Molecular genetics of the sickling syndromes: evolution of new strategies for improved diagnosis.

This survey is intended to illustrate some major areas relevant to the diagnosis and treatment of sickle cell syndromes that have benefited by the input of molecular genetic approaches. The development of gene mapping techniques has permitted the direct examination of the effect of co-inheritance of alpha-thalassemia and sickle cell anemia on clinical severity, providing, for the first time, a direct strategy for investigation of the clinical heterogeneity of these syndromes. In addition, antenatal diagnosis of these disorders is now best done by direct gene mapping whenever appropriate facilities are available. Treatment by manipulation of gamma-globin gene expression has been shown to be an effective means of achieving at least partial reversal of the hemoglobin F to hemoglobin A switch. Whether the magnitude of this reversal is sufficient to interfere with the clinical phenotype of sickle cell disease remains to be determined. Moreover, the agent currently available to accomplish this goal, 5-azacytidine, remains unsuitable for wide-spread clinical application for a variety of reasons. Nonetheless, the molecular geneticist has already demonstrated that desirable effects can be achieved by building on the knowledge of globin gene physiology. This knowledge is best acquired by application of the concepts and methodologies of molecular genetics.