Serum zinc, copper and iron in children with chronic liver diseases

1

Study of serum zinc, copper and iron in

children with chronic liver diseases

By

NOHA LOTFY IBRAHIM

Ahmad mohamed sira

2

3

Introduction

Chronic liver diseases (CLDs) in

children constitutes a major health burden,

on both parents and the diseased child.

They may be caused by infectious,

autoimmune, metabolic, vascular, drugs

and toxins or idiopathic etiologies.

(Hardy and Kleinman, 2007).

4

Introduction

Many of these CLDs progress towards

cirrhosis and eventually liver failure. In

spite some of these disease categories are

subjected to specific treatment with good

prognosis, some are not responding to

treatment, specially when there is no an

identifiable etiology. (Hardy and Kleinman,

2007).

5

Introduction

Liver regulates the metabolic pathways and

transport of trace elements, and consequently

their bioavailability, tissue distribution and

eventual toxicity. The liver also has a role in

the excretion of trace elements through bile

formation. (Kolachi et al., 2012).

6

Introduction

Many trace elements play important roles in

a number of biological processes, through

their activating or inhibiting of enzymatic

reactions, competing with other elements or

metallo-proteins for binding sites, and

affecting the permeability of cell

membranes.(Lin et al., 2006).

7

Introduction

Some trace elements such as zinc (Zn), iron

(Fe), and copper (Cu) exert important

protective or enhancing effects on the

progression of some diseases.(Goldhaber, 2003).

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Introduction

Zn is an essential and the most abundant

intracellular trace element, that plays a

central role in cellular growth and

differentiation. It is a common cofactor of

various enzymatic systems, including the

ammonium metabolism and urea cycle,

which occurs in the liver.(Mohammad et al., 2012)

9

Introduction

Zn is involved in stabilizing the cell

membrane and prevents oxidative

destruction caused by free radicals. The

antioxidant effects of Zn include the

induction of metallothionein (Zn-binding

protein, formed by the liver), which is a

potent scavenger of toxic metals and

hydroxyl radical. (Prasad et al., 2004).

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Fe and Cu ions catalyze the production of

hydroxyl radical from hydrogen peroxide (H2O2).

Zn is known to compete with both Fe and Cu for

binding to cell membrane, thus decreasing the

production of hydroxyl radical (Tuerk and Fazel, 2009).

Thus, it is clear that Zn has multiple roles as an

antioxidant, and is therefore, an excellent

candidate for clinical chemoprevention trials in

humans (Kolachi et al., 2012).

Introduction

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Serum Zn levels among children with CLDs

have not been fully investigated in a large

number of children, and thus, Zn is not a part

of the recommended micronutrient intake for

these patients. It is, likewise, unknown

whether there is an association between the

Zn status and the severity of liver diseases.

(Umusig-Quitain and Gregorio, 2010).

Introduction

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Cu is a trace element that is essential for the

growth and differentiation of cells. However,

it is highly toxic in excess, and results in

cellular damage. It functions as a cofactor in

various redox reactions, and the formation of

deleterious free radicals is enhanced by the

presence of Cu ions.

(Florianczyk, 2003).

Introduction

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Fe is required for many enzymes that are critical

for cellular function. It also plays a fundamental

role in oxygen carrying proteins such as

hemoglobin and myoglobin. However, Fe can be

toxic when present in excess, as it is able to

catalyze the formation of reactive oxygen species.

Highly specialized proteins have been developed

for efficient extracellular transport (transferrin) and

intracellular storage (ferritin) of Fe. (Deugnier et al., 2008).

Introduction

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Aim of the study

The aim of this study is to measure serum

level of essential trace elements in children

with CLDs, regardless the etiology and

correlate these serum levels with

biochemical measures of liver damage,

transaminases, and other liver function

tests.

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Patients and methods

This study included 50 children with CLDs, were

taken from the attendants of the outpatient and

inpatient clinic of Pediatric Hepatology Department,

National Liver Institute, Menoufiya University from

October 2010 to February 2012.

Another group of 50 healthy children age and sex

matched, were enrolled as a control group.

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B-Clinical examination

C- The following investigations

A- Full history taking

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Patients and methods

Laboratory investigations: (A) Liver function

tests including:

Serum ALT

Serum AST

Serum GGT

Serum ALP

Serum total and direct bilirubin

Serum albumin

Serum total protein

All were measured using Automated Beckman

Coulter Analyzer.

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Patients and methods

(B) Trace elements tests including:

Serum Cu was based on Colorimetric test with

Dibrom-PAESA using Biosystem Photometer

Chemistry Analyzer.

Ceruloplasmin (Cp) was measured using radial

immunodiffusion (RID).

Serum Zn was based on Colorimetric test with 5-

brom-PAPS using Biosystem Photometer

Chemistry Analyzer.

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Patients and methods

Serum (Fe / TIBC) based on Colorimetric test with

guanidine / ferrozine method using Biosystem

Photometer Chemistry Analyzer.

Ferritin was measured using ubi magiwel™ ferritin

quantitative device by ELISA.

Transferrin saturation (TS) was calculated by

dividing serum Fe by TIBC.

Statistical analysis was carried out using SPSS

program version 13.

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Results

5.86

6.62

0

1

2

3

4

5

6

7

Age

in y

ears

CLD Control

Figure 1: Comparison between the CLD and control group regarding age.

24

Results

5046

5054

0

10

20

30

40

50

Per

cent

age

(%)

Femal Male

CLD Control

Figure 2: Comparison between the CLD and control group regarding sex.

25

Results

0

1

2

3

4

5

6

7

8

Total Bil D. Bil Total prot Alb

CLD Control

Figure 3: Comparison of total protein, albumin, total and direct bilirubin between CLD group and control group.

26

Results

0

50

100

150

200

250

300

ALT AST ALP GGT

CLD Control

Figure 4: Comparison of ALT, AST, ALP and GGT between CLD group and control group.

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Results

Figure 5: Comparison of serum Zn between the CLD and control group.

CLD Controls0

50

100

150

68.64 19.47

95.92 8.77

P < 0.0001

Serum zinc

Zn

( g

/dl)

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Results

Figure 6: Comparison of serum Cu between the CLD and control group.

CLD Controls50

100

150

200

149.0 17.85

94.84 10.97

P < 0.0001

Serum copper

Cu

( g

/dl)

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Results

Figure 7: Comparison of serum CP between the CLD and control group.

CLD Controls0

10

20

30

40

50

20.08 ± 4.05

31.58 ± 2.41

P < 0.01

Ceruloplasmin

CP

(m

g/d

l)

30

Results

Figure 8: Comparison of serum Cu/Zn ratio between the CLD and control group.

CLD Controls0

1

2

3

4

5

2.67 ± 1.02

0.99 ± 0.08

P < 0.01

Cu/Zn ratio

Cu

/Zn

rat

io

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Results

Figure 9: Comparison of serum Fe between the CLD and control group.

CLD Controls

80

120

160

115.41 17.23

98.82 13.56

P < 0.0001

Serum iorn

Fe

(g

/dl)

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Results

Figure 10: Comparison of serum TIBC between the CLD and control group.

CLD Controls250

300

350

400

450

319.02 22.34363.06 23.43

P < 0.0001

Total iorn binding capacity

TIB

C ( g

/dl)

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Results

Figure 11: Comparison of serum Ferritin between the CLD and control group.

CLD Controls0

100

200

300

400

500

131.58 100.52 68.12 12.46

P < 0.0001

Ferritin

Fer

riti

n (

ng

/ml)

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Results

Figure 12: Comparison of serum TS between the CLD and control group.

CLD Controls10

20

30

40

50

60

36.59 7.32 27.46 4.84

P < 0.0001

Transferrin saturation

TS

(%

)

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Results

Table1: Correlation of trace elements with each other and with liver function tests in CLD group

Studied variable

Zn Cu Fe

r p r p r p

Cu - 0.585 < 0.01

Fe - 0.633 < 0.01 0.699 < 0.01

AST - 0.402 < 0.01 0.581 < 0.01 0.508 < 0.01

ALT - 0.429 < 0.01 0.533 < 0.01 0.502 < 0.01

ALP - 0.175 NS 0.218 NS 0.126 NS

GGT - 0.171 NS 0.353 < 0.05 0.114 NS

Total bilirubin

- 0.216 NS 0.405 < 0.01 0.226 NS

Direct bilirubin

- 0.269 NS 0.446 < 0.01 0.243 NS

Albumin 0.202 NS - 0.203 NS - 0.149 NS

Total protein 0.108 NS - 0.098 NS 0.047 NS

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Conclusion

Serum Fe, Cu, ferritin, TS and Cu / Zn

ratio are significantly elevated in

children with CLDs.

Serum Zn, Cp and TIBC are

significantly decreased in children with

CLDs.

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Conclusion

Serum Fe, Cu, ferritin, TS and Cu / Zn

ratio are positively correlated with

biochemical parameters of liver damage

in children with CLDs.

Serum Zn, Cp and TIBC are negatively

correlated with biochemical parameters

of liver damage in children with CLDs.

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Recommendations

Serum Zn, Cu and Fe could be included

in the routine assessment of children

with CLDs.

Zn supplementation may be encouraged

in children with CLDs as it is an

antioxidant and it is negatively correlated

with liver damage parameters.

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Recommendations

Caution regarding Fe and Cu intake

either dietary or medicinal; should be

taken in children with CLDs.

The level of certain trace elements

such as Cu, Fe, Zn and Cu / Zn ratio

may serve as biomarkers for

monitoring the increased severity of

liver damage in children of CLDs.

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Recommendations

Studies on the action of Zn as

antioxidant agent are recommended.

Studies on the action of Cu and Fe as

promoters for oxidative stress are

recommended.

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