（不吹不黑的論文翻譯）阿膠對改善地中海貧血孕婦貧血症和血紅蛋白成分的治療作用

譯者按：經常看到阿膠黑和阿膠粉互噴，現在明顯丁香醫生方舟子一類的阿膠黑在知乎等網站上佔了更大話語權，這類公眾號總是寫科普文告訴你「沒有足夠證據證實xxx有效「，直到中藥協會搬出2016年廣州中醫藥大學第一附屬醫院婦兒中心科研團隊發表在《國際血液學雜誌（International Journal of Hematology）》上的這篇英文論文反駁他們，然後這類公眾號拿不出能夠證偽這個論文的研究但卻仍然聲稱「沒有足夠證據」。然而直到現在，這篇重要的論文依然還沒人翻譯成中文，這種不重視證據先入為主的互噴讓人心寒，我認為真正的科普應該不吹不黑，因此我拋磚引玉把這篇論文譯成中文，希望激發各方更多關注實質性研究證據，爭取早日真正徹底弄清阿膠的有效作用和局限。

英文原文和中文每段對應如下，同時對於翻譯中的紕漏請大家不吝賜教。

Therapeutic effect of Colla corii asini on improving anemia and hemoglobin compositions in pregnant women with thalassemia

標題：阿膠對改善地中海貧血孕婦貧血症和血紅蛋白成分的治療作用

論文作者（英文名未翻譯）：Yanfang Li1 · Hui He2 · Lilin Yang3 · Xiangyi Li1 · Daocheng Li1 · Songping Luo3

通訊作者（英文名未翻譯）：Songping Luo gynspluo@hotmail.com

作者單位：

1 Department of Obstetrics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China

1 廣州中醫藥大學第一附屬醫院產科，廣州，中國

2 Department of Clinical Laboratory, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China

2 廣州中醫藥大學第一附屬醫院檢驗科，廣州，中國

3 First School of Clinical Medicine, Guangzhou University of Chinese Medicine, No. 12 Jichang Road, Guangzhou 510405, Guangdong, China

3廣州中醫藥大學第一臨床醫學院，廣東，廣州510405

Received: 15 April 2016 / Revised: 14 July 2016 / Accepted: 19 July 2016 . The Japanese Society of Hematology 2016

收稿日期：2016年4月15日/ 修訂日期：2016年7月14日/ 接受日期：2016年7月19日。

Abstract

Currently there is no consensus on treating ane-mia in pregnant thalassemia patients. In China, Colla corii asini (CCA) has been widely used for treating anemia for more than 2000 years. However, its clinical application in the thalassemia population is limited by a lack of quanti-tative evidence. The present study aims to investigate the therapeutic effect of CCA in increasing hemoglobin (Hb) concentration and improving abnormal hemoglobin com-positions in pregnant patients with β-thalassemia. Seventy-two pregnant patients who met inclusion criteria were ran-domly assigned to either the treatment group or control group. Patients in the treatment group were given 15 g of CCA, while the control group were observed and followed up without any treatment. Levels of Hb, serum iron (SI), serum ferritin (SF) and three types of Hb components [adult hemoglobin (HbA), fetal hemoglobin (HbF), minor adult hemoglobin (HbA2)] were measured before and after treatment. Treatment with CCA led to a significant increase of Hb. The major Hb component induced by CCA was HbA, while levels of both HbA2 and HbF dropped after treatment. CCA treatment significantly increased SI, while SF remained unaffected. Our data suggest that CCA can improve anemia and optimize Hb components in pregnant patients with thalassemia without affecting iron reserves.

摘要

目前關於妊娠地中海貧血患者貧血的治療尚未達成共識。在中國，阿膠（Colla corii asini，CCA）已廣泛被用於治療貧血症超過兩千多年了。然而，由於缺乏量化的證據，其在地中海貧血人群中的臨床應用還很少。 本研究旨在探討阿膠在增加妊娠β地中海貧血患者血紅蛋白（Hb）濃度和改善異常血紅蛋白組成方面的治療效果。 符合納入標準的72名孕婦隨機分配到治療組或對照組。 治療組患者給予15g 阿膠，而對照組進行觀察和隨訪，無需任何治療。測定治療前後血紅蛋白（Hb）水平，血清鐵（SI），血清鐵蛋白（SF）和三種血紅蛋白（Hb）成分[成人血紅蛋白（HbA），胎兒血紅蛋白（HbF），成人血紅蛋白次要成分（HbA2）]。 用阿膠治療導致血紅蛋白（Hb）顯著增加。由阿膠誘導產生的主要血紅蛋白（Hb）組分是成人血紅蛋白（HbA），而成人血紅蛋白次要成分（HbA2）和胎兒血紅蛋白（HbF）的水平在治療後下降。 阿膠治療顯著增加血清鐵（SI），而血清鐵蛋白（SF）不受影響。我們的數據表明，阿膠可以改善貧血並優化懷孕地中海貧血患者的血紅蛋白（Hb）成分，而不影響鐵儲備。

Keywords Thalassemia · Anemia · Pregnancy · Hemoglobin · Colla corii asini

關鍵詞：地中海貧血，貧血，妊娠，血紅蛋，阿膠

Introduction

簡介

Thalassemia is a type of hemolytic anemia disease caused by genetic defect of synthesis in one or more globin chains. Among all the single genetic disorders thalassemia has the highest incidence rate in the world and causes heavy bur-dens on public health system. In China, the southern prov-inces suffer from high incidence of thalassemia, which is particularly common in the population of Guangdong, Guangxi and Yunnan provinces. Epidemiological stud-ies showed that in Guangdong alone about 17.83 % of the 14,332 pregnant women across 21 regions examined were diagnosed as carriers of thalassemia [1].

地中海貧血是由一種或多種珠蛋白鏈中的合成遺傳缺陷引起的一種溶血性貧血疾病。 在所有單基因遺傳性疾病中，地中海貧血在世界上發病率最高，並在公共衛生體系中造成沉重負擔。在中國，南方地區是地中海貧血的高發地區，這在廣東，廣西和雲南省的中尤其普遍。 流行病學研究顯示，僅在廣東，21個地區的14,332名孕婦中約有17.83％被診斷為地中海貧血基因攜帶者[1]。

Recent studies showed that compared with healthy con-trols, women with thalassemia are associated with a wide range of abnormality and adverse pregnancy outcomes including cardiovascular disease, thrombotic disease, spon-taneous miscarriage, premature delivery, oligohydramnios, fetal growth restriction and low birth weight. In addition, the severity of adverse pregnancy outcomes is closely linked to low level of hemoglobin (Hb) and high level of fetal hemoglobin (HbF) as well as iron-overloading related complications during pregnancy [2, 3]. Therefore, it is essential to improve the anemic state and optimize the compositions of Hb in pregnant thalassemia patients.

最近的研究表明，與健康對照組相比，地中海貧血女性與各種異常和不良妊娠結果相關，包括心血管疾病，血栓性疾病，自發性流產，早產，羊水過少，胎兒生長受限和低出生體重。 此外，不良妊娠結果的嚴重程度與妊娠期間血紅蛋白（Hb）水平低，胎兒血紅蛋白（HbF）水平高以及鐵過載相關併發症密切相關[2,3]。 因此，改善妊娠地中海貧血患者的貧血狀態和優化血紅蛋白的組成是至關重要的。

As the pregnancy progresses, women experience a series of physiological change, which can lead to physiological and nutritional anemia in thalassemia patients without prior or only mild anemia, further complicating the conditions of thalassemia patients during pregnancy. The risk of anemia becomes higher when the patients enter third trimester and many of them may need treatment for disease management [2]. Currently there is no consensus on treating anemia in pregnant thalassemia patients. Due to the absence of an effec-tive treatment scheme with improved safety, many thalas-semia patients are prone to develop low level of Hb, which can severely impact the fetal growth and maternal health.

隨著妊娠的進行，女性經歷一系列生理變化，這可能導致地貧患者生理性和營養性貧血，而此前沒有或僅有輕度貧血，這使妊娠期地中海貧血患者的病情進一步複雜化。 當患者進入妊娠晚期時，患有貧血的風險會增高，其中許多患者可能需要疾病管理[2]。 目前對懷孕地中海貧血患者治療貧血沒有共識。 由於缺乏安全性有效治療方案，許多地中海貧血患者容易發生血紅蛋白降低，這可能會嚴重影響胎兒生長和孕婦健康。

In traditional Chinese medicine (TCM), Colla corii asini (CCA, E』jiao) is a gelatin-like preparation derived from donkey hide and has been widely used in clinical antanemic therapy for more than 2000 years. In the last decade, many studies had addressed the effect of CCA on the antane-mia process using modern pharmacological approaches. The results indicated that collagen protein and polysac-charides which are the main components of CCA can pro-mote hematopoiesis by a number of mechanisms which eventually increase the peripheral erythrocyte counts and Hb concentration [4]. Therefore, we proposed that these hematopoietic effects of CCA might also contribute to the treatment of thalassemia which is caused by insufficient or abnormal Hb concentration. However, its clinical applica-tion in the thalassemia population is limited by the lack of quantitative evidence. This study aims at investigating the therapeutic effect of CCA in treating mild anemia during pregnancy among β-thalassemia patients.

在中藥中，阿膠是一種來自驢皮的明膠樣製劑，已被廣泛用於臨床貧血治療兩千多年了。在過去的十年中，許多研究已經用現代藥理學方法研究阿膠對於貧血過程的影響。 結果表明，阿膠主要成分膠原蛋白和多糖結合物可通過多種機制促進造血功能，能夠最終增加外周紅細胞計數和血紅蛋白濃度[4]。因此，我們提出阿膠的這些造血作用也可能有助於治療由Hb濃度不足或異常引起的地中海貧血。然而，由於缺乏定量證據，其在地中海貧血人群中的臨床應用還有限。 本研究旨在探討阿膠治療β地中海貧血患者妊娠期輕度貧血的療效。

Materials and methods

材料和方法

Subjects

This is a randomized, open labelled, controlled prospec-tive clinical trial. Subjects were pregnant women diagnosed of minor or intermediate β-thalassemia at the First Affili-ated Hospital of Guangzhou University of Chinese Medi-cine between March 2015 and December 2015. The study was reviewed and approved by the institutional Medical Research Ethics Committee and patient recruitment was conducted in strict accordance to the inclusion and exclu-sion criteria. Informed consent was obtained from all sub-jects before enrollment.

受試者

這是一項隨機，開放標籤，控制的前瞻性臨床試驗。 受試者為2015年3月至2015年12月在廣州中醫藥大學第一附屬醫院診斷為輕微或中度β-地中海貧血的孕婦。 該研究由醫學研究倫理委員會審查並批准，患者招募嚴格按照納入和排除標準進行。 在測試之前所有受試者都已簽署知情同意書。

Diagnosis, inclusion and exclusion criteria

診斷，納入和排除標準

Diagnosis criteria

Patients were diagnosed as carriers of thalassemia based on genetic test. Classification of mild and intermedi-ate β-thalassemia was based on the guidelines published by the Thalassemia International Federation in 2008 [5].

In accordance with the diagnostic criteria of the World Health Organization, patients were classified as mild ane-mia (60 g/L ≤ Hb < 110 g/L) and anemia during pregnancy (Hb < 110 g/L) [6].

診斷標準

基於基因檢測，患者被診斷為地中海貧血的攜帶者。輕度和中度β地中海貧血的分類基於地中海貧血國際聯合會2008年發布的指南[5]。

根據世界衛生組織的診斷標準，患者被分為輕度貧血（60 g /L≤Hb<110 g / L）和妊娠期貧血（Hb <110 g / L）[6]。

Inclusion criteria

(1) Pregnant women diagnosed as thalassemia carri-ers by genetic test with clinical presentation of minor or intermediate β-thalassemia; (2) patients with mild ane-mia (80 g/L ≤ Hb < 110 g/L) prior to study enrollment; (3) singleton pregnancy; (4) patients having not received blood transfusion or any forms of anti-anemia treatment in conventional medicine or TCM in the last 12 weeks; (5) informed consent obtained.

入組標準

（1）通過基因檢測診斷為地中海貧血的孕婦，臨床表現為輕度或中度β地中海貧血; （2）入選研究前輕度貧血（80 g /L≤Hb<110 g / L）的患者; （3）單胎妊娠; （4）過去12周內沒有接受輸血或任何形式的常規藥物或中藥的抗貧血治療的患者; （5）獲得知情同意書。

Exclusion criteria

(1) Patients with major thalassemia; (2) patients with severe anemia (Hb < 80 g/L) prior to study enrollment; (3) twin or multiple pregnancies; (4) patients with any of the following abnormalities: immunodeficiency, primary diseases involving cardiovascular system, liver, kidney, gastrointestinal tract, endocrine system and hematological system; (5) allergic to two or more drugs; (6) patients with mental illness or poor compliance to medical treatment; (7) patients having received blood transfusion or any forms of anti-anemia treatment in conventional medicine or TCM in the last 12 weeks; (8) no informed consent obtained.

排除標準

（1）重型地中海貧血患者; （2）入選研究前患有嚴重貧血（Hb <80 g / L）的患者; （3）雙胞胎或多胎妊娠; （4）具有以下任何異常的患者：免疫缺陷，涉及心血管系統，肝，腎，胃腸道，內分泌系統和血液系統的原發性疾病; （5）對兩種或多種藥物過敏; （6）精神病患者或依從性差的患者; （7）過去12周內在常規藥物或TCM中接受過輸血或任何形式的抗貧血治療的患者; （8）未獲得知情同意。

Treatment scheme

Once diagnosed as thalassemia and enrolled in the study, patients would be required to cease taking medications that contain iron and folic acid. Patients in the treatment group received daily 15 g oral CCA (Shandong Dong-E E-Jiao Co., Ltd) in powder form for 4 consecutive weeks. The dos-age was adjusted to 10 g per day for 6 consecutive weeks if patients encounter any of the following side effects: swollen gums, dry or sore throat, ulcers in oral cavity, local eczema (perioral or alinasal). Patients in control groups do not receive any intervention. Subjects had their blood drawing at baseline, 4 or 6 weeks after initiation of the study.

治療方案

一旦診斷為地中海貧血症並參加研究，患者將被要求停止服用含有鐵和葉酸的藥物。 治療組患者連續4周每天口服阿膠（山東東阿阿膠有限公司）15克。 如果患者出現下列任何副作用：口腔腫脹，乾燥或喉嚨痛，口腔潰瘍，局部濕疹（口周或鼻腔），劑量年齡調整為每天10克，連續6周。 對照組患者不接受任何干預。 受試者在研究開始後的基線數據和4或6周後抽血化驗。

Evaluation

評估

Evaluation of effectiveness

10 mL of blood were drawn after overnight fasting for at least 8 h next early morning before and after treatment for following analysis:

(1) level of Hb was measured by automated hematology analyzerXE5000 (Sysmex, Japan);

(2) levels of adult hemoglobin (HbA), minor adult hemo-globin (HbA2) and fetal hemoglobin (HbF) in periph-eral blood by automated capillary electrophoresis (Sebia, France);

(3) level of serum iron (SI) by full automatic bio-chemistry analyzer cobas8000 (Roche, Germany);

(4) level of serum ferritin (SF) by full automatic immune analyzer I 2000 SR (Abbott, USA).

有效性評估

治療前後的第二天早上至少8小時的禁食後抽取10 mL的血液在，用於以下分析:

（1）Hb水平採用自動血液分析儀XE5000（Sysmex，日本）進行測量;

（2）通過自動化毛細管電泳（Sebia，法國）測定外周血中成人血紅蛋白（HbA），次要成人血球蛋白（HbA2）和胎兒血紅蛋白（HbF）的水平;

（3）全自動生化分析儀cobas8000（Roche，德國）測定血清鐵（SI）水平;

（4）全自動免疫分析儀I 2000 SR（Abbott，美國）測定血清鐵蛋白（SF）水平。

Evaluation of safety

Any symptoms that may be caused by adverse effect were recorded throughout the treatment. Peripheral blood was drawn from subjects before and after treatment to moni-tor changes of blood cell compositions and function of liver and kidney: total white blood count [WBC (×109/L)]; platelet count (×109/L); the percentage of neutrophil (%); serum alanine aminotransferase (U/L); serum aspartate aminotransferase (U/L); serum urea nitrogen (mmol/L); serum creatinine (μmol/L).

安全性評估

在整個治療過程中記錄可能由不良作用引起的任何癥狀。 從治療前後的受試者抽取外周血，監測血細胞組成和肝腎功能的變化：總白細胞計數[WBC（×109 / L）];血小板計數（×109 / L）;中性粒細胞百分比（％）;血清丙氨酸轉氨酶（U / L）;血清天冬氨酸轉氨酶（U / L）;血清尿素氮（mmol / L）;血清肌酐（μmol/ L）。

Sample size calculation and patient randomization

Calculation of sample size to detect statistical signifi-cance was based on the study by Xu and colleagues where 3 month treatment of CCA led to increase of Hb level by

66.9 % [7]. The estimated change of Hb level after 4 weeks of CCA is 20 % and null hypothesis is rejected if α value

<0.05 (power, 0.90; loss of follow-up rate, 0.2). In total 72 patients were included in the final study and patients were randomized to either treatment or the control group in a 2:1 ratio by statistical package for social sciences (SPSS) 21.0 random number generator.

樣本量計算和患者隨機化

樣本大小的計算以檢測統計顯著性是基於徐和其同事的研究，其中服用阿膠3個月導致Hb水平升高66.9％[7]。 因此預計服用阿膠4周血紅蛋白水平的變化為20％，如果α<0.05，則零假設被拒絕（統計功效，0.90;失訪率，0.2）。 總共72名被試者被納入最終研究，通過社會科學統計軟體包（SPSS 21.0）隨機數生成器以2：1的比例隨機分配被試者到治療組或對照組。

Statistics

Statistical analysis was performed by SPSS 21.0. Continu-ous variables are expressed as mean ± standard deviation. Categorical variables are expressed as n (%). Homogene-ity of variance analysis was performed. Group comparison was conducted with independent t test. Enumeration data was present as rates or proportions and analyzed with Chi-square test. P < 0.05 was considered statistically significant.

統計

統計分析由SPSS 21.0進行。 連續變數表示為平均值±標準差。 分類變數表示為n（％）。 進行方差齊性分析。 組間比較採用獨立t檢驗。枚舉數據以比率或比例存在，並用卡方檢驗進行分析。 P <0.05被認為有統計學顯著意義。

Fig. 1 Depiction of study procedure

圖1研究過程的描述

Results

結果

Baseline characteristics

Eighty-one patients were recruited and 76 were included in the final study (Fig. 1). Demographic characteristics were shown in Table 1. No significant differences were detected between the control and treatment groups in terms of preg-nancy history, body mass index (BMI) and gestational week at the time of enrollment. Age of both groups ranged from 23 to 32 years, with an average age of 28.11 years. Gestational age ranged between 25 and 33 weeks with the average of 28.69 weeks. All subjects are married Chinese Han female without history of stillbirth.

基線特徵

最終研究招募了81名患者，其中76名被納入研究（圖1）。 表1顯示了人口特徵。 對照組和治療組之間在妊娠史，體重指數（BMI）和入選時的孕周方面沒有顯著差異。 兩組年齡介於23至32歲之間，平均年齡為28.11歲。 胎齡介於25至33周之間，平均為28.69周。 所有科目都是已婚中國漢族女性，沒有死胎史。

Table 1 The demographic and clinical characteristics at baseline

表1基線時的人口統計學和臨床??特徵 （實驗組48人，控制組24人）

Change of level and proportion in Hb before and after treatment

We examined the level of Hb and the proportion of each Hb component in subjects』 peripheral blood before and after treatment. As shown in Table 2, before treatment, subjects from both groups had similar levels of Hb and Hb compo-nent. Therefore, the subjects did not differ in their severity of anemia and thalassemia. After receiving oral CCA for 4 weeks, patients experienced a significant increase of Hb concentration by an average 9.96 ± 2.75 g/L. On the other hand, the Hb concentrations in the control group dropped by 4.54 ± 2.14 g/L from baseline when no intervention was given. Level of HbA increased significantly after treat-ment while a simultaneous decrease of HbA2 and HbF was observed in subjects treated with CCA. The changes of different Hb components showed an opposite trend in control group where HbF and HbA2 increased while HbA decreased from baseline. Between treatment and control groups, the differences of three Hb components differed substantially after treatment (P < 0.001).

治療前後血紅蛋白水平和比例的變化

我們在治療前後檢查了受試者外周血中Hb水平和每種Hb組分的比例。 如表2所示，治療前，兩組受試者的Hb和Hb成分水平相似。 因此，受試者的貧血和地中海貧血的嚴重程度沒有差異。 口服阿膠4周後，患者Hb濃度顯著增加平均值9.96±2.75 g / L。另一方面，當沒有干預時，對照組的Hb濃度比基線下降了4.54±2.14 g / L。在治療後HbA水平顯著增加，同時在用阿膠治療的受試者中觀察到HbA2和HbF同時降低。不同Hb組分的變化在對照組中呈現相反的趨勢，其中HbF和HbA2增加，而HbA從基線降低。 在治療組和對照組之間，治療後三種Hb組分的差異顯著不同（P <0.001）。

Table 2 The difference of concentration and component of Hb and iron metabolism indexes before and after treatment (standard deviation)

表2治療前後血紅蛋白和鐵代謝指標濃度和成分的差異（標準差） （實驗組48人，控制組24人）

Effect on iron metabolism

As shown in Table 2, treatment of CCA increased SI while decreasing the level of SF in the subjects. In the control group, both SI and SF dropped slightly at the end of the study. Between treatment and control group, the change of SI was significant different after treatment of CCA while SF remained unaffected regardless of the treatment.

對鐵代謝的影響

如表2所示，阿膠治療增加了SI，同時降低了受試者的SF水平。 在對照組中，SI和SF在研究結束時略有下降。 在治療組和對照組之間，在治療阿膠後SI的變化有顯著差異，而SF無論治療如何都不受影響。

Adverse event

Among the treatment group, 78.0 % (39/50) of subjects completed the full course of 4-week treatment while the rest changed to 6-week treatment scheme due to inflamma-tory side effects including sore throat, swollen gums, ulcers in oral cavity and local eczema (perioral or alinasal). Two patients suffered from unbearable inflammatory side effects and discontinued the intervention. No subjects experienced any of the following severe adverse events: systemic rash and throat edema. No significant change was detected in WBC, platelet count, and liver function between control and treatment group (data not shown).

不良事件

在治療組中，78.0％（39/50）的受試者完成了4周的全部療程，而其餘的改為6周的治療方案，因為炎症副作用包括喉嚨痛，牙齦腫脹，口腔潰瘍腔和局部濕疹（口周或鼻翼）。 兩名患者出現難以忍受的炎症副作用，並停止治療。 沒有受試者出現任何以下嚴重不良事件：系統性皮疹和咽喉水腫。 WBC，血小板計數和肝功能在對照組和治療組之間沒有顯著變化（數據未顯示）。

Discussion

討論

Thalassemia is a genetic abnormality that manifests hemo-globin, the major oxygen binding protein in red blood cells. The severity of the disease depends on the type and loca-tion of the mutation. Normal tetrameric Hb is consisted of two non-α chain (β, δ, γ) and two α chain. The composi-tions of the four globin chains determine the type of Hb. There are three major types of Hb: (1) adult hemoglobin (HbA), consisted of two α chains and two β chains (α2β2), which account for more than 95 % of total Hb; (2) minor adult hemoglobin (HbA2), consisted of two α chains and two δ chains (α2δ2), accounting for 2–3 % of total Hb; (3) fetal hemoglobin (HbF), consisted of two α chains and two γ chains (α2γ2), accounting for 1–2 % of total Hb [8].

β-Thalassemia is characterized by mutations in β-globin which result in reduced synthesis or complete loss of β chain. As a result, the relative amount of α chain as well as the compensatory synthesis of γ and δ chain increases, leading to elevated level of HbF and HbA2. The excess globin chain polymer further deposit on the membrane of red blood cell (RBC) and impair the mechanical stabil-ity and transformation ability by inducing immunological damage and reactive oxygen species. Eventually patients suffer from hemolysis and ineffective hematopoiesis [8, 9]. Studies in the last few decades have demonstrated that the imbalanced synthesis of Hb globin chain and abnormal Hb compositions are the major causes of thalassemia and therefore it is essential to target these mechanisms for bet-ter clinical management [8, 9].

地中海貧血是一種基因異常，表現在血紅蛋白，即紅細胞中的主要氧結合蛋白。 疾病的嚴重程度取決於突變的類型和位置。 正常四聚體Hb由兩條非α鏈（β，δ，γ）和兩條α鏈組成。 四種珠蛋白鏈的組成決定了Hb的類型。 Hb主要有三種類型：（1）成人血紅蛋白（HbA），由兩條α鏈和兩條β鏈組成（α2β2），佔總Hb的95％以上; （2）輕微成人血紅蛋白（HbA2）由兩條α鏈和兩條δ鏈（α2δ2）組成，佔總血紅蛋白的2-3％; （3）胎兒血紅蛋白（HbF），由兩條α鏈和兩條γ鏈（α2γ2）組成，佔Hb總數的1-2％[8]。

β-地中海貧血的特徵在於β-珠蛋白的突變，導致β鏈的合成減少或完全喪失。 結果，α鏈的相對量以及γ和δ鏈的代償合成增加，導致HbF和HbA2的水平升高。 過量的珠蛋白鏈聚合物進一步沉積在紅細胞（RBC）膜上，並通過誘導免疫損傷和活性氧損害機械穩定性和轉化能力。 最終患者會出現溶血和無效的造血作用[8,9]。 過去幾十年的研究表明，Hb珠蛋白鏈的不平衡合成和異常Hb組成是導致地中海貧血的主要原因，因此將這些機製作為更好的臨床管理的基礎是至關重要的[8,9]。

Despite of the progress in thalassemia management, no consensus has been reached in treating pregnant thalas-semia patients due to lack of safe and effective treatment, which present a major challenge to gynecologists and obstetricians. Therapies targeted at genetic mutations have captured much attention in the field of thalassemia. Early studies indicated that gene-targeting drugs can significant improve hemolytic anemia in patients with thalassemia. Currently the two major categories of drugs that regulate gene expression of globin chains are activators of γ chain and inhibitor of α chain. The former includes 5-azacy-tidine, hydroxyurea and other antineoplastic agents while the latter is consisted of anti-tuberculosis drugs like isonia-zid. Both categories are potentially teratogenic and carci-nogenic, rendering them unsuitable for pregnant patients. Besides, severe side effect like bone marrow suppression is another concern for clinicians to apply these drugs because fetus and newborns are at high risk of drug exposure through placenta and breast milk [10]. Transfusion remains the only effective means for treating severe anemia during pregnancy. However about 60–80 % of patients with thalas-semia requires blood transfusion during pregnancy, with half of the populations never receiving any blood transfu-sion before. Therefore, an immune response may be elicited and cause massive production of anti-RBC antibodies in thalassemia pregnant women, exposing them to higher risk of autoimmune hemolytic anemia. In severe cases, patients may suffer from a vicious cycle of hemolytic anemia and repeated transfusion in addition to the danger of contract-ing infections disease and iron overloading [2, 11].

儘管在地中海貧血管理方面取得了進展，但由於缺乏安全有效的治療，尚未就治療懷孕的地中海貧血患者達成共識，這對婦產科醫生和產科醫生構成了重大挑戰。 針對基因突變的療法在地中海貧血領域引起了很多關注。 早期研究表明，基因靶向藥物可顯著改善地中海貧血患者的溶血性貧血。 目前調節珠蛋白鏈基因表達的兩大類藥物是γ鏈激活劑和α鏈抑製劑。 前者包括5-氮胞苷，羥基脲和其他抗腫瘤藥物，後者則由抗結核藥物如異煙肼組成。 這兩個類別都有可能致畸和致癌，使其不適合孕婦。 此外，骨髓抑制等嚴重副作用是臨床醫生應用這些藥物的另一個關注點，因為胎兒和新生兒通過胎盤和母乳暴露於高風險的藥物暴露[10]。 輸血仍然是治療妊娠期間嚴重貧血的唯一有效手段。 然而，大約60-80％的地中海患者在懷孕期間需要輸血，其中有一半的人口從未接受任何輸血。 因此，地中海貧血孕婦可能會引發免疫應答並引起抗RBC抗體的大量產生，從而使他們面臨更高的自身免疫性溶血性貧血的風險。 在嚴重的病例中，患者可能遭受溶血性貧血和反覆輸血的惡性循環，此外還有感染疾病和鐵過載的危險[2,11]。

Compared to conventional medicine where synthetic chemicals play an important role, TCM has the advantage of low toxicity and cost. Therefore, TCM is a lucrative resource for future exploration in treating thalassemia with broad prospects of clinical application. TCM practitioners classify thalassemia as a type of 「blood deficiency」 that is caused by both genetic and environmental factors like malnutrition and underdevelopment, the pathogenesis of which involves to the deficiency of qi, blood, yin, yang. The so-called 「blood deficiency」 in TCM is best defined as insufficient hematopoiesis in conventional medicine [12]. Accord-ing to the theory of TCM, pregnant women are prone to 『blood deficiency』 due to the physiological changes during pregnancy, similar to the aggravation of symptoms in preg-nant thalassemia patients [13].

與合成化學藥品發揮重要作用的傳統藥物相比，中藥具有毒性低，成本低的優點。 因此，中醫治療地中海貧血具有廣闊的臨床應用前景，是今後探索治療地貧的有利資源。 中醫從業人員將地中海貧血歸類為由於營養不良和發育不良等遺傳因素和環境因素共同造成的「血虛症」，其發病機制涉及氣血，陰，陽不足。 這個中醫學中所謂的「血虛症」最好定義為常規醫學中的造血不足[12]。 根據中醫理論，孕婦因懷孕期間的生理變化而容易出現「血虛癥狀」，類似於地貧患者癥狀加重[13]。

CCA, as one of the well-known TCM, has been used for treating insufficient hematopoiesis for more than 2000 years. Its therapeutic efficacy has been demonstrated in various hematological diseases including iron-deficiency anemia, aplastic anemia and thrombocytopenia. Clinical studies also showed that it can increase blood cell count and reduce bleeding from threatened abortion [4]. With the development of modern pharmacology, several key com-ponents have been purified from CCA including collagen protein, amino acids, polysaccharides, volatile substances and inorganic substances [4]. The hematopoietic effect and mechanism of CCA were investigated in anemic mice sepa-rately induced by 5-fluorouracil or cyclophosphamide [14, 15]. The results indicated that oral administration of CCA could activate the erythrocyte progenitor cells in bone mar-row and subsequently increase the percentage of periph-eral reticulocytes, eventually leading to the recovery of red blood cell counts and Hb concentration. By examining the expression level of granulocyte macrophage colony stimu-lating factor (GM-CSF) and erythropoietin (EPO) in the kidney and liver of the anemic mice, the investigators fur-ther confirmed that CCA treatment significantly increased serum GM-CSF and EPO level, which suggested that the hematopoietic effect of major components in CCA was partly due to promotion of the proliferation and differentia-tion of hematopoietic stem cells through stimulating GM-CSF and EPO secretion [4, 15]. These potential effect may explain the underlying mechanisms of CCA in the allevia-tion of thalassemia.

作為著名的中醫藥之一，阿膠已被用於治療超過2000年的造血功能不足。 其療效已被證明在包括缺鐵性貧血，再生障礙性貧血和血小板減少症在內的各種血液疾病中。 臨床研究還表明，它可以增加血細胞計數，減少先兆流產的出血[4]。 隨著現代藥理學的發展，已經從阿膠中提純了幾種主要成分，包括膠原蛋白，氨基酸，多糖，揮發性物質和無機物[4]。 在5-氟尿嘧啶或環磷醯胺分別誘導的貧血小鼠中研究阿膠的造血作用和機制[14,15]。 結果表明，口服阿膠可以激活骨髓中的紅細胞祖細胞，並隨後增加外周網織紅細胞的百分比，最終導致紅細胞計數和Hb濃度的恢復。 通過檢測貧血小鼠的腎臟和肝臟中粒細胞巨噬細胞集落刺激因子（GM-CSF）和促紅細胞生成素（EPO）的表達水平，研究人員進一步證實阿膠治療顯著增加了血清GM-CSF和EPO這提示阿膠中主要成分的造血作用部分是由於通過刺激GM-CSF和EPO分泌來促進造血幹細胞的增殖和分化[4,15]。 這些潛在的影響可能解釋阿膠在地中海貧血的緩解機制中的作用。

In the past, majority of the studies on treating thalas-semia by TCM was restricted to mainly case report and observational studies. Quantitative studies in pregnant patients with systematic intervention are lacking, imped-ing greater usage of CCA in this particular population [16]. Our results suggest that powdered CCA alone can improve Hb levels and optimize Hb components without affecting iron reserves. SI is a common indicator of functional iron but can be easily influenced by diet and acute inflammation. Therefore, it is considered as an unreliable parameter for evaluating iron status. On the other hand, SF is an indica-tor of iron reserve and the most commonly used biomarker of iron status in pregnancy [17]. We observed an increase of SI in the treatment group which may be due to the rich iron contained in CCA [4]. It is of clinical importance to maintain a balanced iron metabolism because treatment-induced iron overloading is a severe issue in patients with thalassemia. A small fraction of patients experienced minor adverse events including sore throat and oral ulcers. All the side effects can be managed and alleviated via reducing the dosage and prolonging the treatment duration.

過去，大多數中醫藥治療地中海貧血的研究主要限於病例報告和觀察性研究。缺乏有系統干預的孕婦的定量研究，阻礙了在這一特定人群中更多地使用阿膠 [16]。 我們的研究結果表明，粉末阿膠單獨可以提高血紅蛋白水平，優化血紅蛋白組分，而不影響鐵儲備。 SI是功能性鐵的常見指標，但易受飲食和急性炎症的影響。 因此，它被認為是評估鐵質狀態的不可靠參數。 另一方面，SF是鐵儲備指標，也是妊娠期鐵最常用的生物標誌物[17]。 我們觀察到治療組SI增加，這可能是由於阿膠中含有豐富的鐵[4]。 維持鐵代謝平衡具有臨床重要性，因為治療性鐵超載是地中海貧血患者的嚴重問題。 一小部分患者出現輕微不良事件，包括喉嚨痛和口腔潰瘍。 所有的副作用都可以通過減少劑量和延長治療時間來控制和緩解。

Recent studies have reported that imbalance of glo-bin chain synthesis and abnormal compositions of Hb can largely affect the severity of thalassemia. Moreover the levels of HbF and HbA are closely linked to adverse preg-nancy outcome in women. It has been demonstrated that elevated HbF level is associated with high rate of spontane-ous abortion in thalassemia patients. One plausible expla-nation is that compared to the other two adult hemoglobins (HbA and HbA2), HbF has a higher affinity for oxygen, causing reduced dissociation of oxygen at local tissue and cells and subsequent local hypoxia. Thus it is speculated that by reducing the level of HbF, one can prevent adverse pregnancy outcome, particularly miscarriage by improving oxygen supply to the embryo [11]. Our results suggest that oral administration of CCA not only significantly increase the level of HbA, but also marginally decrease the level of HbF and HbA2. The total improvement in HbA is com-parable to the total decline in HbA2 and HbF. However, the changes in HbA2 percentages and HbF percentages are only modest and likely within the range of laboratory variance, possibly caused by the insufficient sample size. The impact on HbF and HbA2 should be further verified in future study with larger sample size.

最近的研究報道，血紅蛋白鏈合成的不平衡和血紅蛋白的異常組成可以很大程度上影響地中海貧血的嚴重程度。 此外，HbF和HbA水平與女性不良妊娠結局密切相關。 已經證明，HbF水平升高與地中海貧血患者的自發性流產率高有關。 一種合理的解釋是，與其他兩種成人血紅蛋白（HbA和HbA2）相比，HbF對氧有更高的親和力，導致局部組織和細胞中氧的分解減少以及隨後的局部缺氧。 因此據推測，通過降低HbF水平，可以預防不良的妊娠結局，特別是通過改善胚胎供氧的流產[11]。 我們的研究結果表明，口服阿膠不僅會顯著提高HbA水平，還會輕微降低HbF和HbA2的水平。 HbA的總體改善與HbA2和HbF的總體下降相當。然而，HbA2百分比和HbF百分比的變化只是適度的，可能在實驗室變異的範圍內，這可能是由樣本量不足造成的。 對於HbF和HbA2的影響應在未來研究中進一步驗證，並且樣本量較大。

More importantly, our data demonstrated that CCA influences the level of HbA and HbF via mechanism that differs significantly from the conventional γ chain gene activator. The major role of γ chain gene activator is to pro-mote synthesis of γ chain in order to replace the defective β chain so that the excess α chain can form HbF with the γ chain because the newly form HbF can partially com-pensate for the loss of HbA [10]. While this can heighten the total Hb, the increment in HbF also expose the patients to higher change of miscarriage. Other therapies includ-ing erythropoietin increased HbF substantially [10]. On the contrary, CCA improves anemia in β-thalassemia by enhancing HbA but not HbF, although the exact molecular signaling pathway remains unclear. We suspect that CCA enhances total Hb mainly through induction of β-globin chain. As a result the compensatory synthesis of γ and δ chain is reduced, leading to higher level of HbA (α2β2) but lower levels of HbF (α2γ2) and HbA2 (α2δ2). This specu-lation should be confirmed in future study when more in-depth genetic study is coupled with biomarker analysis in order to provide a solid scientific basis for the treatment of anemia in pregnant women with thalassemia.

更重要的是，我們的數據表明，阿膠通過與常規γ鏈基因激活劑顯著不同的機制影響HbA和HbF的水平。 γ鏈基因激活劑的主要作用是促進γ鏈的合成，以取代有缺陷的β鏈，使得過量的α鏈可以與γ鏈形成HbF，因為新形成的HbF可以部分補償失去HbA [10]。 雖然這可以提高總Hb，但HbF的增加也使患者暴露於更高的流產變化。 其他療法包括促紅細胞生成素可顯著增加HbF [10]。 相反，阿膠通過增強HbA而不是HbF改善了β地中海貧血的貧血，儘管確切的分子信號傳導途徑仍不清楚。 我們懷疑阿膠主要通過誘導β-珠蛋白鏈增強總Hb。 結果γ和δ鏈的代償合成減少，導致HbA（α2β2）水平升高，但HbF（α2γ2）和HbA2（α2δ2）水平降低。 這種推測應該在未來的研究中得到證實，當更深入的遺傳學研究與生物標誌物分析相結合時，為地中海貧血孕婦貧血的治療提供堅實的科學依據。

In summary, CCA significantly improves anemia symp-toms without alternating iron reserves in β-thalassemia patients or inducing severe side effect. The therapeutic effect is mainly mediated through simultaneous increase of HbA in β-thalassemia patients respectively. It may also exert its effect via reducing HbF and HbA2 which requires further study to confirm. This study demonstrates the potential of a single ingredient from TCM for treat-ing genetic disorder in pregnant patients. It brings insight to obstetricians and gynecologists to the potential of CCA in treating anemia in pregnant patients with β-thalassemia where optimization of Hb components holds the key for disease control.

總之，阿膠顯著改善貧血癥狀，而不改變β-地中海貧血患者的鐵儲備或誘發嚴重的副作用。 治療效果主要是通過同時增加β地中海貧血患者HbA介導的。 它也可能通過減少HbF和HbA2發揮作用，這需要進一步的研究來證實。 這項研究證明了來自TCM的單一成分用於治療懷孕患者遺傳性疾病的潛力。 它使產科醫生和婦科醫生了解阿膠治療妊娠期β地中海貧血患者貧血的潛力，其中Hb組分優化是疾病控制的關鍵。

Compliance with ethical standards

Conflict of interest The authors have no conflicts of interest.

道德標準的遵守

利益衝突：作者沒有利益衝突。

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