Haematological and electrophoretic characterisation of β-thalassaemia in Yunnan province of Southwestern China

Phenotypic Variability and Hematological Characterization of β0- and β+-Thalassemia Carriers: A Comparative Study

Background

β-Thalassemia is a genetic disorder characterized by decreased or completely absent β-globin synthesis, leading to a spectrum of clinical manifestations. It is a major public health concern in Jordan, as in other Mediterranean countries. β-Thalassemia carriers are normally asymptomatic; nevertheless, laboratory examinations often reveal mild anemia characterized by microcytic hypochromic erythrocytes, with differences influenced by specific phenotypes. This study aimed to assess and correlate the variants among β0 and β+ phenotypes in the Jordanian population with hematological characteristics, as well as establish and determine reference values for distinguishing between the two phenotypes.

Methods

One hundred forty-five β-thalassemia carriers were recruited from various governorates in Jordan. Hematological parameters, including complete blood count (CBC) and capillary electrophoresis of hemoglobin (Hb), were evaluated in all participants. Molecular techniques, specifically polymerase chain reaction (PCR) with hybridization, were employed to identify β-thalassemia variants and classify the participants as having β0 and β+ phenotypes.

Results

Among the 145 β-thalassemia carriers, 64 (44.14%) and 81 (55.86%) had β0-thalassemia and β+-thalassemia, respectively. Participants exhibiting a cutoff value of Hb (≤ 11.0 g/dL), mean corpuscular volume (MCV) (≤ 64.0 fL), mean corpuscular hemoglobin (MCH) (≤ 19.0 pg), and hemoglobin A2 (Hb-A2) (≥ 5.00%) were classified as having the β0 phenotype. These participants demonstrated significantly lower mean Hb, MCV, MCH, and higher mean Hb-A2 than the participants with the β+ phenotype (P < 0.0001).

Conclusions

Hb, MCV, MCH, and Hb-A2 can serve as effective screening tools for predicting β0- and β+-thalassemia in the Jordanian population. These findings have important clinical implications for early diagnosis, genetic counseling, and prenatal screening of β-thalassemia.

Case report: A rare heterozygous Hb CS with heterozygous HbE in a family with thalassemia in China

Thalassemia is a hemoglobin disease characterized by reduced or complete absence of the production of the α/β globin gene. Currently, the detection of β-thalassemia carriers is based on differences in blood cell parameters. However, β-thalassemia carriers cannot be distinguished from α- and β-thalassemia co-inherited carriers based solely on hematological findings, and the differential diagnosis must rely on molecular diagnosis. We report a 32-year-old male from Yunnan Province, who had abnormal hemoglobin E without obvious anemia. A rare αCS (CD142, TAA→CAA) combined with a βE (CD26, GAG→AAG) double heterozygous mutation was identified in the proband by PCR-reverse dot blot (PCR-RDB) and DNA sequencing. Additionally, a family lineage analysis was performed. This study complements the spectrum of rare thalassemia gene variants and is critical for clinical genetic counseling.

Epidemiology of clinically significant forms of alpha- and beta-thalassemia: A global map of evidence and gaps

This systematic literature review assessed the global prevalence and birth prevalence of clinically significant forms of alpha- and beta-thalassemia. Embase, MEDLINE, and the Cochrane Library were searched for observational studies published January 1, 2000, to September 21, 2021. Of 2093 unique records identified, 69 studies reported across 70 publications met eligibility criteria, including 6 records identified from bibliography searches. Thalassemia prevalence estimates varied across countries and even within countries. Across 23 population-based studies reporting clinically significant alpha-thalassemia (e.g., hemoglobin H disease and hemoglobin Bart's hydrops fetalis) and/or beta-thalassemia (beta-thalassemia intermedia, major, and/or hemoglobin E/beta-thalassemia), prevalence estimates per 100 000 people ranged from 0.2 in Spain (over 2014-2017) to 27.2 in Greece (2010-2015) for combined beta- plus alpha-thalassemia; from 0.03 in Spain (2014-2017) to 4.5 in Malaysia (2007-2018) for alpha-thalassemia; and from 0.2 in Spain (2014-2017) to 35.7 to 49.6 in Iraq (2003-2018) for beta-thalassemia. Overall, the estimated prevalence of thalassemia followed the predicted pattern of being higher in the Middle East, Asia, and Mediterranean than in Europe or North America. However, population-based prevalence estimates were not found for many countries, and there was heterogeneity in case definitions, diagnostic methodology, type of thalassemia reported, and details on transfusion requirements. Limited population-based birth prevalence data were found. Twenty-seven studies reported thalassemia prevalence from non-population-based samples. Results from such studies likely do not have countrywide generalizability as they tended to be from highly specific groups. To fully understand the global prevalence of thalassemia, up-to-date, population-based epidemiological data are needed for many countries.

Mutational analysis of hemoglobin genes and functional characterization of detected variants, through in-silico analysis, in Pakistani beta-thalassemia major patients

Thalassemia is one of the most prevalent genetic disorders worldwide. The present study aimed to explore the mutational spectrum of all hemoglobin (HB) encoding genes and to identify the potentially damaging and pathogenic variants in the beta (β)-thalassemia major patients and thalassemia minor carriers of Southern Punjab, Pakistan. A total of 49 β-thalassemia major patients and 49 carrier samples were screened for the identification of HBA1, HBA2, HBB, HBD, HBE1, HBG1 and HBG2 variants by NGS. PCR was performed for the amplification of HB encoding genes and the amplified product of 13 patients and 7 carrier samples were processed for the Sanger sequencing. Various bioinformatics tools and databases were employed to reveal the functional impact and pathogenicity potential of the observed variants. Results depicted a total of 20 variants of HB-related genes by NGS and 5 by Sanger sequencing in thalassemia patients. While 20 variants by NGS and 3 by Sanger were detected in carriers. Few known genetic variants of HB-encoding genes are being reported for the first time in Pakistani thalassemia patients and carriers. However, two novel HBB variants c.375A>C (p.P125P) and c.*61T>G and a novel variant of HBE1 (c.37A>T (p.T13S)) were also documented. Pathogenicity analysis predicted the pathogenic potential of HBB variants (c.47G>A (p.W16*), c.27-28insG (p. S10fs), and c.92+5G>C) for β thalassemia. The study of functional impact indicated that these HBB variants result in the premature termination of translation leading to the loss of functional β-globin protein. It is therefore suggested that the pathogenic HBB variants, identified during present study, can be employed for the diagnosis, carrier screening, and planning therapy of thalassemia.

Thalassemia and Hemoglobinopathy Screening in Women Attending Antenatal Clinic at a Tertiary Care Center in Uttarakhand, India: A Re-look at the Laboratory Parameters Mandating High-Performance Liquid Chromatography Workup

INTRODUCTION

Thalassemia and hemoglobinopathies are the most common inherited hematological disorders. Of these, β thalassemia is the commonest disorder reported in India, followed by certain hemoglobinopathies encountered in different regions of the country. The data pertaining to the incidence of these disorders in the Uttarakhand region of India are sparse.

AIM AND OBJECTIVES

To ascertain the prevalence and spectrum of thalassemia/hemoglobinopathies amongst antenatal women in Uttarakhand. The study also aimed to analyze the ability of red cell indices in differentiating beta thalassemia trait (BTT) from mild iron deficiency anemia (IDA).

MATERIAL AND METHODS

A total of 460 pregnant women in the first trimester of pregnancy were screened by cation exchange high-performance liquid chromatography. Retention time and proportions of normal/abnormal hemoglobin peaks were documented in all cases. Hemoglobin A2 (HbA2) values of ≥4% were taken as a cut-off for diagnosing BTT. Blood samples were also collected for complete blood counts, reticulocyte counts, and serum ferritin. The ability of the various discriminatory indices to differentiate between IDA and BTT was also assessed.

RESULTS

The prevalence of BTT and hemoglobin D-Punjab trait amongst pregnant women was found to be 2.6% and 0.2%, respectively. RBC count, mean corpuscular volume (MCV), and mean corpuscular hemoglobin (MCH) were found to be moderately strong predictors of BTT, with an area under the curve of 0.860, 0.857, and 0.842, respectively, which were comparable to the discriminatory indices found to be most useful in this study.

CONCLUSION

In view of the 2.6% prevalence of BTT in antenatal women in this region of Uttarakhand, a routine screening will be helpful in detecting carriers early in the antenatal period. Careful interpretation of red cell indices is crucial to the distinction between BTT and IDA. Discriminatory indices are reasonably accurate in differentiating BTT from mild iron deficiency, but for practical purposes, MCV and MCH provide equivalent information to identify cases that require further workup.

Identification of a novel 107 kb deletion in the alpha-globin gene cluster using third-generation sequencing

OBJECTIVE

To describe the characterization of a novel deletion causing α-thalassemia.

METHODS

The proband, a 30-year-old female, displayed mild anemia from thalassemia screening. Gap-PCR was used to detect the four common deletional α-thalassemia, and a PCR-reverse dot blot was performed for the three point mutations of the α-globin gene. Multiplex ligation-dependent probe amplification (MLPA) was used to query possible breakpoints of a potential novel deletion. Third-generation sequencing (TGS) was used to identify the novel deletion after the MLPA failed. Gap-PCR and Sanger sequencing were validated for the breakpoint.

RESULTS

No abnormal results were detected by Gap-PCR and PCR-reverse dot blot. MLPA only showed a large deletion upstream of the HBZ-1 probe, but the scope could not be determined. However, a novel 107 kb deletion at the α-globin gene was discovered by the TGS. The Gap-PCR products with the specific breakpoint fragment of the 107 kb deletion were confirmed by Sanger sequencing.

CONCLUSIONS

A 107 kb deletion causing α-thalassemia was the first reported worldwide. TGS played an important role in this study and can be recommended as a reliable tool for rare or potential deletions in thalassemia.

Therapeutic adenine base editing of human hematopoietic stem cells

In β-thalassemia, either γ-globin induction to form fetal hemoglobin (α2γ2) or β-globin repair to restore adult hemoglobin (α2β2) could be therapeutic. ABE8e, a recently evolved adenine base editor variant, can achieve efficient adenine conversion, yet its application in patient-derived hematopoietic stem cells needs further exploration. Here, we purified ABE8e for ribonucleoprotein electroporation of β-thalassemia patient CD34+ hematopoietic stem and progenitor cells to introduce nucleotide substitutions that upregulate γ-globin expression in the BCL11A enhancer or in the HBG promoter. We observed highly efficient on-target adenine base edits at these two regulatory regions, resulting in robust γ-globin induction. Moreover, we developed ABE8e-SpRY, a near-PAMless ABE variant, and successfully applied ABE8e-SpRY RNP to directly correct HbE and IVS II-654 mutations in patient-derived CD34+ HSPCs. Finally, durable therapeutic editing was produced in self-renewing repopulating human HSCs as assayed in primary and secondary recipients. Together, these results support the potential of ABE-mediated base editing in HSCs to treat inherited monogenic blood disorders.

Prevalence and molecular characterization of common thalassemia among people of reproductive age in the border area of Guangxi-Yunnan-Guizhou province in Southwestern China

Objectives: Thalassemia, the most common global monogenetic disorder, is highly prevalent in southern China. Epidemiological and molecular characterization of thalassemia is important for designing appropriate prevention strategies in high-risk areas, especially the border area of Guangxi-Yunnan-Guizhou province in southwestern China.Methods: We recruited 38812 reproductive age couples and screened them for thalassemia. Routine blood tests as well as hemoglobin components and levels were evaluated. In addition, suspected thalassemia were identified by gap polymerase chain reaction (Gap-PCR) and PCR-based reverse dot blot (PCR-RDB).Results: The overall prevalence of thalassemia was 26.76%. Specifically, incidences of α-thalassemia, β-thalassemia, and concurrent α- and β-thalassemia were 17.52%, 6.92%, and 2.32%, respectively. The diagnosed α-thalassemia anomalies were associated with six gene mutations and 25 genotypes. The β-thalassemia anomalies were associated with 12 gene mutations and 15 genotypes. Moreover, among the 1799 concurrent mutated α- and β-thalassemia genes, 95 different genotypes were identified. Couples in which both partners were positive for α-thalassemia and β-thalassemia isotypes were 8.80% and 2.08%, respectively. The proportion of couples at a risk of having children with thalassemia major or intermedia was high.Conclusions: This study elucidates on the prevalence and molecular characterization of thalassemia in the border area of Guangxi-Yunnan-Guizhou provinces. These findings provide valuable baseline data for genetic counseling and prenatal diagnosis, with the overarching goal of preventing and controlling severe thalassemia.

Detection of hemoglobin H disease by long molecule sequencing

Background

Hemoglobin H (Hb H) disease is a moderate‐to‐severe form of α‐thalassemia (α‐thal), and parts of patients may require intermittent transfusion therapy, especially during intercurrent illness. However, rare Hb H diseases remain undetected using routine methods being outside of the testing scope. In this study, we present an approach to detecting Hb H disease by long molecule sequencing (LMS).

Methods

A total of 206 known genotype samples were collected and carried to blind detected by LMS on the PacBio Sequel platform. Circular consensus sequencing reads were aligned to the hg19 reference genome using Free‐Bayes finished LMS. LMS accuracy would be compared with routine methods, including Gap‐PCR and PCR‐Reverse dot blot hybridization (PCR–RDB).

Results

The assay could detect carriers of both deletion and point mutations. It had an overall accuracy of 100% when compared with routine methods. In addition, LMS detected six mutations based on routine methods and corrected three case results. Hb H diseases were identified using LMS, whether a common or rare genotype, a deletion or non‐deletion genotype. However, two cases of Hb H disease were misdiagnosed using routine methods.

Conclusions

Long molecule sequencing can be suggested as a rapid and reliable assay to detect probable carriers of hemoglobinopathies. LMS accurately identified the common and rare genotypes of Hb H disease.

Establishment of pregnant-specific intervals for hemoglobin (Hb) A2, HbF and cut-off points for HbA2 for thalassemia in Chongqing, China

OBJECTIVES

To analyze pregnant-specific intervals for hemoglobin A2 (HbA2), hemoglobin fetal (HbF), and cut-off points of HbA2 for thalassemia in Chongqing, China.

METHODS

Between September 2015 and April 2019, the study recruited 10039 individuals of reproductive age. Of which, 4399 healthy normal individuals were selected to determine reference values for HbA2 and HbF. The remaining 5640 individuals suspected of thalassemia were included to explore the cut-off points of HbA2 for thalassemia.

RESULTS

The reference values of HbA2 in males was 2.3-3.2%, in females was 2.1-3.1%, and in pregnant women was 1.9-3.1%. While the reference values of HbF in males was 0.0-0.0%, in females was 0.0-0.9%, and in pregnant women was 0.0-4.3%. Approximately 2.3% cut-off points for pregnant women was determined to be optimal for α-thalassemia screening. In the entire group, 2.5% was best for all α-thalassemia screenings. The cut-off for β-thalassemia screening using HbA2 was 3.2% for the entire group.

CONCLUSION

The reference interval of HbA2 for pregnant females group was significantly lower than other groups. Therefore, we recommend cut-off points of HbA2 for α-thalassemia at 2.3% for pregnant women. While partitioning was not needed due to gender. Gender and pregnancy had little effect on the cut-off points of HbA2 for β-thalassemia carrier.

Prevalence and molecular spectrum of α- and β-globin gene mutations in Hainan, China

This study investigated prenatal diagnosis of α-thalassemia and β-thalassemia in 3049 families in 18 regions of Hainan Province. Molecular diagnosis was performed in 3049 couples with thalassemia in Hainan Province. Genomic DNA was extracted from peripheral blood of the couples and villus, amniotic fluid, or cord blood of fetuses. DNA-based diagnosis was performed using polymerase chain reaction. The most commonly detected mutation for α-thalassemia was- SEA/αα (31.53%), followed by - α4.2/αα (11.15%) and - α3.7/αα (11.02%). The most common mutation for β-thalassemia was CD41/42 (30.27%), followed by - 28 (2.56%). Prevalence was highest in the coastal regions and lowest in the Wenchang, Lingao, and Ding'an regions. We also found that the most common gene mutations in Han people and other minority groups were not homogeneous. Prenatal diagnosis showed 556 normal fetuses, 116 with α-thalassemia hydrops, and 134 with β-thalassemia major. Our findings provide important information for clinical genetic counseling regarding prenatal diagnosis for thalassemia major in Hainan Province.

Mutation spectrum and erythrocyte indices characterisation of α-thalassaemia and β-thalassaemia in Sichuan women in China: a thalassaemia screening survey of 42 155 women

AIMS

The present study aims to investigate the mutation spectrum of thalassaemia, and characterise the erythrocyte indices of thalassaemia in a large cohort in Sichuan, which is a province with a high prevalence of thalassaemia in southern China.

METHODS

The present study was conducted from July 2017 to July 2019. A total of 42 155 women screened for thalassaemia were enrolled. The thalassaemia carriers were screened by erythrocyte analysis and haemoglobin electrophoresis. Then, the screening test results and genetic results were collected.

RESULTS

A total of 1109 individuals had thalassaemia gene defects. Among these individuals, 69.7% were α-thalassaemia (α-thal) and 28.6% were β-thalassaemia (β-thal). For α-thal defects, carriers with ^--SEA had the lowest mean corpuscular volume (MCV) and mean corpuscular haemoglobin (MCH) values. For β-thal defects, carriers with heterozygous haemoglobin E and -28 had the highest MCV and MCH values. In addition, an MCV cut-off of 80 fl and an MCH cut-off of 27 pg was able to detect 99.1% α0 thalassaemia and 99.7% β0/β+ thalassaemia; however, that criterion could result in a great number of false-negative results in α+ carriers.

CONCLUSION

A criterion of MCV <80 fl and MCH <27 pg is recommended for detecting -SEA carriers and β0/β+ carriers, while higher cut-offs are needed to detect α+ carriers.

Prevalence and genetic analysis of thalassemia in neonates in Wuhan area: a national megacity in central China

BACKGROUND

Thalassemia is one of the most common genetic diseases in southern China. Accurate population frequency data regarding the occurrence and distribution of thalassemia is important for designing appropriate prevention strategies of thalassemia.

OBJECTIVE

The aim of this study is to reveal the prevalence and the mutation spectrum of thalassemia in neonates in the Wuhan region of central China.

METHODS

About 3796 neonates in Wuhan area of China were analyzed by hematological and genetic analysis.

RESULTS

About 2174 subjects were genetically diagnosed as thalassemia carriers or patients, including 1415 cases of α-thalassemia (65.89%), 731 cases of β-thalassemia (33.62%), and 28 cases of α-composite β-thalassemia (1.29%). A total of 11 genotypes and 6 gene mutations were identified in α-thalassemia anomalies, with -^SEA/deletion (50.72%), -α^3.7/deletion (36.36%), and -α^4.2/deletion (7.38%) being the most common α-thalassemia mutations. β-thalassemia anomalies were associated with 17 genotypes and 12 gene mutations; IVS-2-654 mutation was the most common (41.18%), followed by CD41-42 (23.14%), CD17 (14.64%), CD26 (7.32%), and CD27-28 (4.58%) mutations. In addition, 13 genotypes were identified in α-composite β-thalassemia in thalassemia carrier, with the top six genotypes being IVS-2-654/N/-^SEA/αα (17.86%), CD17/N/-α^3.7/αα (17.86%), IVS-2-654/N/-α^3.7/αα (14.29%), CD41-42/N/-^SEA/αα (10.71%), CD71-72/N/-α^3.7/αα (7.14%), and Cap/N/-^SEA/αα (7.14%).

CONCLUSION

There was high heterogeneity and extensive spectrum of thalassemia in the neonates in Wuhan populations. The findings will be useful for genetic counseling and prenatal diagnosis of thalassemia in the Wuhan region.

Molecular epidemiology, pathogenicity, and structural analysis of haemoglobin variants in the Yunnan province population of Southwestern China

Abnormal haemoglobin (Hb) variants result in the most commonly inherited disorders in humans worldwide. In this study, we investigated the molecular epidemiology characteristics of Hb variants, along with associated structural and functional predictions in the Yunnan province population of Southwestern China. A total of 41,933 subjects who sought haemoglobinopathy screening were included. Based on bioinformatics and structural analysis, as well as protein modeling, the pathogenesis and type of Hb genetic mutations were characterized. Among all individuals studied, 328 cases (0.78%) were confirmed as carriers of Hb variants, with 13 cases (0.03%) presenting α-globin variants, 313 (0.75%) β-globin variants, and two δ-globin variants. A total of 19 different mutations were identified, including three novel mutations. In addition, 48 cases of αα^CS mutations and 14 cases of Hb H or Hb Bart’s were found. The isoelectric point, evolutionary conservation, and genotype-phenotype correlation for these mutations were predicted. Additionally, secondary and tertiary protein structure modeling were performed for three selected mutations. In conclusion, the prevalence of Hb variants in the Yunnan population is much higher than other regions of China. Complete characterization of these Hb variants is essential for generating a rational strategy to control the haemoglobinopathies in this region.

Comparison between capillary zone electrophoresis and capillary isoelectric focusing for thalassemia screening in southern China

BACKGROUND

Capillary isoelectric focusing is a type of capillary electrophoresis method newly used for thalassemia screening in China. Although the good performance has been proved by several studies, whether it can best suit the special needs of Chinese patients still requires further investigations.

METHODS

Comparisons were made between capillary zone electrophoresis method applied on Sebia Minicap and capillary isoelectric focusing method applied on Helena V8 platform E-class on identifying Hb E, Hb CS, Hb H, and Hb Barts for patients from southern China. And mixing studies were used to evaluate the lowest detection limits of these 2 kinds of capillary electrophoresis system.

RESULTS

Helena V8 could not make a distinction between peaks of Hb E and peaks of Hb A2 as Sebia Minicap did. All chosen patients with Hb H and/or Hb Barts could be screened out by both 2 systems, but when analyzed by Helena V8, it was hard to distinguish Hb H from Hb Barts sometimes, while Sebia Minicap could make a clear distinction between peaks of Hb H and Hb Barts. Only a part of patients (3 of 8, 37.5%) with Hb CS could be screened out by Helena V8, while all patients could be identified by Sebia Minicap. Sebia Minicap had a lower detection limit for trace peaks than Helena V8 (near to 0.2% vs near to 0.6%).

CONCLUSIONS

Compared with capillary zone electrophoresis, capillary isoelectric focusing applied on Helena V8 maybe is not the first choice for hemoglobinopathy testing in southern China.