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892 Oral Iron Overload* 892 S.A. TYDSKRIF VIR GENEESKUNDE 30 Oktober 1965 ORAL IRON OVERLOAD* THOMAS H. BOTHWELL, M.D. (RAND), M.R.C.P. (LoND.); ROBERT W. CHARLTON, B.sc., M.D. (RAND), M.R.C.P. (EDIN.) AND HAROLD C. SEFTEL, B.Sc., M.B., B.CH., DIP. MED. (RAND) ; CSIR Iron and Red Cell Metabolism Unit, Department of Medicine, University of the Witwatersrand and Johannesburg Hospital There are 3 - 4 G of iron in the body of a healthy adult cirrhosis of the liver is invariably a feature, while diabetes, male.' Three-quarters is functional and is found in haemo­ skin pigmentation, and cardiac failure are often present. globin, myoglobin, a number of tissue enzymes, and Since the pathological manifestations of idiopathic haemo­ attached to transferrin in the plasma. The remainder, chromatosis correlate well with the quantities of iron pre­ amounting to about 1,000 mg., is storage iron and is sent in the affected organs, it has been generally believed distributed in various tissues in the form of ferritin and haemosiderin. The infant is born with a total of 300 mg. REGULATION OF IRON BALANCE donated by his mother and, provided the diet is adequate, IRON NORMAL IRON during childhood and adolescence a small positive daily DEFICIENCY OVERLOAD balance results in a slow accumulation until the adult 3 amount is reached. Thereafter the iron status of the nor­ mal individual remains stable. The amounts of iron ab­ sorbed and excreted each day are small, and once iron 2 has been introduced into the body it is used again and ABSORPTION again. The daily loss from exfoliated cells and secretions is (MGS.) 1 from 0·5 - 1·0 mg. in adult males. In females excretion is approximately twice as great, since menstruation and child­ bearing represt:nt an added drain. These obligatory iron losses are normally replaced by the absorption of iron from food, so that the total iron content of the body tends 1 to remain p.xed within relatively narrow limits. This deli­ EXCRETION cate balance appears largely to depend on the behaviour (MGS.l 2 of the absorbing cells of the upper gastro-intestinal tract, which are to a considerable extent able to adjust the amounts absorbed according to the needs of the individual. 3 Thus the absorption rate tends to rise when the body is depleted of iron, and to fall when body stores are larger Fig. 1. Iron balance is regulated by the duodenal mucosa, than normal. Iron excretion also varies, but within which alters the absorption of available dietary iron narrower limits (Fig. 1). according to body requirements. Obligatory iron loss also varies with the total body iron content, but to a lesser Iron balance may be disturbed in a variety of ways, but extent. the end result is either iron deficiency or iron overload. Iron deficiency represents a major world-wide health pro­ that the iron plays an important role in the production of blem; in contrast, an excess of iron in the body is rela­ tissue damage. The:e are, however, certain disadvantages tively uncommon in most parts of the world. However, to considering idiopathic haemochromatosis as a proto­ there are certain situations which lead to an increase in the type of the long-term effects of increased absorption of body iron content, and when this occurs a number of iron from the gut, since virtually nothing is known of the interesting associations have been noted. Surplus iron may metabolic and pathological findings in that long latent enter the body by either the parenteral or the oral route, period, possibly stretching over half a lifetime, during and is quantitatively deposited in various tissues as ferritin which iron is accumulating in the body. It is because of and haemosiderin. With time, the total body iron content these deficiencies in current knowledge that it is probably may be many-fold normal. Parenteral iron overload is more p:ofitable to consider first the siderosis which occurs usually the result of the repeated administration of blood so commonly in the adult Bantu of Southern Africa, since transfusions to patients with refractory anaemias. While it has been possible to study this condition at all stages the consequences of such therapy have been extensively of its developmt:nt. investigated, the topic falls outside the range of the present discussion and will therefore not be considered further. IRON OVERLOAD IN THE BANTU The classical form of oral iron overload is idiopathic haemochromatosis. In the past it has been customary to Over 30 years have passed since it was first noticed that regard this condition as a rare hereditary disorder in which varying degrees of tissue siderosis are demonstrable in the increased absorption of iron from a normal diet leads to majority of adult Bantu in South Africa: These findings excessive deposits in the tissues.' It is usually diagnosed in have been confirmed in a number of subsequent studies:" middle age, at a time when the iron content of the body is and iron overload has been shown to occur also in the between 20 and 40 G. In this phase of the condition Bantu of Rhodesia, Bechuanaland, Malawi, Mozambique,' Ghana,' and Tanzania: In these various countries the con­ *Based on the Annual Guest Lecture delivered in ovember 1964 by one of us (T.H.B.), to the American Association for dition is seen almost exclusively among the Bantu; it is the Study of Liver Diseases. not found in White sub;ects and is ra:e in Indians (Fig. 2) 30 October 1965 S.A. MEDICAL JOURNAL 893 Although the incidence and severity of the siderosis is high daily intake has been established more directly by variable, the usual pattern is a remarkably constant one, measuring the iron concentrations in faeces."'" These have with most of the excess iron confined to the liver and been found to be considerably higher than in a comparable reticulo-endothelial system.' White population. In one study the mean concentration of 5000 MALES CONCENTRATIONS 30 4000 IN RANGE '".... ~ FOUND IN IDIOPATHIC .... C;; HAEMOCHROMATOSIS I ::J Q '" ~ 3000 ~ AFRICAN 0 .... w 20 ~ I,) ....<: ~ z Z w 0 2000 U et; w 0' a.. '""- 10 1000 '11 INDIAN o 10 20 30 40 50 60 70 80 90 CUMULA TlVE % 0-019 0.2·099 1.0-1.99 2.0+ Fig. 2. Cumulative percentage incidence of various concen­ LIVER IRON trations of storage iron in the livers of 109 White, 327 % DRY WEIGHT Bantu and 76 Indian males. (Data from Mayet and Both­ well.'" Figure reproduced by courtesy of the Editor, South Fig. 3. Liver iron concentrations in 318 B:mtu males dying African Journal of Medical Sciences.) in hospital in Johannesburg. In approximately 20% the iron concentration was more than 2% dry weight. (Data The condition first becomes manifest in late adolescence, from Bothwell and Isaacson.'o) and the incidence and severity reach their greatest degree between the ages of 40 and 60 years.""o Although com­ iron in faeces collected from males on Monday morning3 mone:- and more severe in males, a small proportion of was found to be several times the figure on Thursday morn­ Bantu females also accumulate large amounts of iron. In ings" (Fig. 4). These variations probably reflect the weekend a recent study the extent of the problem in the Johannes­ drinking habits of urban Bantu. Ove;- 80')~ of the iron burg area was defined by estimating the chemical concen­ present in the drinks is in an ionized form. Isotopic studies trations of iron in the livers of several hundred Bantu carried out on radioactively tagged Bantu beer have males dying in hospital.'o It was found that as many as 20% had hepatic iron concentrations in the range of those TABLE I. MEAN IRON CONCENTRATIONS IN SEVERAL HUNDRED SAMPLES described in idiopathic haemochromatosis, i.e. more than OF VARIOUS TYPES OF BANTU ALCOHOLIC BEVERAGES* 2')~ dry weight (Fig. 3). Ingredients Iron concentration Although it has always been accepted that the iron (mg./I00 ml.) overload must be the result of increased absorption from Home-brewed beer Malt, degermed 8·2 the gut, there has been controversy in the past as to why maize meal this should occur. Originally it was postulated that there Barberton Sugar, malt, bread 4·5 was an alteration in the behaviour of the bowel, induced Hops .. Yeast, sugar, malt, hops 5'1 Shimeyana Sugar, malt, potato 7·5 by chronic malnutrition, which resulted in the absorption Gin, tot-tot, etc. Distillates made 1·0 of higher percentages of the dietary iron.' More recently, from other drinks it has been shown that the Bantu diet contains abnormally South African wines* 0·7 n large amounts of iron. ,IO The additional iron is derived • Data from Bothwell et al. 12 from the utensils used in cooking and, more important, from the containers used in the preparation of home­ demonstrated that the iron is absorbed to the same degree brewed alcoholic drinks. In one study in which several as a simple ferric salt, and about one-third as well as the hundred samples of various types of drink were analysed," iron in a ferrous salt" (Fig. 5). In this investigation it was it was found that the mean iron concentrations were noted that the mean absorption rates in Bantu were lower several mg./loo ml. in all except the distilled liquors than in Whites. This can be ascribed to the fact that the (Table I). Since large volumes are consumed, calculations majority of the Bantu studied had varying degrees of iron from these data reveal that the average Bantu male ingests overload, since it has been shown that an increase in the between 50 and 100 mg.
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