ISBT Science Series (2015) 10 (Suppl.

1), 295304

INVITED REVIEW 4C-S32-01 2015 International Society of Blood Transfusion

a
thalassaemia: a genotypephenotype correlation and

management
V. Viprakasit
Division of Hematology-Oncology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand

Throughout the world, a
thalassaemia represents the most common monogenic

disorder in man [1]. A large number of mutations (mainly deletions and a few
nucleotide substitutions) of the human a-globin cluster have been described
which interact to produce one of three broad phenotypes, a-thalassaemia hetero-
zygote, Hb H disease and Hb Barts hydrops fetalis [2]. In terms of public health,
a-thalassaemia trait only causes a mild anaemia and Hb Barts hydrops fetalis is
usually fatal in late gestation [2, 3, 4]. In contrast, Hb H disease is a relatively
common cause of thalassaemia in individuals of Southeast Asian, Middle Eastern
and Mediterranean origins and is associated with a variety of clinically important
complications [3, 5]. This review will focus on the molecular basis of a
thalas-
saemia in general and more specifically illustrate a recent development in
molecular characterization of several, including novel, a
thalassaemia alleles
found recently. The complexity of globin genotypephenotype correlation in
a
thalassaemia disease will be discussed with particular regard to patients with
Hb H disease.
Key words: Barts hydrops fetalis, Hb H disease, a
thalassaemia

16 (
a, last three boxes in Fig. 1). Heterozygotes for sin-

Molecular basis of a
thalassaemia
Clinical phenotypes associated with a
thalassaemia result
from mutations involving the a
globin gene cluster on
the telomeric region of the short arm of chromosome 16
(16p 133) [16]. There are two copies of the a
globin
gene per haploid genome, annotated aa/aa.
In a0-thalassaemia (a condition in which a
globin
expression from one chromosome is completely abol-
ished), both of the linked a
globin genes are lost (--/aa),
most commonly by deletions that involve part or the
entire a
globin gene cluster (Fig. 1).
Heterozygotes for a0-thalassaemia are clinically normal
but have a mild hypochromic, microcytic anaemia. In the
less severe condition (a+-thalassaemia), a
globin expres-
sion from one chromosome is reduced but not abolished.
For example, this includes conditions in which a single
copy of the duplicated a
genes is lost from chromosome
Correspondence: Vip Viprakasit, Department of Pediatrics & Thalassemia
Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok
10700, Thailand.
E-mail: vip.vip@mahidol.ac.th
Invited Review for ISBT Meeting 2014 (Seoul, Korea).
gle a
gene deletions (
a/aa) are clinically and haemato-
logically normal or present with mild microcytosis and
cannot be definitively diagnosed without molecular-based
analysis. There are two common molecular pathology-
causing a0-thalassaemias, a 37-kb (rightward,
a37)
deletion and a 42-kb (leftward,
a42) deletion (Fig. 1).
The 37-kb deletion is more common and has been found
in nearly every region of the world [2, 7, 8].
Less commonly, a+-thalassaemia results from mutations
in one or a few nucleotides in critical regions of the
a
genes. This is called non-deletional a
thalassaemia
[6]. These mutations usually, but not always, affect the
more highly expressed a 2 gene (aTa) rather than the a 1
gene (aaT). These nucleotide mutations are summarized in
Fig. 2 and Table 1. More than 50 different non-deletional
mutations that cause a
thalassaemia have been reported
so far (reviewed in [6]). These may affect mRNA splicing,
initiation of mRNA translation or disturb the poly
(A) addition signal leading to downregulation of the
affected a
globin gene. These mutations, a0-thalassaemia
(--) and a+-thalassaemia (
a or aTa), have different
effects on a
globin expression and can be broadly cate-
gorized as shown (Fig. 3).

295
296 V. Viprakasit

Fig. 1 The a
globin cluster and deletions

resulting in a0- and a+-thalassaemia. Boxes in
the upper panel represent the extents of
deletions which give rise to a0-thalassaemia,
The --SEA, --THAI, --FIL, --MED deletions are
common in some populations and have a GAP-
PCR-based diagnosis available. Three boxes in
the lower panel represent a+- thalassaemia.
Small white boxes at the tip of each deletion
represent uncertain breakpoint ends. Some rare
deletions are not shown in this gure, which is
modied from [6].

Homozygosity for a0-thalassaemia results in a complete
loss of a
globin gene expression. This genotype causes a
very severe clinical syndrome called Haemoglobin Barts
hydrops fetalis. Infants who inherit no a
genes (--/--)
have a severe anaemia in which excess c
chains form a
non-functional tetrameric Hb called Hb Barts (c4). Such
infants survive until the third trimester of pregnancy
because they continue to produce small amounts of the
embryonic Hbs Portland I (f2c2) and Portland II (f2b2).
However, at this stage they often have multiple congeni-
tal abnormalities and die of heart failure as a result of
anaemia (reviewed in [4]).
Compound heterozygotes for a0- and a+-thalassaemia
(--/
a) with only one functional a globin gene have a
severe imbalance in globin chain synthesis. The excess
b
globin chains precipitate and form a characteristic
abnormal haemoglobin, Haemoglobin H (Hb H) or b
glo-
bin tetramer (b4). This causes a phenotype of mild to
moderate chronic haemolytic anaemia named Haemoglo-
bin H disease (Hb H disease) characterized by readily
detectable Hb H inclusion bodies in the peripheral blood.
Alternatively, Hb H disease can result from the interac-
tion between a0-thalassaemia and non-deletional a
thal-
assaemia (--/aTa or --/aaT). The majority of mutations in
the non-deletional forms of a
thalassaemia occur in the
a 2 gene which lies upstream of the a 1 gene and is
expressed two to threefold more highly than the a 1 gene
(reviewed in [3]). The deficit in a
globin expression in
these Hb H patients (--/aTa) appears to be greater than in
the deletional forms of Hb H disease (--/
a), and some-
times the non-deletional mutations have additional dele-
terious effects on terminal erythroid differentiation and
red cell metabolism. Therefore, the clinical phenotypes of
Hb H disease found in non-deletional a
thalassaemia (--/
aTa) are often more severe than those caused by a+-thal-
assaemia resulting from simple deletion (--/
a). Patients
in the former group have lower levels of Hb and higher
levels of Hb H and some of them are transfusion depen-
dent, whereas patients in the latter group rarely require
regular transfusion. However, the clinical course of Hb H
disease appears to be remarkably variable between differ-
ent patients. At one end of the spectrum, some individu-
als with Hb H disease have never sought medical
consultation and are only identified during the course of
investigation for other reasons (e.g. before routine sur-
gery). In those who do seek medical attention, the fre-
quency of complications and requirement for blood
transfusion varies considerably. At the most severe
extreme, some infants with Hb H disease die in the neo-
natal period from profound anaemia and hydrops fetalis

Fig. 2 Summary of nucleotide mutations causing non-deletional a
thalassaemia. Nucleotide mutations have been observed at initiation codons, coding
regions, splice junctions, termination codons and polyadenylation signals (Poly A). Changes include single or oligonucleotide substitutions, deletion(s),
insertion(s) and deletions/insertions exerting effects on mRNA transcription including nonsense mutations, frameshift and transcriptional read through
(Poly A mutation). Missense mutations can produce abnormal globin chains resulting in unstable a
globin. White circles denote mutations described in
the a 1 gene whereas black circles represent those in the a 2 gene. Details of each mutation are available online at http://globin.cse.psu.edu/ (the globin
gene server).

2015 International Society of Blood Transfusion, ISBT Science Series (2015) 10 (Suppl. 1), 295304
 Genotypephenotype in a thalassaemia 297

Table 1 Summary of non-deletional mutations that cause a-thalassaemia

Affected
Affected sequence gene Mutation(s) Distribution Phenotype Reference(s)

mRNA processing
Cryptic splicing a2 Cd 22; C-T Surinamese a+ Harteveld et al. (2004)
IVS (donor) a2 IVS1; 5 by deletion Mediterranean a+ Orkin et al. (1981)
a2 IVS2; T-A North European a+
a0 Harteveld et al. (2006)
a1 IVS1; G-A Thai a+ 51
IVS (acceptor) a2 IVS 1; 116 (A-G) Dutch a+ Harteveld et al. (1996)
a1 IVS 1; 117 (G-A) Asian Indian a+ Curuk et al. (1993)
a2 IVS 2; 142 (G-A) Argentinian a+
a0 Nelida et al. (2001)
a1 IVS 2; 148 (A-G) Iranian a+ Lau et al. (1997)
Poly A signal a2 PA+30 UTR; 16 bp del Arab a+
a0 Tamary et al. (1997)
a2 AATAAA-AATAAG Middle east a+
a0 Higgs et al. (1983)
Mediterranean 45
a2 AATAAA-AATGAA Mediterranean a+
a0 Yuregir et al. (1992)
Chinese Ma et al. (2001)
a2 AATAAA-AATA-- Asian Indian a+
a0 Harteveld et al. (1994)
Thai Hall et al. (1994)
49
mRNA translation
Initiation codon
a37 ATG-GTG African a0 Olivieri et al. (1987)

a37 ACCATG---CATG North African a+
a0 Morle et al. (1985)
Mediterranean Morle et al. (1986)
Viprakasit (submitted)
a2 ATG-ACG Mediterranean a+ Pirastu et al. (1984)
a2 ATG-A-G Vietnam a+ Waye et al. (1996)
a1 ATG--TG Mediterranean a+ Paglietti et al. (1986)
Moi et al. (1987)
a2 ATG--TG Southeast Asian a+ Eng et al. (2006)
Exon I a1 Cd 14;G-A Iranian a0 Harteveld et al. (2003)
a2 Cd 19; del G Iranian a+ Harteveld et al. (2003)
a2 Cd 22; del C African Pereira et al. (2006)
a2 Cd 23; G-T Tunisian a0 Siala et al. (2004)

a Cd 30/31; 2 bp del African a0 Safaya and Raider et al. (1988)
Exon II a2 Cd 39/41; del/ins Yemenite-Jewish a+ Oron-Karni et al. (1997)
a2 Cd 90; AAG-TAG Middle Eastern a+ Twomey et al. (2003)
a1 Cd 51-55; 13 by del Spainish a+ Ayala et al. (1997)
a1 Cd 62; del G African Luo et al. (2007)
a1 Cd 78; del C Black/Chinese Eng et al. (2006)
Exon III a1 Cd 108; C del Jewish a+
a0 Oron-Karni et al. (2002)
a2 Cd 113/114; del C Unknow Eng et al. (2006)
a2 Cd 113-116; 12 bp del (Leida) Spanish a+
a0 Ayala et al. (1996)
a2 Cd 116; G-T African a+ Liebhaber et al. (1987)
a1 Cd 131; T ins (Pak Num Po) Thai a0 54
Termination codon a2 TAA-CAA (Constant Spring) Southeast Asian a+ Clegg et al. (1971)
a2 TAA-AAA (Icaria) Mediterranean a+ Clegg et al. (1974)
Efremov et al. (1990)
a2 TAA-TCA (Koya Dora) Indian a+ De Jong et al. (1975)
a2 TAA-GAA (Seal Rock) African a+ Bradley et al. (1975)
Merritt et al. (1997)
a2 TAA-TAT (Pakse) Laotian a+ Waye et al. (1994)
Thai 45
a2 TAA-CAT (Zurich-Altstetten) Thai Frischknecht and Dutly

2015 International Society of Blood Transfusion, ISBT Science Series (2015) 10 (Suppl. 1), 295304
298 V. Viprakasit

Table 1 (Continued)

Affected
Affected sequence gene Mutation(s) Distribution Phenotype Reference(s)

Post translational
Exon I
a Cd 14; T- G (Evanston, W-R) African a+ Honig et al. (1984)
a2 Cd21; G-C French a+ Wajcman et al. (1989)
a2 Cd21; G-T Dutch a+ Harteveld et al. (2007)
a2 Cd29; T-C (Agrinio, L-P) Mediterranean a+ Hall et al. (1993)
a2 Cd 30; 3 bp del (del Q) Chinese a+
a0 Chan et al. (1997)
a2 Cd 31; G-A (R-L) Chinese a+
a0 Chen et al. (2000)
a2 Cd 33; T-C (Chartres, F-S) (Cd35?) Filipino a+
a0 Lorey et al. (2001) (cloud it be in ex2?)
a2 Cd 35; T-C (S-P) French a+ PrehU et al. (2003) (cloud it be in
ex2?)
a1 Cd 37; 3 by del (Heraklion, del P) Greece a+
a0 Traeger-Synodinos et al. (2000)
Exon II a1 Cd 38/39; 3 by del (Taybe, del T) Arabian a+ Pobedimskaya et al. (1994)
a1 Cd 59; G-A (Adana, G-D) Turkish a+ Curuk et al. (1993)
a1 Cd 59; G-C (G-R) Jewish a+
a0 Oron-Karni et al. 2000)
a2 Cd 32; G-A (Amsterdam, M-I) Surinamese-Black a+
a0 Harteveld et al. (2005)
a2 Cd 59; G-A (Adana, G-D) Chinese a+
a0 Chan et al. (1997)
a1 Cd 60/61; 3 bp del (Clinic, del K) Spanish a+
a0 Ayala et al. (1998)
a2 Cd 62; 3 bp del (Aghia Sophia, del V) Greece a0 Traeger-Synodinos et al. (1999)
a1 Cd 64-74; 33 by del Greece a0 Waye et al. (2001)
a2 Cd 66; T-C (Dartmouth, L-P) Caucasian a+
a0 McBride et al. (2002)
a2 Cd 93; T-G (Bronte, V-G) Italian a+ Lacerra et al. (2003)
a1 Cd 93-99; 22 by dupl Iranian a+
a0 Waye et al. (2001)
a2 Cd 104; G-A (Sallanches, C-Y) French a+ Morie et al. (1995)
Pakistanis Kahn et al. (2000)
Exon III a2 Cd 103 A-T (Hb Bronovo, H-L) Turkish a+ Harteveld et al. (2006)
a1 Cd 104; T-A (Hb Oegstgeest, C-S) Surinamese a+ Harteveld et al. (2005)
a2 Cd 108; C-A (Hb Bleuland, T-N) Surinamese a+ Harteveld et al. (2006)
a2 Cd 109; T-G (Suan Dok, L-R) Thai a+ 48
a1 Cd 110; C-A (Petah Tikva, A-D) Middle east a+ Honig et al. (1981)
a1 Cd 119; C-T (Groene Hart or Moroccan a+ Harteveld et al. (2002)
Bernalda P-S)
a2 Cd 125; T-G (Plasencia, L-A) Spanish a+ Martin et al. (2005)
a2 Cd 125; T-C (Quong Sze, L-P) Chinese a+ Goossens et al. (1982)

a37 Cd 125; T-A (L-G) Jewish a0 Oron-Karni et al. (2000)
a1 Cd 129; T-C (Tunis-Bizerte, L-P) Tunisian a+ Darbellay et al. (1995)
a2 Cd 129; T-C (Utrecht, L-P) Dutch a+ Harteveld et al. (1996)
a2 Cd 130; G-C (Sun Prarie, A-P) Asian Indian a+ Darkness et al. (1990)
a2 Cd 131; T-C (Questember, S-W) French a+ Wajcman et al. (1993)
Yugoslavian Rochette et al. (1995)
a2 Cd 132;T-G (Caen, V-G) Caucasian a+ Wajcman et al. (1993)
a2 Cd 136;T-C (Bibba, L-P) Caucasian a+ Prchal et al. (1995)

del, deletion; ins, insertion; dupl, duplication; Cd, codon; PA, poly(A) signal; UTR, untranslated region.

(Haemoglobin H hydrops fetalis, reviewed in [9]). The
pathophysiological basis for the variable clinical course
between individuals remains unclear.
Unusual forms of a
thalassaemia
Characterization of three unique, sporadic deletions of
sequences located upstream of the b-cluster that leave the
structural b-gene intact in patients with b-thalassaemia
[10] has lead to identification of b-globin locus control
region (b-LCR). This lies upstream of the b
globin cluster
and contains five regulatory elements associated with
DNAse I hypersensitive sites called HS1-5 [1113]. Similar
observations have been made for the a
globin cluster, in
which nine sporadic deletions, each affecting single fami-
lies, have been reported that likewise remove sequences

2015 International Society of Blood Transfusion, ISBT Science Series (2015) 10 (Suppl. 1), 295304
 Genotypephenotype in a thalassaemia 299

Fig. 3 Categories of a
thalassaemia mutations

and their impact on a
globin expression.

lying upstream of the a-globin cluster while leaving the
structural a-genes intact [1421]. These deletions all
remove a major erythroid-specific DNAse I hypersensitive
site (HS -40) lying 40 kb upstream of the f-globin gene
(Fig. 4). This HS-40 element is the only cis acting regula-
tory element to be analysed to date and was demonstrated
to have an enhancer effect on a
globin gene expression in
several in vitro assays [2225]. Upstream deletions in both
a
and b
globin gene clusters are of considerable impor-
tance in establishing the role(s) of putative regulatory ele-
ments in vivo as they represent true human knockout
mutations that exert their effects in these rare patients
throughout all stages of erythroid development and differ-
entiation.21 Heterozygotes for these deletions [denoted as
(aa)/aa] have a haematological phenotype mimicking that
of a0-thalassaemia carriers, suggesting that loss of the
regulatory elements results in substantially decreased
expression of both linked a
globin genes [21]. Compound
heterozygotes for these deletions and a+-thalassaemia
alleles [(aa)/
a] give rise to Hb H disease. Detail haemato-
logical data, clinical phenotype and genotype correlation
of all reported upstream deletions causing unusual a
thal-
assaemia have been recently reviewed [21].
Another unusual form of a
thalassaemia is caused by
mutations in a chromatin remodelling factor, ATRX
(alpha thalassaemia mental retardation-X linked syn-
drome) [26, 27]. Downregulation of the ATRX gene,
mostly by missense mutations involving its zinc-finger
motif, results in decreased expression of normal structural
a globin genes by an unclear mechanism in patients with
ATRX syndrome and ATMDS (alpha thalassaemia and
myelodysplastic syndrome) [28, 29]. The intriguing

Fig. 4 Diagram of upstream deletions of the a
cluster and their relative positions within chromosome 16p 133. Co-ordinate numbers (in kb) given are
according to GenBank accession number AE006462.1. HS-40 or a-major regulatory element (a-MRE) is represented by a white box. The grey, numbered
boxes represent known genes located in this region in addition to the globin genes, other genes are 1, DDX11P; 2, 16pHQG2; 3, IL9RP3; 31, POLR3K; 4,
C16orf33; 5, C16orf8; 6, MPG; 7, C16orf35; and 16, LUC7L (see [58, 59] for details). Black arrows represent the erythroid hypersensitive sites HS-40,
HS-33, HS-10 and HS-8 upstream of the a
globin cluster. The telomere is shown as a round oval at the end of the contig. [modied from Ref. 21]

2015 International Society of Blood Transfusion, ISBT Science Series (2015) 10 (Suppl. 1), 295304
300 V. Viprakasit
molecular mechanism caused by mutations in trans-act-
ing factors underlying unusual causes of thalassaemia
[30, 31] will be reviewed elsewhere.
a
thalassaemia in Asia
Some fifty years ago, Professor Supa Na-Nakorn and Pro-
fessor Prawase Wasi began their pioneering research into
a
thalassaemia and Hb H disease in non-Mediterranean
populations at the Faculty of Medicine, Siriraj hospital,
Thailand. Their outstanding research on a
thalassaemia,
including their prescient concepts regarding duplication
of the a
globin genes and the molecular pathology
underlying Hb H and Hb Barts hydrops fetalis (a
thal-1
and a
thal-2) described some ten years prior to the clon-
ing of the a
globin genes.
In South-East Asia and the Southern region of China,
a
thalassaemias are extremely common. This was previ-
ously predicted from several cord blood studies detecting
Hb Barts (c4), and subsequently confirmed by molecular
analysis [3234]. The spectrum of genotypes associated
with these globin anomalies is heterogenous but some-
what specific to particular areas or regions since a set of
common mutations are responsible for nearly 8090% of
all affected individuals and these sets are different from
one area to another [8].
There are estimated to be at least 7000 new cases of
Hb H disease born each year in Thailand since nearly
13% of its population is heterozygous for either deletional
or non-deletional a
thalassaemia determinants. Previous
studies from Thailand revealed that the molecular basis of
the majority of patients with Hb H disease includes dele-
tional Hb H (--/
a37 or --/
a42) and non-deletional Hb
H caused be a0-thalassaemia and Hb Constant Spring (ter-
mination codon mutation; TAA?CAA, aCSa) [3537].
In the majority of Thai patients with a0-thalassaemia
characterized to date at the molecular level, the Southeast
Asian deletion (SEA, --SEA) is the most common mutation
underlying a0-thalassaemia, accounting for nearly 99% of
cases (Vip Viprakasit, unpublished data). Approximately
193 kb of both a
globin genes (nucleotides 155 400
174 700 of GenBank accession number AE006462.1) is
deleted while an embryonic f
globin gene lying
upstream remains intact and is reactivated. A small
amount of globin peptide from reactivated f
globin
genes has been observed in carriers of the SEA deletion.
It has therefore been proposed that anti-f
globin could
be used as a rapid method for diagnosis and screening for
the SEA deletion carrier (--SEA/aa) [3840].
However, there is another form of a0-thalassaemia
identified in Thailand, namely the THAI deletion (--THAI)
[35, 41]. This deletion removes a total of 335 kb of the
a
globin cluster, between nucleotides 139 800 and
2015 International Society of Blood Transfusion, ISBT Science Series (2015) 10 (Suppl. 1), 295304
173 300 including the f
globin gene. We have previ-
ously identified an interaction of this deletion with Hb
CS, which gave rise to the severe phenotype of Hb H-CS
disease [42]. It is thought that homozygosity for the THAI
deletion would cause early fetal death and spontaneous
abortion due to lack of the f
globin genes during embry-
onic erythropoiesis, although such a case has not yet
been reported. We have also predicted that compound
heterozygosity for the SEA and THAI deletions would
produce Hb Barts hydrops fetalis syndrome [42]. This
prediction was substantiated by a recent report describing
such an interaction [43]. Although a0-thalassaemia was
included in the pilot study started since 1995 for the
Thailand national programme for the prevention and con-
trol of severe thalassaemias including Hb Barts hydrops
fetalis, homozygous b-thalassaemia and Hb E-b-thal, only
the SEA type deletion screening using a PCR-based
method was adopted in the program [44]. This is to detect
carriers for the SEA deletion and identify couples at risk
of having a baby with Hb Barts hydrops fetalis resulting
from homozygous a0-thalassaemia (--SEA/--SEA). The
THAI deletion may be more prevalent than was previ-
ously thought, and misidentification of this deletion in
our population may hamper the success and effectiveness
of the control program for severe thalassaemia. It is
therefore justified to include this THAI deletion in the
screening program, possibly using a multiplex PCR-based
method. The clinical importance of the aforementioned
THAI deletion has also minimize a benefit of the screen-
ing test using anti-f
globin detection since there is no
reactivation of the f
globin in carriers with the THAI
deletion [40].
There is emerging evidence that the molecular pathol-
ogy underlying Hb H disease in Thailand might be more
heterogeneous than was previously thought. We have
recently shown that at least 15% of patients formerly
diagnosed with Hb H-CS actually have Hb H-Pakse
caused by another termination codon mutation (TAA?
TAT) [45]. Since there is no significant difference in elec-
trophoretic pattern between Hb Pakse (Hb PS) and Hb CS
and molecular analysis for both termination codon muta-
tions using Mnl I gives identical results [45], Hb PS has
not previously been recognized in Thailand. Subsequent
studies have provided further evidence that Hb PS might
be prevalent in the north eastern part of Thailand [46, 47]
where its carrier frequency may be as high as 23%. Our
preliminary results suggest that Hb H-PS patients are not
significantly different in their clinical severity from those
with Hb H-CS. One may ask whether it is necessary to
distinguish between these two termination codon muta-
tions. However, as there is currently insufficient evidence
that both mutations have different clinical consequences,
correct genotyping of both termination codon mutations
 ISBT Science Series (2015) 10 (Suppl. 1), 295304

INVITED REVIEW 4C-S32-01 2015 International Society of Blood Transfusion

a
thalassaemia: a genotypephenotype correlation and

management
V. Viprakasit
Division of Hematology-Oncology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand

Throughout the world, a
thalassaemia represents the most common monogenic

disorder in man [1]. A large number of mutations (mainly deletions and a few
nucleotide substitutions) of the human a-globin cluster have been described
which interact to produce one of three broad phenotypes, a-thalassaemia hetero-
zygote, Hb H disease and Hb Barts hydrops fetalis [2]. In terms of public health,
a-thalassaemia trait only causes a mild anaemia and Hb Barts hydrops fetalis is
usually fatal in late gestation [2, 3, 4]. In contrast, Hb H disease is a relatively
common cause of thalassaemia in individuals of Southeast Asian, Middle Eastern
and Mediterranean origins and is associated with a variety of clinically important
complications [3, 5]. This review will focus on the molecular basis of a
thalas-
saemia in general and more specifically illustrate a recent development in
molecular characterization of several, including novel, a
thalassaemia alleles
found recently. The complexity of globin genotypephenotype correlation in
a
thalassaemia disease will be discussed with particular regard to patients with
Hb H disease.
Key words: Barts hydrops fetalis, Hb H disease, a
thalassaemia

16 (
a, last three boxes in Fig. 1). Heterozygotes for sin-

Molecular basis of a
thalassaemia
Clinical phenotypes associated with a
thalassaemia result
from mutations involving the a
globin gene cluster on
the telomeric region of the short arm of chromosome 16
(16p 133) [16]. There are two copies of the a
globin
gene per haploid genome, annotated aa/aa.
In a0-thalassaemia (a condition in which a
globin
expression from one chromosome is completely abol-
ished), both of the linked a
globin genes are lost (--/aa),
most commonly by deletions that involve part or the
entire a
globin gene cluster (Fig. 1).
Heterozygotes for a0-thalassaemia are clinically normal
but have a mild hypochromic, microcytic anaemia. In the
less severe condition (a+-thalassaemia), a
globin expres-
sion from one chromosome is reduced but not abolished.
For example, this includes conditions in which a single
copy of the duplicated a
genes is lost from chromosome
Correspondence: Vip Viprakasit, Department of Pediatrics & Thalassemia
Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok
10700, Thailand.
E-mail: vip.vip@mahidol.ac.th
Invited Review for ISBT Meeting 2014 (Seoul, Korea).
gle a
gene deletions (
a/aa) are clinically and haemato-
logically normal or present with mild microcytosis and
cannot be definitively diagnosed without molecular-based
analysis. There are two common molecular pathology-
causing a0-thalassaemias, a 37-kb (rightward,
a37)
deletion and a 42-kb (leftward,
a42) deletion (Fig. 1).
The 37-kb deletion is more common and has been found
in nearly every region of the world [2, 7, 8].
Less commonly, a+-thalassaemia results from mutations
in one or a few nucleotides in critical regions of the
a
genes. This is called non-deletional a
thalassaemia
[6]. These mutations usually, but not always, affect the
more highly expressed a 2 gene (aTa) rather than the a 1
gene (aaT). These nucleotide mutations are summarized in
Fig. 2 and Table 1. More than 50 different non-deletional
mutations that cause a
thalassaemia have been reported
so far (reviewed in [6]). These may affect mRNA splicing,
initiation of mRNA translation or disturb the poly
(A) addition signal leading to downregulation of the
affected a
globin gene. These mutations, a0-thalassaemia
(--) and a+-thalassaemia (
a or aTa), have different
effects on a
globin expression and can be broadly cate-
gorized as shown (Fig. 3).

295
302 V. Viprakasit
clinical heterogeneity even within those patients with an
identical genotype, mainly Hb H-CS (--SEA/aCSa). While
many patients with Hb H-CS do not require splenectomy
or have never received transfusion and compensate quite
well, achieving normal growth and pubertal development,
other patients with an identical genotype have a more
severe phenotype and require intensive management.
Acute haemolytic episodes, which are more common in
the first decade of life, may contribute to clinical severity
in Hb H patients. Acute haemolysis appears to decrease in
frequency after the second decade of life, with most
patients requiring no further transfusions by the time
they reach puberty. It has been suggested that acute hae-
molytic episodes are associated, or partially caused by,
concurrent infection and raised body temperature [56].
There would be increased risk of haemolytic crises when
the patients were young because children are more sus-
ceptible to infection due to their underdeveloped immu-
nity [57]. Therefore, this might suggest a substantial
contribution of environmental factors upon clinical pro-
gression in patients with Hb H disease.
The complex interaction between genetic and environ-
mental factors is troublesome in the efficient long-term
management of each patient. One drawback is the lack of
comprehensive analysis of the natural history and long-
term complications in patients with Hb H disease. Our
ongoing-study, which will illustrate a longitudinal picture
of patients with Hb H disease from infancy through child-
hood into adolescence and adulthood, may provide better
insight regarding prediction of the clinical course and
natural history of Hb H disease in future cases. This will
eventually lead to a better standard of care and manage-
ment in patients with this syndrome.
Acknowledgement
The work carried out at the authors laboratory (Depart-
ment of Pediatrics, Faculty of Medicine, Siriraj Hospital,
Bangkok) was supported by the Medical Research Council,
UK and National Institute of Health (US). The author
wholeheartedly wishes to thank Worrawut Chinchang for
his excellent technical assistance, Dr. Alison Merryweath-
er-Clarke for her critical comments on the manuscript,
and to Emeritus Prof. Voravarn S. Tanphaichitr and Prof.
Douglas R. Higgs for their continuous support and
encouragement.
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