A randomized trial of iron depletion in patients with nonalcoholic fatty liver disease and hyperferritinemia

Luca Valenti, Anna Ludovica Fracanzani, Paola Dongiovanni, Serena Rovida, Raffaela Rametta, Erika Fatta, Edoardo Alessandro Pulixi, Marco Maggioni, Silvia Fargion

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Abstract

Aim: To compare iron depletion to lifestyle changes alone in patients with severe nonalcoholic fatty liver disease (NAFLD) and hyperferritinemia, a frequent feature associated with more severe liver damage, despite at least 6 mo of lifestyle changes. Methods: Eligible subjects had to be 18-75 years old who underwent liver biopsy for ultrasonographically detected liver steatosis and hyperferritinemia, ferritin levels ≥ 250 ng/mL, and NAFLD activity score > 1. Iron depletion had to be achieved by removing 350 cc of blood every 10-15 d according to baseline hemoglobin values and venesection tolerance, until ferritin <30 ng/mL and/or transferrin saturation (TS) <25%. Thirty-eight patients were randomized 1:1 to phlebotomy (n = 21) or lifestyle changes alone (n = 17). The main outcome of the study was improvement in liver damage according to the NAFLD activity score at 2 years, secondary outcomes were improvements in liver enzymes [alanine aminotransferases (ALT), aspartate aminotransferase (AST), and gamma-glutamyl-transferases (GGT)]. Results: Phlebotomy was associated with normalization of iron parameters without adverse events. In the 21 patients compliant to the study protocol, the rate of histological improvement was higher in iron depleted vs control subjects (8/12, 67% vs 2/9, 22%, P = 0.039). There was a better improvement in steatosis grade in iron depleted vs control patients (P = 0.02). In patients followed-up at two years (n = 35), ALT, AST, and GGT levels were lower in iron-depleted than in control patients (P <0.05). The prevalence of subjects with improvement in histological damage or, in the absence of liver biopsy, ALT decrease ≥ 20% (associated with histological improvement in biopsied patients) was higher in the phlebotomy than in the control arm (P = 0.022). The effect of iron depletion on liver damage improvement as assessed by histology or ALT decrease ≥ 20% was independent of baseline AST/ALT ratio and insulin resistance (P = 0.0001). Conclusion: Iron depletion by phlebotomy is likely associated with a higher rate of improvement of histological liver damage than lifestyle changes alone in patients with NAFLD and hyperferritinemia, and with amelioration of liver enzymes.

Original languageEnglish
Pages (from-to)3002-3010
Number of pages9
JournalWorld Journal of Gastroenterology
Volume20
Issue number11
DOIs
Publication statusPublished - 2014

Fingerprint

Iron
Phlebotomy
Alanine Transaminase
Liver
Life Style
Aspartate Aminotransferases
Ferritins
Transferases
Biopsy
Non-alcoholic Fatty Liver Disease
Fatty Liver
Enzymes
Transferrin
Insulin Resistance
Histology
Hemoglobins
Outcome Assessment (Health Care)

Keywords

  • Ferritin
  • Iron depletion
  • Nonalcoholic fatty liver disease
  • Randomized controlled trial

ASJC Scopus subject areas

  • Gastroenterology
  • Medicine(all)

Cite this

@article{1b9bef917d104286a616a7e541f7902e,
title = "A randomized trial of iron depletion in patients with nonalcoholic fatty liver disease and hyperferritinemia",
abstract = "Aim: To compare iron depletion to lifestyle changes alone in patients with severe nonalcoholic fatty liver disease (NAFLD) and hyperferritinemia, a frequent feature associated with more severe liver damage, despite at least 6 mo of lifestyle changes. Methods: Eligible subjects had to be 18-75 years old who underwent liver biopsy for ultrasonographically detected liver steatosis and hyperferritinemia, ferritin levels ≥ 250 ng/mL, and NAFLD activity score > 1. Iron depletion had to be achieved by removing 350 cc of blood every 10-15 d according to baseline hemoglobin values and venesection tolerance, until ferritin <30 ng/mL and/or transferrin saturation (TS) <25{\%}. Thirty-eight patients were randomized 1:1 to phlebotomy (n = 21) or lifestyle changes alone (n = 17). The main outcome of the study was improvement in liver damage according to the NAFLD activity score at 2 years, secondary outcomes were improvements in liver enzymes [alanine aminotransferases (ALT), aspartate aminotransferase (AST), and gamma-glutamyl-transferases (GGT)]. Results: Phlebotomy was associated with normalization of iron parameters without adverse events. In the 21 patients compliant to the study protocol, the rate of histological improvement was higher in iron depleted vs control subjects (8/12, 67{\%} vs 2/9, 22{\%}, P = 0.039). There was a better improvement in steatosis grade in iron depleted vs control patients (P = 0.02). In patients followed-up at two years (n = 35), ALT, AST, and GGT levels were lower in iron-depleted than in control patients (P <0.05). The prevalence of subjects with improvement in histological damage or, in the absence of liver biopsy, ALT decrease ≥ 20{\%} (associated with histological improvement in biopsied patients) was higher in the phlebotomy than in the control arm (P = 0.022). The effect of iron depletion on liver damage improvement as assessed by histology or ALT decrease ≥ 20{\%} was independent of baseline AST/ALT ratio and insulin resistance (P = 0.0001). Conclusion: Iron depletion by phlebotomy is likely associated with a higher rate of improvement of histological liver damage than lifestyle changes alone in patients with NAFLD and hyperferritinemia, and with amelioration of liver enzymes.",
keywords = "Ferritin, Iron depletion, Nonalcoholic fatty liver disease, Randomized controlled trial",
author = "Luca Valenti and Fracanzani, {Anna Ludovica} and Paola Dongiovanni and Serena Rovida and Raffaela Rametta and Erika Fatta and Pulixi, {Edoardo Alessandro} and Marco Maggioni and Silvia Fargion",
year = "2014",
doi = "10.3748/wjg.v20.i11.3002",
language = "English",
volume = "20",
pages = "3002--3010",
journal = "World Journal of Gastroenterology",
issn = "1007-9327",
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number = "11",

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TY - JOUR

T1 - A randomized trial of iron depletion in patients with nonalcoholic fatty liver disease and hyperferritinemia

AU - Valenti, Luca

AU - Fracanzani, Anna Ludovica

AU - Dongiovanni, Paola

AU - Rovida, Serena

AU - Rametta, Raffaela

AU - Fatta, Erika

AU - Pulixi, Edoardo Alessandro

AU - Maggioni, Marco

AU - Fargion, Silvia

PY - 2014

Y1 - 2014

N2 - Aim: To compare iron depletion to lifestyle changes alone in patients with severe nonalcoholic fatty liver disease (NAFLD) and hyperferritinemia, a frequent feature associated with more severe liver damage, despite at least 6 mo of lifestyle changes. Methods: Eligible subjects had to be 18-75 years old who underwent liver biopsy for ultrasonographically detected liver steatosis and hyperferritinemia, ferritin levels ≥ 250 ng/mL, and NAFLD activity score > 1. Iron depletion had to be achieved by removing 350 cc of blood every 10-15 d according to baseline hemoglobin values and venesection tolerance, until ferritin <30 ng/mL and/or transferrin saturation (TS) <25%. Thirty-eight patients were randomized 1:1 to phlebotomy (n = 21) or lifestyle changes alone (n = 17). The main outcome of the study was improvement in liver damage according to the NAFLD activity score at 2 years, secondary outcomes were improvements in liver enzymes [alanine aminotransferases (ALT), aspartate aminotransferase (AST), and gamma-glutamyl-transferases (GGT)]. Results: Phlebotomy was associated with normalization of iron parameters without adverse events. In the 21 patients compliant to the study protocol, the rate of histological improvement was higher in iron depleted vs control subjects (8/12, 67% vs 2/9, 22%, P = 0.039). There was a better improvement in steatosis grade in iron depleted vs control patients (P = 0.02). In patients followed-up at two years (n = 35), ALT, AST, and GGT levels were lower in iron-depleted than in control patients (P <0.05). The prevalence of subjects with improvement in histological damage or, in the absence of liver biopsy, ALT decrease ≥ 20% (associated with histological improvement in biopsied patients) was higher in the phlebotomy than in the control arm (P = 0.022). The effect of iron depletion on liver damage improvement as assessed by histology or ALT decrease ≥ 20% was independent of baseline AST/ALT ratio and insulin resistance (P = 0.0001). Conclusion: Iron depletion by phlebotomy is likely associated with a higher rate of improvement of histological liver damage than lifestyle changes alone in patients with NAFLD and hyperferritinemia, and with amelioration of liver enzymes.

AB - Aim: To compare iron depletion to lifestyle changes alone in patients with severe nonalcoholic fatty liver disease (NAFLD) and hyperferritinemia, a frequent feature associated with more severe liver damage, despite at least 6 mo of lifestyle changes. Methods: Eligible subjects had to be 18-75 years old who underwent liver biopsy for ultrasonographically detected liver steatosis and hyperferritinemia, ferritin levels ≥ 250 ng/mL, and NAFLD activity score > 1. Iron depletion had to be achieved by removing 350 cc of blood every 10-15 d according to baseline hemoglobin values and venesection tolerance, until ferritin <30 ng/mL and/or transferrin saturation (TS) <25%. Thirty-eight patients were randomized 1:1 to phlebotomy (n = 21) or lifestyle changes alone (n = 17). The main outcome of the study was improvement in liver damage according to the NAFLD activity score at 2 years, secondary outcomes were improvements in liver enzymes [alanine aminotransferases (ALT), aspartate aminotransferase (AST), and gamma-glutamyl-transferases (GGT)]. Results: Phlebotomy was associated with normalization of iron parameters without adverse events. In the 21 patients compliant to the study protocol, the rate of histological improvement was higher in iron depleted vs control subjects (8/12, 67% vs 2/9, 22%, P = 0.039). There was a better improvement in steatosis grade in iron depleted vs control patients (P = 0.02). In patients followed-up at two years (n = 35), ALT, AST, and GGT levels were lower in iron-depleted than in control patients (P <0.05). The prevalence of subjects with improvement in histological damage or, in the absence of liver biopsy, ALT decrease ≥ 20% (associated with histological improvement in biopsied patients) was higher in the phlebotomy than in the control arm (P = 0.022). The effect of iron depletion on liver damage improvement as assessed by histology or ALT decrease ≥ 20% was independent of baseline AST/ALT ratio and insulin resistance (P = 0.0001). Conclusion: Iron depletion by phlebotomy is likely associated with a higher rate of improvement of histological liver damage than lifestyle changes alone in patients with NAFLD and hyperferritinemia, and with amelioration of liver enzymes.

KW - Ferritin

KW - Iron depletion

KW - Nonalcoholic fatty liver disease

KW - Randomized controlled trial

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U2 - 10.3748/wjg.v20.i11.3002

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JO - World Journal of Gastroenterology

JF - World Journal of Gastroenterology

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