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Juvenile Hemochromatosis With Non-transfused Hemolytic Anemia Caused by a De Novo PIEZO1 Gene Mutation. J Pediatr Hematol Oncol 2023; 45:e510-e513. [PMID: 36898020 DOI: 10.1097/mph.0000000000002639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/10/2023] [Indexed: 03/12/2023]
Abstract
Differential diagnosis of juvenile hemochromatosis along with hemolytic anemia is often difficult. We report a 23-year-old woman with macrocytic hemolytic anemia with iron overload. The patient showed high serum ferritin and transferrin saturation and low serum transferrin and ceruloplasmin. We also noticed stomatocytes in her blood smear, which was confirmed by scanning electron microscopy. Target gene sequencing identified a mutation in PIEZO1 (heterozygous c.6008C>A: p.A2003D). This mutation was reported previously in a family with dehydrated hereditary stomatocytosis (DHS1, [OMIM 194380]), but in the current case, it was identified to be a de novo mutation. We underscore DHS1 in the differential diagnosis of iron overload associated with non-transfused hemolytic anemia in children and young adults.
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Li N, Wu B, Wang J, Yan Y, An P, Li Y, Liu Y, Hou Y, Qing X, Niu L, Ding X, Xie Z, Zhang M, Guo X, Chen X, Cai T, Luo J, Wang F, Yang F. Differential proteomic patterns of plasma extracellular vesicles show potential to discriminate β-thalassemia subtypes. iScience 2023; 26:106048. [PMID: 36824279 PMCID: PMC9941134 DOI: 10.1016/j.isci.2023.106048] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 12/01/2022] [Accepted: 01/20/2023] [Indexed: 01/26/2023] Open
Abstract
The observed specificity of β-thalassemia-subtype phenotypes makes new diagnostic strategies that complement current screening methods necessary to determine each subtype and facilitate therapeutic regimens for different patients. Here, we performed quantitative proteomics of plasma-derived extracellular vesicles (EVs) of β-thalassemia major (TM) patients, β-thalassemia intermedia (TI) patients, and healthy controls to explore subgroup characteristics and potential biomarkers. Plasma quantitative proteomics among the same cohorts were analyzed in parallel to compare the biomarker potential of both specimens. EV proteomics showed significantly more abnormalities in immunity and lipid metabolism in TI and TM, respectively. The differential proteomic patterns of EVs were consistent with but more striking than those of plasma. Notably, we also found EV proteins to have a superior performance for discriminating β-thalassemia subtypes. These findings allowed us to propose a diagnostic model consisting of five proteins in EVs with subtyping potential, demonstrating the ability of plasma-derived EVs for the diagnosis of β-thalassemia patients.
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Affiliation(s)
- Na Li
- Key Laboratory of Protein and Peptide Pharmaceuticals & Laboratory of Proteomics, Institute of Biophysics, Chinese Academy of Sciences, Beijing 100101, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Bowen Wu
- Key Laboratory of Protein and Peptide Pharmaceuticals & Laboratory of Proteomics, Institute of Biophysics, Chinese Academy of Sciences, Beijing 100101, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Jifeng Wang
- Key Laboratory of Protein and Peptide Pharmaceuticals & Laboratory of Proteomics, Institute of Biophysics, Chinese Academy of Sciences, Beijing 100101, China
| | - Yumeng Yan
- Key Laboratory of Protein and Peptide Pharmaceuticals & Laboratory of Proteomics, Institute of Biophysics, Chinese Academy of Sciences, Beijing 100101, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Peng An
- Department of Nutrition and Health, China Agricultural University, Beijing 100193, China
| | - Yuezhen Li
- Department of Nutrition and Health, China Agricultural University, Beijing 100193, China
| | - Yuning Liu
- Department of Nutrition and Health, China Agricultural University, Beijing 100193, China
| | - Yanfei Hou
- Department of Nutrition and Health, China Agricultural University, Beijing 100193, China
| | - Xiaoqing Qing
- Key Laboratory of Protein and Peptide Pharmaceuticals & Laboratory of Proteomics, Institute of Biophysics, Chinese Academy of Sciences, Beijing 100101, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Lili Niu
- Key Laboratory of Protein and Peptide Pharmaceuticals & Laboratory of Proteomics, Institute of Biophysics, Chinese Academy of Sciences, Beijing 100101, China
| | - Xiang Ding
- Key Laboratory of Protein and Peptide Pharmaceuticals & Laboratory of Proteomics, Institute of Biophysics, Chinese Academy of Sciences, Beijing 100101, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Zhensheng Xie
- Key Laboratory of Protein and Peptide Pharmaceuticals & Laboratory of Proteomics, Institute of Biophysics, Chinese Academy of Sciences, Beijing 100101, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Mengmeng Zhang
- Key Laboratory of Protein and Peptide Pharmaceuticals & Laboratory of Proteomics, Institute of Biophysics, Chinese Academy of Sciences, Beijing 100101, China
| | - Xiaojing Guo
- Key Laboratory of Protein and Peptide Pharmaceuticals & Laboratory of Proteomics, Institute of Biophysics, Chinese Academy of Sciences, Beijing 100101, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Xiulan Chen
- Key Laboratory of Protein and Peptide Pharmaceuticals & Laboratory of Proteomics, Institute of Biophysics, Chinese Academy of Sciences, Beijing 100101, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Tanxi Cai
- Key Laboratory of Protein and Peptide Pharmaceuticals & Laboratory of Proteomics, Institute of Biophysics, Chinese Academy of Sciences, Beijing 100101, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Jianming Luo
- Department of Pediatrics, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021 China
| | - Fudi Wang
- The Fourth Affiliated Hospital, School of Public Health, State Key Laboratory of Experimental Hematology, Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Fuquan Yang
- Key Laboratory of Protein and Peptide Pharmaceuticals & Laboratory of Proteomics, Institute of Biophysics, Chinese Academy of Sciences, Beijing 100101, China
- University of Chinese Academy of Sciences, Beijing 100049, China
- Corresponding author
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Koctekin B, Karakus V, Dogan B, Erdem R, Dogan U, Buber H, Kurtoglu E. Optical coherence tomography angiography findings in transfusion-dependent beta-thalassemia patients with and without splenectomy. Photodiagnosis Photodyn Ther 2023; 42:103282. [PMID: 36639006 DOI: 10.1016/j.pdpdt.2023.103282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/31/2022] [Accepted: 01/06/2023] [Indexed: 01/12/2023]
Abstract
BACKGROUND Ocular involvement is common in transfusion-dependent beta-thalassemia (TDβ-T) patients. We aimed to investigate the effect of splenectomy on optical coherence tomography angiography (OCTA) findings in TDβ-T patients. METHODS The study is a prospective cross-sectional study. A total of 45 eyes of 23 patients with splenectomy (34.04±8.83 years), 18 eyes of 9 patients without splenectomy (27.44±5.43 years), and 54 eyes of 27 controls (33.22±6.44 years) were included. Vessel density in superficial capillary plexus, deep capillary plexus and radial peripapillary capillary, foveal avascular zone, choriocapillaris flow area, choroidal and retinal thickness detected by OCTA were evaluated. p < 0.05 was considered significant. RESULTS Vessel density of superficial capillary plexus and deep capillary plexus were similar in patients with and without splenectomy, and controls. Choriocapillaris flow area was significantly decreased in patients with splenectomy than that in those without splenectomy and controls (2.02±0.12 vs. 2.17±0.1 and 2.14±0.12; p < 0.001). Choroidal thickness was significantly lower in patients without splenectomy than in patients with splenectomy and controls (260.05±61.02 vs. 305.11±42.13 and 298.89±29.14, p = 0.008). Parafoveal and perifoveal thickness of the full retina and outer retina were significantly lower in patients without splenectomy than in patients with splenectomy and controls (301.06±10.0, 279.78±10.28 vs. 311.04±14.89, 290.87±13.67 and 316.63±13.57, 289.56±9.31, p < 0.001 and p = 0.002; 174.72±7.81, 167.17±6.21 vs. 182.87±8.81, 173.60±7.09 and 185.11±9.26, 173.96±6.79, p = 0.001 and p < 0.001, respectively). CONCLUSIONS OCTA findings can provide information about the microvascular effects of splenectomy on the retina of patients with TDβ-T.
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Affiliation(s)
- Belkis Koctekin
- Transfusion Center, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkiye.
| | - Volkan Karakus
- Department of Hematology, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Berna Dogan
- Department of Ophthalmology, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Ramazan Erdem
- Department of Hematology, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Ugur Dogan
- Department of General Surgery, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Hakan Buber
- Department of Ophthalmology, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Erdal Kurtoglu
- Department of Hematology, Kolan Hospital Group, Sisli Kolan International, Istanbul, Turkey
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Nakavachara P, Weerakulwattana P, Pooliam J, Viprakasit V. Bone mineral density in primarily preadolescent children with hemoglobin E/β-thalassemia with different severities and transfusion requirements. Pediatr Blood Cancer 2022; 69:e29789. [PMID: 35652568 DOI: 10.1002/pbc.29789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/02/2022] [Accepted: 05/03/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Children with β-thalassemia major and β-thalassemia intermedia frequently have low bone mass. However, studies of bone mineral density (BMD) in children with transfusion-dependent (TD) or non-transfusion-dependent (NTD) hemoglobin (Hb) E/β-thalassemia are scarce. OBJECTIVES To determine the prevalence of low bone mass among mostly preadolescent children with NTD and TD Hb E/β thalassemia and the related factors. METHODS We investigated the BMD of the lumbar spine (LSBMD) and total body (TBBMD), measured by dual-energy X-ray absorptiometry, of 59 children with NTD Hb E/β-thalassemia and 50 with TD Hb E/β-thalassemia. RESULTS The median age of the patients was 10.4 (6.2-13.5) years in the NTD group and 10.3 (5.9-14.1) years in the TD group. These children had a relatively low prevalence of low bone mass (NTD: 1.7%-10.2%; TD: 4%-14%). The values varied with the bone site measured and the BMD size-adjustment method used (height age vs. bone age). The NTD group had significantly lower TBBMD Z-scores (adjusted for height age) than the TD group. The proportion of patients with low lumbar spine bone mass (adjusted for bone age) was significantly higher for the TD group than for the NTD group. CONCLUSIONS Our study demonstrates that most children with either disease had normal BMD. Patients with the NTD form had a lower TBBMD than those with the TD form. Low bone mass affected the lumbar spine of patients with TD Hb E/β-thalassemia more than those with the NTD form.
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Affiliation(s)
- Pairunyar Nakavachara
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Praewvarin Weerakulwattana
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Julaporn Pooliam
- Research Group and Research Network Division, Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Vip Viprakasit
- Division of Pediatric Hematology and Oncology and Thalassemia Center, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Eziefula C, Shah FT, Anie KA. Promoting Adherence to Iron Chelation Treatment in Beta-Thalassemia Patients. Patient Prefer Adherence 2022; 16:1423-1437. [PMID: 35698633 PMCID: PMC9188463 DOI: 10.2147/ppa.s269352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/29/2022] [Indexed: 01/19/2023] Open
Abstract
Thalassaemia is one of the commonest inherited genetic disorders world-wide with around 25,000 births of the most severely affected transfusion dependent children annually. Patients with transfusion dependent thalassaemia require regular blood transfusions to maintain life but because of this will develop iron overload. To remove the excess iron, patients are required to take iron chelation therapy (ICT). ICT requires lifelong adherence to treatment to prevent end organ damage from developing. Many of these preventable complications make adherence to therapy more complex for patients. In this review, we focus on two commonly encountered patient scenarios and discuss how different psychological models and a relational theory can be used to understand and support adherence to treatment.
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Affiliation(s)
- Chinea Eziefula
- Camden & Islington NHS Foundation Trust, London, UK
- Psychology Services, Whittington Health NHS Trust, London, UK
| | - Farrukh T Shah
- Department of Haematology, Whittington Health NHS Trust, London, UK
- Medical Director for Transfusion, NHSBT, London, UK
| | - Kofi A Anie
- London North West University Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
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Link between Genotype and Multi-Organ Iron and Complications in Children with Transfusion-Dependent Thalassemia. J Pers Med 2022; 12:jpm12030400. [PMID: 35330400 PMCID: PMC8950605 DOI: 10.3390/jpm12030400] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/01/2022] [Accepted: 03/03/2022] [Indexed: 01/27/2023] Open
Abstract
We evaluated the impact of the genotype on hepatic, pancreatic and myocardial iron content, and on hepatic, cardiac and endocrine complications in children with transfusion-dependent β-thalassemia (β-TDT). We considered 68 β-TDT patients (11.98 ± 3.67 years, 51.5% females) consecutively enrolled in the Extension-Myocardial Iron Overload in Thalassemia network. Iron overload was quantified by T2* technique and biventricular function by cine images. Replacement myocardial fibrosis was evaluated by late gadolinium enhancement technique. Three groups of patients were identified: homozygous β+ (N = 19), compound heterozygous β0β+ (N = 24), and homozygous β0 (N = 25). The homozygous β0 group showed significantly lower global heart and pancreas T2* values than the homozygous β+ group. Compared to patients with homozygous β+ genotype, β0β+ as well as β0β0 patients were more likely to have pancreatic iron overload (odds ratio = 6.53 and 10.08, respectively). No difference was detected in biventricular function parameters and frequency of replacement fibrosis. No patient had cirrhosis/fibrosis, diabetes or heart failure, and the frequency of endocrinopathies was comparable among the groups. In pediatric β-TDT patients, there is an association between genotype and cardiac and pancreatic iron overload. The knowledge of patients’ genotype can be valuable in predicting some patients’ phenotypic features and in helping the clinical management of β-TDT patients.
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7
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Reisi N, Esmaeil N, Gharagozloo M, Moayedi B. Therapeutic potential of silymarin as a natural iron-chelating agent in β-thalassemia intermedia. Clin Case Rep 2022; 10:e05293. [PMID: 35106163 PMCID: PMC8784915 DOI: 10.1002/ccr3.5293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 01/26/2023] Open
Abstract
Abnormal iron accumulation in vital organs is one of the major complications of β-thalassemia intermedia (β-TI). Silymarin, a flavonolignan isolated from Silybum marianum, significantly decreases the serum ferritin levels of β-TI patients. This finding suggests silymarin as a safe and effective natural iron-chelating agent for the treatment of iron-overloaded conditions.
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Affiliation(s)
- Nahid Reisi
- Department of Pediatric Hematology and OncologyChild Growth and Development Research CenterIsfahan University of Medical SciencesIsfahanIran
| | - Nafiseh Esmaeil
- Department of ImmunologySchool of MedicineIsfahan University of Medical SciencesIsfahanIran
| | | | - Behjat Moayedi
- Department of ImmunologySchool of MedicineIsfahan University of Medical SciencesIsfahanIran
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Shah FT, Porter JB, Sadasivam N, Kaya B, Moon JC, Velangi M, Ako E, Pancham S. Guidelines for the monitoring and management of iron overload in patients with haemoglobinopathies and rare anaemias. Br J Haematol 2022; 196:336-350. [PMID: 34617272 DOI: 10.1111/bjh.17839] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/10/2021] [Accepted: 09/02/2021] [Indexed: 01/19/2023]
Affiliation(s)
- Farrukh T Shah
- Department of Haematology, Whittington Health, London, UK
| | - John B Porter
- Department of Haematology, University College Hospitals, London, UK
| | - Nandini Sadasivam
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Banu Kaya
- Department of Paediatric Haematology and Oncology, Barts Health NHS Trust, London, UK
| | - James C Moon
- Department of Cardiovascular Imaging, Barts Heart Centre, St Bartholomew's Hospital, London, UK
- Institutes for Cardiovascular Science, University College London, London, UK
| | - Mark Velangi
- Department of Haematology, Birmingham Children's Hospital, Birmingham, UK
| | - Emmanuel Ako
- Department of Cardiology, Chelsea and Westminster Hospital, London, UK
| | - Shivan Pancham
- Department of Haematology, Sandwell and West Birmingham NHS Trust, West Bromwich, UK
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Abstract
BACKGROUND Thalassaemia is an autosomal recessive blood disorder, caused by mutations in globin genes or their regulatory regions, resulting in a reduced rate of synthesis of one of the globin chains that make up haemoglobin. In β-thalassaemia there is an underproduction of β-globin chains combined with excess of free α-globin chains. The excess free α-globin chains precipitate in red blood cells, leading to their increased destruction (haemolysis) and ineffective erythropoiesis. The conventional treatment is based on the correction of haemoglobin through regular red blood cell transfusions and treating the iron overload that develops subsequently with iron chelation therapy. Although, early detection and initiations of such supportive treatment has improved the quality of life for people with transfusion-dependent thalassaemia, allogeneic hematopoietic stem cell transplantation is the only widely available therapy with a curative potential. Gene therapy for β-thalassaemia has recently received conditional authorisation for marketing in Europe, and may soon become widely available as another alternative therapy with curative potential for people with transfusion-dependent thalassaemia. This is an update of a previously published Cochrane Review. OBJECTIVES To evaluate the effectiveness and safety of different types of hematopoietic stem cell transplantation, in people with transfusion-dependent β-thalassaemia. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also searched online trial registries. Date of the most recent search: 07 April 2021. SELECTION CRITERIA Randomised controlled trials and quasi-randomised controlled trials comparing hematopoietic stem cell transplantation with each other or with standard therapy (regular transfusion and chelation regimen). DATA COLLECTION AND ANALYSIS Two review authors independently screened trials and had planned to extract data and assess risk of bias using standard Cochrane methodologies and assess the quality using GRADE approach, but no trials were identified for inclusion in the current review. MAIN RESULTS No relevant trials were retrieved after a comprehensive search of the literature. AUTHORS' CONCLUSIONS We were unable to identify any randomised controlled trials or quasi-randomised controlled trials on the effectiveness and safety of different types of hematopoietic stem cell transplantation in people with transfusion-dependent β-thalassaemia. The absence of high-level evidence for the effectiveness of these interventions emphasises the need for well-designed, adequately-powered, randomised controlled clinical trials.
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Affiliation(s)
- Akshay Sharma
- Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - Latika Puri
- St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA
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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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11
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Oyedeji CI, Crawford RD, Shah N. Adherence to Iron Chelation Therapy with Deferasirox Formulations among Patients with Sickle Cell Disease and β-thalassemia. J Natl Med Assoc 2020; 113:170-176. [PMID: 32892996 DOI: 10.1016/j.jnma.2020.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/09/2020] [Accepted: 08/12/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Individuals with hemoglobinopathies experience complications that often require management with multiple transfusions. These chronic transfusions can lead to iron overload, which places them at increased risk of organ damage, malignancy, and even death. Deferasirox is the most common iron chelator used to treat iron overload due to its safety, efficacy, and oral administration. The first formulation of deferasirox, a dispersible tablet for oral suspension (DT) called Exjade®, was associated with adherence challenges due to complaints from poor taste and side effects such as abdominal discomfort. A new film-coated tablet formulation (FCT) called Jadenu® was subsequently developed to overcome these challenges. OBJECTIVE The objective of this study was to compare adherence rates between formulations of deferasirox (DT versus FCT) and describe associations between adherence to chelation therapy and changes in hematological parameters among patients with SCD and β-thalassemia. METHODS In this retrospective study of 20 children and adults with sickle cell disease (SCD) and β-thalassemia with iron overload, we compared adherence rates for deferasirox DT versus deferasirox FCT. We reviewed data from the electronic medical record and pharmacy expense reports between 2014 and 2018. We calculated the mean medication possession ratio (MPR) and analyzed the mean paired difference in MPR and ferritin levels using paired sample t-test. RESULTS The overall mean MPR was 0.15 (0.25) for deferasirox DT and 0.44 (0.32) for deferasirox FCT. The mean paired difference in MPR when transitioning from deferasirox DT to deferasirox FCT was +0.29, p-value < 0.01 (95% CI: 0.19, 0.39). The mean paired difference in ferritin while on deferasirox DT compared to ferritin 6 months after transitioning to deferasirox FCT was -306 ng/mL p-value = 0.14 (95% CI: 719, 113). CONCLUSION There was significant improvement in adherence to iron chelation therapy when patients transitioned from deferasirox DT to deferasirox FCT.
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Affiliation(s)
- Charity I Oyedeji
- Division of Hematology, Duke University School of Medicine Durham, NC, USA.
| | - Regina D Crawford
- Division of Hematology, Duke University School of Medicine Durham, NC, USA; Department of Medicine, Duke Comprehensive Sickle Cell Center, Duke University School of Medicine Durham, NC, USA
| | - Nirmish Shah
- Division of Hematology, Duke University School of Medicine Durham, NC, USA; Department of Medicine, Duke Comprehensive Sickle Cell Center, Duke University School of Medicine Durham, NC, USA; Division of Pediatric Hematology/Oncology, Duke University School of Medicine Durham, NC, USA
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12
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Abstract
BACKGROUND Thalassaemia is a genetic disorder of the haemoglobin protein in red blood cells. It has been historically classified into thalassaemia minor, intermedia and major, depending on the genetic defect and severity of the disease. The clinical presentation of β-thalassaemia varies widely from a mild asymptomatic form in thalassaemia minor, to a severe disease in thalassaemia major where individuals are dependant on life-long blood transfusions. The hallmark of thalassaemia syndromes is the production of defective red blood cells that are removed by the spleen resulting in an enlarged hyperfunctioning spleen (splenomegaly). Removal of the spleen may thus prolong red blood cell survival by reducing the amount of red blood cells removed from circulation and may ultimately result in the reduced need for blood transfusions. OBJECTIVES To assess the efficacy and safety of splenectomy in people with β-thalassaemia major or intermedia. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Review Group's Haemoglobinopathies Trials Register, compiled from searches of electronic databases and the handsearching of journals and conference abstract books. We also searched online trial registries and the reference lists of relevant articles and reviews (27 July 2018).Date of the most recent search of the Group's trials register: 02 August 2019. SELECTION CRITERIA We included randomised controlled and quasi-randomised controlled studies of people of any age with thalassaemia major or intermedia, evaluating splenectomy in comparison to conservative treatment (transfusion therapy and iron chelation) or other forms of splenectomy compared to each other (laparoscopic, open, radio-frequency). DATA COLLECTION AND ANALYSIS Two authors independently selected and extracted data from the single included study using a customised data extraction form and assessed the risk of bias. The quality of the evidence was assessed using GRADE. MAIN RESULTS One study, including 28 participants was included in the review; the results were described, primarily, in a narrative manner. This study assessed the feasibility of splenectomy using a laparoscopic approach versus open surgery. Given the lack of detail regarding the study methods beyond randomisation, the overall risk of bias for this study was unclear. The study was carried out over a period of 3.5 years, with each participant followed up only until discharge (less than one week after the intervention); it did not assess the majority of the outcomes outlined in this review (including two of the three primary outcomes, frequency of transfusion and quality of life). A total of three serious post-operative adverse events (the review's third primary outcome) were reported in the laparoscopic splenectomy group (one case of atelectasis and two cases of bleeding), compared to two events of atelectasis in the open surgery group; however, there were no significant differences between the groups for either atelectasis, risk ratio (RR) 0.50 (95% confidence interval (CI) 0.05 to 4.90) or for bleeding, RR 5.00 (95% CI 0.26 to 95.61) (very low-quality evidence). In addition, the study also reported three serious cases of intra-operative bleeding in the laparoscopic group which mandated conversion to open surgery, although the difference between groups was not statistically significant, RR 7.00 (95% CI 0.39 to 124.14) (very low-quality evidence). These effect estimates are based on very small numbers and hence are unreliable and imprecise. From this small study, there appeared to be an advantage for the laparoscopic approach, in terms of post-operative hospital stay, although the group difference was not large (median difference of 1.5 days, P = 0.03). AUTHORS' CONCLUSIONS The review was unable to find good quality evidence, in the form of randomised controlled studies, regarding the efficacy of splenectomy for treating thalassaemia major or intermedia. The single included study provided little information about the efficacy of splenectomy, and compared open surgery and laparoscopic methods. Further studies need to evaluate the long-term effectiveness of splenectomy and the comparative advantages of surgical methods. Due to a lack of high quality evidence from randomised controlled studies, well-conducted observational studies may be used to answer this question.
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Affiliation(s)
- Akshay Sharma
- St Jude Children's Research Hospital262 Danny Thomas PlaceMS 260MemphisTennesseeUSA38105
| | - Manu Easow Mathew
- Christian Medical CollegeSouth Asian Cochrane Network & Center, Prof. BV Moses Center for Evidence‐Informed Health Care and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
| | - Latika Puri
- St. Jude Children's Research Hospital262 Danny Thomas PlaceMemphisTennessee 38105USAMS 260
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13
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Luo Y, Bajoria R, Lai Y, Pan H, Li Q, Zhang Z, Yang P, Chatterjee R, Liang Y. Prevalence of abnormal glucose homeostasis in Chinese patients with non-transfusion-dependent thalassemia. Diabetes Metab Syndr Obes 2019; 12:457-468. [PMID: 31114275 PMCID: PMC6489622 DOI: 10.2147/dmso.s194591] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/13/2019] [Indexed: 12/28/2022] Open
Abstract
Purpose: To determine the prevalence and underlying pathology of abnormal glucose homeostasis in Chinese patients with non-transfusion-dependent thalassemia (NTDT). Patients and methods: In this study, we enrolled 211 patients aged 4-63 years with NTDT, including 79 β thalassemia intermedia patients, 114 Hb H disease patients and 18 Hb E/β thalassemia patients. All had oral glucose tolerance test, serum ferritin (SF), homeostasis model assessment (HOMA) and liver iron concentration (LIC) measurement. One hundred and twenty healthy age-matched controls were also used for the comparative purpose. Iron load was assessed by using SF and hepatic load by LIC using validated MRI techniques. Results: The 211 patients were divided into three groups according to their fasting and 2 hrs postprandial blood glucose levels: hypoglycemic, normal glucose tolerance (NGT) and hyperglycemic groups. In this study, 149 patients had NGT, 33 had hypoglycemia, 4 had diabetes and 25 had impaired glucose tolerance (IGT). None had impaired fasting glucose. There was a significant correlation between 2 hrs postprandial blood glucose levels and age, PINS120, HOMA-IR, alanine aminotransferase and LIC (P<0.05). Risk factors for IGT in NTDT patients were older age (≥24 years) and SF concentration of ≥2,500 ng/mL. Conclusion: Age ≥24 years and SF ≥2,500 ng/mL of NTDT patients were at a greater risk for impaired glucose tolerance.
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Affiliation(s)
- Yunchen Luo
- Department of Endocrinology and Metabolism, Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Rekha Bajoria
- Reproductive Medicine, Institute for Women’s Health, Haematology Unit, University College Hospitals and Royal Free Hospital, London, UK
| | - Yongrong Lai
- Department of Haematology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Hongfei Pan
- Department of Paediatrics, Affiliated Hospital of Youjiang Medical College for Nationality, Nanning, Guangxi, People’s Republic of China
| | - Qiaochuan Li
- Department of Haematology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Zhongming Zhang
- Department of Haematology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Pijian Yang
- Department of Geriatric Endocrinology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Ratna Chatterjee
- Reproductive Medicine, Institute for Women’s Health, Haematology Unit, University College Hospitals and Royal Free Hospital, London, UK
| | - Yuzhen Liang
- Department of Endocrinology and Metabolism, Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
- Correspondence: Yuzhen Liang The Second Affiliated Hospital of Guangxi Medical University, No.166, University East Road, Xixiangtang District, Nanning, Guangxi, People’s Republic of ChinaTel +861 351 766 5676Email
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Voskaridou E, Kattamis A, Fragodimitri C, Kourakli A, Chalkia P, Diamantidis M, Vlachaki E, Drosou M, Lafioniatis S, Maragkos K, Petropoulou F, Eftihiadis E, Economou M, Klironomos E, Koutsouka F, Nestora K, Tzoumari I, Papageorgiou O, Basileiadi A, Lafiatis I, Dimitriadou E, Kalpaka A, Kalkana C, Xanthopoulidis G, Adamopoulos I, Kaiafas P, Mpitzioni A, Goula A, Kontonis I, Alepi C, Anastasiadis A, Papadopoulou M, Maili P, Dionisopoulou D, Tsirka A, Makis A, Kostaridou S, Politou M, Papassotiriou I. National registry of hemoglobinopathies in Greece: updated demographics, current trends in affected births, and causes of mortality. Ann Hematol 2018; 98:55-66. [DOI: 10.1007/s00277-018-3493-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 08/31/2018] [Indexed: 12/11/2022]
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15
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Viprakasit V, Ajlan A, Aydinok Y, Al Ebadi BAA, Dewedar H, Ibrahim AS, Ragab L, Trad O, Wataify AS, Wong LLL, Taher AT. MRI for the diagnosis of cardiac and liver iron overload in patients with transfusion-dependent thalassemia: An algorithm to guide clinical use when availability is limited. Am J Hematol 2018; 93:E135-E137. [PMID: 29473204 DOI: 10.1002/ajh.25075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 02/12/2018] [Accepted: 02/20/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Vip Viprakasit
- Division of Hematology and OncologyDepartment of Pediatrics and Siriraj Thalassemia Center, Mahidol UniversityBangkok Thailand
| | - Amr Ajlan
- Radiology DepartmentKing Abdulaziz University HospitalJeddah Saudi Arabia
| | - Yesim Aydinok
- Department of Pediatric Hematology and OncologyEge University Children's HospitalIzmir Turkey
| | | | - Hany Dewedar
- Thalassemia CenterHematology Unit, Dubai Health Authority United Arab Emirates
| | | | - Lamis Ragab
- Department of Pediatrics, Faculty of medicineCairo UniversityCairo Egypt
| | - Omar Trad
- Department of Oncology, Division of Hematology‐OncologyTawam HospitalAbu Dhabi United Arab Emirates
| | - Ahmed S. Wataify
- Babylon Center of Hereditary Blood DisordersBabylon universityBabylon Iraq
| | - Lily L. L. Wong
- Hematology UnitQueen Elizabeth HospitalKota Kinabalu Malaysia
| | - Ali T. Taher
- Department of Internal MedicineAmerican University of Beirut Medical CentreBeirut Lebanon
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16
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Fahmey SS, Taha G, El-Refaey A, Adly S. Skin Disorders in Egyptian Children with β-Thalassemia Major. J Trop Pediatr 2018; 64:104-109. [PMID: 28510704 DOI: 10.1093/tropej/fmx035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Thalassemia major is one of the common genetic disorders in Egypt. Skin disorders are usually neglected and frequently underdiagnosed among these patients. OBJECTIVE This work aimed to study the frequency and pattern of skin manifestations in Egyptian children with β-thalassemia. METHODS Fifty-four β-thalassemia major patients being followed at the Hematology Clinic of Beni-Suef University Hospital were selected to participate in this study. All patients underwent detailed history evaluation, clinical examination and laboratory investigations, including complete blood count and serum ferritin. All patients were examined by a dermatologist to record any skin disorders. RESULTS Pruritus (37%), scars (33.3%), hyperpigmentation (31.5%) and xerosis (22.2%) were the most common findings. We found significant relations between serum ferritin and the occurrence of scars, hyperpigmentation, xerosis and ephelides (p <0.05). Also, significant associations between use of deferoxamine and scars (p=0.004), hyperpigmentation (p=0.004), xerosis (p=0.03) and ephelides (p=0.042) were found. CONCLUSION Skin disorders are frequent in Egyptian children with thalassemia major. Careful skin examination is required to provide early diagnosis.
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Affiliation(s)
- Sameh S Fahmey
- Department of Pediatrics, Beni-Suef University, Beni Suef 62511, Egypt
| | - Gamal Taha
- Department of Pediatrics, Beni-Suef University, Beni Suef 62511, Egypt
| | | | - Sherry Adly
- Department of Pediatrics, Beni-Suef University, Beni Suef 62511, Egypt
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17
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Asadov C, Alimirzoeva Z, Mammadova T, Aliyeva G, Gafarova S, Mammadov J. β-Thalassemia intermedia: a comprehensive overview and novel approaches. Int J Hematol 2018; 108:5-21. [PMID: 29380178 DOI: 10.1007/s12185-018-2411-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/19/2018] [Accepted: 01/24/2018] [Indexed: 01/19/2023]
Abstract
β-Thalassemia intermedia is a clinical condition of intermediate gravity between β-thalassemia minor, the asymptomatic carrier, and β-thalassemia major, the transfusion-dependent severe anemia. It is characterized by a significant clinical polymorphism, which is attributable to its genetic heterogeneity. Ineffective erythropoiesis, chronic anemia, and iron overload contribute to the clinical complications of thalassemia intermedia through stepwise pathophysiological mechanisms. These complications, including splenomegaly, extramedullary erythropoiesis, iron accumulation, leg ulcers, thrombophilia, and bone abnormalities can be managed via fetal hemoglobin induction, occasional transfusions, chelation, and in some cases, stem cell transplantation. Given its clinical diversity, thalassemia intermedia patients require tailored approaches to therapy. Here we present an overview and novel approaches to the genetic basis, pathophysiological mechanisms, clinical complications, and optimal management of thalassemia intermedia.
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Affiliation(s)
- Chingiz Asadov
- Institute of Hematology and Transfusiology, M. Gashgai Str. 87, AZ1007, Baku, Azerbaijan.
| | - Zohra Alimirzoeva
- Institute of Hematology and Transfusiology, M. Gashgai Str. 87, AZ1007, Baku, Azerbaijan
| | - Tahira Mammadova
- Institute of Hematology and Transfusiology, M. Gashgai Str. 87, AZ1007, Baku, Azerbaijan
| | - Gunay Aliyeva
- Institute of Hematology and Transfusiology, M. Gashgai Str. 87, AZ1007, Baku, Azerbaijan
| | - Shahla Gafarova
- Institute of Hematology and Transfusiology, M. Gashgai Str. 87, AZ1007, Baku, Azerbaijan
| | - Jeyhun Mammadov
- Thalassemia Centre, Fataly Khan Khoysky Str. 128, AZ1072, Baku, Azerbaijan
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18
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Ricchi P, Meloni A, Spasiano A, Costantini S, Pepe A, Cinque P, Filosa A. The impact of liver steatosis on the ability of serum ferritin levels to be predictive of liver iron concentration in non-transfusion-dependent thalassaemia patients. Br J Haematol 2018; 180:721-726. [PMID: 29363758 DOI: 10.1111/bjh.15083] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 10/26/2017] [Indexed: 12/12/2022]
Abstract
This study analysed the impact of liver steatosis (LS) on the parameters of iron overload in 110 patients with non-transfusion dependent thalassaemia (NTDT). LS was diagnosed by ultrasound. Liver iron concentration (LIC) measurements were available for 64 patients who underwent a magnetic resonance imaging (MRI) scan. LS was frequent (35·5%) and was significantly more prevalent in males than in females (49·0% vs. 24·6%, P = 0·008). Patients with LS had significant higher levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), ALT/AST ratio and ferritin than those without, but LIC values were comparable. An ALT/AST ratio >0·89 predicted the presence of LS with a sensitivity of 0·872 and a specificity of 0·901 (P < 0·0001). Ferritin levels correlated with LIC values (R = 0·558, P < 0·0001) but the correlation was stronger in patients without LS (R = 0·656, P < 0·0001) than in patients with LS (R = 0·426, P = 0·05). LS is a frequent issue in NTDT patients and should be suspected in the presence of an ALT/AST ratio >0·89. Recently, serum ferritin thresholds that predict clinically relevant LIC for guiding iron chelation therapy when MRI is unavailable have been determined. Our data show that LS may cause increase in ferritin levels and may be responsible for anticipating/exceeding chelation treatment in NTDT patients in the absence of LIC evaluation.
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Affiliation(s)
- Paolo Ricchi
- Rare Red Blood Cells Diseases Unit, AORN A. Cardarelli, Naples, Italy
| | - Antonella Meloni
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio, CNR-Regione Toscana, Pisa, Italy
| | - Anna Spasiano
- Rare Red Blood Cells Diseases Unit, AORN A. Cardarelli, Naples, Italy
| | - Silvia Costantini
- Rare Red Blood Cells Diseases Unit, AORN A. Cardarelli, Naples, Italy
| | - Alessia Pepe
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio, CNR-Regione Toscana, Pisa, Italy
| | - Patrizia Cinque
- Rare Red Blood Cells Diseases Unit, AORN A. Cardarelli, Naples, Italy
| | - Aldo Filosa
- Rare Red Blood Cells Diseases Unit, AORN A. Cardarelli, Naples, Italy
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Abstract
Introduction of MRI techniques for identifying and monitoring tissue iron overload and the current understanding of iron homeostasis in transfusion-dependent (TDT) and non-transfusion-dependent thalassemia have allowed for a more robust administration of iron chelation therapies. The development of safe and efficient oral iron chelators and the insights gained from large-scale prospective studies using these agents have improved iron overload management. A significant reduction in iron toxicity-induced morbidity and mortality and improvements in quality of life were observed in TDT. The appropriate management of tissue-specific iron loading in TDT has been portrayed using evidence-based data obtained from investigational studies.
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Affiliation(s)
- Yesim Aydinok
- Department of Pediatric Hematology and Oncology, Ege University Children's Hospital, Bornova, Izmir 35100, Turkey.
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20
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Nakavachara P, Petchkul J, Jeerawongpanich K, Kiattisakthavee P, Manpayak T, Netsakulnee P, Chaichanwattanakul K, Pooliam J, Srichairatanakool S, Viprakasit V. Prevalence of low bone mass among adolescents with nontransfusion-dependent hemoglobin E/β-thalassemia and its relationship with anemia severity. Pediatr Blood Cancer 2018; 65. [PMID: 28801997 DOI: 10.1002/pbc.26744] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 06/19/2017] [Accepted: 07/07/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Low bone mass is common among adolescents with transfusion-dependent β-thalassemia despite adequate transfusion and iron chelation. However, there are few reports regarding bone mineral density (BMD) among adolescents with nontransfusion-dependent thalassemia (NTDT). Indeed, only BMD data in patients with nontransfusion-dependent (NTD) β-thalassemia intermedia have been reported. No previous study has investigated BMD among adolescents with NTD hemoglobin (Hb) E/β-thalassemia. OBJECTIVE To determine the prevalence of low bone mass among adolescents with NTD Hb E/β-thalassemia and factors relating to low bone mass. METHODS We investigated BMD of lumbar spine (L2-L4; BMDLS) and total body (BMDTB), as measured by dual-energy X-ray absorptiometry, in 22 adolescents (aged 13.2-20 years) with NTD Hb E/β-thalassemia. RESULTS Low bone mass was found to be 18.2% and 22.7% at the lumbar spine (BMDLS Z-score adjusted for bone age and height age) and 13.6% and 9.1% at the total body (BMDTB Z-score adjusted for bone age and height age). Patients with mean Hb level <8 g/dl were more likely to have low bone mass (BMDLS and BMDTB Z-scores adjusted for bone age) compared to those with Hb level ≥ 8 g/dl. Mean Hb level correlated with BMDLS and BMDTB Z-scores adjusted for bone age. CONCLUSION We demonstrated that a low Hb level was associated with low bone mass among adolescents with NTD Hb E/β-thalassemia. A significant proportion of low bone mass among these patients highlights the importance of appropriate management, including red cell transfusion, vitamin D and calcium supplementation for improved long-term bone health.
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Affiliation(s)
- Pairunyar Nakavachara
- Division of Pediatric Endocrinology, Faculty of Medicine Siriraj Hospital, Department of Pediatrics, Mahidol University, Bangkok, Thailand
| | - Jaturat Petchkul
- Division of Pediatric Endocrinology, Faculty of Medicine Siriraj Hospital, Department of Pediatrics, Mahidol University, Bangkok, Thailand
| | - Krittha Jeerawongpanich
- Division of Pediatric Endocrinology, Faculty of Medicine Siriraj Hospital, Department of Pediatrics, Mahidol University, Bangkok, Thailand
| | - Pornpimol Kiattisakthavee
- Division of Pediatric Endocrinology, Faculty of Medicine Siriraj Hospital, Department of Pediatrics, Mahidol University, Bangkok, Thailand
| | - Teerarat Manpayak
- Division of Pediatric Endocrinology, Faculty of Medicine Siriraj Hospital, Department of Pediatrics, Mahidol University, Bangkok, Thailand
| | - Parichat Netsakulnee
- Division of Pediatric Endocrinology, Faculty of Medicine Siriraj Hospital, Department of Pediatrics, Mahidol University, Bangkok, Thailand
| | - Katharee Chaichanwattanakul
- Division of Pediatric Endocrinology, Faculty of Medicine Siriraj Hospital, Department of Pediatrics, Mahidol University, Bangkok, Thailand
| | - Julaporn Pooliam
- Clinical Epidemiology Unit, Office for Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Vip Viprakasit
- Thalassemia Center and Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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21
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Karakus V, Kurtoğlu A, Soysal DE, Dere Y, Bozkurt S, Kurtoğlu E. Evaluation of Iron Overload in the Heart and Liver Tissue by Magnetic Resonance Imaging and its Relation to Serum Ferritin and Hepcidin Concentrations in Patients with Thalassemia Syndromes. Indian J Hematol Blood Transfus 2017; 33:389-395. [PMID: 28824242 PMCID: PMC5544633 DOI: 10.1007/s12288-016-0735-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 09/29/2016] [Indexed: 01/16/2023] Open
Abstract
Iron overload is one of the major prognostic factor in thallassemia patients. We aimed to evaluate iron accumulation in the heart and liver by MRI in thalassemia major, thalassemia intermedia, and S-ß thalassemia patients and to examine its association with ferritin and hepcidin levels. Serum ferritin and hepcidin levels were recorded. Iron overload (IOL) in the heart and liver parenchyma was determined based on the standardized T2* and R2 values measured by MRI. The results were evaluated considering the tissue iron overload, serum ferritin and hepcidin levels. Comparing the 109 patients with the 30 healthy controls revealed the mean age: 24.4 ± 11 versus 31.2 ± 5 years, median levels of serum ferritin: 1693 versus 40 ng/mL, and hepcidin: 1.94 versus 0.355 ng/mL; p < 0.001, respectively. Comparison of age, serum ferritin and hepcidin levels and MRI findings of the patients with or without IOL revealed that, ferritin and T2* were significantly different in the patients with IOL in cardiac tissue (p = 0.004 and p < 0.001), and, age, ferritin and R2 were significantly different in the patients with IOL in liver tissue (p = 0.036, p < 0.001 and p < 0.001). The MRI-based T2* and R2 values were moderately and inversely correlated with serum ferritin (r = -0.37; p < 0.001 and r = -0.46; p < 0.001). No correlations were found between the MRI-based T2*, R2 values and serum hepcidin. A moderate and positive correlation existed between serum ferritin and hepcidin (r = 0.45; p < 0.001). We considered that, enhanced intestinal iron absorption characterized by decreased serum hepcidin levels in the intervals between successive transfusions were resulted in iron accumulation in our patients.
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Affiliation(s)
- Volkan Karakus
- Department of Hematology, Muğla Sıtkı Koçman University Training and Research Hospital, 48000 Muğla, Turkey
- Department of Hematology, Antalya Research and Training Hospital, 07000 Konyaaltı, Antalya, Turkey
| | - Ayşegül Kurtoğlu
- Department of Biochemistry, Antalya Research and Training Hospital, 07000 Konyaaltı, Antalya, Turkey
| | - Dilek Ersil Soysal
- Department of Internal Medicine, Faculty of Medicine, Izmir University of Economics, 35360 Balçova, Izmir, Turkey
| | - Yelda Dere
- Department of Pathology, Muğla Sıtkı Koçman University Faculty of Medicine, 48000 Muğla, Turkey
| | - Selen Bozkurt
- Department of Biostatistics and Medical Informatics, Akdeniz University Faculty of Medinice, 48000 Antalya, Turkey
| | - Erdal Kurtoğlu
- Department of Hematology, Antalya Research and Training Hospital, 07000 Konyaaltı, Antalya, Turkey
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Saliba AN, Musallam KM, Cappellini MD, Graziadei G, Daar S, Viprakasit V, Taher AT. Serum ferritin values between 300 and 800 ng/mL in nontransfusion-dependent thalassemia: A probability curve to guide clinical decision making when MRI is unavailable. Am J Hematol 2017; 92:E35-E37. [PMID: 28052365 DOI: 10.1002/ajh.24628] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 12/19/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Antoine N. Saliba
- Department of MedicineIndiana University School of MedicineIndianapolis, Indiana United States
| | - Khaled M. Musallam
- Department of Internal MedicineAmerican University of Beirut Medical CenterBeirut Lebanon
- Department of Clinical Sciences and CommunityUniversity of Milan, IRCCS Ca’ Granda Foundation Maggiore Policlinico HospitalMilan Italy
| | - Maria D. Cappellini
- Department of Clinical Sciences and CommunityUniversity of Milan, IRCCS Ca’ Granda Foundation Maggiore Policlinico HospitalMilan Italy
| | - Giovanna Graziadei
- Department of Clinical Sciences and CommunityUniversity of Milan, IRCCS Ca’ Granda Foundation Maggiore Policlinico HospitalMilan Italy
| | - Shahina Daar
- Department of Hematology, College of Medicine & Health SciencesSultan Qaboos University Oman
| | - Vip Viprakasit
- Department of Pediatrics & Thalassemia Center, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkok Thailand
| | - Ali T. Taher
- Department of Internal MedicineAmerican University of Beirut Medical CenterBeirut Lebanon
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Leecharoenkiat K, Lithanatudom P, Sornjai W, Smith DR. Iron dysregulation in beta-thalassemia. ASIAN PAC J TROP MED 2016; 9:1035-1043. [PMID: 27890361 DOI: 10.1016/j.apjtm.2016.07.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 08/01/2016] [Accepted: 10/14/2016] [Indexed: 11/24/2022] Open
Abstract
Iron deficiency anemia and iron overload conditions affect more than one billion people worldwide. Iron homeostasis involves the regulation of cells that export iron into the plasma and cells that utilize or store iron. The cellular iron balance in humans is primarily mediated by the hepcidin-ferroportin axis. Ferroportin is the sole cellular iron export protein, and its expression is regulated transcriptionally, post-transcriptionally and post-translationally. Hepcidin, a hormone produced by liver cells, post-translationally regulates ferroportin expression on iron exporting cells by binding with ferroportin and promoting its internalization by endocytosis and subsequent degradation by lysosomes. Dysregulation of iron homeostasis leading to iron deposition in vital organs is the main cause of death in beta-thalassemia patients. Beta-thalassemia patients show marked hepcidin suppression, ineffective erythropoiesis, anemia and iron overload. Beta-thalassemia is common in the Mediterranean region, Southeast Asia and the Indian subcontinent, and the focus of this review is to provide an update on the factors mediating hepcidin related iron dysregulation in beta-thalassemia disease. Understanding this process may pave the way for new treatments to ameliorate iron overloading and improve the long term prognosis of these patients.
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Affiliation(s)
- Kamonlak Leecharoenkiat
- Department of Clinical Microscopy, Faculty of Allied Health Sciences, Chulalongkorn University, 154 Rama 4 Road, Bangkok 10330, Thailand
| | - Pathrapol Lithanatudom
- Department of Biology, Faculty of Science, Chiang Mai University, 239 Huaykaew Road, Amphur Muang, Chiang Mai 50200, Thailand
| | - Wannapa Sornjai
- Molecular Pathology Laboratory, Institute of Molecular Biosciences, Mahidol University, 25/25 Phuttamonthon 4 Road, Salaya, Nakhon Pathom 73170, Thailand
| | - Duncan R Smith
- Molecular Pathology Laboratory, Institute of Molecular Biosciences, Mahidol University, 25/25 Phuttamonthon 4 Road, Salaya, Nakhon Pathom 73170, Thailand.
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Bayanzay K, Alzoebie L. Reducing the iron burden and improving survival in transfusion-dependent thalassemia patients: current perspectives. J Blood Med 2016; 7:159-69. [PMID: 27540317 PMCID: PMC4982491 DOI: 10.2147/jbm.s61540] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Hypertransfusion regimens for thalassemic patients revolutionized the management of severe thalassemia; transforming a disease which previously led to early infant death into a chronic condition. The devastating effect of the accrued iron from chronic blood transfusions necessitates a more finely tuned approach to limit the complications of the disease, as well as its treatment. A comprehensive approach including carefully tailored transfusion protocol, continuous monitoring and assessment of total body iron levels, and iron chelation are currently the mainstay in treating iron overload. There are also indications for ancillary treatments, such as splenectomy and fetal hemoglobin induction. The main cause of death in iron overload continues to be related to cardiac complications. However, since the widespread use of iron chelation started in the 1970s, there has been a general improvement in survival in these patients.
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Affiliation(s)
- Karim Bayanzay
- Department of Hematology, Gulf Medical University, Ajman, United Arab Emirates
| | - Lama Alzoebie
- Department of Hematology, Gulf Medical University, Ajman, United Arab Emirates
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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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Vichinsky E. Non-transfusion-dependent thalassemia and thalassemia intermedia: epidemiology, complications, and management. Curr Med Res Opin 2016; 32:191-204. [PMID: 26479125 DOI: 10.1185/03007995.2015.1110128] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The non-transfusion-dependent thalassemias (NTDTs), including thalassemia intermedia (TI), hemoglobin E beta thalassemia, and hemoglobin H disease, have sometimes been regarded as less severe than their transfusion-dependent variants; however, these disorders carry a substantial disease burden (e.g., splenomegaly, iron overload, skeletal effects, and cardiopulmonary disease). The aim of this review is to increase clinician awareness of the growing global problem of NTDT and TI, and discuss the current management strategies for these conditions. METHODS Recent peer-reviewed articles (publication years 2000 through 2015) addressing the epidemiology, complications, management, and monitoring of NTDT were identified in the PubMed database and reviewed. RESULTS The changing epidemiology of thalassemia constitutes a growing health problem. Increased clinician awareness is necessary for the appropriate diagnosis and management of patients with NTDT. CONCLUSIONS Management of NTDT requires a comprehensive approach, beginning with screening and prenatal diagnosis, monitoring for iron overload and associated complications, and iron chelation therapy. Several novel strategies are in the early stages of investigation and may help increase treatment options in patients with NTDT. Importantly, ethnic or cultural barriers may exist within the affected populations and need to be considered in the management approach.
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Affiliation(s)
- Elliott Vichinsky
- a UCSF Benioff Children's Hospital, Oakland , University of California , San Francisco, CA , USA
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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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31
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DeLuca AP, Whitmore SS, Barnes J, Sharma TP, Westfall TA, Scott CA, Weed MC, Wiley JS, Wiley LA, Johnston RM, Schnieders MJ, Lentz SR, Tucker BA, Mullins RF, Scheetz TE, Stone EM, Slusarski DC. Hypomorphic mutations in TRNT1 cause retinitis pigmentosa with erythrocytic microcytosis. Hum Mol Genet 2015; 25:44-56. [PMID: 26494905 DOI: 10.1093/hmg/ddv446] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 10/19/2015] [Indexed: 02/07/2023] Open
Abstract
Retinitis pigmentosa (RP) is a highly heterogeneous group of disorders characterized by degeneration of the retinal photoreceptor cells and progressive loss of vision. While hundreds of mutations in more than 100 genes have been reported to cause RP, discovering the causative mutations in many patients remains a significant challenge. Exome sequencing in an individual affected with non-syndromic RP revealed two plausibly disease-causing variants in TRNT1, a gene encoding a nucleotidyltransferase critical for tRNA processing. A total of 727 additional unrelated individuals with molecularly uncharacterized RP were completely screened for TRNT1 coding sequence variants, and a second family was identified with two members who exhibited a phenotype that was remarkably similar to the index patient. Inactivating mutations in TRNT1 have been previously shown to cause a severe congenital syndrome of sideroblastic anemia, B-cell immunodeficiency, recurrent fevers and developmental delay (SIFD). Complete blood counts of all three of our patients revealed red blood cell microcytosis and anisocytosis with only mild anemia. Characterization of TRNT1 in patient-derived cell lines revealed reduced but detectable TRNT1 protein, consistent with partial function. Suppression of trnt1 expression in zebrafish recapitulated several features of the human SIFD syndrome, including anemia and sensory organ defects. When levels of trnt1 were titrated, visual dysfunction was found in the absence of other phenotypes. The visual defects in the trnt1-knockdown zebrafish were ameliorated by the addition of exogenous human TRNT1 RNA. Our findings indicate that hypomorphic TRNT1 mutations can cause a recessive disease that is almost entirely limited to the retina.
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Affiliation(s)
- Adam P DeLuca
- The Stephen A. Wynn Institute for Vision Research, Department of Ophthalmology and Visual Sciences
| | - S Scott Whitmore
- The Stephen A. Wynn Institute for Vision Research, Department of Ophthalmology and Visual Sciences
| | | | - Tasneem P Sharma
- The Stephen A. Wynn Institute for Vision Research, Department of Ophthalmology and Visual Sciences
| | | | | | - Matthew C Weed
- The Stephen A. Wynn Institute for Vision Research, Department of Ophthalmology and Visual Sciences
| | - Jill S Wiley
- The Stephen A. Wynn Institute for Vision Research, Department of Ophthalmology and Visual Sciences
| | - Luke A Wiley
- The Stephen A. Wynn Institute for Vision Research, Department of Ophthalmology and Visual Sciences
| | - Rebecca M Johnston
- The Stephen A. Wynn Institute for Vision Research, Department of Ophthalmology and Visual Sciences
| | - Michael J Schnieders
- The Stephen A. Wynn Institute for Vision Research, Department of Biomedical Engineering, Department of Biochemistry, and
| | - Steven R Lentz
- Department of Internal Medicine; The University of Iowa, Iowa City, IA, USA
| | - Budd A Tucker
- The Stephen A. Wynn Institute for Vision Research, Department of Ophthalmology and Visual Sciences
| | - Robert F Mullins
- The Stephen A. Wynn Institute for Vision Research, Department of Ophthalmology and Visual Sciences
| | - Todd E Scheetz
- The Stephen A. Wynn Institute for Vision Research, Department of Ophthalmology and Visual Sciences, Department of Biomedical Engineering
| | - Edwin M Stone
- The Stephen A. Wynn Institute for Vision Research, Department of Ophthalmology and Visual Sciences
| | - Diane C Slusarski
- The Stephen A. Wynn Institute for Vision Research, Department of Biology,
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Lee HW, Han SM, Yang Y, Lin TH, Tzeng HE, Chang KH, Hwang WL, Teng CLJ. Thalassemia Phenotypes and Genotypes in Taiwan: A Retrospective Study Based on Thalassemia Screening of Young Men for Military Conscription. Hemoglobin 2015; 39:173-7. [PMID: 26088101 DOI: 10.3109/03630269.2015.1036165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Prenatal thalassemia studies from Taiwan show that one-third of fetuses with genetic abnormalities have β-thalassemia major (β-TM). However, the phenotypes and genotypes of adult thalassemia warrant further investigation. From September 2006 to April 2014, 741 male candidates drafted for military service with mean corpuscular volume (MCV) <80 fL and serum ferritin >20 µg/L were analyzed. The results showed that the detection rates of α- and β-thalassemia (α- an β-thal) were 50.20% (372/741) and 49.12% (364/741), respectively. Only five patients (0.67%) were diagnosed with both α- and β-thal. The - -(SEA)/αα mutation was found in 76.88% (286/372) of α-thal patients. Heterozygous mutations in IVS-II-654 (C > T) and codons 41/42 (-TCTT) accounted for 55.77% (203/364) of β-thal cases. The leukocyte counts for α- and β-thal were 6241.74 ± 1552.99 and 6622.87 ± 1814.41 × 10(9)/L, respectively (p = 0.007). The α-thal patients had lower red blood cell (RBC) mass (5.85 ± 0.44 × 10(12)/L vs. 6.09 ± 0.45 × 10(12)/L; p < 0.001) and higher hemoglobin (Hb) (12.82 ± 0.72 vs. 12.35 ± 0.71 g/dL; p < 0.001) than β-thal patients. Mean serum ferritin values were 169.67 and 241.36 µg/L, respectively, in α- and β-thal patients (p < 0.001), indicating more profound ineffective erythropoiesis in β-thal. Only four of the 741 patients underwent further hematological follow-up. Our study suggests that iron overload might be a potential problem in β-thal patients; therefore, regular follow-up is highly recommended.
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Affiliation(s)
- Hsiao-Wei Lee
- Division of Hematology/Medical Oncology, Department of Medicine, Taichung Veterans General Hospital , Taichung City , Taiwan
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Adekile AD, Azab AF, Al-Sharida SI, Al-Nafisi BA, Akbulut N, Marouf RA, Mustafa NY. Clinical and Molecular Characteristics of Non-Transfusion-Dependent Thalassemia in Kuwait. Hemoglobin 2015; 39:320-6. [DOI: 10.3109/03630269.2015.1053489] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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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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Harb AR, Saliba AN, Taher AT. Non-Transfusion Dependent Thalassemia: Translating Evidence to Guidelines. THALASSEMIA REPORTS 2014. [DOI: 10.4081/thal.2014.4863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The thalassemias are a group of inherited disorders of hemoglobin synthesis characterized by various degrees of defective production of the α- or β-globin chains of adult hemoglobin A. Non-transfusion- dependent thalassemia (NTDT) includes a group of thalassemia patients who do not require regular RBC transfusions for survival, but may require occasional transfusions due to infection or pregnancy or may require more regular transfusions later in life due to splenomegaly or other complications. Due to the rising phenomenon of global migration, this previously well-localized entity is currently spreading more and more worldwide reaching Northern America and Northern Europe. The clinical picture of NTDT is governed by the severity of the ineffective erythropoiesis and the chronic hemolytic anemia, which, in turn, lead to iron overload, hypercoagulability, and an array of clinical complications involving almost every organ system. Patients with NTDT suffer from complications that are distinct from those encountered in patients with transfusion- dependent thalassemia (TDT) in addition to the complications shared by both TDT and NTDT. As a consequence, patients with NTDT deserve a care specifically tailored to their needs. In the care of patients with NTDT, aiming at a standardized yet personalized care is not an easy task especially that NTDT patients lie on a heterogeneous spectrum with a wide variability in their clinical presentation and response to therapy. Therefore, guidelines emerge as a necessity to answer the specific needs of NTDT patients and the clinicians caring for them. In this article, we summarize the complications most commonly associated with NTDT and the recommendations of the guidelines for the management of patients with NTDT, based on the best available evidence.
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Brissot P, Loreal O. Management of Liver Complications in Haemoglobinopathies. THALASSEMIA REPORTS 2014. [DOI: 10.4081/thal.2014.4869] [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
Liver complications in haemoglobinopathies (thalassaemia and sickle cell disease) are due to several factors, dominated (beside chronic viral infections, not considered here) by chronic iron overload, biliary obstruction and venous thrombosis. Whereas the latter two factors can cause acute hepatic syndromes, all three mechanisms - when becoming chronic- can produce fibrosis and cirrhosis and even, in thalassaemia, hepatocellular carcinoma. These chronic hepatic complications are an indirect consequence of the significant improvement in life expectancy due to the overall amelioration of disease management. The diagnostic approach has benefited from non invasive (biochemical and imaging) approaches which have considerably reduced the indication of liver biopsy. The therapeutic management involves relatively efficient curative medical, endoscopic or surgical methods, but should rest primarily on preventive measures focused on the haematological causative factors but also on hepatic co-morbidities. This chapter will focus on hepatic complications in thalassaemia and sickle cell disease (SCD), without considering the complications related to virus B or C infections which will be described in another chapter.
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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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Musallam KM, Cappellini MD, Daar S, Karimi M, El-Beshlawy A, Graziadei G, Magestro M, Wulff J, Pietri G, Taher AT. Serum ferritin level and morbidity risk in transfusion-independent patients with β-thalassemia intermedia: the ORIENT study. Haematologica 2014; 99:e218-21. [PMID: 24997148 DOI: 10.3324/haematol.2013.097220] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Khaled M Musallam
- University of Milan, Ca Granda Foundation IRCCS, Ospedale Maggiore Policlinico, Milan, Italy American University of Beirut Medical Center, Lebanon
| | | | | | - Mehran Karimi
- Hematology Research Center, Shiraz University of Medical Sciences, Iran
| | | | - Giovanna Graziadei
- University of Milan, Ca Granda Foundation IRCCS, Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | | | - Ali T Taher
- American University of Beirut Medical Center, Lebanon Chronic Care Center, Hazmieh, Lebanon
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Taher AT, Porter JB, Viprakasit V, Kattamis A, Chuncharunee S, Sutcharitchan P, Siritanaratkul N, Origa R, Karakas Z, Habr D, Zhu Z, Cappellini MD. Approaching low liver iron burden in chelated patients with non-transfusion-dependent thalassemia: the safety profile of deferasirox. Eur J Haematol 2014; 92:521-6. [PMID: 24460655 PMCID: PMC4232858 DOI: 10.1111/ejh.12270] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2014] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Patients with non-transfusion-dependent thalassemia (NTDT) often develop iron overload and related complications, and may require iron chelation. However, the risk of over-chelation emerges as patients reach low, near-normal body iron levels and dose adjustments may be needed. In the THALASSA study, the threshold for chelation interruption was LIC <3 mg Fe/g dw (LIC<3); 24 patients receiving deferasirox for up to 2 yr reached this target. A post hoc analysis was performed to characterize the safety profile of deferasirox as these patients approached LIC<3. METHODS THALASSA was a randomized, double-blind, placebo-controlled study of two deferasirox regimens (5 and 10 mg/kg/d) versus placebo in patients with NTDT. Patients randomized to deferasirox or placebo in the core could enter a 1-yr extension, with all patients receiving deferasirox (extension starting doses based on LIC at end-of-core and prior chelation response). The deferasirox safety profile was assessed between baseline and 6 months before reaching LIC<3 (Period 1), and the 6 months immediately before achieving LIC<3 (Period 2). RESULTS Mean ± SD deferasirox treatment duration up to reaching LIC<3 was 476 ± 207 d, and deferasirox dose was 9.7 ± 3.0 mg/kg/d. The exposure-adjusted AE incidence regardless of causality was similar in periods 1 (1.026) and 2 (1.012). There were no clinically relevant differences in renal and hepatic laboratory parameters measured close to the time of LIC<3 compared with measurements near the previous LIC assessment. CONCLUSIONS The deferasirox safety profile remained consistent as patients approached the chelation interruption target, indicating that, with appropriate monitoring and dose adjustments in relation to iron load, low iron burdens may be reached with deferasirox with minimal risk of over-chelation.
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Affiliation(s)
- Ali T Taher
- American University of Beirut, Beirut, Lebanon
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Aydinok Y, Kattamis A, Viprakasit V. Current approach to iron chelation in children. Br J Haematol 2014; 165:745-55. [PMID: 24646011 DOI: 10.1111/bjh.12825] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Transfusion-dependent children, mostly with thalassaemia major, but also and occasionally to a more significant degree, with inherited bone marrow failures, can develop severe iron overload in early life. Moreover, chronic conditions associated with ineffective erythropoiesis, such as non-transfusion-dependent thalassaemia (NTDT), may lead to iron overload through increased gut absorption of iron starting in childhood. Currently, the goal of iron chelation has shifted from treating iron overload to preventing iron accumulation and iron-induced end-organ complications, in order to achieve a normal pattern of complication-free survival and of quality of life. New chelation options increase the likelihood of achieving these goals. Timely initiation, close monitoring and continuous adjustment are the cornerstones of optimal chelation therapy in children, who have a higher transfusional requirements compared to adults in order to reach haemoglobin levels adequate for normal growth and development. Despite increased knowledge, there are still uncertainties about the level of body iron at which iron chelation therapy should be started and about the appropriate degree of iron stores' depletion.
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Affiliation(s)
- Yesim Aydinok
- Department of Paediatric Haematology/Oncology, Ege University Children's Hospital, Ege University School of Medicine, Izmir, Turkey
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β -thalassemia intermedia in Northern Iraq: a single center experience. BIOMED RESEARCH INTERNATIONAL 2014; 2014:262853. [PMID: 24719849 PMCID: PMC3955643 DOI: 10.1155/2014/262853] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Revised: 01/18/2014] [Accepted: 01/20/2014] [Indexed: 12/20/2022]
Abstract
To investigate the molecular basis of β-thalassemia intermedia in Northern Iraq and evaluate its management practices, a total of 74 patients from 51 families were enrolled. The patients were clinically and hematologically reevaluated, and had their β-thalassemia mutations characterized, as well as the number of α-globin genes and Xmn I Gγ −158 (C>T) polymorphism studied. Out of 14 β-thalassemia mutations identified, the four most common were IVS-I-6 (T>C) [33.3%], IVS-II-I (G>A) [21.1%], codon 82/83(−G) [10.1%], and codon 8 (−AA) [8.1%]. The most common contributing factors to the less severe phenotype of thalassemia intermedia were found to be the inheritance of mild β-thalassemia alleles and the Xmn I polymorphism, while concomitant α-thalassemia had a limited role. Several complications were documented including: pulmonary hypertension in 20.4%, diabetes mellitus in 1.4%, hypothyroidism in 2.9%, and heart failure in 2.7%, while no documented cases of venous thrombosis were found. Compared to their counterparts in several Mediterranean countries, it appears that our patients were much less frequently transfused and had a lower proportion of patients who were splenectomized, on iron chelation, or hydroxycarbamide therapy. Such practices require further scrutiny to ensure that a better level of care is provided and that growth retardation, skeletal changes, and other complications are prevented or reduced.
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Taher AT, Musallam KM, Viprakasit V, Porter JB, Cappellini MD. Iron chelation therapy for non-transfusion-dependent thalassemia (NTDT): A status quo. Blood Cells Mol Dis 2014; 52:88-90. [DOI: 10.1016/j.bcmd.2013.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 08/21/2013] [Indexed: 01/27/2023]
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Viprakasit V, Rodmai S, Srichairatanakool S. Deferiprone for transfusional iron overload and its roles in developing countries. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.885388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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King A, Hildyard C, Clarke R, Watson C, Roberts D. Interpretation of iron studies. Br J Hosp Med (Lond) 2013; 74 Suppl 12:C184-7. [PMID: 24326759 DOI: 10.12968/hmed.2013.74.sup12.c184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Iron plays a vital role in the human body in oxygen transport, mitochondrial oxidative energy production, inactivation of drugs and toxins, and DNA synthesis (Munoz et al, 2011).
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Affiliation(s)
- Aj King
- Specialist Registrar, Oxford University Hospitals NHS Trust, Churchill Hospital, Oxford
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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
In this issue of Blood, Pasricha et al evaluated serum hepcidin and its putative pathological suppressor growth differentiation factor-15 (GDF-15) in patients with β-thalassemia major before and after transfusion, in the context of erythropoietic activity and iron loading. The study offers insight into dynamic regulation of hepcidin in this disease, reinforces the likely contribution of hepcidin to iron loading between transfusions, and highlights the potential clinical utility of hepcidin measurements in the management of patients with β-thalassemia major.
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