Liver Iron, HFE Gene Mutations, and Hepatocellular Carcinoma Occurrence in Patients With Cirrhosis

Abstract

Background & Aims: The influence of HFE gene mutations and liver iron overload on hepatocellular carcinoma (HCC) occurrence in patients with cirrhosis is subjected to controversial results. The aim of this work was to clarify this influence in a large cohort of prospectively followed-up cirrhotic patients classified according to the cause of their liver disease. Methods: Three hundred one consecutive cirrhotic patients (162 alcoholics and 139 HCV-infected patients) were included at time of diagnosis of cirrhosis and followed-up. Liver iron overload on initial biopsy according to modified Deugnier’s score and C282Y/H63D HFE gene mutations were assessed. Results: In patients with alcoholic cirrhosis (mean iron score, 2.0 ± 3.0; mean time of follow-up, 66.1 ± 45.1 months), 40 (24.6%) developed HCC. Thirteen (8.02%) were heterozygotes for C282Y HFE gene mutation and had higher hepatic iron scores (3.6 ± 3.8 vs 1.9 ± 2.8, respectively, P = .05). In univariate analysis, liver iron overload as a continuous variable (HR, 1.23 [1.13–1.34], P < .001) or in binary coding with an optimal threshold of iron score ≥2.0 (HR, 4.1 [2.1–7.3], P < .0001) and C282Y mutation carriage (HR, 2.7 [1.2–6.3], P = .01) were risk factors for HCC. In multivariate analysis, liver iron and C282Y mutation carriage remained independent risk factors for HCC. In patients with HCV-related cirrhosis (C282Y mutation carriage, 17 [12.23%]; mean liver iron score, 0.9 ± 1.9; mean time of follow-up, 85.5 ± 42.1 months; HCC, 63 [45.32%] patients), C282Y mutation carriage and liver iron were not associated with HCC occurrence. Conclusions: Liver iron overload and C282Y mutation are associated with a higher risk of HCC in patients with alcoholic but not HCV-related cirrhosis. Background & Aims: The influence of HFE gene mutations and liver iron overload on hepatocellular carcinoma (HCC) occurrence in patients with cirrhosis is subjected to controversial results. The aim of this work was to clarify this influence in a large cohort of prospectively followed-up cirrhotic patients classified according to the cause of their liver disease. Methods: Three hundred one consecutive cirrhotic patients (162 alcoholics and 139 HCV-infected patients) were included at time of diagnosis of cirrhosis and followed-up. Liver iron overload on initial biopsy according to modified Deugnier’s score and C282Y/H63D HFE gene mutations were assessed. Results: In patients with alcoholic cirrhosis (mean iron score, 2.0 ± 3.0; mean time of follow-up, 66.1 ± 45.1 months), 40 (24.6%) developed HCC. Thirteen (8.02%) were heterozygotes for C282Y HFE gene mutation and had higher hepatic iron scores (3.6 ± 3.8 vs 1.9 ± 2.8, respectively, P = .05). In univariate analysis, liver iron overload as a continuous variable (HR, 1.23 [1.13–1.34], P < .001) or in binary coding with an optimal threshold of iron score ≥2.0 (HR, 4.1 [2.1–7.3], P < .0001) and C282Y mutation carriage (HR, 2.7 [1.2–6.3], P = .01) were risk factors for HCC. In multivariate analysis, liver iron and C282Y mutation carriage remained independent risk factors for HCC. In patients with HCV-related cirrhosis (C282Y mutation carriage, 17 [12.23%]; mean liver iron score, 0.9 ± 1.9; mean time of follow-up, 85.5 ± 42.1 months; HCC, 63 [45.32%] patients), C282Y mutation carriage and liver iron were not associated with HCC occurrence. Conclusions: Liver iron overload and C282Y mutation are associated with a higher risk of HCC in patients with alcoholic but not HCV-related cirrhosis. See editorial on page 348. See editorial on page 348. Because hepatocellular carcinoma (HCC) is increasingly becoming a major cause of death in cirrhotic patients,1Sangiovanni A. Del Ninno E. Fasani P. et al.Increased survival of cirrhotic patients with a hepatocellular carcinoma detected during surveillance.Gastroenterology. 2004; 126: 1005-1014Abstract Full Text Full Text PDF PubMed Scopus (527) Google Scholar periodical ultrasonographic screening is now widely performed as routine.2Llovet J.M. Bruix J. Early diagnosis and treatment of hepatocellular carcinoma.Baillieres Best Pract Res Clin Gastroenterol. 2000; 14: 991-1008Abstract Full Text PDF PubMed Scopus (47) Google Scholar The search for epidemiologic, biologic, or genetic factors that could help to select patients at higher risk and thus to modulate the indications of screening procedures is necessary.3Llovet J.M. Fuster J. Bruix J. The Barcelona approach: diagnosis, staging, and treatment of hepatocellular carcinoma.Liver Transpl. 2004; 10: S115-S120Crossref PubMed Scopus (611) Google Scholar Moreover, identification of predictive factors could presumably lead to a better understanding of hepatocarcinogenesis and new prevention strategies in these patients.4Lodato F. Mazzella G. Festi D. et al.Hepatocellular carcinoma prevention: a worldwide emergence between the opulence of developed countries and the economic constraints of developing nations.World J Gastroenterol. 2006; 12: 7239-7249PubMed Google Scholar Among these factors, the influence of liver iron overload and HFE gene mutations has been debated over the past few years. The 2 missense mutations C282Y and H63D explain most of the cases of haemochromatosis,5Feder J.N. Gnirke A. Thomas W. et al.A novel MHC class I-like gene is mutated in patients with hereditary haemochromatosis.Nat Genet. 1996; 13: 399-408Crossref PubMed Scopus (3406) Google Scholar a condition characterized by hepatic iron overload and leading to high cancer incidence.6Fargion S. Mandelli C. Piperno A. et al.Survival and prognostic factors in 212 Italian patients with genetic hemochromatosis.Hepatology. 1992; 15: 655-659Crossref PubMed Scopus (202) Google Scholar, 7Kew M.D. Pathogenesis of hepatocellular carcinoma in hereditary hemochromatosis: occurrence in noncirrhotic patients.Hepatology. 1990; 11: 1086-1087Crossref PubMed Scopus (46) Google Scholar Eighty percent to 100% of these patients are homozygotes for the C282Y mutation, and approximately 5% are compound heterozygotes.5Feder J.N. Gnirke A. Thomas W. et al.A novel MHC class I-like gene is mutated in patients with hereditary haemochromatosis.Nat Genet. 1996; 13: 399-408Crossref PubMed Scopus (3406) Google Scholar The issue of whether patients with other liver diseases heterozygotes for these mutations could develop liver iron overload that could enhance liver injury and carcinogenesis remains unclear. Liver iron accumulation leads to reactive oxygen species formation in the liver, thus causing oxidative stress, liver cell DNA mutations, and development of HCC.8Deugnier Y. Iron and liver cancer.Alcohol. 2003; 30: 145-150Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Besides ageing and male sex, which are well-known risk factors for liver iron accumulation as well as for HCC, seeking for genetic markers of HCC such as HFE gene mutations that could act by increasing hepatic iron overload and thus HCC occurrence is of major interest because it would validate the carcinogenic role of liver iron and suggest preventive measures. Whether moderate liver iron overload observed in the course of cirrhosis and the HFE mutations carriage could be associated with the risk of HCC in these patients remains unclear.9Kowdley K.V. Iron, hemochromatosis, and hepatocellular carcinoma.Gastroenterology. 2004; 127: S79-S86Abstract Full Text Full Text PDF PubMed Scopus (326) Google Scholar Some studies described higher prevalence of the C282Y mutation in patients with HCC compared with cirrhotic patients without HCC,10Hellerbrand C. Poppl A. Hartmann A. et al.HFE C282Y heterozygosity in hepatocellular carcinoma: evidence for an increased prevalence.Clin Gastroenterol Hepatol. 2003; 1: 279-284Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar, 11Lauret E. Rodriguez M. Gonzalez S. et al.HFE gene mutations in alcoholic and virus-related cirrhotic patients with hepatocellular carcinoma.Am J Gastroenterol. 2002; 97: 1016-1021Crossref PubMed Google Scholar whereas other studies displayed a lack of association between this mutation and HCC.12Boige V. Castera L. de Roux N. et al.Lack of association between HFE gene mutations and hepatocellular carcinoma in patients with cirrhosis.Gut. 2003; 52: 1178-1181Crossref PubMed Scopus (53) Google Scholar, 13Cauza E. Peck-Radosavljevic M. Ulrich-Pur H. et al.Mutations of the HFE gene in patients with hepatocellular carcinoma.Am J Gastroenterol. 2003; 98: 442-447Crossref PubMed Scopus (53) Google Scholar Moreover, the influence of the HFE mutations on hepatic iron accumulation is also debated. Finally, the influence of liver iron overload on the risk of HCC, requiring prospective cohort studies, has never been clearly shown. Unfortunately, all previous works were case-control studies including small cohorts of cirrhotic patients and mixing various causes of liver diseases, thus limiting the confidence in the different conclusions drawn. Indeed, several limitations are obvious when studying these parameters: the different importance of iron metabolism in hepatocarcinogenesis pathways according to the etiology of liver disease, the strong correlation between liver iron overload and ageing or male sex leading to methodologic bias in multivariate analysis, and the weak prevalence of the C282Y mutation in the studied populations. To our knowledge, the only prospective study dealing with the influence of liver iron overload in cirrhotic patients was the one by Ganne-Carrie et al.14Ganne-Carrie N. Christidis C. Chastang C. et al.Liver iron is predictive of death in alcoholic cirrhosis: a multivariate study of 229 consecutive patients with alcoholic and/or hepatitis C virus cirrhosis: a prospective follow up study.Gut. 2000; 46: 277-282Crossref PubMed Scopus (109) Google Scholar Conducted in 229 cirrhotic patients before the era of routine HFE gene mutations determination, this work displayed a lack of influence of liver iron overload on survival in patients with hepatitis C virus (HCV)-related cirrhosis but a strong influence in alcoholic cirrhotic patients. This study failed to an association between liver iron overload and HCC in these because of an of patients with alcoholic cirrhosis and a of The aim of the study was to on a large cohort of and prospectively followed-up cirrhotic patients the influence of liver iron overload and HFE gene mutations on the risk of HCC according to the cause of liver or and the role of HFE gene mutations in this The study was of an prospective study to the of HCC development in the course of various liver In the all new patients were to our liver for diagnosis and of cirrhosis between and and the by the virus or hepatitis evidence of HCC at the time of as by ultrasonographic and in of a and periodical HCC and for the of of patients all these had a at patients were in 2 cohorts according to etiology of liver disease. with alcoholic cirrhosis = were as and by by with HCV-related cirrhosis = were as and by by In this patients with alcoholic and HCV-related cirrhosis in our during this were = the of was the of the liver biopsy cirrhosis. of or hepatic and and past of were at was by all patients. In patients with HCV-related virus was assessed. patients were prospectively at by liver and these a diagnosis of HCC, and/or and/or a liver biopsy were performed according to the of the Barcelona J.M. Fuster J. Bruix J. The Barcelona approach: diagnosis, staging, and treatment of hepatocellular carcinoma.Liver Transpl. 2004; 10: S115-S120Crossref PubMed Scopus (611) Google Scholar HCC was on one of the evidence or of a 2 in and with by 2 different or the of one this with a of or The 2 were the occurrence of HCC and the occurrence of death or liver at the of death or liver or at the the before which was as the time for the our for patients our liver or by their or their In patients with HCV-related treatment and were DNA were = or liver = without patients for and The of liver for for was by the the of the and mutations of the HFE the DNA of was in according to the et of novel DNA 2002; PubMed Scopus Google Scholar iron was on the initial liver biopsy cirrhosis. Liver were in and liver biopsy were with the and on a by 2 of and To hepatic iron the Deugnier’s hepatic iron score, to cirrhotic as described to N. Christidis C. Chastang C. et al.Liver iron is predictive of death in alcoholic cirrhosis: a multivariate study of 229 consecutive patients with alcoholic and/or hepatitis C virus cirrhosis: a prospective follow up study.Gut. 2000; 46: 277-282Crossref PubMed Scopus (109) Google Scholar were compared the or with of and were compared the correlation was to the between of was also to 2 The was to the occurrence of HCC for at and death was as an in the The of death and HCC were compared with the of liver iron scores for the of death and HCC occurrence were was to select the in the a with a threshold of = score, associated with of HCC on and previous studies were also the P are were at a of was also to for the of for = P are not and of the patients at are in according to the etiology of cirrhosis. with iron the of liver such as score or risk factors for HCC occurrence are displayed in HFE gene mutations, of the studied patients were homozygotes for the C282Y mutation, patients with alcoholic cirrhosis were homozygotes for the H63D mutation, and patients were compound heterozygotes with alcoholic cirrhosis and with HCV-related and of and 139 with alcoholic cirrhosis = with HCV-related cirrhosis = ± ± ± of ± ± ± ± ± of ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± of ± ± ± iron ± ± ± of of of of of ± ± ± of of of HCC Liver of ± of patients. in a new of of in patients with alcoholic cirrhosis was ± patients were to during this of in patients with HCV-related cirrhosis was 85.5 ± 42.1 patients were to during this follow-up, 40 of (24.6%) patients developed HCC to the the of liver iron was associated with the risk of HCC occurrence time to vs respectively, = optimal threshold for liver iron score was associated with HCC occurrence in this cohort time to vs respectively, < In univariate according to the liver iron score was associated with the risk of HCC when as a continuous variable (HR, 1.23 P < .0001) or in binary coding (HR, 4.1 P < .0001) with male sex, and C282Y mutation carriage In multivariate all these liver iron overload remained an independent risk for HCC with and C282Y mutation carriage, when as a continuous variable (HR, P = or in binary coding (HR, P = of liver iron score on the risk of HCC occurrence in patients with alcoholic or HCV-related cirrhosis according to hundred patients with alcoholic cirrhosis time to vs respectively, < hundred patients with HCV-related cirrhosis time to vs respectively, = and the of HCC in or to univariate multivariate liver iron score as a continuous multivariate liver iron score with threshold univariate multivariate liver iron score as a continuous < < < = = = = = = = iron score < = = = iron score < = = = = = = = < < = = in a new follow-up, of patients = or liver = was to liver in all HCC in and/or liver in the other optimal threshold for liver iron score was associated with death in this cohort time of vs respectively, = The of at was not with liver iron score = P = and the risk of HCC occurrence = P = Liver iron score when as a continuous variable was associated in this cohort with male sex, and C282Y mutation carriage and Liver Iron in or = = = = sex vs ± vs ± 1.9 = ± vs ± = score = 0.9 = = = = = = = mutation vs ± 3.8 vs 1.9 ± = ± 1.9 vs 0.9 ± 1.9 = in a new follow-up, 63 of 139 patients developed HCC to the the of liver iron was not associated with the risk of HCC occurrence in this cohort time to vs respectively, 0.9 = to patients with alcoholic optimal liver iron was associated with the risk of HCC In univariate according to the liver iron score was not associated with the risk of only male sex, and of treatment or of were associated with the risk of HCC occurrence in this cohort In multivariate all these only treatment and male sex remained independent risk factors for HCC. follow-up, of 139 patients = or liver = was to liver in all HCC in and/or liver in the other The of liver iron was not associated with the risk of death in this cohort time of vs respectively, = to patients with alcoholic optimal liver iron was associated with the risk of Eighty of 139 patients which to in of patients. of patients had liver In patients with of had liver iron = = vs of = = in patients without = In the of the had liver This liver iron was not associated with the risk of HCC occurrence (HR, = Liver iron score when as a continuous variable was associated in this cohort with male sex, and score Thirteen of patients were of the C282Y mutation Among of developed HCC vs of = to the C282Y mutation carriage was associated with HCC occurrence time to occurrence of vs respectively, 2.7 = In univariate according to the C282Y mutation carriage was associated with the risk of HCC (HR, 2.7 P = .01) with male sex, and liver iron score In multivariate all these C282Y mutation carriage remained an independent risk for HCC with and liver iron score (HR, P = follow-up, of of the C282Y mutation vs of = C282Y mutation carriage was not associated with the risk of death time of vs respectively, = C282Y mutation had higher liver iron scores (3.6 ± 3.8 vs 1.9 ± 2.8, respectively, P = of patients were of the H63D This carriage was not associated with liver iron overload ± vs ± respectively, P = or with the of HCC (HR, = or death (HR, = of 139 patients were of the C282Y mutation Among of 17 developed HCC vs of = to the C282Y mutation carriage was not associated with the risk of HCC occurrence time to occurrence of vs respectively, = follow-up, of 17 of the C282Y mutation vs of = C282Y mutation carriage was not associated with the risk of death time of vs respectively, = of 139 patients were of the H63D This carriage was not associated with liver iron overload ± vs 0.9 ± respectively, P = or with the of HCC (HR, = or death (HR, 0.9 = Finally, C282Y H63D mutations in this cohort not with HCV-related cirrhosis were and had a liver and liver iron scores patients with alcoholic cirrhosis: mean iron score, 0.9 ± 1.9 to = = vs mean iron score, 2.0 ± to = = = the of HCV-infected patients with liver iron iron score, was compared with alcoholic patients vs respectively, P = with HCV-related cirrhosis had a higher of HCC for a time to occurrence of vs respectively, = but this not in multivariate including sex, and cohorts were compared the influence of liver iron overload on the risk of HCC by the the of multivariate this the for patients with HCV-related cirrhosis was = compared with = in patients with alcoholic cirrhosis. iron metabolism in 2 cohorts of cirrhotic patients according to the cause of their liver disease, our suggest that liver iron overload and HFE gene mutations not in or In our patients with HCV-related cirrhosis had hepatic iron scores patients with alcoholic cirrhosis a this iron accumulation not influence the risk of HCC occurrence or death in these patients and was not associated with the of HFE gene The of iron accumulation in hepatitis C are not clearly several works a with HFE gene L. C. et of iron and gene mutations in patients with hepatitis Full Text Full Text PDF PubMed Scopus Google Scholar, A. A. et iron overload in patients with role of HFE gene PubMed Scopus Google Scholar whereas as in our S. et for the gene in liver and on liver 2000; PubMed Scopus Google Scholar, D. G. et role of iron and gene mutations in the of liver in hepatitis 2002; PubMed Scopus Google Scholar suggest that other genetic or factors in hepatic iron it has been that the liver iron overload observed in the course of hepatitis C could be a of leading to of and by E. A. P. et al.Liver iron and in hepatitis C before and PubMed Scopus Google Scholar, C. C. et al.Liver iron accumulation in patients with hepatitis prevalence and role of gene mutations and with hepatic Hepatol. Full Text Full Text PDF PubMed Scopus Google Scholar Indeed, iron overload to be associated with increased and E. A. P. et al.Liver iron and in hepatitis C before and PubMed Scopus Google Scholar, C. C. et al.Liver iron accumulation in patients with hepatitis prevalence and role of gene mutations and with hepatic Hepatol. Full Text Full Text PDF PubMed Scopus Google Scholar and a study that on liver iron accumulation in patients with hepatitis C that the observed iron overload in these patients to liver but not liver et iron and with HFE 2003; Full Text PDF PubMed Scopus Google Scholar Finally, the lack of influence of HFE gene mutations on HCC occurrence in our work is with all previous case-control studies in HCV-related cirrhotic E. Rodriguez M. Gonzalez S. et al.HFE gene mutations in alcoholic and virus-related cirrhotic patients with hepatocellular carcinoma.Am J Gastroenterol. 2002; 97: 1016-1021Crossref PubMed Google Scholar, V. Castera L. de Roux N. et al.Lack of association between HFE gene mutations and hepatocellular carcinoma in patients with cirrhosis.Gut. 2003; 52: 1178-1181Crossref PubMed Scopus (53) Google Scholar, 13Cauza E. Peck-Radosavljevic M. Ulrich-Pur H. et al.Mutations of the HFE gene in patients with hepatocellular carcinoma.Am J Gastroenterol. 2003; 98: 442-447Crossref PubMed Scopus (53) Google Scholar these suggest that moderate liver iron accumulation in the course of hepatitis C is not clearly to the of HFE gene mutations and not lead to a higher of HCC in patients with HCV-related because it is or because hepatocarcinogenesis in the course of this is not to oxidative but to an role of the with the of and factors for HCC occurrence in large cohorts of HCV-infected patients without the influence of the virus on hepatocarcinogenesis to increased hepatic iron accumulation is a to liver injury in the course of alcoholic liver by which leads to liver iron overload been Y. et accumulation in alcoholic liver Clin PubMed Scopus Google Scholar liver iron overload is a in studies, studies failed up to now to clearly role as a risk for HCC, in patients with S. Mandelli C. Piperno A. et al.Survival and prognostic factors in 212 Italian patients with genetic hemochromatosis.Hepatology. 1992; 15: 655-659Crossref PubMed Scopus (202) Google Scholar or patients with HCC developed on noncirrhotic V. et al.Increased of HFE C282Y mutations in patients with iron overload and hepatocellular carcinoma developed in Hepatol. 2000; Full Text Full Text PDF PubMed Scopus Google Scholar The work a strong association between this and the risk of HCC occurrence in patients with alcoholic when liver iron overload as a continuous variable or in a binary of the major for a role of liver iron in hepatocarcinogenesis is the hepatic iron and male sex, which are also risk factors for HCC in cirrhotic patients. a multivariate including these factors is to an independent role of hepatic iron such an was in our study by the large of because of a of our the predictive of C282Y mutation a that liver iron is not the of other risk the observed influence of liver iron on death in these patients et with the optimal threshold N. Christidis C. Chastang C. et al.Liver iron is predictive of death in alcoholic cirrhosis: a multivariate study of 229 consecutive patients with alcoholic and/or hepatitis C virus cirrhosis: a prospective follow up study.Gut. 2000; 46: 277-282Crossref PubMed Scopus (109) Google a of this carcinogenic because patients with high liver iron overload liver before developing HCC. The influence of the C282Y mutation carriage on the risk of HCC as well as on hepatic iron overload is debated. but not case-control studies a higher prevalence of this mutation in patients with HCC developed on alcoholic cirrhosis with higher liver iron C. Poppl A. Hartmann A. et al.HFE C282Y heterozygosity in hepatocellular carcinoma: evidence for an increased prevalence.Clin Gastroenterol Hepatol. 2003; 1: 279-284Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar, 11Lauret E. Rodriguez M. Gonzalez S. et al.HFE gene mutations in alcoholic and virus-related cirrhotic patients with hepatocellular carcinoma.Am J Gastroenterol. 2002; 97: 1016-1021Crossref PubMed Google Scholar as in the Because the prevalence of this mutation is in the all these studies, including a lack of this our the influence of this mutation on the risk of HCC in alcoholic cirrhotic this association remains in multivariate in and the association between the C282Y mutation carriage with higher liver iron scores that the observed influence of this mutation on hepatocarcinogenesis in alcoholic patients is to hepatic iron HFE C282Y mutation is not the alcoholic patients develop hepatic iron factors such as the of or other could be In seeking for genetic factors other HFE gene mutations this accumulation is of major studying the influence of displayed a role of the in by and in in liver iron accumulation and HCC A. P. D. et in modulate hepatic iron accumulation and hepatocellular carcinoma development in patients with 2006; PubMed Scopus Google Scholar, P. A. D. et in and to alcoholic hepatocellular and Gastroenterol Hepatol. Full Text Full Text PDF PubMed Scopus Google Scholar the that hepatic iron accumulation could be also a and not only a cause of oxidative in the course of alcoholic liver disease, the of a that liver iron overload on initial biopsy and C282Y mutation carriage influence the of alcoholic cirrhotic patients is with previous studies in patients with liver disease. Indeed, it has been that iron overload in patients liver was associated with an increased prevalence of K.V. S. et liver cancer and survival in patients liver for 1: PubMed Scopus Google Scholar Moreover, carriage of the C282Y mutation, presumably by iron was also associated with a in patients for M. P. A. et of HFE mutations and of for hepatocellular carcinoma in cirrhotic 2000; PubMed Scopus Google Scholar that these at the time of diagnosis of alcoholic a and that liver iron overload could be a before the of liver disease. these the to prospectively HCC risk factors in cohorts of cirrhotic patients. suggest in patients with alcoholic liver iron overload is a major risk of HCC occurrence. strategies to liver iron in patients help to clarify to HCC occurrence by iron or and be in the in alcoholic cirrhotic patients with liver iron overload and/or of the C282Y Iron, and The of of liver to with the hepatitis C virus has been increasing to the of this is the of new to and modulate other of HCV-related liver disease. is a well of hepatic in patients with hepatitis role for iron in the of hepatitis C has also been PDF