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The predicting formula and scoring system for cardiac iron overload for thalassaemia children: Study from a middle-income country
A formula and scoring system for cardiac iron overload in thalassemic children
https://orcid.org/0000-0001-9351-0373
Rohimi Syarif Conceptualization Data curation Formal analysis Funding acquisition Investigation Writing – original draft 1 *
Siswanto Bambang Budi Conceptualization Supervision Validation Writing – review & editing 2
https://orcid.org/0000-0002-3100-3269
Mansyur Muchtaruddin Data curation Formal analysis Methodology Writing – review & editing 3
Gatot Djajadiman Resources Supervision Visualization Writing – review & editing 4
Sutanto Ina Data curation Supervision Validation Writing – review & editing 5
Pandelaki Jacub Supervision Validation Visualization 6
https://orcid.org/0000-0001-7898-4570
Soesanto Amiliana M. Validation Visualization Writing – review & editing 2
Ontoseno Teddy Validation Visualization Writing – review & editing 7
1 Rumah Sakit Anak dan Bunda RSAB Harapan Kita, Jakarta, Indonesia
2 Harapan Kita National Cardiac Centre Hospital, Jakarta, Indonesia
3 Department of Community Medicine, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
4 Department of Paediatrics, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
5 Department of Clinical Pathology, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
6 Department of Radiology, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
7 Department of Paediatrics, Faculty of Medicine Universitas Airlangga, Jakarta, Indonesia
Castillo-Navarrete Juan Luis Editor
Universidad de Concepción Facultad de Medicina: Universidad de Concepcion Facultad de Medicina, CHILE
Competing Interests: The authors have declared that no competing interests exist.

* E-mail: syarohmi@yahoo.com
4 9 2024
2024
19 9 e030966328 9 2023
15 8 2024
© 2024 Rohimi et al
2024
Rohimi et al
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Magnetic resonance imaging T2* screening is the gold standard for detecting cardiac iron overload in thalassemia, but its implementation in Indonesia is limited by the high costs. A predicting formula and scoring system based on low-cost investigations is needed. This cross-sectional study was conducted among thalassemia aged 6–18 years at Rumah Sakit Anak dan Bunda RSAB Harapan Kita Indonesia, during October 2017 to April 2019. All subjects were scheduled for clinical examination, laboratory tests, ECGs, echocardiography, tissue Doppler imaging, and MRIT2*. Multivariate logistic regression was used to identify the formula, simplifying to a scoring system, and risk classification for myocardial iron overload using odds ratio (OR) and 95% confidence interval (CI). Significance was set as p<0,05. We recruited 80 children, of those, 8 (10%) were classified as cardiac iron overload based on MRI T2* screening. Multivariate logistic regression showed determinant factors for cardiac iron overload were hemoglobin (95% CI:1.92–369.14), reticulocyte (95% CI:1.14–232.33), mitral deceleration time (DT) (95% CI:1.80–810.62,), and tricuspid regurgitation (TR Vmax) (95% CI:1.87–1942.56) with aOR of 26.65, 14.27, 38.22, and 60.27 respectively. The formula for cardiac iron overload was decided as 9.32 + 3.28 (Hb) + 2.9 (reticulocyte) + 3.64 (DT) + 4.1 (TR Vmax). A scoring system was defined by simplifying the formula of Hb ≤ 8.2 g/L, reticulocyte ≤0.33%, DT ≤ 114.5 cm/s, and TR Vmax ≥ 2.37 m/s were given a score of 1, while others were assigned 0. Total scores of 0 or 1, 2 and 3 or 4 were categorized as low, moderate, and high risk for iron cardiac overload. The cardiac iron overload formula was 9.32 + 3.28 (Hb) + 2.9 (reticulocyte) + 3.64 (DT) + 4.1 (TR Vmax). Variables of Hb ≤ 8.2 g/L, reticulocyte ≤0.33%, DT ≤ 114.5 cm/s, and TR Vmax ≥ 2.37 m/s were given a score of 1, while others were assigned 0. Total scores of 0 or 1, 2, and 3 or 4 were categorized as low, moderate, and high risk for iron cardiac overload.

The author(s) received no specific funding for this work. Data AvailabilityAll relevant data are within the manuscript and its Supporting Information files.
Data Availability

All relevant data are within the manuscript and its Supporting Information files.
==== Body
pmcIntroduction

Thalassaemia is a prevalent genetic disorder, with an incidence rate of 1.4–5 per 1,000 live births. Furthermore, its carriers make up 3% of the global population, with 60,000 symptomatic births occurring every year [1]. Thalassaemia β major is known to cause severe clinical symptoms and morbidity, as well as lead to death [2, 3]. In Indonesia, there has been an increase in the number of thalassaemia patients. In recent years, 9,009 (85.7%) out of 10,515 patients were aged 0–20 years in 2019 [4].

Regular blood transfusions are required to treat thalassemia and might cause iron overload, organ dysfunction, heart failure (HF), cardiac fibrosis, pulmonary hypertension and death [1, 3, 5]. Early detection of cardiac iron overload using magnetic resonance imaging (MRI) T2* can prevent heart failure and death [5]. However, at present, MRI T2* is still limited in Indonesia due to its high cost as well as the lack of scanners required. Therefore, this study aims to develop a formula and scoring system for cardiac iron overload to improve management, prevent death, and increase life expectancy based on low-cost investigations. As far as we are aware, there are no study regarding formula and scoring system on cardiac iron overload for thalassaemia major children in Indonesia.

Materials and methods

This cross sectional study was carried out at Rumah Sakit Anak dan Bunda Harapan Kita, Indonesia, during October 2017 to April 2019. Thalassemia major aged 6–18 years with ferritin levels > 1,000 ng/mL were included. The diagnosis of thalassemia major was based on Hb analysis. The clinical and demographic data included age, sex, age at first diagnosis and chelation, interval between transfusions, and type of chelation therapy were collected. Patients with congenital heart disease or complications unrelated to thalassemia were excluded. Chelation adherence was defined based on the ratio of total drug ingested and drug prescribe per month within the last three months. Nutritional status was determined based on left arm circumference.

All subjects were scheduled for laboratory tests, ECG, left and right cardiac function, tricuspid valve regurgitation (TR Vmax), basal left ventricular and septal myocardial velocity with tissue doppler imaging (TDI) one week before blood transfusion. The laboratory test consisted of hemoglobin (Hb), reticulocyte, immature granulocyte (IG), WBC, platelets, urea, creatinine, AST, ALT, SI, and TIBC measurements [6]. The ECG results were manually assessed. Echocardiography and TDI used Epiq7 and were done according to American Society of Echocardiography and a clinician’s guide to TDI [7, 8]. Echocardiograhy and TDI variables were done 3 time and calculated means. MRI T2* was performed at the Department of Radiology, Cipto Mangunkusumo Hospital and Premier Hospital Jakarta. MRI T2* < 20 ms was classified as cardiac iron overload. All authors had access to information that could identify individual participants during or after data collection.

Ethical clearance was provided by the Ethical Research Committee (Faculty of Medicine University of Indonesia S-996/UN2.F1/ETIK/PPM.00.02/2019). Written informed consent was obtained from the participants’ parents or guardians.

The results of the multivariate logistic regression were presented as an adjusted Odds ratio (aOR) with a 95% confidence interval (CI). Significance was set as p<0,05. Transformation of scoring system and risk classification of myocardial iron overload were also carried out [9].

Results

There were 80 children with thalassemia major living in 3 large provinces in Indonesia, namely Jakarta, Banten, and West Java. The mean age was 12.3±2.82 years old, 39 males (48.8%) and 41 females (51.2%), and no significant differences between the sexes. The mean ferritin level was 3827.78 (1002.46–17.976) ng/mL, where 9 (11.25%), 47 (58.75%), and 24 (30%) patients had values of 1000–2000 ng/mL, 2000–5000 ng/mL, and > 5.000 ng/mL, respectively.

The mean MRI T2* in this study was 32.5 (9.9–46,7) ms, and 8 (10%) of this suffered for cardiac iron overload. The youngest patients affected was 9.7 years old, while the oldest was 16.5 years old respectively.

The diagnosis of thalassemia major was based on Hb analysis, and the age of first diagnosis and transfusion varied widely. Among the samples, 56 (70%) were diagnosed before the age of 1 year.

Based on left arm circumference measument, 29 (33.3%), 24 (27.3%), and 27 (30.7%) patients had good, bad, and poor nutritional statuses, All samples received chelation therapy at 3–6 years with different adherence. A total of 22 (27.5%), 44 (55%), and 14 (17.5%) patients received blood transfusion within 2, 3, and 4-week intervals, respectively as shown in Table 1.

10.1371/journal.pone.0309663.t001 Table 1 Baseline characteristics among children with thalassaemia major.

Variable (n = 80)	Results Means; median (min–max)	
Age (years)	12.3±2.8	
Male: female, n (%)	39 (48.8): 41 (51.2)	
Ferritin (ng/mL)	3827.78 (1002.46–17.976)	
MRI T2* (ms)	32.5 (9.9−46.7)	
Thalassaemia: 46major: β/HbE	65 (81%):13 (16%)	
Left arm circumference (cm)	14.8 (14−24.4)	
Age at first diagnosis (months)	8 (2−108)	
Age at first transfusion (months)	8 (2−108)	
Interval between transfusions (weeks)	2.9 (3–4)	
Age at first chelation therapy (years)	1−8	
Type of chelation therapy: FDN: DFR, n (%)	65 (81.3): 15 (18.7)	
DFN deferiprone; FDR deferiprox; MRI magnetic resonance imaging.

Our study showed proportion children with Hb of < 8 gr/dL was quite high (14%) and 69 (86%) had Hb levels of 8–10 gr/dL. All had normal IG values, with of 8 (10%) had an increase in white blood count (>10,000/uL) and of 14 (14,8%) had hs-CRP > 3 mg/L, with no fever nor signs of infection.

Of 19 (24%) children had reticulocyte > 1.49 and of 12,5% showed. thrombocytopenia, but without a history of bleeding, petechiae, and ecchymosis. There were increasing of AST (>27 u/L), ALT (>23 u/L), SI (>170 uL), and TIBC (>450 uL) in 48 (60%), 47 (58.7%), 33 (41.3%), and 2 (2.5%) patients, respectively. Further total protein, albumin, urea, and creatinine levels were normal.

This study revealed QoTC interval of > 44 ms found in 61 (76.3%) but no abnormal rhythm, P, QRS and T wave, left or right ventricle hypertrophy.

Echocardiography showed that LVDD, EF, and TAPSE were within normal limits. We found left ventricular diastolic dysfunction in 7 (8.75%) mitral E wave >0.70 m/s, 3 (3.8%) E/A ratio, 17 (21.25%) DT <110 m/s, and 4 (5%) TR Vmax >2.8 m/s, respectively.

Tissue Doppler Ecocardiography showed basal LV systolic myocardial velocity dysfunction Sm <6.4 cm/s in 4 (5%), diastolic dysfunction Em <11.1 m/s in 1 (1.3%), and Am <4.3 m/s in 2 (2.5%) children, respectively, and none of them had E/Em ratio > 8. The basal septal systolic myocardial velocity, early diastolic, and late diastolic were within normal at 7.21±0.87 cm/s, 12.44±1.52 cm/s, and 6.19±1.31 cm/s, respectively, as shown in Table 2.

10.1371/journal.pone.0309663.t002 Table 2 Laboratory, ECG, echocardiography and TDI results.

	Variable	Result x±SD; median (min–max)	Normal values	
Laboratory	Hb (g/dL)	9.2±1.1	12.0–16.0	
	White blood count (/uL)	6,090 (2100–21,020)	4,500–13,000	
	Immature Granulocyte	0,07 (0,01–0,63)	≤ 10 y: < 0,30
>10 y: 0,74	
	hs-CRP (mg/L)	0,65 (0–26,2)	< 3 mg/L	
	Platelet (/uL)	220.10 3 (95–672.10 3)	150–450. 10 3	
	Reticulocyte (%)	0.62 (0.11–18)	0.90–1.49	
	AST (u/L)	30 (12–178)	< 27	
	ALT (u/L)	32 (4.2–162)	<23	
	SI (u/L)	150.1±54.12	50–170	
	TIBC (u/L)	180 (99–625)	250–450	
ECG	QoTc interval (ms)	0.45 (0.39–0.63)	>0.44	
Echocardiography	LV Diastolic Dimension cm)	4.25±0.45	4±0.52	
	EF (%)	59.5 (55.1–78.1)	> 55	
	TAPSE (cm)	(2,6±0.46 cm)		
	E wave (m/s)	99.56±14.61	<0.70	
	DT (m/s)	132.9±26.2	< 110	
	TR Vmax (m/s)	2.26 (0.67–3.45)	< 2.8	
TDI	Sm Left Basal Lateral (cm/s)	8.25±1.40	8±2.4	
	Em Left Basal Lateral (cm/s)	17.08±2.65	10.3±2.7	
	E/Em Left Basal Lateral Ratio	5.94±1.03	<8	
	Sm basal septal (cm/s)	7.21±0.87	6.1±1,7	
	Em basal septal (cm/s)	12.44±1.52	10.3±2.7	

The proportion of free variables in myocardium iron overload was assessed by performing a bivariate analysis between free and dependent variables. Receiver Operating Characteristics (ROC) procedure was carried out on all free variables. The results showed that Hb, reticulocyte, AST, ferritin, chelation adherence, DT, and TR Vmax had an AUC of > 0.60 (Table 3).

10.1371/journal.pone.0309663.t003 Table 3 Determination of free variable intersecting point based on ROC curve.

Free variable	Intersecting Point	Sensitivity	Specificity	AUC (CI 95%)	
Hb (g/L)	≤ 8.25	0.86	0.63	0.67 (0.41–0.93)	
Reticulocyte (%)	≤0.33	0.74	0.75	0.74 (0.57–092)	
AST (U/L)	≥36.5	0.75	0.75	0.70 (0.52–0.87)	
Ferritin (ng/dL)	≥5,200	0.75	0.63	0.70 (0.48–0.92)	
Chelation Adherence (%)	≤82	0.75	0.79	0.77 (0.59–0.91)	
DT (cm/s)	≤114.5	0.81	0.63	0.87 (0.79–0.96)	
TR Vmax (m/s)	≥2.37	0.76	0.88	0.82 (0.67–0.96)	

The free variables associated with cardiac iron overload based on the ROC curve included Hb, reticulocyte, AST, ferritin, chelation adherence, DT, and TR Vmax, as shown in Table 4. Further, determinant factors that played an independent role in cardiac iron overload were Hb, reticulocyte, DT, and TR Vmax, as shown in Table 5.

10.1371/journal.pone.0309663.t004 Table 4 Bivariate analysis of free variable, presence of iron overload predictor.

Free Variable	Group	CI 95%	
Variable	Intersecting point	cardiac iron overload (n = 8)	No cardiac iron overload (n = 72)	p-value	OR	MM Min–Max	
Hb (g/dL)	≤8.25	5 (33.30)	10 (66.70)	0.00	10.33	2.13–50.14	
>8.25	3 (4.60)	62 (95.40)			
Reticulocyte (%)	≤0.33	6 (24.00)	19 (76.00)	0.01	8.37	1.56–45.08	
>0.33	2 (3.60)	53 (96.40)			
AST (u/L)	≥36.5	6 (25.00)	18 (75.00)	0.01	9.00	1.67–48.62	
	<36.5	2 (3.60)	54 (96.40)			
Ferritin (ng/dL)	≥5,200	5 (21.70)	18 (78.30)	0.04	5.00	1.09–23.03	
	<5,200	3 (5.30)	54 (94.70)			
Chelation adherence (%)	≤82	6 (28.6)	15 (71.4)	0.00	11.4	2.09–62.3	
>82	2 (3.4)	57 (96.6)			
DT (cm/s)	≤114.5	5 (26,30)	14 (73.70)	0.02	6.91	1.47–32.39	
>114.5	3 (4.90)	58 (95.10)			
TR Vmax (m/s)	≥2.37	7 (29.20)	17 (70.80)	0.00	22.65	2.60–197.31	
<2.37	1 (1.80)	55 (98.20)			

10.1371/journal.pone.0309663.t005 Table 5 Determinant factors for cardiac iron overload.

Variable	B	SE	p-value	aOR	CI 95%	
Min–Max	
Hb	3.28	1.34	0.01	26.65	1.92–369.14	
Reticulocyte	2.79	1.36	0.04	16.27	1.14–232.33	
DT	3.64	1.56	0.02	38.22	1.80–810.62	
TR Vmax	4.10	1.77	0.02	60.27	1.87–1,942.56	
Constant	-9.32	2.90	0.01	0.01		
Adjusted OR variables of Hb, reticulocyte, AST, DT, and TR Vmax

Based on the results, the formula for cardiac iron overload was -9.32 + 3.28 (Hb) + 2.79 (Reticulocyte) + 3 .64 (DT) + 4.10 (TR Vmax). Furthermore, the Hosmer and Lameshow test revealed good calibration with p = 0.52 and as well as a good discriminant value at AUC = 0.96 (CI 95% 0.898–1.000) with Nagelkerke R square of 0.68 (Fig 1).

10.1371/journal.pone.0309663.g001 Fig 1 ROC curve of cardiac iron overload based on formula Y = -9,32 + 3,28 (Hb) +2,79 (retikulosit) + 3,64 (DT) + 4,10 (TR Vmax).

Formula of cardiac iron overload based on scoring system

The formula for assessing cardiac iron overload was simplified and scoring system was defined, where the smallest B/SE result (2.06) was reticulocyte with 1 point. Furthermore, Hb, DT, and TR Vmax variables were simplified by rounding up the values, as 1.19, 1.13 and 1.12 and each variable point were simplified as 1.

On transformation of scoring system for each variable category, the dichotomy value was Hb ≤8.2 g/dL = 1 point and > 8.2 g/dL = 0 point. Reticulocyte ≤0.33% = 1 and >0.33 = 0, DT ≤114.5 cm/s = 1 and >114.5 cm/s = 0, while TR Vmax ≥ 2.37 m/s = 1 point and < 2.37 = 0 point.

The discriminant and calibration scoring model was also assessed and the total variable point was treated as a free variable. Furthermore, the probability scoring system model obtained was Y = -8.76 + 3.25 (total point). Hosmer and Lameshow tests showed good calibration (p = 0.94) and discriminant (AUC = 0.96, 95% CI 0.90–1.00).

Based on scoring system and risk classification for iron cardiac overload, scores of 0 or 1, 2, and 3 or 4 were categorized as low, moderate, and high-risk, respectively, as shown in Table 6.

10.1371/journal.pone.0309663.t006 Table 6 Probability and risk classification.

Score	Constant	Coefficient	y	Probability	Risk Classification	
0	-8.76	3.25	-8.76	0.00	Low risk	
1	-8.76	3.25	-5.51	0.00	Low risk	
2	-8.76	3.25	-2.25	0.10	Moderate risk	
3	-8.76	3.25	1.00	0.73	High risk	
4	-8.76	3.25	4.26	0.99	High risk	
y = -8.76+3.25 total point

Probability = 1/(1+exp[-y])

Discussion

Thalassemia major is a significant health burden in Indonesia, with an increasing number of cases reported. The main cause of death was myocardial iron overload, which underscored the need for MRI T2* screening to treat and detect this condition. However, MRI T2* screening was limited due to its high costs and low availability. To address this issue, a low-cost-investigation-based formula and scoring system was needed. Based on previous findings, this is the first study in Indonesia to evaluate the use of the formula and score system for cardiac iron overload among children with thalassemia major.

We studied 80 thalassemia major with the average age of 12.3±2.8 years old, and the sex distribution was similar to that of previous studies [10]. This study recruited children aged > 6 years old who cooperated during the MRIT 2* procedure and ferritin level of > 1,000 ng/mL. As the majority of who those with ferritin level of > 1,000 ng/mL were at risk of cardiac involvement, left ventricular dilatation, abnormal contractility, tricuspid valve regurgitation, and pulmonary hypertension [11].

The mean MRI T2* range was 32.5 (9.9–46,7) ms, and this was similar to a previous study with a value of 34.4 (3.3–76) ms [12]. In this study showed proportion myocardial iron overload 8 (10%). Assis et al [13] carried out a study on 102 thalassemia aged 12 to 23 years who underwent routine transfusion with 3–4 weeks intervals, and the results showed that 36% had a myocardial iron overload. Wahidiyat et al. also assessed patients aged 14 (3–43) years and obtained a 14.8% prevalence [12]. Further, the prevalence of cardiac iron overload often differed in various countries and was affected by age, number of blood transfusions, and adherence to chelation therapy [14].

The transfusion intervals were 2.9 (3–4) weeks, among of 14 (17,5%) children had 4 weeks interval transfusions and 13.7% had Hb levels of < 8 g/dL. Parents’ ignorance of the need for regular transfusion, low social economic, and living in far remote areas were among the cause of the prolonged interval and low Hb level. The 3 weeks transfusion interval aimed to increase low pre-transfusion Hb as well as maintain the level of 10 gr/dL to prevent developmental problems.

Another major contributor to the occurrence of cardiac iron overload was the lack of adherence to chelation therapy due to boredom. There was also a weak correlation between adhering to therapy and myocardial iron overload (r 0.25 p = 0.02). The odd ratio (OR) of chelation adherence of ≤ 82% for developing myocardial iron overload was 11.4 (95% CI 2.09–62.3, p = 0.00). However, the results must be carefully interpreted since the adherence method was calculated with history taking with no medical record support. This was one of limitation of this study. However the adherence to chelation therapy variable was not play a rule on the predicting formula of myocardiac iron overload.

Transfusion without chelation therapy can lead to iron deposition as well as progressive liver, endocrine gland, kidney, and heart dysfunction [5], but most patients in this study received FDN. Studies showed that DFP was associated with less myocardial iron burden and better global systolic ventricular function compared to oral deferasirox or desferrioxamine [14].

Nutritional status was assessed in this study with an upper arm circumference measurement as body weight and body surface can be affected by other variables, such as organomegaly. Based on the measurement, the nutritional status was divided into several categories, where 85–100%, 70–85%, and <70% were classified as good, bad, and poor, respectively [15]. A total of 24 (27.3%) and 27 (30.7%) participants showed bad and poor status, leading to growth delay and short stature. Adequate nutrition was essential for thalassemia as a long-term therapy modality as it helped to prevent nutritional disorders, growth delays, poor puberty development, and immune deficiency [16]. The nutritional intake recommended for patients consisted of high-calorie food, potassium, zinc, vitamins A, D, E, and low iron, while vitamin C must be reduced as it can increase iron absorption [14, 16].

The IG obtained in this study was normal and none of patients suffered from bacterial infection. Of 10 (12.5%) children had thrombocytopenia, however, there was no history of bleeding, petechiae, ecchymosis, and any other related signs. Thrombocytopenia was caused by an increase in platelet destruction and reduced thrombopoietin due to the usage of DFP chelation and hypersplenism, which has a 10% incidence rate of bleeding.

PT and aPTT were not evaluated in this study, but increased levels correlated with ferritin and were commonly found in moderate to severe iron liver deposition compared to normal or mild stages [17, 18]. Delayed PTT was caused by liver dysfunction and the activation of coagulation cascade. This condition can be treated with chronic transfusion and hemolysis-induced kallikrein esterase activity, which required the XI and XII factors [18].

Reticulocyte levels of >1.49% were found in 20 (25%) patients in this study. Furthermore, there was a significant correlation between ferritin and reticulocyte (r = -0.45 p = 0.01). An increase in reticulocyte was reported to correlate with erythropoietin activity and increased ferritin levels [19].

The increase of AST, ALT, SI, and TIBC, which was consistent with previous studies [20]. There was also a significant correlation between AST and ferritin (r = 0.27 p = 0.02), but AST (r = 0.19 p = 0.09) did not correlate with SI (r = 0.21 p = 0.85) and TIBC (r = 0.123 p = 0.275). Average ferritin levels were observed to be higher in groups with increased AST and ALT (r = 0.01 and p = 0.01) [20].

Our study did not carry out Hepatitis B and C screening. Previous reports showed that patients with these conditions had increased AST, ALT, and serum ferritin levels [21]. AST was often present in liver, heart, skeletal muscle, brain, and kidney. It can also be found in the cytosol or mitochondria, and its levels can be increased due to mitochondrial damage. Meanwhile, ALT was reported to be abundant in the liver cytoplasm and more specific in detecting liver dysfunction compared to AST [20, 21].

We found that ECG, echocardiography, and TDI variables did not correlate with MRI T2*. There was also no correlation between QoTc interval with ferritin. These results are inconsistent with those obtained in previous studies due to differences in subject characteristics [22, 23].

Conventional echocardiography showed that both ejection fraction and right systolic function were normal, but there was early LV diastolic dysfunction (E mitral wave > 0.7 m/s) in 77 (96,3%) patients. The TDI study showed lateral myocardial velocity systolic dysfunction (Sm wave) among children with normal EF, and 3 (3,75%) patients had an E/Em ratio of > 8. Systolic and diastolic myocardial velocity dysfunction on TDI has been reported in other studies [24, 25]. TDI was very useful in detecting this condition even in cases with reserve normal EF [26]. The normal basal septal myocardial velocity in this study indicated that the lateral LV wall was affected earlier than the septal part.

A significant difference in QoTc interval, E mitral wave, DT, reduction in Sm lateral wave, and Sm septal wave were found among thalassemia patients with ferritin of >5,000 ng/dL, 2,500–5,000 ng/dL, and <2,500 ng/dL. The difference in result was caused by the age of patients, who were older compared to those in this study [27]. A significant variation in ECG and echocardiography variables were found in the thalassaemia group compared to the normal group. A significant difference was also found between children and adults [28].

This study showed the determinant factors for cardiac iron overload were Hb, reticulocyte, DT, and TR Vmax. Low hemoglobin can affect the cardiovascular system, leading to haemodilution, venous dilation, decreased blood pressure, and increased LVDD. Decreasing in DT in our styudy was consistent with other studies and might followed by E mitral wave abnormality. There is a good correlation between DT, E/Em index and MRIT2* value [29].

Thalassaemia can cause pulmonary hypertension (PH) and the gold standard was cardiac catheterization. In this study, we predicted PH by performing the TR Vmax on echocardiography. We found the average of TR Vmax was 2.25 (0.7–3.5) m/s, of those 24 (30%) were TR Vmax of >2.5 m/s and were 9 (11.25%) TR Vmax >2.8 m/s, respectively. Normal thalassemia major pulmonary arterial pressure is characterized by TR Vmax of 2.5–2.7 m/s. TR Vmax of ≥ 2.5 m/s can be utilized as a screening test to determine the risk for PH [30]. TR Vmax of > 3.4 m/s were significant indicators for pulmonary hypertension [31].

The mechanism of PH was multifactorial, and chronic hemolysis was related to a decrease in bioavailability of nitric oxide (NO) and platelet activation as well as an increase in adhesion molecules and vasoactive peptide Endothelin-1. Hypercoagulopathy has been reported to cause macrovascular and microvascular thrombosis, while splenectomy can lead to a coagulation activation factor [32, 33].

The formula for cardiac iron overload was -9.32+3.28 (Hb) + 2.79 (reticulocyte) + 3,64 (DT)+ 4.1 (TR Vmax). The Hosmer and Lameshow test showed good calibration. A scoring system was then defined by simplifying the formula. Values of Hb ≤ 8.2 g/L, reticulocyte ≤0.33%, DT ≤ 114.5 cm/s, and TR Vmax ≥ 2.37 m/s were given a score of 1, while others were assigned 0. Subsequently, risk for iron cardiac overload, total scores of 0 or 1, 2, and 3 or 4 were categorized as low, moderate, and high, respectively.

The formula and scoring system were developed to improve management in monitoring cardiac iron overload as the leading cause of death among children which is prevalent. Scoring system can be used as an alternative assessment tool in the absence of MRI T2*, thereby increasing patient survival especially in regions where MRI T2 is unavailable as our country as well as other low- and middle-income countries. It may lighten the economic burden of thalassemia management cost. Additionally, the limitations of the study might present opportunities for future research endeavors.

Conclusions

The formula for cardiac iron overload in this study was -9.32+ 3.28 (Hb) + 2.9 (reticulocyte) + 3.64 (DT) + 4.1 (TR Vmax). Variables of Hb ≤ 8.2 g/L, reticulocyte ≤0.33%, DT ≤ 114.5 cm/s, and TR Vmax ≥ 2.37 m/s were given a score of 1, while others were assigned 0. Based on the scoring system and risk classification, values of 0 or 1, 2, and 3 or 4 were categorized as low, moderate, and high-risk for cardiac iron overload, respectively.

Supporting information

S1 Checklist PLOS ONE clinical studies checklist.

(DOCX)

S2 Checklist STROBE statement—Checklist of items that should be included in reports of observational studies.

(DOCX)

S1 File (XLSX)

S2 File (PDF)

S3 File (PDF)

S4 File (XLSX)

The authors are grateful to Prof. Elizabeth Nemeth for providing advice and expert opinion.

10.1371/journal.pone.0309663.r001
Decision Letter 0
Castillo-Navarrete Juan Luis Academic Editor
© 2024 Juan Luis Castillo-Navarrete
2024
Juan Luis Castillo-Navarrete
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version0
2 Apr 2024

PONE-D-23-18085The Predicting formula and scoring system for cardiac iron overload for thalassemia children:  an urgent need in IndonesiaPLOS ONE

Dear Dr. Rohimi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

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It is undoubtedly a very good paper, so I urge the authors to consider the indications of the reviewers, especially, to deepen the discussion and the projections of the article.

==============================

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Reviewer #2: Yes

**********

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Reviewer #2: Yes

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: According to what was presented, conclusive data are obtained to estimate a score that correlates with iron overload. A correlation is also suggested between adherence to chelation treatment and number of transfusions, as it may bias the results.

Detailed demographic data is not found in the supplementary material. It is suggested to attach them to review the data tabulation.

Reviewer #2: Dear Authors,

I hope this letter finds you well. I am delighted to have the opportunity to review your exceptional research in the field of Thalassemia. Your findings are invaluable contributions to the scientific community and hold great significance for both researchers and patients alike. Please allow me to provide some constructive feedback aimed at enhancing the quality of your manuscript, organized according to each section:

1. Title: The title is informative and relevant, effectively capturing the essence of your study.

2. Abstract: I would kindly suggest mentioning the formula in the conclusion section of the abstract. Additionally, incorporating relevant keywords such as "MRI T2" could prove beneficial for indexing and discoverability purposes. Furthermore, I recommend replacing the term "thalassemia major" with the more encompassing "thalassemia" throughout the abstract. The remaining portions of the abstract effectively convey the study's findings and methodological approach.

3. Introduction: While conciseness is appreciated, a more substantial introduction could better communicate the importance and necessity of your research. The research question could be more firmly grounded in the existing literature, necessitating the inclusion of more up-to-date studies and references, particularly recently published works such as those by Meloni et al. and Fedai et al.

4. Methods: The subject selection process is clearly delineated. The variables are well-defined and measured appropriately, and the study methods are valid and reliable. The level of detail provided is sufficient to facilitate replication of the study by others.

5. Results: The presentation of data could be enhanced through the judicious use of visual aids, such as charts and graphs, which would effectively communicate the key findings of your research. A Receiver Operating Characteristic (ROC) graph is highly recommended. Appropriate labeling of columns and rows in tables is appreciated, but I would suggest removing any horizontal lines to enhance readability.

6. Discussion and Conclusions: A more comprehensive discussion, exploring the results from multiple perspectives, would be beneficial. Addressing the socioeconomic implications of your findings and the potential of the formula for early detection of cardiac iron overload in regions where MRI T2 is unavailable could broaden the impact of your work. Generalizing your results to low- and middle-income countries, where the problem you have identified is prevalent, would further underscore the global relevance of your research. The conclusions are well-supported by the results and effectively address the aims of the study. Additionally, the limitations acknowledged present opportunities for future research endeavors.

7. Overall: The study design is appropriate and effectively addresses the research aims, contributing novel insights to the existing body of knowledge on this topic.

I commend your exceptional work and look forward to the positive impact it will have on the scientific community and the lives of those affected by Thalassemia.

**********

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Reviewer #1: Yes: Juan Carlos Rivera Fuentes

Reviewer #2: Yes: Amirreza Nasirzadeh

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10.1371/journal.pone.0309663.r002
Author response to Decision Letter 0
Submission Version1
10 Jul 2024

Respons to Reviewers

ACADEMIC EDITOR:

It is undoubtedly a very good paper, so I urge the authors to consider the indications of the reviewers, especially, to deepen the discussion and the projections of the article.

==============================

Please submit your revised manuscript by May 17 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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No changes on financial disclosure

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

Revision: laboratory protocols has been added

We look forward to receiving your revised manuscript.

Kind regards,

Juan Luis Castillo-Navarrete, Ph.D.

Academic Editor

PLOS ONE

Journal requirements:

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Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

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Revision: Abstract structure has been revised

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

Revision: means data has been added

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: According to what was presented, conclusive data are obtained to estimate a score that correlates with iron overload. A correlation is also suggested between adherence to chelation treatment and number of transfusions, as it may bias the results.

Detailed demographic data is not found in the supplementary material. It is suggested to attach them to review the data tabulation.

Explanation: During study, the chelation adherence and number of transfusion data were taken with history taking as most subjects didn’t have adequate monitoring book so might be bias. However in this study the chelation adherence and number of transfusion were not a parameter for making a formula

Reviewer #2: Dear Authors,

I hope this letter finds you well. I am delighted to have the opportunity to review your exceptional research in the field of Thalassemia. Your findings are invaluable contributions to the scientific community and hold great significance for both researchers and patients alike. Please allow me to provide some constructive feedback aimed at enhancing the quality of your manuscript, organized according to each section:

1. Title: The title is informative and relevant, effectively capturing the essence of your study.

Revision: The predicting formula and scoring system for cardiac iron overload for thalassaemia children: Study from a Middle-Income Country

Short title: A formula and scoring system for cardiac iron overload in thalassemia children

As a suggestion on Discussion and Conclusions below: Addressing the socioeconomic implications of your findings and the potential of the formula for early detection of cardiac iron overload in regions where MRI T2 is unavailable could broaden the impact of your work.

2. Abstract: I would kindly suggest mentioning the formula in the conclusion section of the abstract. Additionally, incorporating relevant keywords such as "MRI T2" could prove beneficial for indexing and discoverability purposes. Furthermore, I recommend replacing the term "thalassemia major" with the more encompassing "thalassemia" throughout the abstract. The remaining portions of the abstract effectively convey the study's findings and methodological approach.

Revision: I have put the formula in the conclusion section of the abstract. I have also replaced the term of thalassemia major with thalassemia throughout the abstract.

3. Introduction: While conciseness is appreciated, a more substantial introduction could better communicate the importance and necessity of your research. The research question could be more firmly grounded in the existing literature, necessitating the inclusion of more up-to-date studies and references, particularly recently published works such as those by Meloni et al. and Fedai et al.

Revision: to a better communicate the importance and necessity of the study, I have added some information regarding side effect of regular blood transfusion such as cardiac fibrosis and pulmonary hypertension on introduction. Regular blood transfusions are required to treat thalassemia and might cause iron overload, organ dysfunction, heart failure (HF), cardiac fibrosis, pulmonary hypertension and death [1,3,5].

I have revised literature:

no 31 with a recently published work which done by Sharma M, Burns AT, Yap K, Prior DL. The role of imaging in pulmonary hypertension. Cardiovasc Diagn Ther 2021; 11:859-80. No 32. Fraidenburg DR, Machado RF. Pulmonary hypertension associated with thalassemia syndromes. Ann N Y Acad Sci. 2016;1:127–39.

4. Methods: The subject selection process is clearly delineated. The variables are well-defined and measured appropriately, and the study methods are valid and reliable. The level of detail provided is sufficient to facilitate replication of the study by others.

No revision done

5. Results: The presentation of data could be enhanced through the judicious use of visual aids, such as charts and graphs, which would effectively communicate the key findings of your research. A Receiver Operating Characteristic (ROC) graph is highly recommended. Appropriate labeling of columns and rows in tables is appreciated, but I would suggest removing any horizontal lines to enhance readability.

Revision: a ROC graph have been added on the manuscript

6. Discussion and Conclusions: A more comprehensive discussion, exploring the results from multiple perspectives, would be beneficial. Addressing the socioeconomic implications of your findings and the potential of the formula for early detection of cardiac iron overload in regions where MRI T2 is unavailable could broaden the impact of your work. Generalizing your results to low- and middle-income countries, where the problem you have identified is prevalent, would further underscore the global relevance of your research. The conclusions are well-supported by the results and effectively address the aims of the study. Additionally, the limitations acknowledged present opportunities for future research endeavors.

Revision: Addressing the socioeconomic implication has been added to the manuscript as well as the possibility of using formula and score system for the others low and middle income countries

7. Overall: The study design is appropriate and effectively addresses the research aims, contributing novel insights to the existing body of knowledge on this topic.

I commend your exceptional work and look forward to the positive impact it will have on the scientific community and the lives of those affected by Thalassemia.

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

Attachment Submitted filename: Response to Reviewers.docx

10.1371/journal.pone.0309663.r003
Decision Letter 1
Castillo-Navarrete Juan Luis Academic Editor
© 2024 Juan Luis Castillo-Navarrete
2024
Juan Luis Castillo-Navarrete
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version1
16 Aug 2024

The Predicting formula and scoring system for cardiac iron overload for thalassemia children:  study from a middle income country

PONE-D-23-18085R1

Dear Dr. Syarif Rohimi,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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PLOS ONE

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Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I would like to start by greeting the authors.

I suggest adding a table that organizes both the application of the formula along with the risk ranges of a simpler one so that clinicians can apply it. The constructed tables show the results obtained and validated, but one that simplifies their application is missing.

In the review they mention the preparation of OR graphs but they do not appear in the article. I suggest adding them.

When consulting the bibliography, an adequate focus on the topic in question is evident. I suggest updating it and strengthening the quotes used.

My most sincere congratulations for the work done.

Reviewer #2: Dear authors,

Thank you for applying the suggested comments. The present version of the manuscript is suitable for publication in PLOS ONE.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Juan Carlos Rivera Fuentes

Reviewer #2: Yes: Amirreza Nasirzadeh

**********

10.1371/journal.pone.0309663.r004
Acceptance letter
Castillo-Navarrete Juan Luis Academic Editor
© 2024 Juan Luis Castillo-Navarrete
2024
Juan Luis Castillo-Navarrete
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
26 Aug 2024

PONE-D-23-18085R1

PLOS ONE

Dear Dr. Rohimi,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

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on behalf of

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Academic Editor

PLOS ONE
==== Refs
References

1 Origa R . Beta-thalassemia. Genet Med. 2017;6 :609−1936.
2 Pignatti CB , Rugolotto S , Stefano PD , Zhao H , Capellini MD , Vecchio GGD , et al . Survival and complication in patients with thalassemia major treated with transfusion and deferoxamine. Haemotologica. 2004;89 :1187−93.
3 Olivery NF . The B Thalassemia. N Engl Med. 1999;341 :99−109.
4 Yayasan Thalassaemia Indonesia. Data Thalassaemia di Indonesia Tahun 2019. Jakarta: Yayasan Thalassaemia Indonesia; 2019. Jakarta; 1–15, Indonesian
5 Kremastinos DT , Farmakis D , Aessopos A , Hahalis G , Hamodraka E , Tsiapras D , et al . β-thalassemia cardiomyopathy: history, present considerations, and future perspectives. Circulation. 2010;3 :451−8.20484195
6 Pedoman Hasil Pemeriksaan Laboratorium Patologi Klinik Rumah Sakit Anak dan Bunda Harapan Kita 2014. Instalasi Laboratorium Terpadu,Jakarta;3–87, Indonesian.
7 Lopez L , Colan SD , Frommlet PC , Ensing GJ , Kendall K , Younoszai AK . Recommendations for quantification methods during the performance of a pediatric echocardiogam: a report from the Pediatric Measurements Writing Group of the American Society of Echocardiography Pediatric and Congenital Heart Disease Council. J Am Soc Echocardiog. 2010;23 ;465–95.
8 Ho CY , Solomon SD . A clinician’s guide to tissue Doppler imaging. Circulation. 2006;113 :396−8. doi: 10.1161/CIRCULATIONAHA.105.579268 16534017
9 Dahlan MS . Regresi linear: disertai praktik dengan SPSS. 1st ed. Jakarta: Epidemiologi Indonesia; 2012. Indonesian.
10 Timan SI . Aktivitas elastase, laktase dan ekspresi hepsidin pada talasemia mayor dengan hemokromatosis sebagai petanda gangguan sistem pencernaan [dissertation]. Jakarta: Fakultas Kedokteran Universitas Indonesia; 2007. Indonesian.
11 Mogharab F , Mogharab V . Evaluation of cardiac complications in patients with thalassemia major using serum ferritin levels. IJJS. 2014;3 :104−8.
12 Wahidiyat PA , Liauw F , Sekarsari D , Putriasih SA , Berdoukas V , Pennell DJ . Evaluation of cardiac and hepatic iron overload in thalassemia major patients with T2* magnetic resonance imaging. Hematology. 2014;8 :501−7.
13 Assis RA , Kay FU , Rosemberg LA , Parma AHC , Nomura CH , Loggetto SR , et al . Iron overload in Brazilian thalassemic patients. Einstein (Sao Paulo). 2011;9 :145–72.26760807
14 Pennell DJ , Udelson JE , Arai AE , Bozkurt B , Cohen AR , Galanello R , et al . Cardiovascular function and treatment in β thalassemia major: a consensus statement from the American Heart Association. Circulation. 2013;128 :281−308.23775258
15 Wahidiyat I , Sastroasmoro S . Pemeriksaan fisis: dalam pemeriksaan klinis pada bayi dan anak. 3rd ed. Jakarta: Sagung Seto; 2014:19−38. Indonesian.
16 Arijanty L , Nasar SS . Masalah nutrisi pada thalassemia. Sari Pediatri. 2003;1 :21–6. Indonesian.
17 Naithani R , Chandra J , Narayan S , Sharma S , Singh V . Thalassemia major–on the verge of bleeding or thrombosis?. Hematology. 2006;11 :57–6. doi: 10.1080/10245330500362087 16522552
18 Arruda VR . The search for the origin of factor VIII synthesis and its impact on therapeutic strategies for hemophilia A. Haematologica. 2015;100 :849−50. doi: 10.3324/haematol.2015.129858 26130509
19 Wagner SC , Gando AC , Castro SM . Reticulocyte indices in thalassaemia trait individuals. Res Bras Hematol Hemater. 2011;5 ;393–7.
20 Salama K , Ibrahim OM , Kaddah AM , Boseila S , Ismail LA , Hamid MMA . Liver enzymes in children with beta thalassemia major: correlation with iron overload and viral hepatitis. OA Maced J Med Sci. 2015;2 :287. doi: 10.3889/oamjms.2015.059 27275237
21 Mahmoud RA , El-Mazary AAM , Khodeary A . Seroprevalence of hepatitis C, hepatitis B, cytomegalovirus, and human immunodeficiency viruses in multitransfused thalassemic children in upper Egypt. Advance in Hematol. 2014;1–7.
22 Detterich J , Noetzli L , Dorey F , Bar-Cohen Y , Harmantz P , Coates T , et al . Electrocardiogaphic consequence of cardiac iron overloaded in thalassemia major. Am J Hematol. 2012;98 :139−44.
23 Barzin M , Kowsarian , Akhalaghpoor S , Jalalian R , Taremi M . Correlation of cardiac MRI T2* with echocardiogaphy in thalassemia major. Eu Rev Med Pharma Sci. 2012;14 ;254−60.
24 Rohimi S , Advani N , Sastroasmoro S , Madiyono B , Putra ST , Djer MD , et al . Tissue doppler imaging in thalassemia major patients: correlation between systolic and diastolic function with serum ferritin level. Pediatr Indones. 2012;52 :187−93.
25 Silvilairat S , Sittiwangkul R , Pongprot Y , Charoenkwan P , Phornphutkul C . Tissue doppler echocardiogaphy reliably reflects severity of iron overload in pediatric patients with B thalassemia: detects early myocardial dysfunction related to myocardial. Eur J Echocardiog. 2008;9 :368−72.
26 Ragab SM , Fathy WM , El-Aziz WFA , Helal RT . The diagnostic value of pulsed waved tissue doppler imaging in asymptomatic beta-thalassemia major children and young adults: relation to chemical biomarkers of left ventricular function and iron overload. Mediter J Hematol Infect Dis. 2015;7 :1−11.
27 Sayed SZ , Aly BA , El-Hakim AAE , Omar SM , Amin SA . The early cardiac involvement in patients with thalssaemia major. EJH.2013.
28 Ibrahim MH , Azab AA , Kamal NM , Salama MA , Soha A , Ebrahim SA , et al . Early detection of myocardial dysfunction in poorly treated pediatric thalassemia children and adolescents: two Saudi centers experience. Ann of Med Surg. 2014:9 :6–11.
29 Barzin M , Kowsarian , Akhalaghpoor , Jalalian R , Taremi M . Correlation of cardiac MRIT2* with echocardiography in thalasaemia major. Eu Rev Med Pharma Sci. 2012;14 :254–60.
30 Morris CR , Kim HY , Trachtenberg F , Wood J , Quinn CT , Sweeters N , et al . Risk factors and mortality associated with an elevated tricuspid regurgitant jet velocity measured by Doppler-echocardiogaphy in thalassemia: a Thalassemia Clinical Reasearch Network report. Blood. 2011;14 :3794−802.
31 Sharma M , Burns AT , Yap K , Prior DL . The role of imaging in pulmonary hypertension. Cardiovasc Diagn Ther 2021; 11 :859–80. doi: 10.21037/cdt-20-295 34295710
32 Fraidenburg DR , Machado RF . Pulmonary hypertension associated with thalassemia syndromes. Ann N Y Acad Sci. 2016;1 :127–39. doi: 10.1111/nyas.13037 27008311
33 Augustine DX , Coates-Bradshaw LD , Willis J , Harkness A , Ring L , Grapsa J , et al . Echocardiogaphic assessment of pulmonary hypertension: a guideline protocol from the British Society of Echocardiography. BSE. 2018;3 :G11−4.
