Does (HFE) hemochromatosis exist in India? Rakesh Aggarwal Department of Gastroenterology SGPGI, Lucknow

Hemochromatosis A progressive increase in body iron content, leading to systemic iron loading of parenchymal cells (particularly hepatocytes) and, eventually, to organ disease.

Iron homeostasis in humans Pietrangelo. New Engl J Med 2004; 350: 2383-97.

Hemochromatosis: Types Primary Secondary Parenteral iron overload RBCs Iron Anemias Chronic liver disease (esp alcohol)

Hemochromatosis Pietrangelo. New Engl J Med 2004; 350: 2383-97.

HFE gene frequency in Caucasians Population sample Country Sample size Prevalence of C282 homozygotes Allele frequency Electoral roll New Zealand 1,064 1 in 213 6.9% Field survey Australia 3,011 1 in 188 7.3% Primary care USA 4,865 1 in 405 5.0% Health clinic 41,038 1 in 270 6.1% USA/Canada 20,130 1 in 322 5.6% Harrison SA, Bacon BR. J Hepatol 2003; 38: S14-S23.

C282Y HFE mutation: Indian population Study City Number of subjects Number of Y alleles Number of total alleles % of Y allelles Kaur, 2003 Delhi 116 *1 232 0.4 Thakur, 2004 134 268 0.0 Garewal, 2005 Chandigarh 60 120 Panigrahi, 2006 74 148 Dhillon, 2007 100 200 80 160 Agarwal, 2007 Lucknow 421 842 Jain, 2011 502 1004 Total 1 2974 0.034 * PCR using sequence-specific primers

HFE C282Y: Indian Thallassemics Study City Number of subjects Number of Y alleles Number of total alleles % of Y allelles Kaur, 2003 Delhi 75 *6 150 4.0 Garewal, 2005 Chandigarh 215 430 0.0 Agarwal, 2006 Lucknow 147 294 Agarwal, 2007 308 616 Sharma, 2007 63 126 Total 6 1616 0.371 * PCR using sequence-specific primers

HFE C282Y: Indian liver disease patients Study City Number of subjects Number of Y alleles Number of total alleles % of Y allelles Thakur, 2004 Delhi 249 498 0.0 Duseja, 2005** Chandigarh 16 32 Agarwal, 2006 Lucknow 65 130 Panigrahi, 2006*** 31 62 Dhillon, 2007 236 472 Jain, 2011 496 *1 992 0.1 Total 1 2186 0.046 * PCR-RFLP ** Non-alcoholic steatohepatitis *** With transferrin saturation >45%

H63D HFE mutation in Indian population Study City Number of subjects Number of Y alleles Number of total alleles % of Y allelles Kaur, 2003 Delhi 116 20 232 8.6 Panigrahi, 2006 74 6 148 4.1 Dhillon, 2007 Chandigarh 100 13 200 6.5 80 160 3.8 Agarwal, 2007 Lucknow 421 47 842 5.6 Jain, 2011 502 46 1004 4.6 Total 138 2586 5.3

HFE H63D: Thallassemia / Liver disease Study City Number of subjects Number of Y alleles Number of total alleles % of Y allelles Thallassemia Kaur, 2003 Delhi 75 19 150 12.7 Agarwal, 2007 Lucknow 308 49 616 8.0 Sharma, 2007 63 8 126 6.3 Total 76 892 8.5 Chronic liver disease Duseja, 2005 Chandigarh 16 4 32 12.5 Panigrahi, 2006 Delhi 31 8 62 12.9 Dhillon, 2007 236 36 472 7.6 Jain, 2011 Lucknow 496 60 992 6.0 Total 108 1558 6.9

Indian liver disease patients: Fe overload Author N Findings Thakur 249 24 (9.6%) had transferrin saturation >60% Duseja 31 Only 1/23 (5%) had transferrin saturation >45%; Liver biopsy in 16: none had 3+/4+ Perl stain Dhillon 236 Only 17 (7.2%) had iron overload Jain 496 Only 13 (2.6%) had iron overload

Indian patients with iron overload Shukla et al. Natl Med J India 2006; 19: 20-3.

Indian patients with iron overload Shukla et al. Natl Med J India 2006; 19: 20-3.

Indian patients with iron overload Shukla et al. Natl Med J India 2006; 19: 20-3.

Indian patients with iron overload PCR-RFLP for C282Y Shukla et al. Natl Med J India 2006; 19: 20-3.

Indian patients with iron overload HFE gene None of the 5 patients had C282Y mutation One had homozygous H63D mutation None had previously known splice site mutations Four had a IVS2+4 T/C change HAMP gene (Hepcidin) None had G71A or IVS2+1(-G) mutation SLC11A3 gene (Ferroportin) Shukla et al. Natl Med J India 2006; 19: 20-3.

Indian patients with iron overload 1 2 3 4 5 6 GTATGTGGAGAGGGGGC AAGG GTACGTCGAGAGGGGGC GTAYGTGGAGAGGGGGC Z92910.1 Patient #1 Patient #2 Patient #3 Patient #4 Patient #5 Y = T or C Splice site Intron Exon Shukla et al. Natl Med J India 2006; 19: 20-3.

Other data from the Indian subcontinent Family Origin Onset age Protein Exon AA change A Bangladesh 19 Hemojuvelin 3 C80Y B Pakistan 26 G99R C 11 D 23 P192L E 32 L194P F Sri Lanka 17 4 A343fsX23 G 21 Hepcidin 2 R42Sfs H Thailand 38 Ferroportin 7 C326Y Lok et al. Blood 2009; 114: 20-5.

Hemochromatosis in India: Summary Iron overload Occasional C282Y mutation Very infrequent C282Y HFE disease Extremely rare