Bone disease in thalassemia: a frequent and still unresolved problem

Abstract

Adults with beta thalassemia major frequently have low BMD, fractures, and bone pain. The purpose of this study was to determine the prevalence of low BMD, fractures, and bone pain in all thalassemia syndromes in childhood, adolescence, and adulthood, associations of BMD with fractures and bone pain, and etiology of bone disease in thalassemia. Patients of all thalassemia syndromes in the Thalassemia Clinical Research Network, > or =6 yr of age, with no preexisting medical condition affecting bone mass or requiring steroids, participated. We measured spine and femur BMD and whole body BMC by DXA and assessed vertebral abnormalities by morphometric X-ray absorptiometry (MXA). Medical history by interview and review of medical records, physical examinations, and blood and urine collections were performed. Three hundred sixty-one subjects, 49% male, with a mean age of 23.2 yr (range, 6.1-75 yr), were studied. Spine and femur BMD Z-scores < -2 occurred in 46% and 25% of participants, respectively. Greater age, lower weight, hypogonadism, and increased bone turnover were strong independent predictors of low bone mass regardless of thalassemia syndrome. Peak bone mass was suboptimal. Thirty-six percent of patients had a history of fractures, and 34% reported bone pain. BMD was negatively associated with fractures but not with bone pain. Nine percent of participants had uniformly decreased height of several vertebrae by MXA, which was associated with the use of iron chelator deferoxamine before 6 yr of age. In patients with thalassemia, low BMD and fractures occur frequently and independently of the particular syndrome. Peak bone mass is suboptimal. Low BMD is associated with hypogonadism, increased bone turnover, and an increased risk for fractures.

FIG. 1

Bone mass vs. age. (A and B) Spine BMD (g/cm²) with age-dependent reference norms for whites (solid line) and ±2 SD (dashed lines) for males (A) and females (B). (C) Whole body BMC (kg) with locally weighted regressions for males (solid line) and females (dashed line). One individual age 75 yr is omitted (symbols: male, □; female, ○).

FIG. 2

Spine, femur, and total body BMD Z-scores with a partial-linear spline (solid line) and 95% CI (dashed lines). Individuals >40 yr of age are omitted.

FIG. 3

Prevalence of low (Z-score < −2 SD), reduced (−2 SD ≤ Z-score < −1 SD), and normal (Z-score ≥ −1 SD) spine and femur Z-scores by thalassemia syndrome.

FIG. 4

Bone turnover markers vs. age stratified by sex and hypogonadal status (hypogonadal, +; not hypogonadal, ○ ) with age-dependent upper and lower limits of normal (dashed lines). One individual age 75 yr is omitted.

FIG. 5

Prevalence of history of fracture (A) and recent bone or joint pain (B) by thalassemia syndrome, stratified by age group (6–10 yr, ○; 11–19 yr, ; 20 or more yrs, •). Point estimates and exact 95% confidence intervals are indicated.