Iron metabolism

1
Iron metabolism And Anemia in chronic kidney
disease
Chittima Sirijerachai
2
Iron distribution

• Intracellular iron

• Intracellular ferrous iron
• Heme iron compound Hb, myoglobin
• Iron containing enzyme
• Intracellular ferric iron
• RE cell, heart, epithelial cell of small intestine

• Extracellular iron

- Ferric-transferrin
3
Dietary iron 1-2 mg/day
Slough mucosal cell 1-2 mg/day
4
Iron absorption

• Promote absorption
• Fructose
• Vitamin C
• Heme iron
• Amino acid

Fe
HCl
Fe

• Inhibit absorption
• Phosphate
• Phytate
• Tannin
• Soil clay

Fe
Fe
ferritin
Fe - transferrin
5
Iron absorption
6
Regulation of iron absorption

• Dietary iron mucosal block

• Iron stores store regulator

• Erythropoitic regulator

7
Iron utilization
8
Iron deficiency anemia
Dietary iron 1-2 mg/day
Slough mucosal cell 1-2 mg/day
9
inflammation
Anemia of chronic disease
Plasma Fe-Tf
10
Iron study

• Serum iron

• Total iron binding capacity (TIBC)

• Transferrin saturation (Tf sat)

• Ferritin

11
Iron depletion
normal
functional
absolute
erythrocyte
Iron stores
12
(No Transcript)
13
Causes of anemia in ESRD

• Decrease erythropoietin

• Iron deficiency

• Nutritional deficiency

• Decrease red cell survival

• Bone marrow suppression by uremia

• Osteitis fibrosa cystica

• Inflammation

• Aluminum toxicity

14
Work-up for a diagnosis of anemia in CKD
Hb
Adult male lt 13.5 g/dl
Adult female lt12.5 g/dl
15
Diagnosis of renal anemia

• Significant impairment of renal function

GFR lt 30 cc/min, Cr gt 2 mg/dl

• No other causes of anemia

• Iron deficiency anemia

• Nutritional deficiency anemia

16
Diagnosis of renal anemia

• History taking

- Dietary intake
- Chronic blood loss

• Physical examination

17
(No Transcript)
18
Investigation

• CBC

• Red cell indices

• Iron study, ferritin

19
CBC and RBC indices
20
(No Transcript)
21
Iron study, ferritin
TSAT lt 20 Ferritin lt 100 ng/ml
Iron deficiency anemia
22
Treatment of renal anemia
23
Benefit of anemia control in ESRD

• Increased survival

• Decreased cardiac complication

• Improved quality of life

• Increased exercise capacity

• Decreased hospitalization

24
Target for anemia treatment
Hb gt 11 g/dl Hct gt 33
Within 4 months
Ferritin 200-500 ng/ml TSAT 30-40
25
Treatment of renal anemia
26
(No Transcript)
27
Iron therapy
Improved response to EPO
Reduced dose of EPO
28
Iron therapy
VS
29
Iron therapy
- Ferrous sulfate 1 x 3
- Iron sucrose 25-150 mg/wk
Monitor- serum ferritin, TSAT q 1-3 months
30
Iron therapy in CKD
Serum ferritin
lt 100 ng/ml - iron deficiency
gt 800 ng/ml - stop iron Rx
Transferrin saturation
lt 20 - iron deficiency
gt 50 - stop iron Rx
31
Side effects of iron therapy

• GI irritation
• Diarrhea
• Constipation

Oral iron

• anaphylactoid
• hypotension
• muscle cramp

IV iron
32
Erythropoietin
Erythropoietin a
Erythropoietin b
Recormon
33
Erythropoietin
80-120 U/kg/wk SC
120-180 U/kg/wk IV
34
Erythropoietin
Side effects
- hypertension
- headache
- PRCA
- Thrombosis
35
Inadequate erythropoietin response
Patient fail to attain the target Hb while
receiving- EPO 300 U/kg/wk SC EPO 450 U/kg/wk
IV
4-6 months
36
Inadequate erythropoietin response

• Iron deficiency anemia
• Chronic blood loss
• Chronic inflammation
• Inadequate dialysis
• hyperparathyroidism

37
(No Transcript)