hypo/micro anemias

absorption of iron occurs in the ___ and proximal ___

duodenum & proximal jejunum

to be absorbed, iron must be in ____ state or bound to ____

ferrous (Fe2+) or bound to heme (animal source)

Iron from plants is in ____ state and must be converted to __ ____

ferric (Fe3+)

ferrous iron (Fe2+)

Bone marrow RBC precursors utilize portion of available iron (65-80%)

• The remainder is stored as ___ or ____

ferritin or hemosiderin

IDA are _____% of anemias in people >65 years

60

Populations to watch

• Infants whose major source of nutrition is cow's milk and juices

• Adolescent females

• Pregnancy

• Elderly

IDA etiology

- iron intake not sufficient to replace normal losses - not intaking enough for demands

- iron not available for erythropoiesis despite adequate intake - malabsorption

- increased loss of body (losing blood) iron not adequately replace by normal intake

iron intake not sufficient to replace normal iron losses -

- 6 months - 2 years

- adolescent females - 1st period; growth

- pregnancy - 3rd trimester

- elderly - insufficient intake (dental issues & decrease in stomach acid)

- pica (eating strange things)

iron not available for erythropoiesis despite adequate intake -

- malabsorption disease - celiac disease, chronic diarrhea, gastrectomy

- achlorhydria - gastric bypass, antacids

increase loss of body iron not adequately replaced by normal intake -

- excessive blood loss

Males: GI - ulcer, carcinoma, hemorrhoids

females: GI or vaginal

- excessive blood donation

pathophysiology for IDA

1. iron depletion

2. iron deficient erythropoiesis

3. iron deficiency anemia

iron depletion -

iron deficient, but NOT anemic yet

- decrease ferritin - Hb NL, RBC indices NL

iron deficient erythropoiesis -

- iron panel abnormalities

- RBC indicies changes: RDW increase (1st) & MCV decreases

iron deficiency anemia

- decrease Hb

- signs & symptoms present

IDA clinical findings:

weakness, fatigue, shortness of breath, headache (noticed w/exercise), pica, pagophagia, pallor, koilonychia, cheilosis, neurologic (irritability), restless leg syndrome

what labs would you order if IDA is suspected

CBC w/diff, iron panel (ferritin)

- UA, fecal occult, imaging - if bleeding suspected

CBC for IDA:

RBC count/Hb/Hct -

MCV/MCH/MCHC -

RDW -

RBC count/Hb/Hct - decreased

MCV/MCH/MCHC - decreased

RDW - increased

iron panel IDA

ferritin:

serum iron:

transferrin/TIBC:

iron saturation/% saturation:

ferritin: decreased (earliest indicator)

serum iron: decreased

transferrin/TIBC: increased

iron saturation/% saturation: decreased

IDA special test

- stainable iron in bone marrow aspiration (gold stand, but very invasive so ferritin = best test)

- occult blood in stool (if positive: GI endoscopy/colonscopy)

- UA

heme iron =

bound to myoglobin & hemoglobin (animal source) 15-33%

non-heme iron =

1-10% less effective absorption - plant source

IDA management

Nonheme iron salts

• Typical Approach:

• Goal is to provide 150-200mg of elemental iron/day, doses split throughout day

• Ferrous sulphate - 325mg 3X/day

• Ferrous fumarate, ferrous gluconate, ferrous bis-glycinate all have different elemental

iron content, so dosage will vary

Alternative

• Double dose, every other day

can - reduce side effects

• Can decrease side effects, but can slow hemoglobin response

nonheme iron salts side effects

- epigastric pain

- nausea

- diarrhea/constipation

- dark stool

heme iron details

- 30-40 mg/per day

- more expensive

- not an option for vegan/vegetarians

- issue w/long term use

other factors impacting iron treatment =

- empty stomach; 30 min before meals, or 2 hours after

- vitamin C to enhance absorption

- calcium, Mg, Cu, zinc, coffee, antacids decrease absorptions

food sources of iron =

- red meat, liver, fish (heme well absorbed)

- beans, green leafy vegetables, dried fruits, whole-grain & enriched breads

response to care

• Reticulocyte count - 7-10 days after treatment

• 2 weeks - hemoglobin should rise .7-1 g/dL/week

• Continue treatment for 3-6 months to replenish iron stores

Iron Utilization Anemia (Sideroblastic Anemia) general facts

• Due to inadequate or abnormal utilization of intracellular iron for hemoglobin synthesis

• Iron levels within mitochondria of RBC precursors are adequate or elevated

• Rare

*protoporphoryn + iron = heme

Iron Utilization Anemia (Sideroblastic Anemia) etiology

• Hereditary

• Acquired

• Primary - idiopathic

• Secondary

• Alcoholism

histora• Drug/toxin induced - lead poisoning

• Nutritional deficiency - B6 (pyridoxine) deficiency

Iron Utilization Anemia (Sideroblastic Anemia) clinical findings

• Moderate to severe anemia

• Hepatosplenomegaly

Iron Utilization Anemia (Sideroblastic Anemia) CBC

• Hypochromic, microcytic anemia

• High RDW

Iron Utilization Anemia (Sideroblastic Anemia) iron panel

• Iron Panel

• Ferritin

• Serum Iron

• TIBC

• % saturation

• Ferritin: increased

• Serum Iron: increased

• TIBC/transferrin: decreased/NL

• % saturation: increased

Iron Utilization Anemia (Sideroblastic Anemia) laboratory findings

• Peripheral blood smear

• May show ringed sideroblasts

• Chem panel

• Liver enzymes elevated

• Special tests

• Low reticulocyte count

• Bone marrow

examination to confirm

diagnosis

• Sideroblasts

Iron Utilization Anemia (Sideroblastic Anemia) treatment

• Specific to cause

• Alcohol use

Iron-Reutilization Anemia

(Anemia of Chronic Disease) can be

*hypo/micro or normo/normo

Iron-Reutilization Anemia

(Anemia of Chronic Disease) general facts

• Second most common anemia in the world

Iron-Reutilization Anemia

(Anemia of Chronic Disease) etiology

chronic infections, inflammatory disease (RA, SLE), certain malignancies (hodgkin lymphoma, multiple myeloma, liver, lung, breast cancer)

*IDA = GI & GU cancers

Iron-Reutilization Anemia

(Anemia of Chronic Disease) clinical findings

• Anemia symptoms

• Underlying disease symptoms

Iron-Reutilization Anemia

(Anemia of Chronic Disease)

CBC

- anemia

- RDW NL or slight elevation

Iron-Reutilization Anemia

(Anemia of Chronic Disease)

iron panel

• Ferritin

• Serum iron

• Transferrin/TIBC

• % saturation

hypo/micro

• Ferritin: increased

• Serum iron: decreased

• Transferrin/TIBC: decreased

• % saturation: decreased

normo/normo

• Ferritin: increased

• Serum iron: NL

• Transferrin/TIBC: NL

• % saturation: NL

Iron-Reutilization Anemia

(Anemia of Chronic Disease) additional test

- CRP

- ESR

(elevated due to underlying inflammatory disease)

- other test associated w/primary condition

Iron-Reutilization Anemia

(Anemia of Chronic Disease) management

treat underlying disease

Combined IDA and ACD -

• Difficult to identify due to acute phase reactants

• Serum transferrin receptor (sTfR) (IDA = increased, ACD = NL)

• Ferritin: < 100 w/evidence of inflammation