seminar on Thalassemia

seminar on Thalassemia

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

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

3. Diagnosis Hereditary hemolytic anemia

4. Seminar on T halassemia

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

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

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

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

9. Site of synthesis of globin

10. Normal hemoglobin component Hb type Name Components Adult A α 2 β 2 A2 α 2 δ 2 Fetal F α 2 γ 2 Embryonic Portland ξ 2 γ 2 Gower 1 ξ 2 ε 2 Gower 2 α 2 ε 2

11. Inheritance Autosomal recessive

12. Types of thalassemia

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

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

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

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

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

18. β -Thalassemia

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

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

21. An absence or deficiency of β -chain synthesis of adult HbAg Pathophysiology of β -thalassemia β Chain synthesis Hb-A α , γ and δ chain Hb A = α 2 β 2

22. Pathophysiology of β -thalassemia

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

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

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

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

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28. Physical Findings History Lab Investigations Severe Anemia Thalassemic facies Hepatosplenomegaly Growth retardation, etc Symptoms of anemia +ve family history H/0 blood transfusion FTT approach to diagnosis

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

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

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

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

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

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

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

36. Complications of thalassemia Ineffective & excessive erythropoiesis Iron overload Chronic hemolysis Hypercoagulable disease Infection Treatment related complications

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

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

39. Thalassemia facies

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

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

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

43. Cirrhosis Diabetes Infertility Pituitary failure Hypothyroidism Hypoparathyroidism Arrythmia Heart failure Dark skin Liver Heart Endocrine organs Skin Features of iron overload

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

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

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

47. INVESTIGATIONS

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

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

50. PBF

51. Target cell Tear drop cell Elliptocyte Hypochromic Microcyte Abnormal RBCs in PBF

52. PBF: Normal vs Hypochromia

53. Anisocytosis

54. Poikilocytosis

55. Target cell

56. Eliptocyte

57. Schistocyte

58. Basophilic stippling

59. Tear drop cell

60. Poikilocytosis

61. PBF: α thalassemia ( Hb H disease)

62. PBF : IDA

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

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

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

66. Normal Hb electrophoresis Normal Hb electrophoresis

67. Hb electrophoresis of homozygous β° thalassemia

68. Hb electrophoresis of β thalassemia trait

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

70. Hb electrophoresis of Hemoglobin H Disease

71. Hb electrophoresis of Hemoglobin Bart’s

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

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

74. Investigations

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

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

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

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79. MANAGEMENT OF THALASSEMIA

80. Treatment modalities Supportive Curative Preventive

81. A. Supportive management Multi-disciplinary approach Focus on each patient’s clinical course

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

83. Blood Transfusion

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

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

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

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

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

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

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

91. CHELATION THERAPY

92. 97

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

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

95. Iron chelating agents

96. Management: iron chelators ( NTGuideline ) Agent Dose Route T 1/2 hours Schedule Clearance Desferrioxamine 40 -50 mg/kg/Day SC Slow infusion 0.3 Infuse over 8-10 hours 5-6 days per week Renal and hepatic Deferiprone 75 mg/kg/day Oral 2-3 3 times daily(After 6 years) Renal Deferasirox 30-40 mg/kg/day Oral 12-16 Once daily Hepatic

97. Desferrioxamine

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

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

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

101. Deferiprone

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

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

104. Deferasirox

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

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

107. Fetal Hb Induction

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

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

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

111. SPLEECTOMY

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

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

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

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

116. Thalassemic diet Should avoid Diet should encourage

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

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

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

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

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

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

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

124. 1980s and early 1990s HSCT- accepted as routine clinical practice More than 3000 HSCTs were performed worldwide ( Angelucci 2010)

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

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

127. Expected probability of overall survival and thalassaemia free survival after HSCT in thalassaemia major CLASS OVERALL SURVIVAL THALASSAEMIA-FREE SURVIVAL Class 1 95% 90% Class 2 85% 80% Class 3 75-80% 65-70% Adult 70-75% 75%

128. Hematological 2014

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

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

131. Beta –globin gene addition

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

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

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

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

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

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

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

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

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

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

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

143. NESTROFT

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

145. Genetic counseling

146. Prenatal diagnosis Chorionvillus sampling Amniocentesis

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

148. Creating awareness

149. Creating awareness

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

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

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

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

154. Do not lose hope The permanent solution is just round the corner Thank you