Alpha-thalassemia

Alpha-thalassemia (α-thalassemia, α-thalassaemia) is an inherited blood disorder and a form of thalassemia. Thalassemias are a group of inherited blood conditions which result in the impaired production of hemoglobin, the molecule that carries oxygen in the blood. Symptoms depend on the extent to which hemoglobin is deficient, and include anemia, pallor, tiredness, enlargement of the spleen, iron overload, abnormal bone structure, jaundice, and gallstones. In severe cases death ensues, often in infancy, or death of the unborn fetus.

The disease is characterised by reduced production of the alpha-globin component of hemoglobin, caused by inherited mutations affecting the genes HBA1 and HBA2. This causes reduced levels of hemoglobin leading to anemia, while the accumulation of surplus beta-globin, the other structural component of hemoglobin, damages red blood cells and shortens their life. Diagnosis is by checking the medical history of near relatives, microscopic examination of blood smear, ferritin test, hemoglobin electrophoresis, and DNA sequencing.

As an inherited condition, alpha thalassemia cannot be prevented although genetic counselling of parents prior to conception can propose the use of donor sperm or eggs. The principle form of management is blood transfusion every 3 to 4 weeks, which relieves the anemia but leads to iron overload and possible immune reaction. Medication includes folate supplementation, iron chelation, bisphosphonates, and removal of the spleen. Alpha thalassemia can also be treated by bone marrow transplant from a well matched donor. Thalassemias were first identified in severely sick children in 1925, with identification of alpha and beta subtypes in 1965. Alpha thalassemia has its greatest prevalence in populations originating from Southeast Asia, Mediterranean countries, Africa, the Middle East, India, and Central Asia. Having a mild form of alpha thalassemia has been demonstrated to protect against malaria and thus can be an advantage in malaria endemic areas.

Alpha-thalassemia is almost always inherited. It is a recessive trait - a single defective gene is insufficient to cause illness. Due to the involvement of four alpha globin genes, the inheritance pattern is complex, with varying severity depending on the number of gene mutations inherited from each parent.

Normal individuals carry 4 alpha-globin genes, comprising autosomal pairs of the HBA1 and HBA2 genes. There are approximately 130 known mutations which can cause alpha thalassemia, mainly comprising deletion of part or all of a gene which then fails to produce alpha globin. If either one gene or two out of the four is faulty, the remaining genes produce sufficient alpha globin for normal life. If three genes are faulty, the sole functioning gene produces relatively small quantities of alpha globin, causing anemia and HbH disease. Four faulty genes (and therefore zero alpha globin) is incompatible with life.

In rare cases alpha thalassemia can be acquired as a consequence of myelodysplastic cancer.

Hemoglobin is a protein containing iron that facilitates the transportation of oxygen in red blood cells. Hemoglobin in the blood carries oxygen from the lungs to the other tissues of the body, where it releases the oxygen to enable metabolism. A healthy level of hemoglobin for men is between 13.2 and 16.6 grams per deciliter, and in women between 11.6 and 15 g/dl.

Normal adult hemoglobin (HbA) is composed of four protein chains, two α and two β-globin chains arranged into a heterotetramer. In thalassemia, patients have defects in the noncoding region of either the α or β-globin genes, causing ineffective production of normal alpha- or beta-globin chains, which can lead to ineffective erythropoiesis, premature red blood cell destruction, and anemia. The thalassemias are classified according to which chain of the hemoglobin molecule is affected. In α-thalassemias, production of the α-globin chain is affected, while in β-thalassemia, production of the β-globin chain is affected.