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Baskin-Miller J, Carson S, Jaffray J, Fletcher C, Singer J, Freyer DR, Wood J, Coates TD, Denton CC. Transfusional hemosiderosis in childhood cancer patients and survivors. Pediatr Blood Cancer 2024; 71:e31220. [PMID: 39096194 DOI: 10.1002/pbc.31220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/21/2024] [Accepted: 07/10/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND Children treated for cancer are at risk for adverse effects of iron due to transfusions administered during prolonged marrow suppression, which may increase exposure to toxic forms of iron, extrahepatic iron accumulation, and long-term organ damage. OBJECTIVE This study aimed to characterize the severity and organ distribution of clinically significant, multisystem iron overload (IO) in an at-risk cohort of pediatric cancer patients. METHODS This was a retrospective, cross-sectional study of childhood cancer patients who underwent a magnetic resonance imaging (MRI) due to clinical concern for IO. Data regarding cancer type and treatment, transfusion history, MRI and laboratory results, and treatment for IO were collected. Severity of IO was analyzed by non-parametric tests with respect to clinical characteristics. RESULTS Of the 103 patients, 98% of whom had a Cancer Intensity Treatment Rating (ITR-3) of 3 or higher, 53% (54/102) had moderate or greater hepatic siderosis, 80% (77/96) had pancreatic siderosis, 4% (3/80) had cardiac siderosis, and 45% (13/29) had pituitary siderosis and/or volume loss. Pancreatic iron was associated with both cardiac (p = .0043) and pituitary iron (p = .0101). In the 73 off-therapy patients, ferritin levels were lower (p = .0008) with higher correlation with liver iron concentration (LIC) (p = .0016) than on-therapy patients. Fifty-eight subjects were treated for IO. CONCLUSION In this heavily treated cohort of pediatric cancer patients, more than 80% had extrahepatic iron loading, which occurs with significant exposure to toxic forms of iron related to decreased marrow activity in setting of transfusions. Further studies should examine the effects of exposure to reactive iron on long-term outcomes and potential strategies for management.
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Affiliation(s)
- Jacquelyn Baskin-Miller
- Division of Pediatric Hematology Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Susan Carson
- Children's Center for Cancer, Blood Diseases and Bone Marrow Transplantation, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Julie Jaffray
- Division of Pediatric Hematology Oncology, Rady Children's Hospital, San Diego, California, USA
| | - Craig Fletcher
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Jessie Singer
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - David R Freyer
- Children's Center for Cancer, Blood Diseases and Bone Marrow Transplantation, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - John Wood
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Thomas D Coates
- Children's Center for Cancer, Blood Diseases and Bone Marrow Transplantation, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Christopher C Denton
- Children's Center for Cancer, Blood Diseases and Bone Marrow Transplantation, Children's Hospital of Los Angeles, Los Angeles, California, USA
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2
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Meloni A, Pistoia L, Ricchi P, Longo F, Cecinati V, Sorrentino F, Borsellino Z, Bagnato S, Rossi V, Fina P, Riva A, Renne S, Peritore G, Positano V, Cademartiri F. Magnetic Resonance Evaluation of Tissue Iron Deposition and Cardiac Function in Adult Regularly Transfused Thalassemia Intermedia Compared with Thalassemia Major Patients. J Clin Med 2024; 13:4791. [PMID: 39200932 PMCID: PMC11355279 DOI: 10.3390/jcm13164791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 07/31/2024] [Accepted: 08/13/2024] [Indexed: 09/02/2024] Open
Abstract
Objectives: This multicenter, retrospective, population-based, matched-cohort study compared clinical characteristics and magnetic resonance imaging (MRI) findings, including hepatic, pancreatic, and cardiac iron levels and cardiac function, between 135 adult regularly transfused thalassemia intermedia (TI) patients (44.73 ± 12.16 years, 77 females) and 135 age- and sex-matched thalassemia major (TM) patients (43.35 ± 9.83 years, 77 females), enrolled in the Extension-Myocardial Iron Overload in Thalassemia Network. Methods: The MRI protocol included the quantification of hepatic, pancreatic, and cardiac iron levels (R2* technique), the assessment of biventricular function parameters (cine images), and the detection of replacement myocardial fibrosis (late gadolinium enhancement technique). Results: Age, sex, frequency of splenectomy and chelation, and serum ferritin levels were not significantly different (p > 0.05) between the two groups, but TI patients started regular transfusions significantly later (p < 0.0001) and showed significantly lower pre-transfusion hemoglobin levels (p = 0.005). No difference was found in hepatic iron levels (p = 0.853). TI patients exhibited significantly lower pancreatic R2* values (p < 0.0001), also correcting for the duration of regular transfusions, and significantly lower cardiac R2* values (p < 0.0001). In the receiver operating characteristic analysis, pancreatic iron was the strongest discriminator between the two diseases. Left and right ventricular end-diastolic volume indexes were significantly higher in TI than in TM patients (p = 0.003 and p = 0.046, respectively), but the correction for the duration of regular transfusions removed the disease-specific differences (p > 0.05). Left ventricular (LV) mass index was significantly higher in TI (p = 0.049), while no difference (p > 0.05) was found in biventricular ejection fractions and replacement myocardial fibrosis. Conclusions: TI patients showed lower pancreatic and cardiac iron burden and more pronounced LV hypertrophy. These differences could not be explained by the different duration of the transfusional regimen.
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Affiliation(s)
- Antonella Meloni
- Bioengineering Unit, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (L.P.); (V.P.)
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Laura Pistoia
- Bioengineering Unit, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (L.P.); (V.P.)
- Unità Operativa Complessa Ricerca Clinica, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Paolo Ricchi
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale “A. Cardarelli”, 80131 Napoli, Italy;
| | - Filomena Longo
- Unità Operativa Day Hospital della Talassemia e delle Emoglobinopatie, Azienda Ospedaliero-Universitaria “S. Anna”, 44124 Cona (FE), Italy;
| | - Valerio Cecinati
- Struttura Semplice di Microcitemia, Ospedale “SS. Annunziata” ASL Taranto, 74123 Taranto, Italy;
| | | | - Zelia Borsellino
- Unità Operativa Complessa Ematologia con Talassemia, “ARNAS” Civico Di Cristina Benfratelli, 90134 Palermo, Italy;
| | - Sergio Bagnato
- Ematologia Microcitemia, Ospedale San Giovanni di Dio—ASP Crotone, 88900 Crotone, Italy;
| | - Vincenza Rossi
- Unità Operativa Complessa Ematologia, Ospedale di Cosenza, 87100 Cosenza, Italy;
| | - Priscilla Fina
- Unità Operativa Complessa Diagnostica per Immagini, Ospedale “Sandro Pertini”, 00157 Roma, Italy;
| | - Ada Riva
- Struttura Complessa di Radiologia, Ospedale “SS. Annunziata” ASL Taranto, 74100 Taranto, Italy;
| | - Stefania Renne
- Struttura Complessa di Cardioradiologia-UTIC, Presidio Ospedaliero “Giovanni Paolo II”, 88046 Lamezia Terme (CZ), Italy;
| | - Giuseppe Peritore
- Unità Operativa Complessa di Radiologia, “ARNAS” Civico Di Cristina Benfratelli, 90127 Palermo, Italy;
| | - Vincenzo Positano
- Bioengineering Unit, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (L.P.); (V.P.)
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
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Forni GL, Kattamis A, Kuo KHM, Maggio A, Sheth S, Taher AT, Viprakasit V. Iron chelation therapy for children with transfusion-dependent β-thalassemia: How young is too young? Pediatr Blood Cancer 2024; 71:e31035. [PMID: 38753107 DOI: 10.1002/pbc.31035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 06/28/2024]
Abstract
In this review, we provide a summary of evidence on iron overload in young children with transfusion-dependent β-thalassemia (TDT) and explore the ideal timing for intervention. Key data from clinical trials and observational studies of the three available iron chelators deferoxamine, deferiprone, and deferasirox are also evaluated for inclusion of subsets of young children, especially those less than 6 years of age. Evidence on the efficacy and safety of iron chelation therapy for children ≥2 years of age with transfusional iron overload is widely available. New data exploring the risks and benefits of early-start iron chelation in younger patients with minimal iron overload are also emerging.
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Affiliation(s)
| | - Antonis Kattamis
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Kevin H M Kuo
- Division of Hematology, University of Toronto, Toronto, Ontario, Canada
| | - Aurelio Maggio
- Campus of Haematology Franco and Piera Cutino, AOOR Villa Sofia-V. Cervello, Palermo, Italy
| | - Sujit Sheth
- Division of Hematology and Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Vip Viprakasit
- Department of Pediatrics & Thalassemia Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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4
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Lakhal-Littleton S, Cleland JGF. Iron deficiency and supplementation in heart failure. Nat Rev Cardiol 2024; 21:463-486. [PMID: 38326440 DOI: 10.1038/s41569-024-00988-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 02/09/2024]
Abstract
Non-anaemic iron deficiency (NAID) is a strategic target in cardiovascular medicine because of its association with a range of adverse effects in various conditions. Endeavours to tackle NAID in heart failure have yielded mixed results, exposing knowledge gaps in how best to define 'iron deficiency' and the handling of iron therapies by the body. To address these gaps, we harness the latest understanding of the mechanisms of iron homeostasis outside the erythron and integrate clinical and preclinical lines of evidence. The emerging picture is that current definitions of iron deficiency do not assimilate the multiple influences at play in patients with heart failure and, consequently, fail to identify those with a truly unmet need for iron. Additionally, current iron supplementation therapies benefit only certain patients with heart failure, reflecting differences in the nature of the unmet need for iron and the modifying effects of anaemia and inflammation on the handling of iron therapies by the body. Building on these insights, we identify untapped opportunities in the management of NAID, including the refinement of current approaches and the development of novel strategies. Lessons learned from NAID in cardiovascular disease could ultimately translate into benefits for patients with other chronic conditions such as chronic kidney disease, chronic obstructive pulmonary disease and cancer.
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Affiliation(s)
| | - John G F Cleland
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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5
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Beleù A, Canonico D, Morana G. T1 and T2-mapping in pancreatic MRI: Current evidence and future perspectives. Eur J Radiol Open 2024; 12:100572. [PMID: 38872711 PMCID: PMC11170358 DOI: 10.1016/j.ejro.2024.100572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 05/11/2024] [Accepted: 05/22/2024] [Indexed: 06/15/2024] Open
Abstract
Conventional T1- and T2-weighted magnetic resonance imaging (MRI) of the pancreas can vary significantly due to factors such as scanner differences and pulse sequence variations. This review explores T1 and T2 mapping techniques, modern MRI methods providing quantitative information about tissue relaxation times. Various T1 and T2 mapping pulse sequences are currently under investigation. Clinical and research applications of T1 and T2 mapping in the pancreas include their correlation with fibrosis, inflammation, and neoplasms. In chronic pancreatitis, T1 mapping and extracellular volume (ECV) quantification demonstrate potential as biomarkers, aiding in early diagnosis and classification. T1 mapping also shows promise in evaluating pancreatic exocrine function and detecting glucose metabolism disorders. T2* mapping is valuable in quantifying pancreatic iron, offering insights into conditions like thalassemia major. However, challenges persist, such as the lack of consensus on optimal sequences and normal values for healthy pancreas relaxometry. Large-scale studies are needed for validation, and improvements in mapping sequences are essential for widespread clinical integration. The future holds potential for mixed qualitative and quantitative models, extending the applications of relaxometry techniques to various pancreatic lesions and enhancing routine MRI protocols for pancreatic pathology diagnosis and prognosis.
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Affiliation(s)
- Alessandro Beleù
- Department of Radiology, Treviso General Hospital, Piazzale Ospedale 1, Treviso, TV 31100, Italy
| | - Davide Canonico
- Department of Health Physics, Treviso General Hospital, Piazzale Ospedale 1, Treviso, TV 31100, Italy
| | - Giovanni Morana
- Department of Radiology, Treviso General Hospital, Piazzale Ospedale 1, Treviso, TV 31100, Italy
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6
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Meloni A, Pistoia L, Putti MC, Longo F, Corigliano E, Ricchi P, Rossi V, Casini T, Righi R, Renne S, Peritore G, Barbuto L, Positano V, Cademartiri F. Pancreatic iron in pediatric transfusion-dependent beta-thalassemia patients: A longitudinal MRI study. Pediatr Blood Cancer 2024; 71:e30923. [PMID: 38385860 DOI: 10.1002/pbc.30923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/02/2024] [Accepted: 02/08/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND In pediatric transfusion-dependent thalassemia (TDT) patients, we evaluated the prevalence, pattern, and clinical associations of pancreatic siderosis and the changes in pancreatic iron levels and their association with baseline and changes in total body iron balance. PROCEDURE We considered 86 pediatric TDT patients consecutively enrolled in the Extension-Myocardial Iron Overload in Thalassemia Network. Iron overload (IO) was quantified by R2* magnetic resonance imaging (MRI). RESULTS Sixty-three (73%) patients had pancreatic IO (R2* > 38 Hz). Global pancreas R2* values were significantly correlated with mean serum ferritin levels, MRI liver iron concentration (LIC) values, and global heart R2* values. Global pancreas R2* values were significantly higher in patients with altered versus normal glucose metabolism. Thirty-one patients also performed the follow-up MRI at 18 ± 3 months. Higher pancreatic R2* values were detected at the follow-up, but the difference versus the baseline MRI was not significant. The 20% of patients with baseline pancreatic IO showed no pancreatic IO at the follow-up. The 46% of patients without baseline pancreatic IO developed pancreatic siderosis. The changes in global pancreas R2* between the two MRIs were not correlated with baseline serum ferritin levels, baseline, final, and changes in MRI LIC values, or baseline pancreatic iron levels. CONCLUSIONS In children with TDT, pancreatic siderosis is a frequent finding associated with hepatic siderosis and represents a risk factor for myocardial siderosis and alterations of glucose metabolism. Iron removal from the pancreas is exceptionally challenging and independent from hepatic iron status.
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Affiliation(s)
- Antonella Meloni
- Bioengineering Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
- U.O.C. Ricerca Clinica, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Maria Caterina Putti
- Dipartimento della Salute della Donna e del Bambino, Clinica di Emato-Oncologia Pediatrica, Azienda Ospedaliero-Università di Padova, Padua, Italy
| | - Filomena Longo
- Unità Operativa Day Hospital della Talassemia e delle Emoglobinopatie, Azienda Ospedaliero-Universitaria "S. Anna,", Cona, Ferrara, Italy
| | | | - Paolo Ricchi
- U.O.S.D. Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale "A. Cardarelli", Naples, Italy
| | | | - Tommaso Casini
- SOC Oncologia, Ematologia e Trapianto di Cellule Staminali Emopoietiche, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Riccardo Righi
- Diagnostica per Immagini e Radiologia Interventistica, Ospedale del Delta, Lagosanto, Ferrara, Italy
| | - Stefania Renne
- Struttura Complessa di Cardioradiologia-UTIC, Presidio Ospedaliero "Giovanni Paolo II,", Lamezia Terme, Italy
| | - Giuseppe Peritore
- Unità Operativa Complessa di Radiologia, "ARNAS" Civico, Di Cristina Benfratelli, Palermo, Italy
| | - Luigi Barbuto
- U.O.C. Radiologia Generale e di Pronto Soccorso, Azienda Ospedaliera di Rilievo Nazionale "A. Cardarelli", Naples, Italy
| | - Vincenzo Positano
- Bioengineering Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
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7
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Meloni A, Pistoia L, Spasiano A, Cossu A, Casini T, Massa A, Bagnato S, Putti MC, Maffei S, Positano V, Pepe A, Cademartiri F, Vassalle C. Oxidative Stress and Antioxidant Status in Adult Patients with Transfusion-Dependent Thalassemia: Correlation with Demographic, Laboratory, and Clinical Biomarkers. Antioxidants (Basel) 2024; 13:446. [PMID: 38671894 PMCID: PMC11047726 DOI: 10.3390/antiox13040446] [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: 03/11/2024] [Revised: 03/26/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Iron overload in beta transfusion-dependent thalassemia (β-TDT) may provoke oxidative stress and reduction of the antioxidant defenses, with serious consequences for the disease course and complications. The present study evaluated the oxidant/antioxidant status of β-TDT patients and its correlation with demographic, clinical, laboratory, and instrumental biomarkers. The OXY-adsorbent assay and the d-ROMs (Diacron, Grosseto, Italy) were evaluated in 58 β-TDT patients (mean age: 37.55 ± 7.83 years, 28 females) enrolled in the Extension-Myocardial Iron Overload in Thalassemia Network. Iron overload was quantified with R2* magnetic resonance imaging. Mean OXY was 323.75 ± 113.19 μmol HClO/mL and 39 (67.2%) patients showed a decreased OXY-Adsorbent level (<350 μmol HClO/mL), of whom 22 (37.9%) showed severely reduced levels. Mean d-ROMs was 305.12 ± 62.19 UA; 12 (20.7%) patients showed oxidative stress, and 4 (6.9%) elevated oxidative stress. OXY showed a significant negative correlation with global and segmental cardiac iron levels. D-ROMs levels significantly correlated with markers of cardiovascular risk (aging, glycemia, and N-terminal pro-B-type natriuretic peptide). Antioxidant depletion is frequent in β-TDT patients, where OXY might serve as additive biomarker to assess heart iron status, whereas the d-ROMs might be helpful to assess the cardiovascular risk burden.
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Affiliation(s)
- Antonella Meloni
- Bioengineering Unit, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (V.P.)
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (L.P.); (F.C.)
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (L.P.); (F.C.)
- Unità Operativa Complessa Ricerca Clinica, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Anna Spasiano
- Unità Operativa Semplice, Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale “A. Cardarelli”, 80131 Napoli, Italy;
| | - Antonella Cossu
- Ambulatorio Trasfusionale—Servizio Immunoematologia e Medicina Trasfusionale, Dipartimento dei Servizi, Presidio Ospedaliero “San Francesco”, 08100 Nuoro, Italy;
| | - Tommaso Casini
- Oncologia, Ematologia e Trapianto di Cellule Staminali Emopoietiche, Meyer Children’s Hospital IRCCS, 50139 Firenze, Italy;
| | - Antonella Massa
- Servizio Trasfusionale, Ospedale “Giovanni Paolo II”, 07026 Olbia, Italy;
| | - Sergio Bagnato
- Ematologia Microcitemia, Ospedale San Giovanni di Dio—ASP Crotone, 88900 Crotone, Italy;
| | - Maria Caterina Putti
- Dipartimento della Salute della Donna e del Bambino, Clinica di Emato-Oncologia Pediatrica, Azienda Ospedaliero, Università di Padova, 35128 Padova, Italy;
| | - Silvia Maffei
- Cardiovascular and Gynaecological Endocrinology Unit, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy;
| | - Vincenzo Positano
- Bioengineering Unit, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (V.P.)
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (L.P.); (F.C.)
| | - Alessia Pepe
- Institute of Radiology, University of Padua, 35128 Padova, Italy;
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (L.P.); (F.C.)
| | - Cristina Vassalle
- Medicina di Laboratorio, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
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Chuansumrit A, Songdej D, Sirachainan N, Kadegasem P, Saisawat P, Sungkarat W, Kempka K, Tungbubpha N. Efficacy and Safety of a Dispersible Tablet of GPO-Deferasirox Monotherapy among Children with Transfusion-Dependent Thalassemia and Iron Overload. Hemoglobin 2024; 48:47-55. [PMID: 38369714 DOI: 10.1080/03630269.2024.2311360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/23/2024] [Indexed: 02/20/2024]
Abstract
The study aimed to determine efficacy and safety of generic deferasirox monotherapy. Deferasirox was administered in transfusion-induced iron overloaded thalassemia. Efficacy was defined as responders and nonresponders by ≤ 15 reduced serum ferritin from baseline. Adverse events were also monitored. Fifty-two patients with mainly Hb E/β-thalassemia at the mean (SD) age of 8.7 (4.1) years, were enrolled. The mean (SD) daily transfusion iron load was 0.47 (0.1) mg/kg and maximum daily deferasirox was 35.0 (6.2) mg/kg. Altogether, 52, 40 and 18 patients completed the first, second and third years of study, respectively. The median baseline serum ferritin 2,383 ng/mL decreased to 1,478, 1,038 and 1,268 ng/mL at the end of first, second and third years, respectively, with overall response rate at 73.1% (38/52). Patients with baseline serum ferritin >2,500 ng/mL showed a change in serum ferritin higher than those ≤2,500 ng/mL starting from the 9th month of chelation. Adverse events were found in 5 of 52 patients (9.6%) including transaminitis (n = 2), one each of proteinuria, rash and proximal tubular dysfunction which resolved after transient stopping or decreasing the chelation dose. Generic deferasirox was effective and safe among pediatric patients with transfusion-induced iron overloaded thalassemia.
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Affiliation(s)
- Ampaiwan Chuansumrit
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Duantida Songdej
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Praguywan Kadegasem
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pawaree Saisawat
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Witaya Sungkarat
- Department of Radiology and Advanced Diagnostic Image Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ketsuda Kempka
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Noppawan Tungbubpha
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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9
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Ricchi P, Meloni A, Pistoia L, Gamberini MR, Cuccia L, Allò M, Putti MC, Spasiano A, Rosso R, Cecinati V, Righi R, Renne S, Peritore G, Vallone A, Positano V, Quaia E, Cademartiri F, Pepe A. Longitudinal prospective comparison of pancreatic iron by magnetic resonance in thalassemia patients transfusion-dependent since early childhood treated with combination deferiprone-desferrioxamine vs deferiprone or deferasirox monotherapy. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2024; 22:75-85. [PMID: 37146300 PMCID: PMC10812892 DOI: 10.2450/bloodtransfus.485] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/03/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND In transfusion-dependent thalassemia patients who started regular transfusions in early childhood, we prospectively and longitudinally evaluated the efficacy on pancreatic iron of a combined deferiprone (DFP) + desferrioxamine (DFO) regimen versus either oral iron chelator as monotherapy over a follow-up of 18 months. MATERIALS AND METHODS We selected patients consecutively enrolled in the Extension-Myocardial Iron Overload in Thalassemia network who received a combined regimen of DFO+DFP (No.=28) or DFP (No.=61) or deferasirox (DFX) (No.=159) monotherapy between the two magnetic resonance imaging scans. Pancreatic iron overload was quantified by the T2* technique. RESULTS At baseline no patient in the combined treatment group had a normal global pancreas T2* (≥26 ms). At follow-up the percentage of patients who maintained a normal pancreas T2* was comparable between the DFP and DFX groups (57.1 vs 70%; p=0.517).Among the patients with pancreatic iron overload at baseline, global pancreatic T2* values were significantly lower in the combined DFO+DFP group than in the DFP or DFX groups. Since changes in global pancreas T2* values were negatively correlated with baseline pancreas T2* values, the percent changes in global pancreas T2* values, normalized for the baseline values, were considered. The percent changes in global pancreas T2* values were significantly higher in the combined DFO+DFP group than in either the DFP (p=0.036) or DFX (p=0.030) groups. DISCUSSION In transfusion-dependent patients who started regular transfusions in early childhood, combined DFP+DFO was significantly more effective in reducing pancreatic iron than was either DFP or DFX.
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Affiliation(s)
- Paolo Ricchi
- U.O.S.D. Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale “A. Cardarelli”, Naples, Italy
| | - Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
- U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Maria R. Gamberini
- Unità Operativa di Day Hospital della Talassemia e delle Emoglobinopatie, Dipartimento della Riproduzione e dell’Accrescimento, Azienda Ospedaliero-Universitaria “S. Anna”, Cona (FE), Italy
| | - Liana Cuccia
- Unità Operativa Complessa Ematologia con Talassemia, ARNAS Civico “Benfratelli-Di Cristina”, Palermo, Italy
| | - Massimo Allò
- Ematologia Microcitemia, Ospedale San Giovanni di Dio-ASP Crotone, Crotone, Italy
| | - Maria C. Putti
- Dipartimento della Salute della Donna e del Bambino, Clinica di Emato-Oncologia Pediatrica, Azienda Ospedaliero-Università di Padova, Padua, Italy
| | - Anna Spasiano
- U.O.S.D. Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale “A. Cardarelli”, Naples, Italy
| | - Rosamaria Rosso
- Unità Operativa Talassemie ed Emoglobinopatie Azienda Ospedaliero-Universitaria Policlinico “Vittorio Emanuele”, Catania, Italy
| | - Valerio Cecinati
- Struttura Semplice di Microcitemia, Ospedale “SS. Annunziata” ASL Taranto, Taranto, Italy
| | - Riccardo Righi
- Diagnostica per Immagini e Radiologia Interventistica, Ospedale del Delta, Lagosanto, Italy
| | - Stefania Renne
- Struttura Complessa di Cardioradiologia-UTIC, Presidio Ospedaliero “Giovanni Paolo II”, Lamezia Terme (CZ), Italy
| | - Giuseppe Peritore
- Unità Operativa Complessa di Radiologia, ARNAS Civico “Benfratelli-Di Cristina”, Palermo, Italy
| | - Antonino Vallone
- Reparto di Radiologia, Azienda Ospedaliera “Garibaldi” Presidio Ospedaliero Nesima, Catania, Italy
| | - Vincenzo Positano
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
- U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Emilio Quaia
- Institute of Radiology, Department of Medicine, University of Padua, Padua, Italy
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Alessia Pepe
- Institute of Radiology, Department of Medicine, University of Padua, Padua, Italy
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Meloni A, Pistoia L, Vassalle C, Spasiano A, Fotzi I, Bagnato S, Putti MC, Cossu A, Massei F, Giovangrossi P, Maffei S, Positano V, Cademartiri F. Low Vitamin D Levels Are Associated with Increased Cardiac Iron Uptake in Beta-Thalassemia Major. Diagnostics (Basel) 2023; 13:3656. [PMID: 38132240 PMCID: PMC10742632 DOI: 10.3390/diagnostics13243656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023] Open
Abstract
We evaluated the association of vitamin D and parathormone (PTH) levels with cardiac iron and function in beta-thalassemia major (β-TM) patients. Two-hundred and seventy-eight TM patients (39.04 ± 8.58 years, 56.8% females) underwent magnetic resonance imaging for the assessment of iron overload (T2* technique), biventricular function parameters (cine images), and replacement myocardial fibrosis (late gadolinium enhancement technique). Vitamin D levels were deficient (<20 ng/dL) in 107 (38.5%) patients, insufficient (20-30 ng/dL) in 96 (34.5%) patients, and sufficient (≥30 ng/dL) in 75 (27.0%) patients. Deficient vitamin D patients had a significantly higher frequency of myocardial iron overload (MIO; global heart T2* < 20 ms) than patients with sufficient and insufficient vitamin D levels and a significantly higher left ventricular end-diastolic volume index and mass index than patients with sufficient vitamin D levels. PTH was not associated with cardiac iron, function, or fibrosis. In the multivariate regression analysis, vitamin D, serum ferritin, and pancreatic iron levels were the strongest predictors of global heart T2* values. In receiver operating characteristic curve analysis, a vitamin D level ≤ 17.3 ng/dL predicted MIO with a sensitivity of 81.5% and a specificity of 75.3% (p < 0.0001). In TM, the periodic and regular assessment of vitamin D levels can be beneficial for the prevention of cardiac iron accumulation and subsequent overt dysfunction.
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Affiliation(s)
- Antonella Meloni
- Bioengineering Unit, Fondazione G. Monasterio CNR—Regione Toscana, 56124 Pisa, Italy; (A.M.); (V.P.)
- Department of Radiology, Fondazione G. Monasterio CNR—Regione Toscana, 56124 Pisa, Italy;
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR—Regione Toscana, 56124 Pisa, Italy;
- Unità Operativa Complessa Ricerca Clinica, Fondazione G. Monasterio CNR—Regione Toscana, 56124 Pisa, Italy
| | - Cristina Vassalle
- Medicina di Laboratorio, Fondazione G. Monasterio CNR—Regione Toscana, 56124 Pisa, Italy;
| | - Anna Spasiano
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale “A. Cardarelli”, 80131 Napoli, Italy;
| | - Ilaria Fotzi
- Oncologia, Ematologia e Trapianto di Cellule Staminali Emopoietiche, Meyer Children’s Hospital IRCCS, 50139 Firenze, Italy;
| | - Sergio Bagnato
- Ematologia Microcitemia, Ospedale San Giovanni di Dio—ASP Crotone, 88900 Crotone, Italy;
| | - Maria Caterina Putti
- Dipartimento della Salute della Donna e del Bambino, Clinica di Emato-Oncologia Pediatrica, Azienda Ospedaliero Università di Padova, 35128 Padova, Italy;
| | - Antonella Cossu
- Ambulatorio Trasfusionale—Servizio Immunoematologia e Medicina Trasfusionale Dipartimento dei Servizi, Presidio Ospedaliero “San Francesco”, 08100 Nuoro, Italy;
| | - Francesco Massei
- Unità Operativa Oncoematologia Pediatrica, Azienda Ospedaliero Universitaria Pisana—Stabilimento S. Chiara, 56126 Pisa, Italy;
| | - Piera Giovangrossi
- Servizio di Immunoematologia e Medicina Trasfusionale, Ospedale S. M. Goretti, 04100 Latina, Italy;
| | - Silvia Maffei
- Cardiovascular and Gynaecological Endocrinology Unit, Fondazione G. Monasterio CNR—Regione Toscana, 56124 Pisa, Italy;
| | - Vincenzo Positano
- Bioengineering Unit, Fondazione G. Monasterio CNR—Regione Toscana, 56124 Pisa, Italy; (A.M.); (V.P.)
- Department of Radiology, Fondazione G. Monasterio CNR—Regione Toscana, 56124 Pisa, Italy;
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR—Regione Toscana, 56124 Pisa, Italy;
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11
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Meloni A, Barbuto L, Positano V, Pistoia L, Spasiano A, Casini T, Massei F, Argento C, Giovangrossi P, Barone A, Romano L, Cademartiri F. Pattern and clinical correlates of renal iron deposition in adult beta-thalassemia major patients. Clin Exp Med 2023; 23:3573-3579. [PMID: 37433990 DOI: 10.1007/s10238-023-01133-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/28/2023] [Indexed: 07/13/2023]
Abstract
We evaluated pattern and clinical correlates of renal T2* measurements in adult β-thalassemia major (β-TM) patients. Ninety β-TM patients (48 females, 38.15 ± 7.94 years), consecutively enrolled in the Extension-Myocardial Iron Overload in Thalassemia network, underwent T2* magnetic resonance imaging (MRI) for quantification of iron overload (IO) in kidneys, liver, pancreas, and heart. Ten (11.1%) patients showed renal IO (T2* < 31 ms). Global kidney T2* values did not show a correlation with gender, age, splenectomy, regular transfusions or chelation starting age, pre-transfusion hemoglobin, and serum ferritin levels. Global kidney T2* values showed an inverse correlation with MRI liver iron concentration (LIC) values (R = - 0.349; p = 0.001) and a positive correlation with global pancreas T2* values (R = 0.212; p = 0.045). Frequency of renal IO was significantly higher in patients with cardiac IO than in patients without cardiac IO (50.0% vs. 6.3%; p = 0.001). A significant inverse association was detected between global kidneys T2* values and lactate dehydrogenase (LDH) (R = - 0.529; p < 0.0001). In multivariate regression analysis, MRI LIC and LDH were the strongest predictors of global kidney T2* values. A MRI LIC > 4.83 mg/g dw predicted the presence of renal IO (sensitivity = 90.0%; specificity = 61.2%). Global kidney T2* values were inversely correlated with uric acid (R = - 0.269; p = 0.025). In conclusion, in adult β-TM patients, renal iron deposition is not common and is linked to both hemolysis and total body iron overload.
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Affiliation(s)
- Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
- U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Luigi Barbuto
- U.O.C. Radiologia Generale E Di Pronto Soccorso, Azienda Ospedaliera Di Rilievo Nazionale "A. Cardarelli", Naples, Italy
| | - Vincenzo Positano
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
- U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
- U.O.S.V.D. Ricerca Clinica, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Anna Spasiano
- U.O.S.D. Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale "A. Cardarelli", Naples, Italy
| | - Tommaso Casini
- S.O.C. Oncologia, Ematologia e Trapianto di Cellule Staminali Emopoietiche, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Francesco Massei
- U.O. Oncoematologia Pediatrica, Azienda Ospedaliero Universitaria Pisana - Stabilimento S. Chiara, Pisa, Italy
| | - Crocetta Argento
- Centro Di Talasssemia, Ospedale "San Giovanni Di Dio", Agrigento, Italy
| | - Piera Giovangrossi
- Servizio Di Immunoematologia E Medicina Trasfusionale, Ospedale S. M. Goretti, Latina, Italy
| | - Angelica Barone
- Unità Operativa di Pediatria e Oncoematologia - Dipartimento Materno-Infantile, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Luigia Romano
- U.O.C. Radiologia Generale E Di Pronto Soccorso, Azienda Ospedaliera Di Rilievo Nazionale "A. Cardarelli", Naples, Italy
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy.
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12
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De Sanctis V, Daar S, Soliman AT, Tzoulis P, Yassin M, Kattamis C. The effects of excess weight on glucose homeostasis in young adult females with β-thalassemia major (β-TM): a preliminary retrospective study. ACTA BIO-MEDICA : ATENEI PARMENSIS 2023; 94:e2023225. [PMID: 37850764 PMCID: PMC10644933 DOI: 10.23750/abm.v94i5.14909] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/06/2023] [Indexed: 04/16/2024]
Abstract
BACKGROUND With the rising prevalence of obesity worldwide, it is becoming imperative to detect disturbed glucose metabolism as early as possible in order to prevent type 2 diabetes (T2D) development. STUDY DESIGN The present retrospective observational study aimed to evaluate the relationship between BMI and glucose metabolism, insulin secretion and sensitivity indices, derived from glucose tolerance test (OGTT), in β -TM female patients who were overweight (BMI 25-29.9 kg/m2) and follow its outcome over time. SUBJECTS AND METHODS Eleven overweight and 11 females with ideal weight and β -TM, matched for age, were recruited. OGTT was undertaken and different indices for β-cell function, insulin sensitivity and insulin secretion were calculated. RESULTS At first evaluation, 7 of 11 overweight β -TM patients (63.6%) and 3 of 11 normal weight β-TM patients (27.2%) had glucose dysregulation (GD) during OGTT. Overweight patients with β-TM had increased HOMA-IR and QUICKI indices associated with decreased Matsuda WBISI index. The mean ± SD duration of follow-up was 4.5 ± 1.2 years. At last observation, 2/11 overweight patients had developed T2D (18.1%). In patients with normal weight, GD increased from 3/11 (27.2%) to 5/11 (45.4%), but none developed T2DM. The difference between SF at first and last observation (1,220 ± 702 vs.1,091 ± 454 ng/mL; P: 0.61) was not significant. CONCLUSION Overweight seems to be an additional risk factor for the development of GD in β-TM patients. This is particularly important in clinical practice, due to the lack of appropriate guidelines dedicated to this group of patients.
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Affiliation(s)
| | - Shahina Daar
- Department of Haematology, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Sultanate of Oman.
| | | | - Ploutarchos Tzoulis
- Department of Diabetes and Endocrinology, Whittington Hospital, University College London, London, UK.
| | - Mohamed Yassin
- Hematology Section, Medical Oncology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation (HMC), Doha, Qatar.
| | - Christos Kattamis
- Τhalassemia Unit, First Department of Paediatrics, National Kapodistrian University of Athens 11527, Greece.
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13
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De Sanctis V, Daar S, Soliman AT, Tzoulis P, Yassin M, Kattamis C. The effects of excess weight on glucose homeostasis in young adult females with β-thalassemia major (β-TM): a preliminary retrospective study. ACTA BIO-MEDICA : ATENEI PARMENSIS 2023; 94:e2023225. [PMID: 37850764 PMCID: PMC10644933 DOI: 10.23750/abm.v94i6.14909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/06/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND With the rising prevalence of obesity worldwide, it is becoming imperative to detect disturbed glucose metabolism as early as possible in order to prevent type 2 diabetes (T2D) development. STUDY DESIGN The present retrospective observational study aimed to evaluate the relationship between BMI and glucose metabolism, insulin secretion and sensitivity indices, derived from glucose tolerance test (OGTT), in β -TM female patients who were overweight (BMI 25-29.9 kg/m2) and follow its outcome over time. SUBJECTS AND METHODS Eleven overweight and 11 females with ideal weight and β -TM, matched for age, were recruited. OGTT was undertaken and different indices for β-cell function, insulin sensitivity and insulin secretion were calculated. RESULTS At first evaluation, 7 of 11 overweight β -TM patients (63.6%) and 3 of 11 normal weight β-TM patients (27.2%) had glucose dysregulation (GD) during OGTT. Overweight patients with β-TM had increased HOMA-IR and QUICKI indices associated with decreased Matsuda WBISI index. The mean ± SD duration of follow-up was 4.5 ± 1.2 years. At last observation, 2/11 overweight patients had developed T2D (18.1%). In patients with normal weight, GD increased from 3/11 (27.2%) to 5/11 (45.4%), but none developed T2DM. The difference between SF at first and last observation (1,220 ± 702 vs.1,091 ± 454 ng/mL; P: 0.61) was not significant. CONCLUSION Overweight seems to be an additional risk factor for the development of GD in β-TM patients. This is particularly important in clinical practice, due to the lack of appropriate guidelines dedicated to this group of patients.
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Affiliation(s)
| | - Shahina Daar
- Department of Haematology, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Sultanate of Oman.
| | | | - Ploutarchos Tzoulis
- Department of Diabetes and Endocrinology, Whittington Hospital, University College London, London, UK.
| | - Mohamed Yassin
- Hematology Section, Medical Oncology, National Center for Cancer Care and Research (NCCCR), Hamad Medical Corporation (HMC), Doha, Qatar.
| | - Christos Kattamis
- Τhalassemia Unit, First Department of Paediatrics, National Kapodistrian University of Athens 11527, Greece.
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14
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Meloni A, Nobile M, Keilberg P, Positano V, Santarelli MF, Pistoia L, Spasiano A, Casini T, Putti MC, Cuccia L, Bitti PP, Messina G, Peritore G, Renne S, Grassedonio E, Quaia E, Cademartiri F, Pepe A. Pancreatic fatty replacement as risk marker for altered glucose metabolism and cardiac iron and complications in thalassemia major. Eur Radiol 2023; 33:7215-7225. [PMID: 37115218 PMCID: PMC10511559 DOI: 10.1007/s00330-023-09630-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 01/18/2023] [Accepted: 02/23/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVES This multicenter study assessed the extent of pancreatic fatty replacement and its correlation with demographics, iron overload, glucose metabolism, and cardiac complications in a cohort of well-treated patients with thalassemia major (TM). METHODS We considered 308 TM patients (median age: 39.79 years; 182 females) consecutively enrolled in the Extension-Myocardial Iron Overload in Thalassemia Network. Magnetic resonance imaging was used to quantify iron overload (IO) and pancreatic fat fraction (FF) by T2* technique, cardiac function by cine images, and to detect replacement myocardial fibrosis by late gadolinium enhancement technique. The glucose metabolism was assessed by the oral glucose tolerance test. RESULTS Pancreatic FF was associated with age, body mass index, and history of hepatitis C virus infection. Patients with normal glucose metabolism showed a significantly lower pancreatic FF than patients with impaired fasting glucose (p = 0.030), impaired glucose tolerance (p < 0.0001), and diabetes (p < 0.0001). A normal pancreatic FF (< 6.6%) showed a negative predictive value of 100% for abnormal glucose metabolism. A pancreatic FF > 15.33% predicted the presence of abnormal glucose metabolism. Pancreas FF was inversely correlated with global pancreas and heart T2* values. A normal pancreatic FF showed a negative predictive value of 100% for cardiac iron. Pancreatic FF was significantly higher in patients with myocardial fibrosis (p = 0.002). All patients with cardiac complications had fatty replacement, and they showed a significantly higher pancreatic FF than complications-free patients (p = 0.002). CONCLUSION Pancreatic FF is a risk marker not only for alterations of glucose metabolism, but also for cardiac iron and complications, further supporting the close link between pancreatic and cardiac disease. KEY POINTS • In thalassemia major, pancreatic fatty replacement by MRI is a frequent clinical entity, predicted by a pancreas T2* < 20.81 ms and associated with a higher risk of alterations in glucose metabolism. • In thalassemia major, pancreatic fatty replacement is a strong risk marker for cardiac iron, replacement fibrosis, and complications, highlighting a deep connection between pancreatic and cardiac impairment.
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Affiliation(s)
- Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
- U. O. C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Mario Nobile
- Sezione Di Scienze Radiologiche - Dipartimento Di Biopatologia E Biotecnologie Mediche, Policlinico "Paolo Giaccone", Palermo, Italy
| | - Petra Keilberg
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Vincenzo Positano
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
- U. O. C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | | | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Anna Spasiano
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera Di Rilievo Nazionale "A. Cardarelli", Napoli, Italy
| | - Tommaso Casini
- Centro Talassemie Ed Emoglobinopatie, Ospedale "Meyer", Florence, Italy
| | - Maria Caterina Putti
- Dipartimento Della Salute Della Donna E del Bambino, Clinica Di Emato-Oncologia Pediatrica, Azienda Ospedaliero-Università Di Padova, Padua, Italy
| | - Liana Cuccia
- Unità Operativa Complessa Ematologia Con Talassemia, ARNAS Civico "Benfratelli-Di Cristina", Palermo, Italy
| | - Pier Paolo Bitti
- Dipartimento Dei Servizi, Servizio Immunoematologia E Medicina Trasfusionale, Presidio Ospedaliero "San Francesco" ASL Nuoro, Nuoro, Italy
| | - Giuseppe Messina
- Centro Microcitemie, Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Giuseppe Peritore
- Unità Operativa Complessa Di Radiologia, ARNAS Civico "Benfratelli-Di Cristina", Palermo, Italy
| | - Stefania Renne
- Struttura Complessa Di Cardioradiologia-UTIC, Presidio Ospedaliero "Giovanni Paolo II", Lamezia Terme, Italy
| | - Emanuele Grassedonio
- Sezione Di Scienze Radiologiche - Dipartimento Di Biopatologia E Biotecnologie Mediche, Policlinico "Paolo Giaccone", Palermo, Italy
| | - Emilio Quaia
- Institute of Radiology, Department of Medicine, University of Padua, Giustiniani, 2 Street, 35128, Padova, Italy
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Alessia Pepe
- Institute of Radiology, Department of Medicine, University of Padua, Giustiniani, 2 Street, 35128, Padova, Italy.
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15
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Meloni A, Pistoia L, Ricchi P, Positano V, Longo F, Borsellino Z, Cecinati V, Messina G, Corigliano E, Rosso R, Righi R, Peritore G, Renne S, Vallone A, Cademartiri F. Pancreatic T2* Magnetic Resonance Imaging for Prediction of Cardiac Arrhythmias in Transfusion-Dependent Thalassemia. J Clin Med 2023; 12:6015. [PMID: 37762955 PMCID: PMC10531669 DOI: 10.3390/jcm12186015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/08/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
We assessed the value of pancreatic T2* magnetic resonance imaging (MRI) for predicting cardiac events from a large prospective database of transfusion-dependent thalassemia (TDT) patients. We considered 813 TDT patients (36.47 ± 10.71 years, 54.6% females) enrolled in the Extension-Myocardial Iron Overload in Thalassemia Network. MRI was used to measure hepatic, pancreatic, and cardiac iron overload (IO), to assess biventricular function and atrial dimensions, and to detect replacement myocardial fibrosis. The mean follow-up was 50.51 ± 19.75 months. Cardiac complications were recorded in 21 (2.6%) patients: one with heart failure (HF) and 20 with arrhythmias. The single patient who developed HF had, at the baseline MRI, a reduced pancreas T2*. Out of the 20 recorded arrhythmias, 17 were supraventricular. Pancreatic T2* values were a significant predictor of future arrhythmia-related events (hazard ratio = 0.89; p = 0.015). Pancreas T2* remained significantly associated with future arrhythmias after adjusting for any other univariate predictor (age and male sex, diabetes, history of previous arrhythmias, or left atrial area index). According to the receiver-operating characteristic curve analysis for arrhythmias, a pancreas T2* < 6.73 ms was the optimal cut-off value. In TDT, pancreatic iron levels had significant prognostic power for arrhythmias. Regular monitoring and the development of targeted interventions to manage pancreatic IO may help improve patient outcomes.
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Affiliation(s)
- Antonella Meloni
- Department of Radiology, Fondazione Gabriele Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (L.P.); (V.P.)
- Unità Operativa Complessa Bioingegneria, Fondazione Gabriele Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Laura Pistoia
- Department of Radiology, Fondazione Gabriele Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (L.P.); (V.P.)
- Unità Operativa Semplice a Valenza Dipartimentale Ricerca Clinica, Fondazione Gabriele Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Paolo Ricchi
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale “Antonio Cardarelli”, 80131 Napoli, Italy;
| | - Vincenzo Positano
- Department of Radiology, Fondazione Gabriele Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (L.P.); (V.P.)
- Unità Operativa Complessa Bioingegneria, Fondazione Gabriele Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Filomena Longo
- Unità Operativa Day Hospital della Talassemia e delle Emoglobinopatie, Azienda Ospedaliero-Universitaria “S. Anna”, 44124 Cona, Italy;
| | - Zelia Borsellino
- Unità Operativa Complessa Ematologia con Talassemia, ARNAS Civico “Benfratelli-Di Cristina”, 90134 Palermo, Italy;
| | - Valerio Cecinati
- Struttura Semplice di Microcitemia, Ospedale “Santissima Annunziata”, 74123 Taranto, Italy;
| | - Giuseppe Messina
- Centro Microcitemie, Grande Ospedale Metropolitano “Bianchi-Melacrino-Morelli”, 89100 Reggio Calabria, Italy;
| | - Elisabetta Corigliano
- Ematologia Microcitemia, Ospedale San Giovanni di Dio—ASP Crotone, 88900 Crotone, Italy;
| | - Rosamaria Rosso
- Unità Operativa Talassemie ed Emoglobinopatie, Azienda Ospedaliero-Universitaria Policlinico “Vittorio Emanuele”, 95100 Catania, Italy;
| | - Riccardo Righi
- Diagnostica per Immagini e Radiologia Interventistica, Ospedale del Delta, 44023 Lagosanto, Italy;
| | - Giuseppe Peritore
- Unità Operativa Complessa di Radiologia, ARNAS Civico “Benfratelli-Di Cristina”, 90127 Palermo, Italy;
| | - Stefania Renne
- Struttura Complessa di Cardioradiologia-UTIC, Presidio Ospedaliero “Giovanni Paolo II”, 88046 Lamezia Terme, Italy;
| | - Antonino Vallone
- Reparto di Radiologia, Azienda Ospedaliera “Garibaldi” Presidio Ospedaliero Nesima, 95126 Catania, Italy;
| | - Filippo Cademartiri
- Department of Radiology, Fondazione Gabriele Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (L.P.); (V.P.)
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16
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Meloni A, Pistoia L, Positano V, Martini N, Borrello RL, Sbragi S, Spasiano A, Casini T, Bitti PP, Putti MC, Cuccia L, Allò M, Massei F, Sanna PMG, De Caterina R, Quaia E, Cademartiri F, Pepe A. Myocardial tissue characterization by segmental T2 mapping in thalassaemia major: detecting inflammation beyond iron. Eur Heart J Cardiovasc Imaging 2023; 24:1222-1230. [PMID: 37070652 DOI: 10.1093/ehjci/jead068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 03/09/2023] [Accepted: 03/23/2023] [Indexed: 04/19/2023] Open
Abstract
AIMS We measured myocardial T2 values by a segmental approach in thalassaemia major (TM) patients, comparing such values against T2* values for the detection of myocardial iron overload (MIO), evaluating their potential in detecting subclinical inflammation, and correlating with clinical status. METHODS AND RESULTS One-hundred and sixty-six patients (102 females, 38.29 ± 11.49years) enrolled in the Extension-Myocardial Iron Overload in Thalassemia Network underwent magnetic resonance imaging for the assessment of hepatic, pancreatic, and cardiac iron overload (T2* technique), of biventricular function (cine images), and of replacement myocardial fibrosis [late gadolinium enhancement (LGE)]. T2 and T2* values were quantified in all 16 myocardial segments, and the global value was the mean of all segments. Global heart T2 values were significantly higher in TM than in a cohort of 80 healthy subjects. T2 and T2* values were significantly correlated. Out of the 25 patients with a decreased global heart T2* value, 11 (44.0%) had reduced T2 values. No patient with a normal T2* value had a decreased T2 value.Eleven (6.6%) patients had a decreased global heart T2 value, 74 (44.6%) a normal global heart T2 value, and 81 (48.8%) an increased global heart T2 value. Biventricular function was comparable amongst the three groups, whilst LGE was significantly more frequent in patients with reduced vs. increased global heart T2 value. Compared with the other two groups, patients with reduced T2 values had significantly higher hepatic and pancreatic iron deposition. CONCLUSION In TM, T2 mapping does not offer any advantage in terms of sensitivity for MIO assessment but detects subclinical myocardial inflammation.
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Affiliation(s)
- Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
- U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Vincenzo Positano
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
- U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Nicola Martini
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
- U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | | | - Sara Sbragi
- Cardiovascular Division, University of Pisa, Pisa, Italy
| | - Anna Spasiano
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale 'A. Cardarelli', Napoli, Italy
| | - Tommaso Casini
- Centro Talassemie ed Emoglobinopatie, Ospedale 'Meyer', Firenze, Italy
| | - Pier Paolo Bitti
- Servizio Immunoematologia e Medicina Trasfusionale-Dipartimento dei Servizi, Presidio Ospedaliero 'San Francesco' ASL Nuoro, Nuoro, Italy
| | - Maria Caterina Putti
- Dipartimento della Salute della Donna e del Bambino, Clinica di Emato-Oncologia Pediatrica, Azienda Ospedaliero-Università di Padova, Padova, Italy
| | - Liana Cuccia
- Unità Operativa Complessa Ematologia con Talassemia, ARNAS Civico 'Benfratelli-Di Cristina', Palermo, Italy
| | - Massimo Allò
- Ematologia Microcitemia, Ospedale San Giovanni di Dio-ASP Crotone, Crotone, Italy
| | - Francesco Massei
- Unità Operativa Oncoematologia Pediatrica, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | | | - Emilio Quaia
- Institute of Radiology, Department of Medicine, University of Padua, Giustiniani, 2 Street, 35128 Padua, Italy
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Alessia Pepe
- Institute of Radiology, Department of Medicine, University of Padua, Giustiniani, 2 Street, 35128 Padua, Italy
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17
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Meloni A, Pistoia L, Gamberini MR, Spasiano A, Cuccia L, Allò M, Messina G, Cecinati V, Geraradi C, Rosso R, Vassalle C, Righi R, Renne S, Missere M, Positano V, Pepe A, Cademartiri F, Ricchi P. The impact of HCV chronic positivity and clearance on extrahepatic morbidity in thalassemia major patients: an observational study from MIOT Network. Eur J Intern Med 2023; 114:93-100. [PMID: 37150716 DOI: 10.1016/j.ejim.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 04/12/2023] [Accepted: 05/02/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND No study has evaluated the effect of hepatitis C virus (HCV) infection on the wide spectrum of complications affecting patients with thalassemia. OBJECTIVES This multicenter study prospectively assessed the relationship of HCV infection with diabetes mellitus and cardiovascular complications in patients with thalassemia major (TM). METHODS We considered 1057 TM patients (539 females; 29.79±10.08 years) enrolled in the MIOT Network and categorized into 4 groups: negative patients (group 1a, N=460), patients who spontaneously cleared the virus within 6months (group 1b, N=242), patients who eradicated the virus after the treatment with antiviral therapy (group 2, N=102), and patients with chronic HCV infection (group 3, N=254). RESULTS Group 1a and 1b were considered as a unique group (group 1). For both groups 1 and 3, a match 1:1 for age and sex with group 2 was performed. The effective study cohort consisted of 306 patients (three groups of 102 patients). During a mean follow-up of 67.93±39.20months, the group 3 experienced a significantly higher % increase/month in aspartate transaminase levels and left ventricular mass index than both groups 1 and 2. The changes in iron overload indexes were comparable among the three groups. Compared to group 1, the chronic HCV group showed a significantly higher risk of diabetes (hazard ratio-HR=5.33; p=0.043) and of cardiovascular diseases (HR=3.80; p=0.034). CONCLUSION Chronic HCV infection is associated with a significant higher risk of diabetes mellitus and cardiovascular complications in TM patients and should be approached as a systemic disease in which extrahepatic complications increase the weight of its pathological burden.
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Affiliation(s)
- Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy; U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy; U.O.S.V.D Ricerca Clinica, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Maria Rita Gamberini
- Unità Operativa Day Hospital della Talassemia e delle Emoglobinopatie, Azienda Ospedaliero-Universitaria "S. Anna", Cona (FE), Italy
| | - Anna Spasiano
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale "A. Cardarelli", Napoli, Italy
| | - Liana Cuccia
- Unità Operativa Complessa Ematologia con Talassemia, ARNAS Civico "Benfratelli-Di Cristina", Palermo, Italy
| | - Massimo Allò
- Ematologia Microcitemia, Ospedale San Giovanni di Dio - ASP Crotone, Crotone, Italy
| | - Giuseppe Messina
- Centro Microcitemie, Azienda Ospedaliera "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Valerio Cecinati
- Struttura Semplice di Microcitemia, Ospedale "SS. Annunziata" ASL Taranto, Taranto, Italy
| | - Calogera Geraradi
- Unità Operativa Semplice di Talassemia, Presidio Ospedaliero "Giovanni Paolo II" - Distretto AG2 di Sciacca, Sciacca (AG), Italy
| | - Rosamaria Rosso
- Unità Operativa Talassemie ed Emoglobinopatie Azienda Ospedaliero-Universitaria Policlinico "Vittorio Emanuele", Catania, Italy
| | - Cristina Vassalle
- Medicina di laboratorio, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Riccardo Righi
- Diagnostica per Immagini e Radiologia Interventistica, Ospedale del Delta, Lagosanto (FE), Italy
| | - Stefania Renne
- Struttura Complessa di Cardioradiologia-UTIC, Presidio Ospedaliero "Giovanni Paolo II", Lamezia Terme (CZ), Italy
| | - Massimiliano Missere
- U.O.C. Radiodiagnostica, Gemelli Molise SpA, Fondazione di Ricerca e Cura "Giovanni Paolo II", Campobasso, Italy
| | - Vincenzo Positano
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy; U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Alessia Pepe
- Institute of Radiology, Department of Medicine, University of Padua, Padova, Italy
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Paolo Ricchi
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale "A. Cardarelli", Napoli, Italy.
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18
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Plaikner M, Lanser L, Kremser C, Weiss G, Henninger B. 1.5-T MR relaxometry in quantifying splenic and pancreatic iron: retrospective comparison of a commercial 3D-Dixon sequence and an established 2D multi-gradient echo sequence. Eur Radiol 2023; 33:4973-4980. [PMID: 36800012 PMCID: PMC10289981 DOI: 10.1007/s00330-023-09451-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 02/18/2023]
Abstract
OBJECTIVES To compare the quantitative measurement of splenic and pancreatic iron content using a commercial 3D-Dixon sequence (qDixon) versus an established fat-saturated R2* relaxometry method (ME-GRE). METHODS We analyzed splenic and pancreatic iron levels in 143 MR examinations (1.5 T) using the qDixon and a ME-GRE sequence (108 patients: 65 males, 43 females, mean age 61.31 years). Splenic and pancreatic R2* values were compared between both methods using Bland-Altman plots, concordance correlation coefficients (CCC), and linear regression analyses. Iron overload (R2* > 50 1/s) was defined for both organs and compared using contingency tables, overall agreement, and Gwet's AC1 coefficient. RESULTS Of all analyzable examinations, the median splenic R2* using the qDixon sequence was 25.75 1/s (range: 5.6-433) and for the ME-GRE sequence 35.35 1/s (range: 10.9-400.8) respectively. Concerning the pancreas, a median R2* of 29.93 1/s (range: 14-111.45) for the qDixon and 31.25 1/s (range: 14-97) for the ME-GRE sequence was found. Bland-Altman analysis showed a mean R2* difference of 2.12 1/s with a CCC of 0.934 for the spleen and of 0.29 1/s with a CCC of 0.714 for the pancreas. Linear regression for the spleen/pancreas resulted in a correlation coefficient of 0.94 (p < 0.001)/0.725 (p < 0.001). Concerning iron overload, the proportion of overall agreement between the two methods was 91.43% for the spleen and 93.18% for the pancreas. CONCLUSIONS Our data show good concordance between R2* values obtained with a commercial qDixon sequence and a validated ME-GRE relaxometry method. The 3D-qDixon sequence, originally intended for liver assessment, seems to be a reliable tool for non-invasive evaluation of iron content also in the spleen and the pancreas. KEY POINTS • A 3D chemical shift imaging sequence and 2D multi-gradient echo sequence show good conformity quantifying splenic and pancreatic R2* values. • The 3D chemical shift imaging sequence allows a reliable analysis also of splenic and pancreatic iron status. • In addition to the liver, the analysis of the spleen and pancreas is often helpful for further differential diagnostic clarification and patient guidance regarding the iron status.
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Affiliation(s)
- Michaela Plaikner
- Department of Radiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Lukas Lanser
- Department of Internal Medicine, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Christian Kremser
- Department of Radiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
| | - Günter Weiss
- Department of Internal Medicine, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Benjamin Henninger
- Department of Radiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
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19
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Vali SW, Lindahl PA. Low-temperature Mössbauer spectroscopy of organs from 57Fe-enriched HFE (-/-) hemochromatosis mice: an iron-dependent threshold for generating hemosiderin. J Biol Inorg Chem 2023; 28:173-185. [PMID: 36512071 PMCID: PMC9981716 DOI: 10.1007/s00775-022-01975-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/26/2022] [Indexed: 12/15/2022]
Abstract
Hereditary hemochromatosis is an iron-overload disease most often arising from a mutation in the Homeostatic Fe regulator (HFE) gene. HFE organs become overloaded with iron which causes damage. Iron-overload is commonly detected by NMR imaging, but the spectroscopic technique is insensitive to diamagnetic iron. Here, we used Mössbauer spectroscopy to examine the iron content of liver, spleen, kidney, heart, and brain of 57Fe-enriched HFE(-/-) mice of ages 3-52 wk. Overall, the iron contents of all investigated HFE organs were similar to the same healthy organ but from an older mouse. Livers and spleens were majorly overloaded, followed by kidneys. Excess iron was generally present as ferritin. Iron-sulfur clusters and low-spin FeII hemes (combined into the central quadrupole doublet) and nonheme high-spin FeII species were also observed. Spectra of young and middle-aged HFE kidneys were dominated by the central quadrupole doublet and were largely devoid of ferritin. Collecting and comparing spectra at 5 and 60 K allowed the presence of hemosiderin, a decomposition product of ferritin, to be quantified, and it also allowed the diamagnetic central doublet to be distinguished from ferritin. Hemosiderin was observed in spleens and livers from HFE mice, and in spleens from controls, but only when iron concentrations exceeded 2-3 mM. Even in those cases, hemosiderin represented only 10-20% of the iron in the sample. NMR imaging can identify iron-overload under non-invasive room-temperature conditions, but Mössbauer spectroscopy of 57Fe-enriched mice can detect all forms of iron and perhaps allow the process of iron-overloading to be probed in greater detail.
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Affiliation(s)
- Shaik Waseem Vali
- Department of Biochemistry and Biophysics, Texas A&M University, College Station, TX, USA
| | - Paul A Lindahl
- Department of Biochemistry and Biophysics, Texas A&M University, College Station, TX, USA.
- Department of Chemistry, Texas A&M University, College Station, TX, 77843-3255, USA.
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20
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De Sanctis V, Soliman AT, Daar S, Tzoulis P, Di Maio S, Kattamis C. Longitudinal study of ICET-A on glucose tolerance, insulin sensitivity and β-cell secretion in eleven β-thalassemia major patients with mild iron overload. ACTA BIO-MEDICA : ATENEI PARMENSIS 2023; 94:e2023011. [PMID: 36786253 PMCID: PMC9987494 DOI: 10.23750/abm.v94i1.14000] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 11/29/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND Iron chelation therapy (ICT) is the gold standard for treating patients with iron overload, though its long-term effects are still under evaluation. According to current recommendations regarding transfusion-dependent (TD) β-thalassemia major (β-TM) patients, their serum ferritin (SF) levels should be maintained below 1,000 ng/mL and ICT should be discontinued when the levels are <500 ng/mL in two successive tests. Alternatively, the dose of chelator could be considerably reduced to maintain a balance between iron input and output of frequent transfusions. STUDY DESIGN Due to the paucity of information on long-term effects of ICT in β-TM with low SF levels on glucose homeostasis, the International Network of Clinicians for Endocrinopathies in Thalassemia and Adolescence Medicine (ICET-A) promoted a retrospective and an ongoing prospective observational study with the primary aim to address the long-term effects of ICT on glucose tolerance and metabolism (β-cell function and peripheral insulin sensitivity) in adult β-TM patients with persistent SF level below 800 ng/mL. PATIENTS AND METHODS 11 β-TM patients (mean age: 35.5 ± 5.5 years; SF range: 345-777 ng/mL) with normal glucose tolerance test (OGTT) or abnormal glucose tolerance (AGT) for a median of 5.3(1.1-8.3) years. RESULTS Abnormal glucose tolerance (AGT) was observed in 7 patients (63.6%) at first observation and ) persisted in 6 patients (54.5%) at last observation. None of them developed diabetes mellitus. AGT was reversed in two patients. One patient with NGT developed early glucose intolerance (1-h PG ≥155 and 2-h PG <140 mg/dL). Three out of 5 patients with isolated impaired glucose tolerance presented a variation of ATG. Stabilization of low indices for β-cell function and insulin sensitivity/resistance was observed. One patient developed hypogonadotrophic hypogonadism. Three out of 6 patients with SF below 500 ng/dL had hypercalciuria. CONCLUSION Despite low SF level, the burden of endocrine complications remains a challenge in β-TM patients. The ability to keep iron at near "normal" level with acceptable risks of toxicity remains to be established.
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Affiliation(s)
| | - Ashraf T Soliman
- Department of Pediatrics, Division of Endocrinology, Hamad General Hospital, Doha, Qatar .
| | - Shahina Daar
- Department of Haematology, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Sultanate of Oman.
| | - Ploutarchos Tzoulis
- Department of Diabetes and Endocrinology, Whittington Hospital, University College London, London, UK.
| | - Salvatore Di Maio
- Emeritus Director in Pediatrics, Children's Hospital "Santobono-Pausilipon", Naples, Italy.
| | - Christos Kattamis
- Τhalassemia Unit, First Department of Paediatrics, National Kapodistrian University of Athens 11527, Greece.
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21
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Chapchap EC, Silva MMA, de Assis RA, Kerbauy LN, Diniz MDS, Rosemberg LA, Loggetto SR, Araujo ADS, Fabron Junior A, Verissimo MPDA, Baldanzi GR, Esposito BP, Tricta F, Steagall MEA, Vellozo CÂGDS, Fertrin KY, Baroni RH, Hamerschlak N. Cardiac iron overload evaluation in thalassaemic patients using T2* magnetic resonance imaging following chelation therapy: a multicentre cross-sectional study. Hematol Transfus Cell Ther 2023; 45:7-15. [PMID: 34090847 PMCID: PMC9938451 DOI: 10.1016/j.htct.2021.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/28/2020] [Accepted: 01/27/2021] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Magnetic resonance imaging (MRI) T2* technique is used to assess iron overload in the heart, liver and pancreas of thalassaemic patients. Optimal iron chelation and expected tissue iron response rates remain under investigation. The objective of this study was to analyse serum ferritin and the iron concentration in the heart, liver and pancreas measured by MRI T2*/R2* during regular chelation therapy in a real-world cohort of patients with thalassemia. METHODS We evaluated thalassaemic patients ≥ 7 years old undergoing chelation/transfusion therapy by MRI and assessed serum ferritin at baseline and follow-up from 2004-2011. RESULTS We evaluated 136 patients, 92% major thalassaemic, with a median age of 18 years, and median baseline ferritin 2.033ng/ml (range: 59-14,123). Iron overload distribution was: liver (99%), pancreas (74%) and heart (36%). After a median of 1.2 years of follow-up, the iron overload in the myocardium reduced from 2,63 Fe mg/g to 2,05 (p 0.003). The optimal R2* pancreas cut-off was 148 Hertz, achieving 78% sensitivity and 73% specificity. However, when combining the R2* pancreas cut off ≤ 50 Hertz and a ferritin ≤ 1222 ng/ml, we could reach a negative predictive value (NPV) of 98% for cardiac siderosis. Only 28% were undergoing combined chelation at baseline assessment, which increased up to 50% on follow up evaluation. CONCLUSIONS Chelation therapy significantly reduced cardiac siderosis in thalassaemic patients. In patients with moderate/severe liver iron concentration undergoing chelation therapy, ferritin levels and myocardium iron improved earlier than the liver siderosis.
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Lupu M, Tudor D, Filip A. Iron metabolism and cardiovascular disease: Basic to translational purviews and therapeutical approach. Rev Port Cardiol 2022; 41:1037-1046. [PMID: 36228833 DOI: 10.1016/j.repc.2021.09.022] [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: 01/28/2021] [Revised: 08/09/2021] [Accepted: 09/13/2021] [Indexed: 11/15/2022] Open
Abstract
Iron interactions with the cardiovascular system were proposed about half a century ago, yet a clear-cut understanding of this micronutrient and its intricacies with acute and chronic events is still lacking. In chronic heart failure, patients with decreased iron stores appear to benefit from intravenous administration of metallic formulations, whereas acute diseases (e.g., myocardial infarction, stroke) are barely studied in randomized controlled trials in humans. However, proof-of-concept studies have indicated that the dual redox characteristics of iron could be involved in atherosclerosis, necrosis, and ferroptosis. To this end, we sought to review the currently available body of literature pertaining to these temporal profiles of heart diseases, as well as the pathophysiologic mechanism by which iron enacts, underlining key points related to treatment options.
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Affiliation(s)
- Mihai Lupu
- Iuliu Hatieganu University of Medicine and Pharmacy, Department of Physiology, Cluj-Napoca, Romania.
| | - Diana Tudor
- Iuliu Hatieganu University of Medicine and Pharmacy, Department of Physiology, Cluj-Napoca, Romania
| | - Adriana Filip
- Iuliu Hatieganu University of Medicine and Pharmacy, Department of Physiology, Cluj-Napoca, Romania
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23
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Quantitative T2* MRI for bone marrow iron overload: normal reference values and assessment in thalassemia major patients. Radiol Med 2022; 127:1199-1208. [DOI: 10.1007/s11547-022-01554-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
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Hoe HG, Git KA, Loh CK, Abdul Latiff Z, Hong J, Abdul Hamid H, Wan Sulaiman WNA, Mohd Zaki F. Magnetic resonance imaging T2 * of the pancreas value using an online software tool and correlate with T2 * value of myocardium and liver among patients with transfusion-dependent thalassemia major. FRONTIERS IN RADIOLOGY 2022; 2:943102. [PMID: 37492672 PMCID: PMC10365003 DOI: 10.3389/fradi.2022.943102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/28/2022] [Indexed: 07/27/2023]
Abstract
Objective Patients with thalassemia major do require lifetime blood transfusions that eventually result in iron accumulation in different organs. We described the usefulness of using magnetic resonance imaging (MRI) T2*imaging values for the evaluation of pancreatic iron load in these patients, and we correlated it with MRI T2* haemosiderosis of the myocardium and liver that has been recognized as a non-invasive assessment of iron overload among patients with thalassemia major. Materials and methods We conducted a cross-sectional study on 39 patients with thalassemia major in one of the tertiary university hospitals for a 1-year period. Demographic data were collected from the patient's history. MRI T2* of the pancreas, liver, and heart were executed on all patients in the same setting. Objective values of iron overload in these organs were obtained using the MRI post-processing software from online software. Results A total of 32 (82.1%) patients had pancreatic iron overload including 2 patients (5.1%) with severe iron overload and 15 patients (38.5%) with moderate and mild iron overload, respectively. Nine patients (23.1%) had myocardial iron overload, which included 3 patients (7.7%) who had severe cardiac haemosiderosis. Notably, 37 patients (94.9%) had liver iron overload, which included 15 patients (38.5%) who had severe liver haemosiderosis. There was a moderate positive correlation between the relaxation time of the pancreas and heart haemosiderosis (r = 0.504, P < 0.001). No significant correlation was found between the relaxation time of the pancreas with the liver and the heart with the liver. Conclusion Pancreatic haemosiderosis precedes cardiac haemosiderosis, which establishes a basis for initiating earlier iron chelation therapy to patients with thalassemia major.
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Affiliation(s)
- Han Guan Hoe
- Department of Radiology, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Kim-Ann Git
- Department of Radiology, Hospital Selayang, Batu Caves, Malaysia
| | - C-Khai Loh
- Paediatric Oncology and Haematology Unit, Department of Paediatrics, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Zarina Abdul Latiff
- Paediatric Oncology and Haematology Unit, Department of Paediatrics, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Joyce Hong
- Paediatric Endocrinology Unit, Department of Paediatrics, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Hamzaini Abdul Hamid
- Department of Radiology, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | | | - Faizah Mohd Zaki
- Department of Radiology, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
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Meloni A, Positano V, Pistoia L, Cademartiri F. Pancreatic iron quantification with MR imaging: a practical guide. Abdom Radiol (NY) 2022; 47:2397-2407. [PMID: 35596775 DOI: 10.1007/s00261-022-03552-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/02/2022] [Accepted: 05/02/2022] [Indexed: 11/30/2022]
Abstract
Accurate determination of pancreatic iron status is crucial for preventing impairment of the exocrine and endocrine function of the pancreas and for prospectively stratifying the cardiac iron risk. The following article should be a sort of practical guide for radiologists interested in quantifying pancreatic iron overload by Magnetic Resonance Imaging (MRI). After a brief background on iron-deposition diseases, we will describe basic principles and relative advantages and disadvantages of the more widely used and clinically feasible MRI-based techniques for pancreatic iron assessment. These methods can be classified into signal intensity ratio (SIR) and relaxometry methods. We will examine different technical aspects representing the key for accurate and precise relaxation time measurement.
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Affiliation(s)
- Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
- U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Vincenzo Positano
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
- U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy.
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The (Bio)Chemistry of Non-Transferrin-Bound Iron. Molecules 2022; 27:molecules27061784. [PMID: 35335148 PMCID: PMC8951307 DOI: 10.3390/molecules27061784] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 12/14/2022] Open
Abstract
In healthy individuals, virtually all blood plasma iron is bound by transferrin. However, in several diseases and clinical conditions, hazardous non-transferrin-bound iron (NTBI) species occur. NTBI represents a potentially toxic iron form, being a direct cause of oxidative stress in the circulating compartment and tissue iron loading. The accumulation of these species can cause cellular damage in several organs, namely, the liver, spleen, and heart. Despite its pathophysiological relevance, the chemical nature of NTBI remains elusive. This has precluded its use as a clinical biochemical marker and the development of targeted therapies. Herein, we make a critical assessment of the current knowledge of NTBI speciation. The currently accepted hypotheses suggest that NTBI is mostly iron bound to citric acid and iron bound to serum albumin, but the chemistry of this system remains fuzzy. We explore the complex chemistry of iron complexation by citric acid and its implications towards NTBI reactivity. Further, the ability of albumin to bind iron is revised and the role of protein post-translational modifications on iron binding is discussed. The characterization of the NTBI species structure may be the starting point for the development of a standardized analytical assay, the better understanding of these species’ reactivity or the identification of NTBI uptake mechanisms by different cell types, and finally, to the development of new therapies.
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Link between Genotype and Multi-Organ Iron and Complications in Children with Transfusion-Dependent Thalassemia. J Pers Med 2022; 12:jpm12030400. [PMID: 35330400 PMCID: PMC8950605 DOI: 10.3390/jpm12030400] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/01/2022] [Accepted: 03/03/2022] [Indexed: 01/27/2023] Open
Abstract
We evaluated the impact of the genotype on hepatic, pancreatic and myocardial iron content, and on hepatic, cardiac and endocrine complications in children with transfusion-dependent β-thalassemia (β-TDT). We considered 68 β-TDT patients (11.98 ± 3.67 years, 51.5% females) consecutively enrolled in the Extension-Myocardial Iron Overload in Thalassemia network. Iron overload was quantified by T2* technique and biventricular function by cine images. Replacement myocardial fibrosis was evaluated by late gadolinium enhancement technique. Three groups of patients were identified: homozygous β+ (N = 19), compound heterozygous β0β+ (N = 24), and homozygous β0 (N = 25). The homozygous β0 group showed significantly lower global heart and pancreas T2* values than the homozygous β+ group. Compared to patients with homozygous β+ genotype, β0β+ as well as β0β0 patients were more likely to have pancreatic iron overload (odds ratio = 6.53 and 10.08, respectively). No difference was detected in biventricular function parameters and frequency of replacement fibrosis. No patient had cirrhosis/fibrosis, diabetes or heart failure, and the frequency of endocrinopathies was comparable among the groups. In pediatric β-TDT patients, there is an association between genotype and cardiac and pancreatic iron overload. The knowledge of patients’ genotype can be valuable in predicting some patients’ phenotypic features and in helping the clinical management of β-TDT patients.
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The Link of Pancreatic Iron with Glucose Metabolism and Cardiac Iron in Thalassemia Intermedia: A Large, Multicenter Observational Study. J Clin Med 2021; 10:jcm10235561. [PMID: 34884261 PMCID: PMC8658115 DOI: 10.3390/jcm10235561] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 11/23/2021] [Accepted: 11/23/2021] [Indexed: 02/06/2023] Open
Abstract
In thalassemia major, pancreatic iron was demonstrated as a powerful predictor not only for the alterations of glucose metabolism but also for cardiac iron, fibrosis, and complications, supporting a profound link between pancreatic iron and heart disease. We determined for the first time the prevalence of pancreatic iron overload (IO) in thalassemia intermedia (TI) and systematically explored the link between pancreas T2* values and glucose metabolism and cardiac outcomes. We considered 221 beta-TI patients (53.2% females, 42.95 ± 13.74 years) consecutively enrolled in the Extension–Myocardial Iron Overload in Thalassemia project. Magnetic Resonance Imaging was used to quantify IO (T2* technique) and biventricular function and to detect replacement myocardial fibrosis. The glucose metabolism was assessed by the oral glucose tolerance test (OGTT). Pancreatic IO was more frequent in regularly transfused (N = 145) than in nontransfused patients (67.6% vs. 31.6%; p < 0.0001). In the regular transfused group, splenectomy and hepatitis C virus infection were both associated with high pancreatic siderosis. Patients with normal glucose metabolism showed significantly higher global pancreas T2* values than patients with altered OGTT. A pancreas T2* < 17.9 ms predicted an abnormal OGTT. A normal pancreas T2* value showed a 100% negative predictive value for cardiac iron. Pancreas T2* values were not associated to biventricular function, replacement myocardial fibrosis, or cardiac complications. Our findings suggest that in the presence of pancreatic IO, it would be prudent to initiate or intensify iron chelation therapy to prospectively prevent both disturbances of glucose metabolism and cardiac iron accumulation.
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Mousa SO, Abd Alsamia EM, Moness HM, Mohamed OG. The effect of zinc deficiency and iron overload on endocrine and exocrine pancreatic function in children with transfusion-dependent thalassemia: a cross-sectional study. BMC Pediatr 2021; 21:468. [PMID: 34686155 PMCID: PMC8532363 DOI: 10.1186/s12887-021-02940-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 10/12/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Children with transfusion-dependent thalassemia (TDT) suffer from secondary hemosiderosis and the delirious effects this iron overload has on their different body organs, including the pancreas. They are also more prone to develop zinc deficiency than the general pediatric population. This study aimed to determine the effect of zinc deficiency and iron overload on the endocrine and exocrine pancreas in TDT children. METHODS Eighty children, already diagnosed with TDT, were included in this study. We assessed the following in the participant children: serum ferritin, serum zinc, endocrine pancreatic function (oral glucose tolerance test (OGTT), fasting insulin level and from them, HOMA-IR was calculated), and exocrine pancreatic function (serum lipase and serum amylase). RESULTS Forty-four TDT children had a subnormal zinc level, while 36 of them had a normal serum zinc level. TDT children with low serum zinc had significantly more impaired endocrine pancreatic function and an abnormally high serum lipase than children with normal serum zinc, p < 0.05 in all. Serum zinc was significantly lower in TDT children with serum ferritin above the ferritin threshold (≥2500 ng/ml) than those below (59.1 ± 20.2 vs. 77.5 ± 28.13), p = 0.02. TDT children, having a serum ferritin ≥2500 ng/ml, had significantly more frequently impaired endocrine pancreatic function and abnormally high serum lipase than TDT children below the ferritin threshold, p < 0.05 in all. CONCLUSION In children with transfusion-dependent thalassemia, zinc deficiency aggravates iron-induced pancreatic exocrine and endocrine dysfunction.
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Affiliation(s)
- Suzan O. Mousa
- Pediatric Department, Children’s University hospital, Faculty of Medicine, Minia University, El-Minya, Egypt
| | - Ebtihal M. Abd Alsamia
- Pediatric Department, Children’s University hospital, Faculty of Medicine, Minia University, El-Minya, Egypt
| | - Hend M. Moness
- Department of Clinical Pathology, Minia University hospitals, Minia University, El-Minya, Egypt
| | - Osama G. Mohamed
- Pediatric Department, Children’s University hospital, Faculty of Medicine, Minia University, El-Minya, Egypt
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Sevimli C, Yilmaz Y, Bayramoglu Z, Comert RG, Gul N, Dursun M, Karakas Z. Pancreatic MR imaging and endocrine complications in patients with beta-thalassemia: a single-center experience. Clin Exp Med 2021; 22:95-101. [PMID: 34245399 DOI: 10.1007/s10238-021-00735-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 06/22/2021] [Indexed: 10/20/2022]
Abstract
Iron deposition in various organs can cause endocrine complications in patients with transfusion-dependent beta-thalassemia. The aim was to investigate the relationship between endocrine complications and pancreatic iron overload using magnetic resonance imaging (MRI). Forty patients with transfusion-dependent thalassemia (TDT) were enrolled in the study. The magnetic resonance imagings of the patients were performed using a 1.5 Tesla Philips MRI scanner. Two out of three patients had at least one clinical endocrine complication. The rate of iron deposition was 62.5% in liver, and 45% in pancreas tissue, and was 12.5% in heart tissue. Pancreatic T2* and hepatic T2* values were significantly positively correlated (p = 0.006). Pancreatic T2* and ferritin were significantly negatively correlated (p = 0.03). Cardiac T2* values were negatively correlated with fasting blood glucose (p = 0.03). Patients with short stature had significantly higher cardiac iron burden (22.3 vs. 36.6 T2*ms; p 0.01), and patients with hypothyroidism had higher liver iron concentrations (9.9 vs. 6.4 LIC mg/g; p = 0.05). The ferritin level of 841 ng/mL and liver iron concentration (LIC) value of 8.7 mg/g were detected as the threshold level for severe pancreatic iron burden (AUC 70%, p:0.04, AUC 80%, p = 0.002, respectively). Moreover, males were found to have decreased pancreas T2* values compared with the values in females (T2* 19.3 vs. 29.9, p = 0.05). Patients with higher ferritin levels over than 840 ng/mL should be closely monitored for pancreatic iron deposition, and patients with endocrine complications should be assessed in terms of cardiac iron burden.
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Affiliation(s)
- Cihangir Sevimli
- Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Yasin Yilmaz
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Institute of Health Sciences, Istanbul, Turkey.
| | - Zuhal Bayramoglu
- Department of Pediatric Radiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Rana Gunoz Comert
- Department of Pediatric Radiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Nurdan Gul
- Department of Internal Medicine, Division of Endocrinology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Memduh Dursun
- Department of Pediatric Radiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Zeynep Karakas
- Department of Pediatrics, Division of Hematology and Oncology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Pituitary Volume and Iron Overload Evaluation by 3T MRI in Thalassemia. Indian J Pediatr 2021; 88:656-662. [PMID: 33675027 DOI: 10.1007/s12098-020-03629-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate pituitary volume and iron overload in beta thalassemia major, with the objective of assessing the reliability of this method in predicting hypogonadism. METHODS 3T MRI was used to measure pituitary R2 and T2* in 57 beta thalassemia major patients and 30 controls. Anterior pituitary volume was evaluated by MRI planimetry. Cardiac, hepatic, and pancreatic iron overload were also assessed using MRI T2*. Mean serum ferritin was estimated by sandwich immuno-assay. Short stature was defined as height < 3 rd percentile for age, and clinical hypogonadism defined as absence of secondary sexual characteristics at ages ≥ 13 y for females and ≥ 14 y for males. RESULTS Short stature was present in 32 patients (56.1%). Of the 47 patients in the pubertal age group, 11(23.4%) had hypogonadism. Serum ferritin correlated positively with pituitary R2 (p = 0.004) and negatively with anterior pituitary volume (p = 0.006), whereas pituitary R2 correlated negatively with cardiac T2* (p = 0.001). Patients with hypogonadism had lower pituitary R2 (p = 0.186), T2* (p = 0.048), and anterior pituitary volumes (p = 0.012) compared to those with normal sexual maturity. Regardless of stature, no significant difference was observed between pituitary R2 (p = 0.267) and T2* (p = 0.451). Mean pituitary R2 in patients (78.99 Hz) was higher than in controls (20.8 Hz) (p = 0.0001). Anterior pituitary volume was lower in patients (264.83 mm3) than in controls (380.87 mm3) (p = 0.0001). A threshold value of 22.85 Hz for pituitary R2 gave a sensitivity of 84.2% and a specificity of 73.3% in distinguishing pituitary iron content of patients from controls, with an area of 0.864 under the ROC curve. CONCLUSIONS 3T MRI is a reliable method to detect pituitary iron overload and predict risk of hypogonadism in beta Thalassemia.
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Huang J, Shen J, Yang Q, Cheng Z, Chen X, Yu T, Zhong J, Su Y, Guo H, Liang B. Quantification of pancreatic iron overload and fat infiltration and their correlation with glucose disturbance in pediatric thalassemia major patients. Quant Imaging Med Surg 2021; 11:665-675. [PMID: 33532266 DOI: 10.21037/qims-20-292] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background Diabetes mellitus affects more than a quarter of patients with thalassemia major (TM) worldwide, and increases the risk for cardiac complications, contributing to significant morbidity. Pancreatic iron overload (IO) and fat infiltration have been correlated with this endocrinal complication in adult TM patients. It has been shown that in adult TM patients, iron accumulation and fat infiltration are found to be heterogeneous in the pancreatic head, body, and tail region. R2* and a fat fraction (FF) generated by gradient-echo imaging can be used as quantitative parameters to assess the iron and fat contents of the pancreas. This study aimed to determine the pattern of pancreatic iron accumulation and fat infiltration in pediatric TM patients with gradient-echo imaging and evaluate the association between pancreatic IO and fat infiltration and glucose disturbances. Methods A total of 90 children with TM (10.7±3.1 years) were included. All patients underwent pancreatic magnetic resonance imaging (MRI) using multi-echo gradient-echo sequences. IO was measured by R2* relaxometry in 90 patients, and FF values were measured using iterative decomposition of water and fat with echo asymmetry and the least-squares estimation (IDEAL) method in 40 patients. R2* and FF were assessed in the pancreatic head, body, and tail. The global R2* and global FF values were obtained by averaging the respective values from the pancreatic head, body, and tail. The correlations between global R2*, global FF, and fasting glucose were determined using Spearman's correlation analysis. The Friedman test was used to compare R2* and FF among different pancreatic regions. Receiver operating characteristic (ROC) analysis was used to determine the performance of global R2* and global FF in discriminating impaired fasting glucose from normal fasting glucose patients. Results The global R2* was positively correlated with the global FF in the pancreas (r=0.895, P<0.001). No significant differences were found in R2* among the 3 regions of the pancreas (χ2=4.050, P=0.132), but significant differences were found in FF among the 3 pancreatic regions (χ2=16.350, P<0.001). Both global pancreatic R2* (r=0.408, P<0.001) and global FF (r=0.523, P=0.001) were positively correlated with fasting glucose. ROC analysis showed that global pancreatic R2* and global FF had an area under the curve of 0.769 and 0.931 (both P<0.001), respectively, in discriminating between impaired and normal glucose function patients. Conclusions Pediatric TM patients can have homogeneous iron siderosis and heterogeneous fat infiltration in the pancreas as measured by gradient-echo imaging, both of which are risk factors for diabetes.
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Affiliation(s)
- Jingwen Huang
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jun Shen
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qihua Yang
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ziliang Cheng
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaodong Chen
- Department of Radiology, Affiliated hospital of Guangdong Medical University, Zhanjiang, China
| | - Taihui Yu
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jinglian Zhong
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yun Su
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hua Guo
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University, Beijing, China
| | - Biling Liang
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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Ni N, Su Y, Wei Y, Ma Y, Zhao L, Sun X. Tuning Nanosiliceous Framework for Enhanced Cancer Theranostic Applications. ADVANCED THERAPEUTICS 2021. [DOI: 10.1002/adtp.202000218] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Nengyi Ni
- Department of Chemical and Biomolecular Engineering National University of Singapore Singapore 117585 Singapore
| | - Yaoquan Su
- State Key Laboratory of Natural Medicine, The School of Basic Medical Sciences and Clinical Pharmacy China Pharmaceutical University Nanjing 211198 China
| | - Yuchun Wei
- Shandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical Sciences Jinan 250117 China
| | - Yanling Ma
- Department of Chemical and Biomolecular Engineering National University of Singapore Singapore 117585 Singapore
| | - Lingzhi Zhao
- State Key Laboratory of Natural Medicine, The School of Basic Medical Sciences and Clinical Pharmacy China Pharmaceutical University Nanjing 211198 China
| | - Xiao Sun
- Shandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical Sciences Jinan 250117 China
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Casale M, Forni GL, Cassinerio E, Pasquali D, Origa R, Serra M, Campisi S, Peluso A, Renni R, Cattoni A, De Michele E, Allò M, Poggi M, Ferrara F, Di Concilio R, Sportelli F, Quarta A, Putti MC, Notarangelo LD, Sau A, Ladogana S, Tartaglione I, Picariello S, Marcon A, Sturiale P, Roberti D, Lazzarino AI, Perrotta S. Risk factors for endocrine complications in transfusion-dependent thalassemia patients on chelation therapy with deferasirox: a risk assessment study from a multicentre nation-wide cohort. Haematologica 2021; 107:467-477. [PMID: 33406815 PMCID: PMC8804575 DOI: 10.3324/haematol.2020.272419] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Indexed: 01/19/2023] Open
Abstract
Transfusion-dependent patients typically develop iron-induced cardiomyopathy, liver disease, and endocrine complications. We aimed to estimate the incidence of endocrine disorders in transfusiondependent thalassemia (TDT) patients during long-term iron-chelation therapy with deferasirox (DFX). We developed a multi-center follow-up study of 426 TDT patients treated with once-daily DFX for a median duration of 8 years, up to 18.5 years. At baseline, 118, 121, and 187 patients had 0, 1, or ≥2 endocrine diseases respectively. 104 additional endocrine diseases were developed during the follow-up. The overall risk of developing a new endocrine complication within 5 years was 9.7% (95% Confidence Interval [CI]: 6.3–13.1). Multiple Cox regression analysis identified three key predictors: age showed a positive log-linear effect (adjusted hazard ratio [HR] for 50% increase 1.2, 95% CI: 1.1–1.3, P=0.005), the serum concentration of thyrotropin showed a positive linear effect (adjusted HR for 1 mIU/L increase 1.3, 95% CI: 1.1–1.4, P<0.001) regardless the kind of disease incident, while the number of previous endocrine diseases showed a negative linear effect: the higher the number of diseases at baseline the lower the chance of developing further diseasess (adjusted HR for unit increase 0.5, 95% CI: 0.4–0.7, P<0.001). Age and thyrotropin had similar effect sizes across the categories of baseline diseases. The administration of levothyroxine as a covariate did not change the estimates. Although in DFX-treated TDT patients the risk of developing an endocrine complication is generally lower than the previously reported risk, there is considerable risk variation and the burden of these complications remains high. We developed a simple risk score chart enabling clinicians to estimate their patients’ risk. Future research will look at increasing the amount of variation explained from our model and testing further clinical and laboratory predictors, including the assessment of direct endocrine magnetic resonance imaging.
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Affiliation(s)
- Maddalena Casale
- Department of Women, Child and General and Specialized Surgery, University " Luigi Vanvitelli", via Luigi De Crecchio n. 4, 80138, Naples.
| | - Gian Luca Forni
- Center of Microcitemia and Congenital Anemias, Galliera Hospital, Mura delle Cappuccine 14 16128, Genoa
| | - Elena Cassinerio
- Rare Diseases Center, General Medicine Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan
| | - Daniela Pasquali
- Endocrinology, Department of Advanced Medical and Surgical Sciences, University " Luigi Vanvitelli", Naples
| | - Raffaella Origa
- Thalassemia Centre, Pediatric Hospital A CAO, AOG Brotzu, Cagliari
| | - Marilena Serra
- Thalassemia Centre, Department of Internal Medicine, Hospital "V. Fazzi", Lecce
| | | | - Angelo Peluso
- Centre of Microcitemia, POC SS.Annunziata - ASL TA, Taranto
| | - Roberta Renni
- Thalassemia Centre, Department of Internal Medicine, Hospital F.Ferrari, Casarano
| | - Alessandro Cattoni
- Department of Pediatrics, Università degli Studi di Milano Bicocca, Fondazione Monza e Brianza per il Bambino e la sua Mamma, Azienda Ospedaliera San Gerardo, Monza
| | - Elisa De Michele
- Immunotransfusion Medicine Unit, AOU OO.RR. S. Giovanni di Dio e Ruggi d'Aragona, Salerno
| | | | | | | | | | | | - Antonella Quarta
- Center for Microcythemia, Iron Metabolism disorders, Gaucher disease-Hematology and Transplantation Unit, "A. Perrino" Hospital, Brindisi
| | | | | | - Antonella Sau
- Department of Pediatric Hematology and Oncology, Hospital "Spirito Santo", Pescara
| | - Saverio Ladogana
- Pediatric Oncohematology Unit, "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo
| | - Immacolata Tartaglione
- Department of Women, Child and General and Specialized Surgery, University " Luigi Vanvitelli", via Luigi De Crecchio n. 4, 80138, Naples
| | - Stefania Picariello
- Department of Women, Child and General and Specialized Surgery, University " Luigi Vanvitelli", via Luigi De Crecchio n. 4, 80138, Naples
| | - Alessia Marcon
- Rare Diseases Center, General Medicine Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan
| | | | - Domenico Roberti
- Department of Women, Child and General and Specialized Surgery, University " Luigi Vanvitelli", via Luigi De Crecchio n. 4, 80138, Naples
| | - Antonio Ivan Lazzarino
- EPISTATA - Agency for Clinical Research and Medical Statistics, London E8 3SY, United Kingdom
| | - Silverio Perrotta
- Department of Women, Child and General and Specialized Surgery, University " Luigi Vanvitelli", via Luigi De Crecchio n. 4, 80138, Naples
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Pinto VM, Forni GL. Management of Iron Overload in Beta-Thalassemia Patients: Clinical Practice Update Based on Case Series. Int J Mol Sci 2020; 21:E8771. [PMID: 33233561 PMCID: PMC7699680 DOI: 10.3390/ijms21228771] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/14/2020] [Accepted: 11/18/2020] [Indexed: 12/29/2022] Open
Abstract
Thalassemia syndromes are characterized by the inability to produce normal hemoglobin. Ineffective erythropoiesis and red cell transfusions are sources of excess iron that the human organism is unable to remove. Iron that is not saturated by transferrin is a toxic agent that, in transfusion-dependent patients, leads to death from iron-induced cardiomyopathy in the second decade of life. The availability of effective iron chelators, advances in the understanding of the mechanism of iron toxicity and overloading, and the availability of noninvasive methods to monitor iron loading and unloading in the liver, heart, and pancreas have all significantly increased the survival of patients with thalassemia. Prolonged exposure to iron toxicity is involved in the development of endocrinopathy, osteoporosis, cirrhosis, renal failure, and malignant transformation. Now that survival has been dramatically improved, the challenge of iron chelation therapy is to prevent complications. The time has come to consider that the primary goal of chelation therapy is to avoid 24-h exposure to toxic iron and maintain body iron levels within the normal range, avoiding possible chelation-related damage. It is very important to minimize irreversible organ damage to prevent malignant transformation before complications set in and make patients ineligible for current and future curative therapies. In this clinical case-based review, we highlight particular aspects of the management of iron overload in patients with beta-thalassemia syndromes, focusing on our own experience in treating such patients. We review the pathophysiology of iron overload and the different ways to assess, quantify, and monitor it. We also discuss chelation strategies that can be used with currently available chelators, balancing the need to keep non-transferrin-bound iron levels to a minimum (zero) 24 h a day, 7 days a week and the risk of over-chelation.
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Affiliation(s)
- Valeria Maria Pinto
- Centro della Microcitemia e delle Anemie Congenite Ente Ospedaliero Ospedali Galliera, Via Volta 6, 16128 Genoa, Italy;
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Pepe A, Pistoia L, Gamberini MR, Cuccia L, Peluso A, Messina G, Spasiano A, Allò M, Bisconte MG, Putti MC, Casini T, Dello Iacono N, Celli M, Vitucci A, Giuliano P, Peritore G, Renne S, Righi R, Positano V, De Sanctis V, Meloni A. The Close Link of Pancreatic Iron With Glucose Metabolism and With Cardiac Complications in Thalassemia Major: A Large, Multicenter Observational Study. Diabetes Care 2020; 43:2830-2839. [PMID: 32887708 DOI: 10.2337/dc20-0908] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/08/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We systematically explored the link of pancreatic iron with glucose metabolism and with cardiac complications in a cohort of 1,079 patients with thalassemia major (TM) enrolled in the Extension-Myocardial Iron Overload in Thalassemia (E-MIOT) project. RESEARCH DESIGN AND METHODS MRI was used to quantify iron overload (T2* technique) and cardiac function (cine images) and to detect macroscopic myocardial fibrosis (late gadolinium enhancement technique). Glucose metabolism was assessed by the oral glucose tolerance test (OGTT). RESULTS Patients with normal glucose metabolism showed significantly higher global pancreas T2* values than patients with impaired fasting glucose, impaired glucose tolerance, and diabetes. A pancreas T2* <13.07 ms predicted an abnormal OGTT. A normal pancreas T2* value showed a 100% negative predictive value for disturbances of glucose metabolism and for cardiac iron. Patients with myocardial fibrosis showed significantly lower pancreas T2* values. Patients with cardiac complications had significantly lower pancreas T2* values. No patient with arrhythmias/heart failure had a normal global pancreas T2*. CONCLUSIONS Pancreatic iron is a powerful predictor not only for glucose metabolism but also for cardiac iron and complications, supporting the close link between pancreatic iron and heart disease and the need to intensify iron chelation therapy to prevent both alterations of glucose metabolism and cardiac iron accumulation.
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Affiliation(s)
- Alessia Pepe
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Laura Pistoia
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Maria Rita Gamberini
- Dipartimento della Riproduzione e dell'Accrescimento, Day Hospital della Talassemia e delle Emoglobinopatie, Azienda Ospedaliero-Universitaria di Ferrara - Arcispedale Sant'Anna, Ferrara, Italy
| | - Liana Cuccia
- Unità Operativa Complessa Ematologia con Talassemia, Azienda di Rilievo Nazionale ed Alta Specializzazione Ospedali Civico Di Cristina Benfratelli, Palermo, Italy
| | - Angelo Peluso
- Struttura Semplice di Microcitemia, Ospedale "SS. Annunziata" ASL Taranto, Taranto, Italy
| | - Giuseppe Messina
- Centro Microcitemie, Azienda Ospedaliera "Bianchi-Melacrino-Morelli," Reggio Calabria, Italy
| | - Anna Spasiano
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale "Antonio Cardarelli," Napoli, Italy
| | - Massimo Allò
- Ematologia Microcitemia, Ospedale San Giovanni di Dio-Azienda Sanitaria Provinciale Crotone, Crotone, Italy
| | - Maria Grazia Bisconte
- Centro di Microcitemia, Unità Operativa Ematologia, Azienda Ospedaliera Cosenza, Cosenza, Italy
| | - Maria Caterina Putti
- Clinica di Emato-Oncologia Pediatrica, Dipartimento di Salute della Donna e del Bambino, Azienda Ospedaliero di Padova-Università di Padova, Padova, Italy
| | - Tommaso Casini
- Centro Talassemie ed Emoglobinopatie, Ospedale "Meyer," Firenze, Italy
| | - Nicola Dello Iacono
- Centro Microcitemia, Day Hospital Thalassemia, Poliambulatorio "Giovanni Paolo II," Ospedale Casa Sollievo della Sofferenza IRCCS, San Giovanni Rotondo, Italy
| | - Mauro Celli
- Unità Operativa Complessa di ImmunoEmatologia, Dipartimenti Assistenziali Integrati di Pediatria e Neuropsiachiatria Infantile, Roma, Italy
| | - Angelantonio Vitucci
- Ematologia con Trapianto-Servizio Regionale Talassemie, Dipartimento dell'Emergenza e dei Trapianti d'Organo, Azienda Universitaria Ospedaliera Consorziale - Policlinico Bari, Bari, Italy
| | - Pietro Giuliano
- Cardiologia con UTIC, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico Di Cristina Benfratelli, Palermo, Italy
| | - Giuseppe Peritore
- Unità Operativa Complessa di Radiologia, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico Di Cristina Benfratelli, Palermo, Italy
| | - Stefania Renne
- Struttura Complessa di Cardioradiologia-UTIC, Presidio Ospedaliero "Giovanni Paolo II," Lamezia Terme, Italy
| | - Riccardo Righi
- Diagnostica per Immagini e Radiologia Interventistica, Ospedale del Delta, Lagosanto, Italy
| | - Vincenzo Positano
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Vincenzo De Sanctis
- Pediatric and Adolescent Outpatient Clinic, Quisisana Hospital, Ferrara, Italy
| | - Antonella Meloni
- Magnetic Resonance Imaging Unit, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
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Salama K, Abdelsalam A, Eldin HS, Youness E, Selim Y, Salama C, Hassanein G, Samir M, Zekri H. The relationships between pancreatic T2* values and pancreatic iron loading with cardiac dysfunctions, hepatic and cardiac iron siderosis among Egyptian children and young adults with β-thalassaemia major and sickle cell disease: a cross-sectional study. F1000Res 2020; 9:1108. [PMID: 34249348 PMCID: PMC8261758 DOI: 10.12688/f1000research.25943.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 01/21/2023] Open
Abstract
Background: Cardiac, hepatic and pancreatic T2* measured by magnetic resonance imaging (MRI) has been proven to be an accurate and non-invasive method for measuring iron overload in iron overload conditions. There is accumulating evidence that pancreatic iron can predict cardiac iron in young children because the pancreas loads earlier than the heart. The aim of our study was to assess the relationships between pancreatic T2* values and pancreatic iron loading with cardiac dysfunctions and liver and cardiac iron
among patients with β-thalassaemia major (βTM) and sickle cell disease (SCD). Methods: 40 βTM and 20 transfusion-dependant SCD patients were included along with 60 healthy age and sex-matched controls. Echocardiography and Tissue Doppler Imaging were performed for all subjects as well as the control group. Hepatic, cardiac and pancreatic iron overload in cases were assessed by MRI T2*. Results: The mean age of our patients was 13.7 years with mean frequency of transfusion/year 12. Mean cardiac T2* was 32.9 ms and mean myocardial iron concentration was 0.7 mg/g; One patient had cardiac iron overload of moderate severity. Mean pancreatic T2* was 22.3 ms with 20 patients having mild pancreatic iron overload. Pancreatic T2* correlated positively peak late diastolic velocity at septal mitral annulus (r=0.269, p=0.038), peak early diastolic velocity at tricuspid annulus (r=0.430, p=0.001) and mitral annular plane systolic excursion (r=0.326, p=0.01); and negatively with end systolic pulmonary artery pressure (r=-0.343, p=0.007) and main pulmonary artery diameter (MPA) (r=-0.259, p=0.046). We couldn’t test the predictability of pancreatic T2* in relation to cardiac T2* as only one patient had cardiac T2*<20 ms. Conclusion: There was a relationship between pancreatic iron siderosis with cardiac dysfunction in multi-transfused patients with βTM and SCD. No direct relation between pancreatic iron and cardiac siderosis was detected.
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Affiliation(s)
- Khaled Salama
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amina Abdelsalam
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hadeel Seif Eldin
- Department of Radiodiagnosis, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Eman Youness
- Department of Medical Biochemistry, National Research Centre, Giza, Egypt
| | - Yasmeen Selim
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Christine Salama
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Gehad Hassanein
- Department of Radiodiagnosis, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Samir
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hanan Zekri
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
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Bilgin BK, Yozgat AK, Isik P, Çulha V, Kacar D, Kara A, Ozbek NY, Yarali N. The effect of deferasirox on endocrine complications in children with thalassemia. Pediatr Hematol Oncol 2020; 37:455-464. [PMID: 32131650 DOI: 10.1080/08880018.2020.1734124] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Endocrine system dysfunctions are the significant complications of excessive iron overload in beta thalassemia patients. The aim of this study was to evaluate the long-term effect of chelation with deferasirox on endocrine complications. The study group consisted of children with beta thalassemia who had been evaluated for the growth and pubertal development, bone metabolism, thyroid/parathyroid functions, glucose metabolism dysfunctions in the department of pediatric hematology of Ankara Dışkapı Child Health and Diseases Hematology Oncology Training And Research Hospital between 2009-2011 and reevaluated after deferasirox chelation therapy in 2018. Thirty-one transfusion dependent beta-thalassemia patients were enrolled for the study. Seventeen (54.8%) patients were male and the mean age was 16.9 ± 3.8 (9-23) years. Splenectomy was performed in 11 patients (35.5%). In the initial evaluation, 26 patients (84%) received deferoxamine and/or deferiprone and five (17%) patients received deferasirox as a chelator; in the final evaluation all patients were receiving deferasirox. The mean duration of deferasirox treatment was 5.9 ± 2.02 years (1-10 years). Of the 26 patients who had endocrine complications between 2009-2011, 18 were recovered. In the final evaluation, eight patients (25%) developed new endocrinopathies. The frequency of endocrine complications seen before the deferasirox treatment (83%) was higher than the frequency of complications while receiving deferasirox treatment (25.8%) (p < 0,05). In this study, it was determined that both existing endocrine abnormalities were reduced and recent developed problems were less likely with long-term deferasirox treatment in thalassemia patients.
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Affiliation(s)
- Burçak Kurucu Bilgin
- Department of Pediatric Hematology, Ankara Dışkapı Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Ayça Koca Yozgat
- Department of Pediatric Hematology, Ankara Dışkapı Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Pamir Isik
- Department of Pediatric Hematology, Ankara Dışkapı Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Vildan Çulha
- Department of Pediatric Hematology, Ankara Dışkapı Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Dilek Kacar
- Department of Pediatric Hematology, Ankara Dışkapı Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Abdurrahman Kara
- Department of Pediatric Hematology, Ankara Dışkapı Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Namık Yasar Ozbek
- Department of Pediatric Hematology, Ankara Dışkapı Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Nese Yarali
- Department of Pediatric Hematology, Ankara Dışkapı Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
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Bush AM, Sandino CM, Ramachandran S, Ong F, Dwork N, Zucker EJ, Syed AB, Pauly JM, Alley MT, Vasanawala SS. Rosette Trajectories Enable Ungated, Motion-Robust, Simultaneous Cardiac and Liver T 2 * Iron Assessment. J Magn Reson Imaging 2020; 52:1688-1698. [PMID: 32452088 DOI: 10.1002/jmri.27196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Quantitative T2 * MRI is the standard of care for the assessment of iron overload. However, patient motion corrupts T2 * estimates. PURPOSE To develop and evaluate a motion-robust, simultaneous cardiac and liver T2 * imaging approach using non-Cartesian, rosette sampling and a model-based reconstruction as compared to clinical-standard Cartesian MRI. STUDY TYPE Prospective. PHANTOM/POPULATION Six ferumoxytol-containing phantoms (26-288 μg/mL). Eight healthy subjects and 18 patients referred for clinically indicated iron overload assessment. FIELD STRENGTH/SEQUENCE 1.5T, 2D Cartesian and rosette gradient echo (GRE) ASSESSMENT: GRE T2 * values were validated in ferumoxytol phantoms. In healthy subjects, test-retest and spatial coefficient of variation (CoV) analysis was performed during three breathing conditions. Cartesian and rosette T2 * were compared using correlation and Bland-Altman analysis. Images were rated by three experienced radiologists on a 5-point scale. STATISTICAL TESTS Linear regression, analysis of variance (ANOVA), and paired Student's t-testing were used to compare reproducibility and variability metrics in Cartesian and rosette scans. The Wilcoxon rank test was used to assess reader score comparisons and reader reliability was measured using intraclass correlation analysis. RESULTS Rosette R2* (1/T2 *) was linearly correlated with ferumoxytol concentration (r2 = 1.00) and not significantly different than Cartesian values (P = 0.16). During breath-holding, ungated rosette liver and heart T2 * had lower spatial CoV (liver: 18.4 ± 9.3% Cartesian, 8.8% ± 3.4% rosette, P = 0.02, heart: 37.7% ± 14.3% Cartesian, 13.4% ± 1.7% rosette, P = 0.001) and higher-quality scores (liver: 3.3 [3.0-3.6] Cartesian, 4.7 [4.1-4.9] rosette, P = 0.005, heart: 3.0 [2.3-3] Cartesian, 4.5 [3.8-5.0] rosette, P = 0.005) compared to Cartesian values. During free-breathing and failed breath-holding, Cartesian images had very poor to average image quality with significant artifacts, whereas rosette remained very good, with minimal artifacts (P = 0.001). DATA CONCLUSION Rosette k-sampling with a model-based reconstruction offers a clinically useful motion-robust T2 * mapping approach for iron quantification. J. MAGN. RESON. IMAGING 2020;52:1688-1698.
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Affiliation(s)
- Adam M Bush
- Department of Radiology, Stanford University, Palo Alto, California, USA
| | - Christopher M Sandino
- Department of Electrical Engineering, Stanford University, Palo Alto, California, USA
| | - Shreya Ramachandran
- Department of Electrical Engineering and Computer Science, University of California, Berkeley, California, USA
| | - Frank Ong
- Department of Radiology, Stanford University, Palo Alto, California, USA
| | - Nicholas Dwork
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
| | - Evan J Zucker
- Department of Radiology, Stanford University, Palo Alto, California, USA
| | - Ali B Syed
- Department of Radiology, Stanford University, Palo Alto, California, USA
| | - John M Pauly
- Department of Electrical Engineering, Stanford University, Palo Alto, California, USA
| | - Marcus T Alley
- Department of Radiology, Stanford University, Palo Alto, California, USA
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Karadas N, Yurekli B, Bayraktaroglu S, Aydinok Y. Insulin secretion-sensitivity index-2 could be a novel marker in the identification of the role of pancreatic iron deposition on beta-cell function in thalassemia major. Endocr J 2019; 66:1093-1099. [PMID: 31527320 DOI: 10.1507/endocrj.ej19-0191] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The purpose of this study is to evaluate the impact of insulin secretion-sensitivity index-2 (ISSI-2) in the identification of the role of pancreatic iron deposition on beta-cell function in thalassemia major. Tissue iron stores were measured with magnetic resonance imaging (MRI) in the liver (R2), pancreas (R2*), and heart (T2*). ISSI-2 was assessed as a novel oral glucose tolerance test-based measure of beta-cell function. Also, the Stumvoll index showing the insulin sensitivity and Stumvoll index estimating first and second phase insulin secretion were calculated. Fourteen of the 51 Thalassemia Major patients, aged 8-34 (mean 21.1 ± 7.2) years-old, had either an impaired glucose tolerance test (n = 9, 17.6%) or diabetes mellitus (n = 5, 9.8%)-referred to as the glucose dysregulation (GD) group. The median serum ferritin and the mean liver R2 and cardiac T2* values were not significantly different between the GD and normal glucose tolerance (NGT, n = 37) groups whereas pancreas R2* was significantly higher in the GD group compared to the NGT group (p = 0.004). Patients with GD showed significantly lower ISSI-2 index (p < 0.001) as well as the Stumvoll index and Stumvoll first and second phase indices compared to those with NGT (p < 0.001). All patients with GD displayed a pancreas R2* >50 Hz and ISSI-2 <2. In conclusion, Pancreas R2* MRI combined with ISSI-2 index may be valuable parameters to identify patients at the highest risk for developing glucose dysregulation.
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Affiliation(s)
- Nihal Karadas
- Department of Pediatric Hematology & Oncology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Banu Yurekli
- Department of Endocrinology, Ege University Faculty of Medicine, Izmir, Turkey
| | | | - Yesim Aydinok
- Department of Pediatric Hematology & Oncology, Ege University Faculty of Medicine, Izmir, Turkey
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Coates TD. Iron overload in transfusion-dependent patients. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:337-344. [PMID: 31808901 PMCID: PMC6913424 DOI: 10.1182/hematology.2019000036] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Before the advent of effective iron chelation, death from iron-induced cardiomyopathy occurred in the second decade in patients with transfusion-dependent chronic anemias. The advances in our understanding of iron metabolism; the ability to monitor iron loading in the liver, heart, pancreas and pituitary; and the availability of several effective iron chelators have dramatically improved survival and reduced morbidity from transfusion-related iron overload. Nevertheless, significantly increased survival brings about new complications such as malignant transformation resulting from prolonged exposure to iron, which need to be considered when developing long-term therapeutic strategies. This review discusses the current biology of iron homeostasis and its close relation to marrow activity in patients with transfusion-dependent anemias, and how biology informs clinical approach to treatment.
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Affiliation(s)
- Thomas D Coates
- Hematology Section, Children's Center for Cancer, Blood Diseases and Bone Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
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Glucose dysregulation in patients with iron overload: is there a relationship with quantitative pancreas and liver iron and fat content measured by MRI? Eur Radiol 2019; 30:1616-1623. [PMID: 31712958 DOI: 10.1007/s00330-019-06487-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/27/2019] [Accepted: 10/09/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The aim was to investigate the relationship between pancreatic and hepatic iron and fat to glucose metabolism in patients with iron overload and address conflicting results in literature as regards the relationship between pancreas iron and glucose dysregulation. METHODS We retrospectively evaluated pancreatic and hepatic R2*, fat fraction (FF), liver iron concentration (LIC), and glucose metabolism in 105 patients with iron overload obtained with a multi-echo gradient echo R2* technique and assessed the correlation between pancreatic R2* and FF to glucose dysregulation. RESULTS There were no significant differences in pancreatic R2*, liver R2*, and FF in patients with iron overload and glucose dysregulation compared to those with normoglycemia (p = 0.435, p = 0.674, and p = 0.976), whereas pancreatic FF was significantly higher, 23.5% vs 16.7% respectively (p = 0.011). Pancreatic FF and R2* demonstrated an area under the curve of 0.666 and 0.571 for discriminating glucose dysregulation. Pancreatic FF of 26.2% yielded specificity and sensitivity of 80% and 45% for prediction of glucose dysregulation. Pancreatic R2* weakly correlated with pancreatic FF, r = 0.388 (p < 0.001), and liver R2*, r = 0.201 (p = 0.033), and showed no correlation with hepatic FF r = -0.013 (p = 0.892) or LIC categories (p = 0.493). CONCLUSION Pancreatic FF but not pancreatic R2* was associated with glucose dysregulation in patients with iron overload. Prior studies reporting correlation of pancreatic R2* to glucose dysregulation likely relate from inadequate MRI technique or analysis employed, which unlike our study did not perform simultaneous measurements of fat and iron essential to avoid their confounding effects during quantitative analysis. KEY POINTS • Pancreatic fat fraction, unlike iron, is associated with glucose dysregulation in iron overload. • Simultaneous measurement of pancreatic iron and fat content with MRI is essential to avoid confounding effects of one another during quantitative analysis. • Pancreatic fat fraction could be utilized to predict glucose dysregulation in iron overload states.
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Woei-A-Jin FJSH, Zheng SZ, Kiliçsoy I, Hudig F, Luelmo SAC, Kroep JR, Lamb HJ, Osanto S. Lifetime Transfusion Burden and Transfusion-Related Iron Overload in Adult Survivors of Solid Malignancies. Oncologist 2019; 25:e341-e350. [PMID: 32043782 DOI: 10.1634/theoncologist.2019-0222] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 07/31/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Limited data exist on transfusion burden and transfusion-related iron overload in adult survivors of solid malignancies. METHODS Hospital-specific cancer registry data of patients with solid tumor receiving systemic anticancer treatment between January 2008 and September 2009 at the Oncology Department of the Leiden University Medical Center (The Netherlands) were retrieved and cross-referenced with red blood cell (RBC) transfusion records. Individual lifetime transfusion burden was captured in April 2015. Multitransfused long-term survivors with serum ferritin >500 μg/L were subsequently screened for hepatic and cardiac iron overload using 1.5 Tesla magnetic resonance imaging. RESULTS The study population consisted of 775 adult patients with solid cancer (45.2% male; median age, 58 years; >75% chemotherapy-treated), 423 (54.6%) of whom were transfused with a median of 6.0 RBC units (range 1-67). Transfusion triggers were symptomatic anemia or hemoglobin <8.1-8.9 g/dL prior to each myelosuppressive chemotherapy cycle. We identified 123 (15.9%) patients across all tumor types with a lifetime transfusion burden of ≥10 RBC units. In the absence of a hemovigilance program, none of these multitransfused patients was screened for iron overload despite a median survival of 4.6 years. In 2015 at disclosure of transfusion burden, 26 multitransfused patients were alive. Six (23.1%) had hepatic iron overload: 3.9-11.2 mg Fe/g dry weight. No cardiac iron depositions were found. CONCLUSION Patients with solid malignancies are at risk for multitransfusion and iron overload even when adhering to restrictive RBC transfusion policies. With improved long-term cancer survivorship, increased awareness of iatrogenic side effects of supportive therapy and development of evidence-based guidelines are essential. IMPLICATIONS FOR PRACTICE In the presence of a restrictive transfusion policy, ∼30% of transfused adult patients with solid cancer are multitransfused and ∼50% become long-term survivors, underscoring the need for evidence-based guidelines for the detection and management of transfusion-related iron overload in this group of patients. In each institution, a hemovigilance program should be implemented that captures the lifetime cumulative transfusion burden in all patients with cancer, irrespective of tumor type. This instrument will allow timely assessment and treatment of iron overload in cancer survivors, thus preventing organ dysfunction and decreased quality of life.
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Affiliation(s)
- F J Sherida H Woei-A-Jin
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Laboratory of Clinical Chemistry and Hematology, Haga Hospital, The Hague, The Netherlands
| | - Shu Zhen Zheng
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Inci Kiliçsoy
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Francisca Hudig
- Department of Laboratory of Clinical Chemistry and Hematology, Haga Hospital, The Hague, The Netherlands
| | - Saskia A C Luelmo
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Judith R Kroep
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Susanne Osanto
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
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Tavares AHJ, Benites BD, Fertrin KY. Myocardial Iron Overload in Sickle Cell Disease: A Rare But Potentially Fatal Complication of Transfusion. Transfus Med Rev 2019; 33:170-175. [PMID: 31153715 DOI: 10.1016/j.tmrv.2019.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/09/2019] [Accepted: 04/18/2019] [Indexed: 02/02/2023]
Abstract
Sickle cell disease (SCD) is a frequent indication for chronic transfusion, which can cause iron overload. Excess iron often affects the liver, but not the heart in SCD. Magnetic resonance (MR) is recommended to detect myocardial iron overload (MIO) but its elevated cost requires optimized indication. We aimed to compile all published data on MIO in SCD upon the description of a fatal case of severe MIO in our institution, and to determine associated risk factors. We performed a systematic review using the PRISMA guidelines in two databases (PubMed and Web of Science). Inclusion criteria were publication in English, patients diagnosed with SCD, and reporting ferritin and MIO by MR. Twenty publications reported on 865 SCD adult and pediatric patients, with at least 10 other cases of MIO. The prevalence of MIO in chronically transfused SCD patients can be estimated to be 3% or less, and is associated with high transfusion burden, top-up transfusions, and low adherence to iron chelation. Cardiac siderosis in SCD is rarely reported, and increased awareness with better use of the available screening tools are necessary. Prospective studies should define the recommended chelation regimens depending on the severity of MIO.
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Affiliation(s)
| | | | - Kleber Yotsumoto Fertrin
- Hematology and Hemotherapy Center, University of Campinas - UNICAMP, Campinas, Brazil; Division of Hematology, University of Washington, Seattle, WA.
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Abstract
Most cells in the body acquire iron via receptor-mediated endocytosis of transferrin, the circulating iron transport protein. When cellular iron levels are sufficient, the uptake of transferrin decreases to limit further iron assimilation and prevent excessive iron accumulation. In iron overload conditions, such as hereditary hemochromatosis and thalassemia major, unregulated iron entry into the plasma overwhelms the carrying capacity of transferrin, resulting in non-transferrin-bound iron (NTBI), a redox-active, potentially toxic form of iron. Plasma NTBI is rapidly cleared from the circulation primarily by the liver and other organs (e.g., pancreas, heart, and pituitary) where it contributes significantly to tissue iron overload and related pathology. While NTBI is usually not detectable in the plasma of healthy individuals, it does appear to be a normal constituent of brain interstitial fluid and therefore likely serves as an important source of iron for most cell types in the CNS. A growing body of literature indicates that NTBI uptake is mediated by non-transferrin-bound iron transporters such as ZIP14, L-type and T-type calcium channels, DMT1, ZIP8, and TRPC6. This review provides an overview of NTBI uptake by various tissues and cells and summarizes the evidence for and against the roles of individual transporters in this process.
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Affiliation(s)
- Mitchell D Knutson
- Food Science and Human Nutrition Department, University of Florida, Gainesville, FL, USA.
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Multicenter validation of the magnetic resonance T2* technique for quantification of pancreatic iron. Eur Radiol 2018; 29:2246-2252. [PMID: 30338366 DOI: 10.1007/s00330-018-5783-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/28/2018] [Accepted: 09/20/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To assess the transferability of the magnetic resonance imaging (MRI) multislice multiecho T2* technique for pancreatic iron overload assessment. METHODS Multiecho T2* sequences were installed on ten 1.5-T MRI scanners of the three main vendors. Five healthy subjects (n = 50) were scanned at each site. Five patients with thalassemia (n = 45) were scanned locally at each site and were rescanned at the reference site within 1 month. T2* images were analyzed using a previously validated software and the global pancreatic T2* value was calculated as the mean of T2* values over the head, body, and tail. RESULTS T2* values of healthy subjects were above 26 ms and showed inter-site homogeneity. The T2* values measured in the MRI sites were comparable to the correspondent values observed in the reference site (12.02 ± 10.20 ms vs 11.98 ± 10.47 ms; p = 0.808), and the correlation coefficient was 0.978 (p < 0.0001). Coefficients of variation (CoVs) ranged from 4.22 to 9.77%, and the CoV for all the T2* values independently from the sites was 8.55%. The intraclass correlation coefficient (ICC) for each MRI site was always excellent and the global ICC was 0.995, independently from the sites. The mean absolute difference in patients with pancreatic iron (n = 39) was -0.15 ± 1.38 ms. CONCLUSION The gradient-echo T2* MRI technique is an accurate and reproducible means for the quantification of pancreatic iron and may be transferred among MRI scanners by different vendors in several centers. KEY POINTS • The gradient-echo T2* MRI technique is an accurate and reproducible means for the quantification of pancreatic iron. • The gradient-echo T2* MRI technique for the quantification of pancreatic iron may be transferred among MRI scanners by different vendors in several centers. • Pancreatic iron might serve as an early predictor of cardiac siderosis and is the strongest overall predictor of glucose dysregulation.
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Serai SD, Trout AT, Fleck RJ, Quinn CT, Dillman JR. Measuring liver T2* and cardiac T2* in a single acquisition. Abdom Radiol (NY) 2018; 43:2303-2308. [PMID: 29470624 DOI: 10.1007/s00261-018-1477-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE The purpose of this study is determine if both liver T2* and cardiac T2* can be measured on a single breath-hold acquisition. MATERIALS AND METHODS For this IRB-approved retrospective study, 137 patients with dedicated Cardiac MRI and Liver MRI examinations obtained sequentially on 1.5T scanners and on the same day were included for analysis. Both the cardiac and liver MRI examinations utilized GRE sequences for quantification of tissue iron. Specifically, T2* was measured using an 8-echo, multi-echo gradient echo single breath-hold sequence. Liver T2* was measured in a blinded manner on images from each of the cardiac and dedicated liver MRI examinations and were correlated. Bland-Altman difference plot was used to assess mean bias. RESULTS 137 examinations from 93 subjects met inclusion criteria. 10 examination pairs were excluded because the first echo time (TE) on the cardiac MRI was insufficiently short for the very high liver iron content. After exclusion, 127 studies from 89 subjects (67.4% males) were included in the final analysis. The mean subject age (± standard deviation) was 11.5 ± 7.5 years (range 0-29.3 years; median 10.5 years). Mean liver T2* measured on cardiac MRI was 8.3 ± 7.7 ms and mean liver T2* measured on dedicated liver MRI was 7.8 ± 7.4 ms (p < 0.001). There was strong positive correlation between the two liver T2* measurements (r = 0.989, p < 0.0001; 95% CI 0.985-0.992). With the exception of borderline outliers, all values fell within two standard deviations on the Bland-Altman difference plots, with a mean bias of 0.5 ms (range - 1.8 to + 2.7 ms). CONCLUSION In most patients with suspected or known iron overload, a single breath-hold GRE sequence may be sufficient to evaluate the iron concentration (T2*) of both the myocardium and the liver.
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Affiliation(s)
- Suraj D Serai
- Department of Radiology, MLC 5031, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Andrew T Trout
- Department of Radiology, MLC 5031, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Robert J Fleck
- Department of Radiology, MLC 5031, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Charles T Quinn
- Department of Hematology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Jonathan R Dillman
- Department of Radiology, MLC 5031, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
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Santarelli MF, Meloni A, De Marchi D, Pistoia L, Quarta A, Spasiano A, Landini L, Pepe A, Positano V. Estimation of pancreatic R2* for iron overload assessment in the presence of fat: a comparison of different approaches. MAGNETIC RESONANCE MATERIALS IN PHYSICS BIOLOGY AND MEDICINE 2018; 31:757-769. [PMID: 30043125 DOI: 10.1007/s10334-018-0695-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 06/13/2018] [Accepted: 07/18/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To propose a method for estimating pancreatic relaxation rate, R2*, from conventional multi-echo MRI, based on the nonlinear fitting of the acquired magnitude signal decay to MR signal models that take into account both the signal oscillations induced by fat and the different R2* values of pancreatic parenchyma and fat. MATERIALS AND METHODS Single-peak fat (SPF) and multi-peak fat (MPF) models were introduced. Single-R2* and dual-R2* assumptions were considered as well. Analyses were conducted on simulated data and 20 thalassemia major patients. RESULTS Simulations revealed the ability of the MPF model to correctly estimate the R2* value in a large range of fat fractions and R2* values. From the comparison between the results obtained with a single R2* value for water and fat and the dual-R2* approach, the latter is more accurate in both water R2* and fat fraction estimation. In patient's data analysis, a strong concordance was found between SPF and MPF estimated data with measurements done with manual signal correction and from fat-saturated images. The MPF method showed better reproducibility. CONCLUSION The MPF dual-R2* approach improves reproducibility and reduces image analysis time in the assessment of pancreatic R2* value in patients with iron overload.
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Affiliation(s)
| | - Antonella Meloni
- Fondazione CNR Regione Toscana "G. Monasterio", Via Moruzzi, 1, 56124, Pisa, Italy
| | - Daniele De Marchi
- Fondazione CNR Regione Toscana "G. Monasterio", Via Moruzzi, 1, 56124, Pisa, Italy
| | - Laura Pistoia
- Fondazione CNR Regione Toscana "G. Monasterio", Via Moruzzi, 1, 56124, Pisa, Italy
| | | | - Anna Spasiano
- UOS Malattie Rare Del Globulo Rosso, AORN Cardarelli, Naples, Italy
| | - Luigi Landini
- Fondazione CNR Regione Toscana "G. Monasterio", Via Moruzzi, 1, 56124, Pisa, Italy
- Department of Information Engineering, University of Pisa, Pisa, Italy
| | - Alessia Pepe
- Fondazione CNR Regione Toscana "G. Monasterio", Via Moruzzi, 1, 56124, Pisa, Italy
| | - Vincenzo Positano
- Fondazione CNR Regione Toscana "G. Monasterio", Via Moruzzi, 1, 56124, Pisa, Italy.
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Rostoker G. When should iron supplementation in dialysis patients be avoided, minimized or withdrawn? Semin Dial 2018; 32:22-29. [PMID: 29956370 PMCID: PMC7379289 DOI: 10.1111/sdi.12732] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Parenteral iron is used to restore the body's iron pool before and during erythropoiesis‐stimulating agent (ESA) therapy; together these agents form the backbone of anemia management in end‐stage renal disease (ESRD) patients undergoing hemodialysis. ESRD patients receiving chronic intravenous iron products, which exceed their blood loss are exposed to an increased risk of positive iron balance. Measurement of the liver iron concentration (LIC) reflects total body iron stores in patients with secondary hemosiderosis and genetic hemochromatosis. Recent studies of LIC in hemodialysis patients, measured by quantitative MRI and magnetic susceptometry, have demonstrated a high risk of iron overload in dialysis patients treated with IV iron products at doses advocated by current anemia management guidelines for dialysis patients. Liver iron overload causes increased production of hepcidin and elevated plasma levels, which can activate macrophages of atherosclerotic plaques. This mechanism may explain the results of 3 long‐term epidemiological studies which showed the association of excessive IV iron doses with increased risk of cardiovascular morbidity and mortality among hemodialysis patients. A more physiological approach of iron therapy in ESRD is needed. Peritoneal dialysis patients, hemodialysis patients infected with hepatitis C virus, and hemodialysis patients with ferritin above 1000 μg/L without a concomitant inflammatory state, all require specific and cautious iron management. Two recent studies have shown that most hemodialysis patients will benefit from lower maintenance IV iron dosages; their results are applicable to American hemodialysis patients. Novel pharmacometric and economic approaches to iron therapy and anemia management are emerging which are designed to lessen the potential side effects of excessive IV iron while maintaining hemoglobin stability without an increase in ESA dosing.
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Affiliation(s)
- Guy Rostoker
- Ramsay-Générale de Santé, Division of Nephrology and Dialysis, Hôpital Privé Claude Galien, Quincy sous Sénart, France
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50
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Viprakasit V, Ajlan A, Aydinok Y, Al Ebadi BAA, Dewedar H, Ibrahim AS, Ragab L, Trad O, Wataify AS, Wong LLL, Taher AT. MRI for the diagnosis of cardiac and liver iron overload in patients with transfusion-dependent thalassemia: An algorithm to guide clinical use when availability is limited. Am J Hematol 2018; 93:E135-E137. [PMID: 29473204 DOI: 10.1002/ajh.25075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 02/12/2018] [Accepted: 02/20/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Vip Viprakasit
- Division of Hematology and OncologyDepartment of Pediatrics and Siriraj Thalassemia Center, Mahidol UniversityBangkok Thailand
| | - Amr Ajlan
- Radiology DepartmentKing Abdulaziz University HospitalJeddah Saudi Arabia
| | - Yesim Aydinok
- Department of Pediatric Hematology and OncologyEge University Children's HospitalIzmir Turkey
| | | | - Hany Dewedar
- Thalassemia CenterHematology Unit, Dubai Health Authority United Arab Emirates
| | | | - Lamis Ragab
- Department of Pediatrics, Faculty of medicineCairo UniversityCairo Egypt
| | - Omar Trad
- Department of Oncology, Division of Hematology‐OncologyTawam HospitalAbu Dhabi United Arab Emirates
| | - Ahmed S. Wataify
- Babylon Center of Hereditary Blood DisordersBabylon universityBabylon Iraq
| | - Lily L. L. Wong
- Hematology UnitQueen Elizabeth HospitalKota Kinabalu Malaysia
| | - Ali T. Taher
- Department of Internal MedicineAmerican University of Beirut Medical CentreBeirut Lebanon
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