Yves DEUGNIER

HCV and iron The middle age ? Yves Deugnier Dominique Guyader Liver Unit & CIC Inserm 0203 Rennes - France PHC - Paris 22 & 23/01/07

Blumberg BS et al, PNAS 1979;76:2438-41

IRON 1991-2007 = 527 studies HCV

Iron status in HCV infected patients

Serum iron-related indices in CHC 25 - 59 % Ferritin 25 - 60 % Transferrin saturation 10 - 25 % Di Bisceglie AM, Gastroenterology 1992;102:2108-13 Alla V, Sem Liver Dis 2005;25:461-72

Hepatic iron-related indices in CHC Hepatic iron concentration 10 - 36 % Slight increase (x 1.5 - 3 N) Mesenchymal deposition Except in cirrhosis Di Bisceglie AM, Gastroenterology 1992;102:2108-13 Alla V, Sem Liver Dis 2005;25:461-72

Distribution of hepatic iron deposits in CHC Hepatocytic 34% Mesenchymal 12% Mixed 54% Guyader D, J Hepatol 2007 [Epub ahead of print]

Distribution of hepatic iron deposits in CHC Hepatocytic 34% Deugnier Y, Am J Surg Pathol 1997 Ludwig J, Gastroenterology 1997

Relationship between iron-related indices in CHC 46% 46% Guyader D, J Hepatol 2007 [Epub ahead of print]

Iron status in HCV infected patients Direct Mechanisms HCV

Clinical data • No well-designed comparative study of iron status in various chronic liver diseases • Prevalence and type of abnormalities of iron-related indices roughly similar in CHC, NASH and ASH Bonkovsky HL, Hepatology 1997;25:759-768 Alla V, Sem Liver Dis 2005;25:461-472

Biological data HCV-induced modification in HFE metabolism ? Homology between HCV and iron protein biology 5’ Internal Ribosome Entry Site = 5’ Iron Responsive Elements Synergism / competition between HFE and HCV HCV-induced modification in HFE metabolism ? HFE as a non classical MHC molecule hCMV US2 degradation of HFE in human and mouse cells Upregulation of TfR1 by HCV ? Ben-Arieh SV, J Virol 2001;75:10557-62 Saito H, Hepatology Res 2005;31:203-10 Spahn CM, Science 2001;291:1959-62

IRON HCV Iron status in HCV infected patients Direct Mechanisms Indirect Hyperferritinemia <> hepatic iron HCV

Serum ferritin in chronic hepatitis C • Liver damage • Hepatic iron Serum ferritin Di Bisceglie AM, Gastroenterology 1992;102:2108-13

Serum ferritin in chronic hepatitis C • Liver damage • Hepatic iron Associated factors • Age • Sex • Alcohol consumption • Metabolic syndrome • Steatosis • Thyroïditis, PCT… Serum ferritin Bonkovsky HL, Hepatology 1997;25:759-768 Alla V, Sem Liver Dis 2005;25:461-472

Hepatic iron in chronic hepatitis C • Liver damage Inconstant correlation Hepatic iron METAVIR A METAVIR F Guyader D, J Hepatol 2007 [Epub ahead of print]

NTBI Tf TS Fe Increased hepatic iron content in cirrhosis Hepatic insufficiency Transferrin Tf NTBI TS Hepcidin Fe Alcohol Stuart KA, Gastroenterology 2004;39:492-7 Detivaud L, Blood 2005;106:746-8 Bridle KR, Alc Clin Exp Res 2006;30:106-112

Hepatic iron in chronic hepatitis C • Liver damage • Antiviral drugs • Duration of infection Associated factors • Age and sex • Alcohol consumption • Metabolic syndrome • PCT • HFE mutations Hepatic iron Bonkovsky HL, Hepatology 1997;25:759-768 Alla V, Sem Liver Dis 2005;25:461-472

Aggravative effect on CHC ? Prevalence of HFE mutations in CHC Aggravative effect on CHC ? ? C282Y ++ & compound heterozygotes Excluded Included N C282Y & H63D prevalence Vs controls Piperno A, Hepatology 1998 - Smith BC, Hepatology 1998 - Hézode C, J Hepatol 1999 - Fontana RJ, Hepatology 2000 - Kazemi-Shirazi, Gastroenterology 1999 - Martinelli AL, Acta Haematol 2000 - Negro F, J Med Virol 2000 - Pirisi M, Am J Clin Pathol, 2000 - Bonkovsky HL, J Hepatol 2002. Diwakaran HH, J Hepatol 2002 - Thung BY, Gastroenterology 2003 - Bonkowsky H, Gastroenterology 2006

HFE genotypes and iron status in CHC Serum iron-related indices Hepatic iron deposition C282Y H63D Inclusion bias Small samples Confounding factors Piperno A, Hepatology 1998 - Smith BC, Hepatology 1998 - Kazemi-Shirazi, Gastro enterology 1999 - Martinelli AL, Acta Haematol 2000 - Negro F, J Med Virol 2000 - Pirisi M, Am J Clin Pathol, 2000 - Bonkovsky HL, J Hepatol 2002 - Thorburn D, Gut 2002 - Tung BY, Gastroenterology 2003 - Bonkowsky H Gastroenterology 2006.

IRON HCV Iron status in HCV infected patients Direct Mechanisms Indirect Mechanisms HCV

Effects of iron on HCV replication IRES EMCV IRES HCV 3’UTR NPT II NS3 NS4A NS4B NS5A NS5B HCV subgenomic replicon Huh 7 cells Fillebeen C, JBC 2005;280:9049-9057

IRON HCV Iron status in HCV infected patients Direct Mechanisms Indirect Mechanisms Liver damage Hepatitis course HCV

Hepatic iron ROS Fibrosis progression Iron as an aggravating factor for fibrosis in CHC Biological evidence Hepatic iron ROS Fibrosis progression Fujita N, Free Rad Biol Med 2007;42:353-62

Hepatic iron ? Fibrosis progression Iron as an aggravating factor for fibrosis in CHC Clinical relevance Hepatic iron ? Fibrosis progression Pietrangelo A, Gastroenterology 2003;124:1509-23 Guyader D, J Hepatol 2007 [Epub ahead of print]

Hepatic iron ? Fibrosis progression Iron as an aggravating factor for fibrosis in CHC Clinical relevance Hepatic iron ? Fibrosis progression Male sex Age at contamination > 40 y Duration of infection Daily alcohol consumption > 50 g Necroinflammatory activity Steatosis Metabolic syndrome HFE mutations Pietrangelo A, Gastroenterology 2003;124:1509-23 Guyader D, J Hepatol 2007 [Epub ahead of print]

Necroinflammatory activity Effects of phlebotomies in chronic hepatitis C Serum transaminases Necroinflammatory activity Fibrosis progression Risk of cancer Phlebotomies Hayashi H, Am J Gastroenterol 1994 & J Hepatol 1995 - Fong TL, J Hepatol 1998 - Guyader D, Am J Gastroenterol 1999 - Fontana RJ, Hepatology 2000 - Di Bisceglie AM, Hepatology 2000 - Yano M, AJGE 2002.

No effect on viral load Effects of phlebotomies in chronic hepatitis C Hayashi H, Am J Gastroenterol 1994 & J Hepatol 1995 - Fong TL, J Hepatol 1998 - Guyader D, Am J Gastroenterol 1999 - Fontana RJ, Hepatology 2000 - Di Bisceglie AM, Hepatology 2000 - Yano M, AJGE 2002.

IRON HCV Iron status in HCV infected patients Direct Mechanisms Indirect Mechanisms Fibrosis Hepatitis course Cancer HCV

NTBI Tf TS Fe Lipid peroxidation DNA damage Increased hepatic iron and cancer risk Transferrin Tf NTBI TS Hepcidin Fe Lipid peroxidation DNA damage Turlin B, Hepatology 1995 Deugnier Y, Alcohol 2003

Furutani T, Gastroenterology 2006;130:2087-98 Diet with either normal (45 mg/kg) or excessive iron (225 mg/kg) content (carbonyl iron - CI) for 12 months CI - 45 CI - 225 Liver tumors 45% Hepatic 8 OHdG 1 x 2 PCNA index x 5 Lipid peroxidation Ab mitochondria No Yes Steatosis x 3 Hepatic Tg ALT Hepatic iron FL-N/35 transgenic* mouse *polyprotein-coding region of HCV 1b Furutani T, Gastroenterology 2006;130:2087-98

IRON HCV Iron status in HCV infected patients Direct Mechanisms Indirect Fibrosis Cancer Hepatitis course HCV Response to therapy

Hepatic iron and response to antiviral therapy IFN Increased HIC Mesenchymal iron PEG + RBV Endothelial iron Prediction of poor SVR Olynyk J, Gastroenterology 1995;108:1104-9 Barton AL, Am J Clin Pathol 1995;103:419-24 Rulyak SJ, Am J Gastroenterol 2005;100:332-7 Bonkowsky H, Gastroenterology 2006;131:1440-51

No effect on sustained virological response Effects of phlebotomies on response to therapy No effect on sustained virological response Antiviral therapy + Phlebotomies Hayashi H, Am J Gastroenterol 1994 & J Hepatol 1995 - Fong TL, J Hepatol 1998 - Guyader D, Am J Gastroenterol 1999 - Fontana RJ, Hepatology 2000 - Di Bisceglie AM, Hepatology 2000 - Yano M, AJGE 2002.

Effect of HFE mutations on virological response rate HALT C study - 1145 NR C282Y H63D S65C Bonkowsky H, Gastroenterology 2006;131:1440-51 Distante S, Liver 2002;22:269-75 (SVR - C282Y) Lebray P, J Viral Hepat 2004;11:175-82 (VR - H63D)

IRON HCV Disease progression Response to therapy HFE mutations Liver damage Antiviral drugs Diet, alcohol PCT, MS… ROS HFE mutations Iron proteins Immune fcts Disease progression (fibrosis, cancer…) Response to therapy

Hyperferritinemia <> Increased hepatic iron Alcohol, PCT Thyroïditis Inflammation Metabolic syndrome… Direct assessment of hepatic iron

Hepatic iron Naive NR Normal ? LIC/age < 2 + LIC/age >2 Indication of phlebotomies Hepatic iron Naive NR Normal ? LIC/age < 2 + LIC/age >2 + Avoid to induce anemia in order not to impair compliance to antiviral Tt

HCV and iron The middle age ? Yves Deugnier Dominique Guyader Liver Unit & CIC Inserm 0203 Rennes - France PHC - Paris 22 & 23/01/07