Haematological and Clinical Assessment of Steady State Homozygous Hb Sand Homozygous Hb A

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1 IOSR Jounal of Dental and Medical Sciences (IOSR-JDMS) e-issn: , p-issn: Volume 16, Issue 2 Ve. III (Febuay. 2017), Haematological and Clinical Assessment of Steady State Homozygous Hb Sand Homozygous Hb A Uche CL 1,Akinola NO 2,Duosinmi MA 2 1 Depatment of Haematology Abia State Univesity Teaching Hospital, Aba 2 Depatment of Haematology and Blood Tansfusion,Obafemi Awolowo Univesity Teaching Hospitals Complex, Ile Ife, Nigeia Abstact Intoduction:The abnomalities in patients with sickle cell anaemia (HbSS) esult in multi- ogan and systemic complications and clinical manifestations. The study aims at assessing and detemining the coelates of the haematological and some clinical paametes in steady state adults with homozygous Hb S compaed with adults with homogygous Hb A contols. Method: It is a coss-sectional study involving 83 subjects (58 patients and age- and sex-matched 25 Hb A contols).atients aged yeas with confimed HbSS using cellulose acetate electophoesis at ph8.4 in steady state and age and sex- matched HbAA appaently healthy contols wee ecuited. atients wee physically examined and vital signs, height, weight, size of the live and spleen, Kanofsky pefomance scale, KS (0-100%) and visual analogue scale VAS fo well-being wee obtained. Venous blood (4.5mls) was collected into an EDTA bottle fo a full blood count (WBC, RBC, Hb, CV, MCV, MCH, MCHC, RDW and platelet count). Data was analyzed using Excel and SSS vesion 20 statistical package. Results: atients with Hb SS had a significantly lowe mean ± SD fo visual analogue scale out of 10 (VAS; 8.4 ± 1.1); Kanofsky (85.8 ± 7.8%); ulse ate (83.8 ± 11.9 beats/mm) and diastolic B (64 ± 9.4 mmhg) than the contols ( < 0.01), but systolic B was not significantly diffeent fom Hb AA contols (102.9 ± 10 mmhg and ± 10.8 mmhg espectively; > 0.05). Hepatomegaly (15.2%), splenomegaly (6.8%) and both (17.2%) wee obseved in patients with sickle cell anaemia only. Out of the nine paametes measued with the use of automated cell counte seven paametes: RBC, Hb, CV, WBC, platelets, MCHC, and ed cell distibution width (RDW) wee obseved to be significantly lowe in patients than contols but MCV and MCH wee not significantly diffeent ( > 0.05). Thity six (62%) patients had elevated WBC (i.e. >10 ± 10/L) while 11 (19%) patients had elevated platelet counts (i.e. > 400 ± 10 9 /L). Significant positive coelations wee found between the ed cell counts, Hb, haematocit, SB and DB. While Hb and haematocit coelated significantly with height and weight espectively. Weight and height also coelated significantly with SB and DB and futhemoe WBC invesely coelated significantly with SB and DB ( = and = espectively; < 0.05). Conclusion:esistent splenomegaly was not as common as hepatomegaly in patientswith Hb SSin this study,who wee obseved to have a elatively lowe diastolic blood pessue, pulse ate and state of well-being than the Hb AA contols. atients had highe values of MCHC, platelets and white blood cell counts and the ed cell count, haemoglobin, haematocit, weight and height had a positive elationship with blood pessue indices in patients only. Keywods:clinical assessment, haematological paametes, HbAA, HbSS, steady state. I. Intoduction Haemoglobin S is a mutant haemoglobin poduced when a non-pola valine is substituted fo pola glutamic acid at position six of the globin polypeptide chain. The solubility of Hb S in deoxygenated state is makedly educed esulting to a tendency to polymeize into igid aggegates that distot the cell membane. Consequent to polymeization, the cells become sickled and appea like a cescent o holly leaf in shape. The sickled shape etuns to nomal duing eoxygenation, howeve, epeated episodes of sickling and unsickling in ciculation causes ed cell membane damage leading to the fomation of ievesibly sickled ed cells. The poduction of these abnomal sickle cells is the mainstay of cises and cetain complications seen in these patients.nomal ed blood cells life span is days, but sickle cells have shotened life-span of about days. 1 This accounts fo low haemoglobin levels that ange fom 6 to 8g/dl and high eticulocyte counts even in the steady state. Haemolysis esults fom membane fagmentation and loss as a esult of sickling, incease ed cell igidityand destuction by eticuloendothelial cells (chonic extavascula haemolysis) Othe DOI: / age

2 mechanisms by which haemolysis occus includes the vaious aspects of the oxidative phenomenaand sickled haemoglobin instability. 6,7 Othe blood constituents ae also affected in the pathophysiology of this disease condition as vascula lumen obstuction in sickle cell anaemia is as a esult of inteaction of eythocyte, platelets, leucocyte, plasma potein and blood vessels. High level of leukocytes coelate positively with clinical seveity of sickle cell anaemia. 8 Leucocytosis in the absence of infection is common in patients with sickle cell anaemia (SCA) and it is a pedictive featue fo stoke, acute chest syndome and oveall motality. Neutophils and monocytes have been shown to be activated in these individuals. 9 A study conducted by TetWun (2001) to detemine the neutophil activity in sickle cell disease (SCD), showed significant diffeences in the activated state of neutophils in non-symptomatic patients with SCD when compaed to healthy HbAA contols as shown by the significant decease in L-selectin expession, enhanced expession of CD64, and inceased levels of soluble makes like sl-selectin, elastase, and scd It was also obseved that duing vaso-occlusive cisis the diffeences wee even moe ponounced. These esults show that neutophils ae activated in SCD, thus suggesting thei impotance in the pathophysiology of the disease. 11 Thee ae evidences suggesting that ciculating platelets in patients with SCD ae chonically activated and may contibute to the obseved hypecoagulable state in these indivduals. 12 A ecent study suggests that haemolysis, with deceased bio-availability of nitic oxide, may contibute at least in pat, to the pathogenesis of platelet activation in SCD. 13 Lowe ateial blood pessue has been epoted, but anothe study showed a compaable systolic blood pessue in patients and contols while the diastolic blood pessue was lowe and pulse pessue was significantly highe in patients than in contols. 14,15 Factos contibuting to the loweed ateial blood pessue include: salt losing sickle cell nephopathy, a loweed peipheal esistance, alteation in ciculating levels of catecholamine, enin, aldosteone, and postaglandin, o changes in the sensitivity of eceptos to these agents Splenomegaly is a usual featue in patients with sickle cell anaemic (SCA)in the fist decade of life, but theeafte, atophy sets in due to epeated infaction leading to autosplenectomy. Some may have pesistent splenomegaly even into adult life atients with hepatomegaly had significantly highe clinical seveity scoes. 22 The impact of oganomegaly on the haematological paametes in patients with SCA in the steady state is yet to be fully elucidated in this envionment. The study aims at assessing and detemining the coelation of the haematological and clinical paametes of steady state adults with homozygous Hb S compaed to adults with homogygous HbA only contols. II. Methods It is a coss-sectional study involving 58 patients and 25age- and sex-matched HbA only contols. Infomed consent was obtained fom all the paticipants, and ethical appoval fo the study obtained fom the Ethical and Reseach Committee of OAUTHC, Ile- Ife, Nigeia. atients aged yeas with confimed Hb S only using cellulose acetate electophoesis at ph8.4 in the steady state, which is defined as a peiod of stable clinical condition that occus at least one week befoe o thee weeks afte a vaso occlusive cisis (VOC) o thee months afte a haemolytic cisis equiing blood tansfusion. 23 Those who had eceived blood tansfusion in pevious thee months, o had hypetension, diabetes mellitus, smoked cigaettes, o took excessive amounts of alcohol wee excluded fom the study. Age and sex- matched Hb A only as confimed by cellulose acetate electophoesis who wee appaently healthy individuals wee ecuited as contols. atients wee physically examined fo vital signs, height, weight, size of the live and spleen, Kanofsky pefomance scale, KS (0-100% ) and visual analogue scale VAS fo well-being (1 epesenting the wost state of well-being (a nea death expeience), while 10 epesented the best feeling of well-being eve expeienced) wee detemined. Venous blood (4.5mls) was collected into an EDTA bottle fo full blood count (WBC, RBC, Hb, CV, MCV, MCH, MCHC, RDW and platelet count). Data was analyzed using Excel and SSS vesion 20 statistical package. Continuous vaiables wee pesented using desciptive [means, standad deviation (SD)] and compaed using infeential statistics (e.g. Student T-test, chi- squae and Fishe s exact test) appopiately. A -value 0.05 was consideed to be statistically significant. III. Results atients with SCA had a significantly lowe mean ± SD fo VAS (8.4 ± 1.1); Kanofsky (85.8 ± 7.8%); ulse ate (83.8 ± 11.9 beats/mm); diastolic B (64 ± 9.4 mmhg) and pulse pessue (38 ± 2.9) than the contols (Table 1), but the systolic B was not significantly diffeent fom that of contols (102.9 ± 10 mmhg and the ± 10.8 mmhg espectively; > 0.05). Oganomegaly (hepatomegaly and splenomegaly) was obseved in the patients only (17.2%). The mean ± SD of live size in nine (15.2%) patients with hepatomegaly was 5.9 ±3.2 cm and the mean spleen size of fou(6.8%) patients with splenomegaly was 5.5 ± 2.5cm. Out of the nine paametes obtained fom the automated cell counte, fou paametes; WBC, latelets, MCHC, and ed cell distibution width (RDW) wee obseved to be significantly highe in patients (11.1 ± 3.3, 309 ± 121.8, 31.3 ± 1.4, 19.5 ± 5.3 espectively) than the contols (4.8 ± 1.4, 210 ± 44.9, 29.5 ± 1.7, 15.7 ± 3.4 DOI: / age

3 espectively;table 2), but MCV and MCH wee not significantly diffeent ( > 0.05). Thity six (62%) patients had elevated WBC (i.e. >10 ± 10x 10 9 /L), while 11 (19%) patients had elevated platelet count (i.e. > 400 ± 10 x 10 9 /L). None of the contols had eithe leukocytosis o thombocytosis. Thee was no significant diffeence in WBC diffeential fo both patients and contols (Table 3). Table 1: Clinical assessment of patients and contols aamete atients Contols -value (n = 58) (n = 25) VAS (well-being) 8.4 ± ± 0.2 < KARNOFSKY (%) 85.8 ± ± 2.8 < R (beats/min) 83.8 ± ± 11 <0.01 SB (mmhg) ± ± 10.8 NS DB (mmhg) ulse essue 64 ± ± ± ± 1.4 Hepatomegaly(cm) 5.9 ± 3.2 (15.2%) n = 9 0 (below costal magin) Splenomegaly (cm) 5.5 ± 2.5 (6.8%) n = 4 0 < < VAS- visual analogue scale, SB- systolic blood pessue, DB- Diastolic blood pessue, - pulse pessue. Table 2: Haematological paametes of patients and contols aamete atients Contol -value n = 58 n = 25 WBC (10 9 /L) 11.1 ± ± 1.4 < RBC (10 6 /L) 3 ± ± 0.6 < Hb (g/dl) 8.1 ± ± 1.5 < CV (%) 26.2 ± ± 4.7 < MCV (fl) 87.7 ± ± 7 NS MCH (pg) 27.5 ± ± 2.4 NS MCHC(mg/dl) 31.3 ± ± lt (10 9 /L) ± ± 44.9 <0.001 RDW (%) 19.5 ± ± 3.4 <0.01 WBC- white blood cell, RBC- ed blood cell, Hb- haemoglobin, CV- pack cell volume, MCV- mean cell volume, MCH- mean cell haemoglobin, MCHC- mean cell haemoglobin concentation, lt-platelet, RDW- ed cell distibution width Table 3: WBC diffeentials in both patients and contols atients Contols T-test -value Neutophils (%) 47.1± ± NS Lymphocytes (%) 50.6± ±16 25 NS Eosinophils (%) 2.0± ± NS Basophils (%) 1.9± ± NS Monocytes (%) 1.3± ±0.5 5 NS Effect of oganomegaly on haematological paametes: haematological paametes of patients with oganomegaly mild (<5cm below the subcoastal magin) to modeate oganomegaly (<8cm below the subcoastal magin) had lowe values of RBC, Hb, CV, and platelets when compaed to patients without oganomegaly that wee not statistically diffeent ( > 0.05). The eduction was found to be moe in sevee oganomegaly(>8cm below the subcoastal magin), but it was also not significance statististically, howeve,the WBC values wee highe in patients with oganomegaly than those without oganomegaly though not significant statistically. DOI: / age

4 Table 4:Coelation between haematological paametes, blood pessue indices and anthopometic vaiables Haematological SB DB R Height Weight BMI aametes Red blood cell * * Haemoglobin ** ** * * Haematocit * * * latelets WBC Height p * * * ** Weight p 0.373** * BMI p Key:**. Coelation is significant at the 0.01 level (2-tailed). *. Coelation is significant at the 0.05 level (2-tailed). Table 4 shows a significant coelation between ed cell count and systolic blood pessue, ( = 0.312;p= 0.023), diastolic blood pessue ( =0.328; p =0.017). Haemoglobin coelated significantly with systolic blood pessue ( = 0.434, p = 0.001), diastolic blood pessue ( = 0.415; p = 0.002) and also with height ( = 0.281, p = 0.036) and weight ( = 0.310, p = 0.020). Haematocit coelated with systolic blood pessue ( = 0.341; p = 0.013), diastolic blood pessue ( = 0.343, p = 0.012)and weight ( = 0.281; p = 0.036). White blood cell invesely coelated with the systolic blood pessue ( = , p = 0.022), and diastolic blood pessue ( = ; p =0.028). Height ( = 0.289; p = 0.036) and weight ( = 0.373, p = 0.006) coelated significantly with SB, but BMI did not coelate with any blood pessue measuement o haematological paamete. IV. Discussion The visual analogue scale and Kanofsky pefomance scale though significantly lowe in patients than in the contols evealed a good quality of life fo the patients in this seies since adequate pefomance status is associated with Kanofsky scoe > 70%and nomal VAS Blood pessue in these patients showed a compaable systolic blood pessue to that of the contols while the diastolic blood pessue and pulse pessue wee found to be significantly lowe (Table1; < 0.001) than the contols. These findings ae simila to that of DOI: / age

5 the study conducted in UNTH, Enugu and that by Ayo et al while anothe studies epoted a significantly lowe systolic and diastolic blood pessue. 15,25-26 The elatively lowe blood pessues wee patly explained in these patients by anaemia. 26 Splenomegaly with hepatomegally was obseved in 17.2% of these patients. This is in keeping with findings that some patients have pesistence splenomegaly even into adult life. 19,20 This study also tied to elucidate the effect of oganomegaly (splenomegaly with o without hepatomegaly) on haematological paamete. Thee was a eduction in ed cell paametes and platelet counts with inceasing oganomegaly that was howeve not statistically significant. Significant positive coelations wee obseved between the ed cell counts, Hb, haematocit, SB and DB. While Hb and Haematocit coelated significantly with height and weight espectively. Weight and height also coelated significantly with SB and DB and futhemoe, WBC invesely coelated significantly with SB and DB. These findings ae in keeping with pevious studies whee haemotocit coelated significantly with blood pessue indices. 14,15, These studies also showed a positive coelation between BMI, enal function, age and sex. 14,15 Howeve, ou study did not demonstate significant coelation between blood pessue and BMI and did not coelate with age and sex. Sickle cell anaemia is chaacteized by a state of chonic haemolysis even in the steady state and this accounts fo the clinical and laboatoy featues seen in this disode. In this study, the values of the haematocit, haemoglobin, wee found to be significantly lowe in patients with SCA than in contols as expected (Table2). This is simila to the esults of pevious studies conducted in this county and these featues ae pat of the chaacteistic featues of this chonic haemolytic disode The mean total white blood cell count seen in the patients compaed to the contols was significantly highe (Table 2; < ) as epoted in pevious studies Leucocytosis above 15 x 10 9 /l in the absence of infection is common in SCA and this pedicts the isk of stoke, acute chest syndome, motality and oveall suvival. 9 Neutophil and monocytes have been found to be activated in patients with SCD. 9 Activated leucocytes futhe pomote vascula inflammation and vessel damage. Thee is no significant diffeence between the WBC diffeentials in both patients and contols, confiming that the patients wee in the steady state (Table 3). The mean platelet count in these patients was significantly highe than in the contols (Table 2; < 0.001) and this agees with othe epots. 27,28,30 Thombocytosis in SCA has been associated with the backgound haemolytic anaemia and loss of splenic platelet pool function esulting fom autosplenectomy/functional asplenia.the mean cell haemoglobin concentation (MCHC) in this study was significantly highe in patients compaed with contols (Table 2; < ), while thee is no significant diffeence in the mean of MCV fo both patients and contols; these findings ae in ageement with pevious studies. 28,29 Although the mean MCH of patients was not significantly highe than that of contols and this is not in ageement with epots fom elsewhee. 27,31 The high MCHC esult fom an incease in the concentation of haemoglobin in solution and cellula dehydation and this can pedispose the cell to sickle when subsequently deoxygenated. Futhemoe, a high MCHC is associated with an incease in cytoplasmic viscosity and a decease in defomity thus leading to obstuction of small vessels and ultimately vaso-occlusive cisis. V. Conclusion atients with homogygous Hb S have elatively lowe diastolic blood pessue than the homozygous Hb A contols. Hepatomegaly is moe common than splenomegaly in patients. Red cell count, haemoglobin, haematocit, weight and height have a positive elationship with blood pessue indices in patients with HbS. atients with homozygous HbSS have highe values of MCHC, platelets and white blood cell counts when compaed to contols. Refeences [1]. Sickle cell anaemia: emedicine Emegency, Retieved 2010 : [2]. adilla F. Bombeg,.A. and Jensen, W.N. The Sickle-unsicklecycle: a cause of cell fagmentation leading to pemanently defomed cells. Blood 41, 1973, [3]. Dean J. Schehte, H.N. Sickle Cell Anemia: N. Eng. J. Med. 299:( ), , [4]. Evans E.A. and Mohandas. N. 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