Constitutive Activation of Hemostasis in Children with Sickle Cell Disease.

Recent studies of sickle cell disease (SCD) suggest that hemostatic activation is a key aspect of pathophysiology, leading to clinical consequences such as vaso-occlusive crises and stroke. In many of these studies a SCD-associated hypercoagulable state has been inferred from markers suggestive of increased hemostatic activity, such as elevated levels of plasma thrombin-antithrombin complexes and tissue factor-containing microparticles. As part of a study using a broad-spectrum approach to explore the relationships among various aspects of normal and abnormal hemostasis in SCD we used a whole-blood coagulation assay (thromboelastography, TEG) to directly assess global hemostatic activation in children with SCD defined by genotype (SS and SC), together with a group of unaffected children. We also assessed platelet activation and procoagulant surface expression in platelets and red blood cells (RBCs) using flow cytometry. Eligible SCD subjects included:

• patients with painful crisis assessed at two time points: hospital admission (crisis group) and clinic follow-up appointment (follow-up group);

• patients not in crisis attending a regular clinic appointment (steady-state group).

Patients were ineligible if they had received a recent blood transfusion, hydroxyurea, anticoagulants or aspirin. The results of TEG assays with citrated whole blood showed that compared to SC patients (n = 16) and normal children (n = 16), SS patients (n = 45) had significantly (p<0.001) earlier clotting onset (mean R times were 4.5, 6.5 and 7.6 minutes for SS, SC and normals respectively) and significantly (p<0.001) higher rates of clotting (mean maximum clotting rates were 16.8, 12.6 and 10.9 mm/min for SS, SC and normals respectively). TEG clotting onset and maximum clotting rates were not significantly different among steady-state, crisis and follow-up groups of children with SCD (both SS and SC genotypes), nor between sexes within each study group. Whole blood flow cytometry revealed that platelet GPIIb/IIIa activation (PAC-1 binding) was significantly elevated (p<0.05) in SCD patients relative to normal children. In addition, markers of RBC procoagulant surface expression (RBC annexin A5 binding) and RBC-platelet aggregates were elevated in SCD patients compared to normal children. These results indicate that children with the SS genotype have an activated hemostatic system relative to normal and SC genotype children, and that this hypercoagulable state is maintained during sickle cell crisis as well as during steady state. It remains to be determined whether pharmacological interventions and/or RBC transfusions which improve clinical outcomes in SCD patients modify their constitutively hypercoagulable state.