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Nephropathy is a common and progressive complication of sickle cell anemia (SCA). In SCA mice, we found that hyperangiotensinemia in the absence of hypertension underlies nephropathy, and its downregulation by losartan, an angiotensin-II-receptor-1 blocker, reduced albuminuria and progression of nephropathy. Therefore, we performed a phase-2 trial of oral losartan, given for 6 months, to explore whether it reduced albuminuria in children and adults with SCA. Participants were allocated to groups defined by class of baseline urinary albumin-to-creatinine ratio (UACR): no albuminuria (NoA), microalbuminuria (MicroA), and macroalbuminuria (MacroA). The primary endpoint was a ≥25% reduction UACR from baseline. There were 32 evaluable participants (mean age 24 years; NoA = 14, MicroA = 12, MacroA = 6). The primary endpoint was met in 83% of the MacroA group (P < 0.0001) and 58% of the MicroA group (P < 0.0001). Median fold-change in UACR was -0.74 for MacroA and -0.46 for MicroA. In MacroA and MicroA, UACR classification improved in 50% but worsened in 11%. Urine osmolality and estimated glomerular filtration rate (eGFR) did not change significantly. Losartan was discontinued in three participants [leg cramps, N = 1; decline in eGFR >25% (142➝104 mL/minute/1.73 m 2 ), N = 1; rise in serum creatinine >50% (0.2➝0.3 mg/dL), N = 1]. Albuminuria was associated with diastolic dysfunction and impaired functional capacity, although cardiopulmonary status was unchanged after 6 months of losartan therapy. In summary, losartan decreased urinary albumin excretion in most participants with albuminuria. Those with macroalbuminuria had the greatest benefit. This study forms the basis for a phase-3, randomized, placebo-controlled trial of losartan for the nephropathy of SCA., (© 2017 Wiley Periodicals, Inc.)

Sickle cell disease (SCD) and β-thalassemia are among the most common inherited diseases, affecting millions of persons globally. It is estimated that 5-7% of the world's population is a carrier of a significant hemoglobin variant. Without early diagnosis followed by initiation of preventative and therapeutic care, both SCD and β-thalassemia result in significant morbidity and early mortality. Despite great strides in the understanding of the molecular basis and pathophysiology of these conditions, the burden of disease remains high, particularly in limited resource settings. Current therapy relies heavily upon the availability and safety of erythrocyte transfusions to treat acute and chronic complications of these conditions, but frequent transfusions results in significant iron overload, as well as challenges from acquired infections and alloimmunization. Hydroxyurea is a highly effective treatment for SCD but less so for β-thalassemia, and does not represent curative therapy. As technology and use of cellular and gene therapies expand, SCD and thalassemia should be among the highest disease priorities.

Context: Sickle cell disease (SCD) confers an increased risk of invasive pneumococcal disease, especially among young children. Pneumococcal vaccination decreases this risk, but the completion rate of age-appropriate vaccinations is not well defined in SCD., Objective: The goal of this study was to assess whether pneumococcal vaccines are administered to high-risk children with SCD according to recommended vaccine schedules., Design: A case-control design was used to conduct this study., Setting: Administrative data were obtained on Michigan Medicaid or Children's Special Health Care Services programs enrollees. In addition, Michigan Newborn Screening and Michigan Care Improvement Registry records were used to confirm diagnosis and vaccine administration., Participants: This study compared pneumococcal vaccination rates in a cohort of 179 children with SCD with 537 age-matched non-SCD controls (1:3) enrolled in the Michigan Medicaid Program between 2001 and 2008. Study subjects were born in the state of Michigan between 2001 and 2005., Main Outcome Measure: The main outcome measure was the proportion of children defined as up to date for pneumococcal vaccines at defined milestone ages., Results: Children with SCD had significantly higher vaccination rates than controls, yet these values were much lower than state and national immunization survey rates., Conclusion: Barriers to completing age-appropriate recommended pneumococcal immunizations should be identified and addressed to further reduce invasive pneumococcal disease in this high-risk patient population.

Proper management of sickle cell anemia (SCA) begins with establishing the correct diagnosis early in life, ideally during the newborn period. The identification of affected infants by neonatal screening programs allows early initiation of prophylactic penicillin and pneumococcal immunizations, which help prevent overwhelming sepsis. Ongoing education of families promotes the early recognition of disease-released complications, which allows prompt and appropriate medical evaluation and therapeutic intervention. Periodic evaluation by trained specialists helps provide comprehensive care, including transcranial Doppler examinations to identify children at risk for primary stroke, plus assessments for other parenchymal organ damage as patients become teens and adults. Treatment approaches that previously highlighted acute vaso-occlusive events are now evolving to the concept of preventive therapy. Liberalized use of blood transfusions and early consideration of hydroxyurea treatment represent a new treatment paradigm for SCA management.

Acidification in the toad bladder occurs as a result of electrogenic H+ secretion (JH). When a pH gradient is applied in a stepwise fashion in the absence of exogenous CO2, JH decreases linearly with the mucosal (M) solution pH and is null when pHm is approximately 4.5. When pHm is returned to initial values (7.4) in a stepwise fashion, JH increases linearly with pHm. However, on this return, higher values of JH are initially obtained. To investigate this hysteresis, hemibladders mounted in chambers were used to measure the change in the H+ current before and after acid pulses were applied to the mucosal solution. In the absence of exogenous CO2, the application of graded acid pulses to mucosa for 1, 2, 4, and 8 min resulted in a graded decrease in JH. The restoration of pHm to 7.4 was followed by an immediate transient overshoot of reversed short-circuit current (Irsc), which was related to the time of exposure and the magnitude of the acid pulse. The longer the acid pulse or the larger the pulse, the greater the Irsc overshoot. The addition of protonophores, dinitrophenol, or salicylate, into the mucosal solution enhanced this overshoot. Similar Irsc overshoots could be obtained with the application of pulses of adverse electrical gradients. Introduction of exogenous CO2 into the system (3%) completely inhibited the overshoot in JH after an acid pulse. In conclusion, when pHm is decreased JH is reduced and the cell pH presumably decreases because of continued exit of alkali at the serosal side of the cell and entry of H+ from the mucosal solution. The decrease in cell pH then triggers the pump to produce a sharp overshoot in JH when pHm returns to 7.4.