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Szczerbinska A, Kasztelan-Szczerbinska B, Rycyk-Bojarzynska A, Kocki J, Cichoz-Lach H. Hemochromatosis-How Not to Overlook and Properly Manage "Iron People"-A Review. J Clin Med 2024; 13:3660. [PMID: 38999226 PMCID: PMC11242024 DOI: 10.3390/jcm13133660] [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: 05/16/2024] [Revised: 06/20/2024] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
Hemochromatosis (HC) is the main genetic disorder of iron overload and is regarded as metal-related human toxicosis. HC may result from HFE and rare non-HFE gene mutations, causing hepcidin deficiency or, sporadically, hepcidin resistance. This review focuses on HFE-related HC. The illness presents a strong biochemical penetrance, but its prevalence is low. Unfortunately, the majority of patients with HC remain undiagnosed at their disease-curable stage. The main aim of HC management is to prevent iron overload in its early phase and remove excess iron from the body by phlebotomy in its late stage. Raising global awareness of HC among health staff, teaching them how not to overlook early HC manifestations, and paying attention to careful patient monitoring remain critical management strategies for preventing treatment delays, upgrading its efficacy, and improving patient prognosis.
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Affiliation(s)
- Agnieszka Szczerbinska
- Faculty of Medicine, Medical University of Warsaw, 61 Zwirki i Wigury Street, 02-091 Warsaw, Poland
| | - Beata Kasztelan-Szczerbinska
- Department of Gastroenterology with Endoscopy Unit, Medical University of Lublin, 8 Jaczewski Street, 20-954 Lublin, Poland
| | - Anna Rycyk-Bojarzynska
- Department of Gastroenterology with Endoscopy Unit, Medical University of Lublin, 8 Jaczewski Street, 20-954 Lublin, Poland
| | - Janusz Kocki
- Department of Clinical Genetics, Medical University of Lublin, 11 Radziwillowska Street, 20-080 Lublin, Poland
| | - Halina Cichoz-Lach
- Department of Gastroenterology with Endoscopy Unit, Medical University of Lublin, 8 Jaczewski Street, 20-954 Lublin, Poland
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Corti P, Ferrari GM, Faraguna MC, Capitoli G, Longo F, Corradini E, Casini T, Boscarol G, Pinto VM, Ghilardi R, Russo G, Colombatti R, Mariani R, Piperno A. Haemochromatosis in children: A national retrospective cohort promoted by the A.I.E.O.P. (Associazione Italiana Emato-Oncologia Pediatrica) study group. Br J Haematol 2024; 204:306-314. [PMID: 37990447 DOI: 10.1111/bjh.19208] [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: 07/21/2023] [Revised: 10/25/2023] [Accepted: 11/06/2023] [Indexed: 11/23/2023]
Abstract
Haemochromatosis (HC) encompasses a range of genetic disorders. HFE-HC is by far the most common in adults, while non-HFE types are rare due to mutations of HJV, HAMP, TFR2 and gain-of-function mutations of SLC40A1. HC is often unknown to paediatricians as it is usually asymptomatic in childhood. We report clinical and biochemical data from 24 paediatric cases of HC (10 cases of HFE-, 5 TFR2-, 9 HJV-HC), with a median follow-up of 9.6 years. Unlike in the adult population, non-HFE-HC constitutes 58% (14/24) of the population in our series. Transferrin saturation was significantly higher in TFR2- and HJV-HC compared to HFE-HC, and serum ferritin and LIC were higher in HJV-HC compared to TFR2- and HFE-HC. Most HFE-HC subjects had relatively low ferritin and LIC at the time of diagnosis, so therapy could be postponed for most of them after the age of 18. Our results confirm that HJV-HC is a severe form already in childhood, emphasizing the importance of early diagnosis and treatment to avoid the development of organ damage and reduce morbidity and mortality. Although phlebotomies were tolerated by most patients, oral iron chelators could be a valid option in early-onset HC.
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Affiliation(s)
- Paola Corti
- Pediatria, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | - Martha Caterina Faraguna
- Pediatria, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Residency in Pediatrics, University of Milano Bicocca, Milan, Italy
| | - Giulia Capitoli
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Filomena Longo
- Thalassemia Reference Centre, Orbassano, Italy
- Regional HUB Centre for Thalassaemia and Haemoglobinopathies, Department of Medicine, AOU S. Anna, Ferrara, Italy
| | - Elena Corradini
- Internal Medicine Unit and Centre for Hemochromatosis and Hereditary Liver Diseases, ERN-EuroBloodNet and ERN-RARE-LIVER, Azienda Ospedaliero-Universitaria di Modena-Policlinico, Modena, Italy
| | - Tommaso Casini
- Pediatric Hematology/Oncology Department, Meyer's Children University Hospital, Firenze, Italy
| | | | - Valeria Maria Pinto
- Centro della Microcitemia e delle Anemie Congenite, Ospedale Galliera, Genova, Italy
| | - Roberta Ghilardi
- Department of Pediatrics, Ospedale Maggiore Policlinico, IRCCS, Milano, Italy
| | - Giovanna Russo
- Pediatric Hematology and Oncology Unit, Azienda Policlinico "Rodolico-San Marco", University of Catania, Catania, Italy
| | - Raffaella Colombatti
- Pediatric Hematology Oncology and Bone Marrow Transplantation Unit, Department of Woman's and Child's Health, University of Padova, Padova, Italy
| | - Raffaella Mariani
- SSD Rare Diseases-European Reference Network for Rare Hematological Diseases-EuroBloodNet-Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Alberto Piperno
- SSD Rare Diseases-European Reference Network for Rare Hematological Diseases-EuroBloodNet-Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Centro Ricerca Tettamanti, Monza, Italy
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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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Abstract
Hereditary hemochromatosis (HH) is one of the most common genetic disorders among persons of northern European descent. There have been recent advances in the diagnosis, management, and treatment of HH. The availability of molecular diagnostic testing for HH has made possible confirmation of the diagnosis for most patients. Several genotype-phenotype correlation studies have clarified the differences in clinical features between patients with the C282Y homozygous genotypes and other HFE mutation patterns. The increasing use of noninvasive tests such as MRI T2* has made quantification of hepatic iron deposition easier and eliminated the need for liver biopsy in most patients. Serum ferritin of <1,000 ng/mL at diagnosis remains an important diagnostic test to identify patients with a low risk of advanced hepatic fibrosis and should be used routinely as part of the initial diagnostic evaluation. Genetic testing for other types of HH is available but is expensive and generally not useful in most clinical settings. Serum ferritin may be elevated among patients with nonalcoholic fatty liver disease and in those with alcoholic liver disease. These diagnoses are more common than HH among patients with elevated serum ferritin who are not C282Y homozygotes or C282Y/H63D compound heterozygotes. A secondary cause for liver disease should be excluded among patients with suspected iron overload who are not C282Y homozygotes. Phlebotomy remains the mainstay of therapy, but emerging novel therapies such as new chelating agents may have a role for selected patients.
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Arts HH, Eng B, Waye JS. Multiplex Allele-Specific PCR for Simultaneous Detection of H63D and C282Y HFE Mutations in Hereditary Hemochromatosis. J Appl Lab Med 2018; 3:10-17. [PMID: 33626828 DOI: 10.1373/jalm.2017.024984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 12/04/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hereditary hemochromatosis (HH) is characterized by excessive iron absorption in the intestine, which can lead to failure of vital organs such as the heart, liver, and pancreas. Among northern Europeans, HH is most often associated with the C282Y and H63D mutations of the HFE gene. We developed a test that allows screening for both mutations in a single reaction. METHODS A multiplex allele-specific PCR was developed for simultaneous genotyping of the H63D and C282Y HFE mutations. PCR fragments were designed such that the resulting PCR product can be analyzed in a single polyacrylamide gel lane. RESULTS Test results from our multiplex assay were concordant with genotypes of 55 Canadian patients with suspected hemochromatosis, which had previously been established by allele-specific PCRs that targeted H63D and C282Y in separate reactions. CONCLUSIONS Molecular diagnostic detection of H63D and C282Y mutations can be achieved by a variety of methods, but these are not necessarily time-efficient or economical. Multiplex allele-specific PCR is an excellent tool for molecular diagnostic screening for H63D and C282Y mutations in patients with suspected hemochromatosis. This method is inexpensive, accurate, and highly efficient in terms of labor, throughput, and turnaround time.
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Affiliation(s)
- Heleen H Arts
- Department of Pathology & Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Barry Eng
- Hamilton Regional Laboratory Medicine Program, Hamilton Health Sciences, Hamilton, ON, Canada
| | - John S Waye
- Department of Pathology & Molecular Medicine, McMaster University, Hamilton, ON, Canada.,Hamilton Regional Laboratory Medicine Program, Hamilton Health Sciences, Hamilton, ON, Canada
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Radford-Smith DE, Powell EE, Powell LW. Haemochromatosis: a clinical update for the practising physician. Intern Med J 2018; 48:509-516. [DOI: 10.1111/imj.13784] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 10/09/2017] [Accepted: 11/02/2017] [Indexed: 01/19/2023]
Affiliation(s)
| | - Elizabeth E. Powell
- Centre for Liver Disease Research, Translational Research Institute, School of Medicine; The University of Queensland; Brisbane Queensland Australia
- Department of Gastroenterology and Hepatology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Lawrie W. Powell
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
- QIMR Berghofer Medical Research Institute; Brisbane Queensland Australia
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Abstract
Iron participates in oxygen transport, energetic, metabolic, and immunologic processes. There are 2 main causes of iron overload: hereditary hemochromatosis which is a primary cause, is a metabolic disorder caused by mutations of genes that control iron metabolism and secondary hemochromatosis caused by multitransfusions, chronic hemolysis, and intake of iron rich food. The most common type of hereditary hemochromatosis is caused by HFE gene mutation. In this study, we analyzed iron metabolism in 100 healthy Polish children in relation to their HFE gene status. The wild-type HFE gene was predominant being observed in 60 children (60%). Twenty-five children (25%), presented with heterozygotic H63D mutation, and 15 children (15%), presented with other mutations (heterozygotic C282Y and S65C mutation, compound heterozygotes C282Y/S65C, C282Y/H63D, H63D homozygote). The mean concentration of iron, the level of ferritin, and transferrin saturation were statistically higher in the group of HFE variants compared with the wild-type group. H63D carriers presented with higher mean concentration of iron, ferritin levels, and transferrin saturation compared with the wild-type group. Male HFE carriers presented with higher iron concentration, transferrin saturation, and ferritin levels than females. This preliminary investigation demonstrates allelic impact on potential disease progression from childhood.
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Abstract
Haemochromatosis is now known to be an iron-storage disease with genetic heterogeneity but with a final common metabolic pathway resulting in inappropriately low production of the hormone hepcidin. This leads to increase in intestinal absorption and deposition of excessive amounts of iron in parenchymal cells which in turn results in eventual tissue damage and organ failure. A clinical enigma has been the variable clinical expression with some patients presenting with hepatic cirrhosis at a young age and others almost asymptomatic for life. Research is unravelling this puzzle by identifying environmental factors-especially alcohol consumption-and associated modifying genes that modulate phenotypic expression. A high index of suspicion is required for early diagnosis but this can lead to presymptomatic therapy and a normal life expectancy. Venesection (phlebotomy) therapy remains the mainstay of therapy, but alternative therapies are the subject of current research.
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Affiliation(s)
- Lawrie W Powell
- Centre for the Advancement of Clinical Research, Royal Brisbane and Women's Hospital, Brisbane, The University of Queensland, Brisbane, Australia.
| | - Rebecca C Seckington
- Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Australia
| | - Yves Deugnier
- University Hospital and University of Rennes 1, Rennes, France
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Nigg JT, Elmore AL, Natarajan N, Friderici KH, Nikolas MA. Variation in an Iron Metabolism Gene Moderates the Association Between Blood Lead Levels and Attention-Deficit/Hyperactivity Disorder in Children. Psychol Sci 2015; 27:257-69. [PMID: 26710823 DOI: 10.1177/0956797615618365] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 10/29/2015] [Indexed: 12/12/2022] Open
Abstract
Although attention-deficit/hyperactivity disorder (ADHD) is a heritable neurodevelopmental condition, there is also considerable scientific and public interest in environmental modulators of its etiology. Exposure to neurotoxins is one potential source of perturbation of neural, and hence psychological, development. Exposure to lead in particular has been widely investigated and is correlated with neurodevelopmental outcomes, including ADHD. To investigate whether this effect is likely to be causal, we used a Mendelian randomization design with a functional gene variant. In a case-control study, we examined the association between ADHD symptoms in children and blood lead level as moderated by variants in the hemochromatosis (HFE) gene. The HFE gene regulates iron uptake and secondarily modulates lead metabolism. Statistical moderation was observed: The magnitude of the association of blood lead with symptoms of ADHD was altered by functional HFE genotype, which is consistent with a causal hypothesis.
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Affiliation(s)
- Joel T Nigg
- Department of Psychiatry, Oregon Health & Science University Department of Behavioral Neuroscience, Oregon Health & Science University
| | - Alexis L Elmore
- Department of Psychological & Brain Sciences, University of Iowa
| | - Neil Natarajan
- Department of Psychiatry, Oregon Health & Science University
| | - Karen H Friderici
- Department of Microbiology and Molecular Genetics, Michigan State University
| | - Molly A Nikolas
- Department of Microbiology and Molecular Genetics, Michigan State University
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Abstract
INTRODUCTION The discovery of hemochromatosis genes and the availability of molecular-genetic tests considerably modified the knowledge of the disease relative to physiopathology, penetrance, and expression, and had major impact in the diagnostic settings. AREAS COVERED Hemochromatosis is a heterogenous disorder at both genetic and phenotypic level. The review discusses criteria to define patients' iron phenotype and to use molecular tests to diagnose HFE-related and non-HFE hemochromatosis. The material examined includes articles published in the journals covered by PubMed US National Library of Medicine. The author has been working in the field of iron overload diseases for several years and has contributed 18 of the papers cited in the references. EXPERT OPINION Hemochromatosis genotyping is inseparable from phenotype characterization. A full clinical assessment is needed and DNA test performed when data suggest a clear indication of suspicion of being at risk for HH. HFE testing for p.Cys282Tyr mutation and p.His63Asp variant is the first molecular diagnostic step. Genotyping for rare mutations can be offered to patients with negative first-level HFE testing who have iron overload with no other explanation and should be performed in referral centers for iron overload disorders that can provide genetic advice and in-house genotyping services.
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Affiliation(s)
- Alberto Piperno
- University of Milano-Bicocca, Centre for the Diagnosis and Treatment of Hemochromatosis and Iron Disorders, S.Gerardo Hospital, Department of Health Sciences, Monza, Italy.
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Delatycki MB, Wolthuizen M, Collins V, Varley E, Craven J, Allen KJ, Aitken MA, Bond L, Lockhart PJ, Wilson GR, Macciocca I, Metcalfe SA. Implementation of ironXS: a study of the acceptability and feasibility of genetic screening for hereditary hemochromatosis in high schools. Clin Genet 2010; 77:241-8. [DOI: 10.1111/j.1399-0004.2009.01308.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Borry P, Goffin T, Nys H, Dierickx K. Attitudes regarding predictive genetic testing in minors: a survey of European clinical geneticists. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2008; 148C:78-83. [PMID: 18200522 DOI: 10.1002/ajmg.c.30165] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The aim of this study is to gather information from European clinical geneticists about their practices and attitudes with regard to presymptomatic and predictive genetic testing in minors. European clinical institutes where genetic counseling is offered to patients were contacted. One hundred seventy-seven of the 287 eligible respondents (63%) answered a questionnaire. There was strongest support for testing young children when it provides a clear medical benefit, such as in the case of FAP and MEN2A. However, there is disagreement about when to provide predictive genetic testing for childhood-onset disorders for which therapeutic or preventive measures exist with some supporting the rule of earliest onset and others giving parents wider discretion. However, for childhood-onset disorders that do not have therapeutic measures, the majority of the respondents is unwilling to provide a presymptomatic or predictive genetic test. With respect to adolescents, many held a cautious position regarding presymptomatic and predictive genetic testing. Most clinical geneticists were unwilling to provide a presymptomatic or predictive genetic test for adult-onset diseases, except if it might provide a medical benefit. Although adolescents might be legally in the position to request a presymptomatic or predictive genetic test personally, the clinical geneticists are significantly more willing to provide a test if this request is made together with the minor's parents. This variability demonstrates the need for clinical geneticists to discuss their contradicting views and to develop harmonized practices throughout Europe.
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Affiliation(s)
- Pascal Borry
- the Centre for Biomedical Ethics and Law, KU Leuven, Belgium.
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Ayonrinde OT, Milward EA, Chua ACG, Trinder D, Olynyk JK. Clinical Perspectives on Hereditary Hemochromatosis. Crit Rev Clin Lab Sci 2008; 45:451-84. [DOI: 10.1080/10408360802335716] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Yen AW, Fancher TL, Bowlus CL. Revisiting hereditary hemochromatosis: current concepts and progress. Am J Med 2006; 119:391-9. [PMID: 16651049 DOI: 10.1016/j.amjmed.2005.10.041] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2005] [Revised: 10/22/2005] [Accepted: 10/22/2005] [Indexed: 12/14/2022]
Abstract
Originally regarded as a rare affliction notable for its distinctive evolution to "bronze diabetes," hereditary hemochromatosis is now recognized as the most common genetic disorder in populations of European ancestry. Recent advances in our understanding of iron metabolism, the identification of the gene responsible for hemochromatosis, and large epidemiologic studies have changed the diagnostic approach toward patients with hereditary hemochromatosis and other forms of iron overload. This article reviews the pathophysiology, epidemiology, clinical features, diagnostic testing, and management of hemochromatosis for the primary care provider.
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Affiliation(s)
- Andrew W Yen
- University of California, Davis Medical Center, Department of Internal Medicine, Sacramento, Calif 95817, USA.
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Gason AA, Aitken MA, Metcalfe SA, Allen KJ, Delatycki MB. Genetic susceptibility screening in schools: attitudes of the school community towards hereditary haemochromatosis. Clin Genet 2005; 67:166-74. [PMID: 15679829 DOI: 10.1111/j.1399-0004.2004.00389.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Carrier screening to provide reproductive options has been offered to students in the school setting for a number of years; however, genetic susceptibility screening for disease predisposition has not been introduced to the school community. Experience has shown that the success of a population-based programme relies on the community's acceptance. Therefore, we sought to establish the Australian secondary school community's attitudes towards genetic susceptibility screening in schools, with hereditary haemochromatosis as the model condition with an available prevention. School students, aged 15-18 (n = 748), completed a questionnaire immediately before and following an oral educational presentation. Their parents (n = 179) and staff (n = 89) received written information and returned a questionnaire by post. Semi-structured interviews were with Government representatives. Attitudes towards genetic screening in schools and knowledge of genetic and clinical features of haemochromatosis, as well as the likelihood of accepting a genetic susceptibility test for haemochromatosis, were all measured. Participants were positive about genetic screening for disease susceptibility in schools. Their knowledge was high following education with no significant differences between participants of each group. Sixty-eight percent of students would be likely to have the test if it were offered, with parents and staff, indicating that they would like the students to be offered a test, on average. Genetic susceptibility screening in schools is a novel concept. The results of our study indicate that it could be a public health success with the support of the community.
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Affiliation(s)
- A A Gason
- Murdoch Children's Research Institute, Royal Children's Hospital, Flemington Road, Parkville, 3052 Victoria, Australia.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to identify and discuss recent findings related to inherited metabolic disorders of the liver that increase our understanding of the pathophysiology and treatment for hemochromatosis and other iron overload disorders, Wilson disease and alpha one antitrypsin deficiency. RECENT FINDINGS The main theme in the recent discoveries for both iron overload disorders and Wilson disease is our increasing understanding that the phenotypic expression of these disorders are greatly influenced by genes involved in the metabolic pathways for these metals, or influence the progression of liver disease independent of metal metabolism. For example, the role of hepcidin dysregulation in hemochromatosis has been a surprising discovery that provides some mechanistic understanding for the increased iron absorption that is present in this disorder. SUMMARY Given the recent explosion of information on iron and copper metabolism and the cellular processing of alpha one antitrypsin, the highlights reviewed in this article will help the reader keep up to date with the current understanding of these diseases and potential future approaches to their treatment.
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Affiliation(s)
- Michael L Schilsky
- Department of Medicine, Center for Liver Disease and Transplantation, Weill Cornell Medical Center, New York, NY 10021, USA.
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