1. Iron

2. Micronutrients : (intake does not exceed 100 mg daily) Daily intake Body stores Zinc 10 mg2200 mg Copper 2.5 mg70 mg Iron 1-2 mg 4000 mg Manganese 10 mg Molybdenum10 mg Cobalt1.5 mg Chromium 1.5 mg

3. Body contains: 4 grams of iron (men) 3 grams (women) 2.5 grams of total body iron exist as haemoglobin Only 1-2 mg of iron is taken up daily from the diet (which contains 10-20mg iron) Iron metabolism in the body is a closed system little intake and little loss

4. Only 1 mg of iron is lost daily from the body (about 0.025% of total body iron) nonspecific pathways (sloughing of dead cells, iron excretion in bile) In women, additional 30 mg of iron is lost monthly by menstruation (about 1% of total body iron) Body iron stores are thus greater in men than in women

5. The basic rule about body iron regulation: There is no special pathway for iron excretion The amount of total body iron is determined only at the level of iron uptake from the duodenum

6. Chemical forms of iron: Ferric (3+) iron: insoluble at physiological pH Ferrous (2+) iron:dangerous if free, forms free radicals Since free iron is insoluble or toxic, it must be bound to proteins

7. Two types of iron-containing proteins: 1)Haemoproteins 2)Non-haem iron proteins

8. Haemoproteins: contain iron in the form of haem Haem: iron inserted in a tetrapyrrole ring

9. Porphyrins: They are intensely red Under ultraviolet light, they display very strong red fluorescence Accumulation of porphyrins is harmful, and results in rare inherited diseases called porphyrias Porphyrin plus iron gives Haem Heme is an exceptional porphyrin compound: HAEM IS NOT FLUORESCENT

10. Porphyrin Haem

11. Iron in Haemoproteins Cytochromes of the mitochondrial respiratory chain (100 mg of iron) Haemoglobin: more than one half of total body iron (2.5 grams) Myoglobin: about 0.3 grams Fe, muscle oxygen storage protein Cytochrome P450: most abundant haemoprotein of the liver (about 1 mg) detoxifies foreign compounds

12. Non - heme iron proteins Ferritin - iron storage protein Transferrin: iron transport protein

13. Ferritin: iron storage protein. In men, contains up to 1 gram of iron 450 kDa protein consisting of 24 subunits Inside the ferritin shell, iron ions form crystallites together with phosphate and hydroxide ions. The resulting particle is similar to the mineral ferrihydrite. Each ferritin complex can store about 4500 iron (Fe3+) ions. Reflects the amount of BODY IRON STORES men: 20-275 μg/litre women: 5-200 μg/litre 15 μg/litre and less: insufficient iron stores

14. Transports iron in the blood Contains only 2 atoms of iron Transferrin is the only source of iron for hemoglobin Transferrin saturation is clinically useful for iron metabolism studies (iron-saturated Tf / total Tf) Transferrin

15. Transferrin saturation: Normal about 30-50 % Transferrin saturation under 15 %= Iron deficiency

16. Ribonucleotide reductase a protein which is necessary for DNA synthesis: One more iron-containing protein:

17. Regulation of iron metabolism: There is no pathway for iron excretion from the body therefore Total body iron level is regulated only at the level of iron absorption from the small intestine

18. Disorders of iron metabolism 1) Increased absorption of iron from the gut: HAEMOCHROMATOSIS 2) Decreased amount of iron in the body: IRON DEFICIENCY ANAEMIA 3) Inflammation-induced change of iron distributrion: ANAEMIA OF CHRONIC DISEASE

19. Primary Haemochromatosis Excessive absorption of iron from the gut: Iron accumulates in the liver, heart and pancreas, excess iron damages these organs by free radical production Transferrin saturation increases, serum ferritin increases Therapy: Phlebotomy (removal of 0.5 l of blood): a decrease of iron in the circulation leads to iron mobilisation from stores

20. Transfusion dependent anemias, for example thalassemia major leukaemia Therapy: iron chelators Secondary Haemochromatosis

21. Lack of iron in the body: Iron deficiency (anaemia) (most common anaemia) Hypochromic microcytic erythrocytes Serum ferritin decreases (iron stores are depleted) transferrin saturation decreases (15 % or less)

22. If iron deficiency anemia is seen in a male patient, the patient should always be checked for blood loss from the gastrointestinal tract men have higher iron stores than women. Menstruation, pregnancy and birth deplete iron stores, Iron deficiency is more common in women than in men Most common cause of iron-deficiency anemia in women: simply lack of iron in the diet.

23. Inflammation-induced changes of iron distribution: Anemia of chronic disease Mild anemia combined with increased iron stores mild anemia + increased ferritin

24. Regulation of iron metabolism

25. Transferrin uptake Transferrin receptor Transferrin Transferrin receptor Cells which need iron express high number of transferrin receptors on their surface

26. Transferrin receptor expression is regulated posttranscriptionally at the level of transferrin receptor mRNA stability: Lack of iron stabilises mRNA for transferrin receptor

27. Regulation of gene expression: Transcriptional: Increasing the amount of mRNA Posttranscriptional: Regulation of mRNA stability (transferrin receptor) Regulation of mRNA translation (ferritin)

28. Recent (2001) look at iron metabolism: Iron metabolism is regulated mainly at the level of IRON EXPORT FROM THE CELL Iron is transported from the cell by FERROPORTIN (a recently discovered iron export protein)

29. Which cells must be able to export iron? Macrophages: they must recycle about 30 mg daily from old erythrocytes Enterocytes (endothelial cells in small intestine): daily uptake and export of about 1 mg of iron from the diet Hepatocytes: Able to mobilise stored iron from ferritin if needed

30. Hepcidin: Hepatic bactericidal protein Hepcidin has antibacterial properties

31. Discovery of HEPCIDIN (2000) Hepcidin: "iron regulatory hormone" Hepcidin is produced in the liver, is transported in the blood stream, and BLOCKS IRON EXPORT FROM THE CELL Control of Iron Export from Cells:

32. Hepcidin blocks iron export from: MACROPHAGES ENTEROCYTES IN THE SMALL INTESTINE

39. Pathophysiology of hereditary hemochromatosis All hereditary hemochromatosis subtypes display decreased hepcidin levels Decreased hepcidin allows more iron to be exported from the enterocytes into blood

40. Juvenile Haemochromatosis (2004): Extremely severe form of hemochromatosis caused by mutation of the hepcidin gene

41. Regulation of hepcidin expression: Iron overload increases hepcidin expression Iron deficiency decreases hepcidin expression Increased erythropoiesis decreases hepcidin expression (Vokurka M et al, 2006: Hepcidin mRNA levels in mouse liver respond to inhibition of erythropoiesis)

42. Pathophysiology of x-linked sideroblastic anemia: A mutation of porphyrin biosynthesis enzyme causes ineffective erythropoiesis Ineffective erythropoiesis decreases hepcidin Lack of hepcidin leads to increased iron absorption Iron overload damages pancreas and myocardium Patients are treated by repeated phlebotomies

43. Hepcidin is an acute phase protein (a protein synthesised in the liver, whose synthesis is increased during inflammation) 2001-2002: Hepcidin expression dramatically increases during inflammation

44. Hepcidin demonstrates the strong connection between iron metabolism and defence against pathogens Bacteria need iron for their ribonucleotide reductase (DNA synthesis) Host needs iron for his antibacterial enzymes (Nitric oxide synthase and others) Bacteria and host compete for free iron

45. Pathophysiology of anemia of chronic disease 1) Inflammation increases hepcidin synthesis 2) Hepcidin decreases iron export from macrophages 3) Iron is locked up inside the macrophages 4) Iron is locked up in enterocytes, and does not enter the body

48. Pathophysiology of both hemochromatosis and anemia of chronic disease can be easily explained by the action of hepcidin.

49. Hepcidin summary: Hepcidin is released from the liver according to body iron status: iron overload increases hepcidin, iron deficiency decreases hepcidin expression. Hepcidin blocks iron export from macrophages and enterocytes. Inflammation increases hepcidin production.