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Galvis M, Díaz JD, Cuartas DE, Tovar JR, Fernandez-Trujillo L, Sua LF. Chronic disease prevalence in a population with structural hemoglobin disorders undergoing diabetes diagnosis: A bayesian approach. Heliyon 2024; 10:e23855. [PMID: 38223742 PMCID: PMC10787264 DOI: 10.1016/j.heliyon.2023.e23855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 01/16/2024] Open
Abstract
Background Structural disorders of hemoglobin are a group of rare and fatal genetic diseases that disrupt the transport and exchange of oxygen in the blood, causing tissue damage and ultimately leading to chronic conditions. The hemoglobin (Hb) S variant predominantly impacts individuals of Afro-descendant heritage. A significant concentration of the Afro-descendant population in Colombia, notably 12.5 %, is found in the city of Cali. Previous research has identified this city's structural hemoglobin disorders prevalence rate of 3.78 %. The aim of this study was to determine the prevalence of HbC, HbS, HbF, and HbA2 variants within a population who underwent HbA1c testing, as well as the prevalence of chronic diseases among patients with these hemoglobin alterations, at a high-complexity hospital in the city of Cali from 2015 to 2019. Methods A descriptive observational study was conducted, involving a study population that comprised patients with both suspected and monitored diagnoses of diabetes. The cohort was selected from a high-complexity hospital in Cali. A total of 15,608 patients were included in the analysis, all of whom underwent HbA1C measurement through capillary electrophoresis, which also offers an indirect diagnosis of certain structural disorders of hemoglobin. Bayesian methods were employed for frequency analysis. Results Among the 15,608 patients assessed, 63.6 % (n = 9920) were women. The overall prevalence of structural hemoglobin disorders was 1.98 % (n = 287, 95 % CI = 1.77 %-2.21 %). The co-occurrence of diabetes and kidney disease emerged as the most prevalent combination of pathologies observed in individuals with HbC, for both men and women across various age groups: 18-42 (58.3 % and 50.0 % respectively), 43-55 (50.0 % for both), 56-65 (50.0 % and 37.5 % respectively), and >65 years (66.7 % and 57.1 % respectively). Conclusions The observed prevalence of the studied variants exceeded 1 %, a threshold underscored by the World Health Organization (WHO) as epidemiologically significant. Among HbC and HbS-positive patients, the elevated prevalence of diabetes and kidney disease is a guiding factor in developing proactive prevention strategies.
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Affiliation(s)
- Maryory Galvis
- Universidad del la Valle, Colombia
- Universidad Libre. Cali, Colombia
| | - Juan D. Díaz
- Facultad de Salud, Universidad del Valle. Cali, Colombia
| | | | - José R. Tovar
- Universidad del Valle. Director of Statistics School, Universidad del Valle. Cali, Colombia
| | - Liliana Fernandez-Trujillo
- Department of Internal Medicine, Pulmonology Service. Fundación Valle del Lili, Cali, Colombia
- Faculty of Health Sciences, Universidad Icesi. Cali, Colombia
| | - Luz F. Sua
- Faculty of Health Sciences, Universidad Icesi. Cali, Colombia
- Department of Pathology and Laboratory Medicine. Fundación Valle del Lili, Cali, Colombia
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Brittenham GM, Moir-Meyer G, Abuga KM, Datta-Mitra A, Cerami C, Green R, Pasricha SR, Atkinson SH. Biology of Anemia: A Public Health Perspective. J Nutr 2023; 153 Suppl 1:S7-S28. [PMID: 37778889 DOI: 10.1016/j.tjnut.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/04/2023] [Accepted: 07/31/2023] [Indexed: 10/03/2023] Open
Abstract
Our goal is to present recent progress in understanding the biological mechanisms underlying anemia from a public health perspective. We describe important advances in understanding common causes of anemia and their interactions, including iron deficiency (ID), lack of other micronutrients, infection, inflammation, and genetic conditions. ID develops if the iron circulating in the blood cannot provide the amounts required for red blood cell production and tissue needs. ID anemia develops as iron-limited red blood cell production fails to maintain the hemoglobin concentration above the threshold used to define anemia. Globally, absolute ID (absent or reduced body iron stores that do not meet the need for iron of an individual but may respond to iron supplementation) contributes to only a limited proportion of anemia. Functional ID (adequate or increased iron stores that cannot meet the need for iron because of the effects of infection or inflammation and does not respond to iron supplementation) is frequently responsible for anemia in low- and middle-income countries. Absolute and functional ID may coexist. We highlight continued improvement in understanding the roles of infections and inflammation in causing a large proportion of anemia. Deficiencies of nutrients other than iron are less common but important in some settings. The importance of genetic conditions as causes of anemia depends upon the specific inherited red blood cell abnormalities and their prevalence in the settings examined. From a public health perspective, each setting has a distinctive composition of components underlying the common causes of anemia. We emphasize the coincidence between regions with a high prevalence of anemia attributed to ID (both absolute and functional), those with endemic infections, and those with widespread genetic conditions affecting red blood cells, especially in sub-Saharan Africa and regions in Asia and Oceania.
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Affiliation(s)
- Gary M Brittenham
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY, United States.
| | - Gemma Moir-Meyer
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Department of Medical Biology, The University of Melbourne, Parkville, VIC, Australia
| | - Kelvin Mokaya Abuga
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Ananya Datta-Mitra
- Department of Pathology and Laboratory Medicine, University of California, Davis, CA, United States
| | - Carla Cerami
- The Medical Research Council Unit, The Gambia, London School of Hygiene and Tropical Medicine, London, UK
| | - Ralph Green
- Department of Pathology and Laboratory Medicine, University of California, Davis, CA, United States
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Department of Medical Biology, The University of Melbourne, Parkville, VIC, Australia; Diagnostic Haematology, The Royal Melbourne Hospital; and Clinical Haematology at the Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, VIC Australia
| | - Sarah H Atkinson
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya; Department of Paediatrics, University of Oxford, Oxford, UK
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Jayasekera PT, Fernandopulle R, Weerasenghe T, de Soysa S, Ranaweera T, Edirisinghe E. Hip fractures and outcome in elderly patients in a tertiary care hospital of Sri Lanka. Arch Osteoporos 2023; 18:113. [PMID: 37672198 DOI: 10.1007/s11657-023-01323-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 08/21/2023] [Indexed: 09/07/2023]
Abstract
This study assessed how elderly patients with hip fractures were affected by factors such as comorbidities, fracture type, treatments, complications, and health-related quality of life. The majority of participants had surgery for their fracture with good prognoses despite having comorbidities. Reductions in the general level of activities related to daily living were proportionately higher even after one year. INTRODUCTION Hip fractures in older adults are associated with significant morbidity, mortality, loss of independence, and financial burdens. In this study, we assessed how these effects were influenced by factors such as comorbidities, fracture type, treatment methods, complications, and health-related quality of life (HRQoL) in elderly patients presented with hip fractures. METHODS A prospective observational study was conducted over 6 months on all patients with fall and hip fractures above 65 years of age that presented to the Accident and Emergency Department (A&E) of Provincial General Hospital Kurunegala. The subjects were followed up with for up to 1 year. Data forms were made according to the Charlson comorbidity index, the Johns Hopkins Fall Risk Assessment tool, and the International Society of Fracture Repair-International Osteoporosis Foundation (ISFR-IOF)) hip fracture outcome working group recommendations. Direct questions from these assessment guides were not used in data collection. Being able to walk independently and return to a premorbid state following surgery was considered a good outcome. RESULTS There were 117 patients (mean age 78 (± 7.31) years); 80% were female. Out of them, 81% had comorbidities without significant morbidity or mortality during surgery. Ninety-six (88%) had surgery for their fracture with good prognoses (p<0.05) and better outcomes due to early surgery (p=0.008). Independent walking was significantly better in intracapsular fractures than extracapsular fractures (p<0.05). Patients with post-surgical complications had significant mortality (p<0.001). Ninety-nine per cent, 81%, and 75% of patients remained dependent 1 month, 3 months, and 1 year following surgery, respectively. HRQoL was impaired in 3 months (95% SF, 12<50) and in 1 year (78.6% SF, 12 <50) following surgery. The mortality during admission, in 1 month, 3 months, and 1 year was 8.5% (10), 14.5% (17), 21.3% (25), and 35% (41), respectively. CONCLUSION A greater majority of hip fracture victims were female. Prognoses were good after surgery irrespective of the comorbidities with better outcomes in early surgery. Independent walking was significantly better in intracapsular fractures than extracapsular fractures. Patients with post-surgical complications had significant mortality. Significant loss of HRQoL increased in patients even after surgery, which resulted in an increased burden to families.
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Affiliation(s)
| | | | - T Weerasenghe
- Provincial General Hospital Kurunegala, Kurunegala, Sri Lanka
| | - S de Soysa
- Provincial General Hospital Kurunegala, Kurunegala, Sri Lanka
| | - T Ranaweera
- Provincial General Hospital Kurunegala, Kurunegala, Sri Lanka
| | - Emdt Edirisinghe
- University Hospital Kotelawala Defence University, Boralesgamuwa, Sri Lanka
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4
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Neyer PJ, Kaboré B, Nakas CT, Hartmann B, Post A, Diallo S, Tinto H, Hammerer-Lercher A, Largiadèr CR, van der Ven AJ, Huber AR. Exploring the host factors affecting asymptomatic Plasmodium falciparum infection: insights from a rural Burkina Faso study. Malar J 2023; 22:252. [PMID: 37658365 PMCID: PMC10474782 DOI: 10.1186/s12936-023-04686-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/23/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND Asymptomatic Plasmodium falciparum parasitaemia forms a reservoir for the transmission of malaria disease in West Africa. Certain haemoglobin variants are known to protect against severe malaria infection. However, data on the potential roles of haemoglobin variants and nongenetic factors in asymptomatic malaria infection is scarce and controversial. Therefore, this study investigated the associations of iron homeostasis, inflammation, nutrition, and haemoglobin mutations with parasitaemia in an asymptomatic cohort from a P. falciparum-endemic region during the high transmission season. METHODS A sub-study population of 688 asymptomatic individuals (predominantly children and adolescents under 15 years, n = 516) from rural Burkina Faso previously recruited by the NOVAC trial (NCT03176719) between June and October 2017 was analysed. Parasitaemia was quantified with conventional haemocytometry. The haemoglobin genotype was determined by reverse hybridization assays targeting a selection of 21 HBA and 22 HBB mutations. Demographics, inflammatory markers (interleukins 6 and 10, hepcidin), nutritional status (mid upper-arm circumference and body mass index), and anaemia (total haemoglobin, ferritin, soluble transferrin receptor) were assessed as potential predictors through logistic regression. RESULTS Malaria parasites were detected in 56% of subjects. Parasitaemia was associated most strongly with malnutrition. The effect size increased with malnutrition severity (OR = 6.26, CI95: 2.45-19.4, p < 0.001). Furthermore, statistically significant associations (p < 0.05) with age, cytokines, hepcidin and heterozygous haemoglobin S were observed. CONCLUSIONS According to these findings, asymptomatic parasitaemia is attenuated by haemoglobin S, but not by any of the other detected genotypes. Aside from evidence for slight iron imbalance, overall undernutrition was found to predict parasitaemia; thus, further investigations are required to elucidate causality and inform strategies for interventions.
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Affiliation(s)
- Peter J Neyer
- Institute of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland.
- Graduate School for Cellular & Biomedical Sciences, University of Bern, Bern, Switzerland.
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Bérenger Kaboré
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
- IRSS/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Christos T Nakas
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Laboratory of Biometry, Department of Agriculture Crop, Production and Rural Environment, University of Thessaly, Volos, Greece
| | - Britta Hartmann
- Institute of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Annelies Post
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Salou Diallo
- IRSS/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Halidou Tinto
- IRSS/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | | | - Carlo R Largiadèr
- Graduate School for Cellular & Biomedical Sciences, University of Bern, Bern, Switzerland
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andre J van der Ven
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Andreas R Huber
- Private University in the Principality of Liechtenstein, Triesen, Principality of Liechtenstein
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Redesigning New Policy Options for Thalassemia Prevention in Sri Lanka. THALASSEMIA REPORTS 2022. [DOI: 10.3390/thalassrep12040018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Sri Lanka, a country with 22 million people, has nearly 2000 thalassemia patients with severe thalassemia, two-thirds of whom have beta thalassemia major (TM). The current prevention program based on promoting “safe marriages”, which has been in existence for over 15 years, has failed to reduce thalassemia major births. We set about to examine the cost-effectiveness of novel policy options for thalassemia prevention in Sri Lanka. Methods: The current cost for treatment of a thalassemia major patient (USD 2602/yr) was compared against the cost per reduction of single birth with three novel strategies, namely intensifying the screening in the current five districts combined with an education program (policy option 1), a nationwide screening program (policy option 2), and antenatal screening combined with the termination of pregnancy (policy option 3). The incremental cost-effectiveness ratio (ICER) of the different strategies was calculated. Results: The status quo was considered to reduce one TM birth whilst the new policy options were able to reduce births by 14, 35, and 48, respectively. The costs incurred for the program for a year for status quo and the three novel programs were USD 104,788, 173,884, 781,372, and 904,186 respectively. Cost per prevention of a thalassemia major birth was USD 87,324, 12,420, 22,324, and 20,084, respectively. The lifetime cost per treatment of a thalassemia major patient was USD 34,653. Conclusions: Given the current legal restriction on termination of pregnancy for fetal indications, policy option 2, an island-wide screening with mass education, is the most cost-effective and will be expected to deliver a substantial reduction in new births.
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Premawardhena AP, Madushanka HDP. Thalassemia in Sri Lanka. Hemoglobin 2022; 46:71-73. [PMID: 35950586 DOI: 10.1080/03630269.2022.2025826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The island nation of Sri Lanka with 22 million people (in 2020) has an estimated 2000 patients with severe thalassemia. The majority have β-thalassemia (β-thal) major (β-TM), and Hb E (HBB: c.79G>A)/β-thal accounts for most of the remainder. Carrier rate for α+-thalassemia (α+-thal) trait is 9.9% and β-thal trait is 2.5%, with very similar rates in the three major ethnic groups (Sinhalese, Tamils and Moors). The distribution of thalassemia type reveals a remarkable variation, even in this small island, mirroring historical distribution of malaria. Even though healthcare is provided free by the state including blood transfusions and chelation, the overall survival of patients of β-TM is still not on a par with that of the Mediterranean countries. A national thalassemia prevention program was set up in 2007, but overall success of the exercise based essentially on dissuasion of marriages is not very promising.
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Affiliation(s)
- Anuja P Premawardhena
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
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7
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Darshana T, Rees D, Premawardhena A. Hydroxyurea and blood transfusion therapy for Sickle cell disease in South Asia: inconsistent treatment of a neglected disease. Orphanet J Rare Dis 2021; 16:148. [PMID: 33757549 PMCID: PMC7989007 DOI: 10.1186/s13023-021-01781-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/16/2021] [Indexed: 04/12/2024] Open
Abstract
Background Hydroxyurea and blood transfusion therapies remain the main therapeutic strategies for Sickle cell disease. Preliminary data suggest substantial variation and inconsistencies in practice of these two therapeutic modalities in South Asia. In this systematic review we searched Medline, Cochrane library and Scopus for articles on usage of hydroxyurea and blood transfusion therapies for sickle cell disease in South Asia published in English between October 2005 and October 2020. Results We selected 41 papers: 33 from India, 3 from Sri Lanka, 2 each from Pakistan and Bangladesh and one from Nepal. Only 14 prospective trials focused on hydroxyurea therapy from which majority (n = 10; 71.4%) adopted fixed low dose (10 mg/kg/day) regimen. With hydroxyurea therapy, 12 and 9 studies reported significant reductions in vaso-occlusive crises and transfusion requirement respectively. Severe anaemia (haemoglobin level < 6–7 g/dl) was the commonest indicator (n = 8) for transfusion therapy followed by vaso-occlusive crisis. Conclusions Published data on the hydroxyurea and transfusion therapies in South Asia are limited and heterogeneous. A clear gap of knowledge exists about the nature of the sickle cell disease in the Indian subcontinent particularly from countries outside India necessitating further evidence-based assessments and interventions.
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Affiliation(s)
- Thamal Darshana
- Department of Medical Laboratory Sciences, Faculty of Allied Health Sciences, University of Sri Jayewardenepura, Gangodawila, 10250, Nugegoda, Sri Lanka.
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Yasara N, Wickramarathne N, Mettananda C, Manamperi A, Premawardhena A, Mettananda S. Efficacy and safety of oral hydroxyurea in transfusion-dependent β-thalassaemia: a protocol for randomised double-blind controlled clinical trial. BMJ Open 2020; 10:e041958. [PMID: 33109679 PMCID: PMC7592299 DOI: 10.1136/bmjopen-2020-041958] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Despite being one of the first diseases to be genetically characterised, β-thalassaemia remains a disorder without a cure in a majority of patients. Most patients with β-thalassaemia receive only supportive treatment and therefore have a poor quality of life and shorter life spans. Hydroxyurea, which has shown to induce fetal haemoglobin synthesis in human erythroid cells, is currently recommended for the treatment of sickle cell disease. However, its clinical usefulness in transfusion-dependent β-thalassaemia is unclear. Here, we present a protocol for a randomised double-blind controlled clinical trial to evaluate the efficacy and safety of oral hydroxyurea in transfusion-dependent β-thalassaemia. METHODS AND ANALYSIS This single-centre randomised double-blind placebo-controlled clinical trial is conducted at the Thalassaemia Centre of Colombo North Teaching Hospital, Ragama, Sri Lanka. Adult and adolescent patients with haematologically and genetically confirmed transfusion-dependent β-thalassaemia are enrolled and randomised into the intervention or control group. The intervention group receives oral hydroxyurea 10-20 mg/kg daily for 6 months, while the control group receives a placebo which is identical in size, shape and colour to hydroxyurea without its active ingredient. Transfused blood volume, pretransfusion haemoglobin level, fetal haemoglobin percentage and adverse effects of treatment are monitored during treatment and 6 months post-treatment. Cessation or reduction of blood transfusions during the treatment period will be the primary outcome measure. The statistical analysis will be based on intention to treat. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Ethics Committee of Faculty of Medicine, University of Kelaniya (P/116/05/2018) and the trial is approved by the National Medicinal Regulatory Authority of Sri Lanka. Results of the trial will be disseminated in scientific publications in reputed journals. TRIAL REGISTRATION NUMBER SLCTR/2018/024; Pre-results.
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Affiliation(s)
- Nirmani Yasara
- Department of Paediatrics, University of Kelaniya, Ragama, Sri Lanka
| | | | | | - Aresha Manamperi
- Molecular Medicine Unit, University of Kelaniya, Ragama, Sri Lanka
| | - Anuja Premawardhena
- Department of Medicine, University of Kelaniya, Ragama, Sri Lanka
- Colombo North Teaching Hospital, Ragama, Sri Lanka
| | - Sachith Mettananda
- Department of Paediatrics, University of Kelaniya, Ragama, Sri Lanka
- Colombo North Teaching Hospital, Ragama, Sri Lanka
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Darshana T, Bandara D, Nawarathne U, de Silva U, Costa Y, Pushpakumara K, Pathirage S, Basnayake S, Epa C, Dilrukshi P, Wijayawardena M, Anthony AA, Rodrigo R, Manamperi A, Smith F, Allen A, Menzel S, Rees D, Premawardhena A. Sickle cell disease in Sri Lanka: clinical and molecular basis and the unanswered questions about disease severity. Orphanet J Rare Dis 2020; 15:177. [PMID: 32631379 PMCID: PMC7339547 DOI: 10.1186/s13023-020-01458-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 06/29/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Though case reports and limited case series of Sickle cell disease in Sri Lanka have been reported previously, no attempt has been made hitherto to undertake a comprehensive genotypic-phenotypic analysis of this "rare" group of patients. RESULTS All accessible Sickle cell disease patients, totaling 60, including, 51 Sickle β-thalassaemia and 9 homozygous sickle patients were enrolled from seven thalassaemia treatment centres between December 2016-March 2019. The majority of patients were of Sinhalese ethnicity (n = 52, 86.67%). Geographically, two prominent clusters were identified and the distribution of Sickle haemoglobin in the island contrasted markedly with the other haemoglobinopathies. 3/ 9 homozygous sickle patients and 3/ 51 Sickle β-thalassaemia patients were receiving regular transfusion. Joint pain was the commonest clinical symptom among all sickle cell disease patients (n = 39, 65.0%). Dactylitis was significantly more common in homozygous sickle patients compared with the Sickle β-thalassaemia groups (p 0.027). Two genetic backgrounds sickle mutation were identified namely, Arab Indian and Benin. Among the regulators of Foetal hemoglobin in Sickle patients of the present study rs1427407 G > T seemed to be the most prominent modifier, with a significant association with Foetal haemoglobin levels (p 0.04). CONCLUSIONS Overall, the clinical course of the Asian version of Sickle cell disease in Sri Lanka appears to be milder than that described in India.
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Affiliation(s)
- Thamal Darshana
- Department of Medical Laboratory Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka.
| | - Dayananda Bandara
- National Thalassaemia Centre, Teaching Hospital, Kurunegala, Sri Lanka
| | - Upul Nawarathne
- Department of Pediatrics, Teaching Hospital, Kurunegala, Sri Lanka
| | - Udaya de Silva
- Thalassaemia Unit, Teaching Hospital, Anuradhapura, Sri Lanka
| | - Yasinta Costa
- Department of Haematology, Teaching Hospital, Ragama, Sri Lanka
| | | | - Sumithra Pathirage
- Department of Pediatrics, District General Hospital, Hambantota, Sri Lanka
| | - Seuwandi Basnayake
- Department of Haematology, District General Hospital, Monaragala, Sri Lanka
| | - Chamila Epa
- Department of Haematology, Teaching Hospital, Batticaloa, Sri Lanka
| | | | | | - Angela A Anthony
- Department of Clinical Sciences, Eastern University, Batticaloa, Sri Lanka
| | - Rexan Rodrigo
- Thalassaemia Adult and Adolescent Care Centre, Teaching Hospital, Ragama, Sri Lanka
| | - Aresha Manamperi
- Molecular Medicine Unit, University of Kelaniya, Ragama, Sri Lanka
| | - Frances Smith
- Molecular Pathology Department, Viapath at King's College Hospital, London, UK
| | - Angela Allen
- Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Stephan Menzel
- School of Cancer and Pharmaceutical Sciences, The Rayne Institute, King's College London, London, UK
| | - David Rees
- Department of Haematological Medicine, King's College Hospital, London, UK
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Mettananda S, Paranamana S, Fernando R, Suranjan M, Rodrigo R, Perera L, Vipulaguna T, Fernando P, Fernando M, Dayanath BKTP, Costa Y, Premawardhena A. Microcytic anemia in children: parallel screening for iron deficiency and thalassemia provides a useful opportunity for thalassemia prevention in low- and middle-income countries. Pediatr Hematol Oncol 2020; 37:326-336. [PMID: 32072846 DOI: 10.1080/08880018.2020.1725200] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Microcytic anemia in children is commonly attributed to iron deficiency without attempting to find the cause. Inadequate investigations to exclude hemoglobinopathies lead to missed opportunities for identification of thalassemia carriers. Here we aim to describe the relative contribution of iron deficiency and thalassemia to microcytic anemia in children. This hospital-based prospective study was conducted at the Colombo North Teaching Hospital, Ragama, Sri Lanka. All newly diagnosed patients with microcytic anemia were recruited and data were collected using an interviewer-administered questionnaire. Full blood count, blood film, serum ferritin, c-reactive protein, quantification of hemoglobin sub-types and α-globin genotype were performed using 4 ml of venous blood. A total of 104 children (Male- 60.5%) were recruited. Iron deficiency was the cause for anemia in 49% whilst 16% and 10% had α- and β-thalassemia trait respectively. Seven (6.7%) children had co-existing iron deficiency and thalassemia trait while two coinherited α- and β-thalassemia trait. Children with β-thalassemia trait had significantly higher red cell count and lower mean corpuscular volume compared to children with iron deficiency. However, none of the red cell parameters were significantly different between children with α-thalassemia trait and iron deficiency. Iron deficiency contributes only to half of children with microcytic anemia; one-fourth had thalassemia trait. Co-existence of iron deficiency and thalassemia trait or co-inheritance of α- and β-thalassemia trait were found in 9%. Parallel investigation of children with microcytic anemia to diagnose iron deficiency and thalassemia provides an opportunity to identify thalassemia carriers which is beneficial for thalassemia prevention.
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Affiliation(s)
- Sachith Mettananda
- Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka.,Colombo North Teaching Hospital, Ragama, Sri Lanka
| | | | | | - Marius Suranjan
- Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Rexan Rodrigo
- Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Lakshman Perera
- Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | | | | | | | | | | | - Anuja Premawardhena
- Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka.,Colombo North Teaching Hospital, Ragama, Sri Lanka
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Marriage patterns in Sri Lanka and the prevalence of parental consanguinity in patients with β-thalassaemia: a cross-sectional descriptive analysis. J Biosoc Sci 2019; 52:573-584. [PMID: 31648661 DOI: 10.1017/s0021932019000658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Consanguineous marriages potentially play an important role in the transmission of β-thalassaemia in many communities. This study aimed to determine the rate and socio-demographic associations of consanguineous marriages and to assess the influence on the prevalence of β-thalassaemia in Sri Lanka. Three marriage registrars from each district of Sri Lanka were randomly selected to prospectively collect data on all couples who registered their marriage during a 6-month period starting 1st July 2009. Separately, the parents of patients with β-thalassaemia were interviewed to identify consanguinity. A total of 5255 marriages were recorded from 22 districts. The average age at marriage was 27.3 (±6.1) years for males and 24.1 (±5.7) years for females. A majority (71%) of marriages were 'love' marriages, except in the Moor community where 84% were 'arranged' marriages. Overall, the national consanguinity rate was 7.4%. It was significantly higher among ethnic Tamils (22.4%) compared with Sinhalese (3.8%) and Moors (3.2%) (p < 0.001). Consanguinity rates were also higher in 'arranged' as opposed to 'love' marriages (11.7% vs 5.6%, p < 0.001). In patients with β-thalassaemia, the overall consanguinity rate was 14.5%; it was highest among Tamils (44%) and lowest among Sinhalese (12%). Parental consanguinity among patients with β-thalassaemia was double the national average. Although consanguinity is not the major factor in the transmission of the disease in the country, emphasis should be given to this significant practice when conducting β-thalassaemia prevention and awareness campaigns, especially in high-prevalence communities.
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Allen A, Perera S, Perera L, Rodrigo R, Mettananda S, Matope A, Silva I, Hameed N, Fisher CA, Olivieri N, Weatherall DJ, Allen S, Premawardhena A. A "One-Stop" Screening Protocol for Haemoglobinopathy Traits and Iron Deficiency in Sri Lanka. Front Mol Biosci 2019; 6:66. [PMID: 31448286 PMCID: PMC6696778 DOI: 10.3389/fmolb.2019.00066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/24/2019] [Indexed: 01/19/2023] Open
Abstract
Introduction: The high frequencies of carriers of severe haemoglobinopathies and of iron deficiency in Southeast Asia require reliable and affordable tests to improve on current screening procedures. Objectives: We evaluate a "one stop" approach using the THALCON dichlorophenolindophenol (DCIP) and one-tube osmotic fragility (OF) tests and measurement of Zinc Protoporphyrin (ZPP) to detect and distinguish HbE and β-thalassaemia traits from iron deficiency. We compare findings with current screening practice in Sri Lanka that relies on the identification of low mean red cell volume and/or mean red cell hemoglobin for this purpose. Methods: Between November 2017 and May 2018, we undertook a cross-sectional survey of secondary school students in Gampaha district, Sri Lanka. The THALCON-DCIP and OF tests were compared to capillary electrophoresis (CE), used as a gold standard to detect haemoglobinopathies. ZPP was measured in whole blood. Plasma ferritin and C-reactive protein (CRP) were measured in students with a raised ZPP concentration. Results: We collected venous blood samples from 1,324/1,332 (99.4%) students. The median age of the students was 17 (IQR 16-18) years, all were Sinhalese and 814/1,324 (61.5%) were female. CE identified 3 students with HbE trait and 26 students with β-thalassaemia trait. The THALCON-DCIP test was positive only in the 3 students with HbE (sensitivity 100%, 95% CI 29.2-100.0; specificity 100%, 95% CI 99.7-100.0). The THALCON-OF test identified all 26 students with β-thalassaemia trait (sensitivity = 100%, 95% CI 86.8-100.0) and 287 students with a normal CE result (specificity = 77.9%; 95% CI 75.5-80.1). It was also positive in 2/3 (66.7%) students with HbE trait. Iron deficiency (ZPP > 70 μmol/mol heme) was present in 118/1,240 (9.5%) students with a normal hemoglobin genotype, all of whom had plasma ferritin <15 ng/ml and CRP <5 mg/L. Conclusion: This one-stop approach offers reliable and affordable population screening for both haemoglobinopathy traits and iron deficiency in resource-limited settings where these conditions are common and ensures that iron supplements are targeted only to those who require them. Further work is warranted to refine the OF test to reduce the number of false positive results.
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Affiliation(s)
- Angela Allen
- MRC Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom.,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Shiromi Perera
- Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka
| | - Luxman Perera
- Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka
| | - Rexan Rodrigo
- Thalassemia Care Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka
| | | | - Agnes Matope
- Tropical Clinical Trials Unit, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Ishari Silva
- Thalassemia Care Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka
| | - Nizri Hameed
- Thalassemia Care Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka
| | - Christopher A Fisher
- MRC Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Nancy Olivieri
- Pediatrics, Medicine, and Public Health Sciences, University of Toronto, Toronto, ON, Canada
| | - David J Weatherall
- MRC Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Stephen Allen
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Anuja Premawardhena
- Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka.,Thalassemia Care Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka
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Mettananda S, Pathiraja H, Peiris R, Bandara D, de Silva U, Mettananda C, Premawardhena A. Health related quality of life among children with transfusion dependent β-thalassaemia major and haemoglobin E β-thalassaemia in Sri Lanka: a case control study. Health Qual Life Outcomes 2019; 17:137. [PMID: 31395066 PMCID: PMC6686351 DOI: 10.1186/s12955-019-1207-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/30/2019] [Indexed: 01/19/2023] Open
Abstract
Background Thalassaemia is a chronic disease without an effective cure in a majority. The clinical management has improved considerably during recent years; however, minimal attempts are made to up lift the quality of life among patients, especially in developing countries. Here we aim to describe and compare and to determine factors associated with health related quality of life among patients with transfusion dependent β-thalassaemia major and haemoglobin E β-thalassemia in Sri Lanka. Methods A case control study was conducted in the three largest thalassaemia centres of Sri Lanka. All patients with transfusion dependent β-thalassaemia (β-thalassaemia major and haemoglobin E β-thalassaemia) aged 5–18 years were recruited as cases whilst a randomly selected group of children without chronic diseases were recruited as controls. Socio-demographic and clinical data were collected using an interviewer-administered questionnaire and health related quality of life was measured using the validated Paediatric Quality of Life Inventory Version 4.0. Results Two hundred and seventy one patients with transfusion dependent β-thalassaemia (male-49.1%; mean age- 10.9 ± 3.6 years) and 254 controls (male-47.2%; mean age- 10.4 ± 3.5 years) were recruited. Mean health-related quality of life scores were significantly lower in patients compared to controls (72.9 vs. 91.5, p < 0.001). Of the patients, 224 (84%) had β-thalassaemia major and 43 (16%) had haemoglobin E β-thalassaemia. Quality of life scores in psychological health (p < 0.05), emotional functioning (p < 0.05) and social functioning (p < 0.05) were significantly lower in patients with haemoglobin E β-thalassaemia compared to β-thalassaemia major. Splenectomy (p < 0.05), short stature (p < 0.05), under nutrition (p < 0.05) and longer hospital stays (p < 0.05) were significantly associated with lower quality of life scores. Conclusions Despite improvements in management, the quality of life among patients with β-thalassaemia still remains low. This is more pronounced in the subset of patients with haemoglobin E β-thalassaemia. Splenectomy, short stature, undernutrition and longer hospital stays were significantly associated with poor quality of life. It is timely, even in developing countries, to direct emphasis and to take appropriate steps to improve standards of living and quality of life of patients with β-thalassaemia.
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Affiliation(s)
- Sachith Mettananda
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Thalagolla Road, Ragama, 11010, Sri Lanka. .,Colombo North Teaching Hospital, Ragama, Sri Lanka.
| | - Hashan Pathiraja
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Thalagolla Road, Ragama, 11010, Sri Lanka
| | - Ravindu Peiris
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Thalagolla Road, Ragama, 11010, Sri Lanka
| | | | | | - Chamila Mettananda
- Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Anuja Premawardhena
- Colombo North Teaching Hospital, Ragama, Sri Lanka.,Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
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Hockham C, Ekwattanakit S, Bhatt S, Penman BS, Gupta S, Viprakasit V, Piel FB. Estimating the burden of α-thalassaemia in Thailand using a comprehensive prevalence database for Southeast Asia. eLife 2019; 8:40580. [PMID: 31120421 PMCID: PMC6533055 DOI: 10.7554/elife.40580] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 05/01/2019] [Indexed: 12/27/2022] Open
Abstract
Severe forms of α-thalassaemia, haemoglobin H disease and haemoglobin Bart’s hydrops fetalis, are an important public health concern in Southeast Asia. Yet information on the prevalence, genetic diversity and health burden of α-thalassaemia in the region remains limited. We compiled a geodatabase of α-thalassaemia prevalence and genetic diversity surveys and, using geostatistical modelling methods, generated the first continuous maps of α-thalassaemia mutations in Thailand and sub-national estimates of the number of newborns with severe forms in 2020. We also summarised the current evidence-base for α-thalassaemia prevalence and diversity for the region. We estimate that 3595 (95% credible interval 1,717–6,199) newborns will be born with severe α-thalassaemia in Thailand in 2020, which is considerably higher than previous estimates. Accurate, fine-scale epidemiological data are necessary to guide sustainable national and regional health policies for α-thalassaemia management. Our maps and newborn estimates are an important first step towards this aim. Editorial note: This article has been through an editorial process in which the authors decide how to respond to the issues raised during peer review. The Reviewing Editor's assessment is that all the issues have been addressed (see decision letter).
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Affiliation(s)
- Carinna Hockham
- The George Institute for Global Health, Sydney, Australia.,Evolutionary Ecology of Infectious Disease Group, Department of Zoology, University of Oxford, Oxford, United Kingdom
| | - Supachai Ekwattanakit
- Thalassaemia Centre, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Samir Bhatt
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College, London, United Kingdom
| | - Bridget S Penman
- Warwick Infectious Disease Epidemiology Research, School of Life Sciences, Warwick University, Coventry, United Kingdom
| | - Sunetra Gupta
- Evolutionary Ecology of Infectious Disease Group, Department of Zoology, University of Oxford, Oxford, United Kingdom
| | - Vip Viprakasit
- Thalassaemia Centre, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Department of Paediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Frédéric B Piel
- MRC-PHE Centre for Environment and Health, Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom
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Mettananda S, Pathiraja H, Peiris R, Wickramarathne N, Bandara D, de Silva U, Mettananda C, Premawardhena A. Blood transfusion therapy for β-thalassemia major and hemoglobin E β-thalassemia: Adequacy, trends, and determinants in Sri Lanka. Pediatr Blood Cancer 2019; 66:e27643. [PMID: 30697927 DOI: 10.1002/pbc.27643] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Regular blood transfusion therapy still remains the cornerstone in the management of β-thalassemia. Although recommendations are clear for patients with β-thalassemia major, uniform transfusion guidelines are lacking for patients with hemoglobin E β-thalassemia. In this study, we aim to describe the adequacy, trends, and determinants of blood transfusion therapy in a large cohort of pediatric patients with β-thalassemia major and hemoglobin E β-thalassemia. METHODS/PROCEDURE This cross-sectional study was performed among all regularly transfused patents with β-thalassemia aged 2 to 18 years attending three large thalassemia centers in Sri Lanka. Data were collected using an interviewer-administered questionnaire, perusal of clinical records, and physical examination of patients by trained doctors. RESULTS A total of 328 patients (male 47%) were recruited; 83% had β-thalassemia major, whereas 16% had hemoglobin E β-thalassemia. Sixty-one percent of patients had low pretransfusion hemoglobin levels (< 9.0 g/dL) despite receiving high transfusion volumes (> 200 mL/kg/year) by a majority (56%). Median pretransfusion hemoglobin was significantly lower in patients with hemoglobin E β-thalassemia compared with β-thalassemia major (P < 0.001); however, there was no difference in requirement for high transfusion volumes over 200 mL/kg/year in both groups (P = 0.14). Hepatomegaly and splenomegaly were more common in hemoglobin E β-thalassemia and were associated with lower pretransfusion hemoglobin. Transfusion requirements were higher among patients with hepatitis C and in those who are underweight. CONCLUSIONS Over 60% of regularly transfused patients with β-thalassemia have low pretransfusion hemoglobin levels despite receiving large transfusion volumes. Patients with hemoglobin E β-thalassemia are undertransfused and specific recommendations should be developed to guide transfusions in these patients.
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Affiliation(s)
- Sachith Mettananda
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Sri Lanka.,Colombo North Teaching Hospital, Ragama, Sri Lanka
| | - Hashan Pathiraja
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Sri Lanka
| | - Ravindu Peiris
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Sri Lanka
| | | | | | | | - Chamila Mettananda
- Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Sri Lanka
| | - Anuja Premawardhena
- Colombo North Teaching Hospital, Ragama, Sri Lanka.,Department of Medicine, Faculty of Medicine, University of Kelaniya, Sri Lanka
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16
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Allen A, Premawardhena A, Allen S, Rodrigo R, Manamperi A, Perera L, Wray K, Armitage A, Fisher C, Drakesmith A, Robson K, Weatherall D. The p.H63D allele of the HFE gene protects against low iron stores in Sri Lanka. Blood Cells Mol Dis 2019; 76:72-77. [PMID: 30827762 DOI: 10.1016/j.bcmd.2019.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 02/19/2019] [Indexed: 01/02/2023]
Abstract
In hereditary hemochromatosis, iron overload is associated with homozygosity for the p.C282Y mutation. A second mutation, p.H63D, occurs at significant frequencies in Europe, North Africa, the Middle East and Asia. Early studies in Sri Lanka indicated that the variant had arisen independently, suggesting that it had been the subject of selective pressure. However, its role in iron absorption is unclear. In a survey of 7526 Sri Lankan secondary school students, we determined hemoglobin genotype and measured red cell indices, serum ferritin, transferrin receptor, iron zinc protoporphyrin and hepcidin. These variables were compared according to the presence or absence of the p.H63D variant in a subset of 1313 students for whom DNA samples were available. Students were classified as having low red cell indices if they had an MCV <80 fl and/or MCH <27 pg. Hetero and/or homozygosity for the p.H63D variant was more common in students with normal than low red cell indices (16.4% and 11.9% respectively; p = 0.019). Iron biomarkers and red cell indices were greater in children with the p.H63D variant than in normal and this was statistically significant for MCV (p = 0.046). Our findings suggest that selective pressure by mild iron deficiency contributes to the high frequencies of the p.H63D variant.
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Affiliation(s)
- Angela Allen
- MRC Molecular Hematology Unit, MRC Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Anuja Premawardhena
- Faculty of Medicine, University of Kelaniya, Sri Lanka; Thalassemia Care Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka
| | - Stephen Allen
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Rexan Rodrigo
- Faculty of Medicine, University of Kelaniya, Sri Lanka; Thalassemia Care Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka
| | | | - Luxman Perera
- Thalassemia Care Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka
| | - Katherine Wray
- MRC Immunology Unit, MRC Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Andrew Armitage
- MRC Immunology Unit, MRC Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Christopher Fisher
- MRC Molecular Hematology Unit, MRC Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Alexander Drakesmith
- MRC Immunology Unit, MRC Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Kathryn Robson
- MRC Molecular Hematology Unit, MRC Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - David Weatherall
- MRC Molecular Hematology Unit, MRC Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
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Abstract
The thalassemias and other inherited disorders of hemoglobin are likely to remain a serious global health problem for the foreseeable future. Currently, they are most frequent in the tropical belt; an assessment of their true frequency and the likely cost of management for the governments of these countries will require a form of micromapping. Over recent years, there has been major progress toward better prevention and management of the thalassemias in richer countries; it is likely that, using the tools of molecular genetics, they will eventually be completely curable, although this is probably a long time in the future.
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Affiliation(s)
- David J Weatherall
- University of Oxford, Weatherall Institute of Molecular Medicine, John Radcilffe Hospital, Headington, Oxford OX3 9DS, UK.
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18
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Mettananda S, Suranjan M, Fernando R, Dias T, Mettananda C, Rodrigo R, Perera L, Gibbons R, Premawardhena A, Higgs D. Anaemia among females in child-bearing age: Relative contributions, effects and interactions of α- and β-thalassaemia. PLoS One 2018; 13:e0206928. [PMID: 30388173 PMCID: PMC6214573 DOI: 10.1371/journal.pone.0206928] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 10/21/2018] [Indexed: 12/04/2022] Open
Abstract
Introduction Anaemia in women during pregnancy and child bearing age is one of the most common global health problems. Reasons are numerous, but in many cases only minimal attempts are made to elucidate the underlying causes. In this study we aim to identify aetiology of anaemia in women of child bearing age and to determine the relative contributions, effects and interactions of α- and β-thalassaemia in a region of the world where thalassaemia is endemic. Methods A cross sectional study was conducted at the Colombo North Teaching Hospital of Sri Lanka. The patient database of deliveries between January 2015 and September 2016 at University Obstetrics Unit was screened to identify women with anaemia during pregnancy and 253 anaemic females were randomly re-called for the study. Data were collected using an interviewer-administered questionnaire and haematological investigations were done to identify aetiologies. Results Out of the 253 females who were anaemic during pregnancy and were re-called, 8 were excluded due to being currently pregnant. Of the remaining 245 females, 117(47.8%) remained anaemic and another 22(9.0%) had non-anaemic microcytosis. Of anaemic females, 28(24.8%) were iron deficient, 40(35.4%) had low-normal serum ferritin without fulfilling the criteria for iron deficiency,18(15.3%) had β-haemoglobinopathy trait and 20(17.0%) had α-thalassaemia trait. Of females who had non-anaemic microcytosis, 14(66.0%) had α-thalassaemia trait. In 4 females, both α- and β-thalassaemia trait coexist. These females had higher levels of haemoglobin (p = 0.06), MCV (p<0.05) and MCH (p<0.01) compared to individuals with only β-thalassaemia trait. A significantly higher proportion of premature births (p<0.01) and lower mean birth weights (p<0.05) were observed in patients with α-thalassaemia trait. Conclusions Nearly one third of anaemic females in child bearing age had thalassaemia trait of which α-thalassemia contributes to a majority. Both α- and β-thalassaemia trait can co-exist and have ameliorating effects on red cell indices in heterozygous states. α-Thalassaemia trait was significantly associated with premature births and low birth weight. It is of paramount importance to investigate the causes of anaemia in women of child bearing age and during pregnancy in addition to providing universal iron supplementation.
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Affiliation(s)
- Sachith Mettananda
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
- Colombo North Teaching Hospital, Ragama, Sri Lanka
- * E-mail:
| | - Marius Suranjan
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Roshale Fernando
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Tiran Dias
- Colombo North Teaching Hospital, Ragama, Sri Lanka
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Chamila Mettananda
- Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Rexan Rodrigo
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Lakshman Perera
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Richard Gibbons
- MRC Molecular Haematology Unit, MRC Weatherall Institute Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Anuja Premawardhena
- Colombo North Teaching Hospital, Ragama, Sri Lanka
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Douglas Higgs
- MRC Molecular Haematology Unit, MRC Weatherall Institute Molecular Medicine, University of Oxford, Oxford, United Kingdom
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Wray K, Allen A, Evans E, Fisher C, Premawardhena A, Perera L, Rodrigo R, Goonathilaka G, Ramees L, Webster C, Armitage AE, Prentice AM, Weatherall DJ, Drakesmith H, Pasricha SR. Hepcidin detects iron deficiency in Sri Lankan adolescents with a high burden of hemoglobinopathy: A diagnostic test accuracy study. Am J Hematol 2017; 92:196-203. [PMID: 27883199 PMCID: PMC5324588 DOI: 10.1002/ajh.24617] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 11/22/2016] [Accepted: 11/23/2016] [Indexed: 12/23/2022]
Abstract
Anemia affects over 800 million women and children globally. Measurement of hepcidin as an index of iron status shows promise, but its diagnostic performance where hemoglobinopathies are prevalent is unclear. We evaluated the performance of hepcidin as a diagnostic test of iron deficiency in adolescents across Sri Lanka. We selected 2273 samples from a nationally representative cross-sectional study of 7526 secondary schoolchildren across Sri Lanka and analyzed associations between hepcidin and participant characteristics, iron indices, inflammatory markers, and hemoglobinopathy states. We evaluated the diagnostic accuracy of hepcidin as a test for iron deficiency with estimation of the AUCROC , sensitivity/specificity at each hepcidin cutoff, and calculation of the Youden Index to find the optimal threshold. Hepcidin was associated with ferritin, sTfR, and hemoglobin. The AUCROC for hepcidin as a test of iron deficiency was 0.78; hepcidin outperformed Hb and sTfR. The Youden index-predicted cutoff to detect iron deficiency (3.2 ng/mL) was similar to thresholds previously identified to predict iron utilization and identify deficiency in African populations. Neither age, sex, nor α- or β-thalassemia trait affected diagnostic properties of hepcidin. Hepcidin pre-screening would prevent most iron-replete thalassemia carriers from receiving iron whilst still ensuring most iron deficient children were supplemented. Our data indicate that the physiological relationship between hepcidin and iron status transcends specific populations. Measurement of hepcidin in individuals or populations could establish the need for iron interventions. Am. J. Hematol. 92:196-203, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Katherine Wray
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford; Oxford UK
- BRC Blood Theme; NIHR Oxford Biomedical Research Centre; Oxford UK
| | - Angela Allen
- Liverpool School of Tropical Medicine; Centre for Tropical and Infectious Diseases; Liverpool UK
| | - Emma Evans
- Department of Biochemistry and Immunology; Birmingham Heartlands Hospital; Birmingham UK
| | - Chris Fisher
- MRC Molecular Haematology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford; Oxford UK
| | | | - Lakshman Perera
- Department of Medicine; University of Kelaniya; Colombo Sri Lanka
| | - Rexan Rodrigo
- Department of Medicine; University of Kelaniya; Colombo Sri Lanka
| | | | - Lebbe Ramees
- Department of Medicine; University of Kelaniya; Colombo Sri Lanka
| | - Craig Webster
- Department of Biochemistry and Immunology; Birmingham Heartlands Hospital; Birmingham UK
| | - Andrew E Armitage
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford; Oxford UK
| | - Andrew M Prentice
- MRC Unit The Gambia, MRC Keneba; The Gambia
- MRC International Nutrition Group, London School of Hygiene and Tropical Medicine; London UK
| | - David J Weatherall
- MRC Molecular Haematology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford; Oxford UK
| | - Hal Drakesmith
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford; Oxford UK
- BRC Blood Theme; NIHR Oxford Biomedical Research Centre; Oxford UK
| | - Sant-Rayn Pasricha
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford; Oxford UK
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