Oxidant/antioxidant status of placenta, blood, and cord blood samples from pregnant women supplemented with iron

Oxidative Stress in Pregnancy

Recent years have seen an increased interest in the role of oxidative stress (OS) in pregnancy. Pregnancy inherently heightens susceptibility to OS, a condition fueled by a systemic inflammatory response that culminates in an elevated presence of reactive oxygen species (ROS) and reactive nitrogen species (RNS) in the circulatory system. The amplified OS in pregnancy can trigger a series of detrimental outcomes such as underdevelopment, abnormal placental function, and a host of pregnancy complications, including pre-eclampsia, embryonic resorption, recurrent pregnancy loss, fetal developmental anomalies, intrauterine growth restriction, and, in extreme instances, fetal death. The body's response to mitigate the uncontrolled increase in RNS/ROS levels requires trace elements that take part in non-enzymatic and enzymatic defense processes, namely, copper (Cu), zinc (Zn), manganese (Mn), and selenium (Se). Determination of ROS concentrations poses a challenge due to their short half-lives, prompting the use of marker proteins, including malondialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GPx), glutathione reductase (GR), catalase (CAT), and glutathione (GSH). These markers, indicative of oxidative stress intensity, can offer indirect assessments of pregnancy complications. Given the limitations of conducting experimental studies on pregnant women, animal models serve as valuable substitutes for in-depth research. This review of such models delves into the mechanism of OS in pregnancy and underscores the pivotal role of OS markers in their evaluation.

Correlation of perilipin 2 and lipid metabolism in elective cesarean section and vaginal delivery: a prospective study with oxidative and apoptotic pathways

Vaginal delivery (VD) and elective cesarean (CS) delivery modes may cause significant differences in maternal and fetal metabolism. In this study, we aimed to investigate changes in lipid metabolism, oxidative and apoptotic signaling pathways during VD and CS in maternal and cord blood and placenta tissue. The study included two groups of participants delivered via 90 CS and 90 VD. Maternal and cord blood samples were collected from the participants. In addition, placenta samples were also taken after delivery. Total oxidant (TOS), malondialdehyde (MDA), total antioxidant (TAS), glutathione (GSH), cleaved caspase 3 (CASP3) and perilipin 2 (PLIN2) levels were measured to determine oxidative stress, antioxidant levels and apoptosis status in the VD and CS groups. Besides, PLIN2 mRNA expressions in placental specimens were analyzed. We found no statistically significant difference in maternal age, body mass index, gestational age, birth weight and Apgar scores in both groups (P > 0.05). The increase in MDA, TOS, GSH and TAS levels was higher in the VD group compared to the CS group (P < 0.05). Similarly, PLIN2 levels and lipid profiles showed an increase in the VD group (P < 0.05 vs CS group). Likewise, PLIN2 expression enhanced in the VD group (P < 0.05 vs CS group). However, CASP3 activity reduced in maternal and cord blood in the VD group compared to the CS group. Our results support that the delivery mode may cause differences in lipid profile, oxidative and apoptotic status by affecting PLIN2 levels in both maternal and cord blood and placenta tissue.

Maternal Vitamin C and Iron Intake during Pregnancy and the Risk of Islet Autoimmunity and Type 1 Diabetes in Children: A Birth Cohort Study

Our aim was to study the associations between maternal vitamin C and iron intake during pregnancy and the offspring’s risk of developing islet autoimmunity and type 1 diabetes. The study was a part of the Finnish Type 1 Diabetes Prediction and Prevention (DIPP) prospective birth cohort including children genetically at risk of type 1 diabetes born between 1997–2004. The diets of 4879 mothers in late pregnancy were assessed with a validated food frequency questionnaire. The outcomes were islet autoimmunity and type 1 diabetes. Cox proportional hazards regression analysis adjusted for energy, family history of diabetes, human leukocyte antigen (HLA) genotype and sex was used for statistical analyses. Total intake of vitamin C or iron from food and supplements was not associated with the risk of islet autoimmunity (vitamin C: HR 0.91: 95% CI (0.80, 1.03), iron: 0.98 (0.87, 1.10)) or type 1 diabetes (vitamin C: 1.01 (0.87, 1.17), iron: 0.92 (0.78, 1.08)), neither was the use of vitamin C or iron supplements associated with the outcomes. In conclusion, no association was found between maternal vitamin C or iron intake during pregnancy and the risk of islet autoimmunity or type 1 diabetes in the offspring.

Anemia in pregnancy: it's effect on oxidative stress and cardiac parameters

OBJECTIVE

We aimed to evaluate the changes in cardiac functions by echocardiography and oxidative stress markers in pregnant women with iron deficiency anemia.

METHOD

A total of 100 patients (pregnant women with IDA n = 34, healthy pregnant women n = 33, non-pregnant control group n = 33) were enrolled. Demographic data, serum thiol-disulfide and ischemia modified albumin levels, and echocardiographic parameters were compared.

RESULTS

Native thiol (NT) (p < .001) and Total Thiol (TT) (p < .001) levels as antioxidant markers; left ventricular ejection fraction (LVEF) (p < .001), tricuspid annular plane systolic excursion (TAPSE) (p < .001) were significantly decreased in the IDA group compared to healthy pregnant women and non-pregnant controls. Adjusted IMA ratios were significantly increased in the IDA group (p =.001). A significant negative correlation was determined between adjusted IMA and LVEF (r = -0,4226; p =.016), a significant positive correlation was determined between thiol levels and TAPSE (r = 0.361; p =.041) in IDA group, no correlation was observed in healthy pregnant women and healthy non-pregnant control group.

CONCLUSION

Anemia in pregnanc may trigger oxidative stress and increased OS may be related to changes in cardiac functions. The possible cardiovascular impact should be considered in pregnant women with anemia and clinicians should not neglect to refer these patients to cardiology in clinical practise.

Prenatal iron exposure and childhood type 1 diabetes

Iron overload due to environmental or genetic causes have been associated diabetes. We hypothesized that prenatal iron exposure is associated with higher risk of childhood type 1 diabetes. In the Norwegian Mother and Child cohort study (n = 94,209 pregnancies, n = 373 developed type 1 diabetes) the incidence of type 1 diabetes was higher in children exposed to maternal iron supplementation than unexposed (36.8/100,000/year compared to 28.6/100,000/year, adjusted hazard ratio 1.33, 95%CI: 1.06-1.67). Cord plasma biomarkers of high iron status were non-significantly associated with higher risk of type 1 diabetes (ferritin OR = 1.05 [95%CI: 0.99-1.13] per 50 mg/L increase; soluble transferrin receptor: OR = 0.91 [95%CI: 0.81-1.01] per 0.5 mg/L increase). Maternal but not fetal HFE genotypes causing high/intermediate iron stores were associated with offspring diabetes (odds ratio: 1.45, 95%CI: 1.04, 2.02). Maternal anaemia or non-iron dietary supplements did not significantly predict type 1 diabetes. Perinatal iron exposures were not associated with cord blood DNA genome-wide methylation, but fetal HFE genotype was associated with differential fetal methylation near HFE. Maternal cytokines in mid-pregnancy of the pro-inflammatory M1 pathway differed by maternal iron supplements and HFE genotype. Our results suggest that exposure to iron during pregnancy may be a risk factor for type 1 diabetes in the offspring.

Placental growth factor (PlGF) as an angiogenic/inflammatory switcher: lesson from early pregnancy losses

Placental growth factor (PlGF) is an angiogenic factor which belongs to vascular endothelial growth factor (VEGF) family. In addition to the angiogenic function of PlGF, in some conditions such as preeclampsia and early pregnancy losses, it can induce inflammatory reactions which could be accompanied with reduced angiogenesis. Hence, it is crucial to investigate inflammatory and angiogenic switching states and understand underlying mechanisms. PlGF is expressed in endometrium, placenta and trophoblast cells and is involved in maturation of uterine NK cells. Up-regulation of PlGF directs VEGF to VEGFR-2 and reinforces angiogenesis. However, when VEGF/VEGFR-2 signaling pathway is impaired, PlGF may shift to severe inflammation and cause tissue damages which could lead to early pregnancy losses. Downregulation of PlGF has also been reported in pregnancy complications. In this review, we discussed the role of PlGF in embryo implantation failure and early pregnancy loss and also possible mechanisms regarding the role of PlGF in angiogenic/inflammatory switching in early pregnancy losses. Furthermore, we summarized the effects of various compounds on PlGF expression and briefly talked about its therapeutic potential that may be an opportunity for prevention of pregnancy loss.

Effects of different regimens of iron prophylaxis on maternal iron status and pregnancy outcome: a randomized control trial

PURPOSE

Iron supplementation is associated with side effects and overload risk. We compared different regimens of iron supplementation on maternal hematological status and pregnancy outcome in a cohort of healthy pregnant women.

MATERIALS AND METHODS

Eighty non-anemic women with a normal singleton pregnancy were recruited at 11-13 weeks and randomized into controls (C; n = 20) and groups supplemented with ferrous iron 30 mg (FI; n = 20), liposomal iron 14 mg (Sideral® Pharmanutra, Pisa PI, Italy) (LI14; n = 20) and liposomal iron 28 mg/daily (LI28; n = 20) up to 6 weeks post-partum. Longitudinal maternal blood samples for iron markers were collected. Data on birth outcome were recorded. The treatment effect was evaluated using a mixed-effect regression model.

RESULTS

Both LI28 and LI14 groups showed significantly higher hemoglobin and ferritin concentrations compared with controls. Birth weight showed a trend to increase with supplementation, resulting in higher birth weight in the LI28 group compared with controls (3499 ± 464.1 g and 3092 ± 469.5 g, respectively, p < 0.01).

CONCLUSIONS

Our data show the effectiveness of 28 mg and 14 mg LI on maternal anemia prevention, as previously reported with FI 40 mg. LI has similar effects of higher doses of ferrous iron on maternal hematological parameters, thus allowing to reduce iron doses and side effects.

Oxidative Profile and δ-Aminolevulinate Dehydratase Activity in Healthy Pregnant Women with Iron Supplementation

An oxidative burst occurs during pregnancy due to the large consumption of oxygen in the tissues and an increase in metabolic demands in response to maternal physiological changes and fetal growth. This study aimed to determine the oxidative profile and activity of δ-aminolevulinate dehydratase (δ-ALA-D) in pregnant women who received iron supplementation. Oxidative stress parameters were evaluated in 25 pregnant women with iron supplementation, 25 pregnant women without supplementation and 25 non-pregnant women. The following oxidative stress parameters were evaluated: thiobarbituric acid reactive substances (TBARS), protein thiol groups (P-SH), non-protein thiol levels (NP-SH), vitamin C levels, catalase and δ-ALA-D activity. Markers of oxidative stress and cell damage, such as TBARS in plasma were significantly higher in pregnant women without supplementation. Levels of P-SH, NP-SH and δ-ALA-D activity were significantly lower in pregnant women without supplementation compared to non-pregnant and pregnant women with supplementation, while vitamin C levels were significantly lower in pregnant women without supplementation when compared to non-pregnant women. The increase in the generation of oxidative species and decrease of antioxidants suggest the loss of physiological oxidative balance during normal pregnancy, which was not observed in pregnant women with iron supplementation, suggesting a protective effect of iron against oxidative damage.

Chronic maternal vitamin B12 restriction induced changes in body composition & glucose metabolism in the Wistar rat offspring are partly correctable by rehabilitation

Maternal under-nutrition increases the risk of developing metabolic diseases. We studied the effects of chronic maternal dietary vitamin B12 restriction on lean body mass (LBM), fat free mass (FFM), muscle function, glucose tolerance and metabolism in Wistar rat offspring. Prevention/reversibility of changes by rehabilitating restricted mothers from conception or parturition and their offspring from weaning was assessed. Female weaning Wistar rats (n = 30) were fed ad libitum for 12 weeks, a control diet (n = 6) or the same with 40% restriction of vitamin B12 (B12R) (n = 24); after confirming deficiency, were mated with control males. Six each of pregnant B12R dams were rehabilitated from conception and parturition and their offspring weaned to control diet. While offspring of six B12R dams were weaned to control diet, those of the remaining six B12R dams continued on B12R diet. Biochemical parameters and body composition were determined in dams before mating and in male offspring at 3, 6, 9 and 12 months of their age. Dietary vitamin B12 restriction increased body weight but decreased LBM% and FFM% but not the percent of tissue associated fat (TAF%) in dams. Maternal B12R decreased LBM% and FFM% in the male offspring, but their TAF%, basal and insulin stimulated glucose uptake by diaphragm were unaltered. At 12 months age, B12R offspring had higher (than controls) fasting plasma glucose, insulin, HOMA-IR and impaired glucose tolerance. Their hepatic gluconeogenic enzyme activities were increased. B12R offspring had increased oxidative stress and decreased antioxidant status. Changes in body composition, glucose metabolism and stress were reversed by rehabilitating B12R dams from conception, whereas rehabilitation from parturition and weaning corrected them partially, highlighting the importance of vitamin B12 during pregnancy and lactation on growth, muscle development, glucose tolerance and metabolism in the offspring.

Effect of multivitamin versus multivitamin-mineral supplementation on metabolic profiles and biomarkers of oxidative stress in pregnant women: a double-blind randomized clinical trial

OBJECTIVE

This study was designed to determine the favorable effects of received multivitamin versus multivitamin-mineral supplements on metabolic profiles and biomarkers of oxidative stress among Iranian pregnant women.

METHODS

This double-blind randomized-controlled clinical trial was conducted among 70 pregnant women, primigravida, aged 18-35 years old between 16 and 37 weeks gestation. Subjects were randomly assigned to receive either the multivitamin (n = 35) or multivitamin-mineral supplements (n = 35) for 20 weeks. Fasting blood samples were taken at baseline and after a 20-week intervention to measure lipid profiles and biomarkers of oxidative stress.

RESULTS

After 20 weeks of intervention, multivitamin-mineral supplementation resulted in a significant difference on serum triglycerides levels (changes from baseline in multivitamin-mineral group: +6.1 versus in multivitamin group: +45.9 mg/dl, p = 0.04) compared with the multivitamin group. In addition, increased concentrations of serum HDL-cholesterol (changes from baseline in multivitamin-mineral group: +0.1 versus in multivitamin group: -7.4 mg/dl, p = 0.02) and total glutathione (GSH) levels (changes from baseline in multivitamin-mineral group: +151.09 versus in multivitamin group: -116.21 µmol/l, p = 0.003) were also seen in the multivitamin-mineral group compared with the multivitamin group.

CONCLUSION

Supplementation of multivitamin-mineral compared to multivitamin supplementation for 20 weeks during pregnancy had beneficial effects on triglycerides, HDL-cholesterol and GSH levels.

Multiple micronutrient needs in pregnancy in industrialized countries

BACKGROUND

As nutritional deficiencies are known to lead to adverse pregnancy outcomes, a woman's nutritional status should be assessed preconceptionally with the goal of optimizing maternal, fetal and infant health. Worldwide micronutrient intakes do not fit pregnancy requirements, so that their supplementation is recommended from the beginning of pregnancy in most of the low- and middle-income countries. Conversely, data on multiple supplementation in developed countries appear few and controversial. Key Message: Although a balanced diet is generally accessible in industrialized countries, a switch to a high-fat and low-quality diet has led to an inadequate vitamin and mineral intake during pregnancy, so that recent data show the micronutrient intake and supplementation to be lower than recommended even in high-income countries, particularly for iron, folic acid, calcium and vitamin D.

CONCLUSIONS

Currently, even if there is insufficient evidence to support routine supplementation at the population level, except for periconceptional folate supplementation, these results need to be evaluated at an individual level in order to avoid nutritional deficiencies and to encourage women to establish healthful dietary practices prior to conception. The new goal in industrialized countries needs to be an individualized approach that takes account of the phenotypic, genotypic and metabolic differences among individuals of the same population.

Association between maternal iron supplementation during pregnancy and risk of celiac disease in children

BACKGROUND & AIMS

The aim of our study was to determine whether the use of iron supplements during pregnancy affects the risk for celiac disease in children.

METHODS

We assessed data from the prospective Norwegian Mother and Child cohort study, in which individuals with celiac disease were identified by answers on questionnaires and linkage to the Norwegian Patient Register. Complete data were available for 78,846 children (mean age 5.9 years, range 2-12 years); 314 children were identified with celiac disease. Questionnaires were given to pregnant women to collect information on use of iron-containing supplements, diet, anemia, and levels of hemoglobin.

RESULTS

Celiac disease was diagnosed in 4.65 of 1000 children whose mothers took iron supplements while they were pregnant, compared with 3.15 of 1000 children whose mothers did not. After adjusting for children's age, sex, and age of gluten introduction, and the presence of celiac disease in mothers, iron supplementation during pregnancy remained significantly associated with celiac disease in children (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.05-1.68; P = .019). However, celiac disease was not associated with the mothers' intake of iron from foods (adjusted OR, 1.00; 95% CI, 0.97-1.03). Anemia before or during the early stages of pregnancy was not significantly associated with the risk of celiac disease in children (adjusted OR, 1.24; 95% CI, 0.84-2.00; P = .24). The use of iron supplements during pregnancy remained significantly associated with celiac disease in children after adjusting for children who were given iron supplements before 18 months of age, which itself was associated with celiac disease.

CONCLUSIONS

In a prospective Norwegian Mother and Child cohort study, we found an increased risk of celiac disease in children whose mothers used iron supplements during pregnancy; this association does not appear to arise from maternal anemia.

Is oxidative stress induced by iron status associated with gestational diabetes mellitus?

Gestational diabetes mellitus (GDM) is a common pregnancy complication in high risk populations, and is associated with increased perinatal and long term outcomes for both mothers and newborns. Both its prevention and early management can be reinforced by identifying risks factors, particularly those factors influencing glucose metabolism. On the other hand, several epidemiological studies have shown an increased oxidative stress (OS) in pregnant women with GDM. Elevated OS was also reported in pregnant women supplemented with iron, which can generate OS and may also influence insulin resistance. This review summarizes the current state of knowledge, highlighting the potential relationship between OS induced by iron status and the development of GDM.

Iron and genome stability: an update

Iron is an essential micronutrient which is required in a relatively narrow range for maintaining metabolic homeostasis and genome stability. Iron participates in oxygen transport and mitochondrial respiration as well as in antioxidant and nucleic acid metabolism. Iron deficiency impairs these biological pathways, leading to oxidative stress and possibly carcinogenesis. Iron overload has been linked to genome instability as well as to cancer risk increase, as seen in hereditary hemochromatosis. Iron is an extremely reactive transition metal that can interact with hydrogen peroxide to generate hydroxyl radicals that form the 8-hydroxy-guanine adduct, cause point mutations as well as DNA single and double strand breaks. Iron overload also induces DNA hypermethylation and can reduce telomere length. The current Recommended Dietary Allowances (RDA) for iron, according with Institute of Medicine Dietary Reference Intake (DRI), is based in the concept of preventing anemia, and ranges from 7mg/day to 18mg/day depending on life stage and gender. Pregnant women need 27mg/day. The maximum safety level for iron intake, the Upper Level (UL), is 40-45mg/day, based on the prevention of gastrointestinal distress associated to high iron intakes. Preliminary evidence indicates that 20mg/day iron, an intake slightly higher than the RDA, may reduce the risk of gastrointestinal cancer in the elderly as well as increasing genome stability in lymphocytes of children and adolescents. Current dietary recommendations do not consider the concept of genome stability which is of concern because damage to the genome has been linked to the origin and progression of many diseases and is the most fundamental pathology. Given the importance of iron for homeostasis and its potential influence over genome stability and cancer it is recommended to conduct further studies that conclusively define these relationships.

Supplementation of iron alone and combined with vitamins improves haematological status, erythrocyte membrane fluidity and oxidative stress in anaemic pregnant women

Pregnancy is a condition exhibiting increased susceptibility to oxidative stress, and Fe plays a central role in generating harmful oxygen species. The objective of the present study is to investigate the changes in haematological status, oxidative stress and erythrocyte membrane fluidity in anaemic pregnant women after Fe supplementation with and without combined vitamins. The study was a 2 months double-blind, randomised trial. Pregnant women (n 164) were allocated to four groups: group C was the placebo control group; group I was supplemented daily with 60 mg Fe (ferrous sulphate) daily; group IF was supplemented daily with Fe plus 400 μg folic acid; group IM was supplemented daily with Fe plus 2 mg retinol and 1 mg riboflavin, respectively. After the 2-month trial, Hb significantly increased by 15.8, 17.3 and 21.8 g/l, and ferritin by 2.8, 3.6 and 11.0 μg/l, in the I, IF and IM groups compared with placebo. Polarisation (ρ) and microviscosity (η) decreased significantly in other groups compared with placebo, indicating an increase in membrane fluidity. Significant decreases of ρ and η values compared with group C were 0.033 and 0.959 for group I, 0.037 and 1.074 for group IF and 0.064 and 1.865 for group IM, respectively. In addition, significant increases of glutathione peroxidase activities and decreases of malondialdehyde were shown in all treated groups, as well as increases of plasma retinol and urine riboflavin in group IM. The findings show that supplementation with Fe and particularly in combination with vitamins could improve the haematological status as well as oxidative stress and erythrocyte membrane fluidity.

Role of oxidative stress while controlling iron deficiency anemia during pregnancy - Indian scenario

Iron Deficiency anemia ranks 9(th) among 26 diseases with highest burden. Asia bears 71% of this global burden. Adverse maternal and birth outcome associated with hemoglobin status renders the issue worth attention. Indian scenario has worsened over the period despite continuous international and national efforts. This indicates some lacunae in the approach and strategies applied. Various reports state that even with maximum effort to increase outreach and monitoring for adherence to Iron schedule, consumer's compliance remains abysmally low. Recent studies has pointed out biological basis of side effects (gastrointestinal complains and systemic events) as raised oxidative stress for which iron is the key catalyst. Up till now the only target of research has been to raise hemoglobin of pregnant women above 11gm/dl. With the reports of pregnancy specific morbidities i.e. hemorrhage and septicemia with low hemoglobin, eclampsia, small for gestation age, gestational diabetes with higher ranges of hemoglobin, alarm is raised to define optimum range. Use of oxidative stress as biochemical marker with different doses and schedules has been defined because India lack information for its own population upon oxidative stress status when iron is supplemented as per current guidelines. Studies done in India and abroad have defined that too much and too less, both may raise oxidative stress and studies of this sort may provide biochemical scale for optimization. This review therefore has evaluated currently available Indian research and reports to understand the need of future research area. Important findings from other countries have been incorporated for comparison.

Iron behaving badly: inappropriate iron chelation as a major contributor to the aetiology of vascular and other progressive inflammatory and degenerative diseases

BACKGROUND

The production of peroxide and superoxide is an inevitable consequence of aerobic metabolism, and while these particular 'reactive oxygen species' (ROSs) can exhibit a number of biological effects, they are not of themselves excessively reactive and thus they are not especially damaging at physiological concentrations. However, their reactions with poorly liganded iron species can lead to the catalytic production of the very reactive and dangerous hydroxyl radical, which is exceptionally damaging, and a major cause of chronic inflammation.

REVIEW

We review the considerable and wide-ranging evidence for the involvement of this combination of (su)peroxide and poorly liganded iron in a large number of physiological and indeed pathological processes and inflammatory disorders, especially those involving the progressive degradation of cellular and organismal performance. These diseases share a great many similarities and thus might be considered to have a common cause (i.e. iron-catalysed free radical and especially hydroxyl radical generation).The studies reviewed include those focused on a series of cardiovascular, metabolic and neurological diseases, where iron can be found at the sites of plaques and lesions, as well as studies showing the significance of iron to aging and longevity. The effective chelation of iron by natural or synthetic ligands is thus of major physiological (and potentially therapeutic) importance. As systems properties, we need to recognise that physiological observables have multiple molecular causes, and studying them in isolation leads to inconsistent patterns of apparent causality when it is the simultaneous combination of multiple factors that is responsible.This explains, for instance, the decidedly mixed effects of antioxidants that have been observed, since in some circumstances (especially the presence of poorly liganded iron) molecules that are nominally antioxidants can actually act as pro-oxidants. The reduction of redox stress thus requires suitable levels of both antioxidants and effective iron chelators. Some polyphenolic antioxidants may serve both roles.Understanding the exact speciation and liganding of iron in all its states is thus crucial to separating its various pro- and anti-inflammatory activities. Redox stress, innate immunity and pro- (and some anti-)inflammatory cytokines are linked in particular via signalling pathways involving NF-kappaB and p38, with the oxidative roles of iron here seemingly involved upstream of the IkappaB kinase (IKK) reaction. In a number of cases it is possible to identify mechanisms by which ROSs and poorly liganded iron act synergistically and autocatalytically, leading to 'runaway' reactions that are hard to control unless one tackles multiple sites of action simultaneously. Some molecules such as statins and erythropoietin, not traditionally associated with anti-inflammatory activity, do indeed have 'pleiotropic' anti-inflammatory effects that may be of benefit here.

CONCLUSION

Overall we argue, by synthesising a widely dispersed literature, that the role of poorly liganded iron has been rather underappreciated in the past, and that in combination with peroxide and superoxide its activity underpins the behaviour of a great many physiological processes that degrade over time. Understanding these requires an integrative, systems-level approach that may lead to novel therapeutic targets.