1 Department of Computational Biology.
2 Department of Biostatistics.
3 Department of Hematology.
4 Center for Applied Bioinformatics.
5 Department of Psychology, Concordia University, Montreal, Canada.
6 Department of Anesthesiology, St. Jude Children's Research Hospital, Memphis, TN.
7 Section of Hematology/Oncology/Bone Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.
8 Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN.
9 School of Public Health, The University of Texas Health Science Center-Houston (UTHealth), Houston, TX.
10 HudsonAlpha Institute for Biotechnology, Huntsville, AL.
11 Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital,

Individuals with monogenic disorders can experience variable phenotypes that are influenced by genetic variation. To investigate this in sickle cell disease (SCD), we performed whole-genome sequencing (WGS) of 722 individuals with hemoglobin HbSS or HbSß0-thalassemia from Baylor College of Medicine and from the St. Jude Children's Research Hospital Sickle Cell Clinical Research and Intervention Program (SCCRIP) longitudinal cohort study. We developed pipelines to identify genetic variants that modulate sickle hemoglobin polymerization in red blood cells and combined these with pain-associated variants to build a polygenic score (PGS) for acute vaso-occlusive pain (VOP). Overall, we interrogated the a-thalassemia deletion -a3.7 and 133 candidate single-nucleotide polymorphisms (SNPs) across 66 genes for associations with VOP in 327 SCCRIP participants followed longitudinally over 6 years. Twenty-one SNPs in 9 loci were associated with VOP, including 3 (BCL11A, MYB, and the ß-like globin gene cluster) that regulate erythrocyte fetal hemoglobin (HbF) levels and 6 (COMT, TBC1D1, KCNJ6, FAAH, NR3C1, and IL1A) that were associated previously with various pain syndromes. An unweighted PGS integrating all 21 SNPs was associated with the VOP event rate (estimate, 0.35; standard error, 0.04; P = 5.9 × 10-14) and VOP event occurrence (estimate, 0.42; standard error, 0.06; P = 4.1 × 10-13). These associations were stronger than those of any single locus. Our findings provide insights into the genetic modulation of VOP in children with SCD. More generally, we demonstrate the utility of WGS for investigating genetic contributions to the variable expression of SCD-associated morbidities.