Non-hematopoietic deficiency of proprotein convertase subtilisin/kexin type 9 deficiency leads to more severe anemia in a murine model of sickle cell disease

Proprotein convertase subtilisin/kexin type 9 (PCSK9) deficiency leads to lower cholesterol and is associated with reduced vascular complications in the general population. Cholesterol lowering may also have beneficial effects in sickle cell disease (SCD). The objective of this study was to determine effects of PCSK9 deficiency in a mouse model of SCD. Bone marrow transplantation (BMT) was performed from donor SCD mice to wild-type, PCSK9-deficient, and LDLR-deficient recipients to generate SCD controls ( Pcsk9 + / + , SCD bmt ) with preserved PCSK9 status, SCD mice with deficiency of PCSK9 ( Pcsk9 −/− , SCD bmt ), and SCD mice with deficiency of LDLR ( Ldlr −/− , SCD bmt ). Although cholesterol levels were lower in Pcsk9 −/− , SCD bmt mice compared to Pcsk9 + / + , SCD bmt mice, anemia was more severe in Pcsk9 −/− , SCD bmt mice. Increased reticulocytosis, enhanced ex vivo erythrocyte sickling, and increased erythrocyte phosphatidylserine exposure was also observed. Livers, spleens, and kidneys contained increased iron in Pcsk9 −/− , SCD bmt mice compared to Pcsk9 + / + , SCD bmt mice consistent with greater hemolysis. SCD mice with deficiency of LDLR ( Ldlr −/− , SCD bmt mice) had similar anemia as Ldlr + / + , SCD bmt mice despite higher serum cholesterol. In conclusion, deficiency of PCSK9 is associated with worsened anemia in SCD mice due to increased hemolysis. These findings may have implications for lipid-lowering strategies in patients with SCD, as well as for potential novel modifiers of anemia severity.