Acute renal insufficiency occurring during intravenous desferrioxamine therapy

Abrupt increased serum creatinine in a hyperferritinemia patient treated with deferoxamine after cord blood transplantation: a case report with literature review

BACKGROUND

Erythrocyte transfusion is an indispensable component of supportive care after hematopoietic stem cell transplantation (HSCT). However, HSCT recipients are susceptible to the development of acute kidney injury (AKI) with multifactorial causes. We report a case of a rapid elevation in serum creatinine associated with deferoxamine after cord blood transplantation (CBT).

CASE PRESENTATION

A 36-year-old Japanese male diagnosed with relapsed Philadelphia-positive acute lymphoblastic leukemia received CBT. At day 88 post-CBT, multidrug-resistant Pseudomonas aeruginosa (MDRP) was isolated from urine culture. Subsequently, colistin 200 mg/day was administered parenterally for treatment of epididymitis from day 91 to 117 post-CBT. Despite concomitant administration of potential nephrotoxic agents such as piperacillin-tazobactam, acyclovir, and liposomal amphotericin B, no development of AKI was observed during this period. At day 127 post-CBT, MDRP was detected in blood and urine cultures, and colistin 200 mg/day was re-started parenterally. Due to extremely higher ferritin level, deferoxamine was administered intravenously at day 133 post-CBT. While serum creatinine was 1.03 mg/dL before starting deferoxamine, the level increased to 1.36 mg/dL one day after commencing deferoxamine (day 134 post-CBT), and further increased to 2.11 mg/dL at day 141. Even though colistin was discontinued at day 141 post-CBT, serum creatinine continued to increase. Deferoxamine was withdrawn at day 145 post-CBT, when serum creatinine peaked at 2.70 mg/dL. In addition, no cylinduria is observed during the period of development of AKI. In adverse drug reaction (ADR) assessment using Naranjo probability score, the scores of 3 in deferoxamine and 2 in colistin, respectively, indicated "possible" ADR. However, while colistin-associated AKI manifested early onset, recovery time within 2 weeks after discontinuation and development of cylinduria, this case was discordant with the properties. Furthermore, in the literature review, development of AKI within 1 day, including sudden increase in serum creatinine or abrupt reduction in urine volume, was reported in 3 identified cases.

CONCLUSIONS

We considered the rapid creatinine elevation to be the result of deferoxamine rather than ADR caused by colistin. Therefore, careful monitoring of kidney function is required in recipients of HSCT treated with deferoxamine.

Origin and Consequences of Necroinflammation

When cells undergo necrotic cell death in either physiological or pathophysiological settings in vivo, they release highly immunogenic intracellular molecules and organelles into the interstitium and thereby represent the strongest known trigger of the immune system. With our increasing understanding of necrosis as a regulated and genetically determined process (RN, regulated necrosis), necrosis and necroinflammation can be pharmacologically prevented. This review discusses our current knowledge about signaling pathways of necrotic cell death as the origin of necroinflammation. Multiple pathways of RN such as necroptosis, ferroptosis, and pyroptosis have been evolutionary conserved most likely because of their differences in immunogenicity. As the consequence of necrosis, however, all necrotic cells release damage associated molecular patterns (DAMPs) that have been extensively investigated over the last two decades. Analysis of necroinflammation allows characterizing specific signatures for each particular pathway of cell death. While all RN-pathways share the release of DAMPs in general, most of them actively regulate the immune system by the additional expression and/or maturation of either pro- or anti-inflammatory cytokines/chemokines. In addition, DAMPs have been demonstrated to modulate the process of regeneration. For the purpose of better understanding of necroinflammation, we introduce a novel classification of DAMPs in this review to help detect the relative contribution of each RN-pathway to certain physiological and pathophysiological conditions.

Safety profiles of iron chelators in young patients with haemoglobinopathies

BACKGROUND

This review describes the safety of deferoxamine (DFO), deferiprone (DFP), deferasirox (DFX) and combined therapy in young patients less than 25 yr of age with haemoglobinopathies.

METHODS

Searches in electronic literature databases were performed. Studies reporting adverse events associated with iron chelation therapy were included. Study and reporting quality was assessed using AHRQ Risk of Bias Assessment Tool and McMaster Quality Assessment Scale of Harms. Prospective clinical studies were pooled in a random-effects meta-analysis of proportions.

RESULTS

Safety data of 2040 patients from 34 studies were included. Ninety-two case reports of 246 patients were identified. DFX (937 patients) and DFP (667 patients) possess the largest published safety evidence. Fewer studies on combination regimens are available. Increased transaminases were seen in all regimens (3.9-31.3%) and gastrointestinal disorders with DFP and DFX (3.7-18.4% and 5.8-18.8%, respectively). Therapy discontinuations due to adverse events were low (0-4.1%). Reporting quality was selective and poor in most of the studies.

CONCLUSION

Iron chelation therapy is generally safe in young patients, and published data correspond to summary of product characteristics. Each iron chelation regimen has its specific safety risks. DFO seems not to be associated with serious adverse effects in recommended doses. In DFP and DFX, rare, but serious, adverse reactions can occur. Data on combined therapy are scarce, but it seems equally safe compared to monotherapy.

Benefits and risks of deferiprone in iron overload in Thalassaemia and other conditions: comparison of epidemiological and therapeutic aspects with deferoxamine

Deferiprone is the only orally active iron-chelating drug to be used therapeutically in conditions of transfusional iron overload. It is an orphan drug designed and developed primarily by academic initiatives for the treatment of iron overload in thalassaemia, which is endemic in the Mediterranean, Middle East and South East Asia and is considered an orphan disease in the European Union and North America. Deferiprone has been used in several other iron or other metal imbalance conditions and has prospects of wider clinical applications. Deferiprone has high affinity for iron and interacts with almost all the iron pools at the molecular, cellular, tissue and organ levels. Doses of 50-120 mg/kg/day appear to be effective in bringing patients to negative iron balance. It increases urinary iron excretion, which mainly depends on the iron load of patients and the dose of the drug. It decreases serum ferritin levels and reduces the liver and heart iron content in the majority of chronically transfused iron loaded patients at doses >80 mg/kg/day. It is metabolised to a glucuronide conjugate and cleared through the urine in the metabolised and a non-metabolised form, usually of a 3 deferiprone: 1 iron complex, which gives the characteristic red colour urine. Peak serum levels of deferiprone are observed within 1 hour of its oral administration and clearance from blood is within 6 hours. There is variation among patients in iron excretion, the metabolism and pharmacokinetics of deferiprone. Deferiprone has been used in more than 7500 patients aged from 2-85 years in >50 countries, in some cases daily for >14 years. All the adverse effects of deferiprone are considered reversible, controllable and manageable. These include agranulocytosis with frequency of about 0.6%, neutropenia 6%, musculoskeletal and joint pains 15%, gastrointestinal complains 6% and zinc deficiency 1%. Discontinuation of the drug is recommended for patients developing agranulocytosis. Deferiprone is of similar therapeutic index to subcutaneous deferoxamine but is more effective in iron removal from the heart, which is the target organ of iron toxicity and mortality in iron-loaded thalassaemia patients. Deferiprone is much less expensive to produce than deferoxamine. Combination therapy of deferoxamine and deferiprone has been used in patients not complying with subcutaneous deferoxamine or experiencing toxicity or not excreting sufficient amounts of iron with use of either drug alone. New oral iron-chelating drugs are being developed, but even if successful these are likely to be more expensive than deferiprone and are not likely to become available in the next 5-8 years. About 25% of treated thalassaemia patients in Europe and more than 50% in India are using deferiprone. For most thalassaemia patients worldwide who are not at present receiving any form of chelation therapy the choice is between deferiprone and fatal iron toxicity.

Acute renal failure following deferoxamine overdose

A 17-year-old patient with sickle cell-beta thalassemia undergoing treatment with home iron chelation therapy inadvertently received ten times the recommended dose of intravenous deferoxamine. Acute renal failure (ARF) developed within hours. Immediate treatment with high-efficiency hemodialysis resulted in the prompt return of renal function after only one hemodialysis session. No long-term nephrotoxic effects of the deferoxamine overdose developed after more than 1 year of follow-up. Children with sickle cell disease who are on intravenous deferoxamine and their parents should be cautioned about the possibility of ARF with overdose due to malfunction of the pump and/or inadequate monitoring during treatment. ARF, should it occur in such children, appears to respond well to treatment with high-efficiency hemodialysis.

The toxic effects of desferrioxamine

DF has a low general toxicity, perhaps because of its low lipid solubility, Kpart 0.01 (Porter et al, 1988b). This feature of the molecule may prevent it from penetrating most cells of the body. It appears that there may be a specific mechanism of uptake of the drug by hepatocytes (Porter et al, 1987), making the iron in these cells available for excretion via the bile, while the iron excreted in the urine may all come from extracellular chelation, particularly when iron leaves the reticuloendothelial cells (Hershko et al, 1978). On this hypothesis, cellular toxicity occurs only when DF penetrates sensitive cells in sufficient amounts so that some free DF remains after all the available iron in such cells has been chelated. Such a hypothesis accounts for the protection of cells by iron overload and therefore the greater sensitivity of unloaded patients. The retina and central nervous system are further protected by the blood-retinal or blood-brain barrier, and increased penetration of this barrier, mediated by high peak levels of DF, by drugs or other diseases would lead to the retinal or neurotoxic effects seen. In the ear, high levels of unliganded DF for a period of time may be necessary to cause deafness. Thus the very property that prevents its oral activity may be part of the reason for the low toxicity of DF. The severe toxic effects on vision, hearing and growth are all more likely at higher doses of DF and there appears to be partial protection against them by iron overload. These two conclusions have to be taken into account when deciding on the appropriate dosage for each patient. With care, the dosage can be adjusted to remove enough iron to prevent iron accumulation and therefore its toxic effects, whilst keeping doses low enough to prevent DF from being toxic itself. It appears that even in very iron-overloaded patients dosages higher than 125 mg kg-1 day-1 may cause visual disturbances and should be avoided. In patients on renal dialysis with aluminium toxicity great care is needed to avoid retinal toxicity even with dosages as low as 50 mg kg-1 day-1, although the drug should not be withheld if clinically indicated. The administration of DF to renal dialysis patients is described by Pogglitsch et al (1981, 1983), Pacitti et al (1983), Ihle et al (1986) and Molitoris et al (1987). DF should not be given to patients unless there is a clearly established clinical indication.(ABSTRACT TRUNCATED AT 400 WORDS)

Deferoxamine (Desferal)-induced ocular toxicity

A 4-year-old girl with juvenile chronic myeloid leukemia relapsed after an allogeneic bone marrow transplantation (BMT) and became refractory to conventional chemotherapy. Treatment with two courses of high-dose deferoxamine, an iron chelator (130-180 mg/kg/day), along with low-dose ARA-c (5 mg/kg/day) caused a remarkable decrease of the WBC and fetal Hb. Three days following the last dose of deferoxamine, the patient experienced an acute visual loss, confirmed by electroretinogram (ERG) and visual evoked response (VER). Slight improvement occurred a few days later, but the patient developed severe pancytopenia and died of Klebsiella septic shock. The ocular manifestations were attributed to deferoxamine toxicity in light of the rapid onset after first exposure, the electrophysiological pattern of metabolic damage in the ERG and VER, and the long interval between the last chemotherapy and BMT. The pathogenesis of deferoxamine toxicity is discussed.

The effects of deferoxamine mesylate and hypoxia on the cochlea

Deferoxamine mesylate (DF) is a chelating agent used for the treatment of iron overload. Recently audiological testing of patients on long-term treatment with this drug indicated the possibility of an ototoxic side effect (1). We administered DF to chinchillas with both acute and chronic regimes. Functional and histological damage to the cochlea was detected only in the acute experiment. This was assumed to come not from the direct effect of DF on the cochlea but from the hypoxia as a result of respiratory suppression due to DF toxicity. To confirm this, animals were exposed to hypoxia during the same time course as for the DF experiment. Histological and physiological consequences of this hypoxia alone revealed very similar results to that observed in the acute DF experiment. This implies that DF has little direct toxic effect on the cochlea and, more importantly that considerable attention to hypoxia should be paid when assessing the cochlear pathology of animals which have been subjected to general anesthesia for long periods.

Iron poisoning

Iron poisoning continues to be a major toxicologic problem, with major impact on the gastrointestinal and circulatory systems. Failure to recognize the severity of iron intoxication may result in an inappropriate level of intervention. By using estimates of the total body burden of iron, clinical symptoms, and the serum iron concentration, an appropriate decision can be made to initiate aggressive chelation therapy with deferoxamine. In severe intoxication, the use of intravenous deferoxamine is indicated, along with supportive care, with particular attention to maintaining the intravascular volume. Other important measures include correction of acidosis and disorders of coagulation and replacement of blood components when there is evidence of gastrointestinal hemorrhage. Under rare circumstances in which large numbers of iron tablets are present in the gastrointestinal tract, surgical removal may be indicated. In addition, measures such as hemodialysis and exchange transfusion should be reserved for those unusual poisonings in which more conservative therapy is unsuccessful. In rare cases of iron intoxication, late sequelae such as hepatic necrosis and gastrointestinal scarring with obstruction may occur. The prompt recognition and initiation of management of children with acute iron poisoning is the single most critical element in decreasing the morbidity and mortality associated with these products.

Deferoxamine (Desferal)-induced toxic retinal pigmentary degeneration and presumed optic neuropathy

Eight patients (16 eyes) developed ocular toxicity while undergoing intravenous deferoxamine mesylate (Desferal) chelation therapy for transfusional hemosiderosis. Presenting symptoms included decreased visual acuity, color vision abnormalities, and night blindness. Six patients presented as presumed retrobulbar optic neuropathy demonstrating central scotomas and color vision abnormalities. The remaining two patients presented with pigmentary changes confined either to the macula or equator. Following cessation of therapy, vision improved in all but four eyes, which did not attain their pretreatment visual acuity. Optic neuropathy resolved in all cases. However, follow-up revealed development of retinal pigmentary degeneration in seven patients, involving the macula in six and the equatorial retina in one. Fluorescein angiography and electrophysiological tests suggested toxicity at the level of retinal pigment epithelium and photoreceptors.

Use of high doses of deferoxamine (Desferal) in an adult patient with acute iron overdosage

Deferoxamine, a specific chelator of ferric iron, has recognized efficacy in the treatment of acute iron overdosage. Toxicological references, however, vary in the preferred route of administration and recommended maximum dosage. A 19-year-old female patient ingested an estimated 50-60 ferrous sulfate tablets, representing approximately 9.8-11.7 g of elemental iron. At the time of admission, she had a serum iron level of 915 micrograms/dL and a total iron binding capacity of 515 micrograms/dL. She was treated with intravenous deferoxamine at 15 mg/kg/h via continuous infusion for a total dose of 37.1 g over a 52-h period until her urine exhibited no evidence of deferoxamine-iron chelation products for 24 consecutive hours. This paper supports the safety and efficacy of a slow IV infusion of deferoxamine in an adult patient, using a regimen recommended for pediatric patients.