Regular Chelation Research Articles

Post Splenectomy Outcome in β-Thalassemia.

To evaluate changes in annual blood transfusion requirements and complications after splenectomy in patients with β-thalassemia. Forty post-splenectomy β-thalassemic patients aged 8-33 y, receiving regular blood transfusions and chelation therapy were included and non transfusion dependant patients were excluded from this retrospective cross-sectional study. Details about their surgery, transfusion requirements, and platelet levels were recorded on a standard proforma. All patients underwent a B-mode and color-coded duplex sonography of the hepatoportal system during the study period. The average ferritin level in the year prior to the study was 4432 mcg/L (range 480-12,200 mcg/L). The annual blood transfusion requirement in the first year and 5 y post splenectomy [mean ± SD (138.41 ± 90.38 ml/kg/y); (116 ± 41.44 ml/kg/y)] were significantly different from requirements before splenectomy [(mean ± SD) 294.85 ± 226 ml/kg/y; p value <0.001]. There was a significant rise in platelet counts within 24 h post splenectomy with a mean rise of 4,51,000/mm(3) (p value < 0.001). During the follow up period, infections were noted in 50 % of patients, with malaria (18.75 %) being the most common. Doppler study of the portal system in one case showed portal vein thrombosis. A significant sustained fall in annual blood transfusion requirement and a rise in platelet counts occurred post-splenectomy. Increase in annual blood transfusion requirement should be investigated to find the cause.

Prevalence of human immunodeficiency virus and hepatitis B among multi-transfused thalassemia children

Background: Thalassemia is an inherited disorder of the blood. It is best treated with regular blood transfusion and chelation in developing countries which carries the risk of acquisition of blood-borne viral infection. Though hepatitis B infection can be effectively prevented by vaccine, yet no such vaccine is available for human immunodeficiency virus (HIV). The only strategy to prevent HIV infection is effective screening of blood products. There is a lack of sufficient reported data on transfusion transmitted infections in β-thalassemia major from India. Moreover, data on risk factors associated with HIV transmission in thalassemia children are scanty. Subjects and Methods: This retrospective study was conducted at pediatric thalassemia ward of KT Children Hospital, Rajkot. Case records of patients were retrieved from July 2011 to August 2012. Information regarding age, sex, the number of transfusions, place of transfusion, immunization against hepatitis B, the status of HIV, and hepatitis B surface antigen (HBsAg) were recorded in standard performa. HIV and HBsAg were tested by using patient sera with enzyme-linked immunosorbent assay. Results: Study subject consisted of 237 children. There were 160 males and 77 females. Of 237 children 8 (3.37%) children were found to be HIV positive and 3 (1.26%) children found to be HBsAg positive. Univariate analysis showed that incomplete immunization for hepatitis B was significantly associated with increased risk of HIV (P = 0.00). Conclusion: The prevalence of HIV and hepatitis B is significant in our study. Routine hepatitis B immunization and HIV screening by more stringent method are required.

Multisystem, Induced Pluripotent Stem Cell (iPSC) Modeling Reveals a Role for Growth Differentiation Factors (GDFs) in the Etiology of β Thalassemia and Ineffective Erythropoiesis

β Thalassemia is one of the most common monogenic diseases in man encompassing a heterogeneous group of naturally occurring, inherited mutations characterized by abnormal globin gene expression. Iron overload is the principle cause of morbidity and mortality in β thalassemia. The hepatic hormone hepcidin regulates iron homeostasis modulating iron concentration in the plasma and its distribution in tissues throughout the body. Dysregulation of hepcidin production underlies many iron disorders with emerging evidence suggesting that deficiency of the hormone may result from the strong suppressive effect of high erythropoietic activity on hepcidin expression. Current treatment modalities for iron overload include phlebotomy and iron chelation. In β thalassemia, phlebotomy is not feasible and regular chelation is the principal treatment for iron overload. Iron chelators have side effects ranging from mild to very serious, and compliance is often suboptimal. Hepcidin diagnostics and the development of novel therapeutic options are clearly desirable and may help in the management of patients with β thalassemia.Hepcidin dysregulation, along with the ineffective erythropoiesis and anemia noted in β thalassemia highlight the need for a model capable of recapitulating the multisystem complexity of this clinically variable disease. Using induced pluripotent stem cell (iPSC) technology, cell lines can be established that are genetically identical to the individual from whom they are derived, allowing for disease modeling and the development of novel therapeutics in the exact genetic context of the patient. We have generated disease-specific iPSC lines from patients with β thalassemia major. Harnessing the pluripotency of iPSCs, we demonstrate the modeling of this multisystem disease through the directed differentiation of patient-specific iPSCs into hepatocytes that produce hepcidin as well as erythroblasts produced via a platform that allows for exponentially greater production of blood cells in comparison to existing methodologies (Smith et. al, Blood, 2013). We demonstrate that β thalassemia iPSC-derived erythroblasts secrete greater amounts of GDFs 11 and 15, and that exposure of the patient’s own iPSC-derived hepatocytes to disease-specific erythroblast supernatants results in a marked decrease in hepcidin expression recapitulating essential aspects of the disease in vitro. Furthermore, exposure of developing iPSC-derived erythroblasts to recombinant GDFs results in the production of immature cells that fail to reach maturity, providing a potential novel mechanism contributing to the development of ineffective erythropoiesis. Taken together, these results validate this iPSC-based, patient-specific in vitro system as a platform for testing new diagnostic approaches as well as novel therapeutic strategies targeting the correction of hepcidin dysregulation. DisclosuresNo relevant conflicts of interest to declare.

The Role of Cardiovascular T2*MRI and Tissue Doppler Measurement in Assesment of Cardiac Status in β-Thalassemia Major

Introduction: Early detection of myocardial dysfunction and modification of treatment may prevent from progressing into the end stage heart failure and lethal arrhythmias in beta-thalassemia major (β-TM). T2* magnetic resonance imaging (MRI), a non-invasive technic determining iron accumulation in myocardium has been widespreadly used in these patients. Cardiac T2* MRI is not capable to evaluate cardiac functions but, indicates patients with risk for developing cardiac disease. Therefore, combining T2*MRI with tissue Doppler (TD) echocardiography, another technic defining both functional and structural evaluation of myocardium, could give a better information in evaluating the actual status of myocardium.The aim of this study was to evaluate cardiac status of thalassemics by using both T2*MRI and TD measurement.Methods: The study group includedpatientswith β-TM on regular transfusion and chelation program with preserved systolic function; ejection fraction > 55% and fractional shortening > 30% determined by conventional echocardiography. None of them had other organ dysfunctions adversely effecting cardiac functions. The control group was consisted of age and sex matched healthy persons. Serum ferritin levels were measured in both groups. In addition, TD measurements (S,E,A waves, time intervals; ejection time, total systolic time, isovolumetric accelaration time, isovolumetric contraction time, isovolumetric relaxation time and myocardial performance index) were obtained from three different regions of myocardium; septum, left and right ventricular posterior walls. T2* MRI was only determined in thalassemics.The study group was divided into two different subgroups according to serum ferritin level (low ferritin < 2500 ng/ml and high ferritin > 2500 ng/ml) and T2* MRI score (iron overloaded <20 ms and unloaded >20ms). The results obtained by TD within these subgroups were compared. TD measurements in thalassemics without cardiac iron overload were separately compared with the controls.Results: The study and control groups were consisted of 33 β-TM patients (16 girls/17 boys, mean age 18,7±7,7 years) and 37 healthy individuals (18 girls/19 boys, age 19,9±8,4 years), in respectively. Gender and age were similar (p>0,05). Systolic and diastolic functions by TD were found significantly impaired in thalassemics compared to the controls (p<0,05). S-lateral wave measurement showing early myocardial systolic function was more adversely effected in thalassemics (p<0,001). The patients’ mean ferritin level was found 2242,3±2174,2 ng/ml (109-9843). Twelve patients (36,4%; 12/33) had high ferritin level and the rest (63,6%; 21/33) had low. T2*MRI and TD measurements did not differ in both subgroups (p>0.05). The mean T2*MRI score was 18,7±7,7 (7,3-29,8) ms in the study group. Twenty-one patients (63,6%; 21/33) had myocardial iron overload. Serum ferritin levels were similar between iron overloaded and unloaded groups (p>0.05). Both isovolumetric acceleration time of left ventricule and myocardial performance index (MPI-septal) showing systolic and diastolic functions were found significantly impaired in iron overloaded subgroup (p<0,05). There was negative correlation between MPI-septal and T2*MRI measurements in thalassemics (r:-0,343, p=0,050, fig 1).When we compared the velocity measurements (S,E,A waves) of iron unloaded thalassemics with the controls; only S wave velocity obtained from left ventricular wall was found significantly low (p<0,05). The time intervals measured from septum were found similar with the controls (p>0,05) but, the same measurements obtained from left and right ventricular posterior walls were significantly impaired (p<0,05). [Display omitted] Conclusions: This study showed that thalassemics with iron overload had significantly impaired TD measurements and MPI-septal index worsened when the mycardial iron load was increased (fig 1). Patients considered as iron unloaded according to T2*MRI result had left and right ventricular dysfunction determined by TD. Normal cardiac T2*MRI does not always associated with normal cardiac function. Therefore, we conclude that combining T2*MRI with TD measurements in evaluating cardiac status in β-TM, especially in patients with normal T2*MRI score, could lead to a better management of cardiac complications. DisclosuresNo relevant conflicts of interest to declare.

A T2* MRI Prospective Survey on Cardiac and Hepatic Iron in Non-Trasfusion-Dependent Thalassemia Intermedia Patients Treated with Desferrioxamine

Background. In thalassemia intermedia (TI) patients no observational study prospectively evaluated in the real life the efficacy of the desferrioxamine (DFO) therapy in removing or preventing iron overload from the heart and the liver by T2* Magnetic Resonance Imaging (MRI). The efficacy endpoint of this study is represented by the changes in cardiac T2* and MRI LIC (liver iron concentration) values in non-transfusion dependent (NTD) TI patients after 18 months of desferrioxamine therapy.Methods. Among the 325 TI patients enrolled in the MIOT (Myocardial Iron Overload in Thalassemia) network, we selected 129 TI patients NTD. We considered 29 patients who had been received DFO alone between the two MRI scans. Cardiac iron overload was assessed by the T2* multiecho technique. Hepatic T2* values were converted into liver iron concentration (LIC) values.Results. Mean age was 39.69 ± 8.12 years and 14 (48.3%) patients were females. Patients started regular chelation therapy at a mean age of 21.92 ± 15.89 years. The mean administered dosage of DFO via subcutaneous route was 38.46 ± 10.27 mg/kg body weight on 3.32 ± 1.54 days/week. The percentage of patients with excellent/good levels of compliance to the chelation treatment was 82.1%.At baseline only one patient showed cardiac iron overload (global heart T2*=15.23 ms) but he recovered at the FU (global heart T2*=26.93 ms). All patients without cardiac iron maintained the same status at the follow-up (FU).Eighteen patients (62.1%) had hepatic iron overload (MRI LIC ≥3 mg/g/dw) at the baseline.For this subgroup, the baseline and the FU LIC values were, respectively, 9.15 ± 7.97 mg/g/dw and 7.41 ± 6.28 mg/g/dw. The reduction in MRI LIC values was not significant (P=0.102). Out of the 11 patients with a baseline MRI LIC <3 mg/g/dw, only one (9.1%) showed hepatic iron at the FU. The Figure shows the evolution of different hepatic iron overload risk classes between the baseline and the FU.Conclusions. In this small population of sporadically or non transfused TI patients, DFO showed 100% efficacy in maintaining a normal global heart T2* value. As regards as the hepatic iron overload, the DFO therapy did not prevent the transition to a worst class in 2 patients. [Display omitted] DisclosuresPepe:Chiesi: Speakers Bureau; ApoPharma Inc.: Speakers Bureau; Novartis: Speakers Bureau.

Hematopoietic stem cell transplantation for people with ß-thalassaemia major.

Thalassemia is an inheritedblood disorder, caused by mutations in regulatory genes and transmitted as an autosomal recessive disorder, which results ina reduced rate of synthesis of one of the globin chains that make up haemoglobin. In ß-thalassaemia major there is an underproduction of ß-globin chains combined with excess of free α-globin chains. The excess free α-globin chains damage the red blood cell membranes, leading to their destruction and a phenomenon termed ineffective erythropoiesis. The conventional approach to treatment is based on the correction of haemoglobin status through regular blood transfusions and iron chelation therapy for iron overload. Although conventional treatment has the capacity to improve the quality of life of people with ß-thalassaemia major, allogeneic hematopoietic stem cell transplantation is the only currently available procedure which has the potential to definitively cure the disease. To evaluate the effectiveness and safety of different types of allogeneic hematopoietic stem cell transplantation, in people with severe transfusion-dependant ß-thalassaemia major, ß-thalassaemia intermedia or ß0/+- thalassaemia variants requiring chronic blood transfusion. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Date of the most recent search: 11 November 2013. Randomised controlled trials and quasi-randomised controlled trials comparing allogeneic hematopoietic stem cell transplantation with each other or with standard therapy (regular transfusion and chelation regimen). Two review authors independently screened studies and had planned to extract data and assess risk of bias using standard Cochrane Collaboration methodologies but no studies were identified for inclusion. No relevant studies were retrieved after a comprehensive search of the literature. We were unable to identify any randomised controlled trials or quasi-randomised controlled trials on the effectiveness and safety of different types of allogeneic stem cell transplantation in people with severe transfusion-dependant ß-thalassaemia major or ß0/+- thalassaemia variants requiring chronic blood transfusion. The absence of high-level evidence for the effectiveness of these interventions emphasises the need for well-designed, adequately-powered, randomised controlled clinical trials.

Examination of echocardiographic parameters for the early diagnosis of cardiac dysfunction in beta thalassemia major patients

Objective: This study aimed to determine the utility of tissue Doppler, pulse-wave Doppler, and conventional echocardiography for the detection of cardiac dysfunction in the early period in beta thalassemia patients. Methods: Forty beta thalassemia major patients undergoing regular blood transfusion and chelation therapy and 30 healthy controls with similar demographic factors were included in the study. Both the patient and control groups were examined with, tissue Doppler, pulse-wave Doppler, motion-mode echocardiography. Ferritin values and T2* magnetic resonance measurements were recorded for those in the patient group. Results: Diastolic dysfunction indicators like early ventricular filling rate, atrial contraction rate, mitral A wave time, and reverse pulmonary venous flow velocity were higher in the patient group (p

Liver and heart iron deposition status in patients with β thalassemia major: a multicenter study

To observe the status of iron deposition in patient with β thalassemia major, and to formulate appropriate treatment strategies. The data of status of transfusion and chelation in 135 patients aged from 6 years and 4 months to 17 years and 11 months with β thalassemia major were collected and analyzed. Serum ferritin levels were determined and cardiac and hepatic iron deposition was determined using MRI T2(*) technology. Of the 135 cases studied, 66 were male, and 69 were female, their average age was 12.1 years. Serum ferritin (SF) was determined for 111 cases, it varied from 1 086.8 µg/L to 15 011.5 µg/L. Among them, 16 cases had SF level <2 000 µg/L (14.5%) , in 41 cases SF were between 2 000 and 4 000 µg/L (36.0%) ;in 54 cases SF >4 000 µg/L (48.7%) . Liver MRI T2(*) results showed that in only 8 cases (5.9%) iron content in the liver was in normal range, 19 cases (14.9%) showed mild liver iron deposition;34 (25.2%) moderate and 74 (54.8%, the youngest one was only 6 years and 4 months of age) had severe iron deposition respectively. Cardiac MRI T2(*) showed that in 89 cases (65.9%) iron content in the heart was in normal range;19 cases (14.1%) had mild cardiac iron deposition and 27 (20.0%) presented severe iron deposition (the youngest one was only 9 years and 3 months of age) . SF level was obviously related to liver and cardiac iron deposition (MRI T2(*)) r and P value were -0.284, 0.003 and -0.374, 0.000 respectively. In 108 cases regular transfusion and chelation were delayed due to financial problem. The late and insufficient dosage administered and irregular chelation caused the higher SF level and the severe iron deposition. The survival status of β thalassemia major in China is worrisome. Majority of them had not received regular transfusion and chelation. Liver and cardiac iron deposition occur early and had a high incidence.

Glucose homeostasis in Egyptian children and adolescents with β-Thalassemia major: Relationship to oxidative stress.

Background:Oxidative stress in children with β-thalassemia may contribute to shortened life span of erythrocytes and endocrinal abnormalities.Aim:This study was aimed to evaluate glucose homeostasis in Egyptian children and adolescents with β-thalassemia major and its relation to oxidative stress.Materials and Methods:Sixty children and adolescents with β-thalassemia major were studied in comparison to 30 healthy age and sex-matched subjects. Detailed medical history, thorough clinical examination, and laboratory assessment of oral glucose tolerance test (OGTT), serum ferritin, alanine transferase (ALT), fasting insulin levels, plasma malondialdehyde (MDA) as oxidant marker and serum total antioxidants capacity (TAC) were performed. Patients were divided into two groups according to the presence of abnormal OGTT.Results:The prevalence of diabetes was 5% (3 of 60) and impaired glucose tolerance test (IGT) was 8% (5 of 60). Fasting blood glucose, 2-hour post-load plasma glucose, serum ferritin, ALT, fasting insulin level, homeostatic model assessment for insulin resistance index (HOMA-IR) and MDA levels were significantly elevated while TAC level was significantly decreased in thalassemic patients compared with healthy controls (P < 0.001 for each). The difference was more evident in patients with abnormal OGTT than those with normal oral glucose tolerance (P < 0.001 for each). We also observed that thalassemic patients not receiving or on irregular chelation therapy had significantly higher fasting, 2-h post-load plasma glucose, serum ferritin, ALT, fasting insulin, HOMA-IR, oxidative stress markers OSI and MDA levels and significantly lower TAC compared with either those on regular chelation or controls. HOMA-IR was positively correlated with age, serum ferritin, ALT, MDA, and negatively correlated with TAC.Conclusions:The development of abnormal glucose tolerance in Egyptian children and adolescents with β--thalassemia is associated with alteration in oxidant-antioxidant status and increase in insulin resistance.Recommendation:1- Glucose tolerance tests, HOMA-IR, and MDA should be an integral part of the long-term follow-up of children and adolescents with β-thalassemia major. 2- Regular iron chelation and antioxidant therapy should be advised for thalassemic patients to improve glucose hemostasis.

Insidious Renal Damage in Patients with Thalassemia Major: Is it More Serious than Appreciated?

Aim: To investigate early renal injury in thalassemia major patients by using novel serum markers and demonstrate the factors leading to renal injury. Material and Methods: Seventy-one thalassemia major patients (37 males) who were on regular transfusion and chelation programme with deferasirox have been enrolled in this study. Thirty-five healthy children of the same age served as a control group. Serum urea-creatinine, electrolytes, cystatin C and glomerular filtration rate were all noted in our cohort and compared with the control group. Proteinuria was also investigated by calculating UPr/UCr ratio. Results: The median serum creatinine level was 0.4 mg/dL (range; 0.2-0.76 mg/dL ) and the median glomerular filtration rate level was 192 mL/min/1.73 m2 (range; 106-308 mL/min/1.73 m2 ) in patients. More than half of the patients had glomerular hyperfiltration (n=48, 67.6%). Hyperfiltration was prominent in thalassemia group (66.2% vs. 19.4%) (p=0.0001). Mean serum cystatin C levels were found to be statistically elevated in patient group comparing with controls (p=0.0001). Serum cystatin C level was above >1 mg/L in 46 patients (64.7%) whereas only three in controls (p=0.0001). Sex, age, hemoglobin level and cardiac T2* MRI results were not related to the elevated cystatin C levels. On the other hand, liver iron burden and serum ferritin levels were noted to be statistically correlated to elevated cystatin C level (p=0.024 and p=0.04). Deferasirox dose below 25 mg/kg/day was also found in relation with elevated cystatin C levels. Conclusion: Renal injury is multifactorial, insidious but progressive in thalassemia patients. High index of suspicion and routine use of novel markers are required for detection of renal injury during the follow up of thalassemia patients.

Comparative Study of Deferiprone and Silymarin versus Deferiprone and Placebo as Iron Chelators in Children with Beta Thalassemia with Iron Overload

Background: Beta thalassemia is an inherited hemoglobin disorder resulting in chronic hemolytic anemia requiring life-long blood transfusion that cause iron overload. Silymarin plays a role as an iron chelator in iron overloaded patients. The aim of this work was to compare the iron chelating efficacy of combination therapy of oral Deferiprone and silymarin with oral Deferiprone and placebo. Patients and methods: This study was conducted on 40 children with beta thalassemia major under follow up at Hematology Unit, Pediatric Department, Tanta University Hospital in the period between October 2012 and October 2013 with their serum ferritin levels more than 1000 ng/ml and they was divided in two groups. Group I: Received oral Deferiprone and silymarin for 6 months. Group II: Received oral Deferiprone and placebo for 6 months. Results: In the current study, there were no significant differences in the initial serum ferritin, serum iron and TIBC levels between group I and group II but after regular chelation therapy, serum ferritin and serum iron were significantly lower and TIBC was significantly higher in group I than group II. No statistically significant difference in serum creatinine, blood urea, ALT, AST and serum bilirubin levels between Group I and Group II before and after chelation therapy. Conclusion: From this study we concluded that, Deferiprone in combination with silymarin are better iron chelators in iron-loaded thalassemic patients than Deferiprone and placebo.

Cardiovascular Complications Of Thalassemia Patients In The Iron Chelation Therapy Era

BackgroundCardiac complications are the most common cause of death in thalassemia, accounting for up to 71% in the past. Iron chelation therapy is given to patients with iron overload to prevent these complications. The cost effectiveness of iron chelation therapy was arguable.This study aims to evaluate the prevalence of cardiac complication and the correlation between risk factors in iron chelation therapy era. MethodThis is a cross sectional study from June 2011- May 2012. All thalassemia aged > 15 years old were enrolled. Clinical data and hemoglobin typing were reviewed. Echocardiography and CMR T2*, a technique represent cardiac iron deposition used to evaluate cardiac function, were used to evaluate cardiac complications. ResultsNinety one patients were enrolled, 63.7% were females, median age of 31 years (16-75). There was 49.5 % homozygous β thalassemia, 31.9% β thalassemia/Hb E disease, 18.7% Hb H disease. Half of patients were transfusion dependent and 63.7% underwent splenectomy. Eighty four percent of patients received iron chelation therapy but few of them got their preferable choice in adequate dosage. Patients with serum ferritin levels more than 1,000 ng/ml. received deferoxamine, deferiprone or deferasirox.Even with the iron chelation therapy, mean serum ferritin level was still high at 3,820 ng/ml for the whole group.CMR T2* was more sensitive in detecting cardiac function. The CMR T2* showed shorter signal (≤ 20 msec) in 11.1%. Only 8.2% had impaired ejection fraction <55% by echocardiography. The CMR T2* ≤ 20 msec was significant correlated with higher maximum ferritin 5,739.14 ng/ml compared to 3,614 ng/ml (p=0.001). Pulmonary hypertension was found 7 patients (12.7%) and 71.42% had underwent splenectomy. ConclusionFrom our study, the CMR T2* is the sensitive method for detecting cardiomyopathy and highly correlated with serum ferritin levels. Splenectomy remains the major risk factor for pulmonary hypertension.The incidence of cardiac complications has decreased with iron chelation therapy for maintaining acceptable serum ferritin levels but the problem with cardiomyopathy and pulmonary hypertension still exist. Early detection, more sensitive implementation and aggressive iron chelation therapy are necessary to prevent these complications.The majority of the patients in Thailand which are under universal health-care coverage scheme could not get access to more effective and expensive iron chelator. Regular and adequate chelation plays a major role in the prevention of cardiac complications and the achievement of better quality of life. Disclosures:No relevant conflicts of interest to declare.

The Effect of HFE Polymorphisms on Cardiac Iron Overload in Patients with Beta-Thalassemia Major

Objective: We aimed to investigate the effect of human hemochromatosis protein (HFE) polymorphisms on cardiac iron overload in patients with beta-thalassemia major. Methods: Our study included 33 patients diagnosed with beta-thalassemia major who were treated with regular transfusions and chelation therapy. M-mode, tissue Doppler, and pulsed wave Doppler echocardiography were performed on all patients. T2* magnetic resonance imaging (MRI) scans were also performed. The HFE polymorphisms (H63D, C282Y, S65C, Q283P, E168Q, E168X, W169X, P160delC, Q127H, H63H, V59M, and V53M) were studied using polymerase chain reaction. Results: The H63D polymorphism was detected in six patients with beta-thalassemia major. Five patients were heterozygous for the H63D polymorphism, while one was homozygous. There were no other polymorphisms. There was no relationship between the HFE polymorphisms and either the serum ferritin levels or the T2-weighted MRI values (P > .05). Moreover, conventional echo and tissue Doppler echo findings were not correlated with the HFE polymorphisms. Pulmonary vein atrial reversal flow velocity, which is a manifestation of diastolic dysfunction measured with pulse wave echo, was higher in the patients with HFE polymorphisms (P = .036). Conclusions: The HFE polymorphisms had no effect on cardiac iron overload. However, pulmonary vein atrial reversal flow velocity measurements can provide important information for detecting diastolic dysfunction during cardiac follow-up of patients with HFE polymorphisms. Studies with more patients are needed to provide more information regarding this matter.

Risk adopted allogeneic hematopoietic stem cell transplantation using a reduced intensity regimen for children with thalassemia major

Patients with thalassemia in developing countries have limited access to safe transfusions, regular medical care and chelation therapy. Although allogeneic hematopoietic stem cell transplantation (HSCT) can offer a curative approach, there are limited data on the use of this procedure in developing countries. Forty-four patients underwent a risk adopted HSCT from matched related family donor in Jordan. Thirty-one patients (7 Class 1 and 24 Class 2) underwent myeloablative conditioning (MAC) with busulfan (16 mg/kg), cyclophosphamide (200 mg/kg) and antithymocyte globulin (ATG). Thirteen patients all with Class 3, seven with hepatitis C received reduced intensity conditioning (RIC) with busulfan (8 mg/kg), fludarabine (175 mg/m(2)), total lymphoid irradiation (500 cGy) and ATG. All patients had initial neutrophil and platelet engraftment. Secondary graft failure was observed in 2 (6%) patients receiving myeloablative HSCT and 3 (23%) patients receiving RIC. At a median follow up of 64 months (13-108), 43 of 44 patients are alive. The 5-year probability of overall survival (OS) was 97.8% for all patients, 96.8% for patients received MAC and 100% for patients received RIC. The 5-year probability of thalassemia-free survival was 86.4% for all patients, 90.3% and 77% for patients who received MAC and RIC, respectively. Implementing a risk-adopted therapy in patient with thalassemia in Jordan can result in an excellent thalassemia free and OS, especially in those at highest risk.

JAK2 V617F mutation positive primary myelofibrosis with concomitant t(9;11;22)(q34;p15;q11.2) but no BCR/ABL fusion

Dear Sir, A 50-year-old woman with a strong family history of cancer (ca: father ca lung age 52, mother ca lung age 50, brother ca colon age 42) and hepatitis B virus carriage on tenofovir presented with anemia [hemoglobin (Hb), 5.6 g/ dL; white blood cell (WCC), 19.4 9 10/L; platelet (Plat), 150 9 10/L with a leukoerythroblastic peripheral blood picture (Fig. 1a). Gross splenomegaly was also observed (Fig. 1b). Serum lactate dehydrogenase (LDH) was raised at 1985 IU/L, reference range 143–280]. A marrow biopsy showed osteosclerosis with markedly thickened bony trabeculae, narrowed intertrabecular spaces (Fig. 1c), and dilated sinusoids. Focal areas showed prominent blasts and clusters of megakaryocytes abutting on vascular sinuses (Fig. 1d). Reticulin fibres are markedly coarsened. The overall features were consistent with the fibrotic stage of primary myelofibrosis (PMF). A polymerase chain reaction (PCR) test showed the presence of JAK2 V6517F mutation. Cytogenetic studies, however, showed a sub-clone with a three-way translocation generating a Ph chromosome: 47,XX, ? 8[1]/47,idem,t(9;11;22)(q34;p15;q11.2)[5]/46,XX[1] (Fig. 1e). Reverse transcription PCR and fluorescent in situ hybridization (FISH) studies showed no BCR/ABL fusion (Fig. 1e). There was no clinical response to a trial of imatinib mesylate. She was treated with oral hydroxyurea, and a splenectomy (1.5 kg) specimen showed extramedullary haemopoiesis only. One year later, she remained stable (Hb, 7.9 g/dL; WCC, 22.7 9 10/L; Plat, 226 9 10/L; LDH, 655 IU/L) on regular transfusion and chelation. She refused work up for stem-cell transplantation and remained well at 2 years post-diagnosis. In myeloproliferative disorders (MPD) JAK2 mutations and BCR/ABL fusion are regarded as hallmark events. They occur in polycythemia vera/essential thrombocytosis/PMF and chronic myelogenous leukemia (CML), respectively. Although there may be preceding genetic events, both are definitive clonal markers and are mutually exclusive. There are many reports of patients possessing both the JAK2 V617F mutation and BCR/ABL transcripts. These two lesions can occur in either sequence, resulting in a transition in disease phenotype [1, 2]. Rarely, they may occur concomitantly at diagnosis, resulting in a mixed disease phenotype [3, 4]. A review of nine cases showed a median age of 48 years (range 32–66), male predominance (8/9), and a median lapse of 48 months (0–144) between the two disorders [3]. The two clones are always distinct [1–3, 5, 6]. The response of the CML element to tyrosine kinase inhibitor (TKI) is good and overall prognosis is favorable. The emergence of the second MPD should not be mistaken for TKI failure [5]. In our patient, the three-way translocation generates a morphological Ph chromosome-looking der(22). This was a subclonal evolution from a stem trisomy 8 clone. There was no BCR/ABL fusion or any clinical response to TKI. The presentation and disease course is also typical for PMF. Hence the ‘‘Philadelphia’’ chromosome in our case appeared to be an incidental cytogenetic anomaly. On the metaphase FISH analysis, the entire ABL gene was translocated onto 11p, no residue ABL signal was found in 9q. W.-Y. Au (&) Department of Medicine, Queen Mary Hospital, UMU, 4/F, Professorial Block, Pokfulam Road, Hong Kong, China e-mail: auwing@hotmail.com

Growth and endocrine disorders in thalassemia: The international network on endocrine complications in thalassemia (I-CET) position statement and guidelines

The current management of thalassemia includes regular transfusion programs and chelation therapy. It is important that physicians be aware that endocrine abnormalities frequently develop mainly in those patients with significant iron overload due to poor compliance to treatment, particularly after the age of 10 years. Since the quality of life of thalassemia patients is a fundamental aim, it is vital to monitor carefully their growth and pubertal development in order to detect abnormalities and to initiate appropriate and early treatment. Abnormalities should be identified and treatment initiated in consultation with a pediatric or an adult endocrinologist and managed accordingly. Appropriate management shall put in consideration many factors such as age, severity of iron overload, presence of chronic liver disease, thrombophilia status, and the presence of psychological problems. All these issues must be discussed by the physician in charge of the patient's care, the endocrinologist and the patient himself. Because any progress in research in the field of early diagnosis and management of growth disorders and endocrine complications in thalassemia should be passed on to and applied adequately to all those suffering from the disease, on the 8 May 2009 in Ferrara, the International Network on Endocrine Complications in Thalassemia (I-CET) was founded in order to transmit the latest information on these disorders to the treating physicians. The I-CET position statement outlined in this document applies to patients with transfusion-dependent thalassemia major to help physicians to anticipate, diagnose, and manage these complications properly.

Associated Complications In Beta Thalassemia Patients

Every year approximately 100,000 children with Thalassemia major are born world over, of which 10,000 are born in India. The combination of regular blood transfusions and chelation therapy has dramatically increased the life expectancy of thalassemics into 4th & 5th decades of life. On the other hand, frequent blood transfusion has also led to iron overload with many complications including endocrinopathies, behavioral and neurotic problems, growth failure etc. In the present study analysis of beta thalassemia major cases was done to determine the frequency and extent of complications associated with thalassemia. Two hundred thirty one patients of beta thalassemia were studied in the present investigation. It is concluded that commonest complication of beta thalassemia major is growth failure. Other complications are also not uncommon and involve liver, heart and endocrine glands. This study would help in early detection of the associated complications in beta thalassemia patients which would be quite helpful to reduce the burden of disease through preventive measures.

The Antioxidant Effects of Capparis Ovata and Deferasirox in Patients with Thalassemia Major

Iron overload and auto-oxidation of unpaired globin chains is the main cause of oxidative stress in thalassemia. We aimed to show the additive antioxidant effect of capparis Ovata and deferasirox in thalassemic patients. A total number of 40 thalassemia major patient aged between 7-30 years, who have been taken regular red cell 15 cc/kg/month to maintain Hb >10 gr/dl) and chelation (30 mg/kg/day ICL-670) for one year are involved. They were divided into two groups as control and study group randomly. Both study and control groups were followed by regular transfusion and chelation therapy. In addition study group has been taken capparis marmalade at the breakfast with a dose of a dessert-spoon (12.5 gr) younger than 10 years and a soup-spoon (25 gr) older than 10 years for 6 months. Hematological and biochemical parameters, ferritin at every month and oxidative-antioxidant status (MDA, CAT, Gpx, SOD) were measured at the beginning and at the end of the study. Serum ferritin and MDA levels declined significiantly in both groups (for ferritin; control group p=0.00; study group p=0.00) during the study but a much more decrease occured at MDA levels in the capparis given group (p=0.02). There was no statistically significant difference between the groups at the initial and last SOD CAT, GPX, SOD levels. Further more in the study group a significant decrease in liver function tests has been occured (AST p= 0.05, ALT p= 0.01). The high levels of MDA in iron overloaded thalassemic patients is the best marker of oxidative stres. Generally decreased iron burden was associated with decreased oxidant damage. In vitro it was shown that iron chelators such as deferoxamine and deferipron neutrolyse intraselluler free iron and inhibits oxidation. Our findings suggest that combination of capparis with deferasirox maybe have additive effect on decreasing the oxidative damage and hepatoxicity.

Outcome of Early Introduction of Hypertransfusion/Chelation Program in Children with Thalassemia Intermedia

Abstract 3260 Background:The standard of care for patients with thalassemia intermedia (TI) is regular follow up and iron chelation therapy. Patients with TI are usually transfusion independent and receive irregular transfusion when they develop low hemoglobin levels as in case of infection. However, with the current policy, these patients are liable to many complications; thalassemic facies, growth retardation, splenomegaly, hypersplenism, hypercoagulability, pulmonary hypertension, heart failure, cholelithiasis, diabetes mellitus, hypothyroidism, osteoporosis, and hypogonadism. We planned to investigate the impact of early introduction of hypertransfusion on delaying these complications. Material and Methods:All newly diagnosed children with TI at the Pediatric Thalassemia Day Care Centre, Sultan Qaboos University Hospital, Oman, starting from August 2006 were included in the study. They were diagnosed as intermedia based on clinical grounds of late age presentation (>5 years), maintaining mean baseline hemoglobin of 7 g/dL (range 6.1–7.9 g/dL), and transfusion independence. In addition, eight patients had a definitive TI mutation Hb Dhofar [β29(GGC–GGT)gly-gly, β58(CCT–CGT)pro-arg]. They were 10 females and 10 males included in the study. The mean age at presentation was 7.17 ± 3.9 years. At diagnosis, they were started on monthly hypertransfusion program to maintain a pretransfusion hemoglobin level above 9.5 g/dl and a post transfusion level of 14 g/dl. The mean duration of transfusion therapy was 6.2 ± 3.7 years and the mean follow up duration was 7.1 ± 3.2 years. Results:None of the 20 patients developed thalassemic facies, splenomegaly or hypersplenism. Sixteen patients maintained a normal weight (above 5th centile) and height (above 10thcentile), while 4 patients were at or below the 3rd centile. Of the 10 children above eleven years of age, 7 children reached normal puberty at their expected age. All 10 patients above eleven years of age, had a normal thyroid function test (TSH 2.27 ± 1.07 mIU/L, T4 11.04 ± 2.65 pmol/L) with no clinical or laboratory evidence of diabetes. Eight of the elder patients who had echocardiography had no evidence of pulmonary hypertension. Baseline bone densitometry done in 2 patients revealed a low Z-Score (below −2.5), with no improvement on follow-up. The mean total transfusion requirement was 162 ± 23 ml/kg/year. Patients were maintained on either deferiprone (n=14, dose 87 ± 12 mg/kg/day) or deferasirox chelation (n=6, dose 32 ± 4 mg/kg/day). Preliminary results of a self esteem questionnaire of these patients were better than our older patients who had not received hypertransfusion/chelation. Conclusion:TI children who were started at presentation on hypertansfusion/chelation regimen, have improved growth, better self esteem and they did not develop many of the complications known to occur in the non-transfused ones. However, this regimen needs to be evaluated in a larger prospective cohort study and to confirm the cost-effectiveness given the regular blood transfusion and continuous iron chelation. Disclosures:No relevant conflicts of interest to declare.

Preimplantation diagnosis for β-thalassemia combined with HLA matching: first “savior sibling” is born after embryo selection in Brazil

β-Thalassemia is a common hereditary hemoglobinopathy disorder that affects many organs and represents the most common monogenetic disorder worldwide [8, 11]. Diverse phenotypes exist within the β-thalassemia syndromes, ranging from the β-thalassemia minor to the β-thalassemia major [3]. β-Thalassemia major is characterized by reduced synthesis of the hemoglobin subunit beta (hemoglobin beta chain) that results in severe anemia and hepatosplenomegaly [3, 11]. Affected children require regular blood transfusions to sustain life and, without treatment, have shortened life expectancy [14]. Treatment with a regular transfusion program and chelation therapy allows for normal growth and development and extends life expectancy into the third to fifth decade [1]. Bone marrow transplantation (BMT) remains the only definitive cure currently available for patients with β-thalassemia [3]. The success of haematopoietic stem cell (HSC) transplantation will depend on the ability of the human leukocyte antigen (HLA) types of the donor and recipient to match. When the search for compatible donors in bone marrow living donor banks and databases is exhausted, the only way to save the life of a child may be to use preimplantation genetic diagnostic (PGD) to facilitate the birth of a child who can be a matching tissue donor, the so called “savior siblings” [13]. Currently, the selection of a compatible sibling to assist a transplant is an acceptable application of PGD, through HLA haplotyping. The ESHRE PGD consortium reported that in the last decade there were 225 cycles of HLA typing along with exclusion of a specific disorder. The majority (75 %) were for β-haemoglobinopathy [4]. Other indications include Fanconi anaemia, Gaucher disease, adrenoleukodystrophy and osteopetrosis. According to the ESHRE PGD Consortium “when all other clinical options have been exhausted, PGD is acceptable for couples who already have a child affected with a malignant disorder or a genetic disorder, if the affected child is likely to be cured or life expectancy is substantially prolonged by stem cell transplantation with cord blood from a HLA-matched sibling” [5]. This article presents the first Brazilian clinical experience demonstrating feasibility of combined PGD and HLA matching for β-thalassemia major, designed to preselect for transfer only those unaffected embryos that are HLA antigen compatible with a sibling needing cord blood transplantation.