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Kalamara TV, Dodos K, Vlachaki E. Splenectomy is significantly associated with thrombosis but not with pulmonary hypertension in patients with transfusion-dependent thalassemia: a meta-analysis of observational studies. Front Med (Lausanne) 2023; 10:1259785. [PMID: 37886361 PMCID: PMC10598854 DOI: 10.3389/fmed.2023.1259785] [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] [Received: 07/16/2023] [Accepted: 09/27/2023] [Indexed: 10/28/2023] Open
Abstract
Introduction Thromboembolism (TE) and pulmonary hypertension (PH) constitute frequently occurring complications in patients with transfusion-dependent thalassemia and have been associated with splenectomy in different studies. Nevertheless, the size of the possible association varies greatly in literature. Herein, we sought to provide pooled effect estimates regarding the impact of splenectomy on TE and PH in transfusion dependent thalassemia (TDT) by retrieving relevant, available studies. Methods We systematically searched articles published in PubMed, Cochrane library, Scopus and gray literature from inception until the 30th of May, 2023. Pooled estimates in terms of odds ratios (OR) and 95% confidence intervals (CI) were calculated according to outcome measures. Risk of bias and quality of studies were evaluated. Results Regarding TE, 4 studies were selected for meta-analysis and the pooled data demonstrated that splenectomy was significantly associated with this outcome in TDT patients [OR = 4.08, 95% CI (1.03, 16.11), p = 0.04]. On the other hand, we pooled data from seven investigating PH, and, interestingly, the quantitative analysis revealed no association between splenectomy and PH [OR = 1.76, 95% CI (0.91, 3.41), p = 0.1]. Conclusion Splenectomy is associated with higher risks of TE, but not with PH in patients with TDT.
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Affiliation(s)
- Tsampika-Vasileia Kalamara
- Adults Thalassemia Unit, Hippokration General Hospital, Second Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Dodos
- Third Department of Pediatrics, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efthymia Vlachaki
- Adults Thalassemia Unit, Hippokration General Hospital, Second Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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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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3
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Tennenbaum J, Volle G, Buffet P, Ranque B, Pouchot J, Arlet JB. [Splenic dysfunction in sickle cell disease: An update]. Rev Med Interne 2023:S0248-8663(23)00005-X. [PMID: 36710088 DOI: 10.1016/j.revmed.2023.01.005] [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: 10/18/2022] [Revised: 01/01/2023] [Accepted: 01/08/2023] [Indexed: 01/30/2023]
Abstract
The spleen filters blood cells and contributes to the immune defense. The red pulp clears the blood from altered red blood cells via its unique microcirculatory network ; while the white pulp is a secondary lymphoid organ, directly connected to the bloodstream, whose specificity is the defense against encapsulated bacteria through the production of "natural" IgM in the marginal zone. Various health conditions can cause acquired impairment of the splenic function (or hyposplenism) directly and/or through therapeutic splenectomy. Hypo/asplenia is complicated by an increased susceptibility to encapsulated germ infections, but an increased risk of thrombosis and pulmonary hypertension has also been reported after surgical splenectomy. Homozygous sickle cell disease is the most common disease associated with functional asplenia. The latter appears early in childhood likely through repeated ischemic alterations caused by the sickling of red blood cells. In addition, specific complications such as hypersplenism and acute splenic sequestration can occur and may be life-threatening. We provide here an update on the role and physiology of the spleen, which will allow a better understanding of the pathophysiology of spleen damage and its consequences in sickle cell disease.
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Affiliation(s)
- J Tennenbaum
- Service de médecine interne, Centre de référence national de la drépanocytose de l'adulte, Hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, Paris, France.
| | - G Volle
- Service de médecine interne, Hôpital Henri-Mondor, Assistance publique-Hôpitaux de Paris, Créteil, France
| | - P Buffet
- Laboratoire d'Excellence GR-Ex, Biologie intégrée du globule rouge (BIGR), Université Paris Cité, Inserm, Paris, France
| | - B Ranque
- Service de médecine interne, Centre de référence national de la drépanocytose de l'adulte, Hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, Paris, France; Laboratoire d'Excellence GR-Ex, Biologie intégrée du globule rouge (BIGR), Université Paris Cité, Inserm, Paris, France; Faculté de médecine Paris Cité, Paris, France
| | - J Pouchot
- Service de médecine interne, Centre de référence national de la drépanocytose de l'adulte, Hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, Paris, France; Faculté de médecine Paris Cité, Paris, France
| | - J-B Arlet
- Service de médecine interne, Centre de référence national de la drépanocytose de l'adulte, Hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, Paris, France; Laboratoire d'Excellence GR-Ex, Biologie intégrée du globule rouge (BIGR), Université Paris Cité, Inserm, Paris, France; Faculté de médecine Paris Cité, Paris, France; Inserm U1163, CNRS 8254, Institut IMAGINE, Hôpital Necker, Assistance publique-Hôpitaux de Paris, Paris, France
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4
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The long-term efficacy in blood transfusions, hematologic parameter changes, and complications after splenectomy in patients with transfusion-dependent thalassemia. Transfus Apher Sci 2022:103620. [PMID: 36509632 DOI: 10.1016/j.transci.2022.103620] [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: 04/25/2022] [Revised: 11/29/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND A splenectomy can reduce transfusion requirements in patients with thalassemia. However, the role of a splenectomy remains controversial because its efficacy has not yet been fully determined and there are concerns over potential complications. The purpose of this study was to assess the efficacy, potential changes in hematologic parameters, and any complications associated with splenectomy. METHODS Medical records of 50 patients with transfusion-dependent thalassemia (TDT) who had undergone a splenectomy, along with those of 20 control subjects with intact spleens, were retrospectively reviewed. RESULTS The primary outcomes indicate the efficacy of a splenectomy in reducing red cell transfusions. Fifty TDT post-splenectomy patients were included in this study, of which 28 (56%) were female. The median age of all patients was 20.5 (18-28 years of age). Twenty-seven patients (54%) transformed from TDT to non-transfusion-dependent thalassemia (NTDT) after the splenectomy; 100% with Hb H disease, 58.3% with beta-thalassemia/Hb E disease, and 23.5% with homozygous beta-thalassemia. According to multivariable logistic regression analysis, Hb H disease (adjusted OR 55.23, 95% CI 1.35-22.8.10) and receiving a splenectomy at > ten years of age (adjusted OR 25.36, 95% CI 1.62-396.47) were associated with higher responses. The prevalence of pulmonary hypertension and thromboembolic events were similar between the splenectomy patients and non-splenectomy patients. CONCLUSION Splenectomy reduced transfusion requirements in TDT patients. The predictive factors as a response to a splenectomy included Hb H disease amongthose receiving a splenectomy at > ten years of age.
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5
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Shash H. Non-Transfusion-Dependent Thalassemia: A Panoramic Review. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58101496. [PMID: 36295656 PMCID: PMC9608723 DOI: 10.3390/medicina58101496] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/08/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022]
Abstract
Non-transfusion-dependent thalassemia (NTDT) has been considered less severe than its transfusion-dependent variants. The most common forms of NTDT include β-thalassemia intermedia, hemoglobin E/beta thalassemia, and hemoglobin H disease. Patients with NTDT develop several clinical complications, despite their regular transfusion independence. Ineffective erythropoiesis, iron overload, and hypercoagulability are pathophysiological factors that lead to morbidities in these patients. Therefore, an early and accurate diagnosis of NTDT is essential to ascertaining early interventions. Currently, several conventional management options are available, with guidelines suggested by the Thalassemia International Federation, and novel therapies are being developed in light of the advancement of the understanding of this disease. This review aimed to increase clinicians’ awareness of NTDT, from its basic medical definition and genetics to its pathophysiology. Specific complications to NTDT were reviewed, along with the risk factors for its development. The indications of different therapeutic options were outlined, and recent advancements were reviewed.
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Affiliation(s)
- Hwazen Shash
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam 31441, Saudi Arabia;
- Department of Pediatrics, King Fahad Hospital of the University, Al-Khobar 31952, Saudi Arabia
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6
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Fakhr-Moosavi S, Salari A, Borghei Y, Hasandokht T, Haghdoost A, Mousavi S, Ramezani S. What is the Prevalence of Pulmonary Hypertension in Thalassemic Patients in Guilan? A Retrospective Analytic Study. Res Cardiovasc Med 2022. [DOI: 10.4103/rcm.rcm_18_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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7
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Mehta V, Kirubarajan A, Sabouhanian A, Jayawardena SM, Chandrakumaran P, Thangavelu N, Cader R, Mettananda S, Bandara D, Khan S, Weatherall DJ, Allen A, Premawardhena AP, Olivieri NF. Leg Ulcers: A Report in Patients with Hemoglobin E Beta Thalassemia and Review of the Literature in Severe Beta Thalassemia. Acta Haematol 2021; 145:334-343. [PMID: 34753145 DOI: 10.1159/000520731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 10/05/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Leg ulcers are a frequent complication in patients with the inherited hemoglobin disorders. In thalassemia, the literature is limited, and factors associated with the development of leg ulcers in hemoglobin E (HbE) beta thalassemia, the most common form of severe beta-thalassemia worldwide, have not previously been reported. METHODS We reviewed all available medical records of patients with HbE beta thalassemia to document the onset of leg ulcers at the 2 largest treatment centers in Sri Lanka. We reviewed the literature to identify studies reporting outcomes of interventions for ulcers in severe thalassemia. RESULTS Of a total of 255 actively registered patients with HbE thalassemia in the 2 centers, 196 patient charts were evaluable. A leg ulcer with a documented date of onset was recorded in 45 (22%) of 196 evaluable patients, aged (mean ± SEM) 22.2 ± 1.4 years. Most had been irregularly transfused; steady-state hemoglobin was 6.4 ± 0.2 g/dL. Treatment achieving healing in 17 patients included transfusions, antibiotics, oral zinc, wound toileting, and skin grafting. CONCLUSION Leg ulcers may be more common in HbE beta thalassemia than in other forms of thalassemia. A systematic approach to treatment will be needed to document the prevalence and factors placing such patients at risk for leg ulcers. Controlled trials to evaluate the optimal treatment of this common complication are indicated.
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Affiliation(s)
- Vikita Mehta
- Arts and Science, McMaster University, Hamilton, Ontario, Canada
| | | | - Amir Sabouhanian
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Nila Thangavelu
- Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Refai Cader
- Policy Analysis and Development, Ministry of Health, Colombo, Sri Lanka
| | - Sachith Mettananda
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Dayananda Bandara
- National Thalassaemia Centre, Kurunegala, Sri Lanka
- Teaching Hospital Kurunegala, Kurunegala, Sri Lanka
| | - Shawn Khan
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David J Weatherall
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Angela Allen
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Nancy F Olivieri
- Pediatrics, Medicine and Public Health Sciences, University of Toronto, Toronto, Ontario, Canada
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8
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Hasan B, Hansmann G, Budts W, Heath A, Hoodbhoy Z, Jing ZC, Koestenberger M, Meinel K, Mocumbi AO, Radchenko GD, Sallmon H, Sliwa K, Kumar RK. Challenges and Special Aspects of Pulmonary Hypertension in Middle- to Low-Income Regions: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 75:2463-2477. [PMID: 32408981 DOI: 10.1016/j.jacc.2020.03.047] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/19/2020] [Accepted: 03/23/2020] [Indexed: 01/19/2023]
Abstract
Challenges and special aspects related to the management and prognosis of pulmonary hypertension (PH) in middle- to low-income regions (MLIRs) range from late presentation to comorbidities, lack of resources and expertise, cost, and rare options of lung transplantation. Expert consensus recommendations addressing the specific challenges for prevention and therapy of PH in MLIRs with limited resources have been lacking. To date, 6 MLIR-PH registries containing mostly adult patients with PH exist. Importantly, the global prevalence of PH is much higher in MLIRs compared with high-income regions: group 2 PH (left heart disease), pulmonary arterial hypertension associated with unrepaired congenital heart disease, human immunodeficiency virus, or schistosomiasis are highly prevalent. This consensus statement provides selective, tailored modifications to the current PH guidelines to address the specific challenges faced in MLIRs, resulting in the first pragmatic and cost-effective consensus recommendations for PH care providers, patients, and their families.
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Affiliation(s)
- Babar Hasan
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan.
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany.
| | - Werner Budts
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Alexandra Heath
- Division of Pediatric Cardiology, Kardiozentrum, La Paz, Bolivia
| | - Zahra Hoodbhoy
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Zhi-Cheng Jing
- Department of Cardiology, Peking Union Medical College Hospital & Key Lab of Pulmonary Vascular Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Katharina Meinel
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Ana Olga Mocumbi
- Instituto Nacional de Saúde, Vila de Marracuene, Maputo, Mozambique
| | - Ganna D Radchenko
- Secondary Hypertension Department with Pulmonary Hypertension Center, State Institute National Scientific Center, MD Strazhesko Institute of Cardiology of Ukrainian National Academy of Medical Science, and Bogomolets National Medical University, Kyiv, Ukraine
| | - Hannes Sallmon
- Department of Pediatric Cardiology, Charité University Medical Center, Berlin, Germany
| | - Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa, Departments of Medicine and Cardiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - R Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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9
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Mohammad AM, Dawad MM, Kashmoola MA, Al-Allawi N. Doppler-defined pulmonary hypertension in β-thalassemia major in Kurdistan, Iraq. PLoS One 2020; 15:e0243648. [PMID: 33301537 PMCID: PMC7728223 DOI: 10.1371/journal.pone.0243648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 11/24/2020] [Indexed: 01/19/2023] Open
Abstract
Cardiopulmonary complications are among the most important complications of thalassemia major. Pulmonary hypertension is among these complications and studies addressing its frequency and associations in the latter disorder are sparse from Iraq. For this purpose a total 100 thalassemia major patients (≥ 8 years old) were enrolled from a main thalassemia center in Kurdistan, Northern Iraq. All patients had a full history and clinical examination. Full blood count, biochemical tests and viral screen including hepatitis B surface antigen and hepatitis C virus antibody, in addition to transthoracic Doppler echocardiography for tricuspid regurgitation jet velocity (TRV). The enrolled patients had a mean (SD) age of 17.6 (5.5) years, and included 52 males and 48 females. Pulmonary hypertension as defined by TRV> 2.8 m/s coupled with both exertional dyspnea and an absence of left sided heart failure, was identified in nine patients (9%). The latter subgroup of patients had significantly higher reticulocyte counts, S. LDH, S. ferritin, and hepatitis C sero-positivity compared to those without this complication by univariate analysis. While by multivariate logistic regression only reticulocytes and hepatitis C sero-positivity remained significant. Furthermore, TRV as a continuous variable was positively correlated with reticulocytes, S. bilirubin and LDH (p<0.001, p = 0.002 and p<0.001 respectively), but not with age or S. ferritin (p = 0.77, and p = 0.93 respectively). In conclusion, pulmonary hypertension is not uncommon in Iraqi patients with thalassemia major, and it appears to be linked to chronic hemolysis rather than iron overload.
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Affiliation(s)
- Ameen M. Mohammad
- Department of Internal Medicine, College of Medicine, University of Duhok, Duhok, Iraq
- * E-mail:
| | | | - Muna A. Kashmoola
- Department of Pathology, College of Medicine, University of Mousel, Mousel, Iraq
| | - Nasir Al-Allawi
- Department of Pathology, College of Medicine, University of Duhok, Duhok, Iraq
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10
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Sanpakit K, Narkbunnam N, Buaboonnam J, Takpradit C, Viprakasit V, Pongtanakul B. Impact of splenectomy on outcomes of hematopoietic stem cell transplantation in pediatric patients with transfusion-dependent thalassemia. Pediatr Blood Cancer 2020; 67:e28483. [PMID: 32568454 DOI: 10.1002/pbc.28483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 05/08/2020] [Accepted: 05/20/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND The role of splenectomy prior to hematopoietic stem cell transplantation (HSCT) is controversial. Only few studies compared the outcomes of splenectomized and nonsplenectomized children with transfusion-dependent thalassemia (TDT) undergoing allogeneic HSCTs. METHODS A retrospective analysis was undertaken on a transplantation cohort of TDT patients; August 1987-December 2014 to compare transplant outcomes between splenectomized and nonsplenectomized groups. RESULTS Ninety-six transplants in 86 TDT patients were analyzed. Sixteen patients were splenectomized before HSCTs. The splenectomized patients were significantly older (8.0 ± 1.9 vs 4.7 ± 0.6 years; P = 0.001), had larger livers and spleens (P = 0.001), and had a significantly shorter neutrophil engraftment time (absolute neutrophil count > 500/mm3 ; 15.0 ± 2.3 vs 19.2 ± 1.3 days; P = 0.004). Graft rejection occurred in 13.8% of the nonsplenectomized group, but not among the splenectomized patients. Though the splenectomized group's mortality rate was higher (25.0% vs 8.8%), this was not statistically significant (P = 0.491). The main causes of death in both groups were severe infections. The five-year overall survival (OS) rate was better for the nonsplenectomized group (91.78% vs 75.00%; P = 0.06). CONCLUSIONS Although splenectomies prior to HSCT for the TDT patients in our cohort were associated with faster neutrophil engraftments and lower rejection rates, they did not produce significantly better OS or affect the mortality. As the splenectomies did not provide any distinct advantages, this procedure should not be routinely performed as a pre-HSCT regimen for TDT patients with splenomegaly. Better pre-HSCT preparation for TDT patients, including early and adequate blood transfusions to avoid splenomegaly, is recommended.
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Affiliation(s)
- Kleebsabai Sanpakit
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Salaya, Thailand
| | - Nattee Narkbunnam
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Salaya, Thailand
| | - Jassada Buaboonnam
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Salaya, Thailand
| | - Chayamon Takpradit
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Salaya, Thailand
| | - Vip Viprakasit
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Salaya, Thailand.,Thalassemia Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Salaya, Thailand
| | - Bunchoo Pongtanakul
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Salaya, Thailand
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11
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Long B, Koyfman A, Gottlieb M. Complications in the adult asplenic patient: A review for the emergency clinician. Am J Emerg Med 2020; 44:452-457. [PMID: 32247651 DOI: 10.1016/j.ajem.2020.03.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/23/2020] [Accepted: 03/23/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The spleen performs several important physiologic functions. However, patients can have functional asplenia or have their spleen removed for a number of reasons, which can put them at risk for several dangerous complications. OBJECTIVE This narrative review provides a focused evaluation of adult asplenic patients and complications in the emergency departing setting. DISCUSSION The spleen plays integral roles in the immune and reticuloendothelial systems and also modulates the inflammatory and coagulation cascades. Asplenia refers to the anatomic or physiologic loss of splenic function, which may be due to trauma, immunological, hematological, or oncological etiologies. Asplenic patients are at risk for several complications including infection, arterial and venous thrombosis, and pulmonary hypertension. Fever in an asplenic patient and overwhelming post-splenectomy infection (OPSI) are medical emergencies with a high mortality and require rapid evaluation and management with broad-spectrum antibiotics. Asplenic patients are at increased risk of arterial thrombosis, such as coronary artery disease, and venous thrombosis including deep venous thrombosis, pulmonary embolism, and splenic and portal vein thrombosis. Management of venous thrombosis includes anticoagulation. Pulmonary hypertension with associated right ventricular dysfunction may also occur in asplenia. These patients require hemodynamic stabilization with an emphasis on inciting causes and treatment of the pulmonary hypertension. CONCLUSIONS The spleen is an integral organ involved in several physiologic functions. Asplenia, or absence of spleen function, is associated with severe complications. Knowledge of these complications can improve the care of these patients.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, United States
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12
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Nameq M, Shamoon R, Saka M. Evaluation of cardiac complications in transfusion-dependent thalassemia (TDT) and non-transfusion dependent thalassemia (NTDT) beta thalassemia patients. IRAQI JOURNAL OF HEMATOLOGY 2020. [DOI: 10.4103/ijh.ijh_12_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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13
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Sinha AA, Adusumilli T, Cohen HW, Nouraie M, Little J, Manwani D. Splenectomy is not associated with a higher tricuspid regurgitant jet velocity in people with sickle cell anemia. Pediatr Blood Cancer 2019; 66:e27928. [PMID: 31322833 DOI: 10.1002/pbc.27928] [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: 02/06/2019] [Revised: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Vascular complications such as pulmonary hypertension (PH) occur at an increased rate following splenectomy in patients with various hemolytic blood disorders including thalassemia. The goal of this retrospective cross-sectional analysis was to assess the independent association of splenectomy with an elevated tricuspid regurgitation velocity (TRV) in people with homozygous sickle cell disease (HbSS). TRV is a noninvasive screening test for PH and a surrogate marker of prognosis in sickle cell disease (SCD). PROCEDURE Data were obtained from the multicenter Walk-PHaSST (treatment of pulmonary hypertension and sickle cell disease with sildenafil therapy) study of PH (NCT00492531). We compared TRV in the cohort of patients with HbSS who were surgically splenectomized with patients who were not surgically splenectomized. RESULTS We found no significant differences in TRV between the two groups. CONCLUSIONS The lack of difference in TRV between the two groups is most likely because members of the comparator nonsurgical group in many cases experienced autoinfarction of the spleen in childhood. Splenectomy does not seem to confer additional risk for the development of a higher TRV in HbSS, unlike in patients with thalassemia or other hemolytic anemias. This could be an important consideration when weighing the risks and benefits of splenectomy in patients with HbSS.
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Affiliation(s)
- Arpan A Sinha
- Jimmy Everest Section of Pediatric Hematology/Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Tanvi Adusumilli
- Department of Pediatrics, Albert Einstein College of Medicine, New York
| | - Hillel W Cohen
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York
| | - Mehdi Nouraie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jane Little
- Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Deepa Manwani
- Department of Pediatrics, Albert Einstein College of Medicine, New York
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Chanpeng P, Svasti S, Paiboonsukwong K, Smith DR, Leecharoenkiat K. Platelet proteome reveals specific proteins associated with platelet activation and the hypercoagulable state in β-thalassmia/HbE patients. Sci Rep 2019; 9:6059. [PMID: 30988349 PMCID: PMC6465338 DOI: 10.1038/s41598-019-42432-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/29/2019] [Indexed: 12/24/2022] Open
Abstract
A hypercoagulable state leading to a high risk of a thrombotic event is one of the most common complications observed in β-thalassemia/HbE disease, particularly in patients who have undergone a splenectomy. However, the hypercoagulable state, as well as the molecular mechanism of this aspect of the pathogenesis of β-thalassemia/HbE, remains poorly understood. To address this issue, fifteen non-splenectomized β-thalassemia/HbE patients, 8 splenectomized β-thalassemia/HbE patients and 20 healthy volunteers were recruited to this study. Platelet activation and hypercoagulable parameters including levels of CD62P and prothrombin fragment 1 + 2 were analyzed by flow cytometry and ELISA, respectively. A proteomic analysis was conducted to compare the platelet proteome between patients and normal subjects, and the results were validated by western blot analysis. The β-thalassemia/HbE patients showed significantly higher levels of CD62P and prothrombin fragment 1 + 2 than normal subjects. The levels of platelet activation and hypercoagulation found in patients were strongly associated with splenectomy status. The platelet proteome analysis revealed 19 differential spots which were identified to be 19 platelet proteins, which included 10 cytoskeleton proteins, thrombin generation related proteins, and antioxidant enzymes. Our findings highlight markers of coagulation activation and molecular pathways known to be associated with the pathogenesis of platelet activation, the hypercoagulable state, and consequently with the thrombosis observed in β-thalassemia/HbE patients.
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Affiliation(s)
- Puangpaka Chanpeng
- Oxidation in Red Cell Disorders and Health Task Force, Department of Clinical Microscopy, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Saovaros Svasti
- Thalassemia Research Center, Institute of Molecular Biosciences, Mahidol University, Bangkok, Thailand
| | - Kittiphong Paiboonsukwong
- Thalassemia Research Center, Institute of Molecular Biosciences, Mahidol University, Bangkok, Thailand
| | - Duncan R Smith
- Molecular Pathology Laboratory, Institute of Molecular Biosciences, Mahidol University, Bangkok, Thailand
| | - Kamonlak Leecharoenkiat
- Oxidation in Red Cell Disorders and Health Task Force, Department of Clinical Microscopy, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand.
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Uaprasert N, Satitthummanid S, Akkawat B, Sutcharitchan P, Rojnuckarin P. Vascular and hemostatic alterations associated with pulmonary hypertension in β-thalassemia hemoglobin E patients receiving regular transfusion and iron chelation. Thromb Res 2018; 174:104-112. [PMID: 30584959 DOI: 10.1016/j.thromres.2018.12.021] [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: 09/19/2018] [Revised: 11/18/2018] [Accepted: 12/19/2018] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Pulmonary hypertension (PH) is the commonest cardiac complication in β-thalassemia intermedia, including β-thalassemia/hemoglobin E (β-thal/HbE), and is strongly associated with splenectomy. We aimed to define the prevalence and comprehensively explore mechanisms of PH in β-thal/HbE patients receiving regular transfusion and iron chelation, which were reported to alleviate PH. MATERIALS AND METHODS β-Thal/HbE patients receiving regular transfusion and iron chelation over one year were enrolled. Patients at risk for PH were defined by tricuspid-regurgitant-jet-velocity (TRV) ≥ 2.5 m/s. Laboratory and echocardiographic variables were compared with healthy controls. RESULTS There were 68 β-thal/HbE, including 31 (45.6%) splenectomized patients, and 38 controls included for analysis. PH was detected in 29 β-thal/HbE (42.6%). β-Thal/HbE with PH had a significant reduction in nitric oxide metabolites (NOx) but elevations in thrombin-antithrombin (TAT) complex, soluble thrombomodulin (sTM), endothelin-1 (ET-1) and flow-mediated dilation (FMD) values compared to those without PH (all, p < 0.05). TRV was significantly correlated with NOx, TAT, sTM, ET-1 and FMD values (r = -0.514, r = 0.281, r = 0.313, r = 0.245 and r = -0.474; all p < 0.05). Erythropoietic activity, serum ferritin, circulating total tissue factor (TF) antigen, microparticle-associated TF activity, microparticle's procoagulant activity and soluble p-selectin levels were not different between PH and non-PH subgroups. Notably, there were no significant associations between splenectomy and PH. CONCLUSIONS PH remains prevalent in β-thal/HbE patients receiving long-term transfusion and iron chelation. PH is not associated with splenectomy status but correlated with NO depletion, TF-independent hypercoagulability and endothelial perturbation.
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Affiliation(s)
- Noppacharn Uaprasert
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand.
| | - Sudarat Satitthummanid
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and Cardiac Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Benjaporn Akkawat
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Pranee Sutcharitchan
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Ponlapat Rojnuckarin
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
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Rashidi F, Sate H, Mohammadi A, Koohi A, Nejati B, Naybzadeh A. Echocardiographic evaluation of prevalence of pulmonary hypertension in β-thalassemia major: A cross sectional study. Pediatr Hematol Oncol 2018; 35:322-330. [PMID: 30468099 DOI: 10.1080/08880018.2018.1534914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Pulmonary hypertension is a common complication associated with thalassemia syndromes and it may play an important role in the pathogenesis of right ventricle failure. The true prevalence of pulmonary hypertension in patients with thalassemia major remains unclear and has been reported to be between 2 and 79%. MATERIALS AND METHODS In total, 70 patients with thalassemia major were initially examined. Patients with valvular left heart disease, congenital heart diseases such as atrial septal defect (ASD) and ventricular septal defect (VSD), left heart failure, and chronic embolism were excluded. All patients with thalassemia major underwent echocardiography. Based on tricuspid regurgitation velocity (TRV), the patients were divided into the following three groups: low, medium, and high risk of pulmonary hypertension. RESULTS The mean age of the subjects was 24 y; 60.6% of the subjects were males and 39.4% of the subjects were females. Overall, three (4.5%) subjects were considered at a high risk of pulmonary hypertension. The mean hemoglobin level in the patients with a high probability of pulmonary hypertension was 8.2 g/dL and that in the patients with a low or medium probability of pulmonary hypertension was 9.1 g/dL. No significant difference was observed between the groups (p = .059). CONCLUSION This study showed that, based on new echocardiography criteria, the prevalence of pulmonary hypertension secondary to β-thalassemia was 4.5% and there was no correlation between TRV and the number of received blood units or disease duration.
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Affiliation(s)
- Farid Rashidi
- a Tuberclosis and Lung Disease Research Center , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Hossein Sate
- b Department of Cardiology, Cardiovascular Research Center , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Ali Mohammadi
- a Tuberclosis and Lung Disease Research Center , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Ata Koohi
- a Tuberclosis and Lung Disease Research Center , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Babak Nejati
- c Oncology Research Center , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Ahad Naybzadeh
- c Oncology Research Center , Tabriz University of Medical Sciences , Tabriz , Iran
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17
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Haw A, Palevsky HI. Pulmonary hypertension in chronic hemolytic anemias: Pathophysiology and treatment. Respir Med 2018; 137:191-200. [DOI: 10.1016/j.rmed.2018.02.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 01/31/2018] [Accepted: 02/26/2018] [Indexed: 01/19/2023]
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18
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Segraves JM, Cartin-Ceba R, Leise MD, Krowka MJ. Relationship between portopulmonary hypertension and splenectomy: Mayo Clinic experience and review of published works. Hepatol Res 2018; 48:E340-E346. [PMID: 28667665 DOI: 10.1111/hepr.12930] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 06/23/2017] [Indexed: 12/31/2022]
Abstract
AIM Portopulmonary hypertension is a serious complication of portal hypertension that can lead to right heart failure and death. To our knowledge, an association between portopulmonary hypertension and prior splenectomy has not been described previously. The goals of this study were to describe the frequency of splenectomy in portopulmonary hypertension and compare selected parameters between portopulmonary hypertension subgroups. METHODS This is a retrospective analysis of patients diagnosed with portopulmonary hypertension between 1 January 1988 and 30 June 2015 at Mayo Clinic (Rochester, MN, USA). We compared age, sex, right ventricle systolic pressure by echocardiography, and right heart catheterization measurements/calculations among subgroups of portopulmonary hypertension patients with splenectomy and/or autoimmune liver disease (autoimmune hepatitis/primary biliary cirrhosis/primary sclerosing cholangitis). RESULTS The cohort consisted of 141 patients, of whom 8 (6%) had a history of splenectomy prior to the development of portopulmonary hypertension. Twenty-seven (19%) portopulmonary hypertension patients had autoimmune liver disease, and 5 of 8 (62.5%) splenectomized portopulmonary hypertension patients had autoimmune liver disease. No significant difference was noted in right heart catheterization measurements/calculations between splenectomized and non-splenectomized portopulmonary hypertension patients. Right ventricle systolic pressure by echocardiography was significantly higher in those splenectomized. CONCLUSIONS Prior history of splenectomy in portopulmonary hypertension was 6% in this cohort. The combination of autoimmune liver disease and splenectomy in portopulmonary hypertension was not uncommon. History of splenectomy in patients with portal hypertension and/or autoimmune liver disease may have clinical implications.
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Affiliation(s)
- Justin M Segraves
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rodrigo Cartin-Ceba
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Michael D Leise
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Krowka
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
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19
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Review of the Association between Splenectomy and Chronic Thromboembolic Pulmonary Hypertension. Ann Am Thorac Soc 2018; 13:945-54. [PMID: 27058013 DOI: 10.1513/annalsats.201512-826fr] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Recent evidence suggests that there may be a link between splenectomy and the later development of pulmonary hypertension, in particular World Health Organization group IV pulmonary hypertension (chronic thromboembolic pulmonary hypertension). Epidemiological studies have demonstrated an odds ratio as high as 18 for the development of chronic thromboembolic pulmonary hypertension after splenectomy in comparison with matched control subjects who have not undergone splenectomy. The mechanisms governing the association between removal of the spleen and the subsequent development of chronic thromboembolic pulmonary hypertension remain incompletely understood; however, recent advances in understanding of coagulation homeostasis have shed some light on this association. Splenectomy increases the risk of venous thromboembolic disease, a necessary precursor of chronic thromboembolic pulmonary hypertension, by generating a prothrombotic state. This prothrombotic state likely results from a reduction in the removal of circulating procoagulant factors from the bloodstream after splenectomy. Although much is to be learned, circulating microparticles have emerged as the most likely mediator for the development of thrombosis after splenectomy. Apparently because of a reduction in reticuloendothelial cell clearance, microparticle levels are elevated in patients after splenectomy. Elevated circulating microparticle levels have been linked to thromboembolism and pulmonary hypertension in a dose-dependent fashion. It is important for health care providers to be aware of the link between splenectomy and chronic thromboembolic pulmonary hypertension. We are optimistic that clarification of the exact mechanisms that govern this association will yield clinical guidelines and potential treatments.
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20
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Mathews V, Balasubramanian P, Abraham A, George B, Srivastava A. Allogeneic stem cell transplantation for thalassemia major in India. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2017. [DOI: 10.1016/j.phoj.2018.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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21
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Pulmonary Hypertension in Children With β Thalassemia Major, Are Splenectomy and High-Ferritin Levels Related or Not? J Pediatr Hematol Oncol 2017; 39:259-265. [PMID: 28234742 DOI: 10.1097/mph.0000000000000803] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We evaluated the risk of pulmonary hypertension (PH) by measuring the velocity of the tricuspid regurgitation jet velocity (TRV) on echocardiography and the associations among the TRV, ferritin, and history of splenectomy in children with β thalassemia major (TM). In total, 85 children with TM were examined with continuous Doppler flow. Patients with an abnormal TRV (>2.5 m/s) were grouped into those with a TRV of 2.5 to 2.9 m/s and TRV>2.9 m/s. A TRV of >2.5 m/s was identified in 72; 31 (36%) of these patients had a TRV of >2.9 m/s, suggesting a risk for significant PH. The ferritin concentration was significantly higher in patients with a TRV of >2.9 m/s and showed a positive correlation with a TRV. The TRV was significantly correlated with markers of diastolic function: the tricuspid peak early diastolic wave (E) was higher in patients with a TRV of >2.9 m/s and showed a significant correlation with the TRV (R=0.315). The ratio of the TRV over the velocity-time integral (VTI) at the right ventricular outflow tract (TRV/VTI RVOT), which is correlated with the pulmonary vascular resistance, was higher in patients with a TRV of >2.9 m/s. In total, 27 patients had splenectomy. Splenectomized patients had a higher TRV and splenectomy was correlated with the TRV (R=-0.221). A risk of PH as defined by a TRV of >2.9 m/s was common in our patients with TM. Screening with Doppler flow indices on echocardiography can detect PH in early stages.
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22
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Tantawy AAG, Adly AAM, Ismail EAR, Youssef OI, Ali ME. Soluble fms-Like Tyrosine Kinase 1 as a Link Between Angiogenesis and Endothelial Dysfunction in Pediatric Patients With β-Thalassemia Intermedia. Clin Appl Thromb Hemost 2017; 23:943-950. [DOI: 10.1177/1076029617692879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Endothelial damage has been implicated in the pathogenesis of vascular complications in β-thalassemia intermedia (β-TI). Soluble fms-like tyrosine kinase 1 (sFLT-1) is a member of the vascular endothelial growth factor receptor (VEGFR) family. Soluble fms-like tyrosine kinase 1 is an antiangiogenic protein that induces endothelial dysfunction by adhering to and inhibiting VEGF and placenta growth factor. The aim of this study was to assess the level of sFLT-1 in 35 children and adolescents with β-TI, correlating it with markers of hemolysis and iron overload as well as cardiopulmonary complications. Patients were studied focusing on the history of cardiac disease, splenectomy, transfusion, chelation/hydroxyurea therapy, serum ferritin, and sFLT-1 levels. Echocardiography and measurement of carotid intima–media thickness (CIMT) were done for all participants. Soluble fms-like tyrosine kinase 1 was significantly higher in TI patients compared to the control group (median [interquartile range], 110 [80-155] pg/mL versus 70 [60-90] pg/mL; P < .001). Splenectomized patients and those who had pulmonary hypertension risk or heart disease had higher sFLT-1 levels than those without ( P < .001). The sFLT-1 cutoff value that differentiates patients with and without pulmonary hypertension risk or heart disease was determined. Soluble fms-like tyrosine kinase 1 was lower among patients who received chelation therapy and/or hydroxyurea. Significant positive relations were observed between sFLT-1 and lactate dehydrogenase, serum ferritin, liver iron concentration, tricuspid regurgitant jet velocity, and CIMT. We suggest that sFLT-1 represents a link between angiogenesis, endothelial dysfunction, and subclinical atherosclerosis. Measurement of sFLT-1 as a marker of vascular dysfunction in β-TI may provide utility for early identification of patients at increased risk of cardiopulmonary complications.
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Affiliation(s)
| | | | | | | | - Mohamed ElSayed Ali
- Pediatrics Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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23
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Mathew R, Huang J, Wu JM, Fallon JT, Gewitz MH. Hematological disorders and pulmonary hypertension. World J Cardiol 2016; 8:703-718. [PMID: 28070238 PMCID: PMC5183970 DOI: 10.4330/wjc.v8.i12.703] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/07/2016] [Accepted: 10/09/2016] [Indexed: 02/06/2023] Open
Abstract
Pulmonary hypertension (PH), a serious disorder with a high morbidity and mortality rate, is known to occur in a number of unrelated systemic diseases. Several hematological disorders such as sickle cell disease, thalassemia and myeloproliferative diseases develop PH which worsens the prognosis. Associated oxidant injury and vascular inflammation cause endothelial damage and dysfunction. Pulmonary vascular endothelial damage/dysfunction is an early event in PH resulting in the loss of vascular reactivity, activation of proliferative and antiapoptotic pathways leading to vascular remodeling, elevated pulmonary artery pressure, right ventricular hypertrophy and premature death. Hemolysis observed in hematological disorders leads to free hemoglobin which rapidly scavenges nitric oxide (NO), limiting its bioavailability, and leading to endothelial dysfunction. In addition, hemolysis releases arginase into the circulation which converts L-arginine to ornithine, thus bypassing NO production. Furthermore, treatments for hematological disorders such as immunosuppressive therapy, splenectomy, bone marrow transplantation, and radiation have been shown to contribute to the development of PH. Recent studies have shown deregulated iron homeostasis in patients with cardiopulmonary diseases including pulmonary arterial hypertension (PAH). Several studies have reported low iron levels in patients with idiopathic PAH, and iron deficiency is an important risk factor. This article reviews PH associated with hematological disorders and its mechanism; and iron homeostasis and its relevance to PH.
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Bazarbachi AHA, Chaya BF, Moukhadder HM, Taher AT. Non-Transfusion-Dependent Thalassaemia: A Panoramic Survey from Pathophysiology to Treatment. EUROPEAN MEDICAL JOURNAL 2016. [DOI: 10.33590/emj/10311793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
Non-transfusion-dependent thalassaemia (NTDT) is a rather broad term that encompasses a group of thalassaemia syndromes, most commonly β-thalassaemia intermedia, haemoglobin E/β-thalassemia, and α-thalassaemia intermedia (haemoglobin H disease). Importantly, these entities do not require regular blood transfusions for survival, and therefore have transfusion independence. Clinical morbidities associated with the NTDTs are the end result of the culmination of three principal pathophysiological aberrancies: ineffective erythropoiesis, chronic anaemia (and associated haemolysis), and iron overload. Such complications involve multiple organs and organ systems; hence, the importance of prompt identification of at-risk individuals and holistic management of diagnosed subjects can never be overstated. Several management options, both medical and surgical, remain at the disposal of involved clinicians, with a significant body of data favouring the virtue of iron chelation therapy, fetal haemoglobin induction, and treatment with blood transfusions, the latter only when absolutely indicated, with reservation of splenectomy to a few select cases. Yet, a better understanding of the molecular phenomena at the origin of the disease process in the NTDT syndromes calls for a pressing need to explore novel therapeutic modalities, in light of the increasing incidence of NTDT in the developed world.
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Affiliation(s)
| | - Bachar F. Chaya
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hassan M. Moukhadder
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali T. Taher
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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25
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Shalev H, Al-Athamen K, Levi I, Levitas A, Tamary H. Morbidity and mortality of adult patients with congenital dyserythropoietic anemia type I. Eur J Haematol 2016; 98:13-18. [PMID: 27206021 DOI: 10.1111/ejh.12778] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2016] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Hanna Shalev
- Pediatric Division, Soroka University Medical Center, Beer Sheva, Israel
| | - Kaid Al-Athamen
- Hematology Department Soroka Medical Center, Faculty of Medicine, Ben-Gurion University, Beer Sheva, Israel
| | - Itai Levi
- Hematology Department Soroka Medical Center, Faculty of Medicine, Ben-Gurion University, Beer Sheva, Israel
| | - Aviva Levitas
- Pediatric Cardiology Unit, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion University of Negev, Beer-Sheva, Israel
| | - Hannah Tamary
- Hematology Unit, Schneider Children's Medical Center of Israel, Petach Tikva; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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26
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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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27
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O'Neal HR, Niven AS, Karam GH. Critical Illness in Patients With Asplenia. Chest 2016; 150:1394-1402. [PMID: 27068019 DOI: 10.1016/j.chest.2016.03.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 02/29/2016] [Accepted: 03/27/2016] [Indexed: 10/22/2022] Open
Abstract
The critically ill, asplenic patient presents a variety of management challenges. Historically, the focus of the care of the asplenic population has been the prevention and management of infection, including the often-fatal overwhelming postsplenectomy infection with encapsulated organisms such as Streptococcus pneumoniae. Recently, however, there has been increasing recognition of the spleen's function in areas outside of immunity because the asplenic state has been identified as a risk factor for such vascular complications as thrombosis and pulmonary hypertension resulting from dysregulated inflammation and coagulation. Because of the relatively small size of this population and the relative infrequency with which critical illness occurs in it, there are few controlled trials that can serve as a basis for therapeutic maneuvers; thus, optimal management requires an astute clinician with an understanding of the pathogenetic mechanisms underlying the reported consequences of splenectomy. The purpose of this review is to explore the pathophysiology of the asplenic state-impairment in adaptive immunity, loss of blood filtration, endothelial dysfunction, and dysregulated coagulation-and how it leads to infection, thrombosis, and pulmonary hypertension as well as to discuss the implications of these conditions on the management of the critically ill, splenectomized patient.
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Affiliation(s)
- Hollis R O'Neal
- LSU Health Sciences Center - Baton Rouge, Department of Internal Medicine, Baton Rouge, LA
| | - Alexander S Niven
- Uniformed Services University of the Health Sciences, Department of Medicine, Bethesda, MD
| | - George H Karam
- LSU Health Sciences Center - Baton Rouge, Department of Internal Medicine, Baton Rouge, LA.
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28
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Natesirinilkul R, Charoenkwan P, Nawarawong W, Boonsri S, Tantivate P, Wongjaikum S, Manowong S, Sanguansermsri T. Hypercoagulable state as demonstrated by thromboelastometry in hemoglobin E/beta-thalassemia patients: Association with clinical severity and splenectomy status. Thromb Res 2016; 140:125-131. [DOI: 10.1016/j.thromres.2016.02.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 01/16/2016] [Accepted: 02/12/2016] [Indexed: 01/12/2023]
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29
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Fraidenburg DR, Machado RF. Pulmonary hypertension associated with thalassemia syndromes. Ann N Y Acad Sci 2016; 1368:127-39. [PMID: 27008311 PMCID: PMC4870173 DOI: 10.1111/nyas.13037] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 02/05/2016] [Accepted: 02/11/2016] [Indexed: 01/19/2023]
Abstract
Chronic hemolytic anemia has increasingly been identified as an important risk factor for the development of pulmonary hypertension (PH). Within the thalassemia syndromes, there are multiple mechanisms, both distinct and overlapping, by which PH develops and that differ among β-thalassemia major or intermedia patients. PH in β-thalassemia major correlates with the severity of hemolysis, yet in patients whose disease is well treated with chronic transfusion therapy, the development of PH can be related to cardiac dysfunction and the subsequent toxic effects of iron overload rather than hemolysis. β-Thalassemia intermedia, on the other hand, has a higher incidence of PH owing to the low level of hemolysis that exists over years without the requirement for frequent transfusions, while splenectomy is shown to play an important role in both types. Standard therapies such as chronic transfusion have been shown to mitigate PH, and appropriate chelation therapy can avoid the toxic effects of iron overload, yet is not indicated in many patients. Limited evidence exists for the use of pulmonary vasodilators or other therapies, such as l-carnitine, to treat PH associated with thalassemia. Here, we review the most recent findings regarding the pathogenic mechanisms, epidemiology, presentation, diagnosis, and treatment of PH in thalassemia syndromes.
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Affiliation(s)
- Dustin R Fraidenburg
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Roberto F Machado
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy Medicine, University of Illinois at Chicago, Chicago, Illinois
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Roggero S, Vullo S, Volpe G, Piga A, Albera C. Management of pulmonary arterial hypertension associated to thalassemia: when pulmonary endarterectomy is the best therapeutical option? A case report. J Thromb Thrombolysis 2015; 39:139-43. [PMID: 24788071 DOI: 10.1007/s11239-014-1073-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Pulmonary arterial hypertension (PAH) has been reported with nearly all forms of the inherited as well as the acquired hemolytic anemias. Although screening studies suggested that PAH has emerged as major complication of thalassemia patients, its impact on survival is unknown; the pathophysiology of the PAH in these patients is multifactorial, and a thorough diagnostic evaluation is essential. Understanding the PAH pathogenesis, diagnostic options, prevention is critical for clinicians who care for the thalassemic patients; there are virtually no high-quality data on the safety/efficacy of PAH treatment strategy in this patient population. We are reporting the case of a thalassemic patient suffering from progressive severe PAH, not responding to medical treatment and related to chronic thromboembolic disease. After carefully considering all the options, we decided to proceed with vascular disobliteration by pulmonary endarterectomy (PEA), the first line choice in these cases. This intervention led to a significant improvement in the clinical status and in the functional parameters. Therefore, even if haemolytic anemia-associated-PAH is included in the group I of the Dana-point classification, an individualized approach is recommended as well as a particular management with disease-specific measures and a comprehensive evaluation of other causes of PAH; this current report supports the feasibility and effectiveness of PEA also in the thalassemic patients with surgically accessible chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
- Simona Roggero
- Hemoglobinopathies Centre, San Luigi Hospital-Orbassano, University of Torino, Turin, Italy,
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Palkar AV, Agrawal A, Verma S, Iftikhar A, Miller EJ, Talwar A. Post splenectomy related pulmonary hypertension. World J Respirol 2015; 5:69-77. [PMID: 26949600 PMCID: PMC4778975 DOI: 10.5320/wjr.v5.i2.69] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 03/25/2015] [Accepted: 05/11/2015] [Indexed: 02/06/2023] Open
Abstract
Splenectomy predisposes patients to a slew of infectious and non-infectious complications including pulmonary vascular disease. Patients are at increased risk for venous thromboembolic events due to various mechanisms that may lead to chronic thromboembolic pulmonary hypertension (CTEPH). The development of CTEPH and pulmonary vasculopathy after splenectomy involves complex pathophysiologic mechanisms, some of which remain unclear. This review attempts to congregate the current evidence behind our understanding about the etio-pathogenesis of pulmonary vascular disease related to splenectomy and highlight the controversies that surround its management.
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Moghaddam HM, Badiei Z, Eftekhari K, Shakeri R, Farhangi H. Prevalence of Pulmonary Hypertension in Patients with Thalassemia Intermedia in 2009: a single center's experience. Electron Physician 2015; 7:1102-7. [PMID: 26388975 PMCID: PMC4574695 DOI: 10.14661/2015.1102-1107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 05/28/2015] [Indexed: 01/09/2023] Open
Abstract
Background: There are various clinical symptoms of thalassemia intermedia, and they lie roughly between those of major and minor forms of the disease. Patients with thalassemia intermedia occasionally require blood transfusions. This renders them susceptible to pulmonary arterial hypertension (PAH) syndrome, which is one of the most significant complications in patients with thalassemia intermedia. PAH is more common in in thalassemia intermedia than in thalassemia major, and it may cause cardiac complications in patients who are older than 30. The objective of this study was to estimate the prevalence of PAH in thalassemia intermedia patients so that they can be referred expeditiously for treatment, thereby preventing the complications that occur later. Methods: This cross sectional study was conducted under the supervision of hematology department of Mashhad Medical University. Forty-one patients with thalassemia intermedia were examined at the Sarvar Thalassemia and Hemophilia Clinic of Mashhad. Electrocardiography, chest radiography, and echocardiography tests were performed for all of the patients by the same pediatric cardiologist. The data were processed by SPSS software, version 11.5, and the results were analyzed using chi-squared, Student’s t, and Mann-Whitney tests. Results: The mean age of the patients was 21.93±8.34. They had been under pediatric heart specialists’ constant examination and treatment since their childhood when they were diagnosed with TI, and continue to receive regular follow-up care. The prevalence of pulmonary hypertension was 24% in our study population. In patients with thalassemia intermedia, the left ventricular (LV) mass indices were about 3–5 times higher than would be expected in a normal population. Patients with higher LV mass indices have a greater risk of developing pulmonary hypertension, and those with serum ferritin levels below 1000 ng/ml are less susceptible to diastolic dysfunction. Conclusion: Pulmonary hypertension is common in patients with thalassemia intermedia. Irregular chelation therapy or absence of this treatment might lead to diastolic dysfunction, and serum ferritin levels below 1000 ng/ml could be an important factor in preventing the development of diastolic dysfunction or slowing down its progression.
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Affiliation(s)
- Hassan Mottaghi Moghaddam
- Associate Professor of Pediatric Cardiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zahra Badiei
- Associate Professor of Pediatric Hematology & Oncology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Kambiz Eftekhari
- Assistant Professor of Pediatric Gastroenterology, Bahrami Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Shakeri
- Fellow of Pediatric Cardiology, Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Farhangi
- Assistant Professor of Pediatric Hematology & Oncology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Inthawong K, Charoenkwan P, Silvilairat S, Tantiworawit A, Phrommintikul A, Choeyprasert W, Natesirinilkul R, Siwasomboon C, Visrutaratna P, Srichairatanakool S, Chattipakorn N, Sanguansermsri T. Pulmonary hypertension in non-transfusion-dependent thalassemia: Correlation with clinical parameters, liver iron concentration, and non-transferrin-bound iron. ACTA ACUST UNITED AC 2015; 20:610-7. [PMID: 25964094 DOI: 10.1179/1607845415y.0000000014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Pulmonary hypertension is a major cardiac complication in non-transfusion-dependent thalassemia (NTDT). Several clinical and laboratory parameters, including iron overload, have been shown to have a positive correlation with the incidence of pulmonary hypertension. Non-transferrin-bound iron (NTBI) is a form of free-plasma iron that is a good indicator of iron overload. OBJECTIVES The aim of this study was to determine the prevalence of pulmonary hypertension in patients with NTDT and to investigate its correlation with the clinical parameters, liver iron concentration (LIC) and NTBI. METHODS Patients with NTDT were evaluated using echocardiography, and magnetic resonance imaging for cardiac T2* and LIC. Pulmonary hypertension was defined as peak tricuspid regurgitation velocity ≥2.9 m/s measured using trans-thoracic echocardiography. Clinical parameters and the status of iron overload as determined by LIC, serum ferritin, and NTBI level were evaluated for their association with pulmonary hypertension. RESULTS Of 76 NTDT patients, mean age 23.7 ± 8.5 years, seven patients (9.2%) had pulmonary hypertension. Previous splenectomy (71.4 vs. 24.6%, P-value 0.019), higher cumulative red blood cell (RBC) transfusions (received ≥10 RBC transfusions 85.7 vs. 33.3%, P-value 0.011), higher nucleated RBCs (353 ± 287 vs. 63 ± 160/100 white blood cells, P-value <0.001), and a high NTBI level (5.7 ± 3.0 vs. 3.3 ± 2.8 µmol/l, P-value 0.034) were associated with pulmonary hypertension. There was no significant correlation between LIC or serum ferritin and pulmonary hypertension. CONCLUSION Pulmonary hypertension in NTDT is common, and is associated with splenectomy and its related factors. NTBI level shows a significant correlation with pulmonary hypertension.
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Meloni A, Detterich J, Pepe A, Harmatz P, Coates TD, Wood JC. Pulmonary hypertension in well-transfused thalassemia major patients. Blood Cells Mol Dis 2015; 54:189-94. [PMID: 25488617 PMCID: PMC4297514 DOI: 10.1016/j.bcmd.2014.11.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 11/13/2014] [Indexed: 02/09/2023]
Abstract
The risk for pulmonary hypertension (PH) in thalassemia major (TM) patients remains controversial. We report echocardiography results from 60 TM patients: we evaluated the association between tricuspid regurgitation velocities (TRV), iron stores, and serologic markers of hemolysis and arginine dysregulation. Patients were enrolled from August 2004 until May 2009. All parameters were inversely weighted by the number of exams. TRV was comparable between sexes and it was uncorrelated with age. At the first exam, TR velocities at the upper limits of normal (2.5-2.7m/s) were observed in 8 patients. An abnormal TRV (2.9m/s) was found in 1 patient. Borderline increases in TRV were associated with a reduced global arginine bioavailability (R=-0.399 P=0.005), increased anemia (hemoglobin: R=-0.219 P=0.0461), cardiac index (R=0.223 P=0.0481), and diastolic dysfunction (E/A: R=0.289 P=0.0088; E/E': R=0.223 P=0.0453), but not hemolysis, iron overload and systolic function evaluated by Magnetic Resonance Imaging, and splenectomy. Well-transfused TM patients have a lower risk for PH than thalassemia intermedia patients. However, they do have vascular stressors that raise their lifetime PH risk to levels higher than for the general population. Consequently, we support recommendations for annual echocardiographic screening and cardiac catheterization for persistent TRV above 3m/s.
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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, CA, USA
| | - Jon Detterich
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Alessia Pepe
- CMR Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Paul Harmatz
- Division of Gastroenterology, Children's Hospital Oakland, Oakland, CA, USA
| | - Tom D Coates
- Section of Hematology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John C Wood
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Radiology, Children's Hospital Los Angeles, Los Angeles, CA, USA.
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Taher AT, Radwan A, Viprakasit V. When to consider transfusion therapy for patients with non-transfusion-dependent thalassaemia. Vox Sang 2015; 108:1-10. [PMID: 25286743 PMCID: PMC4302976 DOI: 10.1111/vox.12201] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 07/17/2014] [Accepted: 08/05/2014] [Indexed: 01/19/2023]
Abstract
Non-transfusion-dependent thalassaemia (NTDT) refers to all thalassaemia disease phenotypes that do not require regular blood transfusions for survival. Thalassaemia disorders were traditionally concentrated along the tropical belt stretching from sub-Saharan Africa through the Mediterranean region and the Middle East to South and South-East Asia, but global migration has led to increased incidence in North America and Northern Europe. Transfusionists may be familiar with β-thalassaemia major because of the lifelong transfusions needed by these patients. Although patients with NTDT do not require regular transfusions for survival, they may require transfusions in some instances such as pregnancy, infection or growth failure. The complications associated with NTDT can be severe if not properly managed, and many are directly related to chronic anaemia. Awareness of NTDT is important, and this review will outline the factors that should be taken into consideration when deciding whether to initiate and properly plan for transfusion therapy in these patients in terms of transfusion interval and duration of treatment.
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Affiliation(s)
- A T Taher
- American University of Beirut, Beirut, Lebanon
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Srihirun S, Tanjararak N, Chuncharunee S, Sritara P, Kaewvichit R, Fucharoen S, Pattanapanyasat K, Sibmooh N. Platelet hyperactivity in thalassemia patients with elevated tricuspid regurgitant velocity and the association with hemolysis. Thromb Res 2015; 135:121-6. [DOI: 10.1016/j.thromres.2014.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 10/06/2014] [Accepted: 10/08/2014] [Indexed: 01/19/2023]
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Chueamuangphan N, Wongtheptian W, Patumanond J, Sukonthasarn A, Chuncharunee S, Tawichasri C, Nawarawong W. Effect of acetylsalicylic acid on thalassemia with pulmonary arterial hypertension. Int J Gen Med 2014; 7:525-9. [PMID: 25506240 PMCID: PMC4259867 DOI: 10.2147/ijgm.s71644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To compare pulmonary artery systolic pressure (PASP) between thalassemic patients with pulmonary arterial hypertension (PAH) for whom acetylsalicylic acid (ASA) was and was not prescribed after 1 year. METHODS A retrospective cohort study was conducted at the hematological outpatient clinic at Chiang Rai Hospital, Chiang Rai, Thailand. All new cases of thalassemia with PAH from January 2007 to January 2012 were studied at the first month and at 12 months. The patients were classified into two groups. In one group, ASA 81 mg daily was prescribed for 1 year, whereas in another group no ASA was prescribed, due to its contraindications, which included bleeding, gastrointestinal side effects, and thrombocytopenia. PASP, estimated by a Doppler echocardiography, was measured by the same cardiologist. Propensity score adjustment was used to control confounding variables by indication and contraindication. Multivariable regression analysis was used to evaluate the effects of ASA. RESULTS Of the 63 thalassemia patients with PAH, there were 47 (74.6%) in the ASA group and 16 (25.4%) in the no ASA group. ASA, as compared with no ASA, did not significantly reduce PASP (adjusted difference -0.95; 95% confidence interval -16.99 to 15.10; P=0.906). CONCLUSION Low-dose ASA may not have a beneficial effect on PASP after 1 year of treatment of PAH in thalassemia.
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Affiliation(s)
- Nonlawan Chueamuangphan
- Clinical Epidemiology Program, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand ; Department of Medicine, Chiang Rai Hospital, Chiang Rai, Thailand
| | | | - Jayanton Patumanond
- Clinical Epidemiology Program, Faculty of Medicine, Thammasat University, Bangkok, Thailand
| | - Apichard Sukonthasarn
- Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Suporn Chuncharunee
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Weerasak Nawarawong
- Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Harb AR, Saliba AN, Taher AT. Non-Transfusion Dependent Thalassemia: Translating Evidence to Guidelines. THALASSEMIA REPORTS 2014. [DOI: 10.4081/thal.2014.4863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The thalassemias are a group of inherited disorders of hemoglobin synthesis characterized by various degrees of defective production of the α- or β-globin chains of adult hemoglobin A. Non-transfusion- dependent thalassemia (NTDT) includes a group of thalassemia patients who do not require regular RBC transfusions for survival, but may require occasional transfusions due to infection or pregnancy or may require more regular transfusions later in life due to splenomegaly or other complications. Due to the rising phenomenon of global migration, this previously well-localized entity is currently spreading more and more worldwide reaching Northern America and Northern Europe. The clinical picture of NTDT is governed by the severity of the ineffective erythropoiesis and the chronic hemolytic anemia, which, in turn, lead to iron overload, hypercoagulability, and an array of clinical complications involving almost every organ system. Patients with NTDT suffer from complications that are distinct from those encountered in patients with transfusion- dependent thalassemia (TDT) in addition to the complications shared by both TDT and NTDT. As a consequence, patients with NTDT deserve a care specifically tailored to their needs. In the care of patients with NTDT, aiming at a standardized yet personalized care is not an easy task especially that NTDT patients lie on a heterogeneous spectrum with a wide variability in their clinical presentation and response to therapy. Therefore, guidelines emerge as a necessity to answer the specific needs of NTDT patients and the clinicians caring for them. In this article, we summarize the complications most commonly associated with NTDT and the recommendations of the guidelines for the management of patients with NTDT, based on the best available evidence.
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Teawtrakul N, Pussadhamma B, Ungprasert P, Prayalaw P, Fucharoen S, Jetsrisuparb A, Pongudom S, Sirijerachai C, Chansung K, Wanitpongpun C, Thongbuaban S, Thinkhamrop B, Chuncharunee S. A risk score for predicting pulmonary hypertension in patients with non-transfusion-dependent thalassemia in northeastern Thailand: The E-SAAN score. Hematology 2014; 20:416-21. [DOI: 10.1179/1607845414y.0000000211] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Affiliation(s)
- Nattiya Teawtrakul
- Division of HematologyDepartment of Internal Medicine, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Burabha Pussadhamma
- Division of Cardiovascular systemDepartment of Internal Medicine, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Phuangpaka Ungprasert
- Division of Cardiovascular systemDepartment of Internal Medicine, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Patcharawadee Prayalaw
- Center for Research and Development of Medical Diagnostic LaboratoriesFaculty of Associated Medical Science, Khon Kaen University, Khon Kaen, Thailand
| | - Supan Fucharoen
- Center for Research and Development of Medical Diagnostic LaboratoriesFaculty of Associated Medical Science, Khon Kaen University, Khon Kaen, Thailand
| | - Arunee Jetsrisuparb
- Division of HematologyDepartment of Pedriatrics, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | | | - Chittima Sirijerachai
- Division of HematologyDepartment of Internal Medicine, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Kanchana Chansung
- Division of HematologyDepartment of Internal Medicine, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - Chinadol Wanitpongpun
- Division of HematologyDepartment of Internal Medicine, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | | | - Bandit Thinkhamrop
- Department of Biostatistics and DemographyFaculty of Public Health, Khon Kaen University, Khon Kaen, Thailand
| | - Suporn Chuncharunee
- Division of HematologyDepartment of Internal Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Mathews V, Srivastava A, Chandy M. Allogeneic stem cell transplantation for thalassemia major. Hematol Oncol Clin North Am 2014; 28:1187-200. [PMID: 25459187 DOI: 10.1016/j.hoc.2014.08.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Allogeneic stem cell transplant remains the only curative option for β-thalassemia major. In patients with good risk features it is reasonable to anticipate a greater than 90% chance of a successful transplant outcome. The conventional risk stratification system has limitations and alternative systems are being explored to better identify subsets that require innovative approaches. Several novel regimens have been evaluated to reduce treatment-related morbidity and mortality. There remain challenges in improving the clinical outcome of high-risk patients. There are limited data on the role of splenectomy before transplantation or optimal posttransplant chelation and care of these patients.
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Affiliation(s)
- Vikram Mathews
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore, TN 632004, India.
| | - Alok Srivastava
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore, TN 632004, India
| | - Mammen Chandy
- Department of Haematology and Bone Marrow Transplant, Tata Medical Center, Rajarhat, Kolkata 700020, India
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Chueamuangphan N, Patumanond J, Wongtheptien W, Nawarawong W, Sukonthasarn A, Chuncharunee S, Tawichasri C. Benefits of chronic blood transfusion in hemoglobin E/β thalassemia with pulmonary arterial hypertension. Int J Gen Med 2014; 7:411-6. [PMID: 25170276 PMCID: PMC4145826 DOI: 10.2147/ijgm.s66610] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective The aim of the research reported here was to compare pulmonary artery systolic pressure (PASP) and 6-minute walk distance after 1 year of follow-up in hemoglobin E/β thalassemia (E/β-Thal) with pulmonary arterial hypertension (PAH) patients who received chronic blood transfusions versus those who received occasional transfusions. Methods A nonrandomized clinical trial was conducted at the Hematological Outpatient Clinic of Chiang Rai Hospital, Thailand. All adult cases of E/β-Thal with PAH (defined as PASP >35 mmHg by Doppler echocardiography) were evaluated and followed for the next 12 months. The patients were classified into two groups by patient preference. Group 1 patients received chronic blood transfusions – one to two units of leukocyte-poor packed red cells every 2–4 weeks – over 1 year to maintain pre-transfusion hemoglobin levels of ≥7.0 g/dL. Group 2 patients received occasional transfusions over the course of 1 year, with more than 4 weeks between transfusions. All patients were treated with iron chelation when serum ferritin levels were ≥1,000 μg/dL. PASP and the 6-minute walk distance were evaluated at baseline and at 6 and 12 months. Propensity score adjustment was used to control for confounding by indication and contraindication. Multivariable regression analysis was used to evaluate the effects of chronic blood transfusion. Results There were 16 (53.3%) patients in Group 1 and 14 (46.7%) in Group 2. At 12 months, patients in Group 1 had a greater reduction in PASP than those in Group 1 (adjusted mean difference, −16.83; 95% confidence interval, −26.35 to −7.32; P=0.001). The 6-minute walk distance at 12 months in Group 1 patients was greater than that in Group 2 patients (adjusted mean difference, 46.55; 95% confidence interval, 18.08 to 75.02; P=0.001). Conclusion This study found evidence that chronic blood transfusions may have beneficial effects in PAH in thalassemia patients over 1 year.
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Affiliation(s)
- Nonlawan Chueamuangphan
- Clinical Epidemiology Program, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand ; Department of Medicine, Chiang Rai Hospital, Chiang Rai, Thailand
| | - Jayanton Patumanond
- Clinical Epidemiology Program, Faculty of Medicine, Thammasat University, Bangkok, Thailand
| | | | - Weerasak Nawarawong
- Department of Medicine Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Apichard Sukonthasarn
- Department of Medicine Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Suporn Chuncharunee
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Agha H, El Tagui M, El Ghamrawy M, Hady MA. The 6-min walk test: an independent correlate of elevated tricuspid regurgitant jet velocity in children and young adult sickle cell patients. Ann Hematol 2014; 93:1131-8. [DOI: 10.1007/s00277-014-2030-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 02/06/2014] [Indexed: 01/27/2023]
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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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Atichartakarn V, Chuncharunee S, Archararit N, Udomsubpayakul U, Lee R, Tunhasiriwet A, Aryurachai K. Prevalence and risk factors for pulmonary hypertension in patients with hemoglobin E/β-thalassemia disease. Eur J Haematol 2014; 92:346-53. [PMID: 24330103 DOI: 10.1111/ejh.12242] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2013] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To find the prevalence and risk factors of pulmonary hypertension (PHT) in adult patients with hemoglobin E/β-thalassemia disease (E/β-Thal). METHODS One hundred and ten clinically stable E/β-Thal outpatients, sixty-one of whom had undergone splenectomy, were prospectively studied using their clinical profiles, selected blood tests, chest roentgenogram, and transthoracic echocardiogram. Based on the pulmonary artery systolic pressure (PASP) values estimated by the echocardiogram of ≥36 mmHg, they were dichotomized into those with (PHT+) and without (PHT-) PHT. RESULTS PHT was found in 41 (37.3%) patients without gender preponderance. It was not due to the left heart and was not severe (PASP = 46.3 ± 10.4 mmHg). PASP was higher in splenectomized patients (48.0 ± 11 vs. 40.3 ± 4.7 mmHg (P = 0.004)). PHT was found in 32 of 61 (52.5%) splenectomized patients, mostly (53%) in the second decade, and rarely (6.3%) during the first 5 yr after splenectomy. PHT+ patients had more hemolysis (P = 0.001-0.04 depending on the parameters), more asplenic cases (P < 0.001), and higher serum soluble vascular cell adhesion molecule-1 (sVCAM-1) and high-sensitivity C-reactive protein levels (P = 0.004 and 0.008, respectively). Strong risk factors by univariate analysis were serum sVCAM-1 levels ≥1600 ng/mL, serum cell-free Hb ≥ 3 mg/dL, asplenia, and amount of NRBCs/100 WBCs >40. CONCLUSIONS Prevalence of PHT in E/β-Thal patients was 37.3% without gender preponderance. Those with severe hemolysis and asplenia invariably had severer PHT. Strong risk factors were asplenia and associated markedly elevated values of sVCAM-1, cell-free Hb, and NRBCs in blood.
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Affiliation(s)
- Vichai Atichartakarn
- Division of Hematology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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45
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Weledji EP. Benefits and risks of splenectomy. Int J Surg 2013; 12:113-9. [PMID: 24316283 DOI: 10.1016/j.ijsu.2013.11.017] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 10/27/2013] [Accepted: 11/24/2013] [Indexed: 12/22/2022]
Abstract
UNLABELLED Splenectomy is a powerful therapeutic procedure in a wide variety of medical disorders provided that it is not undertaken lightly and the risks are weighed against the potential benefits in each individual case. Most of this risk seems to be due to the underlying splenectomy indication and not to splenectomy alone. There has been an increased tendency in recent years towards splenic preservation to prevent not only the risk of subsequent overwhelming post-splenectomy infection (OPSI) but the long term risk of cardiovascular complications. As there is no condition that can be cured by splenectomy, this paper reviewed the rationale behind the indications for, and the associated risks. METHOD Electronic searches of the medline (PubMed) database, Cochrane library, and science citation index were performed to identify original published studies on splenectomy. Relevant articles were searched from relevant chapters in specialized texts and all included.
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Affiliation(s)
- Elroy P Weledji
- Department of Surgery, Faculty of Health Sciences, University of Buea, PO Box 126, Limbe, Cameroon.
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46
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Anthi A, Orfanos SE, Armaganidis A. Pulmonary hypertension in β thalassaemia. THE LANCET RESPIRATORY MEDICINE 2013; 1:488-96. [PMID: 24429247 DOI: 10.1016/s2213-2600(13)70078-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Pulmonary hypertension is one of the leading causes of morbidity and mortality in patients with haemolytic disorders and is a frequent finding in echocardiographic screening of patients with β thalassaemia. Substantial progress has been made in understanding of the multifactorial pathophysiology of pulmonary hypertension in β thalassaemia. Haemolysis, reduced nitric oxide bioavailability, iron overload, and hypercoagulopathy are among the main pathogenetic mechanisms. Various disease-directed therapeutic methods, such as transfusion, chelation, and splenectomy, have important roles in the development of pulmonary hypertension in β thalassaemia. Studies investigating the prevalence of pulmonary hypertension in β thalassaemia are mostly based on echocardiographic findings, and are thus limited by the scarcity of information derived from right heart catheterisation. Invasive pulmonary haemodynamic data are needed to clarify the true prevalence of pulmonary hypertension in β thalassaemia, to better understand the underlying pathophysiology and risk factors, and to define the optimum therapy for this devastating complication.
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Affiliation(s)
- Anastasia Anthi
- 2nd Department of Critical Care, University of Athens Medical School, Attikon University Hospital, Haidari, Athens, Greece; Pulmonary Hypertension Clinic, Attikon University Hospital, Haidari, Athens, Greece.
| | - Stylianos E Orfanos
- 2nd Department of Critical Care, University of Athens Medical School, Attikon University Hospital, Haidari, Athens, Greece; Pulmonary Hypertension Clinic, Attikon University Hospital, Haidari, Athens, Greece
| | - Apostolos Armaganidis
- 2nd Department of Critical Care, University of Athens Medical School, Attikon University Hospital, Haidari, Athens, Greece; Pulmonary Hypertension Clinic, Attikon University Hospital, Haidari, Athens, Greece
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47
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Yin XL, Zhang XH, Wu ZK, Zhao DH, Zhou YL, Yu YH, Liu TN, Fang SP, Zhou TH, Wang L, Huang J. Pulmonary hypertension risk in patients with hemoglobin h disease: low incidence and absence of correlation with splenectomy. Acta Haematol 2013; 130:153-9. [PMID: 23711936 DOI: 10.1159/000347177] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 01/14/2013] [Indexed: 01/24/2023]
Abstract
Pulmonary hypertension (PHT) is a common complication for patients with β thalassemia intermediate (TI), especially splenectomized patients. However, the frequency and risk factors of PHT in patients with hemoglobin H (HbH) disease is unknown. The purpose of this study was to identify the prevalence of PHT risk manifested as tricuspid regurgitant jet velocity (TRV) ≥2.5 m/s in patients with HbH disease and its correlation with splenectomy. One hundred and ninety-eight patients with HbH disease who visited the 303rd Hospital of the People's Liberation Army (Nanning, China) were investigated. Thirteen subjects (6.5%) were diagnosed as having a risk of PHT. Regression analyses showed that the prevalence of PHT risk was correlated only with age (r = 0.195, p = 0.006) and not with splenectomy. The risk of PHT in patients older than 35 years was 5.7 times (range 1.8-18.6) greater than that for patients younger than 35 years. For splenectomized patients compared to those with HbH disease, patients with TI had a higher frequency of PHT risk, higher nucleated red blood cell counts (46.03 ± 41.11 × 10(9)/l vs. 0.18 ± 1.19 × 10(9)/l, p < 0.001) and a higher platelet counts (837.6 ± 178.9 × 10(9)/l vs. 506.7 ± 146.2 × 10(9)/l, p < 0.001). PHT risk is low in patients with HbH disease and does not correlate with splenectomy. Patients older than 35 years should be monitored regularly.
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Affiliation(s)
- Xiao-Lin Yin
- Department of Hematology, 303rd Hospital of the People's Liberation Army, Nanning, PR China
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48
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Morris CR, Kim HY, Wood J, Porter JB, Klings ES, Trachtenberg FL, Sweeters N, Olivieri NF, Kwiatkowski JL, Virzi L, Singer ST, Taher A, Neufeld EJ, Thompson AA, Sachdev V, Larkin S, Suh JH, Kuypers FA, Vichinsky EP. Sildenafil therapy in thalassemia patients with Doppler-defined risk of pulmonary hypertension. Haematologica 2013; 98:1359-67. [PMID: 23585527 DOI: 10.3324/haematol.2012.082065] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Pulmonary hypertension is a common but often overlooked complication associated with thalassemia syndromes. There are limited data on the safety and efficacy of selective pulmonary vasodilators in this at-risk population. We, therefore, designed a 12-week, open-label, phase 1/2, pilot-scale, proof-of-principle trial of sildenafil therapy in 10 patients with β-thalassemia and at increased risk of pulmonary hypertension based on an elevated tricuspid regurgitant jet velocity >2.5 m/s on Doppler-echocardiography. Variables compared at baseline and after 12 weeks of sildenafil treatment included Doppler-echocardiographic parameters, 6-minute walked distance, Borg Dyspnea Score, New York Heart Association functional class, pulmonary function, and laboratory parameters. Treatment with sildenafil resulted in a significant decrease in tricuspid regurgitant jet velocity by 13.3% (3.0±0.7 versus 2.6±0.5 m/s, P=0.04), improved left ventricular end systolic/diastolic volume, and a trend towards a improved New York Heart Association functional class. No significant change in 6-minute walked distance was noted. Sildenafil was well tolerated, although minor expected adverse events were commonly reported. The total dose of sildenafil (mg) was strongly correlated with percent change in nitric oxide metabolite concentration in the plasma (ρ=0.80, P=0.01). There were also significant increases in plasma and erythrocyte arginine concentrations. Our study suggests that sildenafil is safe and may improve pulmonary hemodynamics in patients at risk of pulmonary hypertension; however, it was not demonstrated to improve the distance walked in 6 minutes. Clinical trials are needed to identify the best treatment strategy for pulmonary hypertension in patients with β-thalassemia. (clinicaltrials.gov identifier: NCT00872170).
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Affiliation(s)
- Claudia R Morris
- Department of Pediatrics, Division of Emergency Medicine, Emory-Children’s Center for Developmental Lung Biology,Emory University School of Medicine, Atlanta, GA, USA.
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Musallam KM, Taher AT, Rachmilewitz EA. β-thalassemia intermedia: a clinical perspective. Cold Spring Harb Perspect Med 2012; 2:a013482. [PMID: 22762026 PMCID: PMC3385943 DOI: 10.1101/cshperspect.a013482] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Our understanding of the molecular and pathophysiological mechanisms underlying the disease process in patients with β-thalassemia intermedia has substantially increased over the past decade. Earlier studies observed that patients with β-thalassemia intermedia experience a clinical-complications profile that is different from that in patients with β-thalassemia major. In this article, a variety of clinical morbidities are explored, and their associations with the underlying disease pathophysiology and risk factors are examined. These involve several organs and organ systems including the vasculature, heart, liver, endocrine glands, bone, and the extramedullary hematopoietic system. The effects of some therapeutic interventions on the development of clinical complications are also discussed.
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Affiliation(s)
- Khaled M Musallam
- Department of Medicine and Medical Specialties, IRCCS Cà Granda Foundation Maggiore Policlinico Hospital, 20122 Milan, Italy
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50
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Zanjani KS. Platelets in pulmonary hypertension: a causative role or a simple association? IRANIAN JOURNAL OF PEDIATRICS 2012; 22:145-57. [PMID: 23056879 PMCID: PMC3446075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Revised: 01/13/2012] [Accepted: 02/11/2012] [Indexed: 11/30/2022]
Abstract
PATHOPHYSIOLOGY OF PULMONARY ARTERIAL HYPERTENSION IS BASED ON THREE BASIC MECHANISMS: thrombotic pulmonary vascular lesions, vasoconstriction and vascular remodeling. Platelets are related to all of these mechanisms by their aggregation, production, storage and release of several mediators. The role of platelets is more prominent in some types of pulmonary arterial hypertension, including those which are secondary to inflammatory and infectious diseases, hemoglobinopathies, essential thrombocythemia, drugs, thromboembolism, and cardiac surgery. Most pulmonary antihypertensive drugs have a negative effect on platelets. In this review, the mechanisms of platelets association with pulmonary arterial hypertension, those types of pulmonary arterial hypertension with greatest platelet contribution to their pathophysiology, and the effects of pulmonary antihypertensive drugs on platelets are summarized.
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Affiliation(s)
- Keyhan Sayadpour Zanjani
- Corresponding Author:Address: Children's Medical Center, No 62, Dr Gharib St, 14194 Tehran, Iran. E-mail:
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