Professional Documents
Culture Documents
REVIEW
Received 27 August 1992 and in revised form 1 February 1993; accepted 8 February 1993
fatty acids, and bile acids serving to prevent iron from Transport of iron from gut to liver
precipitation [5,6,16]. This is of particular importance
in the pH-neutral environment of the duodenum where The excretion mechanism of iron at the basolateral site
the actual absorption process takes place [I 71. of the mucosal cells is incompletely understood. It is
Uptake of iron by mucosal cells involves several thought to involve the enzymatic formation of Fe2+
steps: (a) presentation of chelated iron to the cell which passes plasma membranes easier than Fe3+[28].
surface; (b) binding and translocation across the After release from the basolateral site of the plasma
microvillous membrane of the mucosal cell; (c) intra- membrane the toxic effects of Fe2+ (initiation of lipid
cellular transport bound to an intracytoplasmic iron peroxidation, oxidation of catecholamines) are pre-
binding factor; (d) release at the basolateral site of the vented by several mechanisms: (a) binding to low
plasma membrane. In studies with human microvillous molecular weight natural chelating agents (amino
plasma membrane vesicles from duodenum it was acids, ascorbic acid, etc.); (b) oxidation to Fe3+ by
recently shown that the essential step of translocation ceruloplasmin; (c) binding to apo-transferrin which
across the apical plasma membrane represents a transports iron via the portal blood to the liver and
facilitated, high affinity transport system [ 181. A other organs [29]. The transferrin bound iron is taken
glycoprotein composed of three 55 kD subunits was up by the transferrin receptor endosomal pathway
described as the responsible carrier protein [18]. It was [22,30]. In addition a non-endosomal pathway for
shown that this protein is regulated by the body iron uptake of transferrin bound iron was suggested [3 1,321.
status with high expression in iron deficiency anaemia It was thought to involve reduction of Fe3+-transferrin
and downregulation in secondary iron overload dis- at the transferrin receptor site with labilization of Fe2+
ease [19]. After translocation across the plasma mem- binding, translocation across the membrane and rapid
brane iron has to be complexed to an intracytoplasmic incorporation into cytosolic ferritin. However, there
iron binding factor to prevent cell damage by the were methodological problems with this study and the
formation of hydroxy radicals. Whether this factor concept of hepatic iron uptake by an iron reduction
represents a protein or a suitable organic chelator is process is questionable [33].
still unclear. The cytoplasmic transit-iron pool is of Transferrin is a glycoprotein which like other
significance for intracellular iron metabolism, because plasma glycoproteins can be desialated by liver endo-
it coordinates the distribution of intracellular iron thelial cells [34]. This asialotransferrin may then be
according to the cellular needs [20]. taken up into hepatocytes by asialoglycoprotein recep-
tors and enter an endosomal compartment [35]. In
contrast to the pathway of normal (sialylated) trans-
Iron storage proteins ferrin, asialotransferrin does not recycle to the plasma
membrane but is degraded in the lysosomal compart-
Intracellular iron storage proteins are ferritin and ment [35]. While under physiologic conditions this
haemosiderin which are of particular importance in pathway is of no major relevance, in alcoholism
the liver [21,22]. Ferritin is a soluble cytoplasmic asialotransferrin is markedly increased and correlates
protein serving as pure iron storage protein with the with the hepatic iron content and fibrosis as well as
ability of rapid accumulation and release of iron by a with the amount of alcohol consumed (means for
yet unknown molecular mechanism [23]. Structurally, detection of alcohol abuse) [36,37].
ferritin is a spheric complex composed of 24 apoferri- In addition there are endocytotic pathways for
tin monomers of the isotypes H (heavy, 21 kD) and/or hepatocellular incorporation of haeme. Haeme is
L (light, 19 kD) with a total apparent molecular weight taken up in the form of haemoglobin-haptoglobin
of 450.000. To a small extent the complex ferritin complexes [38], as haeme-haemopexin complexes [39]
molecule is released in plasma from which it is taken up and possibly directly from haeme-albumin complexes
by a specific ferritin receptor into certain cell types, e.g. [40]. For the uptake of non-transferrin bound iron the
hepatocytes [24,25]. Haemosiderin is present as an presence of a membrane carrier protein was demon-
insoluble complex in secondary lysosomes, particu- strated, similar to the carrier protein identified in
larly in liver, serving as long-term or even final storage duodenal brush border plasma membranes [ 18,191.
form of iron. It is assumed that haemosiderin is a
proteolytic degradation product of ferritin [26].
Although this amorphous haemosiderin may remain Iron metabolism in haemochromatosis
relatively inert, it may be one major source of the labile
iron thought to be of significance for cellular toxicity Definition and classification of haemochromatosis
[27]. At the light microscopy level, excess soluble The term haemochromatosis defines the pathological
ferritin appears as a blue homogeneous colouration of deposition of excessive iron in the parenchymal cells of
the cytosol on Perl’s Prussian blue staining, while many organs, leading to cellular toxicity and damage
haemosiderin is identified by the same stain as blue followed by functional insufficiency. In genetic haemo-
granular deposits localized most densely around the chromatosis the increase in total body iron stores is
biliary canaliculi of hepatocytes. due to an inappropriately high level of intestinal iron
PATHOGENESIS OF GENETIC HAEMOCHROMATOSIS 323
absorption resulting from an inherited abnormality in shown to be present at the basolateral site of duodenal
iron metabolism. When the accumulation of excess mucosal cells [49-521. At this site the transferrin
iron is due to other conditions, the term secondary iron receptor facilitates entry of iron into the mucosal cell
overload syndrome is used. Of particular importance from plasma by internalizing plasma derived diferric
are diseases associated with disordered erythropoiesis, transferrin. Transferrin receptors are increased in
usually thalassaemia or sideroblastic anaemia. In anaemia, particularly in iron deficient states [53]. It is
addition to the defect in iron utilization and increased assumed that under these conditions iron is absorbed
intestinal iron absorption, those conditions are also in greater amounts by the enterocyte and rapidly
complicated by a parenteral iron overload component diverted to the blood stream. The reduction of the
due to the requirement of multiple transfusions. This intracellular iron pool may activate transferrin recep-
latter component leads to excessive iron deposition tor gene expression in an attempt to restore cellular
initially confined to the RE-system. In later stages iron iron balance. Concomitant with this activation of
is transferred also to the parenchymal cells resembling transferrin receptor gene expression, a decrease in
the organ distribution pattern in genetic haemo- ferritin mRNAs was observed [53]. On the other hand,
chromatosis. Due to the autosomal recessive trait of secondary iron overload conditions reveal a down-
inheritance the full disease is only expressed in homo- regulation of duodenal transferrin receptor and a
zygotes. The clinical features of advanced symptoma- significant higher ferritin H- and L-subunit gene
tic haemochromatosis are characteristic. Patients expression [53].Both situations represent the physiolo-
usually present with lethargy, loss of libido, joint pain, gic response of epithelial cells to iron deficiency and
symptoms related to the onset of diabetes mellitus or iron overload, accomplished by the concerted transla-
upper abdominal pain. Hepatomegaly, skin pigmen- tional regulation of the mRNAs for ferritin and
tation, testicular atrophy/amenorrhoea, and arthro- transferrin receptor [54]. The genes encoding the
pathy are the most prominent physical signs [41]. The ferritin and the transferrin receptor are regulated in
clinical and biochemical expression of the disease response to changing levels of iron by alteration in
varies, depending on such factors as age, sex, and mRNA translocation efficiency of mRNA stability,
chronic blood loss. The lower prevalence of sympto- respectively (Fig. 1). Limitation of iron results in an
matic disease among females (1 : 10) is attributed to increase in the expression of the transferrin receptor,
physiologic iron losses and lower intake of dietary whereas iron excess decreases transferrin receptor
iron. Young patients, identified by family screening are expression. The synthesis of ferritin is regulated in the
often asymptomatic [41]. They rarely present with opposite direction: it increases in the presence of iron
advanced haemochromatosis. In these cases cardio- excess and decreases in iron deficiency. Transferrin
myopathy is a relatively frequent clinical feature. receptor regulation allows for modulation of iron
Heterozygous carriers of the haemochromatosis uptake, and ferritin regulation allows for adequate
gene may reveal minor biochemical expression of the sequestration of excess iron and minimizes sequest-
disease with a slightly increased level of iron absorp- ration when iron is limited. The opposite but coordi-
tion in 20-32% of the cases (42-44). However, nate regulation of these two genes is mediated by
progressive iron overload with full clinical and bio- similar cis-acting RNA sequence/structure motifs
chemical expression is not a feature of heterozygous forming moderately stable stem-loop configurations in
subjects, not even in subjects who have an excessive the untranslated regions of both mRNAs (iron respon-
intake of alcohol [45,46,47]. sive elements (IRE’S) [55]. While for ferritin the IRE is
localized in the 5‘ untranslated region of the mRNA
and controls translation initiation, the IRE of the
Speculation about the underlying metabolic defect in transferrin receptor is localized at the 3’ untranslated
genetic haemochromatosis region of the mRNA [55]. A common trans-acting
RNA-binding protein (IRE-BP, also called iron regu-
The genetic defect in genetic haemochromatosis leads latory factor IRF) serves as key participant in the
to an inappropriate 2-4-fold increase in iron absorp- regulation of both genes [56,57]. This IRE-BP binds
tion. It indicates a disorder in the regulation of the iron under iron deficient conditions to the IRES of both
absorption process. mRNAs. This binding is mediated by a complex
mechanism (‘sulfhydryl switch’) controlled by the
cellular iron status [58,59]. Binding of IRE-BP to the
Regulation of proteins involved in iron metabolism IRE at the 5’ untranslated region of the ferritin mRNA
inhibits translation, while binding to the 3’ IRE of
The first question is whether a defect in the regulation the transferrin receptor mRNA stabilizes the message.
of transferrin, transferrin receptor and ferritin, as key The net result is that in iron deficiency ferritin
proteins of iron metabolism, is responsible for the biosynthesis is decreased while the transferrin receptor
increased absorption from gut. The transferrin recep- expression is increased. The reverse mechanism acts in
tor, although not involved in the uptake of iron at the secondary iron overload where ferritin expression is
luminal brush border plasma membrane [48], was high and transferrin receptor expression is low.
324 W. STREMMEL et al.
Cellular Iron S u m ly
m kw
Regulatory
Figure 1. Regulatory feedback mechanisms controlling iron homeostasis. Illustrated is the regulation ofthree key proteins in iron
metabolism: transferrin receptor (TfR), ferritin and erythroid 5-aminolcvulinic acid synthase (eALAS). IRE-BP activity is
modulated by a regulatory intracellular iron pool. Under conditions of low iron supply, this cytoplasmic mRNA-binding protein
becomes active and binds to IRES in the 5’. respectively. 3’ untranslated regions of the mRNA species encoding above proteins of
central importance in iron metabolism. As a consequence. iron uptake, iron storage, and erythroid haeme synthesis are
coordinately regulated in a way to compensate for iron deficiency. At increased iron levels, thc regulatory cascade is invcrsed.
Thus, under physiological steady-state conditions, iron is expected to maintain IRE-BP at an intermediate level of activation,
and thereby to control its own homeostasis. (Reproduced with permission from the publisher, Elsevier Science Publishing
Co., Inc. [<6]).
level is not known. For the latter hypothesis one could The dark pigmentation of the skin, although a
postulate a disordered interaction of a regulatory typical clinical feature, is not alone due to iron
RNA binding protein with a secondary RNA motif at deposits. The epidermis of the skin is thin, and
the 3’ untranslated region of the mRNA with the increased melanin is found in the cells of the basal
consequence of enhanced biosynthesis. Thus cellular layer.
iron uptake may be increased and in concert with the Deposits of iron are observed around the synovial
low mucosal ferritin concentration, the translocation lining cells of joints and calcium pyrophosphate
across the enterocyte may be accelerated (Fig. 2). It is crystals may be seen within deposits of calcium
not excluded that the increased expression of this embedded in the synovial tissue. This arthropathy
carrier protein represents the underlying metabolic develops in 25-30% of patients at any stage of the
defect in haemochromatosis. However, the structure disease [71]. The small joints of the hands (2nd and 3rd
of the protein and the corresponding mRNA as well as metacarpophalangeal joints) are the first joints to be
the localization of the gene on a specific chromosome involved. A progressive polyarthritis involving wrists,
are not yet established. hips, and knees may ensue. Roentgenologic manifes-
Another hypothesis for the underlying pathogenetic tations consist of subchondral sclerosis and cystic
factor in genetic haemochromatosis suggested a failure changes, loss of articular cartilage, diffuse deminerali-
of the RE-system to adequately process and retain iron zation, hypertrophic bone proliferation and calcifica-
with the consequence of increased transfer of dietary tion of the synovium.
iron to the liver [47]. Although a relative increase of The parenchymal deposits of iron in the liver of
transferrin receptor expression in relation to the body patients with genetic haemochromatosis consist of
iron stores has been observed in peripheral blood ferritin and haemosiderin. In early stages, these de-
monocytes from patients with genetic haemochroma- posits are found in the periportal parenchymal cells,
tosis [62], there is no evidence for an intrinsic abnor- especially within lysosomes in the pericanalicular
mality in iron metabolism by circulating monocytes or cytoplasm of the hepatocytes. This stage progresses to
macrophages [62,63]. However, recent observations perilobular fibrosis and deposition of iron in the bile
have suggested that the intestinal macrophage, which duct epithelium, Kupffer cells, and fibrous septa. In
may serve a ‘gatekeeper’ function in intestinal iron advanced disease the pattern of cirrhosis is character-
absorption, may be defective in genetic haemochroma- ized by broad fibrous septa surrounding large areas of
tosis, leading to a decrease in RE-cell iron in the comparatively normal parenchyma. Hepatocellular
intestinal mucosa and to an excess in intestinal iron carcinoma without iron deposition in tumour cells is
absorption [64]. However, conclusive data and insights observed in about 30% of cirrhotic patients, even after
into the involved metabolic pathway have not been removal of excess body iron stores by phlebotomy
presented yet. therapy [41].The pathogenesis of hepatocellular carci-
From a genetic point of view, the hypothesis that the noma is uncertain. One hypothesis suggests a relation
metabolic defect is due to mutations of the transferrin to increased oxidative stress produced by iron with
or transferrin receptor gene is also unlikely, because oxidant damage to the DNA, acting as initiator or
both genes are localized on chromosome 3 [65]. promotor of carcinogenesis [72,74].The recent sugges-
Moreover, the structure of these proteins and their tion that there may be a link to concomitant HBV
regulation were shown to be normal in genetic haemo- infection with integration of HBV-DNA into the
chromatosis. The gene encoding the IRE-binding host’s genome is intriguing but not yet conclusively
protein has been localized on chromosome 9 [66], thus proven [75].
removing this protein as a candidate for the primary Although iron deposits in the pancreas are predom-
defect in hereditary haemochromatosis. This applies inantly localized in the exocrine parenchyma with
also to the ferritin genes, because the light (L) and development of tissue fibrosis, functional impairment
heavy (H) subunits are localized on chromosome 19 of digestive enzyme secretion is a rare clinical feature.
and 11, respectively [67,68,69]. The significance of However, the selective accumulation of iron in B-cells
ferritin pseudogenes which were identified on chromo- of the endocrine pancreas in advanced disease contri-
some 6 is still unclear and at present under investiga- butes to the diabetes often observed in these patients
tion [70]. [41]. Along with the component of impaired insulin
secretion by damaged B-cells, there is an almost
obligatory insulin resistance observed in iron overload
Puthophysiologic consequences of iron overloud disease [76]. This is due to an insulin receptor/post-
receptor defect in the iron loaded liver, which is-in
Increased iron absorption leads to a positive iron contrast to the destruction of the B-cells-reversible
balance and accumulation of excess body iron in after completion of the phlebotomy therapy [76].
genetic haemochromatosis. It is interesting that only Iron deposition in the heart is observed in 15% of
specific organs are affected by iron loading. Those patients. Those deposits are more extensive in ventri-
include liver and pancreas and to a lesser extent cular than in atrial myocardium, resulting in intracel-
endocrine glands, particularly the pituitary, as well as lular disruption [77]. The ensuing haemodynamic
heart and joints. derangement is generally designated as dilated cardio-
326 W. STREMMEL et al.
increased autophagy of hepatocytes accounting for the chaft. The authors are very much indebted to Mrs Ch.
characteristic changes in liver biopsy specimens from Scheil for the accurate preparation of the manuscript.
haemochromatotic patients [94]. In mitochondria
iron-induced lipid peroxidation impairs among other
enzymes the activity of cytochrome oxidase, the termi-
nal enzyme of the mitochondria1 electron transport
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