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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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2
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Teschke R. Copper, Iron, Cadmium, and Arsenic, All Generated in the Universe: Elucidating Their Environmental Impact Risk on Human Health Including Clinical Liver Injury. Int J Mol Sci 2024; 25:6662. [PMID: 38928368 PMCID: PMC11203474 DOI: 10.3390/ijms25126662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 06/12/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
Humans are continuously exposed to various heavy metals including copper, iron, cadmium, and arsenic, which were specifically selected for the current analysis because they are among the most frequently encountered environmental mankind and industrial pollutants potentially causing human health hazards and liver injury. So far, these issues were poorly assessed and remained a matter of debate, also due to inconsistent results. The aim of the actual report is to thoroughly analyze the positive as well as negative effects of these four heavy metals on human health. Copper and iron are correctly viewed as pollutant elements essential for maintaining human health because they are part of important enzymes and metabolic pathways. Healthy individuals are prepared through various genetically based mechanisms to maintain cellular copper and iron homeostasis, thereby circumventing or reducing hazardous liver and organ injury due to excessive amounts of these metals continuously entering the human body. In a few humans with gene aberration, however, liver and organ injury may develop because excessively accumulated copper can lead to Wilson disease and substantial iron deposition to hemochromatosis. At the molecular level, toxicities of some heavy metals are traced back to the Haber Weiss and Fenton reactions involving reactive oxygen species formed in the course of oxidative stress. On the other hand, cellular homeostasis for cadmium and arsenic cannot be provided, causing their life-long excessive deposition in the liver and other organs. Consequently, cadmium and arsenic represent health hazards leading to higher disability-adjusted life years and increased mortality rates due to cancer and non-cancer diseases. For unknown reasons, however, liver injury in humans exposed to cadmium and arsenic is rarely observed. In sum, copper and iron are good for the human health of most individuals except for those with Wilson disease or hemochromatosis at risk of liver injury through radical formation, while cadmium and arsenic lack any beneficial effects but rather are potentially hazardous to human health with a focus on increased disability potential and risk for cancer. Primary efforts should focus on reducing the industrial emission of hazardous heavy metals.
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Affiliation(s)
- Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, 63450 Hanau, Germany; ; Tel.: +49-6181/21859; Fax: +49-6181/2964211
- Academic Teaching Hospital of the Medical Faculty, Goethe University Frankfurt/Main, 60590 Hanau, Germany
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3
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Teschke R. Hemochromatosis: Ferroptosis, ROS, Gut Microbiome, and Clinical Challenges with Alcohol as Confounding Variable. Int J Mol Sci 2024; 25:2668. [PMID: 38473913 DOI: 10.3390/ijms25052668] [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: 01/29/2024] [Revised: 02/21/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
Hemochromatosis represents clinically one of the most important genetic storage diseases of the liver caused by iron overload, which is to be differentiated from hepatic iron overload due to excessive iron release from erythrocytes in patients with genetic hemolytic disorders. This disorder is under recent mechanistic discussion regarding ferroptosis, reactive oxygen species (ROS), the gut microbiome, and alcohol abuse as a risk factor, which are all topics of this review article. Triggered by released intracellular free iron from ferritin via the autophagic process of ferritinophagy, ferroptosis is involved in hemochromatosis as a specific form of iron-dependent regulated cell death. This develops in the course of mitochondrial injury associated with additional iron accumulation, followed by excessive production of ROS and lipid peroxidation. A low fecal iron content during therapeutic iron depletion reduces colonic inflammation and oxidative stress. In clinical terms, iron is an essential trace element required for human health. Humans cannot synthesize iron and must take it up from iron-containing foods and beverages. Under physiological conditions, healthy individuals allow for iron homeostasis by restricting the extent of intestinal iron depending on realistic demand, avoiding uptake of iron in excess. For this condition, the human body has no chance to adequately compensate through removal. In patients with hemochromatosis, the molecular finetuning of intestinal iron uptake is set off due to mutations in the high-FE2+ (HFE) genes that lead to a lack of hepcidin or resistance on the part of ferroportin to hepcidin binding. This is the major mechanism for the increased iron stores in the body. Hepcidin is a liver-derived peptide, which impairs the release of iron from enterocytes and macrophages by interacting with ferroportin. As a result, iron accumulates in various organs including the liver, which is severely injured and causes the clinically important hemochromatosis. This diagnosis is difficult to establish due to uncharacteristic features. Among these are asthenia, joint pain, arthritis, chondrocalcinosis, diabetes mellitus, hypopituitarism, hypogonadotropic hypogonadism, and cardiopathy. Diagnosis is initially suspected by increased serum levels of ferritin, a non-specific parameter also elevated in inflammatory diseases that must be excluded to be on the safer diagnostic side. Diagnosis is facilitated if ferritin is combined with elevated fasting transferrin saturation, genetic testing, and family screening. Various diagnostic attempts were published as algorithms. However, none of these were based on evidence or quantitative results derived from scored key features as opposed to other known complex diseases. Among these are autoimmune hepatitis (AIH) or drug-induced liver injury (DILI). For both diseases, the scored diagnostic algorithms are used in line with artificial intelligence (AI) principles to ascertain the diagnosis. The first-line therapy of hemochromatosis involves regular and life-long phlebotomy to remove iron from the blood, which improves the prognosis and may prevent the development of end-stage liver disease such as cirrhosis and hepatocellular carcinoma. Liver transplantation is rarely performed, confined to acute liver failure. In conclusion, ferroptosis, ROS, the gut microbiome, and concomitant alcohol abuse play a major contributing role in the development and clinical course of genetic hemochromatosis, which requires early diagnosis and therapy initiation through phlebotomy as a first-line treatment.
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Affiliation(s)
- Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, D-63450 Hanau, Germany
- Academic Teaching Hospital of the Medical Faculty, Goethe University Frankfurt/Main, D-60590 Frankfurt am Main, Germany
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Ahmed G, Rathi S, Sidhu HK, Muzaffar M, Wajid MH, Kumari K, Fakhor H, Attia NM, Majumder K, Kumar V, Tejwaney U, Ram N. Paroxysmal atrial fibrillation and hemochromatosis: a narrative review. Ann Med Surg (Lond) 2024; 86:909-919. [PMID: 38333328 PMCID: PMC10849313 DOI: 10.1097/ms9.0000000000001605] [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: 07/20/2023] [Accepted: 11/29/2023] [Indexed: 02/10/2024] Open
Abstract
Paroxysmal atrial fibrillation (PAF) and hemochromatosis have a complex relationship. This review explores its mechanisms, prevalence, correlations, and clinical manifestations. Hereditary hemochromatosis (HH) involves iron overload due to HFE protein mutations, while atrial fibrillation (AF) is characterized by irregular heart rhythms. Iron overload in hemochromatosis can promote cardiac arrhythmias. AF is prevalent in developed countries and may be linked to cryptogenic strokes. Genetic variations and demographic factors influence the occurrence of both conditions. HH affects multiple organ systems, including the heart, while AF causes palpitations and reduced exercise tolerance. Diagnosis involves iron markers, genotypic testing, and electrocardiogram (ECG) findings. Treatment strategies focus on reducing iron levels in hemochromatosis and managing AF through antithrombotic therapy and rhythm control. Untreated hemochromatosis carries a higher risk of complications, and PAF is associated with increased cardiovascular-related mortality. For better understanding of the mechanisms and to improve management, additional studies are required. Tailored approaches and combined treatments may enhance patient outcomes.
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Zhabyeyev P, Sadasivan C, Shah S, Wang F, Oudit GY. Amlodipine rescues advanced iron overload cardiomyopathy in hemojuvelin knockout murine model: Clinical implications. Front Cardiovasc Med 2023; 10:1129349. [PMID: 37153462 PMCID: PMC10160373 DOI: 10.3389/fcvm.2023.1129349] [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] [Received: 12/21/2022] [Accepted: 03/28/2023] [Indexed: 05/09/2023] Open
Abstract
Background Iron overload cardiomyopathy (IOC) is a major co-morbidity of genetic hemochromatosis and secondary iron overload with limited therapeutic options. We aim to investigate mechanisms of rescue action of amlodipine in the murine model of iron overload, characterize changes in human cardiac tissue due to IOC, and compare them to the changes in the animal model of IOC. Methods and results As an animal model, we used male hemojuvelin knockout (HJVKO) mice, which lacked hemojuvelin (a co-receptor protein for hepcidin expression). The mice were fed a high-iron diet from 4 weeks to 1 year of age. As a rescue, iron-fed mice received the Ca2+ channel blocker, amlodipine, from 9 to 12 months. Iron overload resulted in systolic and diastolic dysfunctions and changes in the cardiac tissue similar to the changes in the explanted human heart with IOC. An IOC patient (β-thalassemia) with left-ventricular ejection fraction (LVEF) 25% underwent heart transplantation. The murine model and the explanted heart showed intra-myocyte iron deposition, fibrosis, hypertrophy, oxidative stress, remodeling of Ca2+ cycling proteins, and metabolic kinases typical of heart failure. Single-myocyte contractility and Ca2+ release were diminished in the murine model. The amlodipine-treated group exhibited normalization of cellular function and reversed fibrosis, hypertrophy, oxidative stress, and metabolic remodeling. We also report a clinical case of primary hemochromatosis successfully treated with amlodipine. Conclusions The aged HJVKO murine model on the iron-rich diet reproduced many features of the human case of IOC. The use of amlodipine in the murine model and clinical case reversed IOC remodeling, demonstrating that amlodipine is effective adjuvant therapy for IOC.
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Affiliation(s)
- Pavel Zhabyeyev
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
- MazankowskiAlberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - Chandu Sadasivan
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
- MazankowskiAlberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - Saumya Shah
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
- MazankowskiAlberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - Faqi Wang
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Gavin Y. Oudit
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
- MazankowskiAlberta Heart Institute, University of Alberta, Edmonton, AB, Canada
- Correspondence: Gavin Y. Oudit
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6
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Buerkli S, Salvioni L, Koller N, Zeder C, Teles MJ, Porto G, Habermann JH, Dubach IL, Vallelian F, Frey BM, Moretti D, Baumgartner J, Zimmermann MB. The effect of a natural polyphenol supplement on iron absorption in adults with hereditary hemochromatosis. Eur J Nutr 2022; 61:2967-2977. [PMID: 35320401 PMCID: PMC9363374 DOI: 10.1007/s00394-022-02829-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 02/04/2022] [Indexed: 11/29/2022]
Abstract
Objectives We developed a natural polyphenol supplement that strongly chelates iron in vitro and assessed its effect on non-heme iron absorption in patients with hereditary hemochromatosis (HH). Methods We performed in vitro iron digestion experiments to determine iron precipitation by 12 polyphenol-rich dietary sources, and formulated a polyphenol supplement (PPS) containing black tea powder, cocoa powder and grape juice extract. In a multi-center, single-blind, placebo-controlled cross-over study, we assessed the effect of the PPS on iron absorption from an extrinsically labelled test meal and test drink in patients (n = 14) with HH homozygous for the p.C282Y variant in the HFE gene. We measured fractional iron absorption (FIA) as stable iron isotope incorporation into erythrocytes. Results Black tea powder, cocoa powder and grape juice extract most effectively precipitated iron in vitro. A PPS mixture of these three extracts precipitated ~ 80% of iron when 2 g was added to a 500 g iron solution containing 20 µg Fe/g. In the iron absorption study, the PPS reduced FIA by ~ 40%: FIA from the meal consumed with the PPS was lower (3.01% (1.60, 5.64)) than with placebo (5.21% (3.92, 6.92)) (p = 0.026)), and FIA from the test drink with the PPS was lower (10.3% (7.29 14.6)) than with placebo (16.9% (12.8 22.2)) (p = 0.002). Conclusion Our results indicate that when taken with meals, this natural PPS can decrease dietary iron absorption, and might thereby reduce body iron accumulation and the frequency of phlebotomy in patients with HH. Trial registry: clinicaltrials.gov (registration date: 9.6.2019, NCT03990181). Supplementary Information The online version contains supplementary material available at 10.1007/s00394-022-02829-8.
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Affiliation(s)
- Simone Buerkli
- Laboratory of Human Nutrition, Institute of Food Nutrition and Health, Department of Health Science and Technology, Swiss Federal Institute of Technology (ETH Zurich), LFV D27.2, Schmelzbergstrasse 7, CH8092, Zurich, Switzerland.
| | - Laura Salvioni
- Laboratory of Human Nutrition, Institute of Food Nutrition and Health, Department of Health Science and Technology, Swiss Federal Institute of Technology (ETH Zurich), LFV D27.2, Schmelzbergstrasse 7, CH8092, Zurich, Switzerland
| | - Natalie Koller
- Laboratory of Human Nutrition, Institute of Food Nutrition and Health, Department of Health Science and Technology, Swiss Federal Institute of Technology (ETH Zurich), LFV D27.2, Schmelzbergstrasse 7, CH8092, Zurich, Switzerland
| | - Christophe Zeder
- Laboratory of Human Nutrition, Institute of Food Nutrition and Health, Department of Health Science and Technology, Swiss Federal Institute of Technology (ETH Zurich), LFV D27.2, Schmelzbergstrasse 7, CH8092, Zurich, Switzerland
| | - Maria José Teles
- Clinical Pathology, S. João University Hospital Center, Porto, Portugal
| | - Graça Porto
- Clinical Hematology, Santo António Hospital, Porto University Hospital Center (CHUP), Porto, Portugal.,Abel Salazar Institute for Biomedical Sciences (ICBAS), Porto, Portugal.,Institute of Research and Innovation in Health Sciences (i3S) of the University of Porto, Porto, Portugal
| | | | - Irina Léa Dubach
- Division of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Florence Vallelian
- Division of Internal Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Beat M Frey
- Blood Transfusion Service, Swiss Red Cross, Schlieren, Switzerland
| | - Diego Moretti
- Laboratory of Human Nutrition, Institute of Food Nutrition and Health, Department of Health Science and Technology, Swiss Federal Institute of Technology (ETH Zurich), LFV D27.2, Schmelzbergstrasse 7, CH8092, Zurich, Switzerland.,Department of Health, Swiss Distance University of Applied Sciences, Regensdorf/Zurich, Switzerland
| | - Jeannine Baumgartner
- Laboratory of Human Nutrition, Institute of Food Nutrition and Health, Department of Health Science and Technology, Swiss Federal Institute of Technology (ETH Zurich), LFV D27.2, Schmelzbergstrasse 7, CH8092, Zurich, Switzerland
| | - Michael B Zimmermann
- Laboratory of Human Nutrition, Institute of Food Nutrition and Health, Department of Health Science and Technology, Swiss Federal Institute of Technology (ETH Zurich), LFV D27.2, Schmelzbergstrasse 7, CH8092, Zurich, Switzerland
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7
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Emmet E, Jagadish A, Malik R, Mehta R. Selected Disorders of the Blood and Hematopoietic System. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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8
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McMillen S, Lönnerdal B. Postnatal Iron Supplementation with Ferrous Sulfate vs. Ferrous Bis-Glycinate Chelate: Effects on Iron Metabolism, Growth, and Central Nervous System Development in Sprague Dawley Rat Pups. Nutrients 2021; 13:1406. [PMID: 33921980 PMCID: PMC8143548 DOI: 10.3390/nu13051406] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/18/2021] [Accepted: 04/20/2021] [Indexed: 02/05/2023] Open
Abstract
Iron-fortified formulas and iron drops (both usually ferrous sulfate, FS) prevent early life iron deficiency, but may delay growth and adversely affect neurodevelopment by providing excess iron. We used a rat pup model to investigate iron status, growth, and development outcomes following daily iron supplementation (10 mg iron/kg body weight, representative of iron-fortified formula levels) with FS or an alternative, bioavailable form of iron, ferrous bis-glycinate chelate (FC). On postnatal day (PD) 2, sex-matched rat litters (n = 3 litters, 10 pups each) were randomly assigned to receive FS, FC, or vehicle control until PD 14. On PD 15, we evaluated systemic iron regulation and CNS mineral interactions and we interrogated iron loading outcomes in the hippocampus, in search of mechanisms by which iron may influence neurodevelopment. Body iron stores were elevated substantially in iron-supplemented pups. All pups gained weight normally, but brain size on PD 15 was dependent on iron source. This may have been associated with reduced hippocampal oxidative stress but was not associated with CNS mineral interactions, iron regulation, or myelination, as these were unchanged with iron supplementation. Additional studies are warranted to investigate iron form effects on neurodevelopment so that iron recommendations can be optimized for all infants.
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Affiliation(s)
| | - Bo Lönnerdal
- Department of Nutrition, University of California, Davis, CA 95616, USA;
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9
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Santiago de Sousa Azulay R, Magalhães M, Tavares MDG, Dualibe R, Barbosa L, Sá Gaspar S, Faria AM, Nascimento GC, Damianse SDSP, Rocha VCDC, Gomes MB, Dos Santos Faria M. Novel Mutation in the Hemojuvelin Gene (HJV) in a Patient with Juvenile Hemochromatosis Presenting with Insulin-dependent Diabetes Mellitus, Secondary Hypothyroidism and Hypogonadism. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e923108. [PMID: 32327622 PMCID: PMC7200091 DOI: 10.12659/ajcr.923108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Juvenile hemochromatosis is a rare genetic disease that leads to intense iron accumulation. The disease onset usually occurs before the third decade of life and causes severe dysfunction in various organs. The most classical clinical findings are hypogonadotropic hypogonadism, cardiomyopathy, liver fibrosis, glycemic changes, arthropathy and skin pigmentation. However, secondary hypothyroidism is not reported in these patients. Juvenile hemochromatosis has an autosomal recessive inheritance and might be type 2A or type 2B, due to mutation in either the hemojuvelin gene (HJV) or hepcidin antimicrobial peptide (HAMP) gene. CASE REPORT A 26-year-old female patient was admitted with a recent history of diabetic ketoacidosis. Three months after that admission, she presented with arthralgia, diffuse abdominal pain, adynamia, hair loss, darkening of the skin and amenorrhea. Severe iron overload was found and findings in the hepatic biopsy were compatible with hemochromatosis. An upper abdominal magnetic resonance imaging (MRI) showed iron deposition in the liver and pancreas and pituitary MRI exhibited accumulation on the anterior pituitary. After 16 months the patient presented with dyspnea and lower limb edema, and cardiac MRI indicated iron deposition in the myocardium. The patient was diagnosed with juvenile hemochromatosis presenting with hypogonadotropic hypogonadism, cardiomyopathy, insulin-dependent diabetes mellitus, and secondary hypothyroidism. A novel homozygous mutation, c.697delC, in the HJV gene was detected. CONCLUSIONS We describe for the first time a severe and atypical case of juvenile hemochromatosis type 2A presenting classical clinical features, as well as secondary hypothyroidism resulting from a novel mutation in the HJV gene.
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Affiliation(s)
- Rossana Santiago de Sousa Azulay
- Endocrinology Unit, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil.,Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), São Luís, Brazil
| | - Marcelo Magalhães
- Endocrinology Unit, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil.,Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), São Luís, Brazil.,Clinical Research Center of the University Hospital of the Federal University of Maranhão (CEPEC - HUUFMA), São Luís, Brazil
| | - Maria da Gloria Tavares
- Endocrinology Unit, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil.,Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), São Luís, Brazil
| | - Roberta Dualibe
- Endocrinology Unit, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil.,Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), São Luís, Brazil
| | - Lívia Barbosa
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), São Luís, Brazil
| | - Silvia Sá Gaspar
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), São Luís, Brazil
| | - André M Faria
- Neuroendocrine Unit, Functional Neurosurgery Division, Psychiatry Institute, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Gilvan Cortês Nascimento
- Endocrinology Unit, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil.,Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), São Luís, Brazil
| | - Sabrina Da Silva Pereira Damianse
- Endocrinology Unit, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil.,Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), São Luís, Brazil
| | - Viviane Chaves de Carvalho Rocha
- Endocrinology Unit, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil.,Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), São Luís, Brazil
| | - Marília B Gomes
- Diabetes Unit, State University of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Manuel Dos Santos Faria
- Endocrinology Unit, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil.,Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), São Luís, Brazil.,Clinical Research Center of the University Hospital of the Federal University of Maranhão (CEPEC - HUUFMA), São Luís, Brazil
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10
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Murphree CR, Nguyen NN, Raghunathan V, Olson SR, DeLoughery T, Shatzel JJ. Diagnosis and management of hereditary haemochromatosis. Vox Sang 2020; 115:255-262. [PMID: 32080859 DOI: 10.1111/vox.12896] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/13/2020] [Accepted: 01/24/2020] [Indexed: 12/14/2022]
Abstract
Hereditary haemochromatosis, one of the most common genetic disorders in the United States, can produce systemic iron deposition leading to end-organ failure and death if untreated. The diagnosis of this condition can be challenging as elevated serum ferritin may be seen in a variety of conditions, including acute and chronic liver disease, a range of systemic inflammatory states, and both primary and secondary iron overload syndromes. Appropriate and timely diagnosis of haemochromatosis is paramount as simple interventions, such as phlebotomy, can prevent or reverse organ damage from iron overload. The recognition of other aetiologies of elevated ferritin is also vital to ensure that appropriate intervention is provided and phlebotomy only utilized in patients who require it. In this review, we summarize the existing data on the work up and management of hereditary haemochromatosis and present a practical algorithm for the diagnosis and management of this disease.
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Affiliation(s)
- Catherine R Murphree
- Division of Hematology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Nga N Nguyen
- Division of Hematology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Vikram Raghunathan
- Division of Hematology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Sven R Olson
- Division of Hematology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Thomas DeLoughery
- Division of Hematology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Joseph J Shatzel
- Division of Hematology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
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11
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Selected Disorders of the Blood and Hematopoietic System. Fam Med 2020. [DOI: 10.1007/978-1-4939-0779-3_158-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Hamdi-Rozé H, Ben Ali Z, Ropert M, Detivaud L, Aggoune S, Simon D, Pelletier G, Deugnier Y, David V, Bardou-Jacquet E. Variable expressivity of HJV related hemochromatosis: "Juvenile" hemochromatosis? Blood Cells Mol Dis 2018; 74:30-33. [PMID: 30389309 DOI: 10.1016/j.bcmd.2018.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/19/2018] [Accepted: 10/19/2018] [Indexed: 12/18/2022]
Abstract
Juvenile hemochromatosis is a rare autosomal recessive disease due to variants in the Hemojuvelin (HJV) gene. Although biological features mimic HFE hemochromatosis, clinical presentation is worst with massive iron overload diagnosed during childhood. Our study describes clinical features and results of genetic testing for a group of patients initially referred for a hepcidino-deficiency syndrome and for whom HJV hemochromatosis was finally diagnosed. 662 patients with iron overload and high serum transferrin saturation were tested, and five genes (HFE, HJV, HAMP, TFR2, SLC40A1) were sequenced. Among our cohort, ten unrelated patients were diagnosed with HJV hemochromatosis. Genetic testing revealed five previously published and five undescribed variants: p.Arg41Pro, p.His180Arg, p.Lys299Glu, p.Cys361Arg and p.Ala384Val. Surprisingly, this study revealed a late age of onset in some patients, contrasting with the commonly accepted definition of "juvenile" hemochromatosis. Five of our patients were 30 years old or older, including two very late discoveries. Biological features and severity of iron overload were similar in younger and older patients. Our study brings new insight on HJV hemochromatosis showing that mild phenotype and late onset are possible. Genetic testing for HJV variants should thus be performed for all patients displaying a non-p.Cys282Tyr homozygous HFE hemochromatosis with hepcidin deficiency phenotype.
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Affiliation(s)
- Houda Hamdi-Rozé
- Univ Rennes, CHU Rennes, INSERM, French Reference Center for Hemochromatosis and Iron Metabolism Disease, F-35000 Rennes, France; Univ Rennes, CHU Rennes, CNRS, IGDR, UMR 6290, Molecular Genetics Department, F-35000 Rennes, France.
| | - Zeineb Ben Ali
- Univ Rennes, CHU Rennes, INSERM, French Reference Center for Hemochromatosis and Iron Metabolism Disease, F-35000 Rennes, France; Univ Rennes, CHU Rennes, INSERM, Liver Disease Department, F-35000 Rennes, France
| | - Martine Ropert
- Univ Rennes, CHU Rennes, INSERM, French Reference Center for Hemochromatosis and Iron Metabolism Disease, F-35000 Rennes, France; Univ Rennes, CHU Rennes, INSERM, Biochemistry Department, F-35000 Rennes, France
| | - Lénaïck Detivaud
- Univ Rennes, CHU Rennes, INSERM, French Reference Center for Hemochromatosis and Iron Metabolism Disease, F-35000 Rennes, France
| | - Samira Aggoune
- EPH Belfort, Pediatric Department, El Harrach, Alger 16000, Algeria
| | - Dominique Simon
- Hopital Universitaire Robert-Debré, Endocrinology and Pediatric Diabetology, Paris 75019, France
| | - Gilles Pelletier
- Hopital Bicêtre, Hepatogastroenterology, Le Kremlin-Bicêtre 94275, France
| | - Yves Deugnier
- Univ Rennes, CHU Rennes, INSERM, French Reference Center for Hemochromatosis and Iron Metabolism Disease, F-35000 Rennes, France; Univ Rennes, CHU Rennes, INSERM, Liver Disease Department, F-35000 Rennes, France
| | - Véronique David
- Univ Rennes, CHU Rennes, CNRS, IGDR, UMR 6290, Molecular Genetics Department, F-35000 Rennes, France
| | - Edouard Bardou-Jacquet
- Univ Rennes, CHU Rennes, INSERM, French Reference Center for Hemochromatosis and Iron Metabolism Disease, F-35000 Rennes, France; Univ Rennes, CHU Rennes, INSERM, Liver Disease Department, F-35000 Rennes, France
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Buzzetti E, Kalafateli M, Thorburn D, Davidson BR, Tsochatzis E, Gurusamy KS. Interventions for hereditary haemochromatosis: an attempted network meta-analysis. Cochrane Database Syst Rev 2017; 3:CD011647. [PMID: 28273330 PMCID: PMC6464659 DOI: 10.1002/14651858.cd011647.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hereditary haemochromatosis is a genetic disorder related to proteins involved in iron transport, resulting in iron load and deposition of iron in various tissues of the body. This iron overload leads to complications including liver cirrhosis (and related complications such as liver failure and hepatocellular carcinoma), cardiac failure, cardiac arrhythmias, impotence, diabetes, arthritis, and skin pigmentation. Phlebotomy (venesection or 'blood letting') is the currently recommended treatment for hereditary haemochromatosis. The optimal treatment of hereditary haemochromatosis remains controversial. OBJECTIVES To assess the comparative benefits and harms of different interventions in the treatment of hereditary haemochromatosis through a network meta-analysis and to generate rankings of the available treatments according to their safety and efficacy. However, we found only one comparison. Therefore, we did not perform the network meta-analysis and we assessed the comparative benefits and harms of different interventions using standard Cochrane methodology. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and randomised clinical trials registers to March 2016 to identify randomised clinical trials on treatments for hereditary haemochromatosis. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or publication status) in participants with hereditary haemochromatosis. We excluded trials which included participants who had previously undergone liver transplantation. We considered any of the various interventions compared with each other or with inactive treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We calculated the odds ratio (OR) and rate ratio with 95% confidence intervals (CI) using both fixed-effect and random-effects models with RevMan 5 based on available-participant analysis. We assessed risk of bias according to Cochrane, controlled risk of random errors with Trial Sequential Analysis, and assessed the quality of the evidence using GRADE. MAIN RESULTS Three trials with 146 participants met the inclusion criteria of this review. Two parallel group trials with 100 participants provided information on one or more outcomes. The remaining trial was a cross-over trial, with no usable data for analysis. All the trials were at high risk of bias. Overall, all the evidence was of very low quality. All three trials compared erythrocytapheresis (removal of red cells only, instead of whole blood) versus phlebotomy. Two of the trials shared the same first author. The mean or median age in the three trials ranged from 42 to 55 years. None of the trials reported whether the included participants were symptomatic or asymptomatic or a mixture of both. Two trials were conducted in people who were haemochromatosis treatment-naive. The trial that provided most data for this review excluded people with malignancy, heart failure, and serious cardiac arrhythmias. We found no trials assessing iron-chelating agents.Only one of the trials with 38 participants reported no short-term mortality and no serious adverse events at the end of the short-term follow-up (eight months). Two trials reported the proportion of people with adverse events: 10/49 (20.4%) in the erythrocytapheresis group versus 11/51 (21.6%) in the phlebotomy group. One of these two trials provided data on adverse event rates (42.1 events per 100 participants with erythrocytapheresis versus 52.6 events per 100 participants with phlebotomy). There was no evidence of differences in the proportion of people with adverse events and the number of adverse events (serious and non-serious) between the groups (proportion of people with adverse events: OR 0.93, 95% CI 0.36 to 2.43; participants = 100; trials = 2; number of adverse events: rate ratio 0.80, 95% CI 0.32 to 2.03; participants = 38; trial = 1). There was no difference between the groups regarding short-term health-related quality of life (mean difference (MD) 1.00, 95% CI -10.80 to 12.80; participants = 38; trials = 1). This outcome was measured using EQ-VAS (range: 0 to 100 where a higher score indicates better health-related quality of life). None of the trials reported mortality beyond one year, health-related quality of life beyond one year, liver transplantation, decompensated liver disease, cirrhosis, hepatocellular carcinoma, diabetes, or cardiovascular complications during the long-term follow-up.The two trials that provided data for this review were funded by parties with no vested interest in the results; the source of funding of the third trial was not reported. AUTHORS' CONCLUSIONS There is currently insufficient evidence to determine whether erythrocytapheresis is beneficial or harmful compared with phlebotomy. Phlebotomy has less equipment requirements and remains the treatment of choice in people with hereditary haemochromatosis who require blood letting in some form. However, it should be noted that there is no evidence from randomised clinical trials that blood letting in any form is beneficial in people with hereditary haemochromatosis. Having said this, a trial including no treatment is unlikely to be conducted. Future trials should compare different frequencies of phlebotomy and erythrocytapheresis versus phlebotomy with and without different iron-chelating agents compared with each other, and with placebo. Such trials should include long-term follow-up of participants (e.g. using national record linkage databases) to determine whether treatments are beneficial or harmful in terms of clinical outcomes such as deaths, health-related quality of life, liver damage and its consequences, heart damage and its consequences, and other outcomes that are of importance to people with hereditary haemochromatosis.
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Affiliation(s)
- Elena Buzzetti
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
| | - Maria Kalafateli
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
| | - Douglas Thorburn
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryPond StreetLondonUKNW3 2QG
| | - Emmanuel Tsochatzis
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
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Hamdi‐Rozé H, Beaumont‐Epinette M, Ben Ali Z, Le Lan C, Loustaud‐Ratti V, Causse X, Loreal O, Deugnier Y, Brissot P, Jouanolle A, Bardou‐Jacquet E. Rare HFE variants are the most frequent cause of hemochromatosis in non-c282y homozygous patients with hemochromatosis. Am J Hematol 2016; 91:1202-1205. [PMID: 27518069 DOI: 10.1002/ajh.24535] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 07/02/2016] [Accepted: 08/09/2016] [Indexed: 02/01/2023]
Abstract
p.Cys282Tyr (C282Y) homozygosity explains most cases of HFE-related hemochromatosis, but a significant number of patients presenting with typical type I hemochromatosis phenotype remain unexplained. We sought to describe the clinical relevance of rare HFE variants in non-C282Y homozygotes. Patients referred for hemochromatosis to the National Reference Centre for Rare Iron Overload Diseases from 2004 to 2010 were studied. Sequencing was performed for coding region and intronic flanking sequences of HFE, HAMP, HFE2, TFR2, and SLC40A1. Nine private HFE variants were identified in 13 of 206 unrelated patients. Among those, five have not been previously described: p.Leu270Argfs*4, p.Ala271Valfs*25, p.Tyr52*, p.Lys166Asn, and p.Asp141Tyr. Our results show that rare HFE variants are identified more frequently than variants in the other genes associated with iron overload. Rare HFE variants are therefore the most frequent cause of hemochromatosis in non-C282Y homozygote HFE patients. Am. J. Hematol. 91:1202-1205, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Houda Hamdi‐Rozé
- CHU Rennes, French Reference Centre for Rare Iron Overload Diseases of Genetic OriginRennes France
- Molecular Genetics DepartmentCHU RennesRennes35000 France
| | - Marie‐Pascale Beaumont‐Epinette
- CHU Rennes, French Reference Centre for Rare Iron Overload Diseases of Genetic OriginRennes France
- Molecular Genetics DepartmentCHU RennesRennes35000 France
| | - Zeineb Ben Ali
- CHU Rennes, French Reference Centre for Rare Iron Overload Diseases of Genetic OriginRennes France
- Liver Disease DepartmentCHU RennesRennes35000 France
| | - Caroline Le Lan
- CHU Rennes, French Reference Centre for Rare Iron Overload Diseases of Genetic OriginRennes France
- Liver Disease DepartmentCHU RennesRennes35000 France
| | - Véronique Loustaud‐Ratti
- CHU Rennes, French Reference Centre for Rare Iron Overload Diseases of Genetic OriginRennes France
- CHU Limoges Service d'Hépato‐gastroentérologie, U850 INSERM Univ LimogesF‐87000Limoges France
| | - Xavier Causse
- CHU Rennes, French Reference Centre for Rare Iron Overload Diseases of Genetic OriginRennes France
- Hepatology and Gastroenterology departmentRegional Hospital of OrléansOrléans45000 France
| | - Olivier Loreal
- CHU Rennes, French Reference Centre for Rare Iron Overload Diseases of Genetic OriginRennes France
- University of Rennes1, Inserm UMR 991Rennes35000 France
| | - Yves Deugnier
- CHU Rennes, French Reference Centre for Rare Iron Overload Diseases of Genetic OriginRennes France
- Liver Disease DepartmentCHU RennesRennes35000 France
| | | | - Anne‐Marie Jouanolle
- CHU Rennes, French Reference Centre for Rare Iron Overload Diseases of Genetic OriginRennes France
- Molecular Genetics DepartmentCHU RennesRennes35000 France
| | - Edouard Bardou‐Jacquet
- CHU Rennes, French Reference Centre for Rare Iron Overload Diseases of Genetic OriginRennes France
- Liver Disease DepartmentCHU RennesRennes35000 France
- University of Rennes1, Inserm UMR 991Rennes35000 France
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Farrell CP, Parker CJ, Phillips JD. Exome sequencing for molecular characterization of non-HFE hereditary hemochromatosis. Blood Cells Mol Dis 2015; 55:101-3. [PMID: 26142323 PMCID: PMC4491409 DOI: 10.1016/j.bcmd.2015.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 04/16/2015] [Indexed: 01/29/2023]
Abstract
Diagnostic genetic testing for hereditary hemochromatosis is readily available for clinically relevant HFE variants (i.e., those that generate the C282Y, H63D and S65C HFE polymorphisms); however, genetic testing for other known causes of iron overload, including mutations affecting genes encoding hemojuvelin, transferrin receptor 2, HAMP, and ferroportin is not. As an alternative to conventional genetic testing we propose diagnostic use of whole exome sequencing for characterization of non-HFE hemochromatosis. To illustrate the effectiveness of whole exome sequencing as a diagnostic tool, we present the case of an 18-year-old female with a probable case of juvenile hemochromatosis, who was referred for specialty care after testing negative for commonly occurring HFE variants. Whole exome sequencing offered complete coverage of target genes and is a fast, cost effective diagnostic tool for characterization of non-HFE hemochromatosis.
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Affiliation(s)
- Colin P Farrell
- University of Utah School of Medicine, Hematology Division, 30North 1900 East, Salt Lake City, UT 84132, United States
| | - Charles J Parker
- University of Utah School of Medicine, Hematology Division, 30North 1900 East, Salt Lake City, UT 84132, United States
| | - John D Phillips
- University of Utah School of Medicine, Hematology Division, 30North 1900 East, Salt Lake City, UT 84132, United States.
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Heeney MM. Iron clad: iron homeostasis and the diagnosis of hereditary iron overload. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2014; 2014:202-209. [PMID: 25696856 DOI: 10.1182/asheducation-2014.1.202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Iron is an ubiquitous metal of vital importance to the normal physiologic processes of many organisms. Over the last 2 decades, the discovery of mutations in genes leading to hereditary disorders of iron overload, iron deficiency, and iron maldistribution have accelerated our understanding of human iron homeostasis. This chapter provides an updated overview of the human iron cycle, regulation of iron homeostasis, and how perturbations in these homeostatic mechanisms lead to iron overload disease and provides strategies for the diagnosis of hereditary iron overload.
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Affiliation(s)
- Matthew M Heeney
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA
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