Search

Congenital Anomalies of the Kidney and the Urinary Tract (CAKUT) are defined as a heterogeneous group of anomalies that resulted from defects in kidney and urinary tract embryogenesis. CAKUT have a complex etiology. Genetic, epigenetic and environmental factors have been investigated in this context. Angiotensin II is a potent vasoconstrictor and exerts an important role in kidney embryogenesis. The angiotensin-converting enzyme (ACE) converts Angiotensin I into Angiotensin II (Ang II) and ACE gene has insertion/deletion (I/D) polymorphisms that have been evaluated in several nephropathies. This study aimed to evaluate whether the I/D polymorphisms of ACE gene and the circulating levels of Ang II are associated with any CAKUT phenotype or CAKUT in general.Our study was performed with 225 pediatric patients diagnosed with CAKUT and 210 age-and-sex matched healthy controls. ACE I/D alleles were analysed by real-time polymerase chain reaction (RT-PCR). The distribution of ACE I/D polymorphisms were compared between CAKUT patients and healthy controls, as well between ureteropelvic junction obstruction (UPJO), vesicoureteral reflux (VUR), multicystic dysplastic kidney (MCDK) phenotypes and control group. No statistical association was detected between ACE I/D polymorphism and CAKUT and UPJO, VUR, and MCDK phenotypes. In a subset of 80 CAKUT patients and 80 controls, plasma levels of Ang II were measured. No significant differences were found between CAKUT patients and controls, even in regard to comparisons of UPJO, VUR and MCDK with control group.Although CAKUT is a complex disease and the ACE gene may exert a role in kidney embryogenesis, CAKUT was not associated with any ACE I/D polymorphisms nor with differences in plasma levels of Ang II in this Brazilian pediatric population.

Aim: The aim of this study was to compare novel kidney injury biomarkers in sickle cell anemia (SCA) children with and without albuminuria or glomerular hyperfiltration. Materials & methods: A total of 358 Brazilian children with SCA were studied. Fifteen kidney injury biomarkers in urine were measured. Albuminuria was defined as urine albumin/creatinine ratio >100 mg/g. Glomerular hyperfiltration was defined as estimated glomerular filtration rate ≥140 ml/min/1.73 m2. Results: After adjustment for age, sex and modifying therapies in use, EGF and collagen IV urinary levels were associated with albuminuria. Renin and clusterin levels were associated with hyperfiltration. Conclusion: Levels of novel kidney injury biomarkers were associated with albuminuria and hyperfiltration in Brazilian children with SCA, suggesting concomitant structural and functional abnormalities.

Background The kinetics of hematopoietic recovery after autologous stem cell transplantation (ASCT) may be affected by laboratory procedures. The aim of this study was to evaluate the influence of characteristics of the cryopreserved units of peripheral blood stem cells (PBSC) on postthawing cell viability and engraftment outcomes after ASCT. Study design and methods This was a retrospective cohort study including individuals referred for ASCT. Cryopreservation was conducted at a single processing facility between 2014 and 2019, and patients received clinical care at six transplant centers. Covariates and outcome data were retrieved from participants' records. Results The study population comprised 619 patients (345 [55.7%] male). Median age was 53 years. Multiple myeloma was the most common diagnosis (62.7%). Higher preapheresis CD34+ cell count, lower nucleated cell (NC) concentration per cryobag, and composition of the cryoprotectant solution (5% dimethyl sulfoxide [DMSO] and 6% hydroxyethyl starch) were statistically significantly associated with higher postthawing cell viability. The linear regression model for time to neutrophil and platelet engraftment included the infused CD34+ cell dose and the composition of the cryoprotectant solution. Patients who had PBSC cryopreserved using 10% DMSO solution presented six times higher odds (odds ratio [OR] = 6.9; 95% confidence interval [CI]: 2.2-21.1; p = .001) of delayed neutrophil engraftment (>14 days) and two times higher odds (OR = 2.3, 95%CI: 1.4-3.7; p = .001) of prolonged hospitalization (>18 days). Discussion The study showed that mobilization efficacy, NC concentration, and the composition of the cryoprotectant solution significantly affected postthawing cell viability. In addition, the composition of the cryoprotectant solution significantly impacted engraftment outcomes and time of hospitalization after ASCT.

Single nucleotide polymorphisms (SNPs) of BCL11A gene and HBS1L-MYB intergenic region (named HMIP-2) affect both fetal hemoglobin (HbF) concentration and clinical outcomes in patients with sickle cell anemia (SCA). However, no previous study has examined the interaction among these SNPs in the regulation of HbF. We examined whether HbF-boosting haplotypes combining alleles of functional SNPs of BCL11A and HMIP-2 were associated with clinical outcomes and hematological parameters, and whether they interact to regulate HbF in a cohort of Brazilian children with SCA. The minor haplotype of BCL11A ("TCA", an allele combination of rs1427407, rs766432, and rs4671393) was associated with higher HbF, hemoglobin and lower reticulocytes count compared to reference haplotype "GAG". The minor haplotype of HMIP-2 ("CGC", an allele combination of rs9399137, rs4895441, and rs9494145) was associated with higher HbF and hemoglobin compared to reference haplotype "TAT". Subjects carrying minor haplotypes showed reduced rate of clinical complications compared to reference haplotypes. Non-carriers of both minor haplotypes for BCL11A and HMIP-2 showed the lowest HbF concentration. Subjects carrying only the minor haplotype of BCL11A showed significantly higher HbF concentration than non-carriers of any minor haplotype, which showed no significant difference compared to subjects carrying only the minor haplotype of HMIP-2. Interestingly, subjects carrying both minor haplotypes of BCL11A ("TCA") and HMIP-2 ("CGC") showed significantly higher HbF levels than subjects carrying only the minor haplotype of BCL11A. Our novel findings suggest that HbF-boosting haplotypes of BCL11A and HMIP-2 can predict clinical outcomes and may interact to regulate HbF in patients with SCA.

BACKGROUND AND OBJECTIVES: Incidence in first-time and repeat blood donors is an important measure of transfusion-transmitted HIV infection (TT-HIV) risk. This study assessed HIV incidence over time at four large blood centers in Brazil. MATERIALS AND METHODS: Donations were screened and confirmed using serological assays for HIV from 2007 – 2016, and additionally screened by nucleic acid testing from 2011 forward. Limiting antigen (LAg) avidity testing was conducted on HIV seroreactive samples from first-time donors to classify whether an infection was recently acquired. We calculated incidence in first-time donors using the mean duration of recent infection and in repeat donors using classical methods. Time and demographic trends were assessed using Poisson regression. RESULTS: Over the 10-year period, HIV incidence in first-time donors was highest in Recife (45.1/100,000 person–years (10(5) py)) followed by São Paulo (32.2/10(5) py) and then Belo Horizonte (23.3/10(5) py), and in repeat donors was highest in Recife (33.2/10(5) py), Belo Horizonte (27.5/10(5) py) and São Paulo (17.0/10(5) py). Results from Rio de Janeiro were available from 2013 to 2016 with incidence in first time donors of 35.9/10(5) py and repeat donors from 2011 to 2016 of 29.2/10(5) py. Incidence varied by other donor demographics. When incidence was considered in 2-year intervals, no significant trend was evident. Overall residual risk of TT-HIV was 5.46 and 7.41 per million units of pRBC and FFP transfused, respectively. CONCLUSION: HIV incidence in both first-time and repeat donors varied by region in Brazil. Clear secular trends were not evident.

We described the clinical, laboratory and molecular characteristics of individuals with Hb S (HBB: c.20A>T)/β-thalassemia (Hb S/β-thal) participating in the Recipient Epidemiology and Donor Evaluation Study (REDS-III) Brazil Sickle Cell Disease cohort. HBB gene sequencing was performed to genotype each β-thal mutation. Patients were classified as Hb S/β0-thal, Hb S/β+-thal-severe or Hb S/β+-thal based on prior literature and databases of hemoglobin (Hb) variants. Characteristics of patients with each β-thal mutation were described and the clinical profile of patients grouped into Hb S/β0-thal, Hb S/β+-thal and Hb S/β+-thal-severe were compared. Of the 2793 patients enrolled, 84 (3.0%) had Hb S/β0-thal and 83 (3.0%) had Hb S/β+-thal; 40/83 (48.2%) patients with Hb S/β+-thal had mutations defined as severe. We identified 19 different β-thal mutations, eight Hb S/β0-thal, three Hb S/β+-thal-severe and eight Hb S/β+-thal. The most frequent β0 and β+ mutations were codon 39 (HBB: c.118C>T) and IVS-I-6 (T>C) (HBB: c.92+6T>C), respectively. Individuals with Hb S/β0-thal had a similar clinical and laboratory phenotype when compared to those with Hb S/β+-thal-severe. Individuals with Hb S/β+-thal-severe had significantly lower total Hb and Hb A levels and higher Hb S, white blood cell (WBC) count, platelets and hemolysis markers when compared to those with Hb S/β+-thal. Likewise, individuals with Hb S/β+-thal-severe showed a significantly higher occurrence of hospitalizations, vaso-occlusive events (VOE), acute chest syndrome (ACS), splenic sequestration, blood utilization, and hydroxyurea (HU) therapy.

Aim Chronic kidney disease (CKD) has a significant impact on sickle cell disease (SCD) morbidity and mortality. Early identification of individuals at highest risk of developing CKD may allow therapeutic intervention to prevent worse outcomes. This study aimed to evaluate the prevalence and risk factor for CKD among adults with SCD in Brazil. Methods Participants in the REDS-III multicenter SCD cohort with more severe genotypes [sickle cell anemia (SCA) = hemoglobin (Hb) SS, Hb Sβ0-thalassemia, Hb Sβ+-thalassemia with mutations associated with severe phenotype] aged ≥18 years at time of enrollment with at least two serum creatinine values were analyzed. Participants were enrolled between 2013-2015 and were prospectively followed and monitored for the occurrence of clinical complication, including death, for up to three years. The estimated glomerular filtration rate (eGFR) was calculated using the JSCCS-GFR Equation. The CKD stage was defined according to the K/DOQI. For participants with multiple eGFR measures, we use the two most recent values to define CKD; for those who presented different CKD stages, we used the mean value to define the outcome. Because albuminuria status was not known in all participants, those with CKD stage 2 or higher were compared to those with eGFR≥90. The association among the characteristics and the presence of CKD stage 2 or higher were assessed using binary logistic regression model. Results 497 (65.7%) participants were receiving hydroxyurea (HU) therapy, 105 (13.9%) were treated with chronic blood transfusion (CBT), and 69 (9.1%) were under both therapies. Among the 756 participants, 569 (75.3%) had eGFR≥90, 175 (23.1%) had stage-2, six (0.79%) had stage-3, and six (0.79%) had ESRD. Participants with CKD stage 2 or higher were significantly older and predominantly male when compared with those with eGFR≥90. There was no association between CKD stage 2 or higher and HU or CBT. Participants with CKD stage 2 or higher had a 2.3 (95%CI: 1.4–3.7) times higher odds for death when compared to those with eGFR≥90. Male sex (OR: 34.7; 95%CI: 20.3–62.5), higher age (OR: 1.03; 95%CI: 1.01–1.05), higher diastolic blood pressure (OR: 1.03; 95%CI: 1.002–1.05), lower Hb (OR: 0.704; 95%CI: 0.59–0.83), and lower reticulocytes (OR: 0.91; 95%CI: 0.86–0.96) levels were significantly associated with stage 2 or higher in the final multivariate model. Discussion We observed a higher odds for mortality in participants with CKD stage 2 or higher when compared to those with eGFR≥90. This highlights the importance of early detection and implementation of preventative therapies. We also observed a significant independent association between lower levels of Hb and reticulocytes with CKD stage 2 or higher. These data might reflect a state of hypoproliferative anemia in participants with CKD stage 2 or higher likely due to deficiency of erythropoietin. In this study, CKD stage 2 or higher was more prevalent in men than in women, and male sex was the strongest independent predictor of CKD stage 2 or higher in the final model. This finding might be used to target individuals at highest risk for CKD in prevention campaigns. Conclusion CKD stage 2 or higher was observed in one-quarter of adults with SCA. Older age, male sex, higher diastolic blood pressure, lower hemoglobin, and lower reticulocytes levels were significantly associated with occurrence of CKD stage 2 or higher, which, in turn, significantly increased the risk of mortality.

A hemoglobina fetal (HbF) é uma das mais importantes moduladoras do fenótipo da anemia falciforme (AF) por inibir a polimerização da HbS, mecanismo molecular primário na cascata de eventos fisiopatológicos da AF. Polimorfismos no íntron 2 do gene BCL11A e na região intergênica situada entre os genes HBS1L e MYB (nomeada HMIP) têm sido associados à regulação da HbF. Porém, a combinação de alelos em haplótipos fornece maior poder em estudos de associação. Nosso objetivo foi examinar a associação de haplótipos de BCL11A e HMIP-2 e interação entre estes loci na predição de desfechos clínicos e hematológicos AF. A amostra foi composta por uma coorte de 220 crianças não aparentadas com AF acompanhadas no hemocentro de Belo Horizonte da Fundação HEMOMINAS. Nós realizamos anotação funcional de polimorfismos de nucleotídeo único (SNPs) de BCL11A e HMIP-2, previamente associados à concentração elevada de HbF, e combinamos alelos de SNPs funcionais em haplótipos. Comparado ao haplótipo referência (“GAG”), o haplótipo que combina os alelos alterados de BCL11A (“TCA”dos SNPs rs1427407, rs766432 e rs4671393, respectivamente) foi associado com maior concentração de HbF (p 0,05). Interessante destacar que os portadores de ambos os haplótipos alterados (“TCA”e “CGC”de BCL11A e HMIP-2, respectivamente) apresentaram concentração de HbF significativamente maior (21,73% ± 1,71) que os portadores apenas do haplótipo alterado (“TCA”) de BCL11A (p = 0,0058). BCL11A e MYB participam diretamente da via de regulação da HbF. Nossos resultados mostram que haplótipos alterados de BCL11A (“TCA”) e HMIP-2 (“CGC”) foram associados com maior concentração de HbF e com menor gravidade clínica em crianças com AF e podem constituir ferramenta relevante de predição de risco da AF. A combinação de haplótipos sugere que os loci BCL11A e HMIP-2 interagem de maneira epistática na regulação da HbF.

Introdução: As úlceras de perna (UP) na doença falciforme (DF) são relativamente comuns, dolorosas e persistentes. A microbiota presente em UP de indivíduos com DF não é conhecida. Objetivo: descreve a microbiota da UP em pacientes com DF e comparar com a microbiota presente na pele integra. Métodos: De junho de 2017 a abril de 2019, 87 pacientes HbSS do Hemocentro de Belo Horizonte (Fundação Hemominas) e 30 participantes saudáveis foram inscritos, pareados por sexo e idade. Quatro grupos de amostras foram obtidas: caso 1 - UP; caso 2 - pele íntegra de pacientes com UP; controle 1 - pele íntegra de pacientes com DF e sem histórico de UP; e controle 2 - pele íntegra de participantes sem DF e sem histórico de outras doenças crônicas. O DNA bacteriano foi extraído utilizando o FastDNA™ Spin Kit (MP Biomedicals) e a amplificação do domínio V4 do gene 16S RNAr foi realizada. As amostras foram quantificadas com o fluorímetro Qubit®2.0 (InvitrogenTM) e a biblioteca foi realizada pelo Ion Chef System. O sequenciamento conduzido pela plataforma Ion Torrent e as sequências analisadas pelo QIIME 2. As métricas das diversidades alfa (OTUs, uniformidade de Pielou, Shannon, Simpson, Chao1 e diversidade filogenética de Faith) e beta (Jaccard, Bray-Curtis, UniFrac não ponderada e UniFrac ponderada) foram estimadas por Kruskal-Wallis e PERMANOVA, respectivamente. Além disso, realizou-se análise de abundância diferencial (ANCOM). Resultados: Foram sequenciadas 84 amostras, sendo 22 amostras de UP, 17 de pele íntegra de pacientes com UP, 23 de pele íntegra de paciente HbSS sem história de UP e 22 de pele íntegra do participante sem DF e outras doenças crônicas. Diferenças estatísticas foram encontradas entre amostras dos diferentes grupos para a diversidade alfa (p < 0,05), com exceção das amostras de pele íntegra dos pacientes DF com UP e sem UP. A diversidade pelo índice de Pielou não apresentou diferenças estatisticamente significativas entre os grupos de pele íntegra. Na diversidade beta, diferenças estatísticas foram observadas (p < 0,05), exceto na comparação da pele íntegra dos pacientes com UP e a dos pacientes sem história de UP pelo índice de Unifrac ponderada. Dos 38 filos de bactérias identificados, os de maior abundância foram Proteobacteria, Firmicutes e Actinobacteria. Na comparação entre as peles íntegras, diferenças significativas foram encontradas na abundância do filo OP3 (p = 0,01890; p = 0,04890) para a pele íntegra dos pacientes com e sem UP e entre a pele íntegra dos pacientes sem UP e dos controles sem história de doenças crônicas, respectivamente. As diferenças também foram observadas nas abundâncias dos filos FBP (p = 0,01560), Nitrospirae (p = 0,00799) e SBR1093 (p = 0,00697) para a pele íntegra dos pacientes com UP e dos sem histórico de doenças crônicas. A espécie Kocuria palustris apresentou maior abundância nas UP (86%). Discussão: O microbioma contribui no equilíbrio da saúde humana e são raros os estudo que o correlacionam com as úlceras de perna na AF. Houve diferenças significativas na microbioma presente na LU e pele íntegra, sugerindo que a microbiota pode contribuir para a persistência da ferida, podendo ser alvo de tratamentos. Conclusão: Nosso estudo mostrou diferenças na diversidade microbiana das UP quando comparada com a pele íntegra. Além disso, descreveu-se pela primeira vez maior abundância da espécie Kocuria palustris na UP, sugerindo associação com a persistência da ferida.

Introdução: O transplante de medula óssea (TMO) autólogo é uma modalidade de tratamento para vários tipos de doença. A predição do sucesso na mobilização pode ser útil para otimizar a coleta de células progenitoras hematopoéticas (CPH). O objetivo foi identificar características que podem influenciar a eficácia da mobilização e criar um modelo de predição de sucesso da mobilização em candidatos ao TMO do estado de Minas Gerais. Materiais e métodos: Tratou-se de estudo retrospectivo, sendo que foram analisados dados dos pacientes candidatos ao TMO autólogo entre 09/2015 e 12/2019. Os participantes foram assistidos em cinco hospitais e os procedimentos laboratoriais foram realizados no Centro de Processamento Celular (CPC) do Cetebio/Fundação Hemominas. Os prontuários dos participantes foram revistos para obtenção das seguintes informações: sexo, idade, peso, diagnóstico, esquema de mobilização, ciclo de mobilização, número de esquemas prévios de quimioterapia, radioterapia prévia e sorologia positiva. Os dados laboratoriais analisados foram contagem de células CD34+ e o hemograma da amostra de sangue periférico (SP) pré-coleta. A contagem de células CD34+ foi realizada usando o protocolo ISHAGE. O hemograma foi realizado utilizando contador automatizado (SYSMEX XN-1000 AS-01). O desfecho estudado, mobilização boa, foi definido como a contagem de células CD34+ viáveis ≥ 20/uL no SP. A regressão logística foi usada para determinar o efeito independente de cada covariável no desfecho estudado. Resultados: a população do estudo consistiu em 559 pacientes, sendo 297 (53,1%) do sexo masculino. A mediana de idade foi 54 (20) anos. O mieloma múltiplo foi o diagnóstico mais comum (n = 323; 57,8%), seguido de linfoma não Hodgkin (n = 106; 19%) e linfoma de Hodgkin (n = 100; 17,9%). Dos 559 participantes, 321 (57,4%) eram bons mobilizadores. Das variáveis laboratoriais, a viabilidade das células CD34+ (OR = 1,2; IC95%: 1,11-1,30; p < 0,001), o VCM (OR = 0,92; IC95%:0,87-0,95; p < 0,001), o nRBC (OR = 3006,5; IC95%: 42,1-214.711,3; p < 0,001) e a contagem de granulócitos imaturos (OR = 1,43; IC95%: 1,30-1,57; p < 0,001) foram significativamente associadas à mobilização boa no modelo multivariado. Além disso, os participantes com diagnóstico de mieloma múltiplo apresentaram chance 2,8 vezes (OR = 2,82; IC95%: 1,76-4,5; p < 0,001) maior de serem bons mobilizadores se comparado aos pacientes com linfoma. Participantes que realizaram a coleta no primeiro ciclo de mobilização apresentaram chance 3,6 vezes (OR = 3,63; IC95%: 1,59-8,28; p = 0,002) maior de serem bons mobilizadores. Discussão: O CPC do Cetebio atende nove centros transplantadores. Os centros que realizam a coleta das CPH estão localizados entre 40 a 568 km de distância do Cetebio (local de quantificação de células CD34+). A predição do desfecho da mobilização pode permitir a adoção de medidas complementares como, por exemplo, o uso de plerixafor. Além disso, permitiria otimizar a coleta de CPH por aférese. Assim, seria possível evitar dias adicionais de coleta, reduzindo custos e riscos relacionados à administração de doses adicionais de G-CSF, manutenção de cateter e internação hospitalar prolongada. Conclusão: O sucesso na mobilização foi maior nos participantes que fizeram o primeiro ciclo de mobilização e que apresentavam diagnóstico de mieloma múltiplo. Além disso, níveis maiores de nRBC, granulócitos imaturos e viabilidade das células CD34+, bem como níveis menores de VCM foram associados ao sucesso na mobilização.

Manifestations of sickle cell disease (SCD) begin early in childhood and cause morbidity and decreased life expectancy. Hematopoietic stem cell transplantation (HSCT) is curative but associated with risk of mortality attributable to the transplant. This risk should be counterbalanced with SCD morbidity and mortality. A severity score using a Bayesian network model was previously validated to predict the risk of death in adult individuals with SCD. The objective of this study is to calculate the severity scores of participants in a multicenter cohort of Brazilians with SCD, using a previously published Bayesian network-derived score, associated with risk of death and then compare the severity scores between participants with and without an indication for HSCT as defined by the Brazilian Ministry of Health (MoH) criteria. This is an observational, retrospective study. We analyzed 2063 individuals with sickle cell anemia from the Recipient Epidemiology and Donor Evaluation Study-III Brazil SCD cohort and applied a Bayesian network-derived score to compare candidates and non-candidates for HSCT according to the Brazilian MoH transplant criteria. Classical statistical methods were used to analyze data and make comparisons. We compared severity scores between cohort members with (n = 431) and without (n = 1632) HSCT indications according to Brazilian MoH. Scores were not different in adult participants with ≥1 HSCT indication when compared to those with no indication (mean 0.342 versus 0.292; median 0.194 versus 0.183, P = .354) and receiver operating characteristic curves did not demonstrate an obvious threshold to differentiate participants with or without HSCT indications. Severity score may predict risk of death but does not differentiate HSCT candidates. Current indications should be evaluated to ensure that patients with more severe disease who might benefit from HSCT are appropriately identified.

Background Lifelong glucocorticoid (GC) replacement is the mainstay treatment of congenital adrenal hyperplasia (CAH) due to classic 21-hydroxylase deficiency (21-OHD). Challenges posed by therapeutic management of these patients are well known, but novel insights into the variability in clinical response to GC highlight a role for single nucleotide polymorphisms (SNPs) of the glucocorticoid receptor gene (NR3C1). Aim To assess whether six commonly studied NR3C1 SNPs, which were previously associated with modified response to GC, are associated with CAH. We further assessed the linkage disequilibrium (LD) among these NR3C1 SNPs and their combination into haplotypes. Methods Genotypes were determined by Taqman allele discrimination assays for Tth111I (rs10052957), ER22 (rs6189), 23 EK (rs6190), N363S (rs56149945), BclI (rs41423247) and 9β (rs6198) in a Brazilian cohort of 102 unrelated 21-OHD patients and 163 unrelated healthy subjects (controls). Haplotypes were estimated using Haplo.stats, and LD among SNPs using Haploview. Results Heterozygous subjects for Tth111I were more frequent in 21-OHD patients (P = 0.004), while heterozygous for BclI were more frequent in controls (P = 0.049). We found a strong LD among the six NR3C1 SNPs, and four out of six common haplotypes contained the Tth111I-variant. Although we found no significant differences in overall haplotype analysis, the BclI-haplotype was less frequent among 21-OHD patients (P = 0.0180). Conclusions BclI-haplotype was less common and heterozygous for Tth111I were more frequent in 21-OHD patients, while heterozygous for BclI were more frequent in controls. Our novel findings may contribute to further clinical studies on the prognostic value of NR3C1 haplotypes towards individualized treatment for 21-OHD patients.

Introduction Priapism is the persistent and painful erection of the penis and is a common sickle cell disease (SCD) complication. Aim The goal of this study was to characterize clinical and genetic factors associated with priapism within a large multi-center SCD cohort in Brazil. Methods Cases with priapism were compared to SCD type-matched controls within defined age strata to identify clinical outcomes associated with priapism. Whole blood single nucleotide polymorphism genotyping was performed using a customized array, and a genome-wide association study (GWAS) was conducted to identify single nucleotide polymorphisms associated with priapism. Main Outcome Measure Of the 1,314 male patients in the cohort, 188 experienced priapism (14.3%). Results Priapism was more common among older patients (P = .006) and more severe SCD genotypes such as homozygous SS (P < .0001). In the genotype- and age-matched analyses, associations with priapism were found for pulmonary hypertension (P = .05) and avascular necrosis (P = .01). The GWAS suggested replication of a previously reported candidate gene association of priapism for the gene transforming growth factor beta receptor 3 (TGFBR3) (P = 2 × 10−4). Clinical Implications Older patients with more severe genotypes are at higher risk of priapism, and there is a lack of consensus on standard treatment strategies for priapism in SCD. Strengths & Limitations This study characterizes SCD patients with any history of priapism from a large multi-center cohort. Replication of the GWAS in an independent cohort is required to validate the results. Conclusion These findings extend the understanding of risk factors associated with priapism in SCD and identify genetic markers to be investigated in future studies to further elucidate priapism pathophysiology.

One of the major chronic complications of sickle cell disease (SCD) is sickle cell nephropathy. The aim of this review is to discuss the pathophysiology, natural history, clinical manifestations, risk factors, biomarkers and therapeutic approaches for sickle cell nephropathy, focusing on studies with pediatric patients. The earliest manifestation of renal disease is an increase in the glomerular filtration rate. A finding that may also be observed in early childhood is microalbuminuria. Nephrin, KIM-1, VGFs, chemokines and renin-angiotensin system molecules have emerged as potential early markers of renal dysfunction in SCD. In regards to a therapeutic approach, renin-angiotensin system inhibitors and angiotensin receptor blockers seem to be effective for the control of albuminuria in adults with SCD, although new studies in children are needed. The precise moment to begin renoprotection in SCD patients who should be treated remains to be determined.

Background: Congenital Anomalies of the Kidney and the Urinary Tract (CAKUT) are defined as a heterogeneous group of anomalies that resulted from defects in kidney and urinary tract embryogenesis. CAKUT have a complex etiology. Genetic, epigenetic and environmental factors have been investigated in this context. Angiotensin II is a potent vasoconstrictor and exerts an important role in kidney embryogenesis. The angiotensin-converting enzyme (ACE) converts Angiotensin I into Angiotensin II and ACE gene has insertion/deletion (I/D) polymorphisms that have been evaluated in several nephropathies. This study aimed to evaluate whether the I/D polymorphisms of ACE gene are associated with any CAKUT phenotype or CAKUT in general. Methods and Results: Our study was performed with 225 pediatric patients diagnosed with CAKUT and 210 age-and-sex matched healthy controls. ACE I/D alleles were analysed by real-time polymerase chain reaction (RT-PCR). The distribution of ACE I/D polymorphisms were compared between CAKUT patients and healthy controls, as well between ureteropelvic junction obstruction (UPJO), vesicoureteral reflux (VUR), multicystic dysplastic kidney (MCDK) phenotypes and control group. No statistical association of ACE I/D genotypes and allelic frequency between patients and controls was found among general CAKUT and UPJO, VUR and MCDK phenotypes. Conclusion: Although CAKUT is a complex disease and the ACE gene may exert a role in kidney embryogenesis, CAKUT was not associated with any ACE I/D polymorphisms in this Brazilian pediatric population.

Fetal Hemoglobin (HbF) is a major modifier of clinical events in patients with sickle cell anemia (SCA). Hydroxyurea (HU) improves their clinical course by raising HbF level. There is variability in the response to HU treatment among SCA patients. Genome-wide association studies (GWAS) have identified the BCL11A gene and HBS1L-MYB intergenic region (HMIP-2) as the main regulators of baseline HbF production, and polymorphisms in both loci have been associated with HbF levels. However, it is unknown whether genetic polymorphisms involved in regulation of baseline HbF can modulate HbF in response to HU treatment. Therefore, we examined whether polymorphisms in BCL11A (rs11886868, rs766432, rs4671393, rs1427407, rs7557939 and rs7599488) and HMIP-2 (rs9399137, rs9402686, rs4895441 and rs9494145) were associated with HbF changes in a retrospective cohort of 110 pediatric patients diagnosed with SCA (HbSS) by the Newborn Screening Program of Minas Gerais, and followed up at Center of Hematology and Hemotherapy of Minas Gerais (HEMOMINAS), Belo Horizonte. Participants have been on HU treatment for at least one year. We assessed “delta HbF”for each patient as the “final HbF relative concentration”(last available test during HU treatment and at least three months after blood transfusion) “minus baseline HbF”(last available test before HU treatment and after the age of 5 years, and at least 3 months after blood transfusion). Genotypes were assessed by Taqman assays and real-time PCR or PCR-RFLP. Univariate associations were performed using Mann-Whitney U Test. For the 110 enrolled SCA patients (59/53.6% were females), we calculated the average age at start of HU (10.0±2.8 years), average HU dose (24.40±4.41 mg/kg/day) and the average HU treatment time (4.23±2.01 years). Mean of baseline HbF was 12.01±6.05% and final HbF concentration 18.97±8.75%. While we found no significant differences at final HbF or delta HbF among genotypes of HMIP-2 polymorphisms, carriers of the minor alleles of rs9402686, rs4895441 and rs9494145 showed higher baseline HbF when compared to wild-type homozygous patients (all p 0.05). Moreover, carriers of the minor allele T (GT or TT genotypes) of rs1427407 showed higher baseline HbF (p = 0.002) and delta HbF (p = 0.049) when compared to GG homozygous patients. Similarly, carriers of the minor allele C (AC or CC genotypes) of rs766432 showed higher delta HbF when compared to AA homozygous patients (p = 0.009). Finally, carriers of the minor allele T (CT or TT genotypes) of rs7599488 showed higher final HbF (p = 0.003) and delta HbF (p = 0.002) when compared to CC homozygous patients. BCL11A is a negative regulator of HbF expression. BCL11A polymorphisms were associated with increased HbF after HU treatment in pediatric patients with SCA, suggesting they modulate HbF levels in response to HU. Understanding genetic factors underlying HU response may clarify the interpatient variability on HbF induction upon HU treatment and help to guide therapy.

Background The collapsing variant of focal segmental glomerulosclerosis (FSGS) is the most aggressive form of FSGS and is characterized by at least one glomerulus with segmental or global collapse and overlying podocyte hypertrophy and hyperplasia. Viruses can act as aetiological agents of secondary FSGS. This study aims to establish an aetiological link between dengue virus (DENV) infection and the collapsing variant of FSGS and to analyse possible influences of the apolipoprotein 1 (APOL1) gene risk alleles on the disease. Methods Biopsies and medical records were gathered from 700 patients of the Instituto de Nefropatologia, Belo Horizonte, Brazil. Screening for the collapsing variant of FSGS was performed and serological, immunohistochemical, tissue polymerase chain reaction (PCR) and genetic analysis were conducted. Results Eight patients were identified with positive DENV serology and negative serological and/or tissue markers for hepatitis B virus, hepatitis C virus, Epstein–Barr virus, human immunodeficiency virus, cytomegalovirus and parvovirus B19. In PCR analysis, six patients had positive markers for DENV strain genetic material, one patient had positive markers for co-infection of Zika virus (ZIKV) and DENV and one patient had positive markers only for ZIKV infection. Six of the eight patients did not show risk alleles of the APOL1 gene. One patient had only one risk allele (G1) and the sample from another did not contain enough DNA for genetic analysis to be performed. Conclusions This study provided strong evidence that DENV can infect renal tissue and possibly functions as a second hit to the development of the collapsing variant of FSGS. Nonetheless, this study also highlights the possible implication of ZIKV infection in FSGS and supports the argument that risk alleles of the APOL1 gene may not be implicated in the susceptibility to FSGS in these patients.

Objectives: Hemoglobin SC is the second most common variant of sickle‐cell disease worldwide, after hemoglobin SS. The objectives of the study were to describe the clinical and laboratory characteristics of hemoglobin SC disease in children from a newborn screening program and treated at a blood center. Methodology: This study assessed a cohort of 461 infants born between 01/01/1999 and 12/31/2012 and followed‐up until 12/31/2014. Clinical events were expressed as rates for 100 patient‐years, with 95% confidence intervals. Kaplan–Meier survival curves were created. Results: The median age of patients was 9.2 years; 47.5% were female. Mean values of blood tests were: hemoglobin, 10.5 g/dL; reticulocytes, 3.4%; white blood cells, 11.24 × 109/L; platelets, 337.1 × 109/L; and fetal hemoglobin, 6.3%. Clinical events: acute splenic sequestration in 14.8%, blood transfusion 23.4%, overt stroke in 0.2%. The incidence of painful vaso‐occlusive episodes was 51 (48.9–53.4) per 100 patient‐years and that of infections, 62.2 episodes (59.8–64.8) per 100 patient‐years. Transcranial Doppler ultrasonography (n = 71) was normal given the current reference values for SS patients. Hydroxyurea was given to ten children, all of whom improvement of painful crises. Retinopathy was observed in 20.3% of 59 children who underwent ophthalmoscopy. Avascular necrosis was detected in seven of 12 patients evaluated, predominantly in the left femur. Echocardiogram compatible with pulmonary hypertension was recorded in 4.6% of 130 children, with an estimated average systolic pulmonary artery pressure of 33.5 mmHg. The mortality rate from all causes was 4.3%. Conclusions: Clinical severity is variable in SC hemoglobinopathy. Several children have severe manifestations similar to those with SS disease. Resumo: Objetivos: A hemoglobinopatia SC é a segunda variante mais comum da doença falciforme no mundo, após a hemoglobinopatia SS. Os objetivos do estudo foram descrever as características clínicas e laboratoriais da hemoglobinopatia SC em recém‐nascidos diagnosticados por programa de triagem neonatal e encaminhados para acompanhamento em hemocentro. Metodologia: Coorte de 461 recém‐nascidos SC nascidos entre 01/01/1999 e 31/12/2012 e seguidos até 31/12/2014. A incidência de eventos clínicos foi expressa por taxas relativas a 100 pacientes‐ano, com limites de confiança a 95%. Curvas de sobrevida foram construídas segundo Kaplan‐Meier. Resultados: Mediana de idade, 9,2 anos; 47,5%, feminino. Médias dos valores hematológicos: hemoglobina 10,5 g/dL; reticulócitos 3,4%; leucometria 11,24 x 109/L; plaquetometria 337,1x109/L; hemoglobina fetal 6,3%. Eventos clínicos: sequestro esplênico agudo em 14,8%, hemotransfusão 23,4%, AVC isquêmico 0,2%. A incidência de episódios vaso‐oclusivos dolorosos foi de 51 (48,9‐53,4) por 100 pacientes‐ano; a de infecções, 62,2 episódios (59,8‐64,8) por 100 pacientes‐ano. Doppler transcraniano (n = 71) foi normal, se usados os valores de referência de crianças SS. Dez pacientes usaram hidroxiureia, todos com melhoria das crises dolorosas. Retinopatia foi observada em 20,3% das 59 crianças que fizeram fundoscopia. Necrose avascular foi detectada em 7 de 12 pacientes avaliados, com predomínio no fêmur esquerdo. Ecocardiograma compatível com hipertensão pulmonar foi registrado em 4,6% de 130 crianças, com média estimada de 33,5 mm Hg de pressão arterial pulmonar. A taxa de mortalidade por todas as causas foi de 4,3%. Conclusões: A hemoglobinopatia SC tem gravidade variável; várias crianças apresentam manifestações clínicas intensas, semelhantes às da hemoglobinopatia SS. Keywords: Sickle‐cell disease, Hemoglobinopathy SC, Children, Neonatal screening, Survival, Treatment, Palavras‐chave: Doença falciforme, Hemoglobinopatia SC, Criança, Triagem neonatal, Sobrevida, Tratamento

Cerebrovascular disease, particularly stroke, is one of the most severe clinical complications associated with sickle cell disease and is a significant cause of morbidity in both children and adults. Over the past two decades, considerable advances have been made in the understanding of its natural history and enabled early identification and treatment of children at the highest risk. Transcranial Doppler screening and regular blood transfusions have markedly reduced the risk of stroke in children. However, transcranial Doppler has a limited positive predictive value and the pathophysiology of cerebrovascular disease is not completely understood. In this review, we will focus on the current state of knowledge about risk factors associated with ischemic stroke in patients with sickle cell disease. A search of PubMed was performed to identify studies. Full texts of the included articles were reviewed and data were summarized in a table. The coinheritance of alpha-thalassemia plays a protective role against ischemic stroke. The influence of other genetic risk factors is controversial, still preliminary, and requires confirmatory studies. Recent advances have established the reticulocyte count as the most important laboratory risk factor. Clinical features associated with acute hypoxemia as well as silent infarcts seem to influence the development of strokes in children. However, transcranial Doppler remains the only available clinical prognostic tool to have been validated. If our understanding of the many risk factors associated with stroke advances further, it may be possible to develop useful tools to detect patients at the highest risk early, improving the selection of children requiring intensification therapy. Keywords: Sickle cell disease, Cerebrovascular disease, Stroke, Risk factors, Transcranial Doppler ultrasonography

Introducao Devido a pandemia do novo Coronavirus, a criopreservacao tem sido recomendada para garantir a continuidade do transplante de medula ossea (TMO) alogenico nao aparentado independentemente da fonte de celulas. Porem, a criopreservacao de celulas progenitoras hematopoeticas coletadas por puncao aspirativa da medula ossea (CPH,MO) e menos utilizada e poucos dados estao disponiveis na literatura. Objetivo descrever a experiencia do Centro de Processamento Celular do Cetebio/Fundacao Hemominas com a criopreservacao de CPH,MO para utilizacao terapeutica em TMO. Metodos Trata-se de um estudo do tipo serie de casos e a casuistica foi composta por oito unidades de CPH,MO criopreservadas entre 10/2020 e 06/2021. As unidades de CPH,MO foram submetidas a deseritrocitacao utilizando hidroxietilamido (HES) 450/0,7 e, em seguida, a centrifugacao para desplasmatizacao. O volume da camada leucocitaria foi ajustado para atingir a concentracao de celulas nucleadas final ≤2 × 108 NC/mL apos a adicao da solucao de criopreservacao (5%HES/5%DMSO). As unidades foram congeladas em freezer mecânico a -80°C e armazenadas em tanque a vapor de nitrogenio. Resultados oito unidades de CPH,MO foram criopreservadas para utilizacao em nove pacientes; uma unidade foi dividida para uso em dois pacientes pediatricos irmaos HLA identicos. Uma (11,1%) unidade foi criopreservada para o uso autologo e oito (88,9%) para uso alogenico nao aparentado. Cinco (55,6%) pacientes eram do sexo masculino. A media de idade dos pacientes foi 14,7 ± 19,1 anos (1–42). Um (11,1%) paciente possuia neuroblastoma, um (11,1%) LMC, um (11,1%) LMA, um (11,1%) sindrome de Griscelli, dois (22,2%) sindrome de Wiskott-Aldrich e tres (33,3%) LLA. O volume (mL) medio das unidades pre e pos-processamento foi 756,9 ± 411,7 e 78,7 ± 45,8, respectivamente. O volume (mL) medio de hemacias pre e pos-processamento foi 239,1 ± 150,8 e 27,02 ± 16,9, respectivamente. A media do total de celulas nucleadas (x108) pre e pos-processamento foi 153,07 ± 80,0 e 120,01 ± 67,7, respectivamente. A media de celulas CD34+ viaveis (x106) pre e pos-processamento foi 131,7 ± 74,0 e 120,2 ± 77,8, respectivamente. Quatro (50%) unidades apresentaram teste microbiologico positivo (Staphylococcus hominis, Staphylococcus epidermidis, Corynebacterium sp e Staphylococcus aureus). A viabilidade celular (%) media pos-descongelamento em amostras de segmento foi 66,1 ± 8,5. Os ensaios clonogenicos realizados em amostras pre-processamento (n = 6), pos-processamento (n = 8) e pos-descongelamento (n = 7) apresentaram crescimento positivo. Seis (66,6%) unidades foram liberadas para uso terapeutico, das quais cinco (83,3%) possuimos os dados da enxertia. Nenhum paciente apresentou falha de enxertia ou obito apos a infusao. O tempo medio de enxertia de granulocitos e plaquetas foi 17 ± 5,8 e 19,5 ± 9,2 dias, respectivamente. Discussao A reducao do volume possibilitou a criopreservacao do material, sendo que a recuperacao celular foi satisfatoria. Os testes de controle de qualidade realizados em todas etapas do processo evidenciaram a qualidade e seguranca do procedimento e foram corroborados pelos dados de enxertia. Alertamos, entretanto, sobre a necessidade de cuidados adicionais com os pacientes devido ao volume de hemacias a ser infundido e a contaminacao bacteriana, mais frequentemente observada nas unidades de CPH,MO. Conclusoes A criopreservacao CPH, MO apresentou resultados satisfatorios, demonstrando que a metodologia utilizada e segura e eficiente.

Background The etiology of stroke, a severe complication of sickle cell anemia, involves inflammatory processes. However, the pathogenetic mechanisms are unknown. The aim of this study was to evaluate the influence of interleukin-10 polymorphisms and haplotypes on the risk of acute cerebral ischemia and high-risk transcranial Doppler in 395 children with sickle cell anemia from the state of Minas Gerais, Brazil. Methods Interleukin-10 haplotypes were determined by polymerase chain reaction-restriction fragment length polymorphism and sequencing. The outcomes studied were acute cerebral ischemia and high-risk transcranial Doppler. Clinical data were retrieved from the children's records. Results There was no statistically significant difference in the frequencies of polymorphisms and haplotypes between children with and without acute cerebral ischemia or children with or without high-risk transcranial Doppler. These data are consistent with a previous report that showed an absence of association between interleukin-10 plasma levels and high-risk transcranial Doppler velocity in children with sickle cell anemia. Conclusion Interleukin-10 haplotypes were not associated with the risk of acute cerebral ischemia or high-risk transcranial Doppler velocity in children with sickle cell anemia from the state of Minas Gerais, Brazil.

Bipolar Disorder (BD) is a chronic a multifactorial psychiatric illness that affects mood, cognition, and functioning. BD is associated with several psychiatric conditions as well clinical comorbidities, particularly cardiovascular diseases. The neurobiology of BD is complex and multifactorial and several systems have been implicated. Considering that the Renin Angiotensin System (RAS) plays an important role in cardiovascular diseases and that recently evidence has suggested its role in psychiatric disorders, the aim of the present study is to summarize and to discuss recent findings related to the modulation of RAS components in BD. A systematic search of the literature using the electronic databases MEDLINE and LILACS was conducted through March 2019. The search terms were: “Bipolar Disorder”; “Renin Angiotensin System”; “Angiotensin 2”; “Angiotensin receptors”; “Angiotensin 1-7”; “ACE”; “ACE2”; “Mas Receptor”. We included original studies assessing RAS in BD patients. Two hundred twenty-two citations were initially retrieved. Eleven studies were included in our systematic review. In the majority of studies (6 of 8), the ACE insertion/deletion (I/D) polymorphism did not differ between BD patients and controls. BD patients presented higher plasma renin activity in comparison with controls. The studies evaluating the RAS molecules in BD are very scarce and heterogeneous. The literature suggests a potential role of RAS in BD. Further studies are necessary to investigate this relationship.

Background Red blood cell (RBC) transfusions are used in sickle cell disease (SCD) to treat acute complications or as chronic transfusion therapy (CTT) to prevent severe manifestations. The objectives of this study were to describe blood utilization and adverse events (AEs) associated with RBCs in the Brazilian SCD population and compare characteristics of patients treated or not with CTT. Study design and methods A SCD cohort was established at six Brazilian centers. Medical and blood bank records were abstracted for clinical and transfusion history. Two controls not treated with CTT matched on center, SCD genotype, sex, and age were selected for each CTT case within the cohort to compare characteristics between the two groups. Results Most of the 2794-member cohort had received a transfusion (75.0% of children and 89.2% of adults) with 29.2% of patients receiving transfusion in the prior year. There were 170 (10.6%) children and 115 (9.2%) adults treated with CTT. Children not treated with CTT were more likely to have pain and acute chest hospitalizations in the prior year (25.3% vs. 11.9%, p = 0.0003; and 22.0% vs. 10.7%, p = 0.002, respectively). Both iron overload and alloimmunization were more common in CTT cases compared to controls (65.6% vs. 17.0% and 36.2% vs. 15.9%, respectively). A higher proportion of adults treated with CTT demonstrated oxygen saturation of greater than 95% compared to controls not treated (51.1% vs. 39.2%), while there was no difference in oxygenation between children treated or not. Of 4501 transfusion episodes, 28 (0.62%) AEs were reported. There was no difference in AEs associated with transfusions for acute indications versus CTT. Conclusion Red blood cell transfusion was common in Brazilian SCD patients, with utilization driven by CTT. Transfusion reactions were not common; however, alloimmunization and iron overload were frequent among those on CTT, highlighting the need for novel clinical strategies to mitigate these risks.

Background Stroke is a severe complication of sickle cell anemia (SCA). The role of glucose-6-phosphate dehydrogenase (G6PD) deficiency in the development of stroke in children with SCA is controversial. Procedure The aim of this study was to investigate the association of clinical ischemic stroke, high-risk transcranial Doppler measurements (TCD), and hematological features with molecular variants usually linked to G6PD deficiency or with the biochemical activity of G6PD in a cohort of 395 Brazilian children with SCA. G6PD activity was quantitatively determined using an enzymatic-colorimetric assay. G6PD mutations were determined by PCR-RFLP and sequencing. Clinical and hematological data were retrieved from the children's records. Results The prevalence of molecularly defined deficiency (hereafter, molecular deficiency) was 4.3% (95% confidence interval: 2.3–6.3%). The mean G6PD activity was 16.88 U/g hemoglobin (Hb) (standard error of the mean [SEM] 0.28) in the group without G6PD molecular deficiency and 8.43 (SEM 1.01) U/g Hb in the group with G6PD A− molecular deficiency. G6PD molecular deficiency was not associated with any hematological features. No effects of G6PD molecular deficiency on clinical ischemic stroke or high-risk TCD were detected. The mean G6PD activity was similar in children who had clinical ischemic stroke and in those without stroke. Similar results were obtained in analyses comparing children who had high-risk TCD and those without high-risk TCD. Conclusions Our study demonstrated that G6PD molecular deficiency was not associated either with clinical ischemic stroke or high-risk TCD. Similarly, we found no associations between G6PD enzyme activity and stroke or high-risk TCD. Small sample size precludes definitive conclusions.