Haematology joint seminar 14/11/2012 Dr Kishore & Dr Ashutosh

15-year-old male WBC 4.5 x 109/L, Hgb 8.6 g/dl, PLT 350 x 109/L with MCV of 76 fl.

Hypochromic, microcytic RBCs No GI symptoms

Serum Fe of 15, transferrin saturation of 5 percent. Given oral iron supplementation No use. IV iron supplementation subsequent partial improvement in Hgb

Two cousins have similar history..

Kishore Kumar

Basic facts

Absorption
Transport & Recycling

Transferrin cycle & storage

Systemic Homeostasis Cellular level regulation Pathogenesis of IDA

A disease believed to be Iron Deficiency Anemia was described in 1554 by Johannes Lange. It was termed cholorsis or green sickness and iron salt was used for its treatment. Almost exclusively in adolescent girls between 14 and 17.

It was depicted in many paintings by Dutch masters .

Most common element on earth.

Still iron deficiency is the most common nutritional

disorder in the world. Thanks to low bioavailability and complex metabolic pathways.. Apart from the commonly known overload states, is also

involved in neurodegenerative diseases, Sideroblastic

anemia , MDS etc..

May be 2+ or 3+
Ferrous (2+) reduced - gained an electron Ferric (3+) oxidised - lost an electron

Fe+++

e- Fe++

Redox states allows activity passing electrons around body

Redox change required for iron metabolism

Stable state of iron in most of its biological complexes is Fe(III).

Reduction needed for transport.

These properties render it potentially toxic.

Haber-Weis-Fentons reaction.

Oxygen transporting Heme containing proteins

(Hemoglobin , myoglobin)

Heme containing enzymes like cytochromes, catalases and peroxidases. Iron-Sulfur containing proteins like Aconitase , ferrochelatase. Iron transport proteins Iron storage proteins.

In a 70 kg male=3.5gms In females= 250-300mg less than males

Full term infants Adult males Adult females

75mg/kg 50mg/kg 35mg/kg

DMT1(Nramp, DCT1) apical membrane of enterocytes & endosomes.

Ferroprotein (IREG1) Export of ferrous iron.

HCP-1 Heme transporter in enterocytes.

Integrin- Mobilferrin complex Ferric iron transport

TfR1 Binds Tf-Fe2 & initiates Transferrin cycle

DcytB Ferrireductase on enterocyte surface Hephaestin Ferro-oxidase in basolateral membrane Ceruloplasmin oxidase in other tissues Heme Oxygenase-1 release of iron from heme

Lactoferrin free iron scavenger in body fluids Siderocalcin Acute phase reactant Hemopexin Haptoglobin

No known regulated pathway of iron excretion

Intestinal mucosa responds to changes in body iron

stores, tissue hypoxia, and demand for iron, and it

alters absorption accordingly.

Duodenum and jejunum excess Ferroprotein conc. For optimal nutrition a daily intake of 8-10 mg of iron is required.

Acidic pH, vitamin C and some low - molecular weight chelates (e.g. sugars, amino acids) enhance absorption.

Therapeutic ferrous iron salts are well absorbed on an

empty stomach.

Phytates, tannates in tea and bran inhibit absorption.

Understanding Heme Transport - N.C Andrews - New England Journal of Medicine:353;23 - 2508

DMT1 is not specific for iron transport but also mediates transport of other divalent metal cations

expressed on the membrane of endosomes

DMT-1 seems to have a role in transport of non

transferrin bounded iron (NTBI)

Murine microcytic anemia

While ferrous iron uses DMT-1, ferric uses integrinmobilferrin pathway (IMT) that solely transports ferric iron.

In the cell cytosol these proteins are integrated into a

large protein complex called paraferritin

Contains beta-2-microglobulin and DMT-1

Transport of iron associated with some proteins

(chaperones) or transcytosis

Sequestrated as ferritin or transported into circulation Enterocytes shed in two days Transport of iron by ferroportin decides whether to keep or discard

These cells also express transferrin receptors type 1 (TfR1)

and iron from the plasma can enter.

Ferroportin represents the only known iron exporter Basolateral membranes of duodenal enterocytes, RES macrophages, hepatocytes and placental cells

Requires change of redox state by ferroxidase hephaestin in the duodenum and ceruloplasmin

elsewhere in the body

Type IV hemochromatosis

Intestinal iron absorption increases with Decreased iron stores Increased erythropoietic activity Ineffective erythropoiesis Anaemia Hypoxia
Intestinal iron absorption decreases in inflammation

Two models have been proposed to explain how the absorption of iron is regulated
Crypt programming model
Hepcidin model

Increased iron in plasma

Increased iron in enterocyte

Forms a complex with IRP/IRE

Translocate s to nucleus

Inhibits Transcription of DMT1,hephestin, ferroportin and increases

ferritin

DcytB

Reduction Fe+++ to Fe++ Transport into cell

DMT1

Ferritin

Storage in cell
Oxidises Fe++ to Fe+++ Transport out

Hephaestin

Ferroportin

Fleming, R. E. et al. N Engl J Med 2009;352:1741-1744

Transferrin provides solubility, reduced reactivity and thus

provides a safe and controlled delivery of iron to all cells in

the body.

Due to high affinity all non-heme iron in circulation is

bounded to transferrin

NTBI refers to all forms binding to ligands other than transferrin.

Capable of free entry into cells. very reactive and could enter
Fenton reaction.

Transferrin has two iron binding sites which binds one iron atom each

Transferrin exists in 3 forms-apotransferrin, monoferric, diferric

30-40% of these sites are occupied under normal

physiological conditions.

Contains only about 3 mg of body iron at any time, it is vital to iron transport, with over 20 mg iron passing through this compartment each day

TfR1 andTfR2.

TfR1 is expressed by all iron-requiring cells but level of

expression varies.

Diferric transferrin has a higher affinity for TfR1 Soluble transferrin receptor (sTfR) is released by proteolytic cleavage of the protein C-terminal end and regulated by transferrin

The level of sTfR reflects the availability of functional iron.

TfR2 - liver, hematopoetic cells, duodenal crypt cells. TfR2 binds to HFE and transferrin in different domains

It is assumed that TfR2/HFE complex is required for

transcriptional regulation of hepcidin production

Pool of iron complexed with low affinity ligands (citrate, ATP,

amino acids, ascorbic acid or by unidentified chaperones)

LIP represents < 5% of the total cellular iron. Supplies iron to the mitochondrion, synthesis of ironcontaining proteins in cytosol thereby controlling numerous metabolic reactions.

LIP is catalytically active and capable of initiating free radical reactions

Ferritin has got dual function of iron detoxification and reserve. The protein shell is constructed of 24 molecules of two distinct ferritin subunits, designated H (for heavy or heart) and L (for light or liver). H chains contain a ferroxidase - oxidize iron & acquire iron more rapidly.

L chains are more stable and resistant to denaturation.

Theoretically 4500 atoms but usually 2000 atoms

Dia-13nm Central core-6nm 6 channels

Small quantities are present in nucleus and mitochondria Biosynthesis of heme and enzymes that contain Fe-S group Very small amount enters into circulation - lysosomal secretory pathway Non-ferous, and its exact biologic purpose is still unknown Plasma ferritin concentration of 1 g/L corresponds to 8-10 mg tissue iron stores

Incompletely degraded ferritin Conglomerate of iron, ferritin proteins,lipids, sialic acids and porphyrin in small amounts

Less soluble Stains with prussian blue

More stable and less available form of storage iron .

 ONE

WORD TO REMEMBER
HEPCIDIN

25 aa peptide secreted from liver.

Antimicrobial activity & Hypoferremic hormone
In 2000,by accident, investigators studying gluconeogenesis in infections silenced the gene for hepcidin in the mouse Unusual increase in PARENCHYMAL IRON.
Decreased iron stores
Increased erythropoietic activity Anemia

Hypoxia

1.Regulation by iron status, dietary iron and iron stores.

2. Regulation by inflammation. 3. Regulation by hypoxia/anemia. 4. Regulation by erythroid factors.

HFE/TfR2/Tf Regulation of Hepcidin Transcription

TfR1 is hypothesized to sequester HFE.

Tf and HFE compete for binding to TfR1 TFR2 is predominantly expressed in hepatocytes Tf induced release of HFE from TfR1 - to increase the association of HFE with TfR2 and to stimulate hepcidin transcription.

HJV is a GPI-linked membrane protein encoded by the gene, HFE2

Homozygous or compound heterozygous mutations in

HFE2 result in a juvenile form of HH.

HJV is a co-receptor for BMP2, BMP4, BMP5, and BMP6 and enhances hepatic hepcidin expression by enhancing BMP signaling

The HJV-BMP ligand-BMP receptors complex induces an intracellular BMP signalling pathway which in turn activates the SMAD4 signalling pathway, which translocates from the cytoplasm to the nucleus to regulate gene expression

Two potential BMP-responsive elements critical for BMP6

and HJV responsiveness are present in both the distal and

the proximal regions of the hepcidin promoter

Essential component of a pathway that detects iron deficiency

Cleaves membrane bound HJV increasing sHJV that competitively impairs BMP signaling.

Each cell has the capacity to regulate its own

utilisation of iron

Cells replete in iron, ferritin TFRC

In contrast, iron-depleted cells, TFRC,

Ferritin

The IRE/IRP Regulatory System IRP act as the cell sensor to iron availability

IRP1, when saturated with iron, acts as a cytosolic

aconitase and catalyzes the conversion of citrate to

isocitrate .

IRP2 is less abundant and does not have an identified enzyme function. IRE at 5-UTR mRNA ferritin, ferroportin - Not repressed IRE at 3-UTR mRNA TfR1, DMT1 - Unstable

DcytB DMT 1 Hemojuvelin FLVCR Ferroprotein Hepcidin

Hemochromatosis (HFE)

IRP1 IRP2 IRE TMPRSS6 GDF-1 TWSG

STEAP3 Transferrin TFR1 TFR2 Ferritin (H)

Hephaestin

Ferritin (L)

EPO

Directly or indirectly modulate hepcidin for ACD

Cancer cells have a high iron demands - clinical

studies using iron chelators as anticancer therapy

Recombinant lactoferrin for treating bacterial and

viral infections

Iron chelators - neuroprotective and neurorestorative effects

Extremely common Due to reduced intake, increased loss or increased demands

Stores reduced before deficiency seen

Iron deficiency is not a diagnosis A cause needs to be identified! Eg obstetric causes, low intake, malabsorption, bowel cancer, haemorrhoids, inflammatory bowel disease

Prelatent

Reduction in iron stores without reduced serum iron levels

detected by a low serum ferritin measurement Latent

Iron stores are exhausted, but the blood hemoglobin level

remains normal

Iron deficiency anemia

Blood hemoglobin concentration falls below the lower limit

of normal

Causes
Increased iron requirements Blood loss Rapid growth in body size between 2 and 36 months of age

Pregnancy and lactation

Inadequate iron supply Poor nutritional intake in children (not a common independent mechanism in adults but often a contributing factor) Malabsorption Gastric bypass surgery for ulcers or obesity Achlorhydria from gastritis or drug therapy

Severe malabsorption (for example, celiac disease [nontropical sprue])

Abnormal transferrin function Autoantibodies to transferrin receptors

GENERAL ANEMIAS SYMPTOMS:

Fatigability Dizzeness Headache Irritability

Palpitation

 Glossitis, stomatitis
DYSPHAGIA ( Plummer-Vinson syndrome)

Atrophic gastritis Dry, pale skin Spoon shaped nails, koilonychia, Blue sclerae Hair loss Pica (apetite for non food substances such as an clay) Increased platelet count

Thanks for your attention..

Now we have to manage the case

Now we have to manage the case..