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Kurban LA, Almarri BK, Alshamsi MH, Abdelrahman SS, Alwahshi SG, Alhorani Q, Syed R, Bakoush O. Optimized serum ferritin prediction of iron overload in transfusion-dependent thalassemia: likelihood ratio and age-adjustment approach. Ann Saudi Med 2023; 43:90-96. [PMID: 37031371 PMCID: PMC10082945 DOI: 10.5144/0256-4947.2023.90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2023] Open
Abstract
BACKGROUND Early detection of iron overload in transfusion-dependent thalassemia (TDT) patients is critical to prevent complications and improve survival. OBJECTIVES Evaluate the utility of serum ferritin (SF) in the prediction of hepatic and myocardial iron overload (HIO and MIO) compared to T2*-MRI. DESIGN Retrospective SETTINGS: Governmental hospitals. PATIENTS AND METHODS Patients with TDT who had T2*-MRI examinations between January 2016 to October 2019 were included. The predictive value of SF for detection of HIO and MIO was assessed by measuring area under the curve (AUC). A sample size of 123 cases was calculated to detect a correlation of 0.25 with 90% power and a two-sided type I error of 0.05. MAIN OUTCOME MEASURES The correlation between SF and estimated hepatic iron concentration. SAMPLE SIZE 137 TDT patients who required regular blood transfusions. RESULTS The predictive value of SF was excellent for detection of HIO (AUC=0.83-0.87) but fair for detection of MIO (AUC=0.67). The two independent predictors of MIO were age and SF. The log of (age × SF) enhanced the SF predictive value for MIO (AUC=0.78). SF values of 700 and 1250 mg/L effectively excluded mild and moderate HIO with a sensitivity of 97.8% and 94.2%, respectively (LR-=0.1). While SF values of 1640 and 2150 mg/L accurately diagnosed mild and moderate HIO with a specificity of 95.55% and 96.4%, respectively (LR+>10). A log of (age × SF) cut-off value of 4.15 effectively excluded MIO (LR-=0.1), while a value of 4.65 moderately confirmed MIO (LR+=3.2). CONCLUSIONS SF is an excellent predictor of hepatic IO in TDT. Age adjustment enhanced its myocardial IO predictive accuracy. Likelihood ratio-based SF cut-off values may help clinicians in risk stratification and treatment decision-making. LIMITATIONS The laboratory data were gathered retrospectively and although the risk of selection bias for T2*-MRI examination is thought to be low, it cannot be ignored. CONFLICT OF INTEREST None.
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Affiliation(s)
- Lutfi Ali Kurban
- From the Department of Radiology, Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates
| | - Bashayer Khamis Almarri
- From the Radiography and Medical Imaging Department, Fatima College of Health Sciences, Al Ain, Abu Dhabi, United Arab Emirates
| | - Maitha Helal Alshamsi
- From the Radiography and Medical Imaging Department, Fatima College of Health Sciences, Al Ain, Abu Dhabi, United Arab Emirates
| | - Shahid Shehadeh Abdelrahman
- From the Radiography and Medical Imaging Department, Fatima College of Health Sciences, Al Ain, Abu Dhabi, United Arab Emirates
| | - Sara Ghumail Alwahshi
- From the Radiography and Medical Imaging Department, Fatima College of Health Sciences, Al Ain, Abu Dhabi, United Arab Emirates
| | - Qays Alhorani
- From the Radiography and Medical Imaging Department, Fatima College of Health Sciences, Al Ain, Abu Dhabi, United Arab Emirates
| | - Rizwan Syed
- From the Department of Radiology, Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates
| | - Omran Bakoush
- From the Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates
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Hoe HG, Git KA, Loh CK, Abdul Latiff Z, Hong J, Abdul Hamid H, Wan Sulaiman WNA, Mohd Zaki F. Magnetic resonance imaging T2 * of the pancreas value using an online software tool and correlate with T2 * value of myocardium and liver among patients with transfusion-dependent thalassemia major. FRONTIERS IN RADIOLOGY 2022; 2:943102. [PMID: 37492672 PMCID: PMC10365003 DOI: 10.3389/fradi.2022.943102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/28/2022] [Indexed: 07/27/2023]
Abstract
Objective Patients with thalassemia major do require lifetime blood transfusions that eventually result in iron accumulation in different organs. We described the usefulness of using magnetic resonance imaging (MRI) T2*imaging values for the evaluation of pancreatic iron load in these patients, and we correlated it with MRI T2* haemosiderosis of the myocardium and liver that has been recognized as a non-invasive assessment of iron overload among patients with thalassemia major. Materials and methods We conducted a cross-sectional study on 39 patients with thalassemia major in one of the tertiary university hospitals for a 1-year period. Demographic data were collected from the patient's history. MRI T2* of the pancreas, liver, and heart were executed on all patients in the same setting. Objective values of iron overload in these organs were obtained using the MRI post-processing software from online software. Results A total of 32 (82.1%) patients had pancreatic iron overload including 2 patients (5.1%) with severe iron overload and 15 patients (38.5%) with moderate and mild iron overload, respectively. Nine patients (23.1%) had myocardial iron overload, which included 3 patients (7.7%) who had severe cardiac haemosiderosis. Notably, 37 patients (94.9%) had liver iron overload, which included 15 patients (38.5%) who had severe liver haemosiderosis. There was a moderate positive correlation between the relaxation time of the pancreas and heart haemosiderosis (r = 0.504, P < 0.001). No significant correlation was found between the relaxation time of the pancreas with the liver and the heart with the liver. Conclusion Pancreatic haemosiderosis precedes cardiac haemosiderosis, which establishes a basis for initiating earlier iron chelation therapy to patients with thalassemia major.
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Affiliation(s)
- Han Guan Hoe
- Department of Radiology, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Kim-Ann Git
- Department of Radiology, Hospital Selayang, Batu Caves, Malaysia
| | - C-Khai Loh
- Paediatric Oncology and Haematology Unit, Department of Paediatrics, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Zarina Abdul Latiff
- Paediatric Oncology and Haematology Unit, Department of Paediatrics, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Joyce Hong
- Paediatric Endocrinology Unit, Department of Paediatrics, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Hamzaini Abdul Hamid
- Department of Radiology, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | | | - Faizah Mohd Zaki
- Department of Radiology, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
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Salmi A, Holmström M, Toiviainen-Salo S, Kanerva J, Taskinen M. Iron overload after allogeneic stem cell transplantation in children with acute lymphoblastic leukemia. Pediatr Transplant 2020; 24:e13846. [PMID: 33111465 DOI: 10.1111/petr.13846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/12/2020] [Accepted: 08/04/2020] [Indexed: 01/19/2023]
Abstract
Red blood cell transfusions are an essential part of supporting care in leukemia treatment. We examined the prevalence of iron overload and its effects on organ function and childhood growth in pediatric patients after allogeneic HSCT for acute lymphoblastic leukemia. Twenty-three patients were included (median age 12.6, range 7.5-21.4 years). Body iron load was determined using laboratory tests, hepatic and cardiac MRI, and by calculating iron received from transfusions. We performed multivariate analysis to determine association of body iron load with liver enzymes, cardiac function, insulin resistance, and growth. Median plasma ferritin was 344 (range 40-3235) ng/mL and exceeded 1000 ng/mL in three patients (13%). In MRI, 11 patients (48%) had hepatic iron overload and 1 patient (4%) myocardial iron overload. In cardiac MRI, 8 patients (35%) had significant but subclinical decrease in ejection fraction (median z-score -1.7, range -3.1-0.14), but cardiac function did not associate with iron status. Alanine transaminase associated with transfused iron per time unit (P = .001) after the median follow-up of 4.5 years. No correlation was found between iron load and growth or insulin resistance. Iron overload is common in children transplanted for ALL, but iron overload associated organ dysfunction is not present at early age. We recommend evaluation of iron load for all patients at least once during follow-up after transplantation.
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Affiliation(s)
- Asta Salmi
- Division of Hematology, Oncology and Stem Cell Transplantation, New Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Miia Holmström
- Department of Pediatric Radiology, HUS Medical Imaging Center, Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sanna Toiviainen-Salo
- Department of Pediatric Radiology, HUS Medical Imaging Center, Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jukka Kanerva
- Division of Hematology, Oncology and Stem Cell Transplantation, New Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mervi Taskinen
- Division of Hematology, Oncology and Stem Cell Transplantation, New Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Acar S, Gözmen S, Bayraktaroğlu S, Acar SO, Tahta N, Aydınok Y, Vergin RC. Evaluation of Liver Iron Content by Magnetic Resonance Imaging in Children with Acute Lymphoblastic Leukemia after Cessation of Treatment. Turk J Haematol 2020; 37:263-270. [PMID: 32077272 PMCID: PMC7702656 DOI: 10.4274/tjh.galenos.2020.2019.0364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Objective There are a limited number of studies evaluating iron overload in childhood leukemia by magnetic resonance imaging (MRI). The aim of this study was to determine liver iron content (LIC) by MRI in children with acute lymphoblastic leukemia (ALL) who had completed treatment and to compare those values with serum iron parameters. Materials and Methods A total of 30 patients between the ages of 7 and 18 who had completed ALL treatment were included in the study. Serum iron parameters (serum iron, serum ferritin [SF], and total iron-binding capacity) and liver function tests were studied. R2 MRI was performed for determining LIC. Results Normal LIC was detected in 22 (63.4%) of the cases. Seven (23.3%) had mild and 1 (3.3%) had moderate liver iron deposition. In contrast, severe iron overload was not detected in any of the cases. LIC levels were correlated with the numbers of packed red blood cell (pRBC) transfusions (r=0.637, p<0.001), pRBC transfusion volume (r=0.449, p<0.013), SF levels (r=0.561, p=0.001), and transferrin saturation (r=0.353, p=0.044). In addition, a positive correlation was found between the number of pRBC transfusions and SF levels (r=0.595, p<0.001). Conclusion We showed that the frequency of liver iron deposition was low and clinically less significant after the end of treatment in childhood ALL patients. LIC was demonstrated to be related to SF and transfusion history. These findings support that SF and transfusion history may be used as references for monitoring iron accumulation or identifying cases for further examinations such as MRI.
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Affiliation(s)
- Sezer Acar
- Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Department of Pediatrics, İzmir, Turkey
| | - Salih Gözmen
- Dr. Behcet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Division of Pediatric Hematology and Oncology, İzmir, Turkey
| | | | - Sultan O. Acar
- Dr. Behcet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Division of Pediatric Hematology and Oncology, İzmir, Turkey
| | - Neryal Tahta
- Dr. Behcet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Division of Pediatric Hematology and Oncology, İzmir, Turkey
| | - Yeşim Aydınok
- Ege University Faculty of Medicine, Division of Pediatric Hematology and Oncology, İzmir, Turkey
| | - Raziye C. Vergin
- Dr. Behcet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Division of Pediatric Hematology and Oncology, İzmir, Turkey
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Shehata SM, Amin MI, Zidan ESH. MRI evaluation of hepatic and cardiac iron burden in pediatric thalassemia major patients: spectrum of findings by T2*. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2019. [DOI: 10.1186/s43055-019-0044-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Iron deposition distorts the local magnetic field exerting T2* signal decay. Biopsy, serum ferritin, echocardiography are not reliable to adjust iron chelation therapy. Quantified MRI signal decay can replace biopsy to diagnose iron burden, guide treatment, and follow up. The objective of this study is to evaluate the role of T2* in quantification of the liver and heart iron burden in thalassemia major patients. This cross-sectional study included 44 thalassemia patients who were referred to MRI unit, underwent T2* MRI.
Results
Twenty-one male (47.7%) and 23 female (52.3%) were included (age range 6–15 years, mean age 10.9 ± 2.9 years). Patients with excess hepatic iron show the following: 11/40 (27.5%) mild, (13/40) 32.5% moderate, and (14/40) 35% severe liver iron overload. High statistical significance regarding association between LIC and liver T2* (p = 0.000) encountered. Cardiac T2* values showed no relationship with age (p = 0.6).
Conclusion
T2* is a good method to quantify, monitor hepatic and myocardial iron burden, guiding chelation therapy and prevent iron-induced cardiac complications.
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Kautsar A, Advani N, Andriastuti M. N-terminal-pro-b-type natriuretic peptide levels and cardiac hemosiderosis in adolescent β-thalassemia major patients. Ann Pediatr Cardiol 2019; 12:32-37. [PMID: 30745767 PMCID: PMC6343373 DOI: 10.4103/apc.apc_49_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Iron-induced cardiomyopathy remains the leading cause of mortality in patients with β-thalassemia major. Iron overload cardiomyopathy, which may be reversible through iron chelation, is characterized by early diastolic dysfunction. Amino-terminal pro-brain natriuretic peptide (NT-proBNP) is a sensitive biomarker of diastolic dysfunction. Aim: The aim of the study is to evaluate the diagnostic value of NT-proBNP as a surrogate marker of iron overload examined with magnetic resonance imaging T2-star (MRI T2*). Methods: Sixty-eight β-thalassemia major patients (10–18 years) with no signs of heart failure underwent NT-proBNP measurement before routine transfusion. All participants prospectively underwent cardiac MRI T2* examination within 3 months (median 19 days). Patients were divided as cardiac hemosiderosis (cardiac MRI T2* <20 ms) and nonhemosiderosis (cardiac MRI T2* >20 ms). Results: Of 68 patients, the male-to-female ratio was 1:1.1 and the median age was 14.1 years (range: 10–17.8 years). NT-proBNP levels were not different between hemosiderosis and nonhemosiderosis patients (P = 0.233). Further receiver operating characteristic analysis resulted in no significant correlation of NT-proBNP and MRI T2* (area under the curve 0.393, P = 0.233). Conclusion: Measurement of NT-proBNP levels cannot be used for early detection of cardiac iron overload in adolescent with β-thalassemia major.
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Affiliation(s)
- Ahmad Kautsar
- Department of Child Health, Faculty of Medicine, University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Najib Advani
- Department of Child Health, Faculty of Medicine, University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Murti Andriastuti
- Department of Child Health, Faculty of Medicine, University of Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
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Wahidiyat PA, Liauw F, Sekarsari D, Putriasih SA, Berdoukas V, Pennell DJ. Evaluation of cardiac and hepatic iron overload in thalassemia major patients with T2* magnetic resonance imaging. Hematology 2017; 22:501-507. [PMID: 28218005 DOI: 10.1080/10245332.2017.1292614] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVES Recent advancements have promoted the use of T2* magnetic resonance imaging (MRI) in the non-invasive detection of iron overload in various organs for thalassemia major patients. This study aims to determine the iron load in the heart and liver of patients with thalassemia major using T2* MRI and to evaluate its correlation with serum ferritin level and iron chelation therapy. METHODS This cross-sectional study included 162 subjects diagnosed with thalassemia major, who were classified into acceptable, mild, moderate, or severe cardiac and hepatic iron overload following their T2* MRI results, respectively, and these were correlated to their serum ferritin levels and iron chelation therapy. RESULTS The study found that 85.2% of the subjects had normal cardiac iron stores. In contrast, 70.4% of the subjects had severe liver iron overload. A significant but weak correlation (r = -0.28) was found between cardiac T2* MRI and serum ferritin, and a slightly more significant correlation (r = 0.37) was found between liver iron concentration (LIC) and serum ferritin. DISCUSSION The findings of this study are consistent with several other studies, which show that patients generally manifest with liver iron overload prior to cardiac iron overload. Moreover, iron accumulation demonstrated by T2* MRI results also show a significant correlation to serum ferritin levels. CONCLUSION This is the first study of its kind conducted in Indonesia, which supports the fact that T2* MRI is undoubtedly valuable in the early detection of cardiac and hepatic iron overload in thalassemia major patients.
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Affiliation(s)
- Pustika Amalia Wahidiyat
- a Pediatric Hematology-Oncology Division, Department of Child Health, Faculty of Medicine , Universitas Indonesia - Dr Cipto Mangunkusumo General Hospital , Jakarta , Indonesia
| | - Felix Liauw
- b Department of Child Health, Faculty of Medicine , Universitas Indonesia - Dr Cipto Mangunkusumo General Hospital , Jakarta , Indonesia
| | - Damayanti Sekarsari
- c Department of Radiology, Faculty of Medicine , Universitas Indonesia - Dr Cipto Mangunkusumo General Hospital , Jakarta , Indonesia
| | - Siti Ayu Putriasih
- b Department of Child Health, Faculty of Medicine , Universitas Indonesia - Dr Cipto Mangunkusumo General Hospital , Jakarta , Indonesia
| | - Vasili Berdoukas
- d University of Southern California, Keck School of Medicine Children's Hospital , Los Angeles , USA
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Majd Z, Haghpanah S, Ajami GH, Matin S, Namazi H, Bardestani M, Karimi M. Serum Ferritin Levels Correlation With Heart and Liver MRI and LIC in Patients With Transfusion-Dependent Thalassemia. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 17:e24959. [PMID: 26023341 PMCID: PMC4443302 DOI: 10.5812/ircmj.17(4)2015.24959] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 02/19/2015] [Accepted: 03/20/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Iron-loaded cardiac complication is the essential cause of mortality in patients with thalassemia. Early detection and treatment of cardiac over-load can reduce mortality. OBJECTIVES The current study aimed to evaluate the relationship between serum ferritin levels and T2* magnetic resonance imaging (MRI) of heart and liver and liver iron concentration (LIC) to diagnose iron over load in countries with limited access. PATIENTS AND METHODS In the current cross-sectional study, 85 Iranian patients with thalassemia with the mean age of 22.7 ± 7 years were randomly selected. All patients were on regular blood transfusion. Echocardiography of heart and liver T2* MRI, determination of serum ferritin levels, and LIC were performed in all subjects at the same time. The correlation of serum ferritin levels with T2*MRI of heart and liver, and LIC was assessed. P value < 0.05 was considered statistically significant. RESULTS Abnormal myocardial iron load (T2* MRI < 20 ms) was detected in 58% of the patients and among whom, 36% had severe myocardial iron load (T2* MRI < 10 ms). Median and interquartile range of serum ferritin levels were 1434 and 2702 respectively in patients with thalassemia. Serum ferritin levels showed a statistically significant positive correlation with LIC (rs = 0.718, P < 0.001) and significant negative correlation with T2* Heart (rs = -0.329, P = 0.002), and T2* Liver (rs = -0.698, P < 0.001). However, Ejection fraction was not significantly correlated with serum ferritin levels in the patients (P = 0.399). CONCLUSIONS Serum ferritin levels can be used to diagnose iron over-load in patients with thalassemiaas an alternative method in areas where T2* MRI is not available.
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Affiliation(s)
- Zahra Majd
- Department of Pediatrics, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Sezaneh Haghpanah
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Gholam Hossein Ajami
- Department of Pediatrics, Division of Pediatric Cardiology, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Sara Matin
- Department of Pediatrics, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Hamid Namazi
- Department of Orthopaedic Surgery, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Marzieh Bardestani
- Department of Library and Information Science, College of Humanities, Khouzestan Sciences and Research Branch, Islamic Azad University, Ahvaz, IR Iran
| | - Mehran Karimi
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Corresponding Author: Mehran Karimi, Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran. Tel/Fax: +98-9173140564, E-mail:
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Yang G, Liu R, Peng P, Long L, Zhang X, Yang W, Tan S, Pan H, Long X, He T, Anderson L, Lai Y. How early can myocardial iron overload occur in beta thalassemia major? PLoS One 2014; 9:e85379. [PMID: 24465548 PMCID: PMC3899006 DOI: 10.1371/journal.pone.0085379] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 11/25/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Myocardial siderosis is the most common cause of death in patients with beta thalassemia major(TM). This study aimed at investigating the occurrence, prevalence and severity of cardiac iron overload in a young Chinese population with beta TM. METHODS AND RESULTS We analyzed T2* cardiac magnetic resonance (CMR), left ventricular ejection fraction (LVEF) and serum ferritin (SF) in 201 beta TM patients. The median age was 9 years old. Patients received an average of 13 units of blood per year. The median SF level was 4536 ng/ml and 165 patients (82.1%) had SF>2500 ng/ml. Myocardial iron overload was detected in 68 patients (33.8%) and severe myocardial iron overload was detected in 26 patients (12.6%). Twenty-two patients ≤10 years old had myocardial iron overload, three of whom were only 6 years old. No myocardial iron overload was detected under the age of 6 years. Median LVEF was 64% (measured by CMR in 175 patients). Five of 6 patients with a LVEF<56% and 8 of 10 patients with cardiac disease had myocardial iron overload. CONCLUSIONS The TM patients under follow-up at this regional centre in China patients are younger than other reported cohorts, more poorly-chelated, and have a high burden of iron overload. Myocardial siderosis occurred in patients younger than previously reported, and was strongly associated with impaired LVEF and cardiac disease. For such poorly-chelated TM patients, our data shows that the first assessment of cardiac T2* should be performed as early as 6 years old.
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Affiliation(s)
- Gaohui Yang
- Department of Hematology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Rongrong Liu
- Department of Hematology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Peng Peng
- Department of Radiology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Liling Long
- Department of Radiology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xinhua Zhang
- Department of Hematology, 303rd Hospital of People's Liberation Army, Nanning, China
| | - Weijia Yang
- Department of Pediatrics, Women and Children Hospital of Guilin, Guilin, China
| | - Shaohong Tan
- Department of Pediatrics, Women and Children Hospital of Yulin, Yulin, China
| | - Hongfei Pan
- Department of Pediatrics, Affiliated Hospital of Youjiang Medical University for Nationality, Baise, China
| | - Xingjiang Long
- Department of Pediatrics, The People's Hospital of Liuzhou, Liuzhou, China
| | - Taigang He
- Cardiovascular Sciences Research Centre, St George's University of London, London, United Kingdom
- Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom
| | - Lisa Anderson
- Cardiovascular Sciences Research Centre, St George's University of London, London, United Kingdom
| | - Yongrong Lai
- Department of Hematology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
- * E-mail:
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de Ville de Goyet M, Moniotte S, Robert A, Dupont S, Vermylen C, Veyckemans F, Brichard B. Iron overload in children undergoing cancer treatments. Pediatr Blood Cancer 2013; 60:1982-7. [PMID: 23897631 DOI: 10.1002/pbc.24705] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 07/04/2013] [Indexed: 01/03/2023]
Abstract
BACKGROUND Iron overload is responsible for severe morbidity and mortality in polytransfused patients. Although repeated blood transfusions are needed during the treatment of most cancers, pediatric patients are not routinely screened for subsequent iron overload. PROCEDURE Seventy-five patients were identified as candidates for cancer treatment and enrolled prospectively in a yearly protocol including a cardiac and liver magnetic resonance imaging coupled with ferritin level measurements. Patients were divided into four groups using the intensity of treatment rating (ITR-3). RESULTS Fifty-nine patients reached 1-year of follow-up and liver iron overload was found in up to 66% of them. Such overload correlated with the total volume of red blood cells transfused and persisted at least 2 years after the initiation of therapy. Moderate myocardial overload was also, but less frequently (14%), observed in these patients. CONCLUSIONS Our study demonstrated that severe liver iron overload as well as moderate myocardial iron overload can be found 1 year after cancer treatment and that this overload persists overtime. The patients with higher ITR and those who have received more than a liter of blood red cells per square meter, regardless of their diagnosis or ITR, are at risk of iron overload and should be screened carefully.
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Affiliation(s)
- Maëlle de Ville de Goyet
- Department of Paediatric Haematology and Oncology, Cliniques universitaires Saint-Luc, Brussels, Belgium; Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
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11
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A practical approach for a wide range of liver iron quantitation using a magnetic resonance imaging technique. Radiol Res Pract 2012; 2012:207391. [PMID: 23365743 PMCID: PMC3530181 DOI: 10.1155/2012/207391] [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: 08/27/2012] [Revised: 11/12/2012] [Accepted: 11/13/2012] [Indexed: 01/19/2023] Open
Abstract
The goal of this study is to demonstrate a practical magnetic resonance imaging technique for quantifying a wide range of hepatic iron concentration (HIC) for hematologic oncology patients with transfusion iron overload in a routine clinical setting. To cover a wide range of T2* values from hematologic patients, we used a dual-acquisition method with two clinically available acquisition protocols on a 1.5T MRI scanner with different ΔTEs to acquire data in two breath-holds. An in-house image postprocessing software tool was developed to generate T2*, iron maps, and water and fat images, when fat is presented in the liver. The resulting iron maps in DICOM format are transferred to the institutional electronic medical record system for review by radiologists. The measured liver T2* values for 28 patients ranged from 0.56 ± 0.13 to 25.0 ± 2.1 milliseconds. These T2* values corresponded to HIC values ranging from 1.2 ± 0.1 mg/g to 45.0 ± 10.0 mg/g (dry weight). A moderate correlation between overall serum ferritin levels and R2* was found with a correlation coefficient of 0.83. Repeated phantom scans confirmed that the precision of this method is better than 4% for T2* measurements. The dual- acquisition method also improved the ability to quantify HIC of the patients with hepatic steatosis.
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Butler A, Patton WN. Iron chelation therapy in myelodysplastic syndromes: we need more evidence, not more guidelines. Intern Med J 2012; 42:481-4. [PMID: 22616959 DOI: 10.1111/j.1445-5994.2012.02769.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Kaushik N, Eckrich MJ, Parra D, Yang E. Chronically transfused pediatric sickle cell patients are protected from cardiac iron overload. Pediatr Hematol Oncol 2012; 29:254-60. [PMID: 22303979 DOI: 10.3109/08880018.2011.630774] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Iron overload is a major toxicity of chronic transfusions. Myocardial iron overload is associated with cardiac dysfunction. Cardiac and liver magnetic resonance imaging (MRI) was performed on 14 chronically transfused sickle cell disease (SCD) and non-sickle cell disease (non-SCD) patients seen at Vanderbilt Children's Hospital from 1 January 2000 to 10 March 2010. Retrospective review was conducted to assess cardiac T2*, liver T2*, ventricular dimensions and function, echocardiogram, length of transfusion, hemoglobin, and ferritin measurements. Ten patients had SCD and 4 had non-SCD, including α-thalassemia, β-thalassemia, and Diamond-Blackfan anemia. Cardiac T2* was normal in all SCD patients (mean 39 ± 12 ms), but abnormal in 3 of 4 non-SCD patients (mean 11.8 ± 2.4 ms). Liver T2* was similar between SCD (mean 6.2 ± 1.6 ms) and non-SCD patients (mean 5.9 ± 1.9 ms), and did not correlate with serum ferritin. Comparing SCD and non-SCD patients with similar transfusion duration, SCD patients had normal cardiac T2* and non-SCD patients had abnormal cardiac T2*. No patients had cardiomyopathy, but ventricular dilatation was common among SCD patients. Chronically transfused pediatric SCD patients are relatively spared of myocardial iron overload, which is unlikely to be due to lower total body iron burden in SCD patients than non-SCD patients.
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Affiliation(s)
- Neeru Kaushik
- Division of Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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The relationship between cardiac and liver iron evaluated by MR imaging in haematological malignancies and chronic liver disease. Blood Cancer J 2012; 2:e49. [PMID: 22829233 PMCID: PMC3270252 DOI: 10.1038/bcj.2011.48] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 11/02/2011] [Accepted: 11/17/2011] [Indexed: 11/26/2022] Open
Abstract
Although iron overload is clinically significant, only limited data have been published on iron overload in haematological diseases. We investigated cardiac and liver iron accumulation by magnetic resonance imaging (MRI) in a cohort of 87 subjects who did not receive chelation, including 59 haematological patients. M-HIC (MRI-based hepatic iron concentration, normal values <36 μmol/g) is a non-invasive, liver biopsy-calibrated method to analyse iron concentration. This method, calibrated to R2 (transverse relaxation rate), was used as a reference standard (M-HIC(R2)). Transfusions and ferritin were evaluated. Mean M-HIC(R2) and cardiac R* of all patients were 142 μmol/g (95% CI, 114–170) and 36.4 1/s (95% CI, 34.2–38.5), respectively. M-HIC(R2) was higher in haematological patients than in patients with chronic liver disease or normal controls (P<0.001). Clearly elevated cardiac R2* was found in two myelodysplastic syndrome (MDS) patients with severe liver iron overload. A poor correlation was found between liver and cardiac iron (n=82, r=0.322, P=0.003), in contrast to a stronger correlation in MDS (n=7, r=0.905, P=0.005). In addition to transfusions, MDS seemed to be an independent factor in iron accumulation. In conclusion, the risk for cardiac iron overload in haematological diseases other than MDS is very low, despite the frequently found liver iron overload.
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Vag T, Kentouche K, Krumbein I, Reichenbach JR, Lopatta E, Renz DM, Stenzel M, Beck J, Kaiser WA, Mentzel HJ. Noninvasive measurement of liver iron concentration at MRI in children with acute leukemia: initial results. Pediatr Radiol 2011; 41:980-4. [PMID: 21674286 DOI: 10.1007/s00247-011-2122-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Revised: 01/06/2011] [Accepted: 01/17/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Routine assessment of body iron load in patients with acute leukemia is usually done by serum ferritin (SF) assay; however, its sensitivity is impaired by different conditions including inflammation and malignancy. OBJECTIVE To estimate, using MRI, the extent of liver iron overload in children with acute leukemia and receiving blood transfusions, and to examine the association between the degree of hepatic iron overload and clinical parameters including SF and the transfusion iron load (TIL). MATERIAL AND METHODS A total of 25 MRI measurements of the liver were performed in 15 children with acute leukemia (mean age 9.75 years) using gradient-echo sequences. Signal intensity ratios between the liver and the vertebral muscle (L/M ratio) were calculated and compared with SF-levels. TIL was estimated from the cumulative blood volume received, assuming an amount of 200 mg iron per transfused red blood cell unit. RESULTS Statistical analysis revealed good correlation between the L/M SI ratio and TIL (r = -0.67, P = 0.002, 95% confidence interval CI = -0.83 to -0.34) in patients with acute leukemia as well as between L/M SI ratio and SF (r = -0.76, P = 0.0003, 95% CI = -0.89 to -0.52). CONCLUSION SF may reliably reflect liver iron stores as a routine marker in patients suffering from acute leukemia.
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Affiliation(s)
- Tibor Vag
- Institute of Diagnostic and Interventional Radiology, Friedrich Schiller University Jena, Jena, Germany.
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Meloni A, Luciani A, Positano V, De Marchi D, Valeri G, Restaino G, Cracolici E, Caruso V, Dell'amico MC, Favilli B, Lombardi M, Pepe A. Single region of interest versus multislice T2* MRI approach for the quantification of hepatic iron overload. J Magn Reson Imaging 2011; 33:348-55. [PMID: 21274976 DOI: 10.1002/jmri.22417] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To evaluate the effectiveness of the single ROI approach for the detection of hepatic iron burden in thalassemia major (TM) patients in respect to a whole liver measurement. MATERIALS AND METHODS Five transverse hepatic slices were acquired by a T2* gradient-echo sequence in 101 TM patients and 20 healthy subjects. The T2* value was calculated in a single region of interest (ROI) defined in the medium-hepatic slice. Moreover, the T2* value was extracted on each of the eight ROIs defined in the functionally independent segments. The mean hepatic T2* value was calculated. RESULTS For patients, the mean T2* values over segments VII and VIII were significantly lower. This pattern was substantially preserved in the two groups identified considering the T2* normal cutoff. All segmental T2* values were correlated with the single ROI T2* value. After the application of a correction map based on T2* fluctuations in the healthy subjects, no significant differences were found in the segmental T2* values. CONCLUSION Hepatic T2* variations are low and due to artifacts and measurement variability. The single ROI approach can be adopted in the clinical arena, taking care to avoid the susceptibility artifacts, occurring mainly in segments VII and VIII.
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Affiliation(s)
- Antonella Meloni
- Fondazione G.Monasterio CNR-Regione Toscana and Institute of Clinical Physiology, Pisa, Italy.
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Sukerkar PA, Rezvi UG, Macrenaris KW, Patel PC, Wood JC, Meade TJ. Polystyrene microsphere-ferritin conjugates: a robust phantom for correlation of relaxivity and size distribution. Magn Reson Med 2010; 65:522-30. [PMID: 21264938 DOI: 10.1002/mrm.22627] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Revised: 07/08/2010] [Accepted: 08/10/2010] [Indexed: 01/28/2023]
Abstract
In vivo iron load must be monitored to prevent complications from iron overload diseases such as hemochromatosis or transfusion-dependent anemias. While liver biopsy is the gold standard for determining in vivo iron load, MRI offers a noninvasive approach. MR phantoms have been reported that estimate iron concentration in the liver and mimic relaxation characteristics of in vivo deposits of hemosiderin. None of these phantoms take into account the size distribution of hemosiderin, which varies from patient to patient based on iron load. We synthesized stable and reproducible microsphere-ferritin conjugates (ferribeads) of different sizes that are easily characterized for several parameters that are necessary for modeling such as iron content and bead fraction. T(1) s and T(2) s were measured on a 1.41-T low-resolution NMR spectrometer and followed a size-dependent trend. Ferribeads imaged at 4.7 and 14.1 T showed that signal intensities are dependent on the distribution of ferritin around the bead rather than the iron concentration alone. These particles can be used to study the effects of particle size, ferritin distribution, and bead fraction on proton relaxation and may be of use in mimicking hemosiderin in a phantom for estimating iron concentration.
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Affiliation(s)
- Preeti A Sukerkar
- Departments of Chemistry, Molecular Biosciences, Neurobiology and Physiology, Radiology, Northwestern University, Evanston, Illinois, USA
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Matter RM, Allam KE, Sadony AM. Gradient-echo magnetic resonance imaging study of pancreatic iron overload in young Egyptian beta-thalassemia major patients and effect of splenectomy. Diabetol Metab Syndr 2010; 2:23. [PMID: 20398341 PMCID: PMC2873247 DOI: 10.1186/1758-5996-2-23] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Accepted: 04/15/2010] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Thalassemic patients suffer from diabetes mellitus secondary to hemosiderosis. AIMS The study aimed to evaluate pancreatic iron overload by T2*-weighted Gradient-echo magnetic resonance imaging (MRI) in young beta-thalassemia major patients and to correlate it with glucose disturbances, hepatic hemosiderosis, serum ferritin and splenectomy. METHODS Forty thalassemic patients (20 non diabetic, 10 diabetic, and 10 with impaired glucose tolerance) were recruited from Pediatric Hematology Clinic, in addition to 20 healthy controls. All patients underwent clinical assessment and laboratory investigations included complete blood count, liver function tests, serum ferritin and oral glucose tolerance test (OGTT). A T2*-weighted gradient-echo sequence MRI was performed with 1.5 T scanner and signal intensity ratio (SIR) of the liver and the pancreas to noise were calculated. RESULTS Significant reduction in signal intensity ratio (SIR) of the liver and the pancreas was shown in thalassemic patients compared to controls (P < 0.0001), Thalassemic patients with abnormal glucose tolerance; including diabetics and thalassemics with impaired glucose tolerance; displayed a higher degree of pancreatic and hepatic siderosis compared to thalassemics with normal glucose tolerance or controls (P < 0.001, P < 0.0001). Splenectomized thalassemic patients had significantly lower SIR of pancreas compared to non splenectomized patients (P < 0.05). A strong correlation was present between hepatic and pancreatic siderosis in studied patients (P < 0.001). CONCLUSIONS pancreatic siderosis can be detected by T2* gradient-echo MRI since childhood in thalassemic patients, and is more evident in patients with abnormal glucose tolerance. After splenectomy, iron deposition may be accelerated in the pancreas. Follow up of thalassemic patients using pancreatic MRI together with intensive chelation therapy may help to prevent the development of overt diabetes.
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Affiliation(s)
- Randa M Matter
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo 11566, Egypt
| | - Khalid E Allam
- Department of Diagnostic Radiology, Faculty of Medicine, Ain Shams University, Cairo 11566, Egypt
| | - Amany M Sadony
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo 11566, Egypt
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Abstract
Accurate evaluation of iron overload is necessary to establish the diagnosis of hemochromatosis and guide chelation treatment in transfusion-dependent anemia. The liver is the primary site for iron storage in patients with hemochromatosis or transfusion-dependent anemia, therefore, liver iron concentration (LIC) accurately reflects total body iron stores. In the past 20 years, magnetic resonance imaging (MRI) has emerged as a promising method for measuring LIC in a variety of diseases. We review the potential role of MRI in LIC determination in the most important disorders that are characterized by iron overload, that is, thalassemia major, other hemoglobinopathies, acquired anemia, and hemochromatosis. Most studies have been performed in thalassemia major and MRI is currently a widely accepted method for guiding chelation treatment in these patients. However, the lack of correlation between liver and cardiac iron stores suggests that both organs should be evaluated with MRI, since cardiac disease is the leading cause of death in this population. It is also unclear which MRI method is the most accurate since there are no large studies that have directly compared the different available techniques. The role of MRI in the era of genetic diagnosis of hemochromatosis is also debated, whereas data on the accuracy of the method in other hematological and liver diseases are rather limited. However, MRI is a fast, non-invasive and relatively accurate diagnostic tool for assessing LIC, and its use is expected to increase as the role of iron in the pathogenesis of liver disease becomes clearer.
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