Effects of alcohol consumption on iron metabolism

Serum ferritin level is associated with liver fibrosis and incident liver-related outcomes independent of HFE genotype in the general population

BACKGROUND & AIMS

Hyperferritinemia reflects iron accumulation in the body and has been associated with metabolic disturbances and alcohol use, and is also a common finding in individuals diagnosed with liver disease. The major genetic regulator of iron metabolism is the HFE gene.

METHODS

The aim of this this study was to investigate the association between serum ferritin and liver fibrosis using the enhanced liver fibrosis (ELF) test, and the association between ferritin and liver-related outcomes in a Finnish population-based cohort of 6194 individuals (45% male, mean [± standard deviation] age, 52.9 ± 14.9 years; body mass index 26.9 ± 4.7 kg/m2). The effects of HFE variants on these associations were also evaluated.

RESULTS

Serum ferritin levels were significantly associated with liver fibrosis, as estimated by enhanced liver fibrosis (ELF) test in weighted linear regression analysis. Serum ferritin was significantly associated with both all liver-related outcomes (n = 92) and severe liver-related outcomes (n = 54) in weighted Cox regression analysis (hazard ratio [HR] per 1 SD, 1.11 [95% confidence interval (CI) 1.02-1.21]; p = 0.012 and HR 1.11 [95% CI 1.02-1.21]; p = 0.013, respectively). However, there was association neither between HFE risk variants and ELF test nor between HFE risk variants and liver-related outcomes.

CONCLUSION

Serum ferritin levels were associated with liver fibrosis and incident liver disease, independent of HFE genotype in the general population. Furthermore, data demonstrated that metabolic disturbances and alcohol use were major risk factors for hyperferritinemia.

Iron, glucose and fat metabolism and obesity: an intertwined relationship

A bidirectional relationship exists between adipose tissue metabolism and iron regulation. Total body fat, fat distribution and exercise influence iron status and components of the iron-regulatory pathway, including hepcidin and erythroferrone. Conversely, whole body and tissue iron stores associate with fat mass and distribution and glucose and lipid metabolism in adipose tissue, liver, and muscle. Manipulation of the iron-regulatory proteins erythroferrone and erythropoietin affects glucose and lipid metabolism. Several lines of evidence suggest that iron accumulation and metabolism may play a role in the development of metabolic diseases including obesity, type 2 diabetes, hyperlipidaemia and non-alcoholic fatty liver disease. In this review we summarise the current understanding of the relationship between iron homoeostasis and metabolic disease.

Effect of alcohol consumption on haemoglobin level among non-pregnant reproductive age women in Ethiopia: a cross-sectional secondary data analysis of the 2016 Ethiopian Demographic Health Survey

OBJECTIVE

The aim of this study was to assess the effect of alcohol consumption on haemoglobin levels among non-pregnant reproductive age women using national representative data.

METHOD

A secondary data analysis was conducted using data from the 2016 Ethiopia Demographic and Health Survey. The main outcome of interest was anaemia defined as a haemoglobin value <12 g/which was measured using HemoCue, and adjusted for both altitude and smoking status. The main exposure variable was alcohol consumption. Both multivariable logistic regression and generalised linear model were employed to assess the association between alcohol consumption and anaemia and to compare the mean of haemoglobin between the non-drinkers and three alcohol consumption frequency categories, respectively, after adjusting for the potential confounders.

RESULT

In the current analysis, a total of 13 436 non-pregnant women were included. The overall prevalence of anaemia among non-pregnant women was 23.2% of which 17.9% were mildly anaemic, 4.6% were moderately anaemic and 0.7% were severely anaemic. There was a significant negative association between anaemia and respondents' history and frequency of alcohol consumption in the pooled sample. Among non-pregnant women, the odds of having anaemia were decreased with a history of alcohol drinking (adjusted OR (AOR)=0.32 (95% CI: 0.214 to 0.394)). Women who drunk alcohol less than once a week ((AOR=0.54 (95% CI: 0.31 to 0.94), those who drunk alcohol at least once a week (AOR=0.50 (95% CI: 0.28 to 0.88)) and who drunk alcohol almost every day in the last 12 months (AOR=0.42 (95% CI: 0.21 to 0.81)) had significantly lower odds of having anaemia than women who had not ever taken a drink that contain alcohol.

CONCLUSION

This study showed that nearly a quarter of non-pregnant women in Ethiopia were found to be anaemic. Alcohol consumption increases haemoglobin concentration. Further cohort or experimental studies are therefore needed to further assess the relationship between alcohol consumption and haemoglobin level among Ethiopian populations.

Iron and iron-related proteins in alcohol consumers: cellular and clinical aspects

Alcohol-associated liver disease (ALD) is one of the most common chronic liver diseases. Its pathological spectrum includes the overlapping stages of hepatic steatosis/steatohepatitis that can progress to liver fibrosis and cirrhosis; both are risk factors for hepatocellular carcinoma. Moreover, ALD diagnosis and management pose several challenges. The early pathological stages are reversible by alcohol abstinence, but these early stages are often asymptomatic, and currently, there is no specific laboratory biomarker or diagnostic test that can confirm ALD etiology. Alcohol consumers frequently show dysregulation of iron and iron-related proteins. Examination of iron-related parameters in this group may aid in early disease diagnosis and better prognosis and management. For this, a coherent overview of the status of iron and iron-related proteins in alcohol consumers is essential. Therefore, here, we collated and reviewed the alcohol-induced alterations in iron and iron-related proteins. Reported observations include unaltered, increased, or decreased levels of hemoglobin and serum iron, increments in intestinal iron absorption (facilitated via upregulations of duodenal divalent metal transporter-1 and ferroportin), serum ferritin and carbohydrate-deficient transferrin, decrements in serum hepcidin, decreased or unaltered levels of transferrin, increased or unaltered levels of transferrin saturation, and unaltered levels of soluble transferrin receptor. Laboratory values of iron and iron-related proteins in alcohol consumers are provided for reference. The causes and mechanisms underlying these alcohol-induced alterations in iron parameters and anemia in ALD are explained. Notably, alcohol consumption by hemochromatosis (iron overload) patients worsens disease severity due to the synergistic effects of excess iron and alcohol.

Serum iron, Magnesium, Copper, and Manganese Levels in Alcoholism: A Systematic Review

The aim of this paper was to review recent literature (from 2000 onwards) and summarize the newest findings on fluctuations in the concentration of some essential macro- and microelements in those patients with a history of chronic alcohol abuse. The focus was mainly on four elements which the authors found of particular interest: Iron, magnesium, copper, and manganese. After independently reviewing over 50 articles, the results were consistent with regard to iron and magnesium. On the other hand, data were limited, and in some cases contradictory, as far as copper and manganese were concerned. Iron overload and magnesium deficiency are two common results of an excessive and prolonged consumption of alcohol. An increase in the levels of iron can be seen both in the serum and within the cells, hepatocytes in particular. This is due to a number of factors: Increased ferritin levels, lower hepcidin levels, as well as some fluctuations in the concentration of the TfR receptor for transferrin, among others. Hypomagnesemia is universally observed among those suffering from alcoholism. Again, the causes for this are numerous and include malnutrition, drug abuse, respiratory alkalosis, and gastrointestinal problems, apart from the direct influence of excessive alcohol intake. Unfortunately, studies regarding the levels of both copper and manganese in the case of (alcoholic) liver disease are scarce and often contradictory. Still, the authors have attempted to summarize and give a thorough insight into the literature available, bearing in mind the difficulties involved in the studies. Frequent comorbidities and mutual relationships between the elements in question are just some of the complications in the study of this topic.

The importance of nutrition in aiding recovery from substance use disorders: A review

BACKGROUND

Nutrition is a prerequisite for health; yet, there is no special nutritional assessment or guidance for drug and alcohol dependent individuals, despite the fact that their food consumption is often very limited, risking malnutrition. Further, the premise is examined that malnutrition may promote drug seeking and impede recovery from substance use disorders (SUD).

METHOD

A narrative review addressed the relationship between substance use disorders and nutrition, including evidence for malnutrition, as well as their impact on metabolism and appetite regulation. The implications of the biopsychology of addiction and appetite for understanding the role of nutrition in SUD were also considered.

RESULTS

The literature overwhelmingly finds that subjects with alcohol use disorder (AUD) and drug use disorder (DUD) typically suffer from nutrient deficiencies. These nutrient deficiencies may be complicit in the alcoholic myopathy, osteopenia and osteoporosis, and mood disorders including anxiety and depression, observed in AUD and DUD. These same individuals have also been found to have altered body composition and altered hormonal metabolic regulators. Additionally, brain processes fundamental for survival are stimulated both by food, particularly sweet foods, and by substances of abuse, with evidence supporting confusion (addiction transfer) when recovering from SUD between cravings for a substance and craving for food.

CONCLUSION

Poor nutritional status in AUD and DUD severely impacts their physical and psychological health, which may impede their ability to resist substances of abuse and recover their health. This review contributes to a better understanding of interventions that could best support individuals with substance use disorders.

Associations between Lifestyle Factors and Iron Overload in Korean Adults

It has been suggested that iron overload, which indicates the accumulation of iron, generates cellular reactive oxygens and causes peroxide damages to the body. Such oxidative stresses, in a broader context, are also caused by lifestyles such as alcohol consumption and smoking. However, there are limited data on the association between these lifestyle factors and internal iron overload. In present study, we evaluated associations between lifestyle factors, such as smoking status, alcohol consumption, and physical activity, and serum markers of iron overload. In a population-based cross-sectional study including 2,347 Korean men and women aged 49–79 years, we assessed serum transferrin saturation (TSAT) levels and defined iron overload as TSAT levels > 50% for men and > 45% for women. After excluding persons with chronic diseases and iron deficiency, multivariate odds ratio (OR) and its 95% confidence interval (CI) were estimated to evaluate associations between lifestyle factors and iron overload in 1,973 participants. In all participants, we examined a significantly positive association between heavy alcohol consumption (> 30 g/day) and iron overload; heavy drinkers showed 1.6-fold higher OR (95% CI, 1.11–2.36) than non-drinkers. Stratified analysis by sex showed that this association was significant only among men. In addition, we observed a potential association between heavy smoking > 10 cigarettes/day and iron overload (p = 0.07). In stratified analysis by sex, we examined a significant association between smoking and iron overload only among women; former or current smokers had 1.9-fold higher OR (95% CI, 1.01–3.63) than never-smoker. Our findings suggest that heavy alcohol consumption and smoking may worsen iron accumulation in the body.

Linking Orders in Electronic Medical Records Can Improve the Frequency With Which Recommended Treatments Are Ordered as Illustrated in the Treatment of Alcohol Withdrawal

OBJECTIVE

The purpose of this study was to collect objective data concerning the prescription of vitamin supplementation treatment in hospitalized patients at risk for alcohol withdrawal.

METHODS

This study compared the total number of orders for folate, thiamine, and multivitamins with assessments ordered using the revised Clinical Institute Withdrawal Assessment of Alcohol (CIWA-Ar) during 2 congruent time periods in a hospital system before and after these orders were linked to determine the effectiveness of the link. Frequency counts of the order sets containing CIWA-Ar with and without doses of folate, thiamine, and multivitamins were extracted from the electronic medical record. One set of frequencies was collected between January 1, 2012, and June 15, 2012. The second set was collected between January 1, 2013, and June 15, 2013, after the intervention in which these orders were linked. Percentages were calculated from the frequency counts.

RESULTS

Results of the study showed that before the intervention linking these orders, thiamine was ordered only 41 times, folate 42 times, and multivitamin 42 times, whereas CIWA-Ar was ordered 1228 times within the same time parameters (3.34%, 3.42%, and 3.42%, respectively), for a total average rate of 10.18%. After orders for thiamine, folate, and multivitamins were linked to the CIWA-Ar, the average rate of these vitamins being ordered with CIWA-Ar reached 77.94%.

CONCLUSION

This study found that linking CIWA-Ar and vitamin supplementation orders within the electronic medical record increases the likelihood of them being ordered together. We propose that this can be applied to other treatments that are commonly ordered together and that such orders should be linked to improve the standards of care for all patients.

Markers of inflammation and mortality in a cohort of patients with alcohol dependence

Inflammation and intestinal permeability are believed to be paramount features in the development of alcohol-related liver damage. We aimed to assess the impact of 3 surrogate markers of inflammation (anemia, fibrinogen, and ferritin levels) on mid-term mortality of patients with alcohol dependence. This longitudinal study included patients with alcohol dependence admitted for hospital detoxification between 2000 and 2010. Mortality was ascertained from clinical charts and the mortality register. Associations between markers of inflammation and all-cause mortality were analyzed with mortality rates and Cox proportional hazards regression models. We also performed a subgroup analysis of mortality rates in patients with anemia, based on their mean corpuscular volume (MCV). We included 909 consecutive patients with alcohol dependence. Patients were mostly male (80.3%), had a median age of 44 years (interquartile range [IQR]: 38-50), and upon admission, their median alcohol consumption was 192 g/day (IQR: 120-265). At admission, 182 (20.5%) patients had anemia; 210 (25.9%) had fibrinogen levels >4.5 mg/dL; and 365 (49.5%) had ferritin levels >200 ng/mL. At the end of follow-up (median 3.8 years [IQR: 1.8-6.5], and a total of 3861.07 person-years), 118 patients had died (12.9% of the study population). Cox regression models showed that the presence of anemia at baseline was associated with mortality (hazard ratio [HR]: 1.67, 95% confidence interval [CI]: 1.11-2.52, P < 0.01); no associations were found between mortality and high fibrinogen or high ferritin levels. A subgroup of patients with anemia was analyzed and compared to a control group of patients without anemia and a normal MCV. The mortality ratios of patients with normocytic and macrocytic anemia were 3.25 (95% CI: 1.41-7.26; P < 0.01) and 3.39 (95% CI: 1.86-6.43; P < 0.01), respectively. Patients with alcohol dependence admitted for detoxification had an increased risk of death when anemia was present at admission. More accurate markers of systemic inflammation are needed to serve as prognostic factors for poor outcomes in this subset of patients.

Biomarkers of iron status and trace elements in welders

Iron status was studied in 137 welders exposed to a geometric mean (GM) air concentration of 214 μg/m(3) (range 1-3230) of manganese (Mn), in 137 referents and in 34 former welders. The GM concentrations of S-ferritin were 119 (3-1498), 112 (9-1277) and 98 (12-989) μg/L (p=0.24) in the three groups, respectively. Also the GM concentrations of S-hepcidin were not significantly different between the groups (8.4 μg/L (2.8-117); 6.6 μg/L (1.8-100); 6.5 μg/L (1.2-22)) (p=0.22). Multiple linear regression analysis including all welders and referents showed an increase in the concentration of S-ferritin associated with having serum carbohydrate deficient transferrin (S-CDT) above the upper reference limit of ≥1.7%, indicating high alcohol consumption. Serum C-reactive protein was not associated with exposure as welders, but an association with S-ferritin was shown. The GM S-ferritin concentrations among all welders and referents with S-CDT≥1.7% were 157 μg/L (95% CI 113-218) as compared to 104 μg/L (95% CI 94-116) (p=0.02) in those with S-CDT<1.7%. The GM concentrations of Mn in biological fluids were higher in the welders as compared to the referents, while S-Fe, S-Co and B-Co were statistically significantly lower. This could suggest a competitive inhibition from Mn on the uptake of Fe and Co. Increasing concentrations of S-CDT was associated with higher S-Mn, S-Fe and B-Co in the multiple linear regression analysis. The association between S-CDT and S-Fe remained when all subjects with high S-CDT (≥1.7%) were excluded, suggesting increased uptake of Fe even at lower alcohol consumption.

The influence of B-complex vitamins upon the prolongation of prothrombin time by acetaldehyde

Alcoholism plays a major role in the insufficient utilization or deficiency of the vitamin B-complex molecules, and the pathologies resulting therefrom. Thiamine, pyridoxamine, and folic acid, each contain primary amine functional groups, whereas nicotinamide and vitamin B12 contain amide groups, each of which are potential reactants with acetaldehyde (AcH), the primary intermediate in the metabolism of ethanol. In this current study, it is reported that prothrombin time (PT), which is prolonged in a fraction of the alcoholic population, can be modified (in the laboratory) when several B-complex vitamins and AcH are added successively to human plasma or are premixed prior to the addition to plasma. Particularly, thiamine, pyridoxamine, and folic acid, at 0.01 mol/l, when added successively with 44.7 mmol/l AcH to plasma, or when premixed prior to addition to plasma, produced a marked reduction in the anticoagulant effect of AcH. Nicotinamide had no effect on PT nor did mixtures with AcH effect PT. However, NAD, which contains a primary amine in its AMP moiety, reacted with AcH, lowering the latter's anticoagulant activity upon addition to plasma. Vitamin B12 did not affect PT. Interestingly, successive mixtures of vitamin B12 and AcH to plasma resulted in a small but statistically significant increase (P≤0.05) in the anticoagulant effect of AcH, whereas premixtures had no statistically significant effect (P>0.05). The decrease in anticoagulant activity of AcH in the presence of B-complex vitamins and NAD suggests that the primary amines in these molecules may form Schiff bases with AcH, thereby lowering both the free AcH concentration as well as the ability of the free vitamins/coenzymes to partake in essential physiological reactions.

Reduction of iron stores and clinical outcomes in peripheral arterial disease: outcome comparisons in smokers and non-smokers

A prospective randomized trial suggested that iron (ferritin) reduction improved outcomes in smokers. The present study reanalyzed the trial results in smokers compared with non-smokers. Randomization of 1262 men with peripheral arterial disease (540 smokers and 722 non-smokers) to iron reduction (phlebotomy) or control groups permitted analysis of the effects of iron reduction and smoking on primary (all-cause mortality) and secondary (death plus non-fatal myocardial infarction or stroke) endpoints. Iron reduction resulted in significant improvement in the primary (hazard ratio [HR] 0.661, 95% confidence interval [CI] 0.45, 0.97; P = 0.036) and secondary (HR 0.64, 95% CI 0.46, 0.88; P = 0.006) endpoints compared with controls in smokers but not in non-smokers. Smokers required removal of a greater volume of blood to attain targeted ferritin reduction as compared with non-smokers ( P = 0.003) and also exhibited differing characteristics from non-smokers, including significantly less statin use. Phlebotomy-related outcomes favored smokers over non-smokers. Biological linkages responsible for this unique effect offer promising lines for future iron reduction studies (ClinicalTrial.Gov Identifier: NCT00032357).

The statin-iron nexus: anti-inflammatory intervention for arterial disease prevention

OBJECTIVES

We postulated the existence of a statin-iron nexus by which statins improve cardiovascular disease outcomes at least partially by countering proinflammatory effects of excess iron stores.

METHODS

Using data from a clinical trial of iron (ferritin) reduction in advanced peripheral arterial disease, the Iron and Atherosclerosis Study, we compared effects of ferritin levels versus high-density lipoprotein to low-density lipoprotein ratios (both were randomization variables) on clinical outcomes in participants receiving and not receiving statins.

RESULTS

Statins increased high-density lipoprotein to low-density lipoprotein ratios and reduced ferritin levels by noninteracting mechanisms. Improved clinical outcomes were associated with lower ferritin levels but not with improved lipid status.

CONCLUSIONS

There are commonalities between the clinical benefits of statins and the maintenance of physiologic iron levels. Iron reduction may be a safe and low-cost alternative to statins.