however , the iron overload in various organs leads to serious problems such as metabolic , endocrine , and growth abnormalities in such patients despite the expanded use of iron - chelator drugs ( 3 - 5 ) . patients with thalassemia intermedia ( ti ) although the rate of iron loading is slower in ti than in tm , patients with ti can eventually develop complications similar to those of the patients with tm , including hepatic , endocrine and cardiac dysfunction ( 6 ) . moreover , in patients with transfusion independent thalassemia , serum ferritin was a poor predictor of liver iron concentration ; therefore , chelation therapy may be postponed in patients with ti ( 7 ) . hepcidin is a small peptid hormone secreted by hepatocytes to regulate plasma iron concentration and distribution in different tissues ( 8 , 9 ) . chronic excess of hepcidin causes iron restricted anemia ( 9 ) , while the hepcidin deficiency leads to iron overload with iron deposition in the liver and parenchyma ( 10 ) . increased plasma and stored iron stimulate hepcidin production , which in turn blocks dietary iron absorption and consequently iron loading .conversely , hepcidin is suppressed in iron deficiency ( 11 ) . hepcidin concentration is significantly higher in chronically transfused patients than in non - transfused ones , presumably due to iron overload ( 12 - 16 ) . despite using iron chelatorin patients with thalassemia , iron overload is one of the main mortality factors in such patients and hepcidin targeted therapeutics can help with better management of iron overload in patients with thalassemia ( 17 ) . the current study aimed to determine the correlation between serum ferritin and hepcidin levels in patients with tm and ti , also compare serum hepcidin and ferritin levels between the two groups of patients . the current cross - sectional study was conducted in hematology research center of shiraz university of medical sciences , shiraz , iran , in 2013 . the study subjects included 90 patients , 50 tm and 40 ti , selected by systematic random sampling from the 500 tm and 280 ti patients registered at the thalassemia clinic of tertiary state hospital affiliated to shiraz university of medical sciences . this is a referral center with 45 beds for patients with thalassemia in southern iran . this study was approved by medical ethics committee of shiraz university of medical sciences ( grant number : 3652 , approval date : 21.03.2011 ) . the diagnosis of thalassemia was based on complete blood count ( cbc ) , hb electrophoresis and clinical history . in the tm group , blood transfusion had been started before two years old and all of them were on regular blood transfusion every - two to four weeks . in the tm group , inclusion criteria were age above 10 years old , under regular follow up and regular blood transfusion , and iron chelation therapy . in the ti group , inclusion criteria were transfusion independence and taking hydroxyurea ( hu ) 10 - 15 mg / kg / day for a duration of at least ten years . patients with the history of any recent infection or surgery , congestive heart and liver failures as well as positive viral hepatitis were excluded from the study . a 2.5 ml sample of venous blood withdrawn from each participant was added to the tubes containing clot activator . plasma centrifuge was done immediately and 2 ml serum was separated and preserved at -20c , then carried by cold box to the laboratory to check serum hepcidin and ferritin levels . also , 2 ml sample of venous blood was withdrawn from each patient and added to the tubes of cbc containing ethylenediamine tetraacetic acid edta anti - coagulant . complete blood count test was performed immediately with peripheral blood smears and then stained with wright stain and the rate of nucleated red blood cells ( nrbc ) per 100 white blood cells ( wbc ) was counted . fasting serum ferritin was checked by enzyme linked fluorescent assay elfa method , using mini vidas ( biomerievx s.a , france ) machine , and hepcidin was measured by enzyme linked immunosorbent assay elisa method ( competitive assay ) , using elisa reader dynex ( usa ) machine with drg hepcidin kit ( eia 4 705 ) . according to the direction of hepcidin kit manufacturer , the normal range of hepcidin in 5% - 95% of people with the age range of 23 to 67 years is from 13.3 to 54.4 ng / ml . the normal range of ferritin was considered as 20 - 300 g / lin males 10 - 100 g / l in females before menopause , 20 - 200 g / l in females after menopause and 150 - 500 test of normality was done by shapiro - wilk test . among all the evaluated variables , only age had normal distribution . descriptive data were summarized as mean and standard deviation , as well as median and interquartile range ( iqr ) , where appropriate . correlation between serum hepcidin and quantitative variables in each of the two groups of patients with tm and ti was evaluated by spearman correlation test . quantitative data between the two groups of patients were compared by student t - test and mann - whitney test . considering the correlation coefficient of 0.68 for urinary hepcidin and serum ferritin levels reported by origa et al . ( 14 ) in 44 patients with thalassemia including 22 tm and 22 ti ,  = 0.05 and  = 0.01 , the sample size was estimated as 29 patients in each group . for higher accuracy , sample size test of normality was done by shapiro - wilk test . among all the evaluated variables , only age had normal distribution . descriptive data were summarized as mean and standard deviation , as well as median and interquartile range ( iqr ) , where appropriate . correlation between serum hepcidin and quantitative variables in each of the two groups of patients with tm and ti was evaluated by spearman correlation test . quantitative data between the two groups of patients were compared by student t - test and mann - whitney test . considering the correlation coefficient of 0.68 for urinary hepcidin and serum ferritin levels reported by origa et al . ( 14 ) in 44 patients with thalassemia including 22 tm and 22 ti ,  = 0.05 and  = 0.01 , the sample size was estimated as 29 patients in each group . for higher accuracy , the mean age of the patients with tm and ti were 21.4  6.1(from 11 to 33 years ) and 23.7 6.1 years ( from 8 to 38 years old ) respectively , and there was no statistically significant difference between the two groups ( p = 0.076 ) . considering gender distributions , 21 ( 43.8% ) and 22 ( 55% ) of the subjects in the tm and ti groups were female , respectively ; there was no statistically significant difference ( p = 0.392 ) . the median iqr for serum hepcidin levels were significantly higher in the tm compared to ti group ( 87.6 , 43.9 vs. 51.8 , 23.4 , p < 0.001 ) . in addition , the median iqr for serum ferritin levels were 2208 ( 3761 ) , and 465 ( 632 ) in the tm and ti groups respectively ; the difference was statistically significant ( p < 0.001 ) ( table 1 ) . table 2 indicates the results of correlation between serum hepcidin levels and the evaluated parameters for the subjects with tm and ti . no statistically significant correlations were found between serum hepcidin with any of the evaluated variables in the two groups . also there were no statistically significant differences in serum hepcidin levels between males and females in patients with tm and ti ( p = 0.107 and p = 0.861 respectively ) . considering the cut - off point of 54.4 ng / ml for serum hepcidin levels , 44 ( 91.7% ) , and 18 ( 45% ) subjects had hepcidin levels higher than normal range in the tm and ti groups , respectively ( p < 0.001 ) . abbreviations : iqr , interquartile range ; sd , standard deviation ; nrbc , nucleated red blood cells ; wbc , white blood cell . data are presented as mean  sd , median ( iqr ) or male / female . data are presented for n = 40 . statistically significant .   in thalassemia major , it was pre - transfusion hemoglobin   abbreviations : nrbc , nucleated red blood cells ; rs , spearman s rho correlation coefficient ; ti , thalassemia intermedia ; tm , thalassemia major ; wbc , white blood cell .   in thalassemia major , it was pre - transfusion hemoglobin . determining hepcidin concentrations in subjects with iron - loading anemias may be useful to identify the patients at higher risk of iron toxicity due to severely decreased hepcidin levels ( 17 ) . based on the current study results , 91.7% of the subjects with tm had serum hepcidin levels above normal compared to the patients with ti , 45% . also , the median of serum hepcidin levels were significantly higher in the tm compared to ti group that was similar to those of the previous studies ( 14 ) . in iron loading anemias not treated by frequent transfusions , such as beta thalassemia intermedia and congenital dyserythropoietic anemias , urinary and serum hepcidin decrease due to high erythroid signals . hepcidin deficiency in turn allows excessive iron absorption and development of systemic iron overload ( 12 - 14 , 18 ) . also , it could be due to more iron overload resulted from regular blood transfusion in the patients with tm compared to ti . as observed in the current study , ferritin levels were significantly higher in the subjects with tm . hemoglobin levels were significantly lower in the subjects with tm than in ti , which may be due to the time of blood sampling in the subjects with tm , immediately before transfusion . during transfusion intervals , it is known that in patients with ti , there is also increased risk of iron over load due to increased intestinal iron absorption triggered by chronic anemia , ineffective erythropoiesis and decreased serum hepcidin ( 19 , 20 ) . the current study showed higher erythropoietic activity in the subjects with ti than tm , since the median value for nrbc was significantly higher in ti compared to tm group . in ti group , since all subjects were on hu therapy for a long time , erythropoietic activity was expected to be suppressed and consequently hepcidin level was expected to be higher . but it did not occur and it seems that hu at a dose of 10 - 15 mg / kg / day was not enough to suppress bone marrow activity and make erythropoiesis ineffective . however , previous reports documented that hu with the same dose was effective in decrease or cessation of the need for regular blood transfusion , as well as increasing hb levels in the patients with thalassemia ( 21 - 24 ) . the current study showed no significant correlation between serum hepcidin and ferritin levels as a marker of iron overload in any of the tm or ti groups . this result was in accordance with the previous reports that demonstrated the dominant role of erythropoiesis compared to iron overload in regulation of hepcidin in patients with thalassemia ( 25 - 27 ) . ( 15 ) , the current study found no statistically significant correlation between hepcidin and pre - transfusion hemoglobin levels in tm patients . in a longitudinal study on 31 patients with tm . the strong point of the current study was large sample size compared to those of the previous reports ; however , there were some limitations in the study , since molecular erythropoietic activity was nit evaluated .   in conclusion , based on the current study results , there was insignificant correlation between serum hepcidin and ferritin levels as a marker of iron overload in any of the two groups of patients with tm and ti , which supported the results of previous studies that regulation of hepcidin in patients with thalassemia is more affected by erythropoeitic activity than by iron overload . also serum hepcidin levels were significantly higher in the tm than in ti group , which could mainly result from higher erythropoeitic activity in ti . in the subjects with ti , it is believed that low dose hu ( 10 - 15 mg / kg / day ) therapy for a long time could increase hb levels and lead to transfusion - independence , but probably not high enough to suppress bone marrow activity and make erythropoiesisin effective . increased awareness of hepcidin levels in the patients with thalassemia could be helpful to diagnose and manage iron burden in such patients .
background : hepcidin is a key regulator of iron absorption in humans 
 . it is mainly affected by hypoxia and iron stores.objectives:the current study aimed to determine the correlation between serum hepcidin and ferritin levels in patients with thalassemia major ( tm ) and thalassemia intermedia ( ti).patients and methods : the current cross - sectional study investigated 88 randomly selected patients with thalassemia , 48 tm and 40 ti , registered at the thalassemia clinic of shiraz university of medical sciences , a referral center for thalassemia in southern iran in 2013 . 
 all patients with ti were receiving hydroxyurea ( hu ) 10 - 15 mg / kg / day for at least 10 years . 
 the serum hepcidin , ferritin levels , hemoglobin ( hb ) and nucleated red blood cell ( rbc ) of the two groups were measured.results:no statistically significant correlation was observed between serum hepcidin and ferritin levels in any of the two groups of patients with tm ( rs = 0.02 , p = 0.892 ) or ti ( rs = 0.055 , p = 0.734 ) . 
 the median interquartile range ( iqr ) for serum hepcidin and ferritin levels were significantly higher in tm compared to ti group , ( hepcidin : 87.6 ( 43.9 ) vs. 51.8 ( 23.4 ) , p < 0.001 ; ferritin : 2208 ( 3761 ) vs. 465 ( 632 ) , p 
 < 0.001).conclusions : there was insignificant correlation between serum hepcidin and ferritin levels in the two groups of patients with tm and ti . 
 it seems that regulation of hepcidin in patients with thalassemia is more affected by erythropoeitic activity than iron stores . also , hepcidin levels were significantly higher in patients with tm than ti , possibly due to higher erythropoeitic activity in ti . 
 in ti , it seems that low dose hu increases hb levels and leads to transfusion - independence , but it is not high enough to suppress bone marrow activity and ineffective erythropoiesis . 
 consequently , serum hepcidin level decreases .