Cascade testing of primary care blood samples with hyperferritinaemia identifies subjects with iron overload and porphyria cutanea tarda.

INTRODUCTION: Serum ferritin is routinely used as a first line test for iron status. Testing subjects with low pre-test probability often results in unexpected abnormal results. Raised ferritin is typically found in subjects with iron overload, liver disease, malignancy or inflammation. We sought to determine whether primary care patients with high ferritin had either porphyria cutanea tarda (PCT) or hereditary haemochromatosis (HH). METHODS: Redundant serum samples were collected from consecutive specimens with high ferritin (>500 µg/L) which had been received from primary care sources. Samples were analysed for serum iron and iron-binding capacity and for porphyrins by fluorescence scanning and HPLC. RESULTS: There were 240 samples (91 females, 149 males) which represented 2.7% of total over the collection period. Serum iron was 17.3 (18.9) µmol/L (median (IQR)), TIBC 47.3 (14.2) µmol/L and transferrin saturation 35.7 (41.1) %. There were 87/240 (36%) with transferrin saturation >45% (57 males, 30 females). Of the samples 19/236 (8%) were positive for porphyrins by spectrofluorimetry and 14/15 (4 insufficient sample) had total porphyrins >11.2 nmol/L (40(63) median (IQR)) with 3/15 (1.25%) having a typical pattern for PCT. DISCUSSION: This study demonstrates the feasibility of cascading tests using laboratory protocols and confirms the ability to identify potential cases. However, further studies for HH genotype and urine and stool porphyrin analysis will be necessary to confirm the diagnoses.

Significance of H63D homozygosity in a Basque population with hemochromatosis.

BACKGROUND: The significance of H63D homozygosity remains uncertain, although it is associated with a tendency for patients to develop iron overload. AIMS: To study the prevalence of homozygotic H63D mutation in patients with phenotypic hemochromatosis (PH) and to compare the results with those of the general population and with patients with porphyria cutanea tarda (PCT) in the Basque Country, Spain. A secondary aim was to evaluate the differences in phenotypic expression and liver injury according to different genotypes in the PH cohort. METHODS: Mutations of the HFE gene were obtained by polymerase chain reaction (PCR). Forty consecutive patients diagnosed with PH, 116 controls and 54 patients with PCT were included in the study. We performed liver biopsies, measured liver iron concentration (LIC), by atomic spectrophotometry, serum ferritin and transferrin saturation, and compared the histology according to the genotype. RESULTS: The H63D homozygote mutation was identified in 7.76% of the control group, in 7.50% of the PH group, and in 11.11% of patients with PCT (P > 0.05). The C282Y/C282Y mutation was present in 50% of patients with PH, and LIC was identified in 15/20. The LIC in C282Y/C282Y patients was higher than in H63D/H63D patients (P = 0.26), while H63D homozygosis caused greater iron overload in PH patients than other genotypes. All the C282Y/C282Y genotype patients had elevated serum ferritin and transferrin saturation. The H63D homozygotes had high ferritin, but two out of three had normal transferrin saturation. Six of the eight patients with high-grade fibrosis and genetic study results were found to be C282Y/C282Y. CONCLUSIONS: The prevalence of H63D mutation in patients with PH in our region does not differ from that of the general Basque population.

Mutaciones del gen de la hemocromatosis en donantes de sangre voluntarios y en pacientes con porfiria cutanea tarda en chile / Mutations of hemochromatosis gene in volunteer blood donors and Chilean porphyria cutanea tarda patients

La acumulación de hierro hepático asociada a mutaciones en el gen HFE de la hemocromatosis hereditaria (HH) en los pacientes con porfiria cutánea tarda (PCT) podría tener un papel en la etiología y en la expresión clínica de esta enfermedad. Se estudió la frecuencia de las mutaciones H63D y C282Y en un grupo de pacientes con PCT y se la comparó con la observada en un grupo de donantes voluntarios desangre. Los pacientes con PCT fueron catalogados como portadores de la forma hereditaria o adquirida de laenfermedad, según presentaran o no mutaciones en el gen uroporfirinógeno decarboxilasa (UROD). El 50% delos pacientes con PCT eran portadores de la forma genética de la enfermedad, porcentaje significativamentemayor que lo informado en otras series. El 23% de los donantes voluntarios de sangre eran portadores de lamutación H63D y 2.4% lo era de la mutación C282Y. Frecuencias similares a lo encontrado por otros autoresen población chilena de etnia blanca, en población argentina y española, pero significativamente más alta quelo encontrado en estudios en población aborigen araucana. Esto tiene, probablemente, relación con el predominio de ascendencia española en la población blanca chilena. La frecuencia de mutación en el gen HFE en pacientes con PCT no fue significativamente diferente que la observada en donantes voluntarios de sangre. Tampoco hubo diferencias significativas en la frecuencia de estas mutaciones entre los casos con PCT adquirida respecto de aquellos en que ésta era de origen genético. Los resultados obtenidos no permiten afirmar que exista asociación entre la PCT y la condición de portador de mutaciones del gen HFE de la hemocromatosis hereditaria

In patients with porphyria cutanea tarda (PCT), hepatic iron accumulation associated to hereditary hemochromatosis (HH) could play a role in the etiology and in the clinical expression of the disease. The H63D and C282Y mutations of the HFE gene frequency were studied in a PCT group of patients and compared with the frequency observed in a group of volunteer blood donors. PCT patients were cataloged as hereditary or acquired PCT carriers, whether or not they presented uroporphyrinogen decarboxilase gene mutations. Fifty percent of PCT patients were carriers of the disease’s genetic type. Such percentage is significantlyhigher than what other authors have previously informed. H63D and C282Y mutations were present in23% and 2.4% of the volunteer blood donors, respectively. Similar frequencies were informed by others authors in Chilean white ethnic populations, and also in Spaniard and Argentinean populations, but significantly higherthan that observed in Chile’s Araucanean aboriginal population. Probably the frequency of H63D and C283Y mutations are related to the Spaniard ascendancy dominance of Chile’s white ethnic population. The frequency of HFE gene mutations in PCT patients was not different than what was observed in volunteer blood donors.Similarly, there was no statistical difference in the frequency of these mutations among patients with acquired or genetic PCT disease. With the obtained results, it is not possible postulate an association between PCT and the hereditary hemochromatosis of HFE gene mutations carrier conditions

Porphyria cutanea tarda in a Swedish population: risk factors and complications.

There are varying reports on the prevalence of risk factors in porphyria cutanea tarda (PCT). We reviewed 84 patients with PCT in a restricted uptake area in Gothenburg, Sweden and evaluated different potential risk factors for the disease and complications. Besides a thorough medical history, the patients were investigated with urinary porphyrin analyses, transferrin saturation, ferritin and liver tests. Subsamples of patients were tested for antibodies to hepatitis C virus (n = 68), haemochromatosis gene mutations (n = 58) and with the oral glucose tolerance test (n = 31). We found a prevalence of about 1 patient with PCT in 10 000 inhabitants. Nineteen (23%) patients reported heredity for PCT. Identified risk factors were alcohol abuse (38% of male patients), oestrogen treatment (55% of female patients), anti-hepatitis C virus positivity (29% of male patients), diabetes (17%) or impaired glucose tolerance (45% of tested patients) and haemochromatosis gene mutations (57% of tested patients). All patients positive for anti-hepatitis C virus belonged to the non-hereditary group. During follow-up we observed a high incidence of stroke, no case of hepatocellular carcinoma and a normal life expectancy.

Effect of high fiber vegetable-fruit diet on the activity of liver damage and serum iron level in porphyria cutanea tarda (PCT).

BACKGROUND: During the treatment of coronary heart disease with a vegetable-fruit diet, we have observed the positive effect of the treatment on PCT patients. Therefore, we have now examined the short-term results of the diet on the selected PCT activity parameters. The study was approved by our Review Board. MATERIAL AND METHODS: A group of 13 male PCT patients (mean age 52 years) was evaluated. We assessed the body mass index (BMI), serum iron level, activity of transaminases (ALT, AST), severity of skin symptoms, and urinary prophyrins excretions, before and after a three-week period of vegetable-fruit diet. The diet was of natural vegetable/fruit products, and its daily caloric content was ca. 500 kcal/day. RESULTS: The mean BMI before and after the diet period were 26.8 +/- 4.7 vs. 25.8 +/- 4.3 (p = 0.001), the serum activities of ALT 122.0 +/- 60.7 U/l vs. 75.6 +/- 31.8 U/l, and of AST 91.8 +/- 56.0 U/l vs. 55.2 +/- 14.2 U/l (p = 0.001), respectively. The mean serum iron levels were 188.6 +/- 75.7 mg/dl vs. 140.2 +/- 56.4 mg/dl, serum ferritin concentrations 574 +/- 351 vs. 499 +/- 340 ng/ml (p = 0.04), respectively. Severity of skin lesions and urinary coproporphyrins excretion were significantly diminished during the diet; urinary uroporphyrins excretion was also lowered, but not to a statistically significant level. CONCLUSION: In our group of PCT patients, we noticed the beneficial effect of the vegetable-fruit diet on selected disease parameters. The diet may be useful in the treatment of PCT and diseases associated with PCT.

Circulating pro- and antioxidant factors in iron and porphyrin metabolism disorders.

BACKGROUND: Porphyria cutanea tarda and haemochromatosis are taken to be spontaneous human models of oxidative cellular damage, with an increased risk of fibrosis and cancer evolution. AIM: To define the relative pro-oxidant roles of porphyrin and iron, in their different molecular forms, and their effects on antioxidant biological systems. PATIENTS: A group of 17 patients with porphyria cutanea tarda and a group of 14 patients with primary and secondary haemochromatosis, were compared with 21 healthy controls. METHODS: Plasma retinol, tocopherol, alpha- and beta-carotene, ascorbic acid, glutathione, malonyldialdehyde and red blood cell free iron were determined using high performance liquid chromatography. RESULTS: Only a modest increase in iron stores was demonstrated in the porphyria cutanea tarda group; in the haemochromatosis patients ferritin levels were almost seven times higher. By contrast, there was a sharp and virtually identical increase in red blood cell free iron and malonyldialdehyde in both the patient groups. A significant reduction was observed in retinol, alpha-, beta-carotene and red blood cell glutathione levels being more marked in porphyria cutanea tarda than in haemochromatosis patients. CONCLUSIONS: The study confirms the strong pro-oxidant effects of porphyrins in vivo, through an induction of the free toxic iron form, even though the total iron pool is not greatly expanded. The additional free-iron and porphyrin oxidant effects are documented both in red blood cell and plasma in the porphyria cutanea tarda group. It confirmed that aging exerts a negative influence in terms of pro- and antioxidant balance in all cases, but particularly in the haemochromatosis group.

Iron and porphyria cutanea tarda.

In order to evaluate the pathogenetic role of iron in Porphyria cutanea tarda (PCT), the metabolism of iron was studied in 440 patient with PCT and associated chronic liver disease (CLD) and in 91 nonporphyric CLD patients (used as a control group). The parameters considered were the following: serum iron, ferritin, Total Iron Binding Capacity (TIBC) and percent saturation of transferrin. The statistical analysis showed that the differences between the means, in the two groups, were not significant in any of the parameters examined. To investigate the possible relationships between iron metabolism and other chemico-clinical parameters concerning the porphyric disease, the associated hepatic disease and hemometry, we studied the correlations between iron parameters and total urinary and serum porphyrins, serum copper, serum albumin, hemoglobin, red blood cells, ALT, AST, CHE and GLDH. This investigation was only possible in the last 99 cases. In addition to the obvious correlations between the parameters concerning iron metabolism, the highly significant (p < 0.001) correlation between ferritin and enzyme activities which indicate cytolysis (ALT, AST, GLDH) is extremely interesting. The results seem to point to the tentative conclusion that the alterations of iron metabolism are more related to the hepatocellular necrosis than to the metabolism of porphyrins.

Urodecarboxilasa en sangre de pacientes hemodializados / Decarboxylase in blood in hemodialysed patients

En la porfiria cutánea tarda(PCT) hay una falla en la uroporfirinógeno decarboxilasa (Uro-D) hepática, como consecuencia se incrementa la concentración de porfirinas altamente carboxiladas. Enla PCT hereditaria la Uro-D está disminuída en sangre y es normal en la PCT adquirida. Parte de la población hemodializada presenta signos cutáneos que son histológica y morfológicamente semejantes a la PCT, asociado a niveles aumentados de porfirias plasmáticas. Se estudió el contenido de porfirinas plasmáticas y la actividad de la Uro-D eritrocitaria, en 12 pacientes hemodializados sin lesiones cutáneas, uno de ellos portador de PCT hereditaria. El contenido de porfirias en plasma estuvo aumentado(0,084 mas igual 0,,10 ug/ml; uroporfirina igual 80 por ciento, cproporfirina igual 20 por ciento) en 30 por ciento de los pacientes estudiados( valor normal: 0,048 mas igual 0,010 ug/ml; coproporfirina igual 100 por ciento). Las porfirinas plasmáticas del paciente PCT al inicio del tratamiento con S-adenosil-L-metionina fue: 1,71 ug/ml; uroporfirina igual 48 por ciento, firiaporfirina igual 41 por ciento hexaporfirina igual 7 por ciento, pentaporfirina igual 3 por ciento y coproporfirina igual 1 por ciento) y luego de 6 años, al final del tratamiento, los valores fueron: 0,089 ug/ml; uriporfirina igual 80 por ciento, firiaporfirina igual 20 por ciento. La remisión clínica se correlacionó con la bioquímica. En los pacientes hemodializados la actividad de URO_D estuvo dentro de los valores normales(12,45 mas igual 1,o U/ml GR), excepto en el portador de la PCT hereditaria en el cual la actividad estuvodisminuída al 50 por ciento. Estos resultados sugieren que la hemodialisis per se no modificaria a la actividad de URO-D eritrocitaria.

Porphyria cutanea tarda and chronic lymphoid leukemia.

A case of a familial porphyria cutanea tarda (PCT-II) is reported in which the clinically overt form of PCT was provoked by factors relating to chronic lymphoid leukemia (CLL). Typical lesions of PCT developed on a 55-year-old woman after several blood transfusions and chlorambucil treatment. Besides these provoking factors, cytomegalovirus (CMV) infection was diagnosed. Erythrocyte uroporphyrinogen decarboxylase activity was about 50% of normal in the patient and in her two children. This case supports the suggestion that development of PCT in patients with hematological disorders is more than coincidental but may in fact be provoked by exogenous factors relating to the treatment of leukemia.

Hepatitis C virus antibodies and liver disease in patients with porphyria cutanea tarda.

The recent identification of the hepatitis C virus and development of assays to detect antibodies to hepatitis C virus has allowed assessment of the prevalence of hepatitis C virus infection in patients with a variety of liver and other diseases. The aim of this study was to investigate the prevalence of hepatitis C virus antibodies and severity of liver injury in patients with porphyria cutanea tarda. Sixty-two patients were studied. Serum samples were analyzed for liver function parameters and markers of hepatitis B virus infection. Frozen serum samples from 34 patients with porphyria cutanea tarda, obtained when patients were seen at the hospital for the first time, were analyzed for hepatitis C virus antibodies with enzyme-linked immunosorbent assays (first- and second-generation) and a recombinant immunoblot assay. As controls, serum samples from 19,788 blood donors, 40 patients with alcoholic liver disease and 138 hospitalized patients without liver disease were also tested for hepatitis C virus antibodies. Liver biopsy was performed in 42 porphyria cutanea tarda patients. Specimens were evaluated for steatosis, siderosis, fibrosis, severity of inflammation and the presence of cirrhosis. In addition, the degree of necroinflammatory change and fibrosis were quantitated with the histologic activity index described by Knodell et al. The prevalence of hepatitis C virus antibodies in patients with porphyria cutanea tarda (62%) was higher than that in blood donors (0.79%), patients with alcoholic liver disease (17.5%) or hospitalized patients without liver disease (5.8%).(ABSTRACT TRUNCATED AT 250 WORDS)