IRON DEFICIENCY ANEMIA M. Kazmierczak XI2012

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IRON DEFICIENCY ANEMIAM. Kazmierczak
XI2012
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ANEMIA - DEFINITION

• REDUCTION OF HEMOGLOBIN CONCENTRATION BELOW
  REFERENCE VALUE

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BLOOD PARAMETERS

• Hemoglobin concentration (Hg)
• F 7,2 10 M 7,8-11,3 mmol Fe/l (12-18 g/dl)
• Erythrocytes count (RBC)
• F 4-5,5 M 4,5-6 x1012/l (4-6 x106 /?l)
• Hematocrit (Hct)
• F 37-47 M 40-54 (37-54)
• Platelet count (Plt)
• 150 450 x 103/?l (150-450 x 109/l)
• Leukocytes count (WBC)
• 4-10 x 109/l (4-10 x 103/ ?l)

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Erythrocytes parameters

• Mean corpuscular volume (MCV)
• N 80-100 fl
• RDW(Red cell Distrubution Width)
• Mean corpuscular hemoglobin (MCH)
• N 27-34 pg
• Mean corpuscular hemoglobin concentration (MCHC)
• N 310 370 g/lRBC (31-37 g/dl)

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Reticulocytes

• RET 0,5-2
• ARC (absolute reticulocyte count )
• 25-75x 109/l
• CRC (corrected reticulocyte count)
• RPI (reticulocyte production index)

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IRON METABOLISM

• Iron concentration (Fe)
• N 50-150 ?g/dl
• Total Iron Binding Capacity
• N 250-450 ?g/dl
• Transferrin saturation
• Transferrin receptor concentration
• Ferritin concentration
• N 50-300 ?g/l

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IRON DEFICIENCY ANEMIA

• IRON METABOLISM
• ABSORPTION IN DUODENUM
• TRANSFERRIN TRANSPORTS IRON TO THE CELLS
• FERRITIN AND HEMOSYDERIN STORE IRON
• 10 of daily iron is absorbed

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• Most body iron is present in hemoglobin in
  circulating red cells
• The macrophages of the reticuloendotelial system
  store iron released from hemoglobin as ferritin
  and hemosiderin
• Small loss of iron each day in urine, faeces,
  skin and nails and in menstruating females as
  blood (1-2 mg daily)

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IRON DEFICIENCY - STAGES

• Prelatent
• reduction in iron stores without reduced serum
  iron levels
• Hb (N), MCV (N), iron absorption (?), transferin
  saturation (N), serum ferritin (?), marrow iron
  (?)
• Latent
• iron stores are exhausted, but the blood
  hemoglobin level remains normal
• Hb (N), MCV (N), TIBC (?), serum ferritin (?),
  transferrin saturation (?), marrow iron (absent)
• Iron deficiency anemia
• blood hemoglobin concentration falls below the
  lower limit of normal
• Hb (?), MCV (?), TIBC (?), serum ferritin (?),
  transferrin saturation (?), marrow iron (absent)

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Laboratory tests in iron deficiency of increasing
severity
Laboratory tests in iron deficiency of increasing severity Normal Iron deficiency without anemia Iron deficiency with mild anemia Severe iron deficiency with severe anemia
Marrow reticulo- endothelial iron 2 to 3 None None None
Serum iron (SI), µg/dL 60 to 150 60 to 150 lt60 lt40
Total iron binding capacity (transferrin, TIBC), µg/dL 300 to 360 300 to 390 350 to 400 gt410
Transferrin saturation (SI/TIBC), percent 20 to 50 30 lt15 lt10
Hemoglobin, g/dL Normal Normal 9 to 12 6 to 7
Red cell morphology Normal Normal Normal or slight hypochromia Hypochromia and microcytosis
Plasma or serum ferritin, ng/mL 40 to 200 lt40 lt20 lt10
Erythrocyte protoporphyrin, ng/mL RBC 30 to 70 30 to 70 gt100 100 to 200
Other tissue changes None None None Nail and epithelial changes
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IRON DEFICIENCY ANEMIA

• ETIOLOGY
• BLOOD LOSS
• Chronic bleeding
• MENORRHAGIA
• PEPTIC ULCER
• STOMACH CANCER
• ULCERATIVE COLITIS
• INTESTINAL CANCER
• HAEMORRHOIDS
• Intravascular
  hemolysis
• Pulmonary
  hemosiderosis
• Response to
  erythropoietin
• DECREASED IRON INTAKE
• INCREASED IRON REQUIRMENT (JUVENILE AGE,
  PREGNANCY, LACTATION)
• CONGENITAL IRON DEFICIENCY

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IRON DEFICIENCY ANEMIA

• GENERAL ANEMIAS SYMPTOMS
• FATIGABILITY
• DIZZINESS
• HEADACHE
• SCOTOMAS
• IRRITABILITY
• ROARING
• PALPITATION
• CHD, CHF

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CHARACTERISTIC SYMPTOMS

• GLOSSITIS, STOMATITIS
• DYSPHAGIA ( Plummer-Vinson syndrome)
• ATROPHIC GASTRITIS
• DRY, PALE SKIN
• SPOON SHAPED NAILS, KOILONYCHIA,
• BLUE SCLERAE
• HAIR LOSS
• PICA (APETITE FOR NON FOOD SUBSTANCES SUCH AS
  ICE, CLAY)
• SPLENOMEGALY (10)
• INCREASED PLATELET COUNT

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IRON DEFICIENCY ANEMIA

• MCV
• MCH
• MCHC N
• Fe
• TIBC and sTfR
• TRANSFERIN SATURATION
• FERRITIN

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BLOOD AND BONE MARROW SMEAR

• BLOOD
• microcytosis, hipochromia, anulocytes,
  anisocytosis poikilocytosis
• BONE MARROW
• high cellularity
• mild to moderate erythroid hyperplasia (25-35 N
  16 18)
• polychromatic and pyknotic cytoplasm of
  erythroblasts is vacuolated and irregular in
  outline (micronormoblastic erythropoiesis)
• absence of stainable iron

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Management

• History and physical examination is sufficient to
  exclude serious disease (e.g pregnant or
  lactating women, adolescents)
• - CURE ANEMIA
• History and/or physical examination is
  insufficient (e.g old men, postmenopausal women)
  
• - FIND ETIOLOGY OF ANEMIA AND CURE (CAUSAL
  TREATMENT)
• Benzidine test
• Gastroscopy
• Colonoscopy
• Gynaecological examination

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ORAL IRON ABSORPTION TEST

• 1. baseline serum iron level
• 2. 200 - 400 mg of elemental iron orally
• 3. serum iron level 1-4 hours after ingestion
• An increase in serum iron of at least 100
  microg/dL indicates that oral iron absorption is
  generally adequate

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IRON DEFICIENCY ANEMIACURE

• ORAL
• 200 mg of iron daily 1 hour before meal (e.g. 100
  mg twice daily)
• How long?
• 14 days (Hg required level Hg current level)
  x 4
• half of the dose - 6 9 months to restore iron
  reserve

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Factors influencing the absorption of dietary iron Absorption of heme iron
Amount of heme iron, especially in meat
Content of calcium in the meal (calcium impairs iron absorption)
Absorption of nonheme iron
Iron status
Amount of potentially available nonheme iron
Balance between positive and negative factors
Positive factors
Ascorbic acid
Meat or fish (heme iron enhances absorption of nonheme iron)
Negative factors
Phytate (in bran, oats, rye fiber)
Polyphenols (in tea, some vegetables and cereals)
Dietary calcium
Soy protein
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IRON DEFICIENCY ANEMIACURE

• PARENTERAL IRON SUBSTITUTION
• Bad oral iron tolerance (nausea, diarrhoea)
• Negative oral iron absorption test
• Necessity of quick management (CHD, CHF)
• iron to be injected (mg) (15 - Hb/g/) x body
  weight (kg) x 3
• IM or IV ? (risk of anaphilactic reactions)
• Intramuscular iron Mobilization of iron from
  intramuscular (IM) sites is slow and occasionally
  incomplete. As a result, the rise in the
  hemoglobin concentration is only slightly faster
  than that which occurs following the use of oral
  iron preparations.
• Ferric carboxymaltose is a novel stable iron
  complex for intravenous (IV) use which can be
  given at single doses of up to 1000 mg of
  elemental iron per week over a recommended
  infusion time of 15 minutes. A number of trials
  have shown efficacy and safety of this agent in
  iron deficient patients.

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SIDEROBLASTIC ANEMIAS

• HEREDITARY DISORDERS (rare)
• SYNONIM FOR MDS (RA,RAES)
• DISTURBANCES IN INTRACELLULAR IRON METABOLISM
• HIGHER SIDEROBLASTS NUMBER IN BONE MARROW
• CORRECT OR HIGHER IRON CONCENTRATION

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