thalassemia: diagnosis and treatment - tsh.or.thtsh.or.th/file_upload/files/2 kitti torcharus -...

Thalassemia: Diagnosis and Treatment

Kittti Torcharus, M.D.

Department of Pediatrics

Phramongkutklao Hospital

Scope of lecture

Incidence

Diagnosis

Blood transfusion

Iron chelation

Treatment related complications

Hematopoietic stem cell transplantation

Preimplantation genetic diagnosis (PGD)

Survival

11/23/2017 Kitti Torcharus, M.D. 2

Prevalence of Thalassemia in The world

MARCH OF DIMES GLOBAL REPORT ON BIRTH DEFECTS; 2006

Prevalence of thalassemia in Thailand

Alpha-thalassemia (%) a-thalassemia 1 Bangkok 3.5

Chiangmai 12.0 a-thalassemia 2 Bangkok 16.0 Chiangmai 19.0

Beta-thalassemia Bangkok 3.0 Chiangmai 9.0

Northeast 2-6 Hemoglobin E Bangkok 13-19

Chiangmai 8.0 Northeast 32-60

Hemoglobin Constant Spring 2-4

Prevalence of thalassemia and hemoglobinopathies

11/23/2017 Kitti Torcharus, M.D. 5 Wongprachum K, et al. Acta Haematol. 2016;135(2):65-9.

Classification: Clinical severity

Severity Clinical Hb (g/dL)

Severe Age onset of anemia < 2 yrs, Age at first blood transfusion < 4 yrs, Weight & Height lower than normal, Facial bone change, Huge splenomegaly

< 7 Homo. b0-thal (b0/b0, b0/b+), b0-thal/Hb E, surviving Hb Bart’s hydrops, Non-deletional Hb H

Moderate Anemia, jaundice, hepatomegaly, splenomegaly

7-9 Homo. b0-thal (b0/b+), b0-thal/Hb E,

Mild Anemia, jaundice, mild splenomegaly >9 Homo. B+-thal (b+/b+), b+-thal/Hb E, Hb H

Asymptomatic No symptoms normal Thal trait, Hb E trait, Homo Hb E

Transfusion-dependent thalassemia (TDT)

Severe type (Clinical severity)

Require regular transfusion with iron chelation

Maintain Hb level 9.5-10.5 g/dL

Thalassemia type: Homo. b0-thal (b0/b+, b0/b+)

b0-thal/Hb E,

Hb Bart’s hydrops fetalis (surviving)

Non-deletional Hb H

Non-transfusion-dependent thalassemia (NTDT)

Moderate-mild type (Clinical severity)

Age onset at diagnosis 2-6 yrs.

Steady-state Hb level 7-10 g/dL

Develop anemia or hemolytic crisis after infection which may require blood transfusion (occasional transfusion)

Thalassemia types: b-thalassemia intermedia (b0/b+, b+/b+),

b-thalassemia/Hb E, (b0/bE, b+/bE) Hb H disease

Clinical severity: severe thalassemia

Hb Bart’s hydrops fetalis Genotype: a-thal 1/a-thal 1

Hydrops, severe anemia

Dead in utero or after birth

Homozygous b0-thalassemia Genotype: b0-thal/b0-thal

Transfusion dependent

Clinical severity: moderate to severe thalassemia (Anemia, jaundice, occasional require blood transfusion)

b-thalassemia/ Hb E

Genotype: b0-thal/bE

Hb H with Hb CS

Genotype: a-thal 1/Hb CS

Mild thalassemia (Anemia, jaundice, not require blood transfusion)

b-thalassemia/ Hb E

Genotype: b+-thal/bE

Hb H disease Genotype: a-thal 1/a-thal 2

Hemolytic crisis in Hb H

Symptoms Fever, pallor, jaundice

Dark urine

Hepato-splenomegaly

Etiology (infection) Influenza, typhoid,

malaria, Dengue hemorrhagic fever

Treatment Treat infection

PRC transfusion

Diagnosis: thalassemia disease

CBC : anemia

Red cell indicies

MCV <80 fL, MCH < 27 pg, RDW > 16%

Blood smear: red cell morphology

Hypochromic, microcytic, anisocytosis, poikilocytosis, target cell

Reticulocytosis

Inclusion bodies

Hb H disease

Hb typing (Hb analysis)

Inclusion bodies Reticulocyte

Blood Smear of thalassemia disease

Hb H disease Hypochromic

Microcytic

Anisocytosis (varied size RBC)

Poikilocytosis (varied RBC morphology)

Beta-thalassemia/Hb E Anisocytosis (varied size RBC)

Poikilocytosis (varied RBC morphology)

Nucleated red cell (NRC)

Target cells

23/11/2017 Torcharus K 14

Diagnosis: thalassemia trait

Carrier screening:

Complete blood count: red cell indicies

MCV < 80 fL, MCH < 27 pg

One tube osmotic fragility (OF) test

Positive: b-thal trait, a-thal 1 trait, Iron deficiency

Dichlorophenolindophenol (DCIP) precipitation test

Positive: Hb E trait, homo. Hb E

Hb E screen test

Positive: Hb E trait, homo. Hb E

Confirmation tests: Hemoglobin typing (HPLC, LPLC, CE)

b-thal trait, Hb E, CS, Pakse, thal. disease (NTDT), etc.

Hb type: Criteria for diagnosis (I) Conditions Hb type

Normal A2 A ( A2 2.5-3.5% )

a-thal 1 trait A2 A ( A2 2.5-3.5% )*

a-thal 2 trait A2 A ( A2 2.5-3.5% )*

b-thal trait A2 A ( A2 > 3.5% )

Hb E trait EA ( E= 25- 35 % )

Hb E homozygous EE ( E >85% )

Hb CS trait CS A2 A ( CS 1-2 % )

Hb CS homozygous CS A2 A ( CS 3-6% )

*Can not diagnose by Hb type

*Diagnose by PCR for a-thal 1 trait and a-thal 2 trait respectively

Hb type: Criteria for diagnosis (I)

Conditions Hb type

Hb Barts’ hydrops Portland, Barts’

Hb H disease A2 A H Barts’

Hb H with Hb CS CS A2 A H Barts

Hb AEBarts’ disease A E Barts’

Homozygous b-thal A2 F

b-thal / Hb E EF

Hb CS trait CS A2 A ( CS 1-2 % )

Molecular Diagnosis (cont.) a-thalassemia:(Gap-PCR)

a-thal 1 trait (aa/- -SEA, aa/- -Thai)

a-thal 2 trait (aa/ - a3.7, aa/- a4.2)

Hb CS trait (aa/aCSa), Hb Pakse trait (aa/aPsa)

b-thalssemia:(ARMS-PCR*, RDB**, Gap-PCR, DNA sequencing)

b0-thalassemia:

CD 41/42(A>T), CD 17 (A>T), CD 35(C>A), IVS 1-1 (G>T), CD 71/72(A>T), etc.

b+-thalassemia:

IVS 1-5 (G>C), IVS 2-654 (C>T), CD 19(A>G), -28 (A>G), CD 26, etc.

db-thalassemia

HPFH: HPFH-6, etc.

*Amplification refractory mutation system, **Reverse dot-blot hybridization

Screening and diagnostic algorithm for thalassemia and hemoglobinopathies

OF+DCIP or MCV+DCIP

Non-thalassemia, Non clinical significant thalassemia

Hb typing:

A2A (A2<3.5%) Suspected a-thal trait

A2A (A2>3.5%) b-thal trait

EA (E=25-35%) Hb E trait

EA (E < 25%) Hb E trait

With/without a-thal trait

EE (E > 85%) Homo. Hb E

With/without a-thal trait

Thalassemia disease (NTDT) a-thal: Hb H disease, etc. b-thal: b+-thal/Hb E, etc. db-thal: db-thal, HPFH, etc.

PCR for a-thal 1: a-thal 1 trait

- /- + /- or - / + or + / +

1. Screening

2. Confirmation

3. Confirmation

Management Strategy

Proper treatment of existing patients

Best patient care and management

Blood transfusion: Hyper transfusion regimen

Iron chelation

Treatment of complications Bone marrow transplantation

Prevention of the disease

Genetics counseling

Screening of thalassemia trait Prenatal diagnosis

Kitti Torcharus, MD. 20

Blood transfusion

Recommended: leucoreduced < 1x 106

Leucocyte depleted packed red cell (LDPRC)

Leucocyte poor packed red cell (LPRC)

• Before first transfusion: antigen typing: C, c, E, e, Mia

Indication for blood transfusion

Homo. b-thalassemia(TDT)

Definite diagnosis

Hb < 7 g/dL or

Hb > 7 g/dL with Facial change

Poor growth

Fracture

Extramedullary hematopoiesis

Growth failure

Poor performance at school

Pregnancy, infection

Symptomatic anemia

Congestive heart failure

Pulmonary hypertension

Leg ulcers

23/11/60 Kitti Torcharus,M.D. 22

Taher A, Blood Cells Mol Dis. 2006;37(1):12-20. Cappellini D, ed. TIF Guidelines : 2007 p. 18-30.

Immune-mediated transfusions-reactions and reported frequencies

Acute Frequency

Febrile non-hemolytic 1/100

Allergic (urticarial) 1/100

Hemolytic (intravascular) 1/25,00

Transfusion –related acute lung injury (TRALI) 1/10,000

Anaphylactic 1/50,000

Delayed frequency

Alloimmune 1/100

Hemolytic (extravascular) 1/2,500

Garft vs Host Disease Rare

Iron chelator Iron chelator Administration

Deferoxamine (DFO), 500 mg/vial

40-60 mg/kg/day, subcutaneous infusion 8-10 hour by infusion pump

Deferiprone (L1), 500 mg/tab

75-100 mg/kg/day

Deferasirox (DFX) , 500 mg/tab

20-30 mg/kg/day

Iron chelation Indication:

Received PRC >10-20 units

Serum ferritin > 1,000 ng/mL

First line:

Deferoxamine (DFO) 40-60 mg/kg/day, sc.

Second line:

Deferiprone (L1) 75-100 mg/kg/day, oral

Deferasirox (DFX) 20-30 mg/kg/day, oral

Combination therapy:

L1: 80-100 mg/kg/day + DFO: 40-60 mg/kg 3-5 days/wk

Kontoghiorghes GJ. Hemoglobin. 2009;33(5):332-8

Assessment and thresholds of iron overload

Assessment Normal Mild Moderate Severe

Ferritin (ng/ml)1 30-300 > 1,000 1,000-2,500 > 2,500

LIC (mg Fe/g dw)2 < 1.2 2 to <7 7 to < 15 > 15

MRI(T2*)mg Fe/g dw3 < 1.8 1.8 to 7 7 to <15 >15

CMR, T2*(ms)4 > 20 <20 to 10 < 10 - 5 < 5

1Olivieri NF, N Engl J Med. 1994 ;331(9):574-8

3CPG, Diagnosis & management.of thalassemia syndromes 2014:26-31

LIC=Liver Iron Concentration MRI = Magnetic resonance imaging CMR =Cardiovascular Magnetic resonance

4Wood JC. Hematology Am Soc Hematol Educ Program. 2011;2011:443-50.

2Angelucci E, N Engl J Med. 2000;343(5):327-31

Iron Chelator: Properties Property Deferoxamine Deferiprone Deferasirox

Usual dose (mg/kg/day)

25-60 75-100 20-40

Route Sc, iv (8-12 hr, 5 days/week)

Oral 3 times dialy

Oral Once daily

Half-life 20-30 min 3-4 hr 8-16 hr

Excretion Urinary, fecal Urinary fecal

Main adverse effects

Local reaction, Ophthalmologic, auditory, growth retardation, allergy

Gastrointestinal disturbances, agranulocytosis, neutropenia, arthralgia, elevated liver enzymes

Gastrointestinal disturbances, rash, mild non-progressive creatinine increase, elevated liver enzymes, Ophthalmologic, auditory

Emergency therapy: Intravenous deferoxamine

Indications:

Severe hemosiderosis & vital organ dysfunction

Cardiac arrhythmia, left-ventricular ejection fraction (LVEF) < 56%

LIC > 15 mg/g dw, cardiac T2* < 10 ms

Deferoxamine:

Dose 50-60 mg/kg/day, iv. dirp 24 hr. 5-6 days per wk

23/11/60 28 Kitti Torcharus,M.D.

Post-transfusion Hypertension, Convulsion, and Cerebral hemorrhage (HCC syndrome)

HCC syndrome Multiple blood

transfusion

Headache

Hypertension

Convulsion

Cerebral hemorrhage

Prevention: furosemide 1

mg/kg/dose

Splenectomy

Indications: Increased blood requirement (200-220 ml/kg/yr)

Hypersplenism (cytopenia)

Symptomatic splenomegaly (massive splenomegaly)

Vaccine Pneumococcal vac.: 2 wk. before; 3-5 yr. after Splenectomy

Influenza vac.: annually

Penicillin prophylaxis 125 mg bid (<5 yr); 250 mg bid (>5yr) for 2 yr

ASA: 2-5 mg/kg if platelets > 800,000 /cu.mm.

Splenectomy adverse events

Peri-operative complications:

Bleeding, atelectasis, subphrenic abscess

Post-operative:

Overwhelming post-splenectomy infection (OPSI)*

Streptococcus pneumoniae, Haemophilus influenzae type b, Neisseria meninggitidisEscherichia coli, Pseudomonas aeruginosa, Salmonella sp., Klebsiella sp.

Thrombosis

Hypercoagulability

Pulmonary hypertension

Iron overload

*Mortality rate 50-70%, death occurs within 24 hr

Treatment related complications

Chronic HBV infection

Serum HBsAg (+ve), HBeAg (–ve), anti HBe Ab (+ve)

HBV viral load> 2,000 IU/ml, ALT > 80 IU

Chronic HCV infection

Anti HCV (+ve), HCV-RNA virus, ALT > 80 IU

Diabetes mellitus

Fasting glucose > 126 mg/dl

Oral glucose tolerance test (2 hr) >200 mg/dl

Gall stone (asymptomatic, 60-80%)

Biliary colic, common bile duct stone, ascending cholangitis, acute cholecystitis

Hematopoietic stem cell transplantation (HSCT)

Indication:

Thalassemia major (transfusion dependent thalassemia)

homozygous b-thalassemia

b-thalassemia/ Hb E (severe)

Source of hematopoietic stem cell

1. Bone marrow

2. Peripheral blood

3. Cord blood

Hematopoietic stem cell transplantation (HSCT)

2.Transfusion of stem cell

4.Post HSCT 3.During HSCT

1.Conditoning chemo. therapy

Overall survival, thalassemia-free survival, non-rejection mortality and rejection for class 1 patients younger than 17 yrs

Gaziev J, Lucarelli G. Curr Stem Cell Res Ther. 2011;6(2):162-9

HSCT: Thai (1988-2011)

HSCT N (%) Cure (%) Alive with disease

Related 190 (74.5) 165 (88.6) 9(4.7) 16 (8.5)

Unrelated 65 (25.5) 50 (76.9) 6 (9.2) 9 (13.8)

Total 255 (100) 215 (84.3) 15 (5.9) 25 (9.8)

HSCT=Hematopoietic stem cell transplantation

HSCT in Department of Pediatrics, PMK

Lymphoma 33%

AML 26%

ALL 7%

Thalassemia 26%

Aplastic anemia 4%

Nuroblastoma 4%

HSCT in Department of Pediatrics, PMK

Comparison of life expectancy for patients who were alive at the beginning of 1970, 1980, 1990 and 2000

Modell B, et al. J Cardiovasc Magn Reson. 2008;10:42

Preimplantation genetic diagnosis (PGD)

Selection of unaffected embryos prior to establishment of pregnancy

Start a pregnancy with a disease free baby

Avoid termination of an affected pregnancy

Proposed schema of gene therapy for β-thalassaemia

Yannaki E, et al.Expert Rev Mol Med. 2010;12:e31

National thalassemia guidelines: Clinical practice guidelines for diagnosis and management of

thalassemia syndromes & Care of thalassemia patients

1st edition: 2006

2nd edition: 2014

1st edition: 2017

Summary • Thalassemia is public health problems in ASEAN

Thailand and LAO PDR (high prevalence, similar genotype-phenotype)

Definite diagnosis, Clinical Practice Guideline, Standard of care

Management Strategy Proper management of existing patients and prevention of new

Life-long survival Early blood transfusion Efficacy and effectiveness of iron chelation HSCT

New treatment: Preimplantation genetic diagnosis & HLA type Gene therapy: “the beginning of a new era of thalassemia”

Thank you for your attention

thalassemia: diagnosis and treatment - tsh.or.thtsh.or.th/file_upload/files/2 kitti torcharus -...

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