The relationship between cardiac and liver iron evaluated by MR imaging in haematological malignancies and chronic liver disease

Prevalence of left ventricular hypertrabeculation/noncompaction among patients with congenital dyserythropoietic anemia Type 1 (CDA1)

BACKGROUND

Congenital dyserythropoietic anemia type 1 (CDA1) is a rare autosomal recessive disease characterized by macrocytic anemia, ineffective erythropoiesis, and secondary hemochromatosis. Left-ventricular noncompaction (LVNC) is a cardiomyopathy that is commonly attributed to intrauterine arrest of normal compaction during the endomyocardial morphogenesis. LV hypertrabeculation/noncompaction (LVHT/NC) morphology, however, might exist in various hemoglobinopathies. Our primary objective was to determine whether the pattern of LVHT/NC is more prevalent among patients with CDA1, in comparison to subjects without CDA1, and to find potential risk factors for LVHT/NC among these patients. Our secondary objective was to evaluate the clinical implication of LVHT/NC.

METHODS

We retrospectively assessed 32 CDA1 patients (median age 17.5, range 6-61) that underwent routine assessment of iron overload by cardiac magnetic resonance. Number and distribution of noncompacted LV segments were assessed in CDA1 patients and compared to 64 age- and gender-matched patients without CDA1. The ratio of noncompacted to compacted myocardium (NC/C ratio) in end-diastole was calculated for each of the three long-axis views. NC/C ratio > 2.3 was considered diagnostic for LVHT/NC.

RESULTS

In multivariate analysis, the presence of CDA1 was independently associated with NC/C ratio > 2.3, a feature of LVHT/NC (adjusted OR = 11.46, 95%CI = 2.6-50.68, p = .001). CDA1 was strongly associated with increased number of myocardial segments exhibiting LVHT/NC pattern. Cardiac volumes and ejection fraction were preserved without clinical adverse events in long term follow-up.

CONCLUSIONS

CDA1 patients have a higher prevalence of LVHT/NC than normal individuals, independent of myocardial iron overload and without effect on ejection fraction or clinical outcome.

MRI for Quantification of Liver and Cardiac Iron in Thalassemia Major Patients: Pilot Study in Indian Population

OBJECTIVE

To evaluate Magnetic resonance imaging (MRI) as a tool to quantify liver and cardiac iron in Indian population with thalassemia major, and correlate liver and cardiac iron values with that of serum ferritin (SF).

METHODS

Fifty patients aged between 8 to 18 y, with thalassemia major on regular blood transfusions and oral iron chelation therapy were enroled in the study. Twenty patients within the same age group, having no history of blood transfusions and no liver or cardiac disease were taken as controls. T2* MRI of heart and liver and SF estimation was done for all the cases as well as controls. All MRI scans were done on a 1.5-T Siemens MRI scanner using body coil.

RESULTS

The mean SF among cases was 2150 ng/ml (SD 2179). Significant correlation was found in patients between liver iron concentration (LIC, mean 15) and SF levels (r = 0.522; p < 0.001), and also significant but weaker correlation was found in patients between myocardial iron concentration (MIC, mean 1.3) and SF levels (r = 0.483; p < 0.001). Seventeen (34%) patients had a SF of <1000 ng/ml. Of these, 11 and 3 patients respectively had LIC and MIC more than normal range.

CONCLUSIONS

T2* MRI is a valuable non-invasive tool for quantification of liver and cardiac iron deposition in patients with thalassemia major. It can demonstrate high LIC and MIC, even though the targeted SF levels are low in thalassemia, indicating the need for escalation of the chelation therapy. This needs to be confirmed on full-fledged larger prospective studies.

Morbidity and mortality of adult patients with congenital dyserythropoietic anemia type I

Congenital dyserythropoietic anemia type I (CDAI) is a rare autosomal recessive disease characterized by macrocytic anemia, ineffective erythropoiesis, and secondary hemochromatosis. To better define the natural history of the disease among adult patients, we studied 32 Bedouin patients (median age 34 yr; range 21-60) all carrying the same CDAN1 founder mutation. Follow-up studies included complete blood count, blood chemistry, abdominal ultrasound, echocardiography, and T2*MRI. Main complications were due to anemia and ineffective erythropoiesis [osteoporosis (8/9, 89%), cholelithiasis (21/30, 70%), pulmonary arterial hypertension (PAH) (6/25, 24%)] and iron overload [hypothyroidism (9/24, 38%), and diabetes mellitus (6/32, 19%)]. T2* MRI revealed increased liver iron but no cardiac iron (13/13). Anemia improved in the majority of patients who underwent splenectomy (5/6). Three patients died (9%) at the age of 46-56 due to PAH (1) and sepsis (2). All previously underwent splenectomy. Analyzing both our patients and the 21 patients previously described by Heimpel et al. (Blood 107:334, 2006), we conclude that adults with CDA I suffer significant morbidity and mortality. Careful monitoring of iron overload and prompt iron chelation therapy is mandatory. Due to possible complications and inconsistent response to splenectomy α-interferon, transfusion therapy or stem cell transplantation should be considered as alternatives to this procedure in severely affected patients.

Safety and efficacy of deferasirox in the management of transfusion-dependent patients with myelodysplastic syndrome and aplastic anaemia: a perspective review

Deferasirox is an orally administered, once-daily iron chelator with a generally good safety and efficacy profile. Reported adverse events in the older myelodysplastic population are somewhat different to the more intensively investigated and younger thalassaemic population. Renal impairment is the most concerning adverse event, but this is reversible if identified and the drug is withdrawn early. Gastrointestinal effects, particularly diarrhoea, can be troublesome for older patients, but can be minimized with tailored therapy. Negative iron balance can be achieved in most patients with a median dose of 20 mg/kg/day, and doses up to 40 mg/kg are possible in patients with severe iron overload, who are at risk of cardiac decompensation.