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Kennady G, Afridi F, Neumann D, Amendolia B, Kilic N, Bhat V, Bhandari V, Aghai ZH. Iron Deficiency Prior to Discharge in Very Low Birth Weight Infants: Screening with Reticulocyte Hemoglobin Content. Am J Perinatol 2024; 41:1560-1566. [PMID: 37890510 DOI: 10.1055/a-2200-3285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
OBJECTIVE This study aimed to assess the iron status prior to discharge in very low birth weight (VLBW) infants utilizing reticulocyte hemoglobin content (CHr) and evaluate the impact of delayed cord clamping (DCC) on iron status. STUDY DESIGN This is a retrospective analysis of VLBW infants from two tertiary level of care Neonatal Intensive Care Units. The primary outcome was the proportion of VLBW infants with low CHr (<29 pg) prior to discharge. Hematologic parameters were also compared between infants who received or did not receive DCC. Infants with a positive newborn screen for hemoglobin Bart's were excluded. RESULTS Among the 315 infants included, 99 infants (31.4%) had low CHr prior to discharge. The median (interquartile range) CHr prior to discharge was 30.8 pg (28.4-39 pg). DCC was performed in 46.7% of infants. Hemoglobin at birth, discharge, and CHr prior to discharge were higher and the need for blood transfusion and the number of infants with low CHr prior to discharge were lower in the DCC group. CONCLUSION Approximately 31.4% of VLBW infants had low CHr near the time of discharge suggesting they were iron deficient. DCC improved hematological parameters prior to discharge in VLBW infants. CHr content can be used to guide iron supplementation in VLBW infants to potentially improve their iron status and long-term neurocognitive outcomes. KEY POINTS · DCC was associated with an improved hemoglobin and iron status at discharge in VLBW infants.. · CHr is an early and reliable marker for iron deficiency.. · Approximately one in three VLBW infants can be iron deficient at the time of discharge..
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Affiliation(s)
- Geetika Kennady
- Division of Neonatology, Department of Pediatrics, Thomas Jefferson University Hospital/Nemours Children's Health, Philadelphia, Pennsylvania
| | - Faraz Afridi
- Division of Neonatology, Department of Pediatrics, Cooper University Hospital, Camden, New Jersey
| | - Dana Neumann
- Division of Neonatology, Department of Pediatrics, Thomas Jefferson University Hospital/Nemours Children's Health, Philadelphia, Pennsylvania
| | - Barbara Amendolia
- Division of Neonatology, Department of Pediatrics, Cooper University Hospital, Camden, New Jersey
| | - Nicole Kilic
- Division of Neonatology, Department of Pediatrics, Cooper University Hospital, Camden, New Jersey
| | - Vishwanath Bhat
- Division of Neonatology, Department of Pediatrics, Cooper University Hospital, Camden, New Jersey
| | - Vineet Bhandari
- Division of Neonatology, Department of Pediatrics, Cooper University Hospital, Camden, New Jersey
| | - Zubair H Aghai
- Division of Neonatology, Department of Pediatrics, Thomas Jefferson University Hospital/Nemours Children's Health, Philadelphia, Pennsylvania
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Poventud-Fuentes I, Chong TH, Dowlin M, Devaraj S, Curry CV. Reticulocyte hemoglobin equivalent as a marker to assess iron deficiency: A large pediatric tertiary care hospital study. Int J Lab Hematol 2024; 46:148-155. [PMID: 37850393 DOI: 10.1111/ijlh.14188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/27/2023] [Indexed: 10/19/2023]
Abstract
INTRODUCTION Detection of iron deficiency (ID) remains challenging. We aimed to evaluate the performance of reticulocyte hemoglobin equivalent (Ret-He) as a potential diagnostic marker to assess ID and iron deficiency anemia (IDA) in a large pediatric cohort. METHODS A total of 3158 patients (aged 15 days to 19 years with a median age of 8.5 years; 60.2% female) were retrospectively studied. Statistical analysis was performed (a) to evaluate relationship of Ret-He with other relevant complete blood count and iron panel parameters; (b) to compare the levels of Ret-He in ID and IDA groups to a control group; and (c) to assess sensitivity and specificity of Ret-He in ID, IDA, and anemia without ID groups. RESULTS Ret-He values were significantly positively correlated to ferritin and transferrin saturation (TSAT). The median Ret-He was significantly lower in ID. A Ret-He cutoff of ≤30.0 pg distinguished cases of ID from the control group with a sensitivity of 90.2%, specificity of 59.5%, and area under curve (AUC) of 0.88. Ret-He showed better diagnostic performance in the IDA group and acceptable performance for ID without anemia. The sensitivity, specificity, and AUC were 90.1%, 80.9%, and 0.93 for IDA at cutoff value of ≤27.4 pg, and 80.8%, 51.1%, and 0.70 for ID without anemia at cutoff value of ≤30.8 pg, respectively. CONCLUSION Our large pediatric tertiary care hospital study demonstrates that Ret-He is a reliable marker to help confirm IDA in pediatric population. However, further studies are needed for its use to capture the early stages of ID.
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Affiliation(s)
- Izmarie Poventud-Fuentes
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
- Department of Pathology, Texas Children's Hospital, Houston, Texas, USA
| | - Thomas H Chong
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
- Department of Pathology, Texas Children's Hospital, Houston, Texas, USA
| | - Michael Dowlin
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
- Department of Pathology, Texas Children's Hospital, Houston, Texas, USA
| | - Sridevi Devaraj
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
- Department of Pathology, Texas Children's Hospital, Houston, Texas, USA
| | - Choladda V Curry
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
- Department of Pathology, Texas Children's Hospital, Houston, Texas, USA
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Chance R, Kang AS. Eukaryotic ribosome display for antibody discovery: A review. Hum Antibodies 2024; 32:107-120. [PMID: 38788063 DOI: 10.3233/hab-240001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Monoclonal antibody biologics have significantly transformed the therapeutic landscape within the biopharmaceutical industry, partly due to the utilisation of discovery technologies such as the hybridoma method and phage display. While these established platforms have streamlined the development process to date, their reliance on cell transformation for antibody identification faces limitations related to library diversification and the constraints of host cell physiology. Cell-free systems like ribosome display offer a complementary approach, enabling antibody selection in a completely in vitro setting while harnessing enriched cellular molecular machinery. This review aims to provide an overview of the fundamental principles underlying the ribosome display method and its potential for advancing antibody discovery and development.
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Friedman T, Dann EJ, Bitton-Worms K, Makhoul M, Glam R, Weis A, Tam DY, Bolotin G. Intravenous iron administration before cardiac surgery reduces red blood cell transfusion in patients without anaemia. Br J Anaesth 2023; 131:981-988. [PMID: 37838604 DOI: 10.1016/j.bja.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/02/2023] [Accepted: 09/14/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND Reducing the need for blood transfusion among patients undergoing cardiac surgery FLA reduce postoperative complications and mortality. Our study aimed to assess the effects of administering preoperative i.v. ferric carboxymaltose on postoperative red cell transfusion requirements in patients without anaemia undergoing on-pump cardiac surgery. METHODS This double-blind, randomised, placebo-controlled trial was conducted between October 2016 and November 2019, with a follow-up period of up to 6 weeks after surgery. Patients without anaemia who underwent on-pump cardiac surgery were included as participants and administered i.v. iron in the form of ferric carboxymaltose or placebo once, 24-72 h before surgery. The primary outcome was the number of red cell units transfused during the first four postoperative days, and the secondary outcome measures were blood haemoglobin concentrations at 4 days and 6 weeks after surgery. RESULTS The 200 patients included were randomly assigned to the ferric carboxymaltose (n=102) and placebo (n=98) groups. By postoperative Day 4, a significantly lower mean number of red cell units were transfused in the ferric carboxymaltose than in the placebo group, 0.3 (0.8) vs 1.6 (4.4), respectively; P=0.007. The mean haemoglobin concentrations on postoperative Day 4 were 9.7 (1) g dl-1 and 9.3 (1) g dl-1, respectively (P=0.03). Corresponding values at 6 weeks after surgery were 12.6 (1.4) g dl-1 and 11.8 (1.5) g dl-1, respectively (P=0.012). CONCLUSIONS In patients without anaemia undergoing on-pump cardiac surgery, treatment with a single dose of 1000 mg ferric carboxymaltose i.v. 1-3 days before surgery significantly reduced the need for red cell transfusions and increased the postoperative haemoglobin concentration. CLINICAL TRIAL REGISTRATION NCT02939794.
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Affiliation(s)
- Tom Friedman
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.
| | - Eldad J Dann
- Blood Bank and Apheresis Unit, Rambam Health Care Campus, Haifa, Israel; Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | | | - Maged Makhoul
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Roi Glam
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Anastasia Weis
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Derrick Y Tam
- Division of Cardiac Surgery, University of Toronto, Toronto, ON, Canada
| | - Gil Bolotin
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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Bakr S, Yousief E, Ezzat EM, Elsary AY, Elamir AM, Gamal M. Screening of subclinical functional hemoglobin and red blood cell abnormalities among blood donors of Fayoum University Hospital in Egypt: Are RET-He, and IRF useful screening tools? Transfus Apher Sci 2023; 62:103781. [PMID: 37524581 DOI: 10.1016/j.transci.2023.103781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/20/2023] [Accepted: 07/26/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND The effectiveness of red cell transfusion in a given blood unit that relied on both quantity and quality of donated cells undoubtedly affects prognostic outcomes. OBJECTIVE We aimed to determine the frequency of subclinical functional hemoglobin and red cell abnormalities in donated blood of Fayoum University Hospital in Egypt. Additionally, to assess the usefulness of reticulocyte mean hemoglobin content (RET-He) and immature reticulocyte fraction (IRF) as screening measures for such abnormalities. MATERIAL AND METHODS This cross-sectional study enrolled 200 volunteer blood donors who met the national standard criterion of blood donation. Complete blood count with reticulocyte parameters, serum ferritin, sickling test, G6PD assay, Mentzer index, and naked-eye single tube red cell osmotic fragility test were carried out. RESULTS Functional red cell abnormalities represented 44 % of this cohort. Out of them, 4.5 % had iron deficiency, 11 % had a positive sickling test, 19 % had G6PD deficiency, and 9.5 % had suspicious thalassemia. The sensitivity and specificity test for RET-He in selective identification of functional hemoglobin abnormalities in donated blood were 83.3 % and 61.2 %, respectively at a cutoff value of 26.9. Though there was no statistically significant effect of RET-He on the selective detection of G6PD deficiency, IRF had a statistically significant high level with a p-value of 0.04. CONCLUSION Subclinical functional red cell abnormalities seem to be prevalent among blood donors. Reticulocyte/ erythrocyte indices could be useful screening tools for red cell abnormalities. Further studies are required for assessing the impact of transfusing such abnormalities to neonates and other critical recipients.
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Affiliation(s)
- Salwa Bakr
- Department of Clinical Pathology/Hematology, Faculty of Medicine, Fayoum University, Fayoum, Egypt.
| | - Eman Yousief
- Department of Clinical Pathology/Hematology, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Eman Mahmoud Ezzat
- Department of Internal Medicine, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Asmaa Younis Elsary
- Department of Public Health and Community Medicine, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Azza M Elamir
- Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Mona Gamal
- Department of Clinical Pathology/Hematology, Faculty of Medicine, Fayoum University, Fayoum, Egypt
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Kim HH, Lee EJ, Kim JK. Rapid increase in the body mass index of very preterm infants is a risk factor for iron deficiency during infancy. Sci Rep 2023; 13:15526. [PMID: 37726416 PMCID: PMC10509161 DOI: 10.1038/s41598-023-42531-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/11/2023] [Indexed: 09/21/2023] Open
Abstract
Iron deficiency (ID) in very preterm infants born at 28-32 weeks of gestational age (GA) can lower mental and motor test scores. This study aimed to determine whether the rapid growth of very preterm infants might be associated with ID. Among 134 very preterm born between January 2014 and December 2020 at Jeonbuk National University Hospital and discharged home, 93 were included in this study. Rapid BMI increase (RBI) was defined as a z-score difference of > 1 standard deviation between birth and 8 months. ID occurred in 23 of 93 (24.7%) infants at 8 months of corrected age (CA). ID was more common in the RBI group (50%) than in the non-RBI group (18.7%). In the multivariate logistic regression corrected for GA, infants small for gestational age (SGA) (odds ratio [OR] 6.06, 95% confidence interval [CI] 1.34-30.21) and RBI by z-score (OR 4.26, 95% CI 1.28-14.65) were identified as independent risk factors for ID at 8 months of CA. Conclusively, both SGA and RBI in the early life of very preterm were risk factors for ID at 8 months of CA.
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Affiliation(s)
- Hyun Ho Kim
- Department of Pediatrics, Jeonbuk National University School of Medicine, Jeonju, South Korea
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
- Department of Statistics and Data Science, Korea National Open University, Seoul, South Korea
| | - Eun Jee Lee
- College of Nursing, Research Institute of Nursing Science, Jeonbuk National University, Jeonju, South Korea
| | - Jin Kyu Kim
- Department of Pediatrics, Jeonbuk National University School of Medicine, Jeonju, South Korea.
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea.
- Department of Pediatrics, Jeonbuk National University Children's Hospital, 20 Geonjiro, Jeonju, 54907, South Korea.
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de Leur K, Pouw NMC, Lopez J, Waals-Prinzen L, Ceelie H, van der Zwan-van Beek EM. The alternative Thomas-plot: A new tool for effective anemia diagnostics. Int J Lab Hematol 2023; 45:96-103. [PMID: 36168666 DOI: 10.1111/ijlh.13964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 08/18/2022] [Indexed: 01/18/2023]
Abstract
INTRODUCTION The Thomas-plot has proven to be a helpful tool to discriminate between different types of anemia. This plot combines the reticulocyte hemoglobin content (Ret-He) with the soluble transferrin receptor (sTfR)/log ferritin (fer) ratio. In this study, we designed an alternative Thomas-plot in which Ret-He is combined with the transferrin (Tf)/log ferritin ratio. We validated both Thomas-plots in a population of anemic patients and compared the performance to the current laboratory diagnostics of anemia. METHODS A total of 536 anemic patients were included. The first 188 patients were used to generate ROC curves to define the optimal cut-off values for both Thomas-plots. With the following 348 patients included we studied the performance of the alternative and classical Thomas-plots compared to current anemia diagnostics. RESULTS Cut-off values were defined (Ret-He: 31.2 pg, sTfR/log(fer): 0.91, and Tf/log(fer): 1.71). With both Thomas-plots the amount of e causa ignota (ECI) cases dropped from 39% to 27%. A more in depth analysis on the iron status of anemia of chronic disease (ACD) patients and a subdivision between latent and classical iron deficiencies could be made with the help of both plots. A shift from classical iron deficiency anemia (IDA) cases according to the classical Thomas-plot toward functional IDA according to the alternative Thomas-plot was observed. CONCLUSION The alternative Thomas-plot is an effective tool that gives a more in depth view on the iron status of anemic patients. In addition, it is easier to implement due to the use of transferrin rather than the soluble transferrin receptor.
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Affiliation(s)
- Kitty de Leur
- Klinisch Chemisch Laboratorium en Trombosedienst, Franciscus Gasthuis & Vlietland, Schiedam, The Netherlands
| | - Nadine M C Pouw
- Klinisch Chemisch Laboratorium en Trombosedienst, Franciscus Gasthuis & Vlietland, Schiedam, The Netherlands
| | - Jordy Lopez
- Klinisch Chemisch Laboratorium en Trombosedienst, Franciscus Gasthuis & Vlietland, Schiedam, The Netherlands
| | - Lenneke Waals-Prinzen
- Klinisch Chemisch Laboratorium en Trombosedienst, Franciscus Gasthuis & Vlietland, Schiedam, The Netherlands
| | - Huib Ceelie
- Klinisch Chemisch Laboratorium en Trombosedienst, Franciscus Gasthuis & Vlietland, Schiedam, The Netherlands
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Perchard M, Barbaro P, Rane M, Norman A. Clinical utility of reticulocyte haemoglobin in the assessment of iron deficiency and iron deficiency anaemia in the paediatric population. J Paediatr Child Health 2023; 59:153-158. [PMID: 36334002 DOI: 10.1111/jpc.16265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/12/2022] [Accepted: 10/16/2022] [Indexed: 11/06/2022]
Abstract
AIM Reticulocyte haemoglobin (Ret-He) is a useful marker in the assessment of iron stores in adult and paediatric patients. It is currently not utilised in Pathology Queensland. The objective of this study is to verify Ret-He in our Pathology Queensland laboratory and assess the clinical utility in the assessment of iron deficiency (ID) and iron deficiency anaemia (IDA) in paediatric patients. METHODS Samples from patients aged <18 years sent to the Pathology Queensland laboratory that had paired full blood count and iron studies were included in this study. A minimum of 120 samples were required for verification of testing requirements and a minimum of 30 samples per age range were required for confirmation of published age-related reference intervals. RESULTS Published Ret-He reference intervals were confirmed for stated age ranges in normal (non-ID) patients. Ret-He below the reference range for age demonstrated a good correlation with ID and IDA. CONCLUSIONS Ret-He is a useful marker in the assessment of ID and IDA in a paediatric population. It is not affected by acute or chronic inflammation. Ret-He is sensitive and specific (86% and 92%) for the diagnosis of ID.
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Affiliation(s)
| | | | - Mark Rane
- Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Andrew Norman
- Queensland Children's Hospital, Brisbane, Queensland, Australia
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Pei LX, Kroeun H, Karakochuk CD. Reticulocyte haemoglobin equivalent (RET-He) as an early marker of responsiveness to oral iron supplementation. J Clin Pathol 2022; 76:407-412. [DOI: 10.1136/jcp-2021-208077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 08/27/2022] [Indexed: 11/04/2022]
Abstract
AimWe investigated the potential of reticulocyte haemoglobin equivalent (RET-He) as an early marker of responsiveness to iron supplementation.MethodsData were obtained from a randomised controlled trial of daily iron supplementation in 356 Cambodian women (18–45 y) who received 60 mg elemental iron for 12 weeks. A fasted venous blood specimen was collected at baseline, 1-week and 12-week timepoints. Whole blood haemoglobin (g/L) and RET-He (pg) were measured using a Sysmex haematology analyser. RET-He measures were evaluated for their predictive ability on haemoglobin response to iron supplementation (defined as ≥10 g/L at 12 weeks). Receiver operating characteristic (ROC) curves were used to assess discrimination performance, and the area under the ROC curve (AUCROC) served as a measure of the ability of each predictor to discriminate between women likely or unlikely to elicit a haemoglobin response.ResultsPredictive ability (AUCROC (95% CI)) of baseline, 1-week, and change from baseline to 1-week RET-He on haemoglobin response was 0.70 (0.63 to 0.76), 0.48 (0.41 to 0.56) and 0.81 (0.75 to 0.87), respectively. Based on the Youden index, an absolute increase in RET-He of ~1.1 pg or a percentage increase of ~4.4% over 1 week were optimal thresholds to predict responsiveness to iron supplementation.ConclusionSingle timepoint RET-He measures have poor predictive ability; however, change in RET-He after 1 week was a strong predictor of haemoglobin response among Cambodian women receiving 60 mg elemental iron and can be measured easily and quickly after only 1 week of iron therapy.
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Suriyun T, Winichagoon P, Fucharoen S, Sripichai O. Impaired Terminal Erythroid Maturation in β 0-Thalassemia/HbE Patients with Different Clinical Severity. J Clin Med 2022; 11:jcm11071755. [PMID: 35407362 PMCID: PMC8999960 DOI: 10.3390/jcm11071755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/15/2022] [Accepted: 03/18/2022] [Indexed: 02/02/2023] Open
Abstract
Anemia in β-thalassemia is associated with ineffective erythropoiesis and a shortened lifespan of erythroid cells. The limited differentiation of β-thalassemic erythroblasts has been documented, but the characteristic feature of terminal erythroid maturation and its physiological relevance are not clearly described in β-thalassemias. Here, the red blood cell and reticulocyte cellular characteristics were determined in patients with β0-thalassemia/HbE in comparison to patients with iron deficiency anemia and healthy normal subjects. Severely affected β0-thalassemia/HbE patients showed the highest increase in immature reticulocytes, but the number of total erythrocytes was the lowest. Despite similar ranges of hemoglobin levels, β0-thalassemia/HbE patients had a higher number of reticulocytes and a greater proportion of immature fraction than patients with iron deficiency anemia did. In vitro CD34+ hematopoietic progenitor cells' culture and flow cytometry analysis were conducted to investigate the erythroid maturation and mitochondrial clearance in β0-thalassemia/HbE erythroid cells as compared to normal cells. The delayed erythroid maturation and evidence of impaired mitochondria clearance were observed in β0-thalassemia/HbE cells at the terminal stage of differentiation. Additionally, increased transcript levels of genes related to erythroid mitophagy, BNIP3L and PINK1, were revealed in β0-thalassemia/HbE erythroblasts. The findings indicate that the erythroid maturation is physiologically relevant, and that the restoration of terminal maturation represents a potential therapeutic target for β-thalassemias.
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Affiliation(s)
- Thunwarat Suriyun
- Department of Biochemistry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand;
| | - Pranee Winichagoon
- Thalassemia Research Center, Institute of Molecular Biosciences, Mahidol University, Nakhonpathom 73170, Thailand; (P.W.); (S.F.)
| | - Suthat Fucharoen
- Thalassemia Research Center, Institute of Molecular Biosciences, Mahidol University, Nakhonpathom 73170, Thailand; (P.W.); (S.F.)
| | - Orapan Sripichai
- Thalassemia Research Center, Institute of Molecular Biosciences, Mahidol University, Nakhonpathom 73170, Thailand; (P.W.); (S.F.)
- National Institute of Health, Department of Medical Sciences, Ministry of Public Health, Nonthaburi 11000, Thailand
- Correspondence: ; Tel.: +66-2951-0011
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Triarico S, Trombatore G, Capozza MA, Romano A, Mastrangelo S, Attinà G, Maurizi P, Ruggiero A. Hematological disorders in children with Down syndrome. Expert Rev Hematol 2022; 15:127-135. [PMID: 35184659 DOI: 10.1080/17474086.2022.2044780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Silvia Triarico
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, 00168 Rome, Italy
| | | | | | - Alberto Romano
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, 00168 Rome, Italy
| | - Stefano Mastrangelo
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, 00168 Rome, Italy
| | - Giorgio Attinà
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, 00168 Rome, Italy
| | - Palma Maurizi
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, 00168 Rome, Italy
| | - Antonio Ruggiero
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, 00168 Rome, Italy
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Kılıç M, Özpınar A, Serteser M, Kilercik M, Serdar M. The effect of reticulocyte hemoglobin content on the diagnosis of iron deficiency anemia: A meta-analysis study. J Med Biochem 2022; 41:1-13. [PMID: 35291499 PMCID: PMC8882014 DOI: 10.5937/jomb0-31435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/27/2021] [Indexed: 12/17/2022] Open
Abstract
Background Iron deficiency anemia (IDA) is the most common type of anemia worldwide and has many adverse effects on life quality. This meta-analysis study aims to show that reticulocyte hemoglobin content (CHr) is more effective than routinely used parameters in the diagnosis of IDA. Methods Comprehensive and systematic research was done using international databases including PubMed, Web of Science, Cochrane Library, Science Direct, and Google Scholar, which contain all articles published on IDA until December 29, 2020. Seventeen articles were included in the meta-analysis. Results The analyses found the Cohen's deffect size (Standardized Mean Difference) values of the parameters. Accordingly, CHr is 2.84 (95% CI 2.36 to 3.31), mean corpus volume (MCV) is 2.46 (95% CI 1.97 to 2.95), ferritin is 2.37 (95% CI 1.63 to 3.11), and transferrin saturation (TSAT) is 3.76 (95% CI 2.14 to 5.38). To diagnose IDA, the sensitivity value of the CHr concentration was found as 83.5% (95% CI 76.1 to 89.8), specificity value to be 91.8% (95% CI 85.5 to 96.4), and mean cut-off value as 28.2 pg. Conclusions The results of our study reveal the findings that CHr is a better biomarker than MCV and ferritin used in determining IDA, and its efficacy is lower than TSAT. It is very important to use it routinely for the pre-diagnosis of IDA, which is very important for public health. The groups in the study are heterogeneous but contain bias. Therefore, meta-analyses of studies with less heterogeneity of CHr are needed.
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Affiliation(s)
- Merve Kılıç
- Acıbadem Mehmet Ali Aydinlar University, School of Medicine, Dept. Medical Biochemistry, Istanbul, Turkey
| | - Aysel Özpınar
- Acıbadem Mehmet Ali Aydinlar University, School of Medicine, Dept. Medical Biochemistry, Istanbul, Turkey
| | - Mustafa Serteser
- Acıbadem Mehmet Ali Aydinlar University, School of Medicine, Dept. Medical Biochemistry, Istanbul, Turkey
| | - Meltem Kilercik
- Acıbadem Mehmet Ali Aydinlar University, School of Medicine, Dept. Medical Biochemistry, Istanbul, Turkey
| | - Muhittin Serdar
- Acıbadem Mehmet Ali Aydinlar University, School of Medicine, Dept. Medical Biochemistry, Istanbul, Turkey
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Nii M, Okamoto T, Sugiyama T, Aoyama A, Nagaya K. Reticulocyte hemoglobin content changes after treatment of anemia of prematurity. Pediatr Int 2022; 64:e15330. [PMID: 36321339 DOI: 10.1111/ped.15330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 07/15/2022] [Accepted: 08/10/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Iron deficiency during infancy is associated with poor neurological development, but iron overload causes severe complications. Appropriate iron supplementation is therefore vital. Reticulocyte hemoglobin content (RET-He) provides a real-time assessment of iron status and chracterezes hemoglobin synthesis in preterm infants. However, the existing literature lacks detailed reports assessing chronological changes in RET-He. The aim of this study was to assess the chronological changes in RET-He during oral iron dietary supplementation, and concomitant therapy with recombinant human erythropoietin (rHuEPO) in preterm very low birthweight infants. METHODS Very low birthweight infants, admitted to our neonatal intensive care unit were analyzed retrospectively. Hemoglobin (Hb), reticulocyte percentage (Ret), mean corpuscular volume, RET-He, serum iron (Fe), and serum ferritin were recorded. Data at birth (T0), the initial day of rHuEPO therapy (T1), the initial day of oral iron supplementation (T2), 1-2 weeks (T3), 3-4 weeks (T4), 5-6 weeks (T5), and 7-8 weeks (T6) from the initial day of oral iron supplementation were extracted, and their changes over time were examined. RESULTS Reticulocyte hemoglobin content was highest at birth and declined rapidly thereafter, especially after starting rHuEPO therapy. There was no upward trend in RET-He after the initiation of oral iron supplementation, with a slower increase during 5-6 weeks after the initiation of iron therapy. CONCLUSIONS During the treatment of anemia of prematurity, low RET-He levels may be prolonged. Anemia of prematurity should therefore be assessed and treated on a case-by-case basis, while considering the iron metabolic capacity of preterm infants.
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Affiliation(s)
- Mitsumaro Nii
- Division of Neonatology, Center for Maternity and Infant Care, Asahikawa Medical University Hospital, Hokkaido, Japan
| | - Toshio Okamoto
- Division of Neonatology, Center for Maternity and Infant Care, Asahikawa Medical University Hospital, Hokkaido, Japan
| | - Tatsutoshi Sugiyama
- Division of Neonatology, Center for Maternity and Infant Care, Asahikawa Medical University Hospital, Hokkaido, Japan
| | - Aiko Aoyama
- Division of Neonatology, Center for Maternity and Infant Care, Asahikawa Medical University Hospital, Hokkaido, Japan
| | - Ken Nagaya
- Division of Neonatology, Center for Maternity and Infant Care, Asahikawa Medical University Hospital, Hokkaido, Japan
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Suria N, Kaur R, Mittal K, Palta A, Sood T, Kaur P, Kaur G. Utility of reticulocyte haemoglobin content and immature reticulocyte fraction in early diagnosis of latent iron deficiency in whole blood donors. Vox Sang 2021; 117:495-503. [PMID: 34816444 DOI: 10.1111/vox.13216] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/05/2021] [Accepted: 10/12/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES The present study was planned to assess the clinical utility of reticulocyte haemoglobin content (CHr) and immature reticulocyte fraction (IRF) in the early detection of latent iron deficiency in blood donors. MATERIALS AND METHODS The prospective longitudinal observational study was conducted using the purposive sampling method. Written informed consent was obtained and donors were allocated into the first-time (FTD) and regular donor (RD) group. The enrolled blood donors (n = 205 in each group) were followed up for two subsequent whole blood donations. Haemoglobin (Hb), CHr, IRF and serum ferritin values were recorded at enrolment and two follow-ups. RESULTS The sensitivity of CHr in detecting iron-deficient erythropoiesis (serum ferritin values ≤ 26 μg/dl) was 45% and 56.7%, specificity 96.7%, positive predictive value (PPV) 85.6% and 90.8% and negative predictive value (NPV) 80.1% and 78.7%, respectively in FTD and RD cohorts. The sensitivity of IRF was 45.1% and 44.8%, specificity 93.4% and 97.1%, PPV 74.8% and 90.4% and NPV 79.6% and 74.5%, respectively in both the cohorts. The sensitivity of CHr in detecting absent iron stores (serum ferritin values ≤ 15 μg/dl) was 66.2% and 74.4%, specificity 92% and 90.6%, PPV 56.7% and 68.7% and NPV 94.5% and 92.8% among FTD and RD cohort, respectively. The sensitivity of IRF was 72.7% and 65.3%, specificity 90.3% and 94.3%, PPV 54.4% and 76% and NPV 95.4% and 90.8%, respectively in both the cohorts. CONCLUSION Reticulocyte hemoglobin content and IRF can be used along with complete blood count for early detection of iron deficiency in blood donors using the same blood sample at no extra cost.
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Affiliation(s)
- Nitika Suria
- Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh, Chandigarh, India
| | - Ravneet Kaur
- Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh, Chandigarh, India
| | - Kshitija Mittal
- Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh, Chandigarh, India
| | - Anshu Palta
- Department of Pathology, Government Medical College and Hospital, Chandigarh, Chandigarh, India
| | - Tanvi Sood
- Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh, Chandigarh, India
| | - Paramjit Kaur
- Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh, Chandigarh, India
| | - Gagandeep Kaur
- Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh, Chandigarh, India
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15
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Lanser L, Fuchs D, Kurz K, Weiss G. Physiology and Inflammation Driven Pathophysiology of Iron Homeostasis-Mechanistic Insights into Anemia of Inflammation and Its Treatment. Nutrients 2021; 13:3732. [PMID: 34835988 PMCID: PMC8619077 DOI: 10.3390/nu13113732] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 02/07/2023] Open
Abstract
Anemia is very common in patients with inflammatory disorders. Its prevalence is associated with severity of the underlying disease, and it negatively affects quality of life and cardio-vascular performance of patients. Anemia of inflammation (AI) is caused by disturbances of iron metabolism resulting in iron retention within macrophages, a reduced erythrocyte half-life, and cytokine mediated inhibition of erythropoietin function and erythroid progenitor cell differentiation. AI is mostly mild to moderate, normochromic and normocytic, and characterized by low circulating iron, but normal and increased levels of the storage protein ferritin and the iron hormone hepcidin. The primary therapeutic approach for AI is treatment of the underlying inflammatory disease which mostly results in normalization of hemoglobin levels over time unless other pathologies such as vitamin deficiencies, true iron deficiency on the basis of bleeding episodes, or renal insufficiency are present. If the underlying disease and/or anemia are not resolved, iron supplementation therapy and/or treatment with erythropoietin stimulating agents may be considered whereas blood transfusions are an emergency treatment for life-threatening anemia. New treatments with hepcidin-modifying strategies and stabilizers of hypoxia inducible factors emerge but their therapeutic efficacy for treatment of AI in ill patients needs to be evaluated in clinical trials.
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Affiliation(s)
- Lukas Lanser
- Department of Internal Medicine II, Medical University of Innsbruck, 6020 Innsbruck, Austria; (L.L.); (K.K.)
| | - Dietmar Fuchs
- Division of Biological Chemistry, Biocenter, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Katharina Kurz
- Department of Internal Medicine II, Medical University of Innsbruck, 6020 Innsbruck, Austria; (L.L.); (K.K.)
| | - Günter Weiss
- Department of Internal Medicine II, Medical University of Innsbruck, 6020 Innsbruck, Austria; (L.L.); (K.K.)
- Christian Doppler Laboratory for Iron Metabolism and Anemia Research, Medical University of Innsbruck, 6020 Innsbruck, Austria
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16
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Perioperative Management of Patients for Whom Transfusion Is Not an Option. Anesthesiology 2021; 134:939-948. [PMID: 33857295 DOI: 10.1097/aln.0000000000003763] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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17
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Karunarathne P, Kulathilake C, Wijesiriwardena I, Hewageegana A, Marasinghe A. Evaluation of Iron Status by Reticulocyte Haemoglobin Content (Chr) in Chronic Kidney Disease Patients on Haemodialysis and Erythropoietin. Indian J Hematol Blood Transfus 2021; 38:359-365. [PMID: 35496960 PMCID: PMC9001800 DOI: 10.1007/s12288-021-01464-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 06/25/2021] [Indexed: 11/25/2022] Open
Abstract
Diagnosing iron deficiency with currently available tests is difficult in patients with chronic kidney disease (CKD) due to the inflammatory state associated with uraemia. The aim of this study was to evaluate the importance of reticulocyte haemoglobin (CHr) as a diagnostic tool of iron deficiency and a predictor to intravenous iron therapy in a cohort of CKD patients on haemodialysis in Sri Lanka. This was a descriptive cross sectional study involving hundred (100) patients with CKD on regular haemodialysis and erythropoietin. Patients were categorised into groups depending on serum ferritin, transferrin saturation and reticulocyte haemoglobin (CHr). All patients with CHr < 29 pg were treated with a single dose of intravenous(IV) iron 500 mg. The CHr was measured 72 h after the IV iron treatment to assess the response. Within the population mean haemoglobin was 9.27 g/dL, mean serum ferritin was 243.5 ng/mL, mean transferrin saturation was 18.6% and mean CHr was 29.2 pg. Thirty three of the 100 patients (33%) were subjected to IV iron therapy and there was a significant increase of CHr 72 h after IV iron treatment (p < 0.001). As a diagnostic tool in iron deficiency in CKD patients on haemodialysis, CHr showed a sensitivity of 56%, specificity of 73% and positive predictive value of 84%. Reticulocyte haemoglobin (CHr) can be used as an early predictor of response to IV iron therapy. However, further evaluation is necessary to consider CHr as a diagnostic tool to detect iron deficiency in CKD patients on haemodialysis.
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Affiliation(s)
- Piumanthi Karunarathne
- Departmet of Pathology, Faculty of Medical Sciences, University of Sri Jayewardenepura, Gangodawila, 10280 Sri Lanka
| | - Chandima Kulathilake
- Departmet of Pathology, Faculty of Medical Sciences, University of Sri Jayewardenepura, Gangodawila, 10280 Sri Lanka
| | - Indira Wijesiriwardena
- Departmet of Pathology, Faculty of Medical Sciences, University of Sri Jayewardenepura, Gangodawila, 10280 Sri Lanka
| | - Anura Hewageegana
- National Institute of Nephrology Dialysis Transplantation, Maligawaththa, Colombo, Sri Lanka
| | - Arjuna Marasinghe
- Nephrology Unit, Colombo South Teaching Hospital, Kalubowila, Sri Lanka
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Weyand AC, McGann PT. Eliminating race-based reference ranges in haematology: a call to action. LANCET HAEMATOLOGY 2021; 8:e462-e466. [PMID: 34048684 DOI: 10.1016/s2352-3026(21)00106-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/26/2021] [Accepted: 03/26/2021] [Indexed: 12/14/2022]
Abstract
In haematology, as in all of medicine, the use of reference intervals for laboratory variables is essential to define disease states and inform treatment decisions. There are many haematological variables, including haemoglobin, mean corpuscular volume, absolute neutrophil count, and iron indices, that are often reported to be different on the basis of a person's race or ethnicity. Although there are many haematological conditions with a genetic basis, such that it is appropriate to consider ancestry in the diagnostic algorithm, defining pathology on the basis of a social construct such as race is unacceptable. The inclusion of separate thresholds or simple statements that so-called normal values vary by race further validates the common misperception that there are physiological differences between Black and white patients. These statements might have downstream effects on diagnostic and treatment decisions that exacerbate existing racial health disparities. In this Viewpoint, we argued for the removal of race-based reference intervals across haematology.
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Affiliation(s)
- Angela C Weyand
- Division of Pediatric Hematology Oncology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Patrick T McGann
- Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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19
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How I treat anemia in the perisurgical setting. Blood 2021; 136:814-822. [PMID: 32556314 DOI: 10.1182/blood.2019003945] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 02/27/2020] [Indexed: 01/12/2023] Open
Abstract
Anemia is a common finding in the perioperative setting with significant untoward consequences including worsening of outcomes and diminished quality of life as well as increased risk of allogeneic blood transfusions. Here, we present 3 cases that illustrate how anemia can be perioperatively managed in patients undergoing cardiac, orthopedic, and oncology surgeries. Timely detection of anemia prior to high-blood loss surgeries can allow clinicians to manage it and optimize hemoglobin level, making patients better prepared for the surgery. Treatment of anemia should be guided by the etiology and may include erythropoietic agents, folic acid, B12, and iron preparations. Other blood management strategies geared toward reducing surgical blood loss such as autologous transfusion techniques and agents to optimize hemostasis are used during surgery and in the immediate postoperative period. Patients should be closely monitored following surgery for signs of ongoing bleeding in need of control. Finally, screening for and management of anemia should continue in the postoperative and postdischarge period, as persistence and recurrence of anemia can further undermine patient's outcomes.
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Alam S, Bhuiyan FR, Emon TH, Hasan M. Prospects of nutritional interventions in the care of COVID-19 patients. Heliyon 2021; 7:e06285. [PMID: 33615017 PMCID: PMC7879162 DOI: 10.1016/j.heliyon.2021.e06285] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 12/08/2020] [Accepted: 02/10/2021] [Indexed: 02/06/2023] Open
Abstract
The novel coronavirus disease 2019 (COVID-19) has unfolded an unprecedented worldwide public health emergency with disastrous economic consequences. Around 96 million coronavirus cases have already been identified with over half a million deaths. Despite numerous efforts by the government as well as international organizations, these numbers are still increasing with a surprising rate. Although urgent and absolutely necessary, a reliable therapeutic or vaccine is still elusive and this status quo may remain for an uncertain period of time. Taken that into account, boosting up adaptive immunity through nutritional interventions may help subside this epidemic and save many lives. This review focuses on the nexus between a balanced diet and adaptive immunity, particularly, how a poor diet may lead to compromised immunity resulting in susceptibility to viral infections. Additionally, we discuss how nutrients (vitamins, minerals, trace elements) can be used as a tool to modulate immune response and thus impede viral infections. The study also summarizes nutritional recommendations to combat COVID-19 in different countries and territories as well as dietary sources of those key nutrients. Moreover, different nutritional intervention strategies based on different age groups, physiological and medical conditions were also included, and the challenges of nutritional interventions towards the care of COVID-19 patients are also discussed. Since the availability of a drug or vaccine is still uncertain, a balanced diet or nutrient therapy can be used as a robust strategy to combat COVID-19. Thus, we hope this review may help to make an informed decision with regard to diet choice both at individual level as well as clinical settings.
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Affiliation(s)
- Sabiha Alam
- Institute of Nutrition and Food Science, University of Dhaka, Bangladesh
| | - Farhana Rumzum Bhuiyan
- Department of Botany, University of Chittagong, Chittagong, Bangladesh
- Laboratory of Biotechnology and Molecular Biology, Department of Botany, University of Chittagong, Chittagong, Bangladesh
| | - Tanvir Hossain Emon
- Department of Genetic Engineering and Biotechnology, Shahjalal University of Science and Technology, Sylhet, Bangladesh
| | - Mahmudul Hasan
- Department of Pharmaceuticals and Industrial Biotechnology, Sylhet Agricultural University, Sylhet, Bangladesh
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21
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Zanetti R, Feldman B, Porea T. Microcytic Anemia. Pediatr Rev 2021; 42:41-43. [PMID: 33386305 DOI: 10.1542/pir.2019-0295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | | | - Timothy Porea
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX
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22
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Anemia in Children With Inflammatory Bowel Disease: A Position Paper by the IBD Committee of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2020; 71:563-582. [PMID: 32947565 DOI: 10.1097/mpg.0000000000002885] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Anemia is one of the most common extraintestinal manifestations of inflammatory bowel disease (IBD). It can be asymptomatic or associated with nonspecific symptoms, such as irritability, headaches, fatigue, dizziness, and anorexia. In IBD patients, the etiology of anemia is often multifactorial. Various causes include iron deficiency, anemia of inflammation and chronic disease, vitamin deficiencies, hemolysis, or myelosuppressive effect of drugs. Anemia and iron deficiency in these patients may be underestimated because of their insidious onset, lack of standardized screening practices, and possibly underappreciation that treatment of anemia is also required when treating IBD. Practitioners may hesitate to use oral preparations because of their intolerance whereas intravenous preparations are underutilized because of fear of adverse events, availability, and cost. Several publications in recent years have documented the safety and comparative efficacy of various intravenous preparations. This article reviews management of anemia in children with IBD, including diagnosis, etiopathogenesis, evaluation of a patient, protocol to screen and monitor patients for early detection and response to therapy, treatment including parenteral iron therapy, and newer approaches in management of anemia of chronic disease. This report has been compiled by a group of pediatric gastroenterologists serving on the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) IBD committee, in collaboration with a pediatric hematologist, pharmacist, and a registered dietician who specializes in pediatric IBD (IBD Anemia Working Group), after an extensive review of the current literature. The purpose of this review is to raise awareness of under-diagnosis of anemia in children with IBD and make recommendations for screening, testing, and treatment in this population.
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23
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Pomrop M, Manopunya S, Tantiprabha W, Khuwuthyakorn V, Kosarat S, Natesirinilkul R. Reticulocyte hemoglobin concentration for screening iron deficiency in very low birth weight preterm neonates. J Matern Fetal Neonatal Med 2020; 35:3348-3352. [PMID: 32930014 DOI: 10.1080/14767058.2020.1818216] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Preterm and low birth weight infants are at risk of iron deficiency. Reticulocyte hemoglobin concentration may be useful as a screening test to diagnose iron deficiency in preterm neonates. OBJECTIVE To evaluate the accuracy and establish the reticulocyte hemoglobin concentration cutoff value for iron deficiency diagnosis in very low birth weight preterm neonates. METHOD This study was conducted between May 2018 and March 2019 at Chiang Mai University Hospital. Preterm infants born at gestational age ≤34 weeks and birth weight ≤1500 g were enrolled. Blood samplings were obtained within the first 48 h of life. Iron deficiency was defined by using two or more of these following parameters: mean corpuscular volume <100 fL, transferrin saturation <16% and serum ferritin <30 µg/L. Neonatal anemia was defined as hemoglobin <15 g/dL. The optimum reticulocyte hemoglobin concentration cutoff values were performed by using predictive values and receiving operation characteristic analysis. RESULT Fifty-seven preterm neonates were enrolled. Nine (15.7%) and three (5.3%) neonates had iron deficiency and iron deficiency anemia, respectively. The reticulocyte hemoglobin concentration cutoff value of <29 pg showed the optimum accuracy to diagnose iron deficiency in very low birth weight preterm neonates with sensitivity, specificity, positive and negative predictive values of 89%, 79%, 42% and 97%, respectively. CONCLUSION Reticulocyte hemoglobin concentration can be used as a screening parameter to diagnose iron deficiency for VLBW preterm neonates. The optimum cutoff value which provided the acceptable accuracy was <29 pg.
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Affiliation(s)
- Mallika Pomrop
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Thailand
| | - Satit Manopunya
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Thailand
| | | | | | - Shanika Kosarat
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Thailand
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24
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Warner MA, Shore-Lesserson L, Shander A, Patel SY, Perelman SI, Guinn NR. Perioperative Anemia. Anesth Analg 2020; 130:1364-1380. [DOI: 10.1213/ane.0000000000004727] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
BACKGROUND Disorders of serum iron balance are frequently observed in chronic hepatitis C (CHC) patients. Iron overload as well as iron deficiency anemia are common clinical findings in these patients. Variceal bleeding is also a common complication. To date, no study has discussed the influence of esophageal bleeding on iron status in anemic CHC bleeders. OBJECTIVE Was to study reticulocyte hemoglobin content (CHr) and serum hepcidin levels in anemic CHC and to evaluate the influence of variceal bleeding on patients' iron status. METHODS Serum hepcidin levels and CHr were assessed in 65 early phase CHC patients (20 nonanemic, 23 anemic nonbleeders, and 22 anemic bleeders), and 20 healthy controls; and were compared with the conventional indices of iron deficiency including mean corpuscular volume, mean corpuscular hemoglobin, red cell distribution width, serum iron, total iron binding capacity, transferrin saturation and ferritin. RESULTS Hepcidin levels were comparable in patients groups, but were significantly lower in patients than in controls (P = 0.01). Child-Pugh class B patients showed significantly lower hepcidin levels than class A patients. CHr levels were comparable in all groups as well as all iron deficiency indices. Patients with ferritin values or less 100 ng/ml and CHr or less 29 pg/cell or Tfsat or less 16% are more likely to have iron deficiency [odds ratio (OR = 3.93, 95% confidence interval (CI) = 2.54-6.08; OR = 10.50, 95% CI = 1.94-56.55, respectively). CONCLUSION Esophageal bleeding has an almost no influence on iron status in CHC patients. Serum hepcidin content is influenced by CHC disease rather than by anemia associated with or without esophageal bleeding and it could be used as a marker of early hepatic insufficiency. Assessing CHr content could add a potential utility in the detection of iron deficiency in CHC patients.
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Mast AE, Langer JC, Guo Y, Bialkowski W, Spencer BR, Lee TH, Kiss J, Cable RG, Brambilla D, Busch MP, Page GP. Genetic and behavioral modification of hemoglobin and iron status among first-time and high-intensity blood donors. Transfusion 2020; 60:747-758. [PMID: 32163187 DOI: 10.1111/trf.15743] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/23/2020] [Accepted: 01/23/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Some people rapidly develop iron deficiency anemia following blood donation, while others can repeatedly donate without becoming anemic. METHODS Two cohorts of blood donors were studied. Participants (775) selected from a 2-year longitudinal study were classified into six analysis groups based on sex, donation intensity, and low hemoglobin deferral. Associations with iron supplement use, cigarette smoking, and four genetic variants of iron metabolism were examined at enrollment and with longitudinal regression models. An unbiased assessment of genetic variability and ability to repeatedly donate blood without experiencing low hemoglobin deferral was conducted on participants (13,403) in a cross-sectional study who were examined by genome wide association (GWA). RESULTS Behaviors and genetic variants were associated with differences in hemoglobin and ferritin change following repeated donation. At least weekly iron supplement use was associated with improved status in first-time donors, while daily use was associated with improved status in high-intensity donors. Cigarette smoking was associated with 0.5 g/dL increased hemoglobin in high-intensity donors. A736V in TMPRSS6 was associated with a rapid drop in hemoglobin and ferritin in first-time females following repeated donation. Conversely, the protective TMPRSS6 genotype was not enriched among high-intensity donors. H63D in HFE was associated with increased hemoglobin in female high-intensity donors. However, no differences in genotype between first-time and high-intensity donors were found in GWA analyses. CONCLUSION Behavioral and genetic modifiers contributed to first-time donor hemoglobin and iron status, while iron supplement use was more important than underlying genetics in high-intensity donors.
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Affiliation(s)
- Alan E Mast
- Blood Research Institute Versiti, Milwaukee, Wisconsin, USA.,Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Yuelong Guo
- RTI International, Durham, North Carolina, USA
| | | | - Bryan R Spencer
- American Red Cross Scientific Affairs, Dedham, Massachusetts, USA
| | - Tzong-Hae Lee
- Vitalant Research Institute, San Francisco, California, USA
| | - Joseph Kiss
- Vitalant Northeast Division, Pittsburgh, Pennsylvania, USA
| | - Ritchard G Cable
- American Red Cross Scientific Affairs, Farmington, Connecticut, USA
| | | | - Michael P Busch
- American Red Cross Scientific Affairs, Dedham, Massachusetts, USA
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Abstract
Introduction: Anemia is a common extraintestinal complication of Crohn's disease (CD) mainly caused by iron deficiency, that affects the quality of life in CD patients. Elucidation of the etiology and pathology of iron-deficiency anemia (IDA) and anemia of chronic diseases (ACD) has developed in recent years. Common biochemical parameters of iron status are insufficient for assessment of patients with anemia and CD. Thus, novel iron indices are required for accurate assessment in IDA patients with CD. Oral iron supplementation for IDA treatment is common and is associated with minor gastrointestinal side effects. Intravenous substitution improves safety profiles but may be not tolerable in some patients. Fortunately, additional therapies for anemia of active CD have emerged in recent years.Area covered: Here, we propose the review article on the link among anemia, iron deficiency, and Crohn's disease. We discuss the current diagnosis and therapy of anemia and iron deficiency in CD and propose the new directions for future research.Expert commentary: Exploring pathogeneses and treatments of anemia and iron deficiency in Crohn's disease will develop potential tools for early diagnosis and effective treatment of anemia in CD patients, and improve their life quality.
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Affiliation(s)
- Chen Yueying
- State Key Laboratory for Oncogenes and Related Genes, Key Laboratory of Gastroenterology & Hepatology, Ministry of Health, Division of Gastroenterology and Hepatology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Cancer Institute, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Wang Yu Fan
- State Key Laboratory for Oncogenes and Related Genes, Key Laboratory of Gastroenterology & Hepatology, Ministry of Health, Division of Gastroenterology and Hepatology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Cancer Institute, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Shen Jun
- State Key Laboratory for Oncogenes and Related Genes, Key Laboratory of Gastroenterology & Hepatology, Ministry of Health, Division of Gastroenterology and Hepatology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Cancer Institute, Shanghai Institute of Digestive Disease, Shanghai, China
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29
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Parodi E, Romano F, Ramenghi U. How We Use Reticulocyte Parameters in Workup and Management of Pediatric Hematologic Diseases. Front Pediatr 2020; 8:588617. [PMID: 33344383 PMCID: PMC7746543 DOI: 10.3389/fped.2020.588617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/13/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Emilia Parodi
- Pediatric Hematology, Department of Pediatric and Public Health Sciences, University of Torino, Turin, Italy
| | - Francesca Romano
- Postgraduate School of Pediatrics, University of Torino, Turin, Italy
| | - Ugo Ramenghi
- Pediatric Hematology, Department of Pediatric and Public Health Sciences, University of Torino, Turin, Italy.,Postgraduate School of Pediatrics, University of Torino, Turin, Italy
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Urrechaga E, de la Hera P, Aguayo FJ. Reticulocyte hemoglobin and hypochromic erythrocytes in the study of erythropoiesis in patients with inflammatory bowel disease. Scandinavian Journal of Clinical and Laboratory Investigation 2019; 80:124-128. [DOI: 10.1080/00365513.2019.1700549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Malczewska-Lenczowska J, Surała O, Orysiak J, Turowski D, Szczepańska B, Tomaszewski P. Utility of Novel Hypochromia and Microcythemia Markers in Classifying Hematological and Iron Status in Male Athletes. Nutrients 2019; 11:nu11112767. [PMID: 31739525 PMCID: PMC6893463 DOI: 10.3390/nu11112767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/04/2019] [Accepted: 11/11/2019] [Indexed: 01/01/2023] Open
Abstract
In athletes, no reliable indices exist for an unambiguous evaluation of hematological and iron status. Therefore, the utility of some new red blood cell (RBC) parameters was explored in 931 elite male athletes aged 13–35 years. To diagnose iron status, the values of ferritin and soluble transferrin receptor (sTfR), total iron binding capacity (TIBC), and basic blood morphology were determined in blood. The new hematological markers included among others: mean cellular hemoglobin content in reticulocytes (CHr), percentage of erythrocytes (HYPOm) and reticulocytes (HYPOr) with decreased cellular hemoglobin concentration, percentage of erythrocytes (LowCHm) and reticulocytes (LowCHr) with decreased cellular hemoglobin content, mean volume of reticulocytes (MCVr), and percentage of erythrocytes with decreased volume (MICROm). Despite adverse changes in reticulocyte hypochromia indices (CHr, LowCHr, HYPOr; p < 0.001) in the iron depletion state, the area under the receiver operating characteristic curve (AUC-ROC) values calculated for them were relatively low (0.539–0.722). In iron-deficient erythropoiesis (IDE), unfavorable changes additionally concern microcythemia indices in both reticulocytes and erythrocytes (MCVr, MCV, MICROm, and red cell volume distribution width—RDW), with especially high values of AUC-ROC (0.947–0.970) for LowCHm, LowCHr, and CHr. Dilutional sports anemia was observed in 6.1% of athletes. In this subgroup, only hemoglobin concentration (Hb), hematocrit (Hct), and RBC (all dependent on blood volume) were significantly lower than in the normal group. In conclusion, the diagnostic utility of the new hematology indices was not satisfactory for the detection of an iron depletion state in athletes. However, these new indices present high accuracy in the detection of IDE and sports anemia conditions.
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Affiliation(s)
- Jadwiga Malczewska-Lenczowska
- Department of Nutrition Physiology and Dietetics, Institute of Sport, National Research Institute, Trylogii 2/16, 01-982 Warsaw, Poland; (O.S.); (J.O.); (B.S.)
- Correspondence: ; Tel.: +48-22-569-99-00
| | - Olga Surała
- Department of Nutrition Physiology and Dietetics, Institute of Sport, National Research Institute, Trylogii 2/16, 01-982 Warsaw, Poland; (O.S.); (J.O.); (B.S.)
| | - Joanna Orysiak
- Department of Nutrition Physiology and Dietetics, Institute of Sport, National Research Institute, Trylogii 2/16, 01-982 Warsaw, Poland; (O.S.); (J.O.); (B.S.)
| | - Dariusz Turowski
- Department of Biochemistry, Institute of Sport, National Research Institute, Trylogii 2/16, 01-982 Warsaw, Poland;
| | - Beata Szczepańska
- Department of Nutrition Physiology and Dietetics, Institute of Sport, National Research Institute, Trylogii 2/16, 01-982 Warsaw, Poland; (O.S.); (J.O.); (B.S.)
| | - Paweł Tomaszewski
- Department of Biometry, Józef Piłsudski University of Physical Education, Marymoncka 34, 00-968 Warsaw, Poland
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Amin K, Bansal M, Varley N, Wang H, Amin S. Reticulocyte hemoglobin content as a function of iron stores at 35-36 weeks post menstrual age in very premature infants. J Matern Fetal Neonatal Med 2019; 34:3214-3219. [PMID: 31662016 DOI: 10.1080/14767058.2019.1680631] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Premature infants are born with lower iron stores and are at risk for iron deficiency during early infancy. To prevent iron deficiency, premature infants are routinely supplemented with 2 mg/kg/day oral elemental iron. Reticulocyte hemoglobin content (RET-He), a measure of iron deficiency, has not been well evaluated prior to discharge in premature infants. OBJECTIVES Our objectives were to evaluate RET-He and its correlation with serum ferritin (SF), an index of iron stores, at 35-36 weeks postmenstrual age (PMA) in ≤32 weeks gestational age (GA) infants. METHODS We performed a prospective nested study involving 24-32 weeks GA infants who were receiving 2 mg/kg/day oral elemental iron with full enteral feedings at 35-36 weeks PMA. Infants with the following conditions were excluded: craniofacial malformation, chromosomal disorders, TORCH (toxoplasmosis, other infections, rubella, cytomegalovirus, and herpes simplex), culture-proven sepsis, C-reactive protein >5 mg/l within 10 days of iron status assessment, or erythropoietin therapy. SF and RET-He were measured at 35-36 weeks PMA using chemiluminescence immunoassay and Sysmex XN hematology analyzer, respectively. RET-He <27 pg was deemed indicative of iron deficiency. RESULTS Ninety-eight infants were studied, of which 21 infants had RET-He <27 pg. There was a positive correlation between RET-He and SF (coefficient 0.22, p = .03) that remained significant after controlling for GA (coefficient 0.21, p = .03) and frequency of prior erythrocyte transfusions (coefficient 0.21, p = .03). On stratified analysis, there was a positive correlation between SF and RET-He in females (N = 52, coefficient 0.23, p = .02), but not in males (N = 46, coefficient 0.05). CONCLUSIONS Most premature infants receiving 2 mg/kg/day oral elemental iron are iron replete for erythropoiesis at 35-36 weeks PMA. RET-He increases with an increase in iron stores, suggesting that additional iron supplementation prior to discharge to very premature infants with borderline low RET-He may help prevent iron deficiency during early infancy.
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Affiliation(s)
- Kanhai Amin
- Student Academic Internship Program, University of Rochester Medical Center, Rochester, NY, USA
| | - Meenakshi Bansal
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center and Rochester General Hospital, Rochester, NY, USA
| | - Nonie Varley
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center and Rochester General Hospital, Rochester, NY, USA
| | - Hongyue Wang
- Department of Biostatistics, University of Rochester Medical Center, Rochester, NY, USA
| | - Sanjiv Amin
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
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Trends in reticulocyte hemoglobin equivalent values in critically ill neonates, stratified by gestational age. J Perinatol 2019; 39:1268-1274. [PMID: 31350450 DOI: 10.1038/s41372-019-0434-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/03/2019] [Accepted: 05/20/2019] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The reticulocyte index reticulocyte hemoglobin equivalent (Ret-He) was evaluated as a marker of iron status. STUDY DESIGN This is a retrospective cohort study of all infants admitted to the University of Washington Neonatal Intensive Care Unit, who received Ret-He measurements as part of routine care within the first 120 days of life. RESULT A total of 730 Ret-He measurements from 249 infants were analyzed (median gestational age at birth 32.1 weeks; 49 infants <28 weeks and 200 ≥28 weeks). Initial Ret-He measurements were lower in infants <28 weeks (28.24 vs. 33.34 pg). Ret-He values initially decreased, then slowly increased. Infants received an average of 3.9, 6.5, and 8.2 mg/kg/day of enteral iron sulfate at 30, 60, and 90 days, respectively. CONCLUSION Ret-He values showed a slow uptrend with enteral iron supplementation following an initial decrease, suggesting that neonates are able to improve their iron sufficiency status with supplementation.
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Karakochuk CD, Hess SY, Moorthy D, Namaste S, Parker ME, Rappaport AI, Wegmüller R, Dary O. Measurement and interpretation of hemoglobin concentration in clinical and field settings: a narrative review. Ann N Y Acad Sci 2019; 1450:126-146. [PMID: 30652320 DOI: 10.1111/nyas.14003] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 12/16/2018] [Accepted: 12/26/2018] [Indexed: 12/26/2022]
Abstract
Anemia affects over 800 million women and children globally. Defined as a limited or insufficient functional red blood cell supply in peripheral blood, anemia causes a reduced oxygen supply to tissues and can have serious health consequences for women and children. Hemoglobin (Hb) concentration is most commonly measured for anemia diagnosis. Methods to measure Hb are usually invasive (requiring a blood sample); however, advances in diagnostic and clinical chemistry over the past decade have led to the development of new noninvasive methods. Accurate diagnosis at the individual level is important to identify individuals who require treatment. At the population level, anemia prevalence estimates are often the impetus for national nutrition policies or programs. Thus, it is essential that methods for Hb measurement are sensitive, specific, accurate, and reproducible. The objective of our narrative review is to describe the basic principles, advantages, limitations, and quality control issues related to methods of Hb measurement in clinical and field settings. We also discuss other biomarkers and tests that can help to determine the severity and underlying causes of anemia. In conclusion, there are many established and emerging methods to measure Hb concentration, each with their own advantages, limitations, and factors to consider before use.
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Affiliation(s)
- Crystal D Karakochuk
- Food, Nutrition and Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sonja Y Hess
- Department of Nutrition, University of California Davis, Davis, California
| | - Denish Moorthy
- USAID-funded Strengthening Partnerships, Results, and Innovation in Nutrition Globally Project, John Snow Inc., Arlington, Virginia
| | | | - Megan E Parker
- Nutrition Innovation, Maternal Newborn and Child Health and Nutrition, PATH, Seattle, Washington
| | - Aviva I Rappaport
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rita Wegmüller
- GroundWork, Fläsch, Switzerland.,Medical Research Council Unit the Gambia, Keneba, the Gambia
| | - Omar Dary
- Nutrition Division, Office of Maternal and Child Health and Nutrition, Bureau for Global Health, United States Agency for International Development, Washington, DC
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- Food, Nutrition and Health, University of British Columbia, Vancouver, British Columbia, Canada
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Sperling D, Freudenschuss B, Shrestha A, Hinney B, Karembe H, Joachim A. Comparative efficacy of two parenteral iron-containing preparations, iron gleptoferron and iron dextran, for the prevention of anaemia in suckling piglets. Vet Rec Open 2018; 5:e000317. [PMID: 30613406 PMCID: PMC6307558 DOI: 10.1136/vetreco-2018-000317] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/06/2018] [Accepted: 11/09/2018] [Indexed: 01/14/2023] Open
Abstract
Iron-deficiency anaemia (IDA) is a serious health problem in neonatal piglets and is controlled by routine application of iron in various formulations. The efficacy and safety of two iron-containing products for the prevention of IDA in suckling piglets were compared in a randomised, parallel study. Newborn piglets were treated with 200 mg iron supplied by intramuscular injection in the neck as either Forceris (gleptoferron; n=13) or Uniferon 200 (iron dextran; n=12) 24–48 hours after birth. Blood samples were collected before and after treatment (2nd, 18th and 31st day of life) for complete haematology. The treatments were well tolerated with only mild transient swelling observed in two piglets (Forceris group). Piglets treated with Forceris had significantly higher haemoglobin, haematocrit, mean corpuscular volume and haemoglobin concentration values, as well as significantly higher plasma iron and transferritin saturation and a lower total iron binding capacity than those treated with Uniferon. No animals in the Forceris group but 17 per cent of piglets in the Uniferon group had haemoglobin levels <9 g/dl after treatment, indicating anaemia. These results suggest that both products were safe and effective in the prophylaxis of IDA in piglets, and that Forceris was superior to Uniferon in preventing IDA in piglets.
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Affiliation(s)
| | - Barbara Freudenschuss
- Department of Pathobiology, Institute of Parasitology, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Aruna Shrestha
- Department of Pathobiology, Institute of Parasitology, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Barbara Hinney
- Department of Pathobiology, Institute of Parasitology, University of Veterinary Medicine Vienna, Vienna, Austria
| | | | - Anja Joachim
- Department of Pathobiology, Institute of Parasitology, University of Veterinary Medicine Vienna, Vienna, Austria
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Löfving A, Domellöf M, Hellström-Westas L, Andersson O. Reference intervals for reticulocyte hemoglobin content in healthy infants. Pediatr Res 2018; 84:657-661. [PMID: 30140071 DOI: 10.1038/s41390-018-0046-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/06/2018] [Accepted: 04/26/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Iron deficiency anemia in childhood is a serious public health problem worldwide. Reticulocyte hemoglobin content (Ret-He) is a novel biomarker of iron deficiency adopted for adults but there is a lack of reference intervals for Ret-He in infants. The aim of this study was to provide data from healthy infants. METHODS Swedish infants (n = 456), born at term after normal pregnancies were included. Ret-He was measured at birth (umbilical cord sample), 48-72 h, 4 months, and 12 months. Reference intervals were calculated as ±2 standard deviations from the mean of Ret-He. RESULTS Reference intervals for newborn Ret-He were 27.4 to 36.0 pg/L (N = 376) in the cord sample, 28.1-37.7 pg/L (N = 253) at 48-72 h, 25.6-33.4 pg/L (N = 341) at four months and 24.9-34.1 pg/L (N = 288) at 12 months. Ret-He was significantly lower among iron-deficient infants, at 4 months mean difference (95% CI) -4.2 pg/L (-6.1 to -2.4) and at 12 months mean difference (95% CI) -3.4 pg/L (-5.0 to -1.8). CONCLUSIONS This longitudinal study presents Ret-He reference intervals based on non-anemic and non-iron-deficient infants and constitutes a step towards standardizing Ret-He as a pre-anemia biomarker of iron deficiency in children.
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Affiliation(s)
- Anders Löfving
- Department of Pediatrics, Hospital of Halland, Halmstad, Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | | | - Ola Andersson
- Department of Pediatrics, Hospital of Halland, Halmstad, Sweden. .,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
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Tiwari AK, Bhardwaj G, Arora D, Aggarwal G, Pabbi S, Dara RC, Sachdev R, Raizada A, Sethi M. Applying newer parameter Ret-He (reticulocyte haemoglobin equivalent) to assess latent iron deficiency (LID) in blood donors-study at a tertiary care hospital in India. Vox Sang 2018; 113:639-646. [PMID: 30101488 DOI: 10.1111/vox.12700] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 06/28/2018] [Accepted: 07/06/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND It is important to detect Latent Iron Deficiency (LID) to prevent development of an overt iron deficiency anemia. Early detection is difficult by using conventional hematological and biochemical parameters. Soluble transferrin receptor (sTfR) is presently the gold standard for diagnosing LID. We evaluated the utility of Reticulocyte Hemoglobin Equivalent (Ret-He), a newer hematological parameter, to predict LID in blood donors as compared to sTfR. METHODS This was a randomized prospective study performed on 501 donor samples over a period of three-months. All donors were included after administering medical history questionnaire and a brief physical examination in accordance with national guidelines (Hb ≥12.5). Additional samples were collected during donation according to the institutional standard operating procedure (SOP). All hemograms were performed on the Sysmex XE-2100 analyzer which included Ret-He. sTfR was measured in batch assays by ELISA (Biovendor, Czech Republic). Ret He <28 pg and sTfR≥3μg/ml were used to diagnose LID. Serum Iron, Total Iron Binding Capacity (TIBC) and Serum Ferritin were also measured simultaneously. RESULTS Of the 501 blood donors, sTfR and Ret-He detected LID in 148 and 135 donors respectively. In comparison to sTfR, Ret-He had sensitivity of 92.7%, a specificity of 97.16%, PPV of 93.1% and NPV of 96.3%. Serum Ferritin, TIBC and serum Iron had comparatively lower sensitivity of 87.16%, 79.7% and 77.7% respectively. CONCLUSION Ret-He can be used as a routine screening test to detect LID in blood donors. This could provide an opportunity to make appropriate and timely interventions like dietary changes or drug supplementation.
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Affiliation(s)
- Aseem K Tiwari
- Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, India
| | - Gunjan Bhardwaj
- Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, India
| | - Dinesh Arora
- Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, India
| | - Geet Aggarwal
- Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, India
| | - Swati Pabbi
- Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, India
| | - Ravi C Dara
- Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, India
| | - Ritesh Sachdev
- Department of Pathology & Lab Medicine, Medanta-The Medicity, Gurgaon, India
| | - Arun Raizada
- Department of Biochemistry, Medanta-The Medicity, Gurgaon, India
| | - Monisha Sethi
- Scientific Affair & Application Support, Sysmex India Pvt. Ltd., Delhi, India
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Abstract
Micronutrients are indispensable for adequate metabolism, such as biochemical function and cell production. The production of blood cells is named haematopoiesis and this process is highly consuming due to the rapid turnover of the haematopoietic system and consequent demand for nutrients. It is well established that micronutrients are relevant to blood cell production, although some of the mechanisms of how micronutrients modulate haematopoiesis remain unknown. The aim of the present review is to summarise the effect of Fe, Mn, Ca, Mg, Na, K, Co, iodine, P, Se, Cu, Li and Zn on haematopoiesis. This review deals specifically with the physiological requirements of selected micronutrients to haematopoiesis, showing various studies related to the physiological requirements, deficiency or excess of these minerals on haematopoiesis. The literature selected includes studies in animal models and human subjects. In circumstances where these minerals have not been studied for a given condition, no information was used. All the selected minerals have an important role in haematopoiesis by influencing the quality and quantity of blood cell production. In addition, it is highly recommended that the established nutrition recommendations for these minerals be followed, because cases of excess or deficient mineral intake can affect the haematopoiesis process.
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Current misconceptions in diagnosis and management of iron deficiency. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018; 15:422-437. [PMID: 28880842 DOI: 10.2450/2017.0113-17] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 06/30/2017] [Indexed: 12/15/2022]
Abstract
The prevention and treatment of iron deficiency is a major public health goal. Challenges in the treatment of iron deficiency include finding and addressing the underlying cause and the selection of an iron replacement product which meets the needs of the patient. However, there are a number of non-evidence-based misconceptions regarding the diagnosis and management of iron deficiency, with or without anaemia, as well as inconsistency of terminology and lack of clear guidance on clinical pathways. In particular, the pathogenesis of iron deficiency is still frequently not addressed and iron not replaced, with indiscriminate red cell transfusion used as a default therapy. In our experience, this imprudent practice continues to be endorsed by non-evidence-based misconceptions. The intent of the authors is to provide a consensus that effectively challenges these misconceptions, and to highlight evidence-based alternatives for appropriate management (referred to as key points). We believe that this approach to the management of iron deficiency may be beneficial for both patients and healthcare systems. We stress that this paper solely presents the Authors' independent opinions. No pharmaceutical company funded or influenced the conception, development or writing of the manuscript.
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Abstract
Assessing iron status in a pediatric population is not easy, as it is based on parameters that undergo physiological variations in childhood and adolescence. Analysis of the reticulocyte hemoglobin content (CHr) to screen for iron deficiency may increase the accuracy of diagnosis, but, to date, reference values in healthy adolescents have not been adequately determined. A cross-sectional study was conducted on a population-based representative sample in the city of Almería (Spain), with 253 healthy non-iron-deficient (ID) subjects, aged 12 to 16 years. The mean CHr value was 31.6±1.3 pg. The CHr 2.5 percentile was 28.7 pg. There were no significant differences as regards age or sex. In the multivariate linear regression analysis, sex did not influence the variability of CHr, but it was related to age. CHr was influenced by hemoglobin and the Mentzer index, as well as by functional iron indicators such as erythrocyte protoporphyrin and serum transferrin receptor. These independent variables predicted two thirds of the variability in healthy adolescents (R=0.55). This study provides CHr reference ranges in healthy adolescents for use in clinical practice for the early detection of ID states. In populations with similar sociodemographic characteristics, values above the 2.5 percentile rule out ID, as values under the 2.5 percentile could be suggestive of functional ID.
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Use of Reticulocyte Hemoglobin Content in the Assessment of Iron Deficiency in Children With Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr 2017; 64:713-720. [PMID: 27429427 PMCID: PMC5239765 DOI: 10.1097/mpg.0000000000001335] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Iron deficiency and anemia affect up to 50% to 75% of patients with inflammatory bowel disease (IBD). Iron deficiency in IBD may be difficult to diagnose because of the effect of inflammation on iron status biomarkers. Thus, there is a need for better methods to accurately determine iron status in IBD. OBJECTIVE The aim of the study was to investigate the association of inflammation with hemoglobin content of reticulocytes (CHr) and the utility of CHr in comparison to standard iron biomarkers. METHODS We conducted a cross-sectional study of children with IBD. Iron biomarkers (CHr, ferritin, soluble transferrin receptor [sTfR], hepcidin, hemoglobin) were measured along with systemic biomarkers of inflammation (C-reactive protein, α1-acid glycoprotein]. Spearman correlations were used to evaluate the relation of inflammation and iron biomarkers. The criterion standard for iron deficiency was defined as inflammation-corrected ferritin <15 μg/L or sTfR >8.3 mg/L. Receiver operating characteristic curves were used to estimate the prognostic values of all iron biomarkers to identify patients with iron deficiency. RESULTS We analyzed data in 62 children ages 5 to 18 years. Sixty-nine percent of our subjects had Crohn disease and 31% had ulcerative colitis, of which 42% were girls and 53% African American. The prevalence of anemia was 32%, of iron deficiency was 52% using ferritin <15 μg/L or sTfR >8.3 mg/L, 39% using red blood cell distribution width of >14.5%, 26% using body iron stores of <0 mg/kg body weight, 25% using CHr of <28 pg, and 11% using mean corpuscular volume of <75 fL/cell. The prevalence of elevated CRP or AGP was 48%. After correcting ferritin and sTfR levels for inflammation, the prevalence of iron deficiency was 68%. CHr was correlated with C-reactive protein (rs -0.44, P < 0.001) and α1-acid glycoprotein (rs -0.37, P < 0.05). The optimal prognostic value for inflammation-adjusted CHr to predict iron deficiency was 34 pg (area under the receiver operating characteristic of 0.70), with 88% sensitivity and 30% specificity. CONCLUSIONS Iron deficiency and anemia are common in this pediatric IBD cohort. All explored iron biomarkers, including CHr, were affected by inflammation and should be adjusted. A single iron biomarker is unlikely to best predict iron deficiency in pediatric IBD. Iron intervention studies are needed to examine the response of iron biomarkers to iron supplementation in the setting of inflammation.
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López-Ruzafa E, Vázquez-López MA, Lendinez-Molinos F, Poveda-González J, Galera-Martínez R, Bonillo-Perales A, Martín-González M. Reference Values of Reticulocyte Hemoglobin Content and Their Relation With Other Indicators of Iron Status in Healthy Children. J Pediatr Hematol Oncol 2016; 38:e207-12. [PMID: 27403769 DOI: 10.1097/mph.0000000000000639] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Reticulocyte hemoglobin content (CHr) is considered an indicator of functional iron deficiency, but is understudied in children. The goals of this study are to determine the reference intervals for CHr in healthy children, and their relation with iron parameters, erythropoiesis, and individual conditions. A total of 902 children without iron deficiency, aged 1 to 11 years were analyzed in a cross-sectional study. Besides a physical examination of the subjects and a questionnaire completed by their parents, the complete blood count, serum transferrin receptor, ferritin, transferrin saturation, erythrocyte protoporphyrin, serum erythropoietin, C-reactive protein, and CHr levels were measured. Changes in CHr, iron status, and erythropoiesis at different age intervals were analyzed and linear multiple regression was used to identify the factors that determine CHr variability. Mean value obtained for CHr was 30.9±1.8 pg (P2.5-P97.5: 26.9 to 34.3 pg), but the influence of age on CHr (the values increased with age) and on the iron parameters justified the establishment of different reference ranges. In addition to age, nutritional status, hematologic measurements, reticulocytes, transferrin saturation, and erythrocyte protoporphyrin accounted for 39% of CHr variability.
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Abstract
Iron, particularly hemosiderin, is a commonly observed pigment in cytology. Many pigments appear green to blue to black, making differentiation of pigment types difficult. While cytologic clues such as erythrophagia can help determine whether pigment is iron, Perl's Prussian Blue stain is used to highlight iron when these clues are not present. Other special stains can identify similar pigments such as copper. Identification of pigments is important as it directs cytologic interpretation, thus directly influencing patient diagnosis. This paper also presents basic iron metabolism, iron disorders in small animals, and laboratory assessment of iron disorders.
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Affiliation(s)
- Lauren B Radakovich
- Department of Microbiology, Immunology, and Pathology, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, 1644 Campus Delivery, Fort Collins, CO 80523, USA
| | - Christine S Olver
- Department of Microbiology, Immunology, and Pathology, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, 1644 Campus Delivery, Fort Collins, CO 80523, USA.
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Abstract
Iron is an essential element and is used by every cell in the body. This article summarizes iron metabolism and disorders associated with iron metabolism in dogs and cats. The diagnostic tests currently in use for assessing iron status are discussed.
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Affiliation(s)
- Andrea A Bohn
- Department of Microbiology, Immunology, and Pathology, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, 1619 Campus Delivery, Fort Collins, CO 80523, USA.
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45
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Urrechaga E, Boveda O, Aguayo FJ, de la Hera P, Muñoz RI, Gallardo I, Escanero JF. Percentage of hypochromic erythrocytes and reticulocyte hemoglobin equivalent predictors of response to intravenous iron in hemodialysis patients. Int J Lab Hematol 2016; 38:360-5. [DOI: 10.1111/ijlh.12496] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 03/08/2016] [Indexed: 11/30/2022]
Affiliation(s)
- E. Urrechaga
- Hematology Laboratory; Hospital Galdakao - Usansolo; Galdakao Vizcaya Spain
| | - O. Boveda
- Hematology Laboratory; Hospital Galdakao - Usansolo; Galdakao Vizcaya Spain
| | - F. J. Aguayo
- Laboratory; Hospital Universitario Basurto; Bilbao Vizcaya Spain
| | - P. de la Hera
- Laboratory; Hospital Universitario Basurto; Bilbao Vizcaya Spain
| | - R. I. Muñoz
- Nephrology. HD Unit. Hospital Galdakao - Usansolo; Galdakao Vizcaya Spain
| | - I. Gallardo
- Nephrology. HD Unit. Hospital Galdakao - Usansolo; Galdakao Vizcaya Spain
| | - J. F. Escanero
- Department of Pharmacology and Physiology; Faculty of Medicine; University of Zaragoza; Zaragoza Spain
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Davidkova S, Prestidge TD, Reed PW, Kara T, Wong W, Prestidge C. Comparison of reticulocyte hemoglobin equivalent with traditional markers of iron and erythropoiesis in pediatric dialysis. Pediatr Nephrol 2016; 31:819-26. [PMID: 26667237 DOI: 10.1007/s00467-015-3284-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 11/19/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Anemia is a major complication for patients on chronic dialysis. Erythropoietin is effective if iron is available, however unnecessary iron supplementation results in iron overload. Reticulocyte hemoglobin equivalent (Ret-He) may be useful for assessing iron status. METHODS A national retrospective cohort study including all children on chronic dialysis in New Zealand between 2007 and 2013, pairing Ret-He with demographic information, anemia indices, and markers of iron status. RESULTS In 606 observations, we found a modest relationship between Ret-He and transferrin saturation (TSAT) (r = 0.34, p < 0.001) and a poor correlation between Ret-He and ferritin (r = 0.09, p = 0.04). There was a negative correlation between ferritin and hemoglobin (r = -0.14, p = 0.002), a weak positive correlation between TSAT and hemoglobin (r = 0.12, p = 0.007), and a modest positive correlation between Ret-He and hemoglobin (r = 0.22, p < 0.001). The diagnostic performance of Ret-He to detect absolute iron deficiency (cut-off value 28.9 pg, sensitivity 90 %, specificity 75 %, AUC 0.87) was good. CONCLUSIONS Ret-He is a more relevant marker of iron status than ferritin and TSAT. This supports prospectively testing Ret-He to distinguish between iron deficiency and suboptimal erythropoietin dosing as competing causes for anemia. Ferritin is an unhelpful biomarker of iron deficiency in this setting.
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Affiliation(s)
- Sarka Davidkova
- Department of Pediatrics, Starship Children's Hospital, Auckland, New Zealand
| | - Timothy D Prestidge
- Blood and Cancer Centre, Starship Children's Hospital, Auckland, New Zealand
| | - Peter W Reed
- Children's Research Centre, Starship Children's Hospital, Auckland, New Zealand
| | - Tonya Kara
- Department of Nephrology, Starship Children's Hospital, Park Road, Private Bag 92024, Auckland, 1142, New Zealand
| | - William Wong
- Department of Nephrology, Starship Children's Hospital, Park Road, Private Bag 92024, Auckland, 1142, New Zealand
| | - Chanel Prestidge
- Department of Nephrology, Starship Children's Hospital, Park Road, Private Bag 92024, Auckland, 1142, New Zealand.
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Absolute Reticulocyte Count and Reticulocyte Hemoglobin Content as Predictors of Early Response to Exclusive Oral Iron in Children with Iron Deficiency Anemia. Anemia 2016; 2016:7345835. [PMID: 27092272 PMCID: PMC4820635 DOI: 10.1155/2016/7345835] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 03/02/2016] [Accepted: 03/03/2016] [Indexed: 11/25/2022] Open
Abstract
We report data regarding kinetic of response to oral iron in 34 iron deficiency anemia children. Twenty-four/34 patients (70.5%) reached reference value of hemoglobin (Hb) concentration for age and sex at day + 30 from the beginning of treatment (complete early responders (CERs)), and 4/34 (12%) reached an Hb concentration at least 50% higher than the original (partial early responders (PERs)). CHr at T1 (within 7 days from the beginning of treatment) was significantly different in the different groups (22.95 in CERs versus 18.41 in other patients; p = 0.001; 22.42 in early responders versus 18.07 in NERs; p = 0.001). Relative increase of CHr from T0 to T1 resulted significantly higher in CERs than in other patients (0.21 versus 0.11, p = 0.042) and in early responders than in NERs (0.22 versus 0.004, p = 0.006). Multivariate logistic models revealed a higher probability of being a complete early responder due to relative increase of ARC from T0 to T1 [OR (95% CI) = 44.95 (1.54–1311.98)] and to CHr at T1 [OR (95% CI) =3.18 (1.24–8.17)]. Our preliminary data confirm CHr as early and accurate predictor of hematological response to oral iron.
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Zubrikhina GN, Blindar VN, Matveeva II. Differential diagnosis of anemia in true and functional iron deficiency in patients with chronic diseases (malignant tumors). TERAPEVT ARKH 2016; 88:61-67. [DOI: 10.17116/terarkh201688461-67] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Radakovich LB, Santangelo KS, Olver CS. Reticulocyte hemoglobin content does not differentiate true from functional iron deficiency in dogs. Vet Clin Pathol 2015; 44:511-8. [DOI: 10.1111/vcp.12294] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Lauren B. Radakovich
- Department of Microbiology, Immunology, and Pathology; College of Veterinary Medicine and Biomedical Sciences; Colorado State University; Fort Collins CO USA
| | - Kelly S. Santangelo
- Department of Microbiology, Immunology, and Pathology; College of Veterinary Medicine and Biomedical Sciences; Colorado State University; Fort Collins CO USA
| | - Christine S. Olver
- Department of Microbiology, Immunology, and Pathology; College of Veterinary Medicine and Biomedical Sciences; Colorado State University; Fort Collins CO USA
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