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Rai HP, Stuart AJ. Beta-Thalassemia in Adulthood Previously Suspected as Treatment-Resistant Iron Deficiency Anemia: A Case Report. Cureus 2024; 16:e60275. [PMID: 38872652 PMCID: PMC11170228 DOI: 10.7759/cureus.60275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 05/14/2024] [Indexed: 06/15/2024] Open
Abstract
Beta-thalassemia (β-thalassemia) is a hematologic genetic condition that causes microcytic anemia due to defective synthesis of the hemoglobin beta chain. As a hypochromic microcytic anemia that is commonly associated with symptoms such as fatigue and pallor when identified in adulthood, β-thalassemia may be commonly underdiagnosed or misdiagnosed as iron deficiency anemia. This study presents a case of a patient with β-thalassemia who was initially misdiagnosed with treatment-resistant iron deficiency anemia. Here, we present the case of a 66-year-old male of Mediterranean descent with a history of military service who presented with persistent fatigue. He had a past medical history of hypertension, diabetes mellitus type 2, sleep apnea, and iron deficiency anemia. Despite undergoing unnecessarily prolonged iron supplementation for suspected iron deficiency anemia, the patient's complete blood count and peripheral blood smear continued to identify hypochromic microcytic anemia. Ultimately, hemoglobin electrophoresis was performed, and mutations were identified in the hemoglobin beta chain consistent with β-thalassemia minor. Due to its rarity and wide variation in presentation, β-thalassemia may be frequently misdiagnosed. β-thalassemia is a spectrum of disorders ranging from β-thalassemia minor, which may be asymptomatic and incidentally discovered in adulthood, to β-thalassemia major, which may include bone marrow deformities from extramedullary hematopoiesis and require frequent blood transfusions to sustain life. Therefore, patients who present with symptoms of β-thalassemia minor may not be identified until later in life after undergoing decades of ineffective treatment. β-thalassemia is a multifactorial disease with a variety of clinical presentations that can easily be misdiagnosed as other types of anemia. This case highlights the importance of performing thorough laboratory testing and casting a wide net of differential diagnoses when evaluating patients with treatment-resistant anemia. This case calls for further research on the genetic contributions to β-thalassemia as well as improved ways to identify this disorder, particularly in patients who may not have a severe form that is easily diagnosed in early childhood.
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Affiliation(s)
- Hitesh P Rai
- Research, Edward Via College of Osteopathic Medicine, Monroe, USA
| | - Anthony J Stuart
- Internal Medicine, Willis Knighton Tri-State Medical Clinic, Shreveport, USA
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Soubrier C, Jean E, De Sainte Marie B, Agouti I, Seguier J, Lavoipierre V, Clapasson C, Iline N, Gonin J, Giorgi R, Schleinitz N, Thuret I, Badens C, Bernit E. [Health status and quality of life in β-thalassemia adults in Marseille, France]. Rev Med Interne 2024; 45:187-193. [PMID: 38519305 DOI: 10.1016/j.revmed.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 11/17/2023] [Accepted: 01/01/2024] [Indexed: 03/24/2024]
Abstract
INTRODUCTION The life expectancy of β-thalassemia patients has increased over the last 20 years. In this study, we evaluated the current health status and quality of life of these patients managed in a reference center in Marseille. METHODS This is a single-center, descriptive study conducted between June and August 2019 in patients over 18 years of age with β-thalassemia major or intermedia. Clinical and paraclinical data were collected retrospectively and the SF-36 health survey questionnaire was proposed to each patient. RESULTS 43 of 64 selected patients were included and divided into 2 groups: 35 patients with transfusion-dependent β-thalassemia and 8 patients with non-transfusion-dependent β-thalassemia. Liver iron overload is the most frequent complication, present in 80% of transfusion-dependent and 62.5% of non-transfusion-dependent patients. Cardiac iron overload is present only in the transfusion dependent β-thalassemia group (20%). Hypogonadotropic hypogonadism remains the most common endocrine disorder (41.9%) followed by osteoporosis (37.2%). Among the 31 patients who completed the SF-36 questionnaire, physical and mental quality of life scores were lowered in transfusion dependent (respectively 42.7 and 46.8) as in non-transfusion-dependent patients (respectively 43.8 and 28.9). CONCLUSION Despite an improvement in medical care, our patients with β-thalassemia show an alteration in their quality of life that will need to be characterized in the entire French cohort.
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Affiliation(s)
- C Soubrier
- Service de médecine interne et médecine polyvalente, centre hospitalier d'Ajaccio Notre-Dame de la Miséricorde, site du Stilettu, 1180, route A.-Madunuccia, 20090 Ajaccio, France.
| | - E Jean
- Département de médecine interne, AP-HM, hôpital Timone, 264, rue Saint-Pierre, 13385 Marseille cedex, France
| | - B De Sainte Marie
- Département de médecine interne, AP-HM, hôpital Timone, 264, rue Saint-Pierre, 13385 Marseille cedex, France
| | - I Agouti
- Centre de référence des syndromes drépanocytaires majeurs, thalassémies et autres pathologies rares du globule rouge et de l'érythropoïèse, hôpital de la Timone, AP-PH, 264, rue Saint-Pierre, 13385 Marseille cedex, France
| | - J Seguier
- Département de médecine interne, AP-HM, hôpital Timone, 264, rue Saint-Pierre, 13385 Marseille cedex, France
| | - V Lavoipierre
- Service de médecine interne, centre hospitalier de Martigues, 3, boulevard des Rayettes, BP 50248, 13698 Martigues cedex, France
| | - C Clapasson
- Établissement français du sang, région PACA, 149, boulevard Baille, 13005 Marseille, France
| | - N Iline
- AP-HM, Hop Timone, BioSTIC, biostatistiques et technologies de l'information et de la communication, Marseille, France
| | - J Gonin
- AP-HM, Hop Timone, BioSTIC, biostatistiques et technologies de l'information et de la communication, Marseille, France
| | - R Giorgi
- AP-HM, Hop Timone, BioSTIC, biostatistiques et technologies de l'information et de la communication, Marseille, France; Aix Marseille université, AP-HM, Inserm, IRD, SESSTIM, sciences économiques & sociales de la santé & traitement de l'information médicale, ISSPAM, Marseille, France
| | - N Schleinitz
- Département de médecine interne, AP-HM, hôpital Timone, 264, rue Saint-Pierre, 13385 Marseille cedex, France; Aix-Marseille université, Marseille, France
| | - I Thuret
- Centre de référence des syndromes drépanocytaires majeurs, thalassémies et autres pathologies rares du globule rouge et de l'érythropoïèse, hôpital de la Timone, AP-PH, 264, rue Saint-Pierre, 13385 Marseille cedex, France
| | - C Badens
- Laboratoire de biochimie, AP-HM, hôpital Timone, 264, rue Saint-Pierre, 13385 Marseille cedex, France
| | - E Bernit
- Unité transversale de la drépanocytose, centre de référence Antilles-Guyane pour la drépanocytose, les thalassémies et les maladies constitutives du globule rouge et de l'érythropoïèse, CHU Guadeloupe, pôle parents-enfants, hôpital Ricou, BP465, 97159 Pointe-à-Pitre cedex, France
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Gollamudi J, Karkoska KA, Gbotosho OT, Zou W, Hyacinth HI, Teitelbaum SL. A bone to pick-cellular and molecular mechanisms of bone pain in sickle cell disease. FRONTIERS IN PAIN RESEARCH 2024; 4:1302014. [PMID: 38239327 PMCID: PMC10794347 DOI: 10.3389/fpain.2023.1302014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/04/2023] [Indexed: 01/22/2024] Open
Abstract
The bone is one of the most commonly affected organs in sickle cell disease (SCD). Repeated ischemia, oxidative stress and inflammation within the bone is largely responsible for promoting bone pain. As more individuals with SCD survive into adulthood, they are likely to experience a synergistic impact of both aging and SCD on their bone health. As bone health deteriorates, bone pain will likely exacerbate. Recent mechanistic and observational studies emphasize an intricate relationship between bone remodeling and the peripheral nervous system. Under pathological conditions, abnormal bone remodeling plays a key role in the propagation of bone pain. In this review, we first summarize mechanisms and burden of select bone complications in SCD. We then discuss processes that contribute to pathological bone pain that have been described in both SCD as well as non-sickle cell animal models. We emphasize the role of bone-nervous system interactions and pitfalls when designing new therapies especially for the sickle cell population. Lastly, we also discuss future basic and translational research in addressing questions about the complex role of stress erythropoiesis and inflammation in the development of SCD bone complications, which may lead to promising therapies and reduce morbidity in this vulnerable population.
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Affiliation(s)
- Jahnavi Gollamudi
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Kristine A. Karkoska
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Oluwabukola T. Gbotosho
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Wei Zou
- Department of Medicine, Division of Bone and Mineral Diseases, and Department of Pathology and Immunology, Division of Anatomic and Molecular Pathology, Washington University School of Medicine, St. Louis, MO, United States
| | - Hyacinth I. Hyacinth
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Steven L. Teitelbaum
- Department of Medicine, Division of Bone and Mineral Diseases, and Department of Pathology and Immunology, Division of Anatomic and Molecular Pathology, Washington University School of Medicine, St. Louis, MO, United States
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Thavonlun S, Houngngam N, Kingpetch K, Numkarunarunrote N, Santisitthanon P, Buranasupkajorn P, Pongchaiyakul C, Sutcharitchan P, Wattanachanya L. Association of osteoporosis and sarcopenia with fracture risk in transfusion-dependent thalassemia. Sci Rep 2023; 13:16413. [PMID: 37775530 PMCID: PMC10541420 DOI: 10.1038/s41598-023-43633-6] [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: 08/14/2023] [Accepted: 09/26/2023] [Indexed: 10/01/2023] Open
Abstract
Patients with transfusion-dependent thalassemia (TDT) have an increased risk of osteoporosis and fractures. They also have several potential factors associated with sarcopenia. There has been currently no study on sarcopenia and its association with falls and fractures in TDT. This study aims to determine the prevalence of and factors associated with osteoporosis, fragility fractures, and sarcopenia in adults with TDT. A cross-sectional study was conducted at the hematologic clinic at King Chulalongkorn Memorial Hospital, Bangkok, Thailand. Clinical data and laboratory testing were collected. Bone mineral density and morphometric vertebral fracture were assessed. Sarcopenia was defined using the 2014 and 2019 Asian Working Group for Sarcopenia (AWGS) criteria. We included 112 TDT patients aged 35.1 ± 12.5 years. The prevalence of osteoporosis was 38.4%. Fragility fractures were found in 20.5% of patients. Lower BMI (OR 0.29; 95% CI 0.12-0.72, P = 0.007) and hypogonadal state (OR 3.72; 95% CI 1.09-12.74, P = 0.036) were independently associated with osteoporosis. According to the 2014 AWGS criteria, the prevalence of overall sarcopenia and severe sarcopenia was 44.6% and 13.4%, respectively. Severe sarcopenia was strongly associated with fragility fractures (OR 4.59, 95% CI 1.21-17.46, P = 0.025). In conclusion, osteoporosis, fragility fractures, and sarcopenia were prevalent in adults with TDT. Severe sarcopenia was associated with fragility fractures. Early osteoporosis and sarcopenia screening and prevention may reduce fracture risk and its complications in these patients.
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Affiliation(s)
- Suttana Thavonlun
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
- Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Natnicha Houngngam
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
- Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Kanaungnit Kingpetch
- Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Numphung Numkarunarunrote
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Prangareeya Santisitthanon
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
- Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Patinut Buranasupkajorn
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
- Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Chatlert Pongchaiyakul
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Pranee Sutcharitchan
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Lalita Wattanachanya
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.
- Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand.
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Saliba AN, Musallam KM, Taher AT. How I treat non-transfusion-dependent β-thalassemia. Blood 2023; 142:949-960. [PMID: 37478396 PMCID: PMC10644094 DOI: 10.1182/blood.2023020683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 07/23/2023] Open
Abstract
The intricate interplay of anemia and iron overload under the pathophysiological umbrella of ineffective erythropoiesis in non-transfusion-dependent β-thalassemia (NTDT) results in a complex variety of clinical phenotypes that are challenging to diagnose and manage. In this article, we use a clinical framework rooted in pathophysiology to present 4 common scenarios of patients with NTDT. Starting from practical considerations in the diagnosis of NTDT, we delineate our strategy for the longitudinal care of patients who exhibit different constellations of symptoms and complications. We highlight the use of transfusion therapy and novel agents, such as luspatercept, in the patient with anemia-related complications. We also describe our approach to chelation therapy in the patient with iron overload. Although tackling every specific complication of NTDT is beyond the scope of this article, we touch on the management of the various morbidities and multisystem manifestations of the disease.
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Affiliation(s)
| | - Khaled M. Musallam
- Thalassemia Center, Burjeel Medical City, Abu Dhabi, United Arab Emirates
| | - Ali T. Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Sawh RN. The patient perspective: The struggles of living with thalassemia as an adult. Ann N Y Acad Sci 2023; 1527:20-24. [PMID: 37468233 DOI: 10.1111/nyas.15040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Today it has become the norm for individuals diagnosed with severe forms of thalassemia who have access to hypertransfusion regimens, chelation therapy, and annual surveillance to survive well beyond childhood. However, with this improvement in prognosis and subsequent transition to adult care, it has become apparent that most adult healthcare providers, including many adult hematologists and primary care providers, are ill-prepared to care for these patients and the complications that accompany their survival into adulthood. Collaborative efforts are needed to develop comprehensive approaches to contend with the challenges faced by adult patients to ensure they are properly managed and supported.
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Affiliation(s)
- Radhika N Sawh
- The Joan H. Marks Graduate Program in Human Genetics, Sarah Lawrence College, Bronxville, New York, USA
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Sunil A, Sivarajakumar B, Kumari V. Beta-Thalassemia Presenting as Moyamoya Syndrome With a Review of Skeletal Manifestations. Cureus 2023; 15:e38372. [PMID: 37265898 PMCID: PMC10230447 DOI: 10.7759/cureus.38372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2023] [Indexed: 06/03/2023] Open
Abstract
Moyamoya angiopathy (MMA) is a progressive vasculopathy characterized by slowly progressive stenosis involving the proximal portions of the major intracranial arteries, resulting in strokes and intracranial hemorrhages. If it occurs secondary to a known cause, it is called Moyamoya syndrome (MMS). Here, we describe the case of a five-year-old male child who presented to us with symptoms of stroke and, upon evaluation, revealed Moyamoya angiopathy. He was further evaluated, and it was found that MMA occurred as a complication of undetected beta-thalassemia. Thalassemia is an autosomal recessive blood disorder where there is a defect in hemoglobin production. It affects 100 to 150 thousand children in the Indian subcontinent. It is classified into two main types: alpha thalassemia and beta thalassemia, depending on which globin chain is affected. It primarily presents with symptoms of anemia such as easy fatiguability, dizziness, jaundice, or breathlessness. The occurrence of Moyamoya syndrome in beta-thalassemia is extremely rare, and it is extremely important to identify MMS at the earliest as it can cause long-term disabilities. We describe the imaging findings in MMS and the various classical skeletal radiographic findings in thalassemia that were seen in our patient.
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Affiliation(s)
- Aswathy Sunil
- Department of Radiology, Osmania Medical College, Hyderabad, IND
| | | | - Vijaya Kumari
- Department of Radiology, Osmania Medical College, Hyderabad, IND
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Thomas DC, Eliav E, Garcia AR, Fatahzadeh M. Systemic Factors in Temporomandibular Disorder Pain. Dent Clin North Am 2023; 67:281-298. [PMID: 36965931 DOI: 10.1016/j.cden.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The science of temporomandibular disorder (TMD) pain and its management has gone through significant changes during the last several decades. The authors strongly feel that the effect of systemic factors influencing TMD pain has been largely overlooked and poorly accounted for, even in established pain-management programs and protocols. The hope is that this article will act as a wake-up call for the pain management community to consider the importance of adequate knowledge of the systemic factors that affect the experience of TMD pain by the patient.
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Affiliation(s)
- Davis C Thomas
- Department of Diagnostic Sciences, Rutgers School of Dental Medicine, 110 Bergen Street, Newark, NJ 07103, USA; Eastman Institute of Oral Health, Rochester, NY, USA.
| | - Eli Eliav
- Eastman Institute for Oral Health, University of Rochester Medical Center, 625 Elmwood Avenue, Rochester, NY 14620, USA
| | - Antonio Romero Garcia
- CranioClinic, Valencia and Dental Sleep Solutions, Plaza San Agustin, Portal C, Piso 2, Puerta 2, Valencia 46002, Spain
| | - Mahnaz Fatahzadeh
- Division of Oral Medicine, Department of Oral Medicine, Rutgers School of Dental Medicine, 110 Bergen Street, Newark, NJ 07103, USA
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Bou-Fakhredin R, Motta I, Cappellini MD, Taher AT. Clinical Complications and Their Management. Hematol Oncol Clin North Am 2023; 37:365-378. [PMID: 36907609 DOI: 10.1016/j.hoc.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
The diversity of disease-related complications among patients with β-thalassemia is complicated by the wide spectrum of genotypes and clinical risk factors. The authors herein present the different complications seen in patients with β-thalassemia, the pathophysiology underlying these complications and their management.
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Affiliation(s)
- Rayan Bou-Fakhredin
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Irene Motta
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; UOC General Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; UOC General Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ali T Taher
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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Uysal A, Oktay G, Ural C, Kalkan NB. The effect of ferritin levels on distal femoral cartilage thickness in patients with beta thalassaemia major. J Bone Miner Metab 2023; 41:95-104. [PMID: 36422676 DOI: 10.1007/s00774-022-01384-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/21/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION To the best of our knowledge, the present study is the first in the literature to assess distal femoral cartilage thickness and its relationship with ferritin levels in adult patients with beta thalassaemia major (BTM). MATERIALS AND METHODS 45 patients with BTM and 45 healthy controls were included in the study. Ferritin and haemoglobin levels of the patient and healthy groups were determined by blood analysis and distal femoral cartilage thicknesses were measured via ultrasound. Then, the patient group was divided into subgroups according to whether their ferritin levels were below or above 2500 µg/L. They were then compared among themselves and with the healthy control group using the available data. RESULTS Distal femoral cartilage thickness values were statistically significantly lower in the BTM group compared to the healthy control group (p values < 0.001). Patients with a ferritin level below 2500 µg/L had statistically significantly higher right and left average distal femoral cartilage thickness values than the patients with a ferritin level above 2500 µg/L (p = 0.029 and p = 0.019, respectively). The right and left average distal femoral cartilage thickness values of the patient subgroup with low ferritin levels were statistically similar to the control group (p = 0.146 and p = 0.164, respectively). CONCLUSION Our study showed that thalassaemia patients are more likely to develop osteoarthritis (OA) than the normal population and possible OA development can be prevented by keeping the ferritin levels of these patients in the optimum range.
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Affiliation(s)
- Alper Uysal
- Physical Medicine and Rehabilitation Clinic, Hatay Training and Research Hospital, Güzelburç, 31001, Antakya, Hatay, Turkey.
| | - Gönül Oktay
- Thalassemia Center, Hatay Training and Research Hospital, Hatay, Turkey
| | - Cihan Ural
- Hematology Clinic, Hatay Training and Research Hospital, Hatay, Turkey
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Piga A, Longo F, Gamberini MR, Voskaridou E, Ricchi P, Caruso V, Pietrangelo A, Zhang X, Shetty JK, Attie KM, Tartaglione I. Long-term safety and erythroid response with luspatercept treatment in patients with β-thalassemia. Ther Adv Hematol 2022; 13:20406207221134404. [PMID: 36505885 PMCID: PMC9726852 DOI: 10.1177/20406207221134404] [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: 01/10/2022] [Accepted: 09/30/2022] [Indexed: 12/09/2022] Open
Abstract
Background β-thalassemia is a hereditary blood disorder resulting in ineffective erythropoiesis and anemia. Management of anemia with regular blood transfusions is associated with complications including iron overload. Here, we report long-term safety and efficacy results of the first clinical study of luspatercept in β-thalassemia, initiated in 2013, enrolling adults with both nontransfusion-dependent (NTD) and transfusion-dependent (TD) β-thalassemia. Objectives The objective was to report long-term safety data, for up to 5 years of treatment, for 64 patients with TD or NTD β-thalassemia, and long-term efficacy data for a subset of 63 patients with β-thalassemia who received high-dose luspatercept (0.6-1.25 mg/kg): 31 NTD and 32 TD patients. Design The study was a phase 2, noncontrolled, open-label trial comprising a dose-finding base phase and a 5-year extension phase. Methods Endpoints include safety; erythroid response over a continuous 12-week period [NTD: hemoglobin increase from baseline ⩾1.0 or ⩾1.5 g/dl; TD: red blood cell (RBC) transfusion burden reduction, ⩾20%, ⩾33%, or ⩾50%]; and changes in biomarkers of ineffective erythropoiesis, iron metabolism parameters, Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-F) scores, and 6-min walking distance. Results Median duration of luspatercept exposure for NTD and TD patients was 910 days (range, 40-1850) and 433 days (range, 21-1790), respectively. Seventeen of 31 (54.8%) NTD patients achieved a mean hemoglobin increase of ⩾1.5 g/dl and 19 of 32 (59.4%) TD patients achieved ⩾50% reduction in RBC transfusion burden, during any continuous 12-week period. Median cumulative duration of response was 1126 days (range, 127-1790) for NTD patients and 909 days (range, 87-1734) for TD patients. The most common treatment-related adverse events of any grade were bone pain, headache, and myalgia. Conclusion Long-term assessment of patients with β-thalassemia showed luspatercept was associated with sustained increases in hemoglobin levels in NTD patients and sustained transfusion burden reductions in TD patients. Trial registration (ClinicalTrials.gov Identifiers: NCT01749540 and NCT02268409). Plain Language Summary Long-term safety and erythroid response with luspatercept treatment in patients with β-thalassemia Background: β-thalassemia is a genetic blood disorder caused by mutations in the β-globin gene, which encodes one of the proteins that comprise hemoglobin, a key constituent of red blood cells. Patients with β-thalassemia experience anemia, the main treatment for which is blood transfusions. Long-term repeated blood transfusions lower patients' quality of life, use hospital resources, and the resulting accumulation of excess iron can cause organ failure and decrease life expectancy. The severity of the anemia experienced by patients with β-thalassemia varies; patients with transfusion-dependent β-thalassemia require regular blood transfusions, compared with those with nontransfusion-dependent β-thalassemia who require infrequent transfusions, or even none at all, to manage their symptoms. Luspatercept (Reblozyl®) is an agent that stimulates the production of red blood cells and is used to treat anemia caused by β-thalassemia. However, the long-term effects of luspatercept treatment on patients with β-thalassemia are not known.Objective: In this study, we report the long-term safety of luspatercept in 64 adult patients with either transfusion-dependent or nontransfusion-dependent β-thalassemia, and the long-term efficacy of high-dose luspatercept (0.6-1.25 mg/kg) in a subset of 63 patients.Results: The average time period that patients were treated with luspatercept was 910 days for nontransfusion-dependent β-thalassemia and 433 days for transfusion-dependent β-thalassemia. We report that in patients with nontransfusion-dependent β-thalassemia, luspatercept treatment was associated with sustained increases, just over 3 years, in hemoglobin levels. Likewise, in transfusion-dependent β-thalassemia, luspatercept treatment was associated with a sustained reduction, 2.5 years, in the amount of blood transfusion required to manage their anemia. Long-term treatment with luspatercept was not associated with any new side effects compared with previous short-term treatment studies. The most common side effects were headache (27 patients), bone pain (20 patients), and muscle pain (14 patients) with more than 90% of these patients experiencing these side effects as mild severity.Conclusion: The results of this study show that in patients with either transfusion-dependent or nontransfusion-dependent β-thalassemia, luspatercept provides lasting reduction in anemia with mostly mild and predictable side effects.
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Affiliation(s)
| | - Filomena Longo
- Department of Clinical and Biological Sciences, Turin University, Turin, Italy
| | | | - Ersi Voskaridou
- Thalassemia and Sickle Cell Center, Laiko General Hospital, Athens, Greece
| | - Paolo Ricchi
- Malattie Rare Del Globulo Rosso, AORN Cardarelli, Naples, Italy
| | | | | | | | - Jeevan K. Shetty
- Celgene International Sàrl, Bristol-Myers Squibb Company, Boudry, Switzerland
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12
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Park-Harris Lines. J Am Acad Orthop Surg 2022; 30:e1483-e1494. [PMID: 36137096 DOI: 10.5435/jaaos-d-22-00515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 08/02/2022] [Indexed: 02/08/2023] Open
Abstract
Park-Harris lines are radiographically apparent linear opacities that occur in a metaphyseal bone in proximity to a physis. Lines correspond to a temporary interruption of the normally ossifying physis with a sclerotic line corresponding to transversely oriented trabeculae. They were first appreciated in the long bones of diabetic children and have since been described in various metabolic, endocrinologic, infectious, neoplastic, and posttraumatic conditions as well as in response to systemic medications. Park-Harris lines are clinically useful in demarcating notable events in whole-body or individual bone development, in tracking longitudinal growth, or in assessing physeal arrest and responses to its treatment. There remains controversy about whether these lines are pathologic or a component of physiologic development and whether they constitute true "growth arrest" or rather "growth recovery." In this review, the history, pathophysiology, imaging, and clinical use of Park-Harris lines as well as an anthropological perspective on their utility for studying illness, nutrition, and historical living conditions over time are discussed.
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13
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Gagliardi I, Celico M, Gamberini MR, Pontrelli M, Fortini M, Carnevale A, Napoli N, Zatelli MC, Ambrosio MR. Efficacy and Safety of Teriparatide in Beta-Thalassemia Major Associated Osteoporosis: A Real-Life Experience. Calcif Tissue Int 2022; 111:56-65. [PMID: 35243531 PMCID: PMC9232424 DOI: 10.1007/s00223-022-00963-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/17/2022] [Indexed: 11/16/2022]
Abstract
Osteoporosis represents a relevant cause of morbidity in adult Thalassemia Major (TM) population. Antiresorptive drugs such as bisphosphonates were demonstrated effective in preventing bone loss. Teriparatide (TP) is an anabolic agent approved for osteoporosis management in the general population, but its use has been very limited in TM patients so far. We evaluated TP efficacy and safety in TM-associated osteoporosis in real-life clinical practice. Retrospective evaluation of 11 TM patients (6 males, 5 females; mean age = 45 ± 4.38 years) with severe osteoporosis and multiple fractures under TP treatment. Mean TP treatment duration was 19 ± 7 months. TP withdrawal was due to poor compliance and side effects (fever and osteo-muscular pain) in two and three patients, respectively. After 12 and 24 months, BMD significantly increased at lumbar (+ 19% and 22%) and femoral sites (+ 13% and 13%). Osteocalcin and cross-laps levels increased after 12 and 24 months (+ 225 and + 54.2%; + 159 and 141%, respectively). No new fractures were detected during TP treatment. Baseline VAS score values (3 ± 3) did not significantly change after 12 and 24 months (3 ± 3 and 2 ± 3, respectively). Five out of eleven patients developed side effects. TP might be an effective treatment for TM-associated osteoporosis since it improves BMD, especially at the lumbar spine, and prevents fragility fractures. TM patients may have a higher frequency of side effects, especially muscle and bone pain under TP treatment, as compared to no TM population. Further studies are needed.
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Affiliation(s)
- Irene Gagliardi
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Via Fossato di Mortara 64/B, 44121, Ferrara, Italy
| | - Mariella Celico
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Via Fossato di Mortara 64/B, 44121, Ferrara, Italy
| | - Maria Rita Gamberini
- Unit of Thalassaemia and Haemoglobinopathies Day Hospital, Regional HUB Centre, Department of Medicine, Azienda Ospedaliero Universitaria S. Anna, Cona, Ferrara, Italy
| | - Margherita Pontrelli
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Via Fossato di Mortara 64/B, 44121, Ferrara, Italy
| | - Monica Fortini
- Unit of Thalassaemia and Haemoglobinopathies Day Hospital, Regional HUB Centre, Department of Medicine, Azienda Ospedaliero Universitaria S. Anna, Cona, Ferrara, Italy
| | - Aldo Carnevale
- Department of Interventional and Diagnostic Radiology, Arcispedale Sant'Anna, Ferrara, Italy
| | - Nicola Napoli
- Division of Endocrinology and Diabetes, University Campus Bio-Medico di Roma, Rome, Italy
| | - Maria Chiara Zatelli
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Via Fossato di Mortara 64/B, 44121, Ferrara, Italy
| | - Maria Rosaria Ambrosio
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Via Fossato di Mortara 64/B, 44121, Ferrara, Italy.
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14
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Ebeling PR, Nguyen HH, Aleksova J, Vincent AJ, Wong P, Milat F. Secondary Osteoporosis. Endocr Rev 2022; 43:240-313. [PMID: 34476488 DOI: 10.1210/endrev/bnab028] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Indexed: 02/07/2023]
Abstract
Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.
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Affiliation(s)
- Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia
| | - Hanh H Nguyen
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Department of Endocrinology and Diabetes, Western Health, Victoria 3011, Australia
| | - Jasna Aleksova
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Amanda J Vincent
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Monash Centre for Health Research and Implementation, School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria 3168, Australia
| | - Phillip Wong
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Frances Milat
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
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15
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Roongta R, Mondal S, Chattopadhyay A. Marrow Matters. Rheumatology (Oxford) 2022; 61:e249-e250. [PMID: 35025990 DOI: 10.1093/rheumatology/keac029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Rashmi Roongta
- Department of Clinical Immunology and Rheumatology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, IndiaSenior Resident
| | - Sumantro Mondal
- Department of Clinical Immunology and Rheumatology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, IndiaSenior Resident
| | - Arghya Chattopadhyay
- Department of Clinical Immunology and Rheumatology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, IndiaSenior Resident
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16
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Charoenngam N, Rittiphairoj T, Ponvilawan B. Fracture prevalence in thalassemia: a systematic review and meta-analysis. Arch Osteoporos 2021; 16:171. [PMID: 34773506 DOI: 10.1007/s11657-021-01026-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 10/11/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Multiple observational studies have reported high prevalence of fracture in patients with thalassemia. However, most of these studies have included limited number of patients, and only few of them have reported prevalence of fracture among patients with different types and severity of thalassemia. OBJECTIVE This systematic review and meta-analysis was conducted to summarize all available data of fracture prevalence among patients with thalassemia. METHODS A systematic review was conducted using EMBASE and MEDLINE databases from inception to June 2021 to determine studies that reported prevalence of fracture in thalassemia patients. The pooled prevalence with 95% confidence interval (95%CI) of fracture across studies was determined using a random-effect, generic inverse variance method. RESULTS After two rounds of systematic review, a total of 25 studies with 4934 patients were included in the meta-analysis. The pooled prevalence of fracture among patients with thalassemia was 16% (95%CI, 15-17%, I2 = 94.3%). The subgroup analyses showed that the pooled prevalence of fracture was 4% (95%CI, 2-6%; I2 = 70.4%) among patients with alpha thalassemia, 17% (95%CI, 16-19%; I2 = 93.2%) among patients with beta thalassemia, 18% (95%CI, 16-19%; I2 = 89.0%) among patients with transfusion-dependent thalassemia, and 7% (95%CI, 4-10%; I2 = 94.2%) among patients with non-transfusion-dependent thalassemia. CONCLUSION Fracture is common in patients with thalassemia, and may be more prevalent in beta thalassemia and transfusion-dependent thalassemia than in alpha thalassemia and non-transfusion-dependent thalassemia.
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Affiliation(s)
- Nipith Charoenngam
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, 330 Mt Auburn St, Cambridge, MA, USA.
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA, USA.
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | | | - Ben Ponvilawan
- Department of Pharmacology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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17
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Manolopoulos PP, Lavranos G, Mamais I, Angouridis A, Giannakou K, Johnson EO. Vitamin D and bone health status in beta thalassemia patients-systematic review. Osteoporos Int 2021; 32:1031-1040. [PMID: 33423084 DOI: 10.1007/s00198-021-05821-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 01/04/2021] [Indexed: 01/31/2023]
Abstract
Thalassemia is a chronic congenital disease characterized by a combination of endocrine and metabolic disorders. Bone disease is a very common complication related to the poor absorption of calcium, the secondary chronic renal disease with low vitamin D, as well as multiple endocrine risk factors. The aim of this systematic review was to estimate the prevalence of vitamin D deficiency in thalassemia, as well as its association with osteoporosis/low bone mass. A systematic review was carried out using PubMed/Medline, Cochrane, and EBSCO databases. The methodological quality of the included studies was assessed with the validated Newcastle-Ottawa Quality Assessment Scale adapted for cross-sectional studies and cohort studies respectfully and the Cochrane Collaboration for clinical trials. After application of predetermined exclusion criteria compatible with the PICOS process, a total of 12 suitable articles were identified. The prevalence of vitamin D deficiency varied considerably. Only five of the reviewed studies examined the correlation between vitamin D levels and BMD of which just three showed a statistically significant positive association of mild/moderate grade. Vitamin D deficiency is a common comorbidity in patients with thalassemia. However, both its prevalence and its severity vary considerably in different populations, and existing evidence is insufficient to conclude whether vitamin D supplementation is also associated with BMD improvement in this special population group.
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Affiliation(s)
- P P Manolopoulos
- School of Medicine, European University Cyprus, Diogenes Street 6, Strovolos, 2404, Nicosia, Cyprus.
- Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus.
| | - G Lavranos
- School of Medicine, European University Cyprus, Diogenes Street 6, Strovolos, 2404, Nicosia, Cyprus
- Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus
| | - I Mamais
- Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus
| | - A Angouridis
- School of Medicine, European University Cyprus, Diogenes Street 6, Strovolos, 2404, Nicosia, Cyprus
| | - K Giannakou
- Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus
| | - E O Johnson
- School of Medicine, European University Cyprus, Diogenes Street 6, Strovolos, 2404, Nicosia, Cyprus
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18
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Doulgeraki A, Fragodimitri C, Athanasopoulou H, Drakaki K, Karabatsos F, Schiza V, Yousef J, Monopolis I, Chatziliami A. Chronic Hemolysis May Adversely Affect Skeletal Health. A Cross-Sectional Study of a Pediatric Population. Hemoglobin 2021; 45:30-36. [PMID: 33557624 DOI: 10.1080/03630269.2021.1879129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Hereditary hemolytic disorders cause ineffective erythropoiesis and bone marrow hyperplasia. Little is known about their effect on growth and skeletal health. The aim of this study was to evaluate growth, bone and body composition of non transfusion-dependent (NTD) pediatric patients with chronic hemolysis. A detailed history and clinical examination, dual-energy X-ray absorptiometry (DXA) of the lumbar spine (LS) and total body less head (TBLH) and bone turnover markers were performed. Thirty-nine patients (22 males and 17 females, 20 prepubertal), aged 11.4 ± 3.6 years [14 had β-thalassemia intermedia (β-TI), 17 α-thalassemia (α-thal) and eight hereditary spherocytosis (HS)] were evaluated. Fifty-seven previously studied controls were used for statistical analysis. The patients had lower weight and body mass index (BMI) (Z-scores -0.2 and -0.3, respectively, p < 0.05). Post-traumatic fractures were reported by 28.0% of the patients. Compared to controls, they had lower lumbar and subcranial bone mineral density (BMD), as well as reduced fat mass (FM), whereas muscle mass was not affected. One in three patients had low vitamin D and there was increased bone resorption and reduced bone formation. Correlations between different parameters revealed a potential role of osteocalcin, hemoglobin (Hb) and lactate dehydrogenase (LDH) as prognostic markers for bone health, in the setting of chronic hemolysis. Hereditary spherocytosis (HS) patients were the least affected in terms of growth and bone profile. Chronic hemolysis may lead to impaired growth and bone health, even in young, NTD patients. The degree of hemolysis determines bone health risk. Regular surveillance of bone health is justifiable.
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Affiliation(s)
- Artemis Doulgeraki
- Department of Bone and Mineral Metabolism, Institute of Child Health, Athens, Greece
| | | | - Helen Athanasopoulou
- Department of Bone and Mineral Metabolism, Institute of Child Health, Athens, Greece
| | - Kalliopi Drakaki
- Thalassemia Unit, Agia Sophia Children's Hospital, Athens, Greece
| | - Fotis Karabatsos
- Thalassemia Unit, Agia Sophia Children's Hospital, Athens, Greece
| | - Vasiliki Schiza
- Thalassemia Unit, Agia Sophia Children's Hospital, Athens, Greece
| | | | - Ioannis Monopolis
- Department of Bone and Mineral Metabolism, Institute of Child Health, Athens, Greece
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19
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Chiabrando D, Fiorito V, Petrillo S, Bertino F, Tolosano E. HEME: a neglected player in nociception? Neurosci Biobehav Rev 2021; 124:124-136. [PMID: 33545213 DOI: 10.1016/j.neubiorev.2021.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 12/16/2020] [Accepted: 01/08/2021] [Indexed: 12/12/2022]
Abstract
Despite increasing progress in the understanding of the pathophysiology of pain, current management of pain syndromes is still unsatisfactory. The recent discovery of novel pathways associated with pain insensitivity in humans represents a unique opportunity to improve our knowledge on the pathophysiology of pain. Heme metabolism recently emerged as a crucial regulator of nociception. Of note, alteration of heme metabolism has been associated with pain insensitivity as well as with acute and chronic pain in porphyric neuropathy and hemolytic diseases. However, the molecular mechanisms linking heme to the pain pathways still remain unclear. The review focuses on the major heme-regulated processes relevant for sensory neurons' maintenance, peripheral and central sensitization as well as for pain comorbidities, like anxiety and depression. By discussing the body of knowledge on the topic, we provide a novel perspective on the molecular mechanisms linking heme to nociception.
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Affiliation(s)
- Deborah Chiabrando
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Turin, Italy.
| | - Veronica Fiorito
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Turin, Italy
| | - Sara Petrillo
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Turin, Italy
| | - Francesca Bertino
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Turin, Italy
| | - Emanuela Tolosano
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Turin, Italy
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20
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Hung HY, Chow LH, Kotlinska JH, Drabik A, Silberring J, Chen YH, Huang EYK. LVV-hemorphin-7 (LVV-H7) plays a role in antinociception in a rat model of alcohol-induced pain disorders. Peptides 2021; 136:170455. [PMID: 33253777 DOI: 10.1016/j.peptides.2020.170455] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 02/08/2023]
Abstract
Alcohol can increase the sensitivity to painful stimulation or convert insensibility to pain at different stages. We hypothesized that chronic alcohol consumption changes the level of LVV-hemorphin-7 (abbreviated as LVV-H7, an opioid-like peptide generated from hemoglobin β-chain), thereby affecting pain sensation. We established a chronic alcohol-exposed rat model to investigate the effects of LVV-H7. Adult male Sprague-Dawley rats were subjected to daily intraperitoneal injection of 10 % ethanol (w/v) at 0.5 g/kg for 15 days and subsequent alcohol withdrawal for 5 days. Using different pharmacological strategies to affect the LVV-H7 level, we investigated the correlation between LVV-H7 and pain-related behavior. Tail-flick and hot plate tests were employed to investigate alcohol-induced pain-related behavioral changes. The serum level of LVV-H7 was determined by ELISA. Our results showed that alcohol first induced an analgesia followed by a hyperalgesia during alcohol withdrawal, which could be driven by the quantitative change of LVV-H7. A positive correlation between the level of LVV-H7 and Δtail-flick latency (measured latency minus basal latency) confirmed this finding. Moreover, we revealed that the LVV-H7 levels were determined by the activity of cathepsin D and red blood cell/hemoglobin counts, which could be affected by alcohol. These results suggest that the deterioration of anti-nociception induced by alcohol is correlated to the decreased level of LVV-H7, and this could be due to alcohol-induced anemia. This study may help to develop LVV-H7 structure-based novel analgesics for treating alcohol-induced pain disorders and thus ameliorate the complications in alcoholics.
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Affiliation(s)
- Hao-Yuan Hung
- Department of Pharmacology, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan; Department of Pharmacy Practice, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Lok-Hi Chow
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jolanta H Kotlinska
- Department of Pharmacology and Pharmacodynamics, Faculty of Pharmacy With Division of Medical Analytics, Medical University of Lublin, Lublin, Poland
| | - Anna Drabik
- Department of Biochemistry and Neurobiology, Faculty of Materials Science and Ceramics, AGH University of Science and Technology, Krakow, Poland
| | - Jerzy Silberring
- Department of Biochemistry and Neurobiology, Faculty of Materials Science and Ceramics, AGH University of Science and Technology, Krakow, Poland
| | - Yuan-Hao Chen
- Department of Pharmacology, National Defense Medical Center, Taipei, Taiwan; Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Eagle Yi-Kung Huang
- Department of Pharmacology, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan.
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21
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Tsartsalis AN, Lambrou GI, Vlachou E, Samartzi A, Chrousos GP, Kanaka-Gantenbein C, Kattamis A. The Effect of Treatment and Bone Metabolic Factors on Fracture Incidence in Patients with Thalassemia-Induced Osteoporosis: An Observational Study. CURRENT DRUG THERAPY 2020. [DOI: 10.2174/1574885515666200106110602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Thalassemia Major (TM) is a hereditary disease caused by defective globin synthesis. Because of the significant increase in life expectancy, these patients suffer from various health conditions, including endocrinopathies and low bone mineral density.
Aim:
The aim of the present study was to evaluate the fracture incidence regarding the markers of bone metabolism, bone mineral density and treatment of osteoporosis as well as treatment of comorbidities.
Methods:
Sixty-four patients with TM (32 men and 32 women) participated in a cross-sectional study design. The patients were recruited from “Aghia Sofia” Children’s Hospital and evaluated using dual-energy X-ray absorptiometry (DXA) of the lumbar spine and femoral neck and with markers of bone remodeling including receptor activator of nuclear factor kappa-Β ligand (RANKL), osteoprotegerin (OPG), C-terminal telopeptide (CTX), and sclerostin.
Results:
The statistical analysis of markers of bone metabolism in relation to fractures revealed no statistical significance. However, statistical analysis of bone mineral density and markers of bone metabolism in relation to fractures was also not significant.
Conclusions:
In TM patients, fractures are not related to bone mineral density. Maybe some other conditions are the cause, haemosidirosis, drugs, comorbid conditions.
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Affiliation(s)
- Athanasios N. Tsartsalis
- Naval Hospital of Athens, Department of Endocrinology Diabetes and Metabolism, Dinokratous 70, 11521, Athens, Greece
| | - George I. Lambrou
- First Department of Pediatrics, National and Kapodistrian University of Athens, Choremeio Research Laboratory, Thivon & Levadeias 8, 11527, Goudi, Athens, Greece
| | - Eugenia Vlachou
- Department of Nursing, School of Health Sciences and Care Professions, University of West Attica, Ag. Spydironos 28, 12243, Aigaleo, Athens, Greece
| | - Athanasia Samartzi
- Naval Hospital of Athens, Department of Endocrinology Diabetes and Metabolism, Dinokratous 70, 11521, Athens, Greece
| | - George P. Chrousos
- First Department of Pediatrics, National and Kapodistrian University of Athens, Choremeio Research Laboratory, Thivon & Levadeias 8, 11527, Goudi, Athens, Greece
| | - Christina Kanaka-Gantenbein
- First Department of Pediatrics, National and Kapodistrian University of Athens, Choremeio Research Laboratory, Thivon & Levadeias 8, 11527, Goudi, Athens, Greece
| | - Antonis Kattamis
- Hematology/Oncology Unit, First Department of Pediatrics, National and Kapodistrian University of Athens, Thivon & Levadeias 8, 11527, Goudi, Athens, Greece
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22
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Sapunarova K, Goranova-Marinova V, Georgiev P, Deneva T, Tsvetkova S, Grudeva-Popova Z. Associations of serum sclerostin with bone mineral density, markers of bone metabolism and thalassaemia characteristics in adult patients with transfusion-dependent beta-thalassaemia. Ann Med 2020; 52:94-108. [PMID: 32212941 PMCID: PMC7877979 DOI: 10.1080/07853890.2020.1744708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 02/23/2020] [Accepted: 03/11/2020] [Indexed: 10/24/2022] Open
Abstract
Aim of the study: To assess serum sclerostin in transfusion-dependent beta-thalassaemia patients versus healthy controls and to examine its associations with bone mineral density, bone metabolism markers and beta thalassaemia alterations.Material and methods: Sixty-two transfusion-dependent beta-thalassaemia (TDßT) patients and 30 healthy controls were evaluated for serum sclerostin, osteocalcin, beta-cross laps, osteoprotegerin and serum level of receptor activator of nuclear factor kappa-Β ligand (sRANKL). Bone mineral density was measured at the lumbar spine and femoral neck. Thalassaemia characteristics were collected from the patients' medical records.Results: A significantly higher sclerostin level (median 565.50 pmol/L) was observed in the transfusion-dependent beta-thalassaemia patients vs. the healthy controls (median 48.65 pmol/L, p < .001). Sclerostin showed significant associations with the Z-scores at the lumbar spine and femoral neck, osteocalcin, beta-cross laps, osteoprotegerin, sRANKL, pretransfusion haemoglobin, liver iron concentration and female gonadal state. Significantly higher levels of sclerostin were observed in splenectomized TDßT patients and in those with fragility fractures. Age, sex, body mass index, disease severity, serum ferritin, cardiac T2* and male gonadal state did not show significant associations with sclerostin.Conclusion: Sclerostin may play a role in the bone pathophysiology of beta-thalassaemia patients and could serve as a marker of severe osteoporosis.KEY MЕSSAGESSerum sclerostin is more than 10-fold higher in adult patients with transfusion-dependent beta-thalassaemia compared to healthy controls.Serum sclerostin is negatively associated with bone mineral density and the bone synthesis markers and positively with the bone resorption indices.Serum sclerostin is significantly associated with pre-transfusion haemoglobin, liver iron concentration, splenectomy status and fragility fracture events in adult patients with transfusion-dependent beta-thalassaemia.Serum sclerostin could serve as a marker of severe osteoporosis in beta-thalassaemia patients.
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Affiliation(s)
- Katya Sapunarova
- First Department of Internal Medicine, Department of Hematology, Medical University, Plovdiv, Bulgaria
- Clinic of Clinical Hematology, University Hospital “Sv. Georgi”, Plovdiv, Bulgaria
| | - Vesselina Goranova-Marinova
- First Department of Internal Medicine, Department of Hematology, Medical University, Plovdiv, Bulgaria
- Clinic of Clinical Hematology, University Hospital “Sv. Georgi”, Plovdiv, Bulgaria
| | - Pencho Georgiev
- First Department of Internal Medicine, Department of Hematology, Medical University, Plovdiv, Bulgaria
- Clinic of Clinical Hematology, University Hospital “Sv. Georgi”, Plovdiv, Bulgaria
| | - Tanya Deneva
- Department of Clinical Laboratory, University Hospital “Sv. Georgi”, Plovdiv, Bulgaria
| | - Silvia Tsvetkova
- Department of Imaging Diagnostics, Medical University, Plovdiv, Bulgaria
| | - Zhanet Grudeva-Popova
- Clinic of Clinical Hematology, University Hospital “Sv. Georgi”, Plovdiv, Bulgaria
- Department of Medical Oncology, University Hospital “Sv. Georgi”, Plovdiv, Bulgaria
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23
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Farmakis D, Giakoumis A, Angastiniotis M, Eleftheriou A. The changing epidemiology of the ageing thalassaemia populations: A position statement of the Thalassaemia International Federation. Eur J Haematol 2020; 105:16-23. [PMID: 32198891 DOI: 10.1111/ejh.13410] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 03/15/2020] [Accepted: 03/17/2020] [Indexed: 01/19/2023]
Abstract
Therapeutic advances in β-thalassaemia have gradually lead to a significant improvement in prognosis over the past few decades. As a result, patients living in areas where disease-specific programmes offering access to modern therapy are in place experience a new era of prolonged survival that tends to reach that of the normal population. This ageing thalassaemia population, however, faces a new spectrum of comorbidities resulting from increasing age that may jeopardise the advances in prognosis provided by current therapy and thus poses new challenges in diagnosis, monitoring and treatment. In this position paper of the Thalassaemia International Federation, we review the changing epidemiology and clinical spectrum of patients with β-thalassaemia and propose actions to be undertaken in order to address the emerging spectrum of comorbidities resulting from ageing.
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Affiliation(s)
- Dimitrios Farmakis
- University of Cyprus Medical School, Nicosia, Cyprus and Heart Failure Unit, Attikon University Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece.,Thalassaemia International Federation, Nicosia, Cyprus
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24
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Management of the aging beta-thalassemia transfusion-dependent population – The Italian experience. Blood Rev 2019; 38:100594. [DOI: 10.1016/j.blre.2019.100594] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 07/29/2019] [Accepted: 08/06/2019] [Indexed: 12/25/2022]
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25
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Yu U, Chen L, Wang X, Zhang X, Li Y, Wen F, Liu S. Evaluation of the vitamin D and biomedical statuses of young children with β-thalassemia major at a single center in southern China. BMC Pediatr 2019; 19:375. [PMID: 31646984 PMCID: PMC6813046 DOI: 10.1186/s12887-019-1744-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/23/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND In young children, β-thalassemia major (β-TM) is associated with potentially severe clinical characteristics, including poor growth, feeding difficulties, hepatosplenomegaly, bone metabolic disorders, and skeletal abnormalities. METHODS In this study, we reviewed the demographic and clinical characteristics (e.g., age, sex, duration of blood transfusion and chelating therapy, and vitamin supplementation) and serum biomarker levels (e.g., iron accumulation, bone metabolism, liver, kidney, and thyroid function markers) of 32 patients that received regular blood transfusion at a single center in southern China with the aim of stratifying the risk of severe complications such as osteopenia, endocrinopathies, and multi-organ failures. RESULTS Although all patients exhibited moderately to strongly elevated serum ferritin levels, this biomarker was significantly higher in children older than ≥5 years, compared to younger children (*p < 0.05, 1512 ± 192.6 vs. 2337 ± 299.8 ng/ml, Mann-Whitney U test). Older children had a significantly lower 25-hydroxy vitamin D3 (25(OH)D3) level, compared to younger children (**p < 0.01, 34.25 ± 11.06 vs. 23.05 ± 9.95 ng/ml, Mann-Whitney U test). No age-related differences were observed in serum calcium, phosphorus, and PTH levels. Regarding liver function, the serum alanine aminotransferase (ALT) level was significantly increased in children older than ≥5 years, compared to younger children (*p < 0.05, 19.17 ± 2.44 vs. 43.45 ± 9.82I U/ml, Mann-Whitney U test). However, no age-related differences were observed in the serum levels of other liver or kidney and thyroid biomarkers. CONCLUSIONS Our results suggest that in older children, hepatic iron overload may be associated with a low serum concentration of 25(OH)D3, an indicator of vitamin D deficiency and altered bone metabolism. Iron accumulation may also be associated with a higher concentration of ALT, a sensitive marker of liver malfunction. These findings may provide important clinical indications of the need for intervention to prevent severe complications in children with β thalassemia.
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Affiliation(s)
- Uet Yu
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, Guangdong, China
| | - Li Chen
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, Guangdong, China
| | - Xiaodong Wang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, Guangdong, China
| | - Xiaoling Zhang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, Guangdong, China
| | - Yue Li
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, Guangdong, China
| | - Feiqiu Wen
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, Guangdong, China
| | - Sixi Liu
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, Guangdong, China.
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26
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Denosumab in transfusion-dependent thalassemia osteoporosis: a randomized, placebo-controlled, double-blind phase 2b clinical trial. Blood Adv 2019; 2:2837-2847. [PMID: 30381400 DOI: 10.1182/bloodadvances.2018023085] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 08/16/2018] [Indexed: 12/20/2022] Open
Abstract
Denosumab (DNM) is a fully human monoclonal antibody against the receptor activator of nuclear factor kappa-B ligand (RANKL) that has been licensed for the treatment of different types of osteoporosis. However, the prospective data for the evaluation of DNM efficacy on transfusion-dependent thalassemia (TDT)-induced osteoporosis are rather limited. Thus, we conducted a randomized, placebo-controlled, double-blind, phase 2b clinical trial to evaluate DNM in TDT osteoporosis. Patients were assigned to receive either 60 mg DNM (n = 32) or placebo (n = 31) subcutaneously on day 0 and 180 during a total of 12 months of follow-up. The percentage increase of L1-L4 bone mineral density was higher in the DNM group than the placebo group (5.92% ± 5.25% vs 2.92% ± 5.56%, respectively; P = .043), whereas the advantage of DNM regarding wrist bone mineral density was much higher compared with placebo (-0.26% ± 5.31% vs -3.92% ± 8.71%, respectively; P = .035). No grade 3 or 4 toxicity was observed. DNM reduced pain scores that remained unaltered in the placebo group. DNM showed a significant reduction of soluble RANKL (sRANKL), sRANKL/osteoprotegerin ratio, C-telopeptide of collagen type I, tartrate-resistant acid phosphatase isoform-5b, and bone-specific alkaline phosphatase between baseline and the 12th month (P < .01 for all comparisons) without changes in dickkopf-1, sclerostin, and osteocalcin. On the contrary, placebo patients showed an increase in sRANKL, osteoprotegerin, dickkopf-1, sclerostin, C-telopeptide of collagen type I, tartrate-resistant acid phosphatase isoform-5b, and bone-specific alkaline phosphatase during the study period (P < .01 for all comparisons). In conclusion, DNM increased lumbar spine and wrist bone mineral density and reduced pain and bone remodeling markers, and thus it is another valuable option for the management of TDT-induced osteoporosis. This trial was registered at www.clinicaltrials.gov as #NCT02559648.
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27
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Shah FT, Sayani F, Trompeter S, Drasar E, Piga A. Challenges of blood transfusions in β-thalassemia. Blood Rev 2019; 37:100588. [PMID: 31324412 DOI: 10.1016/j.blre.2019.100588] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/18/2019] [Accepted: 07/05/2019] [Indexed: 01/28/2023]
Abstract
Patients with β-thalassemia major (BTM) require regular blood transfusions, supported by appropriate iron chelation therapy (ICT), throughout their life. β-thalassemia is a global disease that is most highly prevalent in Southeast Asia, Africa, and Mediterranean countries. However, the global distribution of patients with β-thalassemia is changing due to population migration, and Northern European countries now have significant thalassemia populations. Globally, many patients with BTM have limited access to regular and safe blood transfusions. A lack of voluntary nonremunerated blood donors, poor awareness of thalassemia, a lack of national blood policies, and fragmented blood services contribute to a significant gap between the timely supply of, and demand for, safe blood. In many centers, there is inadequate provision of antigen testing, even for common red cell antigens such as CcEe and Kell. Policies to raise awareness and increase the use of red blood cell antigen testing and requesting of compatible blood in transfusion centers are needed to reduce alloimmunization (the development of antibodies to red blood cell antigens), which limits the effectiveness of transfusions and the potential availability of blood. Patients with BTM are also at risk of transfusion-transmitted infections unless appropriate blood screening and safety practices are in place. Hence, many patients are not transfused or are undertransfused, resulting in decreased health and quality-of-life outcomes. Hemovigilance, leukoreduction, and the ability to thoroughly investigate transfusion reactions are often lacking, especially in resource-poor countries. ICT is essential to prevent cardiac failure and other complications due to iron accumulation. Despite the availability of potentially inexpensive oral ICT, a high proportion of patients suffer complications of iron overload and die each year due to a lack of, or inadequate, ICT. Increased awareness, training, and resources are required to improve and standardize adequate blood transfusion services and ICT among the worldwide population of patients with BTM. ICT needs to be available, affordable, and correctly prescribed. Effective, safe, and affordable new treatments that reduce the blood transfusion burden in patients with β-thalassemia remain an unmet need.
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Affiliation(s)
| | - Farzana Sayani
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Sara Trompeter
- University College London Hospitals, NHS Foundation Trust, London, UK; NHS Blood and Transplant, Bristol, UK.
| | - Emma Drasar
- Whittington Health NHS Trust, London, UK; University College London Hospitals, NHS Foundation Trust, London, UK.
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28
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Activin-A is elevated in patients with thalassemia major and double heterozygous sickle cell/beta-thalassemia and correlates with markers of hemolysis and bone mineral density. Ann Hematol 2019; 98:1583-1592. [PMID: 31041514 DOI: 10.1007/s00277-019-03695-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 04/15/2019] [Indexed: 01/11/2023]
Abstract
Despite the advances in the management of hemoglobinopathies, further insight into disease pathophysiology is necessary to improve our therapeutic approach. Activin-A has emerged as a regulator of erythropoiesis and bone turnover in malignant disorders; however, clinical data in hemoglobinopathies are currently scarce. Thus, we aimed to investigate the role of activin-A among hemoglobinopathy patients and evaluate the rationale of its targeting. Circulating levels of activin-A were measured in patients (n = 227) with beta-thalassemia major (TM) (n = 58), beta-thalassemia intermedia (TI) (n = 43), double heterozygous sickle cell/beta-thalassemia (HbS/beta-thal) (n = 109), or homozygous sickle cell disease (n = 17), and we explored possible correlations with clinical and laboratory data. Seventeen age- and gender-matched, healthy individuals served as controls. Bone marrow density (BMD) was determined using dual-energy X-ray absorptiometry. TM and HbS/beta-thal patients had elevated activin-A compared to controls (p = 0.041 and p = 0.038, respectively). In TM patients, high circulating activin-A showed strong correlations with hemolysis markers, namely reticulocyte count (p = 0.011) and high lactate dehydrogenase (LDH; p = 0.024). Similarly, in HbS/beta-thal patients, activin-A showed positive correlations with indirect bilirubin (p < 0.001), ferritin (p = 0.005), and LDH (p = 0.044). High activin-A correlated with low Z-score of both lumbar spine BMD in TI patients (p < 0.01) and femoral neck BMD in TM patients (p < 0.01). Serum activin-A is elevated in patients with TM and HbS/beta-thal and correlates with markers of hemolysis and low BMD. These data support a role of activin-A in the biology of these disorders and provide further rationale for the broader clinical development of activin-A inhibitors in this setting.
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29
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Clinical and Molecular Study of ELMO-2-Related Massive Intraosseous Vascular Malformations: Lessons Learned From 25 Years of Follow-up. Ann Plast Surg 2019; 83:293-299. [PMID: 30882408 DOI: 10.1097/sap.0000000000001786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Massive intraosseous vascular malformations, a relatively rare entity in the vascular malformation spectrum, deserves attention as involving the membranous bones of the craniofacial skeleton and may lead to severe life-threatening hemorrhages and even death. The main aim of this study was to summarize the 25 years of clinical experience with these vascular malformation osseous patients, focus on the molecular and genetic aspect of the clinical entity, and to emphasize the certain challenging conditions in the treatment of these patients. All the patients appeared to be unaffected at birth, whereas initial symptoms occasionally began with painless swelling in the mandible in early childhood. The disease was progressive in behavior especially in the pubertal ages and was specifically involving the maxilla and mandible of the craniofacial skeleton in all the patients. Calvarium and cranial base were the second most common involved regions among these patients (62.5%). Clavicular (50%), costal (25%), and vertebral (25%) involvements were also a significant manifestation of the disease. Tissue samples obtained from the affected individuals and the blood samples from their families were matched, revealing a loss of function mutation in the ELMO-2 gene of chromosome 20 leading to developmental abnormality of the vascular structures via RAC1 signaling and leading to abnormally enlarged vessels in the intraosseus portion of the membranous bone. Immunohistochemical staining revealed positive CD31 and smooth muscle actin staining but negative proliferation and maturity markers such as Ki-67, desmin, h-caldesmon, and myofibroblast-like desmin. The follow-up of 3 of 5 patients ended up with mortality (60%). vascular malformation osseous is intraosseous vascular malformation with aggressive biological behavior associated with ELMO-2 gene mutation. Further studies for obtaining prenatal diagnosis and achievement of gene therapy should take place. As the disease rapidly progresses as the affected individual grows, surgical interventions should be taken into consideration before the initiation of complications.
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30
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Crippa S, Rossella V, Aprile A, Silvestri L, Rivis S, Scaramuzza S, Pirroni S, Avanzini MA, Basso-Ricci L, Hernandez RJ, Zecca M, Marktel S, Ciceri F, Aiuti A, Ferrari G, Bernardo ME. Bone marrow stromal cells from β-thalassemia patients have impaired hematopoietic supportive capacity. J Clin Invest 2019; 129:1566-1580. [PMID: 30830876 PMCID: PMC6436882 DOI: 10.1172/jci123191] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 01/17/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND. The human bone marrow (BM) niche contains a population of mesenchymal stromal cells (MSCs) that provide physical support and regulate hematopoietic stem cell (HSC) homeostasis. β-Thalassemia (BT) is a hereditary disorder characterized by altered hemoglobin beta-chain synthesis amenable to allogeneic HSC transplantation and HSC gene therapy. Iron overload (IO) is a common complication in BT patients affecting several organs. However, data on the BM stromal compartment are scarce. METHODS. MSCs were isolated and characterized from BM aspirates of healthy donors (HDs) and BT patients. The state of IO was assessed and correlated with the presence of primitive MSCs in vitro and in vivo. Hematopoietic supportive capacity of MSCs was evaluated by transwell migration assay and 2D coculture of MSCs with human CD34+ HSCs. In vivo, the ability of MSCs to facilitate HSC engraftment was tested in a xenogenic transplant model, whereas the capacity to sustain human hematopoiesis was evaluated in humanized ossicle models. RESULTS. We report that, despite iron chelation, BT BM contains high levels of iron and ferritin, indicative of iron accumulation in the BM niche. We found a pauperization of the most primitive MSC pool caused by increased ROS production in vitro which impaired MSC stemness properties. We confirmed a reduced frequency of primitive MSCs in vivo in BT patients. We also discovered a weakened antioxidative response and diminished expression of BM niche–associated genes in BT-MSCs. This caused a functional impairment in MSC hematopoietic supportive capacity in vitro and in cotransplantation models. In addition, BT-MSCs failed to form a proper BM niche in humanized ossicle models. CONCLUSION. Our results suggest an impairment in the mesenchymal compartment of BT BM niche and highlight the need for novel strategies to target the niche to reduce IO and oxidative stress before transplantation. FUNDING. This work was supported by the SR-TIGET Core grant from Fondazione Telethon and by Ricerca Corrente.
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Affiliation(s)
- Stefania Crippa
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), and
| | - Valeria Rossella
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), and
| | - Annamaria Aprile
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), and
| | - Laura Silvestri
- Regulation of Iron Metabolism Unit, Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Rivis
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), and
| | | | - Stefania Pirroni
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), and
| | | | - Luca Basso-Ricci
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), and
| | | | - Marco Zecca
- Oncoematologia Pediatrica, Fondazione IRCCS Policlinico "San Matteo", Pavia, Italy
| | - Sarah Marktel
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Aiuti
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), and.,Vita-Salute San Raffaele University, Milan, Italy.,Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giuliana Ferrari
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), and.,Vita-Salute San Raffaele University, Milan, Italy
| | - Maria Ester Bernardo
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET), and.,Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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31
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Zoledronic Acid for Treatment of Low Bone Mineral Density in Patients with Beta Thalassemia Major. Indian J Hematol Blood Transfus 2018; 34:648-652. [PMID: 30369735 DOI: 10.1007/s12288-018-0953-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 03/21/2018] [Indexed: 01/19/2023] Open
Abstract
To determine the efficacy of zoledronic acid (ZA) in thalassemia major associated low bone mineral density. Prospective, open label, single arm trial. Bone mineral density (BMD) at lumbar, hip and forearm region were performed at baseline and after 1 year of therapy. Initial, 9 patients received a first dose of 4 mg. Due to severe adverse effects, further doses for these patients and all new recruited patients were 1 mg once every 3 months for 4 doses. All patients were receiving 500 mg of calcium carbonate twice daily and 0.25 μg alfacalcidol once daily before and during the entire study period. Dual energy X-ray absoptiometry was performed at baseline and after 1 year. Twenty-seven patients with transfusion dependent thalassemia with a median age 19.5 year (15-38 years) were eligible for ZA treatment. Seven patients had bony pains. Four patients developed grade 4 hypocalcemia (3 developed tetany) and 2 developed infusion related toxicity with initial dose of 4 mg. One mg dose was well tolerated. At the end of 1 year, bone pains had completely resolved. There was significant increase in BMD at lumbar (p = 0.002) and forearm regions (p = 0.04) and intertrochantric area (p = 0.041). The % change in BMD at 1 year was +3.7 ± 3.2%. ZA is an efficacious agent in treatment of low BMD in these patients. ZA produces significant adverse reactions at 4 mg dose but 1 mg dose is well tolerated and is efficacious.
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32
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Al-Hakeim HK, Alhillawi ZH. Effect of serum fibroblast growth factor receptor 2 and CAPS proteins on calcium status in β-thalassaemia major patients who are free from overt inflammation. Growth Factors 2018; 36:178-185. [PMID: 30375242 DOI: 10.1080/08977194.2018.1520707] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Bone disorders and disturbed calcium (Ca) homeostasis are common disorders in β-thalassaemia major (β-TM). In the present study, two bone related markers are studied in β-TM patients with negative C-reactive protein for the first time; fibroblast growth factor receptor 2 (FGFR2) and CAPS protein. Another goal is to estimate the correlation between the recent parameters and bone biomaterials as a function of iron status parameters in β-TM patients. The results revealed that, in patients with β-TM serum FGFR2, CAPS, alkaline phosphatase (ALP) and Mg significantly increased while serum Ca levels were low as compared with controls. Ca status is correlated with iron overload in β-TM. A significant correlation was present between CAPS and FGFR2. In conclusion, FGFR2 and CAPS associated with Ca status and subsequent bone disturbances in β-TM patients. Their level can be predicted from the equation: CAPS =0.001ALP +0.48FGFR2-1.26Ca - 3.95Pi +12.76 with acceptable applicability.
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