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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 1  |  Page : 217-221

Do all chronic hepatitis C virus bleeders develop iron deficiency?


1 Department of Clinical Pathology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Clinical Pathology, National Liver Institute, Menoufia University, Menoufia, Egypt

Date of Submission02-May-2018
Date of Decision22-Jun-2018
Date of Acceptance24-Jun-2018
Date of Web Publication25-Mar-2020

Correspondence Address:
Asmaa S Atta
5-Al Shohada Street, Ashmoun, Menoufia Governorate
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_168_18

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  Abstract 

Objectives
To investigate the changes in hepcidin regulation in anemic chronic hepatitis C virus (HCV) patients with and without bleeding and the role of hepcidin in ameliorating the development of iron deficiency in anemic HCV bleeders.
Background
Chronic liver disease is frequently associated with anemia in about 75% of patients which is usually multifactorial. One of the causes of anemia in chronic liver disease is acute or chronic blood loss into the gastrointestinal tract, resulting in iron deficiency anemia. Hepcidin, the key regulator of iron homeostasis, has a relatively low expression level in the liver in chronic HCV patients; however, the changes in hepcidin regulation have not been examined previously in anemic chronic HCV bleeders compared with nonbleeders.
Patients and methods
This case–control study was carried out at the Faculty of Medicine and National Liver Institute, Menoufia University, in the duration between February 2016 and February 2017. The study included 70 individuals: 50 treatment-naive compensated chronic hepatitis C patients (25 anemic nonbleeders and 25 anemic bleeders) and 20 age-matched and sex-matched healthy individuals. Complete blood counts, iron profile, prothrombin, and serum hepcidin using enzyme-linked immunosorbent assay were done.
Results
Serum hepcidin levels were significantly lower in anemic nonbleeder patients (70.08 ± 13.40) and anemic bleeders (68.91 ± 10.66) than in controls (78.52 ± 7.46). P value is 0.017. There was no significant difference between the patient groups compared with each other. No statistically significant differences between the studied groups were found regarding serum iron, total iron binding capacity, transferrin saturation, and serum ferritin.
Conclusion
Chronic HCV bleeders do not develop iron deficiency.

Keywords: anemia of chronic liver disease, chronic hepatitis C, hepcidin, iron deficiency


How to cite this article:
Khalifa KA, Abbas OM, Shokri NO, Atta AS. Do all chronic hepatitis C virus bleeders develop iron deficiency?. Menoufia Med J 2020;33:217-21

How to cite this URL:
Khalifa KA, Abbas OM, Shokri NO, Atta AS. Do all chronic hepatitis C virus bleeders develop iron deficiency?. Menoufia Med J [serial online] 2020 [cited 2020 Jun 6];33:217-21. Available from: http://www.mmj.eg.net/text.asp?2020/33/1/217/281264




  Introduction Top


Hepatitis C virus (HCV) infection is the most common cause of chronic liver disease (CLD) in the world[1]. Anemia occurs in up to 75% of patients with CLD[2]. The anemia is usually mild to moderate; the hemoglobin level rarely falls below 10 g/dl in the absence of complications. This condition is referred to as 'uncomplicated anemia of liver disease'[3]. However, hemorrhage is a frequent complication often due to complications of portal hypertension such as gastroesophageal variceal rupture, gastropathy, or peptic ulcers, which is common in patients with cirrhosis. Red cell lifespan is also shortened even in uncomplicated liver diseases[2]. An estimated 30–40% of patients with chronic hepatitis C (CHC) have elevated serum iron, transferrin saturation, and ferritin levels[4]. The liver performs a major role in iron homeostasis. It is the main organ for the production of the iron regulatory hormone hepcidin, expressed in iron excess conditions as well as in cases of inflammation, blocking the absorption of iron from the enterocytes and inhibits iron release by macrophages[5]. Serum hepcidin levels are significantly associated with body iron status and are useful indicators in the diagnosis of iron deficiency[6]. The aim of the study was to study the changes in hepcidin regulation in anemic chronic HCV bleeders compared with nonbleeders and the role of hepcidin in ameliorating the development of iron deficiency in anemic HCV bleeders.


  Patients and Methods Top


This study was carried out at the Clinical Pathology Departments, Faculty of Medicine and National Liver Institute, Menoufia University, in the duration between February 2016 and February 2017. A written consent was taken from both controls and patients, also in agreement with the ethics committee of Faculty of Medicine and National Liver Institute, Menoufia University.

Patients

This case–control study was conducted on 70 individuals, 50 of them were treatment-naïve compensated CHC patients classified into 25 anemic nonbleeder patients and 25 anemic bleeders with a negative history of blood transfusions 4 weeks before sample collection. They were compared with 20 apparently healthy individuals of comparable age and sex as a normal control group for all parameters. Patients with eosinophilia, other causes of anemia, pregnant women, chronic inflammatory disease, hepatitis B virus infection, hepatitis B virus-HCV coinfection, hepatocellular carcinoma and Child–Pugh score C patients were excluded from the study.

Methods

All patients were submitted to clinical assessment including full history and clinical examination, abdominal ultrasonography, liver needle biopsy (when possible), and laboratory investigations including liver function tests using (cobas 6000 autoanalyzer; Roche Diagnostics-GmbH, Mannheim, Germany), prothrombin time and concentration using BFT II analyzer (Dade Behring Marburg GmbH, Marburg, Germany), complete blood counting using (XN 1000 autoanalyzer; Sysmex Corporation, Kobe, Japan), serum iron profile markers including serum iron, transferrin saturation, total iron binding capacity (TIBC), and serum ferritin using (cobas 6000 autoanalyzer; Roche Diagnostics-GmbH). Serum hepcidin levels were performed using Human Hepcidin ELISA kit (Catalog Number E-EL-H0077; Hubie Province, China). The assay kit measured human hepcidin level in serum samples using purified human hepcidin antibody to coat microtiter plate wells. Standards or samples were added to the micro enzyme-linked immunosorbent assay plate wells and combined with the specific antibody. Then a biotinylated detection antibody specific for hepcidin and avidin–horseradish peroxidase conjugate was added to each well and incubated. Free components are washed away. The substrate solution was added to each well. The enzyme substrate reaction was terminated by the addition of sulfuric acid solution and the color turned yellow. The optical density was measured spectrophotometrically at a wave length of 450 nm. The calculation of the concentration of hepcidin in samples was by comparing the optical density of the samples to the standard curve.

Statistical analysis

The data collected were tabulated and analyzed by SPSS (SPSS Inc., Chicago, Illinois, USA), statistical package, version 20. Quantitative data were expressed as mean and SD and analyzed by applying Mann–Whitney U test to compare two groups with non-normally distributed variables. Kruskal–Wallis test was used to compare more than two groups of non-normally distributed variables. Results obtained from these tests were considered to be statistically different at a P value of less than 0.05.


  Results Top


Patients with the CHC group had significantly higher aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, total bilirubin, direct bilirubin and lower albumin, prothrombin levels when compared with the control group (P = 0.001) [Table 1]. Significantly lower hemoglobin level and red blood cell counts were present in anemic CHC bleeders and nonbleeders compared with the control group (P = 0.001) [Table 2]. No statistically significant differences between the studied groups were found regarding red blood cell indices including mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and red cell distribution width [Table 2]. Serum hepcidin levels were significantly lower in CHC anemic nonbleeder patients (70.08 ± 13.40) and anemic bleeders (68.91 ± 10.66) compared with the controls (78.52 ± 7.46) with a P value of 0.017 [Table 3]. There was no significant difference between the patient groups compared with each other. No statistical differences between the studied groups were found regarding serum iron, TIBC, transferrin saturation, and serum ferritin [Table 3]. Correlation of hepcidin with the Child–Pugh score shows a statistically significant difference in hepcidin levels it being lower in patients with Child score B than Child score A (P = 0.024) [Table 4].
Table 1: Comparison between the studied groups regarding liver profile tests

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Table 2: Comparison between the studied groups regarding hemoglobin, red blood cells count, and red blood cell indices

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Table 3: Comparison between the studied groups regarding iron profile markers and hepcidin level

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Table 4: Correlation of hepcidin with the Child-Pugh scoring system

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  Discussion Top


Hepcidin is a 25-aa peptide found in human serum and urine, and represents the key hormone, which modulates iron homeostasis in the body. It is mainly produced by the liver[7]. As a negative regulator of iron release, hepcidin inhibits duodenal iron absorption and iron release by macrophages, thereby modulating iron availability and tissue iron stores. Its expression is induced by infection and inflammation and iron overload[8] and is downregulated by hypoxia, anemia, iron deficiency, erythropoietin, erythropoietic stimulation[9], and oxidative stress[10]. Relatively low level of hepcidin expression in the liver was reported in patients with chronic HCV disease[11]. Acute or chronic blood loss into the gastrointestinal tract is one of the major, and potentially treatable, causes of anemia in patients with liver cirrhosis which may predispose one to iron deficiency anemia. The hemorrhage is usually secondary to complications of portal hypertension such as gastroesophageal variceal rupture, gastropathy, or peptic ulcers[12]. The aim of the present study is to study the changes in hepcidin regulation in anemic chronic HCV bleeders compared with nonbleeders and the role of hepcidin in ameliorating the development of iron deficiency in anemic HCV bleeders.

The present study showed a significantly lower levels of hepcidin between CHC patients (anemic nonbleeders and anemic bleeders) and the control group. These results agree with Fujita et al.[11] and Miura et al.[13], who reported that in HCV infection there was downregulation of hepcidin expression that causes iron deposition and therefore liver injury. Miura and colleagues have reported that hepcidin transcription was found to be downregulated through specific inhibition of the promoter by HCV-induced reactive oxygen species. Quite similar results were reported in hepatoma cell lines expressing HCV core and nonstructural proteins.

The present study has shown a statistically significant difference in hepcidin levels, being lower in patients with child score B than child score A. This result agrees with Milward et al.[14], who reported that the main regulator of iron homeostasis, hepcidin, is secreted mainly by the liver. Therefore, in CLD, and especially in cases of severe hepatic injury, there were lower hepcidin levels.

Gkamprela et al.[15] reported that iron deficiency is often documented in patients with CLD, especially in advanced liver disease with portal hypertension, and is usually due to chronic blood loss.

The present study showed no statistical differences between the studied groups regarding serum iron and ferritin.

These results could be explained by lower levels of hepcidin detected in chronic anemic HCV patients which decrease the risk of iron deficiency in anemic HCV patients. Moreover, these patients are at risk of further development of iron overload and hepatic siderosis.

Harrison-Findik[16] reported increased levels of serum iron, transferrin saturation, and ferritin in 20–35% of patients with chronic HCV associated with mild to moderate increase of hepatic iron load, predominantly in the sinusoidal location.

The present study showed no statistical differences between the studied groups regarding TIBC and transferrin saturation.

Decreased TIBC was reported by Ersoy and Buyukafilk[17] as the liver disease progressed from hepatitis toward class C cirrhosis.

Increased transferrin saturation was essentially found in class C cirrhotics. Patients with advanced cirrhosis frequently have increased transferrin saturation (due to decreased TIBC) and ferritin levels. Patients with true systemic iron overload are characterized by hyperferremia in addition to increased transferrin saturation and ferritin levels as reported by Ersoy and Buyukafilk[17].

Transferrin saturation was found to be the best predictor of the status of hepatic iron deposits in CHC[18].

The pathophysiology of iron overload in HCV is likely a combination of release of iron from necrotic hepatocytes, a direct effect of HCV on iron homeostasis, dysregulation of hepcidin[19] associated hematological diseases, multiple transfusions, chronic alcohol abuse[20] and ineffective erythropoiesis due to high GDF-15 expression in patients with chronic HCV[21].


  Conclusion Top


These results suggest that lower levels of hepcidin detected in CHC patients decrease the risk of development of iron deficiency in anemic HCV bleeders.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Pandur E, Sipos K, Grama L, Nagy J, Poor VS, Setalo G, et al. Prohepcidin binds to the hamp promoter and autoregulates its own expression. Biochem J 2013; 451:301–311.  Back to cited text no. 7
    
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Harrison-Findik DD, Schafer D, Klein E, Timchenko NA, Kulaksiz H, Clemens D, et al. Alcohol metabolism-mediated oxidative stress down-regulates hepcidin transcription and leads to increased duodenal iron transporter expression. J Biol Chem 2006; 281:22974–22982.  Back to cited text no. 10
    
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Fujita N, Sugimoto R, Takeo M, Urawa N, Mifuji R, Tanaka H, et al. Hepcidin expression in the liver: relatively low level in patients with chronic hepatitis C. Mol Med 2007; 13:97–104.  Back to cited text no. 11
    
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Luo JC, Leu HB, Hou MC, Huang CC, Lin HC, Lee FY, et al. Cirrhotic patients at increased risk of peptic ulcer bleeding: a nationwide population-based cohort study. Aliment Pharmacol Ther 2012; 36:542–550.  Back to cited text no. 12
    
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Miura K, Taura K, Kodama Y, Schnabl B, Brenner DA. Hepatitis C virus-induced oxidative stress suppresses hepcidin expression through increased histone deacetylase activity. Hepatology 2008;48:1420–1429.  Back to cited text no. 13
    
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Milward E, Johnstone D, Trinder D, Ramm G, Olynyk J. The nexus of iron and inflammation in hepcidin regulation: SMADs, STATs, and ECSIT. Hepatology 2007;45:253–256.  Back to cited text no. 14
    
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Gkamprela E, Deutsch M, Pectasides D. Iron deficiency anemia in chronic liver disease: etiopathogenesis, diagnosis and treatment. Ann Gastroenterol 2017; 30:405.  Back to cited text no. 15
    
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Harrison-Findik D. Gender-related variations in iron metabolism and liver diseases. World J Hepatol 2010; 2:302–331.  Back to cited text no. 16
    
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Ersoy O, Buyukafilk Y. Serum iron parameters in cirrhosis and chronic hepatitis: detailed description. Turk J Gastroenterol 2011; 22:606–611.  Back to cited text no. 17
    
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Fabris C, Toniutto P, Scott CA, Falleti E, Avellini C, Del Forno M, et al. Serum iron indices as a measure of iron deposits in chronic hepatitis C. Clin Chim Acta 2001; 304:49–55.  Back to cited text no. 18
    
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Sumida Y, Yoshikawa T, Okanoue T. Role of hepatic iron in non-alcoholic steatohepatitis. Hepatol Res 2009; 39:213–222.  Back to cited text no. 20
    
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Abbas OM, Helwa MA, El Fert AY, Osheba IS. Growth differentiation factor 15 as a marker of ineffective erythropoiesis in patients with chronic C virus infection. Menoufia Med J 2017; 30:133.  Back to cited text no. 21
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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