Extensive Coagulation Profile in Children with Sickle Cell Disease and Its Role in Cerebral Micro-Vasculopathy
Authors: Colombatti Raffaella , De Bon Emiliano , Bertomoro Antonella , Casonato Sandra , Steffan Agostino , Munaretto Vania , Basso Giuseppe , Teresa Sartori Maria , Sainati Laura 
Published: October 2019

Abstract 3247

Activation of the coagulation system is present in adults with Sickle Cell Disease (SCD) who display higher levels of thrombin-antithrombin complex (TAT), prothrombin fragment F1+2, D-dimer, tissue factor and platelet activity. Whether the activation of the coagulation system is a bystander phenomenon or a main determinant of clinical complications is under investigation. Although thrombotic complications in SCD arise since infancy, the coagulation system in children has been poorly explored. We performed a comprehensive and systematic evaluation of the coagulation system in children with SCD and investigated its possible role in the development of the main clinical manifestations of SCD in childhood.

The following markers of hemostatic and endothelial function were evaluated during steady state: factor VIII activity (FVIII), von Willebrand factor antigen (vWF:Ag) and collagen binding activity (vWF:CBA), PAI-1 antigen (PAI-1:Ag), t-PA antigen (t-PA:Ag), D-dimer, P-selectin, Nitric Oxide (NO), F1+2, TAT, ADAMTS-13 antigen (ADAMTS-13:Ag) and activity (ADAMTS-13:act). Markers of hemolysis (hemoglobin, reticulocytes, aptoglobin, bilirubin, LDH), inflammation (white blood cells, neutrophils, C reactive protein) were measured. Children were not in chronic transfusion.

Magnetic Resonance (MRI), Angio Magnetic Resonance (MRA), Transcranial Doppler (TCD), Tricuspid Regurgitant Velocity (TRV) data and frequency of clinical complications were correlated with coagulation parameters. Continuous variables were compared using two-sided Student's t-test and Mann-Whitney non-parametric test, categorical variables using Chi-square and Fisher's exact test. Correlations between variables were evaluated by the Pearson or Spearman coefficient.

Thirty-five HbS/HbS- 3 HbS/betathalassemia° (20 M and 18 F, mean age 6.49 years), and 6 HbS/HbC patients (3 M and 3 F, mean age 11.2 years) were evaluated. 60% of HbS/HbS and HbS/betathalassemia° children presented higher level of FVIII, D-dimer, F1+2 and lower level of NO, revealing coagulation activation since early age in HbS/HbS and HbS/betathalassemia° but not in HbS/HbC (Table 1). Coagulation variables correlated positively with markers of inflammation, hemolysis, endothelial activation demonstrating a broad involvement of the coagulation system in these processes, while correlated negatively with HbF (Table 2). No correlation was seen between coagulation variables and cerebral large vessel vasculopathy investigated by TCD and MRA nor TRV (p >0.05). Patients with Silent Infarcts on MRI (n.9) showed significant decrease in t-PA (4.53 vs 7.67, p 0.03) and ADAMTS-13 Ag (1.15 vs 1.50, p 0.05) -suggesting the presence of endothelial dysfunction- and a tendency toward higher D-dimer (2879.01 vs 1569.51), F1+2 (319 vs 231), TAT (17.17 vs 10.46) -suggesting a trend towards enhanced clotting activation compared to patients without Silent infarcts (n.21). Increase in D-dimer was associated with a Relative risk of 6 (p <0.05) to develop Silent Infarcts. No correlation was found between coagulation activation and Acute Chest Syndrome or Vaso-occlusive crisis.

Table 1. Coagulation profile in HbS/HbS-HbS/Betathalassemia° and HbS/HbC patients HbS/HbS+HbS/Betathalassemia° HbS/HbC p Variable Mean FVIII:C % 184.96 119.22 0.003 VWF:Ag % 150.05 100.63 0.013 VWF:CBA % 135.38 107.36 0.124 PAI:Ag ng/ml 8.73 6.85 0.833 t-PA ng/ml 6.91 4.52 0.062 D-dimer ng/ml 1906.39 366.48 0.000 NO μmol/L 7.18 8.7 0.336 P-selectin ng/ml 47.76 29.70 0.010 F1+2 pmol/l 254.26 118.50 0.037 TAT ng/ml 12.34 5.14 0.359 ADAMTS-13:Ag μg/ml 1.37 1.46 0.653 ADAMTS-13:act % 79.42 78.94 0.801 ADAMTS-13:act/VWF:Ag 0.52 0.78 0.003

Table 2. Correlations between hematologic and coagulation parameters in HbS/HbS- HbS/Betathalassemia° (first value is Pearson or Spearman coefficient, second is p-value) White Blood Cells Neutrophils Platelets Fetal Hemoglobin Reticulocytes LDH FVIII:C −0.374 0.021 VWF:Ag −0.322 0.049 VWF:CBA 0.368 0.023 PAI:Ag 0.449 0.369 0.333 0.352 0.005 0.025 0.044 0.033 t-PA 0.344 0.034 D-dimer 0.559 0.438 −0.393 0.389 0.421 0.001 0.011 0.021 0.023 0.013 P-selectin 0.461 0.400 0.520 −0.413 0.381 0.004 0.016 0.001 0.011 0.020 F1+2 0.400 0.512 0.337 0.016 0.001 0.044 TAT 0.397 0.381 0.376 0.017 0.022 0.024 ADAMTS-13 Ag 0.471 0.004

Disclosures:

No relevant conflicts of interest to declare.