Severe iron overload usually develops in patients with hereditary hemochromatosis (HHC), but variability in the phenotypic expression of the disease has been reported. This study assessed whether tumor necrosis factor ␣ (TNF-␣) plays a role in phenotypic expression of HHC. Sixty-four patients with HHC and 172 healthy volunteers (controls) were studied. Release of TNF-␣ from stimulated peripheral blood monocytes was measured by enzyme-linked immunosorbent assay, and 308 and 238 TNF-␣ polymorphisms were detected with polymerase chain reaction and restriction fragmentlength polymorphism analysis. The relation between TNF-␣ polymorphisms and clinical expression of HHC was evaluated. Patients with HHC released less TNF-␣ than controls, but the difference was significant only in homozygotes for the C282Y mutation. The prevalence of the 308 TNF-␣ polymorphism was similar in patients and controls, whereas the prevalence of the 238 polymorphic allele was significantly lower in patients (3% versus 16%; P ؍ .002). A lower prevalence of cirrhosis was observed in patients with TNF-␣ polymorphism than in those without it (4 of 15 [27%] versus 28 of 49 [57%]), but the difference was not significant (P ؍ .07). In nonhomozygotes for the C282Y mutation, severe liver siderosis was less prevalent in patients with the 308 polymorphism than in those without it (P ؍ .05). Alanine aminotransferase (ALT) values were significantly lower in patients with TNF-␣ polymorphism (P ؍ .006), even when patients with other hepatotoxic factors were excluded. Multivariate analysis showed that TNF-␣ polymorphism was independently associated with ALT values (P ؍ .0008 and P ؍ .045, respectively, in homozygotes and nonhomozygotes for the C282Y mutation) and siderosis in nonhomozygotes (P ؍ .047). Thus, TNF-␣ appears to play a role in HHC by modulating the severity of liver damage. (Blood. 2001;97:3707-3712)