L'hémochromatose génétique liée au gène HFE (HG) se caractérise par une augmentation de la saturation de la transferrine plasmatique, qui entraîne une surcharge en fer. Ces anomalies sont dues à une sécrétion basse d'hepcidine, le régulateur principal du métabolisme du fer, et définissent le phénotype d'hepcidino déficience. De nouvelles formes de surcharges en fer ayant un phénotype similaire ont été identifiées. Les mécanismes moléculaires en sont parfois mal compris. L'objectif général de ce travail a été de caractériser sur le plan clinique, fonctionnel, et biologique, des surcharges en fer rares d'origine génétique ayant pour point commun un phénotype d'hepcidino-déficience. Nous avons d'abord analysé une cohorte de patients porteurs d'une HG, forme type de l'hepcidino-déficience, et montré que la transplantation hépatique normalisait le métabolisme du fer, montrant ainsi le rôle majeur du foie dans le phénotype d'hepcidino-déficience de l'HG. Nous avons ensuite caractérisé des surcharges en fer à saturation de la transferrine élevée liées à des anomalies de transport du fer : i) nous avons rapporté un cinquième cas de mutations du gène DMT1 et montré le caractère pathogène de la mutation p.Asn491Ser ; ii) nous décrivons un groupe de 12 patients qui présentent une mutation hétérozygote du gène TF, l'augmentation de la saturation de la transferrine ne semblant pas être en rapport avec une hepcidino-déficience, et l'existence de cofacteurs pouvant faciliter la surcharge en fer. Nous avons ensuite décrit l'impact de mutations du gène TFR2, qui sont responsables d'une hepcidino déficience dont l'expression clinique est hétérogène mais qui peut être très précoce. Nous avons alors, pour préciser les mécanismes liant les mutations du gène TFR2 à une diminution anormale de l'hepcidine, montré in vitro que les mutations p.Asn12Ile et p.Gly430Arg altèrent l'adressage cellulaire de TFR2 tandis que la mutation p.Arg768Pro altère son interaction avec la transferrine. N'ayant pu parvenir à induire l'expression d'hepcidine sous l'effet de la transferrine, au contraire de certaines équipes mais en accord avec d'autres, nous n'avons pu analyser l'impact des mutations sur la transduction du signal liant TFR2 et hepcidine. Nos résultats contribuent à préciser les mécanismes impliqués dans l'apparition de surcharges en fer rares à saturation élevée de la transferrine. / HFE related hemochromatosis (HH) is characterized by an increased plasma transferrin saturation level, which causes iron overload. These anomalies are due to low hepcidin secretion, the key regulator of iron metabolism, and define the hepcidin deficiency phenotype. New forms of iron overload with similar phenotype were identified, but their molecular mechanisms remain unclear. The main objective of this work was to characterize the clinical, functional, and biological aspects of rare genetic iron overload with an hepcidin deficiency phenotype. We firstly analyzed a cohort of HH patients, archetype of hepcidin-deficiency and showed that liver transplantation cured the disease, demonstrating the major role of the liver in the phenotype. We then characterized iron overloads with high transferrin saturation related to abnormalities of iron transport: i) we reported a fifth case of patient with DMT1 gene mutations and demonstrated the pathogenicity of the mutation p.Asn491Ser; ii) we described 12 patients with heterozygous mutation of the TF gene, leading to serum transferrin decrease. The increase of transferrin saturation associated to the disease does not seem to be related to a hepcidin-deficiency, and the presence of cofactors may facilitate iron overload. We then described the impact of mutations in the TFR2 gene, which induce hepcidin-deficiency whose expression is heterogeneous but that can occur in young peoples. Then we tried to clarify in vitro the mechanisms linking mutations in the TFR2 gene to an abnormal decrease of hepcidin and showed that the p.Asn12Ile and p.Gly430Arg mutations alter the TFR2 protein intracellular trafficking while the p.Arg768Pro mutation alters its interaction with transferrin. Being unable to induce expression of hepcidin in response to transferrin, unlike some authors, but in agreement with others, we were not able to analyze the impact of mutations on signal transduction toward hepcidin. Our results help to clarify the mechanisms involved in the development of iron overload in rare high saturation of transferrin.

Proefschrift Maastricht. / Met lit. opg. en samenvatting in het Nederlands.

Este trabalho consistiu no desenvolvimento de um sistema para medir a magnetização de amostras paramagnéticas e diamagnéticas em grandes volumes. Sua principal aplicação tem sido a medida susceptométrica do tecido hepático para a quantificação da sobrecarga de ferro no fígado. Esse excesso de ferro no corpo é comum em pacientes talassêmicos e falcêmicos, que são regularmente submetidos a transfusões de sangue e, em pacientes com hemocromatose. Em pessoas normais, esse depósito de ferro pode conter entre 0,1 e 0,5 mg de ferritina (ftn) por grama de tecido úmido (mg ftn/gtecido úmido). Quando com sobrecarga, pode alcançar até 30 mg ftn/gtecido úmido. A contribuição diamagnética devido à presença dos tecidos biológicos (água, pele, gordura, músculo, nervo, osso, etc) é equivalente à contribuição paramagnética devido à presença de, aproximadamente, 6 mg ftn/gtecido úmido distribuídos no tecido hepático. Essa intensa contribuição diamagnética foi sensivelmente reduzida com o uso de uma bolsa de água acoplada ao torso. Medidas in vitro foram realizadas num phantom, composto de um tubo cilíndrico de acrílico preenchido com água e uma esfera de plástico, acoplada internamente ao cilindro, preenchida com solução de Fe3+. O volume cilíndrico representa os tecidos e o esférico representa o fígado. Medidas in vivo foram realizadas com duas modalidades: com e sem o uso da bolsa de água sobre o torso. Essas medidas foram efetuadas em voluntários assintomáticos e pacientes talassêmicos sob tratamento no Hemocentro de Ribeirão Preto (HRP). A medida da magnetização foi realizada com um gradiômetro axial de segunda ordem, acoplado a um SQUID-RF. A amostra foi magnetizada com um campo magnético AC e homogêneo. Os resultados confirmaram a sensibilidade da técnica para quantificar níveis de ferro hepático em pacientes com sobrecarga, com eficiência de diferenciar níveis equivalentes àqueles encontrado(s) em pessoas normais. A automatização da instrumentação e a aquisição dos dados foram feitas em ambiente LabView e as simulações dos modelos, apresentadas juntamente com os processamentos dos sinais, foram realizadas em ambiente MatLab. / This work consisted in the development of a system to measure the magnetization of large paramagnetic and diamagnetic samples. The main application was susceptometric measurements of the hepatic tissue for quantification of the iron overload. Iron excess is commonly observed in thalassemic and sickle cell anemia patients who have repeatedly received red blood cell transfusions for prevention or treatment of chronic complications and in patients with hemocromatosis. In normal subjects, iron concentration is usually between 0.1 and 0.5 mg of ferritin by gram of wet tissue (mg ftn/gwet tissue). However, in individuals with the above diseases, it can reach up to 30 mg ftn/gwet tissue. The diamagnetic contribution due to the presence of biological tissues (water, skin, fat, muscle, nerve, bone, etc) is equivalent to the paramagnetic contribution due to the presence of approximately 6 mg ftn/gwet tissue distributed in the hepatic tissue. This intense diamagnetic contribution was makedly reduced by using a water bag coupled to the subject’s torso. Measurements in vitro were performed in a phantom composed of a cylindrical acrylic tube, filled with pure water containing a plastic sphere placed off axis to simulate the liver position. The sphere was filled with a Fe3+ solution to simulate different iron concentration present in the liver. Measurements in vivo were performed in thalassemic patients undergoing treatment at the Hemocentro de Ribeirão Preto (HRP) and in normal subjects using two different modalities: with and without the use of the water bag on the torso. The measurements of the magnetization were made using a second order axial gradiometer coupled to a RF SQUID. The sample was magnetized using a homogeneous AC magnetic field. The results confirmed the sensitivity of the technique to quantify levels of hepatic iron in patients with overload, with efficiency of differentiating iron levels equivalent to that found in normal subjects. Automation of instrumentation and data acquisition were done in LabView (National Instruments) and susceptometric models simulations and the signal processing were done in MatLab environment.

Este trabalho consistiu no desenvolvimento de um sistema para medir a magnetização de amostras paramagnéticas e diamagnéticas em grandes volumes. Sua principal aplicação tem sido a medida susceptométrica do tecido hepático para a quantificação da sobrecarga de ferro no fígado. Esse excesso de ferro no corpo é comum em pacientes talassêmicos e falcêmicos, que são regularmente submetidos a transfusões de sangue e, em pacientes com hemocromatose. Em pessoas normais, esse depósito de ferro pode conter entre 0,1 e 0,5 mg de ferritina (ftn) por grama de tecido úmido (mg ftn/gtecido úmido). Quando com sobrecarga, pode alcançar até 30 mg ftn/gtecido úmido. A contribuição diamagnética devido à presença dos tecidos biológicos (água, pele, gordura, músculo, nervo, osso, etc) é equivalente à contribuição paramagnética devido à presença de, aproximadamente, 6 mg ftn/gtecido úmido distribuídos no tecido hepático. Essa intensa contribuição diamagnética foi sensivelmente reduzida com o uso de uma bolsa de água acoplada ao torso. Medidas in vitro foram realizadas num phantom, composto de um tubo cilíndrico de acrílico preenchido com água e uma esfera de plástico, acoplada internamente ao cilindro, preenchida com solução de Fe3+. O volume cilíndrico representa os tecidos e o esférico representa o fígado. Medidas in vivo foram realizadas com duas modalidades: com e sem o uso da bolsa de água sobre o torso. Essas medidas foram efetuadas em voluntários assintomáticos e pacientes talassêmicos sob tratamento no Hemocentro de Ribeirão Preto (HRP). A medida da magnetização foi realizada com um gradiômetro axial de segunda ordem, acoplado a um SQUID-RF. A amostra foi magnetizada com um campo magnético AC e homogêneo. Os resultados confirmaram a sensibilidade da técnica para quantificar níveis de ferro hepático em pacientes com sobrecarga, com eficiência de diferenciar níveis equivalentes àqueles encontrado(s) em pessoas normais. A automatização da instrumentação e a aquisição dos dados foram feitas em ambiente LabView e as simulações dos modelos, apresentadas juntamente com os processamentos dos sinais, foram realizadas em ambiente MatLab. / This work consisted in the development of a system to measure the magnetization of large paramagnetic and diamagnetic samples. The main application was susceptometric measurements of the hepatic tissue for quantification of the iron overload. Iron excess is commonly observed in thalassemic and sickle cell anemia patients who have repeatedly received red blood cell transfusions for prevention or treatment of chronic complications and in patients with hemocromatosis. In normal subjects, iron concentration is usually between 0.1 and 0.5 mg of ferritin by gram of wet tissue (mg ftn/gwet tissue). However, in individuals with the above diseases, it can reach up to 30 mg ftn/gwet tissue. The diamagnetic contribution due to the presence of biological tissues (water, skin, fat, muscle, nerve, bone, etc) is equivalent to the paramagnetic contribution due to the presence of approximately 6 mg ftn/gwet tissue distributed in the hepatic tissue. This intense diamagnetic contribution was makedly reduced by using a water bag coupled to the subject’s torso. Measurements in vitro were performed in a phantom composed of a cylindrical acrylic tube, filled with pure water containing a plastic sphere placed off axis to simulate the liver position. The sphere was filled with a Fe3+ solution to simulate different iron concentration present in the liver. Measurements in vivo were performed in thalassemic patients undergoing treatment at the Hemocentro de Ribeirão Preto (HRP) and in normal subjects using two different modalities: with and without the use of the water bag on the torso. The measurements of the magnetization were made using a second order axial gradiometer coupled to a RF SQUID. The sample was magnetized using a homogeneous AC magnetic field. The results confirmed the sensitivity of the technique to quantify levels of hepatic iron in patients with overload, with efficiency of differentiating iron levels equivalent to that found in normal subjects. Automation of instrumentation and data acquisition were done in LabView (National Instruments) and susceptometric models simulations and the signal processing were done in MatLab environment.