Iron Accumulation in Chronic Hepatitis C

[Guest guest]

Thank You. I'm always popping in and out, but it's just gotten to the time of year when we slow down enough to have a life other than work.

There is so much usefull info that is passed on I wouldn't miss it for the world.

[Guest guest]

The high Iorn level is what made them do further testing and lead to the discovery of the Hep-

c. My Iorn levels are normal now.

Eddie

Iron Accumulation in Chronic Hepatitis C

Abstract and Introduction

Abstract

The aim of the present study was to describe the histopathologic features of hepatic iron accumulation in patients with chronic hepatitis C (CH-C) infection, the relation between HFE mutations and hepatic iron location and among iron distribution, HFE, and hepatic damage. We studied 206 patients with CH-C infection. Of 101 patients with hemosiderin deposits, 90.1% had iron deposits in hepatocytes (alone or with sinusoidal and/or portal involvement). The hepatic iron score increased significantly as iron accumulation involved sinusoidal and portal tract compartments and according to HFE genotypes. Severe fibrosis and cirrhosis were associated more markedly with the presence of hemosiderin iron in the 3 hepatic compartments, HFE mutations, and high alcohol intake. We suggest that part of the iron accumulation in CH-C infection derives from increased iron absorption and release from storage cells and that the amount and distribution of hepatic iron deposits is related to hepatic damage. HFE mutations favor both processes, but other factors, genetic or acquired, are involved.

Introduction

Shortly after the hepatitis C virus was cloned, it was noted that many patients with chronic hepatitis C (CH-C) infection had elevated transferrin saturation and serum ferritin and hepatic iron concentrations.[1-3] Many studies have tried to find the causes and effects of iron overload in patients with chronic viral hepatitis (CVH). In general, necroinflammatory events due to the ongoing viral infection are considered the most important cause of biochemical and tissue iron excess. It also has been hypothesized that the viral infection per se or through the activation of cytokines might modify iron trafficking and metabolism in liver cells.[4,5] Experimental and clinical studies suggest that excess iron might exacerbate liver injury in patients with CVH,[6-8] increasing the risk of hepatic fibrosis and cirrhosis,[9,10] favoring the development of hepatocellular carcinoma,[11] and preventing a sustained virologic response to antiviral therapy,[12,13] although other studies denied such relationships.[14,15]

In this context, the genetic predisposition to modify cellular iron handling might be crucial in affecting the iron distribution and amount in the liver and, possibly, the outcome of the infection. For this reason, some studies have analyzed the effect of HFE mutations on hepatic iron content and disease progression.[16] Yet, controversial findings on the association between HFE status and hepatic iron overload or fibrosis score have been reported, as extensively reviewed by Pietrangelo.[4] Only a few studies evaluated the cellular and lobular distribution of iron, and among them, several discrepancies exist: some reported main iron deposits in hepatocytes[17,18] and others in Kupffer cells and/or the portal tract and/or endothelial cells.[19-22] All studies were performed with small series, and some did not analyze the relation with fibrosis and cirrhosis, and, when performed, there was no regression analysis to control for the potential aforementioned confounding factors. Moreover, to our knowledge, there is no large study available in which the relation between HFE mutations and hepatic iron distribution was assessed. The qualitative evaluation of hepatic iron accumulation could provide important information about the pathogenetic mechanisms leading to iron overload and on the role of iron in inducing or favoring hepatic damage in patients with CVH.

The aims of this study were to describe the histopathologic features of hepatic iron accumulation by a qualitative method able to characterize the lobular and cellular distribution of iron in a large number of patients with CH-C infection; determine whether HFE mutations are associated with a specific cellular localization of iron deposits; and evaluate whether hepatic iron overload and, particularly, a specific pattern of iron accumulation are associated with severe fibrosis and cirrhosis in patients with CH-C infection.

Results

The main characteristics of 206 patients with CH-C infection considered as a whole and by sex are given in ( Table 1 ). The majority of the patients were men. Women were older and had a lower alcohol intake than men. The total iron score and hepatic iron concentration showed good correlation, as expected (r = 0.782; P < .001). A total of 101 patients (81 men and 20 women) had hemosiderin deposits in the liver. Iron deposits were distributed homogeneously within the hepatic lobules in 49 (48.5%) patients, whereas in 20 patients (19.8%) and 32 patients (31.7%), they involved two thirds and one third of the hepatic specimen, respectively.

The distribution of hemosiderin in hepatic compartments (hepatocytes, sinusoidal cells, and portal tracts) is shown in ( Table 2 ). Of 101 patients, 91 (90.1%) showed hemosiderin granules in hepatocytes alone or in combination with sinus-oidal and/or portal iron deposits. Hepatic iron score medians increased significantly as iron accumulation involved sinus-oidal and portal tract compartments (P < .001). Sinusoidal iron scores showed a similar trend as median levels tend to be higher when all compartments are involved (P < .001). As shown in (Figure 1), the hepatocyte iron score but not the sinus-oidal iron score showed a decreasing gradient from Rappaport zone 1 to zone 3. Hepatic steatosis (¡Ý5%) was more common in patients with hepatic iron than in those without (65% [63/97] vs 50% [52/105]), but no clear relationship between the amount of iron accumulation and grade of steatosis was observed. According to the recent literature, patients with the hepatitis C virus genotype 3 had a higher amount of steatosis than the other genotypes.[28] Of patients with genotype 3, 50% (15/30) had steatosis involving 25% of hepatocytes or more compared with 25% (30/122) and 18% (9/50) of patients with genotypes 1 and 2, respectively. These percentages did not change when data were analyzed in patients with and without hepatic iron accumulation. Figure 1. (click image to zoom) Distribution of hemosiderin iron deposits by Rappaport zones in hepatocyte compartments (A) and sinusoidal compartments (. A, Zone 1 vs zone 2, P < .001; zone 1 vs zone 3, P < .001; zone 2 vs zone 3, P < .001. B, Zone 1 vs zone 2, P = .978; zone 1 vs zone 3, P = .768; zone 2 vs zone 3, P = .171.

( Table 3 ) shows the frequency of HFE genotypes and alleles in patients with CH-C infection considered as a whole and according to the presence or absence of hemosiderin deposits in the liver and in control subjects. The distribution of HFE genotypes differed between the whole group of patients with CH-C infection and control subjects (P = .029). This was due mainly to the higher frequency of genotypes containing HFE mutations in the subgroup of patients with hepatic iron accumulation (P = .006), whereas no significant difference was observed between the subgroup of patients without hepatic iron deposits and control subjects. To evaluate whether HFE mutations might influence the distribution of iron within hepatic compartments, we analyzed the relationship between HFE genotypes and total iron score, hepatocyte iron score, sinusoidal iron score, and portal iron score (Figure 2). Results mainly indicated that the hepatocyte iron score increased significantly according to the presence of none, 1 (either C282Y or H63D) or 2 HFE mutations, whereas the sinusoidal iron score and portal iron score did not. When applied to alcohol consumption, the hepatocyte iron score and, particularly, the sinusoidal iron score tended to be higher in heavy alcohol drinkers (median scores in heavy drinkers vs non-heavy drinkers: 5 and 4 for hepatocyte iron score, and 1.8 and 1 for sinusoidal iron score, respectively).

Figure 2. (click image to zoom) Total iron score (A, P = .063), hepatocyte iron score (B, P = .029), sinusoidal iron score (C, P = .547), and portal iron score (D, P = .606) by HFE genotype. The box includes all observations between the first and third quartiles; the bold line represents the median; error bars indicate extreme values. The 2 mutations group includes C282Y and H63D homozygotes and C282Y/H63D compound heterozygotes.

The logistic regression model, adjusted for age and grading score, suggested that a specific pattern of iron accumulation, eg, the presence of hemosiderin iron in all 3 hepatic compartments together, and heavy alcohol intake were related to a 4-fold increase in the odds of hepatic damage (P = .030 and P = .012, respectively). The presence of HFE genotypes containing 2 mutations was related to a 9-

fold increased risk of severe fibrosis and cirrhosis (P = .015) ( Table 4 ). Discussion

To our knowledge, the present study is the first one in which a qualitative evaluation and semiquantitative scoring of hepatic iron deposits were performed in a large group of patients with CH-C infection. Of the different methods available to measure hepatic iron, eg, Scheuer and Deugnier scores, and for quantitative biochemical evaluation, the Deugnier score modified according to Turlin and Deugnier[25] that we adopted has, in our opinion, several advantages compared with the other methods. It is sensitive (a critical point, especially when searching for low amounts of accumulated iron as expected in a large number of patients with CVH) and is measured on the whole hepatic specimen and not on a fragment (as occurs by quantitative measurement), reducing the risk of an inadequate evaluation owing to uneven distribution of iron in the hepatic sample.[29] Furthermore, the qualitative evaluation of hepatic iron deposits might be very informative because the mechanisms leading to hepatic iron accumulation in hepatocytes and reticuloendothelial cells are different, and iron can have different pathogenic roles depending on the hepatic cell in which it accumulates.[30]

Based on this kind of evaluation, we demonstrated the following: (1) In our patients with CH-C infection, iron deposits were found mainly in hepatocytes, alone or, more often, in various combinations with sinusoidal cells and portal tracts. (2) Iron deposits in hepatocytes showed a decreasing gradient from the periportal areas to the centrilobular veins in most patients. (3) A significant relation between HFE genotypes and iron deposition in hepatocellular but not in sinusoidal and portal compartments existed.

These findings, which confirm and extend previous findings in a smaller series,[31] allow several conclusions to be made. First, the cause of iron accumulation in CVH is more complex than believed and cannot be attributed only or simply to the release of iron from necrotic hepatocytes or to the inflammatory-mediated perturbation of iron trafficking. In fact, in these cases, iron would accumulate preferentially in nonparenchymal liver (Kupffer cells), a finding reported in some[8,19,21,22] but not all studies, including the present one.[13,17,18] This finding, together with the presence of a decreasing iron gradient from the periportal to the centrilobular zone (Figure 1) in most of our cases, indicates that part of the iron excess in CH-C infection derives from the portal blood possibly through increased intestinal iron absorption.

Second, the observed association between HFE genotypes and hepatocyte iron score, but not sinusoidal and portal iron scores (expected but never demonstrated before), indicates that in patients with CH-C infection, mutated HFE favors iron accumulation in the hepatocytes. Based on this finding and on recent experimental studies on HFE function,[32,33] it also can be speculated that in CH-C infection, the presence of even 1 HFE mutation decreases the ability of macrophages to retain iron as normal macrophages do in response to the hepatitis-related inflammatory challenge. This might favor hepatocyte iron accumulation on the one hand and influence macrophage response to viral infection, favoring viral replication and disease progression, on the other hand.

Third, because a number of patients with CH-C infection with iron accumulation had a wild-type HFE genotype, it could be hypothesized that other factors, genetic or acquired, influence iron absorption in patients with CH-C infection. There is evidence that the amount of iron overload in the liver is highly variable in different animal strains[34] and that susceptibility to hepatic iron loading in murine models has a significant genetic component and is inherited as a complex trait.[35] The different genetic background then would contribute to the amount of hepatic iron in CH-C infection, together with several other environmental- or CH-C infection-related factors. Erythropoietic alterations, intrahepatic shunts, and impaired transferrin synthesis have been implicated in the pathogenesis of hepatocellular iron overload in patients with advanced cirrhosis,[29] and, recently, Detivaud et al[36] found decreased hepcidin levels in patients with advanced liver disease. Although we excluded such patients from the present study (none of them showed reduced hemoglobin, serum albumin, or transferrin levels), we cannot exclude that even less marked variations in hepatic function could modulate iron metabolism in patients with CH-C infection. Heavy alcohol intake seems to favor hepatic iron accumulation in the sinusoidal compartment as reported in a smaller CVH series[31] and in patients with hemochromatosis.[37] This observation might have relevance to the comprehension of the mechanisms by which alcohol and iron interact to increase the risk of fibrosis in patients with CH-C infection[7,27] and needs to be reevaluated in a larger subgroup of patients with CH-C infection with iron overload and heavy alcohol intake.

The last finding of the study is that severe fibrosis and cirrhosis were associated more markedly with higher amounts of hepatic iron accumulation involving hepatocytes, sinusoidal cells, and portal tracts. Although these data could reflect the overall severity of iron overload and the duration of the disease, they might suggest a role for macrophagic iron in hepatic fibrogenesis in agreement with that observed in hemochromatosis[24] and other histopathologic and experimental studies.[7,13,20] Yet, the hepatic iron overload in CH-C infection is lower than in patients with hemochromatosis, indicating that smaller amounts of iron might serve as comorbid factors to increase the severity and/or rate of progression in CH-C infection.

[5,7] However, our study design does not allow the determination of this cause-effect relationship that requires longitudinal studies with follow-up biopsy specimens, studies still not available in the literature.

Besides iron accumulation, severe fibrosis and cirrhosis were associated independently with heavy alcohol intake and the presence of 2 HFE mutations. Age and sex were not independent risk factors for hepatic damage. The effect of alcohol intake and of the interaction between alcohol and iron in increasing the risk of severe fibrosis and cirrhosis in patients with CVH has been reported.[7,27,38] Remarkably, our findings indicate that HFE mutations per se can contribute to accelerated or more severe liver disease in CH-C infection. This finding has been reported by others for genotypes with single HFE mutations[18,39,40] and might indicate an additional role for HFE in immunologic or host defensive mechanisms as suggested by its structural analogy to nonclassic major histocompatibility complex class I molecules, its interaction with transferrin receptors that coparticipate in T-cell activation,[41] and its direct role in the shaping of the T-cell population.[42]

A recent study has shown that a viral protein[43] prevents the expression of HFE complexes by targeting HFE for rapid proteasome-

mediated degradation in human and mouse cells. The fact that pathogenic viruses have evolved mechanisms to inactivate HFE strongly indicates the importance of this molecule in the defensive response against pathogens. Whether mutated HFE can induce similar alterations, favoring viral replication or modifying antiviral immune response, remains to be explored.

Conclusion

In CH-C infection, liver siderosis is common. Description of iron deposits according to cellular and lobular distribution and intensity might have the following general and practical implications: (1) understanding (or suggesting, at least) the physiopathologic mechanisms leading to iron overload in patients; (2) directing genotyping of HFE, limiting its use to patients with prevalent hepatocellular iron deposits; and (3) directing the search for allelic variants of other iron-related genes according to present and future knowledge on iron metabolism. Furthermore, the present study highlights the need for longitudinal studies to define the causal relationship between iron accumulation and distribution and fibrosis to define possible therapeutic strategies.

[Guest guest]

Hey Eddie, Glad to see you posting. I have missed your wonderful humor!! Love JanetTubs46@... wrote: The high Iorn level is what made them do further testing and lead to the discovery of the Hep- c. My Iorn levels are normal now. Eddie I am a rock, I am island...and a rock feels no pain, and a island never cries...- Simon

[Guest guest]

Did you have to have phlebotomies to get your iron levels down ?

Iron Accumulation in Chronic Hepatitis C

Abstract and Introduction

Abstract

The aim of the present study was to describe the histopathologic features of hepatic iron accumulation in patients with chronic hepatitis C (CH-C) infection, the relation between HFE mutations and hepatic iron location and among iron distribution, HFE, and hepatic damage. We studied 206 patients with CH-C infection. Of 101 patients with hemosiderin deposits, 90.1% had iron deposits in hepatocytes (alone or with sinusoidal and/or portal involvement). The hepatic iron score increased significantly as iron accumulation involved sinusoidal and portal tract compartments and according to HFE genotypes. Severe fibrosis and cirrhosis were associated more markedly with the presence of hemosiderin iron in the 3 hepatic compartments, HFE mutations, and high alcohol intake. We suggest that part of the iron accumulation in CH-C infection derives from increased iron absorption and release from storage cells and that the amount and distribution of hepatic iron deposits is related to hepatic damage. HFE mutations favor both processes, but other factors, genetic or acquired, are involved.

Introduction

Shortly after the hepatitis C virus was cloned, it was noted that many patients with chronic hepatitis C (CH-C) infection had elevated transferrin saturation and serum ferritin and hepatic iron concentrations.[1-3] Many studies have tried to find the causes and effects of iron overload in patients with chronic viral hepatitis (CVH). In general, necroinflammatory events due to the ongoing viral infection are considered the most important cause of biochemical and tissue iron excess. It also has been hypothesized that the viral infection per se or through the activation of cytokines might modify iron trafficking and metabolism in liver cells.[4,5] Experimental and clinical studies suggest that excess iron might exacerbate liver injury in patients with CVH,[6-8] increasing the risk of hepatic fibrosis and cirrhosis,[9,10] favoring the development of hepatocellular carcinoma,[11] and preventing a sustained virologic response to antiviral therapy,[12,13] although other studies denied such relationships.[14,15]

In this context, the genetic predisposition to modify cellular iron handling might be crucial in affecting the iron distribution and amount in the liver and, possibly, the outcome of the infection. For this reason, some studies have analyzed the effect of HFE mutations on hepatic iron content and disease progression.[16] Yet, controversial findings on the association between HFE status and hepatic iron overload or fibrosis score have been reported, as extensively reviewed by Pietrangelo.[4] Only a few studies evaluated the cellular and lobular distribution of iron, and among them, several discrepancies exist: some reported main iron deposits in hepatocytes[17,18] and others in Kupffer cells and/or the portal tract and/or endothelial cells.[19-22] All studies were performed with small series, and some did not analyze the relation with fibrosis and cirrhosis, and, when performed, there was no regression analysis to control for the potential aforementioned confounding factors. Moreover, to our knowledge, there is no large study available in which the relation between HFE mutations and hepatic iron distribution was assessed. The qualitative evaluation of hepatic iron accumulation could provide important information about the pathogenetic mechanisms leading to iron overload and on the role of iron in inducing or favoring hepatic damage in patients with CVH.

The aims of this study were to describe the histopathologic features of hepatic iron accumulation by a qualitative method able to characterize the lobular and cellular distribution of iron in a large number of patients with CH-C infection; determine whether HFE mutations are associated with a specific cellular localization of iron deposits; and evaluate whether hepatic iron overload and, particularly, a specific pattern of iron accumulation are associated with severe fibrosis and cirrhosis in patients with CH-C infection.

Results

The main characteristics of 206 patients with CH-C infection considered as a whole and by sex are given in ( Table 1 ). The majority of the patients were men. Women were older and had a lower alcohol intake than men. The total iron score and hepatic iron concentration showed good correlation, as expected (r = 0.782; P < .001). A total of 101 patients (81 men and 20 women) had hemosiderin deposits in the liver. Iron deposits were distributed homogeneously within the hepatic lobules in 49 (48.5%) patients, whereas in 20 patients (19.8%) and 32 patients (31.7%), they involved two thirds and one third of the hepatic specimen, respectively.

The distribution of hemosiderin in hepatic compartments (hepatocytes, sinusoidal cells, and portal tracts) is shown in ( Table 2 ). Of 101 patients, 91 (90.1%) showed hemosiderin granules in hepatocytes alone or in combination with sinus-oidal and/or portal iron deposits. Hepatic iron score medians increased significantly as iron accumulation involved sinus-oidal and portal tract compartments (P < .001). Sinusoidal iron scores showed a similar trend as median levels tend to be higher when all compartments are involved (P < .001). As shown in (Figure 1), the hepatocyte iron score but not the sinus-oidal iron score showed a decreasing gradient from Rappaport zone 1 to zone 3. Hepatic steatosis (¡Ý5%) was more common in patients with hepatic iron than in those without (65% [63/97] vs 50% [52/105]), but no clear relationship between the amount of iron accumulation and grade of steatosis was observed. According to the recent literature, patients with the hepatitis C virus genotype 3 had a higher amount of steatosis than the other genotypes.[28] Of patients with genotype 3, 50% (15/30) had steatosis involving 25% of hepatocytes or more compared with 25% (30/122) and 18% (9/50) of patients with genotypes 1 and 2, respectively. These percentages did not change when data were analyzed in patients with and without hepatic iron accumulation. Figure 1. (click image to zoom) Distribution of hemosiderin iron deposits by Rappaport zones in hepatocyte compartments (A) and sinusoidal compartments (. A, Zone 1 vs zone 2, P < .001; zone 1 vs zone 3, P < .001; zone 2 vs zone 3, P < .001. B, Zone 1 vs zone 2, P = .978; zone 1 vs zone 3, P = .768; zone 2 vs zone 3, P = .171.

( Table 3 ) shows the frequency of HFE genotypes and alleles in patients with CH-C infection considered as a whole and according to the presence or absence of hemosiderin deposits in the liver and in control subjects. The distribution of HFE genotypes differed between the whole group of patients with CH-C infection and control subjects (P = .029). This was due mainly to the higher frequency of genotypes containing HFE mutations in the subgroup of patients with hepatic iron accumulation (P = .006), whereas no significant difference was observed between the subgroup of patients without hepatic iron deposits and control subjects. To evaluate whether HFE mutations might influence the distribution of iron within hepatic compartments, we analyzed the relationship between HFE genotypes and total iron score, hepatocyte iron score, sinusoidal iron score, and portal iron score (Figure 2). Results mainly indicated that the hepatocyte iron score increased significantly according to the presence of none, 1 (either C282Y or H63D) or 2 HFE mutations, whereas the sinusoidal iron score and portal iron score did not. When applied to alcohol consumption, the hepatocyte iron score and, particularly, the sinusoidal iron score tended to be higher in heavy alcohol drinkers (median scores in heavy drinkers vs non-heavy drinkers: 5 and 4 for hepatocyte iron score, and 1.8 and 1 for sinusoidal iron score, respectively).

Figure 2. (click image to zoom) Total iron score (A, P = .063), hepatocyte iron score (B, P = .029), sinusoidal iron score (C, P = .547), and portal iron score (D, P = .606) by HFE genotype. The box includes all observations between the first and third quartiles; the bold line represents the median; error bars indicate extreme values. The 2 mutations group includes C282Y and H63D homozygotes and C282Y/H63D compound heterozygotes.

The logistic regression model, adjusted for age and grading score, suggested that a specific pattern of iron accumulation, eg, the presence of hemosiderin iron in all 3 hepatic compartments together, and heavy alcohol intake were related to a 4-fold increase in the odds of hepatic damage (P = .030 and P = .012, respectively). The presence of HFE genotypes containing 2 mutations was related to a 9-

fold increased risk of severe fibrosis and cirrhosis (P = .015) ( Table 4 ). Discussion

To our knowledge, the present study is the first one in which a qualitative evaluation and semiquantitative scoring of hepatic iron deposits were performed in a large group of patients with CH-C infection. Of the different methods available to measure hepatic iron, eg, Scheuer and Deugnier scores, and for quantitative biochemical evaluation, the Deugnier score modified according to Turlin and Deugnier[25] that we adopted has, in our opinion, several advantages compared with the other methods. It is sensitive (a critical point, especially when searching for low amounts of accumulated iron as expected in a large number of patients with CVH) and is measured on the whole hepatic specimen and not on a fragment (as occurs by quantitative measurement), reducing the risk of an inadequate evaluation owing to uneven distribution of iron in the hepatic sample.[29] Furthermore, the qualitative evaluation of hepatic iron deposits might be very informative because the mechanisms leading to hepatic iron accumulation in hepatocytes and reticuloendothelial cells are different, and iron can have different pathogenic roles depending on the hepatic cell in which it accumulates.[30]

Based on this kind of evaluation, we demonstrated the following: (1) In our patients with CH-C infection, iron deposits were found mainly in hepatocytes, alone or, more often, in various combinations with sinusoidal cells and portal tracts. (2) Iron deposits in hepatocytes showed a decreasing gradient from the periportal areas to the centrilobular veins in most patients. (3) A significant relation between HFE genotypes and iron deposition in hepatocellular but not in sinusoidal and portal compartments existed.

These findings, which confirm and extend previous findings in a smaller series,[31] allow several conclusions to be made. First, the cause of iron accumulation in CVH is more complex than believed and cannot be attributed only or simply to the release of iron from necrotic hepatocytes or to the inflammatory-mediated perturbation of iron trafficking. In fact, in these cases, iron would accumulate preferentially in nonparenchymal liver (Kupffer cells), a finding reported in some[8,19,21,22] but not all studies, including the present one.[13,17,18] This finding, together with the presence of a decreasing iron gradient from the periportal to the centrilobular zone (Figure 1) in most of our cases, indicates that part of the iron excess in CH-C infection derives from the portal blood possibly through increased intestinal iron absorption.

Second, the observed association between HFE genotypes and hepatocyte iron score, but not sinusoidal and portal iron scores (expected but never demonstrated before), indicates that in patients with CH-C infection, mutated HFE favors iron accumulation in the hepatocytes. Based on this finding and on recent experimental studies on HFE function,[32,33] it also can be speculated that in CH-C infection, the presence of even 1 HFE mutation decreases the ability of macrophages to retain iron as normal macrophages do in response to the hepatitis-related inflammatory challenge. This might favor hepatocyte iron accumulation on the one hand and influence macrophage response to viral infection, favoring viral replication and disease progression, on the other hand.

Third, because a number of patients with CH-C infection with iron accumulation had a wild-type HFE genotype, it could be hypothesized that other factors, genetic or acquired, influence iron absorption in patients with CH-C infection. There is evidence that the amount of iron overload in the liver is highly variable in different animal strains[34] and that susceptibility to hepatic iron loading in murine models has a significant genetic component and is inherited as a complex trait.[35] The different genetic background then would contribute to the amount of hepatic iron in CH-C infection, together with several other environmental- or CH-C infection-related factors. Erythropoietic alterations, intrahepatic shunts, and impaired transferrin synthesis have been implicated in the pathogenesis of hepatocellular iron overload in patients with advanced cirrhosis,[29] and, recently, Detivaud et al[36] found decreased hepcidin levels in patients with advanced liver disease. Although we excluded such patients from the present study (none of them showed reduced hemoglobin, serum albumin, or transferrin levels), we cannot exclude that even less marked variations in hepatic function could modulate iron metabolism in patients with CH-C infection. Heavy alcohol intake seems to favor hepatic iron accumulation in the sinusoidal compartment as reported in a smaller CVH series[31] and in patients with hemochromatosis.[37] This observation might have relevance to the comprehension of the mechanisms by which alcohol and iron interact to increase the risk of fibrosis in patients with CH-C infection[7,27] and needs to be reevaluated in a larger subgroup of patients with CH-C infection with iron overload and heavy alcohol intake.

The last finding of the study is that severe fibrosis and cirrhosis were associated more markedly with higher amounts of hepatic iron accumulation involving hepatocytes, sinusoidal cells, and portal tracts. Although these data could reflect the overall severity of iron overload and the duration of the disease, they might suggest a role for macrophagic iron in hepatic fibrogenesis in agreement with that observed in hemochromatosis[24] and other histopathologic and experimental studies.[7,13,20] Yet, the hepatic iron overload in CH-C infection is lower than in patients with hemochromatosis, indicating that smaller amounts of iron might serve as comorbid factors to increase the severity and/or rate of progression in CH-C infection.

[5,7] However, our study design does not allow the determination of this cause-effect relationship that requires longitudinal studies with follow-up biopsy specimens, studies still not available in the literature.

Besides iron accumulation, severe fibrosis and cirrhosis were associated independently with heavy alcohol intake and the presence of 2 HFE mutations. Age and sex were not independent risk factors for hepatic damage. The effect of alcohol intake and of the interaction between alcohol and iron in increasing the risk of severe fibrosis and cirrhosis in patients with CVH has been reported.[7,27,38] Remarkably, our findings indicate that HFE mutations per se can contribute to accelerated or more severe liver disease in CH-C infection. This finding has been reported by others for genotypes with single HFE mutations[18,39,40] and might indicate an additional role for HFE in immunologic or host defensive mechanisms as suggested by its structural analogy to nonclassic major histocompatibility complex class I molecules, its interaction with transferrin receptors that coparticipate in T-cell activation,[41] and its direct role in the shaping of the T-cell population.[42]

A recent study has shown that a viral protein[43] prevents the expression of HFE complexes by targeting HFE for rapid proteasome-

mediated degradation in human and mouse cells. The fact that pathogenic viruses have evolved mechanisms to inactivate HFE strongly indicates the importance of this molecule in the defensive response against pathogens. Whether mutated HFE can induce similar alterations, favoring viral replication or modifying antiviral immune response, remains to be explored.

Conclusion

In CH-C infection, liver siderosis is common. Description of iron deposits according to cellular and lobular distribution and intensity might have the following general and practical implications: (1) understanding (or suggesting, at least) the physiopathologic mechanisms leading to iron overload in patients; (2) directing genotyping of HFE, limiting its use to patients with prevalent hepatocellular iron deposits; and (3) directing the search for allelic variants of other iron-related genes according to present and future knowledge on iron metabolism. Furthermore, the present study highlights the need for longitudinal studies to define the causal relationship between iron accumulation and distribution and fibrosis to define possible therapeutic strategies.

[Guest guest]

They took 200cc every three weeks. The blood letting after the second one was because my hemoglobin keeps getting over 19.0 so they have to keep a watch on that. I have to do one every couple of months for that. my Iron levels are within the limits.

[Guest guest]

It took me three months and 6 sessions before I was in the normal range . I was told I would have to have phlebotomies for the rest of my life , just not as often . I'm glad to hear your in the normal ranges also .

Re: Iron Accumulation in Chronic Hepatitis C

They took 200cc every three weeks. The blood letting after the second one was because my hemoglobin keeps getting over 19.0 so they have to keep a watch on that. I have to do one every couple of months for that. my Iron levels are within the limits.

[Guest guest]

They kept saying I had hemo-chrmiatoses(spelling) but after a lot of test and money they said that I didn't. mine is a hemoglobin problem now not the iron. Been check for everything including leukemia but couldn't find anything(again spent a lot of money). My infectious Dr. says at this point not to worry about it or Hep-C cause it's barley detectable.

"There are only two ways to live your life. One is as though nothing is a miracle. The other is as though everything is a miracle." Eddie Hinman

[Guest guest]

Seeing a Infectious Dr. Really like him because he has a lot of knowledge of Hep-C, and my Gastro didn't. He told me if I had come to him 1st. he would have recommenced not doing the TX.. But I still believe that the 12 weeks of TX is one of the reasons I'm doing so well with the Hep-c.

"Life is not a journey to the grave with the intention of arriving safely in a pretty and well-preserved body...but rather to skid in broadside, thoroughly used up, totally worn out, and loudly proclaiming, WOW! What a ride!"... Eddie Hinman

[Guest guest]

That is awesome , hemachromatosis is a genetic disease which can be triggered by the hep and once triggered you have to treat from the rest or your life . So I am very happy to hear you dont have that . Are you seeing a hepatologist or an infectious disease doctor ?

Re: Iron Accumulation in Chronic Hepatitis C

They kept saying I had hemo-chrmiatoses(spelling) but after a lot of test and money they said that I didn't. mine is a hemoglobin problem now not the iron. Been check for everything including leukemia but couldn't find anything(again spent a lot of money). My infectious Dr. says at this point not to worry about it or Hep-C cause it's barley detectable.

"There are only two ways to live your life. One is as though nothing is a miracle. The other is as though everything is a miracle." Eddie Hinman

[Guest guest]

My hepatologist made me go see a hematologist for my iron problems . I would never have thought of seeing an infectious disease doc . But it sounds like he is a great doc .

Re: Iron Accumulation in Chronic Hepatitis C

Seeing a Infectious Dr. Really like him because he has a lot of knowledge of Hep-C, and my Gastro didn't. He told me if I had come to him 1st. he would have recommenced not doing the TX.. But I still believe that the 12 weeks of TX is one of the reasons I'm doing so well with the Hep-c.

"Life is not a journey to the grave with the intention of arriving safely in a pretty and well-preserved body...but rather to skid in broadside, thoroughly used up, totally worn out, and loudly proclaiming, WOW! What a ride!"... Eddie Hinman

[Guest guest]

Iron Accumulation in Chronic Hepatitis C

Relation of Hepatic Iron Distribution, HFE Genotype, and Disease Course

Chiara Corengia, MD; Stefania Galimberti, PhD; Giorgio Bovo, MD;

Vergani, MD; Cristina Arosio, PhD; Raffaella ni, MD; Alessandro

Redaelli, MD; Alessia Riva, MD; Cristina Cestari, MD; Massimo Pozzi, MD;

Grazia Valsecchi, PhD; Alberto Piperno, MDÂ

Am J Clin Pathol. 2005;124(6):846-853. ©2005 American Society for

Clinical Pathology

Posted 11/30/2005

Abstract and Introduction

Abstract

The aim of the present study was to describe the histopathologic features

of hepatic iron accumulation in patients with chronic hepatitis C (CH-C)

infection, the relation between HFE mutations and hepatic iron location

and among iron distribution, HFE, and hepatic damage. We studied 206

patients with CH-C infection. Of 101 patients with hemosiderin deposits,

90.1% had iron deposits in hepatocytes (alone or with sinusoidal and/or

portal involvement). The hepatic iron score increased significantly as

iron accumulation involved sinusoidal and portal tract compartments and

according to HFE genotypes. Severe fibrosis and cirrhosis were associated

more markedly with the presence of hemosiderin iron in the 3 hepatic

compartments, HFE mutations, and high alcohol intake. We suggest that part

of the iron accumulation in CH-C infection derives from increased iron

absorption and release from storage cells and that the amount and

distribution of hepatic iron deposits is related to hepatic damage. HFE

mutations favor both processes, but other factors, genetic or acquired,

are involved.

Introduction

Shortly after the hepatitis C virus was cloned, it was noted that many

patients with chronic hepatitis C (CH-C) infection had elevated

transferrin saturation and serum ferritin and hepatic iron

concentrations.[1-3] Many studies have tried to find the causes and

effects of iron overload in patients with chronic viral hepatitis (CVH).

In general, necroinflammatory events due to the ongoing viral infection

are considered the most important cause of biochemical and tissue iron

excess. It also has been hypothesized that the viral infection per se or

through the activation of cytokines might modify iron trafficking and

metabolism in liver cells.[4,5] Experimental and clinical studies suggest

that excess iron might exacerbate liver injury in patients with CVH,[6-8]

increasing the risk of hepatic fibrosis and cirrhosis,[9,10] favoring the

development of hepatocellular carcinoma,[11] and preventing a sustained

virologic response to antiviral therapy,[12,13] although other studies

denied such relationships.[14,15]

In this context, the genetic predisposition to modify cellular iron

handling might be crucial in affecting the iron distribution and amount in

the liver and, possibly, the outcome of the infection. For this reason,

some studies have analyzed the effect of HFE mutations on hepatic iron

content and disease progression.[16] Yet, controversial findings on the

association between HFE status and hepatic iron overload or fibrosis score

have been reported, as extensively reviewed by Pietrangelo.[4] Only a few

studies evaluated the cellular and lobular distribution of iron, and among

them, several discrepancies exist: some reported main iron deposits in

hepatocytes[17,18] and others in Kupffer cells and/or the portal tract

and/or endothelial cells.[19-22] All studies were performed with small

series, and some did not analyze the relation with fibrosis and cirrhosis,

and, when performed, there was no regression analysis to control for the

potential aforementioned confounding factors. Moreover, to our knowledge,

there is no large study available in which the relation between HFE

mutations and hepatic iron distribution was assessed. The qualitative

evaluation of hepatic iron accumulation could provide important

information about the pathogenetic mechanisms leading to iron overload and

on the role of iron in inducing or favoring hepatic damage in patients

with CVH.

The aims of this study were to describe the histopathologic features of

hepatic iron accumulation by a qualitative method able to characterize the

lobular and cellular distribution of iron in a large number of patients

with CH-C infection; determine whether HFE mutations are associated with a

specific cellular localization of iron deposits; and evaluate whether

hepatic iron overload and, particularly, a specific pattern of iron

accumulation are associated with severe fibrosis and cirrhosis in patients

with CH-C infection.

Materials and Methods

Patients

From January 1995 to December 1999, 242 Italian patients with CH-C

infection underwent liver biopsy at San Gerardo Hospital, Monza, Italy.

The diagnosis of CH-C infection was based on persistently high

aminotransferase levels for more than 6 months, presence of hepatitis C

antibodies in the serum, and chronic hepatitis with or without cirrhosis

revealed by liver biopsy. All patients had well-compensated liver disease

at the time of liver biopsy. Patients with a history of repeated and/or

recent blood transfusions or parenteral iron therapy, significant

gastrointestinal bleeding, and ribavirin therapy, those with iron loading

anemias, and with typical cutaneous manifestations of porphyria cutanea

tarda and increased urinary porphyrin levels were excluded from the study.

Finally, 206 patients with CH-C infection were considered in the present

study. For all patients, a specimen of hepatic tissue containing at least

6 portal tracts was available for histologic grading, staging, and hepatic

iron assessment. Liver biopsy specimens were examined by one of us (G.B.)

without knowledge of biochemical data and HFE genotyping results. We also

considered 184 apparently healthy control subjects from the same

geographic origin as patients to compare the frequency of HFE alleles and

genotypes. All patients and control subjects gave informed consent for the

study.

Methods

Liver sections were stained with routine stains for histologic evaluation

and with Perls Prussian stain for iron grading. Histologic grading and

staging of chronic hepatitis were evaluated according to the criteria of

Ishak et al.[23] Stainable iron in the liver was graded according to the

Deugnier score.[24] To take into account the possible uneven distribution

of iron in the specimen, Deugnier grading was modified according to the

criteria of Turlin and Deugnier.[25] Steatosis was retrospectively

evaluated and classified in 5 groups according to the percentage of

hepatocytes involved (0%-4%, 5%-24%, 25%-49%, 50%-74%, 75%-100%).[26] The

hepatic iron concentration was determined in 117 patients by atomic

absorption spectrophotometry (Perkin-Elmer S2380, Norwalk, CT) on samples

of at least 0.5 mg dry weight.

Men and women who had consumed at least 60 g/d or 40 g/d of alcohol,

respectively, for more than 10 years, were considered heavy alcohol

drinkers. The body mass index, evaluated at the time of biopsy, was

calculated as the weight (kg)/squared height (m2) ratio.

Genomic DNA, extracted from peripheral leukocytes, was available for 164

patients and all 184 control subjects. C282Y and H63D mutations were

detected as previously reported.[27]

Statistical Analysis

All comparisons involving hepatic iron distribution in different

compartments according to Turlin and Deugnier,[25] hepatocytes (hepatocyte

iron score), sinusoidal cells (sinusoidal iron score), and portal tracts

(portal iron score) were performed on medians according to nonparametric

methods. The Kruskal-Wallis test was used when more than 2 groups were

involved, and the Wilcoxon signed rank test was used for paired data.

Owing to the small numbers of some HFE genotypes, patients were grouped in

3 categories according to the presence of 2 mutations (eg, C282Y or H63D

homozygotes and C282Y/H63D compound heterozygotes), C282Y or H63D

heterozygosity, and the wild-type genotype.

The influence of the variables age, sex, alcohol intake, necroinflammatory

activity, HFE genotype, and pattern of hepatic iron distribution on

hepatic damage (staging scores 5 and 6) was evaluated by means of a

logistic regression model. Portal tract and sinusoidal cell locations were

grouped together owing to the small number of subjects in these

categories. The Fisher exact test was used to assess whether the

distribution of HFE genotypes and alleles differs in control subjects and

patients with CH-C infection. All tests were 2-sided and with a

significance level of α equal to .05.

Results

The main characteristics of 206 patients with CH-C infection considered as

a whole and by sex are given in ( Table 1 ). The majority of the patients

were men. Women were older and had a lower alcohol intake than men.

The total iron score and hepatic iron concentration showed good

correlation, as expected (r = 0.782; P < .001). A total of 101 patients

(81 men and 20 women) had hemosiderin deposits in the liver. Iron deposits

were distributed homogeneously within the hepatic lobules in 49 (48.5%)

patients, whereas in 20 patients (19.8%) and 32 patients (31.7%), they

involved two thirds and one third of the hepatic specimen, respectively.

The distribution of hemosiderin in hepatic compartments (hepatocytes,

sinusoidal cells, and portal tracts) is shown in ( Table 2 ). Of 101

patients, 91 (90.1%) showed hemosiderin granules in hepatocytes alone or

in combination with sinus-oidal and/or portal iron deposits. Hepatic iron

score medians increased significantly as iron accumulation involved

sinus-oidal and portal tract compartments (P < .001). Sinusoidal iron

scores showed a similar trend as median levels tend to be higher when all

compartments are involved (P < .001). As shown in (Figure 1), the

hepatocyte iron score but not the sinus-oidal iron score showed a

decreasing gradient from Rappaport zone 1 to zone 3. Hepatic steatosis

(≥5%) was more common in patients with hepatic iron than in those

without (65% [63/97] vs 50% [52/105]), but no clear relationship between

the amount of iron accumulation and grade of steatosis was observed.

According to the recent literature, patients with the hepatitis C virus

genotype 3 had a higher amount of steatosis than the other genotypes.[28]

Of patients with genotype 3, 50% (15/30) had steatosis involving 25% of

hepatocytes or more compared with 25% (30/122) and 18% (9/50) of patients

with genotypes 1 and 2, respectively. These percentages did not change

when data were analyzed in patients with and without hepatic iron

accumulation.

  Figure 1.Â

  Distribution of hemosiderin iron deposits by Rappaport zones in

hepatocyte compartments (A) and sinusoidal compartments (. A, Zone 1 vs

zone 2, P < .001; zone 1 vs zone 3, P < .001; zone 2 vs zone 3, P < .001.

B, Zone 1 vs zone 2, P = .978; zone 1 vs zone 3, P = .768; zone 2 vs zone

3, P = .171.

  Â

( Table 3 ) shows the frequency of HFE genotypes and alleles in patients

with CH-C infection considered as a whole and according to the presence or

absence of hemosiderin deposits in the liver and in control subjects. The

distribution of HFE genotypes differed between the whole group of patients

with CH-C infection and control subjects (P = .029). This was due mainly

to the higher frequency of genotypes containing HFE mutations in the

subgroup of patients with hepatic iron accumulation (P = .006), whereas no

significant difference was observed between the subgroup of patients

without hepatic iron deposits and control subjects.

To evaluate whether HFE mutations might influence the distribution of iron

within hepatic compartments, we analyzed the relationship between HFE

genotypes and total iron score, hepatocyte iron score, sinusoidal iron

score, and portal iron score (Figure 2). Results mainly indicated that the

hepatocyte iron score increased significantly according to the presence of

none, 1 (either C282Y or H63D) or 2 HFE mutations, whereas the sinusoidal

iron score and portal iron score did not. When applied to alcohol

consumption, the hepatocyte iron score and, particularly, the sinusoidal

iron score tended to be higher in heavy alcohol drinkers (median scores in

heavy drinkers vs non-heavy drinkers: 5 and 4 for hepatocyte iron score,

and 1.8 and 1 for sinusoidal iron score, respectively).

  Figure 2.Â

  Total iron score (A, P = .063), hepatocyte iron score (B, P = .029),

sinusoidal iron score (C, P = .547), and portal iron score (D, P = .606)

by HFE genotype. The box includes all observations between the first and

third quartiles; the bold line represents the median; error bars indicate

extreme values. The 2 mutations group includes C282Y and H63D homozygotes

and C282Y/H63D compound heterozygotes.

  Â

The logistic regression model, adjusted for age and grading score,

suggested that a specific pattern of iron accumulation, eg, the presence

of hemosiderin iron in all 3 hepatic compartments together, and heavy

alcohol intake were related to a 4-fold increase in the odds of hepatic

damage (P = .030 and P = .012, respectively). The presence of HFE

genotypes containing 2 mutations was related to a 9-fold increased risk of

severe fibrosis and cirrhosis (P = .015) ( Table 4 ).

Discussion

To our knowledge, the present study is the first one in which a

qualitative evaluation and semiquantitative scoring of hepatic iron

deposits were performed in a large group of patients with CH-C infection.

Of the different methods available to measure hepatic iron, eg, Scheuer

and Deugnier scores, and for quantitative biochemical evaluation, the

Deugnier score modified according to Turlin and Deugnier[25] that we

adopted has, in our opinion, several advantages compared with the other

methods. It is sensitive (a critical point, especially when searching for

low amounts of accumulated iron as expected in a large number of patients

with CVH) and is measured on the whole hepatic specimen and not on a

fragment (as occurs by quantitative measurement), reducing the risk of an

inadequate evaluation owing to uneven distribution of iron in the hepatic

sample.[29] Furthermore, the qualitative evaluation of hepatic iron

deposits might be very informative because the mechanisms leading to

hepatic iron accumulation in hepatocytes and reticuloendothelial cells are

different, and iron can have different pathogenic roles depending on the

hepatic cell in which it accumulates.[30]

Based on this kind of evaluation, we demonstrated the following: (1) In

our patients with CH-C infection, iron deposits were found mainly in

hepatocytes, alone or, more often, in various combinations with sinusoidal

cells and portal tracts. (2) Iron deposits in hepatocytes showed a

decreasing gradient from the periportal areas to the centrilobular veins

in most patients. (3) A significant relation between HFE genotypes and

iron deposition in hepatocellular but not in sinusoidal and portal

compartments existed.

These findings, which confirm and extend previous findings in a smaller

series,[31] allow several conclusions to be made. First, the cause of iron

accumulation in CVH is more complex than believed and cannot be attributed

only or simply to the release of iron from necrotic hepatocytes or to the

inflammatory-mediated perturbation of iron trafficking. In fact, in these

cases, iron would accumulate preferentially in nonparenchymal liver

(Kupffer cells), a finding reported in some[8,19,21,22] but not all

studies, including the present one.[13,17,18] This finding, together with

the presence of a decreasing iron gradient from the periportal to the

centrilobular zone (Figure 1) in most of our cases, indicates that part of

the iron excess in CH-C infection derives from the portal blood possibly

through increased intestinal iron absorption.

Second, the observed association between HFE genotypes and hepatocyte iron

score, but not sinusoidal and portal iron scores (expected but never

demonstrated before), indicates that in patients with CH-C infection,

mutated HFE favors iron accumulation in the hepatocytes. Based on this

finding and on recent experimental studies on HFE function,[32,33] it also

can be speculated that in CH-C infection, the presence of even 1 HFE

mutation decreases the ability of macrophages to retain iron as normal

macrophages do in response to the hepatitis-related inflammatory

challenge. This might favor hepatocyte iron accumulation on the one hand

and influence macrophage response to viral infection, favoring viral

replication and disease progression, on the other hand.

Third, because a number of patients with CH-C infection with iron

accumulation had a wild-type HFE genotype, it could be hypothesized that

other factors, genetic or acquired, influence iron absorption in patients

with CH-C infection. There is evidence that the amount of iron overload in

the liver is highly variable in different animal strains[34] and that

susceptibility to hepatic iron loading in murine models has a significant

genetic component and is inherited as a complex trait.[35] The different

genetic background then would contribute to the amount of hepatic iron in

CH-C infection, together with several other environmental- or CH-C

infection-related factors. Erythropoietic alterations, intrahepatic

shunts, and impaired transferrin synthesis have been implicated in the

pathogenesis of hepatocellular iron overload in patients with advanced

cirrhosis,[29] and, recently, Detivaud et al[36] found decreased hepcidin

levels in patients with advanced liver disease. Although we excluded such

patients from the present study (none of them showed reduced hemoglobin,

serum albumin, or transferrin levels), we cannot exclude that even less

marked variations in hepatic function could modulate iron metabolism in

patients with CH-C infection. Heavy alcohol intake seems to favor hepatic

iron accumulation in the sinusoidal compartment as reported in a smaller

CVH series[31] and in patients with hemochromatosis.[37] This observation

might have relevance to the comprehension of the mechanisms by which

alcohol and iron interact to increase the risk of fibrosis in patients

with CH-C infection[7,27] and needs to be reevaluated in a larger subgroup

of patients with CH-C infection with iron overload and heavy alcohol

intake.

The last finding of the study is that severe fibrosis and cirrhosis were

associated more markedly with higher amounts of hepatic iron accumulation

involving hepatocytes, sinusoidal cells, and portal tracts. Although these

data could reflect the overall severity of iron overload and the duration

of the disease, they might suggest a role for macrophagic iron in hepatic

fibrogenesis in agreement with that observed in hemochromatosis[24] and

other histopathologic and experimental studies.[7,13,20] Yet, the hepatic

iron overload in CH-C infection is lower than in patients with

hemochromatosis, indicating that smaller amounts of iron might serve as

comorbid factors to increase the severity and/or rate of progression in

CH-C infection.[5,7] However, our study design does not allow the

determination of this cause-effect relationship that requires longitudinal

studies with follow-up biopsy specimens, studies still not available in

the literature.

Besides iron accumulation, severe fibrosis and cirrhosis were associated

independently with heavy alcohol intake and the presence of 2 HFE

mutations. Age and sex were not independent risk factors for hepatic

damage. The effect of alcohol intake and of the interaction between

alcohol and iron in increasing the risk of severe fibrosis and cirrhosis

in patients with CVH has been reported.[7,27,38] Remarkably, our findings

indicate that HFE mutations per se can contribute to accelerated or more

severe liver disease in CH-C infection. This finding has been reported by

others for genotypes with single HFE mutations[18,39,40] and might

indicate an additional role for HFE in immunologic or host defensive

mechanisms as suggested by its structural analogy to nonclassic major

histocompatibility complex class I molecules, its interaction with

transferrin receptors that coparticipate in T-cell activation,[41] and its

direct role in the shaping of the T-cell population.[42]

A recent study has shown that a viral protein[43] prevents the _expression

of HFE complexes by targeting HFE for rapid proteasome-mediated

degradation in human and mouse cells. The fact that pathogenic viruses

have evolved mechanisms to inactivate HFE strongly indicates the

importance of this molecule in the defensive response against pathogens.

Whether mutated HFE can induce similar alterations, favoring viral

replication or modifying antiviral immune response, remains to be

explored.

Conclusion

In CH-C infection, liver siderosis is common. Description of iron deposits

according to cellular and lobular distribution and intensity might have

the following general and practical implications: (1) understanding (or

suggesting, at least) the physiopathologic mechanisms leading to iron

overload in patients; (2) directing genotyping of HFE, limiting its use to

patients with prevalent hepatocellular iron deposits; and (3) directing

the search for allelic variants of other iron-related genes according to

present and future knowledge on iron metabolism. Furthermore, the present

study highlights the need for longitudinal studies to define the causal

relationship between iron accumulation and distribution and fibrosis to

define possible therapeutic strategies.

Table 1. Main Clinical and Histologic Characteristics of 206 Patients

Overall and by Sex*

   Total (N = 206) Men (n = 160) Women (n = 46)

  Age at liver biopsy (y) 48.3 ± 12.3 46.0 ± 12.3 56.2 ± 8.8

  Alcohol intake (g/d) (n = 188, 144, 44, respectively)†32.6 ±

44.8 38.6 ± 47.7 13.0 ± 25.4

    Heavy drinkers‡ 41 (21.8) 37 (25.7) 4 (9)

  Transferrin saturation (%) (n = 183, 141, 42, respectively)†47.3

± 16.2 47.1 ± 15.1 48.1 ± 19.7

    ≥45% 97 (53.0) 75 (53.2) 22 (52)

  Median (range) serum ferritin (µg/L) (n = 186, 144, 42,

respectively)†263 (20-4,207) 269 (20-4,207) 241 (30-2,992)

  BMI (kg/m2) (n = 176, 136, 40, respectively)†24.7 ± 3.6 24.8 ±

3.4 24.2 ± 4.0

    ≥25 kg/m2 75 (42.6) 60 (44.1) 15 (38)

  Median (range) total iron score 0 (0-38) 1 (0-38) 0 (0-30)

    No. (%) >0 101 (49.0) 81 (50.6) 20 (43)

  Staging score

    0-2 98 (47.6) 79 (49.4) 19 (41)

    3-4 69 (33.5) 51 (31.9) 18 (39)

    5-6 39 (18.9) 30 (18.8) 9 (20)

  Grading score

    0-3 42 (20.4) 34 (21.3) 8 (17)

    4-8 150 (72.8) 115 (71.9) 35 (76)

    9-12 13 (6.3) 11 (6.9) 2 (4)

    13-18 1 (0.5) 0 (0.0) 1 (2)

  Steatosis (% hepatocytes involved)

    0-4 87 (42.2) 70 (43.8) 17 (37)

    5-24 65 (31.6) 50 (31.3) 15 (33)

    25-49 26 (12.6) 20 (12.5) 6 (13)

    50-74 12 (5.8) 7 (4.4) 5 (11)

    75-100 12 (5.8) 10 (6.3) 2 (4)

    Not available 4 (1.9) 3 (1.9) 1 (2)

  BMI, body mass index.

  * Data are given as number (percentage) or mean ± SD unless

otherwise indicated.

  †The number of subjects with known data is reported.

  ‡ Alcohol intake >60 g/d in men and >40 g/d in women for more than

10 y.

Table 2. Hepatic Iron Distribution in 101 Patients With Chronic Viral

Hepatitis C and Hemosiderin Deposits

  Hepatic Iron Distribution No. (%) Hepatocyte Iron Score Sinusoidal

Iron Score Portal Iron Score

  Median First-Third

  Quartile Median First-Third

  Quartile Median First-Third

  Quartile

  Hepatocytes 21 (20.8) 4 2-6 — — — —

  Sinusoidal cells 8 (7.9) — — 1 1-3 — —

  Portal tracts 1 (1.0) — — — — 1 —

  Hepatocytes and sinusoidal cells 34 (33.7) 4 2-6 2 1-3 — —

  Hepatocytes and portal tracts 6 (5.9) 6 2-9 — — 2 1-4

  Sinusoidal cells and portal tracts 1 (1.0) — — 6 — 3 —

  Hepatocytes, sinusoidal cells, and portal tracts 30 (29.7) 9 6-15 3

3-4 2 1-3

  Total 101 (100.0) 4 2-6 2 0-3 0 0-1

  Overall test on medians: P <.001 <.001* .844* Â

  *The comparison involves groups with >2 patients.

Table 3. Frequency of HFE Genotypes and Alleles in Patients With Chronic

Viral Hepatitis C, Considered as a Whole and According to the Presence of

Hemosiderin, and in Healthy Control Subjects*

   Patients Control Subjects

  HFE genotype Total (n = 164) TIS = 0 (n = 78) TIS >0 (n = 86) (n =

184)

    C282Y+/+ 1 (0.6) 0 (0) 1 (1) 0 (0.0)

    C282Y/H63D 4 (2.4) 1 (1) 3 (3) 0 (0.0)

    C282Y± 11 (6.7) 5 (6) 6 (7) 5 (2.7)

    H63D+/+ 4 (2.4) 1 (1) 3(3) 2 (1.1)

    H63D± 43 (26.2) 20 (26) 23 (27) 43 (23.4)

    Wild-type 101 (61.6) 51 (65) 50 (58) 134 (72.8)

  HFE alleles Total (n = 328) TIS = 0 (n = 156) TIS >0 (n=172) (n =

368)

    C282Y 17 (5.2) 6 (3.8) 11 (6.4) 5 (1.4)

    H63D 55 (16.8) 23 (14.7) 32 (18.6) 47 (12.8)

    Wild-type 256 (78.0) 127 (81.4) 129 (75.0) 316 (85.9)

  TIS, total iron score.

  *Data are given as number (percentage). For HFE genotypes: patients

vs control subjects, P = .029; patients with hemosiderin (TIS >0) vs

control subjects, P = .006; patients with no hemosiderin (TIS = 0) vs

control subjects, P = .242. For HFE alleles: patients vs control subjects,

P = .004; patients with hemosiderin vs control subjects, P = .001;

patients with no hemosiderin vs control subjects, P = .115. Note that the

numbers of cases are different for genotypes and alleles.

Table 4. Results of Logistic Regression Analysis on Severe Fibrosis or

Cirrhosis

   No. of Cases (n = 151)* No. of Events Odds Ratio SE P

  Age (y)  1.05 0.02 .0951

    <40 47 2  Â

    40-50 26 5  Â

    >50 78 18  Â

  Heavy alcohol drinkers

    No 118 15 1.00 Â

    Yes 33 10 4.31 0.58 .012

  Grading score  1.22 0.13 .121

    0-3 27 1  Â

    4-8 117 22  Â

    ≥9 7 2  Â

  HFE genotype

    Wild-type 93 13 1.00 Â

    H63D± 41 6 0.99 0.63 .987

    C282Y± 9 1 0.99 1.25 .991

    C282Y and H63D homozygotes and C282Y/H63D compound

heterozygotes 8 5 9.09 0.90 .015

  Hepatic iron distribution

    No iron 73 7 1.00 Â

    Hepatocytes 16 1 0.60 1.20 .672

    Sinusoidal cells + portal tracts + sinusoidal cells and portal

tracts 7 1 1.24 1.21 .862

    Hepatocytes and sinusoidal cells 27 5 1.33 0.76 .709

    Hepatocytes and portal tracts 6 2 1.65 1.09 .647

    Hepatocytes, sinusoidal cells, and portal tracts 22 9 4.00 0.64

..030

  * The model was fitted on 151 patients owing to missing values in

the variables considered.

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Reprint Address

Address reprint requests to Dr Piperno: Clinica Medica, Azienda

Ospedaliera San Gerardo, Via Pergolesi, 33, 20052, Monza, Italy.

Chiara Corengia, MD,1 Stefania Galimberti, PhD,2 Giorgio Bovo, MD,3

Vergani, MD,1 Cristina Arosio, PhD,1 Raffaella ni, MD,1 Alessandro

Redaelli, MD,1 Alessia Riva, MD,1 Cristina Cestari, MD,4 Massimo Pozzi,

MD,1 Grazia Valsecchi, PhD,2 and Alberto Piperno, MD1

From the 1Unit of Clinical Medicine and 2Section of Medical Statistics,

Department of Clinical Medicine, Prevention and Biotechnologies,

University of Milano-Bicocca, San Gerardo Hospital; and 3Department of

Clinical Pathology and 4Second Medical Unit, San Gerardo Hospital, Monza,

Italy.

sallyrob

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~I will say of the L-rd, He is my refuge andmy

fortress: my G-d; in Him will I trust.Psalm 91;2~~~~~~~~~~~~~~~~~~~~~~~

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