A Review of Iron Overload in Beta-Thalassemia Plasmatology

Volume 16: 1–9

Major, and a Discussion on Alternative Potent © The Author(s) 2022
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DOI: 10.1177/26348535221103560

Piyush Kumar Yadav and Ajay Kumar Singh

Department of Bioinformatics, Central University of South Bihar, Gaya, Bihar, India.

ABSTRACT: For years, arrhythmias have been well documented in the medical arena as a cardiovascular consequence of iron overload (IO).
They are thought to be linked to the accumulation of iron in the myocardium. Iron is the earth’s fourth most abundant element and the second
most plentiful metal (after aluminium). When it comes to biology, iron fills two roles: it’s necessary and it’s poisonous. It is necessary as a
trace iron element since it is found in hemoproteins such as haemo-globin, but it is poisonous in excess amounts of the ability to produce
free radicals, which can harm the biological system. The high prevalence of cardiomyopathy in patients with hemosiderosis, particularly in
cases of transfusional iron overload, strongly suggests that iron deposition in the heart plays a key role in the development of heart failure.
Thalassemia major, which necessitates blood transfusion as a treatment, absorbs a large amount of iron in the patient’s duodenum. Moreover,
Iron Overload causes a threat to vital organs such as the liver and, initiates events of the pathologic progression involving apoptosis, fibrosis,
and ultimately cardiac dysfunction. Furthermore, we discuss the iron overload issue as it relates to beta-thalassemia major patient blood trans-
fusion treatment, as well as key individuals accountable for iron excess that ultimately leads to cardiomyopathy.

KEYWORDS: Thalassemia major, Iron overload, Chelation Methods

RECEIVED: November 18, 2022. ACCEPTED: May 11, 2022.
TYPE: Review
FUNDING: This work is supported by the Indian Council of Medical Research, New Delhi India
under the ICMR Grant (ISRM/12(22)/2019, ID No. 2019-0370) for this manuscript.
DECLARATION OF CONFLICTING INTERESTS: The author(s) declared no potential conflicts
of interest with respect to the research, authorship, and/or publication of this article.
CORRESPONDING AUTHOR: Ajay Kumar Singh, Department of Bioinformatics, Central
University of South Bihar, Gaya, Bihar, India.
Email: ajaysingh@cusb.ac.in

Introduction by total body iron stores. Standard concentrations of ferritin

Thalassemia is a multi-genetic hereditary condition, namely alpha
thalassemia, beta-thalassemia, delta beta-thalassemia and some
others.1 Thalassemia is a hereditary disease, which means that at
least one parent must be a carrier of the disorder. To be affected
by the disorder, a child must receive one abnormal gene from
each parent.2 It is caused either by a genetic disorder or by the
deletion of certain main segments of the gene. In a cluster of
the beta-globin gene on chromosome 11,3 and the 16 chromo-
somes on alpha-globin gene cluster,4 molecular defects result in
inaccurate production of hemoglobin.5 Thalassemia conditions
with multiple clinical symptoms, phenotypes and therapeutic
options are focused on a continuum of severity. TDT (transfusion-
dependent thalassemia) and NTDT (non-transfusion dependent
thalassemia) are two types of thalassemia.6 In both transfusion-
dependent thalassemia and non-transfusion dependent thalassemia,
iron overload is associated with high morbidity. Iron overload is
caused by an excess accumulation of intestinal iron confirmed
by inadequate erythropoiesis.7 Excess iron deposition, which
begins in the first year of routine blood transfusion, causes
harm to many vital organs.
Hemochromatosis, also known as iron overload, is charac-
terized by improper iron accumulation in the functional parts
of an organ, which results in organ damage and failure.8
Human bodies store iron, mainly in the form of ferritin.
Limited content of ferritin is secreted into bloodstreams. The
blood ferritin concentration is checked, in the absence of
inflammation, this blood ferritin is linked positively corrected,
differ by sex and age.9 Ferritin concentration tends to increase
at the age of around one year and even grow in adulthood.
Males, however, have a higher level of concentration values
than females.10
As NTDT has indeed been significantly investigated and
researched over the past few years, it has been found in patients
that do not rely on regular blood transfusion, iron overload dif-
ferentially affects the liver rather than the myocardium. This
was apparent from retrospective studies that demonstrated a
lack of cardiovascular siderosis in patients with extreme
hepatic iron excess.11 Physiologically there is a lack of a mech-
anism to remove excess iron load caused by blood transfusion
from the human body. 200-250 mg is elemental iron present
in each transfused unit of packed red blood cells. Transfusion
iron normally amounts to 03 to 0.6 mg/kg per day for TDT
patients, with an estimated monthly average transfusion
volume of red blood cells filled with 2 to 4 units. This excess
iron accounts for the disruption of major vital organs’ function-
ing and causes irreversible damage.
Cardiomyopathy, often caused by iron overload, is a frequent
and preventable form of heart failure.8 With atrial and ventricular
tachyarrhythmias, iron accumulation in the heart tissue promotes
non-homogeneous electrical conduction and repolarization.12
The entire cardiac conduction system, particularly the atrioven-
tricular node, may be affected by iron deposition. A permanent
pacemaker may be required if a complete atrioventricular block
is caused by iron deposition.13

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2 Plasmatology
In almost every nation on the planet, including Northern
Europe, where thalassemia was historically absent, migration
and marriages between different ethnicities induced thalassemia
in humans. Beta-thalassemia has been reported to be around
1.5 per cent of the world’s population (80-90 million people)
carriers, with about 60,000 serving as symptoms born globally,
the overwhelming majority in the developing countries in par-
ticular. The internationally estimated average annual frequency
of symptomatic people is 1 in 100,000.14 Beta-thalassemia with
irregular Hb or structural Hb form with thalassemia character-
istics has been the most common combination within the
region of South East Asia with a carrier level of about 50%.2
A keyword search of Cardiac arrhythmia was undertaken in
the literature databases Pubmed, Gene Reviews, and Scientific
Research Journals from 1980 to 2021 for this review paper.
With indications of a relationship between arrhythmia and
iron overload, primarily in beta-thalassemia major and other
blood diseases requiring transfusions, such as hemochromatosis
and severe anaemia.
Etiology
Thalassemia is autosomal recessive, which simply means both
parents need to be affected with or carrier for the disease to
pass it on to the next generation. It is caused by mutations of
the Hb genes, resulting in alpha or beta chains being under-
produced or not present. More than 200 mutations are
known as the causes of thalassemia. Alpha thalassemia and
beta-thalassemia are caused by the deletion of alpha-globin
and beta-globin genes respectively caused by a point mutation
on chromosome 11 in the splice site and promoter regions of
the beta-globin gene.15
Diagnosis
Patients with thalassemia disorder are found to have an inci-
dence count when mild microcytic anemia is observed in their
standard blood samples. Thalassemia, iron deficiency, chronic
sideroblastic anemia and lead poisoning (also known as plum-
bism) are responsible for microcytic anemia.16
Metabolism of thalassemia and iron
Erythropoiesis (from Greek “erythro” meaning “red” and
“poiesis’ meaning “to make”) and iron (Fe) metabolism are
closely related. The hormone that regulates the absorption of
iron is hepcidin, synthesized in the liver.17 Hepcidin synthesis
is regulated by transferrin saturation, the concentration of
iron, inflammation and erythropoiesis demand. Several eryth-
roid factors affect hepcidin development, eg growth differenti-
ation factor (GDF-15) and erythroferrone (Erfe). Increased IE
(interleukin), anemia, and inflammation lead to a rise in
GDF-15 development leading to suppression of hepcidin.18
This, in turn, results in increased absorption of Fe from the
intestine. High intestine absorption of Fe leads to an increase
in iron overload, especially in individuals with NTDT
(Non-transfusion-dependent Thalassemia) and contributes to
the transfusion overload of Fe in individuals with TDT
(Transfusion-dependent Thalassemia).
Therapeutic drugs used for the chelation of iron
Iron chelation therapy is used to minimize the accumulation of
iron deposition in the patient’s vital organs such as the liver and
heart. The most common FDA-approved iron chelators are
Deferoxamine (DFO), intravenous administration for the treat-
ment of transfusion-induced acute iron overdose and chronic
iron excess overload. Deferiprone (DFP), an oral iron chelator
with a 3:1 molar ratio of iron-binding, prevent iron buildup but
does not adequately prevent iron-induced organ dysfunction,
and Deferasirox (DFX/DFRA) is a tridentate oral iron chelator
that binds specifically to ferric iron to mobilise stored iron.19
A severe complication of iron overload in beta-thalassemia is
cardiac dysfunction, which results in a 71 per cent mortality rate
due to iron accumulation in the myocardium.20 It is critical to
reduce LPI (Labile Plasma Iron) and eliminate excess iron to
avoid major consequences from iron overload.21 Phlebotomy
is impossible in individuals with severe beta-thalassemia and
hereditary hemochromatosis because they are anaemic. As a
result, iron chelation therapy is indeed the best option for treat-
ing iron overload.
Efficacy of iron-chelating drugs
Chelating medicines in general have a variety of qualities that
can impact iron elimination along with intake, and they can
be useful in the treatment of a variety of iron-metabolism dis-
eases, including Beta-Thalassemia, and other Iron-Loaded
Non-Transfusion Dependent Thalassemia. In each situation,
a risk-benefit evaluation for the chosen therapy is indicated,
based on the individual differences as well as the chelating med-
ication’s long-term effectiveness, safety, and expense.
Deferasirox (DFX/DFRA) has been reported in iron meta-
bolic balance tests to be effective for increasing faecal, but not
urinary, iron excretion, as well as lowering liver iron and
serum ferritin values in some patients using the recommended
doses of 10–30 mg/kg/day. Medications of 10–40 mg/kg have
been observed in iron-loaded thalassemia patients to generate a
steady rise in iron excretion, which would have been dose-
dependent but not adequate to create a negative iron balance
(>15-20 mg iron excretion) in the number of patients at 20
mg/kg or even in most cases at 30 mg/kg/day. In most patients,
medication of 40 mg/kg of deferasirox is more effective, with a
mean iron excretion rate of 28 mg/day per 50 kg man body
weight.22
DFX/DFRA is now used by millions of transfusional iron-
loaded patients. Many current types of research and assess-
ments have been published indicating that DFRA is a relatively
effective, well-tolerated, and safe medicine, raising the hopes of
Yadav and Singh
many patients for a more effective treatment.23 Acute renal
failure caused mortality, as well as additional major toxic side
effects such as Diarrhea, nausea, constipation, and abdominal
pain; skin rashes; and a rise in serum creatinine level24 caused
by the prolonged use of DFX/DFRA. DFX/DFRA’s effective-
ness is also challenged, as there is no indication that it can achieve
negative iron balance or eliminate excess cardiovascular iron.
The elimination rate of DFO from plasma is faster and is
dependent on the route of drug administration. Intravenous
DFO has a half-life of 5-10 min while intramuscular DFO
has a half-life of roughly 60 min. The elimination of DFO
from blood is faster (5-10 min) than that of its iron complex
(90 min). It is expected that during the 8-12 h long subcutaneous
DFO dose, DFO is eliminated relatively quickly and a threshold
level in plasma is reached after about 4 h.25 The most frequent
major toxic adverse effects of DFO include ocular, auditory,
and bone problems. The side of the DFO injection causes hard-
ness, edoema (excess fluid trapped in the body’s tissues), and dis-
comfort in over 80% of thalassaemia patients. To increase DFO
compliance and efficacy, different formulations and administra-
tion strategies have been used in the past. The oral formulation
of DFO did not affect iron excretion.26
In iron-loaded patients, dosages of 75-120 mg/kg/day of
Deferiprone (DFO/L1) are usually enough to produce a nega-
tive iron balance.27 Gastrointestinal symptoms, granulocytosis,
agranulocytosis, and hepatic enzyme increase.28 The combin-
ation of DFO and L1 is especially beneficial for patients who
are experiencing toxicity from either medicine or who are not
fully cooperating with DFO therapy, because compliance
with L1 is substantially higher than compliance with DF. In
terms of toxicities, the use of combination therapy is especially
beneficial for decreasing high doses of subcutaneous or intra-
venous DFO, which are known to produce auditory and
ocular toxicity in a large percentage of patients, as well as L1
dosages that may cause arthropathy.29
Role of Hepcidin in Iron Metabolism
Iron metabolism is a closely controlled biological process with little
redundancies, and its disruption frequently results in iron deficiency
or iron overload. Anemia, caused by an iron deficiency, is a major
public health hazard that affects up to a billion people globally.
Iron, on the other hand, has the potential to be toxic.30 It produces
reactive oxygen species (ROS) when it combines with oxygen,
causing cell damage. Three regulatory mechanisms manage iron
metabolism in mammals: one controls cellular iron metabolism
through iron regulatory proteins (IRPs), which bind iron-
responsive elements (IREs) in regulated mRNAs.31 In humans,
low hepcidin levels cause iron overload (IO). As a result of low hep-
cidin levels and ferroportin overexpression, iron overload is caused
by increased iron export from enterocytes and macrophages. Iron
builds up in vital organs including the heart, liver, and pancreas,
causing oxidative stress and conditions like cirrhosis, cancer, dia-
betes, and cardiomyopathy.32 As shown in “[ Figure 1]”.
3
Iron Overload in beta-Thalassemia
Standard blood transfusions are required in the most severe form
of beta-thalassemia to reduce the risk of anaemia. Iron overload is
caused by RBC (red blood cell) count being boosted by monthly
blood transfusions, hemolysis, and increased absorption of iron
from the duodenum and proximal jejunum.33 Cardiac stiffness is
the major cause of death in thalassemia patients who have received
blood transfusions.34 1-2 mg of iron is excreted from the human
body in a day, whereas a transfused red blood cell unit contains
about 200 mg of iron.35 In absence of any iron chelation
therapy, an individual getting 25 blood units a year requires 5 g
of iron each year. Iron toxicity is highly harmful to all cells in
the body and can cause severe and permanent organ failure,
such as liver disease, diabetes, cardiac failure and testosterone defi-
ciency.34 The iron surcharge in the bloodstream can be measured
using, urinary iron excretion, hepatic iron content, serum ferritin
and TIBC (Total Iron Binding Capacity) levels.7 The iron toxicity
threshold values are concentration of, serum ferritin > 2500 ng/mL,
urinary iron discharge> 20 mg/day, concentration of liver iron
more than 440 mmol/g and transferrin congestion> 75%.36
Estimating the concentration of hepatic iron by MRI (magnetic
resonance imaging) is a widely used method in beta-thalassemia
major to assess the overburden of iron37 T2* Magnetic
Resonance Imaging (T2* MRI) is a non-invasive approach for
determining heart and liver iron overload.38 T2* MRI is a
highly reproducible and sensitive approach for detecting cardio-
vascular iron overload. Serum ferritin did not affect the T2* MRI
reading (p-value: 0.464).39 Iron over-burden has additionally
been seen in patients with NTDT (non-transfusion-subordinate
thalassemia).40 Beta-thalassemia with histidine to aspartic acid
(H63D) experiences mutation in carriers patients, and iron over-
load at codon 63 of the HFE gene which indicates that the
H63D mutation can influence the absorption of iron.41 Iron
overabundance increases the risk of hepatitis, (swollen liver),
fibrosis, and or irreversible damage to the liver due to scarring
iron excess also leads the chance of abnormal heart rhythms/
arrhythmias, or, and cardiac obstruction.24
Signaling pathways that regulate Hamp/Hepcidin expression
Stat3 signaling pathways- Stat3 signaling pathway is a regulator
for hepcidin, mostly through inflammation.42 This contributes to
the development of IL-6 and IL-22 but not to IL-1β and
factor-α tumour necrosis (TNF-α).43 The Stat3-binding site
and the SiRNA- mediated Stat3 knockdown contain a promoter
from Hamp which significantly lower the transcription of hepci-
din. Stat3 signaling pathway is important not only under condi-
tions of inflammation but also under expression of baseline
hepcidin.43 The activation of IL-6-mediated hepcidin is based
on the signaling pathway IL-6-Stat3.IL-6 binds to the IL-6
receptor (IL-6R), then to glycoprotein 130 (gp130), causing
Stat3 phosphorylation, which facilitates Stat3 translocation to
the nucleus and triggers Hamp transcriptions.44
4 Plasmatology

Figure 1. (A) Elevated iron levels beta thalassemia major, a result of continuous blood transfusions received from packed red blood cell (PRCB) which around
200-250 mg of iron. A small amount of iron is secreted from the excretion route and through menstrual bleeding in adolescent girls and adult females. (B) Hepcidin, a
major iron regulator which is severely monitored, IL-6 activates hepcidin via the IL-6 receptor (IL-6R) and JAK2-STAT3 signalling pathways. In active BMP-SMAD
pathway enables a normal hepcidin expression which inhibits the expression of iron stores and manages the iron metabolism. Transferrin binds iron and transports it
through the bloodstream. The majority of iron is needed for erythropoiesis. (C) An active BMP-SMAD is required for full hepcidin activation. In beta thalassemia
major, an inactive BMP-SMAD pathway causes decreased production of hepcidin, which is unable to block iron reserves transferred from FPN in macrophages and
Entrocytes, resulting in iron overload which leads oxidative stress and cellular damages to major vital organs such as heart, liver and intestine.

Other signaling pathways that regulate Hamp/Hepcidin
expression
In Hamp promoter, estrogen was found as a sex hormone to
down-regulate Hamp expression via an estrogen receptor
element (ERE).45 A report indicated that the membrane com-
ponent, PGRMC1 (membrane-bound progesterone
receptor-1), also contributes to the modulation of hepcidin by
Src-family tyrosine kinases (SFKs).46 The downstream
signaling of SFKs responsible for the regulation of Hamp
expression is still unclear,46 and needs further study.
Hepcidin is regulated by BMP/SMAD protein pathway
There are approximately 20 mammalian bone morphogenetic
proteins (BMPs), among which BMP2, BMP4, BMP5,
BMP6, BMP7 and BMP9 can cause Hamp expression.47
Studies have shown that the most important among all of the
Yadav and Singh
bone morphogenetic proteins (BMPs) is BMP6 which is an
important factor in the regulation of hepcidin.47 To activate
Smad1/5/8 phosphorylation, it attaches to the BMP receptor
(BMPR), and then it translocates to the nucleus together
with Smad4 and binds to the Hamp promoter to promote
Hamp transcription.48 BMPR type I expresses only
Activin-Like Kinase 2/3mammals.49 Unlike many other
members of the BMP protein family, the BMP signaling
pathway is the essential iron-mediated regulator of hepcidin
as BMP6 is sensitive to iron concentrations. BMP6 is devel-
oped in non-parenchymal liver cells and stimulated by iron;
its expression is relative to the amount of hepatic iron.
Furthermore, neutralizing the BMP6 antibody may reduce
hepcidin expression and cause serum iron concentrations to
increase in mice.
Cardiac Dysfunction and its Relation with Iron
Toxicity
Iron is a two-pronged element, its role as an oxygen carrier plays
a critical role in catalyzing enzyme reactions, and disruption in
iron homeostasis results in excessive iron intake and storage,
which is harmful to various tissues and organs. Toxic levels of
ferrous iron are primarily exhibited as cardiac dysfunction and
failure, as well as liver dysfunction and cirrhosis and diabetes
mellitus in the endocrine system. These conditions are generally
detected in the late stages of their recurrence when conse-
quences have already been developed. Arrhythmias and increas-
ing systolic dysfunction are commonly caused by iron
accumulation in the heart muscle tissue. A dilated cardiomyop-
athy with poor left ventricular ejection fraction (LVEF) is the
most common manifestation, which can be reversed only if
recognized and treated in the early stages of diagnosis.50 This
condition is often asymptomatic. Iron deposition can occur
throughout the cardiac conduction system, particularly in the
atrioventricular node. Severe atrioventricular block due to iron
accumulation.13 Non-homogeneous electrical conduction and
repolarization induce cardiomyopathy with atrial and ventricu-
lar tachyarrhythmia and iron buildup in heart muscle.12
Tf-bound iron is not a limiting factor under normal settings,
and the absorption of iron into cells is regulated by TfR1
expression.51 As a result, iron overload occurs only when Tf’s
binding ability is exhausted and non-transferrin-bound iron
(NTBI) or labile plasma iron (LPI), the portion of NTBI
that may infiltrate cells and is chelatable, is present.52
Although NTBI is linked to tissue siderosis, the exact mechan-
ism by which it enters the cell is unknown, owing to a lack of
complete characterization of the iron species involved, which
have a variable composition under different pathological condi-
tions and change their association with macromolecules. Several
plasma components, including citrate, phosphates and proteins,
are said to be linked to NTBI.53 Iron toxicity in cells is caused
by its ability to catalyze the reactive oxygen species (ROS),54
which induce lipid peroxidation and organelle damage,
5
resulting in cell death and fibrosis, as well as reduced systolic
and diastolic function. Cell damages caused by iron are not
limited to cases of systemic iron overload. Unfair iron distribu-
tion within organs or tissues, as well as among cellular compart-
ments, has been shown to impact cell integrity and longevity.
Ischemic heart disease or myocardial infarction is not connected
with cardiac hemochromatosis,55 thus there is a lack of knowl-
edge regarding the basic mechanism of iron overload-induced
arrhythmia.56
Iron Excretion
The amount of iron in the human body is calculated through
dietary consumption of iron, not through iron excretion. The
removal of iron from the human body is handled at a very
small rate. The faecal secretion of iron is equivalent to the con-
sumption of iron by diet, and zero in the case of iron by trans-
fusion.57 However, several cases such as blood transfusion in
beta-thalassemia which suppress in production of hepcidin
may lead to an overload of iron. Unintentional exposures can
cause the majority of serious medical problems, such as
cardiac arrhythmia and liver failure. As a result, iron absorption
is continuously monitored to prevent cell damage. The toxifica-
tion of iron mainly occurs where it is stored i.e, in the liver.
Biliary iron excretion estimated a significant amount of excess
iron extraction through the bile and remaining to be processed
for the reuse of hemoglobin synthesis.58 Urinary iron excretion
a usual routine excretion of iron in the urine is a large propor-
tion of the overall daily iron depletion.59
Therapeutic Targets in Beta-Thalassemia
Mini-hepcidin
Since low hepcidin levels are associated with greater Fe absorp-
tion in the intestine; inhibitors of hepcidin in thalassemia
patients may boost the iron load. Small peptides such as
Mini-hepcidin mimetics are necessary to induce hepcidin
actions; hence, serum iron levels decrease and iron overload
improves. By using this mini-hepcidin, iron overload and
damage to the erythroid cells are significantly reduced.60
Apo-transferrin administration
Apo-transferrin administration can decrease labile plasma iron
concentrations, leading to a normalization of RBC survival and
increased production of Hb. The protein also exists during the
early phases of a clinical study.61 As the Hamp negative regula-
tor, 17b estradiol (E2) therapy reduced Hamp expression in cell
lines HuH7 and Hep G2, which could be blocked by ICI
182780, an estrogen receptor antagonist.45
JAK2 inhibitors
These agents have substantial antiproliferative and anti-
inflammatory activity in patients with b-thalassemia, to regulate
6 Plasmatology
splenomegaly and extra-modular hematopoiesis.62 Through
suppressing the EPO’s key signaling pathway on progenitor
erythrocytes, similar agents can have therapeutic effects on
splenomegaly and secreted blood from the spleen, resulting in
fewer transfusion needs. These agents can be used in place of
splenectomy, once proven to be safe and to decrease additional
medullary hematopoiesis.
Activin receptor Ii ligand traps
These model ligands (Luspatercept/Sotatercept) suppress over
activated SMAD signals in erythroid precursors which inhibit
the effect of GDF-11 cytokine on differentiation and matur-
ation of the advanced stage erythrocytes. These ligands have
been shown to mitigate complications from IE (ineffective
erythropoiesis) diseases, minimizing the excess iron and redu-
cing bone disease deformities in animal models.63 Ongoing
clinical trials are being carried out which show improvements
in 12 weeks of studies on the impact of these drugs on IE
and transfusion-dependent beta-thalassemia patients.64
Transferrin
The main protein in the transportation of iron is transferrin,
which binds to Fe3 + molecules, transported iron is bound to
(TfR1) receptor 1 and (TfR2) receptor 2. Transferrin is endo-
cytosed, the lysosomal, acid framework Fe3 + is produced from
transferrin and is reduced to Fe2 + and is then entered into the
cytosol through divalent metallic transporter 1. Whereas TfR1
with high transferrin saturation is down-regulated.TfR2 is spe-
cific in the liver and intestine, because of high liver iron concen-
tration (LIC), TfR2 lacks an iron-responsive feature and the
iron charge in the liver continues. In most tissues, including
the erythroid, a liver and myocardial precursor, TfR1 is
expressed.65
TMPRSS6
TMPRSS6 is a membrane binding serine protease in hepato-
cytes, it is also known as matriptase-2,66 which modulates the
production of hepcidin negatively.67 TMPRSS6 cleaves HJV
(hemojuvelin) from plasma membrane favourable in vitro con-
ditions.67 This means that TMPPRSS6 down-regulates the
critical BMP/SMAD signalling route important for iron-
dependent hepcidin transcription regulations.
BCL11A (B cell lymphoma-leukaemia 11a)
A decent approach for gene editing strategies is the BCL11a
(TF controlling the transition from HbF to HbA). It is postu-
lated that the production of HbF in thalassemia patients can be
triggered by suppressing the BCL11a. Deletions in the
BCL11a erythroid enhancer are a promising approach, which
is being investigated.68 The Long-dimensional interactions
across the β-globin gene locus between BCL11A and several
regions could mediate β-globin gene silence. Whether this is
a direct result of the suppression of BCL11A or an indirect
effect due to the activation of γ-globin by another process is
uncertain.
Therapies Under Investigation for Iron Overload
Hepcidin deficiency treatment
Hepcidin, the hormone which regulates the accumulation of
absorption of iron and its abnormal transportation are a cause
of iron overload in nearly every form of hereditary hemo-
chromatosis and non-transfused iron overloading anemia.69
Analogues of hepcidin have also been seen reducing the toxicity
of the iron-mediated tissue in mouse models.69 Agonists of
hepcidin known as Mini-hepcidin are based on peptides that
are rationally planned, based on the hepcidin field engaging
with the ferroportin.60 Mini-hepcidin may be helpful in iron
excessive conditions used for treatment or chelation treat-
ment.70 Analogues of normal hepcidin and mini-hepcidin are
studied for preventing the overloading of iron in hemochroma-
tosis and beta-thalassemia. As deficiency in hepcidin causes an
overload of iron It would be expected that agents capable of
mimicking hepcidin action or potentiating its endogenous pro-
duction would inhibit iron.71
Gene therapy management
The treatment by gene therapy of genetic conditions such as
sickle cell anemia and beta-thalassemia will prevent blood
transfusions and reduce iron overload in the tissues.72 In indi-
viduals with hereditary hemochromatosis and beta-thalassemia
including the DMT-1 activation and gene expression of ferro-
portin in enterocytes Over-expression of the wild-type HFE
gene in enterocytes and overexpression of the iron regulatory
peptide hepcidin in the liver are other therapeutic strategies
that could be studied.73 The HFE genotype may influence
the survival of myelodysplastic syndrome patients and tests
need to be carried out if these patients are to be treated with
effective iron chelation therapy.41
Discussion
In the Indian subcontinent, the common genetic disorder is
Thalassemia. Hyper-transfusion has improved the expected
lifespan of thalassemic patients over the decades, but the exces-
sive number of blood transfusions ensures iron overload is an
inevitable complication major in thalassemia patients.74
Several studies have concluded that cirrhosis of the liver is asso-
ciated with increased levels of serum ferritin.75 Iron is an essen-
tial component in biochemical and biological processes,
however, when excess, oxidative stress can lead to tissue
damage. Excess iron in the body can cause damage to organs
such as the liver, spleen, liver, bone marrow, pancreas, pituitary
gland and nervous system.
Yadav and Singh
In the last 20 years, thalassemia major management has devel-
oped to the point where the life expectancy of patients is as high as
normal inhabitants. Therapies that reduce transfusion demands in
TDT and remove insufficient erythropoiesis in NTDT may in
this way be promising. Specific disruptions in factors like
BCL11A that may potentially lead to γ-globin genes being kept
suppressed may result in simpler and safer treatment of
β-thalassemia, depending on transfusions or non-transfusions.7
The developmental stage-specific BCL11A repressor regulates
the expression of hemoglobin. The use of strengthened activin
receptors to enhance delay erythropoiesis by functioning as
ligand traps for the participants in the transformation of superfam-
ily growth factors is also a promising method, currently being
tested in clinical studies.65 Therapy with these agents aims to
increase hemoglobin levels and reduce the need for transfusion
in both NTDT and TDT patients.
Conclusion
In thalassemia major, cardiac illness is still the leading cause of
death. Transfusion and iron chelation treatments have greatly
improved survival and reduced morbidity in thalassemic
patients. In the past patients died by the age of 16, while now
80 per cent live to be at least 40 years of age. This is of a
kind improvement, as no other previously fatal genetic flaw
has shown such a benefit. Heart complications, on the other
hand, continue to be a substantial cause of morbidity and mor-
tality in transfusion-dependent thalassemia (TM) patients.
Some tests can detect the possibility of thalassemia in neonates;
however, depending on the severity of the thalassemia, blood
transfusions may be necessary at a very early stage of life. In
the human body, iron is essential for the creation of heme
enzymes and other iron-containing enzymes involved in elec-
tron transfer and oxidation reductions, as well as the synthesis
of oxygen transport proteins such as haemoglobin and myoglo-
bin. The majority of iron is delivered via haemoglobin, which
circulates in erythrocytes. However, 15% of iron is found in
myoglobin, which is found in muscle tissue and a variety of
other tissues. Transferrin binds to iron and transports it
throughout the body, where it is stored in ferritin molecules.
There is no physiologic mechanism for excreting excess iron
from the body once it has been absorbed, other than blood
loss, such as during pregnancy, menstruation, or other periods
of bleeding. As a result, unabsorbed iron can lead to liver
disease, cardiac troubles, diabetes, and problems with human
growth. The percentage of iron absorbed from the total
amount consumed is normally low, ranging from 5 to 35 per
cent based on the circumstances and type of iron consumed.
Hepcidin is a peptide hormone released by the liver that plays
an important function in iron homeostasis management. It is a
potent inhibitor of systemic iron homeostasis, coordinating iron
uptake, usage, and storage. Hepatocytes produce it, and it’s a
negative regulator of iron absorption into the bloodstream.
Hepcidin specifically binds to ferroportin, an iron transporter
7
found in intestine duodenal cells, macrophages, and placental
cells. The absence of ferroportin on the cell membrane prevents
iron from entering the bloodstream. Low transferrin saturation
results from less iron entrance into plasma and less iron is supplied
to the erythroblast. Higher cell surface ferroportin and increased
iron absorption resulted from decreased hepcidin expression. By
this hepcidin and its interacting constituents (ferroportin, transfer-
ring) became a potent target for tapping the iron overload
problem. These are discussed briefly in the review article.
Clinicians utilize the classic iron chelation approach (use of
drugs ie, Deferoxamine, Deferiprone and Deferasirox) to treat
iron overload in patients who get regular blood transfusions, even
though this method has a significant risk of side effects in later
life of patients. There is no insightful topic in agreement on the
excretion of excess iron; nevertheless, if the study focuses on
excess iron excretion from the body system, individuals with thal-
assemia who require regular blood transfusions may be cured and
lead a longer and healthier life. The use of computational biology
and drug design methods is important in the quest for a powerful
inhibitor of iron overload, and the results can be confirmed in vivo
facility. An alternative to iron chelation that has fewer adverse
effects on the human body can be designed. New emerging tech-
nologies (Drug Designing and Lead Identification) could help find
a better-designed inhibitor in iron overload.
Acknowledgements
Author(s) would like to acknowledge the Department of
Bioinformatics, Central University of South Bihar, Gaya
Bihar and the Indian Council of Medical Research, New
Delhi India for all technical and financial support.
Author Contributions
The authors have contributed equally to the manuscript.
ORCID iD
Ajay Kumar Singh https://orcid.org/0000-0003-4544-3596
REFERENCES
1. Marengo-Rowe AJ. The thalassemias and related disorders. Baylor Univ Med Cent
Proc. 2007;20(1)(Jan):27-31.
2. Galanello R, Origa R. Beta-thalassemia. Orphanet J Rare Dis. 2010;5(Aug):1-15.
3. Thein SL. Molecular basis of β thalassemia and potential therapeutic targets. Blood
Cells, Mol Dis. 2018;70(May):54-65.
4. Farashi S, Harteveld CL. Molecular basis of α-thalassemia. Blood Cells, Molecules,
and Diseases. 2018;70(May):43-53.
5. Muncie HL, Campbell JS. Alpha and beta thalassemia. Am Fam Physician.
2009(Aug):339–344.
6. Musallam KM, Rivella S, Vichinsky E, Rachmilewitz EA. Non-transfusion-dependent
thalassemias. Haematologica. 2013;98(6)(Jun):833-844. doi: 10.3324/haematol.2012.
066845
7. Mishra AK, Tiwari A. Iron overload in Beta thalassaemia major and intermedia
patients. Maedica (Buchar). 2013;8(4)(Sep):328-332.
8. Aronow WS. Management of cardiac hemochromatosis. Arch Med Sci.
2018;14(Apr):560-568. doi: 10.5114/aoms.2017.68729.
9. Domellöf M, Dewey KG, Lönnerdal B, Cohen RJ, Hernell O. The diagnostic criteria
for iron deficiency in infants should be reevaluated. J Nutr. 2002;132(Dec):3680-3686.
doi: 10.1093/jn/132.12.3680.
10. Gibson RS. Principles of Nutritional Assessment. 2nd. Editor Gibson RS ed. Oct.
Oxford University Press Inc.; 2005.
8 Plasmatology
11. Taher AT, Musallam KM, Wood JC, Cappellini MD. Magnetic resonance evalu-
ation of hepatic and myocardial iron deposition in transfusion-independent thalas-
semia intermedia compared to regularly transfused thalassemia major patients. Am
J Hematol. 2010;85(Apr):288-290. doi: 10.1002/ajh.21626.
12. Wu V-C, Huang J W, Wu M-S, et al. The effect of iron stores on corrected QT
dispersion in patients undergoing peritoneal dialysis. Am J Kidney Dis Off J Natl
Kidney Found. 2004;44(Oct):720-728.
13. Aronow WS, Meister L, Kent JR. Atrioventricular block in familial hemochromatosis
treated by permanent synchronous pacemaker. Arch Intern Med. 1969;123(Apr):433-
435.
14. Vichinsky EP. Changing patterns of thalassemia worldwide. Ann N Y Acad Sci.
2005;1054:18-24. doi: 10.1196/annals.1345.003.
15. Jalil T, Yousafzai Y M, Rashid I, et al. Mutational analysis of Beta thalassaemia by
Multiplex Arms-Pcr in Khyber Pakhtunkhwa, Pakistan. J Ayub Med Coll Abbottabad.
2019;31(Jan-Ma):98-103.
16. Brancaleoni V, Di Pierro E, Motta I, Cappellini MD. Laboratory diagnosis of thal-
assemia. Int J Lab Hematol. 2016;38(May):32-40. doi: 10.1111/ijlh.12527.
17. Sangkhae V, Nemeth E. Regulation of the iron homeostatic hormone Hepcidin. Adv
Nutr. 2017;8(Jan):126-136. doi: 10.3945/an.116.013961
18. Pagani A, Nai A, Silvestri L, Camaschella C. Hepcidin and Anemia: a tight relation-
ship. Front Physiol. 2019;10(Oct):1294. doi.org/10.3389/fphys.2019.01294
19. Mobarra N, Shanaki M, Ehteram H, et al. A review on iron chelators in treatment of
iron overload syndromes. Int J Hematol Stem Cell Res. 2016;10(Oct):239-247.
20. Brittenham GM, Griffith P M, Nienhuis A W, et al. Efficacy of deferoxamine in
preventing complications of iron overload in patients with thalassemia major.
N Engl J Med. 1994;331(Sep):567-573. doi: 10.1056/NEJM199409013310902.
21. Xiao W, Beibei F, Guangsi S, et al. Iron overload increases osteoclastogenesis and aggra-
vates the effects of ovariectomy on bone mass. J Endocrinol. 2015;226(Sep):121-134. doi:
10.1530/JOE-14-0657
22. Nisbet-Brown E, Olivieri N F, Giardina P J, et al. Effectiveness and safety of
ICL670 in iron-loaded patients with thalassaemia: a randomised, double-blind,
placebo-controlled, dose-escalation trial. Lancet (London, England).
2003;361(May):1597-1602. doi: 10.1016/S0140-6736(03)13309-0
23. Nick H, Acklin P, Lattmann R, et al. Development of tridentate iron chelators: from
desferrithiocin to ICL670. Curr Med Chem. 2003;10(May):1065-1076. doi: 10.
1016/S0140-6736(03)13309-0.
24. Taher AT, Porter J, Viprakasit V, et al. Deferasirox reduces iron overload signifi-
cantly in nontransfusion-dependent thalassemia: 1-year results from a prospective,
randomized, double-blind, placebo-controlled study. Blood. 2012;120(Aug):970-
977. doi: 10.1182/blood-2012-02-412692.
25. Keberle H. The biochemistry of desferrioxamine and its relation to iron metabolism.
Ann N Y Acad Sci. 1964;119(Oct):758-768. doi: 10.1111/j.1749-6632.1965.tb54077.x.
26. Pippard MJ, Callender ST, Weatherall DJ. Intensive iron chelation therapy with
desferrioxamine in iron loading anaemias. Clin Sci Mol Med. 1978;54(Jan):99-106.
doi: 10.1042/cs0540099.
27. Kontoghiorghes GJ, Aldouri M A, Hoffbrand A V, et al. Effective chelation of iron
in beta thalassaemia with the oral chelator 1,2-dimethyl-3-hydroxypyrid-4-one. Br
Med J (Clin Res Ed). 1987;295(Dec):1509-1512. doi: 10.1136/bmj.295.6612.1509
28. Taher AT, Saliba AN. Iron overload in thalassemia: different organs at different rates.
Hematology. 2017;2017(Dec):265-271. doi: 10.1182/asheducation-2017.1.265
29. Kellenberger CJ, et al. Radiographic and MRI features of deferiprone-related arthropathy
of the knees in patients with β-thalassemia. Am J Roentgenol. 2004;183(OCT):989-994.
30. Liberal Â, Pinela J, Vívar-Quintana AM, Ferreira ICFR, Barros L. Fighting iron-
deficiency anemia: innovations in food fortificants and biofortification strategies.
Foods. 2020;9(Dec):1-19. doi: 10.3390/foods9121871
31. Muckenthaler MU, Galy B, Hentze MW. Systemic iron homeostasis and the iron-
responsive element/iron-regulatory protein (IRE/IRP) regulatory network. Annu
Rev Nutr. 2008;28(Aug):197-213. doi: 10.1146/annurev.nutr.28.061807.155521
32. Chifman J, Laubenbacher R, Torti SV. A systems biology approach to iron metab-
olism. Adv Exp Med Biol. 2014;844:201-225.
33. Gulec S, Anderson GJ, Collins JF. Mechanistic and regulatory aspects of intestinal
iron absorption. Am J Physiol. Gastrointest. Liver Physiol. 2014;307(Aug):G397-
G409. doi: 10.1152/ajpgi.00348.2013.
34. Ginzburg Y, Rivella S. β-thalassemia: a model for elucidating the dynamic regulation
of ineffective erythropoiesis and iron metabolism. Blood. 2011;118(Oct):4321-4330.
doi: 10.1182/blood-2011-03-283614
35. Lymboussaki A, et al. The role of the iron responsive element in the control of fer-
roportin1/IREG1/MTP1 gene expression. J Hepatol. 2003;39(Nov):710-715. doi:
10.1016/s0168-8278(03)00408-2.
36. Hershko C. Pathogenesis and management of iron toxicity in thalassemia. Ann N Y
Acad Sci. 2010;1202(Aug):1-9. doi: 10.1111/j.1749-6632.2010.05544.x.
37. Henninger B, et al. Evaluation of MR imaging with T1 and T2* mapping for the
determination of hepatic iron overload. Eur Radiol. 2012;22(Nov):2478-2486. doi:
10.1007/s00330-012-2506-2
38. Wood JC. Magnetic resonance imaging measurement of iron overload. Curr Opin
Hematol. 2007;14(May):183-190. doi: 10.1097/MOH.0b013e3280d2b76b
39. Alvi N, et al. Burden of cardiac siderosis in a thalassemia-Major endemic population:
a preliminary report from Pakistan. J Pediatr Hematol Oncol. 2016;38(Jul):378-383.
doi: 10.1097/MPH.0000000000000574
40. Musallam KM, Cappellini MD, Taher AT. Iron overload in beta-thalassemia inter-
media: an emerging concern. Curr Opin Hematol. 2013;20(May):187-192. doi: 10.
1097/MOH.0b013e32835f5a5c.
41. Lucijanic M, et al. Hemochromatosis gene mutations may affect the survival of
patients with myelodysplastic syndrome. Hematology. 2016;21(Apr):170-174. doi:
10.1080/10245332.2015.1101964
42. Pigeon C, et al. A new mouse liver-specific gene, encoding a protein homologous to
human antimicrobial peptide hepcidin, is overexpressed during iron overload. J Biol
Chem. 2001;276(Mar):7811-7819. doi: 10.1074/jbc.M008923200
43. Verga Falzacappa MV, et al. STAT3 Mediates hepatic hepcidin expression and its
inflammatory stimulation. Blood. 2007;109(Jan):353-358. doi: 10.1182/blood-2006-
07-033969
44. Yu H, Lee H, Herrmann A, Buettner R, Jove R. Revisiting STAT3 signalling in
cancer: new and unexpected biological functions. Nat Rev Cancer.
2014;14(Nov):736-746. doi: 10.1038/nrc3818.
45. Yang Q, Jian J, Katz S, Abramson SB, Huang X. 17beta-Estradiol Inhibits iron
hormone hepcidin through an estrogen responsive element half-site. Endocrinology.
2012;153(Jul):3170-3178. doi: 10.1210/en.2011-2045
46. Li X, et al. Progesterone receptor membrane component-1 regulates hepcidin bio-
synthesis. J Clin Invest. 2016;126(Jan):389-401. doi: 10.1172/JCI83831
47. Andriopoulos BJ, et al. BMP6 Is a key endogenous regulator of hepcidin expression
and iron metabolism. Nat Genet. 2009;41(Apr):482-487. doi: 10.1038/ng.335
48. Wang R-H, et al. A role of SMAD4 in iron metabolism through the positive regu-
lation of hepcidin expression. Cell Metab. 2005;2(Dec):399-409. doi: 10.1016/j.
cmet.2005.10.010
49. Core AB, Canali S, Babitt JL. Hemojuvelin and bone morphogenetic protein
(BMP) signaling in iron homeostasis. Front Pharmacol. 2014;5(MAY):1-9.
50. Sudmantait V, Celutkien J, Glaveckaite S, Katkus R. Difficult diagnosis of cardiac
haemochromatosis: a case report.. Eur Heart J Case Rep. 2020;4(Jan):1–6. doi: 10.
1093/ehjcr/ytaa012
51. Frazer DM, Anderson GJ. The regulation of iron transport. Biofactors. 2014;40(Mar-
Apr):206-214. doi: 10.1002/biof.1148.
52. Cabantchik ZI. Labile iron in cells and body fluids: physiology, pathology, and pharma-
cology. Front Pharmacol. 2014;5(MAR):1-11. doi: 10.3389/fphar.2014.00045
53. Patel M, Ramavataram DVSS. Non transferrin bound iron: nature, manifestations and
analytical approaches for estimation. Indian J Clin Biochem. 2012;27(Oct):322-332. doi:
10.1007/s12291-012-0250-7
54. Brissot P, Ropert M, Le Lan C, Loréal O. Non-transferrin bound iron: a key role in
iron overload and iron toxicity. Biochim Biophys Acta. 2012;1820(Mar):403-410.
55. Candore G, et al. Association between HFE mutations and acute myocardial infarc-
tion: a study in patients from northern and southern Italy. Blood Cells Mol Dis.
2003;31(Jul-Aug):57-62. doi: 10.1016/s1079-9796(03)00065-2.
56. Shizukuda Y, Rosing DR. Iron overload and arrhythmias: influence of confounding
factors. J Arrhythmia. 2019;35(Aug):575-583. doi: 10.1002/joa3.12208
57. Mercadante CJ, et al. Gastrointestinal iron excretion and reversal of iron excess in a
mouse model of inherited iron excess. Haematologica. 2019;104(Apr):678-689. doi:
10.3324/haematol.2018.198382
58. Hultcrantz R, Angelin B, Björn-Rasmussen E, Ewerth S, Einarsson K. Biliary excretion
of iron and ferritin in idiopathic hemochromatosis. Gastroenterology. 1989;96(Jun):1539-
1545. doi: 10.1016/0016-5085(89)90524-6.
59. Wahidiyat PA, et al. Urinary iron excretion for evaluating iron chelation efficacy in
children with thalassemia major. Blood Cells Mol Dis. 2019;77(Jul):67-71. doi: 10.
1016/j.bcmd.2019.03.007.
60. Preza GC, et al. Minihepcidins are rationally designed small peptides that mimic
hepcidin activity in mice and may be useful for the treatment of iron overload.
J Clin Invest. 2011;121(Dec):4880-4888. doi: 10.1172/JCI57693.
61. Calzolari A, et al. Transferrin receptor 2 is frequently and highly expressed in glio-
blastomas. Transl Oncol. 2010;3(Apr):123-134. doi: 10.1593/tlo.09274
62. Libani IV, et al. Decreased differentiation of erythroid cells exacerbates ineffective erythropoi-
esis in β-thalassemia. Blood. 2008;112(Aug):875-885. doi: 10.1182/blood-2007-12-126938
63. Dussiot M, et al. An activin receptor IIA ligand trap corrects ineffective erythropoi-
esis in β-thalassemia. Nat Med. 2014;20(Apr):398-407. doi: 10.1038/nm.3468
64. Piga A, et al. ACE-536 Increases hemoglobin and decreases transfusion burden and
Serum ferritin in adults with Beta-thalassemia: preliminary results from a phase 2
study. Blood. 2014;124(Dec):53. https://doi.org/10.1182/blood.V124.21.53.53
65. Motta I, Scaramellini N, Cappellini MD. Expert opinion on investigational drugs
investigational drugs in phase I and phase II clinical trials for thalassemia. Expert
Opin Investig Drugs. 2017(26;7). DOI: 10.1080/13543784.2017.1335709
66. Wang C-Y, Meynard D, Lin HY. The role of TMPRSS6/matriptase-2 in iron regu-
lation and anemia. Front Pharmacol. 2014;5:114.
67. Silvestri L, et al. The serine protease matriptase-2 (TMPRSS6) inhibits hepcidin
activation by cleaving membrane hemojuvelin. Cell Metab. 2008;8(Dec):502-511.
doi: 10.1016/j.cmet.2008.09.012.
Yadav and Singh
68. Bauer DE, et al. A erythroid enhancer of BCL11A subject t genetic variation.
Science. 2014;342(Oct 11):253-257. doi: 10.1126/science.1242088
69. Viatte L, et al. Chronic hepcidin induction causes hyposideremia and alters the pattern
of cellular iron accumulation in hemochromatotic mice. Blood. 2006;107(Apr):2952-
2958. doi: 10.1182/blood-2005-10-4071
70. Ramos E, et al. Minihepcidins prevent iron overload in a hepcidin-deficient mouse
model of severe hemochromatosis. Blood. 2012;120(Nov):3829-3836. doi: 10.1182/
blood-2012-07-440743.
71. Xiao JJ, et al. Pharmacokinetics of anti-hepcidin monoclonal antibody Ab 12B9 m
and hepcidin in cynomolgus monkeys. AAPS J. 2010;12(Dec):646-657. doi: 10.
1208/s12248-010-9222-0
9
72. Payen E, Leboulch P. Advances in stem cell transplantation and gene therapy in the beta-
hemoglobinopathies. Hematol Am Soc Hematol Educ Progr. 2012;2012(Dec):276-283. doi:
10.1182/asheducation-2012.1.276.
73. Ezquer F, Nunez MT, Rojas A, Asenjo J, Israel Y. Hereditary hemochromatosis: an
opportunity for gene therapy. Biol Res. 2006;39(Jun):113-124. doi: 10.4067/s0716-
97602006000100014.
74. Riaz H, et al. Serum ferritin levels, socio-demographic factors and desferrioxamine therapy
in multi-transfused thalassemia major patients at a government tertiary care hospital of
Karachi, Pakistan. BMC Res Notes. 2011;4(Aug):287. doi: 10.1186/1756-0500-4-287
75. Knovich MA, Storey JA, Coffman LG, Torti SV, Torti FM. Ferritin for the clin-
ician. Blood Rev. 2009;23(May):95-104. doi: 10.1016/j.blre.2008.08.001