Noor, F. A.; Hossain, M.; Sarker, S. K.; Arafath, K.; Ety, S. S.; Maisha, J. A.; Mahmud-Un-Nabi, M. A.; Bhuyan, G. S.; Sultana, N.; Hossain, A. K. M. E.; Khan, W. A. K.; Shekhor, H. U.; Qadri, F.; Mannoor, K.

Patients with HbE/{beta}-thalassemia inheriting the same {beta}-globin mutations display varied clinical manifestations, the mechanism of which is only partially known. The study aimed to decipher the heterogenous basis of HbE/{beta}-thalassemia patients in more details by focusing on both hematological and genetic modifiers influencing the disease severity, which included- (i) HbF and HbE levels using Hb electrophoresis, (ii) {beta}-thalassemia mutations, (iii) anti3.7triplication using Gap-PCR, (iv) individual and cumulative effects of HbF-inducing SNPs in 4 major modifier genes, namely HBG2, BCL11A, HBSB1L_MYB intergenic-region, and HBBP1 which were genotyped using DNA sequencing and Real-time PCR-HRM methods. Accordingly, 130 diagnosed Bangladeshi patients with HbE/{beta}-thalassemia were enrolled and categorized as mild, moderate, and severe as per Mahidol scoring system. c.79G>A+IVS1_5G>C was the most predominant (73.8% of total) mutation pair across all the 3 severity groups, indicating secondary modifiers might influence the severity. Our study found both HbF and HbE protective to HbE/{beta}-thalassemia, as both were inversely related to the severity score (HbF: p<0.0001/r=-0.55; HbE: p<0.0001/r=-0.56). Four SNPs- XmnI-G{gamma}, rs2071348 (HBBP1), rs489544 and rs28384513 (HBS1L_MYB) showed significant association with the elevated HbF levels (p=0.005, 0.0001, 0.0001, 0.004 respectively). The multivariate analysis showed that the risk genotypes with single or combination of 2, 3,and 4 SNPs showed gradually increased risk [Odd Ratio (95%CI)= 2.51, 5.47, 19.5, 39.0, respectively] of less severe phenotype, suggesting that these linked SNP variants had a cumulative effect on both HbF level and clinical severity score. However, low HbE level and copresence of anti3.7triplication were found to nullify the ameliorating effect of multiple SNPs.