RARE DISEASE
Hemoglobin E disease
Hemoglobin E disease
Hemoglobin E disease
Drug discovery
0
drugs
With orphan designations
Overview
Hemoglobin E (HbE) disease is a hemoglobinopathy caused by a β-globin gene mutation (glutamic acid→lysine substitution), prevalent in Southeast Asia. Homozygous HbE causes mild microcytic anemia with target cells, while compound heterozygosity with β-thalassemia (HbE/β-thalassemia) results in severe anemia, ineffective erythropoiesis, and variable transfusion dependence [1][5][17]. Management focuses on symptom severity, ranging from monitoring to transfusions and hydroxyurea therapy [3][11].
Categories: rare genetic diseases, rare hematological diseases, rare transplant-related disorders
Research Papers
64 drug discovery papers about Hemoglobin E disease, with 1 first-in-class emerging drug candidates forecasted to outperform the average preclinical success rate. Recent publications:
64 drug discovery papers about Hemoglobin E disease, with 1 first-in-class emerging drug candidates forecasted to outperform the average preclinical success rate. Recent publications:
categories:
Small molecules
small molecules
2026-05-28 | Neutrophil extracellular traps induced by activated platelets as a cause of neutrophil-platelet aggregation in β-thalassaemia/haemoglobin E patients.
The hypercoagulable state is a major contributor to thromboembolic events and mortality in β-thalassaemia. The mechanisms underlying platelet-induced neutrophil activation leading to immunothrombosis remain poorly understood. Three-dimensional confocal microscopy demonstrated that platelets induced neutrophil extracellular trap (NET) formation through P-selectin- or high mobility group box 1 protein (HMGB1)-mediated binding to P-selectin glycoprotein ligand-1 (PSGL-1) or receptor for advanced glycation end products (RAGE), respectively, on neutrophils. Molecular signalling pathways involved in NETs-focusing on mitogen-activated protein kinase kinase (MAPKK) or mitogen-activated protein kinase kinase 1/2 (MAP2K) (MEK)/extracellular signal-regulated kinase (ERK), reactive oxygen species (ROS), ofnicotinamide adenine dinucleotide phosphate (NADPH) oxidase complex 2 (NOX2), myeloperoxidase (MPO) and peptidylarginine deiminase 4 (PAD4)-were investigated in neutrophils from β-thalassaemia/haemoglobin E (HbE) patients (splenectomy and non-splenectomy) and from normal subjects by priming neutrophils with specific inhibitors before treatment with either platelets, recombinant P-selectin or disulphide HMGB1. In splenectomised patients, neutrophils primed with U0126, but not an ERK inhibitor, exhibited reduced web-like NETs and cell aggregation, associated with antioxidant effects. In non-splenectomised patients and normal subjects, P-selectin activated MEK/ERK, NOX2, MPO and PAD4 pathways, promoting web-like NETs and cell aggregation. HMGB1 activated neutrophils via MEK/ERK, NOX2, MPO and PAD4 pathways, in all groups, resulting in NETs without aggregation-associated NET morphology. These findings indicate that splenectomy alters P-selectin and HMGB1 expression on platelets, leading to altered signalling dynamics in neutrophils and promoting neutrophil-platelet aggregation. ROS pathway could be a key regulator of NET-driven thrombosis in splenectomised β-thalassaemia/HbE disease and highlight its potential as a therapeutic target.
2026-01-20 | Enhanced induction of fetal hemoglobin by the combination of decitabine with RN-1 in β-thalassemia/HbE erythroid progenitor cells.
BACKGROUND: Fetal hemoglobin (HbF; α2γ2) induction is a well-established approach for β-hemoglobinopathies, including sickle cell disease (SCD) and β-thalassemia. Decitabine, a DNA methyltransferase 1 (DNMT1) inhibitor, has been shown to effectively induce HbF production with a favorable safety profile. However, more potent therapeutic strategies are needed, particularly for β-thalassemia/HbE patients. METHODS: We evaluated the HbF-inducing efficacy of ten DNMT1 inhibitors in erythroid progenitor cells derived from β-thalassemia/HbE patients. To further enhance HbF induction, we investigated a combination treatment with decitabine and RN-1, a lysine-specific demethylase 1 (LSD1) inhibitor. HbF expression, cell viability, erythroid differentiation, and proliferation were assessed. Additionally, we investigated the association between treatment response and well-characterized single-nucleotide polymorphisms (SNPs) previously linked to HbF expression. RESULTS: Of the ten DNMT1 inhibitors tested, SGI-110, a dinucleotide analog of decitabine, exhibited similar HbF-inducing efficacy and toxicity profiles as decitabine at equivalent molar dose. The combination treatment with decitabine and RN-1 resulted in a robust additive increase in HbF expression in β-thalassemia/HbE erythroid progenitor cells, albeit with a slight reduction in cell viability. Additionally, the combination treatment improved the delayed differentiation phenotype in β-thalassemia/HbE erythroid cells, accompanied by a reduction in cell proliferation. Interestingly, individual variability in response to RN-1 and the combination treatments was observed, with major responders exhibiting significantly greater increases in HbF compared to minor responders. We identified two SNPs in the BCL11A gene (rs766432 and rs1427407) that were potentially associated with a higher likelihood of major response to treatments. CONCLUSIONS: Our findings highlight the potential of targeting two distinct epigenetic corepressors within the γ-globin repressor complex to achieve robust HbF induction. The combination of decitabine and RN-1 represents a promising therapeutic strategy for β-thalassemia, warranting further investigation into the molecular mechanisms underlying individual response variability.
2025-12-12 | Deferiprone therapy improves the oxidative status of LDL in patients with β-thalassaemia/HbE.
Oxidative modifications of low-density lipoproteins (LDL) have been reported in patients with β-thalassaemia/haemoglobin E (HbE) and are related to cardiovascular complications. Deferiprone (L1) is an iron chelator that decreases iron overload and, consequently, reduces oxidative stress. This study assesses the protective effect of L1 on the oxidative status of LDL in patients with β-thalassaemia/HbE. Twenty-nine patients with β-thalassaemia/HbE treated with L1 were recruited. The study included a 4-week washout period followed by 4 and 12 weeks of L1 treatment. Non-transferrin-bound iron (NTBI) levels and oxidative stress markers, including thiobarbituric acid reactive substances and α-tocopherol, were monitored at each visit. The rate and content of lipid radical formation following Cu2+-induced LDL oxidation in vitro were detected by NBD-Pen, a specific fluorescence probe. L1 was shown to prevent the depletion of α-tocopherol, decrease thiobarbituric acid reactive substances and preserve the levels of lipid components in LDL. A negative correlation between serum NTBI and LDL α-tocopherol indicated that the circulating non-redox-active NTBI can lead to the depletion of α-tocopherol. LDL from the washout period showed the highest oxidative susceptibility when evaluated by NBD-Pen. Iron chelation therapy with L1 improves the oxidative status of LDL in patients with β-thalassaemia/HbE.
2025-11-25 | Regulation of Alternative Polyadenylation Events by PABPC1 Affects Erythroid Progenitor Cell Expansion
Erythropoiesis is precisely regulated by multilayered networks. It is crucial for maintaining steady-state hemoglobin levels and ensuring effective oxygen transport. Alternative polyadenylation (APA) is a post-transcriptional regulatory mechanism generating multiple mRNA isoforms from a single gene based on specific 3'-untranslated region sequences. While APA plays a vital role in various cellular processes, the underlying mechanism in erythropoiesis remains largely unexplored. In this study, we employed an integrative approach, combining bioinformatics analyses and experimental validations, to systematically investigate the role of APA in erythropoiesis. We mapped the APA landscape during erythroid differentiation and identified significant APA shifts essential for the differentiation of erythroid cells from burst-forming unit erythroid (BFU-E) to colony-forming unit erythroid (CFU-E). Notably, our findings highlighted polyadenylate-binding protein cytoplasmic 1 (PABPC1) as the primary regulator of APA during these stages. Functional analyses have revealed that knockdown of PABPC1 disrupts erythroid progenitor cell proliferation and differentiation. These results implicate an essential role of PABPC1 in modulating cell fate through APA regulation. Furthermore, we found that decreased PABPC1 levels increased the usage of the proximal polyadenylation sites in the TSC22D1 gene. This shift led to elevated expression of TSC22D1, uncovering a novel mechanism by which APA influences erythroid progenitor expansion and differentiation. Our findings provide novel insights into APA regulation in early erythropoiesis and suggest potential therapeutic strategies for diseases associated with erythropoietic disorders.
2025-07-03 | Metabolic reprogramming during ineffective erythropoiesis in β-thalassemia/HbE disease.
Ineffective erythropoiesis, the main cause of anemia in β-thalassemia disease, is characterized by dramatic expansion of erythroblasts and increased erythroblast cell death. The absence or reduction of β-globin chains causes an accumulation of excess α-globin chains and generates cytotoxic reactive oxidant species, resulting in erythroblast cell death. Metabolism provides energy, building blocks for macromolecule synthesis, and cofactors for antioxidative defense systems. We hypothesized that β-thalassemia erythroblasts might alter their metabolism to cope with increased proliferation and cellular stress. Herein, transcriptomic analysis of basophilic and polychromatic erythroblasts isolated from bone marrow obtained from β-thalassemia/HbE patients showed the global up-regulation of metabolic genes in glycolysis, TCA cycle, pentose phosphate pathway, ATP, and fatty acid synthesis pathway. The expression of metabolic genes during terminal erythropoiesis was further determined by PCR array and RT-qPCR in erythroblast culture obtained from β-thalassemia/HbE patients with mild and severe symptoms. The increased expression of enolase1, isocitrate dehydrogenase 1, and bisphosphoglycerate mutase was observed in mild cases compared to severe patients, suggesting that mild patients might modulate metabolic flux for cellular stress defense mechanisms, reducing disease severity. Moreover, the role of BPGM in regulating erythroid differentiation was demonstrated in K562 cells. Inhibition of BPGM promotes cell differentiation in K562 cells. Understanding metabolic reprogramming in thalassemia erythropoiesis opens new therapeutic approaches for β-thalassemia/HbE treatment. Further research is needed to explore how metabolism affects ineffective erythropoiesis and supports thalassemic erythroblasts' high proliferation and oxidative stress defense.
gene therapies
2025-11-21 | Multi-centric origins and gene flow shape the diversity of β-thalassemia mutations in Southern East Asia.
Over 400 β-thalassemia mutations show population-differentiated spectra, yet their origins and evolution remain unclear. Focusing on targeted sequencing of 20,222 individuals and 510 β-thalassemia patients in southern China, we identified three major haplotype groups (HG) at the β-globin locus and observed highest haplotype diversity for CD41/42, -50, and HbE among 13 prevalent mutations in 993 carriers. Allele dating suggest these mutations emerged during agricultural expansions in the past 7420 years, represented by CD41/42 arising in mainland China. However, the -50 mutation likely originated on Hainan Island within 3900 years, subsequently spreading to the mainland and experiencing lineage-specific selection. HbE exhibits substantial haplotype heterogeneity in Yunnan, with network analyses indicating bidirectional disseminations between southern China and South/Southeast Asia. We further suggest an ameliorating effect of HG2, associated with elevated hemoglobin and fetal hemoglobin levels. These findings highlight multi-centric origins of β-thalassemia mutations and underscore the evolutionary context shaping their clinical impact.
2025-11-01 | Phenotypic Expression of Hemoglobinopathies: A Single Centre Study
Background: Hemoglobinopathies are among the most prevalent genetic disorders worldwide, with high phenotypic heterogeneity. The northeastern region of India shows a predominance of hemoglobin E and (HbE)related variants. Methods: This prospective cross-sectional study was conducted at a tertiary care centre in N E India. Seventy patients aged over six months and diagnosed with hemoglobinopathy were included. Detailed demographic data, clinical features, hematological parameters, HPLC results, serum ferritin levels analysed. Genetic mutation profiles were analysed in twenty-five of these patients. Transfusion dependency and phenotypic outcomes were also studied. Results: HbE-related disorders were the most common, seen in 65.7% of cases. HbE/β-thalassemia accounted for 44.2%, followed by beta-thalassemia major (17.1%) and sickle cell disease (5.7%). Nearly 48.5% of the patients were transfusion-dependent. Poorly transfused individuals had significantly higher serum ferritin, hepatosplenomegaly, short stature, delayed puberty, and endocrinopathies. Among genetically analyzed cases, the most frequent mutations were c.79G>A (HbE variant) and IVS1-5(G>C) (β-thalassemia), with compound heterozygosity often predicting a severe phenotype. Conclusion: HbE/β-thalassemia is the predominant hemoglobinopathy in Assam with diverse clinical presentations. Transfusion status and chelation significantly influence growth and endocrine health. Mutation profiling enhances understanding of disease severity and can guide individualized care. Population-based studies are warranted to further characterize the regional mutation spectrum and phenotypic variability.
2025-07-16 | Disrupting ZBTB7A or BCL11A binding sites reactivates fetal hemoglobin in erythroblasts from healthy and β0-thalassemia/HbE individuals.
CRISPR/Cas9 genome editing has emerged as a promising treatment for genetic diseases like β-thalassemia. Editing γ-globin promoters to disrupt ZBTB7A/LRF or BCL11A binding sites has shown potential for reactivating fetal hemoglobin and treating sickle cell disease. However, its application to β0-thalassemia/HbE disease remains unclear. This study utilized CRISPR/Cas9 to disrupt these sites in mobilized CD34 + hematopoietic stem /progenitor cells from healthy donors and β0-thalassemia/HbE patients. The editing efficiency for the BCL11A site (75-92%) was higher than for the ZBTB7A/LRF site (57-60%). Both disruptions similarly increased fetal hemoglobin production in healthy donors (BCL11A 26.2 ± 1.4%, ZBTB7A/LRF 27.9 ± 1.5%) and β0-thalassemia/HbE cells (BCL11A 62.7 ± 0.9%, ZBTB7A/LRF 64.0 ± 1.6%). Off-target effects were absent in BCL11A-edited cells but observed at low frequencies in ZBTB7A/LRF-edited cells. Neither disruption significantly affected erythroid differentiation. These findings highlight the comparable contributions of ZBTB7A/LRF and BCL11A binding sites to γ-globin reactivation. CRISPR/Cas9 editing of either site may offer a potential therapeutic strategy for β0-thalassemia/HbE disease.
2024-08-19 | Clinical characteristics, laboratory features and genetic profile of hemoglobin E (HBB:c.79 G > A)/β (nucleotide -28 A > G) (HBB:c.-78 A > G) -thalassemia subjects identified from community- and hospital-recruited cohorts.
Despite several existing laboratory-based studies of hemoglobin (Hb) E (HBB:c.79 G > A)/ β (nucleotide (NT) -28 A > G) (HBB:c.-78 A > G) -thalassemia, no reports have ever provided clinical severity information as well as dependency of blood transfusion. Previously, a comparative study of community- and hospital-recruited Hb E/β-thalassemia subjects was conducted in the lower northern Thailand between June 2020 and December 2021. A mobile medical team visited each community hospital on-site, collecting clinical severity parameters, and conducting Hb and DNA analyses. The control included Hb E/β-thalassemia patients undergoing transfusions. Subgroup study of adult Hb E/β (NT -28 A > G) -thalassemia subjects was subsequently conducted. Additional pediatric individuals were recruited from prenatal diagnosis databases. Twenty adult and nine pediatric subjects were enrolled; all were classified as having mild disease severity. Twenty-two individuals (75.9 %) were asymptomatic. Six adults (20.7 %) required blood transfusion. The mean Hb level of subjects without transfusion (23 [79.3 %]) was 10.77 ± 1.10 g/dL. Hb analysis revealed a distinct EFA pattern with low Hb F fraction. The positive impact of genetic modifiers could not be statistically demonstrated except rs7482144-XmnI. These findings could provide essential information for parents carrying fetuses with Hb E/β (NT -28 A > G) -thalassemia.
2022-09-29 | The successful strategy of comprehensive pre-implantation genetic testing for beta-thalassaemia-haemoglobin E disease and chromosome balance using karyomapping.
Thalassaemia is the commonest monogenic disease and causes a health and economic burden worldwide. Karyomapping can be used for pre-implantation genetic testing of monogenic disorders (PGT-M). This study applied karyomapping in two PGT-M cycles and made a comparison to polymerase chain reaction (PCR). Two families at risk of having beta-thalassaemia-haemoglobin E disease offspring decided to join the project and informed consent was obtained. Karyomapping results of family A (beta-thalassaemia (c.41_42delTCTT)-Hb E (c.26G>A) disease) revealed four normal, two beta-thalassaemia traits, one Hb E trait and six affected. Three embryos exhibited unbalanced chromosomes. One normal male embryo was transferred. Karyomapping results of family B (beta-thalassaemia (c.17A>T)-Hb E (c.26G>A) disease) revealed six Hb E traits and three affected. Three embryos were chromosomally unbalanced. One Hb E trait embryo was transferred. Two successful karyomapping PGT-M were performed, including deletion and single-base mutations. Karyomapping provides accuracy as regards the protocol and copy number variation which is common in pre-implantation embryos. Impact StatementWhat is already known on this subject? Thalassaemia syndrome is the commonest monogenic disease and causes a health and economic burden worldwide. Modern haplotyping using SNP array (aSNP) and karyomapping algorithms can be used for pre-implantation genetic testing of monogenic disorders (PGT-M). However, few clinical karyomapping PGT-M cycles have been done and validated so far.What do the results of this study add? Two successful clinical PGT-M cycles for beta-thalassaemia (c.41_42delTCTT and c.17A>T mutations)-haemoglobin E (c.26G>A) disease were performed using karyomapping. The outcome was two healthy babies. Multiplex fluorescent polymerase chain reaction (PCR) with mini-sequencing was also used for confirmation mutation analysis results. PCR confirmed haplotyping results in all embryos. Six embryos from both PGT-M cycles exhibited unbalanced chromosomes evidenced by aSNP.What are the implications of these findings for clinical practice and/or further research? Karyomapping provides accurate information quickly and the outcomes of the study will save time as regards protocol development, provide a usable universal PGT-M protocol and add additional copy number variation (CNV) information, chromosome number variation being a common issue in pre-implantation embryos.
cell therapies
2025-05-16 | Genetic polymorphism of novel SNP rs5006884 in OR51B6 and SNP rs4499252 in AHSP among transfusion-dependent and non-transfusion-dependent β-thalassemia/Hb E patients in Thailand: a multivariate analysis of clinical and genetic polymorphism.
Compound heterozygous β-thalassemia and Hb E, a prevalent and severe form of thalassemia in Southeast Asia, manifests in two major clinical forms: transfusion-dependent thalassemia (TDT) and non-transfusion-dependent thalassemia (NTDT). This study investigates the association of genetic polymorphisms rs5006884 in OR51B6, rs4499252 in AHSP, rs9399137 in HBS1L-MYB, and rs4671393 in BCL11A with clinical severity and transfusion dependency in β-thalassemia/Hb E patients in Thailand. A total of 189 samples, including 58 TDT, 58 NTDT, 33 homozygous Hb E, and 40 wild-type individuals, were analyzed. Genotyping of the four single nucleotide polymorphisms (SNPs) was conducted using the rhAmp SNP Genotyping assay. Multivariate regression models were developed to evaluate the combined effects of genetic and clinical factors on transfusion dependency. The results showed that OR51B6 SNP rs5006884 TT genotype was significantly more frequent in the NTDT group (P < 0.05), suggesting a strong association with reduced transfusion dependency. Conversely, the AHSP SNP rs4499252 GG genotype was significantly less frequent in the homozygous Hb E group (P < 0.05) compared to other groups. Multivariate analyses highlighted hemoglobin (Hb) levels as a robust predictor of transfusion dependency, with specific HBB mutations including HBB:c.59 A > G, HBB:c.-78 A > G, HBB:c.316-197 C > T, and NC_000011.10:g.5224302_5227791del being significantly associated with NTDT (P < 0.05). Furthermore, rs5006884 in OR51B6 also played a significant role in NTDT in multivariate analyses. In contrast, SNPs in BCL11A (rs4671393), HBS1L-MYB (rs9399137), and AHSP (rs4499252) showed no significant independent associations with transfusion dependency or disease severity in this cohort. This study explores rs5006884 in OR51B6 and rs4499252 in AHSP in TDT and NTDT patients for the first time. These findings elucidate the interplay of genetic and clinical factors influencing β-thalassemia severity, paving the way for personalized management strategies to mitigate transfusion requirements.
2024-11-05 | Myocardial Fibrosis Occurs in Young Non-Transfusion-Dependent Alpha-Thalassemia Intermedia Patients and Is Related to Anemia and Age in Thalassemia
Introduction A recent landmark study demonstrated that median pretransfusion hemoglobin in transfusion dependent thalassemia (TDT) >10.5 g/dl has 100% ten-year survival compared to 91% at a hemoglobin of 9.0 with the majority of deaths due to non-iron-related cardiac events (Musallam et al., 2024). Increased anemia-related morbidity and mortality has also been seen in non-transfusion-dependent-thalassemia (NTDT) and low-risk myelodysplastic syndrome suggesting even moderate anemia can have severe consequences to a high oxygen demand organ like the heart (Musallam et al., 2021). Patients with NTDT-α-thalassemia intermedia (TI-α; Hemoglobin H disease and Hemoglobin H-Constant Spring), a presumed benign disorder, have lifelong hemoglobin levels of 8-11 g/dL with most around 8.5 g/dL (Musallam et al., 2024) but very little is known about morbidity and mortality beyond the fifth decade. To address this, we assessed cardiac fibrosis, an accepted predictor of future cardiac dysfunction in TI-α and TDT, using MRI-determined extracellular volume (ECV), with ECV >30% indicating diffuse myocardial fibrosis. We found significant myocardial fibrosis in NTDT-TI-α <40 years old, which was related to degree of anemia and age in patients with thalassemia. Methods This study included patients with thalassemia followed at Children's Hospital Los Angeles who had ECV measured by cardiac MRI. ECV was calculated by T1 mapping pre- and post-gadolinium contrast as previously described. Subjects' baseline or pretransfusion hemoglobin was determined as median value over 6 months prior to MRI. Data were collected and analyzed using JMP Pro 15.1.0 (SAS Institute Inc., Cary, NC, 2019). Results Twenty-two subjects with thalassemia were evaluated: seven with TI-α, four with TI-β, three with E/β-thalassemia, and eight with β-thalassemia major. Subjects' ages ranged from 2 to 63 years at initial evaluation, with median age 27.5 years. All β-thalassemia subjects and three of the TI-α subjects were transfused. Median ECV among all subjects was elevated to 32.4%; median ECV was 32.5% in β-thalassemia and 32.4% among TI-α (p=0.94), ranging 29.7% to 43.7% in NTDT-TI-α. All subjects had normal ejection fraction, no cardiac siderosis, and no symptoms of cardiac disease. ECV increased with decreasing hemoglobin among all subjects (p=0.0012, R2=0.34) and in TI-α (p=0.0213, R2=0.61), but the relationship was not significant in β-thalassemia (p=0.5198). ECV increased with age in all subjects (p=0.0148, R2=0.21), particularly in β-thalassemia (p=0.0060, R2=0.35), but not in TI-α (p=0.6086). Both hemoglobin and age were retained in a multivariate model (p=0.0017, p=0.0196, respectively; R2=0.47), while their interaction was not significant. Discussion The most concerning finding is the presence of significant ECV elevation in 3/4 young, asymptomatic NTDT-TI-α patients. We found that ECV is strongly associated with anemia severity in thalassemia, particularly in TI-α. These findings are consistent with the emerging data in TDT, NTDT and other ineffective erythropoiesis-related chronic anemias showing long-term morbidity and mortality is worse with lower hemoglobin. This is clinically important given that implementation of regular transfusion in NTDT was associated with improved morbidity and survival. The multivariate model of ECV in this study shows the long-term effects of anemia and age on fibrosis, and we hypothesize that duration of anemia is important. Larger studies are needed to evaluate the prevalence of myocardial fibrosis and the consequence of diastolic dysfunction and arrhythmia at older ages in this population. Little is known about the outcomes of NTDT-TI-α in older individuals, but this preliminary data suggests this presumed benign disorder is likely similar to NTDT in general.
2020-12-07 | Generation of an immortalised erythroid cell line from haematopoietic stem cells of a haemoglobin E/β-thalassemia patient.
The β-thalassemia syndromes are the most prevalent genetic disorder globally, characterised by reduced or absent β-globin chain synthesis. HbE/β-thalassemia is a subtype of β-thalassemia with extremely high frequency in Asia. Studying molecular defects behind β-thalassemia is severely impeded by paucity of material from patients and lack of suitable cell lines. Approaches to derive erythroid cells from induced pluripotent stem cells (iPSCs) created from patients are confounded by poor levels of erythroid cell expansion, aberrant or incomplete erythroid differentiation and foetal/embryonic rather than adult globin expression. In this study we generate an immortalised erythroid cell line from peripheral blood stem cells of a HbE/β-thalassemia patient. Morphological analysis shows the cells are proerythroblasts with some early basophilic erythroblasts, with no change in morphology over time in culture. The line differentiates along the erythroid pathway to orthochromatic erythroblasts and reticulocytes. Importantly, unlike iPSCs, the line maintains the haemoglobin profile of the patient's red blood cells. This is the first human cellular model for β-thalassemia providing a sustainable source of disease cells for studying underlying disease mechanisms and for use as drug screening platform, particularly for reagents designed to increase foetal haemoglobin expression as we have additionally demonstrated with hydroxyurea.
2017-12-12 | Hematopoietic stem cell transplantation for homozygous β-thalassemia and β-thalassemia/hemoglobin E patients from haploidentical donors.
Thalassemia-free survival after allogeneic stem cell transplantation (SCT) is about 80-90% with either matched-related or -unrelated donors. We explored the use of a mismatched-related ('haplo- ') donor. All patients received two courses of pretransplant immunosuppressive therapy (PTIS) with fludarabine (Flu) and dexamethasone (Dxm). After two courses of PTIS, a conditioning regimen of rabbit antithymocyte globulin, Flu and IV busulfan (Bu) was given followed by T-cell-replete peripheral blood progenitor cells. GvHD prophylaxis consisted of cyclophosphamide (Cy) on days SCT +3 and +4 (post-Cy), and on day SCT +5 tacrolimus or sirolimus was started together with a short course of mycophenolate mofetil. Thirty-one patients underwent haplo-SCT. Their median age was 10 years (range, 2-20 years). Twenty-nine patients engrafted with 100% donor chimerism. Two patients suffered primary graft failure. Median time to neutrophil engraftment was 14 days (range, 11-18 days). Five patients developed mild to moderate, reversible veno-occlusive disease, while nine patients developed acute GvHD grade II. Only five patients developed limited-chronic GvHD. Projected overall and event-free survival rates at 2 years are 95% and 94%, respectively. The median follow up time is 12 months (range, 7-33 months).
2014-02-01 | Favorable Outcomes from Allogeneic Hematopoietic Cell Transplantation in Thailand for Thalassemias and Hemoglobinopathies
Thalassemia syndromes are very prevalent in many parts of the world including Asia. Allogeneic hematopoietic cell transplantation (HCT) is the only curative therapy accepted worldwide. To assess outcomes of HCT for thalassemias and hemoglobinopathies in single medical center in Thailand. Case series study for thalassemia and hemoglobinopathy patients undergoing HCT at Bangkok Hospital Medical Center from February 2009 thru October 2013. There were totally 14 patients. 10 cases were Thais, 1 was French-Thai, 1 was Bangladeshi, 1 was Lao, and 1 was Omani who had sickle cell disease (SCD). 12 cases were diagnosed as beta-thalassemia/hemoglobin E diseases, 1 as transfusion-dependent alpha-thalassemia, and 1 as SCD. Among 14 HCTs, 9 patients underwent bone marrow transplant (BMT), 4 patients underwent umbilical cord blood transplant (CBT), and 1 patient underwent combined cord blood and marrow transplantation. All 14 related donors were fully-HLA-matched, 4 had normal typing, 9 had thalassemia trait, and 1 had sickle cell trait. Male to female patients ratio were 11:3. Patients' ages at transplant varied from 2 years to 15 years 11 months with median of 4 years 10 months. Patient's body weight varied from 11.1 to 50 kilogram (median 17.2 kilogram). According to Pesaro classification, among 13 thalassemia patients there were 8 class I, and 5 class II patients. Busulfan, fludarabine, and rabbit ATG were mainly used as myeloablative conditioning regimen. Cyclosporine and short-course methotrexate were mainly used as graft-versus-host disease (GvHD) prophylaxis in BMT group, while cyclosporine alone was used in CBT group. CD34+ cell doses per kilogram body weight recipients were ranged from 5.6 to 34.7x106 (median 11.3x106) in BMT group (n=9), and from 1.6 to 3x105 (median 2.3x105) in CBT group (n=4). Complete donor engraftments were achieved in 11 patients. Mixed-chimerism states with donor predominance were present in 2 patients from BMT and 1 patient from CBT group. No patients experienced graft failure. Neutrophil recoveries were evident on days +10 to +23 (median day +14), and platelet recoveries were observed on days +19 to +64 (median day +40). 2 patients had mild veno-occlusive diseases and were later completely reversible. No patients developed acute or chronic GvHD. There were no mortalities. 1 patient had treatable pneumocystis pneumonia at 4 months post CBT. Median follow-up time for all patients was 2 years (1 month to 4 years 8 months). Overall (OS) and disease-free survival (DFS) were 100% and 100% for all patients (n=14). Based on risk class, the OS and DFS for class I thalassemia patients (n=9) were 100% and 100%, and class II patients (n=4) were 100% and 100%, respectively. Our experiences in HCT for thalassemias and hemoglobinopathies were very favorable. Regular follow-up visits are encouraged to determine long term outcomes.
proteins
2025-11-03 | Transfusion independence in thalassemia patients after failure of gene therapy or with hemoglobin h constant spring and hb e using luspatercept: A case series
Abstract Background: Individuals with thalassemia who depend on blood transfusions to maintain adequate hemoglobin levels are at high risk of sequelae resulting from frequent blood products. As such, there is increased interest in decreasing transfusion frequency for such patients and limiting side effects. Luspatercept is a recombinant fusion protein that enhances erythropoiesis by binding to select TGF-b ligands and can increase hemoglobin for patients with thalassemia. Luspatercept use was associated with significantly greater reductions in transfusion burden than for the placebo group for transfusion-dependent b-thalassemia (TDT) patients in the BELIEVE trial. Luspatercept was also associated with a significant increase in hemoglobin level among non-transfusion-dependent beta thalassemia (NTDT) in the BEYOND trial. However, currently, there is very limited evidence for the utility luspatercept in thalassemia patients after a failed gene therapy or among those with alpha thalassemia. Here we describe two cases with significant clinical response to luspatercept achieving transfusion independence in distinct thalassemia populations that have not yet been reported in the literature. Case 1: This patient underwent LentiGlobin gene therapy for b-thalassemia (β0/β0) at the age of 34 years in 2015. Prior to gene therapy, she required regular packed red blood cell (pRBCs) transfusions every 4 weeks. After admission for gene therapy per protocol HGB-204, her transfusion needs initially decreased to every 6 to 9 months. However, she was not able to fully wean off transfusions which slowly increased in frequency to every 3 months. She began treatment with luspatercept at the age of 42, and has maintained hemoglobin levels above 10 g/dL without need for a blood transfusion for almost two years since then. Case 2: This patient was diagnosed with hemoglobin H Constant Spring and homozygous HbE by hemoglobin electrophoresis and hemoglobinopathy genetic testing (c.427T>C , Hb Constant Spring; c79G>A, HbE). Up to her third decade of life, she was requiring regular pRBCs transfusions every 3-4 weeks with a pre-transfusion hemoglobin goal of 9-10 g/dL. She also had evidence of significant iron overload due to her transfusion frequency and suboptimal adherence to iron chelation (maximum liver iron content (LIC) of 16.4 mg/g dry weight) with a normal cardiac T2* (42.7 +/- 2.6 msec). She started treatment with luspatercept at the age of 30 years and her transfusion needs soon decreased and she achieved transfusion independence for more than 2 years with occasional transfusion only every 18 months. Concurrently, she was weaned off iron chelation around two years following initiation of luspatercept with an LIC of <3.5 and a ferritin of less than 500 ng/mL. She continues to be on luspatercept with no tolerability issues. These two patient cases demonstrate that luspatercept can also reduce transfusion needs or achieve independence following gene therapy or in alpha thalassemia. Other case reports have previously explored the potential clinical benefits of luspatercept in other settings. Our cases add to the existing experiences by elucidating possible novel applications of luspatercept to additional thalassemia populations. Our findings suggest that luspatercept can successfully increase and stabilize baseline hemoglobin for these patients, and thus could represent a safe and efficacious long-term disease-modifying therapy option for transfusion-dependent alpha thalassemias and patients who failed or had a suboptimal or incomplete response to gene therapy. Further research, including prospective studies and/or randomized trials, will be necessary to evaluate these indications for luspatercept on a larger study population in the future.
2025-02-14 | Long-term efficacy and safety of luspatercept for the treatment of anaemia in patients with transfusion-dependent β-thalassaemia (BELIEVE): final results from a phase 3 randomised trial.
Treatments to reduce red blood cell (RBC) transfusion burden among patients with transfusion-dependent β-thalassaemia remain limited. Here, we report long-term follow-up data from the phase 3 BELIEVE trial of luspatercept for transfusion-dependent β-thalassaemia. BELIEVE was a phase 3, randomised, double-blind, placebo-controlled study performed at 65 sites in 15 countries. The trial included adults with transfusion-dependent β-thalassaemia or haemoglobin E/β-thalassaemia and Eastern Cooperative Oncology Group score of 0-1. Patients were randomly assigned (2:1) using integrated response technology stratified by region to luspatercept (1·0-1·25 mg/kg) or placebo administered subcutaneously once every 21 days. After study unblinding, patients could receive luspatercept in the open-label extension phase (crossover allowed). The primary endpoint results (proportion of patients with reduction in transfusion burden of ≥33% and ≥2 RBC units during weeks 13-24) are described elsewhere; herein we present an update to the primary endpoint analysis consequent to late-reported transfusion events. We also report long-term efficacy (intention-to-treat population) and safety data (safety population) for patients followed up for approximately 3 years. This trial is registered on ClinicalTrials.gov (NCT02604433) and is completed. Between May 2, 2016, and May 16, 2017, 336 patients were randomly assigned to luspatercept (n=224) or placebo (n=112). The median age of patients was 30 years (IQR 23-40); 195 (58%) were female and 141 (42%) male. As of Jan 5, 2021, the median duration of treatment in the luspatercept group was 153·6 weeks (IQR 81·0-171·0) and median study follow-up was 163·1 weeks (140·5-176·2). Due to the difference in treatment duration between the luspatercept and placebo groups, no comparative analyses between the two groups were performed after week 96. Patients in the luspatercept group showed a sustained reduction in RBC transfusion burden from baseline through week 192, with mean decreases of 6·2 RBC units (SD 5·7) during weeks 97-144 and 6·4 RBC units (4·3) during weeks 145-192. In the luspatercept group, a 33% or greater reduction in transfusion burden from baseline was observed in 173 (77%) patients over any 12-week interval and in 116 (52%) patients over any 24-week interval. The median total duration of 33% or greater transfusion burden reduction response during any period of at least 12 weeks was 586·0 days (IQR 264·0-1010·0). The most common grade 3 or worse treatment-emergent adverse events (TEAEs) among all patients who received luspatercept (n=315, including 92 patients who crossed over after study unblinding) were anaemia (nine [3%]), increased liver iron concentration (seven [2%]), and bone pain (seven [2%]); serious TEAEs occurred in 71 (23%) patients. No treatment-related deaths occurred in any group during the study. These long-term results affirm luspatercept's efficacy in addressing key unmet needs of patients with transfusion-dependent β-thalassaemia with a manageable safety profile. Celgene and Acceleron Pharma.
2022-10-03 | Luspatercept for the treatment of anaemia in non-transfusion-dependent β-thalassaemia (BEYOND): a phase 2, randomised, double-blind, multicentre, placebo-controlled trial.
In patients with non-transfusion-dependent β-thalassaemia, haemoglobin concentrations lower than 10 g/dL are associated with a higher risk of morbidity, mortality, and impaired quality of life. No drugs are specifically approved for anaemia management in patients with non-transfusion-dependent β-thalassaemia, other than transfusion therapy administered infrequently in accordance with patients' needs. We assessed the efficacy and safety of luspatercept versus placebo in patients with non-transfusion-dependent β-thalassaemia. We did a phase 2, randomised, double-blind, multicentre, placebo-controlled trial in 12 centres in six countries (Thailand [n=1], Lebanon [n=1], Greece [n=2], Italy [n=5], the UK [n=1], and the USA [n=2]). Eligible patients were aged 18 years or older, had confirmed diagnosis of β-thalassaemia or haemoglobin E/β-thalassaemia (concomitant α-globin deletion, mutation, or duplication were allowed), and a baseline haemoglobin concentration of 10·0 g/dL or lower. All patients were non-transfusion-dependent. Patients were randomly assigned (2:1) to luspatercept or placebo using an interactive response technology system and stratified by baseline haemoglobin concentration (≥8·5 g/dL vs <8·5 g/dL) and baseline Non-Transfusion-Dependent β-thalassaemia-Patient-Reported Outcome Tiredness/Weakness domain score (≥3 vs <3). All patients, study site staff, and sponsor representatives (who reviewed the data), except for designated individuals, were masked to drug assignment until the time the study was unblinded. Luspatercept or placebo was given once subcutaneously every 3 weeks for 48 weeks in the double-blind treatment period. Luspatercept was started at 1·0 mg/kg with titration up to 1·25 mg/kg, or reduction in the event of toxicity or excessive haemoglobin concentration increase. The primary endpoint was achievement of an increase from baseline of 1·0 g/dL or higher in mean haemoglobin concentration over a continuous 12-week interval during weeks 13-24, in the absence of transfusions. The primary efficacy and safety analyses were done in the intention-to-treat population. This trial is registered at ClinicalTrials.gov, NCT03342404, and is ongoing. Between Feb 5, 2018, and Oct 14, 2019, 160 patients were screened for eligiblity, of whom 145 were randomly assigned to luspatercept (n=96) or placebo (n=49). 82 (57%) patients were female and 63 (43%) were male. 44 (30%) patients were Asian, 87 (60%) were White, and 14 (10%) identified as another race. The study met its primary endpoint: 74 (77%) of 96 patients in the luspatercept group and none in the placebo group had an increase of at least 1·0 g/dL in haemoglobin concentration (common risk difference 77·1 [95% CI 68·7-85·5]; p<0·0001). The proportion of patients with serious adverse events was lower in the luspatercept group than in the placebo group (11 [12%] vs 12 [25%]). Treatment-emergent adverse events most commonly reported with luspatercept were bone pain (35 [37%]), headache (29 [30%]), and arthralgia (28 [29%]). No thromboembolic events or deaths were reported during the study. Luspatercept represents a potential treatment for adult patients with non-transfusion-dependent β-thalassaemia, for whom effective approved treatment options are scarce. Celgene and Acceleron Pharma.
2022-04-27 | Erythroid spectrin binding modulates peroxidase and catalase activity of heme proteins.
Hemoglobin oxidation due to oxidative stress and disease conditions leads to the generation of ROS (reactive oxygen species) and membrane attachment of hemoglobin in-vivo, where its redox activity leads to peroxidative damage of membrane lipids and proteins. Spectrin, the major component of the red blood cell (RBC) membrane skeleton, is known to interact with hemoglobin and, here this interaction is shown to increase hemoglobin peroxidase activity in the presence of reducing substrate ABTS (2', 2'-Azino-Bis-3-Ethylbenzothiazoline-6-Sulfonic Acid). It is also shown that in the absence of reducing substrate, spectrin forms covalently cross-linked aggregates with hemoglobin which display no peroxidase activity. This may have implications in the clearance of ROS and limiting peroxidative damage. Spectrin is found to modulate the peroxidase activity of different hemoglobin variants like A, E, and S, and of isolated globin chains from each of these variants. This may be of importance in disease states like sickle cell disease and HbE-β-thalassemia, where increased oxidative damage and free globin subunits are present due to the defects inherent in the hemoglobin variants associated with these diseases. This hypothesis is corroborated by lipid peroxidation experiments. The modulatory role of spectrin is shown to extend to other heme proteins, namely catalase and cytochrome-c. Experiments with free heme and Raman spectroscopy of heme proteins in the presence of spectrin show that structural alterations occur in the heme moiety of the heme proteins on spectrin binding, which may be the structural basis of increased enzyme activity.
2021-12-06 | Association of the Degree of Erythroid Expansion and Maturation Arrest with the Clinical Severity of β0-Thalassemia/Hemoglobin E Patients.
β-Thalassemia/hemoglobin E represents one-half of all the clinically severe β-thalassemias worldwide. Despite similar genetic backgrounds, patients show clinical heterogeneity ranging from nearly asymptomatic to transfusion-dependent thalassemia. The underlying disease modifying factors remain largely obscure. To elucidate the correlation between ineffective erythropoiesis and β0-thalassemia/hemoglobin E (HbE) disease severity, in vitro culture of erythroid cells derived from patients with different clinical symptoms was established. Cell proliferation, viability, and differentiation were investigated. To identify potential molecular mechanisms leading to the arrested erythroid maturation, the expression levels of erythropoiesis modifying factors were measured. The β0-thalassemia/HbE cells exhibited enhanced proliferation, limited differentiation, and impaired erythroid terminal maturation but did not show accelerated erythroblast differentiation and increased cell death. Erythroblasts derived from mild patients showed the highest proliferation rate with a faster cell division time, while erythroblasts derived from severe patients displayed extremely delayed erythroid maturation. Downregulation of growth differentiation factor 11 and FOXO3a was observed in mild β0-thalassemia/HbE erythroblasts, while upregulation of heat shock protein 70 and activin receptor 2A was revealed in severe erythroblasts. The degree of erythroid expansion and maturation arrest contributes to the severity of β0-thalassemia/HbE patients, accounting for the disease heterogeneity. The findings suggest a restoration of erythroid maturation as a promising targeted therapy for severe patients.
other
2023-01-13 | Successful Strategy of Pre-implantation Genetic Testing for Beta-Thalassemia (c.17A>T Mutation)-Hb E Disease Using Multiplex Fluorescent PCR and Mini-Sequencing
Objectives: Hemoglobin E disease, c.26G>A variant of beta-globin gene, is the most common hemoglobinopathy in Asia. Compound heterozygotes inheriting Hb E disease and beta-thalassemia generate beta-thalassemia-Hb E disease with severe anemia. This study aimed to develop a pre-implantation genetic testing for monogenic disorders (PGT-M) protocol for beta–thalassemia (c.17A>T mutation)-Hb E disease (c.26G>A mutation) using multiplex fluorescent polymerase chain reaction (PCR) and mini-sequencing. Materials and Methods: bthalw1 primers were used to amplify a beta-globin gene fragment covering both mutations, i.e. beta– thalassemia (c.17A>T) and Hb E disease. D21S11 microsatellite marker was included for contamination detection. Novel mini-sequencing primers were designed and tested for detection of both mutations. Results: Pre-clinical work up of the optimized PGT-M protocol using 20 single buccal cells of a heterozygous subject showed 100% amplification efficiency and 0% allele drop out (ADO) rate for both primers. In clinical PGT-M cycle, 15 embryos were subjected to biopsy. The results showed two normal, one heterozygous for beta-thalassemia, six heterozygous for Hb E disease, one affected for beta-thalassemia-Hb E disease and five with ambiguous results. Two normally diagnosed embryos were chosen for transfer, one singleton pregnancy was obtained. A healthy baby boy was resulted. Postnatal testing confirmed PGT results. Conclusions: Novel PGT-M protocols for beta-thalassemia-Hb E disease using multiplex fluorescent PCR and mini-sequencing were developed and described here. The protocol was applied in a clinical PGT-M cycle and gave rise to one successful pregnancy and consequently a healthy baby boy. Mini-sequencing was proved to be rapid, accurate and cost-effective protocol for PGT-M.
small molecules
2026-05-28 | Neutrophil extracellular traps induced by activated platelets as a cause of neutrophil-platelet aggregation in β-thalassaemia/haemoglobin E patients.
The hypercoagulable state is a major contributor to thromboembolic events and mortality in β-thalassaemia. The mechanisms underlying platelet-induced neutrophil activation leading to immunothrombosis remain poorly understood. Three-dimensional confocal microscopy demonstrated that platelets induced neutrophil extracellular trap (NET) formation through P-selectin- or high mobility group box 1 protein (HMGB1)-mediated binding to P-selectin glycoprotein ligand-1 (PSGL-1) or receptor for advanced glycation end products (RAGE), respectively, on neutrophils. Molecular signalling pathways involved in NETs-focusing on mitogen-activated protein kinase kinase (MAPKK) or mitogen-activated protein kinase kinase 1/2 (MAP2K) (MEK)/extracellular signal-regulated kinase (ERK), reactive oxygen species (ROS), ofnicotinamide adenine dinucleotide phosphate (NADPH) oxidase complex 2 (NOX2), myeloperoxidase (MPO) and peptidylarginine deiminase 4 (PAD4)-were investigated in neutrophils from β-thalassaemia/haemoglobin E (HbE) patients (splenectomy and non-splenectomy) and from normal subjects by priming neutrophils with specific inhibitors before treatment with either platelets, recombinant P-selectin or disulphide HMGB1. In splenectomised patients, neutrophils primed with U0126, but not an ERK inhibitor, exhibited reduced web-like NETs and cell aggregation, associated with antioxidant effects. In non-splenectomised patients and normal subjects, P-selectin activated MEK/ERK, NOX2, MPO and PAD4 pathways, promoting web-like NETs and cell aggregation. HMGB1 activated neutrophils via MEK/ERK, NOX2, MPO and PAD4 pathways, in all groups, resulting in NETs without aggregation-associated NET morphology. These findings indicate that splenectomy alters P-selectin and HMGB1 expression on platelets, leading to altered signalling dynamics in neutrophils and promoting neutrophil-platelet aggregation. ROS pathway could be a key regulator of NET-driven thrombosis in splenectomised β-thalassaemia/HbE disease and highlight its potential as a therapeutic target.
2026-01-20 | Enhanced induction of fetal hemoglobin by the combination of decitabine with RN-1 in β-thalassemia/HbE erythroid progenitor cells.
BACKGROUND: Fetal hemoglobin (HbF; α2γ2) induction is a well-established approach for β-hemoglobinopathies, including sickle cell disease (SCD) and β-thalassemia. Decitabine, a DNA methyltransferase 1 (DNMT1) inhibitor, has been shown to effectively induce HbF production with a favorable safety profile. However, more potent therapeutic strategies are needed, particularly for β-thalassemia/HbE patients. METHODS: We evaluated the HbF-inducing efficacy of ten DNMT1 inhibitors in erythroid progenitor cells derived from β-thalassemia/HbE patients. To further enhance HbF induction, we investigated a combination treatment with decitabine and RN-1, a lysine-specific demethylase 1 (LSD1) inhibitor. HbF expression, cell viability, erythroid differentiation, and proliferation were assessed. Additionally, we investigated the association between treatment response and well-characterized single-nucleotide polymorphisms (SNPs) previously linked to HbF expression. RESULTS: Of the ten DNMT1 inhibitors tested, SGI-110, a dinucleotide analog of decitabine, exhibited similar HbF-inducing efficacy and toxicity profiles as decitabine at equivalent molar dose. The combination treatment with decitabine and RN-1 resulted in a robust additive increase in HbF expression in β-thalassemia/HbE erythroid progenitor cells, albeit with a slight reduction in cell viability. Additionally, the combination treatment improved the delayed differentiation phenotype in β-thalassemia/HbE erythroid cells, accompanied by a reduction in cell proliferation. Interestingly, individual variability in response to RN-1 and the combination treatments was observed, with major responders exhibiting significantly greater increases in HbF compared to minor responders. We identified two SNPs in the BCL11A gene (rs766432 and rs1427407) that were potentially associated with a higher likelihood of major response to treatments. CONCLUSIONS: Our findings highlight the potential of targeting two distinct epigenetic corepressors within the γ-globin repressor complex to achieve robust HbF induction. The combination of decitabine and RN-1 represents a promising therapeutic strategy for β-thalassemia, warranting further investigation into the molecular mechanisms underlying individual response variability.
2025-12-12 | Deferiprone therapy improves the oxidative status of LDL in patients with β-thalassaemia/HbE.
Oxidative modifications of low-density lipoproteins (LDL) have been reported in patients with β-thalassaemia/haemoglobin E (HbE) and are related to cardiovascular complications. Deferiprone (L1) is an iron chelator that decreases iron overload and, consequently, reduces oxidative stress. This study assesses the protective effect of L1 on the oxidative status of LDL in patients with β-thalassaemia/HbE. Twenty-nine patients with β-thalassaemia/HbE treated with L1 were recruited. The study included a 4-week washout period followed by 4 and 12 weeks of L1 treatment. Non-transferrin-bound iron (NTBI) levels and oxidative stress markers, including thiobarbituric acid reactive substances and α-tocopherol, were monitored at each visit. The rate and content of lipid radical formation following Cu2+-induced LDL oxidation in vitro were detected by NBD-Pen, a specific fluorescence probe. L1 was shown to prevent the depletion of α-tocopherol, decrease thiobarbituric acid reactive substances and preserve the levels of lipid components in LDL. A negative correlation between serum NTBI and LDL α-tocopherol indicated that the circulating non-redox-active NTBI can lead to the depletion of α-tocopherol. LDL from the washout period showed the highest oxidative susceptibility when evaluated by NBD-Pen. Iron chelation therapy with L1 improves the oxidative status of LDL in patients with β-thalassaemia/HbE.
2025-11-25 | Regulation of Alternative Polyadenylation Events by PABPC1 Affects Erythroid Progenitor Cell Expansion
Erythropoiesis is precisely regulated by multilayered networks. It is crucial for maintaining steady-state hemoglobin levels and ensuring effective oxygen transport. Alternative polyadenylation (APA) is a post-transcriptional regulatory mechanism generating multiple mRNA isoforms from a single gene based on specific 3'-untranslated region sequences. While APA plays a vital role in various cellular processes, the underlying mechanism in erythropoiesis remains largely unexplored. In this study, we employed an integrative approach, combining bioinformatics analyses and experimental validations, to systematically investigate the role of APA in erythropoiesis. We mapped the APA landscape during erythroid differentiation and identified significant APA shifts essential for the differentiation of erythroid cells from burst-forming unit erythroid (BFU-E) to colony-forming unit erythroid (CFU-E). Notably, our findings highlighted polyadenylate-binding protein cytoplasmic 1 (PABPC1) as the primary regulator of APA during these stages. Functional analyses have revealed that knockdown of PABPC1 disrupts erythroid progenitor cell proliferation and differentiation. These results implicate an essential role of PABPC1 in modulating cell fate through APA regulation. Furthermore, we found that decreased PABPC1 levels increased the usage of the proximal polyadenylation sites in the TSC22D1 gene. This shift led to elevated expression of TSC22D1, uncovering a novel mechanism by which APA influences erythroid progenitor expansion and differentiation. Our findings provide novel insights into APA regulation in early erythropoiesis and suggest potential therapeutic strategies for diseases associated with erythropoietic disorders.
2025-07-03 | Metabolic reprogramming during ineffective erythropoiesis in β-thalassemia/HbE disease.
Ineffective erythropoiesis, the main cause of anemia in β-thalassemia disease, is characterized by dramatic expansion of erythroblasts and increased erythroblast cell death. The absence or reduction of β-globin chains causes an accumulation of excess α-globin chains and generates cytotoxic reactive oxidant species, resulting in erythroblast cell death. Metabolism provides energy, building blocks for macromolecule synthesis, and cofactors for antioxidative defense systems. We hypothesized that β-thalassemia erythroblasts might alter their metabolism to cope with increased proliferation and cellular stress. Herein, transcriptomic analysis of basophilic and polychromatic erythroblasts isolated from bone marrow obtained from β-thalassemia/HbE patients showed the global up-regulation of metabolic genes in glycolysis, TCA cycle, pentose phosphate pathway, ATP, and fatty acid synthesis pathway. The expression of metabolic genes during terminal erythropoiesis was further determined by PCR array and RT-qPCR in erythroblast culture obtained from β-thalassemia/HbE patients with mild and severe symptoms. The increased expression of enolase1, isocitrate dehydrogenase 1, and bisphosphoglycerate mutase was observed in mild cases compared to severe patients, suggesting that mild patients might modulate metabolic flux for cellular stress defense mechanisms, reducing disease severity. Moreover, the role of BPGM in regulating erythroid differentiation was demonstrated in K562 cells. Inhibition of BPGM promotes cell differentiation in K562 cells. Understanding metabolic reprogramming in thalassemia erythropoiesis opens new therapeutic approaches for β-thalassemia/HbE treatment. Further research is needed to explore how metabolism affects ineffective erythropoiesis and supports thalassemic erythroblasts' high proliferation and oxidative stress defense.
gene therapies
2025-11-21 | Multi-centric origins and gene flow shape the diversity of β-thalassemia mutations in Southern East Asia.
Over 400 β-thalassemia mutations show population-differentiated spectra, yet their origins and evolution remain unclear. Focusing on targeted sequencing of 20,222 individuals and 510 β-thalassemia patients in southern China, we identified three major haplotype groups (HG) at the β-globin locus and observed highest haplotype diversity for CD41/42, -50, and HbE among 13 prevalent mutations in 993 carriers. Allele dating suggest these mutations emerged during agricultural expansions in the past 7420 years, represented by CD41/42 arising in mainland China. However, the -50 mutation likely originated on Hainan Island within 3900 years, subsequently spreading to the mainland and experiencing lineage-specific selection. HbE exhibits substantial haplotype heterogeneity in Yunnan, with network analyses indicating bidirectional disseminations between southern China and South/Southeast Asia. We further suggest an ameliorating effect of HG2, associated with elevated hemoglobin and fetal hemoglobin levels. These findings highlight multi-centric origins of β-thalassemia mutations and underscore the evolutionary context shaping their clinical impact.
2025-11-01 | Phenotypic Expression of Hemoglobinopathies: A Single Centre Study
Background: Hemoglobinopathies are among the most prevalent genetic disorders worldwide, with high phenotypic heterogeneity. The northeastern region of India shows a predominance of hemoglobin E and (HbE)related variants. Methods: This prospective cross-sectional study was conducted at a tertiary care centre in N E India. Seventy patients aged over six months and diagnosed with hemoglobinopathy were included. Detailed demographic data, clinical features, hematological parameters, HPLC results, serum ferritin levels analysed. Genetic mutation profiles were analysed in twenty-five of these patients. Transfusion dependency and phenotypic outcomes were also studied. Results: HbE-related disorders were the most common, seen in 65.7% of cases. HbE/β-thalassemia accounted for 44.2%, followed by beta-thalassemia major (17.1%) and sickle cell disease (5.7%). Nearly 48.5% of the patients were transfusion-dependent. Poorly transfused individuals had significantly higher serum ferritin, hepatosplenomegaly, short stature, delayed puberty, and endocrinopathies. Among genetically analyzed cases, the most frequent mutations were c.79G>A (HbE variant) and IVS1-5(G>C) (β-thalassemia), with compound heterozygosity often predicting a severe phenotype. Conclusion: HbE/β-thalassemia is the predominant hemoglobinopathy in Assam with diverse clinical presentations. Transfusion status and chelation significantly influence growth and endocrine health. Mutation profiling enhances understanding of disease severity and can guide individualized care. Population-based studies are warranted to further characterize the regional mutation spectrum and phenotypic variability.
2025-07-16 | Disrupting ZBTB7A or BCL11A binding sites reactivates fetal hemoglobin in erythroblasts from healthy and β0-thalassemia/HbE individuals.
CRISPR/Cas9 genome editing has emerged as a promising treatment for genetic diseases like β-thalassemia. Editing γ-globin promoters to disrupt ZBTB7A/LRF or BCL11A binding sites has shown potential for reactivating fetal hemoglobin and treating sickle cell disease. However, its application to β0-thalassemia/HbE disease remains unclear. This study utilized CRISPR/Cas9 to disrupt these sites in mobilized CD34 + hematopoietic stem /progenitor cells from healthy donors and β0-thalassemia/HbE patients. The editing efficiency for the BCL11A site (75-92%) was higher than for the ZBTB7A/LRF site (57-60%). Both disruptions similarly increased fetal hemoglobin production in healthy donors (BCL11A 26.2 ± 1.4%, ZBTB7A/LRF 27.9 ± 1.5%) and β0-thalassemia/HbE cells (BCL11A 62.7 ± 0.9%, ZBTB7A/LRF 64.0 ± 1.6%). Off-target effects were absent in BCL11A-edited cells but observed at low frequencies in ZBTB7A/LRF-edited cells. Neither disruption significantly affected erythroid differentiation. These findings highlight the comparable contributions of ZBTB7A/LRF and BCL11A binding sites to γ-globin reactivation. CRISPR/Cas9 editing of either site may offer a potential therapeutic strategy for β0-thalassemia/HbE disease.
2024-08-19 | Clinical characteristics, laboratory features and genetic profile of hemoglobin E (HBB:c.79 G > A)/β (nucleotide -28 A > G) (HBB:c.-78 A > G) -thalassemia subjects identified from community- and hospital-recruited cohorts.
Despite several existing laboratory-based studies of hemoglobin (Hb) E (HBB:c.79 G > A)/ β (nucleotide (NT) -28 A > G) (HBB:c.-78 A > G) -thalassemia, no reports have ever provided clinical severity information as well as dependency of blood transfusion. Previously, a comparative study of community- and hospital-recruited Hb E/β-thalassemia subjects was conducted in the lower northern Thailand between June 2020 and December 2021. A mobile medical team visited each community hospital on-site, collecting clinical severity parameters, and conducting Hb and DNA analyses. The control included Hb E/β-thalassemia patients undergoing transfusions. Subgroup study of adult Hb E/β (NT -28 A > G) -thalassemia subjects was subsequently conducted. Additional pediatric individuals were recruited from prenatal diagnosis databases. Twenty adult and nine pediatric subjects were enrolled; all were classified as having mild disease severity. Twenty-two individuals (75.9 %) were asymptomatic. Six adults (20.7 %) required blood transfusion. The mean Hb level of subjects without transfusion (23 [79.3 %]) was 10.77 ± 1.10 g/dL. Hb analysis revealed a distinct EFA pattern with low Hb F fraction. The positive impact of genetic modifiers could not be statistically demonstrated except rs7482144-XmnI. These findings could provide essential information for parents carrying fetuses with Hb E/β (NT -28 A > G) -thalassemia.
2022-09-29 | The successful strategy of comprehensive pre-implantation genetic testing for beta-thalassaemia-haemoglobin E disease and chromosome balance using karyomapping.
Thalassaemia is the commonest monogenic disease and causes a health and economic burden worldwide. Karyomapping can be used for pre-implantation genetic testing of monogenic disorders (PGT-M). This study applied karyomapping in two PGT-M cycles and made a comparison to polymerase chain reaction (PCR). Two families at risk of having beta-thalassaemia-haemoglobin E disease offspring decided to join the project and informed consent was obtained. Karyomapping results of family A (beta-thalassaemia (c.41_42delTCTT)-Hb E (c.26G>A) disease) revealed four normal, two beta-thalassaemia traits, one Hb E trait and six affected. Three embryos exhibited unbalanced chromosomes. One normal male embryo was transferred. Karyomapping results of family B (beta-thalassaemia (c.17A>T)-Hb E (c.26G>A) disease) revealed six Hb E traits and three affected. Three embryos were chromosomally unbalanced. One Hb E trait embryo was transferred. Two successful karyomapping PGT-M were performed, including deletion and single-base mutations. Karyomapping provides accuracy as regards the protocol and copy number variation which is common in pre-implantation embryos. Impact StatementWhat is already known on this subject? Thalassaemia syndrome is the commonest monogenic disease and causes a health and economic burden worldwide. Modern haplotyping using SNP array (aSNP) and karyomapping algorithms can be used for pre-implantation genetic testing of monogenic disorders (PGT-M). However, few clinical karyomapping PGT-M cycles have been done and validated so far.What do the results of this study add? Two successful clinical PGT-M cycles for beta-thalassaemia (c.41_42delTCTT and c.17A>T mutations)-haemoglobin E (c.26G>A) disease were performed using karyomapping. The outcome was two healthy babies. Multiplex fluorescent polymerase chain reaction (PCR) with mini-sequencing was also used for confirmation mutation analysis results. PCR confirmed haplotyping results in all embryos. Six embryos from both PGT-M cycles exhibited unbalanced chromosomes evidenced by aSNP.What are the implications of these findings for clinical practice and/or further research? Karyomapping provides accurate information quickly and the outcomes of the study will save time as regards protocol development, provide a usable universal PGT-M protocol and add additional copy number variation (CNV) information, chromosome number variation being a common issue in pre-implantation embryos.
cell therapies
2025-05-16 | Genetic polymorphism of novel SNP rs5006884 in OR51B6 and SNP rs4499252 in AHSP among transfusion-dependent and non-transfusion-dependent β-thalassemia/Hb E patients in Thailand: a multivariate analysis of clinical and genetic polymorphism.
Compound heterozygous β-thalassemia and Hb E, a prevalent and severe form of thalassemia in Southeast Asia, manifests in two major clinical forms: transfusion-dependent thalassemia (TDT) and non-transfusion-dependent thalassemia (NTDT). This study investigates the association of genetic polymorphisms rs5006884 in OR51B6, rs4499252 in AHSP, rs9399137 in HBS1L-MYB, and rs4671393 in BCL11A with clinical severity and transfusion dependency in β-thalassemia/Hb E patients in Thailand. A total of 189 samples, including 58 TDT, 58 NTDT, 33 homozygous Hb E, and 40 wild-type individuals, were analyzed. Genotyping of the four single nucleotide polymorphisms (SNPs) was conducted using the rhAmp SNP Genotyping assay. Multivariate regression models were developed to evaluate the combined effects of genetic and clinical factors on transfusion dependency. The results showed that OR51B6 SNP rs5006884 TT genotype was significantly more frequent in the NTDT group (P < 0.05), suggesting a strong association with reduced transfusion dependency. Conversely, the AHSP SNP rs4499252 GG genotype was significantly less frequent in the homozygous Hb E group (P < 0.05) compared to other groups. Multivariate analyses highlighted hemoglobin (Hb) levels as a robust predictor of transfusion dependency, with specific HBB mutations including HBB:c.59 A > G, HBB:c.-78 A > G, HBB:c.316-197 C > T, and NC_000011.10:g.5224302_5227791del being significantly associated with NTDT (P < 0.05). Furthermore, rs5006884 in OR51B6 also played a significant role in NTDT in multivariate analyses. In contrast, SNPs in BCL11A (rs4671393), HBS1L-MYB (rs9399137), and AHSP (rs4499252) showed no significant independent associations with transfusion dependency or disease severity in this cohort. This study explores rs5006884 in OR51B6 and rs4499252 in AHSP in TDT and NTDT patients for the first time. These findings elucidate the interplay of genetic and clinical factors influencing β-thalassemia severity, paving the way for personalized management strategies to mitigate transfusion requirements.
2024-11-05 | Myocardial Fibrosis Occurs in Young Non-Transfusion-Dependent Alpha-Thalassemia Intermedia Patients and Is Related to Anemia and Age in Thalassemia
Introduction A recent landmark study demonstrated that median pretransfusion hemoglobin in transfusion dependent thalassemia (TDT) >10.5 g/dl has 100% ten-year survival compared to 91% at a hemoglobin of 9.0 with the majority of deaths due to non-iron-related cardiac events (Musallam et al., 2024). Increased anemia-related morbidity and mortality has also been seen in non-transfusion-dependent-thalassemia (NTDT) and low-risk myelodysplastic syndrome suggesting even moderate anemia can have severe consequences to a high oxygen demand organ like the heart (Musallam et al., 2021). Patients with NTDT-α-thalassemia intermedia (TI-α; Hemoglobin H disease and Hemoglobin H-Constant Spring), a presumed benign disorder, have lifelong hemoglobin levels of 8-11 g/dL with most around 8.5 g/dL (Musallam et al., 2024) but very little is known about morbidity and mortality beyond the fifth decade. To address this, we assessed cardiac fibrosis, an accepted predictor of future cardiac dysfunction in TI-α and TDT, using MRI-determined extracellular volume (ECV), with ECV >30% indicating diffuse myocardial fibrosis. We found significant myocardial fibrosis in NTDT-TI-α <40 years old, which was related to degree of anemia and age in patients with thalassemia. Methods This study included patients with thalassemia followed at Children's Hospital Los Angeles who had ECV measured by cardiac MRI. ECV was calculated by T1 mapping pre- and post-gadolinium contrast as previously described. Subjects' baseline or pretransfusion hemoglobin was determined as median value over 6 months prior to MRI. Data were collected and analyzed using JMP Pro 15.1.0 (SAS Institute Inc., Cary, NC, 2019). Results Twenty-two subjects with thalassemia were evaluated: seven with TI-α, four with TI-β, three with E/β-thalassemia, and eight with β-thalassemia major. Subjects' ages ranged from 2 to 63 years at initial evaluation, with median age 27.5 years. All β-thalassemia subjects and three of the TI-α subjects were transfused. Median ECV among all subjects was elevated to 32.4%; median ECV was 32.5% in β-thalassemia and 32.4% among TI-α (p=0.94), ranging 29.7% to 43.7% in NTDT-TI-α. All subjects had normal ejection fraction, no cardiac siderosis, and no symptoms of cardiac disease. ECV increased with decreasing hemoglobin among all subjects (p=0.0012, R2=0.34) and in TI-α (p=0.0213, R2=0.61), but the relationship was not significant in β-thalassemia (p=0.5198). ECV increased with age in all subjects (p=0.0148, R2=0.21), particularly in β-thalassemia (p=0.0060, R2=0.35), but not in TI-α (p=0.6086). Both hemoglobin and age were retained in a multivariate model (p=0.0017, p=0.0196, respectively; R2=0.47), while their interaction was not significant. Discussion The most concerning finding is the presence of significant ECV elevation in 3/4 young, asymptomatic NTDT-TI-α patients. We found that ECV is strongly associated with anemia severity in thalassemia, particularly in TI-α. These findings are consistent with the emerging data in TDT, NTDT and other ineffective erythropoiesis-related chronic anemias showing long-term morbidity and mortality is worse with lower hemoglobin. This is clinically important given that implementation of regular transfusion in NTDT was associated with improved morbidity and survival. The multivariate model of ECV in this study shows the long-term effects of anemia and age on fibrosis, and we hypothesize that duration of anemia is important. Larger studies are needed to evaluate the prevalence of myocardial fibrosis and the consequence of diastolic dysfunction and arrhythmia at older ages in this population. Little is known about the outcomes of NTDT-TI-α in older individuals, but this preliminary data suggests this presumed benign disorder is likely similar to NTDT in general.
2020-12-07 | Generation of an immortalised erythroid cell line from haematopoietic stem cells of a haemoglobin E/β-thalassemia patient.
The β-thalassemia syndromes are the most prevalent genetic disorder globally, characterised by reduced or absent β-globin chain synthesis. HbE/β-thalassemia is a subtype of β-thalassemia with extremely high frequency in Asia. Studying molecular defects behind β-thalassemia is severely impeded by paucity of material from patients and lack of suitable cell lines. Approaches to derive erythroid cells from induced pluripotent stem cells (iPSCs) created from patients are confounded by poor levels of erythroid cell expansion, aberrant or incomplete erythroid differentiation and foetal/embryonic rather than adult globin expression. In this study we generate an immortalised erythroid cell line from peripheral blood stem cells of a HbE/β-thalassemia patient. Morphological analysis shows the cells are proerythroblasts with some early basophilic erythroblasts, with no change in morphology over time in culture. The line differentiates along the erythroid pathway to orthochromatic erythroblasts and reticulocytes. Importantly, unlike iPSCs, the line maintains the haemoglobin profile of the patient's red blood cells. This is the first human cellular model for β-thalassemia providing a sustainable source of disease cells for studying underlying disease mechanisms and for use as drug screening platform, particularly for reagents designed to increase foetal haemoglobin expression as we have additionally demonstrated with hydroxyurea.
2017-12-12 | Hematopoietic stem cell transplantation for homozygous β-thalassemia and β-thalassemia/hemoglobin E patients from haploidentical donors.
Thalassemia-free survival after allogeneic stem cell transplantation (SCT) is about 80-90% with either matched-related or -unrelated donors. We explored the use of a mismatched-related ('haplo- ') donor. All patients received two courses of pretransplant immunosuppressive therapy (PTIS) with fludarabine (Flu) and dexamethasone (Dxm). After two courses of PTIS, a conditioning regimen of rabbit antithymocyte globulin, Flu and IV busulfan (Bu) was given followed by T-cell-replete peripheral blood progenitor cells. GvHD prophylaxis consisted of cyclophosphamide (Cy) on days SCT +3 and +4 (post-Cy), and on day SCT +5 tacrolimus or sirolimus was started together with a short course of mycophenolate mofetil. Thirty-one patients underwent haplo-SCT. Their median age was 10 years (range, 2-20 years). Twenty-nine patients engrafted with 100% donor chimerism. Two patients suffered primary graft failure. Median time to neutrophil engraftment was 14 days (range, 11-18 days). Five patients developed mild to moderate, reversible veno-occlusive disease, while nine patients developed acute GvHD grade II. Only five patients developed limited-chronic GvHD. Projected overall and event-free survival rates at 2 years are 95% and 94%, respectively. The median follow up time is 12 months (range, 7-33 months).
2014-02-01 | Favorable Outcomes from Allogeneic Hematopoietic Cell Transplantation in Thailand for Thalassemias and Hemoglobinopathies
Thalassemia syndromes are very prevalent in many parts of the world including Asia. Allogeneic hematopoietic cell transplantation (HCT) is the only curative therapy accepted worldwide. To assess outcomes of HCT for thalassemias and hemoglobinopathies in single medical center in Thailand. Case series study for thalassemia and hemoglobinopathy patients undergoing HCT at Bangkok Hospital Medical Center from February 2009 thru October 2013. There were totally 14 patients. 10 cases were Thais, 1 was French-Thai, 1 was Bangladeshi, 1 was Lao, and 1 was Omani who had sickle cell disease (SCD). 12 cases were diagnosed as beta-thalassemia/hemoglobin E diseases, 1 as transfusion-dependent alpha-thalassemia, and 1 as SCD. Among 14 HCTs, 9 patients underwent bone marrow transplant (BMT), 4 patients underwent umbilical cord blood transplant (CBT), and 1 patient underwent combined cord blood and marrow transplantation. All 14 related donors were fully-HLA-matched, 4 had normal typing, 9 had thalassemia trait, and 1 had sickle cell trait. Male to female patients ratio were 11:3. Patients' ages at transplant varied from 2 years to 15 years 11 months with median of 4 years 10 months. Patient's body weight varied from 11.1 to 50 kilogram (median 17.2 kilogram). According to Pesaro classification, among 13 thalassemia patients there were 8 class I, and 5 class II patients. Busulfan, fludarabine, and rabbit ATG were mainly used as myeloablative conditioning regimen. Cyclosporine and short-course methotrexate were mainly used as graft-versus-host disease (GvHD) prophylaxis in BMT group, while cyclosporine alone was used in CBT group. CD34+ cell doses per kilogram body weight recipients were ranged from 5.6 to 34.7x106 (median 11.3x106) in BMT group (n=9), and from 1.6 to 3x105 (median 2.3x105) in CBT group (n=4). Complete donor engraftments were achieved in 11 patients. Mixed-chimerism states with donor predominance were present in 2 patients from BMT and 1 patient from CBT group. No patients experienced graft failure. Neutrophil recoveries were evident on days +10 to +23 (median day +14), and platelet recoveries were observed on days +19 to +64 (median day +40). 2 patients had mild veno-occlusive diseases and were later completely reversible. No patients developed acute or chronic GvHD. There were no mortalities. 1 patient had treatable pneumocystis pneumonia at 4 months post CBT. Median follow-up time for all patients was 2 years (1 month to 4 years 8 months). Overall (OS) and disease-free survival (DFS) were 100% and 100% for all patients (n=14). Based on risk class, the OS and DFS for class I thalassemia patients (n=9) were 100% and 100%, and class II patients (n=4) were 100% and 100%, respectively. Our experiences in HCT for thalassemias and hemoglobinopathies were very favorable. Regular follow-up visits are encouraged to determine long term outcomes.
proteins
2025-11-03 | Transfusion independence in thalassemia patients after failure of gene therapy or with hemoglobin h constant spring and hb e using luspatercept: A case series
Abstract Background: Individuals with thalassemia who depend on blood transfusions to maintain adequate hemoglobin levels are at high risk of sequelae resulting from frequent blood products. As such, there is increased interest in decreasing transfusion frequency for such patients and limiting side effects. Luspatercept is a recombinant fusion protein that enhances erythropoiesis by binding to select TGF-b ligands and can increase hemoglobin for patients with thalassemia. Luspatercept use was associated with significantly greater reductions in transfusion burden than for the placebo group for transfusion-dependent b-thalassemia (TDT) patients in the BELIEVE trial. Luspatercept was also associated with a significant increase in hemoglobin level among non-transfusion-dependent beta thalassemia (NTDT) in the BEYOND trial. However, currently, there is very limited evidence for the utility luspatercept in thalassemia patients after a failed gene therapy or among those with alpha thalassemia. Here we describe two cases with significant clinical response to luspatercept achieving transfusion independence in distinct thalassemia populations that have not yet been reported in the literature. Case 1: This patient underwent LentiGlobin gene therapy for b-thalassemia (β0/β0) at the age of 34 years in 2015. Prior to gene therapy, she required regular packed red blood cell (pRBCs) transfusions every 4 weeks. After admission for gene therapy per protocol HGB-204, her transfusion needs initially decreased to every 6 to 9 months. However, she was not able to fully wean off transfusions which slowly increased in frequency to every 3 months. She began treatment with luspatercept at the age of 42, and has maintained hemoglobin levels above 10 g/dL without need for a blood transfusion for almost two years since then. Case 2: This patient was diagnosed with hemoglobin H Constant Spring and homozygous HbE by hemoglobin electrophoresis and hemoglobinopathy genetic testing (c.427T>C , Hb Constant Spring; c79G>A, HbE). Up to her third decade of life, she was requiring regular pRBCs transfusions every 3-4 weeks with a pre-transfusion hemoglobin goal of 9-10 g/dL. She also had evidence of significant iron overload due to her transfusion frequency and suboptimal adherence to iron chelation (maximum liver iron content (LIC) of 16.4 mg/g dry weight) with a normal cardiac T2* (42.7 +/- 2.6 msec). She started treatment with luspatercept at the age of 30 years and her transfusion needs soon decreased and she achieved transfusion independence for more than 2 years with occasional transfusion only every 18 months. Concurrently, she was weaned off iron chelation around two years following initiation of luspatercept with an LIC of <3.5 and a ferritin of less than 500 ng/mL. She continues to be on luspatercept with no tolerability issues. These two patient cases demonstrate that luspatercept can also reduce transfusion needs or achieve independence following gene therapy or in alpha thalassemia. Other case reports have previously explored the potential clinical benefits of luspatercept in other settings. Our cases add to the existing experiences by elucidating possible novel applications of luspatercept to additional thalassemia populations. Our findings suggest that luspatercept can successfully increase and stabilize baseline hemoglobin for these patients, and thus could represent a safe and efficacious long-term disease-modifying therapy option for transfusion-dependent alpha thalassemias and patients who failed or had a suboptimal or incomplete response to gene therapy. Further research, including prospective studies and/or randomized trials, will be necessary to evaluate these indications for luspatercept on a larger study population in the future.
2025-02-14 | Long-term efficacy and safety of luspatercept for the treatment of anaemia in patients with transfusion-dependent β-thalassaemia (BELIEVE): final results from a phase 3 randomised trial.
Treatments to reduce red blood cell (RBC) transfusion burden among patients with transfusion-dependent β-thalassaemia remain limited. Here, we report long-term follow-up data from the phase 3 BELIEVE trial of luspatercept for transfusion-dependent β-thalassaemia. BELIEVE was a phase 3, randomised, double-blind, placebo-controlled study performed at 65 sites in 15 countries. The trial included adults with transfusion-dependent β-thalassaemia or haemoglobin E/β-thalassaemia and Eastern Cooperative Oncology Group score of 0-1. Patients were randomly assigned (2:1) using integrated response technology stratified by region to luspatercept (1·0-1·25 mg/kg) or placebo administered subcutaneously once every 21 days. After study unblinding, patients could receive luspatercept in the open-label extension phase (crossover allowed). The primary endpoint results (proportion of patients with reduction in transfusion burden of ≥33% and ≥2 RBC units during weeks 13-24) are described elsewhere; herein we present an update to the primary endpoint analysis consequent to late-reported transfusion events. We also report long-term efficacy (intention-to-treat population) and safety data (safety population) for patients followed up for approximately 3 years. This trial is registered on ClinicalTrials.gov (NCT02604433) and is completed. Between May 2, 2016, and May 16, 2017, 336 patients were randomly assigned to luspatercept (n=224) or placebo (n=112). The median age of patients was 30 years (IQR 23-40); 195 (58%) were female and 141 (42%) male. As of Jan 5, 2021, the median duration of treatment in the luspatercept group was 153·6 weeks (IQR 81·0-171·0) and median study follow-up was 163·1 weeks (140·5-176·2). Due to the difference in treatment duration between the luspatercept and placebo groups, no comparative analyses between the two groups were performed after week 96. Patients in the luspatercept group showed a sustained reduction in RBC transfusion burden from baseline through week 192, with mean decreases of 6·2 RBC units (SD 5·7) during weeks 97-144 and 6·4 RBC units (4·3) during weeks 145-192. In the luspatercept group, a 33% or greater reduction in transfusion burden from baseline was observed in 173 (77%) patients over any 12-week interval and in 116 (52%) patients over any 24-week interval. The median total duration of 33% or greater transfusion burden reduction response during any period of at least 12 weeks was 586·0 days (IQR 264·0-1010·0). The most common grade 3 or worse treatment-emergent adverse events (TEAEs) among all patients who received luspatercept (n=315, including 92 patients who crossed over after study unblinding) were anaemia (nine [3%]), increased liver iron concentration (seven [2%]), and bone pain (seven [2%]); serious TEAEs occurred in 71 (23%) patients. No treatment-related deaths occurred in any group during the study. These long-term results affirm luspatercept's efficacy in addressing key unmet needs of patients with transfusion-dependent β-thalassaemia with a manageable safety profile. Celgene and Acceleron Pharma.
2022-10-03 | Luspatercept for the treatment of anaemia in non-transfusion-dependent β-thalassaemia (BEYOND): a phase 2, randomised, double-blind, multicentre, placebo-controlled trial.
In patients with non-transfusion-dependent β-thalassaemia, haemoglobin concentrations lower than 10 g/dL are associated with a higher risk of morbidity, mortality, and impaired quality of life. No drugs are specifically approved for anaemia management in patients with non-transfusion-dependent β-thalassaemia, other than transfusion therapy administered infrequently in accordance with patients' needs. We assessed the efficacy and safety of luspatercept versus placebo in patients with non-transfusion-dependent β-thalassaemia. We did a phase 2, randomised, double-blind, multicentre, placebo-controlled trial in 12 centres in six countries (Thailand [n=1], Lebanon [n=1], Greece [n=2], Italy [n=5], the UK [n=1], and the USA [n=2]). Eligible patients were aged 18 years or older, had confirmed diagnosis of β-thalassaemia or haemoglobin E/β-thalassaemia (concomitant α-globin deletion, mutation, or duplication were allowed), and a baseline haemoglobin concentration of 10·0 g/dL or lower. All patients were non-transfusion-dependent. Patients were randomly assigned (2:1) to luspatercept or placebo using an interactive response technology system and stratified by baseline haemoglobin concentration (≥8·5 g/dL vs <8·5 g/dL) and baseline Non-Transfusion-Dependent β-thalassaemia-Patient-Reported Outcome Tiredness/Weakness domain score (≥3 vs <3). All patients, study site staff, and sponsor representatives (who reviewed the data), except for designated individuals, were masked to drug assignment until the time the study was unblinded. Luspatercept or placebo was given once subcutaneously every 3 weeks for 48 weeks in the double-blind treatment period. Luspatercept was started at 1·0 mg/kg with titration up to 1·25 mg/kg, or reduction in the event of toxicity or excessive haemoglobin concentration increase. The primary endpoint was achievement of an increase from baseline of 1·0 g/dL or higher in mean haemoglobin concentration over a continuous 12-week interval during weeks 13-24, in the absence of transfusions. The primary efficacy and safety analyses were done in the intention-to-treat population. This trial is registered at ClinicalTrials.gov, NCT03342404, and is ongoing. Between Feb 5, 2018, and Oct 14, 2019, 160 patients were screened for eligiblity, of whom 145 were randomly assigned to luspatercept (n=96) or placebo (n=49). 82 (57%) patients were female and 63 (43%) were male. 44 (30%) patients were Asian, 87 (60%) were White, and 14 (10%) identified as another race. The study met its primary endpoint: 74 (77%) of 96 patients in the luspatercept group and none in the placebo group had an increase of at least 1·0 g/dL in haemoglobin concentration (common risk difference 77·1 [95% CI 68·7-85·5]; p<0·0001). The proportion of patients with serious adverse events was lower in the luspatercept group than in the placebo group (11 [12%] vs 12 [25%]). Treatment-emergent adverse events most commonly reported with luspatercept were bone pain (35 [37%]), headache (29 [30%]), and arthralgia (28 [29%]). No thromboembolic events or deaths were reported during the study. Luspatercept represents a potential treatment for adult patients with non-transfusion-dependent β-thalassaemia, for whom effective approved treatment options are scarce. Celgene and Acceleron Pharma.
2022-04-27 | Erythroid spectrin binding modulates peroxidase and catalase activity of heme proteins.
Hemoglobin oxidation due to oxidative stress and disease conditions leads to the generation of ROS (reactive oxygen species) and membrane attachment of hemoglobin in-vivo, where its redox activity leads to peroxidative damage of membrane lipids and proteins. Spectrin, the major component of the red blood cell (RBC) membrane skeleton, is known to interact with hemoglobin and, here this interaction is shown to increase hemoglobin peroxidase activity in the presence of reducing substrate ABTS (2', 2'-Azino-Bis-3-Ethylbenzothiazoline-6-Sulfonic Acid). It is also shown that in the absence of reducing substrate, spectrin forms covalently cross-linked aggregates with hemoglobin which display no peroxidase activity. This may have implications in the clearance of ROS and limiting peroxidative damage. Spectrin is found to modulate the peroxidase activity of different hemoglobin variants like A, E, and S, and of isolated globin chains from each of these variants. This may be of importance in disease states like sickle cell disease and HbE-β-thalassemia, where increased oxidative damage and free globin subunits are present due to the defects inherent in the hemoglobin variants associated with these diseases. This hypothesis is corroborated by lipid peroxidation experiments. The modulatory role of spectrin is shown to extend to other heme proteins, namely catalase and cytochrome-c. Experiments with free heme and Raman spectroscopy of heme proteins in the presence of spectrin show that structural alterations occur in the heme moiety of the heme proteins on spectrin binding, which may be the structural basis of increased enzyme activity.
2021-12-06 | Association of the Degree of Erythroid Expansion and Maturation Arrest with the Clinical Severity of β0-Thalassemia/Hemoglobin E Patients.
β-Thalassemia/hemoglobin E represents one-half of all the clinically severe β-thalassemias worldwide. Despite similar genetic backgrounds, patients show clinical heterogeneity ranging from nearly asymptomatic to transfusion-dependent thalassemia. The underlying disease modifying factors remain largely obscure. To elucidate the correlation between ineffective erythropoiesis and β0-thalassemia/hemoglobin E (HbE) disease severity, in vitro culture of erythroid cells derived from patients with different clinical symptoms was established. Cell proliferation, viability, and differentiation were investigated. To identify potential molecular mechanisms leading to the arrested erythroid maturation, the expression levels of erythropoiesis modifying factors were measured. The β0-thalassemia/HbE cells exhibited enhanced proliferation, limited differentiation, and impaired erythroid terminal maturation but did not show accelerated erythroblast differentiation and increased cell death. Erythroblasts derived from mild patients showed the highest proliferation rate with a faster cell division time, while erythroblasts derived from severe patients displayed extremely delayed erythroid maturation. Downregulation of growth differentiation factor 11 and FOXO3a was observed in mild β0-thalassemia/HbE erythroblasts, while upregulation of heat shock protein 70 and activin receptor 2A was revealed in severe erythroblasts. The degree of erythroid expansion and maturation arrest contributes to the severity of β0-thalassemia/HbE patients, accounting for the disease heterogeneity. The findings suggest a restoration of erythroid maturation as a promising targeted therapy for severe patients.
other
2023-01-13 | Successful Strategy of Pre-implantation Genetic Testing for Beta-Thalassemia (c.17A>T Mutation)-Hb E Disease Using Multiplex Fluorescent PCR and Mini-Sequencing
Objectives: Hemoglobin E disease, c.26G>A variant of beta-globin gene, is the most common hemoglobinopathy in Asia. Compound heterozygotes inheriting Hb E disease and beta-thalassemia generate beta-thalassemia-Hb E disease with severe anemia. This study aimed to develop a pre-implantation genetic testing for monogenic disorders (PGT-M) protocol for beta–thalassemia (c.17A>T mutation)-Hb E disease (c.26G>A mutation) using multiplex fluorescent polymerase chain reaction (PCR) and mini-sequencing. Materials and Methods: bthalw1 primers were used to amplify a beta-globin gene fragment covering both mutations, i.e. beta– thalassemia (c.17A>T) and Hb E disease. D21S11 microsatellite marker was included for contamination detection. Novel mini-sequencing primers were designed and tested for detection of both mutations. Results: Pre-clinical work up of the optimized PGT-M protocol using 20 single buccal cells of a heterozygous subject showed 100% amplification efficiency and 0% allele drop out (ADO) rate for both primers. In clinical PGT-M cycle, 15 embryos were subjected to biopsy. The results showed two normal, one heterozygous for beta-thalassemia, six heterozygous for Hb E disease, one affected for beta-thalassemia-Hb E disease and five with ambiguous results. Two normally diagnosed embryos were chosen for transfer, one singleton pregnancy was obtained. A healthy baby boy was resulted. Postnatal testing confirmed PGT results. Conclusions: Novel PGT-M protocols for beta-thalassemia-Hb E disease using multiplex fluorescent PCR and mini-sequencing were developed and described here. The protocol was applied in a clinical PGT-M cycle and gave rise to one successful pregnancy and consequently a healthy baby boy. Mini-sequencing was proved to be rapid, accurate and cost-effective protocol for PGT-M.
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