J. P. Kasteleln,2 D. P.M. Brandies,2 W. M. Malruhu,1 and A. van den ... values similar to the method described by Van Kampen and ..... Invest 33, 287 (1974). 9.
I CLIN.CHEM.31/7, 1232-1234 (1985)
UnnaryCreatine:BiochemicalIndicatorfor Evaluationof SickleCell Crises C. Beyer, L W. Statlus van Epa,2J.J. P. Kasteleln,2 D. P.M. Brandies,2 W. M. Malruhu,1 and A. van den Ende1 In a patient with known sickle cell #{176}-thalassemia we measured serum lactate dehydrogenase (LD) activity and 24-h urinary creatine excretion rate as markers to evaluate sickle cell crises. We believe that a distinction based on biochemical findings can be made between hemolytic and painful vaso-occlusive sickle cell crises withmuscularinvolvement. To assesshemolytic crises by objective biochemicalmeasures, we have used assay of LD activity, and to assess painful crises with muscular involvement objectively, the 24-h urinarycreatine excretion rate. We concludethat hemolytic
genase (LI); EC 1.1.1.27) activity during three different periods of hospitalization of a patient with known sickle cell 13-thalassemia.
Objective parameters are needed for evaluating sickle cell crises, especially painful vaso-occiusive crises, for example to distinguish between a true painful crisis or an episode of Tnalingering and to investigate the effects of anti-sickling therapies. Biochemical indices to hemolysis are not always useful in the evaluation of a painful vaso-occiusive sickle cell crisis because hemolytic crises do not necessarily coincide with painful crises (1, 2). In sickle cell anemia, deoxygenation of hemoglobin within the microvasculature results in polymerization of intracorpuscular hemoglobin. This polymerization causes an increased blood viscosity and the formation of microthrombi, resulting in vascular occlusions and micro-infarctions (3). The vascular occlusions lead to the painful crises. Muscle ischemia and necrosis, which is observed in patients with sickle cell anemia (4), contributes to the episodes of pain. Several possible biochemical factors for evaluating sickle cell crises, such as a-hydroxybutyrate dehydrogenase (5, 6), alkaline phoephatase (7), creatine kinase, and myoglobm (6) in serum were investigated for their clinical usefulness. None seems satisfactory. Here we present results of our study concerning the 24-h urinaiy creatine excretion rate and serum lactate dehydro-
(13).
Methods
LI) activity in serum was measured according to the recommendations of the Scandinavian Committee on Enzymes (8,9), except that activity was measured at 25 #{176}C. We used an ACP 5040 Analyzer (Eppendorf Ger#{228}tebau, Netheler & Hinz, Hamburg, F.R.G.). Creatine kinase (CK; EC 2.7.3.2) activity in serum was crisesarecharacterized byhighserumLDactMties.Furtherof the Deutmore,we concludethat-at least in this patient-painful measured according to the recommendations sche Gesellschaft f#{252}r Klinische Chemie, also with the 5040 crisesare accompaniedby high 24-h urinarycreatineexcreAnalyzer (10). tionrates. Our findingssuggestthatmuscleInvolvementmay Hemoglobin was determined in a Hemalog 8/60 (Techniplay an important role in painful vaso-occlusivesickle cell con Instruments Corp., Tarrytown, NY), calibrated to give crises. values similar to the method described by Van Kampen and Zijlstra(11). AddItional K.yphrasee: p-thalassemia lactate deliydrogenUrinary creatine was determined according to a modified hemolytic and painful crises distinguished procedure (12) originally described by Tanzer and Gilvarg
1Department of Clinical Biochemistry, Slotervaart Hospital, Louwesweg 6,1066 EC Amsterdam, The Netherlands. 2Department of Internal Medicine, Slotervaart Hospital, The Netherlands ‘Pnt address: Department of Clinical Chemistry, Rijnoord Hospital, Delftzichtweg 2, 2402 NB Aiphen aan de Rijn, The Netherlands. Received July 2, 1984; accepted April 19,1985.
1232 CLINICAL CHEMISTRY, Vol.31, No. 7, 1985
HbS was measured by microchromatography (14) with commercially available columns (Helena Labs., Beaumont, TX). Serum haptoglobin was measured in the “PDQ” laser nephelometer (Hyland Labs., Costa Mesa, CA) according to Van Lente et al. (15).
Case History First period. A 23-year-old black man with known sickle cell #{176}-thalassemia was hospitalized at the onset of a combined hemolytic and painful vaso-occlusive sickle cell crisis. He complained of severe pain in the muscles, joints, and bones of the back, legs, and shoulders. He was treated with oxygen, analgesics, and intravenous hypotonic saline and his clinical condition improved gradually. Eight days after admission a second painful crisis occurred, for which he was treated with the same regimen. He also received two units of leukocyte-poor erythrocytes (one unit “300 mL of packed cells). During and after this second painful crisis an increase in hemolysis was observed, and 10 days after admission laboratory findings indicated a hemo. lytic crisis. During this crisis he received four units ol leukocyte-poor erythrocytes. On the 20th day after admission the patient was dis. charged from the hospital with no physical complaints. Second period. The patient was hospitalized at the onsel of a combined painful and hemolytic crisis. He complained ol pain in the head, back, and lower back; He was treated as described and also received three units of leukocyte-pooi
activity (378 U/L) and urinary creatine excretion rate (4.2 mmol/24 h) exceeded the normal reference intervals (Figure 1, Table 1). Values for haptoglobin were below the normal reference interval and decreased below detection limits during this hospitalization, and values for CK remained within the reference interval (Table 1). During the second painful crisis the urinary creatine excretion rate increased to a peak value of 6.1 mmol/24 h, while U) activity increased to 329 U/L, indicating the onset of a hemolytic crisis. During the hemolytic crisis occurring directly after the painful crisis, the 24-h urinary creatine excretion rate increased slightly, corresponding to a peak value of 521 U of U) activity per liter, low haptoglobin and hemoglobin concentrations, and reticulocytosis. Second period. At the time of this admission the value for U) activity exceeded the reference interval, while the 24-h urinary creatine excretion rate was within it (Figure 2, Table 1). However, by the next day the value for U) activity had increased almost fivefold, to 1500 U/L, and the 24-h urinary creatine excretion rate almost eightfold to a peak value of 7.0 mmol/24 h. After the combined painful and hemolytic crisis the patient developed a pure painful crisis during which the creatine excretion rate reached a peak value of 6.7 mmol/24 h while the U) activity in serum continued to decrease to normal values. During this hospi-
erythrocytes. Three and four days after admission he complained of severe pain in both legs. Five days after admission his clinical condition improved. Because of his low hemoglobin concentration he was given another three units of leukocyte-poor erythrocytes. Seven days after admission he again complained of pain and developed a pure painful vaso-occiusive sickle cell crisis. He was treated with analgesics. By 10 days after admission the pains had almost disappeared. Thirteen days after admission he was discharged from the hospital with no complaints. Third period. The patient was again hospitalized at the onset of a painful crisis. The pains were only weak, so no medication was prescribed. During this hospitalization he developed a pure hemolytic crisis, during which he received four units of leukocyte-poor erythrocytes. After improvement of the clinical situation he was discharged from the hospital with no physical complaints.
Results The severity of the patient’s disorder was characterized by the following data, obtained three months after the last blood transfusion: hemoglobin A1, 0%; A2, 6%; F, 12.4%; S, 81.6%. Mean corpuscular volume was 66 fL, mean hemoglobin per erythrocyte was 22.5 pg, and mean corpuscular concentration of hemoglobin was 35.5 g/dL of eiythrocytes. First period. At the time of this admission, values for LI)
C
ombin.d
crisis combin.d
“I.,.
p.inf,,i
14.0-
C””.
painful Cr15 S
-
1400
.6.0
L0.
#{163}
t
.500 3
-i
1000
9
4.0
.4.0
“300
C
0
0 .o
6.0
‘
60o.
a U
100 -2.0
a
0.0 10
15
0.’s
a
X
20
a
-‘
2.0
200.
C -
FIg. 1. The 24-h urinary creatine excretion rate, serum LD activIty, and hemoglobin content of a patientwithsicklecell $-thalassemia during
Indicate blood ansfusIon (see text). #{149}, 24 h creatineexcrelicn; 0, LD hemogloblnooncenfrabon -,
U
a
U 5
andaftersicklecell crises(first period) Anuws
a
10
Fig. 2. Data as In Fig. 1 forthe same patient during and aftersicklecell crises (second period)
Table 1. Some Laboratory Findings for a Patient with Sickle Cell 13-Thalassemla during Three Periods of Hospitalization 1.0actMty
CK activity U/I.
Creatins excretion, mmol/24
h
Hb, g/dL
Haptoglobin, WI-
HbS, S
First period At admIssIon
and hemolyticcrisis Painfulcrisis
378
14 4.8
11.0
329
7
6.1
8.5
Hemolytic crisis Second period At admission Combined painful and hemolyticCriSIS Painful crisis
521
18
3.5
6.3
0.69
