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Chapchap EC, Silva MMA, de Assis RA, Kerbauy LN, Diniz MDS, Rosemberg LA, Loggetto SR, Araujo ADS, Fabron Junior A, Verissimo MPDA, Baldanzi GR, Esposito BP, Tricta F, Steagall MEA, Vellozo CÂGDS, Fertrin KY, Baroni RH, Hamerschlak N. Cardiac iron overload evaluation in thalassaemic patients using T2* magnetic resonance imaging following chelation therapy: a multicentre cross-sectional study. Hematol Transfus Cell Ther 2023; 45:7-15. [PMID: 34090847 PMCID: PMC9938451 DOI: 10.1016/j.htct.2021.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/28/2020] [Accepted: 01/27/2021] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Magnetic resonance imaging (MRI) T2* technique is used to assess iron overload in the heart, liver and pancreas of thalassaemic patients. Optimal iron chelation and expected tissue iron response rates remain under investigation. The objective of this study was to analyse serum ferritin and the iron concentration in the heart, liver and pancreas measured by MRI T2*/R2* during regular chelation therapy in a real-world cohort of patients with thalassemia. METHODS We evaluated thalassaemic patients ≥ 7 years old undergoing chelation/transfusion therapy by MRI and assessed serum ferritin at baseline and follow-up from 2004-2011. RESULTS We evaluated 136 patients, 92% major thalassaemic, with a median age of 18 years, and median baseline ferritin 2.033ng/ml (range: 59-14,123). Iron overload distribution was: liver (99%), pancreas (74%) and heart (36%). After a median of 1.2 years of follow-up, the iron overload in the myocardium reduced from 2,63 Fe mg/g to 2,05 (p 0.003). The optimal R2* pancreas cut-off was 148 Hertz, achieving 78% sensitivity and 73% specificity. However, when combining the R2* pancreas cut off ≤ 50 Hertz and a ferritin ≤ 1222 ng/ml, we could reach a negative predictive value (NPV) of 98% for cardiac siderosis. Only 28% were undergoing combined chelation at baseline assessment, which increased up to 50% on follow up evaluation. CONCLUSIONS Chelation therapy significantly reduced cardiac siderosis in thalassaemic patients. In patients with moderate/severe liver iron concentration undergoing chelation therapy, ferritin levels and myocardium iron improved earlier than the liver siderosis.
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Alvarenga AM, da Silva NK, Cançado RD, de Carvalho LEMR, Santos PCJL. Brazilian family with hyperferritinemia-cataract syndrome: case report. EINSTEIN-SAO PAULO 2022; 20:eRC0076. [PMID: 36287435 PMCID: PMC9586555 DOI: 10.31744/einstein_journal/2022rc0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/20/2022] [Indexed: 12/05/2022] Open
Abstract
Hereditary hyperferritinemia-cataract syndrome is a rare autosomal dominant disease caused by a genetic mutation in the iron responsive element in the 5' untranslated region of the ferritin light chain gene. Hereditary hyperferritinemia-cataract syndrome is characterized by elevated serum ferritin levels and bilateral cataract development early in life and may be misdiagnosed as hemochromatosis. This case report describes a Brazilian family with a clinical diagnosis of hereditary hyperferritinemia-cataract syndrome, which was submitted to ferritin light chain gene sequencing. The genetic mutation c.-164C>G was identified in the 5' untranslated region. In conclusion, genetic testing can be used for accurate diagnosis of hereditary hyperferritinemia-cataract syndrome to avoid misdiagnosis of hemochromatosis, other diseases associated with iron overload or ophthalmic diseases.
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Affiliation(s)
- Aline Morgan Alvarenga
- Escola Paulista de MedicinaUniversidade Federal de São PauloSão PauloSPBrazil Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Nathália Kozikas da Silva
- Escola Paulista de MedicinaUniversidade Federal de São PauloSão PauloSPBrazil Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Rodolfo Delfini Cançado
- Faculdade de Ciências MédicasSanta Casa de São PauloSão PauloSPBrazil Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brazil.
| | | | - Paulo Caleb Junior Lima Santos
- Escola Paulista de MedicinaUniversidade Federal de São PauloSão PauloSPBrazil Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
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Triadyaksa P, Overbosch J, Oudkerk M, Sijens PE. T2* assessment of the three coronary artery territories of the left ventricular wall by different monoexponential truncation methods. MAGNETIC RESONANCE MATERIALS IN PHYSICS, BIOLOGY AND MEDICINE 2022; 35:749-763. [PMID: 35437686 PMCID: PMC9463254 DOI: 10.1007/s10334-022-01008-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 02/04/2022] [Accepted: 03/18/2022] [Indexed: 11/28/2022]
Abstract
Abstract
Objectives
This study aimed at evaluating left ventricular myocardial pixel-wise T2* using two truncation methods for different iron deposition T2* ranges and comparison of segmental T2* in different coronary artery territories.
Material and methods
Bright blood multi-gradient echo data of 30 patients were quantified by pixel-wise monoexponential T2* fitting with its R2 and SNR truncation. T2* was analyzed at different iron classifications. At low iron classification, T2* values were also analyzed by coronary artery territories.
Results
The right coronary artery has a significantly higher T2* value than the other coronary artery territories. No significant difference was found in classifying severe iron by the two truncation methods in any myocardial region, whereas in moderate iron, it is only apparent at septal segments. The R2 truncation produces a significantly higher T2* value than the SNR method when low iron is indicated.
Conclusion
Clear T2* differentiation between the three coronary territories by the two truncation methods is demonstrated. The two truncation methods can be used interchangeably in classifying severe and moderate iron deposition at the recommended septal region. However, in patients with low iron indication, different results by the two truncation methods can mislead the investigation of early iron level progression.
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Affiliation(s)
- Pandji Triadyaksa
- University of Groningen, 9700 RB, Groningen, The Netherlands.
- Departemen Fisika, Universitas Diponegoro, Fakultas Sains Dan Matematika, Prof. Sudharto street, Semarang, 50275, Indonesia.
| | - Jelle Overbosch
- Department of Radiology, University of Groningen, University Medical Center Groningen, EB45, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Matthijs Oudkerk
- University of Groningen, 9700 RB, Groningen, The Netherlands
- Institute for Diagnostic Accuracy, Groningen, The Netherlands
| | - Paul Eduard Sijens
- University of Groningen, 9700 RB, Groningen, The Netherlands
- Department of Radiology, University of Groningen, University Medical Center Groningen, EB45, PO Box 30001, 9700 RB, Groningen, The Netherlands
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Milman NT, Schioedt FV, Junker AE, Magnussen K. Diagnosis and Treatment of Genetic HFE-Hemochromatosis: The Danish Aspect. Gastroenterology Res 2019; 12:221-232. [PMID: 31636772 PMCID: PMC6785287 DOI: 10.14740/gr1206] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 08/28/2019] [Indexed: 12/21/2022] Open
Abstract
This paper outlines the Danish aspects of HFE-hemochromatosis, which is the most frequent genetic predisposition to iron overload in the five million ethnic Danes; more than 20,000 people are homozygous for the C282Y mutation and more than 500,000 people are compound heterozygous or heterozygous for the HFE-mutations. The disorder has a long preclinical stage with gradually increasing body iron overload and eventually 30% of men will develop clinically overt disease, presenting with symptoms of fatigue, arthralgias, reduced libido, erectile dysfunction, cardiac disease and diabetes. Subsequently the disease may progress into irreversible arthritis, liver cirrhosis, cardiomyopathy, pancreatic fibrosis and osteoporosis. The effective standard treatment is repeated phlebotomies, which in the preclinical and early clinical stages ensures a normal survival rate. Early detection of the genetic predisposition to the disorder is therefore important to reduce the overall burden of clinical disease. Population screening seems to be cost-effective and should be considered.
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Affiliation(s)
- Nils Thorm Milman
- Digestive Disease Center K, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Frank Vinholt Schioedt
- Digestive Disease Center K, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anders Ellekaer Junker
- Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Karin Magnussen
- Department of Blood Center and Medical Biochemistry, Innlandet Hospital Trust, Lillehammer, Norway
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Ghoz HM, Kröner PT, Stancampiano FF, Bowman AW, Vishnu P, Heckman MG, Diehl NN, McLeod E, Nikpour N, Palmer WC. Hepatic iron overload identified by magnetic resonance imaging-based T2* is a predictor of non-diagnostic elastography. Quant Imaging Med Surg 2019; 9:921-927. [PMID: 31367546 DOI: 10.21037/qims.2019.05.13] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Magnetic resonance elastography (MRE) is a non-invasive test used to assess liver stiffness and fibrosis in chronic liver disease, which includes systemic iron overload. However, iron deposition by itself is associated with technical failure of MRE of the liver which necessitates the use of invasive liver biopsy as an alternative monitoring method for these patients. T2*-weighted magnetic resonance imaging (T2*) is a reliable modality to asses for hepatic as well as total body iron overload. Therefore, we aimed to determine a cutoff value on the T2* reading at which MRE would no longer provide accurate stiffness measurements in patients with iron overload. Methods Ninety-five patients with iron overload who underwent MRE at our institution, between 2010 and 2017 were reviewed retrospectively. We compared T2* values between patients with adequate elastography (N=63) versus those with non-diagnostic elastography (N=32). We additionally examined the ability of T2* to predict the likelihood of non-diagnostic elastography by estimating area under the ROC curve (AUC). Results T2* was significantly different between patients with and without an adequate elastography (P<0.0001) and predicted occurrence of non-diagnostic elastography with an AUC of 0.95. All patients with a non-diagnostic elastography had a T2* value below 20 milliseconds (ms), and correspondingly 55% of the patients with a T2* value below 20 ms had a non-diagnostic elastography. The subgroups of patients with a T2* value ≤10, ≤8, and ≤6 ms, had a higher likelihood of non-diagnostic elastography (87%, 92%, and 95%, respectively). Conclusions T2* can be used to accurately predict which patients are most likely to have a non-diagnostic elastography reading. T2* of 20 ms or lower reflects a higher likelihood of non-diagnostic elastography.
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Affiliation(s)
- Hassan M Ghoz
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Paul T Kröner
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Prakash Vishnu
- Department of Hematology/Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - Nancy N Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - Ethan McLeod
- Clinical Research Internship Study Program (CRISP), Mayo Clinic, Jacksonville, FL, USA
| | - Naveed Nikpour
- Clinical Research Internship Study Program (CRISP), Mayo Clinic, Jacksonville, FL, USA
| | - William C Palmer
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
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Mantovani LF, Santos FPS, Perini GF, Nascimento CMB, Silva LP, Wroclawski CK, Esposito BP, Ribeiro MSS, Velloso EDRP, Nomura CH, Kay FU, Baroni RH, Hamerschlak N, Schuster S. Hepatic and cardiac and iron overload detected by T2* magnetic resonance (MRI) in patients with myelodisplastic syndrome: A cross-sectional study. Leuk Res 2018; 76:53-57. [PMID: 30572266 DOI: 10.1016/j.leukres.2018.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 11/17/2018] [Accepted: 12/03/2018] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Transfusion-dependent anemia and iron overload are associatedwith reduced survival in myelodysplastic syndrome (MDS). This cross-sectional study aimed to evaluate the prevalence of hepatic and cardiac overload in patients with MDS as measured by T2* magnetic resonance imaging (MRI), and its correlation with survival. METHODS MDS or chronic myelomonocytic leukemia patients had iron overload evaluated by T2* MRI. HIO was considered when hepatic iron concentration ≥ 2 g/mg. Cardiac iron overload was considered with a T2*-value < 20 ms. RESULTS Among 71 patients analyzed, median hepatic iron concentration was 3.9 g/mg (range 0.9-16 g/mg), and 68%of patients had hepatic iron overload. Patients with hepatic iron overload had higher mean ferritin levels (1182 ng/mL versus 185 ng/mL, p < 0.0001), transferrin saturation (76% versus 34%, p < 0.0001) and lower survival rates. Median cardiac T2*value was 42 ms (range 19.7-70.1 ms), and only one patienthad a T2* value indicative of cardiac iron overload. CONCLUSIONS Hepatic iron overload is found in two thirds of patients, even in cases without laboratory signs of iron overload. Hepatic iron overload by T2* MRI is associated with a decreased risk of survival in patients with MDS.
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Affiliation(s)
- L F Mantovani
- Hematology and Bone Marrow Transplantation Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - F P S Santos
- Hematology and Bone Marrow Transplantation Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - G F Perini
- Oncology Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - C M B Nascimento
- Oncology Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - L P Silva
- Bone Marrow Transplantation Center, Hospital São Camilo, São Paulo, Brazil
| | - C K Wroclawski
- Hematology Department, Hospital Sírio-Libanês, São Paulo, Brazil
| | - B P Esposito
- Chemistry Institute, Universidade de São Paulo (USP), São Paulo, Brazil
| | - M S S Ribeiro
- Instituto Paulista de Cancerologia, São Paulo, Brazil
| | - E D R P Velloso
- Hematology and Hemotherapy Discipline, Universidade de São Paulo (USP), São Paulo, Brazil
| | - C H Nomura
- Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - F U Kay
- UT Southwestern Medical Center, Dallas, TX, United States
| | - R H Baroni
- Diagnostic Imaging Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - N Hamerschlak
- Hematology and Bone Marrow Transplantation Department, Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | - S Schuster
- Hematology Department, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
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Petroni RC, Rosa SEAD, Carvalho FPD, Santana RAF, Hyppolito JE, Nascimento CMDB, Hamerschlak N, Campregher PV. Ferritin light chain gene mutations in two Brazilian families with hereditary hyperferritinemia-cataract syndrome. ACTA ACUST UNITED AC 2017; 15:492-495. [PMID: 28746593 PMCID: PMC5875167 DOI: 10.1590/s1679-45082017rc4006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 04/11/2017] [Indexed: 01/24/2023]
Abstract
Hereditary hyperferritinemia-cataract syndrome is an autosomal dominant genetic disorder associated with mutations in the 5’UTR region of the ferritin light chain gene. These mutations cause the ferritin levels to increase even in the absence of iron overload. Patients also develop bilateral cataract early due to accumulation of ferritin in the lens, and many are misdiagnosed as having hemochromatosis and thus not properly treated. The first cases were described in 1995 and several mutations have already been identified. However, this syndrome is still a poorly understood. We report two cases of unrelated Brazilian families with clinical suspicion of the syndrome, which were treated in our department. For the definitive diagnosis, the affected patients, their parents and siblings were submitted to Sanger sequencing of the 5’UTR region for detection of the ferritin light gene mutation. Single nucleotide polymorphism-like mutations were found in the affected patients, previously described. The test assisted in making the accurate diagnosis of the disease, and its description is important so that the test can be incorporated into clinical practice.
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