Transfusion-dependent Β-thalassemia Patients Research Articles

Differential gene expression analysis in early and late erythroid progenitor cells in β-thalassaemia.

β- thalassaemia is a disorder of globin gene synthesis resulting in reduced or absent production of the β-globin chain in red blood cells. In this study, haematopoietic stem cells were isolated from the peripheral blood of six transfusion dependent β-thalassaemia patients and six healthy controls. Following 7 and 14d in culture, early- and late- erythroblasts were isolated and purified. No morphological difference in maturation was observed following 7d in culture, while a delayed maturation was observed in the patient group after 14d. Following RNA isolation and linear amplification, gene expression analyses were performed using microarray technology. The generated data were analysed by two methods: the BRB-ArrayTools platform and the Bioconductor platform using bead level data. Following 7d culture, there was no difference in gene expression between the control and patient groups. Following 14d culture, 384 differentially expressed genes were identified by either analysis. A subset of 90 genes was selected and the results were confirmed by Quantitative-Real-Time-polymerase chain reaction. Pathways shown to be significantly altered in the patient group include apoptosis, MAPKinase and the nuclear factor-κB pathway.

Co-inheritance of novel ATRX gene mutation and globin (α & β) gene mutations in transfusion dependent beta-thalassemia patients.

α-Thalassemia X-linked mental retardation syndrome is a rare inherited intellectual disability disorder due to mutations in the ATRX gene. In our previous study of the prevalence of β-thalassemia mutations in the Eastern Province of Saudi Arabia, we confirmed the widespread coinheritance of α-thalassemia mutation. Some of these subjects have a family history of mental retardation, the cause of which is unknown. Therefore, we investigated the presence or absence of mutations in the ATRX gene in these patients. Three exons of the ATRX gene and their flanking regions were directly sequenced. Only four female transfusion dependent β-thalassemia patients were found to be carriers of a novel mutation in the ATRX gene. Two of the ATRX gene mutations, c.623delA and c.848T>C were present in patients homozygous for IVS I-5(G→C) and homozygous for Cd39(C → T) β-thalassemia mutation, respectively. While the other two that were located in the intronic region (flanking regions), were present in patients homozygous for Cd39(C → T) β-thalassemia mutation. The two subjects with the mutations in the coding region had family members with mental retardation, which suggests that the novel frame shift mutation and the missense mutation at coding region of ATRX gene are involved in ATRX syndrome.

Hydroxyurea Treatment in Transfusion-Dependent β-Thalassemia Patients.

Background:β-Thalassemia is an inherited hemoglobin disorder caused by defective synthesis of ß-globin chains. Hemoglobin (Hb) F induction is a possible therapeutic approach which can partially compensate for α and non-α globin chains imbalance.Objectives:We aimed to investigate the efficacy and safety of Hydroxyurea (HU) in diminishing transfusion requirements of patients with β-thalassemia major in Southern Iran.Patients and Methods:In this single-arm clinical trial, all transfusion-dependent β-thalassemia patients older than two years old (n = 97) who had inclusion criteria of the study and had been registered for at least six months in Dastgheib thalassemia outpatient clinic (a referral center affiliated to Shiraz University of Medical Sciences) were evaluated from October 2010 to December 2011. The patients were treated with HU with a mean dose of 10.5 mg/kg for a mean duration of 8 months (range 3-14 months). Transfusion needs and Hb levels were compared before and after HU treatment.Results:The mean volume of blood transfusion decreased significantly following HU treatment (0.71 mL/kg/day vs. 0.43 mL/kg/day, P < 0.001). Two-thirds of the patients showed good and partial response. No serious adverse reaction was observed except persistent neutropenia in two patients.Conclusions:Hydroxyurea can be safely used in some transfusion-dependent β-thalassemia patients to decrease their transfusion needs.

Iron overload in transfusion-dependent β-thalassemia patients: defining parameters of comorbidities

Background Iron overload represents a consistent and almost inevitable complication in patients with transfusion-dependent β-thalassemia. The frequently needed erythrocyte transfusions are known to be the leading source of body iron. Increased iron deposition in tissues was strongly suggested to underlie poor growth and development in transfusion-dependent β-thalassemia. This study aimed to investigate the pattern of increase in iron-overload parameters in relation to the therapeutic measures used and explore its effect on the physical growth of patients with transfusion-dependent β-thalassemia. Patients and methods The study included 60 transfusion-dependent β-thalassemia patients (median age 12.5 years, interquartile range 8-17 years) and 20 age-matched and sex-matched controls; each group was further subcategorized into less than 12-year-old and more than 12-year-old subgroups. The studied clinical parameters comprised weight and height, which were used to calculate the body mass index (BMI). Laboratory assays included complete blood counts for the assessment of pretransfusion hemoglobin, serum iron, total iron-binding capacity, ferritin, and growth differentiation factor 15 (GDF15), and the calculation of the transferrin iron saturation percentage (TISP). Results Less than one-third (30%) of the patients had a low BMI; no patient was overweight or obese. The median pretransfusion hemoglobin was 7.1 g/dl (interquartile range 6.8-7.2 g/dl). Fifty-two (86.7%) patients were inadequately chelated, showing serum ferritin levels more than 1000 ng/ml. In patients older than 12 years of age, the BMI was significantly lower in comparison with controls of the same age subgroup as well as patients less than 12 years old. Patients with a low BMI had significantly higher median values of TISP, ferritin, and GDF15 than those with a normal BMI. GDF15 values of the more than 12-year-old patients showed significant positive correlations with TISP and ferritin levels. Setting optimal cutoffs at 63% for TISP and 1210 ng/ml for serum ferritin (area under the curve 0.965 and 0.957, respectively) had indicated low BMI with higher certainties compared with GDF15 at a level of 10 000 pg/ml (area under the curve 0.783) in the more than 12-year-old patients.Conclusion Avoiding iron overload should be warranted for transfusion-dependent β-thalassemia patients to have normal BMI. Although a high GDF15 level is helpful in pointing toward the development of a low BMI, it added no value to TISP or ferritin as indictors of patients' growth retardation.

Molecular basis of transfusion dependent beta-thalassemia major patients in Sabah

Beta-thalassemia is one of the most prevalent inherited diseases and a public health problem in Malaysia. Malaysia is geographically divided into West and East Malaysia. In Sabah, a state in East Malaysia, there are over 1000 estimated cases of β-thalassemia major patients. Accurate population frequency data of the molecular basis of β-thalassemia major are needed for planning its control in the high-risk population of Sabah. Characterization of β-globin gene defects was done in 252 transfusion dependent β-thalassemia patients incorporating few PCR techniques. The study demonstrates that β-thalassemia mutations inherited are ethnically dependent. It is important to note that 86.9% of transfusion-dependent β-thalassemia major patients in Sabah were of the indigenous population and homozygous for a single mutation. The Filipino β(0)-deletion was a unique mutation found in the indigenous population of Sabah. Mutations common in West Malaysia were found in 11 (4.3%) patients. Four rare mutations (Hb Monroe, CD 8/9, CD 123/124/125 and IVS I-2) were also found. This study is informative on the population genetics of β-thalassemia major in Sabah.

Morbidities and Mortality in Transfusion-Dependent Beta-Thalassemia Patients (Single-Center Experience)

Background: The improvement of quality and duration of life of transfusion-dependent B thalassemia patients over the last years discloses several complications due to the underling disorder, iron overload and the treatment with iron chelators. Our Aim was to assess the morbidity patterns and mortality rate of transfusion-dependent thalassemia patients, and compare the outcomes in relation to age of onset, type, duration, and compliance to iron chelation therapy and frequency of blood transfusion. Procedure: This retrospective study included 447 transfusion-dependent β-thalassemia patients who attended the Thalassemia Center, Ain Shams University Children's Hospital over the last 10 years in the period between January 2000 and January 2010. Data were collected from the patients or their caregivers, as well as by reviewing follow up sheets for examinations and investigations done to detect morbidities as well as iron chelation therapies given. Determination of mortality rate and the causes of death were also done. Results: Results revealed that the most common morbidities were endocrinologic (44.7%) followed by cardiovascular (41.3%) and hepatic (40.5%), then renal (4%). The different iron chelation therapy groups showed a comparable prevalence of different morbidities. The mortality rate was 1.5% and infection was the most common cause of death. The 5, 10, 20 years' survival rate among the studied patients was 80%, 50%, 20%, respectively. Conclusion: In the past 10 years, the survival and morbidity rates in our center have markedly improved as a result of regular blood transfusion, new iron chelators, and better compliance of the patients.

Spectrum of α-Thalassemia Mutations in Transfusion-Dependent β-Thalassemia Patients from the Eastern Province of Saudi Arabia

Both α- and β-thalassemia (α- and β-thal) are highly prevalent in the population of the Al-Qatif and Al-Ahsa regions in the Eastern Province of Saudi Arabia. This study provides a more precise picture of the α-thal mutations prevalent in 104 transfusion-dependent β-thal patients in the Eastern Province. Detection of α-thal mutations was carried out using the α-globin StripAssay kit. A total of 12 α-thal mutations (21 genotypes) were identified in 33.7% of the chromosomes (46 patients). The heterozygous and homozygous –α3.7 (α+) deletion mutations were the most prevalent in the β-thal patients (21.7%). We identified three α0 deletions [– –MED, – –FIL and –(α)20.5] that have not been previously reported for the population of Saudi Arabia. The seven point mutations identified in the β-thal patients were: codon 14 [TGG>TAG (α1)], codon 59 [GGC>GAC (α1)] (Hb Adana), polyadenylation signal site (polyA1) [AATAAA>AATAAG (α2)], codon 142 [TAA>TCA (α2)] (Hb Koya Dora), codon 59 [GGC>GAC (α2)] (Hb Adana), initiation codon [ATG>ACG (α2)] and the αααanti 3.7 gene triplication. The Hb Koya Dora mutation occurred at the highest frequency (15.38%). Comparison of the clinical phenotype of β-thal patients, with and without an α-thal mutation, showed that patients with β-thal alone had a significantly elevated level of alanine transaminase (ALT) (mean 72.5 IU/L) and aspartate transaminase (AST) (mean 71.8 IU/L) (p <0.005). In addition, the β-thal patients without an α-thal mutation had a higher percentage of osteoporosis (16.6%), fractures (12.5%), and splenectomies (58.3%). This confirms previous data that the co-inheritance of α-thal in β-thal patients results in the amelioration of the clinical phenotype of β-thal patients. Moreover, the high frequency of α- and β-thal in the Eastern Province of Saudi Arabia and their coinheritance, necessitates the inclusion of α-thal testing in the current pre marital testing program to highlight the risk to the offspring of affected individuals.

HbA2 levels in β-thalassaemia carriers with the Filipino β0-deletion: are the levels higher than what is found with non-deletional forms of β0-thalassaemia?

Classical carriers of β-thalassaemia are identified by a raised HbA2 level. Earlier studies indicated that the Filipino β-deletion has high raised HbA2 levels. The introduction of automated high performance liquid chromatography (HPLC) for thalassaemia screening is an important advance in technology for haematology laboratories. The BioRad Variant II Hb analyser is a common instrument used to quantify HbA2 levels in thalassaemia screening. This study aimed to determine HbA2 levels in carriers of Filipino β-mutation using the BioRad Variant II Hb analyser. The Filipino β-deletion was identified using gap-polymerase chain reaction (PCR) in the parents of transfusion dependent β-thalassaemia patients who were homozygous for the Filipino β-deletion in the indigenous population of Sabah, Malaysia. Hb subtypes were quantified on the BioRad Variant II Hb analyser. Concurrent α-thalassaemia was identified by multiplex gap-PCR for deletions and amplification refractory mutation system (ARMS)-PCR for non-deletional mutations. The mean HbA2 level for Filipino β-thalassaemia trait was 5.9 ± 0.47 and with coinheritance of α-thalassaemia was 6.3 ± 0.44 (-α heterozygous) and 6.7 ± 0.36 (-α homozygous). The HbA2 levels were all >4% in keeping with the findings of classical β-thalassaemia trait and significantly higher than levels seen in non-deletional forms of β-thalassaemia. The HbA2 level measured on the BioRad Variant II Hb analyser was lower than the level in the first description of the Filipino β-thalassaemia. β-thalassaemia trait with coinheritance of α-thalassaemia (-α) is associated with significantly higher HbA2 level.

Prevalence and Risk Factors of Left Ventricular Noncompaction in Patients with β-Thalassemia.

Abstract 2127Left ventricular noncompaction (LVNC) is a rare cardiomyopathy with potentially serious outcomes. It results in multiple and excessive trabeculations, deep intertrabecular recesses, and a thickened ventricular myocardium with two distinct layers, compacted and noncompacted. The condition is most commonly congenital although acquired forms have been described. A recent report of LVNC detected in a β-thalassemia twin suggested an association with cardiac siderosis. In a cross-sectional study of 135 transfusion-dependent β-thalassemia patients (130 major and 5 intermedia, mean age 29.6 ± 7.7 year, 49.6% males) presenting for cardiac iron assessment by magnetic resonance imaging (MRI), we evaluated the prevalence and risk factors for LVNC. None of the patients had neuromuscular or congenital heart disease. Eighteen patients (13.3%, 95% CI: 8.6–20.1) fulfilled the pre-assigned strict criteria for LVNC on cardiac MRI. There were no statistically significant differences between patients with and without LVNC in respect to: demographics; hemoglobin levels; splenectomy status; systemic, hepatic and cardiac iron overload indices; hepatic disease and infection studies; or iron chelator type. Patients with LVNC were more likely to have heart failure (adjusted OR: 1.77, 95% CI: 0.29 to 10.89); although with high uncertainty. Patients with β-thalassemia have a higher prevalence of LVNC than normal individuals. As this finding could not be explained by conventional risk factors in this patient population, further investigating of the underlying mechanisms of LVNC is warranted. This remains crucial for an entity with adverse cardiac outcomes, especially in a β-thalassemia patients where cardiac disease remains a primary cause of mortality. Disclosures:No relevant conflicts of interest to declare.

Genotype–phenotype relationship of patients with β-thalassemia taking hydroxyurea: a 13-year experience in Iran

We evaluated the clinical responses to hydroxyurea (HU), adverse effects, and β-globin gene variants in a large series of β-thalassemic patients over a 13-year period in Iran. The patients (n=232) were divided into two groups: transfusion-dependent β-thalassemia patients 2years of age and older (n=126; Group 1), and β-thalassemia intermedia (βTI) patients without any history of blood transfusion or with a long-interval transfusion (n=106; Group 2). In Group 1, 86 patients became transfusion-free, and 25 patients needed 1-2 transfusions per year at the end of study. All except three patients in Group 2 were completely transfusion free with a significant increase in Hb level after 1year compared to the baseline Hb value (P<0.0001). We did not find a significant correlation of response to HU with XmnI polymorphism or IVS II-I (G>A) mutation (P>0.05). In our study, HU at a dose of 8-15mg/kg/day was effective in decreasing or effecting cessation of the need for regular blood transfusion, as well as in increasing Hb levels in β-thalassemia patients, without any major side effects. Hydroxyurea may thus represent a safe alternative to blood transfusion in transfusion-dependent β-thalassemia patients, or help to increase Hb level in untransfused βTI patients.

Iron-Chelating Therapies in a Transfusion-Dependent Thalassaemia Population in Thailand

β-Thalassaemia is a major public health problem in Thailand. Use of appropriate iron-chelating agents could prevent thalassaemia-related complications, which are costly to the healthcare system. This study aimed to evaluate the cost effectiveness of deferoxamine (DFO), deferiprone (DFP) and deferasirox (DFX) in Thai transfusion-dependent β-thalassaemia patients from the societal perspective. A Markov model was used to project the life-time costs and outcomes represented as quality-adjusted life-years (QALYs). Data on the clinical efficacy and safety of all therapeutic options were obtained from a systematic review and clinical trials. Transition probabilities were derived from published studies. Costs were obtained from the Thai Drug and Medical Supply Information Center, Thai national reimbursement rate information and other Thai literature sources. A discount rate of 3% was used. Incremental cost-effectiveness ratios (ICERs) were presented as year 2009 values. A base-case analysis was performed for thalassaemia patients requiring regular blood transfusion therapy, while a separate analysis was performed for patients requiring low (i.e. symptom-dependent, less frequent) blood transfusion therapy. A series of sensitivity analysis and cost-effectiveness acceptability curves were constructed. Compared with DFO, using DFP was dominant with lifetime cost savings of $US91 117. Comparing DFX with DFO, the incremental cost was $US522 863 and incremental QALY was 5.77 with an ICER of $US90 648 per QALY. When compared with DFP, the ICER of DFX was $US106 445 per QALY. A cost-effectiveness analysis curve showed the probability of DFX being cost effective was 0% when compared with either DFO or DFP, based on the cost-effectiveness cut-off value of $US2902 per QALY. When compared with DFP, DFX was cost effective only if the DFX cost was as low as $US1.68 per 250 mg tablet. The results of the analysis in patients requiring low blood transfusion therapy were not different from those of the base-case analysis. Our findings suggest that using DFP is cost saving when compared with conventional therapy, while using DFX is not cost effective compared with either DFO or DFP in Thai patients with transfusion-dependent β-thalassaemia. Policy-makers and clinicians may consider using such information in their decision-making process in Thailand.

Improved efficacy and tolerability of oral deferasirox by twice‐daily dosing for patients with transfusion‐dependent β‐thalassemia

Deferasirox is an oral iron-chelating agent taken once-daily by patients with transfusion-dependent iron overload. However, some patients are unresponsive or unable to tolerate once-daily deferasirox. The current study evaluated whether twice-daily deferasirox treatment showed increased efficacy or tolerability in unresponsive or intolerant patients. Patients from two Taiwanese hospitals with transfusion-dependent β-thalassemia, including those who showed increasing serum ferritin levels for six consecutive months, with at least one level >2,500 ng/dl, while treated with >30 mg/kg/day of once-daily deferasirox (unresponsive) or developed deferasirox-related adverse events (AEs) at the dosage required to maintain the iron burden balance (intolerant) and were treated twice-daily with the same total daily dose of deferasirox since 2008, were enrolled in the study and evaluated retrospectively by medical record review. Eighteen patients were included for analysis. A statistically significant median decrease in serum ferritin levels was detected in the 11 unresponsive patients after 6 months of continuous twice-daily deferasirox treatment. Five out of the seven intolerant patients experienced either no deferasirox-related AEs or less severe AEs. The 12 patients from both groups (11 unresponsive, 1 intolerant) who received continuous twice-daily deferasirox for 6 months showed a mild but significant median increase in serum creatinine levels. Twice-daily deferasirox dosing is effective in iron chelation and improves tolerability in transfusion-dependent β-thalassemia patients who are unresponsive to or intolerant of once-daily deferasirox. Future studies with greater patient numbers will be required to confirm the results reported herein.

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.

Impact of Myocardial Iron Loading On Right Ventricular Function.

Abstract 2012Poster Board I-1034 Background:Cardiovascular magnetic resonance (CMR) is being increasingly used worldwide for monitoring chelation therapy in transfusion-dependent β-thalassemia patients. The assessment of cardiac iron loading using myocardial T2 star (T2*) is a reliable, quick and non-invasive method which can be combined with highly accurate and reproducible cardiac volume and function measurements. It has previously been noted that myocardial siderosis (T2*<20ms) is associated with progressive impairment in left ventricular (LV) function but little is known about the relation of T2* measurements to right ventricular (RV) function in these patients. This study assesses the impact of myocardial iron loading on the right ventricle. Methods:A retrospective analysis was performed of 323 consecutive β-thalassemia patients referred for their first CMR scan from 21 UK hematology centers. Only patients on a single chelating agent (deferoxamine) were included. All had received chelation from the mid-to-late 1970s or from an early age if born since then. Patients were excluded if there was significant cardiac, vascular or lung pathology (such as aortic stenosis, pulmonary artery stenosis, tetralogy of Fallot or pulmonary hypertension). All scans were performed using a 1.5T Sonata (Siemens Medical Systems, Germany). A single breath-hold multi-echo sequence with 8 different echo times (TE = 2.54-17.9ms) was used to measure T2* from a full-thickness region of interest in the septum of a mid-ventricular short axis slice. Myocardial T2* was calculated from the exponential signal intensity decay curve using a truncation method to account for background noise. RV and LV volumes and ejection fraction (EF) were calculated from a series of short axis ventricular slices (7mm thickness with 3mm gap). Results:In patients with normal T2* (>20ms), RV EF was within normal limits in 98% of cases (RV EF [mean ±SD] = 65.0 ±6.1%). In patients with myocardial siderosis (T2*<20ms), there was a progressive and significant fall in RV EF (r=0.43, p<0.001) and an increase in RV end-systolic volume index (r= -0.33, p<0.001). LV EF was within the normal range in 99% of patients with T2*>20ms (LV EF = 69.5 ±5.2%). Once again, where T2* fell below 20ms, there was a progressive decline in LV EF (r=0.40, p<0.001). 82.6% of the patients with low T2* and impaired RV ejection fraction also had an impaired LV EF and linear regression analysis showed a significant relation between RV and LV EF (r=0.69, p<0.001). Conclusions:There is a strong association between increasing myocardial iron loading and RV dysfunction which mirrors the decrease in LV ejection fraction seen with worsening myocardial siderosis. RV impairment may be a significant contributor to the syndrome of heart failure associated with severe myocardial siderosis. [Display omitted] Disclosures:Carpenter:Swedish Orphan: Honoraria; Apotex: Honoraria. Porter:Novartis: Consultancy, Research Funding. He:Novartis: Consultancy. Smith:Novartis: Consultancy. Pennell:Siemens: Consultancy; Novartis: Consultancy; Apotex: Honoraria; Cardiovascular Imaging Solutions, London: Equity Ownership.

Assessment of Renal Function in Transfused b-Thalassemia Patients Based on Cystatin C Measurements and Equations.

Cystatin C is a non-glycosylated protein that belongs to the cystatin superfamily of cysteine protease inhibitors. Its low molecular weight (13.3kDa) and positive charge at physiological pH levels facilitates its glomerular filtration and subsequently it is reabsorbed and almost completely catabolized in the proximal renal tubules. Therefore and due to its constant rate of production, its serum concentration is determined by the rate of glomerular filtration (GFR). Cystatin C production in the body is a stable process that is not influenced by renal conditions, increased protein catabolism or dietary factors. Moreover, in contrary to creatinine, it does not change with age or muscle mass. For these reasons, serum cystatin C has been suggested to be an ideal endogenous marker of GFR. Studies on the renal function of patients with transfusion-dependent β-thalassemia are sparse. These studies suggested that the renal abnormalities observed in β-thalassemia are due to proximal tubular dysfunction and postulated that their severity is related with the degree of anemia. They were less severe in patients on hypertransfusion and appropriate desferrioxamine therapy suggesting that the damage might be caused by both anemia and increased oxidation induced by excess iron deposition. None of these studies have demonstrated renal insufficiency as reflected by decreased GFR. This was probably due to the fact that all estimations were based on creatinine measurements. In this study we estimated GFR in 195 transfused patients with β-thalassemia major by measuring cystatin C and calculating GFR according to the recently proposed cystatin C-based prediction equation using only concentration in mg/L and a prepubertal factor:1GFR [mL/min/1.73m2] = 84.7 × cystatin C (mg/L)−1.68 × 1.38* (*if a child <14 years). We found that 136 patients had normal cystatin C levels (0.66–1.03mg/L) and GFR values (80–170mL/min/1.73m2), 36 patients had mild renal insufficiency (cystatin C levels: 1.04–1.22mg/L and GFR values: 60–79mL/min/1.73m2), 21 patients had moderate renal insufficiency (cystatin C levels: 1.23–1.72mg/L and GFR values: 34–59mL/min/1.73m2), while 2 patients had severe renal insufficiency with cystatin C levels >2.5mg/L and GFR values <20mL/min/1.73m2. We further determined plasma levels of Neutrophil gelatinase-associated lipocalin (NGAL) in 30 randomly selected patients. NGAL is a protein expressed on tubular cells of which the production is markedly increased in response to harmful stimuli, such as ischemia or toxicity. We found increased NGAL levels in 19 β-thalassemia patients (mean: 95.0±45.0mg/L compared to normal values of 51.2±11.8mg/L, p<0.0003). NGAL levels correlated significantly with cystatin C levels (r=0.740, p<0.0001), indicating that the renal impairment in these patients seems to be originated from tubular injury. The findings of this study indicate that renal insufficiency is present in a significant proportion of transfusion-dependent β-thalassemia patients. Further studies are warranted in order to identify predisposing factors that contribute to the renal damage in thalassemia and to establish appropriate guidelines for the evaluation and follow up of renal function in these patients. 1. Clin Chem 2005; 51:1420–143.

Treatment of β-Thalassemia Patients with Recombinant Human Erythropoietin: Effect on Transfusion Requirements and Soluble Adhesion Molecules

The most common single genetic disorder and a major public health issue in Greece and other Mediterranean countries is β-thalassemia. Current therapeutic approaches for homozygous β-thalassemia entail blood transfusions and iron chelation therapy with deferoxamine or deferiprone for preventing tissue hemosiderosis. Recently, much effort has focused on various inducers of fetal hemoglobin (HbF) such as recombinant human erythropoietin (rHuEPO), especially in β-thalassemia intermedia. Ten adult patients, 5 with β-thalassemia major and 5 with β-thalassemia intermedia, received 150 IU/kg rHuEPO (epoetin-α) subcutaneously three times a week. Seven patients were transfused every 14–30 days and 3 with β-thalassemia intermedia were only occasionally transfused. The minimum duration of treatment was 12 weeks in order to define if there was any response. Transfusion intervals were modified according to the rHuEPO response to maintain stable Hb values. Lower transfusion requirements were observed in 5 patients after rHuEPO treatment (p = 0.028). In the 3 non-transfused patients, Hb values increased, and the patients are still being treated and followed up for a period ranging from 14 weeks to 2 years. Two patients with thalassemia major discontinued treatment after 12 weeks, as they did not achieve any response regarding transfusion requirements or Hb values. Pretreatment serum transferrin receptor levels were higher than in controls (p < 0.001) and significantly increased following rHuEPO treatment (p = 0.027). Patients had higher serum endothelin-3, sICAM-1 and sE-selectin values before rHuEPO treatment compared to controls (p < 0.001, p < 0.001 and p = 0.016, respectively), but these values were not altered during treatment. HbF values presented a slight, non-significant increase. rHuEPO treatment has a beneficial effect in transfusion-dependent β-thalassemia patients. Although a slight increase in HbF levels was observed, other possible mechanisms are probably involved. None of our patients experienced thrombotic complications and a rise in blood pressure.

A Multicenter Prospective Study on the Risk of Acquiring Liver Disease in Anti–Hepatitis C Virus Negative Patients Affected From Homozygous β-Thalassemia

Although the risk of transfusion-transmitted hepatitis has been recently reduced, transfusion-dependent β-thalassemia patients may still develop liver disease due to viral infection or iron overload. We assessed the frequency and causes of liver dysfunction in a cohort of anti–hepatitis C virus (HCV) negative thalassemics. Of 1,481 thalassemics enrolled in 31 centers, 219 (14.8%) tested anti-HCV− by second-generation assays; 181 completed a 3-year follow-up program consisting of alanine-aminotransferase (ALT) measurement at each transfusion and anti-HCV determination by third-generation enzyme-immunoassay (EIA-3) at the end of study. Serum ferritin levels were determined at baseline and at the end of follow-up. Ten patients were anti-HCV+ by EIA-3 at the end of follow-up. Of them, seven were already positive in 1992 to 1993 when the initial sera were retested by EIA-3, one tested indeterminate by confirmatory assay, and two had true seroconversion (incidence, 4.27/1,000 person years; risk of infection, 1/7,100 blood units, 95% confidence interval [CI], 1 in 2,000-1 in 71,000 units). At baseline, 67 of 174 thalassemics had abnormal ALT. Of those with normal ALT, seven subsequently developed at least one episode of moderate ALT increase (incidence, 24.6/1,000 person-years). All of the 20 patients with ferritin values ≥3,000 ng/mL had clinically relevant ALT abnormalities, as compared with 53 of 151 with &lt;3,000 ng/mL (P&lt; .005). Hepatic dysfunction is still frequent in thalassemics. Although it is mainly attributable to siderosis and primary HCV infection, the role of undiscovered transmissible agents cannot be excluded. © 1998 by The American Society of Hematology.

A Multicenter Prospective Study on the Risk of Acquiring Liver Disease in Anti–Hepatitis C Virus Negative Patients Affected From Homozygous β-Thalassemia

AbstractAlthough the risk of transfusion-transmitted hepatitis has been recently reduced, transfusion-dependent β-thalassemia patients may still develop liver disease due to viral infection or iron overload. We assessed the frequency and causes of liver dysfunction in a cohort of anti–hepatitis C virus (HCV) negative thalassemics. Of 1,481 thalassemics enrolled in 31 centers, 219 (14.8%) tested anti-HCV− by second-generation assays; 181 completed a 3-year follow-up program consisting of alanine-aminotransferase (ALT) measurement at each transfusion and anti-HCV determination by third-generation enzyme-immunoassay (EIA-3) at the end of study. Serum ferritin levels were determined at baseline and at the end of follow-up. Ten patients were anti-HCV+ by EIA-3 at the end of follow-up. Of them, seven were already positive in 1992 to 1993 when the initial sera were retested by EIA-3, one tested indeterminate by confirmatory assay, and two had true seroconversion (incidence, 4.27/1,000 person years; risk of infection, 1/7,100 blood units, 95% confidence interval [CI], 1 in 2,000-1 in 71,000 units). At baseline, 67 of 174 thalassemics had abnormal ALT. Of those with normal ALT, seven subsequently developed at least one episode of moderate ALT increase (incidence, 24.6/1,000 person-years). All of the 20 patients with ferritin values ≥3,000 ng/mL had clinically relevant ALT abnormalities, as compared with 53 of 151 with <3,000 ng/mL (P< .005). Hepatic dysfunction is still frequent in thalassemics. Although it is mainly attributable to siderosis and primary HCV infection, the role of undiscovered transmissible agents cannot be excluded.© 1998 by The American Society of Hematology.