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Original Article

Mortality In Sickle Cell Disease -- Life Expectancy and Risk Factors for Early Death

Orah S. Platt, Donald J. Brambilla, Wendell F. Rosse, Paul F. Milner, Oswaldo Castro, Martin H. Steinberg, and Panpit P. Klug

N Engl J Med 1994; 330:1639-1644June 9, 1994

Abstract

Background

Information on life expectancy and risk factors for early death among patients with sickle cell disease (sickle cell anemia, sickle cell-hemoglobin C disease, and the sickle cell-β-thalassemias) is needed to counsel patients, target therapy, and design clinical trials.

Methods

We followed 3764 patients who ranged from birth to 66 years of age at enrollment to determine the life expectancy and calculate the median age at death. In addition, we investigated the circumstances of death for all 209 adult patients who died during the study, and used proportional-hazards regression analysis to identify risk factors for early death among 964 adults with sickle cell anemia who were followed for at least two years.

Results

Among children and adults with sickle cell anemia (homozygous for sickle hemoglobin), the median age at death was 42 years for males and 48 years for females. Among those with sickle cell-hemoglobin C disease, the median age at death was 60 years for males and 68 years for females. Among adults with sickle cell disease, 18 percent of the deaths occurred in patients with overt organ failure, predominantly renal. Thirty-three percent were clinically free of organ failure but died during an acute sickle crisis (78 percent had pain, the chest syndrome, or both; 22 percent had stroke). Modeling revealed that in patients with sickle cell anemia, the acute chest syndrome, renal failure, seizures, a base-line white-cell count above 15,000 cells per cubic millimeter, and a low level of fetal hemoglobin were associated with an increased risk of early death.

Conclusions

Fifty percent of patients with sickle cell anemia survived beyond the fifth decade. A large proportion of those who died had no overt chronic organ failure but died during an acute episode of pain, chest syndrome, or stroke. Early mortality was highest among patients whose disease was symptomatic. A high level of fetal hemoglobin predicted improved survival and is probably a reliable childhood forecaster of adult life expectancy.

Media in This Article

Figure 1Survival of Patients in the Cooperative Study of Sickle Cell Disease.
Figure 2Probability of Surviving for the Next 10 Years, According to Age, among Males and Females with Sickle Cell Anemia (SS), as Compared with Black Males and Females in the General Population.
Article

The life expectancy of patients with sickle cell disease has improved considerably since 1960, when Sir John Dacie described sickle cell disease as “essentially a disease of childhood.” “Indeed,” he wrote, “the mortality is high and relatively few patients reach adult life, even when the standard of medical care is high”1. In his 1973 review based on autopsies, Diggs estimated a median survival of 14.3 years, with 20 percent of the deaths occurring in the first 2 years of life, one third occurring before the fifth year of life, half between 5 and 30 years of age, and one sixth after the age of 302. In contrast, in the recent Cooperative Study of Sickle Cell Disease (CSSCD), approximately 85 percent of children and adolescents with sickle cell anemia (homozygous for sickle hemoglobin) and 95 percent of patients with sickle cell-hemoglobin C disease (heterozygous for hemoglobin S and C) survived to 20 years of age3. Among the patients less than 20 years of age in that series, mortality peaked between 1 and 3 years of age; the primary cause of death was infection -- predominantly Streptococcus pneumoniae sepsis. A low level of fetal hemoglobin, a low level of total hemoglobin, and an elevated base-line white-cell count were associated with an increased risk of death.

In most studies of mortality among adult patients, the age at death has been determined either from autopsy data or from clinical records. The clinical events leading to death have been recorded only sporadically. In the Jamaican studies by Thomas et al., the acute chest syndrome was the principal cause of death after 10 years of age,4 with chronic organ damage such as renal or cardiac failure, cerebrovascular accident, and complications of pregnancy noted as concomitant causes of death. Powars and colleagues5 described similar findings in a cohort of patients followed in Los Angeles for 25 years, noting that survival estimates based on this group may have been influenced by changes in clinical practice over time. For example, they suggest that the high mortality they observed among women with sickle cell anemia reflected the high mortality among pregnant women before 1975. Accurate knowledge is needed about the contemporary mortality rate, the events that occur shortly before death, and the clinical conditions that are associated with an increased risk of death. Such information is of great importance in counseling patients, in anticipating dangerous clinical situations, and in designing targeted therapy and clinical trials. We undertook a prospective analysis of deaths among patients in the CSSCD, with emphasis on the risk factors for death in patients over 20 years of age.

Methods

The design of the CSSCD is described elsewhere6. The CSSCD is a prospective study of the clinical course of sickle cell disease in which more than 3764 patients were enrolled from birth to 66 years of age, at 23 clinical centers throughout the continental United States (Table 1Table 1Characteristics of Patients in the Cooperative Study of Sickle Cell Disease.). Patients were enrolled at these centers between September 1978 and 1988 and were seen at regular intervals for laboratory evaluation and physical examination. At enrollment, the genotype was confirmed by review of the hematologic data and by quantitative hemoglobin electrophoresis performed at the Centers for Disease Control and Prevention7. Starting late in 1984, α-globin gene mapping was performed in patients with sickle cell anemia by Dr. Stephen H. Embury at the University of California, San Francisco8,9. Consent was obtained from all patients, their parents, or their legal guardians.

The laboratory results analyzed in this report were obtained at routine visits, not during acute illness. All acute and chronic complications were documented at the centers. Deaths were reported on a form that was completed by the center investigator, regardless of whether deaths occurred at the study center or elsewhere; this form included narrative information about the relevant clinical findings and laboratory data, as well as the death certificate. When available, autopsy reports were also provided.

For all patients with sickle cell anemia or sickle cell-hemoglobin C disease we used proportional-hazards regression and the 2L program of BMDP to model age at death rather than the length of time from enrollment to death10,11. The Cnaan and Ryan approach10 is appropriate for analyses of data in studies, like this one, in which patients enter and leave the study cohort and observation begins after the onset of the disease. According to this method, a particular patient contributes to the population at risk for a given death only if that patient is enrolled in the study at the age at which that death occurred.

The probability of survival 10 years after enrollment was estimated as P2/P1, with P1 denoting the proportion of the study population alive at the beginning of the decade and P2 the proportion alive at the end. The proportions were estimated from Kaplan-Meier plots (discussed below).

Because the causes of and risk factors for early death in the children and adolescents in this study had already been reported,3 we concentrated on the risk factors for early death among the patients over 20 years of age. We investigated the circumstances of death in the 209 patients with sickle cell disease (all genotypes) who were 20 years of age or older when they died. For each patient, we reviewed the complete roster of forms recording acute and chronic complications and scheduled visits to the medical center, the death form, and when available, the final hospital discharge summary and autopsy report. On the basis of this review, patients were classified as either having or not having clinically diagnosed chronic organ failure before they died. This classification was based on either the CSSCD working definition of renal failure (a 20 percent increase in the base-line creatinine concentration and a creatinine clearance rate below 100 ml per minute) or the clinical diagnosis of chronic congestive heart failure or chronic debilitating stroke by the local investigator. The CSSCD did not have a specific working definition of chronic pulmonary failure. Acute terminal organ failure and evidence at autopsy of organ damage that was not recognized during life were not criteria for chronic organ failure. Patients without chronic organ failure were classified according to their terminal event. Commonly, a death form describing other acute events (e.g., an episode of pain or the acute chest syndrome) was the only event form submitted, particularly for patients who died outside the center hospital where they were enrolled.

We examined the steady-state laboratory values (the average of yearly routine measurements) and clinical events. Data collected during the last year of life or follow-up were excluded so as to avoid biasing the results with changes related to the ultimate cause of death. We excluded patients without at least one year of observation before the excluded (premortem) year (70 patients) and those for whom data were incomplete (94 patients). The models are based on the data on 964 patients with sickle cell anemia, 85 of whom died. Each potential risk factor was examined in a separate regression analysis. Each statistically significant laboratory variable was then categorized in a variety of ways (e.g., by quartiles or quintiles) to identify the values that contributed to the significant effect.

Likelihood ratios were used for all statistical tests. All the P values presented are two-tailed.

Results

Survival

Kaplan-Meier survival curves for children and adults with sickle cell anemia (1313 females and 1229 males) or sickle cell-hemoglobin C disease (427 females and 417 males) are shown in Figure 1Figure 1Survival of Patients in the Cooperative Study of Sickle Cell Disease.. Among patients with each phenotype, females survived longer than males (P = 0.004 by Cox regression), and patients with sickle cell-hemoglobin C disease survived longer than those with sickle cell anemia (P<0.001 by Cox regression). The median age at death among patients with sickle cell anemia was 42 years for males and 48 years for females. Among patients with sickle cell-hemoglobin C disease, the corresponding ages were 60 and 68 years; the data on age at death among patients with sickle cell-hemoglobin C disease should be interpreted with some caution, however, since the number of deaths was relatively low in this group. The corresponding survival curves for blacks in the general population12 are included for comparison and show that life expectancy among patients with sickle cell anemia was decreased by 25 to 30 years. The improved survival of patients with sickle cell anemia who had fetal hemoglobin levels above the 75th percentile (>8.6 percent) is illustrated in Figure 1C.

To investigate the relation between age and the risk of death in sickle cell disease, we analyzed the data according to decade of age and calculated the probability of surviving each decade (Figure 2Figure 2Probability of Surviving for the Next 10 Years, According to Age, among Males and Females with Sickle Cell Anemia (SS), as Compared with Black Males and Females in the General Population.). The probability of surviving for 10 years dropped dramatically with age, particularly after the age of 20 years, when compared with similar data for blacks in the general population.

Circumstances of Death

Because of the difficulty of ascertaining the exact cause of death in most cases, we focused on the general clinical status of the patients and the circumstances in which they died. The result of the classification is shown in Table 2Table 2Circumstances of Death in 209 Patients with Sickle Cell Disease Who Were 20 Years of Age or Older at the Time of Death.. Thirty-seven percent of the patients underwent autopsies, and approximately 60 percent died outside the study center. For 38 of the patients who died without clinical evidence of chronic organ failure, there was insufficient information to classify their immediate circumstances of death. A small proportion of patients died of causes not related to sickle cell disease, including trauma and cancer. In these cases it was impossible to determine the extent to which the underlying hemoglobinopathy contributed to the death.

Relatively few patients died with clinical evidence of chronic organ failure (renal failure, congestive heart failure, or chronic debilitating cerebrovascular accident). In some instances, the organ failure was attributable to causes other than sickle cell disease, but undoubtedly complicated by it. Because arterial-blood gas measurements and pulmonary-function studies were not required for all patients, there was no working definition of chronic pulmonary failure in this study.

A large number of patients had no overt chronic organ-system failure and died relatively suddenly and unexpectedly, presumably as a complication of a sickle cell crisis. Death occurred in the course of a painful episode in 45 patients, 20 of whom had simultaneous acute chest syndrome. Nine patients had acute chest syndrome alone. Acute stroke occurred before death in 15 patients, with documented hemorrhage in 11. Although 13 of the patients without chronic organ failure died of infection, the infections were varied (Escherichia coli, Staphylococcus aureus, human immunodeficiency virus, tuberculosis, malaria, pneumococcus, and hepatitis), in contrast to the almost universal occurrence of pneumococcal sepsis in children under five years of age who died of infections.

Risk Factors for Early Death

Although males were at greater risk for early death than females, when sex was factored into the analysis of each of the other risk factors, no significant interaction was found (data not shown). Thus, there was no evidence that the risk factors for early death differed according to sex.

The patients with more symptomatic disease were at higher risk of early death. Mortality varied with the following acute and chronic conditions: renal insufficiency, acute painful episodes, acute anemic episodes, seizures, and the acute chest syndrome (Table 3Table 3Acute and Chronic Conditions as Risk Factors for Early Death in Patients with Sickle Cell Anemia Who Were 20 Years of Age or Older.).

The risk of early death was inversely associated with level of fetal hemoglobin (Table 4Table 4Laboratory Values as Risk Factors for Early Death in Patients with Sickle Cell Anemia Who Were 20 Years of Age or Older.). This association was dramatically illustrated by the enhanced survival of patients with sickle cell anemia who had fetal hemoglobin levels above the 75th percentile (Figure 1). Differences within the group with values above the 75th percentile could not be determined because of the small number of deaths.

Two other laboratory values were found to be associated with mortality (Table 4). In each case, the increase in mortality was associated only with values at the end of the distribution; there was no smooth trend of mortality increasing with the laboratory value. Patients with sickle cell anemia who had hemoglobin values below the 10th percentile ( ≤ 7.1 g per deciliter) had a slightly higher risk of death than all other patients (2.8 vs. 1.1 deaths per 100 person-years). Similarly, patients with sickle cell anemia who had an elevated white-cell count (15,100 per cubic millimeter) had a slightly higher risk of death (2.2 vs. 1.2 per 100 person-years). In each case, if the 10 percent of patients in each of these groups was excluded from analysis, no significant associations were found between mortality and the hemoglobin level or the white-cell count.

There was no demonstrable relation between mortality and the presence or absence of α-thalassemia. A binary indicator for α-thalassemia did not make a statistically significant contribution to the proportional-hazards model. The delay in collecting data on α-thalassemia interfered with our ability to perform a more rigorous analysis of this variable.

Multiple Regression Analysis

Since the incidence of clinical conditions may vary with laboratory profile, and since two or more conditions can occur in the same patient, there may be redundancy in the results of the risk-factor modeling by single regression analysis. Therefore, the laboratory values and clinical events associated with significant variation in the risk of death were combined in a multivariate model, and backward elimination was used to reduce the model to the subset of factors that made statistically significant contributions to the variation in mortality (Table 5Table 5Risk Factors for Early Death in Patients with Sickle Cell Anemia Who Were 20 Years of Age or Older.). This model showed that the fetal hemoglobin level, renal insufficiency, acute chest syndrome, seizures, and white-cell count were significant risk factors.

Discussion

This report presents a snapshot of the life expectancy of patients with sickle cell disease in the United States during the 1980s. In contrast to the widely held assumption that patients with sickle cell anemia rarely survive to adulthood, the median age at death among such patients was 42 years for males and 48 years for females. This represents a decrease of roughly 25 to 30 years in life expectancy, as compared with that of the black American population in general. Among patients with sickle cell-hemoglobin C disease, the median age at death was 60 years for males and 68 years for females. The longer survival of females with both types of hemoglobinopathy is typical of the findings in black American and other normal populations.

The pattern of mortality varies with age. We have already reported that the peak incidence of death among children with sickle cell anemia occurred between 1 and 3 years of age and that deaths among patients less than 20 years of age were predominantly caused by pneumococcal sepsis3. We anticipate that the recent acceptance of universal screening of newborns and the early administration of prophylactic penicillin to infants with sickle cell anemia will mean that more than 85 percent of such children will survive to 20 years of age and that overall survival will be even greater than we report here. Unfortunately, the risk of death among those over 20 years of age is not easily assigned to a single preventable cause.

In this study, adults with sickle cell anemia had a high mortality rate, with few surviving into their 60s. The circumstances of their deaths were quite varied. Eighteen percent of the deaths occurred in chronically ill patients with clinically obvious organ-system failure (renal failure, congestive heart failure, or chronic debilitating cerebrovascular accident). Although a minority of these patients had other specific factors that contributed to organ failure (such as systemic lupus erythematosus, renal tuberculosis, and congenital valvular heart disease), sickling was undoubtedly an important accelerator of organ destruction. Thirty-three percent of deaths occurred in relatively healthy patients who did not have overt chronic organ failure but died during a classic sickle crisis. Seventy-eight percent of these patients died during an acute painful episode or an episode of acute chest syndrome. These patients had surely experienced and survived such episodes when they were younger, but they were not able to tolerate them in later years.

The precise causes of death under these circumstances remain elusive, probably involving bone marrow and fat embolization,13-16 excessive narcotization,17 the pain event itself,18 or a combination of these factors. Adults, even those who appear relatively fit, are susceptible to cardiovascular collapse and acute multiorgan-system failure and may die suddenly during episodes of acute pain, the chest syndrome, or both. This finding illustrates the need for more thorough study of acutely ill patients; perhaps some such unexpected deaths can be prevented. The other 22 percent of these “healthy” patients with sickle cell anemia died of acute stroke; all the strokes for which a type was specified were acute hemorrhages.

The clinically well patients were not all as well as they seemed. As Powars and colleagues have described, vascular damage caused by sickling insidiously accumulates in varying degrees5. Our ability to prevent early deaths hinges on the ability to identify patients at high risk so they can be treated before fatal, often silent, vascular lesions develop. We examined clinical and laboratory data to determine whether we could identify adults at high risk for early death. We studied steady-state laboratory values using only those obtained at the time of routine visits rather than during acute illness. We studied steady-state clinical status by excluding events that occurred during the last year of life; we hoped thus to avoid biasing the results with changes associated directly with the cause of death. Our previous reports on this population described a wide range of degrees of clinical severity19. In this analysis, we found that the adult patients who had more symptoms of the disease were at increased risk of early death.

The important laboratory risk factors were a high white-cell count and a low fetal hemoglobin level. Patients with a white-cell count over 15,000 per cubic millimeter were at increased risk. This interesting finding is also well documented in the normal population and is independent of factors, such as smoking, that are known to raise the base-line white-cell count20. In this study we may simply have “rediscovered” this normal enigmatic observation, or may have identified a feature peculiar to sickle cell anemia, such as the relation between inflammatory cytokines and the endothelium, adhesive interactions between white cells and endothelium, or even interactions between white cells and sickle red cells. It is tempting to speculate that lowering very high white-cell counts may be therapeutic in sickle cell disease and that the beneficial effects of hydroxyurea and other cytotoxic chemotherapeutic agents that raise the fetal hemoglobin level may relate to their tendency to lower the white-cell count.

The most straightforward laboratory risk factor was the fetal hemoglobin level. Patients with high levels had an improved life expectancy. Although this result is no surprise, its documentation is of utmost importance. Of all the risk factors we identified in this study, the fetal hemoglobin level is the one known to be relatively stable throughout life21. Adults who had low levels of fetal hemoglobin as children are likely to die earlier than those who had high levels. The fetal hemoglobin level should be considered an important factor in selecting children for high-risk interventions such as bone marrow transplantation and long-term treatment with agents that stimulate the production of fetal hemoglobin.

Supported by the Cooperative Study of Sickle Cell Disease, a program of the Sickle Cell Disease Branch of the National Heart, Lung, and Blood Institute.

Source Information

From the Department of Medicine, Children's Hospital, the Dana-Farber Cancer Institute, and Harvard Medical School -- all in Boston (O.S.P.); New England Research Institute, Watertown, Mass. (D.J.B.); the Department of Medicine, Duke University School of Medicine, Durham, N.C. (W.F.R.); the Department of Medicine, Medical College of Georgia, Augusta (P.F.M.); the Department of Medicine, Center for Sickle Cell Disease, Howard University, Washington, D.C. (O.C.); the Hematology-Oncology Section, Jackson Veterans Affairs Medical Center, and the Department of Medicine, University of Mississippi School of Medicine -- both in Jackson (M.H.S.); and the Hematology Division, Texas Tech University Health Science Center, Amarillo (P.P.K.).

Address reprint requests to Dr. Platt at the Department of Laboratory Medicine, Children's Hospital, 300 Longwood Ave., Boston, MA 02115.

The investigators who participated in this study are listed in the Appendix.

Appendix

The following investigators participated in the Cooperative Study of Sickle Cell Disease: R. Johnson, Alta Bates Hospital, Oakland, Calif.; L. McMahon, Boston City Hospital, Boston; O. Platt, Children's Hospital, Boston; F. Gill and K. Ohene Frempong, Children's Hospital, Philadelphia; G. Bray, J.F. Kelleher, and S. Leikin, Children's Hospital National Medical Center, Washington, D.C.; E. Vichinsky and B. Lubin, Children's Hospital, Oakland, Calif.; A. Bank and S. Piomelli, Columbia Presbyterian Hospital, New York; W. Rosse, J. Falletta, and T.R. Kinney, Duke University, Durham, N.C.; L. Lessin, George Washington University, Washington, D.C.; J. Smith and Y. Khakoo, Harlem Hospital, New York; R.B. Scott, O. Castro, and C. Reindorf, Howard University, Washington, D.C.; H. Dosik, S. Diamond, and R. Bellevue, Interfaith Medical Center, Brooklyn, N.Y.; W. Wang and J. Wilimas, LeBonheur Children's Hospital, Memphis, Tenn.; P. Milner, Medical College of Georgia, Augusta; A. Brown, S. Miller, R. Rieder, and P. Gillette, State University of New York Downstate Medical Center, Brooklyn; W. Lande, S. Embury, and W. Mentzer, San Francisco General Hospital, San Francisco; D. Wethers and R. Grover, St. Luke's-Roosevelt Medical Center, New York; M. Koshy and N. Talishy, University of Illinois, Chicago; C. Pegelow and P. Klug, University of Miami, Miami; M. Steinberg, University of Mississippi, Jackson; A. Kraus, University of Tennessee, Memphis; H. Zarkowsky, Washington University, St. Louis; C. Dampier, Wyler Children's Hospital, Chicago; H. Pearson and A.K. Ritchey, Yale University, New Haven, Conn.; S. McKinlay, D. Gallagher, and D. Brambilla, New England Research Institute, Watertown, Mass.; and M. Gaston and C. Reid, National Heart, Lung, and Blood Institute, Bethesda, Md.

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