Expert Review of Gastroenterology & Hepatology

ISSN: 1747-4124 (Print) 1747-4132 (Online) Journal homepage: http://www.tandfonline.com/loi/ierh20

Hemochromatosis: pathophysiology, evaluation

and management of hepatic iron overload with a
focus on MRI

Shmuel Golfeyz, Sara Lewis & Ilan S Weisberg

To cite this article: Shmuel Golfeyz, Sara Lewis & Ilan S Weisberg (2018): Hemochromatosis:
pathophysiology, evaluation and management of hepatic iron overload with a focus on MRI, Expert
Review of Gastroenterology & Hepatology, DOI: 10.1080/17474124.2018.1496016

To link to this article: https://doi.org/10.1080/17474124.2018.1496016

Accepted author version posted online: 02

Jul 2018.

Submit your article to this journal

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=ierh20
Publisher: Taylor & Francis

Journal: Expert Review of Gastroenterology & Hepatology

DOI: 10.1080/17474124.2018.1496016
Review
Hemochromatosis: pathophysiology, evaluation and management of hepatic iron

t
overload with a focus on MRI

ip
Shmuel Golfeyz1, Sara Lewis2, 3 and Ilan S Weisberg4,5

cr
1
Department of Internal Medicine, Mount Sinai Beth Israel, New York, NY, USA

us
2
Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
3
Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY,
USA
an
4
Department of Digestive Diseases and Hepatology Mount Sinai Beth Israel, New York, NY, USA
5
Icahn School of Medicine at Mount Sinai, New York, NY, USA
M

Correspondence:
ed

Shmuel Golfeyz

353 E 17th St Fl 2 New York, NY, 10003, USA

pt

Email: Shmuel.golfeyz@mountsinai.org
ce

Phone: +1-212-420-3363
Ac
Abstract

Introduction: Hereditary hemochromatosis (HH) is an autosomal recessive disorder that occurs

in approximately 1 in 200-250 individuals. Mutations in the HFE gene leads to excess iron
absorption. Excess iron in the form of non-transferrin bound iron (NTBI) causes injury and is
readily up-taken by cardiomyocytes, pancreatic islet cells and hepatocytes. Symptoms greatly
vary among patients and include fatigue, abdominal pain, arthralgias, impotence, decreased

t
libido, diabetes and heart failure. Untreated hemochromatosis can lead to chronic liver disease,

ip
fibrosis, cirrhosis, and hepatocellular carcinoma (HCC). Many invasive and noninvasive

cr
diagnostic tests are available to aid in diagnosis and treatment. MRI has emerged as the
reference standard imaging modality for the detection and quantification of hepatic iron
deposition, as ultrasound (US) is unable to detect iron overload and computed tomography (CT)

us
findings are non-specific and influenced by multiple confounding variables. If caught and treated
early, HH disease progression can significantly be altered.
an
Area covered: The data on Hemochromatosis, iron overload and MRI were gathered by
searching PubMed.
M
Expert commentary: MRI is a great tool for diagnosis and management of iron overload. It is
safe, effective, and a standard protocol should be included in diagnostic algorithms of future
treatment guidelines.
ed

Keywords: Hemochromatosis, MRI, Iron Overload, Liver Disease, HFE, Liver, Transient
Elastography
pt
ce
Ac
1. Introduction
Hemochromatosis is a disorder of iron homeostasis that results in excessive iron
absorption which leads to iron overload. To date, many different causes of iron overload have
been identified. Broadly, iron overload states have been divided into 3 groups, inherited causes
(dysregulation in iron absorption), secondary causes (iron-loading anemias, parenteral iron
overload, liver disease) and miscellaneous causes [1, 2]. Hereditary hemochromatosis (HH) is
an autosomal recessive disorder that typically affects Caucasians of Northern European

t
ip
ancestry and occurs in approximately 1 in 200-250 individuals [1, 3, 4]. Symptoms develop due
to iron overload and include abnormal liver chemistry tests, lethargy, abdominal pain,

cr
arthralgias, impotence, decreased libido, diabetes and symptoms of heart failure [5]. If left
untreated, hemochromatosis can cause liver injury to progress to cirrhosis or hepatocellular

us
carcinoma (HCC). However, early detection and treatment of HH can significantly alter the
disease course and potentially even eliminate the risk of HCC [1, 5].
an
2. Genetic basis of hemochromatosis and other causes of iron overload
In 1996, the HFE gene was identified by Feder et al as the cause of hereditary
M
hemochromatosis [6]. A guanine to adenine (G to A) missense mutation at nucleotide position
845 in the gene sequence causes substitution of tyrosine (Y) for cysteine (C) at the 282 position
ed

in the amino acid (AA) sequence [6, 7]. Homozygous C282Y gene defects comprise
approximately 80-85% of patients with hereditary hemochromatosis [5]. This mutation results in
a mutant form of the HFE protein which has decreased cell surface expression and undergoes
pt

accelerated degradation subsequently causing iron overload [7]. The exact mechanism of how
the HFE mutation leads to iron overload is not completely elucidated but some of the theories
ce

will be discussed further in the pathogenesis section of this paper. Two other mutations in the
HFE gene have also been identified. The first is a cytosine to guanine (C to G) change at
nucleotide position 187 which causes aspartic acid (D) substitution at position 63 in the AA
Ac

sequence for histidine (H63D) [7]. The second is due to cysteine (C) substituted for serine (S) at
position 65 (S65C) in the AA sequence. These additional gene defects are typically not
implicated in iron overload unless compounded together with a C282Y mutation forming a
compound heterozygote (i.e. C282Y/H63D or C282Y/S65C) or in conjunction with secondary
reasons of iron overload such as chronic liver diseases [1]. Penetrance of homozygous C282Y
gene is variable and thus not all people with the genotype will have phenotypic expression [8,
9]. Penetrance is higher in males and C282Y homozygotes of family members affected by HH
[5].
Non-HFE related causes of iron overload include mutations in hepcidin (HAMP) and
hemojuvelin (HJV) genes (Hemochromatosis type 2) , transferrin receptor 2 (TFR2) gene
(Hemochromatosis type 3), ferroportin (SLC40A1) gene (Hemochromatosis type 4), ferritin
heavy chain 1 (FTH1) gene (Hemochromatosis type 5), as well as African iron overload which is
thought to be due to minor functional changes in the ferroportin gene [1, 2]. Secondary causes

t
ip
of iron overload include iron-loading anemias such as thalassemia, sideroblastic anemia,
hemolytic anemia, aplastic anemia, pyridoxine-responsive anemia, pyruvate kinase deficiency,

cr
as well as excessive red blood cell transfusions, iron-dextran injections and long-term
hemodialysis. Chronic liver diseases such as hepatitis B and C, alcoholic liver disease, non-

us
alcoholic fatty liver disease (NAFLD), and porphyria cutanea tarda (PCT) have also been
implicated as secondary causes of iron overload. Miscellaneous causes of iron overload include
neonatal iron overload, aceruloplasminemia, and congenital atransferrinemia [1].
an
3. Pathogenesis
M
Iron is delicately maintained in the body by multiple different mechanisms and processes
that balance its absorption, regulation, utilization and excretion. The four main cell types
involved in iron homeostasis are duodenal enterocytes (absorption), erythroid precursors
ed

(utilization), reticuloendothelial macrophages (storage and recycling), and hepatocytes (storage)

[2]. Normal body iron is maintained at approximately 40mg Fe/kg of body weight in women and
50mg Fe/kg in men [10, 11]. Total body iron is contained in hemoglobin, myoglobin, bound to
pt

enzymes, or stored in the body as ferritin [12]. Iron is eliminated from the body through
sloughing of intestinal and skin cells, as well as menstruation in females [11]. The amount of
ce

blood lost through sloughing of cells is minimal and thus not effective in controlling iron overload
states.
Ac

Approximately 1-2 mg of dietary iron is absorbed by enterocytes on the apical

membrane daily. As detailed in Figure 1, iron is taken up by divalent metal transporter 1 (DMT1)
and transferred through the cell to the basolateral surface. The iron is then shifted from the
enterocyte into circulation via the ferroportin transporter. Once in the circulation, free iron is
bound to transferrin. Transferrin transports iron to different areas of the body such as the
hepatocytes where it is stored as ferritin or the erythroid precursors where it is used for heme
synthesis. Excess iron, (i.e. iron that is not able to be stored as ferritin or bound to transferrin)
will bind to low-molecular-weight compounds such as citrate and is known as non-transferrin
bound iron (NTBI). NTBI is readily taken up by certain cells including cardiomyocytes,
pancreatic islet cells and hepatocytes. This type of excess labile iron is thought to contribute to
oxidative-mediated cellular damage [2, 12, 13].

Hepcidin, a type II acute-phase 25 amino acid peptide produced by hepatocytes, has

been identified as the key regulator of iron homeostasis and the principal iron regulatory

t
hormone [1, 2, 14]. Hepcidin was initially identified as an antimicrobial peptide, however, true

ip
antimicrobial activity requires much higher concentrations than what is observed in human
circulation [2]. Hepcidin’s main task is to inhibit iron absorption by binding to ferroportin on the

cr
basolateral enterocyte surface and inducing its degradation via the lysosome [15]. This causes
a decrease in iron absorption from the enterocyte into circulation [2, 14].

us
Many different pathways, some of which are still being elucidated, carefully regulate the
expression of hepcidin [2, 14]. There are currently four known pathways involved in regulating
an
hepcidin expression (Figure 2). The first pathway is not fully understood and is via
erythropoiesis. It is postulated, that when erythropoiesis is increased, such as due to
erythropoietin, hemolysis, or phlebotomy, the bone marrow produces growth differentiation
M
factor 15 (GDF-15) and twisted gastrulation protein homolog 1 (TWSG1) which inhibit hepcidin
expression, possibly through the BMP/SMAD pathway [2, 14]. The end result of this pathway
ed

allows for more iron absorption that is needed for heme synthesis. The second pathway is also
incompletely understood and works via iron status. There are two mechanisms in this pathway.
The first is through liver iron stores and the second is through circulating iron. Increased liver
pt

iron stores cause expression of autocrine extracellular signaling molecule bone-morphogenetic

protein-6 (BMP-6) that interacts with the hepatocyte BMP receptor and induces signaling via the
ce

SMAD cascade proteins to induce hepcidin expression. This process is enhanced by

hemojuvelin, which is a BMP co-receptor [2, 14]. Excess circulating iron in the form of diferri-
transferrin (Tf-Fe2) binds to the transmembrane transferrin 1 (TFR1) and transferrin 2 (TFR2)
Ac

hepatic cellular receptors [2, 14]. HFE is a class I-like major histocompatibility complex (MHC)
which seems to work in conjunction with TFR2 to induce hepcidin expression [14, 16]. As is
currently understood, HFE forms a protein-protein complex with TFR1. When Tf-Fe2 binds to
TFR1, it releases the HFE, which then combines with the TFR2 and via the SMAD pathway
induces hepcidin expression [2, 17]. Thus, in cases where there is a mutation in the HFE protein
like in HH, the hepcidin protein is not properly expressed therefore allowing uncontrolled iron
absorption and leading to iron overload. There have been inconsistent results in regards to if the
TFR1 pathway also uses the ERK/MAPK pathway as part of its signaling cascade [14]. The third
pathway in hepcidin expression is via oxygen tension. During times of hypoxia, hypoxia
inducible factor (HIF) up-regulates expression of matriptase-2 and furin. Matriptase-2 cleaves
hemojuvelin from the cell surface and prevents it from properly acting as a co-receptor for the
BMP complex thus inhibiting hepcidin expression. Furin works by cleaving hemojuvelin which
creates a soluble form that acts as a BMP-6 decoy thus inhibiting BMP/SMAD signaling as well
[2, 14]. This pathway seems logical as in times of hypoxia the body wants to create more red

t
ip
cells to distribute oxygen; thus, necessitating more iron. The fourth pathway is via inflammation.
During times of inflammation or infection, inflammatory cytokine interleukin-6 (IL-6) is up-

cr
regulated and binds to the IL-6 receptor which induces hepcidin expression via the JAK/STAT
pathway. This mechanism is believed to inhibit iron uptake which would also be used by certain

us
bacteria in order to thrive [2, 14].

In 2014, Kautz et al [18] discovered a new hormone involved in suppressing hepcidin. It

an
is known as erythroferrone and is a TNF-α superfamily member Fam132b. Factors such as
anemia stimulate erythropoiesis which causes the kidneys to produce high levels of
erythropoietin. Erythropoietin then stimulates erythroblasts to increase erythroferrone
M
concentrations. The erythroferrone hormone works in the liver to suppress hepcidin levels thus
enhancing iron absorption so it can be used for erythropoiesis. Interestingly, erythroferrone is
also being studied to determine its role in thalassemia intermedia [18]. The full role it plays in
ed

iron homeostasis and the factors that regulate its production are still being elucidated
nonetheless it has been helpful in adding another piece to this complicated puzzle.
pt

Dysregulation of the hepcidin-ferroportin axis is typically the cause of most iron overload
disorders. As described above, hepcidin is the key protein which regulates iron absorption. The
ce

second pathway in inducing hepcidin expression is dependent on the HFE protein. Therefore, a
mutation in the HFE protein (like in HH) causes less hepcidin expression and allows for
uncontrolled iron absorption and iron overload. Once the iron absorbed and released into
Ac

circulation exceeds the amount that can be carried by transferrin, NTBI will appear in circulation
and be taken up by susceptible cells where it leads to oxidant injury [2, 13]. Initially, iron is
deposited into the parenchymal cells, however later in the disease progression; iron begins to
accumulate in the reticuloendothelial cells. In transfusional iron overload states, however,
deposition initially starts in the reticuloendothelial cells and then spreads to the parenchymal
cells [19].
 Hepatic iron deposition in the form of hemosiderin initially affects the periportal
hepatocytes (zone 1) as iron deposition continues; it spreads to midzonal (zone 2) and
centrilobular (zone 3) hepatocytes, as well as into the biliary epithelium [7]. Concomitant
diseases such as diabetes, chronic hepatitis B and C, alcoholic liver disease, and NAFLD may
act as a cofactor, potentiating further liver injury in conjunction with the excess iron [1, 20]. Iron
overload states have also been found to increase the susceptibility to infections from Listeria
monocytogenes, Vibrio vulnificus and Yersinia enterocolitica. These bacteria are siderophoric

t
ip
(iron-loving) and thrive in high iron states [21, 22, 23]. Additionally, it seems that excess iron
causes diminished macrophage phagocytosis of Listeria [21].

cr
4. Clinical presentation

us
Hemochromatosis manifests with many non-specific symptoms and can be considered
in patients with abnormal liver chemistry tests, fatigue, right upper quadrant abdominal pain,
an
arthralgias, chondrocalcinosis, impotence, decreased libido, diabetes and symptoms of heart
failure [5]. The following symptoms were uncovered in a study of 251 patients diagnosed with
HH and are (in decreasing order of prevalence): liver chemistry abnormalities, fatigue, skin
M
hyperpigmentation, diabetes (bronze diabetes), arthralgias typically affecting the 2nd and 3rd
metacarpophalangeal (MCP) joints, impotence in males, and electrocardiographic abnormalities
[24]. Untreated hemochromatosis can lead to chronic liver disease, hepatic fibrosis, cirrhosis,
ed

hepatocellular carcinoma (HCC), cardiomyopathy, arrhythmias, hypogonadism, pituitary

dysfunction, and congestive heart failure [1, 5]. Liver disease from HH is due to excessive iron
deposition into hepatocytes via NTBI eventually leading to fibrosis and cirrhosis [25, 26].
pt
ce

5. Limitations of existing methods for evaluation of iron

Prior to the discovery of the HFE gene, HH was diagnosed through liver biopsy [5]. Liver
biopsy provides the hepatic iron concentration (HIC) and allows for liver architecture analysis
Ac

which can help determine if the disease has progressed to cirrhosis. After the discovery of the
HFE mutation, genetic analysis became the diagnostic test of choice. However, HFE genetic
analysis and screening of patients showed a phenotypic expression of HH at much lower HIC
levels that it was not clear if these patients indeed had iron overload. Thus, HFE testing along
with transferrin saturation (TS) and ferritin became the preferred choice for diagnosing HH [1].
Several studies have shown that in HH, ferritin levels above 1000 μg/L had an increased risk for
chronic liver complications [27, 28]. A study of asymptomatic C282Y homozygotes found a
prevalence of cirrhosis as 5.6% in males and 1.9% in females. Serum ferritin levels >1000 μg/L
had 100% sensitivity and 70% specificity in identifying cirrhotic subjects [29].

Unfortunately, ferritin has limitations. Ferritin is an acute phase reactant and thus can be
elevated in inflammatory states. In addition, ferritin can be elevated for other reasons including,
alcoholism and metabolic syndrome [25, 30]. One study to further clarify ferritin’s sensitivities
measured HIC by the Gandon [31] method and compared the results with ferritin levels.

t
Inflammation was measured via erythrocyte sedimentation rate (ESR), c-reactive protein (CRP)

ip
and elevated white blood cells. The study found that ferritin is not sensitive in inflammatory
states for determining iron overload [30]. Serum ferritin levels have also shown to not be

cr
indicative of hepatic iron concentration or total body iron stores [32].

us
Limitations of liver biopsy include the invasive nature and risk of complications [11, 33,
34]. Complications of liver biopsy include bleeding at a rate of 1-6% and mortality of less than
1:10,000 subjects [35]. Furthermore, heterogeneous deposition of iron throughout the liver
an
results in sampling error and high coefficient of variation variability [36, 37].
M

6. Imaging methods for hepatic iron detection and quantification

The established toxicity of hepatic iron deposition, the risk of progression to liver disease
ed

and HCC and the limitations of liver biopsy underscore the importance of non-invasive
biomarkers of hepatic iron quantification. Since hepatic iron concentration (HIC; mg Fe/g dry
liver tissue) has been shown to be a surrogate of total body iron stores, a non-invasive imaging-
pt

based assessment of the liver is therefore ideal to provide this information [10]. MRI has
emerged as the reference standard imaging modality for the detection and quantification of
ce

hepatic iron deposition, as ultrasound (US) is unable to detect iron overload and computed
tomography (CT) findings are non-specific and influenced by multiple confounding variables [11,
Ac

31, 38, 39, 40, 41, 42]. Furthermore, MRI based methods can be used to monitor response to
therapy. In addition to iron quantification, MRI can provide additional important information
regarding the presence and severity of liver fibrosis/cirrhosis, steatosis, portal hypertension and
evaluate for HCC.
6.1 MRI

MRI is highly sensitive to the presence of hepatic iron deposition due to local magnetic
field inhomogeneity caused by the paramagnetic effect of hemosiderin resulting in reduction of
signal intensity in the liver parenchyma [43]. The T2 value of a specific tissue is defined as a
time constant for the decay of transverse magnetization due to atomic or molecular interactions.
The T2* value of a specific tissue is the “observed T2”, reflecting a combination of true T2

t
ip
properties and magnetic field inhomogeneities. The spin echo (SE) and the gradient echo
(GRE) T2-weighted sequences are susceptible to this phenomenon, from which measurement

cr
of transverse relaxation time (T2 and T2*, respectively) of the liver can be measured to evaluate
for iron. T2 and T2* are converted into its reciprocal R2 (R2= 1000/T2) and R2* (R2*= 1000/T2*)

us
in order to increase the dynamic range of values. Ferritin and hemosiderin shorten T2* and T2
hepatic relaxation times and consequently, increase R2* and R2 values; R2 and R2* values are
the most affected by the presence of iron in the liver [44].
an
MRI-based techniques for assessing hepatic iron concentration are gaining widespread
use and are classified into signal intensity ratios (SIRs) and relaxometry methods (R2 and R2*).
M
The SIR method is performed using either spin echo (SE) or gradient echo (GRE) sequence,
and measurements are obtained by taking the ratio of signal intensity (SI) of the liver by the
signal intensity of a reference organ/tissue that does not accumulate iron (such as fat, muscle or
ed

air) using region of interest (ROI) analysis [45]. The method developed by Gandon et al at the
University of Rennes, France, is the most widely used SIR method and is performed by
obtained multiple breath-hold GRE sequence acquisitions, using variable flip angles and
pt

different TEs, while keeping the time to repetition (TR) constant [31]. Liver iron can then be
measured from the images produced due to differences in T1 and T2* weighting. ROI analysis
ce

of the right lobe of the liver and paraspinal muscles is then performed to generate different
liver/muscle signal intensity ratios on each of the imaging acquisitions. Large ROIs are
measured on the same slice on the liver and paraspinal muscle for each imaging acquisition.
Ac

Utilizing a specialized algorithm, the ROI measurement values from each image acquisition are
used to calculate an estimate of HIC (https://imagemed.univ-
rennes1.fr/en/mrquantif/overview.php) [46]. This method is calibrated for MRI scanning
platforms with field strengths up to 1.5T, and more recently, up to 3T. The Gandon method has
been validated against histopathology and has shown high accuracy for iron quantification [31].
In a separate study, the Gandon method showed stronger correlation with R2 relaxometry
(R=0.927, p=<0.001) than R2 and R2* relaxometry (R=0886, p<0.001) [47]. Of note, the
Gandon method is limited by dynamic range and cannot quantify HIC values greater than 20.9
mg/g, which therefore does not capture the entire clinically relevant range of hepatic iron levels
[48].

The assessment of iron overload using relaxometry methods is based on the decrease
in T2 or T2* relaxation times induced in the liver due to the paramagnetic properties of iron, as

t
discussed above. This degree of T2 or T2* relaxation is proportional to the quantity of iron and

ip
results in the decrease in the signal intensity in the liver. R2 or T2 relaxometry is performed
using a spin echo (SE) acquisition with increasing TEs and is thought to have the ability to

cr
overcome some of the challenges of SIR techniques [11]. R2 can be estimated from signal
intensity decay from images acquired at multiple TEs using either mono-exponential or bi-

us
exponential model fitting of the signal intensity decay curves. R2 relaxometry for hepatic iron
quantification was introduced by St Pierre et al, in which a single-echo pulse sequences was
an
employed with the use of short echo spacing, and was shown to have high degrees of sensitivity
and specificity even at high HIC thresholds [49]. This method uses five T2-weighted spin echo
free-breathing sequences with increasing TEs and a constant TR. Furthermore, St Pierre et al
M
have developed a service for calculating T2 for clinical purposes (www.ferriscan.com) [50],
which is currently approved by the US Food and Drug Administration (FDA) and requires
external phantom validation and centralized data analysis [49, 51].
ed

The multiecho R2* relaxometry method, using the GRE sequence, has emerged as a
quick and feasible technique and enables whole liver coverage without motion artifacts in a
pt

single breath-hold [11]. This method quantifies the effective transverse relaxation rate R2* of
liver tissue via assessment of the exponential signal decay seen in multi-echo gradient echo
ce

and has shown excellent sensitivity and specificity for hepatic iron detection and quantification
[43, 52, 53]. In the study by Wood et al, HIC was calibrated to liver R2* in 20 patients with
Thalassemia or sickle cell disease and demonstrated an excellent correlation coefficient of 0.97
Ac

(limits of agreement of −46% to 44%). This study also showed that R2 and R2* values for
estimation of HIC were largely comparable, although the benefit of the R2* method was more
rapid image acquisition [54]. Previous studies performed at 1.5T MRI with histopathology have
shown an excellent linear correlation between HIC and R2*, with a high precision for HIC levels
up to 25mg Fe/g dry weight of liver tissue[54, 55, 56].
6.2 MRI technique
At our institution, hepatic iron quantification is performed routinely on a 1.5T MRI system
using a phased-array body coil. 3T MRI is not yet routinely used clinically for this application, as
multi-echo T2* GRE methods generally suffer a lack in precision at higher field strength due to
rapid signal decay, especially in the setting of massive iron overload (HIC >25mg Fe/g dry
weight) [57, 58]. This remains a topic of ongoing investigation. Representative sequence
parameters from the 1.5T Siemens Aera (Siemens Healthineers, Erlangen, Germany) are

t
ip
described here. Gradient strength is 33 mT/m for T2*-weighted imaging, an axial gradient-
recalled echo (GRE) breath-hold multiecho T2* sequence is performed prior to contrast injection

cr
using 12 TEs. The scanning parameters were as follows: TR (time to repetition) 253; TE (time to
echo) 1.24, 3.06, 4.94, 6.82, 8.70, 10.58, 15.00, 20.00, 25.00, 30.00, 35.00 and 40.00

us
milliseconds; flip angle 12°; slice thickness, 8 mm; matrix size, 128 x 128; field of view, 400 x
300 mm; number of signals acquired, 1; bandwidth, 1560 Hz/pixel; 4 slices acquired through
mid-liver; and total acquisition time, 16 seconds. The range of TEs selected for our multi-echo
an
T2*-weighted sequence protocol included longer TEs, the longest being larger than the T2*
value of normal liver, reported in previous studies to be greater than 24 milliseconds at 1.5T [43,
59, 60].
M
ed

6.3 Image processing and analysis

T2* values are most commonly calculated as the slope of the monoexponential fit of the
natural log of signal intensity versus TE. The reciprocal of T2* is R2* (R2* = 1/ T2* x 1000).
pt

Voxel-based T2* maps were generated by the MRI scanners. T2* maps are qualitatively reviews
for heterogeneity of iron deposition. T2* map slices at mid liver at the level of the portal vein are
ce

selected for region of interest (ROI) measurement. Axial slices near the liver dome are typically
excluded due to the risk of susceptibility artifact from air in the adjacent lung impacting
measurements. Several ROIs measuring approximately 2–3 cm2 in the liver parenchyma are
Ac

placed to measure the signal intensity in the right lobe, from which an averaged measurement is
obtained. At our center, the degree of severity of hepatic iron deposition as measured by T2*
values is interpreted based on threshold values established by Chandarana et al, with mild iron
deposition corresponding to T2* value of less than 24 milliseconds, moderate iron deposition is
less than 21 milliseconds and severe iron deposition is less than 14 milliseconds [43]. Mean T2*
values for all the ROIs can then be averaged and are converted to R2* values in order to
calculate HIC. At our institution, R2* values are evaluated using calibrations curves published by
Wood et al, in which R2* is plotted as a function of biopsied HIC, in order to obtain the
estimated hepatic iron concentration (mg/g dry weight liver) [54].

6.4 Limitations
While the multiecho relaxometry MRI technique is non-invasive, quick to perform, and
accurate, there are a few limitations. Despite published techniques for performing liver iron

t
ip
quantification, a common limitation all of these methods is measurement variability due to non-
standardization and lack of consensus regarding MRI sequence acquisition parameters,

cr
analysis methods and MRI platforms [11, 49]. The T2* and R2* measurements are confounded
by noise, concomitant liver fat and background magnetic field variations. These confounders

us
can result in variability in measurements [11]. Furthermore, a limitation of the method described
by Wood et al is that quantification linearity has been demonstrated only up to a HIC of 32.9 mg
iron/g dry weight. It is possible that linearity of the relationship between R2* and HIC is not
an
maintained at the higher range of HIC because the echo times (TEs) used for measurement
may be too long to reliably measure ultra fast signal decay signal decay [53]. It may be
necessary in these cases to utilize sequences with ultra short first echo times [61].
M
ed

6.5 Additional value of MRI

A comprehensive MRI exam can also provide additional essential information regarding
the presence and severity of liver fibrosis and cirrhosis, steatosis, portal hypertension and
pt

evaluate for HCC. It is established that liver fibrosis and inflammation are common in patients
with iron overload [62, 63]. Magnetic resonance elastography (MRE), that uses the propagation
ce

of mechanical shear waves in tissues to quantify tissue stiffness measurement, has emerged as
the imaging method of choice for detecting and staging liver fibrosis [64, 65, 66, 67, 68]. In a
recent prospective study of 60 patients, MRE demonstrated the highest correlation (r-0.66,
Ac

p<0.001) and diagnostic performance (AUC 0.94) for the detection of advanced liver fibrosis
(>F3) and cirrhosis as compared to other MRI methods such as dynamic contrast-enhanced
MRI (DCE-MRI), diffusion-weighted imaging (DWI), ultrasound-based transient elastography
(TE) and serum markers [64]. A limitation of MRE acquired using gradient recalled echo (GRE)
sequence is sequence failure due to the presence of hepatic iron deposition [69]. The use of
spin echo echo-planar imaging (SE-EPI) magnetic resonance elastography (MRE) sequences
has shown excellent image quality and a reduction in failure rates due to hepatic iron deposition
and is, therefore, a reasonable alternative for MRE sequence acquisition [70]. Hepatic steatosis
and excess iron deposition can currently co-exist, however, the complex interplay of which
between is not fully characterized. Advanced MRI methods can detect and quantify concomitant
steatosis in patients with hepatic iron overload with high accuracy and reproducibility [71]
(Figure 3). The manifestations of portal hypertension, including varices, splenomegaly and
ascites, are readily identified at MRI. The diagnosis of hepatocellular carcinoma is most
commonly an imaging diagnosis based on contrast-enhanced CT or MRI, with characteristic

t
ip
hypervascular enhancement, portal venous phase washout and pseudocapsule appearance.
MRI has emerged as the preferred imaging modality for the diagnosis of HCC, demonstrating

cr
significantly higher per-lesion sensitivity compared to CT in a recent meta-analysis [80% (95%
CI: 68%, 88%) vs. 68% (95% CI: 58%, 76%), p = .0023] [72]. Cross sectional imaging

us
modalities such as MRI offer “one-stop” shop for assessment of liver iron, fat, fibrosis/cirrhosis,
portal hypertension and HCC. an
Another method that can be considered is the use of transient elastography (TE). TE is a
non-invasive, quick, reproducible and easy method to assess liver fibrosis. It has been studied
for the detection of fibrosis in many liver diseases including, NAFLD, alcoholic liver disease,
M
Hepatitis B and Hepatitis C [73, 74]. TE uses ultrasound to measure the velocity of a
mechanical wave as it is pulsed through the liver. Results are reported in kilopascals (kPa).
Velocity of the pulsed wave correlates with tissue stiffness. Stiffer tissue makes it harder for the
ed

wave to pass through causing a higher pressure [75, 76]. Fibrosis is measured from F0 to F4
with F0 being normal, F1 mild fibrosis, F2 moderate fibrosis, F3 severe fibrosis and F4 cirrhosis
or advanced fibrosis [76]. Anything above level F2 is considered significant fibrosis [76]. A meta-
pt

analysis of nine studies involving TE showed accuracy at diagnosing F4 fibrosis with a

sensitivity of 87% and specificity of 91% [77]. F2-4 fibrosis demonstrated a sensitivity of 70%
ce

and specificity of 84% [77]. There are a few studies that have assessed TE use in HH [78, 79].
One study showed that it is reliable in diagnosing fibrosis patients with HH [78]. Another study
showed that in patients with HH who underwent liver biopsy and TE, TE was able to diagnose
Ac

severe fibrosis in 61% of patients. TE results of 6.3 kPa or less effectively excluded severe
hepatic fibrosis and TE results of 13.1 kPa or greater ascertained severe fibrosis [79]. A
drawback of TE is that nearly one in five cases has un-interpretable measurements of liver
stiffness due to obesity, large waist circumference and operator technique/experience [80].
Real-time elastography has also been studied in iron overload states and is a relatively accurate
method of assessing fibrosis in such patients [81].
7. Clinical approach to the detection and diagnosis of hemochromatosis
In patients with suspicious clinical features, liver chemistry test abnormalities, or family
history of HH, a diagnosis of hemochromatosis should be pursued. First degree relatives of
patients with HH should undergo simultaneous HFE gene testing and ferritin/TS analysis.
C282Y and H63D heterozygotes can be reassured they are not at risk of developing iron

t
overload unless associated with other causes of liver injury [1]. In patients that have no family

ip
history of HH, initial testing should focus on obtaining ferritin and transferrin saturation levels
(algorithm 1). If TS <45% and ferritin is normal then iron overload is essentially ruled out. If TS

cr
>45% and ferritin is elevated (above 150 μg/L in females and 200 μg/L in males), then HFE
mutation analysis should be performed [1]. If the patient has a homozygous C282Y mutation

us
and the TS and ferritin are elevated but below 1000 μg/L, and there is no indication of liver
disease, a diagnosis of HH is made and the patient can undergo therapeutic phlebotomy without
an
further iron content investigation. Per current American Association for the Study of Liver
Diseases (AASLD) guidelines, if HFE testing is positive for C282Y homozygosity and the serum
ferritin is greater than 1000 μg/L or there are elevated liver chemistries, the patient should
M
undergo liver biopsy for HIC determination and histopathology and then undergo phlebotomy
[1]. If HFE testing shows compound heterozygosity or non-C282Y mutations and the patient has
a high ferritin and high TS, we suggest pursuing further evaluation with MRI. If MRI displays
ed

high hepatic and splenic iron content then it is likely from transfusion iron overload or other
hematological disease and treatment would be with iron chelation. If there is no hepatic iron
then it is likely metabolic hyperferritinemia. If there is hepatic iron overload and no splenic
pt

overload, then a diagnosis of non-HFE hemochromatosis is made and the patient should
undergo therapeutic phlebotomy. If TS >45% and ferritin is low or normal the next step in the
ce

evaluation would be HFE gene testing and if negative one can routinely monitor ferritin levels.
For patients in whom HFE testing is positive (i.e. C282Y homozygote’s and C282Y/H63D or
C282Y/S65C heterozygote’s) we suggest pursuing MRI for hepatic iron quantification in order to
Ac

assess the need for phlebotomy. If the TS is normal or low and there is an elevated ferritin level,
secondary causes of elevated ferritin should be ruled out first. Diseases correlated with elevated
ferritin include inflammatory disorders (ferritin is an acute phase reactant), NAFLD, cell necrosis,
metabolic syndrome, and alcohol abuse. If a secondary cause for the hyperferritinemia is
uncovered, one should treat the underlying disorder. Once secondary causes of elevated ferritin
are ruled out, it is reasonable to proceed with MRI to further evaluate hepatic and splenic iron
content. Based on MRI findings, if hepatic T2* is <18ms and splenic T2* is > 20ms one can
consider further testing of ceruloplasmin to evaluate for aceruloplasminemia. If hepatic T2* is
>18ms, this effectively excludes hepatic iron overload and further evaluation for L-ferritin (light
chain ferritin) mutations can be undertaken to evaluate for a possible diagnosis of
hyperferritinemia cataract syndrome. If the hepatic T2* is <18ms and splenic T2* is less than
20ms then SLC40A1 gene can be analyzed and a diagnosis of ferroportin disease can be
made, at which point therapeutic phlebotomy versus watchful waiting would have to be decided

t
ip
[1, 2, 5, 25].

cr
8. Treatment of HH and secondary iron overload
Standard HH treatment is by therapeutic phlebotomy (venesection). There are no

us
randomized trials comparing phlebotomy versus no phlebotomy although one study is currently
underway for certain HFE populations [75]. Many studies show improvement in certain areas
an
after phlebotomy including reduced tissue iron stores, improved energy levels, improved
morbidity and mortality, improved cardiac function, improved diabetes control, reduced
abdominal pain, reduced skin hyperpigmentation, normalization of liver chemistries, elimination
M
of risk for HH-associated HCC (if iron is removed prior to cirrhosis development), and reduction
in portal hypertension in patients with cirrhosis [1, 5, 82, 83]. One study also shows decreased
liver fibrosis in some patients after phlebotomy [84]. Established cirrhosis, arthropathy, and
ed

testicular atrophy generally do not improve following phlebotomy [1]. European Association for
the Study of the Liver (EASL) guidelines suggest screening patients for long-term complications
of hemochromatosis including arthropathy, diabetes, endocrine deficiency (hypothyroidism),
pt

cardiac disease, porphyria cutanea tarda, and osteoporosis prior to phlebotomy. Patients with
cirrhosis due to HH should be also immunized against Hepatitis A and B and routinely surveyed
ce

for HCC [5].

It is approximated that every 500 milliliters (mL) of red blood cells (RBC’s) contains 200-
250 mg of iron. Patients with >30 grams of total body iron may take 2-3 years to effectively
Ac

reduce total body iron stores [1]. Per AASLD guidelines, approximately 500 mL or one unit of
blood should be removed weekly or every two weeks to obtain a goal ferritin between 50-100
μg/L [1]. Prior to phlebotomy, hematocrit or hemoglobin (H/H) levels should be assessed so as
to avoid decreasing H/H levels by >20% of baseline or prior levels. TS typically remains
elevated until all iron stores are decreased, however ferritin levels generally decrease with
therapy and can be used as biomarkers for assessing response to treatment. Ferritin and TS
testing should be performed more frequently once close to the therapeutic ferritin target level, so
as not to decrease iron stores to the point of causing iron deficiency. Once ferritin reaches a
target level of 50-100 μg/L, frequent phlebotomy should be discontinued and maintenance
phlebotomy should be initiated. Some patients may require monthly phlebotomy sessions
whereas others may only require phlebotomy every 6-12 months [1]. Interestingly, one study
found that patients taking proton pump inhibitors did not re-accumulate iron as rapidly and
required fewer maintenance phlebotomies [85].

t
ip
Patients with advanced cardiac disease such as cardiomyopathy or arrhythmias have an
increased risk of sudden death with rapid mobilization of iron. For this reason, Vitamin C, which

cr
helps propagate iron onto transferrin, should be avoided especially in patients undergoing
phlebotomy [1]. C282Y homozygotes without evidence of iron overload can be monitored yearly

us
and treatment can be initiated once ferritin levels arise or there are signs of iron overload [5].

Treatment of secondary iron overload states includes phlebotomy in cases such as PCT
an
[1]. Hepatitis C and NAFLD are areas where more research is needed to determine the benefit
of phlebotomy. There are currently a few studies showing improvements in liver chemistries and
insulin resistance from phlebotomy in patients with NAFLD [86, 87, 88]. However, a recent
M
randomized controlled trial showed no benefit with phlebotomy for dysmetabolic iron overload
syndrome (DIOS) patients in glucose control or liver chemistries and was in fact associated with
ed

weight gain [89]. Iron chelation treatment with deferasirox or deferoxamine mesylate is
recommended in iron overload states due to dyserythropoietic syndromes or chronic hemolytic
anemias. In such patients, ferritin levels do not accurately reflect iron burden and other options
pt

such as liver biopsy or MRI can be used to assess treatment progression [1].

Erythrocytapheresis is a technique that removes red blood cells and returns plasma to
ce

patients. This technique removes more iron in one session than a typical phlebotomy session
does. A small trial shows that erythrocytaphersis in C282Y homozygotes achieved a goal ferritin
Ac

level faster than the control group who were receiving standard phlebotomy [90]. Although it
costs more than standard phlebotomy, is not frequently employed, and is not readily available,
this method may be more cost-effective in the long run by reducing the number of blood draws
and improving patient’s productivity [90]. This method has also been shown to be safe in
conjunction with erythropoietin, however further prospective studies must be undertaken to
evaluate its role for HH [91].
9. Expert commentary
HH is a disease which causes iron overload and deposition in hepatic tissues. By
utilizing MRI in conjunction with serum tests, evaluation of HH disease progression, hepatic iron
concentration, and monitoring for complications such as cirrhosis and HCC is possible. Early
screening and treatment of HH significantly alters its course and can prevent liver damage from
progressing to cirrhosis. In our experience, a reasonable approach is to employ non-invasive
imaging-based methods initially, to determine which patients may need or benefit from more

t
ip
invasive techniques like a liver biopsy. We feel that it is reasonable to incorporate MRI to
evaluate HIC, MR Elastography or TE measurement to evaluate for liver fibrosis in the initial

cr
diagnostic workup. If non-invasive methods results are inconclusive or with reasonable clinician
concern, liver biopsy may be performed in order to clarify or solidify a diagnosis. While current

us
practice guidelines do not go into detail about the protocol and use of MRI in HH, it is a
noninvasive tool that provides many additional benefits such as fibrosis assessment and HCC
surveillance, we believe that it significantly contributes to the diagnosis and management of HH
an
and therefore should be fully incorporated in future treatment guidelines.
M
10. Five-year view

To date, many studies have been undertaken to determine the usefulness of MRI as a
ed

diagnostic modality in quantifying iron overload. The current AASLD and EASL guidelines do
not delve into the role of MRI in iron overload and the protocols to use. Within the next five
years, we expect that a universal, standardized protocol will be employed and included in the
pt

next set of guidelines. Further studies should be undertaken to help perfect our current methods
for diagnosing iron overload. Protocols will continue to be modified as we continue to enhance
ce

our imaging modalities. MRE protocols will also be optimized. Within five years, we hope that a
universal protocol will be created and thus allow MRI evaluation of iron to become standardized
Ac

across institutions.
Key issues

• HH is a disease which causes excessive iron absorption.

• NTBI is the form of excess iron which is toxic cardiomyocytes, pancreatic islet cells and
hepatocytes.
• Long-term effects of iron overload include heart problems, pituitary dysfunction,
impotence, chronic liver disease, fibrosis, cirrhosis, and HCC.

t
• MRI has emerged as the reference standard imaging modality for the detection and

ip
quantification of hepatic iron deposition
• Current guidelines do not fully delve into MRI protocols or use as a diagnostic modality

cr
in the algorithms.
• Non-invasive imaging-based methods should be utilized initially prior to liver biopsy. If

us
non-invasive methods results are inconclusive or with reasonable clinician concern, liver
biopsy may be performed.
•
an
MR Elastography or TE measurement can be utilized to evaluate for liver fibrosis.
• MRI is a noninvasive tool that provides many additional benefits such as fibrosis
assessment and HCC surveillance. It significantly contributes to the diagnosis and
M
management of HH and therefore should be fully incorporated in future treatment
guidelines.
• Further studies should be undertaken to create a universal protocol which will allow MRI
ed

evaluation of iron to become standardized across institutions.

pt

Funding
ce

This paper was not funded.

Declaration of interest
Ac

The authors have no relevant affiliations or financial involvement with any organization or entity
with a financial interest in or financial conflict with the subject matter or materials discussed in
the manuscript apart from those disclosed.

Reviewer disclosures
Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.
References

Papers of special note have been highlighted as:

*of interest
**of considerable interest

1. Bacon BR, Adams PC, Kowdley KV, et al. Diagnosis and management of

t
hemochromatosis: 2011 practice guideline by the American Association for the

ip
Study of Liver Diseases. Hepatology. 2011 Jul;54(1):328-43. doi:

cr
10.1002/hep.24330. PubMed PMID: 21452290; PubMed Central PMCID:
PMCPMC3149125.
** Current American guidelines regarding the management and treatment of

us
hemochromatosis
2. Fleming RE, Ponka P. Iron overload in human disease. N Engl J Med. 2012 Jan
an
26;366(4):348-59. doi: 10.1056/NEJMra1004967. PubMed PMID: 22276824; eng.
** Comprehensive overview of iron overload
3. Adams PC, Reboussin DM, Barton JC, et al. Hemochromatosis and iron-overload
M
screening in a racially diverse population. N Engl J Med. 2005 Apr 28;352(17):1769-78.
doi: 10.1056/NEJMoa041534. PubMed PMID: 15858186; eng.
4. Phatak PD, Bonkovsky HL, Kowdley KV. Hereditary hemochromatosis: time for targeted
ed

screening. Ann Intern Med. 2008 Aug 19;149(4):270-2. PubMed PMID: 18711158; eng.
5. EASL clinical practice guidelines for HFE hemochromatosis. J Hepatol. 2010
Jul;53(1):3-22. doi: 10.1016/j.jhep.2010.03.001. PubMed PMID: 20471131; eng.
pt

** Current European guidelines for management and treatment of

hemochromatosis
ce

6. Feder JN, Gnirke A, Thomas W, et al. A novel MHC class I-like gene is mutated in
patients with hereditary haemochromatosis. Nat Genet. 1996 Aug;13(4):399-408. doi:
Ac

10.1038/ng0896-399. PubMed PMID: 8696333; eng.

7. Batts KP. Iron overload syndromes and the liver. Mod Pathol. 2007 Feb;20 Suppl 1:S31-
9. doi: 10.1038/modpathol.3800715. PubMed PMID: 17486050.
8. Beutler E. The HFE Cys282Tyr mutation as a necessary but not sufficient cause of
clinical hereditary hemochromatosis. Blood. 2003 May 01;101(9):3347-50. doi:
10.1182/blood-2002-06-1747. PubMed PMID: 12707220; eng.
9. Lazarescu A, Snively BM, Adams PC. Phenotype variation in C282Y homozygotes for
the hemochromatosis gene. Clin Gastroenterol Hepatol. 2005 Oct;3(10):1043-6.
PubMed PMID: 16234052; eng.
10. Brittenham GM, Badman DG, National Institute of D, et al. Noninvasive measurement of
iron: report of an NIDDK workshop. Blood. 2003 Jan 01;101(1):15-9. doi: 10.1182/blood-
2002-06-1723. PubMed PMID: 12393526.
11. Hernando D, Levin YS, Sirlin CB, et al. Quantification of liver iron with MRI: state

t
ip
of the art and remaining challenges. Journal of magnetic resonance imaging :
JMRI. 2014 Nov;40(5):1003-21. doi: 10.1002/jmri.24584. PubMed PMID: 24585403;

cr
PubMed Central PMCID: PMCPMC4308740.
* A review of quantifying iron overload with MRI

us
12. Andrews NC, Schmidt PJ. Iron homeostasis. Annu Rev Physiol. 2007;69:69-85. doi:
10.1146/annurev.physiol.69.031905.164337. PubMed PMID: 17014365.
13. Brissot P, Ropert M, Le Lan C, et al. Non-transferrin bound iron: a key role in iron
an
overload and iron toxicity. Biochim Biophys Acta. 2012 Mar;1820(3):403-10. doi:
10.1016/j.bbagen.2011.07.014. PubMed PMID: 21855608; eng.
14. Kroot JJ, Tjalsma H, Fleming RE, et al. Hepcidin in human iron disorders: diagnostic
M
implications. Clin Chem. 2011 Dec;57(12):1650-69. doi: 10.1373/clinchem.2009.140053.
PubMed PMID: 21989113.
15. Andrews NC. Closing the iron gate. N Engl J Med. 2012 Jan 26;366(4):376-7. doi:
ed

10.1056/NEJMcibr1112780. PubMed PMID: 22276828; eng.

16. Johnson MB, Enns CA. Diferric transferrin regulates transferrin receptor 2 protein
pt

stability. Blood. 2004 Dec 15;104(13):4287-93. doi: 10.1182/blood-2004-06-2477.

PubMed PMID: 15319290.
ce

17. Schmidt PJ, Toran PT, Giannetti AM, et al. The transferrin receptor modulates Hfe-
dependent regulation of hepcidin expression. Cell Metab. 2008 Mar;7(3):205-14. doi:
10.1016/j.cmet.2007.11.016. PubMed PMID: 18316026; PubMed Central PMCID:
Ac

PMCPMC2292811. eng.
18. Kautz L, Jung G, Valore EV, et al. Identification of erythroferrone as an erythroid
regulator of iron metabolism. Nat Genet. 2014 Jul;46(7):678-84. doi: 10.1038/ng.2996.
PubMed PMID: 24880340; PubMed Central PMCID: PMCPMC4104984.
19. Cairo G, Recalcati S, Montosi G, et al. Inappropriately high iron regulatory protein
activity in monocytes of patients with genetic hemochromatosis. Blood. 1997 Apr
01;89(7):2546-53. PubMed PMID: 9116301; eng.
20. Wood MJ, Powell LW, Dixon JL, et al. Clinical cofactors and hepatic fibrosis in hereditary
hemochromatosis: the role of diabetes mellitus. Hepatology. 2012 Sep;56(3):904-11. doi:
10.1002/hep.25720. PubMed PMID: 22422567; eng.
21. van Asbeck BS, Verbrugh HA, van Oost BA, et al. Listeria monocytogenes meningitis
and decreased phagocytosis associated with iron overload. Br Med J (Clin Res Ed).
1982 Feb 20;284(6315):542-4. PubMed PMID: 6800535; PubMed Central PMCID:
PMCPMC1496163. eng.

t
ip
22. Cherchi GB, Pacifico L, Cossellu S, et al. Prospective study of Yersinia enterocolitica
infection in thalassemic patients. Pediatr Infect Dis J. 1995 Jul;14(7):579-84. PubMed

cr
PMID: 7567285; eng.
23. Gerhard GS, Levin KA, Price Goldstein J, et al. Vibrio vulnificus septicemia in a patient

us
with the hemochromatosis HFE C282Y mutation. Arch Pathol Lab Med. 2001
Aug;125(8):1107-9. doi: 10.1043/0003-9985(2001)125<1107:vvsiap>2.0.co;2. PubMed
PMID: 11473471; eng.
an
24. Niederau C, Strohmeyer G, Stremmel W. Epidemiology, clinical spectrum and prognosis
of hemochromatosis. Adv Exp Med Biol. 1994;356:293-302. PubMed PMID: 7887234;
eng.
M
25. Zoller H, Henninger B. Pathogenesis, Diagnosis and Treatment of
Hemochromatosis. Dig Dis. 2016;34(4):364-73. doi: 10.1159/000444549. PubMed
PMID: 27170390.
ed

* Thorough overview of hemochromatosis

26. Fracanzani AL, Fargion S, Romano R, et al. Portal hypertension and iron depletion in
pt

patients with genetic hemochromatosis. Hepatology. 1995 Oct;22(4 Pt 1):1127-31.

PubMed PMID: 7557861; eng.
ce

27. Morrison ED, Brandhagen DJ, Phatak PD, et al. Serum ferritin level predicts advanced
hepatic fibrosis among U.S. patients with phenotypic hemochromatosis. Ann Intern Med.
2003 Apr 15;138(8):627-33. PubMed PMID: 12693884; eng.
Ac

28. Beaton M, Guyader D, Deugnier Y, et al. Noninvasive prediction of cirrhosis in C282Y-

linked hemochromatosis. Hepatology. 2002 Sep;36(3):673-8. doi:
10.1053/jhep.2002.35343. PubMed PMID: 12198660; eng.
29. Powell LW, Dixon JL, Ramm GA, et al. Screening for hemochromatosis in asymptomatic
subjects with or without a family history. Arch Intern Med. 2006 Feb 13;166(3):294-301.
doi: 10.1001/archinte.166.3.294. PubMed PMID: 16476869; eng.
30. Olthof AW, Sijens PE, Kreeftenberg HG, et al. Correlation between serum ferritin levels
and liver iron concentration determined by MR imaging: impact of hematologic disease
and inflammation. Magn Reson Imaging. 2007 Feb;25(2):228-31. doi:
10.1016/j.mri.2006.09.019. PubMed PMID: 17275618.
31. Gandon Y, Olivié D, Guyader D, et al. Non-invasive assessment of hepatic iron
stores by MRI. The Lancet. 2004;363(9406):357-362. doi: 10.1016/s0140-
6736(04)15436-6.

t
ip
* One of the initial studies with MRI and hepatic iron quantification
32. Nielsen P, Gunther U, Durken M, et al. Serum ferritin iron in iron overload and liver

cr
damage: correlation to body iron stores and diagnostic relevance. J Lab Clin Med. 2000
May;135(5):413-8. doi: 10.1067/mlc.2000.106456. PubMed PMID: 10811057.

us
33. Henninger B, Kremser C, Rauch S, et al. Evaluation of MR imaging with T1 and T2*
mapping for the determination of hepatic iron overload. Eur Radiol. 2012
Nov;22(11):2478-86. doi: 10.1007/s00330-012-2506-2. PubMed PMID: 22645044.
an
34. Idilman IS, Akata D, Ozmen MN, et al. Different forms of iron accumulation in the liver on
MRI. Diagn Interv Radiol. 2016 Jan-Feb;22(1):22-8. doi: 10.5152/dir.2015.15094.
PubMed PMID: 26712679; PubMed Central PMCID: PMCPMC4712893.
M
35. Bravo AA, Sheth SG, Chopra S. Liver biopsy. N Engl J Med. 2001 Feb 15;344(7):495-
500. doi: 10.1056/nejm200102153440706. PubMed PMID: 11172192; eng.
36. Barry M, Sherlock S. Measurement of liver-iron concentration in needle-biopsy
ed

specimens. Lancet. 1971 Jan 16;1(7690):100-3. PubMed PMID: 4099600.

37. Villeneuve JP, Bilodeau M, Lepage R, et al. Variability in hepatic iron concentration
pt

measurement from needle-biopsy specimens. J Hepatol. 1996 Aug;25(2):172-7.

PubMed PMID: 8878778.
ce

38. Mortele KJ, Ros PR. Imaging of diffuse liver disease. Semin Liver Dis. 2001
May;21(2):195-212. doi: 10.1055/s-2001-15496. PubMed PMID: 11436572.
39. Boll DT, Merkle EM. Diffuse liver disease: strategies for hepatic CT and MR imaging.
Ac

Radiographics. 2009 Oct;29(6):1591-614. doi: 10.1148/rg.296095513. PubMed PMID:

19959510.
40. Goldman IS, Winkler ML, Raper SE, et al. Increased hepatic density and
phospholipidosis due to amiodarone. AJR Am J Roentgenol. 1985 Mar;144(3):541-6.
doi: 10.2214/ajr.144.3.541. PubMed PMID: 3871563.
41. De Maria M, De Simone G, Laconi A, et al. Gold storage in the liver: appearance on CT
scans. Radiology. 1986 May;159(2):355-6. doi: 10.1148/radiology.159.2.3961168.
PubMed PMID: 3961168.
42. Akpinar E, Akhan O. Liver imaging findings of Wilson's disease. Eur J Radiol. 2007
Jan;61(1):25-32. doi: 10.1016/j.ejrad.2006.11.006. PubMed PMID: 17161572.
43. Chandarana H, Lim RP, Jensen JH, et al. Hepatic iron deposition in patients with
liver disease: preliminary experience with breath-hold multiecho T2*-weighted

t
ip
sequence. AJR Am J Roentgenol. 2009 Nov;193(5):1261-7. doi:
10.2214/AJR.08.1996. PubMed PMID: 19843739.

cr
** Very important paper discussing MRI techniques for determing hepatic iron
overload

us
44. Ghugre NR, Wood JC. Relaxivity-iron calibration in hepatic iron overload: probing
underlying biophysical mechanisms using a Monte Carlo model. Magn Reson Med. 2011
Mar;65(3):837-47. doi: 10.1002/mrm.22657. PubMed PMID: 21337413; PubMed Central
an
PMCID: PMCPMC3065944.
45. Gandon Y, Guyader D, Heautot JF, et al. Hemochromatosis: diagnosis and
quantification of liver iron with gradient-echo MR imaging. Radiology. 1994
M
Nov;193(2):533-8. doi: 10.1148/radiology.193.2.7972774. PubMed PMID: 7972774.
46. al Ge. MRQuantif to quantify liver iron and fat by MRI University of Rennes,
France[updated January 17, 2018;6/10/2018]. Available from: https://imagemed.univ-
ed

rennes1.fr/en/mrquantif/overview.php
47. Christoforidis A, Perifanis V, Spanos G, et al. MRI assessment of liver iron content in
pt

thalassamic patients with three different protocols: comparisons and correlations. Eur J
Haematol. 2009 May;82(5):388-92. doi: 10.1111/j.1600-0609.2009.01223.x. PubMed
ce

PMID: 19141120.
48. Alustiza Echeverria JM, Castiella A, Emparanza JI. Quantification of iron concentration
in the liver by MRI. Insights Imaging. 2012 Apr;3(2):173-80. doi: 10.1007/s13244-011-
Ac

0132-1. PubMed PMID: 22696043; PubMed Central PMCID: PMCPMC3314738.

49. St Pierre TG, Clark PR, Chua-anusorn W, et al. Noninvasive measurement and imaging
of liver iron concentrations using proton magnetic resonance. Blood. 2005 Jan
15;105(2):855-61. doi: 10.1182/blood-2004-01-0177. PubMed PMID: 15256427.
50. Ferriscan - MRI MEASUREMENT OF LIVER IRON CONCENTRATION 2018
[6/10/2018]. Available from: www.ferriscan.com
51. St Pierre TG, Clark PR, Chua-Anusorn W. Single spin-echo proton transverse
relaxometry of iron-loaded liver. NMR Biomed. 2004 Nov;17(7):446-58. doi:
10.1002/nbm.905. PubMed PMID: 15523601.
52. Krafft AJ, Loeffler RB, Song R, et al. Quantitative ultrashort echo time imaging for
assessment of massive iron overload at 1.5 and 3 Tesla. Magn Reson Med. 2017 Jan
16. doi: 10.1002/mrm.26592. PubMed PMID: 28090666.
53. Sirlin CB, Reeder SB. Magnetic resonance imaging quantification of liver iron. Magn

t
ip
Reson Imaging Clin N Am. 2010 Aug;18(3):359-81, ix. doi: 10.1016/j.mric.2010.08.014.
PubMed PMID: 21094445; PubMed Central PMCID: PMCPMC3430384.

cr
54. Wood JC, Enriquez C, Ghugre N, et al. MRI R2 and R2* mapping accurately
estimates hepatic iron concentration in transfusion-dependent thalassemia and

us
sickle cell disease patients. Blood. 2005 Aug 15;106(4):1460-5. doi: 10.1182/blood-
2004-10-3982. PubMed PMID: 15860670; PubMed Central PMCID:
PMCPMC1895207.
an
** Seminal paper discussing MRI protocols for determining hepatic iron overload
55. Hankins JS, McCarville MB, Loeffler RB, et al. R2* magnetic resonance imaging of the
liver in patients with iron overload. Blood. 2009 May 14;113(20):4853-5. doi:
M
10.1182/blood-2008-12-191643. PubMed PMID: 19264677; PubMed Central PMCID:
PMCPMC2686136.
56. Henninger B, Zoller H, Rauch S, et al. R2* relaxometry for the quantification of hepatic
ed

iron overload: biopsy-based calibration and comparison with the literature. Rofo. 2015
Jun;187(6):472-9. doi: 10.1055/s-0034-1399318. PubMed PMID: 25877992.
pt

57. Storey P, Thompson AA, Carqueville CL, et al. R2* imaging of transfusional iron burden
at 3T and comparison with 1.5T. Journal of magnetic resonance imaging : JMRI. 2007
ce

Mar;25(3):540-7. doi: 10.1002/jmri.20816. PubMed PMID: 17326089; PubMed Central

PMCID: PMCPMC2884049.
58. Ghugre NR, Doyle EK, Storey P, et al. Relaxivity-iron calibration in hepatic iron overload:
Ac

Predictions of a Monte Carlo model. Magn Reson Med. 2015 Sep;74(3):879-83. doi:
10.1002/mrm.25459. PubMed PMID: 25242237; PubMed Central PMCID:
PMCPMC4951155.
59. Westwood M, Anderson LJ, Firmin DN, et al. A single breath-hold multiecho T2*
cardiovascular magnetic resonance technique for diagnosis of myocardial iron overload.
Journal of magnetic resonance imaging : JMRI. 2003 Jul;18(1):33-9. doi:
10.1002/jmri.10332. PubMed PMID: 12815637.
60. Westwood MA, Anderson LJ, Firmin DN, et al. Interscanner reproducibility of
cardiovascular magnetic resonance T2* measurements of tissue iron in thalassemia.
Journal of magnetic resonance imaging : JMRI. 2003 Nov;18(5):616-20. doi:
10.1002/jmri.10396. PubMed PMID: 14579406.
61. Chappell KE, Patel N, Gatehouse PD, et al. Magnetic resonance imaging of the liver with
ultrashort TE (UTE) pulse sequences. Journal of magnetic resonance imaging : JMRI.
2003 Dec;18(6):709-13. doi: 10.1002/jmri.10423. PubMed PMID: 14635156; eng.

t
ip
62. Angelucci E, Muretto P, Nicolucci A, et al. Effects of iron overload and hepatitis C virus
positivity in determining progression of liver fibrosis in thalassemia following bone

cr
marrow transplantation. Blood. 2002 Jul 01;100(1):17-21. PubMed PMID: 12070002.
63. Carneiro AA, Fernandes JP, de Araujo DB, et al. Liver iron concentration evaluated by

us
two magnetic methods: magnetic resonance imaging and magnetic susceptometry.
Magn Reson Med. 2005 Jul;54(1):122-8. doi: 10.1002/mrm.20510. PubMed PMID:
15968652.
an
64. Dyvorne HA, Jajamovich GH, Bane O, et al. Prospective comparison of magnetic
resonance imaging to transient elastography and serum markers for liver fibrosis
detection. Liver Int. 2016 May;36(5):659-66. doi: 10.1111/liv.13058. PubMed PMID:
M
26744140; PubMed Central PMCID: PMCPMC4842106.
65. Huwart L, Sempoux C, Vicaut E, et al. Magnetic resonance elastography for the
noninvasive staging of liver fibrosis. Gastroenterology. 2008 Jul;135(1):32-40. doi:
ed

10.1053/j.gastro.2008.03.076. PubMed PMID: 18471441; eng.

66. Wang Y, Ganger DR, Levitsky J, et al. Assessment of chronic hepatitis and fibrosis:
pt

comparison of MR elastography and diffusion-weighted imaging. AJR Am J Roentgenol.

2011 Mar;196(3):553-61. doi: 10.2214/AJR.10.4580. PubMed PMID: 21343496; PubMed
ce

Central PMCID: PMCPMC3093963.

67. Yin M, Talwalkar JA, Glaser KJ, et al. Assessment of hepatic fibrosis with magnetic
resonance elastography. Clin Gastroenterol Hepatol. 2007 Oct;5(10):1207-1213 e2. doi:
Ac

10.1016/j.cgh.2007.06.012. PubMed PMID: 17916548; PubMed Central PMCID:

PMCPMC2276978.
68. Wu WP, Chou CT, Chen RC, et al. Non-Invasive Evaluation of Hepatic Fibrosis: The
Diagnostic Performance of Magnetic Resonance Elastography in Patients with Viral
Hepatitis B or C. PLoS One. 2015;10(10):e0140068. doi: 10.1371/journal.pone.0140068.
PubMed PMID: 26469342; PubMed Central PMCID: PMCPMC4607490.
69. Wagner M, Corcuera-Solano I, Lo G, et al. Technical Failure of MR Elastography
Examinations of the Liver: Experience from a Large Single-Center Study. Radiology.
2017 Jan 03:160863. doi: 10.1148/radiol.2016160863. PubMed PMID: 28045604.
70. Wagner M, Besa C, Bou Ayache J, et al. Magnetic Resonance Elastography of the Liver:
Qualitative and Quantitative Comparison of Gradient Echo and Spin Echo Echoplanar
Imaging Sequences. Invest Radiol. 2016 Sep;51(9):575-81. doi:
10.1097/RLI.0000000000000269. PubMed PMID: 26982699.

t
ip
71. Horng DE, Hernando D, Reeder SB. Quantification of liver fat in the presence of iron
overload. Journal of magnetic resonance imaging : JMRI. 2017 Feb;45(2):428-439. doi:

cr
10.1002/jmri.25382. PubMed PMID: 27405703; PubMed Central PMCID:
PMCPMC5420327.

us
72. Lee YJ, Lee JM, Lee JS, et al. Hepatocellular carcinoma: diagnostic performance of
multidetector CT and MR imaging-a systematic review and meta-analysis. Radiology.
2015 Apr;275(1):97-109. doi: 10.1148/radiol.14140690. PubMed PMID: 25559230.
an
73. Friedrich-Rust M, Ong MF, Martens S, et al. Performance of transient elastography for
the staging of liver fibrosis: a meta-analysis. Gastroenterology. 2008 Apr;134(4):960-74.
doi: 10.1053/j.gastro.2008.01.034. PubMed PMID: 18395077; eng.
M
74. Manning DS, Afdhal NH. Diagnosis and quantitation of fibrosis. Gastroenterology. 2008
May;134(6):1670-81. doi: 10.1053/j.gastro.2008.03.001. PubMed PMID: 18471546; eng.
75. Ong SY, Dolling L, Dixon JL, et al. Should HFE p.C282Y homozygotes with moderately
ed

elevated serum ferritin be treated? A randomised controlled trial comparing iron

reduction with sham treatment (Mi-iron). BMJ Open. 2015 Aug 12;5(8):e008938. doi:
pt

10.1136/bmjopen-2015-008938. PubMed PMID: 26270952; PubMed Central PMCID:

PMCPMC4538285. eng.
ce

76. Andersen ES, Christensen PB, Weis N. Transient elastography for liver fibrosis
diagnosis. Eur J Intern Med. 2009 Jul;20(4):339-42. doi: 10.1016/j.ejim.2008.09.020.
PubMed PMID: 19524169; eng.
Ac

77. Talwalkar JA, Kurtz DM, Schoenleber SJ, et al. Ultrasound-based transient elastography
for the detection of hepatic fibrosis: systematic review and meta-analysis. Clin
Gastroenterol Hepatol. 2007 Oct;5(10):1214-20. doi: 10.1016/j.cgh.2007.07.020.
PubMed PMID: 17916549; eng.
78. Adhoute X, Foucher J, Laharie D, et al. Diagnosis of liver fibrosis using FibroScan and
other noninvasive methods in patients with hemochromatosis: a prospective study.
Gastroenterol Clin Biol. 2008 Feb;32(2):180-7. PubMed PMID: 18496894; eng.
79. Legros L, Bardou-Jacquet E, Latournerie M, et al. Non-invasive assessment of liver
fibrosis in C282Y homozygous HFE hemochromatosis. Liver Int. 2015 Jun;35(6):1731-8.
doi: 10.1111/liv.12762. PubMed PMID: 25495562; eng.
80. Castera L, Foucher J, Bernard PH, et al. Pitfalls of liver stiffness measurement: a 5-year
prospective study of 13,369 examinations. Hepatology. 2010 Mar;51(3):828-35. doi:
10.1002/hep.23425. PubMed PMID: 20063276; eng.
81. Paparo F, Cevasco L, Zefiro D, et al. Diagnostic value of real-time elastography in the

t
ip
assessment of hepatic fibrosis in patients with liver iron overload. Eur J Radiol. 2013
Dec;82(12):e755-61. doi: 10.1016/j.ejrad.2013.08.038. PubMed PMID: 24050879; eng.

cr
82. Adams PC, Speechley M, Kertesz AE. Long-term survival analysis in hereditary
hemochromatosis. Gastroenterology. 1991 Aug;101(2):368-72. PubMed PMID:

us
2065912; eng.
83. Niederau C, Fischer R, Purschel A, et al. Long-term survival in patients with hereditary
hemochromatosis. Gastroenterology. 1996 Apr;110(4):1107-19. PubMed PMID:
an
8613000; eng.
84. Falize L, Guillygomarc'h A, Perrin M, et al. Reversibility of hepatic fibrosis in treated
genetic hemochromatosis: a study of 36 cases. Hepatology. 2006 Aug;44(2):472-7. doi:
M
10.1002/hep.21260. PubMed PMID: 16871557; eng.
85. Hutchinson C, Geissler CA, Powell JJ, et al. Proton pump inhibitors suppress absorption
of dietary non-haem iron in hereditary haemochromatosis. Gut. 2007 Sep;56(9):1291-5.
ed

doi: 10.1136/gut.2006.108613. PubMed PMID: 17344278; PubMed Central PMCID:

PMCPMC1954964. eng.
pt

86. Franchini M, Targher G, Capra F, et al. The effect of iron depletion on chronic hepatitis C
virus infection. Hepatol Int. 2008 Sep;2(3):335-40. doi: 10.1007/s12072-008-9076-z.
ce

PubMed PMID: 19669262; PubMed Central PMCID: PMCPMC2716881. eng.

87. Facchini FS, Hua NW, Stoohs RA. Effect of iron depletion in carbohydrate-intolerant
patients with clinical evidence of nonalcoholic fatty liver disease. Gastroenterology. 2002
Ac

Apr;122(4):931-9. PubMed PMID: 11910345; eng.

88. Valenti L, Fracanzani AL, Dongiovanni P, et al. Iron depletion by phlebotomy improves
insulin resistance in patients with nonalcoholic fatty liver disease and hyperferritinemia:
evidence from a case-control study. Am J Gastroenterol. 2007 Jun;102(6):1251-8. doi:
10.1111/j.1572-0241.2007.01192.x. PubMed PMID: 17391316; eng.
89. Laine F, Ruivard M, Loustaud-Ratti V, et al. Metabolic and hepatic effects of bloodletting
in dysmetabolic iron overload syndrome: A randomized controlled study in 274 patients.
 Hepatology. 2017 Feb;65(2):465-474. doi: 10.1002/hep.28856. PubMed PMID:
27685251; eng.
90. Rombout-Sestrienkova E, Nieman FH, Essers BA, et al. Erythrocytapheresis versus
phlebotomy in the initial treatment of HFE hemochromatosis patients: results from a
randomized trial. Transfusion. 2012 Mar;52(3):470-7. doi: 10.1111/j.1537-
2995.2011.03292.x. PubMed PMID: 21848963; eng.
91. Bruckl D, Kamhieh-Milz S, Kamhieh-Milz J, et al. Efficacy and safety of

t
ip
erythrocytapheresis and low-dose erythropoietin for treatment of hemochromatosis. J
Clin Apher. 2016 Jun 08. doi: 10.1002/jca.21477. PubMed PMID: 27271482; eng.

cr
us
an
M
ed
pt
ce
Ac
 t
ip
cr
us
an
Figure 1: Iron is absorbed by divalent metal transporter 1 (DMT1) on the apical enterocyte cell
surface. It is transferred through the cell to the basolateral surface where it is then shifted from
M

the enterocyte into circulation via the ferroportin transporter. Once in circulation, free iron is
bound to transferrin and transported to areas such as hepatocytes via transferrin receptor 2 and
ed

the HFE protein. It can then be stored as ferritin or go to erythroid precursors where it is used
for heme synthesis. Hepatocytes produce hepcidin which downregulates activity of ferroportin
especially in the enterocytes and macrophages.
pt
ce
Ac
 t
ip
cr
us
Figure 2:
2 This imag
ge was repriinted with permission g
granted from
m New Engla
and Journal of
Medicine, Iron Ove
erload in Hum
man Diseasse 2012 [2].
an
M
ed

Figure 3:
3 51-year-o h no known liver diseasse and eleva
old man with ated ferritin (536 ng/mL
L) found
pt

to have concomitan
nt moderate
e hepatic iro
on deposition and steato
osis at MRI. A–F, Brea
ath-hold
adient-recallled echo T2
axial gra 2* MR imag
ges of liver (TE, 1.96 [A
A], 4.4 [B], 8.8 [C], 12.8 [D], 17
ce

[E], 21 [[F]); shows non-cirrhotic liver parenchyma and

d progressivve decrease
e in signal in
ntensity of
liver with increasing
g TE. G, Axxial T2* map
p reconstruccted from sixx TEs shows diffuse he
epatic iron
distributtion. Liver T
T2* value wa
as decrease
ed to 14 millliseconds. H
H-I, T1-in ph
hase and T1
1-
Ac

opposed
d phase ima
ages show loss
l of signa
al intensity on opposed
d phase ima
ages in the liver,
consiste
ent with stea
atosis. J, T2
2* corrected
d fat only image obtaine
ed using 3-p
point Dixon method
shows h
hepatic fat frraction of 22
2%. The pa
atient underw
went subseq
quent genettic testing, w
which
revealed
d compound
d heterozyg
gote with one copy of H
H63D and on
ne copy of C
C282Y, conssistent
with the
e diagnosis o
of hemochro
omatosis.
 st
TS and Ferritin Adult 1 Degree
Relative

TS >45% and TS <45% and TS >45% and

Ferritin Normal Normal Ferritin Elevated Ferritin
or Low

Iron Overload HFE Testing

HFE Testing
Ruled Out

t
HFE Testing HFE Testing

rip
Negative Positive Compound Heterozygote C282Y/C282Y
or C282Y heterozygote
Homozygote
or non-HFE
Monitor Consider MRI

c
for further Iron
MRI T2* or Liver Bx
Quantification Ferritin <1000 Ferritin >1000

us
and Normal or Elevated
Liver Liver
Phlebotomy if Monitor if no No Hepatic Hepatic and Hepatic Iron
Chemistries Chemistries
Hepatic iron Iron Splenic Iron and No Splenic

an
Hepatic iron
Iron

Therapeutic Liver Biopsy

TS <45%
Phlebotomy for HIC and

M
and Ferritin Metabolic Transfusional Iron
Non-HFE Histology
Elevated Hyperferritinemia Overload or
Hematological Hemochromatosis
Disease

d
R/O Inflammatory
Treat Disorders, NAFLD,
Underlying
Disorder
Metabolic Syndrome,
te
Cell Necrosis, Alcohol
Abuse
Chelation
ep
MRI T2*
c
Ac

Hepatic T2* <18ms Hepatic T2* >18ms Hepatic T2* <18ms

Splenic T2* >20ms (no Hepatic Iron Splenic T2* <20ms
overload)

Low Ceruloplasmin? SLC40A1 Mutation?

L-ferritin
Classical Ferroportin
CP Gene Mutation? Mutation This algorithm was compiled and adapted, with
Disease
modifications, from Bacon et al., [1] EASL clinical
practice guidelines for HFE hemochromatosis.,[5]
Aceruloplasminemia Hyperferritinemia Phlebotomy? vs Zoller et al., [25] and Fleming et al. [2]
Cataract Syndrome Watchful Waiting