Trace elements play a major role as both oxidants and antioxidants, promoting and protecting from tissue damage. The liver plays a pivotal role in the metabolism of trace elements and consequently their bioavailability. Therefore, we aimed to measure serum levels of essential trace elements in children with chronic liver diseases (CLDs) and to study their correlation with liver function tests.

1. Study of serum zinc,
copper and iron in
children with
chronic liver
diseases
By
NOHA LOTFY IBRAHIM
Ahmad mohamed sira
1

2. 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).
3

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).
4

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).
5

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
affecting
the
for
binding
permeability
sites,
and
of
cell
membranes.
(Lin et al., 2006).
6

7. Introduction
 Some trace elements such as zinc (Zn), iron
(Fe),
and
protective
copper
or
(Cu)
enhancing
exert
important
effects
on
the
progression of some diseases.
(Goldhaber, 2003).
7

8. 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)
8

9. Introduction
 Zn
is
involved
membrane
in
and
stabilizing
the
cell
prevents
oxidative
destruction caused by free radicals. The
antioxidant
induction
effects
of
of
Zn
metallothionein
include
the
(Zn-binding
protein, formed by the liver), which is a
potent scavenger of toxic metals and
hydroxyl radical.
(Prasad et al., 2004).
9

10. Introduction
 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).
10

11. Introduction
 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).
11

12. Introduction
 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).
12

13. Introduction
 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).
13

14. 14

15. 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.
15

16. 16

17. 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.
17

18. A- Full history taking
B-Clinical examination
C- The following investigations
18
18

19. 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
19
Coulter Analyzer.

20. 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 5brom-PAPS
using
Biosystem
Photometer
Chemistry Analyzer.
20

21. 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.
21

22. 22

23. Results
Figure 1: Comparison between the CLD and control group regarding
age.
6.62
5.86
7
6
Age in years
5
4
3
2
1
0
CLD
Control
23

24. Results
Figure 2: Comparison between the CLD and control group regarding
sex.
46
54
50
50
Percentage (%)
50
40
30
20
10
0
Femal
Male
CLD
Control
24

25. Results
Figure 3: Comparison of total protein, albumin, total and direct
bilirubin between CLD group and control group.
8
7
6
5
4
3
2
1
0
Total Bil
D. Bil
Total prot
CLD
Alb
Control
25

26. Results
Figure 4: Comparison of ALT, AST, ALP and GGT between CLD
group and control group.
300
250
200
150
100
50
0
ALT
AST
ALP
CLD
GGT
Control
26

27. Results
Figure 5: Comparison of serum Zn between the CLD and control
group.
P < 0.0001
150
Zn (µg/dl)
95.92 ± 8.77
100
68.64 ± 19.47
50
0
CLD
Controls
Serum zinc
27

28. Results
Figure 6: Comparison of serum Cu between the CLD and control
group.
P < 0.0001
Cu (µg/dl)
200
150
149.0 ± 17.85
94.84 ± 10.97
100
50
CLD
Controls
Serum copper
28

29. Results
Figure 7: Comparison of serum CP between the CLD and control
group.
P < 0.01
50
31.58 ± 2.41
CP (mg/dl)
40
30
20.08 ± 4.05
20
10
0
CLD
Controls
Ceruloplasmin
29

30. Results
Figure 8: Comparison of serum Cu/Zn ratio between the CLD and
control group.
P < 0.01
5
Cu/Zn ratio
4
3
2.67 ± 1.02
2
0.99 ± 0.08
1
0
CLD
Controls
Cu/Zn ratio
30

31. Results
Figure 9: Comparison of serum Fe between the CLD and control
group.
P < 0.0001
Fe (µg/dl)
160
120
115.41 ± 17.23
98.82 ± 13.56
80
CLD
Controls
Serum iorn
31

32. Results
Figure 10: Comparison of serum TIBC between the CLD and control
group.
P < 0.0001
TIBC (µg/dl)
450
400
319.02 ± 22.34
363.06 ± 23.43
350
300
250
CLD
Controls
Total iorn binding capacity
32

33. Results
Figure 11: Comparison of serum Ferritin between the CLD and control
group.
P < 0.0001
Ferritin (ng/ml)
500
400
300
200
100
0
131.58 ± 100.52
68.12 ± 12.46
CLD
Controls
Ferritin
33

34. Results
Figure 12: Comparison of serum TS between the CLD and control
group.
60
P < 0.0001
TS (%)
50
40
36.59 ± 7.32
27.46 ± 4.84
CLD
Controls
30
20
10
Transferrin saturation
34

35. Results
Table1: Correlation of trace elements with each other and with liver
function tests in CLD group
Studied variable
Zn
Cu
r
p
Cu
- 0.585
< 0.01
Fe
- 0.633
AST
Fe
r
p
r
p
< 0.01
0.699
< 0.01
- 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
35
NS

36. 36

37. 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.
37

38. 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.
38

39. 39

40. 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
correlated
with
parameters.
it
is
negatively
liver
damage
40

41. 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
41
liver damage in children of CLDs.

42. 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.
42

43. 43