Abstract
The association between iron overload indices and pathology of the heart and liver in transfusion-dependent patients with β thalassemia major (TM) has been extensively studied. Nonetheless, data on endocrine disease remains limited. This was a cross-sectional study of 382 TM patients treated with regular transfusions and desferrioxamine at the Thalassemia Center in Dubai, UAE. Retrieved data included demographics, splenectomy status, steady-state serum ferritin levels, and the presence of endocrinopathies (diabetes mellitus, hypothyroidism, hypoparathyroidism, and hypogonadism). Multivariate logistic regression analyses were used to determine which variables were independently associated with the occurrence of each endocrinopathy. The mean age of patients was 15.4 ± 7.6 years, with an equal sex distribution. The mean serum ferritin level was 2597.2 ± 1976.8 μg/l. The frequencies of specific endocrinopathies were diabetes mellitus (10.5%), hypothyroidism (6.3%), hypoparathyroidism (10.5%), and hypogonadism (25.9%). On multivariate logistic regression analysis, patients with a serum ferritin level >2,500 μg/l, but not >1,000–2,500 μg/l, were 3.53 times (95% CI 1.09–11.40) more likely to have diabetes mellitus, 3.25 times (95% CI 1.07–10.90) more likely to have hypothyroidism, 3.27 times (95% CI 1.27–8.39) more likely to have hypoparathyroidism, and 2.75 times (95% CI 1.38–5.49) more likely to have hypogonadism compared to patients with a serum ferritin level ≤1,000 μg/l. However, splenectomized patients with serum ferritin levels ≤2,500 μg/l had comparably high rates of all endocrinopathies as patients with serum ferritin levels >2,500 μg/l. Endocrinopathy is common in TM patients treated with desferrioxamine therapy, especially in patients with serum ferritin levels >2,500 μg/l or those splenectomized.
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References
Hershko C (2010) Pathogenesis and management of iron toxicity in thalassemia. Ann N Y Acad Sci 1202:1–9
Cohen AR, Glimm E, Porter JB (2008) Effect of transfusional iron intake on response to chelation therapy in beta-thalassemia major. Blood 111:583–587
Taher AT, Musallam KM, Inati A (2009) Iron overload: consequences, assessment, and monitoring. Hemoglobin 33(Suppl 1):S46–S57
Olivieri NF, Nathan DG, MacMillan JH, Wayne AS, Liu PP, McGee A, Martin M, Koren G, Cohen AR (1994) Survival in medically treated patients with homozygous beta-thalassemia. N Engl J Med 331:574–578
Borgna-Pignatti C, Rugolotto S, De Stefano P, Piga A, Di Gregorio F, Gamberini MR, Sabato V, Melevendi C, Cappellini MD, Verlato G (1998) Survival and disease complications in thalassemia major. Ann N Y Acad Sci 850:227–231
Gabutti V, Piga A (1996) Results of long-term iron-chelating therapy. Acta Haematol 95:26–36
Borgna-Pignatti C, Rugolotto S, De Stefano P, Zhao H, Cappellini MD, Del Vecchio GC, Romeo MA, Forni GL, Gamberini MR, Ghilardi R, Piga A, Cnaan A (2004) Survival and complications in patients with thalassemia major treated with transfusion and deferoxamine. Haematologica 89:1187–1193
Modell B, Khan M, Darlison M, Westwood MA, Ingram D, Pennell DJ (2008) Improved survival of thalassaemia major in the UK and relation to T2* cardiovascular magnetic resonance. J Cardiovasc Magn Reson 10:42
Nathan DM, Buse JB, Davidson MB, Ferrannini E, Holman RR, Sherwin R, Zinman B (2009) Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 32:193–203
Baskin HJ, Cobin RH, Duick DS, Gharib H, Guttler RB, Kaplan MM, Segal RL (2002) American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism and hypothyroidism. Endocr Pract 8:457–469
Shoback D (2008) Clinical practice. Hypoparathyroidism. N Engl J Med 359:391–403
Thuret I, Pondarre C, Loundou A, Steschenko D, Girot R, Bachir D, Rose C, Barlogis V, Donadieu J, de Montalembert M, Hagege I, Pegourie B, Berger C, Micheau M, Bernaudin F, Leblanc T, Lutz L, Galacteros F, Simeoni MC, Badens C (2010) Complications and treatment of patients with beta-thalassemia in France: results of the National Registry. Haematologica 95:724–729
Cunningham MJ, Macklin EA, Neufeld EJ, Cohen AR (2004) Complications of beta-thalassemia major in North America. Blood 104:34–39
Delea TE, Edelsberg J, Sofrygin O, Thomas SK, Baladi JF, Phatak PD, Coates TD (2007) Consequences and costs of noncompliance with iron chelation therapy in patients with transfusion-dependent thalassemia: a literature review. Transfusion 47:1919–1929
Musallam K, Cappellini MD, Taher A (2008) Challenges associated with prolonged survival of patients with thalassemia: transitioning from childhood to adulthood. Pediatrics 121:e1426–e1429
Piga A, Roggero S, Salussolia I, Massano D, Serra M, Longo F (2010) Deferiprone. Ann N Y Acad Sci 1202:75–78
Galanello R, Agus A, Campus S, Danjou F, Giardina PJ, Grady RW (2010) Combined iron chelation therapy. Ann N Y Acad Sci 1202:79–86
Brittenham GM (2011) Iron-chelating therapy for transfusional iron overload. N Engl J Med 364:146–156
Farmaki K, Tzoumari I, Pappa C (2011) Oral chelators in transfusion-dependent thalassemia major patients may prevent or reverse iron overload complications. Blood Cells Mol Dis 47:33–40
Gamberini MR, De Sanctis V, Gilli G (2008) Hypogonadism, diabetes mellitus, hypothyroidism, hypoparathyroidism: incidence and prevalence related to iron overload and chelation therapy in patients with thalassaemia major followed from 1980 to 2007 in the Ferrara Centre. Pediatr Endocrinol Rev 6(Suppl 1):158–169
Farmaki K, Tzoumari I, Pappa C, Chouliaras G, Berdoukas V (2010) Normalisation of total body iron load with very intensive combined chelation reverses cardiac and endocrine complications of thalassaemia major. Br J Haematol 148:466–475
Wang CH, Wu KH, Tsai FJ, Peng CT, Tsai CH (2006) Comparison of oral and subcutaneous iron chelation therapies in the prevention of major endocrinopathies in beta-thalassemia major patients. Hemoglobin 30:257–262
Platis O, Anagnostopoulos G, Farmaki K, Posantzis M, Gotsis E, Tolis G (2004) Glucose metabolism disorders improvement in patients with thalassaemia major after 24–36 months of intensive chelation therapy. Pediatr Endocrinol Rev 2(Suppl 2):279–281
Jaruratanasirikul S, Chareonmuang R, Wongcharnchailert M, Laosombat V, Sangsupavanich P, Leetanaporn K (2008) Prevalence of impaired glucose metabolism in beta-thalassemic children receiving hypertransfusions with a suboptimal dosage of iron-chelating therapy. Eur J Pediatr 167:873–876
Shalitin S, Carmi D, Weintrob N, Phillip M, Miskin H, Kornreich L, Zilber R, Yaniv I, Tamary H (2005) Serum ferritin level as a predictor of impaired growth and puberty in thalassemia major patients. Eur J Haematol 74:93–100
Jensen CE, Tuck SM, Old J, Morris RW, Yardumian A, De Sanctis V, Hoffbrand AV, Wonke B (1997) Incidence of endocrine complications and clinical disease severity related to genotype analysis and iron overload in patients with beta-thalassaemia. Eur J Haematol 59:76–81
Telfer PT, Prestcott E, Holden S, Walker M, Hoffbrand AV, Wonke B (2000) Hepatic iron concentration combined with long-term monitoring of serum ferritin to predict complications of iron overload in thalassaemia major. Br J Haematol 110:971–977
Davis BA, O’Sullivan C, Jarritt PH, Porter JB (2004) Value of sequential monitoring of left ventricular ejection fraction in the management of thalassemia major. Blood 104:263–269
Carpenter JP, He T, Kirk P, Roughton M, Anderson LJ, de Noronha SV, Sheppard MN, Porter JB, Walker JM, Wood JC, Galanello R, Forni G, Catani G, Matta G, Fucharoen S, Fleming A, House MJ, Black G, Firmin DN, St Pierre TG, Pennell DJ (2011) On T2* magnetic resonance and cardiac iron. Circulation 123:1519–1528
St Pierre TG, Clark PR, Chua-anusorn W, Fleming AJ, Jeffrey GP, Olynyk JK, Pootrakul P, Robins E, Lindeman R (2005) Noninvasive measurement and imaging of liver iron concentrations using proton magnetic resonance. Blood 105:855–861
Wood JC, Enriquez C, Ghugre N, Tyzka JM, Carson S, Nelson MD, Coates TD (2005) MRI R2 and R2* mapping accurately estimates hepatic iron concentration in transfusion-dependent thalassemia and sickle cell disease patients. Blood 106:1460–1465
Kirk P, He T, Anderson LJ, Roughton M, Tanner MA, Lam WW, Au WY, Chu WC, Chan G, Galanello R, Matta G, Fogel M, Cohen AR, Tan RS, Chen K, Ng I, Lai A, Fucharoen S, Laothamata J, Chuncharunee S, Jongjirasiri S, Firmin DN, Smith GC, Pennell DJ (2010) International reproducibility of single breathhold T2* MR for cardiac and liver iron assessment among five thalassemia centers. J Magn Reson Imaging 32:315–319
Anderson LJ, Holden S, Davis B, Prescott E, Charrier CC, Bunce NH, Firmin DN, Wonke B, Porter J, Walker JM, Pennell DJ (2001) Cardiovascular T2-star (T2*) magnetic resonance for the early diagnosis of myocardial iron overload. Eur Heart J 22:2171–2179
de Assis RA, Ribeiro AA, Kay FU, Rosemberg LA, Nomura CH, Loggetto SR, Araujo AS, Fabron Junior A, de Almeida Verissimo MP, Baldanzi GR, Esposito BP, Baroni RH, Wood JC, Hamerschlak N (2011) Pancreatic iron stores assessed by magnetic resonance imaging (MRI) in beta thalassemic patients. Eur J Radiol
Restaino G, Meloni A, Positano V, Missere M, Rossi G, Calandriello L, Keilberg P, Mattioni O, Maggio A, Lombardi M, Sallustio G, Pepe A (2011) Regional and global pancreatic T*2 MRI for iron overload assessment in a large cohort of healthy subjects: normal values and correlation with age and gender. Magn Reson Med 65:764–769
Au WY, Lam WW, Chu W, Tam S, Wong WK, Liang R, Ha SY (2008) A T2* magnetic resonance imaging study of pancreatic iron overload in thalassemia major. Haematologica 93:116–119
Noetzli LJ, Papudesi J, Coates TD, Wood JC (2009) Pancreatic iron loading predicts cardiac iron loading in thalassemia major. Blood 114:4021–4026
Wood JC, Noetzl L, Hyderi A, Joukar M, Coates T, Mittelman S (2010) Predicting pituitary iron and endocrine dysfunction. Ann N Y Acad Sci 1202:123–128
Skordis N, Michaelidou M, Savva SC, Ioannou Y, Rousounides A, Kleanthous M, Skordos G, Christou S (2006) The impact of genotype on endocrine complications in thalassaemia major. Eur J Haematol 77:150–156
Tavazzi D, Duca L, Graziadei G, Comino A, Fiorelli G, Cappellini MD (2001) Membrane-bound iron contributes to oxidative damage of beta-thalassaemia intermedia erythrocytes. Br J Haematol 112:48–50
Aydinok Y, Bayraktaroglu S, Yildiz D, Alper H (2011) Myocardial iron loading in patients with thalassemia major in Turkey and the potential role of splenectomy in myocardial siderosis. J Pediatr Hematol Oncol 33:374–378
Eldor A, Rachmilewitz EA (2002) The hypercoagulable state in thalassemia. Blood 99:36–43
Rund D, Rachmilewitz E (2005) Beta-thalassemia. N Engl J Med 353:1135–1146
Cappellini MD, Motta I, Musallam KM, Taher AT (2010) Redefining thalassemia as a hypercoagulable state. Ann N Y Acad Sci 1202:231–236
Atichartakarn V, Likittanasombat K, Chuncharunee S, Chandanamattha P, Worapongpaiboon S, Angchaisuksiri P, Aryurachai K (2003) Pulmonary arterial hypertension in previously splenectomized patients with beta-thalassemic disorders. Int J Hematol 78:139–145
Crary SE, Buchanan GR (2009) Vascular complications after splenectomy for hematologic disorders. Blood 114:2861–2868
Phrommintikul A, Sukonthasarn A, Kanjanavanit R, Nawarawong W (2006) Splenectomy: a strong risk factor for pulmonary hypertension in patients with thalassaemia. Heart 92:1467–1472
Aessopos A, Farmakis D, Deftereos S, Tsironi M, Polonifi A, Moyssakis I, Diamanti-Kandaraki E, Papalambros E (2005) Cardiovascular effects of splenomegaly and splenectomy in beta-thalassemia. Ann Hematol 84:353–357
Acknowledgment
This study was supported by the Dubai Health Authority–Thalassemia Centre. Financial support for medical editorial assistance was provided by Novartis Pharmaceuticals.
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ATT is a member of Novartis Speakers’ Bureau.
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Belhoul, K.M., Bakir, M.L., Saned, MS. et al. Serum ferritin levels and endocrinopathy in medically treated patients with β thalassemia major. Ann Hematol 91, 1107–1114 (2012). https://doi.org/10.1007/s00277-012-1412-7
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DOI: https://doi.org/10.1007/s00277-012-1412-7