Int J Cardiovasc Sci.

2022; 35(6), 770-779

770

ORIGINAL ARTICLE

Association Between Lipid Profile and Clinical Manifestations in Sickle Cell Anemia:
A Systematic Review
Marina Tejo Dantas,1 Andressa Lopes,1 Ana Marice Teixeira Ladeia1
Escola Bahiana de Medicina e Saúde Pública,1 Salvador, BA – Brazil

Abstract

Introduction: Sickle cell anemia (SCA) is a genetic disease associated with frequent episodes of acute illness.
Changes in the lipid profile and a chronic inflammatory process make up the molecular aspects observed in this
disease. Associations between these mechanisms and clinical manifestations could thus define severity profiles and
therapeutic strategies.
Objectives: To verify whether there is an association between lipid profile and clinical manifestations in patients
with SCA and if there is a correlation between lipid profile and laboratory markers in this disease.
Methodology: According to the PRISMA guidelines, a systematic review of the literature was conducted by
searching the MEDLINE/PubMed, LILACS, SciELO, Scopus, and Cochrane databases. Articles were screened by
reading the titles and abstracts, reaching those selected for full-text reading. The included studies were published
between 2010 and 2020, were fully available in the databases, and addressed the proposed theme. The risk of
individual bias was assessed by using the Joanna Briggs Institute checklist and the Newcastle-Ottawa scale.
Results: Out of the 144 identified articles, 15 were selected for analysis, resulting in a sample size of 2,230
individuals. HDL-C, LDL-C, total cholesterol , and triglycerides were the main variables analyzed in the lipid
profiles. A correlation was observed between these variables and some of the most relevant clinical events in the
disease, including vaso-occlusive seizures and acute thoracic syndrome.
Conclusion: Lipid metabolism disorders, especially hypocholesterolemia and hypertriglyceridemia, are linked to
clinical events observed in SCA, suggesting they play a relevant role in the multifactorial pathogenesis of this
disease.
Keywords: Anemia, Sickle Cell; Lipids; Signs and Symptoms.

Introduction Every year, 250,000 children with SCA are born

worldwide.2 In Brazil, this number reaches 3,500 new
Sickle cell anemia (SCA) belongs to the subgroup cases/year.3 being the most frequent hereditary disease
of hereditary hemolytic anemias; its etiology is in the country.4 It is a chronic inflammatory disease
associated with a point mutation in the β-globin gene,
permeated with acute events, with high morbidity and
which has as final consequences the polymerization
early mortality.5
of deoxygenated hemoglobin molecules and sickle-
shaped cells with a reduced average life span. The The pathophysiology of SCA is complex, involving
main repercussions of the disease derive from the changes in lipid metabolism, endothelial dysfunction,
vascular obstruction caused by abnormal hemoglobin and hemolysis, in addition to a chronic inflammatory
(HbS), causing progressive ischemic lesions in process. These mechanisms are associated with markers
different organs. of disease severity.

Mailing Address: Marina Tejo Dantas

Av. Dom João VI, 275, Brotas, Salvador, BA. Postal code: 40290-000 – Brazil
E-mail: [email protected]

DOI: https://doi.org/10.36660/ijcs.20220010 Manuscript received February 3, 2022; revised manuscript April 20, 2022; accepted June 11, 2022.
Int J Cardiovasc Sci. 2022; 35(6), 770-779 Dantas et al.
Original Article Lipid profile and clinical manifestations in SCA 771

Changes in the lipid profile of patients with SCA were excluded, as well as studies that did not present
have been well documented by several studies. Low the subject of this review in the title, abstract, or full text.
levels of total cholesterol (TC), high-density lipoprotein
cholesterol (HDL-C), and low-density lipoprotein Selection of Studies
cholesterol (LDL-C) define hypocholesterolemia, while
increased triglycerides reveal hypertriglyceridemia.6-10 Two independent researchers pre-selected the
Several hypotheses may explain these findings, but studies by reading the titles and abstracts, following
lack scientific evidence.6 Studies on dyslipidemia in the predefined inclusion and exclusion criteria. A
patients with SCA have been restricted to cholesterol third researcher evaluated the articles in which there
metabolism, and a knowledge gap remains on how this was disagreement, completing the selection of articles
lipid alteration is associated with comorbidities of the for full-text reading. In the last selection stage, the
disease. The aim of this study was thus to verify whether full length of each study was analyzed, applying the
there is an association between lipid profile and clinical same selection criteria, to reach the final list of articles
manifestations of SCA. included in the review.

Methods Methodological Quality

Study Design The methodological quality of the studies was assessed

using the Joanna Briggs Institute (JBI) Critical Appraisal
This is a systematic review based on recommendations
Checklist for Analytical Cross-Sectional Studies, the most
by the Preferred Reporting Items for Systematic Reviews
recommended tool for the analysis of cross-sectional
and Meta-Analysis (PRISMA); its protocol was registered
studies, in addition to the Newcastle-Ottawa scale,
in the International Prospective Registry of Systematic
which evaluated a single cohort study. Two independent
Reviews (PROSPERO) under registration number
researchers judged the quality/risk of bias of the studies.
CRD42020214778.

Results
Search Strategy
The search and selection of studies were performed A total of 144 citations were identified in the electronic
in the MEDLINE/PubMed, LILACS, SciELO, Scopus, databases. After removal of duplicate articles and
and Cochrane databases. Each database was explored selection by reading the titles, abstracts, and full texts,
using an individualized strategy consisting of descriptors 15 articles were included in our qualitative synthesis.
among the Medical Subject Headings (MeSH) and Health The flowchart presenting the study selection process is
Sciences Descriptors (DeCS) corresponding to "sickle cell presented in Figure 1.
anemia," "sickle cell disease," "lipids," "lipid," "clinical
manifestations," "signs," "symptoms," and "comorbidity." Characteristics of the included studies
Additionally, a manual search was performed in the
Among the 15 selected articles, 14 were cross-
reference lists of the selected articles to uncover studies
sectional studies and one was a cohort study. The years
missed in the database searches. The databases were last
of publication ranged from 2010 to 2020. The sample
accessed on October 25, 2020.
size ranged from 81 to 367 participants, with a total of
2,230 individuals included in all 15 studies; 1,849 (82.9%)
Eligibility Criteria participants had sickle cell disease and 381 (17.1%) were
Original studies published and available in full in healthy individuals. HDL-C was analyzed in all studies.
the scientific databases or in printed versions, such as TC, triglycerides (TG), and LDL-C were analyzed by
observational studies (cross-sectional, cohort, and case- 14, 13, and 12 studies, respectively. Very low-density
control), experimental studies (clinical trials), and review lipoprotein (VLDL) and TG/HDL appeared in five of the
studies, published between 2010 and 2020, in English and/ articles and non-HDL C was reported in two studies,
or Portuguese, addressing the association between lipid while pro-HDL and TC /HDL were mentioned by one
profile and clinical manifestations in patients with SCA. study each. Table 1 presents the characteristics of the
Letters to the reader, editorials, and duplicate papers studies, the analyzed variables, and their main results.
 Dantas et al. Int J Cardiovasc Sci. 2022; 35(6), 770-779
772 Lipid profile and clinical manifestations in SCA Original Article

PubMed LILACS Scielo Scopus Cochrane

n = 108 n=6 n=3 n = 21 n=6

Studies identified by searching the databases

(n = 144)

Studies left after removing duplicates

(n = 126)

Studies excluded by reading the title

(n = 84)

Studies selected after reading the title

(n = 42)

Studies excluded by reading the abstract

(n = 27)

Studies selected for full-text reading

(n = 15)

Excluded studies:
• Not fully available (n = 1)
• Did not address the topic of the review (n = 4)
Studies added from reference lists
(n = 5)

Studies selected for reviewing

(n = 15)

Figure 1 – Study selection flowchart.

Int J Cardiovasc Sci. 2022; 35(6), 770-779 Dantas et al.
Original Article Lipid profile and clinical manifestations in SCA 773

Main outcome The main limitations of cross-sectional studies were

the identification and control of potential confounding
A reduction in HDL-C levels was associated with
factors. Some of the studies also did not specify the
history of cardiac abnormalities, pneumonia, priapism,
criterion used to confirm the HbSS genotype (eg,
and greater need for blood transfusion, in addition to
hemoglobin electrophoresis or liquid chromatography).
hematological parameters of more severe anemia (2, 8,
The only cohort study included in this review was
and 9). Two studies showed that high HDL-C levels were
evaluated with the Newcastle-Ottawa Scale for Cohort
related to a higher frequency of vaso-occlusive seizures
Studies – Appendix II, which showed a high level of
(VOS) (7 and 14). Decreased TC levels were found
evidence (8 in a 9-point scale).
in patients with suspected pulmonary hypertension
(PH), history of priapism and ulcers in the lower limbs,
and individuals with VOS (2 and 3); they were also
Discussion
correlated with more severe anemia (1). Elevated TC
The alterations in lipid metabolism found in patients
levels were associated with cholelithiasis (8) and a
with SCA are marked by hypocholesterolemia and
history of pneumonia (7). Increased TG levels showed a
hypertriglyceridemia. The main mechanisms proposed to
positive correlation with cholelithiasis (8), in addition to
justify hypocholesterolemia are: (1) increased cholesterol
electrocardiographic abnormalities (4), history of acute
consumption for the synthesis of new red blood cells
thoracic syndrome (ATS), VOS, more severe anemia (6),
due to lower survival or increased hemolysis; and (2)
elevated markers of PH (9), and relative hypertension
dilution of serum cholesterol by decreased erythrocytic
in patients with SCA (BP ≥ 120/70 mmHg and < 140/90
mass and increased plasma volume. 11 In addition,
mmHg) (11). Conversely, one study showed a negative
reduced liver function can lead to lower cholesterol
correlation between VOS and TG, as well as between
production and increased TG. Chronic anemia induces
VOS and LDL-C (3). LDL-C also showed a negative
catabolism, which generates greater release of free fatty
correlation with lower limb ulcers (6) and anemia
acids; their increased supply to the liver leads to higher
severity (7), and a positive correlation with cholelithiasis
TG production.
(8) and pneumonia (6). Elevated VLDL levels were also
The analyzed studies showed an association between
associated with cholelithiasis (8), reduced systolic blood
lipid profile and clinical events observed in SCA . HDL-C,
pressure, and increased diastolic blood pressure (12).
TC, TG, and LDL-C were among the most frequently
Pro-HDL showed a positive correlation with suspected
explored variables.
PH and a negative correlation with priapism (2). High
TG/HDL ratios were associated with a higher number Five studies showed an association between reduced
of ATS and VOS episodes and had a positive correlation HDL-C levels and clinical complications or markers of
with lactate dehydrogenase (LDH), leukocyte count, more severe anemia. Low HDL-C was found in patients
and flow velocity in the right and left cerebral arteries; with history of priapism by Ataga et al. (2015);12 history of
a negative correlation with Hb levels was also observed cardiac abnormalities, pneumonia, and greater need for
for this parameter (6). In one of the studies, ATS, VOS, blood transfusion were found by Seixas MO et al. (2010).13
and osteonecrosis were not affected by TC, HDL-C, and Therefore, HDL was not only a potential biomarker of
LDL-C levels (10); in another study, no correlation was clinical severity, but also linked to laboratory worsening
found between these parameters and markers of PH (9). of the disease. Regarding TC, Zorca et al. (2010) 14
One study explored hearing loss in patients with SCA, reported an inverse correlation between TC levels,
not verifying any associations between lipid profile and HDL-C, and LDL-C and anemia severity. This evidence
such outcome (5). was corroborated by Valente-Frossard et al. (2020)15 and
Emokpae, Kuliya-Gwarzo (2014),16 who also observed
worsening of inflammation, with increased leukocytes,
Quality of the included studies
monocytes, and platelets. Emokpae reinforced the
In the evaluation of cross-sectional studies, among the correlation between reduced HDL-C and a greater need
14 articles analyzed in this review, 12 presented a low risk for blood transfusions, in addition to a higher frequency
of bias (70%-100% of "Yes" answers in the JBI checklist), of VOS. In this sense, Aleluia et al. (2017)17 bring
while 2 studies were classified as having a moderate evidence of a direct association between HDL-C and fetal
risk of bias (50%-69% of "Yes" answers) – Appendix I. hemoglobin (HbF ), whose role is important to prevent
 774

Table 1 – Characterization of the included studies

Dantas et al.

Author Lipid
(year of Country Title Population profile Main results
publication) analyzed

TC
Lipid profile and clinical manifestations in SCA

Association of classical markers and HDL-C HDL-C levels greater than 40.0 mg/dL were associated with
Aleluia MM et al. 99 HbSS patients in steady
1 Brazil establishment of the dyslipidemic LDL-C an improvement in hematological parameters (red blood
(2017) state
subphenotype of sickle cell anemia VLDL-C cell count, Hb, and Ht), in addition to an increase in HbF.
TG

Pro-HDL was increased in patients with suspected

117 patients with sickle cell pulmonary hypertension and decreased in patients with
Association of pro-inflammatory disease: history of priapism.
TC
high-density lipoprotein cholesterol (91 HbSS; 13 HbSC; 5 HbSβ0- TC was reduced in patients with suspected pulmonary
Ataga KI et al. HDL-C
2 USA with clinical and laboratory variables thalassemia and 8 HbSβ+ hypertension. There was a trend towards lower TC levels
(2015) Pro-HDL
in sickle cell disease -thalassemia) in patients with history of priapism and ulcers in the
in addition to 11 healthy lower limbs.
patients (control) HDL was also decreased in patients with history
of priapism.

58 HbSS adults (30 in steady TC

Defective lipid metabolism in sickle state and 28 in vaso-occlusive HDL-C TC, LDL, TG, and TG/HDL were significantly reduced
Akinlade KS et al.
3 Nigeria cell anaemia subjects in vaso- crisis) LDL-C while HDL was increased in patients in vaso-occlusive
(2014)
occlusive crisis in addition to 24 healthy TG crisis when compared to patients in a stable disease state.
adults (control) TG/HDL

TG levels showed a positive correlation with the PR

TC
Electrocardiographic abnormalities 62 HbSS children interval.
Adegoke SA et al. HDL-C
4 Nigeria and dyslipidaemic syndrome in and 40 healthy people of the Mean TG levels were significantly elevated in patients with
(2016) LDL-C
children with sickle cell anaemia same age group SCA and ECG abnormalities compared to those with a
TG
normal ECG.

TC
Rissatto-Lago MR 37 HbSS patients in steady HDL-C
Hidden hearing loss in children and No association was observed between lipid profile and
5 et al. Brazil state and 44 healthy controls LDL-C
adolescents with sickle cell anemia increased acoustic reflex thresholds.
(2018) (all 6-18 years of age) TG
TG/HDL
Original Article
Int J Cardiovasc Sci. 2022; 35(6), 770-779
 Elevated TG/HDL in patients with SCA was associated
Higher TG/HDL-cholesterol ratios TC with more episodes of acute chest syndrome and vaso-
Original Article

hallmark disease severity in children 55 HbSS patients in steady HDL-C occlusive crises.
Teixeira RS et al.
6 Brazil and adolescents with sickle cell state and 41 healthy controls LDL-C TG/HDL also had a positive correlation with LDH,
(2019)
anemia (all 6-18 years of age) TG WBC count, and flow velocity in the right and left cerebral
TG/HDL arteries, in addition to a negative correlation with
Hb levels.
Int J Cardiovasc Sci. 2022; 35(6), 770-779

TC
Investigation of Lipid Profile and Patients with history of pneumonia had increased levels of
HDL-C
Guarda CC et al. Clinical Manifestations in SCA 126 HbSS patients in steady TC and LDL-C. Previous history of lower limb ulcers was
7 Brazil LDL-C
(2020) Children state associated with reduced LDL-C levels. Individuals with
VLDL-C
history of pain crises presented elevated HDL-C levels.
TG

TC Decreased HDL-C levels were associated with a history

152 HbSS children in steady
Levels of high-density lipoprotein HDL-C of cardiac abnormalities, pneumonia, and need for blood
Seixas MO et al. state
8 Brazil cholesterol (HDL-C) among children LDL-C transfusion.
(2010) and
with steady-state sickle cell disease VLDL-C Elevated levels of TC, LDL-C, VLDL-C, and TG were
132 healthy children
TG associated with the occurrence of cholelithiasis.

328 adults with SCA in a TC, HDL-C, and LDL-C were inversely correlated with
Lipid levels in sickle-cell disease TC
stable state (250 SS or Sβ0 anemia severity, but not with markers of pulmonary
Zorca S et al. associated with haemolytic severity, HDL-C
9 USA and 78 SC or Sβ+) hypertension (NT-proBNP and TRV).
(2010) vascular dysfunction and pulmonary LDL-C
and Serum TG levels were positively correlated with markers of
hypertension TG
39 healthy controls pulmonary hypertension.

Patients with elevated TG showed history of acute chest

TC
Lalanne-Mistrih Lipid profiles in French West Indies 159 adults with SCA in syndrome more frequently.
Guadalupe HDL-C
10 ML et al. sickle cell disease cohorts, and their steady state (97 HbSS and 62 Acute chest syndrome, vaso-occlusive crises, and
(France) LDL-C
(2018) general population HbSC) osteonecrosis were not affected by TC, HDL-C, and LDL-C
TG
levels.

Male Gender, Increased Blood Elevated TG levels could increase the risk of developing
Viscosity, Body Mass Index TC relative hypertension (BP ≥ 120/70 mmHg and < 140/90
Lamarre Y et al. Guadalupe and Triglyceride Levels Are 97 HbSS adults in steady HDL-C mmHg) in SCA.
11
(2013) (France) Independently Associated with state LDL-C Patients with borderline/elevated TG levels had history
Systemic Relative Hypertension in TG of acute chest syndrome and vaso-occlusive crises more
Sickle Cell Anemia frequently.
Lipid profile and clinical manifestations in SCA
Dantas et al.
775
 776
Dantas et al.

TC
Normal Non-HDL Cholesterol,
HDL-C
Low Total Cholesterol, and HDL 50 patients with SCA (12
Ephraim RKD LDL-C Increased VLDL was inversely correlated with systolic
Cholesterol Levels in Sickle Cell HbSS and 38 HbSC) in a
12 et al. Gana VLDL-C blood pressure and positively correlated with diastolic
Disease Patients in the Steady State: stable state and
(2016) Non-HDL blood pressure.
A Case-Control Study of Tema 50 healthy controls
TG
Metropolis
TG/HDL
Lipid profile and clinical manifestations in SCA

TC
Polymorphisms in genes that affect Decreased HDL-C levels were associated with elevated
HDL-C
Valente-Frossard the variation of lipid levels in a 161 children and adolescents markers of hemolysis and inflammation.
Non-HDL
13 TNS et al. Brazil Brazilian pediatric population with with SCA (92 HbSS and 69 Elevated TG levels were correlated with lower
TG
(2020) sickle cell disease: rs662799 APOA5 HbSC) in a stable state concentrations of Hb and HDL-C, in addition to an increase
CT/HDL
and rs964184 ZPR1 in leukocytes, LDH, and bilirubin.
TG/HDL

Severe painful vaso-occlusive crises

Darbari DS et al. Elevated HDL was associated with a higher frequency of
14 USA and mortality in a contemporary 264 HbSS adults HDL-C
(2013) vaso-occlusive crises.
adult sickle cell anemia cohort study

TC
The influence of decreased levels of
Emokpae A, 84 patients with SCA in a HDL-C Patients with reduced HDL-C levels had more severe
high density lipoprotein cholesterol
15 Kuliya-Gwarzo A Nigeria stable state LDL-C anemia and a greater need for blood transfusions
on hematological indices in sickle cell
(2014) (all from 15 years old) VLDL-C compared to those with normal HDL.
disease patients
TG

Note: All studies included in the review adopted a statistical significance level of 5%.
Original Article
Int J Cardiovasc Sci. 2022; 35(6), 770-779
Int J Cardiovasc Sci. 2022; 35(6), 770-779 Dantas et al.
Original Article Lipid profile and clinical manifestations in SCA 777

the polymerization of HbS and increase the survival of (2010).13 It is understood that these lipids have an indirect
red blood cells, consequently reducing the occurrence effect on the formation of gallstones, considering that
of VOS and hemolysis.18,19 Lower HbF levels thus may stones seen in patients with SCA and other hemolytic
represent one of the pathophysiological mechanisms anemias are pigmented, composed mainly of calcium
that lead to a greater severity of SCA in patients with bilirubinate, and caused by indirect hyperbilirubinemia
low HDL-C. secondary to chronic hemolysis.
Conversely, two retrospective studies, Guarda et al. Lower levels of LDL-C were found in patients with
(2020)20 and Darbari et al. (2013),21 found an association history of lower limb ulcers, while above-average levels
between higher HDL-C levels and more frequent were observed in patients with history of pneumonia.20
VOS. Lalanne-Mistrih et al. (2018),22 also through a Several mechanisms have been suggested to explain the
retrospective analysis, did not detect a correlation pathophysiology of ulcers in SCA, including physical
between clinical history of VOS and this lipid component. obstruction caused by sickle red blood cells, poor venous
However, due to their retrospective nature, these studies recirculation, reduced nitric oxide bioavailability, and
present a higher risk of bias. It is noteworthy that VOS susceptibility to infections. Lipid alterations are thus
result from a pathological process that involves oxidative understood as part of a multifactorial pathogenic process
stress, increased expression of endothelial adhesion and not as a direct causative agent of this clinical
molecules, inflammatory cytokines, and nitric oxide complication.
depletion. These factors, associated with a lipid profile The higher prevalence of electrocardiographic
disorder, create a positive feedback loop for the chain of abnormalities in patients with SCA is well demonstrated
inflammation that leads to vaso-occlusive phenomena.23 when comparing them to healthy individuals. Adegoke
In patients with SCA, PH has already been attributed et al. (2016)25 demonstrated that children with SCA
were six times more likely to present left ventricular
to endothelial injury resulting from chronic hemolysis,
hypertrophy and had a higher prevalence of first-degree
smooth muscle dystonia, and nitric oxide depletion
atrioventricular block and T-wave alterations compatible
vasculopathy.24 However, Ataga et al. (2015)12 observed
with lateral ischemia. These changes result from an
reduced TC levels in patients with suspected PH when
increased cardiac output secondary to chronic anemia,
compared to those without this suspicion, as well as a
leading to volume overload and eccentric hypertrophy.44
negative correlation between TC and soluble vascular
This study also demonstrated higher TG levels in children
cell adhesion molecule-1 (sVCAM-1), suggesting that
with SCA and electrocardiographic abnormalities,
hypocholesterolemia contributes to the endothelial
suggesting that dyslipidemia is a potential biomarker
activation involved in PH. In disagreement, Zorca et al.
for electrocardiographic changes in these patients.
(2010)14 did not identify an association between TC and
In this perspective, TG were significantly correlated
markers of PH, such as N-terminal B-type natriuretic
with markers of hemolysis, endothelial activation,
peptide (NT-proBNP) and tricuspid regurgitation
and inflammation, being directly linked to vascular
velocity (TRV), or a correlation with markers of
dysfunction; the repercussions of this dysfunction occur
endothelial dysfunction, including sVCAM-1.
in both the macro and microcirculation, harming different
Guarda et al. (2020)20 reported high TC levels in patients vascular sites, including the heart.
with history of pneumonia. It is known that pulmonary
Zorca et al. (2010)14 showed a positive correlation of
complications in SCA are associated with vascular
TG with NT-proBNP and TRV, which are markers of
damage and vasoconstriction, proposing a significant
PH. It is thus possible that the vasculopathy induced
involvement of cholesterol in these mechanisms. The by hypertriglyceridemia has as its main target, within
occurrence of pneumonia in SCA is often associated with SCA, the pulmonary vasculature, contrary to what is
ATS, and these conditions often overlap. However, in a observed in the general population in which the most
study conducted by Lalanne-Mistrih et al. (2018),22 ATS affected tissues are the coronary and cerebral arteries.
was not affected by TC levels. These data suggest that Still considering the effects of this vasculopathy, Lalanne-
the role of cholesterol in pulmonary events still needs Mistrih et al. (2018)22 reported a higher frequency of
to be defined. ATS in patients with high TG levels; this evidence was
Cholelithiasis was associated with high levels of TC, ratified by Lamarre et al. (2013),26 who also observed
LDL-C, VLDL-C, and TG, according to Seixas et al. an association with a higher frequency of VOS. These
 Dantas et al. Int J Cardiovasc Sci. 2022; 35(6), 770-779
778 Lipid profile and clinical manifestations in SCA Original Article

outcomes attest to the negative impact of TG on vascular patients with SCA, suggesting a relevant role in the
function. In addition, increased systolic blood pressure, multifactorial pathogenesis of this disease.
even if lower than 140 mmHg, is associated with an This study demonstrated the association between
increased risk of stroke and mortality in patients with lipid profile and clinical events in SCA, as well
SCA. To this condition, Lamarre attributed the term as a correlation between lipids and laboratory
"relative hypertension," demonstrating that increased markers of the disease. The derangement of the lipid
TG levels were a relevant risk factor for its development. metabolism, marked by hypocholesterolemia and
The TG/HDL ratio is also an important lipid hypertriglyceridemia, was found to be linked to clinical
parameter. This marker shows a strong correlation with manifestations that constitute a more severe course
cardiovascular risk, being a good predictor of acute of the disease, suggesting an important involvement
myocardial infarction27-30 and associated with insulin of these lipids in the processes of inflammation and
resistance.31,32 A study by Teixeira et al. (2019)33 found vascular damage that comprise the multifactorial
the role of TG/HDL as a marker of vascular damage in pathogenesis of SCA.
patients with SCA, finding correlations with markers of
hemolysis (LDH and hemoglobin) and with the increase Author contributions
in blood flow velocity in the middle cerebral arteries on
transcranial Doppler; this last parameter is an important Conception and design of the research and critical
predictor of stroke in these patients. Vascular damage revision of the manuscript for intellectual content:  Dantas
was also evident by the association of an increased TG/ MT, Ladeia AMT; acquisition of data and writing of the
HDL ratio with a higher number of episodes of ATS and manuscript: Dantas MT; analysis and interpretation of
VOS: children with TG/HDL values above 2.93 were 3.77 the data:  Dantas MT, Lopes AC.
times more likely to present at least one of these clinical
events.
Potential Conflict of Interest
The possible limitations of this review are linked
No potential conflict of interest relevant to this article
to disparities between the populations of the included
was reported.
studies, such as the heterogeneity in sample sizes, age
groups, and SCA phenotypes. On the other hand, the
low risk of bias in most of the included studies and the Sources of Funding
rigor in complying with the PRISMA protocol ensure the There were no external funding sources for this study.
methodological quality of this study. The registration
in PROSPERO qualifies the transparency and scientific Study Association
integrity of this review.
This study is not associated with any thesis or
dissertation work.
Conclusion

Lipid metabolism disorders, especially Ethics approval and consent to participate

hypocholesterolemia and hypertriglyceridemia, are This article does not contain any studies with human
linked to the occurrence of clinical events observed in participants or animals performed by any of the authors.

References
1. Zago M, Falcão R, Pasquini R. Hematologia: Fundamentos e Prática. 5. Martins PRJ, Souza H, Silveira T. Morbimortalidade em Doença
São Paulo: Atheneu; 2004. Falciforme. Rev Bras Hematol Hemoter. 2010;32(5):378–83. doi: 10.1590/
S1516-84842010000500010.
2. Lervolino LG, Baldin PE, Picado SM, Calil KB, Viel AA, Campos LA.
Prevalence of Sickle Cell Disease and Sickle Cell Trait in National 6. Naoum F. Alterações do Perfil Lipídico nas Anemias. Rev. Bras. Hematol.
Neonatal Screening Studies. Rev Bras Hematol Hemoter. 2011;33(1):49- Hemoter. 2005;27(3): 223-6. doi: 10.1590/S1516-84842005000300018.
54. doi: 10.5581/1516-8484.20110015.
7. Carvalho M. Doença Falciforme: Avaliação de Biomarcadores
3. Cançado R, Jesus J. A Doença Falciforme no Brazil. Rev Bras Hematol Relacionados ao Perfil Lipídico e Disfunção Endotelial [dissertation].
Hemoter. 2007 Sep;29(3):204–6. doi: 10.1590/S1516-84842007000300002. Salvador: Fundação Oswaldo Cruz; 2014.

4. Braga J, Tone L, Loggetto S. Hematologia para o Pediatra. São Paulo: 8. Nogueira Z. Perfil Lipídico de Crianças com Doença Falciforme. 2015.
Atheneu; 2007. [dissertation]. Salvador: Universidade Federal da Bahia; 2015.
Int J Cardiovasc Sci. 2022; 35(6), 770-779 Dantas et al.
Original Article Lipid profile and clinical manifestations in SCA 779

9. Araújo V. Correlação do Perfil Lipídico e do Quadro Clínico em Pacientes 22. Lalanne-Mistrih ML, Connes P, Lamarre Y, Lemonne N, Hardy-
Portadores de Doença Falciforme no RJ [dissertation]. Rio de Janeiro: Dessources MD, Tarer V, et al. Lipid Profiles in French West Indies Sickle
Universidade do Estado do Rio de Janeiro; 2013. Cell Disease Cohorts, and their General Population. Lipids Health Dis.
2018;17(1):38. doi: 10.1186/s12944-018-0689-5.
10. Frossard T. Estudos Diagnóstico e Avaliativo de Biomarcadores de
Dislipidemias em Indivíduos com Doença Falciforme Acompanhados 23. Ware RE, de Montalembert M, Tshilolo L, Abboud MR. Sickle
nos Hemocentros de Governador Valadares e Uberaba da Fundação Cell Disease. Lancet. 2017;390(10091):311-23. doi: 10.1016/S0140-
Hemominas [dissertation]. Governador Valadares: Universidade Federal 6736(17)30193-9.
de Juiz de Fora; 2018.
24. Doherty DH, Doyle MP, Curry SR, Vali RJ, Fattor TJ, Olson JS, et al.
11. Erasmus RT, Olukoga AO, Ojuawo O. Plasma Lipids and Lipoproteins Rate of Reaction with Nitric Oxide Determines the Hypertensive Effect
in Nigerian Children with Sickle Cell Anemia. Ann Trop Paediatr. of Cell-free Hemoglobin. Nat Biotechnol. 1998;16(7):672-6. doi: 10.1038/
1990;10(4):421-3. doi: 10.1080/02724936.1990.11747468. nbt0798-672.

12. Ataga KI, Hinderliter A, Brittain JE, Jones S, Xu H, Cai J, et al. Association 25. Adegoke SA, Okeniyi JA, Akintunde AA. Electrocardiographic
of Pro-inflammatory High-density Lipoprotein Cholesterol with Clinical Abnormalities and Dyslipidaemic Syndrome in Children with Sickle Cell
and Laboratory Variables in Sickle Cell Disease. Hematol. 2015;20(5):289- Anaemia. Cardiovasc J Afr. 2016;27(1):16-20. doi: 10.5830/CVJA-2015-059.
96. doi: 10.1179/1607845414Y.0000000171.
26. Lamarre Y, Lalanne-Mistrih ML, Romana M, Lemonne N, Mougenel D,
13. Seixas MO, Rocha LC, Carvalho MB, Menezes JF, Lyra IM, Nascimento Waltz X, et al. Male Gender, Increased Blood Viscosity, Body Mass Index
VM, et al. Levels of High-density Lipoprotein Cholesterol (HDL-C) and Triglyceride Levels are Independently Associated with Systemic
Among Children with Steady-state Sickle Cell Disease. Lipids Health Relative Hypertension in Sickle Cell Anemia. PLoS One. 2013;8(6):e66004.
Dis. 2010;9:91. doi: 10.1186/1476-511X-9-91. doi: 10.1371/journal.pone.0066004.

14. Zorca S, Freeman L, Hildesheim M, Allen D, Remaley AT, Taylor JG, et al. 27. Vieira EA, Carvalho WA, Aras R Jr, Couto FD, Couto RD. Razão
Lipid Levels in Sickle-cell Disease Associated with Haemolytic Severity, Triglicérides/HDL-C e Proteína C Reativa de Alta Sensibilidade
Vascular Dysfunction and Pulmonary Hypertension. Br J Haematol. na Avaliação do Risco Cardiovascular. J. Bras. Patol. Med. Lab.
2010;149(3):436-45. doi: 10.1111/j.1365-2141.2010.08109.x. 2011;47(2):113-8. doi: 10.1590/S1676-24442011000200004.

15. Valente-Frossard TNS, Cruz NRC, Ferreira FO, Belisario AR, Pereira BM, 28. Andrade MIS, Dourado KF, de Lima RM, de Orange LG, Bento RA,
Gomides AFF, et al. Polymorphisms in Genes that Affect the Variation Rodrigues DAS, et al. Razão Triglicerídeo/HDL-C como Indicador
of Lipid Levels in a Brazilian Pediatric Population with Sickle Cell de Risco Cardiovascular em Alcoolistas Crônicos. Rev. Bras. Cardiol.
Disease: rs662799 APOA5 and rs964184 ZPR1. Blood Cells Mol Dis. 2012;25(4):267-75.
2020;80:102376. doi: 10.1016/j.bcmd.2019.102376.
29. da Luz PL, Favarato D, Faria-Neto JR Jr, Lemos P, Chagas AC. High
16. Emokpae A, Kuliya-Gwarzo A. The Influence of Decreased Levels of Ratio of Triglycerides to HDL-cholesterol Predicts Extensive Coronary
High Density Lipoprotein Cholesterol on Hematological Indices in Disease. Clinics (São Paulo). 2008;63(4):427-32. doi: 10.1590/s1807-
Sickle Cell Disease Patients. Ann Med Health Sci Res. 2014;4(2):157-61. 59322008000400003.
doi: 10.4103/2141-9248.129020.
30. Vieira EA, Carvalho WA, Aras R Jr, Couto FD, Couto RD. Razão
17. Aleluia MM, da Guarda CC, Santiago RP, Fonseca TC, Neves FI, de triglicérides/HDL-C e proteína C reativa de alta sensibilidade na
Souza RQ, et al. Association of Classical Markers and Establishment of avaliação do risco cardiovascular. J Bras Patol Med Lab. 2011;47(2):113-8.
the Dyslipidemic Sub-phenotype of Sickle Cell Anemia. Lipids Health doi: 10.1590/S1676-24442011000200004.
Dis. 2017;16(1):74. doi: 10.1186/s12944-017-0454-1. 31. Oliveira A, Oliveira A, Oliveira N, Oliveira A, Almeida M, Veneza
18. Franco RS, Yasin Z, Palascak MB, Ciraolo P, Joiner CH, Rucknagel DL. L, et al. Is triglyceride to high-density lipoprotein cholesterol ratio a
The Effect of Fetal Hemoglobin on the Survival Characteristics of Sickle surrogates for insulin resistance in youth? Health. 2013;5: 481-5. doi:
Cells. Blood. 2006;108(3):1073-6. doi: 10.1182/blood-2005-09-008318. 10.4236/health.2013.53066.

19. Charache S. Fetal Hemoglobin, Sickling, and Sickle Cell Disease. Adv 32. Kim JS, Kang HT, Shim JY, Lee HR. The Association between the
Pediatr. 1990;37:1-31. Triglyceride to High-density Lipoprotein Cholesterol Ratio with
Insulin Resistance (HOMA-IR) in the General Korean Population:
20. da Guarda CC, Yahouédéhou SCMA, Santiago RP, Fernandes CFL, Neres Based on the National Health and Nutrition Examination Survey in
JSDS, Oliveira AMJ, et al. Investigation of Lipid Profile and Clinical 2007-2009. Diabetes Res Clin Pract. 2012;97(1):132-8. doi: 10.1016/j.
Manifestations in SCA Children. Dis Markers. 2020;2020:8842362. doi: diabres.2012.04.022.
10.1155/2020/8842362.
33. Teixeira RS, Arriaga MB, Terse-Ramos R, Ferreira TA, Machado VR,
21. Darbari DS, Wang Z, Kwak M, Hildesheim M, Nichols J, Allen D, et al. Rissatto-Lago MR, et al. Higher Values of Triglycerides:HDL-cholesterol
Severe Painful Vaso-occlusive Crises and Mortality in a Contemporary Ratio Hallmark Disease Severity in Children and Adolescents with Sickle
Adult Sickle Cell Anemia Cohort Study. PLoS One. 2013;8(11):e79923. Cell Anemia. Braz J Med Biol Res. 2019;52(10):e8833. doi: 10.1590/1414-
doi: 10.1371/journal.pone.0079923. 431X20198833.

*Supplemental Materials
For additional information, please click here.

This is an open-access article distributed under the terms of the Creative Commons Attribution License