1
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Raief Mosaad BM, Ibrahim AS, Mansour MG, ElAlfy MS, Ebeid FSE, Abdeldayem EH. The role of MRI-R2* in the detection of subclinical pancreatic iron loading among transfusion-dependent sickle cell disease patients and correlation with hepatic and cardiac iron loading. Insights Imaging 2022; 13:140. [PMID: 36057708 PMCID: PMC9440968 DOI: 10.1186/s13244-022-01280-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/01/2022] [Indexed: 11/11/2022] Open
Abstract
Objectives Pancreatic reserve could be preserved by early assessment of pancreatic iron overload among transfusion-dependent sickle cell disease (SCD) patients. This study aimed to measure pancreatic iron load and correlate its value with patients’ laboratory and radiological markers of iron overload. Materials and methods Sixty-six SCD children and young adults underwent MRI T2* relaxometry using a simple mathematical spreadsheet and laboratory assessment. Results The results indicated moderate-to-severe hepatic iron overload among 65.2% of studied cases. None had cardiac iron overload. Normal-to-mild iron overload was present in the pancreas in 86% of cases, and 50% had elevated serum ferritin > 2500 ug/L. There was no significant correlation between pancreatic R2* level, serum ferritin, and hepatic iron overload. Patients with higher levels of hemolysis markers and lower pre-transfusion hemoglobin levels showed moderate-to-severe pancreatic iron overload. Conclusion Chronically transfused patients with SCD have a high frequency of iron overload complications including pancreatic iron deposition, thereby necessitating proper monitoring of the body’s overall iron balance as well as detection of extrahepatic iron depositions.
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Affiliation(s)
| | - Ahmed Samir Ibrahim
- Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohamed G Mansour
- Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohsen Saleh ElAlfy
- Pediatrics Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Emad H Abdeldayem
- Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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2
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Hsu CC, Senussi NH, Fertrin KY, Kowdley KV. Iron overload disorders. Hepatol Commun 2022; 6:1842-1854. [PMID: 35699322 PMCID: PMC9315134 DOI: 10.1002/hep4.2012] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 04/06/2022] [Accepted: 04/16/2022] [Indexed: 01/19/2023] Open
Abstract
Iron overload disorders represent a variety of conditions that lead to increased total body iron stores and resultant end-organ damage. An elevated ferritin and transferrin-iron saturation can be commonly encountered in the evaluation of elevated liver enzymes. Confirmatory homeostatic iron regulator (HFE) genetic testing for C282Y and H63D, mutations most encountered in hereditary hemochromatosis, should be pursued in evaluation of hyperferritinemia. Magnetic resonance imaging with quantitative assessment of iron content or liver biopsy (especially if liver disease is a cause of iron overload) should be used as appropriate. A secondary cause for iron overload should be considered if HFE genetic testing is negative for the C282Y homozygous or C282Y/H63D compound heterozygous mutations. Differential diagnosis of secondary iron overload includes hematologic disorders, iatrogenic causes, or chronic liver diseases. More common hematologic disorders include thalassemia syndromes, myelodysplastic syndrome, myelofibrosis, sideroblastic anemias, sickle cell disease, or pyruvate kinase deficiency. If iron overload has been excluded, evaluation for causes of hyperferritinemia should be pursued. Causes of hyperferritinemia include chronic liver disease, malignancy, infections, kidney failure, and rheumatic conditions, such as adult-onset Still's disease or hemophagocytic lymphohistiocytosis. In this review, we describe the diagnostic testing of patients with suspected hereditary hemochromatosis, the evaluation of patients with elevated serum ferritin levels, and signs of secondary overload and treatment options for those with secondary iron overload.
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Affiliation(s)
- Christine C. Hsu
- Medstar Georgetown University HospitalMedstar Georgetown Transplant InstituteWashingtonDistrict of ColumbiaUSA
| | - Nizar H. Senussi
- Gastroenterology and HepatologyUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Kleber Y. Fertrin
- Division of HematologyDepartment of MedicineUniversity of WashingtonWashingtonUSA
| | - Kris V. Kowdley
- Liver Institute Northwest and Elson S. Floyd College of MedicineWashington State UniversityWashingtonUSA
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3
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Tavares AHJ, Benites BD, Fertrin KY. Myocardial Iron Overload in Sickle Cell Disease: A Rare But Potentially Fatal Complication of Transfusion. Transfus Med Rev 2019; 33:170-175. [PMID: 31153715 DOI: 10.1016/j.tmrv.2019.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/09/2019] [Accepted: 04/18/2019] [Indexed: 02/02/2023]
Abstract
Sickle cell disease (SCD) is a frequent indication for chronic transfusion, which can cause iron overload. Excess iron often affects the liver, but not the heart in SCD. Magnetic resonance (MR) is recommended to detect myocardial iron overload (MIO) but its elevated cost requires optimized indication. We aimed to compile all published data on MIO in SCD upon the description of a fatal case of severe MIO in our institution, and to determine associated risk factors. We performed a systematic review using the PRISMA guidelines in two databases (PubMed and Web of Science). Inclusion criteria were publication in English, patients diagnosed with SCD, and reporting ferritin and MIO by MR. Twenty publications reported on 865 SCD adult and pediatric patients, with at least 10 other cases of MIO. The prevalence of MIO in chronically transfused SCD patients can be estimated to be 3% or less, and is associated with high transfusion burden, top-up transfusions, and low adherence to iron chelation. Cardiac siderosis in SCD is rarely reported, and increased awareness with better use of the available screening tools are necessary. Prospective studies should define the recommended chelation regimens depending on the severity of MIO.
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Affiliation(s)
| | | | - Kleber Yotsumoto Fertrin
- Hematology and Hemotherapy Center, University of Campinas - UNICAMP, Campinas, Brazil; Division of Hematology, University of Washington, Seattle, WA.
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4
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Antmen B, Karakaş Z, Yeşilipek MA, Küpesiz OA, Şaşmaz İ, Uygun V, Kurtoğlu E, Oktay G, Aydogan G, Akın M, Salcioglu Z, Vergin C, Kazancı EG, Ünal S, Çalışkan Ü, Aral YZ, Türkkan E, Meral Güneş A, Tunç B, Gümrük F, Ayhan AC, Söker M, Koç A, Oymak Y, Ertem M, Timur Ç, Yıldırmak Y, İrken G, Apak H, Biner B, Eren TG, Işık Balcı Y, Koçak Ü, Karasu G, Akkaynak D, Patıroğlu T. Deferasirox in children with transfusion‐dependent thalassemia or sickle cell anemia: A large cohort real‐life experience from Turkey (REACH‐THEM). Eur J Haematol 2018; 102:123-130. [DOI: 10.1111/ejh.13180] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 01/01/2023]
Affiliation(s)
| | | | | | | | - İlgen Şaşmaz
- Çukurova University Medical Faculty Adana Turkey
| | - Vedat Uygun
- Antalya Training and Research Hospital Antalya Turkey
| | | | | | - Gonul Aydogan
- Kanuni Sultan Suleyman Training and Research Hospital Istanbul Turkey
| | | | - Zafer Salcioglu
- Kanuni Sultan Suleyman Training and Research Hospital Istanbul Turkey
| | - Canan Vergin
- Dr. Behcet Uz Child Disease and Surgery Training and Research Hospital Izmir Turkey
| | | | - Selma Ünal
- Mersin University Medical Faculty Mersin Turkey
| | - Ümran Çalışkan
- Necmettin Erbakan University Meram Medical Faculty Konya Turkey
| | | | - Emine Türkkan
- Okmeydanı Training and Research Hospital Istanbul Turkey
| | | | - Bahattin Tunç
- Ankara Child Health and Disease, Hematology Oncology Training and Research Hospital Ankara Turkey
| | - Fatma Gümrük
- Hacettepe University Medical Faculty Ankara Turkey
| | | | - Murat Söker
- Dicle University Medical Faculty Diyarbakır Turkey
| | - Ahmet Koç
- Harran University Medical Faculty Şanlıurfa Turkey
| | - Yeşim Oymak
- Harran University Medical Faculty Şanlıurfa Turkey
| | - Mehmet Ertem
- Faculty of Medicine Ankara University Ankara Turkey
| | - Çetin Timur
- Goztepe Training and Research Hospital Istanbul Turkey
| | | | | | - Hilmi Apak
- Istanbul University Cerrahpasa Medical Faculty Istanbul Turkey
| | - Betül Biner
- Trakya University Medical Faculty Edirne Turkey
| | | | | | - Ülker Koçak
- Gazi University Medical Faculty Ankara Turkey
| | - Gülsün Karasu
- Istanbul Zeynep Kamil Women and Children's Diseases raining and Research Hospital Istanbul Turkey
| | - Diyar Akkaynak
- Novartis Saglık, Gıda ve Tarım Ürünleri San. ve Tic. A.S Istanbul Turkey
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5
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Yassin MA, Soliman AT, De Sanctis V, Abdula MAJ, Riaz LM, Ghori FF, Yousaf A, Nashwan AJ, Abusamaan S, Moustafa A, Kohla S, Soliman DS. Statural Growth and Prevalence of Endocrinopathies in Relation to Liver Iron Content (LIC) in Adult Patients with Beta Thalassemia Major (BTM) and Sickle Cell Disease (SCD). ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:33-40. [PMID: 29451227 PMCID: PMC6179035 DOI: 10.23750/abm.v89i2-s.7085] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 02/07/2018] [Indexed: 01/17/2023]
Abstract
Despite regular blood transfusion and iron chelation therapy, growth impairment and pubertal delay are commonly seen in children and adolescents with transfusion-dependent Beta thalassaemia major (BTM) and sickle cell disease (SCD). We evaluated growth parameters and endocrine disorders in relation to the liver iron concentration (LIC) assessed by the Ferriscan® method in a cohort of adults with SCD (n =40) and BTM (n = 52) receiving blood transfusions and iron chelation therapy since early childhood. Before transfusion, hemoglobin concentration had not been less than 9 g/dl in the past 12 years; subcutaneous daily desferrioxamine was administered for all of them since early childhood (2- 5 years of age). All patients were shifted to oral therapy with deferasirox iron chelation, 20 mg/daily for the past 5 years. BTM patients with higher LIC (> 15 mg Fe/g dry weight) had significantly shorter stature, lower insulin-like growth factor-I SDS (IGF-I SDS), higher alanine transferase (ALT) and serum ferritin concentrations compared to thalassemic patients with lower LIC. Patients with SCD with LIC > 8 mg Fe/g dry weight had significantly shorter stature, lower IGF-I SDS and higher ALT compared to SCD patients with lower LIC. Patients with BTM had significantly shorted final height (Ht-SDS) , IGF-I SDS and FT4 level compared to patients with SCD. LIC and mean fasting blood glucose (FBG) were significantly higher in patients with BTM compared to those with SCD. The linear regression analysis showed a significant correlation between LIC and serum ferritin level in SCD and BTM. LIC and serum ferritin level were also correlated significantly with IGF-I level in patients with BTM. LIC was correlated significantly with ALT in patients with BTM. In conclusion, the prevalence of endocrinopathies especially hypothyroidism, DM, and hypogonadism were significantly higher in BTM patients versus SCD patients and higher in patients with higher LIC versus those with lower LIC. These complications occurred less frequently, but still considerable, in chronically transfused patients with SCD.
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Affiliation(s)
- Mohamed A Yassin
- Department of Medical Oncolology Hematology Section, NCCCR, Hamad Medical Corporaton, Doha.
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6
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Niss O, Taylor MD. Applications of cardiac magnetic resonance imaging in sickle cell disease. Blood Cells Mol Dis 2017; 67:126-134. [PMID: 28818577 DOI: 10.1016/j.bcmd.2017.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 08/07/2017] [Indexed: 02/06/2023]
Abstract
Cardiac magnetic resonance imaging (CMR) has evolved from an effective research tool to a non-invasive clinical modality with versatile applications. The accuracy of volume measurements and functional assessment and the ability to identify unique myocardial tissue characteristics non-invasively are the primary advantages of CMR. The use of CMR in sickle cell disease (SCD) has been limited clinically to myocardial iron assessment. The use of other CMR applications to characterize the cardiac pathology in SCD is slowly emerging but remains limited to research level. In this review, we discuss some of the applications of CMR in studying cardiovascular diseases and its potential uses in SCD for research and clinical purposes.
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Affiliation(s)
- Omar Niss
- Divisions of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Michael D Taylor
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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7
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Abstract
Blood transfusion plays a prominent role in the management of patients with sickle cell disease (SCD), but causes significant iron overload. As transfusions are used to treat the severe complications of SCD, it remains difficult to distinguish whether organ damage is a consequence of iron overload or is due to the complications treated by transfusion. Better management has resulted in increased survival, but prolonged exposure to iron puts SCD patients at greater risk for iron-related complications that should be treated. The success of chelation therapy is dominated by patient adherence to prescribed treatment; thus, adjustment of drug regimens to increase adherence to treatment is critical. This review will discuss the current biology of iron homeostasis in patients with SCD and how this informs our clinical approach to treatment. We will present the clinical approach to treatment of iron overload at our centre using serial assessment of organ iron by magnetic resonance imaging.
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Affiliation(s)
- Thomas D. Coates
- Hematology Section, Children’s Centre for Cancer, Blood Diseases and Bone Marrow Transplantation, University of Southern California, Los Angeles California, USA
| | - John C. Wood
- Division of Cardiology, at the Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles California, USA
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8
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Electrocardiographic Study in Adult Homozygous Sickle Cell Disease Patients in Lagos, Nigeria. J Trop Med 2016; 2016:4214387. [PMID: 27738439 PMCID: PMC5050369 DOI: 10.1155/2016/4214387] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 07/26/2016] [Accepted: 08/15/2016] [Indexed: 11/17/2022] Open
Abstract
Background. This study sought to identify the pattern of electrocardiographic changes in steady state adult sickle cell anaemia. Methods. A case-control, cross-sectional study was conducted amongst sickle cell patients attending the sickle cell clinic of Lagos State University Teaching Hospital, Ikeja, and HbAA controls. All consenting participants had haemoglobin electrophoresis done and were subjected to electrocardiography (ECG). The descriptive data were given as means ± standard deviation (SD). The differences were considered to be statistically significant when the p value obtained was <0.05. Results. A total of ninety-three sickle cell anaemia (SCA) patients and ninety haemoglobin AA (controls) were enrolled. There was no significant difference in the age of the participants with SCA and that of the controls but the body mass index was significantly higher in controls (p = 0.0001). Overall, 73.1% (68 of 93) had abnormal ECG while only 2 of 90 (2.2%) of controls had abnormal ECG. The common abnormalities observed were left ventricular hypertrophy, biventricular hypertrophy, and right ventricular hypertrophy. Conclusion. Patients with SCA in steady state tend to have normal heart rate but about 50% of them would have had ECG changes before the age of 20 years. ECG being a noninvasive test may be used to identify patients at risk for early intervention.
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9
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Badawy SM, Liem RI, Rigsby CK, Labotka RJ, DeFreitas RA, Thompson AA. Assessing cardiac and liver iron overload in chronically transfused patients with sickle cell disease. Br J Haematol 2016; 175:705-713. [DOI: 10.1111/bjh.14277] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 06/09/2016] [Indexed: 01/19/2023]
Affiliation(s)
- Sherif M. Badawy
- Department of Pediatrics; Feinberg School of Medicine at Northwestern University; Chicago IL USA
- Division of Hematology, Oncology and Stem Cell Transplant; Ann & Robert H. Lurie Children's Hospital of Chicago; Chicago IL USA
| | - Robert I. Liem
- Department of Pediatrics; Feinberg School of Medicine at Northwestern University; Chicago IL USA
- Division of Hematology, Oncology and Stem Cell Transplant; Ann & Robert H. Lurie Children's Hospital of Chicago; Chicago IL USA
| | - Cynthia K. Rigsby
- Division of Medical Imaging; Ann & Robert H. Lurie Children's Hospital of Chicago; Chicago IL USA
- Department of Radiology; Feinberg School of Medicine at Northwestern University; Chicago IL USA
| | - Richard J. Labotka
- Department of Pediatrics; Division of Hematology and Oncology; University of Illinois School of Medicine at Chicago; Chicago IL USA
| | - R. Andrew DeFreitas
- Department of Pediatrics; Feinberg School of Medicine at Northwestern University; Chicago IL USA
- Division of Pediatric Cardiology; Ann & Robert H. Lurie Children's Hospital of Chicago; Chicago IL USA
| | - Alexis A. Thompson
- Department of Pediatrics; Feinberg School of Medicine at Northwestern University; Chicago IL USA
- Division of Hematology, Oncology and Stem Cell Transplant; Ann & Robert H. Lurie Children's Hospital of Chicago; Chicago IL USA
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10
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Quinn CT, St Pierre TG. MRI Measurements of Iron Load in Transfusion-Dependent Patients: Implementation, Challenges, and Pitfalls. Pediatr Blood Cancer 2016; 63:773-80. [PMID: 26713769 PMCID: PMC5064750 DOI: 10.1002/pbc.25882] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 11/30/2015] [Accepted: 12/01/2015] [Indexed: 01/19/2023]
Abstract
Magnetic resonance imaging (MRI) has played a key role in studies of iron overload in transfusion-dependent patients, providing insights into the relations among liver and cardiac iron loading, iron chelator dose, and morbidity. Currently, there is rapid uptake of these methods into routine clinical practice as part of the management strategy for iron overload in regularly transfused patients. Given the manifold methods of data acquisition and analysis, there are several potential pitfalls that may result in inappropriate decision making. Herein, we review the challenges of establishing suitable MRI techniques for tissue iron measurement in regularly transfused patients.
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Affiliation(s)
- Charles T. Quinn
- Division of HematologyCincinnati Children's Hospital Medical CenterCincinnatiOhio
| | - Tim G. St Pierre
- School of PhysicsThe University of Western AustraliaCrawleyAustralia
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11
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Marsella M, Borgna-Pignatti C. Transfusional iron overload and iron chelation therapy in thalassemia major and sickle cell disease. Hematol Oncol Clin North Am 2015; 28:703-27, vi. [PMID: 25064709 DOI: 10.1016/j.hoc.2014.04.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Iron overload is an inevitable consequence of blood transfusions and is often accompanied by increased iron absorption from the gut. Chelation therapy is necessary to prevent the consequences of hemosiderosis. Three chelators, deferoxamine, deferiprone, and deferasirox, are presently available and a fourth is undergoing clinical trials. The efficacy of all 3 available chelators has been demonstrated. Also, many studies have shown the efficacy of the combination of deferoxamine plus deferiprone as an intensive treatment of severe iron overload. Alternating chelators can reduce adverse effects and improve compliance. Adherence to therapy is crucial for good results.
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Affiliation(s)
- Maria Marsella
- Department of Medical Sciences, University of Ferrara, Azienda Ospedale-Università Via Aldo Moro 8, Cona, Ferrara, Italy
| | - Caterina Borgna-Pignatti
- Department of Medical Sciences, University of Ferrara, Azienda Ospedale-Università Via Aldo Moro 8, Cona, Ferrara, Italy.
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12
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Meloni A, Puliyel M, Pepe A, Berdoukas V, Coates TD, Wood JC. Cardiac iron overload in sickle-cell disease. Am J Hematol 2014; 89:678-83. [PMID: 24664847 DOI: 10.1002/ajh.23721] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 03/19/2014] [Accepted: 03/21/2014] [Indexed: 12/15/2022]
Abstract
Chronically transfused sickle cell disease (SCD) patients have lower risk of myocardial iron overload (MIO) than comparably transfused thalassemia major (TM) patients. However, cardioprotection is incomplete. We present the clinical characteristics of six patients who have prospectively developed MIO, to identify potential risk factors for cardiac iron accumulation. From 2002 to 2011, cardiac, hepatic, and pancreatic iron overload were assessed by R2 and R2 * magnetic resonance imaging techniques in 201 chronic transfused SCD patients as part of their clinical care. At the time, they developed MIO, five of six patients had been on chronic transfusion for more than 11 years; only one was on exchange transfusion. The time to MIO was correlated with reticulocyte and hemoglobin S percentages. All patients had qualitatively poor chelation compliance (<50%). All patients had serum ferritin levels >4600 ng/ml and liver iron concentration >22 mg/g. Pancreatic R2 * was >100 Hz in every patient studied (5/6). Cardiac iron rose proportionally to pancreas R2 *, with all patients having pancreas R2 *>100 Hz when cardiac iron was present. MIO had a threshold relationship with liver iron that was higher than observed in TM patients. In conclusion, MIO occurs in a small percentage of chronically transfused SCD patients and is only associated with exceptionally poor control of total body iron stores. Duration of chronic transfusion is clearly important but other factors, such as levels of effective erythropoiesis, appear to contribute to cardiac risk. Pancreas R2 * can serve as a valuable screening tool for cardiac iron in SCD patients.
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Affiliation(s)
- Antonella Meloni
- CMR Unit; Fondazione G. Monasterio CNR-Regione Toscana; Pisa Italy
- Division of Cardiology; Children's Hospital Los Angeles; Los Angeles California
| | - Mammen Puliyel
- Division of Hematology-Oncology; Children's Hospital Los Angeles; Los Angeles California
| | - Alessia Pepe
- CMR Unit; Fondazione G. Monasterio CNR-Regione Toscana; Pisa Italy
| | - Vasili Berdoukas
- Division of Hematology-Oncology; Children's Hospital Los Angeles; Los Angeles California
| | - Thomas D. Coates
- Division of Hematology-Oncology; Children's Hospital Los Angeles; Los Angeles California
| | - John C. Wood
- Division of Cardiology; Children's Hospital Los Angeles; Los Angeles California
- Department of Radiology; Children's Hospital Los Angeles; Los Angeles California
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13
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Kassim AA, DeBaun MR. The case for and against initiating either hydroxyurea therapy, blood transfusion therapy or hematopoietic stem cell transplant in asymptomatic children with sickle cell disease. Expert Opin Pharmacother 2014; 15:325-36. [DOI: 10.1517/14656566.2014.868435] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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14
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Junqueira FP, Fernandes JL, Cunha GM, T A Kubo T, M A O Lima C, B P Lima D, Uellendhal M, Sales SR, A S Cunha C, L R de Pessoa V, L C Lobo C, Marchiori E. Right and left ventricular function and myocardial scarring in adult patients with sickle cell disease: a comprehensive magnetic resonance assessment of hepatic and myocardial iron overload. J Cardiovasc Magn Reson 2013; 15:83. [PMID: 24050721 PMCID: PMC3848779 DOI: 10.1186/1532-429x-15-83] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 09/11/2013] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Patients with Sickle cell disease (SCD) who receive regular transfusions are at risk for developing cardiac toxicity from iron overload. The aim of this study was to assess right and left cardiac volumes and function, late gadolinium enhancement (LGE) and iron deposits in patients with SCD using CMR, correlating these values with transfusion burden, ferritin and hemoglobin levels. METHODS Thirty patients with SCD older than 20 years of age were studied in a 1.5 T scanner and compared to age- and sex-matched normal controls. Patients underwent analysis of biventricular volumes and function, LGE and T2* assessment of the liver and heart. RESULTS When compared to controls, patients with SCD presented higher left ventricular (LV) volumes with decreased ejection fraction (EF) with an increase in stroke volume (SV) and LV hypertrophy. The right ventricle (RV) also presented with a decreased EF and hypertrophy, with an increased end-systolic volume. Although twenty-six patients had increased liver iron concentrations (median liver iron concentration value was 11.83 ± 9.66 mg/g), only one patient demonstrated an abnormal heart T2* < 20 msec. Only four patients (13%) LGE, with only one patient with an ischemic pattern. CONCLUSIONS Abnormal heart iron levels and myocardial scars are not a common finding in SCD despite increased liver iron overload. The significantly different ventricular function seen in SCD compared to normal suggests the changes in RV and LV function may not be due to the anemia alone. Future studies are necessary to confirm this association.
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MESH Headings
- Adult
- Anemia, Sickle Cell/blood
- Anemia, Sickle Cell/complications
- Case-Control Studies
- Female
- Ferritins/blood
- Hemoglobins/metabolism
- Humans
- Hypertrophy, Left Ventricular/blood
- Hypertrophy, Left Ventricular/diagnosis
- Hypertrophy, Left Ventricular/etiology
- Hypertrophy, Left Ventricular/physiopathology
- Hypertrophy, Right Ventricular/blood
- Hypertrophy, Right Ventricular/diagnosis
- Hypertrophy, Right Ventricular/etiology
- Hypertrophy, Right Ventricular/physiopathology
- Liver/metabolism
- Magnetic Resonance Imaging
- Male
- Middle Aged
- Myocardium/metabolism
- Myocardium/pathology
- Predictive Value of Tests
- Prospective Studies
- Stroke Volume
- Ventricular Dysfunction, Left/blood
- Ventricular Dysfunction, Left/diagnosis
- Ventricular Dysfunction, Left/etiology
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Right/blood
- Ventricular Dysfunction, Right/diagnosis
- Ventricular Dysfunction, Right/etiology
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Function, Left
- Ventricular Function, Right
- Young Adult
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Affiliation(s)
- Flávia P Junqueira
- Clínica de Diagnóstico Por Imagem (CDPI), Av. das Américas 4666 sala 325, Barra da Tijuca, Rio de Janeiro 22649-900RJ, Brazil
- Department of Radiology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Guilherme M Cunha
- Clínica de Diagnóstico Por Imagem (CDPI), Av. das Américas 4666 sala 325, Barra da Tijuca, Rio de Janeiro 22649-900RJ, Brazil
| | - Tadeu T A Kubo
- Clínica de Diagnóstico Por Imagem (CDPI), Av. das Américas 4666 sala 325, Barra da Tijuca, Rio de Janeiro 22649-900RJ, Brazil
- Department of Radiology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Claudio M A O Lima
- Clínica de Diagnóstico Por Imagem (CDPI), Av. das Américas 4666 sala 325, Barra da Tijuca, Rio de Janeiro 22649-900RJ, Brazil
| | - Daniel B P Lima
- Clínica de Diagnóstico Por Imagem (CDPI), Av. das Américas 4666 sala 325, Barra da Tijuca, Rio de Janeiro 22649-900RJ, Brazil
| | | | - Sidney R Sales
- Clínica de Diagnóstico Por Imagem (CDPI), Av. das Américas 4666 sala 325, Barra da Tijuca, Rio de Janeiro 22649-900RJ, Brazil
| | | | | | | | - Edson Marchiori
- Department of Radiology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Kolnagou A, Natsiopoulos K, Kleanthous M, Ioannou A, Kontoghiorghes GJ. Liver iron and serum ferritin levels are misleading for estimating cardiac, pancreatic, splenic and total body iron load in thalassemia patients: factors influencing the heterogenic distribution of excess storage iron in organs as identified by MRI T2*. Toxicol Mech Methods 2013; 23:48-56. [PMID: 22943064 DOI: 10.3109/15376516.2012.727198] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A comparative assessment of excess storage iron distribution in the liver, heart, spleen and pancreas of β-thalassemia major (β-ΤΜ) patients has been carried out using magnetic resonance imaging (MRI) relaxation times T2*. The β-ΤΜ patients (8-40 years, 11 males, 9 females) had variable serum ferritin levels (394-5603 μg/L) and were treated with deferoxamine (n = 10), deferiprone (n = 5) and deferoxamine/deferiprone combination (n = 5). MRI T2* assessment revealed that excess iron is not proportionally distributed among the organs but is stored at different concentrations in each organ and the distribution is different for each β-ΤΜ patient. There is random variation in the distribution of excess storage iron from normal to severe levels in each organ among the β-ΤΜ patients by comparison to the same organs of ten normal volunteers. The correlation of serum ferritin with T2* was for spleen (r = -0.81), liver (r = -0.63), pancreas (r = -0.33) and none with heart. Similar trend was observed in the correlation of liver T2* with the T2* of spleen (r = 0.62), pancreas (r = 0.61) and none with heart. These studies contradict previous assumptions that serum ferritin and liver iron concentration is proportional to the total body iron stores in β-ΤΜ and especially cardiac iron load. The random variation in the concentration of iron in the organs of β-ΤΜ patients appears to be related to the chelation protocol, organ function, genetic, dietary, pharmacological and other factors. Monitoring of the iron load for all the organs is recommended for each β-ΤΜ patient.
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Affiliation(s)
- Annita Kolnagou
- Postgraduate Research Institute of Science, Technology, Environment and Medicine, Limassol, Cyprus
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Taylor BA, Loeffler RB, Song R, McCarville ME, Hankins JS, Hillenbrand CM. Automated T(2) * measurements using supplementary field mapping to assess cardiac iron content. J Magn Reson Imaging 2013; 38:441-7. [PMID: 23292658 DOI: 10.1002/jmri.23990] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 11/14/2012] [Indexed: 01/14/2023] Open
Abstract
PURPOSE To develop and evaluate an algorithm that automatically identifies high-susceptibility areas and excludes them from T(2) * measurements in the left ventricle (LV) for myocardial iron measurements. MATERIALS AND METHODS An autoregressive moving average (ARMA) model was implemented on multigradient echo scans of 24 patients (age range 3-45 years, 10 male/14 female). Voxels with relatively high susceptibility (>3 Hz/mm) were flagged and deselected from the T(2) * calculations for iron quantification. The mean, standard deviation, and coefficient of variation (CoV) of the ARMA-defined region were compared to the CoV of four distinct regions of the LV and the entire LV using a Student's t-test (α = 0.05). RESULTS The CoV of T(2) * values obtained by the ARMA method are comparable with that in the interventricular septum (IS), where susceptibility was the lowest (CoV = 0.31). The ARMA method provides a greater area (51.9 ± 13.7% of the LV) to measure T(2) * than that using the IS alone (21.1 ± 3.4%, P < 0.0001). Areas where low susceptibility are measured corroborate with areas reported in previous studies that investigated T(2) * variations throughout the LV. CONCLUSION An automated method to measure T(2) * relaxation in the LV with minimal effects from susceptibility has been developed. Variability is reduced while covering more regions for cardiac T2 * calculation.
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Affiliation(s)
- Brian A Taylor
- Department of Radiological Sciences, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
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17
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Abstract
Patients with β-thalassemia major (TM) and other refractory anemias requiring regular blood transfusions accumulate iron that damages the liver, endocrine system, and most importantly the heart. The prognosis in TM has improved remarkably over the past 10 years. This improvement has resulted from the development of magnetic resonance imaging (MRI) techniques, especially T2*, to accurately measure cardiac and liver iron, and from the availability of 3 iron-chelating drugs. In this article we describe the use of MRI to determine which adult and pediatric patients need to begin iron chelation therapy and to monitor their progress. We summarize the properties of each of the 3 drugs, deferoxamine (DFO), deferiprone (DFP), and deferasirox (DFX), including their efficacy, patient acceptability, and side effects. We describe when to initiate or intensify therapy, switch to another drug, or use combined therapy. We also discuss the management of refractory anemias other than TM that may require multiple blood transfusions, including sickle cell anemia and myelodysplasia. The development of a potential fourth chelator FBS 0701 and the combined use of oral chelators may further improve the quality of life and survival in patients with TM and other transfusion-dependent patients.
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18
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Gladwin MT, Sachdev V. Cardiovascular abnormalities in sickle cell disease. J Am Coll Cardiol 2012; 59:1123-33. [PMID: 22440212 DOI: 10.1016/j.jacc.2011.10.900] [Citation(s) in RCA: 182] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Revised: 10/05/2011] [Accepted: 10/11/2011] [Indexed: 01/19/2023]
Abstract
Sickle cell disease is characterized by recurrent episodes of ischemia-reperfusion injury to multiple vital organ systems and a chronic hemolytic anemia, both contributing to progressive organ dysfunction. The introduction of treatments that induce protective fetal hemoglobin and reduce infectious complications has greatly prolonged survival. However, with increased longevity, cardiovascular complications are increasingly evident, with the notable development of a progressive proliferative systemic vasculopathy, pulmonary hypertension (PH), and left ventricular diastolic dysfunction. Pulmonary hypertension is reported in autopsy studies, and numerous clinical studies have shown that increased pulmonary pressures are an important risk marker for mortality in these patients. In epidemiological studies, the development of PH is associated with intravascular hemolysis, cutaneous leg ulceration, renal insufficiency, iron overload, and liver dysfunction. Chronic anemia in sickle cell disease results in cardiac chamber dilation and a compensatory increase in left ventricular mass. This is often accompanied by left ventricular diastolic dysfunction that has also been a strong independent predictor of mortality in patients with sickle cell disease. Both PH and diastolic dysfunction are associated with marked abnormalities in exercise capacity in these patients. Sudden death is an increasingly recognized problem, and further cardiac investigations are necessary to recognize and treat high-risk patients.
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Affiliation(s)
- Mark T Gladwin
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, 3459 Fifth Avenue, Montefiore Hospital, Pittsburgh, PA 15213, USA.
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Voskaridou E, Christoulas D, Terpos E. Sickle-cell disease and the heart: review of the current literature. Br J Haematol 2012; 157:664-73. [DOI: 10.1111/j.1365-2141.2012.09143.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Ersi Voskaridou
- Thalassaemia Centre; Laikon General Hospital; Athens; Greece
| | | | - Evangelos Terpos
- Department of Clinical Therapeutics; University of Athens School of Medicine; Athens; Greece
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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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21
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Vasavda N, Gutiérrez L, House MJ, Drašar E, St Pierre TG, Thein SL. Renal iron load in sickle cell disease is influenced by severity of haemolysis. Br J Haematol 2012; 157:599-605. [DOI: 10.1111/j.1365-2141.2012.09093.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 02/11/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Nisha Vasavda
- King's College London School of Medicine, Molecular Haematology; London; UK
| | - Lucía Gutiérrez
- School of Physics; The University of Western Australia; Crawley; WA; Australia
| | - Michael J. House
- School of Physics; The University of Western Australia; Crawley; WA; Australia
| | | | - Tim G. St Pierre
- School of Physics; The University of Western Australia; Crawley; WA; Australia
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22
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Coates TD. Is it time to SWiTCH to composite primary endpoints? Pediatr Blood Cancer 2011; 57:906-7. [PMID: 21594983 DOI: 10.1002/pbc.23182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 04/06/2011] [Indexed: 11/07/2022]
Affiliation(s)
- Thomas D Coates
- Childrens Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California, USA.
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23
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Brugnara C. ASH 2010 meeting report-Top 10 clinically oriented abstracts in sickle-cell disease. Am J Hematol 2011. [DOI: 10.1002/ajh.22004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Inati A, Khoriaty E, Musallam KM. Iron in sickle-cell disease: what have we learned over the years? Pediatr Blood Cancer 2011; 56:182-90. [PMID: 21157888 DOI: 10.1002/pbc.22721] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Accepted: 05/27/2010] [Indexed: 01/19/2023]
Abstract
Over the last four decades, monumental advances have been made in the understanding, assessment, and management of transfusion-dependent patients, which have translated into significant improvements in patient morbidity and mortality. Important lessons have been learned from extensive clinical experience of iron management in the thalassemias, but greater knowledge of key differences in the sickle-cell disease (SCD) population may impact on our approach to patient assessment and management. The unique pathophysiology of SCD is reflected in a distinct pattern of iron loading with minimal organ-specific injury. An appreciation and understanding of these differences should allow us to develop tailored management approaches that optimize patient outcomes.
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Affiliation(s)
- Adlette Inati
- Division of Paediatric Haematology and Oncology, Children's Centre for Cancer and Blood Diseases, Rafik Hariri University Hospital, Beirut, Lebanon.
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25
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Inati A, Khoriaty E, Musallam KM, Taher AT. Iron chelation therapy for patients with sickle cell disease and iron overload. Am J Hematol 2010; 85:782-6. [PMID: 20721892 DOI: 10.1002/ajh.21806] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Adlette Inati
- Division of Pediatric Hematology and Oncology, Children's Centre for Cancer and Blood Diseases, Rafik Hariri University Hospital, Beirut, Lebanon.
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Deferasirox effectively decreases iron burden in patients with double heterozygous HbS/β-thalassemia. Ann Hematol 2010; 90:11-5. [DOI: 10.1007/s00277-010-1029-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 07/02/2010] [Indexed: 10/19/2022]
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