Talassemia intermedia:

Fisiopatologia e diagnosi

Renzo Galanello e Raffaella Origa

Pediatric Clinic 2-University of Cagliari (Italy)
Ospedale Regionale Microcitemie ASL8

15.02.2013 - Torino
Rete Ematologica PEDIATRICA
Piemonte e Valle d’Aosta
 Thalassemia intermedia:definition

Patients not requiring regular RBC transfusion for survival

Patients requiring sporadic/not regular transfusions as

 disease severity progresses

 clinical complications manifest

 Global distribution of
β-thalassaemia intermedia
Hb Annual
disorder births
β-TM 22,989

β-TI Ill-defined

β-TI occurs at a low and varying frequency in every population with a high
frequency of β-thalassaemia and is particularly common in parts of Africa
where mild β-thalassaemia alleles predominate
Weatherall DJ. Blood. 2010;115:4331-6.
Weatherall DJ. Blood Rev. 2012;26S:S3-6.
 β+γ
globin

alpha
globin

Imbalance Of Globin Chain Synthesis

In Beta Thalassemia

Severity Of Clinical Phenotype

9
 NTDT: diagnosis
Clinical phenotype:
Child older than two years of age with microcytic anemia, mild jaundice and
hepatosplenomegaly.
Hematological phenotype:
Hb >7 < 10 g/dl, MCV > 50 < 80 fl and MCH > 16 < 24 pg.
Morphologic changes [microcytosis, hypochromia, anisocytosis, poikilocytosis
(spiculated tear-drop and elongated cells)],nucleated RBC.
Hemoglobin pattern:

Molecular analysis

Globin chain synthesis analysis: α/β+γ generally less imbalanced than in

thalassemia major
Molecular basis of thalassemia intermedia

Homozygous or compound heterozygous state for β thalassemia

Inheritance of mild β thalassemia alleles
Co-inheritance of α thalassemia
Increased Hb F response
Xmn1 Gγ polymorphism
β globin gene promoter mutations
Trans-acting HPFH genetic determinants
Heterozygous state for β thalassemia
Co-inheritance of excess α globin genes
(ααα/αα, ααα/ααα, αααα/αα)
Dominantly inherited β thalassemia
(Hyperunstable β globin chain variants)

Compound heterozygotes for β thalassemia and β chain variants

e.g. Hb E/ β thalassemia

Compound heterozygotes for β thalassemia and mendelian HPFH or δβ thalassemia

SL Thein
 Famiglia G.

Hb,g/dl 12.7 15.2

MCV,fl 76.8 79.6
HbA2,% - 3.0
α/β - 1.9
−α /−α αα/αααα

Hb,g/dl 15.2 10.8

MCV,fl 85.5 58.0
HbA2,% - 4.4
HbF, % - 11.0
α/β 1.2 2.02 −α/αααα
αα/αα −α/αααα

Hb,g/dl 8.2 8.9

MCV,fl 61.0 64.3
HbA2,% 2.8 2.8 Tratto silente β°39
HbF,% 27.0 30.9 /αααα
α/(β+γ) 4.16 4.04
αααα/αα αααα/αα Mild thal. Intermedia
XmnI -/- +/-
Bcl11A rs1427407 GG GT Severe thal. Intermedia
HBS1L-Myb TT TT
ACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATA
GCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTC
CGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGC

DNA sequence variants

TAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGC
GACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACAC
AGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTA
GCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACA
CACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCG
CACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTG ACCTGACACGTGCTAGCTAGCTCCT

Neutral
CTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACCGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGAT
ATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGAACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGC
TCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGAC
GTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGC
GCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGA
CCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGG
CTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCC
TGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGAC
Predisposing
CTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCG
ATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCAC
ACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTC
GAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATAT
ATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCT
CGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGA
GACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATAT
AGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACA
CCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCG
AGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATA
TAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTC
GAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGT
AGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGACGAGA
CGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAG
CGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAG
ACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGG
GCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCC
CTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCG
CTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGATAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCT
AGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCT
AGCTAGCTCCTCTCGACGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTC
GCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACC
GCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACC
GCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGACGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTC
GAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGA
AACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGA
AACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGACGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGAC
CTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGAC
ACACACAGATATTATAGCTCGCGACACACACAGATATATAGCGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGACGAG
ACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATA
GCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAG ACCTGACCTGACA
CGTGCTAGCTAGCTCCTCTCGAGACGTTATAGCTCGCGACACACACAGATATATAGCGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTA
GCTCCTCTCGACGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGAC
ACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCG
AGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGC
G-WAS looks for differences in SNPs between genomes
ACACCGCTCGAGATAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCT
CGATATAGCTCGCGACACACACAGATATATAGCGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGACGAGACGTAGGGC

to detect variants more common in cases than in controls

TCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCT
GAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGC
TAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGC
TAGCTCCTCTCGACGAGACGTAGGGCTCTCGATATAGCTCGCCTCGCGACACACACAGATATATAGCGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACAC
GTGCTAGCTAGCTCCTCTCGACGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACAC
Pathogenic
AGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTA
GCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACA
CACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCG
CACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCT
CTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGATATATAGCGCTCCCTGAAACAGCTCCGACACAGCTCGCACACCGCTCGAGACCTGACCTGACACGTGCTAGCTAGCTCCTCTCGAGACGTAGGGCTCTCGATATAGCTCGCGACACACACAGA
Hb F variation associated SNPs
Chr 2

Chr 6

rs766432
Chr 11
2p16 rs1427407
BCL11A rs4910742
rs11886868 11p15
HBB rs7482144
rs4671393

rs9399137
6q23
MYB rs4895441

p= 0.018
p= 0.446

p= 9.14e-08
 QTLs map to HBS1L-MYB and BCL11A

11346–11351 PNAS July 3, 2007 vol. 104 no. 27

Genome-wide linkage and association scan results for HbF

Uda M.,Galanello R et al, Proc. Natl. Acad. Sci. USA 105, 1620-1625 (2008)
Sankaran et al,2008
 Bcl11A and HbF

 genetic association detected by G-WAS

 SNPs in IVS2 described in different populations, in HPFH,

beta thalassemia, HbE, SCD
 Bcl11A is a repressor of fetal hemoglobin

 High HbF is associated with low Bcl11A expression

 Bcl11A expression varies at different developmental

stages
 Bcl11A is an essential component of hemoglobin switching
in human and mouse
 1
Allele contribution to the thalassemia phenotype
0,8
Proportion of patients

0,6
Thal. Major
Thal. Inter
0,4

0,2

0
0 1 2 3 4
Number of positive alleles

Ameliorating alleles:

• BCL11A rs 11886868 • - alpha/alpha alpha

• HBS1L-Myb rs 9389268 • -alpha/-alpha

Blood,2009
Survival curves for 316 patients with different combinations of predictors for later and earlier time to transfusion

Fi rs t quartile (patients with more positive

predi ctors combinations)

Second quartile

Thi rd quartile

Fourth quartile (patients with more

nega tive predictors combinations)

Danjou F et al.,2012

Locus p Hazards Ratio Harrell’s C-index Predictor for later transfusion start
HBG2:g.-58C>T <0.001 0.081 0.54 +/-
α gene defects <0.001 0.514 0.61 class 2
rs1427407 <0.001 2.391 T allele
BCL11A 0.63
rs10189857 0.005 1.312 G allele
rs4895441 <0.001 1.979 G allele
HBS1L/MYB 0.57
rs6904897 0.020 0.697 TT genotype
Gender 0.016 0.738 0.52 Male
 Extended genotype and starting of
transfusion therapy

Patient: A Patient: B
beta globin genotype β 39 / β 39 β 39 / β 39
alpha globin genotype -α/ α α -α/ α α
Xmn1 Gγ +/- -/-
Bcl11A rs 11886868 T/C T/T
HBS1L-MYB rs 9399137 T/T T/T
12 months 5 months
not transfused first transfusion
Hb 9.2 g/d Pre tfx Hb=7.1 g/dl
Thalassemia intermedia:physiopathology

Rivella S et al, Blood Reviews 2012;

Schematic representation of normal and
ineffective erythropoiesis.

Ginzburg Y , Rivella S Blood 2011;

The Janus Kinase 2- STAT5 pathway

Patnaik et al, Leukemia 2009;

Thalassemia intermedia:physiopathology

Rivella S et al, Blood Reviews 2012;

JAK inhibitors: beyond spleen and symptoms?
 Mechanism of iron overload in
non-transfused patients
Ineffective erythropoiesis

Chronic anaemia

Hypoxia

↑ HIFs ↑ GDF15

↑ Release of
recycled iron
↑ Erythropoietin ↓ Hepcidin from RES
macrophages

↑ Ferroportin ↑ Duodenal iron ↑ LIC

absorption
↓
Serum
ferritin
GDF15 = growth differentiation factor 15; HIF = hypoxia-inducible transcription factor;
LIC = liver iron concentration; RES = reticulo-endothelial system. Taher A, et al. Br J Haematol. 2011;152:512-23.
 1000

2007

hepcidin (ng/mg creatinine)

100

10

TI TM controls
2008

Hb Serum ferritin LIC Cardiac T2*

Age (years) (g/dL) (μg/L) (ng Fe/g dry wt) (ms)

Mean ± SD
8.8 ± 1.3 558 ± 697 5.6 ± 7.8 43 ± 6.3
37.2 ± 10
Ineffective erythropoiesis and hepcidin regulation in
β-thalassemia

Bone marrow
GdF15 in human blood Twsg1 mRNA in murine thalassemia

Twsg1

(Chou St et al, 2007; Tanno T et al, 2009

 Jak2 is required for hepcidin-mediated
Ferroportin internalization.

De Domenico I et al. PNAS 2009;106:3800-3805

Stat5 regulates cellular iron uptake of erythroid cells
via IRP-2 and TfR-1

Kerenji et al. Blood 2008

 Pathophysiology of NTDT vs clinical sequelae

Disrupted α:β globin ratio

Ineffective erythropoiesis Hemolysis

Gut iron absorption

Anaemia
Iron and free radicals
Diabetes mellitus
Growth hormone deficiency Tissue oxygenation
Hypothyroidism
Hypoparathyroidism Erythroid marrow expansion
Hypogonadism
HCC ● “Flip-flop” phenomenon
Renal dysfunction ● Depletion of proteins C and D
● Red cell degenerative products

1. Leg ulcers 1. Facial deformities 1. Hepatosplenomegaly

2. Thrombotic events 2. Osteopenia and jaundice

1. Pulmonary hypertension
2. Congestive heart failure

APOEε4 VDR, OesR, COL1A1 UGT1A1

HCC = hepatocellular carcinoma. Modified from Taher A, et al. Blood Cells Mol Dis. 2006;37:12-20.

Peripheral
blood elements
•Expression of endothelial
adhesion molecules and tissue
factor on endothelial cells
•Formation of microparticles
Nitric oxide
•Hallmark of haemolysis
•↓ Levels leading to vasoconstriction RBCs
• Formation of reactive
oxygen species
•Expression of negatively
charged phospholipids
•Enhanced cohesiveness
and aggregability

Platelets Hypercoagulability Thrombophilia

•Increased platelet aggregation •No role for prothrombotic
•Increased expression of mutations
activation markers •Decreased levels of antithrombin III,
•Presence of platelet protein C, and protein S
morphologic abnormalities •Anti-phospholipid antibodies

Other factors Splenectomy

•Cardiac dysfunction •High platelet counts and
•Hepatic dysfunction hyperactivity
•Endocrine dysfunction •High levels of negatively charged
RBCs

Cappellini MD, et al. Ann N Y Acad Sci 2010;1202:231-6.