MED ICA L PR OGR ES S
Review Article
Medical Progress
T HE b-T HALASSEMIAS
NANCY F. OLIVIERI, M.D.
I
N 1925, Thomas Cooley and Pearl Lee described
a form of severe anemia, occurring in children
of Italian origin and associated with splenomeg-
aly and characteristic bone changes.1 Over the next
decade, a milder form was described independently by
several Italian investigators.2-4 Because all early cases
were reported in children of Mediterranean origin,
the disease was later termed thalassemia, from the
Greek word for sea, thalassa.5 Over the next 20 years,
it became apparent that Cooley and Lee had de-
scribed the homozygous or compound heterozygous
state for a recessive mendelian disorder not confined
to the Mediterranean, but occurring widely through-
out tropical countries. In the past 20 years, the two
important forms of this disorder, a- and b-thalas-
semia, resulting from the defective synthesis of the
a- and b-globin chains of hemoglobin, respectively,
have become recognized as the most common mon-
ogenic diseases in humans.6
This article focuses on the b-thalassemias, the se-
vere forms of which are by far the most important
of all the thalassemias. The molecular and clinical as-
pects of the severe a-thalassemia syndromes have
been reviewed elsewhere.7,8
DISTRIBUTION AND POPULATION
AT RISK
The b-thalassemias are widespread throughout the
Mediterranean region, Africa, the Middle East, the
Indian subcontinent and Burma, Southeast Asia in-
cluding southern China, the Malay Peninsula, and
Indonesia. Estimates of gene frequencies range from
3 to 10 percent in some areas.9 Within each popula-
tion at risk for b-thalassemia a small number of
common mutations are found, as well as rarer ones;
each mutation is in strong linkage disequilibrium
with specific arrangements of restriction-fragment
From the University of Toronto, Toronto. Address reprint requests to
Dr. Olivieri at the Hospital for Sick Children, 555 University Ave., Toronto,
ON M5G 1X8, Canada, or at noliv@sickkids.on.ca.
1999, Massachusetts Medical Society.
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length polymorphisms, or haplotypes, within the
b-globin cluster. A limited number of haplotypes are
found in each population, so that 80 percent of the
mutations are associated with only 20 different hap-
lotypes. This observation has helped demonstrate the
independent origin of b-thalassemia in several pop-
ulations.10 There is evidence that the high frequency
of b-thalassemia throughout the tropics reflects an
advantage of heterozygotes against Plasmodium fal-
ciparum malaria,11 as has already been demonstrated
in a-thalassemia.12
MOLECULAR PATHOLOGY
Structure and Synthesis of Hemoglobin
The structure and regulation of the human globin
genes have been reviewed elsewhere13; only aspects
with direct relevance to an understanding of the
molecular pathology of the b-thalassemias are out-
lined here.
The b-like globin genes, a linked cluster on chro-
mosome 11, are arranged over approximately 60,000
nucleotide bases (Fig. 1). Promoter elements up-
stream from the initiation codon of each active gene
are involved in the initiation of transcription. The
cluster also contains other regulatory elements that in-
teract to promote erythroid-specific gene expression
and to coordinate the developmental regulation of
each gene.
Hemoglobin Switching
As an adaptation to changing oxygen requirements,
different hemoglobins, all composed of two differ-
ent pairs of globin chains each attached to a heme
moiety, are synthesized in the embryo, fetus, and
adult.14 Severe b-thalassemia usually becomes manifest
as a result of the decline in the synthesis of fetal
hemoglobin (a2g 2) during the first year of life (Fig.
1). The precise mechanisms that control the switch
from the production of fetal hemoglobin to that of
adult hemoglobin (a2 b 2) (Fig. 1) are not fully un-
derstood.13-16
Mutations Causing b-Thalassemia
Nearly 200 different mutations have been described
in patients with b-thalassemia and related disorders.
Although most are small nucleotide substitutions
within the cluster, deletions may also cause b-thalas-
semia.9 All the mutations result in either the absence
of the synthesis of b-globin chains (b0-thalassemia)
or a reduction in synthesis (b+-thalassemia) (Fig. 2).
Mutations in or close to the conserved promoter
sequences and in the 5' untranslated region down-
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 The New Eng land Jour nal of Medicine

Chromosome 11

e G g A g cb d b
Locus-control
region
A

50 a
Globin-Chain Synthesis

b
g
(% of total)

30

e
10 z
d

6 18 30 0 6 18 30 42
Before Birth (wk) Birth After Birth (wk)
B

Figure 1. The b -Globin Gene Cluster on the Short Arm of Chromosome 11.
In Panel A, the b -globinlike genes are arranged in the order in which they are expressed during development. The Gg and Ag genes
are both active genes that produce g -globin chains that differ only at position 136 (glycine is the product of the Gg gene, and alanine
is the product of the Ag gene). The cb gene is a pseudogene, an evolutionary remnant of a previously active b -globinlike gene.
Areas of nucleotide homology upstream from the initiation codon of each active gene, termed promoter elements, are involved in
the initiation of transcription and hence play a vital part in gene regulation. The cluster also contains regulatory elements that in-
teract to promote erythroid-specific gene expression and to coordinate the developmental regulation of each gene, including he-
moglobin switching. These include enhancers, distant regulatory elements that increase gene expression, and a master sequence,
the clusters essential distal regulatory element, the b -globin locus-control region. This is a region that lies 20 kb upstream from
the e-globin gene.13 It encompasses five erythroid-lineagespecific nuclease hypersensitive sites (shown in red) that permit expres-
sion of the downstream genes. In addition to these elements for up-regulation, several suppressor regions, or silencers, have been
defined in the b -globin gene cluster.
Panel B shows the timing of the normal developmental switching of human hemoglobin. Early in fetal life the synthesis of the
embryonic a-globinlike (z) chains switches to that of a-globin, which is produced thereafter. At the same time, the synthesis of
embryonic beta-like (e) chains switches to that of g -globin chains. The a-globin and g -globin chains combine to form fetal hemo-
globin (a2g2), the main b -globinlike globin during the remainder of fetal life and throughout early postnatal life. As a result of the
decline in the synthesis of g -globin chains in patients with b -thalassemia, fetal hemoglobin production becomes insufficient to
compensate for the excess of a-globin chains, the production of which is unaffected in b -thalassemia.

regulate transcription, usually resulting in mild script result in b-thalassemia. In some mutations, no
b+-thalassemia. Transcription is also affected by dele- normal message is produced, whereas other muta-
tions in the 5' region, which completely inactivate tions only slightly reduce the amount of normally
transcription and result in b0-thalassemia. spliced mRNA. Mutations within invariant dinucle-
Both splicing of the messenger RNA (mRNA) pre- otides at intronexon junctions, critical to the remov-
cursor and ineffective cleavage of the mRNA tran- al of intervening sequences and the splicing of exons

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 MED ICA L PR OGR ES S

Deletions

Intron
Intron
5' 3'
Exon 1 Intron Exon 2 Exon 3 Intron

Other Mutations
Mutation affecting initiation of
transcription
Mutation affecting splicing of
RNA from introns
Polyadenylation-signal mutation
Mutation affecting initiation of
translation
Nonsense mutation
Frame-shift mutation

Figure 2. The Normal Structure of the b-Globin Gene and the Locations and Types of Mutations Resulting in b-Thalassemia.
All b-globinlike genes contain three exons and two introns between codons 30 and 31 and 104 and 105, respectively. The primary
action of all the mutations is to abolish the output of b-globin chains (b0-thalassemia; shown in red) or reduce the output (b+-thal-
assemia; shown in green). The 170 different mutations that act in this way may interfere with the action of the b-globin gene at the
transcriptional level, in the processing of the primary transcript, in the translation of b-globin messenger RNA, or in the post-trans-
lational stability of the b-globin gene product.

to produce functional mRNA, result in b0-thalasse-
mia. Mutations in highly conserved nucleotides flank-
ing these sequences, or in cryptic splice sites, which
resemble a donor or acceptor splice site, result in
severe as well as mild b+-thalassemia. Substitutions
or small deletions affecting the conserved AATAAA
sequence in the 3' untranslated region result in inef-
fective cleavage of the mRNA transcript and cause
mild b+-thalassemia.
Mutations that interfere with translation involve the
initiation, elongation, or termination of globin-chain
production and result in b0-thalassemia. Approxi-
mately half of all b-thalassemia mutations interfere
with translation; these include frame-shift or nonsense
mutations, which introduce premature termination
codons and result in b0-thalassemia. A more recent-
ly identified family of mutations, usually involving
exon 3, results in the production of unstable globin
chains of varying lengths that, together with a relative
excess of a-globin chains, precipitate in red-cell pre-
cursors and lead to ineffective erythropoiesis, even in
the heterozygous state. This is the molecular basis for
dominantly inherited (b+) thalassemia. In addition,
missense mutations, resulting in the synthesis of un-
stable b-globin chains, cause b-thalassemia.
PATHOPHYSIOLOGY
Mechanisms of Anemia
In severe untreated b-thalassemia, erythropoiesis
may be increased by a factor of up to 10, more than
95 percent of which may be ineffective. Ineffective
erythropoiesis, the hallmark of b-thalassemia, is a re-
sult of the myriad deleterious effects of a relative
excess of a-globin chains.17 This relative excess in-
terferes with most stages of normal erythroid matu-
ration: both intramedullary death of red-cell precur-
sors through arrest in the G1 phase of the cell cycle18
and accelerated intramedullary apoptosis of late eryth-
roblasts19,20 have been demonstrated. Studies of the
consequences of the accumulation of excess a-globin
chains and their degradation products within the red-
cell membrane and its skeleton 20-22 have also demon-
strated abnormalities in the ratio of spectrin to band
3 and in the function of band 4.1. This subject has
been thoroughly reviewed recently.20 The observa-

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 The New Eng land Jour nal of Medicine

Excess free Formation of heme

a-globin chains and hemichromes
Denaturation
Degradation

Iron-mediated toxicity

Membrane
Hemolysis Ineffective
binding of
erythropoiesis
IgG and C3 Removal of
damaged red cells

Increased
erythropoietin Reduced tissue Anemia Splenomegaly
synthesis
oxygenation

Skeletal Erythroid
deformities, Increased Iron
marrow overload
osteopenia iron absorption
expansion

Figure 3. Effects of Excess Production of Free a-Globin Chains.

Primary disease processes are indicated in orange, and compensatory mechanisms in yellow. Excess unbound a-globin chains and
their degradation products precipitate in red-cell precursors, causing defective maturation and ineffective erythropoiesis. Hemolysis,
owing to the presence of inclusions in the red cells and damage to their membranes by a-globin chains and their degradation prod-
ucts, also contributes to the anemia. Anemia stimulates the synthesis of erythropoietin, leading to an intense proliferation of the
ineffective marrow, which in turn causes skeletal deformities and a variety of growth and metabolic abnormalities. The anemia is
further exacerbated by hemodilution, caused by the shunting of blood through the expanded marrow, and by splenomegaly result-
ing from entrapment of abnormal red cells in the spleen. Bone marrow expansion also results in characteristic deformities of the
skull and face, severe osteopenia, and increased iron absorption.

tion that the presence of excess membrane iron may
aggravate membrane changes 22 has led to interest in
the red-cell membrane as a potential therapeutic tar-
get in b-thalassemia. In a mouse model, increased cel-
lular rigidity and decreased stability in connection
with membrane-associated a-globin chains 23 have re-
portedly been ameliorated during exposure to agents
that bind membrane iron.24 Further understanding
of these processes may guide future therapies.
Clinical Consequences of Anemia
The severe ineffective erythropoiesis results in eryth-
roid marrow expansion to as much as 30 times the
normal level. Both an increase in plasma volume as
a result of shunting through expanded marrow and
progressive splenomegaly exacerbate anemia (Fig. 3).
Increased erythropoietin synthesis may stimulate the
formation of extramedullary erythropoietic tissue, pri-
marily in the thorax and paraspinal region. Marrow
expansion also results in characteristic deformities of
the skull and face, as well as osteopenia and focal de-
fects in bone mineralization,25,26 and may aggravate a
painful periarticular syndrome characterized histo-
logically by microfractures and osteomalacia.27 Marrow
hyperplasia leads ultimately to increased iron absorp-
tion and progressive deposition of iron in tissues.
Cellular Heterogeneity and Fetal Hemoglobin Production
Although fetal hemoglobin synthesis persists after
birth to some degree, its production is insufficient

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 MED IC A L PR OGR ES S
to compensate for the reduced synthesis of b-globin
chains and the relative excess of a-globin chains.15
The elevated concentrations of fetal hemoglobin
2 to 4 g per deciliter observed in patients with
b-thalassemia reflect a combination of the selection
of precursors that produce relatively more fetal he-
moglobin and erythroid expansion, which appears to
favor the production of g-globin chains. Even higher
fetal hemoglobin concentrations are associated with
specific b-thalassemia alleles 28,29 or other genetic de-
terminants within or linked to the b-globin com-
plex.15 At least two other determinants may affect the
synthesis of fetal hemoglobin, one on chromosome
630 and the other on the X chromosome.31,32
Clinical Forms
The b-thalassemias include four clinical syndromes
of increasing severity: two conditions are generally
asymptomatic, the silent carrier state and b-thalas-
semia trait, and usually result from the inheritance of
one mutant b-globin gene, and two require medical
management, thalassemia intermedia and thalasse-
mia major. The more severe forms most often result
from homozygosity or compound heterozygosity for
a mutant b-globin allele and, occasionally, from het-
erozygosity for dominant mutations.33 Homozygous
or compound heterozygous b-thalassemia usually pre-
sents no diagnostic problems. The early onset of ane-
mia, characteristic blood changes, and elevated fetal
hemoglobin concentrations are found in no other
condition. The diagnosis can be confirmed by the
demonstration of the b-thalassemia trait in both par-
ents. This condition is characterized by mild anemia,
reduced mean cell volumes and mean cell hemoglobin
concentrations,29 and elevated concentrations of the
normal minor adult component of hemoglobin (usu-
ally exceeding 3.5 percent), hemoglobin A2 (a2d 2).
Thalassemia major and thalassemia intermedia have
no specific molecular correlate but encompass a wide
spectrum of clinical and laboratory abnormalities.34
Patients referred to as having thalassemia major are
usually those who come to medical attention in the
first year of life and subsequently require regular
transfusions to survive. Those who present later or
who seldom need transfusions are said to have thalas-
semia intermedia.35 After thalassemia is diagnosed,
patients who appear not to require immediate trans-
fusion may benefit from a period of observation and
folate repletion, particularly if the disease is diagnosed
after the age of one year. This approach will allow the
identification of patients in whom early growth and
development are normal and whose well-compensat-
ed anemia may be exacerbated only by infection, folate
deficiency, or increasing hypersplenism.34-37 With ad-
vancing age, even patients with mild forms may have
serious complications, including osteopenia, iron load-
ing in tissues, and ectopic marrow expansion. The
classic changes of untreated thalassemia major are now
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regularly seen only in countries without resources to
support long-term transfusion programs.
Relation between Genotype and Phenotype
Several genetic factors may ameliorate the severity
of b-thalassemia.29 First, the underlying mutations
vary widely in their effect on the synthesis of b-globin
chains.38 Co-inheritance of a-thalassemia may reduce
the severity of the globin-chain imbalance. Many dif-
ferent interactions with structural hemoglobin vari-
ants may also result in a complex series of clinical
phenotypes.29 The interactions of b-thalassemia with
two of these variants, hemoglobin S and hemoglo-
bin E, are of global importance.
The clinical consequences of the interaction with
hemoglobin S depend mainly on the b-thalassemia
allele. If inherited with b0-thalassemia or severe
b+-thalassemia, the resulting clinical disorder may
be indistinguishable from sickle cell anemia. By con-
trast, interactions with mild b+-thalassemia alleles
produce a milder sickling disorder.
Although hemoglobin E b-thalassemia is probably
the most common serious hemoglobinopathy world-
wide,39 its natural history remains poorly under-
stood.29 The mutation that produces hemoglobin E
activates a cryptic splice site in exon 1 in the b-globin
gene; hence, hemoglobin E is associated with mild
b-thalassemia. For reasons that are not well under-
stood,29 the interaction of hemoglobin E and b-thal-
assemia results in a wide spectrum of clinical disorders:
some are indistinguishable from thalassemia major,
and some are much milder and not transfusion-
dependent. Finally, a number of acquired and envi-
ronmental factors, including progressive splenomeg-
aly, exposure to infections, socioeconomic factors,
and the availability of medical care, may also modify
the severity of the disease.
COMPLICATIONS OF DISEASE
Iron Overload
Iron overload of tissue, which is fatal with or with-
out transfusion if not prevented or adequately treated,
is the most important complication of b-thalassemia
and is a major focus of management.40 In patients
who are not receiving transfusions, abnormally reg-
ulated iron absorption results in increases in body
iron burden ranging from 2 to 5 g per year, depend-
ing on the severity of erythroid expansion.41,42 Reg-
ular transfusions may double this rate of iron accu-
mulation. Although most clinical manifestations of
iron loading do not appear until the second decade
of life in patients with inadequate chelation, evi-
dence from serial liver biopsies in very young pa-
tients indicates that the deleterious effects of iron are
initiated much earlier than this. After approximately
one year of transfusions, iron begins to be deposited
in parenchymal tissues,43 where it may cause sub-
stantial toxicity as compared with that within retic-
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 The New Eng land Jour nal of Medicine
uloendothelial cells.44,45 As iron loading progresses,
the capacity of serum transferrin, the main transport
protein of iron, to bind and detoxify iron may be ex-
ceeded and a nontransferrin-bound fraction of
plasma iron may promote the generation of free hy-
droxyl radicals, propagators of oxygen-related dam-
age.44,45 The advances in free-radical chemistry that
have clarified the toxic properties of these and other
oxygen-derived species generated by iron, which
may cause widespread tissue damage, have recently
been summarized.45 Although the body maintains a
number of antioxidant mechanisms against damage
induced by free radicals, including superoxide dis-
mutases, catalase, and glutathione peroxidase, in pa-
tients with large iron burdens these may not prevent
oxidative damage.44,45
In the absence of chelating therapy the accumula-
tion of iron results in progressive dysfunction of the
heart, liver, and endocrine glands.40 Within the heart,
changes associated with chronic anemia are usually
present in patients who are not receiving transfusions
and are aggravated by iron deposition. In response
to iron loading, human myocytes in vitro increase
the transport of nontransferrin-bound iron,46 pos-
sibly thereby aggravating cardiac iron loading. Exten-
sive iron deposits are associated with cardiac hyper-
trophy and dilatation, degeneration of myocardial
fibers, and in rare cases fibrosis.47 In patients who are
receiving transfusions but not chelating therapy,
symptomatic cardiac disease has been reported with-
in 10 years after the start of transfusions48 and may
be aggravated by myocarditis49 and pulmonary hy-
pertension.50,51 The survival of patients with b-thal-
assemia is determined by the magnitude of iron
loading within the heart.52,53
Iron-induced liver disease is a common cause of
death in older patients54 and is often aggravated by
infection with hepatitis C virus. Within two years af-
ter the start of transfusions, collagen formation55
and portal fibrosis56 have been reported; in the ab-
sence of chelating therapy, cirrhosis may develop in
the first decade of life.43,57,58 The extent of these
processes may be underestimated if fewer than three
cores of liver are sampled at biopsy.59 The risk of he-
patic fibrosis is augmented at body iron burdens cor-
responding to hepatic iron concentrations of more
than 7 mg per gram of liver, dry weight (Fig. 4).61
As in cultured heart cells, in cultured hepatocytes
the transport of nontransferrin-bound iron is in-
creased,62 possibly aggravating iron loading in vivo.
The striking increases in survival in patients with
b-thalassemia over the past decade have focused at-
tention on abnormal endocrine function, now the
most prevalent iron-induced complication in older
patients. Iron loading within the anterior pituitary is
the primary cause of disturbed sexual maturation, re-
ported in 50 percent of both boys and girls with the
condition.63 Furthermore, early secondary amenor-
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rhea occurs in approximately one quarter of female
patients over the age of 15 years.63 Even in the mod-
ern era of iron-chelating therapy, diabetes mellitus is
observed in about 5 percent of adults.63 As the iron
burden increases and iron-related liver dysfunction
progresses, hyperinsulinemia occurs as a result of re-
duced extraction of insulin by the liver, leading to ex-
haustion of beta cells and reduced circulating insulin
concentrations.64 Studies reporting reduced serum
concentrations of trypsin and lipase65 suggest that the
exocrine pancreas is also damaged by iron loading.
Over the long term, iron deposition also damages
the thyroid, parathyroid, and adrenal glands66,67 and
may provoke pulmonary hypertension, right ventric-
ular dilatation, and restrictive lung disease.51,68-70
In most studies, bone density is markedly reduced
in patients with b-thalassemia, particularly those with
hypogonadism. Osteopenia may be related to marrow
expansion, even in patients who receive transfusions,42
or to iron-induced osteoblast dysfunction, diabetes,
hypoparathyroidism, or hypogonadism.71-73
CONTROL AND MANAGEMENT
Prevention Programs and Prenatal Diagnosis
Screening programs, aimed at prevention of the
disease, and prenatal diagnosis have resulted in a
marked reduction in the birth rate of affected chil-
dren in Greece, Cyprus, continental Italy, and Sar-
dinia.74 Widespread use of similar programs in other
areas of the world has not yet been possible. Screen-
ing for carriers is performed most efficiently by
measurement of the red-cell indexes and, in samples
from persons with reduced mean cell volumes and
mean cell hemoglobin concentrations, estimation of
the hemoglobin A2 concentration. The practical
problems associated with screening for rarer forms
of b-thalassemia and the effect of coexistent a-thal-
assemia on the red-cell indexes have been reviewed
recently.29 Prenatal diagnosis, first carried out by fe-
tal-blood sampling and assessment of globin-chain
synthesis in fetal blood, more recently has involved
direct analysis of fetal DNA obtained by chorionic-
villus sampling. This approach is associated with a
very slightly increased risk of fetal loss and an error
rate in experienced laboratories of less than 1 per-
cent. The practical aspects of fetal-DNA analysis
have also been recently reviewed.29,74
Medical Therapy
A decision to initiate regular transfusions in pa-
tients with b-thalassemia may be difficult and should
be based on the presence and severity of the symp-
toms and signs of anemia, including failure of growth
and development. Only rarely is genotyping helpful
in this decision. The goals of transfusion include cor-
rection of anemia, suppression of erythropoiesis, and
inhibition of increased gastrointestinal absorption
of iron. Hypertransfusion and supertransfusion
 MED IC A L PR OGR ES S

15,000 50
Increased risk of complications

Hepatic Iron (mg/g of liver, dry weight)

Hepatic Iron (g/g of liver, wet weight)
Thalassemia major
Adequate iron chelation

Normal hepatic iron 40

concentration

10,000
Homozygous 30
hemochromatosis

20
5,000 Threshold for cardiac disease and early death

Heterozygous
Optimal iron chelation level 10
hemochromatosis

0 0
0 10 20 30 40 50
Age (years)
Figure 4. Hepatic Iron Burden over Time and the Effect of Various Hepatic Iron Concentrations in Patients with Thalas-
semia Major, Homozygous Hemochromatosis, and Heterozygous Hemochromatosis.
Because efforts to maintain normal hepatic iron concentrations in patients with thalassemia major are frequently asso-
ciated with adverse reactions to deferoxamine, an optimal range within which hepatic iron may be safely maintained,
derived in part from clinical experience with the iron-loading disorder hereditary hemochromatosis, has been proposed.
In a proportion of patients who are heterozygous for hemochromatosis, moderate iron loading corresponding to con-
centrations of approximately 3.2 to 7 mg of iron per gram of liver, dry weight (indicated in yellow), is associated with
normal survival without complications of iron overload.60 In patients who are homozygous for this disorder, concentra-
tions exceeding this range, up to approximately 15 mg of iron per gram of liver, dry weight (indicated in blue), are as-
sociated with an increased risk of complications of iron overload,61 whereas maintenance of levels exceeding 15 mg of
iron per gram of liver, dry weight, greatly increases the risk of cardiac disease and early death in patients with thalas-
semia major.52 In patients with thalassemia major who receive regular transfusions, the rate of iron loading is much
more accelerated and death usually occurs before the third decade of life. The goal of treatment is the maintenance of
a body-iron burden corresponding to a hepatic iron concentration of approximately 3.2 to 7 mg of iron per gram of liver,
dry weight, achievable with regular deferoxamine therapy.40 The serum ferritin concentrations corresponding to these
ranges of hepatic iron are not clearly defined.

regimens, which achieve these goals but are associ- crease the risk of clinical disease.52 Nearly normal con-
ated with substantial iron loading,40,75 have been centrations of hepatic iron can be maintained with
supplanted by regimens in which the hemoglobin modern regimens of deferoxamine. Moreover, defer-
concentration before transfusion does not exceed oxamine arrests the progression of hepatic fibrosis to
9.5 g per deciliter.76 These newer regimens are asso- cirrhosis, even when administered in regimens that
ciated with both adequate marrow suppression and stabilize, rather than reduce, the body iron burden.77
relatively lower rates of iron accumulation. The importance of this finding in the seminal study
The beneficial effects of iron-chelating therapy with that ushered in the modern era of deferoxamine ther-
parenteral deferoxamine, the only chelating agent apy is highlighted by evidence that in another form
widely available for clinical use, on the complications of iron overload, hereditary hemochromatosis, pro-
of iron loading have recently been reviewed.40 As a gression of hepatic fibrosis is a critical event associ-
result of programs of deferoxamine therapy, the prog- ated with an increased risk of death.61
nosis for patients in countries able to afford this A favorable effect of a sustained reduction in body
therapy has greatly improved, in contrast to the prog- iron is also suggested by the relatively low prevalence
nosis for patients in developing countries, where wide- of thyroid, parathyroid, and adrenal abnormalities in
spread implementation of this regimen is still awaited. the modern era.78 In parallel, early and intensive de-
Adequate deferoxamine therapy prevents early death feroxamine therapy may increase the incidence of
from cardiac disease: maintenance of body iron bur- normal sexual maturation,78 but it apparently does not
dens corresponding to hepatic iron concentrations of reverse established abnormalities.40 Similarly, although
less than 15 mg per gram, dry weight, greatly de- deferoxamine prevents diabetes mellitus,52 there is

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 The New Eng land Jour nal of Medicine
no evidence that it can reverse this complication. In
summary, modern regimens of subcutaneous defer-
oxamine may extend survival free of many complica-
tions of iron overload, if body iron is reduced or
maintained below critical concentrations.40,52,53,79
A balance between the effectiveness of deferoxa-
mine and its toxicity the latter observed primarily
in the presence of relatively low body iron burdens80
can be maintained through regular determina-
tions of body iron burden. In clinical practice, the
serum ferritin concentration is commonly used to
assess the effectiveness of treatment. It is increasing-
ly recognized that reliance on this test may lead to
errors in management; changes in body iron account
for little more than half the variation in serum fer-
ritin concentrations.81 By contrast, the measurement
of hepatic iron stores, whose concentrations are
highly correlated with total body iron stores,82 pro-
vides the most quantitative, specific, and sensitive
method of evaluating iron burden in patients with
thalassemia. Determination of hepatic iron concen-
trations in liver-biopsy specimens obtained with ul-
trasonographic guidance is safe and permits rational
adjustments in iron-chelating therapy.40 Magnetic
susceptometry provides a direct measure of hepatic
iron stores that is quantitatively equivalent to that
determined by biopsy of at least 0.6 mg of liver, dry
weight,83 over a range of iron concentrations.84 Mag-
netic susceptometry is currently available in only
two centers worldwide. By contrast, the more widely
available technique of magnetic resonance imaging
fails to provide accurate quantitation of hepatic iron
concentrations in patients with severe iron overload,
hepatic fibrosis, or both.85
Bone Marrow Transplantation
Bone marrow transplantation from HLA-identical
donors has been successfully performed worldwide in
over 1000 patients with severe b-thalassemia.86 Out-
comes after transplantation are greatly influenced by
the presence of hepatomegaly, portal fibrosis, and in-
effective chelating therapy before transplantation.87
Children without any of these risk factors have rates
of survival and disease-free survival exceeding 90 per-
cent three years after transplantation. In those with
all three risk factors, and in most adults, the rates are
approximately 60 percent. Lower success rates are re-
ported at smaller centers.87 Complications include a
rate of chronic graft-versus-host-disease ranging from
2 to 8 percent and a variable incidence of mixed chi-
merism.86 Post-transplantation management of preex-
isting hepatic iron overload, iron-induced cardiac dys-
function, and viral hepatitis may prevent progression
of these processes.86 There is interest in experimental
approaches to bone marrow replacement in patients
with thalassemia, including cord-blood transplanta-
tion,88 the use of unrelated phenotypically matched
donors,89 and in utero transplantation.90
106 Jul y 8, 19 9 9
The New England Journal of Medicine
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Experimental Therapies
Chelators Other Than Deferoxamine
Difficulties associated with deferoxamine therapy
have led to a search for alternatives, including orally
active iron chelators. The administration of one
agent, deferiprone, was reported to have a favorable
short-term effect on body iron in the one study in
which serial systematic determinations of hepatic iron
were obtained.91 Two subsequent long-term studies
have suggested that hepatic iron may stabilize at or
increase to concentrations associated with an in-
creased risk of cardiac disease and early death52 in
approximately half of patients.92,93 Previously recog-
nized adverse effects of deferiprone included embry-
otoxicity, teratogenicity, neutropenia, and agranulo-
cytosis.94 Long-term treatment has been reported to
be associated with progression of hepatic fibrosis; the
odds of progression of fibrosis were estimated to in-
crease by a factor of 5.8 with each additional year of
deferiprone therapy.95 In another study, four deaths
due to cardiac failure were reported during long-term
therapy.92 The results of these clinical trials virtually
recapitulate those in two animal species, in which
deferiprone and a structurally similar compound were
shown to increase hepatic and cardiac iron loading,
worsen hepatic fibrosis, and induce cardiac and mus-
culoskeletal fibrosis.95,96 Taken together, these data
suggest that deferiprone does not adequately control
body iron in a substantial proportion of patients and
may promote worsening of hepatic fibrosis. These
studies support cautions previously expressed about
the long-term administration of this agent.97
The results of long-term follow-up of the effec-
tiveness of other modes of administration of defer-
oxamine are awaited. These include deferoxamine
attached to high-molecular starch,98 administered in
twice-daily subcutaneous boluses,99 and given in a lip-
id vehicle, permitting slow release.100
Augmentation of Fetal-Hemoglobin Synthesis
Several trials have attempted to augment the syn-
thesis of fetal hemoglobin in an effort to ameliorate
the severity of b-thalassemia.101 Administration of in-
travenous 5-azacytidine was associated with increases
in the hemoglobin concentration in a few patients102;
the potential toxicity of the drug later shifted interest
to less toxic alternatives. Therapy with hydroxyu-
rea,103,104 butyric acid compounds,105 and these agents
in combination106 has reduced or eliminated transfu-
sion requirements in some patients. Other studies
have reported only small increases in fetal and total
hemoglobin concentrations during the administra-
tion of hydroxyurea107,108 and both intravenous109,110
and oral111,112 butyrate compounds.
How can the augmentation of fetal hemoglobin
be optimized? Studies in humans and animal models
of b-thalassemia, including transgenic mice,113 have
 MED IC A L PR OGR ES S
suggested that increases in the production of g-glo-
bin chains may be influenced by the degree of eryth-
roid marrow expansion, sequential administration of
specific combinations of agents, the degree to which
the g-globin gene is already partially activated, or all
of these.113-116 Furthermore, the striking clinical re-
sponses observed in patients with mutations104-106 that
delete specific sequences within the b-globin gene
cluster that may have a key role in the silencing of
adjacent genes117 indicate that delineation of some cis
sequences may influence the inducibility of the g-glo-
bin gene.
Although they address a highly desirable, cost-
effective goal in b-thalassemia, therapies to increase
the synthesis of fetal hemoglobin in the disorder have,
with few exceptions, proved disappointing to date.
Nonetheless, important avenues to be pursued in fur-
ther studies include the identification of specific mu-
tations that may respond to therapy, particularly with
specific combinations of agents.
Gene Therapy
Permanent correction of genetic deficit of the
hematopoietic system requires the transfer of genes
into stem cells and long-term, high-level, lineage-
specific expression of these cells after autologous trans-
plantation; mature cells and committed progenitors
do not have the proliferative capacity to reconstitute
the entire hematopoietic system. Over the past dec-
ade, there has been progress in the development of
transduction methods and vectors.118 Remaining
problems include the identification of all sequences
required for stable, high-level expression of the genes
and the development of more effective and safe vec-
tors for the transfer of genes.119 Another approach,
correction of the defective gene by site-directed re-
combination, is feasible, but current methods lack the
degree of efficiency required.120
CONCLUSIONS
Among the first diseases to be studied at the mo-
lecular level, the b-thalassemias remain a model for
understanding the relation between the molecular
pathology of a disease and its clinical diversity. At
the same time, these disorders have become an in-
creasingly important part of clinical practice in all
countries with large populations from the tropics.
The marked increase in survival, to the fifth decade
of life, of patients with well-managed b-thalassemia
in developed countries represents one of the most
dramatic alterations in morbidity and mortality asso-
ciated with a genetic disease in this century. Still,
nearly 75 years after the fascinating initial descrip-
tion of peculiar bone changes and other signs and
symptoms of the disorder, the b-thalassemias have
emerged as a huge public health problem worldwide.
They remain a therapeutic challenge for the next
millennium.
The New England Journal of Medicine
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Copyright 1999 Massachusetts Medical Society. All rights reserved.
Supported in part by research grants from the Medical Research Council
of Canada, the Ontario Heart and Stroke Foundation, and the Ontario
Thalassemia Foundation. Dr. Olivieri is the recipient of a Scientist Award
from the Medical Research Council of Canada.
I am indebted to David Nathan, David Weatherall, Gary Brit-
tenham, John Porter, Alan Schechter, Elliott Vichinsky, Brenda Gal-
lie, Helen Chan, Peter Durie, John Dick, Marc Giacomelli, Paul
Ranalli, Arthur Schafer, Michele Brill-Edwards, Lori West, Miriam
Kaufman, Michael Langlois, David Kern, Bob Phillips, Maria Mu-
raca, Bill Graham, Rhonda Love, Doug Templeton, John Polanyi,
and Michael Baker, without whose support this review would not have
been written.
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