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Di Paola A, Marrapodi MM, Di Martino M, Giliberti G, Di Feo G, Rana D, Ahmed S, Argenziano M, Rossi F, Roberti D. Bone Health Impairment in Patients with Hemoglobinopathies: From Biological Bases to New Possible Therapeutic Strategies. Int J Mol Sci 2024; 25:2902. [PMID: 38474150 DOI: 10.3390/ijms25052902] [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: 12/29/2023] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/14/2024] Open
Abstract
Hemoglobinopathies are monogenic disorders affecting hemoglobin synthesis. Thalassemia and sickle cell disease (SCD) are considered the two major hemoglobinopathies. Thalassemia is a genetic disorder and one of the major hemoglobinopathies determined by an impairment of globin chain production, which causes an alteration of erythropoiesis, an improvement in hemolysis, and an alteration of iron homoeostasis. In SCD, the mutations are on the β-globin chain of hemoglobin which results in a substitution of glutamic acid by valine with consequent formation of Hemoglobin S (HbS). Several factors are involved in bone metabolism alteration in patients with hemoglobinopathies, among them hormonal deficiency, bone marrow hyperplasia, iron overload, inflammation, and increased bone turnover. Bone metabolism is the result of balance maintenance between bone deposition and bone resorption, by osteoblasts (OBs) and osteoclasts (OCs). An impairment of this balance is responsible for the onset of bone diseases, such as osteoporosis (OP). Therefore, here we will discuss the alteration of bone metabolism in patients with hemoglobinopathies and the possible therapeutic strategies to contain and/or counteract bone health impairment in these patients, taking into consideration not only the pharmacological treatments already used in the clinical armamentarium, but also the new possible therapeutic strategies.
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Affiliation(s)
- Alessandra Di Paola
- Department of Woman, Child and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Maria Maddalena Marrapodi
- Department of Woman, Child and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Martina Di Martino
- Department of Woman, Child and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Giulia Giliberti
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Giuseppe Di Feo
- Department of Woman, Child and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Deeksha Rana
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Shakeel Ahmed
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Maura Argenziano
- Department of Woman, Child and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Francesca Rossi
- Department of Woman, Child and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Domenico Roberti
- Department of Woman, Child and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
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Alhuthali HM, Ataya EF, Alsalmi A, Elmissbah TE, Alsharif KF, Alzahrani HA, Alsaiari AA, Allahyani M, Gharib AF, Qanash H, Elmasry HM, Hassanein DE. Molecular patterns of alpha-thalassemia in the kingdom of Saudi Arabia: identification of prevalent genotypes and regions with high incidence. Thromb J 2023; 21:115. [PMID: 37950286 PMCID: PMC10636822 DOI: 10.1186/s12959-023-00560-w] [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: 08/06/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Alpha-thalassemia (α-thalassemia) is one of the most common monogenic diseases in Saudi Arabia and is associated with significant morbidity. Premarital testing programs in Saudi Arabia reduce the burden of hemoglobinopathy disorders, and ongoing monitoring is required. We aimed to explore the molecular nature of α-globin genes and identify the most common genotypes and regions with a high risk of α-thalassemia in Saudi Arabia. METHODS This retrospective study was conducted between January 2021 and December 2022. Six hundred twenty-five samples from patients with microcytic hypochromic anemia in Saudi Arabia were analyzed using reverse dot blot hybridization (RDBH)-based multiplex-PCR, which screens for the known 21 mutations of α-globin genes. RESULTS Seven mutations in the α-globin gene were identified in 88.96% (556) patients. The most frequent abnormality of a-globin genes was -α3.7 (62.3%), followed by α2IVS1(-5nt) (20.7%) and α2 polyA-1 (α2T.Saudi) (14.1%). Interestingly, α2 polyA-2 (α2T.Turkish) was identified in Saudi and presented with -MED, causing Haemoglobin H disease. The incidence of α-thalassemia in Saudi Arabia's cities showed significant differences (P = 0.004). Jeddah City had the highest percentage of cases (25%), followed by Makkah (23%), Taif (13.3%), and Al-Ahassa (12.4%). CONCLUSION The study provides current knowledge about the molecular nature of α- thalassemia, highlights the common genotypes that could contribute to disease occurrence in the Saudi population, and sheds light on Saudi regions with a high incidence. It also recommends further studies in a larger population and with differently composed molecular assays to verify these findings.
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Affiliation(s)
- Hayaa M Alhuthali
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, PO Box 11099, Taif, 21944, Saudi Arabia.
| | - Eman F Ataya
- Basic sciences, College of Applied Medical Sciences, Albaha University, Albaha, 4781, Saudi Arabia
- Lecturer of Public Health and Community Medicine, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Alaa Alsalmi
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, PO Box 11099, Taif, 21944, Saudi Arabia
| | - Triq E Elmissbah
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, PO Box 11099, Taif, 21944, Saudi Arabia
| | - Khalaf F Alsharif
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, PO Box 11099, Taif, 21944, Saudi Arabia
| | - Hind A Alzahrani
- Basic sciences, College of Applied Medical Sciences, Albaha University, Albaha, 4781, Saudi Arabia
| | - Ahad Amer Alsaiari
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, PO Box 11099, Taif, 21944, Saudi Arabia
| | - Mamdouh Allahyani
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, PO Box 11099, Taif, 21944, Saudi Arabia
| | - Amal F Gharib
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, PO Box 11099, Taif, 21944, Saudi Arabia
| | - Husam Qanash
- Department of Medical Laboratory Science, College of Applied Medical Sciences, University of Ha'il, Hail, 55476, Saudi Arabia
- Medical and Diagnostic Research Center, University of Ha'il, Hail, 55473, Saudi Arabia
| | - Heba M Elmasry
- Al Borg Medical laboratories, Al Borg Diagnostics, Jeddah, Saudi Arabia
- Department of Clinical Pathology, South Egypt Cancer Institute, Assiut, Egypt
| | - Doha Elsayed Hassanein
- Al Borg Medical laboratories, Al Borg Diagnostics, Jeddah, Saudi Arabia
- Misr University for Sciences and Technology, Clinical and Chemical Pathology Department, Cairo, Egypt
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Teawtrakul N, Chansai S, Yamsri S, Chansung K, Wanitpongpun C, Lanamtieng T, Phiphitaporn P, Fucharoen S, Pongchaiyakul C. The association of growth differentiation factor-15 levels and osteoporosis in patients with thalassemia. Am J Med Sci 2023:S0002-9629(23)01173-4. [PMID: 37146903 DOI: 10.1016/j.amjms.2023.05.002] [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: 08/18/2022] [Accepted: 05/01/2023] [Indexed: 05/07/2023]
Abstract
INTRODUCTION Ineffective erythropoiesis (IE) is a significant risk factor for osteoporosis in individuals with thalassemia. Growth differentiation factor-15 (GDF15), a biomarker of IE, was found to be elevated in thalassemia patients. This study aimed to examine the association between GDF15 levels and osteoporosis in patients with thalassemia. METHODS A cross-sectional study was conducted in 130 adult patients with thalassemia in Thailand. Bone mineral density (BMD) at the lumbar spine was evaluated by dual-energy X-ray absorptiometry (DXA), and with a Z-score of less than -2.0 SD was defined as osteoporosis. GDF-15 was measured using the enzyme-linked immunosorbent assay (ELISA). Logistic regression analysis was used to examine the associated factors with the development of osteoporosis. Receiver operator characteristic (ROC) curve analysis was used to estimate the threshold of GDF15 in predicting osteoporosis. RESULTS Osteoporosis was detected in 55.4% (72/130) of the patients. Advanced age and high GDF15 levels were positively associated with osteoporosis, while an increased hemoglobin level was negatively associated with osteoporosis in patients with thalassemia. In this study, the GDF15 level's ROC demonstrated a good performance in predicting osteoporosis (AUC=0.77). CONCLUSIONS The prevalence of osteoporosis is high among adult thalassemia patients. Age and high GDF15 levels were significantly associated with osteoporosis in this study. A higher hemoglobin level is associated with a lower risk of osteoporosis. This study suggest that GDF15 could be used as a predictive biomarker for osteoporosis in patients with thalassemia. Adequate red blood cell transfusions and suppression of GDF15 function may be beneficial in preventing osteoporosis.
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Affiliation(s)
- Nattiya Teawtrakul
- Division of Hematology, Department of Internal Medicine, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. 40002.
| | - Siriyakorn Chansai
- Medical science program, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand 40002; Centre for Research and Development of Medical Diagnostics Laboratories, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand. 40002
| | - Supawadee Yamsri
- Centre for Research and Development of Medical Diagnostics Laboratories, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand. 40002
| | - Kanchana Chansung
- Division of Hematology, Department of Internal Medicine, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. 40002
| | - Chinadol Wanitpongpun
- Division of Hematology, Department of Internal Medicine, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. 40002
| | - Theerin Lanamtieng
- Division of Hematology, Department of Internal Medicine, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. 40002
| | - Pisa Phiphitaporn
- Division of Hematology, Department of Internal Medicine, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. 40002
| | - Supan Fucharoen
- Centre for Research and Development of Medical Diagnostics Laboratories, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand. 40002
| | - Chatlert Pongchaiyakul
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. 40002
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Carnevale A, Pellegrino F, Bravi B, Gamberini MR, Gagliardi I, Reverberi R, Zatelli MC, Giganti M, Ambrosio MR. The role of opportunistic quantitative computed tomography in the evaluation of bone disease and risk of fracture in thalassemia major. Eur J Haematol 2022; 109:648-655. [PMID: 36000276 PMCID: PMC9826074 DOI: 10.1111/ejh.13847] [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: 07/05/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Dual-energy X-ray absorptiometry (DXA) remains the cornerstone for osteoporosis evaluation in Thalassemia major. However, several drawbacks have been observed in this unique setting. We sought to determine the correlation between quantitative CT (QCT) and DXA-derived parameters; secondarily, we aimed to investigate the role of the two techniques in predicting the risk of fracture. METHODS We retrospectively included patients with β-thalassemia major who had undergone both lumbar and femoral DXA examinations, and CT scans including the lumbar spine, performed for disparate diagnostic issues, within 4 months from the DXA. CT data were examined employing a phantom-less QCT method for bone mineral density (BMD) assessment. We also retrieved any spontaneous or fragility fractures occurring from 1 year before up to 5 years after the date of DXA scans. RESULTS The 43 patients were included. QCT measures were significantly higher than those determined by DXA. The gap between QCT and DXA values was strongly associated with patient age. The most powerful predictive variable for risk of fracture was the ACR classification based on volumetric BMD obtained by QCT. CONCLUSIONS DXA provided more negative measures than those determined by QCT. However, QCT seemed to evaluate thalassaemic osteopathy better than DXA, since volumetric BMD was a stronger predictor of fracture.
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Affiliation(s)
- Aldo Carnevale
- Department of Translational Medicine, Section of RadiologyUniversity of FerraraFerraraItaly
| | - Fabio Pellegrino
- Department of Translational Medicine, Section of RadiologyUniversity of FerraraFerraraItaly
| | - Beatrice Bravi
- Department of Translational Medicine, Section of RadiologyUniversity of FerraraFerraraItaly
| | - Maria Rita Gamberini
- Unit of Thalassaemia and Haemoglobinopathies Day Hospital, Regional HUB Centre, Department of MedicineAzienda Ospedaliero‐Universitaria Sant'AnnaFerraraItaly
| | - Irene Gagliardi
- Department of Medical Sciences, Section of Endocrinology and Internal MedicineUniversity of FerraraFerraraItaly
| | - Roberto Reverberi
- Blood Transfusion ServiceAzienda Ospedaliero‐Universitaria Sant'AnnaFerraraItaly
| | - Maria Chiara Zatelli
- Department of Medical Sciences, Section of Endocrinology and Internal MedicineUniversity of FerraraFerraraItaly
| | - Melchiore Giganti
- Department of Translational Medicine, Section of RadiologyUniversity of FerraraFerraraItaly
| | - Maria Rosaria Ambrosio
- Department of Medical Sciences, Section of Endocrinology and Internal MedicineUniversity of FerraraFerraraItaly
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Çelik T, Sangün Ö, Ünal Ş, Balcı A, Motor S. Assessment of biochemical bone markers of osteoporosis in children with thalassemia major. Ital J Pediatr 2022; 48:105. [PMID: 35725492 PMCID: PMC9210807 DOI: 10.1186/s13052-022-01290-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 06/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Beta thalassemia major (β-TM) is a common cause of skeletal morbidity and is associated with increased bone fracture risk, particularly in inadequately transfused children. The aim of this study was to investigate some potential biochemical markers as possible early predictors of BMD variations in children with β-TM. METHODS The study included 38 children with β-TM and 40 sex-age matched controls. All patients were subjected to BMD assessment by dual-energy X-ray absorptiometry (DEXA). Serum beta-crosslaps (beta-CTx), osteoprotegerin (OPG), receptor activator of nuclear factor-kappa B ligand (RANKL), urinary deoxypyridinoline (DPD) and ferritin levels were compared between the groups. RESULTS Serum OPG levels were significantly lower in thalassemic children than in controls. The mean ratio of RANKL/OPG was significantly higher in the thalassemic patients than in the control group. Osteoporosis was detected in 10 (3 female and 7 male) of 38 patients (26.3%) according to the femur Z score and in 6 of them (4 male and 2 female) (15.8%) according to the spine Z score. CONCLUSIONS Serum OPG concentrations can be used as a biochemical marker in screening patients with beta-thalassemia major for the development of osteoporosis.
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Affiliation(s)
- Tanju Çelik
- School of Medicine, Pediatrics, Mustafa Kemal University, Hatay, Turkey. .,Department of Pediatrics, University of Health Sciences Dr. Behçet Uz Children's Hospital, İzmir, Turkey.
| | - Özlem Sangün
- Department of Pediatric Endocrinology, Antakya State Hospital, Hatay, Turkey
| | - Şule Ünal
- Department of Pediatric Hematology and Oncology, Antakya State Hospital, Hatay, Turkey.,Department of Pediatrics, Division of Hematology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ali Balcı
- School of Medicine, Department of Radiology, 9 Eylul University, Hatay, Turkey
| | - Sedat Motor
- School of Medicine, Department of Biochemistry, Mustafa Kemal University, Hatay, Turkey
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Youssry I, Saad N, Madboly M, Samy RM, Hamed ST, Tawfik H, Elbatrawy SR, Kaddah N, Abd Elaziz D. Bone health in pediatric transfusion-dependent beta-thalassemia: Circulating osteoprotegerin and RANKL system. Pediatr Blood Cancer 2022; 69:e29377. [PMID: 34699125 DOI: 10.1002/pbc.29377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 08/13/2021] [Accepted: 08/31/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION While the mechanism of bone disease in thalassemia is multifactorial and still under investigation, the receptor activator of nuclear factor kappa B (RANK), receptor activator of nuclear factor kappa B ligand (RANKL), and osteoprotegerin (OPG) have pivotal roles in regulating bone metabolism. This study aimed to measure RANKL and OPG serum levels, and to detect the incidence of RANKL rs9533156, OPG rs2073618, and OPG rs2073617 genotypes in pediatric β-thalassemia patients and to assess their relation to bone mineral density. METHODS Sixty patients with transfusion-dependent β-thalassemia (TBT) patients ages 5 to 14 years were included, and 60 healthy, age- and sex-matched volunteers contributed as a control group. The patients were scanned for bone mineral density. RESULTS The mean of spine dual-energy X-ray absorptiometry (DXA) Z-score in patients was -1.66 ± 1.02 standard deviation (SD). Twenty-four of them had low spine DXA Z-scores. The patients showed significantly lower OPG levels and OPG/RANKLs ratios than the control group (3.28 ± 9.11 ng/ml and 11.38 ± 14.93 ng/ml, and 0.01 ± 0.03 and 0.07 ± 0.09, respectively). The RANKL SNP rs9533156 TC heterozygous genotype was detected more with statistical significance in patients than controls. The incidence of OPG rs2073618 and OPG rs2073617 genotypes were 2.3 times and 1.9 times more frequent in patients than controls, respectively. CONCLUSION The RANK/RANKL/OPG system may have an important role in regulating bone metabolism in TBT patients, although further studies are needed to clarify its role.
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Affiliation(s)
- Ilham Youssry
- Pediatric Department, Cairo University, Cairo, Egypt
| | - Nahla Saad
- Egyptian Ministry of Health and Population, Cairo, Egypt
| | | | - Rania M Samy
- Chemical and Clinical Pathology Department, Cairo University, Cairo, Egypt
| | - Soha T Hamed
- Radiology Department, Cairo University, Cairo, Egypt
| | - Hanaa Tawfik
- Biological Anthropology Department, National Research Center, Cairo, Egypt
| | - Salwa R Elbatrawy
- Biological Anthropology Department, National Research Center, Cairo, Egypt
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Yavropoulou MP, Anastasilakis AD, Tzoulis P, Tourni S, Rigatou E, Kassi E, Kattamis A, Makras P. Approach to the management of β thalassemia major associated osteoporosis - A long-standing relationship revisited. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022305. [PMID: 36300213 PMCID: PMC9686151 DOI: 10.23750/abm.v93i5.13668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/06/2022] [Indexed: 01/25/2023]
Abstract
Adults with β- thalassemia major (β-TM) develop low BMD and fragility fractures at a higher incidence and at a younger age compared to the general population. The disease itself, including direct effects of anemia and iron overload toxicity on bone turnover, genetic susceptibility, thalassemia-related endocrinopathies and acquittance of suboptimal peak bone mass contribute to low bone mass and increased bone fragility frequently encountered among these patients. Current management of osteoporosis requires long-term treatment that can be provided by agents that reduce the risk of all osteoporotic fractures by modulating bone metabolism with different mechanisms of action. These include inhibitors of bone remodeling (e.g., bisphosphonates, denosumab) and stimulators of bone formation (e.g., PTHR1 agonists and sclerostin antibodies). Considering the unique characteristics of osteoporosis associated with β-TM and the clinical importance of balancing the risk/benefit of treatment in the long-term, appropriate use of these therapeutic approaches is essential for patient care. In this review we outline current literature on the use of anti-osteoporotic drugs in β-TM patients with osteoporosis focusing on data on the efficacy, safety, and duration of treatment. In addition, we propose a long-term management plan for β-TM -associated osteoporosis aiming at the optimal patient care for this special population.
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Affiliation(s)
- Maria P. Yavropoulou
- Endocrinology Unit, First Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, 11527, Greece
| | | | - Ploutarchos Tzoulis
- Department of Diabetes and Endocrinology, Whittington Hospital, University College London, London, UK
| | - Symeon Tourni
- Laboratory for Research of the Musculoskeletal System “Th. Garofalidis”, Medical School, National and Kapodistrian University of Athens, KAT General Hospital of Athens, Athens, Greece
| | - Efthimia Rigatou
- Division of Paediatric Haematology-Oncology, First Department of Paediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Eva Kassi
- Endocrinology Unit, First Department of Propaedeutic and Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, 11527, Greece
| | - Antonis Kattamis
- Division of Paediatric Haematology-Oncology, First Department of Paediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Polyzois Makras
- Department of Endocrinology and Diabetes and Department of Medical Research, 251 Hellenic Air Force and VA General Hospital, 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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A systematic review of quality of life in sickle cell disease and thalassemia after stem cell transplant or gene therapy. Blood Adv 2021; 5:570-583. [PMID: 33496753 DOI: 10.1182/bloodadvances.2020002948] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/07/2020] [Indexed: 01/19/2023] Open
Abstract
Patients with sickle cell disease (SCD) and thalassemia experience several complications across their lifespan that lead to impairment in different health-related quality of life (HRQOL) domains. There is increasing interest in curative therapies for patients with SCD and thalassemia, including hematopoietic stem cell transplant (HSCT) and gene therapy; however, the effect of these therapies on various HRQOL domains remains unclear. Our objective was to systematically evaluate the most recent evidence for the effect of HSCT and gene therapy on HRQOL in patients with SCD and thalassemia. A systematic search of medical literature databases was conducted. A total of 16 studies (thalassemia, n = 9; SCD, n = 6; both, n = 1) involving 517 participants met inclusion criteria (thalassemia, n = 416; SCD, n = 101). HSCT was associated with a small to large positive effects in most HRQOL domains (Cohen's d; mean = 0.47; median = 0.37; range, 0.27-2.05). In thalassemia, HSCT was frequently associated with large positive effects in physical and emotional HRQOL domains (median d = 0.79 and d = 0.57, respectively). In SCD, HSCT was associated with large positive effects in all HRQOL domains. Emerging data suggest improvement in HRQOL outcomes across different domains following gene therapy in thalassemia and SCD. The quality of evidence was moderate in 13 studies (81%). HSCT has a positive impact on several HRQOL domains in patients with SCD and thalassemia; however, more longitudinal studies are warranted to assess the sustainability of these effects. Reporting HRQOL outcomes from ongoing gene therapy or gene-editing trials in SCD and thalassemia is key to better understand the benefits of such therapies.
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Kharroubi A, Karmi B, Shamasneh W, Saba E. Bone mineral density among Palestinian patients suffering from hemoglobinopathy disorders. Arch Osteoporos 2020; 15:181. [PMID: 33188480 DOI: 10.1007/s11657-020-00853-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 11/05/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED This study aimed to investigate the correlation between bone mineral density (BMD) with hemoglobin and ferritin levels in Palestinian patients suffering from various types of hemoglobinopathies. The study revealed the thresholds of hemoglobin and ferritin to protect against low BMD in these patients. PURPOSE Iron overload is the main cause of low BMD in subjects with hemoglobinopathies. We used iron overload-related parameters like hemoglobin and ferritin to estimate the cutoff values required to maintain bone health and identify subjects with low BMD. METHODS Palestinian patients (135) suffering from various types of hemoglobinopathies were recruited from various medical centers including 87 β thalassemia major (TM), 13 thalassemia intermedia (TI), 16 sickle cell anemia (SCA), 17 sickle cell thalassemia (SCT), and 1 thalassemia trait (TT). Most subjects (84%) were below the age of 30 years. BMD was measured and the z score was used to identify subjects with low BMD (z < - 2.0). Receiver operator characteristic (ROC) curve analysis was used to estimate the thresholds of hemoglobin and ferritin levels needed to protect against low BMD in these patients. RESULTS No difference in means of age, weight, BMI, hemoglobin, and ferritin levels among the recruited male and female subjects were observed. The results showed that 77% of TM subjects had low BMD levels and femoral neck and total hip BMD were significantly lower among female compared to male subjects. Thalassemia patients (TM, TI, and SCT combined) had significantly low BMD and lower hemoglobin mean values compared to normal BMD subjects (8.54 vs. 9.25 g/dL, p = 0.01). Pearson's correlation analysis showed positive correlation between hemoglobin levels and BMD at the three sites, being higher with lumbar spine (r = 0.444) compared to femoral neck (r = 0.291) and total hip (r = 0.224). Ferritin levels in TM patients (4800 ng/ml) and TI subjects (1500 ng/ml) were abnormally high. ROC curve analysis showed that hemoglobin threshold ≤ 9.3 g/dL represents a risk for developing low BMD with an area under the ROC curve (AUC) 0.699 and sensitivity and specificity were 87.9% and 47.7%, respectively. Similar analysis revealed that Ferritin threshold to protect against low BMD should be maintained below 2300 ng/ml with AUC 0.619 and sensitivity and specificity were 55.0% and 71.4%, respectively. CONCLUSIONS The results of this study strongly recommend to maintain hemoglobin levels above 9.3 g/dL and ferritin below 2300 ng/ml to protects against low BMD in TM subjects and patients suffering from the other related hemoglobinopathies.
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Affiliation(s)
- Akram Kharroubi
- Faculty of Health Professions, Department of Medical Laboratory Sciences, Al-Quds University, Jerusalem, Palestine.
| | - Bashar Karmi
- Thalassemia Patients' Friends Society, Ramallah, Palestine
| | | | - Elias Saba
- Palestinian Osteoporosis Prevention Society [POPS], Bethlehem, Palestine
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11
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Tombak A, Boztepe B, Akbayir S, Dogru G, Sungur MA. Receptor Activator of Nuclear Factor κ-Β Ligand/Osteoprotegerin Axis in Adults with Hb S/β-Thalassemia and β-Thalassemia Trait. Hemoglobin 2020; 44:334-337. [PMID: 32873083 DOI: 10.1080/03630269.2020.1811116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
There is not enough data about osteoporosis and the role of receptor activator of nuclear factor κ-Β ligand (RANKL)/serum osteoprotegerin (OPG) system in patients with double heterozygosity for sickle cell disease and β-thalassemia [Hb S (HBB: c.20A>T)/β-thal] and β-thal trait. Aim of the study was to investigate bone mineral densities (BMD) and the role of RANKL/OPG system in these cases. We studied 58 adults with Hb S/β-thal, 52 adults with β-thal trait, 34 healthy subjects as a control group. The BMD was determined by dual-energy X-ray absorptiometry (DEXA). Biochemical markers of bone metabolism (serum calcium, phosphorus, alkaline phosphatase, osteocalcin) parameters that affect bone metabolism (serum parathyroid hormone, thyroid-stimulating hormone, 25-hydroxyvitamin D, OPG, soluble RANKL [sRANKL]) were studied. Femoral neck Z-scores of 93.2% for β-thal trait, 83.0% for Hb S/β-thal patients were within the expected range. Lumbar spine Z-scores of 89.1% for β-thal, 90.2% for Hb S/β-thal patients were above -2.0 SD. Z-scores of the control group were within the expected range. Median serum sRANKL level was 2.80, 4.52, 5.79 pmol/L in Hb S/β-thal, β-thal trait, control groups, respectively (p = 0.010). Median serum OPG level was 1.07, 0.86, 0.86 pmol/L in Hb S/β-thal, β-thal trait, control groups, respectively (p < 0.001). β-Thalassemia trait alone is not a risk factor for osteopenia/osteoporosis and osteoporosis does not develop in premenopausal women and men younger than 50 years with Hb S/β-thal. However, as we determined lower levels of osteocalcin, compensatory decrease of sRANKL with compensatory increase of OPG, more severe osteoporosis may develop in advanced ages in these patient populations.
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Affiliation(s)
- Anil Tombak
- Deparment of Hematology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Burcu Boztepe
- Department of Internal Medicine, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Serin Akbayir
- Department of Biochemistry, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Gurbet Dogru
- Department of Medical Biology and Genetics, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Mehmet Ali Sungur
- Department of Biostatistics, Faculty of Medicine, Duzce University, Duzce, Turkey
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12
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Yu U, Chen L, Wang X, Zhang X, Li Y, Wen F, Liu S. Evaluation of the vitamin D and biomedical statuses of young children with β-thalassemia major at a single center in southern China. BMC Pediatr 2019; 19:375. [PMID: 31646984 PMCID: PMC6813046 DOI: 10.1186/s12887-019-1744-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/23/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND In young children, β-thalassemia major (β-TM) is associated with potentially severe clinical characteristics, including poor growth, feeding difficulties, hepatosplenomegaly, bone metabolic disorders, and skeletal abnormalities. METHODS In this study, we reviewed the demographic and clinical characteristics (e.g., age, sex, duration of blood transfusion and chelating therapy, and vitamin supplementation) and serum biomarker levels (e.g., iron accumulation, bone metabolism, liver, kidney, and thyroid function markers) of 32 patients that received regular blood transfusion at a single center in southern China with the aim of stratifying the risk of severe complications such as osteopenia, endocrinopathies, and multi-organ failures. RESULTS Although all patients exhibited moderately to strongly elevated serum ferritin levels, this biomarker was significantly higher in children older than ≥5 years, compared to younger children (*p < 0.05, 1512 ± 192.6 vs. 2337 ± 299.8 ng/ml, Mann-Whitney U test). Older children had a significantly lower 25-hydroxy vitamin D3 (25(OH)D3) level, compared to younger children (**p < 0.01, 34.25 ± 11.06 vs. 23.05 ± 9.95 ng/ml, Mann-Whitney U test). No age-related differences were observed in serum calcium, phosphorus, and PTH levels. Regarding liver function, the serum alanine aminotransferase (ALT) level was significantly increased in children older than ≥5 years, compared to younger children (*p < 0.05, 19.17 ± 2.44 vs. 43.45 ± 9.82I U/ml, Mann-Whitney U test). However, no age-related differences were observed in the serum levels of other liver or kidney and thyroid biomarkers. CONCLUSIONS Our results suggest that in older children, hepatic iron overload may be associated with a low serum concentration of 25(OH)D3, an indicator of vitamin D deficiency and altered bone metabolism. Iron accumulation may also be associated with a higher concentration of ALT, a sensitive marker of liver malfunction. These findings may provide important clinical indications of the need for intervention to prevent severe complications in children with β thalassemia.
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Affiliation(s)
- Uet Yu
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, Guangdong, China
| | - Li Chen
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, Guangdong, China
| | - Xiaodong Wang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, Guangdong, China
| | - Xiaoling Zhang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, Guangdong, China
| | - Yue Li
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, Guangdong, China
| | - Feiqiu Wen
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, Guangdong, China
| | - Sixi Liu
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, Guangdong, China.
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13
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Guan S, Zhao Y, Zhuo X, Song W, Geng X, Yang H, Wang J, Wu X, Yang J, Song X, Cheng L. Regional gender differences in an autosomal disease result in corresponding diversity differences. Sci Rep 2019; 9:5472. [PMID: 30940865 PMCID: PMC6445288 DOI: 10.1038/s41598-019-41905-8] [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: 11/24/2017] [Accepted: 03/01/2019] [Indexed: 11/11/2022] Open
Abstract
Regional gender differences in autosomal chromosome disorders have been observed repeatedly. However, the corresponding diversity changes remain unconfirmed. By analyzing previously published thalassemia data from the Dai people in Dehong and Xishuangbanna (two regions in Yunnan Province, China), we found that several sequence types, including HBA CNV and HBB mutations, significantly depend on gender in Xishuangbanna but not in Dehong. With the supportive evidence from previous researches, we accept that some certain mutations depend on gender regionally. This association seems peculiar. It is among one common people on a small geographical scale, while other recorded thalassemia gender difference varies by ethnics and continent.
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Affiliation(s)
- Shenmin Guan
- Shenzhen University Health Sciences Center, School of Basic Medical Sciences, Department of Physiology, Shenzhen, 518061, China.,BGI-Yunnan, BGI-Shenzhen, Kunming, 650106, China
| | - Yingying Zhao
- Shenzhen University Health Sciences Center, School of Basic Medical Sciences, Department of Physiology, Shenzhen, 518061, China
| | - Xiao Zhuo
- BGI-Yunnan, BGI-Shenzhen, Kunming, 650106, China
| | - Wenhui Song
- BGI-Yunnan, BGI-Shenzhen, Kunming, 650106, China
| | - Xiaorui Geng
- Shenzhen Longgang ENT Institute, Shenzhen, 518100, China
| | - Huanming Yang
- BGI-Shenzhen, Shenzhen, 518083, China.,James D. Watson Institute of Genome Sciences, Hangzhou, 310058, China
| | - Jian Wang
- BGI-Shenzhen, Shenzhen, 518083, China.,James D. Watson Institute of Genome Sciences, Hangzhou, 310058, China
| | - Xinhua Wu
- Dali University First affiliated Hospital, Dali, 671000, China
| | - Jinlong Yang
- BGI-Yunnan, BGI-Shenzhen, Kunming, 650106, China. .,Puer University, Puer School of BGI-Yunnan, Puer, 665000, China.
| | - Xin Song
- The Third Affiliated Hospital of Kunming Medical University (Tumor Hospital of Yunnan Province), Kunming, 650000, China.
| | - Le Cheng
- BGI-Yunnan, BGI-Shenzhen, Kunming, 650106, China. .,Shenzhen Longgang ENT Institute, Shenzhen, 518100, China. .,Puer University, Puer School of BGI-Yunnan, Puer, 665000, China. .,Dali University, School of Basic Medical Sciences, Dali, 671003, China.
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14
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Valderrábano RJ, Wu JY. Bone and blood interactions in human health and disease. Bone 2019; 119:65-70. [PMID: 29476979 PMCID: PMC11370649 DOI: 10.1016/j.bone.2018.02.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 02/20/2018] [Accepted: 02/20/2018] [Indexed: 12/18/2022]
Abstract
Under physiologic conditions hematopoiesis takes place in the bone marrow, and the skeleton provides the structural and supportive network necessary for normal hematopoiesis. Chronic disorders affecting hematopoiesis such as sickle cell anemia and thalassemia demonstrate striking skeletal phenotypes including bone loss and increased fracture risk. There is mounting evidence that anemia in older populations may also be associated with bone fragility. Given the interconnectedness of bone and hematopoietic cells, it is important to review the potential clinical implications and opportunities for therapeutic intervention. There are recognized associations between blood-borne and solid tissue malignancy and skeletal health, but our review will focus on non-malignant disease.
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Affiliation(s)
- Rodrigo J Valderrábano
- Division of Endocrinology, University of Miami Miller School of Medicine, Miami, FL, United States.
| | - Joy Y Wu
- Division of Endocrinology, Stanford University School of Medicine, Stanford, CA, United States.
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15
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Darvishi-Khezri H, Kosaryan M, Akbarzadeh R, Aliasgharian A, Fazli M. Administration of Intravenous Zoledronic Acid Every 3 Months vs. Annually in β-thalassemia Patients with Low Bone Mineral Density: a Retrospective Comparison of Efficacy. Med Arch 2018; 72:170-173. [PMID: 30061760 PMCID: PMC6021158 DOI: 10.5455/medarh.2018.72.170-173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: The benefit of annual administration of zoledronic acid in the management of thalassemia-associated osteoporosis is unknown. Aim: The aims of this study were to evaluate the efficacy of treatment with two different dosing regimens of IV zoledronic acid (annually versus every 3 months) for increasing low bone mineral density (BMD) in patients with osteoporosis associated with β-thalassemia as annually and 3-monthly on bone density in patients. Materials and Methods: This retrospective, single-center study analyzed patients’ clinical records and bone density measurements. Those enrolled in the study were 14 to 53 years of age, had documented β-thalassemia, and were treated with IV zoledronic acid on either an annual or every 3 months dosing regimen. Dual-energy X-ray absorptiometry was used to obtain the z-score for BMD in the lumbar spine and femoral neck. Results: Thirty-four patients were enrolled in the study; 15 (44.1%) had been treated annually, and 19 (55.9%) had been treated every month. In patients receiving treatment with the once-yearly dose of zoledronic acid, significant increases were observed in the lumbar spine BMD z-score, from -2.45 ± 0.69 to -1.97 ± 0.82 (P=0.02). When comparing BMD across the two treatment regimens, the mean lumbar spine BMD was 0.82 greater (95% CI 0.31, 1.33, P=0.003) and the mean femoral neck BMD 0.37 greater (95% CI -0.15, 0.87, P=0.1) in the group receiving annual zoledronic acid treatment. Conclusions: In patients with thalassemia-associated osteopenia, annual treatment with zoledronic acid increases lumbar spine bone density while being more effective, less expensive, and associated with fewer adverse events than dosing every 3 months.
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Affiliation(s)
- Hadi Darvishi-Khezri
- Neonatal and Children's Health Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Mehrnoush Kosaryan
- Thalassemia Research Center, Hemoglobinopathy Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Rosseta Akbarzadeh
- Thalassemia Research Center, Hemoglobinopathy Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Aily Aliasgharian
- Student Research Committee, Thalassemia Research Center, Hemoglobinopathy Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mehran Fazli
- Young Researcher and Elite Club, Islamic Azad University, Kazerun Branch, Kazerun, Iran
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16
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Bone Mineral Density (BMD) and Chemical Biomarkers Among Patients with Thalassemia Major and Intermedia in Iran. HEALTH SCOPE 2018. [DOI: 10.5812/jhealthscope.64137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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17
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Bou-Fakhredin R, Elias J, Taher AT. Iron Overload and Chelation Therapy in Hemoglobinopathies. THALASSEMIA REPORTS 2018. [DOI: 10.4081/thal.2018.7478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Iron overload (IOL) is highly prevalent among patients with hemoglobinopathies; both transfusion dependent thalassemia (TDT) and non-transfusion dependent thalassemia (NTDT). Whether IOL is secondary to regular transfusions like in TDT, or develops from increased intestinal absorption like in NTDT, it can cause significant morbidity and mortality. In TDT patients, iron accumulation in organ tissues is highly evident, and leads to organ toxicity and dysfunction. IOL in NTDT patients is cumulative with advancing age, and concern with secondary morbidity starts beyond the age of 10 years, as shown by the OPTIMAL CARE study. Several modalities are available for the diagnosis and monitoring of IOL. Serum ferritin (SF) assessment is widely available and heavily relied on in resource-poor countries. Non-invasive iron monitoring using MRI has become the gold standard to diagnose IOL. Three iron chelators are currently available for the treatment of IOL: deferoxamine (DFO) in subcutaneous or intravenous injection, oral deferiprone (DFP) in tablet or solution form, and oral deferasirox (DFX) in dispersible tablet (DT) and film-coated tablet (FCT). Today, the goal of ICT is to maintain safe levels of body iron at all times. Appropriate tailoring ICT with chelator choices and dose adjustment must be implemented in a timely manner. Clinical decision to initiate, adjust and stop ICT is based on SF, MRI-LIC and cardiac T2*. In this article, we review the mechanism of IOL in both TDT and NTDT, the pathophysiology behind it, its complications, and the different ways to assess and quantify it. We will also discuss the different ICT modalities available, and the emergence of novel therapies.
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18
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Stefanopoulos D, Papaioannou NA, Papavassiliou AG, Mastorakos G, Vryonidou A, Michou A, Dontas IA, Lyritis G, Kassi E, Tournis S. A contemporary therapeutic approach to bone disease in beta-thalassemia - a review. J Frailty Sarcopenia Falls 2018; 3:13-25. [PMID: 32300690 PMCID: PMC7155348 DOI: 10.22540/jfsf-03-013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2018] [Indexed: 01/19/2023] Open
Abstract
Homozygous beta-thalassemia represents a serious hemoglobinopathy, in which an amazing prolongation in the survival rate of patients has been achieved over recent decades. A result of this otherwise positive evolution is the fact that bone problems have become a major issue in this group of patients. Through an in-depth review of the related literature, the purpose of this study is to present and comment on the totality of the data that have been published to date pertaining to the prevention and treatment of thalassemia bone-disease, focusing on: the contribution of diet and lifestyle, the treatment of hematologic disease and its complications, the management of hypercalciuria, the role of vitamins and minerals and the implementation of anti-osteoporosis medical regimen. In order to comprehensively gather the above information, we mainly reviewed the international literature through the PubMed database, searching for the preventive and therapeutic data that have been published pertaining to thalassemia bone-disease over the last twenty-nine years. There is no doubt that thalassemia bone-disease is a complication of a multi-factorial etiopathology, which does not follow the rules of classical postmenopausal osteoporosis. Bisphosphonates have been the first line of treatment for many years now, with varied and usually satisfactory results. In addition, over the last few years, more data have arisen for the use of denosumab, teriparatide, and other molecules that are in the clinical trial phase, in beta-thalassemia.
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Affiliation(s)
- Dimitrios Stefanopoulos
- Laboratory for Research of the Musculoskeletal System “Th. Garofalidis”, KAT Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Nikolaos A. Papaioannou
- Laboratory for Research of the Musculoskeletal System “Th. Garofalidis”, KAT Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Athanassios G. Papavassiliou
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George Mastorakos
- Second Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Aretaieion Hospital, Athens, Greece
| | - Andromachi Vryonidou
- Department of Endocrinology, Diabetes & Metabolism, General Hospital Korgialenio-Benakio, Athens, Greece
| | - Aikaterini Michou
- Deparment of Endocrinology, “Elena Venizelou” General Hospital, Athens, Greece
| | - Ismene A. Dontas
- Laboratory for Research of the Musculoskeletal System “Th. Garofalidis”, KAT Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | | | - Eva Kassi
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- First Department of Internal Medicine - Medical School- Laikon Hospital - National and Kapodistrian University of Athens, Greece
| | - Symeon Tournis
- Laboratory for Research of the Musculoskeletal System “Th. Garofalidis”, KAT Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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De Sanctis V, Soliman AT, Elsefdy H, Soliman N, Bedair E, Fiscina B, Kattamis C. Bone disease in β thalassemia patients: past, present and future perspectives. Metabolism 2018; 80:66-79. [PMID: 28987275 DOI: 10.1016/j.metabol.2017.09.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 09/07/2017] [Accepted: 09/10/2017] [Indexed: 01/23/2023]
Abstract
Bone disorders in patients with thalassemia major (TM) and intermedia (TI) constitute complex conditions that result from various factors affecting the growing skeleton. Although much progress has been made in our understanding of the natural history, pathogenesis and clinical manifestations of β- and δβ-thalassemia, bone manifestations remain a puzzle for the clinician. In this review, we outline the key points in the current literature on the pathogenesis and management of bone disease in patients with TM and TI who were conventionally treated in recent decades with frequent blood transfusions and iron chelation. Prevention, early recognition and treatment are the most effective strategies for the management of bone disease in these patients. However, further studies are required to maintain optimal bone health for both TM and TI patients. Studying bone disease in patients with non-transfusion dependent TI, which seems to worsen considerably with age, is important to delineate the effect of the disease itself on bone health without the intervening factors of transfusions, iron intoxication and chelation.
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Affiliation(s)
- Vincenzo De Sanctis
- Pediatric and Adolescent Outpatient Clinic, Quisisana Hospital, Ferrara, Italy.
| | - Ashraf T Soliman
- Department of Pediatrics, Division of Endocrinology, Hamad General Hospital, Doha, Qatar; Department of Pediatrics, Division of Endocrinology, Alexandria University Children's Hospital, Alexandria, Egypt
| | - Heba Elsefdy
- Department of Pediatrics, Ain Shams University, Cairo, Egypt
| | - Nada Soliman
- Primary Health Care, Ministry of Health, Alexandria, Egypt
| | - Elsaid Bedair
- Department of Radiology, AlKhor Hospital, Hamad Medical Center, Doha, Qatar
| | | | - Christos Kattamis
- First Department of Paediatrics, University of Athens, Athens, Greece
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20
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Teawtrakul N, Jetsrisuparb A, Pongudom S, Sirijerachai C, Chansung K, Wanitpongpun C, Fucharoen S. Epidemiologic study of major complications in adolescent and adult patients with thalassemia in Northeastern Thailand: the E-SAAN study phase I. ACTA ACUST UNITED AC 2017; 23:55-60. [PMID: 28759343 DOI: 10.1080/10245332.2017.1358845] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Thalassemia-related complications are one of the main factors that increase morbidity and mortality in aging patients with thalassemia. This study was aimed to report the prevalence and clinical risk factors for the complications in thalassemia. METHODS A multi-center prospective cohort study was conducted in patients with thalassemia aged ≥10 years old. Thalassemia-related complications were heart failure, pulmonary hypertension, extramedullary hematopoiesis, endocrine disorders, infections, thrombosis and leg ulcers. The clinical parameters significantly associated with the complications were analyzed by logistic regression methods. RESULTS The prevalence of thalassemia-related complications was 60.5% in patients with transfusion-dependent thalassemia (TDT) and 43% in patients with non-transfusion-dependent thalassemia (NTDT). Splenectomy was statistically associated with complications in both TDT and NTDT patients (adjusted odds ratio (AOR) = 7.4, p-value = 0.0001 and AOR = 2.6, p-value = 0.001). Age ≥50 years old (AOR = 2.9, p-value = 0.04) and female gender (AOR = 0.5, p-value = 0.03) were statistically associated with the complications in patients with NTDT. CONCLUSION Nearly half of the patients in this cohort had disease-related complications. Splenectomy and advanced age were important factors for complication involvement. Early screening for the complications may reduce the morbidity and mortality in patients with thalassemia.
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Affiliation(s)
- Nattiya Teawtrakul
- a Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Srinagarind Hospital , Khon Kaen University , Khon Kaen , Thailand
| | - Arunee Jetsrisuparb
- b Division of Hematology, Department of Pedriatrics, Faculty of Medicine, Srinagarind Hospital , Khon Kaen University , Khon Kaen , Thailand
| | | | - Chittima Sirijerachai
- a Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Srinagarind Hospital , Khon Kaen University , Khon Kaen , Thailand
| | - Kanchana Chansung
- a Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Srinagarind Hospital , Khon Kaen University , Khon Kaen , Thailand
| | - Chinadol Wanitpongpun
- a Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Srinagarind Hospital , Khon Kaen University , Khon Kaen , Thailand
| | - Supan Fucharoen
- d Center for Research and Development of Medical Diagnostic Laboratories, Faculty of Associated Medical Science , Khon Kaen University , Khon Kaen , Thailand
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21
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Ferro E, Visalli G, La Rosa MA, Piraino B, Civa R, Randazzo Papa G, Di Pietro A. Genotoxic effect of iron overload and disease complications in transfused β thalassaemic patients. Mutagenesis 2016; 32:275-281. [DOI: 10.1093/mutage/gew062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Bone microarchitecture deteriorations and a fragility fracture in a patient with beta and alpha heterozygous thalassemia: a case report. Wien Klin Wochenschr 2016; 129:212-216. [PMID: 27363996 PMCID: PMC5346126 DOI: 10.1007/s00508-016-1032-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 06/04/2016] [Indexed: 11/25/2022]
Abstract
To date there are few studies that have investigated bone mineral density (BMD) and markers of bone metabolism in patients with thalassemia minor form. None of the previous trials presented bone structure analysis in the patient populations. We present the case of a 24-year-old Turkish woman with heterozygous beta and alpha thalassemia who sustained a low-trauma fracture of the inferior pubic ramus. Despite normal markers of bone metabolism, the dual X‑ray absorptiometry (DXA) showed decreased areal bone mineral density. Furthermore, severely reduced bone structure parameters and reduced volumetric bone mineral density was assessed by high-resolution peripheral quantitative computed tomography (HR-pQCT). Due to these diagnostic findings at time of peak bone mass, an osteoanabolic therapy with teriparatide for 24 months was initiated. The findings concerning BMD and bone structure in this patient can be seen as caused by the beta and alpha thalassemia.
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Zarei T, Haghpanah S, Parand S, Moravej H, Dabbaghmanesh MH, Omrani GR, Karimi M. Evaluation of bone mineral density in patients with hemoglobin H disease. Ann Hematol 2016; 95:1329-32. [DOI: 10.1007/s00277-016-2708-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/23/2016] [Indexed: 01/19/2023]
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Giusti A, Pinto V, Forni GL, Pilotto A. Management of beta-thalassemia-associated osteoporosis. Ann N Y Acad Sci 2016; 1368:73-81. [PMID: 27060977 DOI: 10.1111/nyas.13041] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 02/14/2016] [Accepted: 02/17/2016] [Indexed: 01/19/2023]
Abstract
Beta-Thalassemia-associated osteoporosis is a multifactorial and complex condition. Different acquired and genetic factors are involved in its pathogenesis. These factors produce an imbalance in bone remodeling by inhibiting osteoblast activity and increasing osteoclast function, leading to bone loss and increased fracture risk. The management of patients presenting with thalassemia-associated osteoporosis should consist of the implementation of general measures and the prescription of a specific pharmacological agent, with the aim of reducing fracture risk and preventing disability and deterioration of quality of life. General measures include control of anemia, adequate chelation therapy, healthy nutrition and lifestyle, regular exercise, adequate management of comorbid conditions, hormone replacement therapy in patients with hypogonadism, and vitamin D supplementation/therapy. Among the pharmacological agents currently available for the management of osteoporosis in postmenopausal women and men, bisphosphonates have been shown to improve bone mineral density, to reduce bone turnover, and to decrease bone/back pain in patients with thalassemia-associated osteoporosis, with a good profile of safety and tolerability. On the other hand, there are limited experiences with other pharmacological agents (e.g., denosumab or teriparatide). The complexity of this condition presents diagnostic and therapeutic challenges and underscores the importance of a comprehensive and multidisciplinary approach.
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Affiliation(s)
- Andrea Giusti
- Department of Ortho-Geriatrics, Rehabilitation and Stabilization-Frailty Area, Galliera Hospital, Genoa, Italy
| | - Valeria Pinto
- Center of Microcitemia and Congenital Anemias, Galliera Hospital, Genoa, Italy
| | - Gian Luca Forni
- Center of Microcitemia and Congenital Anemias, Galliera Hospital, Genoa, Italy
| | - Alberto Pilotto
- Department of Ortho-Geriatrics, Rehabilitation and Stabilization-Frailty Area, Galliera Hospital, Genoa, Italy
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Saki N, Abroun S, Salari F, Rahim F, Shahjahani M, Javad MA. Molecular Aspects of Bone Resorption in β-Thalassemia Major. CELL JOURNAL 2015. [PMID: 26199898 PMCID: PMC4503833 DOI: 10.22074/cellj.2016.3713] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
β-thalassemia is the most common single gene disorder worldwide, in which hemoglobin
β-chain production is decreased. Today, the life expectancy of thalassemic patients is
increased because of a variety of treatment methods; however treatment related complications
have also increased. The most common side effect is osteoporosis, which usually
occurs in early adulthood as a consequence of increased bone resorption. Increased bone
resorption mainly results from factors such as delayed puberty, diabetes mellitus, hypothyroidism,
ineffective hematopoiesis as well as hyperplasia of the bone marrow, parathyroid
gland dysfunction, toxic effect of iron on osteoblasts, growth hormone (GH) and
insulin-like growth factor-1 (IGF-1) deficiency. These factors disrupt the balance between
osteoblasts and osteoclasts by interfering with various molecular mechanisms and result
in decreased bone density. Given the high prevalence of osteopenia and osteoporosis in thalassemic patients and
complexity of their development process, the goal of this review is to evaluate the molecular
aspects involved in osteopenia and osteoporosis in thalassemic patients, which may
be useful for therapeutic purposes.
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Affiliation(s)
- Najmaldin Saki
- Health Research Institute, Research Center of Thalassemia and Hemoglobinopathy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Saeid Abroun
- Department of Hematology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Fatemeh Salari
- Health Research Institute, Research Center of Thalassemia and Hemoglobinopathy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Fakher Rahim
- Health Research Institute, Hearing Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohammad Shahjahani
- Health Research Institute, Research Center of Thalassemia and Hemoglobinopathy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohammadi-Asl Javad
- Department of Medical Genetics, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Akcalı A, Kahraman Çeneli S, Gümüş P, Buduneli N, Lappin DF, Özçaka Ö. The Association Between Thalassemia Major and Periodontal Health. J Periodontol 2015; 86:1047-57. [PMID: 25968958 DOI: 10.1902/jop.2015.140639] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The aim of this cross-sectional study is to compare the local and systemic levels of soluble receptor activator of nuclear factor-κB ligand (sRANKL), osteoprotegerin (OPG), a proliferation-inducing ligand (APRIL), B-cell activating factor (BAFF), interleukin (IL)-6, and IL-8 in biofluids of patients with thalassemia major (TM) with or without gingivitis. METHODS Seventy-seven patients are included in this study (TM, n = 29; systemically healthy, n = 48). Gingival crevicular fluid (GCF), saliva, and serum levels of IL-6, IL-8, sRANKL, OPG, BAFF, and APRIL were determined by enzyme-linked immunosorbent assay. Data were analyzed by appropriate non-parametric or parametric statistical tests. RESULTS Median GCF, serum, and saliva levels for BAFF (P <0.001) and IL-6 and IL-8 (P <0.005) were higher in TM gingivitis than in systemically healthy gingivitis (P <0.001). GCF, serum, and saliva levels for APRIL, sRANKL, IL-6, and IL-8 were higher in TM than in systemically and periodontally healthy comparison groups (P <0.05). Positive correlations were found between bleeding on probing (BOP), plaque index (PI) scores, and GCF APRIL, serum sRANKL, serum OPG, and sRANKL concentrations in TM groups (P <0.05). Several significant positive correlations were found between BOP, PI scores, and biofluid parameters also in systemically healthy groups. CONCLUSION TM may have a role in the underlying systemic hematologic condition and potentially affect gingival inflammation via dysregulation of lymphocytes and increased activation of osteoclasts.
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Affiliation(s)
- Aliye Akcalı
- Department of Periodontology, School of Dentistry, Ege University, İzmir, Turkey
| | - Selda Kahraman Çeneli
- Department of Haematology, School of Medicine, Aydın Government Hospital, Aydın, Turkey
| | - Pınar Gümüş
- Department of Periodontology, School of Dentistry, Ege University, İzmir, Turkey
| | - Nurcan Buduneli
- Department of Periodontology, School of Dentistry, Ege University, İzmir, Turkey
| | - David F Lappin
- Infection and Immunity Group; Dental Hospital and School; School of Medicine; College of Medical, Veterinary and Life Sciences; University of Glasgow; Glasgow, Scotland, UK
| | - Özgün Özçaka
- Department of Periodontology, School of Dentistry, Ege University, İzmir, Turkey
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Baldini M, Ulivieri FM, Forti S, Serafino S, Seghezzi S, Marcon A, Giarda F, Messina C, Cassinerio E, Aubry-Rozier B, Hans D, Cappellini MD. Spine bone texture assessed by trabecular bone score (TBS) to evaluate bone health in thalassemia major. Calcif Tissue Int 2014; 95:540-6. [PMID: 25348077 DOI: 10.1007/s00223-014-9919-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 10/10/2014] [Indexed: 02/03/2023]
Abstract
Due to the increasing survival of thalassemic patients, osteopathy is a mounting clinical problem. Low bone mass alone cannot account for the high fracture risk described; impaired bone quality has been speculated but so far it cannot be demonstrated noninvasively. We studied bone quality in thalassemia major using trabecular bone score (TBS), a novel texture measurement extracted from spine dual-energy X-ray absorptiometry (DXA), proposed in postmenopausal and secondary osteoporosis as an indirect index of microarchitecture. TBS was evaluated in 124 adult thalassemics (age range 19-56 years), followed-up with optimal transfusional and therapeutical regimens, and in 65 non-thalassemic patients (22-52 years) undergoing DXA for different bone diseases. TBS was lower in thalassemic patients (1.04 ± 0.12 [range 0.80-1.30]) versus controls (1.34 ± 0.11 [1.06-1.52]) (p < 0.001), and correlated with BMD. TBS and BMD values correlated with age, indicating that thalassemia negatively affects both bone quality and quantity, especially as the patient gets older. TBS was 1.02 ± 0.11 [0.80-1.28] in the osteoporotic thalassemic patients, 1.08 ± 0.12 [0.82-1.30] in the osteopenic ones and 1.15 ± 0.10 [0.96-1.26] in those with normal BMD. No gender differences were found (males: 1.02 ± 0.13 [0.80-1.30], females 1.05 ± 0.11 [0.80-1.30]), nor between patients with and without endocrine-metabolic disorders affecting bone metabolism. Our findings from a large population with thalassemia major show that TBS is a valuable tool to assess noninvasively bone quality, and it may be related to fragility fracture risk in thalassemic osteopathy.
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Affiliation(s)
- M Baldini
- Rare Diseases Center, Department of Medicine and Medical Specialities, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy,
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Hamidieh AA, Mohajeri-Tehrani MR, Behfar M, Vaghari-Meher N, Alimoghaddam K, Mohseni F, Ghavamzadeh A, Larijani B, Hamidi Z. Comparison of bone mineral density changes in pediatric thalassemic patients with and without hematopoietic stem cell transplant. EXP CLIN TRANSPLANT 2014; 13:173-8. [PMID: 25394210 DOI: 10.6002/ect.2014.0178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Beta thalassemia major is a genetic hemoglobin disorder that affects bone density. The disease leads to deteriorating bone structure but can be treated with hematopoietic stem cell transplant. We aimed to assess bone mineral density changes in pediatric beta thalassemia major patients who had undergone a hematopoietic stem cell transplant compared with similarly affected patients who had not undergone a hematopoietic stem cell transplant. MATERIALS AND METHODS Forty beta thalassemia major patients, 20 transplant and 20 nontransplant, younger than 16 years of age were enrolled. The mean age of transplant patients was 8.15 years and nontransplant patients was 9.5 years (P = .242). The female:male ratio was 1:1 in both groups. None of the patients reached puberty during this study. Bone mineral density was evaluated in transplant patients before and 1 year after hematopoietic stem cell transplant. Bone mineral density of nontransplant patients also was evaluated 1 year after their initial bone mineral density test. A Norland XR-46 densitometer was used to make all bone mineral density measurements. None of the patients had a z score < -2. RESULTS Mean bone mineral density changes in the femur and spine during this study were 0.008 ± 0.075 g/cm2 and 0.048 ± 0.045 g/cm2 in transplant patients and 0.045 ± 0.072 g/cm2 and 0.036 ± 0.058 g/cm2 in nontransplant patients. No significant differences between bone mineral density changes in transplant and nontransplant patients were detected during the study. CONCLUSIONS No significant effects on bone mineral density were detected in hematopoietic stem cell transplant pediatric beta thalassemia major patients compared with similarly affected nontransplant patients. Studies of longer duration may be required to identify significant changes in bone mineral density in hematopoietic stem cell transplant patients.
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Affiliation(s)
- Amir Ali Hamidieh
- From the Hematology-Oncology and Stem Cell Transplantation Research Center/Tehran University of Medical Sciences, Tehran, Iran
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Chirico V, Rigoli L, Lacquaniti A, Salpietro V, Piraino B, Amorini M, Salpietro C, Arrigo T. Endocrinopathies, metabolic disorders, and iron overload in major and intermedia thalassemia: serum ferritin as diagnostic and predictive marker associated with liver and cardiac T2* MRI assessment. Eur J Haematol 2014; 94:404-12. [PMID: 25200112 DOI: 10.1111/ejh.12444] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2014] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Endocrinopathies and metabolic disorders-characterized β thalassemic (βT) patients and the prevention and treatment of these comorbidities are important targets to be achieved. The aim of the study was to analyze the diagnostic and prognostic role of ferritin for endocrinopathies and metabolic disorders in βT patients. The ability of iron chelators to treat iron overload and to prevent or reverse metabolic disorders and endocrinopathies was also evaluated. PATIENTS AND METHODS Seventy-two βT patients were treated with different chelation strategies during the study. Receiver operating characteristics analysis was employed to calculate the area under the curve for serum ferritin to find the best cutoff values capable of identifying endocrine dysfunction in thalassemic patients. Kaplan-Meier curves were generated to assess the incidence of endocrinopathy. Adjusted risk estimates for endocrinopathy were calculated using univariate followed by multivariate Cox proportional hazard regression analysis. RESULTS High ferritin levels were observed in patients with hypothyroidism [1500 (872.5-2336.5) μg/L], hypogonadism [878 (334-2010) μg/L], and in patients with hypoparathyroidism or osteoporosis [834 (367-1857) μg/L]. A strict correlation between ferritin and T2* magnetic resonance imaging of heart (r = -0.64; P:0.0006) and liver (r = -0.40; P:0.03) values was observed. Patients with ferritin values above 1800 μg/L experienced a significantly faster evolution to hypothyroidism [log-rank (χ(2) ):7.7; P = 0.005], hypogonadism [log-rank (χ(2) ):10.7; P = 0.001], and multiple endocrinopathies [log-rank (χ(2) ):5.72; P = 0.02]. Ferritin predicted high risk of endocrine dysfunction independently of confounding factors (HR:1.23; P < 0.0001). The intensification of chelation therapy led to an amelioration of hypothyroidism. CONCLUSIONS Ferritin represents a prognostic marker for βT patients and a predictive factor for progression to endocrine dysfunctions. Intensive chelation therapy allows the reversibility of hypothyroidism.
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Affiliation(s)
- Valeria Chirico
- Department of Pediatric Sciences, University of Messina, Messina, Italy
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Rossi F, Perrotta S, Bellini G, Luongo L, Tortora C, Siniscalco D, Francese M, Torella M, Nobili B, Di Marzo V, Maione S. Iron overload causes osteoporosis in thalassemia major patients through interaction with transient receptor potential vanilloid type 1 (TRPV1) channels. Haematologica 2014; 99:1876-84. [PMID: 25216685 DOI: 10.3324/haematol.2014.104463] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The pathogenesis of bone resorption in β-thalassemia major is multifactorial and our understanding of the underlying molecular and cellular mechanisms remains incomplete. Considering the emerging importance of the endocannabinoid/endovanilloid system in bone metabolism, it may be instructive to examine a potential role for this system in the development of osteoporosis in patients with β-thalassemia major and its relationship with iron overload and iron chelation therapy. This study demonstrates that, in thalassemic-derived osteoclasts, tartrate-resistant acid phosphatase expression inversely correlates with femoral and lumbar bone mineral density, and directly correlates with ferritin levels and liver iron concentration. The vanilloid agonist resiniferatoxin dramatically reduces cathepsin K levels and osteoclast numbers in vitro, without affecting tartrate-resistant acid phosphatase expression. The iron chelators deferoxamine, deferiprone and deferasirox decrease both tartrate-resistant acid phosphatase and cathepsin K expression, as well as osteoclast activity. Taken together, these data show that transient receptor potential vanilloid type 1 activation/desensitization influences tartrate-resistant acid phosphatase expression and activity, and this effect is dependent on iron, suggesting a pivotal role for iron overload in the dysregulation of bone metabolism in patients with thalassemia major. Our applied pharmacology provides evidence for the potential of iron chelators to abrogate these effects by reducing osteoclast activity. Whether iron chelation therapy is capable of restoring bone health in humans requires further study, but the potential to provide dual benefits for patients with β-thalassemia major -preventing iron-overload and alleviating associated osteoporotic changes - is exciting.
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Affiliation(s)
- Francesca Rossi
- Department of Woman, Child and of General and Specialist Surgery, Second University of Naples
| | - Silverio Perrotta
- Department of Woman, Child and of General and Specialist Surgery, Second University of Naples;
| | - Giulia Bellini
- Department of Experimental Medicine, Second University of Naples
| | - Livio Luongo
- Department of Experimental Medicine, Second University of Naples
| | - Chiara Tortora
- Department of Woman, Child and of General and Specialist Surgery, Second University of Naples; Department of Experimental Medicine, Second University of Naples
| | - Dario Siniscalco
- Department of Experimental Medicine, Second University of Naples
| | - Matteo Francese
- Department of Woman, Child and of General and Specialist Surgery, Second University of Naples
| | - Marco Torella
- Department of Woman, Child and of General and Specialist Surgery, Second University of Naples
| | - Bruno Nobili
- Department of Woman, Child and of General and Specialist Surgery, Second University of Naples
| | - Vincenzo Di Marzo
- Institute of Biomolecular Chemistry and Institute of Cybernetics, National Research Council, Pozzuoli; and The Endocannabinoid Research Group, Pozzuoli, Italy
| | - Sabatino Maione
- Department of Experimental Medicine, Second University of Naples; The Endocannabinoid Research Group, Pozzuoli, Italy
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Yacobovich J, Tamary H. Thalassemia major and sickle cell disease in adolescents and young adults. Acta Haematol 2014; 132:340-7. [PMID: 25228560 DOI: 10.1159/000360235] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The increased longevity of patients with thalassemia and sickle cell disease (SCD) introduces new clinical challenges due to the accumulation of disease-related morbidity, psychosocial issues and health care adjustments. Patients with thalassemia major now live into adulthood without suffering heart failure but must confront delayed puberty, impaired fertility and progressive bone disease. The increased survival in SCD brings to the front previously unrecognized complications including pulmonary hypertension, silent cerebral infarcts and also reproductive dysfunction. Adolescents and young adults (AYAs) have age-related psychosocial needs in their transition from the pediatric health care environment to the adult system. In this review we present the uniquely age-related medical issues facing the AYA thalassemia and SCD cohort in their transition into adulthood.
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Affiliation(s)
- Joanne Yacobovich
- Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
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Yassin MA, Soliman AT, De Sanctis V, Abdelrahman MO, Aziz Bedair EM, AbdelGawad M. Effects of the anti-receptor activator of nuclear factor kappa B ligand denusomab on beta thalassemia major-induced osteoporosis. Indian J Endocrinol Metab 2014; 18:546-551. [PMID: 25143915 PMCID: PMC4138914 DOI: 10.4103/2230-8210.137516] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Osteoporosis represents the second most common cause of endocrinopathy in patients with beta thalassemia major (BTM). Some drugs proved effective to reduce vertebral and non-vertebral fracture risk. Denosumab is a fully human monoclonal antibody to the receptor activator of nuclear factor kappa B ligand (RANKL), a member of the tumor necrosis factor receptor superfamily essential for osteoclastogenesis. The efficacy and safety of denosumab in BTM-induced osteoporosis has not been tested. OBJECTIVE To evaluate the efficacy and safety of anti-RANKL on the biochemical and radiological parameters of bone mineralization in patients with BTM-induced osteoporosis. DESIGN The study population was selected using the random sampling method from the patient's database of our thalassemia clinic. Transfusion-dependent BTM patients above 18 years with no history of treatment with bisphosphonates were randomly selected. Bone mineral density (BMD) of the lumbar spine (LS) and right femoral neck (FN) were measured by dual energy X-ray absorption (DEXA) scan using a calibrated method. Independent factors likely to be associated with low bone mass were determined and included in the analysis to ascertain possible associations. PATIENTS AND METHODS We studied 30 patients with BTM-induced osteoporosis as per World Health Organization criteria (T Score of less than - 1.0 being defined as osteopenic and a T Score of less than - 2.5 being referred as osteoporotic). 19 males and 11 females aged between 18 and 32 years, with full pubertal development (Tanner's stage 5) at the time of the study. Their mean serum ferritin concentration was 3557 ng ± 1488 ng/ml. Every patient underwent DEXA scan as a baseline and after 12 months of denosumab therapy. Biochemical evaluation including serum concentrations of creatinine, Na, K, calcium, phosphorus, parathormone, bone specific alkaline phosphatase and type 1 collagen carboxy telopetide (ICCT) using enzyme-linked immunosorbent assay (Nordic Bioscience Diagnostics A/S) was done at baseline, after a month and then every 3 months for 12 months after starting denosumab. 60 mg of denosumab was administered subcutaneously twice yearly for a year. The mean BMD T Scores at baseline were -2.7 at the LS and -2.1 at the FN. RESULTS Denosumab therapy for a year was associated with a significant increase in BMD of 9.2% (95% confidence interval [CI], 8.2-10.1) at the LS and 6.0% (95% CI, 5.2-6.7) at the FN. Denosumab treatment decreased serum ICCT levels by 56% at 1 month and normalized them in all patients at 1 year. Significant correlations were found between BMD T Score before and 1 year after denosumab in LS (r = 0.752, P < 0.001) and FN (r = 0.758 P < 0.001), respectively. The most common side effects were pain in the back and extremities (12%) and nausea (10%). Asymptomatic hypocalcaemia occurred in two patients. CONCLUSION Denosumab therapy for a year significantly increased BMD density at LS and FN of patients with BTM and was associated with a rapid and sustained reduction in ICCT levels. Further studies are required to confirm long-term effects of this therapy.
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Affiliation(s)
| | - Ashraf T. Soliman
- Department of Pediatrics, University of Alexandria, Alexandria, Egypt
| | - Vincenzo De Sanctis
- Department of Pediatrics and Pediatric and Adolescent Outpatient Clinic, Quisisana Hospital, 44121 Ferrara, Italy
| | | | | | - Manal AbdelGawad
- Department of Pediatrics, University of Alexandria, Alexandria, Egypt
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Tzoulis P, Ang AL, Shah FT, Berovic M, Prescott E, Jones R, Barnard M. Prevalence of Low Bone Mass and Vitamin D Deficiency in β-Thalassemia Major. Hemoglobin 2014; 38:173-8. [DOI: 10.3109/03630269.2014.905792] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Baldini M, Forti S, Orsatti A, Ulivieri FM, Airaghi L, Zanaboni L, Cappellini MD. Bone disease in adult patients with β-thalassaemia major: a case-control study. Intern Emerg Med 2014; 9:59-63. [PMID: 22179745 DOI: 10.1007/s11739-011-0745-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 11/28/2011] [Indexed: 01/19/2023]
Abstract
Despite the extraordinary improvements carried out in diagnostic and therapeutic management of thalassaemia major over the past few decades, bone demineralization is still a common finding, even in optimally treated patients. The relationships between bone density and several clinical characteristics or hematological markers have been described, and many factors contributing to demineralization have been identified; among them endocrine complications seem to play an important role. Nevertheless, the complex etiological mechanisms of this heterogeneous osteopathy still remains incompletely clarified. While previous studies focused on the characteristics of thalassaemic patients affected from bone demineralization, we conducted a case-control study focused on thalassaemic patients free from bone disease, aimed to detect the distinctive characteristics and any possible protective feature. Among a large cohort of 150 adult patients with β-thalassaemia major, we enrolled 20 patients with normal bone mineralization and 20 patients with osteoporosis matched for gender, BMI, age at first transfusion, serum ferritin and pre-transfusional hemoglobin (Hb) levels. The differences in demographic, clinical and endocrinological profiles were investigated, correcting for physical and hematological features known as confounding variables. The comparison of the two groups for biochemical parameters and endocrine function showed a protective role of normal gonadic function and IGF-1 levels against osteoporosis, and a similar influence of hypoparathyroidism. Treatment-corrected hypothyroidism and diabetes seemed not to affect bone mineralization. In conclusion, from a different perspective our results corroborate the role of endocrinopathies in thalassaemic osteopathy, and once again underline the crucial importance of an early and multi-disciplinary intervention in preventing bone complications in thalassaemic patients.
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Affiliation(s)
- Marina Baldini
- U.O. Medicina Interna 1 A, Fondazione Ca' Granda, Ospedale Maggiore Policlinico (IRCCS), via F. Sforza 35, 20122, Milan, Italy,
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Whitehurst JL, Reid CM. Vitamin D deficiency as a cause of chronic pain in the palliative medicine clinic: two case reports. Palliat Med 2014; 28:87-9. [PMID: 24280278 DOI: 10.1177/0269216313511142] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Vitamin D deficiency is common in the general population and has been implicated as a cause of chronic pain. The palliative care population has a number of risk factors for vitamin D deficiency. We present two cases of unexplained pain in patients attending the palliative medicine outpatient clinic that improved after vitamin D replacement. CASES Case 1 is a 46-year-old man with thalassaemia intermedia and back and leg pain without a clear cause. Case 2 is a 28-year-old woman undergoing treatment for cervical cancer whose initial disease and treatment-related abdominal pain resolved but subsequently reported ongoing non-specific aches and pains. Case management: Both patients were found to have vitamin D levels <50 nmol/L and were treated with vitamin D replacement therapy. Case outcome: Following vitamin D replacement therapy, pain resolved in both patients allowing a reduction in analgesic therapy. CONCLUSIONS The prevalence of vitamin D deficiency in the palliative care population merits further investigation, since these patients are at high risk of deficiency. Having an index of suspicion, particularly in those patients with known risk factors and pain that is not fully explained, may result in better pain control and functional outcomes.
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Marenzana M, Arnett TR. The Key Role of the Blood Supply to Bone. Bone Res 2013; 1:203-15. [PMID: 26273504 DOI: 10.4248/br201303001] [Citation(s) in RCA: 201] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 07/22/2013] [Indexed: 12/16/2022] Open
Abstract
The importance of the vascular supply for bone is well-known to orthopaedists but is still rather overlooked within the wider field of skeletal research. Blood supplies oxygen, nutrients and regulatory factors to tissues, as well as removing metabolic waste products such as carbon dioxide and acid. Bone receives up to about 10% of cardiac output, and this blood supply permits a much higher degree of cellularity, remodelling and repair than is possible in cartilage, which is avascular. The blood supply to bone is delivered to the endosteal cavity by nutrient arteries, then flows through marrow sinusoids before exiting via numerous small vessels that ramify through the cortex. The marrow cavity affords a range of vascular niches that are thought to regulate the growth and differentiation of hematopoietic and stromal cells, in part via gradients of oxygen tension. The quality of vascular supply to bone tends to decline with age and may be compromised in common pathological settings, including diabetes, anaemias, chronic airway diseases and immobility, as well as by tumours. Reductions in vascular supply are associated with bone loss. This may be due in part to the direct effects of hypoxia, which blocks osteoblast function and bone formation but causes reciprocal increases in osteoclastogenesis and bone resorption. Common regulatory factors such as parathyroid hormone or nitrates, both of which are potent vasodilators, might exert their osteogenic effects on bone via the vasculature. These observations suggest that the bone vasculature will be a fruitful area for future research.
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Affiliation(s)
- Massimo Marenzana
- Department of Bioengineering, Imperial College London and Kennedy Institute of Rheumatology, University of Oxford , UK
| | - Timothy R Arnett
- Department of Cell and Developmental Biology, University College London , UK
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37
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Lim HJ, Bang MS, Jung HM, Shin JI, Chun GS, Oh CH. A 635-nm light-emitting diode (LED) therapy inhibits bone resorptive osteoclast formation by regulating the actin cytoskeleton. Lasers Med Sci 2013; 29:659-70. [PMID: 23812848 DOI: 10.1007/s10103-013-1363-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 05/28/2013] [Indexed: 11/26/2022]
Abstract
Bone diseases such as osteoporosis are mainly caused by upregulated activity of osteoclasts. The present study was designed to examine the effects of light-emitting diode (LED) irradiation on the formation and activity of multinucleated osteoclasts, specifically "round-shaped" osteoclast cells (ROC) in different cell types derived from mouse. After 635-nm LED irradiation, the cell viability was evaluated by MTT assay. The amount of total tartrate-resistant acid phosphatase (TRAP) + osteoclast and the number of ROC cells were also estimated by TRAP solution assay and TRAP staining, respectively. Actin rings were stained with rhodamine-conjugated phalloidin, and resorption assay was performed by dentin slices. In addition, gene expression levels between the control and irradiation groups were evaluated by RT-PCR. In a morphological analysis, the formation of ROC was significantly inhibited by 635-nm LED irradiation in the different cell types. Actin rings were seen at cell peripheries in most ROC cells of the control group, but patches containing disorganized actin were found in the irradiation group. Both the number of ROCs and bone resorption activity were much lower in the irradiation group than in the control group. Also, the gene expression levels involved in actin ring formation such as integrin β3 and c-Src decreased in RT-PCR analysis. Overall, 635-nm LED therapy may play a pivotal role in regulating bone remodeling, and it may prove to be a valuable tool to prevent bone loss in osteoporosis and other resorptive bone diseases.
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Affiliation(s)
- Hyun-Ju Lim
- Department of Medical Laser, Graduate school, Dankook University, Cheonan, 330-714, South Korea
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38
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Aslan I, Canatan D, Balta N, Kacar G, Dorak C, Ozsancak A, Oguz N, Cosan R. Bone mineral density in thalassemia major patients from antalya, Turkey. Int J Endocrinol 2012; 2012:573298. [PMID: 22778734 PMCID: PMC3388304 DOI: 10.1155/2012/573298] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 04/23/2012] [Accepted: 04/25/2012] [Indexed: 11/17/2022] Open
Abstract
Aim. We assessed the bone mineral density and related parameters in nine adults, thirty-eight pubertal, prepubertal totally forty-seven patients with thalassemia major living in Antalya, Turkey. Materials and Methods. We measured height and pubertal staging in last five years by six-month intervals. Average ferritin and hemoglobin concentrations were calculated for last three years. The levels of hydroxyproline, calcium, phosphorus, and creatinine were measured in 24 h urine, and those of parathormone, IGF 1, osteocalcine, alkaline phosphatase, calcium, ionized calcium, magnesium, phosphorus, creatine, blood glucose, thyroid stimulating hormone, alanine transaminase, and aspartate transaminase were determined in serum, and also the bone mineral density was measured. Results. The average L1-L4 bone mass density was 27.1 ± 10.1 g cm(-2); the average bone mineral content was 0.65 ± 0.11 g. of the patients with a Z-score under 2.5. A moderate relationship was found between the bone mass density age and height. Subjects in low pubertal staging and short stature (<3% percentile) have significantly lower bone mass densities P < 0.001. Conclusion. he prevalence of osteoporosis is high in patients with thalassemia major, possibly related to delayed puberty.
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Affiliation(s)
- Ibrahim Aslan
- Department of Endocrinology and Metabolism, Antalya Education and Research Hospital, 07100 Antalya, Turkey
- *Ibrahim Aslan:
| | - Duran Canatan
- Hemoglobinopathy Diagnosis Center, Mediterranean Blood Diseases Foundation and Thalassemia Federation of Turkey, Antalya, Turkey
| | - Nihal Balta
- Antalya State Hospital, 07100 Antalya, Turkey
| | - Gulizar Kacar
- Department of Nuclear Medicine, Antalya Education and Research Hospital, 07100 Antalya, Turkey
| | | | | | - Nurgul Oguz
- Antalya State Hospital, 07100 Antalya, Turkey
| | - Ruya Cosan
- Antalya State Hospital, 07100 Antalya, Turkey
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Pirinççioğlu AG, Akpolat V, Köksal O, Haspolat K, Söker M. Bone mineral density in children with beta-thalassemia major in Diyarbakir. Bone 2011; 49:819-23. [PMID: 21798385 DOI: 10.1016/j.bone.2011.07.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 07/08/2011] [Accepted: 07/11/2011] [Indexed: 10/18/2022]
Abstract
Bone mineral status has extensively been investigated in adult thalassemics but less in thalassemic children. This study involves measurements of the bone mineral density (BMD), various demographic and biochemical parameters in 47 thalassemic children and 50 healthy controls with comparable age, sex, socioeconomic and regional distribution. Patients have significantly higher aspartate aminotransferase, alanine aminotransferase, phosphorous, osteocalcin, serum carboxy terminal teleopeptide fragment of type I collagen, intact parathyroid hormone (iPTH) and ferritin levels while they have significantly lower 25-hydroxy vitamin D (25OH-D), alkaline phosphatase and z-scores both at lumbar and femur compared to controls. Patients with high iPTH (30%) had significantly lower z-scores and 25OH-D while larger osteocalcin. We conclude that a significantly lower BMD in beta-thalassemic children compared with their healthy counterparts is a complex process and may partially attributed to their slower physical development, caused by iron overload and chelation therapy which may influence the liver as well as the endocrine tissues.
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Affiliation(s)
- Ayfer Gözü Pirinççioğlu
- Department of Pediatrics, Faculty of Medicine, University of Dicle, 21280, Diyarbakir, Turkey.
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Kyrgidis A, Tzellos TG, Toulis K, Antoniades K. The facial skeleton in patients with osteoporosis: a field for disease signs and treatment complications. J Osteoporos 2011; 2011:147689. [PMID: 21403823 PMCID: PMC3042625 DOI: 10.4061/2011/147689] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2010] [Revised: 12/31/2010] [Accepted: 01/15/2011] [Indexed: 01/04/2023] Open
Abstract
Osteoporosis affects all bones, including those of the facial skeleton. To date the facial bones have not drawn much attention due to the minimal probability of morbid fractures. Hearing and dentition loss due to osteoporosis has been reported. New research findings suggest that radiologic examination of the facial skeleton can be a cost-effective adjunct to complement the early diagnosis and the follow up of osteoporosis patients. Bone-mass preservation treatments have been associated with osteomyelitis of the jawbones, a condition commonly described as osteonecrosis of the jaws (ONJ). The facial skeleton, where alimentary tract mucosa attaches directly to periosteum and teeth which lie in their sockets of alveolar bone, is an area unique for the early detection of osteoporosis but also for the prevention of treatment-associated complications. We review facial bone involvement in patients with osteoporosis and we present data that make the multidisciplinary approach of these patients more appealing for both practitioners and dentists. With regard to ONJ, a tabular summary with currently available evidence is provided to facilitate multidisciplinary practice coordination for the treatment of patients receiving bisphosphonates.
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Affiliation(s)
- Athanassios Kyrgidis
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
- Department of Pharmacology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
| | - Thrasivoulos-George Tzellos
- Department of Pharmacology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
| | - Konstantinos Toulis
- Department of Endocrinology, 424 Military Hospital, Thessaloniki 56429, Greece
| | - Konstantinos Antoniades
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
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