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Li D, Li J, Zhang H, Zhu Q, Wang T, Zhao W, Zhao S, Li W. Hereditary hemochromatosis caused by a C282Y/H63D mutation in the HFE gene: A case report. Heliyon 2024; 10:e28046. [PMID: 38560130 PMCID: PMC10979142 DOI: 10.1016/j.heliyon.2024.e28046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 03/04/2024] [Accepted: 03/11/2024] [Indexed: 04/04/2024] Open
Abstract
Hereditary hemochromatosis (HH) is a disease characterized by disordered iron metabolism. It often involves mutations of the HFE gene, which encodes the homeostatic iron regulator protein (HFE), as well as mutations affecting hepcidin antimicrobial peptide, hemojuvelin, or transferrin receptor 2. Historically, HH has been observed primarily in European and European diaspora populations, while classical HH is rare in Asian populations, including in China. In this article, we report a rare case of HH in a Chinese man that could be attributed to a heterozygous C282Y/H63D HFE mutation. Based on clinical examination, liver biopsy, and genetic testing results, the patient was diagnosed with HH. Clinical signs and symptoms and serum iron-related test results were recorded for a period of two years after the patient began treatment. Over this observation period, the patient was subjected to 25 phlebotomies (accounting for a total blood loss of 10.2 L). His serum ferritin levels decreased from 1550 μg/L to 454 μg/L, his serum iron concentration decreased from 40 μmol/L to 24.6 μmol/L, and his transferrin saturation decreased from 97.5% to 55.1%. Early diagnosis is essential for patients with HH to obtain good outcomes. Regular phlebotomy after diagnosis can improve HH symptoms and delay HH disease progression.
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Affiliation(s)
- Dongdong Li
- Department of Infectious Diseases, First Affiliated Hospital of Bengbu Medical College, 233000 Bengbu, Anhui, China
- National Clinical Research Center for Infectious Diseases, China
| | - Jinfeng Li
- Department of Infectious Diseases, First Affiliated Hospital of Bengbu Medical College, 233000 Bengbu, Anhui, China
- National Clinical Research Center for Infectious Diseases, China
| | - Hongkun Zhang
- Department of Infectious Diseases, First Affiliated Hospital of Bengbu Medical College, 233000 Bengbu, Anhui, China
- National Clinical Research Center for Infectious Diseases, China
| | - Qiuyu Zhu
- Department of Infectious Diseases, First Affiliated Hospital of Bengbu Medical College, 233000 Bengbu, Anhui, China
- National Clinical Research Center for Infectious Diseases, China
| | - Teng Wang
- Yiwu Central Hospital, 322000 Yiwu, Zhejiang, China
| | - Wen Zhao
- Department of Infectious Diseases, First Affiliated Hospital of Bengbu Medical College, 233000 Bengbu, Anhui, China
- National Clinical Research Center for Infectious Diseases, China
| | - Shousong Zhao
- Department of Infectious Diseases, First Affiliated Hospital of Bengbu Medical College, 233000 Bengbu, Anhui, China
- National Clinical Research Center for Infectious Diseases, China
| | - Wei Li
- Department of Infectious Diseases, First Affiliated Hospital of Bengbu Medical College, 233000 Bengbu, Anhui, China
- National Clinical Research Center for Infectious Diseases, China
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Zeitoun T, El-Sohemy A. Using Mendelian Randomization to Study the Role of Iron in Health and Disease. Int J Mol Sci 2023; 24:13458. [PMID: 37686261 PMCID: PMC10487635 DOI: 10.3390/ijms241713458] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/09/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
Iron has been shown to play a dual role in health and disease, with either a protective or harmful effect. Some of the contradictory findings from observational studies may be due to reverse causation, residual confounding, or small sample size. One approach that may overcome these limitations without the high cost of randomized control trials is the use of Mendelian randomization to examine the long-term role of iron in a variety of health outcomes. As there is emerging evidence employing Mendelian randomization as a method of assessing the role of micronutrients in health and disease, this narrative review will highlight recent Mendelian randomization findings examining the role of iron in cardiometabolic disorders, inflammation, neurological disorders, different cancers, and a number of other health-related outcomes.
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Affiliation(s)
| | - Ahmed El-Sohemy
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Medical Sciences Building, Room 5326A, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada;
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Crawford DHG, Ramm GA, Bridle KR, Nicoll AJ, Delatycki MB, Olynyk JK. Clinical practice guidelines on hemochromatosis: Asian Pacific Association for the Study of the Liver. Hepatol Int 2023; 17:522-541. [PMID: 37067673 DOI: 10.1007/s12072-023-10510-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/28/2023] [Indexed: 04/18/2023]
Affiliation(s)
- Darrell H G Crawford
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Gallipoli Medical Research Foundation, Brisbane, Australia
| | - Grant A Ramm
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Kim R Bridle
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.
- Gallipoli Medical Research Foundation, Brisbane, Australia.
| | - Amanda J Nicoll
- Department of Gastroenterology, Eastern Health, Box Hill, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | - Martin B Delatycki
- Bruce Lefroy Centre, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- The University of Melbourne, Melbourne, VIC, Australia
- Victorian Clinical Genetics Services, Parkville, VIC, Australia
| | - John K Olynyk
- Department of Gastroenterology, Fiona Stanley Hospital, Murdoch, WA, Australia
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
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Kouroumalis E, Tsomidis I, Voumvouraki A. Iron as a therapeutic target in chronic liver disease. World J Gastroenterol 2023; 29:616-655. [PMID: 36742167 PMCID: PMC9896614 DOI: 10.3748/wjg.v29.i4.616] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/03/2022] [Accepted: 12/31/2022] [Indexed: 01/20/2023] Open
Abstract
It was clearly realized more than 50 years ago that iron deposition in the liver may be a critical factor in the development and progression of liver disease. The recent clarification of ferroptosis as a specific form of regulated hepatocyte death different from apoptosis and the description of ferritinophagy as a specific variation of autophagy prompted detailed investigations on the association of iron and the liver. In this review, we will present a brief discussion of iron absorption and handling by the liver with emphasis on the role of liver macrophages and the significance of the iron regulators hepcidin, transferrin, and ferritin in iron homeostasis. The regulation of ferroptosis by endogenous and exogenous mod-ulators will be examined. Furthermore, the involvement of iron and ferroptosis in various liver diseases including alcoholic and non-alcoholic liver disease, chronic hepatitis B and C, liver fibrosis, and hepatocellular carcinoma (HCC) will be analyzed. Finally, experimental and clinical results following interventions to reduce iron deposition and the promising manipulation of ferroptosis will be presented. Most liver diseases will be benefited by ferroptosis inhibition using exogenous inhibitors with the notable exception of HCC, where induction of ferroptosis is the desired effect. Current evidence mostly stems from in vitro and in vivo experimental studies and the need for well-designed future clinical trials is warranted.
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Affiliation(s)
- Elias Kouroumalis
- Liver Research Laboratory, University of Crete Medical School, Heraklion 71003, Greece
| | - Ioannis Tsomidis
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki 54621, Greece
| | - Argyro Voumvouraki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki 54621, Greece
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5
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Affiliation(s)
- John K Olynyk
- From the Department of Gastroenterology and Hepatology, Fiona Stanley Fremantle Hospital Group, Murdoch, and the School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA (J.K.O.); and the Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Herston, QLD (G.A.R.) - all in Australia
| | - Grant A Ramm
- From the Department of Gastroenterology and Hepatology, Fiona Stanley Fremantle Hospital Group, Murdoch, and the School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA (J.K.O.); and the Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Herston, QLD (G.A.R.) - all in Australia
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Muacevic A, Adler JR, Ijaz N, Hayat U. H63D Homozygous Mutation: An Unusual Cause of Deranged Liver Function Test in an Elderly Patient. Cureus 2022; 14:e31840. [PMID: 36579242 PMCID: PMC9792325 DOI: 10.7759/cureus.31840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 11/25/2022] Open
Abstract
Hereditary hemochromatosis is an autosomal recessive disorder characterized by dysregulated iron homeostasis resulting in body iron overload. Hemochromatosis leads to excessive iron deposition in the parenchymal cells of different body organs, resulting in the compromise of their normal functioning in genetically predisposed patients. It presents in genetically predisposed male patients aged between 40 and 70 years. Various mutations have been described in hemochromatosis, C282Y is the most prevalent and is commonly associated with iron overload. Other mutations such as H63D and S65C rarely lead to iron overload in patients. We present an unusual case of an 84-year-old male who was referred for comprehensive evaluation. He was found to have mildly elevated liver function tests (LFTs). Further workup revealed raised ferritin levels, and on a detailed investigation, it was found to be homozygous for the H63D mutation for hemochromatosis. The patient was seen by hematology and was treated with therapeutic phlebotomy, which led to the normalization of the LFTs and improvement in ferritin levels and clinical symptoms.
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Andersson L, Powell LW, Ramm LE, Ramm GA, Olynyk JK. Arthritis Prediction of Advanced Hepatic Fibrosis in HFE Hemochromatosis. Mayo Clin Proc 2022; 97:1649-1655. [PMID: 35422339 DOI: 10.1016/j.mayocp.2022.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 01/23/2022] [Accepted: 02/14/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate whether arthritis predicts the likelihood of advanced hepatic fibrosis in HFE hemochromatosis. PATIENTS AND METHODS We conducted a retrospective, cross-sectional analysis of 112 well-characterized patients with HFE hemochromatosis and liver biopsy-validated fibrosis staging recruited between January 1, 1983, and December 31, 2013. Complete clinical, biochemical, hematologic, and noninvasive serum biochemical indices (aspartate aminotransferase to platelet ratio index [APRI] and fibrosis 4 index [FIB4]) were available. Scheuer fibrosis stages 3 and 4, APRI greater than 0.44, or FIB4 greater than 1.1 were used to define advanced hepatic fibrosis. Comparisons between groups were performed using categorical analysis, unpaired or paired t test. RESULTS Male (n=76) and female (n=36) patients were similar in age. Nineteen patients had advanced hepatic fibrosis, and 47 had hemochromatosis arthritis. Arthritis was significantly associated with the presence of advanced hepatic fibrosis as determined by liver biopsy (sensitivity, 84%, [95% CI, 62% to 95%]; negative predictive value, 95% [95% CI, 87% to 99%]; relative risk, 7.4 [95% CI, 2.5 to 23]; P<.001), APRI (sensitivity, 75% [95% CI, 55% to 88%]; negative predictive value, 91% [95% CI, 81% to 96%]; relative risk, 4.5 [95% CI, 2.0 to 10.2]; P<.001), or FIB4 (sensitivity, 61% [95% CI, 41% to 78%]; negative predictive value, 67% [95% CI, 68% to 90%]; relative risk, 2.2 [95% CI, 1.1 to 4.6]; P=.03). Mean cell volume values were significantly higher pretreatment in patients with F3-4 fibrosis (96.7±1.1 fL) compared with F0-2 fibrosis (93.4±0.5 fL; P=.004) and declined following treatment (F3-4, 93.2±0.9 fL, P=.01; F0-2, 91.7±0.6 fL, P=.01). CONCLUSION Advanced hepatic fibrosis is strongly associated with arthritis in HFE hemochromatosis. The absence of arthritis predicts a low likelihood of advanced hepatic fibrosis, supporting its use as a clinical marker for advanced hepatic fibrosis in HFE hemochromatosis.
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Affiliation(s)
- Lauren Andersson
- Department of Gastroenterology and Hepatology, Fiona Stanley Fremantle Hospital Group, Murdoch, Western Australia, Australia
| | - Lawrie W Powell
- Faculty of Medicine, The University of Queensland, Herston, Brisbane, Queensland, Australia
| | - Louise E Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Grant A Ramm
- Faculty of Medicine, The University of Queensland, Herston, Brisbane, Queensland, Australia; Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - John K Olynyk
- Department of Gastroenterology and Hepatology, Fiona Stanley Fremantle Hospital Group, Murdoch, Western Australia, Australia; School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia.
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Zheng M, Allington G, Vilarinho S. Genomic medicine for liver disease. Hepatology 2022; 76:860-868. [PMID: 35076957 PMCID: PMC10460497 DOI: 10.1002/hep.32364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/13/2022] [Accepted: 01/18/2022] [Indexed: 12/08/2022]
Affiliation(s)
- Melanie Zheng
- Departments of Internal Medicine, Section of Digestive Diseases, and of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Garrett Allington
- Departments of Internal Medicine, Section of Digestive Diseases, and of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sílvia Vilarinho
- Departments of Internal Medicine, Section of Digestive Diseases, and of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
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Zoller H, Schaefer B, Vanclooster A, Griffiths B, Bardou-Jacquet E, Corradini E, Porto G, Ryan J, Cornberg M. EASL Clinical Practice Guidelines on haemochromatosis. J Hepatol 2022; 77:479-502. [PMID: 35662478 DOI: 10.1016/j.jhep.2022.03.033] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 03/29/2022] [Indexed: 12/15/2022]
Abstract
Haemochromatosis is characterised by elevated transferrin saturation (TSAT) and progressive iron loading that mainly affects the liver. Early diagnosis and treatment by phlebotomy can prevent cirrhosis, hepatocellular carcinoma, diabetes, arthropathy and other complications. In patients homozygous for p.Cys282Tyr in HFE, provisional iron overload based on serum iron parameters (TSAT >45% and ferritin >200 μg/L in females and TSAT >50% and ferritin >300 μg/L in males and postmenopausal women) is sufficient to diagnose haemochromatosis. In patients with high TSAT and elevated ferritin but other HFE genotypes, diagnosis requires the presence of hepatic iron overload on MRI or liver biopsy. The stage of liver fibrosis and other end-organ damage should be carefully assessed at diagnosis because they determine disease management. Patients with advanced fibrosis should be included in a screening programme for hepatocellular carcinoma. Treatment targets for phlebotomy are ferritin <50 μg/L during the induction phase and <100 μg/L during the maintenance phase.
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Hasan SMM, Farrell J, Borgaonkar M. C282Y/H63D Compound Heterozygosity Is a Low Penetrance Genotype for Iron Overload-related Disease. J Can Assoc Gastroenterol 2022; 5:240-247. [PMID: 36196271 PMCID: PMC9527664 DOI: 10.1093/jcag/gwac025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Hereditary hemochromatosis (HH) occurs due to mutations in the HFE gene. While the C282Y mutation is the most common genotype reported in HH, other genotypes are found less frequently, indicating variable degrees of penetrance. We studied the penetrance of the C282Y/H63D compound heterozygote genotype in developing clinically significant iron overload.
Methods
We have completed a retrospective analysis on every individual within Newfoundland & Labrador who were diagnosed as C282Y/H63D compound heterozygote between 1996 and 2009 through a molecular genetics study. We collected data for up to 10 years following the initial genotyping using electronic health records, including laboratory values, phlebotomy status, radiologic reports and clinic records. Iron overload status was classified based on the HealthIron study.
Results
Between 1996 and 2009, 247 individuals with available health records tested positive for C282Y/H63D compound heterozygosity. Over the 10 years of our study, 5.3% of patients exhibited iron overload-related disease on the background of documented iron overload. Including these individuals, 10.1% of patients had documented iron overload, 23.1% of patients had a provisional iron overload and the remaining 66.8% of patients had no evidence of iron overload. Only 44 patients had documented phlebotomies, likely based on their severe phenotype at baseline. Despite phlebotomy, the prevalence of iron overload was higher among these patients. The penetrance of compound heterozygosity was also significantly higher among men (P < 0.01).
Conclusion
C282Y/H63D compound heterozygosity is a low penetrance genotype in HH. This is the largest reported cohort of C282Y/H63D compound heterozygotes in North America with an extended follow-up.
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Affiliation(s)
- S M Mahmudul Hasan
- Max Rady College of Medicine, University of Manitoba , Winnipeg, Manitoba , Canada
| | - James Farrell
- Discipline of Medicine, Memorial University of Newfoundland, Health Sciences Centre , St. John’s, Newfoundland and Labrador , Canada
| | - Mark Borgaonkar
- Discipline of Medicine, Memorial University of Newfoundland, Health Sciences Centre , St. John’s, Newfoundland and Labrador , Canada
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Iron-mediated tissue damage in acquired ineffective erythropoiesis disease: It’s more a matter of burden or more of exposure to toxic iron form? Leuk Res 2022; 114:106792. [DOI: 10.1016/j.leukres.2022.106792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/16/2022] [Accepted: 01/20/2022] [Indexed: 01/19/2023]
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Hum RM, Ho P. Hereditary haemochromatosis presenting to rheumatology clinic as inflammatory arthritis. BMJ Case Rep 2022; 15:e246236. [PMID: 35039359 PMCID: PMC8768489 DOI: 10.1136/bcr-2021-246236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2021] [Indexed: 11/04/2022] Open
Abstract
Hereditary haemochromatosis (HH) is the most commonly identified genetic disorder in Caucasians. HH has a wide variety of clinical manifestations. As such, the presenting complaint in new diagnoses of HH can be non-specific such as fatigue; however, joint symptoms such as arthralgia are also common. These joint symptoms closely mimic the features of other musculoskeletal diseases such as rheumatoid arthritis (RA). Early diagnosis of HH is key to prevent long-term irreversible complications such as liver damage, diabetes and degenerative joint disease. We present a case of HH which was initially suspected to be early RA, with ultrasound findings of active synovitis. High clinical suspicion, a raised serum ferritin followed by genetic testing for C282Y mutation confirmed the diagnosis of HH. The synovitis responded to corticosteroids and was suspected to be due to pseudogout a known complication of HH. Early diagnosis and treatment resulted in a favourable outcome.
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Affiliation(s)
- Ryan Malcolm Hum
- The Kellgren Centre for Rheumatology, Manchester University NHS Foundation Trust, Manchester, UK
- NIHR Biomedical Research Centre, The University of Manchester, Manchester, UK
| | - Pauline Ho
- The Kellgren Centre for Rheumatology, Manchester University NHS Foundation Trust, Manchester, UK
- NIHR Biomedical Research Centre, The University of Manchester, Manchester, UK
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Barton JC, Barton JC, Patel N, McLaren GD. Abdominal pain and cirrhosis at diagnosis of hemochromatosis: Analysis of 219 referred probands with HFE p.C282Y homozygosity and a literature review. PLoS One 2021; 16:e0261690. [PMID: 34932603 PMCID: PMC8691644 DOI: 10.1371/journal.pone.0261690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 12/07/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In hemochromatosis, causes of abdominal pain and its associations with cirrhosis are poorly understood. METHODS We retrospectively compared characteristics of referred hemochromatosis probands with HFE p.C282Y homozygosity with/without biopsy-proven cirrhosis: sex, age, diabetes, heavy alcohol consumption, abdominal pain/tenderness, hepatomegaly, splenomegaly, non-alcoholic fatty liver disease, chronic viral hepatitis, ascites, transferrin saturation (TS), serum ferritin (SF), and iron removed by phlebotomy (QFe). We performed logistic regression on cirrhosis using characteristics identified in univariate comparisons. We performed computerized and manual searches to identify hemochromatosis case series and compiled prevalence data on cirrhosis and abdominal pain and causes of abdominal pain. RESULTS Of 219 probands, 57.1% were men. Mean age was 48±13 y. In 22 probands with cirrhosis, proportions of men, mean age, prevalences of heavy alcohol consumption, abdominal pain, abdominal tenderness, hepatomegaly, splenomegaly, and chronic viral hepatitis, and median TS, SF, and QFe were significantly greater than in probands without cirrhosis. Regression analysis revealed three associations with cirrhosis: abdominal pain (p = 0.0292; odds ratio 9.8 (95% CI: 1.2, 76.9)); chronic viral hepatitis (p = 0.0153; 11.5 (95% CI: 1.6, 83.3)); and QFe (p = 0.0009; 1.2 (95% CI: 1.1, 1.3)). Of eight probands with abdominal pain, five had cirrhosis and four had diabetes. One proband each with abdominal pain had heavy alcohol consumption, chronic viral hepatitis B, hepatic sarcoidosis, hepatocellular carcinoma, and chronic cholecystitis, cholelithiasis, and sigmoid diverticulitis. Abdominal pain was alleviated after phlebotomy alone in four probands. In 12 previous reports (1935-2011), there was a negative correlation of cirrhosis prevalence and publication year (p = 0.0033). In 11 previous reports (1935-1996), a positive association of abdominal pain prevalence and publication year was not significant (p = 0.0802). CONCLUSIONS Abdominal pain, chronic viral hepatitis, and QFe are significantly associated with cirrhosis in referred hemochromatosis probands with HFE p.C282Y homozygosity. Iron-related and non-iron-related factors contribute to the occurrence of abdominal pain.
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Affiliation(s)
- James C. Barton
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States of America
- Southern Iron Disorders Center, Birmingham, AL, United States of America
- * E-mail:
| | - J. Clayborn Barton
- Southern Iron Disorders Center, Birmingham, AL, United States of America
| | - Neha Patel
- Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, CA, United States of America
| | - Gordon D. McLaren
- Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, CA, United States of America
- Department of Veterans Affairs Long Beach Healthcare System, Long Beach, CA, United States of America
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14
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Adams PC, Richard L, Weir M, Speechley M. Survival and development of health conditions after iron depletion therapy in C282Y-linked hemochromatosis patients. CANADIAN LIVER JOURNAL 2021; 4:381-390. [PMID: 35989887 PMCID: PMC9235120 DOI: 10.3138/canlivj-2021-0016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 07/17/2021] [Accepted: 07/18/2021] [Indexed: 09/29/2023]
Abstract
BACKGROUND We report long-term survival and development of selected health conditions in Ontario-based referred and screened C282Y homozygotes for hemochromatosis treated by phlebotomy compared with an untreated control group known to be without HFE mutations. METHODS Patient characteristics and outcomes (all-cause mortality, liver cancer, diabetes, cirrhosis, hip or knee joint replacement, and osteoarthritis) were ascertained using a linked health administrative database held at ICES. Outcomes were assessed between groups without the outcome at baseline using Cox proportional hazards regression adjusted for age and sex. All C282Y homozygotes with elevated serum ferritin were treated by phlebotomy to reach serum ferritin of 50 µg/L. Our cohort included 527 C282Y homozygotes (311 men, 216 women, mean age 48 years) and 12,879 control participants (5,667 men and 7,212 women). RESULTS C282Y homozygotes had an increased risk of all-cause mortality (aHR 1.44 [1.19-1.75], p <0.001); hepatocellular carcinoma (aHR 8.30 [3.97-17.34], p <0.001); hip or knee joint replacement (aHR 3.06 [2.46-3.81], p <0.001); osteoarthritis (aHR 1.72 [1.47-2.01], p <0.001); and cirrhosis (aHR 3.87 [3.05-4.92], p <0.001). C282Y homozygotes did not have an increased risk for diagnosis of diabetes) (aHR 0.84 [0.67-1.07], p = 0.16) during follow-up (median 17.7 y). CONCLUSIONS C282Y homozygotes experience higher death and complication rates than individuals without HFE mutations, despite treatment by phlebotomy. Diabetes did not increase after phlebotomy therapy.
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Affiliation(s)
- Paul C Adams
- Department of Medicine, Western University, London, Ontario, Canada
| | | | - Matthew Weir
- Department of Medicine, Western University, London, Ontario, Canada
- ICES Western, London, Ontario, Canada
| | - Mark Speechley
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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Utility and limitations of Hepascore and transient elastography to detect advanced hepatic fibrosis in HFE hemochromatosis. Sci Rep 2021; 11:14654. [PMID: 34282177 PMCID: PMC8289828 DOI: 10.1038/s41598-021-94083-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/05/2021] [Indexed: 11/08/2022] Open
Abstract
Aspartate aminotransferase-to-platelet ratio index (APRI) and Fibrosis-4 Index (Fib4) have been validated against liver biopsy for detecting advanced hepatic fibrosis in HFE hemochromatosis. We determined the diagnostic utility for advanced hepatic fibrosis of Hepascore and transient elastography compared with APRI and Fib4 in 134 newly diagnosed HFE hemochromatosis subjects with serum ferritin levels > 300 µg/L using area under the receiver operator characteristic curve (AUROC) analysis and APRI- (> 0.44) or Fib4- (> 1.1) cut-offs for AHF, or a combination of both. Compared with APRI, Hepascore demonstrated an AUROC for advanced fibrosis of 0.69 (95% CI 0.56-0.83; sensitivity = 69%, specificity = 65%; P = 0.01) at a cut-off of 0.22. Using a combination of APRI and Fib4, the AUROC for Hepascore for advanced fibrosis was 0.70 (95% CI 0.54-0.86, P = 0.02). Hepascore was not diagnostic for detection of advanced fibrosis using the Fib4 cut-off. Elastography was not diagnostic using either APRI or Fib4 cut-offs. Hepascore and elastography detected significantly fewer true positive or true negative cases of advanced fibrosis compared with APRI and Fib4, except in subjects with serum ferritin levels > 1000 µg/L. In comparison with APRI or Fib4, Hepascore or elastography may underdiagnose advanced fibrosis in HFE Hemochromatosis, except in individuals with serum ferritin levels > 1000 µg/L.
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Chin J, Powell LW, Ramm LE, Hartel GF, Olynyk JK, Ramm GA. Utility of Serum Biomarker Indices for Staging of Hepatic Fibrosis Before and After Venesection in Patients With Hemochromatosis Caused by Variants in HFE. Clin Gastroenterol Hepatol 2021; 19:1459-1468.e5. [PMID: 32745684 DOI: 10.1016/j.cgh.2020.07.052] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/26/2020] [Accepted: 07/27/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Hemochromatosis that is associated with variants in the homeostatic iron regulator gene (HFE) is characterized by intestinal absorption of iron and excessive body and hepatic iron stores; it can lead to hepatic fibrosis and cirrhosis. Fibrosis has been staged by analysis of liver biopsies, but non-invasive staging methods are available. We evaluated the ability of aspartate aminotransferase:platelet ratio index (APRI), the fibrosis-4 (FIB-4) index, and gamma-glutamyl transferase:platelet ratio (GPR) to assess hepatic fibrosis staging in subjects with HFE-associated hemochromatosis, using liver biopsy-staged fibrosis as the reference standard. METHODS We performed a retrospective, cross-sectional analysis of 181 subjects with HFE-associated hemochromatosis and hepatic fibrosis staged by biopsy analysis and available serum samples. We calculated APRI, FIB-4, and GPR at diagnosis for all 181 subjects and following venesection therapy in 64 of these subjects (7 subjects had follow-up biopsy analysis). We used area under the receiver operating characteristic curve (AUROC) analysis to assess the relationships between APRI score, FIB-4 score, and GPR and advanced (F3-F4) fibrosis and to select cut-off values. RESULTS Hepatic fibrosis stage correlated with APRI score (r = 0.54; P < .0001), FIB-4 score (r = 0.35; P < .0001), and GPR (r = 0.36, P < .0001). An APRI score above 0.44 identified patients with advanced fibrosis with an AUROC of 0.88, 79.4% sensitivity, 79.4% specificity, and 81% accuracy. A FIB-4 score above 1.1 identified patients with advanced fibrosis with an AUROC of 0.86, 80% sensitivity, 80.3% specificity, and 81% accuracy. A GPR above 0.27 identified patients with advanced fibrosis with an AUROC of 0.76, 67.7% sensitivity, 70.3% specificity, and 69% accuracy. APRI score was significantly more accurate than GPR (P = .05) in detecting advanced fibrosis; there was no difference between APRI and FIB-4. Venesection treatment was associated with significant reductions in APRI (P < .0001) and GPR (P < .001), paralleling fibrosis regression observed in available liver biopsies. Post-venesection APRI identified 87% of subjects with advanced fibrosis that decreased to levels that indicate stage F1-F2 fibrosis. CONCLUSIONS In a retrospective study of 181 subjects with HFE-associated hemochromatosis, we found that APRI and FIB-4 scores identified patients with advanced hepatic fibrosis with 81% accuracy. APRI scores might also be used to monitor fibrosis regression following venesection.
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Affiliation(s)
- Justin Chin
- Department of Gastroenterology & Hepatology, Fiona Stanley Fremantle Hospital Group, Murdoch, Western Australia, Australia
| | - Lawrie W Powell
- Faculty of Medicine, University of Queensland, Herston, Brisbane, Queensland, Australia
| | - Louise E Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Gunter F Hartel
- Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - John K Olynyk
- Department of Gastroenterology & Hepatology, Fiona Stanley Fremantle Hospital Group, Murdoch, Western Australia, Australia; School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Grant A Ramm
- Faculty of Medicine, University of Queensland, Herston, Brisbane, Queensland, Australia; Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.
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17
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Anderson GJ, Bardou-Jacquet E. Revisiting hemochromatosis: genetic vs. phenotypic manifestations. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:731. [PMID: 33987429 PMCID: PMC8106074 DOI: 10.21037/atm-20-5512] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Iron overload disorders represent an important class of human diseases. Of the primary iron overload conditions, by far the most common and best studied is HFE-related hemochromatosis, which results from homozygosity for a mutation leading to the C282Y substitution in the HFE protein. This disease is characterized by reduced expression of the iron-regulatory hormone hepcidin, leading to increased dietary iron absorption and iron deposition in multiple tissues including the liver, pancreas, joints, heart and pituitary. The phenotype of HFE-related hemochromatosis is quite variable, with some individuals showing little or no evidence of increased body iron, yet others showing severe iron loading, tissue damage and clinical sequelae. The majority of genetically predisposed individuals show at least some evidence of iron loading (increased transferrin saturation and serum ferritin), but a minority show clinical symptoms and severe consequences are rare. Thus, the disorder has a high biochemical penetrance, but a low clinical prevalence. Nevertheless, it is such a common condition in Caucasian populations (1:100–200) that it remains an important clinical entity. The phenotypic variability can largely be explained by a range of environmental, genetic and physiological factors. Men are far more likely to manifest significant disease than women, with the latter losing iron through menstrual blood loss and childbirth. Other forms of blood loss, immune system influences, the amount of bioavailable iron in the diet and lifestyle factors such as high alcohol intake can also contribute to iron loading and disease expression. Polymorphisms in a range of genes have been linked to variations in body iron levels, both in the general population and in hemochromatosis. Some of the genes identified play well known roles in iron homeostasis, yet others are novel. Other factors, including both co-morbidities and genetic polymorphisms, do not affect iron levels per se, but determine the propensity for tissue pathology.
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Affiliation(s)
- Gregory J Anderson
- Iron Metabolism Laboratory, QIMR Berghofer Medical Research Institute and School of Chemistry and Molecular Bioscience, University of Queensland, Brisbane, Queensland, Australia
| | - Edouard Bardou-Jacquet
- Liver Disease Department, University of Rennes and French Reference Center for Hemochromatosis and Iron Metabolism Disease, Rennes, France
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18
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Monte F, Garrido M, Pereira Guedes T, Reis J, Porto G, Pedroto I. Hemochromatosis and Xeroderma Pigmentosum: Two (Un)Suspicious Neighbors. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2021; 29:38-44. [DOI: 10.1159/000513587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 10/19/2020] [Indexed: 11/19/2022]
Abstract
A 51-year-old woman, clinically diagnosed with <i>Xeroderma pigmentosum</i> (XP), showed abnormalities in liver enzymes, high ferritin and transferrin saturation levels, with ultrasonographic features of chronic liver disease, in addition to skin hyperpigmentation. Genetic testing confirmed the clinical hypothesis of hereditary hemochromatosis (HH). Due to the known proximity of HFE (6p22.2) and POLH (6p21.1) genes, accountable for HH and the XP-V variant, respectively, a genetic test was offered and a rare variant of the POLH gene was identified. We report the first confirmed case, to our knowledge, of a patient diagnosed both with XP and HH, in whom two mutated neighbor genes – POLH and HFE – were identified, possibly the result of genetic linkage.
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19
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Alqanatish J, Alsowailmi B, Alfarhan H, Alhamzah A, Alharbi T. Juvenile Hemochromatosis: Rheumatic Manifestations of 2 Sisters Responding to Deferasirox Treatment. A Case Series and Literature Review. Open Access Rheumatol 2021; 13:15-21. [PMID: 33488128 PMCID: PMC7815067 DOI: 10.2147/oarrr.s276112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/27/2020] [Indexed: 12/24/2022] Open
Abstract
Hereditary hemochromatosis (HH) is an inherited iron overload. The most common form of HH is type 1 hereditary hemochromatosis (HFE-related), which is associated with mutation of the HFE gene located on chromosome 6 and inherited in an autosomal recessive pattern. Type 2 hereditary hemochromatosis or juvenile hemochromatosis is less frequent autosomal recessive disease that results from mutations in the HJV gene on chromosome 1 (type2a) or the HAMP gene on chromosome19 (type2b). Mutation of type 2 transferrin receptor gene and mutation of the ferroportin gene result in hemochromatosis type 3 and hemochromatosis type 4, respectively. Juvenile hemochromatosis is characterized by an early onset of excess accumulation of iron in various organs. It could affect the liver, heart, pancreas and joints, resulting in arthropathy. Most juvenile hemochromatosis cases exhibit severe symptoms due to early onset. Cardiac and hypogonadism are the dominating features of the disease. Prevalence of arthropathy in juvenile hemochromatosis is higher than classic HH. Early diagnosis and intervention of juvenile hemochromatosis may prevent irreversible organ damage. The diagnosis can be made based on laboratory testing (of increased transferrin saturation, serum iron and ferritin levels), liver biopsy, imaging or genotype. According to international guidelines, treatment of HH is indicated when serum ferritin concentrations are above the upper limit of normal. We report two sisters who presented to the rheumatology clinic with arthralgia, which was subsequently found to have a homozygous mutation variant of unknown significance in the HFE2 gene: c.497A>G;p.(His166Arg) and has been treated with deferasirox (Exjade®). Musculoskeletal symptoms completely resolved in both patients in two months and remained so for one year on treatment.
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Affiliation(s)
- Jubran Alqanatish
- King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh 14611, Saudi Arabia.,King Abdullah International Medical Research Center (KAIMRC), Riyadh 14611, Saudi Arabia.,Department of Pediatrics, King Abdullah Specialist Children's Hospital and King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Banan Alsowailmi
- King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh 14611, Saudi Arabia
| | - Haneen Alfarhan
- King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh 14611, Saudi Arabia
| | - Albandari Alhamzah
- King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh 14611, Saudi Arabia
| | - Talal Alharbi
- King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh 14611, Saudi Arabia.,King Abdullah International Medical Research Center (KAIMRC), Riyadh 14611, Saudi Arabia.,Department of Pediatric Hematology/Oncology, King Abdullah Specialist Children's Hospital and King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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20
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Atkins JL, Pilling LC, Masoli JAH, Kuo CL, Shearman JD, Adams PC, Melzer D. Association of Hemochromatosis HFE p.C282Y Homozygosity With Hepatic Malignancy. JAMA 2020; 324:2048-2057. [PMID: 33231665 PMCID: PMC7686863 DOI: 10.1001/jama.2020.21566] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Hereditary hemochromatosis is predominantly caused by the HFE p.C282Y homozygous pathogenic variant. Liver carcinoma and mortality risks are increased in individuals with clinically diagnosed hereditary hemochromatosis, but risks are unclear in mostly undiagnosed p.C282Y homozygotes identified in community genotyping. OBJECTIVE To estimate the incidence of primary hepatic carcinoma and death by HFE variant status. DESIGN, SETTING, AND PARTICIPANTS Cohort study of 451 186 UK Biobank participants of European ancestry (aged 40-70 years), followed up from baseline assessment (2006-2010) until January 2018. EXPOSURES Men and women with HFE p.C282Y and p.H63D genotypes compared with those with neither HFE variants. MAIN OUTCOMES AND MEASURES Two linked co-primary outcomes (incident primary liver carcinoma and death from any cause) were ascertained from follow-up via hospital inpatient records, national cancer registry, and death certificate records, and from primary care data among a subset of participants for whom data were available. Associations between genotype and outcomes were tested using Cox regression adjusted for age, assessment center, genotyping array, and population genetics substructure. Kaplan-Meier lifetable probabilities of incident diagnoses were estimated from age 40 to 75 years by HFE genotype and sex. RESULTS A total of 451 186 participants (mean [SD] age, 56.8 [8.0] years; 54.3% women) were followed up for a median (interquartile range) of 8.9 (8.3-9.5) years. Among the 1294 male p.C282Y homozygotes, there were 21 incident hepatic malignancies, 10 of which were in participants without a diagnosis of hemochromatosis at baseline. p.C282Y homozygous men had a higher risk of hepatic malignancies (hazard ratio [HR], 10.5 [95% CI, 6.6-16.7]; P < .001) and all-cause mortality (n = 88; HR, 1.2 [95% CI, 1.0-1.5]; P = .046) compared with men with neither HFE variant. In lifetables projections for male p.C282Y homozygotes to age 75 years, the risk of primary hepatic malignancy was 7.2% (95% CI, 3.9%-13.1%), compared with 0.6% (95% CI, 0.4%-0.7%) for men with neither variant, and the risk of death was 19.5% (95% CI, 15.8%-24.0%), compared with 15.1% (95% CI, 14.7%-15.5%) among men with neither variant. Among female p.C282Y homozygotes (n = 1596), there were 3 incident hepatic malignancies and 60 deaths, but the associations between homozygosity and hepatic malignancy (HR, 2.1 [95% CI, 0.7-6.5]; P = .22) and death (HR, 1.2 [95% CI, 0.9-1.5]; P = .20) were not statistically significant. CONCLUSIONS AND RELEVANCE Among men with HFE p.C282Y homozygosity, there was a significantly increased risk of incident primary hepatic malignancy and death compared with men without p.C282Y or p.H63D variants; there was not a significant association for women. Further research is needed to understand the effects of early diagnosis and treatment.
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Affiliation(s)
- Janice L. Atkins
- Epidemiology and Public Health Group, University of Exeter Medical School, Exeter, United Kingdom
| | - Luke C. Pilling
- Epidemiology and Public Health Group, University of Exeter Medical School, Exeter, United Kingdom
- Center on Aging, University of Connecticut Health Center, Farmington
| | - Jane A. H. Masoli
- Epidemiology and Public Health Group, University of Exeter Medical School, Exeter, United Kingdom
- Department of Healthcare for Older People, Royal Devon and Exeter Hospital, Barrack Road, Exeter, United Kingdom
| | - Chia-Ling Kuo
- Center on Aging, University of Connecticut Health Center, Farmington
| | - Jeremy D. Shearman
- Department of Gastroenterology, South Warwickshire NHS Foundation Trust, United Kingdom
| | - Paul C. Adams
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - David Melzer
- Epidemiology and Public Health Group, University of Exeter Medical School, Exeter, United Kingdom
- Center on Aging, University of Connecticut Health Center, Farmington
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21
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Parmanand B, Watson M, Boland KJ, Ramamurthy N, Wharton V, Morovat A, Lund EK, Collier J, Le Gall G, Kellingray L, Fairweather-Tait S, Cobbold JF, Narbad A, Ryan JD. Systemic iron reduction by venesection alters the gut microbiome in patients with haemochromatosis. JHEP Rep 2020; 2:100154. [PMID: 32995714 PMCID: PMC7516344 DOI: 10.1016/j.jhepr.2020.100154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 06/29/2020] [Accepted: 07/15/2020] [Indexed: 12/22/2022] Open
Abstract
Background & Aims Iron reduction by venesection has been the cornerstone of treatment for haemochromatosis for decades, and its reported health benefits are many. Repeated phlebotomy can lead to a compensatory increase in intestinal iron absorption, reducing intestinal iron availability. Given that most gut bacteria are highly dependent on iron for survival, we postulated that, by reducing gut iron levels, venesection could alter the gut microbiota. Methods Clinical parameters, faecal bacterial composition and metabolomes were assessed before and during treatment in a group of patients with haemochromatosis undergoing iron reduction therapy. Results Systemic iron reduction was associated with an alteration of the gut microbiome, with changes evident in those who experienced reduced faecal iron availability with venesection. For example, levels of Faecalibacterium prausnitzii, a bacterium associated with improved colonic health, were increased in response to faecal iron reduction. Similarly, metabolomic changes were seen in association with reduced faecal iron levels. Conclusion These findings highlight a significant shift in the gut microbiome of patients who experience reduced colonic iron during venesection. Targeted depletion of faecal iron could represent a novel therapy for metabolic and inflammatory diseases, meriting further investigation. Lay summary Iron depletion by repeated venesection is the mainstay of treatment for haemochromatosis, an iron-overload disorder. Venesection has been associated with several health benefits, including improvements in liver function tests, reversal of liver scarring, and reduced risk of liver cancer. During iron depletion, iron absorption from the gastrointestinal (GI) tract increases to compensate for iron lost with treatment. Iron availability is limited in the GI tract and is crucial to the growth and function of many gut bacteria. In this study we show that reduced iron availability in the colon following venesection treatment leads to a change in the composition of the gut bacteria, a finding that, to date, has not been studied in patients with haemochromatosis. Venesection is the cornerstone of haemochromatosis treatment. Venesection leads to a compensatory increase in intestinal iron absorption. Reduced faecal iron availability leads to shifts in human colonic microbial composition. Changes in the human colonic metabolome occur with reduced faecal iron availability.
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Key Words
- ALT, alanine aminotransferase
- CRP, C-reactive protein
- FAAS, flame atomic absorption spectrophotometry
- GI, gastrointestinal
- HFE, hyperferritinaemia
- HH, hereditary haemachromatosis
- Haemochromatosis
- Iron
- LDA, linear discriminant analysis
- LEfSe, linear discriminant analysis effect size
- Microbiome
- TSP, 3-(trimethylsilyl)-propionate-d4
- Venesection
- WCC, white cell count
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Affiliation(s)
- Bhavika Parmanand
- Quadram Institute, Norwich, UK.,University of East Anglia, Norwich, UK
| | - Michael Watson
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Karen J Boland
- Department of Gastroenterology, Beaumont Hospital/Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Victoria Wharton
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Alireza Morovat
- Department of Clinical Biochemistry, Oxford University Hospitals Foundation Trust, Oxford, UK
| | | | - Jane Collier
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK
| | | | | | | | - Jeremy F Cobbold
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK
| | | | - John D Ryan
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK.,Hepatology Unit, Beaumont Hospital/Royal College of Surgeons in Ireland, Dublin, Ireland
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22
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Prabhu A, Cargill T, Roberts N, Ryan JD. Systematic Review of the Clinical Outcomes of Iron Reduction in Hereditary Hemochromatosis. Hepatology 2020; 72:1469-1482. [PMID: 32500577 DOI: 10.1002/hep.31405] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/08/2020] [Accepted: 05/13/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Anil Prabhu
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, United Kingdom
| | - Tamsin Cargill
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, United Kingdom
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, United Kingdom
| | - John D Ryan
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, United Kingdom.,Hepatology Unit, Beaumont Hospital, Dublin 9, Ireland
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23
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Bardou-Jacquet E, Morandeau E, Anderson GJ, Ramm GA, Ramm LE, Morcet J, Bouzille G, Dixon J, Clouston AD, Lainé F, Turlin B, Powell LW, Deugnier YM. Regression of Fibrosis Stage With Treatment Reduces Long-Term Risk of Liver Cancer in Patients With Hemochromatosis Caused by Mutation in HFE. Clin Gastroenterol Hepatol 2020; 18:1851-1857. [PMID: 31622736 DOI: 10.1016/j.cgh.2019.10.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/20/2019] [Accepted: 10/04/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Fibrosis stage can decrease following treatment in patients with hemochromatosis caused by mutations in the homeostatic iron regulator gene (HFE), but the effects on cirrhosis are not clear. We assessed regression of severe fibrosis and the ensuing risk of liver cancer after treatment. METHODS We performed a retrospective analysis of data from 106 patients in France or Australia who were homozygous for the C282Y mutation in HFE with F3 fibrosis (n = 40) or F4 fibrosis (n = 66) at diagnosis and from whom at least 1 liver biopsy was collected during follow up. We collected data from the time of first biopsy and during follow-up period on patient demographics, treatment, smoking habits, alcohol consumption, infection with hepatitis B or C viruses, and other diseases. The median time between first and last liver biopsy was 9.5 years (range, 3.5-15.6 years). We collected results of tests for liver function, markers of iron stores, and platelet levels. Patients were followed for a median 17.6 years (range, 9.8-24.1 years) for development of liver cancer occurrence. RESULTS At last liver biopsy, 41 patients (38.6%) had fibrosis scores of F2 or less. Liver cancer occurred in 34 patients (52.3%) with F3 or F4 fibrosis at last liver biopsy vs 2 patients (4.8%) with fibrosis scores of F2 or less at last liver biopsy (P < .001). Liver cancer incidences were 32.8 per 1000 person-years (95% CI, 22.7-45.9 per 1000 person-years) in patients with F3 or F4 fibrosis and 2.3 per 1000 person-years (95% CI, 0.2-8.6 per 1000 person-years) in patients with fibrosis scores of F2 or less (P < .001). In multivariate analysis, male sex (hazard ratio [HR], 6.09; 95% CI, 1.21-30.4), age at diagnosis (HR, 1.16; 95% CI, 1.09-1.25), presence of diabetes (HR, 3.07; 95% CI, 1.35-6.97), excess alcohol consumption (HR, 3.1; 95% CI, 1.47-6.35), serum level of ferritin at diagnosis (P < .01), and regression to fibrosis scores of F2 or less (HR, 0.08; 95% CI, 0.01-0.62) were significantly associated with risk of liver cancer. CONCLUSIONS In a retrospective analysis of patients with hemochromatosis caused by the C282Y mutation in HFE, we found that severe liver fibrosis can regress with treatment. In patients with fibrosis regression to a stage F2 or less, the long-term risk for liver cancer is significantly reduced.
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Affiliation(s)
- Edouard Bardou-Jacquet
- University of Rennes, CHU Rennes, INSERM, CIC 1414, Liver Disease Department, French Reference Center for Hemochromatosis and Iron Metabolism Disease, Rennes, France.
| | | | - Gregory J Anderson
- Iron Metabolism Laboratory, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Grant A Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Louise E Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | | | | | - Jeannette Dixon
- Iron Metabolism Laboratory, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Andrew D Clouston
- Faculty of Health Sciences, University of Queensland, Envoi Specialist Pathologists, Brisbane, QLD, Australia
| | - Fabrice Lainé
- CHU Rennes, INSERM, Liver Disease Department, CIC 1414, Rennes, France
| | - Bruno Turlin
- University of Rennes, CHU Rennes, INSERM, Pathology Department, French Reference Center for Hemochromatosis and Iron Metabolism Disease, Rennes, France
| | - Lawrie W Powell
- Iron Metabolism Laboratory, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Yves M Deugnier
- University of Rennes, CHU Rennes, INSERM, CIC 1414, Liver Disease Department, French Reference Center for Hemochromatosis and Iron Metabolism Disease, Rennes, France
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24
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Chin J, Powell LW, Ramm LE, Ayonrinde OT, Ramm GA, Olynyk JK. Utility of hepatic or total body iron burden in the assessment of advanced hepatic fibrosis in HFE hemochromatosis. Sci Rep 2019; 9:20234. [PMID: 31882912 PMCID: PMC6934689 DOI: 10.1038/s41598-019-56732-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 12/03/2019] [Indexed: 01/02/2023] Open
Abstract
Development of advanced hepatic fibrosis in HFE Hemochromatosis (HH) is influenced by hepatic iron concentration (HIC) and age. In patients with HH, it is important to assess the likelihood of cirrhosis and thus the need for confirmatory liver biopsy. Therapeutic phlebotomy also provides an estimate of mobilisable iron stores. We determined whether mobilisable iron stores may predict the presence of advanced fibrosis. Retrospective analysis of 137 male and 65 female HH subjects was undertaken. Biochemical, histological and phlebotomy data were available on all subjects. The mean values of HIC, HIC × [age], mobilisable iron, mobilisable iron × [age] and serum ferritin in the cohort were higher in the group with advanced fibrosis. HIC had an optimum sensitivity and specificity of 73% for the diagnosis of advanced liver fibrosis, with a cut-off HIC level of 200 µmol/g (AUROC 0.83, p < 0.0001). AUROC for HIC was greater in females (0.93) than males (0.79). Mobilisable iron had an optimum sensitivity and specificity both of 83% at a cut-off of 9.6 g for the prediction of advanced fibrosis in all subjects (AUROC 0.92, p < 0.0001). Mobilisable iron stores provide a simple, clinically useful indication of the risk of advanced fibrosis and should routinely be considered.
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Affiliation(s)
- Justin Chin
- Department of Gastroenterology & Hepatology, Fiona Stanley Fremantle Hospital Group, Murdoch, Western Australia, Australia.
| | - Lawrie W Powell
- Faculty of Medicine, The University of Queensland, Herston, Brisbane, Queensland, Australia
| | - Louise E Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Oyekoya T Ayonrinde
- Department of Gastroenterology & Hepatology, Fiona Stanley Fremantle Hospital Group, Murdoch, Western Australia, Australia
| | - Grant A Ramm
- Faculty of Medicine, The University of Queensland, Herston, Brisbane, Queensland, Australia.,Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - John K Olynyk
- Department of Gastroenterology & Hepatology, Fiona Stanley Fremantle Hospital Group, Murdoch, Western Australia, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
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Schonfeld EA, Brown RS. Genetic Causes of Liver Disease: When to Suspect a Genetic Etiology, Initial Lab Testing, and the Basics of Management. Med Clin North Am 2019; 103:991-1003. [PMID: 31582009 DOI: 10.1016/j.mcna.2019.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Genetic causes of liver disease lead to a wide range of presentations. This article describes hereditary hemochromatosis, Gilbert syndrome, alpha-1 antitrypsin deficiency, Wilson disease, PFIC, BRIC, and LAL-D. The most common cause of hereditary hemochromatosis is a C282Y mutation in the HFE gene. Gilbert syndrome is a benign cause of indirect hyperbilirubinemia. Alpha-1 antitrypsin deficiency causes both lung and liver disease. Wilson disease can cause neurologic disease and liver disease. Progressive familial intrahepatic cholestasis and benign recurrent intrahepatic cholestasis are rare causes of cholestasis. LAL-D is a rare disease that can appear similar to NAFLD in adults.
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Affiliation(s)
- Emily A Schonfeld
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, 7th Floor, Aurora, CO 80045, USA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, 1305 York Avenue, 4th Floor, New York, NY 10021, USA.
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HFE Related Hemochromatosis: Uncovering the Inextricable Link between Iron Homeostasis and the Immunological System. Pharmaceuticals (Basel) 2019; 12:ph12030122. [PMID: 31443397 PMCID: PMC6789554 DOI: 10.3390/ph12030122] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/14/2019] [Accepted: 08/15/2019] [Indexed: 02/07/2023] Open
Abstract
The HFE gene (OMIM 235200), most commonly associated with the genetic iron overload disorder Hemochromatosis, was identified by Feder et al. in 1996, as a major histocompatibilty complex (MHC) class I like gene, first designated human leukocyte antigen-H (HLA-H). This discovery was thus accomplished 20 years after the realization of the first link between the then "idiopathic" hemochromatosis and the human leukocyte antigens (HLA). The availability of a good genetic marker in subjects homozygous for the C282Y variant in HFE (hereditary Fe), the reliability in serum markers such as transferrin saturation and serum ferritin, plus the establishment of noninvasive methods for the estimation of hepatic iron overload, all transformed hemochromatosis into a unique age related disease where prevention became the major goal. We were challenged by the finding of iron overload in a 9-year-old boy homozygous for the C282Y HFE variant, with two brothers aged 11 and 5 also homozygous for the mutation. We report a 20 year follow-up during which the three boys were seen yearly with serial determinations of iron parameters and lymphocyte counts. This paper is divided in three sections: Learning, applying, and questioning. The result is the illustration of hemochromatosis as an age related disease in the transition from childhood to adult life and the confirmation of the inextricable link between iron overload and the cells of the immune system.
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Abstract
Hereditary hemochromatosis (HH) is one of the most common genetic disorders among persons of northern European descent. There have been recent advances in the diagnosis, management, and treatment of HH. The availability of molecular diagnostic testing for HH has made possible confirmation of the diagnosis for most patients. Several genotype-phenotype correlation studies have clarified the differences in clinical features between patients with the C282Y homozygous genotypes and other HFE mutation patterns. The increasing use of noninvasive tests such as MRI T2* has made quantification of hepatic iron deposition easier and eliminated the need for liver biopsy in most patients. Serum ferritin of <1,000 ng/mL at diagnosis remains an important diagnostic test to identify patients with a low risk of advanced hepatic fibrosis and should be used routinely as part of the initial diagnostic evaluation. Genetic testing for other types of HH is available but is expensive and generally not useful in most clinical settings. Serum ferritin may be elevated among patients with nonalcoholic fatty liver disease and in those with alcoholic liver disease. These diagnoses are more common than HH among patients with elevated serum ferritin who are not C282Y homozygotes or C282Y/H63D compound heterozygotes. A secondary cause for liver disease should be excluded among patients with suspected iron overload who are not C282Y homozygotes. Phlebotomy remains the mainstay of therapy, but emerging novel therapies such as new chelating agents may have a role for selected patients.
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28
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Mehta KJ, Farnaud SJ, Sharp PA. Iron and liver fibrosis: Mechanistic and clinical aspects. World J Gastroenterol 2019; 25:521-538. [PMID: 30774269 PMCID: PMC6371002 DOI: 10.3748/wjg.v25.i5.521] [Citation(s) in RCA: 146] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/02/2019] [Accepted: 01/10/2019] [Indexed: 02/06/2023] Open
Abstract
Liver fibrosis is characterised by excessive deposition of extracellular matrix that interrupts normal liver functionality. It is a pathological stage in several untreated chronic liver diseases such as the iron overload syndrome hereditary haemochromatosis, viral hepatitis, alcoholic liver disease, non-alcoholic fatty liver disease, non-alcoholic steatohepatitis and diabetes. Interestingly, regardless of the aetiology, iron-loading is frequently observed in chronic liver diseases. Excess iron can feed the Fenton reaction to generate unquenchable amounts of free radicals that cause grave cellular and tissue damage and thereby contribute to fibrosis. Moreover, excess iron can induce fibrosis-promoting signals in the parenchymal and non-parenchymal cells, which accelerate disease progression and exacerbate liver pathology. Fibrosis regression is achievable following treatment, but if untreated or unsuccessful, it can progress to the irreversible cirrhotic stage leading to organ failure and hepatocellular carcinoma, where resection or transplantation remain the only curative options. Therefore, understanding the role of iron in liver fibrosis is extremely essential as it can help in formulating iron-related diagnostic, prognostic and treatment strategies. These can be implemented in isolation or in combination with the current approaches to prepone detection, and halt or decelerate fibrosis progression before it reaches the irreparable stage. Thus, this review narrates the role of iron in liver fibrosis. It examines the underlying mechanisms by which excess iron can facilitate fibrotic responses. It describes the role of iron in various clinical pathologies and lastly, highlights the significance and potential of iron-related proteins in the diagnosis and therapeutics of liver fibrosis.
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Affiliation(s)
- Kosha J Mehta
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King’s College London, London SE1 1UL, United Kingdom
- Division of Human Sciences, School of Applied Sciences, London South Bank University, London SE1 0AA, United Kingdom
| | - Sebastien Je Farnaud
- Faculty Research Centre for Sport, Exercise and Life Sciences, Coventry University, Coventry CV1 2DS, United Kingdom
| | - Paul A Sharp
- Department of Nutritional Sciences, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London SE1 9NH, United Kingdom
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29
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Wynne K, Devereaux B, Dornhorst A. Diabetes of the exocrine pancreas. J Gastroenterol Hepatol 2019; 34:346-354. [PMID: 30151918 DOI: 10.1111/jgh.14451] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 07/31/2018] [Accepted: 08/19/2018] [Indexed: 12/11/2022]
Abstract
Diabetes of the exocrine pancreas (DEP) is a form of diabetes that occurs due to pancreatic disease. It is far more common than has been previously considered, with a recent study showing 1.8% of adults with new-onset diabetes should have been classified as DEP. The majority is misdiagnosed as type 2 diabetes mellitus (T2DM). Patients with DEP exhibit varying degrees of exocrine and endocrine dysfunction. Damage to the islet of Langerhans effects the secretion of hormones from the β, α, and pancreatic polypeptide cells; the combination of low insulin, glucagon, and pancreatic polypeptide contributes to rapid fluctuations in glucose levels. This form of "brittle diabetes" may result in the poorer glycemic control observed in patients with DEP, when compared with those with T2DM. Diabetes of the exocrine pancreas has a different natural history to other forms of diabetes; patients are more likely to require early insulin initiation compared with those with T2DM. Therefore, individuals with DEP should be advised about the symptoms of decompensated hyperglycemia, although they are less likely to develop ketoacidosis. Clinicians should screen for DEP in patients with acute or chronic pancreatitis, following pancreatic resection, or with co-existing cystic fibrosis or hemochromatosis. Incident diabetes may herald the onset of pancreatic ductal carcinoma in a small subset of patients. Once identified, patients with DEP can benefit from specific lifestyle advice, pancreatic enzyme replacement therapy, metformin treatment, appropriate insulin dosing, and monitoring. Further research is needed to establish the ideal treatment regimens to provide optimal clinical outcomes for this unique form of diabetes.
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Affiliation(s)
- Katie Wynne
- Department of Diabetes and Endocrinology, John Hunter Hospital, Newcastle, New South Wales, Australia.,University of Newcastle, Newcastle, New South Wales, Australia
| | - Benedict Devereaux
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
| | - Anne Dornhorst
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK.,Imperial College London, London, UK
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30
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Golfeyz S, Lewis S, Weisberg IS. Hemochromatosis: pathophysiology, evaluation, and management of hepatic iron overload with a focus on MRI. Expert Rev Gastroenterol Hepatol 2018; 12:767-778. [PMID: 29966105 DOI: 10.1080/17474124.2018.1496016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Hereditary hemochromatosis (HH) is an autosomal recessive disorder that occurs in approximately 1 in 200-250 individuals. Mutations in the HFE gene lead to excess iron absorption. Excess iron in the form of non-transferrin-bound iron (NTBI) causes injury and is readily uptaken by cardiomyocytes, pancreatic islet cells, and hepatocytes. Symptoms greatly vary among patients and include fatigue, abdominal pain, arthralgias, impotence, decreased libido, diabetes, and heart failure. Untreated hemochromatosis can lead to chronic liver disease, fibrosis, cirrhosis, and hepatocellular carcinoma (HCC). Many invasive and noninvasive diagnostic tests are available to aid in diagnosis and treatment. MRI has emerged as the reference standard imaging modality for the detection and quantification of hepatic iron deposition, as ultrasound (US) is unable to detect iron overload and computed tomography (CT) findings are nonspecific and influenced by multiple confounding variables. If caught and treated early, HH disease progression can significantly be altered. Area covered: The data on Hemochromatosis, iron overload, and MRI were gathered by searching PubMed. Expert commentary: MRI is a great tool for diagnosis and management of iron overload. It is safe, effective, and a standard protocol should be included in diagnostic algorithms of future treatment guidelines.
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Affiliation(s)
- Shmuel Golfeyz
- a Department of Internal Medicine , Mount Sinai Beth Israel , New York , NY , USA
| | - Sara Lewis
- b Department of Radiology , Icahn School of Medicine at Mount Sinai , New York , NY , USA.,c Translational and Molecular Imaging Institute , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - Ilan S Weisberg
- d Department of Digestive Diseases and Hepatology , Mount Sinai Beth Israel , New York , NY , USA
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31
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Pirasteh A, Yuan Q, Hernando D, Reeder SB, Pedrosa I, Yokoo T. Inter-method reproducibility of biexponential R 2 MR relaxometry for estimation of liver iron concentration. Magn Reson Med 2018; 80:2691-2701. [PMID: 29770484 DOI: 10.1002/mrm.27348] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 04/03/2018] [Accepted: 04/16/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE To assess the reproducibility of biexponential R2 -relaxometry MRI for estimation of liver iron concentration (LIC) between proprietary and nonproprietary analysis methods. METHODS This single-center retrospective study, approved by investigational review board and compliant with the Health Insurance Portability and Accountability Act, included 40 liver MRI exams in 38 subjects with suspected or known iron overload. From spin-echo images of the liver, acquired at 5 different echo times (TE = 6-18 ms), biexponential R2 maps were calculated using 1 proprietary (FerriScan, Resonance Health Ltd., Claremont WA, Australia) and 3 nonproprietary (simulated annealing, nonlinear least squares, dictionary search) analysis methods. Each subject's average liver R2 value was converted to LIC using a previously validated calibration curve. Inter-method reproducibility for liver R2 and LIC were assessed for linearity using linear regression analysis and absolute agreement using intraclass correlation and Bland-Altman analysis. For point estimates, 95% confidence intervals were calculated; P values < 0.05 were considered statistically significant. RESULTS Linearity between the proprietary and nonproprietary methods was excellent across the observed range for R2 (20-312 s-1 ) and LIC (0.4-52.2 mg/g), with all coefficients of determination (R2 ) ≥ 0.95. No statistically significant bias was found (slope estimates ∼ 1; intercept estimates ∼ 0; P values > 0.05). Agreement between the 4 methods was excellent for both liver R2 and LIC (intraclass correlations ≥ 0.97). Bland-Altman 95% limits of agreement in % difference between the proprietary and nonproprietary methods were ≤ 9% and ≤ 16% for R2 and LIC, respectively. CONCLUSION Biexponential R2 -relaxometry MRI for LIC estimation is reproducible between proprietary and nonproprietary analysis methods.
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Affiliation(s)
- Ali Pirasteh
- Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Qing Yuan
- Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Diego Hernando
- Radiology, Medical Physics, University of Wisconsin, Madison, Wisconsin
| | - Scott B Reeder
- Radiology, Medical Physics, Biomedical Engineering, Medicine, Emergency Medicine, University of Wisconsin, Madison, Wisconsin
| | - Ivan Pedrosa
- Radiology, University of Texas Southwestern Medical Center, Dallas, Texas.,Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Takeshi Yokoo
- Radiology, University of Texas Southwestern Medical Center, Dallas, Texas.,Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, Texas
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32
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Fitzsimons EJ, Cullis JO, Thomas DW, Tsochatzis E, Griffiths WJH. Diagnosis and therapy of genetic haemochromatosis (review and 2017 update). Br J Haematol 2018; 181:293-303. [PMID: 29663319 DOI: 10.1111/bjh.15164] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
| | - Jonathan O Cullis
- Department of Haematology, Salisbury NHS Foundation Trust, Salisbury, UK
| | - Derrick W Thomas
- Department of Haematology, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Emmanouil Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free London NHS Foundation Trust and UCL, London, UK
| | - William J H Griffiths
- Department of Hepatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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33
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Grosse SD, Gurrin LC, Bertalli NA, Allen KJ. Clinical penetrance in hereditary hemochromatosis: estimates of the cumulative incidence of severe liver disease among HFE C282Y homozygotes. Genet Med 2018; 20:383-389. [PMID: 28771247 PMCID: PMC5797490 DOI: 10.1038/gim.2017.121] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 06/07/2017] [Indexed: 12/28/2022] Open
Abstract
Iron overload (hemochromatosis) can cause serious, symptomatic disease that is preventable if detected early and managed appropriately. The leading cause of hemochromatosis in populations of predominantly European ancestry is homozygosity of the C282Y variant in the HFE gene. Screening of adults for iron overload or associated genotypes is controversial, largely because of a belief that severe phenotypes are uncommon, although cascade testing of first-degree relatives of patients is widely endorsed. We contend that severe liver disease (cirrhosis or hepatocellular cancer) is not at all uncommon among older males with hereditary hemochromatosis. Our review of the published data from a variety of empirical sources indicates that roughly 1 in 10 male HFE C282Y homozygotes is likely to develop severe liver disease during his lifetime unless iron overload is detected early and treated. New evidence from a randomized controlled trial of treatment allows for evidence-based management of presymptomatic patients. Although population screening for HFE C282Y homozygosity faces multiple barriers, a potentially effective strategy for increasing the early detection and prevention of clinical iron overload and severe disease is to include HFE C282Y homozygosity in lists of medically actionable gene variants when reporting the results of genome or exome sequencing.
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Affiliation(s)
- Scott D. Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lyle C. Gurrin
- Department of Gut and Liver, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, University of Melbourne, Melbourne, Victoria, Australia
| | - Nadine A. Bertalli
- Department of Gut and Liver, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, University of Melbourne, Melbourne, Victoria, Australia
| | - Katrina J. Allen
- Department of Gut and Liver, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Department of Gastroenterology, Royal Children’s Hospital, Melbourne, Victoria, Australia
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34
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Schlottmann F, Vera-Aviles M, Latunde-Dada GO. Duodenal cytochrome b (Cybrd1) ferric reductase functional studies in cells. Metallomics 2018; 9:1389-1393. [PMID: 28937159 DOI: 10.1039/c7mt00254h] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Dietary non-heme ferric iron is reduced by the ferric reductase enzyme, duodenal cytochrome b (Dcytb), before absorption by the divalent metal transporter 1 (DMT1). A single nucleotide polymorphism (SNP rs10455 mutant) that is located in the last exon of the Dcytb gene was reported in C282Y haemochromatosis HFE subjects. The present work therefore investigated the phenotype of this mutant Dcytb in Chinese hamster ovary (CHO) cells. These cultured cells were transfected with either wild type (WT) or the SNP vector plasmids of Dcytb. Ferric reductase assays were performed in Dcytb transgenic CHO cells using the ferrozine spectrophometric assay protocol. The Dcytb SNP rs10455 showed a gain-of-function capability since ferric reductase activity increased significantly (p < 0.01) in the transgenic cells. Varying ferric reductase activity was found when CHO cells were pretreated with modulators of Dcytb protein expression. Although ferric reductase in endogenous CHO cells increased with deferoxamine or CoCl2, iron loading with ferric ammonium citrate (FAC) had the opposite effect. Taken together, the study reveals a gain-of-function phenotype for Dcytb rs10455 mutation that could be a putative modifier of colorectal cancer risk, with attendant variability in penetrance among human HFE C282Y homozygotes.
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Affiliation(s)
- F Schlottmann
- King's College London, Department of Nutritional Sciences, Faculty of Life Sciences and Medicine, Franklin-Wilkins Building, 150 Stamford Street, London, SE1 9NH, UK.
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35
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Abstract
Genetic causes of liver disease lead to a wide range of presentations, from mildly abnormal liver tests to acute liver failure. This article discusses the indications for testing and what to test for hereditary hemochromatosis, progressive familial intrahepatic cholestasis, benign recurrent intrahepatic cholestasis, lysosomal acid lipase deficiency, Gilbert syndrome, alpha-1 antitrypsin deficiency, and Wilson disease.
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Affiliation(s)
- Emily A Schonfeld
- Transitions of Care, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, Center for Liver Disease, 1305 York Avenue, 4th Floor, New York, NY 10021, USA
| | - Robert S Brown
- Transitions of Care, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, Center for Liver Disease, 1305 York Avenue, 4th Floor, New York, NY 10021, USA.
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36
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Wood MJ, Crawford DHG, Wockner LF, Powell LW, Ramm GA. Serum ferritin concentration predicts hepatic fibrosis better than hepatic iron concentration in human HFE-Haemochromatosis. Liver Int 2017; 37:1382-1388. [PMID: 28231420 DOI: 10.1111/liv.13395] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 02/16/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Ferritin is purported to have proinflammatory and profibrogenic effects on hepatic stellate cells. Thus, rather than acting as a passive indicator of hepatic iron concentration (HIC) in haemochromatosis, ferritin may directly influence fibrosis. This study evaluated whether serum ferritin is a better predictor of hepatic fibrosis compared to variables previously associated with increased fibrosis risk in haemochromatosis. METHODS We identified 291 C282Y HFE-homozygous patients who had undergone liver biopsy for histological fibrosis staging and measurement of HIC. Ordinal logistic regression determined the best model for fibrosis stage not including serum ferritin. Then, serum ferritin was introduced into this model to assess whether the predictive power of the model was significantly increased and to evaluate the effect on other predictors of fibrosis. RESULTS Ordinal logistic regression analyses without serum ferritin demonstrated that log HIC (OR 2.89; P < .001), male gender (OR 2.93; P = .005), alcohol consumption (g/day) (OR 1.01; P = .004), steatosis (OR 2.86; P = .01), arthritis (OR 2.46; P = .01) predicted increasing fibrosis stage (n=217). Addition of serum ferritin in multivariate analysis substantially improved the predictive power of the model (χ2 = 37.15; P < .01) and was highly predictive of fibrosis stage (OR 5.44; P < .001). Inclusion of serum ferritin in this model rendered the effects of HIC, gender, alcohol and steatosis to non-significance. CONCLUSIONS In haemochromatosis, serum ferritin is a better predictor of fibrosis stage than HIC, gender, steatosis and alcohol. These data support a hypothesis that ferritin may play a role in fibrosis rather than simply acting as a passive indicator of iron storage.
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Affiliation(s)
- Marnie J Wood
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.,Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Darrell H G Crawford
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Greenslopes Hospital, The Gallipoli Medical Research Foundation, Brisbane, Queensland, Australia
| | - Leesa F Wockner
- Biostatistics Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Lawrie W Powell
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Centre for the Advancement of Clinical Research, Royal Brisbane and Women's Hospital and the University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Grant A Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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37
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Barton JC, Acton RT. Diabetes in HFE Hemochromatosis. J Diabetes Res 2017; 2017:9826930. [PMID: 28331855 PMCID: PMC5346371 DOI: 10.1155/2017/9826930] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 12/12/2016] [Accepted: 01/04/2017] [Indexed: 02/08/2023] Open
Abstract
Diabetes in whites of European descent with hemochromatosis was first attributed to pancreatic siderosis. Later observations revealed that the pathogenesis of diabetes in HFE hemochromatosis is multifactorial and its clinical manifestations are heterogeneous. Increased type 2 diabetes risk in HFE hemochromatosis is associated with one or more factors, including abnormal iron homeostasis and iron overload, decreased insulin secretion, cirrhosis, diabetes in first-degree relatives, increased body mass index, insulin resistance, and metabolic syndrome. In p.C282Y homozygotes, serum ferritin, usually elevated at hemochromatosis diagnosis, largely reflects body iron stores but not diabetes risk. In persons with diabetes type 2 without hemochromatosis diagnoses, serum ferritin levels are higher than those of persons without diabetes, but most values are within the reference range. Phlebotomy therapy to achieve iron depletion does not improve diabetes control in all persons with HFE hemochromatosis. The prevalence of type 2 diabetes diagnosed today in whites of European descent with and without HFE hemochromatosis is similar. Routine iron phenotyping or HFE genotyping of patients with type 2 diabetes is not recommended. Herein, we review diabetes in HFE hemochromatosis and the role of iron in diabetes pathogenesis in whites of European descent with and without HFE hemochromatosis.
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Affiliation(s)
- James C. Barton
- Southern Iron Disorders Center, Birmingham, AL 35209, USA
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Ronald T. Acton
- Southern Iron Disorders Center, Birmingham, AL 35209, USA
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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38
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Barton JC, Chen WP, Emond MJ, Phatak PD, Subramaniam VN, Adams PC, Gurrin LC, Anderson GJ, Ramm GA, Powell LW, Allen KJ, Phillips JD, Parker CJ, McLaren GD, McLaren CE. GNPAT p.D519G is independently associated with markedly increased iron stores in HFE p.C282Y homozygotes. Blood Cells Mol Dis 2016; 63:15-20. [PMID: 27936396 DOI: 10.1016/j.bcmd.2016.11.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 11/08/2016] [Accepted: 11/11/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND GNPAT p.D519G positivity is significantly increased in HFE p.C282Y homozygotes with markedly increased iron stores. We sought to determine associations of p.D519G and iron-related variables with iron stores in p.C282Y homozygotes. METHODS We defined markedly increased iron stores as serum ferritin >2247pmol/L (>1000μg/L) and either hepatic iron >236μmol/g dry weight or iron >10g by induction phlebotomy (men and women). We defined normal or mildly elevated iron stores as serum ferritin <674.1pmol/L (<300μg/L) or either age≥40y with iron ≤2.5g iron by induction phlebotomy or age≥50y with ≤3.0g iron by induction phlebotomy (men only). We compared participant subgroups using univariate methods. Using multivariable logistic regression, we evaluated associations of markedly increased iron stores with these variables: age; iron supplement use (dichotomous); whole blood units donated; erythrocyte units received as transfusion; daily alcohol consumption, g; and p.D519G positivity (heterozygosity or homozygosity). RESULTS The mean age of 56 participants (94.6% men) was 55±10 (SD) y; 41 had markedly increased iron stores. Prevalences of swollen/tender 2nd/3rd metacarpophalangeal joints and elevated aspartate or alanine aminotransferase were significantly greater in participants with markedly increased iron stores. Only participants with markedly increased iron stores had cirrhosis. In multivariable analyses, p.D519G positivity was the only exposure variable significantly associated with markedly increased iron stores (odds ratio 9.9, 95% CI [1.6, 60.3], p=0.0126). CONCLUSIONS GNPAT p.D519G is strongly associated with markedly increased iron stores in p.C282Y homozygotes after correction for age, iron-related variables, and alcohol consumption.
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Affiliation(s)
- James C Barton
- Southern Iron Disorders Center, Birmingham, AL, 35209, USA; Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
| | - Wen-Pin Chen
- Chao Family Comprehensive Cancer Center, Irvine, CA 92697, USA
| | - Mary J Emond
- Department of Biostatistics, University of Washington, Seattle, WA 98195, USA
| | | | - V Nathan Subramaniam
- QIMR Berghofer Medical Research Institute, Brisbane City, QLD 4006, Australia; Faculty of Medicine and Biomedical Sciences, The University of Queensland, Herston, QLD, 4006, Australia
| | - Paul C Adams
- Department of Medicine, London Health Sciences Centre, London, Ontario, N6A 5W9, Canada
| | - Lyle C Gurrin
- Centre for MEGA Epidemiology, The University of Melbourne, Victoria 3010, Australia
| | - Gregory J Anderson
- QIMR Berghofer Medical Research Institute, Brisbane City, QLD 4006, Australia; School of Medicine and School of Chemistry and Molecular Bioscience, University of Queensland, Brisbane, St. Lucia, QLD 4072, Australia
| | - Grant A Ramm
- QIMR Berghofer Medical Research Institute, Brisbane City, QLD 4006, Australia; Faculty of Medicine and Biomedical Sciences, The University of Queensland, Herston, QLD, 4006, Australia
| | - Lawrie W Powell
- QIMR Berghofer Medical Research Institute, Brisbane City, QLD 4006, Australia; Faculty of Medicine and Biomedical Sciences, The University of Queensland, Herston, QLD, 4006, Australia; Royal Brisbane & Women's Hospital, Herston, QLD, 4029, Australia
| | - Katrina J Allen
- Murdoch Childrens Research Institute, Parkville, Victoria 3052, Australia
| | - John D Phillips
- Departments of Medicine and Pathology, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Charles J Parker
- Division of Hematology and Hematologic Malignancies, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Gordon D McLaren
- Department of Veterans Affairs Long Beach Healthcare System, Long Beach, CA 90822, USA; Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, CA 92868, USA
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Juzėnas S, Kupčinskas J, Valantienė I, Šumskienė J, Petrenkienė V, Kondrackienė J, Kučinskas L, Kiudelis G, Skiecevičienė J, Kupčinskas L. Association of HFE gene C282Y and H63D mutations with liver cirrhosis in the Lithuanian population. MEDICINA-LITHUANIA 2016; 52:269-275. [PMID: 27816425 DOI: 10.1016/j.medici.2016.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 07/27/2016] [Accepted: 09/13/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND OBJECTIVE Liver cirrhosis is the end-stage disease of chronic liver injury. Due to differences in the natural course of chronic liver diseases, identification of genetic factors that influence individual outcomes is warranted. HFE-linked hereditary hemochromatosis (HH) predisposes disease progression to cirrhosis; however, the role of heterozygous C282Y or H63D mutations in the development of cirrhosis in the presence of other etiological factors is still debated. The aim of this study was to determine the association between heterozygous C282Y and H63D mutations and non-HH liver cirrhosis in Lithuanian population. MATERIALS AND METHODS The patient cohort consisted of 209 individuals. Diagnosis of cirrhosis was confirmed by clinical, laboratory parameters, liver biopsy, and radiological imaging. Control samples were obtained from 1005 randomly selected unrelated healthy individuals. HFE gene mutations were determined using the PCR-RFLP method. RESULTS The most common causes of cirrhosis were hepatitis C (33.9%), hepatitis B (13.6%), and alcohol (25.8%). C282Y allele was associated with the presence of cirrhosis (OR=2.07; P=0.005); this was also observed under recessive model for C282Y (OR=2.06, P=0.008). The prevalence of C282Y allele was higher in cirrhotic men than in controls (7.0% vs. 2.8%, P=0.002). The carriage of H63D risk allele (OR=1.54; P=0.02), heterozygous C282Y/wt and homozygous H63D/H63D genotypes were associated with liver cirrhosis in males (OR=2.48, P=0.008, and OR=4.13, P=0.005, respectively). CONCLUSIONS Heterozygous C282Y mutation of the HFE gene was associated with liver cirrhosis in the Lithuanian population. In gender-related analysis, heterozygous C282Y and homozygous H63D mutations were linked to liver cirrhosis in men, not in women.
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Affiliation(s)
- Simonas Juzėnas
- Institute for Digestive Research, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Juozas Kupčinskas
- Institute for Digestive Research, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania; Department of Gastroenterology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Irena Valantienė
- Institute for Digestive Research, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania; Department of Gastroenterology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jolanta Šumskienė
- Department of Gastroenterology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Vitalija Petrenkienė
- Department of Gastroenterology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jūrate Kondrackienė
- Department of Gastroenterology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Laimutis Kučinskas
- Institute for Digestive Research, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Gediminas Kiudelis
- Institute for Digestive Research, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania; Department of Gastroenterology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | - Jurgita Skiecevičienė
- Institute for Digestive Research, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Limas Kupčinskas
- Institute for Digestive Research, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania; Department of Gastroenterology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
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Ong SY, Nicoll AJ, Delatycki MB. How should hyperferritinaemia be investigated and managed? Eur J Intern Med 2016; 33:21-7. [PMID: 27346296 DOI: 10.1016/j.ejim.2016.05.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 04/18/2016] [Accepted: 05/12/2016] [Indexed: 12/15/2022]
Abstract
Hyperferritinaemia is commonly found in clinical practice. In assessing the cause of hyperferritinaemia, it is important to identify if there is true iron overload or not as hyperferritinaemia may be seen in other conditions such as excess alcohol intake, inflammation and non-alcoholic fatty liver disease. Assessment of whether the serum ferritin level is elevated or not should take into account body mass index, gender and age. This review article provides an overview of the different causes of hyperferritinaemia, differentiating those due to iron overload from those not due to iron overload, and provides an algorithm for clinicians to use in clinical practice to carry out appropriate investigations and management.
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Affiliation(s)
- Sim Y Ong
- Bruce Lefroy Centre, Murdoch Childrens Research Institute, Flemington Road, Parkville, Victoria 3052, Australia; The University of Melbourne, Parkville, Victoria 3010, Australia; Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050, Australia.
| | - Amanda J Nicoll
- The University of Melbourne, Parkville, Victoria 3010, Australia; Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria 3050, Australia; Department of Gastroenterology, Eastern Health, Arnold Street, Box Hill, Victoria 3128, Australia; Monash University, Clayton, Victoria 3800, Australia.
| | - Martin B Delatycki
- Bruce Lefroy Centre, Murdoch Childrens Research Institute, Flemington Road, Parkville, Victoria 3052, Australia; The University of Melbourne, Parkville, Victoria 3010, Australia; Clinical Genetics, Austin Health, 145 Studley Road, Heidelberg, Victoria 3084, Australia.
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41
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Abstract
Haemochromatosis is now known to be an iron-storage disease with genetic heterogeneity but with a final common metabolic pathway resulting in inappropriately low production of the hormone hepcidin. This leads to increase in intestinal absorption and deposition of excessive amounts of iron in parenchymal cells which in turn results in eventual tissue damage and organ failure. A clinical enigma has been the variable clinical expression with some patients presenting with hepatic cirrhosis at a young age and others almost asymptomatic for life. Research is unravelling this puzzle by identifying environmental factors-especially alcohol consumption-and associated modifying genes that modulate phenotypic expression. A high index of suspicion is required for early diagnosis but this can lead to presymptomatic therapy and a normal life expectancy. Venesection (phlebotomy) therapy remains the mainstay of therapy, but alternative therapies are the subject of current research.
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Affiliation(s)
- Lawrie W Powell
- Centre for the Advancement of Clinical Research, Royal Brisbane and Women's Hospital, Brisbane, The University of Queensland, Brisbane, Australia.
| | - Rebecca C Seckington
- Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Australia
| | - Yves Deugnier
- University Hospital and University of Rennes 1, Rennes, France
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42
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Porto G, Brissot P, Swinkels DW, Zoller H, Kamarainen O, Patton S, Alonso I, Morris M, Keeney S. EMQN best practice guidelines for the molecular genetic diagnosis of hereditary hemochromatosis (HH). Eur J Hum Genet 2016; 24:479-95. [PMID: 26153218 PMCID: PMC4929861 DOI: 10.1038/ejhg.2015.128] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 04/29/2015] [Accepted: 05/06/2015] [Indexed: 12/14/2022] Open
Abstract
Molecular genetic testing for hereditary hemochromatosis (HH) is recognized as a reference test to confirm the diagnosis of suspected HH or to predict its risk. The vast majority (typically >90%) of patients with clinically characterized HH are homozygous for the p.C282Y variant in the HFE gene, referred to as HFE-related HH. Since 1996, HFE genotyping was implemented in diagnostic algorithms for suspected HH, allowing its early diagnosis and prevention. However, the penetrance of disease in p.C282Y homozygotes is incomplete. Hence, homozygosity for p.C282Y is not sufficient to diagnose HH. Neither is p.C282Y homozygosity required for diagnosis as other rare forms of HH exist, generally referred to as non-HFE-related HH. These pose significant challenges when defining criteria for referral, testing protocols, interpretation of test results and reporting practices. We present best practice guidelines for the molecular genetic diagnosis of HH where recommendations are classified, as far as possible, according to the level and strength of evidence. For clarification, the guidelines' recommendations are preceded by a detailed description of the methodology and results obtained with a series of actions taken in order to achieve a wide expert consensus, namely: (i) a survey on the current practices followed by laboratories offering molecular diagnosis of HH; (ii) a systematic literature search focused on some identified controversial topics; (iii) an expert Best Practice Workshop convened to achieve consensus on the practical recommendations included in the guidelines.
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Affiliation(s)
- Graça Porto
- Center for Predictive and Preventive Genetics (CGPP), Institute of Molecular and Cellular Biology (IBMC), Porto, Portugal
- Clinical Haematology, Hospital Santo António (CHP-HAS) and Department of Molecular Pathology and Immunology, Abel Salazar Institute for Biomedical Sciences (ICBAS), University of Porto, Porto, Portugal
| | - Pierre Brissot
- Liver Disease Unit, Pontchaillou University Hospital, University of Rennes, and National Reference Centre for Rare Iron Overload Diseases of Genetic Origin, Rennes, France
| | - Dorine W Swinkels
- Department of Laboratory Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Heinz Zoller
- Department of Medicine II, Gastroenterology and Hepatology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Simon Patton
- European Molecular Quality Network (EMQN), Manchester, UK
| | - Isabel Alonso
- Center for Predictive and Preventive Genetics (CGPP), Institute of Molecular and Cellular Biology (IBMC), Porto, Portugal
| | - Michael Morris
- European Molecular Quality Network (EMQN), Manchester, UK
- Synlab, Lausanne, Switzerland
| | - Steve Keeney
- European Molecular Quality Network (EMQN), Manchester, UK
- Molecular Diagnostics Centre (Haematology), Manchester Royal Infirmary, Manchester, UK
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43
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Sivakumar M, Powell LW. Management of human factors engineering-associated hemochromatosis: A 2015 update. World J Hepatol 2016; 8:395-400. [PMID: 27004087 PMCID: PMC4794529 DOI: 10.4254/wjh.v8.i8.395] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 12/23/2015] [Accepted: 03/09/2016] [Indexed: 02/06/2023] Open
Abstract
This review focuses on the management of iron metabolism and iron overload experienced in the hereditary condition, human factors engineering (HFE)-associated hemochromatosis. Hemochromatosis refers to a group of genetic diseases that result in iron overload; the major one globally is HFE-associated hemochromatosis. The evolution in understanding of the most common form of hereditary hemochromatosis, being the substation of cysteine to a tyrosine at position 282 in the HFE gene, has been extensively studied Novel mutations in both HFE and non-HFE genes have been indicated in this disease which hold significance in its application for the Asia-Pacific region. In conditions with iron overload, the storage of excess iron in various body tissues leads to complications and toxic damage. The most common presenting complaint for this disease is malaise, lethargy and other non-specific symptoms. In order to diagnose hereditary hemochromatosis, there are biochemical, imaging and genetic testing options. Currently, cascade screening of affected families is preferred over population-level screening. The mainstay of treatment is venesection and the appropriate approach to treatment has been consolidated over the years. Recently, the indications for venesection therapy of hemochromatosis have been challenged and are the subject of ongoing research.
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de Graaff B, Neil A, Sanderson K, Yee KC, Palmer AJ. Quality of life utility values for hereditary haemochromatosis in Australia. Health Qual Life Outcomes 2016; 14:31. [PMID: 26922941 PMCID: PMC4770680 DOI: 10.1186/s12955-016-0431-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 02/12/2016] [Indexed: 01/26/2023] Open
Abstract
Background Hereditary hemochromatosis (HH) is a common autosomal recessive disorder amongst persons of northern European heritage. If untreated, iron accumulates in parenchymal tissues causing morbidity and mortality. As diagnosis often follows irreversible organ damage, screening programs have been suggested to increase early diagnosis. A lack of economic evidence has been cited as a barrier to establishing such a program. Previous analyses used poorly estimated utility values. This study sought to measure utilities directly from people with HH in Australia. Methods Volunteers with HH were recruited to complete a web-based survey. Utility was assessed using the Assessment of Quality of Life 4D (AQOL-4D) instrument. Severity of HH was graded into four categories. Multivariable regression analysis was performed to identify parameters associated with HSUV. Results Between November 2013 and November 2014, 221 people completed the survey. Increasing severity of HH was negatively associated with utility. Mean (standard deviation) utilities were 0.76 (0.21), 0.81 (0.18), 0.60 (0.27), and 0.50 (0.27) for categories 1–4 HH respectively. Lower mean utility was found for symptomatic participants (categories 3 and 4) compared with asymptomatic participants (0.583 v. 0.796). Self-reported HH-related symptoms were negatively associated with HSUV (r = −0.685). Conclusions Symptomatic stages of HH and presence of multiple self-reported symptoms were associated with decreasing utility. Previous economic analyses have used higher utilities which likely resulted in underestimates of the cost effectiveness of HH interventions. The utilities reported in this paper are the most robust available, and will contribute to improving the validity of future economic models for HH.
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Affiliation(s)
- Barbara de Graaff
- Menzies Institute for Medical Research, University of Tasmania, Medical Sciences Building 1, 17 Liverpool St, Private Bag 23, Hobart, TAS, 7000, Australia
| | - Amanda Neil
- Menzies Institute for Medical Research, University of Tasmania, Medical Sciences Building 1, 17 Liverpool St, Private Bag 23, Hobart, TAS, 7000, Australia
| | - Kristy Sanderson
- Menzies Institute for Medical Research, University of Tasmania, Medical Sciences Building 1, 17 Liverpool St, Private Bag 23, Hobart, TAS, 7000, Australia
| | - Kwang Chien Yee
- School of Medicine, University of Tasmania, Medical Sciences Building 2, 17 Liverpool St, Private Bag 68, Hobart, TAS, 7000, Australia
| | - Andrew J Palmer
- Menzies Institute for Medical Research, University of Tasmania, Medical Sciences Building 1, 17 Liverpool St, Private Bag 23, Hobart, TAS, 7000, Australia.
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Udompap P, Kim D, Kim WR. Current and Future Burden of Chronic Nonmalignant Liver Disease. Clin Gastroenterol Hepatol 2015; 13:2031-41. [PMID: 26291665 PMCID: PMC4618163 DOI: 10.1016/j.cgh.2015.08.015] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/13/2015] [Accepted: 08/13/2015] [Indexed: 02/07/2023]
Abstract
Disease burden is an important indicator of the state of health of a population. It can be measured as the frequency (eg, incidence and prevalence) of a condition or its effects including fatal and non-fatal health loss from disease (eg, disability-adjusted life years) as well as the financial costs (eg, direct healthcare costs and indirect healthcare expenditures related to lost income because of premature death). Accurate disease burden information is essential for policy-making such as prioritization of health interventions and allocation of resources. Chronic liver disease (CLD) causes substantial health and economic burden in the United States, where nearly 2 million deaths annually are attributable to CLD. In the recent past, overall mortality rate of CLD has been increasing. Viral hepatitis and alcoholic liver disease are thought to be the most common etiologies of chronic liver diseases. More recently, the prevalence of nonalcoholic fatty liver disease is rapidly increasing, and nonalcoholic steatohepatitis has become a leading indication for liver transplantation. In this article, we assemble available data on the burden of CLD in the United States, focusing on nonmalignant complications, whereas the impact on mortality and healthcare expenses of hepatocellular carcinoma, an important consequence of CLD, is discussed elsewhere.
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Affiliation(s)
- Prowpanga Udompap
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California.
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46
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de Graaff B, Neil A, Sanderson K, Si L, Yee KC, Palmer AJ. A Systematic Review and Narrative Synthesis of Health Economic Studies Conducted for Hereditary Haemochromatosis. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2015; 13:469-483. [PMID: 26255179 DOI: 10.1007/s40258-015-0189-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Hereditary haemochromatosis (HH) is a common genetic condition amongst people of northern European heritage. HH is associated with increased iron absorption leading to parenchymal organ damage and multiple arthropathies. Early diagnosis and treatment prevents complications. Population screening may increase early diagnosis, but no programmes have been introduced internationally: a paucity of health economic data is often cited as a barrier. OBJECTIVE To conduct a systematic review of all health economic studies in HH. METHODS Studies were identified through electronic searching of economic/biomedical databases. Any study on HH with original economic component was included. Study quality was formally assessed. Health economic data were extracted and analysed through narrative synthesis. RESULTS Thirty-eight studies met the inclusion criteria. The majority of papers reported on costs or cost effectiveness of screening programmes. Whilst most concluded screening was cost effective compared with no screening, methodological flaws limit the quality of these findings. Assumptions regarding clinical penetrance, effectiveness of screening, health-state utility values (HSUVs), exclusion of early symptomatology (such as fatigue, lethargy and multiple arthropathies) and quantification of costs associated with HH were identified as key limitations. Treatment studies concluded therapeutic venepuncture was the most cost-effective intervention. CONCLUSIONS There is a paucity of high-quality health economic studies relating to HH. The development of a comprehensive HH cost-effectiveness model utilising HSUVs is required to determine whether screening is worthwhile.
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Affiliation(s)
- Barbara de Graaff
- Menzies Institute for Medical Research, University of Tasmania, Medical Science Building 2, 17 Liverpool St (Private Bag 23), Hobart, Tasmania, 7000, Australia
| | - Amanda Neil
- Menzies Institute for Medical Research, University of Tasmania, Medical Science Building 2, 17 Liverpool St (Private Bag 23), Hobart, Tasmania, 7000, Australia
| | - Kristy Sanderson
- Menzies Institute for Medical Research, University of Tasmania, Medical Science Building 2, 17 Liverpool St (Private Bag 23), Hobart, Tasmania, 7000, Australia
| | - Lei Si
- Menzies Institute for Medical Research, University of Tasmania, Medical Science Building 2, 17 Liverpool St (Private Bag 23), Hobart, Tasmania, 7000, Australia
| | - Kwang Chien Yee
- School of Medicine, University of Tasmania, Medical Science 1 Building, 17 Liverpool St, Private Bag 68, Hobart, TAS, 7000, Australia
| | - Andrew J Palmer
- Menzies Institute for Medical Research, University of Tasmania, Medical Science Building 2, 17 Liverpool St (Private Bag 23), Hobart, Tasmania, 7000, Australia.
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Pietrangelo A. Genetics, Genetic Testing, and Management of Hemochromatosis: 15 Years Since Hepcidin. Gastroenterology 2015; 149:1240-1251.e4. [PMID: 26164493 DOI: 10.1053/j.gastro.2015.06.045] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 06/19/2015] [Accepted: 06/30/2015] [Indexed: 12/13/2022]
Abstract
The discovery of hepcidin in 2000 and the subsequent unprecedented explosion of research and discoveries in the iron field have dramatically changed our understanding of human disorders of iron metabolism. Today, hereditary hemochromatosis, the paradigmatic iron-loading disorder, is recognized as an endocrine disease due to the genetic loss of hepcidin, the iron hormone produced by the liver. This syndrome is due to unchecked transfer of iron into the bloodstream in the absence of increased erythropoietic needs and its toxic effects in parenchymatous organs. It is caused by mutations that affect any of the proteins that help hepcidin to monitor serum iron, including HFE and, in rarer instances, transferrin-receptor 2 and hemojuvelin, or make its receptor ferroportin, resistant to the hormone. In Caucasians, C282Y HFE homozygotes are numerous, but they are only predisposed to hemochromatosis; complete organ disease develops in a minority, due to alcohol abuse or concurrent genetic modifiers that are now being identified. HFE gene testing can be used to diagnose hemochromatosis in symptomatic patients, but analyses of liver histology and full gene sequencing are required to identify patients with rare, non-HFE forms of the disease. Due to the central pathogenic role of hepcidin, it is anticipated that nongenetic causes of hepcidin loss (eg, end-stage liver disease) can cause acquired forms of hemochromatosis. The mainstay of hemochromatosis management is still removal of iron by phlebotomy, first introduced in 1950s, but identification of hepcidin has not only shed new light on the pathogenesis of the disease and the approach to diagnosis, but etiologic therapeutic applications from these advances are now foreseen.
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Affiliation(s)
- Antonello Pietrangelo
- Unit of Internal Medicine 2 and Centre for Hemochromatosis, University Hospital of Modena, Modena, Italy.
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48
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McLaren CE, Emond MJ, Subramaniam VN, Phatak PD, Barton JC, Adams PC, Goh JB, McDonald CJ, Powell LW, Gurrin LC, Allen KJ, Nickerson DA, Louie T, Ramm GA, Anderson GJ, McLaren GD. Exome sequencing in HFE C282Y homozygous men with extreme phenotypes identifies a GNPAT variant associated with severe iron overload. Hepatology 2015; 62:429-39. [PMID: 25605615 PMCID: PMC4508230 DOI: 10.1002/hep.27711] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 01/13/2015] [Indexed: 12/12/2022]
Abstract
UNLABELLED To identify polymorphisms associated with variability of iron overload severity in HFE-associated hemochromatosis, we performed exome sequencing of DNA from 35 male HFE C282Y homozygotes with either markedly increased iron stores (n = 22; cases) or with normal or mildly increased iron stores (n = 13; controls). The 35 participants, residents of the United States, Canada, and Australia, reported no or light alcohol consumption. Sequencing data included 82,068 single-nucleotide variants, and 10,337 genes were tested for a difference between cases and controls. A variant in the GNPAT gene showed the most significant association with severe iron overload (P = 3 × 10(-6) ; P = 0.033 by the likelihood ratio test after correction for multiple comparisons). Sixteen of twenty-two participants with severe iron overload had glyceronephosphate O-acyltransferase (GNPAT) polymorphism p.D519G (rs11558492; 15 heterozygotes, one homozygote). No control participant had this polymorphism. To examine functional consequences of GNPAT deficiency, we performed small interfering RNA-based knockdown of GNPAT in the human liver-derived cell line, HepG2/C3A. This knockdown resulted in a >17-fold decrease in expression of the messenger RNA encoding the iron-regulatory hormone, hepcidin. CONCLUSION GNPAT p.D519G is associated with a high-iron phenotype in HFE C282Y homozygotes and may participate in hepcidin regulation.
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Affiliation(s)
| | - Mary J. Emond
- Department of Biostatistics, University of Washington, Seattle, WA
| | - V. Nathan Subramaniam
- QIMR Berghofer Medical Research Institute, Brisbane, Australia,Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Australia
| | | | | | - Paul C. Adams
- Department of Medicine, London Health Sciences Centre, London, ON, Canada
| | - Justin B. Goh
- QIMR Berghofer Medical Research Institute, Brisbane, Australia,Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Australia
| | | | - Lawrie W. Powell
- QIMR Berghofer Medical Research Institute, Brisbane, Australia,Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Australia,Royal Brisbane & Women’s Hospital, Brisbane, Australia
| | - Lyle C. Gurrin
- Centre for MEGA Epidemiology, The University of Melbourne, Melbourne, Australia
| | | | | | - Tin Louie
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Grant A. Ramm
- QIMR Berghofer Medical Research Institute, Brisbane, Australia,Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Australia
| | - Gregory J. Anderson
- QIMR Berghofer Medical Research Institute, Brisbane, Australia,School of Medicine and School of Chemistry and Molecular Bioscience, University of Queensland
| | - Gordon D. McLaren
- Department of Veterans Affairs Long Beach Healthcare System, Long Beach, CA,Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, CA
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49
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Abstract
Hereditary hemochromatosis is a frequent autosomal recessive iron storage disease in northern and western Europe. The classical clinical triad of liver cirrhosis, hyperpigmentation and diabetes is nowadays rare, most probably because of early recognition. The homozygous C282Y mutation in the HFE gene is responsible for most cases of hereditary hemochromatosis, although other much rarer mutations in other genes have been recently identified. Progressive iron overload not only causes liver cirrhosis but also triggers development of a characteristic arthropathy. Bony swelling with intermittent arthritis of the second and third metacarpophalangeal joints is typical as well as occurrence of chondrocalcinosis in wrists and knee joints. The therapy of choice is excess iron removal by phlebotomy. Treatment usually prevents or even reverses liver damage but does not alter the course of hemochromatosis arthropathy.
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50
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Adams PC, Barton JC, Guo H, Alter D, Speechley M. Serum ferritin is a biomarker for liver mortality in the Hemochromatosis and Iron Overload Screening Study. Ann Hepatol 2015. [DOI: 10.1016/s1665-2681(19)31274-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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