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Musallam KM, Cappellini MD, Coates TD, Kuo KHM, Al-Samkari H, Sheth S, Viprakasit V, Taher AT. Αlpha-thalassemia: A practical overview. Blood Rev 2024; 64:101165. [PMID: 38182489 DOI: 10.1016/j.blre.2023.101165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/19/2023] [Accepted: 12/29/2023] [Indexed: 01/07/2024]
Abstract
α-Thalassemia is an inherited blood disorder characterized by decreased synthesis of α-globin chains that results in an imbalance of α and β globin and thus varying degrees of ineffective erythropoiesis, decreased red blood cell (RBC) survival, chronic hemolytic anemia, and subsequent comorbidities. Clinical presentation varies depending on the genotype, ranging from a silent or mild carrier state to severe, transfusion-dependent or lethal disease. Management of patients with α-thalassemia is primarily supportive, addressing either symptoms (eg, RBC transfusions for anemia), complications of the disease, or its transfusion-dependence (eg, chelation therapy for iron overload). Several novel therapies are also in development, including curative gene manipulation techniques and disease modifying agents that target ineffective erythropoiesis and chronic hemolytic anemia. This review of α-thalassemia and its various manifestations provides practical information for clinicians who practice beyond those regions where it is found with high frequency.
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Affiliation(s)
- Khaled M Musallam
- Center for Research on Rare Blood Disorders (CR-RBD), Burjeel Medical City, Abu Dhabi, United Arab Emirates
| | - M Domenica Cappellini
- Department of Clinical Sciences and Community, University of Milan, Ca' Granda Foundation IRCCS Maggiore Policlinico Hospital, Milan, Italy
| | - Thomas D Coates
- Hematology Section, Cancer and Blood Disease Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Kevin H M Kuo
- Division of Hematology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Hanny Al-Samkari
- Center for Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sujit Sheth
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Vip Viprakasit
- Department of Pediatrics & Thalassemia Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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2
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Chaemsaithong P, Luewan S, Taweevisit M, Chiangjong W, Pongchaikul P, Thorner PS, Tongsong T, Chutipongtanate S. Placenta-Derived Extracellular Vesicles in Pregnancy Complications and Prospects on a Liquid Biopsy for Hemoglobin Bart's Disease. Int J Mol Sci 2023; 24:5658. [PMID: 36982732 PMCID: PMC10055877 DOI: 10.3390/ijms24065658] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/18/2023] [Accepted: 02/22/2023] [Indexed: 03/18/2023] Open
Abstract
Extracellular vesicles (EVs) are nano-scaled vesicles released from all cell types into extracellular fluids and specifically contain signature molecules of the original cells and tissues, including the placenta. Placenta-derived EVs can be detected in maternal circulation at as early as six weeks of gestation, and their release can be triggered by the oxygen level and glucose concentration. Placental-associated complications such as preeclampsia, fetal growth restriction, and gestational diabetes have alterations in placenta-derived EVs in maternal plasma, and this can be used as a liquid biopsy for the diagnosis, prediction, and monitoring of such pregnancy complications. Alpha-thalassemia major ("homozygous alpha-thalassemia-1") or hemoglobin Bart's disease is the most severe form of thalassemia disease, and this condition is lethal for the fetus. Women with Bart's hydrops fetalis demonstrate signs of placental hypoxia and placentomegaly, thereby placenta-derived EVs provide an opportunity for a non-invasive liquid biopsy of this lethal condition. In this article, we introduced clinical features and current diagnostic markers of Bart's hydrops fetalis, extensively summarize the characteristics and biology of placenta-derived EVs, and discuss the challenges and opportunities of placenta-derived EVs as part of diagnostic tests for placental complications focusing on Bart's hydrop fetalis.
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Affiliation(s)
- Piya Chaemsaithong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Suchaya Luewan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chiangmai University, Chiangmai 50200, Thailand
| | - Mana Taweevisit
- Department of Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- King Chulalongkorn Memorial Hospital and Thai Red Cross Society, Bangkok 10330, Thailand
| | - Wararat Chiangjong
- Pediatric Translational Research Unit, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Pisut Pongchaikul
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10540, Thailand
- Integrative Computational BioScience Center, Mahidol University, Nakhon Pathom 73170, Thailand
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool CH64 7TE, UK
| | - Paul Scott Thorner
- Department of Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5S1A8, Canada
| | - Theera Tongsong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chiangmai University, Chiangmai 50200, Thailand
| | - Somchai Chutipongtanate
- Division of Epidemiology, Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
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3
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Horvei P, MacKenzie T, Kharbanda S. Advances in the management of α-thalassemia major: reasons to be optimistic. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:592-599. [PMID: 34889445 PMCID: PMC8791144 DOI: 10.1182/hematology.2021000295] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
α-Thalassemia major (ATM) is a severe disease resulting from deletions in all 4 copies of the α-globin gene. Although it is usually fatal before birth, the advent of in utero transfusions has enabled survival of a growing number of children. Postnatal therapy consists of chronic transfusions or stem cell transplantation, similar to patients with β-thalassemia major. In this review, we discuss the experience with postnatal stem cell transplantation in patients with ATM, as well as the ongoing phase 1 clinical trial of in utero stem cell transplantation for this condition.
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Affiliation(s)
- Paulina Horvei
- Division of Pediatric Allergy, Immunology and Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, CA
| | - Tippi MacKenzie
- Division of Pediatric Surgery and Fetal Treatment Center, UCSF Benioff Children's Hospital, University of California, San Francisco, CA
| | - Sandhya Kharbanda
- Division of Pediatric Allergy, Immunology and Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, CA
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4
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Chan WYK, Lee PPW, Lee V, Chan GCF, Leung W, Ha SY, Cheuk DKL. Outcomes of allogeneic transplantation for hemoglobin Bart's hydrops fetalis syndrome in Hong Kong. Pediatr Transplant 2021; 25:e14037. [PMID: 34003560 DOI: 10.1111/petr.14037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/12/2021] [Accepted: 04/24/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hemoglobin Bart's hydrops fetalis syndrome (BHFS) was once considered a fatal condition universally. Medical advances over the past three decades have resulted in increasing numbers of BHFS survivors. This retrospective review summarized local territory-wide experience and outcomes of BHFS patients who received allogeneic hematopoietic stem cell transplantation (HSCT) in Hong Kong. METHODS All BHFS patients who underwent allogeneic HSCT in Hong Kong, either in one of the two former pediatric transplant centers (Queen Mary Hospital and Prince of Wales Hospital) on or before 2019 or in the single territory-wide pediatric transplant center (Hong Kong Children's Hospital) since 2019, from January 1, 1996, till December 31, 2020, were included. Basic demographic data, perinatal history, transplant details, long-term outcomes, and morbidities were reviewed. RESULTS Total five allogeneic HSCT were performed in two males and three females at a median age of 22 months, which include one 8/8 matched-sibling bone marrow transplant, one 5/6 matched-sibling cord blood transplant with HLA-DR antigenic mismatch, two 12/12 matched-unrelated peripheral blood stem cell transplant (PBSCT), and one haploidentical PBSCT with TCRαβ/CD45RA depletion from maternal donor. Neutrophil and platelet engrafted (>20 × 109 /L) at a median of 15 and 22 days, respectively. All achieved near full donor chimerism at 1 month. All patients survived and remained transfusion-independent without significant morbidities with median follow-up duration of 10 years. CONCLUSION To conclude, local data demonstrated favorable outcome of allogeneic HSCT for BHFS patients, but sample number is small. Non-directive approach in counseling and international collaboration is recommended.
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Affiliation(s)
- Wilson Y K Chan
- Department of Pediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Pamela P W Lee
- Department of Pediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Vincent Lee
- Department of Pediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Godfrey C F Chan
- Department of Pediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Wing Leung
- Department of Pediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - S Y Ha
- Department of Pediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
| | - Daniel K L Cheuk
- Department of Pediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong Special Administrative Region, China
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5
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Forager and farmer evolutionary adaptations to malaria evidenced by 7000 years of thalassemia in Southeast Asia. Sci Rep 2021; 11:5677. [PMID: 33707498 PMCID: PMC7952380 DOI: 10.1038/s41598-021-83978-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/08/2021] [Indexed: 11/21/2022] Open
Abstract
Thalassemias are inherited blood disorders that are found in high prevalences in the Mediterranean, Southeast Asia and the Pacific. These diseases provide varying levels of resistance to malaria and are proposed to have emerged as an adaptive response to malaria in these regions. The transition to agriculture in the Holocene has been suggested to have influenced the selection for thalassemia in the Mediterranean as land clearance for farming encouraged interaction between Anopheles mosquitos, the vectors for malaria, and human groups. Here we document macroscopic and microscopic skeletal evidence for the presence of thalassemia in both hunter-gatherer (Con Co Ngua) and early agricultural (Man Bac) populations in northern Vietnam. Firstly, our findings demonstrate that thalassemia emerged prior to the transition to agriculture in Mainland Southeast Asia, from at least the early seventh millennium BP, contradicting a long-held assumption that agriculture was the main driver for an increase in malaria in Southeast Asia. Secondly, we describe evidence for significant malarial burden in the region during early agriculture. We argue that the introduction of farming into the region was not the initial driver of the selection for thalassemia, as it may have been in other regions of the world.
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6
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Chapin J, Giardina PJ. Thalassemia Syndromes. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00040-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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7
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Pangeson T, Sanguansermsri P, Sanguansermsri T, Seeratanachot T, Suwanakhon N, Srikummool M, Kaewkong W, Mahingsa K. Association of Tissue-Specific DNA Methylation Alterations with α-Thalassemia Southeast Asian Deletion. GENETICS & EPIGENETICS 2017; 9:1179237X17736107. [PMID: 29162979 PMCID: PMC5692129 DOI: 10.1177/1179237x17736107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 03/15/2017] [Indexed: 12/31/2022]
Abstract
In the wild-type allele, DNA methylation levels of 10 consecutive CpG sites adjacent to the upstream 5′-breakpoint of α-thalassemia Southeast Asian (SEA) deletion are not different between placenta and leukocytes. However, no previous study has reported the map of DNA methylation in the SEA allele. This report aims to show that the SEA mutation is associated with DNA methylation changes, resulting in differential methylation between placenta and leukocytes. Methylation-sensitive high-resolution analysis was used to compare DNA methylation among placenta, leukocytes, and unmethylated control DNA. The result indicates that the DNA methylation between placenta and leukocyte DNA is different and shows that the CpG status of both is not fully unmethylated. Mapping of individual CpG sites was performed by targeted bisulfite sequencing. The DNA methylation level of the 10 consecutive CpG sites was different between placenta and leukocyte DNA. When the 10th CpG of the mutation allele was considered as a hallmark for comparing DNA methylation level, it was totally different from the unmethylated 10th CpG of the wild-type allele. Finally, the distinct DNA methylation patterns between both DNA were extracted. In total, 24 patterns were found in leukocyte samples and 9 patterns were found in placenta samples. This report shows that the large deletion is associated with DNA methylation change. In further studies for clinical application, the distinct DNA methylation pattern might be a potential marker for detecting cell-free fetal DNA.
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Affiliation(s)
- Tanapat Pangeson
- Department of Biochemistry, Faculty of Medical Science, Naresuan University, Phitsanulok, Thailand.,Department of Biochemistry, School of Medical Sciences, University of Phayao, Phayao, Thailand.,Thalassemia Research Unit, Institute of Human Genetics, University of Phayao, Phayao, Thailand
| | - Phanchana Sanguansermsri
- Department of Biochemistry, Faculty of Medical Science, Naresuan University, Phitsanulok, Thailand
| | - Torpong Sanguansermsri
- Thalassemia Research Unit, Institute of Human Genetics, University of Phayao, Phayao, Thailand
| | - Teerapat Seeratanachot
- Department of Biochemistry, School of Medical Sciences, University of Phayao, Phayao, Thailand.,Thalassemia Research Unit, Institute of Human Genetics, University of Phayao, Phayao, Thailand
| | - Narutchala Suwanakhon
- Thalassemia Research Unit, Institute of Human Genetics, University of Phayao, Phayao, Thailand.,Department of Biology, School of Science, University of Phayao, Phayao, Thailand
| | - Metawee Srikummool
- Department of Biochemistry, Faculty of Medical Science, Naresuan University, Phitsanulok, Thailand
| | - Worasak Kaewkong
- Department of Biochemistry, Faculty of Medical Science, Naresuan University, Phitsanulok, Thailand
| | - Khwanruedee Mahingsa
- Thalassemia Research Unit, Institute of Human Genetics, University of Phayao, Phayao, Thailand
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8
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Jatavan P, Chattipakorn N, Tongsong T. Fetal hemoglobin Bart’s hydrops fetalis: pathophysiology, prenatal diagnosis and possibility of intrauterine treatment. J Matern Fetal Neonatal Med 2017; 31:946-957. [DOI: 10.1080/14767058.2017.1301423] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Phudit Jatavan
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Chiang Mai University, Chiang Mai, Thailand
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand
| | - Theera Tongsong
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Chiang Mai University, Chiang Mai, Thailand
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9
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Songdej D, Babbs C, Higgs DR. An international registry of survivors with Hb Bart's hydrops fetalis syndrome. Blood 2017; 129:1251-1259. [PMID: 28057638 PMCID: PMC5345731 DOI: 10.1182/blood-2016-08-697110] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 12/19/2016] [Indexed: 11/20/2022] Open
Abstract
Hemoglobin (Hb) Bart's hydrops fetalis syndrome (BHFS) resulting from α0-thalassemia is considered a universally fatal disorder. However, over the last 3 decades, improvements in intrauterine interventions and perinatal intensive care have resulted in increasing numbers of BHFS survivors. We have initiated an international registry containing information on 69 patients, of which 31 are previously unpublished. In this perspective, we analyze the available clinical information to document the natural history of BHFS. In the future, once we have accrued sufficient cases, we aim to build on this study and provide information to allow counseling of at-risk couples. To date, 39 patients have survived beyond the age of 5 years, 18 of whom are now older than 10 years. Based on the available cases, we find evidence to suggest that intrauterine therapy provides benefits during the perinatal and neonatal period; however, it may not provide additional benefits to long-term growth and neurodevelopmental outcomes. Growth retardation is a major adverse long-term outcome among BHFS patients with ∼40% being severely affected in terms of weight and ∼50% in terms of height. There is also an increased risk of neurodevelopmental delay as we find 20% (11/55) of BHFS survivors suffer from a serious delay of ≥6 months. Most patients in the registry require lifelong transfusion and often have associated congenital abnormalities and comorbidities. This perspective is a first step in gathering information to allow provision of informed counseling on the predicted outcomes of affected babies.
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Affiliation(s)
- Duantida Songdej
- Medical Research Council Molecular Haematology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom; and
- Division of Hematology/Oncology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Christian Babbs
- Medical Research Council Molecular Haematology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom; and
| | - Douglas R Higgs
- Medical Research Council Molecular Haematology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom; and
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10
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Li CK. New trend in the epidemiology of thalassaemia. Best Pract Res Clin Obstet Gynaecol 2017; 39:16-26. [DOI: 10.1016/j.bpobgyn.2016.10.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 08/21/2016] [Accepted: 10/14/2016] [Indexed: 01/19/2023]
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11
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Pecker LH, Guerrera MF, Loechelt B, Massaro A, Abraham AA, Fasano RM, Meier ER. Homozygous α-thalassemia: Challenges surrounding early identification, treatment, and cure. Pediatr Blood Cancer 2017; 64:151-155. [PMID: 27573913 DOI: 10.1002/pbc.26163] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/05/2016] [Accepted: 07/01/2016] [Indexed: 11/08/2022]
Abstract
The prognosis for homozygous α-thalassemia is changing. Prenatal diagnosis and intrauterine transfusions (IUT) reduce maternofetal morbidity and mortality; hematopoietic stem cell transplant (HSCT) is curative. Empiric evidence to support IUT and HSCT to treat homozygous α-thalassemia is lacking. The first case of curative HSCT for homozygous α-thalassemia was reported in 1997. Nearly 20 years later, five additional reports are published. We review the literature and report an institutional experience with three homozygous α-thalassemia patients. The first died shortly after birth. The second underwent HSCT after years of chronic transfusion therapy. The third benefited from IUT and HSCT. These cases exemplify the varied outcomes associated with this condition.
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Affiliation(s)
- Lydia H Pecker
- Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, District of Columbia.,Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Michael F Guerrera
- Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, District of Columbia.,Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Brett Loechelt
- Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, District of Columbia
| | - An Massaro
- Division of Neonatology, Children's National Health Systems, Washington, District of Columbia
| | - Allistair A Abraham
- Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, District of Columbia.,Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Ross M Fasano
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia
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12
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Successful matched unrelated donor stem cell transplant in Hemoglobin Bart's disease. Bone Marrow Transplant 2016; 51:1522-1523. [PMID: 27295273 DOI: 10.1038/bmt.2016.153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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13
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Chmait RH, Baskin JL, Carson S, Randolph LM, Hamilton A. Treatment of alpha(0)-thalassemia (--(SEA)/--(SEA)) via serial fetal and post-natal transfusions: Can early fetal intervention improve outcomes? ACTA ACUST UNITED AC 2014; 20:217-22. [PMID: 25116001 DOI: 10.1179/1607845414y.0000000187] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE AND IMPORTANCE Homozygous Southeast Asian alpha-thalassemia mutation (--(SEA)/--(SEA)) results in deletion of all alpha-globin genes (alpha(0)-thalassemia). Since all alpha-globin chains are absent, hemoglobin F cannot be synthesized, and hemoglobin Bart's becomes the dominant fetal hemoglobin. Hemoglobin Bart's is a γ tetramer with a very high oxygen affinity, thus oxygen delivery to the tissues is poor. Clinical manifestations include severe fetal anemia, hydrops fetalis, fetal demise, and high risk of neurodevelopmental impairment in the rare survivors. CLINICAL PRESENTATION A 39-year-old Vietnamese woman presented to our center at 28 0/7 weeks' gestation with fetal alpha(0)-thalassemia (--(SEA)/--(SEA) type deletion) and ultrasound markers suggestive of severe fetal anemia. INTERVENTION The fetus was treated with four intrauterine transfusions followed by post-natal chronic transfusions. Formal neurodevelopmental testing (Battelle Developmental Inventory, Second Edition) was performed at 18 months of age, and the developmental quotient was 93 (32nd percentile) with all subdomains noted within normal limits, indicating overall intact neurodevelopment. CONCLUSION We posit that earlier diagnosis and fetal treatment, prior to clinical findings suggestive of fetal anemia, may improve long-term outcomes by enhancing oxygen delivery to the tissues of the developing fetus.
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14
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Normal cognitive functioning in a patient with Hb Bart's hydrops successfully cured by hematopoietic SCT. Bone Marrow Transplant 2013; 49:155-6. [PMID: 23974609 DOI: 10.1038/bmt.2013.131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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15
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Bizzarro MJ, Copel JA, Pearson HA, Pober B, Bhandari V. Pulmonary hypoplasia and persistent pulmonary hypertension in the newborn with homozygous α-thalassemia: a case report and review of the literature. J Matern Fetal Neonatal Med 2009; 14:411-6. [PMID: 15061322 DOI: 10.1080/14767050412331312280] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The survival of infants with homozygous alpha-thalassemia, once considered a lethal diagnosis, is now possible through in utero and postnatal diagnostic and therapeutic interventions. We report the survival of a newborn with homozygous alpha-thalassemia complicated by pulmonary hypoplasia and persistent pulmonary hypertension, an association not previously reported.
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Affiliation(s)
- M J Bizzarro
- Department of Pediatrics, Yale-New Haven Hospital, New Haven, Connecticut, USA
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16
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Yi JS, Moertel CL, Baker KS. Homozygous alpha-thalassemia treated with intrauterine transfusions and unrelated donor hematopoietic cell transplantation. J Pediatr 2009; 154:766-8. [PMID: 19364562 DOI: 10.1016/j.jpeds.2008.11.031] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2008] [Revised: 10/03/2008] [Accepted: 11/17/2008] [Indexed: 11/17/2022]
Abstract
Recently, intrauterine transfusions and hematopoietic cell transplantation (HCT) have changed homozygous alpha-thalassemia from a frequently fatal disease to a potentially survivable condition. We present a patient with Hemoglobin Bart's disease who was cured after failing to engraft with 1 unrelated HCT, but engrafting after a second unrelated donor HCT.
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Affiliation(s)
- Joanna S Yi
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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17
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Roberts IAG. The changing face of haemolytic disease of the newborn. Early Hum Dev 2008; 84:515-23. [PMID: 18621490 DOI: 10.1016/j.earlhumdev.2008.06.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Accepted: 06/03/2008] [Indexed: 11/25/2022]
Abstract
The diagnosis, acute management and follow-up of neonates with haemolytic disease of the newborn (HDN) still represents a significant area of activity for maternity/neonatal services. ABO incompatability is now the single largest cause of HDN in the western world. However, with increasing knowledge at the molecular level, and closer liaison between neonatal paediatricians and haematologists, the diagnosis of non-immune causes of HDN is increasing. As these conditions have an inherited basis and therefore have implications for other family members (or future children), it remains a high priority for all neonatal paediatricians to achieve an accurate diagnosis in all cases of HDN. As the efficacy of phototherapy increases the role of exchange transfusion in acute management is rapidly decreasing. This makes gauging the appropriate time to intervene with exchange transfusion a difficult clinical decision, and guidelines appropriate to the spectrum of contemporary disease are required. In the future intravenous immunoglobulin and/or intramuscular metalloporphyrins may further reduce the need for exchange transfusion and continue to change the spectrum of HDN faced by neonatal paediatricians.
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Affiliation(s)
- Irene A G Roberts
- Department of Haematology, Hammersmith Hospital, London W12 0NN, United Kingdom.
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18
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Lee SYR, Chow CB, Li CK, Chiu MC. Outcome of intensive care of homozygous alpha-thalassaemia without prior intra-uterine therapy. J Paediatr Child Health 2007; 43:546-50. [PMID: 17635683 DOI: 10.1111/j.1440-1754.2007.01131.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To review the outcome of homozygous alpha-thalassaemia without prior intra-uterine therapy treated in neonatal intensive care unit and identify the factors associated with survival. METHODS The hospital records of all patients with homozygous alpha-thalassaemia treated in our neonatal intensive care unit in the last 15 years were reviewed. A literature search beginning in the year 1980 was done to identify homozygous alpha-thalassaemia actively treated in neonatal intensive care units. Those receiving prior intra-uterine therapy were excluded. The following information was collected: the severity of hydrops, sizes of liver and spleen, haemoglobin level, Apgar score at 5 min, ventilator settings, timing and forms of red blood cell transfusion and presence of persistent hypoxaemia. The survivors and the non-survivors were compared. RESULTS In our centre, in the last 15 years there were six infants born with homozygous alpha-thalassaemia who did not receive intra-uterine therapy; one survived and five succumbed despite aggressive respiratory therapy. In our literature search there were more reports of survivors (10) than non-survivors (six) for these infants, suggesting a reporting bias towards selection of rare cases of survival. Apgar score of four or above occurred in seven of the eight survivors with data available in the reports, whereas this occurred in four of the 11 non-survivors (P = 0.035, Fisher Exact test). Five of the 11 survivors had abnormal neurological outcome including developmental delay and spastic quadriplegia. CONCLUSION Without prior intra-uterine therapy, homozygous alpha-thalassaemia has grave outlook in terms of mortality and morbidity despite aggressive respiratory therapy.
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Affiliation(s)
- Shing Y R Lee
- Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Lai King Hill Road, New Territories, Hong Kong, China.
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19
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Han XD, Lin C, Chang J, Sadelain M, Kan YW. Fetal gene therapy of alpha-thalassemia in a mouse model. Proc Natl Acad Sci U S A 2007; 104:9007-11. [PMID: 17496141 PMCID: PMC1885618 DOI: 10.1073/pnas.0702457104] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Fetuses with homozygous alpha-thalassemia usually die at the third trimester of pregnancy or soon after birth. Hence, the disease could potentially be a target for fetal gene therapy. We have previously established a mouse model of alpha-thalassemia. These mice mimic the human alpha-thalassemic conditions and can be used as preclinical models for fetal gene therapy. We tested a lentiviral vector containing the HS 2, 3, and 4 of the beta-LCR, a central polypurine tract element, and the beta-globin gene promoter directing either the EGFP or the human alpha-globin gene. We showed that the GFP expression was erythroid-specific and detected in BFU-E colonies and the erythroid progenies of CFU-GEMM. For in utero gene delivery, we did yolk sac vessel injection at midgestation of mouse embryos. The recipient mice were analyzed after birth for human alpha-globin gene expression. In the newborn, human alpha-globin gene expression was detected in the liver, spleen, and peripheral blood. The human alpha-globin gene expression was at the peak at 3-4 months, when it reached 20% in some recipients. However, the expression declined at 7 months. Colony-forming assays in these mice showed low abundance of the transduced human alpha-globin gene in their BFU-E and CFU-GEMM and the lack of its transcript. Thus, lentiviral vectors can be an effective vehicle for delivering the human alpha-globin gene into erythroid cells in utero, but, in the mouse model, delivery at late midgestation could not transduce hematopoietic stem cells adequately to sustain gene expression.
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Affiliation(s)
- Xiao-Dong Han
- *Cardiovascular Research Institute, Institute of Human Genetics and Department of Medicine, University of California, San Francisco, CA 94143; and
| | - Chin Lin
- *Cardiovascular Research Institute, Institute of Human Genetics and Department of Medicine, University of California, San Francisco, CA 94143; and
| | - Judy Chang
- *Cardiovascular Research Institute, Institute of Human Genetics and Department of Medicine, University of California, San Francisco, CA 94143; and
| | | | - Y. W. Kan
- *Cardiovascular Research Institute, Institute of Human Genetics and Department of Medicine, University of California, San Francisco, CA 94143; and
- To whom correspondence should be addressed at:
Institute of Human Genetics, 513 Parnassus Avenue, HSW 901B, University of California, San Francisco, CA 94143-0793. E-mail:
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20
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Abstract
The changing management of haemolytic disease of the newborn is reviewed
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Affiliation(s)
- Neil A Murray
- Imperial College, Department of Paediatrics, 5th Floor, Ham House, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK.
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21
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Affiliation(s)
- Barbara O'Brien
- Division of Genetics, Department of Pediatrics, Tufts-New England Medical Center, Boston, Massachusetts 02111, USA
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22
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Lücke T, Pfister S, Dürken M. Neurodevelopmental outcome and haematological course of a long-time survivor with homozygous alpha-thalassaemia: case report and review of the literature. Acta Paediatr 2005; 94:1330-3. [PMID: 16279001 DOI: 10.1111/j.1651-2227.2005.tb02096.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM Homozygous alpha-thalassaemia, also called haemoglobin (Hb) Bart's hydrops fetalis, has been thought to be a lethal condition. Due to prenatal diagnosis and intrauterine blood transfusions, a few patients with Hb Bart's hydrops fetalis have survived. This fact raises the urgent questions of clinical management and appropriate follow-up of these patients, both of which are addressed in this article. METHODS We report on a 6.5-y-old patient with homozygous alpha-thalassaemia and review the literature of 13 other survivors published to date. Transfusion requirements were evaluated and the rate of liver iron accumulation was assessed by biomagnetic liver susceptometry before and after institution of iron-chelating therapy. Psychometric evaluation was carried out using Munich's Functional Development Test, the Columbia Mental Maturity Scale, the Kaufman Assessment Battery for Children, and the Peabody Picture Vocabulary Test. RESULTS Our patient had significant delay of psychomotor development. Psychometric evaluation at the age of 5 y revealed an IQ of 85 and an intellectual level of a 4-y-old child. Early tissue iron overload was seen, but a negative iron balance was achieved after institution of desferrioxamine treatment at dosages used for beta-thalassaemia. CONCLUSION Homozygous alpha-thalassaemia should no longer be regarded as a lethal condition. Early intervention during pregnancy and careful haematological as well as neuropsychological follow-up was able to provide long-term survival and good life quality in our patient.
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Affiliation(s)
- Thomas Lücke
- Department of Paediatrics, Hannover Medical School, Hannover, and Department of Paediatrics, University Hospital Mannheim, Germany.
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23
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Adam MP, Chueh J, El-Sayed YY, Stenzel A, Vogel H, Weaver DD, Hoyme HE. Vascular-type disruptive defects in fetuses with homozygous α-thalassemia: report of two cases and review of the literature. Prenat Diagn 2005; 25:1088-96. [PMID: 16231329 DOI: 10.1002/pd.1276] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The thalassemias are an inherited group of heterogeneous anemias in which one or more of the globin chains in the hemoglobin tetramer are absent. Fetuses with homozygous alpha-thalassemia, which is particularly prevalent in people of Southeast Asian extraction, experience deficient alpha-globin chain synthesis and cannot produce hemoglobin F (the primary fetal hemoglobin after 8 weeks' gestation). Instead, they produce an anomalous hemoglobin, hemoglobin Bart's, with an unusually high affinity for oxygen, leading to profound anemia and tissue hypoxia. METHODS AND RESULTS Here we report on two fetuses with homozygous alpha-thalassemia who displayed structural defects of a vascular disruptive type. Both fetuses demonstrated limb anomalies, including terminal transverse limb deficiencies, and one fetus was found to have a brain malformation consisting of a neuronal migrational defect. The limb anomalies and suspected brain malformation were detected on prenatal ultrasound prior to confirmation of the diagnosis of alpha-thalassemia in one case; in the other case prenatal records were not available. While microcephaly, hydrocephalus, and retarded brain growth have been rarely reported in association with homozygous alpha-thalassemia, this is the first report of a true brain malformation in an affected fetus. Limb anomalies, on the other hand, appear to be more frequent. Recently, aggressive in utero and postnatal therapies for homozygous alpha-thalassemia have been attempted with some success. CONCLUSIONS Our cases and those from the medical literature suggest that couples need to be counseled about the risks of congenital anomalies of a vascular disruptive type in affected fetuses. Furthermore, data from the literature suggests that in utero therapy may not significantly decrease these risks as such anomalies may be present prior to the institution of therapy. In addition, in hydropic infants with vascular disruptive defects, especially in those of Southeast Asian origin, homozygous alpha-thalassemia should be suspected as a likely etiology.
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Affiliation(s)
- Margaret P Adam
- Department of Human Genetics and Pediatrics, Emory University School of Medicine, Atlanta, GA 30033, USA.
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24
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Joshi DD, Nickerson HJ, McManus MJ. Hydrops fetalis caused by homozygous alpha-thalassemia and Rh antigen alloimmunization: report of a survivor and literature review. Clin Med Res 2004; 2:228-32. [PMID: 15931362 PMCID: PMC1069098 DOI: 10.3121/cmr.2.4.228] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2004] [Revised: 10/13/2004] [Accepted: 10/22/2004] [Indexed: 11/18/2022]
Abstract
Hematologic causes of hydrops fetalis include homozygous alpha-thalassemia and immune hemolytic anemias. We report the case of a boy with hydrops fetalis who had homozygous alpha-thalassemia and alloimmune hemolytic anemia due to anti-E and anti-C blood group antibodies. He received intrauterine red blood cell transfusions and postnatal chronic transfusion with iron chelation therapy. A non-myeloablative sibling stem cell transplant failed. He is now 5 years and 6 months of age, hypothyroid with short stature, but in overall good health. He is one of the oldest reported homozygous alpha-thalassemia survivors and, to our knowledge, the only survivor with immune- and nonimmune-induced hydrops fetalis.
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Affiliation(s)
- Divya-Devi Joshi
- Pediatric Hematology/Oncology, Marshfield Clinic, Marshfield, Wisconsin 54449, USA.
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25
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Thornley I, Lehmann L, Ferguson WS, Davis I, Forman EN, Guinan EC. Homozygous alpha-thalassemia treated with intrauterine transfusions and postnatal hematopoietic stem cell transplantation. Bone Marrow Transplant 2003; 32:341-2. [PMID: 12858209 DOI: 10.1038/sj.bmt.1704129] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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26
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Abstract
This review summarizes state-of-the-art and emerging techniques in the antenatal diagnosis of fetal anemia and hemoglobinopathies. Fetal anemia may result from hemolytic disease, hemorrhage, suppression of erythropoiesis, infection (eg, parvovirus B19), or trauma. The clinical laboratory plays an essential role in the evaluation of these disorders by way of the use of various hematologic, biochemical, serologic, cytometric, and molecular genetics methods. Hemoglobinopathies are the most common class of single gene disorders worldwide. The authors have used the example of homozygous alpha-thalassemia major (Hb Barts disease) as a paradigmatic case for antenatal hemoglobinopathy screening. Perhaps the most familiar indication for hematologic screening in pregnancy is HDFN, most commonly in pregnancies previously sensitized to the RhD antigen. All pregnant women, regardless of their past medical or obstetric history or previous antibody screens, should have ABO/Rh blood typing and a red cell antibody screen performed at the first prenatal visit. Long-established methods for assaying FMH (KB method), microcytosis (hemogram with red cell indices), and blood group incompatibility (direct antigen test, serologies) remain critical for rapid, sensitive diagnosis. Analysis of fetal free DNA in maternal plasma holds the promise for rapid, ultrasensitive, and noninvasive detection of many fetal hematologic disorders.
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Affiliation(s)
- Lewis P Rubin
- Department of Pediatrics, Program in Fetal Medicine, Brown Medical School and Women and Infants Hospital of Rhode Island, 101 Dudley Street, Providence, RI 02905-2499, USA.
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Zhou X, Ha SY, Chan GC, Luk CW, Chan V, Hawkins B, Lam YH, Liang RH, Lau YL. Successful mismatched sibling cord blood transplant in Hb Bart's disease. Bone Marrow Transplant 2001; 28:105-7. [PMID: 11498754 DOI: 10.1038/sj.bmt.1703104] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2001] [Accepted: 04/30/2001] [Indexed: 11/09/2022]
Abstract
A 20-month-old girl with Hb Bart's disease, who had survived neonatal complications, underwent HLA-DR antigen mismatched sibling cord blood transplantation successfully. Immune thrombocytopenia, which occurred around 2.5 months after transplant, responded to intravenous gamma-globulin. The fetal hemoglobin level rose to a peak of 52.3% on day +69 post transplant and declined gradually during the following year. Ten percent of hemoglobin Bart's was detected 2 months after transplant and this reflects the alpha-thalassemia trait of the donor.
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Affiliation(s)
- X Zhou
- Department of Pediatrics, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
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28
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Singer ST, Styles L, Bojanowski J, Quirolo K, Foote D, Vichinsky EP. Changing outcome of homozygous alpha-thalassemia: cautious optimism. J Pediatr Hematol Oncol 2000; 22:539-42. [PMID: 11132224 DOI: 10.1097/00043426-200011000-00014] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Only a few long-term survivors of homozygous alpha-thalassemia, a usually fatal condition, have been reported. The authors present a surviving infant with this disorder and discuss the complications, treatments, and implications of this genetic hemoglobinopathy. The child had no antenatal intervention and has been treated with regular transfusions. She has had normal growth and development and is currently 2.5-years-old. A literature review of survivors with Bart hemoglobinopathy reveals an intense perinatal course and a great prevalence of congenital urogenital and limb defects. Advances in antenatal diagnosis, intrauterine intervention, and postnatal treatments have resulted in extended survival of children with congenital defects that until recently were considered invariably fatal. Transfusion and chelation therapy and bone marrow transplantation provide long-term treatment and potential curative options.
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Affiliation(s)
- S T Singer
- Division of Hematology/Oncology, Children's Hospital, Oakland, California 94609, USA
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29
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Abstract
In patients with hemoglobinopathy who are treated by allogeneic matched sibling bone marrow transplantation before the onset of disease-associated organ damage, long term, disease-free survival currently stands at approximately 90%, and transplant-associated mortality is 5% or less. Less toxic nonmyeloablative conditioning regimens that have the potential to reduce procedure-related mortality to even lower levels are under active investigation. Expansion of the donor pool by use of unrelated matched donors awaits improvement in HLA-typing methodology.
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Affiliation(s)
- W C Mentzer
- University of California at San Francisco, USA
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