Screening for hereditary haemochromatosis

Hereditary haemochromatosis (HH) is a common autosomal recessive disorder of iron overload in Caucasian populations. Clinical manifestations usually occur in individuals homozygous for the C282Y mutation in the HFE gene product and who have developed significant iron loading. Current screening methods can detect affected individuals either prior to or early during disease evolution, enabling early introduction of phlebotomy treatment that can normalise life expectancy. Evaluation of possible iron overload, via measurement of serum transferrin saturation and ferritin level, is the most appropriate initial test for those subjects presenting clinically for evaluation. HFE genotyping, when combined with serum biochemical measurements, defines the presence of likely iron overload and the underlying genetic disorder and is the preferred initial screening modality for families of an affected individual. Definitive proof of iron overload requires measurement of hepatic iron concentration or total iron burden via therapeutic phlebotomy; elevated serum ferritin level alone is not adequate. We now recognise that the natural history of HH is not as discrete as previously believed, because genetic and environmental modifiers of disease penetrance are increasingly identified as influencing the clinical expression of HH. In fact, a minority of C282Y homozygotes develop classical 'iron overload disease', although it has recently emerged that the disorder may predispose to breast and colorectal cancer. Uncertainties as to the true clinical impact of the condition at a population level lead to current recommendations of cascade screening of families of affected patients, case-finding in high-risk groups, such as patients with clinical manifestations consistent with the diagnosis, and a high level of clinical awareness in the community to facilitate early diagnosis. Generalised population screening is not presently recommended.     

HFE蛋白与遗传性血色病

遗传性血色病(hereditary haemochromatosis,HH)是一种遗传性铁代谢疾病。发病遍及全球,以白种人发病较多,北欧人群发病率可高达1/200。大约1/10的白色人种是HFE突变基因携带者[1]。国内对HH的发病率尚无确切统计数字,但全国各地均有病例报道[2]。HH主要特征为小肠铁吸收过量增加,逐渐在肝、心、胰和其它内分泌器官的实质细胞沉积,造成器官功能障碍、肝硬化、心力衰竭、糖尿病、垂体功能减退和关节疾病等。此种疾病首次报道於1865年,当时认为HH是糖尿病的一种特殊病例。尔后将这类疾病称为色素性肝硬化(pigment cirrho-sis),或古铜色糖…     

ironXS: high-school screening for hereditary haemochromatosis is acceptable and feasible

As the results of the Human Genome Project are realised, screening for genetic mutations that predispose to preventable disease is becoming increasingly possible. How and where such screening should best be offered are critical, unanswered questions. This study aimed to assess the acceptability and feasibility of genetic screening for preventable disease, using the model of hereditary haemochromatosis, in high-school students. Screening was offered for the HFE C282Y substitution to 17,638 students. Questionnaires were administered at the time of screening (Q1) and approximately 1 month after results were communicated (Q2). Outcomes assessed were uptake of screening, change in scores of validated anxiety, affect and health perception scales from Q1 to Q2, knowledge and iron indices in C282Y homozygous individuals. A total of 5757 (32.6%) students had screening and 28 C282Y-homozygous individuals (1 in 206) were identified, and none of the 27 individuals who had iron indices measures had significant iron overload. There was no significant change in measures of anxiety, affect or health perception in C282Y homozygous or non-homozygous individuals. Over 86% of students answered each of five knowledge questions correctly at Q1. Genetic population-based screening for a preventable disease can be offered in schools in a way that results in minimal morbidity for those identified at high risk of disease. The results of this study are not only relevant for haemochromatosis, but for other genetic markers of preventable disease such as those for cardiovascular disease and cancer.     

Homozygosity for the predominant Cys282Tyr mutation and absence of disease expression in hereditary haemochromatosis.

A candidate gene for hereditary haemochromatosis, HLA-H, has recently been presented. Two missense mutations in the HLA-H gene sequence are predicted to account for nearly 90% of all cases of the disease. The aim of this study was to correlate the presence of these missense mutations with the expressivity of the disease, as assessed by standard biochemical evaluation of serum iron parameters. Detection of the known mutations in haemochromatosis, Cys282Tyr and His63Asp, was undertaken in a large pedigree showing variable expression of the disease in successive generations. In three sibs with overt disease (one male, two female, aged 50 to 53 years), homozygosity for the predominant G to A transition (Cys282Tyr) in HLA-H was detected. However, homozygosity for this mutation was also detected in an asymptomatic male sib, aged 50, harbouring an identical genotype. The finding of an asymptomatic homozygous Cys282Tyr subject, haplo-identical to affected sibs, indicates that clinical expression of symptomatic disease is variable, even in middle aged Cys282Tyr homozygotes. This has profound implications for the future use of genetic screening for haemochromatosis.     

Non-C282Y familial iron overload: evidence for locus heterogeneity in haemochromatosis.

Haemochromatosis (HC) is an autosomal recessive disease with progressive iron overload leading to midlife onset of clinical complications. The causal gene (HFE) maps to 6p, in close linkage with the HLA class I genes. An HFE candidate gene recently identified has two missense mutations (C282Y and H63D) associated with the disease. Here we document the phenotypic and genetic analysis of a nuclear family comprising two sibs with symptomatic and massive iron overload before the age of 25. The disease seemed to be recessively transmitted and fitted the agreed criteria for haemochromatosis, but was neither associated with the C282Y and H63D mutations nor linked with HLA markers. Our data strongly support locus heterogeneity in haemochromatosis by showing evidence that the gene responsible for juvenile haemochromatosis (JH) does not map to 6p. In the absence of clear cut phenotypic distinction from typical haemochromatosis, patients below 30 years of age and C282Y negative should be considered as putative juvenile cases. This has practical implications in genetic counselling and family management.     

Development of a multiplex ARMS test for mutations in the HFE gene associated with hereditary haemochromatosis.

Genetic testing for hereditary haemochromatosis is likely to be a significant workload for diagnostic laboratories. The C282Y and H63D mutations in the HFE gene associated with hereditary haemochromatosis have previously been detected using a number of methods including alterations in the restriction digest pattern of polymerase chain reaction (PCR) amplified products. An amplification refractory mutation system (ARMS) has been developed that will simultaneously detect both hereditary haemochromatosis mutations. Comparison of the results obtained from the analysis of 46 samples referred for hereditary haemochromatosis testing showed no discrepancies between ARMS and restriction enzyme digestion. Furthermore, consistent results were obtained by ARMS from both blood and buccal mouthwash samples. The ARMS test is quicker and less expensive in terms of consumables and scientist time than restriction enzyme analysis, and is therefore suited to the routine diagnostic analysis of hereditary haemochromatosis.     

New polymorphic microsatellite markers place the haemochromatosis gene telomeric to D6S105

The haemochromatosis gene (HFE) is linked to both HLA-A andD6S105 on the short arm of chromosome 6 but these markers areseparated by     

A PCR-SSP method for detecting the Cys282Tyr mutation in the HFE gene associated with hereditary haemochromatosis.

Hereditary haemochromatosis is a common genetic disorder that causes hyperabsorption of dietary iron, leading to increased deposition and various organic diseases. Early diagnosis is important if effective treatment is to be applied and the iron overload corrected before the onset of clinical symptoms. Recently, a candidate gene has been identified in which a single point mutation shows a very close association with hereditary haemochromatosis. A polymerase chain reaction method using sequence specific primers (PCR-SSP) is described that, in conjunction with a simple DNA extraction method, would provide a specific diagnostic test or rapid screening procedure for this putative haemochromatosis associated mutation.     

HFE gene mutations analysis in Basque hereditary haemochromatosis patients and controls

C282Y/C282Y genotype is the prevalent genotype in Hereditary Haemochromatosis (HH), however, other genotypes have been associated with the disease. The objective of our study was to analyse the frequency of the three main mutations of HFE gene in HH patients and controls from the Basque population with differential genetic characteristics. Thirty five HH patients and 116 controls were screened for C282Y, H63D and S65C mutations using a PCR-RFLP technique. The association of HLA-A and-B alleles and HFE mutations was also studied in Basque controls. The frequency of C282Y homozygotes in the group of patients was only 57%. The rest of the patients presented heterogeneous genotypes, including compound heterozygotes: 11% of them were C282Y/H63D; and 2.85% were H63D/S65C. H63D or S65C heterozygotes had a frequency of 11% and 2.85 respectively and 5.71% patients lacked any mutation The high frequency of H63D in the healthy Basque population is confirmed in this study. A considerable incidence of S65C is observed either in controls and in HH (3%) or in iron overloaded patients. The peculiar genetic characteristics of Basques could explain the heterogeneity of genotypes in HH patients of this group. Further studies should be carried out to confirm these findings although the implication of other genetic or external factors in the development of HH is suggested.     

Characterization of chromosomes and chromosomal fragments in human lymphocyte micronuclei by telomeric and centromeric FISH

Micronuclei (MN), used as a biomarker of effect in exposure to genotoxic carcinogens, derive from chromosomes and chromosomal fragments lagging behind in anaphase. The two types of MN are usually distinguished from each other by centromeric fluorescence in situ hybridization (FISH), centromere-positive (C(+)) MN representing entire chromosomes and centromere-negative (C(-)) MN chromosomal fragments. The incorporation of various types of chromosomal fragments and chromosomes and chromatids to MN is still poorly understood. We used directly labelled pancentromeric and pantelomeric DNA probes to examine the contents of MN in cultured binucleate lymphocytes of four unexposed, healthy subjects (two men and two women) 35-56 years of age. The presence and number of telomeric and centromeric signals was evaluated in 200 MN (50 MN per subject). These data were used to estimate the proportion of MN harbouring terminal/interstitial fragments, acentric/centric fragments, chromatid-type/chromosome-type fragments and entire chromatids/chromosomes. The majority of the C(+) MN (96% in men and 86% in women) found contained telomeric (T(+)) sequences. Most of the C(+) T(+) MN had one centromere and two or one telomere signals, suggesting that single chromatids were more frequently involved in MN than both sister chromatids. Among the C(-) MN, telomere signals were found in 91% (men) and 79% (women), showing that fragments in MN were mostly terminal. Most C(-) T(+) MN had one telomere signal, indicating higher prevalence for chromatid-type than chromosome-type terminal fragments. Combined centromeric and telomeric FISH is expected to increase the sensitivity of detecting exposure-related effects, when the exposure induces specific types of MN and its effect is low. This approach could particularly have use in discriminating between MN harbouring chromatid- and chromosome-type fragments in studies of human exposure to chemical clastogens and ionizing radiation.     

The importance of the general practitioner as an information source for patients with hereditary haemochromatosis

Objective

To explore hereditary haemochromatosis (HH) patients’ perspectives on genetic information, namely the types of sources used, preferred or trusted.

Methods

A survey online was conducted by the European Federation of Associations of Patients with Haemochromatosis (EFAPH) and applied to members of nine National Associations.

Results

From a total of 1019 validated questionnaires, 895 respondents had performed a genetic testing for HH. From these, 627 self-declared that they were sufficiently informed about the implications of the genetic test to their health. The majority (66%) obtained the information from a specialist doctor, but would like to obtain it from the family doctor. However, the specialist was still the one they trusted more (69%). Regarding the 298 respondents who did not feel sufficiently informed, the majority (78%) also would like to have information from the family doctor although they also trusted the specialist more (75%). A different perspective was reported when patients were asked about the implications of the genetic testing to their family members, where the majority of respondents preferred obtaining information from a specialist (69%).

Conclusion

This study elucidates the patients’ needs for information and identifies the general practitioner (GP) as the preferred source to obtain information about HH.

Practice implications

These results may have important implications in future strategies for HH awareness, giving a special emphasis on GPs as the main players.     

Use of centromeric and telomeric DNA probes in in situ hybridization for differentiation of micronuclei induced by lomefloxacin

Classification of micronuclei induced by lomefloxacin, a difluorinated quinolone bactericidal agent, in mouse bone marrow was performed by fluorescence in situ hybridization using DNA probes for the centromere repeated minor satellite DNA and the telomeric hexamer repeat (5′‐TTAGGG‐3′). Colchicine and mitomycin C were used as a positive control aneugen and clastogen, respectively, and these compounds produced the expected responses. Single doses of 40, 80, 160, or 320 mg/kg lomefloxacin were given via oral intubations and bone marrow was sampled at 24 and 48 hr after treatment. The micronuclei showed significant increases in both sampling times after doses of 320 mg/kg. A statistically significant increase of micronuclei frequency was also detected for 160 mg/kg lomefloxacin at 48 hr aftertreatment. The responses were directly correlated with bone‐marrow cytotoxicity. Following treatment with 160 and 320 mg/kg lomefloxacin, 48.2 and 50.0% of the induced micronuclei, respectively, showed double labeling with centromeric signals and several telomeric signals, indicating that the induced micronuclei were composed of whole chromosomes. Similarly, 51.8 and 50.0% of the induced micronuclei, respectively, were centromere‐negative, demonstrating that lomefloxacin not only induces chromosome loss but also chromosome breakage. The results also showed that chromosomes can be enclosed in a micronucleus before and after centromere separation. Overall, this study provides the first evidence of the potential of lomefloxacin to induce aneugenic effect in mice. However, given the high doses used in this study, the clinical significance of this finding is uncertain. Environ. Mol. Mutagen. 2009. © 2009 Wiley‐Liss, Inc.     

Best practice guidelines for the molecular genetic diagnosis of Type 1 (HFE-related) hereditary haemochromatosis

Background  

Hereditary haemochromatosis (HH) is a recessively-inherited disorder of iron over-absorption prevalent in Caucasian populations. Affected individuals for Type 1 HH are usually either homozygous for a cysteine to tyrosine amino acid substitution at position 282 (C282Y) of the HFE gene, or compound heterozygotes for C282Y and for a histidine to aspartic acid change at position 63 (H63D). Molecular genetic testing for these two mutations has become widespread in recent years. With diverse testing methods and reporting practices in use, there was a clear need for agreed guidelines for haemochromatosis genetic testing. The UK Clinical Molecular Genetics Society has elaborated a consensus process for the development of disease-specific best practice guidelines for genetic testing.     

Genotype-based screening for hereditary haemochromatosis. I: Technical performance, costs and clinical relevance of a German pilot study

In 2001, we initiated a pilot study on DNA-based screening of hereditary haemochromatosis (HH) in Germany. A total of 5882 insurants of the German sickness fund Kaufmannische Krankenkasse-KKH requested information on this project, and 3961 of these individuals provided blood samples for testing of the HFE mutation C282Y. Of these, 3930 samples were successfully tested with two independent test methods, and the results were communicated to the referring doctors. In all, 67 of the tested individuals were homozygous for C282Y. Partially, this high rate (1.7%) can be explained by the fact that 42.6% of the homozygotes already knew their clinical diagnosis HH before sending the blood sample. Iron accumulation with further signs or symptoms of HH was present in eight of 34 newly diagnosed C282Y homozygous individuals. Two major aspects of our study were the analytic validity and the direct laboratory costs of different test methods. Of 7860 tests performed, 7841 (99.6%) gave correct results. The overall error rate was 0.24% (95% CI: 0.15-0.38%). The analytic specificity of the tests methods with respect to the detection of homozygosity for C282Y was 100% (7726 of 7726 nonhomozygous test challenges, 95% CI: 99.95-100%), while the analytic sensitivity was 97% (130 of 134 homozygous test challenges, 95% CI: 92.5-99.2%). The direct costs ranged from 11.20-16.35 \[euro] per test method. We conclude that the test methods for C282Y are robust, highly sensitive and specific, and that a DNA-based HH-screening program can be performed at reasonable laboratory costs.     

Genetic susceptibility screening in schools: attitudes of the school community towards hereditary haemochromatosis

Carrier screening to provide reproductive options has been offered to students in the school setting for a number of years; however, genetic susceptibility screening for disease predisposition has not been introduced to the school community. Experience has shown that the success of a population-based programme relies on the community's acceptance. Therefore, we sought to establish the Australian secondary school community's attitudes towards genetic susceptibility screening in schools, with hereditary haemochromatosis as the model condition with an available prevention. School students, aged 15-18 (n = 748), completed a questionnaire immediately before and following an oral educational presentation. Their parents (n = 179) and staff (n = 89) received written information and returned a questionnaire by post. Semi-structured interviews were with Government representatives. Attitudes towards genetic screening in schools and knowledge of genetic and clinical features of haemochromatosis, as well as the likelihood of accepting a genetic susceptibility test for haemochromatosis, were all measured. Participants were positive about genetic screening for disease susceptibility in schools. Their knowledge was high following education with no significant differences between participants of each group. Sixty-eight percent of students would be likely to have the test if it were offered, with parents and staff, indicating that they would like the students to be offered a test, on average. Genetic susceptibility screening in schools is a novel concept. The results of our study indicate that it could be a public health success with the support of the community.     

Linkage of hereditary haemorrhagic telangiectasia to chromosome 9q34 and evidence for locus heterogeneity.

Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant disorder with unknown pathophysiology that is characterised by arteriovenous lesions and recurrent haemorrhage in virtually every organ. Linkage of HHT to markers on chromosome 9q has recently been reported. In this study we report confirmation of this localisation in three unrelated families of Dutch origin. A fourth unrelated HHT family, in which considerably fewer pulmonary arteriovenous malformations (PAVM) were present, yielded evidence for non-linkage to this region. We conclude that HHT is a genetically heterogeneous disorder and our results indicate that the presence of PAVM may be more common in patients with a chromosome 9 linked form of HHT than in patients with the non-linked form.     

Exclusion mapping of the hereditary dentatorubropallidoluysian atrophy gene from the Huntington''s disease locus.

Hereditary dentatorubropallidoluysian atrophy (DRPLA) is an autosomal dominant neurodegenerative disorder. Clinical and genetic findings in hereditary DRPLA are very similar to those of Huntington's disease (HD). However, it can be differentiated from HD by the pathological findings of dentatorubral and pallidoluysian atrophies and by a lack of prominent atrophy of the striatum at necropsy. The hereditary DRPLA gene has not been localised and the possibility that the two disease loci are allelic has been suggested. We have searched for linkage between the locus for hereditary DRPLA and D4S10 using the G8 probe, which is a genetic marker linked to HD. In four families, there were negative scores at all recombination fractions and the lod score was -2.215 at recombination fraction theta = 0.15. These data indicate that the locus for hereditary DRPLA is not closely linked to D4S10 and that hereditary DRPLA is a distinct disease from HD.     

A FISH approach to defining the extent and possible clinical significance of deletions at the WAGR locus.

Nineteen patients were analysed by fluorescence in situ hybridisation (FISH) with selected 11p13 markers. They were examined because they had either isolated sporadic or familial aniridia, or aniridia with one or more of the WAGR (Wilms' tumour, aniridia, genital anomalies, and mental retardation) syndrome anomalies. The FISH markers from distal 11p13 were cosmids FO2121, PAX6 (aniridia), D11S324, and WT1 (Wilms' tumour predisposition). Two of the patients with isolated aniridia were abnormal, one with an apparently balanced reciprocal 7;11 translocation and an 11p13 breakpoint, which by FISH was shown to be approximately 30 kb distal to the aniridia (PAX6) gene, and the other had a submicroscopic deletion involving part of PAX6 that extended distally for approximately 245 kb. Two patients with aniridia together with other WAGR malformations had deletions involving all four cosmids. One case with aniridia associated with developmental and growth delay had a deletion including FO2121 and PAX6 but not D11S324 and WT1, while in a further case the deletion included all four test cosmids. These studies show that a combined conventional and molecular cytogenetic approach to patients presenting with aniridia is a useful method for differentiating between those with deletions extending into and including WT1 and therefore between those with high and low risks of developing Wilms' tumour.     

The mitochondrial superoxide dismutase A16V polymorphism in the cardiomyopathy associated with hereditary haemochromatosis

The A16V mitochondrial targeting sequence polymorphism influences the antioxidant activity of MnSOD, an enzyme involved in neutralising iron induced oxidative stress. Patients with hereditary haemochromatosis develop parenchymal iron overload, which may lead to cirrhosis, diabetes, hypogonadism, and heart disease. The objective of this study was to determine in patients with haemochromatosis whether the presence of the Val MnSOD allele, associated with reduced enzymatic activity, affects tissue damage, and in particular heart disease, as MnSOD knockout mice develop lethal cardiomyopathy. We studied 217 consecutive unrelated probands with haemochromatosis, and 212 healthy controls. MnSOD polymorphism was evaluated by restriction analysis. The frequency distribution of the polymorphism did not differ between patients and controls. Patients carrying the Val allele had higher prevalence of cardiomyopathy (A/A 4%, A/V 11%, V/V 30%, p = 0.0006) but not of cirrhosis, diabetes, or hypogonadism, independently of age, sex, alcohol misuse, diabetes, and iron overload (odds ratio 10.1 for V/V, p = 0.006). The frequency of the Val allele was higher in patients with cardiomyopathy (0.67 v 0.45, p = 0.003). The association was significant in both C282Y+/+ (p = 0.02), and in non-C282Y+/+ patients (p = 0.003), and for both dilated (p = 0.01) and non-dilated stage (p = 0.04) cardiomyopathy, but not for ischaemic heart disease. In patients with hereditary haemochromatosis, the MnSOD genotype affects the risk of cardiomyopathy related to iron overload and possibly to other known and unknown risk factors and could represent an iron toxicity modifier gene.