Sickle cell disease is a genetic disorder that affects 100,000 Americans and millions more worldwide. Although the sickle mutation affects one protein, which is only expressed in a single cell type, it has profound detrimental effects on nearly every organ system in the body. Young children with sickle cell disease have an 11\% chance of suffering a major stroke event by the age of 16, and a 35\% chance of developing ÒsilentÓ strokes that often result in significant learning and mental disabilities. Clinical investigations suggest that stroke development in people with sickle cell disease results from luminal narrowing of the carotid and cerebral arteries due to excess matrix deposition and fragmentation of the elastic lamina; however, the underlying cellular mechanisms that initiate arterial remodeling in sickle cell disease remain relatively unknown. Cathepsins K and V are members of the cysteine family of proteases and represent two of the most potent elastases yet identified in humans. Furthermore, the role of Cathepsins has been well established in other cardiovascular remodeling diseases, such as atherosclerosis. Due to the compelling histological similarities between vasculopathy in sickle cell disease and atherosclerosis, we tested the hypothesis that the unique inflammatory milieu, in conjunction with the biomechanical vascular environment of sickle cell disease upregulates cathepsin K and V activity in large artery endothelial cells, ultimately leading to arterial remodeling and stroke. Currently, there are few therapeutic options for the prevention of stroke in sickle cell disease; those that do exist carry significant health risks and side effects. Together, this body of work has generated a more mechanistic understanding of how the sickle milieu stimulates the endothelium to initiate arterial remodeling, which has enabled us to identify important pathways (JNK, NF$\kappa$B) downstream of inflammatory and biomechanical stimuli and validate new therapeutic targets within the JNK pathway to establish preclinical proof of efficacy for the prevention of arterial remodeling in sickle cell disease.

<p>Malaria, caused by the apicomplexan parasite Plasmodium, is a disease which affects up to 500 million people each year. Historically, malaria infection has been combated both through the control of its vector, the Anopheles mosquito, and use of a variety of drugs, such as quinine (1800s) and chloroquine (1900s). However, with the evolution of resistance to the majority of available anti-malarial drugs, current approaches have settled upon combinatorial therapies. The most effective of these currently are ACTs (Artemisinin Combination Therapies - Artemisinin derivatives combined with a number of other drugs). However reports of Artemisinin resistance are continuing to emerge, suggesting that new approaches and increased understanding of the Plasmodium parasite is required.</p><p> Beginning with the complete sequencing of Plasmodium falciparum genome and continuing with comprehensive profiling of both the parasite's proteome and transcriptome, various genomic approaches applied in the study of malaria have led to significant new insights into the underlying biology of this parasite. While these new findings have greatly increased our understanding of genetic regulation within the malaria parasite, they largely have not yet translated into new therapeutic approaches. For this reason, considerable attention has been paid to the study of human genetic disorders which convey resistance to malaria, in the hopes that elucidating the mechanisms behind these resistances might lead to increased understanding of the parasite's biology and thus novel therapeutic approaches.</p><p> Sickle cell (HbS) erythrocytes are well known to resist malaria infection. However, the molecular basis of this resistance, long been recognized as multifactorial, contains elements which remain poorly understood. Here we show that the dysregulated erythrocytic microRNA composition, present in both HbAS and HbSS erythrocytes, is a significant determinant of resistance against the malaria parasite Plasmodium falciparum. During the intraerythrocytic lifecycle of P. falciparum, a subset of erythrocyte microRNAs translocate into the parasite. Two microRNAs, miR-451 and let-7i, were highly enriched in HbAS and HbSS erythrocytes and these miRNAs, along with miR-223, negatively regulated parasite growth. Surprisingly, we found that miR-451 and let-7i integrated into essential parasite mRNAs and, via impaired ribosomal loading, resulted in translational inhibition of the target mRNA. Hence, sickle cell erythrocytes exhibit cell-intrinsic resistance to malaria in part through an atypical microRNA activity which may present a novel host defense strategy against complex eukaryotic pathogens. In addition, the formation of these chimeric transcripts even in normal host erythrocytes illustrates a unique parasitic post-transcriptional adaptation to the host-cell environment.</p> / Dissertation

Sickle cell disease (SCD) is one of the most common genetic diseases worldwide. HbS polymerisation causes altered red blood cell (RBC) rheology and fragility, increase in blood viscosity with blockage of small blood vessels, and RBC membrane permeability changes. Excessive levels of cell-free Hb, high autoxidation of Hb, contribute to the production of reactive oxygen species (ROS) in SCD patients. In this work, oxidants showed direct and indirect effects on the main cation permeability pathways involved in dehydration of HbS/S RBCs - Psickle, the Gardos channel and the KCl cotransporter (KCC) - and thus on RBC volume causing polymersation. Psickle and Gardos channel activities showed significant correlation, consistent with the hypothesis that Ca2+ entry via Psickle causes activation of the Ca2+-dependent K+ channel. Treatment of SCD remains inadequate relying on the blood transfusion and supportive therapy depending on the organ affected. In the present study antioxidants and aromatic aldehydes showed some promising results towards future alternative treatments for SCD. Antioxidants showed inhibitory effects on the cation permeability pathways leading to inhibition of polymerisation and haemolysis and thus maintained RBC volume. Aromatic aldehydes interact with HbS and are usually given to increase oxygen affinity, thereby reducing its tendency to polymerise. GBT1118 had a marked inhibitory effect on all three cation permeability pathways. It reduced sickling, Psickle and Gardos activity. It inhibited KCC by affecting the regulatory protein phosphorylation cascade. It maintained RBC hydration, and stabilised RBCs. Historically Oman was the principal trading port of the Persian Gulf region, resulting in the complex mix of social and ethnic backgrounds. In 1989 a second mutation in the β chain of Hb, at position β121 was found in an Omani patient in addition to the usual HbS mutation at the β6 position, and termed HbS-Oman. At low percentage of HbS-Oman patients show severe SCD symptoms. Despite RBCs containing at most 25% HbS-Oman, there was high sickling percentage and K+ permeability showed many features similar to those seen in homozygous HbS/S patients. The presence of α thalassaemia was protective and represents an obvious potential prognostic marker for this rare SCD genotype. Overall, the present work contributes to elucidation of the pathogenesis of SCD, suggests approaches to the development of novel therapies and increases our understanding of a rare SCD genotype, HbS-Oman.

In this study we present feasibility of a mobile monitoring and reporting system that would provide an accurate unbiased screening tool to systematically analyze opioid adherence in Sickle cell disease patients. In addition, the software simultaneously measures pain. The Mobile Applications Rating Scale: a new and validated tool for assessing the quality of health mobile apps for engagement, functionality, aesthetics, information quality, subjective quality, relevance and overall impact was administered post usage to evaluate the application. A total of 28 patients were recruited to review and test the software at one sitting. The majority of the population found the application to be relevant for their care. Patients were also asked to report on the completeness of information within the app, the majority (96%) reported on the application’s completeness while 4% estimated the information to be minimal or overwhelming. The quality of information as it pertains to sickle cell patients was overwhelimingly reported to be relevant (91.7%); only 8.3% found the application to be poorly relevant to sickle cell disease. The application’s performance was positively rated while the ease of its use positively rated at 91.7%. Most participants (85.7%) found the application to be interesting to use while 74% found it entertaining. All users found the application’s navigation to be logical and accurate with consistent and intuitive gestural design. We conclude that surveyed patients believe it is feasible to use a smartphone application specifically targeted to monitor opioid use and behavior in patients with sickle cell disease (SCD)-associated pain

O avanço de novas tecnologias tem conduzido à geração de grandes volumes de dados biológicos, provenientes, por exemplo, de sequenciamento de genomas, expressão de genes e proteínas, estrutura de proteínas e RNAs, análise de imagens, formulários eletrônicos e exames médicos. Com o intuito de transformar esses volumosos conjuntos de dados brutos em informação e conhecimento que sejam compreensíveis e interpretáveis, técnicas de mineração de dados têm sido aplicadas no estudos de diversos processos biológicos, como a predição de genes, funções de genes, fenótipos, módulos regulatórios, estrutura de proteínas, função de proteínas e descoberta de interações moleculares. Cada conjunto de dados tem suas particularidades, demandando o emprego de distintas metodologias de análises e algoritmos de reconhecimento de padrões, como Florestas Aleatórias, Redes Neurais, Deep Learning, Modelo Oculto de Markov, Máquina de Vetores de Suporte, K-médias e Análise de Componentes Principais. A escolha do algoritmo a ser utilizado é influenciada por fatores como o tipo dos dados, a forma como são gerados, sua natureza, suas características e o objetivo do estudo. Assim, este trabalho teve como objetivo explorar técnicas de reconhecimento de padrões e estatística aplicadas a um conjunto de dados biológicos envolvendo pacientes com anemia falciforme, para extração de informação e conhecimento sobre os processos, fenômenos e sistemas biológicos envolvidos na doença. Foram realizadas análises de um conjunto de dados diverso, proveniente de registros clínicos, entrevistas com pacientes, exames clínicos e sequenciamento de polimorfismos de nucleotídeo único. Os dados demandam diferentes abordagens de análises, exploração e revelação da estrutura de dados intrínseca. Em uma análise inicial, foram aplicados algoritmos de reconhecimento de padrões a dados clínicos de pacientes com anemia falciforme, com o objetivo de obter grupos contendo pacientes similares. Os algoritmos PCAMix, PAM e TwoStep clustering foram capazes de gerar grupos homogêneos de pacientes, sendo que estes grupos apresentam distintas características clínicas e diferentes níveis de gravidade da doença quando comparados entre si. Os resultados indicam que características como idade, níveis de bilirrubina, histórico de transfusões, dor aguda da anemia falciforme, síndrome torácica aguda, acidente vascular cerebral, infarto cerebral silencioso, ataque isquêmico transitório, úlcera de pernas, moyamoya, ferritina, contagem de reti- culócitos, retinopatias, ataques epiléticos e hemossiderose transfusional são importantes para a definição de grupos homogêneos de pacientes, que apresentem distintos níveis de gravidade de anemia falciforme quando comparados entre si. Adicionalmente à análise de agrupamento, o conjunto de pacientes com histórico de priapismo, uma das complicações da anemia falciforme, foi estudado. O objetivo desta análise foi caracterizar clinicamente os pacientes com histórico de priapismo, e investigar fatores genéticos que alterassem o risco da doença. Observou-se que o priapismo ocorreu mais frequentemente em pacientes com genótipo HbSS, estando associado a idades mais avançadas e à ocorrência de hipertensão pulmonar e necrose avascular. Dois novos SNPs foram associados à ocorrência de priapismo, bem como houve indicativo de replicação da associação do gene TGFBR3 ao risco da doença. / Technology has been producing large biological datasets of genome sequences, gene and protein expression, RNA and protein structure, images, electronic questionnaires and laboratory test results. In order to extract information and knowledge from these large datasets, data mining techniques have been used in the investigation of a wide range of biological processes, with the goal of predicting gene, gene function, phenotype, regulatory modules, molecular interaction, protein function and protein structure. Each dataset has different characteristics and demands the application of different statistical methodologies and pattern recognition algorithms, such as Random Forests, Neural Networks, Deep Learning, Markov Hidden Model, Support Vector Machine, K-means and Principal Component Analysis. The choice of the algorithm depends on data type, data generation, data characteristics and goal of the study. Therefore, the goal of this work was to explore pattern recognition and statistical techniques in a biological dataset on sickle cell disease patients, in order to extract information and knowledge about the biological systems, processes and mechanisms associated with the disease. A diverse dataset was analyzed, containing data from medical records, patient interviews, laboratory tests and single nucleotide polymorphisms. The dataset requires a variety of analysis approaches, in order to explore and reveal the hidden data structure. In an initial investigation, pattern recognition algorithms were used in the analysis of clinical data from sickle cell patients, in order to obtain clusters containing similar patients. PCAMix, PAM and TwoStep clustering algorithms generated homogeneous clusters of patients that display different clinical characteristics and different levels of disease severity. The results show that age, bilirubin levels, transfusion history, vaso-occlusive pain episodes, acute chest syndrome, infarctive stroke, hemorrhagic stroke, ischemic attack, leg ulcers, moyamoya, ferritin, reticulocyte count, retinopathy, seizures and transfusional hemosiderosis are important to define homogeneous patient clusters, with distinct levels of sickle cell severity. Additionally, the patients with history of priapism, a sickle cell related complication, were studied. The goal of the study was to characterize patients with priapism history and investigate genetic factors that modify the risks of the disease. Priapism more frequently occurred among patients with HbSS genotype and was associated with older age and occurrence of pulmonary hypertension and avascular necrosis. Two novel SNPs were associated with priapism and there was evidence of replication of a previously reported association of TGFBR3 with priapism risk.

Nucleic acids are an emerging class of therapeutics with the capacity to repair both DNA and RNA mutations in clinically relevant targets. We have used two approaches, mobile group II introns and Spliceosome Mediated RNA Trans-splicing (SMaRT), to correct β-globin mutations at the DNA and RNA levels respectively. We show that the group II intron inserts site-specifically into its DNA target, even when similar targets are available. Experiments transitioning this therapeutic into mammalian cell systems are then described. We also illustrate how SMaRT RNA repair can be used to correct β-globin mutations involved in sickle cell disease and some forms of β- thalassemia. We uncovered diverse repair efficiencies when targeting sickle cell versus β- thalassemia transcripts in mammalian cells. Possible reasons for this and how it might direct target choice for the SMaRT therapeutic approach are both discussed. The therapeutic molecule in SMaRT, a Pre-Trans-splicing Molecule or PTM, is also delivered via lentivirus to erythrocyte precursors cultured from the peripheral blood of sickle cell patients. Preliminary results from these experiments are discussed. / Dissertation

Sickle cell disease (SCD) is a severe hemoglobin disorder caused by co-inheritance of a single mutation in the β-globin gene of adult hemoglobin (HbA; α2β2). This alteration leads to the formation of sickle hemoglobin (HbS; α2βS2) and deformed, sickle-shaped red blood cells (RBCs). Sickle RBCs obstruct small blood vessels resulting in anemia, excruciating pain crises, organ damage, and stroke. For the millions of people affected by this disease, life expectancy is only 40-60 years of age. The only cure for SCD is hematopoietic stem cell (HSC, CD34+) transplantation, which requires a human leukocyte antigen (HLA)-matched donor. However, this option runs the risk of complications associated with graft versus host disease and infection. Before birth, individuals with SCD do well because their RBCs are filled with γ-globin containing fetal hemoglobin (HbF; α2γ2), which inhibits the formation of HbS. In fact, some SCD patients who co-inherit mutations that allow for high-level expression of HbF into adulthood are asymptomatic. This suggests that genetic modification of the patient’s own HSCs to permit HbF production would be a viable therapeutic alternative to HSC transplantation. Our work has focused on the use of lentiviral vectors to introduce an exogenous γ-globin gene or shRNA sequences designed to knockdown repressors of γ-globin, such as the zinc-finger transcription factor, BCL11A, to prevent silencing of the endogenous γ-globin genes allowing for persistent expression of HbF. Despite significant progress using both approaches, we have been unable to increase the level of HbF > 30%; a curative threshold for SCD patients who continue to produce HbF into adulthood. The goal of my project was to combine these approaches into a single lentiviral vector to achieve co-regulated, erythroid-specific expression and augmented levels of HbF. I successfully modified the insulated, erythroid-specific γ-globin vector (termed V5m3-400) to include microRNA (miR)-adapted shRNAs (or shmiRs) targeting BCL11A (based on miR-30 and miR-E architectures) in the first and second noncoding introns of the γ-globin genomic sequences. Inclusion of shmiRs had no appreciable effect on integrity of the integrated provirus or vector titer. Vector performance was initially tested using human K562 erythroleukemia cells expressing a flag-tagged version of BCL11A. In this cell line, BCL11A knockdown was significantly improved using miR-E-shRNAs due to a dramatic increase (up to 350-fold) in processing of mature shRNA sequences. The miR-E vectors also provided high-level expression of γ-globin. Erythroid-specific expression of the γ-globin transgene and BCL11A knockdown was confirmed in maturing erythroid cells derived from transduced CD34+ cells of a healthy donor resulting in a 50% increase in HbF levels compared with cells transduced with V5m3-400 as a control. While encouraging, I was unable to discriminate HbF derived from the vector-encoded versus endogenous γ-globin genes. To address this, I introduced a single base change in exon 2 of the γ-globin gene encoded by V5m3-400 such that threonine replaces isoleucine at amino acid 75 (I75T). This variant was successfully distinguished from endogenous γ-globin gene products by reverse phase high performance liquid chromatography (HPLC) in culture-differentiated erythroid cells. Based on these findings, I created compound γ-globin/shmiR-E vectors that include the I75T substitution (I75Tγ-globin/shmiR-E). Future studies will focus on testing this novel vector design in erythroid cells derived from transduced CD34+ cells of healthy donors and patients with SCD. I anticipate that this compound vector has the potential to maximize γ-globin expression and promote levels of HbF that are unlikely to be safely and effectively achieved by conventional globin gene addition or shRNA knockdown approaches alone.

La drépanocytose est la première maladie génétique en France et notamment en Guadeloupe. Il s’agit d’une maladie du sang qui est due à une mutation ponctuelle au niveau du gène de la β-globine, laquelle entre dans la composition de l’hémoglobine. Ainsi les drépanocytaires ont une hémoglobine anormale appelée « HbS », contrairement à l’hémoglobine normale « HbA ». En condition de faible oxygénation, l’HbS polymérise et forme des fibres à l’intérieur des érythrocytes. Ces fibres rigidifient et fragilisent les globules rouges. Par conséquent ils peuvent bloquer la circulation à cause de leur faible déformabilité, et causer des crises vaso-occlusives douloureuses, complication caractéristique de la drépanocytose. Ce modèle physiopathologique classique a été complété par les résultats plus récents montrant l’importance du rôle des leucocytes dans l’établissement de ces obstructions. Par ailleurs, les globules rouges des drépanocytaires sont plus prompts à l’hémolyse en raison de leur fragilité. En raison de l’hémolyse exacerbée, l’hémoglobine se retrouve dans le plasma et diminue la biodisponibilité du principal vasodilatateur, le monoxyde d’azote. De plus, les globules rouges rigides et déformés entrainent activation de l’endothélium. Il en résulte dans la drépanocytose, un contexte pro-inflammatoire et pro-adhérent mais aussi pro-coagulant.Ce contexte est propice à l’activation des cellules sanguines et notamment à celle des plaquettes et des érythrocytes qui par bourgeonnement de leur membrane, émettent alors en grandes quantités, des vésicules sub-micrométriques appelées microparticules, ou MP. En l’absence de traitement curatif applicable à tous les patients drépanocytaires, nous avons décidé d’étudier le profil mais aussi le rôle des MP de patients drépanocytaires dans le but de mieux comprendre cette maladie et dans l’espoir de peut-être découvrir une nouvelle piste diagnostique ou thérapeutique.Nous avons donc montré que les patients SC ont des concentrations sanguines en MP plus importantes que les sujets AA, mais moindres que les patients SS. Etonnamment les MP SC, qu’elles soient d’origine érythrocytaire ou plaquettaire, ont aussi plus de phosphatidylsérine (PS) à leur surface que les MP SS. Ce phospholipide étant impliqué dans l’activation de la cascade de la coagulation, il serait intéressant d’évaluer l’intensité de cette activation par des MP SS ou SC. On pourrait aussi comparer ces intensités à celle induite par des MP de patients SS sous hydroxyurée. En effet nous avons aussi montré que 2 ans après avoir commencé ce traitement, les MP érythrocytaires des patients ont une taille plus importante et une exposition de la PS diminuée drastiquement.Les MP étant physiologiquement dans le sang, elles peuvent entrer en contact avec les cellules sanguines mais aussi avec l’endothélium vasculaire. Etant donné l’importance des changements que connaît cet endothélium chez les drépanocytaires (pro-adhérent, pro-inflammatoire et pro-coagulant), nous nous sommes ensuite focalisés sur l’impact des MP de drépanocytaires sur les cellules endothéliales. Ces dernières provenaient de la moelle osseuse humaine, territoire fréquemment affecté par les vaso-occlusions. Il ressort de ces travaux que les MP de patients SS et SC induisent, par rapport aux MP de sujets AA, une surexpression dose-dépendante de gènes impliqués dans l’adhérence (ICAM-1, VCAM-1, E-sélectine), dans l’inflammation (IL-6, IL-1β et CD40-I) et dans la coagulation (TF). Au niveau protéique, ICAM-1 est aussi surexprimé. En effet les MP SS induisent dès 4 heures d’incubation, une augmentation de la densité moyenne d’ICAM-1 membranaire, ainsi qu’une augmentation de la proportion de cellules exprimant cette protéine. ICAM-1 étant impliquée dans l’adhérence des leucocytes à l’endothélium (roulement, adhérence ferme et même transmigration). / Sicle cell disease (SCD) is the first genetic disease in France and more specifically in Guadeloupe. It is a blood disorder due to a point mutation in the β-globin gene. The corresponding peptide chain being a part of hemoglobin, SCD patients have an abnormal hemoglobin called “HbS”, contrary to the normal one, so called “HbA”. In hypoxic conditions, HbS forms polymers inside red blood cells (RBCs), thereby making them rigid but also fragile. Consequently, RBCs can stop blood flow due to their low deformability, and so cause a painful vaso-occlusive crisis, which is a complication characterizing SCD. This pathophysiological model has been modified by recent results showing the involvement of leukocytes in the establishing of these occlusions. Besides, sickle RBCs are more prone to hemolysis owing to their being fragile. Due to this exacerbated hemolysis, hemoglobin is released in the plasma and diminishes the bioavailability of the main vasodilator, nitrite monoxide. Moreover, rigid sickled RBCs entail endothelium activation, which results in a pro-inflammatory, a pro-adhesive and a pro-coagulant context. This latter favors blood cells activation, among which are platelets and erythrocytes that bud high quantities of submicrometric membrane vesicles called microparticles, or MPs. In the absence of curative treatment for all patients, we decided to study the profile but also the role of MPs from SCD patients to better understand this disease and hoping to find a new diagnostic or therapeutic pathway. We showed that SC patients have lower MP levels than SS patients, but higher MP levels than AA subjects. Surprisingly, we have observed that SC MPs, whether they derive from RBCs or platelets (PLTs), have higher densities of exposed phosphatidylserine (PS) than SS MPs. Since this phospholipid is involved in the activation of the coagulation cascade, it would be interesting to evaluate the intensity of this activation by SS or SC MPs. One could also compare these intensities to the one induced by MPs from SS patients under hydrocarbamide. Indeed we also showed that 2 years after the beginning of this treatment, erythrocyte-derived MP are larger and expose PS much less.As MPs are physiologically in the blood, they can interact with blood cells but also with the vascular endothelium. Given the known changes of this endothelium in SCD (pro-adhesive, pro-inflammatory and pro-coagluant), we then focused on the impact of SCD MPs on endothelial cells (ECs). These cells came from human bone marrow, a territory frequently affected by vaso-occlusions. These experiments showed that SS and SC MPs, induce, compared to AA MPs, a dose-dependent overexpression of genes involved in adherence (ICAM-1, VCAM-1, E-selectin), in inflammation (IL-6, IL-1β and CD40-I) and in coagulation (TF). At the protein level, ICAM-1 is also overexpressed. Indeed SS MPs induce within 4 hours of incubation, an increase of the mean membrane density of ICAM-1, but also an increased proportion of cells bearing this protein. As ICAM-1 is involved in leukocytes adherence to the endothelium (rolling, firm adhesion and even transmigration), SS MPs may, by triggering ICAM-1 overexpression at the endothelium surface, allow their adherence to the endothelium, thereby promoting RBC adherence and so the occlusion of the vessel and the occurring of a VOC. It would be interesting to determine which type of MP cause the overexpression of ICAM-1 and to evaluate if it is sufficient to increase in vitro adherence of leukocytes to ECs stimulated with MPs. This would allow to evaluate how important MPs are when considering the fight against sickle cell disease.

Orientador: Helena Zerlotti Wolf Grotto / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-08T13:21:42Z (GMT). No. of bitstreams: 1 Noronha_JoseFernandodeAlmeida_D.pdf: 5060365 bytes, checksum: 9a433693a12ebc4fc3a72a0639d93c73 (MD5) Previous issue date: 2007 / Resumo: Introdução: Plaquetas reticuladas (PRs) são plaquetas jovens recentemente liberadas pela medula óssea para a circulação e que possuem alto conteúdo de RNA em seu citoplasma. As PRs são descritas como plaquetas grandes, densas e mais ativas no processo de formação do trombo hemostático. A participação das plaquetas ativadas nos fenÃ'menos vaso-oclusivos que acometem pacientes com síndrome falciformes (SF) já está documentada, mas a avaliação do papel das PRs não foi ainda descrito. Assim, avaliamos o número e a atividade das PRs, correlacionando-os com os níveis séricos de P-selectina solúvel (sCD62p), interleucinaâ?¿6 (IL-6), interleucina-3 (IL-3) e trombopoietina (TPO) em sangue periférico de pacientes em diferentes estágios clínicos das SF. Casuística e Métodos: Foram estudados 89 pacientes adultos, sendo 38 em fase â?¿estávelâ??, 27 em crise hemolítica (CH), 27 em crise vaso-oclusiva (CVO) e 30 indivíduos saudáveis (grupo controle - GC). Os parâmetros plaquetários, incluindo a quantificação de macroplaquetas foram determinados em analisador hematológico. Através da técnica da citometria de fluxo com o uso de anticorpos monoclonais e thiazole orange (TO), realizamos as identificações e quantificações das plaquetas ativadas (anti CD41a + anti CD62p), PRs (anti CD41a + TO) PRs ativadas (TO + anti CD62p). As dosagens de sCD62p, IL-6, IL-3 e TPO foram realizadas pela técnica de ELISA. Resultados: O número de macroplaquetas foi significativamente superior nas 3 fases clínicas das SF em relação ao GC. O número de plaquetas ativadas, tanto reticuladas como maduras foi superior em todas as fases clínicas quando comparadas ao GC. Os valores de PRs mostraram-se mais elevados no grupo de pacientes em CVO do que na fase â?¿estávelâ?? e na CH. Em todos os grupos as PRs apresentaram um maior grau de ativação quando comparadas às plaquetas maduras. Os pacientes em CVO apresentaram maiores níveis de sCD62p em relação ao GC. Nas diferentes fases das SF observamos níveis séricos elevados de IL-6, IL-3 e TPO, embora não tenha sido observada correlação entre essas determinações com os números absolutos de PRs, Plaquetas ativadas (CD62p+) e PRs ativadas (TO+/CD62p+). Conclusões: Os resultados sugerem a contribuição das PRs na trombogênese das Síndromes Falciformes. Níveis elevados das interleucinas provavelmente indicam a participação das mesmas no processo inflamatório que acompanha os fenÃ'menos de vaso-oclusão, mas aparentemente esses moduladores inflamatórios não exercem efeito sobre a trombopoiese em pacientes com SF / Abstract: Introduction: Reticulated Platelets (RPs) are youngest platelets released recently from bone marrow to the blood and are characterized by the high citoplasmatic RNA content. RPs are described as higher size, denser and more active in the formation of thrombus than mature platelets. The participation of activated platelets in vaso-occlusive process in sickle cell disease patients have been documented, but the evaluation of the RPs role has not been established at the moment. We evaluated the number and activity of RPs and correlated them with serum soluble P-selectin (sCD62p), Interleukin-6 (IL-6), Interleukin 3 (IL-3) and thrombopoetin (TPO) levels in patients with sickle cell diseases in different clinical expressions. Casuistic and Methods: Eighty-nine adult patients were studied: 38 in steady-state, 27 in hemolytic crisis (HC), 27 in vascular-occlusive crisis (CVO) and 30 healthy individuals (control groupâ?¿CG). Platelet parameters including the percentage of larger platelets were obtained by an automatic hematological analyzer. Monoclonal antibodies, thiazole orange (TO) dye and flow cytometric technique were used to identify and to quantify activated platelets (anti CD41a+ and anti CD62p+), RPs (anti CD41a+ and TO+) and activated RPs (TO+ and anti CD62p+). Soluble CD62p, IL-3, IL-6 and TPO determinations were measured by ELISA tests. Results: The number of macroplatelets was significantly higher in steady-state, CVO and HC groups than in CG. The number of activated mature platelets and activated RPs was higher in all stages of the disease when compared with CG. PRs values were more elevated in group of patients with CVO than in HC and steady-state. The degree of activation was higher in PRs than in mature platelets independently on sickle cell disease phase. CVO patients showed higher serum levels of sCD62p than CG. IL-6, IL-3 and TPO serum levels were increased in sickle cell disease, but there was not a correlation between those determinations and parameters related to platelets. Conclusions: Our results suggest that PRs contribute to the thrombogenesis process in sickle cell disease. Increased serum levels of interleukins probably indicate the participation of PRs in inflammatory process which is associated to vascular-occlusive phenomenon, but apparently those inflammatory mediators do not have an effect on thrombopoiese in sickle cell disease patients / Doutorado / Ciencias Biomedicas / Doutor em Ciências Médicas

Actuellement, l’Hydroxyurée est le seul traitement médicamenteux qui permet d’améliorer la qualité de vie et l’espérance de vie des patients drépanocytaires. Ses effets sont essentiellement liés à l’augmentation de l’HbF par l’inhibition de la polymérisation de l’hémoglobine S qui constitue la base physiopathologique de la drépanocytose. Cependant d’autres paramètres de réponse contribuent à l’amélioration clinique, principalement les atteintes chroniques, et ce indépendamment de l’augmentation du %HbF. Le phénotype hémolytique est associé aux globules rouges denses (DRBC) qui constituent une sous population de globules rouges présentant une densité supérieure à 1,11. L’amélioration des manifestations chroniques est associée à une diminution du %DRBC qui semble être une cible thérapeutique de l’Hydroxyurée. Par son efficacité de plus en plus démontrée, l’Hydroxyurée pourrait être le traitement de recours dans le traitement de fond de la drépanocytose, cependant son mode d’action reste encore partiellement élucidé.Ce travail a été réalisé dans le but de mieux comprendre le mode d’action de l’Hydroxyurée.La première étude consiste à déterminer les facteurs prédictifs de la diminution des DRBC sous Hydroxyurée. Après 6 mois de traitement, une diminution significative du %DRBC associée à une amélioration des paramètres d’hémolyses a été observée. Cet effet est indépendant de l’augmentation du %HbF. La diminution du %DRBC semble être plus constante que l’augmentation du %HbF sous Hydroxyurée.La deuxième étude a pour but de mettre au point une nouvelle approche de mesure de la teneur en HbF par globule rouge. L’outil de quantification actuellement utilisé donne une mesure du pourcentage moyen de l’HbF. Or la teneur en HbF par globule rouge peut varier pour un même %HbF conduisant à une variabilité de réponse clinique et biologique. Dans l’hypothèse d’un seuil d’HbF inhibant la polymérisation de l’hémoglobine S, une méthode précise de mesure de la teneur en HbF par globule rouge a été développée. Dans le cadre d’une preuve de concept, une étude de la distribution de l’HbF a été effectuée au cours du traitement par Hydroxyurée. Le suivi longitudinal montre une distribution hétérogène de l’HbF avant le début du traitement par Hydroxyurée. La distribution de l’HbF devient homogène après 6 mois sur l’ensemble des globules rouges avec une diminution rapide du nombre de globules rouges ne contenant pas d’HbF au profit des autres populations globulaires.La troisième étude a pour but d’optimiser le traitement par Hydroxyurée. En effet les atteintes rénales associées à la drépanocytose sont de plus en plus fréquentes et constituent un facteur de mortalité. Elles peuvent influencer la pharmacocinétique de l’Hydroxyurée car l’excrétion rénale constitue une voie d’élimination de l’Hydroxyurée. Nous avons d’abord développé unetechnique de mesure simple et fiable de dosage de l’Hydroxyurée. La pharmacocinétique de l’Hydroxyurée a été comparée entre les patients drépanocytaires présentant une fonction rénale normale avec ceux présentant une insuffisance rénale modérée et une hyper filtration glomérulaire. Une diminution de l’élimination de l’Hydroxyurée associée à une augmentation des concentrations plasmatiques ont été observées chez les insuffisants rénaux. La pharmacocinétique de l’Hydroxyurée semble être similaire chez les patients normo-rénaux et hyperfiltrants.Ce travail a apporté des éléments de réponse que nous jugeons important quant à l’action de l’Hydroxyurée sur les DRBC impliqués dans la vasculopathie chronique et sur la distribution de l’HbF. Nous avons également apporté une nouvelle technique de mesure de l’Hydroxyurée et montré qu’une adaptation de dose est nécessaire chez les patients ayant une insuffisance rénale. / Hydroxyurea, the only sickle-cell–disease approved drug, has proven its efficacy in ameliorating patient quality of life and life expectancy. The classical biological response of Hydroxyurea therapy is increased fetal hemoglobin (HbF) which inhibits deoxy hemoglobin S polymerization. However, other parameters also support clinical benefits of Hydroxyurea especially for chronic organ failures which are related to hemolysis. Sickle-cell–disease hemolytic phenotype is associated with dense red blood cells (DRBC) defined as having a density >1,11. Improvement of chronic clinical complications is associated with a marked decrease in %DRBC emphasizing its role as a therapeutic target for Hydroxyurea treatment. Despite the known benefits in both acute and chronic sickle-cell–disease manifestations, the mechanism action of Hydroxyurea has not been fully elucidated.This thesis was undertaken in order to investigate the mechanism of action of Hydroxyurea in sickle-cell–disease treatment.The first aim is to determine biological parameters predictive of %DRBC decrease under Hydroxyurea. A significant decrease in %DRBC after 6 months of Hydroxyurea therapy was observed. This biological response was associated with a decrease in hemolysis. However no correlation with %HbF increase was detected; the decrease in %DRBC under Hydroxyurea was more constant than the increase in %HbF.The second aim of this study was to develop a new approach for HbF determination in individual red blood cells. Indeed, routine HbF quantification only provides a mean value. However clinical amelioration is not exclusively dependent on the average %HbF, since a wide distribution of HbF content per cell could indicate a HbF content threshold for inhibition of deoxy hemoglobin S polymerization. In this context, a simple and precise method was developed in order to assay HbF content per cell. The distribution of HbF during Hydroxyurea therapy was analyzed as proof of concept. The longitudinal monitoring showed an uneven distribution of HbF before Hydroxyurea and a normal distribution in the whole red blood cells after 6 months of therapy. A rapid decrease in red blood cells not containing HbF in favor of cells expressing a high quantity of HbF was observed.The third objective consisted of Hydroxyurea therapy optimization. Chronic kidney disease is a frequent complication during sickle-cell–disease. Since Hydroxyurea is cleared from plasma partially by renal excretion, impaired renal function could potentially affect Hydroxyurea pharmacokinetics. A new simple Hydroxyurea dosage method was performed in this context.Hydroxyurea pharmacokinetic parameters were compared among sickle-cell–disease patients with normal renal function, moderate renal insufficiency and renal hyper filtration. A decrease in Hydroxyurea elimination associated with a marked plasma concentration was observed inrenally impaired patients. No significant difference was observed between renal hyper filtration and normal patients.These results provide answers about Hydroxyurea effect on DRBC which are involved in chronic vasculopathy and on HbF distribution. Hydroxyurea dosage method underpins the need for dose adjustment in renally impaired patients.