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Lugthart G, Verweij EJT, Harteveld CL, Tan RNGB, Knapen MFCM, Slaghekke F, Haak MC, Mohseny AB, Smiers FJ. Suppression of Hb Bart's to improve tissue oxygenation and fetal development in homozygous alpha-thalassemia. Am J Hematol 2024; 99:1613-1615. [PMID: 38655712 DOI: 10.1002/ajh.27344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 04/26/2024]
Abstract
Intra-uterine reduction of Hb Bart's only reached with exchange transfusions.
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Affiliation(s)
- G Lugthart
- Leiden University Medical Center (LUMC) Willem-Alexander Children's Hospital, Pediatric Hematology and HSCT, Leiden, The Netherlands
| | - E J T Verweij
- Department of Obstetrics and Fetal Therapy, LUMC, Leiden, The Netherlands
| | - C L Harteveld
- Department of Clinical Genetics, LUMC, Leiden, The Netherlands
| | - R N G B Tan
- LUMC Willem-Alexander Children's Hospital, Neonatal Intensive Care Unit, Leiden, The Netherlands
| | - M F C M Knapen
- Department of Obstetrics and Prenatal Medicine, ErasmusMC, Rotterdam, The Netherlands
| | - F Slaghekke
- Department of Obstetrics and Fetal Therapy, LUMC, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics and Fetal Therapy, LUMC, Leiden, The Netherlands
| | - A B Mohseny
- Leiden University Medical Center (LUMC) Willem-Alexander Children's Hospital, Pediatric Hematology and HSCT, Leiden, The Netherlands
| | - F J Smiers
- Leiden University Medical Center (LUMC) Willem-Alexander Children's Hospital, Pediatric Hematology and HSCT, Leiden, The Netherlands
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Lal A, Viprakasit V, Vichinsky E, Lai Y, Lu MY, Kattamis A. Disease burden, management strategies, and unmet needs in α-thalassemia due to hemoglobin H disease. Am J Hematol 2024. [PMID: 39037279 DOI: 10.1002/ajh.27440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 06/28/2024] [Accepted: 07/09/2024] [Indexed: 07/23/2024]
Abstract
Alpha-thalassemia is an inherited blood disorder caused by impaired α-globin chain production, leading to anemia and other complications. Hemoglobin H (HbH) disease is caused by a combination of mutations generally affecting the expression of three of four α-globin alleles; disease severity is highly heterogeneous, largely driven by genotype. Notably, non-deletional mutations cause a greater degree of ineffective erythropoiesis and hemolysis, higher transfusion burden, and increased complication risks versus deletional mutations. There are limited treatment options for HbH disease, and effective therapies are needed. This review discusses the pathophysiology of HbH disease, current management strategies, unmet needs, and emerging treatment options.
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Affiliation(s)
- Ashutosh Lal
- University of California-San Francisco School of Medicine, Pediatric Hematology, Oakland, California, USA
| | - Vip Viprakasit
- Department of Pediatrics & Thalassemia Center, Siriraj Research Hospital, Mahidol University, Bangkok, Thailand
| | - Elliott Vichinsky
- University of California-San Francisco School of Medicine, Pediatric Hematology, Oakland, California, USA
| | - Yongrong Lai
- Department of Hematology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Meng-Yao Lu
- Department of Paediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Antonis Kattamis
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
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Abstract
Clinical manifestations of α-thalassemia range from no symptoms to severe transfusion-dependent anemia. Alpha thalassemia trait is deletion of 1 to 2 α-globin genes, whereas α-thalassemia major (ATM; Barts hydrops fetalis) is the deletion all 4 α genes. All other genotypes of intermediate severity are categorized as HbH disease, a vastly heterogenous group. Clinical spectrum is classified as mild, moderate, and severe by symptoms and need for intervention. Anemia in prenatal period may be fatal without intrauterine transfusions. New therapies to modify HbH disease or provide cure for ATM are under development.
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Affiliation(s)
- Ashutosh Lal
- UCSF School of Medicine, UCSF Benioff Children's Hospital, 747 52nd Street, Oakland, CA 94609, USA.
| | - Elliott Vichinsky
- UCSF School of Medicine, UCSF Benioff Children's Hospital, 747 52nd Street, Oakland, CA 94609, USA
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Abstract
Thalassemia syndromes are common monogenic disorders and represent a significant health issue worldwide. In this review, the authors elaborate on fundamental genetic knowledge about thalassemias, including the structure and location of globin genes, the production of hemoglobin during development, the molecular lesions causing α-, β-, and other thalassemia syndromes, the genotype-phenotype correlation, and the genetic modifiers of these conditions. In addition, they briefly discuss the molecular techniques applied for diagnosis and innovative cell and gene therapy strategies to cure these conditions.
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Affiliation(s)
- Nicolò Tesio
- Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Torino, Regione Gonzole, 10, 10043 Orbassano, Turin, Italy. https://twitter.com/nicolotesio
| | - Daniel E Bauer
- Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Pediatrics, Harvard Stem Cell Institute, Broad Institute, Harvard Medical School, Boston, MA, USA.
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Singh K. Prenatal Interventions for the Treatment of Congenital Disorders. Regen Med 2023. [DOI: 10.1007/978-981-19-6008-6_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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The impact of in utero transfusions on perinatal outcomes in patients with alpha thalassemia major: the UCSF registry. Blood Adv 2022; 7:269-279. [PMID: 36306387 PMCID: PMC9860434 DOI: 10.1182/bloodadvances.2022007823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/30/2022] [Accepted: 09/19/2022] [Indexed: 01/29/2023] Open
Abstract
Alpha thalassemia major (ATM) is a hemoglobinopathy that usually results in perinatal demise if in utero transfusions (IUTs) are not performed. We established an international registry (NCT04872179) to evaluate the impact of IUTs on survival to discharge (primary outcome) as well as perinatal and neurodevelopmental secondary outcomes. Forty-nine patients were diagnosed prenatally, 11 were diagnosed postnatally, and all 11 spontaneous survivor genotypes had preserved embryonic zeta-globin levels. We compared 3 groups of patients; group 1, prenatally diagnosed and alive at hospital discharge (n = 14), group 2, prenatally diagnosed and deceased perinatally (n = 5), and group 3, postnatally diagnosed and alive at hospital discharge (n = 11). Group 1 had better outcomes than groups 2 and 3 in terms of the resolution of hydrops, delivery closer to term, shorter hospitalizations, and more frequent average or greater neurodevelopmental outcomes. Earlier IUT initiation was correlated with higher neurodevelopmental (Vineland-3) scores (r = -0.72, P = .02). Preterm delivery after IUT was seen in 3/16 (19%) patients who continued their pregnancy. When we combined our data with those from 2 published series, patients who received ≥2 IUTs had better outcomes than those with 0 to 1 IUT, including resolution of hydrops, delivery at ≥34 weeks gestation, and 5-minute appearance, pulse, grimace, activity, and respiration scores ≥7. Neurodevelopmental assessments were normal in 17/18 of the ≥2 IUT vs 5/13 of the 0 to 1 IUT group (OR 2.74; P = .01). Thus, fetal transfusions enable the survival of patients with ATM and normal neurodevelopment, even in those patients presenting with hydrops. Nondirective prenatal counseling for expectant parents should include the option of IUTs.
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Amid A, Barrowman N, Odame I, Kirby-Allen M. Optimizing transfusion therapy for survivors of Haemoglobin Bart's hydrops fetalis syndrome: Defining the targets for haemoglobin-H fraction and "functional" haemoglobin level. Br J Haematol 2022; 197:373-376. [PMID: 35176810 DOI: 10.1111/bjh.18077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 11/29/2022]
Abstract
Owing to the unique pathophysiology of anaemia in haemoglobin Bart's hydrops fetalis (HBHF), a transfusion strategy based on beta-thalassemia guidelines is suboptimal for chronically transfused HBHF patients. A more aggressive transfusion aimed at reducing the proportion of non-functional HbH and improving the "functional" haemoglobin (f-Hb) can lead to reduced haemolysis and improved tissue oxygenation. However, the optimal transfusion targets for these parameters are not yet defined. In this retrospective, longitudinal study on four chronically transfused patients with HBHF, we used receiver operating characteristic curves to find a pre-transfusion f-Hb of 106 g/l and a HbH of 16.1% to be the optimal thresholds to achieve a normal soluble transferrin receptor and lactate dehydrogenase, respectively.
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Affiliation(s)
- Ali Amid
- Division of Hematology/Oncology, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Nick Barrowman
- Division of Biostatistics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Isaac Odame
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Melanie Kirby-Allen
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
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