Prevalence of ß-Thalassemia Mutations among Northeastern Iranian Population and their Impacts on Hematological Indices and Application of Prenatal Diagnosis, a Seven-Years Study
Mohammad Ehsan Jaripour1#, Kourosh Hayatigolkhatmi1#, Vahid Iranmanesh1, Farhad Khadivi Zand1, Zahra Badiei2, Hamid Farhangi2, Ali Ghasemi2, Abdollah Banihashem2, Reza Jafarzadeh Esfehani3 and Ariane Sadr-Nabavi1,3,4*.
1 Iranian Academic Center for Education, Culture and Research, (ACECR), Mashhad, Iran.
2 Department of Pediatric Diseases, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
3 Department of Medical Genetics, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
4 Medical Genetics Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
# These authors contributed equally to this work.
Received: March 13, 2018
Accepted: June 14, 2018
Mediterr J Hematol Infect Dis 2018, 10(1): e2018042 DOI 10.4084/MJHID.2018.042
This article is available on PDF format at:
| This is an Open Access article distributed
under the terms of the Creative Commons Attribution License
(https://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background and Objective: ß-thalassemia results from a diverse range of mutations inside the hemoglobin subunit β (HBB)
gene. In a study of β-thalassemia carriers and some of their at-risk
fetuses in the Khorasan province of Iran, we aimed to recognize the
most common mutations in the region. We also investigated a possible
link between these mutations and some of the relevant hematological
Researches prove that ß-thalassemia is one of the most frequent genetic diseases worldwide, with a range of ethnically and geographically distributed mutations.[1,2] Moreover, the large number of carriers is a warning for the health system and an emphasis on the importance of preventing programs.[3-14] ß-globin genetic mutations distribute among every ethnic group. Identification of these mutations helps authorities for more accurate evaluations and more practical prevention programs.[3-14]
The purpose of this study was to recognize the most common mutations related to ß-thalassemia in the Khorasan province of Iran and to find the possible relation of these mutations with some of the relevant hematological indices. These indices are presented in complete blood count (CBC) and Hb electrophoresis tests (identifying HbA1, HbA2, and HbF). These indices include RBC, Hb, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH).
Material and Methods
Study subjects: The population investigated in this study comprises of 1593 individuals with Fars ethnicity, suspected of possessing a mutated allele for ß-thalassemia and referred to the ACECR diagnostic medical genetics laboratory for molecular diagnosis. Personal consent form to obtain the permission to use the patients’ samples and the relevant data in the research performed by the ACECR was signed by every single individual of this study. The ACECR ethics committee, which functions under the regulations of the national medical ethics committee, approved these consent forms. Clinical criteria for suspicious ß-thalassemia was determined by the hypochromic microcytic anemia, including decreased MCV (<80 fL) and MCH (<27 pg/cell) and unusual findings in Hb electrophoresis, including elevated HbA2 (≥ 3.5 %) or HbF (≥ 1%) and other abnormally high Hb variants. Peripheral blood (PB) samples from subjects were collected in EDTA containing tubes. Furthermore, chorionic villus samples (CVS) were collected from 644 conceptions, whose fetuses were at risk of inheriting two mutated alleles for hemoglobin subunit β (HBB) gene. Samples were collected by a neonatologist and sent to the ACECR medical genetics laboratory for ß-thalassemia prenatal diagnosis (PND). All samples (PB and CVS) were collected since March of 2011 up to January of 2018.
DNA extraction: DNA from selected individuals was extracted using standard salting out method as described by. DNA from CVS was isolated using QiAmp® DNA Blood Mini Kit (Qiagen GmbH, Hilden, Germany) as described by the company instructions.
Mutation detection: For each amplification-refractory mutation system (ARMS-PCR) was used to detect ten common β-globin mutations: IVS-I-5, IVS-II-1, IVS-I-110, IVS-I-1, IVS-II-745, IVS-I-6, codon 30, codon 39, codon 819, and codon 16. In cases, where none of the mentioned variants was detected; standard Sanger sequencing of the HBB had been performed to reveal the mutation. Supplementary table 1 shows primer sequences, micro-tube components and the thermal protocol used for the mentioned methods. Moreover, in some emergency cases, reverse dot blot (strip assay) was conducted using Thalassemia StripAssays® kit (ViennaLab, Vienna, Austria). For ß-thalassemia PND cases, we have routinely confirmed the result with two alternative molecular techniques. (See supplementary files)
Statistical analysis: Data was analyzed using the statistical package for social sciences (SPSS) version 22 (IBM Inc, Chicago, Il, USA). Continuous data were checked for normality using the Kolmogorov-Smirnov test. Means and standard deviations (SD) were used to describe continuous variables while frequency and percentage were used to describe categorical variables. Analysis of variance (ANOVA) was used to compare parametric variables, including RBC count, Hb, MCV, MCH, HbA2, and HbA1, between the mutation categories while the Kruskal-Wallis test was used to compare non-parametric variable (HbF) values between mutation groups. Multinomial logistic regression was performed to assess the relationship between the mutation categories and the study parameters considering other mutations than the nine evaluated (mostly reported mutations) as the reference category. The odds ratio (OR) and 95% confidence interval (CI) for OR were presented along with p-value for the regression model. Values of p less than 0.05 were considered statistically significant.
During the years of this study, 644 conception cases on the formerly mentioned ß-thalassemia carrier couples were subjected to PND, using CVS samples as described in the “methods” section.
For 118 cases which were reported to carry no detectable pathogenic variant and 352 cases which were detected as carriers (heterozygous with one pathogenic variant in HBB) and expected to show the ND ß-thalassemia phenotype, pregnancies were followed up till the delivery. Whereas 174 cases, which were diagnosed as homozygous with two pathogenic variants in HBB and expected as TD ß-thalassemia phenotype, have received the proper genetic counseling based on the regional guidelines and prevention programs.[13,14]
Further, the relation of the first nine more commonly reported mutations with the hematological indices was observed as mentioned previously. There was a significant difference in MCV and HbA2 levels between the mutation types (p<0.001) (Table 1). Multinomial logistic regression model revealed that mutation categorized as IVS-II-I was associated with increased risk for higher MCH (p=0.01, OR=1.15, 95% CI for OR= 1.03 and 1.28) and HbA2 (p=0.002, OR= 1.26, 95% CI for OR= 1.09, 1.46) and lower MCV (p<0.001, OR=0.93, 95% CI for OR= 0.90, 0.97) compared to other mutations. Furthermore, the codons 8/9 mutation was found to be associated with significant increase in HbF values compared to other mutations (p=0.04, OR= 1.05, 95% CI for OR= 1.00, 1.09).
Additionally, we investigated the relation of the first nine most commonly reported mutations with the hematological indices as mentioned formerly. The highest and the lowest RBC mean values were reported among Los Angeles and IVS-I-110 carriers respectively (ranges from 5.89 - 5.46 x 106 cells/mcL). The highest and the lowest Hb mean values were reported among IVS-I-5 and -88 carriers respectively (ranges from 13.23 – 11.47 mg/dL). The highest and the lowest MCV mean values were reported among codon 5 and IVS-II-1 carriers respectively (ranges from 69.12 – 64.59 fL). The highest and the lowest MCH mean values were reported among IVS-I-5 and Los Angeles carriers respectively (ranges from 22.46 – 19.77 pg/cell). The highest and the lowest HbA2 mean values were reported among IVS-II-1 and codon 5 carriers respectively (ranges from 4.72 – 3.80% of the total Hb). The highest and the lowest HbF mean values were reported among IVS-I-5 and Los Angeles carriers respectively (ranges from 3.16 – 0.26% of the total Hb). The highest and the lowest HbA1 mean values were reported among IVS-I-110 and IVS-I-5 carriers respectively (ranges from 94.92 – 83.26% of the total Hb). Hence, these reported values while considering the SD, p-value, OR and referring to the relevant guidelines can be helpful in offering a hint to the local clinicians for more accurate referrals. This can also be helpful as a boost for laboratory professionals for a more straightforward ß-thalassemia testing guide in the region. We have also found a significant difference regarding the MCV and the HbA2 levels between the mutation types. Our findings mean that the type of mutation causing ß-thalassemia has a high chance of affecting the MCV value and HbA2 ratio. In addition, moving further into the details of mutations impact on hematological indices we have illustrated that IVS-II-1 was associated with increased risk for higher MCH and HbA2 in comparison to other reported variants. It is also causing a lower MCV compared to other mutations. Also, the codons 8/9 mutation was found to be associated with significant increase in HbF values compared to other mutations. That means that the IVS-II-1 variant has a high chance of increasing the MCH and HbA2 while lowering the MCV when compared to other mutation types. On the other hand, the presence of the codons 8/9 will probably raise the HbF proportion when compared to other mutations. These findings act as a start point for more focused interdisciplinary studies on the genomic and hematologic profile of ß-thalassemia patients to find a more comprehensive map of genotype-phenotype correlation.
As previously discussed, ß-thalassemia is one of the most common genetic disorders worldwide and also in Iran.[3-14] Although there are some treatments available for controlling and recovering the disease such as routine blood transfusion (followed by the iron chelation therapy), bone marrow transplantation and even gene therapy, still genetic counseling and PND are known to be the best available preventive options.[1,2] Authors hope the current study will make a more accurate and useful guide for ß-thalassemia diagnosis and prevention in the region.
- Galanello R, Origa R. Beta-thalassemia. Orphanet J Rare Dis. 2010 Dec;5(1):11. https://doi.org/10.1186/1750-1172-5-11 PMid: 20492708
- Campbell JS. Alpha and beta thalassemia. Am Fam Physician. 2009 Aug 15;80(4). PMid:19678601
AD, Cheraghi Z, Bitaraf S, Cheraghi P, Safiri S. Prevalence of alpha
and beta-thalassemia mutations among carriers of thalassemia in
Shadegan city, southwest of Iran. Zahedan J Res Med Sci. 2015;17(8). https://doi.org/10.17795/zjrms1032
Z, Raygani AV, Merat A, Haghshenass M, Gerard N, Nagel RL,
Krishnamoorthy R. Thalassemic mutations in southern Iran. Iran J Med
Sci. 2015 Aug 31;31(2).
D, Filon D, Strauss N, Rachmilewitz EA, Oppenheim A. Mean corpuscular
volume of heterozygotes for beta-thalassemia correlates with the
severity of mutations. Blood. 1992 Jan 1;79(1):238-43. PMid:1728311
AR, Banoei MM, Khalili E, Houshmand M. Beta-Thalassemia in Iran: new
insight into the role of genetic admixture and migration. Scientific
World Journal. 2012;2012. https://doi.org/10.1100/2012/635183 PMid: 23319887
N, Rabbani B. Beta thalassemia in 31,734 cases with HBB gene mutations:
pathogenic and structural analysis of the common mutations; Iran as the
crossroads of the Middle East. Blood Rev. 2016 Nov 1;30(6):493-508. https://doi.org/10.1016/j.blre.2016.07.001 PMid: 27453201
MR, Ahmadi MH, Amirizadeh N. Molecular Spectrum of Beta-Globin
Mutations in Transfusion-Dependent Patients with Thalassemia in Qazvin
Province, Iran. Iran J Med Sci. 2015 May 12;34(1):17-22.
MR, Ahmadi MH. Rare and unexpected beta thalassemic mutations in Qazvin
province of Iran. Afr J Biotechnol. 2010;9(1)
P, Hourfar H, Heidari M, Kheirollahi M, Miryounesi M. The spectrum of
β-thalassemia mutations in Isfahan Province of Iran. Iran J Public
P, Akhavan-Niaki H, Tamaddoni A, Ghawidel-Parsa S, Holakouie Naieni K,
Rahmani M, Babrzadeh F, Dilmaghani-Zadeh M, Daneshvar Farhud D.
Distribution of β-thalassemia mutations in the northern provinces of
Iran. Hemoglobin. 2007 Jan 1;31(3):351-6. https://doi.org/10.1080/03630260701462030
F, Keikhani B, Aberumand M. Prenatal diagnosis (PND) of β-thalassemia
in the Khuzestan province, Iran. J Clin Diagn Res. 2007 Jan
H, Ghamari A, Sahebjam F, Kariminejad R, Hadavi V, Khatibi T, Samavat
A, Mehdipour E, Modell B, Kariminejad MH. Fourteen-year experience of
prenatal diagnosis of thalassemia in Iran. Public Health Genomics.
2006;9(2):93-7. https://doi.org/10.1159/000091486 PMid: 16612059
H, Amid A, Zeinali S, Radfar MH, Eshghi P, Rahiminejad MS, Ehsani MA,
Najmabadi H, Akbari MT, Afrasiabi A, Akhavan-Niaki H. Thalassemia in
Iran: epidemiology, prevention, and management. J Pediatr Hematol
Oncol. 2007 Apr 1;29(4):233-8. https://doi.org/10.1097/MPH.0b013e3180437e02 PMid: 17414565
S, Ford JC, Chitayat D, Désilets VA, Farrell SA, Geraghty M, Nelson T,
Nikkel SM, Shugar A, Skidmore D, Allen VM. Carrier screening for
thalassemia and hemoglobinopathies in Canada. J Obstet Gynaecol Can.
2008 Oct 1;30(10):950-9. https://doi.org/10.1016/S1701-2163(16)32975-9 PMid: 19038079
SA, Dykes DD, Polesky HF. A simple salting out procedure for extracting
DNA from human nucleated cells. Nucleic Acids Res. 1988 Feb
11;16(3):1215. https://doi.org/10.1093/nar/16.3.1215 PMid:3344216 PMCid:PMC334765
JM, Varawalla NY, Weatherall DJ. Rapid detection and prenatal diagnosis
of β-thalassaemia: studies in Indian and Cypriot populations in the UK.
Lancet. 1990 Oct 6;336(8719):834-7. https://doi.org/10.1016/0140-6736(90)92338-I PMid: 1976877
- Giardine B, van Baal S, Kaimakis P, Riemer C, Miller W, Samara M, Kollia P, Anagnou NP, Chui DH, Wajcman H, Hardison RC. HbVar database of human hemoglobin variants and thalassemia mutations: 2007 update. Hum mutat. 2007 Feb 1;28(2):206. https://doi.org/10.1002/humu.9479 PMid: 17221864