Hereditary Hemochromatosis Patients Research Articles

Invariant Natural Killer T Cells are Reduced in Hereditary Hemochromatosis Patients.

Invariant natural killer T (iNKT) cells are CD1d restricted-T cells that react to lipid antigens. iNKT cells were shown to be important in infection, autoimmunity and tumor surveillance. Alterations in the number and function of these cells were described in several pathological conditions including autoimmune and/or liver diseases. CD1d is critical for antigen presentation to iNKT cells, and its expression is increased in liver diseases. The liver is the major organ affected in Hereditary Hemochromatosis (HH), an autosomal recessive disorder caused by excessive iron absorption. Herein, we describe the study of iNKT cells of HH patients. Twenty-eight HH patients and 24 control subjects from Santo António Hospital, Porto, were included in this study. Patient's iron biochemical parameters (serum transferrin saturation and ferritin levels) and the liver function marker alanine transaminase (ALT) were determined at the time of study. Peripheral blood iNKT cells were analyzed by flow cytometry using an anti-CD3 antibody and the CD1d tetramer loaded with PBS57. We found a decrease in the percentage and number of circulating iNKT cells from HH patients when compared with control population independently of age. iNKT cell defects were more pronounced in untreated patients, relating with serum ferritin and transferrin saturation levels. No correlation was found with ALT, a marker of active liver dysfunction. Altogether, our results demonstrate that HH patients have reduced numbers of iNKT cells and that these are influenced by iron overload.

The quality of hereditary haemochromatosis guidelines: A comparative analysis

Hereditary haemochromatosis (HH) is the most prevalent genetic liver disease, with an incidence of 1/200 to 1/400 in the Caucasian population. HH patients are treated by family physicians as well as different specialists. When left untreated or insufficiently treated, the complications can become life threatening. To support and evaluate qualitative care for HH, we evaluated and compared the available structured guidelines on screening, diagnosis and management of HH patients. Seven appraisers systematically reviewed the retrieved guidelines. The Appraisal of Guidelines Research and EvaluationII (AGREEII) was used to score and discuss the quality and reach consensus. The content of recommendations and the evidence behind them, were evaluated. Three guidelines, developed by the American Association for the Study of Liver Diseases (AASLD), the European Association for the Study of the Liver (EASL) and a DUTCH guideline were found. Fifty-seven percent of the recommendations were not shared between the guidelines, pointing to inconsistency of their content. Only two references supporting the recommendations were shared between all three guidelines. The AASLD guideline contains no information about management and follow-up. Moreover, the methodological quality of the AASLD guideline was rated insufficient, except for 'clarity and presentation' (77%). Applicability of the guidelines was scored very low in all three (AASLD: 31%, EASL: 23%, DUTCH: 35%). The DUTCH guideline was judged best. Very poor consistency between available guidelines for HH hampers qualitative care and its evaluation. An updated high-quality and evidence-based guideline that covers follow-up and management of patients with HH is needed.

Genome-wide association study identifies TF as a significant modifier gene of iron metabolism in HFE hemochromatosis

Hereditary hemochromatosis (HH) is the most common form of genetic iron loading disease. It is mainly related to the homozygous C282Y/C282Y mutation in the HFE gene that is, however, a necessary but not a sufficient condition to develop clinical and even biochemical HH. This suggests that modifier genes are likely involved in the expressivity of the disease. Our aim was to identify such modifier genes. We performed a genome-wide association study (GWAS) using DNA collected from 474 unrelated C282Y homozygotes. Associations were examined for both quantitative iron burden indices and clinical outcomes with 534,213 single nucleotide polymorphisms (SNP) genotypes, with replication analyses in an independent sample of 748 C282Y homozygotes from four different European centres. One SNP met genome-wide statistical significance for association with transferrin concentration (rs3811647, GWAS p value of 7×10(-9) and replication p value of 5×10(-13)). This SNP, located within intron 11 of the TF gene, had a pleiotropic effect on serum iron (GWAS p value of 4.9×10(-6) and replication p value of 3.2×10(-6)). Both serum transferrin and iron levels were associated with serum ferritin levels, amount of iron removed and global clinical stage (p<0.01). Serum iron levels were also associated with fibrosis stage (p<0.0001). This GWAS, the largest one performed so far in unselected HFE-associated HH (HFE-HH) patients, identified the rs3811647 polymorphism in the TF gene as the only SNP significantly associated with iron metabolism through serum transferrin and iron levels. Because these two outcomes were clearly associated with the biochemical and clinical expression of the disease, an indirect link between the rs3811647 polymorphism and the phenotypic presentation of HFE-HH is likely.

The importance of the general practitioner as an information source for patients with hereditary haemochromatosis

ObjectiveTo explore hereditary haemochromatosis (HH) patients’ perspectives on genetic information, namely the types of sources used, preferred or trusted. MethodsA survey online was conducted by the European Federation of Associations of Patients with Haemochromatosis (EFAPH) and applied to members of nine National Associations. ResultsFrom a total of 1019 validated questionnaires, 895 respondents had performed a genetic testing for HH. From these, 627 self-declared that they were sufficiently informed about the implications of the genetic test to their health. The majority (66%) obtained the information from a specialist doctor, but would like to obtain it from the family doctor. However, the specialist was still the one they trusted more (69%). Regarding the 298 respondents who did not feel sufficiently informed, the majority (78%) also would like to have information from the family doctor although they also trusted the specialist more (75%). A different perspective was reported when patients were asked about the implications of the genetic testing to their family members, where the majority of respondents preferred obtaining information from a specialist (69%). ConclusionThis study elucidates the patients’ needs for information and identifies the general practitioner (GP) as the preferred source to obtain information about HH. Practice implicationsThese results may have important implications in future strategies for HH awareness, giving a special emphasis on GPs as the main players.

Endoscopic and Histologic Abnormalities of Gastrointestinal Tract in Patients With Hereditary Hemochromatosis

Patients with iron overload frequently complained of upper gastrointestinal (GI) symptoms. This study aimed to systemically evaluate the association between hereditary hemochromatosis (HH) and gut inflammation. HH patients were identified using the ICD-9 codes. Inclusion criteria were patients with primary HH who had esophagogastroduodenoscopy (EGD) and/or colonoscopy with GI biopsies (N=39). Patients undergoing EGD with duodenal biopsy for the indication of "rule out celiac disease" were included in the control group (N=40). GI biopsy specimens were rereviewed and scored. Of the 39 patients with genetically confirmed primary HH in the study group, 28 (71.8%) had liver biopsy and 25 (89.3%) of them showed iron deposition. Twenty-five patients (64.1%) had EGD and 23 (59.0%) had colonoscopy. Histologic inflammation was identified in the esophagus in 2 patients (8.0%), stomach in 11 (44.0%), duodenum in 2 (8.7%), and colon in 3 (13.0%). Duodenal biopsy specimen was available for rereview in 16 patients (41.0%). Patient demographics were comparable between the 16 cases in the study group and the 40 cases in the control group. On histology, the frequency of intraepithelial lymphocytosis of small intestine was 25.5% in the HH cases versus 2.5% in controls (P=0.020). HH patients also had a greater proportion of intraepithelial neutrophil infiltration (31.2% vs. 2.5%, P=0.006) and lamina propria lymphocyte infiltration (31.2% vs. 0%, P=0.001) than controls. GI inflammation was common in HH patients, which from the different perspective, supports the notion that iron overload may lead to GI inflammation.

Evaluation of genome-wide loci of iron metabolism in hereditary hemochromatosis identifies PCSK7 as a host risk factor of liver cirrhosis

Genome-wide association studies (GWAS) have revealed genetic determinants of iron metabolism, but correlation of these with clinical phenotypes is pending. Homozygosity for HFE C282Y is the predominant genetic risk factor for hereditary hemochromatosis (HH) and may cause liver cirrhosis. However, this genotype has a low penetrance. Thus, detection of yet unknown genetic markers that identify patients at risk of developing severe liver disease is necessary for better prevention. Genetic loci associated with iron metabolism (TF, TMPRSS6, PCSK7, TFR2 and Chr2p14) in recent GWAS and liver fibrosis (PNPLA3) in recent meta-analysis were analyzed for association with either liver cirrhosis or advanced fibrosis in 148 German HFE C282Y homozygotes. Replication of associations was sought in additional 499 Austrian/Swiss and 112 HFE C282Y homozygotes from Sweden. Only variant rs236918 in the PCSK7 gene (proprotein convertase subtilisin/kexin type 7) was associated with cirrhosis or advanced fibrosis (P = 1.02 × 10(-5)) in the German cohort with genotypic odds ratios of 3.56 (95% CI 1.29-9.77) for CG heterozygotes and 5.38 (95% CI 2.39-12.10) for C allele carriers. Association between rs236918 and cirrhosis was confirmed in Austrian/Swiss HFE C282Y homozygotes (P = 0.014; ORallelic = 1.82 (95% CI 1.12-2.95) but not in Swedish patients. Post hoc combined analyses of German/Swiss/Austrian patients with available liver histology (N = 244, P = 0.00014, ORallelic = 2.84) and of males only (N = 431, P = 2.17 × 10(-5), ORallelic = 2.54) were consistent with the premier finding. Association between rs236918 and cirrhosis was not confirmed in alcoholic cirrhotics, suggesting specificity of this genetic risk factor for HH. PCSK7 variant rs236918 is a risk factor for cirrhosis in HH patients homozygous for the HFE C282Y mutation.

Effects of Highly Conserved Major Histocompatibility Complex (MHC) Extended Haplotypes on Iron and Low CD8+ T Lymphocyte Phenotypes in HFE C282Y Homozygous Hemochromatosis Patients from Three Geographically Distant Areas

Hereditary Hemochromatosis (HH) is a recessively inherited disorder of iron overload occurring commonly in subjects homozygous for the C282Y mutation in HFE gene localized on chromosome 6p21.3 in linkage disequilibrium with the human leukocyte antigen (HLA)-A locus. Although its genetic homogeneity, the phenotypic expression is variable suggesting the presence of modifying factors. One such genetic factor, a SNP microhaplotype named A-A-T, was recently found to be associated with a more severe phenotype and also with low CD8+T-lymphocyte numbers. The present study aimed to test whether the predictive value of the A-A-T microhaplotype remained in other population settings. In this study of 304 HH patients from 3 geographically distant populations (Porto, Portugal 65; Alabama, USA 57; Nord-Trøndelag, Norway 182), the extended haplotypes involving A-A-T were studied in 608 chromosomes and the CD8+ T-lymphocyte numbers were determined in all subjects. Patients from Porto had a more severe phenotype than those from other settings. Patients with A-A-T seemed on average to have greater iron stores (p = 0.021), but significant differences were not confirmed in the 3 separate populations. Low CD8+ T-lymphocytes were associated with HLA-A*03-A-A-T in Porto and Alabama patients but not in the greater series from Nord-Trøndelag. Although A-A-T may signal a more severe iron phenotype, this study was unable to prove such an association in all population settings, precluding its use as a universal predictive marker of iron overload in HH. Interestingly, the association between A-A-T and CD8+ T-lymphocytes, which was confirmed in Porto and Alabama patients, was not observed in Nord-Trøndelag patients, showing that common HLA haplotypes like A*01–B*08 or A*03–B*07 segregating with HFE/C282Y in the three populations may carry different messages. These findings further strengthen the relevance of HH as a good disease model to search for novel candidate loci associated with the genetic transmission of CD8+ T-lymphocyte numbers.

Hepcidin-Induced Hypoferremia Is a Host-Defense Mechanism Against Siderophilic Bacteria

IntroductionThe iron-regulatory hormone hepcidin, a 25 amino acid peptide secreted by hepatocytes, is greatly increased during infection or inflammation, causing hypoferremia. Hypoferremia during infections has been proposed as a host defense mechanism that evolved to restrict iron availability for pathogen growth but specific support for this hypothesis has been lacking. Hereditary hemochromatosis, an iron overload disease caused by hepcidin deficiency, is associated with greatly increased risk of infections with siderophilic pathogens such as Vibrio vulnificus and Yersinia enterocolitica. Hepatic iron overload, high plasma iron concentrations and impaired hypoferremic response to infection could contribute to the susceptibility of hereditary hemochromatosis patients to infections with siderophilic bacteria. In this study we investigated the role of hepcidin-induced hypoferremia in murine resistance to Vibrio vulnificus infection. MethodsIn order to examine the effect of iron stores, plasma iron concentrations and inflammatory hypoferremia on susceptibility to infection, we iron-depleted or iron-loaded wild type (WT) and hepcidin KO (Hamp1-/-) mice by dietary manipulations: WT mice were fed low (4 ppm) or high (10,000 ppm) iron diets, and hepcidin KO mice were fed low (4 ppm) or standard (270 ppm) iron diets. The mice were infected with V. vulnificus(CMCP6 strain) by subcutaneous administration. We analyzed survival, CFU counts in blood and tissues, as well as iron and inflammatory parameters. In addition, we tested the host-protective effect of acute hypoferremia induced by the minihepcidin PR73, a hepcidin agonist developed in our laboratory. ResultsAs expected, V. vulnificus growth and resulting host mortality was greatly enhanced in iron-loaded as compared to iron-depleted mice, in both WT and Hamp1-/- groups. Comparing WT to Hamp1-/- mice, both iron-loaded and iron-depleted Hamp1-/- mice had much higher mortality than either iron-loaded or iron-depleted WT when given the same number of bacteria. Relative to the number of injected bacterial CFU, Hamp1-/- mice had much higher post-infection bacterial counts in blood, liver and spleen. Furthermore, Hamp1-/- mice did not develop hypoferremia during infection whereas WT mice responded to the infection by acutely increasing plasma hepcidin concentration (within 6 h) and lowering serum iron (Table 1). To isolate the role of hypoferremia, we next compared iron-loaded WT mice to iron-depleted Hamp1-/- mice. Despite identical baseline serum iron concentrations (WT 65±4 vs Hamp1-/- 69±7 μM) and lower hepatic iron stores of Hamp1-/- (WT 425±109 vs Hamp1-/- 112±81 μg/g, p<0.001), iron-depleted Hamp1-/- mice were still much more susceptible to V. vulnificus infection than iron-loaded WT mice, with 1000-fold lower number of bacteria needed for lethal infection (1x103 CFU for Hamp1-/- vs 1x106 CFU for WT), suggesting that hepcidin-dependent hypoferremia is critical for the control of V. vulnificus infection. Experimental induction of hypoferremia in Hamp1-/- mice by the administration of the minihepcidin PR73 prior to infection abated mortality from a lethal dose of V. vulnificus (Table 2) and dramatically reduced bacterial burden in blood and tissues. Minihepcidin treatment was life-saving even when administered 3 h after infection to iron-overloaded Hamp1-/- mice (Figure 1). [Display omitted] [Display omitted] [Display omitted] ConclusionReactive hepcidin-induced hypoferremia after V. vulnificus infection restricts bacterial growth and helps protect the host from acute mortality. Timely administration of hepcidin agonists to hepcidin-deficient subjects may protect against morbidity and mortality from infections with siderophilic microorganisms. Disclosures:Ganz:Intrinsic LifeSciences: Equity Ownership, Membership on an entity's Board of Directors or advisory committees. Nemeth:Intrinsic LifeSciences: Equity Ownership, Membership on an entity's Board of Directors or advisory committees.

The efficiency of therapeutic erythrocytapheresis compared to phlebotomy: A mathematical tool for predicting response in hereditary hemochromatosis, polycythemia vera, and secondary erythrocytosis

Recently, therapeutic erythrocytapheresis (TE) was suggested to be more efficient in depletion of red blood cells (RBC) compared to manual phlebotomy in the treatment of hereditary hemochromatosis (HH), polycythemia vera (PV), and secondary erythrocytosis (SE). The efficiency rate (ER) of TE, that is, the increase in RBC depletion achieved with one TE cycle compared to one phlebotomy procedure, can be calculated based on estimated blood volume (BV), preprocedural hematocrit (Hct(B)), and delta-hematocrit (ΔHct). In a retrospective evaluation of 843 TE procedures (in 45 HH, 33 PV, and 40 SE patients) the mean ER was 1.86 ± 0.62 with the highest rates achieved in HH patients. An ER of 1.5 was not reached in 37.9% of all procedures mainly concerning patients with a BV below 4,500 ml. In 12 newly diagnosed homozygous HH patients, the induction phase duration was medially 38.4 weeks (medially 10.5 procedures). During the maintenance treatment of HH, PV, and SE, the interval between TE procedures was medially 13.4 weeks. This mathematical model can help select the proper treatment modality for the individual patient. Especially for patients with a large BV and high achievable ΔHct, TE appears to be more efficient than manual phlebotomy in RBC depletion thereby potentially reducing the numbers of procedures and expanding the interprocedural time period for HH, PV, and SE.

HFE Hemochromatosis: Is there Room to Improve our Diagnosis and Treatment?

Purpose: Hereditary hemochromatosis (HH) is the most common and easily treatable genetic condition amongst Caucasians. Failure to identify and treat HH is associated with significant morbidity and mortality. Herein, we assessed if HH was being diagnosed in a timely manner, and the providers most commonly associated with diagnostic delays. We then evaluated if HH patients were treated to goal ferritin levels of less than 100 ng/ml, as recommended by AASLD. Lastly, we assessed if patients were aware of the need for their offspring to be screened. Methods: This was a retrospective chart review of 23 patients diagnosed with HH at an academic institution between 2000 and 2012. A clinical clue which should lead the astute clinician to consider HH as a diagnosis was defined as abnormal liver function tests or iron studies, family history of HH, or cirrhosis. The time between initial clue appearance and the date an appropriate action was taken on the clue was calculated. A time interval of greater than 90 days was defined as a diagnostic delay. The time between initial clue appearance and diagnosis of HH was calculated. The time to achieve goal ferritin levels was also determined. A telephone interview was conducted to evaluate patient knowledge on the need for their offspring to be screened. Results: C282Y homozygotes represented 16 of the 23 patients. The most common presenting clues were abnormal iron studies (15 patients) and abnormal LFTs (8 patients). A diagnostic delay was found in 10 patients. 18 of the 23 patients had a diagnosis of HH made within 1 year of their presenting clue. PCPs were more commonly involved in diagnostic delays, as compared to gastroenterologists and other sub-specialists. 74% of patients achieved goal ferritin levels of less than 100 ng/ml within 2 years of their diagnosis. Eleven of 12 patients available and eligible for a phone interview were aware of the hereditary nature of the disease and the need for their offspring to be screened. Conclusion: HH is an easily treatable genetic condition; however, without recognition of its presenting clues, timely diagnosis, treatment to recommended ferritin levels, and appropriate screening of offspring of affected patients, the diagnosis may be delayed or missed. There is room to improve our diagnosis of HH, as a diagnostic delay was identified in 43% (10 patients) of our study population. Despite these results, most patients were diagnosed by one year of their presenting clue. Also, most patients were treated to recommended ferritin levels within two years of their diagnosis, and were aware of the need for their offspring to be screened. Further studies are needed to evaluate whether enhancing awareness of HH at the PCP level will decrease diagnostic delays.

TFR2-related hereditary hemochromatosis as a frequent cause of primary iron overload in patients from Central-Southern Italy

Hereditary hemochromatosis (HH) is a common Mendelian disorder of iron metabolism. Eighty percent of northern Europeans descendant HH patients carry the same mutation (p.C282Y) in the HFE gene. Simultaneously, due to a founder effect, its frequency varies considerably between different populations. In Central-Southern Italy the prevalence of p.C282Y mutation is low and in several patients the disease has different causes. Four additional rarer forms have been described. Type 3 HH has been reported in about 50 families and no more than 30 TFR2 pathogenic mutations have been globally identified. The aim of this study is to assess the TFR2 role in non-HFE HH pathogenesis. TFR2 sequence analysis was performed on 45 Italian patients without HFE mutations. This study revealed TFR2 biallelic pathogenic mutations in 7/45 (15.6%) individuals. Moreover monoallelic TFR2 deleterious defects (18%) or polymorphisms with unclear meaning (36%) were identified. Besides, we recognized 10 novel variants and 9 described changes. We believe this to be the largest series of type 3 HH patients described so far. Present findings support the hypothesis of a main role of the TFR2 gene in HH pathogenesis in those regions, such as Central-Southern Italy, where the p.C282Y frequency is low.

Disordered vascular compliance in haemochromatosis

A relationship may exist between body iron stores, endothelial dysfunction and overall cardiovascular risk. To compare vascular compliance, biochemical endothelial function and antioxidant status between patients with homozygous hereditary haemochromatosis and healthy controls. Haemochromatosis patients and healthy controls were recruited. Measures of vascular compliance were assessed by applanation tonometry. Serological markers of endothelial function (plasma lipid hydroperoxides, cell adhesion molecules), antioxidant levels (ascorbate, lipid soluble antioxidants) and high-sensitivity C-reactive protein (CRP) were also measured. Thirty-five hereditary haemochromatosis patients (ten females, mean age 54.6) and 36 controls (27 female, mean age 54.0) were recruited. Haemochromatosis patients had significantly higher systolic and diastolic blood pressures. Pulse wave velocity (PWV) was significantly higher in male haemochromatosis patients (9.90 vs. 8.65 m/s, p = 0.048). Following adjustment for age and blood pressure, male haemochromatosis patients continued to have a trend for higher PWVs (+1.37 m/s, p = 0.058). Haemochromatosis patients had significantly lower levels of ascorbate (46.11 vs. 72.68 μmol/L, p = 0.011), retinol (1.17 vs. 1.81 μmol/L, p = 0.001) and g-tocopherol (2.51 vs. 3.14 μmol/L, p = 0.011). However, there was no difference in lipid hydroperoxides (0.46 vs. 0.47 nmol/L, p = 0.94), cell adhesion molecule levels (ICAM: 348.12 vs. 308.03 ng/mL, p = 0.32 and VCAM: 472.78 vs. 461.31 ng/mL, p = 0.79) or high-sensitivity CRP (225.01 vs. 207.13 mg/L, p = 0.32). Haemochromatosis is associated with higher PWVs in males and diminished antioxidants across the sexes but no evidence of endothelial dysfunction or increased lipid peroxidation.

Relevance of dietary iron intake and bioavailability in the management of HFE hemochromatosis: a systematic review

Hereditary hemochromatosis (HH) leads to iron loading because of a disturbance in the negative-feedback mechanism between dietary iron absorption and iron status. The management of HH is achieved by repeated phlebotomies. We investigated whether HH patients would benefit from a diet with low iron intake and bioavailability. We performed a systematic review of studies that linked iron bioavailability and status with dietary factors in subjects with diagnosed HH. Studies on heterozygotes for the HFE mutation were excluded. No prospective, randomized study was reported. Nine studies that directly measured iron bioavailability from test meals in HH patients have been described as well as 3 small, prospective, longitudinal studies in HH patients. Eight cross-sectional studies were identified that investigated the effect of dietary composition on iron status. Calculations of iron bioavailability in HH were made by extrapolating data on hepcidin concentrations and their association with iron bioavailability. The potential reduction in the yearly amount of blood to be phlebotomized when restricting dietary iron absorbed was estimated in the 3 longitudinal studies and ranged between 0.5 and 1.5 L. This amount would be dependent on individual disease penetrance as well as the dietary intervention. Despite the limited quantitative evidence and the lack of randomized, prospective trials, dietary interventions that modify iron intake and bioavailability may affect iron accumulation in HH patients. Although this measure may be welcome in patients willing to contribute to their disease management, limited data exist on the clinical and quality-of-life benefit.

A parkinsonian movement disorder with brain iron deposition and a haemochromatosis mutation

A 60-year-old, right-handed, Caucasian woman presented to the outpatient department with a three-month history of clumsiness and resting tremor in her right hand, associated with micrographia. She had no significant past medical history. Her family history included a brother who died at the age of 50 after a gastrointestinal bleed, attributed to alcoholic liver disease. Examination showed hypomimia, right hand resting tremor, and right arm and leg rigidity with bradykinesia. There was reduced arm swing during gait, and retropulsion on pull testing. The provisional diagnosis was idiopathic Parkinson’s disease. She was started on dopamine agonists and later on levodopa. However, the symptoms progressed rapidly, with worsening slowness and stiffness, development of postural hypotension and incomplete bladder emptying. She also reported daytime somnolence and snoring at night. As such, the diagnosis was revised to a Parkinson’s-plus syndrome: multiple system atrophy. Investigations revealed mildly raised serum alanine aminotransferase (63 IU/L), but the other liver function tests, full blood count, and copper studies (including serum ceruloplasmin) were all normal. No iron studies were performed. A 24-h cardiac monitor showed no arrhythmias. MRI-head (T1, T2, FLAIR and Gradient echo) at the time of presentation was normal. The patient did not attend for planned autonomic and respiratory function tests. Thirteen months after the first clinic appointment she died in her sleep. A post-mortem examination showed extraand intra-cellular deposition of iron in the globus pallidus, putamen, substantia nigra, locus coeruleus, red nuclei and dentate nuclei. This iron was visualised by Perl’s stain (Figs. 1 and 2), and was in fine granules, in moderate amounts. In addition, there was marked and diffuse neuronal loss from the substantia nigra and locus coeruleus with pale bodies within their neurons. However, no Lewy bodies were seen (alpha-synuclein negative). Axonal spheroids were present, dispersed through brain white matter tracts, consistent with secondary axonal damage. The liver was strongly positive for iron throughout (Perl’s stain). A DNA sample from post-mortem tissue was homozygous for the C282Y Hereditary Haemochromatosis mutation. This is the first case reported of a patient with a movement disorder and a haemochromatosis mutation, in which clear iron deposition in relevant parts of the brain has been seen at postmortem. Several idiopathic neurological conditions (including Parkinson’s disease) are associated with increased brain iron [1], but this is at the level of percentage changes in overall concentration, rather than the gross iron deposition seen in the case reported here. Very high brain iron does occur in conjunction with extrapyramidal disorders in neurodegeneration with brain iron accumulation (NBIA), a group of inherited diseases [2]. Our patient’s age, family history, liver iron, and C282Y mutation all go against this diagnosis. Hereditary haemochromatosis (HH) involves pathological iron deposition in a variety of organs [3]. However, central nervous system disorders are not traditionally listed among the sequelae of the disease. Previous postmortem studies in HH patients have shown excess iron in choroid plexus and pituitary, but not elsewhere in the brain [4], suggesting the blood brain barrier is protective. S. Williams (&) M. R. Vinjam A. Ismail A. Hassan Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK e-mail: stefanwilliams@doctors.org.uk

SAT0360 HFE C282Y/H63D Compound Heterozygotes are at Lower Risk of Hemochromatosis-Related Arthropathy

BackgroundArthropathy that mimics osteoarthritis (OA) and osteoporosis (OP) are considered classic complications of hereditary hemochromatosis (HH). There are limited data comparing OA and OP among HH patients with different HFE...

Paraoxonase-1 status in patients with hereditary hemochromatosis

Hereditary hemochromatosis (HH) is characterized by accumulation of iron, oxidative stress, inflammation, and fibrogenesis in liver tissue. In this setting, research on the protection afforded by intracellular antioxidants is of clinical relevance. Paraoxonase-1 (PON1) is an enzyme that degrades lipid peroxides. This study investigates the alterations in serum PON1 status, PON1 gene polymorphisms, and PON1 hepatic expression in patients with HH. We performed a case-control study in 77 patients with HH (80.5% men, 22-70 years of age) and 408 healthy individuals (43.1% men, 26-74 years of age). Serum PON1 activities against different substrates and PON1192 and PON155 polymorphisms were analyzed. PON1 protein expression was investigated in 20 liver biopsies. HH patients had significantly lower serum PON1 activity, which was inversely correlated with ferritin (marker of iron stores) and serum 8-isoprostane concentrations (index of oxidative stress). PON1 protein expression in liver tissue was higher in patients and showed stronger staining in hepatocytes surrounding the areas of inflammation. Our study provides preliminary evidence that PON1 may play a role in protecting against iron-induced oxidative stress in hereditary hemochromatosis.

VCAM-1 serum levels are associated with arthropathy in hereditary haemochromatosis

ObjectivesThe aim of this study was to assess the role of vascular adhesion molecule 1 (VCAM-1) in patients with hereditary haemochromatosis (HH) with or without arthropathy.MethodsSera from a large cross-sectional...

Role of Magnetic Ressonance Imaging – T2* in Hereditary Hemochromatosis.

AbstractAbstract 2096 Introduction:Hereditary hemochromatosis (HH) is an autossomic recessive disorder characterized by increased iron absorption. Magnetic resonance imaging – T2* (MRI-T2*) has become a reliable and robust methodology to directly assess the iron burden, with better results in transfusional hemosiderosis compared to indirect methods, such as serum ferritin and transferrin saturation (TS). However, little is known about its role in HH. Objectives:Describe the demographic profile of HH type 1 patients as to the type of the HFE mutation and correlate laboratory parameters to MRI-T2*results. Methods:We collected data from patients with a positive HFE gene mutation who performed abdominal and/or cardiac MRI-T2* in our institution from 2004 to 2011. Images retrieved from the digital archive were analyzed by two blinded independent radiologists using the Thalassemia-Tools software (Cardiovascular Imaging Solutions, London, UK). Laboratory data available within 6 months before or after the MRI study were analyzed using the t-Student test, Exact Fisher's test analysis and multivariate analyses. Results:We analyzed 81 patients, 76 (93%) males and 5 (6.2%) females, with a median age of 48 years (21–80). Liver, pancreatic and splenic MRI-T2*values and LIC calculation were performed in 80 patients, and cardiac T2* assessment in 57 patients. The inter-observer T2* variation coefficient was 5%. Serum ferritin was abnormal in 70 patients (90.9%), while TS was abnormal in 34% of the tests.In our study sample, the H63D mutation was present in 70 patients (86.4%): 11 (13.6%) were homozygous, 59 (72.8%) heterozygous and 7 (8.6%) double heterozygous for C282Y/H63D. Only three patients (3.7%) were homozygous and 6 (7.4%) were heterozygous only for the C282Y mutation. The S65C mutation was detected in heterozygous state in 2 (2.5%) of cases.Two out 57 cases had a positive T2* result and were classified as light cardiac overload (T2*:18.98 e 19.14 ms). Both had the H63D mutation (1 homozygous and 1 heterozygous). Thirty seven out of 80 patients (46.3%) had liver overload in abdominal MRI (T2*: 3.8–11.4ms), being 33 (41.3%) light overload and four (5%) moderate overload (T2*:1.8–3.8ms). We found that 77.8% of patients with liver overload were C282Y carriers, of which 57.2% had double mutation and 40.3% had H63D mutation in hetero or homozigosity. Pancreatic overload was found in 20 patients (25.1%), while 30 patients (37.5%) had splenic overload. There was a slight correlation (r: 0.365) between liver T2* and splenic T2* (p=0.001).The presence of C282Y and H63D mutations was statistically associated with a higher frequency of abnormal liver T2* (p=0.017 and p=0.042, respectively). The H63D mutation was associated with iron accumulation in the liver (p=0,037) and homozygous carriers showed higher levels of liver overload (p=0,038). Conclusion:In our study, serum ferritin was a better surrogate marker for iron overload than ST. In addition, up to 40.3% of patients with H63D mutation had evidence of hepatic iron overload by MRI. These findings differ from the currente literature. The higher RMI positivity might be due to a higher sensitivity to detect lower levels of organic iron. Despite the lack of a control group and laboratory tests or MRI in all the cases studied, our results suggest that RMI-T2* is a promising methodology to guide the therapeutic management of HH patients. The clinical impact of this finding must be investigated in further studies. Disclosures:No relevant conflicts of interest to declare.

Effect of the A736V TMPRSS6 polymorphism on the penetrance and clinical expression of hereditary hemochromatosis

Hereditary hemochromatosis (HH) is most frequently related to homozygosity for the p.C282Y HFE mutation (C282Y(+/+)), hampering hepcidin induction in response to iron. The rs855791 polymorphism, encoding for the p.A736V variant of TMPRSS6 regulating hepcidin, influences iron status in the population. The aim of this study was to assess the influence of rs855791 on the penetrance and clinical expression of HH. We retrospectively considered 315 HH patients (163 C282Y(+/+), and 152 with other HFE genotypes) evaluated at the time of diagnosis, and 271 healthy controls with normal iron parameters, residents of Northern Italy; TMPRSS6 genotype was assessed by allele specific polymerase chain reaction. The p.736V variant determining higher hepcidin release was under-represented in the patients (p=0.0023), independently of the presence of the C282Y(+/+) genotype, and the p.736V/V genotype protected from HH independently of age and sex (OR of HH for p.736A/A: 2.57, 1.3-4.1 and for p.736A/V: 1.84, 1.1-3.2). In the 96 C282Y(+/+) male patients without chronic viral hepatitis and alcohol abuse, the "high hepcidin" p.736V allele was negatively associated with cirrhosis independently of age, ferritin, ALT levels, and alcohol intake (OR 3.93, 95% C.I. 1.17-14.61 for the p.736A variant), and with the cumulative incidence of hepatocellular carcinoma (17% p.736A/A, 4% p.736A/V, 0 p.736V/V, p=0.05). The p.A736V TMPRSS6 polymorphism is likely a modifier of HH expression. Additional studies are warranted to validate these findings in other cohorts and test their potential relevance for the clinical management of HH patients.

Duodenal expression of iron transport molecules in patients with hereditary hemochromatosis or iron deficiency

Disturbances of iron metabolism are observed in chronic liver diseases. In the present study, we examined gene expression of duodenal iron transport molecules and hepcidin in patients with hereditary hemochromatosis (HHC) (treated and untreated), involving various genotypes (genotypes which represent risk for HHC were examined), and in patients with iron deficiency anaemia (IDA). Gene expressions of DMT1, ferroportin, Dcytb, hephaestin, HFE and TFR1 were measured in duodenal biopsies using real-time PCR and Western blot. Serum hepcidin levels were measured using ELISA. DMT1, ferroportin and TFR1 mRNA levels were significantly increased in post-phlebotomized hemochromatics relative to controls. mRNAs of all tested molecules were significantly increased in patients with IDA compared to controls. The protein expression of ferroportin was increased in both groups of patients but not significantly. Spearman rank correlations showed that DMT1 versus ferroportin, Dcytb versus hephaestin and DMT1 versus TFR1 mRNAs were positively correlated regardless of the underlying cause, similarly to protein levels of ferroportin versus Dcytb and ferroportin versus hephaestin. Serum ferritin was negatively correlated with DMT1 mRNA in investigated groups of patients, except for HHC group. A decrease of serum hepcidin was observed in IDA patients, but this was not statistically significant. Our data showed that although untreated HHC patients do not have increased mRNA levels of iron transport molecules when compared to normal subjects, the expression is relatively increased in relation to body iron stores. On the other hand, post-phlebotomized HHC patients had increased DMT1 and ferroportin mRNA levels possibly due to stimulated erythropoiesis after phlebotomy.