The major part of hepatocellular iron is derived from uptake of transferrin-bound iron by means of nonspecific fluid-phase endocytosis and specific, saturable binding on high-affinity transferrin receptors. We investigated the expression of transferrin receptors on hepatocytes in liver biopsies of 22 cases of hemochromatosis (21 primary hemochromatosis and 1 secondary hemochromatosis), using immunohistochemical demonstration of the human transferrin receptor with the specific monoclonal antibody OKT9. Fifty liver biopsies (normal and pathological) without demonstrable iron storage (Perls' stain negative) served as controls. In the controls, membranous and/or cytoplasmic transferrin receptor expression was always present on hepatocytes, albeit in variable numbers and patterns without obvious relation to the underlying liver disease. In 19 of 22 hemochromatosis cases with severe iron overload, OKT9 immunoreactivity on hepatocytes was completely absent. Three hemochromatosis cases showed few hepatocytes positive for OKT9. One showed mild iron overload, while the second, a successfully treated case, was free of iron. The remaining hemochromatosis case was a known alcoholic with severe iron overload. Since OKT9 binding to the transferrin receptor is not blocked by previous binding of transferrin, the findings show that in advanced hemochromatosis hepatocytes do not express transferrin receptors. This finding is in keeping with the inverse relation between transferrin receptor expression and exogenous iron supply in various cell cultures.

These results indicate that in hemochromatosis, apparently as a result of progressive iron overload, transferrin receptor expression on hepatocytes disappears. This leaves the hepatocytes with a nonsaturable mechanism for uptake of transferrin-bound iron (fluid-phase pinocytosis) and with uptake of potentially more toxic forms of nontransferrin-bound iron, which may represent up to 30% of serum iron in fully established hemochromatosis.