# Disproportionate Decline in Trabecular Bone Score Compared to Bone Mineral Density in Southeast Asian Patients with Thalassemia: A Matched Control Study

## TL;DR

Southeast Asian thalassemia patients show worse bone microstructure than healthy controls, with transfusion-dependent cases being most affected.

## Contribution

Identifies significant and disproportionate trabecular bone score decline in thalassemia patients, independent of bone mineral density.

## Key findings

- Thalassemia patients had significantly lower TBS, LS Z-score, and FN Z-score compared to controls.
- TDT patients showed a tenfold higher prevalence of degraded bone microarchitecture (TBS < 1.200) compared to controls.
- TDT status was independently associated with lower TBS after adjusting for age, sex, BMI, and LS BMD.

## Abstract

We aimed to assess trabecular bone score (TBS) alongside lumbar spine (LS) and femoral neck (FN) bone mineral density (BMD) in patients with transfusion-dependent thalassemia (TDT) and non-transfusion-dependent thalassemia (NTDT) compared with healthy controls. A cross-sectional study was conducted involving adult thalassemia patients and healthy controls matched at a 2:1 ratio by age and sex. LS and FN BMD and TBS were measured using dual-energy X-ray absorptiometry. Univariate and multivariate analyses were performed to identify factors influencing TBS. The study protocol was approved by the institutional ethics committee. Eighty-six thalassemia patients (mean ± SD age 32.2 ± 11.9 years; 60.5% women) and 172 healthy controls (mean ± SD age 33.7 ± 10.9 years; 60.5% women) were included. Thalassemia patients had significantly lower BMI, LS Z-score, FN Z-score and TBS than controls (all p < 0.001). Only 24.4% of thalassemia patients had normal TBS (≥ 1.350) compared to 77.9% of controls, with a tenfold higher prevalence of degraded microarchitecture (TBS < 1.200). Although TDT patients exhibited more severe disease features than NTDT patients, TBS was similarly reduced in both groups. In multivariate analysis adjusted for age, sex, BMI, and LS BMD, TDT status remained independently associated with lower TBS (β = − 0.047; 95% CI: − 0.083 to − 0.012). No significant correlations were found between TBS and hemoglobin, serum ferritin, lactate dehydrogenase or glucose levels. This study provides new evidence that TBS was significantly impaired in Southeast Asian patients with thalassemia, independent of BMD, with a disproportionate reduction observed particularly in TDT patients.

The online version contains supplementary material available at 10.1007/s00223-026-01483-0.