Azita Azarkeivan

Blood Transfusion and Alloimmunization in Patients with Thalassemia: Multicenter Study

One of transfusions side effects is alloimmunization against red blood cell (RBC) antigens. Early diagnosis by antibody screening is an important step in the detection of these alloantibodies. The authors studied the frequency of alloimmunization in thalassemic patients of 4 centers (2 adult and 2 pediatric centers) and compared the rates in children (up to 15 years) and adults. Antibody screening tests were performed by gel method according to its standard pattern and respective program. In positive cases, antibody identification test by gel method was performed. Eight hundred thirty-five patients were studied; 548 (65.6%) were adults (mean age = 24.5), and 287 (34.4%) cases were pediatrics (mean age = 10.05). Of these patients, 74.1% had no history of transfusion reaction, whereas 21 (2.5%) had hemolytic complications. Seventy-eight (9.3%) exhibited allergic symptoms, and 117 (14%) cases experienced febrile reactions during transfusion. Antibody screening showed positive results in 22 pediatric cases (7.7%) and 79 adults (14.4%); 72 (71.3%), 19 (18.8%), 3 (3%), and 1 (1%) cases exhibited single, double, triple, and autoantibodies, respectively. Anti-Kell antibody was seen in 34 (33.7%) cases, anti-D was seen in 11 (10.9%) cases, and anti-E in was seen in 10 (9.9%) cases. The authors observed 8 anti-D+C (7.9%) cases, 1 anti-D+E (1%), 3 anti-Kell+E, 3 anti-Kell+Kpa (3%), and 1 anti-Kell+D double antibodies. These antibodies were also a combination of Rh subgroups or Rh and Kell subgroups. The authors observed meaningful relations between history of transfusion reactions and age with antibody screening results (P = .005). Based on alloantibodies types, more than two thirds of them were Rh subgroups and Kell groups. Phenotype determination of RBCs before beginning chronic blood transfusion and careful cross-matching with Kell and Rh subgroups in addition to ABO may help reduce alloimmunization in chronic transfusion patients.

PULMONARY FUNCTION TEST IN TRANSFUSION-DEPENDENT β-THALASSEMIA PATIENTS

β-Thalassaemia is the most common hemoglobinopathies in our region with treatment of regular blood transfusion. Iron overload and hemosiderosis can cause organ involvement. Recent studies have focused on pulmonary involvement and pathophysiology of lung damage. The goal of this study was to investigate the pulmonary abnormalities in thalassemic patients in relation with sign and symptoms and iron overload. The authors studied pulmonary function test (PFT) at the Adult Thalassemia Clinic in Tehran. The history of blood transfusion, iron chelation, respiratory problems, and drug usage was taken. Physical examination, PFT, arterial blood gas (ABG), and chest X-ray (CXR) were done. In total, 139 patients were studied. The mean age was 21.1 years and mean duration of transfusion was 18 years. It was found that 133 patients (95.7%) did not have respiratory problems and only 6 (4.3%) had some respiratory complaints. In CXR, 100 patients (89.3%) had normal lung pattern and others (10.7%) had variable degrees of abnormal lung pattern. In ABG, mean of Po2 was 73.5% and mean of O2 saturation was 90.6%. In PFT, 101 patients (72.7%) had restrictive pattern, 35 (25.1%) had normal pattern, and 3 (2.2%) had combined pattern. According to vital capacity, the patients were placed in five categories: 54 patients (38.8%) normal, 37 (26.6%) mild, 35 (25.3%) moderate, 10 (7.2%) severe, and 3 (2.1%) extremely severe pulmonary deficit. There was no statistical significance between PFT results with all variables studied, except duration of blood transfusion, which may be considered a indirect effect of iron load (p =. 05, r =. 361). According to these results, restrictive pattern was the most common finding (72.7%) in PFT, while 95.7% of patients had no respiratory complaint, and in the chest X-ray group, 89.3% had normal pattern. The authors conclude that the lung may be considered a site for organ damage, and alteration of pulmonary function may be expected in transfusion-dependent patients in spite of no pulmonary symptoms or normal CXR. In recent years, because of new iron chelating drugs, doctors can expect thalassemic patients to have a long life-time and need to increase their quality of life. One way to do this is to evaluate the respiratory system by PFT to prevent the squeal of pulmonary disease.

The incidence of hepatitis C in patients with thalassemia after screening in blood transfusion centers: a fourteen‐year study

BACKGROUND: Blood safety is important in all transfusion centers. The aim has always been to try to guarantee the recipients safety through careful screening and examination of donors blood samples. In Iran the hepatitisu2003C virus (HCV) screening test became mandatory for blood donations from 1996. We decided to determine the incidence of new cases of HCV in patients with thalassemia, after screening of blood bags was initiated.

ANTIBODY TITRATION AND IMMUNE RESPONSE OF IRANIAN β-THALASSEMIC PATIENTS TO HEPATITIS B VIRUSE VACCINE (BOOSTER EFFECT)

Background: Thalassemia is hereditary anemia with lifelong transfusion as treatment and hepatitis B virus (HBV) infection is one of the transfusion transmitted infections (TTI). HBV vaccinination is obligatory for these patients by 3 double-dose injections. The authors studied the HBV status and immune response to vaccination by hepatitis B surface antibody (HBsAb) titration in their thalassemic patients. They also compared these results with their previous study to find out the effectiveness of a booster dose in the immunity of patients against HBV. Materials and Methods: Hepatitis B surface antigen (HBsAg), HBsAb, and hepatitis B core antibody (HBcAb) were detected in sera of 416 patients at the Tehran Adult Thalassemia Clinic. The immune status was classified into 4 categories: (1) immune to HBV via the vaccination (positive vaccinal)—if HBs Ag: negative, HBsAb: positive, HBcAb: negative; (2) immune to HBV via the natural disease (past infection)—if HBs: negative, HBsAb and HBcAb: both positive; (3) nonimmune to HBV (negative)—if all three parameters were negative; (4) carrier of HBV (carrier state)—if HBs Ag was positive and HBsAb and HBc Ab: both negative. Also grading of immunity done by HBsAb titration as positive if HBsAb titer was more than 100 IU/mL, negative if HBsAb titer was less than 10 IU/mL, and weakly positive if antibody level was 10–100 IU/mL. Results: There were 416 patients: 302 (72.5%) with thalassemia major (TM), 104 (25%) thalssemia intermedia (TI), 7 (1.6%) sickle thalassemia (ST), and 3(0.7%) α-thalassemia (HbH disease). The mean age was 25.6 ± 8.3 yr and median age was 24 yr; there were 247 (59.4%) males and 169 (40.6%) females. A total of 257 patients (61.7%) were splenectomized. According to our classification 289 (69.4%) were immunized by vaccination; 80 (19.2%) were immunuzed by past infection; 44 (10.5%) were negative, and 3 (0.7%) were in carrier state of HBV. In grading of immunity to HBV vaccination, 319 (76.6%) patients had HBsAb > 100 IU/mL (positive), 77 (18.5%) between 10 and 100 IU/mL (weakly positive), and 20 (4.8%) less than 10 IU/mL (negative). There was no significant correlation between the level of HBsAb and spelenectomy or type of thalassemia. Conclusion: Response rate to vaccination is more than 95% after complete course (3 doses) in healthy individuals but failure to fulfill vaccination seems a problem in chronic transfused patients. These results reflect advantages of a booster dose of vaccine, which increased the protection level among these high-risk patients from 46.9% (in the authors’ previous data) up to 69.4% in this study.

RBC alloimmunization and double alloantibodies in thalassemic patients

Abstract Purpose Alloimmunization is a common consequence of chronic blood transfusion. Double alloantibody production may complicate the condition of such patients especially for finding matched blood. In this study, we evaluated the frequency of alloantibodies in thalassemic patients with previous history of transfusion reactions. Samples and methods This study was performed on 441 multiply transfused thalassemia patients Antibody screening test was carried out using three cell-panel by gel method. Positive patients were followed up for antibody identification using 11-cell panel. Direct combs’ test was performed to detect auto antibodies. Results In a total of 441 cases (362 thalassemia major and 79 intermedia), 234 were males (53.1%) and 207 females (46.9%); mean age 22 years, range 3-61 years. Alloimmunization was detected in 50(11.3%) patients, including 37(74%) patients with one alloantibody, 8(16%) with two antibodies, 4(8%) patients with unknown antibodies and one patient (2%) with autoantibody. The most common alloantibodies were anti-Rh antibodies (-E/e/C/c/Cw) (26%), anti-K (28%), anti-D (16%), and anti-Colton (4%). Double antibodies were detected in eight out of 50 patients, including: Anti-D+anti-C (8%), anti-D+anti-E (2%), anti-Kell+anti-D (2%), and anti-Kell+KPa (2%). A significant association was observed between the transfusion reaction history and the alloantibody detection results (p < 0.05). Conclusion Antibody production against RBC antigens makes hard condition in regular blood transfusion. Double antibodies production may more complicate this situation. Thus, it is advisable to phenotype patients and matches the red cells in multiply transfused thalassemia patients.

Erythrocytic phosphatidylserine exposure and hemostatic alterations in β-thalassemia intermediate patients

Abstract Introduction Hypercoagulable state is one of the common findings in beta-thalassemia intermedia (β-TI), particularly in splenectomized patients, with infrequent blood transfusion. Abnormality of the red blood cells (RBC) membrane due to oxidative damage is suggestive of possible etiologies. Membrane lipid peroxidation increases the exposure of phosphatidylserine (PS) that plays a role in the activation of coagulation factors V and X, subsequently initiating thrombosis. Our aim of this study was to find the probable correlation of the alteration of the PS on the RBC outer membrane with the hypercoagulable state in the β-TI patients. Materials and methods Our cross-sectional study was conducted on 39 splenectomized β-TI patients and 38 age-matched healthy controls. The mean age was 37 years. Analysis of the PS exposure on the RBCs was performed by fluorescein isothiocyanate (FITC) conjugated AV protein .Measurement of the coagulation factors X, V and antithrombin III (AT-III) was performed. We also checked the D-dimer levels .Analysis was performed by SPSS16. Results Fluorescence of FITC-Annexin V labeling on patients RBCs were higher than healthy controls; (2.8 ± 2.2%) of the patients versus (0.4 ± 0.18%) in the control group and was statistically significant (P < 0.05). Mean levels of factor X and AT-III of the patients as compared with the control group decreased and showed significant difference (P < 0.05). Conclusions Circulation of thalassemic RBCs, which abnormally possess PS on RBC membrane outer surface, suggests the possibility of the gradual consumption of the coagulation factors in the presence of a chronic coagulability state.

Evaluation of new cases of HCV infection in thalassaemia patients for source of infection.

Background: Screening tests on blood bags is important step for blood safety. In Iran, screening for HCV started from 1996. We decided to determine the new cases of hepatitis C in our thalassemic patients, after screening of blood bags was initiated and trace backing from recipients to find their donors. Materials and Methods: The study was done on patients with complete files for HCVAb test results. Only cases that had a positive HCVAb result following a negative result were considered as new cases. For trace backing, we recorded the blood transfusions’ date and the blood bags’ number from last negative test results (HCVAb) to the first positive test result. These data were sent to the transfusion center. The suspected donors were contacted and asked to be tested again in the transfusion center. Results: A total of 395 patients were studied; 229 (58%) males and 166 (42%) females. Mean age was 27.5 years. We had 109 HCV (27.5%) positive cases of whom 21 were infected after 1996. We traced the last five cases contaminated during 2003 and 2004. These five patients had 13, 10, 13, 12, and 6 donors, respectively (totally 54 donors were found). We proved the healthy state in 68.5% (37 of 54) of our donors population. Of them, 81% were repeated donors and 17 of 54 donors (31.5%) could not be traced (because of change in addresses). We did not have any HCV new cases after 2004. Conclusion: We could not prove HCV transmission from donors as the source of infection. Although parenteral transmission is always on top of the list in HCV infection, the possibility of hospital and/or nursing personnel transmission and/or patient-to-patient transmission such as use of common instruments like subcutaneous Desferal® infusion pumps; which the patients used for iron chelation therapy, should also be kept in mind.

The correlation between cardiac magnetic resonance T2* and left ventricular global longitudinal strain in people with β-thalassemia

Heart failure is the biggest cause of mortality and morbidity in people with thalassemia, and iron deposition in cardiac tissue impairs cardiovascular function. Therefore, early detection of cardiac involvement is important to improve the prognosis in these individuals.

Fertility assessment in thalassemic men

Male infertility in β-thalassemia patients is typically considered to be the consequence of iron deposition in the endocrine glands. Adult male patients with β-thalassemia, on regular blood transfusions, are prone to developing acquired hypogonadism. The aim of this study was to evaluate the fertility indicators in male patients with β-thalassemia major and intermedia. In this study we evaluated testicular volume, semen parameters and serum FSH, LH, and Testosterone concentrations in 62 male patients in reproductive age, with major and intermedia thalassemia, at a tertiary care hospital in Tehran, Iran. The range of serum ferritin level in our patients was from 182 to 11053 ng/mL (mean 2067 ng/mL). The mean concentration of sperm was 61.04 million per milliliter. The mean volume of right and left testes was 11.4 cc and 11.7 cc, respectively. Those patients who had lower testicular volumes significantly had lower sperm concentration, lower percents of motile and also lower percents of normal morphologic sperms (P=0.04). The frequency of hypogonadism was significantly higher in patients whose testicular volume was lower (P=0.02). Hypogonadism and hypothyroidism were seen in 22.6% and 17.7% of patients, respectively. Patients with hypogonadism had significantly lower ejaculate volume, lower sperm concentration, lower percents of motile and progressively motile sperms and also lower percents of normal morphologic sperms (P=0.001). This study suggests that in thalassemic men, concentrations of serum testosterone, LH, FSH has significant correlation with sperm parameters and testicular volume. β地中海贫血患者中的男性不育症通常被认为是内分泌腺中铁沉积的结果。成年男性β地中海贫血患者在常规输血时易发生获得性性腺功能减退。本研究旨在评估男性重型和中间型β地中海贫血患者的生育指标。在本研究中，我们在伊朗德黑兰的一家三级保健医院对62名处于生育年龄的男性重型和中间型地中海贫血患者的睾丸体积、精液参数以及血清FSH、LH和睾酮浓度进行了评估。在我们的患者中，血清铁蛋白水平范围是182到11053ng/mL（平均2067ng/mL）。平均精子浓度为每毫升6104万。右侧和左侧睾丸的平均体积分别为11.4cc和11.7cc。睾丸体积较小的患者明显存在精子浓度低、活动精子比例低以及正常形态精子百分比低的情况（P=0.04）。睾丸体积较小的患者性腺机能减退的频率明显更高（P=0.02）。分别在22.6%和17.7%的患者中发现性腺功能减退和甲状腺功能减退。性腺功能减退症患者的射精量、精子浓度、活动精子比例和前向运动精子比例都明显偏低，正常形态精子的比例也存在同样的情况（P=0.001）。本研究表明，在男性地中海贫血患者中，血清睾酮、LH、FSH的浓度与精子参数和睾丸体积有显著的相关性。

Comparison of MicroRNAs Mediated in Reactivation of the γ-Globin in β-Thalassemia Patients, Responders and Non-Responders to Hydroxyurea

Abstract Drug induction of Hb F seems to be an ideal therapy for patients with hemoglobin (Hb) disorders, and many efforts have been made to reveal the mechanism behind it. Thus, we examined in vivo expression of some microRNAs (miRNAs) that are thought to be involved in this process. Among β-thalassemia (β-thal) patients who were undergoing hydroxyurea (HU) therapy in the past 3 months and five healthy individuals, five responders and five non-responders, were also included in the study. Erythroid progenitors were isolated by magnetic activated cell sorting (MACS) and miRNA expression analyzed using reverse transcription-polymerase chain reaction (RT-PCR). We showed that γ-globin, miR-210 and miR-486-3p had higher levels in the responders than the non-responders group. Moreover, miR-150 and miR-320 had higher levels in the healthy group than both non-responders and responders groups, but the expression of miR-96 did not show any significant difference between the study groups. To the best of our knowledge, this is the first study proposing that ‘induction of cellular hypoxic condition by Hb F inducing agents’ could be the milestone of possible mechanisms that explain why responders are able to reactivate γ-globin genes and subsequently, more production of Hb F, in response to these agents in comparison to non-responders. However, further investigations need to be performed to verify this hypothesis.