montekids.org
Sickle Cell Anemia -striving to
provide comprehensive care at
CHAM
Kerry Morrone, MD
Director of the Pediatric Sickle Cell Program
11-2-16
montekids.org
Objectives
• Demonstrate how to interpret a hemoglobin
electrophoresis
• Update on treatment guidelines from the NHLBI
• Review vaccination guidelines
• Overview on special considerations in prescribing
medications or performing surgical procedures in
sickle cell disease
•
montekids.org
Prevalence in U.S 90-100,000 Incidence in Africa 200,000 infants/year
Sickle Cell Disease: A Public Health Problem
montekids.org
Hemoglobin Structure
montekids.org Stuart . 2014 Lancet
Pathophysiology of vaso-occulsion
montekids.org
Name Genotype Percent
Homozygous SS (Sickle Cell Anemia) S-S 65
Heterozygous SC (Hb SC Disease)
S- C 24
Heterozygous S-+ thal S- + thal 7
Heterozygous S-° thal
S- ° thal
3
montekids.org
Mortality in sickle cell disease-more to be done
montekids.org
Perspectives from a clinical case
• Two siblings present with their parents to clinic
after recently immigrating from Liberia.
• They think their children may have a blood
disorder, but are unsure.
• Fareed the 10 year old child had to be
hospitalized several times for infection and gets
pain intermittently
• Kadida is 2 years old and has not had any
complications
montekids.org
How would you test this family? What are the
methods to screen for sickle cell trait/disease?
• As of 2006 all 50 states now require new born screen
testing for sickle cell disease
• Best screening methods: hemoglobin electrophoresis,
HPLC, isoelectric focusing
• Sickle cell solubility test has many potential errors
• NCAA offers testing of all athletes in Divisions I-III
• 16 % of individuals and 37 % of parents of children
tested are aware of their sickle cell carrier status
Treadwell et al. J Nat Med Assoc . 2006
Naik and Haywood. 2015. Ash Education Program
montekids.org
Perspectives from a clinical case
• Fareed’s labs:
• 15>7/24<550
• MCV: 75
• Retic: 10
• LDH: 400
• TB/DB: 2.5/.4
• Hemoglobin electrophoresis:
• S%: 90 A2%: 3 F%: 7
• Kadida’s labs:
• 5>12/36<300
• MCV: 75
• Retic: 1
• LDH: 200
• TB/DB: .4/.2
• Hemoglobin electrophoresis:
• S%: 25 A%: 65 A2%: 3 F%: 7
What do you inform this family?
montekids.org
Perspectives from a clinical case
• The family is informed that Fareed has SS
disease and that Kadida has sickle trait .
• The family wants to discuss the risk factors for
Kadida and want to know what does the
literature say?
montekids.org
Are there additional risks of having sickle cell trait ?
• No systematic review of complications
• Exertional related injury documented in
retrospective reports
• NEJM- 2016 not increased
• Chronic kidney disease and albuminuira – 1.57
OR (CI 1.34-1.84)
Naik et al. 2014 JAMA
Kark JA et al. 1987 NEJM
Harmon KG et al. 2012 Br J Sports
montekids.org
Another common scenario…
• Destiny is a 2 month old born in Florida whose
family has moved to the Bronx this week and
mom wants to establish care
• Mom knows there is sikcle cell trait in her family
and missed her follow up appointment to go
over newborn screen results. She asks for her
daughter to be tested
montekids.org
Another common scenario…
• 10>12<350 MCV: 75 retic: 1.5
• Hemoglobin electrophoresis: S-20 % F->40%
A2:5%
• Does this patient have sickle cell disease or
trait?
• Do they need any additional follow up or
treatments ?
montekids.org
Another common scenario…
• This patient has sickle cell disease and should
be started on penicillin prophylaxis and referred
to a hematologist
• Fetal hemoglobin is elevated in the newborn
period
• In sickle cell disease the level of fetal
hemoglobin is not stabilized even up until 5
years old
montekids.org
30 years later from the landmark prophylaxis
study …
montekids.org
Vaccination recommendations
Steinberg. 2015 BJH
montekids.org
What is the rate of infection
post vaccination era?
• Post vaccine rate of bacteremia: .8 % in setting
of febrile episodes
• Presence of a central venous line, band count,
clinical appearance and age helped to predict
bacteremia
• Patients still require a blood culture, broad
spectrum antibiotics and ability to have close
follow up
Chang et al. 2013
montekids.org
What does the CDC suggest for
meningococcal vaccinations?
• New updates for children with anatomic or functional
asplenia (including sickle cell disease):
• Can start vaccinating at 2 months old with Menveo or
Menhibirix
• If start vaccinating at 2 months then should receive
vaccines at 2,4, 6 and 12 months
• Catch up vaccine schedule
• Menactra can be used in over 2 years of age
montekids.org
At 430 pm on a Friday afternoon
• Jose and his mother present to the Adolescent
doctor for his routine visit
• He is noted to be tachypneic and febrile to 102
• He states he was febrile this morning but felt
better after motrin.
• Besides the tachypnea he is very well
appearing and states he wants to go home..
• What do you do ?
montekids.org
NHLBI guidlelines for fever
montekids.org
• Jose is seen in the emergency room and as the resident
is doing medication reconciliation they notice he is on
hydroxyurea
• On further questioning Jose states he has had very few
crises and very minimal complications
• The family states his hematologist suggested he be on it
for his general health
• Is there an indication to do that?
Hydroxyurea- who , when and why ?
montekids.org
Randomized phase III trial
9-18 months
N=193
18 month follow up
Excellent safety profile
Decreased pain crisis
Decreased dactylitis
Improved hemoglobin
Decreased inpatient hospitalization costs
Wang Pediatrics 2013
montekids.org
< 5 yrs
5 <10yrs
10 <15yrs
>15yrs
Never
Death
Stroke
Renal Disease
Hepatic disease
Sepsis/Infection
montekids.org
NHLBI 2014 Guidelines:
Hydroxyurea
****
montekids.org
• Jose tells you he is also upset because he is supposed to
have surgery tomorrow to help with his snoring
• He is afraid his fever will prevent him from getting the
surgery
• After checking his labs his hemoglobin returns at 8 , retic:
10
• If he is feeling better should be just go to the ambulatory
suite tomorrow to remove his tonsils?
Surgical considerations
montekids.org
What are common surgeries or procedures
for patients with sickle cell anemia?
• Tonsillectomy & adenoidectomy
• Cholecystectomy
• Orthopedic procedures (core decompression of
hip)
• Splenectomy
montekids.org
Procedural/Surgical Preparations for Sickle
Cell Disease
montekids.org
Procedure/Surgical Preparation
• Refer to your patient’s hematologist
• Blood work is done and patients are optimized
by blood transfusions and/or IVF
• Patients typically admitted the night prior to
surgery or procedure if it requires sedation
• Medical clearance should be provided by
hematologist
montekids.org
By request: special considerations
• No estrogen containing contraception
• Steriods- to be used judiciously and tapered for
risk of VOC and ACS rebound
• Headache restrictions (triptans)
Whitley- ASH education book
montekids.org
Objectives
• Demonstrate how to interpret a hemoglobin
electrophoresis
• Update on treatment guidelines from the NHLBI
• Review vaccination guidelines
• Overview on special considerations in prescribing
medications or performing surgical procedures in
sickle cell disease
montekids.org
CHAM Pediatric Hematology team