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

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.

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.

None of the 20 patients developed thalassemic facies, splenomegaly or hypersplenism. Sixteen patients maintained a normal weight (above 5^th centile) and height (above 10^thcentile), while 4 patients were at or below the 3^rd 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.

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.

No relevant conflicts of interest to declare.