Prognostic Significance of Subclinical Joint Changes on MRI in Hemophilia

Joint Bleeding in Hemophiliacs and Its Consequences

For patients with hemophilia, joint bleeding is typical. Repeated joint bleeds lead to significant joint damage and the development of changes, known as hemophilic arthropathy. Joint tissue damage occurs with the first (even subclinical) joint bleed.

Prophylaxis, i.e., the preventive regular administration of concentrate with FVIII, aims to reduce and ideally completely prevent these bleeds. However, it is expensive, demanding for patients, and achieving so-called trough levels between 1 and 2% does not guarantee complete prevention of bleeding.

Study Methodology and Course

Authors from Utrecht, the Netherlands, focused on the prospective assessment of the prognostic significance of synovial changes according to MRI for joint bleeding and the progression of arthropathy in the next 5 years, in an article published in January 2020 in the journal Blood Advances.

Both knee and ankle joints in patients aged 12–30 years without significant arthropathy (i.e., at most 1 joint with a Pearson score ≥ 4) were monitored. MRI images were evaluated by 2 independent radiologists using the International Prophylaxis Study Group score. Patients were followed for 5 years using clinical assessments and repeated radiological examinations. Associations between MRI findings at study entry and bleeding rate over 5 years or potential arthropathy progression (defined as worsening of the Pearson score by ≥ 1) were expressed using odds ratios (OR), adjusted for hemophilia severity and joint bleeding history.

Findings

Twenty-six patients were included, and 104 joints were examined. The median age of patients was 21 years. Four ankles with significant involvement according to entry MRI were not included in the evaluation. Follow-up was available for 96 joints. During the 5-year follow-up, bleeding was documented in 36% of joints.

Bleeding was significantly more frequent in joints with synovial hypertrophy at study entry (80%) compared to joints without synovial changes (27%): OR 10.1 (95% confidence interval [CI] 3.4−31.3). In joints with normal entry X-ray findings, all changes seen on entry MRI, except effusion, were associated with changes developing on joint X-rays after 5 years.

Discussion and Conclusion

Joints with synovial hypertrophy on MRI had a significantly higher chance of bleeding over the next 5 years. All MRI changes, except effusions, were strong predictors of arthropathy development on subsequent X-ray images.

MRI examination provides important prognostic information for hemophilia patients without clinically present arthropathy. The results of this study indicate the need to monitor the joint condition of these patients not only clinically but also using tools capable of distinguishing subclinical changes. Further treatment can then be based on these findings.

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Source: Foppen W., van der Schaaf I. C., Beek F. J. A. et al. MRI predicts 5-year joint bleeding and development of arthropathy on radiographs in hemophilia. Blood Advances 2020 Jan 14; 4 (1): 113−121, doi: 10.1182/bloodadvances.2019001238.