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Meloni A, Pistoia L, Ricchi P, Longo F, Cecinati V, Sorrentino F, Cuccia L, Corigliano E, Rossi V, Righi R, Fina P, Renne S, Barbuto L, Positano V, Cademartiri F. Multiparametric cardiac magnetic resonance in patients with thalassemia intermedia: new insights from the E-MIOT network. LA RADIOLOGIA MEDICA 2024; 129:879-889. [PMID: 38683500 DOI: 10.1007/s11547-024-01821-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 04/16/2024] [Indexed: 05/01/2024]
Abstract
PURPOSE In a relatively large cohort of thalassemia intermedia (TI) patients, we systematically investigated myocardial iron overload (MIO), function, and replacement fibrosis using cardiac magnetic resonance (CMR), we assessed the clinical determinants of global heart T2* values, and we explored the association between multiparametric CMR findings and cardiac complications. MATERIALS AND METHODS We considered 254 beta-TI patients (43.14 ± 13.69 years, 138 females) consecutively enrolled in the Extension-Myocardial Iron Overload in Thalassemia project. MIO was quantified by T2* technique and biventricular function and atrial areas by cine images. Macroscopic myocardial fibrosis was detected by late gadolinium enhancement technique. RESULTS Compared to never/sporadically transfused patients, regularly transfused (RT)-TI patients exhibited significantly lower global heart T2* values, biventricular end-diastolic volume indexes, left ventricular mass index, and cardiac index. In RT-TI patients, age and serum ferritin levels were the strongest predictors of global heart T2* values. Independently from the transfusional state, cardiac T2* values were not associated with biventricular function. Of the 103 (40.6%) patients in whom the contrast medium was administrated, 27 (26.2%) had replacement myocardial fibrosis. Age, sex distribution, cardiac iron, and biventricular function parameters were comparable between patients without and without replacement myocardial fibrosis. Twenty-five (9.8%) patients had a history of cardiac complications (heart failure and arrhythmias). Increased age and replacement myocardial fibrosis emerged as significant risk markers for cardiac complications. CONCLUSIONS In TI, regular transfusions are associated with less pronounced cardiac remodeling but increase the risk of MIO. Replacement myocardial fibrosis is a frequent finding associated with cardiac complications.
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Affiliation(s)
- Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
- U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
- U.O.C. Ricerca Clinica, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Paolo Ricchi
- U.O.S.D. Malattie Rare del Globulo Rosso, Azienda Ospedaliera Di Rilievo Nazionale "A. Cardarelli", Naples, Italy
| | - Filomena Longo
- Unità Operativa Day Hospital Della Talassemia e delle Emoglobinopatie, Azienda Ospedaliero-Universitaria ''S. Anna'', Cona, FE, Italy
| | - Valerio Cecinati
- Struttura Semplice di Microcitemia, Ospedale "SS. Annunziata" ASL Taranto, Taranto, Italy
| | | | - Liana Cuccia
- Unità Operativa Complessa di Radiologia, ''ARNAS'' Civico, Di Cristina Benfratelli, Palermo, Italy
| | | | | | - Riccardo Righi
- Diagnostica per Immagini e Radiologia Interventistica, Ospedale del Delta, Lagosanto, FE, Italy
| | - Priscilla Fina
- Unità Operativa Complessa Diagnostica per Immagini, Ospedale ''Sandro Pertini'', Rome, Italy
| | - Stefania Renne
- Struttura Complessa di Cardioradiologia-UTIC, Presidio Ospedaliero "Giovanni Paolo II", Lamezia Terme, Italy
| | - Luigi Barbuto
- U.O.C. Radiologia Generale e di Pronto Soccorso, Azienda Ospedaliera di Rilievo Nazionale "A. Cardarelli", Naples, Italy
| | - Vincenzo Positano
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
- U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy.
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Meloni A, Parravano M, Pistoia L, Cossu A, Grassedonio E, Renne S, Fina P, Spasiano A, Salvo A, Bagnato S, Gerardi C, Borsellino Z, Cademartiri F, Positano V. Phenotypic Clustering of Beta-Thalassemia Intermedia Patients Using Cardiovascular Magnetic Resonance. J Clin Med 2023; 12:6706. [PMID: 37959172 PMCID: PMC10647397 DOI: 10.3390/jcm12216706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 11/15/2023] Open
Abstract
We employed an unsupervised clustering method that integrated demographic, clinical, and cardiac magnetic resonance (CMR) data to identify distinct phenogroups (PGs) of patients with beta-thalassemia intermedia (β-TI). We considered 138 β-TI patients consecutively enrolled in the Myocardial Iron Overload in Thalassemia (MIOT) Network who underwent MR for the quantification of hepatic and cardiac iron overload (T2* technique), the assessment of biventricular size and function and atrial dimensions (cine images), and the detection of replacement myocardial fibrosis (late gadolinium enhancement technique). Three mutually exclusive phenogroups were identified based on unsupervised hierarchical clustering of principal components: PG1, women; PG2, patients with replacement myocardial fibrosis, increased biventricular volumes and masses, and lower left ventricular ejection fraction; and PG3, men without replacement myocardial fibrosis, but with increased biventricular volumes and masses and lower left ventricular ejection fraction. The hematochemical parameters and the hepatic and cardiac iron levels did not contribute to the PG definition. PG2 exhibited a significantly higher risk of future cardiovascular events (heart failure, arrhythmias, and pulmonary hypertension) than PG1 (hazard ratio-HR = 10.5; p = 0.027) and PG3 (HR = 9.0; p = 0.038). Clustering emerged as a useful tool for risk stratification in TI, enabling the identification of three phenogroups with distinct clinical and prognostic characteristics.
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Affiliation(s)
- Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, PI, Italy; (L.P.); (F.C.); (V.P.)
- Unità Operativa Complessa Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, PI, Italy;
| | - Michela Parravano
- Unità Operativa Complessa Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, PI, Italy;
- Dipartimento di Ingegneria dell’Informazione, Università degli Studi di Pisa, 56122 Pisa, PI, Italy
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, PI, Italy; (L.P.); (F.C.); (V.P.)
- Unità Operativa Complessa Ricerca Clinica, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, PI, Italy
| | - Alberto Cossu
- Unità Operativa Radiologia Universitaria, Azienda Ospedaliero-Universitaria “S. Anna”, 44124 Cona, FE, Italy;
| | - Emanuele Grassedonio
- Sezione di Scienze Radiologiche, Dipartimento di Biopatologia e Biotecnologie Mediche, Policlinico “Paolo Giaccone”, 90127 Palermo, PA, Italy;
| | - Stefania Renne
- Struttura Complessa di Cardioradiologia-UTIC, Presidio Ospedaliero “Giovanni Paolo II”, 88046 Lamezia Terme, CZ, Italy;
| | - Priscilla Fina
- Unità Operativa Complessa Diagnostica per Immagini, Ospedale “Sandro Pertini”, 00157 Roma, RM, Italy;
| | - Anna Spasiano
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale “A. Cardarelli”, 80131 Napoli, NA, Italy;
| | - Alessandra Salvo
- Unità Operativa Semplice Talassemia, Presidio Ospedaliero “Umberto I”, 96100 Siracusa, SR, Italy;
| | - Sergio Bagnato
- Ematologia Microcitemia, Ospedale San Giovanni di Dio—ASP Crotone, 88900 Crotone, KR, Italy;
| | - Calogera Gerardi
- Unità Operativa Semplice Dipartimentale di Talassemia, Presidio Ospedaliero “Giovanni Paolo II”—Distretto AG2 di Sciacca, 92019 Sciacca, AG, Italy;
| | - Zelia Borsellino
- Unità Operativa Complessa Ematologia con Talassemia, ARNAS Civico “Benfratelli-Di Cristina”, 90134 Palermo, PA, Italy;
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, PI, Italy; (L.P.); (F.C.); (V.P.)
| | - Vincenzo Positano
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, PI, Italy; (L.P.); (F.C.); (V.P.)
- Unità Operativa Complessa Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, PI, Italy;
- Dipartimento di Ingegneria dell’Informazione, Università degli Studi di Pisa, 56122 Pisa, PI, Italy
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Saliba AN, Musallam KM, Taher AT. How I treat non-transfusion-dependent β-thalassemia. Blood 2023; 142:949-960. [PMID: 37478396 PMCID: PMC10644094 DOI: 10.1182/blood.2023020683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 07/23/2023] Open
Abstract
The intricate interplay of anemia and iron overload under the pathophysiological umbrella of ineffective erythropoiesis in non-transfusion-dependent β-thalassemia (NTDT) results in a complex variety of clinical phenotypes that are challenging to diagnose and manage. In this article, we use a clinical framework rooted in pathophysiology to present 4 common scenarios of patients with NTDT. Starting from practical considerations in the diagnosis of NTDT, we delineate our strategy for the longitudinal care of patients who exhibit different constellations of symptoms and complications. We highlight the use of transfusion therapy and novel agents, such as luspatercept, in the patient with anemia-related complications. We also describe our approach to chelation therapy in the patient with iron overload. Although tackling every specific complication of NTDT is beyond the scope of this article, we touch on the management of the various morbidities and multisystem manifestations of the disease.
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Affiliation(s)
| | - Khaled M. Musallam
- Thalassemia Center, Burjeel Medical City, Abu Dhabi, United Arab Emirates
| | - Ali T. Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Ghazaiean M, Aliasgharian A, Karami H, Darvishi-Khezri H. Ebselen: A promising therapy protecting cardiomyocytes from excess iron in iron-overloaded thalassemia patients. Open Med (Wars) 2023; 18:20230733. [PMID: 37465348 PMCID: PMC10350894 DOI: 10.1515/med-2023-0733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 05/04/2023] [Accepted: 05/14/2023] [Indexed: 07/20/2023] Open
Abstract
Iron-overload-associated cardiomyopathy has been one of the primary causes of mortality in thalassemia patients with iron burden. There is growing evidence citing the beneficial effects of ebselen as an antioxidant selectively blocking the divalent metal transporter 1 (DMT-1) to deter iron ingress into cardiomyocytes, raising internets in viewing this component in this population in order to treat and even prevent cardiomyopathy occurring from iron surplus. In this article, we reviewed the potential advantageous effects of ebselen in thalassemia patients who suffer from iron excess, susceptible to cardiomyopathy induced by iron overload. A systematic search in several databases, including PubMed, Scopus, and Web of Science, was conducted to explore the role of ebselen in controlling iron-overload-related cardiomyopathy in thalassemia patients by the keywords of Ebselen AND iron. The inclusion criteria were English-written preclinical and clinical studies investigating the efficacy and side effects of ebselen in an iron-overload context. After searching the databases, 44 articles were found. Next, of 19 published articles, 3 were included in this article. After reviewing the references of the included studies, no articles were added. In conclusion ebselen can be a promising adjuvant therapy in patients with thalassemia alongside the standard treatment with iron chelators, particularly in severe cases with cardiomyopathy, due to falling iron inflow by inhibiting DMT-1 and increasing ferroportin-1 expression and antioxidant properties. However, clinical studies need to be carried out to reach a definite conclusion.
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Affiliation(s)
- Mobin Ghazaiean
- Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Aily Aliasgharian
- Thalassemia Research Center (TRC), Hemoglobinopathy Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Hossein Karami
- Department of Pediatric, School of Medicine, Thalassemia Research Center (TRC), Hemoglobinopathy Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Hadi Darvishi-Khezri
- Thalassemia Research Center (TRC), Hemoglobinopathy Institute, Mazandaran University of Medical Sciences, Sari, Iran
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Bruzzese A, Martino EA, Mendicino F, Lucia E, Olivito V, Bova C, Filippelli G, Capodanno I, Neri A, Morabito F, Gentile M, Vigna E. Iron chelation therapy. Eur J Haematol Suppl 2023; 110:490-497. [PMID: 36708354 DOI: 10.1111/ejh.13935] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 01/29/2023]
Abstract
Iron overload is a pathological condition resulting from a congenital impairment of its regulation, increased intestinal iron absorption secondary to bone marrow erythroid hyperplasia, or a chronic transfusional regimen. In normal conditions, intracellular and systemic mechanisms contribute to maintaining iron balance. When this complex homeostatic mechanism fails, an iron overload could be present. Detecting an iron overload is not easy. The gold standard remains the liver biopsy, even if it is invasive and dangerous. Identifying iron using noninvasive techniques allowed a better understanding of the rate of iron overload in different organs, with a low risk for the patient. Estimating serum ferritin (mg/L) is the easiest and, consequently, the most employed diagnostic tool for assessing body iron stores, even if it could be a not specific method. The most common hematological causes of iron overload are myelodysplastic syndromes, sickle cell disease, and thalassemia. In all of these conditions, three drugs have been approved for the treatment of iron overload: deferiprone, deferoxamine, and deferasirox. These chelators have been demonstrated to help lower tissue iron levels and prevent iron overload complications, improving event-free survival (EFS). Nowadays, the decision to start chelation and which chelator to choose remains the joint decision of the clinician and patient.
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Affiliation(s)
- Antonella Bruzzese
- Hematology Unit, Department of Onco-hematology, A.O. of Cosenza, Cosenza, Italy
| | | | - Francesco Mendicino
- Hematology Unit, Department of Onco-hematology, A.O. of Cosenza, Cosenza, Italy
| | - Eugenio Lucia
- Hematology Unit, Department of Onco-hematology, A.O. of Cosenza, Cosenza, Italy
| | - Virginia Olivito
- Hematology Unit, Department of Onco-hematology, A.O. of Cosenza, Cosenza, Italy
| | - Carlo Bova
- Internal Medicine Department, AO of Cosenza, Cosenza, Italy
| | | | - Isabella Capodanno
- SOC Ematologia Azienda USL-IRCSS di Reggio Emilia, Reggio Emilia, Emilia Romagna, Italy
| | - Antonino Neri
- Scientific Direction Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Emilia Romagna, Italy
| | - Fortunato Morabito
- Biotechnology Research Unit, Aprigliano, A.O./ASP of Cosenza, Cosenza, Italy
| | - Massimo Gentile
- Hematology Unit, Department of Onco-hematology, A.O. of Cosenza, Cosenza, Italy.,Department of Pharmacy, Health and Nutritional Science, University of Calabria, Rende, Italy
| | - Ernesto Vigna
- Hematology Unit, Department of Onco-hematology, A.O. of Cosenza, Cosenza, Italy
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Lee YC, Yen CT, Lee YL, Chen RJ. Thalassemia Intermedia: Chelator or Not? Int J Mol Sci 2022; 23:ijms231710189. [PMID: 36077584 PMCID: PMC9456380 DOI: 10.3390/ijms231710189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/19/2022] Open
Abstract
Thalassemia is the most common genetic disorder worldwide. Thalassemia intermedia (TI) is non-transfusion-dependent thalassemia (NTDT), which includes β-TI hemoglobin, E/β-thalassemia and hemoglobin H (HbH) disease. Due to the availability of iron chelation therapy, the life expectancy of thalassemia major (TM) patients is now close to that of TI patients. Iron overload is noted in TI due to the increasing iron absorption from the intestine. Questions are raised regarding the relationship between iron chelation therapy and decreased patient morbidity/mortality, as well as the starting threshold for chelation therapy. Searching all the available articles up to 12 August 2022, iron-chelation-related TI was reviewed. In addition to splenectomized patients, osteoporosis was the most common morbidity among TI cases. Most study designs related to ferritin level and morbidities were cross-sectional and most were from the same Italian study groups. Intervention studies of iron chelation therapy included a subgroup of TI that required regular transfusion. Liver iron concentration (LIC) ≥ 5 mg/g/dw measured by MRI and ferritin level > 300 ng/mL were suggested as indicators to start iron chelation therapy, and iron chelation therapy was suggested to be stopped at a ferritin level ≤ 300 ng/mL. No studies showed improved overall survival rates by iron chelation therapy. TI morbidities and mortalities cannot be explained by iron overload alone. Hypoxemia and hemolysis may play a role. Head-to-head studies comparing different treatment methods, including hydroxyurea, fetal hemoglobin-inducing agents, hypertransfusion as well as iron chelation therapy are needed for TI, hopefully separating β-TI and HbH disease. In addition, the target hemoglobin level should be determined for β-TI and HbH disease.
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Affiliation(s)
- Yen-Chien Lee
- Department of Medical Oncology, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan 70043, Taiwan
- Department of Internal Medicine, College of Medicine, National Cheng Kung University Hospital, Tainan 70403, Taiwan
- Correspondence: (Y.-C.L.); (R.-J.C.)
| | - Chi-Tai Yen
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan 70043, Taiwan
| | - Yen-Ling Lee
- Department of Medical Oncology, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan 70043, Taiwan
| | - Rong-Jane Chen
- Department of Food Safety/Hygiene and Risk Management, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
- Correspondence: (Y.-C.L.); (R.-J.C.)
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Huang Y, Yang G, Wang M, Wei X, Pan L, Liu J, Lei Y, Peng, Long L, Lai Y, Liu R. Iron overload status in patients with non-transfusion-dependent thalassemia in China. Ther Adv Hematol 2022; 13:20406207221084639. [PMID: 35321211 PMCID: PMC8935562 DOI: 10.1177/20406207221084639] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 02/15/2022] [Indexed: 11/25/2022] Open
Abstract
Background: Iron overload is one of the main factors that increase morbidity and mortality in patients with non-transfusion dependent thalassemia (NTDT). Aim: This study aimed at investigating the prevalence and severity of iron overload in Chinese NTDT patients. Methods: we analyzed serum ferritin (SF), liver iron concentration (LIC) and cardiac T2* in 178 Chinese NTDT in this cross-sectional study. Results: The median SF level was 996.00(27.15–19704.00) ng/ml and the median LIC value was 8.90(0.60–43.00) mg Fe/g dry weight (dw). The youngest patient with liver iron overload was 5 years old with 5.6 mg Fe/g dw in LIC. The median cardiac T2* was 33.06(7.46–75.08) ms. 6 patients had cardiac T2*⩽20ms. The patients with β thalassemia intermedia and HbE/β thalassemia showed a statistically significant lower Hb and higher values of SF and LIC than those of hemoglobin H disease patients. On multivariate logistic regression analysis, patients in ⩾ age 30-year old had a significant higher risk for iron overload (OR: 77.75, 95% CI: 8.76–690.49) in the age group. The detailed analysis of proportions of different LIC indicate in > 30-year old group, 76.8% patients suffered from moderate and severe LIC. Conclusion: Our study provides a strong support for the novel findings that Chinese NTDT patients have a high prevalence of iron overload. The first assessment of MRI LIC should be performed as early as 5 years old. Then, NTDT patients > 30 years old may suffer with a high burden of iron overload.
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Affiliation(s)
- Yumei Huang
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Gaohui Yang
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Man Wang
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiaoyun Wei
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lingyuan Pan
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jiaodi Liu
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yu Lei
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Peng
- Department of Radiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Liling Long
- Department of Radiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yongrong Lai
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi, China
| | - Rongrong Liu
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi, China
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Atmakusuma TD, Lubis AM. Correlation of Serum Ferritin and Liver Iron Concentration with Transient Liver Elastography in Adult Thalassemia Intermedia Patients with Blood Transfusion. J Blood Med 2021; 12:235-243. [PMID: 33883962 PMCID: PMC8055280 DOI: 10.2147/jbm.s303703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/19/2021] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Iron overload is a common feature of thalassemia intermedia due to regular blood transfusion and increased gastrointestinal iron absorption. Early detection and adequate iron chelator can decrease morbidity and mortality from iron overload. Liver iron concentration (LIC) by MRI T2* is the best non-invasive way to measure body iron stores. However, this method is expensive and not available nationwide in Indonesia. The aim of this study was to identify liver iron overload and correlation of transferrin saturation, serum ferritin, liver MRI T2* and LIC with transient liver elastography in adult thalassemia intermedia patients. METHODS This is a cross-sectional study of 45 patients with thalassemia intermedia with blood transfusion and with and without iron chelator therapy. The study was conducted at Cipto Mangunkusumo Hospital from August through October 2016. We performed measurements of transferrin saturation, serum ferritin level, transient liver elastography and liver MRI T2*. Pearson and Spearman correlation tests were used to evaluate the correlation between transient liver elastography with transferrin saturation, serum ferritin, liver MRI T2*and LIC. RESULTS AND DISCUSSION This study showed that 64.4% of study subjects are β-Hb E thalassemia intermedia. Furthermore, 84.4% of study subjects have regular transfusion. Based on liver MRI T2*all subjects suffered from liver iron overload, 48.9% had severe degree. Median value of liver MRI T2* was 1.6 ms. Mean serum ferritin was 2831 ng/mL, with median transferrin saturation of 66%. Mean of LIC corresponding to liver MRI T2* and mean liver stiffness measurement was 15.36±7.37 mg Fe/gr dry weight and 7.7±3.8 kPa, respectively. Liver stiffness correlated with serum ferritin (r=0.651; p=0.000), liver MRI T2* (r=-0.357; p=0.016), and LIC (r=0.433; p=0.003). No correlation was found between liver elastography and transferrin saturation (r=0.204; p=0.178). CONCLUSION Serum ferritin, liver MRI T2*and LIC correlated with liver elastography. No correlation was found between transferrin saturation and liver elastography.
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Affiliation(s)
- Tubagus Djumhana Atmakusuma
- Division of Hematology-Medical Oncology, Department of Internal Medicine, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Anna Mira Lubis
- Division of Hematology-Medical Oncology, Department of Internal Medicine, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
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Ruan DD, Gan YM, Lu T, Yang X, Zhu YB, Yu QH, Liao LS, Lin N, Qian X, Luo JW, Tang FQ. Genetic diagnosis history and osteoarticular phenotype of a non-transfusion secondary hemochromatosis. World J Clin Cases 2020; 8:5962-5975. [PMID: 33344595 PMCID: PMC7723718 DOI: 10.12998/wjcc.v8.i23.5962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/23/2020] [Accepted: 10/13/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND It is not easy to identify the cause of various iron overload diseases because the phenotypes overlap. Therefore, it is important to perform genetic testing to determine the genetic background of patients.
AIM To investigate the genetic background of a patient with hemochromatosis complicated by psoriasis on both lower extremities.
METHODS Ten years ago, a 61-year-old male presented with iron overload, jaundice, hemolytic anemia and microcytic hypochromic anemia. Computed tomography of the left knee joint showed enlargement of the tibial medullary cavity and thinned bone cortices. Magnetic resonance imaging showed hepatic hemochromatosis, extensive abnormal signals from bone marrow cavities and nodular lesions in the lateral medullary cavity of the upper left lateral tibia. Single photon emission computed tomography showed radial dots of abnormal concentration in the upper end of the left tibia and radial symmetry of abnormal concentrations in joints of the extremities. The patient showed several hot spot mutations of the HFE and G6PD genes detected by next-generation sequencing, but no responsible gene mutation was found. The thalassemia gene was detected by gap-PCR.
RESULTS The patient was found to carry the -α4.2 and --SEA deletion mutations of the globin gene. These two mutations are common causes of Southeast Asian α-thalassemia, but rarely cause severe widespread non-transfusion secondary hemochromatosis osteoarthropathy. The simultaneous presence of an auxiliary superposition effect of a rare missense mutation of the PIEZO1 gene (NM_001142864, c.C4748T, p.A1583V) was considered. Moreover, several rare mutations of the IFIH1, KRT8, POFUT1, FLG, KRT2, and TGM5 genes may be involved in the pathogenesis of psoriasis.
CONCLUSION The selection of genetic detection methods for hemochromatosis still needs to be based on an in-depth study of the clinical manifestations of the disease.
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Affiliation(s)
- Dan-Dan Ruan
- Shengli Clinical Medical College, Fujian Medical University, Fuzhou 350001, Fujian Province, China
| | - Yu-Mian Gan
- Shengli Clinical Medical College, Fujian Medical University, Fuzhou 350001, Fujian Province, China
| | - Tao Lu
- Shengli Clinical Medical College, Fujian Medical University, Fuzhou 350001, Fujian Province, China
| | - Xiao Yang
- Department of Management, Fujian Health College, Fuzhou 350101, Fujian Province, China
| | - Yao-Bin Zhu
- Department of Traditional Chinese Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, Fujian Province, China
| | - Qing-Hua Yu
- Shengli Clinical Medical College, Fujian Medical University, Fuzhou 350001, Fujian Province, China
| | - Li-Sheng Liao
- Shengli Clinical Medical College, Fujian Medical University, Fuzhou 350001, Fujian Province, China
| | - Ning Lin
- Shengli Clinical Medical College, Fujian Medical University, Fuzhou 350001, Fujian Province, China
| | - Xin Qian
- Shengli Clinical Medical College, Fujian Medical University, Fuzhou 350001, Fujian Province, China
| | - Jie-Wei Luo
- Shengli Clinical Medical College, Fujian Medical University, Fuzhou 350001, Fujian Province, China
| | - Fa-Qiang Tang
- Shengli Clinical Medical College, Fujian Medical University, Fuzhou 350001, Fujian Province, China
- Department of Orthopedics, Fujian Provincial Hospital, Fuzhou 350001, Fujian Province, China
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10
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Ruan DD, Gan YM, Lu T, Yang X, Zhu YB, Yu QH, Liao LS, Lin N, Qian X, Luo JW, Tang FQ. Genetic diagnosis history and osteoarticular phenotype of a non-transfusion secondary hemochromatosis. World J Clin Cases 2020. [DOI: 10.12998/wjcc.v8.i23.5959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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11
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Pinto VM, Forni GL. Management of Iron Overload in Beta-Thalassemia Patients: Clinical Practice Update Based on Case Series. Int J Mol Sci 2020; 21:E8771. [PMID: 33233561 PMCID: PMC7699680 DOI: 10.3390/ijms21228771] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/14/2020] [Accepted: 11/18/2020] [Indexed: 12/29/2022] Open
Abstract
Thalassemia syndromes are characterized by the inability to produce normal hemoglobin. Ineffective erythropoiesis and red cell transfusions are sources of excess iron that the human organism is unable to remove. Iron that is not saturated by transferrin is a toxic agent that, in transfusion-dependent patients, leads to death from iron-induced cardiomyopathy in the second decade of life. The availability of effective iron chelators, advances in the understanding of the mechanism of iron toxicity and overloading, and the availability of noninvasive methods to monitor iron loading and unloading in the liver, heart, and pancreas have all significantly increased the survival of patients with thalassemia. Prolonged exposure to iron toxicity is involved in the development of endocrinopathy, osteoporosis, cirrhosis, renal failure, and malignant transformation. Now that survival has been dramatically improved, the challenge of iron chelation therapy is to prevent complications. The time has come to consider that the primary goal of chelation therapy is to avoid 24-h exposure to toxic iron and maintain body iron levels within the normal range, avoiding possible chelation-related damage. It is very important to minimize irreversible organ damage to prevent malignant transformation before complications set in and make patients ineligible for current and future curative therapies. In this clinical case-based review, we highlight particular aspects of the management of iron overload in patients with beta-thalassemia syndromes, focusing on our own experience in treating such patients. We review the pathophysiology of iron overload and the different ways to assess, quantify, and monitor it. We also discuss chelation strategies that can be used with currently available chelators, balancing the need to keep non-transferrin-bound iron levels to a minimum (zero) 24 h a day, 7 days a week and the risk of over-chelation.
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Affiliation(s)
- Valeria Maria Pinto
- Centro della Microcitemia e delle Anemie Congenite Ente Ospedaliero Ospedali Galliera, Via Volta 6, 16128 Genoa, Italy;
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12
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Saliba AN, Atoui A, Labban M, Hamade H, Bou-Fakhredin R, Mufarrij A, Taher AT. Thalassemia in the emergency department: special considerations for a rare disease. Ann Hematol 2020; 99:1967-1977. [PMID: 32621178 PMCID: PMC7333588 DOI: 10.1007/s00277-020-04164-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/29/2020] [Indexed: 01/19/2023]
Abstract
Thalassemia is characterized by a defect in the synthesis of one or more of the globin subunits of hemoglobin. This defect results in imbalance in the α/β-globin chain ratio, ineffective erythropoiesis, chronic hemolytic anemia, and iron overload. With advances in diagnosis, treatment, and transfusion support, the prognosis of patients with thalassemia has improved over the past few decades. An increasing number of patients with thalassemia is living with long-term complications, including cardiomyopathy, chronic liver disease, endocrinopathy, and infections. In this paper, we review common complications that bring the patient with thalassemia to urgent or emergent medical attention. We also discuss the aspects of emergency care that are most relevant while caring for the patient with thalassemia in the emergency department.
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Affiliation(s)
- Antoine N Saliba
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ali Atoui
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Labban
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani Hamade
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rayan Bou-Fakhredin
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Afif Mufarrij
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali T Taher
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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13
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Ho PJ, Hiwase D, Ramakrishna R, Viiala N, Solterbeck A, Traficante R, Zor E, Gervasio OL, High LM, Ross DM, Bowden DK. Cardiac and hepatic siderosis in myelodysplastic syndrome, thalassemia and diverse causes of transfusion-dependent anemia: the TIMES study. Hemasphere 2019; 3:e224. [PMID: 31723837 PMCID: PMC6746020 DOI: 10.1097/hs9.0000000000000224] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 01/30/2019] [Accepted: 03/20/2019] [Indexed: 01/19/2023] Open
Abstract
Supplemental Digital Content is available in the text The significant morbidity and mortality associated with iron overload can be reduced by effective iron chelation. Magnetic resonance imaging (MRI) provides accurate and reproducible iron load assessment. The aim of this epidemiological study was to assess the prevalence and severity of cardiac and hepatic siderosis by MRI and to evaluate the impact of MRI on clinical management in patients with transfusion-dependent anemia and non-transfusion-dependent thalassemia (NTDT). We enrolled 243 patients with myelodysplastic syndromes (MDS), thalassemia major (TM), NTDT or other chronic anemia. Overall, 10% and 48% had cardiac and hepatic siderosis, respectively. Mean liver iron concentration (LIC) was above target range in all groups; mean myocardial T2∗ was normal. Hepatic siderosis was more prevalent than myocardial siderosis in patients with MDS, occurring in 54.4% and 4.4% of patients, respectively. As also observed in patients with NTDT or other anemia, hepatic siderosis was present in a large proportion of MDS patients who were chelation naïve (57.7%), as well as in patients receiving iron chelation therapy (ICT) (52.4%), despite a lower transfusion load compared with TM. Correlation between LIC and serum ferritin was observed across diseases; however, not all patients requiring ICT could be identified with serum ferritin alone, as serum ferritin underestimated LIC in 4.4% and overestimated LIC in 7.5% of patients. Exploratory analyses showed serum ferritin thresholds for liver siderosis detected by MRI at approximately 300 ng/mL higher in MDS than in TM. Most patients reported low–medium adherence to ICT; MRI assessment led to change in ICT in 46% of evaluable patients, including 52% of MDS patients. Accurate organ iron monitoring by MRI facilitated appropriate initiation of chelation, dose optimization and clinical decision making. Trial registration: ClinicalTrials.gov: NCT01736540.
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Affiliation(s)
- P Joy Ho
- Royal Prince Alfred Hospital, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | | | | | | | | | | | - Evren Zor
- Novartis Pharmaceuticals, Sydney, Australia
| | | | | | - David M Ross
- Flinders University and Medical Centre, Adelaide, Australia
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14
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Tole S, Amid A, Baker J, Kuo K, Pugi J, Carcao M. Mild Hereditary Spherocytosis without Accompanying Hereditary Haemochromatosis: An Unrecognised Cause of Iron Overload. Acta Haematol 2019; 141:256-260. [PMID: 30965318 DOI: 10.1159/000497175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 01/22/2019] [Indexed: 11/19/2022]
Abstract
Hereditary spherocytosis (HS) is a common inherited haemolytic anaemia and has great variability in its presentation. Non-transfusion iron overload in HS has only been reported with co-inheritance of hereditary haemochromatosis (HHC). We present 4 unrelated patients of East Asian ethnicity with mild HS and significant non-transfusion iron overload in the absence of known disease-causing mutations in HHC genes. We hypothesise that, in patients with mild HS, life-long chronic haemolysis and erythropoietic drive may promote iron absorption. This suggests that mild HS may not be entirely benign, and that patients with mild HS should be monitored for iron overload.
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Affiliation(s)
- Soumitra Tole
- Department of Paediatrics, Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ali Amid
- Department of Paediatrics, Division of Haematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Jillian Baker
- Department of Paediatrics, Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Medicine, Division of Haematology/Oncology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Kevin Kuo
- Department of Medicine, Division of Haematology/Oncology, University Health Network, Toronto, Ontario, Canada
| | - Jakob Pugi
- Department of Paediatrics, Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Manuel Carcao
- Department of Paediatrics, Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada,
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada,
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15
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Abstract
The relationship between blood transfusion intensity, chelatable iron pools, and extrahepatic iron distribution is described in thalassemia. Risk factors for cardiosiderosis are discussed with particular reference to the balance of transfusional iron loading rate and transferrin-iron utilization rate as marked by plasma levels of soluble transferrin receptors. Low transfusion regimens increase residual erythropoiesis allowing for apotransferrin-dependent clearance of non-transferrin-bound iron species otherwise destined for myocardium. The impact of transfusion rates on chelation dosing required for iron balance is also shown.
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Affiliation(s)
- John B Porter
- Haematology Department, University College London, UCLH and Whittington Hospitals, UCL Cancer Institute, Paul O'Gorman Building, 72 Huntley Street, London WC1E 6BT, UK.
| | - Maciej W Garbowski
- Haematology Department, University College London, Cancer Institute, UCL Cancer Institute, Paul O'Gorman Building, 72 Huntley Street, London WC1E 6BT, UK
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16
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Using IVIM-MRI and R2⁎ Mapping to Differentiate Early Stage Liver Fibrosis in a Rat Model of Radiation-Induced Liver Fibrosis. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4673814. [PMID: 30627558 PMCID: PMC6304485 DOI: 10.1155/2018/4673814] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 11/09/2018] [Accepted: 11/21/2018] [Indexed: 12/17/2022]
Abstract
Rationale and Objectives To investigate the utility of intravoxel incoherent motion MRI (IVIM-MRI) and R2⁎ mapping in diagnosing early stage liver fibrosis in a radiation-induced rat model. Materials and Methods Thirty rats were randomly divided into three groups with 10 rats in each group. Liver fibrosis was induced by exposure of right lobe of liver in each animal to 20 Gy of radiation. MRI examination was conducted at baseline, one month, two months, and three months after radiation using T1WI, T2WI, IVIM-DWI, and R2⁎ sequences. The pathological examination included hematoxylin eosin, masson trichrome, and prussian blue staining. D, D⁎, f, and R2⁎ values were measured in both left and right lobes for quantitative analysis. Results Regarding the surviving 23 rats, eight rats were diagnosed with stage F0, ten with stage F1, and five with stage F2 liver fibrosis using METAVIR Scores. The D values of right lobes decreased (P<0.05), and R2⁎ values increased (P<0.01) significantly as fibrosis levels increased. But there was no statistical difference in D⁎ (P=0.970) and f values (P=0.079). R2⁎ value showed a strong positive correlation (r=0.819, P<0.001), while D value showed a negative correlation with fibrosis stages (r=-0.424, P<0.001). D⁎ (r=0.029, P=0.744) and f values (r=-0.055, P=0.536) were poorly correlated with fibrosis levels. Conclusion IVIM-MRI and R2⁎ mapping are useful techniques for evaluating the severity of liver fibrosis in a radiation-induced rat model, and R2⁎ value is the most sensitive parameter in detecting early stage fibrosis.
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17
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Deferasirox: Over a Decade of Experience in Thalassemia. Mediterr J Hematol Infect Dis 2018; 10:e2018066. [PMID: 30416698 PMCID: PMC6223547 DOI: 10.4084/mjhid.2018.066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 09/15/2018] [Indexed: 01/19/2023] Open
Abstract
Thalassemia incorporates a broad clinical spectrum characterized by decreased or absent production of normal hemoglobin leading to decreased red blood cell survival and ineffective erythropoiesis. Chronic iron overload remains an inevitable complication resulting from regular blood transfusions (transfusion-dependent) and/or increased iron absorption (mainly non-transfusion-dependent thalassemia), requiring adequate treatment to prevent the significant associated morbidity and mortality. Iron chelation therapy has become a cornerstone in the management of thalassemia patients, leading to improvements in their outcome and quality of life. Deferasirox (DFX), an oral iron chelating agent, is approved for use in transfusion dependent and non-transfusion-dependent thalassemia and has shown excellent efficacy in this setting. We herein present an updated review of the role of deferasirox in thalassemia, exploring over a decade of experience, which has documented its effectiveness and convenience; in addition to its manageable safety profile.
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18
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Bou-Fakhredin R, Elias J, Taher AT. Iron Overload and Chelation Therapy in Hemoglobinopathies. THALASSEMIA REPORTS 2018. [DOI: 10.4081/thal.2018.7478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Iron overload (IOL) is highly prevalent among patients with hemoglobinopathies; both transfusion dependent thalassemia (TDT) and non-transfusion dependent thalassemia (NTDT). Whether IOL is secondary to regular transfusions like in TDT, or develops from increased intestinal absorption like in NTDT, it can cause significant morbidity and mortality. In TDT patients, iron accumulation in organ tissues is highly evident, and leads to organ toxicity and dysfunction. IOL in NTDT patients is cumulative with advancing age, and concern with secondary morbidity starts beyond the age of 10 years, as shown by the OPTIMAL CARE study. Several modalities are available for the diagnosis and monitoring of IOL. Serum ferritin (SF) assessment is widely available and heavily relied on in resource-poor countries. Non-invasive iron monitoring using MRI has become the gold standard to diagnose IOL. Three iron chelators are currently available for the treatment of IOL: deferoxamine (DFO) in subcutaneous or intravenous injection, oral deferiprone (DFP) in tablet or solution form, and oral deferasirox (DFX) in dispersible tablet (DT) and film-coated tablet (FCT). Today, the goal of ICT is to maintain safe levels of body iron at all times. Appropriate tailoring ICT with chelator choices and dose adjustment must be implemented in a timely manner. Clinical decision to initiate, adjust and stop ICT is based on SF, MRI-LIC and cardiac T2*. In this article, we review the mechanism of IOL in both TDT and NTDT, the pathophysiology behind it, its complications, and the different ways to assess and quantify it. We will also discuss the different ICT modalities available, and the emergence of novel therapies.
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Abstract
Inherited haemoglobin disorders, including thalassaemia and sickle-cell disease, are the most common monogenic diseases worldwide. Several clinical forms of α-thalassaemia and β-thalassaemia, including the co-inheritance of β-thalassaemia with haemoglobin E resulting in haemoglobin E/β-thalassaemia, have been described. The disease hallmarks include imbalance in the α/β-globin chain ratio, ineffective erythropoiesis, chronic haemolytic anaemia, compensatory haemopoietic expansion, hypercoagulability, and increased intestinal iron absorption. The complications of iron overload, arising from transfusions that represent the basis of disease management in most patients with severe thalassaemia, might further complicate the clinical phenotype. These pathophysiological mechanisms lead to an array of clinical manifestations involving numerous organ systems. Conventional management primarily relies on transfusion and iron-chelation therapy, as well as splenectomy in specific cases. An increased understanding of the molecular and pathogenic factors that govern the disease process have suggested routes for the development of new therapeutic approaches that address the underlying chain imbalance, ineffective erythropoiesis, and iron dysregulation, with several agents being evaluated in preclinical models and clinical trials.
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Affiliation(s)
- Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Centre, Beirut, Lebanon.
| | - David J Weatherall
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community, University of Milan, IRCCS Ca'Granda Foundation Maggiore Policlinico Hospital, Milan, Italy
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20
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Taher AT, Saliba AN. Iron overload in thalassemia: different organs at different rates. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:265-271. [PMID: 29222265 PMCID: PMC6142532 DOI: 10.1182/asheducation-2017.1.265] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Thalassemic disorders lie on a phenotypic spectrum of clinical severity that depends on the severity of the globin gene mutation and coinheritance of other genetic determinants. Iron overload is associated with increased morbidity in both patients with transfusion-dependent thalassemia (TDT) and non-transfusion-dependent thalassemia (NTDT). The predominant mechanisms driving the process of iron loading include increased iron burden secondary to transfusion therapy in TDT and enhanced intestinal absorption secondary to ineffective erythropoiesis and hepcidin suppression in NTDT. Different organs are affected differently by iron overload in TDT and NTDT owing to the underlying iron loading mechanism and rate of iron accumulation. Serum ferritin measurement and noninvasive imaging techniques are available to diagnose iron overload, quantify its extent in different organs, and monitor clinical response to therapy. This chapter discusses the general approach to iron chelation therapy based on organ involvement using the available iron chelators: deferoxamine, deferiprone, and deferasirox. Other novel experimental options for treatment and prevention of complications associated with iron overload in thalassemia are briefly discussed.
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Affiliation(s)
- Ali T. Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon; and
| | - Antoine N. Saliba
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
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21
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Garbowski MW, Evans P, Vlachodimitropoulou E, Hider R, Porter JB. Residual erythropoiesis protects against myocardial hemosiderosis in transfusion-dependent thalassemia by lowering labile plasma iron via transient generation of apotransferrin. Haematologica 2017. [PMID: 28642302 PMCID: PMC5622848 DOI: 10.3324/haematol.2017.170605] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Cardiosiderosis is a leading cause of mortality in transfusion-dependent thalassemias. Plasma non-transferrin-bound iron and its redox-active component, labile plasma iron, are key sources of iron loading in cardiosiderosis. Risk factors were identified in 73 patients with or without cardiosiderosis. Soluble transferrin receptor-1 levels were significantly lower in patients with cardiosiderosis (odds ratio 21). This risk increased when transfusion-iron loading rates exceeded the erythroid transferrin uptake rate (derived from soluble transferrin receptor-1) by >0.21 mg/kg/day (odds ratio 48). Labile plasma iron was >3-fold higher when this uptake rate threshold was exceeded, but non-transferrin-bound iron and transferrin saturation were comparable. The risk of cardiosiderosis was decreased in patients with low liver iron, ferritin and labile plasma iron, or high bilirubin, reticulocyte counts or hepcidin. We hypothesized that high erythroid transferrin uptake rate decreases cardiosiderosis through increased erythroid re-generation of apotransferrin. To test this, iron uptake and intracellular reactive oxygen species were examined in HL-1 cardiomyocytes under conditions modeling transferrin effects on non-transferrin-bound iron speciation with ferric citrate. Intracellular iron and reactive oxygen species increased with ferric citrate concentrations especially when iron-to-citrate ratios exceeded 1:100, i.e. conditions favoring kinetically labile monoferric rather than oligomer species. Excess iron-binding equivalents of apotransferrin inhibited iron uptake and decreased both intracellular reactive oxygen species and labile plasma iron under conditions favoring monoferric species. In conclusion, high transferrin iron utilization, relative to the transfusion-iron load rate, decreases the risk of cardiosiderosis. A putative mechanism is the transient re-generation of apotransferrin by an active erythron, rapidly binding labile plasma iron-detectable ferric monocitrate species.
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Affiliation(s)
- Maciej W Garbowski
- Research Haematology Department, Cancer Institute, University College London, UK .,University College London Hospitals and
| | - Patricia Evans
- Research Haematology Department, Cancer Institute, University College London, UK
| | | | - Robert Hider
- Institute of Pharmaceutical Sciences, King's College London, UK
| | - John B Porter
- Research Haematology Department, Cancer Institute, University College London, UK.,University College London Hospitals and
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22
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Kumfu S, Fucharoen S, Chattipakorn SC, Chattipakorn N. Cardiac complications in beta-thalassemia: From mice to men. Exp Biol Med (Maywood) 2017; 242:1126-1135. [PMID: 28485683 DOI: 10.1177/1535370217708977] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Beta-thalassemia is an inherited hemoglobin disorder caused by reduced or absent synthesis of the beta globin chains of hemoglobin. This results in variable outcomes ranging from clinically asymptomatic to severe anemia, which then typically requires regular blood transfusion. These regular blood transfusions can result in an iron overload condition. The iron overload condition can lead to iron accumulation in various organs, especially in the heart, leading to iron overload cardiomyopathy, which is the major cause of mortality in patients with thalassemia. In the past decades, there is no doubt that the use of β-thalassemic mice as a study model to investigate the pathophysiology of iron overload cardiomyopathy and the role of various pharmacological interventions, has shed some light in understanding this serious complication and in improving the associated cardiac dysfunction. In this review, the effects that iron overload has on the hearts of β-thalassemic mice under conditions of iron overload as well as the efficacy of pharmacological interventions to combat these adverse effects on the heart are reviewed and discussed. The in-depth understanding of biomolecular alterations in the heart of these iron overload thalassemic mice will help give guidance for more effective therapeutic approaches in the near future. Impact statement Iron overload cardiomyopathy is a major cause of morbidity and mortality in patients with thalassemia. Since investigation of iron overload cardiomyopathy in thalassemia patients has many limitations, a search for an animal model for this condition has been ongoing for decades. In the past decades, there is no doubt that the use of β-thalassemic mice as a study model to investigate the pathophysiology of iron overload cardiomyopathy and the role of various pharmacological interventions, has shed some light in understanding this serious complication and in improving the associated cardiac dysfunction. In this review, the effects of iron overload on the hearts of β-thalassemic mice under conditions of iron overload as well as the efficacy of pharmacological interventions to combat these adverse effects on the heart are reviewed and discussed.
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Affiliation(s)
- Sirinart Kumfu
- 1 Faculty of Medicine, Cardiac Electrophysiology Research and Training Center, Chiang Mai University, Chiang Mai 50200, Thailand.,2 Faculty of Medicine, Department of Physiology, Cardiac Electrophysiology Unit, Chiang Mai University, Chiang Mai 50200, Thailand.,3 Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Suthat Fucharoen
- 4 Thalassemia Research Center, Institute of Molecular Biosciences, Mahidol University, Nakhon Pathom 73170, Thailand
| | - Siriporn C Chattipakorn
- 1 Faculty of Medicine, Cardiac Electrophysiology Research and Training Center, Chiang Mai University, Chiang Mai 50200, Thailand.,3 Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai 50200, Thailand.,5 Faculty of Dentistry, Department of Oral Biology and Diagnostic Sciences, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Nipon Chattipakorn
- 1 Faculty of Medicine, Cardiac Electrophysiology Research and Training Center, Chiang Mai University, Chiang Mai 50200, Thailand.,2 Faculty of Medicine, Department of Physiology, Cardiac Electrophysiology Unit, Chiang Mai University, Chiang Mai 50200, Thailand.,3 Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai 50200, Thailand
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Huang Y, Wang M, Yu C, Lei Y, Lai Y, Liu R. Clinical presentation of the hemoglobin Youngstown variant in a Chinese family. Ann Hematol 2016; 95:1925-7. [DOI: 10.1007/s00277-016-2763-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 07/20/2016] [Indexed: 11/24/2022]
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Wang M, Liu R, Liang Y, Yang G, Huang Y, Yu C, Sun K, Lai Y, Xia Y. Iron overload correlates with serum liver fibrotic markers and liver dysfunction: Potential new methods to predict iron overload-related liver fibrosis in thalassemia patients. United European Gastroenterol J 2016; 5:94-103. [PMID: 28405327 DOI: 10.1177/2050640616646525] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 04/03/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Early detection of liver fibrosis in thalassemia patients and rapid initiation of treatment to interfere with its progression are extremely important. OBJECTIVE This study aimed to find a sensitive, easy-to-detect and noninvasive method other than liver biopsy for early detection of liver fibrosis in thalassemia patients. METHODS A total of 244 Chinese Thalassemia patients with non-transfusion-dependent thalassemia (NTDT, n = 105) or thalassemia major (TM, n = 139) and 120 healthy individuals were recruited into the present study, and blood collagen type IV (C IV), precollagen type III (PIIINPC) and hyaluronic acid (HA), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and ferritin were measured. Liver iron concentration was determined by MRI. The correlation of serum markers with liver iron load and liver function was evaluated. RESULTS Serum C IV, PIIINPC and HA were significantly elevated in Chinese patients with NTDT and further elevated in TM patients. Moreover, C IV, PIIINPC and HA were also positively correlated to serum ferritin and liver iron concentration and further elevated during the progression to multi-organ damage in NTDT patients. Finally, serum ferritin and liver iron concentration were significantly correlated with liver dysfunction determined by AST and ALT. CONCLUSION Taken together, our results indicate that monitoring serum C IV, PIIINPC and HA is a potentially sensitive method to predict the risks for iron overload-related liver fibrosis in Chinese thalassemia patients.
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Affiliation(s)
- Man Wang
- Department of Hematology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Rongrong Liu
- Department of Hematology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yuzhen Liang
- Department of Endocrinology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Gaohui Yang
- Department of Hematology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yumei Huang
- Department of Hematology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Chunlan Yu
- Department of Hematology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Kaiqi Sun
- Department of Biochemistry and Molecular Biology, University of Texas Medical School, Houston, TX, USA
| | - Yongrong Lai
- Department of Hematology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yang Xia
- Department of Biochemistry and Molecular Biology, University of Texas Medical School, Houston, TX, USA
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Halawi R, Motta I, Taher A, Cappellini MD. Deferasirox: an orphan drug for chronic iron overload in non-transfusion dependent thalassemia syndromes. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1182018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Racha Halawi
- Internal Medicine, Emory University, Atlanta GA, USA
| | - Irene Motta
- Department of Medical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
| | - Ali Taher
- Hematology and Oncology, American University of Beirut, Beirut, Lebanon
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Saliba AN, Taher AT. Morbidities in non-transfusion-dependent thalassemia. Ann N Y Acad Sci 2016; 1368:82-94. [DOI: 10.1111/nyas.13083] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 04/06/2016] [Accepted: 04/07/2016] [Indexed: 01/19/2023]
Affiliation(s)
- Antoine N. Saliba
- Department of Medicine; Indiana University School of Medicine; Indianapolis Indiana
| | - Ali T. Taher
- Department of Internal Medicine; American University of Beirut Medical Center; Beirut Lebanon
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Tantiworawit A, Charoenkwan P, Hantrakool S, Choeyprasert W, Sivasomboon C, Sanguansermsri T. Iron overload in non-transfusion-dependent thalassemia: association with genotype and clinical risk factors. Int J Hematol 2016; 103:643-8. [DOI: 10.1007/s12185-016-1991-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 03/08/2016] [Accepted: 03/15/2016] [Indexed: 12/17/2022]
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Vitrano A, Calvaruso G, Tesé L, Gioia F, Cassarà F, Campisi S, Butera F, Commendatore V, Rizzo M, Santoro V, Cigna V, Quota A, Bagnato S, Argento C, Fidone C, Schembari D, Gerardi C, Barbiera F, Bellisssima G, Giugno G, Polizzi G, Rosso R, Abbate G, Caruso V, Chiodi E, Gamberini MR, Giorgi B, Putti MC, Filosa A, De Ritis MR, Oliva E, Arcadi N, Fustaneo M, Mistretta L, Di Maggio R, Sacco M, Veronica DS, Giangreco A, Maggio A. Real-life experience with liver iron concentration R2 MRI measurement in patients with hemoglobinopathies: baseline data from LICNET. Eur J Haematol 2016; 97:361-70. [DOI: 10.1111/ejh.12740] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2016] [Indexed: 01/19/2023]
Affiliation(s)
- Angela Vitrano
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Giuseppina Calvaruso
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Lorenzo Tesé
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Francesco Gioia
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Filippo Cassarà
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | | | | | | | | | | | | | | | | | - Crocetta Argento
- U.O.S. di Talassemia Ospedale San Giovanni di Dio; Agrigento Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Aldo Filosa
- U.O.D. Malattie Rare del Globulo Rosso; A.O.R.N. ‘A. Cardarelli’; Napoli Italy
| | | | - Esther Oliva
- A.O. ‘Bianchi-Melacrino-Morelli’; Reggio Calabria Italy
| | - Nicola Arcadi
- A.O. ‘Bianchi-Melacrino-Morelli’; Reggio Calabria Italy
| | - Maria Fustaneo
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Laura Mistretta
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Rosario Di Maggio
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Massimiliano Sacco
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Di Salvo Veronica
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Antonino Giangreco
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
| | - Aurelio Maggio
- Campus of Haematology Franco e Piera Cutino- A.O.O.R. ‘Villa Sofia-Cervello’; Palermo Italy
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Ricchi P, Marsella M. Profile of deferasirox for the treatment of patients with non-transfusion-dependent thalassemia syndromes. Drug Des Devel Ther 2016; 9:6475-82. [PMID: 26719673 PMCID: PMC4687615 DOI: 10.2147/dddt.s40694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
It has been clearly shown that iron overload adds progressively significant morbidity and mortality in patients with non-transfusion-dependent thalassemia (NTDT). The lack of physiological mechanisms to eliminate the excess of iron requires effective iron chelation therapy. The reduced compliance to deferoxamine and the risk of severe hematological adverse events during deferiprone treatment have limited the use of both these drugs to correct iron imbalance in NTDT. According to the principles of evidence-based medicine, following the demonstration of the effectiveness and the safety of deferasirox (Exjade®) in a prospective, randomized, controlled trial, deferasirox was approved by the US Food and Drug Administration in May 2013 for the treatment of iron overload associated with NTDT. This review, assessing the available scientific literature, will focus on the profile of DFX in the treatment of non-transfusional hemosiderosis in patients with NTDT.
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Affiliation(s)
- Paolo Ricchi
- UOSD Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale "Antonio Cardarelli", Naples, Italy
| | - Maria Marsella
- UOSD Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale "Antonio Cardarelli", Naples, Italy ; UOC Pediatria, Azienda Ospedaliera di Rilievo Nazionale G. Rummo, Benevento, Italy
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Saliba AN, El Rassi F, Taher AT. Clinical monitoring and management of complications related to chelation therapy in patients with β-thalassemia. Expert Rev Hematol 2015; 9:151-68. [DOI: 10.1586/17474086.2016.1126176] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Saiviroonporn P, Viprakasit V, Krittayaphong R. Improved R2* liver iron concentration assessment using a novel fuzzy c-mean clustering scheme. BMC Med Imaging 2015; 15:52. [PMID: 26530825 PMCID: PMC4632332 DOI: 10.1186/s12880-015-0097-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 10/29/2015] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND In thalassemia patients, R2* liver iron concentration (LIC) measurement is a common clinical tool for assessing iron overload and for determining necessary chelator dose and evaluating its efficacy. Despite the importance of accurate LIC measurement, existing methods suffer from LIC variability, especially at the severe iron overload range due to inclusion of vessel parts in LIC calculation. In this study, we build upon previous Fuzzy C-Mean (FCM) clustering work to formulate a scheme with superior performance in segmenting vessel pixels from the parenchyma. Our method (MIX-FCM) combines our novel 2D-FCM with the existing 1D-FCM algorithm. This study further assessed possible optimal clustering parameters (OP scheme) and proposed a semi-automatic (SA) scheme for routine clinical application. METHODS Segmentation of liver parenchyma and vessels was performed on T2* images and their LIC maps in 196 studies from 147 thalassemia major patients. We used manual segmentation as the reference. 1D-FCM clustering was performed on the acquired image alone and 2D-FCM used both the acquired image and its LIC data. To execute the MIX-FCM method, the best outcome (OP-MIX-FCM) was selected from the aforementioned methods and was compared to the SA-MIX-FCM scheme. We used the percent value of the normalized interquartile range (nIQR) to its median to evaluate the variability of all methods. RESULTS 2D-FCM clustering is more effective than 1D-FCM clustering at the severe overload range only, but inferior for other ranges (where 1D-FCM provides suitable results). This complementary performance between the two methods allows MIX-FCM to improve results for all ranges. OP-MIX-FCM clustering error was 2.1 ± 2.3%, compared with 10.3 ± 9.9% and 7.0 ± 11.9% from 1D- and 2D-FCM clustering, respectively. SA-MIX-FCM result was comparable to OP-MIX-FCM result, with both schemes showing ability to decrease overall nIQR by approximately 30%. CONCLUSION Our proposed 2D-FCM algorithm is not as superior to 1D-FCM as hypothesized. In contrast, our MIX-FCM method benefits from the best of both methods to obtain the highest segmentation accuracy at all ranges. Moreover, segmentation accuracy of the practical scheme (SA-MIX-FCM) is comparable to segmentation accuracy of the reference scheme (OP-MIX-FCM). Finally, we confirmed that segmentation is crucial to improving LIC assessments, especially at the severe iron overload range.
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Affiliation(s)
- Pairash Saiviroonporn
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand.
| | - Vip Viprakasit
- Haematology/Oncology Division, Department of Pediatrics and Thalassemia Center, Mahidol University, Bangkok, Thailand.
| | - Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Taher AT, Radwan A, Viprakasit V. When to consider transfusion therapy for patients with non-transfusion-dependent thalassaemia. Vox Sang 2015; 108:1-10. [PMID: 25286743 PMCID: PMC4302976 DOI: 10.1111/vox.12201] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 07/17/2014] [Accepted: 08/05/2014] [Indexed: 01/19/2023]
Abstract
Non-transfusion-dependent thalassaemia (NTDT) refers to all thalassaemia disease phenotypes that do not require regular blood transfusions for survival. Thalassaemia disorders were traditionally concentrated along the tropical belt stretching from sub-Saharan Africa through the Mediterranean region and the Middle East to South and South-East Asia, but global migration has led to increased incidence in North America and Northern Europe. Transfusionists may be familiar with β-thalassaemia major because of the lifelong transfusions needed by these patients. Although patients with NTDT do not require regular transfusions for survival, they may require transfusions in some instances such as pregnancy, infection or growth failure. The complications associated with NTDT can be severe if not properly managed, and many are directly related to chronic anaemia. Awareness of NTDT is important, and this review will outline the factors that should be taken into consideration when deciding whether to initiate and properly plan for transfusion therapy in these patients in terms of transfusion interval and duration of treatment.
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Affiliation(s)
- A T Taher
- American University of Beirut, Beirut, Lebanon
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Mohammad AM. Echocardiographic evaluation of thalassemia intermedia patients in Duhok, Iraq. BMC Cardiovasc Disord 2014; 14:183. [PMID: 25495194 PMCID: PMC4272797 DOI: 10.1186/1471-2261-14-183] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 12/01/2014] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Cardiac complications are among the most serious problems of thalassemia intermedia patients. The current study was initiated to address the latter issue through the study of the echocardiographic findings and correlate it with clinical characteristics of thalassemia intermedia patients in Duhok, Kurdistan region, Iraq. METHODS An echocardiographic assessment of 61 beta-thalassemia intermedia cases was performed. It included 30 males and 31 females, with a mean age 19.6 ± 7.5 years. The standard echostudy of two-dimension and M-mode measurements of cardiac chambers were done. The continuous doppler regurgitant jet of tricuspid and pulmonary valves were recorded. Left ventricle diastolic function was assessed by pulsed doppler of mitral valve inflow. To correlate the clinical with echocardiographic findings, patients were divided, according to tricuspid regurgitant velocity, into three groups (<2.5 m/sec, 2.5-2.9 m/sec and ≥3 m/sec). RESULTS Tricuspid regurgitant velocity <2.5 m/sec, 2.5-2.9 m/sec and ≥3 m/sec occurred in 42(69%), 11(18%) and 8(13%) respectively. Comparing to other groups patients with tricuspid regurgitant velocity ≥3 m/sec were older and included more males. They had lower hemoglobin levels, but higher ferritin levels. Their age at diagnosis and the age of the initiation of blood transfusion were later. Most of them had significant exertional dyspnea. They also had relatively lower left ventricle ejection fraction values. Right ventricular diameter and right atrial size were larger in the same group. Tricuspid regurgitant velocity as a continuous predictor was associated positively with age, cardiac volumes and pulmonary regurgitation though negatively associated with ejection fraction. CONCLUSIONS Echo-derived right and left side cardiac complications are not uncommon in thalassemia intermedia patients. Therapeutic trails targeting these complications are indicated, and echocardiographic assessment is necessary to be offered early for thalassemia intermedia.
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Affiliation(s)
- Ameen Mosa Mohammad
- Department of Medicine, Division of Cardiology, Medical School, Faculty of Medical Sciences, Duhok University, Kurdistan, Iraq.
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Identification and key management of non-transfusion-dependent thalassaemia patients: not a rare but potentially under-recognised condition. Orphanet J Rare Dis 2014; 9:131. [PMID: 25265971 PMCID: PMC4193991 DOI: 10.1186/s13023-014-0131-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 08/05/2014] [Indexed: 01/27/2023] Open
Abstract
Patients with non-transfusion-dependent thalassaemia (NTDT) have a genetic defect or combination of defects that affect haemoglobin synthesis, but which is not severe enough to require regular blood transfusions. The carrier frequency of NTDT is high (up to 80% in some parts of the world) but the prevalence of symptomatic patients varies with geography and is estimated to be from 1 in 100,000 to 1 in 100. NTDT has a variable presentation that may include mild to severe anaemia, enlarged spleen and/or liver, skeletal deformities, growth retardation, elevated serum ferritin and iron overload. The contributing factors to disease progression are ineffective erythropoiesis and increased haemolysis, which lead to chronic anaemia. The body's attempts to correct the anaemia result in constantly activated erythropoiesis, leading to marrow expansion and extramedullary haematopoiesis. Diagnosis of NTDT is largely clinical but can be confirmed by genetic sequencing. NTDT must be differentiated from other anaemias including sideroblastic anaemia, paroxysmal nocturnal haemoglobinuria, congenital dyserythropoietic anaemia, myelodysplastic syndromes and iron-deficiency anaemia. Management of NTDT is based on managing symptoms, and includes blood transfusions, hydroxyurea treatment, iron chelation and sometimes splenectomy. Prognosis for well managed patients is good, with most patients living a normal life. Since NTDT is mainly prevalent in sub-tropical regions, patients who present in other parts of the world, in particular the Northern hemisphere, might not been correctly recognised and it can be considered a 'rare' condition. It is particularly important to identify and diagnose patients early, thereby preventing complications.
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Novel approach to reactive oxygen species in nontransfusion-dependent thalassemia. BIOMED RESEARCH INTERNATIONAL 2014; 2014:350432. [PMID: 25121095 PMCID: PMC4119900 DOI: 10.1155/2014/350432] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 06/07/2014] [Indexed: 12/13/2022]
Abstract
The term Nontransfusion dependent thalassaemia (NTDT) was suggested to describe patients who had clinical manifestations that are too severe to be termed minor yet too mild to be termed major. Those patients are not entirely dependent on transfusions for survival.
If left untreated, three main factors are responsible for the clinical sequelae of NTDT: ineffective erythropoiesis, chronic hemolytic anemia, and iron overload. Reactive oxygen species (ROS) generation in NTDT patients is caused by 2 major mechanisms. The first one is chronic hypoxia resulting from chronic anemia and ineffective erythropoiesis leading to mitochondrial damage and the second is iron overload also due to chronic anemia and tissue hypoxia leading to increase intestinal iron absorption in thalassemic patients. Oxidative damage by reactive oxygen species (generated by free globin chains and labile plasma iron) is believed to be one of the main contributors to cell injury, tissue damage, and hypercoagulability in patients with thalassemia. Independently increased ROS has been linked to a myriad of pathological outcomes such as leg ulcers, decreased wound healing, pulmonary hypertension, silent brain infarcts, and increased thrombosis to count a few. Interestingly many of those complications overlap with those found in NTDT patients.
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Musallam KM, Rivella S, Vichinsky E, Rachmilewitz EA. Non-transfusion-dependent thalassemias. Haematologica 2013; 98:833-44. [PMID: 23729725 DOI: 10.3324/haematol.2012.066845] [Citation(s) in RCA: 205] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Non-transfusion-dependent thalassemias include a variety of phenotypes that, unlike patients with beta (β)-thalassemia major, do not require regular transfusion therapy for survival. The most commonly investigated forms are β-thalassemia intermedia, hemoglobin E/β-thalassemia, and α-thalassemia intermedia (hemoglobin H disease). However, transfusion-independence in such patients is not without side effects. Ineffective erythropoiesis and peripheral hemolysis, the hallmarks of disease process, lead to a variety of subsequent pathophysiologies including iron overload and hypercoagulability that ultimately lead to a number of serious clinical morbidities. Thus, prompt and accurate diagnosis of non-transfusion-dependent thalassemia is essential to ensure early intervention. Although several management options are currently available, the need to develop more novel therapeutics is justified by recent advances in our understanding of the mechanisms of disease. Such efforts require wide international collaboration, especially since non-transfusion-dependent thalassemias are no longer bound to low- and middle-income countries but have spread to large multiethnic cities in Europe and the Americas due to continued migration.
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Affiliation(s)
- Khaled M Musallam
- Department of Medicine and Medical Specialties, IRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy.
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Matta BN, Musallam KM, Maakaron JE, Koussa S, Taher AT. A killer revealed: 10-year experience with beta-thalassemia intermedia. ACTA ACUST UNITED AC 2013; 19:196-8. [PMID: 24074485 DOI: 10.1179/1607845413y.0000000120] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Patients with beta-thalassemia intermedia tend to present later in life with milder anemia than beta-thalassemia major patients. The incidence of mortality and its causes in this patient population remains unknown. We aim to reveal the incidence and most common causes of death in this population. METHODS AND RESULTS We reviewed the charts of all of the beta-thalassemia intermedia patients who had been followed at the Chronic Care Center in Hazmieh, Lebanon during a 10-year period. A total of 18 patients out of 127 had died during the follow-up period giving a cumulative 10-year mortality incidence of 14%. The most common causes of cardiac deaths were due to renal and cardiac causes. DISCUSSION Most causes of death have been linked to the high levels of iron coupled with anemia present in this patient population. Many of deaths could be prevented by adequate treatment. CONCLUSION Larger studies with more comprehensive data capture on risk factors of mortality in this patient population are called for.
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Taher AT, Temraz S, Cappellini MD. Deferasirox for the treatment of iron overload in non-transfusion-dependent thalassemia. Expert Rev Hematol 2013; 6:495-509. [PMID: 24083402 DOI: 10.1586/17474086.2013.827411] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Non-transfusion-dependent thalassemia (NTDT) defines a group of patients who do not require regular transfusions for survival, but are at significant risk of iron accumulation from underlying disease-related mechanisms distinct from transfusional iron overload. Management of iron overload in NTDT has received little attention compared with that of β-thalassemia major, despite evidence of significant iron-induced complications with advancing age. The efficacy and safety of the iron chelator deferasirox in NTDT has been evaluated in two pilot studies and the first prospective, randomized, placebo-controlled study (THALASSA) of any chelator in NTDT. Treatment with deferasirox for up to 2 years yielded a sustained reduction in iron burden, with a clinically manageable safety profile. Following these trial data, deferasirox is the first iron chelator approved for use in NTDT patients, and with NTDT guidelines now available, physicians are better equipped to achieve effective monitoring and management of iron burden in NTDT.
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Affiliation(s)
- Ali T Taher
- Department of Internal Medicine, American University of Beirut, Riad El Solh 1107 2020, Beirut, Lebanon
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Abstract
PURPOSE OF REVIEW The aim is to overview recent evidence on consequences, assessment, and management of iron overload in transfusion-independent patients with β-thalassemia intermedia. RECENT FINDINGS Despite their transfusion-independence, β-thalassemia intermedia patients can still accumulate iron due to increased intestinal absorption. Recent observational studies show that iron burden in this group of patients can ultimately reach considerably high thresholds, and leads to a variety of serious morbidities involving the liver, endocrine glands, and arguably the vascular system. The diagnosis of iron overload in this patient population can follow established guidelines from β-thalassemia major patients, although with careful interpretation of spot serum ferritin levels. Data from a recent randomized clinical trial demonstrated the efficacy and safety of iron chelation therapy in decreasing liver iron concentration in this group of patients, which may ultimately help in reducing morbidity risk. SUMMARY Iron overload in transfusion-independent patients with β-thalassemia intermedia deserves careful attention, and prompt diagnosis and management are recommended.
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Taher AT, Viprakasit V, Musallam KM, Cappellini MD. Treating iron overload in patients with non-transfusion-dependent thalassemia. Am J Hematol 2013; 88:409-15. [PMID: 23475638 PMCID: PMC3652024 DOI: 10.1002/ajh.23405] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 01/21/2013] [Accepted: 01/23/2013] [Indexed: 01/19/2023]
Abstract
Despite receiving no or only occasional blood transfusions, patients with non-transfusion-dependent thalassemia (NTDT) have increased intestinal iron absorption and can accumulate iron to levels comparable with transfusion-dependent patients. This iron accumulation occurs more slowly in NTDT patients compared to transfusion-dependent thalassemia patients, and complications do not arise until later in life. It remains crucial for these patients' health to monitor and appropriately treat their iron burden. Based on recent data, including a randomized clinical trial on iron chelation in NTDT, a simple iron chelation treatment algorithm is presented to assist physicians with monitoring iron burden and initiating chelation therapy in this group of patients. Am. J. Hematol. 88:409–415, 2013. © 2013 Wiley Periodicals, Inc.
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Affiliation(s)
- Ali T. Taher
- Department of Internal MedicineAmerican University of Beirut Medical CenterBeirut Lebanon
| | - Vip Viprakasit
- Department of Pediatrics and Siriraj‐Thalassemia CenterFaculty of MedicineSiriraj HospitalMahidol UniversityBangkok Thailand
| | - Khaled M. Musallam
- Department of Internal MedicineAmerican University of Beirut Medical CenterBeirut Lebanon
- Department of Medicine and Medical SpecialitiesUniversitá di MilanoCa' Granda Foundation IRCCSMilan Italy
| | - M. Domenica Cappellini
- Department of Medicine and Medical SpecialitiesUniversitá di MilanoCa' Granda Foundation IRCCSMilan Italy
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Musallam KM, Motta I, Salvatori M, Fraquelli M, Marcon A, Taher AT, Cappellini MD. Longitudinal changes in serum ferritin levels correlate with measures of hepatic stiffness in transfusion-independent patients with β-thalassemia intermedia. Blood Cells Mol Dis 2012; 49:136-9. [DOI: 10.1016/j.bcmd.2012.06.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 05/24/2012] [Accepted: 05/30/2012] [Indexed: 02/06/2023]
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Musallam KM, Cappellini MD, Wood JC, Taher AT. Iron overload in non-transfusion-dependent thalassemia: a clinical perspective. Blood Rev 2012; 26 Suppl 1:S16-9. [PMID: 22631036 DOI: 10.1016/s0268-960x(12)70006-1] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Iron overload due to increased intestinal iron absorption represents an important clinical problem in patients with non-transfusion-dependent thalassemia (NTDT), particularly as they advance in age. Current models for iron metabolism in patients with beta (β)-thalassemia intermedia (TI) suggest that suppression of serum hepcidin results in increased iron absorption and release of iron from the reticuloendothelial system, leading to depletion of macrophage iron, relatively low levels of serum ferritin, and liver iron loading. The clinical consequences of iron overload in patients with NTDT are multifactorial and include endocrinopathy, bone disease, thromboembolism, pulmonary hypertension, cerebrovascular and neuronal damage, liver fibrosis or cirrhosis, and increased risk of hepatocellular carcinoma. Although serum ferritin levels correlate with liver iron concentration (LIC), they underestimate iron load in these patients compared with transfusion-dependent patients with equivalent LIC. Therefore, direct measurement of LIC is recommended with chelation therapy as indicated.
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Affiliation(s)
- Khaled M Musallam
- IRCCS Ca' Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy
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Musallam KM, Taher AT, Rachmilewitz EA. β-thalassemia intermedia: a clinical perspective. Cold Spring Harb Perspect Med 2012; 2:a013482. [PMID: 22762026 PMCID: PMC3385943 DOI: 10.1101/cshperspect.a013482] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Our understanding of the molecular and pathophysiological mechanisms underlying the disease process in patients with β-thalassemia intermedia has substantially increased over the past decade. Earlier studies observed that patients with β-thalassemia intermedia experience a clinical-complications profile that is different from that in patients with β-thalassemia major. In this article, a variety of clinical morbidities are explored, and their associations with the underlying disease pathophysiology and risk factors are examined. These involve several organs and organ systems including the vasculature, heart, liver, endocrine glands, bone, and the extramedullary hematopoietic system. The effects of some therapeutic interventions on the development of clinical complications are also discussed.
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Affiliation(s)
- Khaled M Musallam
- Department of Medicine and Medical Specialties, IRCCS Cà Granda Foundation Maggiore Policlinico Hospital, 20122 Milan, Italy
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Karimi M, Musallam KM, Cappellini MD, Daar S, El-Beshlawy A, Belhoul K, Saned MS, Temraz S, Koussa S, Taher AT. Risk factors for pulmonary hypertension in patients with β thalassemia intermedia. Eur J Intern Med 2011; 22:607-10. [PMID: 22075289 DOI: 10.1016/j.ejim.2011.05.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Revised: 05/20/2011] [Accepted: 05/27/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pulmonary hypertension (PHT) is a common yet poorly understood complication of β thalassemia intermedia (TI). METHODS We herein evaluated risk factors for PHT in TI, through comparing 64 TI patients with evidence of PHT by symptomatology and echocardiography (Group I) to age- and sex-matched TI patients without PHT (Group II). Retrieved data included demographics, laboratory parameters, clinical characteristics, and received treatments that may influence PHT development; and reflected the period prior to PHT occurrence in Group I. RESULTS The mean age of Group I patients at development of PHT was 37.3±10.6years; with 44% being males. Among studied parameters, Group I patients were more likely to be splenectomized (4.9-times), transfusion-naive (3.5-times); hydroxyurea-naive (2.6-times), or iron chelation-naive (2.3-times); and have nucleated red blood cell count ≥300×10(6)/l (2.59-times) or a previous history of thromboembolic events (3.69-times). CONCLUSION TI patients who eventually develop PHT may be identified early on by being splenectomized, having high nucleated red blood cell counts and a previous history of thromboembolism. Prospective clinical trials that evaluate the efficacy, safety, and cost effectiveness of transfusion, iron chelation, and hydroxyurea therapy in preventing PHT in TI are invited.
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Affiliation(s)
- Mehran Karimi
- Department of Pediatrics, Shiraz University of Medical Sciences, Shiraz, Iran
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Musallam KM, Cappellini MD, Wood JC, Motta I, Graziadei G, Tamim H, Taher AT. Elevated liver iron concentration is a marker of increased morbidity in patients with β thalassemia intermedia. Haematologica 2011; 96:1605-12. [PMID: 21791471 DOI: 10.3324/haematol.2011.047852] [Citation(s) in RCA: 138] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Patients with β thalassemia intermedia can have substantial iron overload, irrespectively of their transfusion status, secondary to increased intestinal iron absorption. This study evaluates whether iron overload in patients with β thalassemia intermedia is associated with morbidity. DESIGN AND METHODS This was a cross-sectional study of 168 patients with β thalassemia intermedia treated at two centers in Lebanon and Italy. Data on demographics, splenectomy status, transfusion status, and presence of co-morbidities were retrieved. Laboratory values of serum ferritin, fetal and total hemoglobin levels, as well as platelet and nucleated red blood cell counts were also obtained. Iron burden was determined directly by measuring liver iron concentration using magnetic resonance imaging. Patients were subdivided according to transfusion and splenectomy status into groups with phenotypes of different severity. RESULTS The mean age of the patients was 35.2 ± 12.6 years and 42.9% of them were male. The mean liver iron concentration was 8.4 ± 6.7 mg Fe/g dry weight. On multivariate logistic regression analysis, after adjusting for age, gender, splenectomy status, transfusion status, and laboratory indices, an increase in 1 mg Fe/g dry weight liver iron concentration was independently and significantly associated with higher odds of thrombosis, pulmonary hypertension, hypothyroidism, osteoporosis, and hypogonadism. A liver iron concentration of at least 7 and at least 6 mg Fe/g dry weight were the best thresholds for discriminating the presence and absence of vascular and endocrine/bone morbidities, respectively (area under the receiver-operating characteristic curve: 0.72, P<0.001). Elevated liver iron concentration was associated with an increased rate of morbidity in patients with phenotypes of all severity, with a steeper increase in the rate of vascular morbidity being attributed to aging, and an earlier appearance of endocrine and bone disease. CONCLUSIONS Elevated liver iron concentration in patients with β thalassemia intermedia is a marker of increased vascular, endocrine, and bone disease.
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Affiliation(s)
- Khaled M Musallam
- Department of Internal Medicine, Division of Hematology & Oncology, American University of Beirut Medical Center, Beirut, Lebanon
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Musallam KM, Nasreddine W, Beydoun A, Hourani R, Hankir A, Koussa S, Haidar M, Taher AT. Brain positron emission tomography in splenectomized adults with β-thalassemia intermedia: uncovering yet another covert abnormality. Ann Hematol 2011; 91:235-41. [DOI: 10.1007/s00277-011-1291-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Accepted: 07/01/2011] [Indexed: 12/15/2022]
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Saad GSA, Musallam KM, Taher AT. The surgeon and the patient with β-thalassaemia intermedia. Br J Surg 2011; 98:751-60. [DOI: 10.1002/bjs.7533] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2011] [Indexed: 01/28/2023]
Abstract
Abstract
Background
Unlike patients with β-thalassaemia major, where lifelong transfusion and iron chelation therapy are necessary for survival, patients with β-thalassaemia intermedia (TI) generally have a milder course and anaemia. The underlying pathophysiology of the disease still allows several complications to manifest. Surgical management during the course of the disease is common but relevant data from the literature have never been reviewed constructively. This aim of this review was to highlight this clinical entity to the surgeon, and ensure optimal and timely intervention.
Methods
The review was based on potentially relevant studies identified from an electronic search of MEDLINE and PubMed databases. There were no language or publication year restrictions. References in published articles were also reviewed.
Results
Surgical intervention is often essential to ensure optimal control of the associated morbidity in TI. Several general considerations are necessary before surgical intervention with regard to anaemia, cardiovascular disease, thromboembolic events and the effects of iron overload. Splenectomy, cholecystectomy, leg ulcers, fractures and extramedullary pseudotumours are the most commonly encountered surgical problems related to TI.
Conclusion
Awareness of TI and its associated morbidity is important so that appropriate preoperative care can occur.
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Affiliation(s)
- G S Abi Saad
- Department of Surgery, American University of Beirut Medical Centre, Beirut, Lebanon
| | - K M Musallam
- Department of Internal Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
| | - A T Taher
- Department of Internal Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
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Fragasso A, Ciancio A, Mannarella C, Gaudiano C, Scarciolla O, Ottonello C, Francone M, Nardella M, Peluso A, Melpignano A, Veglio MR, Quarta G, Turchetti C. Myocardial iron overload assessed by magnetic resonance imaging (MRI)T2* in multi-transfused patients with thalassemia and acquired anemias. Eur J Intern Med 2011; 22:62-5. [PMID: 21238896 DOI: 10.1016/j.ejim.2010.10.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 09/29/2010] [Accepted: 10/25/2010] [Indexed: 02/05/2023]
Abstract
BACKGROUND Cardiac complications secondary to iron overload remain a significant matter in patients with transfusion dependent anemias. PATIENTS AND METHODS To evaluate cardiac siderosis, Magnetic resonance imaging T2* (MRI T2*) was performed in 3 cohorts of transfusion dependent patients: 99 with thalassemia major (TM), 20 with thalassemia intermedia (TI), and 10 with acquired anemias (AA). Serum ferritin was measured and all patients underwent echocardiographic evaluation. RESULTS In TM patients cardiac T2* pathologic values (below 20 ms) were found in 37 patients. Serum ferritin was negatively associated with age (r=-0.32, p=0.001) and weakly with T2* values (r=-0.19, p=0.057). A positive correlation was found between T2* and LVEF (r=0.27, p=0.006). Out of 37 patients with T2*<20 ms, 18 (48%) had serum ferritin values<1000 ng/ml. In TI cohort, 3 patients had cardiac T2* pathologic values. In AA cohort, pathologic T2* values were found in 2 patients, who received 234 and 199 PRBC units, respectively, and were both on chelation therapy (in one patient ferritin value was 399 ng/ml). T2* values were negatively associated, but not significantly, with the number of PRBC transfused (r=-0.53, p=0.07). CONCLUSION In our experience, 37% of TM patients had a myocardial iron overload assessed by MRI T2*; this value is higher than in TI patients. Serum ferritin measurement was a poor predictor of myocardial siderosis. In patients with AA, more than 200 PRBC units transfused were required to induce cardiac hemosiderosis, in spite of chelation therapy and, in one patient, of normal ferritin values.
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Affiliation(s)
- Alberto Fragasso
- Unità Semplice di Ematologia, Ospedale Madonna delle Grazie, Matera, Italy.
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Taher AT, Musallam KM, Cappellini MD, Weatherall DJ. Optimal management of β thalassaemia intermedia. Br J Haematol 2011; 152:512-23. [DOI: 10.1111/j.1365-2141.2010.08486.x] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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