for diagnosis. Treatment of HIV-related anemia should address the correctable underlying causes of this disorder, such as modifications of offending medications, nutritional deficiencies, and parvovirus infection. Patients with HIV infection have a blunted erythropoietin response to anemia. Therapeutic modalities for anemia that is not amenable to correction include blood transfusion and recombinant human erythropoietin (epoetin alfa).     

Nutritional deficiencies in iron overloaded patients with hemoglobinopathies

One of the hallmarks of both sickle cell disease (SCD) and thalassemia major (TM) is accelerated oxidative damage. Decreased antioxidant levels and increased oxidant stress biomarkers are found in both diseases. Although isolated vitamin deficiencies have been reported in TM and nontransfused SCD patients, a comprehensive evaluation of vitamin and trace mineral levels has never been performed in chronically transfused SCD or TM patients. As vitamins and trace minerals may be consumed as a result of chronic oxidative stress; we hypothesized that levels of these compounds would correlate with surrogates of iron overload, hemolysis, and inflammation in chronically transfused patients. Using a convenience sample of our group of chronically transfused patients we studied 43 patients with SCD (17 male, 26 female) and 24 patients with TM (13 male and 11 female). The age range for our patients varied from 1.5 to 31.4 years. Levels of vitamins A, thiamin, B6, B12, C, D, E as well as selenium, zinc, copper, and ceruloplasmin were measured. We found that 40–75% of the patients were deficient in A, C, D and selenium and 28–38% of the patients had low levels of B vitamins and folate. There was little association with iron overload, hemolysis, or inflammation. Although the precise mechanism of these deficiencies is unclear, they may contribute to the morbidity of chronically transfused hemoglobinopathy patients. Am. J. Hematol., 2009. © 2009 Wiley‐Liss, Inc.     

Vitamin D deficiency, cardiac iron and cardiac function in thalassaemia major

Vitamin D25-OH and D1-25OH levels were compared with cardiac R2* (1/T2*), left ventricular ejection fraction (LVEF), age, ferritin and liver iron in 24 thalassaemia major patients. Vitamin D25-OH levels were reduced in 13/24 patients while vitamin D1-25OH levels were often elevated. Vitamin D25-OH levels decreased with age ( r ² = 0·48) and with liver iron ( r ² = 0·20). Cardiac R2* was inversely related with the ratio of D25-OH to D1-25OH levels ( r ² = 0·42). LVEF was also proportional to the D25-OH/D1-25OH ratio ( r ² = 0·49). Vitamin D deficiency may be associated with cardiac iron uptake and ventricular dysfunction in thalassaemia major patients.     

Arginine therapy: a new treatment for pulmonary hypertension in sickle cell disease?

Pulmonary hypertension is a life-threatening complication of sickle cell disease. L-Arginine is the nitrogen donor for synthesis of nitric oxide, a potent vasodilator that is deficient during times of sickle cell crisis. This deficiency may play a role in pulmonary hypertension. The enzyme arginase hydrolyzes arginine to ornithine and urea, and thus, it may compete with nitric oxide synthase, leading to decreased nitric oxide production. Nitric oxide therapy by inhalation has improved pulmonary hypertension associated with acute chest syndrome in sickle cell disease, and several studies demonstrate therapeutic benefits of arginine therapy for primary and secondary pulmonary hypertension. We sought to determine the effects of arginine therapy on pulmonary hypertension in patients with sickle cell disease. Arginase activity was also determined. Oral arginine produced a 15.2% mean reduction in estimated pulmonary artery systolic pressure (63.9 +/- 13 to 54.2 +/- 12 mm Hg, p = 0.002) after 5 days of therapy in 10 patients. Arginase activity was elevated almost twofold (p = 0.07) in patients with pulmonary hypertension and may limit arginine bioavailability. With limited treatment options and a high mortality rate for patients with sickle cell disease who develop pulmonary hypertension, arginine is a promising new therapy that warrants further investigation.     

Neutrophils mediate lipid peroxidation in human red cells

Activated neutrophils (ANs) are known to release reactive oxygen species that may cause oxidative damage to surrounding tissues. We determined if ANs could induce lipid peroxidation (LP) in human red cells and investigated the mechanism involved in this interaction. We studied neonatal glucose-6-phosphate dehydrogenase (G6PD) deficient, and sickle red cells, since each of these are known to be susceptible to oxidant injury. Neutrophils were isolated from whole blood and activated by incubation with opsonized zymosan. Mixtures of such neutrophils and red cells at a ratio of 1:100 were incubated for two hours at 37 degrees C, after which the malonyldialdehyde content in red cells was measured as an index of LP. All red cells underwent LP after AN treatment, and the degree of LP was proportional to the amount of AN in the mixture. Superoxide dismutase and catalase partially inhibited LP. When compared to normal red cells, only sickle cells demonstrated a significant increase in AN-mediated LP. Conversion of hemoglobin to carboxy-hemoglobin increased AN-mediated LP, whereas conversion to met- hemoglobin decreased AN-mediated LP. The protective effect of met- hemoglobin on LP was less in sickle cells than in normal cells. We conclude that AN can induce LP in red cells in vitro and that sickle cells are more susceptible to this process than normal cells. Hemoglobin can serve as an electron trap and protect the cell against peroxidative damage, but this mechanism is impaired in sickle cells. We speculate that the pathogenesis of hemolysis associated with infectious disease may include AN-induced red cell LP.     

Neutrophil-induced K+ leak in human red cells: a potential mechanism for infection-mediated hemolysis

Activated neutrophils (AN) when incubated with red blood cells (RBCs) at a ratio of 1:100 were shown to damage RBCs as reflected by an increase in passive potassium (K+) permeability. Oxygenated sickle cells were more susceptible to this injury than normal (AA) RBCs. In both normal and sickle cells, the degree of K+ leak was found to be linearly related to the amount of AN in the incubation mixture. Pretreatment of AA RBCs with low-dose H2O2 resulted in an increased K+ leak after exposure to AN. Compared with patients with stable sickle cell anemia, those who were observed while infected or in crisis had notably more K+ leak from their RBCs after AN exposure. Addition of activated neutrophils from a patient with chronic granulomatous disease resulted in K+ leak from normal RBCs, despite a deficiency in production of toxic oxygen species. Cell-free supernatants from AN also mediated K+ leak. Sickle cells were, again, leakier after exposure to these preparations. Scavengers of toxic oxygen species inhibited up to 40% of the leak, whereas the maximal inhibition obtained by using protease inhibitors was 60%. Addition of autologous plasma in low concentrations inhibited the leak but also resulted in hemolysis, probably via a different mechanism. These studies demonstrate that measurement of passive K+ loss from RBCs allows discrimination between two separate mechanisms of AN-induced damage, an oxidant mechanism, as has been previously described, and a new pathway that appears to be mediated by granule-associated enzymes released from AN. The increased susceptibility of sickle RBCs, especially during periods of increased physiologic stress, suggests that previous membrane damage in vivo may render these RBCs more sensitive to the action of either oxidants or granules released from neutrophils.     

First report of reversal of organ dysfunction in sickle cell anemia by the use of hydroxyurea: splenic regeneration

Much of the morbidity associated with sickle cell anemia (SCA) is due to ongoing infarction resulting in organ dysfunction. Because the spleen is often the first organ damaged in this illness, there is a significant impairment of the immune system in these patients. Hydroxyurea (HU) has been shown to increase fetal hemoglobin (HbF) and decrease painful episodes in patients with this disease. It is unclear whether HU can prevent organ damage. We treated two SCA patients with HU for several years and found evidence of reversal of previously documented splenic dysfunction. Patient no. 1 was treated for 30 months with an increase in HbF to 30%. HU was stopped because of cytopenia. She developed left upper quadrant pain. A splenectomy was performed due to the possibility of splenic abscesses. A pathologic review found no evidence of infection and an enlarged spleen that showed active germinal centers. Patient no. 2 was treated for 24 months with HU before developing splenomegaly. His HbF levels were 25% to 30%, his pit counts averaged 2%, and his liver spleen scans showed uptake. These two cases show that chronic HU therapy may reverse splenic dysfunction in certain patients and suggest that this drug may have efficacy beyond the elimination of pain in SCA.     

Effect of hydroxyurea on mortality and morbidity in adult sickle cell anemia: risks and benefits up to 9 years of treatment

Context  Hydroxyurea increases levels of fetal hemoglobin (HbF) and decreases morbidity from vaso-occlusive complications in patients with sickle cell anemia (SCA). High HbF levels reduce morbidity and mortality. Objective  To determine whether hydroxyurea attenuates mortality in patients with SCA. Design  Long-term observational follow-up study of mortality in patients with SCA who originally participated in the randomized, double-blind, placebo-controlled Multicenter Study of Hydroxyurea in Sickle Cell Anemia (MSH), conducted in 1992-1995, to determine if hydroxyurea reduces vaso-occlusive events. In the MSH Patients' Follow-up, conducted in 1996-2001, patients could continue, stop, or start hydroxyurea. Data were collected during the trial and in the follow-up period. Setting  Inpatients and outpatients in 21 sickle cell referral centers in the United States and Canada. Patients  Two-hundred ninety-nine adult patients with frequent painful episodes enrolled in the follow-up. Follow-up data through May 2001 were complete for 233 patients. Intervention  In the MSH, patients were randomly assigned to receive hydroxyurea (n = 152) or placebo (n = 147). Main Outcome Measure  Mortality, HbF levels, painful episodes, acute chest syndrome, and blood cell counts. The randomized trial was not designed to detect specified differences in mortality. Results  Seventy-five of the original 299 patients died, 28% from pulmonary disease. Patients with reticulocyte counts less than 250 000/mm³ and hemoglobin levels lower than 9 g/dL had increased mortality (P = .002). Cumulative mortality at 9 years was 28% when HbF levels were lower than 0.5 g/dL after the trial was completed compared with 15% when HbF levels were 0.5 g/dL or higher (P = .03 ). Individuals who had acute chest syndrome during the trial had 32% mortality compared with 18% of individuals without acute chest syndrome (P = .02). Patients with 3 or more painful episodes per year during the trial had 27% mortality compared with 17% of patients with less frequent episodes (P = .06). Taking hydroxyurea was associated with a 40% reduction in mortality (P = .04) in this observational follow-up with self-selected treatment. There were 3 cases of cancer, 1 fatal. Conclusions  Adult patients taking hydroxyurea for frequent painful sickle cell episodes appear to have reduced mortality after 9 of years follow-up. Survival was related to HbF levels and frequency of vaso-occlusive events. Whether indications for hydroxyurea treatment should be expanded is unknown.