**6. Conclusions**

β thalassemias arise from a number of underlying genetic defects that interfere with the synthesis of the β hemoglobin chain and the subsequent production of the normal α2β2 hemoglobin tetramer. As a consequence of this decreased/absent β-chain synthesis, unpaired, monomeric, α-hemoglobin chains are produced. While the presence of the highly unstable α-chains mediate the pathophysiology of the RBC, it has been difficult to fully elucidate the mechanisms underlying their destructive processes in human cells. This lack of understanding of the mechanisms of α-chain mediated damage is due, in large part, to the fact that peripheral RBC isolated from β thalassemic individuals are already severely damaged cells (with most being destroyed within the bone marrow). Moreover, severe β thalassemia patients are typically transfused to both correct the severe anemia accompanying the disease and to prevent endogenous erythropoiesis of defective RBC. Hence, murine models of β thalassemia have been developed and extensively studied. However, problems exist with these models (e.g., mouse vs. human α-chains; interaction of human globins with mouse cytoskeletal proteins) and these mice, as in human patients, still suffer from the heterogeneity of RBC changes arising from the different ages of the peripheral blood RBC [11–17].

To better study the *fate of unpaired α-chains* in human RBC, the model β thalassemic cell was developed [18–34]. The entrapment of purified α-hemoglobin chains within normal erythrocytes via osmotic lysis and resealing provides an excellent and reproducible human model for studying the pathologic effects of the unpaired α-chains on the structural and functional characteristics of the RBC. Indeed, as noted in **Table 2**, the α-chain induced structural and functional RBC changes are very similar to those observed in human donor derived β thalassemic RBC. Schematically the pathophysiology of the β thalassemic RBC, and its downstream consequences, as elucidated by the model human β thalassemic RBC, are summarized in **Figure 9**. Importantly, these studies have demonstrated that the unpaired α-chains initiate an *iron, GSH-dependent, self-amplifying and selfpropagating reaction* with the subsequent release of even more heme and, eventually, free iron (**Figure 4**). Membrane proteins and reactive thiol groups (not shown) were rapidly decreased in a pattern similar to that observed *in vivo* in β thalassemia [18, 20–23, 25–27]. These oxidative events also result in membrane vesiculation of the thalassemic RBC. One consequence of membrane vesiculation is the preferential loss of phosphatidylinositol (PI) anchored proteins from the RBC. Among these PI-anchored proteins are decay accelerating factor (DAF; CD55) and the membrane inhibitor of reactive lysis (MIRL; CD59) both of which play important roles in preventing complement-mediated binding and lysis. The effects of the

**81**

*Model Human β Thalassemic Erythrocytes: Effect of Unpaired Purified α-Hemoglobin Chains…*

vesiculation-mediated loss of CD55 and CD59 can range from sublytic levels of bound complement enhancing phagocytosis to overt hemolysis. Indeed, a common endpoint for all the α-chain mediated injury is enhanced erythrophagocytosis. As shown, oxidized RBC or the heme from these cells (**Figure 8**) significantly inhibits antigen processing, presentation and T cell proliferation. The systemic importance of this on cell-mediated immunity has not be fully appreciated and may potentially explain the predisposition of thalassemic patients to recurrent bacterial infections. In sum, these findings show the utility of the model β thalassemic human RBC for investigating the pathophysiology of the unpaired α-chains. Moreover, these cells are easily 'manufactured' from normal donor RBC and may provide an effective means to evaluate therapeutic approaches to ameliorate the damage to the thalassemic cell in β thalassemia intermedia in order to prolong RBC survival and

*Schematic representation of the pathophysiology of the β thalassemic RBC and its immunological consequences.*

This work was supported by grants from Canadian Blood Services and Health Canada. The views expressed herein do not necessarily represent the view of the federal government of Canada. We thank the Canada Foundation for Innovation and the Michael Smith Foundation for Health Research for infrastructure funding at the University of British Columbia Centre for Blood Research. The funders had no role in study design, data collection and analysis, decision to publish, or prepara-

*DOI: http://dx.doi.org/10.5772/intechopen.90288*

reduce transfusions [23, 25–27, 40].

**Acknowledgements**

**Figure 9.**

tion of the manuscript.

**Conflict of interest**

There are no conflicts of interest.

*Model Human β Thalassemic Erythrocytes: Effect of Unpaired Purified α-Hemoglobin Chains… DOI: http://dx.doi.org/10.5772/intechopen.90288*

**Figure 9.** *Schematic representation of the pathophysiology of the β thalassemic RBC and its immunological consequences.*

vesiculation-mediated loss of CD55 and CD59 can range from sublytic levels of bound complement enhancing phagocytosis to overt hemolysis. Indeed, a common endpoint for all the α-chain mediated injury is enhanced erythrophagocytosis. As shown, oxidized RBC or the heme from these cells (**Figure 8**) significantly inhibits antigen processing, presentation and T cell proliferation. The systemic importance of this on cell-mediated immunity has not be fully appreciated and may potentially explain the predisposition of thalassemic patients to recurrent bacterial infections.

In sum, these findings show the utility of the model β thalassemic human RBC for investigating the pathophysiology of the unpaired α-chains. Moreover, these cells are easily 'manufactured' from normal donor RBC and may provide an effective means to evaluate therapeutic approaches to ameliorate the damage to the thalassemic cell in β thalassemia intermedia in order to prolong RBC survival and reduce transfusions [23, 25–27, 40].

#### **Acknowledgements**

This work was supported by grants from Canadian Blood Services and Health Canada. The views expressed herein do not necessarily represent the view of the federal government of Canada. We thank the Canada Foundation for Innovation and the Michael Smith Foundation for Health Research for infrastructure funding at the University of British Columbia Centre for Blood Research. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

## **Conflict of interest**

There are no conflicts of interest.

*Beta Thalassemia*

**6. Conclusions**

mutans in a dose dependent manner.

the different ages of the peripheral blood RBC [11–17].

non-deformable RBC are trapped and then cleared by circulating macrophages. Regardless of the location of removal, erythrophagocytosis results in impaired MPS function. As shown in **Figure 8A**, antigen presentation of purified tetanus toxoid (TT; a peptide) or fixed, intact, *S. mutans* (SM; an intact bacteria) by normal human antigen presenting cells (APC; blood monocytes) was dramatically, and differentially, affected by the presence of either control (unoxidized) or oxidized (50 μM PMS as per **Figure 7**) human RBC. As shown, oxidized RBC prevented successful antigen presentation to human T cells while normal RBC showed no detrimental effects. Further experimentation demonstrated that the inhibitory effect was due to heme/iron. As shown in **Figure 8B, C**, direct addition of hemin to the APC impaired successful antigen presentation of both tetanus toxoid and Strep.

β thalassemias arise from a number of underlying genetic defects that interfere with the synthesis of the β hemoglobin chain and the subsequent production of the normal α2β2 hemoglobin tetramer. As a consequence of this decreased/absent β-chain synthesis, unpaired, monomeric, α-hemoglobin chains are produced. While the presence of the highly unstable α-chains mediate the pathophysiology of the RBC, it has been difficult to fully elucidate the mechanisms underlying their destructive processes in human cells. This lack of understanding of the mechanisms of α-chain mediated damage is due, in large part, to the fact that peripheral RBC isolated from β thalassemic individuals are already severely damaged cells (with most being destroyed within the bone marrow). Moreover, severe β thalassemia patients are typically transfused to both correct the severe anemia accompanying the disease and to prevent endogenous erythropoiesis of defective RBC. Hence, murine models of β thalassemia have been developed and extensively studied. However, problems exist with these models (e.g., mouse vs. human α-chains; interaction of human globins with mouse cytoskeletal proteins) and these mice, as in human patients, still suffer from the heterogeneity of RBC changes arising from

To better study the *fate of unpaired α-chains* in human RBC, the model β thalassemic cell was developed [18–34]. The entrapment of purified α-hemoglobin chains within normal erythrocytes via osmotic lysis and resealing provides an excellent and reproducible human model for studying the pathologic effects of the unpaired α-chains on the structural and functional characteristics of the RBC. Indeed, as noted in **Table 2**, the α-chain induced structural and functional RBC changes are very similar to those observed in human donor derived β thalassemic RBC. Schematically the pathophysiology of the β thalassemic RBC, and its downstream consequences, as elucidated by the model human β thalassemic RBC, are summarized in **Figure 9**. Importantly, these studies have demonstrated that the unpaired α-chains initiate an *iron, GSH-dependent, self-amplifying and selfpropagating reaction* with the subsequent release of even more heme and, eventually, free iron (**Figure 4**). Membrane proteins and reactive thiol groups (not shown) were rapidly decreased in a pattern similar to that observed *in vivo* in β thalassemia [18, 20–23, 25–27]. These oxidative events also result in membrane vesiculation of the thalassemic RBC. One consequence of membrane vesiculation is the preferential loss of phosphatidylinositol (PI) anchored proteins from the RBC. Among these PI-anchored proteins are decay accelerating factor (DAF; CD55) and the membrane inhibitor of reactive lysis (MIRL; CD59) both of which play important roles in preventing complement-mediated binding and lysis. The effects of the

**80**

*Beta Thalassemia*

## **Author details**

Mark D. Scott1,2,3

1 Canadian Blood Services, Ottawa, ON, Canada

2 Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada

3 Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada

\*Address all correspondence to: mdscott@mail.ubc.ca

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**83**

*Model Human β Thalassemic Erythrocytes: Effect of Unpaired Purified α-Hemoglobin Chains…*

[10] Turbpaiboon C, Wilairat P. Alphahemoglobin stabilizing protein: Molecular function and clinical correlation. Frontiers in Bioscience (Landmark Edition). 2010;**15**:1-11.

[11] Rubin EM, Kan YW, Mohandas N. Effect of human beta (s)-globin chains on cellular properties of red cells from beta-thalassemic mice. The Journal of Clinical Investigation. 1988;**82**:1129- 1133. DOI: 10.1172/JCI113670

[12] Sorensen S, Rubin E, Polster H, Mohandas N, Schrier S. The role of membrane skeletal-associated alphaglobin in the pathophysiology of betathalassemia. Blood. 1990;**75**:1333-1336.

[13] Advani R, Rubin E, Mohandas N, Schrier SL. Oxidative red blood cell membrane injury in the pathophysiology of severe mouse β-thalassemias. Blood. 1992;**79**:1064-

[14] Pászty C. Transgenic and gene knock-out mouse models of sickle cell anemia and the thalassemias. Current Opinion in Hematology. 1997;**4**:88-93.

Stamatoyannopoulos G, Emery DW. Effects of human gamma-globin in murine beta-thalassaemia. British Journal of Haematology.

10.1111/j.1365-2141.2006.06102.x

[16] Huo Y, McConnell SC, Liu SR, Yang R, Zhang TT, Sun CW, et al. Humanized mouse model of Cooley's anemia. The Journal of Biological Chemistry. 2009;**284**:4889-4896. DOI:

[17] McColl B, Vadolas J. Animal models of β-hemoglobinopathies: Utility and

PMID: 20036801

PMID: 1690033

1067. PMID: 1737090

PMID: 9107524

[15] Nishino T, Cao H,

2006;**134**:100-108. DOI:

10.1074/jbc.M805681200

*DOI: http://dx.doi.org/10.5772/intechopen.90288*

hemoglobin. The Journal of Laboratory and Clinical Medicine. 1957;**50**:745-752.

[2] Weatherall DJ, Clegg JB. Molecular basis of thalassemia. British Journal of Haematology. 1975;**31**:133-141. DOI: 10.1111/j.1365-2141.1975.tb00906.x

[3] Weatherall DJ. Pathophysiology of thalassaemia. Baillière's Clinical Haematology. 1998;**11**:127-146. PMID:

[4] Higgs DR. The molecular basis of α-thalassemia. Cold Spring Harbor Perspectives in Medicine. 2013;**3**:a011718. DOI: 10.1101/

[5] Piel FB, Weatherall DJ. The α-thalassemias. The New England Journal of Medicine. 2014;**371**:1908- 1916. DOI: 10.1056/NEJMra1404415

[6] Mettananda S, Gibbons RJ, Higgs DR. α-Globin as a molecular target in the treatment of β-thalassemia. Blood. 2015;**125**:3694-3701. DOI: 10.1182/blood-2015-03-633594

basis and genetic modifiers of thalassemia. Hematology/

[8] Taher AT, Weatherall DJ,

[9] Weatherall DJ. The evolving spectrum of the epidemiology of thalassemia. Hematology/Oncology Clinics of North America. 2018;**32**:165- 175. DOI: 10.1016/j.hoc.2017.11.008

S0140-6736(17)31822-6

hoc.2017.11.003

[7] Mettananda S, Higgs DR. Molecular

Oncology Clinics of North America. 2018;**32**:177-191. DOI: 10.1016/j.

Cappellini MD. Thalassaemia. Lancet. 2018;**391**:155-167. DOI: 10.1016/

[1] Robinson AR, Robson M, Harrison AP, Zuelzer WW. A new technique for differentiation of

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10872475

cshperspect.a011718

*Model Human β Thalassemic Erythrocytes: Effect of Unpaired Purified α-Hemoglobin Chains… DOI: http://dx.doi.org/10.5772/intechopen.90288*

### **References**

*Beta Thalassemia*

**82**

**Author details**

Mark D. Scott1,2,3

Canada

1 Canadian Blood Services, Ottawa, ON, Canada

\*Address all correspondence to: mdscott@mail.ubc.ca

Columbia, Vancouver, BC, Canada

provided the original work is properly cited.

2 Centre for Blood Research, University of British Columbia, Vancouver, BC,

3 Department of Pathology and Laboratory Medicine, University of British

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

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[3] Weatherall DJ. Pathophysiology of thalassaemia. Baillière's Clinical Haematology. 1998;**11**:127-146. PMID: 10872475

[4] Higgs DR. The molecular basis of α-thalassemia. Cold Spring Harbor Perspectives in Medicine. 2013;**3**:a011718. DOI: 10.1101/ cshperspect.a011718

[5] Piel FB, Weatherall DJ. The α-thalassemias. The New England Journal of Medicine. 2014;**371**:1908- 1916. DOI: 10.1056/NEJMra1404415

[6] Mettananda S, Gibbons RJ, Higgs DR. α-Globin as a molecular target in the treatment of β-thalassemia. Blood. 2015;**125**:3694-3701. DOI: 10.1182/blood-2015-03-633594

[7] Mettananda S, Higgs DR. Molecular basis and genetic modifiers of thalassemia. Hematology/ Oncology Clinics of North America. 2018;**32**:177-191. DOI: 10.1016/j. hoc.2017.11.003

[8] Taher AT, Weatherall DJ, Cappellini MD. Thalassaemia. Lancet. 2018;**391**:155-167. DOI: 10.1016/ S0140-6736(17)31822-6

[9] Weatherall DJ. The evolving spectrum of the epidemiology of thalassemia. Hematology/Oncology Clinics of North America. 2018;**32**:165- 175. DOI: 10.1016/j.hoc.2017.11.008

[10] Turbpaiboon C, Wilairat P. Alphahemoglobin stabilizing protein: Molecular function and clinical correlation. Frontiers in Bioscience (Landmark Edition). 2010;**15**:1-11. PMID: 20036801

[11] Rubin EM, Kan YW, Mohandas N. Effect of human beta (s)-globin chains on cellular properties of red cells from beta-thalassemic mice. The Journal of Clinical Investigation. 1988;**82**:1129- 1133. DOI: 10.1172/JCI113670

[12] Sorensen S, Rubin E, Polster H, Mohandas N, Schrier S. The role of membrane skeletal-associated alphaglobin in the pathophysiology of betathalassemia. Blood. 1990;**75**:1333-1336. PMID: 1690033

[13] Advani R, Rubin E, Mohandas N, Schrier SL. Oxidative red blood cell membrane injury in the pathophysiology of severe mouse β-thalassemias. Blood. 1992;**79**:1064- 1067. PMID: 1737090

[14] Pászty C. Transgenic and gene knock-out mouse models of sickle cell anemia and the thalassemias. Current Opinion in Hematology. 1997;**4**:88-93. PMID: 9107524

[15] Nishino T, Cao H, Stamatoyannopoulos G, Emery DW. Effects of human gamma-globin in murine beta-thalassaemia. British Journal of Haematology. 2006;**134**:100-108. DOI: 10.1111/j.1365-2141.2006.06102.x

[16] Huo Y, McConnell SC, Liu SR, Yang R, Zhang TT, Sun CW, et al. Humanized mouse model of Cooley's anemia. The Journal of Biological Chemistry. 2009;**284**:4889-4896. DOI: 10.1074/jbc.M805681200

[17] McColl B, Vadolas J. Animal models of β-hemoglobinopathies: Utility and

limitations. Journal of Blood Medicine. 2016;**7**:263-274. DOI: 10.2147/JBM. S87955

[18] Scott MD, Rouyer-Fessard P, Lubin BH, Beuzard Y. Entrapment of purified alpha-hemoglobin chains in normal erythrocytes. A model for beta thalassemia. Journal of Biological Chemistry. 1990;**265**:17953-17959. PMID: 2211672

[19] Rouyer-Fessard P, Scott MD, Leroy-Viard K, Garel MC, Bachir D, Galacteros F, et al. Fate of alpha-hemoglobin chains and erythrocyte defects in beta-thalassemia. Annals of the New York Academy of Sciences. 1990;**612**:106-117. DOI: 10.1111/j.1749-6632.1990.tb24296.x

[20] Scott MD, Rouyer-Fessard P, Ba MS, Lubin BH, Beuzard Y. Alpha- and betahaemoglobin chain induced changes in normal erythrocyte deformability: Comparison to beta thalassaemia intermedia and Hb H disease. British Journal of Haematology. 1992;**80**:519- 526. DOI: 10.1111/j.1365-2141.1992. tb04567.x

[21] Scott MD. Entrapment of purified alpha-hemoglobin chains in normal erythrocytes as a model for human beta thalassemia. Advances in Experimental Medicine and Biology. 1992;**326**:139- 148. PMID: 1295299

[22] Scott MD, van den Berg JJ, Repka T, Rouyer-Fessard P, Hebbel RP, Beuzard Y, et al. Effect of excess alpha-hemoglobin chains on cellular and membrane oxidation in model beta-thalassemic erythrocytes. The Journal of Clinical Investigation. 1993;**91**:1706-1712. DOI: 10.1172/JCI116380

[23] Scott MD, Eaton JW. Thalassaemic erythrocytes: Cellular suicide arising from iron and glutathione-dependent oxidation reactions? British Journal of Haematology. 1995;**91**:811-819. DOI: 10.1111/j.1365-2141.1995.tb05394.x

[24] Kuypers FA, Schott MA, Scott MD. Phospholipid composition and organization in model beta-thalassemic erythrocytes. American Journal of Hematology. 1996;**51**:45-54. DOI: 10.1002/ (SICI)1096-8652(199601)51:1<45::AID-AJH8>3.0.CO;2-7

[25] Scott MD, Yang L, Ulrich P, Shupe T. Pharmacologic interception of heme: A potential therapeutic strategy for the treatment of ß thalassemia? Redox Report. 1997;**3**:159-167. DOI: 10.1080/13510002.1997.11747104

[26] Scott MD. Intraerythrocytic iron chelation: A new therapy for thalassemia. Hematology. 2001;**6**:73-89. DOI: 10.1080/10245332.2001.11746557

[27] Scott MD. H2O2 injury in beta thalassemic erythrocytes: Protective role of catalase and the prooxidant effects of GSH. Free Radical Biology & Medicine. 2006;**40**:1264-1272. DOI: 10.1016/j. freeradbiomed.2005.11.017

[28] Scott MD, Eaton JW, Kuypers FA, Chiu D-Y, Lubin BH. Enhancement of erythrocyte superoxide dismutase activity: Effects on cellular oxidant defense. Blood. 1989;**74**:2542-2549. PMID: 2553167

[29] Scott MD, Kuypers FA, Butikofer P, Bookchin RM, Ortiz OE, Lubin BH. Effect of osmotic lysis and resealing on red cell structure and function. The Journal of Laboratory and Clinical Medicine. 1990;**115**:470-480. PMID: 1691257

[30] Scott MD, Ranz A, Kuypers FA, Lubin BH, Meshnick SR. Parasite uptake of desferroxamine: A prerequisite for antimalarial activity. British Journal of Haematology. 1990;**75**:598-602. DOI: 10.1111/j.1365- 2141.1990.tb07805.x

[31] Scott MD, Lubin BH, Zuo L, Kuypers FA. Erythrocyte defense

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[41] Lunn G, Dale GL, Beutler E. Transport accounts for glutathione turnover in human erythrocytes. Blood.

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Etkin NL. Catalase activity and red cell metabolism. In: Brewer GJ, editor. Hemoglobin and Red Cell Structure and Function. New York: Plenum Publishing Corp; 1972. pp. 121-131. DOI: 10.1007/978-1-4684-3222-0\_8

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against hydrogen peroxide: Preeminent importance of catalase. The Journal of Laboratory and Clinical Medicine. 1991;**118**:7-16. PMID: 2066646

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Acta. 1993;**1181**:163-168. DOI: 10.1016/0925-4439(93)90106-b

[34] Scott MD. Glucose-6-phosphate dehydrogenase deficiency: A new hypothesis for an old disease. Redox Report. 1995;**1**:235-237. DOI: 10.1080/13510002.1995.11746992

[35] Bucci E, Fronticelli C. A new

method for the preparation of alpha and beta subunits of human hemoglobin. The Journal of Biological Chemistry. 1965;**240**:PC551-PC552. PMID:

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Chiu DT. Decreased catalase activity is the underlying mechanism of oxidant susceptibility in glucose-6 phosphate dehydrogenase-deficient erythrocytes. Biochimica et Biophysica

2018843

14253474

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against hydrogen peroxide: Preeminent importance of catalase. The Journal of Laboratory and Clinical Medicine. 1991;**118**:7-16. PMID: 2066646

*Beta Thalassemia*

PMID: 2211672

tb04567.x

148. PMID: 1295299

10.1172/JCI116380

S87955

limitations. Journal of Blood Medicine. 2016;**7**:263-274. DOI: 10.2147/JBM.

[24] Kuypers FA, Schott MA,

and organization in model beta-thalassemic erythrocytes. American Journal of Hematology. 1996;**51**:45-54. DOI: 10.1002/

AJH8>3.0.CO;2-7

Scott MD. Phospholipid composition

(SICI)1096-8652(199601)51:1<45::AID-

Shupe T. Pharmacologic interception of heme: A potential therapeutic strategy for the treatment of ß thalassemia? Redox Report. 1997;**3**:159-167. DOI: 10.1080/13510002.1997.11747104

[25] Scott MD, Yang L, Ulrich P,

[26] Scott MD. Intraerythrocytic iron chelation: A new therapy for thalassemia. Hematology. 2001;**6**:73-89. DOI: 10.1080/10245332.2001.11746557

[27] Scott MD. H2O2 injury in beta thalassemic erythrocytes: Protective role of catalase and the prooxidant effects of GSH. Free Radical Biology & Medicine. 2006;**40**:1264-1272. DOI: 10.1016/j.

[28] Scott MD, Eaton JW, Kuypers FA, Chiu D-Y, Lubin BH. Enhancement of erythrocyte superoxide dismutase activity: Effects on cellular oxidant defense. Blood. 1989;**74**:2542-2549.

Butikofer P, Bookchin RM, Ortiz OE, Lubin BH. Effect of osmotic lysis and resealing on red cell structure and function. The Journal of Laboratory and Clinical Medicine. 1990;**115**:470-480.

[30] Scott MD, Ranz A, Kuypers FA, Lubin BH, Meshnick SR. Parasite uptake of desferroxamine: A

prerequisite for antimalarial activity. British Journal of Haematology. 1990;**75**:598-602. DOI: 10.1111/j.1365-

[31] Scott MD, Lubin BH, Zuo L, Kuypers FA. Erythrocyte defense

freeradbiomed.2005.11.017

[29] Scott MD, Kuypers FA,

PMID: 2553167

PMID: 1691257

2141.1990.tb07805.x

[18] Scott MD, Rouyer-Fessard P, Lubin BH, Beuzard Y. Entrapment of purified alpha-hemoglobin chains in normal erythrocytes. A model for beta thalassemia. Journal of Biological Chemistry. 1990;**265**:17953-17959.

[19] Rouyer-Fessard P, Scott MD, Leroy-Viard K, Garel MC, Bachir D, Galacteros F, et al. Fate of alpha-hemoglobin chains and

erythrocyte defects in beta-thalassemia. Annals of the New York Academy of Sciences. 1990;**612**:106-117. DOI: 10.1111/j.1749-6632.1990.tb24296.x

[20] Scott MD, Rouyer-Fessard P, Ba MS, Lubin BH, Beuzard Y. Alpha- and betahaemoglobin chain induced changes in normal erythrocyte deformability: Comparison to beta thalassaemia intermedia and Hb H disease. British Journal of Haematology. 1992;**80**:519- 526. DOI: 10.1111/j.1365-2141.1992.

[21] Scott MD. Entrapment of purified alpha-hemoglobin chains in normal erythrocytes as a model for human beta thalassemia. Advances in Experimental Medicine and Biology. 1992;**326**:139-

[22] Scott MD, van den Berg JJ, Repka T, Rouyer-Fessard P, Hebbel RP, Beuzard Y, et al. Effect of excess alpha-hemoglobin chains on cellular and membrane oxidation in model beta-thalassemic erythrocytes. The Journal of Clinical Investigation. 1993;**91**:1706-1712. DOI:

[23] Scott MD, Eaton JW. Thalassaemic erythrocytes: Cellular suicide arising from iron and glutathione-dependent oxidation reactions? British Journal of Haematology. 1995;**91**:811-819. DOI: 10.1111/j.1365-2141.1995.tb05394.x

**84**

[32] Scott MD, Zuo L, Lubin BH, Chiu DT. NADPH, not glutathione, status modulates oxidant sensitivity in normal and glucose-6-phosphate dehydrogenase-deficient erythrocytes. Blood. 1991;**77**:2059-2064. PMID: 2018843

[33] Scott MD, Wagner TC, Chiu DT. Decreased catalase activity is the underlying mechanism of oxidant susceptibility in glucose-6 phosphate dehydrogenase-deficient erythrocytes. Biochimica et Biophysica Acta. 1993;**1181**:163-168. DOI: 10.1016/0925-4439(93)90106-b

[34] Scott MD. Glucose-6-phosphate dehydrogenase deficiency: A new hypothesis for an old disease. Redox Report. 1995;**1**:235-237. DOI: 10.1080/13510002.1995.11746992

[35] Bucci E, Fronticelli C. A new method for the preparation of alpha and beta subunits of human hemoglobin. The Journal of Biological Chemistry. 1965;**240**:PC551-PC552. PMID: 14253474

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[41] Lunn G, Dale GL, Beutler E. Transport accounts for glutathione turnover in human erythrocytes. Blood. 1979;**54**:238-244. PMID: 444668

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[43] Wagner TC, Scott MD. Single extraction method for the spectrophotometric quantification of oxidized and reduced pyridine nucleotides in erythrocytes. Analytical Biochemistry. 1994;**222**:417-426. DOI: 10.1006/abio.1994.1511

[44] Eaton JW, Boraas M, Etkin NL. Catalase activity and red cell metabolism. In: Brewer GJ, editor. Hemoglobin and Red Cell Structure and Function. New York: Plenum Publishing Corp; 1972. pp. 121-131. DOI: 10.1007/978-1-4684-3222-0\_8

[45] Kirkman HN, Gaetani GF. Catalase: A tetrameric enzyme with four tightly bound molecules of NADPH. Proceedings of the National Academy of Sciences of the United States of America. 1984;**81**:4343-4347. DOI: 10.1073/pnas.81.14.4343

[46] Kirkman HN, Galiano S, Gaetani GF. The function of catalasebound NADPH. The Journal of Biological Chemistry. 1987;**262**:660- 666. PMID: 3805001

[47] Gaetani GF, Canepa L, Galiano S, Ferraris AM, Kirkman HK. Catalase and glutathione peroxidase are equally active in the detoxification of hydrogen peroxide in human erythrocytes. Blood. 1989;**73**:334-339. PMID: 2491951

[48] Scott MD, Meshnick SR, Williams RA, Chiu DT, Pan HC, Lubin BH, et al. Qinghaosu-mediated oxidation in normal and abnormal erythrocytes. The Journal of Laboratory and Clinical Medicine. 1989;**114**:401- 406. PMID: 2794752

[49] Meshnick SR, Scott MD, Lubin B, Ranz A, Eaton JW. Antimalarial activity of diethyldithiocarbamate. Potentiation by copper. Biochemical Pharmacology. 1990;**40**:213-216. DOI: 10.1016/0006-2952(90)90680-J

[50] Kuypers FA, Scott MD, Schott MA, Lubin B, Chiu DT. Use of ektacytometry to determine red cell susceptibility to oxidative stress. The Journal of Laboratory and Clinical Medicine. 1990;**116**:535-545. PMID: 2212862

[51] Hong YL, Pan HZ, Scott MD, Meshnick SR. Activated oxygen generation by a primaquine metabolite: Inhibition by antioxidants derived from Chinese herbal remedies. Free Radical Biology & Medicine. 1992;**12**:213-218. DOI: 10.1016/0891-5849(92)90029-G

[52] Minetti M, Mallozzi C, Scorza G, Scott MD, Kuypers FA, Lubin BH. Role of oxygen and carbon radicals in hemoglobin oxidation. Archives of Biochemistry and Biophysics. 1993;**302**:233-244. DOI: 10.1006/ abbi.1993.1205

[53] Aird WC. Spatial and temporal dynamics of the endothelium. Journal of Thrombosis and Haemostasis. 2005;**3**:1392-1406. DOI: 10.1111/j.1538-7836.2005.01328.x

[54] Wexler L, Bergel DH, Gabe IT, Makin GS, Mills CJ. Velocity of blood flow in normal human venae cavae. Circulation Research. 1968;**23**:349-359. DOI: 10.1161/01.RES.23.3.349

[55] Weiss L, Tavassoli M. Anatomical hazards to the passage of erythrocytes through the spleen. Seminars in Hematology. 1970;**7**:372-380. PMID: 5473419

[56] Chen LT, Weiss L. The role of the sinus wall in the passage of erythrocytes through the spleen. Blood. 1973;**41**:529- 537. PMID: 4688868

[57] LaCelle PL. Alteration of membrane deformability in hemolytic anemias. Seminars in Hematology. 1970;**7**:355- 371. PMID: 5473418

[58] Weed RI. The importance of erythrocyte deformability. The American Journal of Medicine. 1970;**49**:147-150. DOI: 10.1016/ S0002-9343(70)80069-9

[59] Chien S, Usami S, Bertles JF. Abnormal rheology of oxygenated blood in sickle cell anemia. The Journal of Clinical Investigation. 1970;**49**:623- 634. DOI: 10.1172/JCI106273

[60] Chien S, Usami S, Dellenback RJ, Gregersen MI. Sheardependent deformation of erythrocytes in rheology of human blood. The American Journal of Physiology. 1970;**219**:136-142. DOI: 10.1152/ ajplegacy.1970.219.1.136

**87**

*Model Human β Thalassemic Erythrocytes: Effect of Unpaired Purified α-Hemoglobin Chains…*

[69] Blendis LM, Modell CB,

2141.1974.tb06641.x

Bowdler AJ, Williams R. Some effects of splenectomy in thalassaemia major. British Journal of Haematology. 1974;**28**:77-87. DOI: 10.1111/j.1365-

[70] Dickerman JD. Bacterial infection and the asplenic host: A review. The Journal of Trauma. 1976;**16**:662-668. DOI: 10.1097/00005373-197608000-00012

[71] Dickerman JD. Splenectomy and sepsis: A warning. Pediatrics. 1979;**63**:938-941. PMID: 377203

Stefano P, Barone F, Concia E. Penicillin

[72] Borgna-Pignatti C, De

6468437

PMID: 3689941

PMID: 2825835

3689944

[75] Wasi C, Kuntang R,

compliance in splenectomized thalassemics. European Journal of Pediatrics. 1984;**142**:83-85. PMID:

[73] Fucharoen S, Piankijagum A, Wasi P. Deaths in beta-thalassemia/ Hb E patients secondary to infections. Birth Defects Original Article Series. 1987;**23**:495-500. PMID: 3689937

[74] Aswapokee P, Aswapokee N, Fucharoen S, Sukroongreung S, Wasi P. Severe infection in thalassemia: A prospective study. Birth Defects

Original Article Series. 1987;**23**:521-526.

Louisirirotchanakul S, Siritantikorn S, Fucharoen S, Aswapokee P, et al. Viral infections in beta-thalassemia/ hemoglobin E patients. Birth Defects Original Article Series. 1987;**23**:547-555.

[76] Swarup-Mitra S. Immunologic status of Hb E-thalassemia patients. Birth Defects. 1988;**23**:571-579. PMID:

[77] Swarup-Mitra S. Morbidity pattern in Hb E-thalassemia disease. Birth Defects Original Article Series. 1988;**23**:501-504. PMID: 3689938

*DOI: http://dx.doi.org/10.5772/intechopen.90288*

[62] La Celle PL. Pathogenic erythrocytes in the capillary microcirculation. Blood

[63] Havell TC, Hillman D, Lessin LS. Deformability characteristics of sickle cells by microelastimetry. American Journal of Hematology. 1978;**4**:9-16. DOI: 10.1002/ajh.2830040103

[64] Mohandas N, Phillips WM, Bessis M. Red blood cell deformability and hemolytic anemias. Seminars in Hematology. 1979;**16**:95-114. PMID:

[65] Clark MR, Mohandas N,

DOI: 10.1172/JCI109650

Shohet SB. Deformability of oxygenated irreversibly sickled cells. The Journal of Clinical Investigation. 1980;**65**:189-195.

[66] Clark MR, Mohandas N, Shohet SB. Osmotic gradient ektacytometry: Comprehensive characterization of red cell volume and surface maintenance. Blood. 1983;**61**:899-910. PMID:

[67] Snyder LM, Fortier NL, Trainor J, Jacobs J, Leb L, Lubin B, et al. Effect of hydrogen peroxide exposure on normal human erythrocyte deformability, morphology, surface characteristics, and spectrin-hemoglobin cross-linking. The Journal of Clinical Investigation. 1985;**76**:1971-1977. DOI: 10.1172/

[68] Snyder LM, Fortier NL, Leb L, McKenney J, Trainor J, Sheerin H, et al.

sulfhydryl groups in hydrogen peroxidemediated membrane damage in human erythrocytes. Biochimica et Biophysica

The role of membrane protein

Acta. 1988;**937**:229-240. DOI: 10.1016/0005-2736(88)90245-3

[61] Bessis M, Mohandas N. Red cell structure, shapes and deformability. British Journal of Haematology. 1975;**31**:5-11. DOI: 10.1111/j.1365-

2141.1975.tb00893.x

Cells. 1975;**1**:269-284

384522

6831052

JCI112196

*Model Human β Thalassemic Erythrocytes: Effect of Unpaired Purified α-Hemoglobin Chains… DOI: http://dx.doi.org/10.5772/intechopen.90288*

[61] Bessis M, Mohandas N. Red cell structure, shapes and deformability. British Journal of Haematology. 1975;**31**:5-11. DOI: 10.1111/j.1365- 2141.1975.tb00893.x

*Beta Thalassemia*

[45] Kirkman HN, Gaetani GF. Catalase:

of oxygen and carbon radicals in hemoglobin oxidation. Archives of Biochemistry and Biophysics. 1993;**302**:233-244. DOI: 10.1006/

[53] Aird WC. Spatial and temporal dynamics of the endothelium. Journal of Thrombosis and

Haemostasis. 2005;**3**:1392-1406. DOI: 10.1111/j.1538-7836.2005.01328.x

[54] Wexler L, Bergel DH, Gabe IT, Makin GS, Mills CJ. Velocity of blood flow in normal human venae cavae. Circulation Research. 1968;**23**:349-359.

[55] Weiss L, Tavassoli M. Anatomical hazards to the passage of erythrocytes through the spleen. Seminars in Hematology. 1970;**7**:372-380. PMID:

[56] Chen LT, Weiss L. The role of the sinus wall in the passage of erythrocytes through the spleen. Blood. 1973;**41**:529-

[57] LaCelle PL. Alteration of membrane deformability in hemolytic anemias. Seminars in Hematology. 1970;**7**:355-

[58] Weed RI. The importance of erythrocyte deformability. The American Journal of Medicine. 1970;**49**:147-150. DOI: 10.1016/ S0002-9343(70)80069-9

[59] Chien S, Usami S, Bertles JF. Abnormal rheology of oxygenated blood in sickle cell anemia. The Journal of Clinical Investigation. 1970;**49**:623-

634. DOI: 10.1172/JCI106273

Dellenback RJ, Gregersen MI. Sheardependent deformation of erythrocytes in rheology of human blood. The American Journal of Physiology. 1970;**219**:136-142. DOI: 10.1152/

[60] Chien S, Usami S,

ajplegacy.1970.219.1.136

DOI: 10.1161/01.RES.23.3.349

abbi.1993.1205

5473419

537. PMID: 4688868

371. PMID: 5473418

NADPH. Proceedings of the National Academy of Sciences of the United States of America. 1984;**81**:4343-4347.

Gaetani GF. The function of catalasebound NADPH. The Journal of Biological Chemistry. 1987;**262**:660-

[47] Gaetani GF, Canepa L, Galiano S, Ferraris AM, Kirkman HK. Catalase and glutathione peroxidase are equally active in the detoxification of hydrogen peroxide in human erythrocytes. Blood.

1989;**73**:334-339. PMID: 2491951

[49] Meshnick SR, Scott MD, Lubin B, Ranz A, Eaton JW. Antimalarial activity

Potentiation by copper. Biochemical Pharmacology. 1990;**40**:213-216. DOI: 10.1016/0006-2952(90)90680-J

[50] Kuypers FA, Scott MD, Schott MA, Lubin B, Chiu DT. Use of ektacytometry to determine red cell susceptibility to oxidative stress. The Journal of Laboratory and Clinical Medicine. 1990;**116**:535-545. PMID: 2212862

[51] Hong YL, Pan HZ, Scott MD, Meshnick SR. Activated oxygen

generation by a primaquine metabolite: Inhibition by antioxidants derived from Chinese herbal remedies. Free Radical Biology & Medicine. 1992;**12**:213-218. DOI: 10.1016/0891-5849(92)90029-G

[52] Minetti M, Mallozzi C, Scorza G, Scott MD, Kuypers FA, Lubin BH. Role

[48] Scott MD, Meshnick SR, Williams RA, Chiu DT, Pan HC, Lubin BH, et al. Qinghaosu-mediated oxidation in normal and abnormal erythrocytes. The Journal of Laboratory and Clinical Medicine. 1989;**114**:401-

406. PMID: 2794752

of diethyldithiocarbamate.

A tetrameric enzyme with four tightly bound molecules of

DOI: 10.1073/pnas.81.14.4343

[46] Kirkman HN, Galiano S,

666. PMID: 3805001

**86**

[62] La Celle PL. Pathogenic erythrocytes in the capillary microcirculation. Blood Cells. 1975;**1**:269-284

[63] Havell TC, Hillman D, Lessin LS. Deformability characteristics of sickle cells by microelastimetry. American Journal of Hematology. 1978;**4**:9-16. DOI: 10.1002/ajh.2830040103

[64] Mohandas N, Phillips WM, Bessis M. Red blood cell deformability and hemolytic anemias. Seminars in Hematology. 1979;**16**:95-114. PMID: 384522

[65] Clark MR, Mohandas N, Shohet SB. Deformability of oxygenated irreversibly sickled cells. The Journal of Clinical Investigation. 1980;**65**:189-195. DOI: 10.1172/JCI109650

[66] Clark MR, Mohandas N, Shohet SB. Osmotic gradient ektacytometry: Comprehensive characterization of red cell volume and surface maintenance. Blood. 1983;**61**:899-910. PMID: 6831052

[67] Snyder LM, Fortier NL, Trainor J, Jacobs J, Leb L, Lubin B, et al. Effect of hydrogen peroxide exposure on normal human erythrocyte deformability, morphology, surface characteristics, and spectrin-hemoglobin cross-linking. The Journal of Clinical Investigation. 1985;**76**:1971-1977. DOI: 10.1172/ JCI112196

[68] Snyder LM, Fortier NL, Leb L, McKenney J, Trainor J, Sheerin H, et al. The role of membrane protein sulfhydryl groups in hydrogen peroxidemediated membrane damage in human erythrocytes. Biochimica et Biophysica Acta. 1988;**937**:229-240. DOI: 10.1016/0005-2736(88)90245-3

[69] Blendis LM, Modell CB, Bowdler AJ, Williams R. Some effects of splenectomy in thalassaemia major. British Journal of Haematology. 1974;**28**:77-87. DOI: 10.1111/j.1365- 2141.1974.tb06641.x

[70] Dickerman JD. Bacterial infection and the asplenic host: A review. The Journal of Trauma. 1976;**16**:662-668. DOI: 10.1097/00005373-197608000-00012

[71] Dickerman JD. Splenectomy and sepsis: A warning. Pediatrics. 1979;**63**:938-941. PMID: 377203

[72] Borgna-Pignatti C, De Stefano P, Barone F, Concia E. Penicillin compliance in splenectomized thalassemics. European Journal of Pediatrics. 1984;**142**:83-85. PMID: 6468437

[73] Fucharoen S, Piankijagum A, Wasi P. Deaths in beta-thalassemia/ Hb E patients secondary to infections. Birth Defects Original Article Series. 1987;**23**:495-500. PMID: 3689937

[74] Aswapokee P, Aswapokee N, Fucharoen S, Sukroongreung S, Wasi P. Severe infection in thalassemia: A prospective study. Birth Defects Original Article Series. 1987;**23**:521-526. PMID: 3689941

[75] Wasi C, Kuntang R, Louisirirotchanakul S, Siritantikorn S, Fucharoen S, Aswapokee P, et al. Viral infections in beta-thalassemia/ hemoglobin E patients. Birth Defects Original Article Series. 1987;**23**:547-555. PMID: 2825835

[76] Swarup-Mitra S. Immunologic status of Hb E-thalassemia patients. Birth Defects. 1988;**23**:571-579. PMID: 3689944

[77] Swarup-Mitra S. Morbidity pattern in Hb E-thalassemia disease. Birth Defects Original Article Series. 1988;**23**:501-504. PMID: 3689938

[78] Sukroongreung S, Nilakul C, Aswapokee N, Aswapokee P, Fucharoen S, Wasi P. Oropharyngeal colonization with aerobic bacteria in β-thalassemia/hemoglobin E disease. Birth Defects Original Article Series. 1988;**23**:535-541. PMID: 3318952

[79] Sukroongreung S, Wasi P. Serum of thalassemic patients promotes growth of *Streptococci*. Birth Defects Original Article Series. 1988;**23**:543-546. PMID: 3689943

[80] Ampel NM, Van Wyck DB, Aguirre ML, Willis DG, Popp RA. Resistance to infection in murine betathalassemia. Infection and Immunity. 1989;**57**:1011-1017. PMCID: PMC313221

[81] Ampel NM, Bejarano GC, Saavedra M. Deferoxamine increases the susceptibility of beta-thalassemic, iron-overloaded mice to infection with Listeria monocytogenes. Life Sciences. 1992;**50**:1327-1332. DOI: 10.1016/0024-3205(92)90283-u

[82] Cherchi GB, Cossellu S, Pacifico L, Gallisai D, Ranucci A, Zanetti S, et al. Incidence and outcome of *Yersinia enterocolitica* infection in thalassemic patients. Contributions to Microbiology and Immunology. 1995;**13**:16-18. PMID: 8833786

[83] Wanachiwanawin W, Phucharoen J, Pattanapanyasat K, Fucharoen S, Webster HK. Lymphocytes in betathalassemia/HbE: Subpopulations and mitogen responses. European Journal of Haematology. 1996;**56**:153-157. PMID: 8598234

[84] Vento S, Cainelli F, Cesario F. Infections and thalassaemia. The Lancet Infectious Diseases. 2006;**6**:226-233. DOI: 10.1016/S1473-3099(06)70437-6

[85] Rahav G, Volach V, Shapiro M, Rund D, Rachmilewitz EA, Goldfarb A. Severe infections in thalassaemic patients: Prevalence and predisposing factors. British Journal of Haematology. 2006;**133**:667-674. DOI: 10.1111/j.1365-2141.2006.06082.x

[86] Yapp AR, Lindeman R, Gilroy N, Gao Z, Macintyre CR. Infection outcomes in splenectomized patients with hemoglobinopathies in Australia. International Journal of Infectious Diseases. 2009;**13**:696-700. DOI: 10.1016/j.ijid.2008.10.011

[87] Kao JK, Wang SC, Ho LW, Huang SW, Chang SH, Yang RC, et al. Chronic Iron overload results in impaired bacterial killing of THP-1 derived macrophage through the inhibition of lysosomal acidification. PLoS One. 2016;**11**:e0156713. DOI: 10.1371/journal.pone.0156713

[88] Loegering DJ, Grover GJ, Schneidkraut MJ. Effect of red blood cells and red blood cell ghosts on reticuloendothelial system function. Experimental and Molecular Pathology. 1984;**41**:67-73. DOI: 10.1016/0014-4800(84)90008-X

[89] Loegering DJ, Blumenstock FA. Depressing hepatic macrophage complement receptor function causes increased susceptibility to endotoxemia and infection. Infection and Immunity. 1985;**47**:659-664. PMCID: PMC261348

[90] Commins LM, Loegering DJ, Gudewicz PW. Effect of phagocytosis of erythrocytes and erythrocyte ghosts on macrophage phagocytic function and hydrogen peroxide production. Inflammation. 1990;**14**:705-716. DOI: 10.1007/BF00916373

[91] Loegering DJ, Schwacha MG. Macrophage hydrogen peroxide production and phagocytic function and decreased following phagocytosis mediated by Fc receptors but not complement receptors. Biochemical and Biophysical Research Communications. 1991;**180**:268-272. DOI: 10.1016/ S0006-291X(05)81287-2

**89**

*Model Human β Thalassemic Erythrocytes: Effect of Unpaired Purified α-Hemoglobin Chains…*

*DOI: http://dx.doi.org/10.5772/intechopen.90288*

[92] Schwacha MG, Gudewicz PW, Snyder JA, Loegering DJ. Depression of macrophage respiratory burst capacity and arachidonic acid release after Fc receptor-mediated phagocytosis. Journal of Immunology. 1993;**150**:236-

[93] Loegering DJ, Raley MJ, Reho TA, Eaton JW. Macrophage dysfunction following the phagocytosis of IgG coated erythrocytes: Production of lipid peroxidation products. Journal of Leukocyte Biology. 1996;**59**:357-363.

[94] de Sousa M. Blood transfusions and allograft survival: Iron-related immunosuppression [Letter]. Lancet. 1983;**2**(8351):681-682. DOI: 10.1016/

245. PMID: 8417125

DOI: 10.1002/jlb.59.3.357

s0140-6736(83)92558-8

*Model Human β Thalassemic Erythrocytes: Effect of Unpaired Purified α-Hemoglobin Chains… DOI: http://dx.doi.org/10.5772/intechopen.90288*

[92] Schwacha MG, Gudewicz PW, Snyder JA, Loegering DJ. Depression of macrophage respiratory burst capacity and arachidonic acid release after Fc receptor-mediated phagocytosis. Journal of Immunology. 1993;**150**:236- 245. PMID: 8417125

*Beta Thalassemia*

3689943

8833786

8598234

[78] Sukroongreung S, Nilakul C, Aswapokee N, Aswapokee P,

Fucharoen S, Wasi P. Oropharyngeal colonization with aerobic bacteria in β-thalassemia/hemoglobin E disease. Birth Defects Original Article Series. 1988;**23**:535-541. PMID: 3318952

predisposing factors. British Journal of Haematology. 2006;**133**:667-674. DOI: 10.1111/j.1365-2141.2006.06082.x

Gilroy N, Gao Z, Macintyre CR. Infection outcomes in splenectomized patients with hemoglobinopathies in Australia. International Journal of Infectious Diseases. 2009;**13**:696-700. DOI:

[86] Yapp AR, Lindeman R,

10.1016/j.ijid.2008.10.011

[87] Kao JK, Wang SC, Ho LW, Huang SW, Chang SH, Yang RC, et al. Chronic Iron overload results in impaired bacterial killing of THP-1 derived macrophage through the inhibition of lysosomal acidification. PLoS One. 2016;**11**:e0156713. DOI: 10.1371/journal.pone.0156713

[88] Loegering DJ, Grover GJ,

Experimental and Molecular Pathology. 1984;**41**:67-73. DOI: 10.1016/0014-4800(84)90008-X

Schneidkraut MJ. Effect of red blood cells and red blood cell ghosts on reticuloendothelial system function.

[89] Loegering DJ, Blumenstock FA. Depressing hepatic macrophage complement receptor function causes increased susceptibility to endotoxemia and infection. Infection and Immunity. 1985;**47**:659-664. PMCID: PMC261348

[90] Commins LM, Loegering DJ, Gudewicz PW. Effect of phagocytosis of erythrocytes and erythrocyte ghosts on macrophage phagocytic function and hydrogen peroxide production. Inflammation. 1990;**14**:705-716. DOI:

[91] Loegering DJ, Schwacha MG. Macrophage hydrogen peroxide production and phagocytic function and decreased following phagocytosis mediated by Fc receptors but not complement receptors. Biochemical and Biophysical Research Communications.

1991;**180**:268-272. DOI: 10.1016/

S0006-291X(05)81287-2

10.1007/BF00916373

[79] Sukroongreung S, Wasi P. Serum of thalassemic patients promotes growth of *Streptococci*. Birth Defects Original Article Series. 1988;**23**:543-546. PMID:

[80] Ampel NM, Van Wyck DB, Aguirre ML, Willis DG, Popp RA. Resistance to infection in murine betathalassemia. Infection and Immunity. 1989;**57**:1011-1017. PMCID: PMC313221

[81] Ampel NM, Bejarano GC, Saavedra M. Deferoxamine increases the susceptibility of beta-thalassemic, iron-overloaded mice to infection with Listeria monocytogenes. Life Sciences. 1992;**50**:1327-1332. DOI: 10.1016/0024-3205(92)90283-u

[82] Cherchi GB, Cossellu S, Pacifico L, Gallisai D, Ranucci A, Zanetti S, et al. Incidence and outcome of *Yersinia enterocolitica* infection in thalassemic patients. Contributions to Microbiology and Immunology. 1995;**13**:16-18. PMID:

[83] Wanachiwanawin W, Phucharoen J, Pattanapanyasat K, Fucharoen S, Webster HK. Lymphocytes in betathalassemia/HbE: Subpopulations and mitogen responses. European Journal of Haematology. 1996;**56**:153-157. PMID:

[84] Vento S, Cainelli F, Cesario F. Infections and thalassaemia. The Lancet Infectious Diseases. 2006;**6**:226-233. DOI: 10.1016/S1473-3099(06)70437-6

[85] Rahav G, Volach V, Shapiro M, Rund D, Rachmilewitz EA, Goldfarb A. Severe infections in thalassaemic patients: Prevalence and

**88**

[93] Loegering DJ, Raley MJ, Reho TA, Eaton JW. Macrophage dysfunction following the phagocytosis of IgG coated erythrocytes: Production of lipid peroxidation products. Journal of Leukocyte Biology. 1996;**59**:357-363. DOI: 10.1002/jlb.59.3.357

[94] de Sousa M. Blood transfusions and allograft survival: Iron-related immunosuppression [Letter]. Lancet. 1983;**2**(8351):681-682. DOI: 10.1016/ s0140-6736(83)92558-8

**91**

**Chapter 6**

**Abstract**

**1. Introduction**

*Nadia Maria Sposi*

Oxidative Stress and Iron Overload

In β-thalassemia, the erythropoietic process is markedly altered, and the lack or reduced synthesis of β-globin chains induces an excess of free α-globin chains within the erythroid cells. Aggregation, denaturation, and degradation of these chains lead to the formation of insoluble precipitates causing damage to the red blood cell membrane. One of the major consequences in this genetic disorder is iron overload due to ineffective erythropoiesis and premature hemolysis in the plasma and in major organs such as heart, liver, and endocrine glands. The chapter describes the etiology of iron accumulation, the role of hepcidin in regulating increased iron absorption, and the pathophysiology resulting from excess of "free iron" and discusses new ways to decrease the iron overload and to neutralize its

β-thalassemias are a group of hereditary blood disorders characterized by the reduced or absent synthesis of β-globin chains representing one of the most common autosomal recessive disorders worldwide. It is prevalent in the Mediterranean countries, the Middle East, and Southeast Asia, as well as countries along the Americas, coincidental with the occurrence of malaria. Carriers of β-thalassemia genes are considered relatively protected against malaria parasite. At present, because of vast population migration and intermarriage between different ethnic groups, β-thalassemia is also common in North and South America, Northern Europa, Australia, and the Caribbean. As a consequence of the reduced or absent synthesis of β-globin chains, there is an excess on α-globin chains that are instable and precipitate in red blood cell precursors causing abnormal cell maturation and their premature destruction in the bone marrow (ineffective erythropoiesis). Red blood cells that survive to reach the peripheral circulation are prematurely destroyed in the spleen. The break down products of Hb, heme, and iron catalyze chemical reactions that generate free radicals, including reactive oxygen species (ROS), which in excess are toxic, causing damage to vital organs such as the heart and liver and the endocrine system [1]. More than 300 different point mutations cause β-thalassemia. They are inherited in a multitude of genetic combinations responsible for clinical manifestations extremely diverse, spanning a broad spectrum from the transfusion-dependent state of thalassemia major

deleterious effects in the tissues other than iron chelation.

**Keywords:** oxidative stress, iron overload, β-thalassemia

(TM) to the asymptomatic state of heterozygous carriers for β<sup>0</sup>

semia trait). β-thalassemia intermedia requires only periodic blood transfusion,

or β<sup>+</sup>

(thalas-

in β-Thalassemia: An Overview

#### **Chapter 6**
