Effects of iron overload and hepatitis C virus positivity in determining progression of liver fibrosis in thalassemia following bone marrow transplantation

Abstract

To identify the role of iron overload in the natural history of liver fibrosis, we reviewed serial hepatic biopsy specimens taken annually from patients cured of thalassemia major by bone marrow transplantation. The patients underwent transplantation between 1983 and 1989 and did not receive any chelation or antiviral therapy. Two hundred eleven patients (mean age, 8.7 ؎ 4 years) were evaluated for a median follow-up of 64 months (interquartile range, 43-98 months) by a median number of 5 (interquartile range, 3-6) biopsy samples per patient. Hepatic iron concentration was stratified by tertiles (lower, 0.5-5.6 mg/g; medium, 5.7-12.7 mg/g; upper, 12.8-40.6 mg/g dry weight). Forty-six (22%) patients showed signs of liver fibrosis progression; the median time to progression was 51 months (interquartile range, 36-83 months). In a multivariate Cox proportional hazard model, the risk for fibrosis progression correlated to medium hepatic iron content (hazard rate, 1.9; 95% confidence interval [CI], 0.74-5.0), high hepatic iron content (hazard rate, 8.7; 95% CI, 3.6-21.0) and hepatitis C virus (HCV) infection (hazard rate, 3.1; 95% CI, 1.5-6.5). A striking increase in the risk for progression was found in the presence of both risk factors. None of the HCV-negative patients with hepatic iron content lower than 16 mg/g dry weight showed fibrosis progression, whereas all the HCV-positive patients with hepatic iron concentration greater than 22 mg/g dry weight had fibrosis progression in a minimum follow-up of 4 years. Thus, iron overload and HCV infection are independent risk factors for liver fibrosis progression, and their concomitant presence results in a striking increase in risk. IntroductionLiver fibrosis and cirrhosis are well-known complications of thalassemia, but no data are available on the risk for and rate of fibrosis progression in this disease or other posttransfusional iron overload conditions.A bone marrow transplantation (BMT) program 1 for thalassemia has been operational in Pesaro, Italy since 1983. At that time there was no knowledge of the effect of iron overload and chelation therapy after BMT; therefore, watchful waiting through periodic percutaneous liver biopsy was established for all patients cured of thalassemia by BMT. These patients were affected by iron overload but did not receive any chelation therapy. Before entering an effective iron reduction program, they had stable liver iron levels and represented unique model group to study the natural history of liver fibrosis in this condition. Thus, all the hepatic biopsies performed during this watchful waiting program have been blindly re-evaluated to assess the risk for and the rate of fibrosis progression. Patients and methods Study populationPatients cured of thalassemia by BMT in Pesaro took part in a watchful waiting program based on yearly liver biopsy to monitor unanticipated complications of marrow transplantation and iron overload. All these patients had received unmodified bone marrow from an HLA-identical related donor. All but 4 we...

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