Sickle Cell Genetics and Pathophysiology

The Thein group conducts research on the pathophysiology of sickle cell disease (SCD) applying insights from genotype-phenotype observations to accelerate translation of basic discovery to therapeutic applications. By combining clinical, laboratory, imaging and new diagnostic techniques, we hope to improve phenotypic definition of SCD at all levels and to introduce more targeted pharmaceutical therapies for SCD. The Thein laboratory is also involved in pre-clinical and clinical testing of drugs and innovative compounds that reduce sickle hemoglobin (HbS) polymerization, improve red cell rheology, or induce fetal hemoglobin.

SCD is an inherited hemoglobin disorder prevalent in regions where malaria was historically endemic, including sub-Saharan Africa, India, the Middle East, and the Mediterranean. Currently, an estimated 300,000 affected babies are born each year, more than 80% of whom are in Africa. In the United States, SCD is considered “rare”, but nonetheless affects and estimated 100,000 Americans (the majority being of African descent) and 1 in 365 African-American births.

The single nucleotide change underpinning SCD belies the extreme variability and severity of SCD complications, that will become more apparent with aging, and presents major challenges in clinical management. Both acquired and inherited factors contribute to this clinical complexity of SCD. Numerous genetic association studies (candidate gene, genome-wide association (GWA), whole exome and whole genome sequencing) have attempted to identify genetic variants with particular disease complications. In a GWA study in 2007, the Thein group identified BCL11A as a key repressor of gamma-globin gene, a finding that resuscitated the field in fetal hemoglobin regulation and therapeutic re-activation of gamma-globin genes for the beta-hemoglobinopathies. The finding has led to genetic strategies targeting BCL11A regulation for therapeutic reactivation in SCD and beta thalassemia under clinical development with promising results.

Prediction of disease severity and clinical course of SCD has been the topic of many reviews and, to date there is no clear algorithm using genetic and/or imaging, and/or laboratory markers that can reliably predict mortality risk in SCD. The clinical implications of delineating the genetic modifiers of SCD are significant; it will provide us the ability to predict disease severity based on a genetic SCD “panel”, and dissecting the role of new genetic modifiers might suggest new therapeutic targets for investigation. A primary approach for disease risk prediction has been polygenic risk scoring but the results remain moderately successful; they may not be so applicable in a complex disorder such as SCD that has numerous potential predictor variables. Towards the advancement of personalized medicine, the Thein group is exploring new machine learning methods incorporating predictive biomarkers (laboratory, imaging, and physiological) with genetic (germline and somatic) risk variants into risk assessment algorithms to improve risk stratification before end organ damage sets in.

While we apply insights from the basic research to identify new therapeutic targets, the Thein lab is also involved in a project with Dr Bill Eaton (Laboratory of Chemical Physics, NIDDK/NIH) to discover newer anti-sickling agents using high throughput screening of drug libraries. Not only will the compounds provide further insight on the sickling mechanisms, but those that show therapeutically significant effects at concentrations known to be non-toxic can be very rapidly approved for clinical trials as these agents are either already FDA-approved or under clinical development for other diseases. It could well be that this small molecule game changer for SCD already exists among the drugs that are being used for other disorders. Furthermore, unravelling the mechanisms of the anti-sickling effects of these agents could well reveal fresh insights on the HbS fiber formation.