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Iron-mediated tissue damage in acquired ineffective erythropoiesis disease: It’s more a matter of burden or more of exposure to toxic iron form? Leuk Res 2022; 114:106792. [DOI: 10.1016/j.leukres.2022.106792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/16/2022] [Accepted: 01/20/2022] [Indexed: 01/19/2023]
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Efficacy and Safety of Iron Chelation Therapy After Allogeneic Hematopoietic Stem Cell Transplantation in Pediatric Thalassemia Patients: A Retrospective Observational Study. J Pediatr Hematol Oncol 2022; 44:e26-e34. [PMID: 34986131 DOI: 10.1097/mph.0000000000002328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 07/02/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Studies on the increased body iron load in patients with thalassemia major have thoroughly demonstrated the problems caused by iron overload. In patients who undergo hematopoietic stem cell transplantation (HSCT) as curative therapy, iron overload continues long after transplantation. There are few pediatric studies on chelation therapy in the posttransplant period. In this study, we present the outcomes of our patients who received posttransplant oral chelation therapy. PATIENTS AND METHODS This retrospective observational study evaluated the outcomes of pediatric patients with thalassemia major who used oral chelation therapy after allogeneic HSCT at the Akdeniz University Pediatric Bone Marrow Unit between January 2008 and October 2019. RESULTS Deferasirox therapy was initiated in 58 pediatric patients who underwent HSCT for thalassemia. Pretreatment mean serum ferritin was 2166±1038 ng/mL. Treatment was initiated at a mean of 12±6.7 months after transplantation and continued for a mean of 15.7±11.5 months. At treatment discontinuation, the mean serum ferritin was 693±405 ng/mL and the mean reduction was -1472.75±1121.09 ng/mL (P<0.001 vs. posttreatment). Serum ferritin was below 500 ng/mL in 52% of the patients at treatment discontinuation. Manageable side effects such as nausea, vomiting, liver enzyme elevation, and proteinuria were observed in 17% of the patients, while one patient developed ototoxicity. CONCLUSIONS Deferasirox therapy effectively reduces iron overload in the posttransplant period. Studies evaluating the effects of early treatment on the graft may help to establish guidelines for posttransplant chelation therapy. Clear guidelines are needed regarding when to initiate and discontinue treatment.
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Abstract
Hemoglobinopathies are the most common single-gene diseases and are estimated to affect millions of people worldwide. Thalassemia and sickle cell disease are the most prevalent diseases of this group. Today, despite the decreasing number of newborns diagnosed with a hemoglobinopathy, it remains an important health problem for many countries. Although regular red blood cell (RBC) transfusions, advanced iron chelation, and supportive therapy alternatives have improved life expectancy, allogeneic hematopoietic stem cell transplantation (HSCT) is the only curative option for patients with hemoglobinopathies to prevent irreversible organ damage. Modern transplantation approaches and careful posttransplantation follow-up of patients have improved survival outcomes, and HSCT has now been performed in several patients with hemoglobinopathies worldwide. Considering current experiences, hematopoietic stem cell transplantation is recommended in cases of β-thalassemia (β-thal) in the presence of a matched family or unrelated donor, without secondary organ damage due to transfusion. In patients with sickle cell anemia, transplantation indications include transfusion dependence and cases of secondary organ damage. Recently, gene therapy as a possible treatment option has yielded promising results, though it is not in routine clinical use at its current stage.
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Affiliation(s)
- M Akif Yesilipek
- Department of Pediatric Hematology and Pediatric Stem Cell Transplantation Unit, Medicalpark Antalya Hospital, Antalya, Turkey
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Kontoghiorghes GJ. How to manage iron toxicity in post-allogeneic hematopoietic stem cell transplantation? Expert Rev Hematol 2020; 13:299-302. [PMID: 32037922 DOI: 10.1080/17474086.2020.1719359] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- George J Kontoghiorghes
- Postgraduate Research Institute of Science Technology, Environment and Medicine, Limassol, Cyprus
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Iron Toxicity and Hemopoietic Cell Transplantation: Time to Change the Paradigm. Mediterr J Hematol Infect Dis 2019; 11:e2019030. [PMID: 31205634 PMCID: PMC6548208 DOI: 10.4084/mjhid.2019.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 03/21/2019] [Indexed: 02/07/2023] Open
Abstract
The issue of iron overload in hemopoietic cell transplantation has been first discussed in the field of transplantation for thalassemia. Thalassemia major is characterized by ineffective erythropoiesis and hemolysis leading to severe anemia. Patients require regular blood transfusion therefore they develop iron overload causing organ damage and hematopoietic cell transplantation (HCT) is a consolidated reliably curative option. In this category of patients an important issue for transplant outcome is the iron burden before transplant and in the long-life post-transplant. Nevertheless today the concept of the impact of iron overload / toxicity on the outcome of HCT has been extended to other diseases characterized by periods of variable duration of transfusion dependence. Recent preclinical data has shown how increased production of reactive oxygen species (ROS) resulting under iron overload condition, could impair the stem cells clonality capacity, proliferation and maturation. Also, microenvironment cells could be affected through this mechanism. For this reason, iron overload is becoming an important issue also in the engraftment period post-transplant. The aim of this review is to update consolidated knowledge about the role of iron overload/iron toxicity in the HCT setting in non-malignant and in malignant diseases introducing the concept of exposition of free toxic iron forms and related cellular damage in the different stage of transplant.
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Shenoy S, Gaziev J, Angelucci E, King A, Bhatia M, Smith A, Bresters D, Haight AE, Duncan CN, de la Fuente J, Dietz AC, Baker KS, Pulsipher MA, Walters MC. Late Effects Screening Guidelines after Hematopoietic Cell Transplantation (HCT) for Hemoglobinopathy: Consensus Statement from the Second Pediatric Blood and Marrow Transplant Consortium International Conference on Late Effects after Pediatric HCT. Biol Blood Marrow Transplant 2018; 24:1313-1321. [DOI: 10.1016/j.bbmt.2018.04.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 04/02/2018] [Indexed: 12/14/2022]
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7
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Angelucci E, Pilo F. Management of iron overload before, during, and after hematopoietic stem cell transplantation for thalassemia major. Ann N Y Acad Sci 2016; 1368:115-21. [PMID: 26999450 DOI: 10.1111/nyas.13027] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 01/20/2016] [Accepted: 01/22/2016] [Indexed: 12/21/2022]
Abstract
Solid evidence has established the negative impact of high iron burden and related tissue damage on the outcome of hemopoietic stem cell transplantation for thalassemia major. Recent improvements in our knowledge of iron metabolism have been focused on elevated non-transferrin-bound iron and labile plasma iron levels in the peritransplantation period as potential contributors to tissue toxicity and subsequent adverse transplant outcome. As mouse models have shown, iron overload can injure bone marrow hematopoiesis by increasing reactive oxygen species. The Pesaro experience, conducted in the deferoxamine-only era, clearly defined three iron-related factors (liver fibrosis, hepatomegaly, and quality of lifelong chelation) as significantly affecting transplant outcome. The detrimental effect of iron has only been clarified in recent years. Active interventional strategies are ongoing. Although successful hematopoietic stem cell transplantation clinically resolves the thalassemia marrow defect, patients still remain carriers of iron overload and of all the clinical complications acquired during prior years of transfusion therapy. Therefore, adequate "iron diagnosis" and management is mandatory after hemopoietic stem cell transplantation. In transplanted thalassemia patients, body iron should be returned to within the normal range. Phlebotomy is the gold standard to reduce iron burden; though deferoxamine is a proven, acceptable alternative, clinical investigations on deferasirox are ongoing.
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Affiliation(s)
- Emanuele Angelucci
- Unità Operativa Ematologia e Centro Trapianti, Ospedale Oncologico di Riferimento Regionale "Armando Businco,", Azienda Ospedaliera di Rilievo Nazionale "Brotzu,", Cagliari, Italy
| | - Federica Pilo
- Unità Operativa Ematologia e Centro Trapianti, Ospedale Oncologico di Riferimento Regionale "Armando Businco,", Azienda Ospedaliera di Rilievo Nazionale "Brotzu,", Cagliari, Italy
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El Sayed SM, Baghdadi H, Abou-Taleb A, Mahmoud HS, Maria RA, Ahmed NS, Helmy Nabo MM. Al-hijamah and oral honey for treating thalassemia, conditions of iron overload, and hyperferremia: toward improving the therapeutic outcomes. J Blood Med 2014; 5:219-37. [PMID: 25382989 PMCID: PMC4222535 DOI: 10.2147/jbm.s65042] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Iron overload causes iron deposition and accumulation in the liver, heart, skin, and other tissues resulting in serious tissue damages. Significant blood clearance from iron and ferritin using wet cupping therapy (WCT) has been reported. WCT is an excretory form of treatment that needs more research efforts. WCT is an available, safe, simple, economic, and time-saving outpatient modality of treatment that has no serious side effects. There are no serious limitations or precautions to discontinue WCT. Interestingly, WCT has solid scientific and medical bases (Taibah mechanism) that explain its effectiveness in treating many disease conditions differing in etiology and pathogenesis. WCT utilizes an excretory physiological principle (pressure-dependent excretion) that resembles excretion through renal glomerular filtration and abscess evacuation. WCT exhibits a percutaneous excretory function that clears blood (through fenestrated skin capillaries) and interstitial fluids from pathological substances without adding a metabolic or detoxification burden on the liver and the kidneys. Interestingly, WCT was reported to decrease serum ferritin (circulating iron stores) significantly by about 22.25% in healthy subjects (in one session) and to decrease serum iron significantly to the level of causing iron deficiency (in multiple sessions). WCT was reported to clear blood significantly of triglycerides, low-density lipoprotein (LDL) cholesterol, total cholesterol, uric acid, inflammatory mediators, and immunoglobulin antibodies (rheumatoid factor). Moreover, WCT was reported to enhance the natural immunity, potentiate pharmacological treatments, and to treat many different disease conditions. There are two distinct methods of WCT: traditional WCT and Al-hijamah (WCT of prophetic medicine). Both start and end with skin sterilization. In traditional WCT, there are two steps, skin scarification followed by suction using plastic cups (double S technique); Al-hijamah is a three-step procedure that includes skin suction using cups, scarification (shartat mihjam in Arabic), and second skin suction (triple S technique). Al-hijamah is a more comprehensive technique and does better than traditional WCT, as Al-hijamah includes two pressure-dependent filtration steps versus one step in traditional WCT. Whenever blood plasma is to be cleared of an excess pathological substance, Al-hijamah is indicated. We will discuss here some reported hematological and therapeutic benefits of Al-hijamah, its medical bases, methodologies, precautions, side effects, contraindications, quantitative evaluation, malpractice, combination with oral honey treatment, and to what extent it may be helpful when treating thalassemia and other conditions of iron overload and hyperferremia.
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Affiliation(s)
- Salah Mohamed El Sayed
- Department of Medical Biochemistry, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt ; Department of Clinical Biochemistry and Molecular Medicine, Taibah Faculty of Medicine, Taibah University, Al-Madinah Al-Munawwarah, Kingdom of Saudi Arabia
| | - Hussam Baghdadi
- Department of Clinical Biochemistry and Molecular Medicine, Taibah Faculty of Medicine, Taibah University, Al-Madinah Al-Munawwarah, Kingdom of Saudi Arabia
| | - Ashraf Abou-Taleb
- Department of Pediatrics, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Hany Salah Mahmoud
- World Federation of Alternative and Complementary Medicine, Cairo Regional Headquarter, Cairo, Egypt
| | - Reham A Maria
- Department of Clinical Biochemistry and Molecular Medicine, Taibah Faculty of Medicine, Taibah University, Al-Madinah Al-Munawwarah, Kingdom of Saudi Arabia ; Department of Medical Biochemistry, Tanta Faulty of Medicine, Tanta University, Tanta, Egypt
| | - Nagwa S Ahmed
- Department of Medical Biochemistry, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Manal Mohamed Helmy Nabo
- Department of Pediatrics, Sohag Teaching Hospital, Sohag, Egypt ; Division of Pediatric Cardiology, Department of Pediatrics, Maternity and Children Hospital, King Abdullah Medical City, Al-Madinah Al-Munawwarah, Kingdom of Saudi Arabia
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Pulsipher MA, Skinner R, McDonald GB, Hingorani S, Armenian SH, Cooke KR, Gracia C, Petryk A, Bhatia S, Bunin N, Nieder ML, Dvorak CC, Sung L, Sanders JE, Kurtzberg J, Baker KS. National Cancer Institute, National Heart, Lung and Blood Institute/Pediatric Blood and Marrow Transplantation Consortium First International Consensus Conference on late effects after pediatric hematopoietic cell transplantation: the need for pediatric-specific long-term follow-up guidelines. Biol Blood Marrow Transplant 2012; 18:334-47. [PMID: 22248713 PMCID: PMC3281504 DOI: 10.1016/j.bbmt.2012.01.003] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 01/11/2012] [Indexed: 12/21/2022]
Abstract
Existing standards for screening and management of late effects occurring in children who have undergone hematopoietic cell transplantation (HCT) include recommendations from pediatric cancer networks and consensus guidelines from adult-oriented transplantation societies applicable to all HCT recipients. Although these approaches have significant merit, they are not pediatric HCT-focused, and they do not address post-HCT challenges faced by children with complex nonmalignant disorders. In this article we discuss the strengths and weaknesses of current published recommendations and conclude that pediatric-specific guidelines for post-HCT screening and management would be beneficial to the long-term health of these patients and would promote late effects research in this field. Our panel of late effects experts also provides recommendations for follow-up and therapy of selected post-HCT organ and endocrine complications in pediatric patients.
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Affiliation(s)
- Michael A Pulsipher
- Primary Children's Medical Center, University of Utah School of Medicine/Huntsman Cancer Institute, Division of Hematology/BMT, Salt Lake City, Utah 84132, USA.
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Kida A, McDonald GB. Gastrointestinal, Hepatobiliary, Pancreatic, and Iron-Related Diseases in Long-Term Survivors of Allogeneic Hematopoietic Cell Transplantation. Semin Hematol 2012; 49:43-58. [DOI: 10.1053/j.seminhematol.2011.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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11
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Nieder ML, McDonald GB, Kida A, Hingorani S, Armenian SH, Cooke KR, Pulsipher MA, Baker KS. National Cancer Institute-National Heart, Lung and Blood Institute/pediatric Blood and Marrow Transplant Consortium First International Consensus Conference on late effects after pediatric hematopoietic cell transplantation: long-term organ damage and dysfunction. Biol Blood Marrow Transplant 2011; 17:1573-84. [PMID: 21963877 PMCID: PMC3215762 DOI: 10.1016/j.bbmt.2011.09.013] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Accepted: 09/27/2011] [Indexed: 01/19/2023]
Abstract
Long-term complications after hematopoietic cell transplantation (HCT) have been studied in detail. Although virtually every organ system can be adversely affected after HCT, the underlying pathophysiology of these late effects remain incompletely understood. This article describes our current understanding of the pathophysiology of late effects involving the gastrointestinal, renal, cardiac, and pulmonary systems, and discusses post-HCT metabolic syndrome studies. Underlying diseases, pretransplantation exposures, transplantation conditioning regimens, graft-versus-host disease, and other treatments contribute to these problems. Because organ systems are interdependent, long-term complications with similar pathophysiologic mechanisms often involve multiple organ systems. Current data suggest that post-HCT organ complications result from cellular damage that leads to a cascade of complex events. The interplay between inflammatory processes and dysregulated cellular repair likely contributes to end-organ fibrosis and dysfunction. Although many long-term problems cannot be prevented, appropriate monitoring can enable detection and organ-preserving medical management at earlier stages. Current management strategies are aimed at minimizing symptoms and optimizing function. There remain significant gaps in our knowledge of the pathophysiology of therapy-related organ toxicities disease after HCT. These gaps can be addressed by closely examining disease biology and identifying those patients at greatest risk for adverse outcomes. In addition, strategies are needed for targeted disease prevention and health promotion efforts for individuals deemed at high risk because of their genetic makeup or specific exposure profile.
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Affiliation(s)
| | - George B. McDonald
- University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Aiko Kida
- University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Sangeeta Hingorani
- University of Washington, Seattle Children’s Hospital, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Kenneth R. Cooke
- Case Western Reserve University, Rainbow Babies & Children’s Hospital, Cleveland, OH
| | - Michael A. Pulsipher
- Primary Children’s Medical Center, Division of Hematology/BMT, University of Utah School of Medicine/Huntsman Cancer Institute, Salt Lake City, UT
| | - K. Scott Baker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
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12
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Abstract
Accurate evaluation of iron overload is necessary to establish the diagnosis of hemochromatosis and guide chelation treatment in transfusion-dependent anemia. The liver is the primary site for iron storage in patients with hemochromatosis or transfusion-dependent anemia, therefore, liver iron concentration (LIC) accurately reflects total body iron stores. In the past 20 years, magnetic resonance imaging (MRI) has emerged as a promising method for measuring LIC in a variety of diseases. We review the potential role of MRI in LIC determination in the most important disorders that are characterized by iron overload, that is, thalassemia major, other hemoglobinopathies, acquired anemia, and hemochromatosis. Most studies have been performed in thalassemia major and MRI is currently a widely accepted method for guiding chelation treatment in these patients. However, the lack of correlation between liver and cardiac iron stores suggests that both organs should be evaluated with MRI, since cardiac disease is the leading cause of death in this population. It is also unclear which MRI method is the most accurate since there are no large studies that have directly compared the different available techniques. The role of MRI in the era of genetic diagnosis of hemochromatosis is also debated, whereas data on the accuracy of the method in other hematological and liver diseases are rather limited. However, MRI is a fast, non-invasive and relatively accurate diagnostic tool for assessing LIC, and its use is expected to increase as the role of iron in the pathogenesis of liver disease becomes clearer.
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13
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Hematopoietic stem cell transplantation for hemoglobinopathies: current practice and emerging trends. Pediatr Clin North Am 2010; 57:181-205. [PMID: 20307718 DOI: 10.1016/j.pcl.2010.01.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Despite improvements in the management of thalassemia major and sickle cell disease, treatment complications are frequent and life expectancy remains diminished for these patients. Hematopoietic stem cell transplantation (HSCT) is the only curative option currently available. Existing results for HSCT in patients with hemoglobinopathy are excellent and still improving. New conditioning regimens are being used to reduce treatment-related toxicity and new donor pools accessed to increase the number of patients who can undergo HSCT.
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15
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Hematopoietic cell transplantation for thalassemia and sickle cell disease: past, present and future. Bone Marrow Transplant 2007; 41:109-17. [DOI: 10.1038/sj.bmt.1705943] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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16
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Abstract
Iron overload is characterised by excessive iron deposition and consequent injury and dysfunction of target organs, especially the heart, liver, anterior pituitary, pancreas and joints. Iron overload disorders are common worldwide and occur in most major race/ethnicity groups. Physiological mechanisms to excrete iron are very limited. Thus, all patients with iron overload need safe and effective treatment that is compatible with their co-existing medical conditions. Treatments for iron overload include phlebotomy and erythrocytapheresis that remove iron predominantly as haemoglobin, and chelation therapy with drugs that bind excess iron selectively and increase its excretion. The most important potential benefits of therapy are preventing deaths due to cardiac siderosis and hepatic cirrhosis. Preventing iron-related injury to endocrine organs is critical in children. Successful treatment or prevention of iron overload increases quality of life and survival in many patients. This article characterises the major categories of iron overload disorders, tabulates methods to evaluate and treat iron overload, and describes treatment options for iron overload disorders. Research needed to advance knowledge about treatment of iron overload is proposed.
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Affiliation(s)
- James C Barton
- Southern Iron Disorders Center, Birmingham, Alabama 35209, USA.
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Mavrogeni S, Gotsis ED, Berdousi E, Ladis V, Verganelakis D, Toulas P, Cokkinos DV. Myocardial and hepatic T2* magnetic resonance evaluation in ex-thalassemic patients after bone-marrow transplantation. Int J Cardiovasc Imaging 2007; 23:739-45. [PMID: 17235481 DOI: 10.1007/s10554-006-9203-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2006] [Accepted: 12/23/2006] [Indexed: 11/28/2022]
Abstract
Bone marrow transplantation (BMT) is the only complete cure for b-thalassemia. Iron depletion therapy is still required to remove excess iron, accumulated before BMT. Hepatic and myocardial iron load were evaluated using T2* magnetic resonance in 8 ex-thalassemic patients after BMT, aged 19.5 +/- 4.25 years, who were in iron depletion therapy. Average hepatic T2* was 18.8 +/- 11.0 msec (4.1-35.0 msec). In 4 out of 8 patients iron overload was detected, not exceeding however 4 mg/gr dry tissue. Average heart T2* was 31.0 +/- 4.6 msec (25.6-35.2 msec), not significantly different (P = 0.18) from our age-matched normal population (33.0 +/- 4.0). Normal left ventricular ejection fraction was found in 7 out of 8 patients (mean 64.5 +/- 7.0%) with the remaining having a marginal value of 54.1%. Ferritin level before BMT was 1748 +/- 451 mug/l and dropped to 536 +/- 260 microg/l at the end of iron depletion therapy after BMT. Current ferritin level was 271 +/- 253 microg/l and although it was significant lower compared to both ferritin before BMT (P < 0.001) and after iron depletion (P < 0.001), evidence of residual hepatic iron load was identified by T2*. Hepatic and myocardial T2* magnetic resonance can be used as a more reliable index than ferritin for evaluation of iron depletion therapy in ex-thalassemic patients after BMT.
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Locatelli F, Stefano PD. New insights into haematopoietic stem cell transplantation for patients with haemoglobinopathies. Br J Haematol 2004; 125:3-11. [PMID: 15015962 DOI: 10.1111/j.1365-2141.2004.04842.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Franco Locatelli
- Oncoematologia Pediatrica, IRCCS Policlinico S. Matteo, Pavia, Italy.
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Medeiros BC, Kolhouse JF, Cagnoni PJ, Ryder J, Nieto Y, Rabinovitch R, Shpall EJ, Bearman SI, Jones RB, McSweeney PA. Nonmyeloablative allogeneic hematopoietic stem cell transplantation for congenital sideroblastic anemia. Bone Marrow Transplant 2003; 31:1053-5. [PMID: 12774059 DOI: 10.1038/sj.bmt.1704038] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Congenital sideroblastic anemia (CSA) is a dyserythropoietic disorder that leads to transfusion dependency and subsequent iron overload. Nonmyeloablative allogeneic hematopoietic stem cell transplantation (NST) was performed for a patient with CSA, who had contraindications to conventional allografting. Conditioning was fludarabine, low-dose total body irradiation and antithymocyte globulin, followed by peripheral blood stem cell transplant. Cyclosporine and mycophenolate mofetil were used for graft-versus-host disease prophylaxis. Complete donor chimerism was observed day +131. Early after transplant, the patient became transfusion independent, allowing a regular phlebotomy program. On day +190, refractory lactic acidosis followed by fatal cardiovascular collapse developed, without evidence of infection. Data from this case demonstrates that NST may correct the erythropoietic defect of CSA.
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Affiliation(s)
- B C Medeiros
- Department of Medicine, University of Colorado Health Sciences Center, Denver, CO, USA
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Affiliation(s)
- G Lucarelli
- U.O. Ematologia e Centro Trapianto Midollo Osseo di Muraglia, Azienda Ospedale S. Salvatore di Pesaro, Pesaro, Italy
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Affiliation(s)
- J B Porter
- University College London, Thalassaemia and Sickle Unit UCL Hospitals, London, UK.
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22
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Abstract
In patients with hemoglobinopathy who are treated by allogeneic matched sibling bone marrow transplantation before the onset of disease-associated organ damage, long term, disease-free survival currently stands at approximately 90%, and transplant-associated mortality is 5% or less. Less toxic nonmyeloablative conditioning regimens that have the potential to reduce procedure-related mortality to even lower levels are under active investigation. Expansion of the donor pool by use of unrelated matched donors awaits improvement in HLA-typing methodology.
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Affiliation(s)
- W C Mentzer
- University of California at San Francisco, USA
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23
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Barton JC, Bertoli LF. Transfusion iron overload in adults with acute leukemia: manifestations and therapy. Am J Med Sci 2000; 319:73-8. [PMID: 10698089 DOI: 10.1097/00000441-200002000-00001] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Hepatic dysfunction occurs commonly among persons successfully treated for acute leukemia, and iron overload is a possible cause of hepatic and other abnormalities in these patients. METHODS We identified 5 adults 40+/-13 (mean +/- S.D.) years of age who developed transfusion iron overload in association with successful chemotherapy of de novo acute leukemia. None had evidence of hemochromatosis, viral hepatitis, or other primary hepatic disorders. RESULTS The mean serum ferritin concentration of our patients was 1531+/-572 ng/mL. Other abnormalities associated with transfusion iron overload were increased stainable iron in bone marrow macrophages, elevated serum concentrations of hepatic enzymes, hyperpigmentation, hyperferremia, elevated iron saturation of serum transferrin, and increased stainable iron in Kupffer cells and hepatocytes. Rheumatologic, endocrinologic, or cardiac abnormalities attributable to iron overload were not observed. Therapeutic phlebotomy was initiated after chemotherapy; recovery of hemoglobin concentrations after phlebotomy permitted weekly treatment in each case. This yielded an average of 28+/-9 units per patient (range 15-35 units). Abnormalities associated with transfusion iron overload resolved after iron depletion therapy. The mean leukemia-free survival of our patients is 96+/-36 months (range 40-125 months). CONCLUSIONS Our data and those of others suggest that 15 to 20% of adults who are long-term survivors of acute leukemia develop iron overload, often with hepatic abnormalities. Iron overload is a relatively common sequela to successful management of acute leukemia in adults for which routine evaluation should be performed and for which therapeutic phlebotomy should be used as treatment.
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Affiliation(s)
- J C Barton
- Southern Iron Disorders Center, Birmingham, Alabama, USA
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