Journal of Hepatology
Volume 53, Issue 1 , Pages 3-22, July 2010

EASL clinical practice guidelines for HFE hemochromatosis

Received 28 February 2010; accepted 9 March 2010. published online 19 April 2010.

Article Outline

Iron overload in humans is associated with a variety of genetic and acquired conditions. Of these, HFE hemochromatosis (HFE-HC) is by far the most frequent and most well-defined inherited cause when considering epidemiological aspects and risks for iron-related morbidity and mortality. The majority of patients with HFE-HC are homozygotes for the C282Y polymorphism [1]. Without therapeutic intervention, there is a risk that iron overload will occur, with the potential for tissue damage and disease. While a specific genetic test now allows for the diagnosis of HFE-HC, the uncertainty in defining cases and disease burden, as well as the low phenotypic penetrance of C282Y homozygosity poses a number of clinical problems in the management of patients with HC. This Clinical Practice Guideline will therefore, focus on HFE-HC, while rarer forms of genetic iron overload recently attributed to pathogenic mutations of transferrin receptor 2, (TFR2), hepcidin (HAMP), hemojuvelin (HJV), or to a sub-type of ferroportin (FPN) mutations, on which limited and sparse clinical and epidemiologic data are available, will not be discussed. We have developed recommendations for the screening, diagnosis, and management of HFE-HC.

 

Back to Article Outline

Introduction 

This Clinical Practice Guideline (CPG) has been developed to assist physicians and other healthcare providers as well as patients and interested individuals in the clinical decision making process for HFE-HC. The goal is to describe a number of generally accepted approaches for the diagnosis, prevention, and treatment of HFE-HC. To do so, four clinically relevant questions were developed and addressed:

(1)What is the prevalence of C282Y homozygosity?

(2)What is the penetrance of C282Y homozygosity?

(3)How should HFE-HC be diagnosed?

(4)How should HFE-HC be managed?

Each question has guided a systematic literature review in the Medline (PubMed version), Embase (Dialog version), and the Cochrane Library databases from 1966 to March 2009. The study selection was based on specific inclusion and exclusion criteria (Table 1). The quality of reported evidence has been graded according to the Grades of Recommendation, Assessment, Development, and Evaluation system (GRADE) [2], [3], [4], [5], [6]. The GRADE system classifies recommendations as strong or weak, according to the balance of the benefits and downsides (harms, burden, and cost) after considering the quality of evidence (Table 2). The quality of evidence reflects the confidence in estimates of the true effects of an intervention, and the system classifies quality of evidence as high, moderate, low, or very low according to factors that include the study methodology, the consistency and precision of the results, and the directness of the evidence [2], [3], [4], [5], [6]. Every recommendation in this CPG is followed by its GRADE classification in parentheses.

Table 1. Inclusion and exclusion criteria for the literature search.
Inclusion and exclusion criteria for searching references
Inclusion criteria
1. Populations: adults age >18 years, population applicable to Europe, North America, Australia, New Zealand, screening population with elevated iron measures, asymptomatic iron overload, or HFE C282Y homozygosity (all ages were included for questions on C282Y prevalence)
2. Disease: symptomatic (liver fibrosis, cirrhosis, hepatic failure, hepatocellular carcinoma, diabetes mellitus, cardiomyopathy, or arthropathy hypogonadism, attributable to iron overload) or asymptomatic with or without C282Y homozygosity
3. Design:
a. Questions on prevalence: cohort or cross-sectional studies (also studies in newborns)
b. Questions on burden, natural history, penetrance: cross-sectional and longitudinal cohort studies
c. Questions on therapeutics: RCTs and large case series
4. Outcomes: incidence, severity, or progression of clinical hemochromatosis or iron measures, nonspecific symptoms (for questions on therapy)
Exclusion criteria
1. Non-human study
2. Non-English-language
3. Age: <18 years unless adult data are analyzed separately
4. Design: case-series with <15 patients, editorial, review, letter, congress abstract (except research letters)
5. For questions on epidemiology and diagnosis: does not include HFE genotyping
6. Does not report relevant prevalence or risk factors (for questions on prevalence–penetrance), does not report relevant outcomes (for questions on therapy)
7. Not phlebotomy treatment (for questions on therapy)
Table 2. Quality of evidence and strength of recommendations according to GRADE.
ExampleNoteSymbol
Quality of evidence
HighRandomized trials that show consistent results, or observational studies with very large treatment effectsFurther research is very unlikely to change our confidence in the estimate of effectA
ModerateRandomized trials with methodological limitations, or observational studies with large effectFurther research is likely to have an important impact on our confidence in the estimate of effect and may change the estimateB
Low and very LowObservational studies without exceptional strengths, or randomized trials with very serious limitations; unsystematic clinical observations (e.g. case reports and case series; expert opinions) as evidence of very-low-quality evidenceFurther research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Any estimate of effect is very uncertainC
Strength of recommendations∗
StrongDefined as being ‘confident that adherence to the recommendation will do more good than harm or that the net benefits are worth the costs’ 1
WeakDefined as being ‘uncertain that adherence to the recommendation will do more good than harm OR that the net benefits are worth the costs’The uncertainty associated with weak recommendations follows either from poor-quality evidence, or from closely balanced benefits versus downsides2

∗Factors that affect the strength of a recommendation are: (a) quality of evidence; (b) uncertainty about the balance between desirable and undesirable effect; (c) uncertainty or variability in values and preferences; (d) uncertainty about whether the intervention represents a wise use of resources (see Refs. [2], [3], [4], [5], [6]).

Back to Article Outline

What is the prevalence of C282Y homozygosity? 

The prevalence of HFE gene polymorphisms in the general population 

The frequency of HC-associated HFE gene polymorphisms in the general population was determined in 36 screening studies, which fulfilled the inclusion criteria (Table 3). The allelic frequency of C282Y was 6.2% in a pooled cohort of 127,613 individuals included in the individual patient meta-analysis from these 36 studies (Table 3).

Table 3. Prevalence of the common HFE polymophisms C282Y and H63D in the general population.
AuthorsRef.Country – PopulationIndividuals screenedAllele frequency for
c.845 C>A (Y282)c.187 C>G (D63)
Beckman et al. (1997)[7]Mordvinia850.0176
Finland1730.052
Sweden – Saamis1510.0199
Sweden – Saamis2060.0752
Merryweather-Clarke et al. (1997)[8]UK3680.0600.12
Ireland450.10.189
Iceland900.0670.106
Norway940.0740.112
Former USSR1540.0100.104
Finland3800.118
Denmark370.0950.22
Netherlands390.0260.295
Germany1150.0390.148
Ashkenazi3500.086
Italy910.0050.126
Greece1960.0130.135
Turkey7000.136
Spain780.0320.263
Datz et al. (1998)[9]Austria2710.0410.258
Burt et al. (1998)[10]New Zealand of European ancestry10640.0700.144
Jouanolle et al. (1998)[11]France – Brittany10000.065
Merryweather-Clarke et al. (1999)[12]Scandinavia8370.0510.173
Distante et al. (1999)[13]Norway5050.0780.229
Olynyk et al. (1999)[14]Australia30110.0757
Marshall et al. (1999)[15]USA – non-Hispanic whites1000.050.24
Beutler et al. (2000)[16]USA – whites76200.0640.154002625
Steinberg et al. (2001)[17]USA – non-Hispanic whites20160.06370.153769841
Andrikovics et al. (2001)[18]Hungarian blood donors9960.0340.014
Pozzato et al. (2001)[19]Italy – Celtic populations1490.036910.144295302
Byrnes et al. (2001)[20]Ireland8000.12750.171875
Beutler et al. (2002)[21]USA – non-Hispanic whites30,6720.0622
Guix et al. (2002)[22]Spain – Balearic Islands6650.02030.201503759
Deugnier et al. (2002)[23]France93960.07636228
Cimburova et al. (2002)[24]Czech Republic2540.039370080.142
Van Aken et al. (2002)[25]Netherlands12130.06141797
Phatak et al. (2002)[26]USA32270.05070.1512
Jones et al. (2002)[27]UK1590.0850.173
Candore et al. (2002)[28]Italy – five regions5780.0250.147
Salvioni et al. (2003)[29]Italy – North6060.04702970.143564356
Papazoglou et al. (2003)[30]Greece26400.089015152
Sanchez et al. (2003)[31]Spain53700.031564250.208007449
Mariani et al. (2003)[32]Italy – North11320.0320.134
Altes et al. (2004)[33]Spain – Catalonia10430.02828380.19894535
Adams et al. (2005)[34]USA – whites44,0820.068259150.153157751
Barry et al. (2005)[35]USA – non-Hispanic whites35320.0570.14
Meier et al. (2005)[36]Germany7090.044
Matas et al. (2006)[37]Jewish populations – Chuetas2550.007843140.123529412
Hoppe et al. (2006)[38]USA – non-Hispanic whites9910.054994950.134207871
Aranda et al. (2007)[39]Spain – Northeastern8120.031403940.219211823
Terzic et al. (2006)[40]Bosnia and Herzegovina2000.02250.115
Floreani et al. (2007)[41]Italy – Central5020.01892430.148406375
Raszeja-Wyszomirska et al. (2008)[42]Poland – Northwestern15170.044166120.154251813

From this allelic frequency for C282Y, a genotype frequency of 0.38% or 1 in 260 for C282Y homozygosity can be calculated from the Hardy–Weinberg equation. The reported frequency of C282Y homozygosity is 0.41%, which is significantly higher than the expected frequency. This probably reflects a publication or ascertainment bias.

Significant variations in frequencies of the C282Y allele between different geographic regions across Europe have been reported with frequencies ranging from 12.5% in Ireland to 0% in Southern Europe (Fig. 1).

In addition to C282Y, which is also known as the ‘major’ HFE-associated polymorphism, H63D, considered to be the ‘minor’ HFE polymorphism, has been found more frequently in HC patients than in the control population. The frequency of the H63D polymorphism shows less geographic variation, with an average allelic frequency of 14.0% from pooled data (23,733 of 170,066 alleles). An additional HFE polymorphism is S65C, which can be associated with excess iron when inherited in trans with C282Y on the other parental allele. The allelic frequency of this polymorphism is ∼0.5% and appears to be higher in Brittany, France.

The prevalence of homozygosity for C282Y in the HFE gene in clinically recognized hemochromatosis 

The prevalence of C282Y homozygosity in clinically recognized individuals with iron overload was assessed in a meta-analysis including 32 studies with a total of 2802 hemochromatosis patients of European ancestry (Table 4). This analysis of pooled data shows that 80.6% (2260 of 2802) of HC patients are homozygous for the C282Y polymorphism in the HFE gene. Compound heterozygosity for C282Y and H63D was found in 5.3% of HC patients (114 of 2117, Table 4). In the control groups, which were reported in 21 of the 32 studies, the frequency of C282Y homozygosity was 0.6% (30 of 4913 control individuals) and compound heterozygosity was present in 1.3% (43 of 3190 of the control population).

Table 4. Prevalence of C282Y homozygosity and C282Y/H63D compound heterozygosity in clinically recognized hemochromatosis.
AuthorsRef.Study populationPrevalence of HLA/HFE among clinical hemochromatosis cases
No. of casesC282Y homozygoteC282Y/H63D compound heterozygoteWild type both alleles
Feder et al. (1996)[1]USA – Multicenter187148 21
Jazwinska et al. (1996)[43]Australia1121120
Jouanolle et al. (1996)[44]France656530
Beutler et al. (1996)[45]USA – European origin147121
Borot et al. (1997)[46]France – Toulouse9468418
Carella et al. (1997)[47]Italy – Northern75485
Datz et al. (1998)[9]Austria4031
Willis et al. (1997)[48]UK – Eastern England1818
The UK Haemochromatosis Consortium (1997)[49]UK – Consortium115105 5
Press et al. (1998)[50]USA – Portland3712
Cardoso et al. (1998)[51]Sweden878031
Sanchez et al. (1998)[52]Spain312721
Ryan et al. (1998)[53]Ireland605612
Nielsen et al. (1998)[54]Germany – Northern92874
Murphy et al. (1998)[55]Ireland3027
Mura et al. (1999)[56]France – Brittany7115704035
Brissot et al. (1999)[57]France – Northwest21720942
Bacon et al. (1999)[58]USA66602
Brandhagen et al. (2000)[60]USA – Liver transplant recipients54
Rivard et al. (2000)[60]Canada – Quebec321438
Papanikolaou et al. (2000)[61]Greece103 5
Guix et al. (2000)[62]Spain – Balearic Islands1413
Brandhagen et al. (2000)[63]USA8270 2
Sham et al. (2000)[64]USA – Minnesota12374156
Van Vlierberghe et al. (2000)[65]Belgium – Flemish494621
Bell et al. (2000)[66]Norway120923
Hellerbrand et al. (2001)[67]Germany – Southern362632
de Juan et al. (2001)[68]Spain – Basque population352042
Guix et al. (2002)[22]Spain – Balearic Islands302720
De Marco et al. (2004)[69]Italy – Southern4691011
Bauduer et al. (2005)[70]France – Basque population1582
Cukjati et al. (2007)[71]Slovenia211022

Hence, 19.4% of clinically characterized HC patients have the disease in the absence of C282Y homozygosity. Although compound heterozygosity (H63D/C282Y) appears to be disease associated, in such individuals with suspected iron overload, cofactors should be considered as a cause [72], [73], [74].

The prevalence of HFE genotypes in selected patient groups 

Fatigue 

To date, there are only cross-sectional or case-control studies investigating the prevalence of C282Y homozygosity in patients with fatigue or chronic fatigue syndrome [75], [76], [77]. None of the three studies found the prevalence of C282Y homozygosity to be increased.

Arthralgia 

Most available studies investigated the prevalence of C282Y mutations in patients with inflammatory arthritis [78], [79], [80]; there are few studies in patients with non-inflammatory arthralgia or chondrocalcinosis [75], [81]. In the majority of studies of patients with undifferentiated osteoarthritis the prevalence of C282Y homozygosity did not exceed that of the control population [3], [80]. In patients with osteoarthritis in the 2nd and 3rd metacarpophalangeal joints, higher allele frequencies of the HFE-polymorphisms (C282Y and H63D) were found, although this was not accompanied by an increased frequency of C282Y homozygotes [82], [83]. A higher prevalence of C282Y homozygosity was only found in patients with well-characterized chondrocalcinosis [81].

Diabetes 

Association of the C282Y polymorphism with diabetes mellitus has been mainly evaluated in patients with type 2 diabetes mellitus in cross-sectional and case-control studies [84], [85], [86], [87], [88], [89], [90], [91], [92], [93], [94], [95]. Apart from one exception, no association between type 2 diabetes and C282Y homozygosity was found [75]. A higher prevalence of the C282Y allele was found in proliferative diabetic retinopathy and nephropathy complicating type 2 diabetes [96], although the frequency of C282Y homozygosity was not increased. The prevalence of C282Y homozygotes in patients with type 1 diabetes mellitus has been addressed in only one study where a significantly higher rate of C282Y homozygotes was detected (odds ratio 4.6; prevalence 1.26%) [97].

Liver disease 

There are a limited number of studies reporting C282Y-homozygosity in unselected patients with liver disease [98], [99], [100]. Three to 5.3% of patients were C282Y-homozygous, which is about 10-fold higher than the reported prevalence in the general population. The prevalence of C282Y homozygosity increased to 7.7% if patients were selected on the basis of a transferrin saturation of >45% [98].

Hepatocellular carcinoma 

Hepatocellular carcinoma (HCC) is a recognized complication of HFE-HC. Nevertheless few studies have analyzed the frequency of C282Y homozygosity in patients with HCC and these are limited with respect to their size [101], [102], [103], [104], [105], [106]. The etiology of HCC differed significantly between the studies. Patients with clinical HC were specifically excluded in one study [103]. Subgroup analysis for gender specific prevalence and different etiologies were statistically underpowered. However, three studies in HCC reported a frequency of C282Y-homozygotes of 5.5–10% [101], [102], [106] and three further studies found an increased prevalence of C282Y heterozygosity [103], [105], [107]. Only one study [104] did not find an association between HCC and the C282Y-polymorphism.

Hair loss, hyperpigmentation, amenorrhea, loss of libido 

There were no hits according to the search criteria.

Porphyria cutanea tarda 

The prevalence of C282Y homozygosity among patients with porphyria cutanea tarda (PCT) was found to be increased significantly compared with control populations, ranging from 9% to 17% in several studies [108], [109], [110], [111], [112], [113], [114], [115], [116], [117], [118], [119], [120], [121], [122], [123], [124]. No association between PCT and the C282Y polymorphism was found in Italian patients [125]. The association between PCT and the common HFE gene polymorphisms C282Y and H63D is illustrated by a recent meta-analysis, where the odds ratios for PCT were 48 (24–95) in C282Y homozygotes, and 8.1 (3.9–17) in C282Y/H63D compound heterozygotes [126].

The prevalence of C282Y homozygosity in individuals with biochemical iron abnormalities 

There is considerable variation in the cut-off of ferritin and transferrin saturation used for genetic screening of hereditary hemochromatosis (HH).

Serum ferritin 

The prevalence of elevated ferritin varies between 4% and 41% in healthy populations depending on the cut-off and the screening setting (Table 5) [10], [13], [14], [23], [84]. The positive predictive value of an elevated ferritin for detection of C282Y-homozygotes was 1.6–17.6% (Table 5). The frequency of a ferritin concentration above 1000μg/L was 0.2–1.3% in non-selected populations [34], [133].

Table 5. Prevalence of C282Y homozygosity in patients with elevated serum ferritin and transferrin saturation.
AuthorsRef.Study populationPrevalence of C282Y homozygotes among patients with elevated serum ferritinPrevalence of C282Y homozygotes among patients with elevated transferrin saturation (TS)Comments
Prevalence of elevated serum ferritinPrevalence of C282YPrevalence of TS elevationPrevalence of C282Y
Deugnier et al.[23]Cross-sectional, n=9396em76 of 981 (7.5%)21 of 76 (17.6%)70 of 993 (7%)26 of 70 (18%)Health care, young patients; ferritin available for a subgroup only
Olynyk et al.[14]Cross-sectional, n=3011fn405 of 3011 (13.5%)8 of 405 (2%)202 of 3011 (6.7%)15 of 202 (7.4%)Patient selection included persistently elevated TS (45% or higher) or homozygosity for the C282Y mutation
Burt et al.[10]Cross-sectional, n=1064gl42 of 1040 (4.0%)2 of 42 (4.8%)46 of 1040 (4.4%)5 of 46 (10.9%)Voters
Distante et al.[13]Cross-sectional, n=505hl23 of 505 (4.6%)2 of 23 (8.7%)25 of 505 pts (5%)2 of 25 (8%)Health care
McDonnell et al.[127]Cross-sectional, n=1450ioNo dataNo data60 of 1640 (3.7%)13 of 60 (21.7%)HMO employees; only data for TS
Delatycki et al.[128]Cross-sectional, n=11,307No dataNo dataNo dataNo data2 of 47 pts (biopsy in 6 pts) had precirrhotic fibrosis
Adams et al.[129]Cross-sectional, n=5211pNo dataNo data60 of 5211 (1.2%)4 of 60 (6.7%)Blood donors
150 of 5211 (2.9%)9 of 150 (6%)
278 of 5211 (5.3%)12 of 278 (4.3%)
Adams et al.[34]Cross-sectional, n=99,711aqNo dataNo dataNo dataNo dataHEIRS study
Beutler et al.[16]Cross-sectional, n=9650brNo dataNo data67% of males, 39% of females
80% of males, 50% of females
Barton et al.[130]Cross-sectional, n=43,453 caucasianar9299 whites (21.4%)147 of 9299 (1.6%)2976 of 43,453 (6.8%)166 of 2976 (5.6%)
Asberg et al.[131]Cross-sectional, n=65,238mNo dataNo data2.7% of males, 2.5% of females269 of 1698 (15.8%)
Gordeuk et al.[132]Cross-sectional, n=101,168ar2253 of 101,168 (2.2%) 2253 of 101,168 (2.2%)155 of 2253 (6.9%)Primary care combination of TS and ferritin

Ferritin [μg/L] cutoffs: a>300 males and postmenopausal females, >200 females, b>250 males and >200 females, c>300 males and females, d>250 males and >200 females, e>280 males >130 females, f>300 males and females, g>428 males >302 females, h>200 males and females, i95% percentile Transferrin saturation [%] cutoff: k>55: males >45: females, l>50, m>55: males and >50: females, n>45, o>55: males, >60: females, p>54 or >49 or >45, q>55: males >45: females, r>50 overall >45 overall.

Transferrin saturation 

Elevated transferrin saturation was found in 1.2–7% of screened individuals in unselected populations [10], [13], [14], [23], [129], [130], [131] (Table 5). The positive predictive value of elevated transferrin saturation for the detection of C282Y-homozygotes was 4.3–21.7% (Table 5).

Back to Article Outline

What is the penetrance of C282Y homozygosity? 

Differences in inclusion criteria and in the definition of biochemical and disease penetrance have produced a range of estimates for the penetrance of C282Y homozygosity. The disease penetrance of C282Y homozygosity was 13.5% (95% confidence interval 13.4–13.6%) when 19 studies were included in the meta-analysis and the results of individual studies weighted on the inverse variance of the results of the individual study (Fig. 2) [134], [135].

Excess iron 

Although the majority of C282Y homozygotes may have a raised serum ferritin and transferrin saturation, this cannot be relied upon as secure evidence of iron overload. An individual patient data meta-analysis including 1382 C282Y homozygous individuals reported in 16 studies showed that 26% of females and 32% of males have increased serum ferritin concentrations (>200μg/L for females and >300μg/L in males) (Table 6). The prevalence of excess tissue iron (>25μmoles/g liver tissue or increased siderosis score) in 626 C282Y homozygotes who underwent liver biopsy was 52% in females and 75% in males as reported in 13 studies. The higher penetrance of tissue iron overload is due to the selection of patients for liver biopsy, which is more likely to be carried out in patients with clinical or biochemical evidence of iron overload.

Table 6. Data from studies addressing the penetrance of C282Y homozygotes.
AuthorsRef.Study typeC282Y homozygotes (females)Definition of penetrant diseaseAffected individualsPenetranceComments
Burt et al. (1998)[10]Cross-sectional5 (4)Hepatic iron index >1.9 upon liver biopsy360%No liver biopsy in unaffected individuals because of normal serum iron parameters
Distante et al. (1999)[13]Cross-sectional2 (1)Iron removed >5g or HII >1.9 or histological iron grade >2+150%Unaffected patient had Pearl’s stain Grade 2 and HII of 1.7
McDonnell et al. (1999)[127]Cross-sectional4 (3)Iron removed >5g or HII >1.9 or histological iron grade >2+375%One unaffected patient had elevated serum iron parameters
Olynyk et al. (1999)[14]Cross-sectional16 (9)HII >1.9 or histological iron grade >2956.3%Two additional patients had serum ferritin of 1200μg/L and 805μg/L respectively, but did not undergo liver biopsy. Cirrhosis was found in 1 patient, fibrosis in 3 patients, and arthritis in 6 patients
Distante et al. (2000)[136]Cross-sectional & short term follow up14 (9)HII>1.9 or histological iron grade >2 or congestive heart failure+marked and persistent hyperferritinemia and TS >55%321.4%Liver biopsy available only in 5 patients; a total of 5 patients of whom 4 had no biopsy had persistent hyperferritinemia
Bulaj et al. (2000)[137]Cross-sectional – affected individuals184 (48)At least one disease-related condition (cirrhosis, fibrosis, elevated ALT or AST, arthropathy)13774.5%
Cross-sectional – family members214 (101) 3315.4%
Cross-sectional – unselected107 (41) 76.5%
Barton et al. (1999)[138]Cross-sectional – family based25 (n.d.)Cirrhosis or diabetes attributable to iron overload6–2324–79%Ill-defined HC phenotype was present in a total of 23 patients
Beutler et al. (2002)[21]Cross-sectional152 (79)‘liver problems’ (assessed in 124)108.1%Signs and symptoms that would suggest a diagnosis of HC in only one patient
Waalen et al. (2002)[139]Cross-sectional141 (80)Only symptoms and serum iron parameters reported 92 patients had elevated serum ferritin concentrations, disease-associated symptoms were equal in control group and C282Y homozygotes
Deugnier et al. (2002)[23]Cross-sectional54 (44)At least one disease-related symptom (fatigue, arthralgia, diabetes, increased ALT)3564.8%21 patients had increased serum iron parameters
Phatak et al. (2002)[26]Cross-sectional12 (8)Iron removed >5g for males and >3g for females542%Increased serum ferritin in 50% of patients
Poullis et al. (2003)[98]Cross-sectional12 (5)Histological iron grade >2758%Increased serum ferritin in 11 out of 12 patients, but coincidence of significant co-morbidities (HCV and iron in 5 patients)
Olynyk et al. (2004)[140]Longitudinal10 (6)Hepatic iron >25μmol/g660%Gradual increase in TS over 10 year observation – no biopsy in 4 patients
Andersen et al. (2004)[141]Longitudinal23 (16)At least one disease-related condition (cirrhosis, fibrosis, elevated ALT or AST, arthropathy)313.0%Increased serum ferritin in 16 patients
Gleeson et al. (2004)[142]Family based study71 (25)Histological iron grade >3+2636.6%Only 71 out of 209 C282Y homozygote patients who underwent liver biopsy were included
Rossi et al. (2004)[143]Cross-sectional2 00%No clinical symptoms
Delatycki et al. (2005)[128]Cross-sectional51 (26)Disease-associated symptoms4588%45 patients had disease-associated symptoms (tiredness, abdominal pain, joint pain)
Powell et al. (2006)[144]Cross-sectional – family based401 (201)Histological iron grade >212832%At least one disease related condition 17%
Cross-sectional – population based271 (112)Histological iron grade >213550%At least one disease related condition 27%
Asberg et al. (2007)[145]Cross-sectional319 (0)Cirrhosis11–163.4–5%Predicted/calculated penetrance
Allen et al. (2008)[146]Longitudinal203 (108)Serum ferritin >1000μg/L4019.7%In persons homozygous for the C282Y mutation, iron overload-related disease developed in a substantial proportion of men but in a small proportion of women

When all 1382 patients with reported iron parameters were included in the meta-analysis, the penetrance of excess liver iron was then 19% for females and 42% for males.

Clinical penetrance and progression 

Disease penetrance based on symptoms (e.g. fatigue, arthralgia) is difficult to assess due to the non-specific nature and high frequency of such symptoms in control populations [21].

Disease penetrance based on hepatic histology has been studied but is biased by the fact that liver biopsy is usually reserved for patients with a high pre-test likelihood for liver damage. However, these studies give an estimate of disease expression in C282Y homozygotes. Elevated liver enzymes were found in 30% of males in one study [142]. Liver fibrosis was present in 18% of males and 5% in females homozygous for C282Y; cirrhosis was present in 6% of males and 2% of females [66], [144]. A recent meta-analysis concludes that 10–33% of C282Y homozygotes eventually would develop hemochromatosis-associated morbidity [147].

Penetrance is generally higher in male than in female C282Y homozygotes. C282Y homozygotes identified during family screening have a higher risk of expressing the disease (32–35%) when compared with C282Y homozygotes identified during population based studies (27–29%).

Three longitudinal (population screening) studies are available and show disease progression in only a minority of C282Y homozygotes [140], [141], [146]. Available data suggest that up to 38–50% of C282Y homozygotes may develop iron overload, with (as already stated) 10–33% eventually developing hemochromatosis-associated morbidity [147]. The proportion of C282Y homozygotes with iron overload-related disease is substantially higher for men than for women (28% vs. 1%) [146].

The prevalence and predictive value of abnormal serum iron indices for C282Y homozygosity in an unselected population 

Serum iron studies are usually used as the first screening test when hemochromatosis is suspected. The predictive value of screening for serum iron parameters in the general population is highlighted by two studies [131], [145].

The prevalence of persistently increased serum transferrin saturation upon repeated testing was 1% (622 of over 60,000). Of these individuals ∼50% also had hyperferritinemia (342 of 622). Homozygosity for C282Y could be detected in ∼90% of men and ∼75% of women with a persistently elevated transferrin saturation and increased serum ferritin. From a cross-sectional point of view, the disease penetrance of the C282Y/C282Y genotype in this study cohort, defined as the prevalence of liver cirrhosis, was ∼5.0% in men and <0.5% in women [145].

Back to Article Outline

Recommendations for genetic testing: 

General population:

•Genetic screening for HFE-HC is not recommended, because disease penetrance is low and only in few C282Y homozygotes will iron overload progress (1B).Patient populations:

•HFE testing should be considered in patients with unexplained chronic liver disease pre-selected for increased transferrin saturation (1C).

•HFE testing could be considered in patients with:
–Porphyria cutanea tarda (1B).

–Well-defined chondrocalcinosis (2C).

–Hepatocellular carcinoma (2C).

–Type 1 diabetes (2C).


•HFE testing is not recommended in patients with
–Unexplained arthritis or arthralgia (1C).

–Type 2 diabetes (1B).


Back to Article Outline

How should HFE-HC be diagnosed? 

The EASL CPG panel agreed on the following case definition for diagnosis of HFE-HC:

C282Y homozygosity and increased body iron stores with or without clinical symptoms.

The following section will address the genetic tests and tools for assessing body iron stores.

Genetic testing – Methodology 

C282Y homozygosity is required for the diagnosis of HFE-HC, when iron stores are increased (see diagnostic algorithms). Any other HFE genotype must be interpreted with caution. The available methods are reported in Table 7. The intronic variant c.892+48 G>A may complicate amplification refractory mutation system (ARMS) – PCR for genetic testing [183]. The common S65C polymorphism may complicate interpretation of real-time PCR and melting curve analysis tests [184]. Finally, in cis inheritance of rare genetic variants [185] must be considered when gene tests are interpreted.

Table 7. Methods for HFE genotyping.
Method Simultaneous detection of multiple mutationsbf Detection of novel/rare genetic variationsSpecialized equipment requiredAmenable for high throughputRef.
RFLPPCR amplification followed by restriction fragment length polymorphism−−−+/−[148], [149], [150], [151], [152], [153], [154], [155], [156], [157], [158], [159], [160], [161], [162], [163], [164], [165], [166], [167], [168], [169], [170], [171], [172], [173], [174], [175], [176], [177], [178], [179], [180], [181], [182], [183], [184], [185], [186], [187], [188], [189], [190], [191], [192], [193], [194], [195], [196], [197], [198], [199], [200], [201], [202], [203], [204], [205], [206], [207], [208], [209], [210], [211], [212], [213], [214], [215], [216], [217], [218], [219], [220], [221], [222], [223], [224], [225], [226], [227], [228], [229], [230], [231], [232], [233], [234]
Direct sequencingPCR amplification followed by direct sequencing++−−[151], [152], [153], [154]
Allelic discrimination PCRReal time PCR (TaqMan®) with displacing probes and modifications−−+/−+/−[155], [156], [157], [158], [159], [160]
Melting curve analysis(Light Cycler®)+++/−+/−[161], [162]
D-HPLCDenaturing HPLC+++/−+[163]
SSPSequence specific priming PCR−−−+[164], [165], [166], [167], [168], [169], [170]
SPASolid-phase amplification−−−+[171]
SSCPSingle strand conformation polymorphism analysis++−+/−[172], [173]
OLAOligonucleotide ligation assay−−−+[148]
SCAIPSingle-condition amplification with internal primer+/−+/−−+[151]
Advanced read-outMass spectrometry based, capillary electrophoresis, chip basedn/an/an/a+[174], [175], [176], [177], [178], [179]
Reverse hybridization assayMultiplex PCR amplification followed by reverse hybridizationn/an/an/a+[21], [150], [180], [181]
Novel extraction methodsDried blood spots, whole-blood PCRn/an/an/a++[38], [158], [182]

Sequencing of the HFE gene in C282Y heterozygotes presenting with a phenotype compatible with hemochromatosis has revealed the existence of other rare HFE mutations. Among these, the S65C mutation has been more intensively studied [56]. It may contribute – but only when inherited in trans with the C282Y mutation – to the development of mild iron overload with no clinical expression in the absence of co-morbid factors.

Homozygosity for H63D is not a sufficient genetic cause of iron overload and when H63D homozygosity is found in association with hyperferritinemia, co-morbid factors are usually present and do not reflect true iron overload [186]. In a population based study of blood donors, homozygosity for H63D was associated with higher transferrin saturation [187].

In rare selected pedigrees, private mutations have also been reported (V59M [188], R66C [163], G93R, I105T [154], [188], E168Q [181], R224G [163], E277K & V212V [189], and V295A [27]) as well as intronic HFE variant frame shift mutations c.340+4 T>C (also referred to as IVS2, T-C +4) [190], c.1008+1 G>A (also referred to as IVS5+1G/A) [153], and c.471del [152]. Some of these may result in a severe HC phenotype when present in the homozygous state [153] or in the compound heterozygote state with C282Y [191], [192].

In C282Y heterozygotes with mildly increased iron stores, compound heterozygosity with other HFE variants including H63D and S65C have been reported [56], [193], [194], [195].

Increased body iron stores 

Serum ferritin 

The most widely used biochemical surrogate for iron overload is serum ferritin. According to validation studies where body iron stores were assessed by phlebotomy, serum ferritin is a highly sensitive test for iron overload in hemochromatosis [21]. Thus, normal serum concentrations essentially rule out iron overload. However, ferritin suffers from low specificity as elevated values can be the result of a range of inflammatory, metabolic, and neoplastic conditions such as diabetes mellitus, alcohol consumption, and hepatocellular or other cell necrosis.

Serum iron concentration and transferrin saturation do not quantitatively reflect body iron stores and should therefore not be used as surrogate markers of tissue iron overload.

Therefore, in clinical practice, hyperferritinemia may be considered as indicative of iron overload in C282Y homozygotes in the absence of the confounding factors listed above.

Imaging 

Magnetic resonance imaging (MRI): The paramagnetic properties of iron have been exploited to detect and quantify iron by MRI. The ‘gradient recalled echo techniques’ are sensitive when using a well-calibrated 1.5Tesla device. There is an excellent inverse correlation between MRI signal and biochemical hepatic iron concentration (HIC) (correlation coefficient: −0.74 to −0.98) allowing for the detection of hepatic iron excess within the range 50–350μmol/g with a 84–91% sensitivity and a 80–100% specificity according to cut-off levels of HIC ranging from 37 to 60μmol/gwt [196], [197], [198]. MRI may also help to (i) identify heterogeneous distribution of iron within the liver, (ii) differentiate parenchymal (normal splenic signal and low hepatic, pancreatic, and cardiac signals) from mesenchymal (decreased splenic signal) iron overload, and (iii) detect small iron-free neoplastic lesions. However, only a few patients with HFE-proven HC were studied [197].

Superconducting quantum interference device (SQUID) susceptometer: The SQUID susceptometer allows for in vivo measurement of the amount of magnetization due to hepatic iron. Results are quantitatively equivalent to biochemical determination on tissue obtained by biopsy. However, the device was not specifically validated in HFE-HC patients. In addition, it is not widely available, which restricts its use in clinical routine [199], [200], [201].

Liver biopsy 

Liver biopsy used to be the gold standard for the diagnosis of HC before HFE genotyping became available. Now that this is readily available, homozygosity for C282Y in patients with increased body iron stores with or without clinical symptoms is sufficient to make a diagnosis of HFE-HC.

Where there is hyperferritinemia with confounding cofactors, liver biopsy may still be necessary to show whether iron stores are increased or not [98]. Liver biopsy still has a role in assessing liver fibrosis. The negative predictive value of serum ferritin <1000μg/L and normal AST in absence of hepatomegaly for the presence of severe fibrosis or cirrhosis averaged 95% [202], [203].

Serum hyaluronic acid is reported to correlate with the degree of hepatic fibrosis in HC, and if validated may provide an alternative approach to liver biopsy for the diagnosis of advanced fibrosis [204]. Transient elastography can also be helpful for determination of advanced fibrosis and cirrhosis [205].

Amount of iron removed 

The total number of phlebotomies required to achieve low concentrations of serum ferritin may be a useful retrospective surrogate marker for the excess body iron stores in HFE-HC. The assumption that 1L of blood contains 0.5g of iron allows for an estimate of the amount of iron removed by phlebotomies. This broadly correlates with pre-therapeutic hepatic iron concentration. Allowing for the amount of absorbed iron during therapy and taking into account the initial and post-therapeutic haemoglobin levels improves the reliability of the calculation, especially when the interval between phlebotomies exceeds one week [203].

Family screening 

Siblings of patients with HFE-related HC must undergo screening, since they have a 25% chance of being susceptible. Serum ferritin, and transferrin saturation should be assessed. Ideally HFE mutation analysis should be encouraged after appropriate counseling with regard to the pros and cons of testing (mortgage, insurance issues).

Whether they are screened with the above procedure depends upon their age, health status, and the attitude of the family.

Individuals who are C282Y homozygotes, or have HFE-related HC, frequently ask for advice on the evaluation of the susceptibility of their children who are often younger than the age of consent. In this situation, HFE genotyping of the unaffected spouse is valuable [206], so that the likelihood of genetic susceptibility and thus the need for testing of children later in life can be established.

Back to Article Outline

Recommendations for the diagnosis of HFE-HC: 


•Patients with suspected iron overload should first receive measurement of fasting transferrin saturation and serum ferritin (1B), and HFE testing should be performed only in those with increased transferrin saturation (1A).

•Patients from liver clinics should be screened for fasting transferrin saturation and serum ferritin (1C) and offered genetic HFE testing if transferrin saturation is increased (1B).

•HFE testing for the C282Y and H63D polymorphism should be carried out in all patients with otherwise unexplained increased serum ferritin and increased transferrin saturation (1B).

•Diagnosis of HFE hemochromatosis should not be based on C282Y homozygosity alone, but requires evidence of increased iron stores (1B).

•C282Y/H63D compound heterozygotes and H63D homozygotes presenting with increased serum ferritin (>200μg/L in females, >300μg/L in males), increased transferrin saturation (>45% in females, >50% in males) or increased liver iron should first be investigated for other causes of hyperferritinemia (1C).

•In C282Y homozygote patients with increased iron stores, liver biopsy is no longer necessary to diagnose hemochromatosis. Liver biopsy could be offered to C282Y homozygous patients with serum ferritin above 1000μg/L, elevated AST, hepatomegaly, or age over 40 years (1C).

•Genetic testing of ‘other hemochromatosis genes’ (TFR2, SLC40A1, HAMP, HJV) could be considered in patients with increased iron stores after exclusion of C282Y homozygosity if (i) iron excess has been proven by direct assessment, i.e. by MRI or liver biopsy, and (ii) other hepatic and haematological disorders have been ruled out (2C).

•According to the autosomal recessive transmission of HFE-HC, genetic testing of siblings of individuals with HFE-HC should be carried out. Genetic testing of other 1st degree relatives should be considered (1B). (Practical and cost effective strategies for family screening have been published [206].)

Back to Article Outline

Which strategy should be used to diagnose HFE-HC? 

To outline a diagnostic strategy in patients with suspected HC, several clinical scenarios for patients who should be investigated for HFE-HC have been selected. The following section will discuss a practical diagnostic approach to patients with suspected iron overload.

In contrast to the previous sections, where evidence based recommendations were made, this section is based on the expert opinion of the EASL CPG panelists (Y.D., J.D., A.E., A.P., R.S., H.Z.).

Suggestive symptoms and signs 

In patients with symptoms or signs suggestive of HC (unexplained liver disease, chondrocalcinosis, type 1 diabetes, arthralgia, HCC, cardiomyopathy, or porphyria cutanea tarda) serum iron parameters should be determined. If any of these symptoms is related to HC or iron overload, they will be associated with increased serum ferritin concentrations and diagnostic work-up should be carried out as described below.

Hyperferritinemia 

In patients presenting with increased serum ferritin concentrations, it is mandatory to search for common causes of hyperferritinemia before genetic tests are carried out (Fig. 3). It is estimated that in over 90% of outpatients with hyperferritinemia, one of the following causes can be identified: chronic alcohol consumption, inflammation (check for CRP), cell necrosis (check for AST, ALT and CK), tumors (ESR, CT scan), and non-alcoholic fatty liver disease (NAFLD) and/or the metabolic syndrome (check for blood pressure, BMI, cholesterol, triglycerides, and serum glucose). In the absence of such conditions or when hyperferritinemia persists despite treatment of another potential underlying cause, transferrin saturation (TS) should be determined. After confirmation of TS elevation, HFE genotyping should be done.

If the patient is a C282Y homozygote, the diagnosis of HFE-HC can be established. For all other genotypes, confounding cofactors, compensated iron loading anemia, or non-HFE hemochromatosis should be considered. If other factors are suspected, molecular analysis for rare HFE, HJV, HAMP, and TFR2 mutations can be undertaken, with the genetic focus selected according to the clinical, laboratory, and pathological features. Patients with compound heterozygosity for the C282Y and the H63D usually present with mild iron overload, which is associated with comorbid factors such as obesity, NAFLD, chronic alcohol consumption, and end-stage cirrhosis.

If the transferrin saturation is either normal or low, the presence or absence of iron overload will guide further diagnostic work-up. Assessment of liver iron stores by direct means (i.e. MRI or liver biopsy) is recommended. If liver iron concentration is increased, iron overload related to alcohol consumption or to metabolic abnormalities should be considered before genetic testing for non-hemochromatotic genetic iron overload diseases is carried out (ferroportin disease, aceruloplasminemia).

If liver iron concentration is normal, the common causes of hyperferritinemia should be reconsidered before genetic testing for l-ferritin gene mutations (to investigate the hyperferritinemia-cataract syndrome).

In patients with an unclear presentation, family members should be evaluated for the evidence of iron overload, and/or the exact amount of iron removed by phlebotomy should be calculated before rare genetic disorders are tested for by candidate gene sequencing and linkage analysis by a research laboratory.

C282Y homozygosity 

If an individual is found to be homozygous for C282Y, management is guided by the serum ferritin concentration (Fig. 4). If the serum ferritin concentration is normal, follow-up once a year is proposed. If the serum ferritin is elevated, initial evaluation should include fasting blood glucose, serum AST, and ALT activity. Further tests should be ordered according to the clinical features (liver scanning, ECG, echocardiography, gonadotropic hormones). For the staging of liver fibrosis, liver biopsy should be considered in patients with serum ferritin >1000μg/L, unless cirrhosis is obvious upon scanning.

Documented tissue iron overload (liver biopsy or MRI) 

In patients displaying hepatic iron deposition in their liver biopsy, further diagnostic considerations depend on the cellular and lobular distribution of iron and on the presence or absence of associated findings including fibrosis, steatosis, steatohepatitis, abnormal crystal inclusions, and chronic hepatitis (Fig. 5). In patients with pure parenchymal (i.e. hepatocellular) iron overload, the two main differential diagnoses are: (i) early HC in the absence of cirrhosis after excluding compensated iron loading anemia; and (ii) end-stage cirrhosis in which iron distribution is heterogeneous from one nodule to the next, and there are no iron deposits in fibrous tissues, biliary walls, or vascular walls. In patients with mesenchymal or mixed iron overload, the correct diagnosis can be suggested according to the type of associated lesions.

Back to Article Outline

How should HFE-HC be managed? 

There are very few data on the threshold of tissue iron excess at which tissue damage is seen. A study of the degree of lipid peroxidation has been done in treated and untreated HC patients, as well as in heterozygotes, suggesting changes at low levels of iron loading [207]; however, this study has not been confirmed. The relationship between liver iron concentration [208], serum ferritin (>1000μg/L) [202], and hepatic damage do not help define when the treatment of iron overload should begin. Another marker of toxicity and tissue damage may be non-transferrin bound (ie. free or labile) plasma iron because of its potential for catalyzing the generation of reactive oxygen species in vivo [209].

How to manage iron overload in HFE-HC 

How should HFE-HC be treated? 

Three approaches have been used to remove excess iron. None have undergone randomized controlled trials. Phlebotomy is the mainstay of treatment. Iron chelators are avaliable and can be an option in patients who are intolerant or when phlebotomy is contraindicated. Erythrocytophoresis has been reported in treatment of HC, but is not widely practiced.

There are no studies addressing survival in genotyped C282Y homozygous HC patients. The benefit of phlebotomy has been demonstrated by case series of clinically diagnosed HC, and benefit shown by comparison with historical groups of patients not treated with phlebotomy [210], or inadequately treated with phlebotomy [211], based on measures of iron depletion. In the latter study, Kaplan–Meier analysis of survival at 5 years was 93% for adequately phlebotomized patients, compared to 48% for inadequately phlebotomized patients (10 year survival 78% vs. 32%).

There are studies on clinical and histopathological improvement by phlebotomy: two of these studies included HFE genotyped patients [212], [213]. Fatigue, elevated transaminases, and skin pigmentation improved [214]. Milman et al. [211] reported improvement in the stage of fibrosis on repeat liver biopsy in 15–50% of patients. In another study this was found in all cases (except when cirrhosis was present) [213]. Falize et al. [212] reported improvement in the METAVIR fibrosis score in 35–69% of cases depending upon the initial fibrosis score. In cirrhotic patients, improvement in or resolution of esophageal varices has also been reported [215].

It is recognized, however, that several clinical features are unlikely to improve with iron depletion, in particular arthralgia [211], [214]. Improvement in endocrinological disorders, including diabetes mellitus, and cardiological abnormalities varies, likely related to the degree of tissue/organ damage at the start of treatment.

The benefit of iron depletion by phlebotomy has therefore been established, despite the absence of randomized controlled trials, and is the accepted standard of care. Phlebotomy is well tolerated by patients [216] and the majority of patients comply with treatment [217]. Long-term unwanted effects of venesection have not been reported.

There are no studies providing data to direct the optimal time at which to start venesection. Current recommendations of when to initiate treatment are empirical. Survival of treated patients without cirrhosis and diabetes has been found to be equivalent to that of the normal population, whereas those with these complications have a significantly reduced survival [211], [214]. These data emphasize the early initiation of iron removal. The threshold of serum ferritin at which to start treatment is currently taken as above the normal range. There are no studies from which to give an evidence base to the protocol of therapeutic venesection (i.e. frequency, endpoint).

How to monitor HFE-HC: 

Based on empirical and clinical experience, haemoglobin and haematocrit should be monitored at the time of each venesection. If anemia is detected, phlebotomy should be postponed until the anemia is resolved.

Serum ferritin is measured and is sufficient to monitor iron depletion. The frequency of measurements depends upon the absolute concentration. When ferritin levels are high, measurement is required less frequently (every 3 months or so); however, as ferritin approaches the normal range, measurements should become more frequent.

Endpoint of therapeutic phlebotomy: 

There is no evidence base on which to direct the endpoint of therapeutic phlebotomy. The recommendations that exist are based upon (i) a theoretical argument that maintains it is necessary to achieve iron deficiency in order to lower tissue iron levels to normal, and (ii) that a stated target is better than a statement of ‘to normal’, which would likely lead to variable interpretation and practice. The standard clinical practice is to achieve a target of serum ferritin that is less than 50μg/L.

Maintenance therapy 

There are no data from which to base the optimal treatment regimen and target serum iron indices. Once iron depletion has been achieved, the aim is to prevent re-accumulation. The advocated standard practice is to maintain the serum ferritin at 50–100μg/L. This is usually achieved with 3–6 months of venesection.

Patients may be offered the alternative approach of ceasing venesection with monitoring of serum ferritin, with the reinstitution of a short therapeutic program when the serum ferritin reaches the upper limit of the normal range [218].

After therapeutic phlebotomy, some patients may not show re-accumulation of iron at the expected rate. Some are taking proton pump inhibitors, which have been reported to be associated with reduced iron absorption and a reduced requirement for venesection [219]. Others may be on prescribed non-steroidal anti-inflammatory drugs. However, in older patients it is necessary to be alert to conditions that may lead to iron loss, such as peptic ulcers, colonic disease, and hematuria, which will need appropriate investigation.

Diet 

There are no studies proving that dietary interventions and avoidance of dietary iron have an additional beneficial effect on the outcome in patients undergoing venesection. Although diets avoiding excess iron have been discussed, this panel considers that the important issue is maintaining a broadly healthy diet. Iron containing vitamin preparations and iron supplemented foods such as breakfast cereals should be avoided. Compliance with phlebotomy will prevent iron overload.

Tea drinking has been reported as possibly reducing the increase in iron stores in HC patients [220], but this finding was not confirmed in a subsequent study [221]. Non-citrus fruit intake has also been reported to be associated with a lower serum ferritin, but whether this truly reflects a biological effect on iron stores has not been shown [221].

Vitamin C has been reported to be potentially toxic in patients with iron overload [222]. However, there are no articles on the effect of vitamin C on iron absorption or iron stores in HFE-HC. A single case report in a genetically uncharacterized HC patient in whom vitamin C could have had a negative effect on cardiac function [223], has led to the recommendation that it is prudent to limit ingestion of vitamin C supplements to 500mg/day [224].

As in many liver diseases, excess alcohol ingestion leads to increased hepatic damage in HFE-HC [225]. In addition, recent experimental studies show suppression of hepatic hepcidin expression by alcohol in experimental models [226]. This could account for the observation that there is a linear correlation between alcohol intake and serum iron indices and increased iron absorption in alcoholics [227], [228], [229].

Pregnancy 

A normal full term pregnancy removes around 1g of iron from the mother [230]. Iron supplements should not be given routinely to pregnant women with HFE-related HC. Serum ferritin should be monitored. Iron deficiency should be treated according to the usual guidelines applied to pregnancy. If the ferritin is high, therapeutic phlebotomy should be deferred until the end of pregnancy unless there are cardiac or hepatic issues, in which case the appropriate specialist should be involved in the discussion of the positive and negative effects of treatment.

How to manage tissue/organ damage 

Cirrhosis (US, AFP, transplant): It is important to define whether or not the patient with HFE-HC has cirrhosis. In newly recognized affected patients liver biopsy is recommended in order to assess liver architecture when serum ferritin >1000μg/L. Transient elastography is a non-invasive tool that can be helpful for the determination of advanced fibrosis and liver cirrhosis [205].

HFE-HC patients with cirrhosis have a 100-fold greater chance of developing HCC than the normal population [214]. As in cases of cirrhosis from other causes (e.g. hepatitis C and B), screening to detect an early tumor is recommended using ultrasound examination and serum alpha fetoprotein measurement every 6 months. Despite some case reports of HCC in non-cirrhotic HC patients, this is very rare, and screening for HCC is not considered necessary in this group.

Hepatic decompensation with ascites, spontaneous bacterial peritonitis, encephalopathy, variceal haemorrhage, and early small tumor formation may require assessment for liver transplantation.

Early reports on the outcome of HFE-HC after liver transplantation for HFE-HC [59], [231], [232] have found that survival may be lower than in other groups. Survival for transplant patients is around 64% after 1 year, and 34% after 5 years [231]. Reduced survival compared to other aetiological groups was considered to be related to iron overload; few patients had iron depletion prior to transplantation. Causes of death were heart disease, infection, and malignancy [231].

Diabetes mellitus: Improvement in glucose control may occur during phlebotomy treatment, but insulin dependency is not reversed [214]. Diabetes mellitus is managed in the same way as for other patients with diabetes.

Arthralgia, arthritis: Physical and radiological evaluation is necessary. Unfortunately it is unusual for symptoms to be alleviated by phlebotomy treatment. Symptoms, such as joint destruction, often progress.

Anti-inflammatory agents are often ineffective but can be used. Podiatric assessment is valuable with use of insoles in shoes to help with foot pain. Joint replacement (hip and knee) may be necessary.

Cardiac disease: Although cardiac failure is a recognized complication of severe iron overload, it is clinically unusual (except in patients with juvenile HC). Electrocardiographic abnormalities have been reported in one third of patients [214], and in one third of these, there is improvement with phlebotomy.

However, any cardiac symptoms should be investigated by the cardiologist, if needed by electrocardiogram (ECG), echocardiography, and 24h ambulatory ECG monitoring. There is no recognized ferritin level above which cardiac assessment is recommended.

Endocrine disease: Hypothyroidism has been reported in 10% of males with HC [233]. Hypogonadism with loss of potency is a recognized complication [214]. Thus the clinical history of patients with these symptoms should be obtained, and thyroid function tests and serum testosterone levels monitored.

Osteoporosis: Patients with HC are at risk of osteoporosis, and should undergo a DEXA scan and receive appropriate routine advice or treatment for osteoporosis if diagnosed [234].

Back to Article Outline

Recommendations for the management of HFE-HC: 


•Patients with HFE-HC and evidence of excess iron should be treated with phlebotomy (1C).

•C282Y homozygotes without evidence for iron overload could be monitored annually and treatment instituted when the ferritin rises above normal (2C).

•Phlebotomy should be carried out by removing 400–500ml of blood (200–250mg iron) weekly or every two weeks. Adequate hydration before and after treatment, and avoidance of vigorous physical activity for 24h after phlebotomy is recommended (1C).

•Phlebotomy can be carried out also in patients with advanced fibrosis or cirrhosis (2C).

•Before the initiation of phlebotomy, patients with HFE-HC should be assessed for complications including diabetes mellitus, joint disease, endocrine deficiency (hypothyroidism), cardiac disease, porphyria cutanea tarda, and osteoporosis (1C).

•Complications of HFE-HC (liver cirrhosis, diabetes, arthropathy, hypogonadism, PCT) should be managed regardless of whether or not HC is the underlying cause and whether there is symptomatic relief or improvement during phlebotomy (1C).

•To minimize the risk of additional complications, patients with HFE-HC could be immunized against hepatitis A and B while iron overloaded (2C).

Back to Article Outline

Patient organizations, use of blood from phlebotomy, reimbursement policies and fee exemptions 

Patient organizations 

The European Federation of Associations of Patients with Hemochromatosis (EFAPH) federates national European patient organizations. Its mission is to provide information for HC patients and their relatives, to raise public awareness, and to improve the quality of care for HC patients through the support of basic and clinical research (http://www.european-haemochromatosis.eu/index2.html).

Genetic testing 

Measures must be put in place to avoid discrimination of HC patients. In accordance with legal regulations in most countries, genetic testing for HFE-HC should only be carried out after informed consent has been obtained and the results should be made available only to the patient and physicians involved in the management of HFE-HC.

The use of blood 

Blood taken from patients with HFE-HC at phlebotomy should be made available for national blood transfusion services for the public good, if there is no medical contraindication and the patient has given consent. It is recognized that many patients with HFE-HC will have clinical features that exclude them from being accepted as donors (elevated liver function tests, diabetes, medications). But in the absence of these, there appears to be no medical reason, other than administrative and bureaucratic, for why the blood taken may not be used. In Europe, the fact that the blood is being taken for therapeutic reasons should not be a hindrance to its utilization.

A recent survey of EFAPH has shown that regulations for the use of blood obtained from venesection vary within Europe and even within some countries (Germany, Portugal, UK, Norway, and Italy). In Ireland and France, blood from patients with HFE-HC can be used for transfusion purposes under the appropriate medical circumstances. In France, blood donation is not forbidden in patients with HC although not explicitly permitted. According to this survey of the EFAPH, which only covered some parts of Europe, the use of blood from therapeutic venesection of HC patients is explicitly forbidden in some countries (Austria, Hungary, Iceland, Italy, The Netherlands, and Spain). The EASL CPG board for HFE-HC advocates the use of blood for therapeutic phlebotomomy (where there are no medical contraindications) for transfusion.

Fee exemptions and reimbursement policies 

HFE-HC is a significant cause of liver disease and phenotypic testing for HC should be offered to all individuals suspected to suffer from iron overload or patients who are at risk for the development of the disease. Genetic testing for HFE-HC is not paid for in most countries; however, in some, such as France, it is reimbursed. The EASL CPG board on HC advocates full reimbursement of phenotypic and, where indicated, genetic testing for HFE-HC.

According to the EFAPH survey, reimbursement for the treatment is also highly variable across Europe and even varies within countries, where reimbursement may depend on where the treatment is carried out. The EASL CPG board on HC advocates full reimbursement for treatment of HFE-HC both in the therapeutic and the maintenance phase of therapy.

Back to Article Outline

Contributors 

Clinical Practice Guidelines Panel: Antonello Pietrangelo, Yves Deugnier, James Dooley, Andreas Erhardt, Heinz Zoller, Rifaat Safadi.

Reviewers: Bruce Bacon, John Crowe, Claus Niederau.

Back to Article Outline

Financial disclosures 

Heinz Zoller has received lecture fees from Novartis. Claus Niederau has received research funding and consultancy fees from Novartis. All other contributors and reviewers declare they have nothing to disclose.

Back to Article Outline

References 

  1. Feder JN, Gnirke A, Thomas W, Tsuchihashi Z, Ruddy DA, Basava A, et al. A novel MHC class I-like gene is mutated in patients with hereditary haemochromatosis. Nat Genet. 1996;13:399–408
  2. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336:924–926
  3. Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter Y, Schunemann HJ. What is ‘quality of evidence’ and why is it important to clinicians?. BMJ. 2008;336:995–998
  4. Guyatt GH, Oxman AD, Kunz R, Jaeschke R, Helfand M, Liberati A, et al. Incorporating considerations of resources use into grading recommendations. BMJ. 2008;336:1170–1173
  5. Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE, Liberati A, et al. Going from evidence to recommendations. BMJ. 2008;336:1049–1051
  6. Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, et al. Grading quality of evidence and strength of recommendations. BMJ. 2004;328:1490
  7. Beckman LE, Saha N, Spitsyn V, Van Landeghem G, Beckman L. Ethnic differences in the HFE codon 282 (Cys/Tyr) polymorphism. Hum Hered. 1997;47(5):263–267
  8. Merryweather-Clarke AT, Pointon JJ, Shearman JD, Robson KJ. Global prevalence of putative haemochromatosis mutations. J Med Genet. 1997;34(4):275–278
  9. Datz C, Lalloz MR, Vogel W, Graziadei I, Hackl F, Vautier G, et al. Predominance of the HLA-H Cys282Tyr mutation in Austrian patients with genetic haemochromatosis. J Hepatol. 1997;27(5):773–779
  10. Burt MJ, George PM, Upton JD, Collett JA, Frampton CM, Chapman TM, et al. The significance of haemochromatosis gene mutations in the general population: implications for screening. Gut. 1998;43:830–836
  11. Jouanolle AM, Fergelot P, Raoul ML, Gandon G, Roussey M, Deugnier Y, et al. Prevalence of the C282Y mutation in Brittany: penetrance of genetic hemochromatosis?. Ann Genet. 1998;41(4):195–198
  12. Merryweather-Clarke AT, Simonsen H, Shearman JD, Pointon JJ, Norgaard-Pedersen B, Robson KJ. A retrospective anonymous pilot study in screening newborns for HFE mutations in Scandinavian populations. Hum Mutat. 1999;13(2):154–159
  13. Distante S, Berg JP, Lande K, Haug E, Bell H. High prevalence of the hemochromatosis-associated Cys282Tyr HFE gene mutation in a healthy Norwegian population in the city of Oslo, and its phenotypic expression. Scand J Gastroenterol. 1999;34:529–534
  14. Olynyk JK, Cullen DJ, Aquilia S, Rossi E, Summerville L, Powell LW. A population-based study of the clinical expression of the hemochromatosis gene. N Engl J Med. 1999;341:718–724
  15. Marshall DS, Linfert DR, Tsongalis GJ. Prevalence of the C282Y and H63D polymorphisms in a multi-ethnic control population. Int J Mol Med. 1999;4(4):389–393
  16. Beutler E, Felitti V, Gelbart T, Ho N. The effect of HFE genotypes on measurements of iron overload in patients attending a health appraisal clinic. Ann Intern Med. 2000;133(5):329–337
  17. Steinberg KK, Cogswell ME, Chang JC, Caudill SP, McQuillan GM, Bowman BA, et al. Prevalence of C282Y and H63D mutations in the hemochromatosis (HFE) gene in the United States. JAMA. 2001;285(17):2216–2222
  18. Andrikovics H, Kalmar L, Bors A, Fandl B, Petri I, Kalasz L, et al. Genotype screening for hereditary hemochromatosis among voluntary blood donors in Hungary. Blood Cells Mol Dis. 2001;27(1):334–341
  19. Pozzato G, Zorat F, Nascimben F, Gregorutti M, Comar C, Baracetti S, et al. Haemochromatosis gene mutations in a clustered Italian population: evidence of high prevalence in people of Celtic ancestry. Eur J Hum Genet. 2001;9(6):445–451
  20. Byrnes V, Ryan E, Barrett S, Kenny P, Mayne P, Crowe J. Genetic hemochromatosis, a Celtic disease: is it now time for population screening?. Genet Test. 2001;5(2):127–130
  21. Beutler E, Felitti VJ, Koziol JA, Ho NJ, Gelbart T. Penetrance of 845G→A (C282Y) HFE hereditary haemochromatosis mutation in the USA. Lancet. 2002;359:211–218
  22. Guix P, Picornell A, Parera M, Galmes A, Obrador A, Ramon MM, et al. Distribution of HFE C282Y and H63D mutations in the Balearic Islands (NE Spain). Clin Genet. 2002;61(1):43–48
  23. Deugnier Y, Jouanolle AM, Chaperon J, Moirand R, Pithois C, Meyer JF, et al. Gender-specific phenotypic expression and screening strategies in C282Y-linked haemochromatosis: a study of 9396 French people. Br J Haematol. 2002;118:1170–1178
  24. Cimburova M, Putova I, Provaznikova H, Horak J. Hereditary hemochromatosis: detection of C282Y and H63D mutations in HFE gene by means of guthrie cards in population of Czech Republic. Genet Epidemiol. 2002;23(3):260–263
  25. Van Aken MO, De Craen AJ, Gussekloo J, Moghaddam PH, Vandenbroucke JP, Heijmans BT, et al. No increase in mortality and morbidity among carriers of the C282Y mutation of the hereditary haemochromatosis gene in the oldest old: the Leiden 85-plus study. Eur J Clin Invest. 2002;32(10):750–754
  26. Phatak PD, Ryan DH, Cappuccio J, Oakes D, Braggins C, Provenzano K, et al. Prevalence and penetrance of HFE mutations in 4865 unselected primary care patients. Blood Cells Mol Dis. 2002;29(1):41–47
  27. Jones DC, Young NT, Pigott C, Fuggle SV, Barnardo MC, Marshall SE, et al. Comprehensive hereditary hemochromatosis genotyping. Tissue Antigens. 2002;60:481–488
  28. Candore G, Mantovani V, Balistreri CR, Lio D, Colonna-Romano G, Cerreta V, et al. Frequency of the HFE gene mutations in five Italian populations. Blood Cells Mol Dis. 2002;29(3):267–273
  29. Salvioni A, Mariani R, Oberkanins C, Moritz A, Mauri V, Pelucchi S, et al. Prevalence of C282Y and E168X HFE mutations in an Italian population of Northern European ancestry. Haematologica. 2003;88(3):250–255
  30. Papazoglou D, Exiara T, Speletas M, Panagopoulos I, Maltezos E. Prevalence of hemochromatosis gene (HFE) mutations in Greece. Acta Haematol. 2003;109(3):137–140
  31. Sanchez M, Villa M, Ingelmo M, Sanz C, Bruguera M, Ascaso C, et al. Population screening for hemochromatosis: a study in 5370 Spanish blood donors. J Hepatol. 2003;38(6):745–750
  32. Mariani R, Salvioni A, Corengia C, Erba N, Lanzafame C, De Micheli V, et al. Prevalence of HFE mutations in upper Northern Italy: study of 1132 unrelated blood donors. Dig Liver Dis. 2003;35(7):479–481
  33. Altes A, Ruiz A, Barcelo MJ, Remacha AF, Puig T, Maya AJ, et al. Prevalence of the C282Y, H63D, and S65C mutations of the HFE gene in 1146 newborns from a region of Northern Spain. Genet Test. 2004;8(4):407–410
  34. Adams PC, Reboussin DM, Barton JC, McLaren CE, Eckfeldt JH, McLaren GD, et al. Hemochromatosis and iron-overload screening in a racially diverse population. N Engl J Med. 2005;352:1769–1778
  35. Barry E, Derhammer T, Elsea SH. Prevalence of three hereditary hemochromatosis mutant alleles in the Michigan Caucasian population. Community Genet. 2005;8(3):173–179
  36. Meier P, Schuff-Werner P, Steiner M. Hemochromatosis gene HFE Cys282Tyr mutation analysis in a cohort of Northeast German hospitalized patients supports assumption of a North to South allele frequency gradient throughout Germany. Clin Lab. 2005;51(9-10):539–543
  37. Matas M, Guix P, Castro JA, Parera M, Ramon MM, Obrador A, et al. Prevalence of HFE C282Y and H63D in Jewish populations and clinical implications of H63D homozygosity. Clin Genet. 2006;69(2):155–162
  38. Hoppe C, Watson RM, Long CM, Lorey F, Robles L, Klitz W, et al. Prevalence of HFE mutations in California newborns. Pediatr Hematol Oncol. 2006;23(6):507–516
  39. Aranda N, Viteri FE, Fernandez-Ballart J, Murphy M, Arija V. Frequency of the hemochromatosis gene (HFE) 282C→Y, 63H→D, and 65S→C mutations in a general Mediterranean population from Tarragona, Spain. Ann Hematol. 2007;86(1):17–21
  40. Terzic R, Sehic A, Teran N, Terzic I, Peterlin B. Frequency of HFE gene mutations C282Y and H63D in Bosnia and Herzegovina. Coll Antropol. 2006;30(3):555–557
  41. Floreani A, Rosa Rizzotto E, Basso D, Navaglia F, Zaninotto M, Petridis I, et al. An open population screening study for HFE gene major mutations proves the low prevalence of C282Y mutation in Central Italy. Aliment Pharmacol Ther. 2007;26(4):577–586
  42. Raszeja-Wyszomirska J, Kurzawski G, Suchy J, Zawada I, Lubinski J, Milkiewicz P. Frequency of mutations related to hereditary haemochromatosis in northwestern Poland. J Appl Genet. 2008;49(1):105–107
  43. Jazwinska EC, Cullen LM, Busfield F, Pyper WR, Webb SI, Powell LW, et al. Haemochromatosis and HLA-H. Nat Genet. 1996;14(3):249–251
  44. Jouanolle AM, Gandon G, Jezequel P, Blayau M, Campion ML, Yaouanq J, et al. Haemochromatosis and HLA-H. Nat Genet. 1996;14(3):251–252
  45. Beutler E, Gelbart T, West C, Lee P, Adams M, Blackstone R, et al. Mutation analysis in hereditary hemochromatosis. Blood Cells Mol Dis. 1996;22(2):187–194discussion 194a–194b
  46. Borot N, Roth M, Malfroy L, Demangel C, Vinel JP, Pascal JP, et al. Mutations in the MHC class I-like candidate gene for hemochromatosis in French patients. Immunogenetics. 1997;45(5):320–324
  47. Carella M, D’Ambrosio L, Totaro A, Grifa A, Valentino MA, Piperno A, et al. Mutation analysis of the HLA-H gene in Italian hemochromatosis patients. Am J Hum Genet. 1997;60(4):828–832
  48. Willis G, Jennings BA, Goodman E, Fellows IW, Wimperis JZ. A high prevalence of HLA-H 845A mutations in hemochromatosis patients and the normal population in eastern England. Blood Cells Mol Dis. 1997;23(2):288–291
  49. The UK Haemochromatosis Consortium. A simple genetic test identifies 90% of UK patients with haemochromatosis. Gut 1997;41(6):841–4.
  50. Press RD, Flora K, Gross C, Rabkin JM, Corless CL. Hepatic iron overload: direct HFE (HLA-H) mutation analysis vs quantitative iron assays for the diagnosis of hereditary hemochromatosis. Am J Clin Pathol. 1998;109(5):577–584
  51. Cardoso EM, Stal P, Hagen K, Cabeda JM, Esin S, de Sousa M, et al. HFE mutations in patients with hereditary haemochromatosis in Sweden. J Intern Med. 1998;243(3):203–208
  52. Sanchez M, Bruguera M, Bosch J, Rodes J, Ballesta F, Oliva R. Prevalence of the Cys282Tyr and His63Asp HFE gene mutations in Spanish patients with hereditary hemochromatosis and in controls. J Hepatol. 1998;29(5):725–728
  53. Ryan E, O’Keane C, Crowe J. Hemochromatosis in Ireland and HFE. Blood Cells Mol Dis. 1998;24(4):428–432
  54. Nielsen P, Carpinteiro S, Fischer R, Cabeda JM, Porto G, Gabbe EE. Prevalence of the C282Y and H63D mutations in the HFE gene in patients with hereditary haemochromatosis and in control subjects from Northern Germany. Br J Haematol. 1998;103(3):842–845
  55. Murphy S, Curran MD, McDougall N, Callender ME, O’Brien CJ, Middleton D. High incidence of the Cys 282 Tyr mutation in the HFE gene in the Irish population – implications for haemochromatosis. Tissue Antigens. 1998;52(5):484–488
  56. Mura C, Raguenes O, Ferec C. HFE mutations analysis in 711 hemochromatosis probands: evidence for S65C implication in mild form of hemochromatosis. Blood. 1999;93:2502–2505
  57. Brissot P, Moirand R, Jouanolle AM, Guyader D, Le Gall JY, Deugnier Y, et al. A genotypic study of 217 unrelated probands diagnosed as ‘genetic hemochromatosis’ on ‘classical’ phenotypic criteria. J Hepatol. 1999;30(4):588–593
  58. Bacon BR, Olynyk JK, Brunt EM, Britton RS, Wolff RK. HFE genotype in patients with hemochromatosis and other liver diseases. Ann Intern Med. 1999;130(12):953–962
  59. Brandhagen DJ, Alvarez W, Therneau TM, Kruckeberg KE, Thibodeau SN, Ludwig J, et al. Iron overload in cirrhosis-HFE genotypes and outcome after liver transplantation. Hepatology. 2000;31:456–460
  60. Rivard SR, Mura C, Simard H, Simard R, Grimard D, Le Gac G, et al. Mutation analysis in the HFE gene in patients with hereditary haemochromatosis in Saguenay-Lac-Saint-Jean (Quebec, Canada). Br J Haematol. 2000;108(4):854–858
  61. Papanikolaou G, Politou M, Terpos E, Fourlemadis S, Sakellaropoulos N, Loukopoulos D. Hereditary hemochromatosis: HFE mutation analysis in Greeks reveals genetic heterogeneity. Blood Cells Mol Dis. 2000;26(2):163–168
  62. Guix P, Picornell A, Parera M, Tomas C, Muncunill J, Castro JA, et al. Prevalence of the C282Y mutation for haemochromatosis on the Island of Majorca. Clin Genet. 2000;58(2):123–128
  63. Brandhagen DJ, Fairbanks VF, Baldus WP, Smith CI, Kruckeberg KE, Schaid DJ, et al. Prevalence and clinical significance of HFE gene mutations in patients with iron overload. Am J Gastroenterol. 2000;95(10):2910–2914
  64. Sham RL, Raubertas RF, Braggins C, Cappuccio J, Gallagher M, Phatak PD. Asymptomatic hemochromatosis subjects: genotypic and phenotypic profiles. Blood. 2000;96(12):3707–3711
  65. Van Vlierberghe H, Messiaen L, Hautekeete M, De Paepe A, Elewaut A. Prevalence of the Cys282Tyr and His63Asp mutation in Flemish patients with hereditary hemochromatosis. Acta Gastroenterol Belg. 2000;63(3):250–253
  66. Bell H, Berg JP, Undlien DE, Distante S, Raknerud N, Heier HE, et al. The clinical expression of hemochromatosis in Oslo, Norway. Excessive oral iron intake may lead to secondary hemochromatosis even in HFE C282Y mutation negative subjects. Scand J Gastroenterol. 2000;35:1301–1307
  67. Hellerbrand C, Bosserhoff AK, Seegers S, Lingner G, Wrede C, Lock G, et al. Mutation analysis of the HFE gene in German hemochromatosis patients and controls using automated SSCP-based capillary electrophoresis and a new PCR–ELISA technique. Scand J Gastroenterol. 2001;36(11):1211–1216
  68. de Juan D, Reta A, Castiella A, Pozueta J, Prada A, Cuadrado E. HFE gene mutations analysis in Basque hereditary haemochromatosis patients and controls. Eur J Hum Genet. 2001;9(12):961–964
  69. De Marco F, Liguori R, Giardina MG, D’Armiento M, Angelucci E, Lucariello A, et al. High prevalence of non-HFE gene-associated haemochromatosis in patients from southern Italy. Clin Chem Lab Med. 2004;42(1):17–24
  70. Bauduer F, Scribans C, Degioanni A, Renoux M, Dutour O. Distribution of the C282Y and H63D polymorphisms in hereditary hemochromatosis patients from the French Basque Country. Ann Hematol. 2005;84(2):99–102
  71. Cukjati M, Vaupotic T, Rupreht R, Curin-Serbec V. Prevalence of H63D, S65C and C282Y hereditary hemochromatosis gene mutations in Slovenian population by an improved high-throughput genotyping assay. BMC Med Genet. 2007;8:69
  72. Walsh A, Dixon JL, Ramm GA, Hewett DG, Lincoln DJ, Anderson GJ, et al. The clinical relevance of compound heterozygosity for the C282Y and H63D substitutions in hemochromatosis. Clin Gastroenterol Hepatol. 2006;4:1403–1410
  73. Rossi E, Olynyk JK, Cullen DJ, Papadopoulos G, Bulsara M, Summerville L, et al. Compound heterozygous hemochromatosis genotype predicts increased iron and erythrocyte indices in women. Clin Chem. 2000;46:162–166
  74. Lim EM, Rossi E, De-Boer WB, Reed WD, Jeffrey GP. Hepatic iron loading in patients with compound heterozygous HFE mutations. Liver Int. 2004;24:631–636
  75. Cadet E, Capron D, Perez AS, Crepin SN, Arlot S, Ducroix JP, et al. A targeted approach significantly increases the identification rate of patients with undiagnosed haemochromatosis. J Intern Med. 2003;253:217–224
  76. Swinkels DW, Aalbers N, Elving LD, Bleijenberg G, Swanink CM, van der Meer JW. Primary haemochromatosis: a missed cause of chronic fatigue syndrome?. Neth J Med. 2002;60:429–433
  77. Vital Durand D, Francois S, Nove-Josserand R, Durupt S, Durieu I, Morel Y, et al. [Haemochromatosis screening in 120 patients complaining with persistent fatigue]. Rev Med Interne. 2004;25:623–628
  78. Willis G, Scott DG, Jennings BA, Smith K, Bukhari M, Wimperis JZ. HFE mutations in an inflammatory arthritis population. Rheumatology (Oxford). 2002;41:176–179
  79. Li J, Zhu Y, Singal DP. HFE gene mutations in patients with rheumatoid arthritis. J Rheumatol. 2000;27:2074–2077
  80. Rovetta G, Grignolo MC, Buffrini L, Monteforte P. Prevalence of C282Y mutation in patients with rheumatoid arthritis and spondylarthritis. Int J Tissue React. 2002;24:105–109
  81. Timms AE, Sathananthan R, Bradbury L, Athanasou NA, Wordsworth BP, Brown MA. Genetic testing for haemochromatosis in patients with chondrocalcinosis. Ann Rheum Dis. 2002;61:745–747
  82. Carroll GJ. Primary osteoarthritis in the ankle joint is associated with finger metacarpophalangeal osteoarthritis and the H63D mutation in the HFE gene: evidence for a hemochromatosis-like polyarticular osteoarthritis phenotype. J Clin Rheumatol. 2006;12:109–113
  83. Cauza E, Hanusch-Enserer U, Bischof M, Spak M, Kostner K, Tammaa A, et al. Increased C282Y heterozygosity in gestational diabetes. Fetal Diagn Ther. 2005;20:349–354
  84. Acton RT, Barton JC, Passmore LV, Adams PC, Speechley MR, Dawkins FW, et al. Relationships of serum ferritin, transferrin saturation, and HFE mutations and self-reported diabetes in the Hemochromatosis and Iron Overload Screening (HEIRS) study. Diabetes Care. 2006;29:2084–2089
  85. Hahn JU, Steiner M, Bochnig S, Schmidt H, Schuff-Werner P, Kerner W. Evaluation of a diagnostic algorithm for hereditary hemochromatosis in 3500 patients with diabetes. Diabetes Care. 2006;29:464–466
  86. Frayling T, Ellard S, Grove J, Walker M, Hattersley AT. C282Y mutation in HFE (haemochromatosis) gene and type 2 diabetes. Lancet. 1998;351:1933–1934
  87. Davis TM, Beilby J, Davis WA, Olynyk JK, Jeffrey GP, Rossi E, et al. Prevalence, characteristics and prognostic significance of HFE gene mutations in type 2 diabetes: The Fremantle Diabetes Study. Diabetes Care. 2008;31:1795–1801
  88. Habeos IG, Psyrogiannis A, Kyriazopoulou V, Psilopanagiotou A, Papavassiliou AG, Vagenakis AG. The role of Hemochromatosis C282Y and H63D mutations in the development of type 2 diabetes mellitus in Greece. Hormones (Athens). 2003;2:55–60
  89. Qi L, Meigs J, Manson JE, Ma J, Hunter D, Rifai N, et al. HFE genetic variability, body iron stores, and the risk of type 2 diabetes in U.S. women. Diabetes. 2005;54:3567–3572
  90. Halsall DJ, McFarlane I, Luan J, Cox TM, Wareham NJ. Typical type 2 diabetes mellitus and HFE gene mutations: a population-based case-control study. Hum Mol Genet. 2003;12:1361–1365
  91. Fernandez-Real JM, Vendrell J, Baiget M, Gimferrer E, Ricart W. C282Y and H63D mutations of the hemochromatosis candidate gene in type 2 diabetes. Diabetes Care. 1999;22:525–526
  92. Braun J, Donner H, Plock K, Rau H, Usadel KH, Badenhoop K. Hereditary haemochromatosis mutations (HFE) in patients with Type II diabetes mellitus. Diabetologia. 1998;41:983–984
  93. Malecki MT, Klupa T, Walus M, Czogala W, Greenlaw P, Sieradzki J. A search for association between hereditary hemochromatosis HFE gene mutations and type 2 diabetes mellitus in a Polish population. Med Sci Mon Int Med J Exp Clin Res. 2003;9:BR91–BR95
  94. Sampson MJ, Williams T, Heyburn PJ, Greenwood RH, Temple RC, Wimperis JZ, et al. Prevalence of HFE (hemochromatosis gene) mutations in unselected male patients with type 2 diabetes. J Lab Clin Med. 2000;135:170–173
  95. Njajou OT, Alizadeh BZ, Vaessen N, Vergeer J, Houwing-Duistermaat J, Hofman A, et al. The role of hemochromatosis C282Y and H63D gene mutations in type 2 diabetes: findings from the Rotterdam Study and meta-analysis. Diabetes Care. 2002;25:2112–2113
  96. Peterlin B, Globocnik Petrovic M, Makuc J, Hawlina M, Petrovic D. A hemochromatosis-causing mutation C282Y is a risk factor for proliferative diabetic retinopathy in Caucasians with type 2 diabetes. J Hum Genet. 2003;48:646–649
  97. Ellervik C, Mandrup-Poulsen T, Nordestgaard BG, Larsen LE, Appleyard M, Frandsen M, et al. Prevalence of hereditary haemochromatosis in late-onset type 1 diabetes mellitus: a retrospective study. Lancet. 2001;358:1405–1409
  98. Poullis A, Moodie SJ, Ang L, Finlayson CJ, Levin GE, Maxwell JD. Routine transferrin saturation measurement in liver clinic patients increases detection of hereditary haemochromatosis. Ann Clin Biochem. 2003;40:521–527
  99. Poullis A, Moodie SJ, Maxwell JD. Clinical haemochromatosis in HFE mutation carriers. Lancet. 2002;360:411–412
  100. Nichols L, Dickson G, Phan PG, Kant JA. Iron binding saturation and genotypic testing for hereditary hemochromatosis in patients with liver disease. Am J Clin Pathol. 2006;125:236–240
  101. Willis G, Bardsley V, Fellows IW, Lonsdale R, Wimperis JZ, Jennings BA. Hepatocellular carcinoma and the penetrance of HFE C282Y mutations: a cross sectional study. BMC Gastroenterol. 2005;1:5–17
  102. Cauza E, Peck-Radosavljevic M, Ulrich-Pur H, Datz C, Gschwantler M, Schoniger-Hekele M, et al. Mutations of the HFE gene in patients with hepatocellular carcinoma. Am J Gastroenterol. 2003;98:442–447
  103. Hellerbrand C, Poppl A, Hartmann A, Scholmerich J, Lock G. HFE C282Y heterozygosity in hepatocellular carcinoma: evidence for an increased prevalence. Clin Gastroenterol Hepatol. 2003;1:279–284
  104. Boige V, Castera L, de Roux N, Ganne-Carrie N, Ducot B, Pelletier G, et al. Lack of association between HFE gene mutations and hepatocellular carcinoma in patients with cirrhosis. Gut. 2003;52:1178–1181
  105. Lauret E, Rodriguez M, Gonzalez S, Linares A, Lopez-Vazquez A, Martinez-Borra J, et al. HFE gene mutations in alcoholic and virus-related cirrhotic patients with hepatocellular carcinoma. Am J Gastroenterol. 2002;97:1016–1021
  106. Pirisi M, Toniutto P, Uzzau A, Fabris C, Avellini C, Scott C, et al. Carriage of HFE mutations and outcome of surgical resection for hepatocellular carcinoma in cirrhotic patients. Cancer. 2000;89:297–302
  107. Fargion S, Stazi MA, Fracanzani AL, Mattioli M, Sampietro M, Tavazzi D, et al. Mutations in the HFE gene and their interaction with exogenous risk factors in hepatocellular carcinoma. Blood Cells Mol Dis. 2001;27:505–511
  108. Bonkovsky HL, Poh Fitzpatrick M, Pimstone N, Obando J, Di Bisceglie A, Tattrie C, et al. Porphyria cutanea tarda, hepatitis C, and HFE gene mutations in North America. Hepatology (Baltimore, MD). 1998;27:1661–1669
  109. Chiaverini C, Halimi G, Ouzan D, Halfon P, Ortonne JP, Lacour JP. Porphyria cutanea tarda, C282Y, H63D and S65C HFE gene mutations and hepatitis C infection: a study from southern France. Dermatology (Basel, Switzerland). 2003;206:212–216
  110. Cribier B, Chiaverini C, Dali Youcef N, Schmitt M, Grima M, Hirth C, et al. Porphyria cutanea tarda, hepatitis C, uroporphyrinogen decarboxylase and mutations of HFE gene. A case-control study. Dermatology (Basel, Switzerland). 2009;218:15–21
  111. Egger NG, Goeger DE, Payne DA, Miskovsky EP, Weinman SA, Anderson KE. Porphyria cutanea tarda: multiplicity of risk factors including HFE mutations, hepatitis C, and inherited uroporphyrinogen decarboxylase deficiency. Dig Dis Sci. 2002;47:419–426
  112. Frank J, Poblete Gutierrez P, Weiskirchen R, Gressner O, Merk HF, Lammert F. Hemochromatosis gene sequence deviations in German patients with porphyria cutanea tarda. Physiol Res. 2006;55:S75–S83
  113. Gonzalez Hevilla M, de Salamanca RE, Morales P, Martinez Laso J, Fontanellas A, Castro MJ, et al. Human leukocyte antigen haplotypes and HFE mutations in Spanish hereditary hemochromatosis and sporadic porphyria cutanea tarda. J Gastroenterol Hepatol. 2005;20:456–462
  114. Hift RJ, Corrigall AV, Hancock V, Kannemeyer J, Kirsch RE, Meissner PN. Porphyria cutanea tarda: the etiological importance of mutations in the HFE gene and viral infection is population-dependent. Cell Mol Biol (Noisy le Grand, France). 2002;48:853–859
  115. Kratka K, Dostalikova Cimburova M, Michalikova H, Stransky J, Vranova J, Horak J. High prevalence of HFE gene mutations in patients with porphyria cutanea tarda in the Czech Republic. Br J Dermatol. 2008;159:585–590
  116. Lamoril J, Andant C, Gouya L, Malonova E, Grandchamp B, Martasek P, et al. Hemochromatosis (HFE) and transferrin receptor-1 (TFRC1) genes in sporadic porphyria cutanea tarda (sPCT). Cell Mol Biol (Noisy-le-grand). 2002;48:33–41
  117. Martinelli AL, Zago MA, Roselino AM, Filho AB, Villanova MG, Secaf M, et al. Porphyria cutanea tarda in Brazilian patients: association with hemochromatosis C282Y mutation and hepatitis C virus infection. Am J Gastroenterol. 2000;95:3516–3521
  118. Mehrany K, Drage LA, Brandhagen DJ, Pittelkow MR. Association of porphyria cutanea tarda with hereditary hemochromatosis. J Am Acad Dermatol. 2004;51:205–211
  119. Nagy Z, Koszo F, Par A, Emri G, Horkay I, Horanyi M, et al. Hemochromatosis (HFE) gene mutations and hepatitis C virus infection as risk factors for porphyria cutanea tarda in Hungarian patients. Liver Int. 2004;24:16–20
  120. Roberts AG, Whatley SD, Morgan RR, Worwood M, Elder GH. Increased frequency of the haemochromatosis Cys282Tyr mutation in sporadic porphyria cutanea tarda. Lancet. 1997;349:321–323
  121. Stolzel U, Kostler E, Schuppan D, Richter M, Wollina U, Doss MO, et al. Hemochromatosis (HFE) gene mutations and response to chloroquine in porphyria cutanea tarda. Arch Dermatol. 2003;139:309–313
  122. Stuart KA, Busfield F, Jazwinska EC, Gibson P, Butterworth LA, Cooksley WG, et al. The C282Y mutation in the haemochromatosis gene (HFE) and hepatitis C virus infection are independent cofactors for porphyria cutanea tarda in Australian patients. J Hepatol. 1998;28:404–409
  123. Tannapfel A, Stolzel U, Kostler E, Melz S, Richter M, Keim V, et al. C282Y and H63D mutation of the hemochromatosis gene in German porphyria cutanea tarda patients. Virchows Arch. 2001;439:1–5
  124. Toll A, Celis R, Ozalla MD, Bruguera M, Herrero C, Ercilla MG. The prevalence of HFE C282Y gene mutation is increased in Spanish patients with porphyria cutanea tarda without hepatitis C virus infection. J Eur Acad Dermatol Venereol. 2006;20:1201–1206
  125. Sampietro M, Piperno A, Lupica L, Arosio C, Vergani A, Corbetta N, et al. High prevalence of the His63Asp HFE mutation in Italian patients with porphyria cutanea tarda. Hepatology (Baltimore, MD). 1998;27:181–184
  126. Ellervik C, Birgens H, Tybjaerg Hansen A, Nordestgaard BG. Hemochromatosis genotypes and risk of 31 disease endpoints: meta-analyses including 66,000 cases and 226,000 controls. Hepatology (Baltimore, MD). 2007;46:1071–1080
  127. McDonnell SM, Hover A, Gloe D, Ou CY, Cogswell ME, Grummer-Strawn L. Population-based screening for hemochromatosis using phenotypic and DNA testing among employees of health maintenance organizations in Springfield, Missouri. Am J Med. 1999;107(1):30–37
  128. Delatycki MB, Allen KJ, Nisselle AE, Collins V, Metcalfe S, du Sart D, et al. Use of community genetic screening to prevent HFE-associated hereditary haemochromatosis. Lancet. 2005;366(9482):314–316
  129. Adams PC, Kertesz AE, McLaren CE, Barr R, Bamford A, Chakrabarti S. Population screening for hemochromatosis: a comparison of unbound iron-binding capacity, transferrin saturation, and C282Y genotyping in 5211 voluntary blood donors. Hepatology. 2000;31:1160–1164
  130. Barton JC, Acton RT, Lovato L, Speechley MR, McLaren CE, Harris EL, et al. Initial screening transferrin saturation values, serum ferritin concentrations, and HFE genotypes in Native Americans and whites in the Hemochromatosis and Iron Overload Screening Study. Clin Genet. 2006;69:48–57
  131. Asberg A, Hveem K, Thorstensen K, Ellekjter E, Kannelonning K, Fjosne U, et al. Screening for hemochromatosis: high prevalence and low morbidity in an unselected population of 65,238 persons. Scand J Gastroenterol. 2001;36:1108–1115
  132. Gordeuk VR, Reboussin DM, McLaren CE, Barton JC, Acton RT, McLaren GD, et al. Serum ferritin concentrations and body iron stores in a multicenter, multiethnic primary-care population. Am J Hematol. 2008;83(8):618–626
  133. Waalen J, Felitti VJ, Gelbart T, Beutler E. Screening for hemochromatosis by measuring ferritin levels: a more effective approach. Blood. 2008;111:3373–3376
  134. Bax L, Yu LM, Ikeda N, Tsuruta H, Moons KG. Development and validation of MIX: comprehensive free software for meta-analysis of causal research data. BMC Med Res Methodol. 2006;6:50
  135. Bax L, Yu LM, Ikeda N, Tsuruta H, Moons KGM. MIX: comprehensive free software for meta-analysis of causal research data. Version 1.7., 2009.
  136. Distante S, Berg JP, Lande K, Haug E, Bell H. HFE gene mutation (C282Y) and phenotypic expression among a hospitalised population in a high prevalence area of haemochromatosis. Gut. 2000;47(4):575–579
  137. Bulaj ZJ, Ajioka RS, Phillips JD, LaSalle BA, Jorde LB, Griffen LM, et al. Disease-related conditions in relatives of patients with hemochromatosis. N Engl J Med. 2000;343(21):1529–1535
  138. Barton JC, Rothenberg BE, Bertoli LF, Acton RT. Diagnosis of hemochromatosis in family members of probands: a comparison of phenotyping and HFE genotyping. Genet Med. 1999;1(3):89–93
  139. Waalen J, Felitti V, Gelbart T, Ho NJ, Beutler E. Prevalence of hemochromatosis-related symptoms among individuals with mutations in the HFE gene. Mayo Clin Proc. 2002;77(6):522–530
  140. Olynyk JK, Hagan SE, Cullen DJ, Beilby J, Whittall DE. Evolution of untreated hereditary hemochromatosis in the Busselton population: a 17-year study. Mayo Clin Proc. 2004;79:309–313
  141. Andersen RV, Tybjaerg-Hansen A, Appleyard M, Birgens H, Nordestgaard BG. Hemochromatosis mutations in the general population: iron overload progression rate. Blood. 2004;103:2914–2919
  142. Gleeson F, Ryan E, Barrett S, Crowe J. Clinical expression of haemochromatosis in Irish C282Y homozygotes identified through family screening. Eur J Gastroenterol Hepatol. 2004;16:859–863
  143. Rossi E, Kuek C, Beilby JP, Jeffrey GP, Devine A, Prince RL. Expression of the HFE hemochromatosis gene in a community-based population of elderly women. J Gastroenterol Hepatol. 2004;19(10):1150–1154
  144. Powell LW, Dixon JL, Ramm GA, Purdie DM, Lincoln DJ, Anderson GJ, et al. Screening for hemochromatosis in asymptomatic subjects with or without a family history. Arch Intern Med. 2006;166:294–301
  145. Asberg A, Hveem K, Kannelonning K, Irgens WO. Penetrance of the C28Y/C282Y genotype of the HFE gene. Scand J Gastroenterol. 2007;42:1073–1077
  146. Allen KJ, Gurrin LC, Constantine CC, Osborne NJ, Delatycki MB, Nicoll AJ, et al. Iron-overload-related disease in HFE hereditary hemochromatosis. N Engl J Med. 2008;358:221–230
  147. Whitlock EP, Garlitz BA, Harris EL, Beil TL, Smith PR. Screening for hereditary hemochromatosis: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2006;145:209–223
  148. Feder JN. The hereditary hemochromatosis gene (HFE): a MHC class I-like gene that functions in the regulation of iron homeostasis. Immunol Res. 1999;20(2):175–185
  149. Jazwinska EC, Powell LW. Hemochromatosis and ‘HLA-H’: definite!. Hepatology. 1997;25(2):495–496
  150. Koeken A, Cobbaert C, Quint W, van Doorn LJ. Genotyping of hemochromatosis-associated mutations in the HFE gene by PCR-RFLP and a novel reverse hybridization method. Clin Chem Lab Med FESCC. 2002;40(2):122–125
  151. Cunat S, Giansily Blaizot M, Bismuth M, Blanc F, Dereure O, Larrey D, et al. Global sequencing approach for characterizing the molecular background of hereditary iron disorders. Clin Chem. 2007;53(12):2060–2069
  152. Cukjati M, Koren S, Curin Serbec V, Vidan-Jeras B, Rupreht R. A novel homozygous frameshift deletion c.471del of HFE associated with hemochromatosis. Clin Genet. 2007;71(4):350–353
  153. Steiner M, Ocran K, Genschel J, Meier P, Gerl H, Ventz M, et al. A homozygous HFE gene splice site mutation (IVS5+1 G/A) in a hereditary hemochromatosis patient of Vietnamese origin. Gastroenterology. 2002;122:789–795
  154. Barton JC, Sawada Hirai R, Rothenberg BE, Acton RT. Two novel missense mutations of the HFE gene (I105T and G93R) and identification of the S65C mutation in Alabama hemochromatosis probands. Blood Cells Mol Dis. 1999;25:147–155
  155. de Kok JB, Wiegerinck ET, Giesendorf BA, Swinkels DW. Rapid genotyping of single nucleotide polymorphisms using novel minor groove binding DNA oligonucleotides (MGB probes). Hum Mutat. 2002;19(5):554–559
  156. Behrens M, Lange R. A highly reproducible and economically competitive SNP analysis of several well characterized human mutations. Clin Lab. 2004;50(5–6):305–316
  157. Alsmadi OA, Al Kayal F, Al Hamed M, Meyer BF. Frequency of common HFE variants in the Saudi population: a high throughput molecular beacon-based study. BMC Med Genet. 2006;7:43
  158. Castley A, Higgins M, Ivey J, Mamotte C, Sayer DC, Christiansen FT. Clinical applications of whole-blood PCR with real-time instrumentation. Clin Chem. 2005;51(11):2025–2030
  159. Walburger DK, Afonina IA, Wydro R. An improved real time PCR method for simultaneous detection of C282Y and H63D mutations in the HFE gene associated with hereditary hemochromatosis. Mutat Res. 2001;432(3–4):69–78
  160. Cheng J, Zhang Y, Li Q. Real-time PCR genotyping using displacing probes. Nucleic Acids Res. 2004;32(7):e61
  161. Bach V, Barcelo MJ, Altes A, Remacha A, Felez J, Baiget M. Genotyping the HFE gene by melting point analysis with the LightCycler system: Pros and cons. Blood Cells Mol Dis. 2006;36(2):288–291
  162. Moyses CB, Moreira ES, Asprino PF, Guimaraes GS, Alberto FL. Simultaneous detection of the C282Y, H63D and S65C mutations in the hemochromatosis gene using quenched-FRET real-time PCR. Braz J Med Biol Res [Rev Bras Pesq Med Biol, Sociedade Brasileira de Biofisica]. 2008;41(10):833–838
  163. Biasiotto G, Belloli S, Ruggeri G, Zanella I, Gerardi G, Corrado M, et al. Identification of new mutations of the HFE, hepcidin, and transferrin receptor 2 genes by denaturing HPLC analysis of individuals with biochemical indications of iron overload. Clin Chem. 2003;49:1981–1988
  164. Smillie D. A PCR-SSP method for detecting the Cys282Tyr mutation in the HFE gene associated with hereditary haemochromatosis. Mol Pathol. 1997;50(5):275–276
  165. Smillie D. A PCR-SSP method for detecting the His63Asp mutation in the HFE gene associated with hereditary haemochromatosis. Mol Pathol. 1998;51(4):232–233
  166. Steffensen R, Varming K, Jersild C. Determination of gene frequencies for two common haemochromatosis mutations in the Danish population by a novel polymerase chain reaction with sequence-specific primers. Tissue Antigens. 1998;52(3):230–235
  167. Wenz HM, Baumhueter S, Ramachandra S, Worwood M. A rapid automated SSCP multiplex capillary electrophoresis protocol that detects the two common mutations implicated in hereditary hemochromatosis (HH). Hum Genet. 1999;104(1):29–35
  168. Guttridge MG, Carter K, Worwood M, Darke C. Population screening for hemochromatosis by PCR using sequence-specific primers. Genet Test. 2000;4(2):111–114
  169. Guttridge MG, Thompson J, Worwood M, Darke C. Rapid detection of genetic mutations associated with haemochromatosis. Vox Sang. 1998;75(3):253–256
  170. Kaur G, Rapthap CC, Xavier M, Saxena R, Choudhary VP, Reuben SK, et al. Distribution of C282Y and H63D mutations in the HFE gene in healthy Asian Indians and patients with thalassaemia major. Natl Med J India. 2003;16(6):309–310
  171. Turner MS, Penning S, Sharp A, Hyland VJ, Harris R, Morris CP, et al. Solid-phase amplification for detection of C282y and H63D hemochromatosis (HFE) gene mutations. Clin Chem. 2001;47(8):1384–1389
  172. Bosserhoff AK, Seegers S, Hellerbrand C, Scholmerich J, Buttner R. Rapid genetic screening for hemochromatosis using automated SSCP-based capillary electrophoresis (SSCP-CE). Biotechniques. 1999;26(6):1106–1110
  173. Simonsen K, Dissing J, Rudbeck L, Schwartz M. Rapid and simple determination of hereditary haemochromatosis mutations by multiplex PCR-SSCP: detection of a new polymorphic mutation. Ann Hum Genet. 1999;63(Pt 3):193–197
  174. Kim S, Edwards JR, Deng L, Chung W, Ju J. Solid phase capturable dideoxynucleotides for multiplex genotyping using mass spectrometry. Nucleic Acids Research. 2002;30(16):e85
  175. Bernacki SH, Farkas DH, Shi W, Chan V, Liu Y, Beck JC, et al. Bioelectronic sensor technology for detection of cystic fibrosis and hereditary hemochromatosis mutations. Arch Pathol Lab Med. 2003;127(12):1565–1572
  176. Footz T, Somerville MJ, Tomaszewski R, Elyas B, Backhouse CJ. Integration of combined heteroduplex/restriction fragment length polymorphism analysis on an electrophoresis microchip for the detection of hereditary haemochromatosis. Analyst. 2004;129(1):25–31
  177. Bosserhoff AK, Buettner R, Hellerbrand C. Use of capillary electrophoresis for high throughput screening in biomedical applications. A minireview. Comb Chem High Throughput Screen. 2000;3(6):455–466
  178. Devaney JM, Pettit EL, Kaler SG, Vallone PM, Butler JM, Marino MA. Genotyping of two mutations in the HFE gene using single-base extension and high-performance liquid chromatography. Anal Chem. 2001;73(3):620–624
  179. Lubin IM, Yamada NA, Stansel RM, Pace RG, Rohlfs EM, Silverman LM. HFE genotyping using multiplex allele-specific polymerase chain reaction and capillary electrophoresis. Arch Pathol Lab Med. 1999;123(12):1177–1181
  180. Kotze MJ, de Villiers JN, Bouwens CS, Warnich L, Zaahl MG, van der Merwe S, et al. Molecular diagnosis of hereditary hemochromatosis: application of a newly-developed reverse-hybridization assay in the South African population. Clin Genet. 2004;65(4):317–321
  181. Oberkanins C, Moritz A, de Villiers JN, Kotze MJ, Kury F. A reverse-hybridization assay for the rapid and simultaneous detection of nine HFE gene mutations. Genet Test. 2000;4:121–124
  182. Rivers CA, Barton JC, Acton RT. A rapid PCR-SSP assay for the hemochromatosis-associated Tyr250Stop mutation in the TFR2 gene. Genet Test. 2001;5(2):131–134
  183. Somerville MJ, Sprysak KA, Hicks M, Elyas BG, Vicen-Wyhony L. An HFE intronic variant promotes misdiagnosis of hereditary hemochromatosis. Am J Hum Genet. 1999;65:924–926
  184. Klaassen CH, van Aarssen YA, van der Stappen JW. Improved real-time detection of the H63D and S65C mutations associated with hereditary hemochromatosis using a SimpleProbe assay format. Clin Chem Lab Med. 2008;46:985–986
  185. Schranz M, Talasz H, Graziadei I, Winder T, Sergi C, Bogner K, et al. Diagnosis of hepatic iron overload: a family study illustrating pitfalls in diagnosing hemochromatosis. Diagn Mol Pathol. 2009;18:53–60
  186. Sebastiani G, Wallace DF, Davies SE, Kulhalli V, Walker AP, Dooley JS. Fatty liver in H63D homozygotes with hyperferritinemia. World J Gastroenterol. 2006;12:1788–1792
  187. Jackson HA, Carter K, Darke C, Guttridge MG, Ravine D, Hutton RD, et al. HFE mutations, iron deficiency and overload in 10,500 blood donors. Br J Haematol. 2001;114:474–484
  188. de Villiers JN, Hillermann R, Loubser L, Kotze MJ. Spectrum of mutations in the HFE gene implicated in haemochromatosis and porphyria. Hum Mol Genet. 1999;8:1517–1522
  189. Bradbury R, Fagan E, Payne SJ. Two novel polymorphisms (E277K and V212V) in the haemochromatosis gene HFE. Hum Mutat. 2000;15:120
  190. Floreani A, Navaglia F, Basso D, Zambon CF, Basso G, Germano G, et al. Intron 2 [IVS2, T-C +4] HFE gene mutation associated with S65C causes alternative RNA splicing and is responsible for iron overload. Hepatol Res. 2005;33:57–60
  191. Piperno A, Arosio C, Fossati L, Vigano M, Trombini P, Vergani A, et al. Two novel nonsense mutations of HFE gene in five unrelated italian patients with hemochromatosis. Gastroenterology. 2000;119:441–445
  192. Wallace DF, Dooley JS, Walker AP. A novel mutation of HFE explains the classical phenotype of genetic hemochromatosis in a C282Y heterozygote. Gastroenterology. 1999;116:1409–1412
  193. Gochee PA, Powell LW, Cullen DJ, Du Sart D, Rossi E, Olynyk JK. A population-based study of the biochemical and clinical expression of the H63D hemochromatosis mutation. Gastroenterology. 2002;122:646–651
  194. Wallace DF, Walker AP, Pietrangelo A, Clare M, Bomford AB, Dixon JL, et al. Frequency of the S65C mutation of HFE and iron overload in 309 subjects heterozygous for C282Y. J Hepatol. 2002;36:474–479
  195. Aguilar Martinez P, Biron C, Blanc F, Masmejean C, Jeanjean P, Michel H, et al. Compound heterozygotes for hemochromatosis gene mutations: may they help to understand the pathophysiology of the disease?. Blood Cells Mol Dis. 1997;23:269–276
  196. Gandon Y, Olivie D, Guyader D, Aube C, Oberti F, Sebille V, et al. Non-invasive assessment of hepatic iron stores by MRI. Lancet. 2004;363:357–362
  197. St Pierre TG, Clark PR, Chua-Anusorn W, Fleming AJ, Jeffrey GP, Olynyk JK, et al. Noninvasive measurement and imaging of liver iron concentrations using proton magnetic resonance. Blood. 2005;105:855–861
  198. Ernst O, Sergent G, Bonvarlet P, Canva-Delcambre V, Paris JC, L’Hermine C. Hepatic iron overload: diagnosis and quantification with MR imaging. AJR Am J Roentgenol. 1997;168:1205–1208
  199. Brittenham GM, Farrell DE, Harris JW, Feldman ES, Danish EH, Muir WA, et al. Magnetic-susceptibility measurement of human iron stores. N Engl J Med. 1982;307:1671–1675
  200. Nielsen P, Engelhardt R, Duerken M, Janka GE, Fischer R. Using SQUID biomagnetic liver susceptometry in the treatment of thalassemia and other iron loading diseases. Transfus Sci. 2000;23:257–258
  201. Fischer R, Piga A, Harmatz P, Nielsen P. Monitoring long-term efficacy of iron chelation treatment with biomagnetic liver susceptometry. Ann NY Acad Sci. 2005;1054:350–357
  202. Guyader D, Jacquelinet C, Moirand R, Turlin B, Mendler MH, Chaperon J, et al. Noninvasive prediction of fibrosis in C282Y homozygous hemochromatosis. Gastroenterology. 1998;115:929–936
  203. Morrison ED, Brandhagen DJ, Phatak PD, Barton JC, Krawitt EL, El-Serag HB, et al. Serum ferritin level predicts advanced hepatic fibrosis among U.S. patients with phenotypic hemochromatosis. Ann Intern Med. 2003;138:627–633
  204. Crawford DH, Murphy TL, Ramm LE, Fletcher LM, Clouston AD, Anderson GJ, et al. Serum hyaluronic acid with serum ferritin accurately predicts cirrhosis and reduces the need for liver biopsy in C282Y hemochromatosis. Hepatology. 2009;49:418–425
  205. Adhoute X, Foucher J, Laharie D, Terrebonne E, Vergniol J, Castera L, et al. Diagnosis of liver fibrosis using FibroScan and other noninvasive methods in patients with hemochromatosis: a prospective study. Gastroenterol Clin Biol. 2008;32:180–187
  206. El Serag HB, Inadomi JM, Kowdley KV. Screening for hereditary hemochromatosis in siblings and children of affected patients. A cost-effectiveness analysis. Ann Intern Med. 2000;132:261–269
  207. Houglum K, Ramm GA, Crawford DH, Witztum JL, Powell LW, Chojkier M. Excess iron induces hepatic oxidative stress and transforming growth factor beta1 in genetic hemochromatosis. Hepatology. 1997;26:605–610
  208. Bassett ML, Halliday JW, Powell LW. Value of hepatic iron measurements in early hemochromatosis and determination of the critical iron level associated with fibrosis. Hepatology. 1986;6:24–29
  209. Le Lan C, Loreal O, Cohen T, Ropert M, Glickstein H, Laine F, et al. Redox active plasma iron in C282Y/C282Y hemochromatosis. Blood. 2005;105:4527–4531
  210. Bomford A, Williams R. Long term results of venesection therapy in idiopathic haemochromatosis. Q J Med. 1976;45:611–623
  211. Milman N, Pedersen P, a Steig T, Byg KE, Graudal N, Fenger K. Clinically overt hereditary hemochromatosis in Denmark 1948–1985: epidemiology, factors of significance for long-term survival, and causes of death in 179 patients. Ann Hematol. 2001;80:737–744
  212. Falize L, Guillygomarc’h A, Perrin M, Laine F, Guyader D, Brissot P, et al. Reversibility of hepatic fibrosis in treated genetic hemochromatosis: a study of 36 cases. Hepatology. 2006;44:472–477
  213. Powell LW, Kerr JF. Reversal of ‘cirrhosis’ in idiopathic haemochromatosis following long-term intensive venesection therapy. Australas Ann Med. 1970;19:54–57
  214. Niederau C, Fischer R, Purschel A, Stremmel W, Haussinger D, Strohmeyer G. Long-term survival in patients with hereditary hemochromatosis. Gastroenterology. 1996;110:1107–1119
  215. Fracanzani AL, Fargion S, Romano R, Conte D, Piperno A, D’Alba R, et al. Portal hypertension and iron depletion in patients with genetic hemochromatosis. Hepatology. 1995;22:1127–1131
  216. Adams PC. Factors affecting the rate of iron mobilization during venesection therapy for genetic hemochromatosis. Am J Hematol. 1998;58:16–19
  217. Hicken BL, Tucker DC, Barton JC. Patient compliance with phlebotomy therapy for iron overload associated with hemochromatosis. Am J Gastroenterol. 2003;98:2072–2077
  218. Adams PC, Kertesz AE, Valberg LS. Rate of iron reaccumulation following iron depletion in hereditary hemochromatosis. Implications for venesection therapy. J Clin Gastroenterol. 1993;16:207–210
  219. Hutchinson C, Geissler CA, Powell JJ, Bomford A. Proton pump inhibitors suppress absorption of dietary non-haem iron in hereditary haemochromatosis. Gut. 2007;56:1291–1295
  220. Kaltwasser JP, Werner E, Schalk K, Hansen C, Gottschalk R, Seidl C. Clinical trial on the effect of regular tea drinking on iron accumulation in genetic haemochromatosis. Gut. 1998;43:699–704
  221. Milward EA, Baines SK, Knuiman MW, Bartholomew HC, Divitini ML, Ravine DG, et al. Noncitrus fruits as novel dietary environmental modifiers of iron stores in people with or without HFE gene mutations. Mayo Clin Proc. 2008;83:543–549
  222. Nienhuis AW. Vitamin C and iron. N Engl J Med. 1981;304:170–171
  223. Schofield RS, Aranda JM, Hill JA, Streiff R. Cardiac transplantation in a patient with hereditary hemochromatosis: role of adjunctive phlebotomy and erythropoietin. J Heart Lung Transplant. 2001;20:696–698
  224. Barton JC, Grindon AJ, Barton NH, Bertoli LF. Hemochromatosis probands as blood donors. Transfusion. 1999;39:578–585
  225. Fletcher LM, Dixon JL, Purdie DM, Powell LW, Crawford DH. Excess alcohol greatly increases the prevalence of cirrhosis in hereditary hemochromatosis. Gastroenterology. 2002;122:281–289
  226. Harrison-Findik DD, Klein E, Crist C, Evans J, Timchenko N, Gollan J. Iron-mediated regulation of liver hepcidin expression in rats and mice is abolished by alcohol. Hepatology. 2007;46:1979–1985
  227. Chapman RW, Morgan MY, Boss AM, Sherlock S. Acute and chronic effects of alcohol on iron absorption. Dig Dis Sci. 1983;28:321–327
  228. Ioannou GN, Dominitz JA, Weiss NS, Heagerty PJ, Kowdley KV. The effect of alcohol consumption on the prevalence of iron overload, iron deficiency, and iron deficiency anemia. Gastroenterology. 2004;126:1293–1301
  229. Ioannou GN, Weiss NS, Kowdley KV. Relationship between transferrin-iron saturation, alcohol consumption, and the incidence of cirrhosis and liver cancer. Clin Gastroenterol Hepatol. 2007;5:624–629
  230. Barton JC, McDonnell SM, Adams PC, Brissot P, Powell LW, Edwards CQ, et al. Management of hemochromatosis. Hemochromatosis Management Working Group. Ann Intern Med. 1998;129:932–939
  231. Kowdley KV, Brandhagen DJ, Gish RG, Bass NM, Weinstein J, Schilsky ML, et al. Survival after liver transplantation in patients with hepatic iron overload: the national hemochromatosis transplant registry. Gastroenterology. 2005;129:494–503
  232. Yu L, Ioannou GN. Survival of liver transplant recipients with hemochromatosis in the United States. Gastroenterology. 2007;133:489–495
  233. Edwards CQ, Kelly TM, Ellwein G, Kushner JP. Thyroid disease in hemochromatosis. Increased incidence in homozygous men. Arch Intern Med. 1983;143:1890–1893
  234. Guggenbuhl P, Deugnier Y, Boisdet JF, Rolland Y, Perdriger A, Pawlotsky Y, et al. Bone mineral density in men with genetic hemochromatosis and HFE gene mutation. Osteoporos Int. 2005;16:1809–1814

PII: S0168-8278(10)00197-2

doi:10.1016/j.jhep.2010.03.001

Journal of Hepatology
Volume 53, Issue 1 , Pages 3-22, July 2010

Article Tools

* Image Usage & Resolution