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Villa Nogueyra S, Trujillo Rodríguez MF, Garcia Oliva ML, Vidal-Gallardo A, Ramírez Leal A, Beltran Hernandez J, Vargas Beltran AM, Guillen Sandoval JD, Arriaga Escamilla D, Martinez Ramirez M. The Genetic Diagnostics of Hemochromatosis: Disparities in Low- Versus High-Income Countries. Cureus 2024; 16:e64074. [PMID: 39114232 PMCID: PMC11305073 DOI: 10.7759/cureus.64074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2024] [Indexed: 08/10/2024] Open
Abstract
This study provides a comprehensive overview of hereditary hemochromatosis (HH), a genetic condition characterized by iron overload due to excessive iron absorption. It elucidates diverse inheritance patterns and clinical manifestations by exploring mutations in critical genes such as HFE (hemochromatosis), HJV (hemojuvelin), HAMP (hepcidin antimicrobial peptide), TfR2 (transferrin receptor 2), and FP (ferroportin). The significance of early screening, diagnosis, and personalized management strategies based on genetic classification is emphasized, particularly in terms of high-income vs. low-income countries. Addressing challenges in diagnosis, genetic testing accessibility, and healthcare disparities, the study highlights the importance of early detection, cost-effective screening strategies, and enhancing healthcare outcomes globally. Advanced genetic testing in high-income countries facilitates early diagnosis and management, reducing complications such as liver disease and cardiomyopathy. In contrast, low-income populations face several barriers, including limited access to genetic testing, high costs, and inadequate healthcare infrastructure. Cost-effective serum ferritin (SF) and transferrin saturation (TS) tests and emerging point-of-care (POC) tests offer affordable diagnostic options for low-resource settings. Additionally, the ongoing development of hepcidin measurement methods holds promise for enhancing diagnostic capabilities. Implementing these strategies can aid healthcare providers in improving global HH management and reducing the burden of iron overload complications. Furthermore, the study underscores the need for public health initiatives to raise awareness about HH, promote routine screenings, and advocate for equitable healthcare policies. Collaborative efforts between governments, healthcare organizations, and research institutions are crucial in addressing the global burden of HH. By fostering international cooperation and resource-sharing, it is possible to bridge the gap between high-income and low-income countries, ensuring all individuals have access to the necessary diagnostic and treatment options. This holistic approach can ultimately lead to better health outcomes and improved quality of life for individuals affected by HH worldwide. This comprehensive examination of HH not only illuminates the genetic and clinical aspects of the condition but also provides a roadmap for addressing the multifaceted challenges associated with its diagnosis and management.
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Affiliation(s)
| | | | | | | | - Amanda Ramírez Leal
- Faculty of Medicine, Universidad Nacional Autónoma de México, Mexico City, MEX
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Schaefer B, Pammer LM, Pfeifer B, Neururer S, Troppmair MR, Panzer M, Wagner S, Pertler E, Gieger C, Kronenberg F, Lamina C, Tilg H, Zoller H. Penetrance, cancer incidence and survival in HFE haemochromatosis-A population-based cohort study. Liver Int 2024; 44:838-847. [PMID: 38263707 DOI: 10.1111/liv.15797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 11/02/2023] [Accepted: 11/04/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND AND AIMS Haemochromatosis is characterized by progressive iron overload affecting the liver and can cause cirrhosis and hepatocellular carcinoma. Most haemochromatosis patients are homozygous for p.C282Y in HFE, but only a minority of individuals with this genotype will develop the disease. The aim was to assess the penetrance of iron overload, fibrosis, hepatocellular carcinoma and life expectancy. METHODS A total of 8839 individuals from the Austrian region of Tyrol were genotyped for the p.C282Y variant between 1997 and 2021. Demographic, laboratory parameters and causes of death were assessed from health records. Penetrance, survival, and cancer incidence were ascertained from diagnosed cases, insurance- and cancer registry data. Outcomes were compared with a propensity score-matched control population. RESULTS Median age at diagnosis in 542 p.C282Y homozygous individuals was 47.8 years (64% male). At genotyping, the prevalence of iron overload was 55%. The cumulative penetrance of haemochromatosis defined as the presence of provisional iron overload was 24.2% in males and 10.5% in females aged 60 years or younger. Among p.C282Y homozygotes of the same ages, the cumulative proportion of individuals without fibrosis (FIB-4 score < 1.3) was 92.8% in males and 96.7% in females. Median life expectancy was reduced by 6.8 years in individuals homozygous for p.C282Y when compared with population-matched controls (p = .001). Hepatocellular carcinoma incidence was not significantly higher in p.C282Y homozygotes than in controls matched for age and sex. CONCLUSION Reduced survival and the observed age-dependent increase in penetrance among p.C282Y homozygotes call for earlier diagnosis of haemochromatosis to prevent complications.
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Affiliation(s)
- Benedikt Schaefer
- Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lorenz M Pammer
- Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bernhard Pfeifer
- Division for Digital Medicine and Telehealth, UMIT TIROL-Private University for Health Sciences and Health Technology, Hall (Tyrol), Austria
- Tyrolean Federal Institute for Integrated Care, Tirol Kliniken Gmbh, Innsbruck, Austria
| | - Sabrina Neururer
- Division for Digital Medicine and Telehealth, UMIT TIROL-Private University for Health Sciences and Health Technology, Hall (Tyrol), Austria
- Tyrolean Federal Institute for Integrated Care, Tirol Kliniken Gmbh, Innsbruck, Austria
| | - Maria R Troppmair
- Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Medical University of Innsbruck, Innsbruck, Austria
| | - Marlene Panzer
- Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sonja Wagner
- Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Medical University of Innsbruck, Innsbruck, Austria
- Christian Doppler Laboratory for Iron and Phosphate Biology, Medical University of Innsbruck, Innsbruck, Austria
| | - Elke Pertler
- Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Medical University of Innsbruck, Innsbruck, Austria
- Christian Doppler Laboratory for Iron and Phosphate Biology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Gieger
- Institute of Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
- Research Unit of Molecular Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - Florian Kronenberg
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudia Lamina
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Herbert Tilg
- Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Medical University of Innsbruck, Innsbruck, Austria
| | - Heinz Zoller
- Department of Medicine I, Gastroenterology, Hepatology and Endocrinology, Medical University of Innsbruck, Innsbruck, Austria
- Christian Doppler Laboratory for Iron and Phosphate Biology, Medical University of Innsbruck, Innsbruck, Austria
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Liu XY, Lu JF, Wang LD, Wang ZY. Diagnostic value of shear wave velocity measured by virtual touch tissue imaging quantification combined with hepatic blood flow index measured by single-photon emission computed tomography first-pass method for hepatitis B fibrosis. Shijie Huaren Xiaohua Zazhi 2023; 31:492-500. [DOI: 10.11569/wcjd.v31.i12.492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 02/17/2023] [Accepted: 06/16/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND The degree of liver fibrosis in patients with chronic liver disease can be evaluated by combining single-photon emission computed tomography (SPECT) first-pass method to measure hepatic blood flow index with virtual touch tissue imaging quantification (VTIQ) to detect shear wave velocity (SWV).
AIM To evaluate the clinical value of VTIQ combined with SPECT first-pass method for the diagnosis of liver fibrosis in patients with chronic hepatitis B (CHB).
METHODS Forty-two CHB patients with liver fibrosis at our hospital from August 2020 to August 2021 were selected as a study group, and another 42 patients with CHB without hepatic fibrosis were selected as a control group. VTIQ was performed to obtain the shear wave transverse velocity (SWV), and SPECT examination was performed to obtain liver blood flow index. General data, routine blood indexes [white blood cell count (WBC), absolute monocyte count (AMC), and neutrophil count (NEUT)], blood coagulation function [prothombin time (PT) and prothrombin activity (PTA)], liver function indexes [total bilirubin (TBIL), alanine aminotransferase (ALT), aspartate aminotransferase (AST), and albumin (ALB)] and SWV, and liver blood flow index were compared between the two groups. The degree of liver fibrosis in the study group was determined through liver tissue pathology, and SWV and liver blood flow index were compared among patients with different liver fibrosis degrees. Spearman correlation coefficient was used to assess the correlation of SWV and liver blood flow index with CHB liver fibrosis degree. The value of SWV and liver blood flow index in diagnosing CHB liver fibrosis was assessed by receiver operating characteristic (ROC) curve analysis.
RESULTS The SWV and liver blood flow index of the study group were significantly higher than those of the control group (P < 0.05). The SWV and hepatic blood flow index were significantly higher in patients with liver fibrosis grade S3-S4 in the study group than in those with grade S1-S2, and and in those with grade S2 than in those with grade S1 (P < 0.05). SWV and liver blood flow index were positively correlated with CHB liver fibrosis degree (P < 0.05). The area under the curve (AUC) values of SWV and liver blood flow index, alone or in combination, for the diagnosis of CHB liver fibrosis were all > 0.7, and the AUC of the combination was the largest (0.930).
CONCLUSION SWV measured by VTIQ combined with liver blood flow index measured by SPECT has appreciated value in the diagnosis of CHB liver fibrosis and in the assessment of the degree of liver fibrosis.
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Affiliation(s)
- Xiang-Yan Liu
- Department of Hepatological Surgery, Shulan (Hangzhou) Hospital, Hangzhou 310000, Zhejiang Province, China
| | - Jian-Fang Lu
- Department of Hepatological Surgery, Shulan (Hangzhou) Hospital, Hangzhou 310000, Zhejiang Province, China
| | - Li-Dong Wang
- Department of Hepatological Surgery, Shulan (Hangzhou) Hospital, Hangzhou 310000, Zhejiang Province, China
| | - Zhuo-Yi Wang
- Department of Hepatological Surgery, Shulan (Hangzhou) Hospital, Hangzhou 310000, Zhejiang Province, China
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Abstract
Haemochromatosis is one of the most common genetic diseases affecting patients of northern European ancestry. It is overdiagnosed in patients without iron overload and is underdiagnosed in many patients. Early diagnosis by genetic testing and therapy by periodic phlebotomy can prevent the most serious complications, which include liver cirrhosis, liver cancer, and death. This Seminar includes an update on the origins of haemochromatosis; and an overview pathophysiology, genetics, natural history, signs and symptoms, differential diagnoses, treatment with phlebotomy, outcomes, and future directions.
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Affiliation(s)
- Paul C Adams
- Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
| | - Gary Jeffrey
- Medical School, University of Western Australia, Perth, WA, Australia
| | - John Ryan
- Royal College of Surgeons of Ireland, Dublin, Ireland
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Olynyk JK, Grainger R, Currie H, Ramm LE, Ramm GA. The ancestral haplotype markers HLA -A3 and B7 do not influence the likelihood of advanced hepatic fibrosis or cirrhosis in HFE hemochromatosis. Sci Rep 2023; 13:7775. [PMID: 37179448 PMCID: PMC10183001 DOI: 10.1038/s41598-023-35028-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 05/11/2023] [Indexed: 05/15/2023] Open
Abstract
Advanced hepatic fibrosis occurs in up to 25% of individuals with C282Y homozygous hemochromatosis. Our aim was to determine whether human leukocyte antigen (HLA)-A3 and B7 alleles act as genetic modifiers of the likelihood of advanced hepatic fibrosis. Between 1972 and 2013, 133 HFE C282Y homozygous individuals underwent clinical and biochemical evaluation, HLA typing, liver biopsy for fibrosis staging and phlebotomy treatment. Hepatic fibrosis was graded according to Scheuer as F0-2 (low grade hepatic fibrosis), F3-4 (advanced hepatic fibrosis), and F4 cirrhosis. We analysed associations between the severity of fibrosis and HLA-A3 homozygosity, heterozygosity or absence, with or without the presence of HLA-B7 using categorical analysis. The mean age of HLA-A3 homozygotes (n = 24), heterozygotes (n = 65) and HLA-A3 null individuals (n = 44) was 40 years. There were no significant differences between the groups for mean(± SEM) serum ferritin levels (1320 ± 296, 1217 ± 124, 1348 ± 188 [Formula: see text]g/L), hepatic iron concentration (178 ± 26, 213 ± 22, 199 ± 29 [Formula: see text]mol/g), mobilizable iron stores (9.9 ± 1.5, 9.5 ± 1.5, 11.5 ± 1.7 g iron removed via phlebotomy), frequency of advanced hepatic fibrosis (5/24[12%], 13/63[19%], 10/42[19%]) or cirrhosis (3/24[21%], 12/63[21%], 4/42[24%]), respectively. The presence or absence of HLA-B7 did not influence the outcome. Thus, HLA-A3 and HLA-B7 alleles are not associated with the risk of advanced hepatic fibrosis or cirrhosis in C282Y hemochromatosis.
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Affiliation(s)
- John K Olynyk
- Medical School, Curtin University, Bentley, WA, Australia.
- Department of Gastroenterology, Fiona Stanley Fremantle Hospital Group, Murdoch, WA, Australia.
| | - Richard Grainger
- Department of Gastroenterology, Fiona Stanley Fremantle Hospital Group, Murdoch, WA, Australia
| | - Helen Currie
- Department of Gastroenterology, Fiona Stanley Fremantle Hospital Group, Murdoch, WA, Australia
| | - Louise E Ramm
- QIMR-Berghofer Medical Research Institute, Herston, QLD, Australia
- Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
| | - Grant A Ramm
- QIMR-Berghofer Medical Research Institute, Herston, QLD, Australia
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Barton JC, Barton JC, Acton RT. Non-alcoholic fatty liver disease in hemochromatosis probands with iron overload and HFE p.C282Y/p.C282Y. BMC Gastroenterol 2023; 23:137. [PMID: 37118679 PMCID: PMC10148383 DOI: 10.1186/s12876-023-02763-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/11/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND The aim of this study was to identify characteristics of non-alcoholic fatty liver disease (NAFLD) in adults with HFE p.C282Y/p.C282Y. METHODS We retrospectively studied non-Hispanic white hemochromatosis probands with iron overload (serum ferritin (SF) > 300 µg/L (M), > 200 µg/L (F)) and p.C282Y/p.C282Y at non-screening diagnosis who did not report alcohol consumption > 14 g/d, have cirrhosis or other non-NAFLD liver disorders, use steatogenic medication, or have diagnoses of heritable disorders that increase NAFLD risk. We identified NAFLD-associated characteristics using univariate and multivariable analyses. RESULTS There were 66 probands (31 men, 35 women), mean age 49 ± 14 (SD) y, of whom 16 (24.2%) had NAFLD. The following characteristics were higher in probands with NAFLD: median SF (1118 µg/L (range 259, 2663) vs. 567 µg/L (247, 2385); p = 0.0192); prevalence of elevated ALT/AST (alanine/aspartate aminotransferase) (43.8% vs. 10.0%; p = 0.0056); and prevalence of type 2 diabetes (T2DM) (31.3% vs. 10.0%; p = 0.0427). Mean age, sex, and prevalences of human leukocyte antigen-A*03 positivity, body mass index ≥ 30.0 kg/m2, hyperlipidemia, hypertension, and metabolic syndrome in probands with/without NAFLD did not differ significantly. Logistic regression on NAFLD using variables SF, elevated ALT/AST, and T2DM revealed: SF (p = 0.0318; odds ratio 1.0-1.0) and T2DM (p = 0.0342; 1.1-22.3). Median iron removed to achieve iron depletion (QFe) in probands with/without NAFLD did not differ significantly (3.6 g (1.4-7.2 g) vs. 2.8 g (0.7-11.0 g), respectively; p = 0.6862). CONCLUSIONS NAFLD in hemochromatosis probands with p.C282Y/p.C282Y is associated with higher median SF and greater T2DM prevalence, after adjustment for other factors. NAFLD does not influence QFe significantly.
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Affiliation(s)
- James C Barton
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
- Southern Iron Disorders Center, Birmingham, AL, USA.
| | | | - Ronald T Acton
- Southern Iron Disorders Center, Birmingham, AL, USA
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, USA
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Cathcart J, Mukhopadhya A. European Association for Study of the Liver (EASL) clinical practice guidelines on haemochromatosis. Frontline Gastroenterol 2023; 14:282-286. [PMID: 37409332 PMCID: PMC11138169 DOI: 10.1136/flgastro-2022-102296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 02/14/2023] [Indexed: 07/07/2023] Open
Abstract
The European Association for the Study of the Liver has recently updated guidance on haemochromatosis with a more extensive discussion on investigation and management.[ The new guidance focuses on non-invasive methods for fibrosis assessment and early diagnosis to include more extensive genetic testing if needed. Early diagnosis and treatment is vital as it reduces morbidity and mortality. We review this guideline and offer key updated messages with a focus on new developments since the last guidance and key aspects of current practice.
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Ibrahim WH, Abokresha MM, Nigm DA, Abdelal SM, Kelani A, Aly MG. Relation of Liver Siderosis to Liver Fibrosis in Hemodialysis Patients With Severe Hyperferritinemia Secondary to High Doses of Intravenous Iron Supplementation. J Ren Nutr 2023; 33:337-345. [PMID: 36182059 DOI: 10.1053/j.jrn.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/14/2022] [Accepted: 08/21/2022] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Aggressive iron substitution in hemodialysis (HD) patients leads to iron overload. The association between liver siderosis and fibrosis is still debatable. We studied the association of liver siderosis with liver fibrosis in HD patients. Furthermore, we studied the performance of liver stiffness measurements (LSMs) in identifying advanced liver fibrosis. We investigated the performance of biochemical indicators of iron status in identifying advanced liver fibrosis. METHODS Fifty-five HD patients (average HD duration 6 ± 2 years) with hyperferritinemia secondary to intravenous iron supplementation (weakly iron dose 252.7 ± 63 mg; median blood transfusions 3 [2-5]) were recruited. The liver fibrosis grade was determined with Fibroscan, aminotransferase-to-platelet ratio index (APRI), and Fib-4 index. Liver iron concentration (LIC) was estimated with magnetic resonance imaging (MRI). Iron parameters and liver function biochemical indicators were also assessed. RESULTS The median serum ferritin and transferrin saturation (TSAT) were 3531 μg/L and 77%, respectively. 34.5%, 20%, and 45.5% of the patients showed mild, moderate, or severe liver siderosis, respectively. All patients with severe liver siderosis showed advanced liver fibrosis. Patients with severe liver siderosis and advanced liver stiffness showed higher serum iron, TSAT, aspartate aminotransferase (AST), alanine aminotransferase (ALT), serum bilirubin, APRI, and Fib-4 index scores than those with mild liver siderosis. Serum iron and TSAT showed good utility in identifying advanced liver fibrosis determined with Fibroscan, APRI, and Fib-4 index. Liver stiffness exhibited good utility in identifying advanced liver fibrosis diagnosed with APRI and Fib-4 index. CONCLUSIONS High weekly intravenous iron dose associated with severe hyperferritinemia, high serum iron, and TSAT might lead to severe liver siderosis and concomitant liver fibrosis in HD patients. Serum iron, TSAT, Fibroscan, Fib-4, and APRI scores might offer noninvasive tools for identifying advanced liver fibrosis in those patients.
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Affiliation(s)
- Walaa H Ibrahim
- Nephrology Unit, Internal Medicine Department, Assiut University, Assiut, Egypt
| | - Marwa M Abokresha
- Gastroenterology Unit, Internal Medicine Department, Assiut University, Assiut, Egypt
| | - Dalia A Nigm
- Clinical Pathology Department, Assiut University, Assiut, Egypt
| | | | - Abdalla Kelani
- Gastroenterology Unit, Internal Medicine Department, Assiut University, Assiut, Egypt
| | - Mostafa G Aly
- Nephrology Unit, Internal Medicine Department, Assiut University, Assiut, Egypt; Transplantation Immunology, Institute of Immunology, University Hospital Heidelberg, Heidelberg, Germany.
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Affiliation(s)
- John K Olynyk
- From the Department of Gastroenterology and Hepatology, Fiona Stanley Fremantle Hospital Group, Murdoch, and the School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA (J.K.O.); and the Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Herston, QLD (G.A.R.) - all in Australia
| | - Grant A Ramm
- From the Department of Gastroenterology and Hepatology, Fiona Stanley Fremantle Hospital Group, Murdoch, and the School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA (J.K.O.); and the Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Herston, QLD (G.A.R.) - all in Australia
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Schreiner AD, Moran WP, Zhang J, Livingston S, Marsden J, Mauldin PD, Koch D, Gebregziabher M. The Association of Fibrosis-4 Index Scores with Severe Liver Outcomes in Primary Care. J Gen Intern Med 2022; 37:3266-3274. [PMID: 35048297 PMCID: PMC9550951 DOI: 10.1007/s11606-021-07341-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 12/15/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The Fibrosis-4 Index (FIB-4)non-invasively assesses fibrosis risk in chronic liver disease (CLD), but underdiagnosis limits FIB-4's application in primary care. OBJECTIVE To evaluate the association of FIB-4 risk with hazard of severe liver outcomes in primary care patients with and without diagnosed CLD. DESIGN Retrospective cohort study of primary care data from 2007 to 2018. PARTICIPANTS Adult patients with qualifying aminotransferase and platelet count results were included and a single FIB-4 score was calculated for each patient using the first of these values. Patients with a CLD diagnosis or outcome prior to their FIB-4 score were excluded. MEASURES FIB-4 advanced fibrosis risk categorization (low, indeterminate, and high) was the primary predictor variable. Patients were followed from FIB-4 score to a severe liver outcome, a composite of cirrhosis, liver transplantation, and hepatocellular carcinoma. We analyzed the association of FIB-4 risk categories with hazard risk of a severe liver outcome using stratified Cox regression models, stratifying patients by known CLD. KEY RESULTS A total of 20,556 patients were followed for a mean 2,978 days (SD 1,201 days), and 4% of patients experienced a severe liver outcome. Of patients with low-, indeterminate-, and high-risk FIB-4 scores, 2%, 4%, and 20% suffered a severe liver outcome, respectively. In the overall adjusted model, high-risk FIB-4 scores were associated with hazard of severe liver disease (HR 6.64; 95% CI 5.58-7.90). High-risk FIB-4 scores were associated with severe liver outcomes for patients with known NAFLD (HR 7.32; 95% CI 3.44-15.58), other liver disease (HR 11.39; 95% CI 8.53-15.20), and no known CLD (HR 4.05; 95% CI 3.10-5.28). CONCLUSIONS High-risk FIB-4 scores were strongly associated with risk of severe liver outcomes in patients with and without known CLD. Comprehensive FIB-4 application in primary care may signal silently advancing liver fibrosis.
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Affiliation(s)
- Andrew D Schreiner
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA.
| | - William P Moran
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Jingwen Zhang
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Sherry Livingston
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Justin Marsden
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Patrick D Mauldin
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - David Koch
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, 29425, USA
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Andersson L, Powell LW, Ramm LE, Ramm GA, Olynyk JK. Arthritis Prediction of Advanced Hepatic Fibrosis in HFE Hemochromatosis. Mayo Clin Proc 2022; 97:1649-1655. [PMID: 35422339 DOI: 10.1016/j.mayocp.2022.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 01/23/2022] [Accepted: 02/14/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate whether arthritis predicts the likelihood of advanced hepatic fibrosis in HFE hemochromatosis. PATIENTS AND METHODS We conducted a retrospective, cross-sectional analysis of 112 well-characterized patients with HFE hemochromatosis and liver biopsy-validated fibrosis staging recruited between January 1, 1983, and December 31, 2013. Complete clinical, biochemical, hematologic, and noninvasive serum biochemical indices (aspartate aminotransferase to platelet ratio index [APRI] and fibrosis 4 index [FIB4]) were available. Scheuer fibrosis stages 3 and 4, APRI greater than 0.44, or FIB4 greater than 1.1 were used to define advanced hepatic fibrosis. Comparisons between groups were performed using categorical analysis, unpaired or paired t test. RESULTS Male (n=76) and female (n=36) patients were similar in age. Nineteen patients had advanced hepatic fibrosis, and 47 had hemochromatosis arthritis. Arthritis was significantly associated with the presence of advanced hepatic fibrosis as determined by liver biopsy (sensitivity, 84%, [95% CI, 62% to 95%]; negative predictive value, 95% [95% CI, 87% to 99%]; relative risk, 7.4 [95% CI, 2.5 to 23]; P<.001), APRI (sensitivity, 75% [95% CI, 55% to 88%]; negative predictive value, 91% [95% CI, 81% to 96%]; relative risk, 4.5 [95% CI, 2.0 to 10.2]; P<.001), or FIB4 (sensitivity, 61% [95% CI, 41% to 78%]; negative predictive value, 67% [95% CI, 68% to 90%]; relative risk, 2.2 [95% CI, 1.1 to 4.6]; P=.03). Mean cell volume values were significantly higher pretreatment in patients with F3-4 fibrosis (96.7±1.1 fL) compared with F0-2 fibrosis (93.4±0.5 fL; P=.004) and declined following treatment (F3-4, 93.2±0.9 fL, P=.01; F0-2, 91.7±0.6 fL, P=.01). CONCLUSION Advanced hepatic fibrosis is strongly associated with arthritis in HFE hemochromatosis. The absence of arthritis predicts a low likelihood of advanced hepatic fibrosis, supporting its use as a clinical marker for advanced hepatic fibrosis in HFE hemochromatosis.
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Affiliation(s)
- Lauren Andersson
- Department of Gastroenterology and Hepatology, Fiona Stanley Fremantle Hospital Group, Murdoch, Western Australia, Australia
| | - Lawrie W Powell
- Faculty of Medicine, The University of Queensland, Herston, Brisbane, Queensland, Australia
| | - Louise E Ramm
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Grant A Ramm
- Faculty of Medicine, The University of Queensland, Herston, Brisbane, Queensland, Australia; Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - John K Olynyk
- Department of Gastroenterology and Hepatology, Fiona Stanley Fremantle Hospital Group, Murdoch, Western Australia, Australia; School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia.
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Zoller H, Schaefer B, Vanclooster A, Griffiths B, Bardou-Jacquet E, Corradini E, Porto G, Ryan J, Cornberg M. EASL Clinical Practice Guidelines on haemochromatosis. J Hepatol 2022; 77:479-502. [PMID: 35662478 DOI: 10.1016/j.jhep.2022.03.033] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 03/29/2022] [Indexed: 12/15/2022]
Abstract
Haemochromatosis is characterised by elevated transferrin saturation (TSAT) and progressive iron loading that mainly affects the liver. Early diagnosis and treatment by phlebotomy can prevent cirrhosis, hepatocellular carcinoma, diabetes, arthropathy and other complications. In patients homozygous for p.Cys282Tyr in HFE, provisional iron overload based on serum iron parameters (TSAT >45% and ferritin >200 μg/L in females and TSAT >50% and ferritin >300 μg/L in males and postmenopausal women) is sufficient to diagnose haemochromatosis. In patients with high TSAT and elevated ferritin but other HFE genotypes, diagnosis requires the presence of hepatic iron overload on MRI or liver biopsy. The stage of liver fibrosis and other end-organ damage should be carefully assessed at diagnosis because they determine disease management. Patients with advanced fibrosis should be included in a screening programme for hepatocellular carcinoma. Treatment targets for phlebotomy are ferritin <50 μg/L during the induction phase and <100 μg/L during the maintenance phase.
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Barton JC, Barton JC, Acton RT. HLA-A*03, the hemochromatosis ancestral haplotype, and phenotypes of referred hemochromatosis probands with HFE p.C282Y homozygosity. Hereditas 2022; 159:25. [PMID: 35659379 PMCID: PMC9169309 DOI: 10.1186/s41065-022-00237-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Human leukocyte antigen (HLA)-A*03, hemochromatosis ancestral haplotype marker, was associated with greater iron overload in hemochromatosis cohorts reported before discovery of the HFE gene. We sought to learn whether an A*03-linked locus influences phenotypes in referred HFE p.C282Y homozygotes. Methods We tabulated these phenotypes in probands with p.C282Y homozygosity: age, transferrin saturation (TS), serum ferritin (SF), conditions related to iron overload, fibrosis-four variables (FIB-4) index and aspartate aminotransferase-to-platelet ratio index (APRI) predictors of severe hepatic fibrosis, and iron removed to achieve depletion (QFe/age). We analyzed phenotypes of men and women separately across three A*03 subgroups. Results There were 104 men (57.8%) and 76 women (42.2%). Mean age (SD) was 49 ± 13 y. Mean TS was 79 ± 17%. Median SF (range) was 715 µg/L (28, 6103). Related conditions included: hemochromatosis arthropathy (21.7%); type 2 diabetes (18.9%); hypogonadotropic hypogonadism (5.8% of men); cardiomyopathy (0%); and cirrhosis (10.0%). Median QFe/age was 61 mg/y (0, 714). A*03 homozygosity, heterozygosity, and no A*03 occurred in 37 (20.6%), 104 (57.8%), and 39 probands (21.7%), respectively. In men, mean TS and median SF were significantly higher in A*03 homozygotes than heterozygotes but not A*03-negative probands. In men, median APRI was significantly lower in A*03 heterozygotes than homozygotes and A*03-negative probands. No other phenotypes, including QFe/age, differed significantly across A*03 subgroups in either men or women. Conclusions Our results suggest that an A*03-linked locus does not influence phenotypes in referred HFE p.C282Y homozygotes. It is unlikely that heritable factors that modify phenotypes of p.C282Y homozygotes are linked to the hemochromatosis ancestral haplotype.
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Affiliation(s)
- James C Barton
- Southern Iron Disorders Center, Birmingham, AL, USA. .,Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | | | - Ronald T Acton
- Southern Iron Disorders Center, Birmingham, AL, USA.,Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, USA
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Kunkel J, Schott E. Rheumatologie und Hepatologie
interdisziplinär. AKTUEL RHEUMATOL 2021. [DOI: 10.1055/a-1626-8710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
ZusammenfassungRheumatologische und hepatologische Erkrankungen haben einige
Überschneidungen, die für Behandler aus beiden Disziplinen
relevant sind. In dieser Übersicht wird ein Schlaglicht auf 2
Erkrankungen geworfen, die sich an der Schnittstelle befinden: Arthropathie bei
Hämochromatose und Systemische Sklerose bei Primär
Biliärer Cholangitis. Daneben werden hepatologische Fragestellungen bei
rheumatologischer Therapie beleuchtet.
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Affiliation(s)
- Jan Kunkel
- Klinik für Innere Medizin II, HELIOS Klinikum Emil von Behring
Berlin-Zehlendorf, Berlin, Deutschland
| | - Eckart Schott
- Klinik für Innere Medizin II, HELIOS Klinikum Emil von Behring
Berlin-Zehlendorf, Berlin, Deutschland
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Utility and limitations of Hepascore and transient elastography to detect advanced hepatic fibrosis in HFE hemochromatosis. Sci Rep 2021; 11:14654. [PMID: 34282177 PMCID: PMC8289828 DOI: 10.1038/s41598-021-94083-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/05/2021] [Indexed: 11/08/2022] Open
Abstract
Aspartate aminotransferase-to-platelet ratio index (APRI) and Fibrosis-4 Index (Fib4) have been validated against liver biopsy for detecting advanced hepatic fibrosis in HFE hemochromatosis. We determined the diagnostic utility for advanced hepatic fibrosis of Hepascore and transient elastography compared with APRI and Fib4 in 134 newly diagnosed HFE hemochromatosis subjects with serum ferritin levels > 300 µg/L using area under the receiver operator characteristic curve (AUROC) analysis and APRI- (> 0.44) or Fib4- (> 1.1) cut-offs for AHF, or a combination of both. Compared with APRI, Hepascore demonstrated an AUROC for advanced fibrosis of 0.69 (95% CI 0.56-0.83; sensitivity = 69%, specificity = 65%; P = 0.01) at a cut-off of 0.22. Using a combination of APRI and Fib4, the AUROC for Hepascore for advanced fibrosis was 0.70 (95% CI 0.54-0.86, P = 0.02). Hepascore was not diagnostic for detection of advanced fibrosis using the Fib4 cut-off. Elastography was not diagnostic using either APRI or Fib4 cut-offs. Hepascore and elastography detected significantly fewer true positive or true negative cases of advanced fibrosis compared with APRI and Fib4, except in subjects with serum ferritin levels > 1000 µg/L. In comparison with APRI or Fib4, Hepascore or elastography may underdiagnose advanced fibrosis in HFE Hemochromatosis, except in individuals with serum ferritin levels > 1000 µg/L.
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