Learning Objectives Prevalence of IDA Significance of Iron deficiency Iron homeostasis Stages of Iron deficiency Symptoms & Signs of IDA Etiology of IDA Lab. Workup of IDA Treatment of IDA
IRON DEFICIENCY ANEMIA • Data from the Third National Health and Nutrition Examination Survey (NHANES III; 1988 to 1994) indicated that iron deficiency anemia was present in 1 to 2 percent of adults
It is estimated that 3% of men and 8% of women in the UK have iron deficiency anaemia
Among low-income pregnant women in the US, the prevalence of anaemia in the first, second, and third trimesters was 9%, 14%, and 37%, respectively
IDA has been noted in up to 80% of Mexican pregnant women living in the US and in >35% of children aged under 2 years living in Argentina
IDA The most common type of anemia all over the world
Iron deficiency without anemia was more common, occurring in up to 11 percent of women (most often premenopausal) and 4 percent of men.
……..found 36% of female and 6% of male subjects to be iron deficient without anemia. J Am Diet Assoc. 2005 Jun;105(6):975-8. Prevalence of iron deficiency with and without anemia in recreationally active men and women. Sinclair LM, Hinton PS. Department of Nutritional Sciences, University of Missouri-Columbia, 65211, USA
In our research,85% of pregnant women(on daily iron supplement) were iron deficient
Hemoglobin in circulating red cells and developing erythroblasts — about 2.5 g Iron-containing proteins (eg, myoglobin, cytochromes, catalase) — 400 mg Plasma transferrin-bound iron — 3 to 7 mg The remainder is storage iron in the form of ferritin or hemosiderin.
IRON BODY CONTENT Storage iron male: 800- 1000mg Female:300-500 mg
The generally lower value for iron stores in adult women, for example, reflects the composite effect of menstrual losses (approximately 1 mg of iron loss per day), lower caloric intake, use of supplemental iron, and iron losses associated with pregnancy and lactation (about 1000 mg each for pregnancy, delivery, and nursing).
Storage iron in adult men has been estimated as being approximately 10 mg/kg, and is found mostly in liver, spleen, and bone marrow
For ferritin levels in the range from 20 to 300 ng/mL, there appears to be a direct quantitative relationship between the ferritin concentration and iron stores Iron stores (mg)= (8 to 10) x ferritin (ng/mL)
Iron in daily DietMale Female15-20 mg 10-15 mgDaily Iron NeedMale Female1 mg 2 mg
Iron Bioavailability Oxalates, Phytates,& Phosphetes retard iron absorption
Iron Bioavailability Ascorbate, lactate, pyruvate, succinate, fructose,cystein and sorbitol increase iron absorption
IRON ABSORPTION Heme iron: Heme carrier Protein 1 (HCP1)?? .Ferric iron: duodenal cytochrom b reductase divalent metal transporter(DMT)1 Ferroportin Hephaestin Hepcidin
Causes of iron deficiency:1-Increased demand for iron and / or hematopoiesis• pregnancy• rapid growth in infancy or adolescence.• erythropoietin therapy2- Increased iron loss•chronic blood loss •Menses•Acute blood loss•Blood donation•Phlebotomy as treatment for polycetemia vera3- Decreased iron intake or absorption• inadequate diet• malabsorption from disease (sprue, crohn’s disease)• malabsorption from surgery (post-gastrectomy) • acute or chronic inflammation
Blood loss • Although reduced gastrointestinal absorption of iron and a diet deficient in iron can also cause iron deficiency, it is most reasonable to believe, as a first assumption, that iron deficiency reflects blood loss, in order to avoiding missing an occult malignancy or other bleeding intestinal lesion
In a study of 9024 participants in the NHANES I study, men and postmenopausal women with iron deficiency anemia had an increased risk of being diagnosed with a gastrointestinal malignancy within the subsequent two years (relative risk versus non-iron deficient controls 31, 95% CI 9-107)
In a report dealing with 148 consecutive patients with iron deficiency anemia, 18 patients (12 percent) were found to have a malignant tumor . Using multivariate analysis, the odds ratio for the presence of malignancy in a patient with a serum ferritin <10 microg/L and an LDH >250 U/L, when compared with patients having a ferritin >10 and an LDH <250, was 74 (95% CI 7-776).
Decreased iron absorption • Gastrointestinal malabsorption of iron is a relatively uncommon cause of iron deficiency, although it may be observed in certain diseases associated with generalized malabsorption or achlorhydria . However, the use of proton pump inhibitors, which reduce gastric acid secretion, has not been associated with clinical iron deficiency.
These diagnoses (eg, atrophic gastritis, Helicobacter pylori gastritis, celiac disease) should be considered in patients with otherwise unexplained iron deficiency, especially when there is refractoriness to oral iron therapy
Celiac disease was the cause of iron deficiency in up to 10 percent of patients referred to a gastroenterologist in one report , and in up to 8.5 percent of patients with iron deficiency anemia unresponsive to oral iron therapy in another study
Clinical manifestations • The usual presenting symptoms in adults, as seen in current practice, are primarily due to anemia and include weakness, headache, irritability and varying degrees of fatigue and exercise intolerance.
Clinical manifestations • Most frequently,symptoms are misinterpreted as depression.
Clinical manifestations • However, many patients are asymptomatic and present only with anemia.
PICA • refers to a perverted appetite for substances not fit as food : • Geophaia • Pagophagia • Amylophagia • …..(carrot,tea,dried lemon ,cube sugar)
PICA • Pagophagia, or pica for ice, is considered quite specific for the iron deficiency state
PICA • It may be present in patients who are not anemic and responds rapidly to treatment with iron, often before any increase is noted in the hemoglobin concentration. In one study of 55 unselected patients with iron deficiency anemia secondary to gastrointestinal blood loss, pica was present in 32 and pagophagia in 28
Neuromuscular symptoms Impaired auditory development Impaired cognitive development Involuntary movements (during sleep) Restless leg syndrome
The sensitivity and specificity for pallor in the palms, nail beds, face, or conjunctivae as a predictor for anemia varies from 19 to 70 percent and 70 to 100 percent, respectively