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Truong J, Naveed K, Beriault D, Lightfoot D, Fralick M, Sholzberg M. The origin of ferritin reference intervals: a systematic review. Lancet Haematol 2024; 11:e530-e539. [PMID: 38937026 DOI: 10.1016/s2352-3026(24)00103-0] [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: 02/20/2024] [Revised: 03/27/2024] [Accepted: 04/08/2024] [Indexed: 06/29/2024]
Abstract
Iron deficiency is a highly prevalent condition, which contributes to unnecessary morbidity, mortality, and health inequity. A serum ferritin concentration of less than 30 μg/L has a high specificity and sensitivity for diagnosing iron deficiency in adults, but the laboratory reported lower limit of normal (LLN) is typically lower. These LLNs might not be rooted in rigorous scientific evidence and might be contributing to structural underdiagnosis of iron deficiency. A systematic review was done per systematic reviews and meta-analysis guidelines with the use of medical literature databases from inception of each database to Nov 30, 2021, to identify studies that determined ferritin reference intervals in healthy adults and grey literature search for the five most common ferritin assays (registration number CRD42022268844). The objectives were to systematically summarise the ferritin reference intervals and to do a methodological quality assessment of the included studies. 2306 studies were screened and 61 full texts were included. 37 studies were eligible for analysis of the ferritin LLN in the general population. The population the sample was comprised of was a total of 21 882 females and 23 650 males participants. The ferritin LLN was a median of 8 μg/L (IQR 5-15) and mean of 9 μg/L (SD 11) in females and a median of 25 μg/L (IQR 16-44) and mean of 25 μg/L (SD 29) in males. 30 (49%) of 61 studies did not explicitly screen for patients at risk of iron deficiency, and 32 (52%) did not refer to a reference interval establishment guideline (eg, guideline recommended by Clinical and Laboratory Standards Institute). The five most used commercial ferritin laboratory assays reported reference intervals with a median LLN of 11 (IQR 9-12) and mean of 9 μg/L (SD 4) for females and median of 22 (IQR 22-24) and mean of 23 μg/L (SD 4) for males. In the literature, serum ferritin reference intervals in healthy adults consistently report a LLN of less than 30 μg/L. Data driving these ferritin reference intervals are at high risk of bias, given no exclusion of individuals at risk for iron deficiency in the presumed normal population sample and no adherence to reference interval establishment standards. We suggest the use of evidence-based laboratory clinical decision limits to diagnose iron deficiency.
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Affiliation(s)
- Judy Truong
- Department of Medicine Canada, University of Toronto, Ontario, Canada.
| | - Kanza Naveed
- Department of Medicine Canada, University of Toronto, Ontario, Canada
| | - Daniel Beriault
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Ontario, Canada; St Michael's Hospital, Toronto, ON, Canada
| | | | - Michael Fralick
- Sinai Health System, Division of General Internal Medicine, Toronto, ON, Canada
| | - Michelle Sholzberg
- Department of Medicine Canada, University of Toronto, Ontario, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Ontario, Canada; St Michael's Hospital, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, ON, Canada
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2
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Kim HJ, Han R, Kang KP, Ryu JH, Kim MG, Huh KH, Park JB, Kim CD, Han S, Kim HW, Kim BS, Yang J. Impact of iron status on kidney outcomes in kidney transplant recipients. Sci Rep 2023; 13:861. [PMID: 36650247 PMCID: PMC9845230 DOI: 10.1038/s41598-023-28125-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 01/13/2023] [Indexed: 01/19/2023] Open
Abstract
Iron plays an important role in hemodynamics and the immunity, independent of anemia. Since dynamic changes occur in iron storage after kidney transplantation (KT), we investigated the association between iron status and kidney outcomes in KT patients. We analyzed data from the KoreaN cohort study for Outcome in patients With KT (KNOW-KT). The iron status was classified into three groups based on ferritin or transferrin saturation (TSAT) levels one year after KT, with reference ranges of 20‒35% and 100‒300 ng/mL for TSAT and ferritin, respectively. The primary outcome was the composite outcome, which consisted of death, graft failure, and an estimated glomerular filtration rate decline ≥ 50%. In total, 895 patients were included in the final analysis. During a median follow-up of 5.8 years, the primary outcome occurred in 94 patients (19.8/1000 person-years). TSAT levels decreased one year after KT and thereafter gradually increased, whereas ferritin levels were maintained at decreased levels. The adjusted hazard ratios (95% confidence intervals) for the composite outcome were 1.67 (1.00-2.77) and 1.20 (0.60-2.40) in the TSAT > 35% and ferritin > 300 ng/mL groups, respectively. High iron status with high TSAT levels increases the risk of graft failure or kidney functional deterioration after KT.
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Affiliation(s)
- Hyo Jeong Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ro Han
- Department of Internal Medicine, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Kyung Pyo Kang
- Department of Internal Medicine, Research Institute of Clinical Medicine, Jeonbuk National University Medical School, Jeonju, Republic of Korea.,Biomedical Research Institute, Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Jung-Hwa Ryu
- Department of Internal Medicine, Ewha Womans University Seoul Hospital, Seoul, Republic of Korea
| | - Myung-Gyu Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kyu Ha Huh
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae Berm Park
- Department of Surgery, Seoul Samsung Medical Center, Sungkyunkwan University, Seoul, Republic of Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Seungyeup Han
- Department of Internal Medicine, Dongsan Medical Center, Keimyung University, Daegu, Republic of Korea
| | - Hyung Woo Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Beom Seok Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jaeseok Yang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea. .,Division of Nephrology, Department of Internal Medicine, College of Medicine, Yonsei University, 50 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea.
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3
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Tada A, Nagai T, Koya T, Nakao M, Ishizaka S, Mizuguchi Y, Aoyagi H, Imagawa S, Tokuda Y, Takahashi M, Kato Y, Machida M, Matsutani K, Saito T, Anzai T. Applicability of new proposed criteria for iron deficiency in Japanese patients with heart failure. ESC Heart Fail 2022; 10:985-994. [PMID: 36495060 PMCID: PMC10053267 DOI: 10.1002/ehf2.14265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/12/2022] [Accepted: 11/27/2022] [Indexed: 12/14/2022] Open
Abstract
AIMS Iron deficiency (ID) is a common co-morbidity in patients with heart failure (HF). A recent study showed that ID defined by the current guideline criteria was not associated with worse clinical outcomes, and new ID criteria was proposed in patients with HF. However, the external applicability of the new proposed criteria is unclear. We sought to investigate the applicability of the proposed ID criteria in Japanese patients with HF. METHODS AND RESULTS We prospectively examined 763 patients with chronic HF from a Japanese multicentre registry. The proposed ID criteria were transferrin saturation (TSAT) < 20% and serum iron ≤13 mmol/L and the guideline ID criteria were serum ferritin <100 ng/mL or, when ferritin was 100-299 ng/mL, TSAT <20%. Among all patients (456 male, mean age 71 ± 13 years), 213 (28%) and 444 (58%) met the proposed and guideline ID criteria, respectively. During a median follow-up period of 436 days (interquartile range 297-565), the primary outcome of all-cause mortality occurred in 56 (7%) patients. There was no significant difference in the primary outcome between the patients with and without guideline ID criteria (P = 0.32), whereas patients with serum iron ≤10 μmol/L showed higher mortality (P = 0.002). In multivariable Cox regressions, the proposed ID criteria, but not guideline ID criteria, were independently associated with the risk of all-cause mortality (HR 2.01, 95% CI 1.16-3.51 and HR 1.32, 95% CI 0.76-2.28, respectively), even after adjustment for covariates. CONCLUSIONS When defined by the proposed criteria and not the guideline criteria, ID was associated with higher mortality in patients with chronic HF, suggesting that the proposed ID criteria is applicable to the Japanese population.
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Affiliation(s)
- Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
| | - Taro Koya
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
| | - Motoki Nakao
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
| | - Suguru Ishizaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
| | - Yoshifumi Mizuguchi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
| | - Hiroyuki Aoyagi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
| | - Shogo Imagawa
- Department of Clinical Research National Hospital Organization Hakodate National Hospital Hakodate Japan
| | - Yusuke Tokuda
- Division of Cardiology Hakodate Municipal Hospital Hakodate Japan
| | - Masashige Takahashi
- Department of Cardiology Japan Community Health Care Organization Hokkaido Hospital Sapporo Japan
| | - Yoshiya Kato
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
- Department of Cardiology Kushiro City General Hospital Kushiro Japan
| | - Masaharu Machida
- Department of Cardiology Tomakomai City Hospital Tomakomai Japan
| | - Kenichi Matsutani
- Department of Cardiology Sunagawa City Medical Center Sunagawa Japan
| | - Takahiko Saito
- Department of Cardiology Japan Red Cross Kitami Hospital Kitami Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine Hokkaido University Sapporo Japan
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Masini G, Graham FJ, Pellicori P, Cleland JG, Cuthbert JJ, Kazmi S, Inciardi RM, Clark AL. Criteria for Iron Deficiency in Patients With Heart Failure. J Am Coll Cardiol 2022; 79:341-351. [DOI: 10.1016/j.jacc.2021.11.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 02/07/2023]
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The relationship between FGF23 and anemia in HD and renal transplant patients. Int Urol Nephrol 2021; 54:1117-1122. [PMID: 34482498 DOI: 10.1007/s11255-021-02982-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 08/21/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Recent studies claim that FGF23 is also associated with anemia and inflammation. In this study, the relationship between FGF23 and anemia in hemodialysis (HD) and renal transplantation patients (RTx patients) patients was investigated. METHODS This was a cross-sectional study involving 40 RTx patients (13 females, 27 males; mean age, 45.93 ± 12.49 years) who had transplantation at least 6 months before, 25 HD patients (12 females, 13 males; mean age, 54.72 ± 15.5 years), and 20 healthy control subjects (13 females, 7 males; mean age, 36.7 ± 9.38 years). FGF23 was studied using Elisa method. Parameters such as iron, ferritin, total iron binding capacity, and transferrin saturation were assessed. RESULTS FGF23 level was significantly higher in HD patients when compared with the RTx patients and control groups. In the bivariate correlation analysis, hemoglobin was positively correlated with albumin (r = 0.681, p = 0.000), ferritin (r = 0.446, p = 0.043), and negatively correlated with CRP (r = - 0.476, p = 0.016) and FGF23 (r = 0.493, p = 0.043). FGF23 was found to be an independent predictor of decreased hemoglobin in HD patients. In addition, this association was observed to disappear after transplantation. CONCLUSION While FGF23 is closely related to hemoglobin levels in HD patients, we have shown that this relationship disappears after transplantation.
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Farrag K, Ademaj K, Leventi E, Aksan A, Stein J. Diagnostic utility of low hemoglobin density to detect iron deficiency in patients with inflammatory bowel disease. Ann Gastroenterol 2021; 34:521-527. [PMID: 34276191 PMCID: PMC8276368 DOI: 10.20524/aog.2021.0622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/31/2020] [Indexed: 11/24/2022] Open
Abstract
Background In the absence of a feasible noninvasive gold standard, iron deficiency (ID) anemia (IDA) is best measured using multiple indicators. However, the choice of an appropriate single iron biomarker for ID screening continues to be debated. Low hemoglobin density (LHD%) from Coulter counters has been suggested as a useful tool to detect ID. This study investigated the reliability of LHD% for the assessment of iron status in patients with inflammatory bowel disease (IBD) and IDA, anemia of chronic disease (ACD) or mixed anemia (MIX). Methods The study population consisted of 143 patients with IBD (aged 39.03±12.53 years, 61.5% female). Blood count, transferrin saturation, serum ferritin, and C-reactive protein were determined by routine assays. Patients with anemia were divided into 3 groups: IDA, ACD and MIX, according to specific criteria. Receiver operator characteristic (ROC) curves were constructed. Results ROC analysis for LHD% in the detection of ID yielded a cutoff value of 3.8%. In anemic patients, LHD% values did not differ statistically significantly between groups (IDA, ACD, MIX) and no significant difference in LHD% values was observed between patients with IDA and ID. Conclusions These results demonstrate that LHD% is a reliable biomarker for the detection of iron deficiency in patients with IBD and anemia, regardless of whether inflammation is present. Our findings indicate that LHD% can provide added value in diagnosing iron deficiency.
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Affiliation(s)
- Karima Farrag
- Gastroenterology and Clinical Nutrition, DGD Kliniken Sachsenhausen, Frankfurt am Main (Karima Farrag, Krenare Ademaj, Jürgen Stein).,Gastroenterology and Clinical Nutrition, DGD Kliniken Sachsenhausen, Frankfurt am Main (Karima Farrag, Krenare Ademaj, Jürgen Stein)
| | - Krenare Ademaj
- Gastroenterology and Clinical Nutrition, DGD Kliniken Sachsenhausen, Frankfurt am Main (Karima Farrag, Krenare Ademaj, Jürgen Stein).,Gastroenterology and Clinical Nutrition, DGD Kliniken Sachsenhausen, Frankfurt am Main (Karima Farrag, Krenare Ademaj, Jürgen Stein)
| | - Eleni Leventi
- Interdisziplinäres Crohn Colitis Centrum Rhein-Main, Frankfurt am Main (Karima Farrag, Krenare Ademaj, Eleni Leventi, Aysegül Aksan, Jürgen Stein).,Department of Gastroenterology, Klinikum Hanau (Eleni Leventi)
| | - Aysegül Aksan
- Interdisziplinäres Crohn Colitis Centrum Rhein-Main, Frankfurt am Main (Karima Farrag, Krenare Ademaj, Eleni Leventi, Aysegül Aksan, Jürgen Stein).,Institute of Nutritional Science, Justus-Liebig University Giessen (Aysegül Aksan), Germany
| | - Jürgen Stein
- Gastroenterology and Clinical Nutrition, DGD Kliniken Sachsenhausen, Frankfurt am Main (Karima Farrag, Krenare Ademaj, Jürgen Stein).,Gastroenterology and Clinical Nutrition, DGD Kliniken Sachsenhausen, Frankfurt am Main (Karima Farrag, Krenare Ademaj, Jürgen Stein)
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7
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Abstract
Despite increasing use of targeted therapies to treat cancer, anemia remains a common complication of cancer therapy. Physician concerns about the safety of intravenous (IV) iron products and erythropoiesis-stimulating agents (ESAs) have resulted in many patients with cancer receiving no or suboptimal anemia therapy. In this article, we present 4 patient cases that illustrate both common and complex clinical scenarios. We first present a review of erythropoiesis and then describe our approach to cancer-associated anemia by identifying the contributing causes before selecting specific treatments. We summarize clinical trial data affirming the safety and efficacy of currently available IV iron products used to treat cancer-associated anemia and illustrate how we use commonly available laboratory tests to assess iron status during routine patient management. We compare adverse event rates associated with IV iron vs red cell transfusion and discuss using first-line IV iron monotherapy to treat anemic patients with cancer, which decreases the need for ESAs. A possible mechanism behind ESA-induced tumor progression is discussed. Finally, we review the potential of novel therapies such as ascorbic acid, prolyl hydroxylase inhibitors, activin traps, hepcidin, and bone morphogenetic protein antagonists in treating cancer-associated anemia.
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8
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Karaboyas A, Morgenstern H, Fleischer NL, Schaubel DE, Robinson BM. Replicating Randomized Trial Results with Observational Data Using the Parametric g-Formula: An Application to Intravenous Iron Treatment in Hemodialysis Patients. Clin Epidemiol 2020; 12:1249-1260. [PMID: 33204166 PMCID: PMC7667704 DOI: 10.2147/clep.s283321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/27/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Reproducibility of clinical and epidemiologic research is important to generalize findings and has increasingly been scrutinized. A recently published randomized trial, PIVOTAL, evaluated high vs low intravenous iron dosing strategies to manage anemia in hemodialysis patients in the UK. Our objective was to assess the reproducibility of the PIVOTAL trial findings using data from a well-established cohort study, the Dialysis Outcomes and Practice Patterns Study (DOPPS). METHODS To overcome the absence of randomization in the DOPPS, we applied the parametric g-formula, an extension of standardization to longitudinal data. We estimated the effect of a proactive high-dose vs reactive low-dose iron supplementation strategy on all-cause mortality (primary outcome), hemoglobin, two measures of iron concentration (ferritin and TSAT), and erythropoiesis-stimulating agent dose over 12 months of follow-up in 6325 DOPPS patients. RESULTS Comparing high- vs low-iron dose strategies, the 1-year mortality risk difference was 0.020 (95% CI: 0.008, 0.031) and risk ratio was 1.20 (95% CI: 1.07, 1.33), compared with null 1-year findings in the PIVOTAL trial. Differences in secondary outcomes were directionally consistent but of lesser magnitude than in the PIVOTAL trial. CONCLUSION Our findings are somewhat consistent with the recent PIVOTAL trial, with discrepancies potentially attributable to model misspecification and differences between the two study populations. In addition to the importance of our results to nephrologists and hence hemodialysis patients, our analysis illustrates the utility of the parametric g-formula for generalizing results and comparing complex and dynamic treatment strategies using observational data.
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Affiliation(s)
- Angelo Karaboyas
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
- University of Michigan, Department of Epidemiology, Ann Arbor, MI, USA
| | - Hal Morgenstern
- University of Michigan, Departments of Epidemiology and Environmental Health Sciences, School of Public Health, and Department of Urology, Medical School, Ann Arbor, MI, USA
| | - Nancy L Fleischer
- University of Michigan, Department of Epidemiology, Ann Arbor, MI, USA
| | - Douglas E Schaubel
- University of Michigan, Department of Biostatistics, Ann Arbor, MI, USA
- University of Pennsylvania, Department of Biostatistics, Epidemiology and Informatics, Philadelphia, PA, USA
| | - Bruce M Robinson
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA
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Chen Y, Wan J, Xia H, Li Y, Xu Y, Lin H, Iftikhar H. Total iron binding capacity (TIBC) is a potential biomarker of left ventricular remodelling for patients with iron deficiency anaemia. BMC Cardiovasc Disord 2020; 20:4. [PMID: 31914941 PMCID: PMC6947819 DOI: 10.1186/s12872-019-01320-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 12/24/2019] [Indexed: 01/21/2023] Open
Abstract
Background Preclinical studies indicate iron deficiency (ID) plays an important role in cardiac remodelling. However, the relationship between ID and cardiac remodelling remains unknown in clinical setting. This retrospective study aims to identify a potential biomarker for the myocardial remodelling in patients with ID. Due to limited patients with ID are identified without iron deficiency anaemia (IDA), we analyse the relationship of total iron binding capacity (TIBC) and the left ventricular mass index (LVMI) in patients with iron deficiency anaemia. Methods A total of 82 patients with IDA exhibiting the diagnostic criteria for IDA were enrolled in the study. Among the patients, 65 had reported LVMI values. Subsequently, these patients were divided into two groups according to abnormal LVMI (> 115 g/m2 in men and > 95 g/m2 in women). Linear bivariate analysis was performed to detect the associations of haemoglobin or TIBC with clinical and echocardiographic characteristics. Simple linear regression analysis was used to evaluate the correlation between LVMI and the parameters of IDA, while multivariable linear analysis was used to assess the association of LVMI with age, TIBC and haemoglobin. Logistic regression analysis was utilized to determine the relationship of LV remodelling with anaemia severity and TIBC. Results As compared with control group, the levels of TIBC in abnormal LVMI group are increased. Using log transformed LVMI as the dependent variable, simultaneously introducing age, TIBC, and haemoglobin into the simple linear regression or multivariable linear regression analysis confirmed the positive association among these factors. Bivariate correlation analysis reveals the irrelevance between haemoglobin and TIBC. In logistic regression analysis, TIBC is associated with the risk of LV remodelling. Conclusions Results of study indicate that TIBC exhibit an explicit association with LVMI in patients with iron deficiency anaemia. Logistic analysis further confirms the contribution of TIBC to abnormal LVMI incidence among this population with IDA.
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Affiliation(s)
- Yan Chen
- Division of Cardiology, Department of Medicine, Zhongnan Hospital, Wuhan University, Wuhan, Hubei, People's Republic of China, 430071
| | - Jing Wan
- Division of Cardiology, Department of Medicine, Zhongnan Hospital, Wuhan University, Wuhan, Hubei, People's Republic of China, 430071.
| | - Haidan Xia
- Division of Cardiology, Department of Medicine, Zhongnan Hospital, Wuhan University, Wuhan, Hubei, People's Republic of China, 430071
| | - Ya Li
- Division of Cardiology, Department of Medicine, Zhongnan Hospital, Wuhan University, Wuhan, Hubei, People's Republic of China, 430071
| | - Yufeng Xu
- Division of Hematology, Department of Medicine, Zhongnan Hospital, Wuhan University, Wuhan, Hubei, People's Republic of China, 430071
| | - Haiyan Lin
- Division of Hematology, Department of Medicine, Zhongnan Hospital, Wuhan University, Wuhan, Hubei, People's Republic of China, 430071
| | - Hassah Iftikhar
- Division of Cardiology, Department of Medicine, Zhongnan Hospital, Wuhan University, Wuhan, Hubei, People's Republic of China, 430071
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Abstract
Anemia is a common and clinically important consequence of chronic kidney disease (CKD). It is most commonly a result of decreased erythropoietin production by the kidneys and/or iron deficiency. Deciding on the appropriate treatment for anemia associated with CKD with iron replacement and erythropoietic-stimulating agents requires an ability to accurately diagnose iron-deficiency anemia. However, the diagnosis of iron-deficiency anemia in CKD patients is complicated by the relatively poor predictive ability of easily obtained routine serum iron indices (eg, ferritin and transferrin saturation) and more invasive gold standard measures of iron deficiency (eg, bone marrow iron stores) or erythropoietic response to supplemental iron. In this review, we discuss the diagnostic utility of currently used serum iron indices and emerging alternative markers of iron stores.
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11
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Nguyen LT, Buse JD, Baskin L, Sadrzadeh SH, Naugler C. Influence of diurnal variation and fasting on serum iron concentrations in a community-based population. Clin Biochem 2017; 50:1237-1242. [DOI: 10.1016/j.clinbiochem.2017.09.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 09/15/2017] [Accepted: 09/21/2017] [Indexed: 11/28/2022]
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12
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Reticulocyte and erythrocyte hypochromia markers in detection of iron deficiency in adolescent female athletes. Biol Sport 2017; 34:111-118. [PMID: 28566804 PMCID: PMC5424450 DOI: 10.5114/biolsport.2017.64584] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 07/05/2016] [Accepted: 10/12/2016] [Indexed: 11/27/2022] Open
Abstract
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.
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13
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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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Gomez S, Diawara A, Gbeha E, Awadalla P, Sanni A, Idaghdour Y, Rahimy MC. Comparative Analysis of Iron Homeostasis in Sub-Saharan African Children with Sickle Cell Disease and Their Unaffected Siblings. Front Pediatr 2016; 4:8. [PMID: 26942167 PMCID: PMC4762986 DOI: 10.3389/fped.2016.00008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/01/2016] [Indexed: 01/19/2023] Open
Abstract
Iron is an essential trace element subject to tight regulation to ensure adequate running of biological processes. In sub-Saharan Africa where hemoglobinopathies are common, iron homeostasis is likely to be impaired by these conditions. Here, we assessed and compared key serum proteins associated with iron metabolism between sub-Saharan African children with sickle cell disease (SCD) and their unaffected siblings. Complete blood counts and serum concentrations of four key proteins involved in iron regulation (ferritin, transferrin, sTfR, and hepcidin) were measured for 73 children with SCD and 68 healthy siblings in Benin, West Africa. We found significant differences in concentration of transferrin, sTfR, and ferritin between the two groups. Hepcidin concentrations were found at unusually high concentrations but did not differ among the two groups. We found a significant negative correlation between hepcidin levels and both MCH and MCV in the SCD group and report that sTfR concentrations show a correlation with MCV and MHC in opposite directions in the two groups. These results highlight the unusually high levels of hepcidin in the Beninese population and the patterns of differential iron homeostasis taking place under SCD status. These results lay the foundation for a systematic evaluation of the underlying mechanisms deregulating iron homeostasis in populations with SCD or high prevalence of iron deficiency.
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Affiliation(s)
- Selma Gomez
- Laboratoire de Biochimie et de Biologie Moléculaire, Faculté des Sciences et Techniques, University of Abomey-Calavi, Cotonou, Benin; Centre de Prise en charge Médicale Intégrée du Nourrisson et de la Femme Enceinte atteints de Drépanocytose, Faculté des Sciences de la Santé, University of Abomey-Calavi, Cotonou, Benin
| | - Aïssatou Diawara
- Biology Program, Division of Science and Mathematics, New York University Abu Dhabi , Abu Dhabi , United Arab Emirates
| | - Elias Gbeha
- Sainte-Justine Research Centre, Centre Hospitalier et Universitaire Sainte Justine , Montréal, QC , Canada
| | - Philip Awadalla
- Sainte-Justine Research Centre, Centre Hospitalier et Universitaire Sainte Justine , Montréal, QC , Canada
| | - Ambaliou Sanni
- Laboratoire de Biochimie et de Biologie Moléculaire, Faculté des Sciences et Techniques, University of Abomey-Calavi , Cotonou , Benin
| | - Youssef Idaghdour
- Biology Program, Division of Science and Mathematics, New York University Abu Dhabi , Abu Dhabi , United Arab Emirates
| | - M Cherif Rahimy
- Centre de Prise en charge Médicale Intégrée du Nourrisson et de la Femme Enceinte atteints de Drépanocytose, Faculté des Sciences de la Santé, University of Abomey-Calavi , Cotonou , Benin
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Enko D, Wagner H, Kriegshäuser G, Kimbacher C, Stolba R, Halwachs-Baumann G. Assessment of human iron status: A cross-sectional study comparing the clinical utility of different laboratory biomarkers and definitions of iron deficiency in daily practice. Clin Biochem 2015; 48:891-6. [DOI: 10.1016/j.clinbiochem.2015.05.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 05/08/2015] [Indexed: 02/07/2023]
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Cunha JD, Maselli LMF, Ferreira JDS, Spada C, Bydlowski SP. The Effects of Treatment on Serum Hepcidin and Iron Homeostasis in HIV-1-Infected In-dividuals. ACTA ACUST UNITED AC 2015. [DOI: 10.4236/wja.2015.53018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Majoni SW, Ellis JA, Hall H, Abeyaratne A, Lawton PD. Inflammation, high ferritin, and erythropoietin resistance in indigenous maintenance hemodialysis patients from the Top End of Northern Australia. Hemodial Int 2014; 18:740-50. [PMID: 24766376 DOI: 10.1111/hdi.12173] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Use of erythropoiesis-stimulating agents (ESAs) has improved the management of anemia in patients on maintenance hemodialysis (MHD). Iron deficiency and inflammation cause ESAs resistance and are both common among indigenous people of Northern Australia. As part of quality assurance in our Renal Anaemia Management program, we observed that there was use of higher doses of ESAs and adjuvant iron therapy in our MHD patients. This study aimed to explore the relationship among iron studies, inflammation, ESA responsiveness, and ESAs and iron requirements in indigenous patients on MHD from the Top End of Northern Australia. We performed a retrospective cohort analysis of anemia management in a cohort of our patients on MHD. We extracted data for 178 indigenous and 19 non-indigenous patients from 1 March 2009 to 28 February 2010 from the Renal Anaemia Management database, which collects data prospectively in MHD patients. Ninety-nine percent of the whole sample had a ferritin level above the international guidelines threshold of >500 µg/L. Indigenous patients had higher ferritin (1534 ± 245.5 µg/L vs. 1013 ± 323.3 µg/L, P = 0.002). C-reactive protein (CRP) was high in 56.9% of the total cohort. One hundred percent of those with normal CRP had high ferritin (>500 µg/L). C-reactive protein was higher in indigenous than in non-indigenous patients. Erythropoiesis-stimulating agents hyporesponsiveness was higher in indigenous patients (P < 0.0001). There was no significant difference in ESAs hyporesponsiveness among different levels of CRP (P = 0.116), ferritin (P = 0.408), and transferrin saturation (P = 0.503). Indigenous patients required higher total iron dose (2820.30 [2000-4350] vs. 2336.12 [1912-2900], P = 0.02). There was no significant relationship between the high ferritin and CRP. In indigenous dialysis patients, iron therapy and ESAs use are higher. The high iron use is due to a lack of published evidence to guide the administration of iron in patients with high ferritin. The high ferritin and ESAs resistance could not be fully explained by inflammation and need further evaluation. Further studies are required to determine the safe use of iron and management of ESAs resistance in our hemodialysis population.
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Affiliation(s)
- Sandawana William Majoni
- Department of Nephrology, Division of Medicine, Royal Darwin Hospital, Casuarina, Northern Territory, Australia; Northern Territory Clinical School, Royal Darwin Hospital Campus, Flinders University, Tiwi, Northern Territory, Australia
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Damodar S, Raghunath ST, Murthy S, Jayanthi KJ, S Latha BR. Low hemoglobin density as a measure of iron status. Indian J Hematol Blood Transfus 2014; 29:75-6. [PMID: 24426340 DOI: 10.1007/s12288-012-0162-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Accepted: 05/08/2012] [Indexed: 11/27/2022] Open
Abstract
Iron deficiency anemia is the commonest cause of anemia in the developing countries. Iron status is the result of the balance between the rate of erythropoiesis and the amount of iron stored in the body. Various biochemical parameters have been used to assess iron status such as iron levels, transferrin, transferrin saturation and ferritin, and all of them may be influenced by acute phase response and are also expensive tests 1-4. In our situation where patients cannot afford exhaustive tests to document iron deficiency we utilized the LHD values as a predictor of iron status based on the formula provided by Urrechaga 5.
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Affiliation(s)
- Sharat Damodar
- Department of Haematology, Narayana Hrudayalaya, #258/A Bommasandra Industrial Area, Anekal Taluk, Bangalore, 560099 India
| | - Sneha T Raghunath
- Department of Haematology, Narayana Hrudayalaya, #258/A Bommasandra Industrial Area, Anekal Taluk, Bangalore, 560099 India
| | - Sreedhar Murthy
- Department of Laboratory Medicine (Haematology and Biochemistry), Narayana Hrudayalaya, #258/A Bommasandra Industrial Area, Anekal Taluk, Bangalore, 560099 India
| | - K J Jayanthi
- Department of Laboratory Medicine (Haematology and Biochemistry), Narayana Hrudayalaya, #258/A Bommasandra Industrial Area, Anekal Taluk, Bangalore, 560099 India
| | - B R S Latha
- Department of Laboratory Medicine (Haematology and Biochemistry), Narayana Hrudayalaya, #258/A Bommasandra Industrial Area, Anekal Taluk, Bangalore, 560099 India
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Sedighi O, Makhlough A, Janbabai G, Neemi M. Comparative study of intravenous iron versus intravenous ascorbic Acid for treatment of functional iron deficiency in patients under hemodialysis: a randomized clinical trial. Nephrourol Mon 2013; 5:913-7. [PMID: 24350091 PMCID: PMC3842563 DOI: 10.5812/numonthly.12038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Revised: 05/30/2013] [Accepted: 06/08/2013] [Indexed: 11/21/2022] Open
Abstract
Background Functional iron deficiency (FID) may cause erythropoietin resistance in patients under hemodialysis (HD). Since the role of chronic inflammation or oxidative stress in its pathogenesis is unclear, controversy remains to whether intravenous iron or intravenous ascorbic acid (an antioxidant) can improve this anemia due to decreased iron availability. Objectives The current study compared the effect of intravenous iron versus intravenous ascorbic acid in the management of FID in HD patients. Patients and Methods Forty HD patients with hemoglobin (Hb) ≤ 11 g/dL, serum ferritin ≥ 500 ng/mL and transferrin saturation (TSAT) ≤ 25% were randomly divided into two groups. 20 patients received 100 mg of intravenous (IV) iron (group I), and 20 patients received 300 mg of IV ascorbic acid (group II) postdialysis, twice a week for 5 consecutive weeks. Hb and iron metabolism indices were measured before the onset of the study and after 12 weeks following therapy. Results Twenty one percent of all HD patients, exhibited high serum ferritin, low TSAT and sufficient data for analysis. Both Group I (n = 20) and Group II (n = 20) patients showed a significant increase in Hb, serum iron, and TSAT (P < 0.001). There were no significant differences between both groups in increasing Hb (P = 0.076), serum iron (P = 0.589), serum ferritin (0.725), and TSAT (P = 0.887). Conclusions This study showed that both IV iron and IV ascorbic acid can improve FID in HD patients. A larger randomized trial is warranted to determine the optimal management of FID in HD patients.
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Affiliation(s)
- Omid Sedighi
- Department of Nephrology, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, IR Iran
| | - Atieh Makhlough
- Molecular and Cell Biology Research Center, Department of Nephrology, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, IR Iran
- Corresponding author: Atieh Makhlough, Department of Nephrology, Molecular and Cell Biology Research Center, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, IR Iran. Tel: +98-9111510564, Fax: +98-1512261704, E-mail:
| | - Ghasem Janbabai
- Department of Oncology, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, IR Iran
| | - Mohammad Neemi
- Department of Internal Medicine, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, IR Iran
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Claes J, Ellis JAL, Rettie F, Butcher B, Bradley J. ARE C-REACTIVE PROTEIN AND FERRITIN LEVELS BEING OVERLOOKED IN INDIGENOUS AUSTRALIANS WITH CHRONIC KIDNEY DISEASE? J Ren Care 2013; 39:176-81. [DOI: 10.1111/j.1755-6686.2013.12015.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Jamin Claes
- Department of Renal Medicine; Cairns Base Hospital; Cairns; Australia
| | - Joy-Anne L. Ellis
- Royal Darwin Hospital; Tiwi, and Nightcliff Renal Unit; Nightcliff; Northern Territory; Australia
| | - Fiona Rettie
- Nightcliff Renal Unit; Nightcliff; Northern Territory; Australia
| | - Belinda Butcher
- WriteSource Medical Pty Ltd; Lane Cove; New South Wales; Australia
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Urrechaga E, Borque L, Escanero JF. Biomarkers of hypochromia: the contemporary assessment of iron status and erythropoiesis. BIOMED RESEARCH INTERNATIONAL 2013; 2013:603786. [PMID: 23555091 PMCID: PMC3600252 DOI: 10.1155/2013/603786] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 01/28/2013] [Indexed: 11/18/2022]
Abstract
Iron status is the result of the balance between the rate of erythropoiesis and the amount of the iron stores. Direct consequence of an imbalance between the erythroid marrow iron requirements and the actual supply is a reduction of red cell hemoglobin content, which causes hypochromic mature red cells and reticulocytes. The diagnosis of iron deficiency is particularly challenging in patients with acute or chronic inflammatory conditions because most of the biochemical markers for iron metabolism (serum ferritin and transferrin ) are affected by acute phase reaction. For these reasons, interest has been generated in the use of erythrocyte and reticulocyte parameters, available on the modern hematology analyzers. Reported during blood analysis routinely performed on the instrument, these parameters can assist in early detection of clinical conditions (iron deficiency, absolute, or functional; ineffective erythropoiesis, including iron restricted or thalassemia), without additional cost. Technological progress has meant that in recent years modern analyzers report new parameters that provide further information from the traditional count. Nevertheless these new parameters are exclusive of each manufacturer, and they are patented. This is an update of these new laboratory test biomarkers of hypochromia reported by different manufactures, their meaning, and clinical utility on daily practice.
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Affiliation(s)
- Eloísa Urrechaga
- Laboratory Hospital Galdakao-Usansolo, 48960 Galdakao, Biscay, Spain.
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22
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Larson DS, Coyne DW. Understanding and exploiting hepcidin as an indicator of anemia due to chronic kidney disease. Kidney Res Clin Pract 2013; 32:11-5. [PMID: 26894030 PMCID: PMC4716122 DOI: 10.1016/j.krcp.2013.01.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 12/24/2012] [Accepted: 12/28/2012] [Indexed: 12/21/2022] Open
Abstract
Hepcidin, produced by the liver, is the master regulator of iron balance. Serum hepcidin is increased by high iron stores, blocks intestinal iron absorption, and impairs storage iron release. Conversely, iron deficiency lowers hepcidin levels and enhances intestinal iron absorption and the release of storage iron. As with ferritin, hepcidin is an acute phase reactant. Consequently, inflammation increases hepcidin and leads to impaired iron absorption, lowers serum iron and transferrin saturation, and contributes to the anemia of chronic kidney disease (CKD). We review the physiology of iron absorption, its relationship to hepcidin and the transmembrane iron transporter ferroportin, the role of hepcidin in CKD related anemia, and the possible diagnostic implications and limitations of using hepcidin as a marker of iron status.
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Affiliation(s)
- Derek S Larson
- Renal Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel W Coyne
- Renal Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Halwachs-Baumann G. Diagnosis of anaemia: old things rearranged. Wien Med Wochenschr 2012; 162:478-88. [PMID: 23135251 DOI: 10.1007/s10354-012-0149-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 09/28/2012] [Indexed: 02/08/2023]
Abstract
Anaemia is one of the most leading causes of morbidity and mortality, as declared by the World Health Organisation. This syndrome is characterised by low haemoglobin levels and nonspecific clinical symptoms such as weakness, fatigue and dyspnoea. The symptoms are unspecific as the underlying causes are heterogeneous. Thus, good knowledge of the useful biomarkers and their correct assignment is needed to allow rapid and targeted diagnosis.
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Affiliation(s)
- Gabriele Halwachs-Baumann
- Department for Laboratory Medicine, Central Hospital Steyr, Sierningerstrasse 170, 4400 Steyr, Austria.
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24
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Adequacy of maternal iron status protects against behavioral, neuroanatomical, and growth deficits in fetal alcohol spectrum disorders. PLoS One 2012; 7:e47499. [PMID: 23094056 PMCID: PMC3477151 DOI: 10.1371/journal.pone.0047499] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 09/17/2012] [Indexed: 11/23/2022] Open
Abstract
Fetal alcohol spectrum disorders (FASD) are the leading non-genetic cause of neurodevelopmental disability in children. Although alcohol is clearly teratogenic, environmental factors such as gravidity and socioeconomic status significantly modify individual FASD risk despite equivalent alcohol intake. An explanation for this variability could inform FASD prevention. Here we show that the most common nutritional deficiency of pregnancy, iron deficiency without anemia (ID), is a potent and synergistic modifier of FASD risk. Using an established rat model of third trimester-equivalent binge drinking, we show that ID significantly interacts with alcohol to impair postnatal somatic growth, associative learning, and white matter formation, as compared with either insult separately. For the associative learning and myelination deficits, the ID-alcohol interaction was synergistic and the deficits persisted even after the offsprings’ iron status had normalized. Importantly, the observed deficits in the ID-alcohol animals comprise key diagnostic criteria of FASD. Other neurobehaviors were normal, showing the ID-alcohol interaction was selective and did not reflect a generalized malnutrition. Importantly ID worsened FASD outcome even though the mothers lacked overt anemia; thus diagnostics that emphasize hematological markers will not identify pregnancies at-risk. This is the first direct demonstration that, as suggested by clinical studies, maternal iron status has a unique influence upon FASD outcome. While alcohol is unquestionably teratogenic, this ID-alcohol interaction likely represents a significant portion of FASD diagnoses because ID is more common in alcohol-abusing pregnancies than generally appreciated. Iron status may also underlie the associations between FASD and parity or socioeconomic status. We propose that increased attention to normalizing maternal iron status will substantially improve FASD outcome, even if maternal alcohol abuse continues. These findings offer novel insights into how alcohol damages the developing brain.
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Urrechaga E, Borque L, Escanero JF. Erythrocyte and reticulocyte indices in the assessment of erythropoiesis activity and iron availability. Int J Lab Hematol 2012; 35:144-9. [DOI: 10.1111/ijlh.12013] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 08/10/2012] [Indexed: 11/29/2022]
Affiliation(s)
- E. Urrechaga
- Haematology Laboratory; Hospital Galdakao - Usansolo; Galdakao; Vizcaya; Spain
| | - L. Borque
- Department of Pharmacology and Physiology; Faculty of Medicine; University of Zaragoza; Zaragoza; Spain
| | - J. F. Escanero
- Department of Pharmacology and Physiology; Faculty of Medicine; University of Zaragoza; Zaragoza; Spain
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Al-Ageel NA, Al-Aqeel SA, Abanmy NO, Alwakeel JS, Sabry A, Alsaran KA. Appropriateness of anemia management in hemodialysis patients. Saudi Pharm J 2012; 20:85-91. [PMID: 23960781 DOI: 10.1016/j.jsps.2011.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 08/17/2011] [Indexed: 11/24/2022] Open
Abstract
UNLABELLED The anemia of end stage renal disease (ESRD) is common and often severe complication that can be managed successfully by erythropoiesis-stimulating agents (ESA) administration. AIMS To investigate current practice of anemia management in hemodialysis patients and to assess the appropriateness of anemia management by comparing observed practice to the Kidney Disease Outcomes Quality Initiative (KDOQI) guideline recommendations. SETTINGS AND DESIGN The study was conducted at two hemodialysis centers in Riyadh, Saudi Arabia. Data on anemia parameters, comorbidities, ESA dosing and iron supplementation were collected. The data were collected for 7 months retrospectively from April to the end of May 2008 and prospectively from June to October 2008. Patients who were over 18 years of age with ESRD undergoing hemodialysis were included. Patients were excluded if they have cancer or receiving chemotherapy or radiotherapy. RESULTS Data were collected from 87 patients. Mean Hgb value for those patients was 11.16 ± 0.97 g/dL. Thirty-nine patients (45%) had mean Hgb values between 11.0 and 12.0 g/dL the target range recommended by KDOQI guideline. The mean weekly prescribed dose of erythropoietin was 8099 ± 5946 IU/Week (135 ± 99 IU/kg/Week). Information on ferritin concentrations was available for 48 (55%) patients. The mean serum ferritin concentration for those patients was 693 ± 420.5 ng/mL. Fifty-two patients had transferrin saturation (TSAT) values recorded. The mean TSAT value was 38.5 ± 19.7%. CONCLUSIONS There is an opportunity to improve anemia management in hemodialysis patients particularly thorough evaluation of causes of inadequate response rate and better monitoring and management of iron status.
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Affiliation(s)
- Nahla A Al-Ageel
- Department of Clinical Pharmacy, King Saud University, Saudi Arabia
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Tomaszuk-Kazberuk A, Malyszko J, Bachorzewska-Gajewska H, Kozuch M, Mysliwiec M, Musial WJ. Left ventricular morphology and function in diabetic and nondiabetic hemodialyzed patients. Hemodial Int 2011; 16:259-65. [PMID: 22136420 DOI: 10.1111/j.1542-4758.2011.00646.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Morbidity in end-stage renal disease (ESRD) diabetic patients is worse than in patients without diabetes mellitus (DM). This study aims to compare clinical, laboratory, and echocardiographic features between the ESRD patients with and without DM. Fifty-eight ESRD patients on dialysis were prospectively divided into two groups according to the presence of DM. Demographic, clinical, laboratory, and echocardiographic features (ejection fraction and wall motion score index) were compared between the two groups. Overall, 20 out of 58 patients (37.8%) with ESRD had DM. There were no significant differences between the patients with DM and those without DM when it comes to age (60.6 ± 10.6 vs. 59.0 ± 10.6 years, P = 0.665), ejection fraction (52.6% ± 12.8% vs. 54.2% ± 12.8%, P = 0.59), and wall motion score index (1.21 ± 0.3 vs.1.15 ± 0.3, P = 0.37). In multivariant analysis of the interventricular septum, posterior wall thickness and left atrium size correlated positively with DM. There was also no statistical difference in myocardial perfusion disturbances on real-time contrast echocardiography between the groups with and without DM (12 (60%) patients vs. 14 patients (36.8%), P = 0.079). Among diabetics 77.8% had significant atherosclerotic changes, while in the group without DM, only 38.1%, P = 0.01. From the laboratory parameters ferritin and high-sensitivity C-reactive protein levels were significantly higher in the group with DM, P = 0.014 and P = 0.026, respectively. Patients with ESRD and DM have significantly bigger left atrial size, thicker left ventricular walls, and higher serum ferritin and high-sensitivity C-reactive protein levels than the patients without DM. The aforementioned features may be possible risk factors for the development of adverse cardiac events in patients on hemodialysis.
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28
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Urrechaga E, Unceta M, Borque L, Escanero JF. Low hemoglobin density potential marker of iron availability. Int J Lab Hematol 2011; 34:47-51. [PMID: 21722324 DOI: 10.1111/j.1751-553x.2011.01355.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Low hemoglobin density (LHD%) is a new parameter provided by Beckman-Coulter derived from the mean cell hemoglobin concentration, using the mathematical sigmoid transformation LHD% = 100×√(1-(1/(1 + e(1.8(30-MCHC)))). This study investigated the reliability of LHD% for the assessment of iron status in the presence of inflammation. METHODS Healthy subjects (n = 90) and patients with iron deficiency (IDA, n = 110), chronic kidney disease (CKD, n = 65) and anemia of chronic disease (ACD, n = 85; 24 were iron deficient and 61 were iron sufficient) were analyzed on a LH 780 analyzer (Beckman Coulter Inc., Miami, FL, USA). Independent samples U test and receiver operating characteristic (ROC) curve analysis were applied. To determine the concordance between LHD% and soluble transferrin receptor (sTrR) Cohen's κ index was calculated. RESULTS LHD % values showed no statistical difference in patients with IDA and patients with ACD accompanied with IDA (P = 0.6427); LHD% values in these patients were significantly different (P < 0.0001) compared with the iron-sufficient patients with ACD. ROC analysis for LHD% in the detection of iron deficiency showed the following: area under curve 0.903; cut off 5.5%, sensitivity 88.6%, specificity 76.9%; κ index, 0.65. CONCLUSION LHD% is a reliable parameter for the detection of iron deficiency in patients with anemia in the presence of inflammation.
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Affiliation(s)
- E Urrechaga
- Hematology Laboratory, Hospital Galdakao-Usansolo, Galdakao, Vizcaya, Spain.
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Iron Deficiency Anemia in Adult Onset Still's Disease with a Serum Ferritin of 26,387 μg/L. Anemia 2011; 2011:184748. [PMID: 21738862 PMCID: PMC3124123 DOI: 10.1155/2011/184748] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Accepted: 03/05/2011] [Indexed: 11/22/2022] Open
Abstract
Serum ferritin rises in the anemia of chronic inflammation reflecting increased iron storage and other changes mediated by inflammation. When iron deficiency coexists, the ferritin may not always decline into the subnormal range. We describe the rare interaction of iron deficiency with the extreme hyperferritinemia characteristic of adult onset Still's disease. The combination has clinical relevance and allows deductions about the presence of serum ferritin at 26,387 μg/L despite obvious iron depletion. The diagnosis of iron deficiency anemia was delayed and became fully obvious when her Still's disease remitted and serum ferritin decreased to 6.5 μg/L. The coexistence of iron deficiency should be considered when evaluating a patient with anemia of chronic inflammation even when the ferritin level is elevated several hundredfold. Further insights on ferritin metabolism in Still's disease are suggested by the likelihood that the patient's massive hyperferritinemia in the acute phase of Still's disease was almost entirely of the iron-free apoferritin form.
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Na HS, Shin SY, Hwang JY, Jeon YT, Kim CS, Do SH. Effects of intravenous iron combined with low-dose recombinant human erythropoietin on transfusion requirements in iron-deficient patients undergoing bilateral total knee replacement arthroplasty (CME). Transfusion 2011; 51:118-24. [DOI: 10.1111/j.1537-2995.2010.02783.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Elston DM. Commentary: Iron deficiency and hair loss: problems with measurement of iron. J Am Acad Dermatol 2010; 63:1077-82. [PMID: 20888066 DOI: 10.1016/j.jaad.2009.09.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Revised: 09/03/2009] [Accepted: 09/03/2009] [Indexed: 11/18/2022]
Abstract
Iron is involved in many critical physiologic processes within the hair follicle, suggesting that iron deficiency could disrupt hair synthesis. However, studies of iron as a cause of hair loss have produced conflicting results. Some of the discrepancies may relate to limitations of assays for iron deficiency. This commentary discusses the sensitivity and specificity of available tests for iron deficiency and presents practical guidelines for testing and supplementation.
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Affiliation(s)
- Dirk M Elston
- Department of Dermatology, Geisinger Medical Center, Danville, Pennsylvania 17822-5206, USA.
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Wu CJ, Lin HC, Lee KF, Chuang CK, Chen YC, Chen HH. Comparison of parenteral iron sucrose and ferric chloride during erythropoietin therapy of haemodialysis patients. Nephrology (Carlton) 2010; 15:42-7. [PMID: 20377770 DOI: 10.1111/j.1440-1797.2009.01160.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To compare the effects of i.v. iron sucrose and Fe chloride on the iron indices of haemodialysis patients with anaemia. METHODS One hundred and eight haemodialysis patients receiving recombinant human erythropoiesis-stimulating agent (ESA) (mean age 59.37 years) were enrolled and randomly assigned to an iron sucrose or an Fe chloride group. Iron supplements were administered at 100 mg/week during the first 4 weeks (loading dose). Ferritin and transferrin saturation (TSAT) were then measured and dose adjusted. Ninety-eight subjects completed treatment; 51 in the iron sucrose group and 47 in the Fe chloride group. Ferritin, TSAT, haematocrit (Hct), reticulocyte count, serum albumin, fractional clearance of urea (Kt/V) and intact parathyroid hormone (iPTH) were measured. RESULTS There was no significant difference in baseline characteristics between the groups. Significant differences between the groups were observed in both iron indices and ESA dosage. Hct at week 24 (31.1% vs 29.7%, P = 0.006) and ferritin at week 20 (731.3 vs 631.7 ng/mL, P = 0.006) in the iron sucrose group were significantly higher than in the Fe chloride group. ESA dosage used in the iron sucrose group at week 8 was significantly lower than in the Fe chloride group (244.9 vs 322.6 U/kg per month, P = 0.003), and iron sucrose group received significantly lower iron dose than the Fe chloride group at week 8 (P = 0.005). CONCLUSION Although the differences in ESA dosage, ferritin and iron dosage between two groups were found during the study period while similar results were shown at the end of 24 week study. Thus, iron sucrose and Fe chloride are safe and work equally well for haemodialysis patients.
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Affiliation(s)
- Chih-Jen Wu
- Department of Nephrology, Mackay Memorial Hospital, College of Medicine, Taipei, Taiwan
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Urrechaga E, Borque L, Escanero JF. Erythrocyte and Reticulocyte Indices on the LH 750 as Potential Markers of Functional Iron Deficiency. Anemia 2010; 2010:625919. [PMID: 21490909 PMCID: PMC3065816 DOI: 10.1155/2010/625919] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2009] [Accepted: 03/31/2010] [Indexed: 12/02/2022] Open
Abstract
Reticulocyte hemoglobin content (CHr) and percentage of hypochromic cells (%Hypo) are restricted to the Siemens analysers. The aims of the study were to investigate the correlation of Red cells size factor (RSf) and low Hemoglobin density (LHD%), reported by Beckman-Coulter analysers, with CHr and %Hypo in the assessment of iron status in the presence of inflammation. 381 samples were run on both LH 750 (Beckman-Coulter) and Advia 2120 (Siemens) analysers. Correlation between parameters were calculated and the diagnostic performance of the new parameters was assessed. Results. Correlation between RSf and CHr, r = 0.85. ROC curve analysis for RSf in the diagnosis of iron restricted erythropoiesis defined as CHr < 28 pg: AUC 0.983; Cutoff 91.1%; Sensitivity 98.8%; Specificity 89.6% Correlation between LHD% and %Hypo, r = 0.869. ROC curve analysis for LHD% in the diagnosis of iron deficiency defined by %Hypo >5%: AUC 0.954; Cut off 6.0%; Sensitivity 96.6%; Specificity 83.2% Conclusions. RSf and LHD% could be reliable parameters for the study of iron metabolism status.
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Affiliation(s)
- Eloísa Urrechaga
- Hematology Laboratory, Hospital Galdakao—Usansolo, Galdakao, 48960 Vizcaya, Spain
| | - Luís Borque
- Department of Pharmacology and Physiology, Faculty of Medicine, University of Zaragoza, Zaragoza, Spain
| | - Jesús F. Escanero
- Department of Pharmacology and Physiology, Faculty of Medicine, University of Zaragoza, Zaragoza, Spain
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Goldhaber A, Ness-Abramof R, Ellis MH. Prevalence of anemia among unselected adults with diabetes mellitus and normal serum creatinine levels. Endocr Pract 2010; 15:714-9. [PMID: 19625242 DOI: 10.4158/ep09119.orr] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine the prevalence of anemia in a cohort of patients with diabetes and normal serum creatinine concentration in a primary care clinic. METHODS We undertook a retrospective cohort study, comparing adult patients who had diabetes, with or without anemia. Patients older than 18 years who had diabetes were identified by using the computerized database for the years 2006 and 2007 in a primary care clinic. Patients with hemoglobin levels <13.7 g/dL (men <60 years old), < or =13.2 g/dL (men > or =60 years old), or <12.2 g/dL (women) with no known cause of anemia were identified and compared with patients who had diabetes but not anemia. All patients had normal serum creatinine levels (men < or =1.5 mg/dL and women < or =1.4 mg/dL). RESULTS Of 594 eligible patients with diabetes, 192 (32%) had anemia. Older age, higher serum urea and creatinine levels, lower estimated glomerular filtration rates, and reduced serum iron levels were more common in the patients with diabetes who had anemia than in those without anemia. The prevalence of anemia was higher in patients treated with "glitazones," insulin, and angiotensin receptor blockers in comparison with those receiving other orally administered hypoglycemic medications. In stepwise logistic regression analysis, only serum creatinine, age, and use of glitazones retained statistical significance. CONCLUSION In a community clinic, the prevalence of anemia in unselected patients with diabetes and normal serum creatinine levels was 32%. Factors associated with anemia were older age, higher serum creatinine levels, and use of glitazone therapy.
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Affiliation(s)
- Adiv Goldhaber
- Klalit Health Services, Family Practice, Eliezer Yafe, Ra'anana, Israel
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URRECHAGA E. The new mature red cell parameter, low haemoglobin density of the Beckman-Coulter LH750: clinical utility in the diagnosis of iron deficiency. Int J Lab Hematol 2010; 32:e144-e150. [DOI: 10.1111/j.1751-553x.2008.01127.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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37
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Doulias PT, Vlachou C, Boudouri C, Kanavaros P, Siamopoulos KC, Galaris D. Flow cytometric estimation of ‘labile iron pool’ in human white blood cells reveals a positive association with ageing. Free Radic Res 2009; 42:253-9. [DOI: 10.1080/10715760801911649] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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38
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Addeo R, Caraglia M, Del Prete S. Highlights of the Pananemia National meeting of the Italian Southern Oncological Group (GOIM): pharmacological and molecular treatment of cancer-induced anemia. Expert Opin Pharmacother 2009; 10:1089-93. [DOI: 10.1517/14656560902868159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Variability of ferritin measurements in chronic kidney disease; implications for iron management. Kidney Int 2009; 75:104-10. [DOI: 10.1038/ki.2008.526] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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40
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Rocha LA, Barreto DV, Barreto FC, Dias CB, Moysés R, Silva MRR, Moura LAR, Draibe SA, Jorgetti V, Carvalho AB, Canziani MEF. Serum ferritin level remains a reliable marker of bone marrow iron stores evaluated by histomorphometry in hemodialysis patients. Clin J Am Soc Nephrol 2009; 4:105-9. [PMID: 18842949 PMCID: PMC2615700 DOI: 10.2215/cjn.01630408] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2008] [Accepted: 08/23/2008] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES As well as being a marker of body iron stores, serum ferritin (sFerritin) has also been shown to be a marker of inflammation in hemodialysis (HD) patients. The aim of this study was to analyze whether sFerritin is a reliable marker of the iron stores present in bone marrow of HD patients. DESIGN Histomorphometric analysis of stored transiliac bone biopsies was used to assess iron stores by determining the number of iron-stained cells per square millimeter of bone marrow. RESULTS In 96 patients, the laboratory parameters were hemoglobin = 11.3 +/- 1.6 g/dl, hematocrit = 34.3 +/- 5%, sFerritin = 609 +/- 305 ng/ml, transferrin saturation = 32.7 +/- 22.5%, and C-reactive protein (CRP) = 0.9 +/- 1.4 mg/dl. sFerritin correlated significantly with CRP, bone marrow iron, and time on HD treatment (P = 0.006, 0.001, and 0.048, respectively). The independent determinants of sFerritin were CRP (beta-coef = 0.26; 95% CI = 24.6 to 132.3) and bone marrow iron (beta-coef = 0.32; 95% CI = 0.54 to 2.09). Bone marrow iron was higher in patients with sFerritin >500 ng/ml than in those with sFerritin < or =500 ng/ml. In the group of patients with sFerritin < or =500 ng/ml, the independent determinant of sFerritin was bone marrow iron (beta-coef = 0.48, 95% CI = 0.48 to 1.78), but in the group of patients with sFerritin >500 ng/ml, no independent determinant of sFerritin was found. CONCLUSIONS sFerritin adequately reflects iron stores in bone marrow of HD patients.
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Affiliation(s)
- Lillian A Rocha
- Division of Nephrology, Department of Internal Medicine, Federal University of São Paulo, São Paulo, SP, Brazil
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41
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Knovich MA, Storey JA, Coffman LG, Torti SV, Torti FM. Ferritin for the clinician. Blood Rev 2008; 23:95-104. [PMID: 18835072 DOI: 10.1016/j.blre.2008.08.001] [Citation(s) in RCA: 362] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Ferritin, a major iron storage protein, is essential to iron homeostasis and is involved in a wide range of physiologic and pathologic processes. In clinical medicine, ferritin is predominantly utilized as a serum marker of total body iron stores. In cases of iron deficiency and overload, serum ferritin serves a critical role in both diagnosis and management. Elevated serum and tissue ferritin are linked to coronary artery disease, malignancy, and poor outcomes following stem cell transplantation. Ferritin is directly implicated in less common but potentially devastating human diseases including sideroblastic anemias, neurodegenerative disorders, and hemophagocytic syndrome. Additionally, recent research describes novel functions of ferritin independent of iron storage.
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Affiliation(s)
- Mary Ann Knovich
- Section on Hematology and Oncology, Wake Forest University Health Sciences, Winston-Salem, NC 27157-1082, USA.
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42
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Coyne DW, Trout JR, Kapoian T. Comment on "Does ferric gluconate lower epoetin requirements in hemodialysis patients with high ferritin levels?". NATURE CLINICAL PRACTICE. NEPHROLOGY 2008; 4:E1-E2. [PMID: 18818660 DOI: 10.1038/ncpneph0965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Accepted: 09/04/2008] [Indexed: 05/26/2023]
Affiliation(s)
- Daniel W Coyne
- Washington University School of Medicine, St Louis, MO 63110, USA.
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43
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Silverstein SB, Gilreath JA, Rodgers GM. Intravenous Iron Therapy: A Summary of Treatment Options and Review of Guidelines. J Pharm Pract 2008. [DOI: 10.1177/0897190008318916] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Iron replacement for iron-deficiency anemia has historically been accomplished with the use of oral iron therapy. Although oral iron is appropriate for most iron-deficiency anemia patients, many patients do not respond to or may be intolerant of oral iron, or may experience bleeding of sufficient magnitude to require higher iron doses than that achievable with oral iron. Intravenous iron therapy is a useful option for these latter patients. Three intravenous iron products are recommended: low-molecular weight iron dextran (INFeD), ferric gluconate (Ferrlecit), and iron sucrose (Venofer). These intravenous iron products have superior safety profiles compared to high-molecular weight iron dextran. The Food and Drug Administration's approval of erythropoietic-stimulating agents to treat certain types of anemia has increased usage of intravenous iron for functional iron deficiency. This review summarizes the current status of intravenous iron products and discusses their advantages and disadvantages in treating both absolute and functional iron deficiency.
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Affiliation(s)
- Scott B. Silverstein
- Department of Pharmacy Services, Huntsman Cancer Hospital, University of Utah Hospitals and Clinics, Salt Lake City, Utah,
| | - Jeffrey A. Gilreath
- Department of Pharmacy Services, Huntsman Cancer Hospital, University of Utah Hospitals and Clinics, Salt Lake City, Utah
| | - George M. Rodgers
- Departments of Medicine and Pathology, Huntsman Cancer Institute, University of Utah Health Sciences Center, Salt Lake City, Utah
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Katodritou E, Zervas K, Terpos E, Brugnara C. Use of erythropoiesis stimulating agents and intravenous iron for cancer and treatment-related anaemia: the need for predictors and indicators of effectiveness has not abated. Br J Haematol 2008; 142:3-10. [DOI: 10.1111/j.1365-2141.2008.07163.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
A growing body of literature supports the use of intravenous iron as a compliment to erythropoiesis stimulatory therapy and in a significant number of disease states where iron is necessary and oral iron is ineffective or not tolerated. The differences in efficacy, safety, and clinical nature of serious adverse events that occur with the various iron preparations are poorly understood. Misinterpretation of adverse events leads to underutilization of this important treatment modality. Understanding the history of the development and use of intravenous iron is crucial to appreciate its importance in the management of anemias of dialysis, cancer, and cancer chemotherapy and properly assess side effects and toxicity. The benefits seen with intravenous iron therapy are independent of the pretreatment levels of serum ferritin, iron, total iron binding capacity, and percent transferrin saturation. Intravenous iron has been shown to overcome hepcidin induced iron restricted erythropoiesis in iron-replete patients. Available clinical and experimental data suggest that increased utilization of intravenous iron should be considered.
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Affiliation(s)
- Michael Auerbach
- Division of Hematology and Oncology, Private Practice Baltimore Maryland, Clinical Professor of Medicine, Georgetown University School of Medicine, Washington, DC, USA.
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46
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Katodritou E, Verrou E, Zervas K. Intravenous iron: a useful therapeutic tool but not a panacea. Am J Hematol 2008; 83:521-3. [PMID: 18506701 DOI: 10.1002/ajh.21189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
Chronic kidney disease may result in complete kidney failure and contribute to many other health issues. Anemia is a logical consequence of the disease because the kidneys are the primary source of erythropoietin, the hormone that acts to stimulate red blood cell production in the bone marrow. All patients with chronic kidney disease are at risk for anemia, and treating anemia is extremely important to their health and well-being. Preventing or reversing the effects of anemia on the heart may decrease morbidity and mortality and improve quality of life. Many patients fail to receive treatment for anemia before requiring renal replacement therapy for end-stage renal disease. Pharmacists can play a vital role in screening, evaluating, designing proper treatment regimens, and monitoring patients with anemia of chronic kidney disease. Current recommendations regarding anemia are reviewed, including evaluation, pharmacotherapeutic agents, monitoring parameters, and goals of therapy.
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Affiliation(s)
- Sarah Tomasello
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Department of Pharmacy Practice, Piscataway, New Jersey,
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48
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Amato M, Pacini S, Aterini S, Punzi T, Gulisano M, Ruggiero M. Iron indices and vitamin D receptor polymorphisms in hemodialysis patients. Adv Chronic Kidney Dis 2008; 15:186-90. [PMID: 18334245 DOI: 10.1053/j.ackd.2008.01.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Cardiovascular disease caused by accelerated atherosclerosis is the major determinant of morbidity and mortality in chronic kidney disease patients. Vitamin D and its analogs provide survival benefit for hemodialysis (HD) patients. Vitamin D exerts its effects through the vitamin D receptor (VDR) that is coded for by a gene showing several polymorphisms that, in turn, are associated with a variety of diseases and differential responses to vitamin D. In this study, we evaluated the association between 4 VDR polymorphisms (ie, those identified by the restriction enzymes BsmI, ApaI, TaqI, and FokI) and iron indices (serum iron, transferrin, transferrin saturation, and ferritin) in 88 hemodialysis patients routinely treated with vitamin D. The absence or presence of the BsmI, ApaI, TaqI, and FokI restriction sites were denominated B and b, A and a, T and t, F and f, respectively. Our results show that in HD patients with transferrin saturation <20%, the F allele was more frequent than in HD patients with transferrin saturation >20% (P = .03). This relationship may provide a link between VDR alleles and iron and nutritional markers, which are highly predictive variables of cardiovascular morbidity and mortality in hemodialysis patients.
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Nybo M, Benn M, Mogelvang R, Jensen JS, Schnohr P, Rehfeld JF, Goetze JP. Impact of Hemoglobin on Plasma Pro-B-Type Natriuretic Peptide Concentrations in the General Population. Clin Chem 2007; 53:1921-7. [PMID: 17872941 DOI: 10.1373/clinchem.2007.089391] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractBackground: Age, sex, and renal function contribute to variations in plasma concentrations of B-type natriuretic peptide (BNP) and its molecular precursor (proBNP). Recent studies indicate that anemia may also affect proBNP concentrations in patients with heart failure or stroke. However, the impact of hemoglobin status on proBNP concentrations has not been established in the general population.Methods: In the 4th examination in the Copenhagen City Heart Study, we performed a nested case-control study of 6238 individuals from a Danish general population. Of these, 3497 randomly selected participants also underwent an echocardiographic examination. The population was stratified into groups depending on health and hemoglobin status. Correlations between hemoglobin and proBNP concentrations were examined by simple and multiple regression analyses, adjusted for variables known to influence the proBNP plasma concentration.Results: The mean proBNP concentration was increased 1.7-fold in the group with anemia vs the nonanemic group [mean (SD) 42 (45) pmol/L vs 25 (29) pmol/L, P <0.0001, n = 5892]. Multiple regression analysis confirmed an independent effect of hemoglobin on proBNP concentrations. In a selected subgroup without signs or symptoms of heart disease (n = 2855), lower hemoglobin concentrations, defined as <120 g/L in women and <130 g/L in men, were associated with increased circulating proBNP concentrations, but the contribution to the overall variation in proBNP concentrations was modest.Conclusions: Because moderate anemia is associated with a 1.7-fold increase in proBNP concentrations, hemoglobin concentrations should be taken into consideration in patients with nonspecific symptoms of heart disease and increased proBNP concentrations.
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Affiliation(s)
- Mads Nybo
- Department of Clinical Biochemistry, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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50
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Singh AK, Coyne DW, Shapiro W, Rizkala AR. Predictors of the response to treatment in anemic hemodialysis patients with high serum ferritin and low transferrin saturation. Kidney Int 2007; 71:1163-71. [PMID: 17396118 DOI: 10.1038/sj.ki.5002223] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Treating hemodialysis patients to combat anemia corrects hemoglobin but exacerbates iron deficiency by utilizing iron stores. Patients needing iron should receive this by intravenous (i.v.) means. The Dialysis patients' Response to IV iron with Elevated ferritin (DRIVE) trial investigated the role of i.v. iron in anemic patients with high ferritin, low transferrin saturation, and adequate epoetin doses. We examined whether baseline iron and inflammation markers predict the response of hemoglobin to treatment. Patients (134) were randomized to no added iron or to i.v. ferric gluconate for eight consecutive hemodialysis sessions spanning 6 weeks with epoetin increased by 25% in both groups. The patients started with hemoglobin less than or equal to 11 g/dl, ferritin between 500 and 1200 ng/ml, and transferrin saturation of less than 25%. Significantly, patients with a reticulocyte hemoglobin content greater than or equal to 31.2 pg were over five times more likely to achieve a clinically significant increase in hemoglobin of greater than 2 g/dl. Lower reticulocyte hemoglobin contents did not preclude a response to i.v. iron. Significantly higher transferrin saturation or lower C-reactive protein but not ferritin or soluble transferrin receptor levels predicted a greater response; however their influence was not clinically significant in either group. We conclude that none of the studied markers is a good predictor of response to anemia treatment in this patient sub-population.
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Affiliation(s)
- A K Singh
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
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