Iron deficiency anemia

Introduction
One of the most prevalent forms of malnutrition
Globally 50% of anemia is attributable to iron
deficiency

Iron metabolism
Critical element
Various functions
Carry O2 as part of Hemoglobin
Myoglobin
Cytochrome system in mitochondria
Free iron is toxic

Body iron distribution

Iron content in mg
ADULT MALE ,8O Kg

ADULT FEMALE,60 kg

Hemoglobin

2500

1700

Myoglobin

500

300

Transferrin iron

Iron stores

600-1000

0-300

Iron cycle
Regulated by absorption
Iron losses are unregulated
Gi loss and menstrual cycle loss
Absortion in duodenum

Iron absorption
Dietary Fe in ferric form
Reduced to Fe2+ by ferric reductase
Transported through DMT1
Inside the cell stored as ferritin
Transported across BL membrane through
ferroportin

 Ferroportin is negatively regulated by hepcidin

Hephaestin is a ferroxidase which oxidises Fe2+
to Fe3+
Fe3+ binds to transferrin
Transferrin has 2 binding sites

 Normally transferrin is 35% saturated with Fe

Diferric transferrin has high affinity to
transferrin receptors in marrow erythroid cells
The complex is internalised via clathrin coated
pits and in the endosome Fe is released

 Fe utilized for heme synthesis

Remaining bind to apoferritin to form ferritin
Transferrin receptors are present in liver
parenchymal cells also.
Senescent RBCs phagocytosed by RE cells,
Fe is released and bind to transferrin.

Factors affecting Fe absorption

Vit C
Gastric HCl
Heme Fe (redmeat)> liver Fe> egg Fe> veg Fe
Phytates
Phosphates
Tannates
Fe deficiency
Erythroid hyperplasia

hepcidin low

Normal iron parameters

Seum ferritin

50-200 ug/l

TIBC

300-360 ug/dl

Serum Fe

50-150 ug/dl

Transferrin saturation

30-50%

Marrow sideroblasts

40-60%

RBC protoporphyrin

30-50 ug/dl

 Averae Fe intake is 15mg/d with 6% absorption

in males
11mg/d with 12% absorption in femles

Iron deficiency anemia

STAGES OF IRON DEFICIENCY
Negative iron balance
Iron deficient erythropoeisis
Iron deficiency anemia

Negative iron balance

Demand exceeds capacity to absorb
Physiologic increased demand,blood
loss,inadequate dietary intake
Moblization of Fe from RE storage sites
Serum ferritin decreases

Iron deficient erythropoiesis

Serum ferritin <15 ug/l indicates absent iron
stores
hemoglobin synthesis remain unaffectedas long
as serum Fe is wnl
When transferrin satn falls to 15-20%
hemoglobin synthesis is impaired

Iron def anemia

Hemoglobin and hematocrit begin to fall
T .sat is 10-15%

Causes of iron deficiency

INCREASED DEMAND FOR IRON
Rapid growth in infancy or adolescence
Pregnancy
Erythropoietin therapy

 INCREASED IRON LOSS

Chronic blood loss esp GI blood loss

Menorrhagia
Acute blood loss
Phlebotomy

 DECREASED IRON INTAKE OR ABSORPTION

Inadequate diet
Malabsorption syndromes
Post gastrecomy
Acute or chronic nflammation

Clinical features
Fatigue
Exercise intolerance
Dyspnea ,palpitation,syncope
Pica
Symptoms related to etiology

o/e
Pallor
Glossitis
Cheilitis
Platynychia,longitudinal ridging,koilonychia

Lab investigations
HEMOGRAM
Anemia
Low MCV,MCH
RDW high
Platelet count elevated

Peripheral smear
Microcytic hypochromic anemia with
anisopoikilocytosis

Iron studies

Low serum ferritin

Low serum iron
Increased TIBC
Low T sat ( seum iron* 100/TIBC )
Transferrin receptor protein levels elevated
Increased redcell protoporphyrin

Differential diagnosis
Beta thalssemia trait
Anemia of chronic disease
MDS

TREATMENT
Red cell transfusion
Oral iron therapy
200-300mg/d in empty stomach in divided
doses
Ferrous
sulfate,fumarate,gluconate,polysaccharide iron
6-12 months after correction of anemia

 Side effects
Abdominal pain,nausea,vomiting,constipation
Response to treatment
Reticulocyte increasewithin 4-7 d and peaks at 11.5 wks

Pareteral iron
Indications
Oral iron intolerance
Whose iron needs are relatively acute
Who need iron on an ongoing basis

Iron dextran,sodium ferric gluconate, iron

sucrose

 2 modes
To administer total dose of iron together
To give small repeated doses of iron over a
period

 Amount of iron needed

Body weight (kg)* 2.3* (15-patients
hemoglobin) + 500 -1000 mg
Side effects
Anaphylaxis,arthralgias,skin rash,low grade
fever

Take home message

Preventable cause of anemia
IDA in elderly ,rule out GI malignancies
Mild to mod iron deficiency is hypoproliferative
anemia while in severe iron deficiency there will
be erythroid hyperplasia..