seminar on Thalassemia by Dr. habib Dr. mehadi Dr. asad

1. Welcome to Seminar
Dr. Habibur Rahman Bhuiyan
Dr. Mehadi Hasan
Dr. Asaduzzaman
Residents year 1, Neonatology

2. Case scenario
 Sajib, a 8 years old boy of consanguineous parents presented with
complaints of not growing well, gradual pallor & abdominal distension for
4 years.
 On examination he was severely pale; facial dysmorphism &
hepatosplenomegaly were present. He had history of repeated blood
transfusion.

3. Diagnosis
Hereditary hemolytic anemia

4. Seminar on
Thalassemia

5. Introduction
"Thalassemia" is a Greek term derived from “Thalassa”, which
means "the sea" and “Emia” means "related to blood.“
It was coined because the condition called "Mediterranean
anemia" was first described in people
of Mediterranean ethnicities.

6. History
in 1925 Prof. Thomas Benton Cooley
observed in some children that severe
anemia combined with massive
hepatosplenomegaly, bone deformities
and severe growth retardation. He
named this disorder "erythroblastic
anemia," but it became popularly known
as Cooley's anemia.
The word thalassemia was first used in
1932 by Dr. Whipple and Dr. Bradford
from University of Rochester. Prof. Thomas Benton Cooley

7. Epidemiology
World:
• Beta thalassemia trait: 8%
of population
• More than 100 million
carriers
• Hb E: 53 million
Bangladesh:
• Beta thalassemia trait:
4.1%
• Hb E trait: 6.1%
• Hb E Beta thalassemia-
10.2%
(Source: DSH Thalassemia center)

9. 
 

HbA
98%
HbA2
<3.5%
HbF
~1%








Hemoglobin in normal adult

10. Site of synthesis of globin

11. Normal hemoglobin component
Hb type Name Components
Adult A α2β2
A2 α2δ2
Fetal F α2γ2
Embryonic Portland ξ2γ2
Gower 1 ξ2ε2
Gower 2 α2ε2

12. Inheritance
•Autosomal
recessive

13. Types of thalassemia
α Thalassemia
β Thalassemia

14. •Transfusion dependent thalassemia
- β-Thalassemia major
- Hb E - β-Thalassemia (severe)
•Non transfusion dependent thalassemia
- β-Thalassemia intermedia
- β-Thalassemia trait
- Hb E - β-Thalassemia (mild ,moderate)
- Alpha-Thalassemia intermedia(HbH disease)
- Hb E disease
- Hb E trait
- Alpha-Thalassemia carrier

15. α Thalassemia
• The two α chains in HbA are
encoded by an identical pair
of α-globin genes on
chromosome 16.
• The α-thalassemias are
caused by inherited
deletions that result in
reduced or absent synthesis
of α-globin chains.

16. Clinical syndromes
Clinical Syndromes Genotype Clinical Features
Silent carrier −/α α/α
Asymptomatic; no red cell
abnormality Mainly gene
deletions
α-Thalassemia trait
−/− α/α
−/α −/α
Asymptomatic, like β-
thalassemia minor
HbH disease −/− −/α
Severe; resembles β-
thalassemia intermedia
Hydrops fetalis
(Hb Barts)
−/− −/−
Lethal in utero without
transfusions

17. Diagnosis of α-Thalassemia
CBC:
• Silent Carrier: no microcytosis , no anaemia.
• α-Thalassemia trait: microcytosis, hypochromia, mild anaemia.
• Hb H disease: variable severity of anaemia & hemolysis.
PBF: Hb H inclusion body (brilliant cresyl blue) in Hb H disease.

18. Hb electrophoresis –
Hb H:
• (2-40%) Hb H
• others Hb A
• Hb F & Hb A2
Hb Bart's:
• (80-90%) Bart's,
• no Hb A, Hb F, Hb
A2
Diagnosis of α-thalassemia
Hydrops fetalis

19. β-Thalassemia

20. Single pair of β-globin genes
(chromosome 11).
Point mutations cause deficient
synthesis of β-globin.
 This leads to:
 hemoglobin deficiency from reduced β-
globin synthesis
 Relative excess of a globin which
precipitate within red cell precursors,
causing membrane damage and
apoptosis.
β-Thalassemia

21. With a mutation on one of the 2 beta globin genes ,
a carrier is formed with lower protein production
but enough hemoglobin
Without a mutation enough
hemoglobin
No
carrier
With one mutation
less hemoglobin
Beta thalassemia
carrier but less
hemoglobin
Slight anemia
With two mutation
No beta globin
Beta
thalassemia
major pt with
severe anemia
Gene from father
Gene from mother
Chromosome 11 gene defects

23. An absence or deficiency of β-
chain synthesis of adult HbAg
Pathophysiology of β-thalassemia
β Chain synthesis Hb-A
α , γ and δ chain
Hb A = α2β2

24. Pathophysiology of β-thalassemia

25. The causative mutations fall into two categories:
• β0 mutations, associated with absent β-globin synthesis, and
• β+ mutations, characterized by reduced (but detectable) β-
globin synthesis.
Pathogenesis

27. Clinical syndromes
Clinical
Syndromes
Genotype Clinical Features
β-Thalassemia
major
Homozygous
β-thalassemia (β0/β0, β+/β+,
β0/β+)
Severe; clinical course is brief
without regular blood transfusions.
β-Thalassemia
intermedia
Variable (β0/β+, β+/β+, β0/β,
β+/β)
Severe but does not require regular
blood transfusions
β-Thalassemia
minor
Heterozygous
β-thalassemia (β0/β, β+/β)
Asymptomatic with mild or absent
anemia; red cell abnormalities seen

28. Hb E β-Thalassemia
• Most prevalent thalassemia variant in Southeast Asia &
Bangladesh.
• Double heterozygous state.
• β thalassemia: reduced synthesis of β chain.
• Hemoglobin E: Lysine substitutes glutamic acid in 26th position
in the β chain. Divided into mild, moderate & severe form with
clinical features varying from thalassemia intermedia to
thalassemia major

29. Types Sign & symptom
Mild
Asymptomatic
Hb 9 -12 gm/dl
Requires no treatment.
Moderately severe
Majority of patient are in this group
Hb 6 -7 gm/dl
Resembles thalassemia intermedia.
Severe
Clinical manifestations resemble
Thalassemia major (severe anaemia,
growth retardation, hepatosplenomegaly,
skeletal deformities).
Hb: 4-5 gm/dl
Treated as thalassemia major.
Variants of Hb E β-thalassemia

30. NEXT

31. • Severe Anemia
• Thalassemic facies
• Hepatosplenomegaly
• Growth retardation, etc
• Symptoms of anemia
• +ve family history
• H/0 blood transfusion
• FTT
approach to diagnosis

32. • Is there progressive pallor?
• Profound weakness, fatigue
• Poor appetite, lethargy.
• H/O jaundice
• Time of 1st transfusion
• Gradual abdominal swelling
• Family H/O same kind of illness
• H/O sibling death
• Consanguinity; Leg ulcer etc
History

33. Infant:
Age at presentation : 6-9 month ( Hb F replaced by HbA)
progressive pallor
cardiac failure
Failure to thrive , gross motor delay
Feeding problems
Bouts of fever & diarrhea
Hepatosplenomegaly
Clinical Features ( Thalassemia Major)

34. By childhood:
Growth retardation
severe anemia- cardiac dialatation
Transfusion dependent
Icterus
Changes in skeletal system
Clinical Features ( Thalassemia Major)

35. • Age of onset: usually 2-6 years but Patient may be symptomless until
adult.
• Varying degree of pallor,
• Hepato-splenomegaly and
• bony change.
• Less transfusion dependent
• Longer survival than thalassemia major
Clinical Features ( Thalassemia
Intermedia)

36. • Usually asymptomatic.
• Incidental finding or during family analysis.
• May present as Fe deficiency anemia
• Unresponsive/ refractory to iron therapy
• Normal life expectancy
Clinical Features ( Thalassemia Minor)

37. Thalassemia Major
Child with no transfusion
or inadequate
transfusion
Child with regular blood
transfusion but no
chelation
Child with regular blood
transfusion & chelation
Leads natural course of
disease, may die within 5
yrs of age
Manifestation of iron
overload at the end of
1st decade
May enter into normal
puberty & have normal
life expectancy
Natural course

38. Clinical features
General features
• Weakness
• Gradual Pallor
• Fatigue
• Dyspnoea on
exertion
• Poor appetite
• Palpitation
• Poor growth

39. Complications of thalassemia
A. Ineffective & excessive erythropoiesis
B. Iron overload
C. Chronic hemolysis
D. Hypercoagulable disease
E. Infection
F. Treatment related complications

40. • Anemia.
• Failure to thrive in early childhood.
• Growth retardation, delayed puberty, primary amenorrhea in females,
and other endocrine disturbances secondary to chronic anemia and
iron overload.
Ineffective erythropoiesis and
hemolysis

41. Ineffective erythropoiesis and
hemolysis
• Bone abnormalities
1.Abnormal facies :
 prominence of malar eminences,
 frontal bossing,
 depression of bridge of the nose,
 exposure of upper central teeth.

42. Thalassemia facies

43. • Bone abnormalities
2. Skull radiographs showing hair-
on-end appearance due to
widening of diploic spaces.
3. Fractures due to marrow
expansion and abnormal bone
structure.
4. Osteopenia and osteoporosis are
common

44. Features of
extramedullary
hematopoiesis
Features of
hemolysis
Jaundice
Hyperurecemia-Gout
Gallstone

45. Hypercoagulable disease
Impaired platelet function Deep venous thrombosis
Elevated endothelial adhesion
protein level
Pulmonary embolism
Activation of coagulation cascade
by damage RBC
Cerebral ischemia

46. Cirrhosis
Diabetes
Infertility
Pituitary failure
Hypothyroidism
Hypoparathyroidism
Arrythmia
Heart failure
Dark skin
Liver Heart Endocrine organsSkin
Features of iron overload

48. • Acute hemolytic reactions
• Delayed transfusion reaction
• Autoimmune hemolytic anemia
• Febrile transfusion reaction
• Allergic reaction
• Transfusion related acute lung injury (TRALI)
• Graft versus host disease (GVHD)
• Volume overload
• Transfusion of disease – HAV, HBV, HIV
Complications due to blood
transfusions

49. • Anemia
• Iron overload – Yersinia, Klebsiella
• Hypersplenism
• Splenectomy – Pneumococci, Meningococci, Hemophilus influenzae
• Transfusion related – HBV, HCV, HIV etc.
Infection

50. • Congestive heart failure
• Arrhythmia
• Sepsis due to increase susceptibility to infection
• Multiple organ failure due to hemochromatosis (commonest
cause)
Causes of death in thalassemia

51. INVESTIGATIONS

52. Investigations
CBC:
• Hb level - Depends on severity
–β-thalassemia major: 3-6 gm/dl
• TC/DC– normal / increased / decreased
• Platelet- normal / decreased

53. • RBC Indices- MCV, MCH, MCHC are low
• RDW- Normal or raised
• Reticulocyte count- Increased(5-10%)
PBF: Microcytic hypochromic cells with marked anisocytosis,
poikilocytosis and other abnormal cells.
Investigations

54. PBF

55. 1. Target cell
2. Tear drop cell
3. Elliptocyte
4. Hypochromic
5. Microcyte
Abnormal RBCs in PBF

56. PBF: Normal vs Hypochromia

57. Anisocytosis

58. Poikilocytosis

59. Target cell

60. Eliptocyte

61. Schistocyte

62. Basophilic stippling

63. Tear drop cell

64. Poikilocytosis

66. PBF: α thalassemia (Hb H disease)

67. PBF : IDA

68. Thalassemia
minor
Thalassemia
intermedia
Thalassemia
major
CBC Hb Slightly reduced 7-10 g/dl <7 g/dl
MCH Slightly reduced 16-24 pg 12-20 pg
MCV Slightly reduced 50-80 fl 50-70 fl
PBF Less severe
erythrocyte
morphology
changes.
No erythroblast.
Microcytosis, Hypochromia,
Anisocytosis, Poikilocytosis ,
Tear drop cells, Elongated cells
Erythroblasts
Difference

69. Investigations
• Osmotic fragility: Decreased
• Iron Profile:
 S. Iron & ferritin- Increased
 TIBC- Decreased
 High % saturation of transferrin
• S. bilirubin (indirect): Increased

70. Hb electrophoresis
Hb NORMAL MAJOR MINOR INTERMEDIATE
Hb F <1% 90-98% 1-5 % Variable
Hb A 97% Absent 90-95% Variable
Hb A2 1-3% Variable 3.5-7% >3.5%

71. Normal Hb electrophoresis
Normal Hb electrophoresis

72. Hb electrophoresis of
homozygous β° thalassemia

73. Hb electrophoresis of β
thalassemia trait

74. • Hb H:
• (2-40%) Hb H
• others Hb A
• Hb F & Hb A2 in small amount
• Hb Bart's:
• (80-90%) Bart's,
• no Hb A, Hb F, Hb A2
Hb electrophoresis of
α thalassemia

75. Hb electrophoresis of
Hemoglobin H Disease

76. Hb electrophoresis of
Hemoglobin Bart’s

77. • Widened diploic spaces
• Hair-on-end appearance (Crew
cut appearance)
• Thinning of cortex
X ray skull

78. • Rectangular appearance
• Medullary portion of bone is
widened
• Bony cortex thinned out
• Coarse trabecular pattern in
medulla
X-ray of hand

79. Investigations

80. Investigations
• DNA analysis:
Determine specific defect at molecular DNA level.
• HPLC (High Performance Liquid Chromatography):
Identify & quantify large number of abnormal Hb.

81. To see complications
• Thyroid function test
• FSH, LH, Testosterone, Estradiol
• Ca, Phosphate, PTH
• Blood Sugar
• Bone profile
• Liver function test
• Liver Iron Concentration (LIC): T2 MRI, Liver Biopsy
• Cardiac Iron Measurement by: T2 MRI

82. Full medical and family history, CBC and RBC indices and PBF
Low MCV (< 80fl)
± Low MCH (< 27pg) Other cause of anemia?
Serum ferritin
≤12 ng/ml
Consider iron deficiency
anemia
Adequate iron supplement for 3
months
Hb electrophoresis and HPLC
Improved
Not
improved
Hb A2 variable
Hb F > 90-98%
Hb A2 ≥ 4%
Hb F ≤ 0.1-5%
Hb A2 > 4%
Hb F variable
Hb A2 < 4%
Hb F < 1%
+ Other normal Hb
variant
ß-Thalassemia
major
ß-Thalassemia
minor
ß-Thalassemia
intermedia
𝛼-Thalassemia
Hb S, Hb E,
Hb C and others
DNA analysis for 𝛼-globin ß-globin chain mutation
Serum ferritin
>12 ng/ml
Microcytosis, Hypochromia, Target cells
± inclusion bodies (Hb H)
Diagnosing Thalassemia

83. NEXT

84. MANAGEMENT OF THALASSEMIA

85. Treatment modalities
A. Supportive
B. Curative
C. Preventive

86. A. Supportive management
• Multi-disciplinary approach
• Focus on each patient’s clinical course
Transfusion
Iron Chelation
Fetal Hb Induction
Splenectomy
Treatment of complications

87. Objectives of supportive management
• Maintenance of growth and development
• Correction of anemia
• Prevention of iron overload
• Treatment of complications
• Counseling and Prevention

88. Blood Transfusion

89. Whom to transfuse?
•Confirmed diagnosis of thalassemia major
• Laboratory criteria:
Hb < 7gm/dl on 2 occasions > 2 weeks apart
• Laboratory and clinical criteria:
Hb > 7gm/dl with:
• Facial changes
• Poor growth
• Fractures
• Extramedullary hematopoiesis
• Cardiac complication
• Decrease normal physical activity
• Hypersplenism
ref.TIF

90. How to achieve target Hb Level
Target in 
Hb
Haematocrit of Donor Red Cells
50% 60% 75% 80%
1 gm/dl 4.2 ml/kg 3.5 ml/kg 2.8 ml/kg 2.6 ml/kg
2 gm/dl 8.4 ml/kg 7.0 ml/kg 5.6 ml/kg 5.2 ml/kg
3 gm/dl 12.6 ml/kg 10.5 ml/kg 8.4 ml/kg 7.8 ml/kg
4 gm/dl 16.8 ml/kg 14.0 ml/kg 11.2 ml/kg 10.4 ml/kg

91. Recommended Transfusion
To maintain pre transfusion Hb >9–10.5 gm/dl –
 Transfusion volume usually 10–15 cc/kg of packed Leuko-depleted red cells
Lifelong regular blood transfusions, every 3–5 weeks interval
Interval depend on patients work/school schedule and other lifestyle issue

92. A higher target pre-transfusion hemoglobin level
of 11- 12 gm/dl may appropriate for patients with
*Heart disease or other medical condition
*Patients who do not achieve adequate
suppression of bone marrow activity at
lower Hb level.
Keep post transfusion Hb not higher than 14-
15g/dl
patient with cardiac failure or very low initial Hb
levels should receive smaller amount of red cells
at slower rate of infusion

93. Recommendations
Careful donor selection and screening
Confirm laboratory and clinical criteria before initiation of transfusion
Before first transfusion, extended red cell antigen typing of patients
(at least for C, E and kell)
Before each transfusion, give ABO, Rh(D),C, E, and Kell compatible
blood
Before each transfusion, full cross-match and screen for new
antibodies

94. Keep record of annual transfusions requirements ,red cell antibodies
and transfusion reactions for each patient
Use leucoreduced packed red cells.Pre-storage filtration is
recommended.
Washed red cells for patients who have severe allergic reactions.
Use red cells stored in CPDA , as fresh as possible(less than one week)
Avoidance of transfusion first-degree relative donors

95. Regular transfusion allows
• Normal growth and
developments
• Normal physical activities
• Minimizes extra medullary
haematopoiesis
• Minimizes iron accumulation
• Reducing and/or delaying
the onset of complications

96. CHELATION THERAPY

97. 97

98. Evaluation of iron overload
Serum ferritin concentration
Liver iron concentration (LIC)
- liver biopsy
- MRI
- SQUID
Cardiac iron estimation by T2
MRI
Guideline- Thalassemia International Federation-2008

101. Guidelines for starting treatment of
iron overload in patients with β-
thalassemia major
Thalassemia International Federation guidelines for
the clinical management of thalassemia (2008)1
recommend that chelation therapy is considered
when patients:
Have received 10–20 transfusion episodes
OR
Have a serum ferritin level of >1000 ng/mL
1Thalassemia International Federation. Guidelines for the clinical management of thalassemia, 2nd Edition revised 2008;
2Angelucci E et al. Haematologica 2008;93:741–752

102. Iron chelating agents
Desferrioxamine(DFO)
Deferiprone
Defrasirox

103. Management: iron chelators(NTGuideline)
Agent Dose Route T1/2
hours Schedule Clearance
Desferrioxamine 40 -50
mg/kg/Day
SC
Slow
infusion
0.3 Infuse over
8-10 hours
5-6 days
per week
Renal and
hepatic
Deferiprone 75
mg/kg/day
Oral 2-3 3 times
daily(After 6
years)
Renal
Deferasirox 30-40
mg/kg/day
Oral 12-16 Once daily Hepatic

104. Desferrioxamine

105. Desferrioxamine
• Desferrioxamine has been in clinical use since the 1970s and widely
used since about 1980.
• The process of iron chelation ceases soon after an infusion is complete
• Efficacy of chelation is 14%
• With adequate dose and duration Desferrioxamine monotherepy
effectively control serum ferritin,liver iron, cardiac iron and hence
total body iron store.
• Vitamin C(2-3 mg/kg/day) increases iron excretion by increasing the
availability of chelatable iron
• Can be used in pregnancy
• The most common sites of infusion are abdomen, thighs and upper
arms

106. Intensive chelation with Desferrioxamine –
continuous 24-hourly infusions IV or SC.
Indications:
a) Persistently high serum ferritin;
b) LIC > 15 mg/g dry weight;
c) Significant heart disease, and;
d) Prior to bone marrow transplantation
Dose: 50 mg/kg/day (up to 60 mg/kg/day)

107. Adverse effects
Local skin reactions
Hearing impairment
Ophthalmologic impairment
Growth retardation
Skeletal changes
Rare complications

108. Deferiprone

109. Deferiprone
• Orally absorbed iron chelator that began clinical trials
in UK in the 1980
• At currently used doses ,about 6% of the drug binds
iron before it is excreted or metabolised (6%
efficiency)
• There is no significant difference in reducing serum
ferritin, liver iron or cardiac iron in between
deferiprone and desferrioxamine
• Contraindicated in pregnancy
• Should be used after 6 years of age .
• Can causes cytopenias.

110. Adverse effects
agranulocytosis
Gastrointestinal symptoms
Arthropathy
Elevation o liver enzymes

111. Deferasirox

112. Deferasirox
• Deferasirox was developed by Novartis as a once daily
oral monotherapy
• It has been licensed as first line monotherapy for
thalassaemia in over 70 countries.
• Deferasirox-30-40 mg/kg/day orally dissolving in
plane water/orange juice 30 minutes before BF.
• Efficiency of chelation is 28%
• Use in children >2 years of age
• Contraindicated in pregnancy and in significant renal
dysfunction.

113. Adverse effects
Gastrointestinal effects
Renal impairment
Liver dysfunction
Skin rashes

114. Fetal Hb Induction

115. Induction of fetal hemoglobin
Hb F enhancement..
• Hydroxyurea
• Butyrate derivatives
• Erythropoietin
• Decitabine
• 5-Azacytadine

116. • Increasing the synthesis of fetal hemoglobin can
help to alleviate anaemia and thereby improve the
clinical status of patients with thalassemia
intermedia.
• Agents including cytosine arabinoside and
hydroxyurea may alter the pattern of erythropoiesis
and increase the expression of foetal gamma globin
gene.

117. • Erythropoietin has been shown to be effective, with a possible
additive effect in combination with hydroxyurea.
• Butyrate (short chain fatty acid derivatives) acts as a foetal globin
gene promoter and rises two to six fold high foetal globin.

118. SPLEECTOMY

119. SPLENECTOMY
Deferred as long as possible. At least till 5-6 yrs age.
• Splenectomy reduces the transfusion requirements
in patients with hypersplenism.
• Splenectomy is avoided if possible due to the risk of
infection, pulmonary hypertension and
thromboembolism

120. Indications for splenectomy
include:
• Persistent increase in blood transfusion requirements by
50% or more over initial needs for over 6 months.
• Annual packed cell transfusion requirements in excess of
250 ml/kg/year in the face of uncontrolled iron overload
(ferritin greater than 1,500 ng/ml or increased hepatic iron
concentration).
• Evidence of hypersplenism (cytopenia )
• Massive splenomegaly causing mechanical discomfort or concern
about splenic rupture.

121. Preventative measures in splenectomy
• Immunoprophylaxis–
 At least 2 weeks before splenectomy
 Pneumococcus/meningococcus/Hemophilus
• Chemoprophylaxis-
 Chemoprophylaxis with life-long oral penicillin.

122. Diet and supplementation
• High iron contained food should be avoided.
• Diet which decreases iron absorption such as milk
& milk products should be taken adequately
• Folic acid
• Calcium
• Zinc
• Vit. D, Vit. E

123. Thalassemic diet
Should avoidDiet should encourage

124. Management of complications
• Heart failure: Restriction of physical activity, slow
blood transfusion with diuretics, ACE inhibitor,
diuretics, beta blocker if arrhythmia, combination
therapy (DFO & deferiprone)
• Hypothyroidism: Thyroxine
• Hypoparathyroidism: Calcium, vitamin D
• Osteoporosis: Regular blood transfusion, good
chelation, calcium, vit D, biphosphonates, sex
hormones (if associated with hypogonadism)

125. • Hypogonadism: Testosterone in boys & estrogen in
girls.
• Diabetes mellitus: Injection insulin
• Infections: Infections transmitted by Blood
Transfusion can be prevented by proper screening
blood before transfusion.
Other infections are managed accordingly.

126. • Hypogonadism: Testosterone in boys & estrogen in
girls.
• Diabetes mellitus: Injection insulin
• Infections: Infections transmitted by Blood
Transfusion can be prevented by proper screening
blood before transfusion.
Other infections are managed accordingly.

127. B. Curative treatment in thalassemia
• Hematopoietic Stem cell transplantation
• Gene therapy

128. Hematopoietic stem cell
transplantation
•Only curative option available.
•Outcome is best for children <17 years with
HLA identical sibling donor
•Overall survival is greater than 90%
•Overall outcome depends on-
• Inadequate chelation therapy,
• hepatomegaly,
• presence of liver fibrosis.
•Treatment-related mortality is
approximately 10%.
Guideline- Thalassemia International Federation-2008

129. Newer approaches in HSCT
• HSCT following reduced intensity conditioning –
Matched sibling Donor / matched family-related UCB
donor
• Matched unrelated HSCT
• Non-myeloablative Haploidentical HSCT
• Non-myeloablative mobilized peripheral blood HSCT
• Unrelated UCB following HLA-haploidentical HSCT.

130. Overview of transplantation
Accepted and experimental transplantation
approaches in thalassemia
HLA identical sibling transplant Accepted
HLA well matched unrelated donor
transplant
Accepted
HLA identical sibling cord blood
transplant
Accepted
HLA matched unrelated cord blood
transplant
Experimental
HLA mismatched related donor
transplant
Experimental

131. 1980s and early 1990s
HSCT- accepted as routine clinical practice
More than 3000 HSCTs were performed worldwide (Angelucci 2010)

132. Results of 900 consecutive unselected
HSCTs for Thalassemia performed in
Pesaro since 1982.
Emanuele Angelucci Hematology 2010;2010:456-462
©2010 by American Society of Hematology

133. Categories of risk and Lucarelli
Classification
Lucarelli G et al. N Engl J Med 1990

134. EXPECTED PROBABILITY OF OVERALL SURVIVAL AND
THALASSAEMIA FREE SURVIVAL AFTER HSCT IN
THALASSAEMIA MAJOR
CLASS OVERALL SURVIVAL THALASSAEMIA-FREE
SURVIVAL
Class 1 95% 90%
Class 2 85% 80%
Class 3 75-80% 65-70%
Adult 70-75% 75%

136. Hematological 2014

137. Gene therapy
• Stable transfer of a normal functioning copy of a beta-
globin therapy gene unit into the patient’s own HSC via
retrovirus delivery vector ,resulting in the permanent
splicing or integration of the therapy gene into the HSC
DNA generates normal rather than diseased RBC for
life long.
• HSC are isolated from the patient’s bone marrow and
infected or transduced with the beta-globin lentiviral
vector.
• The corrected cells are then returned to the patient,
who
in the meantime undergone chemotherapy to partially
or completely destroy their diseased bone marrow.
Guidelines for the Management of transfusion dependent Thalassemia,3rd

138. Gene Therapy
Defect in Beta Globin
gene loci
LCR –Locus
control region.

139. Beta –globin gene addition

140. Induction of Fetal Haemoglobin
• Gene modification
• Lentivirus carrying sequences of miRNAs inhibiting BCL11A
• Antisense oligonucleotides BCL11A inactivator
• ZFN(Zinc fingar nucleage)-driven activation of the Promoter of γ-globin gene
• ZFN-driven BCL11A enhancer ablation
• CRISPR-Cas9 mediated BCL11A enhancer inactivation

142. Gene Therapy in Patients with Transfusion Dependent
β-Thalassemia
N Engl J Med 2018; 378:1479-1493
Gene therapy with autologous CD34+ cells transduced with the BB305 vector
reduced or eliminated the need for long-term red-cell transfusions in 22
patients with severe β-thalassemia without serious adverse events related to
the drug product.

143. Role of surgery in thalassemia
• Cholelithiasis – Cholecystectomy
• Choledocholithiasis – Choledocholithotomy
• Cirrhosis (due to iron overload) – Liver biopsy and
liver transplantation
• Leg ulcer – Surgical dressing
• Pathological fracture – Surgical correction
• Spinal cord compression - Laminectomy

144. Follow up
Monthly:
• Complete blood count
• Complete blood chemistry (including liver function
tests, BUN, creatinine) if taking deferasirox
• Record transfusion volume.

145. Follow up
Every 3 months:
• Measurement of height and weight
• Measurement of ferritin (trends in ferritin used to
adjust chelation);
• Complete blood chemistry, including liver function
tests

146. Follow up
Every 6 months:
• Complete physical examination including Tanner
staging,
• Monitor growth and development
• Dental examination

147. Follow up
Every year:
• Cardiac function – echocardiograph, ECG, Holter
monitor (as indicated)
• Endocrine function (TFTs, PTH, FSH/LH, fasting glucose,
testosterone/estradiol, FSH, LH, IGF-1, Vitamin D levels)
• Ophthalmological examination and auditory acuity
• Viral serologies (HAV, HBV panel, HCV (or if HCV1,
quantitative HCV RNA PCR), HIV)
• Bone densitometry
• Ongoing psychosocial support.

148. Follow up
Every 2 years:
• Evaluation of tissue iron burden
• Liver iron measurement – R2 MRI, SQUID, or biopsy
• T2* MRI measurement of cardiac iron (age .10
years).

149. C. Prevention and control
 Career detection/Screening
 Genetic counseling
 Prenatal diagnosis
 Health education

150. Screening
• RBC indices (MCV, MCH, MCHC)
• NESTROFT
• DCIP(2,6‐dichlorophenolindophenol)

151. Career detection/screening
Mass screening: NESTROFT (Necked Eye Single Tube Red Cell Osmotic
Fragility Test)
• Very cheap and easy to perform require small amount of blood
• Based on principle that Thalassemic red cell resists hypotonic solution more
than that of normal person
• Give positive result on NESTROFT
• Sensitivity 90-98% and specificity 85-90%

152. Career detection/screening
Automated CBC:
• Thalassemic red cells are microcytic and hypochromic
• WHO recommends MCV <77fl and MCH <27 pg as screening tools to
pick up cases for confirmation by electrophoresis

153. Genetic counseling

154. Prenatal diagnosis
Chorionvillus sampling Amniocentesis

155. Health education/awareness
• Knowledge of genetic nature of thalassemia
• Transmission of the disease
• Ways to avoid to have further child with the disease
• Aware about economic burden to the family and
govt.

156. Creating awareness

157. Creating awareness

158. Prognosis
Thalassemia major-life expectancy:
• Without regular transfusion - Less than 10 years
• With regular transfusion and no or poor iron
chelation - Less than 25 years
• With regular transfusion and good iron chelation -
40 years, or longer…

159. Transfusion medicine dept. BSMMU
(july 17-june 18 )
MONTH RCC Transfusion Iron chelation
July 17 655 02
August 17 679 02
September 17 470 07
October 17 619 04
November 17 650 10
December 17 531 07
January 18 457 00
Februry 18 499 47
March 18 624 56
April 18 602 16
May 18 615 21
June 18 465 04
TOTAL 6866 176

160. Transfusion medicine dept. BSMMU
(july 18-june 19 )
MONTH RCC Transfusion for Thalassemia Iron chelation
July 18 706 12
August 18 460 00
September 18 574 19
October 18 582 05
November 18 513 10
December 18 446 00
January 19 558 05
Februry 19 456 07
March 19 590 10
April 19 563 22
May 19 501 11
June 19
TOTAL 5949 101

161. 3000 enrolled patient
20 bed for day care transfusion
40-50
patients/day
Iron chelator
Hydroxyurea
Leukocyte
filter
02 consultant
05 medical
officer
T2 MRI
Ferriscan
Full Blood
bank with
aphaeresis
facilities
Laboratory
facilities

162. Founded in 1998
Full phase activity in 2005
OPD and follow up
clinic
Indoor ward
Bed no -14
Total enrolled pt around 5,000
(Major-25% , E-beta -75%)
RCC transfusion
Chelation
Splenectomy
Complications
management
DNA analysis lab