Higher Iron Stores Research Articles

Next generation sequencing to identify iron status and individualise blood donors' experience.

Young adults form the majority of first-time blood donors to Australian Red Cross Lifeblood. However, these donors pose unique challenges for donor safety. Young blood donors, who are still undergoing neurological and physical development, have been found to have lower iron stores, and have higher risks of iron deficiency anaemia when compared to older adults and non-donors. Identifying young donors with higher iron stores may improve donor health and experience, increase donor retention, and reduce the burden on product donation. In addition, these measures could be used to individualise donation frequency. Stored DNA samples from young male donors (18-25 years; n=47) were sequenced using a custom panel of genes identified in the literature to be associated with iron homeostasis. The custom sequencing panel used in this study identified and reported variants to human genome version 19 (Hg19). 82 gene variants were analysed. Only one of which, rs8177181, was found to have a statistically significant (p<0.05) association with plasma ferritin level. Heterozygous alleles of this Transferrin gene variant, rs8177181T>A, significantly predicted a positive effect on ferritin levels (p=0.03). This study, identified gene variants involved in iron homeostasis using a custom sequencing panel and analysed their association with ferritin levels in a young male blood donor population. Additional studies of factors associated with iron deficiency in blood donors are required if a goal of personalised blood donation protocols is to be achieved.

Increasing serum iron levels and their role in the risk of infectious diseases: a Mendelian randomization approach.

Increased iron stores have been associated with elevated risks of different infectious diseases, suggesting that iron supplementation may increase the risk of infections. However, these associations may be biased by confounding or reverse causation. This is important, since up to 19% of the population takes iron supplementation. We used Mendelian randomization (MR) to bypass these biases and estimate the causal effect of iron on infections. As instrumental variables, we used genetic variants associated with iron biomarkers in two genome-wide association studies (GWASs) of European ancestry participants. For outcomes, we used GWAS results from the UK Biobank, FinnGen, the COVID-19 Host Genetics Initiative or 23andMe, for seven infection phenotypes: 'any infections', combined, COVID-19 hospitalization, candidiasis, pneumonia, sepsis, skin and soft tissue infection (SSTI) and urinary tract infection (UTI). Most of our analyses showed increasing iron (measured by its biomarkers) was associated with only modest changes in the odds of infectious outcomes, with all 95% odds ratios confidence intervals within the 0.88 to 1.26 range. However, for the three predominantly bacterial infections (sepsis, SSTI, UTI), at least one analysis showed a nominally elevated risk with increased iron stores (P <0.05). Using MR, we did not observe an increase in risk of most infectious diseases with increases in iron stores. However for bacterial infections, higher iron stores may increase odds of infections. Hence, using genetic variation in iron pathways as a proxy for iron supplementation, iron supplements are likely safe on a population level, but we should continue the current practice of conservative iron supplementation during bacterial infections or in those at high risk of developing them.

Body Iron Store and its Association with Risk of First Episode of Spontaneous Lower Extremity Deep Vein Thrombosis/Pulmonary Embolism: A Case-Control Study.

The association between body iron stores and risk of deep vein thrombosis/pulmonary embolism (DVT/PE) has not been studied among Indian subjects. This study aimed to evaluate the same and also study the association between iron stores and recanalization of affected veins at week-12. This Case-Control with follow-up study enrolled 85 consecutive adult (≥ 18years) cases presenting with first episode of spontaneous, proximal lower extremity DVT/PE and 170 age (± 3years) and sex matched adult controls without DVT/PE. Those with haemoglobin(Hb) < 9g/dl, malignancies, serum creatinine ≥ 2mg/dL, heart failure and concurrent infections/inflammatory disorders were excluded. All participants underwent iron profile, serum ferritin light-chain (FtL) and hepcidin testing. Anaemia [OR = 2.3 (95% CI = 1.3-4.0), p = 0.001] and elevated RDW (RDW-CV > 15%) [OR = 2.3(95% CI = 1.2-4.3), p = 0.012] were significantly associated with increased risk of DVT/PE. Iron deficiency (ID, defined as serum ferritin < 30µg/L, along with TSAT < 20%) was not associated with DVT/ PE risk [OR = 0.8(95% CI = 0.4-1.7), p > 0.05]. Serum FtL in the highest quartile (> 75th centile) was associated with higher risk of DVT/PE (OR = 5, 95% CI = 2.6-9.6) and levels < 25th centile with protection against DVT/PE (OR = 0.1, 95% CI = 0.01-0.32), compared to levels between 25th and 75th centiles (referent range). Highest DVT/PE risk was associated with FtL > 90th centile [OR≈12(95% CI = 3.9-37.2)]. No associations were noted between serumhepcidin and DVT/PE risk and ID and DVT recanalization at week-12. Higher iron stores, rather than ID, were associated with increased risk of DVT/PE among those with Hb ≥ 9g/dL. Anaemia and elevated RDW were also associated with risk of DVT/PE. ID was not associated with poorer DVT recanalization at week-12.

Physiologically based cord clamping for infants ≥32+0 weeks gestation: A randomised clinical trial and reference percentiles for heart rate and oxygen saturation for infants ≥35+0 weeks gestation.

Globally, the majority of newborns requiring resuscitation at birth are full term or late-preterm infants. These infants typically have their umbilical cord clamped early (ECC) before moving to a resuscitation platform, losing the potential support of the placental circulation. Physiologically based cord clamping (PBCC) is clamping the umbilical cord after establishing lung aeration and holds promise as a readily available means of improving early newborn outcomes. In mechanically ventilated lambs, PBCC improved cardiovascular stability and reduced hypoxia. We hypothesised that PBCC compared to ECC would result in higher heart rate (HR) in infants needing resuscitation, without compromising safety. Between 4 July 2018 and 18 May 2021, infants born at ≥32+0 weeks' gestation with a paediatrician called to attend were enrolled in a parallel-arm randomised trial at 2 Australian perinatal centres. Following initial stimulation, infants requiring further resuscitation were randomised within 60 seconds of birth using a smartphone-accessible web link. The intervention (PBCC) was to establish lung aeration, either via positive pressure ventilation (PPV) or effective spontaneous breathing, prior to cord clamping. The comparator was early cord clamping (ECC) prior to resuscitation. The primary outcome was mean HR between 60 to 120 seconds after birth, measured using 3-lead electrocardiogram, extracted from video recordings blinded to group allocation. Nonrandomised infants had deferred cord clamping (DCC) ≥120 seconds in the observational study arm. Among 508 at-risk infants enrolled, 123 were randomised (n = 63 to PBCC, n = 60 to ECC). Median (interquartile range, IQR) for gestational age was 39.9 (38.3 to 40.7) weeks in PBCC infants and 39.6 (38.4 to 40.4) weeks in ECC infants. Approximately 49% and 50% of the PBCC and ECC infants were female, respectively. Five infants (PBCC = 2, ECC = 3, 4% total) had missing primary outcome data. Cord clamping occurred at a median (IQR) of 136 (126 to 150) seconds in the PBCC arm and 37 (27 to 51) seconds in the ECC arm. Mean HR between 60 to 120 seconds after birth was 154 bpm (beats per minute) for PBCC versus 158 bpm for ECC (adjusted mean difference -6 bpm, 95% confidence interval (CI) -17 to 5 bpm, P = 0.39). Among 31 secondary outcomes, postpartum haemorrhage ≥500 ml occurred in 34% and 32% of mothers in the PBCC and ECC arms, respectively. Two hundred ninety-five nonrandomised infants (55% female) with median (IQR) gestational age of 39.6 (38.6 to 40.6) weeks received DCC. Data from these infants was used to create percentile charts of expected HR and oxygen saturation in vigorous infants receiving DCC. The trial was limited by the small number of infants requiring prolonged or advanced resuscitation. PBCC may provide other important benefits we did not measure, including improved maternal-infant bonding and higher iron stores. In this study, we observed that PBCC resulted in similar mean HR compared to infants receiving ECC. The findings suggest that for infants ≥32+0 weeks' gestation who receive brief, effective resuscitation at closely monitored births, PBCC does not provide additional benefit over ECC (performed after initial drying and stimulation) in terms of key physiological markers of transition. PBCC was feasible using a simple, low-cost strategy at both cesarean and vaginal births. The percentile charts of HR and oxygen saturation may guide clinicians monitoring the transition of at-risk infants who receive DCC. Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618000621213.

Ceruloplasmin gene variants are associated with hyperferritinemia and increased liver iron in patients with NAFLD

Non-alcoholic fatty liver disease (NAFLD) is a multifactorial disorder resulting from genetic and environmental factors. Hyperferritinemia has been associated with increased hepatic iron stores and worse outcomes in patients with NAFLD. The aim of this study was to evaluate the prevalence of variants of iron-related genes and their association with hyperferritinemia, hepatic iron stores and liver disease severity in patients with NAFLD. From a cohort of 328 individuals with histological NAFLD, 23 patients with ferritin >750ng/ml and positive iron staining, and 25 controls with normal ferritin and negative iron staining, were selected. Patients with increased transferrin saturation, anemia, inflammation, β-thalassemia trait, HFE genotype at risk of iron overload and ferroportin mutations were excluded. A panel of 32 iron genes was re-sequenced. Literature and in silico predictions were employed for prioritization of pathogenic mutations. Patients with hyperferritinemia had a higher prevalence of potentially pathogenic rare variants (73.9% vs. 20%, p= 0.0002) associated with higher iron stores and more severe liver fibrosis (p <0.05). Ceruloplasmin was the most mutated gene and its variants were independently associated with hyperferritinemia, hepatic siderosis, and more severe liver fibrosis (p <0.05). In the overall cohort, ceruloplasmin variants were independently associated with hyperferritinemia (adjusted odds ratio 5.99; 95% CI 1.83-19.60; p= 0.0009). Variants in non-HFE iron genes, particularly ceruloplasmin, are associated with hyperferritinemia and increased hepatic iron stores in patients with NAFLD. Carriers of such variants have more severe liver fibrosis, suggesting that genetic predisposition to hepatic iron deposition may translate into liver disease. Non-alcoholic fatty liver disease (NAFLD) is a common disease which can progress to cirrhosis and liver cancer. Increased levels of serum ferritin are often detected in patients with NAFLD and have been associated with altered iron metabolism and worse patient outcomes. We found that variants of genes related to iron metabolism, particularly ceruloplasmin, are associated with high ferritin levels, hepatic iron deposition and more severe liver disease in an Italian cohort of patients with NAFLD.

The effect of donation activity dwarfs the effect of lifestyle, diet and targeted iron supplementation on blood donor iron stores.

The iron status of blood donors is a subject of concern for blood establishments. The Finnish Red Cross Blood Service addresses iron loss in blood donors by proposing systematic iron supplementation for demographic at-risk donor groups. We measured blood count, ferritin and soluble transferrin receptor (sTfR) and acquired lifestyle and health information from 2200 blood donors of the FinDonor 10000 cohort. We used modern data analysis methods to estimate iron status and factors affecting it with a special focus on the effects of the blood service’s iron supplementation policy. Low ferritin (< 15 μg/L), an indicator of low iron stores, was present in 20.6% of pre-menopausal women, 10.6% of post-menopausal women and 6% of men. Anemia co-occurred with iron deficiency more frequently in pre-menopausal women (21 out of 25 cases) than in men (3/6) or post-menopausal women (1/2). In multivariable regression analyses, lifestyle, dietary, and blood donation factors explained up to 38% of the variance in ferritin levels but only ~10% of the variance in sTfR levels. Days since previous donation were positively associated with ferritin levels in all groups while the number of donations during the past 2 years was negatively associated with ferritin levels in pre-menopausal women and men. FRCBS-provided iron supplementation was negatively associated with ferritin levels in men only. Relative importance analyses showed that donation activity accounted for most of the explained variance in ferritin levels while iron supplementation explained less than 1%. Variation in ferritin levels was not significantly associated with variation in self-reported health. Donation activity was the most important factor affecting blood donor iron levels, far ahead of e.g. red-meat consumption or iron supplementation. Importantly, self-reported health of donors with lower iron stores was not lower than self-reported health of donors with higher iron stores.

High Iron Stores in the Low Malaria Season Increase Malaria Risk in the High Transmission Season in a Prospective Cohort of Rural Zambian Children

Background: Higher iron stores, defined by serum ferritin (SF) concentration, may increase malaria risk.Objective: We evaluated the association between SF assessed during low malaria season and the risk of malaria during high malaria season, controlling for inflammation.Methods: Data for this prospective study were collected from children aged 4-8 y (n = 745) participating in a biofortified maize efficacy trial in rural Zambia. All malaria cases were treated at baseline (September 2012). We used baseline SF and malaria status indicated by positive microscopy at endline (March 2013) to define exposure and outcome, respectively. Iron status was defined as deficient (corrected or uncorrected SF <12 or <15 μg/L, depending on age <5 or ≥5 y, respectively), moderate (<75 μg/L, excluding deficient), or high (≥75 μg/L). We used a modified Poisson regression to model the risk of malaria in the high transmission seasons (endline) as a function of iron status assessed in the low malaria seasons (baseline).Results: We observed an age-dependent, positive dose-response association between ferritin in the low malaria season and malaria incidence during the high malaria season in younger children. In children aged <6 y (but not older children), we observed a relative increase in malaria risk in the moderate iron status [incidence rate ratio (IRR) with SF: 1.56; 95% CI: 0.64, 3.86; IRR with inflammation-corrected SF: 1.92; 95% CI: 0.75, 4.93] and high iron status (IRR with SF: 2.66; 95% CI: 1.10, 6.43; or IRR with corrected SF: 2.93; 95% CI: 1.17, 7.33) categories compared with the deficient iron status category. The relative increase in malaria risk for children with high iron status was statistically significant only among those with a concurrently normal serum soluble transferrin receptor concentration (<8.3 mg/L; IRR: 1.97; 95% CI: 1.20, 7.37).Conclusions: Iron adequacy in 4- to 8-y-old children in rural Zambia was associated with increased malaria risk. Our findings underscore the need to integrate iron interventions with malaria control programs. This trial was registered at clinicaltrials.gov as NCT01695148.

Elective caesarean: does delay in cord clamping for 30 s ensure sufficient iron stores at 4 months of age? A historical cohort control study

ObjectiveTo compare iron stores in infants born after elective caesarean section (CS) and a 30 s delay of umbilical cord clamping with those born vaginally after early (≤10 s) or...

PRIMERJAVA PREDNOSTI IN SLABOSTI TAKOJŠNJE TER ODLOŽENE PREKINITVE POPKOVNICE PRI NOVOROJENČKU

Background: Umbilical cord clamping in the third stage of labour is still controversial. Early cord clamping is defined as clamping at 10, 15, 30 or 60 seconds after delivery and delayed as clamping after 60 seconds or at 2-5 minutes after delivery, when the cord stops pulsating or when the placenta is visible within the birth canal. Early clamping is one of the three components of active management of the third stage of labour, which has been used widely in modern obstetrics during the last century. However, in some northern European countries, various parts of the USA and Canada and in developing countries physiological management is preferred.Conclusions: After publication of several trials describing advantages of delayed clamping, this has recently been progressively replacing early clamping. The most important advantages of delayed cord clamping are higher haemoglobin and ferritin levels, higher iron stores, lower incidence of iron deficiency anaemia, better cardiopulmonary adaptation, lower rate of respiratory distress syndrome, and longer duration of early breastfeeding in term neonates, while there is no increase in the incidence of postpartum haemorrhage. Delayed clamping seems to bring some advantages for preterm neonates as well. However, caution is still advised because of the potential adverse effects, especially polycythaemia with hyperviscosity, hyperbilirubinaemia and respiratory distress.

Iron status is associated with asthma and lung function in US women.

BackgroundAsthma and iron deficiency are common conditions. Whether iron status affects the risk of asthma is unclear.ObjectiveTo determine the relationship between iron status and asthma, lung function, and pulmonary inflammation.MethodsRelationships between measures of iron status (serum ferritin, serum soluble transferrin receptor (sTfR), and sTfR/log10ferritin (sTfR-F Index)) and asthma, lung function, and pulmonary inflammation were examined in women 20-49 years in the National Health and Nutrition Examination Survey. Logistic, linear, and quadratic regression models accounting for the survey design of NHANES were used to evaluate associations between iron status and asthma-related outcomes and were adjusted for race/ethnicity, age, smoking status, income, and BMI.ResultsApproximately 16% reported a lifetime history of asthma, 9% reported current asthma, and 5% reported a recent asthma episode/attack (n = 2906). Increased ferritin (iron stores) was associated with decreased odds of lifetime asthma, current asthma, and asthma attacks/episodes in the range of ferritin linearly correlated with iron stores (20-300ng/ml). The highest quintile of ferritin (>76 ng/ml) was also associated with a decreased odds of asthma. Ferritin levels were not associated with FEV1. Increased values of the sTfR-F Index and sTfR, indicating lower body iron and higher tissue iron need, respectively, were associated with decreased FEV1, but neither was associated with asthma. None of the iron indices were associated with FeNO.ConclusionIn US women, higher iron stores were inversely associated with asthma and lower body iron and higher tissue iron need were associated with lower lung function. Together, these findings suggest that iron status may play a role in asthma and lung function in US women.

Effect of maternal cigarette smoking on newborn iron stores

Maternal smoking has been known to have a negative impact on the well being of the developing fetus. Prenatal smoking has been associated with premature births, low birth weight and with certain birth defects. Small research studies have also found a negative correlation between maternal smoking and neonatal body iron. To study and compare the relationship between maternal and infants' body iron in smokers and non-smokers in a large matched-pair cohort. This was a prospective cohort study involving 144 mothers - 72 smokers and 72 non-smokers and their respective infants. Samples were obtained from maternal and infants' cord blood at delivery for Serum transferrin receptor (sTfR) and ferritin levels. Serum TfR and ferritin were measured by RAMCO ELISA and RIA assays. Total Body Iron (TBI) was calculated using the sTfR/ferritin ratio in a previously described formula by Cook et al. Women who smoked had lower sTfR, higher ferritin and higher body iron compared to nonsmoking women. In contrast to their respective mothers, we found a small, but statistically significant negative correlation between smoking and infants' total body iron. The number of packs per day smoked was also negatively correlated with infants' ferritin and total body iron. Lower birth weight was noted in babies of smokers compared to nonsmokers (mean /- SD =3270 +/-475 vs. 3393 g +/- 475 g, p=0.03). Women who smoked during pregnancy had higher iron stores but their newborn infants had lower iron stores than those of non-smoking mothers. The more packs per day (PPD) and more days smoked during pregnancy led to lower total body iron of the babies. There may be a negative dose-dependent response between fetal smoke exposure and infant iron stores.

Iron-deficiency anaemia in an outpatient inflammatory bowel disease cohort

Iron deficiency is found frequently in patients with inflammatory bowel disease (IBD) and can have a significant effect on their quality of life. The causes of iron deficiency are gastrointestinal blood loss, poor oral intake of iron, malabsorption, and inflammation. Previous studies have highlighted the correlation between higher iron stores and quality of life as well as the under diagnosis and treatment of iron deficiency in IBD by medical professionals. This article analyses the diagnosis and treatment of iron deficiency in the authors' local IBD cohort. The authors compared their findings to guidance developed by the British Society of Gastroenterology (BSG) and reviewed similar studies, comparing management options that use different iron preparations.

Effect Of Maternal Cigarette Smoking On Newborn Iron Stores

Objective Previous small-scale studies suggest that maternal smoking lowers neonatal body iron. Our objective was to study and compare the relationship between maternal and infants’ body iron in smokers and non-smokers in a large matched-pair cohort. Method This was a prospective cohort study involving 144 mothers – 72 smokers and 72 non-smokers and their respective infants. Samples were obtained from maternal blood and infants’ cord blood at delivery for serum transferrin receptor (sTfR) and ferritin levels. Serum TfR and ferritin levels were measured by RAMCO ELISA and RIA assays. The total body iron (TBI) was calculated using the sTfR/ferritin ratio. Results Maternal total body iron and smoking status Women who smoked had lower sTfR, higher ferritin and higher body iron compared to nonsmoking women. Infant’s total body iron, measurements at birth and smoking status In contrast to their respective mothers, we found a small but statistically significant negative correlation between smoking and infants’ total body iron. The number of PPD smoked was negatively correlated with infants’ ferritin and total body iron. The number of days smoked during pregnancy was also negatively correlated with infants’ ferritin and total body iron and positively correlated with infants' sTfR. Birth weight was lower in babies of smokers compared to nonsmokers (mean /- SD =3270 +/-475 vs. 3393 g +/- 475 g, p=0.03). Correlation studies revealed that birth weight in infants of smokers was negatively correlated with PPD smoked and number of days smoked. Birth length in the same infants was also negatively correlated with PPD smoked and number of days smoked. Conclusion Mothers who smoked during pregnancy had higher iron stores but their newborn infants had lower iron stores than those of non-smoking mothers. There may be a negative dose-dependent response between fetal smoke exposure and infant iron stores. Disclosures: No relevant conflicts of interest to declare.

Role of Cellular Iron and Oxygen in the Regulation of HIV-1 Infection

Despite efficient antiretroviral therapy, eradication of HIV-1 infection is challenging and requires novel biological insights and therapeutic strategies. Among other physiological and environmental factors, intracellular iron greatly affects HIV-1 replication. Higher iron stores were shown to be associated with faster progression of HIV-1 infection and to inversely correlate with the survival of HIV-1 infected patients. Iron is required for several steps in the HIV-1 life cycle, including reverse transcription, HIV-1 gene expression and capsid assembly. Here, the authors present a comprehensive review of the molecular mechanisms involved in iron- and oxygen-mediated regulation of HIV-1 replication. We also propose key intracellular pathways that may be involved in regulating HIV-1 replication, via protein kinase complexes, CDK9/cyclin T1 and CDK 2/cyclin E, protein phosphatase-1 and other host factors.

OP61 Is Maternal Iron Status Associated with offspring’s Blood Pressure and Adiposity? A Mendelian Randomization Study

BackgroundIron deficiency during pregnancy is a common problem. Experimental animal studies suggest that mothers deficient in iron during pregnancy are more likely to have offspring who become obese and have...

Body iron stores and risk of type 2 diabetes: results from the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam study

Aims/hypothesisThe aim of this study was to prospectively examine the association between body iron stores and risk of type 2 diabetes.MethodsWe designed a case–cohort study among 27,548 individuals within the population-based European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam study. During 7 years of follow-up, 849 incident cases of type 2 diabetes were identified. Of these, 607 remained for analyses after exclusion of participants with missing data or abnormal glucose levels at baseline. A sub-cohort of 2,500 individuals was randomly selected from the full cohort, comprising 1,969 individuals after applying the same exclusion criteria.ResultsAfter adjustment for age, sex, BMI, waist circumference, sports activity, bicycling, education, occupational activity, smoking habit, alcohol consumption and circulating levels of γ-glutamyltransferase, alanine aminotransferase, fetuin-A, high-sensitivity C-reactive protein, adiponectin, HDL-cholesterol and triacylglycerol, higher serum ferritin concentrations were associated with a higher risk of type 2 diabetes (RR in the highest vs lowest quintile, 1.73; 95% CI 1.15, 2.61; p trend = 0.002). No significant association was observed for soluble transferrin receptor (RR 1.33; 95% CI 0.85, 2.09; p trend = 0.50). The soluble transferrin receptor-to-ferritin ratio was significantly inversely related to risk (RR 0.61; 95% CI 0.41, 0.91; p trend = 0.02).Conclusions/interpretationHigh ferritin levels are associated with higher risk of type 2 diabetes independently of established diabetes risk factors and a range of diabetes biomarkers whereas soluble transferrin receptor concentrations are not related to risk. These results support the hypothesis that higher iron stores below the level of haemochromatosis are associated with risk of type 2 diabetes.

Effect of An Interaction Between Age and Ferritin Level on Clinical Outcomes In Peripheral Arterial Disease (PAD)

AbstractAbstract 4302 Background:The hypothesis that increasing iron burden (assessed by the serum ferritin level) with age contributes to the pathogenesis of cardiovascular (CVD) and other diseases of aging was tested in a 24-hospital, 6-year prospective randomized single blinded clinical trial of iron reduction by calibrated phlebotomy (JAMA 2007;297:603-9; JNCI 2008;100:996-1002). The primary outcome was all cause mortality and the secondary outcome death plus non-fatal MI and stroke (total n = 1,277 patients with PAD). Mean follow-up ferritin levels were significantly reduced in iron reduction patients (p<0.001). Although iron reduction had no significant effect on CVD outcomes overall, an association was observed for the secondary endpoint by age quartile (p for interaction = 0.004). The Cox proportional hazards regression model showed improved primary (p=0.02) and secondary (p<0.001) endpoints in the youngest age quartile patients (age 43 to 61) randomized to iron reduction versus control. Age analyzed as a continuous variable in the Cox proportional hazards regression model and the log relative hazards plots revealed that age interacted nonlinearly with iron reduction in both the primary (p=0.04) and secondary (p<0.001) endpoints. HYPOTHESIS: Iron reduction has beneficial effects on overall CVD outcomes that can be masked by interactions between age and ferritin level. METHODS: Computer randomization to iron reduction (n = 636) versus control (n = 641) groups was stratified by age, ferritin level and other prognostic variables at entry. Data tracked prospectively (including data on compliance with intervention) were subjected to pre-planned, intent-to-treat analysis. RESULTS: Mean follow-up ferritin levels declined with increasing age at entry in control patients. Older age (p = 0.027) and higher ferritin levels (p<0.001) at entry predicted poorer compliance with phlebotomy in iron reduction patients. Separation of mean follow-up ferritin levels between groups diminished with increasing age at entry. Plots of mean follow-up ferritin levels versus the log relative hazard for the primary and secondary endpoints for iron reduction patients showed significantly improved outcomes with lower mean follow-up ferritin levels (p = 0.028 and 0.044 respectively). Improvement in the primary outcome with lower ferritin levels was also found upon analysis of the entire cohort (p = 0.037). Kaplan-Meier analysis of mean follow-up ferritin levels for the entire cohort comparing patients having ferritin levels above versus below the mean showed improved primary and secondary outcomes with lower ferritin levels (p = 0.003 and 0.067 respectively). CONCLUSIONS: Lower body iron burden predicted improved clinical outcomes in patients with cardiovascular disease regardless of age or randomization status. Two factors seemed to account for the lack of an effect of intervention in the overall cohort. First, serum ferritin levels decreased with increasing age in control patients, apparently because patients with higher iron stores were more likely to die earlier. Second, younger iron reduction patients were more likely to comply with the phlebotomy intervention. Consequently, iron reduction therapy had less of a potential effect in older compared to younger patients because mean follow-up ferritin levels between groups converged with increasing age. An implication for future studies, and possibly for practice, is that adequate iron reduction targeted to patients with higher ferritin levels is more likely to be effective. These findings suggest cost – effective strategies for improving outcomes in diseases of aging. Disclosures:No relevant conflicts of interest to declare.

Iron intake and markers of iron status and risk of Barrett’s esophagus and esophageal adenocarcinoma

To investigate the association between iron intake and iron status with Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC). A total of 220 BE patients, 224 EAC patients, and 256 frequency-matched controls completed a lifestyle and food frequency questionnaire and provided serum and toenail samples between 2002 and 2005. Using multiple logistic regression, odds ratios (OR) and 95% confidence intervals (95% CI) were calculated within quartiles of intake/status. Comparing the fourth to the first quartile, ferritin (OR 0.47; 95% CI: 0.23, 0.97) and transferrin saturation (OR 0.41; 95% CI: 0.20, 0.82) were negatively associated with BE; while total iron binding capacity was positively associated per 50 μg/dl increment (OR 1.47; 95% CI: 1.12, 1.92). Comparing the fourth to the first quartile, iron intake (OR 0.50; 95% CI: 0.25, 0.98), non-heme iron intake per 10 mg/day increment (OR 0.29; 95% CI: 0.08, 0.99), and toenail iron (OR 0.40; 95% CI: 0.17, 0.93) were negatively associated with EAC; while heme iron intake was positively associated (OR 3.11 95% CI: 1.46, 6.61). In contrast to the hypothesis that increased iron intakes and higher iron stores are a risk factor for BE and EAC, this study suggests that higher iron intakes and stores may have a protective association with BE and EAC, with the exception of what was found for heme iron intake.

HFE mutations in nonalcoholic fatty liver disease

We read with interest the article by Nelson et al.1 on the relationship between HFE (hemochromatosis) mutations and severity of liver damage in a North American cohort of 126 patients with nonalcoholic steatohepatitis (NASH). They found that heterozygosity for the C282Y mutation was associated with higher iron stores and prevalence of severe fibrosis compared to other genotypes, but diabetes was the only predictor of fibrosis at multivariate analysis considering demographic/anthropometric features and HFE status. These results are important, especially because iron overload is a treatable condition, and iron depletion improves the metabolic picture in patients with nonalcoholic fatty liver disease (NAFLD) and hyperferritinemia.2 Nelson et al. hypothesize that the C282Y mutation facilitates fibrogenesis by increasing iron stores and oxidative stress, but they did not report significant differences in the prevalence of HFE mutations between their cohort of patients with NASH and 2 recent North American studies in the general population.3, 4 However, it appears that in Caucasians the prevalence of the C282Y mutation, but not that of the H63D mutation, was significantly higher in patients with NASH (21.6%) compared to prevalence reported by Beutler et al.4 (11.4%, P = 0.002) and Adams et al.3 (12%, P = 0.006) in the general population. This was true for both the C282Y/H63D (5.1% versus 1.9%, P = 0.02 and versus 2%, P = 0.03, respectively), and the C282Y/wild-type (16.3% versus 9.5%, P = 0.03 and versus 10%, P = 0.006) genotypes. These results suggest increased susceptibility to NASH in patients carrying the C282Y mutation, although definite evidence is precluded by the lack of matched controls. Increased susceptibility to fatty liver in Caucasian subjects positive for the C282Y HFE mutation was previously demonstrated in Italian patients, with careful evaluation of ascertainment bias.5 Data obtained in studies of NAFLD also indicated that C282Y heterozygotes developed steatosis for a lower degree of overweight, and that the C282Y mutation and body iron stores were associated with a relative deficit of beta-cell function. These results provide possible mechanisms by which iron overload may indirectly promote fibrogenesis, that is, by interfering with lipid metabolism6 and by promoting hyperglycemia, which fit well with results of the multivariate analysis elaborated by Nelson et al.1 Interestingly, we also recently observed increased risk of steatosis in patients with chronic hepatitis C virus infection who were positive for HFE mutations, independently of age, sex, body mass index, and alcohol intake (odds ratio 1.59, 95% confidence interval 1.1–2.4, P = 0.02), suggesting that the effect of iron on steatosis development may extend to other liver diseases.7 Supporting the authors' results relative to fibrosis progression, in a cohort of 212 Italian patients with biopsy-proven NAFLD with complete characterization of iron status,8 HFE genotypes predisposing to iron overload (C282Y/H63D and H63D/H63D),3 though observed less frequently than in subjects of Northern European descent, were associated with higher iron stores and prevalence of severe fibrosis independently of confounders (Table 1). Taken together, these observations suggest that HFE mutations may promote fibrogenesis by inducing fatty liver and dysmetabolism. Additional studies are required to confirm this hypothesis. Luca Valenti*, Paola Dongiovanni*, Anna Ludovica Fracanzani*, Silvia Fargion*, * Department of Internal Medicine, Medicina Interna IB, Universita' di Milano, Ospedale Policlinico Mangiagalli Regina Elena IRCCS, Milan, Italy.

HFE Genotype Influences Erythropoiesis Support Requirement in Hemodialysis Patients: A Prospective Study

Background/Aims: HFE protein controls iron absorption and cycling, and HFE mutations influence iron status. The aim was to evaluate the effect of the HFE genotype on the need for iron and erythropoietin in Italian hemodialysis patients. Methods: Ninety-six prevalent patients were evaluated at the time of enrolment and prospectively followed for 3 years. Patients were given r-HuEPO and Fe³⁺-gluconate according to guidelines. The HFE genotype was determined by restriction analysis. Results: Three patients (3%) carried the C282Y mutation, 4 (4%) were homozygous and 18 (19%) heterozygous for the H63D mutation, and 71 (74%) were negative for both. At enrolment, subjects positive for HFE mutations had higher iron stores (ferritin 617 ± 663 vs. 423 ± 386 ng/ml, p = 0.05), were receiving less iron (82.5 ± 66 vs. 110 ± 154 mg/month, p = 0.05) and a lower r-HuEPO dosage (98 ± 83 vs. 142 ± 138 U/kg/week, p = 0.03). Consistently during the study period, patients positive for HFE mutations received a lower amount of r-HuEPO (94.5 ± 63 vs. 186 ± 344 U/kg/week, p = 0.01) and iron (97 ± 63 vs. 121 ± 68 mg/month, p = 0.07). Upon Cox regression analysis, after adjustment for confounding variables, the presence of HFE mutations was associated with a reduced risk of death (HR 0.6, 95% CI 0.34–1.03, p = 0.06). Conclusion:HFE mutations reduce the amount of r-HuEPO and iron necessary to support erythropoiesis in hemodialysis.