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Research Article | DOI: https://doi.org/10.31579/2641-0419/364
1Specialist of Internal Medicine, MD, Turkey
2Manager of Writing and Statistics, Turkey
3Middle-East Academy for Medicine of Aging, MD, Lebanon
4Medi-WORLD International, Australia
*Corresponding Author: Mehmet Rami Helvaci, Specialist of Internal Medicine, MD, Turkey.
Citation: Mehmet R. Helvaci, Saziye Cayir, Hulya Halici, Alper Sevinc, Celaletdin Camci, et al, (2024), Red blood cell transfusions may have the stongest analgesic effect during acute painful crises in sickle cell diseases, J Clinical Cardiology and Cardiovascular Interventions, 7(5); DOI: 10.31579/2641-0419/364
Copyright: © 2024, Mehmet Rami Helvaci. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 12 April 2024 | Accepted: 08 May 2024 | Published: 24 May 2024
Keywords: sickle cell diseases; acute painful crises; hardened red blood cells; capillary endothelial inflammation; capillary endothelial edema; tissue hypoxia; sudden death
Background: The hardened red blood cells (RBC)-induced capillary endothelial damage, inflammation, edema, and fibrosis are initiated at birth, and terminate with disseminated tissue hypoxia, acute painful crises, multiorgan failures, and sudden death even at childhood in the sickle cell diseases (SCD).
Methods: All cases with the SCD were included into the study.
Results: We studied 222 males and 212 females with similar mean ages (30.8 vs 30.3 years, p>0.05, respectively). Disseminated teeth losses (5.4% vs 1.4%, p<0.001), ileus (7.2% vs 1.4%, p<0.001), cirrhosis (8.1% vs 1.8%, p<0.001), leg ulcers (19.8% vs 7.0%, p<0.001), digital clubbing (14.8% vs 6.6%, p<0.001), coronary heart disease (18.0% vs 13.2%, p<0.05), chronic renal disease (9.9% vs 6.1%, p<0.05), chronic obstructive pulmonary disease (25.2% vs 7.0%, p<0.001), and stroke (12.1% vs 7.5%, p<0.05) were all higher but not acute chest syndrome (2.7% vs 3.7%, p>0.05) or pulmonary hypertension (12.6% vs 11.7%, p>0.05) or deep venous thrombosis and/or varices and/or telangiectasias (9.0% vs 6.6%, p>0.05) in males, significantly.
Conclusion: Infections, medical or surgical emergencies, or emotional stress-induced increased basal metabolic rate aggravates the sickling and capillary endothelial inflammation and edema, and may terminate with disseminated tissue hypoxia, acute painful crises, multiorgan failures, and sudden deaths in the SCD. RBC support may have the stongest analgesic effect, and decrease the risk of multiorgan failures and sudden death by decreasing the density of causative hardened cells from the circulation during such severe crises.
Chronic endothelial damage may be the major cause of aging and death by causing end-organ failures in human being (1). Much higher blood pressures (BPs) of the afferent vasculature may be the major accelerating factor by causing recurrent injuries on vascular endothelial cells. Probably, whole afferent vasculature including capillaries are mainly involved in the process. Thus the term of venosclerosis is not as famous as atherosclerosis in the literature. Due to the chronic endothelial damage, inflammation, edema, and fibrosis, vascular walls thicken, their lumens narrow, and they lose their elastic natures, those eventually reduce blood supply to the terminal organs, and increase systolic and decrease diastolic BPs further. Some of the well-known accelerating factors of the inflammatory process are physical inactivity, sedentary lifestyle, animal-rich diet, smoking, alcohol, overweight, chronic inflammations, prolonged infections, and cancers for the development of terminal consequences including obesity, hypertension (HT), diabetes mellitus (DM), cirrhosis, chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD), chronic renal disease (CRD), stroke, peripheric artery disease (PAD), mesenteric ischemia, osteoporosis, dementia, early aging, and premature death (2, 3). Although early withdrawal of the accelerating factors can delay terminal consequences, after development of obesity, HT, DM, cirrhosis, COPD, CRD, CHD, stroke, PAD, mesenteric ischemia, osteoporosis, and dementia-like end-organ insufficiencies and aging, the endothelial changes can not be reversed due to their fibrotic natures, completely. The accelerating factors and terminal consequences of the vascular process are researched under the titles of metabolic syndrome, aging syndrome, and accelerated endothelial damage syndrome in the literature (4-6). On the other hand, sickle cell diseases (SCD) are chronic inflammatory and highly destructive processes on vascular endothelium, initiated at birth and terminated with an advanced atherosclerosis induced end-organ insufficiencies in much earlier ages of life (7, 8). Hemoglobin S causes loss of elastic and biconcave disc shaped structures of red blood cells (RBC). Probably loss of elasticity instead of shape is the major problem because sickling is rare in peripheric blood samples of the cases with associated thalassemia minors (TM), and human survival is not affected in hereditary spherocytosis or elliptocytosis. Loss of elasticity is present during whole lifespan, but exaggerated with inflammations, infections, and additional stresses of the body. The hardened RBC induced chronic endothelial damage, inflammation, edema, and fibrosis terminate with tissue hypoxia all over the body (9). As a difference from other causes of chronic endothelial damage, SCD keep vascular endothelium particularly at the capillary level (10, 11), since the capillary system is the main distributor of the hardened RBC into the tissues. The hardened RBC induced chronic endothelial damage builds up an advanced atherosclerosis in much earlier ages of life. Vascular narrowings and occlusions induced tissue ischemia and end-organ insufficiencies are the final consequences, so the mean life expectancy is decreased by 25 to 30 years for both genders in the SCD (8).
The study was performed in Medical Faculty of the Mustafa Kemal University between March 2007 and June 2016. All patients with the SCD were included. The SCD were diagnosed with the hemoglobin electrophoresis performed via high performance liquid chromatography (HPLC). Medical histories including smoking, alcohol, acute painful crises per year, transfused units of RBC in their lives, leg ulcers, stroke, surgical operations, deep venous thrombosis (DVT), epilepsy, and priapism were learnt. Patients with a history of one pack-year were accepted as smokers, and one drink-year were accepted as drinkers. A complete physical examination was performed by the Same Internist, and patients with disseminated teeth losses (<20>
The study included 222 males and 212 females with similar ages (30.8 vs 30.3 years, p>0.05, respectively). Prevalences of associated TM were similar in both genders, too (72.5% vs 67.9%, p>0.05, respectively). Smoking (23.8% vs 6.1%) and alcohol (4.9% vs 0.4%) were higher in males (p<0>(Table 1). Transfused units of RBC in their lives (48.1 vs 28.5, p=0.000), disseminated teeth losses (5.4% vs 1.4%, p<0>0.05) or PHT (12.6% vs 11.7%, p>0.05) or DVT and/or varices and/or telangiectasias (9.0% vs 6.6%, p>0.05) in males, significantly. Although the mean age of mortality (30.2 vs 33.3 years) was lower in males, the difference was not significant, probably due to the small sample size of the study cases (Table 2). Interestingly, mean ages of the stroke (33.5 years), COPD (33.6 years), digital clubbing (35.4 years), CHD (35.7 years), cirrhosis (37.0 years), and CRD (39.4 years) were the highest among the other atherosclerotic consequences in the SCD (Table 3)
| Variables | Male patients with SCD* | p-value | Female patients with SCD |
| Prevalence | 51.1% (222) | Ns† | 48.8% (212) |
| Mean age (year) | 30.8 ± 10.0 (5-58) | Ns | 30.3 ± 9.9 (8-59) |
| Associated TM‡ | 72.5% (161) | Ns | 67.9% (144) |
| Smoking | 23.8% (53) | <0> | 6.1% (13) |
| Alcoholism | 4.9% (11) | <0> | 0.4% (1) |
Table 1: Characteristic features of the study cases
| Variables | Male patients with SCD* | p-value | Female patients with SCD |
| Painful crises per year | 5.0 ± 7.1 (0-36) | Ns† | 4.9 ± 8.6 (0-52) |
| Transfused units of RBC‡ | 48.1 ± 61.8 (0-434) | 0.000 | 28.5 ± 35.8 (0-206) |
| Disseminated teeth losses (<20> | 5.4% (12) | <0> | 1.4% (3) |
| COPD§ | 25.2% (56) | <0> | 7.0% (15) |
| Ileus | 7.2% (16) | <0> | 1.4% (3) |
| Cirrhosis | 8.1% (18) | <0> | 1.8% (4) |
| Leg ulcers | 19.8% (44) | <0> | 7.0% (15) |
| Digital clubbing | 14.8% (33) | <0> | 6.6% (14) |
| CHD¶ | 18.0% (40) | <0> | 13.2% (28) |
| CRD** | 9.9% (22) | <0> | 6.1% (13) |
| Stroke | 12.1% (27) | <0> | 7.5% (16) |
| PHT*** | 12.6% (28) | Ns | 11.7% (25) |
| Autosplenectomy | 50.4% (112) | Ns | 53.3% (113) |
| DVT**** and/or varices and/or telangiectasias | 9.0% (20) | Ns | 6.6% (14) |
| Rheumatic heart disease | 6.7% (15) | Ns | 5.6% (12) |
| Avascular necrosis of bones | 24.3% (54) | Ns | 25.4% (54) |
| Sickle cell retinopathy | 0.9% (2) | Ns | 0.9% (2) |
| Epilepsy | 2.7% (6) | Ns | 2.3% (5) |
| ACS***** | 2.7% (6) | Ns | 3.7% (8) |
| Mortality | 7.6% (17) | Ns | 6.6% (14) |
| Mean age of mortality (year) | 30.2 ± 8.4 (19-50) | Ns | 33.3 ± 9.2 (19-47) |
Table 2: Associated pathologies of the study cases
*Sickle cell diseases †Nonsignificant (p>0.05) ‡Red blood cells §Chronic obstructive pulmonary disease ¶Coronary heart disease **Chronic renal disease ***Pulmonary hypertension ****Deep venous thrombosis *****Acute chest syndrome
| Variables | Mean age (year) |
| Ileus | 29.8 ± 9.8 (18-53) |
| Hepatomegaly | 30.2 ± 9.5 (5-59) |
| ACS* | 30.3 ± 10.0 (5-59) |
| Sickle cell retinopathy | 31.5 ± 10.8 (21-46) |
| Rheumatic heart disease | 31.9 ± 8.4 (20-49) |
| Autosplenectomy | 32.5 ± 9.5 (15-59) |
| Disseminated teeth losses (<20> | 32.6 ± 12.7 (11-58) |
| Avascular necrosis of bones | 32.8 ± 9.8 (13-58) |
| Epilepsy | 33.2 ± 11.6 (18-54) |
| Priapism | 33.4 ± 7.9 (18-51) |
| Left lobe hypertrophy of the liver | 33.4 ± 10.7 (19-56) |
| Stroke | 33.5 ± 11.9 (9-58) |
| COPD† | 33.6 ± 9.2 (13-58) |
| PHT‡ | 34.0 ± 10.0 (18-56) |
| Leg ulcers | 35.3 ± 8.8 (17-58) |
| Digital clubbing | 35.4 ± 10.7 (18-56) |
| CHD§ | 35.7 ± 10.8 (17-59) |
| DVT¶ and/or varices and/or telangiectasias | 37.0 ± 8.4 (17-50) |
| Cirrhosis | 37.0 ± 11.5 (19-56) |
| CRD** | 39.4 ± 9.7 (19-59) |
Table 3: Mean ages of the consequences of the sickle cell diseases
*Acute chest syndrome †Chronic obstructive pulmonary disease ‡Pulmonary hypertension §Coronary heart disease ¶Deep venous thrombosis **Chronic renal disease
Acute painful crises are the most disabling symptoms of the SCD. Although some authors reported that pain itself may not be life threatening directly, infections, medical or surgical emergencies, or emotional stress are the most common precipitating factors of the crises (19). The increased basal metabolic rate during such stresses aggravates the sickling, capillary endothelial damage, inflammation, edema, tissue hypoxia, and multiorgan insufficiencies. So the risk of mortality is much higher during the crises. Actually, each crisis may complicate with the following crises by leaving significant sequelaes on the capillary endothelial system all over the body. After a period of time, the sequelaes may terminate with sudden end-organ failures and death during a final acute painful crisis that may even be silent, clinically. Similarly, after a 20-year experience on such patients, the deaths seem sudden and unexpected events in the SCD. Unfortunately, most of the deaths develop just after the hospital admission, and majority of them are patients without hydroxyurea therapy (23, 24). Rapid RBC supports are usually life-saving for such patients, although preparation of RBC units for transfusion usually takes time. Beside that RBC supports in emergencies become much more difficult in terminal cases due to the repeated transfusions-induced blood group mismatch. Actually, transfusion of each unit of RBC complicates the following transfusions by means of the blood subgroup mismacth. Due to the significant efficacy of hydroxyurea therapy, RBC transfusions should be kept just for acute events and emergencies in the SCD (23, 24). According to our experiences, simple and repeated transfusions are superior to RBC exchange in the SCD (25, 26). First of all, preparation of one or two units of RBC suspensions in each time rather than preparation of six units or higher provides time to clinicians to prepare more units by preventing sudden death of such high-risk patients. Secondly, transfusions of one or two units of RBC suspensions in each time decrease the severity of pain, and relax anxiety of the patients and their relatives since RBC transfusions probably have the strongest analgesic effects during the crises. Actually, the decreased severity of pain by transfusions also indicates the decreased severity of inflammation all over the body. Thirdly, transfusions of lesser units of RBC suspensions in each time by means of the simple transfusions will decrease transfusion-related complications including infections, iron overload, and blood group mismatch in the future. Fourthly, transfusion of RBC suspensions in the secondary health centers may prevent some deaths developed during the transport to the tertiary centers for the exchange. Finally, cost of the simple and repeated transfusions on insurance system is much lower than the exchange that needs trained staff and additional devices. On the other hand, pain is the result of complex and poorly understood interactions between RBC, white blood cells (WBCs), platelets (PLTs), and endothelial cells, yet. Whether leukocytosis contributes to the pathogenesis by releasing cytotoxic enzymes is unknown. The adverse actions of WBCs on endothelium are of particular interest with regard to the cerebrovascular diseases in the SCD. For example, leukocytosis even in the absence of any infection was an independent predictor of the severity of the SCD (20), and it was associated with the risk of stroke in a cohort of Jamaican patients (21). Disseminated tissue hypoxia, releasing of inflammatory mediators, bone infarctions, and activation of afferent nerves may take role in the pathophysiology of the intolerable pain. Because of the severity of pain, narcotic analgesics are usually required to control them (22), but according to our practice, simple and repeated RBC transfusions may be highly effective both to relieve pain and to prevent sudden death that may develop secondary to multiorgan failures on the chronic inflammatory background of the SCD.
Hydroxyurea may be the only life-saving drug for the treatment of the SCD. It interferes with the cell division by blocking the formation of deoxyribonucleotides by means of inhibition of ribonucleotide reductase. The deoxyribonucleotides are the building blocks of DNA. Hydroxyurea mainly affects hyperproliferating cells. Although the action way of hydroxyurea is thought to be the increase in gamma-globin synthesis for fetal hemoglobin (Hb F), its main action may be the suppression of leukocytosis and thrombocytosis by blocking the DNA synthesis in the SCD (27, 28). By this way, the chronic inflammatory and destructive process of the SCD is suppressed with some extent. Due to the same action way, hydroxyurea is also used in moderate and severe psoriasis to suppress hyperproliferating skin cells. As in the viral hepatitis cases, although presence of a continuous damage of sickle cells on the capillary endothelium, the severity of destructive process is probably exaggerated by the patients’ own WBCs and PLTs. So suppression of proliferation of them may limit the endothelial damage-induced edema, ischemia, and infarctions in whole body (29). Similarly, final Hb F levels in hydroxyurea users did not differ from their pretreatment levels (30). The Multicenter Study of Hydroxyurea (MSH) studied 299 severely affected adults with the SCA, and compared the results of patients treated with hydroxyurea or placebo (31). The study particularly researched effects of hydroxyurea on painful crises, ACS, and requirement of blood transfusion. The outcomes were so overwhelming in the favour of hydroxyurea that the study was terminated after 22 months, and hydroxyurea was initiated for all patients. The MSH also demonstrated that patients treated with hydroxyurea had a 44
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