Jacobs Journal of Genetics

Sickle Cell Anemia: only one Single Point Mutation but Many Pathophysiological Issues

*Danilo Grünig Humberto Da Silva
Department Of Biology Hemoglobin And Hematologic, UNESP — Sao Paulo State University, Brazil

*Corresponding Author:
Danilo Grünig Humberto Da Silva
Department Of Biology Hemoglobin And Hematologic, UNESP — Sao Paulo State University, Brazil
Email:dangrunig@gmail.com

Published on: 2017-09-18

Abstract

It has been 100 years since Herrick published the first medical case report of the anemia describing abnormal shapes of red blood cells (RBCs) and gave sickle cell anemia (SCA) its name [1]. Afterwards, Vernon Ingram [2] discovered that the defect of the disease was a single aminoacid substitution in the hemoglobin (Hb) molecule (HBBglu6val), and understanding has gradually increased since then. Even with improved knowledge of the human genome, development of new genomic tools and identification of single nucleotide polymorphisms (SNPs) associated with subphenotypes of SCA by genome-wide association studies (GWAS) [3], and more than 100 different blood and urine biomarkers have been described in SCA [4]. There is still a major challenge to combine all these variables and establish potential predictors of the SCA severity [5].

Keywords

Introduction

The last 60 years have resulted in an increasingly coherent detailed molecular-level description of the SCA pathophysiology [6]. Despite our precise knowledge of the molecular defect that is associated with hemoglobin S (HbS) in RBCs [7]. Furthermore, recent progress in understanding the molecular events that control polymerization of HbS and sickling of erythrocytes [8]. Nevertheless, these mechanisms are not sufficient to explain the heterogeneous phenotype found among SCA patients, such as pain episodes, acute chest syndrome, neurological complications, leg ulcers and other symptoms. In this way, despite HbS presence is indispensable for the disease establishment, several other phenomena affected by a multitude of genes other than the one directly involved (HBB*S) play an important role [9].

While great progress has been made in describing the ba- sic disease process that accounts for hemolytic anemia and the obstructive events underlying vaso-occlusive events (VOE), many questions remain [6]. The simple mutation in the β6-location of globin has a profound effect on all tissues and organs in the SCA patient, and because the vasculopathy affects a large variety of physiologic mechanisms, the varied genetic background of individual patients makes prediction of the clinical severity highly complex [6]. In this way, clinical broad spectrum of SCA can be affected by a number of modi- fying factors including the haplotype of β-globin gene cluster [10], the coinheritance of polymorphisms associated with both clinical aspects [11] and treatment response [3], he- moglobin fetal (Hb F) levels [12], chronic inflammation and oxidative states [13, 14] as well as gender, and others [10]. Among the new evidences, oxidative stress processes have been increasingly related to the SCA pathophysiology [4]. The increased production of prooxidant elements is caused by intrinsic disease mechanisms, such as increased activity of several oxidases (NADPH oxidase and endothelial xanthine oxidase) [15, 16], HbS auto-oxidation [17], heme iron release, increased asymmetric dimethylarginine (ADMA) [18], uncoupling of nitric oxide synthase (NOS) activity, and decreased nitric oxide (NO) levels [19]. As the antioxidant defense systems in SCD are affected and/or are not sufficient to neutralize excessive production of oxidant species [20], chronic oxidative stress establishes, being a critical factor in endothelial dysfunction, inflammation and damage to multiple organs [21]. In this way, oxidative stress is directly related to both cause and consequence of inflammation, he- molysis, vasculopathy, vaso-occlusion, infection, and injury by ischemia/reperfusion, e.g. [22]. For this reason, newer therapeutic agents that can target oxidative stress may con- stitute valuable means for preventing or delaying the devel- opment of organ complications [23, 24]. Thus, antioxidant therapy is being a worthy, promising and increasing goal for SCA treatment. In this context, McCarty [25] suggested the use of comprehensive nutraceutical strategy for mitigating the contribution of oxidative stress to SCA pathogenesis, dubbed as ‘‘full-spectrum antioxidant therapy”. Many recent studies, both in vitro and in vivo, have investigated different strategies as antioxidant therapy for SCA treatment [26-28]. However, paradoxical observations with regard of certain prooxidant effects of antioxidant compounds have been reported under some experimental conditions, indicating the complex interdependency among the pool of physiological relevant cellular antioxidants [29]. Therefore, more studies focusing newer and more specific oxidative stress biomarkers can be helpful to obtain better clues about effective prognostic information of SCA patients. Furthermore, it may be fundamental to the development of more efficacious therapeutic drugs in order to mitigate the devastating clinical manifestations of SCA.

References

1. Herrick JB. Peculiar elongated and sickle-shaped red blood corpuscles in a case of severe anemia. Yale J Biol Med. 2001, 74(3): 179-184.

2. Ingram VM. Gene mutations in human haemoglobin: the chemical difference between normal and sickle cell haemoglobin. Nature. 1957, 180(4581): 326-328.

3. Fertrin KY, Costa FF. Genomic polymorphisms in sickle cell disease: implications for clinical diversity and treatment. Expert Rev Hematol. 2010, 3(4) : 443–458.

4. Rees DC, Gibson JS. Biomarkers in sickle cell disease. Br J Haematol. 2012, 156(4): 433-445.

5. Lettre G. The search for genetic modifiers of disease severity in the beta-hemoglobinopathies. Cold Spring Harb Perspect Med. 2012, 2(10): 1-12.

6. Kuypers FA. Hemoglobin s polymerization and red cell membrane changes. Hematol Oncol Clin North Am 2014, 28(2): 155-179.

7. Christoph GW, Hofrichter J, Eaton WA. Understanding the shape of sickled red cells. Biophys. J 2005, 88(2): 1371-1376.

8. Ferrone FA. Polymerization and Sickle Cell Disease: A Molecular View. Microcirculation. 2004, 11(2): 115-128.

9. Nagel RL. Severity, pathobiology, epistatic effects, and genetic markers in sickle cell anemia. Semin Hematol. 1991, 28(3): 180-201.

10. Kulozik AE, Wainscoat JS, Serjeant GR, Kar BC, Al-Awamy B et al. Geographical Survey of βS-Globin Gene Haplotypes: Evidence for an Independent Asian Origin of the Sickle-Cell Mutation. Am J Hum Genet. 1986, 39(2): 239-44.

11. Steinberg MH. Predicting clinical severity in sickle cell anaemia. Br J Haematol. 2005, 129(4): 465-481.

12. Steinberg ME. Management of sickle cell disease. N Engl J Med. 1999, 340(13): 1021-1030.

13. Conran N, Franco-Penteado CF, Costa FF. Newer aspects of the pathophysiology of sickle cell disease vaso-occlusion. Hemoglobin 2009, 33(1): 1-16.

14. Fibach E, Rachmilewitz E. The Role of Oxidative Stress in Hemolytic Anemia. Curr Mol Med. 2008, 8(7): 609-19. 108

15. Aslan M, Ryan TM, Adler B, Townes TM, Parks DA et al. Oxygen radical inhibition of nitric oxide-dependent vascular function in sickle cell disease. Proc Natl Acad Sci U S A. 2001, 98(26): 15215-15220.

16. Wood KC, Hebbel RP, Granger DN. Endothelial cell NADPH oxidase mediates the cerebral microvascular dysfunction in sickle cell transgenic mice. The FASEB Journal. 2005, 19(8): 989-991.

17. Hebbel RP, Eaton JW, Balasingam M, Steinberg MH. Spontaneous oxygen radical generation by sickle erythrocytes. J Clin Invest. 1982, 70(6): 1253-9.

18. Landburg PP, Teerlink T, Biemond BJ, Brandjes DP, Muskiet FA et al. Plasma asymmetric dimethylarginine concentrations in sickle cell disease are related to the hemolytic phenotype. Blood Cells Mol Dis. 2010, 44(4): 229-232.

19. Morris CR, Kato GJ, Poljakovic M, Wang X, Blackwelder WC et al. Dysregulated arginine metabolism, hemolysis-associated pulmonary hypertension, and mortality in sickle cell disease. Jama. 2005, 294(1): 81-90.

20. Amer J, Ghoti H, Rachmilewitz E, Koren A, Levin C et al. Red blood cells, platelets and polymorphonuclear neutrophils of patients with sickle cell disease exhibit oxidative stress that can be ameliorated by antioxidants. Br J Haematol. 2006, 132(1): 108-113.

21. Hebbel* RP, Osarogiagbon R, Kaul D. The Endothelial Biology of Sickle Cell Disease: Inflammation and a Chronic Vasculopathy. Microcirculation. 2004, 11(2): 129-151.

22. Rees DC, Williams TN, Gladwin MT. Sickle-cell disease. The Lancet. 2010, 376(9597): 2018-2031.

23. Wood KC, Granger DN. Sickle cell disease: role of reactive oxygen and nitrogen metabolites. Clin. Exp. Pharmacol. Physiol. 2007, 34(9): 926-932.

24. Nur E, Biemond BJ, Otten HM, Brandjes DP, Schnog JJ. Oxi- dative stress in sickle cell disease; pathophysiology and poten- tial implications for disease management. Am J Hematol. 2011, 86(6): 484-489.

25. McCarty MF. Potential utility of full-spectrum antioxidant therapy, citrulline, and dietary nitrate in the management of sickle cell disease. Med Hypotheses. 2010, 74(6): 1055-1058.

26. Vichinsky E. Emerging ‘A’ therapies in hemoglobinopa- thies: agonists, antagonists, antioxidants, and arginine. Hema- tology Am Soc Hematol Educ Program. 2012, 2012: 271-5.

27. Silva DG, Belini Junior E, de Almeida EA, Bonini-Domingos CR. Oxidative stress in sickle cell disease: an overview of eryth- rocyte redox metabolism and current antioxidant therapeutic strategies. Free Radic Biol Med. 2013, 65: 1101-1109.

28. Silva DGH, Júnior-Ricci O, Almeida EA, Bonini-Domingos CR. Potential utility of melatonin as an antioxidant therapy in the management of sickle cell anemia. J Pineal Res. 2015, 58(2): 178–188.

29. Chan AC, Chow CK, Chiu D. Interaction of antioxidants and their implication in genetic anemia. Proc Soc Exp Biol Med. 1999, 222 (3): 274-282.