Metabolic liver disease

Haemochromatosis

Whats new?

William Rosenberg

Hepcidin has been identified as the key regulator of iron

absorption and macrophage iron release
At least five different types of hereditary haemochromatosis
are now recognized
There is greater awareness that the common genotype
of haemochromatosis has a relatively low penetrance

Abstract

The recognition that penetrance of HFE mutations is

variable has led to a search for other genes that modify
patterns of iron loading

Hereditary haemochromatosis is the syndrome of end-organ damage due to progressive iron accumulation caused by genetic disorders. It is the commonest genetic disorder of northern Europeans.
In over 90% of cases the disease is associated with mutations in
the HFE gene. Identification of the genetic basis of rare causes of
hereditary haemochromatosis has greatly increased understanding
of iron metabolism. Symptoms of haemochromatosis are frequently
non-specific and include abdominal pain, arthralgia and general malaise. Iron accumulates predominantly in the liver, leading to liver
dysfunction, and ultimately to cirrhosis and hepatocellular cancer.
Iron accumulation in the pancreas and joints result in diabetes and
degenerative arthritis. Diagnosis of the common form of haemochromatosis can be made in the majority of cases using biochemical
tests of iron, transferrin and ferritin combined with genetic tests for
mutations in HFE. Liver biopsy may reveal a characteristic pattern of
iron deposition in periportal hepatocytes, with relative Kupffer cell
sparing and liver fibrosis that may progress to cirrhosis. Treatment
with phlebotomy removes iron in haemoglobin, drawing iron out of
other tissues. This can effectively reduce the morbidity and mortality of the disease if diagnosed in the pre-cirrhotic state. Due to
the poor specificity of symptoms, late diagnosis remains a problem
and is associated with significant morbidity and mortality. Screening with biochemical and genetic tests, particularly in families, may
prevent disease.

Transferrin receptor-2, ferroportin, haemojuvelin and

hepcidin have been identified as proteins implicated in
rare forms of hereditary haemochromatosis

cells that absorb iron (duodenal enterocytes), utilize iron

(erythroid precursors) and store iron (hepatocytes and tissue
resident macrophages). A newly identified -defensin-like
antimicrobial peptide, hepcidin,1,2 is thought to be the molecule that controls iron absorption and macrophage iron
release. The genetic and metabolic defects that cause HHC
have recently been defined, increasing knowledge of the condition and making screening, testing and early diagnosis and
treatment feasible.

Causes of iron overload

Keywords biochemistry; cirrhosis; genetics; haemochromatosis; iron;

Primary iron overload

Hereditary haemochromatosis (C282Y, transferrin receptor-1,
ferroportin)
Congenital aceruloplasminaemia
Congenital atransferrinaemia

liver; macrophages; phlebotomy

Secondary iron overload

Parenteral iron loading (blood transfusion, iron dextran
infusions, chronic haemodialysis)
Iron-loading anaemia (thalassaemia, sideroblastic anaemia,
pyruvate kinase deficiency)
Liver disease (post-portacaval anastomosis)
Dietary iron overload (prolonged oral iron therapy)

Iron is vital for many basic cellular processes, including the

transport of oxygen and electrons. In excess, these potent
oxidative processes can lead to tissue damage and fibrosis, resulting in organ failure. Iron overload may occur as
a genetic condition termed hereditary haemochromatosis
(HHC) or as a secondary event (Table 1). Tight regulation
of iron metabolism is vitally important. Maintenance of iron
homeostasis is effected through communication between the

Complex iron overload

Juvenile haemochromatosis
Neonatal haemochromatosis
Alcoholic liver disease
Porphyria cutanea tarda
African iron overload (Bantu siderosis)

William Rosenberg MA DPhil FRCP is Professor of Hepatology in the

School of Medicine at the University of Southampton and Honorary
Consultant Physician at Southampton General Hospital, Southampton,
UK. Competing interests: none declared.

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Table 1

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Metabolic liver disease

loading, fibrosis leads to cirrhosis despite the absence of an

overt necro-inflammatory reaction. Cirrhosis carries a risk of
hepatocellular carcinoma; most tumours are multifocal and/or
metastatic by the time they are symptomatic.
Juvenile haemochromatosis (JH) typically presents in the
second decade of life, and in contrast to HHC commonly presents
with abdominal pain, hypogonadatrophic hypogonadism, cardiac
arrhythmias, intractable cardiac failure and impaired glucose
tolerance, Two causes of juvenile haemochromatosis have been
identified.
HJV exists in membrane bound and soluble forms. JH is
associated with mutation in HJV located in the region that encodes the membrane binding part of the molecule and are associated with low or unmeasurable levels of hepcidin. It has been
suggested that excess soluble HJV binds to neogenin in the liver
to down regulate hepcidin leading to iron overload.
The first gene identified as a cause of JH was hepcidin antimicrobial peptide (HAMP). Identification and subsequent study of
this important peptide has greatly advanced understanding of the
biology of iron regulation.
Transferrin receptor 2 deficiency TFR2 is expressed predominantly in the liver and erythroid precursors. Genetic haemochromatosis linked to mutations in the TFR2 gene is rare and
appears to be clustered in families of Southern European origin.
It is thought that TFR2 is the sensor of plasma transferring saturation in the signalling pathway that regulates hepcidin, accounting for the low levels of hepcidin found in patients with TFR2
mutations.
Ferroportin disease ferroportin is expressed mainly in
Kupffer cells and splenic macrophages, at the basolateral
border of enterocytes and to a lesser extent in hepatocytes.
It functions as an iron exporter and is tightly regulated by
hepcidin. Hepcidin binds to ferroportin in epithelial cells
and macrophages and induces internalization and degradation of ferroportin, thus blocking iron export. Mutations in
SCL40A1 appear to render ferroportin unresponsive to hepcidin. Ferroportin disease differs from classical HHC. Young
patients present with isolated hyperferritinaemia and normal
or slightly elevated transferring saturation. Marked hepatic
iron overload develops with characteristic accumulation of
iron in Kupffer cells (in contrast to classical HHC). Therapeutic phlebotomy is often poorly tolerated, leading to iron
deficiency anaemia.

Aetiology
Finch and Finch first recognized HHC as a familial disorder in
1955. In 1996, positional cloning and linkage studies isolated
the responsible gene (HFE) on chromosome 6p; 90% of cases of
classical HHC are associated with homozygous substitution of
tyrosine for cysteine (C282Y) at position 282 of the HFE protein.
A second mutation at position 63 changes histidine to aspartic
acid (H63D), but this seldom appears to cause iron overload
except in individuals heterozygous for H63D and heterozygous
for C282Y (compound heterozygosity).
HFE encodes a class 1 HLA-like protein which, when
associated with 2-microglobulin, is transported to the basolateral cell surface where it binds to transferrin receptor-1.
The C282Y mutation prevents HFE from associating with b2microglobulin, but how this leads to HHC remains to be elucidated. In 10% of cases the cause of HHC cannot be attributed
to mutations in HFE mutations. The search for other causes
of hereditary iron overload has led to the identification of
rare gene defects that effect iron metabolism to produce distinct syndromes of hereditary iron overload. Mutations in
the haemojuvelin gene3 (HJV) and hepcidin gene2 (HAMP)
cause iron overload in the first two decades of life leading
to cardiac damage (juvenile haemochromatosis). Mutation in
the transferrin receptor 2 gene4 (TFR2) and ferroportin gene5
(SLC40A1) have also been shown to account for rare causes
of HHC.
In the UK, homozygosity for C282Y is found in 1/300
population, but only a minority of homozygotes have iron
overload. Expression of the disease is influenced by environmental factors including dietary iron intake, alcohol
and blood loss (e.g. menstruation). The heterozygote carrier frequency rate of 1/10 makes HHC the most common
human recessive genetic disorder in Northern Europeans,
suggesting selection pressure for the mutation (perhaps
via protection from anaemia or an infectious agent). The
C282Y mutation is almost exclusively found in populations
of Celtic origin.

Clinical features
HHC is usually asymptomatic in the early stages, but as iron
deposition progresses, end-organ damage may lead to:
skin pigmentation
liver failure
maturity-onset diabetes mellitus
arthopathy (commonly affects metacarpophalangeal joints,
wrists and knees and may be complicated by chondrocalcinosis and pseudogout)
cardiac failure or cardiac dysrhythmia
anterior pituitary dysfunction (loss of libido may antedate
other clinical manifestations).
Clinical manifestations usually become overt at age 4050 years.
Women are protected by iron loss through menstruation and
pregnancy and thus often present later than men.
Liver disease is the most common clinical manifestation
of HHC. Iron accumulates preferentially in hepatocytes (initially periportal), with relative sparing of Kupffer cells (in
contrast to secondary iron overload). With progressive iron

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Investigations
Genetic testing is widely available. In its absence, HHC may
be diagnosed using clinical tests to detect iron overload
(Table 2). When clinical suspicion is high, patients should
be managed on the basis of clinical criteria irrespective of
genetic results (10% lack the common HFE mutations). With
the advent of genetic testing, it is anticipated that, in future,
HHC will be diagnosed most commonly in asymptomatic
individuals. Other genetic forms of HHC are very rare, particularly amongst patients of northern European origin. Investigation of these patients requires access to specialist genetic
services.
Liver biopsy is often useful to confirm the diagnosis, to exclude
other pathology and to assess prognosis. Biopsy is unnecessary
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Metabolic liver disease

Clinical and genetic tests for hereditary haemochromatosis

Test

Abnormality/notes

False-positive

False-negative

Serum ferritin

> 300 mg/litre in men, > 200

mg/litre in women found in > 95%
> 55% found in 90%

Any inflammatory condition,

particularly liver disease
Oral iron therapy

< 5%

Allows assessment of liver damage,

prediction of prognosis and measurement
of dry-weight liver iron
> 1.9 in 91%

Rare

Rare

Very rare

Rare, fatty liver

Quantitative calibration to dry-weight liver

iron required, no histology obtained
Useful for assessing hepatic damage but not
presence of disease
C282Y homozygosity > 90% of UK
hereditary haemochromatosis
patients
C282Y/H63D compound heterozygotes

Unknown

Unknown

Many

Many

None

10% in UK, more in

Southern Europe
?Worldwide

Transferrin saturation
Serum iron/total iron-binding
capacity
Liver biopsy

Hepatic iron index

Dry-weight liver iron
(mmol/g)/age (years)
MRI
Liver function tests
Genetic testing

Raised total iron-binding

capacity

Table 2

in patients who are homozygous for the C282Y substitution with

a ferritin level of less than 1000 mg/litre and normal liver function tests these individuals do not have significant hepatic
fibrosis.

HFE mutations or compound heterozygosity need long-term

follow-up.

Prognosis
The prognosis in patients with HHC diagnosed before the onset
of cirrhosis and treated with regular phlebotomy is similar to that
in the healthy population. Late presentation is associated with
early mortality; extent of liver fibrosis at presentation is the most
important prognostic indicator.

Management
The aim of management of HHC is diagnosis and treatment
before organ damage develops; this requires integration of
genetic screening, counselling and clinical hepatology services. Excess iron is removed by phlebotomy of 500 ml of
blood (200250 mg iron) once or twice per week, continued
until serum ferritin is in the lownormal range (<50 mg/litre);
this is maintained by phlebotomy every few months. Anaemia or cardiovascular compromise is managed by removing
smaller volumes of blood or by increasing the interval between
phlebotomies.
Once treatment is commenced, liver and cardiac problems seem to improve. Joint pain is less predictable and can
improve or worsen as iron is removed. Impaired glucose tolerance may recover, but frank diabetes mellitus is unlikely to
resolve. Many patients report improvements in malaise and
abdominal pain; occasionally, loss of libido and impotence
resolve.
Even in established cirrhosis, phlebotomy to remove excess
iron is indicated. Liver failure and its complications are managed
as in other liver diseases.
Screening relatives first-degree relatives (particularly siblings) should be screened using clinical, biochemical and genetic
testing. Relatives with normal iron stores but homozygous

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References
1 Pigeon C, Ilyin G, Courselaud B et al. A new mouse liver-specific
gene, encoding a protein homologous to human antimicrobial
peptide hepcidin, is overexpressed during iron overload. J Biol
Chemistry 2001; 276: 781119.
2 Roetto A, Papanikolaou G, Politou M et al. Mutant antimicrobial
peptide hepcidin is associated with severe juvenile
hemochromatosis. Nat Genet 2003; 33: 212.
3 Papanikolaou G, Samuels M E, Ludwig E H et al. Mutations in
HFE2 cause iron overload in chromosome 1q-linked juvenile
hemochromatosis. Nat Genet 2004; 36: 7782.
4 Camaschella C, Roetto A, Cali A et al. The gene TFR2 is mutated in a
new type of haemochromatosis mapping to 7q22. Nat Genet 2000;
25: 1415.
5 Njajou O T, Vaessen N, Joosse M et al. A mutation in SLC11A3 is
associated with autosomal dominant hemochromatosis. Nat Genet
2001; 28: 21314.

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Metabolic liver disease

Practice points
Further reading
Nidereau C, Fischer R, Purschel A, Stremmel W, Haussinger D,
Strohmeyer G. Long-term survival in patients with
hereditary haemochromatosis. Gastroenterology 1996;
110: 11079.
Swinkels D W, Janssen M C H, Bergmans J, Marx J J M.
Hereditary hemochromatosis: genetic complexity and
new diagnostic approaches. Clinical Chemistry 2006; 52:
95068.

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HHC is a common disorder

Genetic tests are useful for diagnosis and screening
Iron overload is assessed using biochemical tests and liver biopsy
Symptoms may be absent or variable
Treatment with venesection, before cirrhosis develops,
restores normal life expectancy
Screening of family members is mandatory

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2006 Published by Elsevier Ltd.