ARTICLES
305
Thalassemia Syndromes
IntroductionA growing number of studies describe BCL11A as a major repressor of fetal hemoglobin (HbF) expression. These include the description of several single nucleotide polymorphisms (SNPs) located in the BCL11A gene and linked to HbF level, and thus, the severity of sickle cell disease and beta-thalassemia (bthal) 1-4 and the demonstration of the direct binding of this transcription factor onto several locations in the b-globin cluster, in particular, to a region located 5' to the d-globin gene. 5 All these studies allow us to draw a network of co-operating transacting factors (KLF1, SOX6, GATA1 and BCL11A) involved in the switch between fetal and adult hemoglobin (Hb). A recent study 6 using the analysis of large deletions has defined a critical area located 5' to the d-globin gene that appears to exert the main repressor activity of BCL11A.However, if the role of the BCL11A binding region is now well documented, no studies have evaluated the consequence of the deletion of that region in terms of HbF output. We report the precise analysis of the correlation between phenotype and genotype of patients displaying a short deletion (under 25 kb) differing at the 5' d-globin gene breakpoint. The short length of the deletions found in our patients makes these events not comparable with hereditary persistence of fetal Hb (HPFH) deletions whose mechanism is likely to bring the 3'HS (3' hypersensitive site) activator site close to the g-globin genes, and thus enhances HbF expression.
Design and MethodsA cohort of 10 patients was selected from our DNA bank of patients referred to our laboratory for the molecular analysis of a bthal phenotype. Prior to sampling, patients received genetic counseling and gave their written, informed consent to the study. The selected patients were heterozygous carriers of a short deletion featuring the 5' breakpoint within the gb-d intergenic region. The phenotypic analysis of patients included red blood cell (RBC) count carried out on an automated cell counter, and Hb study using cation exchange high performance liquid chromatography (HPLC) (VARI-ANT II™; Bio-Rad Laboratories, Hercules, CA, USA). 8 The results are shown in Table 1. Relevant hematologic data were obtained to verify that no patient had received a blood transfusion which could compromise data interpretation. This retrospective study was approved by the Institutional Review Board of the Henri Mondor Hospital, Créteil, France.The molecular analysis of the b-globin cluster was achieved including deletion detection using the quantitative multiplex polymerase chain reaction of short fragment (QMPSF) procedure.
9Precise localization of unknown breakpoints was determined using a custom CGH-array chip with high probe density on the b-and aglobin clusters, 10 and achieved by amplification then sequencing, using primers extrapolated from probes flanking the deletions (Online Supplementary Figures S1-S6).In order to evaluate any correlation as precisely as possible, genotyping of the a-globin c...