Effective method of evaluating myocardial iron concentration in pediatric patients with thalassemia major

Assessment of Cardiac, Hepatic and Pancreatic Iron Overload in Transfusion Dependent Thalassemia Patients Using T2* Magnetic Resonance Imaging

We planned to assess iron overload in young transfusion-dependent thalassemia (TDT) patients with T2* MRI and correlate with serum ferritin. This study included young TDT patients aged 3 to 38 years on regular transfusion in a tertiary care facility from July 2017 to December 2018. T2* MRI was performed on all patients and correlated with serum ferritin values. Out of 193 cases over a period of one and half year, 26 (13.4%) cases showed mild, 48 (24.8%) moderate, and 92 (47.6%) cases showed severe hepatic iron overload. Cardiac iron overload detected none in 129, mild in 21, moderate in 12, severe in 31 patients. Pancreatic iron overload was observed none in 67, mild 35, moderate in 43, severe in 33 patients and could not be done in 15 patients. There is strong negative correlation between serum ferritin level and liver T2*. Moderate negative correlation of serum ferritin was found with cardiac T2*. Statistically significant difference was observed between pancreas iron overload and age group (P-value = 0.001). The results of this study are comparable with those of several earlier studies In addition, there is a significant correlation between serum ferritin levels and iron overload determined by T2* MRI data.

Cardiac injury caused by iron overload in thalassemia

Cardiac iron overload affects approximately 25% of patients with β-thalassemia major, which is associated with increased morbidity and mortality. Two mechanisms are responsible for iron overload in β-thalassemia: increased iron absorption due to ineffective erythropoiesis and blood transfusions. This review examines the mechanisms of myocardial injury caused by cardiac iron overload and role of various clinical examination techniques in assessing cardiac iron burden and functional impairment. Early identification and intervention for cardiac injury and iron overload in β-thalassemia have the potential to prevent and reverse or delay its progression in the early stages, playing a crucial role in its prognosis.

Ethiopian residents' knowledge and attitude towards blood donation and its associated factors: systematic review and meta-analysis

INTRODUCTION

Despite the existence of numerous blood donation centers globally, there remains a significant gap between the demand and supply of blood. In Ethiopia, replacement blood donation is more common than voluntary donation. The National Blood Bank of Ethiopia collects approximately 200,000 units of blood each year, while the daily requirement is 18,000 units. Donors' knowledge and attitudes are vital for ensuring a steady blood supply. This systematic review and meta-analysis sought to evaluate the knowledge and attitudes of Ethiopian residents regarding blood donation and the factors influencing them.

METHODS

Relevant research articles were identified through searches of various databases. Data extraction and organization were performed using Microsoft Excel, and the data were then analyzed using STATA/MP 17.0. A weighted inverse variance random-effects model with a 95% confidence interval was employed to pool the data. Heterogeneity was examined with the Galbraith plot and Cochrane I² statistics. To identify sources of heterogeneity, meta-regression, subgroup analysis, and sensitivity analysis were conducted. Publication bias was assessed using Egger's test and managed with trim and fill analysis. The adjusted odds ratio was calculated to explore the relationship between knowledge and attitudes towards blood donation, with a significance threshold of p < 0.05.

RESULTS

The pooled prevalence of favorable attitudes towards blood donation was 65.95%. Moderators such as study year (p = 0.72), publication year (p = 0.877), and sample size (p = 0.291) were not significant, indicating they did not contribute to heterogeneity. Studies from Northern Ethiopia reported the highest prevalence of favorable attitudes at 69.95%, while research on healthcare workers also indicated a high proportion of favorable attitudes at 69.29%. There was a significant association between knowledge and attitudes towards blood donation (AOR = 2.03).

CONCLUSION

The pooled prevalence of favorable attitudes towards blood donation was 65.95%, with the highest levels observed in Northern Ethiopia and among healthcare workers. A significant association between knowledge and positive attitudes towards blood donation was found. To enhance attitudes towards blood donation, increasing public awareness and education about the importance and safety of donating blood is crucial.

Correlation between plasma biochemical parameters and cardio-hepatic iron deposition in thalassemia major patients

INTRODUCTION

Major Thalassemia patients suffer from iron overload and organ damage, especially heart and liver damage. Early diagnosis and treatment with a chelator can reduce the complications and mortality of iron overload. Therefore, we aimed to investigate the biochemical and hematological predictors as an alternative and indirect indicator of iron deposition in heart and liver cells in comparison with the MRI T2* method as the gold standard.

MATERIAL AND METHOD

MRI T2* was evaluated in the heart and liver tissues of 62 major beta-thalassemia patients undergoing regular transfusion and chelator therapy. Biochemical and hematological factors were also measured, including serum ferritin, serum electrolytes, liver enzymes, hemoglobin, blood glucose, and serum magnesium. The correlation between these factors was assessed using statistical evaluations.

RESULT

Serum ferritin had a positive and significant correlation with liver siderosis based on MRI T2* (p-value = .015), and no significant association was observed with cardiac siderosis (p-value = .79). However, there was a significant positive correlation between cardiac iron deposition and fasting blood sugar level (p-value = -.049), and plasma level of liver enzymes (alanine aminotransferase (ALT) (p-value = .001), aspartate aminotransferase (AST ((p-value = .01)). Moreover, there was a significant negative correlation between cardiac iron overload and plasma magnesium level (p-value = .014). According to MRI T2*, there was no significant correlation between cardiac and hepatic iron overload (p value = .36).

CONCLUSION

An increase in blood sugar or liver enzymes and a decrease in serum magnesium was associated with an increase in cardiac iron overload based on MRI T2*. Liver iron overload based on MRI T2* had a significant correlation with serum ferritin.

Left Ventricular Myocardial Dysfunction Evaluation in Thalassemia Patients Using Echocardiographic Radiomic Features and Machine Learning Algorithms

Heart failure caused by iron deposits in the myocardium is the primary cause of mortality in beta-thalassemia major patients. Cardiac magnetic resonance imaging (CMRI) T2* is the primary screening technique used to detect myocardial iron overload, but inherently bears some limitations. In this study, we aimed to differentiate beta-thalassemia major patients with myocardial iron overload from those without myocardial iron overload (detected by T2*CMRI) based on radiomic features extracted from echocardiography images and machine learning (ML) in patients with normal left ventricular ejection fraction (LVEF > 55%) in echocardiography. Out of 91 cases, 44 patients with thalassemia major with normal LVEF (> 55%) and T2* ≤ 20 ms and 47 people with LVEF > 55% and T2* > 20 ms as the control group were included in the study. Radiomic features were extracted for each end-systolic (ES) and end-diastolic (ED) image. Then, three feature selection (FS) methods and six different classifiers were used. The models were evaluated using various metrics, including the area under the ROC curve (AUC), accuracy (ACC), sensitivity (SEN), and specificity (SPE). Maximum relevance-minimum redundancy-eXtreme gradient boosting (MRMR-XGB) (AUC = 0.73, ACC = 0.73, SPE = 0.73, SEN = 0.73), ANOVA-MLP (AUC = 0.69, ACC = 0.69, SPE = 0.56, SEN = 0.83), and recursive feature elimination-K-nearest neighbors (RFE-KNN) (AUC = 0.65, ACC = 0.65, SPE = 0.64, SEN = 0.65) were the best models in ED, ES, and ED&ES datasets. Using radiomic features extracted from echocardiographic images and ML, it is feasible to predict cardiac problems caused by iron overload.

Correlation of T-regulatory Cells and Iron Status in β-Thalassemia Major Patients

Background The increased risk of infections in transfusion-dependent β-thalassemia major (TDT) patients is mainly due to underlying immune dysfunction; however, its cause is largely unidentified. There is sufficient evidence to suggest immune changes due to iron deficiency; however, similar studies demonstrating the effects of iron excess on immune cells in these cases are limited. Aim and objectives To analyze the correlation between T-regulatory cells and iron stores in β-thalassemia major patients. Methods In this study, 20 β-thalassemia major cases and 20 healthy controls were studied for complete hemogram, iron profile, and flow cytometric immunophenotyping for CD3+, CD4+, CD8+, and T-regulatory cells markers (CD4+CD25+ and CD4+CD25+FOXP3+). Result Significantly higher levels of serum iron, ferritin, transferrin saturation, and CD4+ cell percentage were observed in cases than in controls. In 70% of cases with serum ferritin cut-off levels of less than 1000 µg/L, the T-regulatory cell marker CD4+CD25+ and serum ferritin revealed a significant moderate positive correlation (p=0.031, r=0.627). These same 70% cases also demonstrated a moderately significant positive correlation between serum iron and absolute lymphocyte count (r=0.529, p=0.042). Conclusion The results suggest that serum ferritin in excess amounts can increase T-regulatory cells, which may further alter the immune status of TDT patients; however, the absence of such a correlation in cases with serum ferritin of more than 1000 µg/L remains unanswered. It is important to understand immune system alterations as this will help provide new modalities for managing thalassemia patients in the form of immunoregulatory therapies.

The Outcomes of Patients with Haemoglobin Disorders in Cyprus: A Joined Report of the Thalassaemia International Federation and the Nicosia and Paphos Thalassaemia Centres (State Health Services Organisation)

Haemoglobinopathies, including thalassaemias and sickle-cell syndromes, are demanding, lifelong conditions that pose a significant burden to patients, families, and healthcare systems. Despite the therapeutic advances and the resulting improvements in prognosis accomplished in past decades, these patients still face important challenges, including suboptimal access to quality care in areas with developing economies, changing epidemiology due to massive migration flows, an evolving clinical spectrum due to ageing in well-treated patients, and limited access to novel high-cost therapies. We herein describe the organization of healthcare services for haemoglobinopathies in Cyprus—with particular focus on beta-thalassaemia, the most prevalent condition in this region—along with selected patient outcomes. This report aims at underscoring the fact that nationally funded and well-coordinated prevention and care programmes for chronic and complex conditions, such as haemoglobinopathies, with active involvement from patient organizations lead to effective disease control and excellent outcomes in survival, quality of life, social adaptation, and public health savings, and allow timely and effective responses to emerging crises, such as the COVID-19 pandemic. The Cyprus paradigm could therefore serve as a blueprint for the organization or adaptation of haemoglobinopathy programs in other countries since these disorders are still widely occurring.

Diagnostic Modalities in Detecting Cardiovascular Complications of Thalassemia

Thalassemia major is the most common monogenetic disorder worldwide, manifested as chronic hemolytic anemia. This condition leads to the need for chronic blood transfusion to be monitored for an iron overload that may be stored in several tissues and organs, including cardiomyocytes, that might cause a broad spectrum of cardiac iron toxicities such as heart failure conduction delays, myocarditis, and arrhythmias. Non-invasive imaging modalities have their benefits and limitations. Each modality complements and generates a comprehensive diagnostic and monitoring of cardiac siderosis in thalassemia major patients.

A double-blind, controlled, crossover trial of amlodipine on iron overload status in transfusion dependent β-thalassemia patients

BACKGROUND AND AIM

This study examined whether administration of amlodipine could improve myocardial iron loading status in patients with transfusion dependent β-thalassemia (TDT), through a placebo-controlled, crossover study.

METHODS

Amlodipine (5 mg, daily) or placebo were prescribed to all patients (n = 19) for 6 months, and after a 2-week washout period, patients were crossed over to the other group. The efficacy of amlodipine on iron loading was assessed by measuring myocardial T2*-weighted magnetic resonance imaging (MRI T2*, millisecond [ms]) and serum ferritin (ng/mL).

RESULTS

Seventeen patients completed the study. The mean ± standard deviation [SD] of myocardial MRI T2* at baseline was 9.83 ± 2.67 ms Myocardial MRI T2* value rose to 11.44 ± 4.14 ms post amlodipine treatment in all patients. After placebo, myocardial MRI T2* value reached 10.29 ± 4.01 ms After controlling the baseline measures, Hedges's g for ferritin and myocardial MRI T2* outcomes were estimated 3.84 (95% confidence interval [CI] 2.68 to 4.97) and -1.80 (95% CI -2.58 to -0.10), respectively.

CONCLUSION

Amlodipine might improve myocardial MRI T2* and serum ferritin level compared to placebo. However, larger clinical studies are needed to confirm the results.

Assessment of cardiac and liver iron overload by magnetic resonance imaging in patients with thalassemia major: short-term follow-up

Objective

This study was performed to assess cardiac and hepatic iron overload in young patients with thalassemia.

Methods

We reviewed the medical records of patients with thalassemia at a pediatric hematology clinic who had recently undergone cardiac and hepatic magnetic resonance imaging.

Results

Eleven patients underwent cardiac and hepatic T2* imaging at a mean age of 13.9 ± 4.48 (range, 9–21) years. Three patients had cardiac iron overload and all patients had hepatic iron overload according to the magnetic resonance imaging scan. Ten patients underwent control imaging approximately 1 year later. The mean serum ferritin level at the initial imaging examination was 1820.87 ± 1275.22 (range, 634.04–4221.03) ng/mL. There was a strong negative correlation between the ferritin level and cardiac T2* time and between the blood hemoglobin level and hepatic T2* time. Among the 10 patients who underwent control imaging, the average hemoglobin and ferritin levels significantly decreased from the initial to control imaging examinations, but there was no significant increase in the cardiac and hepatic T2*times.

Conclusions

Cardiac and hepatic T2* imaging is a feasible method of assessing cardiac and hepatic iron overload even before complications and clinical signs of iron overload appear.

Relation of hepcidin gene expression in blood mononuclear cells with iron overload severity among β-thalassemia major patients

Iron overload is the main cause of morbidity and mortality in β-thalassemia major patients, and cardiac iron overload is the most common reason for death in these transfusion-dependent patients. Hepcidin, a liver-derived peptide hormone, plays a key role in plasma iron levels regulation by controlling two main stages, digestive iron absorption in enterocytes, and iron recycling in macrophages. Although hepcidin is mainly secreted from hepatocytes in the liver, it is also synthesized from mononuclear cells consisting of monocytes and lymphocytes. Binding of this molecule to ferroportin, a specific cellular exporter of iron, leads to degradation of the ligand-receptor complex, which reduces the iron overload by lowering the amounts of iron released into the plasma. Likewise, the same mechanism has been proved to be true for lymphocyte-drived hepcidin. The expression levels of hepcidin mRNA were evaluated using quantitative real time PCR (qRT-PCR) in 50 β-thalassemia major patients, as well as 25 healthy volunteers as the group of control. There was a significantly positive correlation between the cardiac iron concentration, showed by higher T2 values, and hepcidin levels in the patients (p = 0.028; r = 0.311). However, hepcidin expression levels did not significantly correlate with ferritin and liver iron concentrations. Hepcidin can act as a beneficial marker to determine iron overload degrees, particularly in the heart, in β-thalassemia major patients and be used as a logical therapeutic agent for treatment of β-thalassemia disorders.