Evaluation of liver fibrosis in patients with thalassemia: the important role of hyaluronic acid.

Patients with transfusion-dependent thalassemia major often develop liver fibrosis due to liver iron overload and/or hepatitis virus C (HCV) infection. Hyaluronic acid (HA) plays a prominent role in the pathogenesis of liver fibrosis and the elevation of serum HA concentration is due to either increased synthesis by inflammatory cells and hepatic stellate cells or impaired degradation by sinusoidal endothelial cells (SECs) and thus is proposed as a non-invasive biomarker of liver fibrosis either by itself and/or included in the Hepascore formula. In this study we evaluated prospectively a screening of liver fibrosis in 201 adult patients aged 19-54 years with transfusion-dependent thalassemia major, based on HA measurements. 41/201 patients were HCV-RNA (+). HA was measured with a turbidimetric assay applied on a clinical chemistry analyzer. The Hepascore was computed from the results by using the model previously published. The main results of the study showed that: a) HA levels were increased in 110/201 (55%) thalassemia patients 85.0 ± 10.3 ng/ml, ranged from 15.0 to 1495.0 µg/l, compared to 20.8 ± 7.4 µg/l reference laboratory values, p<0.001, b) HA levels were significantly higher in HCV-RNA(+) compared to HCV-RNA(-) patients, 171.6 ± 202 vs 53.8 ± 35.5 µg/l, p<0.0001 c) no significant correlations were found between HA levels and/or Hepascore with ferritin and liver iron content (LIC) assessed with MRI (p>0.324 and p>0.270, respectively). Our findings indicate that hyaluronic acid measurements contribute to the assessment of liver fibrosis in patients with thalassemia and might be helpful for further evaluation of patients with liver biopsy if this is truly needed. Furthermore, liver fibrosis in thalassemia seems to be independent from liver siderosis.

Relation of chelation regimes to cardiac mortality and morbidity in patients with thalassaemia major: an observational study from a large Greek Unit.

OBJECTIVES: Cardiac complications because of transfusional iron overload are the main cause of death in thalassaemia major. New chelators and iron monitoring methods such as cardiac magnetic resonance (CMR) became available after the year 2000. We evaluated the impact of these new management options on cardiac mortality and morbidity. METHODS: The risk of cardiac death during 1990-1999 and 2000-2008 was compared. Furthermore, after 1999, morbidity, mortality and reversal of heart failure were evaluated according to chelation regime: desferrioxamine (DFO), deferiprone (DFP) and combination therapy of DFO and DFP. We also present preliminary results for deferasirox (DFX), a new oral chelator. RESULTS: Three hundred and fifty-four patients were included in the de novo cardiac event evaluation, while 86 were included in the improvement component. The annual risk of cardiac death in patients aged between 20-30 and 30-40 reduced from 1.52% to 0.67% and 1.87% to 0.56%, respectively, before and after the year 2000. The risk for a de novo cardiac event for DFO was 9.1 times greater than that of DFP and 23.6 than with the combination of DFP and DFO. For DFX, there was one cardiac event over 269 patient-years. The risk of cardiac death was 9.5 per 1000 patient-years for DFO, 2.5 on DFP, 1.4 on combination. In the DFX group no cardiac deaths were recorded. The odds of improvement were 8.5 times greater with DFP and 6.1 with combination therapy compared to DFO. CONCLUSIONS: The new chelation regimes, together with CMR have contributed significantly to the reduction in cardiac morbidity and mortality in patients with thalassaemia major.

Cystatin C levels in patients with beta-thalassemia during deferasirox treatment.

Deferasirox (Exjade) is a once-daily, oral iron chelator approved for the treatment of transfusional iron overload. This study was conducted to analyze changes in cystatin C concentration, an endogenous marker of glomerular filtration rate (GFR), in patients with thalassemia receiving daily deferasirox therapy over a period of at least 9 months. One hundred and fifty beta-thalassemia patients were treated with deferasirox at doses of 20-40 mg/kg/day for 9 consecutive months. Cystatin C concentrations were measured at regular intervals and GFR was calculated according to the cystatin C-based prediction equation. Plasma concentrations of NGAL protein and NT-proBNP were also monitored as indicators of renal function and LVEF, respectively. Serum ferritin concentration was also measured to assess iron overload. Throughout the 9 months of deferasirox treatment cystatin C concentration remained stable (p>0.850). The baseline cystatin C mean values were 0.97+/-0.27 mg/L and reached a maximum of 1.01+/-0.29 mg/L at 4 months of treatment. No correlation was found between cystatin C and NGAL concentrations (p>0.674). Cystatin C and NT-proBNP concentrations correlated positively with a binomial equation (p<0.004), as also did cystatin C and serum ferritin (p<0.001). These findings suggest that slight changes of cystatin C during deferasirox treatment may not reflect renal injury. However hemodynamic signals such as LVEF alterations and iron mobilization do appear to affect changes in cystatin C concentration.

Effect of iron overload on exercise capacity in thalassemic patients with heart failure.

In b-thalassemia, myocardial iron overload contributes to heart failure, despite chelation treatment. We hypothesized that myocardial T2*, an index of iron overload, influences patients' physical activity. We assessed a thalassemic population by both cardiovascular magnetic resonance imaging (CMR) and ergospirometry test. Sixty-six thalassemic patients aged 27 (19-40) years, 30 without (NHF) and 36 with heart failure (HF), were studied. Cardiac T2* and left ventricular ejection fraction (LVEF) were evaluated using a 1.5 T system. VO(2max), AT, Mets and duration of exercise by ergospirometry were also assessed. Myocardial T2* was lower in HF compared to NHF patients (14.7 +/- 6.6 vs. 39 +/- 2 ms, P < 0.001). LVEDV and LVESV were higher in HF group compared to NHF patients (139.9 +/- 16.3 vs. 124.6 +/- 20.86 ml, P < 0.01 and 94.9 +/- 24 vs. 38.3 +/- 10.1 ml, P < 0.001, respectively). Additionally, LVEF in HF was lower compared to NHF patients (21.3 +/- 6.1% vs. 69.6 +/- 3.7, P < 0.001, respectively). All exercise parameters were lower in HF compared to NHF patients (P < 0.001). Patients within the HF group were additionally analyzed according to T2* values (<10 ms). HF patients with T2* < 10 ms (n = 13) were considered as high iron overloaded (HF-H) and the rest of them (n = 23) as (HF-L). Although LVEDV, LVESV, LVEF were similar in the two subgroups, the exercise parameters were significantly lower in the HF-H group (P < 0.001). Heart T2* correlated with all exercise parameters (P < 0.001). HF thalassemic patients have reduced exercise indexes compared to non HF. Myocardial iron overload, expressed as T2*, has a direct influence on exercise capacity, independent of LV ejection fraction and functional class.

The efficacy of iron chelator regimes in reducing cardiac and hepatic iron in patients with thalassaemia major: a clinical observational study.

BACKGROUND: Available iron chelation regimes in thalassaemia may achieve different changes in cardiac and hepatic iron as assessed by MR. The aim of this study was to assess the efficacy of four available iron chelator regimes in 232 thalassaemia major patients by assessing the rate of change in repeated measurements of cardiac and hepatic MR. RESULTS: For the heart, deferiprone and the combination of deferiprone and deferoxamine significantly reduced cardiac iron at all levels of iron loading. As patients were on deferasirox for a shorter time, a second analysis ("Initial interval analysis") assessing the change between the first two recorded MR results for both cardiac and hepatic iron (minimum interval 12 months) was made. Combination therapy achieved the most rapid fall in cardiac iron load at all levels and deferiprone alone was significantly effective with moderate and mild iron load. In the liver, deferasirox effected significant falls in iron load and combination therapy resulted in the most rapid decline. CONCLUSION: With the knowledge of the efficacy of the different available regimes and the specific iron load in the heart and the liver, appropriate tailoring of chelation therapy should allow clearance of iron. Combination therapy is best in reducing both cardiac and hepatic iron, while monotherapy with deferiprone or deferasirox are effective in the heart and liver respectively. The outcomes of this study may be useful to physicians as to the chelation they should prescribe according to the levels of iron load found in the heart and liver by MR.

Cardiac related death in thalassaemia major: time trend and risk factors in a large Greek Unit.

BACKGROUND: Cardiac complications are the leading cause of death in thalassaemic patients (TM) worldwide. Improved management protocols including new chelators and imaging have reduced cardiac-related deaths but also require more advanced analytical methods to reflect temporal fluctuations in mortality risk. OBJECTIVES: To evaluate time patterns of risk of cardiac death in TM patients according to birth cohort, gender and degree of haemosiderosis and to apply new flexible methods of analysis that may allow assessment of trends in risks as affected by innovations in management. DESIGN AND METHODS: Cardiac-free survival and time trend of the risk of cardiac-related death were assessed in 648 transfusion-depended thalassaemic patients (48.3% females) managed in a single unit located in Athens, Greece. Patients were classified according to birth cohort (prior or after 1/1/1975) and according to the severity of haemosiderosis (mild, moderate and severe) as estimated by the mean ferritin levels during the last 5 yr of follow-up. RESULTS: The median time of observation was 27.8 yr and 84 cardiac deaths were recorded. A parametric analysis predicted a non-monotonous time pattern for the cardiac risk with an initial increasing phase until the fourth decade of life followed by a drop off in deaths. Women have 23% longer life expectancy than men (P = 0.010) while patients born after 1975 die of heart complications at an older age compared to those born prior to 1975 (time ratio = 1.34, P = 0.003). Patients with mild and moderate haemosiderosis lived 89% (P < 0.001) and 43% (P < 0.001) longer, respectively, compared with patients with severe haemosiderosis. CONCLUSIONS: These results on risk of death in thalassaemia, accord with expectations. This type of analysis will be useful in the future when the expected impact of cardiac MRI with appropriate tailoring of chelation therapy using all current and future options will modify the pattern of risk of cardiac death observed to date.

Magnetic resonance evaluation of liver and myocardial iron deposition in thalassemia intermedia and b-thalassemia major.

INTRODUCTION: b-Thalassemia major (TM) and thalassemia intermedia (TI) are forms of inherited hemoglobinopathies. Our aim was to evaluate a population of asymptomatic TM and TI patients using cardiovascular magnetic resonance (CMR). We hypothesized that the TI group could be differentiated from the TM group based on T2*. We also hypothesized that the TI group would demonstrate significantly higher cardiac output compared to the TM group. PATIENTS AND METHODS: Twenty-one consecutive TI patients aged 23(19-25) years, 21 TM patients and 21 age and sex matched controls were studied. Evaluation of heart, liver T2* relaxation time and right and left ventricular parameters was performed using a 1.5 T system. RESULTS: Myocardial and liver T2* values were significantly higher in TI patients compared to TM (34.35 +/- 2.36 vs 15.77 +/- 3.53 m, P < 0.001 and 5.12 +/- 6.52 vs 1.36 +/- 0.53 ms, P < 0.001, respectively). Controls had myocardial T2* 35.07 +/- 4.52 ms (similar to TI patients, but significantly increased compared to TM patients, P < 0.001) and liver T2* 26.28 +/- 2.37 ms (significantly increased compared to both TI and TM patients, P < 0.001). Left ventricular end-diastolic (LVEDV), end-systolic (LVESV) volumes and left ventricular ejection fraction (LVEF) were higher in TI patients compared to TM (P < 0.001). Stroke volume (LVSV), cardiac output (LVCO) and cardiac index (LVCI) were similarly increased in TI patients compared to TM (P < 0.001). Right ventricular end-diastolic volume (RVEDV), right ventricular end-systolic volume (RVESV) and right ventricular ejection fraction (RVEF) were higher in TI patients compared to TM (P < 0.001). CONCLUSIONS: Although in TM iron plays a crucial role in the evolution of the disease, in TI the high output cardiac state seems to be the most prominent finding.

A prospective randomized controlled trial on the safety and efficacy of alternating deferoxamine and deferiprone in the treatment of iron overload in patients with thalassemia.

We compared the safety and efficacy of alternating deferoxamine and deferiprone with that of deferoxamine monotherapy. Sixty transfusion-dependent thalassemia patients regularly treated with deferoxamine were randomized to continue deferoxamine alone or to receive an alternating therapy for one year. Both arms resulted in equivalent decreases of serum ferritin and liver iron concentration. There was no significant difference in the proportion of patients with adverse events in the two therapy groups although the nature of the adverse events differed according to the chelation regimen.

Iron chelation treatment with combined therapy with deferiprone and deferioxamine: a 12-month trial.

The simultaneous use of deferioxamine (DFO) and deferiprone (DFP) has an additive effect in iron excretion in transfusion-dependent thalassemic patients. In a prospective study, we evaluated the safety and effectiveness of combined therapy with these two chelators. Fifty patients with beta-thalassemia were uniformly treated with DFP for 4 days per week and combined therapy with DFP and DFO for 3 days of the week. Efficacy was evaluated by ferritin and cardiac shortening fraction (SF). Hepatic hemosiderosis was also assessed by estimation of the T2 relaxation time by magnetic resonance in a subgroup of patients. Forty-three patients completed 1 year of therapy. Mean ferritin decreased from 3363.7 +/- 2144.5 microg/L to 2323.2 +/- 1740.8 microg/L (P < 0.0001). The reduction was significant even in the group of patients with ferritin <2500 microg/L. Significant improvement in T2 relaxation and SF was observed. The most common adverse events were gastrointestinal symptoms (20%) and transaminasemia (18%). The rate of agranulocytosis was 4.2 cases per 100 patient-years. Prolonged use of combined therapy with DFP and DFO is effective in decreasing iron load and improving cardiac function. Its possible association with higher incidence of agranulocytosis emphasizes the need for close monitoring.

Erythroid bone marrow activity and red cell hemoglobinization in iron sufficient beta-thalassemia heterozygotes as reflected by soluble transferrin receptor and reticulocyte hemoglobin in content. Correlation with genotypes and Hb A(2) levels.

BACKGROUND AND OBJECTIVES: Ferrokinetic studies and erythroid cell ultrastructural studies have indicated some degree of ineffective erythropoiesis in heterozygous beta-thalassemia, although a wide case-to-case variation was observed. In this study we applied rapid biochemical and hematologic measurements to assess erythroid marrow activity (sTfR) and reticulocyte hemoglobin content (CHr) in iron-sufficient individuals with heterozygous beta-thalassemia and investigated the correlation with the degree of globin polypeptide chain imbalance by comparing parameters between beta-thalassemia heterozygotes with genotypes of variable severity. DESIGN AND METHODS: We studied 57 iron-sufficient adults with heterozygous beta-thalassemia, divided into groups according to genotype: group A: beta(silent)-thalassemia heterozygotes, group B: beta(+)-thalassemia heterozygotes and group C: beta(0)-thalassemia heterozygotes. Twenty-one hematologically normal individuals served as controls (group D). We measured hematologic parameters including CHr with a Bayer-Advia 120 hematology analyzer. Hemoglobins were analyzed by high performance liquid chromatography, while biochemical parameters of iron status (iron, ferritin, transferrin and sTfR) were measured with chemical, luminometric and nephelometric methods. RESULTS: We found significant positive correlations between sTfR values for all beta-thalassemia heterozygote groups when plotted against Hb A(2) and Hb F levels (r=0.566, p<0.0001 and r=0.283, p<0.03, respectively) and significantly negative correlation between CHr and Hb A(2) values (r=-0.790, p<0.00001). These data reflect the fine association of globin polypeptide chain imbalance with erythron expansion and the greater degree of ineffective erythropoiesis in beta-thalassemia heterozygotes with more severe genotypes. INTERPRETATION AND CONCLUSIONS: This study is the first demonstration that sTfR and CHr are useful parameters for evaluating the relative severity of different genotypes in heterozygous beta-thalassemia.