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, MD
First Department of Medicine
Hamamatsu University School of Medicine
Hamamatsu, Japan

Initial Posting: ; Last Update: November 5, 2015.


Clinical characteristics.

Aceruloplasminemia is characterized by iron accumulation in the brain and viscera. The clinical triad of retinal degeneration, diabetes mellitus (DM), and neurologic disease is seen in individuals ranging from age 25 years to older than 70 years. The neurologic findings of movement disorder (blepharospasm, grimacing, facial and neck dystonia, tremors, chorea) and ataxia (gait ataxia, dysarthria) correspond to regions of iron deposition in the brain. Individuals with aceruloplasminemia often present with anemia prior to onset of DM or obvious neurologic problems. Cognitive dysfunction including apathy and forgetfulness occurs in more than half of individuals with this condition.


Aceruloplasminemia, a disorder of iron metabolism caused by the complete absence of ceruloplasmin ferroxidase activity, is caused by pathogenic variants in CP, which encodes ceruloplasmin. The diagnosis of aceruloplasminemia in a symptomatic individual relies on demonstration of the absence of serum ceruloplasmin and some combination of the following: low serum copper concentration, low serum iron concentration, high serum ferritin concentration, and increased hepatic iron concentration. The diagnosis is strongly supported by characteristic MRI findings of abnormal low intensities reflecting iron accumulation in the brain (striatum, thalamus, dentate nucleus) and liver on both T1- and T2-weighted images.


Treatment of manifestations: Iron chelating agents (i.e., desferrioxamine or deferasirox) to decrease serum ferritin concentration, decrease brain and liver iron stores, and prevent progression of neurologic signs/symptoms in symptomatic individuals with blood hemoglobin concentration higher than 9 g/dL; combined IV desferrioxamine and fresh-frozen human plasma (FFP) is effective in decreasing iron content in the liver; repetitive FFP treatment can improve neurologic signs/symptoms; antioxidants such as vitamin E may be used along with a chelator or oral administration of zinc to prevent tissue damage, particularly to the liver and pancreas.

Surveillance: Annual glucose tolerance test starting at age 15 years to evaluate for the onset of diabetes mellitus; ECG evaluation early in the course of the disease; evaluation of thyroid and liver function and complete blood count annually starting at the time of diagnosis.

Agents/circumstances to avoid: Iron supplements.

Evaluation of relatives at risk: If the pathogenic variants in the family are known, molecular genetic testing of asymptomatic sibs of a proband allows for early diagnosis and initiation of surveillance and treatment. If pathogenic variants are unknown, monitoring of serum concentrations of hemoglobin and hemoglobin A1c in asymptomatic sibs is recommended.

Genetic counseling.

Aceruloplasminemia is inherited in an autosomal recessive manner. At conception, each sib of an affected individual has a 25% chance of being affected, a 50% chance of being an asymptomatic carrier, and a 25% chance of being unaffected and not a carrier. Carrier testing for at-risk relatives and prenatal testing for pregnancies at increased risk are possible if the CP pathogenic variants in the family have been identified.


Aceruloplasminemia is characterized by iron accumulation in the brain and viscera.

Suggestive Findings

Aceruloplasminemia should be suspected in individuals with characteristic MRI findings and more than one of the following findings:

  • Retinal degeneration
  • Diabetes mellitus (DM)
  • Anemia
  • Neurologic disturbance (ataxia, involuntary movement)

MRI. Abnormal low intensities in the liver as well as the striatum, thalamus, and dentate nucleus of the brain on T1- and T2-weighted images are consistent with iron deposition and support a diagnosis of aceruloplasminemia (see Figure 1).

Figure 1. . CT and T1- and T2-weighted MRI of an individual with aceruloplasminemia.

Figure 1.

CT and T1- and T2-weighted MRI of an individual with aceruloplasminemia. CT (A, D), T2- (B, E) and T1- (C) weighted axial images of the brain (upper row) and abdomen (bottom row). Brain and abdomen CT show abnormal high-density areas in the basal ganglia (more...)

Retinal degeneration. Ophthalmologic examinations typically reveal evidence of early-onset macular degeneration [Dunaief et al 2005]. Ninety-three percent of Japanese individuals with aceruloplasminemia demonstrate retinal degeneration [Miyajima et al 2003]. Visual acuity is not disturbed. Several small yellowish opacities are scattered over grayish atrophy of the retinal pigment epithelium. Fluorescein angiography demonstrates window defects corresponding to the yellowish opacities. These findings differ from diabetic retinopathy [Yamaguchi et al 1998].

Laboratory Testing

Serum ceruloplasmin is not detectable by Western blot analysis (normal serum concentration: 21-36 mg/dL).

Serum copper concentration is lower than10 µg/dL (normal range: 70-125 µg/dL).

Serum iron concentration is lower than 45 µg/dL (normal range: male 60-180 µg/dL; female 60-140 µg/dL).

Serum ferritin concentration is 850-4000 ng/mL (normal range: male 45-200 ng/mL; female 30-100 ng/mL).

Plasma ceruloplasmin ferroxidase activity is not detectable using the method described by Erel [1998]. (normal activity is 500-680 U/L).

Pathologic diagnosis. Visceral organs, especially the liver, pancreas, and heart, have iron deposition:

  • The liver shows no cirrhotic changes. The iron content in the liver is greater than the iron content in the brain. The hepatic iron concentration (HIC) is determined in µmol/g of dry weight. The hepatic iron index (HII) is then calculated by dividing the hepatic iron concentration by the age (in years) of the individual. Normal individuals have an HII of 1.1 or less; more than 80% of individuals with aceruloplasminemia have an HII greater than 1.3. (HIC [µg/g dry weight] 56 = HIC [µmol/g dry weight], HIC [µmol/g dry weight]/age [years] = HII).
  • Islet beta cells demonstrate iron deposition, which results in diabetes mellitus.
  • The distribution in order of iron level in the brain is globus pallidus > putamen > cerebral cortex > cerebellar cortex. Severe iron overload and extensive neuronal loss are observed in the basal ganglia, while iron deposition and neuronal cell loss are trivial in the frontal cortices. The cerebellar cortex shows marked loss of Purkinje cells. Iron deposition is more prominent in the astrocytes than in the neurons. Astrocytic deformity and globular structures are characteristic features in brains of individuals with aceruloplasminemia. The globular structures in the astrocytes are seen in proportion to the degree of iron deposition [Kaneko et al 2002, Miyajima 2003, Oide et al 2006].

Establishing the Diagnosis

The diagnosis of aceruloplasminemia is established in a proband on identification of biallelic pathogenic variants in CP on molecular genetic testing (see Table 1).

Molecular testing approaches can include single-gene testing, use of a multi-gene panel, and more comprehensive genomic testing:

  • Single-gene testing. Sequence analysis of CP is performed first and followed by gene-targeted deletion/duplication analysis if only one or no pathogenic variant is found.
  • A multi-gene panel that includes CP and other genes of interest (see Differential Diagnosis) may also be considered. Note: The genes included and sensitivity of multi-gene panels vary by laboratory and over time.
  • More comprehensive genomic testing (when available) including exome sequencing, genome sequencing, and mitochondrial sequencing may be considered if serial single-gene testing (and/or use of a multi-gene panel) fails to confirm a diagnosis in an individual with features of aceruloplasminemia. For an introduction to comprehensive genomic testing click here. More detailed information for clinicians ordering genomic testing can be found here.

Table 1.

Molecular Genetic Testing Used in Aceruloplasminemia

Gene 1Test MethodProportion of Probands with Pathogenic Variants 2 Detectable by This Method
CPSequence analysis 3>92% 4
Gene-targeted deletion/duplication analysis 5Unknown 6

See Molecular Genetics for information on allelic variants detected in this gene.


Sequence analysis detects variants that are benign, likely benign, of uncertain significance, likely pathogenic, or pathogenic. Pathogenic variants may include small intragenic deletions/insertions and missense, nonsense, and splice site variants; typically, exon or whole-gene deletions/duplications are not detected. For issues to consider in interpretation of sequence analysis results, click here.


Individuals of Japanese heritage [Miyajima et al 1999]. Sequence analysis identifies at least one pathogenic variant in all individuals with abnormal low intensity areas in both the basal ganglia and the liver on MRI.


Gene-targeted deletion/duplication analysis detects intragenic deletions or duplications. Methods that may be used include: quantitative PCR, long-range PCR, multiplex ligation-dependent probe amplification (MLPA), and a gene-targeted microarray designed to detect single-exon deletions or duplications.


No data on detection rate of gene-targeted deletion/duplication analysis are available.

Clinical Characteristics

Clinical Description

Clinical manifestations of aceruloplasminemia are a triad of retinal degeneration, diabetes mellitus (DM), and neurologic signs/symptoms [Miyajima 2003]. Individuals with aceruloplasminemia often present with anemia prior to onset of DM or neurologic signs/symptoms. Phenotypic expression varies even within families.

A summary of clinical manifestations in 71 Japanese individuals is shown in Table 2. The manifestations (in order of frequency) are anemia, retinal degeneration, diabetes mellitus, and neurologic signs/symptoms. The neurologic signs/symptoms correspond to regions of brain iron accumulation and include ataxia, involuntary movement, parkinsonism, and cognitive dysfunction. Molecular genetic testing of CP on a research basis allowed for confirmation of the diagnosis in individuals with atypical clinical findings, further expanding the phenotypic spectrum [Miyajima et al 2003, Kono 2012, Kono & Miyajima 2015]

Table 2.

Clinical Manifestations/Age at Onset in 71 Individuals with Aceruloplasminemia

Clinical ManifestationsAge at Onset of Manifestation
Anemia (80%)
Diabetes mellitus (70%)<30 yrs: 18%
30-39 yrs: 35%
40-49 yrs: 31%
>50 yrs: 16%
Retinal degeneration (76%)At least >20 yrs
Neurologic symptoms (68%)Ataxia (71%) incl dysarthria, gait ataxia, limb ataxia, nystagmus<40 yrs: 7%
40-49 yrs: 38%
50-59 yrs: 42%
>60 yrs: 13%
Involuntary movement (64%) incl dystonia (blepharospasm, grimacing, neck dystonia), tremors, chorea
Parkinsonism (20%) incl rigidity, akinesia
Cognitive dysfunction (60%) incl apathy, forgetfulness

Additional Findings

Laboratory findings

  • Undetectable serum ceruloplasmin
  • Elevated serum ferritin
  • Decreased serum iron
  • Iron refractory microcytic anemia
  • Low serum copper and normal urinary copper levels

MRI (magnetic resonance imaging) findings

  • Low intensity on both T1- and T2-weighted MRI in the liver and the basal ganglia, including the caudate nucleus, putamen and pallidum, and the thalamus

Liver biopsy results

  • Excess iron accumulation (>1200 µg/gram dry weight) within hepatocytes and reticuloendothelial cells
  • Normal hepatic architecture and histology without cirrhosis or fibrosis
  • Normal copper accumulation

Neuropathology in the brain includes bizarrely formed astrocytes and grumose or foamy spheroid bodies [Kaneko et al 2002, Oide et al 2006].

Genotype-Phenotype Correlations

No clear genotype-phenotype correlation exists for aceruloplasminemia.

Individuals with typical clinical signs/symptoms who are compound heterozygotes for the p.His978Gln pathogenic variant showed normal serum ceruloplasmin concentrations but absent ferroxidase activity [Takeuchi et al 2002]. Another individual with retinal degeneration and diabetes mellitus who was homozygous for the p.Gly969Ser pathogenic variant showed a decrease in serum ceruloplasmin concentration because of the secretion of only apoceruloplasmin without any ferroxidase activity [Kono et al 2006b]. This is a caveat in making the diagnosis on normal ceruloplasmin concentrations alone.


Aceruloplasminemia was originally called familial apoceruloplasmin deficiency [Miyajima et al 1987].


The serum ceruloplasmin concentrations of about 5,000 adults undergoing medical examination were screened (Table 3). The prevalence of aceruloplasminemia was estimated at one in 2,000,000 in non-consanguineous marriages in Japan [Miyajima et al 1999].

Table 3.

Frequencies of Aceruloplasminemia

Parental RelatednessHomozygotesHeterozygotes
Non-consanguineous4.90 x 10-71.40 x 10-3
Consanguineous3.29 x 10-61.39 x 10-3

Heterozygotes for the ceruloplasmin gene were estimated to account for 0.1% of individuals with diabetes in Japan [Daimon et al 1997].

Differential Diagnosis

Neurodegeneration with brain iron accumulation (NBIA) is a group of progressive extrapyramidal disorders with radiographic evidence of focal iron accumulation in the brain, usually the basal ganglia. Later-onset, slowly progressive NBIA includes atypical pantothenate kinase-associated neurodegeneration (PKAN) [Hayflick et al 2003], which results from pathogenic variants in PANK2 [Zhou et al 2001]; neuroferritinopathy, a disorder associated with pathogenic variants in FTL; and aceruloplasminemia.

Low serum concentration of ceruloplasmin is not specific for aceruloplasminemia. Ceruloplasmin deficiency is a characteristic feature in copper metabolic disorders, including Wilson disease and Menkes disease:

  • In Wilson disease, an inability to transfer copper into the ceruloplasmin precursor protein, apoceruloplasmin, and a decrease in biliary copper excretion results in serum ceruloplasmin deficiency and excess copper accumulation.
  • In Menkes disease, copper absorption from the intestine is decreased, leading to copper and ceruloplasmin deficiencies in the body. In contrast, aceruloplasminemia is an iron metabolic disorder in which ceruloplasmin deficiency is caused by a lack of apoceruloplasmin biosynthesis and copper metabolism is not disturbed (see ATP7A-Related Copper Transport Disorders).

Aceruloplasminemia is characterized by marked iron accumulation in the brain as well as in the visceral tissues despite low serum iron concentrations. In these findings, aceruloplasminemia differs significantly from HFE-associated hereditary hemochromatosis, the most common iron metabolic disorder.

  • Because aceruloplasminemia has features of Wilson disease and HFE-associated hereditary hemochromatosis, it could be incorrectly diagnosed as "mild hemochromatosis with hypoceruloplasminemia" or "mild Wilson disease with hemosiderosis."

Ceruloplasmin synthesis can be reduced with acute liver failure or decompensated cirrhosis of any etiology. Decreased serum concentrations of ceruloplasmin are observed in protein-losing enteropathy, nephrotic syndrome, and malnutrition.

Differential diagnoses for the neurologic manifestations of aceruloplasminemia include Huntington disease, dentatorubral-pallidoluysian atrophy (DRPLA), juvenile Parkinson disease including Parkin type of early-onset Parkinson disease (see also Parkinson Disease Overview), dystonia (see Dystonia Overview), drug effects or toxicity, and hereditary spinocerebellar ataxias (see Hereditary Ataxia Overview).


Evaluations Following Initial Diagnosis

To establish the extent of disease and needs in an individual diagnosed with aceruloplasminemia, evaluations for the following are recommended:

  • Iron deposition. Serum ferritin concentration, brain and abdomen MRI findings, and hepatic iron and copper content by the liver biopsy
  • Neurologic findings. Brain MRI
  • Diabetes mellitus. Glucose tolerance test; blood concentrations of insulin and HbA1c
  • Retinal degeneration. Examination of the optic fundi and fluorescein angiography
  • Anemia. Complete blood count
  • Other. Consultation with a clinical geneticist and/or genetic counselor

Treatment of Manifestations

Note: Individual case reports indicate the effectiveness of treatment in patients with aceruloplasminemia; however, no large series of symptomatic patients treated with iron chelators and zinc is available and there is no universally accepted treatment regimen. A systematic review/analysis of studies designed to evaluate the clinical effectiveness of desferrioxamine, deferiprone, deferasirox, and zinc as monotherapy for the initial treatment of various clinical presentations of aceruloplasminemia is needed.

Desferrioxamine. Treatment with iron chelating agents (i.e., desferrioxamine) can be considered for symptomatic individuals whose blood hemoglobin concentration is higher than 9 g/dL. Treatment can decrease serum ferritin concentration as well as brain and liver iron stores, and can prevent progression of the neurologic signs/symptoms [Miyajima et al 1997].

Intravenous infusions of 500 mg of desferrioxamine (desferoxamine mesylate) dissolved in 100 mL of isotonic saline solution are given over one hour. Desferrioxamine is infused twice a week for six to ten months.

  • In the Miyajima et al [1997] study, head MRI evaluations were performed before and after treatment to evaluate the effect of treatment on iron storage in the brain. Serum concentrations of iron, ferritin, copper, hemoglobin, and hemoglobin A1c, as well as C-peptide immunoreactivity, were measured before and after treatment. Lipid peroxidation in plasma samples also was measured by the thiobarbituric acid method. T2-weighted MRI showed an increase in the signal intensity of the basal ganglia. Serum ferritin concentration was markedly reduced and hepatic iron concentration was decreased, whereas serum iron concentration was elevated and anemia and DM were ameliorated.
  • In the Mariani et al [2004] report, the brain MRI did not change after more than one year of desferoxamine treatment, whereas excess iron in the liver was removed.
  • Pan et al [2011] reported an affected individual age 52 years who was treated with desferrioxamine (500 mg) by intravenous infusion in a 5% glucose solution once a week for four years. After four years of treatment, brain MRI evaluation demonstrated improvement in low-intensity areas in the basal ganglia, suggesting that iron chelation can reduce abnormal iron deposition in the central nervous system.

Deferasirox. Iron chelation therapy with deferasirox, an oral iron chelating agent, led to a mild improvement in clinical symptoms, including cognitive performance, gait, and balance, in an individual with aceruloplasminemia who had no response to both deferoxamine and fresh-frozen plasma therapy [Skidmore et al 2008]. Oral administration of deferasirox may prevent tissue damage, particularly to the liver and pancreas [Finkenstedt et al 2010].

Deferiprone. This iron chelator has a lower molecular weight and more lipophilic properties. Deferiprone therapy had no beneficial effects in a patient in a previous report [Mariani et al 2004]; however, it has been shown to protect against retinal degeneration and neurodegeneration and to increase the life span if initiated early in mice exhibiting knockout for ceruloplasmin and hephaestin [Hadziahmetovic et al 2011].

Fresh-frozen human plasma. After the intravenous administration of fresh-frozen human plasma (FFP) containing ceruloplasmin, serum iron content increases for several hours because of ferroxidase activity of ceruloplasmin. Iron content in the liver decreases more with the combined intravenous administration of FFP and desferrioxamine than with FFP administration alone. Neurologic signs/symptoms can improve following repetitive FFP treatment [Yonekawa et al 1999].

Antioxidants such as vitamin E may be used along with a chelator or oral administration of zinc to prevent tissue damage, particularly to the liver and pancreas [Kuhn et al 2007].

Prevention of Primary Manifestations

Zinc concentrations in these patients were decreased in the brain and visceral organs, and zinc showed opposing distributions to those for iron. Because zinc has antioxidant activity, treatment with an iron chelator accompanied by zinc may be useful in patients with aceruloplasminemia to diminish iron accumulation in the brain and body and to prevent or ameliorate systemic and neurologic symptoms [Miyajima 2015].


Marked accumulation of iron in parenchymal tissues including the liver, pancreas, heart, and thyroid can result in diabetes mellitus, cardiac failure, and hypothyroidism.

  • All affected individuals should have an annual glucose tolerance test starting at age 15 years to evaluate for the onset of diabetes mellitus.
  • ECG evaluation should be performed early in the course of the disease.
  • Evaluation of thyroid and liver function and complete blood count are indicated annually starting at the time of diagnosis.

Agents/Circumstances to Avoid

Iron supplements. Individuals with aceruloplasminemia erroneously diagnosed as having iron deficiency anemia and treated with iron supplements had accelerated iron accumulation.

Evaluation of Relatives at Risk

It is appropriate to evaluate apparently asymptomatic older and younger sibs of a proband (starting at age 15 years) in order to identify as early as possible those who would benefit from surveillance and initiation of treatment. However, the proper preventive approach for asymptomatic sibs is unknown:

Evaluations can include:

  • Molecular genetic testing if the pathogenic variants in the family are known;
  • Monitoring of serum concentrations of hemoglobin and hemoglobin A1c as anemia and diabetes may precede neurologic symptoms (see also Surveillance).

See Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.

Therapies Under Investigation

Search for access to information on clinical studies for a wide range of diseases and conditions.

Genetic Counseling

Genetic counseling is the process of providing individuals and families with information on the nature, inheritance, and implications of genetic disorders to help them make informed medical and personal decisions. The following section deals with genetic risk assessment and the use of family history and genetic testing to clarify genetic status for family members. This section is not meant to address all personal, cultural, or ethical issues that individuals may face or to substitute for consultation with a genetics professional. —ED.

Mode of Inheritance

Aceruloplasminemia is inherited in an autosomal recessive manner.

Risk to Family Members

Parents of a proband

  • The parents of an individual with aceruloplasminemia are obligate heterozygotes (i.e., carriers of one CP pathogenic variant).
  • Clinical disease is not known to occur in heterozygotes, although data are not adequate to exclude the possibility in older individuals

Sibs of a proband

  • At conception, each sib of an affected individual has a 25% chance of being affected, a 50% chance of being a carrier, and a 25% chance of being unaffected and not a carrier.
  • Heterozygotes (carriers) with clinical signs/symptoms have not been reported, although data are not adequate to exclude the possibility in older individuals.

Offspring of a proband. The offspring of an individual with aceruloplasminemia are obligate heterozygotes (carriers) for a pathogenic variant in CP.

Other family members of a proband. Each sib of the proband’s parents is at a 50% risk of being a carrier of a CP pathogenic variant.

Carrier (Heterozygote) Detection

Carrier testing for at-risk relatives requires prior identification of the CP pathogenic variants in the family.

Related Genetic Counseling Issues

See Management, Evaluation of Relatives at Risk for information on evaluating at-risk relatives for the purpose of early diagnosis and treatment.

Testing of at-risk asymptomatic individuals. Consideration of molecular genetic testing of young, at-risk sibs is appropriate for guiding medical management (see Management, Evaluation of Relatives at Risk).

Molecular genetic testing can be used with certainty to clarify the genetic status of at-risk family members if both CP pathogenic variants have been identified in an affected family member.

Family planning

  • The optimal time for determination of genetic risk, clarification of carrier status, and discussion of the availability of prenatal testing is before pregnancy.
  • It is appropriate to offer genetic counseling (including discussion of potential risks to offspring and reproductive options) to young adults who are affected, are carriers, or are at risk of being carriers.

DNA banking is the storage of DNA (typically extracted from white blood cells) for possible future use. Because it is likely that testing methodology and our understanding of genes, allelic variants, and diseases will improve in the future, consideration should be given to banking DNA of affected individuals.

Prenatal Testing and Preimplantation Genetic Diagnosis

Once the CP pathogenic variants have been identified in an affected family member, prenatal testing for a pregnancy at increased risk and preimplantation genetic diagnosis for aceruloplasminemia are possible.

Differences in perspective may exist among medical professionals and within families regarding the use of prenatal testing, particularly if the testing is being considered for the purpose of pregnancy termination rather than early diagnosis. Although most centers would consider decisions regarding prenatal testing to be the choice of the parents, discussion of these issues is appropriate.


GeneReviews staff has selected the following disease-specific and/or umbrella support organizations and/or registries for the benefit of individuals with this disorder and their families. GeneReviews is not responsible for the information provided by other organizations. For information on selection criteria, click here.

  • NBIA Disorders Association
    2082 Monaco Court
    El Cajon CA 92019-4235
    Phone: 619-588-2315
    Fax: 619-588-4093
  • Association for Neuro-Metabolic Disorders (ANMD)
    5223 Brookfield Lane
    Sylvania OH 43560-1809
    Phone: 419-885-1809; 419-885-1497
  • NBIA Disorders Association Research Registry and Treat Iron-Related Childhood-Onset Neurodegeneration (TIRCON) Registry
    CA 92019-4235
    Phone: 619-588-2315
    Fax: 619-588-4093
  • NBIAcure Registry for NBIA and Related Disorders
    Oregon Health & Science University
    Phone: 503-494-4344
    Fax: 503-494-6886

Molecular Genetics

Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED.

Table A.

Aceruloplasminemia: Genes and Databases

GeneChromosome LocusProteinLocus-Specific DatabasesHGMDClinVar
CP3q24-q25CeruloplasminCP databaseCPCP

Data are compiled from the following standard references: gene from HGNC; chromosome locus from OMIM; protein from UniProt. For a description of databases (Locus Specific, HGMD, ClinVar) to which links are provided, click here.

Table B.

OMIM Entries for Aceruloplasminemia (View All in OMIM)


Molecular Genetic Pathogenesis

Approximately 50 pathogenic variants have been identified [Kono 2012]. More than half of the pathogenic variants in CP are the pathogenic truncated variants leading to the formation of a premature stop codon. These pathogenic variants would be predicted to result in formation of a protein lacking the copper-binding sites presumed to be critical for enzymatic function. Molecular analysis of the pathogenic missense variants has shown several different mechanisms by which pathogenic variants in the ceruloplasmin gene can result in the lack of enzymatic activity (see Figure 2). Some mutated proteins are retained in the endoplasmic reticulum caused by defects in protein trafficking. Ceruloplasmin deficiency can arise through other mechanisms, either by indirect dysfunction of a copper-binding site or by other structural abnormalities in the protein that prevent the incorporation of copper into ceruloplasmin [Kono & Miyajima 2006].

Figure 2. . Ceruloplasmin (Cp) biosynthesis.

Figure 2.

Ceruloplasmin (Cp) biosynthesis. Several different mechanisms by which CP pathogenic missense variants result in the lack of enzymatic activity. As p.Pro177Arg, p.Gly176Arg, and p.Ile9Phe mutated protein is retained in the endoplasmic reticulum, aceruloplasminemia (more...)

Gene structure. CP is approximately 4.4 kb in a total of 19 exons; it encodes the ceruloplasmin precursor. For a detailed summary of gene and protein information, see Table A, Gene.

Pathogenic variants. More than 70 pathogenic variants in CP have been identified in over 60 affected families belonging to different racial groups [Yoshida et al 1995, Yazaki et al 1998, Miyajima et al 1999, Daimon et al 2000, Hellman et al 2000, Kohno et al 2000, Bosio et al 2002, Hellman et al 2002, Loréal et al 2002, Hatanaka et al 2003, Mariani et al 2004, Kuhn et al 2005, Pérez-Aguilar et al 2005, Kono et al 2006a, Shang et al 2006, Kono 2012]. See Figure 3. No hot spots for pathogenic variants in CP have been observed.

Figure 3. . Pathogenic variants (mutations) characterized in individuals with aceruloplasminemia and their family members.

Figure 3.

Pathogenic variants (mutations) characterized in individuals with aceruloplasminemia and their family members. The structure of the human ceruloplasmin gene consists of 20 exons (exon numbering based on Kono & Miyajima [2015]). Alternative splicing (more...)

Table 4.

CP Pathogenic Variants Discussed in This GeneReview

DNA Nucleotide ChangePredicted Protein Change
(Alias 1)
Reference Sequences

Note on variant classification: Variants listed in the table have been provided by the author. GeneReviews staff have not independently verified the classification of variants.

Note on nomenclature: GeneReviews follows the standard naming conventions of the Human Genome Variation Society (varnomen​ See Quick Reference for an explanation of nomenclature.


Variant designation that does not conform to current naming conventions; in this instance the alias refers to the length of the mature peptide.

Normal gene product. The product of CP, ceruloplasmin, is a blue copper oxidase that carries more than 95% of the plasma copper content in vertebrates.

Ceruloplasmin has two forms: (1) a secreted form (1040 amino acids) mainly produced and secreted by hepatocytes; and, (2) a glycosylphosphatidylinositol (GPI)-anchored form (1065 amino acids) mainly expressed in astrocytes as well as visceral organs (see Figure 4) [Patel et al 2000]:

Figure 4. . The secreted and GPI-anchored forms of ceruloplasmin generated by alternative splicing.

Figure 4.

The secreted and GPI-anchored forms of ceruloplasmin generated by alternative splicing. Northern blot analyses of two forms of ceruloplasmin in the organs (lane 1: brain; lane 2: lung; lane 3: liver; lane 4: heart; lane 5: kidney; lane 6: pancreas).

  • The secreted form, alpha2-glycoprotein, is synthesized mainly in the liver; it plays an important role in iron mobilization from the tissues as a ferroxidase.
  • The GPI-anchored form is generated by alternative RNA splicing. The splicing occurs downstream of exon 18 and replaces the five C-terminal amino acids of the secreted form with an alternative 30-amino acid sequence that signals GPI anchor addition. The GPI-anchored form of ceruloplasmin is expressed in astrocytes and plays an important role in iron metabolism in the central nervous system through its ferroxidase activity [Jeong & David 2003].

Abnormal gene product. Abnormal gene products are usually degraded immediately after release from the hepatocytes. With some pathogenic nonsense CP variants, abnormal ceruloplasmin is retained within the endoplasmic reticulum (early secretory pathway); and, with other pathogenic variants, abnormal ceruloplasmin results in decreased copper incorporation into ceruloplasmin in the Golgi apparatus (late secretory pathway) [Hellman et al 2002, Kono & Miyajima 2006, Kono et al 2006a]. In CP-null mice, different mechanisms could underlie the loss of astrocytes and neurons [Jeong & David 2006].


Literature Cited

  • Bosio S, De Gobbi M, Roetto A, Zecchina G, Leonardo E, Rizzetto M, Lucetti C, Petrozzi L, Bonuccelli U, Camaschella C. Anemia and iron overload due to compound heterozygosity for novel ceruloplasmin mutations. Blood. 2002;100:2246–8. [PubMed: 12200392]
  • Daimon M, Susa S, Ohizumi T, Moriai S, Kawanami T, Hirata A, Yamaguchi H, Ohnuma H, Igarashi M, Kato T. A novel mutation of the ceruloplasmin gene in a patient with heteroallelic ceruloplasmin gene mutation (HypoCPGM). Tohoku J Exp Med. 2000;191:119–25. [PubMed: 10997552]
  • Daimon M, Yamatani K, Tominaga M, Manaka H, Kato T, Sasaki H. NIDDM with a ceruloplasmin gene mutation. Diabetes Care. 1997;20:678. [PubMed: 9097006]
  • Dunaief JL, Richa C, Franks EP, Schultze RL, Aleman TS, Schenck JF, Zimmerman EA, Brooks DG. Macular degeneration in a patient with aceruloplasminemia, a disease associated with retinal iron overload. Ophthalmology. 2005;112:1062–5. [PubMed: 15882908]
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Suggested Reading

  • McNeill A, Pandolfo M, Kuhn J, Shang H, Miyajima H. The neurological presentation of ceruloplasmin gene mutations. Eur Neurol. 2008;60:200–5. [PubMed: 18667828]

Chapter Notes


Aceruloplasminemia research is funded in part by a Grant-in-Aid of Science from the Ministry of Education, Science, Culture, Sports, and Technology, Japan.

Revision History

  • 5 November 2015 (me) Comprehensive update posted live
  • 18 April 2013 (me) Comprehensive update posted live
  • 17 February 2011 (me) Comprehensive update posted live
  • 29 April 2008 (me) Comprehensive update posted to live Web site
  • 15 August 2005 (me) Comprehensive update posted to live Web site
  • 12 August 2003 (me) Review posted to live Web site
  • 23 June 2003 (hm) Original submission
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