HEMATOLOGICAL AND BONE METABOLISM ABNORMALITIES IN CHILDREN AND ADOLESCENTS WITH Β-THALASSEMIA MAJOR

We investigated the biochemical markers of bone metabolism in children with Helicobacter pylori infection. Biochemical markers of bone metabolism and serum levels of vitamin B12, ferritin and estradiol were measured in 41 H. pylori-positive (+) children (23 girls, 18 boys; aged 11.8+/-3 years). Serum levels of intact parathyroid hormone, ss-collagen I carboxy terminal telopeptide, total alkaline phosphatase (ALP), bone-specific ALP, N-terminal cross-links of human procollagen type I, N-mid-osteocalcin, calcium, phosphate, ferritin, and estradiol did not differ significantly between H. pylori(+) and H. pylori negative (-) children. Vitamin B12 levels were significantly decreased in H. pylori(+) compared to H. pylori(-) children. H. pylori infection was not accompanied by significant changes in markers of bone metabolism in children, although vitamin B12 levels were decreased. Further studies are required to clarify whether H. pylori infection causes time-dependent changes in bone turnover markers during the long course of this inflammatory disease.

Background MRI has become the gold standard for monitoring somatic iron stores. It is assumed that there would be a latency time before pancreatic iron burden could give impaired glucose tolerance. The therapeutic window between clinically silent iron deposition and irreversible pancreatic damage is an appropriate timing for intensification of iron chelation and saving organ function Objective The primary objective of our study is to determine pancreatic, cardiac and hepatic iron overload using MRI T2* in patients with transfusion dependent thalassemia(TDT) and correlate it with type and dose of iron chelation and serum ferritin. The secondary objective is to correlate these findings and the effect on Beta cell function and glucose dysregulation. Subjects and Methods This was a cross sectional study of 50 patients with TDT, 30 (60%) males and 20 (40%) females, aged 7-16 years. Clinical data involved mainly; frequency of transfusion, history of splenectomy, iron chelation therapy and compliance on medications in addition to anthropometric measures and Tanner staging. Laboratory work up included mainly mean pre-transfusion Hb, serum ferritin, serum fructosamine, fasting glucose and insulin levels with calculation of (HOMA-B and HOMA-IR) and MRI T2* to assess Cardiac, liver and pancreatic MRI. Results The mean age was 9.8 ± 2.52 yrs. Almost 40% of adolescents had delayed puberty (Tanner stage 1) of the studied TDT patients, 48% were on Deferasirox, 6% on Deferiprone, 20% was on Deferasirox &Deferiprone and 18% were on Deferiprone & Deferoxamine and two thirds were compliant on iron chelation therapy. Almost 50% were on hydroxyurea. The mean serum ferritin was 2646.6 ± 2334.55ng/ml. 16% had mild hepatic iron overload, 20% had moderate hepatic iron overload while 8% only had severe hepatic iron overload. Regarding the cardiac MRI results, 96% of studied group had no evident cardiac iron overload while 4% had moderate cardiac iron overload and 8% had evidence of severe pancreatic iron overload. The mean fructosamine was 236±56.72, mean HOMA-IR value was 1.4±0.79(0.32-2.5) yet only 4 patients(8%) had HOMA-IR of ≥ 2.5 indicating mild insulin resistance. There was significant positive correlation between LIC(p0.028), fasting glucose(p0.050), insulin level(p > 0.001) and HOMA IR, positive correlation between T2*-weighted MRI pancreas and insulin level (p0.026) as well as positive correlation between mean serum ferritin and insulin level(p0.001),negative non-significant correlation(p0.455) between mean serum ferritin and cardiacMRIT2*. Conclusion In patients with TDT, pancreatic siderosis (late onset presentation) was correlated with hepatic T2*;but not with the cardiac T2* values. Glucose homeostasis and markers of insulin resistance were correlated to pancreatic and liver iron load. Glucose dysregulation may precedes evident pancreatic siderosis so strict iron chelation is essential to maintain B-cell function.

Chapter 14 - Biochemical Markers of Bone Metabolism

Guidelines for the monitoring and management of iron overload in patients with haemoglobinopathies and rare anaemias.

Clinical Impact of Iron Overload on Morbidity in Patients with Sickle Cell Disease

Background: Thalassemia is one of the most common inherited hemoglobin disorders worldwide, characterized by defective globin chain synthesis leading to chronic hemolytic anemia. Regular blood transfusions remain the mainstay of therapy, yet they predispose patients to transfusional iron overload and its systemic complications. This study aimed to evaluate the clinico-hematological profile and iron overload status of thalassemia patients on regular transfusion and chelation therapy. Methods: A cross-sectional observational study was conducted on 20 diagnosed thalassemia patients receiving regular blood transfusions at a tertiary care center over a period of 18 months. Demographic data, clinical features, hematological parameters, peripheral smear findings, and serum ferritin levels were recorded. Iron chelation therapy details and compliance were documented. Results: The majority of patients (80.0%) had β-thalassemia major with a male predominance (60.0%). The mean hemoglobin at the time of presentation for transfusion was 7.1 ± 1.5 g/dL. Splenomegaly and hepatomegaly were observed in 70.0% and 55.0% of patients, respectively. The mean serum ferritin was 3180 ± 1920 ng/mL, with significantly higher levels in patients with longer transfusion duration (p=0.018) and irregular chelation compliance (p=0.024). Deferasirox was the most commonly used chelator (60.0%). Conclusion: Even in this small cohort, thalassemia patients on regular transfusion therapy exhibit significant iron overload despite chelation, particularly with poor compliance. Regular clinico-hematological assessment is essential for optimizing transfusion protocols and chelation regimens. Larger multicentric studies are warranted to validate these findings.

Biochemical expression of heterozygous hereditary hemochromatosis

IntroductionPatients with cow's milk allergy (CMA) and following a cow milk protein-free diet for a long time are potentially at risk of developing bone abnormalities. To assess the balance between bone formation and resorption processes, we determined serum concentrations of osteocalcin (OC), bone alkaline phosphatase (BALP), C-terminal telopeptide of type I collagen (CTX), fetuin-A, osteoprotegerin (OPG) and receptor activator of nuclear factor κB ligand (RANKL) in children with CMA.Material and methodsThe study included 50 prepubertal children with diagnosed cow's milk allergy, who were under systematic medical and nutritional care at the Institute of Mother and Child and 40 healthy counterparts as a control group. The concentrations of bone metabolism markers were determined by immunoenzymatic assays.ResultsThe diets of all investigated children were correct in terms of phosphorus and magnesium contents but deficient in terms of calcium and vitamin D. Serum OC and CTX as well as fetuin-A concentrations were similar in both studied groups. The BALP activity was significantly (p < 0.05) higher in children with cow's milk allergy than in the controls. Serum OPG concentration was comparable in both groups, but the RANKL level was higher (p < 0.05) in CMA children than in healthy ones. Hence, the ratio of OPG/RANKL was lower in children with CMA.ConclusionsOur study demonstrates slight disturbances in the profile of bone metabolism markers in growing children with CMA. The increase in RANKL level and decrease in OPG/RANKL ratio may contribute to intensification of bone resorption in these patients.

Bone metabolism can be influenced by a range of factors. We selected children with self-limited epilepsy with centrotemporal spikes (SeLECTS) and lifestyles similar to those of healthy children to control for the confounding factors that may influence bone metabolism. We aimed to identify the specific effects of epilepsy and/or anti-seizure medications (ASMs) on bone metabolism. Patients with SeLECTS were divided into an untreated group and a monotherapy group, and the third group was a healthy control group. We determined the levels of various biochemical markers of bone metabolism, including procollagen type I nitrogenous propeptide (PINP), alkaline phosphatase (ALP), osteocalcin (OC), collagen type I cross-linked C-telopeptide (CTX), calcium, magnesium, phosphorus, parathyroid hormone (PTH), and vitamin D3 (VD3 ). A total of 1487 patients (from 19 centers) were diagnosed with SeLECTS; 1032 were analyzed, including 117 patients who did not receive any ASMs (untreated group), 643 patients who received only one ASM (monotherapy group), and 272 children in the healthy control group. Except for VD3 , other bone metabolism of the three groups were different (p < .001). Bone metabolism was significantly lower in the untreated group than the healthy control group (p < .05). There were significant differences between the monotherapy and healthy control group in the level of many markers. However, when comparing the monotherapy and untreated groups, the results were different; oxcarbazepine, levetiracetam, and topiramate had no significant effect on bone metabolism. Phosphorus and magnesium were significantly lower in the valproic acid group than the untreated group (adjusted p < .05, Cliff's delta .282-.768). CTX was significantly higher in the lamotrigine group than in the untreated group (adjusted p = .012, Cliff's delta = .316). Epilepsy can affect many aspects of bone metabolism. After controlling epilepsy and other confounders that affect bone metabolism, we found that the effects of ASMs on bone metabolism differed. Oxcarbazepine, levetiracetam, and topiramate did not affect bone metabolism, and lamotrigine corrected some of the abnormal markers of bone metabolism in patients with epilepsy.

ObjectiveResearch is limited regarding biochemical markers of bone metabolism among children with cow’s milk protein allergy (CMPA). We aimed to determine differences in vitamin D and bone metabolism markers between infants with CMPA and healthy infants and explore relationships between these in a cross-sectional study.MethodsIn total, we included 41 children diagnosed with CMPA and under systematic medical and nutritional care at our center, and 50 healthy children as a control group. We reviewed demographic and clinical characteristics and measured serum biomarkers.ResultsWe found that serum 25-hydroxyvitamin D (25(OH)D) levels among infants in the CMPA group were significantly lower than those in the control group, and levels of bone-specific alkaline phosphatase (BALP), serum phosphorus, and serum calcitonin were reduced. Pearson correlation analysis showed that serum 25(OH)D concentrations in the CMPA group were negatively correlated with parathyroid hormone but not significantly correlated with calcitonin and BALP. Logistic regression showed that CMPA was a risk factor for vitamin D deficiency.ConclusionsOur study indicated that CMPA was associated with disturbances in bone metabolism. Levels of vitamin D in children with CMPA were lower than those in healthy children. CMPA was a risk factor for vitamin D deficiency.

Adverse Effects of Antiepileptic Drugs on Bone Mineral Density

Nutritional rickets is a major pediatric bone disorder closely associated with vitamin D deficiency. Clinical practice has gradually shifted from vitamin D monotherapy toward combination regimens aiming to enhance therapeutic efficacy through complementary mechanisms. However, head-to-head evidence comparing different vitamin D-based combinations remains limited, and their relative efficacy and safety rankings are unclear. To systematically compare the efficacy and safety of different oral vitamin D-based combination therapies for nutritional rickets in children and to provide evidence-based guidance for clinical decision-making. We conducted a systematic search of PubMed, Embase, the Cochrane Library, Web of Science, CNKI, Wanfang, and VIP databases, followed by a Bayesian network meta-analysis. The study protocol was prospectively registered in PROSPERO (CRD420251029274). Ten randomized controlled trials involving 867 children were included, comparing nine vitamin D-based combination regimens with vitamin D3 monotherapy. Pairwise meta-analyses showed that combination therapies significantly improved serum 25-hydroxyvitamin D levels, reduced bone-specific alkaline phosphatase, and increased serum calcium and phosphate concentrations, without an increased risk of adverse events. Subgroup analyses indicated significantly greater benefits among term infants than preterm infants (P < 0.001). Network meta-analysis revealed distinct relative advantages across outcomes among different combinations. Sensitivity analyses confirmed the robustness of the findings. Vitamin D-based combination therapies are overall more effective than vitamin D3 monotherapy in improving biochemical markers of bone metabolism in children with rickets, without compromising safety. Different regimens exhibit outcome-specific advantages, with clearer benefits observed in term infants. These findings support individualized, goal-oriented combination strategies, although further high-quality trials are required to strengthen the evidence base. https://www.crd.york.ac.uk/prospero/, identifier CRD420251029274.

Where do we go from HEIRS?

Future challenges in the use of magnetic resonance imaging for the diagnosis of iron overload.

Iron overload is the most common complication in transfusion-dependent thalassemias. Iron overloaded patients are frequently susceptible to gram-negative organisms such as Klebsiella pneumonaie. Literature has shown that iron overload can alter immune response but hitherto little work has been done on the effect of iron-overload on dendritic cells or T helper cells. We aimed to investigate if iron overload in beta thalassemia patients can predispose to gram-negative infection.&#13;\n&#13;\nFirst, we investigated the effect of iron overload on Th-related cytokine expression in β-thalassemia patients. All iron overload patients on various chelators had suppressed Th1-; Th2- or Th17-related cytokine expression. Only IL23 was elevated but it was not associated with an elevated Th17 response. Next we evaluated iron overload using two recently developed assays and examined the strength of association between iron overload and Th cytokine expression. Short term iron overload were inversely associated with Th1-, Th2- and Th17- cytokine expression levels with the exception of IL23. However, confounding variables such as the effect of blood transfusion could not be completely ruled out.&#13;\n&#13;\nTherefore, we used monocyte derived dendritic cells (DCs) as our model, since DCs direct the class and magnitude of the T helper cell response. Iron overload suppressed IL12 and IL23, cytokines critical for Th1 and Th17 expansion, and increased IL4, crucial for Th2 generation. There was a concurrent increase in Th2 cells and suppression of Th1 and Th17 cell populations. The expansion of Th2 cell population was not only induced by an increase in DC-mediated IL4 expression, but also from PDL2 suppression. The increase in CD4+ cell proliferation could also be explained by suppressed PDL2. We confirmed that these results were not due to iron-induced cellular apoptosis. Since Th1 and Th17 are critical for protective immunity against pathogenic gram-negative bacteria, our results provided a possible explanation as to why iron overloaded beta-thalassemia patients are prone to K. pneumoniae infections. The defective Th17 response correlated well with our clinical data obtained from thalassaemia patients.&#13;\n&#13;\nAside from the functional effect, we also observed that iron overload affects the morphology of mature DCs. We used various gram-negative analogues to show that iron overload could increase dendrite formations and decrease cellular aggregations in mature but not immature DCs. This phenomenon was abrogated by deferasirox. We also showed that iron overload induced dynamic remodeling of dendrite formations and cell aggregates ex vivo. We investigated the mechanisms involved by using inhibitors specific for MAPK pathway proteins. Iron augments LPS-induced phosphorylation of p38 leading to increased dendritic formations. Iron also enhances LPS-induced phosphorylation of JNK to suppress cell aggregation.&#13;\n&#13;\nFinally, we investigated an adverse effect associated with deferasirox use. Deferasirox is a commercially available iron chelator indicated for iron overload β-thalassemia. Compared to those on other chelation regimens, patients on deferasirox were more likely to develop renal tubular dysfunction, and/or serum electrolyte imbalances. These effects were reversible with suspension or dose reduction of deferasirox. Vigilant monitoring of renal tubular dysfunction and serum electrolyte is recommended in patients who receive deferasirox.