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Abstract
BackgroundTransfusions with packed erythrocytes is a common practice in pediatric patients with acute lymphoblastic leukemia (ALL) who are on chemotherapy. Since there is no physiological excretion mechanism for iron, the iron related to erythrocyte transfusions accumulates and may contribute to late cardiac, hepatic and endocrine complications in these patients. ProcedureIn order to evaluate the iron burden among pediatric patients with ALL and define the risk factors associated with higher iron loading, we evaluated 79 pediatric patients with ALL (36 were off-therapy). Cardiac and hepatic T2* were ordered to a total of 22 (28%) patients who were either transfused with erythrocytes ≥10 times (n=11; 50%), had serum ferritin (SF) ≥1000ng/ml (n=2; 9.1%) or both (n=9; 40.9%). ResultsHalf of the patients who were screened by T2* MRI had hepatic T2*<7ms and six (27%) of the patients had cardiac T2*<20ms, indicating iron loading. Patients who had serum ferritin <1000 vs ≥1000ng/ml had median cardiac T2* values of 28.3ms (15–40) vs 21 (7.9–36), (p=0.324); whereas hepatic T2* of 10.8 (5.32–27) vs 4.7 (2.2–36), (p=0.017). Patients who had erythrocyte transfusion <10 vs ≥10 times had median cardiac T2* values of 34ms (28–38) vs 23 (7.93–40), (p=0.021); whereas hepatic T2* of 13.6 (6.6–36) vs 5.32 (2.2–27), (p=0.046). ConclusionsOur results indicate that pediatric patients with ALL should be screened for transfusional iron load and the amount of erythrocyte transfusions seems to be a more reliable indication than serum ferritin levels to detect cardiac iron loading in these patients.
Highlights
Patients with acute lymphoblastic leukemia (ALL) receive multiple erythrocyte transfusions during treatment that may lead to iron loading ending up with further increase in oxidative stress adding to that produced by the chemotherapeutics [1,2], contributing to long-term organ damage
Cardiac related mortality has been reported to increase ≥10-fold among childhood cancer survivors [18,19,20]
The iron overloading may contribute to these late morbidities in these patients, in addition to contributing potential endocrinopathies such as hypogonadotropic hypogonadism or hypothyroidism, similar to those reported in patients with  thalassemia major [23,24]
Summary
Patients with acute lymphoblastic leukemia (ALL) receive multiple erythrocyte transfusions during treatment that may lead to iron loading ending up with further increase in oxidative stress adding to that produced by the chemotherapeutics [1,2], contributing to long-term organ damage. The transfusional hemosiderosis in these patients may exacerbate the potential cardiac, hepatic and endocrine late complications related to chemotherapy and is usually an underestimated risk factor. Cardiac and hepatic T2* were ordered to a total of 22 (28%) patients who were either transfused with erythrocytes ≥10 times (n = 11; 50%), had serum ferritin (SF) ≥1000 ng/ml (n = 2; 9.1%) or both (n = 9; 40.9%). Conclusions: Our results indicate that pediatric patients with ALL should be screened for transfusional iron load and the amount of erythrocyte transfusions seems to be a more reliable indication than serum ferritin levels to detect cardiac iron loading in these patients
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