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Puttawibul P, Kritsaneepaiboon S, Chotsampancharoen T, Vichitkunakorn P. The relationship between liver stiffness by two-dimensional shear wave elastography and iron overload status in transfusion-dependent patients. Pediatr Hematol Oncol 2024:1-13. [PMID: 38978478 DOI: 10.1080/08880018.2024.2353900] [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: 08/26/2022] [Accepted: 06/21/2023] [Indexed: 07/10/2024]
Abstract
Increased liver stiffness (LS) can be result of increased liver iron concentration (LIC) which may not yet be reflected in the liver fibrotic status. The objective of our study was to examine relationship between hemochromatosis, LS, and serum ferritin level in transfusion-dependent patients. We recruited all 70 transfusion-dependent patients, whose median age was 15, referred for evaluating LIC status by magnetic resonance imaging (MRI) followed by two-dimensional ultrasonography shear wave elastography (2D-SWE). Thalassemia beta affected the majority of the patients. The optimal cut point for prediction of severe hemochromatosis using median SWE (kPa) and SWV (m/s) was ≥ 7.0 kPa and ≥ 1.54 m/s, respectively, with sensitivity of 0.76 (95% confidence interval [CI] 0.55, 0.91) and, specificity of 0.69 (95%CI 0.53, 0.82). When combing the optimal cut point of SWE (kPa) at ≥ 7.0 and serum ferritin ≥ 4123 ng/mL, the sensitivity increased to 0.84 (95%CI 0.64, 0.95) with specificity of 0.67 (95%CI 0.50, 0.80), positive predictive value (PPV) of 0.60 (95%CI 0.42, 0.76), and negative predictive value (NPV) of 0.88 (95%CI 0.71, 0.96). Simultaneous tests of 2D-SWE and serum ferritin for prediction of severe hemochromatosis showed the highest sensitivity of 84% (95%CI 0.64-0.95), as compared to 2D-SWE alone at 76% (95%CI 0.55, 0.91) or serum ferritin alone at 44% (95%CI 0.24-0.65). We recommend measuring both 2D-SWE and serum ferritin in short interval follow up patients. Adding 2D-SWE to management guideline will help in deciding for aggressive adjustment of iron chelating medication and increased awareness of patients having severe hemochromatosis.
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Affiliation(s)
- Pimporn Puttawibul
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Thailand
| | | | | | - Polathep Vichitkunakorn
- Department of Family Medicine and Preventive Medicine, Faculty of Medicine, Prince of Songkla University, Thailand
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Feng Q, Yi J, Li T, Liang B, Xu F, Peng P. Narrative review of magnetic resonance imaging in quantifying liver iron load. Front Med (Lausanne) 2024; 11:1321513. [PMID: 38362538 PMCID: PMC10867177 DOI: 10.3389/fmed.2024.1321513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 01/18/2024] [Indexed: 02/17/2024] Open
Abstract
Objective To summarize the research progress of magnetic resonance imaging (MRI) in quantifying liver iron load. Methods To summarize the current status and progress of MRI technology in the quantitative study of liver iron load through reviewing the relevant literature at home and abroad. Results Different MRI sequence examination techniques have formed a series of non-invasive methods for the examination of liver iron load. These techniques have important clinical significance in the imaging diagnosis of liver iron load. So far, the main MRI methods used to assess liver iron load are: signal intensity measurement method (signal intensity, SI) [signal intensity ratio (SIR) and difference in in-phase and out-of-phase signal intensity], T2/R2 measurement (such as FerriScan technique), ultra-short echo time (UTE) imaging technique, and susceptibility weighted imaging (including conventional susceptibility weighted imaging) (SWI), quantitative susceptibility mapping (QSM), T2*/R2* measurement, Dixon and its derivative techniques. Conclusion MRI has become the first choice for the non-invasive examination of liver iron overload, and it is helpful to improve the early detection of liver injury, liver fibrosis, liver cirrhosis and liver cancer caused by liver iron overload.
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Affiliation(s)
- Qing Feng
- Department of Radiology, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou Workers' Hospital, Liuzhou, China
| | - Jixing Yi
- Department of Radiology, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou Workers' Hospital, Liuzhou, China
| | - Tao Li
- Department of Radiology, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou Workers' Hospital, Liuzhou, China
| | - Bumin Liang
- School of International Education, Guangxi Medical University, Nanning, China
| | - Fengming Xu
- Department of Radiology, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou Workers' Hospital, Liuzhou, China
- Department of Radiology, 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
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Saliba AN, Musallam KM, Taher AT. How I treat non-transfusion-dependent β-thalassemia. Blood 2023; 142:949-960. [PMID: 37478396 PMCID: PMC10644094 DOI: 10.1182/blood.2023020683] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 07/23/2023] Open
Abstract
The intricate interplay of anemia and iron overload under the pathophysiological umbrella of ineffective erythropoiesis in non-transfusion-dependent β-thalassemia (NTDT) results in a complex variety of clinical phenotypes that are challenging to diagnose and manage. In this article, we use a clinical framework rooted in pathophysiology to present 4 common scenarios of patients with NTDT. Starting from practical considerations in the diagnosis of NTDT, we delineate our strategy for the longitudinal care of patients who exhibit different constellations of symptoms and complications. We highlight the use of transfusion therapy and novel agents, such as luspatercept, in the patient with anemia-related complications. We also describe our approach to chelation therapy in the patient with iron overload. Although tackling every specific complication of NTDT is beyond the scope of this article, we touch on the management of the various morbidities and multisystem manifestations of the disease.
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Affiliation(s)
| | - Khaled M. Musallam
- Thalassemia Center, Burjeel Medical City, Abu Dhabi, United Arab Emirates
| | - Ali T. Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Ali MS, Borhany M, Butt AJ, Munawar Ali R, Kashif S, Wahaj M, Shamsi T. Correlation Between Serum Ferritin and Degree of Hepatic Fibrosis on Fibroscan in Thalassemic Patients. Cureus 2023; 15:e42069. [PMID: 37602123 PMCID: PMC10434294 DOI: 10.7759/cureus.42069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 08/22/2023] Open
Abstract
Aim and objective This study aimed to examine the relationship between serum ferritin levels and the degree of hepatic fibrosis as detected on Fibroscan in thalassemia patients. Materials and methods This was a single-center and cross-sectional study conducted from April 2021 to December 2022. The sample population comprised 55 beta-thalassemia patients receiving treatment at the National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, Pakistan. The data was compiled through a series of patient interviews, an examination of medical records and was analyzed to obtain the results. Descriptive statistics were used for several variables, including diagnosis, Fibroscan score, blood group, comorbidity, visceromegaly, consanguinity, serum glutamate pyruvate transaminase (SGPT), viral markers, and C reactive protein (CRP). The correlation analysis was done using Spearman's correlation test. Results There were 55 participants in the study, 40 of whom were male and 15 of whom were female. The mean age of the patients was eight years, while the average age at diagnosis was nine months with a transfusion frequency of every 20 days. Spearman's rho (r = 0.287), and the significant value of (p = 0.033) confirmed a statistically significant positive correlation between serum ferritin levels and hepatic fibrosis. On Fibroscan, 74.5% of patients had F0-F1 stage fibrosis followed by 14.5% of the patients having F2 stage fibrosis. HCV seropositivity was the most prevalent comorbidity among the patients. 80% of patients had serum ferritin levels greater than 1000 ug/mL. Hepatosplenomegaly was present in 43.6% of the patients. 78.2% of patients were born out of consanguineous marriages. Conclusion In conclusion, this study found a statistically significant positive correlation between serum ferritin levels and hepatic fibrosis in beta-thalassemia patients. The study emphasizes the significance of monitoring serum ferritin levels in thalassemia patients to prevent hepatic fibrosis.
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Affiliation(s)
- Muhammad Shujat Ali
- Clinical Hematology, National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, PAK
| | - Munira Borhany
- Clinical Hematology, National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, PAK
| | - Aqsa Javed Butt
- Clinical Hematology, National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, PAK
| | - Rabeea Munawar Ali
- Clinical Hematology, National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, PAK
| | - Syed Kashif
- Internal Medicine, Dr. Ruth K. M. Pfau Civil Hospital Karachi, Karachi, PAK
| | - Muhammad Wahaj
- Medicine, Peshawar Institute of Medical Sciences, Peshawar, PAK
| | - Tahir Shamsi
- Clinical Hematology, National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, PAK
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5
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Nehring P, Szeligowska J, Przybyłkowski A. Elastography of the Liver in Wilson's Disease. Diagnostics (Basel) 2023; 13:diagnostics13111898. [PMID: 37296749 DOI: 10.3390/diagnostics13111898] [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: 04/12/2023] [Revised: 05/22/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
Staging of liver fibrosis is of special significance in Wilson's disease as it determines the patient's prognosis and treatment. Histopathological examination is a standard method for fibrosis assessment; however, non-invasive methods like transient elastography and share wave elastography are believed to be reliable and repetitive and are expected to replace liver biopsy in Wilson's disease. This article presents a short description of available elastography techniques and the results of the most recent studies on elastography of the liver in patients with Wilson's disease.
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Affiliation(s)
- Piotr Nehring
- Department of Gastroenterology and Internal Medicine, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
| | - Jowita Szeligowska
- Department of Gastroenterology and Internal Medicine, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
| | - Adam Przybyłkowski
- Department of Gastroenterology and Internal Medicine, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
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Musallam KM, Taher AT, Kattamis A, Kuo KHM, Sheth S, Cappellini MD. Profile of Luspatercept in the Treatment of Anemia in Adults with Non-Transfusion-Dependent β-Thalassemia (NTDT): Design, Development and Potential Place in Therapy. Drug Des Devel Ther 2023; 17:1583-1591. [PMID: 37255740 PMCID: PMC10226484 DOI: 10.2147/dddt.s368584] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/20/2023] [Indexed: 06/01/2023] Open
Abstract
Over the past decade, evidence has been mounting on the detrimental clinical sequelae of untreated anemia in patients with non-transfusion-dependent β-thalassemia (NTDT). There are no pharmacologic agents that are specifically approved for the management of anemia in NTDT, and available options such as splenectomy, transfusion therapy, and hydroxyurea each come with their own shortcomings, especially for long-term use. Luspatercept is an erythroid maturation agent that has been evaluated in a Phase 2, randomized trial and showed a significant benefit in raising hemoglobin level by at least 1 g/dL in adults with NTDT and a baseline hemoglobin level ≤10 g/dL. These data led to luspatercept's approval by the European Commission for the treatment of anemia in adults with NTDT and presents the first evidence-based approach for a novel agent that is able to ameliorate anemia in this patient population.
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Affiliation(s)
- Khaled M Musallam
- Thalassemia Center, Burjeel Medical City, Abu Dhabi, United Arab Emirates
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Antonis Kattamis
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Kevin H M Kuo
- Division of Hematology, University of Toronto, Toronto, ON, Canada
| | - Sujit Sheth
- Division of Hematology and Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community, University of Milan, Ca’ Granda Foundation IRCCS Maggiore Policlinico Hospital, Milan, Italy
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Lee YC, Yen CT, Lee YL, Chen RJ. Thalassemia Intermedia: Chelator or Not? Int J Mol Sci 2022; 23:ijms231710189. [PMID: 36077584 PMCID: PMC9456380 DOI: 10.3390/ijms231710189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/19/2022] Open
Abstract
Thalassemia is the most common genetic disorder worldwide. Thalassemia intermedia (TI) is non-transfusion-dependent thalassemia (NTDT), which includes β-TI hemoglobin, E/β-thalassemia and hemoglobin H (HbH) disease. Due to the availability of iron chelation therapy, the life expectancy of thalassemia major (TM) patients is now close to that of TI patients. Iron overload is noted in TI due to the increasing iron absorption from the intestine. Questions are raised regarding the relationship between iron chelation therapy and decreased patient morbidity/mortality, as well as the starting threshold for chelation therapy. Searching all the available articles up to 12 August 2022, iron-chelation-related TI was reviewed. In addition to splenectomized patients, osteoporosis was the most common morbidity among TI cases. Most study designs related to ferritin level and morbidities were cross-sectional and most were from the same Italian study groups. Intervention studies of iron chelation therapy included a subgroup of TI that required regular transfusion. Liver iron concentration (LIC) ≥ 5 mg/g/dw measured by MRI and ferritin level > 300 ng/mL were suggested as indicators to start iron chelation therapy, and iron chelation therapy was suggested to be stopped at a ferritin level ≤ 300 ng/mL. No studies showed improved overall survival rates by iron chelation therapy. TI morbidities and mortalities cannot be explained by iron overload alone. Hypoxemia and hemolysis may play a role. Head-to-head studies comparing different treatment methods, including hydroxyurea, fetal hemoglobin-inducing agents, hypertransfusion as well as iron chelation therapy are needed for TI, hopefully separating β-TI and HbH disease. In addition, the target hemoglobin level should be determined for β-TI and HbH disease.
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Affiliation(s)
- Yen-Chien Lee
- Department of Medical Oncology, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan 70043, Taiwan
- Department of Internal Medicine, College of Medicine, National Cheng Kung University Hospital, Tainan 70403, Taiwan
- Correspondence: (Y.-C.L.); (R.-J.C.)
| | - Chi-Tai Yen
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan 70043, Taiwan
| | - Yen-Ling Lee
- Department of Medical Oncology, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan 70043, Taiwan
| | - Rong-Jane Chen
- Department of Food Safety/Hygiene and Risk Management, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
- Correspondence: (Y.-C.L.); (R.-J.C.)
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8
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Relationship between Serum Ferritin and Outcomes in β-Thalassemia: A Systematic Literature Review. J Clin Med 2022; 11:jcm11154448. [PMID: 35956067 PMCID: PMC9369259 DOI: 10.3390/jcm11154448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/22/2022] [Accepted: 07/26/2022] [Indexed: 12/10/2022] Open
Abstract
Among the difficulties of living with β-thalassemia, patients frequently require blood transfusions and experience iron overload. As serum ferritin (SF) provides an indication of potential iron overload, we conducted a systematic literature review (SLR) to assess whether SF levels are associated with clinical and economic burden and patient-reported outcomes (PROs). The SLR was conducted on 23 April 2020 and followed by analysis of the literature. Dual-screening was performed at the title, abstract, and full-text levels using predefined inclusion and exclusion criteria. Ten studies identified by the SLR were eligible for inclusion in the analysis. Seven studies were conducted in Europe, and most were prospective or retrospective in design. The patient populations had a median age of 20.7–42.6 years, with a percentage of men of 38–80%. Sparse data were found on the correlation between SF levels and mortality, and hepatic, skeletal, and cardiac complications; however, in general, higher SF levels were associated with worsened outcomes. The bulk of the evidence reported on the significant association between higher SF levels and endocrine dysfunction in its many presentations, including a 14-fold increase in the risk of diabetes for patients with persistently elevated SF levels. No studies reporting data on PROs or economic burden were identified by the SLR. SF levels provide another option for prognostic assessment to predict a range of clinical outcomes in patients with β-thalassemia.
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9
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Huang Y, Yang G, Wang M, Wei X, Pan L, Liu J, Lei Y, Peng, Long L, Lai Y, Liu R. Iron overload status in patients with non-transfusion-dependent thalassemia in China. Ther Adv Hematol 2022; 13:20406207221084639. [PMID: 35321211 PMCID: PMC8935562 DOI: 10.1177/20406207221084639] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 02/15/2022] [Indexed: 11/25/2022] Open
Abstract
Background: Iron overload is one of the main factors that increase morbidity and mortality in patients with non-transfusion dependent thalassemia (NTDT). Aim: This study aimed at investigating the prevalence and severity of iron overload in Chinese NTDT patients. Methods: we analyzed serum ferritin (SF), liver iron concentration (LIC) and cardiac T2* in 178 Chinese NTDT in this cross-sectional study. Results: The median SF level was 996.00(27.15–19704.00) ng/ml and the median LIC value was 8.90(0.60–43.00) mg Fe/g dry weight (dw). The youngest patient with liver iron overload was 5 years old with 5.6 mg Fe/g dw in LIC. The median cardiac T2* was 33.06(7.46–75.08) ms. 6 patients had cardiac T2*⩽20ms. The patients with β thalassemia intermedia and HbE/β thalassemia showed a statistically significant lower Hb and higher values of SF and LIC than those of hemoglobin H disease patients. On multivariate logistic regression analysis, patients in ⩾ age 30-year old had a significant higher risk for iron overload (OR: 77.75, 95% CI: 8.76–690.49) in the age group. The detailed analysis of proportions of different LIC indicate in > 30-year old group, 76.8% patients suffered from moderate and severe LIC. Conclusion: Our study provides a strong support for the novel findings that Chinese NTDT patients have a high prevalence of iron overload. The first assessment of MRI LIC should be performed as early as 5 years old. Then, NTDT patients > 30 years old may suffer with a high burden of iron overload.
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Affiliation(s)
- Yumei Huang
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Gaohui Yang
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Man Wang
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiaoyun Wei
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lingyuan Pan
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jiaodi Liu
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yu Lei
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Peng
- Department of Radiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Liling Long
- Department of Radiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yongrong Lai
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi, China
| | - Rongrong Liu
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi, China
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Musallam KM, Vitrano A, Meloni A, Pollina WA, Karimi M, El-Beshlawy A, Hajipour M, Di Marco V, Ansari SH, Filosa A, Ricchi P, Ceci A, Daar S, Vlachaki E, Singer ST, Naserullah ZA, Pepe A, Scondotto S, Dardanoni G, Bonifazi F, Sankaran VG, Vichinsky E, Taher AT, Maggio A. Survival and causes of death in 2,033 patients with non-transfusion-dependent β-thalassemia. Haematologica 2021; 106:2489-2492. [PMID: 33882642 PMCID: PMC8409024 DOI: 10.3324/haematol.2021.278684] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Indexed: 11/09/2022] Open
Affiliation(s)
| | - Angela Vitrano
- Campus of Haematology Franco and Piera Cutino, AOOR Villa Sofia-V. Cervello, Palermo
| | | | | | - Mehran Karimi
- Haematology Research Center, Shiraz University of Medical Sciences, Shiraz
| | - Amal El-Beshlawy
- Department of Pediatric Haematology, Faculty of Medicine, Cairo University, Cairo
| | - Mahmoud Hajipour
- Pediatric Gastroenterology, Hepatology and Nutrition Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran
| | - Vito Di Marco
- Sezione di Gastroenterologia e Epatologia, Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo
| | - Saqib Hussain Ansari
- Department of Pediatric Haematology and Molecular Medicine, National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi
| | - Aldo Filosa
- Rare Blood Cell Disease Unit, "Cardarelli" Hospital, Naples
| | - Paolo Ricchi
- Rare Blood Cell Disease Unit, "Cardarelli" Hospital, Naples
| | - Adriana Ceci
- Fondazione per la Ricerca Farmacologica Gianni Benzi Onlus, Valenzano (BA)
| | - Shahina Daar
- Department of Haematology, College of Medicine and Health Sciences, Sultan Qaboos University, Sultanate of Oman; Wallenberg Research Centre, Stellenbosch Institute for Advanced Study, Stellenbosch University, Stellenbosch
| | | | - Sylvia Titi Singer
- Division of Hematology-Oncology, Department of Pediatrics, University of California San Francisco, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | | | - Alessia Pepe
- MRI Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa
| | | | | | - Fedele Bonifazi
- Fondazione per la Ricerca Farmacologica Gianni Benzi Onlus, Valenzano (BA)
| | - Vijay G Sankaran
- Division of Hematology/Oncology, Boston Children's Hospital and Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Harvard Stem Cell Institute, Cambridge, MA
| | - Elliott Vichinsky
- Division of Hematology-Oncology, Department of Pediatrics, University of California San Francisco, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut
| | - Aurelio Maggio
- Campus of Haematology Franco and Piera Cutino, AOOR Villa Sofia-V. Cervello, Palermo.
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11
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Rujeerapaiboon N, Tantiworawit A, Piriyakhuntorn P, Rattanathammethee T, Hantrakool S, Chai-Adisaksopha C, Rattarittamrong E, Norasetthada L, Fanhchaksai K, Charoenkwan P. Correlation Between Serum Ferritin and Viral Hepatitis in Thalassemia Patients. Hemoglobin 2021; 45:175-179. [PMID: 34121572 DOI: 10.1080/03630269.2021.1926277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Serum ferritin is an acute phase protein; importantly, its level is noticeably increased in response to iron overload and systemic inflammation. The iron overload status in thalassemia patients has been recognized as a potential way to measure liver iron concentration (LIC) levels using magnetic resonance imaging (MRI). The aim of this study was to investigate the effect of chronic viral hepatitis on the level of serum ferritin in patients with thalassemia. A cross-sectional study was conducted involving chronic viral hepatitis infection. Mean serum ferritin and LIC levels were recorded. The LIC values were used to divide the patients into two groups; a higher LIC group (>5 mg Fe/g) and a lower LIC group (<5 mg Fe/g). Mean serum ferritin levels were then compared between the two LIC groups. We identified 32 thalassemia patients comprising of 13 chronic viral hepatitis patients, seven patients with hepatitis B virus (HBV), and six patients with hepatitis C virus (HCV). With regard to the group with higher LIC values, the mean serum ferritin levels in the hepatitis group were significantly higher than for those in the non hepatitis group (1776 ± 488 vs. 967 ± 860 ng/mL, p = 0.03). Furthermore, the linear correlation between the mean serum ferritin levels and the viral load in the non transfusion-dependent thalassemia (NTDT) group were found to be significantly correlated (r = 0.7, p = 0.04). Chronic viral hepatitis was determined to be a possible casualty of disproportionately high ferritin levels in the NTDT group.
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Affiliation(s)
- Natthapat Rujeerapaiboon
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Adisak Tantiworawit
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pokpong Piriyakhuntorn
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Thanawat Rattanathammethee
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sasinee Hantrakool
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chatree Chai-Adisaksopha
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Ekarat Rattarittamrong
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Lalita Norasetthada
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kanda Fanhchaksai
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pimlak Charoenkwan
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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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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Pinto VM, Forni GL. Management of Iron Overload in Beta-Thalassemia Patients: Clinical Practice Update Based on Case Series. Int J Mol Sci 2020; 21:E8771. [PMID: 33233561 PMCID: PMC7699680 DOI: 10.3390/ijms21228771] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/14/2020] [Accepted: 11/18/2020] [Indexed: 12/29/2022] Open
Abstract
Thalassemia syndromes are characterized by the inability to produce normal hemoglobin. Ineffective erythropoiesis and red cell transfusions are sources of excess iron that the human organism is unable to remove. Iron that is not saturated by transferrin is a toxic agent that, in transfusion-dependent patients, leads to death from iron-induced cardiomyopathy in the second decade of life. The availability of effective iron chelators, advances in the understanding of the mechanism of iron toxicity and overloading, and the availability of noninvasive methods to monitor iron loading and unloading in the liver, heart, and pancreas have all significantly increased the survival of patients with thalassemia. Prolonged exposure to iron toxicity is involved in the development of endocrinopathy, osteoporosis, cirrhosis, renal failure, and malignant transformation. Now that survival has been dramatically improved, the challenge of iron chelation therapy is to prevent complications. The time has come to consider that the primary goal of chelation therapy is to avoid 24-h exposure to toxic iron and maintain body iron levels within the normal range, avoiding possible chelation-related damage. It is very important to minimize irreversible organ damage to prevent malignant transformation before complications set in and make patients ineligible for current and future curative therapies. In this clinical case-based review, we highlight particular aspects of the management of iron overload in patients with beta-thalassemia syndromes, focusing on our own experience in treating such patients. We review the pathophysiology of iron overload and the different ways to assess, quantify, and monitor it. We also discuss chelation strategies that can be used with currently available chelators, balancing the need to keep non-transferrin-bound iron levels to a minimum (zero) 24 h a day, 7 days a week and the risk of over-chelation.
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Affiliation(s)
- Valeria Maria Pinto
- Centro della Microcitemia e delle Anemie Congenite Ente Ospedaliero Ospedali Galliera, Via Volta 6, 16128 Genoa, Italy;
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Chan LKL, Mak VWM, Chan SCH, Yu ELM, Chan NCN, Leung KFS, Ng CKM, Ng MHL, Chan JCW, Lee HKK. Liver complications of haemoglobin H disease in adults. Br J Haematol 2020; 192:171-178. [PMID: 33095929 DOI: 10.1111/bjh.17115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/27/2020] [Indexed: 12/15/2022]
Abstract
Haemoglobin H (HbH) disease is a type of non-transfusion-dependent thalassaemia. This cross-sectional study aimed at determining the prevalence and severity of liver iron overload and liver fibrosis in patients with HbH disease. Risk factors for advanced liver fibrosis were also identified. A total of 80 patients were evaluated [median (range) age 53 (24-79) years, male 34%, non-deletional HbH disease 24%]. Patients underwent 'observed' T2-weighted magnetic resonance imaging examination for liver iron concentration (LIC) quantification, and transient elastography for liver stiffness measurement (LSM) and fibrosis staging. In all, 25 patients (31%) had moderate-to-severe liver iron overload (LIC ≥7 mg/g dry weight). The median LIC was higher in non-deletional than in deletional HbH disease (7·8 vs. 2.9 mg/g dry weight, P = 0·002). In all, 16 patients (20%) had advanced liver fibrosis (LSM >7.9 kPa) and seven (9%) out of them had probable cirrhosis (LSM >11.9 kPa). LSM positively correlated with age (R = 0·24, P = 0·03), serum ferritin (R = 0·36, P = 0·001) and LIC (R = 0·28, P = 0·01). In multivariable regression, age ≥65 years [odds ratio (OR) 4·97, 95% confidence interval (CI) 1·52-17·50; P = 0·047] and moderate-to-severe liver iron overload (OR 3·47, 95% CI 1·01-12·14; P = 0·01) were independently associated with advanced liver fibrosis. The findings suggest that regular screening for liver complications should be considered in the management of HbH disease.
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Affiliation(s)
- Luke K L Chan
- Division of Haematology, Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, China
| | - Vivien W M Mak
- Division of Haematology, Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, China
| | - Stanley C H Chan
- Department of Radiology, Princess Margaret Hospital, Hong Kong, China
| | - Ellen L M Yu
- Clinical Research Centre, Princess Margaret Hospital, Hong Kong, China
| | - Nelson C N Chan
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Kate F S Leung
- Division of Haematology, Department of Pathology, Princess Margaret Hospital, Hong Kong, China
| | - Carmen K M Ng
- Division of Gastroenterology and Hepatology, Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, China
| | - Margaret H L Ng
- Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Joyce C W Chan
- Division of Haematology, Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, China
| | - Harold K K Lee
- Division of Haematology, Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, China
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15
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Transient Elastography to Represent Hepatic Copper Accumulation in Wilson Disease. Indian Pediatr 2020. [DOI: 10.1007/s13312-020-1932-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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16
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Arezes J, Foy N, McHugh K, Quinkert D, Benard S, Sawant A, Frost JN, Armitage AE, Pasricha SR, Lim PJ, Tam MS, Lavallie E, Pittman DD, Cunningham O, Lambert M, Murphy JE, Draper SJ, Jasuja R, Drakesmith H. Antibodies against the erythroferrone N-terminal domain prevent hepcidin suppression and ameliorate murine thalassemia. Blood 2020; 135:547-557. [PMID: 31899794 PMCID: PMC7046598 DOI: 10.1182/blood.2019003140] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/12/2019] [Indexed: 01/19/2023] Open
Abstract
Erythroferrone (ERFE) is produced by erythroblasts in response to erythropoietin (EPO) and acts in the liver to prevent hepcidin stimulation by BMP6. Hepcidin suppression allows for the mobilization of iron to the bone marrow for the production of red blood cells. Aberrantly high circulating ERFE in conditions of stress erythropoiesis, such as in patients with β-thalassemia, promotes the tissue iron accumulation that substantially contributes to morbidity in these patients. Here we developed antibodies against ERFE to prevent hepcidin suppression and to correct the iron loading phenotype in a mouse model of β-thalassemia [Hbb(th3/+) mice] and used these antibodies as tools to further characterize ERFE's mechanism of action. We show that ERFE binds to BMP6 with nanomolar affinity and binds BMP2 and BMP4 with somewhat weaker affinities. We found that BMP6 binds the N-terminal domain of ERFE, and a polypeptide derived from the N terminus of ERFE was sufficient to cause hepcidin suppression in Huh7 hepatoma cells and in wild-type mice. Anti-ERFE antibodies targeting the N-terminal domain prevented hepcidin suppression in ERFE-treated Huh7 cells and in EPO-treated mice. Finally, we observed a decrease in splenomegaly and serum and liver iron in anti-ERFE-treated Hbb(th3/+) mice, accompanied by an increase in red blood cells and hemoglobin and a decrease in reticulocyte counts. In summary, we show that ERFE binds BMP6 directly and with high affinity, and that antibodies targeting the N-terminal domain of ERFE that prevent ERFE-BMP6 interactions constitute a potential therapeutic tool for iron loading anemias.
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Affiliation(s)
- João Arezes
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Niall Foy
- BioMedicine Design, Pfizer Biotherapeutics R&D, Dublin, Ireland
| | - Kirsty McHugh
- Jenner Institute, University of Oxford, Oxford, United Kingdom
| | - Doris Quinkert
- Jenner Institute, University of Oxford, Oxford, United Kingdom
| | - Susan Benard
- BioMedicine Design, Pfizer Biotherapeutics R&D, Cambridge, MA
| | - Anagha Sawant
- Rare Disease Research Unit, Pfizer Inc., Cambridge, MA
| | - Joe N Frost
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Andrew E Armitage
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Sant-Rayn Pasricha
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
- Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
- Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia; and
| | - Pei Jin Lim
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - May S Tam
- Rare Disease Research Unit, Pfizer Inc., Cambridge, MA
| | | | | | - Orla Cunningham
- BioMedicine Design, Pfizer Biotherapeutics R&D, Dublin, Ireland
| | - Matthew Lambert
- BioMedicine Design, Pfizer Biotherapeutics R&D, Dublin, Ireland
| | - John E Murphy
- Rare Disease Research Unit, Pfizer Inc., Cambridge, MA
| | - Simon J Draper
- Jenner Institute, University of Oxford, Oxford, United Kingdom
| | - Reema Jasuja
- Rare Disease Research Unit, Pfizer Inc., Cambridge, MA
| | - Hal Drakesmith
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
- Haematology Theme NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
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17
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The effect of vitamin D pathway genes and deferasirox pharmacogenetics on liver iron in thalassaemia major patients. THE PHARMACOGENOMICS JOURNAL 2019; 19:417-427. [PMID: 30651574 DOI: 10.1038/s41397-019-0071-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 10/01/2018] [Accepted: 12/21/2018] [Indexed: 02/07/2023]
Abstract
Monitoring and treating iron overload is crucial in transfusion-dependent thalassaemia patients. Liver stiffness measurement by transient elastography and T2* magnetic resonance imaging represent non-invasive ways to evaluate the adequacy of the iron chelation treatment. We explored the role of single nucleotide polymorphisms involved in vitamin D metabolism, transport and activity, and in deferasirox metabolism on liver iron burden parameters. One-hundred and five beta-thalassaemia patients, treated with deferasirox, have been enrolled. Drug plasma Ctrough and AUC were measured by a HPLC-UV method. Allelic discrimination was performed by real-time PCR. Age, UGT1A1-364 CT/TT and CYP27B1 -1260 GT/TT positively predicted liver stiffness values. Deferasirox dose and serum ferritin negatively predicted T2* data, whereas age and CYP2D6 1457 GG genotype positively influenced these values. The discoveries of this research may be useful for personalized medicine and the proposed method could be applied in patients with hereditary hemochromatosis and myelodysplastic syndromes.
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18
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How I manage medical complications of β-thalassemia in adults. Blood 2018; 132:1781-1791. [PMID: 30206117 DOI: 10.1182/blood-2018-06-818187] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 09/09/2018] [Indexed: 02/06/2023] Open
Abstract
The complex pathophysiology in β-thalassemia can translate to multiple morbidities that affect every organ system. Improved survival due to advances in management means that patients are exposed to the harmful effects of ineffective erythropoiesis, anemia, and iron overload for a longer duration, and we started seeing new or more frequent complications in adult compared with younger patients. In this article, we highlight particular aspects of managing adult patients with β-thalassemia, using our own experience in treating such patients. We cover both transfusion-dependent and nontransfusion-dependent forms of the disease and tackle specific morbidities of highest interest.
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19
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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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Abstract
Inherited haemoglobin disorders, including thalassaemia and sickle-cell disease, are the most common monogenic diseases worldwide. Several clinical forms of α-thalassaemia and β-thalassaemia, including the co-inheritance of β-thalassaemia with haemoglobin E resulting in haemoglobin E/β-thalassaemia, have been described. The disease hallmarks include imbalance in the α/β-globin chain ratio, ineffective erythropoiesis, chronic haemolytic anaemia, compensatory haemopoietic expansion, hypercoagulability, and increased intestinal iron absorption. The complications of iron overload, arising from transfusions that represent the basis of disease management in most patients with severe thalassaemia, might further complicate the clinical phenotype. These pathophysiological mechanisms lead to an array of clinical manifestations involving numerous organ systems. Conventional management primarily relies on transfusion and iron-chelation therapy, as well as splenectomy in specific cases. An increased understanding of the molecular and pathogenic factors that govern the disease process have suggested routes for the development of new therapeutic approaches that address the underlying chain imbalance, ineffective erythropoiesis, and iron dysregulation, with several agents being evaluated in preclinical models and clinical trials.
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Affiliation(s)
- Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Centre, Beirut, Lebanon.
| | - David J Weatherall
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community, University of Milan, IRCCS Ca'Granda Foundation Maggiore Policlinico Hospital, Milan, Italy
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21
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Maira D, Cassinerio E, Marcon A, Mancarella M, Fraquelli M, Pedrotti P, Cappellini MD. Progression of liver fibrosis can be controlled by adequate chelation in transfusion-dependent thalassemia (TDT). Ann Hematol 2017; 96:1931-1936. [DOI: 10.1007/s00277-017-3120-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/21/2017] [Indexed: 01/19/2023]
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22
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Ferraioli G, Lissandrin R, Tinelli C, Scudeller L, Bonetti F, Zicchetti M, Longo F, Murgia M, Bernuzzi S, Zecca M, Casula P, Piga A, Filice C. Liver stiffness assessed by transient elastography in patients with β thalassaemia major. Ann Hepatol 2017; 15:410-7. [PMID: 27049495 DOI: 10.5604/16652681.1198817] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
RATIONALE FOR THE STUDY This cross-sectional multicenter study was conducted to investigate any difference in liver stiffness measurements (LSM), evaluated by transient elastography, between patients affected by β thalassaemia major, with and without hepatitis C virus (HCV) infection, and healthy blood donors (controls). Secondary aim was to assess any correlation between transient elastography and serum ferritin, liver magnetic resonance imaging (MRI) T2* or superconductive quantum interference device (SQUID) liver susceptometry values. MATERIALS AND METHODS The study involved three centers. Transient elastography and MRI T2* examinations were performed in all centers. SQUID liver susceptometry was performed in center1 and center2. T-test for independent data or Mann-Whitney U test was used to analyse differences between two groups. Univariate Pearson's r coefficient was used to test correlations between liver stiffness measurements and all other variables. RESULTS In a study with 119 patients and 183 controls, patients who had never been infected with HCV showed significantly higher LSMs than controls [5.7 (95% CI, 5.2-6.2) kPa vs. 4.3 (95% CI, 4.1-4.4) kPa, p < 0.0001]. A moderate correlation between LSMs and ferritin values, adjusted for gender and age, was found in patients (r = 0.49, p < 0.0001) but not in controls (r = -0.22, p = 0.6). No correlation between LSMs and MRI T2* or SQUID liver susceptometry values was observed. In conclusion, compared to controls β thalassaemia major patients had a significant increase in LSMs independently from HCV infection.
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Affiliation(s)
- Giovanna Ferraioli
- Ultrasound Unit, Infectious Diseases Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Italy
| | - Raffaella Lissandrin
- Ultrasound Unit, Infectious Diseases Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Italy
| | - Carmine Tinelli
- Clinical Epidemiology and Biometric Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Luigia Scudeller
- Clinical Epidemiology and Biometric Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Federico Bonetti
- Pediatric Haematology Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Mabel Zicchetti
- Ultrasound Unit, Infectious Diseases Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Italy
| | - Filomena Longo
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Mauro Murgia
- Immuno-ematologia e Medicina Trasfusionale, Ospedale San Martino, Oristano, Italy
| | - Stefano Bernuzzi
- Department of "Medicina Diagnostica e dei Servizi", Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marco Zecca
- Pediatric Haematology Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Paolo Casula
- Immuno-ematologia e Medicina Trasfusionale, Ospedale San Martino, Oristano, Italy
| | - Antonio Piga
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Carlo Filice
- Ultrasound Unit, Infectious Diseases Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Italy
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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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Ricchi P, Marsella M. Profile of deferasirox for the treatment of patients with non-transfusion-dependent thalassemia syndromes. Drug Des Devel Ther 2016; 9:6475-82. [PMID: 26719673 PMCID: PMC4687615 DOI: 10.2147/dddt.s40694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
It has been clearly shown that iron overload adds progressively significant morbidity and mortality in patients with non-transfusion-dependent thalassemia (NTDT). The lack of physiological mechanisms to eliminate the excess of iron requires effective iron chelation therapy. The reduced compliance to deferoxamine and the risk of severe hematological adverse events during deferiprone treatment have limited the use of both these drugs to correct iron imbalance in NTDT. According to the principles of evidence-based medicine, following the demonstration of the effectiveness and the safety of deferasirox (Exjade®) in a prospective, randomized, controlled trial, deferasirox was approved by the US Food and Drug Administration in May 2013 for the treatment of iron overload associated with NTDT. This review, assessing the available scientific literature, will focus on the profile of DFX in the treatment of non-transfusional hemosiderosis in patients with NTDT.
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Affiliation(s)
- Paolo Ricchi
- UOSD Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale "Antonio Cardarelli", Naples, Italy
| | - Maria Marsella
- UOSD Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale "Antonio Cardarelli", Naples, Italy ; UOC Pediatria, Azienda Ospedaliera di Rilievo Nazionale G. Rummo, Benevento, Italy
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Saliba AN, El Rassi F, Taher AT. Clinical monitoring and management of complications related to chelation therapy in patients with β-thalassemia. Expert Rev Hematol 2015; 9:151-68. [DOI: 10.1586/17474086.2016.1126176] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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26
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D’Ambrosio R, Poggiali E, Cappellini MD. Treating hepatitis C in patients with hemoglobinopathies. Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1086333] [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: 01/19/2023]
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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. Defining serum ferritin thresholds to predict clinically relevant liver iron concentrations for guiding deferasirox therapy when MRI is unavailable in patients with non-transfusion-dependent thalassaemia. Br J Haematol 2014; 168:284-90. [PMID: 25212456 DOI: 10.1111/bjh.13119] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 07/26/2014] [Indexed: 12/19/2022]
Abstract
Liver iron concentration (LIC) assessment by magnetic resonance imaging (MRI) remains the gold standard to diagnose iron overload and guide iron chelation therapy in patients with non-transfusion-dependent thalassaemia (NTDT). However, limited access to MRI technology and expertise worldwide makes it practical to also use serum ferritin assessments. The THALASSA (assessment of Exjade(®) in non-transfusion-dependent THALASSemiA patients) study assessed the efficacy and safety of deferasirox in iron-overloaded NTDT patients and provided a large data set to allow exploration of the relationship between LIC and serum ferritin. Using data from screened patients and those treated with deferasirox for up to 2 years, we identified clinically relevant serum ferritin thresholds (for when MRI is unavailable) for the initiation of chelation therapy (>800 μg/l), as well as thresholds to guide chelator dose interruption (<300 μg/l) and dose escalation (>2000 μg/l). (clinicaltrials.gov identifier: NCT00873041).
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Affiliation(s)
- Ali T Taher
- American University of Beirut, Beirut, Lebanon
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Novel approach to reactive oxygen species in nontransfusion-dependent thalassemia. BIOMED RESEARCH INTERNATIONAL 2014; 2014:350432. [PMID: 25121095 PMCID: PMC4119900 DOI: 10.1155/2014/350432] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 06/07/2014] [Indexed: 12/13/2022]
Abstract
The term Nontransfusion dependent thalassaemia (NTDT) was suggested to describe patients who had clinical manifestations that are too severe to be termed minor yet too mild to be termed major. Those patients are not entirely dependent on transfusions for survival.
If left untreated, three main factors are responsible for the clinical sequelae of NTDT: ineffective erythropoiesis, chronic hemolytic anemia, and iron overload. Reactive oxygen species (ROS) generation in NTDT patients is caused by 2 major mechanisms. The first one is chronic hypoxia resulting from chronic anemia and ineffective erythropoiesis leading to mitochondrial damage and the second is iron overload also due to chronic anemia and tissue hypoxia leading to increase intestinal iron absorption in thalassemic patients. Oxidative damage by reactive oxygen species (generated by free globin chains and labile plasma iron) is believed to be one of the main contributors to cell injury, tissue damage, and hypercoagulability in patients with thalassemia. Independently increased ROS has been linked to a myriad of pathological outcomes such as leg ulcers, decreased wound healing, pulmonary hypertension, silent brain infarcts, and increased thrombosis to count a few. Interestingly many of those complications overlap with those found in NTDT patients.
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Deferasirox: A Review of Its Use for Chronic Iron Overload in Patients with Non-Transfusion-Dependent Thalassaemia. Drugs 2014; 74:1017-27. [DOI: 10.1007/s40265-014-0238-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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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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Derchi G, Galanello R, Bina P, Cappellini MD, Piga A, Lai ME, Quarta A, Casu G, Perrotta S, Pinto V, Musallam KM, Forni GL. Prevalence and Risk Factors for Pulmonary Arterial Hypertension in a Large Group of β-Thalassemia Patients Using Right Heart Catheterization. Circulation 2014; 129:338-45. [DOI: 10.1161/circulationaha.113.002124] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Giorgio Derchi
- From the Galliera Hospital, Genoa, Italy (G.D., V.P., G.L.F.); University of Cagliari, Cagliari, Italy (R.G., P.B., M.-E.L.); IRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy (M.D.C., K.M.M.); University of Turin, Turin, Italy (A.P.); Perrino Hospital, Brindisi, Italy (A.Q.); S. Francesco Hospital, Nuoro, Italy (G.C.); and Seconda University, Naples, Italy (S.P.)
| | - Renzo Galanello
- From the Galliera Hospital, Genoa, Italy (G.D., V.P., G.L.F.); University of Cagliari, Cagliari, Italy (R.G., P.B., M.-E.L.); IRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy (M.D.C., K.M.M.); University of Turin, Turin, Italy (A.P.); Perrino Hospital, Brindisi, Italy (A.Q.); S. Francesco Hospital, Nuoro, Italy (G.C.); and Seconda University, Naples, Italy (S.P.)
| | - Patrizio Bina
- From the Galliera Hospital, Genoa, Italy (G.D., V.P., G.L.F.); University of Cagliari, Cagliari, Italy (R.G., P.B., M.-E.L.); IRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy (M.D.C., K.M.M.); University of Turin, Turin, Italy (A.P.); Perrino Hospital, Brindisi, Italy (A.Q.); S. Francesco Hospital, Nuoro, Italy (G.C.); and Seconda University, Naples, Italy (S.P.)
| | - Maria Domenica Cappellini
- From the Galliera Hospital, Genoa, Italy (G.D., V.P., G.L.F.); University of Cagliari, Cagliari, Italy (R.G., P.B., M.-E.L.); IRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy (M.D.C., K.M.M.); University of Turin, Turin, Italy (A.P.); Perrino Hospital, Brindisi, Italy (A.Q.); S. Francesco Hospital, Nuoro, Italy (G.C.); and Seconda University, Naples, Italy (S.P.)
| | - Antonio Piga
- From the Galliera Hospital, Genoa, Italy (G.D., V.P., G.L.F.); University of Cagliari, Cagliari, Italy (R.G., P.B., M.-E.L.); IRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy (M.D.C., K.M.M.); University of Turin, Turin, Italy (A.P.); Perrino Hospital, Brindisi, Italy (A.Q.); S. Francesco Hospital, Nuoro, Italy (G.C.); and Seconda University, Naples, Italy (S.P.)
| | - Maria-Eliana Lai
- From the Galliera Hospital, Genoa, Italy (G.D., V.P., G.L.F.); University of Cagliari, Cagliari, Italy (R.G., P.B., M.-E.L.); IRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy (M.D.C., K.M.M.); University of Turin, Turin, Italy (A.P.); Perrino Hospital, Brindisi, Italy (A.Q.); S. Francesco Hospital, Nuoro, Italy (G.C.); and Seconda University, Naples, Italy (S.P.)
| | - Antonella Quarta
- From the Galliera Hospital, Genoa, Italy (G.D., V.P., G.L.F.); University of Cagliari, Cagliari, Italy (R.G., P.B., M.-E.L.); IRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy (M.D.C., K.M.M.); University of Turin, Turin, Italy (A.P.); Perrino Hospital, Brindisi, Italy (A.Q.); S. Francesco Hospital, Nuoro, Italy (G.C.); and Seconda University, Naples, Italy (S.P.)
| | - Gavino Casu
- From the Galliera Hospital, Genoa, Italy (G.D., V.P., G.L.F.); University of Cagliari, Cagliari, Italy (R.G., P.B., M.-E.L.); IRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy (M.D.C., K.M.M.); University of Turin, Turin, Italy (A.P.); Perrino Hospital, Brindisi, Italy (A.Q.); S. Francesco Hospital, Nuoro, Italy (G.C.); and Seconda University, Naples, Italy (S.P.)
| | - Silverio Perrotta
- From the Galliera Hospital, Genoa, Italy (G.D., V.P., G.L.F.); University of Cagliari, Cagliari, Italy (R.G., P.B., M.-E.L.); IRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy (M.D.C., K.M.M.); University of Turin, Turin, Italy (A.P.); Perrino Hospital, Brindisi, Italy (A.Q.); S. Francesco Hospital, Nuoro, Italy (G.C.); and Seconda University, Naples, Italy (S.P.)
| | - Valeria Pinto
- From the Galliera Hospital, Genoa, Italy (G.D., V.P., G.L.F.); University of Cagliari, Cagliari, Italy (R.G., P.B., M.-E.L.); IRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy (M.D.C., K.M.M.); University of Turin, Turin, Italy (A.P.); Perrino Hospital, Brindisi, Italy (A.Q.); S. Francesco Hospital, Nuoro, Italy (G.C.); and Seconda University, Naples, Italy (S.P.)
| | - Khaled M. Musallam
- From the Galliera Hospital, Genoa, Italy (G.D., V.P., G.L.F.); University of Cagliari, Cagliari, Italy (R.G., P.B., M.-E.L.); IRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy (M.D.C., K.M.M.); University of Turin, Turin, Italy (A.P.); Perrino Hospital, Brindisi, Italy (A.Q.); S. Francesco Hospital, Nuoro, Italy (G.C.); and Seconda University, Naples, Italy (S.P.)
| | - Gian Luca Forni
- From the Galliera Hospital, Genoa, Italy (G.D., V.P., G.L.F.); University of Cagliari, Cagliari, Italy (R.G., P.B., M.-E.L.); IRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy (M.D.C., K.M.M.); University of Turin, Turin, Italy (A.P.); Perrino Hospital, Brindisi, Italy (A.Q.); S. Francesco Hospital, Nuoro, Italy (G.C.); and Seconda University, Naples, Italy (S.P.)
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Musallam KM, Rivella S, Vichinsky E, Rachmilewitz EA. Non-transfusion-dependent thalassemias. Haematologica 2013; 98:833-44. [PMID: 23729725 DOI: 10.3324/haematol.2012.066845] [Citation(s) in RCA: 205] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Non-transfusion-dependent thalassemias include a variety of phenotypes that, unlike patients with beta (β)-thalassemia major, do not require regular transfusion therapy for survival. The most commonly investigated forms are β-thalassemia intermedia, hemoglobin E/β-thalassemia, and α-thalassemia intermedia (hemoglobin H disease). However, transfusion-independence in such patients is not without side effects. Ineffective erythropoiesis and peripheral hemolysis, the hallmarks of disease process, lead to a variety of subsequent pathophysiologies including iron overload and hypercoagulability that ultimately lead to a number of serious clinical morbidities. Thus, prompt and accurate diagnosis of non-transfusion-dependent thalassemia is essential to ensure early intervention. Although several management options are currently available, the need to develop more novel therapeutics is justified by recent advances in our understanding of the mechanisms of disease. Such efforts require wide international collaboration, especially since non-transfusion-dependent thalassemias are no longer bound to low- and middle-income countries but have spread to large multiethnic cities in Europe and the Americas due to continued migration.
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Affiliation(s)
- Khaled M Musallam
- Department of Medicine and Medical Specialties, IRCCS Ca’ Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy.
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Matta BN, Musallam KM, Maakaron JE, Koussa S, Taher AT. A killer revealed: 10-year experience with beta-thalassemia intermedia. ACTA ACUST UNITED AC 2013; 19:196-8. [PMID: 24074485 DOI: 10.1179/1607845413y.0000000120] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Patients with beta-thalassemia intermedia tend to present later in life with milder anemia than beta-thalassemia major patients. The incidence of mortality and its causes in this patient population remains unknown. We aim to reveal the incidence and most common causes of death in this population. METHODS AND RESULTS We reviewed the charts of all of the beta-thalassemia intermedia patients who had been followed at the Chronic Care Center in Hazmieh, Lebanon during a 10-year period. A total of 18 patients out of 127 had died during the follow-up period giving a cumulative 10-year mortality incidence of 14%. The most common causes of cardiac deaths were due to renal and cardiac causes. DISCUSSION Most causes of death have been linked to the high levels of iron coupled with anemia present in this patient population. Many of deaths could be prevented by adequate treatment. CONCLUSION Larger studies with more comprehensive data capture on risk factors of mortality in this patient population are called for.
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Abstract
PURPOSE OF REVIEW The aim is to overview recent evidence on consequences, assessment, and management of iron overload in transfusion-independent patients with β-thalassemia intermedia. RECENT FINDINGS Despite their transfusion-independence, β-thalassemia intermedia patients can still accumulate iron due to increased intestinal absorption. Recent observational studies show that iron burden in this group of patients can ultimately reach considerably high thresholds, and leads to a variety of serious morbidities involving the liver, endocrine glands, and arguably the vascular system. The diagnosis of iron overload in this patient population can follow established guidelines from β-thalassemia major patients, although with careful interpretation of spot serum ferritin levels. Data from a recent randomized clinical trial demonstrated the efficacy and safety of iron chelation therapy in decreasing liver iron concentration in this group of patients, which may ultimately help in reducing morbidity risk. SUMMARY Iron overload in transfusion-independent patients with β-thalassemia intermedia deserves careful attention, and prompt diagnosis and management are recommended.
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Paparo F, Cevasco L, Zefiro D, Biscaldi E, Bacigalupo L, Balocco M, Pongiglione M, Banderali S, Forni GL, Rollandi GA. Diagnostic value of real-time elastography in the assessment of hepatic fibrosis in patients with liver iron overload. Eur J Radiol 2013; 82:e755-61. [PMID: 24050879 DOI: 10.1016/j.ejrad.2013.08.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 07/12/2013] [Accepted: 08/18/2013] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The objective of our prospective monocentric work was to determine the diagnostic value of real-time elastography (RTE) in the assessment of liver fibrosis in patients with iron overload, using transient elastography (TE) as reference standard. METHODS Sixty-seven consecutive patients with MRI detectable iron overload (T2*<6.3 ms) were enrolled. TE and RTE were performed on the same day as MRI. Elastograms were acquired by an experienced operator and analyzed by calculating the elastic ratio between perihepatic soft tissues and liver parenchyma. An elliptical ROI of 1cm(2) (Z1) was positioned in the liver parenchyma and a smaller elliptical ROI of 2mm(2) (Z2) was positioned in a homogeneously soft (red) region of the diaphragm, which was considered as internal control to calculate the elastic ratio Z2/Z1. RESULTS Seven patients were excluded because of invalid TE or RTE examinations. The remaining 60 patients were 57% males and 43% females (mean age: 42 [21-76] years), including 37 homozygous-β-thalassemics, 13 patients with β-thalassemia intermedia, 6 with primary hemochromatosis, and 4 with myelodysplastic syndrome. Increasing elastic ratios were significantly correlated with increasing TE values (r=0.645, 95% CI 0.468-0.772, P<0.0001). The mean elastic ratios for each METAVIR group were as follows: F0/1 = 1.9 ± 0.4; F2 = 2.2 ± 0.4; F3 = 2.9 ± 0.5; F4 = 3.2 ± 0.4. The diagnostic accuracy of RTE for F ≥ 2 evaluated by AUC-ROC analysis was 0.798 (95% CI 0.674-0.890). The diagnostic accuracy of RTE for F ≥ 3 was 0.909 (95% CI 0.806-0.968). At a cut-off ≥ 2.75, RTE showed a sensitivity of 70% (95% CI 45.7-88.1) and a specificity of 97.5% (95% CI 86.8-99.9). CONCLUSIONS In patients with MRI-detectable liver iron-overload RTE allows to discriminate between F0/1-F2 and F3-F4 with a reasonable diagnostic accuracy.
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Affiliation(s)
- Francesco Paparo
- Department of Radiology, E.O. Ospedali Galliera, Mura della Cappuccine 14, 16128 Genoa, Italy
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Evaluation of the 5mg/g liver iron concentration threshold and its association with morbidity in patients with β-thalassemia intermedia. Blood Cells Mol Dis 2013; 51:35-8. [DOI: 10.1016/j.bcmd.2013.01.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Revised: 01/22/2013] [Accepted: 01/22/2013] [Indexed: 01/27/2023]
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Taher AT, Viprakasit V, Musallam KM, Cappellini MD. Treating iron overload in patients with non-transfusion-dependent thalassemia. Am J Hematol 2013; 88:409-15. [PMID: 23475638 PMCID: PMC3652024 DOI: 10.1002/ajh.23405] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 01/21/2013] [Accepted: 01/23/2013] [Indexed: 01/19/2023]
Abstract
Despite receiving no or only occasional blood transfusions, patients with non-transfusion-dependent thalassemia (NTDT) have increased intestinal iron absorption and can accumulate iron to levels comparable with transfusion-dependent patients. This iron accumulation occurs more slowly in NTDT patients compared to transfusion-dependent thalassemia patients, and complications do not arise until later in life. It remains crucial for these patients' health to monitor and appropriately treat their iron burden. Based on recent data, including a randomized clinical trial on iron chelation in NTDT, a simple iron chelation treatment algorithm is presented to assist physicians with monitoring iron burden and initiating chelation therapy in this group of patients. Am. J. Hematol. 88:409–415, 2013. © 2013 Wiley Periodicals, Inc.
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Affiliation(s)
- Ali T. Taher
- Department of Internal MedicineAmerican University of Beirut Medical CenterBeirut Lebanon
| | - Vip Viprakasit
- Department of Pediatrics and Siriraj‐Thalassemia CenterFaculty of MedicineSiriraj HospitalMahidol UniversityBangkok Thailand
| | - Khaled M. Musallam
- Department of Internal MedicineAmerican University of Beirut Medical CenterBeirut Lebanon
- Department of Medicine and Medical SpecialitiesUniversitá di MilanoCa' Granda Foundation IRCCSMilan Italy
| | - M. Domenica Cappellini
- Department of Medicine and Medical SpecialitiesUniversitá di MilanoCa' Granda Foundation IRCCSMilan Italy
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