Β-thalassemia Intermedia Research Articles

Severe β-Thalassemia Intermedia in a Compound Heterozygous Patient for the −30 (T>A) β+-Thalassemia Mutation and the δ0β+-Senegalese Deletion

We report the clinical and biochemical studies of a patient initially diagnosed with β-thalassemia intermedia (β-TI), which, with age, has progressed to a severe transfusion-dependent form. The patient is a compound heterozygote for the −30 (T>A) β+-thalassemia (β+-thal) mutation and the rare δ0β+-Senegalese deletion. Many complications are reported as well as the specific treatments initiated.

Identification of the Linkage of a 1.357 KB β-Globin Gene Deletion and A γ-Globin Gene Triplication in a Chinese Family

The 1.357 kb β-globin gene deletion was identified in a Chinese family by multiplex ligation-dependent probe amplification (MLPA) followed by gap-polymerase chain reaction (gap-PCR) and sequencing. Interestingly, this form of the deletion was linked to a –Gγ–AGγ–Aγ triplication. The proband, a compound heterozygote for this linked mutant gene and a β-globin gene [−28 (A>G)] mutation, had a phenotype of β-thalassemia intermedia (β-TI). She was not transfusion dependent and had the following parameters: a Hb level of 5.3 g/dL, 72.8% Hb F and 55.1% Gγ chain in Hb F. Four members of the family, who were carriers of this linked mutant gene, had a hematological phenotype of β0-thalassemia (β0-thal) with high Hb F and low Gγ chain values. RNA analyses showed decreased levels of β-globin mRNA and increased levels of γ-globin mRNA in heterozygotes. Haplotype analyses indicated that the unusual form of the β-globin gene deletion and γ-globin gene triplication in cis were linked to halotype [+ – – – – – –].

Molecular Characterization of a Chinese Pedigree with β-Thalassemia Intermedia

Hereditary persistence of fetal hemoglobin (HPFH), often associated with mutations in the β-globin gene cluster, is normally benign, but a person carrying both HPFH and another β-thalassemia (β-thal) mutation will develop serious anemia. These people might be erroneously diagnosed as having homozygous β-thal with common reverse dot-blot methods. Here we report a 5-year old boy with thalassemia intermedia, who is a compound heterozygote for the rare HPFH-6 deletion with codons 41/42 (–TCTT) β0-thal, who inherited the deletion from his mother and the β41/42 mutation from his father.

Magnetic resonance imaging to determine the incidence of brain ischaemia in patients with β-thalassaemia intermedia

One complication in patients with beta-thalassaemia who had prolonged survival is chronic hypercoagulable state, which results in thromboembolic events involving major organs including the brain. We determined the prevalence of microthrombosis in the brain in an asymptomatic subgroup of patients with b-thalassaemia intermedia (TI) who had undergone splenectomy. This retrospective review included 200 patients with TI diagnosed on the basis of blood count, haemoglobin (Hb) electrophoresis and clinical data. Their ages ranged from 18 to 34 years, 19 (63.3%) were women and 11 (36.7%) were men. We selected 30 patients at random who fulfilled the inclusion criteria: Hb concentration >7 g/dl), splenectomy and platelet count >500,000/ml. Their mean Hb concentration was 8.4 g/dl and their mean ferritin concentration was 519 ng/ml. Magnetic resonance imaging (MRI) was done in every patient, and the findings were interpreted by an expert neuroradiologist. Imaging studies showed pathological findings in 28% of the patients. Six had changes in the white matter suggestive of ischaemia and two had evidence of small infarctions. 1) In this small subset of patients diagnostic magnetic resonance imaging to monitor early asymptomatic or subclinical vascular damage in the brain can be considered when they reach the age of 20 years, and repeated every 3-5 years. 2) Treatment with antiplatelet aggregants is suggested in patients with documented asymptomatic brain ischaemia. 3) These results require confirmation in a larger group of similar patients with other types of thalassaemia who are multitransfused or have an intact spleen.

N-Terminal Natriuretic Peptide and Ventilation-Perfusion Lung Scan in Sickle Cell Disease and Thalassemia Patients with Pulmonary Hypertension

The aim of this study was to determine the prevalence of pulmonary hypertension (PH) in sickle cell disease and thalassemia patients in relation to clinical and laboratory parameters of hemolysis and hemosidersosis, as well as plasma N-terminal pro-brain natriuretic peptide (NT-pro-BNP). The study also aimed to define the role of thromboembolic pulmonary artery (PA) obstruction in its etiology. Forty sickle cell disease and 30 thalassemia patients [15 β-thalassemia major (β-TM) and 15 β-thalassemia intermedia (β-TI)] were screened for PH defined as tricuspid regurgitant velocity (TRV) >2.5 m/sec and evaluated for PA obstruction using ventilation-perfusion lung scan (V/Q), together with measurement of their plasma levels of NT-pro-BNP. Patients were prospectively followed up for a mean of 18 ± 6.1 months. The prevalence of PH was 37.5, 40.0 and 26.7% in sickle cell disease, β-TI and β-TM patients, respectively. Pulmonary hypertension patients were older, had longer disease duration, higher serum ferritin, serum lactate dehydrogenase (LDH) and NT-pro-BNP with lower hemoglobin (Hb) levels compared to patients without PH. N-terminal pro-BNP was positively correlated with duration of illness, TRV, LDH, serum ferritin, and negatively correlated with Hb levels. The strongest predictor for TRV was serum ferritin followed by the NT-pro-BNP level. Forty-six-point-seven percent of sickle cell disease patients with PH had either high or intermediate probability V/Q scan results compared to 10% of thalassemic patients with PH who had high probability V/Q scan results. Pulmonary hypertension is highly prevalent in young sickle cell disease and thalassemia patients, where elevated serum ferritin and NT-pro-BNP are the main indicators.

Future alternative therapies for β-thalassemia

β-thalassemia is an inherited disorder due to mutations found in the β-globin gene, leading to anemia and requiring sporadic or chronic blood transfusions for survival. Without proper chelation, β-thalassemia results in iron overload. Ineffective erythropoiesis can lead to iron overload even in untransfused patients who are affected by β-thalassemia intermedia. Better understanding of the molecular biologic aspects of this disorder has led to improvements in population screening and prenatal diagnosis, which, in turn, have led to dramatic reductions in the number of children born with β-thalassemia major in the Mediterranean littoral. However, as a consequence of decreases in neonatal and childhood mortality in other geographical areas, β-thalassemia has become a worldwide clinical problem. A number of unsolved pathophysiological issues remain, such as ineffective erythropoieis, abnormal iron absorption, oxidative stress, splenomegaly and thrombosis. In the last few years, novel studies have the potential to introduce new therapeutic approaches that might reduce these problems and limit the need for blood transfusion.

Randomized Phase II Study Evaluating the Efficacy and Safety of Deferasirox in Non-Transfusion-Dependent Thalassemia Patients with Iron Overload.

Abstract 5111 BackgroundClinically mild forms of thalassemia exist that, unlike β-thalassemia major, require no or only infrequent transfusions (eg. β-thalassemia intermedia, HbH disease). However, due to increased gastrointestinal iron absorption secondary to ineffective erythropoiesis these patients may still develop iron overload. For example, thalassemia intermedia patients (n=74) within a cross-sectional study had a mean serum ferritin (SF) of 1023 ng/mL (range 15–4140) and a mean liver iron concentration (LIC) of 9 mg Fe/g dw (range 0.5–32.1) at baseline despite most being transfusion-naïve (n=20) or rarely transfused (n=45), and only nine receiving regular transfusions (2–4 times/yr) (Taher et al. ITIFPaP: 13th International TIF Conference for Thalassaemia Patients & Parents, October 8–11 2008, Singapore, poster number MON04). Non-transfusional iron overload leads to the same serious clinical sequelae as transfusional iron overload, including liver, cardiac and endocrine dysfunctions. As patients with non-transfusional iron overload are not candidates for phlebotomy due to their underlying anemia, chelation therapy is the only available option for decreasing their iron burden. However, there is currently limited data available on the use of chelation in this population. The once-daily oral iron chelator deferasirox (Exjade®) is currently approved for the treatment of iron overload in patients with transfusion-dependent anemia. This prospective, randomized, double-blind, placebo-controlled Phase II ‘THALASSA' study will evaluate the efficacy and safety of deferasirox in patients with non-transfusion-dependent thalassemia. MethodsNon-transfusion-dependent thalassemia patients aged ≥10 yrs will be randomized 2:1:2:1 to starting doses of deferasirox/placebo 5 mg/kg/day/ deferasirox/placebo 10 mg/kg/day over a planned 12-month treatment period. Doses can be doubled after 6 months should patients require a higher dose, which will be determined after 6 months of treatment. All patients are required to have a baseline LIC of ≥5 mg Fe/g dw, as measured by R2 magnetic resonance imaging, and SF levels of >300 ng/mL. Patients will be excluded if they have: anticipated regular transfusions during the study (sporadic transfusions, such as in cases of infection, are allowed); any transfusion within 6 months prior to study start, chelation within 1 month prior to study start; HbS variants of thalassemia; impaired renal and liver function. Primary efficacy endpoint is absolute change from baseline in LIC at 12 months; secondary efficacy endpoints include change from baseline in LIC after 6 months and in SF after 6 and 12 months, as well as change in hematological and iron metabolism parameters (eg hemoglobin, transferrin saturation). Safety assessments include adverse event and laboratory parameter monitoring. 156 patients are planned for inclusion. ResultsAs of 3 August 2009, 18 sites had been activated. Sites currently activated are in Thailand (n=5), Turkey (n=4), Italy (n=3), Malaysia (n=2), UK (n=2) Lebanon (n=1). Fifty-seven patients have been randomized to either deferasirox or placebo and their demographic data are shown in Table 1. [Display omitted] ConclusionsSimilar to transfusion-dependent thalassemia patients, non- transfusion-dependent thalassemia patients also develop iron overload. This ongoing study will generate prospective efficacy and safety data for the use of deferasirox in non-transfusion-dependent thalassemia patients with iron overload. To prevent long term complications due to iron overload, it is important to assess iron chelation in this patient population as they are not candidates for phlebotomy due to the underlying anemia. DisclosuresTaher:Novartis: Honoraria, Research Funding. Porter:Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Vifor International: Membership on an entity's Board of Directors or advisory committees. Kattamis:Novartis: Consultancy, Honoraria, Speakers Bureau. Viprakasit:Thai Government: Employment; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Government Pharmaceutical Organization of Thailand: Honoraria, Research Funding. Lawniczek:Novartis Pharma AG: Employment. Pereno:Novartis Pharma AG: Employment. Schoenborn-Kellenberger:Novartis Pharma AG: Employment. Cappellini:Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Genzyme: Membership on an entity's Board of Directors or advisory committees.

Prevalence of haemoglobinopathies in 34 030 healthy adults in Tehran, Iran

Background:Haemoglobinopathies are a group of inherited disorders of haemoglobin synthesis. Their frequency varies considerably with geographic location and ethnic group.Aims:To establish the prevalence of haemoglobinopathies in a mainly healthy Iranian...

P076 Laboratory features of mixed myelodysplastic syndrome associated with B-thalassemia intermedia

P076 Laboratory features of mixed myelodysplastic syndrome associated with B-thalassemia intermedia

Homozygosity for a Rare β0-Thalassemia Mutation [Frameshift Codons 25/26 (+T)] Causes β-Thalassemia Intermedia in an Iranian Family

The severity of β-thalassemia (β-thal) is remarkable for its variability in different populations, even in different patients. We studied a family from Azerbaijan Province, Northwestern Iran, who had a rare β0-thal mutation, namely the frameshift codons (FSC) 25/26 (+T), originally reported in Tunisia. Unlike the Tunisian family, in our family the mutation was a β0 type and the affected members were dependent and independent of blood transfusions. This mutation was linked to the –158 (C>T) polymorphism on the Gγ-globin gene (XmnI marker) and two other polymorphisms in the Aγ-globin promoter at position +25 (G>A) and –588 (G>A). Deletions in the α- and β-globin gene clusters were excluded in all samples. This is the first description of the FSC 25/26 mutation in Iran. The results of this study emphasize the complexity of genetic interactions that underlie the phenotype of β-thal intermedia and highlight the importance of the regulation of hemoglobin (Hb) F production in the β-thal syndromes. Simultaneous inheritance of some loci that interfere with the elevation of Hb F probably caused them to have high levels of total Hb and to be transfusion independent.

The Hypercoagulable State in Thalassemia Intermedia

Although the life expectancy of β-thalassemia patients has markedly improved over the last few years, patients still suffer from many complications of this congenital disease. The presence of a high incidence of thromboembolic events, mainly in β-thalassemia intermedia, has led to the identification of a hypercoagulable state in these patients. In this review, the molecular and cellular mechanisms leading to hypercoagulability in β-thalassemia are highlighted, with a special focus on thalassemia intermedia being the group with the highest incidence of thrombotic events as compared to other types of thalassemia. Recommendations for thrombosis prophylaxis in these patients are also discussed.

Interaction of Hb South Florida (codon 1; GTG→ATG) and HbE, with β-thalassemia (IVS1-1; G→A): expression of different clinical phenotypes

Interactions of different hemoglobin variants with thalassemia alleles can result in various clinical phenotypes. HbE-beta-thalassemia generally manifests with severe anemia where individuals exhibit beta-thalassemia major with regular blood transfusions or beta-thalassemia intermedia with periodic blood transfusions. This study presents a unique Malay family with three beta-globin gene defects-HbE, Hb South Florida, and IVS1-1 (G-->A). HbE activates a cryptic splice site that produces non-functional mRNAs. Hb South Florida is a rare beta-hemoglobin variant, and its interactions with other beta-thalassemia alleles have not been reported. IVS1-1 is a Mediterranean mutation that affects mRNA processing giving rise to beta(o)-thalassemia. Fifteen mutations along the beta-globin gene complex were analyzed using the amplification refractory mutation system. Hb South Florida was identified by direct sequencing using genomic DNA. The affected child with HbE/IVS1-1 produced a beta-thalassemia major phenotype. Compound heterozygosity for Hb South Florida/IVS1-1 produced a beta-thalassemia carrier phenotype in the mother.

The Hydroxyurea Effects on Plasma Levels and Surface Expression of Adhesion Molecules ICAM-1 VCAM-1, E-SELECTIN and on Plasma Levels of Protein C and Protein S in Patients with Sickle Cell Disease and β-Thalassemia Intermedia

Abstract The pathophysiological mechanism of vaso-occlusion in Sickle Cell disease (SCA) is complex, involving adhesive processes between sickle red blood, leukocyte, and the activated endothelium. Reduced activity of the protein C and protein S may contribute to vaso-occlusion. We investigated the effect of Hydroxyurea (HU) on surface expression of the circulating endothelial cells (CEC) ICAM-1 (CD54), VCAM-1 (CD106), E-SELECTIN (CD62E), on plasma levels of soluble sICAM-1, sVCAM-1, sESELECTIN, and on plasma levels of protein C and protein S in patients with SCA and β-Thalassemia Intermedia (TI) Methods : We studied 10 patients with SCA disease, 15 patients with TI, and 12 healthy controls (HC). Flow cytometric analysis was performed with a FC-500. For surface expression on CEC of CD54, CD106, CD62E whole blood (EDTA) is incubated with a panel of MoAbs. Activated CEC were defined as CD45 negative, CD54, CD106, CD62E positive. Plasma was separated from blood of patients and controls, and sICAM-1, sVCAM-1, sE-SELECTIN levels were quantified using specific kit Flowcytomix human adhesion 6plex (Bender MedSystem) according to the manufacturer’s instructions. Results : The percentage (%) of positive CEC expressing markers of endothelial-cell activation were significantly higher in patients with SCA and TI no taking HU, comparated with healthy controls, so as plasma levels (ng/ml) of sICAM-1, sVCAM-1, sE-SELECTIN. SCA patients: CD54+ = 10,9±6,5 % vs 1,4±0,7 % respectively, P= 0,001; CD106+ = 19,7±18,5 % vs 2,1±1,1 % P= 0,03; CD62E+ = 21,2± 20,8 % vs 3,7±1,6 % P= 0,02; sICAM-1=1263,12±445,48 (ng/ml) vs 102,24±14,50 (ng/ml), P=0,03; sVCAM= 1978,67± 985,08 (ng/ml) vs 300,81±70,35 (ng/ml) P=0,01; sESELECTIN= 935,04±313,54 (ng/ml) vs 352,59±50,32 (ng/ml) P= 0,03; TI patients: CD54+ = 12,1±7,1 % vs 1,4±0,7 % P=0,003; CD106+ = 3,68± 2,0 % vs 2,1±1,1 % P=0,42; CD62E+ = 7,08± 9,1 %vs 3,7±1,6 % P=0,87; sICAM-1 = 1911,16±509,90 (ng/ml) vs 102,24±14,50 (ng/ml) respectively, P=0,05; sVCAM = 1067,61±755,37 (ng/ml) vs 300,81±70,35 (ng/ml) P=0,03; sE-SELECTIN = 746,92± 236,47 (ng/ml) vs 352,59±50,32 (ng/ml) P=0,05.The expression of adhesion molecules on CEC and plasma levels of soluble sICAM-1, sVCAM-1, sE-SELECTIN were significantly reduced during HU therapy. SCA patients: CD54+ = 5,01± 4,5 % P=0,01; CD106+ = 9,9± 6,7 % P=0,26; CD62E+ = 11,6± 8,4 % P=0,38;sICAM-1 = 511,81±180,95 (ng/ml) P=0,01; sVCAM = 870,41±419,04 (ng/ml) P=0,02; sE-SELECTIN = 587,49± 364,16 (ng/ml) P=0,03. TI patients: CD54+ = 2,0±2,5% P=0,003; CD106+ = 2,1±0,9 % P=0,42; CD62E+ = 1,8±1,0 % P=0,87;sICAM-1 = 1294,18±350,69 (ng/ml) P=0,05; sVCAM = 1067,61±755,32(ng/ml) P=0,03; sE-SELECTIN = 746,92± 236,47 (ng/ml) P=0,05. The plasma levels of protein C and protein S were increased in SCA and TI patients on HU therapy comparated to those no taking HU; however, this difference was not significant. (SCA patients: Protein C = 106,76±15,79 % vs 77,59±24,73 P=0,14; Protein S = 79,070±1,38 % vs 65,96±6,36 P=0,49; TI patients: Protein C = 83,46±24,99 % vs 64,65±26,67 % P=0,23; Protein S = 80,50±0,77 % vs 74,33±2,36 % P=0,12). Conclusion : Our results confirm that the vascular endothelium is activated in patients with SCA and TI disease, as evidenced from the higher expression of adhesion molecules CD54, CD106, CD62E on the surface of CEC and from the higher levels of soluble sICAM-1, sVCAM-1, sE-SELECTIN, reflecting an increased capacity for the adhesion of sickle erythrocytes and leucocytes to the endothelium. HU therapy reduce the expression on the endothelial cell surface, so as plasma levels, of adhesion molecules, reducing the activation state of the endothelium. Furthermore, HU therapy increase plasma levels of anticoagulants protein C and protein S, reducing hypercoagulable state, which means smaller endothelial damages and vaso-occlusive-events.

Epigenetic Analysis of Beta-Globin Gene Cluster during Hematopoiesis.

Hemoglobin (Hb) switching is described as temporal, tissue- and stage-specific patterns of globin gene expression; from embryonic to fetal and adult Hb in parallel to developmental stages of erythropoiesis. DNA methylation, one of the epigenetic mechanisms, was associated with inactivated chromatin domain and repressive transcription. To study the role of the DNA methylation on the beta (β)-globin genes, we analyzed CpG dinucleotides in 87 kb regions around β-globin gene cluster, including 5'upstream locus control regions (LCR; DNAse I Hypersensitive site (HS) 1–5), 3'HS1, the promoter regions of the G-and A-gamma (Gγ and Aγ), and β-globin genes, in several representative cells. These cells wereprimary adult erythroid cells culture (three different stages: early, intermediate, and late),fetal cord blood DNA, andneutrophil cell line (non-erythroid).Using bisulphite modification, followed by nested PCR and in vitro translation, the cleavage products were analysed by MALDI-TOF Mass Spectrometry to quantify the DNA methylation level. The results were consistent with bisulphite sequencing. We found that the promoters of Gγ and Aγ-globin genes were significantly hypomethylated in fetal cells (44% and 47% global methylation), when γ-globin genes were fully expressed, while they were heavily methylated in non-erythroid (86% and 95%). There was also a decreasing trend of the DNA methylation level at Gγ and Aγ-globin genes during adult erythroid differentiation from 80% and 82%, in early stage, to 67% and 66% in late stage (p=0.12 and 0.04). At β-globin promoter, the global methylation level changed from 90% in non-erythroid to 81%, 42%, and 26% in fetal, early and late adult erythroid cells, respectively. Moreover, we found the significant changes at 5'HS4, 3, and 1 as all erythroid cells were hypomethylated compare to non-erythroid. While at the insulators, 5'HS5 and 3'HS1, all tested CpG dinucleotides were heavily methylated in all cells. This is the first report that demonstrates the differences in DNA methylation at β-globin LCR between erythroid and non-erythroid cells. These epigenetic marks were associated with globin genes expression and might be useful to predict clinical severity in patients with β-thalassemia intermedia.

Thalassemia and hypercoagulability

Thalassemia is a congenital hemolytic disease caused by defective globin synthesis resulting in decreased quantity of globin chains. Although the life expectancy of beta-thalassemia patients has markedly improved over the last few years, patients still suffer from many complications of this congenital disease. The presence of a high incidence of thromboembolic events, mainly in beta-thalassemia intermedia, has led to the identification of a hypercoagulable state in these patients. In this paper, we review the molecular and cellular mechanisms leading to hypercoagulability in beta-thalassemia, with a special focus on thalassemia intermedia being the group with the highest incidence of thrombotic events as compared to other types of thalassemias. We also discuss the recommendations for thrombosis prophylaxis in these patients.

Elevated levels of circulating procoagulant microparticles in patients with -thalassemia intermedia

Patients with β-thalassemia intermedia (β TI) are completely asymptomatic until adult life, experiencing only mild anemia, maintaining hemoglobin levels between 7 and 10 g/dL, and require only occasional blood transfusions, if any. MPs are shed submicrometric plasma membrane fragments (~0.1–1 μ

Painful Spinal Cord Compression as a Complication of Extramedullary Hematopoiesis Associated with β-Thalassemia Intermedia

Spinal cord compression due to extramedullary hematopoiesis (EMH) is a rare manifestation of thalassemia. General therapeutic recommendations do not exist. We report a 23 year old male with beta-thalassemia intermedia and back pain resistant to analgetic medication. Multiple extradural mass lesions on MRI of the lumbar spine were identified. Hypertransfusion was initiated with no relief of symptoms. Low dose irradiation with 20 Gy had to be added to achieve adaequate response. With the combination of transfusion therapy and irradiation a rapid and long-lasting relief of symptoms was achieved. 12 month post irradiation the patient is free of pain and neurological symptoms. Clinical awareness of this phenomenon and knowledge of the available treatment option is essential for successful outcome. In treatment refractory symptoms irradiation could successfully contribute to a rapid therapeutic response.

Loss of vision associated with angioid streaks in β-thalassemia intermedia

An acquired diffuse elastic tissue defect that resembles inherited pseudoxanthoma elasticum (PXE) has been noticed with a significant age-related frequency in hemoglobin disorders, especially beta-thalassemia and has been held responsible for a number of complications observed in these cases, some of which are quite severe. We report here two patients with beta-thalassemia intermedia, who presented with severe visual acuity impairment associated with angioid streaks, the typical ocular manifestation of PXE.

Outcome of Thalassemia Intermedia Mothers and Newborns in Two Tertiary Care Centers, Beirut and Milan.

Introduction: β-thalassemia intermedia (TI) patients either present with a severe disease between the ages of 2–6 years, or remain asymptomatic until they present with a milder disease during adult life. With the advances in assisted reproductive technology and medical management, pregnancy has become possible in most TI cases. Spontaneous abortions, intrauterine growth restriction (IUGR), and preterm labor are complications that face women with TI. This study aimed at evaluating the pregnancy outcome of women with TI in two tertiary care centers, one in Lebanon and another in Italy.Methods: Patient databases at the Chronic Care Center, Lebanon and at the Hereditary Anemia Center in Milan, Italy were reviewed. Maternal and neonatal charts of women with TI and documented pregnancy were identified and reviewed using a specially formulated questionnaire that focused on demographic characteristics (maternal age, gestational age (GA), parity, and abortions), past medical history related to thalassemia, course of pregnancy and complications, intrapartum events and neonatal outcome. Patients were then contacted by phone for any missing information.Results: A total of 44 pregnant TI patients, 11 in Lebanon and 33 in Italy were identified. Mean age at diagnosis of TI was 9.2 ± 9.7 years (range 1–42 years) with 34 (77.3%) splenectomized patients identified. Fourteen patients (31.8%) were frequently transfused, 25 (56.8%) occasionally transfused and only 4 (9.1%) never transfused. Mean age at pregnancy was 29.5 ± 3.9 years (range 21–38 years) with 11 patients (28.2%) receiving the first transfusion during pregnancy. Twenty eight patients were on chelation therapy: 21 (48.8%) received deferioxamine, 4 (9.3%) deferiprone and 3 (7%) deferasirox. After excluding 4 women with ongoing pregnancies, information on 79 pregnancies, all spontaneous, were available, 30 from Lebanon and 49 from Italy. These resulted in 60 live births (75.9%), 17 abortions (21.5%), and 2 intrauterine fetal deaths (2.5%), at 26 and 36 weeks of gestation, respectively. Three patients (7.5%) had recurrent abortions (≥3 abortions). Of women whose pregnancies progressed beyond 20 weeks of gestation (n=62), the following obstetrical complications were encountered: preterm delivery <37 weeks of gestation (18, 29.0%), IUGR (14, 22.6%), preeclampsia (1, 1.6%), placental abruption (2, 3.2%) and cholestasis of pregnancy (1, 1.6%). Mean GA at delivery was 36.8 ±2.8 weeks. Thrombotic events were encountered during 4/79 (5.1%) pregnancies: deep vein thrombosis (DVT) ante- and post-partum (n=2), antepartum DVT (n=1) and placental thrombosis (n=1). Two women had postpartum splenectomy. Cesarean delivery was performed in 44 pregnancies (70.9%). No significant differences were noted when the course of pregnancy and obstetrical outcomes of women in Lebanon and Milan were compared.Conclusions: Preterm delivery complicates 29% of pregnancies with TI which are at a 23% risk of IUGR. Cesarean delivery is the most common route of delivery in these patients (70.9%). As with any chronic disease affecting different organs, TI presents a challenge for pregnant patients, their fetuses and physicians and requires close monitoring for any events that might compromise the patient or the newborn. Further studies comprising more patients need to be carried out to determine the effects of splenectomy and transfusions during pregnancy and on the outcome of those pregnancies.

Apotransferrin Injection Leads to More Effective Erythropoiesis in β-Thalassemic Mice.

β-thalassemia is a disease resulting from a β-globin gene mutation which leads to less β-globin, expanded and ineffective erythropoiesis, and anemia. Additionally, mature red blood cells have a shortened survival. Although the degree of anemia varies, from severe transfusion-dependence to only an increase in iron absorption in the gut to maintain hemoglobin levels, all thalassemic patients develop some degree of iron overload. In a previous study using β-thalassemic mice, we were able to induce iron overload using iron dextran injections and demonstrated an increase in hemoglobin with increased reticulocytosis and an expansion of extramedullary erythropoiesis in the liver and spleen. The fact that iron administration reduced anemia in β-thalassemic mice was surprising. Since patients with β-thalassemia have ample iron supply, we hypothesized that part of the anemia in β-thalassemia may result from a maldistribution of iron as a consequence of insufficient circulating transferrin to deliver iron for erythropoiesis. In the present study, we analyzed the effect of intraperitoneal human apotransferrin injections on markers of hematopoiesis and iron metabolism in thalassemic mice. We used three different doses of apotransferrin - 5mg, 10mg, and 30mg - daily, for a 10 day course. Mice with β-thalassemia intermedia (Hbbth1/th1) were compared with age and gender matched control C57BL/6J mice. Although no increase in hemoglobin was observed, the reticulocyte count decreased after apotransferrin injections (2975±125 x 109 vs. 1636±130 x 109 cells/L, P=2.29 x 10−5). The efficiency of erythropoiesis, as measured by red cell to reticulocyte ratio, increased after apotransferrin injections (0.029±0.002 vs. 0.007±0.0007, P=0.0002), confirming that more red cells circulate as a result of each maturing erythroid precursor. We were able to demonstrate that apotransferrin is effective in increasing transferrin iron binding capacity (TIBC) (739.5±98.4 vs. 419.1±18.3 mg/dL, P=0.002) without changing the transferrin saturation (23.0±7.1 vs. 34.9±4.2%, P=0.15) in our mice. Apotransferrin injections also resulted in a reduction of iron deposition in the liver (5.49±0.48 vs. 11.08±1.24 mg/g dry weight, P=0.003) and heart (1.25±0.18 vs. 2.26±0.26 mg/g dry weight, P=5.7 x 10−5) of Hbbth1/th1 mice without changes in labile plasma iron levels. Using flow cytometry, we demonstrated an increase in erythroid precursors in the bone marrow of Hbbth1/th1 mice (68.7±1.5 vs. 56.5±3.96% ter119+ precursors, P=0.01) but a decrease in the spleen (41.05±3.16 vs. 60.95±8.3% ter119+ precursors, P=0.03) compared to baseline. Lastly, liver hepcidin expression was progressively suppressed with increasing transferrin dose in our mice. Taken together, this data strongly suggests that exogenous apotransferrin is able to mobilize stored iron for production of erythroid precursors in the bone marrow; this process leads to hepcidin suppression. Diseases of ineffective erythropoiesis, in which expanding erythropoiesis may be limited by the iron delivery system to maintain hemoglobin production, may be a result of insufficient transferrin and relative iron deficiency. The significance of our current findings has potential broad implications for the mobilization of stored iron for use in erythropoiesis in many diseases in which iron overload co-exists with anemia such as β-thalassemia, sideroblastic anemia, and the myelodysplastic syndromes.