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Sharma P, Bhatia P, Singh M, Jamwal M, Pallavelangini S, Das R, Malhotra P, Attri SV, Ducamp S, Fleming MD, Trehan A. Comprehensive Genomic Analysis Identifies a Diverse Landscape of Sideroblastic and Nonsideroblastic Iron-Related Anemias with Novel and Pathogenic Variants in an Iron-Deficient Endemic Setting. J Mol Diagn 2024; 26:430-444. [PMID: 38360212 DOI: 10.1016/j.jmoldx.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 01/19/2024] [Accepted: 01/30/2024] [Indexed: 02/17/2024] Open
Abstract
Inherited iron metabolism defects are possibly missed or underdiagnosed in iron-deficient endemic settings because of a lack of awareness or a methodical screening approach. Hence, we systematically evaluated anemia cases (2019 to 2021) based on clinical phenotype, normal screening tests (high-performance liquid chromatography, α gene sequencing, erythrocyte sedimentation rate, C-reactive protein, and tissue transglutaminase), and abnormal iron profile by targeted next-generation sequencing (26-gene panel) supplemented with whole-exome sequencing, multiplex ligation probe amplification/mitochondrial DNA sequencing, and chromosomal microarray. Novel variants in ALAS2, STEAP3, and HSPA9 genes were functionally validated. A total of 290 anemia cases were screened, and 41 (14%) enrolled for genomic testing as per inclusion criteria. Comprehensive genomic testing revealed pathogenic variants in 23 of 41 cases (56%). Congenital sideroblastic anemia was the most common diagnosis (14/23; 61%), with pathogenic variations in ALAS2 (n = 6), SLC25A38 (n = 3), HSPA9 (n = 2) and HSCB, SLC19A2, and mitochondrial DNA deletion (n = 1 each). Nonsideroblastic iron defects included STEAP3-related microcytic anemia (2/23; 8.7%) and hypotransferrenemia (1/23; 4.3%). A total of 6 of 22 cases (27%) revealed a non-iron metabolism gene defect on whole-exome sequencing. Eleven novel variants (including variants of uncertain significance) were noted in 13 cases. Genotype-phenotype correlation revealed a significant association of frameshift/nonsense/splice variants with lower presentation age (0.8 months versus 9 years; P < 0.01) compared with missense variants. The systematic evaluation helped uncover an inherited iron defect in 41% (17/41) of cases, suggesting the need for active screening and awareness for these rare diseases in an iron-deficient endemic population.
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Affiliation(s)
- Pankaj Sharma
- Pediatric Haematology Oncology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Prateek Bhatia
- Pediatric Haematology Oncology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Minu Singh
- Pediatric Haematology Oncology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manu Jamwal
- Department of Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Swetha Pallavelangini
- Pediatric Haematology Oncology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Reena Das
- Department of Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Clinical Haematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Savita V Attri
- Pediatric Biochemistry Laboratory, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sarah Ducamp
- Department of Pathology, Boston Children's Hospital, Boston, Massachusetts
| | - Mark D Fleming
- Department of Pathology, Boston Children's Hospital, Boston, Massachusetts
| | - Amita Trehan
- Pediatric Haematology Oncology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Rodrigues F, Coman T, Fouquet G, Côté F, Courtois G, Trovati Maciel T, Hermine O. A deep dive into future therapies for microcytic anemias and clinical considerations. Expert Rev Hematol 2023; 16:349-364. [PMID: 37092971 DOI: 10.1080/17474086.2023.2206556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
INTRODUCTION Microcytic anemias (MA) have frequent or rare etiologies. New discoveries in understanding and treatment of microcytic anemias need to be reviewed. AREAS COVERED Microcytic anemias with a focus on most frequent causes and on monogenic diseases that are relevant for understanding biocellular mechanisms of MA. All treatments excepting gene therapy, with a focus on recent advances. Pubmed search with references selected by expert opinion. EXPERT OPINION As the genetic and cellular background of dyserythropoiesis will continue to be clarified, collaboration with bioengineering of treatments acting specifically at the protein domain level will continue to provide new therapies in haematology as well as oncology and neurology.
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Affiliation(s)
- François Rodrigues
- Université de Paris, service d'hématologie adultes, Hôpital Necker - Enfants Malades, Asrsistance Publique- Hôpitaux de Paris, France
- Inserm U1163, CNRS ERL8254 Imagine Institute, Paris, France
| | - Tereza Coman
- Inserm U1163, CNRS ERL8254 Imagine Institute, Paris, France
- Département d'hématologie, Institut Gustave Roussy, Villejuif, France
| | - Guillemette Fouquet
- Université de Paris, service d'hématologie adultes, Hôpital Necker - Enfants Malades, Asrsistance Publique- Hôpitaux de Paris, France
- Hématologie clinique, Centre Hospitalier Sud Francilien, Corbeil Essonnes, France
| | - Francine Côté
- Inserm U1163, CNRS ERL8254 Imagine Institute, Paris, France
| | | | | | - Olivier Hermine
- Université de Paris, service d'hématologie adultes, Hôpital Necker - Enfants Malades, Asrsistance Publique- Hôpitaux de Paris, France
- Inserm U1163, CNRS ERL8254 Imagine Institute, Paris, France
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Scaramellini N, Fischer D, Agarvas AR, Motta I, Muckenthaler MU, Mertens C. Interpreting Iron Homeostasis in Congenital and Acquired Disorders. Pharmaceuticals (Basel) 2023; 16:ph16030329. [PMID: 36986429 PMCID: PMC10054723 DOI: 10.3390/ph16030329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/13/2023] [Accepted: 02/17/2023] [Indexed: 02/25/2023] Open
Abstract
Mammalian cells require iron to satisfy their metabolic needs and to accomplish specialized functions, such as hematopoiesis, mitochondrial biogenesis, energy metabolism, or oxygen transport. Iron homeostasis is balanced by the interplay of proteins responsible for iron import, storage, and export. A misbalance of iron homeostasis may cause either iron deficiencies or iron overload diseases. The clinical work-up of iron dysregulation is highly important, as severe symptoms and pathologies may arise. Treating iron overload or iron deficiency is important to avoid cellular damage and severe symptoms and improve patient outcomes. The impressive progress made in the past years in understanding mechanisms that maintain iron homeostasis has already changed clinical practice for treating iron-related diseases and is expected to improve patient management even further in the future.
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Affiliation(s)
- Natalia Scaramellini
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milano, Italy
- Unit of Medicine and Metabolic Disease, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Dania Fischer
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Anand R. Agarvas
- Center for Translational Biomedical Iron Research, Department of Pediatric Oncology, Immunology, and Hematology, University of Heidelberg, INF 350, 69120 Heidelberg, Germany
| | - Irene Motta
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milano, Italy
- Unit of Medicine and Metabolic Disease, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Martina U. Muckenthaler
- Center for Translational Biomedical Iron Research, Department of Pediatric Oncology, Immunology, and Hematology, University of Heidelberg, INF 350, 69120 Heidelberg, Germany
- Molecular Medicine Partnership Unit, 69120 Heidelberg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Side, 69120 Heidelberg, Germany
| | - Christina Mertens
- Center for Translational Biomedical Iron Research, Department of Pediatric Oncology, Immunology, and Hematology, University of Heidelberg, INF 350, 69120 Heidelberg, Germany
- Molecular Medicine Partnership Unit, 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-6221564582; Fax: +49-6221564580
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Cervera Bravo A, Osuna Marco MP, Morán-Jiménez MJ, Martín-Hernández E. Unexpected Cause of Persistent Microcytosis and Neurological Symptoms in a Child: Niemann-Pick Disease Type C. J Pediatr Hematol Oncol 2021; 43:e1238-e1240. [PMID: 33661177 DOI: 10.1097/mph.0000000000002135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 01/27/2021] [Indexed: 11/25/2022]
Abstract
Atypical microcytic anemias are rare diseases of iron/heme metabolism that can be diagnostically challenging. We report the case of a 2-year-old twin boy with neurodevelopmental delay and persistent microcytosis in whom atypical microcytic anemias was initially suspected. He had low blood iron and transferrin saturation with normal/high ferritin despite iron therapy. Hemoglobinopathies were excluded by conventional/DNA studies. Hepcidin was high but iron-refractory-iron-deficiency anemia was ruled out by a genetic panel. Bone marrow aspiration revealed foamy cells and iron depletion. A genetic study confirmed the diagnosis of Niemann-Pick disease type C which was finally considered the origin of microcytosis through anemia of chronic disease.
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Affiliation(s)
| | - Marta P Osuna Marco
- Department of Pediatric Hematology and Oncology, Montepríncipe HM Hospital, Boadilla del Monte
| | - María-José Morán-Jiménez
- Instituto de Investigación Sanitaria (Health Research Institute) of the 12 de Octubre University Hospital (imas12), Section 3: Rare Diseases, Group: Porphyrias, Hemochromatosis and Anemias
| | - Elena Martín-Hernández
- Unit of Hereditary Mitochondrial & Metabolic Diseases, Department of Pediatrics, 12 de Octubre University Hospital, National Reference Center for Hereditary Metabolic Diseases (C.S.U.R.) and European Reference Network for Hereditary Metabolic Disorders (MetabERN), Madrid, Spain
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Silvestri L, Nai A. Iron and erythropoiesis: A mutual alliance. Semin Hematol 2021; 58:145-152. [PMID: 34389106 DOI: 10.1053/j.seminhematol.2021.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/26/2021] [Accepted: 05/31/2021] [Indexed: 02/07/2023]
Abstract
The large amount of iron required for hemoglobin synthesis keeps iron homeostasis and erythropoiesis inter-connected, both iron levels being affected by increased erythropoiesis, and erythropoiesis regulated by serum iron. The connection between these 2 processes is maintained even when erythropoiesis is ineffective. In the last years great advances in the understanding of the mechanisms of this crosstalk have been achieved thanks to the discovery of 2 essential players: hepcidin, the master regulator of iron homeostasis, and erythroferrone, the long sought erythroid regulator. In addition, how circulating transferrin-bound iron contributes to the crosstalk between the 2 systems has started to be unraveled.
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Affiliation(s)
- Laura Silvestri
- Regulation of Iron Metabolism Unit-Div. Genetics & Cell Biology-IRCCS San Raffaele Scientific Institute, Milano, Italy; San Raffaele Vita-Salute University, Milano, Italy.
| | - Antonella Nai
- Regulation of Iron Metabolism Unit-Div. Genetics & Cell Biology-IRCCS San Raffaele Scientific Institute, Milano, Italy; San Raffaele Vita-Salute University, Milano, Italy
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Lira Zidanes A, Marchi G, Busti F, Marchetto A, Fermo E, Giorgetti A, Vianello A, Castagna A, Olivieri O, Bianchi P, Girelli D. A Novel ALAS2 Missense Mutation in Two Brothers With Iron Overload and Associated Alterations in Serum Hepcidin/Erythroferrone Levels. Front Physiol 2020; 11:581386. [PMID: 33281618 PMCID: PMC7689258 DOI: 10.3389/fphys.2020.581386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/01/2020] [Indexed: 01/19/2023] Open
Abstract
Iron loading anemias are characterized by ineffective erythropoiesis and iron overload. The prototype is non-transfusion dependent ß-thalassemia (NTDT), with other entities including congenital sideroblastic anemias, congenital dyserythropoietic anemias, some hemolytic anemias, and myelodysplastic syndromes. Differential diagnosis of iron loading anemias may be challenging due to heterogeneous genotype and phenotype. Notwithstanding the recent advances in linking ineffective erythropoiesis to iron overload, many pathophysiologic aspects are still unclear. Moreover, measurement of hepcidin and erythroferrone (ERFE), two key molecules in iron homeostasis and erythropoiesis, is scarcely used in clinical practice and of uncertain utility. Here, we describe a comprehensive diagnostic approach, including next-generation sequencing (NGS), in silico modeling, and measurement of hepcidin and erythroferrone (ERFE), in two brothers eventually diagnosed as X-linked sideroblastic anemia (XLSA). A novel pathogenic ALAS2 missense mutation (c.1382T>A, p.Leu461His) is described. Hyperferritinemia with high hepcidin-25 levels (but decreased hepcidin:ferritin ratio) and mild-to-moderate iron overload were detected in both patients. ERFE levels were markedly elevated in both patients, especially in the proband, who had a more expressed phenotype. Our study illustrates how new technologies, such as NGS, in silico modeling, and measurement of serum hepcidin-25 and ERFE, may help in diagnosing and studying iron loading anemias. Further studies on the hepcidin-25/ERFE axis in additional patients with XLSA and other iron loading anemias may help in establishing its usefulness in differential diagnosis, and it may also aid our understanding of the pathophysiology of these genetically and phenotypically heterogeneous entities.
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Affiliation(s)
- Acaynne Lira Zidanes
- Section of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy.,EuroBloodNet Referral Center for Rare Disorders of Iron Metabolism, University Hospital of Verona, Verona, Italy
| | - Giacomo Marchi
- Section of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy.,EuroBloodNet Referral Center for Rare Disorders of Iron Metabolism, University Hospital of Verona, Verona, Italy
| | - Fabiana Busti
- Section of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy.,EuroBloodNet Referral Center for Rare Disorders of Iron Metabolism, University Hospital of Verona, Verona, Italy
| | | | - Elisa Fermo
- Hematology and Pathophysiology of Anemias Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCSS) Ca' Granda Foundation, Policlinico Milano, Milan, Italy
| | | | - Alice Vianello
- Section of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy.,EuroBloodNet Referral Center for Rare Disorders of Iron Metabolism, University Hospital of Verona, Verona, Italy
| | - Annalisa Castagna
- Section of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy.,EuroBloodNet Referral Center for Rare Disorders of Iron Metabolism, University Hospital of Verona, Verona, Italy
| | - Oliviero Olivieri
- Section of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy.,EuroBloodNet Referral Center for Rare Disorders of Iron Metabolism, University Hospital of Verona, Verona, Italy
| | - Paola Bianchi
- Hematology and Pathophysiology of Anemias Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCSS) Ca' Granda Foundation, Policlinico Milano, Milan, Italy
| | - Domenico Girelli
- Section of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy.,EuroBloodNet Referral Center for Rare Disorders of Iron Metabolism, University Hospital of Verona, Verona, Italy
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Cappellini MD, Russo R, Andolfo I, Iolascon A. Inherited microcytic anemias. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:465-470. [PMID: 33275715 PMCID: PMC7727536 DOI: 10.1182/hematology.2020000158] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Inherited microcytic anemias can be broadly classified into 3 subgroups: (1) defects in globin chains (hemoglobinopathies or thalassemias), (2) defects in heme synthesis, and (3) defects in iron availability or iron acquisition by the erythroid precursors. These conditions are characterized by a decreased availability of hemoglobin (Hb) components (globins, iron, and heme) that in turn causes a reduced Hb content in red cell precursors with subsequent delayed erythroid differentiation. Iron metabolism alterations remain central to the diagnosis of microcytic anemia, and, in general, the iron status has to be evaluated in cases of microcytosis. Besides the very common microcytic anemia due to acquired iron deficiency, a range of hereditary abnormalities that result in actual or functional iron deficiency are now being recognized. Atransferrinemia, DMT1 deficiency, ferroportin disease, and iron-refractory iron deficiency anemia are hereditary disorders due to iron metabolism abnormalities, some of which are associated with iron overload. Because causes of microcytosis other than iron deficiency should be considered, it is important to evaluate several other red blood cell and iron parameters in patients with a reduced mean corpuscular volume (MCV), including mean corpuscular hemoglobin, red blood cell distribution width, reticulocyte hemoglobin content, serum iron and serum ferritin levels, total iron-binding capacity, transferrin saturation, hemoglobin electrophoresis, and sometimes reticulocyte count. From the epidemiological perspective, hemoglobinopathies/thalassemias are the most common forms of hereditary microcytic anemia, ranging from inconsequential changes in MCV to severe anemia syndromes.
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Affiliation(s)
| | - Roberta Russo
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, Naples, Italy; and
- CEINGE Biotecnologie Avanzate, Naples, Italy
| | - Immacolata Andolfo
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, Naples, Italy; and
- CEINGE Biotecnologie Avanzate, Naples, Italy
| | - Achille Iolascon
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, Naples, Italy; and
- CEINGE Biotecnologie Avanzate, Naples, Italy
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Lobbes H, Reynaud Q, Mainbourg S, Lega JC, Durieu I, Durupt S. [Aceruloplasminemia, a rare condition not to be overlooked]. Rev Med Interne 2020; 41:769-775. [PMID: 32682623 DOI: 10.1016/j.revmed.2020.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/26/2020] [Accepted: 06/01/2020] [Indexed: 01/01/2023]
Abstract
Aceruloplasminemia is a rare iron-overload disease that should be better known by physicians. It is an autosomal recessive disorder due to mutations in ceruloplasmin gene causing systemic iron overload, including cerebral and liver parenchyma. The impairment of ferroxidase ceruloplasmin activity leads to intracellular iron retention leading aceruloplasminemia symptoms. Neurologic manifestations include cognitive impairment, ataxia, extrapyramidal syndrome, abnormal movements, and psychiatric-like syndromes. Physicians should search for aceruloplasminemia in several situations with high ferritin levels: microcytic anaemia, diabetes mellitus, neurological and psychiatric disorders. Diagnosis approach is based on the study of transferrin saturation and hepatic iron content evaluated by magnetic resonance imaging of the liver. Ceruloplasmin dosage is required in case of low transferrin saturation and high hepatic iron content and genetic testing is mandatory in case of serum ceruloplasmin defect. Neurological manifestations occur in the sixties decade and leads to disability. Iron chelators are widely used. Despite their efficacy on systemic and cerebral iron overload, iron chelators tolerance is poor. Early initiation of iron chelation therapy might prevent or slowdown neurodegeneration, highlighting the need for an early diagnosis but their clinical efficacy remains uncertain.
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Affiliation(s)
- H Lobbes
- Service de médecine interne, hôpital Estaing, CHU de Clermont-Ferrand, 1, place Lucie-et-Raymond-Aubrac, 63000 Clermont-Ferrand, France.; Service de médecine interne et vasculaire, Centre de compétence des surcharges en fer rares d'origine génétique, hôpital Lyon Sud, Hospices civils de Lyon, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France..
| | - Q Reynaud
- Service de médecine interne et vasculaire, Centre de compétence des surcharges en fer rares d'origine génétique, hôpital Lyon Sud, Hospices civils de Lyon, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France
| | - S Mainbourg
- Service de médecine interne et vasculaire, Centre de compétence des surcharges en fer rares d'origine génétique, hôpital Lyon Sud, Hospices civils de Lyon, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France
| | - J-C Lega
- Service de médecine interne et vasculaire, Centre de compétence des surcharges en fer rares d'origine génétique, hôpital Lyon Sud, Hospices civils de Lyon, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France
| | - I Durieu
- Service de médecine interne et vasculaire, Centre de compétence des surcharges en fer rares d'origine génétique, hôpital Lyon Sud, Hospices civils de Lyon, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France
| | - S Durupt
- Service de médecine interne et vasculaire, Centre de compétence des surcharges en fer rares d'origine génétique, hôpital Lyon Sud, Hospices civils de Lyon, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France
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Jackson BS, Nunes Goncalves J, Pretorius E. Comparison of pathological clotting using haematological, functional and morphological investigations in HIV-positive and HIV-negative patients with deep vein thrombosis. Retrovirology 2020; 17:14. [PMID: 32571345 PMCID: PMC7310079 DOI: 10.1186/s12977-020-00523-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 06/16/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Patients infected with the human immunodeficiency virus (HIV) are more prone to systemic inflammation and pathological clotting, and many may develop deep vein thrombosis (DVT) as a result of this dysregulated inflammatory profile. Coagulation tests are not routinely performed unless there is a specific reason. METHODS We recruited ten healthy control subjects, 35 HIV negative patients with deep vein thrombosis (HIV negative-DVT), and 13 HIV patients with DVT (HIV positive-DVT) on the primary antiretroviral therapy (ARV) regimen-emtricitabine, tenofovir and efavirenz. Serum inflammatory markers, haematological results, viscoelastic properties using thromboelastography (TEG) and scanning electron microscopy (SEM) of whole blood (WB) were used to compare the groups. RESULTS The DVT patients (HIV positive and HIV negative) had raised inflammatory markers. The HIV positive-DVT group had anaemia in keeping with anaemia of chronic disorders. DVT patients had a hypercoagulable profile on the TEG but no significant difference between HIV negative-DVT and HIV positive-DVT groups. The TEG analysis compared well and supported our ultrastructural results. Scanning electron microscopy of DVT patient's red blood cells (RBCs) and platelets demonstrated inflammatory changes including abnormal cell shapes, irregular membranes and microparticle formation. All the ultrastructural changes were more prominent in the HIV positive-DVT patients. CONCLUSIONS Although there were trends that HIV-positive patients were more hypercoagulable on functional tests (viscoelastic profile) compared to HIV-negative patients, there were no significant differences between the 2 groups. The sample size was, however, small in number. Morphologically there were inflammatory changes in patients with DVT. These ultrastructural changes, specifically with regard to platelets, appear more pronounced in HIV-positive patients which may contribute to increased risk for hypercoagulability and deep vein thrombosis.
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Affiliation(s)
- Brandon S Jackson
- Department of Surgery, University of Pretoria, Pretoria, 0007, South Africa
| | | | - Etheresia Pretorius
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, Private Bag X1 Matieland, 7602, South Africa.
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Vila Cuenca M, Marchi G, Barqué A, Esteban-Jurado C, Marchetto A, Giorgetti A, Chelban V, Houlden H, Wood NW, Piubelli C, Dorigatti Borges M, Martins de Albuquerque D, Yotsumoto Fertrin K, Jové-Buxeda E, Sanchez-Delgado J, Baena-Díez N, Burnyte B, Utkus A, Busti F, Kaubrys G, Suku E, Kowalczyk K, Karaszewski B, Porter JB, Pollard S, Eleftheriou P, Bignell P, Girelli D, Sanchez M. Genetic and Clinical Heterogeneity in Thirteen New Cases with Aceruloplasminemia. Atypical Anemia as a Clue for an Early Diagnosis. Int J Mol Sci 2020; 21:E2374. [PMID: 32235485 PMCID: PMC7178074 DOI: 10.3390/ijms21072374] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/26/2020] [Indexed: 12/11/2022] Open
Abstract
Aceruloplasminemia is a rare autosomal recessive genetic disease characterized by mild microcytic anemia, diabetes, retinopathy, liver disease, and progressive neurological symptoms due to iron accumulation in pancreas, retina, liver, and brain. The disease is caused by mutations in the Ceruloplasmin (CP) gene that produce a strong reduction or absence of ceruloplasmin ferroxidase activity, leading to an impairment of iron metabolism. Most patients described so far are from Japan. Prompt diagnosis and therapy are crucial to prevent neurological complications since, once established, they are usually irreversible. Here, we describe the largest series of non-Japanese patients with aceruloplasminemia published so far, including 13 individuals from 11 families carrying 13 mutations in the CP gene (7 missense, 3 frameshifts, and 3 splicing mutations), 10 of which are novel. All missense mutations were studied by computational modeling. Clinical manifestations were heterogeneous, but anemia, often but not necessarily microcytic, was frequently the earliest one. This study confirms the clinical and genetic heterogeneity of aceruloplasminemia, a disease expected to be increasingly diagnosed in the Next-Generation Sequencing (NGS) era. Unexplained anemia with low transferrin saturation and high ferritin levels without inflammation should prompt the suspicion of aceruloplasminemia, which can be easily confirmed by low serum ceruloplasmin levels. Collaborative joint efforts are needed to better understand the pathophysiology of this potentially disabling disease.
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Affiliation(s)
- Marc Vila Cuenca
- Iron Metabolism: Regulation and Diseases Group, Josep Carreras Leukaemia Research Institute (IJC), Campus Can Ruti, Badalona, 08916 Barcelona, Spain; (M.V.C.); (A.B.); (C.E.-J.)
| | - Giacomo Marchi
- EuroBloodNet Referral Center for Iron Disorders and Gruppo Interdisciplinare Malattie del Ferro, Internal Medicine Unit, Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (G.M.); (F.B.)
| | - Anna Barqué
- Iron Metabolism: Regulation and Diseases Group, Josep Carreras Leukaemia Research Institute (IJC), Campus Can Ruti, Badalona, 08916 Barcelona, Spain; (M.V.C.); (A.B.); (C.E.-J.)
| | - Clara Esteban-Jurado
- Iron Metabolism: Regulation and Diseases Group, Josep Carreras Leukaemia Research Institute (IJC), Campus Can Ruti, Badalona, 08916 Barcelona, Spain; (M.V.C.); (A.B.); (C.E.-J.)
| | - Alessandro Marchetto
- Department of Biotechnology, University of Verona, 37134 Verona, Italy; (A.M.); (A.G.); (E.S.)
| | - Alejandro Giorgetti
- Department of Biotechnology, University of Verona, 37134 Verona, Italy; (A.M.); (A.G.); (E.S.)
| | - Viorica Chelban
- National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK; (V.C.); (H.H.); (N.W.W.)
- Department of Neuromuscular Diseases, Institute of Neurology, University College London, London WC1N 3BG, UK
- Department of Neurology and Neurosurgery, Institute of Emergency Medicine, Toma Ciorbă 1, Chisinau, MD-2052 Chisinau, Republic of Moldova
| | - Henry Houlden
- National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK; (V.C.); (H.H.); (N.W.W.)
- Department of Neuromuscular Diseases, Institute of Neurology, University College London, London WC1N 3BG, UK
- Neurogenetics Laboratory, The National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK
| | - Nicholas W Wood
- National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK; (V.C.); (H.H.); (N.W.W.)
- Neurogenetics Laboratory, The National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK
| | - Chiara Piubelli
- Centre for Tropical Diseases, Ospedale Sacro Cuore - Don Calabria, 37024 Negrar (VR), Italy;
| | - Marina Dorigatti Borges
- Hematology and Hemotherapy Center—Hemocentro Campinas, University of Campinas—UNICAMP, Campinas 13083-878, Brazil; (M.D.B.); (D.M.d.A.); (K.Y.F.)
| | - Dulcinéia Martins de Albuquerque
- Hematology and Hemotherapy Center—Hemocentro Campinas, University of Campinas—UNICAMP, Campinas 13083-878, Brazil; (M.D.B.); (D.M.d.A.); (K.Y.F.)
| | - Kleber Yotsumoto Fertrin
- Hematology and Hemotherapy Center—Hemocentro Campinas, University of Campinas—UNICAMP, Campinas 13083-878, Brazil; (M.D.B.); (D.M.d.A.); (K.Y.F.)
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Ester Jové-Buxeda
- Internal Medicine Department, Parc Tauli Hospital Universitari, Institut d’ Investigació i Innovació Parc Tauli I3PT, Universidad Autonoma de Barcelona, 08208 Sabadell, Spain;
| | - Jordi Sanchez-Delgado
- Hepatology Unit, Digestive Diseases Department, Parc Tauli Hospital Universitari. Institut d’ Investigació i Innovació Parc Tauli I3PT, Universidad Autonoma de Barcelona, 08208 Sabadell, Spain;
- Centro de Investigación Biomedica y en red Enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Neus Baena-Díez
- Genetic Department, Parc Tauli Hospital Universitari, Institut d’ Investigació i Innovació Parc Tauli I3PT, Universidad Autonoma de Barcelona, 08208 Sabadell, Spain;
| | - Birute Burnyte
- Department of Human and Medical Genetics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (B.B.); (A.U.)
| | - Algirdas Utkus
- Department of Human and Medical Genetics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (B.B.); (A.U.)
| | - Fabiana Busti
- EuroBloodNet Referral Center for Iron Disorders and Gruppo Interdisciplinare Malattie del Ferro, Internal Medicine Unit, Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (G.M.); (F.B.)
| | - Gintaras Kaubrys
- Clinic of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, 08661 Vilnius, Lithuania;
| | - Eda Suku
- Department of Biotechnology, University of Verona, 37134 Verona, Italy; (A.M.); (A.G.); (E.S.)
| | - Kamil Kowalczyk
- Department of Adult Neurology, Medical University of Gdańsk, 80-210 Gdańsk, Poland; (K.K.); (B.K.)
| | - Bartosz Karaszewski
- Department of Adult Neurology, Medical University of Gdańsk, 80-210 Gdańsk, Poland; (K.K.); (B.K.)
| | - John B. Porter
- Joint Red Cell Unit, Haematology Department, University College London NHS Foundation Trust, Cancer Services, 250 Euston Road, London NW1 2PG, UK; (J.B.P.); (P.E.)
| | - Sally Pollard
- Consultant Paediatrician, Bradford Royal Infirmary, Duckworthlane, Bradford BD9 6RJ, UK;
| | - Perla Eleftheriou
- Joint Red Cell Unit, Haematology Department, University College London NHS Foundation Trust, Cancer Services, 250 Euston Road, London NW1 2PG, UK; (J.B.P.); (P.E.)
| | - Patricia Bignell
- Oxford Regional Genetics Laboratory, Oxford University Hospitals NHS Foundation Trust, The Churchill Hospital, Oxford OX3 7LE, UK;
| | - Domenico Girelli
- EuroBloodNet Referral Center for Iron Disorders and Gruppo Interdisciplinare Malattie del Ferro, Internal Medicine Unit, Azienda Ospedaliera Universitaria Integrata di Verona, 37134 Verona, Italy; (G.M.); (F.B.)
| | - Mayka Sanchez
- Iron Metabolism: Regulation and Diseases Group, Department of Basic Sciences, Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya (UIC); Sant Cugat del Valles, 08017 Barcelona, Spain
- Program of Program of Predictive and Personalized Medicine of Cancer (PMPPC), Institut d ‘Investigació Germans Trias i Pujol (IGTP), Campus Can Ruti, Badalona, 08916 Barcelona, Spain
- BloodGenetics S.L., Esplugues de Llobregat, 08950 Barcelona, Spain
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11
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Camaschella C, Nai A, Silvestri L. Iron metabolism and iron disorders revisited in the hepcidin era. Haematologica 2020; 105:260-272. [PMID: 31949017 PMCID: PMC7012465 DOI: 10.3324/haematol.2019.232124] [Citation(s) in RCA: 308] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/18/2019] [Indexed: 02/06/2023] Open
Abstract
Iron is biologically essential, but also potentially toxic; as such it is tightly controlled at cell and systemic levels to prevent both deficiency and overload. Iron regulatory proteins post-transcriptionally control genes encoding proteins that modulate iron uptake, recycling and storage and are themselves regulated by iron. The master regulator of systemic iron homeostasis is the liver peptide hepcidin, which controls serum iron through degradation of ferroportin in iron-absorptive enterocytes and iron-recycling macrophages. This review emphasizes the most recent findings in iron biology, deregulation of the hepcidin-ferroportin axis in iron disorders and how research results have an impact on clinical disorders. Insufficient hepcidin production is central to iron overload while hepcidin excess leads to iron restriction. Mutations of hemochro-matosis genes result in iron excess by downregulating the liver BMP-SMAD signaling pathway or by causing hepcidin-resistance. In iron-loading anemias, such as β-thalassemia, enhanced albeit ineffective ery-thropoiesis releases erythroferrone, which sequesters BMP receptor ligands, thereby inhibiting hepcidin. In iron-refractory, iron-deficiency ane-mia mutations of the hepcidin inhibitor TMPRSS6 upregulate the BMP-SMAD pathway. Interleukin-6 in acute and chronic inflammation increases hepcidin levels, causing iron-restricted erythropoiesis and ane-mia of inflammation in the presence of iron-replete macrophages. Our improved understanding of iron homeostasis and its regulation is having an impact on the established schedules of oral iron treatment and the choice of oral versus intravenous iron in the management of iron deficiency. Moreover it is leading to the development of targeted therapies for iron overload and inflammation, mainly centered on the manipulation of the hepcidin-ferroportin axis.
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Affiliation(s)
- Clara Camaschella
- Regulation of Iron Metabolism Unit, Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milan
| | - Antonella Nai
- Regulation of Iron Metabolism Unit, Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milan.,Vita Salute San Raffaele University, Milan, Italy
| | - Laura Silvestri
- Regulation of Iron Metabolism Unit, Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milan.,Vita Salute San Raffaele University, Milan, Italy
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12
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Pagani A, Nai A, Silvestri L, Camaschella C. Hepcidin and Anemia: A Tight Relationship. Front Physiol 2019; 10:1294. [PMID: 31649559 PMCID: PMC6794341 DOI: 10.3389/fphys.2019.01294] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 09/25/2019] [Indexed: 12/13/2022] Open
Abstract
Hepcidin, the master regulator of systemic iron homeostasis, tightly influences erythrocyte production. High hepcidin levels block intestinal iron absorption and macrophage iron recycling, causing iron restricted erythropoiesis and anemia. Low hepcidin levels favor bone marrow iron supply for hemoglobin synthesis and red blood cells production. Expanded erythropoiesis, as after hemorrhage or erythropoietin treatment, blocks hepcidin through an acute reduction of transferrin saturation and the release of the erythroblast hormone and hepcidin inhibitor erythroferrone. Quantitatively reduced erythropoiesis, limiting iron consumption, increases transferrin saturation and stimulates hepcidin transcription. Deregulation of hepcidin synthesis is associated with anemia in three conditions: iron refractory iron deficiency anemia (IRIDA), the common anemia of acute and chronic inflammatory disorders, and the extremely rare hepcidin-producing adenomas that may develop in the liver of children with an inborn error of glucose metabolism. Inappropriately high levels of hepcidin cause iron-restricted or even iron-deficient erythropoiesis in all these conditions. Patients with IRIDA or anemia of inflammation do not respond to oral iron supplementation and show a delayed or partial response to intravenous iron. In hepcidin-producing adenomas, anemia is reverted by surgery. Other hepcidin-related anemias are the “iron loading anemias” characterized by ineffective erythropoiesis and hepcidin suppression. This group of anemias includes thalassemia syndromes, congenital dyserythropoietic anemias, congenital sideroblastic anemias, and some forms of hemolytic anemias as pyruvate kinase deficiency. The paradigm is non-transfusion-dependent thalassemia where the release of erythroferrone from the expanded pool of immature erythroid cells results in hepcidin suppression and secondary iron overload that in turn worsens ineffective erythropoiesis and anemia. In thalassemia murine models, approaches that induce iron restriction ameliorate both anemia and the iron phenotype. Manipulations of hepcidin might benefit all the above-described anemias. Compounds that antagonize hepcidin or its effect may be useful in inflammation and IRIDA, while hepcidin agonists may improve ineffective erythropoiesis. Correcting ineffective erythropoiesis in animal models ameliorates not only anemia but also iron homeostasis by reducing hepcidin inhibition. Some targeted approaches are now in clinical trials: hopefully they will result in novel treatments for a variety of anemias.
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Affiliation(s)
- Alessia Pagani
- Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milan, Italy
| | - Antonella Nai
- Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Laura Silvestri
- Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Clara Camaschella
- Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milan, Italy
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13
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Marchi G, Busti F, Lira Zidanes A, Castagna A, Girelli D. Aceruloplasminemia: A Severe Neurodegenerative Disorder Deserving an Early Diagnosis. Front Neurosci 2019; 13:325. [PMID: 31024241 PMCID: PMC6460567 DOI: 10.3389/fnins.2019.00325] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 03/21/2019] [Indexed: 01/01/2023] Open
Abstract
Aceruloplasminemia (ACP) is a rare, adult-onset, autosomal recessive disorder, characterized by systemic iron overload due to mutations in the Ceruloplasmin gene (CP), which in turn lead to absence or strong reduction of CP activity. CP is a ferroxidase that plays a key role in iron export from various cells, especially in the brain, where it maintains the appropriate iron homeostasis with neuroprotective effects. Brain iron accumulation makes ACP unique among systemic iron overload syndromes, e.g., various types of genetic hemochromatosis. The main clinical features of fully expressed ACP include diabetes, retinopathy, liver disease, and progressive neurological symptoms reflecting iron deposition in target organs. However, biochemical signs of the disease, namely a mild anemia mimicking iron deficiency anemia because of microcytosis and low transferrin saturation, but with "paradoxical" hyperferritinemia, usually precedes the onset of clinical symptoms of many years and sometimes decades. Prompt diagnosis and therapy are crucial to prevent neurological complications of the disease, as they are usually irreversible once established. In this mini-review we discuss some major issues about this rare disorder, pointing out the early clues to the right diagnosis, instrumental to reduce significant disability burden of affected patients.
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Affiliation(s)
- Giacomo Marchi
- Department of Medicine, University of Verona, Verona, Italy
| | - Fabiana Busti
- Department of Medicine, University of Verona, Verona, Italy
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14
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Evaluation of lipid peroxidation and the level of some elements in rat erythrocytes during separate and combined vanadium and magnesium administration. Chem Biol Interact 2018; 293:1-10. [PMID: 30028963 DOI: 10.1016/j.cbi.2018.07.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/02/2018] [Accepted: 07/16/2018] [Indexed: 12/18/2022]
Abstract
The impact of vanadium (V) and magnesium (Mg) as sodium metavanadate (SMV, 0.125 mg V/ml) and magnesium sulfate (MS, 0.06 mg Mg/ml) on lipid peroxidation (LPO) and selected elements in the rat erythrocytes (RBCs) was investigated. Relationships between some indices determined in RBC were also studied. SMV alone (Group II) elevated the malondialdehyde level (MDARBC) (by 95% and 60%), compared with the control (Group I) and MS-supplemented rats (Group III), respectively, reduced the concentration of CuRBC (by 23.5%), in comparison with Group I, but did not change the levels of NaRBC, KRBC, and CaRBC, whereas MS alone (Group III) only reduced the CuRBC concentration (by 22%), compared with Group I. The SMV + MS combination (Group IV) reduced and elevated the CuRBC (by 24%) and CaRBC (by 111%) concentrations, respectively, in comparison with Groups I and III, and these changes were induced by the V-Mg antagonistic and synergistic interaction, respectively. The combined SMV + MS effect also enhanced the MDARBC level, compared with Groups I (by 79%) and III (by 47%) and slightly limited its concentration, compared with Group II, which, in turn, resulted from the distinct trend toward the V-Mg antagonistic interaction. We can conclude that V (as SMV) is able to stimulate LPO in rat RBCs and that V-Mg interactive effects are involved in changes in CuRBC, CaRBC, and MDARBC. Further studies are needed to elucidate the exact mechanisms of the V-Mg antagonistic/synergistic interactions and to provide insight into the biochemical mechanisms of changes in rats suffering from anemia [1], characterized by a disrupted antioxidant barrier in RBCs [2] and an intensified free radical process in these cells.
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15
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Colin JY, Vignon G, Mottaz P, Labrousse J, Carrere F, Augereau PF, Aucher P, Lellouche F. [Diagnostic workup in front of an atypical non hemolytic anemia]. Rev Med Interne 2018; 39:855-862. [PMID: 29661593 DOI: 10.1016/j.revmed.2018.03.382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/26/2018] [Accepted: 03/27/2018] [Indexed: 11/26/2022]
Abstract
The most potential causes of "non hemolytic" anemias are iron, folate or vitamin B12 deficiencies, severe renal impairment, endocrine diseases, inflammation and medullary disorders. In a non-exceptionnal way no cause is found, sometimes because of a wrong interpretation of analysis results and sometimes because of a little known etiology. The goal of this review is to point out analytical difficulties and to remember some rarer etiologies.
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Affiliation(s)
- J Y Colin
- Service de médecine interne, centre hospitalier de Royan, 20, avenue de St-Sordelin, 17640 Vaux-sur-Mer, France
| | - G Vignon
- Groupement de coopération sanitaire de Saintonge, laboratoire inter-hospitalier de biologie médicale, centres hospitaliers de St-Jean-d'Angély, Saintes-et-Royan, 18, avenue du Port, 17400 St-Jean-d'Angély, France
| | - P Mottaz
- Service de médecine interne, centre hospitalier de Royan, 20, avenue de St-Sordelin, 17640 Vaux-sur-Mer, France
| | - J Labrousse
- Groupement de coopération sanitaire de Saintonge, laboratoire inter-hospitalier de biologie médicale, centres hospitaliers de St-Jean-d'Angély, Saintes-et-Royan, 18, avenue du Port, 17400 St-Jean-d'Angély, France
| | - F Carrere
- Groupement de coopération sanitaire de Saintonge, laboratoire inter-hospitalier de biologie médicale, centres hospitaliers de St-Jean-d'Angély, Saintes-et-Royan, 18, avenue du Port, 17400 St-Jean-d'Angély, France
| | - P F Augereau
- Groupement de coopération sanitaire de Saintonge, laboratoire inter-hospitalier de biologie médicale, centres hospitaliers de St-Jean-d'Angély, Saintes-et-Royan, 18, avenue du Port, 17400 St-Jean-d'Angély, France
| | - P Aucher
- Groupement de coopération sanitaire de Saintonge, laboratoire inter-hospitalier de biologie médicale, centres hospitaliers de St-Jean-d'Angély, Saintes-et-Royan, 18, avenue du Port, 17400 St-Jean-d'Angély, France
| | - F Lellouche
- Service de médecine interne, centre hospitalier de Royan, 20, avenue de St-Sordelin, 17640 Vaux-sur-Mer, France; Groupement de coopération sanitaire de Saintonge, laboratoire inter-hospitalier de biologie médicale, centres hospitaliers de St-Jean-d'Angély, Saintes-et-Royan, 18, avenue du Port, 17400 St-Jean-d'Angély, France.
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16
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Carlos AM, Souza BMBD, Souza RAVD, Resende GAD, Pereira GDA, Moraes-Souza H. Causes of microcytic anaemia and evaluation of conventional laboratory parameters in the differentiation of erythrocytic microcytosis in blood donors candidates. ACTA ACUST UNITED AC 2018. [PMID: 29521164 DOI: 10.1080/10245332.2018.1446703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
CONTEXT AND OBJECTIVE Microcytic anaemia results from defective synthesis of haemoglobin in the erythroid precursors, causing a reduction in its mean corpuscular volume (MCV). The most common causes of microcytosis, without the increase in HbA2 levels, are iron deficiency anaemia (IDA) and α-thalassemia. The aim of this study was to identify the causes of microcytic anaemia and evaluate the haematological parameters from blood donors deemed ineligible (due to the low haematocrit level) that would differentiate the IDA and α-thal, whether isolated or in association. METHODS Genomic DNA was submitted to the polymerase chain reaction multiplex for the diagnosis of the most common allele deletions of α-thal and erythrogram and in order to verify haematological parameters. Iron deficiency (ID) was determined through the measurement of serum ferritin. RESULTS Of the 204 samples, 82 (40.2%) were identified with ID, 24 (17.8%) with α-thal and 10 (4.9%) with ID associated with α-thal. In the α-thal with ID group haemoglobin (Hb), MCV, mean corpuscular Hb concentration (MCHC) and mean corpuscular Hb (MCH) values were significantly lower compared to the isolated α-thal. In the group with ID Hb, MCV, MCHC and MCH values were significantly lower compared to those with isolated α-thal. The α-thal with ID group, showed Hb, MCV, MCHC and MCH significantly reduced when compared to those with IDA. CONCLUSIONS This study showed that the values of haematological parameters, especially haematocrit, Hb, MCV, MCH, MCHC and red blood cell distribution width (RDW), are lower in patients with IDA, especially when associated with α-thal and therefore it may be useful to discriminate between the different types of microcytic anaemia.
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Affiliation(s)
- Aline Menezes Carlos
- a Department of Medicine , Universidade Federal do Triângulo Mineiro (UFTM) , Uberaba , Minas Gerais , Brazil
| | - Bruna Maria Bereta de Souza
- a Department of Medicine , Universidade Federal do Triângulo Mineiro (UFTM) , Uberaba , Minas Gerais , Brazil
| | | | | | - Gilberto de Araújo Pereira
- b Department of Nursing , Universidade Federal do Triângulo Mineiro (UFTM) , Uberaba , Minas Gerais , Brazil
| | - Helio Moraes-Souza
- c Department of Medicine , Universidade Federal do Triângulo Mineiro (UFTM) , Uberaba , Minas Gerais , Brazil
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17
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Makis A, Georgiou I, Traeger-Synodinos J, Chaliasos N, Grosso M, Gambale A, Iolascon A. Diagnosis and molecular characterization of a novel α 0 -thalassemia deletion (-Kozani) found in a Greek child with unexplained microcytic hypochromic anemia. Int J Lab Hematol 2017; 39:e124-e126. [PMID: 28603861 DOI: 10.1111/ijlh.12690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 03/24/2017] [Indexed: 11/27/2022]
Affiliation(s)
- A Makis
- Child Health Department, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - I Georgiou
- Genetics and IVF Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - J Traeger-Synodinos
- Laboratory of Medical Genetics, National and Kapodistrian University of Athens, Athens, Greece
| | - N Chaliasos
- Child Health Department, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - M Grosso
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, CEINGE- Advanced Biotechnologies, Italy
| | - A Gambale
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, CEINGE- Advanced Biotechnologies, Italy
| | - A Iolascon
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, CEINGE- Advanced Biotechnologies, Italy
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18
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Camaschella C. New insights into iron deficiency and iron deficiency anemia. Blood Rev 2017; 31:225-233. [PMID: 28216263 DOI: 10.1016/j.blre.2017.02.004] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 02/10/2017] [Indexed: 12/27/2022]
Abstract
Recent advances in iron metabolism have stimulated new interest in iron deficiency (ID) and its anemia (IDA), common conditions worldwide. Absolute ID/IDA, i.e. the decrease of total body iron, is easily diagnosed based on decreased levels of serum ferritin and transferrin saturation. Relative lack of iron in specific organs/tissues, and IDA in the context of inflammatory disorders, are diagnosed based on arbitrary cut offs of ferritin and transferrin saturation and/or marker combination (as the soluble transferrin receptor/ferritin index) in an appropriate clinical context. Most ID patients are candidate to traditional treatment with oral iron salts, while high hepcidin levels block their absorption in inflammatory disorders. New iron preparations and new treatment modalities are available: high-dose intravenous iron compounds are becoming popular and indications to their use are increasing, although long-term side effects remain to be evaluated.
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Affiliation(s)
- Clara Camaschella
- Vita Salute University and IRCCS Ospedale San Raffaele, Milan, Italy.
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19
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Camaschella C, Pagani A, Nai A, Silvestri L. The mutual control of iron and erythropoiesis. Int J Lab Hematol 2016; 38 Suppl 1:20-6. [PMID: 27161430 DOI: 10.1111/ijlh.12505] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Iron is essential for hemoglobin synthesis during terminal erythropoiesis. To supply adequate iron the carrier transferrin is required together with transferrin receptor endosomal cycle and normal mitochondrial iron utilization. Iron and iron protein deficiencies result in different types of anemia. Iron-deficiency anemia is the commonest anemia worldwide due to increased requirements, malnutrition, chronic blood losses and malabsorption. Mutations of transferrin, transferrin receptor cycle proteins, enzymes of the first step of heme synthesis and iron sulfur cluster biogenesis lead to rare anemias, usually accompanied by iron overload. Hepcidin plays an indirect role in erythropoiesis by controlling plasma iron. Inappropriately high hepcidin levels characterize the rare genetic iron-refractory iron-deficiency anemia (IRIDA) and the common anemia of chronic disease. Iron modulates both effective and ineffective erythropoiesis: iron restriction reduces heme and alpha-globin synthesis that may be of benefit in thalassemia. MATERIAL AND METHODS This review relies on the analysis of the most recent literature and personal data. RESULTS Erythropoiesis controls iron homeostasis, by releasing erythroferrone that inhibits hepcidin transcription to increase iron acquisition in iron deficiency, hypoxia and EPO treatment. Erythroferrone, produced by EPO-stimulated erythropoiesis, inhibits hepcidin only when the activity of BMP/SMAD pathway is low, suggesting that EPO somehow modulates the latter signaling. Erythroblasts sense circulating iron through the second transferrin receptor (TFR2) that, in animal models, modulates the sensitivity of the erythroid cells to EPO. DISCUSSION The advanced knowledge of the regulation of systemic iron homeostasis and erythropoiesis-mediated hepcidin regulation is leading to the development of targeted therapies for anemias and iron disorders.
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Affiliation(s)
- C Camaschella
- Vita Salute University and San Raffaele Scientific Institute, Milano, Italy
| | - A Pagani
- Vita Salute University and San Raffaele Scientific Institute, Milano, Italy
| | - A Nai
- Vita Salute University and San Raffaele Scientific Institute, Milano, Italy
| | - L Silvestri
- Vita Salute University and San Raffaele Scientific Institute, Milano, Italy
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20
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Abstract
Iron is essential for life because it is indispensable for several biological reactions, such as oxygen transport, DNA synthesis, and cell proliferation. Over the past few years, our understanding of iron metabolism and its regulation has changed dramatically. New disorders of iron metabolism have emerged, and the role of iron as a cofactor in other disorders has begun to be recognized. The study of genetic conditions such as hemochromatosis and iron-refractory iron deficiency anemia (IRIDA) has provided crucial insights into the molecular mechanisms controlling iron homeostasis. In the future, these advances may be exploited to improve treatment of both genetic and acquired iron disorders. IRIDA is caused by mutations in TMPRSS6, the gene encoding matriptase-2, which downregulates hepcidin expression under conditions of iron deficiency. The typical features of this disorder are hypochromic, microcytic anemia with a very low mean corpuscular volume of erythrocytes, low transferrin saturation, no (or inadequate) response to oral iron, and only a partial response to parenteral iron. In contrast to classic iron deficiency anemia, serum ferritin levels are usually low-normal, and serum or urinary hepcidin levels are inappropriately high for the degree of anemia. Although the number of cases reported thus far in the literature does not exceed 100, this disorder is considered the most common of the “atypical” microcytic anemias. The aim of this review is to share the current knowledge on IRIDA and increase awareness in this field.
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Affiliation(s)
- Ebru Yılmaz Keskin
- Samsun Education and Research Hospital, Clinic of Pediatric Hematology and Oncology, Samsun, Turkey. E-mail:
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22
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Abstract
Microcytic anemia is the most common form of anemia, characterized by reduced hemoglobin (Hb) synthesis associated with decreased red blood cell volume (MCV). It is a very heterogeneous group of diseases that may be either acquired or inherited. Microcytic hypochromic anemia can result from defects in globin (hemoglobinopathies or thalassemias) or heme synthesis or in iron availability, or acquisition by the erythroid precursors. Diagnosis of microcytic anaemia appears to be important in children/adolescents, especially to set, where possible, a treatment plan on the basis of the etiology and pathogenesis. After excluding the acquired causes of microcytic anemia that represent the most frequent etiology, according to the differential diagnosis, the analysis of genetic causes, mostly hereditary, must be considered. This review will consider acquired and hereditary microcytic anemias due to heme synthesis or to iron metabolism defects and their diagnosis.
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Affiliation(s)
- Mariasole Bruno
- Department of Molecular Medicine and Medical Biotechnology, University Federico II, Naples, Italy; CEINGE, Advanced Biotechnologies, Naples, Italy; Department of Medicine, Section of Internal Medicine, University of Verona, AOUI-Policlinico GB Rossi, 37134 Verona, Italy
| | - Luigia De Falco
- Department of Molecular Medicine and Medical Biotechnology, University Federico II, Naples, Italy; CEINGE, Advanced Biotechnologies, Naples, Italy
| | - Achille Iolascon
- Department of Molecular Medicine and Medical Biotechnology, University Federico II, Naples, Italy; CEINGE, Advanced Biotechnologies, Naples, Italy.
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So CC, Liu AK, Tsang MH, Ngai DY, Leung KS, Chan AY. Genetic basis of persistent red blood cell microcytosis in the Chinese unexplained by phenotypical testing. J Clin Pathol 2014; 68:69-72. [PMID: 25352644 DOI: 10.1136/jclinpath-2014-202568] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS Hypochromic microcytic anaemia is the hallmark phenotype of thalassaemia. Current phenotypical tests do not provide a diagnosis in a small proportion of patients with red blood cell microcytosis. We aim to evaluate the genetic basis of red cell microcytosis in these cases in our Chinese population. METHODS We identified from a large cohort of 1684 unselected requests for thalassaemia testing 23 Chinese subjects who had unexplained microcytosis after phenotypical iron and haemoglobin studies. In 18 of these subjects with available DNA, extensive genotypical analysis of the α and β globin gene cluster was performed, including gap-PCR, multiplex amplification-refractory mutation system, Sanger sequencing and multiplex ligation-dependent probe amplification. RESULTS Occult single and double α globin gene (HBA1, HBA2) deletions and α thalassaemic haemoglobinopathies (Haemoglobin Quong Sze, Haemoglobin Constant Spring) were the genetic basis for the microcytosis. Occult β globin gene (HBB) mutations and δ globin gene (HBD) abnormalities masking β thalassaemia are not seen. CONCLUSIONS A cost-effective genotyping approach for the detection of these occult globin gene mutations can be proposed. The identification of these mutations is important for making a diagnosis and for the provision of accurate genetic counselling. (This paper adds to our understanding of the genetic basis of red blood cell microcytosis in clinical practice, and it provides a cost-effective approach for genotyping in diagnostic laboratories).
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Affiliation(s)
- Chi-Chiu So
- Department of Pathology, Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Ada K Liu
- Department of Pathology and Clinical Biochemistry, Queen Mary Hospital, Hong Kong, Hong Kong
| | - Mandy H Tsang
- Department of Pathology and Clinical Biochemistry, Queen Mary Hospital, Hong Kong, Hong Kong
| | - Donna Y Ngai
- Department of Pathology and Clinical Biochemistry, Queen Mary Hospital, Hong Kong, Hong Kong
| | - Kin-Sang Leung
- Department of Pathology and Clinical Biochemistry, Queen Mary Hospital, Hong Kong, Hong Kong
| | - Amy Y Chan
- Department of Pathology, Queen Elizabeth Hospital, Hong Kong, Hong Kong
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Coates TD. Physiology and pathophysiology of iron in hemoglobin-associated diseases. Free Radic Biol Med 2014; 72:23-40. [PMID: 24726864 PMCID: PMC4940047 DOI: 10.1016/j.freeradbiomed.2014.03.039] [Citation(s) in RCA: 101] [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: 02/14/2014] [Revised: 03/26/2014] [Accepted: 03/27/2014] [Indexed: 01/19/2023]
Abstract
Iron overload and iron toxicity, whether because of increased absorption or iron loading from repeated transfusions, can be major causes of morbidity and mortality in a number of chronic anemias. Significant advances have been made in our understanding of iron homeostasis over the past decade. At the same time, advances in magnetic resonance imaging have allowed clinicians to monitor and quantify iron concentrations noninvasively in specific organs. Furthermore, effective iron chelators are now available, including preparations that can be taken orally. This has resulted in substantial improvement in mortality and morbidity for patients with severe chronic iron overload. This paper reviews the key points of iron homeostasis and attempts to place clinical observations in patients with transfusional iron overload in context with the current understanding of iron homeostasis in humans.
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Affiliation(s)
- Thomas D Coates
- Children׳s Center for Cancer and Blood Diseases, Children׳s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA 90027, USA.
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Abstract
Iron deficiency anemia is a common global problem whose etiology is typically attributed to acquired inadequate dietary intake and/or chronic blood loss. However, in several kindreds multiple family members are affected with iron deficiency anemia that is unresponsive to oral iron supplementation and only partially responsive to parenteral iron therapy. The discovery that many of these cases harbor mutations in the TMPRSS6 gene led to the recognition that they represent a single clinical entity: iron-refractory iron deficiency anemia (IRIDA). This article reviews clinical features of IRIDA, recent genetic studies, and insights this disorder provides into the regulation of systemic iron homeostasis.
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Sirdah MM, Yassin MM, El Shekhi S, Lubbad AM. Homocysteine and vitamin B12 status and iron deficiency anemia in female university students from Gaza Strip, Palestine. Rev Bras Hematol Hemoter 2014; 36:208-12. [PMID: 25031061 PMCID: PMC4109749 DOI: 10.1016/j.bjhh.2014.03.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 11/19/2013] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Nutritional deficiencies are very significant to the overall health of humans at all ages and for both genders, yet in infants, children and women of childbearing age these deficiencies can seriously affect growth and development. The present work is aimed to assess homocysteine and vitamin B12 status in females with iron deficiency anemia from the Gaza Strip. METHODS Venous blood samples were randomly collected from 240 female university students (18-22 years old) and parameters of the complete blood count, serum ferritin, homocysteine and vitamin B12 were measured. Statistical analysis included the t-test and analysis of variance (ANOVA) using the IBM SPSS software (version 18). Statistical significance was set for p-values <0.05. RESULTS The results revealed that 20.4% of the students have iron deficiency anemia. The mean serum vitamin B12 level in females with iron deficiency anemia (212.9±62.8pg/mL) was significantly lower than in normal controls (286.9±57.1pg/mL) and subjects with microcytic anemia and normal ferritin (256.7±71.1pg/mL). Significantly higher serum homocysteine levels were reported in the iron deficiency anemia group (27.0±4.6μmol/L) compared to normal controls (15.5±2.9μmol/L) and in subjects with microcytic anemia and normal ferritin (18.1±2.7μmol/L). Statistically significant negative correlations were reported for serum homocysteine with serum ferritin, vitamin B12, hemoglobin, and hematocrit levels. CONCLUSION Important associations were found between serum homocysteine and markers of iron deficiency. Monitoring homocysteine levels might be essential to understand the development of different clinical conditions including anemia. It seems necessary to conduct prospective trials to determine whether treating anemia ameliorates homocysteine levels.
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Abstract
Endoscopic gastrointestinal workup fails to establish the cause of iron deficiency anemia (IDA) in a substantial proportion of patients. In patients referred for hematologic evaluation with unexplained or refractory IDA, screening for celiac disease, autoimmune gastritis, Helicobacter pylori, and hereditary forms of IDA is recommended. About 4% to 6% of patients with obscure refractory IDA have celiac disease, and autoimmune gastritis is encountered in 20% to 27% of patients. Stratification by age cohorts in autoimmune gastritis implies a disease presenting as IDA many years before the establishment of clinical cobalamin deficiency. Over 50% of patients with unexplained refractory IDA have active H pylori infection and, after excluding all other causes of IDA, 64% to 75% of such patients are permanently cured by H pylori eradication. In young patients with a history suggestive of hereditary iron deficiency with serum ferritin higher than expected for IDA, mutations involving iron trafficking and regulation should be considered. Recognition of the respective roles of H pylori, autoimmune gastritis, celiac disease, and genetic defects in the pathogenesis of iron deficiency should have a strong impact on the current diagnostic workup and management of unexplained, or refractory, IDA.
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Silvestri L, Rausa M, Pagani A, Nai A, Camaschella C. How to Assess Causality ofTMPRSS6Mutations? Hum Mutat 2013; 34:1043-5. [DOI: 10.1002/humu.22321] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 03/12/2013] [Indexed: 12/26/2022]
Affiliation(s)
- Laura Silvestri
- Vita-Salute University and San Raffaele Scientific Institute; Division of Genetic and Cell Biology; Milan Italy
| | - Marco Rausa
- Vita-Salute University and San Raffaele Scientific Institute; Division of Genetic and Cell Biology; Milan Italy
| | - Alessia Pagani
- Vita-Salute University and San Raffaele Scientific Institute; Division of Genetic and Cell Biology; Milan Italy
| | - Antonella Nai
- Vita-Salute University and San Raffaele Scientific Institute; Division of Genetic and Cell Biology; Milan Italy
| | - Clara Camaschella
- Vita-Salute University and San Raffaele Scientific Institute; Division of Genetic and Cell Biology; Milan Italy
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