Nutritional Deficiencies Are Common in Patients with Transfusion-Dependent Thalassemia and Associated with Iron Overload

Association of age to nutritional status and muscle mass in children with transfusion-dependent β-thalassemia: a cross-sectional study

Background

Transfusion-dependent β-thalassemia (TDT) is a hereditary blood disorder that often leads to complications affecting growth, nutritional status, and muscle mass in children. This study aims to investigate the associations between age, nutritional status, and muscle mass in children with TDT, providing insights into the progressive impact of age on these parameters.

Methods

One hundred twenty-two children with TDT from March 2023 to March 2024 were enrolled in this cross-sectional study. Their nutritional status was assessed using the 2006-2007 World Health Organization (WHO) Growth Charts, and their muscle mass was measured using bioelectrical impedance analysis (BIA). Data related to age, gender, weight, height, fat-free mass (FFM), skeletal muscle mass (SMM), and soft lean mass (SLM) of children were collected for comparative analysis from the hospital record room. Furthermore, Spearman's rank correlation coefficients and regression analyses were utilized to investigate the associations between age and both nutritional status and muscle mass.

Results

The results of this study revealed negative correlations between age and wasting (r = -0.26, p < 0.001), stunting (r = -0.28, p < 0.001), FFM (r = -0.3, p < 0.001), SMM (r = -0.23, p < 0.01), and SLM (r = -0.36, p < 0.001). The regression analysis indicated that age was an independent predictor of wasting, stunting, and reduced muscle mass in these children (all p < 0.001).

Conclusion

Our study observed a trend of worsening stunting, wasting, and muscle loss in children with TDT as they age. These findings highlight the importance of monitoring both nutritional and muscular health in TDT patients. Early detection and comprehensive nutritional management may improve outcomes in this population.

Nutritional Support Best Practices in Pediatric Blood and Marrow Transplant Patients: An Integrative Review

Nutrition is vital to the long-term survival of children undergoing blood and marrow transplantation (BMT), but there is no standardization on how to optimize the nutritional status of these patients. A literature search was performed to evaluate nutritional support approaches currently in practice for pediatric patients who are undergoing BMT. CINAHL, Embase, and Cochrane databases were searched for peer-reviewed articles evaluating nutritional interventions for BMT recipients aged 20 or younger. Nine articles published between 2019 and 2023 were found and reviewed. The nutritional support varied between enteral nutrition, parenteral nutrition, a combination of both, and prophylactic feeding tube placement. The post-transplant outcomes identified as associated with alterations in nutritional regimens included length of stay, date of platelet engraftment, incidence of acute graft-versus-host disease, infection rate, and overall survival. The use of any amount of enteral nutrition compared to parenteral alone was beneficial. Complications during BMT can potentially be decreased via prioritizing enteral nutrition over parenteral. The paucity of literature on this topic highlights an unmet need in the field. Future research should focus on ways to optimize the nutritional support of transplant recipients, including increasing the likelihood of enteral feeding tube placement and utilization.

Nutritional studies in patients with β-thalassemia major: A short review

BACKGROUND

Patients with β-thalassemia major (BTM) had variable prevalence of undernutrition and abnormal body composition.  Methods: We performed an electronic search in PubMed, Scopus, Research gate, and Web of Sciences to evaluate the prevalence of nutritional disorders in patients with BTM worldwide in relation to their body composition and possible etiological factors. In addition, we reviewed the published nutritional intervention studies.  Results: 22 studies on the prevalence of undernutrition (12 countries) and 23 nutritional intervention studies were analyzed.  Undernutrition occurred in a considerable number of patients but varied greatly among different countries (from 5.2% to 70%). The lower middle income (LMI) countries (India, Pakistan, Iran, Egypt) had higher prevalence, while (high -middle and high income (Turkey, Greece, North America, USA, Canada) had lower prevalence.  Even in patients with normal BMI, abnormalities of body composition are common with decreased muscle mass, lean-body mass, and bone mineral density. 65% to 75% of them had lower energy intake with low levels of circulating nutrients, minerals (zinc, selenium, and copper), and vitamins (D, E) versus controls. Increased macro and micronutrient requirements decreased absorption and /or increased loss or excretion are etiologic factors. Undernutrition was associated with short stature and lower quality of life (QOL). High prevalence of endocrinopathies, poor transfusion regimen (tissue hypoxia), improper chelation, and lack of maternal education, represented important risk factors in the production of poor growth in weight and stature.

CONCLUSIONS

Timely detection of undernutrition in patients with BTM and proper nutritional intervention could prevent growth delay and comorbidities.

Optimum dose of oral folic acid supplementation in transfusion-dependent thalassemia: a randomized controlled trial

AIM AND OBJECTIVES

We compared the effect of different doses of oral folic acid (FA) supplementation (5 mg/day vs. 2.5 mg/day vs. 5 mg/week) on the proportion of children with folate excess (serum folate &gt;20 ng/ml) and plasma homocysteine (Hcys) excess (&gt;15 µmol/l) in transfusion-dependent thalassemia (TDT).

MATERIALS AND METHODS

Children with TDT aged 5-18 years received oral FA in doses of 5 mg/day (Group 1), 2.5 mg/day (Group 2) and 5 mg/week (Group 3) for 9 months, after a wash-off period of 8 weeks. Folate levels (Serum and RBC) and plasma Hcys levels were measured after the therapy.

RESULTS

Ninety children were randomized to receive one of the three interventions (30 per group). After wash-off period, the median serum folate levels were significantly lower and five children developed folate deficiency; the median [interquartile range (IQR)] serum folate levels (ng/dl) were comparable in the three groups [Group 1: 6.5 (3.3-14.2), Group 2: 5.1 (2.6-10.5) and Group 3: 4.8 (3.4-10.0)]. After 9 months of intervention, the median (IQR) serum folate levels (ng/ml) were comparable in all participants [Group 1: 18.0 (6.5-28), Group 2: 13.5 (6.4-24.5) and Group 3: 9.7 (5.3-22.5); p = 0.11]. Proportion of children with serum folate excess was 40%, 26.7% and 26.7% in Group 1, Group 2 and Group 3 (p = 0.48). Proportion of children with RBC folate excess was 92%, 86.7% and 86.7% in Group 1, Group 2 and Group 3 (p = 0.79). Hyperhomocysteinemia was seen in eight children with no significant difference between median Hcys levels in the groups (p = 0.75).

CONCLUSION

Folic acid supplementation is recommended in TDT with 5 mg weekly dose being adequate.

Iron-Induced Hepatocarcinogenesis—Preventive Effects of Nutrients

The liver is a primary organ that stores body iron, and plays a central role in the regulation of iron homeostasis. Hepatic iron overload (HIO) is a prevalent feature among patients with chronic liver diseases (CLDs), including alcoholic/nonalcoholic liver diseases and hepatitis C. HIO is suggested to promote the progression toward hepatocellular carcinoma because of the pro-oxidant nature of iron. Iron metabolism is tightly regulated by various factors, such as hepcidin and ferroportin, in healthy individuals to protect the liver from such deteriorative effects. However, their intrinsic expressions or functions are frequently compromised in patients with HIO. Thus, various nutrients have been reported to regulate hepatic iron metabolism and protect the liver from iron-induced damage. These nutrients are beneficial in HIO-associated CLD treatment and eventually prevent iron-mediated hepatocarcinogenesis. This mini-review aimed to discuss the mechanisms and hepatocarcinogenic risk of HIO in patients with CLDs. Moreover, nutrients that hold the potential to prevent iron-induced hepatocarcinogenesis are summarized.

Nutrition in Thalassemia: A Systematic Review of Deficiency, Relations to Morbidity, and Supplementation Recommendations

BACKGROUND

Reports of nutritional deficiencies in patients with thalassemia (Thal) are common. Despite its importance, however, nutritionally focused research in Thal has been limited by inadequate sample size, inconsistent methodology, a lack of control comparisons, and few interventional trials. Due to these limitations, clinicians lack evidence-based nutrition recommendations to support clinical decision-making. This systematic review summarizes observed relationships between nutrition and morbidity in Thal published in the last 3 decades.

METHODS

PubMed, Web of Science, and Embase were screened for articles pertaining to nutrition in Thal using comprehensive search terms. Studies performed in humans, written in English, and published between 1990 and 2020 were included. Over 2100 manuscripts were identified, from which 97 were included.

RESULTS

Patients with Thal were most often deficient in vitamins A, C, D, selenium, and zinc. Prevalence of nutritional deficiency was positively correlated with age and iron overload. Evidence to support the role of vitamin D and zinc for bone health was observed; zinc was also found to improve glucose metabolism.

CONCLUSIONS

Due to the risk for multinutrient deficiency, nutritional status should be assessed annually in patients with Thal with prompt nutrient replacement when deficiency is detected. Routine supplementation with vitamin D and zinc is recommended.

Assessment of the Nutritional Status, Bone Mineralization, and Anthropometrics of Children with Thalassemia Major

Objective:

Children with thalassemia major (TM) are prone to growth failure and micronutrient deficiency. Thus, this study aimed to evaluate nutritional status, anthropometrics, and bone mineralization defects in patients with regular blood transfusion.

Methods:

Data obtained were analyzed by evaluating laboratory tests, anthropometric measures, and bone mineral density.

Results:

This study included 29 patients (62% male and 38% female) with a mean age of 12.26±4.74 years, mean pre-transfusion hemoglobin of 8.64±1.01 g/dL, and mean serum ferritin of 1158.6±556.8 ng/mL. Vitamin D (72.4%), selenium (72.4%), and folate (37.9%) deficiencies were most frequent. Hypocalcemia was observed in 17.2%, hypomagnesemia in 3.5%, and decreased ceruloplasmin in 10.3% of patients. Folate was higher between 2 and 6 years old (p=0.028). Ceruloplasmin was higher between 6 and 10 years old (p=0.018). Selenium was significantly higher in patients with a ferritin of ≥1,500 (p=0.008). No significant ferritin-related differences were found in other micronutrients (p>0.05). Body mass index (BMI) were <5 percentile (p) in 31% of patient, whereas none was >95 p. Height in 24.5% and weight in 20.7% of patients were <3 p, whereas none with >97 p. BMI of patients aged 10-18 years was significantly higher (p=0.001). Anthropometric percentiles did not significantly differ in the mean serum ferritin and micronutrient levels. Hypoparathyroidism was observed in 13.8% and hypothyroidism in 3.5% of patients. Low bone density was detected in 14.8% (2 osteopenic and 2 osteoporotic) of patients. Bone mineral density did not significantly differ in the ferritin and micronutrient levels.

Conclusions:

Nutritional support and deficiency prevention are important to minimize the burden of complications and increase the life expectancy and quality in patients with TM.

A Retrospective Long-Term Study on Age at Menarche and Menstrual Characteristics in 85 Young Women with Transfusion-Dependent β-Thalassemia (TDT)

Background

Menarche is an important milestone in a feminine reproductive life, and regular menstrual cycles reflect normal functioning of the hypothalamic-pituitary-ovarian axis, a vital sign of women’s general health.

Aim of the study

We explored the age at menarche and the following menstrual cycles characteristics among 85 unmarried Transfusion-Dependent β-Thalassemia (TDT) women, born between 1965 and 1995, concerning iron chelation therapy (ICT) with desferrioxamine (DFO) and nutritional status, assessed by body mass index (BMI).

Results

53 adolescents who had begun ICT before the age of 10 years experienced menarche at 13,7 ± 1,6 years (mean ± DS), whereas 32 who began treatment after ten years experienced menarche significantly later (15.5 ± 1.9 yrs; p: 0.001). At the age of menarche: BMI-Z score (n= 67, −0,09 ±1) was inversely correlated with both age at starting ICT (r = −0,39; p = 0001) and age at menarche (−0,45, p = 0,0001). Serum ferritin levels (SF) were significantly correlated with the age at starting chelation therapy (n = 79; r = 0,34; p = 0,022). In 56 TDT adolescents who developed secondary amenorrhea (SA), the SF levels were significantly higher (4,098 ± 1,907 ng/mL) compared to 23 TDT adolescents with regular menstrual cycles (2,913±782 ng/mL; p = 0,005). Nutritional status of “thinness” at menarche was associated with a lower prevalence of subsequent regular menstrual cycles and a higher prevalence of early SA.

Conclusion

An early ICT in TDT patients was associated with a normal “tempo” of pubertal onset and a higher frequency of subsequent regular menstrual cycles. In TDT patients, who developed SA, a diagnosis of acquired central hypogonadism was made, mainly due to the chronic exposure to iron overload, however other potential causes linked to nutritional status, deficient levels of circulating nutrients, and the chronic disease itself cannot be fully excluded.

Drug utilization study and cost analysis of adult β-thalassemia major patient therapy at Dr. Soetomo General Hospital Surabaya

OBJECTIVES

The main therapy of β-thalassemia major are blood transfusion and iron chelation drugs. However, those therapies also have some adverse effects and problems such as iron overload, transfusion reactions, nutritional deficiencies, and patient compliance problems. Those arising problems also have an impact on therapy cost. Hence, this study was designed to analyze drug utilization study and cost of therapy in β-thalassemia major adult patients at Dr. Soetomo General Hospital Surabaya.

METHODS

This research was conducted in descriptive observational-retrospective design using secondary data obtained from patient's medical records and billing registrations from January 1-December 31, 2019.

RESULTS

There were 18 patients out of 233 patients that were analyzed. Deferasirox was the most administered drug with doses between 500 mg/day-1,500 mg/day while deferiprone was ranged between 1,500 and 4,500 mg/day. Patients also received transfusion reaction drugs with dexamethasone injection 5 mg/ml which was administered the most. The most administered supplement was folic acid 1 mg. Patients had an increase in serum ferritin due to low compliance. Deferasirox had the most adherence number of patients with decrease of serum ferritin. The two highest costs of direct medical components were top-up medicines and consumable medical supplies. Overall, the hospital gained profit from national health insurance claims.

CONCLUSIONS

The most administered chelating agent was deferasirox. Deferasirox also had the most adherence number of patients with decreased number of serum ferritin. However, deferasirox also yielded the highest cost. Yet, overall, the hospital gained profit from national health insurance claims.

Oxidative status in the β-thalassemia syndromes in Sri Lanka; a cross-sectional survey

In the β-thalassemias, oxidative stress, resulting from chronic hemolysis, globin chain imbalance, iron overload and depleted antioxidant defences, likely contributes to cell death, organ damage, anemia, hypoxia and inflammation. We assessed variations in these parameters in β-thalassemia syndromes in Sri Lanka. Between November 2017 and June 2018, we assessed children and adults attending two thalassemia centres in Sri Lanka: 59 patients with HbE β-thalassemia, 50 β-thalassemia major, 40 β-thalassemia intermedia and 13 HbS β-thalassemia. Median age was 26.0 years (IQR 15.3-38.8), 101 (62.3%) were female and 152 (93.8%) of Sinhalese ethnicity. Methemoglobin, plasma hemoglobin, heme and ferritin were measured as sources of oxidants; plasma total antioxidant capacity, haptoglobin, hemopexin and vitamins C and E assessed antioxidant status; plasma thiobarbituric acid reactive substances and 8-hydroxy-2'-deoxyguanosine assessed oxidative damage; hemoglobin, plasma erythropoietin and transferrin receptor assessed anemia and hypoxia and plasma interleukin-6 and C-reactive protein assessed inflammation. Fruit and vegetable intake was determined by dietary recall. Physical fitness was investigated using the 6-min walk test and measurement of handgrip strength. Oxidant sources were frequently increased and antioxidants depleted, with consequent oxidative damage, anemia, hypoxia and inflammation. Biomarkers were generally most abnormal in HbE β-thalassemia and least abnormal in β-thalassemia intermedia but also varied markedly between individuals with the same thalassemia syndrome. Oxidative stress and damage were also more severe in splenectomized patients and/or those receiving iron chelation therapy. Less than 15% of patients ate fresh fruits or raw vegetables frequently, and plasma vitamins C and E were deficient in 132/160 (82.5%) and 140/160 (87.5%) patients respectively. Overall, physical fitness was poor in all syndromes and was likely due to anemic hypoxia. Studies of antioxidant supplements to improve outcomes in patients with thalassemia should consider individual patient variation in oxidative status both between and within the thalassemia syndromes.

Increased prevalence of fractures in inadequately transfused and chelated Indian children and young adults with beta thalassemia major

INTRODUCTION

In patients with beta thalassemia major, inadequate transfusion and chelation may compromise bone health and increase risk of fractures. The objective of this study was to describe the prevalence of fractures in Indian inadequately transfused and chelated children, adolescents and young adults with beta thalassemia major.

METHODS

We studied 179 patients with beta thalassemia (3.6-28.3 years; 105 boys). Medical, transfusion, chelation and fracture history were recorded. Vertebral fracture assessment (VFA) was performed using lateral spine images acquired using the GE Lunar iDXA (Wisconsin, MD). Fractures were classified according to an adapted semi-quantitative method.

RESULTS

History of non-traumatic long bone fractures was observed in 21% patients (n = 37); there were significantly greater (p < 0.05) number of males (n = 30) than females (n = 15). The 21% fracture prevalence in the present study is higher than the reported fractures of 9% in healthy Indian children and adolescents. The prevalence of vertebral fractures was 4.5% (n = 8) in the study group. Of those with fractures, four patients had both long bone and vertebral fractures, and (any, long bone or vertebral fractures) sixteen patients had more than 1 fracture; eleven patients had 2 fractures, four patients had 3 fractures and one patient had 5 fractures. Thus, in 179 patients, there were a total of 68 single fractures which translates to 307 fractures per 10,000 patient years.

CONCLUSION

This study found increased prevalence of non-traumatic long bone and vertebral fractures in children and adolescents with thalassemia major.

Moderate to severe liver siderosis and raised AST are independent risk factors for vitamin D insufficiency in β-thalassemia patients

Numerous problematic disorders such as vitamin D (Vit-D) deficiency subsequent to large iron loading can be developed in patients with β-thalassemia. The study aimed to estimate Vit-D insufficiency and its risk factors in patients with β-thalassemia. In this multicenter and observational study, all β-thalassemia patients, who referred to 14 hospital-based thalassemia divisions or clinics in Mazandaran province, Iran were included in the study. The data belong to December 2015 until December 2019. The study population was made of transfusion dependent thalassemia (TDT) and non-transfusion-dependent thalassemia (NTDT) patients. Serum levels of 25-OHD3 have been measured by high performance liquid chromatography (HPLC) method as ng/mL. Demographic and clinical information along with some biological tests, as well as the results of T2*-weighted magnetic resonance imaging were analyzed. Of 1959 registered patients, 487 (24.9%) patients had Vit-D-related data. The prevalence of Vit-D insufficiency (< 30 ng/mL) was 41.9, 95% CI 37.5–46.3. The adjusted risks of moderate to severe liver siderosis and raised AST (aspartate aminotransferase) for Vit-D insufficiency (< 30 ng/mL) were 2.31, 95% CI 1.38–3.89 and 2.62, 95% CI 1.43–4.79, respectively. The receiver operating characteristic (ROC) curve analysis showed that the predictive accuracy of ferritin for Vit-D insufficiency status was 0.61, 95% CI 0.54–0.68 with a cutoff point of 1,078 ng/mL (P = 0.03, sensitivity 67%, specificity 49%, positive predictive value [PPV] 47% and negative predictive value [NPV] 68%). In spite of the national programs for treating Vit-D deficiency and our previous efforts for giving supplements to all patients, Vit-D insufficiency/deficiency is still common in our patients. Also, moderate to severe liver siderosis and raised AST were the independent risk factors for the Vit-D insufficiency.

Vitamin and mineral supplementation for β-thalassemia during COVID-19 pandemic

AIM

Low levels of immune-related micronutrients have been identified in β-thalassemia samples. Moreover, the excess amount of iron, contributing to oxidative stress in the pathogenesis of the disease, alters the immune system in β-thalassemia, which is important during the COVID-19 pandemic.

MATERIALS & METHODS

Searches of PUBMED and EMBASE were conducted to identify the level and supplementation of micronutrients in β-thalassemia, published from 2001-May 2020.

RESULTS

The review found six observational and five interventional studies supporting the importance of supplementing vitamins and minerals among patients with β-thalassemia.

CONCLUSION

Supplementation of immune-related vitamins and minerals might bring benefits to the immune system, especially in reducing oxidative stress in β-thalassemia.