Iron Overload

IRON OVERLOAD
1. Due to germline mutations/polymorphisms in genes for:
HFE
• Hemojuvelin
• Ferroportin
• Hepcidin (HAMP)
• Transferrin receptor-2 (TFR-2)
• Ferritin heavy or light chain (FTH-1, FTL)
2. Chronic ineffective erythropoiesis or hemolysis
• Thalassemia, hereditary hemolytic anemia, congenital dyserythropoietic anemias
• Erythroferrone produced by erythroblasts suppresses hepcidin production
3. Repeated transfusion
4. Dietary
• 15%+ incidence in sub-Saharan Africa due to high iron content in traditional beer;
additional genetic factors may be involved
Too much iron is bad for you
• Promotes formation of toxic oxygen radicals
• Protein and DNA damage, lipid peroxidation
• Mitochondrial injury
• Accumulation in lysosomes impairs their function
• Iron in excess is carcinogenic
• Oxidative damage to DNA
• Promotes tumor proliferation
• Impairs immune function
• Iron increases cardiotoxicity of anthracyclines, and pulmonary toxicity of
bleomycin
• “Free” iron more dangerous than iron stored in macrophages
 • 20 mg of iron per day required
for erythropoiesis

• Most of this iron is recycled

from old RBC after they are
eaten by macrophages
Maintaining • 1-2 mg of “new” iron absorbed
iron balance from gut

• 1-2 mg of iron lost via

sloughing of enterocytes

 No mechanism for eliminating

excess iron

• Excess iron stored

preferentially in hepatic
Kupffer cells

N Engl J Med 2004;350:2383

Most of your iron is in your red cells

• 1 cc of red cells contains about 1 mg iron

• 1 cc of whole blood contains 0.5 mg iron
• In healthy people a 1 µg/ml increase in ferritin is
associated with about an 8 mg increase in storage iron
The HFE gene and protein
• Closely linked to HLA-A locus on chromosome 6
• HFE protein homologous to MHC class 1 proteins
• Extracellular domain with 3 disulfide-bonded loops, transmembrane
domain, cytoplasmic tail
• Associates with ß2-microglobulin and transferrin receptors 1 & 2 in
membrane
• Gene expressed in hepatocytes, Kupffer cells, bile duct epithelium, gut
enterocytes, granulocytes and monocyte/macrophages
• Most production in liver
• HFE regulates hepcidin production through uncertain mechanisms
Hepcidin regulates iron uptake and storage
 Hepcidin is a small
peptide produced mainly
in the liver.
 Interacts with ferroportin
to inhibit iron release from
villus enterocytes and
macrophages.
 Production is upregulated
by high iron levels or
inflammation.
 Low iron levels decrease
hepcidin production,
increasing iron absorption
and release from
enterocytes into the blood,
and release from
macrophages into tissue
N Engl J Med 2004;350:2383
Regulation of hepcidin production
• Iron-bound transferrin binds
TF receptors, which interact
with HFE protein to increase
hepcidin production
• Erythroferrone produced by
EPO-stimulated RBC
precursors decreases
production
Erythroferrone

• Bone morphogenetic
proteins (BMP) interact with
hemojuvelin to increase
hepcidin production when
iron stores increase
Hepcidin gene • IL-6 promotes hepcidin
production in inflammatory
NEJM 2012;366:360 states
HFE polymorphisms/mutations
• C282Y (cysteine→tyrosine) disrupts disulfide bond stabilizing extracellular
domain of HFE; mutant protein retained in Golgi, degraded
• 10% of individuals of N European ancestry carry this polymorphism
• >80% of patients with clinical hemochromatosis homozygous for C282Y
• Many homozygotes for C282Y never develop overt hemochromatosis
although most exhibit some iron overload (incomplete penetrance)
• H63D (histidine→aspartate) polymorphism very common (15-40% of
Caucasians); when found in compound heterozygosity with C282Y rarely
causes hemochromatosis (risk 200-fold lower than in C282Y homozygotes)
• Rare reports of other HFE mutations in patients with hemochromatosis
 Prevalence of HFE C282Y and H63D in
99711 HIERS study participants
Ethnicity (n) C282Y/C282Y C282Y/H63D H63D/H63D C282Y/wt H63D/wt wt/wt

White (44082) 0.44 2.0 2.4 10 24 61

Native American (648) 0.11 0.77 1.3 5.7 20 72

Hispanic (12459) 0.027 0.33 1.1 2.9 18 78

Black (27124) 0.014 0.071 0.089 2.3 5.7 92

Pacific Islander (698) 0.012 0.096 0.20 2.0 8.4 89

Asian (12772) 0.000039 0.0055 0.20 0.012 8.4 91

N Engl J Med 2006;352:1769

Non-genetic variables affecting severity of
iron overload in C282Y homozygotes
• Sex (most important)
• Age (average age of onset about 45 in men)
• Blood donation status
• Dietary iron
• Alcohol consumption
• GI tract factors (PPI use, calcium antacids, malabsorption, bariatric
surgery all decrease iron uptake)
Transferrin saturation and serum ferritin vs genotype

N Engl J Med 2006;352:1769

Phenotypic characteristics of C282Y
heterozygotes
• 12% of Caucasians in US carry this gene
• They often have mildly elevated ferritin or transferrin saturation
(men>women) but rarely have marked abnormalities in iron studies
• Higher hemoglobin and MCV on average
• They may occasionally have enough iron overload to cause tissue injury if
there are other factors (alcohol, chronic hemolysis) that enhance iron
uptake/retention
• Higher incidence of porphyria cutanea tarda
• Female heterozygotes are less likely to become iron deficient
• Prudent to avoid unnecessary iron supplementation
Diagnosis of HFE-related hemochromatosis - 1
• Increased serum iron and high transferrin saturation
• TF saturation >80% strongly suggests C282Y homozygosity)
• Saturation persistently > 45% (women) or 50% (men) suspicious
for HC-related genotype, but not sensitive
• Very high serum ferritin
• Level typically over 1000 in symptomatic patients with HC, but…
Most patients with ferritin >1000 do not have iron overload
• DNA testing
The many causes of high serum
ferritin
• Primary/genetic iron overload
• Alcohol (chronic use increases apoferritin production)
• Liver disease (ferritin released from injured hepatocytes)
• Chronic renal failure
• Inflammation
• Cancer (hepatic metastases or inflammation)
• Acute MI
• Infection
• Hyperferritinemia-cataract syndrome
High serum ferritin ≠ hemochromatosis
Diagnosis of HFE-related hemochromatosis
-2
• Liver biopsy
• Hepatic iron typically >10,000 µg/g dry weight in patients with
HC-related liver disease, 3-4x higher than in most secondary iron
overload states (normal <1500)
• Iron deposited in parenchymal cells in HC
• Indications: C282Y homozygosity with ferritin>1000 or abnormal
LFTs
• MRI (liver or heart)
• May replace liver biopsy for assessing hepatic iron (technique-
dependent) but biopsy better for assessing severity of liver injury
• Useful for assessing cardiac iron load
• Marrow biopsy may not show increased iron in HC
• Low hepcidin → less iron retained in marrow macrophages
MRI R2* scanning accurately detects excess hepatic
iron

Hernando et al, Eur J Radiol 2020

When to suspect non-HFE-related inherited
hemochromatosis
• Young person or premenopausal woman with severe unexplained iron
overload
• Hemojuvelin, hepcidin, TRF gene mutations cause severe, early onset
hemochromatosis (recessive)
• Anyone with unexplained severe iron overload who does not have a high-
risk HFE genotype
• Consider possible compound heterozygosity for HFE and HJV or HAMP mutations
• Dominant inheritance with normal or low transferrin saturation (ferroportin
mutations)
• Iron overload in young person with very low transferrin (hereditary
atransferrinemia)
Hyperferritinemia-cataract syndrome
• Mutations in ferritin light chain gene decrease binding of regulatory
proteins to ferritin, dysregulate ferritin synthesis
• Autosomal dominant inheritance
• High ferritin levels with normal iron/TIBC, no iron overload
• Ferritin crystals in lens cause premature cataract formation
• May be mistaken for HHC if there is a concomitant HFE mutation
Prevention Genetics hemochromatosis panel

Ferritin heavy chain

Ferritin light chain
Hepcidin

Hemojuvelin
Ferroportin
Transferrin receptor-2
 Complications of iron overload
• Cirrhosis, hepatocellular carcinoma
• Porphyria cutanea tarda (often in C282Y heterozygotes)
• Endocrine failure (diabetes, hypogonadism)
• Arthropathy
• Darkening (“bronzing”) of skin
• Cardiomyopathy, heart failure
• Unusual infections (Vibrio vulnificus, Yersinia sp)

• Cirrhosis and diabetes best predictors of decreased survival

• Treatment of hereditary HC by phlebotomy prevents these problems and can
reverse early tissue damage
Relative risk of self-reported hemochromatosis-related
morbidity in C282Y homozygotes (vs wild type)
Men Women
Arthritis 0.99 (0.59-1.66) 1.10 (0.75-1.62)
Diabetes 1.06 (0.57-1.99) 0.80 (0.43-1.50)
Liver disease 3.28 (1.49-7.22) 0.60 (0.15-2.44)
Heart Disease 0.62 (0.23-1.73) 0.26 (0.04-1.87)
Impotence or 1.42 (0.69-2.91) 1.09 (0.53-2.24)
infertility

N Engl J Med 2006;352:1769

Liver disease in hemochromatosis
Liver disease in iron overload states
• Increased fibrogenesis (may be reversible with treatment)
• Severity proportional to hepatic iron levels and duration of iron overload
• Cirrhosis (irreversible)
• Hepatocellular carcinoma (primarily in cirrhotic patients)
• Porphyria cutanea tarda (improves with iron depletion)
• Higher risk of liver dz in HFE hemochromatosis at any given iron load
due to preferential deposition of iron in hepatocytes
• Liver injury enhanced by alcohol, steatohepatitis, viral hepatitis
• Regular screening for cancer indicated in patients with cirrhosis
Bronzing of skin in hemochromatosis

Generally a marker of advanced disease

Joint disease in hemochromatosis
Joint disease in hemochromatosis
• Symmetrical polyarthritis, usually starts in hands (2nd, 3rd MCP joints)
• Often begins in 30s and 40s in men
• Iron deposition in cartilage and synovium causes joint damage
• Calcium pyrophosphate deposition causes chondrocalcinosis and
predisposes to pseudogout
• Iron-avid genotypes may worsen joint damage in other arthropathies
• Joint disease often does not improve much with iron depletion
Endocrinopathy
• Iron overload in hemochromatosis enhances risk of diabetes when present in
conjunction with other genetic and acquired risk factors
• Diabetes very common in hemochromatosis patients with cirrhosis and advanced
iron overload
• Iron deposition in pancreas mirrors that in liver
• Overall DM prevalence in HC uncertain (ascertainment bias)
• Hypogonadism associated with advanced iron overload
• Much more common in men
• Typically type 2 (hypogonadotrophic)
• Panyhypopituitarism (rare)
• Incidence of thyroid disease not greatly increased in HC
Iron overload is associated with insulin
resistance in the absence of hemochromatosis
• Mild to moderate hepatic iron overload, with or without HFE
mutations, is associated with metabolic syndrome & insulin resistance
• Distribution of iron in liver differs from that in HFE hemochromatosis
• Associated with hepatic steatosis and NASH
• Phlebotomy may be beneficial in conjunction with weight loss and
dietary modification
Heart disease in iron overload states
• Juvenile hemochromatosis (hemojuvelin mutations)
• Adolescents or young adults with cirrhosis, hypogonadism, arthropathy
• Transfusional iron overload
• Heart failure from iron overload is major cause of death in β-thal major
• Uncommon in HFE hemochromatosis
• Most cardiac problems in these patients due to conventional risk factors
Infection and iron overload
• Vibrio vulnificus septicemia: from eating raw shellfish
• Patients with iron overload should be counseled to avoid eating or handling
raw or undercooked shellfish or saltwater fish
• Yersinia enterocolitica: Gram-negative enteric organism can cause
sepsis, gastroenteritis, ileocolitis, and liver abscess.
• Risk of infection highest during chelation therapy
Reversing iron overload in HFE hemochromatosis
• Phlebotomy is treatment of choice
• Blood donation an attractive alternative for eligible patients who do not have
severe iron overload
• Iron removal prevents all complications of HC if instituted prior to
development of tissue damage
• Assess response by monitoring serum ferritin (NOT serum iron or
transferrin saturation)
• Most guidelines suggest a target ferritin level of 50 μg/mL (expert
opinion, not based on trial data)
Who needs phlebotomy?
• C282Y homozygotes with elevated ferritin
• They are at highest risk for progression to organ damage
• C282Y/H63D genotype with evidence of significant iron overload by
MRI or liver biopsy
• C282Y heterozygotes (or other low risk genotypes) with PCT or
evidence of significant iron overload in setting of other risk factors
(NAFLD, alcohol, etc)
• Anyone else with significant iron overload by liver biopsy or MRI and
evidence of associated end-organ damage (if able to tolerate
phlebotomy)
How I use phlebotomy to treat HFE-related
hemochromatosis
• Patients with severe iron overload (confirmed by MRI or biopsy) or evidence of end-organ
damage: 1 unit phlebotomy every 1-2 weeks (as tolerated) until ferritin ≤50
• At-risk patients with moderate iron overload, no evidence of end-organ damage:
phlebotomy every 2-4 weeks until ferritin ≤50
• At-risk patients with mild iron overload: phlebotomy every 1-2 months or encourage
frequent blood donation if eligible
• When ferritin ≤50, monitor at 3-month intervals and do phlebotomy or blood donation
when ferritin >50
• Increase monitoring frequency if ferritin rises progressively
• Older/frail/small patients may need smaller volume phlebotomy and/or concomitant fluid
administration
• Patients with low-risk genotypes, no other risk factors, and mildly or moderately high
ferritin: encourage frequent blood donation, no medical phlebotomy unless ferritin rises
progressively
Transfusional iron overload
• More severe in patients with hemolysis or ineffective erythropoiesis
• Erythroferrone from EPO-stimulated RBC precursors suppresses hepcidin
• Thal major, hereditary hemolytic anemias, congenital dyserythropoietic anemia, etc
• Cardiac disease more prominent than in inherited HC
• Early aggressive chelation therapy prolongs life in thal major
• Distribution of excess iron differs from hereditary HC
• Toxicity may begin after 12-15 U RBC but substantial variability from patient to
patient
• Co-inheritance of HC genes increases risk
• Direct assessment of iron loading (biopsy, MRI) more accurate than ferritin
• Phlebotomy impractical in most patients → chelation needed
Chelating agents
• Deferoxamine (desferrioxamine or Desferal®): parenteral, short half-
life, requires frequent infusions (nightly sq administration most
common)
• Deferasirox (Exjade® or generic): Oral, once daily. GI side effects
• Deferiprone (Ferriprox® or generic): Oral, twice daily. May be better
tolerated than the others listed above
• All of these depend on renal excretion of mobilized iron, will be
relatively ineffective in patients with advanced kidney disease
?