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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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Shah N, Khadilkar A, Ekbote V, Mughal Z, Gondhalekar K, Khadilkar S, Ramanan V, Khadilkar V, Padidela R. DXA and pQCT derived parameters in Indian children with beta thalassemia major - A case controlled study. Bone 2021; 143:115730. [PMID: 33137537 DOI: 10.1016/j.bone.2020.115730] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/26/2020] [Accepted: 10/20/2020] [Indexed: 01/19/2023]
Abstract
Children with beta thalassemia major (BTM) are known to have reduced bone mass which increases incidence of non-traumatic fractures. Few studies have assessed prevalence of fractures and bone health in underprivileged children with BTM. Our objectives were to 1) determine prevalence of fractures in underprivileged Indian children with BTM, 2) assess size corrected bone density and bone geometry using Dual x-ray absorptiometry (DXA) and peripheral quantitative computerized tomography (pQCT) in these children and healthy controls 3) determine predictors of fractures in children with BTM 4) compare differences in bone density between children with BMT with and without fractures. Bone mineral content and areal bone mineral density (aBMD) of lumbar spine and whole body and vertebral fracture assessment (VFA) was performed by DXA in 334 children (3-18 years, 167 BTM + 167 controls). Volumetric BMD (vBMD) and bone geometry were assessed by pQCT (subset, 70 BTM, 70 healthy) at distal radius. Children with BTM had higher prevalence of vertebral and long bone fractures (p < 0.05). DXA aBMD was lower in children with BTM (p < 0.05), whereas, lumbar spine bone mineral apparent density (LSBMAD) was higher (p > 0.05). Children with BTM had lower total distal radial vBMD, cortical vBMD and strength strain index (SSI) at 66% site whereas, distal radial trabecular vBMD at 4% was higher (p < 0.05). On height adjustment, children with BTM had lower muscle area and cortical thickness and higher marrow area (p < 0.05) at 66% site. Age, body size, total body less head (TBLH) aBMD and strength strain index (SSI) were important predictors of fractures in children with BTM. Thus, children with BTM had higher prevalence of non-traumatic fractures. Despite lower areal and volumetric densities, they had higher LSBMAD and trabecular densities which may be attributed to erythroid hyperplasia and iron deposition due to inadequate transfusion and chelation. As LSBMAD is raised in these children, it is unlikely to identify BTM subjects at risk of fracture; VFA thus maybe useful in identifying asymptomatic vertebral fractures.
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Affiliation(s)
- Nikhil Shah
- Department of Growth and Pediatric Endocrinology, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India
| | - Anuradha Khadilkar
- Department of Growth and Pediatric Endocrinology, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India.
| | - Veena Ekbote
- Department of Growth and Pediatric Endocrinology, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India
| | - Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University, NHS Foundation Trust, Manchester, UK
| | - Ketan Gondhalekar
- Department of Growth and Pediatric Endocrinology, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India
| | - Shachi Khadilkar
- Department of Growth and Pediatric Endocrinology, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India
| | - Vijay Ramanan
- Clinical Hematology and Transplant, Yashoda Hematology Clinic, Pune, Maharashtra, India
| | - Vaman Khadilkar
- Department of Growth and Pediatric Endocrinology, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India
| | - Raja Padidela
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University, NHS Foundation Trust, Manchester, UK
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Zoledronic Acid for Treatment of Low Bone Mineral Density in Patients with Beta Thalassemia Major. Indian J Hematol Blood Transfus 2018; 34:648-652. [PMID: 30369735 DOI: 10.1007/s12288-018-0953-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 03/21/2018] [Indexed: 01/19/2023] Open
Abstract
To determine the efficacy of zoledronic acid (ZA) in thalassemia major associated low bone mineral density. Prospective, open label, single arm trial. Bone mineral density (BMD) at lumbar, hip and forearm region were performed at baseline and after 1 year of therapy. Initial, 9 patients received a first dose of 4 mg. Due to severe adverse effects, further doses for these patients and all new recruited patients were 1 mg once every 3 months for 4 doses. All patients were receiving 500 mg of calcium carbonate twice daily and 0.25 μg alfacalcidol once daily before and during the entire study period. Dual energy X-ray absoptiometry was performed at baseline and after 1 year. Twenty-seven patients with transfusion dependent thalassemia with a median age 19.5 year (15-38 years) were eligible for ZA treatment. Seven patients had bony pains. Four patients developed grade 4 hypocalcemia (3 developed tetany) and 2 developed infusion related toxicity with initial dose of 4 mg. One mg dose was well tolerated. At the end of 1 year, bone pains had completely resolved. There was significant increase in BMD at lumbar (p = 0.002) and forearm regions (p = 0.04) and intertrochantric area (p = 0.041). The % change in BMD at 1 year was +3.7 ± 3.2%. ZA is an efficacious agent in treatment of low BMD in these patients. ZA produces significant adverse reactions at 4 mg dose but 1 mg dose is well tolerated and is efficacious.
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Naithani R, Seth T, Tandon N, Chandra J, Pati H, Saxena R, Choudhry VP. Fractures and Low Bone Mineral Density in Patients with Beta Thalassemia Major. Indian J Hematol Blood Transfus 2017; 34:163-165. [PMID: 29398822 DOI: 10.1007/s12288-017-0820-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 04/19/2017] [Indexed: 12/01/2022] Open
Affiliation(s)
- Rahul Naithani
- 1Department of Hematology, All India Institute of Medical Science, New Delhi, India.,4Division of Hematology and Bone Marrow Transplantation, Max Super Speciality Hospital, New Delhi, India
| | - Tulika Seth
- 1Department of Hematology, All India Institute of Medical Science, New Delhi, India
| | - Nikhil Tandon
- 2Department of Endocrinology and Metabolism, All India Institute of Medical Science, New Delhi, India
| | - Jagdish Chandra
- 3Division of Pediatric Hematology-Oncology, Department of Pediatrics, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi, India
| | - H Pati
- 1Department of Hematology, All India Institute of Medical Science, New Delhi, India
| | - Renu Saxena
- 1Department of Hematology, All India Institute of Medical Science, New Delhi, India
| | - V P Choudhry
- 1Department of Hematology, All India Institute of Medical Science, New Delhi, India
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Dede AD, Trovas G, Chronopoulos E, Triantafyllopoulos IK, Dontas I, Papaioannou N, Tournis S. Thalassemia-associated osteoporosis: a systematic review on treatment and brief overview of the disease. Osteoporos Int 2016; 27:3409-3425. [PMID: 27503175 DOI: 10.1007/s00198-016-3719-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/20/2016] [Indexed: 01/19/2023]
Abstract
Thalassemia-associated osteoporosis constitutes a major complication in patients with thalassemia. This review presents the existing studies on the treatment of thalassemia-associated osteoporosis and discusses the management of this debilitating complication. A brief presentation of the disease characteristics and pathogenetic mechanisms is also provided. The life expectancy of patients with thalassemia has increased markedly in recent years resulting in the aging of the population and the emergence of new comorbidities. The majority of patients with thalassemia have low bone mineral density and experience lifelong fracture rates as high as 71 %. The pathogenesis of thalassemia-associated osteoporosis (TAO) is multifactorial with anemia and iron overload playing crucial role in its development. Data concerning the prevention and treatment of TAO are extremely limited. We performed a literature research in Pubmed and Scopus to identify interventional studies evaluating the effects of various agents on TAO. Seventeen studies were retrieved. We present the results of these studies as well as a brief overview of TAO including presentation, pathogenesis, and management. Most of the studies identified are of poor quality, are not randomized controlled, and include small number of participants. There are no data concerning effects on fracture rates. Bisphosphonates are the most widely studied agents and among them zoledronic acid is the most well studied. Hormone replacement treatment (HRT) shows beneficial but small effects. Denosumab and strontium ranelate have each been evaluated in only a single study, while there are no data about the effects of anabolic agents. Given the increased life expectancy and the increase in fracture rates with age, more data about the management of TAO are warranted. Moreover, due to the need for lifelong management starting at young age, careful treatment plans which may include sequential treatment may often be required. However, currently, there are no relevant data available.
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Affiliation(s)
- A D Dede
- Laboratory for Research of Musculoskeletal System "Theodoros Garofalidis", KAT Hospital, University of Athens, 10 Athinas Str., Kifissia, 145 61, Athens, Greece.
| | - G Trovas
- Laboratory for Research of Musculoskeletal System "Theodoros Garofalidis", KAT Hospital, University of Athens, 10 Athinas Str., Kifissia, 145 61, Athens, Greece
| | - E Chronopoulos
- Orthopedic Department, Konstantopoulion Hospital, University of Athens, Nea Ionia, Greece
| | - I K Triantafyllopoulos
- Laboratory for Research of Musculoskeletal System "Theodoros Garofalidis", KAT Hospital, University of Athens, 10 Athinas Str., Kifissia, 145 61, Athens, Greece
| | - I Dontas
- Laboratory for Research of Musculoskeletal System "Theodoros Garofalidis", KAT Hospital, University of Athens, 10 Athinas Str., Kifissia, 145 61, Athens, Greece
| | - N Papaioannou
- Laboratory for Research of Musculoskeletal System "Theodoros Garofalidis", KAT Hospital, University of Athens, 10 Athinas Str., Kifissia, 145 61, Athens, Greece
| | - S Tournis
- Laboratory for Research of Musculoskeletal System "Theodoros Garofalidis", KAT Hospital, University of Athens, 10 Athinas Str., Kifissia, 145 61, Athens, Greece
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Scacchi M, Danesi L, Cattaneo A, Sciortino G, Radin R, Ambrogio AG, Vitale G, D'Angelo E, Mirra N, Zanaboni L, Arvigo M, Boschetti M, Ferone D, Marzullo P, Baldini M, Cassinerio E, Cappellini MD, Persani L, Cavagnini F. Bone turnover and mineral density in adult thalassemic patients: relationships with growth hormone secretory status and circulating somatomedins. Endocrine 2016; 53:551-7. [PMID: 26825070 DOI: 10.1007/s12020-016-0865-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 01/11/2016] [Indexed: 11/30/2022]
Abstract
Previous evidence supports a role for growth hormone (GH)-insulin-like growth factor (IGF)-I deficiency in the pathophysiology of osteopenia/osteoporosis in adult thalassemia. Moreover, serum IGF-II has never been studied in this clinical condition. Thus, we elected to study the GH secretory status and the levels of circulating somatomedins, correlating these parameters with bone mineral density (BMD) and biochemical markers of bone turnover. A hundred and thirty-nine normal weight adult thalassemic patients (72 men and 67 women) were studied. Lumbar and femoral neck BMD were measured in 106/139 patients. Sixty-eight patients underwent growth hormone releasing hormone plus arginine testing. Measurement of baseline IGF-I and IGF-II was performed in all patients, while osteocalcin, C-terminal telopeptide of type I collagen (CTx), and urinary cross-linked N-telopeptides of type I collagen (NTx) were assayed in 95 of them. Femoral and lumbar osteoporosis/Z score below the expected range for age were documented in 61.3 and in 56.6 % of patients, respectively. Severe GH deficiency (GHD) was demonstrated in 27.9 % of cases, whereas IGF-I SDS was low in 86.3 %. No thalassemic patients displayed circulating levels of IGF-II below the reference range. GH peaks were positively correlated with femoral, but not lumbar, Z score. No correlations were found between GH peaks and osteocalcin, CTx and NTx. GH peaks were positively correlated with IGF-I values, which in their turn displayed a positive correlation with osteocalcin, CTx, and NTx. No correlations emerged between IGF-I values and either femoral or lumbar Z scores. No correlations were found between IGF-II and any of the following parameters: GH peaks, osteocalcin, CTx, NTx, femoral Z score, and lumbar Z score. Our study, besides providing for the first time evidence of a normal IGF-II production in thalassemia, contributes to a better understanding of the involvement of the somatotropin-somatomedin axis in the pathophysiology of bone demineralization in this disease. In particular, the contribution of GHD to femoral osteoporosis appears to be likely mediated by locally produced rather than circulating IGF-I.
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Affiliation(s)
- Massimo Scacchi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
- Ospedale San Giuseppe IRCCS, Division of Endocrinology and Metabolic Diseases, Istituto Auxologico Italiano, Oggebbio-Piancavallo, Verbania, Italy.
| | - Leila Danesi
- Ospedale San Luca IRCCS, Division of Endocrinology and Metabolic Diseases, Istituto Auxologico Italiano, Milan, Italy
| | - Agnese Cattaneo
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giovanna Sciortino
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Raffaella Radin
- Ospedale San Luca IRCCS, Division of Endocrinology and Metabolic Diseases, Istituto Auxologico Italiano, Milan, Italy
| | - Alberto Giacinto Ambrogio
- Ospedale San Luca IRCCS, Division of Endocrinology and Metabolic Diseases, Istituto Auxologico Italiano, Milan, Italy
| | - Giovanni Vitale
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Ospedale San Luca IRCCS, Division of Endocrinology and Metabolic Diseases, Istituto Auxologico Italiano, Milan, Italy
| | - Emanuela D'Angelo
- Second Pediatric Clinic, University of Milan, Fondazione Policlinico Mangiagalli Regina Elena, Milan, Italy
| | - Nadia Mirra
- Second Pediatric Clinic, University of Milan, Fondazione Policlinico Mangiagalli Regina Elena, Milan, Italy
| | - Laura Zanaboni
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Marica Arvigo
- Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa, Italy
| | - Mara Boschetti
- Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa, Italy
| | - Diego Ferone
- Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa, Italy
| | - Paolo Marzullo
- Ospedale San Giuseppe IRCCS, Division of Endocrinology and Metabolic Diseases, Istituto Auxologico Italiano, Oggebbio-Piancavallo, Verbania, Italy
- Department of Translational Medicine, Università del Piemonte Orientale "A. Avogadro", Novara, Italy
| | - Marina Baldini
- Department of Medicine and Medical Specialties, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena Cassinerio
- Department of Medicine and Medical Specialties, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Medicine and Medical Specialties, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luca Persani
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Ospedale San Luca IRCCS, Division of Endocrinology and Metabolic Diseases, Istituto Auxologico Italiano, Milan, Italy
| | - Francesco Cavagnini
- Laboratory of Neuroendocrine Research, Istituto Auxologico Italiano, Milan, Italy
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