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Singh SP, Jagia P, Ojha V, Seth T, Naik N, Ganga KP, Kumar S. Diagnostic Value of T1 Mapping in Detecting Iron Overload in Indian Patients with Thalassemia Major: A Comparison with T2* Mapping. Indian J Radiol Imaging 2024; 34:54-59. [PMID: 38106847 PMCID: PMC10723946 DOI: 10.1055/s-0043-1772467] [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] [Indexed: 12/19/2023] Open
Abstract
Purpose T2* is the gold standard for iron quantification in liver as well as myocardium. In this study, we evaluated the diagnostic accuracy of myocardial T1 mapping for the assessment of myocardial iron overload (MIO) as compared to the T2* mapping in patients with thalassemia major (TM). Methods Consecutive TM patients attending the thalassemia clinic were prospectively enrolled. Magnetic resonance imaging was performed on a 1.5 T scanner (Siemens Healthineers, Germany) using a gradient echo T2* as well as a T1 mapping (MOLLI) sequence done at a mid-ventricular short-axis single 8 mm slice of the left ventricle. Values were analyzed by manually drawing a region of interest in the mid-septum. T2*less than 20ms was used as the cutoff for significant MIO. Results One-hundred three patients (58 males, mean age: 17 ± 7.8 years, mean ferritin: 2009.5 µg/L) underwent cardiovascular magnetic resonance. Median T2* of myocardium was 33.45ms. Nineteen patients (18.4%) had T2*less than 20ms. T1 value was low (<850ms) in all the patients with T2* less than 20 ms. Receiver operating characteristic curve analysis revealed the best cutoff of native T1 mapping value as 850 ms which had high specificity (95.2%), sensitivity (94.2%) and negative predictive value (98.8%) for T2* less than 20ms. There was excellent agreement between T1 and T2* for diagnosis of MIO (Kappa-0.848, p <0.001). We did not find any patient who had normal T1 mapping values but had MIO on T2*. Conclusion T1 and T2* correlate well and normal T1 values may rule out presence of MIO. T1 mapping can act as additional imaging marker for MIO and may be helpful in centers with nonavailability or limited experience of T2*.
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Affiliation(s)
- Surya Pratap Singh
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Priya Jagia
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Vineeta Ojha
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Tulika Seth
- Department of Haematology, All India Institute of Medical Sciences, New Delhi, India
| | - Nitish Naik
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Kartik P. Ganga
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Kumar
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
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Wood JC. Cardiac complications in thalassemia throughout the lifespan: Victories and challenges. Ann N Y Acad Sci 2023; 1530:64-73. [PMID: 37902424 PMCID: PMC10841366 DOI: 10.1111/nyas.15078] [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] [Indexed: 10/31/2023]
Abstract
Thalassemias are among the most common hereditary diseases in the world because heterozygosity offers protection against malarial infection. Affected individuals have variable expression of alpha or beta chains that lead to their unbalanced utilization during hemoglobin formation, oxidative stress, and apoptosis of red cell precursors prior to maturation. Some individuals produce sufficient hemoglobin to survive but suffer the vascular stress imposed by chronic anemia and ineffective erythropoiesis. In other patients, mature red cell formation is insufficient, and chronic transfusions are required-suppressing anemia and ineffective erythropoiesis but at the expense of iron overload. The cardiovascular consequences of thalassemia have changed dramatically over the previous five decades because of evolving treatment practices. This review summarizes this evolution, focusing on complications and management pertinent to modern patient cohorts.
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Affiliation(s)
- John C Wood
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, California, USA
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Raief Mosaad BM, Ibrahim AS, Mansour MG, ElAlfy MS, Ebeid FSE, Abdeldayem EH. The role of MRI-R2* in the detection of subclinical pancreatic iron loading among transfusion-dependent sickle cell disease patients and correlation with hepatic and cardiac iron loading. Insights Imaging 2022; 13:140. [PMID: 36057708 PMCID: PMC9440968 DOI: 10.1186/s13244-022-01280-x] [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: 04/13/2022] [Accepted: 08/01/2022] [Indexed: 11/11/2022] Open
Abstract
Objectives Pancreatic reserve could be preserved by early assessment of pancreatic iron overload among transfusion-dependent sickle cell disease (SCD) patients. This study aimed to measure pancreatic iron load and correlate its value with patients’ laboratory and radiological markers of iron overload. Materials and methods Sixty-six SCD children and young adults underwent MRI T2* relaxometry using a simple mathematical spreadsheet and laboratory assessment. Results The results indicated moderate-to-severe hepatic iron overload among 65.2% of studied cases. None had cardiac iron overload. Normal-to-mild iron overload was present in the pancreas in 86% of cases, and 50% had elevated serum ferritin > 2500 ug/L. There was no significant correlation between pancreatic R2* level, serum ferritin, and hepatic iron overload. Patients with higher levels of hemolysis markers and lower pre-transfusion hemoglobin levels showed moderate-to-severe pancreatic iron overload. Conclusion Chronically transfused patients with SCD have a high frequency of iron overload complications including pancreatic iron deposition, thereby necessitating proper monitoring of the body’s overall iron balance as well as detection of extrahepatic iron depositions.
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Affiliation(s)
| | - Ahmed Samir Ibrahim
- Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohamed G Mansour
- Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohsen Saleh ElAlfy
- Pediatrics Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Emad H Abdeldayem
- Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Bayraktaroglu S, Karadas N, Onen S, Karapinar DY, Aydinok Y. Modern management of iron overload in thalassemia major patients guided by MRI techniques: real-world data from a long-term cohort study. Ann Hematol 2022; 101:521-529. [DOI: 10.1007/s00277-021-04748-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/15/2021] [Indexed: 01/19/2023]
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5
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Casale M, Forni GL, Cassinerio E, Pasquali D, Origa R, Serra M, Campisi S, Peluso A, Renni R, Cattoni A, De Michele E, Allò M, Poggi M, Ferrara F, Di Concilio R, Sportelli F, Quarta A, Putti MC, Notarangelo LD, Sau A, Ladogana S, Tartaglione I, Picariello S, Marcon A, Sturiale P, Roberti D, Lazzarino AI, Perrotta S. Risk factors for endocrine complications in transfusion-dependent thalassemia patients on chelation therapy with deferasirox: a risk assessment study from a multicentre nation-wide cohort. Haematologica 2021; 107:467-477. [PMID: 33406815 PMCID: PMC8804575 DOI: 10.3324/haematol.2020.272419] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Indexed: 01/19/2023] Open
Abstract
Transfusion-dependent patients typically develop iron-induced cardiomyopathy, liver disease, and endocrine complications. We aimed to estimate the incidence of endocrine disorders in transfusiondependent thalassemia (TDT) patients during long-term iron-chelation therapy with deferasirox (DFX). We developed a multi-center follow-up study of 426 TDT patients treated with once-daily DFX for a median duration of 8 years, up to 18.5 years. At baseline, 118, 121, and 187 patients had 0, 1, or ≥2 endocrine diseases respectively. 104 additional endocrine diseases were developed during the follow-up. The overall risk of developing a new endocrine complication within 5 years was 9.7% (95% Confidence Interval [CI]: 6.3–13.1). Multiple Cox regression analysis identified three key predictors: age showed a positive log-linear effect (adjusted hazard ratio [HR] for 50% increase 1.2, 95% CI: 1.1–1.3, P=0.005), the serum concentration of thyrotropin showed a positive linear effect (adjusted HR for 1 mIU/L increase 1.3, 95% CI: 1.1–1.4, P<0.001) regardless the kind of disease incident, while the number of previous endocrine diseases showed a negative linear effect: the higher the number of diseases at baseline the lower the chance of developing further diseasess (adjusted HR for unit increase 0.5, 95% CI: 0.4–0.7, P<0.001). Age and thyrotropin had similar effect sizes across the categories of baseline diseases. The administration of levothyroxine as a covariate did not change the estimates. Although in DFX-treated TDT patients the risk of developing an endocrine complication is generally lower than the previously reported risk, there is considerable risk variation and the burden of these complications remains high. We developed a simple risk score chart enabling clinicians to estimate their patients’ risk. Future research will look at increasing the amount of variation explained from our model and testing further clinical and laboratory predictors, including the assessment of direct endocrine magnetic resonance imaging.
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Affiliation(s)
- Maddalena Casale
- Department of Women, Child and General and Specialized Surgery, University " Luigi Vanvitelli", via Luigi De Crecchio n. 4, 80138, Naples.
| | - Gian Luca Forni
- Center of Microcitemia and Congenital Anemias, Galliera Hospital, Mura delle Cappuccine 14 16128, Genoa
| | - Elena Cassinerio
- Rare Diseases Center, General Medicine Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan
| | - Daniela Pasquali
- Endocrinology, Department of Advanced Medical and Surgical Sciences, University " Luigi Vanvitelli", Naples
| | - Raffaella Origa
- Thalassemia Centre, Pediatric Hospital A CAO, AOG Brotzu, Cagliari
| | - Marilena Serra
- Thalassemia Centre, Department of Internal Medicine, Hospital "V. Fazzi", Lecce
| | | | - Angelo Peluso
- Centre of Microcitemia, POC SS.Annunziata - ASL TA, Taranto
| | - Roberta Renni
- Thalassemia Centre, Department of Internal Medicine, Hospital F.Ferrari, Casarano
| | - Alessandro Cattoni
- Department of Pediatrics, Università degli Studi di Milano Bicocca, Fondazione Monza e Brianza per il Bambino e la sua Mamma, Azienda Ospedaliera San Gerardo, Monza
| | - Elisa De Michele
- Immunotransfusion Medicine Unit, AOU OO.RR. S. Giovanni di Dio e Ruggi d'Aragona, Salerno
| | | | | | | | | | | | - Antonella Quarta
- Center for Microcythemia, Iron Metabolism disorders, Gaucher disease-Hematology and Transplantation Unit, "A. Perrino" Hospital, Brindisi
| | | | | | - Antonella Sau
- Department of Pediatric Hematology and Oncology, Hospital "Spirito Santo", Pescara
| | - Saverio Ladogana
- Pediatric Oncohematology Unit, "Casa Sollievo della Sofferenza" Hospital, IRCCS, San Giovanni Rotondo
| | - Immacolata Tartaglione
- Department of Women, Child and General and Specialized Surgery, University " Luigi Vanvitelli", via Luigi De Crecchio n. 4, 80138, Naples
| | - Stefania Picariello
- Department of Women, Child and General and Specialized Surgery, University " Luigi Vanvitelli", via Luigi De Crecchio n. 4, 80138, Naples
| | - Alessia Marcon
- Rare Diseases Center, General Medicine Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan
| | | | - Domenico Roberti
- Department of Women, Child and General and Specialized Surgery, University " Luigi Vanvitelli", via Luigi De Crecchio n. 4, 80138, Naples
| | - Antonio Ivan Lazzarino
- EPISTATA - Agency for Clinical Research and Medical Statistics, London E8 3SY, United Kingdom
| | - Silverio Perrotta
- Department of Women, Child and General and Specialized Surgery, University " Luigi Vanvitelli", via Luigi De Crecchio n. 4, 80138, Naples
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Controversies on the Consequences of Iron Overload and Chelation in MDS. Hemasphere 2020; 4:e357. [PMID: 32647792 PMCID: PMC7306315 DOI: 10.1097/hs9.0000000000000357] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 02/17/2020] [Indexed: 12/15/2022] Open
Abstract
Many patients with MDS are prone to develop systemic and tissue iron overload in part as a consequence of disease-immanent ineffective erythropoiesis. However, chronic red blood cell transfusions, which are part of the supportive care regimen to correct anemia, are the major source of iron overload in MDS. Increased systemic iron levels eventually lead to the saturation of the physiological systemic iron carrier transferrin and the occurrence of non-transferrin-bound iron (NTBI) together with its reactive fraction, the labile plasma iron (LPI). NTBI/LPI-mediated toxicity and tissue iron overload may exert multiple detrimental effects that contribute to the pathogenesis, complications and eventually evolution of MDS. Until recently, the evidence supporting the use of iron chelation in MDS was based on anecdotal reports, uncontrolled clinical trials or prospective registries. Despite not fully conclusive, these and more recent studies, including the TELESTO trial, unravel an overall adverse action of iron overload and therapeutic benefit of chelation, ranging from improved hematological outcome, reduced transfusion dependence and superior survival of iron-loaded MDS patients. The still limited and somehow controversial experimental and clinical data available from preclinical studies and randomized trials highlight the need for further investigation to fully elucidate the mechanisms underlying the pathological impact of iron overload-mediated toxicity as well as the effect of classic and novel iron restriction approaches in MDS. This review aims at providing an overview of the current clinical and translational debated landscape about the consequences of iron overload and chelation in the setting of MDS.
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Yang Y, Tang Z, An T, Zhao L. The impact of iron chelation therapy on patients with lower/intermediate IPSS MDS and the prognostic role of elevated serum ferritin in patients with MDS and AML: A meta-analysis. Medicine (Baltimore) 2019; 98:e17406. [PMID: 31577751 PMCID: PMC6783160 DOI: 10.1097/md.0000000000017406] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Serum ferritin (SF) has been identified as a potential prognostic factor for patients undergoing stem cell transplantation, but the prognostic value of SF in acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) patients and the impact of iron chelation therapy (ICT) on MDS patients are controversial. The present meta-analysis aimed to better elucidate these relationships.Three electronic databases were searched systematically to identify reports on the prognostic role of SF in MDS and AML patients, and those investigating the impact of ICT on prognosis of MDS patients. The hazard ratios (HRs) and its 95% confidence interval (95%CI) were extracted from the identified studies using Cox proportional hazard regression model for overall survival (OS) and progression of MDS to AML.Twenty reports including 1066 AML patients and 4054 MDS patients were included in present study. The overall pooled HRs for OS of AML and MDS patients with elevated SF prior to transplantation was 1.73 (1.40-2.14), subgroup analyses stratified by the cut-off value of SF ≥1400/1000 ng/mL showed that the pooled HRs were 1.45 (0.98-2.15) and 1.65 (1.30-2.10), respectively. The pooled HRs for ICT in MDS patients was 0.30 (0.23-0.40). For ICT, the pooled HRs for the progression of MDS to AML was 0.84 (0.61-1.61).SF has a negative impact on the OS of AML and MDS patients when it is higher than 1000 ng/mL. ICT can improve the OS of MDS patients with iron overload but it is not associated with the progression of MDS to AML.
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Affiliation(s)
- Yuan Yang
- The First Clinical Medical School of Lanzhou University
- Center Laboratory of The First Hospital of Lanzhou University
| | - Zengwei Tang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou
| | - Tianli An
- The First Clinical Medical School of Lanzhou University
- Center Laboratory of The First Hospital of Lanzhou University
| | - Li Zhao
- The First Clinical Medical School of Lanzhou University
- Center Laboratory of The First Hospital of Lanzhou University
- Department of Hematology, The First Hospital of Lanzhou University, Lanzhou, China
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8
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Saito T, Ikuta K, Hatayama M, Shibusa K, Matsui K, Tanaka R, Toki Y, Kato D, Iizuka N, Okumura T. Novel automated measuring system for evaluating labile plasma iron in serum. Ann Clin Biochem 2019; 56:654-661. [PMID: 31237766 DOI: 10.1177/0004563219861413] [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: 11/15/2022]
Abstract
BackgroundAs the saturation of transferrin by iron in the serum is approximately 30%, iron loaded to the blood can bind to transferrin not bearing iron. Nevertheless, prolonged iron influx finally results in full transferrin saturation, and iron not bound to transferrin will appear in the serum; this iron is known as non-transferrin-bound iron (NTBI). NTBI damages organs through the production of free radicals. Previously, we established an automated quantification system for NTBI; however, measuring labile plasma iron, which is considered as a highly redox-active component of NTBI, should be a better prognostic factor in iron-overloaded patients.MethodsWe designed and developed a novel system for evaluating labile plasma iron utilizing the Trinder reaction. Automated system was utilized because the previously reported methods for labile plasma iron are intricate and the introduction to the clinical stage has been challenging. Validations such as the contribution of serum proteins and metal ions for this system were evaluated using human serum samples.ResultsWe confirmed that our novel system can evaluate labile plasma iron utilizing Trinder reaction and the oxidative potential of ceruloplasmin in the serum. This system was also confirmed to be clinically practical. Metals other than iron did not influence this system. We observed that samples with high NTBI did not always exhibit high labile plasma iron and vice versa, highlighting the necessity of labile plasma iron quantification in evaluating the toxicity of NTBI.ConclusionsOur novel system should contribute to fundamental and clinical research because it can measure labile plasma iron using the high-throughput automated analyser.
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Affiliation(s)
- Takeshi Saito
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Katsuya Ikuta
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Mayumi Hatayama
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Kotoe Shibusa
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Kozo Matsui
- Research and Development Department, Shino-Test Corporation, Sagamihara, Kanagawa, Japan
| | - Riki Tanaka
- Research and Development Department, Shino-Test Corporation, Sagamihara, Kanagawa, Japan
| | - Yasumichi Toki
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Daisuke Kato
- Research and Development Department, Shino-Test Corporation, Sagamihara, Kanagawa, Japan
| | - Naomi Iizuka
- Research and Development Department, Shino-Test Corporation, Sagamihara, Kanagawa, Japan
| | - Toshikatsu Okumura
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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Deferasirox: Over a Decade of Experience in Thalassemia. Mediterr J Hematol Infect Dis 2018; 10:e2018066. [PMID: 30416698 PMCID: PMC6223547 DOI: 10.4084/mjhid.2018.066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 09/15/2018] [Indexed: 01/19/2023] Open
Abstract
Thalassemia incorporates a broad clinical spectrum characterized by decreased or absent production of normal hemoglobin leading to decreased red blood cell survival and ineffective erythropoiesis. Chronic iron overload remains an inevitable complication resulting from regular blood transfusions (transfusion-dependent) and/or increased iron absorption (mainly non-transfusion-dependent thalassemia), requiring adequate treatment to prevent the significant associated morbidity and mortality. Iron chelation therapy has become a cornerstone in the management of thalassemia patients, leading to improvements in their outcome and quality of life. Deferasirox (DFX), an oral iron chelating agent, is approved for use in transfusion dependent and non-transfusion-dependent thalassemia and has shown excellent efficacy in this setting. We herein present an updated review of the role of deferasirox in thalassemia, exploring over a decade of experience, which has documented its effectiveness and convenience; in addition to its manageable safety profile.
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Steinberg-Shemer O, Yacobovich J, Cohen M, Cabantchik IZ, Tamary H. Labile plasma iron as an indicator of patient adherence to iron chelation treatment. Blood Cells Mol Dis 2018; 71:1-4. [PMID: 29395830 DOI: 10.1016/j.bcmd.2018.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/13/2018] [Accepted: 01/15/2018] [Indexed: 10/18/2022]
Abstract
Poor adherence of transfusion-dependent patients to chelation treatment is often the cause of persistent iron overload and ensuing morbidity. However, a tool to assess patient compliance with therapy is lacking in clinical practice. Labile plasma iron (LPI, the redox-active component of non-transferrin bound iron) has been studied as an indicator of systemic iron overload and of chelation efficacy, and may particularly reflect recent iron equilibrium. We considered the use of LPI as a potential indicator for recent chelation treatment in 18 transfusion-dependent pediatric patients. Samples were collected under chelation treatment or after a short interruption of the treatment, and LPI was measured by the FeROS assay (Aferrix, Tel Aviv, Israel). LPI was significantly higher after a short-term interruption of the chelation (median of 0.4 μM off-therapy [range:0-4] vs 0 μM on-therapy [range:0-2.8] (p < .001)). Conversely, serum iron, serum ferritin and calculated transferrin saturation were not significantly higher in the "off-therapy" samples compared to "on-therapy". In addition, in multivariate logistic regression analysis LPI was the variable most significantly associated with recent chelation treatment (p = .001). We conclude that LPI could serve as a useful indicator of compliance to chelation therapy.
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Affiliation(s)
- Orna Steinberg-Shemer
- Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva 49202, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Joanne Yacobovich
- Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva 49202, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Miriam Cohen
- Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva 49202, Israel
| | - Ioav Z Cabantchik
- Institute of Life Sciences, Hebrew University of Jerusalem, Jerusalem 91904, Israel
| | - Hannah Tamary
- Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva 49202, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel.
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Abstract
Introduction of MRI techniques for identifying and monitoring tissue iron overload and the current understanding of iron homeostasis in transfusion-dependent (TDT) and non-transfusion-dependent thalassemia have allowed for a more robust administration of iron chelation therapies. The development of safe and efficient oral iron chelators and the insights gained from large-scale prospective studies using these agents have improved iron overload management. A significant reduction in iron toxicity-induced morbidity and mortality and improvements in quality of life were observed in TDT. The appropriate management of tissue-specific iron loading in TDT has been portrayed using evidence-based data obtained from investigational studies.
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Affiliation(s)
- Yesim Aydinok
- Department of Pediatric Hematology and Oncology, Ege University Children's Hospital, Bornova, Izmir 35100, Turkey.
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12
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Affiliation(s)
- John C Wood
- Department of Pediatrics and Radiology, Division of Pediatric Cardiology, Children's Hospital Los Angeles-USC Keck School of Medicine, Los Angeles, CA, United States
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13
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Maximova N, Gregori M, Boz G, Simeone R, Zanon D, Schillani G, Zennaro F. MRI-based evaluation of multiorgan iron overload is a predictor of adverse outcomes in pediatric patients undergoing allogeneic hematopoietic stem cell transplantation. Oncotarget 2017; 8:79650-79661. [PMID: 29108345 PMCID: PMC5668078 DOI: 10.18632/oncotarget.19021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 06/19/2017] [Indexed: 01/11/2023] Open
Abstract
The medical records of 44 pediatric patients who underwent allogeneic transplantation from 2011 to 2015 were retrospectively reviewed. Magnetic resonance imaging was used to measure iron concentrations in the liver, spleen, pancreas and bone. These patients were divided into two groups, 18 with non-elevated (< 100 μmol/g; Group 1) liver iron concentration before transplantation and 26 with elevated (> 100 μmol/g; Group 2) concentration . We compared transplant-related outcomes in the two groups. Iron overload was a negative prognostic risk factor for sinusoidal obstruction syndrome (OR = 17), osteoporosis (OR = 6.8), pancreatic insufficiency (OR = 17) and metabolic syndrome (OR = 15.1). No statistically significant differences in overall survival, disease-free survival, relapse incidence and incidence of acute or chronic graft-versus host disease were observed between the two groups. Mean times to engraftment of platelets (43.0 ± 35.3 days vs. 22.1 ± 9.5 days, p < 0.05) and neutrophils (23.1 ± 10.4 days vs. 17.8 ± 4.6 days, p < 0.05) appear significantly longer in Group 2 than in Group 1. Time to platelet engraftment showed statistically significant correlation with pre-transplant liver (r = 0.5775; p < 0.001) and bone iron concentration (r = 0.7305; p < 0.001). Post-transplant evaluation pointed out that iron concentration analyzed at the first follow-up peaked in all tissues. The iron accumulation was highest in bone, followed by the spleen, liver and pancreas. One year post transplant 9 of 18 (50%) patients in Group 1 and 6 of 22 (27%) in Group 2 presented with bone and/or spleen iron overload, but not with liver overload. Liver iron concentration is not always a reliable indicator of systemic siderosis or of the efficacy of chelation therapy.
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Affiliation(s)
- Natalia Maximova
- Bone Marrow Transplant Unit, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Massimo Gregori
- Department of Radiology, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Giulia Boz
- University of Trieste, Piazzale Europa, 34128 Trieste, Italy
| | - Roberto Simeone
- Department of Transfusion Medicine, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Davide Zanon
- Pharmacy, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Giulia Schillani
- Bone Marrow Transplant Unit, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Floriana Zennaro
- Department of Radiology, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
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Garbowski MW, Evans P, Vlachodimitropoulou E, Hider R, Porter JB. Residual erythropoiesis protects against myocardial hemosiderosis in transfusion-dependent thalassemia by lowering labile plasma iron via transient generation of apotransferrin. Haematologica 2017. [PMID: 28642302 PMCID: PMC5622848 DOI: 10.3324/haematol.2017.170605] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Cardiosiderosis is a leading cause of mortality in transfusion-dependent thalassemias. Plasma non-transferrin-bound iron and its redox-active component, labile plasma iron, are key sources of iron loading in cardiosiderosis. Risk factors were identified in 73 patients with or without cardiosiderosis. Soluble transferrin receptor-1 levels were significantly lower in patients with cardiosiderosis (odds ratio 21). This risk increased when transfusion-iron loading rates exceeded the erythroid transferrin uptake rate (derived from soluble transferrin receptor-1) by >0.21 mg/kg/day (odds ratio 48). Labile plasma iron was >3-fold higher when this uptake rate threshold was exceeded, but non-transferrin-bound iron and transferrin saturation were comparable. The risk of cardiosiderosis was decreased in patients with low liver iron, ferritin and labile plasma iron, or high bilirubin, reticulocyte counts or hepcidin. We hypothesized that high erythroid transferrin uptake rate decreases cardiosiderosis through increased erythroid re-generation of apotransferrin. To test this, iron uptake and intracellular reactive oxygen species were examined in HL-1 cardiomyocytes under conditions modeling transferrin effects on non-transferrin-bound iron speciation with ferric citrate. Intracellular iron and reactive oxygen species increased with ferric citrate concentrations especially when iron-to-citrate ratios exceeded 1:100, i.e. conditions favoring kinetically labile monoferric rather than oligomer species. Excess iron-binding equivalents of apotransferrin inhibited iron uptake and decreased both intracellular reactive oxygen species and labile plasma iron under conditions favoring monoferric species. In conclusion, high transferrin iron utilization, relative to the transfusion-iron load rate, decreases the risk of cardiosiderosis. A putative mechanism is the transient re-generation of apotransferrin by an active erythron, rapidly binding labile plasma iron-detectable ferric monocitrate species.
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Affiliation(s)
- Maciej W Garbowski
- Research Haematology Department, Cancer Institute, University College London, UK .,University College London Hospitals and
| | - Patricia Evans
- Research Haematology Department, Cancer Institute, University College London, UK
| | | | - Robert Hider
- Institute of Pharmaceutical Sciences, King's College London, UK
| | - John B Porter
- Research Haematology Department, Cancer Institute, University College London, UK.,University College London Hospitals and
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15
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Mobarra N, Shanaki M, Ehteram H, Nasiri H, Sahmani M, Saeidi M, Goudarzi M, Pourkarim H, Azad M. A Review on Iron Chelators in Treatment of Iron Overload Syndromes. Int J Hematol Oncol Stem Cell Res 2016; 10:239-247. [PMID: 27928480 PMCID: PMC5139945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Iron chelation therapy is used to reduce iron overload development due to its deposition in various organs such as liver and heart after regular transfusion. In this review, different iron chelators implicated in treatment of iron overload in various clinical conditions have been evaluated using more up-to-date studies focusing on these therapeutic agents. Deferoxamine, Deferiprone and Deferasirox are the most important specific US FDA-approved iron chelators. Each of these chelators has their own advantages and disadvantages, various target diseases, levels of deposited iron and clinical symptoms of the afflicted patients which may affect their selection as the best modality. Taken together, in many clinical disorders, choosing a standard chelator does not have an accurate index which requires further clarifications. The aim of this review is to introduce and compare the different iron chelators regarding their advantages and disadvantages, usage dose and specific applications.
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Affiliation(s)
- Naser Mobarra
- Metabolic Disorders Research Center, Department of Biochemistry, School of Medicine, Golestan University of Medical Sciences, Gorgan, Iran
| | - Mehrnoosh Shanaki
- Department of Laboratory Medicine, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hassan Ehteram
- Department of Pathology, School of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Hajar Nasiri
- Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Sahmani
- Department of Clinical Biochemistry, Cellular and Molecular Research Center, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Mohsen Saeidi
- Stem Cell Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Mehdi Goudarzi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hoda Pourkarim
- Department of Hematology, Allied Medical School, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Azad
- Department of Medical Laboratory Sciences, Faculty of Allied Medicine, Qazvin University of Medical Sciences, Qazvin, Iran
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16
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Ho PJ, Tay L, Teo J, Marlton P, Grigg A, St Pierre T, Brown G, Badcock CA, Traficante R, Gervasio OL, Bowden DK. Cardiac iron load and function in transfused patients treated with deferasirox (the MILE study). Eur J Haematol 2016; 98:97-105. [DOI: 10.1111/ejh.12793] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2016] [Indexed: 01/24/2023]
Affiliation(s)
- P. Joy Ho
- Institute of Haematology; Royal Prince Alfred Hospital; University of Sydney; Sydney NSW Australia
| | - Lay Tay
- Department of Haematology; Royal Adelaide Hospital; Adelaide SA Australia
| | - Juliana Teo
- Department of Haematology; The Children's Hospital at Westmead; Sydney NSW Australia
| | - Paula Marlton
- Department of Haematology; Princess Alexandra Hospital; School of Medicine University of Queensland; Brisbane QLD Australia
| | - Andrew Grigg
- Department of Clinical Haematology; Royal Melbourne Hospital; Melbourne VIC Australia
| | | | - Greg Brown
- Department of Radiology; Royal Adelaide Hospital; Adelaide SA Australia
| | | | | | | | - Donald K. Bowden
- Thalassaemia Services Victoria; Monash Medical Centre; Melbourne VIC Australia
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17
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Lioudaki E, Whyte M. Acute cardiac decompensation in a patient with beta-thalassemia and diabetes mellitus following cessation of chelation therapy. Clin Case Rep 2016; 4:992-996. [PMID: 27761254 PMCID: PMC5054478 DOI: 10.1002/ccr3.686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 07/05/2016] [Accepted: 08/04/2016] [Indexed: 01/19/2023] Open
Abstract
Patients with higher liver iron stores are likely to have a worse cardiac outcome following noncompliance with chelation. Cardiovascular magnetic resonance identifies myocardial siderosis allowing optimization of iron chelation regimes. Diabetes puts thalassemic patients at increased risk of myocardial fibrosis. Dual chelation therapy with deferoxamine and deferiprone offers improved cardiac outcomes.
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Affiliation(s)
| | - Martin Whyte
- Department of Medicine King's College NHS Trust London UK
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18
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Roghi A, Poggiali E, Duca L, Mafrici A, Pedrotti P, Paccagnini S, Brenna S, Galli A, Consonni D, Cappellini MD. Role of Non-Transferrin-Bound Iron in the pathogenesis of cardiotoxicity in patients with ST-elevation myocardial infarction assessed by Cardiac Magnetic Resonance Imaging. Int J Cardiol 2015; 199:326-32. [DOI: 10.1016/j.ijcard.2015.07.056] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 07/18/2015] [Indexed: 12/15/2022]
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19
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Borgna-Pignatti C, Marsella M. Iron Chelation in Thalassemia Major. Clin Ther 2015; 37:2866-77. [PMID: 26519233 DOI: 10.1016/j.clinthera.2015.10.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 10/01/2015] [Accepted: 10/02/2015] [Indexed: 01/19/2023]
Abstract
PURPOSE Iron chelation has improved survival and quality of life of patients with thalassemia major. there are currently 3 commercially available iron-chelating drugs with different pharmacokinetic and pharmacodynamic activity. The choice of adequate chelation treatment should be tailored to patient needs and based on up-to-date scientific evidence. METHODS A review of the most recent literature was performed. FINDINGS The ability of the chelators to bind the redox active component of iron, labile plasma iron, is crucial for protecting the cells. Chelation therapy should be guided by magnetic resonance imaging that permits the tailoring of therapy according to the needs of the patient because different chelators preferentially clear iron from different sites. Normal levels of body iron seem to decrease the need for hormonal and cardiac therapy. IMPLICATIONS The 3 chelators currently available have different benefits, different safety profiles, and different acceptance on the part of the patients. Good-quality, well-designed, randomized, long-term clinical trials continue to be needed.
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Affiliation(s)
| | - Maria Marsella
- Pediatrics and Adolescentology Unit, Maternal and Child Health Department, "G. Rummo" Hospital, Benevento, Italy
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20
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de Swart L, Hendriks JCM, van der Vorm LN, Cabantchik ZI, Evans PJ, Hod EA, Brittenham GM, Furman Y, Wojczyk B, Janssen MCH, Porter JB, Mattijssen VEJM, Biemond BJ, MacKenzie MA, Origa R, Galanello R, Hider RC, Swinkels DW. Second international round robin for the quantification of serum non-transferrin-bound iron and labile plasma iron in patients with iron-overload disorders. Haematologica 2015; 101:38-45. [PMID: 26385212 DOI: 10.3324/haematol.2015.133983] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 09/18/2015] [Indexed: 01/19/2023] Open
Abstract
Non-transferrin-bound iron and its labile (redox active) plasma iron component are thought to be potentially toxic forms of iron originally identified in the serum of patients with iron overload. We compared ten worldwide leading assays (6 for non-transferrin-bound iron and 4 for labile plasma iron) as part of an international inter-laboratory study. Serum samples from 60 patients with four different iron-overload disorders in various treatment phases were coded and sent in duplicate for analysis to five different laboratories worldwide. Some laboratories provided multiple assays. Overall, highest assay levels were observed for patients with untreated hereditary hemochromatosis and β-thalassemia intermedia, patients with transfusion-dependent myelodysplastic syndromes and patients with transfusion-dependent and chelated β-thalassemia major. Absolute levels differed considerably between assays and were lower for labile plasma iron than for non-transferrin-bound iron. Four assays also reported negative values. Assays were reproducible with high between-sample and low within-sample variation. Assays correlated and correlations were highest within the group of non-transferrin-bound iron assays and within that of labile plasma iron assays. Increased transferrin saturation, but not ferritin, was a good indicator of the presence of forms of circulating non-transferrin-bound iron. The possibility of using non-transferrin-bound iron and labile plasma iron measures as clinical indicators of overt iron overload and/or of treatment efficacy would largely depend on the rigorous validation and standardization of assays.
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Affiliation(s)
- Louise de Swart
- Departments of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan C M Hendriks
- Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lisa N van der Vorm
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Z Ioav Cabantchik
- Department of Biochemical Chemistry, Hebrew University of Jerusalem, Israel
| | | | - Eldad A Hod
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA
| | - Gary M Brittenham
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | | | - Boguslaw Wojczyk
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA
| | - Mirian C H Janssen
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - John B Porter
- Department of Haematology, University College London, UK
| | | | - Bart J Biemond
- Department of Hematology, Academic Medical Center, Amsterdam, The Netherlands
| | - Marius A MacKenzie
- Departments of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Raffaella Origa
- Department of Biomedical Science and Biotechnology, Regional Microcythemia Hospital, University of Cagliari, Italy
| | - Renzo Galanello
- Department of Biomedical Science and Biotechnology, Regional Microcythemia Hospital, University of Cagliari, Italy
| | - Robert C Hider
- Institute of Pharmaceutical Science, King's College London, UK
| | - Dorine W Swinkels
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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21
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Abstract
Iron overload is becoming an increasing problem as haemoglobinopathy patients gain greater access to good medical care and as therapies for myelodysplastic syndromes improve. Therapeutic options for iron chelation therapy have increased and many patients now receive combination therapies. However, optimal utilization of iron chelation therapy requires knowledge not only of the total body iron burden but the relative iron distribution among the different organs. The physiological basis for extrahepatic iron deposition is presented in order to help identify patients at highest risk for cardiac and endocrine complications. This manuscript reviews the current state of the art for monitoring global iron overload status as well as its compartmentalization. Plasma markers, computerized tomography, liver biopsy, magnetic susceptibility devices and magnetic resonance imaging (MRI) techniques are all discussed but MRI has come to dominate clinical practice. The potential impact of recent pancreatic and pituitary MRI studies on clinical practice are discussed as well as other works-in-progress. Clinical protocols are derived from experience in haemoglobinopathies but may provide useful guiding principles for other iron overload disorders, such as myelodysplastic syndromes.
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Affiliation(s)
- John C Wood
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, CA, USA
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22
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Abstract
Abstract
Both primary and secondary iron overload are increasingly prevalent in the United States because of immigration from the Far East, increasing transfusion therapy in sickle cell disease, and improved survivorship of hematologic malignancies. This chapter describes the use of historical data, serological measures, and MRI to estimate somatic iron burden. Before chelation therapy, transfusional volume is an accurate method for estimating liver iron burden, whereas transferrin saturation reflects the risk of extrahepatic iron deposition. In chronically transfused patients, trends in serum ferritin are helpful, inexpensive guides to relative changes in somatic iron stores. However, intersubject variability is quite high and ferritin values may change disparately from trends in total body iron load over periods of several years. Liver biopsy was once used to anchor trends in serum ferritin, but it is invasive and plagued by sampling variability. As a result, we recommend annual liver iron concentration measurements by MRI for all patients on chronic transfusion therapy. Furthermore, it is important to measure cardiac T2* by MRI every 6-24 months depending on the clinical risk of cardiac iron deposition. Recent validation data for pancreas and pituitary iron assessments are also presented, but further confirmatory data are suggested before these techniques can be recommended for routine clinical use.
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23
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Abstract
Treatment of iron overload requires robust estimates of total-body iron burden and its response to iron chelation therapy. Compliance with chelation therapy varies considerably among patients, and individual reporting is notoriously unreliable. Even with perfect compliance, intersubject variability in chelator effectiveness is extremely high, necessitating reliable iron estimates to guide dose titration. In addition, each chelator has a unique profile with respect to clearing iron stores from different organs. This article presents the tools available to clinicians to monitor their patients, focusing on noninvasive magnetic resonance imaging methods because they have become the de facto standard of care.
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Affiliation(s)
- John C Wood
- Department of Pediatrics, Children's Hospital, Los Angeles, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA; Department of Radiology, Children's Hospital, Los Angeles, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA.
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24
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Meloni A, Puliyel M, Pepe A, Berdoukas V, Coates TD, Wood JC. Cardiac iron overload in sickle-cell disease. Am J Hematol 2014; 89:678-83. [PMID: 24664847 DOI: 10.1002/ajh.23721] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 03/19/2014] [Accepted: 03/21/2014] [Indexed: 12/15/2022]
Abstract
Chronically transfused sickle cell disease (SCD) patients have lower risk of myocardial iron overload (MIO) than comparably transfused thalassemia major (TM) patients. However, cardioprotection is incomplete. We present the clinical characteristics of six patients who have prospectively developed MIO, to identify potential risk factors for cardiac iron accumulation. From 2002 to 2011, cardiac, hepatic, and pancreatic iron overload were assessed by R2 and R2 * magnetic resonance imaging techniques in 201 chronic transfused SCD patients as part of their clinical care. At the time, they developed MIO, five of six patients had been on chronic transfusion for more than 11 years; only one was on exchange transfusion. The time to MIO was correlated with reticulocyte and hemoglobin S percentages. All patients had qualitatively poor chelation compliance (<50%). All patients had serum ferritin levels >4600 ng/ml and liver iron concentration >22 mg/g. Pancreatic R2 * was >100 Hz in every patient studied (5/6). Cardiac iron rose proportionally to pancreas R2 *, with all patients having pancreas R2 *>100 Hz when cardiac iron was present. MIO had a threshold relationship with liver iron that was higher than observed in TM patients. In conclusion, MIO occurs in a small percentage of chronically transfused SCD patients and is only associated with exceptionally poor control of total body iron stores. Duration of chronic transfusion is clearly important but other factors, such as levels of effective erythropoiesis, appear to contribute to cardiac risk. Pancreas R2 * can serve as a valuable screening tool for cardiac iron in SCD patients.
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Affiliation(s)
- Antonella Meloni
- CMR Unit; Fondazione G. Monasterio CNR-Regione Toscana; Pisa Italy
- Division of Cardiology; Children's Hospital Los Angeles; Los Angeles California
| | - Mammen Puliyel
- Division of Hematology-Oncology; Children's Hospital Los Angeles; Los Angeles California
| | - Alessia Pepe
- CMR Unit; Fondazione G. Monasterio CNR-Regione Toscana; Pisa Italy
| | - Vasili Berdoukas
- Division of Hematology-Oncology; Children's Hospital Los Angeles; Los Angeles California
| | - Thomas D. Coates
- Division of Hematology-Oncology; Children's Hospital Los Angeles; Los Angeles California
| | - John C. Wood
- Division of Cardiology; Children's Hospital Los Angeles; Los Angeles California
- Department of Radiology; Children's Hospital Los Angeles; Los Angeles California
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25
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Berdoukas V, Nord A, Carson S, Puliyel M, Hofstra T, Wood J, Coates TD. Tissue iron evaluation in chronically transfused children shows significant levels of iron loading at a very young age. Am J Hematol 2013; 88:E283-5. [PMID: 23861216 DOI: 10.1002/ajh.23543] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 06/28/2013] [Accepted: 07/09/2013] [Indexed: 01/17/2023]
Abstract
Chronic blood transfusions start at a very young age in subjects with transfusion-dependent anemias, the majority of whom have hereditary anemias. To understand how rapidly iron overload develops, we retrospectively reviewed 308 MRIs for evaluation of liver, pancreatic, or cardiac iron in 125 subjects less than 10 years old. Median age at first MRI evaluation was 6.0 years. Median liver iron concentrations in patients less than 3.5 years old were 14 and 13 mg/g dry weight in thalassemia major (TM) and Diamond-Blackfan anemia (DBA) patients, respectively. At time of first MRI, pancreatic iron was markedly elevated (> 100 Hz) in DBA patients, and cardiac iron ( R₂* >50 Hz) was present in 5/112 subjects (4.5%), including a 2.5 years old subject with DBA. Five of 14 patients (38%) with congenital dyserythropoietic anemia (CDA) developed excess cardiac iron before their 10th birthday. Thus, clinically significant hepatic and cardiac iron accumulation occurs at an early age in patients on chronic transfusions, particularly in those with ineffective or absent erythropoiesis, such as DBA, CDA, and TM, who are at higher risk for iron cardiomyopathy. Performing MRI for iron evaluation in the liver, heart, and pancreas as early as feasible, particularly in those conditions in which there is suppressed bone marrow activity is very important in the management of iron loaded children in order to prescribe appropriate chelation to prevent long-term sequelae. .
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Affiliation(s)
- Vasilios Berdoukas
- Division of Hematology/Oncology, Department of Pediatrics, Keck School of Medicine, Children's Hospital Los Angeles; University of Southern California; Los Angeles California
| | - Anne Nord
- Division of Hematology/Oncology, Department of Pediatrics, Keck School of Medicine, Children's Hospital Los Angeles; University of Southern California; Los Angeles California
| | - Susan Carson
- Division of Hematology/Oncology, Department of Pediatrics, Keck School of Medicine, Children's Hospital Los Angeles; University of Southern California; Los Angeles California
| | - Mammen Puliyel
- Division of Hematology/Oncology, Department of Pediatrics, Keck School of Medicine, Children's Hospital Los Angeles; University of Southern California; Los Angeles California
| | - Thomas Hofstra
- Division of Hematology/Oncology, Department of Pediatrics, Keck School of Medicine, Children's Hospital Los Angeles; University of Southern California; Los Angeles California
| | - John Wood
- Division of Cardiology, Department of Pediatrics, Keck School of Medicine, Children's Hospital Los Angeles; University of Southern California; Los Angeles California
| | - Thomas D. Coates
- Division of Hematology/Oncology, Department of Pediatrics, Keck School of Medicine, Children's Hospital Los Angeles; University of Southern California; Los Angeles California
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26
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Ambati SR, Randolph RE, Mennitt K, Kleinert DA, Weinsaft JW, Giardina PJ. Longitudinal monitoring of cardiac siderosis using cardiovascular magnetic resonance T2* in patients with thalassemia major on various chelation regimens: a 6-year study. Am J Hematol 2013; 88:652-6. [PMID: 23640778 DOI: 10.1002/ajh.23469] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 04/21/2013] [Accepted: 04/23/2013] [Indexed: 01/19/2023]
Abstract
Cardiovascular magnetic resonance (CMR) and hepatic magnetic resonance imaging (MRI) have become reliable noninvasive tools to monitor iron excess in thalassemia major (TM) patients. However, long-term studies are lacking. We reviewed CMR and hepatic MRI T2* imaging on 54 TM patients who had three or more annual measurements. They were managed on various chelation regimens. Patients were grouped according to their degree of cardiac siderosis: severe (T2*, <10 msec), mild to moderate (T2* = 10-20 msec), and no cardiac siderosis (T2*, >20 msec). We looked at the change in cardiac T2*, liver iron concentration (LIC) and left ventricular ejection fraction (LVEF) at years 3 and 5. In patients with severe cardiac siderosis, cardiac T2* (mean ± SD) improved from 6.9 ± 1.6 at baseline to 13.6 ± 10.0 by year 5, mean ΔT2* = 6.7 (P = 0.04). Change in cardiac T2* at year 3 was not significant in the severe group. Patients with mild to moderate cardiac siderosis had mean cardiac T2* of 14.6 ± 2.9 at baseline which improved to 26.3 ± 9.5 by year 3, mean ΔT2* = 1.7 (P = 0.01). At baseline, median LICs (mg/g dry weight) in patients with severe, mild-moderate, and no cardiac siderosis were 3.6, 2.8, and 3.3, whereas LVEFs (mean ± SD) (%) were 56.3 ± 10.1, 60 ± 5, and 66 ± 7.6, respectively. No significant correlation was noted between Δ cardiac T2* and Δ LIC, Δ cardiac T2*, and Δ LVEF at years 3 and 5. Throughout the observation period, patients with no cardiac siderosis maintained their cardiac T2* above 20 msec. The majority of patients with cardiac siderosis improve cardiac T2* over time with optimal chelation.
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Affiliation(s)
- Srikanth R. Ambati
- Department of Pediatrics; Memorial Sloan-Kettering Cancer Center; New York; New York
| | - Rachel E. Randolph
- Department of Pediatrics; Weill Cornell Medical College; New York; New York
| | - Kevin Mennitt
- Department of Radiology; Weill Cornell Medical College; New York; New York
| | | | - Jonathan W. Weinsaft
- Cardiac MR/CT Imaging Program; Division of Cardiology, Weill Cornell Medical College; New York; New York
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27
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Pennell DJ, Udelson JE, Arai AE, Bozkurt B, Cohen AR, Galanello R, Hoffman TM, Kiernan MS, Lerakis S, Piga A, Porter JB, Walker JM, Wood J. Cardiovascular function and treatment in β-thalassemia major: a consensus statement from the American Heart Association. Circulation 2013; 128:281-308. [PMID: 23775258 DOI: 10.1161/cir.0b013e31829b2be6] [Citation(s) in RCA: 261] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This aim of this statement is to report an expert consensus on the diagnosis and treatment of cardiac dysfunction in β-thalassemia major (TM). This consensus statement does not cover other hemoglobinopathies, including thalassemia intermedia and sickle cell anemia, in which a different spectrum of cardiovascular complications is typical. There are considerable uncertainties in this field, with a few randomized controlled trials relating to treatment of chronic myocardial siderosis but none relating to treatment of acute heart failure. The principles of diagnosis and treatment of cardiac iron loading in TM are directly relevant to other iron-overload conditions, including in particular Diamond-Blackfan anemia, sideroblastic anemia, and hereditary hemochromatosis. Heart failure is the most common cause of death in TM and primarily results from cardiac iron accumulation. The diagnosis of ventricular dysfunction in TM patients differs from that in nonanemic patients because of the cardiovascular adaptation to chronic anemia in non-cardiac-loaded TM patients, which includes resting tachycardia, low blood pressure, enlarged end-diastolic volume, high ejection fraction, and high cardiac output. Chronic anemia also leads to background symptomatology such as dyspnea, which can mask the clinical diagnosis of cardiac dysfunction. Central to early identification of cardiac iron overload in TM is the estimation of cardiac iron by cardiac T2* magnetic resonance. Cardiac T2* <10 ms is the most important predictor of development of heart failure. Serum ferritin and liver iron concentration are not adequate surrogates for cardiac iron measurement. Assessment of cardiac function by noninvasive techniques can also be valuable clinically, but serial measurements to establish trends are usually required because interpretation of single absolute values is complicated by the abnormal cardiovascular hemodynamics in TM and measurement imprecision. Acute decompensated heart failure is a medical emergency and requires urgent consultation with a center with expertise in its management. The first principle of management of acute heart failure is control of cardiac toxicity related to free iron by urgent commencement of a continuous, uninterrupted infusion of high-dose intravenous deferoxamine, augmented by oral deferiprone. Considerable care is required to not exacerbate cardiovascular problems from overuse of diuretics or inotropes because of the unusual loading conditions in TM. The current knowledge on the efficacy of removal of cardiac iron by the 3 commercially available iron chelators is summarized for cardiac iron overload without overt cardiac dysfunction. Evidence from well-conducted randomized controlled trials shows superior efficacy of deferiprone versus deferoxamine, the superiority of combined deferiprone with deferoxamine versus deferoxamine alone, and the equivalence of deferasirox versus deferoxamine.
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28
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Chen Y, Dodd SJ, Tangrea MA, Emmert-Buck MR, Koretsky AP. Measuring collective cell movement and extracellular matrix interactions using magnetic resonance imaging. Sci Rep 2013; 3:1879. [PMID: 23698816 PMCID: PMC3662010 DOI: 10.1038/srep01879] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 05/01/2013] [Indexed: 02/02/2023] Open
Abstract
Collective cell behaviors in migration and force generation were studied at the mesoscopic-level using cells grown in a 3D extracellular matrix (ECM) simulating tissues. Magnetic resonance imaging (MRI) was applied to investigate dynamic cell mechanics at this level. MDCK, NBT2, and MEF cells were embedded in 3D ECM, forming clusters that then migrated and generated forces affecting the ECM. The cells demonstrated MRI contrast due to iron accumulation in the clusters. Timelapse-MRI enabled the measurement of dynamic stress fields generated by the cells, as well as simultaneous monitoring of the cell distribution and ECM deformation/remodeling. We found cell clusters embedded in the 3D ECM can exert translational forces to pull and push, as well as torque, their surroundings. We also observed that the sum of forces generated by multiple cell clusters may result in macroscopic deformation. In summary, MRI can be used to image cell-ECM interactions mesoscopically.
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Affiliation(s)
- Yun Chen
- National Institutes of Neurological Disorders and Stroke, National Institutes of Health
| | - Stephen J. Dodd
- National Institutes of Neurological Disorders and Stroke, National Institutes of Health
- These authors contributed equally to this work
| | - Michael A. Tangrea
- National Cancer Institute, National Institutes of Health
- These authors contributed equally to this work
| | | | - Alan P. Koretsky
- National Institutes of Neurological Disorders and Stroke, National Institutes of Health
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Wermke M, Schmidt A, Middeke JM, Sockel K, von Bonin M, Schönefeldt C, Mair S, Plodeck V, Laniado M, Weiss G, Schetelig J, Ehninger G, Theurl I, Bornhäuser M, Platzbecker U. MRI-Based Liver Iron Content Predicts for Nonrelapse Mortality in MDS and AML Patients Undergoing Allogeneic Stem Cell Transplantation. Clin Cancer Res 2012; 18:6460-8. [DOI: 10.1158/1078-0432.ccr-12-1683] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Pennell DJ, Carpenter JP, Roughton M, Cabantchik ZI. On improvement in ejection fraction with iron chelation in thalassemia major and the risk of future heart failure. J Cardiovasc Magn Reson 2011; 13:45. [PMID: 21910880 PMCID: PMC3180261 DOI: 10.1186/1532-429x-13-45] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Accepted: 09/12/2011] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Trials of iron chelator regimens have increased the treatment options for cardiac siderosis in beta-thalassemia major (TM) patients. Treatment effects with improved left ventricular (LV) ejection fraction (EF) have been observed in patients without overt heart failure, but it is unclear whether these changes are clinically meaningful. METHODS This retrospective study of a UK database of TM patients modelled the change in EF between serial scans measured by cardiovascular magnetic resonance (CMR) to the relative risk (RR) of future development of heart failure over 1 year. Patients were divided into 2 strata by baseline LVEF of 56-62% (below normal for TM) and 63-70% (lower half of the normal range for TM). RESULTS A total of 315 patients with 754 CMR scans were analyzed. A 1% absolute increase in EF from baseline was associated with a statistically significant reduction in the risk of future development of heart failure for both the lower EF stratum (EF 56-62%, RR 0.818, p < 0.001) and the higher EF stratum (EF 63-70%, RR 0.893 p = 0.001). CONCLUSION These data show that during treatment with iron chelators for cardiac siderosis, small increases in LVEF in TM patients are associated with a significantly reduced risk of the development of heart failure. Thus the iron chelator induced improvements in LVEF of 2.6% to 3.1% that have been observed in randomized controlled trials, are associated with risk reductions of 25.5% to 46.4% for the development of heart failure over 12 months, which is clinically meaningful. In cardiac iron overload, heart mitochondrial dysfunction and its relief by iron chelation may underlie the changes in LV function.
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Affiliation(s)
- DJ Pennell
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London UK
- National Heart and Lung Institute, Imperial College, London UK
| | - JP Carpenter
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London UK
- National Heart and Lung Institute, Imperial College, London UK
| | - M Roughton
- Department of Statistics, University College London, UK
| | - ZI Cabantchik
- Life Sciences Institute, Hebrew University of Jerusalem, Safra Campus-Givat Ram, Jerusalem, Israel
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31
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Wood JC. Impact of iron assessment by MRI. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2011; 2011:443-450. [PMID: 22160072 DOI: 10.1182/asheducation-2011.1.443] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The use of magnetic resonance imaging (MRI) to estimate tissue iron was conceived in the 1980s, but has only become a practical reality in the last decade. The technique is most often used to estimate hepatic and cardiac iron in patients with transfusional siderosis and has largely replaced liver biopsy for liver iron quantification. However, the ability of MRI to quantify extrahepatic iron has had a greater impact on patient care and on our understanding of iron overload pathophysiology. Iron cardiomyopathy used to be the leading cause of death in thalassemia major, but is now relatively rare in centers with regular MRI screening of cardiac iron, through earlier recognition of cardiac iron loading. Longitudinal MRI studies have demonstrated differential kinetics of uptake and clearance among the difference organs of the body. Although elevated serum ferritin and liver iron concentration (LIC) increase the risk of cardiac and endocrine toxicities, some patients unequivocally develop extrahepatic iron deposition and toxicity despite having low total body iron stores. These observations, coupled with the advent of increasing options for iron chelation therapy, are allowing clinicians to more appropriately tailor chelation therapy to individual patient needs, producing greater efficacy with fewer toxicities. Future frontiers in MRI monitoring include improved prevention of endocrine toxicities, particularly hypogonadotropic hypogonadism and diabetes.
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Affiliation(s)
- John C Wood
- Department of Pediatrics and Radiology, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA.
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