New Approaches to Using Knowledge Gained from HH

PROFESSOR JOHN K. OLYNYKDepartment of Gastroenterology, Fiona Stanley &

Fremantle Hospitals;Curtin Innovation Health Research Institute;

Institute for Immunology & Infectious Diseases, Murdoch University

KNOWN KNOWNS

(Andrews, 1999)

Gan et al Expert Rev Endocrinol Metab 2009;4:229

Too much or too little iron Too much

Absolute – iron overload diseases

Too little Absolute

Low intake Loss – bleeding

Too much Functional

Cancer

Too little Functional

Chronic diseases Obesity

Testing for iron overload

Kruger et al CCR 2012

INTERPRETATION OF BLOOD TESTS

ELEVATIONS OF SERUM IRON STUDIES ARE COMMON

31% Australian males and 5% of females have elevated serum ferritin levels > 300 μg/L 35% increase in the number of males exceeding

limits since 1995 40% of haemodialysis patients have ferritin

levels > 500 μg/L 30% of adults have fatty liver

30-50% of these can have elevated ferritin levels

Olynyk et al NEJM 1999; Ombiga et al Semin Liv Dis 2005; ANZDATA 2009; McKinnon et al Clin Gastroenterol Hepatol 2014

SO WHAT SHOULD BE THE REFERENCE RANGE FOR FERRITIN?

CURRENT LAB RANGES

McKinnon et al Clin Gastroenterol Hepatol 2014

McKinnon et al Clin Gastroenterol Hepatol 2014

Detection of Hereditary Haemochromatosis using Haematology ParametersBentley P, Ferman M, Trinder D, Chua A, Hazeldine S, Olynyk JK

MCH – ROC AUC 0.82> 31 pg sensitivity 80% specificity 76%

HOW MUCH IRON DO I REALLY HAVE

St Pierre et al Blood 2005;105:855-861

0

50

100

150

200

250

300

0 10 20 30 40

HepatitisHemochromatosis-thalassemia/ Hb E-thalassemia

Mea

n tr

ansv

erse

rela

xatio

n ra

te <

R2>

(s-1

)

Biopsy iron concentration (mg.g-1 dry tissue)

p<0.0001r=0.98 n=105 20

40

60

0.5 2

Application of new technology

Which patient has haemochromatosis?

TRS 75%Ferritin 1200 g/L

Which patient has haemochromatosis?

TRS 75%Ferritin 1200 g/L

TRS 45%Ferritin 1400 g/L

Which patient has haemochromatosis?

TRS 75%Ferritin 1200 g/L

TRS 45%Ferritin 1400 g/L

TRS 90%Ferritin 1100 g/L

ASSUMPTION

Serum ferritin levels reflect iron stores Ferritin < 20 μg/L = Fe depletion Ferritin < 10 μg/L = Fe deficiency What about ferritin > ULN?

Clark Curr Opinion Gastroenterol 2009

FERRITIN OVERVIEWROLE IN DIAGNOSIS

Ferritin is to hemochromatosis as fecal occult blood screening is to bowel cancer An elevated result requires a definitive test

to confirm the diagnosis Invasive – liver biopsy Non-invasive – MRI methods Quantitative phlebotomy (retrospective

method)

FERRITIN AS A PREDICTOR OF HIC

0 1000 2000 3000 4000 50000

100

200

300

400

500

Ferritin vs HIC HH

r=0.542p=0.009

Serum Ferritin (g/L)

HIC

( m

ol/g

)

Olynyk et al Clin Gastroenterol Hepatol 2009

Ferritin vs HIC in HFE wild-type individuals

0 1000 2000 3000 40000

20

40

60

80

r2=0.002p=0.75

Ferritin g/L

HIC

(m

ol/g

)

0

1000

2000

3000

4000

5000 Wild type

HFE HH

Isolated hyperferritinemia

Renal

Ferr

itin

(ng/

ml)

Olynyk et al Clin Gastro Hepatol 2009;7:359-362

0

100

200

300

400 Wild type

HFE HH

**

** P<0.01 vs No HFE orIsolated hyperferritinemia

Isolated hyperferritinemia

Renal

**

HIC

(um

ol/g

)

Chronic kidney disease – a balancing act between too little and too much

REGULATION OF FE ABSORPTION AND RELEASE IN CKD

REASON FOR IRON THERAPYANEMIA IN CKD

48% predialysis CKD patients anemic (range 26-75% dependent on GFR)

35% HD patients anemia Treatment of anemia with ESA/Fe improves

QOL, reduces hospitalisation, reduces transfusion

Criteria for Fe – ferritin < 100 μg/L & TSAT < 20%

McClellan et al Curr Med Res Opin 2004;9:1501-10 Roger. CARI guidelines Nephrology 2006;11:S217KDOQI guidelines. Am J Kidney Dis 2006;47:S11 ANZDATA 2009;5:16Jones et al Kidney Int 2004;65:757-767

TOO MUCH OF A GOOD THING?

Increasing mortality Hb > 120g/L Cost > $150 million per annum and rising Ferritin > 2000 μg/L – risk of

hemochromatosis Ferritin 300-1200 μg/L – lowest risk of

morbidity and mortality Cease Fe supplementation when ferritin >

500 μg/LUnger et al N Engl J Med 2010;362:182-192 ANZDATA 2009Carter et al Brit Med J 1969;3:206 Kalantar-Zadeh et al J Am Soc Nephrol 2005;16:3070-80Roger. CARI guidelines Nephrology 2006;11:S217KDOQI guidelines. Am J Kidney Dis 2006;47:S11

Ferrari et al CJASN 2011;6:77

15 subjects > 12 months HD

900 day mean 217 mg Fe monthly Ferritin > 500 μg/L

on 2 occasions over 3 months

Ferrari et al CJASN 2011;6:77

LIVER and CARDIAC IRON LOADING –MODERN CARI CARE

Holman et al Nephrology 2016

Novel treatments for anaemia of CKD

Ferrari et al Nephrology 2010; Gummer et al Nephrology 2016

New understanding of mechanisms of anaemia during treatment with interferon alpha

Van Rijnsoever et al J Int Cytokine Res 2016

OBESITY AND TOO LITTLE IRON

Background Overweight and obesity are risk factors for

iron deficiency and dysregulated iron metabolism

Dysregulated iron metabolism in obesity is related to a chronic inflammatory state, possibly via a hepcidin-mediated mechanism

The specific effects of NAFLD on iron metabolism vs those mediated by obesity is unclear

Hutchinson C Eur J Clin Nutr 2016

Discrete effects of obesity and NAFLD on iron metabolism and haematology parametersMcKinnon EJ, Chua AC, Trinder D, Ayonrinde OT, Adams LA, Olynyk JK

Raine study 17 year old cohort (n=963) Measured haematological, iron

parameters Determined NAFLD (US – 53/727 lean

7%, 33/145 overweight 23%, 60/91 obese 66%

Linear regression – adjustment for sex, BMI

020

4060

8010

0

020

4060

8010

0

16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44

Coun

t

Coun

t

Body mass index Body mass index

MALES FEMALESResults – adiposity and NAFLD

No fatty liver NAFLD(non-alcoholic fatty liver disease)

Fatty liver more prevalent in those with higher BMI, but not exclusively associated with being overweight or

obese

Healthy Overweight

Obese

No fatty liver

674 112 31

NAFLD 53 (7%) 33(23%) 60(66%)

hs-CRP Ferritin TSAT

0.5

1.0

2.0

4.0

3040

5060

70

0.5

1.0

2.0

4.0

3040

5060

70Se

urm

ferri

tin (μ

g/L

)SF

(μg/

L )

Tran

sfer

rin s

atur

atio

n (%

)TS

AT (%

)

hs-C

RP (m

g/L

)hs

-CRP

(mg/

L )

1520

2530

1520

2530

17 years

20 years

Results

no fatty liver NAFLD(sex and BMI-adjusted, 2 SE)From 17 to 20 years of age:• consistent increases across demographic groups in serum ferritin • increased impact of NAFLD on serum iron and TSAT especially

TSAT

SERUMFERRITIN

TSAT TSAT5 10 50

510

5010

0

5 10 50

510

5010

0

5 10 50

510

5010

0

Lean Overweight Obese

By 20 years of age• Evidence NAFLD with excess adiposity increases risk of

functional iron deficiency, but usefulness of serum ferritin as marker compromised by chronic inflammation.

NAFLD diagnosed at 17 yearshs-CRP >40 Serum ferritin & TSAT both below limits indicating iron deficiency

Results – obesity impacts on iron parameters

HaemoglobinMean corpuscular

volumeMean corpuscular

haemoglobin

14.0

14.5

15.0

15.5

8283

8485

8687

88

28.0

29.0

30.0

MCV

(fL

)

MCH

(pg)

HB (g

/L )17 years

no fatty liver NAFLD (sex and BMI-adjusted, 2 SE)

Results

At 17 years of age:• Evidence of impaired haemoglobinisation associated with NAFLD,

particularly in overweight/obese

Summary NAFLD independently increased risk of

functional iron deficiency and impaired Hb production

?could functional iron deficiency in NAFLD / obese individuals impair ability to exercise and lose weight

IRON AND CANCER

Conflicting evidence that iron status relates to risk of cancer Human studies show links between iron

content of diet and risk of cancer No links between ferritin levels and cancer

(in fact negative if anything)

Background

Fonseca-Nunes et al Cancer Epidemiol Biomarkers Prevention 2014

Background C282Y homozygosity

3-fold increased risk of colorectal cancer in men and women 3-fold increased risk of breast cancer in women

H63D homozygosity Genetic modifier of cancer development in HNPCC with mutations in MMR

genes 3-fold increased risk of cancer in MMR gene mutation carriers and earlier

onset of cancer Iron reduction

1200 subjects (male, mean age 67) randomised to phlebotomy (fer 80) vs no phleb (fer 120)

4.5 year FU Risk of new visceral malignancy 0.65 in phlebotomy group

Osborne et al. Hepatology 2010;51:1311-18Shi et al. Int J Cancer 2009;125:78-83Zacharski et al JNCI 2008;100:996-1002

Serum iron and cancer

Wen et al Cancer Res 2014120 ug/dl = 21 umol//L35% men and 20% women exceed this value

Serum iron and cancer

Wen et al Cancer Res 2014

Prospective study of subjects who participated in the 1994/1995 health survey

Eligibility: had data on relevant variables, no history of cancer before survey and serum ferritin ≥ 20 μg/L

1597 men and 1795 women aged 25-79 years Ferritin, Fe and Transferrin Saturation (TRS) examined

as continuous variable (after log transformation) and age specific tertiles

Evaluated death from cancer, incident non-skin cancer, incident breast cancer, prostate cancer and colorectal cancer at 2010 by data linkage

Busselton Health Cohort

Iron and cancer outcomes in womenAdjusted* HR for log Iron = increase in risk of cancer per each unit increase in log Iron

*Adjusted for age, smoking, drinking, bmi, waist, sbp, dbp, HDL, logTrig, logGlucose, logHOMA-R, logCRP, logALT, LogGGT, bilirubin, and albumin. Model for breast cancer also adjusted for menopausal status.

n=76 n=268 n=80 n=45

n = number of cancer outcome eventsChua et al Am J Clin Nutr in press

Adjusted* HR for log TS = increase in risk of cancer per each unit increase in log TS

Transferrin saturation and cancer outcomes in women

*Adjusted for age, smoking, drinking, bmi, waist, sbp, dbp, HDL, logTrig, logGlucose, logHOMA-R, logCRP, logALT, LogGGT, bilirubin, and albumin. Model for breast cancer also adjusted for menopausal status.

n=76 n=268 n=80 n=45

n = number of cancer outcome eventsChua et al Am J Clin Nutr in press

Common cancers in women and risk of cancer death may be iron sensitive diseases

Raises questions regarding: Iron supplementation of women – is it good or

bad? Men are different to women! Will reducing iron status in women reduce the

risk of cancer? E.g. encourage more women to be blood donors

Conclusions