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Depletion of Trace Elements and Acute Ocular Toxicity Induced by Desferrioxamine in Patients with Thalassaemia

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Depletion of Trace Elements and Acute Ocular Toxicity Induced by Desferrioxamine in Patients with Thalassaemia Arch Dis Child: first published as 10.1136/adc.63.3.250 on 1 March 1988. Downloaded from Archives of Disease in Childhood, 1988, 63, 250-255 Depletion of trace elements and acute ocular toxicity induced by desferrioxamine in patients with thalassaemia S DE VIRGILIIS, M CONGIA, M P TURCO, F FRAU, C DESSI, F ARGIOLU, R SORCINELLI,* A SITZIA,* AND A CAO Istituto di Clinica e Biologia dell Eta' Evolutiva, Universita' Studi Cagliari, and *Istituto di Clinica Oculistica, Universita' Studi Cagliari, Cagliari, Sardinia, Italy SUMMARY High doses of intravenous desferrioxamine infused over a short period of time induce a large faecal and urinary iron excretion but also produce retinal abnormalities that are characterised by decreased amplitude on electroretinography and defective dark adaptation. This regimen also results in high faecal iron, zinc, and copper excretion, and reduced granulocyte zinc concentrations and alkaline phosphatase activity. The retinal abnormalities may be related to the zinc and copper deficiency and/or iron depletion 'per se' which interferes negatively with critical iron dependent enzymes. Subcutaneous infusion of desferrioxamine is the comply with the regimen of subcutaneous adminis- most efficient method for reducing the iron burden tration. in patients with thalassaemia major who are trans- fusion dependent.1 The daily infusion of 40- Patients and methods 60 mg/kg over 12 hours for six days a week is usually sufficient to obtain iron balance.'v Because some Fifteen children, aged from 9 to 16 years, with http://adc.bmj.com/ patients fail to comply with this regimen the addi- transfusion dependent thalassaemia major and tional administration of large doses by intravenous moderate iron overload (serum ferritin concentra- infusion has been proposed.3 High doses of desferri- tions from 1100 to 2000 [tg/l), because of low oxamine, either by intravenous or subcutaneous compliance with daily infusion of subcutaneous administration, however, may result in optic neuro- desferrioxamine, were treated by a combination of pathy or high frequency sensorineural hearing loss, traditional daily subcutaneous infusion and monthly or both.7 8 Likewise, in rabbits anaesthetised with intravenous administration of very large doses on October 1, 2021 by guest. Protected copyright. urethane, the intravenous infusion of large doses of according to a previously published scheme.11 Each desferrioxamine produced a reversible reduction in patient was treated for 10 consecutive months but the amplitude of the electroretinogram.9 Toxic the balance study (see later) was carried out only concentrations are probably reached when the dose once. of desferrioxamine administered is disproportion- The dose of desferrioxamine for subcutaneous ately high in relation to the amount of iron available infusion was 40-60 mg/kg over a period of 12 hours for chelation. In these conditions desferrioxamine each night for six days a week. The intravenous may chelate critical trace elements such as copper infusion was given over a period of 24 hours at the and zinc,10 the depletion of these elements may be dosage of 10-12 g (200-450 mg/kg) dissolved in responsible for the neurotoxic effect of the drug. 750 ml of 5% glucose solution. Urinary and faecal In this study we monitored the development of iron concentrations, zinc and copper excretion, ocular abnormalities and possible zinc or copper serum zinc pattern, leukocyte zinc concentrations, depletion, or both, in a group of patients with and alkaline phosphatase activities were analysed thalassaemia major who were chelated with des- only once, as detailed later, before and after ferrioxamine by a combination of traditional daily the infusion of intravenous desferrioxamine when subcutaneous infusion and monthly intravenous we introduced the combination of both intravenous administration of large doses because of failure to and subcutaneous administration. 250 Arch Dis Child: first published as 10.1136/adc.63.3.250 on 1 March 1988. Downloaded from Depletion of trace elements and acute ocular toxicity in patients with thalassaemia 251 Ophthalmic evaluation was also carried out use, all glassware and plastic containers were acid before and after the termination of the infusion, but washed in 1-0 N hydrochloric acid for 30 minutes this assessment was repeated from two to three and rinsed six times in deionised water. times at times of successive intravenous infusion and Blood samples from peripheral veins were col- again one, two, and three months after we inter- lected with plastic syringes and stainless steel rupted the intravenous infusions while continuing needles and put into plastic tubes. Serum and the subcutaneous administration. granulocyte zinc concentrations and granulocyte alkaline phosphatase activity were measured in OPHTHALMOLOGIC ASSESSMENT samples taken before and at the end of the The ophthalmic assessment included determina- intravenous infusion as well as one month later. tion of the best corrected visual acuity by standard Basal iron, zinc, and copper excretion were methods, pupillary reaction, ocular motility, slit evaluated in urine and faeces collected for three lamp examination for changes in the anterior days before the infusion of desferrioxamine. The segment, and visual field measurement on a cali- effect of this infusion was determined by measuring brated Goldman kinetic perimeter with light inten- these elements in the urine and faeces collected on sity regulated at 31-5 apostilb. A decrease above the day of the infusion as well as three days after. 20% in the average peripheral extent of the field in During this study period the subcutaneous infusion at least two quadrants was considered abnormal. was interrupted. Adapted electroretinograms were obtained accord- An aliquot of the preinfusion and postinfusion ing to Babel12 with flashes of white light of constant urinary pools was prepared and frozen for further colour range and intensity of 2 joule, 1 hertz/second analysis. The faeces were homogenised with a at 30 cm from ocular plane (Pantops 200-Ferlux known amount of deionised water. An aliquot was Instruments). The amplitudes of the response were removed and dried at 100°C overnight and then considered abnormal when the value was decreased ashed in a muffle furnace at 550°C and left over- more than 20% from normal values (190 (SD15) ,uV). night. The resultant ash was dissolved with 10% During dark adaptation, after a preliminary light hydrochloric acid, transferred to a volumetric flask, adaptation, we noted the stage at which the ampli- and made up to volume with demineralised water. tude of the slow scotopic positive wave (the scotopic Serum, urinary, and faecal iron, zinc, and copper components of the electroretinogram are mainly due were determined by atomic absorption (IL 551 to the activity of the rods in dark adaptation) Spectrophotometer). Granulocyte alkaline phos- reached that of the photopic component. This is phatase activity was assayed with p-nitrophenyl- referred to as the 'transition phenomenon,' which is phosphate as substrate according to It-Koon and http://adc.bmj.com/ a valuable sign for the judgment of the scotopic Moss.14 Granulocytes were separated from the function. 13 other blood cells according to Boyum.'5 The speci- mens used for the analysis contained a percentage of METABOLIC STUDIES granulocytes varying from 90 to 100%. Statistical In order to carry out copper, zinc, and iron balance analysis was carried out by Student's paired t test. studies each patient was admitted to the hospital for a week. With the aim of eliminating any residual Results on October 1, 2021 by guest. Protected copyright. effect of the subcutaneous infusion the day before admission the daily infusion of subcutaneous des- OPHTHALMOLOGIC EVALUATION ferrioxamine was interrupted. While in the hospital Visual acuity and average field size were normal in the patients were on a strict controlled diet con- all subjects. No isolated field defect (scotomata) or taining roughly 8-10 mg/day iron, 0-1 mg copper/kg enlargement of the blind spot were detected. body weight, and 0-3-0-4 mg zinc/kg body weight. Fundoscopy showed no pigment abnormalities, Diet and collection of the urine and stool were focal lesions, macular oedema, or unusual vascular carefully controlled by nurses who were specifically patterns. In three patients the electroretinograms instructed to avoid any faecal contamination with showed a decreased amplitude before and at the urine. Collection periods of stools were defined by. end of the desferrioxamine infusions as well as at administering radio-opaque markers. follow up examinations carried out at one, two, and Precautions against environmental contamination three months later. Seven patients, who had a were taken for all diet, blood, urine, and stool normal electroretinogram before the infusion, collections and analyses. Specimens were stored showed a decreased amplitude at the evaluation only in plastic containers and only low mineral carried out when the infusion was terminated. The content water and ultra high purity reagents were same pattern was recorded at least twice at each used in sample and standards preparation; before successive infusion. In these subjects a normal Arch Dis Child: first published as 10.1136/adc.63.3.250 on 1 March 1988. Downloaded from 252 De Virgiliis, Congia, Turco, Frau, Dessi, Argiolu, Sorcinelli, Sitzia, and Cao 240- electroretinogram was seen at follow up examina- tion after the termination of intravenous treatment (fig 1). 200- In the three patients with permanent abnormali- ties shown on their electroretinograms and in six out of the seven with the transient effects we noted 200- when control measurements were taken immedi- ately after infusion of intravenous desferrioxamine a 180- 'transition phenomenon' appeared after 14 to 18 minutes in the dark. In our age matched controls this phenomenon occurred from a minimum of 8 to a 160- maximum of 10 minutes. The remaining five patients did not show any abnormalities of their electroretinograms. 140- METABOLIC STUDIES Fig 2 shows the effeLt of the intravenous infusion of 120- desferrioxamine on serum zinc concentrations.
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