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Hattapoğlu S, Çetinçakmak MG. Evaluation of iron overload in visceral organs in thalassemia patients by point shear-wave elastography. Ir J Med Sci 2024:10.1007/s11845-024-03719-0. [PMID: 38789665 DOI: 10.1007/s11845-024-03719-0] [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: 04/24/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION The aim of this study was to investigate the value of point shear-wave elastography (pSWE) in the measurement of iron overload in the liver and other visceral organs in patients with beta thalassemia major (BTM). MATERIALS AND METHODS The study included 103 patients diagnosed with BTM who were referred to our clinic for cardiac and liver T2* measurement and a control group of 120 age- and gender-matched healthy volunteers. Cardiac and hepatic T2* measurements were performed in the patient group. Hepatic, pancreatic, splenic, and renal pSWE values were measured in both groups. The pSWE values were compared between the two groups. In the patient group, correlations between pSWE values, cardiac-hepatic T2* values and hepatic size, patient age, and serum ferritin levels were analyzed. RESULTS Hepatic, pancreatic, splenic, and renal pSWE values were significantly higher in the patient group compared to the control group (p ≤ 0.001, < 0.001, 0.014, 0.026, respectively). In the patient group, hepatic pSWE values established a significant correlation with cardiac T2* values, liver size-T2*, pancreatic pSWE values, serum ferritin levels, and age (p = 0.006, < 0.001, 0.001, 0.042, 0.001, 0.032, respectively). In the ROC analysis, the area under the ROC curve was 0.807 for hepatic pSWE in the discrimination of thalassemia patients and healthy controls, and the cut-off value was 1.42, which gave a sensitivity and specificity of 75.7% and 75%, respectively. CONCLUSıON: Point shear-wave elastography can be a useful technique in the clinical measurement of iron overload in the liver, pancreas, spleen, and kidney.
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Affiliation(s)
- Salih Hattapoğlu
- Department of Radiology, Medical School, Dicle University, Diyarbakır, Turkey.
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Zhou Y, Cao Y, Fang Z, Huang K, Yang M, Pang G, Zhao J, Liu Y, Luo J. Research on the clinical factors of cardiac iron deposition in children with beta-thalassemia major. Eur J Pediatr 2024; 183:875-882. [PMID: 37938353 PMCID: PMC10912130 DOI: 10.1007/s00431-023-05300-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/09/2023] [Accepted: 10/19/2023] [Indexed: 11/09/2023]
Abstract
Magnetic resonance imaging (MRI) T2* is the gold standard for detecting iron deposition in cardiac tissue, but the technique has limitations and cannot be fully performed in paediatric thalassemia patients. The aim of this study was to analyse clinical data to identify other predictors of cardiac iron deposition. A retrospective analysis was performed on 370 children with β-TM. According to the cardiac MRI results, patients were allocated to a cardiac deposition group and noncardiac deposition group. Multivariate analysis revealed that genotype and corrected QT interval were associated with cardiac iron deposition, indicating that the-β0/β0 genotype conferred greater susceptibility to cardiac iron deposition. Receiver operating characteristic curve (ROC) analysis was performed, and the area under the curve (AUC) of genotype was 0.651. The AUC for the corrected QT interval was 0.711, at a cut-off value of 418.5 ms. ROC analysis of the combined genotype and corrected QT interval showed an AUC of 0.762 with 81.3% sensitivity and 64.7% specificity. Compared to patients with the β+/β+ and β0β+ genotypes, β0β0 children with β-TM were more likely to have cardiac iron deposition. Conclusion: The genotype and QTc interval can be used to predict cardiac iron deposition in children with β-TM who are unable to undergo MRI T2 testing.
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Affiliation(s)
- Yuhang Zhou
- Department of Pediatrics, The First Affiliated Hospital Of Guangxi Medical University, Nanning, China
| | - Yaxuan Cao
- Department of Pediatrics, The First Affiliated Hospital Of Guangxi Medical University, Nanning, China
| | - Zhenhua Fang
- Department of Pediatrics, The First Affiliated Hospital Of Guangxi Medical University, Nanning, China
| | - Ken Huang
- Department of Pediatrics, The First Affiliated Hospital Of Guangxi Medical University, Nanning, China
| | - Mengxin Yang
- Department of Pediatrics, The First Affiliated Hospital Of Guangxi Medical University, Nanning, China
| | - Guanxiu Pang
- Department of Pediatrics, The First Affiliated Hospital Of Guangxi Medical University, Nanning, China
| | - Jie Zhao
- Department of Pediatrics, The First Affiliated Hospital Of Guangxi Medical University, Nanning, China
| | - Yang Liu
- Department of Pediatrics, The First Affiliated Hospital Of Guangxi Medical University, Nanning, China
| | - Jianming Luo
- Department of Pediatrics, The First Affiliated Hospital Of Guangxi Medical University, Nanning, China.
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Sawicka-Zukowska M, Kretowska-Grunwald A, Kania A, Topczewska M, Niewinski H, Bany M, Grubczak K, Krawczuk-Rybak M. Iron Overload in Children with Acute Lymphoblastic and Acute Myeloblastic Leukemia-Experience of One Center. Cancers (Basel) 2024; 16:367. [PMID: 38254856 PMCID: PMC10814127 DOI: 10.3390/cancers16020367] [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: 11/15/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Transfusions of packed red blood cells (PRBCs), given due to an oncological disease and its acute complications, are an indispensable part of anticancer therapy. However, they can lead to post-transfusion iron overload. The study aim was to evaluate the role of ferritin as a nonspecific marker of leukemic growth and marker of transfusion-related iron overload. We performed a longitudinal study of PRBC transfusions and changes in ferritin concentrations during the oncological treatment of 135 patients with childhood acute lymphoblastic and acute myeloblastic leukemia (ALL and AML, median age 5.62 years). At the diagnosis, 41% of patients had a ferritin level over 500 ng/mL, and 14% of patients had a ferritin level over 1000 ng/mL. At the cessation of the treatment, 80% of the children had serum ferritin (SF) over 500 ng/mL, and 31% had SF over 1000 ng/mL. There was no significant difference between SF at the beginning of the treatment between ALL and AML patients, but children with AML finished treatment with statistically higher SF. AML patients had also statistically higher number of transfusions. We found statistically significant positive correlations between ferritin and age, and weight and units of transfused blood. Serum ferritin at the moment of diagnosis can be a useful marker of leukemic growth, but high levels of SF are connected with iron overload in both AML and ALL.
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Affiliation(s)
- Malgorzata Sawicka-Zukowska
- Department of Pediatric Oncology and Hematology, Medical University of Bialystok, Jerzego Waszyngtona 17, 15-274 Bialystok, Poland; (A.K.-G.); (A.K.); (H.N.); (M.B.); (M.K.-R.)
| | - Anna Kretowska-Grunwald
- Department of Pediatric Oncology and Hematology, Medical University of Bialystok, Jerzego Waszyngtona 17, 15-274 Bialystok, Poland; (A.K.-G.); (A.K.); (H.N.); (M.B.); (M.K.-R.)
- Faculty of Computer Science, Bialystok University of Technology, Wiejska 45A, 15-351 Bialystok, Poland;
| | - Agnieszka Kania
- Department of Pediatric Oncology and Hematology, Medical University of Bialystok, Jerzego Waszyngtona 17, 15-274 Bialystok, Poland; (A.K.-G.); (A.K.); (H.N.); (M.B.); (M.K.-R.)
| | - Magdalena Topczewska
- Faculty of Computer Science, Bialystok University of Technology, Wiejska 45A, 15-351 Bialystok, Poland;
| | - Hubert Niewinski
- Department of Pediatric Oncology and Hematology, Medical University of Bialystok, Jerzego Waszyngtona 17, 15-274 Bialystok, Poland; (A.K.-G.); (A.K.); (H.N.); (M.B.); (M.K.-R.)
| | - Marcin Bany
- Department of Pediatric Oncology and Hematology, Medical University of Bialystok, Jerzego Waszyngtona 17, 15-274 Bialystok, Poland; (A.K.-G.); (A.K.); (H.N.); (M.B.); (M.K.-R.)
| | - Kamil Grubczak
- Department of Regenerative Medicine and Immune Regulation, Medical University of Bialystok, Jerzego Waszyngtona 13, 15-269 Bialystok, Poland;
| | - Maryna Krawczuk-Rybak
- Department of Pediatric Oncology and Hematology, Medical University of Bialystok, Jerzego Waszyngtona 17, 15-274 Bialystok, Poland; (A.K.-G.); (A.K.); (H.N.); (M.B.); (M.K.-R.)
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Hamid B, Majeed N, Ganai BA, Hassan S, Bashir Z, Wani PA, Perveen K, Sayyed RZ. Heavy-metal tolerant bacterial strains isolated from industrial sites and scrap yards in Kashmir, India. J Basic Microbiol 2023; 63:1361-1372. [PMID: 37712102 DOI: 10.1002/jobm.202300349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/07/2023] [Accepted: 08/26/2023] [Indexed: 09/16/2023]
Abstract
Heavy metal pollution has posed a severe danger to environmental stability due to its high toxicity and lack of biodegradability. The present study deals with the appraisement of tolerance shown by various bacteria in varied copper and iron concentrations. Among the 20 isolates, four isolates, GN2, SC5, SC8, and SC10, exhibiting more significant iron and copper tolerance, were selected and identified by 16 S ribosomal ribonucleic acid (rRNA) gene sequence analysis as Pantoea agglomerans strain GN2, Pantoea sp. strain SC5, Bacillus sp. strain SC8 and Priestia aryabhattaistrain SC10. The minimum inhibitory concentration of molecularly identified strains revealed that P. agglomerans strain GN2 showed tolerance to iron sulfate and copper sulfate upto 600 and 400 µg/mL, whereas Bacillus sp. SC8 (OQ202165) showed tolerance of 700 and 250 µg/mL were tolerant to iron sulfate and copper sulfate up to 700 and 150 µg/mL, respectively. Pantoea sp. strain SC5 showed significant tolerance to both heavy metals. The isolates were further studied for their ability to grow at varying temperatures and pH ranges. Most of the isolates showed optimal growth at 37°C and pH 7. However, Pantoea sp. SC5 was competent to have prominent growth at 45°C and pH 8.0. Microbial remediation, which is eco-friendly, has proven the most effective method for bioremediation of heavy metal-contaminated environments. Using heavy metal-resistant bacteria for microbial remediation of iron and copper-contaminated environments could be a viable and valuable strategy. These isolates could also be used to decontaminate heavy metal-polluted agricultural soils.
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Affiliation(s)
- Burhan Hamid
- Centre of Research for Development, University of Kashmir, Srinagar, India
| | - Neesa Majeed
- Centre of Research for Development, University of Kashmir, Srinagar, India
| | - Bashir Ahmad Ganai
- Centre of Research for Development, University of Kashmir, Srinagar, India
| | - Shahnawaz Hassan
- Department of Environmental Science, University of Kashmir, Srinagar, India
| | - Zaffar Bashir
- Centre of Research for Development, University of Kashmir, Srinagar, India
| | - Parvaze Ahmad Wani
- Centre of Research for Development, University of Kashmir, Srinagar, India
| | - Kahkashan Perveen
- Department of Botany & Microbiology, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - R Z Sayyed
- Department of Microbiology, PSGVP Mandal's Shri S I Patil Arts, G B Patel Science, and STKVS Commerce College, Shahada, India
- Asian PGPR Society, Department of Entomology, Auburn University, Auburn, Alabama, USA
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Wang Y, Yue S, Cai F, Zhu W, Zhong Y, Chen J, Li C. Treatment of berberine alleviates diabetic nephropathy by reducing iron overload and inhibiting oxidative stress. Histol Histopathol 2023; 38:1009-1016. [PMID: 36861878 DOI: 10.14670/hh-18-599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
Diabetic nephropathy (DN) has become one of the major fatal factors in diabetic patients. The aim of this study was to elucidate the function and mechanism by which berberine exerts renoprotective effects in DN. In this work, we first demonstrated that urinary iron concentration, serum ferritin and hepcidin levels were increased and total antioxidant capacity was significantly decreased in DN rats, while these changes could be partially reversed by berberine treatment. Berberine treatment also alleviated DN-induced changes in the expression of proteins involved in iron transport or iron uptake. In addition, berberine treatment also partially blocked the expression of renal fibrosis markers induced by DN, including MMP2, MMP9, TIMP3, β-arrestin-1, and TGF-β1. In conclusion, the results of this study suggest that berberine may exert renoprotective effects by ameliorating iron overload and oxidative stress and reducing DN.
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Affiliation(s)
- Yujing Wang
- Department of Hemodialysis, Haikou Affiliated Hospital of Central South University Xiangya School of Medicine, Xiangya, China
| | - Shuling Yue
- Department Renal Pathology, King Medical Diagnostics Center, Guangzhou, China
| | - Feng Cai
- Department Ophthalmology, Haikou Affiliated Hospital of Central South University Xiangya School of Medicine, Xiangya, China
| | - Wen Zhu
- College of Tropical Crops, Hainan University, Hainan, China
| | - Yuxiang Zhong
- Deparment of Hemodialysis, Haikou Affiliated Hospital of Central South University Xiangya School of Medicine, Xiangya, China
| | - Juanjuan Chen
- Deparment of Hemodialysis, Haikou Affiliated Hospital of Central South University Xiangya School of Medicine, Xiangya, China
| | - Chunyun Li
- Clinical Laboratory, Haikou Affiliated Hospital of Central South University Xiangya School of Medicine, Xiangya, China.
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Zhang Q, Huo Y, Sun Q, Liu N, Shi H, Wang M, Xiao J, Yuan H, Tang X. Case report: Curing a rare, unstable hemoglobin variant Hb Bristol-Alesha using haploidentical hematopoietic stem cell transplantation. Front Immunol 2023; 14:1188058. [PMID: 37457725 PMCID: PMC10348747 DOI: 10.3389/fimmu.2023.1188058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
Unstable hemoglobinopathies are a rare, heterogeneous group of diseases that disrupt the stability of hemoglobin (Hb), leading to chronic hemolysis and anemia. Patients with severe phenotypes often require regular blood transfusions and iron chelation therapy. Although rare, studies have reported that hematopoietic stem cell transplantation (HSCT) seems to be an available curative approach in transfusion-dependent patients with unstable hemoglobinopathies. Here, we describe successful haploidentical HSCT for the treatment of an unstable Hb variant, Hb Bristol-Alesha, in a 6-year-old boy with severe anemia since early childhood. Two years after transplantation, he had a nearly normal hemoglobin level without evidence of hemolysis. DNA analysis showed complete chimerism of the donor cell origin, confirming full engraftment with normal erythropoiesis.
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Affiliation(s)
- Qin Zhang
- Department of Hematology, No.971 Hospital of People's Liberation Army Navy, Qingdao, Shandong, China
| | - Yujia Huo
- Department of Traditional Chinese Medicine, Qingdao Special Service Sanatorium of People's Liberation Army Navy, Qingdao, Shandong, China
| | - Qinggang Sun
- Department of Hematology, No.971 Hospital of People's Liberation Army Navy, Qingdao, Shandong, China
| | - Nan Liu
- Department of Hematology, No.971 Hospital of People's Liberation Army Navy, Qingdao, Shandong, China
| | - Hongchuan Shi
- Department of Hematology, No.971 Hospital of People's Liberation Army Navy, Qingdao, Shandong, China
| | - Minghui Wang
- Department of Hematology, No.971 Hospital of People's Liberation Army Navy, Qingdao, Shandong, China
| | - Jinming Xiao
- Department of Hematology, No.971 Hospital of People's Liberation Army Navy, Qingdao, Shandong, China
| | - Hanzi Yuan
- Department of Pediatrics, the Sixth Medical Center of People's Liberation Army General Hospital, Beijing, China
| | - Xiangfeng Tang
- Department of Pediatrics, the Seventh Medical Center of People's Liberation Army General Hospital, Beijing, China
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De Sanctis V, Soliman AT, Daar S, Tzoulis P, Di Maio S, Kattamis C. Longitudinal study of ICET-A on glucose tolerance, insulin sensitivity and β-cell secretion in eleven β-thalassemia major patients with mild iron overload. ACTA BIO-MEDICA : ATENEI PARMENSIS 2023; 94:e2023011. [PMID: 36786253 PMCID: PMC9987494 DOI: 10.23750/abm.v94i1.14000] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 11/29/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND Iron chelation therapy (ICT) is the gold standard for treating patients with iron overload, though its long-term effects are still under evaluation. According to current recommendations regarding transfusion-dependent (TD) β-thalassemia major (β-TM) patients, their serum ferritin (SF) levels should be maintained below 1,000 ng/mL and ICT should be discontinued when the levels are <500 ng/mL in two successive tests. Alternatively, the dose of chelator could be considerably reduced to maintain a balance between iron input and output of frequent transfusions. STUDY DESIGN Due to the paucity of information on long-term effects of ICT in β-TM with low SF levels on glucose homeostasis, the International Network of Clinicians for Endocrinopathies in Thalassemia and Adolescence Medicine (ICET-A) promoted a retrospective and an ongoing prospective observational study with the primary aim to address the long-term effects of ICT on glucose tolerance and metabolism (β-cell function and peripheral insulin sensitivity) in adult β-TM patients with persistent SF level below 800 ng/mL. PATIENTS AND METHODS 11 β-TM patients (mean age: 35.5 ± 5.5 years; SF range: 345-777 ng/mL) with normal glucose tolerance test (OGTT) or abnormal glucose tolerance (AGT) for a median of 5.3(1.1-8.3) years. RESULTS Abnormal glucose tolerance (AGT) was observed in 7 patients (63.6%) at first observation and ) persisted in 6 patients (54.5%) at last observation. None of them developed diabetes mellitus. AGT was reversed in two patients. One patient with NGT developed early glucose intolerance (1-h PG ≥155 and 2-h PG <140 mg/dL). Three out of 5 patients with isolated impaired glucose tolerance presented a variation of ATG. Stabilization of low indices for β-cell function and insulin sensitivity/resistance was observed. One patient developed hypogonadotrophic hypogonadism. Three out of 6 patients with SF below 500 ng/dL had hypercalciuria. CONCLUSION Despite low SF level, the burden of endocrine complications remains a challenge in β-TM patients. The ability to keep iron at near "normal" level with acceptable risks of toxicity remains to be established.
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Affiliation(s)
| | - Ashraf T Soliman
- Department of Pediatrics, Division of Endocrinology, Hamad General Hospital, Doha, Qatar .
| | - Shahina Daar
- Department of Haematology, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Sultanate of Oman.
| | - Ploutarchos Tzoulis
- Department of Diabetes and Endocrinology, Whittington Hospital, University College London, London, UK.
| | - Salvatore Di Maio
- Emeritus Director in Pediatrics, Children's Hospital "Santobono-Pausilipon", Naples, Italy.
| | - Christos Kattamis
- Τhalassemia Unit, First Department of Paediatrics, National Kapodistrian University of Athens 11527, Greece.
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Germing U, Fenaux P, Platzbecker U, Buckstein R, Santini V, Díez-Campelo M, Yucel A, Tang D, Fabre S, Zhang G, Zoffoli R, Ha X, Miteva D, Hughes C, Komrokji RS, Zeidan AM, Garcia-Manero G. Improved benefit of continuing luspatercept therapy: sub-analysis of patients with lower-risk MDS in the MEDALIST study. Ann Hematol 2023; 102:311-321. [PMID: 36635381 PMCID: PMC9889415 DOI: 10.1007/s00277-022-05071-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 12/07/2022] [Indexed: 01/14/2023]
Abstract
Red blood cell transfusion independence (RBC-TI) is an important goal in treating lower-risk myelodysplastic syndromes with ring sideroblasts. In the phase 3 MEDALIST study, RBC-TI of ≥ 8 weeks was achieved by significantly more luspatercept- versus placebo-treated patients in the first 24 weeks of treatment. In this post hoc analysis, we evaluated RBC transfusion units and visits based on patients' baseline transfusion burden level and the clinical benefit of luspatercept treatment beyond week 25 in initial luspatercept nonresponders (patients who did not achieve RBC-TI ≥ 8 weeks by week 25) but continued luspatercept up to 144 weeks. RBC transfusion burden, erythroid response, serum ferritin levels, and hemoglobin levels relative to baseline were evaluated. Through week 25, fewer RBC transfusion units and visits were observed in luspatercept-treated patients versus placebo, regardless of baseline transfusion burden. This continued through 144 weeks of luspatercept treatment, particularly in patients with low baseline transfusion burden. Sixty-eight patients were initial nonresponders at week 25 but continued treatment; most (81%) received the maximum dose of luspatercept (1.75 mg/kg). Sixteen percent achieved RBC-TI for ≥ 8 weeks during weeks 25-48, 26% had reduced RBC transfusion burden, 10% achieved an erythroid response, 44% had reduced serum ferritin, and hemoglobin levels increased an average of 1.3 g/dL from baseline. These data have implications for clinical practice, as transfusion units and visits are less in luspatercept-treated patients through week 25 regardless of baseline transfusion burden, and continuing luspatercept beyond week 25 can potentially provide additional clinical benefits for initial nonresponders. Trial registration: NCT02631070.
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Affiliation(s)
- Ulrich Germing
- University Clinic, Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine University, Düsseldorf, Germany.
| | - Pierre Fenaux
- Service d'Hématologie Séniors, Hôpital Saint-Louis, Université Paris, Paris, France
| | - Uwe Platzbecker
- Hematology and Cellular Therapy, Medical Clinic and Policlinic 1, University Hospital Leipzig, Leipzig, Germany
| | - Rena Buckstein
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Valeria Santini
- MDS Unit, Azienda Ospedaliero Universitaria Careggi, University of Florence, Florence, Italy
| | - María Díez-Campelo
- Hematology Department, Institute of Biomedical Research of Salamanca, University Hospital of Salamanca, Salamanca, Spain
| | | | - Derek Tang
- Bristol Myers Squibb, Princeton, NJ, USA
| | | | | | | | - Xianwei Ha
- Bristol Myers Squibb, Princeton, NJ, USA
| | | | | | | | - Amer M Zeidan
- Department of Internal Medicine, Yale University, New Haven, CT, USA
- Yale Cancer Center, New Haven, CT, USA
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Light J, Boucher M, Baskin-Miller J, Winstead M. Managing the Cerebrovascular Complications of Sickle Cell Disease: Current Perspectives. J Blood Med 2023; 14:279-293. [PMID: 37082003 PMCID: PMC10112470 DOI: 10.2147/jbm.s383472] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/31/2023] [Indexed: 04/22/2023] Open
Abstract
The importance of protecting brain function for people with sickle cell disease (SCD) cannot be overstated. SCD is associated with multiple cerebrovascular complications that threaten neurocognitive function and life. Without screening and preventive management, 11% of children at 24% of adults with SCD have ischemic or hemorrhagic strokes. Stroke screening in children with SCD is well-established using transcranial Doppler ultrasound (TCD). TCD velocities above 200 cm/s significantly increase the risk of stroke, which can be prevented using chronic red blood cell (RBC) transfusion. RBC transfusion is also the cornerstone of acute stroke management and secondary stroke prevention. Chronic transfusion requires long-term management of complications like iron overload. Hydroxyurea can replace chronic transfusions for primary stroke prevention in a select group of patients or in populations where chronic transfusions are not feasible. Silent cerebral infarction (SCI) is even more common than stroke, affecting 39% of children and more than 50% of adults with SCD; management of SCI is individualized and includes careful neurocognitive evaluation. Hematopoietic stem cell transplant prevents cerebrovascular complications, despite the short- and long-term risks. Newer disease-modifying agents like voxelotor and crizanlizumab, as well as gene therapy, may treat cerebrovascular complications, but these approaches are investigational.
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Affiliation(s)
- Jennifer Light
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maria Boucher
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jacquelyn Baskin-Miller
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mike Winstead
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Correspondence: Mike Winstead, Division of Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC, USA, Tel +1 919-966-1178, Fax +1 919-966-7629, Email
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Mulzer LM, Reutter H, Jüngert J, Knisely AS, Schmid M, Hoerning A, Morhart P. Premature birth associated with a favorable course in gestational alloimmune liver disease (GALD): A case report. Front Pediatr 2023; 11:1104530. [PMID: 37009281 PMCID: PMC10054034 DOI: 10.3389/fped.2023.1104530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/20/2023] [Indexed: 04/04/2023] Open
Abstract
Gestational alloimmune liver disease (GALD) is a rare neonatal disorder with high mortality and morbidity. The patients come to caregivers' attention aged a few hours or days. The disease manifests as acute liver failure with or without siderosis. The differential diagnosis of neonatal acute liver failure (NALF) is broad, including mainly immunologic, infectious, metabolic and toxic disorders. The most common cause, however, is GALD followed by herpes simplex virus (HSV) infection. The best suited pathophysiological paradigm of GALD is that of a maternofetal alloimmune disorder. State of the art treatment combines intravenously administered immunoglobulin (IVIG) with exchange transfusion (ET). We report an infant born at 35 + 2 weeks' gestation in whom GALD had a favorable course, of interest because premature birth in our patient may have exerted protective aspects and lessened morbidity in that intrauterine exposure to maternal complement-fixing antibodies was shortened. The diagnosis of GALD was challenging and difficult. We suggest a modified diagnostic algorithm combining clinical findings with histopathologic findings in liver and lip mucosa and, if available, on abdominal magnetic resonance imaging-study focusing on the liver, spleen, and pancreas. This diagnostic workup must be followed by ET and subsequent administration of IVIG without delay.
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Affiliation(s)
- Linda-Marie Mulzer
- Department of Pediatrics, University of Erlangen-Nürnberg, Erlangen, Germany
- Correspondence: Linda-Marie Mulzer
| | - Heiko Reutter
- Department of Pediatrics, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Jörg Jüngert
- Department of Pediatrics, University of Erlangen-Nürnberg, Erlangen, Germany
| | - A. S. Knisely
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Margit Schmid
- Department of Pediatrics, University of Erlangen-Nürnberg, Erlangen, Germany
| | - André Hoerning
- Department of Pediatrics, University of Erlangen-Nürnberg, Erlangen, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), ZSEER, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg, Erlangen, Germany
| | - Patrick Morhart
- Department of Pediatrics, University of Erlangen-Nürnberg, Erlangen, Germany
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Updates on Quantitative MRI of Diffuse Liver Disease: A Narrative Review. BIOMED RESEARCH INTERNATIONAL 2022; 2022:1147111. [PMID: 36619303 PMCID: PMC9812615 DOI: 10.1155/2022/1147111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 12/10/2022] [Accepted: 12/12/2022] [Indexed: 12/29/2022]
Abstract
Diffuse liver diseases are highly prevalent conditions around the world, including pathological liver changes that occur when hepatocytes are damaged and liver function declines, often leading to a chronic condition. In the last years, Magnetic Resonance Imaging (MRI) is reaching an important role in the study of diffuse liver diseases moving from qualitative to quantitative assessment of liver parenchyma. In fact, this can allow noninvasive accurate and standardized assessment of diffuse liver diseases and can represent a concrete alternative to biopsy which represents the current reference standard. MRI approach already tested for other pathologies include diffusion-weighted imaging (DWI) and radiomics, able to quantify different aspects of diffuse liver disease. New emerging MRI quantitative methods include MR elastography (MRE) for the quantification of the hepatic stiffness in cirrhotic patients, dedicated gradient multiecho sequences for the assessment of hepatic fat storage, and iron overload. Thus, the aim of this review is to give an overview of the technical principles and clinical application of new quantitative MRI techniques for the evaluation of diffuse liver disease.
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12
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Alvarenga AM, Brissot P, Santos PCJL. Haemochromatosis revisited. World J Hepatol 2022; 14:1931-1939. [PMID: 36483608 PMCID: PMC9724105 DOI: 10.4254/wjh.v14.i11.1931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/27/2022] [Accepted: 11/03/2022] [Indexed: 11/24/2022] Open
Abstract
Haemochromatosis is a genetic disease caused by hepcidin deficiency, responsible for an increase in intestinal iron absorption. Haemochromatosis is associated with homozygosity for the HFE p.Cys282Tyr mutation. However, rare cases of haemochromatosis (non-HFE haemochromatosis) can also be caused by pathogenic variants in other genes (such as HJV, HAMP, TFR2 and SLC40A1). A working group of the International Society for the Study of Iron in Biology and Medicine (BIOIRON Society) has concluded that the classification based in different molecular subtypes is difficult to be adopted in clinical practice and has proposed a new classification approaching clinical questions and molecular complexity. The aim of the present review is to provide an update on classification, pathophysiology and therapeutic recommendations.
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Affiliation(s)
- Aline Morgan Alvarenga
- Department of Pharmacology - Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo 04044-020, Brazil
| | | | - Paulo Caleb Junior Lima Santos
- Department of Pharmacology - Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo 04044-020, Brazil
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13
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Abbina S, Abbasi U, Gill A, Leitch H, Kizhakkedathu JN. Active transport nanochelators for the reduction of liver iron burden in iron overload. J Control Release 2022; 350:857-869. [PMID: 36058353 DOI: 10.1016/j.jconrel.2022.08.056] [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: 11/04/2021] [Revised: 08/25/2022] [Accepted: 08/27/2022] [Indexed: 11/28/2022]
Abstract
Liver dysfunction and failure account for a major portion of premature deaths in patients suffering from various iron associated pathogeneses, particularly primary and secondary iron overload disorders, despite intensive treatment. The liver is a central player in iron homeostasis and a major iron storage organ, and currently, there are no active approaches for the excretion of excess liver iron. Herein, we report a new method for the rapid reduction of iron burden in iron overload diseases by developing a new class of liver targeted nanochelators with favorable pharmacokinetics and biodistribution. The new nanochelators bypass the reticuloendothelial system and specifically target hepatocytes without non-specific accumulation in other organs. The targeted nanochelators bound and neutralized excess iron in the liver and from the vasculature and, eventually leading to rapid hepatobiliary excretion of labile iron. Further, these rapidly excreted nanochelators did not induce toxicity in the liver, were highly cytocompatible in both iron overload and non-loaded conditions, and were promising in mitigating iron triggered free radical oxidative damage. These studies provide key insights into the development of organ targeted nanochelating systems and the rapid reduction of iron burden in vivo. This methodology allows for further development of nanotherapeutics for specific iron overload diseases.
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Affiliation(s)
- Srinivas Abbina
- Centre for Blood Research, Life Sciences Institute, The University of British Columbia, Vancouver, BC., Canada; Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, BC., Canada
| | - Usama Abbasi
- Centre for Blood Research, Life Sciences Institute, The University of British Columbia, Vancouver, BC., Canada; Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, BC., Canada
| | - Arshdeep Gill
- Centre for Blood Research, Life Sciences Institute, The University of British Columbia, Vancouver, BC., Canada; Department of Chemistry, The University of British Columbia, Vancouver, BC, Canada
| | - Heather Leitch
- Centre for Blood Research, Life Sciences Institute, The University of British Columbia, Vancouver, BC., Canada; Hematology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada
| | - Jayachandran N Kizhakkedathu
- Centre for Blood Research, Life Sciences Institute, The University of British Columbia, Vancouver, BC., Canada; Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, BC., Canada; Department of Chemistry, The University of British Columbia, Vancouver, BC, Canada; The School of Biomedical Engineering, The University of British Columbia, Vancouver, BC, Canada.
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14
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Lee YC, Yen CT, Lee YL, Chen RJ. Thalassemia Intermedia: Chelator or Not? Int J Mol Sci 2022; 23:ijms231710189. [PMID: 36077584 PMCID: PMC9456380 DOI: 10.3390/ijms231710189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/19/2022] Open
Abstract
Thalassemia is the most common genetic disorder worldwide. Thalassemia intermedia (TI) is non-transfusion-dependent thalassemia (NTDT), which includes β-TI hemoglobin, E/β-thalassemia and hemoglobin H (HbH) disease. Due to the availability of iron chelation therapy, the life expectancy of thalassemia major (TM) patients is now close to that of TI patients. Iron overload is noted in TI due to the increasing iron absorption from the intestine. Questions are raised regarding the relationship between iron chelation therapy and decreased patient morbidity/mortality, as well as the starting threshold for chelation therapy. Searching all the available articles up to 12 August 2022, iron-chelation-related TI was reviewed. In addition to splenectomized patients, osteoporosis was the most common morbidity among TI cases. Most study designs related to ferritin level and morbidities were cross-sectional and most were from the same Italian study groups. Intervention studies of iron chelation therapy included a subgroup of TI that required regular transfusion. Liver iron concentration (LIC) ≥ 5 mg/g/dw measured by MRI and ferritin level > 300 ng/mL were suggested as indicators to start iron chelation therapy, and iron chelation therapy was suggested to be stopped at a ferritin level ≤ 300 ng/mL. No studies showed improved overall survival rates by iron chelation therapy. TI morbidities and mortalities cannot be explained by iron overload alone. Hypoxemia and hemolysis may play a role. Head-to-head studies comparing different treatment methods, including hydroxyurea, fetal hemoglobin-inducing agents, hypertransfusion as well as iron chelation therapy are needed for TI, hopefully separating β-TI and HbH disease. In addition, the target hemoglobin level should be determined for β-TI and HbH disease.
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Affiliation(s)
- Yen-Chien Lee
- Department of Medical Oncology, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan 70043, Taiwan
- Department of Internal Medicine, College of Medicine, National Cheng Kung University Hospital, Tainan 70403, Taiwan
- Correspondence: (Y.-C.L.); (R.-J.C.)
| | - Chi-Tai Yen
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan 70043, Taiwan
| | - Yen-Ling Lee
- Department of Medical Oncology, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan 70043, Taiwan
| | - Rong-Jane Chen
- Department of Food Safety/Hygiene and Risk Management, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
- Correspondence: (Y.-C.L.); (R.-J.C.)
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15
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See WS, So EKF, Hwang GYY, Chin L, Ip L, Lam WWM, Ha SY, Cheung YF. Native cardiac magnetic resonance T1 mapping and cardiac mechanics as assessed by speckle tracking echocardiography in patients with beta-thalassaemia major. IJC HEART & VASCULATURE 2022; 38:100947. [PMID: 35024432 PMCID: PMC8733147 DOI: 10.1016/j.ijcha.2021.100947] [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: 07/29/2021] [Revised: 11/14/2021] [Accepted: 12/24/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND We hypothesize that cardiac magnetic resonance (CMR) native T1 is associated with myocardial deformation in thalassaemia patients. The present study aimed to compare CMR native T1 values to conventional T2* values in patients with beta-thalassaemia and to explore relationships between these CMR parameters of myocardial iron overload and left ventricular (LV) and left atrial (LA) myocardial deformation. METHODS Thirty-four (16 males) patients aged 35.5 ± 9.2 years were studied. Myocardial T2* and T1 mapping were performed to assess the cardiac iron overload, while two-dimensional speckle-tracking echocardiography was performed in determine LV and LA myocardial deformation. RESULTS T2* was 36.4 ± 8.7 ms with 3 patients having myocardial iron load (T2*<20 ms). The native T1 was 947.1 ± 84.8 ms, which was significantly lower than the reported normal values in the literature. There was a significant correlation between T1 and T2* values (r = 0.68, p < 0.001). There were no significant correlations between T1 and T2* values and conventional and tissue Doppler parameters of left ventricular systolic and diastolic function. On the other hand, T1, but not T2*, values were found to correlate negatively with maximum LA area indexed by body surface area (r = -0.34, p = 0.047) and positively with LA strain rate at atrial contraction (r = 0.36, p = 0.04). There were no associations between either of these CMR parameters with indices of ventricular deformation. CONCLUSIONS In patients with beta-thalassaemia major, native T1 values are decreased, associated with T2* values, and correlated with maximum LA area and LA strain rate at atrial contraction.
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Affiliation(s)
- Wing-Shan See
- Department of Paediatrics & Adolescent Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Edwina Kam-fung So
- Department of Paediatrics & Adolescent Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Gloria Yu-Yan Hwang
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Leanne Chin
- Department of Radiology, Queen Mary Hospital, Hong Kong
| | - Lawrence Ip
- Department of Radiology, Queen Mary Hospital, Hong Kong
| | | | - Shau-yin Ha
- Department of Paediatrics & Adolescent Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Yiu-fai Cheung
- Department of Paediatrics & Adolescent Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
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16
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Biopsy-based optimization and calibration of a signal-intensity-ratio-based MRI method (1.5 Tesla) in a dextran-iron loaded mini-pig model, enabling estimation of very high liver iron concentrations. MAGNETIC RESONANCE MATERIALS IN PHYSICS, BIOLOGY AND MEDICINE 2022; 35:843-859. [PMID: 35038062 PMCID: PMC9463247 DOI: 10.1007/s10334-021-00998-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 12/26/2021] [Accepted: 12/28/2021] [Indexed: 11/15/2022]
Abstract
Objective Magnetic resonance imaging (MRI)-based techniques for non-invasive assessing liver iron concentration (LIC) in patients with iron overload have a limited upper measuring range around 35 mg/g dry weight, caused by signal loss from accelerated T1-, T2-, T2* shortening with increasing LIC. Expansion of this range is necessary to allow evaluation of patients with very high LIC. Aim To assess measuring range of a gradient-echo R2* method and a T1-weighted spin-echo (SE), signal intensity ratio (SIR)-based method (TE = 25 ms, TR = 560 ms), and to extend the upper measuring range of the SIR method by optimizing echo time (TE) and repetition time (TR) in iron-loaded minipigs. Methods Thirteen mini pigs were followed up during dextran-iron loading with repeated percutaneous liver biopsies for chemical LIC measurement and MRIs for parallel non-invasive estimation of LIC (81 examinations) using different TEs and TRs. Results SIR and R2* method had similar upper measuring range around 34 mg/g and similar method agreement. Using TE = 12 ms and TR = 1200 ms extended the upper measuring range to 115 mg/g and yielded good method of agreement. Discussion The wider measuring range is likely caused by lesser sensitivity of the SE sequence to iron, due to shorter TE, leading to later signal loss at high LIC, allowing evaluation of most severe hepatic iron overload. Validation in iron-loaded patients is necessary.
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17
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Correlation between Serum Fatty Acid Binding Protein 4 (FABP4) Levels and Cardiac Function in Patients with Thalassemia Major. DISEASE MARKERS 2022; 2021:5130628. [PMID: 34987673 PMCID: PMC8723846 DOI: 10.1155/2021/5130628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 10/10/2021] [Accepted: 12/04/2021] [Indexed: 12/02/2022]
Abstract
Background Patients with thalassemia major may suffer from complications due to iron overload. It has been suggested that several adipokines may play a potential role in the development of complications in thalassemia. Fatty acid-binding protein 4 (FABP4) is one of the adipokines, bridging several aspects of metabolic and inflammatory pathways. Little is known about the relationship between this adipokine and cardiac and liver function, especially in patients with thalassemia major. Aims This study is aimed at determining serum FABP4 levels in patients with thalassemia major and whether its concentration correlated with serum ferritin levels, as well as cardiac and liver function. Methods Thalassemia major outpatients (n = 48) completed laboratory examination, echocardiography, and electrocardiography. Results The mean age was 21.9 ± 8.0 years. A negative and weak correlation between serum ferritin and FABP4 was observed (r = −0.291, p < 0.05). In addition, there was moderate and positive correlation between left atrial volume index (LAVI) and FABP4 (r = 0.316, p < 0.05). Conclusions Serum FABP4 correlated with serum ferritin and cardiac function in patients with thalassemia major. FABP4 may be a potential clinical biomarker for cardiac dysfunction via metabolic and inflammatory pathways due to iron accumulation and toxicity in patients with thalassemia major.
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18
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De Sanctis V, Daar S, Soliman AT, Tzoulis P, Karimi M, Kattamis C. The evolution of glucose-insulin homeostasis in children with β-thalassemia major (β -TM): A twenty-year retrospective ICET- A observational analysis from early childhood to young adulthood. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022243. [PMID: 35775765 PMCID: PMC9335438 DOI: 10.23750/abm.v93i3.12643] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 12/05/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Thalassemia guidelines recommend oral glucose tolerance test (OGTT), starting from the age of 10 years, or earlier in the presence of iron overload. OBJECTIVE The aim of this retrospective study was to review and document the changes of glucose-insulin homeostasis from early childhood to young adulthood in β-thalassemia major (β -TM) patients with impaired fasting glucose (IFG) and normal OGTT. METHODS All data of the clinical patients' records of 18 β -TM patients' from September 1983 to September 2021 were included in the study. Annual or biennial OGTT results, for a duration of 15-20 years, were available for all patients. RESULTS The main findings are: a) IFG in children with β -TM represents a risk factor for the development of glucose dysregulation (GD) at later age; b) fluctuations of glucose homeostasis during follow-up were observed mainly in β-TM patients with IFG at baseline; and c) the primary defect of GD appears to be a low degree insulin resistance (IR), as estimated by HOMA-IR, followed by an insulin secretion defect. CONCLUSION These results are noteworthy as they revealed that firstly, the baseline IFG predicts future development of GD, and secondly, that almost half of patients with IFG at the outset had normal glucose handling 15 years later. Understanding the sequence of abnormalities in the progression from normal glucose homeostasis to GD and identifying the risk factors for the glycometabolic defects in thalassemic patients might help in the formulation of interventions.
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Affiliation(s)
- Vincenzo De Sanctis
- Coordinator of ICET-A Network (International Network of Clinicians for Endocrinopathies in Thalassemia and Adolescent Medicine), Pediatric and Adolescent Outpatient Clinic, Quisisana Hospital, Ferrara, Italy
| | - Shahina Daar
- Department of Haematology, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Sultanate of Oman
| | - Ashraf T Soliman
- Department of Pediatrics, Division of Endocrinology, Hamad General Hospital, Doha, Qatar and Department of Pediatrics, Division of Endocrinology, Alexandria University Children’s Hospital, Alexandria, Egypt
| | - Ploutarchos Tzoulis
- Department of Diabetes and Endocrinology, Whittington Hospital, University College London, London, UK
| | - Mehran Karimi
- National Center for Cancer Care and Research, Medical Oncology Hematology Section HMC, Doha, Qatar
| | - Christos Kattamis
- First Department of Paediatrics, National Kapodistrian University of Athens 11527, Greece
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Deferiprone vs deferoxamine for transfusional iron overload in SCD and other anemias: a randomized, open-label, noninferiority study. Blood Adv 2021; 6:1243-1254. [PMID: 34847228 PMCID: PMC8864642 DOI: 10.1182/bloodadvances.2021004938] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 10/14/2021] [Indexed: 11/26/2022] Open
Abstract
The efficacy of deferiprone was noninferior to deferoxamine for treating transfusional iron overload in patients with SCD or other anemias. The safety profile of deferiprone in patients with SCD was tolerable and similar to previous reports in patients with thalassemia syndromes.
Many people with sickle cell disease (SCD) or other anemias require chronic blood transfusions, which often causes iron overload that requires chelation therapy. The iron chelator deferiprone is frequently used in individuals with thalassemia syndromes, but data in patients with SCD are limited. This open-label study assessed the efficacy and safety of deferiprone in patients with SCD or other anemias receiving chronic transfusion therapy. A total of 228 patients (mean age: 16.9 [range, 3-59] years; 46.9% female) were randomized to receive either oral deferiprone (n = 152) or subcutaneous deferoxamine (n = 76). The primary endpoint was change from baseline at 12 months in liver iron concentration (LIC), assessed by R2* magnetic resonance imaging (MRI). The least squares mean (standard error) change in LIC was −4.04 (0.48) mg/g dry weight for deferiprone vs −4.45 (0.57) mg/g dry weight for deferoxamine, with noninferiority of deferiprone to deferoxamine demonstrated by analysis of covariance (least squares mean difference 0.40 [0.56]; 96.01% confidence interval, −0.76 to 1.57). Noninferiority of deferiprone was also shown for both cardiac T2* MRI and serum ferritin. Rates of overall adverse events (AEs), treatment-related AEs, serious AEs, and AEs leading to withdrawal did not differ significantly between the groups. AEs related to deferiprone treatment included abdominal pain (17.1% of patients), vomiting (14.5%), pyrexia (9.2%), increased alanine transferase (9.2%) and aspartate transferase levels (9.2%), neutropenia (2.6%), and agranulocytosis (0.7%). The efficacy and safety profiles of deferiprone were acceptable and consistent with those seen in patients with transfusion-dependent thalassemia. This trial study was registered at www://clinicaltrials.gov as #NCT02041299.
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Anterior Pituitary Volume in Patients with Transfusion Dependent Anemias: Volumetric Approaches and Relation to Pituitary MRI‑R2. Clin Neuroradiol 2021; 32:259-267. [PMID: 34709410 PMCID: PMC8894216 DOI: 10.1007/s00062-021-01111-4] [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: 07/17/2021] [Accepted: 10/04/2021] [Indexed: 10/29/2022]
Abstract
PURPOSE Anterior pituitary iron overload and volume shrinkage is common in patients with transfusion-dependent anemia and associated with growth retardation and hypogonadotropic hypogonadism. We investigated the accuracy of different MRI-based pituitary volumetric approaches and the relationship between pituitary volume and MRI-R2, particularly with respect to growth and hypogonadism. METHODS In 43 patients with transfusion-dependent anemia (12-38 years) and 32 healthy controls (12-72 years), anterior pituitary volume was measured by a sagittal T1 GRE 3D sequence at 1.5T and analyzed by 3D semi-automated threshold volumetry (3D-volumetry). This reference method was compared with planimetric 2D-volumetry, approximate volume calculations, and pituitary height. Using a multiple SE sequence, pituitary iron as MRI-R2 was assessed by fitting proton signal intensities to echo times. Growth and hypogonadism were obtained from height percentile tables and patients' medical charts. From body surface area and age adjusted anterior pituitary volumes of controls, Z‑scores were calculated for all subjects. Separation of controls and patients with respect to Z and pituitary R2 was performed by bivariate linear discriminant analysis. RESULTS Tuned 2D volumes showed highest agreement with reference 3D-volumes (bias -4.8%; 95% CI:-8.8%|-0.7%). A linear discriminant equation of Z = -17.8 + 1.45 · R2 revealed optimum threshold sensitivity and specificity of 65% and 100% for discrimination of patients from controls, respectively. Of correctly classified patients 71% and 75% showed hypogonadism and growth retardation, respectively. CONCLUSION Accurate assessment of anterior pituitary size requires 3D or precise 2D volumetry, with shorter analysis time for the latter. Anterior pituitary volume Z‑scores and R2 allow for the identification of patients at risk of pituitary dysfunction.
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De Simone G, Quattrocchi A, Mancini B, di Masi A, Nervi C, Ascenzi P. Thalassemias: From gene to therapy. Mol Aspects Med 2021; 84:101028. [PMID: 34649720 DOI: 10.1016/j.mam.2021.101028] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/19/2021] [Indexed: 12/26/2022]
Abstract
Thalassemias (α, β, γ, δ, δβ, and εγδβ) are the most common genetic disorders worldwide and constitute a heterogeneous group of hereditary diseases characterized by the deficient synthesis of one or more hemoglobin (Hb) chain(s). This leads to the accumulation of unstable non-thalassemic Hb chains, which precipitate and cause intramedullary destruction of erythroid precursors and premature lysis of red blood cells (RBC) in the peripheral blood. Non-thalassemic Hbs display high oxygen affinity and no cooperativity. Thalassemias result from many different genetic and molecular defects leading to either severe or clinically silent hematologic phenotypes. Thalassemias α and β are particularly diffused in the regions spanning from the Mediterranean basin through the Middle East, Indian subcontinent, Burma, Southeast Asia, Melanesia, and the Pacific Islands, whereas δβ-thalassemia is prevalent in some Mediterranean regions including Italy, Greece, and Turkey. Although in the world thalassemia and malaria areas overlap apparently, the RBC protection against malaria parasites is openly debated. Here, we provide an overview of the historical, geographic, genetic, structural, and molecular pathophysiological aspects of thalassemias. Moreover, attention has been paid to molecular and epigenetic pathways regulating globin gene expression and globin switching. Challenges of conventional standard treatments, including RBC transfusions and iron chelation therapy, splenectomy and hematopoietic stem cell transplantation from normal donors are reported. Finally, the progress made by rapidly evolving fields of gene therapy and gene editing strategies, already in pre-clinical and clinical evaluation, and future challenges as novel curative treatments for thalassemia are discussed.
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Affiliation(s)
- Giovanna De Simone
- Dipartimento di Scienze, Università Roma Tre, Viale Guglielmo Marconi 446, 00146, Roma, Italy
| | - Alberto Quattrocchi
- Dipartimento di Scienze e Biotecnologie Medico-Chirurgiche, Facoltà di Farmacia e Medicina, "Sapienza" Università di Roma, Corso della Repubblica, 79, 04100, Latina, Italy
| | - Benedetta Mancini
- Dipartimento di Scienze, Università Roma Tre, Viale Guglielmo Marconi 446, 00146, Roma, Italy
| | - Alessandra di Masi
- Dipartimento di Scienze, Università Roma Tre, Viale Guglielmo Marconi 446, 00146, Roma, Italy
| | - Clara Nervi
- Dipartimento di Scienze e Biotecnologie Medico-Chirurgiche, Facoltà di Farmacia e Medicina, "Sapienza" Università di Roma, Corso della Repubblica, 79, 04100, Latina, Italy.
| | - Paolo Ascenzi
- Dipartimento di Scienze, Università Roma Tre, Viale Guglielmo Marconi 446, 00146, Roma, Italy; Accademia Nazionale dei Lincei, Via della Lungara 10, 00165, Roma, Italy.
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22
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Doyle EK, Thornton S, Ghugre NR, Coates TD, Nayak KS, Wood JC. Effects of B 1 + Heterogeneity on Spin Echo-Based Liver Iron Estimates. J Magn Reson Imaging 2021; 55:1419-1425. [PMID: 34555245 PMCID: PMC8940739 DOI: 10.1002/jmri.27928] [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] [Received: 02/04/2021] [Revised: 09/07/2021] [Accepted: 09/10/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Liver iron concentration (LIC) measured by MRI has become the clinical reference standard for managing iron overload in chronically transfused patients. Transverse relaxivity (R2 or R2 * ) measurements are converted to LIC units using empirically derived calibration curves. HYPOTHESIS That flip angle (FA) error due to B1 + spatial heterogeneity causes significant LIC quantitation error. B1 + scale (b1 , [FAactual /FAspecified ]) variation is a major problem at 3 T which could reduce the accuracy of transverse relaxivity measurements. STUDY TYPE Prospective. POPULATION Forty-seven subjects with chronic transfusional iron overload undergoing clinically indicated LIC assessment. FIELD STRENGTH/SEQUENCE 5 T/3 T dual-repetition time B1 + mapping sequence ASSESSMENT: We quantified the average/standard deviation b1 in the right and left lobes of the liver from B1 + maps acquired at 1.5 T and 3 T. The impact of b1 variation on spin echo LIC estimates was determined using a Monte Carlo model. STATISTICAL TESTS Mean, median, and standard deviation in whole liver and right and left lobes; two-sided t-test between whole-liver b1 means. RESULTS Average b1 within the liver was 99.3% ± 12.3% at 1.5 T versus 69.6% ± 14.6% at 3 T and was independent of iron burden (P < 0.05). Monte Carlo simulations demonstrated that b1 systematically increased R2 estimates at lower LIC (<~25 mg/g at 1.5 T, <~15 mg/g at 3 T) but flattened or even inverted the R2 -LIC relationship at higher LIC (≥~25 mg/g to 1.5 T, ≥~15 mg/g to 3 T); changes in the R2 -LIC relationship were symmetric with respect to over and under excitation and were similar at 1.5 T and 3 T (for the same R2 value). The R2 * -LIC relationship was independent of b1 . CONCLUSION Spin echo R2 measurement of LIC at 3 T is error-prone without correction for b1 errors. The impact of b1 error on current 1.5 T spin echo-based techniques for LIC quantification is large enough to introduce measurable intersubject variability but the in vivo effect size needs a dedicated validation study. LEVEL OF EVIDENCE 1. TECHNICAL EFFICACY STAGE 2.
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Affiliation(s)
- Eamon K Doyle
- Department of Biomedical Engineering, University of Southern California, Los Angeles, California, USA.,Division of Cardiology and Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Samuel Thornton
- Ming Hsieh Department of Electrical and Computer Engineering, University of Southern California, Los Angeles, California, USA
| | - Nilesh R Ghugre
- Schulich Heart Research Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Thomas D Coates
- Division of Hematology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Krishna S Nayak
- Ming Hsieh Department of Electrical and Computer Engineering, University of Southern California, Los Angeles, California, USA
| | - John C Wood
- Department of Biomedical Engineering, University of Southern California, Los Angeles, California, USA.,Division of Cardiology and Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Bhalla D, Jana M. MRI in Pituitary Iron Overload: Current Perspective and Future Directions. Indian J Pediatr 2021; 88:641-642. [PMID: 34021865 DOI: 10.1007/s12098-021-03812-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/12/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Deeksha Bhalla
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Manisha Jana
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Pituitary Volume and Iron Overload Evaluation by 3T MRI in Thalassemia. Indian J Pediatr 2021; 88:656-662. [PMID: 33675027 DOI: 10.1007/s12098-020-03629-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate pituitary volume and iron overload in beta thalassemia major, with the objective of assessing the reliability of this method in predicting hypogonadism. METHODS 3T MRI was used to measure pituitary R2 and T2* in 57 beta thalassemia major patients and 30 controls. Anterior pituitary volume was evaluated by MRI planimetry. Cardiac, hepatic, and pancreatic iron overload were also assessed using MRI T2*. Mean serum ferritin was estimated by sandwich immuno-assay. Short stature was defined as height < 3 rd percentile for age, and clinical hypogonadism defined as absence of secondary sexual characteristics at ages ≥ 13 y for females and ≥ 14 y for males. RESULTS Short stature was present in 32 patients (56.1%). Of the 47 patients in the pubertal age group, 11(23.4%) had hypogonadism. Serum ferritin correlated positively with pituitary R2 (p = 0.004) and negatively with anterior pituitary volume (p = 0.006), whereas pituitary R2 correlated negatively with cardiac T2* (p = 0.001). Patients with hypogonadism had lower pituitary R2 (p = 0.186), T2* (p = 0.048), and anterior pituitary volumes (p = 0.012) compared to those with normal sexual maturity. Regardless of stature, no significant difference was observed between pituitary R2 (p = 0.267) and T2* (p = 0.451). Mean pituitary R2 in patients (78.99 Hz) was higher than in controls (20.8 Hz) (p = 0.0001). Anterior pituitary volume was lower in patients (264.83 mm3) than in controls (380.87 mm3) (p = 0.0001). A threshold value of 22.85 Hz for pituitary R2 gave a sensitivity of 84.2% and a specificity of 73.3% in distinguishing pituitary iron content of patients from controls, with an area of 0.864 under the ROC curve. CONCLUSIONS 3T MRI is a reliable method to detect pituitary iron overload and predict risk of hypogonadism in beta Thalassemia.
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Abbasi U, Abbina S, Gill A, Takuechi LE, Kizhakkedathu JN. Role of Iron in the Molecular Pathogenesis of Diseases and Therapeutic Opportunities. ACS Chem Biol 2021; 16:945-972. [PMID: 34102834 DOI: 10.1021/acschembio.1c00122] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Iron is an essential mineral that serves as a prosthetic group for a variety of proteins involved in vital cellular processes. The iron economy within humans is highly conserved in that there is no proper iron excretion pathway. Therefore, iron homeostasis is highly evolved to coordinate iron acquisition, storage, transport, and recycling efficiently. A disturbance in this state can result in excess iron burden in which an ensuing iron-mediated generation of reactive oxygen species imparts widespread oxidative damage to proteins, lipids, and DNA. On the contrary, problems in iron deficiency either due to genetic or nutritional causes can lead to a number of iron deficiency disorders. Iron chelation strategies have been in the works since the early 1900s, and they still remain the most viable therapeutic approach to mitigate the toxic side effects of excess iron. Intense investigations on improving the efficacy of chelation strategies while being well tolerated and accepted by patients have been a particular focus for many researchers over the past 30 years. Moreover, recent advances in our understanding on the role of iron in the pathogenesis of different diseases (both in iron overload and iron deficiency conditions) motivate the need to develop new therapeutics. We summarized recent investigations into the role of iron in health and disease conditions, iron chelation, and iron delivery strategies. Information regarding small molecule as well as macromolecular approaches and how they are employed within different disease pathogenesis such as primary and secondary iron overload diseases, cancer, diabetes, neurodegenerative diseases, infections, and in iron deficiency is provided.
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Affiliation(s)
- Usama Abbasi
- Centre for Blood Research, Life Sciences Institute, The University of British Columbia, Vancouver, British Columbia, Canada V6T 1Z3
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, British Columbia, Canada V6T 1Z7
| | - Srinivas Abbina
- Centre for Blood Research, Life Sciences Institute, The University of British Columbia, Vancouver, British Columbia, Canada V6T 1Z3
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, British Columbia, Canada V6T 1Z7
| | - Arshdeep Gill
- Centre for Blood Research, Life Sciences Institute, The University of British Columbia, Vancouver, British Columbia, Canada V6T 1Z3
- Department of Chemistry, The University of British Columbia, Vancouver, British Columbia, Canada V6T 1Z1
| | - Lily E. Takuechi
- Centre for Blood Research, Life Sciences Institute, The University of British Columbia, Vancouver, British Columbia, Canada V6T 1Z3
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, British Columbia, Canada V6T 1Z7
| | - Jayachandran N. Kizhakkedathu
- Centre for Blood Research, Life Sciences Institute, The University of British Columbia, Vancouver, British Columbia, Canada V6T 1Z3
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, British Columbia, Canada V6T 1Z7
- Department of Chemistry, The University of British Columbia, Vancouver, British Columbia, Canada V6T 1Z1
- The School of Biomedical Engineering, The University of British Columbia, Vancouver, British Columbia, Canada V6T 1Z3
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Singer ST, Fischer R, Allen I, Lal A, Vichinsky E, Yuan Q, Wang ZJ. Pituitary iron and factors predictive of fertility status in transfusion dependent thalassemia. Haematologica 2021; 106:1740-1744. [PMID: 33121232 PMCID: PMC8168491 DOI: 10.3324/haematol.2020.252726] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Sylvia T Singer
- Division of Hematology-Oncology, Department of Pediatrics, University of California San Francisco, UCSF Benioff Children's Hospital Oakland, Oakland, CA.
| | | | | | - Ashutosh Lal
- Division of Hematology-Oncology, Department of Pediatrics, University of California San Francisco, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Elliott Vichinsky
- Division of Hematology-Oncology, Department of Pediatrics, University of California San Francisco, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Qing Yuan
- University of Texas Southwestern Medical Center
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27
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Iron Overload in Transfusion-Dependent Indonesian Thalassemic Patients. Anemia 2021; 2021:5581831. [PMID: 33953980 PMCID: PMC8062201 DOI: 10.1155/2021/5581831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/26/2021] [Accepted: 03/30/2021] [Indexed: 01/19/2023] Open
Abstract
Thalassemia is a genetic disease caused by disruption of globin chain synthesis leading to severe anemia and thus regular blood transfusion is necessary. However, there have been known transfusions-related consequences, including iron overload and multi-organ damage. The aims of this study were to evaluate liver and cardiac function in youth and adult transfusion-dependent Indonesian thalassemic patients and to assess its correlation with serum ferritin levels, as well as T2 ∗ magnetic resonance imaging (MRI). Transfusion-dependent thalassemic (TDT) outpatients (n = 66; mean age, 21.5 ± 7.2 years) were carried out for the complete assessment consisting of blood test including liver enzyme and serum ferritin, followed by electrocardiography (ECG) and echocardiography. Subjects were also divided by serum ferritin levels into three groups: < 2500 ng/mL, 2500-5000 ng/mL, and >5000 ng/mL. Additionally, subgroup analysis in patients with T2∗ MRI assessment was conducted. In terms of age of first blood transfusion, subjects with ferritin >5000 ng/mL were the youngest among others. The alanine aminotransferase (ALT) levels in group with serum ferritin >5000 ng/mL were significantly higher than those of the group with serum ferritin <2500 ng/mL. Additionally, youth and adult TDT patients whose serum ferritin >5000 ng/mL had significantly lower tricuspid annular plane systolic excursion (TAPSE) when compared with those who had serum ferritin <2500 ng/mL. Similarly, TAPSE in patients with moderate cardiac siderosis based on cardiac T2∗ MRI was significantly lower than those without cardiac siderosis. There was significant, but only moderate correlation between serum ferritin and cardiac T2∗ MRI. Based on these findings, it is important to routinely monitor iron accumulation-related complications, including liver and cardiac damage in youth and adult TDT patients.
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Adam DL, Bowes L, Goodyear L, Moorehead PC. Conservative Management of Hyperferritinemia in Hemolytic Disease of the Fetus and Newborn: A Case Report and Review of the Literature. J Pediatr Hematol Oncol 2021; 43:73-76. [PMID: 31460887 DOI: 10.1097/mph.0000000000001586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 07/13/2019] [Indexed: 11/26/2022]
Abstract
We report a newborn with hemolytic disease of the fetus and newborn (HDFN) with rapid resolution of extreme hyperferritinemia without chelation. An infant born at 35+3 weeks with HDFN and a history of 3 intrauterine transfusions developed severe hyperferritinemia (maximum, 8258 mcg/L) without evidence of toxic iron deposition on liver biopsy. Her hyperferritinemia was managed with observation alone, and ferritin levels normalized rapidly. This case supports observation as being the preferred alternative to chelation therapy for significant hyperferritinemia in newborns with HDFN in the absence of demonstrated toxic end-organ iron deposition. We also include a review of the related available literature.
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Affiliation(s)
- Danielle L Adam
- Janeway Children's Health and Rehabilitation Centre
- Division of Pediatric Respirology, University of Alberta, Stollery Children's Hospital, Alberta, Canada
| | - Lynette Bowes
- Section of Pediatric Hematology/Oncology, Janeway Children's Health and Rehabilitation Centre
- Faculty of Medicine
| | - Lisa Goodyear
- Section of Pediatric Hematology/Oncology, Janeway Children's Health and Rehabilitation Centre
- Faculty of Medicine
| | - Paul C Moorehead
- Section of Pediatric Hematology/Oncology, Janeway Children's Health and Rehabilitation Centre
- Faculty of Medicine
- Janeway Pediatric Research Unit, Memorial University, St. John's, NL
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Huang J, Shen J, Yang Q, Cheng Z, Chen X, Yu T, Zhong J, Su Y, Guo H, Liang B. Quantification of pancreatic iron overload and fat infiltration and their correlation with glucose disturbance in pediatric thalassemia major patients. Quant Imaging Med Surg 2021; 11:665-675. [PMID: 33532266 DOI: 10.21037/qims-20-292] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background Diabetes mellitus affects more than a quarter of patients with thalassemia major (TM) worldwide, and increases the risk for cardiac complications, contributing to significant morbidity. Pancreatic iron overload (IO) and fat infiltration have been correlated with this endocrinal complication in adult TM patients. It has been shown that in adult TM patients, iron accumulation and fat infiltration are found to be heterogeneous in the pancreatic head, body, and tail region. R2* and a fat fraction (FF) generated by gradient-echo imaging can be used as quantitative parameters to assess the iron and fat contents of the pancreas. This study aimed to determine the pattern of pancreatic iron accumulation and fat infiltration in pediatric TM patients with gradient-echo imaging and evaluate the association between pancreatic IO and fat infiltration and glucose disturbances. Methods A total of 90 children with TM (10.7±3.1 years) were included. All patients underwent pancreatic magnetic resonance imaging (MRI) using multi-echo gradient-echo sequences. IO was measured by R2* relaxometry in 90 patients, and FF values were measured using iterative decomposition of water and fat with echo asymmetry and the least-squares estimation (IDEAL) method in 40 patients. R2* and FF were assessed in the pancreatic head, body, and tail. The global R2* and global FF values were obtained by averaging the respective values from the pancreatic head, body, and tail. The correlations between global R2*, global FF, and fasting glucose were determined using Spearman's correlation analysis. The Friedman test was used to compare R2* and FF among different pancreatic regions. Receiver operating characteristic (ROC) analysis was used to determine the performance of global R2* and global FF in discriminating impaired fasting glucose from normal fasting glucose patients. Results The global R2* was positively correlated with the global FF in the pancreas (r=0.895, P<0.001). No significant differences were found in R2* among the 3 regions of the pancreas (χ2=4.050, P=0.132), but significant differences were found in FF among the 3 pancreatic regions (χ2=16.350, P<0.001). Both global pancreatic R2* (r=0.408, P<0.001) and global FF (r=0.523, P=0.001) were positively correlated with fasting glucose. ROC analysis showed that global pancreatic R2* and global FF had an area under the curve of 0.769 and 0.931 (both P<0.001), respectively, in discriminating between impaired and normal glucose function patients. Conclusions Pediatric TM patients can have homogeneous iron siderosis and heterogeneous fat infiltration in the pancreas as measured by gradient-echo imaging, both of which are risk factors for diabetes.
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Affiliation(s)
- Jingwen Huang
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jun Shen
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qihua Yang
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ziliang Cheng
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaodong Chen
- Department of Radiology, Affiliated hospital of Guangdong Medical University, Zhanjiang, China
| | - Taihui Yu
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jinglian Zhong
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yun Su
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hua Guo
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University, Beijing, China
| | - Biling Liang
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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Naghavi B, Fattahi H, Parsaee M, Rezaeian N, Azarkeivan A, Meimand S, Mohammadi K. Comparison between two and three-dimensional speckle-tracking echocardiography and cardiac T2* magnetic resonance imaging in ß-thalassemia. Res Cardiovasc Med 2021. [DOI: 10.4103/rcm.rcm_15_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Jiang X, Hintenlang DE, White RD. Lower limit of iron quantification using dual-energy CT - a phantom study. J Appl Clin Med Phys 2020; 22:299-307. [PMID: 33369002 PMCID: PMC7856509 DOI: 10.1002/acm2.13124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/08/2020] [Accepted: 11/20/2020] [Indexed: 11/29/2022] Open
Abstract
Purpose Dual‐energy computed tomography (DECT) has been proposed for quantification of hepatic iron concentration (IC). However, the lower limit of quantification (LLOQ) has not been established, limiting the clinical adoption of this technology. In this study, we aim to (a) establish the LLOQ using phantoms and (b) investigate the effects of patient size, dose level, energy combination, and reconstruction method. Methods Three phantom sizes and eight vials of ferric nitrate solution with IC ranging from 0 to 10 mg/ml were used. DECT scans were performed at 80/140 and 100/140Sn kVp, and using five different levels of CT dose index (CTDI). An image‐domain three‐material‐decomposition algorithm was used to calculate the IC. The LLOQ was determined based on the coefficient of variation from repeated measurements. Results The measured IC correlated strongly with the true IC in the small and medium phantoms (R2 of linear regression > 0.99) and moderately in the large phantom (0.8 < R2<0.9). The LLOQ improved with increased CTDI. At 30 mGy, the LLOQ was found to be 0.50/1.73/6.25 mg/ml in the small/medium/large phantoms, respectively. 80/140Sn kVp resulted in superior LLOQ for all phantom sizes compared to 100/140Sn kVp, primarily due to the difference in their iron enhancement ratios (1.94 and 1.55, respectively). Iterative reconstruction was found to further improve the LLOQ (by ~ 11%), whereas reconstruction kernel smoothness had negligible effect. The LLOQ of iron was significantly higher than that of iodine due to its lack of a useful k‐edge and lower enhancement ratio. Conclusion Iron quantification at clinically important levels was achieved in a small‐ and a medium‐sized phantom using DECT, but proved challenging in a large phantom. Wide spectral separation and accurate calibration were found to be critical to the success of the technology.
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Affiliation(s)
- Xia Jiang
- Department of Radiology, Ohio State University College of Medicine, Columbus, OH, USA
| | - David E Hintenlang
- Department of Radiology, Ohio State University College of Medicine, Columbus, OH, USA
| | - Richard D White
- Department of Radiology, Ohio State University College of Medicine, Columbus, OH, USA
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Amin KA. Editorial for “Rosette Trajectories Enable Motion Robust, Simultaneous Cardiac and Liver
T
2
* Iron Assessment”. J Magn Reson Imaging 2020; 52:1699-1700. [DOI: 10.1002/jmri.27263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 11/06/2022] Open
Affiliation(s)
- Kathan A. Amin
- Department of Radiology University of Washington 1959 NE Pacific Street, Box 357115 Seattle Washington 98195 USA
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Pinto VM, Forni GL. Management of Iron Overload in Beta-Thalassemia Patients: Clinical Practice Update Based on Case Series. Int J Mol Sci 2020; 21:E8771. [PMID: 33233561 PMCID: PMC7699680 DOI: 10.3390/ijms21228771] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/14/2020] [Accepted: 11/18/2020] [Indexed: 12/29/2022] Open
Abstract
Thalassemia syndromes are characterized by the inability to produce normal hemoglobin. Ineffective erythropoiesis and red cell transfusions are sources of excess iron that the human organism is unable to remove. Iron that is not saturated by transferrin is a toxic agent that, in transfusion-dependent patients, leads to death from iron-induced cardiomyopathy in the second decade of life. The availability of effective iron chelators, advances in the understanding of the mechanism of iron toxicity and overloading, and the availability of noninvasive methods to monitor iron loading and unloading in the liver, heart, and pancreas have all significantly increased the survival of patients with thalassemia. Prolonged exposure to iron toxicity is involved in the development of endocrinopathy, osteoporosis, cirrhosis, renal failure, and malignant transformation. Now that survival has been dramatically improved, the challenge of iron chelation therapy is to prevent complications. The time has come to consider that the primary goal of chelation therapy is to avoid 24-h exposure to toxic iron and maintain body iron levels within the normal range, avoiding possible chelation-related damage. It is very important to minimize irreversible organ damage to prevent malignant transformation before complications set in and make patients ineligible for current and future curative therapies. In this clinical case-based review, we highlight particular aspects of the management of iron overload in patients with beta-thalassemia syndromes, focusing on our own experience in treating such patients. We review the pathophysiology of iron overload and the different ways to assess, quantify, and monitor it. We also discuss chelation strategies that can be used with currently available chelators, balancing the need to keep non-transferrin-bound iron levels to a minimum (zero) 24 h a day, 7 days a week and the risk of over-chelation.
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Affiliation(s)
- Valeria Maria Pinto
- Centro della Microcitemia e delle Anemie Congenite Ente Ospedaliero Ospedali Galliera, Via Volta 6, 16128 Genoa, Italy;
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Abstract
Iron overload is a common clinical problem resulting from hereditary hemochromatosis or secondary hemosiderosis (mainly associated with transfusion therapy), being also associated with chronic liver diseases and metabolic disorders. Excess of iron accumulates in organs like the liver, pancreas and heart. Without treatment, patients with iron overload disorders will develop liver cirrhosis, diabetes and cardiomyopathy. Iron quantification is therefore crucial not only for diagnosis of iron overload but also to monitor iron-reducing therapies. Liver iron concentration is considered the surrogate marker of total body iron stores. Because liver biopsy is invasive and prone to high variability and sampling bias, MR imaging has emerged as a non-invasive method and gained wide acceptance, now being considered the standard of care for assessing iron overload. Nevertheless, there are different MR techniques for iron quantification and there is still no consensus about the best technique or postprocessing tool for hepatic iron quantification, with the choice of imaging technique depending mainly on the local expertise as well on the available equipment and software. Because different methods should not be used interchangeably, it is important to choose one method and use the same one when following up patients over time.
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Affiliation(s)
- Manuela França
- Radiology Department - Centro Hospitalar Universitário do Porto, Largo Prof Abel Salazar, 4099-001, Porto, Portugal.
- Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, I3S, Instituto de Investigação e Inovação em Saúde, Porto, Portugal.
| | - João Gomes Carvalho
- Radiology Department - Centro Hospitalar Universitário do Porto, Largo Prof Abel Salazar, 4099-001, Porto, Portugal
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Thomaides-Brears HB, Lepe R, Banerjee R, Duncker C. Multiparametric MR mapping in clinical decision-making for diffuse liver disease. Abdom Radiol (NY) 2020; 45:3507-3522. [PMID: 32761254 PMCID: PMC7593302 DOI: 10.1007/s00261-020-02684-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/12/2020] [Accepted: 07/22/2020] [Indexed: 02/07/2023]
Abstract
Accurate diagnosis, monitoring and treatment decisions in patients with chronic liver disease currently rely on biopsy as the diagnostic gold standard, and this has constrained early detection and management of diseases that are both varied and can be concurrent. Recent developments in multiparametric magnetic resonance imaging (mpMRI) suggest real potential to bridge the diagnostic gap between non-specific blood-based biomarkers and invasive and variable histological diagnosis. This has implications for the clinical care and treatment pathway in a number of chronic liver diseases, such as haemochromatosis, steatohepatitis and autoimmune or viral hepatitis. Here we review the relevant MRI techniques in clinical use and their limitations and describe recent potential applications in various liver diseases. We exemplify case studies that highlight how these techniques can improve clinical practice. These techniques could allow clinicians to increase their arsenals available to utilise on patients and direct appropriate treatments.
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Affiliation(s)
| | - Rita Lepe
- Texas Liver Institute, 607 Camden St, Suite 101, San Antonio, TX, 78215, USA
| | | | - Carlos Duncker
- Perspectum, 600 N. Pearl St. Suite 1960, Plaza of The Americas, Dallas, TX, 75201, USA
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Silvilairat S, Charoenkwan P, Saekho S, Tantiworawit A, Srichairatanakool S. Early detection of ventricular dysfunction by tissue Doppler echocardiography related to cardiac iron overload in patients with thalassemia. Int J Cardiovasc Imaging 2020; 37:91-98. [PMID: 32728990 DOI: 10.1007/s10554-020-01949-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/20/2020] [Indexed: 01/18/2023]
Abstract
Cardiac T2* MRI is used as a gold standard for cardiac iron quantification in patients with transfusion-dependent thalassemia (TDT). We hypothesized that left ventricular (LV) diastolic dysfunction would reflect the severity of iron overload and can serve as an early detection of cardiac iron deposits. A study was conducted on all patients with TDT. Hemoglobin, serum ferritin and non-transferrin bound iron, together with a complete echocardiography and cardiac T2* MRI, were performed on all patients. Seventy-seven patients with TDT were enrolled (median age 14 years). In the patient group with a mean serum ferritin of > 2500 ng/mL during the past 12 months, there were more patients with severe cardiac iron deposits than in the group with a mean serum ferritin of ≤ 2500 ng/mL. Diastolic dysfunction was absent in all patients with a serum ferritin of < 1000 ng/mL. All patients with cardiac T2* ≤ 20 ms had grade III LV diastolic dysfunction. However, twenty-one percent of patients with cardiac T2* > 20 ms had LV diastolic dysfunction. The differences observed in pulmonary vein atrial reversal duration and mitral A-wave (PVAR-MVA) duration ≥ - 1 ms and an E/E' ratio ≥ 11 were proven to be the associated factors with the cardiac T2* ≤ 20 ms. Increased PVAR-MVA duration and increased E/E' ratio reliably reflected a severe iron overload, according to a cardiac T2* in patients with TDT. LV diastolic dysfunction can occur prior to severe cardiac iron deposition. Tissue Doppler echocardiography has the potential for the early detection of cardiac involvement in patients with TDT .
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Affiliation(s)
- Suchaya Silvilairat
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand.
| | - Pimlak Charoenkwan
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Suwit Saekho
- Department of Radiologic Technology, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand.,Biomedical Engineering Center, Faculty of Engineering, Chiang Mai University, Chiang Mai, Thailand
| | - Adisak Tantiworawit
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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37
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Strategies for managing transfusional iron overload: conventional treatments and novel strategies. Curr Opin Hematol 2020; 26:139-144. [PMID: 30855336 DOI: 10.1097/moh.0000000000000499] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW For individuals who have transfusion-dependent anemia, iron overload is the long-term complication, which results in significant morbidity. Ameliorating this is now the biggest unmet need. This review specifically addresses this issue. RECENT FINDINGS Over the last decade or so, major advances in the treatment of these individuals, has resulted from novel strategies aimed at reducing transfusion requirement as well as optimizing chelation therapy. This review will summarize these advances and provide insights into some of the therapies in the pipeline. Strategies aimed at reducing transfusion requirement include modulation of erythropoietic regulation by reducing ineffective red cell production through activin trapping, as well as stem cell gene modification approaches, which aim for a cure, and transfusion independence. Refined means of assessing tissue iron and the introduction of oral chelators have facilitated tailoring chelation regimens with closer monitoring and improved compliance. Newer approaches to ameliorate iron toxicity have focused on the hepcidin pathway, all of which would result in increased hepcidin levels and reduction of iron absorption from the intestine, sequestration of iron in normal storage sites and reduced exposure of more susceptible organs, such as the heart and endocrine organs, to the toxic effects of increased iron. SUMMARY These advances offer the promise of improved management of transfusion-dependent individuals.
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Lopes IDCC, Schütze M, Bolina MB, de Oliveira Sobrinho TÂ, Ramos LFM, Diniz RLFC, Fernandes JDL, Siqueira MHA. Comparison of automated and manual protocols for magnetic resonance imaging assessment of liver iron concentration. Radiol Bras 2020; 53:148-154. [PMID: 32587421 PMCID: PMC7302902 DOI: 10.1590/0100-3984.2019.0029] [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] [Indexed: 01/19/2023] Open
Abstract
Objective To compare automated and manual magnetic resonance imaging protocols for estimating liver iron concentrations at 1.5 T. Materials and Methods Magnetic resonance imaging examination of the liver was performed in 53 patients with clinically suspected hepatic iron overload and in 21 control subjects. Liver iron concentrations were then estimated by two examiners who were blinded to the groups. The examiners employed automated T2* and T1 mapping, as well as manual T2* and signal-intensity-ratio method. We analyzed accuracy by using ROC curves. Interobserver and intraobserver agreement were analyzed by calculating two-way intraclass correlation coefficients. Results The area under the ROC curve (to discriminate between patients and controls) was 0.912 for automated T2* mapping, 0.934 for the signal-intensity-ratio method, 0.908 for manual T2*, and 0.80 for T1 mapping, the last method differing significantly from the other three. The level of interobserver and intraobserver agreement was good (intraclass correlation coefficient, 0.938-0.998; p < 0.05). Correlations involving T1 mapping, although still significant, were lower. Conclusion At 1.5 T, T2* mapping is a rapid tool that shows promise for the diagnosis of liver iron overload, whereas T1 mapping shows less accuracy. The performance of T1 mapping is poorer than is that of T2* methods.
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Affiliation(s)
- Izabella de Campos Carvalho Lopes
- Radiology and Diagnostic Imaging, Hospital Mater Dei, Pós-Graduação Ciências Médicas de Minas Gerais (PGCM-MG), Belo Horizonte, MG, Brazil
| | - Manuel Schütze
- Radiology and Diagnostic Imaging, Hospital Mater Dei, Pós-Graduação Ciências Médicas de Minas Gerais (PGCM-MG), Belo Horizonte, MG, Brazil
| | - Marina Borges Bolina
- Radiology and Diagnostic Imaging, Hospital Mater Dei, Pós-Graduação Ciências Médicas de Minas Gerais (PGCM-MG), Belo Horizonte, MG, Brazil
| | | | - Laura Filgueiras Mourão Ramos
- Radiology and Diagnostic Imaging, Hospital Mater Dei, Pós-Graduação Ciências Médicas de Minas Gerais (PGCM-MG), Belo Horizonte, MG, Brazil
| | | | | | - Maria Helena Albernaz Siqueira
- Radiology and Diagnostic Imaging, Hospital Mater Dei, Pós-Graduação Ciências Médicas de Minas Gerais (PGCM-MG), Belo Horizonte, MG, Brazil
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Evaluation of liver iron overload with R2* relaxometry with versus without fat suppression: both are clinically accurate but there are differences. Eur Radiol 2020; 30:5826-5833. [PMID: 32535737 DOI: 10.1007/s00330-020-07010-5] [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] [Received: 01/22/2020] [Revised: 04/28/2020] [Accepted: 06/04/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To assess clinically relevant difference in hepatic iron quantification using R2* relaxometry with (FS) and without (non-FS) fat saturation for the evaluation of patients with suspected hepatic iron overload. METHODS We prospectively enrolled 134 patients who underwent 1.5-T MRI R2* relaxometry with FS and non-FS gradient echo sequences (12 echoes, initial TE = 0.99 ms). Proton density fat fraction for the quantification of steatosis was assessed. Linear regression analyses and Bland-Altman plots including Lin's concordance correlation coefficient were performed for correlation of FS R2* with non-FS R2*. Patients were grouped into 4 severity classes of iron overload (EASL based), and agreement was evaluated by contingency tables and the proportion of overall agreement. RESULTS A total of 41.8% of patients showed hepatic iron overload; 67.9% had concomitant steatosis; and 58.2% revealed no iron overload of whom 60.3% had steatosis. The mean R2* value for all FS data was 102.86 1/s, for non-FS 108.16 1/s. Linear regression resulted in an R-squared value of 0.99 (p < 0.001); Bland-Altman plot showed a mean R2* difference of 5.26 1/s (SD 17.82). The concordance correlation coefficient was only slightly lower for patients with steatosis compared with non-steatosis (0.988 vs. 0.993). The overall agreement between FS and non-FS R2* measurements was 94.8% using either method to classify patients according to severity of iron storage. No correlation between R2* and proton density fat fraction was found for both methods. CONCLUSION R2* relaxometry showed an excellent overall agreement between FS and non-FS acquisition. Both variants can therefore be used in daily routine. However, clinically relevant differences might result when switching between the two methods or during patient follow-up, when fat content changes over time. We therefore recommend choosing a method and keeping it straight in the context of follow-up examinations. KEY POINTS • Both variants of R2* relaxometry (FS and non-FS) may be used in daily routine. • Clinically relevant differences might result when switching between the two methods or during patient follow-up, when fat content changes over time. • It seems advisable choosing one method and keeping it straight in the context of follow-up examinations.
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Doyle E, Ghugre N, Coates TD, Wood JC. Fixing the MRI R2-iron calibration in liver. Am J Hematol 2020; 95:E120-E122. [PMID: 32048331 DOI: 10.1002/ajh.25754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/03/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Eamon Doyle
- Department of BioengineeringUSC Viterbi School of Engineering Los Angeles California
| | | | - Thomas D. Coates
- Children's Hospital of Los AngelesUSC Keck School of Medicine Los Angeles California
| | - John C. Wood
- Children's Hospital of Los AngelesUSC Keck School of Medicine Los Angeles California
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Piperno A, Pelucchi S, Mariani R. Inherited iron overload disorders. Transl Gastroenterol Hepatol 2020; 5:25. [PMID: 32258529 DOI: 10.21037/tgh.2019.11.15] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/12/2019] [Indexed: 12/21/2022] Open
Abstract
Hereditary iron overload includes several disorders characterized by iron accumulation in tissues, organs, or even single cells or subcellular compartments. They are determined by mutations in genes directly involved in hepcidin regulation, cellular iron uptake, management and export, iron transport and storage. Systemic forms are characterized by increased serum ferritin with or without high transferrin saturation, and with or without functional iron deficient anemia. Hemochromatosis includes five different genetic forms all characterized by high transferrin saturation and serum ferritin, but with different penetrance and expression. Mutations in HFE, HFE2, HAMP and TFR2 lead to inadequate or severely reduced hepcidin synthesis that, in turn, induces increased intestinal iron absorption and macrophage iron release leading to tissue iron overload. The severity of hepcidin down-regulation defines the severity of iron overload and clinical complications. Hemochromatosis type 4 is caused by dominant gain-of-function mutations of ferroportin preventing hepcidin-ferroportin binding and leading to hepcidin resistance. Ferroportin disease is due to loss-of-function mutation of SLC40A1 that impairs the iron export efficiency of ferroportin, causes iron retention in reticuloendothelial cell and hyperferritinemia with normal transferrin saturation. Aceruloplasminemia is caused by defective iron release from storage and lead to mild microcytic anemia, low serum iron, and iron retention in several organs including the brain, causing severe neurological manifestations. Atransferrinemia and DMT1 deficiency are characterized by iron deficient erythropoiesis, severe microcytic anemia with high transferrin saturation and parenchymal iron overload due to secondary hepcidin suppression. Diagnosis of the different forms of hereditary iron overload disorders involves a sequential strategy that combines clinical, imaging, biochemical, and genetic data. Management of iron overload relies on two main therapies: blood removal and iron chelators. Specific therapeutic options are indicated in patients with atransferrinemia, DMT1 deficiency and aceruloplasminemia.
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Affiliation(s)
- Alberto Piperno
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Centre for Rare Diseases, Disorder of Iron Metabolism, ASST-Monza, S. Gerardo Hospital, Monza, Italy
| | - Sara Pelucchi
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Raffaella Mariani
- Centre for Rare Diseases, Disorder of Iron Metabolism, ASST-Monza, S. Gerardo Hospital, Monza, Italy
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Ganz T, Aronoff GR, Gaillard CAJM, Goodnough LT, Macdougall IC, Mayer G, Porto G, Winkelmayer WC, Wish JB. Iron Administration, Infection, and Anemia Management in CKD: Untangling the Effects of Intravenous Iron Therapy on Immunity and Infection Risk. Kidney Med 2020; 2:341-353. [PMID: 32734254 PMCID: PMC7380433 DOI: 10.1016/j.xkme.2020.01.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Patients with chronic kidney disease (CKD) are at increased risk for infection, attributable to immune dysfunction, increased exposure to infectious agents, loss of cutaneous barriers, comorbid conditions, and treatment-related factors (eg, hemodialysis and immunosuppressant therapy). Because iron plays a vital role in pathogen reproduction and host immunity, it is biologically plausible that intravenous iron therapy and/or iron deficiency influence infection risk in CKD. Available data from preclinical experiments, observational studies, and randomized controlled trials are summarized to explore the interplay between intravenous iron and infection risk among patients with CKD, particularly those receiving maintenance hemodialysis. The current evidence base, including data from a recent randomized controlled trial, suggests that proactive judicious use of intravenous iron (in a manner that minimizes the accumulation of non-transferrin-bound iron) beneficially replaces iron stores while avoiding a clinically relevant effect on infection risk. In the absence of an urgent clinical need, intravenous iron therapy should be avoided in patients with active infection. Although serum ferritin concentration and transferrin saturation can help guide clinical decision making about intravenous iron therapy, definition of an optimal iron status and its precise determination in individual patients remain clinically challenging in CKD and warrant additional study.
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Affiliation(s)
- Tomas Ganz
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA
| | | | | | - Lawrence T Goodnough
- Department of Pathology, Stanford University, Stanford, CA.,Department of Medicine (Hematology), Stanford University, Stanford, CA
| | - Iain C Macdougall
- Department of Renal Medicine, King's College Hospital, London, United Kingdom
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Graça Porto
- Pathology and Molecular Immunology Department, Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Porto, Portugal.,i3S, Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
| | - Wolfgang C Winkelmayer
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX
| | - Jay B Wish
- Division of Nephrology, Indiana University Health, Indianapolis, IN
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Zhou Y, Meng JL, Feng L, Huang YH, Ye J, Li M, Xu ZY, Li XW, Yuan F, Song B. Abdominal magnetic resonance imaging examination of Tibetan patients with abnormal iron metabolism and a preliminary study of correlations with blood cell analysis. J Int Med Res 2020; 48:300060520905483. [PMID: 32228088 PMCID: PMC7133079 DOI: 10.1177/0300060520905483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE The objective was to investigate factors influencing the high incidence of abnormal iron metabolism in a Tibetan population. METHODS This was a retrospective observational study. Magnetic resonance imaging and blood analysis of 363 Tibetan patients were performed and patients divided into normal and abnormal groups based on the clinical diagnostic standard. The upper limit of normal liver iron content was 50 μmol/g. We analyzed the association between abnormal iron metabolism and blood cell indicators using the Spearman rank correlation test. RESULTS In male patients, differences in mean corpuscular hemoglobin (MCH) and MCH concentration in blood between the normal and abnormal groups were significant. Abnormal iron metabolism in male patients was positively correlated with MCH and MCH concentration. In female patients, differences in erythrocytes, hemoglobin, and hematocrit levels between the two groups were significant. Erythrocyte counts and hemoglobin and hematocrit levels of female patients were positively correlated. CONCLUSION Iron overload in male patients was correlated with an increase in MCH and MCH concentration, and that in female patients was correlated with levels of erythrocytes, hemoglobin, and hematocrit. The incidence rate of iron overload was higher in males than in females and was correlated with age in this Tibetan population.
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Affiliation(s)
- Yi Zhou
- Department of Radiology, Hospital of Chengdu office of People’s Government of Tibetan Autonomous Region (Hospital C. T.), Chengdu, China
| | - Jin-Li Meng
- Department of Radiology, Hospital of Chengdu office of People’s Government of Tibetan Autonomous Region (Hospital C. T.), Chengdu, China
| | - Li Feng
- Department of Radiology, Hospital of Chengdu office of People’s Government of Tibetan Autonomous Region (Hospital C. T.), Chengdu, China
| | - Yong-Hong Huang
- Department of Radiology, Hospital of Chengdu office of People’s Government of Tibetan Autonomous Region (Hospital C. T.), Chengdu, China
| | - Jin Ye
- Department of Radiology, Hospital of Chengdu office of People’s Government of Tibetan Autonomous Region (Hospital C. T.), Chengdu, China
| | - Man Li
- Department of Radiology, Hospital of Chengdu office of People’s Government of Tibetan Autonomous Region (Hospital C. T.), Chengdu, China
| | - Zhong-You Xu
- Department of Radiology, Hospital of Chengdu office of People’s Government of Tibetan Autonomous Region (Hospital C. T.), Chengdu, China
| | - Xiang-Wei Li
- Department of Radiology, Hospital of Chengdu office of People’s Government of Tibetan Autonomous Region (Hospital C. T.), Chengdu, China
| | - Fang Yuan
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Bin Song
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
- Bin Song, Department of Radiology, West China Hospital, Sichuan University, 37 Guoxue Alley, Wu Hou District, Chengdu, 610041, P. R. China.
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Liu B, Pan X, Liu Z, Han M, Xu G, Dai X, Wang W, Zhang H, Xie L. Fecal microbiota as a noninvasive biomarker to predict the tissue iron accumulation in intestine epithelial cells and liver. FASEB J 2020; 34:3006-3020. [PMID: 31912587 DOI: 10.1096/fj.201901635rr] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 12/06/2019] [Accepted: 12/16/2019] [Indexed: 12/12/2022]
Abstract
Iron is an essential trace mineral required for growth, metabolism, and immune response. Dysregulation of iron homeostasis is linked with the development and progression of various diseases. Iron accumulation is associated with inflammatory diseases and cancer, while iron deficiency leads to the growth retardation. Several studies have suggested that iron imbalance results in alteration of gut microbiota, leading to the disruption of microbial diversity, the increase of pathogen abundance, and the induction of intestinal inflammation. However, in screening studies done in the past decades, the association between the iron availability and gut microbiota has not been systemically explored. Furthermore, a noninvasive and convenient approach to determine the iron levels in tissues is lacking. In the present study, a murine model for iron dysregulation was established. 16S rRNA amplicon sequencing and bioinformatic algorithms were used to identify the key taxa. Using the key taxa identified and machine learning models, we established an easily accessible prediction model, which could accurately distinguish between iron-deprived or iron-fortified condition. This prediction model could precisely predict the iron level of the intestinal epithelial cells and the liver and could be used for early diagnosis of iron dysbiosis-related diseases, in a noninvasive manner, in the future.
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Affiliation(s)
- Bingdong Liu
- State Key Laboratory of Applied Microbiology Southern China, Guangdong Provincial Key Laboratory of Microbial Culture Collection and Application, Guangdong Open Laboratory of Applied Microbiology, Guangdong Institute of Microbiology, Guangdong Academy of Sciences, Guangdong, China.,The First Affiliated Hospital of Jinan University, Guangdong, China
| | - Xiaohan Pan
- State Key Laboratory of Applied Microbiology Southern China, Guangdong Provincial Key Laboratory of Microbial Culture Collection and Application, Guangdong Open Laboratory of Applied Microbiology, Guangdong Institute of Microbiology, Guangdong Academy of Sciences, Guangdong, China
| | - Zhihong Liu
- State Key Laboratory of Applied Microbiology Southern China, Guangdong Provincial Key Laboratory of Microbial Culture Collection and Application, Guangdong Open Laboratory of Applied Microbiology, Guangdong Institute of Microbiology, Guangdong Academy of Sciences, Guangdong, China
| | - Mulan Han
- State Key Laboratory of Applied Microbiology Southern China, Guangdong Provincial Key Laboratory of Microbial Culture Collection and Application, Guangdong Open Laboratory of Applied Microbiology, Guangdong Institute of Microbiology, Guangdong Academy of Sciences, Guangdong, China
| | - Guohuan Xu
- State Key Laboratory of Applied Microbiology Southern China, Guangdong Provincial Key Laboratory of Microbial Culture Collection and Application, Guangdong Open Laboratory of Applied Microbiology, Guangdong Institute of Microbiology, Guangdong Academy of Sciences, Guangdong, China
| | - Xiaoshuang Dai
- BGI Institute of Applied Agriculture, BGI-Shenzhen, Guangdong, China
| | - Wei Wang
- College of Veterinary Medicine, Jilin University, Jilin, China
| | - Huabing Zhang
- Department of Biochemistry and Molecular Biology, School of Basic Medicine, Anhui Medical University, Anhui, China
| | - Liwei Xie
- State Key Laboratory of Applied Microbiology Southern China, Guangdong Provincial Key Laboratory of Microbial Culture Collection and Application, Guangdong Open Laboratory of Applied Microbiology, Guangdong Institute of Microbiology, Guangdong Academy of Sciences, Guangdong, China.,Zhujiang Hospital, Southern Medical University, Guangdong, China
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Brissot E, Bernard DG, Loréal O, Brissot P, Troadec MB. Too much iron: A masked foe for leukemias. Blood Rev 2020; 39:100617. [DOI: 10.1016/j.blre.2019.100617] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 08/20/2019] [Accepted: 08/30/2019] [Indexed: 02/07/2023]
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Coates TD. Iron overload in transfusion-dependent patients. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:337-344. [PMID: 31808901 PMCID: PMC6913424 DOI: 10.1182/hematology.2019000036] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Before the advent of effective iron chelation, death from iron-induced cardiomyopathy occurred in the second decade in patients with transfusion-dependent chronic anemias. The advances in our understanding of iron metabolism; the ability to monitor iron loading in the liver, heart, pancreas and pituitary; and the availability of several effective iron chelators have dramatically improved survival and reduced morbidity from transfusion-related iron overload. Nevertheless, significantly increased survival brings about new complications such as malignant transformation resulting from prolonged exposure to iron, which need to be considered when developing long-term therapeutic strategies. This review discusses the current biology of iron homeostasis and its close relation to marrow activity in patients with transfusion-dependent anemias, and how biology informs clinical approach to treatment.
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Affiliation(s)
- Thomas D Coates
- Hematology Section, Children's Center for Cancer, Blood Diseases and Bone Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
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Woei-A-Jin FJSH, Zheng SZ, Kiliçsoy I, Hudig F, Luelmo SAC, Kroep JR, Lamb HJ, Osanto S. Lifetime Transfusion Burden and Transfusion-Related Iron Overload in Adult Survivors of Solid Malignancies. Oncologist 2019; 25:e341-e350. [PMID: 32043782 DOI: 10.1634/theoncologist.2019-0222] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 07/31/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Limited data exist on transfusion burden and transfusion-related iron overload in adult survivors of solid malignancies. METHODS Hospital-specific cancer registry data of patients with solid tumor receiving systemic anticancer treatment between January 2008 and September 2009 at the Oncology Department of the Leiden University Medical Center (The Netherlands) were retrieved and cross-referenced with red blood cell (RBC) transfusion records. Individual lifetime transfusion burden was captured in April 2015. Multitransfused long-term survivors with serum ferritin >500 μg/L were subsequently screened for hepatic and cardiac iron overload using 1.5 Tesla magnetic resonance imaging. RESULTS The study population consisted of 775 adult patients with solid cancer (45.2% male; median age, 58 years; >75% chemotherapy-treated), 423 (54.6%) of whom were transfused with a median of 6.0 RBC units (range 1-67). Transfusion triggers were symptomatic anemia or hemoglobin <8.1-8.9 g/dL prior to each myelosuppressive chemotherapy cycle. We identified 123 (15.9%) patients across all tumor types with a lifetime transfusion burden of ≥10 RBC units. In the absence of a hemovigilance program, none of these multitransfused patients was screened for iron overload despite a median survival of 4.6 years. In 2015 at disclosure of transfusion burden, 26 multitransfused patients were alive. Six (23.1%) had hepatic iron overload: 3.9-11.2 mg Fe/g dry weight. No cardiac iron depositions were found. CONCLUSION Patients with solid malignancies are at risk for multitransfusion and iron overload even when adhering to restrictive RBC transfusion policies. With improved long-term cancer survivorship, increased awareness of iatrogenic side effects of supportive therapy and development of evidence-based guidelines are essential. IMPLICATIONS FOR PRACTICE In the presence of a restrictive transfusion policy, ∼30% of transfused adult patients with solid cancer are multitransfused and ∼50% become long-term survivors, underscoring the need for evidence-based guidelines for the detection and management of transfusion-related iron overload in this group of patients. In each institution, a hemovigilance program should be implemented that captures the lifetime cumulative transfusion burden in all patients with cancer, irrespective of tumor type. This instrument will allow timely assessment and treatment of iron overload in cancer survivors, thus preventing organ dysfunction and decreased quality of life.
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Affiliation(s)
- F J Sherida H Woei-A-Jin
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Laboratory of Clinical Chemistry and Hematology, Haga Hospital, The Hague, The Netherlands
| | - Shu Zhen Zheng
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Inci Kiliçsoy
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Francisca Hudig
- Department of Laboratory of Clinical Chemistry and Hematology, Haga Hospital, The Hague, The Netherlands
| | - Saskia A C Luelmo
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Judith R Kroep
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Susanne Osanto
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
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Fouquet C, Le Rouzic M, Leblanc T, Fouyssac F, Leverger G, Hessissen L, Marlin S, Bourrat E, Fahd M, Raffoux E, Vannier J, Jäkel N, Knoefler R, Triolo V, Pasquet M, Bayart S, Thuret I, Lutz P, Vermylen C, Touati M, Rose C, Matthes T, Isidor B, Kannengiesser C, Ducassou S. Genotype/phenotype correlations of childhood‐onset congenital sideroblastic anaemia in a European cohort. Br J Haematol 2019; 187:530-542. [DOI: 10.1111/bjh.16100] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 05/08/2019] [Indexed: 01/19/2023]
Affiliation(s)
| | | | | | | | - Guy Leverger
- CHU de Paris Hôpital Armand Trousseau Paris France
| | | | | | | | - Mony Fahd
- CHU de Paris Hôpital Robert Debré Paris France
| | | | | | - Nadja Jäkel
- Department für Hämatologie Onkologie und Hämostaseologie Leipzig Germany
| | - Ralf Knoefler
- Department of Pediatric Haemostaseology University Hospital Carl Gustav Carus Dresden Germany
| | | | | | | | | | - Patrick Lutz
- CHU de Strasbourg Hôpital de Hautepierre Strasbourg France
| | - Christiane Vermylen
- Université Catholique de Louvain, Cliniques universitaires Saint‐Luc Brussels Belgium
| | | | | | - Thomas Matthes
- Geneva University Hospital, Hematology Service Geneva Switzerland
| | | | - Caroline Kannengiesser
- Assistance Publique des Hôpitaux de Paris, Département de Génétique Hôpital Bichat, Université Paris VII Paris France
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Chang VC, Cotterchio M, Khoo E. Iron intake, body iron status, and risk of breast cancer: a systematic review and meta-analysis. BMC Cancer 2019; 19:543. [PMID: 31170936 PMCID: PMC6555759 DOI: 10.1186/s12885-019-5642-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 04/26/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Iron has been shown to promote breast carcinogenesis in animal models through generation of oxidative stress and interaction with estrogen. Heme iron, which is found exclusively in animal-sourced foods, is suggested to have a more detrimental effect. Epidemiological evidence of the association between iron and breast cancer risk remains inconclusive and has not been comprehensively summarized. This systematic review and meta-analysis evaluated associations between both iron intake and body iron status and breast cancer risk. METHODS Four electronic databases (MEDLINE, EMBASE, CINAHL, and Scopus) were searched up to December 2018 for studies assessing iron intake and/or biomarkers of iron status in relation to breast cancer risk. Using random-effects meta-analyses, pooled relative risks (RRs) and 95% confidence intervals (CIs) were calculated comparing the highest vs. lowest category of each iron measure. Dose-response meta-analyses were also performed to investigate linear and nonlinear associations. RESULTS A total of 27 studies were included in the review, of which 23 were eligible for meta-analysis of one or more iron intake/status measures. Comparing the highest vs. lowest category, heme iron intake was significantly associated with increased breast cancer risk, with a pooled RR of 1.12 (95% CI: 1.04-1.22), whereas no associations were found for dietary (1.01, 95% CI: 0.89-1.15), supplemental (1.02, 95% CI: 0.91-1.13), or total (0.97, 95% CI: 0.82-1.14) iron intake. Associations of iron status indicators with breast cancer risk were generally in the positive direction; however, a significant pooled RR was found only for serum/plasma levels (highest vs. lowest) of iron (1.22, 95% CI: 1.01-1.47), but not for ferritin (1.13, 95% CI: 0.78-1.62), transferrin saturation (1.16, 95% CI: 0.91-1.47), or total iron-binding capacity (1.10, 95% CI: 0.97-1.25). In addition, a nonlinear dose-response was observed for heme iron intake and serum iron (both Pnonlinearity < 0.05). CONCLUSIONS Heme iron intake and serum iron levels may be positively associated with breast cancer risk. Although associations were modest, these findings may have public health implications given the widespread consumption of (heme) iron-rich foods. In light of methodological and research gaps identified, further research is warranted to better elucidate the relationship between iron and breast cancer risk.
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Affiliation(s)
- Vicky C Chang
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada. .,Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, ON, M5G 2L7, Canada.
| | - Michelle Cotterchio
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada.,Prevention and Cancer Control, Cancer Care Ontario, 620 University Avenue, Toronto, ON, M5G 2L7, Canada
| | - Edwin Khoo
- Analytics and Informatics, Cancer Care Ontario, Toronto, ON, Canada
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Thyroid Disorders in Homozygous β-Thalassemia: Current Knowledge, Emerging Issues and Open Problems. Mediterr J Hematol Infect Dis 2019; 11:e2019029. [PMID: 31205633 PMCID: PMC6548211 DOI: 10.4084/mjhid.2019.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 03/08/2019] [Indexed: 12/19/2022] Open
Abstract
Changes in thyroid function and thyroid function tests occur in patients with β-thalassemia major (TM). The frequency of hypothyroidism in TM patients ranges from 4% to 29 % in different reports. The wide variation has been attributed to several factors such as patients’ genotype, age, ethnic heterogeneity, treatment protocols of transfusions and chelation, and varying compliance to treatment. Hypothyroidism is the result of primary gland failure or insufficient thyroid gland stimulation by the hypothalamus or pituitary gland. The main laboratory parameters of thyroid function are the assessments of serum thyroid-stimulating hor-mone (TSH) and serum free thyroxine (FT4). It is of primary importance to interpret these measurements within the context of the laboratory-specific normative range for each test. An elevated serum TSH level with a standard range of serum FT4 level is consistent with subclinical hypothyroidism. A low serum FT4 level with a low, or inappropriately normal, serum TSH level is consistent with secondary hypothyroidism. Doctors caring for TM patients most commonly encounter subjects with subclinical primary hypothyroidism in the second decade of life. Several aspects remain to be elucidated as the frequency of thyroid cancer and the possible existence of a relationship between thyroid dysfunction, on one hand, cardiovascular diseases, components of metabolic syndrome (insulin resistance) and hypercoagulable state, on the other hand. Further studies are needed to explain these emerging issues. Following a brief description of thyroid hormone regulation, production and actions, this article is conceptually divided into two parts; the first reports the spectrum of thyroid disease occurring in patients with TM, and the second part focuses on the emerging issues and the open problems in TM patients with thyroid disorders.
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