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Thalassemia: Diagnosis and Treatment
Kittti Torcharus, M.D.
Department of Pediatrics
Phramongkutklao Hospital
Scope of lecture
Incidence
Diagnosis
Blood transfusion
Iron chelation
Treatment related complications
Hematopoietic stem cell transplantation
Preimplantation genetic diagnosis (PGD)
Survival
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Prevalence of Thalassemia in The world
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MARCH OF DIMES GLOBAL REPORT ON BIRTH DEFECTS; 2006
Prevalence of thalassemia in Thailand
Alpha-thalassemia (%) a-thalassemia 1 Bangkok 3.5
Chiangmai 12.0 a-thalassemia 2 Bangkok 16.0 Chiangmai 19.0
Beta-thalassemia Bangkok 3.0 Chiangmai 9.0
Northeast 2-6 Hemoglobin E Bangkok 13-19
Chiangmai 8.0 Northeast 32-60
Hemoglobin Constant Spring 2-4
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Prevalence of thalassemia and hemoglobinopathies
11/23/2017 Kitti Torcharus, M.D. 5 Wongprachum K, et al. Acta Haematol. 2016;135(2):65-9.
Classification: Clinical severity
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Severity Clinical Hb (g/dL)
Type
Severe Age onset of anemia < 2 yrs, Age at first blood transfusion < 4 yrs, Weight & Height lower than normal, Facial bone change, Huge splenomegaly
< 7 Homo. b0-thal (b0/b0, b0/b+), b0-thal/Hb E, surviving Hb Bart’s hydrops, Non-deletional Hb H
Moderate Anemia, jaundice, hepatomegaly, splenomegaly
7-9 Homo. b0-thal (b0/b+), b0-thal/Hb E,
Mild Anemia, jaundice, mild splenomegaly >9 Homo. B+-thal (b+/b+), b+-thal/Hb E, Hb H
Asymptomatic No symptoms normal Thal trait, Hb E trait, Homo Hb E
Transfusion-dependent thalassemia (TDT)
Severe type (Clinical severity)
Require regular transfusion with iron chelation
Maintain Hb level 9.5-10.5 g/dL
Thalassemia type: Homo. b0-thal (b0/b+, b0/b+)
b0-thal/Hb E,
Hb Bart’s hydrops fetalis (surviving)
Non-deletional Hb H
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Non-transfusion-dependent thalassemia (NTDT)
Moderate-mild type (Clinical severity)
Age onset at diagnosis 2-6 yrs.
Steady-state Hb level 7-10 g/dL
Develop anemia or hemolytic crisis after infection which may require blood transfusion (occasional transfusion)
Thalassemia types: b-thalassemia intermedia (b0/b+, b+/b+),
b-thalassemia/Hb E, (b0/bE, b+/bE) Hb H disease
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Clinical severity: severe thalassemia
Hb Bart’s hydrops fetalis Genotype: a-thal 1/a-thal 1
Hydrops, severe anemia
Dead in utero or after birth
Homozygous b0-thalassemia Genotype: b0-thal/b0-thal
Transfusion dependent
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Clinical severity: moderate to severe thalassemia (Anemia, jaundice, occasional require blood transfusion)
b-thalassemia/ Hb E
Genotype: b0-thal/bE
Hb H with Hb CS
Genotype: a-thal 1/Hb CS
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Mild thalassemia (Anemia, jaundice, not require blood transfusion)
b-thalassemia/ Hb E
Genotype: b+-thal/bE
Hb H disease Genotype: a-thal 1/a-thal 2
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Hemolytic crisis in Hb H
Symptoms Fever, pallor, jaundice
Dark urine
Hepato-splenomegaly
Etiology (infection) Influenza, typhoid,
malaria, Dengue hemorrhagic fever
Treatment Treat infection
PRC transfusion
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Diagnosis: thalassemia disease
CBC : anemia
Red cell indicies
MCV <80 fL, MCH < 27 pg, RDW > 16%
Blood smear: red cell morphology
Hypochromic, microcytic, anisocytosis, poikilocytosis, target cell
Reticulocytosis
Inclusion bodies
Hb H disease
Hb typing (Hb analysis)
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Inclusion bodies Reticulocyte
Blood Smear of thalassemia disease
Hb H disease Hypochromic
Microcytic
Anisocytosis (varied size RBC)
Poikilocytosis (varied RBC morphology)
Beta-thalassemia/Hb E Anisocytosis (varied size RBC)
Poikilocytosis (varied RBC morphology)
Nucleated red cell (NRC)
Target cells
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Diagnosis: thalassemia trait
Carrier screening:
Complete blood count: red cell indicies
MCV < 80 fL, MCH < 27 pg
One tube osmotic fragility (OF) test
Positive: b-thal trait, a-thal 1 trait, Iron deficiency
Dichlorophenolindophenol (DCIP) precipitation test
Positive: Hb E trait, homo. Hb E
Hb E screen test
Positive: Hb E trait, homo. Hb E
Confirmation tests: Hemoglobin typing (HPLC, LPLC, CE)
b-thal trait, Hb E, CS, Pakse, thal. disease (NTDT), etc.
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Hb type: Criteria for diagnosis (I) Conditions Hb type
Normal A2 A ( A2 2.5-3.5% )
a-thal 1 trait A2 A ( A2 2.5-3.5% )*
a-thal 2 trait A2 A ( A2 2.5-3.5% )*
b-thal trait A2 A ( A2 > 3.5% )
Hb E trait EA ( E= 25- 35 % )
Hb E homozygous EE ( E >85% )
Hb CS trait CS A2 A ( CS 1-2 % )
Hb CS homozygous CS A2 A ( CS 3-6% )
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*Can not diagnose by Hb type
*Diagnose by PCR for a-thal 1 trait and a-thal 2 trait respectively
Hb type: Criteria for diagnosis (I)
Conditions Hb type
Hb Barts’ hydrops Portland, Barts’
Hb H disease A2 A H Barts’
Hb H with Hb CS CS A2 A H Barts
Hb AEBarts’ disease A E Barts’
Homozygous b-thal A2 F
b-thal / Hb E EF
Hb CS trait CS A2 A ( CS 1-2 % )
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Molecular Diagnosis (cont.) a-thalassemia:(Gap-PCR)
a-thal 1 trait (aa/- -SEA, aa/- -Thai)
a-thal 2 trait (aa/ - a3.7, aa/- a4.2)
Hb CS trait (aa/aCSa), Hb Pakse trait (aa/aPsa)
b-thalssemia:(ARMS-PCR*, RDB**, Gap-PCR, DNA sequencing)
b0-thalassemia:
CD 41/42(A>T), CD 17 (A>T), CD 35(C>A), IVS 1-1 (G>T), CD 71/72(A>T), etc.
b+-thalassemia:
IVS 1-5 (G>C), IVS 2-654 (C>T), CD 19(A>G), -28 (A>G), CD 26, etc.
db-thalassemia
HPFH: HPFH-6, etc.
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*Amplification refractory mutation system, **Reverse dot-blot hybridization
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Screening and diagnostic algorithm for thalassemia and hemoglobinopathies
OF+DCIP or MCV+DCIP
Non-thalassemia, Non clinical significant thalassemia
Hb typing:
A2A (A2<3.5%) Suspected a-thal trait
A2A (A2>3.5%) b-thal trait
EA (E=25-35%) Hb E trait
EA (E < 25%) Hb E trait
With/without a-thal trait
EE (E > 85%) Homo. Hb E
With/without a-thal trait
Thalassemia disease (NTDT) a-thal: Hb H disease, etc. b-thal: b+-thal/Hb E, etc. db-thal: db-thal, HPFH, etc.
PCR for a-thal 1: a-thal 1 trait
- /- + /- or - / + or + / +
1. Screening
2. Confirmation
3. Confirmation
Management Strategy
Proper treatment of existing patients
Best patient care and management
Blood transfusion: Hyper transfusion regimen
Iron chelation
Treatment of complications Bone marrow transplantation
Prevention of the disease
Genetics counseling
Screening of thalassemia trait Prenatal diagnosis
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Blood transfusion
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Recommended: leucoreduced < 1x 106
Leucocyte depleted packed red cell (LDPRC)
Leucocyte poor packed red cell (LPRC)
• Before first transfusion: antigen typing: C, c, E, e, Mia
Indication for blood transfusion
Homo. b-thalassemia(TDT)
Definite diagnosis
Hb < 7 g/dL or
Hb > 7 g/dL with Facial change
Poor growth
Fracture
Extramedullary hematopoiesis
NTDT
Growth failure
Poor performance at school
Pregnancy, infection
Symptomatic anemia
Congestive heart failure
Pulmonary hypertension
Leg ulcers
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Taher A, Blood Cells Mol Dis. 2006;37(1):12-20. Cappellini D, ed. TIF Guidelines : 2007 p. 18-30.
Immune-mediated transfusions-reactions and reported frequencies
Acute Frequency
Febrile non-hemolytic 1/100
Allergic (urticarial) 1/100
Hemolytic (intravascular) 1/25,00
Transfusion –related acute lung injury (TRALI) 1/10,000
Anaphylactic 1/50,000
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Delayed frequency
Alloimmune 1/100
Hemolytic (extravascular) 1/2,500
Garft vs Host Disease Rare
Iron chelator Iron chelator Administration
Deferoxamine (DFO), 500 mg/vial
40-60 mg/kg/day, subcutaneous infusion 8-10 hour by infusion pump
Deferiprone (L1), 500 mg/tab
75-100 mg/kg/day
Deferasirox (DFX) , 500 mg/tab
20-30 mg/kg/day
Iron chelation Indication:
Received PRC >10-20 units
Serum ferritin > 1,000 ng/mL
First line:
Deferoxamine (DFO) 40-60 mg/kg/day, sc.
Second line:
Deferiprone (L1) 75-100 mg/kg/day, oral
Deferasirox (DFX) 20-30 mg/kg/day, oral
Combination therapy:
L1: 80-100 mg/kg/day + DFO: 40-60 mg/kg 3-5 days/wk
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Kontoghiorghes GJ. Hemoglobin. 2009;33(5):332-8
Assessment and thresholds of iron overload
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Assessment Normal Mild Moderate Severe
Ferritin (ng/ml)1 30-300 > 1,000 1,000-2,500 > 2,500
LIC (mg Fe/g dw)2 < 1.2 2 to <7 7 to < 15 > 15
MRI(T2*)mg Fe/g dw3 < 1.8 1.8 to 7 7 to <15 >15
CMR, T2*(ms)4 > 20 <20 to 10 < 10 - 5 < 5
1Olivieri NF, N Engl J Med. 1994 ;331(9):574-8
3CPG, Diagnosis & management.of thalassemia syndromes 2014:26-31
LIC=Liver Iron Concentration MRI = Magnetic resonance imaging CMR =Cardiovascular Magnetic resonance
4Wood JC. Hematology Am Soc Hematol Educ Program. 2011;2011:443-50.
2Angelucci E, N Engl J Med. 2000;343(5):327-31
Iron Chelator: Properties Property Deferoxamine Deferiprone Deferasirox
Usual dose (mg/kg/day)
25-60 75-100 20-40
Route Sc, iv (8-12 hr, 5 days/week)
Oral 3 times dialy
Oral Once daily
Half-life 20-30 min 3-4 hr 8-16 hr
Excretion Urinary, fecal Urinary fecal
Main adverse effects
Local reaction, Ophthalmologic, auditory, growth retardation, allergy
Gastrointestinal disturbances, agranulocytosis, neutropenia, arthralgia, elevated liver enzymes
Gastrointestinal disturbances, rash, mild non-progressive creatinine increase, elevated liver enzymes, Ophthalmologic, auditory
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Emergency therapy: Intravenous deferoxamine
Indications:
Severe hemosiderosis & vital organ dysfunction
Cardiac arrhythmia, left-ventricular ejection fraction (LVEF) < 56%
LIC > 15 mg/g dw, cardiac T2* < 10 ms
Deferoxamine:
Dose 50-60 mg/kg/day, iv. dirp 24 hr. 5-6 days per wk
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Post-transfusion Hypertension, Convulsion, and Cerebral hemorrhage (HCC syndrome)
HCC syndrome Multiple blood
transfusion
Headache
Hypertension
Convulsion
Cerebral hemorrhage
Prevention: furosemide 1
mg/kg/dose
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Splenectomy
Indications: Increased blood requirement (200-220 ml/kg/yr)
Hypersplenism (cytopenia)
Symptomatic splenomegaly (massive splenomegaly)
Vaccine Pneumococcal vac.: 2 wk. before; 3-5 yr. after Splenectomy
Influenza vac.: annually
Penicillin prophylaxis 125 mg bid (<5 yr); 250 mg bid (>5yr) for 2 yr
ASA: 2-5 mg/kg if platelets > 800,000 /cu.mm.
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Splenectomy adverse events
Peri-operative complications:
Bleeding, atelectasis, subphrenic abscess
Post-operative:
Overwhelming post-splenectomy infection (OPSI)*
Streptococcus pneumoniae, Haemophilus influenzae type b, Neisseria meninggitidisEscherichia coli, Pseudomonas aeruginosa, Salmonella sp., Klebsiella sp.
Thrombosis
Hypercoagulability
Pulmonary hypertension
Iron overload
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*Mortality rate 50-70%, death occurs within 24 hr
Treatment related complications
Chronic HBV infection
Serum HBsAg (+ve), HBeAg (–ve), anti HBe Ab (+ve)
HBV viral load> 2,000 IU/ml, ALT > 80 IU
Chronic HCV infection
Anti HCV (+ve), HCV-RNA virus, ALT > 80 IU
Diabetes mellitus
Fasting glucose > 126 mg/dl
Oral glucose tolerance test (2 hr) >200 mg/dl
Gall stone (asymptomatic, 60-80%)
Biliary colic, common bile duct stone, ascending cholangitis, acute cholecystitis
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Hematopoietic stem cell transplantation (HSCT)
Indication:
Thalassemia major (transfusion dependent thalassemia)
homozygous b-thalassemia
b-thalassemia/ Hb E (severe)
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Source of hematopoietic stem cell
1. Bone marrow
2. Peripheral blood
3. Cord blood
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1 3
2
Hematopoietic stem cell transplantation (HSCT)
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2.Transfusion of stem cell
4.Post HSCT 3.During HSCT
1.Conditoning chemo. therapy
Overall survival, thalassemia-free survival, non-rejection mortality and rejection for class 1 patients younger than 17 yrs
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Gaziev J, Lucarelli G. Curr Stem Cell Res Ther. 2011;6(2):162-9
HSCT: Thai (1988-2011)
HSCT N (%) Cure (%) Alive with disease
Death
Related 190 (74.5) 165 (88.6) 9(4.7) 16 (8.5)
Unrelated 65 (25.5) 50 (76.9) 6 (9.2) 9 (13.8)
Total 255 (100) 215 (84.3) 15 (5.9) 25 (9.8)
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HSCT=Hematopoietic stem cell transplantation
HSCT in Department of Pediatrics, PMK
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Lymphoma 33%
AML 26%
ALL 7%
Thalassemia 26%
Aplastic anemia 4%
Nuroblastoma 4%
HSCT in Department of Pediatrics, PMK
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Comparison of life expectancy for patients who were alive at the beginning of 1970, 1980, 1990 and 2000
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Modell B, et al. J Cardiovasc Magn Reson. 2008;10:42
Preimplantation genetic diagnosis (PGD)
Selection of unaffected embryos prior to establishment of pregnancy
Start a pregnancy with a disease free baby
Avoid termination of an affected pregnancy
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Proposed schema of gene therapy for β-thalassaemia
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Yannaki E, et al.Expert Rev Mol Med. 2010;12:e31
National thalassemia guidelines: Clinical practice guidelines for diagnosis and management of
thalassemia syndromes & Care of thalassemia patients
1st edition: 2006
2nd edition: 2014
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1st edition: 2017
Summary • Thalassemia is public health problems in ASEAN
Thailand and LAO PDR (high prevalence, similar genotype-phenotype)
Definite diagnosis, Clinical Practice Guideline, Standard of care
Management Strategy Proper management of existing patients and prevention of new
cases
Life-long survival Early blood transfusion Efficacy and effectiveness of iron chelation HSCT
New treatment: Preimplantation genetic diagnosis & HLA type Gene therapy: “the beginning of a new era of thalassemia”
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Thank you for your attention
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