Exploring the Role of Ferroptosis in the Pathophysiology and Circadian Regulation of Restless Legs Syndrome

The study objectives were to investigate the role of ferroptosis, the mechanism linking iron accumulation, oxidative stress, and dopaminergic dysfunction, in restless legs syndrome (RLS), and to explore its connection with circadian regulation, a key feature of RLS and a known modulator of ferroptosis. We conducted pathway and gene expression analyses in 17 RLS patients and 39 controls, focusing on pathways related to ferroptosis, oxidative stress, iron metabolism, dopaminergic signaling, circadian rhythms, and immune responses. Enrichment analysis, differential gene expression, and cross-pathway gene overlaps were assessed. Ferroptosis and efferocytosis pathways were significantly upregulated in RLS, while oxidative phosphorylation, phosphatidylinositol signaling, PI3K-Akt, FoxO, and adipocytokine pathways were downregulated. The circadian rhythm pathway was markedly suppressed, with 12 circadian genes downregulated, suggesting that circadian disruption may drive ferroptosis activation. Decreased expression of protective pathways, including antioxidant responses and autophagy, was associated with increased iron accumulation, oxidative stress, and inflammation. Dopaminergic synapse genes were upregulated, possibly as a compensatory response to neuronal damage. Several genes overlapped across ferroptosis, circadian, and dopaminergic pathways, indicating a shared pathogenic mechanism. Our findings support a model in which circadian disruption promotes ferroptosis in RLS, contributing to iron overload, oxidative damage, and dopaminergic dysfunction. This pathogenic cascade may also enhance immune activation and inflammation. Circadian regulation and ferroptosis emerge as promising therapeutic targets in RLS. Further studies in larger cohorts are warranted to validate these mechanistic insights.