Storage iron is divided about equally among
- Reticuloendothelial cells (Spleen, Liver & Bone marrow)
- Hepatic parenchymal cells
- Skeletal muscle
Storage iron occurs in two forms:
- Ferritin
- Hemosiderin
Important information bullets:
- Hemosiderin is the main form in RES; Ferritin is the main form in hepatocytes.
- In deficiency ferritin form is more easily mobilized and in overload hemosiderin is more increased.
- About 3-4 mg of iron is present in plasma which is bound to transferrin.
- Transferrin transports iron from alimentary tract to tissue stores, from stores to bone marrow erythroblasts and from one store to another store.
- The concentration of transferrin in blood is total iron binding capacity (TIBC).
- The percentage of transferrin to which iron is attached is called percentage saturation of iron binding protein (transferrin)
- Serum ferritin concentrations generally correlate well with tissue iron stores. A serum Ferritin level of 12 μg/l or less is diagnostic of iron deficiency. Single best test to confirm IDA.
Sites of absorption:
- Stomach
- Duodenum, Proximal jejunum
Dietary iron requirement:
- Male: 1 mg/day
- Menstruating female: 2 mg/day
- Pregnancy: 3 mg/day
Serum transferrin receptor:
Directly related to extent of erythroid activity as well as being inversely related to iron supply to cells
Serum Iron Profile:
- Thalassaemia: ALL NORMAL
- IDA: Only TIBC & soluble transferrin receptor – increased, all decreased
- ACD:
- Remember: ফেরারী (ferritin) আসামীরা chronic (ACD) ঘুরে বেড়ায় (বাড়ে)
- Only serum ferritin increased, all decreased
- Sideroblastic anemia: NO DECREASED
- Serum iron; ferritin; transferrin saturation – increased
- TIBC, soluble transferrin receptor- N
Causes of Iron Deficiency
- For men or postmenopausal women
- Peptic ulcer disease, gastritis, Hookworm infestations, schistosomiasis
- Occult gastric on colorectal malignancy, IBD, Haemorrhoids
- Diverticulitis, polyp, angiodysplasia,
- Chronic hemoptysis, Hematuria
- Achlorhydria, Gastric surgery, Coeliac disease
- Drugs: Aspirin or NSAID use
- Female of child bearing age
- Menstrual blood loss, pregnancy, breast feeding
| Increased Demand for Iron |
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| Increased Iron Loss |
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| Decreased Iron Intake or Absorption |
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Investigation
- Investigation to confirm diagnosis: CBC, PBF, Iron profile
- Investigation to find out cause: eg. stool RE
| Investigation | Finding |
| CBC PBF |
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Iron profile
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| Serum soluble transferrin Receptor |
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| Bone marrow aspirate/biopsy for iron stain |
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| UGI endoscopy, colonoscopy |
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Small gut imaging:
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Investigations for Schistosomiasis
- Blood
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- CBC, ESR – Eosinophilia
- ELISA – positive
- Urinary system:
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- Urine dipstick Examination – blood and Albumin
- Microscopic examination of centrifuged deposit: eggs
- USG of KUB: Bladder wall thickening, Bladder calcification, Hydronephrosis
- cystoscopy: sandy patches, bleeding mucosa, distention of mucosa
- Sigmoidoscopy: Inflammation and bleeding
Q. Malignancy that may develop, if this patient remains untreated (IDA)?
- Esophageal carcinoma (from Plummer – Vinson syndrome)
Management of IDA:
- Treatment of underlying cause: stop aspirin/NSAIDs
- Correction of iron deficiency.
Iron Preparation:
- Oral: Ferrous sulfate 200 mg, 3 times daily after meals 3-6 months
- Parenteral: Ferric carboxymaltose (Inj. ferisen)
| Oral Iron Preparations | Parenteral: chance of anaphylaxis |
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Q. What are the causes of failure to response to oral therapy:
- Non compliance
- Malabsorption
- Continued blood loss
- Incorrect diagnosis
- Delayed release iron preparation
Q. What investigation will you do to monitor the response to therapy?
- After 7-10 days
- Hb% and
- Reticulocyte count
Q. What are the indication for parenteral iron therapy:
- Malabsorption
- Chronic gut disease
- Iability to tolerate
Q. What are the problems with ferrous sulfate
- Dyspepsia
- Altered bowel habit
- Solve: either dose reduction to 200 mg BD, or switch to ferrous gluconate
Calculation of Dosage: (parenteral)
- The amount of iron needed by an individual patient is calculated by the following formula: (harrisson)
| Body weight (kg) × 2.3 × (15 – patient’s Hb, g/dL) + 500 or 1000 mg (for stores) |
Follow Up:
- The hemoglobin rise by 1 g/dl per weeks (7– 10 days)
- Reticulocytosis within a week
- If no response of the hematological parameters is observed after 1 to 2 weeks, the original diagnosis should be reconsidered.
*** *** ***
OSPE: A 32 year-old woman has presented with weakness, dizziness and palpitation with no organomegaly. Study her hematology report and give answer to the following questions:
- Hemoglobin 10.7 g/dl
- WBC- 5.5 x 109/L
- Platelets- 220 x 109/L
- RDW-CV: 24%
- PCV-0.29
- MCV- 66 fl
- MCH-20 pg
- MCHC-24
Q. What is your diagnosis?
- Iron deficiency anemia (2) / microcytic hypochromic anemia (1)
Q. Mention her treatment with appropriate formulation, dose and duration.
- Ferrous sulfate 200 mg, thrice daily after meals at least for three months after correction
Q. What investigations will you do to monitor the response to therapy?
- After 7 to 10 days,
- Hb% and reticulocyte count
Q. If there is inadequate response what are the factors you will consider?
- Non compliance
- Continued blood loss
- Malabsorption
- Incorrect diagnosis
- Incorrect drug formulation
| IDA |
| PBF Finding | History |
CBC:
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| Examination | Investigation |
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