Results of surveys to assess iron status in Europe

Many studies have been undertaken to assess the iron status of Europeans. However, differences in dietary patterns, methodology, contraceptive choice, and epidemiologic factors lead to confounding factors that need consideration as the data from available studies are reviewed.

Kupffer cell iron overload induces intercellular adhesion molecule-1 expression on hepatocytes in genetic hemochromatosis

The mechanisms underlying iron-induced liver fibrogenesis in patients with genetic hemochromatosis are poorly understood. We studied signs of Kupffer cell activation and inflammatory responses in liver biopsy specimens obtained from 15 patients with untreated and six patients with treated hemochromatosis. Immunohistochemistry was performed on 11 of the untreated and all treated patients. Three of the untreated patients (20%) had cirrhosis and eight (53%) had fibrosis. None had chronic active hepatitis (CAH). Immunohistochemistry indicated that 55% of the untreated patients had sparse intercellular adhesion molecule-1 (ICAM-1) expression by hepatocytes, and all of these had Kupffer cell iron overload. No ICAM-1 expression was seen by hepatocytes in treated patients or healthy controls. ICAM-1 was strongly expressed by hepatocytes from control patients with inflammatory liver disease. HLA-DR reactivity was seen on sinusoidal cells in all groups, but not on hepatocytes except for two of the control patients with CAH. Twenty-seven percent of the untreated hemochromatosis patients displayed moderate infiltration by CD3-positive lymphocytes. Electron microscopy of samples from untreated hemochromatosis patients showed hypertrophic Kupffer cells containing iron-rich remnants of phagocytosed hepatocytes. Fat-storing cells close to iron-laden hepatocytes contained multiple lipid droplets and adjacent collagen fibril bundles. Thus, in patients with untreated genetic hemochromatosis and Kupffer cell iron overload, hepatocytes occasionally express ICAM-1. In regions with heavy iron overload, Kupffer cell hypertrophy and transition of fat-storing cells are seen. Our findings indicate that release of factors from iron-loaded, activated Kupffer cells is of importance for the transformation of fat-storing cells and increased collagen deposition seen in genetic hemochromatosis.

Was Beethoven's cirrhosis due to hemochromatosis?

Dr. Wagner's description of an advanced macronodular cirrhosis is compatible with end-stage liver disease due to a variety of causes. An alcoholic etiology seems more probable than chronic viral hepatitis since such a diagnosis might also account for the chronic pancreatitis, unless it was related to the cholelithiasis. However, Dr. Wagner's description favors a diagnosis of biliary pigment sludge related to hemolysis. Furthermore, the controversy over the extent of Beethoven's alcohol consumption and the absence of mention of pancreatic calcification weakens the case for an alcoholic etiology. On the other hand, Dr. Wagner's emphasis of bluish-green pigmentation of the liver, blackish pigmentation of the spleen, and an arteropathy of the hepatic vessels suggests the probability of hemochromatosis, which diagnosis is also in keeping with Beethoven's medical history. In this regard the composer's history of recurrent obscure abdominal pain, commencing in his third decade, is especially in keeping with hemochromatosis. As many as a third of patients present with recurrent abdominal pain, and eventually up to 40% of cases develop significant abdominal pain in the course of their disease. While some of these cases of abdominal pain have been attributed to hepatoma, ascites, pancreatitis, perisplenitis, or diabetic neuropathy, the majority remain ill-defined (32). Even so, the diagnosis of hemochromatosis remains unproved in the absence of a histological examination and measurement of hepatic iron concentration. It is proposed that the combined additive, toxic effects of alcohol and iron were the most likely cause of Beethoven's cirrhosis.

Liver pathology in genetic hemochromatosis: a review of 135 homozygous cases and their bioclinical correlations

Liver pathology was assessed in 135 patients with well-defined genetic hemochromatosis ranging from mild disease to severe overload. Three lesions were clearly linked to iron-overload intensity--scarce sidero-necrosis, mild inflammation, and progressive fibrosis. Iron-free foci made of typical or dysplastic hepatocytes were found in 7.4% of the cases. An original grading allowed a reliable quantification of iron and the study of cellular and lobular distribution of iron, which permitted (a) the accurate identification of a decreasing iron gradient in hepatocytes from zone 1 to zone 3 in all cases, (b) the definition of a threshold hepatocytic/mesenchymal iron ratio related to the appearance of sidero-necrosis and to the development of fibrosis, and (c) demonstration that non-iron-related factors (mainly alcoholism) could shift iron from hepatocytes to sinusoidal cells without an increase in the total liver iron amount. This study provides a dynamic view of the iron overload process and suggests that sidero-necrosis and progressive sinusoidal iron overload play a role in the development of fibrosis in human genetic hemochromatosis.

A clinicopathological review of 100 cases of primary malignant tumours of the liver

One hundred cases of primary malignant tumour of the liver coming to necropsy in the period 1900-1969 have been reviewed. The overall tumour incidence was 0.46% of all necropsies. The overall tumour incidence in hepatic cirrhosis was 12.3%, but the corresponding male and female incidences were 17.5 and 4.4% respectively. There was no significantly increased tumour incidence in haemochromatosis. An increasing incidence of primary malignant tumours of the liver has been noted since 1940 and appears to be due to a corresponding increase in incidence of hepatic cirrhosis. Hepatocellular carcinomas outnumbered cholangiocarcinomas by 8 to 1, were more common in males than females (6 to 1), and in 77% of cases occurred in cirrhotic livers. Tumours supervened as a complication of macronodular or predominantly macronodular cirrhotic patterns.

Hepatic cirrhosis: a clinico-pathological review of 520 cases

A clinico-pathological review of 520 patients with hepatic cirrhosis coming to necropsy at the Western Infirmary, Glasgow over the period 1900-69 is reported. There has been an overall increase in incidence of cirrhosis since the 1940s, and this has been largely due to a rise in female incidence. A similar trend in the period 1940-71 has been confirmed at a national level in data abstracted from the Annual Reports of the Registrar General for Scotland. The mean age at death has risen for both sexes. Aetiologically, the cirrhosis was alcoholic in 18.5%, posticteric in 10.4%, cryptogenic in 61.9%, and haemochromatosis was diagnosed in 7.5%. Primary malignant tumours of liver supervened in 12.3%. The causes of death and the morphological patterns of the cirrhosis are reviewed.