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We sought to characterize the relationship between PFH and more clinically available hemolytic markers including lactate dehydrogenase (LDH), aspartate aminotransferase (AST), bilirubin, reticulocyte percentage and to derive a composite hemolysis score derived from principal component analysis (PCA) of these biomarkers. In 68 adult patients (median age 31 years old, IQR 25\u201339) with HbSS or HbS\u03b2\n                    <jats:sup>0<\/jats:sup>\n                    -thalassemia enrolled in the IMPROVE II study, median PFH was elevated at 21.9\u00a0mg\/dL (IQR 9.9\u201344.9\u00a0mg\/dL) at steady state. Using Pearson correlation analysis, PFH had a stronger relationship to LDH (\n                    <jats:italic>R<\/jats:italic>\n                    \u2009=\u20090.699), AST (\n                    <jats:italic>R<\/jats:italic>\n                    \u2009=\u20090.587), and total bilirubin (\n                    <jats:italic>R<\/jats:italic>\n                    \u2009=\u20090.475), compared to reticulocyte count (\n                    <jats:italic>R<\/jats:italic>\n                    \u2009=\u20090.316). The hemolysis score was significantly associated with PFH (\n                    <jats:italic>R<\/jats:italic>\n                    \u2009=\u20090.677). When compared with other laboratory measures, PFH correlated with hemoglobin (\n                    <jats:italic>R<\/jats:italic>\n                    = -0.275) and HbS (\n                    <jats:italic>R<\/jats:italic>\n                    \u2009=\u20090.277), but did not correlate with white blood cell count (WBC) or HbF. The hemolysis score was significantly associated with WBC (\n                    <jats:italic>R<\/jats:italic>\n                    \u2009=\u20090.307), hemoglobin (\n                    <jats:italic>R<\/jats:italic>\n                    = -0.393), HbF (\n                    <jats:italic>R<\/jats:italic>\n                    =- 0.424), and HbS (\n                    <jats:italic>R<\/jats:italic>\n                    \u2009=\u20090.423). This study confirms that the conventional hemolytic biomarkers LDH, AST, bilirubin, and reticulocyte percentage correlate with PFH. Additionally, the hemolysis score is a valid tool to measure hemolysis and that it may be a marker of global hemolysis as opposed to PFH, which quantifies intravascular hemolysis. Further studies will be needed to elucidate the role of PFH and intravascular hemolysis in the development of clinical complications of sickle cell disease. Statements and Funding Declarations: The research leading to these results received funding from the National Heart, Lung, and Blood Institute (NHLBI) R01 HL142671 Grant under J.G. J.G. has also served as a consultant for CSL Behring, Novartis, and Novo Nordisk synteract DSMB and is supported by NHLBI RO1HL159116, R01 HL142671, R01 ES030717, UG1 HL138645, UH3 HL143192, U01HL167036, and the Doris Duke Charitable Foundation Advancing Cures grant. S.C. has served as a consultant for Pfizer and is supported by the NHLBI 5K23HL151884 grant. A.L. is supported by the NHLBI 5T32HL129974-05. C.J.M is supported by the NHLBI 5T32HL129974-05. P.S., and S.M. declare no conflicts and\/or funding.\n                  <\/jats:p>","DOI":"10.1007\/s00277-025-06253-w","type":"journal-article","created":{"date-parts":[[2025,2,19]],"date-time":"2025-02-19T01:04:24Z","timestamp":1739927064000},"page":"2221-2228","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":13,"title":["Plasma free hemoglobin is associated with LDH, AST, total bilirubin, reticulocyte count, and the hemolysis score in patients with sickle cell anemia"],"prefix":"10.1007","volume":"104","author":[{"given":"Angela","family":"Liu","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charleen","family":"Jacobs-McFarlane","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paola","family":"Sebastiani","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeffrey","family":"Glassberg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah","family":"McCuskee","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susanna","family":"Curtis","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,2,19]]},"reference":[{"key":"6253_CR1","doi-asserted-by":"publisher","first-page":"18010","DOI":"10.1038\/nrdp.2018.10","volume":"4","author":"GJ Kato","year":"2018","unstructured":"Kato GJ, Piel FB, Reid CD, Gaston MH, Ohene-Frempong K, Krishnamurti L, Smith WR, Panepinto JA, Weatherall DJ, Costa FF, Vichinsky EP (2018) Sickle cell disease. 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