Arginine in sickle cell vaso-occlusive crisis: A randomised placebo control trial

Introduction

Pain is the hall mark of vaso-occlusive crisis & accounts for about 70% of hospitalizations in Sickle Cell Disease(SCD) patients.1 Nationally,78% of the nearly 200,0000 annual emergency department visit for SCD are for a complaint of pain, yet there is no effective therapy that targets the underlying mechanisms of VOE.2 Vaso-occlusion leads to organ damage, a decreased quality of life, & a decreased life expectancy in patients with sickle cell disease (SCD).3 Dactylics, referred to as hand-foot syndrome, is often the first manifestation of pain in infants & young children with sickle cell anemia.4, 5 Arginase is released from ruptured erythrocytes, platelets, & the liver.6, 7, 8, 9

Arginine is a fundamental compound for the development of nitric oxide (NO), which is an intense vasodilator. 10 It is diminished in SCD patients, which might cause hindrance in the microcirculation, repetitive agony, and hospitalization, with expanded Arginine accessibility, there is more prominent NO unions, which prompts further developed microcirculation and patient clinical profiles.11

Vasculopathy, a significant reason for dreariness and mortality in sickle-cell disease,12 is related with endothelial brokenness. This brokenness incorporates expanded endothelial cell initiation and bond, unusual tone, responsiveness, and vessel architecture,13 which can be upset by intravascular haemolysis, expanded oxidative pressure, and diminished nitric oxide bioavailability. Arginase is set free from burst erythrocytes, platelets, and the liver. High groupings of arginase lessen plasma arginine, the sole substrate of endothelial nitric oxide synthase, in this manner diminishing nitric oxide production.14

During hemolysis, arginase as compound that utilizes L-arginine and adds to a diminishing in NO fixation in SCA patients, is delivered. Different examinations have shown that NO is a cofactor for the protein guanvate cycles which is liable for the transformation of guano sine triphosphate (GTP) to cyclic guanine monophosphate (cGMP). cGMP is liable for smooth and vascular muscle unwinding and vasodilation. The most reduced arginine level were found in kids requiring confirmation for VOE, with arginine levels getting back to benchmark during recovery in the hospital. 2 An expanded compensatory interest for NO in bringing about diminished L-Arg and NO levels during VOE.15 L-arginine levels are discouraged in patients with sickle cell illness, especially during vaso-occlusive torment crisis.16 When a solitary portion of arginine is given to patients with SCD during VOE, there is a powerful portion subordinate expansion in plasma NO.2

Diminished nitric oxide bioavailability is embroiled in the pathophysiology of a few problems including endothelial capability, including sickle-cell illness, hypertension, and persistent kidney sickness. Further developing arginine fixations could further develop results in these disorders14 so this study was done.

Aim & Objective

Materials and Methods

After getting clearance from the institutional ethical & research committee, the study was carried out from November 2019 to October 2021 in the Indoor of Pediatrics Department, Veer Surendra Sai Institute of Medical Science (VIMSAR), Burla, Sambalpur. It’s location is 21°29´38.88” N 83°53´10.06” E, where the incidence of sickle cell disease is high. It was randomized placebo control trial.

Observation

A randomized control trail was conducted in the In-Patient Department (IPD) of Pediatric Department of a tertiary Medical College Hospital Veer Surendra Sai Institute Of Medical Science & Research Center, Burla, Odisha, India enrolling 64 child patients aged between 2 year to 14years by random sampling with inclusion criteria. Patients were enrolled & randomly allocated into intervention & control group by randomization by computer generated mixed block randomization. Pain was measured at the time of hospitalization with help of Wong Baker Faces Scale (WBS) for children between 2-8 years of age & Visual Analog Scale (VAS) Pain Score for children between 8-14 years of age.

Treatment was initiated in the form of case group receiving oral L-argininesachet, Control group was probiotic sachet. L-arginine & probiotic sachet were being mixed with 200ml of water & being served to the patient. L-arginine was at dose of 100mg/kg/dose three times a day with maximum dose of 10gm for 15 doses or untill discharge whichever occurs first. Control group was given probiotic sachet.

All the patient were monitored as regard pain severity after 24hour of oral therapy till pain relief & discharge. The relevant data including demographic characters like age, gender, HbS %, previous history of vaso occlusive crisis, treatment with hydroxyurea is collected &analyzed.

The above table shows age wise distribution of total cases admitted with sickle cell VOC. Age group between 6-10year contributes to majority of cases with 55%, least being 11-14 year age group which contributes to 10%, 2-5year age group contributes to 35%. Table 1

Age group between 6-10year contributes to majority of cases with 55%, least being 11-14 year age group which contributes to 10%, 2-5year age group contributes to 35%. Comparison of mean weight of the study participants between two groups, maximum number of patient had weight between 21-25kg, while patient between 26-30 & 31-35kg were comparatively less. Most (42.2%) of SCD patients had height measuring between 101-120cm, height between 141-160cm is very less (6.2%). Majority (65.1%) of SCD patient had BMI ranging from 16-18, followed by 13-15(22.2%) & 19-21(12.7%). As far as socioeconomic level is concerned majority falls on upper middle & lower middle groups (31.2%).Table 2

The table signifies that most of patient had 3-4episodes of hospitalization for VOC in the past. Majority of SCD patients had severe pain during admission as evidenced by pain score ranging from 7-9(45.3%) followed by 4-6(37.5%) & 1-3(17.2%) during admission. All SCD patients were using hydroxyurea.Table 3

Most of SCD had HbS % from 56-60% (35%) followed by 61-65 %(23.4%). Majority of SCD had TLC from 8000-10999per mm3(40.6%) & 11000-15000per mm3(39.1%). Most of SCD patient had haemoglobin concentration between 7.1-8gm/dl(50%) followed by 8.1-9gm/dl(45.3%). The mean LFT profile of among two study groups, which shows mean LFT profile within normal limit for choicing patient for study group. All the SCD patient had renal profile within normal limit with majority of patient having Sr.creatinine level between 0.6-0.8mg/dl (53.1%), followed by 0.3-0.5mg/dl(39.1%)Comparison of efficacy of Arginine in VOC management in term of post-interventional outcomes.Table 4

Mean fall in pain score in case group is 5.09 as compared to 3.59 in control group with P value less than 0.001 which shows significant reduction in pain score in case group. There was significant reduction in pain score in case group at 24hr, 48hr & 72hr with P value less than 0.05.Table 5

Mean length of hospital stay in case group is 2.16, while in control group it is 2.69, which shows significant reduction in length score in case group. The case group had maximum hospitalization till day2 while control had maximum hospitalization till day 3. To evaluate the role of Arginine therapy in relieving the pain, the time require to reduce the pain was considered as marker & hence, duration of hospital stay. If the duration of hospital stay was less than or equal to 2 days, it was considered success & more then 2 days was considered failure.Table 6

The success rate with arginine was very good as indicated by the p value of 0.001097 without any side effect. Table 7

Outcome + Outcome - Total Inc risk * Odds

Exposed + 11 24 35 31.4 0.458 Exposed - 21 8 29 72.4 2.625 Total 32 32 64 50.0 1.000

Point estimates & 95% CIs:

Inc risk ratio 0.43 (0.25, 0.74)

Odds ratio 0.17 (0.06, 0.52)

Attrib risk in the exposed * -40.99 (-63.37, -18.60)

Attrib fraction in the exposed (%) -130.41 (-294.77, -34.48)

Attrib risk in the population * -22.41 (-42.78, -2.05)

Attrib fraction in the population (%) -44.83 (-78.74, -17.35)

Uncorrected chi2 test that OR = 1: chi2(1) = 10.656 Pr>chi2 = 0.001

Fisher exact test that OR = 1: Pr>chi2 = 0.002

Wald confidence limits

CI: confidence interval * Outcomes per 100 population units

Measures of association strength: 7

Measures of effect in the exposed: 3 1

Number needed to treat for benefit (NNTB) & harm (NNTH): 5

Measures of effect in the population: 4 2

Discussion

Sickle cell disease is one of most common hemoglobinopathy in India. It is more prevalent in western Odisha, Maharashtra, Madhya Pradesh. Vaso-occlusive crisis in sickle cell disease is one of the most common morbidity encountered during early childhood phase of life .Vaso-occlusive crisis is one the most common indication requiring hospitalization .Number of pharmacological & non pharmacological approaches are being used for relief of pain.

As evidenced in the prevalence of vaso-occlusive crisis in Sickle cell disease patient admitted in present study is more in age group between 6-10years (54.7%) followed by 2-5years (34.4%) & 11-14years (10.9%). Studies done by Mohammed Zolaly, , Ghaidaa Al-Mohammadi et 17 all had similar finding which may be related to less knowledge about sickle cell vaso-occlusive crisis during initial few years .

The majority of sickle cell vaso-occlusive crisis is contributed by male patients (70.3%) as compared to female patients (29.7%). In current study majority of sickle cell disease patient had mean weight of 22.67. Mean weight among case group was 22.91, while mean weight among control group was 22.44. Weight for age is less than normal as compared to normal healthy patient. Malnutrition, infection, psychological effect, parents negligence towards their child may be the contributing factor for less than normal weight for age . These are finding are similar to Amanda Cristina da Silva de Jesusa, TulioKonstantyner et al.18

We found sickle cell disease patients had less height for age compared to normal healthy child. Mean height among case group was 115.53, while in control group was 114.91. This discrepancy is may be due to consequences of the disease, such as repetitive infections, pain, blood transfusions & frequent hospitalization which highlights the importance of inadequate nutritional support.

Since both weight & height were less than normal for age as compared to normal healthy child, BMI(Body Mass Index) of sickle cell disease patients were less than normal as per age. It can explained by undernourishment & co-morbidities associated with sickle cell disease

Most of sickle cell disease patient admitted with vaso-occlusive crisis were belonging into lower socio-economic in present study status which will effect the nutritional support, absenteeism & lower school performance. Low level of education of children’s guardians, which makes it difficult to get a formal job. Thus, families are more inclined to work with informal & uncertain services, without the security of a monthly income.

In present review, just homozygous sickle cell illness patient conceded with vaso-occlusive emergency were being considered. Thus, every one of the patient had HbS rate over half. Mean HbS rate is 58.95%. Transcendent HbS % lies between56-60% (35%) trailed by 61-65 %(23.4%)&50-55% (18.8%). More the HbS%, more the possibilities of vaso-occlusive emergency.

In present review, greater part of sickle cell illness patient had previous history of hospitalization for vaso-occlusive emergency. The vast majority of sickle cell illness patient had 3-4 episode of hospitalization (67.2%), whileless than 3 episode of vaso-occlusive episode was noted 20.3%, 5-6 episode of vaso-occlusive episode was noted among 12.5% of sickle cell infection patient. These rising episodes of vaso-occlusive emergency is might be a result of expanded degree of HbS% and diminished degree of Fetal haemoglobin(HbF), more significant level of haematocrit, relationship with alpha thalassemia. Comparable finding were seen with Deepika S. Darbari, Vivien A. Sheehan, Samir K. Hotshot et al.19

In present review, all the sickle cell illness patients were on ordinary hydroxyurea theraphywho got conceded for vaso-occlusive emergency. Hydroxyurea is found to decrease the vaso-occlusive episodes. Hydroxyurea is found to diminish the majority of morbidities connected with sickle cell illness. Hydroxyurea stays a foundation of customary administration inferable from its oral viability and low poisonousness. The infection changing properties of hydroxyurea were at first ascribed to its capacity to actuate fetalhemoglobin and decline hemoglobin S polymerization. Other advantageous impacts have along these lines arisen including expanding complete hemoglobin levels, diminishing platelet and white platelet counts, changing articulation of bond atoms, and nitric oxide age. Comparative discoveries were seen with study done by Paolo Rigano, Lucia De Franceschi, Laura Sainati, Antonio Piga et al. 20

Greater part of patients had complete leucocyte count running between8000-10999 cells/mm3(40.6%), 11000-15000 cells/mm3 (39.6%), followed by 5000-7999 cells/mm3 (20.3%). Endothelial brokenness and sterile irritation, which are signs of SCD, may add to upregulation of selectins (P-and E-), vascular-cell-bond atom 1 (VCAM-1), ICAM-1, and significant leukocyte chemo attractants or interleukin-8 (IL-8) on endothelial cells. 21

Larger part of sickle cell infection patient had hemoglobin level going from 7.1-8gm/dl (half), while 45.3% patient had hemoglobin level going from 8.1-9gm/dl, not many patient had hemoglobin from 6.1-7gm/dl (4.7%). In sickle cell illness there is harm to coursing erythrocytes happens with wide variety among people. This heterogeneity emerges from contrasts in natural attributes of sickle erythrocytes, as heterocellular fetal hemoglobin (HbF) conveyance, HbSconcentration, hydration, and thickness and the cell's ecological advances from large scale to microcirculation, laminar to fierce stream, normoxia to hypoxia, isotonic to hypertonic climate. Subsequently the greater part of sickle cell illness patient had hemoglobin levels in lower limit according to their age, orientation. These finding were like review done by Gregory J. Kato, Martin H. Steinberg, and Mark T. Gladwin.22

Persistent liver injury in patients with sickle cell illness is a multifactorial peculiarity relying for the most part upon covering elements like iron over-burden and viral harm as opposed to essential sickness itself. Liver Pathology found in sickle cell illness incorporates Intrasinusoidal sickling and Kupffer cell hyperplasia, hepatitis, constant latent clog, normal conduit deterrent, alcoholic liver infection, pregnancy, collagen-vascular illness and sarcoidosis. Present review doesn't corelate with study done by Emel Gürkan, Yilmaz Ergun, Suzan Zorludemir, Fikri Başlamişli, Rikkat Koçak. 23 In current review patient are chosen when there is no previous liver pathology.

Sickle cell illness patient with renal capability test inside typical breaking point, are being remembered for the current concentrate as exhibited in table 15, Majority of sickle cell infection patient had Sr creatinine level going between 0.6-0.9mg/dl (53.1%), while not very many sickle cell illness patient had Sr creatinine level going from 0.9-1.1mg/dl (7.8%), outstanding patients had Sr creatinine level going from 0.3-0.5mg/dl (39.1%). Renal contribution is normally more serious in homozygous illness (sickle cell frailty, HbSS) than in compound heterozygous sorts of SCD (for instance HbSC and HbSβ +-thalassaemia), and is commonly gentle, less pervasive, in the heterozygous state (sickle cell characteristic, HbAS). Renal inclusion contributes considerably to the lessened future of patients with SCD. Renal inclusion can happen over the lifetime of a patient with SCD. Signs like hyperfiltration, hypertrophy, and hindered urinary concentrating skill are portrayed as soon as in earliest stages. Microalbuminuria is seen in certain patients in adolescence, though haematuria and intense kidney injury (AKI) can happen at whatever stage in life. Large scale albuminuria will in general happen in ahead of schedule to center adulthood, and can be joined by relapse of the glomerular filtration rate (GFR) to the typical reach. In the later many years, the gamble of constant kidney illness (CKD), moderate decrease of GFR, and end-stage renal sickness (ESRD) increments. These discoveries were not predictable with study done by Karl A. Nath and Robert P. Hebbel 24 as the consideration measures for present review was renal capability test inside ordinary breaking point.

A large portion of sickle cell infection patient had moderate to extreme vaso-occlusive episodes. Torment in sickle cell illness typically follows the four sequential advances. The vast majority of gentle type of vaso-occlusive episodes is being overseen in home by utilizing NSAIDs (Non-Steroidal Anti Inflmmatory Drugs) and oral hydration treatment. When vaso-occlusive episode becomes insufferable, patients come to clinic, during which they are assessed for the hastening reason for vaso-occlusive episode like pallor, leucocytosis, drying out and treated appropriately. Moderate agony are dealt with powerless narcotics alongside Non-Steroidal Anti-InflmmatoryDrugs. Comparative outcomes were seen with study done by Miller ST, Sleeper LA, Pegelow CH, Enos LE, Wang WC et al. 25

Conclusion

Sickle cell illness is perhaps of the most well-known hemoglobinopathy in India. Now and again connected with alpha, beta-thalassemia. Different co-morbidities related with sickle cell illness incorporates stroke, leg ulcers, priapism, intense chest syndrome, aplastic emergency, vaso-occlusive episode. Sickle cell infection is a condition where multisystem are impacted. It influences the renal, pneumonic, vascular framework, genitalia, appendages, cardiovascular, gastrointestinal systems. A vaso-occlusive emergency is one of the most well-known signs for hospitalization. It is encouraged by different variables like HbS polymerization, lack of hydration, stress, contamination, sickliness, openness to cool, raised neutrophil and platelet count. Milder vaso-occlusive episodes are being overseen in-home by oral NSAIDs, while a moderate and serious assortment of torment looks for hospitalization care. It normally follows 4 stages beginning from unclear agony to die down. It is all the more generally found in male kids when contrasted with female youngsters in the early age bunch. The majority of the patients were having a place into center and lower financial situations with. Most of the patient were undernourished as appeared by lower weight, level and BMI when contrasted with offspring of a similar age bunch.

Leucocyte count is elevated in sickle cell disease along with the increase in pro-inflammatory cytokines. Hemoglobin level is reduced due to intravascular hemolysis, dehydration, circulation through the microvessels. Renal involvement results in hyperfiltration, hypertrophy, & impaired urinary concentrating ability in infancy. Liver damage is caused by primary pathology in sickle cell disease, along with that liver damage is also caused by iron load & viral damage which will result in intrasinusoidal sickling & Kupffer cell hyperplasia, hepatitis, chronic passive congestion, common duct obstruction. Hydroxyurea is a cornerstone in sickle cell disease which helps to prevent the co-morbidities related to sickle cell disease, it is recommended to start hydroxyurea therapy from 9 months of age. It acts by various mechanisms like enhancing HbF, reducingHbS polymerization, release NO.

L-arginine plays a vital role in treating vaso-occlusive episodes. It acts by releasing nitric oxide from endothelium thereby resulting in vasodilatation. It helps to reduce the pain gradually as evidenced by noting down pain score at the time of admission & every 24 hours of therapy till discharge. It also helps to reduce the mean duration of hospitalization in vaso-occlusive episode

Authors’ Contribution

Subas Chandra Majhi - Study concept, Research design; Santosh Patil - Literature, Data collection; Himanshu Nayak - Data compilation, Method; Sameer Kiro - Data analysis, Method, Sitanshu Kumar Meher - Method, design; Mangal Charan Murmu - Manuscript preparation & Editing, Coordination

Source of Funding

None.

Conflict of Interest

None.