Β-thal Patients Research Articles

Iron Overload, Cardiac and Other Factors Affecting Pregnancy in Thalassemia Major

The reproductive thalassemic population is growing older and doctors confront the challenge of the thalassemic pregnancy. Pregnancy is characterized by dynamic multiple system changes, resulting in increased basal oxygen consumption, changes in energy substrate use by different organs and increased susceptibility to oxidative stress, while homozygous transfusion-dependent β-thalassemia (β-thal) patients manifest cardiac, hepatic, endocrine, and metabolic disorders attributable to chronic anoxia and iron overload. Pregnant thalassemic patients require significantly larger amount of total blood transfusion during pregnancy and iron overload increases the oxidative stress of pregnancy, while the risk for cardiovascular events, in a high cardiac output state, is augmented and chelation treatment is generally avoided due to the potential teratogenicity. Pregnancy in thalassemia major should be considered high risk, and be cared for by an expert team with special caution and sensitivity.

The profile of free amino acids in latent fingerprint of healthy and beta-thalassemic volunteers

The aim of the present work is to apply a non-invasive test, using thumb fingerprint residue analysis, for detection of beta-thalassemia (β-Thal). The relative percentages of free amino acids (AA) in the latent fingerprint of β-Thal patients and healthy subjects were compared. The sample included 24 β-Thal patient and 24 healthy subjects, aged 5–10 years old. Twenty-three AA plus ammonia were analyzed by a sensitive high-performance liquid chromatographic method with fluorescence detection. The profile of AA was calculated based on the percentage of relative amount of each AA to serine (Ser) as it found to be the predominant peak. The statistical and chromatographic profiles of β-Thal patients were characterized by significant decrease of ornithine, lysine, and zero tyrosine, with significant increase of ammonia, and proline. Other amino acids that exist in low ratios were estimated statistically for significance changes. The relative percentages of each AA of healthy subjects were approximately constant. For this reason, these mentioned AA were assigned as major fingerprint markers of β-Thal.

Association between apolipoprotein ε4 allele, factor V Leiden, and plasma lipid and lipoprotein levels with sickle cell disease in southern Iran

To investigate whether there is any association between various APOE alleles and factor V Leiden (FVL) with lipid profiles and sickle cell disease (SCD) in Southern Iran. 65 SCD patients consisting of 35 sickle cell anemia homozygous (SS), 15 sickle cell heterozygous (AS) and 15 sickle cell/βThalassemia (S/βthal) patients and 68 healthy individuals with normal hematological indices were studied. APOE and FVL polymorphisms were detected by PCR-RFLP and serum lipid level was measured enzymatically. The frequencies of FVL and APOE-ε4 allele were significantly higher in SCD patients than in control (15.4 vs. 4.4 and 13.7% vs. 3.3%, respectively). The distributions of APOE ε3ε3, ε2ε3 and ε2ε4+ε3ε4 alleles in SCD patients were significantly different from those in the control group. The SCD subjects particularly SS/S βthal (SS+S/βthal) and SS patients have significantly lower frequency of APOE ε3ε3 allele (P<0.05) whereas SCD, SS patients and AS individuals have a significantly higher frequency of APOE ε4 allele (ε2ε4+ε3ε4; P=0.003, P=0.011 and P=0.035, respectively) compared to the control group. The LDL-C (P=0.006) and total cholesterol (P<0.001) levels in SCD subjects were found to be significantly lower than those in the control group. In addition, the presence of non-APOE ε4 allele (ε2ε3+ε3ε3) resulted in a significant decrease in the level of LDL-C and total cholesterol in SCD subjects in general and in SS and SS/S βthal patients in particular compared to controls. Furthermore, the presence of APOE ε4 allele (ε2ε4+ε3ε4) was found to be associated with the risk of sickle cell anemia [OR=4.1, P=0.04]. The presence of either FVL mutation (OR=4.6; CI: 0.91-24, P=0.07) or APOE-ε4 allele (OR=4.07; CI: 1.01-16.4, P=0.048) is associated with the risk of sickle cell disease in Southern Iran. This data suggest that the activation of coagulation system enhances thrombus generation and decreases antioxidant activity in SCD patients from Southern Iran.

Spinal Cord Compression And Extramedullary Hematopoiesis in Young Egyptian β-thalassemia Patients

The problem of spinal cord compression (SCC) related to extramedullary hematopoiesis (EMH) in β-thalassemia (β-thal) patients, both clinically and radiologically and its correlation with laboratory parameters of anemia and hemosiderosis was assessed. Sixty β-thal patients were included and divided into group I: 40 β-thal major patients (β-TM), aged 7–30 years with a mean age of 15 ± 5.3 years, group II: 20 β-thal intermedia patients (β-TI) aged 6–20 years with a mean age of 13 ± 4.6 years. They were subjected to neurological examination, thoracic and lumbosacral computed tomography (CT) and magnetic resonance imaging (MRI). Spinal EMH was found in 13.3% of the thalassemic patients with a higher incidence in β-TI compared to β-TM patients (p = 0.03). Evidence of spinal EMH was associated with higher serum ferritin (p < 0.0001), lower pre transfusion hemoglobin (Hb) (p = 0.002) and lower transfusion index (p = 0.01). Extramedullary hematopoiesis was more evident in young β-TI patients, and was related to inadequate chelation, high serum ferritin and inadequate transfusion therapy.

Prevalence and Predictors of Pulmonary Arterial Hypertension in Hemoglobin E/ β-Thalassemia Patients.

Abstract 2015Poster Board I-1037 Introduction:Pulmonary arterial hypertension (PAH) associated with thalassemia (Thal) hemoglobinopathy is now an accepted clinical entity. Most of the reports are in sickle cell disease and splenectomized β-Thal patients. Once manifested, it connotes poor prognosis. We herein present its prevalence and predictors in hemoglobin E/β-Thal (E/β-Thal) patients. Patients and Methods:One hundred and ten clinically stable E/β-Thal outpatients, on no medication aside from folic acid and who received no blood transfusion in the preceding 4 weeks were studied. All gave written informed consent, and study protocol was approved by the institution ethics committee on studies in humans (#0774/2548). Echocardiogram was used to estimate systolic PA pressure (SPAP). PAH was defined as an estimated SPAP ≥36 mmHg. Clinical features and laboratory data were stratified according to the presence or absence of PAH, and statistical analysis was done by STATA version 10 (Stata Corp, Texas), considering a P value <0.05 as statistically significant. Predictors of PAH were considered in univariate analysis. Results:There were 110 patients, 56 of whom were female and 61 were asplenic. PAH was present in 41 patients (37.3%), all of whom had normal left ventricular ejection fraction. There was no gender difference between the 2 groups (p=0.055). Selected statistically significant results are shown in the table.ResultsWith PAH (41 Patients)Without PAH (69 Patients)P valueAge at 1st transfusion (median)6 years11.25 years0.03Total transfusions (median)37 units PRBC15 units PRBC0.04Splenectomy78%42%<0.001Cardiomegaly52.5%32.3%0.042Extramedullary hematopoiesis56.4%30.6%0.01RBC count3.24 +/- 0.93 × 106/μL3.65 +/- 0.9 × 106/μL0.034Corrected reticulocyte count (median)4%1.7%0.02Nucleated RBC (median)530/100 WBCs15.5/100 WBCs<0.001Corrected WBC count9.34 +/- 4 × 103/μL7.8 +/- 3.5 × 103/μL0.036Platelet count627.7 +/- 313.2 × 103/μL436 +/- 267.4 × 103/μL0.001Globulin4.4 +/- 1.2 g/dL3.8 +/-0.8 g/dL0.002LDH323.3 +/- 117.2 u/L243.3 +/- 85.6 u/L<0.001Free hemoglobin (median)4.42 mg/dL2.7 mg/dL0.001C-reactive protein (high sens) (median)2.9 mg/L1.3 mg/L0.008Soluble VCAM-11,896.1 +/- 553.5 ng/mL1,463 +/- 622 ng/mL0.004NT pro BNP11.7 pmol/L6.2 pmol/L0.026 Conclusions:Prevalence of PAH in E/β-Thal patients is 37.3% without gender preponderance. Predictors are asplenia, more severe hemolysis, higher number of circulating (activated) platelets and nucleated RBCs, increased chronic low grade inflammation and increased cellular adhesion between blood and endothelial cells. These changes could facilitate development of thrombotic pulmonary arteriopathy, the underlying basis of PAH. Serum NT pro BNP assay can be utilized as a predictor or a screener of PAH in these patients. Disclosures:No relevant conflicts of interest to declare.

Abnormal Glucose Tolerance in β-Thalassemia: Assessment of Risk Factors

In β-thalassemia (β-thal) major, the pathogenetic mechanisms leading from siderosis to diabetes are poorly understood. We assessed the glycometabolic status in transfusion-dependent Egyptian β-thal patients and evaluated their possible risk factors for abnormal glucose tolerance (AGT). An oral glucose tolerance test (OGTT) was done on 54 multi-transfused patients and 28 age-matched normal controls, measuring their serum insulin levels at 0 and 120 min. Insulin sensitivity and insulin release indices were calculated. Indicators of iron overload and liver status were recorded. Thirteen patients (24.1%) had AGT. Cases with AGT had significantly higher mean postprandial insulin, fasting insulin resistance index (FIRI) and homeostasis model assessment (HOMA) insulin resistance (IR), p = 0.0001 for all, and significantly lower mean HOMA β cell, p = 0.007, when compared with normal glucose tolerance (NGT) cases. Abnormal glucose tolerance is common in multi-transfused β-thal major patients and could be attributed to early impaired β-cell function with increasing IR.

β-Thalassemia Mutations in the Iranian Kurdish Population of Kurdistan and West Azerbaijan Provinces

The aim of this study was to investigate the prevalence and spectrum of β-thalassemia (β-thal) mutations in the population of Sunni Muslim Kurds in western Iran and to set up a prenatal diagnostic laboratory. Sixty unrelated Kurdish β-thal patients identified in hematology clinics from different cities were studied. The mutations in 120 chromosomes were studied by polymerase chain reaction–amplification refractory mutation system and direct sequencing methods. We found fifteen β-thal mutations, and IVS-II-1 (G>A) was the most frequent, comprising 35% of all mutations. Other common mutations were frameshift codons 8/9 (+G) 15.7%, IVS-I-1 (G>A) 8%, FSC 5 (–CT) 6.7%, FSC 8 (–AA) 6.7%, and IVS-I-110 (G>A) 6%. This is the first comprehensive study in this region and could provide a reference for prenatal testing and genetic counseling in this population.

Polymerase Chain Reaction-Based Search for Two α-Globin Gene Mutations in India

We have used restriction site-dependent polymerase chain reaction (PCR)-based methodology for detection of the α-globin polyadenylation (poly A) signal mutation, AATAAA>AATA– – and Hb Sun Prairie [α130(H13)Ala→Pro, GCT>CCT (α2)] mutation. The former mutation produces Hb H disease in the homozygous state and occurs frequently in the Indian population. It was detected in nine of 77 putative α-thalassemia (α-thal) patients and in three of 13 β-thal intermedia patients tested. Four of the nine α-thal patients were homozygotes for the mutation. The Hb Sun Prairie mutation was confirmed in two α-thal patients, one of whom was a homozygote and the other a heterozygote.

Stem Cell Transplantation in Hemoglobinopathies

β-Thalassemia (thal) and sickle cell disease are the most common genetic diseases worldwide. Although supportive therapies such as regular transfusion and chelation for β-thal and hydroxyurea (HU) for sickle cell disease have significantly improved clinical manifestations and the quality of life, they cannot eliminate disease and therapy-related complications. Today, hematopoietic stem cell transplantation (HSCT) is the only curative treatment for patients with hemoglobinopathies. The first successful HSCT was reported in 1981. At that time, more than 1,000 patients underwent HSCT in Pesaro, Italy. Sixty β-thal patients underwent HSCT at the Department of Pediatric Hematology-Oncology, Akdeniz University School of Medicine, Antalya, Turkey between 1998 and 2006. We found stable mixed chimerism in 14 patients out of 45 (31%) in our transplanted thalassemia patients. The thalassemia free survival and overall survival rates were found to be 84.0 and 91.0%, respectively. The literature and our results indicate that HSCT can offer a cure for hemoglobinopathy patients.

Study of β-Thalassemia Mutations Using the Polymerase Chain Reaction-Amplification Refractory Mutation System and Direct DNA Sequencing Techniques in a Group of Egyptian Thalassemia Patients

The aim of this study was the molecular characterization of β-thalassemia (thal) mutations in a group of 95 Egyptian thalassemic patients from Fayoum in Upper Egypt, Cairo, Alexandria and Tanta in Lower Egypt and the Nile Delta. To identify these anomalies, the polymerase chain reaction-amplification refractory mutation system (PCR-ARMS) technique was used, complemented by direct DNA sequencing for uncharacterized cases.In 80 of the 95 patients, the β-thal mutation was detected by PCR-ARMS. The most common allele encountered in our study was IVS-I-6 (T→C) (36.3%); the second most common mutation was IVS-I-110 (G→A) (25.8%). In addition, we report three homozygous cases for the promoter region −87 (C→G) allele with a frequency of 3.2%. DNA sequencing of uncharacterized cases (14 cases, 15 alleles) revealed six cases (six alleles) of codon 27 (G→T), and three cases (three alleles) of the IVS-II-848 (C→A) mutation. Codon 37 (G→A) in the homozygous state was found in one patient with positive consanguinity. The frameshift codon 5 (−CT) mutation was detected in two of our uncharacterized cases. The codon 15 (TGG→TGA) mutations was detected in one patient (one allele, 0.5%). All studied cases were fully characterized by this strategy.Screening for β-thalassemic mutations using ARMS-PCR for the seven most frequent alleles in Egypt succeeded in determining the β-globin genotype in 84.2% of our patients (91.6% of the expected alleles). To improve the efficiency of routine screening, the PCR-ARMS mutation panel should be updated to include the reported rare alleles. Direct DNA sequencing is an additional way to allow a full characterization of β-thal patients in the Egyptian population.

The Molecular Analysis of β-Thalassemia Mutations in Lorestan Province, Iran

β-Thalassemia (thal) is one of the most common genetic disorders in Iran and other countries. Getting information on the distribution of mutations in different ethnic groups of Iran is of fundamental importance for the purpose of health planning and prenatal diagnosis programs. One hundred and thirty chromosomes from 65 unrelated homozygous β-thal patients were investigated for β‐globin gene mutations by amplification refractory mutation system-polymerase chain reaction (ARMS-PCR). The most common mutations of the Mediterranean region were examined in this study. Our results showed that the frameshift codons (FSC) 36/37 (–T) mutation, with a frequency of 33.8%, is the most common mutation in Lorestan Province. The other most frequent mutations were of the Mediterranean type and consisted of IVS-II-1 (G →A), IVS-I-110 (G →A), FSC 8/9 (+G) and IVS-I-5 (G →C) with frequencies of 27.7, 11.5, 10.8 and 4.5%, respectively. The less frequent alleles, IVS-II-745 (C →G), FSC 5 (–CT), IVS-I (25 bp deletion) and FSC 44 (–C) accounted for only 3.9% of the mutations. The unknown alleles comprised 7.7% of the mutations. These data showed that the spectrum of mutations found in Lorestan Province was different from those reported from other thalassemic regions of Iran and also of some neighboring countries.

The Molecular Pathology of β-Thalassemia in Turkey: The Boğaziçi University Experience

The thalassemias are a diverse group of hemoglobin (Hb) disorders characterized by a reduced synthesis of the globin chains of Hb. Today, more than 200 mutations, affecting different levels of β-globin gene expression, by a variety of mechanisms, are known to result in a β-thalassemia (thal) phenotype. According to recent findings, the multilayered complexity in the phenotype of β-thal is the result not only of marked molecular heterogeneity at the β-globin locus, but at the level of several other genes as well. The heterogeneity at the β-globin locus, which is the most reliable and predictive factor of disease phenotype, is simplified, to a certain extent, by the fact that the mutations are ethnic-group specific. Fifty out of >200 β-thal mutations account for 90–95% β-thalassemias worldwide. In the broad group of Mediterranean countries, ∼35 mutations have been reported thus far; however, allele frequencies vary among countries.β-Thal is a major public health concern in Turkey; throughout the country the gene frequency is estimated to be 2.1%, but in certain regions, this figure increases to 10%. The estimated number of carriers is 1,300,000 and the number of homozygous β-thal patients is around 4,000. The number of affected births is higher than expected, since the birthrate is still very high in Turkey, and the number of consanguineous marriages is above 60% in the eastern parts of the country. Unlike many other Mediterranean countries, β-thal in Turkey is very heterogeneous at the clinical level, transfusion-dependent β-thal major predominating. Between 1987 and 2006, more than 1,500 patients with homozyous β-thal, unrelated and not preselected, were investigated by DNA analysis. Our results revealed that by far the most common mutation in Turkey is IVS-I-110 (G→A), followed by IVS-I-6 (T→C) and frameshift codon (FSC) 8 (−AA). The six most common mutations add up to ∼70.3%, and the overall frequency of the first 12 mutations is 83.3%. The ratio of β 0:β +-thal mutations is 1:1, but the majority of β +-thal cases carry the severe IVS-I-110 lesion; thus, most of these mutations give rise to β-thal major in homozygous or compound heterozygous combinations. In addition to the 12 common mutations, several rare and four novel β-thal mutations were reported in the framework of this project, totaling 36 mutations. Turkey's large molecular heterogeneity can be explained by its unique geographical position and rich history, an important crossroad between cultures, civilizations and continents for several centuries. This study shows that despite its great molecular heterogeneity, and with the advent of polymerase chain reaction (PCR)-based techniques and improved methods of early fetal sampling, heterozygote screening and prenatal diagnosis are feasible in Turkey.

The magnetic susceptibilities of iron deposits in thalassaemic spleen tissue

The iron-specific magnetic susceptibility of tissue iron deposits is used in the field of non-invasive measurement of tissue iron concentrations. It has generally been assumed to be a constant for all tissue and disease types. The iron-specific magnetic susceptibilities χ Fe for spleen tissue samples from 7 transfusion dependent β-thalassaemia (β-thal) patients and 11 non-transfusion dependent β-thalassaemia/Haemoglobin E (β/E) patients were measured at 37 °C. Both groups of patients were iron loaded with no significant difference in the distribution of spleen iron concentrations between the two groups. There was a significant difference between the mean χ Fe of the spleen tissue from each group. The non-transfusion dependent β/E patients had a higher mean (± standard deviation) spleen χ Fe (1.55 ± 0.23 × 10 − 6 m 3/kg Fe) than the transfusion dependent β-thal patients (1.16 ± 0.25 × 10 − 6 m 3/kg Fe). Correlations were observed between χ Fe of the spleen tissue and the fraction of magnetic hyperfine split sextet in the 57Fe Mössbauer spectra of the tissues at 78 K (Spearman rank order correlation r = − 0.54, p = 0.03) and between χ Fe of the spleen tissue and the fraction of doublet in the spectra at 5 K ( r = 0.58, p = 0.02) indicating that χ Fe of the spleen tissue is related to the chemical speciation of the iron deposits in the tissue.

Detection of Two Rare β-Thalassemia Alleles Found in the Tunisian Population: Codon 47 (+A) and Codons 106/107 (+G)

We here present the first report of the detection of two rare β0-thalassemia (thal) mutations in the Tunisian population: codon 47 (+A) and codons 106/107 (+G). To the best of our knowledge this is the second report of the codon 47 (+A) mutation, the first being identified in a Surinamese subject. The codons 106/107 (+G) mutation was first described in American Blacks, subsequently in Egyptians and Palestinians, and now in Tunisians. These mutations were detected by denaturing gradient gel electrophoresis (DGGE) screening followed by automated nucleotide sequencing. The former was found in two related β-thal major patients in the homozygous state, while the latter was identified in a homozygous state in a transfusion-dependent β-thal subject and in a sickle cell β-thal patient. Both mutations are in linkage disequilibrium with haplotype V and sequence framework 2. Given the known wide spectrum of β-thal alleles in the Tunisian population, the present report further confirms such heterogeneity. The knowledge of an updated spectrum of β-thal alleles in Tunisia must allow the implementation of a more efficient screening strategy for genetic counseling and prenatal diagnosis.

Novel application of IGF-I and IGFBP-3 generation tests in the diagnosis of growth hormone axis disturbances in children with beta-thalassaemia.

Children with beta-thalassaemia major (beta-thal) frequently have growth retardation in the presence of low serum IGF-I and a normal GH response to pharmacological stimulation suggesting that they have GH insensitivity (GHIS). This study was carried out to study the cause of their growth retardation. We studied IGF-I and IGFBP-3 generation after exogenous GH administration for four days, in 15 prepubertal controls (C) and 41 prepubertal beta-thal patients divided into three groups according to their growth status: (Group 1) 15 with normal growth (N-thal) (Group 2) 16 with decelerated growth (D-thal) and (Group 3) 10 with short stature (S-thal), in order to determine whether GHIS is the cause of their growth retardation. IGF-I and IGFBP-3 were measured daily, before and for 4 days after daily administration of 0.1 IU/kg hGH, in 3 groups of prepubertal beta-thal patients and normal controls. N-thal and C had similar basal serum IGF-I (142 +/- 52 and 196 +/- 56 ng/ml, respectively) and IGFBP-3 concentrations (2.07 +/- 0.49 and 2.66 +/- 0.41 mg/l, respectively) as well as a similar percent increase of IGF-I (101 +/- 23% and 104 +/- 37%, respectively) and IGFBP-3 (52 +/- 36%, and 38 +/- 14%, respectively) during the generation tests. S-thal and D-thal had significantly lower basal IGF-I and IGFBP-3 concentrations (85 +/- 42 and 101 +/- 36 ng/ml; and 1.60 +/- 0.49 and 1.79 +/- 0.52 mg/l, respectively) as compared to N-thal and C (P < 0.001 and P < 0.005, respectively), and a significantly higher percent increase of IGF-I and IGFBP-3 during the generation tests (249 +/- 43 and 161 +/- 76%; and 121 +/- 99 and 73 +/- 35%, respectively) as compared to N-thal and C (P < 0.0001 and P < 0.01, respectively). Twenty-five percent of the growth retarded patients had classic GH deficiency (GHD) and percent increases of IGF-I and IGFBP-3 in the generation tests (164 +/- 86% and 80 +/- 49%, respectively) which were similar to those of the remaining growth-retarded children. The greater percent increases of IGF-I and IGFBP-3 in the generation tests of the growth retarded beta-thal patients, both with and without GHD, strongly suggest impaired GH secretion rather than GHIS as the cause of their growth retardation. We conclude that the IGF-I and IGFBP-3 generation tests are useful tools for the study not only of GHIS but also of GH secretory disorders in patients with beta-thal and short stature that can easily be performed in an outpatient setting as an initial test to identify the patients that may benefit from GH therapy.

Spectrum of β-Thalassemia Mutations in Egypt

Carrier screening and prenatal diagnosis programs have successfully reduced the incidence of β-thalassemia (thal) in countries where the carrier rates are high (1-3). The incidence of β-thal is particularly high in Egypt (4) due to the combined effects of high carrier rates (5) and consanguineous marriages (6). As a prerequisite to establishing effective programs for prenatal diagnosis, it is important to identify the spectrum of mutations within the population. To this end, we have surveyed the β-thal mutations for a cohort of 55 transfusion-dependent β-thal patients from the Alexandria region of Egypt and the adjacent rural governorates. Affected siblings were not included in the study. The patients were either Moslem (46/55, 84%) or Christian (9/55, 16%). Almost three-quarters (40/55, 73%) of the patients had consanguineous parents.