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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 41  |  Issue : 3  |  Page : 144-147

Serum micronutrient levels and disease severity score in patients with sickle cell anaemia


1 Department of Hematology, Nnamdi Azikiwe University, Nnewi, Nigeria
2 Department of Medical Laboratory Science, College of Health Sciences, Nnamdi Azikiwe University, Nnewi, Nigeria
3 Department of Chemical Pathology, Nnamdi Azikiwe University Teaching Hospital, Nnamdi Azikiwe University, Nnewi, Nigeria

Date of Submission13-Nov-2015
Date of Acceptance07-Dec-2015
Date of Web Publication27-Dec-2016

Correspondence Address:
John C Aneke
Department of Hematology, PMB 5025, Zip Code: 435101, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-1067.196220

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  Abstract 

Background Disease severity in patients with sickle cell anaemia (SCA) is accentuated by the risk for infection, which could potentially be influenced by serum levels of micronutrients, particularly those that are components of the antioxidant system of the body.
Objective The aim of this study was to evaluate serum levels of the micronutrients zinc, copper, selenium and magnesium in our SCA patients and to compare these with the objective score of disease severity.
Patients and methods Twenty-six confirmed (using cellulose acetate electrophoresis, in alkaline pH) homozygous sickle cell patients were prospectively recruited in steady-state conditions. Each participant had 8 ml of venous blood collected for haemoglobin electrophoresis and determination of serum levels of the micronutrients zinc, copper, selenium and magnesium (using atomic absorption spectrophotometry). The objective score of disease severity was calculated as previously described and correlated with serum micronutrient levels using the Pearson's linear regression for bivariate correlation. A P value less than 0.05 was taken as significant. Ethical approval was obtained from the institutional review board and each participant gave informed consent.
Results The mean age of study participants was 21.58 ± 9.58 years, and the mean serum level of selenium, copper, magnesium and zinc was 0.60 ± 0.29, 0.13 ± 0.07, 8.76 ± 1.14, and 0.40 ± 0.14 mg/l, respectively. Serum copper was significantly correlated with disease severity score (r = 0.61, P = 0.001), whereas no significant correlation was observed between disease severity score and other micronutrients.
Conclusion Serum copper level has the potential to become a surrogate marker of disease severity in steady-state SCA patients.

Keywords: disease severity score, serum micronutrients, sickle cell anaemia


How to cite this article:
Okocha CE, Aneke JC, Manafa PO, Nwogbo SC, Ibeh NC, Onah CE. Serum micronutrient levels and disease severity score in patients with sickle cell anaemia. Egypt J Haematol 2016;41:144-7

How to cite this URL:
Okocha CE, Aneke JC, Manafa PO, Nwogbo SC, Ibeh NC, Onah CE. Serum micronutrient levels and disease severity score in patients with sickle cell anaemia. Egypt J Haematol [serial online] 2016 [cited 2020 Jan 21];41:144-7. Available from: http://www.ehj.eg.net/text.asp?2016/41/3/144/196220


  Introduction Top


Sickle cell disease (SCD) is highly prevalent in sub-Saharan Africa and other parts of the world. Globally, it has been estimated that up to 87% of the 330 000 infants born annually with haemoglobin disorders have this disease [1]. Sickle cell anaemia (SCA) is the most severe form of SCD and typically presents with recurrent episodes of vaso-occlusion and inflammation with resultant progressive end-organ dysfunction [2]. A number of studies have documented scoring indices with which to estimate disease severity in patients with SCA, using parameters such as blood counts and markers of inflammation [3],[4].

Micronutrients have been ascribed very important roles in the catalytic activity of major antioxidant systems in the body. The elements copper and zinc form a part of the superoxide dismutase (Cu–Zn–SOD) antioxidant system, whereas selenium forms an important component of the enzyme glutathione peroxidase. These enzyme systems work in concert to rid the body of harmful oxidant species generated in the course of normal body metabolism. The SOD system catalyzes the breakdown of superoxide radicals to hydrogen peroxide, which is scavenged and subsequently removed by glutathione peroxidase [5],[6]. The importance of these elements was highlighted in the work of El-Behairy et al. [7], in which decreased function of the SOD and glutathione peroxidase enzyme systems was documented in deficiency states of selenium, zinc and copper, with potential increase in the risk for oxidant tissue damage. In Ibadan, south–west Nigeria, Arinola et al. [8] observed lower levels of micronutrients in SCD patients, compared with haemoglobin AA controls and attributed this to the high demand of antioxidants for tissue repair, occasioned by high predisposition to infection (particularly malaria) in these patients.

Even though a number of studies had evaluated serum levels of micronutrients in patients with SCD, very few (to the best knowledge of the authors) compared these with objective scores of disease severity, particularly in Nigerian cohorts [8],[9],[10],[11]. The present study was therefore designed to evaluate serum levels of micronutrients (zinc, copper, selenium and magnesium) in Nigerian SCA patients and to compare these with objective scores of disease severity.


  Patients and methods Top


Twenty-six confirmed (by cellulose acetate electrophoresis, in alkaline pH) homozygous sickle cell patients who routinely visited the Haematology Outpatient Clinic of our hospital participated in this study. They were consecutively recruited at presentation for follow-up clinics. Inclusion criteria were confirmed haemoglobin SS phenotype and being in steady-state conditions. Steady-state conditions were defined as no manifest crises in the last 1 month and no blood transfusion 3 months preceding recruitment [12]. Each participant had 8 ml of venous blood collected following standard procedure for phlebotomy; a volume of 3 ml was transferred into ethylenediaminetetraaceticacid tubes for haemoglobin electrophoresis and the remaining was transferred into plain tubes and left on the bench to clot for ~20 min. Thereafter, serum was extracted from the clotted sample by means of centrifugation at 5000 rpm for 5 min and dispensed into clean plain tubes for determination of serum levels of the micronutrients zinc, copper, selenium and magnesium. These were measured using atomic absorption spectrophotometry, as previously described by L’vov [13]. Objective severity scores were calculated using the protocol earlier described by Okocha et al. [4].

All data analysis was carried out using SPSS (version 20 computer software; SPSS Inc., Chicago, Illinois, USA) and the results of serum level of micronutrients was presented as means ± SD. Relationship between objective severity scores and serum levels of micronutrients was assessed using the Pearson's linear regression for bivariate correlation. A P value less than 0.05 was accepted as significant.

Ethical approval for this study was obtained from the institutional review board and each participant gave informed consent.


  Results Top


The mean age of study participants was 21.58 ± 9.58 years, and the mean serum level of selenium, copper, magnesium and zinc was 0.60 ± 0.29, 0.13 ± 0.07, 8.76 ± 1.14, and 0.40 ± 0.14 mg/l, respectively ([Table 1]).
Table 1 Age and serum micronutrient levels in test participants

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The correlation analysis between serum levels of selenium and copper with severity score in study participants is shown in [Table 2]. There was no significant correlation between serum selenium levels and severity score (r = −0.32, P = 0.12), whereas serum copper was significantly correlated with severity score (r = 0.61, P = 0.001). [Figure 1] is a scatter plot, showing the positive significant correlation between serum copper and disease severity score in test participants.
Table 2 Correlation of micronutrient levels with severity score in test participants

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Figure 1 Scatter plot of sickle cell severity score and serum copper (Cu) concentration in test patients.

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Serum magnesium and zinc levels were not significantly correlated with severity score of test participants in this study (r = 0.02, P = 0.93, and r = −0.17, P = 0.42, respectively; [Table 2]).


  Discussion Top


Patients with SCD have long been known to have subnormal immune status, which is believed to be due to reduced efficiency of the alternate complement pathway [14]. In addition, homozygous haemoglobin S disease (HbSS) patients have what has been described as functional asplenia (arising from ‘autosplenectomy’), which predisposes them to infections by a number of microorganisms, particularly those that are encapsulated [15]. These observations significantly increase infection risk in these patients. Gaston et al [16] reported the inclusion of antibiotic prophylaxis with penicillin V as a part of their management, especially in those under the age of 5 years. The high predisposition to infection in these patients potentially increases tissue oxidant stress and justifies the importance of a robust and intact antioxidant system.

Arinola et al. [8] had observed that micronutrient levels (and antioxidant status) were low in SCD patients, particularly in those with malaria infection, and advocated micronutrient supplementation in patients in malaria-endemic regions. The micronutrient selenium is known to attenuate the adverse tissue effects of microbial inversion through the glutathione peroxidase antioxidant system [5],[6]. Indeed, studies have indicated that depleted serum levels of selenium could be associated with worse outcomes in some infectious diseases, particularly the HIV infection [17],[18]. Baum et al. [19] reported that low selenium and multivitamin levels were associated with a higher risk for HIV progression in the treatment naive patients in Botswana and recommended selenium and multivitamin supplementation in these patients. The importance of adequate serum levels of selenium in patients with SCD was highlighted in the study by Durosinmi et al. [11], in which the deficiency state of this element was reported to be associated with biochemical and functional red cell abnormalities. The serum selenium level observed in this study was lower than what was earlier reported among haemoglobin AA controls in Ibadan, south–west Nigeria (0.60 ± 0.25 vs. 67.9 ± 22.0 mg/l, respectively) and was negatively correlated with objective severity score in participants. This was, however, not statistically significant (r2 = −0.32, P = 0.12; [Table 1]) [8]. This observation may imply that, even though the role of selenium in immune function is well recognized, it does not appear to significantly have impact on markers of disease severity in patients with SCA.

The micronutrients zinc and copper are components of the Cu–Zn–SOD antioxidant system and deficiency states have been associated with reduced antioxidant activity with potentially increased infection risk and even growth retardation [7],[9]. A number of reports have observed zinc deficiency in SCD patients and attributed this to increased urinary loss (hyperzincuria) and adverse effects of some medications, such as hydroxyurea [20],[21]. In this study, both serum copper and zinc levels were lower than that previously reported in haemoglobin AA controls in Nigeria (0.13 ± 0.07 and 0.40 ± 0.14 mg/l vs. 60.8 ± 16.0 and 17.2 ± 5.0 mg/l, respectively) [8]. We observed a significant positive correlation between the serum level of copper and objective severity score in study participants ([Table 1]). Studies have shown that intracellular copper could potentially induce red cell haemolysis, through its ability to generate superoxide ions in the presence of sulfhydryl groups [22],[23]. When haemolysis occurs, particularly intravascularly, free haemoglobin is released, which scavenges and depletes nitric oxide (a potent vasodilator) as well as dysregulates arginine metabolism, leading to increased preponderance of complications such as sickle nephropathy and acute chest syndrome [24],[25]. We therefore hypothesize that the significant positive correlation observed between copper and disease severity score in this study could be linked to the effect of copper-induced red cell haemolysis in triggering disease-related complications in SCA patients.

There was no significant correlation between serum zinc levels and disease severity score in our study participants. This is in agreement with the report of Akenami et al. [10] in steady-state SCD patients at the University College Hospital, Ibadan, Nigeria.

The lower serum levels of selenium, copper and zinc in our study compared with previous report in haemoglobin AA controls is reiterated by the findings of Arinola et al. [8] and has been attributed to high demands from oxidant tissue damage, which is worsened by the high prevalence of infection in SCA patients.

The micronutrient magnesium has been reported to be cardioprotective, being associated with a reduced prevalence of adverse cardiac events, particularly atrial fibrillation and supraventricular tachycardia, in the normal population [26]. The serum level of magnesium in this study was higher than that observed in an earlier report that involved haemoglobin AA controls (8.76 ± 1.14 vs. 5.1 ± 1.3 mg/l, respectively) [8]. Akenami et al. [10] similarly reported a higher serum level of magnesium in steady-state SCA patients compared with controls in Ibadan, south–west Nigeria. Even though the reason for the higher serum magnesium levels in SCA patients was not apparent from this study, it may in fact be protective with regard to sickling of red blood cells. Magnesium has been noted to inhibit the Gardos channels in red cells, thereby enhancing cellular hydration with subsequent reduction in the propensity to sickling [27]. There was no significant correlation between serum magnesium level and objective score of disease severity in our study patients.


  Conclusion Top


SCA patients had lower micronutrient levels compared with earlier-defined cutoffs in normal (haemoglobin AA) individuals in Nigeria (with the exception of serum magnesium levels). This is in agreement with similar reports in the literature and has been attributed to the increased antioxidant demands of SCA occasioned by higher predisposition to infections, especially malaria. Serum copper level correlated positively with disease severity in this study. This could be a pointer to the role of copper in triggering red cell haemolysis, a phenomenon that has been linked with a number of SCA-related complications. Serum copper level could potentially become a surrogate marker of disease severity in steady-state SCA patients. We suggest further research on this topic, using a larger number of steady-state SCA individuals to further corroborate this observation.

Limitation

The small number of steady-state SCA patients recruited into this study is a limitation.

Acknowledgements

C.E. Okocha designed the project, critically reviewed the manuscript for intellectual content, gave approval for version to be sent for publication, guarantor of the work. J.C. Aneke carried out literature search, manuscript preparation, data interpretation, reviewed manuscript for intellectual content. P.O. Manafa contributed in project design, conducted experimental studies, manuscript review. S.C. Nwogbo contributed in project design, conducted experimental studies, manuscript review. N.C. Ibeh contributed in data interpretation, manuscript review for critical intellectual content. C.E. Onah carried out statistical analysis and data interpretation, reviewed the manuscript for intellectual content.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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