Evaluation of erythrocyte and reticulocyte parameters as indicative of iron deficiency in patients with anemia of chronic disease

Red cell size factor is a sensitive index in the early diagnosis of nondigestive tract cancer-related anemia: An observational study

Cancer-related anemia (CRA) is a common comorbidity in cancer patients, and it can lead to a worse prognosis. The aim of this cross-sectional study is to investigate the clinical value of the red cell size factor (Rsf) in the early diagnosis of nondigestive tract CRA. A total of 231 patients with nondigestive tract solid cancer were included, and they were divided into anemic and nonanemic subjects according to the hemoglobin (Hb) levels. A BC-7500 blood analyzer was used to detect the indices of red blood cell and reticulocyte, and the mean corpuscular volume (MCV), mean reticulocyte volume (MRV), reticulocyte hemoglobin (RHE) content, and reticulocyte production index were observed. Subsequently, the Rsf was calculated. Receiver operating characteristic curve analysis was used to evaluate the identifying power of Rsf for anemia diagnosed by the combination of RHE and reticulocyte production index. The adjusted-multivariate analysis and quartiles were used to assess the relation of reduced Rsf level with the risk and incidence of anemia diagnosed by combining the MCV, MCH, and mean corpuscular hemoglobin concentration (MCHC), respectively. Rsf levels showed no statistical differences between anemia and nonanemia subjects grouped by Hb (P > .05). Rsf has a high correlation with the RHE level (R > 0.900, P < .001), or MCV, mean corpuscular hemoglobin (MCH), and MCHC in anemia patients (r: 0.435-0.802, P < .001). Receiver operating characteristic curves showed that Rsf had the highest overall area under curve of 0.886 (95% confidence interval: 0.845-0.927) in identifying anemia of cancer patients (P < .001). When the optimal cutoff values of Rsf were set at 97.05 fl in males and 94.95 fl in females, the sensitivity and specificity were 0.94 and 0.76, and 0.98 and 0.75, respectively. Being treated as a categorical variable, Rsf had a highest odds ratio value of 30.626 (12.552-74.726; P < .001) for the risk of anemia. The increment of Rsf quartiles was highly associated with the decreased incidence of overall anemia (P trend < 0.001). The study suggests that decreased Rsf level is a potentially powerful predictor of overt anemia in nondigestive tract cancer, and it can be used as a convenient, practical, cost-free, and sensitive index in early diagnosis of nondigestive tract CRA.

In vitro oxidation and digestibility profiles of iron-loaded whey protein isolate/gum Arabic complexes with different morphologies

This study was designed to investigate the promotion of oxidation of lipids in oil-in-water (o/w) emulsions and digestive properties of the bionic dynamic gastrointestinal system of whey protein isolate (WPI) and gum arabic (GA) complexes loaded with iron ions, which were fabricated previously and shown as WPI/GA_Fe³⁺ nanoparticles (WGS) and WPI/GA_Fe³⁺ fibers (WGF). Compared with emulsions containing Fe³⁺ and GA-loaded complex (GA_Fe³⁺), WGS and WGF greatly improved the oxidative stability of lipids along with the reduced lipid oxidation products and volatile compounds, attributed to the encapsulation of iron ions. During the bionic dynamic gastrointestinal digestion, the iron ion release of WGF was significantly higher than that of WGS, probably due to different assembled internal structures. Accordingly, two proposed WPI/GA_Fe³⁺ complexes with different morphologies are expected to be developed as novel stable iron fortifiers with delayed lipid oxidation and controlled iron-ion release in food emulsions.

Evaluation of RET-He values as an early indicator of iron deficiency anemia in pregnant women

INTRODUCTION

During pregnancy, women are at an increased risk of developing iron-deficiency anemia.

OBJECTIVE

The objective of this study was to assess the diagnostic performance of the reticulocyte hemoglobin equivalent (RET-He) in the early detection of iron-deficiency anemia in a group of pregnant women and to establish a reference range for this parameter in a group of control individuals.

METHOD

A total of 60 patients and 130 control subjects were included in the study. Blood samples collected from the subjects were submitted to a complete blood count and a serum ferritin test and the data were analyzed by comparing the groups and ROC curves.

RESULTS

The reference range found for the RET-He was between 29.75pg and 38.24pg, with a median of 35pg. The receiver operating characteristic (ROC) curve analysis for the ferritin parameter showed an area under the curve of 0.732 for the RET-He, 0.586 for hemoglobin, 0.551 for the mean corpuscular hemoglobin concentration and 0.482 for the mean corpuscular volume.

CONCLUSION

Early diagnosis of iron deficiency anemia in pregnancy is essential to prevent damage to both maternal and fetal health. The RET-He presents an excellent potential as an auxiliary tool for the diagnosis of iron deficiency in pregnant women.

Anemia, iron deficiency, and cobalamin deficiency in cats with chronic gastrointestinal disease

BACKGROUND

Iron deficiency and cobalamin deficiency, as sequelae to chronic gastrointestinal (GI) disease, could result in anemia and increased morbidity in cats with chronic enteropathies.

OBJECTIVE

To evaluate iron deficiency in cats with chronic GI disease and its relationship with hypocobalaminemia, anemia, and disease severity.

ANIMALS

Twenty client-owned cats with primary GI disease.

METHODS

Prospective, cross-sectional study. Cats were enrolled at the time of evaluation for chronic GI disease, after exclusion of comorbidities. CBC with reticulocyte indices, iron metabolism (serum iron and ferritin concentrations, total iron binding capacity [TIBC]), serum methylmalonic acid (MMA), cobalamin, and folate concentrations, pancreatic lipase and trypsin-like immunoreactivity, and disease severity were evaluated.

RESULTS

Anemia (hematocrit <30%), iron deficiency, and cobalamin deficiency were diagnosed in 4/20, 7/20, and 8/20 cats, respectively. Hematocrit (r_s = -.45; P < .05) and body condition score (r_s = -.60; P < .01) negatively correlated with MMA. Median TIBC was lower in cats with increased vs normal MMA (218 μg/mL; range, 120-466 μg/mL vs 288 μg/mL; range, 195-369 μg/mL; P = .02). Hematocrit (r_s = .51; P = .02), reticulocyte MCV (r_s = .52; P = .02), reticulocyte hemoglobin content (r_s = .71; P < .001), and percent transferrin saturation (r_s = .79; P < .0001) positively correlated with serum iron concentration.

CONCLUSIONS AND CLINICAL IMPORTANCE

Functional iron deficiency was common in cats with chronic GI disease. Associations between hypocobalaminemia, iron parameters, and hematologic parameters warrant further investigation on the impact of iron deficiency on chronic GI disease morbidity in cats.

The validity of reticulocyte hemoglobin content and percentage of hypochromic red blood cells for screening iron-deficiency anemia among patients with end-stage renal disease: a retrospective analysis

BACKGROUND

Early detection of iron-deficiency anemia (IDA) can enhance the efficiency and effectiveness of clinical treatment and quality of life for end-stage renal disease (ESRD) patients. This study aimed to evaluate the validity of CHr and %Hypo in screening IDA among ESRD patients and compare their performance with screening IDA among non-ESRD patients.

METHOD

A retrospective analysis of 312 participants was conducted at Cho Ray Hospital, Vietnam, including healthy control participants and ESRD patients. Receiver operator characteristics curves and the area under the curve (AUC) of models were used to evaluate the performance of CHr, %Hypo. Optimal cut-off values were determined using Youden's index.

RESULTS

Detecting IDA in ESRD patients is more complicated, as the screening performance of CHr and %Hypo in predicting IDA among ESRD patients were lower than non ESRD group, but still reasonable with AUC = 0.748 (95% CI: 0.656-0.840, power = 0.997) and 0.740 (95% CI: 0.647-0.833, power = 0.996), respectively. Cut-off values of CHr < 31.5 pg and %Hypo> 10.0 pg are recommended to obtain optimal screening ability for Vietnamese ESRD patients.

CONCLUSION

CHr and %Hypo appears to be useful tools for screening IDA among both non ESRD and ESRD patients. The low cost and accessible of the two markers encourage their utility as effective screening tools in clinical practice.

Diagnostic performance of reticulocyte hemoglobin equivalent in assessing the iron status

Background

Measurement of reticulocyte hemoglobin equivalent (RET‐He) is rapid, convenient, and cost‐effective. Yet, researches on its performance in diagnosing iron deficiency with concurrent inflammation are limited. Hence, this study investigated RET‐He value in various states, including inflammation, and evaluated its diagnostic performance in iron status assessment.

Methods

Retrospectively, 953 clinical data and laboratory results—complete blood count, reticulocyte count, RET‐He, and serum ferritin—were reviewed. Patients on iron therapy were excluded. Iron status was defined by serum ferritin as the reference method. RET‐He among populations was investigated. Its diagnostic performance and optimal cutoff were determined by ROC analysis.

Results

Three population groups were classified: healthy control, iron deficiency anemia (IDA), and non‐ID anemia. Significantly, RET‐He value in IDA was lower than that of healthy control, anemia of inflammation, and chronic kidney disease (P < .0001). Low RET‐He was also observed in IDA with concomitant inflammation despite normal‐to‐high serum ferritin levels. No significant difference was observed between RET‐He values in pure IDA and thalassemia (P = .57). ROC curve analysis revealed AUC of 0.876 (P < .0001) at cutoff 30 pg, by which IDA was discriminated with 74.2% sensitivity and 97.4% specificity. Applying cutoff ≤30 pg, IDA can be diagnosed with 96% sensitivity, 97.4% specificity, 80% PPV, and 99.6% NPV. Hence, RET‐He >30 pg signifies a non‐IDA state.

Conclusion

In addition to convenience and cost‐effectiveness, RET‐He cutoff >30 pg can be potentially used to exclude IDA due to its excellent diagnostic sensitivity and specificity.

Utility of Novel Hypochromia and Microcythemia Markers in Classifying Hematological and Iron Status in Male Athletes

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.

Reticulocyte Hemoglobin Equivalent (Ret-He) Combined with Red Blood Cell Distribution Width Has a Differentially Diagnostic Value for Thalassemias

As a type of congenital microcytic hypochromic anemia, thalassemia trait is often confused with other conditions, such as congenital sideroblastic anemia (CSA) and iron deficiency anemia, before a specific work-up is performed. However, these tests, including hemoglobin (Hb) electrophoresis, gene mutations and Prussian blue staining after bone marrow aspirate, are relatively expensive, time-consuming and invasive. To find labor-saving parameters to facilitate differential diagnosis, we retrospectively analyzed the routine blood indexes of 59 thalassemia trait cases [22 α-thalassemia (α-thal), 36 β-thalassemia (β-thal) and one α/β-thal], 21 CSA patients, and 238 iron deficiency anemia controls. Significantly higher reticulocyte Hb equivalent (Ret-He) and lower red blood cell (RBC) distribution width (RDW) were prominent in thalassemia trait. Furthermore, RDW-standard deviation (SD) was independent of the severity of anemia in thalassemia trait, similar to Ret-He in CSA. In the context of the same grades of anemia, Ret-He combined with RDW was powerful in differentiation of thalassemia from CSA and iron deficiency anemia. By receiver operation curve (ROC) analysis, Ret-He had a specificity of 67.06% and a sensitivity of 76.92% with a cutoff value of 20.9 pg for thalassemia trait in mild anemia and a specificity of 84.09% and a sensitivity of 68.42% with a cutoff value of 19.1 pg for thalassemia trait in moderate anemia. Regarding CSA, Ret-He had 92.94% specificity and 60.00% sensitivity in mild anemia, with a cutoff value of 18.1 pg. Overall, Ret-He and RDW are two convenient indexes able to differentiate thalassemia from the other two microcytic anemias, CSA and iron deficiency anemia.

Diagnosis of anemia-A synoptic overview and practical approach

Anemia is common in everyday clinical practice. In the following, the characteristics of apparently proven as well as new biomarkers are presented - for diagnosis and therapy control, considering their diagnostic value. In spite of new diagnostic tools, the importance of microscopy in hematological manifestations is illustrated. Based on a classification of anemia, a strategy is proposed for an economic diagnosis of different types of anemia and their predisposition.

Evaluation of reticulocyte hemoglobin for assessment of anemia in rheumatological disorders

OBJECTIVE

The aim of this study was to evaluate the role of reticulocyte hemoglobin (Ret He) estimation in subtyping of anemia and to find the correlation of Ret He with the severity of anemia.

METHODS

Ninety-four patients with rheumatic diseases with anemia were enrolled. Blood samples were taken to determine various parameters. Patients were divided into three groups: iron deficiency anemia, anemia of chronic disease with iron deficiency and anemia of chronic disease depending on the iron status and inflammatory markers. Analysis of variance and Pearson correlation coefficient were used. Receiver operating characteristic analysis was used to evaluate the accuracy of the parameters in differentiating anemia.

RESULTS

Statistically significant differences among groups were seen with regard to parameters such as erythrocyte sedimentation rate, C-reactive protein, serum ferritin, total iron binding capacity, transferrin saturation, transferrin receptor protein, soluble transferrin receptor/log ferritin and Ret He. Ret He correlates with the subtype of anemia in patients with rheumatic disorders but it does not correlate with the severity of anemia. Soluble transferrin receptor/log ferritin, Ret He and serum ferritin values were the best parameters to differentiate between various groups. Ret He (pg) values of <24, 24-26.5 and >26.5, while serum ferritin levels (µg/L) of <35, 35-178 and >178 were highly sensitive and specific for iron deficiency anemia, anemia of chronic disease with iron deficiency and anemia of chronic disease groups, respectively.

CONCLUSION

In cost constraints settings, a simple investigation like Ret He alone or with serum ferritin can help us to diagnose and differentiate between the different types of anemia accompanying rheumatological disorders without doing other serum iron studies and expensive tests like transferrin receptor protein which are not readily available.

Anemia of inflammation

Anemia of inflammation (AI), also known as anemia of chronic disease (ACD), is regarded as the most frequent anemia in hospitalized and chronically ill patients. It is prevalent in patients with diseases that cause prolonged immune activation, including infection, autoimmune diseases, and cancer. More recently, the list has grown to include chronic kidney disease, congestive heart failure, chronic pulmonary diseases, and obesity. Inflammation-inducible cytokines and the master regulator of iron homeostasis, hepcidin, block intestinal iron absorption and cause iron retention in reticuloendothelial cells, resulting in iron-restricted erythropoiesis. In addition, shortened erythrocyte half-life, suppressed erythropoietin response to anemia, and inhibition of erythroid cell differentiation by inflammatory mediators further contribute to AI in a disease-specific pattern. Although the diagnosis of AI is a diagnosis of exclusion and is supported by characteristic alterations in iron homeostasis, hypoferremia, and hyperferritinemia, the diagnosis of AI patients with coexisting iron deficiency is more difficult. In addition to treatment of the disease underlying AI, the combination of iron therapy and erythropoiesis-stimulating agents can improve anemia in many patients. In the future, emerging therapeutics that antagonize hepcidin function and redistribute endogenous iron for erythropoiesis may offer additional options. However, based on experience with anemia treatment in chronic kidney disease, critical illness, and cancer, finding the appropriate indications for the specific treatment of AI will require improved understanding and a balanced consideration of the contribution of anemia to each patient's morbidity and the impact of anemia treatment on the patient's prognosis in a variety of disease settings.

Preparation and stability of nano-scaled gel beads of λ-carrageenan bound with ferric ions

Iron-deficiency anemia (IDA) is a major global public health problem, and the iron fortifiers in diet are clearly needed in the prevention and improvement of IDA for humans. A novel nano-scaled gel beads of λ-carrageenan (λ-car) specifically binding with ferric ions was developed to be a promising iron fortifier with no adverse organoleptic changes on food. Turbidity measurement, thermogravimetric analysis and Fourier transform infrared spectroscopy confirmed the successful chelating. The gel beads of λ-car-Fe³⁺ complex showed good dispersibility and solvent stability. The in vitro cell viability of HepG2 cells treated with λ-car-Fe³⁺ was over 75% at 5 mg/mL of ferric ions, indicating a significant cytotoxicity reduction of ferric ions. The stability of λ-car-Fe³⁺ complex powder was obviously increased against browning during 60 d storage with zein coating, which was attributed to the prevention of moisture permeation. Zein coated gel beads also performed a slow release of ferric ions in simulated gastrointestinal juices, resulting from the compact and hydrophobic zein surface delaying the dissociation of λ-car-Fe³⁺ in acidic environment. This λ-car-Fe³⁺ complex would have a great potential as a safe iron fortifier and facilitate iron supplementary with the advantage to relieve the side effects of iron ions.

Reticulocyte and erythrocyte hypochromia markers in detection of iron deficiency in adolescent female athletes

The aim of this study was to analyse the effectiveness of new haematology parameters related to reticulocytes and mature red blood cells to differentiate pre latent and latent iron deficiency. The study included 219 female athletes (aged 15-20 years) representing volleyball, handball, cycling, canoeing, cross-country skiing, swimming and judo. To assess iron status the concentration of ferritin, soluble transferrin receptor (sTfR), iron and total iron binding capacity (TIBC) were determined in serum. In addition to blood morphology, the mean cellular haemoglobin content in erythrocytes (CH) and reticulocytes (CHr), mean cellular haemoglobin concentration in reticulocytes (CHCMr), the percentage of erythrocytes (HYPOm) and reticulocytes (HYPOr) with decreased cellular haemoglobin concentration, the percentage of erythrocytes (LowCHm) and reticulocytes (LowCHr) with decreased cellular haemoglobin content, and percentage of erythrocytes with decreased volume (MICROm) were determined. Subjects with ferritin <30 ng/ml were classified as having stage I (pre-latent) iron deficiency (ID). The second stage (latent ID) was diagnosed when low ferritin was accompanied by elevated sTfR and/or elevated TIBC values. The frequency of ID (without anaemia symptoms) was high, amounting to 60% (stage I in 45%, stage II in 15% of subjects). In subjects with stage I ID significant changes in haematological variables concerned mainly reticulocytes: CHCMr (p<.001), CHr (p<.05), LowCHr (p<.05), HYPOr (p<.001) in comparison to normal iron stores. In athletes with latent ID, there were also significant changes (p<.001) in many indices of mature red blood cells, i.e. haemoglobin concentration (Hb), mean corpuscular haemoglobin (MCH), mean corpuscular haemoglobin concentration (MCHC), CH, %LowCHm, as well as %MICROm (p<.01) in relation to the group without iron deficiency. The main finding of this study was that the diminished or exhausted iron stores had already caused changes in reticulocytes, and intensified iron deficiency (stage II) increased changes in both reticulocytes’ and erythrocytes’ hypochromia indices, while microcythaemia symptoms appeared later. This suggests that the markers of hypochromia relating especially to reticulocytes are useful for diagnosis of early ID in athletes with absence of an acute phase reaction.

Copper, zinc and iron levels in premature infants following red blood cell transfusion

This study aimed to investigate effect of erythrocyte suspension (ES) transfusion on Cu, Zn, and Fe levels. It was conducted on 53 premature infants who were admitted to Hacettepe Hospital and received EST for first time. Blood samples were drawn before and 96h after ES transfusion to determine Cu, Zn, and Fe levels in plasma and/or erythrocytes. The mean plasma Cu levels were 99±3μg/dl and 113±3μg/dl; Zn levels were 105±2μg/dl and 115±23μg/dl; mean plasma Fe level was 58.1±19.4 and 75.2±25.4μg/dl and mean erythrocyte Fe level was 4182±2314μg/ml and 7009±5228μg/ml, before and after ES transfusion. The differences between before and after ES transfusion in Cu, Zn and Fe levels were significant. Correlation between plasma and erythrocyte Fe levels was significant both before and after ES transfusion. Though Fe overload is a major cause of morbidity/mortality after ES transfusion, alterations in trace elements should also be considered when transfusing blood to infants and children.

Is Correction of Iron Deficiency a New Addition to the Treatment of the Heart Failure?

Anemia is present in about 40% of heart failure (HF) patients. Iron deficiency (ID) is present in about 60% of the patients with anemia (about 24% of all HF patients) and in about 40% of patients without anemia (about 24% of all HF patients). Thus ID is present in about half the patients with HF. The ID in HF is associated with reduced iron stores in the bone marrow and the heart. ID is an independent risk factor for severity and worsening of the HF. Correction of ID with intravenous (IV) iron usually corrects both the anemia and the ID. Currently used IV iron preparations are very safe and effective in treating the ID in HF whereas little information is available on the effectiveness of oral iron. In HF IV iron correction of ID is associated with improvement in functional status, exercise capacity, quality of life and, in some studies, improvement in rate of hospitalization for HF, cardiac structure and function, and renal function. Large long-term adequately-controlled intervention studies are needed to clarify the effect of IV iron in HF. Several heart associations suggest that ID should be routinely sought for in all HF patients and corrected if present. In this paper we present our approach to diagnosis and treatment of iron deficiency in heart failure.