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Faranoush M, Faranoush P, Heydari I, Foroughi‐Gilvaee MR, Azarkeivan A, Parsai Kia A, Sadighnia N, Elahinia A, Zandi A, Rezvany MR, Hashemi‐Madani N, Ziaee A, Nekouian R, Rohani F. Complications in patients with transfusion dependent thalassemia: A descriptive cross-sectional study. Health Sci Rep 2023; 6:e1624. [PMID: 37841947 PMCID: PMC10568004 DOI: 10.1002/hsr2.1624] [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: 07/10/2023] [Revised: 08/30/2023] [Accepted: 09/28/2023] [Indexed: 10/17/2023] Open
Abstract
Background and Aims One of the most common hemoglobinopathies globally related to blood transfusion and iron overload in the body is thalassemia syndrome. Increasing ferritin levels can cause severe damage to the patient's body organs. This study aims to evaluate the complications of iron overload on vital body organs in patients with transfusion-dependent beta-thalassemia. Methods This descriptive cross-sectional study was performed in Iran University of Medical Sciences Hospitals on patients with a beta-thalassemia major with frequent blood transfusions. To evaluate the effect of iron overload on vital body organs, hematologic and blood analysis, echocardiography with measurement of pulmonary artery pressure (PAP) and ejection fraction (EF) tests, bone densitometry, and audiometric tests were performed for all patients. Results Of the 1010 patients participating in this study, 497 (49%) were males, 513 were (51%) females aged 5-74 years, and the majority of participants (85%) were over 20 years old. This study demonstrated that increasing ferritin levels had no notable correlation with sex, cholesterol, low-density lipoprotein, parathyroid hormone, T4, and aspartate aminotransferase. However, elevating ferritin levels had significant correlations with increasing triglyceride, phosphorus, thyroid stimulating hormone, alkaline phosphatase, alanine transaminase, and PAP levels, age, hearing disorders, splenectomy, osteoporosis, and decreasing high-density lipoprotein, body mass index, calcium, and EF levels. Conclusion Improvement in beta-thalassemia patients' survival and quality of life can be due to multidisciplinary care in a comprehensive unit through regular follow-up and early complication detection.
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Affiliation(s)
- Mohammad Faranoush
- Pediatric Growth and Development Research Center, Institute of EndocrinologyIran University of Medical SciencesTehranIran
- Cardio‐Oncology Research Center, Rajaie Cardiovascular Medical & Research CenterIran University of Medical SciencesTehranIran
| | - Pooya Faranoush
- Pediatric Growth and Development Research Center, Institute of EndocrinologyIran University of Medical SciencesTehranIran
- Nano Bio Electronic Devices Lab, Cancer Electronics Research Group, School of Electrical and Computer Engineering, College of EngineeringUniversity of TehranTehranIran
| | - Iraj Heydari
- Pediatric Growth and Development Research Center, Institute of EndocrinologyIran University of Medical SciencesTehranIran
| | - Mohammad Reza Foroughi‐Gilvaee
- Pediatric Growth and Development Research Center, Institute of EndocrinologyIran University of Medical SciencesTehranIran
- Nano Bio Electronic Devices Lab, Cancer Electronics Research Group, School of Electrical and Computer Engineering, College of EngineeringUniversity of TehranTehranIran
| | - Azita Azarkeivan
- Blood Transfusion Research CenterHigh Institute for Research and Education in Transfusion MedicineTehranIran
| | - Ali Parsai Kia
- Robotics Research Laboratory, School of Mechanical EngineeringIran University of Science and TechnologyTehranIran
| | - Negin Sadighnia
- Pediatric Growth and Development Research Center, Institute of EndocrinologyIran University of Medical SciencesTehranIran
| | - Ali Elahinia
- Pediatric Growth and Development Research Center, Institute of EndocrinologyIran University of Medical SciencesTehranIran
| | - Afsoon Zandi
- Department of Otolaryngology, Head & Neck Surgery, Taleghani HospitalShahid Beheshti University of Medical SciencesTehranIran
| | - Mohammad Reza Rezvany
- Pediatric Growth and Development Research Center, Institute of EndocrinologyIran University of Medical SciencesTehranIran
| | - Nahid Hashemi‐Madani
- Pediatric Growth and Development Research Center, Institute of EndocrinologyIran University of Medical SciencesTehranIran
| | - Amir Ziaee
- Pediatric Growth and Development Research Center, Institute of EndocrinologyIran University of Medical SciencesTehranIran
| | - Reza Nekouian
- Pediatric Growth and Development Research Center, Institute of EndocrinologyIran University of Medical SciencesTehranIran
| | - Farzaneh Rohani
- Pediatric Growth and Development Research Center, Institute of EndocrinologyIran University of Medical SciencesTehranIran
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Shah R, Shah A, Badawy SM. An evaluation of deferiprone as twice-a-day tablets or in combination therapy for the treatment of transfusional iron overload in thalassemia syndromes. Expert Rev Hematol 2023; 16:81-94. [PMID: 36755516 PMCID: PMC9992344 DOI: 10.1080/17474086.2023.2178409] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/06/2023] [Indexed: 02/10/2023]
Abstract
INTRODUCTION Regular blood transfusions in patients with thalassemia syndromes can cause iron overload resulting in complications including cirrhosis, heart problems, or endocrine abnormalities. To prevent iron overload toxicity in these patients, three iron chelators are currently FDA-approved for use: deferoxamine, deferasirox, and deferiprone. In the United States, deferiprone has been approved for three times daily dosing since 2011 and has recently gained approval for twice-daily administration. AREAS COVERED A PubMed literature search was performed with the keywords 'deferiprone' and 'thalassemia.' Relevant original research studying deferiprone's effects on transfusional iron overload in patients with thalassemia syndromes was included. Exclusion criteria included case reports and review papers. Deferiprone is effective at reducing serum ferritin levels in patients with iron overload. Twice-daily administration provides a similar level of iron chelation as three times daily dosing with a comparable side effect profile and increased patient acceptability. EXPERT OPINION New studies are highlighting deferiprone's potential for combination therapy with either deferoxamine or deferasirox to improve iron chelation. Deferiprone's ability to significantly decrease cardiac and liver iron content can be utilized in other transfusion-dependent hematologic conditions, as evidenced by its recent approval for use in the United States for sickle cell disease or other anemias.
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Affiliation(s)
- Richa Shah
- Division of Hematology, Oncology, and Stem Cell Transplant, Lurie Children’s Hospital of Chicago, Chicago, IL, 60611, USA
| | - Aashaka Shah
- University of Illinois College of Medicine, Chicago, IL, 60612, USA
| | - Sherif M. Badawy
- Division of Hematology, Oncology, and Stem Cell Transplant, Lurie Children’s Hospital of Chicago, Chicago, IL, 60611, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
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Ehsanipour F, Faranoush P, Foroughi‐Gilvaee MR, Sadighnia N, Fallahpour M, Motamedi M, Zandi A, Safaei Z, Zandi A, Faranoush M. Evaluation of immune system in patients with transfusion-dependent beta-thalassemia in Rasoul-e-Akram Hospital in 2021: A descriptive cross-sectional study. Health Sci Rep 2022; 5:e871. [PMID: 36210881 PMCID: PMC9528955 DOI: 10.1002/hsr2.871] [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: 06/13/2022] [Revised: 09/13/2022] [Accepted: 09/15/2022] [Indexed: 11/21/2022] Open
Abstract
Background and aims Thalassemia syndromes are the most common hemoglobinopathy globally related to blood transfusion and iron overload in the body. Splenectomy, excessive iron overload, and repeated exposure to antigens in blood transfusions can cause severe damage to the patient's immune system making the patient prone to frequent infection. This study evaluates the immune system status and infection rate in beta-thalassemia major patients receiving iron chelators. Methods This descriptive cross-sectional study was performed in Rasoul-e-Akram Hospital on patients with a beta-thalassemia major who had iron overload due to frequent blood transfusions. The percentage of lymphocyte markers was determined by flow cytometry. Serum levels of immunoglobin were measured by nephelometric assay. Also, Nitro blue tetrazolium and dihydrorhodamine assays were used to evaluate the phagocytic function. Results Of the 106 patients participating in this study, 59 (55.7%) and 47 (44.3%) are male and female, respectively. The mean age ± SD of participants was 24.7 ± 12.1 years with 4 to 55 years. There was no significant correlation between sex, the C3 and C4 complements, the lymphocyte markers, and the immunoglobulin levels. Furthermore, all of these variables increased significantly over 30 (p < 0.05). Moreover, there was a strong positive correlation between splenectomy and IgG immunoglobulin (p < 0.001) and CD16 (p = 0.005) lymphocyte marker. Conclusion Iron chelator agents effectively improve patients' immune system with thalassemia major. The increase in IgG and IgM immunoglobulins levels is due to frequent blood transfusions, which stimulate the immune system.
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Affiliation(s)
- Fahime Ehsanipour
- Pediatric Growth and Development Research center, Institute of EndocrinologyIran University of Medical SciencesTehranIran
| | - Pooya Faranoush
- Pediatric Growth and Development Research center, Institute of EndocrinologyIran University of Medical SciencesTehranIran,Nano Bio Electronic Devices Lab, Cancer Electronics Research Group, School of Electrical and Computer Engineering, College of EngineeringUniversity of TehranTehranIran
| | - Mohammad Reza Foroughi‐Gilvaee
- Pediatric Growth and Development Research center, Institute of EndocrinologyIran University of Medical SciencesTehranIran,Nano Bio Electronic Devices Lab, Cancer Electronics Research Group, School of Electrical and Computer Engineering, College of EngineeringUniversity of TehranTehranIran
| | - Negin Sadighnia
- Pediatric Growth and Development Research center, Institute of EndocrinologyIran University of Medical SciencesTehranIran
| | - Morteza Fallahpour
- Pediatric Growth and Development Research center, Institute of EndocrinologyIran University of Medical SciencesTehranIran
| | - Mona Motamedi
- Pediatric Growth and Development Research center, Institute of EndocrinologyIran University of Medical SciencesTehranIran
| | - Afsoon Zandi
- Department of Otolaryngology, Head & Neck Surgery, Taleghani HospitalShahid Beheshti University of Medical SciencesTehranIran
| | - Zahra Safaei
- Department of Medical EducationSemnan University of Medical SciencesSemnanIran
| | - Ashkan Zandi
- Nano Bio Electronic Devices Lab, Cancer Electronics Research Group, School of Electrical and Computer Engineering, College of EngineeringUniversity of TehranTehranIran
| | - Mohammad Faranoush
- Pediatric Growth and Development Research center, Institute of EndocrinologyIran University of Medical SciencesTehranIran,Cardio‐Oncology Research Center, Rajaie Cardiovascular Medical & Research CenterIran University of Medical SciencesTehranIran
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Association of Serum Ferritin With Marrow Iron Concentration Using a Three-Dimension Fat Analysis & Calculation Technique Sequence in Postmenopausal Women. J Comput Assist Tomogr 2022; 46:464-469. [PMID: 35405711 DOI: 10.1097/rct.0000000000001296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to determine whether serum iron and ferritin levels are determinants of iron accumulation in bone marrow using a three-dimension Fat Analysis & Calculation Technique (FACT) sequence. METHODS We measured spinal marrow R2* using a 3T FACT sequence in 112 postmenopausal women (mean age, 62.6 years; range, 50-82.6 years). Serum iron and ferritin levels were determined in blood specimens. Lumbar spine bone mineral density was measured by dual-energy x-ray absorptiometry. The levels of serum iron and ferritin were evaluated in relation to the spinal marrow R2* values before and after adjustments for potential confounders. RESULTS In the unadjusted model, magnetic resonance imaging-based spinal marrow R2* was positively correlated to the levels of serum ferritin (Spearman ρ = 0.436, P < 0.001) and iron (Spearman ρ = 0.245, P = 0.009). Multiple stepwise linear regression analyses (adjusting for age, years since menopause, body mass index, alcohol intake, tobacco use, physical activity, serum lipids profile, biomarkers of bone turnover, and lumbar spine bone density) were performed in 3 separate models with marrow R2* values as potential explanatory variables. The level of serum ferritin, but not iron, was an independent predictor of marrow R2* (standardized β coefficient, 0.302, 95% confidence interval, 0.141-0.509, P = 0.001). Similarly, spinal marrow R2* increased with a linear trend from the lowest (<139 ng/mL) to highest (≥180 ng/mL) serum ferritin quartiles (P for trend = 0.007). CONCLUSIONS Quantitative assessment of R2* derived from FACT is a fast, simple, noninvasive, and nonionizing method to evaluate marrow iron accumulation.
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Sfikakis PP, Vlachogiannis NI, Ntouros PA, Mavrogeni S, Maris TG, Karantanas AH, Souliotis VL. Microvasculopathy-Related Hemorrhagic Tissue Deposition of Iron May Contribute to Fibrosis in Systemic Sclerosis: Hypothesis-Generating Insights from the Literature and Preliminary Findings. Life (Basel) 2022; 12:life12030430. [PMID: 35330181 PMCID: PMC8955192 DOI: 10.3390/life12030430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/24/2022] [Accepted: 03/14/2022] [Indexed: 11/21/2022] Open
Abstract
Microvascular wall abnormalities demonstrated by nailfold capillaroscopy in systemic sclerosis (SSc) may result in microhemorrhagic deposition of erythrocyte-derived iron. Such abnormalities precede fibrosis, which is orchestrated by myofibroblasts. Iron induces endothelial-to-mesenchymal transition in vitro, which is reversed by reactive oxygen species (ROS) scavengers. The conversion of quiescent fibroblasts into profibrotic myofibroblasts has also been associated with ROS-mediated activation of TGF-β1. Given that iron overload predisposes to ROS formation, we hypothesized that the uptake of erythrocyte-derived iron by resident cells promotes fibrosis. Firstly, we show that iron induces oxidative stress in skin-derived and synovial fibroblasts in vitro, as well as in blood mononuclear cells ex vivo. The biological relevance of increased oxidative stress was confirmed by showing the concomitant induction of DNA damage in these cell types. Similar results were obtained in vivo, following intravenous iron administration. Secondly, using magnetic resonance imaging we show an increased iron deposition in the fingers of a patient with early SSc and nailfold microhemorrhages. While a systematic magnetic resonance study to examine tissue iron levels in SSc, including internal organs, is underway, herein we propose that iron may be a pathogenetic link between microvasculopathy and fibrosis and an additional mechanism responsible for increased oxidative stress in SSc.
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Affiliation(s)
- Petros P. Sfikakis
- First Department of Propaedeutic Internal Medicine and Joint Academic Rheumatology Program, National and Kapodistrian University of Athens Medical School, 11527 Athens, Greece; (N.I.V.); (P.A.N.); (V.L.S.)
- Correspondence:
| | - Nikolaos I. Vlachogiannis
- First Department of Propaedeutic Internal Medicine and Joint Academic Rheumatology Program, National and Kapodistrian University of Athens Medical School, 11527 Athens, Greece; (N.I.V.); (P.A.N.); (V.L.S.)
| | - Panagiotis A. Ntouros
- First Department of Propaedeutic Internal Medicine and Joint Academic Rheumatology Program, National and Kapodistrian University of Athens Medical School, 11527 Athens, Greece; (N.I.V.); (P.A.N.); (V.L.S.)
| | | | - Thomas G. Maris
- Department of Radiology, University of Crete Medical School, 71003 Heraklion, Greece; (T.G.M.); (A.H.K.)
- Computational BioMedicine Laboratory, Institute of Computer Science, Foundation for Research and Technology-Hellas (FORTH), 70013 Heraklion, Greece
| | - Apostolos H. Karantanas
- Department of Radiology, University of Crete Medical School, 71003 Heraklion, Greece; (T.G.M.); (A.H.K.)
- Computational BioMedicine Laboratory, Institute of Computer Science, Foundation for Research and Technology-Hellas (FORTH), 70013 Heraklion, Greece
| | - Vassilis L. Souliotis
- First Department of Propaedeutic Internal Medicine and Joint Academic Rheumatology Program, National and Kapodistrian University of Athens Medical School, 11527 Athens, Greece; (N.I.V.); (P.A.N.); (V.L.S.)
- Institute of Chemical Biology, National Hellenic Research Foundation, 11635 Athens, Greece
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Musculoskeletal imaging manifestations of beta-thalassemia. Skeletal Radiol 2021; 50:1749-1762. [PMID: 33559685 DOI: 10.1007/s00256-021-03732-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/27/2021] [Accepted: 01/29/2021] [Indexed: 02/02/2023]
Abstract
Beta-thalassemia is a heterogeneous group of anemic disorders caused by the absence or defective production of beta-globin chains. Their clinical manifestations vary from asymptomatic to severe symptoms leading to a transfusion-dependent anemic state. The genes that cause thalassemia are prevalent in Asian and African populations, particularly concentrated in the Middle East, Mediterranean region, parts of India, and South East Asia. Over time, the disease causes various musculoskeletal abnormalities with complex pathophysiology secondary to chronic anemia. The compensatory mechanisms result in diffuse marrow hyperplasia, yellow to red marrow reconversion, osteopenia, and pathologic fractures. Inability to remove excess iron and inevitable iron overload as a result of multiple blood transfusions in patients with thalassemia major and intermedia is another face of the disease. Musculoskeletal manifestations include osteopenia, coarse trabeculae, bone expansion, synovitis, joint effusion, and metaphyseal dysplasia. These complications have long-lasting effects on the skeletal growth pattern resulting in bone deformity, short stature, premature closure of physes, and predisposition to infection. Additionally, there are radiologic features of iron-chelator therapy, which are unique and unrelated to the disease process itself. Familiarity of radiologists with the imaging features of beta-thalassemia is crucial in both diagnosis and timely management of the disease and its complications.
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Piscaglia F, Marcelli E. The expanding potential of functional liver imaging: From research tools to clinical practice in oncology and internal medicine. Eur J Intern Med 2020; 79:23-24. [PMID: 32680652 DOI: 10.1016/j.ejim.2020.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Fabio Piscaglia
- Unit of Internal Medicine, Azienda Ospedaliero Universitaria S.Orsola Malpighi di Bologna, Bologna, Italy.
| | - Emanuela Marcelli
- Laboratory of Bioengineering, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy
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Wells SA. Quantification of Hepatic Fat and Iron with Magnetic Resonance Imaging. Magn Reson Imaging Clin N Am 2014; 22:397-416. [PMID: 25086936 DOI: 10.1016/j.mric.2014.04.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Fisher SA, Brunskill SJ, Doree C, Chowdhury O, Gooding S, Roberts DJ. Oral deferiprone for iron chelation in people with thalassaemia. Cochrane Database Syst Rev 2013:CD004839. [PMID: 23966105 DOI: 10.1002/14651858.cd004839.pub3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Thalassaemia major is a genetic disease characterised by a reduced ability to produce haemoglobin. Management of the resulting anaemia is through red blood cell transfusions.Repeated transfusions result in an excessive accumulation of iron in the body (iron overload), removal of which is achieved through iron chelation therapy. A commonly used iron chelator, deferiprone, has been found to be pharmacologically efficacious. However, important questions exist about the efficacy and safety of deferiprone compared to another iron chelator, desferrioxamine. OBJECTIVES To summarise data from trials on the clinical efficacy and safety of deferiprone and to compare the clinical efficacy and safety of deferiprone with desferrioxamine for thalassaemia. SEARCH METHODS We searched the Cochrane Cystic fibrosis and Genetic Disorders Group's Haemoglobinopathies trials Register and MEDLINE, EMBASE, CENTRAL (The Cochrane Library), LILACS and other international medical databases, plus registers of ongoing trials and the Transfusion Evidence Library (www.transfusionevidencelibrary.com). We also contacted the manufacturers of deferiprone and desferrioxamine.All searches were updated to 05 March 2013. SELECTION CRITERIA Randomised controlled trials comparing deferiprone with another iron chelator; or comparing two schedules or doses of deferiprone, in people with transfusion-dependent thalassaemia. DATA COLLECTION AND ANALYSIS Two authors independently assessed trials for risk of bias and extracted data. Missing data were requested from the original investigators. MAIN RESULTS A total of 17 trials involving 1061 participants (range 13 to 213 participants per trial) were included. Of these, 16 trials compared either deferiprone alone with desferrioxamine alone, or a combined therapy of deferiprone and desferrioxamine with either deferiprone alone or desferrioxamine alone; one compared different schedules of deferiprone. There was little consistency between outcomes and limited information to fully assess the risk of bias of most of the included trials.Four trials reported mortality; each reported the death of one individual receiving deferiprone with or without desferrioxamine. One trial reported five further deaths in patients who withdrew from randomised treatment (deferiprone with or without desferrioxamine) and switched to desferrioxamine alone. Seven trials reported cardiac function or liver fibrosis as measures of end organ damage.Earlier trials measuring the cardiac iron load indirectly by magnetic resonance imaging (MRI) T2* signal had suggested deferiprone may reduce cardiac iron more quickly than desferrioxamine. However, a meta-analysis of two trials suggested that left ventricular ejection fraction was significantly reduced in patients who received desferrioxamine alone compared with combination therapy. One trial, which planned five years of follow up, was stopped early due to the beneficial effects of combined treatment compared with deferiprone alone in terms of serum ferritin levels reduction.The results of this and three other trials suggest an advantage of combined therapy over monotherapy to reduce iron stores as measured by serum ferritin. There is, however, no conclusive or consistent evidence for the improved efficacy of combined deferiprone and desferrioxamine therapy over monotherapy from direct or indirect measures of liver iron. Both deferiprone and desferrioxamine produce a significant reduction in iron stores in transfusion-dependent, iron-overloaded people. There is no evidence from randomised controlled trials to suggest that either has a greater reduction of clinically significant end organ damage.Evidence of adverse events were observed in all treatment groups. Occurrence of any adverse event was significantly more likely with deferiprone than desferrioxamine in one trial, RR 2.24 (95% CI 1.19 to 4.23). Meta-analysis of a further two trials showed a significant increased risk of adverse events associated with combined deferiprone and desferrioxamine compared with desferrioxamine alone, RR 3.04 (95% CI 1.18 to 7.83). The most commonly reported adverse event was joint pain, which occurred significantly more frequently in patients receiving deferiprone than desferrioxamine, RR 2.64 (95% CI 1.21 to 5.77). Other common adverse events included gastrointestinal disturbances as well as neutropenia or leucopenia, or both. AUTHORS' CONCLUSIONS In the absence of data from randomised controlled trials, there is no evidence to suggest the need for a change in current treatment recommendations; namely that deferiprone is indicated for treating iron overload in people with thalassaemia major when desferrioxamine is contraindicated or inadequate. Intensified desferrioxamine treatment (by either subcutaneous or intravenous route) or use of other oral iron chelators, or both, remains the established treatment to reverse cardiac dysfunction due to iron overload. Indeed, the US Food and Drug Administration (FDA) recently only gave support for deferiprone to be used as a last resort for treating iron overload in thalassaemia, myelodysplasia and sickle cell disease. However, there is evidence that adverse events are increased in patients treated with deferiprone compared with desferrioxamine and in patients treated with combined deferiprone and desferrioxamine compared with desferrioxamine alone. There is an urgent need for adequately-powered, high-quality trials comparing the overall clinical efficacy and long-term outcome of deferiprone with desferrioxamine.
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Affiliation(s)
- Sheila A Fisher
- Systematic Review Initiative, NHS Blood and Transplant, Level 2, John Radcliffe Hospital, Headington, Oxford, Oxon, UK, OX3 9BQ
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Fisher SA, Brunskill SJ, Doree C, Gooding S, Chowdhury O, Roberts DJ. Desferrioxamine mesylate for managing transfusional iron overload in people with transfusion-dependent thalassaemia. Cochrane Database Syst Rev 2013:CD004450. [PMID: 23963793 DOI: 10.1002/14651858.cd004450.pub3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Thalassaemia major is a genetic disease characterised by a reduced ability to produce haemoglobin. Management of the resulting anaemia is through red blood cell transfusions.Repeated transfusions result in an excessive accumulation of iron in the body (iron overload), removal of which is achieved through iron chelation therapy. Desferrioxamine mesylate (desferrioxamine) is one of the most widely used iron chelators. Substantial data have shown the beneficial effects of desferrioxamine, although adherence to desferrioxamine therapy is a challenge. Alternative oral iron chelators, deferiprone and deferasirox, are now commonly used. Important questions exist about whether desferrioxamine, as monotherapy or in combination with an oral iron chelator, is the best treatment for iron chelation therapy. OBJECTIVES To determine the effectiveness (dose and method of administration) of desferrioxamine in people with transfusion-dependent thalassaemia.To summarise data from trials on the clinical efficacy and safety of desferrioxamine for thalassaemia and to compare these with deferiprone and deferasirox. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register. We also searched MEDLINE, EMBASE, CENTRAL (The Cochrane Library), LILACS and other international medical databases, plus ongoing trials registers and the Transfusion Evidence Library (www.transfusionevidencelibrary.com). All searches were updated to 5 March 2013. SELECTION CRITERIA Randomised controlled trials comparing desferrioxamine with placebo, with another iron chelator, or comparing two schedules or doses of desferrioxamine, in people with transfusion-dependent thalassaemia. DATA COLLECTION AND ANALYSIS Six authors working independently were involved in trial quality assessment and data extraction. For one trial, investigators supplied additional data upon request. MAIN RESULTS A total of 22 trials involving 2187 participants (range 11 to 586 people) were included. These trials included eight comparisons between desferrioxamine alone and deferiprone alone; five comparisons between desferrioxamine combined with deferiprone and deferiprone alone; eight comparisons between desferrioxamine alone and desferrioxamine combined with deferiprone; two comparisons of desferrioxamine with deferasirox; and two comparisons of different routes of desferrioxamine administration (bolus versus continuous infusion). Overall, few trials measured the same or long-term outcomes. Seven trials reported cardiac function or liver fibrosis as measures of end organ damage; none of these included a comparison with deferasirox.Five trials reported a total of seven deaths; three in patients who received desferrioxamine alone, two in patients who received desferrioxamine and deferiprone. A further death occurred in a patient who received deferiprone in another who received deferasirox alone. One trial reported five further deaths in patients who withdrew from randomised treatment (deferiprone with or without desferrioxamine) and switched to desferrioxamine alone.One trial planned five years of follow up but was stopped early due to the beneficial effects of a reduction in serum ferritin levels in those receiving combined desferrioxamine and deferiprone treatment compared with deferiprone alone. The results of this and three other trials suggest an advantage of combined therapy with desferrioxamine and deferiprone over monotherapy to reduce iron stores as measured by serum ferritin. There is, however, no evidence for the improved efficacy of combined desferrioxamine and deferiprone therapy against monotherapy from direct or indirect measures of liver iron.Earlier trials measuring the cardiac iron load indirectly by measurement of the magnetic resonance imaging T2* signal had suggested deferiprone may reduce cardiac iron more quickly than desferrioxamine. However, meta-analysis of two trials showed a significantly lower left ventricular ejection fraction in patients who received desferrioxamine alone compared with those who received combination therapy using desferrioxamine with deferiprone.Adverse events were recorded by 18 trials. These occurred with all treatments, but were significantly less likely with desferrioxamine than deferiprone in one trial, relative risk 0.45 (95% confidence interval 0.24 to 0.84) and significantly less likely with desferrioxamine alone than desferrioxamine combined with deferiprone in two other trials, relative risk 0.33 (95% confidence interval 0.13 to 0.84). In particular, four studies reported permanent treatment withdrawal due to adverse events from deferiprone; only one of these reported permanent withdrawals associated with desferrioxamine. Adverse events also occurred at a higher frequency in patients who received deferasirox than desferrioxamine in one trial. Eight trials reported local adverse reactions at the site of desferrioxamine infusion including pain and swelling. Adverse events associated with deferiprone included joint pain, gastrointestinal disturbance, increases in liver enzymes and neutropenia; adverse events associated with deferasirox comprised increases in liver enzymes and renal impairment. Regular monitoring of white cell counts has been recommended for deferiprone and monitoring of liver and renal function for deferasirox.In summary, desferrioxamine and the oral iron chelators deferiprone and deferasirox produce significant reductions in iron stores in transfusion-dependent, iron-overloaded people. There is no evidence from randomised clinical trials to suggest that any one of these has a greater reduction of clinically significant end organ damage, although in two trials, combination therapy with desferrioxamine and deferiprone showed a greater improvement in left ventricular ejection fraction than desferrioxamine used alone. AUTHORS' CONCLUSIONS Desferrioxamine is the recommended first-line therapy for iron overload in people with thalassaemia major and deferiprone or deferasirox are indicated for treating iron overload when desferrioxamine is contraindicated or inadequate. Oral deferasirox has been licensed for use in children aged over six years who receive frequent blood transfusions and in children aged two to five years who receive infrequent blood transfusions. In the absence of randomised controlled trials with long-term follow up, there is no compelling evidence to change this conclusion.Worsening iron deposition in the myocardium in patients receiving desferrioxamine alone would suggest a change of therapy by intensification of desferrioxamine treatment or the use of desferrioxamine and deferiprone combination therapy.Adverse events are increased in patients treated with deferiprone compared with desferrioxamine and in patients treated with combined deferiprone and desferrioxamine compared with desferrioxamine alone. People treated with all chelators must be kept under close medical supervision and treatment with deferiprone or deferasirox requires regular monitoring of neutrophil counts or renal function respectively. There is an urgent need for adequately-powered, high-quality trials comparing the overall clinical efficacy and long-term outcomes of deferiprone, deferasirox and desferrioxamine.
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Affiliation(s)
- Sheila A Fisher
- Systematic Review Initiative, NHS Blood and Transplant, Level 2, John Radcliffe Hospital, Headington, Oxford, Oxon, UK, OX3 9BQ
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Kolnagou A, Michaelides Y, Kontoghiorghe CN, Kontoghiorghes GJ. The importance of spleen, spleen iron, and splenectomy for determining total body iron load, ferrikinetics, and iron toxicity in thalassemia major patients. Toxicol Mech Methods 2013; 23:34-41. [PMID: 23039902 DOI: 10.3109/15376516.2012.735278] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The importance of spleen, spleen iron and splenectomy has been investigated in 28 male and 19 female β-thalassemia major (β-ΤΜ), adult patients. In one study, an increase from about five (615 g; 19.5 × 11.0 × 6.0 cm) to twenty (2030 g; 25.0 × 17.5 × 12.0 cm) times higher than the normal size and weight of spleen has been observed in twenty patients following splenectomy. In a second study, the mean size for the liver (19.4 cm, range 13.5-26.0 cm) and spleen (15.6 cm, range 7.0-21.0 cm) measured by magnetic resonance imaging (MRI) and by ultrasound imaging for spleen (15.1 cm, range 9.0-21.0 cm) of 16 patients indicated that on average the spleen is about 80% of the size of the liver. In the third study, comparison of the iron load using MRI T(2)* and iron grading of stained biopsies indicated that substantial but variable amounts of excess iron are stored in the spleen (0-40%) in addition to that in the liver. Following splenectomy, total body iron storage capacity is reduced, whereas serum ferritin (p = 0.0085) and iron concentration in other organs appears to increase despite the reduction in the rate of transfusions (p = 0.0001) and maintenance of hemoglobin levels (p = 0.1748). Spleen iron seems to be cleared faster than liver iron using effective chelation protocols. Spleen iron is a major constituent of the total body iron load in β-ΤΜ patients and should be regularly monitored and targeted for chelation. Normalization of the body iron stores at an early age could maintain the spleen in near normal capacity and secondary effects such as cardiac and other complications could be avoided.
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Affiliation(s)
- Annita Kolnagou
- Postgraduate Research Institute of Science, Technology, Environment and Medicine, Limassol, Cyprus
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Tesch H, Ihling C. Loss of Transfusion Dependency Following Deferasirox Treatment of Iron Overload in a Woman with Myelofibrosis and Spherocytosis - a Case Report. ACTA ACUST UNITED AC 2013; 36:205-8. [DOI: 10.1159/000349939] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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13
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Sirlin CB, Reeder SB. Magnetic resonance imaging quantification of liver iron. Magn Reson Imaging Clin N Am 2011; 18:359-81, ix. [PMID: 21094445 DOI: 10.1016/j.mric.2010.08.014] [Citation(s) in RCA: 136] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Iron overload is the histologic hallmark of hereditary hemochromatosis and transfusional hemosiderosis but also may occur in chronic hepatopathies. This article provides an overview of iron deposition and diseases where liver iron overload is clinically relevant. Next, this article reviews why quantitative noninvasive biomarkers of liver iron would be beneficial. Finally, we describe current state-of-the-art methods for quantifying iron with MR imaging and review remaining challenges and unsolved problems.
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Affiliation(s)
- Claude B Sirlin
- Liver Imaging Group, Department of Radiology, University of California San Diego, 408 Dickinson Street, San Diego, CA 92103-8226, USA.
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Descamps V, Landry J, Francès C, Marinho E, Ratziu V, Chosidow O. Facial Cosmetic Filler Injections as Possible Target for Systemic Sarcoidosis in Patients Treated with Interferon for Chronic Hepatitis C: Two Cases. Dermatology 2008; 217:81-4. [PMID: 18446029 DOI: 10.1159/000128281] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Accepted: 11/22/2007] [Indexed: 11/19/2022] Open
Affiliation(s)
- Vincent Descamps
- Department of Dermatology, Bichat Claude Bernard Hospital, Paris, France.
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