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ANEMIA
Anemias are a group of diseases characterized by a decrease in either the hemoglobin (Hgb) or the volume of red blood cells (RBCs), which results in decreased oxygen-carrying capacity of the blood.
Definition
Hb levels to diagnosa anaemia
Pregnant woman
Prevalence of anaemia
Adjustment to measured haemoglobine for smokers
Classification systems for anemias
MoRphology etiology
Algoritma Diagnosa Anemia
PATHOLOGY, SYMPTOMS, AND SIGNS OF ANEMIA
Normal ADB Anemia penyakit kronik
Thalasemia
MCV 80 – 90 fl Menurun <70 fl Menurun/N Menurun
MCH 27 – 31 pg Menurun Menurun/N Menurun
Besi serum 50 – 150 μg/dL Menurun <50 μg/dL
Menurun Normal
TIBC 240 – 360 μg/dL Meningkat >360 μg/dL
Menurun Normal/Meningkat
Saturasi transferin
30 – 35% Menurun < 15%
Menurun/N10-20%
Meningkat>20%
Besi sumsum tulang
Positif Negatif Positif Positif kuat
FEP 15 – 18 μg/dL Meningkat >100 μg/dL
Meningkat Normal
Feritin serum 20 – 250 μg/dL Menurun <20 μg/dL
Normal Meningkat>50 μg/dL
Elektrofoesis Hb
Normal Normal Hb A2meningkat
IRON DEFICIENCY ANEMIA
The anaemia of iron deficiency is caused by defective synthesis of haemoglobin, resulting in red cells that are smaller than normal (microcytic) and contain reduced amounts of haemoglobin (hypochromic).
Iron deficiency anemia
Nail changes in iron deficiency anaemia
ANGULAR CHEILITIS AND SMOOTH TONGUE IN IRON DEFICIENCY
Investigation of iron deficiency anaemia
CAUSES OF IRON DEFICIENCY ANEMIA
Causes of iron deficiency anemiaReproductive system : menorrhagiaGastrointestinal tract :Bleeding : Oesophagitis, Oesophageal varises, Hiatus hernia, peptic ulcer, Inflammatory bowel disease, Haemorrhoids, Carcinoma stomach and colorectalMalabsorption : Coeliac disease, Atrophic gastritis, gastrectomy, chronic diarrheaPhysiological : Growth spurts, pregnancy (increased iron needs)Dietary : vegans, elderly (inadequate dietary iron intake)
Wordwide commonest cause of iron deficiency is hookworm infection
Risk factors in iron deficiency
Prevalence of anaemia
Diagnostics:Iron levels Total iron-binding capacity (TIBC)Serum Ferritin
Diagnostic of Iron Deficiency anemia
MedicationsMedications:Iron supplements, oral or parenteralVit. C
Adverse reactions to therapeutic doses of iron are primarily gastrointestinal in nature and consist of a dark discoloration of feces, constipation or diarrhea, nausea, and vomiting
Gastrointestinal side effects are usually dose-related Patients most likely to experience adverse effects
with iron dextran include individuals with a history of allergies, asthma, or inflammatory diseases.
Iron sucrose injection should not be administered concomitantly with oral iron preparations, as it will reduce the absorption of oral iron and adverse effects include leg cramps and hypotension
Adverse reactions to therapeutic doses of iron
Many patients must take their iron with food, as they experience nausea and diarrhea when iron is administered on an empty stomach
Iron should be preferably administered at least 1 hour prior to meals, as food interferes with its absorption
A positive response to a trial of oral iron therapy would result in a modest reticulocytosis in 5 to 7 days, with an increase in Hgb at a rate of about 2 to 4 g/dL every 3 weeks until Hgb is normalized.
Evaluation of therapeutic outcome
Evaluation of therapeutic outcome
Patients with negative iron balances caused by bleeding may require iron replacement therapy for only 1 month after correction of the underlying lesion, whereas patients with recurrent negative balances may require long-term treatment. This latter group may require as little as 30 to 60 mg of elemental iron daily.Patients receiving regular IV iron should be
monitored for clinical or laboratory evidence of iron toxicity or overload. .Iron overload may be indicated by abnormal liver
function tests, serum ferritin greater than 800 ng/mL or a transferrin saturation greater than 50%
MEGALOBLASTIC ANEMIA
Megaloblastic anemia is a common disorder that may have several etiologies :Anemia associated with vit B12 deficiencyAnemia associated with folic acid deficiency
Megaloblastic anemias
CAUSES OF MEGALOBASTIC ANEMIA
Vit B12 and folic acid are both necessary for nucleic acid precursor used for DNA synthesis
DHF, dihydrofolate; 5-MTHF,5-methyl-tetrahydrofolate; 5,10-MTHF, 5,10-methyl tetrahydrofolate THF; THF, tetrahydrofolate
Vitamin B 12 deficiency may also result from overgrowth of bacteria in the bowel that utilizes vitamin B 12 ,or from injury or removal of ileal receptor sites where vitamin B 12 and the intrinsic factor complex are absorbed.
COMPARISON OF FEATURES OF VITAMIN B12 AND FOLIC ACIDDEFICIENCY STATES
Causes of megaloblastic anemia
Clinical features include pallor and jaundice. The onset is gradual, and a severely anaemic patient may present in congestive heart failure or only when an infection supervenes.
The blood film shows oval macrocytes and hypersegmented neutrophil nuclei (with six or more lobes). In severe cases, the white cell count and platelet count also fall (pancytopenia).
The bone marrow shows characteristic megaloblastic, erythroblasts and giant metamyelocytes
there is an increase in plasma of unconjugated bilirubin and serum lactic Dehydrogenase and presence in urine of haemosiderin.
The clinical features of megaloblastic anemia
Diagnostics:Schilling test (Urinating 8 - 40%
of the radioactive vitamin B12 within 24 hours is normal)
Medications:Vit. B12 parenteral
Vit. B12 deficiency anemia
Inadequate intake: Chronically malnourished Older adults Alcoholics Drug addicted persons
Increased need: Pregnant women: neural tube defects in fetus Persons experiencing rapid growth Malabsorption disorders: Celiac sprue Persons taking methotrexate and other
chemotherapy
Folic acid deficiency anemia
Good sources of folic acid
medicationsFolate deficiency is treated with folic acid, usually 5 mg daily orally for four months
HEMOLYTIC ANEMIA
Hemolytic anemia results from decreased survival time of RBCs secondary to destruction in the spleen or circulation.
Causes of hemolytic anemia in the younger patient differ from those in the elderly patient.
Most younger patients exhibit congenital disease, whereas older patients most often experience autoimmune hemolytic anemia .
Hemolytic anemia
Common Classes of Hemolytic Anemias
Causes: Mechanical trauma to RBC: prosthetic heart
valves Autoimmune disorders Bacterial or protozoan infection Immune system-mediated responses drugs, toxins, chemical agents
Manifestations: Anemia splenomegaly, jaundice, pathologic fractures
Acquired hemolytic anemia
Therapy for hemolytic anemia consists of managing the underlying cause of the anemia.
Steroids and other immunosuppressive agents have been used for management of autoimmune hemolytic anemias.
In some instances, a splenectomy is indicated in an attempt to reduce RBC destruction.
Treatment
THE HEREDITARY ANEMIA
Hereditary anaemias include disorders of the structure or synthesis of haemoglobin; deficiencies of enzymes that provide the red cell with energy or protect it from chemical damage; and abnormalities of the proteins of the red cell’s membrane.
The hereditary anemia
The structure of human haemoglobin (Hb) changes during development
Simplified representation of the genetic control of human haemoglobin. Because chains are shared by both fetal and adult Hb, mutations of the globin genes affect Hb production in both fetal and adult life; diseases that are due to defective globin production are only manifest after birth when Hb A replace Hb F
Normal Adult Blood
α2β2 = Hgb A (97%)α2δ2 = Hgb A2 (2%)α2γ2 = Hgb F (<1%)
http://sickle.bwh.harvard.edu/hbsynthesis.html
Haemoglobin structure
Haem consists of a protoporphyrin ring with an iron atom at its centre.
The protoporphyrin ring consists of four pyrrole groups which are united by methane bridges (=C-).
The hydrogen atoms in the pyrrole groups are replaced by four methylene (CH3-), two vinyl (-C=CH2) and two propionic acid (-CH2-CH2-COOH) groups.
There are mainly two types of abnormalities, these are :
Quantitative abnormalities: where there is reduction in the production of certain types of globins e.g. a thalassaemia
b thalassaemia Qualitative abnormalities: where there is
production of abnormal haemoglobin e.g. sickle cell anaemia.
Haemoglobin abnormalities
What Is Sickle Cell Disease? An inherited disease of red blood cells Affects hemoglobin Polymerization of hemoglobin leads to a
cascade of effects decreasing blood flow Tissue hypoxia causes acute and chronic
damage
Pathophysiology Inheritance of mutated hemoglobin β-globin chain Mutation GAG GTG at 6th codon Glutamic acid Valine at 6th AA α2βS = heterozygote = Sickle trait α2S2 = homozygote recessive = Sickle cell disease
Pathophysiology
1. Deoxygenation HgbS protein conformational change
2. Hydrophobic Valine exposed at molecular surface
3. Val6 of B2 chain of 1st Hgb S chain forms hydrophobic bond with Phe85 and Leu88 of a 2nd Hgb S B1 chain
4. Pairing Hgb S monomers polymerize to form Hgb S chains
5. Hgb S polymers precipitate in RBCs as long, rigid fibers
Sickling Mechanism
Wood AJ. NEJM, 340(13): 1021-1030, 1999.
Why Do Cells Sickle?
Glutamic acid is substituted for valine
Allowing the polymerization of sickle hemoglobin when deoxygenated
The origin of the disease is a small change in the protein
hemoglobin
The change in cell structure arises from a change in the structure of hemoglobin.
A single change in an amino acid causes hemoglobin to aggregate.
Normal Vs. Sickle Red Cells
Normal Disc-Shaped Deformable Life span of 120
days
Sickle Sickle-Shaped Rigid Lives for 20 days
or less
The function of hemoglobin is to carry oxygen
Biswal, B. K., Vijayan, M.: Structures of Human Oxy-and Deoxyhaemoglobin at Different Levels of Humidity: Variability in the T State Acta Crystallogr., Sect.D 58 pp. 1155 (2002)
Hemoglobin A
Normal hemoglobin hasfour subunits that eachcontain an oxygen bindingsite.
The origin of sickle cell anemia is a mutation in hemoglobin
Padlan, E. A., Love, W. E.: Refined crystal structure of deoxyhemoglobin S. I. Restrained least-squares refinement at 3.0-Å resolution. J Biol Chem 260 pp. 8272 (1985)
Hemoglobin S
A single mutation in hemoglobin results in abinding of one proteinto another.
Hemoglobin is a carrier protein
Lungs Tissues
O2
CO2
HbO2
deoxy Hb (CO2)
Hemoglobin changes structure for efficient oxygen uptake and delivery
HbO2
deoxy Hb (CO2)
Strong binding state R state
Weak binding state T state
The small change in hemoglobin structure leads to aggregation
Normal hemoglobin (Hb A) Sickle cell hemoglobin (Hb S)
ab
Subunits
Sickle Cells
Inheritance of Sickle Cell Anemia
If one parent has sickle cell trait (HbAS) and the
other does not carry the sickle
hemoglobin at all (HbAA) then none of the children will have
sickle cell anemia. There is a one in two (50%) chance that any given child will get one copy of the HbAS gene and therefore have the
sickle cell trait. It is equally likely that
any given child will get two HbAA genes and
be completely unaffected.
Source from http://www.sicklecellsociety.org/education/inherit.htm#anchor298279
Inheritance of Sickle Cell Anemia
If both parents have sickle cell trait (HbAS)
there is a one in four (25%) chance that any given child
could be born with sickle cell anemia.
There is also a one in four chance that any given child
could be completely unaffected.
There is a one in two (50%) chance that any given child will get the sickle cell trait.
Source from http://www.sicklecellsociety.org/education/inherit.htm#anchor298279
Inheritance of Sickle Cell Anemia
If one parent has sickle cell trait
(HbAS) and the other has sickle cell
anaemia (HbSS) there is a one in two (50%) chance that any given
child will get sickle cell trait and a one in two (50%) chance that any
given child will get sickle cell anemia.
No children will be completely unaffected.
Source from http://www.sicklecellsociety.org/education/inherit.htm#anchor298279
Inheritance of Sickle Cell Anemia
If one parent has sickle cell anaemia (HbSS) and the other is completely unaffected (HbAA) then
all the children will have sickle cell trait.
None will have sickle cell anemia.
The parent who has sickle cell anemia (HbSS) can only pass the sickle hemoglobin
gene to each of their children.
Source from http://www.sicklecellsociety.org/education/inherit.htm#anchor298279
Screening Hemoglobin Electrophoresis: Once blood has been drawn, an blood
analysis is performed to determine the concentration of different hemoglobin molecules as percentages of the total hemoglobin count.
Normal Levels: Hgb A1: 95% to 98%
Hgb A2: 2% to 3% Hgb F: 0.8% to 2%
Hgb S: 0% Hgb C: 0%
Sickle-Cell Test: In this test, blood is extracted to determine if an individual possesses abnormal hemoglobin, labeling them either carriers (sickle-cell trait individuals) or affected (sickle-cell anemia individuals).
Complete Blood Count Test: Patients are screened for blood-cell counts, sizes, concentration, and hemoglobin content.
Manifestations: pallor, fatigue, jaundice, irritability Painful swelling hands and feet, large joints,
abdominal pain, stroke Aplastic anemia Blood pools in liver and spleen
Sickle cell crises
Complication of Sickle Cell Anemia
Hand-Food Syndrome
Splenic Crisis Infections Acute Chest
Syndrome Delayed growth
and puberty in children
Stroke Eye problem
Priapism Gallstone Ulcers on the legs Pulmonary Arterial
Hypertension (High blood pressure)
Multiple Organ Failure
Sickle Cell Disease
Health MaintenanceAnd
Management
Management Health maintenance Infection prevention Pain management Sickle emergencies Chronic disease management
Health Maintenance
Frequent visits: every 3 to 6 months Immunizations
◦ Routine immunizations◦ Hib- 6 months and older◦ 23 valent Pneumovax at five years
Penicillin prophylaxis beginning no later than two months
Nutrition and fluids◦ Folate supplementation is controversial
Health Maintenance Physical exam with attention to:
◦ Growth and development, jaundice, liver/spleen size, heart murmur of anemia, malocclusion from increased bone marrow activity, delayed puberty
Lab evaluations: ◦ CBC with differential and reticulocyte count,
urinalysis, renal & liver function
Treat precipitating factors
Folic acid supplementation
Blood transfusionsGenetic counseling
Interventions
New Treatments and Medicines Bone marrow transplants Gene therapy New medicine
◦ Butyric acid. This is a food additive that may increase normal hemoglobin in the blood.
◦ Clotrimazole. This is used now to treat fungus infections. This medicine helps prevent the loss of water from a red blood cell and can keep the cell from turning into a sickle cell.
◦ Nitric oxide. This may make sickle cells less sticky and keep blood vessels open. People with sickle cell anemia have low levels of nitric acid in their blood.
Prevention Identify what can trigger the
“Crisis” such as stress, avoid extremes of heat and cold weather, don’t travel airplane that is not cabin pressurized
Maintain healthy lifestyle habits
Eating healthy Avoid dehydration Exercise regularly Get enough sleep and rest Avoid alcohol and don’t smoke
Regular medical checkups and treatment are important
Treatment
Treatments For Splenic Sequestion Intravenous fluids
◦ Maintain vascular volume
Cautious blood transfusion◦ Treat anemia,
sequestered blood can be released from spleen
Spleen removal or splenectomy◦ If indicated
Pain Management
Mild-moderate pain Acetaminophen
◦ Hepatotoxic Non-steroidal anti-inflammatory
agents (NSAIDs)-Contraindicated in patients with gastritis/ulcers and renal failure -Monitor renal function if used chronically
Pain Management Moderate-severe pain
◦ Opioids are first-line treatment◦ Morphine sulfate or hydromorphone
Moderate or less severe pain◦ Acetaminophen or NSAID's in combination with
opioids◦ Other adjuvant medications (sedatives,
anxiolytics) May increase efficacy of analgesics
THALASEMIA
Genetic blood disorder resulting in a mutation or deletion of the genes that control globin production.
Normal hemoglobin is composed of 2 alpha and 2 beta globins
Mutations in a given globin gene can cause a decrease in production of that globin, resulting in deficiency
2 types of thalassemia: alpha and beta.Manifestations: Minor: asymptomatic; mild anemia,
splenomegaly, bronze skin, bone marrow hyperplasia
Major: severe anemia, heart failure, liver and spleen enlargement; fractures of long bones, ribs, vertebrae
What is thalassemia?
Pathophysiology of –Thalassemia/Hb E Disease
Thalasemia is hereditary disesase
mutation of 1 or more of the 4 alpha globin genes on chromosome 16
severity of disease depends on number of genes affected
results in an excess of beta globins
Alpha Thalassemia
Pathophysiology of α thalasemia
Result from gene deletions One deletion—Silent carrier; no clinical
significance Two deletions—a Thal trait; mild
hypochromic microcytic anemia Three deletions—Hgb H; variable
severity, but less severe than Beta Thal Major
Four deletions—Bart’s Hgb; Hydrops Fetalis; In Utero or early neonatal death
Alpha Thalassemias
• Normal / • Silent carrier - / • Minor -/-
--/• Hb H disease --/-• Barts hydrops fetalis --/--
Classification & TerminologyAlpha Thalassemia
1 functional globin gene results in very lightly coloured red blood
cells and possible severe anemia hemoglobin H is susceptible to oxidation,
therefore oxidant drugs and foods are avoided
treated with folate to aid blood cell production
Hemoglobin H Disease
Usually no treatment indicated 4 deletions incompatible with life 3 or fewer deletions have only mild anemia
Alpha Thalassemias
mutations on chromosome 11 Disease results in an overproduction of a-globin
chains, which precipitate in the cells and cause splenic sequestration of RBCs......(results in excess of alpha globins)
Severity depends on where the hit(s) lie◦ b0-no b-globin synthesis; ◦ b+ reduced synthesis
Erythropoiesis increases, sometimes becomes extramedullary
Beta Thalassemia
• Normal /• Minor /0
/+
• Intermedia 0/+
• Major 0/0
+/+
Classification & Terminology Beta Thalassemia
b-Thalassemia Minor◦ Minor point mutation◦ Minimal anemia; no treatment indicated
b-Thalassemia Intermedia◦ Homozygous minor point mutation or more severe
heterozygote◦ Can be a spectrum; most often do not require
chronic transfusions b-Thalassemia Major-Cooley’s Anemia
◦ Severe gene mutations◦ Need careful observation and intensive treatment
b-Thal--Clinical
It is characterize by severe anemia that can begin months after birth
Paleness Delays in growth and development Bone marrow expansion. Untreated Beta Thalassemia major can lead
to child death due to heart failure.
Symptoms of Beta Thalassemia
Beta Thalassemia Trait
lack of beta globin is more significant bony deformities due to bone marrow trying
to make more blood cells to replace defective ones
causes late development, exercise intolerance, and high levels of iron in blood due to reabsorption in the GI tract
if unable to maintain hemoglobin levels between 6 gm/dl – 7 gm/dl, transfusion or splenectomy is recommended
Beta Thalassemia Intermedia
complete absence of beta globin enlarged spleen, lightly coloured blood cells severe anemia chronic transfusions required, in conjunction
with chelation therapy to reduce iron (desferoxamine)
Beta Thalassemia Major
Reduced or nonexistent production of b-globin◦ Poor oxygen-carrying capacity of RBCs
Failure to thrive, poor brain development◦ Increased alpha globin production and precipitation
RBC precursors are destroyed within the marrow Increased splenic destruction of dysfunctional
RBCs◦ Anemia, jaundice, splenomegaly
Hyperplastic Bone Marrow◦ Ineffective erythropoiesis—RBC precursors
destroyed Poor bone growth, bone pain
◦ Increase in extramedullary erythropoiesis Iron overload—increased absorption and
transfusions◦ Endocrine disorders, Cardiomyopathy, Liver failure
Beta Thalassemia Major
Hypochromic, microcytic anemia◦ nucleated RBCs, anisocytosis
Reticulocytosis Hemoglobin electrophoresis shows
◦ Increased Hgb A2—delta globin production◦ Increased Hgb F—gamma globin production
Hyperbilirubinemia LFT abnormalities (late finding) TFT abnormalities, hyperglycemia (late
endocrine findings)
b-Thalassemia Major—Lab findings
Chronic Transfusion Therapy◦ Maximizes growth and development◦ Suppresses the patient’s own ineffective erythropoiesis and
excessive dietary iron absorption ◦ PRBC transfusions often monthly to maintain Hgb 10-12
Chelation Therapy◦ Binds free iron and reduces hemosiderin deposits◦ 8-hour subcutaneous infusion of deferoxamine, 5
nights/week or deferasirox 1x1◦ Start after 1year of chronic transfusions or ferritin>1000
ng/dl Splenectomy—indications
◦ PRBCs per year >250cc/kg◦ Severe leukopenia or thrombocytopenia◦ hipersplenomegali
Folic acid
b-Thalassemia Major--Treatment
Blood Transfusion0.3-0.5 mg iron/kg/day
In a 50kg person
15-25 mg/day
Iron Excretion(Urine & Feces)
1-2mg/day
IronAccumulation13-24 mg/day
Iron Accumulation in Transfusion-dependent Anemias
Hepatic Fibrosis --> Cirrhosis
Cardiac arrhythmia
Hypogonadism
Diabetes
Hypothyroidism
Hypoparathyroidism
Cardiac Failure
0
20
40
60
80
100
120
1 3 5 7 9 11 13 15 17 19
Age (years)
Iro
n (
g)
Tran
sfusi
onal
Iron Death
Transfusional Iron Overload in Thalassemia
Goals of iron chelation therapy Maintain iron balance/induce negative iron balance
Avoid accumulation of redox-active iron
Prevent/reverse organ dysfunction
Prolong survival
Avoid chelator toxicity
Maximise adherence to prescribed therapy
Maximize quality of life
Comparison of Currently Available Iron Chelators
Licensed
Licensed outside US/Canada
(approved in 46 countries)
LicensedStatus
FaecalUrinaryUrinary, faecalExcretion
12-16 hr3-4 hr20-30 minHalf-life
Oral (Once daily)
Oral(3 times daily)
SC, IV (8-12 hr, 5 d/wk)
Route
20-307525-60Usual dose(mg/kg/d)
DeferasiroxDeferiproneDesferrioxamineProperty
Chelators for managing iron overload
Chelator Advantages DisadvantagesDesferrioxamine 4 decades experience Parenteral route
Survival advantage Compliance problemsHeart failure prevented Dose dependent
toxicityHeart failure reversed -eye, ear, bone
Deferiprone Oral administration 3 x/day x7/weekCardiac protection Short plasma t 1/2
Unreliable control of body iron
AgranulocytosisArthropathyZinc deficiency
Deferasirox Oral administration Short clinical experience
Long plasma t1/2 Cardiac protection unknown
1/day administration Changes in creatinineControl of body iron
DESFERRIOXAMINE
Dose Schedule:
Ferriprox:70-80
mg/kg/d,7 days/week
Desferal:20-50 mg/kg/d,
2-6 days/week
DFO Desferrioxamine 20-50 mg/kg/day DFP Deferiprone 75-100 mg/kg/day DFX Deferasirox 20-30 mg/kg/day
Effects of Iron Chelators on Ferritin
MDS: myelodysplasticsyndrome; SCD: sickle cell disease.
Deferasirox 5 10 20 30Doses (mg/kg/day)
-1500
-1000
-500
0
500
1000
1500
2000
2500
Mean
Ch
an
ge in
Seru
m
Ferr
itin
(µg
/L)
SCD β-thalassaemia, MDS, other rare anaemias
β-thalassaemia
Desferrioxamine, deferiprone, and deferasiroxall decrease ferritin
Deferasiroxshown to maintain and reduce serum ferritinlevels in phase 2/3 clinical trials in adult and paediatricpatients (12 -month efficacy—serum ferritin )
Adverse events: Deferasirox
• GI events (15.2%): abdominal pain, nausea and vomiting, diarrhea, constipation
• Skin rash (10.8%)
• Mild, non progressive increases in serum creatinine. No reports of renal failure
• Increased transaminases (>5x ULN) in 5.7% Drug-induced hepatitis: Two cases both leading to discontinuation of Exjade
• Adverse effects on the ear/eye appear to be similar in frequency to those seen with DFO
Effects of Iron Chelators on Heart: Desferrioxamine(DFO) and Deferiprone (DFP)
MRI-T2*-LVEF
DFP more effective in reducing cardiac iron (27% vs 13%; P = .023) and increasing LVEF
(3.1% vs 0.3%; P= .003) than DFO3129Pennellet al.6
Clinical9/532 patients died of heart failure–532Ceciet al.5
Clinical-survival
5-year cardiac disease-free survival higher with DFP than DFO (P< .003)7554Pigaet al.1
MRI-T2*-LVEF
DFP is more effective than DFO in reducing cardiac iron
3015Anderson et al.2
MRI-ISRSimilar decrease in cardiac iron with
each drug7371Maggioet al.3
Clinical4/51 patients died of cardiac causes–51Hoffbrandet al.4
3,610*
DFO (n)
52 cardiac events on DFO; 0 on DFP
Data
Borgna-Pignattiet al.7
Author
Clinical750*
Estimated by
DFP (n)
*Patient-years. 1. PigaA et al. Haematologica. 2003;88:489.2. AndersonLJ et al. Lancet. 2002;360:516. 3. MaggioA et al. Blood Cells Mol Dis. 2002;28:196. 4. HoffbrandAV et al. Blood. 1998;91:295. 5. Ceci A et al. Br J Haematol. 2002;118:330. 6. Pennell DJ et al. Blood.
2006;107:3738. 7. Borgna-Pignatti C et al. Blood. 2006;107:3733.
Sepsis—Encapsulated organisms◦ Strep Pneumo
Cardiomyopathy—presentation in CHF◦ Use diuretics, digoxin, and deferoxamine
Endocrinopathies—presentation in DKA◦ Take care during hydration so as not to
precipitate CHF from fluid overload
b-Thalassemia Major Complications and Emergencies
Immunizations—Hepatitis B, Pneumovax Follow for signs of diabetes, hypothyroid,
gonadotropin deficiency Follow for signs of cardiomyopathy or
CHF Follow for signs of hepatic dysfunction Osteoporosis prevention
◦ Diet, exercise◦ Hormone supplementation◦ Osteoclast-inhibiting medications
Follow ferritin levels
Anticipatory Guidance and Follow Up
Family study Genetic counselling Prenatal diagnosis
Prevention
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