Serum ferritin, an early marker of cardiovascular risk: a study in Chinese men of first-degree relatives with family history of type 2 diabetes

The pan-PPAR agonist lanifibranor improves cardiometabolic health in patients with metabolic dysfunction-associated steatohepatitis

Lanifibranor, a pan-PPAR agonist, improves liver histology in patients with metabolic dysfunction-associated steatohepatitis (MASH), who have poor cardiometabolic health (CMH) and cardiovascular events as major mortality cause. NATIVE trial secondary and exploratory outcomes (ClinicalTrials.gov NCT03008070) were analyzed for the effect of lanifibranor on IR, lipid and glucose metabolism, systemic inflammation, blood pressure (BP), hepatic steatosis (imaging and histological grading) for all patients of the original analysis. With lanifibranor, triglycerides, HDL-C, apolipoproteins, insulin, HOMA-IR, HbA1c, fasting glucose (FG), hs-CRP, ferritin, diastolic BP and steatosis improved significantly, independent of diabetes status: most patients with prediabetes returned to normal FG levels. Significant adiponectin increases correlated with hepatic and CMH marker improvement; patients had an average weight gain of 2.5 kg, with 49% gaining ≥2.5% weight. Therapeutic benefits were similar regardless of weight change. Here, we show that effects of lanifibranor on liver histology in MASH are accompanied with CMH improvement, indicative of potential cardiovascular clinical benefits.

Associations between metabolic hyperferritinaemia, fibrosis-promoting alleles and clinical outcomes in steatotic liver disease

BACKGROUND & AIMS

Ferritin has been investigated as a biomarker for liver fibrosis and iron in patients with metabolic dysfunction-associated steatotic liver disease (MASLD). However, whether metabolic hyperferritinaemia predicts progression of liver disease remains unknown. In this study, we sought to understand associations between hyperferritinaemia and (1) adverse clinical outcomes and (2) common genetic variants related to iron metabolism and liver fibrosis.

METHODS

This was a retrospective analysis of adults with MASLD seen at the University of Michigan Health System, where MASLD was defined by hepatic steatosis on imaging, biopsy or vibration-controlled transient elastography, plus metabolic risk factors in the absence of chronic liver diseases other than hemochromatosis. The primary predictor was serum ferritin level, which was dichotomized based on a cut-off of 300 or 450 mcg/L for women or men. Primary outcomes included (1) incident cirrhosis, liver-related events, congestive heart failure (CHF), and mortality and (2) distribution of common genetic variants associated with hepatic fibrosis and hereditary hemochromatosis.

RESULTS

Of 7333 patients with MASLD, 1468 (20%) had elevated ferritin. In multivariate analysis, ferritinaemia was associated with increased mortality (HR 1.68 [1.35-2.09], p < .001) and incident liver-related events (HR 1.92 [1.11-3.32], p = .019). Furthermore, elevated ferritin was associated with carriage of cirrhosis-promoting alleles including PNPLA3-rs738409-G allele (p = .0068) and TM6SF2-rs58542926-T allele (p = 0.0083) but not with common HFE mutations.

CONCLUSIONS

In MASLD patients, metabolic hyperferritinaemia was associated with increased mortality and higher incidence of liver-related events, and cirrhosis-promoting alleles but not with iron overload-promoting HFE mutations.

New Perspectives on Circulating Ferritin: Its Role in Health and Disease

The diagnosis of iron disturbances usually includes the evaluation of serum parameters. Serum iron is assumed to be entirely bound to transferrin, and transferrin saturation-the ratio between the serum iron concentration and serum transferrin-usually reflects iron availability. Additionally, serum ferritin is commonly used as a surrogate of tissue iron levels. Low serum ferritin values are interpreted as a sign of iron deficiency, and high values are the main indicator of pathological iron overload. However, in situations of inflammation, serum ferritin levels may be very high, independently of tissue iron levels. This presents a particularly puzzling challenge for the clinician evaluating the overall iron status of the patient in the presence of an inflammatory condition. The increase in serum ferritin during inflammation is one of the enigmas regarding iron metabolism. Neither the origin, the mechanism of release, nor the effects of serum ferritin are known. The use of serum ferritin as a biomarker of disease has been rising, and it has become increasingly diverse, but whether or not it contributes to controlling the disease or host pathology, and how it would do it, are important, open questions. These will be discussed here, where we spotlight circulating ferritin and revise the recent clinical and preclinical data regarding its role in health and disease.

Association Between Ferritin Levels and Altitude-Dependent Cardiorespiratory Fitness in Mountain Guides

Pühringer, Reinhard, Martina Muckenthaler, and Martin Burtscher. Association between ferritin levels and altitude-dependent cardiorespiratory fitness in mountain guides. High Alt Med Biol. 24:139-143, 2023. Background: Higher ferritin levels may be associated with lower cardiorespiratory fitness (CRF; i.e., maximal oxygen uptake, VO2max) and may represent early markers of cardiovascular risk but may also support high-altitude acclimatization. To evaluate these potential associations, data recordings from a large sample of male mountain guides have been analyzed. Methods: A total of 154 data sets (including anthropometric data, VO2max, blood lipids, hemoglobin, ferritin, and transferrin levels) of regularly physically active and well-acclimatized mountain guides were available for analyses. Participants performed equal incremental cycle ergometer tests to exhaustion at low (600 m) and (∼1 week later) at moderate altitude (2,000 m). Results: Ferritin levels were positively correlated with levels of hemoglobin (r = 0.29, p < 0.01), total cholesterol (r = 0.18, p < 0.05), triglycerides (r = 0.23, p < 0.01), and low-density lipoprotein (r = 0.22, p < 0.01), and negatively with high-density lipoprotein levels (r = -0.16, p < 0.05) and also with baseline (taken at low altitude) VO2max values (r = -0.19, p < 0.05). In contrast, higher ferritin levels were associated with less VO2max decline from low-to-moderate altitude (r = 0.26, p < 0.01). Conclusion: Higher ferritin levels in male mountain guides are weakly associated with lower CRF and higher prevalence of cardiovascular risk factors but with slightly less reduction in VO2max when acutely exposed to moderate altitude. The clinical relevance of these observations needs further investigation.

Serum Ferritin in Metabolic Syndrome-Mechanisms and Clinical Applications

Metabolic syndrome (MS) is a cluster of conditions including central obesity, hypertriglyceridemia, low HDL cholesterol, hyperglycaemia, and hypertension with a prevalence rate of 20−25% of the world’s adult population. Metabolic syndrome is often characterized by insulin resistance, which some have suggested is a major supportive connection between physical inactivity and MS. Various studies suggest that moderately elevated iron and ferritin levels are associated with an increased prevalence of metabolic syndrome and are markers of insulin resistance. Increased body iron stores are associated with the development of glucose intolerance, type 2 diabetes mellitus, and insulin resistance syndrome (IRS). This is a hospital-based cross-sectional observational study, which was conducted in the department of internal medicine of a tertiary care hospital in northern India. The study was conducted from 1 January 2019 to 30 June 2020 and included 100 patients and 100 controls. All subjects in the age group of 35−65 years were enrolled and investigated as per the study design. Metabolic syndrome patients were diagnosed according to the modified National Cholesterol Education Program Adult Treatment Panel-III (NCEP ATP-III) with BMI > 23 kg/m2. All baseline investigations were undertaken, including serum ferritin levels. Insulin resistance (IR) was calculated using the homeostasis model assessment IR (HOMA-IR) formula. We found a positive association between an increase in serum ferritin with the prevalence of metabolic syndrome and its clinical parameter. The serum ferritin level was positively correlated with the level of insulin resistance and inversely correlated with the insulin level of the patients.

Body iron stores had no impact on coronary heart disease outcomes: a middle-aged male cohort from the general population with 21-year follow-up

Background

Body iron stores (BISs) have been proposed to be related to the development of cardiovascular diseases. However, results from epidemiological studies are conflicting. Knowledge on the long-term impact of BIS on cardiovascular outcomes in the general population is lacking.

Purpose

The aim of this study was to explore the relationship between BIS and coronary heart disease (CHD) including death due to CHD.

Methods

This investigation is part of ‘The Study of Men Born in 1943’, a longitudinal prospective study of men living in the city of Gothenburg, Sweden. This random population sample was examined in 1993 (all at 50 years of age at baseline). A medical examination was performed, and questionnaires were used to evaluate lifestyle factors. Biomarkers for iron stores (serum ferritin and serum transferrin receptor) was analysed from frozen blood samples in 2014. All hospital admissions were registered through national registers during the entire follow-up from 1993 to 2014. HRs were estimated by Cox proportional-hazard regression analyses.

Results

During the 21 years follow-up period, 120 participants (15.2%) developed CHD and 16 patients (2%) died due to CHD. The all-cause mortality was 15.2% (n=120) including 40 cardiovascular deaths (5.1%). In a multivariable Cox regression analysis, the daily smoking, hypertension and the increased resting heart rate was independent predictors of CHD, while no significant association was found between BIS and risk of CHD.

Conclusions

In a cohort of middle-aged men from the general population with well validated and prospectively collected data, we did not find any association between serum ferritin or serum transferrin receptor as markers of BIS and CHD events after 21 years of follow-up.

Trail registration number

NCT03138122.

Psoriasis and Cardiometabolic Comorbidities: An Evaluation of the Impact of Systemic Treatments in Randomized Clinical Trials

The association between psoriasis, metabolic syndrome, and cardiovascular disease is well established. The shared pathways between psoriasis, metabolic syndrome, and atherosclerosis suggest that treatments targeting the inflammatory pathways of psoriasis may also be beneficial in the treatment of associated cardiometabolic comorbidities. This paper reviews the most recent data regarding the impact of systemic psoriasis treatments on comorbid cardiovascular and metabolic disease. Data from randomized clinical trials with systemic and biologic agents are presented. Overall, studies demonstrate beneficial effects on several cardiometabolic markers and risk factors in psoriasis patients; however, longer randomized controlled trials to characterize the direct benefit for cardiovascular outcomes are needed.

Longitudinal Effect of Hemoglobin Concentration With Incident Ischemic Heart Disease According to Hepatic Steatosis Status Among Koreans

Background: An increased hemoglobin (Hb) level may have detrimental effects on hepatic steatosis (HS) as well as cardiovascular disease (CVD). We investigated Hb's effect on incident ischemic heart disease (IHD) risk in the context of hepatic steatosis (HS).

Methods: We assessed 17,521 non-diabetic participants and retrospectively screened for IHD using the Korea National Health Insurance data. High Hb was defined as Hb levels ≥16.3 g/dL in men and 13.9 g/dL in women (>75th percentile). The participants were divided into five groups: reference (group 1), mild HS only (group 2), mild HS and high Hb (group 3), severe HS only (group 4), and severe HS and high Hb (group 5). We assessed hazard ratios (HRs) with 95% confidence intervals (CIs) for IHD using multivariate Cox proportional hazards regression models over 50 months from the baseline survey.

Results: During the follow-up period, 330 (1.9%) participants developed IHD (310 angina pectoris and 20 myocardial infarction). Compared with the reference group (group 1), the HRs for IHD were 1.04 (95% CI, 0.75–1.46) in group 2, 1.14 (95% CI, 0.70–1.85) in group 3, 1.58 (95% CI, 1.08–2.32) in group 4, and 1.79 (95% CI, 1.15–2.80) in group 5, after adjusting for IHD risk factors.

Conclusions: We found the combined effect of HS and Hb levels on the incidence of IHD.

Ferroptosis and cardiovascular disease: role of free radical-induced lipid peroxidation

Cardiovascular disease (CVD), including heart attack, stroke, heart failure, arrhythmia, and other congenital heart diseases remain the leading cause of morbidity and mortality worldwide. The leading cause of deaths in CVD is attributed to myocardial infarction due to the rupture of atherosclerotic plaque. Atherosclerosis refers a condition when restricted or even blockage of blood flow occurs due to the narrowing of blood vessels as a result of the buildup of plaques composed of oxidized lipids. It is well-established that free radical oxidation of polyunsaturated fatty acids (PUFAs) in lipoproteins or cell membranes, termed lipid peroxidation (LPO), plays a significant role in atherosclerosis. LPO products are involved in immune responses and cell deaths in this process, in which previous evidence supports the role of programmed cell death (apoptosis) and necrosis. Ferroptosis is a newly identified form of regulated cell death characterized by the iron-dependent accumulation of lipid hydroperoxides to lethal levels, which exhibits distinct features from apoptosis, necrosis and autophagy in morphology, biochemistry and genetics. Emerging evidence appears to demonstrate that ferroptosis is also involved in CVD. In this review, we summarize the recent progress on ferroptosis in CVD and atherosclerosis, highlighting the role of free radical LPO. The evidence underlying the ferroptosis and challenges in the field will also be critically discussed.