ALBERT

Description: Abstract 1537 Poster Board I-560 Sickle cell disease (SCD) is characterized by intravascular hemolysis generating cell-free hemoglobin at concentrations that exceed the scavenging capabilities of heme-binding plasma proteins. Heme is a major source of oxidative stress, which is widely known to increase vascular permeability and cause tissue edema. Barrier disruptive effects of oxidative stress can however be counterbalanced by adaptive antioxidant defenses. Hitherto, the identity of specific antioxidant enzymes and cognate mechanisms protecting individual organs from oxidative stress in SCD remains poorly defined. In this study, microarray analysis was performed using non-toxic concentrations of hemin to analyze mechanisms of antioxidant defense by the endothelium. Multiple candidate antioxidant enzymes were identified each differentially elevated in several major organs in anemic SCD mice compared to non-anemic heterozygote and hemizygote littermates. Remarkably, none of the antioxidants was elevated in the brain of sickle mice. Moreover, the antioxidant phenotype in the kidney, spleen and liver of sickle mice were predominantly acute while the sickle lung was characterized by a predominantly chronic antioxidant phenotype. This latter finding was confirmed in SCD patients with chronic lung disease. Antioxidant enzyme activity was significantly higher in the lungs of adult sickle mice aged 3-6 months than in younger mice aged 4-6 weeks (p=0.004). However, this enhanced antioxidant activity declined significantly in middle-age mice 11-13 months old (p=0.005). Vascular permeability assessed by extravsasation of Evans blue dye was normal in the brain of sickle mice of all ages in agreement with our data indicating absence of oxidative stress in this organ. On the contrary, vascular permeability in the lung, kidney and heart of adult sickle mice was abnormally high. This abnormality deteriorated significantly exclusively in the lung (p= 0.04) but not in the heart or kidney in middle-age mice. Increased lung permeability in middle-age sickle mice was confirmed by overt tissue edema determined by lung wet/dry weight ratios. Our study has shown for the first time that the antioxidant response to the systemic chronic hemolysis of SCD is organ-specific. Furthermore, we have identified decline of antioxidant reserve concomitant with tissue edema as potential age-dependant risk factors for fatal lung complications in SCD. Finally, our data provide a framework to develop targeted antioxidant therapies to preserve organ function in SCD. Disclosures No relevant conflicts of interest to declare.

Description: Abstract 1538 Poster Board I-561 Circulating plasma hemoglobin contributes to major vasculopathies including pulmonary hypertension in patients who have sickle cell disease (SCD). There is an emerging concept that such vasculopathies are relatively mild because of activation of several cytoprotective pathways in SCD. The biochemical profile of plasma and the transcriptome of peripheral blood cells in patients who have SCD offer indirect support for this concept. Indeed, heme oxygenase-1 (HO-1), an acute phase enzyme that degrades heme into intermediates and byproducts with vasculoprotective properties is markedly elevated in mononuclear leukocytes of patients who have SCD. Nonetheless, the scope of the cytoprotective mechanisms of the lung and other organs impacted directly by sickle vasculopathies remain poorly appreciated. We previously identified an array of cytoprotective enzymes in lung endothelial cells chronically exposed to non-toxic concentrations of hemin in vitro. In this study, we examined the expression of NAD(P)H oxidase and candidate cytoprotective enzymes in two models of transgenic mice with SCD, and examined HO-1 expression in sickle chronic lung disease. Although NAD(P)H oxidase catalyzes reactive oxygen species generation by heme and is responsible for increased adhesion of leukocytes to the endothelium in SCD mice, there was no elevation of any of its subunits (gp91Phox and p22Phox, p47Phox, p67Phox and p40 Phox) in sickle mice lungs compared to hemizygote control mice lungs. Quantitative RT-PCR analysis revealed unexpectedly no difference in HO-1 mRNA level in sickle and non-sickle control lungs. On the contrary, analysis of the same tissues showed significantly higher NAD(P)H quinone oxidoreductase-1 (NQO1) mRNA level in both Berkeley and Townes knock-in sickle mice compared to controls (p

Description: Emerging evidence indicate the concentration of circulating heme in patients who have sickle cell disease (SCD) is sufficient to contribute to vasculopathies such as pulmonary hypertension. Despite this significance, the identity of specific molecules and pathways responsible for heme-induced pulmonary complications in SCD remains poorly understood. This study was conceived with the idea that whole-genome expression profiling offered a rigorous approach to identify specific molecules involved in both pathological and vasculoprotective mechanisms of sickle chronic lung disease. Human pulmonary artery endothelial cells (PAECs) and pulmonary microvascular endothelial cells (PMVECs) were exposed to a concentration (0–25 mM) range of hemin for seven days and total RNA isolated and interrogated with Affymetrix U133 plus 2.0 Genechips. Microarray data from 24 independent experiments was analyzed using the Bioconductor in the R framework and GeneSpring to generate two unique lists of genes regulated by hemin in PAECs and PMVECs. Multiple genes widely known to be influenced by heme including heme oxygenase-1 (HO-1), ferritin, transferrin receptor, and delta-aminolevulinate synthase were altered as expected thus validating the experimental, statistical and bio-informatics approaches used in this study. The microarray expression data was validated for 26 transcripts in PAECs and 14 transcripts in PMVECs using low-density array multiplex quantitative RT-PCR. Our findings indicate that the cytoprotective response to hemin is markedly more enhanced in PMVECs than in PAECs as determined by the number and the magnitude of differential expression of genes in the oxidative stress response and glutathione metabolism pathways. This finding is supported by a higher basal expression of nuclear factor erythroid 2-related factor 2 (Nrf2) in PMVECs than in PAECs. Heterogeneity of these anti-oxidant phenotypes was confirmed at the protein level in a concentration-dependent manner for multiple enzymes regulated by Nrf2 including NAD(P)H:quinone oxidoreductase 1 (NQO1), which is critical for preventing participation of quinones in redox cycling and generation of reactive oxygen species. Moreover, while NQO1 expression increased 3-fold in PMVECs exposed to hemin for seven days no significant increase in NQO1 expression occurred following shorter periods of hemin treatment. The clinicopathological and pathophysiological relevance of these findings were investigated in post-mortem lung tissues of cases of sickle chronic lung disease and in transgenic mice with SCD. Compared to normal human lung tissues, NQO1 expression increased 3-to 5-fold in the endothelium of small caliber size vessels as well as in both large and small airway epithelium in severe cases of sickle chronic lung disease with extensive pulmonary vascular remodeling. On the contrary, no significant difference in NQO1 expression was detected in the lungs of wild-type mice and transgenic hemizygous or homozygous SCD mice lacking pulmonary vascular remodeling. We conclude that different pulmonary segments and specific anti-oxidant molecules respond uniquely to heme. Unraveling this complex heterogeneity is critical to improving understanding of the pathogenesis and treatment of lung complications in SCD. Induction of NQO1 or its upstream regulator Nrf2 offers a potentially attractive strategy to augment the anti-oxidant phenotype of PAECs to slow the progression of pulmonary vasculopathies in SCD.

Description: Nuclear factor erythroid 2-related factor 2 (Nrf2) is the major transcription factor that coordinates the body's antioxidant and cytoprotective defense against a variety of toxins. Several Nrf2 activators can reactivate gamma globin gene expression and augment fetal hemoglobin production. More recently, genetic and pharmacologic evidence have shown that Nrf2 activation can specifically mitigate the severity of hemolytic anemia, and systemic and local inflammation in transgenic sickle cell disease (SCD) mice. Based on these encouraging results Nrf2 activation has emerged as an attractive therapeutic strategy in SCD. However, the BEACON trial of the Nrf2 activator CDDO-Methyl Ester (CDDO-Me) showed that this therapeutic approach can cause adverse cardiovascular events in patients with chronic kidney disease with comorbid diabetes. Hitherto, the efficacy-toxicity profile generated by individual Nrf2 activating drugs has not been investigated in SCD. There are hundreds of synthetic and naturally occurring Nrf2 activating compounds, and each class of Nrf2 activating compound has a unique pharmacokinetic, pharmacodynamic, toxicokinetic and toxicodynamic profile. We have recently demonstrated that intravascular hemolysis deteriorates with aging in transgenic sickle (SS) mice in a process that can be mitigated by the Nrf2 activator 3H-1,2-dithiole-3-thione (D3T) (Ghosh et al., JCI Insight, 2016). In this study, an in vitro screen of five Nrf2 activating compounds revealed CDDO-Me to be the most potent inducer of cytoprotective enzymes in human pulmonary microvascular endothelial cells. Thus, we performed a long-term prophylactic CDDO-Me treatment of SS mice and examined the effect of the drug on intravascular hemolysis and vascular dysfunction. A cohort of newly weaned SS mice aged ~4 weeks were randomly assigned to receive CDDO-Me (20µmoles/kg/TIW, n=6) or Vehicle (DMSO/TIW, n=10) by oral gavage for 4 months. After the treatment, the total hemoglobin increased by 10% in the CDDO-Me group while it decreased by 5% in the vehicle-treated group (p

Description: Abstract 2113 Sickle cell disease (SCD) is characterized by multiple exacerbating events that cause intravascular hemolysis. Heme released into the circulation is scavenged by multiple plasma proteins and delivered to the liver for degradation. Our recent data indicate that this process is impaired in SCD resulting in excess protein-free plasma heme (PFPH) that triggers a lethal form of acute lung injury (ALI) in mice. In this study, we tested the hypothesis that toll-like receptor 4 (TLR4) mediates heme-induced ALI. Wild-type and two TLR4 mutant strains (B6.B10ScN-Tlr4lps-del/JthJ and C3H/HeJ) were intravenously injected with a dose range of ferric heme (0–210 micromoles/kg) and respiratory function monitored using a pulse oximeter. Excess PFPH was associated with reductions in oxygen saturation (SpO2) and breath rate in the wild-type mice but not in the TLR4 variants. Lungs of heme-treated wild-type mice were congested, edematous, hemorrhagic, and had thickened alveolar walls, while no histological abnormalities were found in the TLR4 variants. All heme-treated wild-type mice succumbed within 2 hours, while all TLR4 variants survived. Transgenic mice expressing exclusively human sickle hemoglobin (SS) were intravenously injected with a small molecule TLR4 inhibitor (resatorvid/TAK-242), or a lipid vehicle prior to induction of lung injury with heme (35 micromoles/kg). TAK-242 preserved lung function in the majority of SS mice that failed to scavenge excess PFPH, while both SpO2 and breath rate deteriorated in vehicle treated mice. The unique response to heme by TAK-242 and vehicle-treated SS mice was supported by histological analysis and survival (TAK-242; 76.9% vehicle; 23.5%, n=13–17; log-rank survival test, p

Description: Acute chest syndrome (ACS) is a major cause of morbidity and mortality in sickle cell disease (SCD). The diagnosis, prevention and treatment of ACS pose major clinical concerns in SCD partly because the mechanism underlying the pathogenesis of this syndrome remains elusive. Our group first reported that excess intravascular hemin causes a lethal acute lung injury (ALI) in transgenic SCD mice reminiscent of ACS (Ghosh and Ofori-Acquah, Blood 116 Suppl 1:944, 2010). Subsequently, large-scale genomics studies by Bean et al., (Blood 120:3822-8, 2012) and Galarneau et al., (Blood, 122:434-42, 2013) have implicated hemin catabolism and inflammation in the pathogenesis of ACS. In addition, we have reported recently that raised plasma free hemin increases the odds of ACS in children with SCD (Adisa et al., Br J Haematol. 2013). Collectively, these studies support a new theme of ACS pathogenesis involving extracellular hemin. In the current study, we validated the respiratory dysfunction of this ACS model, tested the hypothesis that toll-like receptor 4 (TLR4) mediates the associated lung injury, and examined the efficacy of two strategies to treat the condition in mice. Arterial blood gas analysis of SS mice with the ACS-like disease confirmed severe hypoxemia (PaO2; 40.23 ±3.85 mmHg, SO2; 58.72±6.6%, p

Description: Acute chest syndrome (ACS) is a potentially fatal lung complication of sickle cell disease (SCD). There are currently no mechanistic based therapies for ACS and it continues to be a leading cause of death in SCD. Recent studies have identified independent links between extracellular heme with ACS, and with vaso-occlusive crisis (VOC) a common prodrome of ACS. Our experimental ACS model involves intravenous injection of purified hemin typically 35 µmoles/kg, which raises total plasma heme to a clinically relevant pathophysiologic level equivalent to ~0.5g/dl of hemoglobin, and causes respiratory failure exclusively in transgenic SCD mice of both the Townes and Berkeley strains (Ghosh et al., J Clin Invest, 2013). We have determined using time-lapse video microscopy and electrical cell impedance that hemin rapidly disrupts the pulmonary endothelial barrier in vitro. Hemopexin blocks hemin-induced pulmonary endothelial barrier disruption in vitro and respiratory failure in hemin-challenged SS mice. Importantly, genetic polymorphisms in the gene encoding heme oxygenase-1 the rate-limiting heme degradation enzyme are associated with ACS risk in the Cooperative Study of Sickle Cell Disease and the Silent Infarct Transfusion cohorts. These human data and our mechanistic results in SS mice support the heme hypothesis for ACS pathogenesis. P-selectin is a cell adhesion molecule involved in vascular inflammation. It is normally sequestered inside quiescent endothelium. However, recent evidence indicates extracellular heme activates the release of P-selectin unto the endothelial surface wall. Thus, in this study, we tested the hypothesis that P-selectin promotes ACS development. Infusion of a function blocking anti-P-selectin antibody protected SS mice (n=3) from hemin-induced ACS while all control SS mice (n=3) pretreated with IgG before the hemin challenge died (p=0.03) with severe hypoxemia and postmortem evidence of alveolar flooding. The apparent requirement for P-selectin in heme-induced lethal acute lung injury was confirmed by a 100% survival of P-selectin-/- (n=5) and 100% lethality of congenic P-selectin+/+ (n=5) mice challenged with hemin infusions (p=0.005). To identify the cell population involved in this disease process we generated bone marrow chimeric C57BL/6 mice lacking P-selectin in hematopoietic (P-selectinPLT-/-) and non-hematopoietic (P-selectinEC-/-) compartments. Seventy-five percent of P-selectinEC-/- mice were protected while all P-selectinPLT-/- congenic controls succumbed to hemin (n=3-4). The severity of lung injury in the P-selectinPLT-/- C57BL/6 mice was reflected by severe hypoxemia (SpO2: 82.75±2.14%) and a significantly higher lung wet/dry weight ratio compared to the ratio of the P-selectinEC-/- mouse lungs (p

Description: Inflammation is a cardinal component of the pathogenesis of sickle cell disease (SCD). Increased plasma concentration of the inflammatory agonist hemin increases the odds of acute chest syndrome (ACS) in children with SCD (Adisa et al., Br. J Haematol, 2013). In addition, free hemin promotes the development of a lethal ACS-like disease in transgenic sickle mice (Ghosh et al., J Clin Invest, 2013). Hemin degradation is controlled by the rate-limiting enzyme heme oxygenase-1 (HO-1). Polymorphism of a (GT)n dinucleotide repeat in the HO-1 promoter, which enhances expression of the gene, is associated with lower rates of hospitalization for ACS in children. Over-expression of HO-1 reduces stasis in a mouse model of SCD vaso-occlusion. However, the role of plasma HO-1 in SCD patients is entirely unknown. In this study, we measured steady-state plasma HO-1 in two cohorts of patients. Cohort 1 in Atlanta (n=98) consisted of children with a mean age of 10.07±0.42 years (range 2-19 years) and cohort 2 from Accra (n=80) consisted of older patients (mean age 25.30±1.0 years, range 13-58 years). The mean plasma HO-1 of both cohorts was significantly higher compared to the mean value of age- and ethnic-matched individuals with normal adult Hb; Atlanta: 10.19±5.80 vs. 2.08± 1.16, p

Description: Acute organ failure is a major clinical concern in sickle cell disease (SCD). However, the mechanism responsible for this potentially lethal complication is poorly understood. We tested the hypothesis that extracellular hemin liberates an intracellular danger molecule that promotes acute organ failure in SCD. Transgenic homozygous SCD (SS), sickle-trait (AS) and normal human hemoglobin (Hb) AA mice were infused with purified hemin (35 µmoles/kg), which raised total plasma hemin by ∼0.45 mM (equivalent to 0.72 g/dl Hb) within 5 min in all three groups of mice. In agreement with our previous results, SS but not AA and AS mice (n= 6 for each genotype) developed cardiopulmonary depression at 30 min evident by reductions in oxygen saturation (99.88±0.23% to 92.1±1.3%, p

Description: Pulmonary vascular occlusion is a major cause of morbidity and mortality in sickle cell disease. Adhesion between sickle erythrocytes, leukocytes and the endothelium are intimately involved in pulmonary vascular occlusion, which contributes to the pathogenesis of the acute chest syndrome. Despite this significance, specific molecules and cognate mechanisms responsible for trapping sickle erythrocytes in the lung microcirculation are poorly understood. In this study, we show for the first time that products released by activated neutrophils act through the phosphatidyserine and phosphatidylserine receptor axis to promote retention of sickle erythrocytes in the lung microcirculation. We demonstrated that co-incubation with autologous activated neutrophils increased 2-fold the proportion of phosphatidylserine exposed sickle erythrocytes. This effect was abrogated by prior treatment of neutrophils with zileuton a pharmacological inhibitor of 5-lipoxygenase. We next determined that primary endothelial cells derived from the pulmonary vasculature expressed the stereospecific receptor for phosphatidylserine. Transcripts for phosphatidylserine receptor (PSR) were 2-fold more abundant in endothelial cells from the pulmonary microvasculature compared to those from the pulmonary artery. To determine the relevance of neutrophil activation in PSR expression, cultures of PMVECs were treated with supernatants of activated neutrophils from patients with sickle cell anemia, and this resulted in 2-fold increase in PSR transcripts. To unravel the pathophysiological relevance of these findings, isolated rat lungs were perfused with 51Cr labeled sickle erythrocytes pre-incubated with annexin V, and retention of sickle erythrocytes quantified by 51Cr radioactivity. The number of sickle erythrocytes trapped in isolated lungs was 2-fold lower compared to the value in control experiments performed with untreated sickle erythrocytes. In agreement with our previous findings activated neutrophils significantly increased sickle erythrocyte retention in the lung (P=0.0004), however cloaking of sickle erythrocytes with annexin V reduced retention by 3-fold. Collectively, these data show that activation of neutrophils increases expression of PSR and its cognate ligand on endothelial cells and sickle erythrocytes respectively, providing the molecular basis for an adhesion complex that increases retention of sickle erythrocytes in the pulmonary endothelium. The PSR-phosphatidylserine adhesion complex therefore offers a novel therapeutic target to reduce pulmonary vascular occlusive events in sickle cell disease.