ALBERT

Description: Background: Sickle cell anemia (SCA) is a monogenic disease resulting in polymerization of hemoglobin in hypoxic conditions. This leads to red blood cell (RBC) membrane damage and sickling, causing vaso-occlusion and hemolysis. Continual, excessive release of lysed RBC contents within the vascular space can activate the inflammasome, a multiprotein oligomer that promotes maturation and secretion of pro-inflammatory cytokines, including interleukin 1-beta (IL-1β). The intravascular inflammation associated with SCA, e.g., increased serum c-reactive protein (CRP) and absolute counts of neutrophils and monocytes, is predictive of long-term morbidity and mortality. Inflammation is a major component of many of the clinical complications of SCA, including vaso-occlusive pain episodes, acute chest syndrome, vascular-endothelial dysfunction, renal disease and other forms of end organ damage. Standard of care for SCA is hydroxyurea, which augments fetal hemoglobin levels and may have some anti-inflammatory effects by reducing neutrophil and monocyte counts. Canakinumab is a fully human monoclonal antibody targeting IL-1ß and blocking its downstream pro-inflammatory activities with potential to ameliorate the inflammatory complications of SCA. Objective:To clinically validate in pediatric and young adult SCA patients the hypothesis that IL-1ß blockade by canakinumab is safe and provides clinical benefits. Methods: A multi-center, randomized, parallel group, double-blind, placebo-controlled trial recruited SCA patients (HbSS or HbS/ß0thalassemia) with history of ≥2 major pain episodes/year, screening baseline detectable pain (using pain e-diaries) and serum high sensitivity CRP level ≥1.0 mg/L. Patients were randomized with 1:1 ratio to receive six monthly s.c. injections of either canakinumab 300 mg (4 mg/kg for patients ≤40 kg) or placebo. The concurrent use of hydroxyurea was a stratification factor at randomization. Outcomes were measured at baseline and at weeks 4, 8, 12, 16, 20, 24, after which all patients moved to open label canakinumab treatment for additional 6 months. Electronic patient reported outcomes included daily pain intensity with a 0-10 cm visual analog scale, school/work absences secondary to SCA, fatigue and analgesic use. The primary outcome was change from baseline in the 4-week average daily pain intensity at week 12. Other secondary and exploratory outcomes included daily activity measured by wrist actigraphy, rate of hospitalization and adverse events, serious adverse events, transcranial Doppler velocities, percent oxygen saturation and laboratory markers of inflammation and hemolysis. Results: A planned interim analysis for futility and safety was performed on the first 30 enrolled patients (canakinumab, n=16; placebo, n=14), of whom 26 patients completed the Week 12 assessments (canakinumab, n=14; placebo, n=12), and 13 patients completed the Week 24 assessments. Enrolled patients (median age 17 years, range 12-20; 19 male, 11 female) were evenly distributed between treatment arms. All except one patient were maintained on a stable hydroxyurea regimen. Baseline overall disease activity levels (median, [range]) included average daily pain 3.93 [0.29, 6.57]; high sensitivity CRP 3.93 mg/L [1, 64.7]; transcranial Doppler velocities 85.0 m/s [23, 267]; hemoglobin 94.8 g/L [73.5, 121]. Futility criteria were not met and no canakinumab-associated safety issues were identified in this first interim analysis. Conclusions: Canakinumab was well tolerated and not associated with any major side effects in SCA. Results from a second interim analysis of study outcomes for all currently enrolled patients (n=49) completing the blinded, 24-week treatment period will be available in November 2019. Disclosures Rees: Agios: Other: Grants; TauRx (methylene blue): Other: Data monitoring committees; Astra Zeneca (ticagrelor): Other: Data monitoring committees; Novartis: Other: Strategic advisory role,Principal investigator,sickle cell disease2.6 Investigator; Emmaus: Other: Strategic advisory role; Celgene: Other: Strategic advisory role; Global Blood Therapeutics: Other: Strategic advisory role; Alnylam: Other: Principal investigator. Dampier:Micelle Biopharma: Consultancy, Research Funding; Merck: Research Funding; Hudson Publishing Company: Consultancy; Global Blood Therapeutics: Consultancy; Ironwood: Consultancy; Epizyme: Consultancy; Modus Therapeutics: Consultancy; Pfizer: Consultancy, Research Funding; Novartis: Consultancy, Research Funding. Mahlangu:Sanofi Genzyme: Research Funding, Speakers Bureau; Pfizer: Consultancy, Research Funding, Speakers Bureau; Takeda: Consultancy, Honoraria, Speakers Bureau; Novartis: Research Funding; Baxalta: Consultancy, Research Funding, Speakers Bureau; LFB: Consultancy; Biomarin: Research Funding; uniQure: Research Funding; Spark: Consultancy, Speakers Bureau; Chugai: Consultancy; CSL Behring: Consultancy, Research Funding, Speakers Bureau; Freeline Therapeutics: Research Funding; NovoNordisk: Consultancy, Research Funding, Speakers Bureau; Roche: Consultancy, Research Funding, Speakers Bureau; Shire: Consultancy, Research Funding, Speakers Bureau; Sobi: Research Funding, Speakers Bureau; World Federation of Haemophilia: Speakers Bureau. Mortier:Novartis Pharma AG: Employment. McNamara:Novartis Pharma AG: Employment. Li:Novartis Pharma AG: Employment. Oliver:Novartis Pharma AG: Employment, Equity Ownership. OffLabel Disclosure: canakinumab use in the treatment of sickle cell anemia.

Description: Abstract 2110 Introduction: Iron chelation is the life-saving therapy in patients with chronic transfusion therapy. Treatment with deferoxamine, deferiprone or deferasirox has dramatically improved the life expectancy, but still myocardial siderosis and hepatic siderosis is cause of morbidity and mortality in regularly transfused patients with ß-thalassemia major (TM) or Diamond-Blackfan Anemia (DBA). Deferasirox (DSX) a once-daily oral iron chelator has demonstrated efficacy in reducing hepatic iron and body iron burden, as well as cardiac iron. But in patients with severe cardiac siderosis (T2* ≤ 10ms) a combination therapy with deferiprone (Ferriprox®) and deferoxamine (Desferal®) is the recommended therapy. However, some patients will not benefit from this treatment due to unacceptable toxicity, poor response or noncompliance. Method: We tested a twice-daily deferasirox (Exjade®) -dose with special respect to its efficacy on reducing cardiac iron overload. A group of six patients with severe secondary siderosis was studied, TM (n=5) and DBA (n=1), (5 females, age 8–37 years, mean age 27.7 years). In all patients the liver iron concentration was measured repeatedly by SQUID biosusceptometry or by magnetic resonance imaging (MRI) using the MRI-R2 technique (St. Pierre et al, 2005). In 4 patients with severe cardiac siderosis (T2* ≤ 10ms) we also followed the cardiac iron concentration by MRI using a single breath-hold, multi-echo T2* method. Patients received a daily DSX dose of 19 mg/kg/d – 45 mg/kg/d, with a mean dose of 32 mg/kg/d. Results: The mean initial liver iron concentration of 2.7 mg/g-liver (0.96 – 5.5mg/g) decreased to 1.5 mg/g-liver (0.6 – 3.9 mg/g). The mean monthly liver iron clearance was 6.8%/month (1.7 – 16.8%/month) in a treatment interval of 4 – 26 months (mean: 9.8 months), the patients demonstrated a significant liver iron reduction of 44.4%. The mean serum ferritin was reduced from 3048 μg/l to 1786 μg/l. The mean monthly cardiac iron clearance was 3.1%/month (1.2 – 4.7%/month) and the mean T2* value improved from 9.5 ms to 14.3 ms (+50%). We showed a substantial improvement in patients with severe cardiac siderosis with a T2* improvement of 50 % after a mean treatment period of 12 months with a mean DSX dose of 32 mg/kg/d. In comparison, an improvement of 23.8% was found in 6 patients with T2* 〈 10 ms, after a treatment period of 18 months with a once daily DSX mean dose of 38 mg/kg/d (Pathare et al, 2010). Other authors reported an improvement of 10.8% in 47 patients (T2* 〈 10 ms, treatment period 12 months) with a once daily DSX mean dose of 32 mg/kg/d (Pennell et al, 2009). No severe side effects were seen in our patients and only minor increases in creatinine values, which were reversible with dose reduction. Conclusion: Deferasirox divided in twice daily doses is a safe and effective therapy for patients with severe cardiac iron overload (T2* 〈 10ms) or hepatic iron overload, who do not well tolerate a combination therapy with deferiprone and deferoxamine. Disclosures: Off Label Use: Deferasirox (Exade)is given instead of a once daily dose, in a twice daily divided dose. The daily dose of Deferasirox is in recommended range.

Description: Introduction Complications of transfusional iron overload vary with the underlying hematologic condition and may be affected by inherent differences in non-transferrin bound iron (NTBI) generation between these conditions. We have previously reported high NTBI levels in Diamond Blackfan anemia (DBA) relative to sickle cell (SCD), despite lower serum ferritin and LIC associated with very low sTfR levels in DBA. This suggested that low transferrin iron utilization in DBA relative to SCD and thalassemia major (TM) accounted for high NTBI levels. It is known that pro-inflammatory cytokine IL6 will increase hepcidin synthesis thereby decreasing ferroportin expression on macrophages but it is not known whether high levels of inflammatory cytokines can overcome or limit the effects of iron overload in raising NTBI and transferrin saturation. Here we have examined additional factors that may affect NTBI levels in different forms of inherited anemias. The relationship of inflammatory markers, the hepcidin/ferritin ratio and monocyte ferroportin in these conditions to NTBI levels have been examined. The possible effect of vitamin C or vitamin D deficiency on NTBI has also been examined. Methods 15 iron-overloaded patients (5 from each group of TM, SCD, and DBA) with ferritin 〉 1500 g/dl or LIC 〉 7 mg/g dry wt, age 16, age 0 to 9 at initiation of transfusion and 10 to 20 years of transfusion exposure were enrolled from 3 sites in the US and Europe. 5 non-transfused healthy controls were also enrolled. Fasting, early morning blood samples (including WBC isolation) were obtained one day prior to transfusion. Chelation was held for 72 hours prior to each sample and samples taken pre-transfusion. Measurement of hepcidin, sTfR, GDF-15, transferrin saturation, NTBI and LPI was as described elsewhere. Inflammatory cytokine IL6 and IL10 were measured by multiplex bead fluorimetry. Ferroportin expression in circulating monocytes, a potential marker of its expression in resident macrophages of spleen, liver and bone marrow was measured by western blotting. Results Results shown in Table 1 are most notable for the following findings: in DBA, the inflammatory markers IL6 and IL10 are high as in SCD or TM. Furthermore plasma hepcidin levels and hepcidin/ferritin ratios are higher in DBA, than in SCD or TM. Despite these high values of hepcidin, IL6 and IL10, monocyte ferroportin levels and NTBI remain high in DBA. This suggests that chronically high levels of circulating hepcidin do not decrease NTBI in patients with low transferrin iron utilization (as in DBA) and that this latter effect combined with iron overload is the more powerful determinant in raising NTBI levels. If the circulating monocytes are a true reflection of resident tissue macrophages that phagocytize red cells, this would suggest that high hepcidin levels are insufficient to suppress ferroportin expression in the presence of severe iron overload. TGFb was most raised in SCD whereas TNFα, were similar in SCD, Thal and DBA. In SCD ferroportin levels on circulating monocytes were lower than DBA and Thal as well as being lower than control which could contribute to low transferrin saturation and low NTBI levels. Vitamin C levels were also lowest and this could contribute to iron retention within macrophages and hence the low NTBI levels observed in SCD. Conclusions Taken with our previous findings (ASH abstract 2012), our results are consistent with NTBI and Tf saturation being determined by an interaction of opposing effects, which vary depending on the underlying cause of anemia. NTBI and Tf saturation are increased by (a) iron overload, (b) low erythropoiesis though low utilization of transferrin iron. The findings in this study extension suggest that vitamin C deficiency in SCD could be a contributing factor to low NTBI and this requires further investigation. However the presence of a raised inflammatory cytokine and raised hepcidin appears to be insufficient to abrogate the combined effects of low utilization of transferrin iron and iron overload on raising NTBI in DBA. Disclosures: Porter: Novartis: Consultancy, Research Funding; Celgene: Consultancy; Shire: Consultancy. Walter:Novartis: Research Funding. Harmatz:Novartis: Research Funding; Shire: Consultancy, Honoraria, Research Funding, travel, travel Other. Vichinsky:Novartis: Honoraria, Research Funding.

Description: Abstract 5168 Chelation treatment of iron overload from chronic blood (RBC) transfusion is still a challenge to both, patients and medical caretakers. Different treatment regimes have been recommended so far, especially for chronically transfused patients with low or even normal liver iron concentration. We report the results from 16 regularly transfused patients with thalassemia major (TM) who were on iron chelation treatment under normal to mild liver iron concentration (LIC). All patients received deferoxamine (DFO) treatment before they changed to deferasirox (DSX) treatment. 16 TM patients (mean age 13.6 y) were treated with DSX (median dose 18 mg/kg/d, range: 7 – 33 mg/kg/d) for 6 to 71 months. Liver iron measurements by biomagnetic susceptometry (BLS) and/or MRI-R2 as well as cardiac MRI-R2* were performed in intervals of 6 to 12 months. The median LIC was 782 μ g/g-liver wet weight (range: 460 μ g – 1122 μ g). Median RBC transfusion rate was 8500 ml/y, equivalent to about 2 erythrocyte concentrates per 3 weeks or a daily iron influx of 16.2 mg/d. For each measurement interval, the ratio of daily iron influx and DSX dose rate was calculated. This represents the equilibrium molar efficacy for iron balance. In all 16 TM patients no severe side effects were observed and creatinine was in the normal range of 〈 0.9 mg/d throughout the treatment with DSX. From baseline DFO treatment interval to the endpoint of DSX treatment, liver iron decreased by 124 – 4689 μ g/g-liver (conversion factor of 6 for mg/g-dry-wgt), while serum ferritin decreased by -596 to 8283 μ g/l. For all measurement intervals, molar chelation efficacies between 18 % and 56 % were calculated at equilibrium with a median efficacy of 31 % (interquartile range = 16 %). This agrees with molar efficacies of DSX reported earlier, but for relatively higher LIC and chelation doses (Blood 2005; 106(11):#2690 and Blood 2007; 110(11):#2776). The cardiac R2* (median R2* = 38 s-1) was either below the normal threshold of 50 s-1 (T2* 〉 20 ms) or decreased by about 24 %/y under DSX treatment. In these few patients at low LIC, this was even higher than recently reported. Conclusion: Even in patients with normal to mild LIC iron chelation treatment with DSX is safe, does not result in increased creatinine levels or severe side effects and is as efficient as in patients with higher LIC. Disclosures: No relevant conflicts of interest to declare.

Description: Since the introduction of an improved blood transfusion and iron chelation therapy in patients with beta-thalassemia major (TM) and intermedia (TI), changes in bone structure and bone deformities are significantly diminished. However, older patients with thalassemia have a higher prevalence for fractures caused by osteoporosis. Additionally, most of these patients suffer from chronic bone pain. In 13 patients (10 TM und 3 TI, age 8 – 32 years), we have measured the bone mineral density (BMD) by dual-energy x-ray absorption (DXA). All patients, except one, regularly received blood transfusions and iron chelation treatment (deferoxamine, deferiprone, or deferasirox). In the young patient group (n = 5, age: 8 -20 y), a mean Z-score of −1.53 was found (Z-score was calculated from age related BMD). In patients 〉 20 years (n = 8, age: 21 – 32 years), a mean T-score of −1.66 was observed (T-score was calculated from BMD related to 30 years). Except two patients, all patients had a decreased BMD in comparison to the normal population. One female patient with normal BMD, already received osteoporosis treatment since 5 years due to initially low BMD. Moreover, all patients had a reduced vertebra height in comparison to the normal population. First results from monitoring the bone density by DXA and the trabecular bone structure by micro-CT, will be reported in all patients after 12 to 18 months under oral supplementation treatment with calcium and vitamin D.

Description: Objective: Patients with iron overload suffer from different organ damage due to increased iron concentration. Iron overload in the bone marrow and the influence of iron chelation therapy on bone marrow iron content may play an additional role in these patients and is until now not well examined. Material and Methods: We performed MRI-R2* measurements in the vertebral bone marrow using water-fat chemical shift relaxometry for estimation of iron and fat content in comparison to hepatic and splenic iron concentrations and serum ferritin in patients with iron overload due to hereditary hemochromatosis (HHC) and patients with siderosis due to red blood cell transfusions and /or iron loading anemia. 112 patients with iron overload, mean age: 32 y (transfusion dependent thalassemia major (TM) n=65, Diamond-Blackfan anemia (DBA) n=12, HHC n=10, iron loading anemia (EA) n=7, transfusion siderosis n=12 and stem cell transplantation n=6) and 14 control subjects underwent MRI for determination of the transverse relaxation rate R2*assessed from ROI based signal intensities of one transversal slice (10mm) through the liver, spleen, and mid-vertebral bone marrow. Breathhold water-fat relaxometry (12 echo times, TE=1.3-26ms, FA=20°, bandwidth=1955Hz/px) was performed to determine apparent fat contents (aFC) and bone marrow R2*. Additionally, serum ferritin values were assessed. In 67 patients with TM under chelation therapy with Deferasirox (DFX) we compared R2* bone marrow iron content with the ratio of the chelator dose rate (Deferasirox, [mmol/d]) to the total liver iron (LivFe = LIC*volume [g-Fe]). Results: Relative to controls (n=14, R2* = 95s-1) and HHC (n=10, R2* = 95s-1), median bone marrow R2* rates were significantly increased in patients with TM (n=65, R2* = 398s-1, p

Description: Background. The TWiTCH multicentre randomised phase III trial showed recently non inferiority of hydroxyurea (HU) with phlebotomy versus transfusions with chelation for primary stroke prevention and management of iron overload in children with sickle cell anemia, having had abnormal transcranial Doppler but no severe vasculopathy and after at least one year of transfusion. Importantly, children in the HU arm received the drug at the maximum tolerated dose (MTD) with escalation of dosage until absolute neutrophil count (ANC) is 48 hours, ACS, hospitalizations, and blood transfusion in the 12 months, decreased significantly under HU (P 3.0 x109/L, their mean HbF was 13.04 ± 8.6 %; 21 (13.20%) had ANC 〈 3.0 x109/L, their mean HbF was 21.02 ± 9.64 %. In conclusion We show that children included in the ESCORT-cohort received median HU dosage quite lower than the one given to children included in the TWiTCH trial which resulted in quite lower HbF %. This dosage was sufficient to very dramatically reduce SCD-related painful events. Whether it can exert the same brain protection as the one demonstrated in the TWiTCH study is so far not known. We encourage physicians to reach MTD when the indication for HU is brain protection. Disclosures De Montalembert: Addmedica: Research Funding; Novartis: Research Funding, Speakers Bureau.

Description: Abstract 995 Background: β-thalassemia major (TM) is the paradigm for chronic transfusional iron overload, in which the extra-hepatic organ failure is best described. In Sickle Cell Disease (SCD), these consequences appear later and at a lower frequency. In chronically transfused Diamond Blackfan Anemia (DBA), extra-hepatic iron overload, although less well documented, appears to occur early and at high frequency. A Multicenter Study of Iron Overload (MCSIO) aims to explore how key candidate factors affect iron distribution; including inflammation, ineffective erythropoiesis, level of iron overload, and hepcidin synthesis. Plasma non-transferrin bound iron (NTBI) could be a key mechanism by which iron is delivered to tissues and may determine the propensity for extra-hepatic iron distribution. Here we focus on how markers of ineffective erythropoiesis (IE) and erythron expansion impact iron distribution, with particular reference to NTBI and iron distribution determined by MRI. Methods: Iron-overloaded patients (5 TM, 5 SCD, and 5 DBA) with ferritin 〉 1500 g/dl or LIC 〉 7 mg/g dry wt, age ≥16, age 0 to 9 at initiation of transfusion and 10 to 20 years of transfusion exposure were enrolled from 3 sites in the US and Europe. 5 non-transfused healthy controls were also enrolled. A detailed medical, transfusion and chelation history were obtained with standardized MRI evaluations for hepatic, cardiac, and pituitary iron deposition. Fasting, early morning blood samples were obtained one day prior to transfusion. Chelation was held for 72 hours prior to each sample. Results: Results are shown in the table as median values. DBA patients had the highest NTBI prior to transfusion despite having the lowest ferritin and LIC levels. GDF15 levels were highest in TM, with similar levels in SCD and DBA. EPO levels were nearly two orders of magnitude higher in DBA than TM or SCD. DBA patients also had the highest median cardiac R2*; two patients showing values above the control range. Whereas the median pituitary R2 in DBA was not above control, two of the patients had the highest R2 values, suggesting heavy iron deposition. EPO values in DBA are nearly two orders of magnitude higher that in SCD or TM despite similar pre-transfusion Hb values. GDF15 values are approximately three times controls, while soluble transferrin receptors (sTfR) values are almost undetectable. With SCD, no patients had increased cardiac iron loading, despite median SF and LIC being the highest in this group. Surprisingly all SCD patients had pituitary R2 values above the upper limit of normal. 1 TM patient had increased cardiac R2* whereas three had increased pituitary iron. In TM, NTBI was strongly correlated with GDF15 (Pearson's Rho=0.93) but in DBA, GDF15 was inversely correlated with NTBI (-.95). Conclusions: High GDF15 levels have been reported in conditions associated with IE, such as TM, but not in DBA. GDF15 reputedly suppresses hepcidin synthesis, thereby increasing iron absorption and potentially NTBI levels. The increased GDF15 in DBA, while sTfr remain less than controls, suggests that erythropoietic precursors do not reach the stage where sTfr are expressed and that this occurs at a later differentiation stage than GDF15. Increasing NTBI in TM with increasing GDF15 is consistent with IE contributing to NTBI formation, but the lack of this relationship in DBA suggest another mechanism for high NTBI. As the erythron is destroyed at a pre-hemoglobinised stage in DBA, IE would not contribute directly to NTBI formation. However, the extremely high EPO levels in DBA may inhibit hepcidin synthesis, as in other conditions, thereby increasing NTBI. This in turn may account for the extra-hepatic iron distribution demonstrated by MRI in DBA. The increased pituitary iron without cardiac loading in the heavily loaded SCD patients suggests that with prolonged exposure to heavy iron overload, the pituitary iron loading may be the first indicator of extra-hepatic deposition. Disclosures: Porter: Novartis: Consultancy, Research Funding. Walter:Novartis: Research Funding. Harmatz:Novartis: Research Funding; Ferrokin: Research Funding. Wood:Ferrokin Biosciences: Consultancy; Shire: Consultancy; Apotex: Consultancy, Honoraria; Novartis: Honoraria, Research Funding. Vichinsky:Novartis: Consultancy, Research Funding; ApoPharma: Consultancy, Research Funding; ARUP Research lab: Research Funding.

Description: Abstract 5185 Thalassemia syndromes are among the most common hereditary diseases worldwide and are widespread throughout the Mediterranean Region, Africa, the Middle East, India, Burma, the Southeast Asia and Indonesia. Similarly, hemoglobinopathies are common in different ethnic groups and mixed syndromes of Thalassemia and hemoglobinopathies exist. In this retrospective study we report the number and type of Thalassemia mutations and their combination with hemoglobinopathies detected mostly in individuals with a migration background now living in Germany. DNA samples were analyzed by polymerase chain reaction (PCR) and direct DNA-sequencing and additionally by multiplex ligation-dependent amplification (MRC-HOLLAND MLPA®). Mutations in one or both beta-globin chains were found in 77 patients. Most of these mutations were beta Thalassemia mutations, n=41 (Thalassemia minor n=33, Thalassemia major/intermedia n=7, homozygous Quin-Hai Hemoglobinopathy n=1). In 34 samples we found the hemoglobin S single base mutation c. 20A〉T p. E7V, either alone or in combination with a hemoglobin C mutation c. 19G〉A p. E7K or beta Thalassemia mutation (HbAS n=14, HbSS n=12, HbSC n=6, HbSThal n=2). In two patients we found only the hemoglobin C mutation by itself (HbAC n=1, HbCC n=1). In 52 samples we found mutations on the alpha-globin chains, most often the 3. 7KB deletion (n=27), followed by the SEA (n=4), the 20. 5 KB deletion (n=4), the 4. 2 KB deletion (n=4), the Dutch deletion (n=3) and alpha triplication (n=3). Two of the remaining seven samples showed new alpha Thalassemia mutations which have not been described yet. In an additional 34 DNA samples we found a combination of alpha- and beta-globin chain changes. In 4 of these samples we detected new mutations in the alpha-globin chains. The prevalence of mutations in the alpha- and beta-globin chains varies greatly because of a complex ethnic structure of our patients. Changes of the alpha-globin chains could not be safely detected by hemoglobin-electrophoresis. These situations are very important for genetic counseling in a population in which consanguineous marriages are common. Furthermore, alpha-globin mutations are genetic modifiers for beta Thalassemia and sickle cell disease and will influence the phenotype of beta-globin chain mutations. Patients with a compound heterozygous mutation for beta Thalassemia will probably not be detected by hemoglobin-electrophoresis alone, as in milder forms and early childhood the hemoglobin is not severely decreased and hemoglobin electrophoresis may be misinterpreted for Thalassemia minor. Our findings underline the heterogeneity of beta-globin and alpha-globin chain mutations and the importance of hematological and molecular analyses in the diagnosis and genetic counseling. Disclosures: No relevant conflicts of interest to declare.

Description: Introduction Iron overload (IO) in transfusion-dependent anemias (Thalassemia major, Sickle Cell Disease, Diamond-Blackfan and Fanconi Anemia) persist after hematopoietic stem cell transplantation (HSCT) and can result in increased morbidity in long term survivors, e.g. nonspecific liver dysfunction, hepatic cell carcinoma, heart failure and endocrinological complications. To reduce IO, phlebotomy or iron chelation is a required and effective treatment. Although existing recommendations for screening and prevention of late effects following HSCT suggest determining serum ferritin (SF) levels 1year post transplant, there are no clear guidelines for screening IO and initiating treatment. It is well known that SF levels depend on several factors beyond IO, e.g. infection or graft versus host disease, thus it is very often elevated as an acute phase protein in the post-transplant period. Aim of the Study In a multicenter, retrospective study we analyzed the concordance between liver iron concentration (LIC) and SF in 90 measurements of 33 patients (median age 8.9 y, range 1-11 y) with transfusion-dependent anemias (Thalassemia major, Diamond-Blackfan and Fanconi Anemia) who underwent HSCT between 1996 and 2014. LIC was determined either by MRI-R2 (Ferriscan®) or SQUID liver susceptometry. Statistical methods We examine the concordance between the classification according to LIC and SF: for SF 〈 800 μg/L, SF 〉 800 μg/L, and for the total range of SF levels. Pearson correlation was used to examine the relationship between paired values of LIC and SF. To analyze the classification sensitivity of SF levels according to LIC ≥ 4.5 mg/gdw we applied receiver operating characteristic (ROC) analysis. This approach estimates the sensitivity and the specificity as function of each SF cut-off level. The predictive accuracy of SF measurements in predicting LIC classification was investigated by area under the ROC curve. All statistical tests are two-sided with a significance level of 5%. Data analysis was performed using commercial software (R, ROCR package and Graph Prism software) Results Correlation between serum ferritin and LIC A moderate correlation among ferritin and LIC was found for the overall measurements (n=90). The Pearson coefficient correlation was equal to 0.69 (p 800 μg/L (n=65) the relationship is moderate (p 800 μg/L (n=65) was 81%. Instead, ROC analysis for SF measurements 〈 800 μg/L (n=25) indicates non-informative prediction (area=0.53) (Fig. 2). Conclusion The values of of SF 〉 800 μg/L are applicable for predicting the classification according to LIC at a threshold ≥ 4.5 mg/gdw. A SF 〈 800 μg/L is not appropriate for predicting an initiating treatment of IO, because of a weak correlation (p=0.2) between paired SF and LIC values. Furthermore, the accuracy of SF indicated a non-informative prediction of classification according to LIC (ROC area = 0.53). Our data suggest that initiating and stopping treatment of IO in transfusion dependent patients after HSCT should be done on the basis of LIC measured via MRI or SQUID instead of SF measurements only. Figure 1. Correlation among LIC and SF Figure 1. Correlation among LIC and SF Figure 2. Accuracy of SF to predict LIC (ROC curve) Figure 2. Accuracy of SF to predict LIC (ROC curve) Disclosures Grosse: Swedish Orphan Biovitrum: Honoraria; Novartis Oncology: Honoraria, Research Funding.