Iron overload

Iron overload
Micrograph of haemosiderosis. Liver biopsy. Iron stain.
Specialty Hematology

Iron overload (variously known as haemochromatosis, hemochromatosis, hemochromocytosis, Celtic curse, Irish illness, British gene, Scottish sickness and bronzing diabetes) indicates accumulation of iron in the body from any cause. The most important causes are hereditary haemochromatosis (HHC), a genetic disorder, and transfusional iron overload, which can result from repeated blood transfusions.[1][2]

Signs and symptoms

Organs most commonly affected by haemochromatosis are the liver, heart, and endocrine glands.[3]

Haemochromatosis may present with the following clinical syndromes:[4]

Diabetes in people with iron overload occurs as a result of selective iron deposition in islet beta cells in the pancreas leading to functional failure and cell death.

Arthritis, from calcium pyrophosphate deposition in joints leading to joint pains. The most commonly affected joints are those of the hands, particularly the knuckles of the second and third fingers.[5]

Bronzing of the skin. This deep tan color, in concert with insulin insufficiency due to pancreatic damage, is the source of a nickname for this condition: "bronze diabetes".

Causes and forms

The causes can be distinguished between primary cases (hereditary or genetically determined) and less frequent secondary cases (acquired during life).[6] People of Celtic (Irish, Scottish, Welsh, Cornish, Breton etc.), English, and Scandinavian origin[7] have a particularly high incidence, with about 10% being carriers of the principal genetic variant, the C282Y mutation on the HFE gene, and 1% having the condition.[8]

Primary haemochromatosis

Although it was known most of the 20th century that most cases of haemochromatosis were inherited, they were incorrectly assumed to depend on a single gene.[9] The overwhelming majority depend on mutations of the HFE gene discovered in 1996, but since then others have been discovered and sometimes are grouped together as "non-classical hereditary haemochromatosis",[10] "non-HFE related hereditary haemochromatosis",[11] or "non-HFE haemochromatosis".[12]

DescriptionOMIMMutation
Haemochromatosis type 1: "classical" haemochromatosis235200HFE
Haemochromatosis type 2A: juvenile haemochromatosis602390Haemojuvelin ("HJV", also known as RGMc and HFE2)
Haemochromatosis type 2B: juvenile haemochromatosis606464hepcidin antimicrobial peptide (HAMP) or HFE2B
Haemochromatosis type 3604250transferrin receptor-2 (TFR2 or HFE3)
Haemochromatosis type 4/
African iron overload		604653ferroportin (SLC11A3/SLC40A1)
Neonatal haemochromatosis231100(unknown)
Acaeruloplasminaemia (very rare)604290caeruloplasmin
Congenital atransferrinaemia (very rare)209300transferrin
GRACILE syndrome (very rare)603358BCS1L

Most types of hereditary haemochromatosis have autosomal recessive inheritance, while type 4 has autosomal dominant inheritance.[13]

Secondary haemochromatosis

Diagnosis

Selective iron deposition (blue) in pancreatic islet beta cells(red).

There are several methods available for diagnosing and monitoring iron loading.

Blood tests are usually the first test if there is a clinical suspicion of iron overload. Serum ferritin testing is a low-cost, readily available, and minimally invasive method for assessing body iron stores. However, the major problem with using it as an indicator of iron overload is that it can be elevated in a range of other medical conditions unrelated to iron levels including infection, inflammation, fever, liver disease, kidney disease, and cancer. Also, total iron binding capacity may be low, but can also be normal.[14] Serum ferritin: In males and postmenopausal females, a serum ferritin value of over 300 ng/mL (670 pmol/L) indicates iron overload.[15][16][17] In premenopausal females, a serum ferritin value of over 150[15] or 200[16] ng/mL (330 or 440 pmol/L)[17] indicates iron overload. If the person is capable of showing the symptoms, they may need to be tested more than once throughout their lives as a precautionary, most commonly in women after menopause. Transferrin saturation is a more specific test.

DNA/screening: the standard of practice in diagnosis of haemochromatosis places emphasis on genetic testing.[18] Positive HFE analysis confirms the clinical diagnosis of haemochromatosis in asymptomatic individuals with blood tests showing increased iron stores, or for predictive testing of individuals with a family history of haemochromatosis. The alleles evaluated by HFE gene analysis are evident in ~80% of patients with haemochromatosis; a negative report for HFE gene does not rule out haemochromatosis. First degree relatives of those with primary haemochromatosis should be screened to determine if they are a carrier or if they could develop the disease. This can allow preventive measures to be taken. Screening the general population is not recommended.[19]

Liver biopsy is the removal of small sample in order to be studied and can determine the cause of inflammation or cirrhosis. In someone with negative HFE gene testing, elevated iron status for no other obvious reason, and family history of liver disease, additional evaluation of liver iron concentration is indicated. In this case, diagnosis of haemochromatosis is based on biochemical analysis and histologic examination of a liver biopsy. Assessment of the hepatic iron index (HII) is considered the "gold standard" for diagnosis of haemochromatosis.

Magnetic resonance imaging (MRI) is used as a noninvasive way to accurately estimate iron deposition levels in the liver as well as heart, joints, and pituitary gland.

Treatment

Phlebotomy/venesection: routine treatment consists of regularly scheduled phlebotomies (bloodletting or erythrocytapheresis). When first diagnosed, the phlebotomies may be performed every week or fortnight, until iron levels can be brought to within normal range. Once the serum ferritin and transferrin saturation are within the normal range, treatments may be scheduled every two to three months depending upon the rate of reabsorption of iron. A phlebotomy session typically draws between 450 and 500 mL of blood.[20]

Diet low in iron is generally recommended, but has little effect compared to venesection. The human diet contains iron in two forms - heme iron and non-heme iron. Heme iron is the most easily absorbed form of iron. People with iron overload may be advised to avoid food that are high in heme iron. Highest in heme iron is red meat such as beef, venison, lamb, buffalo, and fish such as bluefin tuna. A strict low iron diet is usually not necessary. Non-heme iron is not as easily absorbed in the human system and is found in plant-based foods like grains, beans, vegetables, fruits, nuts, and seeds.[21]

Medication: For those unable to tolerate routine blood draws, there are chelating agents available for use.[22] The drug deferoxamine binds with iron in the bloodstream and enhances its elimination in urine and faeces. Typical treatment for chronic iron overload requires subcutaneous injection over a period of 8–12 hours daily. Two newer iron chelating drugs that are licensed for use in patients receiving regular blood transfusions to treat thalassaemia (and, thus, who develop iron overload as a result) are deferasirox and deferiprone.[23][24]

Prognosis

In general, provided there has been no liver damage, patients should expect a normal life expectancy if adequately treated by venesection. If the serum ferritin is greater than 1000 ug/L at diagnosis there is a risk of liver damage and cirrhosis which may eventually shorten their life.[25] The presence of cirrhosis increases the risk of hepatocellular carcinoma.[26]

Epidemiology

It is most common in certain European populations (such as the Irish and Norwegians) and occurs in 0.6% of the population.[19] Men with the disease are 24 times more likely to experience symptoms than affected women.[19]

History

Stone age

Two factors are thought to have had large influence on the mutation of genes related to Iron overload during the Stone Age: diet and the environment. Starting during the Mesolithic Era, communities of people lived in an environment that was fairly sunny, warm and had the dry climates of the Middle East. Most of the humans who lived at the time were foragers and their diets consisted mostly of hunting game, gathering and even fishing when and if the opportunity arose. With the archaeologists studying dental plaque and the assumptions of what would have been available to the people due to their environment, leads to the theories of Mesolithic foragers eating substances such as tubers, nuts, plantains, grass and much of the food would have been was very rich in iron. Over hundreds of years and many generations, the body was very well adapted to the high level of iron content in the consumption.[27]

Moving forward in time and studying the Neolithic Era, which was during the end of the Stone Age, we see significant changes in both the environment and diet of the traveling people. During the European Neolithic era, some communities of foragers migrated north. The change in lifestyle and environment, with a decrease in temperatures and a change in the landscape in which the foragers then needed to adapt to. As the people began to develop and advance their use of tools and learn new ways of producing food, hunting and gathering was no longer the main food source, and farming also slowly developed. The change that the travelers encountered would have lead to serious stress on the body and a decrease in iron rich consumption. This transition is a key factor in which researchers can start to see the link between the travelers diets, environment and the mutations of genes, especially those that regulated the iron absorption within the body. Iron, which makes of 70% of our red blood cell composition, is a critical micronutrient for effective thermoregulation in the body.[28] When the body encounters a deficiency of its micronutrients, in this case iron, it will lead to a drop in the core temperature. When the travelers encountered the much more chilly and damp environments of Europe, the supplementary iron from food was a necessity to help keep their temperatures regulated--however, without the iron supplements from the food the human body would have undergone serious stress to make up for the lost iron and would have started to store iron at higher rates than normal. This theory hypothesizes that the pressures caused by the migration would be the initiation to the gene mutation that allowed the body to absorb and store higher amounts of iron.[29] It is not known the exact time at which the gene mutated or in which location these people were in when it happened. However, when the time frame at which the migrators would have started to move north and the increasing probability of the people’s bodies adapting, lead to the assumption that the travelers would have moved and helped to develop the Celtic Empire during the Bronzing Age. This theory would also offer an explanation of why the name ‘Celtic Curse’ became a well known alternative/nickname for hemochromatosis.

Viking hypothesis

Many studies and surveys are being conducted in order to determine the frequencies of the disease in countries and also to understand how the mutation migrated around the globe. The theory that this disease initially evolved from travelers migrating north helped to give an understanding of how it may have initially evolved. Through the surveys and counting of affected, there was a very particular distribution pattern of the disease in which there are large clusters and frequencies of the gene mutations found along the coastline of Europe.[30] This is the pattern that has been noticed is what helped lead to the development of the “Viking Hypothesis”.[31] The locations of clusters and mapped patterns of this mutation have a very close correlation to the migration of Vikings and locations of Viking settlements in Europe that occurred around the time of c.700 AD to c.1100 AD. The Vikings originally came from the three countries of Scandinavia (Norway, Sweden and Denmark) and when on land, they had multiple Kingdoms and their way of life mostly evolved around farming and trade. When the Northmen took to the sea they were given the name ‘Vikings’ which was developed from the Old Norse language and meant ‘pirates’.[32] The Viking ships made their way along the coastline of Europe in search for trade, riches, land and the migration of their people. The genetic studies to date along with the extremely high frequency patterns in some European countries lead to the suggestion that the mutation could have been easily spread by Vikings and later by the Normans, indicating a genetic link between hereditary hemochromatosis and Viking ancestry.[33]

Modern times

In 1865, Armand Trousseau (a French internist) was one of the first to describe many of the symptoms of a diabetic patient with cirrhosis of the liver and had bronzed skin color.[34] The term hemochromatosis was first used by German pathologist named Friedrich Daniel von Recklinghausen in 1890 when he introduced an accumulation of iron in body tissue. In 1935 J.H. Sheldon, a British physician, described the pathophysiology mechanism linked to iron metabolism for the first time.[35]

In 1996 Felder and colleagues identified the hemochromatosis gene, HFE gene. Felder found that the HFE gene has two main mutations, C282Y and H63D, which were the main cause of hereditary hemochromatosis. The next year the CDC and the National Human Genome Research Institute sponsored an examination of hemochromatosis following the discovery of the HFE gene which helped lead to the population screenings and estimates that are still being used today.

Terminology

Historically, the term haemochromatosis (spelled hemochromatosis in American English) was initially used to refer to what is now more specifically called haemochromatosis type 1 (or HFE-related hereditary haemochromatosis). Currently, haemochromatosis (without further specification) is mostly defined as iron overload with a hereditary or primary cause,[36][37] or originating from a metabolic disorder.[38] However, the term is currently also used more broadly to refer to any form of iron overload, thus requiring specification of the cause, for example, hereditary haemochromatosis. Hereditary haemochromatosis is an autosomal recessive disorder with estimated prevalence in the population of 1 in 200 among patients with European ancestry, with lower incidence in other ethnic groups.[39] The gene responsible for hereditary haemochromatosis (known as HFE gene) is located on chromosome 6; the majority of hereditary haemochromatosis patients have mutations in this HFE gene.

Hereditary haemochromatosis is characterized by an accelerated rate of intestinal iron absorption and progressive iron deposition in various tissues. This typically begins to be expressed in the third to fifth decades of life, but may occur in children. The most common presentation is hepatic (liver) cirrhosis in combination with hypopituitarism, cardiomyopathy, diabetes, arthritis, or hyperpigmentation. Because of the severe sequelae of this disorder if left untreated, and recognizing that treatment is relatively simple, early diagnosis before symptoms or signs appear is important.[18][40]

In general, the term haemosiderosis is used to indicate the pathological effect of iron accumulation in any given organ, which mainly occurs in the form of the iron-storage complex haemosiderin.[41][42] Sometimes, the simpler term siderosis is used instead.

Other definitions distinguishing haemochromatosis or haemosiderosis that are occasionally used include:

  • Haemosiderosis is haemochromatosis caused by excessive blood transfusions, that is, haemosiderosis is a form of secondary haemochromatosis.[43][44]
  • Haemosiderosis is haemosiderin deposition within cells, while haemochromatosis is haemosiderin within cells and interstitium.[45]
  • Haemosiderosis is iron overload that does not cause tissue damage,[46] while haemochromatosis does.[47]
  • Haemosiderosis is arbitrarily differentiated from haemochromatosis by the reversible nature of the iron accumulation in the reticuloendothelial system.[48]

See also

References

  1. ↑ Hider, Robert C.; Kong, Xiaole (2013). "Chapter 8. Iron: Effect of Overload and Deficiency". In Astrid Sigel, Helmut Sigel and Roland K. O. Sigel. Interrelations between Essential Metal Ions and Human Diseases. Metal Ions in Life Sciences. 13. Springer. pp. 229–294. doi:10.1007/978-94-007-7500-8_8.
  2. 1 2 Lu JP, Hayashi K. Selective iron deposition in pancreatic islet B cells of transfusional iron-overloaded autopsy cases. Pathol Int. 1994 Mar;44(3):194-9. PubMed PMID 8025661.
  3. ↑ Andrews, Nancy C. (1999). "Disorders of Iron Metabolism". New England Journal of Medicine. 341 (26): 1986–95. doi:10.1056/NEJM199912233412607. PMID 10607817.
  4. ↑ John Murtagh (2007). General Practice. McGraw Hill Australia. ISBN 0-07-470436-2.
  5. ↑ Bruce R Bacon, Stanley L Schrier. "Patient information: Hemochromatosis (hereditary iron overload) (Beyond the Basics)". UpToDate. Retrieved 2016-07-14. Literature review current through: Jun 2016. | This topic last updated: Apr 14, 2015.
  6. ↑ Pietrangelo, A (2003). "Haemochromatosis". Gut. 52 (90002): ii23–30. doi:10.1136/gut.52.suppl_2.ii23. PMC 1867747. PMID 12651879.
  7. ↑ The Atlantic: "The Iron in Our Blood That Keeps and Kills Us" by Bradley Wertheim January 10, 2013
  8. ↑ "Hemachromatosis". Encyclopædia Britannica.com. Retrieved 17 April 2017.
  9. ↑ Cam Patterson; Marschall S. Runge (2006). Principles of molecular medicine. Totowa, NJ: Humana Press. p. 567. ISBN 1-58829-202-9.
  10. ↑ Mendes, Ana Isabel; Ferro, Ana; Martins, Rute; Picanço, Isabel; Gomes, Susana; Cerqueira, Rute; Correia, Manuel; Nunes, António Robalo; Esteves, Jorge; Fleming, Rita; Faustino, Paula (2008). "Non-classical hereditary hemochromatosis in Portugal: novel mutations identified in iron metabolism-related genes". Annals of Hematology. 88 (3): 229–34. doi:10.1007/s00277-008-0572-y. PMID 18762941.
  11. ↑ Maddrey, Willis C.; Schiff, Eugene R.; Sorrell, Michael F. (2007). Schiff's diseases of the liver. Hagerstwon, MD: Lippincott Williams & Wilkins. p. 1048. ISBN 0-7817-6040-2.
  12. ↑ Pietrangelo, Antonello (2005). "Non-HFE Hemochromatosis". Seminars in Liver Disease. 25 (4): 450–60. doi:10.1055/s-2005-923316. PMID 16315138.
  13. ↑ Franchini, Massimo (2006). "Hereditary iron overload: Update on pathophysiology, diagnosis, and treatment". American Journal of Hematology. 81 (3): 202–9. doi:10.1002/ajh.20493. PMID 16493621.
  14. ↑ labtestsonline.org TIBC & UIBC, Transferrin Last reviewed on October 28, 2009.
  15. 1 2 Ferritin by: Mark Levin, MD, Hematologist and Oncologist, Newark, NJ. Review provided by VeriMed Healthcare Network
  16. 1 2 Andrea Duchini. "Hemochromatosis Workup". Medscape. Retrieved 2016-07-14. Updated: Jan 02, 2016
  17. 1 2 Molar concentration is derived from mass value using molar mass of 450,000 g•mol−1 for ferritin
  18. 1 2 Pietrangelo, Antonello (2010). "Hereditary Hemochromatosis: Pathogenesis, Diagnosis, and Treatment". Gastroenterology. 139 (2): 393–408. doi:10.1053/j.gastro.2010.06.013. PMID 20542038.
  19. 1 2 3 Crownover, BK; Covey, CJ (Feb 1, 2013). "Hereditary hemochromatosis". American Family Physician. 87 (3): 183–90. PMID 23418762.
  20. ↑ Barton, James C. (1 December 1998). "Management of Hemochromatosis". Annals of Internal Medicine. 129 (11_Part_2): 932. doi:10.7326/0003-4819-129-11_Part_2-199812011-00003.
  21. ↑ "Welcome". Hemochromatosis.org - An Education Website for Hemochromatosis and Too Much Iron. Retrieved 2018-04-11.
  22. ↑ Miller, Marvin J. (1989-11-01). "Syntheses and therapeutic potential of hydroxamic acid based siderophores and analogs". Chemical Reviews. 89 (7): 1563–1579. doi:10.1021/cr00097a011.
  23. ↑ Choudhry VP, Naithani R (2007). "Current status of iron overload and chelation with deferasirox". Indian J Pediatr. 74 (8): 759–64. doi:10.1007/s12098-007-0134-7. PMID 17785900.
  24. ↑ Hoffbrand, A. V. (20 March 2003). "Role of deferiprone in chelation therapy for transfusional iron overload". Blood. 102 (1): 17–24. doi:10.1182/blood-2002-06-1867.
  25. ↑ Allen, KJ; Gurrin, LC; Constantine, CC; Osborne, NJ; Delatycki, MB; Nicoll, AJ; McLaren, CE; Bahlo, M; Nisselle, AE; Vulpe, CD; Anderson, GJ; Southey, MC; Giles, GG; English, DR; Hopper, JL; Olynyk, JK; Powell, LW; Gertig, DM (17 January 2008). "Iron-overload-related disease in HFE hereditary hemochromatosis". The New England Journal of Medicine. 358 (3): 221–30. doi:10.1056/NEJMoa073286. PMID 18199861.
  26. ↑ Kowdley, KV (November 2004). "Iron, hemochromatosis, and hepatocellular carcinoma". Gastroenterology. 127 (5 Suppl 1): S79–86. doi:10.1016/j.gastro.2004.09.019. PMID 15508107.
  27. ↑ "The Evolution of Diet". National Geographic. Retrieved 2018-04-11.
  28. ↑ Rosenzweig, P. H.; Volpe, S. L. (March 1999). "Iron, thermoregulation, and metabolic rate". Critical Reviews in Food Science and Nutrition. 39 (2): 131–148. doi:10.1080/10408399908500491. ISSN 1040-8398. PMID 10198751.
  29. ↑ Heath, Kathleen M.; Axton, Jacob H.; McCullough, John M.; Harris, Nathan (May 2016). "The evolutionary adaptation of the C282Y mutation to culture and climate during the European Neolithic". American Journal of Physical Anthropology. 160 (1): 86–101. doi:10.1002/ajpa.22937. ISSN 0002-9483. PMC 5066702. PMID 26799452.
  30. ↑ "Clinical Penetrance of HFE Hereditary Hemochromatosis, Serum Ferritin Levels, and Screening Implications: Can We Iron This Out?". www.hematology.org. 2008-05-01. Retrieved 2018-04-11.
  31. ↑ Symonette, Caitlin J; Adams, Paul C (June 2011). "Do all hemochromatosis patients have the same origin? A pilot study of mitochondrial DNA and Y-DNA". Canadian Journal of Gastroenterology. 25 (6): 324–326. ISSN 0835-7900. PMC 3142605. PMID 21766093.
  32. ↑ "Vikings - Exploration - HISTORY.com". HISTORY.com. Retrieved 2018-04-11.
  33. ↑ "Videos: Hereditary Hemochromatosis | Canadian Hemochromatosis Society". www.toomuchiron.ca. Retrieved 2018-04-11.
  34. ↑ Geller, Stephen A.; de Campos, Fernando P. F. (2015-03-30). "Hereditary hemochromatosis". Autopsy & Case Reports. 5 (1): 7–10. doi:10.4322/acr.2014.043. ISSN 2236-1960. PMC 4608170. PMID 26484318.
  35. ↑ "Haemochromatosis". Blood Reviews. 4 (2): 75–87. 1990-06-01. doi:10.1016/0268-960X(90)90030-V. ISSN 0268-960X.
  36. ↑ thefreedictionary.com > hemochromatosis, citing:
    • The American Heritage Medical Dictionary, 2004 by Houghton Mifflin Company
    • McGraw-Hill Concise Dictionary of Modern Medicine. 2002
  37. ↑ Merriam-Webster's Medical Dictionary > hemochromatosis Retrieved on December 11, 2009
  38. ↑ thefreedictionary.com, citing:
    • Dorland's Medical Dictionary for Health Consumers, 2007
    • Mosby's Medical Dictionary, 8th edition. 2009
    • Jonas: Mosby's Dictionary of Complementary and Alternative Medicine. 2005.
  39. ↑ "Hemochromatosis".
  40. ↑ Brandhagen, D J; Fairbanks, V F; Batts, K P; Thibodeau, S N (1999). "Update on hereditary hemochromatosis and the HFE gene". Mayo Clinic Proceedings. 74 (9): 917–21. doi:10.4065/74.9.917. PMID 10488796.
  41. ↑ Merriam-Webster's Medical Dictionary > hemosideroses Retrieved on December 11, 2009
  42. ↑ thefreedictionary.com > hemosiderosis, citing:
    • The American Heritage Medical Dictionary, 2004 by Houghton Mifflin Company
    • Mosby's Medical Dictionary, 8th edition.
  43. ↑ eMedicine Specialties > Radiology > Gastrointestinal > Hemochromatosis Author: Sandor Joffe, MD. Updated: May 8, 2009
  44. ↑ thefreedictionary.com > hemosiderosis, citing:
    • Gale Encyclopedia of Medicine. Copyright 2008
  45. ↑ Notecards on radiology gamuts, diseases, anatomy 2002, Charles E. Kahn, Jr., MD. Medical College of Wisconsin
  46. ↑ thefreedictionary.com > hemosiderosis, citing:
    • Dorland's Medical Dictionary for Health Consumers, 2007
    • Mosby's Dental Dictionary, 2nd edition.
    • Saunders Comprehensive Veterinary Dictionary, 3rd ed. 2007
  47. ↑ The HealthScout Network > Health Encyclopedia > Diseases and Conditions > Hemochromatosis Retrieved on December 11, 2009
  48. ↑ thefreedictionary.com > hemosiderosis, citing:
    • McGraw-Hill Concise Dictionary of Modern Medicine. 2002
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