The association between steatosis and liver damage in transfusion-dependent beta thalassaemia patients

Liver disease in patients with transfusion-dependent β-thalassemia: The emerging role of metabolism dysfunction-associated steatotic liver disease

In this Editorial, we highlight the possible role that metabolism dysfunction-associated steatotic liver disease (MASLD) may play in the future, regarding liver disease in patients with transfusion-dependent β-thalassemia (TDBT). MASLD is characterized by excessive accumulation of fat in the liver (hepatic steatosis), in the presence of cardiometabolic factors. There is a strong correlation between the occurrence of MASLD and insulin resistance, while its increased prevalence parallels the global epidemic of diabetes mellitus (DM) and obesity. Patients with TDBT need regular transfusions for life to ensure their survival. Through these transfusions, a large amount of iron is accumulated, which causes saturation of transferrin and leads to the circulation of free iron molecules, which cause damage to vital organs (primarily the liver and myocardium). Over the past, the main mechanisms for the development of liver disease in these patients have been the toxic effect of iron on the liver and chronic hepatitis C, for which modern and effective treatments have been found, resulting in successful treatment. Additional advances in the treatment and monitoring of these patients have led to a reduction in deaths, and an increase in their life expectancy. This increased survival makes them vulnerable to the onset of diseases, which until recently were mainly related to the non-thalassemic general population, such as obesity and DM. There is insufficient data in the literature regarding the prevalence of MASLD in this population or on the risk factors for its occurrence. However, it was recently shown by a study of 45 heavily transfused patients with beta-thalassemia (Padeniya et al, BJH), that the presence of steatosis is a factor influencing the value of liver elastography and thus liver fibrosis. These findings suggest that future research in the field of liver disease in patients with TDBT should be focused on the occurrence, the risk factors, and the effect of MASLD on these patients.

Obesity, liver steatosis and metabolic syndrome: The hidden enemies in transfusion-dependent thalassaemia

In their paper, the authors quantified liver iron concentration (LIC) and hepatic steatosis (HS) using MRI-T2* technology in transfusion-dependent thalassaemia (TDT) patients and healthy controls and found that the prevalence of HS among patients with TDT was 36.4%. In comparison with healthy controls, the hepatic fat fraction (FF) was significantly higher in the TDT population (p = 0.013). Active hepatitis C virus infection, body mass index (BMI) and LIC were independent predictors of HS. An inverse correlation between hepatic FF and high-density lipoprotein cholesterol (p = 0.042) and a significant association of high glycaemia level (p = 0.037) with higher hepatic FF and a significant relationship (p = 0.026) between HS and higher BMI (though in a 'lean' group of patients) in TDT patients indicated that 'metabolic syndrome' was present in this subset with TDT. The impact of metabolic syndrome on TDT, including cardiac disease unrelated to iron overload, needs further study. Commentary on: Ricchi et al. Liver steatosis in patients with transfusion-dependent thalassaemia. Br J Haematol 2024 (Online ahead of print). doi: 10.1111/bjh.19496.

Liver steatosis in patients with transfusion-dependent thalassaemia

We evaluated the prevalence and the clinical associations of liver steatosis (LS) in patients with transfusion-dependent thalassaemia (TDT). We considered 301 TDT patients (177 females, median age = 40.61 years) enrolled in the Extension-Myocardial Iron Overload in Thalassaemia Network, and 25 healthy subjects. Magnetic resonance imaging was used to quantify iron overload and hepatic fat fraction (FF) by T2* technique and cardiac function by cine images. The glucose metabolism was assessed by the oral glucose tolerance test (OGTT). Hepatic FF was significantly higher in TDT patients than in healthy subjects (median value: 1.48% vs. 0.55%; p = 0.013). In TDT, hepatic FF was not associated with age, gender, serum ferritin levels or liver function parameters, but showed a weak inverse correlation with high-density lipoprotein cholesterol. The 36.4% of TDT patients showed LS (FF >3.7%). Active hepatitis C virus (HCV) infection, increased body mass index and hepatic iron were independent determinants of LS. A hepatic FF >3.53% predicted the presence of an abnormal OGTT. Hepatic FF was not correlated with cardiac iron, biventricular volumes or ejection fractions, but was correlated with left ventricular mass index. In TDT, LS is a frequent finding, associated with iron overload, increased weight and HCV, and conveying an increased risk for the alterations of glucose metabolism.

Correlation Between Serum Ferritin and Degree of Hepatic Fibrosis on Fibroscan in Thalassemic Patients

Aim and objective This study aimed to examine the relationship between serum ferritin levels and the degree of hepatic fibrosis as detected on Fibroscan in thalassemia patients. Materials and methods This was a single-center and cross-sectional study conducted from April 2021 to December 2022. The sample population comprised 55 beta-thalassemia patients receiving treatment at the National Institute of Blood Diseases and Bone Marrow Transplantation, Karachi, Pakistan. The data was compiled through a series of patient interviews, an examination of medical records and was analyzed to obtain the results. Descriptive statistics were used for several variables, including diagnosis, Fibroscan score, blood group, comorbidity, visceromegaly, consanguinity, serum glutamate pyruvate transaminase (SGPT), viral markers, and C reactive protein (CRP). The correlation analysis was done using Spearman's correlation test. Results There were 55 participants in the study, 40 of whom were male and 15 of whom were female. The mean age of the patients was eight years, while the average age at diagnosis was nine months with a transfusion frequency of every 20 days. Spearman's rho (r = 0.287), and the significant value of (p = 0.033) confirmed a statistically significant positive correlation between serum ferritin levels and hepatic fibrosis. On Fibroscan, 74.5% of patients had F0-F1 stage fibrosis followed by 14.5% of the patients having F2 stage fibrosis. HCV seropositivity was the most prevalent comorbidity among the patients. 80% of patients had serum ferritin levels greater than 1000 ug/mL. Hepatosplenomegaly was present in 43.6% of the patients. 78.2% of patients were born out of consanguineous marriages. Conclusion In conclusion, this study found a statistically significant positive correlation between serum ferritin levels and hepatic fibrosis in beta-thalassemia patients. The study emphasizes the significance of monitoring serum ferritin levels in thalassemia patients to prevent hepatic fibrosis.

Liver fibrosis in young patients with transfusion-dependent thalassaemia (TDT), understanding the role of steatosis

Using transient elastography Padeniya et al. detected steatosis and fibrosis in a cohort of young heavily iron overloaded patients with transfusion-dependent thalassaemia; steatosis was associated only with increasing body mass index, but not with iron overload and diabetes. Recently, great efforts have been devoted to eliminating or reducing iron overload and hepatitis C infection, which are well-recognised causes of liver damage. Thus, haematologists should be aware that steatosis and probably more complex metabolism alterations may be encountered very early in these patients and could be responsible for further liver damage. Commentary on: Padeniya et al. The association between steatosis and liver damage in transfusion-dependent beta thalassaemia patients. Br J Haematol 2023;200:517-523.