Comparative Analysis of Erythroferrone and Hepcidin as Emerging Biomarkers of Iron Homeostasis in Patients with β-Thalassemia Major: A Case-Control Study from Pakistan.

Iron dysregulation in β-thalassemia major arises from a cycle of ineffective erythropoiesis, chronic transfusions, and suppressed hepcidin activity, leading to progressive iron overload and multi-organ toxicity. Erythroferrone (ERFE) plays a key role in modulating hepcidin and is associated with iron overload in β-thalassemia. This study aimed to evaluate ERFE and hepcidin levels in patients with β-thalassemia major with high plasma ferritin, and to compare them with those of healthy controls, while controlling for age, gender, disease progression, transfusion effects, chelation therapy, and splenomegaly. In this cross-sectional study, 85 participants (45 patients with β-thalassemia and 40 healthy controls) were enrolled. Blood samples were collected from patients 2 weeks post-transfusion to minimize the impact of the transfusion on ERFE and hepcidin levels. ERFE and hepcidin levels were measured by immunoassay. ERFE levels were significantly higher in patients with β-thalassemia (90.00 ng/ml [75.25 - 103.50]) than in controls (19.30 ng/ml [13.85 - 30.22]), whereas hepcidin levels were lower in patients (22.80 ng/ml [17.40 - 33.17]) than in controls (49.55 ng/ml [30.42 - 74.12]). Ferritin was significantly elevated in patients at 2998.00 ng/ml (1998.50 - 4087.50), concurrent with increased serum iron at 234.00 μg/dl (182.00-264.00) and decreased iron-binding capacity. Notable correlations included an inverse relationship between ERFE and hepcidin (ρ = -0.408, p = 0.005) and a positive correlation between ERFE and ferritin (ρ = 0.320, p = 0.032). These findings reveal a significant association of elevated ferritin with iron overload in β-thalassemia major. Hepcidin suppression appears primarily disease-driven, and ERFE inversely correlates with hepcidin levels. Targeted interventions are necessary to address iron overload and dysregulated hepcidin in affected individuals.