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Wang J, Xu J, Jiang N, Liu H, Li F, Wang B, Wang J, Chu Z, Tan L, Li S. Case report: A rare case of hereditary hemochromatosis caused by a mutation in the HAMP gene in Fuyang, China. Front Med (Lausanne) 2024; 11:1417611. [PMID: 39005658 PMCID: PMC11239416 DOI: 10.3389/fmed.2024.1417611] [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: 04/15/2024] [Accepted: 06/10/2024] [Indexed: 07/16/2024] Open
Abstract
Hemochromatosis, also known as siderosis, is a disease caused by excessive iron deposition in human organs and tissues, resulting from iron metabolism disorders. It is clinically characterized by skin pigmentation (bronze color), liver cirrhosis, diabetes, weakness, and fatigue. Additional symptoms may include arthritis, hypothyroidism, heart failure, and sexual hypofunction. Clinical manifestations can vary from person to person, with a few patients showing no clinical manifestations, which makes the diagnosis difficult for clinicians. In this case report, we described hereditary hemochromatosis related to a mutation in the HAMP gene in Fuyang City, China, as a reference for clinicians. Hereditary hemochromatosis is rarely reported in China. Clinicians in China have relatively insufficient knowledge of this disease, which leads to frequent misdiagnosis. In this case report, we describe hereditary hemochromatosis related to HAMP gene mutation in Fuyang City, China, for the clinician's reference.
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Affiliation(s)
- Jinling Wang
- Department of Hepatology, The Second People's Hospital of Fuyang City, Fuyang, Anhui, China
| | - Jing Xu
- Department of Hepatology, The Second People's Hospital of Fuyang City, Fuyang, Anhui, China
| | - Ning Jiang
- Department of Hepatology, The Second People's Hospital of Fuyang City, Fuyang, Anhui, China
| | - Hui Liu
- Department of Pathology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Fengcheng Li
- Department of Hepatology, The Second People's Hospital of Fuyang City, Fuyang, Anhui, China
| | - Beibei Wang
- Department of Hepatology, The Second People's Hospital of Fuyang City, Fuyang, Anhui, China
| | - Jin Wang
- Department of Hepatology, The Second People's Hospital of Fuyang City, Fuyang, Anhui, China
| | - Ziyu Chu
- Department of Hepatology, The Second People's Hospital of Fuyang City, Fuyang, Anhui, China
| | - Lin Tan
- Department of Hepatology, The Second People's Hospital of Fuyang City, Fuyang, Anhui, China
| | - Shasha Li
- Department of Hepatology, The Second People's Hospital of Fuyang City, Fuyang, Anhui, China
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2
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Okazaki Y. Iron from the gut: the role of divalent metal transporter 1. J Clin Biochem Nutr 2024; 74:1-8. [PMID: 38292117 PMCID: PMC10822759 DOI: 10.3164/jcbn.23-47] [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: 06/24/2023] [Accepted: 10/10/2023] [Indexed: 02/01/2024] Open
Abstract
Mammalian cells contain thousands of metalloproteins and evolved systems to correctly incorporate metal cofactors into their designated sites. Among the transient metals in living cells, iron is the most abundant element that present as an iron sulfur cluster, mono- and dinuclear iron centers or heme for catalytic reactions. Iron homeostasis is tightly regulated by intestinal iron absorption in mammals owing to the lack of an iron excretive transport system, apart from superficial epithelial cell detachment and urinary outflow reabsorptive impairment. In mammals, the central site for iron absorption is in the duodenum, where the divalent metal transporter 1 is essential for iron uptake. The most notable manifestation of mutated divalent metal transporter 1 presents as iron deficiency anemia in humans. In contrast, the mutation of ferroportin, which exports iron, causes iron overload by either gain or loss of function. Furthermore, hepcidin secretion from the liver suppresses iron efflux by internalizing and degrading ferroportin; thus, the hepcidin/ferroportin axis is extensively investigated for its potential as a therapeutic target to treat iron overload. This review focuses on the divalent metal transporter 1-mediated intestinal iron uptake and hepcidin/ferroportin axis that regulate systemic iron homeostasis.
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Affiliation(s)
- Yasumasa Okazaki
- Department of Pathology and Biological Responses, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi 466-8550, Japan
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3
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Crawford DHG, Ramm GA, Bridle KR, Nicoll AJ, Delatycki MB, Olynyk JK. Clinical practice guidelines on hemochromatosis: Asian Pacific Association for the Study of the Liver. Hepatol Int 2023; 17:522-541. [PMID: 37067673 DOI: 10.1007/s12072-023-10510-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/28/2023] [Indexed: 04/18/2023]
Affiliation(s)
- Darrell H G Crawford
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Gallipoli Medical Research Foundation, Brisbane, Australia
| | - Grant A Ramm
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Hepatic Fibrosis Group, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Kim R Bridle
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.
- Gallipoli Medical Research Foundation, Brisbane, Australia.
| | - Amanda J Nicoll
- Department of Gastroenterology, Eastern Health, Box Hill, VIC, Australia
- Monash University, Melbourne, VIC, Australia
| | - Martin B Delatycki
- Bruce Lefroy Centre, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- The University of Melbourne, Melbourne, VIC, Australia
- Victorian Clinical Genetics Services, Parkville, VIC, Australia
| | - John K Olynyk
- Department of Gastroenterology, Fiona Stanley Hospital, Murdoch, WA, Australia
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
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Alvarenga AM, Brissot P, Santos PCJL. Haemochromatosis revisited. World J Hepatol 2022; 14:1931-1939. [PMID: 36483608 PMCID: PMC9724105 DOI: 10.4254/wjh.v14.i11.1931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/27/2022] [Accepted: 11/03/2022] [Indexed: 11/24/2022] Open
Abstract
Haemochromatosis is a genetic disease caused by hepcidin deficiency, responsible for an increase in intestinal iron absorption. Haemochromatosis is associated with homozygosity for the HFE p.Cys282Tyr mutation. However, rare cases of haemochromatosis (non-HFE haemochromatosis) can also be caused by pathogenic variants in other genes (such as HJV, HAMP, TFR2 and SLC40A1). A working group of the International Society for the Study of Iron in Biology and Medicine (BIOIRON Society) has concluded that the classification based in different molecular subtypes is difficult to be adopted in clinical practice and has proposed a new classification approaching clinical questions and molecular complexity. The aim of the present review is to provide an update on classification, pathophysiology and therapeutic recommendations.
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Affiliation(s)
- Aline Morgan Alvarenga
- Department of Pharmacology - Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo 04044-020, Brazil
| | | | - Paulo Caleb Junior Lima Santos
- Department of Pharmacology - Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo 04044-020, Brazil
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5
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Baschant U, Altamura S, Steele-Perkins P, Muckenthaler MU, Spasić MV, Hofbauer LC, Steinbicker AU, Rauner M. Iron effects versus metabolic alterations in hereditary hemochromatosis driven bone loss. Trends Endocrinol Metab 2022; 33:652-663. [PMID: 35871125 DOI: 10.1016/j.tem.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 06/08/2022] [Accepted: 06/26/2022] [Indexed: 11/18/2022]
Abstract
Hereditary hemochromatosis (HH) is a genetic disorder in which mutations affect systemic iron homeostasis. Most subtypes of HH result in low hepcidin levels and iron overload. Accumulation of iron in various tissues can lead to widespread organ damage and to various complications, including liver cirrhosis, arthritis, and diabetes. Osteoporosis is another frequent complication of HH, and the underlying mechanisms are poorly understood. Currently, it is unknown whether iron overload in HH directly damages bone or whether complications associated with HH, such as liver cirrhosis or hypogonadism, affect bone secondarily. This review summarizes current knowledge of bone metabolism in HH and highlights possible implications of metabolic dysfunction in HH-driven bone loss. We further discuss therapeutic considerations managing osteoporosis in HH.
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Affiliation(s)
- Ulrike Baschant
- Department of Medicine III & Center for Healthy Aging, Technische Universität Dresden, Dresden, Germany
| | - Sandro Altamura
- Department of Pediatric Hematology, Oncology and Immunology, University of Heidelberg, Heidelberg, Germany
| | - Peter Steele-Perkins
- Institute of Comparative Molecular Endocrinology, University of Ulm, Ulm, Germany
| | - Martina U Muckenthaler
- Department of Pediatric Hematology, Oncology and Immunology, University of Heidelberg, Heidelberg, Germany
| | - Maja Vujić Spasić
- Institute of Comparative Molecular Endocrinology, University of Ulm, Ulm, Germany
| | - Lorenz C Hofbauer
- Department of Medicine III & Center for Healthy Aging, Technische Universität Dresden, Dresden, Germany
| | - Andrea U Steinbicker
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Martina Rauner
- Department of Medicine III & Center for Healthy Aging, Technische Universität Dresden, Dresden, Germany.
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6
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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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7
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Hasan SMM, Farrell J, Borgaonkar M. C282Y/H63D Compound Heterozygosity Is a Low Penetrance Genotype for Iron Overload-related Disease. J Can Assoc Gastroenterol 2022; 5:240-247. [PMID: 36196271 PMCID: PMC9527664 DOI: 10.1093/jcag/gwac025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Hereditary hemochromatosis (HH) occurs due to mutations in the HFE gene. While the C282Y mutation is the most common genotype reported in HH, other genotypes are found less frequently, indicating variable degrees of penetrance. We studied the penetrance of the C282Y/H63D compound heterozygote genotype in developing clinically significant iron overload.
Methods
We have completed a retrospective analysis on every individual within Newfoundland & Labrador who were diagnosed as C282Y/H63D compound heterozygote between 1996 and 2009 through a molecular genetics study. We collected data for up to 10 years following the initial genotyping using electronic health records, including laboratory values, phlebotomy status, radiologic reports and clinic records. Iron overload status was classified based on the HealthIron study.
Results
Between 1996 and 2009, 247 individuals with available health records tested positive for C282Y/H63D compound heterozygosity. Over the 10 years of our study, 5.3% of patients exhibited iron overload-related disease on the background of documented iron overload. Including these individuals, 10.1% of patients had documented iron overload, 23.1% of patients had a provisional iron overload and the remaining 66.8% of patients had no evidence of iron overload. Only 44 patients had documented phlebotomies, likely based on their severe phenotype at baseline. Despite phlebotomy, the prevalence of iron overload was higher among these patients. The penetrance of compound heterozygosity was also significantly higher among men (P < 0.01).
Conclusion
C282Y/H63D compound heterozygosity is a low penetrance genotype in HH. This is the largest reported cohort of C282Y/H63D compound heterozygotes in North America with an extended follow-up.
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Affiliation(s)
- S M Mahmudul Hasan
- Max Rady College of Medicine, University of Manitoba , Winnipeg, Manitoba , Canada
| | - James Farrell
- Discipline of Medicine, Memorial University of Newfoundland, Health Sciences Centre , St. John’s, Newfoundland and Labrador , Canada
| | - Mark Borgaonkar
- Discipline of Medicine, Memorial University of Newfoundland, Health Sciences Centre , St. John’s, Newfoundland and Labrador , Canada
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8
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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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9
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Girelli D, Busti F, Brissot P, Cabantchik I, Muckenthaler MU, Porto G. Hemochromatosis classification: update and recommendations by the BIOIRON Society. Blood 2022; 139:3018-3029. [PMID: 34601591 PMCID: PMC11022970 DOI: 10.1182/blood.2021011338] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 09/05/2021] [Indexed: 12/15/2022] Open
Abstract
Hemochromatosis (HC) is a genetically heterogeneous disorder in which uncontrolled intestinal iron absorption may lead to progressive iron overload (IO) responsible for disabling and life-threatening complications such as arthritis, diabetes, heart failure, hepatic cirrhosis, and hepatocellular carcinoma. The recent advances in the knowledge of pathophysiology and molecular basis of iron metabolism have highlighted that HC is caused by mutations in at least 5 genes, resulting in insufficient hepcidin production or, rarely, resistance to hepcidin action. This has led to an HC classification based on different molecular subtypes, mainly reflecting successive gene discovery. This scheme was difficult to adopt in clinical practice and therefore needs revision. Here we present recommendations for unambiguous HC classification developed by a working group of the International Society for the Study of Iron in Biology and Medicine (BIOIRON Society), including both clinicians and basic scientists during a meeting in Heidelberg, Germany. We propose to deemphasize the use of the molecular subtype criteria in favor of a classification addressing both clinical issues and molecular complexity. Ferroportin disease (former type 4a) has been excluded because of its distinct phenotype. The novel classification aims to be of practical help whenever a detailed molecular characterization of HC is not readily available.
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Affiliation(s)
- Domenico Girelli
- Department of Medicine, Section of Internal Medicine, EuroBloodNet Center, University of Verona and Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Fabiana Busti
- Department of Medicine, Section of Internal Medicine, EuroBloodNet Center, University of Verona and Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Pierre Brissot
- INSERM, Univ-Rennes, Institut National de la Recherche Agronomique, Unité Mixte de Recherche 1241, Institut NuMeCan, Rennes, France
| | - Ioav Cabantchik
- Alexander Silberman Institute of Life Sciences, Hebrew University, Jerusalem, Israel
| | - Martina U. Muckenthaler
- Department of Pediatric Oncology, Hematology, and Immunology and Molecular Medicine Partnership Unit, University of Heidelberg, Heidelberg, Germany
- Molecular Medicine Partnership Unit, European Molecular Biology Laboratory, Heidelberg, Germany
- Translational Lung Research Center, German Center for Lung Research, Heidelberg, Germany
- German Centre for Cardiovascular Research, Partner Site Heidelberg, Mannheim, Germany
| | - Graça Porto
- Institute for Molecular and Cell Biology, Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- Clinical Hematology, Santo António Hospital, Porto University, Porto, Portugal
| | - on behalf of the Nomenclature Committee of the International Society for the Study of Iron in Biology and Medicine (BIOIRON Society)
- Department of Medicine, Section of Internal Medicine, EuroBloodNet Center, University of Verona and Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
- INSERM, Univ-Rennes, Institut National de la Recherche Agronomique, Unité Mixte de Recherche 1241, Institut NuMeCan, Rennes, France
- Alexander Silberman Institute of Life Sciences, Hebrew University, Jerusalem, Israel
- Department of Pediatric Oncology, Hematology, and Immunology and Molecular Medicine Partnership Unit, University of Heidelberg, Heidelberg, Germany
- Molecular Medicine Partnership Unit, European Molecular Biology Laboratory, Heidelberg, Germany
- Translational Lung Research Center, German Center for Lung Research, Heidelberg, Germany
- German Centre for Cardiovascular Research, Partner Site Heidelberg, Mannheim, Germany
- Institute for Molecular and Cell Biology, Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- Clinical Hematology, Santo António Hospital, Porto University, Porto, Portugal
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Identification of Common Pathogenic Pathways Involved in Hemochromatosis Arthritis and Calcium Pyrophosphate Deposition Disease: a Review. Curr Rheumatol Rep 2022; 24:40-45. [PMID: 35143028 DOI: 10.1007/s11926-022-01054-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Arthritis is a common clinical manifestation of hereditary hemochromatosis (HH), and HH is one of a handful of conditions linked to calcium pyrophosphate deposition (CPPD) in joints. The connection between these two types of arthritis has not yet been fully elucidated. In light of new pathogenic pathways recently implicated in CPPD involving bone, we reviewed the literature on the etiology of hemochromatosis arthropathy (HHA) seeking shared pathogenic mechanisms. RESULTS Clinical observations reinforce striking similarities between HHA and CPPD even in the absence of CPP crystals. They share a similar joint distribution, low grade synovial inflammation, and generalized bone loss. Excess iron damages chondrocytes and bone cells in vitro. While direct effects of iron on cartilage are not consistently seen in animal models of HH, there is decreased osteoblast alkaline phosphatase activity, and increased osteoclastogenesis. These abnormalities are also seen in CPPD. Joint repair processes may also be impaired in both CPPD and HHA. CONCLUSIONS Possible shared pathogenic pathways relate more to bone and abnormal damage/repair mechanisms than direct damage to articular cartilage. While additional work is necessary to fully understand the pathogenesis of arthritis in HH and to firmly establish causal links with CPPD, this review provides some plausible hypotheses explaining the overlap of these two forms of arthritis.
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11
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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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12
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Cancado RD, Alvarenga AM, Santos PCJ. HFE hemochromatosis: an overview about therapeutic recommendations. Hematol Transfus Cell Ther 2021; 44:95-99. [PMID: 34824033 PMCID: PMC8885398 DOI: 10.1016/j.htct.2021.06.020] [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: 07/06/2020] [Revised: 06/12/2021] [Accepted: 06/24/2021] [Indexed: 11/17/2022] Open
Abstract
Hemochromatosis is currently characterized by the iron overload caused by hepcidin deficiency. Large advances in the knowledge on the hemochromatosis pathophysiology have occurred due to a better understanding of the protein of the iron metabolism, the genetic basis of hemochromatosis and of other iron overload diseases or conditions which can lead to this phenotype. In the present review, the main aims are to show updates on hemochromatosis and to report a practical set of therapeutic recommendations for the human factors engineering protein (HFE) hemochromatosis for the p.Cys282Tyr (C282Y/C282Y) homozygous genotype, elaborated by the Haemochromatosis International Taskforce.
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Affiliation(s)
- Rodolfo D Cancado
- Irmandade da Santa Casa de Misericórdia de São Paulo, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brazil
| | | | - Paulo Caleb Jl Santos
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
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13
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Baas FS, Rishi G, Swinkels DW, Subramaniam VN. Genetic Diagnosis in Hereditary Hemochromatosis: Discovering and Understanding the Biological Relevance of Variants. Clin Chem 2021; 67:1324-1341. [PMID: 34402502 DOI: 10.1093/clinchem/hvab130] [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: 04/01/2021] [Accepted: 06/23/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Hereditary hemochromatosis (HH) is a genetic disease, leading to iron accumulation and possible organ damage. Patients are usually homozygous for p. Cys282Tyr in the homeostatic iron regulator gene but may have mutations in other genes involved in the regulation of iron. Next-generation sequencing is increasingly being utilized for the diagnosis of patients, leading to the discovery of novel genetic variants. The clinical significance of these variants is often unknown. CONTENT Determining the pathogenicity of such variants of unknown significance is important for diagnostics and genetic counseling. Predictions can be made using in silico computational tools and population data, but additional evidence is required for a conclusive pathogenicity classification. Genetic disease models, such as in vitro models using cellular overexpression, induced pluripotent stem cells or organoids, and in vivo models using mice or zebrafish all have their own challenges and opportunities when used to model HH and other iron disorders. Recent developments in gene-editing technologies are transforming the field of genetic disease modeling. SUMMARY In summary, this review addresses methods and developments regarding the discovery and classification of genetic variants, from in silico tools to in vitro and in vivo models, and presents them in the context of HH. It also explores recent gene-editing developments and how they can be applied to the discussed models of genetic disease.
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Affiliation(s)
- Floor S Baas
- Translational Metabolic Laboratory (TML 831), Radboudumc, Nijmegen, the Netherlands.,Hepatogenomics Research Group, School of Biomedical Sciences, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - Gautam Rishi
- Hepatogenomics Research Group, School of Biomedical Sciences, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - Dorine W Swinkels
- Translational Metabolic Laboratory (TML 831), Radboudumc, Nijmegen, the Netherlands
| | - V Nathan Subramaniam
- Hepatogenomics Research Group, School of Biomedical Sciences, Queensland University of Technology (QUT), Brisbane, QLD, Australia
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14
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Wu L, Zhang W, Li Y, Zhou D, Zhang B, Xu A, Wu Z, Wu L, Li S, Wang X, Zhao X, Wang Q, Li M, Wang Y, You H, Huang J, Ou X, Jia J. Correlation of genotype and phenotype in 32 patients with hereditary hemochromatosis in China. Orphanet J Rare Dis 2021; 16:398. [PMID: 34583728 PMCID: PMC8479922 DOI: 10.1186/s13023-021-02020-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 09/20/2021] [Indexed: 12/22/2022] Open
Abstract
Background Hereditary hemochromatosis (HH) is widely recognized and clinical manifestations of hemochromatosis-related (HFE-related) HH is well studied in European populations. Less is known about the clinical and laboratory characteristics of non-HFE related HH in Asian population. We aimed to explore the relationship between genotype and clinical phenotype in Chinese patients with non-HFE related hereditary hemochromatosis. Methods Peripheral blood samples and clinical data of patients with primary iron overload were collected from the China Registry of Genetic/Metabolic Liver Diseases. Sanger sequencing was performed in cases with primary iron overload, for 5 known HH related genes (HFE, HJV, HAMP, TFR2 and SLC40A1) and 2 novel iron homeostasis-related genes (DENND3 and SUGP2). The correlation of genotype and clinical phenotype in these patients was analyzed. Results Of the 32 patients with primary iron overload (23 were males and 9 were females), non-HFE variants were detected in 31 (31/32, 97%), including 8 pathogenic variants in HJV, 7 pathogenic variants in SLC40A1, 8 likely pathogenic variants in SUGP2 and 5 likely pathogenic variants in DENND3 cases. Among these 31 cases, 4 cases harbored homozygous variants, 2 cases harbored homozygous + heterozygous variants, 19 cases harbored heterozygous or combined heterozygous variants, and 6 cases harbored no any damaging variants. None of investigated cases carried damaging HAMP and TFR2 variants were found. 8 cases were classified as type 2A HH and 6 cases as type 4 HH, 10 cases as non-classical genotype, and 6 cases had no pathogenic variants from 31 cases. During the statistical analysis, we excluded one case (SLC40A1 IVS3 + 10delGTT + SUGP2 p. R639Q(homo)) with difficulty in grouping due to combined damaging variants. Cases with type 2A HH have an earlier age at diagnosis (p = 0.007). The iron index of cases in type 2A HH and type 4 HH was higher than that in other groups (p = 0.01). Arthropathy was relatively rare in all groups. None of cases with type 2A HH developed cirrhosis. Cirrhosis and diabetes are more prevalent in type 4 HH. The incidence of cirrhosis (p = 0.011), cardiac involvement (p = 0.042), diabetes (p = 0.035) and hypogonadism (p = 0.020) was statistically significant in the four groups. However, due to the limited sample size, the pairwise comparison showed no significant difference. Conclusions This is the first comprehensive analysis about the gene variant spectrum and phenotypic aspects of non-HFE HH in China. The results will be useful to the identification, diagnosis and management of HH in China.
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Affiliation(s)
- Liyan Wu
- Beijing Key Laboratory of Translational Medicine On Liver Cirrhosis , Liver Research Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Beijing, 100050, China.,National Clinical Research Center for Digestive Diseases, Beijing, 100050, China
| | - Wei Zhang
- Beijing Key Laboratory of Translational Medicine On Liver Cirrhosis , Liver Research Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Beijing, 100050, China.,National Clinical Research Center for Digestive Diseases, Beijing, 100050, China
| | - Yanmeng Li
- National Clinical Research Center for Digestive Diseases, Beijing, 100050, China.,Liver Research Center, Experimental Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Beijing, 100050, China
| | - Donghu Zhou
- National Clinical Research Center for Digestive Diseases, Beijing, 100050, China.,Liver Research Center, Experimental Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Beijing, 100050, China
| | - Bei Zhang
- National Clinical Research Center for Digestive Diseases, Beijing, 100050, China.,Liver Research Center, Experimental Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Beijing, 100050, China
| | - Anjian Xu
- National Clinical Research Center for Digestive Diseases, Beijing, 100050, China.,Liver Research Center, Experimental Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Beijing, 100050, China
| | - Zhen Wu
- Beijing Key Laboratory of Translational Medicine On Liver Cirrhosis , Liver Research Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Beijing, 100050, China.,National Clinical Research Center for Digestive Diseases, Beijing, 100050, China
| | - Lina Wu
- Beijing Key Laboratory of Translational Medicine On Liver Cirrhosis , Liver Research Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Beijing, 100050, China.,National Clinical Research Center for Digestive Diseases, Beijing, 100050, China
| | - Shuxiang Li
- Beijing Key Laboratory of Translational Medicine On Liver Cirrhosis , Liver Research Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Beijing, 100050, China.,National Clinical Research Center for Digestive Diseases, Beijing, 100050, China
| | - Xiaoming Wang
- Beijing Key Laboratory of Translational Medicine On Liver Cirrhosis , Liver Research Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Beijing, 100050, China.,National Clinical Research Center for Digestive Diseases, Beijing, 100050, China
| | - Xinyan Zhao
- Beijing Key Laboratory of Translational Medicine On Liver Cirrhosis , Liver Research Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Beijing, 100050, China.,National Clinical Research Center for Digestive Diseases, Beijing, 100050, China
| | - Qianyi Wang
- Beijing Key Laboratory of Translational Medicine On Liver Cirrhosis , Liver Research Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Beijing, 100050, China.,National Clinical Research Center for Digestive Diseases, Beijing, 100050, China
| | - Min Li
- Department of Clinical Epidemiology and EBM, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Yu Wang
- Beijing Key Laboratory of Translational Medicine On Liver Cirrhosis , Liver Research Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Beijing, 100050, China.,National Clinical Research Center for Digestive Diseases, Beijing, 100050, China
| | - Hong You
- Beijing Key Laboratory of Translational Medicine On Liver Cirrhosis , Liver Research Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Beijing, 100050, China.,National Clinical Research Center for Digestive Diseases, Beijing, 100050, China
| | - Jian Huang
- Beijing Key Laboratory of Translational Medicine On Liver Cirrhosis , Liver Research Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Beijing, 100050, China. .,National Clinical Research Center for Digestive Diseases, Beijing, 100050, China. .,Liver Research Center, Experimental Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Beijing, 100050, China.
| | - Xiaojuan Ou
- Beijing Key Laboratory of Translational Medicine On Liver Cirrhosis , Liver Research Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Beijing, 100050, China. .,National Clinical Research Center for Digestive Diseases, Beijing, 100050, China.
| | - Jidong Jia
- Beijing Key Laboratory of Translational Medicine On Liver Cirrhosis , Liver Research Center, Beijing Friendship Hospital, Capital Medical University, 95 Yong-An Road, Beijing, 100050, China. .,National Clinical Research Center for Digestive Diseases, Beijing, 100050, China.
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15
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Kowdley DS, Kowdley KV. Appropriate Clinical Genetic Testing of Hemochromatosis Type 2-4, Including Ferroportin Disease. Appl Clin Genet 2021; 14:353-361. [PMID: 34413666 PMCID: PMC8369226 DOI: 10.2147/tacg.s269622] [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: 05/13/2021] [Accepted: 07/18/2021] [Indexed: 11/23/2022] Open
Abstract
Hereditary hemochromatosis (HH) is an inherited iron overload disorder due to a deficiency of hepcidin, or a failure of hepcidin to degrade ferroportin. The most common form of HH, Type 1 HH, is most commonly due to a homozygous C282Y mutation in HFE and is relatively well understood in significance and action; however, other rare forms of HH (Types 2–4) exist and are more difficult to identify and diagnose in clinical practice. In this review, we describe the clinical characteristics of HH Type 2–4 and the mutation patterns that have been described in these conditions. We also review the different methods for genetic testing available in clinical practice and a pragmatic approach to the patient with suspected non-HFE HH.
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Affiliation(s)
- Devan S Kowdley
- Liver Institute Northwest and Elson S. Floyd College of Medicine, Washington State University, Seattle, WA, USA
| | - Kris V Kowdley
- Liver Institute Northwest and Elson S. Floyd College of Medicine, Washington State University, Seattle, WA, USA
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16
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Kalpouzos G, Mangialasche F, Falahati F, Laukka EJ, Papenberg G. Contributions of HFE polymorphisms to brain and blood iron load, and their links to cognitive and motor function in healthy adults. Neuropsychopharmacol Rep 2021; 41:393-404. [PMID: 34291615 PMCID: PMC8411306 DOI: 10.1002/npr2.12197] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 12/14/2022] Open
Abstract
Background Brain iron overload is linked to brain deterioration, and cognitive and motor impairment in neurodegenerative disorders and normal aging. Mutations in the HFE gene are associated with iron dyshomeostasis and are risk factors for peripheral iron overload. However, links to brain iron load and cognition are less consistent and data are scarce. Aims and methods Using quantitative susceptibility mapping with magnetic resonance imaging, we investigated whether C282Y and H63D contributed to aging‐related increases in brain iron load and lower cognitive and motor performance in 208 healthy individuals aged 20‐79 years. We also assessed the modulatory effects of HFE mutations on associations between performance and brain iron load, as well as peripheral iron metabolism. Results Independent of age, carriers of either C282Y and/or H63D (HFE‐pos group, n = 66) showed a higher load of iron in putamen than non‐carriers (HFE‐neg group, n = 142), as well as higher transferrin saturation and lower transferrin and transferrin receptors in blood. In the HFE‐neg group, higher putaminal iron was associated with lower working memory. In the HFE‐pos group, higher putaminal iron was instead linked to higher executive function, and lower plasma transferrin was related to higher episodic memory. Iron‐performance associations were modest albeit reliable. Conclusion Our findings suggest that HFE status is characterized by higher regional brain iron load across adulthood, and support the presence of a modulatory effect of HFE status on the relationships between iron load and cognition. Future studies in healthy individuals are needed to confirm the reported patterns. This study investigated the contribution of genetic polymorphisms in the HFE gene (C282Y and H63D) on blood and brain iron load, and their relationships with cognition, in a healthy sample of adults. The findings indicated that carriers of C282Y and/or H63D displayed higher iron load in putamen and higher transferrin saturation in blood. Results further suggested that in carriers, higher iron load may be beneficial for cognitive performance, independent of age.![]()
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Affiliation(s)
- Grégoria Kalpouzos
- Department of Neurobiology, Care Sciences and Society, Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Francesca Mangialasche
- Department of Neurobiology, Care Sciences and Society, Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden.,Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Center for Alzheimer Research, Karolinska Institutet, Stockholm, Sweden
| | - Farshad Falahati
- Department of Neurobiology, Care Sciences and Society, Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Erika J Laukka
- Department of Neurobiology, Care Sciences and Society, Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden.,Stockholm Gerontology Research Center, Stockholm, Sweden
| | - Goran Papenberg
- Department of Neurobiology, Care Sciences and Society, Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
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17
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Pagliosa CM, Vieira FGK, Dias BV, Brognoli Franco VK, Ramos HP, da Silva EL. Ilex paraguariensis (A. St.-Hil.) leaf infusion decreases iron absorption in patients with hereditary hemochromatosis: a randomized controlled crossover study. Food Funct 2021; 12:7321-7328. [PMID: 34173816 DOI: 10.1039/d1fo00482d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
This study proposed to investigate the effect of Ilex paraguariensis infusion on the absorption of non-heme iron in hereditary hemochromatosis (HH) patients with the HFE genotype. A two-way randomized, controlled, crossover trial was conducted on patients, aged 29-69 years, undergoing maintenance therapy. Fourteen HFE-HH patients ingested a meal containing 11.4 mg iron and 200 mL either of water (control) or of Ilex paraguariensis leaf infusion. The beverages were offered in random order, at intervals separated by a washout period of 7 days. Active surveillance showed no adverse effects. Blood samples were drawn shortly before and 1, 2, 3, and 4 h after the meal for serum iron measurement. A significant reduction in the postprandial serum iron was observed for HH patients after intake of the Ilex paraguariensis infusion (area under the curve (AUC) expressed as mean ± SEM: 173.3 ± 44.7 μmol h-1 L-1) compared to water (1449.4 ± 241.5 μmol h-1 L-1) (p < 0.001). In summary, intake of Ilex paraguariensis leaf infusion significantly inhibited the absorption of iron in patients with HH and, therefore, should be considered as a potential adjuvant for iron overload control.
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Affiliation(s)
- Cristiane Manfé Pagliosa
- Post-graduate Program in Nutrition, Health Sciences Center, Federal University of Santa Catarina, Florianópolis, Brazil.
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18
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Kesler AM, Kröner PT, Wijarnpreecha K, Palmer WC. Increased rates of spinal fusion surgery in patients with hereditary hemochromatosis: a five-year propensity matched cohort analysis. Eur J Gastroenterol Hepatol 2021; 33:899-904. [PMID: 32568803 DOI: 10.1097/meg.0000000000001810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECT Spinal arthropathy is associated with hereditary hemochromatosis and has been linked to calcium pyrophosphate dehydrate crystal deposition (CPPD) which resembles ankylosing spondylitis on radiograph, yet lacks clinical findings of inflammatory spinal arthritis. The aim of our study was to assess the use of spinal surgery and its outcomes in the US inpatient population with hereditary hemochromatosis from 2012 to 2016 by using the US Nationwide Inpatient Sample (NIS) database. METHODS The observational retrospective cohort study uses the NIS 2012 to 2016. All patients with hereditary hemochromatosis were included using International Classification of Diseases 9th and 10th revisions, Clinical Modification codes. The cohort was stratified according to having undergone spinal surgery and substratified by the type of surgery. The primary outcome was determining the use of spinal surgery in patients with hereditary hemochromatosis. Secondary outcomes were determining length of hospital stay and total hospital charges and costs. RESULTS A total of 39 780 patients with hereditary hemochromatosis were identified and propensity matched to nonhereditary hemochromatosis controls. The mean patient age was 61 years, and 65% were females. For the primary outcome patients with hereditary hemochromatosis underwent significantly more spinal fusion surgery compared to patients without hereditary hemochromatosis odds of 2.13 (P = 0.05). While there was no difference in mean LOS, or costs, patients with hereditary hemochromatosis had higher hospital charges. CONCLUSION Hereditary hemochromatosis is associated with higher odds of spinal fusion. It is a major complication not improved by phlebotomy, and there are currently no therapies to prevent this joint disease.
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Affiliation(s)
| | - Paul T Kröner
- Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Karn Wijarnpreecha
- Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - William C Palmer
- Departments of Medicine
- Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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19
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Kowdley KV, Gochanour EM, Sundaram V, Shah RA, Handa P. Hepcidin Signaling in Health and Disease: Ironing Out the Details. Hepatol Commun 2021; 5:723-735. [PMID: 34027264 PMCID: PMC8122377 DOI: 10.1002/hep4.1717] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 12/19/2022] Open
Abstract
Hepcidin, a peptide hormone produced by hepatocytes, is the central regulator of systemic iron homeostasis through its interaction with ferroportin, the major cellular iron export protein. Hepcidin binding to ferroportin results in reduced iron export from macrophages and intestinal absorptive cells, leading to decreased serum iron levels. Hepcidin expression is influenced by several factors that include serum and liver iron stores, erythropoiesis, hypoxia, inflammation, and infection. Erythropoietic drive and hypoxia suppress hepcidin expression and promote red cell production. In contrast, inflammation and infection are associated with increased hepcidin production to sequester iron intracellularly as a means of depriving microorganisms of iron. Chronic inflammation may up-regulate hepcidin expression through the interleukin-6 (IL-6)-Janus kinase 2 (JAK2)-signal transducer and activator of transcription 3 (STAT3) pathway. The bone morphogenetic protein (BMP)-mothers against decapentaplegic homolog (SMAD) pathway is a major positive driver of hepcidin expression in response to either increased circulating iron in the form of transferrin or iron loading in organs. Hereditary hemochromatosis (HH) consists of several inherited disorders that cause inappropriately reduced hepcidin expression in response to body iron stores, leading to increased iron absorption from a normal diet. The most common form of HH is due to a mutation in the HFE gene, which causes a failure in the hepatocyte iron-sensing mechanism, leading to reduced hepcidin expression; the clinical manifestations of HFE-HH include increased serum transferrin-iron saturation and progressive iron loading in the liver and other tissues over time among patients who express the disease phenotype. In this article, we review the physiologic mechanisms and cellular pathways by which hepcidin expression is regulated, and the different forms of HH resulting from various mutations that cause hepcidin deficiency. We also review other drivers of hepcidin expression and the associated pathophysiologic consequences.
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Affiliation(s)
- Kris V. Kowdley
- Liver Institute Northwest and Elson S. Floyd College of MedicineWashington State UniversitySpokaneWAUSA
- Liver Care Network and Organ Care ResearchSwedish Medical CenterSeattleWAUSA
| | - Eric M. Gochanour
- Liver Institute Northwest and Elson S. Floyd College of MedicineWashington State UniversitySpokaneWAUSA
- Liver Care Network and Organ Care ResearchSwedish Medical CenterSeattleWAUSA
| | - Vinay Sundaram
- Division of Gastroenterology and Comprehensive Transplant CenterLos AngelesCAUSA
| | - Raj A. Shah
- Liver Care Network and Organ Care ResearchSwedish Medical CenterSeattleWAUSA
| | - Priya Handa
- Liver Care Network and Organ Care ResearchSwedish Medical CenterSeattleWAUSA
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20
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Kang W, Barad A, Clark AG, Wang Y, Lin X, Gu Z, O'Brien KO. Ethnic Differences in Iron Status. Adv Nutr 2021; 12:1838-1853. [PMID: 34009254 PMCID: PMC8483971 DOI: 10.1093/advances/nmab035] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 02/07/2023] Open
Abstract
Iron is unique among all minerals in that humans have no regulatable excretory pathway to eliminate excess iron after it is absorbed. Iron deficiency anemia occurs when absorbed iron is not sufficient to meet body iron demands, whereas iron overload and subsequent deposition of iron in key organs occur when absorbed iron exceeds body iron demands. Over time, iron accumulation in the body can increase risk of chronic diseases, including cirrhosis, diabetes, and heart failure. To date, only ∼30% of the interindividual variability in iron absorption can be captured by iron status biomarkers or iron regulatory hormones. Much of the regulation of iron absorption may be under genetic control, but these pathways have yet to be fully elucidated. Genome-wide and candidate gene association studies have identified several genetic variants that are associated with variations in iron status, but the majority of these data were generated in European populations. The purpose of this review is to summarize genetic variants that have been associated with alterations in iron status and to highlight the influence of ethnicity on the risk of iron deficiency or overload. Using extant data in the literature, linear mixed-effects models were constructed to explore ethnic differences in iron status biomarkers. This approach found that East Asians had significantly higher concentrations of iron status indicators (serum ferritin, transferrin saturation, and hemoglobin) than Europeans, African Americans, or South Asians. African Americans exhibited significantly lower hemoglobin concentrations compared with other ethnic groups. Further studies of the genetic basis for ethnic differences in iron metabolism and on how it affects disease susceptibility among different ethnic groups are needed to inform population-specific recommendations and personalized nutrition interventions for iron-related disorders.
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Affiliation(s)
- Wanhui Kang
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Alexa Barad
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Andrew G Clark
- Department of Molecular Biology and Genetics, Cornell University, Ithaca, NY, USA,Department of Computational Biology, Cornell University, Ithaca, NY, USA
| | - Yiqin Wang
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Xu Lin
- Shanghai Institute of Nutrition and Health, Chinese Academy of Sciences, Shanghai, China
| | - Zhenglong Gu
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
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21
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Iron at the Interface of Hepatocellular Carcinoma. Int J Mol Sci 2021; 22:ijms22084097. [PMID: 33921027 PMCID: PMC8071427 DOI: 10.3390/ijms22084097] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/06/2021] [Accepted: 04/13/2021] [Indexed: 12/12/2022] Open
Abstract
Cancer incidence and mortality are rapidly growing, with liver cancer being the sixth most diagnosed cancer worldwide and the third leading cause of cancer death in 2020. A number of risk factors have been identified that trigger the progression to hepatocellular carcinoma. In this review, we focus on iron as a potential risk factor for liver carcinogenesis. Molecules involved in the regulation of iron metabolism are often upregulated in cancer cells, in order to provide a supply of this essential trace element for all stages of tumor development, survival, proliferation, and metastasis. Thus, cellular and systemic iron levels must be tightly regulated to prevent or delay liver cancer progression. Disorders associated with dysregulated iron metabolism are characterized with increased susceptibility to hepatocellular carcinoma. This review discusses the association of iron with metabolic disorders such as hereditary hemochromatosis, non-alcoholic fatty liver disease, obesity, and type 2 diabetes, in the background of hepatocellular carcinoma.
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22
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Griffiths WJH, Besser M, Bowden DJ, Kelly DA. Juvenile haemochromatosis. THE LANCET CHILD & ADOLESCENT HEALTH 2021; 5:524-530. [PMID: 33861982 DOI: 10.1016/s2352-4642(20)30392-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/25/2020] [Accepted: 12/09/2020] [Indexed: 12/13/2022]
Abstract
Juvenile haemochromatosis is a severe inherited iron-loading disorder that can present in children and adolescents. Typical manifestations include heart failure, endocrine failure (including diabetes and hypogonadism), cirrhosis, and arthropathy. Compared with HFE haemochromatosis, juvenile haemochromatosis affects female and male individuals similarly, presents at a younger age, and causes multiple organ dysfunction; the principle of iron loading into tissues from the gut is shared by both forms, but the process is far more rapid in juvenile haemochromatosis. Juvenile haemochromatosis is initially recognised by extreme increases of serum ferritin and transferrin saturation, which is supported by an MRI showing iron deposition in the heart and liver. MRI software techniques allow quantification of iron in these organs, and can therefore be used to monitor progress. Juvenile haemochromatosis is autosomal recessive and is generally associated with mutations in HJV (type 2A) or HAMP (type 2B). Mutations in TFR2 cause an intermediate severity phenotype (type 3), but this phenotype can cross over into the juvenile haemochromatosis spectrum so it might need to be additionally considered during diagnosis. Treatment needs to be administered without delay, in the form of aggressive iron chelation, and a multidisciplinary approach is essential. Because iron is removed, organ function is restored, which could obviate the need for cardiac or liver transplantation. Substantial restoration of health can ensue, but patients require life-long monitoring. Family screening is an important component of the management of juvenile haemochromatosis. Genetic advances which underpin the haemochromatosis types also clarify the role of iron metabolism in health and disease, particularly the role of hepcidin in regulating iron homoeostasis. Therefore, juvenile haemochromatosis is an important condition to understand; it can present insidiously in children and adolescents, and awareness of the diagnosis is needed to inform early recognition and treatment.
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Affiliation(s)
| | - Martin Besser
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - David J Bowden
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Deirdre A Kelly
- Liver Unit, Birmingham Women's and Children's NHS Trust and University of Birmingham, Birmingham, UK
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23
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Wu HX, Liu JY, Yan DW, Li L, Zhuang XH, Li HY, Zhou ZG, Zhou HD. Atypical juvenile hereditary hemochromatosis onset with positive pancreatic islet autoantibodies diabetes caused by novel mutations in HAMP and overall clinical management. Mol Genet Genomic Med 2020; 8:e1522. [PMID: 33016646 PMCID: PMC7767552 DOI: 10.1002/mgg3.1522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/06/2020] [Accepted: 09/17/2020] [Indexed: 12/19/2022] Open
Abstract
Background Atypical clinical symptoms of juvenile hereditary hemochromatosis (JHH) often leads to misdiagnosis and underdiagnosis bringing ominous outcomes, even death. Methods The whole exome was sequenced and interpreted. A literature review assisted to analyze and verify the phenotype–genotype relationships. We revealed the entire process of diagnosis, treatments, and outcome of two diabetic onset of JHH families to provide new insights for genotype–phenotype relation with novel compound heterozygous mutations in the hepcidin antimicrobial peptide (HAMP, OMIM: 606464). Results Two probands were diagnosed and treated as type 1 diabetes initially because of specific symptoms and positive islet autoantibodies. Poor control of hyperglycemia and progressive symptoms occurred. Sequencing informed that the compound heterozygous and homozygous mutations c.166C>G and c.223C>T in HAMP caused type 1 diabetic‐onset JHH. The two patients accessed irregular phlebotomy treatments, and then, experienced poor prognosis. We summarized the process of overall clinical management of reported 26 cases comparing to our novel atypical diabetic onsets Juvenile Hereditary Hemochromatosis cases. Conclusion It was first reported that positive pancreatic islet autoantibodies diabetes onset of JHH resulted from loss‐of‐function mutations of HAMP, of which the atypical JHH should be differentially diagnosed with type 1 diabetes at the onset. Early administration of phlebotomy and vital organs protection and surveillance might be important for the treatment of atypical JHH.
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Affiliation(s)
- Hui-Xuan Wu
- National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory for Metabolic Bone Diseases, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jun-Ying Liu
- Department of Endocrinology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - De-Wen Yan
- Department of Endocrinology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Long Li
- National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory for Metabolic Bone Diseases, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Xiang-Hua Zhuang
- Department of Endocrinology, The Second Hospital of Shandong University, Jinan, Shandong, China
| | - Hai-Yan Li
- Department of Endocrinology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Zhi-Guang Zhou
- National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory for Metabolic Bone Diseases, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Hou-De Zhou
- National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory for Metabolic Bone Diseases, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
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24
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Corradini E, Buzzetti E, Pietrangelo A. Genetic iron overload disorders. Mol Aspects Med 2020; 75:100896. [PMID: 32912773 DOI: 10.1016/j.mam.2020.100896] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/11/2020] [Accepted: 08/17/2020] [Indexed: 02/06/2023]
Abstract
Due to its pivotal role in orchestrating vital cellular functions and metabolic processes, iron is an essential component of the human body and a main micronutrient in the human diet. However, excess iron causes an increased production of reactive oxygen species leading to cell dysfunction or death, tissue damage and organ disease. Iron overload disorders encompass a wide spectrum of pathological conditions of hereditary or acquired origin. A number of 'iron genes' have been identified as being associated with hereditary iron overload syndromes, the most common of which is hemochromatosis. Although linked to at least five different genes, hemochromatosis is recognized as a unique syndromic entity based on a common pathogenetic mechanism leading to excessive entry of unneeded iron into the bloodstream. In this review, we focus on the pathophysiologic basis and clinical aspects of the most common genetic iron overload syndromes in humans.
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Affiliation(s)
- Elena Corradini
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia; Internal Medicine and Centre for Hemochromatosis and Heredometabolic Liver Diseases, ERN -EuroBloodNet Center, Azienda Ospedaliero-Universitaria di Modena, Policlinico, Modena, Italy
| | - Elena Buzzetti
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia; Internal Medicine and Centre for Hemochromatosis and Heredometabolic Liver Diseases, ERN -EuroBloodNet Center, Azienda Ospedaliero-Universitaria di Modena, Policlinico, Modena, Italy
| | - Antonello Pietrangelo
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia; Internal Medicine and Centre for Hemochromatosis and Heredometabolic Liver Diseases, ERN -EuroBloodNet Center, Azienda Ospedaliero-Universitaria di Modena, Policlinico, Modena, Italy.
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Nguyen CD, Morel V, Pierache A, Lion G, Cortet B, Flipo RM, Canva-Delcambre V, Paccou J. Bone and joint complications in patients with hereditary hemochromatosis: a cross-sectional study of 93 patients. Ther Adv Musculoskelet Dis 2020; 12:1759720X20939405. [PMID: 32728396 PMCID: PMC7366396 DOI: 10.1177/1759720x20939405] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 06/13/2020] [Indexed: 12/21/2022] Open
Abstract
Background The aim of this study was to determine the frequency and characteristics of bone and joint complications, specifically bone fragility, joint replacement surgery, and arthropathy, in hereditary hemochromatosis (HH) and related factors. Methods This study was a cross-sectional observational study of 93 patients with HH. Radiographs of the hands, wrists, knees, and ankles were scored for joint space narrowing, erosions and cysts, osteophytes, and chondrocalcinosis. Prevalent (vertebral and non-vertebral) fragility fractures were recorded and bone mineral density (BMD) was systematically evaluated by dual energy X-ray absorptiometry. Bone fragility was defined as (i) a T-score ⩽ -2.5 at any site with or without a prevalent fragility fracture, or (ii) a T-score between -1.0 and -2.5 at any site and a prevalent fragility fracture. Results The mean age of the patients was 60.0 (11.2) years, and 58.0% of them were men. The frequency of radiographic MCP2-3 arthropathy was 37.6% (95% CI 0.28-0.48). Radiographic MCP2-3 arthropathy was independently associated with older age [OR 1.17 (1.09-1.26) per year, p < 0.0001], male sex [OR 3.89 (1.17-12.97), p = 0.027] and C282Y+/+ genotype [OR 4.78 (1.46-15.68), p = 0.010]. The frequency of joint replacement surgery was 12.9% (95% CI 0.07-0.21). The frequency of bone fragility was 20.4% (95% CI 0.13-0.30). Bone fragility was independently associated with hepatic cirrhosis [OR 8.20 (1.74-38.68), p = 0.008]. Discussion Radiographic MCP2-3 arthropathy was found to occur in 37.6% of patients with HH. The association observed between this form of arthropathy and C282Y homozygosity, male sex, and older age suggests that demographic characteristics and genetic background are likely to be major determinants of this joint disorder and play a more important role than severity of iron overload. Bone fragility was observed in a fifth of the patients with HH, independently of genetic background and severity of iron overload, and was strongly associated with hepatic cirrhosis. Conclusion Future investigations should focus on pathogenesis and early identification of patients at risk of developing bone and joint complications secondary to HH.
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Affiliation(s)
| | - Vincent Morel
- Service de radiologie ostéoarticulaire, CHU Lille, Lille, France
| | - Adeline Pierache
- EA 2694 - Santé Publique: épidémiologie et qualité des soins, Université de Lille, CHU Lille, F-Lille, France
| | - Georges Lion
- Service de médecine nucléaire, CHU Lille, Lille, France
| | | | | | | | - Julien Paccou
- Service de rhumatologie, Hôpital Roger Salengro, Rue Emile Laine, CHRU, 59037 Lille cedex, France
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26
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Secondes ES, Wallace DF, Rishi G, McLaren GD, McLaren CE, Chen WP, Ramm LE, Powell LW, Ramm GA, Barton JC, Subramaniam VN. Increased frequency of GNPAT p.D519G in compound HFE p.C282Y/p.H63D heterozygotes with elevated serum ferritin levels. Blood Cells Mol Dis 2020; 85:102463. [PMID: 32652459 DOI: 10.1016/j.bcmd.2020.102463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 12/12/2022]
Abstract
Glyceronephosphate O-acyltransferase (GNPAT) p.D519G (rs11558492) was identified as a genetic modifier correlated with more severe iron overload in hemochromatosis through whole-exome sequencing of HFE p.C282Y homozygotes with extreme iron phenotypes. We studied the prevalence of p.D519G in HFE p.C282Y/p.H63D compound heterozygotes, a genotype associated with iron overload in some patients. Cases were Australian participants with elevated serum ferritin (SF) levels ≥300μg/L (males) and ≥200μg/L (females); subjects whose SF levels were below these cut-offs were designated as controls. Samples were genotyped for GNPAT p.D519G. We compared the allele frequency of the present subjects, with/without elevated SF, to p.D519G frequency in public datasets. GNPAT p.D519G was more prevalent in our cohort of p.C282Y/p.H63D compound heterozygotes with elevated SF (37%) than European public datasets: 1000G 21%, gnomAD 20% and ESP 21%. We conclude that GNPAT p.D519G is associated with elevated SF in Australian HFE p.C282Y/p.H63D compound heterozygotes.
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Affiliation(s)
- Eriza S Secondes
- School of Biomedical Sciences, Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.
| | - Daniel F Wallace
- School of Biomedical Sciences, Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.
| | - Gautam Rishi
- School of Biomedical Sciences, Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.
| | - Gordon D McLaren
- Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, CA, USA; Department of Veterans Affairs Long Beach Healthcare System, Long Beach, CA, USA.
| | | | - Wen-Pin Chen
- Chao Family Comprehensive Cancer Center, University of California, Irvine, CA.
| | - Louise E Ramm
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.
| | - Lawrie W Powell
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.
| | - Grant A Ramm
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.
| | - James C Barton
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA, Southern Iron Disorders Center, Birmingham, AL, USA
| | - V Nathan Subramaniam
- School of Biomedical Sciences, Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), Brisbane, Queensland, Australia; QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.
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27
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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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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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29
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Camaschella C, Nai A, Silvestri L. Iron metabolism and iron disorders revisited in the hepcidin era. Haematologica 2020; 105:260-272. [PMID: 31949017 PMCID: PMC7012465 DOI: 10.3324/haematol.2019.232124] [Citation(s) in RCA: 324] [Impact Index Per Article: 81.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/18/2019] [Indexed: 02/06/2023] Open
Abstract
Iron is biologically essential, but also potentially toxic; as such it is tightly controlled at cell and systemic levels to prevent both deficiency and overload. Iron regulatory proteins post-transcriptionally control genes encoding proteins that modulate iron uptake, recycling and storage and are themselves regulated by iron. The master regulator of systemic iron homeostasis is the liver peptide hepcidin, which controls serum iron through degradation of ferroportin in iron-absorptive enterocytes and iron-recycling macrophages. This review emphasizes the most recent findings in iron biology, deregulation of the hepcidin-ferroportin axis in iron disorders and how research results have an impact on clinical disorders. Insufficient hepcidin production is central to iron overload while hepcidin excess leads to iron restriction. Mutations of hemochro-matosis genes result in iron excess by downregulating the liver BMP-SMAD signaling pathway or by causing hepcidin-resistance. In iron-loading anemias, such as β-thalassemia, enhanced albeit ineffective ery-thropoiesis releases erythroferrone, which sequesters BMP receptor ligands, thereby inhibiting hepcidin. In iron-refractory, iron-deficiency ane-mia mutations of the hepcidin inhibitor TMPRSS6 upregulate the BMP-SMAD pathway. Interleukin-6 in acute and chronic inflammation increases hepcidin levels, causing iron-restricted erythropoiesis and ane-mia of inflammation in the presence of iron-replete macrophages. Our improved understanding of iron homeostasis and its regulation is having an impact on the established schedules of oral iron treatment and the choice of oral versus intravenous iron in the management of iron deficiency. Moreover it is leading to the development of targeted therapies for iron overload and inflammation, mainly centered on the manipulation of the hepcidin-ferroportin axis.
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Affiliation(s)
- Clara Camaschella
- Regulation of Iron Metabolism Unit, Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milan
| | - Antonella Nai
- Regulation of Iron Metabolism Unit, Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milan.,Vita Salute San Raffaele University, Milan, Italy
| | - Laura Silvestri
- Regulation of Iron Metabolism Unit, Division of Genetics and Cell Biology, San Raffaele Scientific Institute, Milan.,Vita Salute San Raffaele University, Milan, Italy
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30
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Abstract
Iron is an essential micronutrient for oxygen transport, cellular energy metabolism, and many enzymatic reactions. Complex physiological processes have evolved for iron acquisition to meet metabolic needs while avoiding toxicity from iron-generated free radicals. Systemic iron homeostasis is centered around the regulation of iron absorption from duodenum and iron release from stores by hepcidin. Intracellular iron is maintained under tight control by iron regulatory proteins acting at post-transcriptional level. Despite these elaborate mechanisms, iron status is frequently altered by environmental or genetic influences. Iron deficiency anemia is the most common nutritional disorder affecting a quarter of the world population. Iron deficiency is associated with impaired cognitive development and reduced capacity for physical work, making it a high priority for public health initiatives. Chronic inflammation from infections or other causes limits iron availability and contributes to anemia of chronic disease. At the opposite end are conditions where iron overload leads to serious complications from organ damage. Mutations in HFE gene are the most frequent cause of hereditary hemochromatosis in European population, but rare elsewhere in the world. Iron overload develops in dyserythropoietic anemias from increased intestinal absorption. Transfusional iron overload, most often observed in thalassemia, is increasing among cancer survivors due to the use of protocols requiring intensive transfusion support. Tissue-specific brain iron overload is observed in some degenerative neurological diseases without an increase in systemic iron. New insights into iron metabolism are guiding the development of novel therapies for iron deficiency and iron overload.
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Affiliation(s)
- Ashutosh Lal
- Hematology/Oncology, Department of Pediatrics, University of California, San Francisco, California, USA.
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31
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Kawaguchi T, Ikuta K, Tatsumi Y, Toki Y, Hayashi H, Tonan T, Ohtake T, Hoshino S, Naito M, Kato K, Okumura T, Torimura T. Identification of heterozygous p.Y150C and p.V274M mutations in the HJV gene in a Japanese patient with a mild phenotype of juvenile hemochromatosis: A case report. Hepatol Res 2020; 50:144-150. [PMID: 31472034 DOI: 10.1111/hepr.13423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 08/07/2019] [Accepted: 08/20/2019] [Indexed: 12/08/2022]
Abstract
Juvenile hemochromatosis (JH) is known as a progressive iron-storage disease, and causes severe organ impairments, including cardiomyopathy and liver cirrhosis. However, JH is a rare genetic disorder, and information for genetic mutations and phenotypes is limited. Here, we report a case of JH with heterozygous p.Y150C and p.V274M mutations in the HJV gene. A 39-year-old Japanese man was referred to Kurume University Hospital, Kurume, Japan, for fatigue and liver injury, which first appeared at the age of 25 years. There was no history of alcohol abuse and medication, and viral hepatitis, autoimmune liver diseases, and Wilson's disease were absent. However, transferrin saturation, serum ferritin, and fasting serum hepcidin levels were 98.4%, 6421 ng/mL, and 7.4 ng/mL, respectively. Furthermore, a marked reduction in signal intensity of the liver in T1/T2-weighted magnetic resonance images was seen and the R2* maps showed hepatic iron overload. Family history of hemochromatosis and severe organ impairment, such as cardiac dysfunction and diabetes mellitus, were negative. In addition, the HFE and HAMP genes did not show any mutation. However, we identified novel heterozygous p.Y150C and p.V274M mutations in the HJV gene in the patient. The p.Y150C and p.V274M mutations were seen in his mother and father, respectively. After phlebotomy, fatigue disappeared and serum transaminase levels were normalized. Furthermore, R2* maps showed a reduction of hepatic iron concentration. We first demonstrated heterozygous p.Y150C and p.V274M mutations in the HJV gene of patients with a mild JH phenotype. Thus, genetic testing should be considered even in patients with a mild phenotype of hemochromatosis.
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Affiliation(s)
- Takumi Kawaguchi
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Katsuya Ikuta
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Yasuaki Tatsumi
- Laboratory of Medicine, Aichi-Gakuin University, School of Pharmacy, Nagoya, Japan
| | - Yasumichi Toki
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Hisao Hayashi
- Laboratory of Medicine, Aichi-Gakuin University, School of Pharmacy, Nagoya, Japan
| | - Tatsuyuki Tonan
- Department of Radiology, Kurume University School of Medicine, Kurume, Japan
| | - Takaaki Ohtake
- Department of Gastroenterology, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | | | | | - Koichi Kato
- Laboratory of Medicine, Aichi-Gakuin University, School of Pharmacy, Nagoya, Japan
| | - Toshikatsu Okumura
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Takuji Torimura
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
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Qian ZM, Ke Y. Hepcidin and its therapeutic potential in neurodegenerative disorders. Med Res Rev 2019; 40:633-653. [PMID: 31471929 DOI: 10.1002/med.21631] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/18/2019] [Accepted: 08/05/2019] [Indexed: 12/12/2022]
Abstract
Abnormally high brain iron, resulting from the disrupted expression or function of proteins involved in iron metabolism in the brain, is an initial cause of neuronal death in neuroferritinopathy and aceruloplasminemia, and also plays a causative role in at least some of the other neurodegenerative diseases including Alzheimer's disease, Parkinson's disease, Huntington's disease, and Friedreich's ataxia. As such, iron is believed to be a novel target for pharmacological intervention in these disorders. Reducing iron toward normal levels or hampering the increases in iron associated with age in the brain is a promising therapeutic strategy for all iron-related neurodegenerative disorders. Hepcidin is a crucial regulator of iron homeostasis in the brain. Recent studies have suggested that upregulating brain hepcidin levels can significantly reduce brain iron content through the regulation of iron transport protein expression in the blood-brain barrier and in neurons and astrocytes. In this review, we focus on the discussion of the therapeutic potential of hepcidin in iron-associated neurodegenerative diseases and also provide a systematic overview of recent research progress on how misregulated brain iron metabolism is involved in the development of multiple neurodegenerative disorders.
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Affiliation(s)
- Zhong-Ming Qian
- Institute of Translational & Precision Medicine, Nantong University, Nantong, Jiangsu, China.,Laboratory of Neuropharmacology, School of Pharmacy & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Ya Ke
- School of Biomedical Sciences and Gerald Choa Neuroscience Centre, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
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Kong X, Xie L, Zhu H, Song L, Xing X, Yang W, Chen X. Genotypic and phenotypic spectra of hemojuvelin mutations in primary hemochromatosis patients: a systematic review. Orphanet J Rare Dis 2019; 14:171. [PMID: 31286966 PMCID: PMC6615163 DOI: 10.1186/s13023-019-1097-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 05/19/2019] [Indexed: 12/12/2022] Open
Abstract
Hereditary hemochromatosis (HH) is a genetic disorder that causes excess absorption of iron and can lead to a variety of complications including liver cirrhosis, arthritis, abnormal skin pigmentation, cardiomyopathy, hypogonadism, and diabetes. Hemojuvelin (HJV) is the causative gene of a rare subtype of HH worldwide. This study aims to systematically review the genotypic and phenotypic spectra of HJV-HH in multiple ethnicities, and to explore the genotype-phenotype correlations. A comprehensive search of PubMed database was conducted. Data were extracted from 57 peer-reviewed original articles including 132 cases with HJV-HH of multiple ethnicities, involving 117 biallelic cases and 15 heterozygotes. Among the biallelic cases, male and female probands of Caucasian ancestry were equally affected, whereas males were more often affected among East Asians (P=1.72×10-2). Hepatic iron deposition and hypogonadism were the most frequently reported complications. Hypogonadism and arthropathy were more prevalent in Caucasians than in East Asians (P=9.30×10-3, 1.69×10-2). Among the recurrent mutations, G320V (45 unrelated cases) and L101P (7 unrelated cases) were detected most frequently and restricted to Caucasians. [Q6H; C321*] was predominant in Chinese patients (6 unrelated cases). I281T (Chinese and Greek), A310G (Brazilian and African American), and R385* (Italian and North African) were reported across different ethnicities. In genotype-phenotype correlation analyses, 91.30% of homozygotes with exon 2-3 mutations developed early-onset HH compared to 66.00% of those with exon 4 mutations (P=2.40×10-2). Hypogonadism occurred more frequently in homozygotes with missense mutations (72.55%) than in those with nonsense mutations (35.71%; P=2.43×10-2). Liver biopsy was accepted by more probands with frame-shift or missense mutations (85.71% and 60.78%, respectively) than by those with nonsense mutations (28.57%; P=2.37×10-2, 3.93×10-2). The present review suggests that patients' ethnicity, geographical region, and genetic predisposition should be considered in the diagnosis, prognosis and management of HJV-HH.
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Affiliation(s)
- Xiaomu Kong
- Department of Endocrinology, China-Japan Friendship Hospital, No. 2 Yinghua East Street, Chaoyang District, Beijing, 100029, China
| | - Lingding Xie
- Department of Endocrinology, China-Japan Friendship Hospital, No. 2 Yinghua East Street, Chaoyang District, Beijing, 100029, China
| | - Haiqing Zhu
- Department of Endocrinology and Metabolism, China Meitan General Hospital, No. 29 Xibahe Nanli, Chaoyang District, Beijing, 100029, China
| | - Lulu Song
- Department of Endocrinology, China-Japan Friendship Hospital, No. 2 Yinghua East Street, Chaoyang District, Beijing, 100029, China
| | - Xiaoyan Xing
- Department of Endocrinology, China-Japan Friendship Hospital, No. 2 Yinghua East Street, Chaoyang District, Beijing, 100029, China
| | - Wenying Yang
- Department of Endocrinology, China-Japan Friendship Hospital, No. 2 Yinghua East Street, Chaoyang District, Beijing, 100029, China
| | - Xiaoping Chen
- Department of Endocrinology, China-Japan Friendship Hospital, No. 2 Yinghua East Street, Chaoyang District, Beijing, 100029, China.
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Simão M, Gavaia PJ, Camacho A, Porto G, Pinto IJ, Ea HK, Cancela ML. Intracellular iron uptake is favored in Hfe-KO mouse primary chondrocytes mimicking an osteoarthritis-related phenotype. Biofactors 2019; 45:583-597. [PMID: 31132316 DOI: 10.1002/biof.1520] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/06/2019] [Indexed: 12/20/2022]
Abstract
HFE-hemochromatosis is a disease characterized by a systemic iron overload phenotype mainly associated with mutations in the HFE protein (HFE) gene. Osteoarthritis (OA) has been reported as one of the most prevalent complications in HFE-hemochromatosis patients, but the mechanisms associated with its onset and progression remain incompletely understood. In this study, we have characterized the response to high iron concentrations of a primary culture of articular chondrocytes isolated from newborn Hfe-KO mice and compared the results with that of a similar experiment developed in cells from C57BL/6 wild-type (wt) mice. Our data provide evidence that both wt- and Hfe-KO-derived chondrocytes, when exposed to 50 μM iron, develop characteristics of an OA-related phenotype, such as an increased expression of metalloproteases, a decreased extracellular matrix production, and a lower expression level of aggrecan. In addition, Hfe-KO cells also showed an increased expression of iron metabolism markers and MMP3, indicating an increased susceptibility to intracellular iron accumulation and higher levels of chondrocyte catabolism. Accordingly, upon treatment with 50 μM iron, these chondrocytes were found to preferentially differentiate toward hypertrophy with increased expression of collagen I and transferrin and downregulation of SRY (sex-determining region Y)-box containing gene 9 (Sox9). In conclusion, high iron exposure can compromise chondrocyte metabolism, which, when simultaneously affected by an Hfe loss of function, appears to be more susceptible to the establishment of an OA-related phenotype.
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Affiliation(s)
- Márcio Simão
- PhD Program Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
- Centre of Marine Sciences (CCMAR), University of Algarve, Faro, Portugal
- Department of Biomedical Sciences and Medicine (DCBM), University of Algarve, Faro, Portugal
| | - Paulo J Gavaia
- Centre of Marine Sciences (CCMAR), University of Algarve, Faro, Portugal
- Department of Biomedical Sciences and Medicine (DCBM), University of Algarve, Faro, Portugal
| | - António Camacho
- Department of Orthopedics, Hospital de Cascais, Alcabideche, Portugal
| | - Graça Porto
- Department of Pathology and Molecular Immunology, Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
- Hematology Service, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
- Instituto de Biologia Molecular e Celular (IBMC) and Instituto de Investigação e Inovação em Saúde (I3S), University of Porto, Porto, Portugal
| | - I Jorge Pinto
- Instituto de Biologia Molecular e Celular (IBMC) and Instituto de Investigação e Inovação em Saúde (I3S), University of Porto, Porto, Portugal
| | - Hang-Korng Ea
- Inserm U1132/BIOSCAR, Université Paris 7 Denis Diderot, Paris, France
| | - M Leonor Cancela
- Centre of Marine Sciences (CCMAR), University of Algarve, Faro, Portugal
- Department of Biomedical Sciences and Medicine (DCBM), University of Algarve, Faro, Portugal
- Algarve Biomedical Centre (ABC) and Centre for Biomedical Research (CBMR), University of Algarve, Faro, Portugal
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Wang X, Zhang M, Flores SRL, Woloshun RR, Yang C, Yin L, Xiang P, Xu X, Garrick MD, Vidyasagar S, Merlin D, Collins JF. Oral Gavage of Ginger Nanoparticle-Derived Lipid Vectors Carrying Dmt1 siRNA Blunts Iron Loading in Murine Hereditary Hemochromatosis. Mol Ther 2019; 27:493-506. [PMID: 30713087 PMCID: PMC6401192 DOI: 10.1016/j.ymthe.2019.01.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 12/21/2018] [Accepted: 01/08/2019] [Indexed: 12/19/2022] Open
Abstract
Nanoparticles (NPs) have been utilized to deliver drugs to the intestinal epithelium in vivo. Moreover, NPs derived from edible plants are less toxic than synthetic NPs. Here, we utilized ginger NP-derived lipid vectors (GDLVs) in a proof-of-concept investigation to test the hypothesis that inhibiting expression of divalent metal-ion transporter 1 (Dmt1) would attenuate iron loading in a mouse model of hereditary hemochromatosis (HH). Initial experiments using duodenal epithelial organ cultures from intestine-specific Dmt1 knockout (KO) (Dmt1int/int) mice in the Ussing chamber established that Dmt1 is the only active iron importer during iron-deficiency anemia. Further, when Dmt1int/int mice were crossed with mice lacking the iron-regulatory hormone, hepcidin (Hepc-/-), iron loading was abolished. Hence, intestinal Dmt1 is required for the excessive iron absorption that typifies HH. Additional experiments established a protocol to produce GDLVs carrying functional Dmt1 small interfering RNAs (siRNAs) and to target these gene delivery vehicles to the duodenal epithelium in vivo (by incorporating folic acid [FA]). When FA-GDLVs carrying Dmt1 siRNA were administered to weanling Hepc-/- mice for 16 days, intestinal Dmt1 mRNA expression was attenuated and tissue iron accumulation was blunted. Oral delivery of functional siRNAs by FA-GDLVs is a suitable therapeutic approach to mitigate iron loading in murine HH.
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Affiliation(s)
- Xiaoyu Wang
- Food Science & Human Nutrition Department, University of Florida, Gainesville, FL, USA
| | - Mingzhen Zhang
- Institute of Medical Engineering, School of Basic Medical Science, Health Science Center, Xi'an Jiaotong University, Xi'an, China; Center for Diagnostics and Therapeutics, Institute for Biomedical Science, Georgia State University, Atlanta, GA, USA
| | - Shireen R L Flores
- Food Science & Human Nutrition Department, University of Florida, Gainesville, FL, USA
| | - Regina R Woloshun
- Food Science & Human Nutrition Department, University of Florida, Gainesville, FL, USA
| | - Chunhua Yang
- Center for Diagnostics and Therapeutics, Institute for Biomedical Science, Georgia State University, Atlanta, GA, USA
| | - Liangjie Yin
- Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
| | - Ping Xiang
- Food Science & Human Nutrition Department, University of Florida, Gainesville, FL, USA; State Key Lab of Pollution Control and Resource Reuse, School of the Environment, Nanjing University, Nanjing, China
| | - Xiaodong Xu
- Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
| | - Michael D Garrick
- Department of Biochemistry, State University of New York (SUNY), Buffalo, NY, USA
| | | | - Didier Merlin
- Center for Diagnostics and Therapeutics, Institute for Biomedical Science, Georgia State University, Atlanta, GA, USA; Atlanta Veterans Affairs Medical Center, Decatur, GA, USA
| | - James F Collins
- Food Science & Human Nutrition Department, University of Florida, Gainesville, FL, USA.
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