1
|
Zekavat OR, Fallah Tafti F, Bordbar M, Parand S, Haghpanah S. Iron Overload in Children With Leukemia; Identification of a Cutoff Value for Serum Ferritin Level. J Pediatr Hematol Oncol 2024; 46:e137-e142. [PMID: 38132565 DOI: 10.1097/mph.0000000000002808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To determine the prevalence of iron overload in children with acute lymphoblastic leukemia (ALL) after treatment cessation and establish a cutoff value for serum ferritin level as an indicator of iron overload. BACKGROUND Early detection and monitoring of iron overload in patients with leukemia is crucial. METHODS In this prospective cohort study, 66 pediatric patients with ALL who were treated at a tertiary referral center affiliated with Shiraz University of Medical Sciences in Shiraz, Southern Iran, were investigated from July 2020 to December 2022. Serum ferritin levels were measured 6 months after treatment completion. T2* magnetic resonance imaging of the liver and heart was done for all patients. The receiver operating characteristic curve was used to illustrate the area under the receiver operating characteristic curve to assess the diagnostic value of serum ferritin level and total transfusion volume. RESULTS A total of 24 patients (36.4%) had iron overload in the heart or liver based on T2 magnetic resonance imaging findings. Serum ferritin level was a highly accurate diagnostic marker for iron overload in pediatric patients with ALL, with a sensitivity of 95.8%, and specificity of 85.7% for a cutoff value of 238.5 ng/mL. Also, blood transfusion was a good predictor of iron overload a sensitivity of 75% and specificity of 81% for a cutoff value of 28.3 mL/kg. CONCLUSION We identified specific cutoff values for serum ferritin and blood transfusion volume to predict iron overload with high sensitivity and specificity. These markers offer a cost-effective and accessible approach for periodic screening of iron deposition, particularly in resource-constrained settings.
Collapse
Affiliation(s)
- Omid Reza Zekavat
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | | | | | | |
Collapse
|
2
|
Basso L, Baldi D, Mannelli L, Cavaliere C, Salvatore M, Brancato V. Investigating Dual-Energy CT Post-Contrast Phases for Liver Iron Quantification: A Preliminary Study. Dose Response 2021; 19:15593258211011359. [PMID: 34121963 PMCID: PMC8173994 DOI: 10.1177/15593258211011359] [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: 01/13/2021] [Revised: 03/17/2021] [Accepted: 03/29/2021] [Indexed: 12/03/2022] Open
Abstract
Background and Purpose: Quantification of hepatic virtual iron content (VIC) by using Multidetector Dual Energy Computed Tomography (DECT) has been recently investigated since this technique could offer a good compromise between accuracy and non-invasiveness for liver iron content quantification. The aim of our study is to investigate differences in VIC at different DECT time points (namely baseline and arterial, venous and tardive phases), identifying the most reliable and also exploring the underlying temporal trend of these values. Materials and Methods: Eleven patients who underwent DECT examination and were characterized by low liver fat content were included in this retrospective study. By using the Syngo.via Frontier–DE IronVNC tool, regions of interest (ROI) were placed on the VIC images at 3 hepatic levels, both in left and right liver lobes, at each DECT time point. Friedman’s test followed by Bonferroni-adjusted Wilcoxon signed-rank test for post-hoc analysis was performed to assess differences between DECT timepoints. Page’s L test was performed to test the temporal trend of VIC across the 4 examined timepoints. Results: For both liver lobes, Friedman’s test followed by Bonferroni-adjusted Wilcoxon signed-rank test revealed that VIC values differed significantly when extracted from ROIs placed at the 4 different timepoints. The Page’s L test for multiple comparison revealed a significant growing trend for VIC, from baseline acquisition to the fourth and last time point post-contrast agent injection. Conclusions: The extraction of hepatic VIC in healthy subjects was found to be significantly influenced by the DECT time point chosen for the extrapolation of the VIC values.
Collapse
|
3
|
Zhang Y, Xiao C, Li J, Song LX, Zhao YS, Han S, Li ZW, Guo C, Zhao JG, Chang CK. Comparative Study on Iron Content Detection by Energy Spectral CT and MRI in MDS Patients. Front Oncol 2021; 11:646946. [PMID: 33828991 PMCID: PMC8019931 DOI: 10.3389/fonc.2021.646946] [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: 12/28/2020] [Accepted: 02/22/2021] [Indexed: 01/19/2023] Open
Abstract
Objective: The purpose of this study was to identify the difference between dual energy spectral computed tomography (DECT) and magnetic resonance imaging (MRI) used to detect liver/cardiac iron content in Myelodysplastic syndrome (MDS) patients with differently adjusted serum ferritin (ASF) levels. Method: Liver and cardiac iron content were detected by DECT and MRI. Patients were divided into different subgroups according to the level of ASF. The receiver operating characteristic curve (ROC) analysis was applied in each subgroup. The correlation between iron content detected by DECT/MRI and ASF was analyzed in each subgroup. Result: ROC curves showed that liver virtual iron content (LVIC) Az was significantly less than liver iron concentration (LIC) Az in the subgroup with ASF < 1,000 ng/ml. There was no significant difference between LVIC Az and LIC Az in the subgroup with 1,000 ≤ ASF < 2,500 ng/ml and 2,500 ≤ ASF < 5,000 ng/ml. LVIC Az was significantly higher than LIC Az in the subgroup with ASF <5,000 and 5,000 ≤ ASF ng/ml. In patients undergoing DECT and MRI examination on the same day, ASF was significantly correlated with LVIC, whereas no significant correlation was observed between ASF and LIC. After removing the data of ASF > 5,000 mg/L in LIC, LIC became correlated with ASF. There was no significant difference between the subgroup with 2,500 ≤ ASF < 5,000 ng/ml and 5,000 ng/ml ≤ ASF in LIC expression. Furthermore, both LIC and liver VIC had significant correlations with ASF in patients with ASF < 2,500 ng/ml, while LVIC was still correlated with ASF, LIC was not correlated with ASF in patients with 2,500 ng/ml ≤ ASF. Moreover, neither cardiac VIC nor myocardial iron content (MIC) were correlated with ASF in these subgroups. Conclusion: MRI and DECT were complementary to each other in liver iron detection. In MDS patients with high iron content, such as ASF ≥ 5,000 ng/ml, DECT was more reliable than the MRI in the assessment of iron content. But in patients with low iron content, such as ASF < 1,000 ng/ml, MRI is more reliable than DECT. Therefore, for the sake of more accurately evaluating the iron content, the appropriate detection method can be selected according to ASF.
Collapse
Affiliation(s)
- Yao Zhang
- Department of Hematology, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Chao Xiao
- Department of Hematology, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Jing Li
- Department of Radiology, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Lu-Xi Song
- Department of Hematology, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - You-Shan Zhao
- Department of Hematology, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Shuang Han
- Department of Hematology, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Zhao-Wei Li
- Department of Hematology, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Cha Guo
- Department of Hematology, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Jun-Gong Zhao
- Department of Radiology, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Chun-Kang Chang
- Department of Hematology, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Song LL, Lu HY, Xiao C, Wu LY, Wu D, Su JY, Zhou LY, Chang CK. [Study of iron overload assessment by T2* magnetic resonance imaging in patients with myelodysplastic syndromes]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:222-226. [PMID: 30929390 PMCID: PMC7342544 DOI: 10.3760/cma.j.issn.0253-2727.2019.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Indexed: 01/19/2023]
Abstract
Objectives: To analyze the cardiac T2* value, liver iron concentration (LIC) , and related laboratory parameters in myelodysplastic syndrome (MDS) with iron overload and evaluate the changes of organ functions after iron chelation therapy. To explore the value of magnetic resonance imaging (MRI) T2* in making early diagnosis and assessing organs iron overload. Methods: Retrospective investigation was used to observe the cardiac T2* value, LIC, iron metabolism parameters and related laboratory parameters of 85 MDS patients from Nov 2014 to Jan 2018. Among them, 7 MDS patients with Low/Int-1 have received iron chelation therapy for 6 months during two MRI examinations. The above parameters were collected before and after iron chelation therapy for comparison. Results: Correlations were found between heart T2* value and age (rs=-0.290, P=0.007) and left ventricular ejection fraction (LVEF) (rs=0.265, P=0.009) . There was a significant negative correlation between heart T2* value and blood transfusion units (rs=-0.701, P<0.001) . There was a significant positive correlation between LIC and serum ferritin (SF) (rs=0.577, P<0.001) . There was also a correlation between LIC and ALT (rs=0.268, P=0.014) and blood transfusion units (rs=0.244, P=0.034) . There was no correlation between heart T2* and pro-BNP, SF (all P>0.05) , and no correlation between LIC and age (P>0.05) . The increase of heart T2* between the normal and abnormal groups was statistically significant (P=0.005) , but the iron overload ratio of the heart T2*<20 ms was not significant between the two groups. There was statistical significance in the proportion of severe liver iron overload (LIC>15 mg/g DW) (P=0.045) . After iron chelation therapy, the values of SF, transferrin saturation, ALT, AST, pro-BNP and LIC of 7 patients were decreased compared with values before iron chelation therapy, and the peripheral blood cell level was increased. However, the changes of LVEF and T2* values after iron chelation were not obvious. Conclusion: MRI T2* may be a predictor of iron overload in patients with MDS in early stage, and may be more valuable compare with LVEF, SF and other laboratory indicators. The safety and repeatability of MRI cardiac T2* examination are recognized, and it can be used as an ideal detection for patients with iron overload.
Collapse
Affiliation(s)
- L L Song
- Department of Hematology, Shanghai No.6 People's Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200233, China
| | - H Y Lu
- Department of Hematology, Yangpu Hospital, Tongji University, Shanghai 200090, China
| | - C Xiao
- Department of Hematology, Shanghai No.6 People's Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200233, China
| | - L Y Wu
- Department of Hematology, Shanghai No.6 People's Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200233, China
| | - D Wu
- Department of Hematology, Shanghai No.6 People's Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200233, China
| | - J Y Su
- Department of Hematology, Shanghai No.6 People's Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200233, China
| | - L Y Zhou
- Department of Hematology, Shanghai No.6 People's Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200233, China
| | - C K Chang
- Department of Hematology, Shanghai No.6 People's Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200233, China
| |
Collapse
|
6
|
Abstract
MRI is a key tool in the current management of patients with thalassemia. Given its capability of assessing iron overload in different organs noninvasively and without contrast, it has significant advantages over other metrics, including serum ferritin. Liver iron concentration can be measured either with relaxometry methods T2*/T2 or signal intensity ratio techniques. Myocardial iron can be assessed in the same examination through T2* imaging. In this review, we focus on showing how MRI evaluates iron in both organs and the clinical applications as well as practical approaches to using this tool by clinicians taking care of patients with thalassemia.
Collapse
|
7
|
Werner S, Krauss B, Haberland U, Bongers M, Starke U, Bakchoul T, Enkel S, Nikolaou K, Horger M. Dual-energy CT for liver iron quantification in patients with haematological disorders. Eur Radiol 2018; 29:2868-2877. [DOI: 10.1007/s00330-018-5785-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/28/2018] [Accepted: 09/20/2018] [Indexed: 12/22/2022]
|
8
|
Song H, Zhang S, Sun X, Liu J, Wu Y, Guo W, Wang F, Ou X, Cong M, Jin E, Li W, Liu S. Distinct Iron Deposition Profiles of Liver Zones in Various Models with Iron Homeostasis Disorders. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2018; 5:1800866. [PMID: 30479929 PMCID: PMC6247051 DOI: 10.1002/advs.201800866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/19/2018] [Indexed: 06/09/2023]
Abstract
Determination of iron accumulation is crucial in diagnosing the occurrence and progression of many liver- and iron-related diseases. Thus far, little is known about the profiles of iron deposition in different liver zones, particularly under conditions with disordered iron homeostasis. Here, uneven iron distribution in livers of patients with hereditary hemochromatosis (HH) is uncovered, showing the region with the highest iron concentration near the entrance site of the portal vein and hepatic artery in contrast to the sites with the lowest iron concentration close to the distal edge. Distinct iron distribution profiles are also found throughout liver zones in wild-type mice and various mouse models with iron metabolism disorders, including hemochromatosis (Hfe-/- ), iron deficiency, and inflammation. Of note, similar findings observed in HH patients are further demonstrated in Hfe-/- mice. Moreover, the zones with greater iron accumulation appear to be more sensitive to iron changes, e.g., there is iron increase upon iron overload and iron loss in response to iron deficiency. Mechanistic investigation manifests that these differential iron changes in liver zones are subjected to the regulation by the hepcidin-ferroportin axis. Additionally, the data corroborate the reliability of magnetic resonance imaging (MRI) in recognizing the differential iron deposition profiles among liver zones.
Collapse
Affiliation(s)
- Haoyang Song
- Anhui Province Key Laboratory of Embryo Development and Reproductive RegulationAnhui Province Key Laboratory of Environmental Hormone and ReproductionFuyang Normal UniversityFuyang236037China
- State Key Laboratory of Environmental Chemistry and EcotoxicologyResearch Center for Eco‐Environmental SciencesChinese Academy of SciencesBeijing100085China
| | - Shuping Zhang
- Institute for Medical Engineering and ScienceMassachusetts Institute of TechnologyCambridgeMA02139USA
| | - Xia Sun
- Radiology DepartmentBeijing Friendship HospitalCapital Medical UniversityBeijing100050China
| | - Jing Liu
- State Key Laboratory of Environmental Chemistry and EcotoxicologyResearch Center for Eco‐Environmental SciencesChinese Academy of SciencesBeijing100085China
| | - Yakun Wu
- State Key Laboratory of Environmental Chemistry and EcotoxicologyResearch Center for Eco‐Environmental SciencesChinese Academy of SciencesBeijing100085China
- University of Chinese Academy of SciencesBeijing100049China
| | - Wenli Guo
- College of FisheriesHenan Normal UniversityXinxiang453007China
- QIMR Berghofer Medical Research InstituteBrisbane4029Australia
| | - Fudi Wang
- Department of NutritionNutrition Discovery Innovation CenterInstitute of Nutrition and Food SafetySchool of Public HealthSchool of MedicineZhejiang UniversityHangzhou310085China
| | - Xiaojuan Ou
- Liver Research CenterBeijing Friendship HospitalCapital Medical UniversityBeijing100050China
| | - Min Cong
- Liver Research CenterBeijing Friendship HospitalCapital Medical UniversityBeijing100050China
| | - Erhu Jin
- Radiology DepartmentBeijing Friendship HospitalCapital Medical UniversityBeijing100050China
| | - Wenyong Li
- Anhui Province Key Laboratory of Embryo Development and Reproductive RegulationAnhui Province Key Laboratory of Environmental Hormone and ReproductionFuyang Normal UniversityFuyang236037China
| | - Sijin Liu
- State Key Laboratory of Environmental Chemistry and EcotoxicologyResearch Center for Eco‐Environmental SciencesChinese Academy of SciencesBeijing100085China
- University of Chinese Academy of SciencesBeijing100049China
| |
Collapse
|
9
|
|
10
|
Abstract
Iron overload is becoming an increasing problem as haemoglobinopathy patients gain greater access to good medical care and as therapies for myelodysplastic syndromes improve. Therapeutic options for iron chelation therapy have increased and many patients now receive combination therapies. However, optimal utilization of iron chelation therapy requires knowledge not only of the total body iron burden but the relative iron distribution among the different organs. The physiological basis for extrahepatic iron deposition is presented in order to help identify patients at highest risk for cardiac and endocrine complications. This manuscript reviews the current state of the art for monitoring global iron overload status as well as its compartmentalization. Plasma markers, computerized tomography, liver biopsy, magnetic susceptibility devices and magnetic resonance imaging (MRI) techniques are all discussed but MRI has come to dominate clinical practice. The potential impact of recent pancreatic and pituitary MRI studies on clinical practice are discussed as well as other works-in-progress. Clinical protocols are derived from experience in haemoglobinopathies but may provide useful guiding principles for other iron overload disorders, such as myelodysplastic syndromes.
Collapse
Affiliation(s)
- John C Wood
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
11
|
Abstract
Abstract
Both primary and secondary iron overload are increasingly prevalent in the United States because of immigration from the Far East, increasing transfusion therapy in sickle cell disease, and improved survivorship of hematologic malignancies. This chapter describes the use of historical data, serological measures, and MRI to estimate somatic iron burden. Before chelation therapy, transfusional volume is an accurate method for estimating liver iron burden, whereas transferrin saturation reflects the risk of extrahepatic iron deposition. In chronically transfused patients, trends in serum ferritin are helpful, inexpensive guides to relative changes in somatic iron stores. However, intersubject variability is quite high and ferritin values may change disparately from trends in total body iron load over periods of several years. Liver biopsy was once used to anchor trends in serum ferritin, but it is invasive and plagued by sampling variability. As a result, we recommend annual liver iron concentration measurements by MRI for all patients on chronic transfusion therapy. Furthermore, it is important to measure cardiac T2* by MRI every 6-24 months depending on the clinical risk of cardiac iron deposition. Recent validation data for pancreas and pituitary iron assessments are also presented, but further confirmatory data are suggested before these techniques can be recommended for routine clinical use.
Collapse
|
12
|
Panch SR, Yau YY, West K, Diggs K, Sweigart T, Leitman SF. Initial serum ferritin predicts number of therapeutic phlebotomies to iron depletion in secondary iron overload. Transfusion 2014; 55:611-22. [PMID: 25209879 DOI: 10.1111/trf.12854] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 07/26/2014] [Accepted: 07/28/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Therapeutic phlebotomy is increasingly used in patients with transfusional siderosis to mitigate organ injury associated with iron overload (IO). Laboratory response variables and therapy duration are not well characterized in such patients. STUDY DESIGN AND METHODS We retrospectively evaluated 99 consecutive patients undergoing therapeutic phlebotomy for either transfusional IO (TIO, n = 88; 76% had undergone hematopoietic transplantation) or nontransfusional indications (hyperferritinemia or erythrocytosis; n = 11). Complete blood cell count, serum ferritin (SF), transferrin saturation, and transaminases were measured serially. Phlebotomy goal was an SF level of less than 300 μg/L. RESULTS Mean SF levels before phlebotomy among TIO and nontransfusional subjects were 3093 and 396 μg/L, respectively. Transfusion burden in the TIO group was 94 ± 108 (mean ± SD) RBC units; approximately half completed therapy with 24 ± 23 phlebotomies (range, 1-103). One-third were lost to follow-up. Overall, 15% had mild adverse effects, including headache, nausea, and dizziness, mainly during first phlebotomy. Prior transfusion burden correlated poorly with initial ferritin and total number of phlebotomies to target in the TIO group. However, number of phlebotomies to target was strongly correlated with initial SF (R(2) = 0.8; p < 0.0001) in both TIO and nontransfusional groups. ALT decreased significantly with serial phlebotomy in all groups (mean initial and final values, 61 and 39 U/L; p = 0.03). CONCLUSIONS Initial SF but not transfusion burden predicted number of phlebotomies to target in patients with TIO. Despite good treatment tolerance, significant losses to follow-up were noted. Providing patients with an estimated phlebotomy number and follow-up duration, and thus a finite endpoint, may improve compliance. Hepatic function improved with iron offloading.
Collapse
Affiliation(s)
- Sandhya R Panch
- Hematology/Transfusion Medicine, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | | | | | | | | |
Collapse
|
13
|
Abstract
Treatment of iron overload requires robust estimates of total-body iron burden and its response to iron chelation therapy. Compliance with chelation therapy varies considerably among patients, and individual reporting is notoriously unreliable. Even with perfect compliance, intersubject variability in chelator effectiveness is extremely high, necessitating reliable iron estimates to guide dose titration. In addition, each chelator has a unique profile with respect to clearing iron stores from different organs. This article presents the tools available to clinicians to monitor their patients, focusing on noninvasive magnetic resonance imaging methods because they have become the de facto standard of care.
Collapse
Affiliation(s)
- John C Wood
- Department of Pediatrics, Children's Hospital, Los Angeles, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA; Department of Radiology, Children's Hospital, Los Angeles, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA.
| |
Collapse
|
14
|
Nichols-Vinueza DX, White MT, Powell AJ, Banka P, Neufeld EJ. MRI guided iron assessment and oral chelator use improve iron status in thalassemia major patients. Am J Hematol 2014; 89:684-8. [PMID: 24652616 DOI: 10.1002/ajh.23715] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 03/14/2014] [Accepted: 03/18/2014] [Indexed: 01/19/2023]
Abstract
Oral iron chelators and magnetic resonance imaging (MRI) assessment of heart and liver iron burden have become widely available since the mid 2000s, allowing for improved patient compliance with chelation and noninvasive monitoring of iron levels for titration of therapy. We evaluated the impact of these changes in our center for patients with thalassemia major and transfusional iron overload. This single center, retrospective observational study covered the period from 2005 through 2012. Liver iron content (LIC) was estimated both by a T2* method and by R2 (Ferriscan® ) technique. Cardiac iron was assessed as cT2*. Forty-two patients (55% male) with transfused thalassemia and at least two MRIs were included (median age at first MRI, 17.5 y). Over a mean follow-up period of 5.2 ± 1.9 y, 190 MRIs were performed (median 4.5 per patient). Comparing baseline to last MRI, 63% of patients remained within target ranges for cT2* and LIC, and 13% improved from high values to the target range. Both the median LIC and cT2* (cR2* = 1000/cT2*) status improved over time: LIC 7.3 to 4.5 mg/g dry weight, P = 0.0004; cR2* 33.4 to 28.3 Hz, P = 0.01. Individual responses varied widely. Two patients died of heart failure during the study period. Annual MRI iron assessments and availability of oral chelators both facilitate changes in chelation dose and strategies to optimize care.
Collapse
Affiliation(s)
- Diana X. Nichols-Vinueza
- Division of Hematology/Oncology; Boston Children's Hospital and Harvard Medical School; Boston Massachusetts
| | - Matthew T. White
- Clinical Research Center and Department of Psychiatry; Boston Children's Hospital and Harvard Medical School; Boston Massachusetts
| | - Andrew J. Powell
- Department of Cardiology; Boston Children's Hospital and Harvard Medical School; Boston Massachusetts
| | - Puja Banka
- Department of Cardiology; Boston Children's Hospital and Harvard Medical School; Boston Massachusetts
| | - Ellis J. Neufeld
- Division of Hematology/Oncology; Boston Children's Hospital and Harvard Medical School; Boston Massachusetts
| |
Collapse
|
15
|
Tsai YS, Chen JS, Wang CK, Lu CH, Cheng CN, Kuo CS, Liu YS, Tsai HM. Quantitative assessment of iron in heart and liver phantoms using dual-energy computed tomography. Exp Ther Med 2014; 8:907-912. [PMID: 25120622 PMCID: PMC4113552 DOI: 10.3892/etm.2014.1813] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 06/04/2014] [Indexed: 11/17/2022] Open
Abstract
The aim of the present study was to determine the correlation between dual-energy computed tomography (DECT) Hounsfield units (HU) and iron concentration, as well as the correlation between HU and magnetic resonance imaging (MRI)-derived R2* values, in phantoms of the heart and liver tissue. Phantoms were constructed containing pig heart or liver tissue and varying concentrations of iron (0.1, 5, 10, 15, 20 and 25 mg/ml). The phantoms were then examined by DECT and MRI. Linear regression analysis was used to determine the correlations between HU and iron concentration and HU and R2* values. The HU value of DECT increased with increasing iron concentrations in the liver and heart phantoms in a linear manner. The slope of the HU value change against iron concentration revealed that ΔH80–140 provided a better discernment of iron concentration as compared with ΔH100–140. The derived R2 values were all >0.9 for the associations of DECT and MRI measurements with iron concentrations. Therefore, DECT may be used for the determination of iron concentration in the liver and heart tissue, with the results correlating with those obtained with MRI.
Collapse
Affiliation(s)
- Yi-Shan Tsai
- Department of Diagnostic Radiology, National Cheng-Kung University College of Medicine and Hospital, Tainan 704, Taiwan, R.O.C
| | - Jiang-Shiuh Chen
- Department of Pediatrics, National Cheng-Kung University College of Medicine and Hospital, Tainan 704, Taiwan, R.O.C
| | - Chien-Kuo Wang
- Department of Diagnostic Radiology, National Cheng-Kung University College of Medicine and Hospital, Tainan 704, Taiwan, R.O.C
| | - Chia-Hsing Lu
- Department of Diagnostic Radiology, National Cheng-Kung University College of Medicine and Hospital, Tainan 704, Taiwan, R.O.C
| | - Chao-Neng Cheng
- Department of Pediatrics, National Cheng-Kung University College of Medicine and Hospital, Tainan 704, Taiwan, R.O.C
| | - Chin-Shun Kuo
- Department of Diagnostic Radiology, National Cheng-Kung University College of Medicine and Hospital, Tainan 704, Taiwan, R.O.C
| | - Yi-Sheng Liu
- Department of Diagnostic Radiology, National Cheng-Kung University College of Medicine and Hospital, Tainan 704, Taiwan, R.O.C
| | - Hong-Ming Tsai
- Department of Diagnostic Radiology, National Cheng-Kung University College of Medicine and Hospital, Tainan 704, Taiwan, R.O.C
| |
Collapse
|
16
|
Pennell DJ, Udelson JE, Arai AE, Bozkurt B, Cohen AR, Galanello R, Hoffman TM, Kiernan MS, Lerakis S, Piga A, Porter JB, Walker JM, Wood J. Cardiovascular function and treatment in β-thalassemia major: a consensus statement from the American Heart Association. Circulation 2013; 128:281-308. [PMID: 23775258 DOI: 10.1161/cir.0b013e31829b2be6] [Citation(s) in RCA: 261] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This aim of this statement is to report an expert consensus on the diagnosis and treatment of cardiac dysfunction in β-thalassemia major (TM). This consensus statement does not cover other hemoglobinopathies, including thalassemia intermedia and sickle cell anemia, in which a different spectrum of cardiovascular complications is typical. There are considerable uncertainties in this field, with a few randomized controlled trials relating to treatment of chronic myocardial siderosis but none relating to treatment of acute heart failure. The principles of diagnosis and treatment of cardiac iron loading in TM are directly relevant to other iron-overload conditions, including in particular Diamond-Blackfan anemia, sideroblastic anemia, and hereditary hemochromatosis. Heart failure is the most common cause of death in TM and primarily results from cardiac iron accumulation. The diagnosis of ventricular dysfunction in TM patients differs from that in nonanemic patients because of the cardiovascular adaptation to chronic anemia in non-cardiac-loaded TM patients, which includes resting tachycardia, low blood pressure, enlarged end-diastolic volume, high ejection fraction, and high cardiac output. Chronic anemia also leads to background symptomatology such as dyspnea, which can mask the clinical diagnosis of cardiac dysfunction. Central to early identification of cardiac iron overload in TM is the estimation of cardiac iron by cardiac T2* magnetic resonance. Cardiac T2* <10 ms is the most important predictor of development of heart failure. Serum ferritin and liver iron concentration are not adequate surrogates for cardiac iron measurement. Assessment of cardiac function by noninvasive techniques can also be valuable clinically, but serial measurements to establish trends are usually required because interpretation of single absolute values is complicated by the abnormal cardiovascular hemodynamics in TM and measurement imprecision. Acute decompensated heart failure is a medical emergency and requires urgent consultation with a center with expertise in its management. The first principle of management of acute heart failure is control of cardiac toxicity related to free iron by urgent commencement of a continuous, uninterrupted infusion of high-dose intravenous deferoxamine, augmented by oral deferiprone. Considerable care is required to not exacerbate cardiovascular problems from overuse of diuretics or inotropes because of the unusual loading conditions in TM. The current knowledge on the efficacy of removal of cardiac iron by the 3 commercially available iron chelators is summarized for cardiac iron overload without overt cardiac dysfunction. Evidence from well-conducted randomized controlled trials shows superior efficacy of deferiprone versus deferoxamine, the superiority of combined deferiprone with deferoxamine versus deferoxamine alone, and the equivalence of deferasirox versus deferoxamine.
Collapse
|