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Iron, alcohol, biopsy
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Iron, alcohol, biopsy

I am a 27 y/o male in generally good health (I hope).  However, a few years ago (about 3) I took high dose iron supplements for a few months.  At the time I was ignorant about iron toxicity and also abused alcohol.  Since then I now avoid any supplemental iron and only consume about 3 alcoholic drinks/month.  

My basic concern is if I've damaged my liver.  I understand alcohol increases iron absorption and toxicity.  I've read the same applies for vitamin a and because I was taking a multivitamin at the time I was abusing alcohol and taking iron that the combination may have caused fibrosis of my liver.  I'm not nor have I ever been an alcoholic, but for a period of about 5 years (college and thereafter) I was quite a heavy drinker.  In the past few years I've turned my lifestyle around to be quite healthy.  However, I'm still concerned the iron and alcohol may have damaged my liver.    

I've had the standard LFT's several times--always in normal range, but my bilirubin (direct and indirect) is always right on the border of being abnormally high.  My platelet count is normal at about 200 and normal albumin.  However my transferrin saturation has ranged from 35-54% on different occassions.  I'm aware that even cirrhotic patients may have completely normal LFT's and other labs.  I do not have any viral hepatitis.

My ferritin has ranged from 70-85, which I thought was very good/low and that below 1000 liver damage was unlikely.  However I found an article on pubmed titled "serum ferritin in iron overload and liver damage: correlation to body iron stores and diagnostic relevance" which basically says serum ferritin is a poor indicator of liver damage/iron stores in patients with iron overload.  (I don't want a hemochromatosis genetic analysis due to the possibilit of genetic discrimination).

I have a (second) appointment w/ a hepatologist this week.  I know that liver biopsy is a serious thing, but we are going to discuss the possibility as it is the gold standard for assessing hepatic iron stores and fibrosis.  Here are my questions:

1. I understand ultrasound/CT/MRI cannot distinguish fatty liver from fibrosis/cirrhosis.  Can it tell if my liver is normal?

2.  Can I rely on serum ferritin to indicate the liver iron load or would biopsy be more accurate?  My transferrin saturation was once high at 54 while ferritin was only 70.  

3.  If ferritin is an unreliable marker of hepatic iron stores in those with iron overload (per the article I referenced), how does one go about managing phlebotomy is it is indicated?  

Basically I'd like to know what the best course of action is in terms of diagnosis and treatment if necessary.  Should I have a biopsy to check for fibrosis/ iron overload? It is important for my piece of mind to know if there is a problem or not.  If there is overload can I rely on ferritin to guide phlebotomy?  Any other advice you can give would be much appreciated.  Thanks for your time and help.  
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To answer your questions:
1) An ultrasound would be the most reasonable initial test.  It can suggest cirrhosis.  However, the only way to be sure would be via a liver biopsy.

2) The biopsy will be more accurate.  However, with the ferritin at your level, hemochromatosis is less likely.

3) You are correct in that ferritin is an unreliable marker of iron stores.  Despite that, that level, as well as the transferrin saturation, are the principal ways currently used to measure response to phlebotomy.

If the studies for iron stores are non-revealing, biopsy and genetic testing can be considered if hemochromatosis is still in question.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
http://www.straightfromthedoc.com
2 Comments
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Addition:  Prothrombin time normal at 10.0, INR normal at 1.0
No diabetes or anemia.
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OK, I know I've already posted about a million questions on my thread, but am curious if fibrosure might be an alternative to biopsy even though I don't have HCV?  My understanding is it is good at distinguishing none/mild fibrosis from severe/cirrhosis but is rather gray inbetween.
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