CARDIAC DISEASE Cardiac hemosiderosis, resulting in arrhythmias, cardiomyopathy, and congestive heart failure, is the most serious (often

life-threatening) complication faced by thalassemia patients. Arrhythmias are most often supraventricular (premature atrial or ventricular contractions or paroxysmal atrial tachycardia), but ventricular tachycardia also is seen. Arrhythmias unresponsive to digitalization, including those of ventricular origin, have responded to such anti-arrhythmic medications as quinidine, disopyramide, phenytoin, procainamide, and mexiletine. Severe congestive heart failure unresponsive to digitalis and diuretics may be treated with vasodilating agents to reduce afterboad and improve cardiac reserve. Prenatal Diagnosis of Thalassemia Currently, the simple screening methods for thalassemia trait (Table 2), genetic counseling, and prenatal diagnosis allow couples at risk to make an informed choice to have children. Screening should be encouraged for children and families of Mediterranean, Asiatic Indian, Southeast Asian, Chinese, and African origin. In the United States, most children are born with thalassemia major to parents who were unaware of their risk, in contrast to many countries in Europe and Asia where widespread screening, counseling, and prenatal diagnostic programs have developed. During the past decade, safe and accurate prenatal diagnosis has been available. Prenatal diagnosis was first performed in the mid-1970s using fetoscopy to obtain a fetal blood sampie and to measure the alpha-to-beta globin chain ratios. Current prenatal diagnostic methods include cordocentesis, ubtrasonographically directed percutaneous umbilical cord sampling for alpha-tobeta chain ratio diagnosis, or DNA analysis obtained from amniotic fluid cells at 16 weeks gestation or from the chorionic villus at 8 to 12 weeks of gestation. Identification of the specific type of DNA defect causing beta thalassemia can be accomplished in only 90% of atrisk pregnancies because the specific DNA defects may not be identifiable within every family. A small risk of induced abortion is present for cordocentesis and fetoscopy (2% to <5%), amniocentesis ( < 1%), and chorionic vilius sampling ( <4%). In countries where a high frequency of beta thalassemia presents a major public health problem, intensive programs of screening, counseling, and prenatal diagnosis have developed. Voluntary terminations of affected pregnancies have brought about a major decrease in births of affected children in certain regions of the Mediterranean and Asia. In Sardinia, Italy, where a national prevention program has been in effect since 1975, the incidence of the homozygous state has decreased from 1/250 live births to 1/1000 live births. Because of the development of comprehensive preventive programs, the birth rate of homozygous infants has been reduced by 90% in Greece and by 97% in Cyprus. Downloaded from http://pedsinreview.aappublications.org/ at Indonesia:AAP Sponsored on October 13, 2012 Tabel 2. ScreenIng for Thalauemla If mean corpuscular volume is less than 80 p.m3 [80 IL] in the adult or less

than normal for age, perform a hemoglobin electrophoresis and evaluate iron stores. If patient is iron-deficient, correct the iron deficiency and repeat the hemoglobin electrophoresis. If patient's hemoglobin A2 or fetal hemoglobin levels are elevated, diagnose a beta thalassemia disorder; if hemoglobin A2 level is low or normal, assume an alpha thalassemia disorder. Genetic counseling should be provided for all individuals identified as having the trait. Couples at increased risk for transmitting the trait should be made aware of the possibility of prenatal diagnosis to allow them to make an informed choice concerning the current and future pregnancies. Pediatrics in Review VoL 13 No. 2 February 1992 61 HEMATOLOGY Thalassemla Molecular Biology of Beta Thalassemla The genes controlling the formation of alpha globin chains are located on chromosome number 16. Those controlling for beta, delta, and gamma gbobin chains are on chromosome number 11. There are two fully functional and nearly identical alpha and gamma genes on each chromosome, reflecting their duplication during evolution. There are only two functional beta genes in each human diploid erythroid cell. The majority of the thalassemia phenotypes are caused by defective beta globin genes that produce little (beta) or no (beta#{176b}e)ta globin chains or by unstable or abnormal globin chains. A wide spectrum of the beta thalassemia mutations have been described in a number of population groups. The mutations are usually specific to a given ethnic group. Because so many mutations are found in each ethnic group, most individuals who have beta thalassemia carry two different point mutations, called genetic compounds; few are true homozygotes, who carry the two identical mutations. To date, 91 point mutations that are responsible for the phenotypic diversity of the beta thalassemia disorders have been identified inside and outside the beta globin chain region. These mutations may affect either the processing or normal coding capacity of mRNA at all levels of activation, initiation, transcription (cap site mutations), processing, splicing, cleavage (polyadenylations mutations), translation, and termination. A few deletional mutations also have been described, the most common of which is

at the 3' portion of the beta globin gene and its adjacent sequences found in individuals of Indian ancestry. Deletions of both the delta and beta globin genes give rise to hereditary persistance of fetalhemoglobin and delta-beta thalassemia. CLINICAL AND GENETIC HETEROGENEITY The clinical heterogeneity of the thaiassemia patient is based in part on the diversity of specific mutations and their variable effect on mRNA and gbobin production. It is now recognized that a spectrum of beta thaiassemia genes exists, varying in severity from the silent carrier gene to that which produces thalassemia intermedia in the heterozygous state. Some individuals produce no beta globin chains (beta#{176w})hile others produce quantitatively variable amounts (beta). Individuals homozygous for specific point mutations that produce beta#{17t6h}alassemia will have severe disease as will those homozygous for mutations that produce markedly decreased beta gbbin production. In contrast, an individual homozygous for a mild mutation will have the thalassemia intermedia phenotype. The intermedia phenotype also may result from a severe gene mutation in the heterozygous state. Masa Depan Prospek GENE ThERAPY Advances in molecular biology have raised the prospect of treating thalassemia by introducing normal functional copies of gene into the cells of affected individuals. The insertion of normal globin genes into bone marrow stem cells of thalassemic individuals offers the possibility of cure. Currently, the transfer of genes into tissue culture cells is a routine procedure. Early work in gene transfer involved the use of cloned genes into the pronucleus of a fertilized mouse egg. The transgenic mouse experiments are an important functional approach to observe the effect of specific DNA sequences on the developmental expression of genes. Lines of mice have been developed that express both human gamma and beta gbobin gene production of fetal and adult hemoglobin. Currently, investigations using the transgenic mouse model focus on the study of globin gene regulations, the mechanism of gene switching during development, and the gene expression. One of these is the recognition of irnportant enhancer sequences (locus control or activating regions) 5 ' to the embryonic globin gene, which control a very high expression of human gbobin genes. Significant work is being conducted to accomplish gene transfer into the hernatopoietic pluripotential stem cell using retrovirus infection. Various investigators are studying the effect of pharmacologic pretreatment protocols and the use of hernatopoietic growth factors before and/or during retroviral infection to enhance the efficacy of gene transfer. It is currently possible to infect reconstituting mice hematopoietic stem cells and obscure long-term expression of the transduced gene in myeboid and lymphoid progeny of the stem cell. However, the efficacy of the retromediated gene transfer must be improved before it can be considered a feasible therapeutic strategy. ORAL IRON CHELATION DFO is an extremely efficient chelator with minimal toxicity, and its regular use has reduced the morbidity and mortality associated with transfusional iron overload in thalassemia patients.

Unfortunately, it is not absorbed orally and must be administered parenterally. Despite the beneficial effects of DFO for some patients, daily subcutaneous administration over a prolonged period is cumbersome and difficult to tolerate. During the past decade, an extensive search for an effective and safe oral iron chelator has been underway. Several promising compounds that can be administered orally have been identified. These compounds may prove to be extremely effective, and trials for chronic animal toxicity testing must proceed. If dose-related toxicity is identified, it is feasible that cautious and carefully controlled clinical trials may demonstrate safety and efficacy. ENHANCED FETAL HEMOGLOBINPRODUCTION Various pharmacologic agents have been identified that are capable of increasing fetal hemoglobin production. However, their efficacy in thalassemia has not been promising. During 1985, 5-azacytidine (AZT) was shown to increase fetal hemoglobin production in baboons, and further studies in human trials had similar results. To date, AZT, hydroxyurea, cytosine arabinoside, busulfan, and butyric acid analogs each have been studied in animals or patients who have thalassemia. An understanding of the mechanisms that enhance fetal globin production remains speculative, although the demethylation of gamma genes by AZT may play a role. Short-term studies in two thalassemic individuals showed that AZT increased the reticulocyte count and maintained a higher-than-anticipated hemoglobin level; prolonged treatment was unsuccessful, however. Cytotoxic cornpounds may accelerate erythropoiesis secondary to cytoreduction. In short courses of treatment of two additional patients with hydroxyurea, no significant improvement in reticubocyte count or hemoglobin level was achieved. However, two patients treated with busulfan had a prolonged improvement in hemoglobin levels. Further studies using combinations of pharmacologic agents are being studied in patients who have sickle cell anemia. The success of these studies may readdress the use of pharmacologic enhancement of fetal hemoglobin in thalassemia. Ringkasan Many advances in the understanding and management of the thalassmia syndromes have been made during the past several years. Our knowledge of normal globin gene function and of the consequences of specific mutations has been advanced by identification of the genetic defects causing thalassemia. Prenatal diagnosis is now possible with molecular biology technology. Standards have been established for transfusion, splenectomy, prevention of postsplenectomy infection, and effective iron chelation therapy. Bone marrow transplantation is now available for those with a compatible I familial donor. Research efforts currently are directed toward safer blood products, oral iron chelators, and improved understanding of the developmental regulation of gbobin gene expression for effective gene transfer.