Severe Iron Overload Research Articles

Efficacy and Safety of Combined Oral Chelation with Deferiprone and Deferasirox on Iron Overload in Transfusion Dependent Children with Thalassemia - A Prospective Observational Study.

To assess the efficacy and safety of dual oral iron chelation therapy (deferiprone and deferasirox) in decreasing iron overload status, using serum ferritin and liver and cardiac MRI as indicators, in transfusion dependent thalassemic children. This was a prospective observational study conducted in a tertiary care hospital for a period of one year. Children with thalassemia between 2 and 18 y of age with serum ferritin above 1500ng/ml were started on oral deferiprone and deferasirox. They were followed up for one year. Serum ferritin and MRI quantification of liver and cardiac iron concentration was done at enrolment and end of 12 mo. They were also monitored monthly for any adverse effects. Twenty one thalassemic children with mean age of 7.8 y (range 4-12 y) and a mean ferritin value of 3129 + 1231.5ng/ml were enrolled. Mean serum ferritin decreased by 1226.3ng/ml (p = 0.047, 95% CI =10.2, 1504.3) with 16.8% fall from baseline. The reduction in ferritin correlated significantly with the initial ferritin level (spearman's rho = 0.742, p = 0.001). Mean liver iron concentration and myocardial iron concentration did not change significantly. Red color urine, transient rise in creatinine and liver enzymes were noted during the study period. Combined oral chelation with deferiprone and deferasirox significantly decreases the serum ferritin level in children with severe iron overload. The drugs were tolerated well without any serious adverse effects.

Increased frequency of GNPAT p.D519G in compound HFE p.C282Y/p.H63D heterozygotes with elevated serum ferritin levels

Glyceronephosphate O-acyltransferase (GNPAT) p.D519G (rs11558492) was identified as a genetic modifier correlated with more severe iron overload in hemochromatosis through whole-exome sequencing of HFE p.C282Y homozygotes with extreme iron phenotypes. We studied the prevalence of p.D519G in HFE p.C282Y/p.H63D compound heterozygotes, a genotype associated with iron overload in some patients. Cases were Australian participants with elevated serum ferritin (SF) levels ≥300μg/L (males) and ≥200μg/L (females); subjects whose SF levels were below these cut-offs were designated as controls. Samples were genotyped for GNPAT p.D519G. We compared the allele frequency of the present subjects, with/without elevated SF, to p.D519G frequency in public datasets. GNPAT p.D519G was more prevalent in our cohort of p.C282Y/p.H63D compound heterozygotes with elevated SF (37%) than European public datasets: 1000G 21%, gnomAD 20% and ESP 21%. We conclude that GNPAT p.D519G is associated with elevated SF in Australian HFE p.C282Y/p.H63D compound heterozygotes.

Iron overload causes a mild and transient increase in acute lung injury.

Recent studies have demonstrated a strong link between acute respiratory distress syndrome (ARDS) and the levels of iron and iron‐related proteins in the lungs. However, the role of iron overload in ARDS development has yet to be characterized. In this study, we compared the highly iron‐overloaded hepcidin knockout mice (HKO) to their iron‐sufficient wild‐type (WT) littermates in a model of sterile acute lung injury (ALI) induced by treatment with oropharyngeal (OP) LPS. There were no major differences in systemic inflammatory response or airway neutrophil infiltration between the two groups at the time of maximal injury (days 2 and 3) or during the recovery phase (day 7). Hepcidin knockout mice had transiently increased bronchoalveolar lavage fluid (BALF) protein and MPO activity in the lung and BALF on day 3, indicating worse vascular leakage and increased neutrophil activity, respectively. The increased ALI severity in iron‐overloaded mice may be a result of increased apoptosis of lung tissue, as evidenced by an increase in cleaved capsase‐3 protein in lung homogenates from HKO mice versus WT mice on day 3. Altogether, our data suggest that even severe iron overload has a relatively minor and transient effect in LPS‐induced ALI.

Observational study on the current status of thalassaemia in Malaysia: a report from the Malaysian Thalassaemia Registry

ObjectiveThalassaemia is the most common inherited blood disorder in Malaysia. This study aims to report the current status of thalassaemia in Malaysia and provide a comprehensive understanding of the disease...

Inherited iron overload disorders.

Hereditary iron overload includes several disorders characterized by iron accumulation in tissues, organs, or even single cells or subcellular compartments. They are determined by mutations in genes directly involved in hepcidin regulation, cellular iron uptake, management and export, iron transport and storage. Systemic forms are characterized by increased serum ferritin with or without high transferrin saturation, and with or without functional iron deficient anemia. Hemochromatosis includes five different genetic forms all characterized by high transferrin saturation and serum ferritin, but with different penetrance and expression. Mutations in HFE, HFE2, HAMP and TFR2 lead to inadequate or severely reduced hepcidin synthesis that, in turn, induces increased intestinal iron absorption and macrophage iron release leading to tissue iron overload. The severity of hepcidin down-regulation defines the severity of iron overload and clinical complications. Hemochromatosis type 4 is caused by dominant gain-of-function mutations of ferroportin preventing hepcidin-ferroportin binding and leading to hepcidin resistance. Ferroportin disease is due to loss-of-function mutation of SLC40A1 that impairs the iron export efficiency of ferroportin, causes iron retention in reticuloendothelial cell and hyperferritinemia with normal transferrin saturation. Aceruloplasminemia is caused by defective iron release from storage and lead to mild microcytic anemia, low serum iron, and iron retention in several organs including the brain, causing severe neurological manifestations. Atransferrinemia and DMT1 deficiency are characterized by iron deficient erythropoiesis, severe microcytic anemia with high transferrin saturation and parenchymal iron overload due to secondary hepcidin suppression. Diagnosis of the different forms of hereditary iron overload disorders involves a sequential strategy that combines clinical, imaging, biochemical, and genetic data. Management of iron overload relies on two main therapies: blood removal and iron chelators. Specific therapeutic options are indicated in patients with atransferrinemia, DMT1 deficiency and aceruloplasminemia.

Beta Thalassemia Major: Overview of Molecular Etiology, Pathophysiology, Current and Novel Therapeutic Approaches

Major beta thalassemia is a severe form of thalassemia caused by the alteration of two beta globin genes resulting in a defective synthesis of hemoglobin.
 It is characterized by chronic severe anemia, ineffective erythropoiesis (IE) and iron overload. However although the thransfusion and chelation assosciated constitute the basis of the traitement curently recommended, they do not allow always to control the iron overload induced by pathology and repeated transfusions.
 Hematopoietic stem cell transplantation (HSCT) has proven to be a definitive treatment for beta thalassemia. However, this procedure is confronted to immunological complications and the small nomber of histocompatible donors. In the face of these therapeutic blocks, much research has been undertaken in recent years leading to the development of a number of promising therapeutic strategies in order to reduce the constraints linked to current chronic treatments, and to move towards an access to healing for all patients. Among other three approaches are envisaged and are in the experimental phase: Gene therapy to restore globin chain imbalance, Improve ineffective erythropoiesis and Improve iron dysregulation. In this article we give a view on the pathophysiology, clinical manifestations, genetic origin of beta-thalassaemia major. The second part presents the therapeutic arsenal currently used, and its limits leading to therapeutic impasse. The last part explores the scientific tracks that present a real therapeutic potential in β-Thalassemia.

Bone and joint complications in patients with hereditary hemochromatosis: a cross-sectional study of 93 patients.

Background:The aim of this study was to determine the frequency and characteristics of bone and joint complications, specifically bone fragility, joint replacement surgery, and arthropathy, in hereditary hemochromatosis (HH) and related factors.Methods:This study was a cross-sectional observational study of 93 patients with HH. Radiographs of the hands, wrists, knees, and ankles were scored for joint space narrowing, erosions and cysts, osteophytes, and chondrocalcinosis. Prevalent (vertebral and non-vertebral) fragility fractures were recorded and bone mineral density (BMD) was systematically evaluated by dual energy X-ray absorptiometry. Bone fragility was defined as (i) a T-score ⩽ −2.5 at any site with or without a prevalent fragility fracture, or (ii) a T-score between −1.0 and −2.5 at any site and a prevalent fragility fracture.Results:The mean age of the patients was 60.0 (11.2) years, and 58.0% of them were men. The frequency of radiographic MCP2–3 arthropathy was 37.6% (95% CI 0.28–0.48). Radiographic MCP2–3 arthropathy was independently associated with older age [OR 1.17 (1.09–1.26) per year, p < 0.0001], male sex [OR 3.89 (1.17–12.97), p = 0.027] and C282Y+/+ genotype [OR 4.78 (1.46–15.68), p = 0.010]. The frequency of joint replacement surgery was 12.9% (95% CI 0.07–0.21). The frequency of bone fragility was 20.4% (95% CI 0.13–0.30). Bone fragility was independently associated with hepatic cirrhosis [OR 8.20 (1.74–38.68), p = 0.008].Discussion:Radiographic MCP2–3 arthropathy was found to occur in 37.6% of patients with HH. The association observed between this form of arthropathy and C282Y homozygosity, male sex, and older age suggests that demographic characteristics and genetic background are likely to be major determinants of this joint disorder and play a more important role than severity of iron overload. Bone fragility was observed in a fifth of the patients with HH, independently of genetic background and severity of iron overload, and was strongly associated with hepatic cirrhosis.Conclusion:Future investigations should focus on pathogenesis and early identification of patients at risk of developing bone and joint complications secondary to HH.

Myocardial iron is strongly associated with reproductive function in beta-thalassemic women under chelation therapy

Objective: To evaluate gynaecological features of a group of transfusion dependent beta-thalassemic women and to analyze their reproductive function with the morpho-functional features of genital female tract. Materials and Methods: Cross-sectional study in a University Hospital and Tertiary Care Center. Fifty-nine transfusion-dependent beta-thalassemic women in reproductive age, were divided into two groups: to group A were assigned women with spontaneous menarche (n=44), while to group B were allocated patients with inducted menarche. Data on demographic characteristics, iron overload in liver and heart (evaluated with T2* RMN method), chelation therapy, and reproductive function were collected. Difference in demographic characteristics, chelation therapy, iron status, and reproductive function between groups were assessed, together with correlation analysis of iron overload. Results: Patients in group B had a worse reproductive function and a higher myocardial iron overload, than patients in group A. Moreover multivariate logistic regression showed a significant correlation between uterine biometry, FSH, E2, parity and hearth iron T2*HSIV, but not with liver iron. Conclusion: The present data shows that myocardial iron loading could be putative of prolonged and severe iron overload in the female genital tract, impairing fertility and reproductive function in patients affected with beta-thalassemia major under chelation therapy.

Extensive iron overload in bone marrow: A cause of pancytopenia in a thalassemia major patient – A case report

Iron overload-associated organ damage in transfusion-dependent anemias is a well-known phenomenon. Here, we discuss a case of 28-year-old, poorly chelated thalassemia major patient, whose blood workup revealed pancytopenia and moderately raised serum ferritin levels. His bone marrow examination was performed which revealed massive iron overload. Aggressive iron chelation led to successful recovery of peripheral blood counts in his patient. This case focuses on the importance of early detection and timely management of reversible iron overload toxicities. Serum ferritin although is convenient marker to asses iron overload, but it should not be relied upon to assess the severity of iron overload. Hence, organ-specific diagnostic modalities must be used along with serum ferritin to assess the severity of iron overload to prevent long-term complications in patients with regular blood transfusions.

Hepatic iron load differs strikingly between peritoneal dialysis and hemodialysis patients

Introduction &#x0D; Iron overload is one of the most controversial topics in the management of anemic dialysis patients. Parenteral iron supplementation is commonly prescribed to hemodialysis (HD) patients but less frequently to peritoneal dialysis (PD) patients. Moreover, ferritin targets are far lower and more physiological in PD than in HD.&#x0D; Methods&#x0D; We compared the liver iron concentration (LIC) measured by means of Signal-Intensity ratio (SIR) magnetic resonance imaging (MRI) according to Rennes University method in a cohort of 32 PD patients living in the Paris region published in 2017, with two cohorts of French HD patients studied in the same way (119 patients reported in 2012 and 80 further patients reported in 2014).&#x0D; Results&#x0D; Normal hepatic iron load (LIC ≤ 50 µmol/g of dry weight) was observed in 81.3% of the 32 PD patients (CI: 64.3-91.5%), as compared to only 16% (CI: 10.4-23.7%) in the first HD cohort and 35% (CI: 25.4-45.9%) in the second HD cohort (p&lt;0.0001 for both comparisons; X2 test). Mild iron overload (50 &lt; LIC ≤ 100 µmol/g) was found in 5 PD patients and severe overload (LIC &gt; 200 µmol/g) in only one PD patient (who had received IV iron) (3.1%; CI: 0-17.1%). Conversely, severe iron overload was found in 30.3% of patients in the first HD cohort (CI: 22.7-39%) and 11.3% of those in the second HD cohort (CI: 5.8-20.2%) (p= 0.0033 versus the first HD cohort, X2 test).&#x0D; Conclusion&#x0D; Contrary to hemodialysis patients, iron overload is rare and mostly mild in peritoneal dialysis patients.

MRI evaluation of hepatic and cardiac iron burden in pediatric thalassemia major patients: spectrum of findings by T2*

BackgroundIron deposition distorts the local magnetic field exerting T2* signal decay. Biopsy, serum ferritin, echocardiography are not reliable to adjust iron chelation therapy. Quantified MRI signal decay can replace biopsy to diagnose iron burden, guide treatment, and follow up. The objective of this study is to evaluate the role of T2* in quantification of the liver and heart iron burden in thalassemia major patients. This cross-sectional study included 44 thalassemia patients who were referred to MRI unit, underwent T2* MRI.ResultsTwenty-one male (47.7%) and 23 female (52.3%) were included (age range 6–15 years, mean age 10.9 ± 2.9 years). Patients with excess hepatic iron show the following: 11/40 (27.5%) mild, (13/40) 32.5% moderate, and (14/40) 35% severe liver iron overload. High statistical significance regarding association between LIC and liver T2* (p = 0.000) encountered. Cardiac T2* values showed no relationship with age (p = 0.6).ConclusionT2* is a good method to quantify, monitor hepatic and myocardial iron burden, guiding chelation therapy and prevent iron-induced cardiac complications.

Evaluation of Pulmonary Function in Patient with Transfusion Dependent Beta Thalassemia with Severe Iron Overload

Background; Transfusion-dependent β-thalassemia (TDT) is a severe form of congenital anemia. Regular blood transfusion and continual administration of iron-chelators are conventional therapeutic strategies in TDT. Despite progressive advancements in developing various iron scavenging drugs, iron overload is still considered a challenging conundrum in these patients. Multiple organ dysfunctions result from the toxic effect of excess iron deposition in parenchymal tissues that cause high morbidity and mortality among TDT patients. The greatest affected tissues include endocrine glands, liver, heart, and kidneys. Aim of the study: To investigate pulmonary function of patients with TDT in relation to their iron overload. Patients and Methods: Pulmonary function tests were done for 10 Patient with TDT (table 1) in a well-equipped lung function unit in a tertiary care hospital by experienced respiratory technicians. An ideal test session was taken up following ATS/ERS recommendations. A proper grading system including acceptability and repeatability criteria was applied. Measurement of DLCO is done with a technique of single breath carbon monoxide (CO) uptake in the lung and lung volume is measured with gas dilution and body plethysmography. Chest x ray (CXR) was obtained in all patients. Pulmonary function test was classified according to the following categories based on ATS/ERS criteria and American medical association criteria (AMA); Normal: FEV1/FVC more than 70% FEV1, FVC, TLC, RV and DLCO normal (at least 80% predicted)Obstructive: FEV1/FVC less than 70% FEV1 and FVC (less than 80% predicted). TLC and RV either normal or elevated (at least 120% predicted). DLCO normal (at least 80% predicted)Restrictive: FEV1/FVC ratio (more than 70%) (1) FEV1, FVC, and TLC decreased (no more than 80% predicted) and a decrease in DLCO (no more than 80% predicted) or (2) TLC and RV decreased (no more than 80% predicted) with normal DLCO, FEV1, FVC, and FEV1/FVC, suggestive of low lung volumes, or (3) reduced TLC and DLCO.Mixed obstructive and restrictive: FEV1/FVC ratio reduced, suggestive of obstructive disease. TLC and RV reduced, suggestive of restrictive disease. DLCO normalIsolated low DLCO: DLCO decreased with normal FEV1, FVC, FEV1/FVC, TLC, and RV (As per AMA DLCO less than 75% were considered abnormal) Results: In our 10 TDT patients 9 had normal CXR. One patient had minimal patchy ground glass opacity. Six patients (60%) had abnormally low DLCO indicating some impairment at the level of alveolar capillary membrane. None of them had obstructive pattern. However 2 patients had some air trapping. DLCO, DLCO/Hb, DLCO/VA and RV were correlated negatively with LIC (fig 1) . PFTs (DLCO, RV, and TLC) were correlated negatively with the LIC. In addition, FEV1 and FVC were correlated negatively with ferritin level (r = -0.7 and -0.77 respectively, p &lt;0.01) (fig2). Discussion: we documented a significant alveolar capillary membrane dysfunction in a good number of asymptomatic patients with TDT. This dysfunction appears to increase with advance of age. Iron deposition in the lung parenchyma appears to be the etiology of this abnormality as supported by the significant negative correlations between PFT parameters on the one hand and LIC and ferritin level on the other hand. Conclusions: Substantial alveolar capillary membrane dysfunction occurs in a good number of asymptomatic patients with TDT which is correlated with the degree of iron overload. Further studies are required to confirm these abnormalities on a large scale. Disclosures No relevant conflicts of interest to declare.

Selecting ß-Thalassemia Patients for Gene Therapy: A Decision-Making Algorithm

Introduction and Aim Till today, the only curative and most widely used therapy for β-thalassemia (β-TDT) is allogeneic HSCT: the European Society for Bone Marrow Transplantation Hemoglobinopathy Registry reported over 90% overall survival in under-14 patients transplanted from an HLA identical family donor. However, with the new therapeutic scenario opened up by Gene Therapy (GT), it has become essential to identify and prioritize patient profiles for which GT could be applied. The "Pesaro Patients Risk Classification" showed the importance of risk stratification in order to achieve the best results. The Italian Scientific Society for Thalassemias and Hemoglobinopathies (SITE) closely involved in the cure and overall approach to these pathologies, decided to carry out this project of analysis and assessment to establish the possible inclusion and exclusion criteria for access to GT of patients with β-TDT and to collect the outcomes. The aim of this study is to identify which patients with β-TDT could benefit from GT, based on evidence and consensus. Methods The decision-making algorithm was developed within the scientific activity of SITE, which defined the feasibility of the project and selected the multidisciplinary panel of experts in hemoglobinopaties for the elaboration of clinical issues. Published literature (Medline, PubMed, Embase, Cochrane Library) was searched in order to get solid evidences regarding best candidates to allogeneic SCT, who should not therefore undergo GT. Evaluation of literature and scientific evidences were reported and discussed through call conferences and mails communications. The final review has been performed by a pool of external reviewers who evaluated the clinical relevance, the applicability, the legibility of the document and the consistency between the recommendations and the summaries of the tests produced to test the algorithm. This step is in progress. The final version of the document will be made available on the web site of SITE (www.site-italia.org). The outcomes of the procedures will be collected in the electronic clinic database used by the Centers (i.e Webthal©) to perform a risk stratification. Results and Conclusions The patient selection procedure must be performed by the joint evaluation of the Center of the "Hemoglobinopathies Italian Network" together with the qualified treatment Center for HCS transplantation. The document is proposed as a dynamic and up-datable tool. It is structured such as to allow two levels of consultation: an interactive flow chart (Figure) presenting the different clinical issues discussed with conclusive practical indications linked to chapters providing detailed information on each aspect of the subject. Applying the appropriate cautionary considerations, patients are considered non-eligible in the case of: exclusion criteria indicated by the Regulatory Authorities (i.e. EMA/CHMP/166977/2019);Severe iron overload and/or organ damage (i.e. pulmonary hypertension). Manageable iron overload is a condition of re-evaluation. Caution is mandatory in the evaluation of patients with complications or comorbidities. The access to GT needs to be re-evaluated on the basis of scientific and regulatory updates. Figure Disclosures Longo: Blue Bird Bio: Consultancy. Pinto:Novartis: Consultancy; Bluebird Bio.: Consultancy. Angelucci:Novatis: Honoraria, Other: Chair Steering Committee TELESTO protocol; Celgene: Honoraria, Other: Participation in DMC; BlueBirdBio: Other: Local advisory board; Jazz Pharmaceuticals: Other: Local advisory board; Roche: Other: Local advisory board; Vertex Pharmaceuticals Incorp., and CRISPR Therapeutics: Other: Participation in DMC. Cappellini:Novartis: Membership on an entity's Board of Directors or advisory committees; Vifor Pharmaceutical: Membership on an entity's Board of Directors or advisory committees; Celgene Corporation: Honoraria; CRISPR Therapeutics: Membership on an entity's Board of Directors or advisory committees; Genzyme/Sanofi: Honoraria, Membership on an entity's Board of Directors or advisory committees. Piga:Acceleron Pharma: Research Funding; Novartis: Consultancy, Research Funding; Celgene Corporation: Consultancy, Research Funding. Forni:Roche, Erithropoiesis Stimulation: Research Funding; Celgene, Erithropoiesis Stimulation: Research Funding; Novartis, Iron chelation: Research Funding; BlueBirdBio: Consultancy.

Increased Allele Frequency of GNPAT p.D519G in Compound HFE p.C282Y/p.H63D Heterozygotes with Elevated Serum Ferritin Levels

In hemochromatosis, iron overload is due to increased intestinal iron absorption attributable to mutations in several genes involved in the regulation of iron absorption and metabolism. The most common type of hemochromatosis is caused by mutations in the HFE gene, and homozygosity for the HFE p.C282Y mutation is associated with a risk of iron overload. Approximately 1:200 people of Caucasian origin are homozygous for p.C282Y, but only a minority of p.C282Y homozygotes develop significant iron overload. This is attributed in part to the presence of putative genetic modifiers of iron absorption. Recently, we identified GNPAT, encoding glyceronephosphate O-acyltransferase, as a potential modifier of HFE hemochromatosis in a whole-exome sequencing study of p.C282Y homozygotes with extreme iron overload phenotypes. A GNPAT polymorphism (p.D519G, rs11558492) was associated with severe iron overload among p.C282Y homozygous men (Hepatology 2015;62:429-39). Other studies have either substantiated or contradicted the importance of GNPAT p.D519G as a genetic modifier of iron phenotypes in HFE p.C282Y homozygotes. p.D519G is also a risk factor for familial (but not sporadic) porphyria cutanea tarda (Plos One 2016;11:e0163322). Some patients with hemochromatosis phenotypes are heterozygous for p.C282Y and a different HFE polymorphism, p.H63D (which is also common but usually not itself associated with clinically significant iron overload). Many p.C282Y/p.H63D compound heterozygotes have milder iron overload phenotypes than p.C282Y homozygotes. Herein, we report studies of the prevalence of p.D519G in a cohort of compound heterozygous p.C282Y/p.H63D Australian patients, with or without elevated serum ferritin (SF) levels. We also compared p.D519G allele frequency of the present p.C282Y/p.H63D compound heterozygotes with those of large population cohorts. We identified 72 HFE p.C282Y/p.H63D compound heterozygotes with DNA available for analysis. Of these, 9 had missing SF data and were excluded. GNPAT p.D519G was assessed in the remaining 63 subjects. Compound heterozygotes with elevated SF levels ≥300 µg/mL (males) and ≥200 µg/mL (females) were selected as cases (n=28), and participants with SF levels below these cut-offs were classified as controls (n=35). The mean age at the time of testing was 31 y (males 31, females 31) in the control group and 48 y (males 47, females 51) in subjects with elevated SF levels. Among cases, mean SF was 612 µg/L (median 557 µg/L, IQR 361- 821 µg/L). Mean SF in the control group was 85 µg/L (median 58 µg/L, IQR 38 - 121 µg/L). All samples were genotyped for GNPAT p.D519G. We compared the p.D519G allele frequency of the present subjects, with and without elevated SF, to the p.D519G frequency in publically available datasets. p.D519G allele frequency was greater in the elevated SF group (37.5%) than the control group (24.3%), but this difference was not significant (p=0.1285). p.D519G was more prevalent in our cohort of p.C282Y/p.H63D compound heterozygotes with elevated SF (37.5%) than in European populations reported in public datasets: ExAC 19.7%, 1000G 21.3%, gnomAD 20.4%, and ESP 20.6%. There was a significant association between allele count and case/control status among men (type 3 analysis of effects; p = 0.049) but not women. For a male case, the odds of having either 1 or 2 alleles versus having 0 alleles was 5.08 (95% CI, 1.01, 25.66) times higher than that of a male control. In conclusion, our results demonstrate that GNPAT p.D519G is associated with elevated SF levels in Australian HFE p.C282Y/p.H63D compound heterozygotes and that the p.D519G allele frequency is greater in p.C282Y/p.H63D compound heterozygotes with elevated SF than in several large European population cohorts. We found a statistically significant association between the allele count and the case/control status among men. The small number of subjects with elevated SF in our study may have limited our ability to demonstrate significant differences in some comparisons. Some subjects with p.D519G do not have elevated SF, suggesting that there are other factors, genetic or environmental, which also affect iron absorption in p.C282Y/p.H63D compound heterozygotes. Disclosures No relevant conflicts of interest to declare.

Pancreatic Iron Deposition Following the Role of Iron Loading Among Transfusion Dependent Sickle Cell Disease Egyptian Children and Young Adults

Background: Transfusion in sickle cell disease (SCD) is uncommon but a well-defined practice; either as a replacement in severe anemia or as a prophylactic therapy for its major complications mainly stroke. Differential iron loading in SCD especially the extrahepatic organs is not fully studied. Primary objective is to measure pancreatic iron load among Egyptian transfusion-dependant SCD patients by using MRI T2* relaxometry method. Secondaryobjective is to correlate pancreatic iron load to transfusion iron input, both hepatic and cardiac iron load, trend of serum ferritin. Subjects and Methods: Sixty-six transfusion-dependant SCD child and young adults 8-25 years with more than twenty transfusions before enrollment, non was on regular exchange transfusion; they underwent clinical and laboratory assessments; complete hemogram, serum ferritin and serum amylase. All patients performed MRI examination on a 1.5- Tesla super conductive MR Philips scanner in MRI unit in Ain Shams University Hospital; the study takes about 10 -15 minutes. Radiological quantification of iron overload was performed via simple mathematical models using Microsoft Excel Spread Sheet for heart, pancreas, and kidneys. Results: The mean age of the studied SCD patients were 15.68 ± 7.02 years, they were 35 male (53.0%), 43 of them (65.2%) had positive family history of SCD. All were multiple transfusion; 22 for cardiopulmonary complication and acute chest syndrome (ASC), nine for stroke prevention and 35 for frequent sickling crisis and symptomatic anemia. Most of patients (80.3%) were on chelation therapies that were mainly (92.5%) oral mono-therapy. High frequencies of comorbidities were recorded in the studied cohort; delayed puberty (65.2%), hepatitis C infection (23.1%) and stroke (14.1%). The studied SCD patients had median transfusion index of 120ml/kg/year with mean iron overload per day 0.23 ± 0.15 mg/kg and half of them had serum ferritin &gt; 2500ug/L. Almost two-thirds had moderate to severe liver iron overload with median LIC 11.63 mg/g liver dry weight, none had cardiac iron overload with median cardiac T2* 31 msec and nearly half of them (42.2%) showed marked decrease in signal intensity of renal cortex with relative sparing of the renal medulla and pelvis. Most of them (86%) had normal to mild pancreatic iron overload with median pancreatic R2* 53.8 msec. Pancreatic R2 level was not significantly correlated to either transfused iron, liver iron or serum ferritin and amylase. Patients with moderate to severe pancreatic iron overload had lower pre-transfusion hemoglobin level (p=0.004), higher level of marker of hemolysis (total bilirubin (p=0.012) and indirect bilirubin (p=0.048) than those with normal pancreatic MRI. Radiological quantification of iron overload was performed via a simple cheap and quick method for analysis of data. Conclusion: Moderately heavy transfused patients with SCD had no iron overload in the heart; pancreas follow same pattern as heart with minimal or no pancreatic iron loading, however moderate to severe hepatic iron loading. Whether iron loading might be related only to frequency of transfusion or also to frequency of vaso-occlusive will be discussed. Disclosures No relevant conflicts of interest to declare.

3183 Explanted Liver Confirming Hereditary Hemochromatosis in an African American Male

INTRODUCTION: Hereditary hemochromatosis (HH) is a disorder in which intestinal iron absorption leads to iron overload. It is associated with mutations in the HFE gene. Most commonly seen in Caucasian individuals; however, it is infrequent to see it present in those of African descent. CASE DESCRIPTION/METHODS: A 52-year-old African American male with a history of decompensated alcoholic cirrhosis with ascites, portosystemic encephalopathy (PSE), and non-bleeding esophageal varices presented to hepatology clinic with a MELD score of 16. He quit drinking ten years before the presentation. He was evaluated for a liver transplant, was subsequently deemed a candidate, and placed on the list. As a part of transplant evaluation, an MRI of the abdomen was obtained approximately which showed cirrhotic liver morphology with no hypervascular liver lesions, but the presence of diffuse T2 hypointensity suggestive of iron overload and fibrosis, located in the liver, pancreas and myocardial tissue (Figure 1). A dedicated cardiac MRI with iron protocol was done to confirm findings and give quantification, which showed iron overload with an iron concentration of 1.8 mg/g of dry weight. Serology showed serum iron 125 ug/dL (normal), ferritin 1281 ng/mL (very high), 95% transferrin saturation (very high), and total iron binding capacity of 132 ug/dL (very low). Hereditary hemochromatosis (HH) was suspected, and genetic testing was conducted. The patient was found to be negative for HFE mutations C282Y, H63D, and S65C. Two months following the serological workup, he underwent a liver transplant with an ABO identical allograft liver. The explanted liver (Figure 2) showed severe iron overload in the hepatocytes confirmed by iron stain with pericanalicular accentuation (Figure 3). The diagnosis was confirmed to be HH. DISCUSSION: HH was confirmed when the presence of multi-organ iron overload was seen in imaging, serology showed significant ferritinemia with 95% transferrin saturation, and biopsy showed the presence of severe iron overload in the hepatocytes. While genetic testing for C282Y, H63D, and S65C was negative, this does not mean HH can be ruled out. Identifying these mutations is not necessary for the diagnosis of HH, but the mutations are predominantly positive in Caucasians. For other ethnicities, including Africans, there are rare HH mutations that can return positive but were not tested. This case describes a rare phenomenon of biopsy proven HH found in an African American male.

Erythroferrone Hormone a Novel Biomarker is associated with Anemia and Iron Overload in Beta Thalassemia Patients.

Erythroferrone (ERFE) is a glycoprotein hormone produced by erythroblasts in response to erythropoietic activity by stimulation of erythropoietin that acts directly on the liver to inhibit production of hepcidin, lead to increases iron delivery for intensified activity of erythropoietic. Beta thalassemia are inherited disorders characterized by reduced or absent synthesis of beta globin chains in the hemoglobin (Hb) molecule1 The pathophysiology has been recognized by anemia and iron overload continually with resultant of frequented blood transfusions. We intend to investigate serum ERFE level and their associations with each other. Beta Thalassemia (BT) patients, who were inspected at thalassemia center in ALzahraà hospital teaching period transfusions blood (PTB) for each (14-30 day). Seventy patients were aged about (11-28 year) and 20 subjects healthy as control group, who matched were included in the study. Results. Serum ERFE levels were significantly higher in BT patients compared to control groups. There were significantly (p<0.05) differences in these biomarker between (BTM and BTI), (splenectomy and non splenectomy) groups. a negative correlation between ERFE levels with HB, PCV, MCV, MCH, Iron, and Ferritin while it was a not significant correlated with MCHC and PTB. High level of ERFE as new biomarker in patients with BTM and BTI is associated with mild or severe anemia and iron overload especially in patients with splenectomy.

Mouse models of hereditary hemochromatosis do not develop early liver fibrosis in response to a high fat diet.

Hepatic iron overload, a hallmark of hereditary hemochromatosis, triggers progressive liver disease. There is also increasing evidence for a pathogenic role of iron in non-alcoholic fatty liver disease (NAFLD), which may progress to non-alcoholic steatohepatitis (NASH), fibrosis, cirrhosis and hepatocellular cancer. Mouse models of hereditary hemochromatosis and NAFLD can be used to explore potential interactions between iron and lipid metabolic pathways. Hfe-/- mice, a model of moderate iron overload, were reported to develop early liver fibrosis in response to a high fat diet. However, this was not the case with Hjv-/- mice, a model of severe iron overload. These data raised the possibility that the Hfe gene may protect against liver injury independently of its iron regulatory function. Herein, we addressed this hypothesis in a comparative study utilizing wild type, Hfe-/-, Hjv-/- and double Hfe-/-Hjv-/- mice. The animals, all in C57BL/6J background, were fed with high fat diets for 14 weeks and developed hepatic steatosis, associated with iron overload. Hfe co-ablation did not sensitize steatotic Hjv-deficient mice to liver injury. Moreover, we did not observe any signs of liver inflammation or fibrosis even in single steatotic Hfe-/- mice. Ultrastructural studies revealed a reduced lipid and glycogen content in Hjv-/- hepatocytes, indicative of a metabolic defect. Interestingly, glycogen levels were restored in double Hfe-/-Hjv-/- mice, which is consistent with a metabolic function of Hfe. We conclude that hepatocellular iron excess does not aggravate diet-induced steatosis to steatohepatitis or early liver fibrosis in mouse models of hereditary hemochromatosis, irrespectively of the presence or lack of Hfe.

Genotype/phenotype correlations of childhood-onset congenital sideroblastic anaemia in a European cohort.

Congenital sideroblastic anaemia (CSA) is a rare disease caused by germline mutations of genes involved in haem and iron-sulphur cluster formation, and mitochondrial protein biosynthesis. We performed a retrospective multicentre European study of a cohort of childhood-onset CSA patients to explore genotype/phenotype correlations. We studied 23 females and 20 males with symptoms of CSA. Among the patients, the most frequently mutated genes were ALAS2 (n=10; 23·3%) and SLC25A38 (n=8; 18·6%), causing isolated forms of microcytic anaemia of varying severity. Five patients with SLC19A2 mutations suffered from thiamine-responsive megaloblastic anaemia and three exhibited the 'anaemia, deafness and diabetes' triad. Three patients with TRNT1 mutations exhibited severe early onset microcytic anaemia associated with thrombocytosis, and two exhibited B-cell immunodeficiency, inflammatory syndrome and psychomotor delay. The prognoses of patients with TRNT1 and SLC2A38 mutations were generally dismal because of comorbidities or severe iron overload. No molecular diagnosis could be established in 14/43 cases. This study emphasizes the frequency of ALAS2 and SLC25A38 mutations and provides the largest comprehensive analysis to date of genotype/phenotype correlations in CSA. Further studies of CSA patients with data recorded in an international registry would be helpful to improve patient management and establish standardized guidelines.

GNPAT variant (D519G) is not associated with an elevated serum ferritin or iron removed by phlebotomy in patients referred for C282Y-linked hemochromatosis

Background. Previous studies in high and low expressors has demonstrated that a variant in the GNPAT gene (D519G, Rs11558492, chromosome 1, exon 11) has been associated with severe iron overload in C282Y homozygotes for hemochromatosis. In this study, a GNPATvariant was assessed prospectively in patients referred for HFE testing over a range of serum ferritin levels.Material and methods. Consecutive patients sent for HFE testing were studied for the GNPAT variant using a TaqMan kit assay (Life Technologies, Burlington, ON). Serum ferritin and iron removed by phlebotomy was compared in C282Y homozygotes with and without the GNPATvariant. The frequency of the GNPATvariant in referred patients was compared to a control population of voluntary blood donors without HFE mutations.Results. There were 533 patients that had GNPATanalysis. The allele frequency for the GNPATvariant in C282Y homozygotes (n = 75) was 0.226 and in wild type control patients (n = 458) was 0.213 (p = .07). Forty-eight percent (of the C282Y homozygotes were heterozygous (n = 28) or homozygous (n = 8) for the GNPATvariant. The mean (log)ferritin and iron removed did not significantly differ between C282Y homozygous with GNPAT homozygotes, GNPAT heterozygotes, and without the GNPATvariant (p = 0.84).Conclusions. C282Y homozygotes referred for HFE testing commonly have a GNPATvariant. This GNPATvariant does not appear be a co-modifying gene affecting expression of HFE related hemochromatosis in this population. The GNPATvariant does not predict the severity of iron overload.