[Management of hemochromatosis linked to HFE gene]

Juvenile Hemochromatosis: Rheumatic Manifestations of 2 Sisters Responding to Deferasirox Treatment. A Case Series and Literature Review

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.

Portable hemoglobinometer is a reliable technology for the follow-up of venesections tolerance in hemochromatosis

BACKGROUND

The treatment of HFE-related hemochromatosis, one of the most common genetic diseases, is based on phlebotomies whose tolerance is evaluated by regular monitoring of hemoglobin. Using a portable hemoglobinometer (PH) could provide an easy and fast determination of hemoglobin. Therefore, the aim of the present study was to compare, in hemochromatosis patients treated by bloodletting, the hemoglobin concentrations as assayed, on capillary blood, by a PH device and, on venous blood, by a cell counter (CC) device.

METHODS

For a total period of 12 weeks duration, all patients undergoing phlebotomies in the same hospital outpatient unit had hemoglobin determinations both by the HemoCue and by the laboratory's DxH 800 Coulter. To evaluate the sensitivity and specificity of the HemoCue, patients were classified as presenting or not anemia as defined by hemoglobin level below 11 g/dl.

RESULTS

Measurements of hemoglobin were performed in 122 patients. The sensitivity and specificity of PH compared to CC were 100 and 98.1%, respectively. Capillary hemoglobin by PH slightly underestimated venous hemoglobin by CC. The Pearson's correlation coefficient between PH and CC was 0.80 (P<0.0001).

CONCLUSION

PH is a reliable, quick and easy technology, which can be proposed to follow-up the tolerance of venesections in hemochromatosis patients.

Erythrocytapheresis compared with whole blood phlebotomy for the treatment of hereditary haemochromatosis

BACKGROUND

Hereditary haemochromatosis may result in severe organ damage which can be prevented by therapy. We studied the possible advantages and disadvantages of erythrocytapheresis as compared with phlebotomy in patients with hereditary haemochromatosis.

MATERIALS AND METHODS

In a prospective, randomised, open-label study, patients with hereditary haemochromatosis were randomised to bi-weekly apheresis or weekly whole blood phlebotomy. Primary end-points were decrease in ferritin levels and transferrin saturation. Secondary endpoints were decrease in haemoglobin levels, discomfort during the therapeutic procedure, costs and technicians' working time.

RESULTS

Sixty-two patients were included. Thirty patients were randomised to apheresis and 32 to whole blood phlebotomy. Initially, ferritin levels declined more rapidly in the apheresis group, and the difference became statistically highly significant at 11 weeks; however, time to normalisation of ferritin level was equal in the two groups. We observed no significant differences in decline of transferrin saturation, haemoglobin levels or discomfort. The mean cumulative technician time consumption until the ferritin level reached 50 μg/L was longer in the apheresis group, but the difference was not statistically significant. The cumulative costs for materials until achievement of the desired ferritin levels were three-fold higher in the apheresis group.

CONCLUSION

Treatment of hereditary haemochromatosis with erythrocytapheresis instead of whole blood phlebotomy results in a more rapid initial decline in ferritin levels and a reduced number of procedures per patient, but not in earlier achievement of target ferritin level. The frequency of discomfort was equally low with the two methods. The costs and, probably, technician time consumption were higher in the apheresis group.