Anemia falciforme: una revisión sobre el genotipo de la enfermedad, haplotipos, diagnóstico y estudios asociados / Disease genotype, haplotypes, diagnosis and associated studies in sickle cell anemia

Sickle cell anemia is a type of hemoglobinopathy characterized by a specific mutation in the beta globin gene with the consequent generation of an unstable hemoglobin that crystallizes in a state of hypoxia. This causes a change in the structure of the red blood cell, which ends up producing vaso-occlusion with the corresponding clinical complications for the patient. Worldwide, various diagnostic tests have been developed that allow the appropriate approach to the affected patient. These include techniques for the determination of hemoglobin and the use of molecular markers, among others. There are new therapeutic alternatives to the use of hydroxyurea and L-glutamine, such as the use of gene therapy tools. The most recent experimental trials are exploring gene editing techniques.

Occurrence of unusual haemoglobinopathies in balochistan: hb sd and hb se - presentation with osteomyelitis / Ocorrência de hemoglobinopatias incomuns no baluchistão: hb sd e hb se - apresentação com osteomielite

ABSTRACT Objective: To describe two cases of unusual variants of sickle cell disease. Case description: We present two cases of sickle cell disease variants (haemoglobinopathies), from unrelated families, in the state of Balochistan (Pakistan). One was diagnosed with sickle cell disease in the haemoglobin electrophoresis, whereas the other was diagnosed with sickle cell SE disease. Both were diagnosed based on the presentation of osteomyelitis. Comments: Haemoglobin SD disease (Hb SD) and haemoglobin SE disease (Hb SE) are rare haemoglobinopathies in the world. The lack of available literature suggests that both are variants of sickle cell disease (SCD), with heterogeneous nature. The prevalence of sickle cell disease with compound heterozygotes was found at a variable frequency in the population of the Asian Southeast. The frequency of osteomyelitis in SCD is 12 to 18%, but its occurrence among variant haemoglobinopathies is little reported. Both reported cases presented with osteomyelitis as a characteristic of the disease presentation.

RESUMO Objetivo: Descrever dois casos de variantes raras da hemoglobinopatia falciforme. Descrição do caso: Apresentamos aqui dois casos de hemoglobinopatias variantes das células falciformes, de famílias não relacionadas, no estado do Baluchistão (Paquistão), sendo um diagnosticado como doença da hemoglobina SD na eletroforese de hemoglobina, enquanto o outro com doença da hemoglobina SE. Ambos foram diagnosticados a partir da apresentação de osteomielite. Comentários: Hemoglobina SD (Hb SD) e hemoglobina SE (Hb SE) são hemoglobinopatias raras no mundo. A escassez de literatura disponível sugere que ambas são variantes da doença falciforme (DF) com natureza heterogênea. A prevalência de hemoglobinopatia falciforme com heterozigosidade composta foi encontrada com frequência variável na população do sudeste asiático. A frequência de osteomielite na DF é de 12 a 18%, mas sua ocorrência entre as hemoglobinopatias falciformes variantes é pouco relatada. Os dois casos reportados apresentaram osteomielite como característica de apresentação da doença.

Evaluation of hydroxyurea genotoxicity in patients with sickle cell disease / Avaliação da indução de genotoxicidade pela hidroxiureia em pacientes com doença falciforme

ABSTRACT Objective To evaluate the induction of DNA damage in peripheral blood mononuclear cells of patients with sickle cell disease, SS and SC genotypes, treated with hydroxyurea. Methods The study subjects were divided into two groups: one group of 22 patients with sickle cell disease, SS and SC genotypes, treated with hydroxyurea, and a Control Group composed of 24 patients with sickle cell disease who were not treated with hydroxyurea. Peripheral blood samples were submitted to peripheral blood mononuclear cell isolation to assess genotoxicity by the cytokinesis-block micronucleus cytome assay, in which DNA damage biomarkers - micronuclei, nucleoplasmic bridges and nuclear buds - were counted. Results Patients with sickle cell disease treated with hydroxyurea had a mean age of 25.4 years, whereas patients with sickle cell disease not treated with hydroxyurea had a mean age of 17.6 years. The mean dose of hydroxyurea used by the patients was 12.8mg/kg/day, for a mean period of 44 months. The mean micronucleus frequency per 1,000 cells of 8.591±1.568 was observed in the Hydroxyurea Group and 10.040±1.003 in the Control Group. The mean frequency of nucleoplasmic bridges per 1,000 cells and nuclear buds per 1,000 cells for the hydroxyurea and Control Groups were 0.4545±0.1707 versus 0.5833±0.2078, and 0.8182±0.2430 versus 0.9583±0.1853, respectively. There was no statistically significant difference between groups. Conclusion In the study population, patients with sickle cell disease treated with the standard dose of hydroxyurea treatment did not show evidence of DNA damage induction.

RESUMO Objetivo Avaliar o efeito da indução de danos ao DNA em células monocelulares do sangue periférico de pacientes com doença falciforme, genótipos SS e SC, tratados com hidroxiureia. Métodos Os sujeitos da pesquisa foram divididos em dois grupos: um de 22 pacientes com doença falciforme genótipos SS e SC tratados com hidroxiureia, e o outro controle, composto por 24 pacientes com doença falciforme que não eram tratados com o fármaco. As amostras de sangue periférico foram submetidas ao isolamento de células mononucleares do sangue periférico para avaliação da genotoxicidade pelo ensaio de micronúcleo citoma com bloqueio da citocinese, tendo sido quantificados os biomarcadores de danos ao DNA - micronúcleos, pontes nucleoplasmáticas e brotamento nuclear. Resultados Os pacientes com doença falciforme tratados com hidroxiureia apresentaram média de idade de 25,4 anos, enquanto aqueles com doença falciforme não tratados com hidroxiureia tiveram média de idade de 17,6 anos. A dose média de hidroxiureia utilizada pelos pacientes foi de 12,8mg/kg/dia, por período médio de 44 meses. A frequência média de micronúcleos por 1.000 células de 8,591±1,568 foi observada no Grupo Hidroxiureia e de 10,040±1,003 no Grupo Controle. Adicionalmente, a frequência média de pontes nucleoplasmáticas por 1.000 células e brotamento nuclear por 1.000 células para o Grupo Hidroxiureia e Controle foi de 0,4545±0,1707 versus 0,5833±0,2078, e de 0,8182±0,2430 versus 0,9583±0,1853, respectivamente. Não houve diferença estatisticamente significativa entre os grupos. Conclusão Na população estudada de pacientes com doença falciforme com tratamento em dose padrão de hidroxiureia, não houve evidência de indução de danos ao DNA.

Prevalência de hemoglobinas variantes em comunidades quilombolas no estado do Piauí, Brasil / Prevalence of hemoglobin variants in quilombola communities in the state of Piauí, Brazil

Resumo As hemoglobinas variantes (Hb) decorrem de mutações nos genes da globina. As variantes estruturais mais frequentes são HbS, HbC, HbD e HbE. O gene da hemoglobina S tem frequência elevada na América, enquanto que no Brasil é maior no Sudeste e Nordeste. O presente artigo tem por objetivo investigar a presença de hemoglobinas variantes em 15 comunidades quilombolas do estado do Piauí. Foram analisadas 1.239 amostras, nas quais as hemoglobinas foram triadas pela cromatografia líquida de alta eficiência (HPLC). Aplicou-se questionário referente a gênero, etnia e consanguinidade das populações. Das 1.239 amostras, 5,4% apresentaram o traço falciforme AS, as doenças falciformes SS e SC apareceram em 0,8% do total, nas hemoglobinas AC, AD e DD. Das 1.069 pessoas negras, 84 apresentaram alteração das hemoglobinas; destas, 34 eram do sexo masculino e 53 do feminino. Ocorreu a presença de 13 casamentos consanguíneos dentre as 84 alterações das hemoglobinas. O estudo das hemoglobinas variantes em 15 comunidades remanescentes de quilombos do Piauí contribui para sua educação em saúde frente aos aspectos da herança genética destas proteínas, relevante questão de saúde pública, proporcionando subsídios para a implantação do Programa Estadual da Doença Falciforme do Piauí.

Abstract Hemoglobin variants (Hb) result from mutations in globin genes, with amino acid substitution in the polypeptide chain. Among the most common structural variants are HbS, HbC, HbD and HbE. The S hemoglobin gene is a high frequency gene across America and Brazil, where it is more frequent in the Southeast and Northeast. The scope of this article is to investigate the presence of hemoglobin variants in 15 quilombos (fugitive slave communities) of Piaui. The sample was of 1,239 people and hemoglobin was screened by high-performance liquid chromatography (HPLC). A questionnaire was applied related to gender, ethnicity and consanguinity. Of the samples analyzed, 5.4% had AS sickle cell trait, while SS and SC sickle cell anemia showed a rate of 0.8%, with AC, AD and DD hemoglobin. Of the 1,069 Afro-descendants, 84 revealed hemoglobin abnormalities, 34 being male 53 being female. There were 13 consanguineous marriages among the 84 hemoglobin alterations. The study of hemoglobin variants in 15 former quilombo communities in the state of Piaui contributes to their education in health in the aspects of genetic inheritance of hemoglobin, a relevant public health issue, providing input for the implementation of the State Program of Sickle Cell Disease of Piaui.

Profile of Reproductive Issues Associated with Different Sickle Cell Disease Genotypes / Perfil reprodutivo associado aos diferentes genótipos da doença falciforme

Abstract Purpose To describe the reproductive variables associated with different sickle cell disease (SCD) genotypes and the influence of contraceptive methods on acute painful episodes among the women with the homozygous hemoglobin S (HbSS) genotype. Methods A cross-sectional study was conducted between September of 2015 and April of 2016 on 158 women afflicted with SCD admitted to a hematology center in the Northeast of Brazil. The reproduction-associated variables of different SCD genotypes were assessed using the analysis of variance (ANOVA) test to compare means, and the Kruskal-Wallis test to compare medians. The association between the contraceptive method and the acute painful episodes was evaluated by the Chi-square test. Results Themean age of women with SCD was 28.3 years and 86.6% were mixed or of African-American ethnicity. With respect to the genotypes, 134 women (84.8%) had HbSS genotype, 12 women (7.6%) had hemoglobin SC (HbSC) disease genotype, and 12 (7.6%) were identified with hemoglobinopathy S-beta (S-β) thalassemia. The mean age of HbSS diagnosis was lower than that of HbSC disease, the less severe formof SCD (p < 0.001). The mean age ofmenarche was 14.8 ± 1.8 years for HbSS and 12.7 ± 1.5 years for HbSC (p < 0.001). Among women with HbSS who used progestin-only contraception, 16.6% had more than 4 acute painful episodes per year. There was no statistically significant difference when compared with other contraceptive methods. Conclusion With respect to reproduction-associated variables, only the age of the menarche showed delay in HbSS when compared with HbSC. The contraceptive method used was not associated with the frequency of acute painful episodes among the HbSS women.

Resumo Objetivo Descrever as variáveis reprodutivas em diferentes genótipos da doença falciforme (DF) e a influência dos métodos contraceptivos na frequência das crises álgicas em mulheres com homozigose da hemoglobina S (HbSS). Métodos Estudo de corte transversal realizado entre setembro de 2015 e abril de 2016 com 158 mulheres com DF atendidas em um centro de hematologia no Nordeste do Brasil. As variáveis reprodutivas dos diferentes genótipos da DF foram avaliadas utilizando-se o teste de análise de variância (ANOVA) para comparação de médias e o teste de Kruskal-Wallis para comparação de medianas. A associação entre o método contraceptivo e a frequência das crises álgicas foi avaliada pelo teste Qui-quadrado. Resultados A idade média das mulheres com DF foi de 28,3 anos e 86,6% eram afrodescentes. Em relação aos genótipos, 134 mulheres (84,8%) tinham genótipo HbSS, 12 mulheres (7,6%) tinham genótipo para doença da hemoglobina SC (HbSC) e 12 (7,6%) foram identificadas com beta talassemia (S-β). A idade média do diagnóstico de HbSS foi menor do que a da HbSC, sendo esta a forma menos grave da DF (p < 0,001). A idade média da menarca foi de 14,8 ± 1,8 anos para HbSS e de 12,7 ± 1,5 anos para HbSC (p < 0,001). Entre as mulheres com HbSS que fizeram contracepção com progesterona isolada, 16,6% apresentaram mais de 4 episódios de crises álgicas agudas por ano. Não houve diferença estatisticamente significativa quando comparado com outros métodos anticoncepcionais. Conclusão Em relação às variáveis reprodutivas, apenas a idade da menarca apresentou atraso no HbSS em relação ao HbSC. O método anticoncepcional utilizado não foi associado à frequência de crises álgicas entre as mulheres com HbSS.

Síndrome drepanocítico: Asociación de hemoglobina S Y &ß talasemia / Sickle cell syndrome. Association between hemoglobin S and ß thalassemia

El síndrome drepanocítico HbS/β talasemia responde a la herencia de tipo mendeliana en simultáneo de un alelo βs de la hemoglobina S (HbS) y un alelo de β talasemia. Vinculado fundamentalmente a individuos que comparten ascendencia africana y de países del Mediterráneo. La mutación responsable de la HbS es puntual, mientras que para la β talasemia existen más de 200 mutaciones que causan diferentes grados de deficiencia de síntesis de la cadena de β globina, lo cual justifica la heterogeneidad clínica y genética de este síndrome. Se presenta el caso clínico de un adulto joven de escasos recursos que consulta por dolores óseos de larga data. Registra hemogramas con anemia y marcada microcitosis. Se le realizó electroforesis de Hb detectándose un pico anómalo en posición de HbS y elevada fracción de HbA2. El resultado de la electroforesis de hemoglobina indica dos posibles alteraciones moleculares en simultáneo, por tal motivo se realizó el estudio molecular de las mutaciones más frecuentes en nuestra población de β talasemia y de la mutación puntual responsable de la hemoglobinopatía S. A partir de la clínica y datos del laboratorio bioquímico se diagnosticó el síndrome drepanocítico y se confirmó por biología molecular la portación de las mutaciones IVS-Int 110 G > A (β talasemia) y del codón 6 A > T (GAG→GTG: Glu→Val) responsable de la hemoglobinopatía S. Dado que es una enfermedad de alto impacto sanitario, es importante un adecuado asesoramiento genético a toda la familia.

Sickle cell syndrome HbS/β thalassemia is an inheritable mendelian type disease where two affected alleles are simultaneously present, one from HbS (βS) and the other from β thalassemia. That situation is mainly linked to individuals who share African and Mediterranean ancestors. The mutation responsible for HbS is a point mutation, whereas for β thalassemia, there are more than 200 mutations that cause different degrees of deficiency synthesis of β globin chain, which justifies the clinical and genetic heterogeneity of this syndrome. It is presented a clinical case of a young adult man with limited resources that consulted by longstanding bone pain. The patient presented anemia with a marked microcytosis. Hemoglobin electrophoresis was performed, an abnormal peak in position of HbS and high HbA2 fraction were detected. These last results indicated two possible molecular alterations simultaneously, for this reason the molecular study was performed looking for the most common β thalassemia mutations in our population and, the point mutation responsible for S hemoglobinopathy. Clinical data and biochemical laboratory allowed the diagnosis of sickle cell syndrome. The molecular study confirmed the syndrome carrying mutations IVS-I nt 110 G > A, responsible for β thalassemia and, codon 6 A > T (GAG → GTG: Glu → Val) responsible for S hemoglobinophaty. Since it is a disease of high health impact, it is important to provide genetic counseling to the whole family.

Genetic determinants and stroke in children with sickle cell disease / Determinantes genéticos e Acidente Vascular Encefálico em crianças com doença falciforme

Abstract Objective: To verify genetic determinants associated with stroke in children with sickle cell disease (SCD). Methods: Prospective cohort with 110 children submitted to neonatal screening by the Neonatal Screening Program, between 1998 and 2007, with SCD diagnosis, followed at a regional reference public service for hemoglobinopathies. The analyzed variables were type of hemoglobinopathy, gender, coexistence with alpha thalassemia (α-thal), haplotypes of the beta globin chain cluster, and stroke. The final analysis was conducted with 66 children with sickle cell anemia (SCA), using the chi-squared test in the program SPSS® version 14.0. Results: Among children with SCD, 60% had SCA. The prevalence of coexistence with α-thal was 30.3% and the Bantu haplotype (CAR) was identified in 89.2%. The incidence of stroke was significantly higher in those with SCA (27.3% vs. 2.3%; p = 0.001) and males (24.1% vs. 9.6%; p = 0.044). The presence of α-thal (p = 0.196), the CAR haplotype (p = 0.543), and socioeconomic factors were not statistically significant in association with the occurrence of stroke. Conclusion: There is a high incidence of stroke in male children and in children with SCA. Coexistence with α-thal and haplotypes of the beta globin chain cluster did not show any significant association with stroke. The heterogeneity between previously evaluated populations, the non-reproducibility between studies, and the need to identify factors associated with stroke in patients with SCA indicate the necessity of conducting further research to demonstrate the relevance of genetic factors in stroke related to SCD.

Resumo Objetivo: Verificar fatores genéticos associados ao acidente vascular encefálico (AVE) em crianças com doença falciforme (DF). Métodos: Coorte prospectiva de 110 crianças submetidas à triagem neonatal pelo Programa de Triagem Neonatal, entre 1998-2007, com o diagnóstico de DF, atendidas em serviço público regional de referência em hemoglobinopatias. As variáveis analisadas foram: tipo de hemoglobinopatia, sexo, coexistência da alfa-Talassemia (α-Tal), haplótipos do cluster da cadeia beta globina e AVE. A análise estatística final foi feita com 66 crianças com anemia falciforme, por meio do teste do qui-quadrado no programa SPSS® 14.0. Resultados: Entre as crianças com DF, 60% eram portadoras de anemia falciforme. A prevalência da coexistência com a α-Tal foi de 30,3% e o haplótipo Bantu (CAR) foi identificado em 89,2%. A incidência de AVE foi significativamente maior nas crianças com AF (27,3% versus 2,3%; p = 0,001) e no sexo masculino (24,1% versus 9,6%; p = 0,044. A presença da α-Tal (p = 0,196), do haplótipo CAR (p = 0,543) e de fatores socioeconômicos não foi significantemente associada à ocorrência de AVE. Conclusão: O AVE apresenta alta incidência em crianças com AF e em crianças do sexo masculino. Coexistência de α-Tal ou de haplótipos do cluster da betaglobina não apresentaram associação significante com AVE. A heterogeneticidade entre as populações previamente avaliadas e a não reprodutibilidade entre estudos indicam a necessidade de novas pesquisas para verificar o papel desses fatores genéticos no AVE em crianças com DF.

The relationship between genotype, psychiatric symptoms and quality of life in adult patients with sickle cell disease in São Paulo, Brazil: a cross-sectional study / A relação entre genótipo, sintomas psiquiátricos e qualidade de vida em pacientes adultos com doença falciforme em São Paulo, Brasil: um estudo transversal

CONTEXT AND OBJECTIVE: Health-related quality of life (HRQoL) may be worsened in sickle cell patients due to the presence of psychiatric disorders. The aims of this study were to describe the psychiatric symptoms in Brazilian sickle cell patients and to evaluate the relationship of these symptoms to the genotype of the disease and the subject's HRQoL. DESIGN AND SETTING: Cross-sectional study conducted at the hematology outpatient clinic, Hospital São Paulo. METHODS: Adult patients with sickle cell disease completed the Medical Outcome Study - Short Form 36 and the Patients' Health Questionnaire. Clinical data were gathered from their medical files. Linear regression models were developed to study the dependency of HRQoL domains on the genotype controlling for psychiatric symptoms. RESULTS: In the study period, 110 patients were evaluated. The most frequent psychiatric symptom was depression (30%), followed by anxiety (12.7%) and alcohol abuse (9.1%). Patients with the more severe genotype (SS and Sβthal0) showed lower scores for the "general health" and "role-physical" HRQoL domains, without interference from psychiatric symptoms. In the "role-physical" domain, the more severe genotype operated as a protective factor for HRQoL (β = 0.255; P = 0.007). CONCLUSION: The more severe genotypes worsened HRQoL in two domains of physical health (general health and role-physical), but they did not have any influence on mental health, thus suggesting that physicians should be more attentive to aspects of HRQoL relating to the functionality of sickle cell disease patients, so as to be aware of the limitations that these patient live with.

CONTEXTO E OBJETIVO: A qualidade de vida relacionada à saúde (QVRS) pode ser piorada em pacientes com doença falciforme na presença de transtornos psiquiátricos. O objetivo deste estudo é descrever a sintomatologia psiquiátrica presente no paciente brasileiro com doença falciforme e avaliar a relação desses sintomas com o genótipo da doença e a QVRS do sujeito. TIPO DE ESTUDO E LOCAL: Estudo com delineamento transversal, realizado no ambulatório de Hematologia do Hospital São Paulo. MÉTODOS: Adultos com doença falciforme responderam ao Questionário de Qualidade de Vida (SF-36) e ao Questionário sobre a Saúde do Paciente (PHQ). Dados clínicos foram obtidos no prontuário médico. Modelos de regressão linear foram desenvolvidos para estudar a dependência dos domínios de QVRS no genótipo com controle para sintomas psiquiátricos. RESULTADOS: No período do estudo, 110 pacientes foram avaliados. O sintoma psiquiátrico mais frequente foi o depressivo (30%), seguido do ansioso (12,7%) e de abuso de álcool (9,1%). Os pacientes com genótipo mais grave (SS e S βthal0) apresentaram menores médias nos domínios de QVRS de "saúde geral" e de "aspectos físicos", sem interferência dos sintomas psiquiátricos. No domínio "aspectos físicos", o genótipo mais grave funcionou como fator protetor da QVRS (β = 0,255; P = 0,007). CONCLUSÃO: Os genótipos mais graves pioraram a QVRS em dois domínios do componente físico ("aspectos físicos" e "saúde geral"), mas não influenciaram o componente mental, sugerindo que o médico deve estar atento aos aspectos da QVRS relacionados com a funcionalidade do portador da doença falciforme, conhecendo as limitações com as quais o paciente convive.

Genetic variants associated with fetal hemoglobin levels show the diverse ethnic origin in Colombian patients with sickle cell anemia / Las variantes genéticas asociadas con niveles de hemoglobina fetal señalan diversos orígenes étnicos en pacientes colombianos con anemia falciforme.

Introduction: Fetal hemoglobin is an important factor in modulating the severity of sickle cell anemia. Its level in peripheral blood underlies strong genetic determination. Associated loci with increased levels of fetal hemoglobin display population-specific allele frequencies. Objective: We investigated the presence and effect of known common genetic variants promoting fetal hemoglobin persistence (rs11886868, rs9399137, rs4895441, and rs7482144) in 60 Colombian patients with sickle cell anemia. Materials and methods: Four single nucleotide polymorphisms (SNP) were genotyped by restriction fragment length polymorphisms (RFLP) and the use of the TaqMan procedure. Fetal hemoglobin (HbF) from these patients was quantified using the oxyhemoglobin alkaline denaturation technique. Genotype frequencies were compared with frequencies reported in global reference populations. Results: We detected genetic variants in the four SNPs, reported to be associated with higher HbF levels for all four SNPs in the Colombian patients. Genetic association between SNPs and HbF levels did not reach statistical significance. The frequency of these variants reflected the specific ethnic make-up of our patient population: A high prevalence of rs7482144-'A' reflects the West-African origin of the sickle cell mutation, while high frequencies of rs4895441-'G' and rs11886868-'C' point to a significant influence of an Amerindian ethnic background in the Colombian sickle cell disease population. Conclusion: These results showed that in the sickle cell disease population in Colombia there is not a unique genetic background, but two (African and Amerindian). This unique genetic situation will provide opportunities for a further study of these loci, such as fine-mapping and molecular-biological investigation. Colombian patients are expected to yield a distinctive insight into the effect of modifier loci in sickle cell disease.

Introducción. La hemoglobina fetal es un importante factor modulador de la gravedad de la anemia falciforme, cuya expresión está muy condicionada por el factor genético. Los loci asociados con el incremento de la hemoglobina fetal pueden presentar frecuencias alélicas específicas para cada población. Objetivo. Investigar la presencia y el efecto de las variantes genéticas rs11886868, rs9399137, rs4895441 y rs7482144 asociadas con la persistencia de hemoglobina fetal, en 60 pacientes colombianos con anemia falciforme. Materiales y métodos. Se hizo la genotipificación de los polimorfismos de nucleótido simple ( Single Nucleotide Polymorphisms, SNP) mediante la técnica de polimorfismos de longitud de fragmentos de restricción ( Restriction Fragment Length Polymorphisms, RFLP) y el procedimiento TaqMan. La hemoglobina fetal (HbF) se cuantificó utilizando la técnica de desnaturalización alcalina de la oxihemoglobina. Las frecuencias genotípicas se compararon con las reportadas en poblaciones de referencia global. Resultados. Se observaron variantes genéticas ya reportadas para aumento de HbF en los cuatro SNP. La asociación genética entre los SNP y el incremento de la HbF no alcanzó significancia estadística. La frecuencia de estos alelos reflejó la siguiente composición específica en esta muestra de pacientes colombianos: una gran prevalencia de rs7482144-'A', lo que indica que el origen de la mutación para la anemia falciforme es África occidental, y una gran frecuencia de rs4895441-'G' y rs11886868-'C', lo que denota la influencia significativa del origen genético amerindio. Conclusión. Los resultados evidenciaron que la población con anemia falciforme de Colombia no tiene un único origen genético, sino que existen dos (africano y amerindio). Esta situación genética única ofrece la oportunidad de llevar a cabo un estudio más amplio de estos loci a nivel molecular. Se espera que el estudio de pacientes colombianos permita una visión diferente del efecto de los loci modificadores en esta enfermedad.

Caracterização do uso de atividades físicas em crianças e adolescentes com anemia falciforme / Characterization of the use of physical activities of children and adolescents with sickle cell anemia

Das anemias hereditárias, a falciforme (AF) configura-se como a anemia hemolítica do tipo autossômica recessiva mais prevalente no mundo, determinada por uma alteração dahemoglobina que não consegue transpor-se pelos vasos e fazendocom o que o sistema circulatório apresente dificuldades para levar aoxigenação ao organismo. Visto que na literatura brasileira têm-seponderações apenas em relação à descrição da prática de atividadefísica por indivíduos com o traço falciforme, este estudo buscou investigar e pontuar considerações referentes ao desempenho ocupacional de crianças/adolescentes com AF para a realização de atividades físicas. Foi realizado um estudo de naturezaqualitativa exploratória e como procedimento de delineamento o estudo de caso, os dados foram coletados utilizando-se a Medida Canadense de Desempenho Ocupacional com 13 sujeitos, crianças/adolescentes com o diagnóstico de AF. Foram constatadasalterações obtidas no desempenho das crianças/adolescentes com AF no que diz respeito às atividades físicas, como a indisposição, cansaço, dor, edema. Contudo, verificou-se que tais acometimentos não são compreensíveis para esta população, e que existemdistintos graus de limitação...

In hereditary anemias, sickle cell disease (SCD) is confi gured as hemolytic anemia autosomal recessive type most prevalent in the world, determined by an altered hemoglobinthat cannot be transposed vessels, making with the circulatory system will have problems to carry oxygen to the body. Whereas in Brazilian literature have been weighted only for the description of physical activity for individuals with sickle cell trait, this study sought to investigate and scoring considerations regarding theoccupational performance of children/adolescents with SCD toperform physical activities. A qualitative and exploratory study was performed design procedure as a case study; data were collected through the Canadian Occupational Performance Measure(COPM) with 13 subjects, children and adolescents diagnosed with SCD. Changes obtained were found in the performance of children and adolescents with SCD related to sports activities, such as malaise, fatigue, pain and edema. However, it was foundthat these affections are not understandable for this population,and that there are different degrees of limitation...

Comparison of in-vitro and in-vivo response to fetal hemoglobin production and γ-mRNA expression by hydroxyurea in Hemoglobinopathies.

BACKGROUND: Hydroxyurea, which induces Fetal hemoglobin (HbF) synthesis, is the only drug widely used in different hemoglobinopathies; however, the response is very variable. We compared the efficacy of hydroxyurea in-vitro in erythroid cultures and in-vivo in the same patients with different hemoglobinopathies to induce HbF production and enhance γ-messenger RNA expression. MATERIALS AND METHODS: A total of 24-patients with different Hemoglobinopathies were given hydroxyurea and their response was studied in-vivo and in-vitro on mononuclear cells collected from them simultaneously. RESULTS: A total of 57.7% of patients (responders) showed no further crisis or transfusion requirements after hydroxyurea therapy with a mean increase in fetal cells (F-cells) of 63.8 ± 59.1% and γ-mRNA expression of 205.5 ± 120.8%. In-vitro results also showed a mean increase in F-cells of 27.2 ± 24.7% and γ-mRNA expression of 119.6% ± 65.4% among the treated cells. Nearly 19.0% of the partial-responders reduced their transfusion requirements by 50% with a mean increase in F-cells of 61.2 ± 25.0% and 28.4 ± 25.3% and γ-mRNA-expression of 21.0% ± 1.4% and 80.0% ± 14.1% in-vivo and in-vitro respectively. The non-responders (15.3%) showed no change in their clinical status and there was no significant increase in F-cells levels and γ-mRNA expression in-vivo or in-vitro. CONCLUSION: Thus, this method may help to predict the in-vivo response to hydroxyurea therapy; however, a much larger study is required.

Polimorfismos no gene klotho e hemoglobinopatia SC (HBB glu6val E glu6lys): associação com subfenótipos da doença / Polymorphisms in klotho and hemoglobin SC disease gene (HBB glu6val And glu6lys): association with disease subphenotypes

A variabilidade clínica descrita na doença falciforme (DF) tem sido associada ao efeito epistático de vários genes, a exemplo do gene Klotho (Kl), cujos polimorfismos interferem na regulação de canais de potássio (K+), cálcio (Ca2+) e fósforo, na expressão de vitamina D (VitD) e paratormônio (PTH), e na supressão do estresse oxidativo. Com isto, o presente estudo teve por objetivos investigar a frequência de SNPs no Kl em indivíduos com hemoglobinopatia SC (HbSC), associando-os a marcadores de gravidade e subfenótipos da doença e investigar associações entre os níveis de K+, Ca2+, fósforo, VitD e PTH com tais marcadores de gravidade. Foi desenvolvido um estudo de corte transversal com 113 indivíduos com HbSC provenientes da Fundação HEMOBA, Salvador-Ba. As análises hematológicas foram realizadas em contador eletrônico de células; o perfil de hemoglobinas foi confirmado pela cromatografia líquida de alto desempenho; os marcadores lipídicos, de hemólise, de função hepática e renal, Ca2+ e fósforo foram avaliados por método colorimétrico, assim como o K+, por eletrodo de íon seletivo; as concentrações de VitD e PTH foram investigadas por quimioluminescência e de anti-estreptolisina-O (ASLO) e proteína C reativa (PCRe) por nefelometria; os SNPs no Kl (rs1207568, rs9527025, rs564481 e rs648202) foram genotipados pelo ensaio de discriminação alélica pelo sistema TaqMan; os haplótipos dos genes da globina beta foram investigados pela reação da polimerase em cadeia - com restrição dos fragmentos com endonucleases de restrição (PCR-RFLP). Os dados clínicos foram coletados em prontuários médicos. O SNP rs1207568 foi associado à ocorrência de infecções (P=0,0170) e a níveis séricos elevados de albumina (P=0,0370), o SNP rs648202 foi associado ao uso de medicações (P=0,0208) e o SNP rs9527025 a níveis elevados de fósforo e bilirrubina direta (BD) (P=0,0044 e P=0,0092, respectivamente). O K+ foi positivamente correlacionado com os leucócitos (r=0,2916,P=0,0034), linfócitos típicos (r=0,2644, P=0,0082), monócitos (r=0,2370,P=0,0182), plaquetas (r=0,4889, P<0,0001), colesterol total (r=0,2521, P=0,0118), colesterol LDL (Col-LDL) (r=0,2953, P=0,0030), fósforo (r=0,2447, P=0,0277), proteínas totais (PTs) (r=0,2415, P=0,0160), ferritina (r=0,2263, P=0,0283), PCRe (r=0,2369, P=0,0222) e HbS (r=0,2474, P=0,0135). O K+ teve correlação negativa com hemácias (r=-0,2076, P=0,0392) e Hb fetal (r=-0,2328, P=0,0204). O Ca2+ apresentou correlação positiva com PTs (r=0,2991, P=0,0028) e albumina (r=0,3242, P=0,0011) e negativa com o ASLO (r=-0,2216, P=0,0309). O fósforo foi negativamente correlacionado com Hb (r=-0,3083, P=0,0051), hematócrito (r=-0,2610, P=0,0186), bilirrubina indireta (r=-0,2685, P=0,0154) e creatinina (r=-0,3844, P=0,0004)...

The clinical variability described in sickle cell disease (SCD) has been linked to epistatic effect of various genes, such as Klotho (Kl), whose polymorphisms affect the potassium (K+), calcium (Ca2+) and phosphorus channels regulation, the vitamin D (VitD) and parathyroid hormone (PTH) expression, and oxidative stress suppression. With this, the present study aims to investigate the Kl SNPs frequency in hemoglobinopathy SC (HbSC) individuals, associating them with markers of severity and disease sub-phenotypes, and to investigate associations between K+, Ca2+, phosphorus, VitD and PTH levels with such gravity markers. We developed a cross-sectional study of 113 individuals with HbSC from HEMOBA Foundation, Salvador - Ba. The hematological values were determined in electronic cell counter; the hemoglobin (Hb) profile were confirmed by high performance liquid chromatography; the lipid, hemolysis, liver and kidney markers, Ca2+ and phosphorus were evaluated by colorimetric method, as well as the K+ by ion selective electrode; the VitD and PTH concentrations were investigated by chemiluminescence and the anti-streptolysin O (ASO) and C-reactive protein (PCRe) by nephelometry; the Kl SNPs (rs1207568, rs9527025, rs564481 and rs648202) were genotyped by allelic discrimination assay by TaqMan system for genotyping; the beta globin genes haplotypes were investigated by polymerase chain reaction - restriction fragment length polimorphism (PCR-RFLP). Clinical data were collected from medical records. The SNP rs1207568 was associated with the infection occurrence (P=0.0170) and raised serum albumin levels (P=0.0370), the SNP rs648202 was associated with the medications use (P=0.0208) and the SNP rs9527025 with raised direct bilirubin (BD) and phosphorus levels (P=0.0044 and P=0.0092, respectively). The K+ was positively correlated with leukocytes (r=0.2916, P=0.0034), typical lymphocytes (r=0.2644, P=0.0082), monocytes (r=0.2370, P=0,0182), platelets (r=0.4889, P<0.0001), total cholesterol (r=0.2521, P=0.0118), LDL cholesterol (Col-LDL) (r=0.2953, P=0.0030), phosphorus (r=0.2447, P=0.0277), total proteins (PTs) (r=0.2415, P=0.0160), ferritin (r=0.2263, P=0.0283), PCRe (r=0.2369, P=0.0222) and Hb (r=0.2474, P=0.0135). The K+ had a negative correlation with red blood cells (r=-0.2076, P=0.0392) and fetal Hb (r=-0.2328, P=0.0204). The Ca2+ was positively correlated with PTs (r=0.2991, P=0.0028) and albumin (r=0.3242, P=0.0011) and negatively with the ASO (r=-0.2216, P=0,0309). The phosphorus was negatively correlated with Hb (r=-0.3083, P=0.0051), hematocrit (r=-0.2610, P=0.0186), indirect bilirubin (r=- 0.2685, P=0.0154) and creatinine (r=-0.3844, P=0.0004)...

Homozygous sickle cell disease in Uganda and Jamaica a comparison of Bantu and Benin haplotypes / La anemia de células falciformes homocigóticas en Uganda y Jamaica comparación de haplotipos Bantú y Benin

OBJECTIVE: To compare the haematological and clinical features of homozygous sickle cell (SS) disease in Bantu and Benin haplotypes in a cross-sectional study of 115 Ugandan patients attending the Sickle Cell Clinic at Mulago Hospital, Kampala, Uganda, with 311 patients in the Jamaican Cohort Study. METHODS: This involved comparison of clinical features and haematology with special reference to genetic determinants of severity including fetal haemoglobin levels, beta-globin haplotype and alpha thalassaemia status. RESULTS: The Bantu haplotype accounted for 94% of HbS chromosomes in Ugandan patients and the Benin haplotype for 76% of HbS chromosomes in Jamaica. Ugandan patients were marginally more likely to have alpha thalassaemia, had similar total haemoglobin and fetal haemoglobin levels but had higher reticulocyte counts and total bilirubin levels consistent with greater haemolysis. Ugandan patients had less leg ulceration and priapism, but the mode of clinical presentation, prevalence of dactylitis, features of bone pain and degree of delay in sexual development, assessed by menarche, were similar in the groups. In Ugandan patients, a history of anaemic episodes was common but these were poorly documented. CONCLUSION: The haematological and clinical features of the Bantu haplotype in Uganda were broadly similar to the Benin haplotype in Jamaica except for less leg ulceration and priapism and possibly greater haemolysis among Ugandan subjects. Anaemic episodes in Uganda were treated empirically by transfusion often without a clear diagnosis; better documentation including reticulocyte counts and observations on spleen size is necessary to evolve appropriate models of care.

OBJETIVO: Comparar los rasgos clínicos de la anemia de células falciformes homocigóticas (SS) en los haplotipos Bantú y Benin en un estudio transversal de 115 pacientes ugandeses que asisten a la Clínica de la anemia de células falciformes en el Hospital de Mulago, Kampala, Uganda, con 311 pacientes en un estudio de cohorte jamaicano. MÉTODOS: El estudio conllevó la comparación de los rasgos clínicos y hematológicos con referencia especial a los determinantes genéticos de la severidad, incluyendo los niveles de la hemoglobina fetal, haplotipos del gen de la globina beta, y el estado de la alfa talasemia. RESULTADOS: El haplotipo Bantú dio cuenta del 94% de los cromosomas HbS en los pacientes ugandeses, en tanto que los haplotipos Benin dieron cuenta del 76% de los cromosomas de HbS en Jamaica. Los pacientes de Uganda presentaron una probabilidad marginalmente mayor de alfa talasemia, tenían niveles similares de hemoglobina total y hemoglobina fetal, pero en cambio presentaban conteos más altos de reticulocitos así como niveles mayores de bilirrubina total, en correspondencia con una mayor hemólisis. Los pacientes ugandeses presentaban menor ulceración de las piernas y priapismo, pero el modo de presentación clínica, la prevalencia de dactilitis, los rasgos de dolor óseo, y el grado de retraso en el desarrollo sexual, evaluado por la menarquia, fueron similares en todos los grupos. Los pacientes de Uganda se caracterizaron comúnmente por una historia de episodios de anemia, pobremente documentados. CONCLUSIÓN: Los rasgos clínicos y hematológicos del haplotipo Bantú en Uganda fueron considerablemente similares al haplotipo Benin en Jamaica, salvo por una menor presencia de ulceración de las piernas y priapismo, así como posiblemente mayor hemólisis entre los sujetos de Uganda. Los episodios de anemia en Uganda fueron tratados empíricamente mediante transfusión, a menudo sin un diagnóstico claro. Se necesita una mejor documentación - incluyendo conteos de reticulocitos - así como observaciones del tamaño del bazo, a fin de desarrollar modelos de cuidado apropiados.

Haplotipos del gen de la globina beta en portadores de hemoglobina S en Colombia / Beta globin haplotypes in hemoglobin S carriers in Colombia

Introducción. La mutación de la hemoglobina S (HbS) va acompañada por otras mutaciones en la región del cromosoma 11, conocida como conjunto de la globina beta(beta globin cluster). El patrón de combinación de estos polimorfismos da lugar a los haplotipos que se heredan junto con la mutación de la hemoglobina S, se denominan haplotipos de la mutación bs y revisten gran importancia epidemiológica y clínica. Objetivo. Determinar la frecuencia de los principales haplotipos asociados al gen HBB en pacientes colombianos heterocigotos para hemoglobina S. Materiales y métodos. En la Clínica Colsanitas se han estudiado a la fecha 1.200 muestras de sangre periférica de niños en busca de hemoglobinopatías, y se ha encontrado el rasgo falciforme como la hemoglobinopatía más frecuente. Se determinaron los haplotipos del gen HBB que presentaron la mutación beta-S en 33 niños con patrón electroforético de hemoglobina AS, mediante reacción en cadena de la polimerasa (PCR) y enzimas de restricción. Se determinaron el patrón electroforético de la hemoglobina, el nivel de hemoglobina fetal y los parámetros hematológicos de cada individuo. Resultados. Los haplotipos de la hemoglobina S encontrados con mayor frecuencia en la muestra analizada son de origen africano y su orden de aparición fue mayor para el haplotipo Bantú (36,4 %), seguido por Senegal (30,3 %), Benín (21,2 %) y Camerún (12,1 %). La electroforesis de hemoglobina confirmó el fenotipo AS; la dosificación de hemoglobina fetal mostró niveles por debajo de 1 % y los parámetros hematológicos analizados mostraron valores normales en el 100 % de los individuos. Conclusión. Los haplotipos de la HbS encontrados con mayor frecuencia en la muestra estudiada eran de origen africano y su distribución variaba de acuerdo con el lugar de prodedencia del individuo. La mayor frecuencia correspodió al haplotipo Bantú.

Introduction. The hemoglobin S (HbS) mutation is accompanied by other mutations in the region of chromosome 11 known as "beta globin cluster". The pattern of combination of these polymorphisms giving rise to the haplotypes that co-inherit the HbS mutation, are called haplotypes bs, and are of great epidemiological and clinical significance. Objective. The frequencies of major haplotypes associated with S beta-globin gene was determined in Colombian patients heterozygous for hemoglobin S. Materials and methods. As part of the national neonatal screening program at Clínica Colsanitas, located in major cities of Colombia, nearly 1,200 children from different areas of the country were examined for hemoglobinopathies. The sickle cell trait was identified as the most common. S beta-globin gene haplotypes were determined by PCR and restriction enzymes in 33 children with AS hemoglobin electrophoretic patterns (carrier state). In addition, electrophoretic patterns of hemoglobin, fetal hemoglobin levels and hematologic parameters of each individual were identified. Results. The most frequent haplotypes in Colombia were the Bantú haplotype (36.4 %), followed by Senegal (30.3 %), Benin (21.2 %) and Cameroon (12.1 %) haplotypes. Hemoglobin electrophoresis confirmed the AS phenotype in all patients, and fetal hemoglobin levels below 1%. Other hematological parameters were normal in all cases. Conclusion. The HbS haplotypes found more frequently in the sample were of African origin, and their distribution varied according to the place of origin of the individual. The most frequent corresponded to the Bantu haplotype.

Sickle cell disease in Middle East Arab countries.

The sickle cell (HbS) gene occurs at a variable frequency in the Middle Eastern Arab countries, with characteristic distribution patterns and representing an overall picture of blood genetic disorders in the region. The origin of the gene has been debated, but studies using β-globin gene haplotypes have ascertained that there were multiple origins for HbS. In some regions the HbS gene is common and exhibits polymorphism, while the reverse is true in others. A common causative factor for the high prevalence and maintenance of HbS and thalassaemia genes is malaria endemicity. The HbS gene also co-exists with other haemoglobin variants and thalassaemia genes and the resulting clinical state is referred to as sickle cell disease (SCD). In the Middle Eastern Arab countries, the clinical picture of SCD expresses two distinct forms, the benign and the severe forms, which are related to two distinct β-globin gene haplotypes. These are referred to as the Saudi-Indian and the Benin haplotypes, respectively. In a majority of the Middle Eastern Arab countries the HbS is linked to the Saudi-Indian haplotype, while in others it is linked to the Benin haplotype. This review outlines the frequency, distribution, clinical feature, management and prevention as well as gene interactions of the HbS genes with other haemoglobin disorders in the Middle Eastern Arab countries.

Manifestações retinianas em pacientes portadores de anemia de células falciformes / Retinal sings in patients with sickle cell disease

A Organização Mundial de Saúde estima que mais de 5 por cento da população mundial seja portadora de algum tipo de hemoglobinopatia. Dentre essas encontramos a anemia de células falciformes, que tem seu principal efeito lesivo sobre a vasculatura periférica. Na retina, as lesões falciformes possuem fisiopatologia e classificação bem definidas. O objetivo é identificar as manifestações retinianas à anemia falciforme em pacientes encaminhados ao Hospital Bettina Ferro de Souza a partir do Hemocentro do Estado do Pará - HEMOPA. MÉTODOS: No Serviço de Oftalmologia do Hospital Universitário Bettina Ferro de Souza realizou-se em cinquenta pacientes portadores de anemia de células falciformes, sendo 37 genótipo SS e 13 genótipo SC, foram acompanhados pelo ambulatório de anemia falciforme do HEMOPA e selecionados aleatoriamente, sendo submetidos à entrevista para registro de sexo; idade; cor; genótipo; alterações oculares; medicamentos utilizados. exame oftalmológico, incluindo angiofluoresceínografia nos casos com alteração retiniana. RESULTADOS: Registro em protocolo de pesquisa e posteriormente submetidos à análise estatística utilizando o teste estatístico Qui-quadrado e p<0,05. Oitenta e oito por cento dos pacientes estudados não possuíam qualquer lesão retiniana falciforme, 3 por cento apresentaram oclusão vascular periférica, em 2 por cento evidenciou-se placa pigmentada, e 7 por cento apresentaram lesões não compatíveis com a doença falciforme; quanto ao sexo houve proporcionalidade de 50 por cento para ambos; faixa etária de maior predominância foi a de 11 e 15 anos com 38 por cento, 74 por cento enquandraram-se no genótipo SS e 26 por cento no SC. Em relação ao uso de medicamentos, notou-se maior prevalência de alterações oculares nos pacientes que faziam uso do ácido fólico isolado com 5 por cento, em contraste com aqueles em uso da associação hidróxiuréia e ácido fólico em que todos (27 por cento) possuíam exame fundoscópico normal. Todos os pacientes (29 por cento) com hemoglobina fetal acima de 10 por cento possuíam retina sem alterações. CONCLUSÃO: Poucos casos de lesões retinianas foram observados no grupo estudado, ainda assim esta pesquisa reafirma a importância da realização do exame oftalmológico de maneira precoce e periódica, visto que, a retinopatia falciforme é fato bem documentado e suas complicações podem resultar em amaurose.

The World Health Organization counts that more than 5 percent of the world's population carry some type of hemoglobinopathy. Among them we find the sickle cell aneamia that presents its main harmful effect on the peripheral vasculature. In the retina, the falciform lesions have a well defined physiopathology and classification. To identify the retinal manifestations caused by the falciform aneamia in patients directed to the Bettina Ferro de Souza Hospital from the Hemocenter of the State of Pará - HEMOPA, in the months of September through December of 2006. METHODS: Ophthalmologic examination was performed in the Department of Ophthalmology of the Bettina Ferro de Souza Hospital. and fifty patients with sickle cell aneamia (SS or SC) followed by the department of falciform aneamia of the Hematologia e Hemoterapia do Pará - HEMOPA have been randomly selected and submitted to interview in order to register their: sex; age; color; genotype; ocular alterations; medicines taken. Ophthalmologic examination was performed in the Department of Ophthalmology of the Bettina Ferro de Souza Hospital. It consisted of: evaluation of the acuity of vision with and without correction, indirect biomicroscopy, indirect binocular ophthalmoscopy, and, in case the latter presented alterations, a complementary study with angiofluoresceinography would be carried through. RESULTS: The outcomes have been registered in research protocol and later submitted to the statistic analysis using the Qui-square test, adopting, as level of significance, p<0,05. Eighty-eight percent of the patients did not present any falciform retinal sign, 3 percent presented peripheral vascular occlusion; in 2 percent, pigmented plate was shown, and 7 percent presented injuries which were not compatible with the falciform disease; there was a proportionality of 50 percent for males and females; there was a higher predominance (38 percent) of people aged from 11 and 15; 74 percent had SS genotype and 26 percent SC genotype; in relation to the use of medicines there was a higher prevalence of ocular alterations in patients who had made use of the folic acid isolated, with 5 percent, in contrast with those who had used the hidroxyurea association and folic acid, when all (27 percent) presented normal fundoscopic examination; all the patients (29 percent) that showed fetal hemoglobin rate above 10 percent had retina without alterations. CONCLUSION: Few cases of retinal signs have been observed in the studied group, however this research does not diminish the importance of early and periodic ophthalmologic examination, since falciform retinopathy is largely registered and its complications can lead to amaurosis.

The inherited disorders of haemoglobin: an increasingly neglected global health burden.

An estimated 300,000 babies are born each year with a severe inherited disease of haemoglobin and that over 80 per cent of these births occur in low- or middle-income countries. As these countries go through the epidemiological transition, characterized by a reduction in childhood and infant mortality due to improved public health measures, infants who had previously died of these conditions before they were recognised are now surviving to present for diagnosis and treatment. For a variety of reasons, even in the rich countries there are limited data about the true frequency, natural history, and survival of patients with these disorders, information that is absolutely critical towards providing governments and international health agencies with accurate information about the true global health burden of these conditions. The situation can only be improved by major action on the part of the rich countries together with the formation of partnerships between rich and poor countries and input from the major international health agencies and funding organisations.