1. S L I D E 1 Hemochromatosis – Diagnosis and Management Pramod K. Mistry, MA, PhD, MD, FRCP Professor of Pediatrics and Medicine Chief, Pediatric Gastroenterology and Hepatology Indian Association for the Study of the Liver ‘Metabolic Liver Disease’ Mumbai. January 13, 2012

2. Non-contrast CT 65 yr old male, ferritin 2660, AFP 6324 DDx GSD, thorotrast, amiodarone, cisplatin What is the diagnosis?

3. Inherited Causes of Cirrhosis  1 – antitrypsin deficiency  1 – antitrypsin deficiency Other CF Wilson's Familial intrahepatic cholestasis Hemochromatosis Newborn and infants Adults Inherited Causes of Cirrhosis

4. Pituitary Gonadotropin deficiency Skin bronzing Cardiomyopathy Conduction disorders Cirrhosis Hepatocellular carcinoma Diabetes mellitus Bacteremia Testicular atrophy Arthropathy Arthritis Pseudogout Pituitary Gonadotropin deficiency Skin bronzing Cardiomyopathy Conduction disorders Cirrhosis Hepatocellular carcinoma Diabetes mellitus Bacteremia Testicular atrophy Arthropathy Arthritis Pseudogout Hemochromatosis - Clinical Manifestations Clinical Manifestations

5. Clinical Manifestations of Hereditary Hemochromatosis

6. Serum TransferrinQuantitative ironTIBCsaturationFerritinhepatic iron (  g/dL)(  g/dL)(%) (  g/dL) (  g/g dry wt) 60-180230-37020-5020-200 300-1500 >180 50>300>3000 Serum TransferrinQuantitative ironTIBCsaturationFerritinhepatic iron (  g/dL)(  g/dL)(%) (  g/dL) (  g/g dry wt) 60-180230-37020-5020-200 300-1500 >180 50>300>3000 Hemochromatosis Normal Hemochromatosis - Iron Balance Values

8. Classification of Iron Overload Syndromes

9. Ingested 10-20 mg/day Ingested 10-20 mg/day Absorbed 1-2 mg/day Absorbed 1-2 mg/day Lost Gut, skin, urine - 1-2 mg/day Menses - 30 mg/month Lost Gut, skin, urine - 1-2 mg/day Menses - 30 mg/month Normal Iron Balance In HH daily absorption of iron is 2-4 mg despite systemic iron overload

10. Pietrangelo, A. N Engl J Med 2004;350:2383-2397 Iron Homeostasis in Health and Disease HH – sparing of Kuppfer cells

11. Iron Transport and Storage Transport Transferrin - two iron atoms Transport Transferrin - two iron atoms Intracellular storage Ferritin - thousands of iron atoms Intracellular storage Ferritin - thousands of iron atoms Total body iron - 4g Storage iron Storage iron Other RBCs Iron Transport and Storage

12. Normal Hfe Mutation ‘Mild’ Hemochromatosis

13. TfR2 hemochromatosis Mild iron overload HJV hemochromatosis Massive iron overload HAMP hemochromatosis Dramatic iron overload Ferroportin hemochromatosis – Tissue iron overload with Relative circulatory iron deficiency

14.  Heavy chain  2 microglobulin 11 11 22 22 33 33 C282Y Mutation H63D Mutation NH2 COOH HFE Protein Structure Bacon BR, et al. Gastroenterology 1999; 116: 193 S65C mutation

15. What about India?

16. Global Prevalence of HFE Mutations Frequency (%) C282Y H63D Population allelic allelic Frequency (%) C282Y H63D Population allelic allelic United Kingdom6.412.8 Norway6.411.2 Denmark9.512.2 Finland011.8 Former USSR1.010.4 Germany3.914.8 Italy0.512.6 Spain3.226.3 Greece1.313.5 Saudi Arabia08.5 Africa02.6 Indian subcontinent0.28.4 Asia01.9 Australasia00.2 Americas0.72.6 United Kingdom6.412.8 Norway6.411.2 Denmark9.512.2 Finland011.8 Former USSR1.010.4 Germany3.914.8 Italy0.512.6 Spain3.226.3 Greece1.313.5 Saudi Arabia08.5 Africa02.6 Indian subcontinent0.28.4 Asia01.9 Australasia00.2 Americas0.72.6 Bacon, et al., Gastroenterology 1999; 116:193 Global Prevalence of HFE Mutations

17. Andrews, N. C. et al. N Engl J Med 2005;353:189-198 Pietrangelo, A. N Engl J Med 2004;350:2383-2397

18. Total body iron (g) Total body iron (g) Age (years) 0 0 20 30 40 20 30 50 10 40  Serum iron Cirrhosis, organ failure  Hepatic iron Tissue injury Normal Natural History Hemochromatosis

19. Phenotype Expression  Men > women  Increases with age  Correlates with amount of iron in the diet  Chronic hemolysis, alcoholism, steatohepatitis, hepatitis C  Men > women  Increases with age  Correlates with amount of iron in the diet  Chronic hemolysis, alcoholism, steatohepatitis, hepatitis C Phenotype Expression

20. Risk of HCC 119 x N Cirrhosis 10 xN Cardiomyopathy 306 x N Diabetes mellitus 10 x N Reduced survival in cirrhotic HH. Non-cirrhotic HH, normal survival (Niederau, Gastro 1996 250 patients followed for 14 +/- 7 yrs – 69 patients died) Prognosis

21. Serum Transferrin Quantitative ironTIBCsaturationFerritin hepatic iron (  g/dL) (  g/dL) (%)(  g/dL) (  g/g dry wt) 60-180230-370 20-50 20-200 300-1500 >180 50 >300 >3000 Serum Transferrin Quantitative ironTIBCsaturationFerritin hepatic iron (  g/dL) (  g/dL) (%)(  g/dL) (  g/g dry wt) 60-180230-370 20-50 20-200 300-1500 >180 50 >300 >3000 Hemochromatosis Normal Iron Balance Values

22. Family history or suspicion of hemochromatosis Repeat iron panel high; Ferritin >1000 Elevated AST/ALT Extrahepatic manifestations of iron overload; Positive FH Repeat iron panel high; Ferritin >1000 Elevated AST/ALT Extrahepatic manifestations of iron overload; Positive FH Therapeutic Phlebotomy, response confirms diagnosis Therapeutic Phlebotomy, response confirms diagnosis % sat. >50% Ferritin >250  g/L >300  g/L % sat. >50% Ferritin >250  g/L >300  g/L  stainable Fe Iron index >2  stainable Fe Iron index >2 Fe / TIBC -% saturation Ferritin Fe / TIBC -% saturation Ferritin Liver biopsy with iron stain and quantitative iron ? Modified Diagnostic Algorithm for Use in India Diagnostic Testing Equivocal results

23. Interpretation of Ferritin Levels  Ferritin and Normal ferritin and  iron  Ferritin and  iron  iron  iron Hemochromatosis Acute liver injury Acute phase reactant Chronic disease Iron deficiency Interpretation of Ferritin Levels

24. Index Normals Alcoholic Heterozygotes Hemochromatosis Homozygotes Precirrhotic Cirrhotic Liver iron Age 0 0 1 1 2 2 3 3 4 4 5 5 10 15 (  mol/g)(yr) Hepatic Iron Index

25. Phlebotomy Acute 1 unit (250 mg Fe) weekly or biweekly until mildly anemic Maintenance Once iron stores are depleted (ferritin <50ng/ml, transferrin sat <50%) continue with phlebotomy every 2-3 months. Monitor hemoglobin, ferritin and transferrin saturation Acute 1 unit (250 mg Fe) weekly or biweekly until mildly anemic Maintenance Once iron stores are depleted (ferritin <50ng/ml, transferrin sat <50%) continue with phlebotomy every 2-3 months. Monitor hemoglobin, ferritin and transferrin saturation Phlebotomy – Therapy for Iron Overload

26. Phlebotomy Improves Survival Preventable:all clinical manifestations Reversible:cardiac dysfunction, glucose intolerance, hepatomegaly, skin pigmentation Irreversible:cirrhosis risk of hepatocellular carcinoma arthropathy, hypogonadism Preventable:all clinical manifestations Reversible:cardiac dysfunction, glucose intolerance, hepatomegaly, skin pigmentation Irreversible:cirrhosis risk of hepatocellular carcinoma arthropathy, hypogonadism Phlebotomy Improves Survival Niederau C, et al. N Engl J Med 1985; 313:1256

27. Iron Depletion Improves Survival 0 0 40 80 10 0 20 10 15 25 5 5 20 60 0 0 Cumulative survival (%) Cumulative survival (%) Time (years) Iron depleted after 18 months Untreated after 18 months Iron Depletion Improves Survival Niederau C, et al. N Engl J Med 1985; 313:1256

28. Response to Phlebotomy 0 0 40 60 80 100 4 4 12 20 24 32 500 1000 1500 20 8 8 0 0 16 28 2000 Transferri n % Transferri n % Time (months) Hgb drop s Hgb drop s Ferritin ng/ml Ferritin ng/ml Phlebotomy Serum ferritin Transferrin saturation Response to Phlebotomy Edwards CQ, et al. Hospital Practice 1991; 26:30

29. Quantitative Phlebotomy As A Diagnostic Test For HH Indication liver biopsy cannot be performed but suspected iron overload Determine the number of weekly 500 mL phlebotomies, each of which removes 200 to 250 mg of elemental iron, which are required to produce iron deficient erythropoiesis. Normal men have approximately 1 g of iron stores. Therefore, 4-5 phlebotomies during 4-8 weeks will produce an iron deficiency anemia In contrast, patients with significant iron loading usually have at least 5 g (and often 20 g or more) of iron stores, requiring at least 20 units of phlebotomy to induce iron deficiency

30. Inherited Causes of Cirrhosis  1 – antitrypsin deficiency  1 – antitrypsin deficiency Other CF Wilson's Familial intrahepatic cholestasis Hemochromatosis Newborn and infants Adults Genetic Diseases - Liver Inherited Causes of Cirrhosis

31. Neonatal Hemochromatosis Late fetal or early neonatal lossLate fetal or early neonatal loss Renal hypoplasiaRenal hypoplasia Often with oligohydramniosOften with oligohydramniosFeatures Raised ferritinRaised ferritin Hepatocellular synthetic failureHepatocellular synthetic failure Extensive cholestasisExtensive cholestasis Low or absent AST/ALTLow or absent AST/ALT AFP >200,000AFP >200,000 Systemic iron overload – Dx investigation: buccal biopsySystemic iron overload – Dx investigation: buccal biopsy

32. Andrews, N. C. et al. N Engl J Med 2005;353:189-198 Neonatal Hemochromatosis

33. NH – pathogenetic mechanisms Non-specific consequence of any type of liver injuryNon-specific consequence of any type of liver injury Genetic: Recurrence rate 80% in children born to same mothers *Genetic: Recurrence rate 80% in children born to same mothers * Infectious diseaseInfectious disease Immune mediated diseaseImmune mediated disease Occurs inOccurs in hemolysis with giant cell hepatitis congental nephrotic syndrome, arthrogryphosis multiplex, all allo-immune mediated maternal diseases IgG from NH affected mother into pregnant mouse dams leads to liver failure in the newbornIgG from NH affected mother into pregnant mouse dams leads to liver failure in the newborn

34. NH – Treatments IVIG (Whitington, Lancet, 2001)IVIG (Whitington, Lancet, 2001) Chelation/antioxidant cocktailChelation/antioxidant cocktail NACNAC TransplantTransplant