Cited by 748Hemoglobinopathies and Related DisordersHemoglobin structure and functionBlood properties and coagulation

Intravascular hemolysis and the pathophysiology of sickle cell disease

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Kato, Gregory J., Steinberg, Martin H., Gladwin, Mark T.·2017·Journal of Clinical Investigation

Abstract

flow, normoxia to hypoxia, isotonic to hypertonic environment, and acidotic to alkalotic milieu.Multiple components contribute to sickle hemoglobinopathy pathophysiology, including primary components arising from HbS polymerization and secondary components that are downstream effects of the HbS polymer. Understanding how these components' complexity is compounded by genetic and environmental modulation provides insight into the well-known clinical heterogeneity of sickle cell disease (SCD).A cardinal feature of SCD pathogenesis involves inflammation, accompanied by heterocellular leukocyte-platelet-erythrocyte-endothelial adhesive events that trigger vaso-occlusive episodes, acute organ ischemia, and reperfusion injury.Twenty-five years ago, epidemiological studies identified leukocytosis, lower HbF levels, and higher total hemoglobin levels as risk factors associated with increasing incidence of acute painful episodes and acute chest syndrome (ACS) (5).The independent association of high total hemoglobin levels with more pain, ACS events, and osteonecrosis was never mechanistically explained; however, it was implied to be a result of increased blood viscosity (Table 1).Recent epidemiological studies found that lower hemoglobin levels and higher intensity of steady-state hemolytic anemia consistently associate with vasculopathic complications of disease, such as stroke, leg ulcers, PH, priapism, and renal failure.This suggests that certain subphenotypes of SCD relate more to hemolytic anemia severity rather than sickle vaso-occlusion.The reader is referred to recent reviews describing the exceptional strides made in understanding the roles of red cell rigidity (6), inflammation, and cell adhesion in sickle vaso-occlusion (7-9).Here, we review the complementary role of intravascular hemolysis and anemia.Hemolysis is a fundamental feature of sickle cell anemia that contributes to its pathophysiology and phenotypic variability.Decompartmentalized hemoglobin, arginase 1, asymmetric dimethylarginine, and adenine nucleotides are all products of hemolysis that promote vasomotor dysfunction, proliferative vasculopathy, and a multitude of clinical complications of pulmonary and systemic vasculopathy, including pulmonary hypertension, leg ulcers, priapism, chronic kidney disease, and large-artery ischemic stroke.Nitric oxide (NO) is inactivated by cell-free hemoglobin in a dioxygenation reaction that also oxidizes hemoglobin to methemoglobin, a non-oxygen-binding form of hemoglobin that readily loses heme.Circulating hemoglobin and heme represent erythrocytic danger-associated molecular pattern (eDAMP) molecules, which activate the innate immune system and endothelium to an inflammatory, proadhesive state that promotes sickle vaso-occlusion and acute lung injury in murine models of sickle cell disease.Intravascular hemolysis can impair NO bioavailability and cause oxidative stress, altering redox balance and amplifying physiological processes that govern blood flow, hemostasis, inflammation, and angiogenesis.These pathological responses promote regional vasoconstriction and subsequent blood vessel remodeling.Thus, intravascular hemolysis represents an intrinsic mechanism for human vascular disease that manifests clinical complications in sickle cell disease and other chronic hereditary or acquired hemolytic anemias.

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Crossref · 10.1172/jci89741

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  • As HbF falls and fewer F-cells are protected from HbS polymer damage, the propensity for vascular occlusion and intravascular hemolysis increases with the release of heme products into the circulation that scavenge nitric oxide causing endothelial damage and vasculopathy.

    “As HbF falls and fewer F-cells are protected from HbS polymer damage, the propensity for vascular occlusion and intravascular hemolysis increases with the release of heme products into the circulation that scavenge nitric oxide causing endothelial damage and vasculopathy.[57][58][59]”

    From Fetal hemoglobin in sickle cell anemia (2020) · cites this paper as [58]

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  • IL-1β binding to IL-1R on leukocytes and vascular cells activates neutrophils and platelets and upregulates endothelial E-selectin, P-selectin, VCAM-1, ICAM-1, and IL-8, promoting vaso-occlusion.

    “Once released, IL-1β binds to IL-1 receptor (IL-1R) on leukocytes and vascular cells, promoting a cascade of downstream events that lead to activation of neutrophils and platelets and upregulation of E-selectin, P-selectin, VCAM-1, ICAM-1, and chemokines such as IL-8 in endothelial cells, all of which promote vaso-occlusion (14, 17) (Figure 1).”

    From Pathophysiology of Sickle Cell Disease (2019) · cites this paper as [17]

    The Abstract describes an inflammatory, proadhesive endothelial state that promotes sickle vaso-occlusion, and “Evidence linking cell-free hemoglobin to SCD complications” reports platelet activation. Neither passage attributes those effects to IL-1β binding IL-1R or describes the claimed neutrophil activation and endothelial upregulation of E-selectin, P-selectin, VCAM-1, ICAM-1, and IL-8. Page numbers were not provided in our copy. (LLM, conf=0.84)

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  • Vaso-occlusion causes ischemia-reperfusion injury, which together with released erythrocyte damage-associated molecular patterns drives progression of sterile inflammation in SCD.

    “Vaso-occlusion contributes to ischemia-reperfusion injury, which, along with release of eDAMPs, promotes the progression of sterile inflammation (Figure 1d) in SCD (14, 17, 18).”

    From Pathophysiology of Sickle Cell Disease (2019) · cites this paper as [17]

    The section ‘Evidence linking cell-free hemoglobin to SCD complications’ says eDAMPs promote sterile inflammation and may be central to the inflammation of sickle vaso-occlusion. The cited paper also links vaso-occlusive episodes to enhanced eDAMP release, but the passages do not establish the claimed ischemia-reperfusion injury step; a search for that term found no supporting passage. (LLM, conf=0.85)

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  • The hyperhemolysis phenotype of sickle cell disease is linked to stroke risk in adults.

    “Studies in adults with SCD lend further support to the role of hemolysis by showing a link between the hyperhemolysis phenotype of SCD and stroke risk (17).”

    From Pathophysiology of Sickle Cell Disease (2019) · cites this paper as [17]

    Table 1 (The hemolysis hypothesis; page unavailable) lists increased risk of stroke or elevated transcranial Doppler velocity with the hyperhemolytic subphenotype, and the Hyperhemolysis-associated SCD subphenotypes section includes cerebrovascular disease. The table combines stroke with Doppler findings and does not establish that the reported stroke-risk association specifically came from studies in adults. (LLM, conf=0.78)

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  • Unequal protection by HbF across the gamut of sickle cell disease complications might be partially explained by differences in the pathophysiologic roots of these complications.

    “Unequal protection by HbF across the gamut of sickle cell disease complications might be partially explained by differences in the pathophysiologic roots of these complications.57,58”

    From Fetal hemoglobin in sickle cell anemia (2020) · cites this paper as [58]

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Research works printed but not linked: 5

  1. [6]6. Barabino GA, Platt MO, Kaul DK. Sickle cell biome- chanics. Annu Rev Biomed Eng. 2010;12:345-367.
  2. [56]56. Lee MT, Rosenzweig EB, Cairo MS. Pulmonary hypertension in sickle cell disease. Clin Adv Hematol Oncol. 2007;5(8):645-653.
  3. [73]73. Forrest S, Kim A, Carbonella J, Pashankar F. Pro- teinuria is associated with elevated tricuspid regur- gitant jet velocity in children with sickle cell dis- ease. Pediatr Blood Cancer. 2012;58(6):937-940.
  4. [156]156. Powars DR, Chan L, Schroeder WA. The influ- ence of fetal hemoglobin on the clinical expres- sion of sickle cell anemia. Ann N Y Acad Sci. 1989;565:262-278.
  5. [183]183. Fox PD, Higgs DR, Serjeant GR. Influence of α-thalassemia on the retinopathy of homo- zygous sickle-cell disease. Br J Ophthalmol. 1993;77(2):89-90.

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Authors
Kato, G. J., Steinberg, M. H., & Gladwin, M. T.
Affiliations
  • University of Pittsburgh (US)
  • Boston University (US)
Corresponding author
Gladwin, Mark T.
Venue
Journal of Clinical Investigation
Published
2017-03-01
Volume
127
Issue
3
Pages
750-760
ISSN
  • 0021-9738 (ISSN-L)
  • 1558-8238
OpenAlex
W2592339311
Cited by
748
References
193
Citations by year
2026: 90 · 2025: 81 · 2024: 76 · 2023: 65 · 2022: 116 · 2021: 81 · 2020: 87 · 2019: 76 · 2018: 53 · 2017: 21 · 2016: 1
FWCI
9.15
Type
journal article
Language
en
Open access
Locations
  • Journal of Clinical Investigation (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • Patient-Centered Outcomes Research Institute
  • University of Pittsburgh
  • Hemophilia Center of Western Pennsylvania
  • National Institutes of Health (HL098032)
  • National Heart, Lung, and Blood Institute (R01HL087681, R01HL068970, P01HL103455, RC2HL101212, R01HL121386, U01HL107443, T32HL007501, R01HL125886, R01HL098032, T32HL110849)
  • National Institute on Minority Health and Health Disparities (R01MD009162)
Topics
  • Health Sciences › Medicine › Genetics › Hemoglobinopathies and Related Disorders
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Cell Biology › Hemoglobin structure and function
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Blood properties and coagulation
Keywords
intravascular hemolysis, sickle cell disease, free hemoglobin, nitric oxide, methemoglobin, heme, arginase-1, asymmetric dimethylarginine, adenine nucleotides, pulmonary hypertension, inflammation
MeSH terms
Anemia, Sickle Cell, Hemolysis, Humans, Methemoglobin, Nitric Oxide, Vascular Diseases, Vasomotor System

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