Living with Anemia- Past, Present, Future

Living with Anemia: Past, Present & Future Blanche P Alter, MD, MPH Clinical Genetics Branch Division of Cancer Epidemiology and Genetics National Cancer Institute Department of Health and Human Services Bethesda, MD National Anemia Conference, Toronto, Sept 24, 2005 Never make predictions, especially about the future (Yogi Berra) Themes of this Conference  Hemoglobinopathies  Sickle Cell Disease (SS)  Thalassemia (Thal)  Bone marrow failure (BMF)  Aplastic anemia (AA)  Myelodysplastic Syndrome (MDS) Overview  Definitions  Problems  Management – past, present, future Cell Types  Red blood cells (RBC)  Contain hemoglobin (Hb)  Carry oxygen in, CO2 out  White blood cells (WBC)  Neutrophils and monocytes fight infections  Lymphocytes provide immune functions  Platelets (Plat)  Form blood clots to stop bleeding Normal Blood Red cell Monocyte Reticulocyte Platelets Lymphocyte Neutrophil Bone Marrow (BM) Biopsy Normal Aplastic Anemia  “Low blood”  Hemoglobin (Hb) or hematocrit (Hct) below the normal range for age and sex  May or may not lead to symptoms  Tired  No energy  Short of breath Hematocrits Plasma White cells Red cells Normal, Hemorrhage, IDA, Leukemia, Hemolysis, B12, P Vera Features of the Syndromes Feature Anemia Low WBC Low Platelets SS Yes no No Thal Yes no No AA Yes Yes Yes MDS Yes Yes Yes BM Cellularity BM Cell Types Inc Inc Dec Dec Inc Dysplastic Inc Inc Erythroid Erythroid Spleen size Splenectomy Small Auto Large Yes Normal No Normal No Hemoglobinopathies  Sickle cell disease  Thalassemia Hemoglobin      Contains 4 proteins called “globin” 2 alpha (a) and 2 beta (b) globins Heme Iron Binds O2 Production of Hemoglobin • • • • • GgAgb DNA: a a aa Gg Ag b RNA: a a aa Gg Ag b Globin protein a Fetal Hb F a2g2 (a2Gg2, a2Ag2) Adult Hb A a2b2 GgAgb Gg Ag b Hemoglobin S  A structural hemoglobinopathy involving b globin Base 16 20 24 Hb A CCT GAG GAG Pro Glu Glu CCT GTG GAG Pro Val Glu Codon 5 6 7 Hb S Heterogeneity of Sickle Cell Disease Clinical Laboratory Pain Dactylitis Stroke Acute chest syndrome Osteonecrosis Longevity Gallstones Renal failure Retinopathy Bilirubin Hemoglobin Red cell production Leucocytes Dense cells Hb F, F-cells, Hb F per F-cell LDH Creatinine, proteinuria Reticulocytes Adapted from Steinberg, Br J Haematol 129:465, 2005 Clinical Laboratory Predictors of Complications in Sickle Cell Disease Predictor Low Hb High Hb Low Hb F High WBC Outcome Death, stroke, leg ulcers Pain, ACS, AVN Death, ACS, pain, leg ulcers Death, ACS Hydroxyurea a thalassemia present a thalassemia absent Frequent pain crises Transcranial Doppler Inc Hb, Hb F AVN Stroke Adult death, AVN Low (<200cm/sec) ACS, acute chest syndrome. AVN, avascular necrosis Research Predictors of Complications in Sickle Cell Disease Predictor b haplotype Gg158 C to T QTLs for Hb F: Xp22, 6q22, 8q Hydroxyurea response Good Prognosis Senegal, Arab-Indian Yes Good SNP Inc Hb, Hb F Poor Prognosis Bantu No Bad SNP No effect Interacting genes Good SNP Bad SNP Treatment Rationale - Present  Increase Hb F  Decrease mature bone marrow cells and increase erythroid regeneration by less less mature cells, which produce Hb F - hydroxyurea  Increase new red cell production - erythropoietin  Increase hypomethylation of gamma gene promoters, increasing expression and Hb F – 5-azacitidine  Inhibit histone deacetylase and change chromatin structure – butyric acid, valproic acid  Dilute proportion of cells with Hb S  Transfuse with normal rbcs  Cytopheresis of patient to remove old cells  Neocytopheresis of donor to provide only young cells Treatment Rationale - Future  Prevent Hb S polymerization  Prevent sickle RBC damage and dehydration  Interrupt endothelial damage, RBC and WBC adherence, WBC-RBC interaction, vasoconstriction  Decrease inflammation, reperfusion injury, oxidant radical production  Increase O2 delivery and unsickle deformed cells  Inhibit endothelial activation Treatment of Sickle Cell Disease  Past  Hydration, antibiotics, pain medicines  Present        Penicillin Screen for stroke risk with transcranial Doppler Transfusions Iron chelation Hydroxyurea (+ erythropoietin) Cytopheresis and neocytopheresis Stem cell transplants Treatment of Sickle Cell Disease - Future Agent Short chain fatty acid -butyrate Sulfasalazine aVb3 antibodies Anionic polysaccharides Mechanism Inhibit HDAC, increase Hb F Dec endothelial activation Block adherence Inhibit adhesion to endothelium Oxygenated fluorocarbons IgG Heparin Statins Inc O2 delivery Inhibit WBC-RBC and WBC adherence Inhibit P-selection-RBC interaction Induce nitric oxide Nitric oxide Gene therapy Pulmonary vasodilator Replace b-S gene with b-A gene Adapted from Steinberg, ASH Education book Hematology 2004, p 42 Thalassemia  Thalassa = the sea  Defective globin synthesis  Normal a = b (a/b = 1)  a, b, db, gdb thalassemia Heterogeneity of b-Thalassemia        b-thalassemia ~200 mutations bo = no b globin b+ = decreased production of b globin Thal major Thal intermedia Thal trait Complications in b-Thalassemia  Transfusions     Iron overload Hepatitis C, other viruses Liver disease Endocrinopathies  Osteopenia and osteoporosis  Cardiovascular  Congestive heart failure  Arrythmias  Pulmonary hypertension  Hypercoagulability and Thrombophilia  Inc platelets  RBCs and Platelets with phosphatidylserine on membranes  Inc activation peptides, dec antithrombotic proteins Treatment of b-Thalassemia  Past  Transfusions  Present  Transfusions  Iron chelation  Stem cell transplants  Future     Oral iron chelation Hydroxyurea (+ erythropoietin) 5-azacitidine Gene therapy Early Diagnoses • Premarital screening/counseling • At risk for S, C, thal, E • Newborn (or infant) screening • Presymptomatic diagnosis with clinical intervention – penicillin for Hb SS, transfusions for b-thalassemia • Prenatal diagnosis • Birth of healthy children, termination of affecteds, or in utero stem cell transplant • Preimplantation Genetic Diagnosis • Birth of healthy children, implant only the healthy IVF and PGD • In Vitro Fertilization • Ova and sperm combined in vitro • Preimplantation Genetic Diagnosis • Single cell removed from 8 cell blastocyst • PCR for single gene mutation • PCR for HLA type (for stem cell transplant) Bone Marrow Disorders  Aplastic anemia  Myelodysplastic Syndromes Definitions  Aplastic Anemia (AA)  Pancytopenia  Hypocellular bone marrow  Myelodysplastic Syndrome (MDS)  Cytopenias with hypercellular bone marrow  Acute Leukemia (AL)  Malignant proliferation of immature cells Aplastic Anemia Blood Bone Marrow Biopsy Aplastic Anemia: Signs and Symptoms  Anemia (low Hb, Hct)  fatigue, lassitude, dyspnea  Thrombocytopenia (low platelets)  bruises, petechiae  serious bleeding  Neutropenia (low neutrophils, a type of white cell)  infections Aplastic Anemia  Acquired  Past: Environmental exposures such as drugs, toxins, hepatitis  Present: Possible underlying genetic predispositions  Future: Clarification of genetic predispositions, polymorphisms in genes that activate or detoxify drugs and chemical exposures  Inherited  Past: Benign hematology  Present: High risk of cancer  Future: Genotype/phenotype/cancer correlations Acquired Aplastic Anemia        Drugs Chemicals Viruses Immune diseases Paroxysmal nocturnal hemoglobinuria (PNH) Pregnancy IDIOPATHIC Severity of Aplastic Anemia  Severe  2 of the following 3: neutrophils <500, platelets <20,000, reticulocytes <20,000  BM cellularity <25% with < 30% hematopoietic cells  Very severe  Neutrophils <200  Non-severe (moderate)  Better than above Treatment of AA  Past  Transfusions  Antibiotics  Androgens  Present  Stem cell transplant  Immunosuppression: Antithymocyte globulin + cyclosporine A  Transfusions Complications after Treatment of AA  BMT  Survival 75% if <20 yo, 35% if>40 yo  Graft vs host disease  Solid tumor 12%  ATG/CsA  Survival 50-75%  CsA-induced renal failure, hypertension, infection  Clonal disease: PNH, MDS, AML 20-30%  Cyclophosphamide  Survival ~70%, no PNH, MDS, AML  Still research Association between AA and Genetic Variants in Modifier and Interacting Genes Enzymes Cytochromes (CYP) Glutathione-S-transferases (GST) NAD(P)H: quinone oxidoreductase (NQO1) CTLA4 Tumor necrosis factor-a Interleukin-6 Interleukin-10 Transforming growth factor-b Interferon-g No X X X X X X X Yes X X X X Treatment of AA  Past/Present  Stem cell transplant  Immunosuppression: Antithymocyte globulin + cyclosporine A  Future  Cyclophosphamide?  New types of immunosuppression (mycophenolate mofetil, rapamycin)  Tailor treatment to genetic modifiers Inherited AA: Benign Hematology Oncology Syndrome Fanconi’s Anemia (FA) Dyskeratosis Congenita (DC) Diamond-Blackfan Anemia (DBA) Hematology Aplastic Aplastic Pure anemia Leukemia AML AML AML Solid Tumors SCC SCC Sarcomas Shwachman-Diamond Syndrome (SD) Severe Congenital Neutropenia (SCN) Amegakaryocytic Thrombocytopenia Thrombocytopenia Absent Radii (TAR) Neutropenia Neutropenia Thrombocytopenia Thrombocytopenia AML AML AML AML - These disorders are the major “Inherited Bone Marrow Failure Syndromes.” Features of the IBMFS FA Genetics Genes Phys Abnl Usual Heme AA AR >12 + AA + DC XLR, AD >3 + AA + DBA AD >2 + PRCA - SD AR >1 + neut + SCN Amega TAR AD >2 neut AR 1 plat + AR ? + plat - Specific Test Leuk Tumors Chrom brks Telomeres + + + + eADA + + GI + - + - + - + - AR, autosomal recessive. AD, autosomal dominant. XLR, X-linked recessive Treatment of the IBMFS FA RBC Tx Plat Tx Andr + + + DC + + + DBA + + SD +? +? SCN Amega + + + + TAR Steroid + Ep, GCSF future Growth Ep, G- Ep, G- Ep? GGFactor CSF CSF CSF CSF Gene future future future future future Therapy ? Treatment of IBMFS  Past             Androgens Corticosteroids Transfusions Antibiotics Stem cell transplant Androgens Corticosteroids Growth factors Improved transplants Better and more growth factors Gene therapy Effective and nontoxic treatment for leukemia and tumors  Present  Future Myelodysplastic Syndromes (MDS)     Clonal diseases Neoplastic Refractory anemias Potential for acute myeloid leukemia (AML) Past: FAB* CLASSIFICATION      RA: refractory anemia, <5% blasts RARS: RA with >15% ringed sideroblasts RAEB: RA with excess blasts, 5-20% blasts RAEBiT: RAEB in transformation, 21-30% blasts CMML: chronic myelomonocytic leukemia, PB monocytes >1000/mL  AML: >30% blasts *French-American-British Present: WHO* Classification  RA: erythroid dysplasia, <5% blasts  RCMD: refractory cytopenia with multilineage dysplasia, <5% blasts  MDS-U: unclassified  MDS with 5q- syndrome  RARS: RA with >15% ringed sideroblasts  RSCMD: RCMD with ringed sideroblasts  RAEB-1: 5 to 9% blasts  RAEB-2: 10 to 19% blasts  AML: >20% blasts *World Health Organization Present: International Prognostic Scoring System Prognostic Variable BM blasts % Karyotype* Score 0 <5 Good 0.5 5-10 Intermediate 1.0 Poor 1.5 11-20 2.0 21-30 - No. of cytopenias** 0 or 1 2 or 3 - - - *Good: normal, -Y, 5q-, 20q-. Int: Other. Poor: abnl 7, or >3 abnl. **Hb <10 g/dL. ANC <1800/uL. Plat <100,000/uL. Total score is the sum of the above scores. IPSS Risk Categories: Category Score Low 0 Int-1 0.5, 1.0 Int-2 1.5, 2.0 High >2.5 Treatment of MDS  Past/Present:  Cure: Stem cell transplant  Support: Transfusions, Erythropoietin, G-CSF  Immunosuppression: steroids, antithymocyte globulin, cyclosporine  Chemotherapy: Cytarbine, Mylotarg  Methyl transferase inhibitors: 5-Azacitidine  Future:  Antiangiogenics: thalidomide, lenalidomide  Farnesyl transferase inhibitors: tipifarnib, lonafarnib Future Predictors of Severity or of Treatment for any of the Anemias      Genotype/phenotype Gene/environment Interacting genes, epistasis Gene modifiers, epigenetics Pharmacogenomics Common to All “Anemias”  Genetic predisposition  Germline  Somatic  Support  Hematopoietic growth factors  Blood transfusions, blood substitutes  Iron chelation  Cure  Stem cell transplant  Gene therapy  Family Planning (for genetic diseases)  Prenatal diagnosis  Preimplantation genetic diagnosis