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Author Topic: The levels of nitric oxide in beta-thalassemia minor  (Read 46278 times)
Andy Battaglia
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« on: February 04, 2012, 01:38:47 PM »

http://www.thefreelibrary.com/The+levels+of+nitric+oxide+in+beta-thalassemia+minor%2FBeta+talasemi...-a0195681338

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Introduction

Normal individuals have three different hemoglobin electrophoretic patterns: Hb A, Hb [A.sub.2] and Hb F. Thalassemias are characterized by reduced or absent production of one or more globin  chains in the Hb A structure, which is a tetramer  consisting of two pairs of globin polypeptide chains: one pair of alpha chains and one pair of beta chains [1].

Beta-thalassemia is the classical form of thalassemias and was first described by Dr. Thomas Cooley in 1925. The name thalassemia  comes from its being a disorder most common among people of Mediterranean descent. It is an inherited type of anemia caused by the beta-thalassemia genes received from one's parents. This disorder arises from mutations in the gene on chromosome 11, which encodes the globin polypeptide subunits of hemoglobin, resulting in impaired production of beta globin chains [2]. The clinical severity of thalassemia varies tremendously depending on the amount of beta globin chains produced by the defective genes and whether the patient is homozygous or heterozygous. Beta-thalassemias are broadly classified into three groups, based on clinical severity: major, intermedia and minor. Impaired production of beta globin chains leads to a variable accumulation of alpha globin chains in erythroid  precursors, which results in decreased production of Hb A and abnormal erythroblast  formation. This leads to hemolysis of red cells in the peripheral circulation. Chronic hemolytic anemia, resulting from ineffective erythropoiesis , is the hallmark of all thalassemia syndromes [3].
Nitric oxide (NO), a diffusible  intercellular messenger, is produced by most mammalian cells including vascular endothelium, neurons, smooth muscle cells, macrophages, neutrophils, platelets and epithelium [4]. It is also found in the cytoplasm of follicular cells as well as in the endothelial cells of the thyroid gland [5,6]. Immunohistochemical studies have also demonstrated that nitrosamines are found in villous  vascular endothelium, and surrounding vascular smooth muscle cells and villous stroma of the placenta [7]. Endothelial dysfunction related to chronic hemolysis is well documented in hemoglobinopathies and may be a result of decreased NO availability [8].

To the best of our knowledge, the relationship between beta-thalassemia minor and NO has not been identified in the literature.

The objective of this study was to demonstrate plasma NO levels in beta-thalassemia minor patients.

Materials and Methods

Patients

Patients with beta-thalassemia minor who applied to the Hematology Polyclinic  of Inonu University Medical Faculty between January 2005 and December 2006 were included in the study. Of the 60 beta-thalassemia minor patients, 30 were male and 30 were female, with a median age of 26 years. In all patients with decreased mean corpuscular volume  (MCV) values and increased red blood cell  (RBC) counts, ferritin  levels were measured. Patients with iron deficiency anemia  and other causes of microcytosis were excluded from the study. After normal serum ferritin levels were documented, hemoglobin electrophoresis was performed. The patients diagnosed as beta-thalassemia minor by demonstrating increased levels of Hb [A.sub.2] on hemoglobin electrophoresis were included in the study. We excluded those with alpha-thalassemia or other hemoglobinopathies. Informed consent was obtained at the beginning of the study from all participants, both the beta-thalassemia minor patients and the healthy control subjects. The control group consisted of 60 healthy subjects (30 M, 30 F, median age: 24 years), NO levels in the blood samples were measured and statistical significance was evaluated.

Hemoglobin Electrophoresis and Assessment of Proteinuria   

Electrophoresis was performed with Hydrogel Hemoglobin agarose gel kits (Hayras Sebia, USA).

Assay for Nitric Oxide

Plasma nitrite/nitrate levels were measured with the Griess reaction using a spectrophotometer at 545 nm.

Statistical Analysis

Comparisons between groups of data were performed by Mann-Whitney U test. A value of p<0.005 was considered significant.

Results

Plasma direct and total nitrite levels were 7.561 [+ or -] 6.19 and 42.548 [+ or -] 7.37 in beta-thalassemia minor patients versus 36.9 [+ or -] 19.8 and 85.9 [+ or -] 35.3 in controls, respectively, and the difference between the two groups was statistically significant (p<0.001). Plasma nitrate level was 34.84 [+ or -] 6.24 in beta-thalassemia minor patients versus 48.61 [+ or -] 17.35 in controls, respectively, and the difference between the two groups was statistically significant (p<0.001) (Table 1).

Discussion

Thalassemia describes a group of inherited blood disorders caused by genes received from one's parents [3]. Thalassemia, also called Mediterranean anemia, is among the most common genetic disorders worldwide and is relatively frequent in people of Mediterranean descent. It has a broad clinical spectrum, ranging from the transfusion-dependent state of thalassemia major to the asymptomatic state of thalassemia trait [2].

Hemoglobinopathies characterized by chronic hemolysis are currently considered sources of strong oxidative stress. Reports have shown that the free heme and the red cell membrane elements that are produced during hemolysis have a negative effect on NO and arginine availability, which in turn promotes vasoconstriction. They also lead to further endothelial dysfunction, resulting in a more pronounced NO reduction [9]. In hemoglobinopathies, NO binds very rapidly to deoxyhemoglobin, forming a stable Hb ([Fe.sup.+2])-NO complex. NO also reacts with and converts oxygenated hemoglobin to methemoglobin  and nitrate (N[O.sub.3.sup.-]). Rates of intravascular NO scavenging are reduced significantly when hemoglobin is sequestered within red cell membranes [10].

Pathological processes in thalassemia accelerate the destruction of NO, and limit the compensatory increase in NO production. Hemoglobin decompartmentalized from the red cell into blood plasma by intravascular hemolysis reaches steady-state levels of 5-10 [micro]M, at times exceeding 50 [micro]M. This hemoglobin reacts with NO in a rapid, nearly diffusion-limited reaction to produce methemoglobin and inert nitrate. In addition, NO is also consumed by reaction with reactive oxygen species produced as a by-product of the highly expressed enzymatic activities of xanthine oxidase and NADPH oxidase. Lastly, more recent studies suggest that hemolysis leads to uncoupling of endothelial NO synthase activity, likely secondary to heme-mediated oxidative damage to the enzyme, also producing reactive oxygen species. These mechanisms may combine additively to markedly accelerate NO destruction [11]. Arginase  activity is elevated in red blood cells of thalassemia patients and is likely related to reticulocytosis, since immature cells and reticulocytes are known to contain a high concentration of arginase. It is therefore likely that erythrocyte release of arginase during hemolysis will limit the availability of arginine to nitric oxide synthase, resulting in a deficiency of NO and dysregulation of arginine metabolism in thalassemia patients through a similar mechanism identified in sickle cell disease . Multiple mechanisms directly and indirectly attributable to hemolysis reduce NO bioavailability in thalassemia. The resulting impairment in NO bioavailability is associated with vasoconstriction, endothelial dysfunction and thrombosis. Autopsy findings in thalassemia, particularly pulmonary thrombi , have been observed in patients who had previously undergone splenectomy  [12].

Many factors associated with vascular dysfunction or hemolysis have been shown to affect NO levels. Therefore, patients with the diagnosis of thalassemia minor and no other risk factor were included in the current study and NO levels were measured as soon as blood samples were obtained.

Chronic hemolysis in patients with underlying hemoglo-binopathies may be a result of decreased NO availability. However, the relationship between beta-thalassemia minor and NO levels has not yet been proven in the literature. We found that plasma NO levels in beta-thalassemia minor patients were significantly lower than those in controls. The laboratory findings are shown in Table 1. This may be explained by hemolysis-associated endothelial dysfunction. In contrast, thalassemia intermedia and thalassemia major are probably associated with more severe degrees of hemolysis. It would have been preferable if the NO levels of the patient group were also compared with thalassemia major patients or Hb S patients as a positive control. Our study population consisted of patients diagnosed with beta-thalassemia minor. This issue may only be fully clarified by further molecular studies.

In conclusion, low NO levels are thought to be related to the chronic hemolysis. Supportive treatment of hemolytic anemia hemolysis may increase the NO bioavailability, which may be helpful in assessing the prognosis and follow-up of the patients. To draw such a conclusion, further prospective studies are needed in a large number of patients.

Received: September 1, 2008 Accepted: November 10, 2008

Gelis tarihi: 1 Eylul 2008 Kabul tarihi: 10 Kasim 2008

References

[1.] Riou J, Godart C, Mathis M, Hurtrel D, Wajcman H, Prehu C, Bardakdjian J. Evaluation of the Bio-Rad VARIANT II HbA2/HbA1C Dual Program for measurement of hemoglobin concentrations and detection of variants. Clin Chem Lab Med 2005;43:237-43.

[2.] Engelborghs S, Pickut BA, De Deyn PP. Recurrent transient ischemic  attacks in a 15-year-old boy with beta-thalassemia minor and thrombophilia. Contribution of perfusion SPECT to clinical diagnosis. Acta Neurol Belg 2003;103:99-102.

[3.] Rund D, Rachmilewitz E. Beta-thalassemia. N Engl J Med 2005;353:1135-46.

[4.] Mayer B, Hemmens B. Biosynthesis and action of nitric oxide in mammalian cells. Trends Biochem Sci 1997;22:477-81.

[5.] Domachowske JB, Rafferty SP, Singhania N, Mardiney M 3rd, Malech HL. Nitric oxide alters the expression of gamma-globin, H-ferritin and transferrin receptor in human K562 cells at the posttranscriptional level. Blood 1996;15:2980-8.

[6.] Reddy PL, Bowie LJ, Callistein S. Binding of nitric oxide to thiols and hemes in hemoglobin H: implications for alpha-thalassemia and hypertension. Clin Chem 1997;43:1442-7.

[7.] Punnonen K, Irjala K, Rajamaki A. Iron-deficiency anemia with high concentrations of transferrin receptor in serum. Clin Chem 1994;40:774-6.

[8.] Vichinsky EP. Pulmonary hypertension in sickle cell disease. N Engl J Med 2004;350:857-9.

[9.] Aessopos A, Kati M, Farmakis D. Heart disease in thalassemia intermedia: a review of the underlying pathophysiology. Haematologica 2007;92:658-65.

[10.] Aslan M, Freeman BA. Redox-dependent impairment of vascular function in sickle cell disease. Free Radic Biol Med 2007;1:1469-83.

[11.] Kato GJ, Onyekwere OC, Gladwin MT. Pulmonary hypertension in sickle cell disease: relevance to children. Pediatr Hematol Oncol 2007;24:159-70.

[12.] Morris CR, Kuypers FA, Kato GJ, Lavrisha L, Larkin S, Singer T, Vichinsky EP. Hemolysis-associated pulmonary hypertension in thalassemia Ann NY Acad Sci 2005;1054:481-5.

Nihayet Bayraktar (1), Mehmet Ali Erkurt (2), Ismet Aydogdu (2), Yalcin Basaran (3)

(1) Department of Biochemistry, Inonu University Faculty of Medicine, Malatya, Turkey (2) Department of Hematology, Inonu University Faculty of Medicine, Malatya, Turkey (3) Department of Internal Medicine, Gulhane Military Medical Academy, Ankara, Turkey

Address for Correspondence: Dr. Mehmet Ali Erkurt, Department of Hematology Inonu University, Faculty of Medicine Turgut Ozal Medical Center 44069 Malatya, Turkey Phone: +90 505 649 57 05 Fax: +90 422 341 07 28 E-mail: erkurtali@hotmail.com
Table 1. Laboratory findings of thalassemia patients and controls

                    Thalassemia patients
                            n=60

Hb A (%)           89.787 [+ or -] 4.959

Hb F (%)           5.593 [+ or -] 2.021

Hb A2 (%)          3.735 [+ or -] 0.974

Carbonic           1.156 [+ or -] 0.354
anhydrase (%)

Direct nitrite     7.561 [+ or -] 6.198
([micro]mol/dl)

Total nitrite      42.548 [+ or -] 7.379
([micro]mol/dl)

Nitrate            34.845 [+ or -] 6.249
([micro]mol/dl)

                       Control group         p value
                            n=60

Hb A (%)           96.522 [+ or -] 7.675     p<0.001

Hb F (%)

Hb A2 (%)          2.123 [+ or -] 0.216      p<0.001

Carbonic           2.085 [+ or -] 0.421      p<0.001
anhydrase (%)

Direct nitrite     36.963 [+ or -] 19.833    p<0.001
([micro]mol/dl)

Total nitrite      85.975 [+ or -] 35.286    p<0.001
([micro]mol/dl)

Nitrate            48.613 [+ or -] 17.359    p<0.001
([micro]mol/dl)
COPYRIGHT 2008 Aves Yayincilik
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2008 Gale, Cengage Learning. All rights reserved.

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Andy Battaglia
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« Reply #1 on: February 04, 2012, 01:43:31 PM »

I have posted this to emphasize the findings that nitric oxide levels have been measured to be low in thal minors. Even though the conclusion (as always) is more study is needed, we can draw some conclusions from this study.
First, minors are low in NO.
Second, it is suspected that low NO levels contribute to the hemolysis that already exists in thal minors, creating a vicious cycle. Low NO increases hemolsysis, which also leads to lower NO levels.

This is why I suggest that minors supplement with nitric oxide inducers like L-carnitine, L-arginine or L-citrulline, along with following a wholesome diet rich in NO inducing foods. Many fresh fruits fall into this category.
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« Reply #2 on: February 05, 2012, 11:15:02 PM »

Thanks Andy,

This research is very helpful. 

I have one question about L-carnitine.  I understand that there is a contraindication for hypothyroid and L-carnitine b/c L-carnitine interferes with thyroid hormone uptake - is this correct or am I misunderstanding something? 

Many thanks,

Sharmin
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« Reply #3 on: February 06, 2012, 06:11:11 AM »

Thanks Andy,

I'm hypothyroid too, so I have the same question. Also how much L carnitine supplement is needed for a thal minor?

Thnx.
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« Reply #4 on: February 07, 2012, 08:45:19 PM »

Sharmin,

This question proved quite a challenge. Results found in internet searches are dominated by the same incorrect information that is drawn from an erroneous conclusion, which was NOT the conclusion of those who ran the study that everyone wants to quote with the ever present phrase, L-carnitine SEEMS to inhibit the effects of thyroid hormone. In the original study, women with goiters were given thyroid hormone in amounts that cause hyperthyroidism. To counter the side effects of hyperthyroidism, 50 women were given L-carnitine, which did have an effect as an antagonist to thyroid hormone and did lessen symptoms. However, nothing was studied about hypothyroid and carnitine, yet many, including many in the medical profession, immediately jumped to a false conclusion that what seemed to be the opposite, must also be true. But there is absolutely nothing to prove that assumption.

While looking for something of relevance, I kept wondering why there was such a blanket acceptance of something that had not even been suggested in the original research. There is a huge problem on the internet and that is repeating of wrong information. Once it is read in one place, it can spread like wildfire, as few will take the time to research the topic themselves. I'm too stubborn for that and spent two days looking for anything that wasn't from a forum and wasn't just parroting of the same wrong information.
Finally, I found a couple doctor's sites saying that carnitine was needed in all forms of thyroid disease, so I knew there had to be more to the story. Both hyper and hypo, and this goes for Hashimoto's which manifests as hypo, result in carnitine depletion and patients of both test low. As it turns out, the explanation of why carnitine inhibits the entrance of thyroid hormone into cells, is that carnitine is protecting the mitochondria from over-stimulation in the presence of too much thyroid hormone. This does not relate to hypothyroid because there is not an excess of thyroid hormone. L-carnitine actually has a major protective effect on the cells. It is known that carnitine is essential for muscle development and it is suspected this holds true for bone strength and development, also.

Some sites did suggest that if L-carnitine is affecting your thyroid hormone levels, you will see this in the results of your annual thyroid test. Because you have thyroid disease and are a thal minor, you have two things working against you, both which deplete carnitine levels in your body. The muscle weakness aspect of thyroid disease has me ready to start L-carnitine again.

Pretty, the daily dose is 500-1000 mg daily. In hyperthyroid cases, 2000 mg daily are suggested.

I am including links to some pages that were of help understanding the relationship between carnitine and the cells.
http://www.metametrixinstitute.org/file.axd?file=2011%2F6%2FPage-554.pdf
http://jcem.endojournals.org/content/86/8/3579.long
http://www.drhoffman.com/page.cfm/607
Quote
Also critical is carnitine. Patients with hypothyroid have lower levels and lower production of this key fat-burning nutrient and elevated thyroid hormones increase carnitine loss as well. Supplemental carnitine will also help lower elevated lipid levels associated with hypothyroid.
http://www.lef.org/magazine/mag2007/dec2007_report_thyroid_02.htm
Quote
The researchers obtained skeletal muscle samples from both hyper- and hypothyroid patients, as well as from a group of normal controls. Samples from patients with thyroid disease were also repeated after a course of appropriate traditional treatment. When they measured muscle carnitine content in the samples, the researchers found a significant reduction in hyperthyroid patients, with a return to normal levels as the condition improved under treatment. They found smaller, less significant decreases in muscle carnitine content in the hypothyroid group as well, which also improved with treatment. Dr. Sinclair and his colleagues, like their Italian counterparts, recognized that the decreased availability of carnitine in muscles means that “there will be less energy (in the form of long-chain fatty acids) transported into the mitochondria” and further point out that “this might lead to diminished fatty acid oxidation in skeletal muscle and, consequently, lead to weakness.”
« Last Edit: February 07, 2012, 08:51:41 PM by Andy » Logged

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« Reply #5 on: May 21, 2012, 06:39:50 PM »

Hi Andy,

L-Arginine helps to elevate NO levels which should help ED issues.

Does L-Arginine help with ED issues in Thal-minor ? Any complications of taking L-Arginine and Cialis together ?

I read some articles about L-Arginine and Viagra might have some blood pressure issues.

Thanks so much.
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« Reply #6 on: May 21, 2012, 06:59:24 PM »

L-arginine has been shown to have value for ED. There is no interaction listed between Cialis and L-arginine. Both have a positive effect on pulmonary arterial pressure, but this should not be confused with blood pressure. Many older thal minors show mild symptoms of pulmonary hypertension, so supplementing with L-arginine, L-carnitine or L-citrulline may be beneficial.
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« Reply #7 on: May 21, 2012, 07:34:59 PM »

Thanks Andy. One more question - as a Thal minor, should we get our NO levels checked before supplementing ? What is the test to check NO levels ?
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« Reply #8 on: May 22, 2012, 09:49:45 AM »

No need for testing of NO. It is one of the most essential of all the body's needs. Toxic side effects of high dose usage of this group of supplements has not been reported, and it should be mentioned that body builders routinely take much higher doses than what I would suggest, without side effects. The goal is to keep a continuous supply of nitric oxide available to the circulatory system.
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« Reply #9 on: May 22, 2012, 10:38:50 AM »

Hi Andy, I've couple more questions if you don't mind.

- I couldn't find any interactions of L-Arginine and Cialis too. Cialis (just like other similar drugs) does have a very small chance of Priapism. With L-Arginine supplementation in addition to Cialis, the chances of Priapism shouldn't go up, right ?

Hopefully, over-time, just L-Arginine should be good enough without Cialis supplementation for ED.

- Any recommendations for L-Arginine or any of the CVS/Walgreens is good enough ? Also, any dosage recommendations ?

Thanks a lot again!
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« Reply #10 on: May 22, 2012, 07:26:04 PM »

L-arginine should have a positive effect on blood flow over the long term , which can only be a positive in terms of priapism. Assuming that pirapism in thal is similar in nature to that in sickle cell, it would seem that the problem would lie in the defective red blood cells being produced, along with the by-products of their breakdown. This "cutter" may be the reason for priapism, as it may be that it causes a blockage in the veins, as is the case with sickle shaped blood cells. Natural vitamin E, B-complex and magnesium will all help to build better quality red cells that don't break down as quickly, and vitamin E is also a mild natural blood thinner, which also will help circulation. I don't know if there's much difference in quality among the various L-arginine supplements. 1000-3000 mg daily.
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« Reply #11 on: August 29, 2016, 05:54:33 AM »

Andy, are we talking here about minors only or do you see also some use in b' major for intake arginine as supplements? I 've read something about 3000 mg / daily, is that correct?
By the way, I 've tried l-carnitin for some time but with no result.
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« Reply #12 on: August 29, 2016, 04:26:43 PM »

The need for promoting nitric oxide is much greater in majors and intermedia patients, as it can help to prevent pulmonary hypertension, which is a killer of older thals. The effects may never be noticed physically, but the preventative aspect is still there.
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« Reply #13 on: August 29, 2016, 05:54:11 PM »

thnx andy! By the way I am about to write something about thal minors having symptoms and whatsoever for our website, but I am a little concerned about the reaction it may cause! See, the thing is I have searched a little the German web about this and the only I have found was some articles on kind of haematologic / oncologic sites writen by Doctors which in genneral saying kind of  "for Minor there are no symptoms and therefore no need for treatment"
Although I am a patients advocate and have some quite good experience I musst admit I am afraid they will EAT ME ALIVE!!  Undecided
Any thought about this?



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« Reply #14 on: September 06, 2016, 08:55:25 PM »

Every doctor saying that is quoting the same wrong information found in countless texts and articles about thalassemia. None seem to understand that information like this is accepted without question by every publication that repeats it. The part of the attitude that bothers me most is the complete lack of understanding of basic math by so many doctors. When your body produces insufficient alpha or beta globin, you don't produce enough hemoglobin to be normal. Anemia is a very visible effect. So, how is anemia no symptoms? It is the most obvious symptom. But beyond that, once you take a look at what the defective red blood cells and the unmatched tetramers do in the body and to the body, then you get into the causes of even more symptoms. The processes at work in thal minor are undeniable, and honestly, modern medicine can do very little about it, because these are not symptoms that can be treated with drugs, so the industry as a whole has little incentive to help patients. This is why I do not ever suggest seeking medical treatment for thal minor, but instead, I encourage people to learn about the processes at work in their bodies and how they can try to adjust and compensate for the added nutritional needs that come with thalassemia. I don't think being a patient advocate for thal minors needs to incorporate the medical industry.
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