HbE Beta Thalassemia Research Articles

Non-healing leg ulcers in HbE-beta thalassemia.

Non-healing leg ulcers in HbE-beta thalassemia.

Prevalence of Haemoglobin Variants and Haemoglobinopathies in a Single Paediatric Centre in Southern India: A Retrospective Cross-sectional Study

Introduction: Haemoglobinopathies are qualitative disorders of Haemoglobin (Hb) resulting from structural defects in the amino acid sequence of one of the globin chains, whereas, thalassaemia results from quantitative defects in the synthesis of one or more of the globin chain subunits of the Hb tetramer. Cation Exchange- High Performance Liquid Chromatography (CE-HPLC) is one of the methods for initial screening of Hb variants like HbS, HbD, HbE etc and for quantification of HbF, HbA and HbA2 levels. Aim: To find out the prevalence of haemoglobinopathies in patients of a Government paediatric tertiary care hospital in south India. Materials and Methods: In this retrospective, cross-sectional study, all laboratory requests, in the period from August 2019 to July 2021, for Hb variant analysis by HPLC were collected, irrespective of provisional diagnosis. The Hb variant analysis was carried out by CE-HPLC on the Bio-Rad D-10 analyser. This study was conducted in a Government Paediatric tertiary care hospital in Southern India for patients who had any clinical or familial suspicion of haemoglobinopathies. The Statistical analysis was performed using Microsoft Excel 2010. Results: Total data of 704 laboratory requests for Hb Variant analysis were obtained. Out of 704 laboratory request, 585 were from children younger than 12 years of age and 119 were parental screening. There were 164 abnormal chromatograms. Out of 164 patients, 91 were female patients and 73 were male patients. Out of 164 abnormal chromatograms, 97 (59.15%) were beta- thalassaemia trait, 18 (10.98%) were beta-thalassaemia major, 13 (7.93%) were sickle cell trait, 2 (1.22%) were sickle cell disease, 21 (12.80%) were HbE trait, 2 (1.22%) were homozygous HbE, 2 (1.22%) were HbD trait, 3 (1.83%) were Hereditary Persistence of Foetal Hb (HPFH)/delta beta-thalassaemia, 2 (1.22%) were HbJ trait, 1 (0.61%) was HbE beta-thalassaemia, 1 (0.61%) was sickle- beta-thalassaemia and 2 (1.22%) were alpha thalassaemia. Conclusion: From this study, beta-thalassaemia trait and beta- thalassaemia major were found to be the first and second most prevalent haemoglobinopathies in children below 12 years of age. This data suggests the importance of premarital and antenatal screening procedures that can help in reducing the possibility of such haemoglobinopathies in the future generation, suffering and burden of disease to the family and society.

The Benefits Trial of PB-04 to Evaluate Safety, PK, and Preliminary Efficacy in Inducing Fetal Globin Expression in Beta Thalassemia Intermedia and Sickle Cell Disease

Increased expression of fetal globin (HBG) has been shown to reduce clinical severity of beta-globin disorders and increase survival in sickle cell disease (SCD), through improved globin chain balance in beta thalassemia and reduced HbS polymerization. Pharmacologic approaches are considered most feasible for a majority of patients. Both proportions of F-cells and quantity of hemoglobin F (HbF)/cell are important for therapeutic effects. PB-04 was identified in a high-throughput screen of US and EU-approved drugs to activate HBG gene transcription, without cytotoxicity, to induce fetal globin expression (gamma globin mRNA, F-cells, HbF/cell, HbF), and to suppress or displace 4 repressors of the fetal globin gene promoter (BCL11A, LSD-1, KLF-1, and HDAC-3) in hemoglobinopathy patients' erythroid progenitors. PB-04 enhanced HbF in progenitors from hydroxyurea (HU)-treated patients with sickle cell disease. In in vivo studies, PB-04 induced fetal globin expression >20-fold with oral dosing in anemic baboons, and by 3.5-fold in mice transgenic for 2 copies of the human β-globin gene locus. This agent has been approved and in broad use for Parkinson's Disease treatment for 5 decades in Europe and Canada, to enhance the PK of an active Parkinson's agent, solely in a combination formulation. Because of its safety with chronic dosing up to 1300 mg/day, PB-04 is therefore of interest for repurposing in the treatment of thalassemia and SCD.This Ph1b trial (NCT004432623) will evaluate safety, tolerability, PK, and preliminary efficacy (fetal globin expression) with at least 3 escalating dose cohorts in up to 24 beta thalassemia intermedia (BTI) patients and 12 patients with sickle cell disease, > 18 years, both genders, with 12 weeks of treatment and 4 weeks of follow-up. Doses to be explored were selected from safe and active human equivalent doses in preclinical toxicology and efficacy studies in 2 species. Primary inclusion criteria include clinical diagnosis of BTI, including HbE beta thalassemia, with at least one beta globin gene mutation, or diagnosis of HbSS or HbSb thalassemia (after dose selection); total Hb levels 6-10 gm/dL. Exclusion criteria include red blood cell (RBC) transfusion within 2 months prior to administration of study medication, receiving regular transfusions, and hepatic or renal function > 3 x institutional ULN.Primary endpoints include occurrence, severity, and duration of adverse events by CTCAE v5.0 criteria and PK parameters. Secondary endpoints include change from baseline in assays of HbF expression, total Hb, markers of hemolysis . Exploratory endpoints include select polymorphisms associated with basal fetal globin expression and in vitro responses to the study drug. Statistical analysis will assess the rate of adverse events, PK parameters by dose, and changes in F-cells, F-reticulocytes, HbF/cell, HbF (% and total), compared to 2 averaged baseline values using the Wilcoxon signed rank test. Changes will be analyzed by mixed effect models during the 12-week dosing and 4-week follow-up period. Currently 3 dose cohorts with BTI are enrolled. This study, if successful, will provide a rational basis for definitive trials of an established safe oral therapeutic, with no overlapping toxicities with other experimental or approved agents, for combined use with HU and other therapeutics which enhance red cell viability in the globin disorders.The expertise and contributions of Jim Cradock of NCATS TRND to this work before his passing are gratefully acknowledged. DisclosuresKuo: Agios: Consultancy, Membership on an entity's Board of Directors or advisory committees; Bioverativ: Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy; Apellis: Consultancy; Bluebird Bio: Consultancy; Pfizer: Consultancy, Research Funding; Novartis: Consultancy, Honoraria; Alexion: Consultancy, Honoraria. Sheth: CRISPR: Consultancy; Bluebird bio: Consultancy; Bristol Myers Squibb: Consultancy, Research Funding; Chiesi: Consultancy; Imara: Research Funding; Agios: Consultancy; Dispersol: Research Funding. Al-Samkari: Moderna: Consultancy; Amgen: Research Funding; Rigel: Consultancy; Argenx: Consultancy; Novartis: Consultancy; Dova/Sobi: Consultancy, Research Funding; Agios: Consultancy, Research Funding. Pace: Imara Inc.: Consultancy. Kuypers: Forma Therapeutics, Inc.: Research Funding. Nouraie: Phoenicia BioScience Inc.: Consultancy. Perrine: Agios Pharmaceuticals: Consultancy; Emmaus Medical: Consultancy.

The Correlation Between Iron Overload and Endocrine Function in Adult Transfusion-Dependent Beta-Thalassemia Patients with Growth Retardation.

BackgroundIron overload is a major problem in patients with transfusion-dependent beta-thalassemia (TDT). Reports on the correlation between iron overload and endocrine function with growth retardation in such a population in Indonesia have not been established. Therefore, this study aims to obtain a profile of iron load and endocrine function of adult transfusion dependent beta-thalassemia patients and their correlation with growth retardation.MethodsA cross-sectional study was performed, involving adult homozygous and HbE beta-thalassemia patients receiving blood transfusions at the Cipto Mangunkusumo Hospital, Jakarta. Iron overload was represented by serum ferritin (FS) and transferrin saturation (TS), while the endocrine function was examined by the Thyroid Stimulating Hormone-sensitive (TSHs), free T4 (fT4), and insulin-like growth factor-1 (IGF-1). The results were analyzed using bivariate analysis plus Pearson and Spearman correlation tests.ResultsIn general, 58 subjects were selected from 224 adult transfusion dependent beta- thalassemia patients, consisting of 31 males (53.4%) and 27 females (46.6%). Furthermore, their median age was 21 (18–24) years, while the subclinical hypothyroid proportion was 32.7% and low IGF-1 levels were detected in 79.3% of the total population. There was a weak negative correlation between FS and fT4 (Spearman rho=−0.361; p=0.003), as well as IGF-1 (Spearman rho=−0.313; p=0.008), but FS and TSHs had no correlation (Spearman rho=0.074; p=0.29). Also, there was no correlation between ST with TSHs (Spearman rho=0.003; p=0.492), fT4 (Spearman rho=0.018; p=0.448), and IGF-1 (Spearman rho=−0.142; p=0.143).ConclusionBased on serum ferritin, iron overload is discovered to have a negative correlation with free T4 and insulin-like growth factor-1.

Efficacy and Safety of Deferasirox in Chelation Naïve HbEβ Thalassemia Patients: Initial Experience from a Tertiary Centre of Eastern India

Introduction: In India, more than 10,000 new cases of thalassemia are born every year. In Eastern India, Hb E Beta thalassemia accounts for more than 50 % of the disease burden (Olivieri NF et al, Indian J Med Res 2011;134:522-31). Initially patients were used to get chelation with deferoxamine or deferiprone mostly, but with wide availability of Deferasirox (DFX) it has become the most commonly used chelating agent in Eastern India, however. Limited data are available on chelation from this part of the country. Objective: To assess the response to DFX in chelation-naïve patients with HbE beta thalassemia in terms of changes of serum ferritin level and to document its adverse effects in these patients. Materials and Methods: The study was undertaken from January 2014 to September 2015 at the thalassemia clinic of Institute of Haematology and Transfusion Medicine, Medical College, Kolkata, India. Sixty five patients of HbE beta thalassemia with serum ferritin level >1000 ng/ml and no history of any sort of chelation therapy were enrolled. Evaluation was done to rule out any pre-existing chronic liver disease, renal disease, gastro-intestinal bleed or anaphylaxis. Deferasirox was given at the dose of 40 mg/kg daily to thalassemia major patients and at the dose of 10 mg/kg daily to non-transfusion dependent thalassemia (NTDT) patients. The adverse effects of Deferasirox on HbE beta thalassemia patients were closely monitored. Serial changes in serum ferritin, bilirubin, ALT and creatinine clearance were noted every 3 months. Results: 23% of total patients were NTDT. Mean baseline hemoglobin was 6.72±0.62 gm/dl and mean baseline serum ferritin was 2122±622 ng/ml. Nausea, vomiting, pain abdomen were the most common adverse effects seen (Figure 1). There was no incidence of drug discontinuation or dose reduction. 34% patients had no adverse effects. In rest of the patients, gastrointestinal symptoms were the most commonly associated complaints with DFX therapy. Proteinuria was also found in 21.4 % patients. There was significant reduction of serum ferritin level on repeated measurements. Alterations of bilirubin or ALT were found, but it was statistically not significant. Decrease in creatinine clearance was seen in significant number of patients on DFX. There was no significant association of absence or presence of adverse effects with concomitant hydroxyurea therapy in NTDT patients (Table 2). Discussions: DFX was well tolerated by the patients. Gastrointestinal symptoms, most commonly nausea followed by vomiting and pain abdomen, were the most common adverse effects as seen in other studies like EPIC trial (Ann Hematol 2013 92:211-219). No serious adverse effects like hypoaccusis, GI bleed, anaphylaxis, anasarca as mentioned in other studies (Ali Taher et al. Br J Haematol. 2009;147:752-759) leading to stoppage or dose reduction of DFX were observed. Mixed regression analysis for repeated measures revealed significant decrease in serum ferritin level in comparison to previous ferritin level with DFX therapy (Table No 1), as shown in similar study by Capellini et al (Blood. 2006;107:3455-3462). There was no statistical correlation with absence of any adverse effects when compared with concomitant hydroxyurea therapy, when applicable. Conclusion: Deferasirox was found to be effective in reducing serum ferritin level in Indian HbE beta thalassemia patients without any major adverse drug effects, although more studies with longer duration are needed to achieve robust evidence. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Decitabine As Hemoglobin F Inducer in Hemoglobin E/β Thalassemia

IntroductionPhenotypic severity of HbE-beta thalassemia depends on hemoglobin F Level. Gamma globin chain induction has the potential of increasing HbF and decreasing transfusion dependence, and disease severity. Decitabine as a hypomethylating agent can activate repressed gamma globin gene and lead to increase in hemoglobin F.ObjectivesTo study effect of Decitabine on hemoglobin level, hemoglobin F and transfusion requirement as well as its adverse effects.Materials and MethodsThirty patients of HbE Beta thalassemia were enrolled. Both transfusion dependent (TDT) and non-transfusion dependent patients (NTDT) were included after obtaining informed consent. Inclusion criteria included - age greater than 18 years, free of transfusion for at least 90 days before entry (only for NTDT to get better idea of baseline hemoglobin), without any co-morbidity.Participants received 0.2 mg/kg of 5-aza-2′-deoxycytidine (decitabine) subcutaneously on two consecutive days a week for at least 12 weeks. Complete hemogram was done every two weeks and HPLC at every four week interval, till two months after last dose of drug. Patients were transfused packed red blood cells (PRBC) if symptomatic or if Hb < 5gm/dl.ResultsThirty patients (21- NTDT and 9 - TDT), were included in this study. Study comprised of 16 males (53.3 percent) and 14 females (46.7 percent) with a mean age of 29.33 years (summarized in table 1). Hemoglobin increment of > 1gm/dl was seen in 7 (33.3 percent) and >0.5 gm/dl was seen in 8 (38.1 percent) patients of NTDT group. For NTDT group peak mean increment in hemoglobin was 0.938 gm/dl (p value <.001, 95 percent confidence interval 1.33 to 0.539). Detailed results and paired analysis given in table 2. Graph A and Graph B shows trends in hemoglobin and hemoglobin F percentage respectively.Transfusion requirement decreased to 0.24 units compared to 0.96 units per patient per month for TDT patients over a period of last one year. Out of the nine transfusion dependent patients five (55 percent cases) became transfusion independent and continued to remain so during mean follow up period of 6 months (range: 4months to 10 months), three patients continued to remain transfusion independent even after discontinuation of therapy.Decitabine was well tolerated, no hematological toxicity was documented. Regarding non-hematological toxicities, 1 patient complained of chest tightness (grade 1), 1 patient had malena (grade III), endoscopy of this patient showed gastric erosion, 3 patients developed respiratory tract infection (grade I/II- managed on day care basis), 1 patient complained of small joint pain (grade I).DiscussionVarious drugs like hydroxyurea, 5-azacytidine, decitabine, erythropoietin stimulating agents have been evaluated as hemoglobin F inducing agents. Hydroxyurea has shown beneficial effect in HbE Beta Thalassemia patients, with range of response being in between 1% and 90%, and averaging at 20% (Musallam KM et. al Blood 2013). The efficacy of agents such as hydroxyurea is compromised by the suppressive effects on bone marrow function. Hydroxyurea has mutagenic effect also. (Bradai M et al. Transfusion. 2007).Few studies noted a decline in hematological response beyond 12 months (Rigano P et al. BJH 2010). So an alternative is required.Hypomethylating agents can cause activation of gamma globin gene and hence, use of decitabine can be a promising strategy. The only study done previously, showed increased total hemoglobin and absolute fetal hemoglobin. Treatment was well tolerated, with the main adverse event being an elevation in platelet counts (Oliviero NF et al. Blood 2011).In the present study relatively larger number of patients were followed up for a longer period of time and included both TDT and NTDT group.Decitabine was found to increase both hemoglobin and hemoglobin F in NTDT group. In the TDT group it decreased transfusion requirement significantly with increase in hemoglobin F percentage.Even though this study showed good response in HbE/ Beta thalassemia, a randomized control trial with hydroxyurea, with even longer duration of follow up needs to be done to compare both the drugs.ConclusionDecitabine is well tolerated, and is efficacious in increasing hemoglobin F percentage in HbE Beta thalassemia patients. There is decrease in transfusion requirement in TDT group. There is improvement in total hemoglobin as seen in NTDT group. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Comparison of efficacy and safety of thalidomide vs hydroxyurea in patients with Hb E-β thalassemia - a pilot study from a tertiary care Centre of India

IntroductionHemoglobin (Hb)-F inducers are known to improve Hb level and transfusion dependence in thalassemia. This pilot study was conducted to assess the efficacy and safety of Hb-F inducer thalidomide compared to hydroxyurea (HU) in Hb E-β thalassemia patients. MethodsThis was a prospective interventional single-centre study with 45 Hb E-beta thalassemia patients equally divided into group-I (thalidomide+folic acid), group-II (HU + folic acid) and group-III (folic acid). Response was assessed at various time intervals with 12-months follow up period. Primary end points were increment in Hb, Hb-F level and improvement in transfusion requirement; secondary end point were tolerability and safety. ResultsThere was 100% responder (R: Hb-increment ≥1 g/dl) in group-I with 66.67% major responder (MaR: Hb-increment ≥2 g/dl), while there were 40% and 0% responder in group-II and III respectively. Hb-increment was significantly (p-value <0.0001) better in thalidomide arm compared to HU. The Hb-increment was attributable to both increase in Hb-F levels and reduction in ineffective erythropoiesis in thalidomide arm. Transfusion reduction was significantly better in group-I compared to group-II (100% vs 34%). No severe adverse effects was reported by patients of any group. ConclusionThalidomide showed a persistent significant Hb-increment and transfusion independence in Hb E-β thalassemia patients compared to HU.

Efficacy of Dichlorophenolindophenol (DCIP) as Screening Test for Hb E: Revisited.

Hb E-beta thalassemia is a major public health problem in West Bengal, India and is the predominant symptom producing thalassemia in this part of the country. To search for an easy, reliable and cost effective screening method for HbE that can be used at the community level where more sophisticated methods are not readily available. And the DCIP test was performed for the purpose. Blood samples of 425 asymptomatic family members from 80 diagnosed cases of HbE beta Thalassemia patients were tested for Hb, RBC indices, DCIP test, HPLC, and in discordant cases confirmed by DNA mutation analysis. The present study shows DCIP screening test to have a sensitivity, specificity, positive predictive value and negative predictive value of 96.39%, 97.43%, 96.39% and 97.43% respectively. It also shows a false positive rate and false negative rate in 2.56% and 4.6% cases respectively. The advantage with DCIP over HPLC is that it can be easily performed at the community level by a person with minimum technical skill, few samples (even a single sample) can be tested at time, at a low cost.

Key Determinants of Phenotypic Heterogeneity of Hb E/β Thalassemia: A Comparative Study from Eastern India.

HbE Beta thalassemia is phenotypically very diverse disease. We aim to study role of various genetic factors in determining severity of this disease. 243 diagnosed cases of HbE Beta thalassemia were included in this study. Patients were divided in two arms-transfusion dependent and non-transfusion dependent arms. Various factors (percentage of haemoglobin F, hemoglobin E, type of Beta mutation, Xmn1 polymorphism, alpha deletion, HPFH mutation) were evaluated in these patients. Xmn1 polymorphism (homozygous and heterozygous), presence of HPFH mutation and alpha deletion were more prevalent in NTDT arm versus TDT arm (p value < 0.001). Higher prevelance of severe beta mutation IVS 1-5 (G → C) mutation {64(61.54%) vs 38(27.34); p value < 0.001} was found in TDT arm when above factors were excluded from analysis. Higher mean haemoglobin F and mean Hemoglobin E percentage was associated with NTDT arm (p value < 0.001). Various factors (hemoglobin F and E percentage, Xmn1 polymorphism, HPFH mutation, alpha deletion and IVS 1-5 Beta mutation) were identified to affect severity of this cohort.

Phenotypic Diversity and Clinico-Hematological Profile of Hb E-Beta Thalassemic Children.

Hb E-Beta thalassemia is a disease with marked clinical diversity. In this study,phenotypic diversity of Hb E-β thalassemia childrenwere analysed by studying the clinical and hematological parameters. This was a cross sectional study done in one and a half year period in the department of Pediatrics of a tertiary care teaching hospital. Participants were 62 Hb E-β thalassemic children of age group 1month to 18years coming to the Thalassemia day care centre for blood transfusion. Data collected from history, examination findings and investigation reports were analyzed. M:F ratio was 1.07:1; 71% children were above 5years of age. 90.3% children were Hindu. In 66.1% children, Hb level was below 5 gm/dl at the time of diagnosis. Mean HbF level was 32.6% ± 11.2. Stunting was seen in 64.5%. Average liver and spleen size were 2.5 and 4.4cm respectively. Beside pallor, most common clinical findings were splenomegaly (93.5%), facial deformity (87%), dusky skin color (82.5%) and hepatomegaly (75.8%). 1.6% children were mild, 43.5% children were moderate and 54.8% children were of severe type. In our study there was no significant correlation between severity of the disease and HbF level (r = 0.0853, p = 0.0509). Age at the time of diagnosis, hemoglobin level at the time of first transfusion, age at receiving first blood transfusion, requirement of blood transfusion, spleen size and growth, are some factors affecting severity of the disease. But severity cannot be assessed by considering only one clinical or hematological parameter but by considering several parameters together.

A comparative Clinico-hematological profile analysis of HbE beta thalassemia and homozygous HbE disease in adult and children at a tertiary care hospital

Hemoglobinopathies are classified as quantitative or qualitative decrease in production of hemoglobin. Thalassemias result from quantitative decrease of often structurally normal globin proteins. Mutations causing decrease in the synthesis of beta globins cause beta (β) thalassemia. Hemoglobin E is a β chain variant, caused by the structural change at the 26th position where glutamic acid is replaced by lysine in the β globin. It is highly frequent in South-east Asia and is commonly found in India. Hemoglobin E beta thalassemia (HbE β thalassemia), a compound heterozygous state, result in a very variable phenotype ranging from thalassemia trait, Non Transfusion dependent Thalassemia (NTDT), to Transfusion dependent Thalassemia (TDT). Patients with Hemoglobin E disease are usually asymptomatic and result from homozygous presence of Hemoglobin E chains. In this study, fifty cases of HbE disorder involving 43 cases of HbE beta thalassemia and 7 cases of homozygous HbE disease were considered. Their Clinico-hematological highlights and results of high performance liquid chromatography (HPLC) were analyzed. The main concern remain of the Hemoglobin E beta thalassemia, in which it is difficult from HPLC results to interpret whether the patient will behave as a trait, NTDT or TDT.

Association of alpha hemoglobin-stabilizing protein (AHSP) gene mutation and disease severity among HbE-beta thalassemia patients.

In this study, we aimed to investigate the pattern and association of genetic mutations occurring within the alpha hemoglobin-stabilizing protein (AHSP) gene among HbE beta thalassemia patients with varying phenotypic expressions. Fifty-four diagnosed cases of HbE beta thalassemia (transfusion dependent and independent) were included in the study. Among them, 38 patients with similar genotypes (IVS 1-5, alpha gene deletion and triplication, Xmn polymorphism) were selected for further analysis. AHSP gene sequencing was done for these 38 samples to study associated mutations in AHSP gene. HbE beta thalassemia patients with similar genotypes but different phenotypic expressions were found to have mutations in the AHSP gene. There were five mutations found most prevalent among the samples analyzed for AHSP gene sequencing. Among these, two mutations were from intron 1 region of AHSP and three mutations were found in exon 3. The most prevalent mutation was found at the Oct binding site at intron 1 of AHSP. The mutations in exon 3 were more prevalent among the TDT groups. A mutation in exon 3 changing the amino acid (33rd) from serine to phenylalanine was found to be associated with only TDT group. This study documents that among the HbE beta thalassemia patients with varying severity, an exon mutation in AHSP is significantly prevalent only among the TDT group. Further understanding of the mechanism will shed light upon the impact of AHSP in modifying the disease severity in thalassemia.

Clinical Profile of Thalassemia Syndrome in Children of Northern Bangladesh

Background: Thalassemia is a common hematological disorder in our country having wide spectrum of clinical presentation. The frequency and severity of the several types of thalassemia depend on the racial background of the population. Hb-E Beta thalassemia is prevalent in our country.&#x0D; Objective: To see the clinical features of different types of Thalassemia in northern area of Bangladesh. Methods: Hundred cases were selected from Thalassemia patient admitted in department of pediatrics, on May 2012 to October 2012. A prescribed questionnaire was used to record the information. The methods were explained to the patients and consent was taken. Necessary physical examination was performed and investigations were done. The data was analyzed by standard procedure.&#x0D; Results: Out of hundred (100) cases, most (61%) were Hb-E beta Thalassemia, less common (1%) was Hb-E disease, and 1 % case was Hb-E trait. Majority (64%) manifested clinically under one year of age. 54% were male and 46% were female. The major presenting symptom was progressive pallor in 70% cases. Others presenting complaints were low grade fever (40%). Hemoglobin concentration at the time of diagnosis was below 5 gm/dl in 53.33% patients. In hemoglobin electrophoresis it was Hb-E ranged from 54.64 ± 13.02%, Hb-F 34.84±13.73%, Hb-A 23.32± 18.15% and Hb-A2 3.5± 70%. Radiological findings revealed gross bony changes occur in long standing cases. Enlarged cardiac shadow was found in those cases having severe anemia with heart failure.&#x0D; Conclusion: In countries with a high incidence of thalassemia, it is vitally important to offer prospective genetic counseling and to warn carriers about the risks of intramarriage. Nutritional and folic acid supplementation with regular blood transfusion along with iron chelation therapy is essential to improve the prognosis.&#x0D; TAJ 2018; 31(2): 6-11

Clinical, Hematological and Mutation Profile of HbE-Beta Thalassemia in Eastern Uttar Pradesh (A single centre experience)

Clinical, Hematological and Mutation Profile of HbE-Beta Thalassemia in Eastern Uttar Pradesh (A single centre experience)

Kelainan pada Sintesis Hemoglobin: Thalassemia dan Epidemiologi Thalassemia

Hemoglobinopathy includes structural abnormalities and haemoglobin synthesis disorders (thalassemia), is a single gene disorder that was originally found in malaria endemic areas but nowadays can be found all over the world. The birth rate of homozygous or compound heterozygous hemoglobinopathies, including alpha and beta thalassemia is less than 2.4 per 1000 births. Sickle cell anemia is the most prevalent compared to beta major and HbE-beta thalassemia. In Southeast Asia with more than 600 million people, abnormalities in hemoglobin including thalassaemia, HbE and HbCS are the most common and highly prevalent genetic disorders. Indonesia, has several areas that are endemic to malaria, there are many cases of abnormalities in Hb including thalassemia. If the percentage of carriers is associated with the birth rate and the number of Indonesian population and based on the study, it is estimated that the number of thalassemia patients born each year around 2500 children. As the case of thalassemia is increasing from year to year, it is necessary that prevention starts with screening in individuals who have relatives known as a carrier or thalassemia patient.

Hydroxyurea responses in clinically varied beta, HbE-beta thalassaemia and sickle cell anaemia patients of Eastern India.

The haematological and clinical response to hydroxyurea was estimated in HbE-beta, beta thalassaemia and sickle cell anaemia patients of Eastern India, with variable clinical severity and transfusion requirement to determine whether hydroxyurea can help these patients to maintain their steady haemoglobin level without blood transfusions. Three hundred patients (189 HbE-beta thalassaemia, 95 beta thalassaemia and 16 other haemoglobinopathies including sickle cell anaemia) were selected for hydroxyurea therapy and were followed up for 48-60months. Results suggest significant response to hydroxyurea therapy in 19 beta and 99 HbE-beta patients in the transfusion-dependent group (GR-I). All of them became transfusion-independent while on hydroxyurea therapy. The majority of responding patients were IVS1-5(G-C) in one of their alleles in HbE-beta cases (83 out of 119). Though IVS1-5(G-C) was found to be the commonest mutation in our selected patients, the mutational background of the patients does not found to have any significant correlation with the response category towards hydroxyurea as per the results observed in our study. But, the drug works pretty well in most of the transfusion-dependent patients, as these patients were withdrawn from regular blood transfusion. At the same time, partial or no response to the drug hydroxyurea was also recorded in our study.

Variant Hemoglobin Spectrum By Cation Exchange High Performance Liquid Chromatography: A Study 0f 2035 Subjects

Introduction Hemoglobinopathies and thalassemia are hereditary disorders of hemoglobin (Hb) affecting mankind at prevalent regional level. Automated cation exchange high performance liquid chromatography is being increasingly used as the initial diagnostic method for identifying normal and abnormal hemoglobin variants. Methodology Total 2035 sample received and studied. All samples run on cation exchange high performance liquid chromatography machine by BIO-RAD. Results: Total 386(18.96%) cases had abnormal hemoglobin fractions. Beta thalassemia major cases were 17(0.83%). Beta thalassemia intermedia cases were 4(0.19%). Sickle cell trait (heterozygous Hb S) cases were 96(4.71%). Double heterozygous for sickle cell-beta thalassemia cases were 14(0.68%). There were 06 cases (0.29%) of Hb D heterozygous. There were one each case of Hb E heterozygous and Hb E-beta thalassemia (0.04% each). Hb F was raised in 7 adult cases (0.34%). Conclusion: To conclude, cation exchange high performance liquid chromatography is less time consuming, cost effective, labor saving, reproducible, accurate, sensitive and specific method to detect hemoglobinopathies and thalassemia. Most of the abnormal cases are diagnosed with this method, with few inconclusive cases require further genetic and molecular workup. DOI: 10.21276/APALM.1393

An epidemiological study on the clinico-hematological profile of pediatric patients with congenital hemolytic anemia

Background: Among the inherited disorders of blood, haemoglobinopathy and thalassaemia constitute a major bulk of congenital hemolytic anemia in India.Methods: The present cross sectional study was conducted on pediatric patients aged 0-15 years admitted in pediatric ward of Department of Pediatrics, MGM Medical College and LSK Hospital, Kishanganj, Bihar, India between December 2015 to November, 2016. The data on socio-demographic profile, relevant clinical history and examination and hematological parameters were assessed. Results: Out of 211 patients evaluated, most common cause of congenital hemolytic anemia was Hb E Beta thalassemia (39.8%), followed by beta thalassemia (27.9%), beta thalassemia trait (14.2%), Hb E disease (11.3 %) and Hb E trait (6.6%). There was male preponderance (male 63%, female 37 %). The mean hemoglobin was found to be lowest in patients of β thalassemia (5.1 gm/gl) and HbE β thalassemia (5.8 gm/dl). The mean total serum bilirubin was found to be highest among β Thalassemia patients (3.0 mg/dl). Hepatomegaly was the most common clinical finding among the study population (57.8%), followed by splenomegaly (54.9%) and hemolytic facies and jaundice (both 53%).Conclusions: The incidence of HbE beta thalassemia is relatively high in comparison to other varieties of thalassemias and is a major public health problem in this area of the country.

Haemoglobinopathies among the tribal and non-tribal antenatal mothers in a tertiary care hospital of rural West Bengal, India

Introduction: Anaemia in pregnancy is still a major concern in reducing maternal morbidity and mortality in India particularly in rural population. Haemoglobinopathies are important contributors to anaemia in pregnancy in rural India particularly in tribal population. Beta thalassemia is the commonest type of haemoglobinopathy all over the world. Thalassemia and other haemoglobinopathies are highly prevalent among the tribal communities in West Bengal. Bankura is one of the districts of West Bengal where more tribal population are present. So detection and prevention of thalassemias is one of the major public health problems in this part of the state of West Bengal. Study done by Manna et al4 showed that about 10% of the population is carrier of haemoglobin disorder. This study was taken up to document the recent prevalence status of hemoglobinopathies particularly Thalassemias and coexistence of iron deficiency anaemiasObjective: To find out prevalence of haemoglobinopathies and to compare the prevalence of different types of Thalassemias among the antenatal mothers.Materials and Methods: This study was carried out in Bankura Sammilani Medical College (BSMC), Bankura West Bengal among 3500 tribal and non-tribal antenatal mothers. Cation exchange-high performance liquid chromatography (CE-HPLC) is being used for investigation for hemoglobinopathies and thalassemias. Together with a complete blood count, the CE-HPLC is effective in categorizing hemoglobinopathies as traits, homozygous disorders and compound heterozygous disorders.Results: In our study 275 mothers had haemoglobinopathy. The commonest disorder we encountered was Beta Thalassemia trait (57.5%), followed by HbE carrier (36%), homozygous HbE disease (1%), HbS carrier (4%), HbE Beta Thalassemia (1.5%).Bangladesh Journal of Medical Science Vol.15(1) 2016 p.90-94

Transient Elastography of Liver in Hb E Beta Thalassemia: A Novel Tool to Determine Hepatic Iron Overload?

▪Introduction: Transient Elastography (TE) of liver is a well established tool to measure liver stiffness, mainly used for assessment of hepatic fibrosis due to chronic hepatitis. Liver biopsy is the gold standard test for measurement of liver iron concentration (LIC) whereas T2* MRI is the best available non-invasive method for the same in thalassemia. We intended to use hepatic TE as an alternative cheaper tool to assess hepatic iron overload so that it can be applied to larger number of patients.Objective: To assess degree of liver stiffness by TE in patients with HbE beta thalassemia and correlate the findings with LIC calculation by T2* MRI of liver.Materials and Method: 53 patients with HbE beta thalassemia from the thalassemia clinic of Institute of Haematology and Transfusion Medicine, Medical College, Kolkata were enrolled for the study. Patients with known liver disease were excluded. Baseline data like HbE%, mutations, transfusion requirement, growth status, serum ferritin level etc were collected. All of them underwent TE of liver in the School of Digestive and Liver Diseases, IPGMER using the FibroScan Touch 502 machine (Di Marco et al, British Journal of Haematology, Volume 148,3, 476-479, February 2010). 20 randomly selected patients were also assessed by T2*MRI of liver for hepatic iron assessment at the same time. LIC calculation was done from T2* value (J S Hankins et al, Blood, 14 May 2009, Volume 113:20). Data were analyzed by SPSS software-19, IBM.Results: The patients with HbE beta thalassemia had a mean HbE level of 53.66 (±18.45) %. Common beta mutations [mostly IVS-1-5(G-C)] usually found in this part of India, were detected. Mean and median age of the study population was 24.11±13.11 years and 20 years, respectively. Median age of 1st transfusion was 11 years. 35.84% patients were non-transfusion dependent. 39/53 patients had facial deformity and growth retardation. Mean baseline hemoglobin was 7.10±0.76 gm/ dl. Mean serum ferritin level was 3183.66±338.45 ng/ml. TE showed 30.18 % patients had severe liver stiffness (Liver stiffness measurement, LSM >15 kPa) whereas 43.34% had minimum stiffness (LSM≤7 kPa). No significant statistical correlation was found between serum ferritin and LSM. 12/20 patients showed very high calculated LIC (>15 mg/g) and lower T2* value (<1.8 ms) whereas only 10% of them showed mildly elevated calculated LIC. Rest had intermediate LIC.Discussion: There is lack of data regarding hepatic iron overload in HbE beta thalassemia and so also from this part of India. There was a trend that higher the age, higher was the LSM irrespective of the serum ferritin level though not found statistically significant (Figure 1). Serum ferritin level was also not significantly correlated with the calculated LIC in those 20 patients assessed with T2* MRI. 2 patients with mildly elevated LIC had a high ferritin level. Preliminary report indicates that with increase in LSM there was increase in calculated LIC also. Statistical analysis revealed patients with LSM≥7.2 kPa had moderate or severe hepatic iron overload and thus undermine the need for routine T2*MRI. The cut off value signifies that patients with LSM<7.2 kPa might or might not have significantly high liver iron overload, so obviously to be assessed by T2*MRI (Table 1). Therefore use of TE may be an alternative preliminary diagnostic method to gauge hepatic iron overload in HbE beta thalassemia patients. It would be of more value in countries like India where T2* MRI facility is not yet feasible in many centers catering to huge number of HbE-beta thalassemia patients. However, further exploration with larger number of patients is necessary to establish association of LIC and LSM in a more robust way.Conclusion: In resource-poor countries like India, TE may be a relatively cheap tool to be used as a marker of hepatic iron overload in future.Table 1Finding Cut off: ROC (TE-value and LIC categories), n=20Positive if Greater Than or Equal ToaSensitivity1 - Specificity2.31.001.003.41.00.504.4.94.505.7.88.506.2.83.506.5.77.507.2.77.008.2.72.008.85.66.009.45.61.0010.2.55.0011.85.50.0013.85.44.0015.75.38.0018.3.33.0022.9.27.0027.9.22.0035.9.16.0044.7.11.0048.0.05.0049.8.00.00Table 2. The smallest cutoff value is the minimum observed test value minus 1, and the largest cutoff value is the maximum observed test value plus 1. LSM more than 7.2 had a sensitivity of 77.2 % and specificity of 100%. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.