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Haematology > 4) The Haemoglobin Molecule and Thalassemia > Flashcards

4) The Haemoglobin Molecule and Thalassemia Flashcards

1
Q

What are the different types of globin proteins?

A

Alpha, Beta, Gamma, Delta (and embryonic)

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2
Q

State the three different haemoglobins that are present in the human body.

A

HbA – alpha + beta = 95%
HbA2 – alpha + delta = 1-3.5%
HbF – alpha + gamma = trace

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3
Q

Describe how affinity of haemoglobin changes with oxygen binding and how this helps its role of oxygen transport.

A

The more oxygen binds, the greater the affinity of the haemoglobin for oxygen.
This is good because if deoxyhaemoglobin has a low affinity for oxygen(as no oxygen is already bound), it will only pick up oxygen if the oxygen saturation is very high (i.e. in the lungs) so it will not take up oxygen in the metabolically active tissues where the oxygen saturation is low and where the tissues need oxygen.
Similarly, oxyhaemoglobin has a high affinity for oxygen so it will only give up oxygen in environments where the oxygen saturation is very low (i.e. respiring tissues that need oxygen)

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4
Q

What effect does 2,3-DPG have on oxygen delivery?

A

It facilitates oxygen delivery by making the haemoglobin molecule less flexible and pushing out the oxygen.

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5
Q

State 4 factors that can shift the oxygen dissociation curve to the right.

A

Increase in 2,3-DPG
Increase in [H+]
CO2
HbS

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6
Q

What effect do HbS and HbF have on the oxygen dissociation curve?

A

HbS has a lower affinity for oxygen than HbA so it shifts the ODC to the right
HbF has a higher affinity for oxygen than HbA so it shifts the ODC to the left

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7
Q

What is special about alpha globin genes?

A

There are TWO alpha globin genes from each parent so there are FOUR alpha globin genes in total.

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8
Q

Which globin chains are present in early embryonic life but are switched off after about 3 months gestation?

A

Zeta and epsilon

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9
Q

Which globins are present in foetal haemoglobin?

A

Alpha

Gamma

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10
Q

When are the genes coding for the globin in foetal haemoglobin switched off?

A

It is decreased towards birth and in the first year after birth.
After 1 year of life, the normal adult pattern of haemoglobin synthesis would have been established.

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11
Q

Which globin chains are present in HbA2?

A

Alpha

Delta

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12
Q

On which chromosomes are the two globin gene clusters and which genes are present in each cluster?

A 
Chromosome 16 – ALPHA cluster 
 TWO alpha genes  
 Zeta gene  
Chromosome 11 – BETA cluster 
 Beta gene  
 Gamma gene 
 Delta gene  
 Epsilon gene
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13
Q

What is thalassemia?

A

Disorders in which there is a reduced production of one of the two types of globin chains in haemoglobin leading to imbalanced globin chain synthesis

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14
Q

What are the two clinical variations of thalassemia?

A

Thalassemia trait = common variant with little clinical significance
Transfusion dependent – Thalassemia Major = fatal without transfusion

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15
Q

What is the outcome of alpha thalassemia major?

A

Fatal in utero because alpha globin is needed to make HbF (alpha + gamma)

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16
Q

What is the outcome of beta thalassemia major?

A

Diagnosed and treated in early infancy with regular transfusions

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17
Q

What is the name given to the loss of function of three alpha globin genes?

A

Haemoglobin H

Need life-long transfusions

18
Q

What is the name given to the loss of function of four alpha globin genes?

A

Haemoglobin barts

Fatal in utero because alpha globin is needed to make HbF

19
Q

What is beta thalassemia major? Describe how the disease progresses.

A

Severe defect in both beta globin chains
The foetus will have no problem in utero because they have normal functioning HbF (which doesn’t need beta globin)
At around 2-3 month after birth, you get a transition from HbF to HbA
At this time the baby will become profoundly anaemic.
They will need life-long transfusions from this point onwards.

20
Q

State some features of thalassemia trait.

A

This the carrier state of thalassemia.
They may be mildly anaemic but they can also be normal.
Usually have a LOW MCH and LOW MCV

21
Q

What can be used to distinguish between alpha thalassemia trait and beta thalassemia trait?

A

Haemoglobin electrophoresis can be used to measure the relative proportions of HbA2
Beta Thalassemia = raised HbA2 (> 3.5%)
Alpha Thalassemia = normal/low HbA2

22
Q

What types of mutation cause alpha thalassemia and beta thalassemia?

A

Alpha thalassemia – deletion

Beta thalassemia – point mutation

23
Q

What is alpha + thalassemia?

A

The situation in which one of the two globin genes on a chromosome are deleted (this can happen on one or both chromosomes)
Someone who is heterozygous for alpha+ thalassemia will still have 3 functioning alpha globin genes so they will only be mildly anaemic

24
Q

What is alpha 0 thalassemia?

A

The situation in which both of the two globin genes on a chromosome are deleted (this can happen in one or both chromosomes)
In the heterozygous state there are still 2 functioning alpha globin genes so they will also only experience mild anaemia

25
Q

How can you distinguish between alpha + and alpha 0 thalassemia?

A

Most people with alpha 0 thalassemia have a MCH < 25 pg

26
Q

What could be the potentially devastating consequences for someone with mild anaemia caused by alpha 0 thalassemia?

A

Someone with alpha 0 thalassemia may not experience any symptoms themselves, but if they try and have a child with someone who also has alpha 0 thalassemia then there is a chance that their child may not have any functioning alpha genes (haemoglobin barts).

27
Q

Which ethnic groups have a high prevalence of thalassemia?

A 
Chinese 
South-east Asian 
Greek 
Turkish 
Cypriot
28
Q

What is beta + thalassemia?

A

There is a reduction in beta globin output but there is still some residual beta globin gene expression

29
Q

What is beta 0 thalassemia?

A

There is NO output of beta globin

30
Q

What is the main cause of the pathophysiology of beta thalassemia?

A

The surplus of alpha globin chains form tetramers.
These alpha globin tetramers precipitate in the bone marrow, which leads to ineffective erythropoiesis and haemolysis in the peripheralcirculation.

31
Q

What are the features of beta thalassemia trait?

A

Haemoglobin may be normal LOW MCV
LOW MCH
HIGH RBC
HbA2 INCREASED

32
Q

What are the symptoms of beta thalassemia major that are present in the first year of life?

A

Profound anaemia
Failure to thrive
Malaise
Splenomegaly

33
Q

Describe the pathogenesis of beta thalassemia.

A

There is death of red cells in the marrow because of ineffective erythropoiesis
The removal of red cells by the spleen causes:
 Large spleen
 Anaemia
 Increased EPO
 Expansion of bone marrow

34
Q

What are the consequences of regular blood transfusions used to treat beta thalassemia major?

A

Iron Overload
 Iron can accumulate in the liver (cirrhosis), heart (cardiac failure), endocrine organs (hypopituitarism, hypothyroidism, hypogonadism, diabetes) etc.
Potential viral transmission - screen blood - for yersinia and other gram negative bacteria. prophylaxis in splenectomised patients e.g. antibiotics and immunisation

35
Q

Name three drugs that can be used to treat iron overload. List anynegative aspects of these drugs.

A 
Desferrioxamine (DFO) 
-  Not orally active – must be given via subcutaneous infusion 
-  Expensive 
Deferiprone 
-  Oral
-  Urinary excretion  
-  Risk of agranulocytosis (can lead to life-threatening sepsis) 
-  Patients need to be monitored closely for neutropenia 
-  Good for reducing myocardial iron 
Deferasirox 
-  Oral
-  Faecal excretion
36
Q

What are the key indicators of iron overload?

A

Serum ferritin

Liver iron/ liver biopsy

37
Q

What are the good aspects of stem cell transplantation?

A 
No transfusions  
No chelation 
Growth is normal  
Curative treatment
Good result in paid unless poor chelation/ large liver' evidence of fibrosis in biopsy
38
Q

What are the bad aspects of stem cell transplantation?

A

Transplant associated mortality is high over the age of 17 (30%)
Relatively few transplants done in adults
Infertility due to stem cell transplant
If the patient is iron overloaded at the time of transplantation there is a massively increased risk

39
Q

MCH and MCV in Alpha + and Alpha 0

A

Alpha+ MCV 77 MCH26

Alpha0 MCV 66 MCH24

40
Q

normal RBC concentration

A

3.5 - 5 x10^12

Haematology (12 decks)

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