Ascertainment of iron deficiency and depletion in blood donors through screening questions for pica and restless legs syndrome

Iron deficiency-related symptoms in non-anemic whole blood donors

INTRODUCTION

Whole blood donors are at increased risk for iron deficiency (ID). ID anemia is associated with several symptoms, such as fatigue, cognitive dysfunction, pica, and restless leg syndrome (RLS). However, it is unclear if these symptoms also occur when a donor has developed ID without anemia. This study aims to determine whether non-anemic ID (NAID) is associated with the occurrence of ID-related symptoms.

STUDY DESIGNS AND METHODS

We combined data from three studies in whole blood donors (i.e., Donor Insight-III, FIND'EM, and FORTE) to create a substantial sample size (N = 12,143). The self-reported occurrence and severity of ID-related symptoms, such as physical and mental health, fatigue, cognitive functioning, pica, and RLS, was measured using validated questionnaires. Associations were studied using logistic regression modeling with ID-related symptoms derived from the questionnaires as the dependent variable and ferritin level group (0-15 μg/L, 15-30 μg/L, and >30 μg/L) as explanatory variable.

RESULTS

After applying inclusion and exclusion criteria, 9829 donors were eligible for analysis. In the models corrected for age, body mass index, Hb level, and cohort, only fatigue was shown to be associated with ferritin levels in men, showing lower odds (OR 1.41, 95% CI 1.11-1.79) for fatigue with higher ferritin levels.

CONCLUSION

In these studies, NAID was only associated with self-reported fatigue in male donors. Although selection bias may have led to underestimated associations, ferritin measurements in donors should be primarily considered as a measure to prevent anemia, rather than to prevent or mitigate NAID-related symptoms.

Analysis of erythrocyte and iron study data among plateletpheresis donors in Hangzhou, China

BACKGROUND

The purpose of this study is to obtain the iron parameters level of blood donors and the population who need to pay attention to iron parameters level in this area.

METHODS

A total of 993 plateletpheresis donors were included in this study, including 798 males and 195 females. The results of erythrocyte and iron parameters of blood donors were compared and analyzed in different groups according to the gender, age and number of blood donations.

RESULT

The proportion of men and women with low serum ferritin (SF) levels was 10.8 % and 27.7 %, respectively. The mean levels of serum iron (SI), SF, transferrin saturation (Tfs), hemoglobin (Hb) and hematocrit (HCT) of male blood donors decreased with the increase of age groups, but there was no significant statistical difference between the results of female blood donors. The level of SI, SF, Tfs, Hb and HCT of male donors decreased with the increase of blood donations in the past year, while TRF and TIBC increased. The level of Hb, HCT and SF of female donors showed no significant downward trend, while the levels of TRF increased with increasing donations in the past year, excluding first-time donors. The SI of female donors trended down, and TIBC trended up with increasing donations.

CONCLUSION

Blood collection institutions need to focus on iron parameters levels in older and frequent male donors, and young fertile female donors.

Surviving Critical Low Hemoglobin Levels and Pica

Iron deficiency is the most common nutritional deficiency. Pica is commonly associated with iron deficiency anemia (IDA). A case of a 40-year-old female who presented with a critical record of low hemoglobin (Hgb) (1.6 g/dL) with severe iron deficiency and pica with no lasting deficits despite such low hemoglobin is discussed in this article. The patient presented to the emergency room with complaints of weight loss, weakness, palpitation, fatigue, dysphagia, and on-and-off vomiting for about a year and severe menorrhagia for about one and a half years. She also has had pica for the past several years where she eats and chews toilet paper. Several of her female family members also have pica. She was found to have critically low hemoglobin of 1.6 g/dL and serum iron of 8 ug/dL and ferritin of less than 1 ng/mL. The patient was treated with six units of packed red blood cells and IV and oral iron supplementation. She was discharged with a hemoglobin of 7.3 g/dL. She was later found to have a 9.6 cm uterine mass that is consistent with leiomyoma (fibroid) in transvaginal ultrasound and is following up with a gynecologist for the definitive management. She did not have lasting deficits from the critically low hemoglobin and has stopped engaging in pica behavior.

A multivariate analysis of the risk of iron deficiency in plateletpheresis donors based on logistic regression

BACKGROUND

The purpose of this study was to analyze the application of individual factors, blood cell related indicators, and blood donation frequency in predicting the risk of iron deficiency of plateletpheresis donors.

METHODS

A total of 801 plateletpheresis donors were included in this study. The relationship between risk factors and iron deficiency was retrospectively analyzed by univariate analysis and logistic regression analysis. The application of Hb, MCHC, RDW-CV and blood donation frequency combined prediction of iron deficiency risk among plateletpheresis donors was evaluated.

RESULT

The rate of iron deficiency in this study was 31.5 % (241/766). The age, gender (the ratio of male donors), red blood cell related indicators, blood donation frequency were statistically different between the normal and iron deficiency group (all P < 0.05). Age, gender, the reciprocal of Hb and MCHC, RDW-CV, total number of blood donation and number of plateletpheresis donation in the past year, these indicators to predict the risk of iron deficiency area under the curve (AUC) were 0.558, 0.672, 0.785, 0.717, 0.599, 0.621, 0.646, respectively. The AUC of these indicators combined to predict the risk of iron deficiency was 0.877, higher than all single indicators. The sensitivity and specificity of these indicators combined in prediction of iron deficiency were 88.89 % and 81.57 %, respectively.

CONCLUSION

Age, gender, the reciprocal of Hb and MCHC, RDV-CV, blood donation frequency are associated with the risk of iron deficiency in plateletpheresis donors. The combination of these indicators has high value in predicting the risk of iron deficiency.

Iron Deficiency and Blood Donation: Links, Risks and Management

The purpose of this review is to raise awareness about the frequently underappreciated association of blood donation with iron deficiency, and to describe methods for its prevention and management. Blood donors cannot expect any health benefits from the donation but have justified expectations of no harm. Iron deficiency without anemia (IDWA) and iron deficiency anemia (IDA) are common consequences of regular blood donation, and this activity is the most important factor affecting iron status in regular blood donors. Awareness of blood donation as a primary cause of sideropenia is surprisingly low among physicians. Blood donation screening identifies potential donors with IDA but is frequently inadequate to detect IDWA. For the assessment of body iron stores, plasma or serum ferritin, transferrin saturation (TSAT) and soluble transferrin receptors (sTfR) concentrations are the most widely used biochemical markers, although the percentage of hypochromic mature erythrocytes and the hemoglobin content of reticulocytes are also useful. IDWA can be prevented by limiting the total volume of blood collected, by iron deficiency screening and deferral of sideropenic donors, by prolonging the interdonation intervals, and by iron supplementation between donations. IDWA tends to be more prevalent in younger people, females, and high-intensity donors. A potentially effective strategy to address sideropenia in blood donors is serum ferritin testing, but this may lead to a higher rate of deferral. Most regular blood donors cannot replenish their iron deficit by an iron-rich diet alone and will benefit from low-dose oral iron administration with various commercially available products post-donation, a well-tolerated strategy. However, valid concerns exist regarding the possibility of worsening the iron overload in donors with undiagnosed hemochromatosis or masking the symptoms of a clinically important gastrointestinal hemorrhage or other underlying medical condition. Finally, educational efforts should be intensified to improve the awareness of blood donation as a primary cause of iron deficiency among physicians of all specialties.

The incidence, complications, and treatment of iron deficiency in pregnancy

Iron deficiency and/or iron deficiency anemia (IDA) complicate nearly 50% of pregnancies globally, negatively impacting both maternal and fetal outcomes. Iron deficiency can cause a range of symptoms that range from aggravating to debilitating including fatigue, poor quality of life, pagophagia, and restless leg syndrome. Iron deficiency and IDA are also associated with maternal complications including preterm labor, increased rates of cesarean delivery, postpartum hemorrhage, and maternal death. Fetal complications include increased rates of low birth weight and small for gestational age newborns. Prenatal maternal anemia has also been associated with autism spectrum disorders in the neonate, although causation is not established. Deficiency in the newborn is associated with compromised memory, processing, and bonding, with some of these deficits persisting into adulthood. Despite the prevalence and consequences associated with iron deficiency in pregnancy, data show that it is routinely undertreated. Due to the physiologic changes of pregnancy, all pregnant individuals should receive oral iron supplementation. However, the bioavailability of oral iron is poor and it is often ineffective at preventing and treating iron deficiency. Likewise, it frequently causes gastrointestinal symptoms that can worsen the quality of life in pregnancy. Intravenous iron formulations administered in a single or multiple dose series are now available. There is increasing data suggesting that newer intravenous formulations are safe and effective in the second and third trimesters and should be strongly considered in pregnant individuals without optimal response to oral iron repletion.

Iron status of blood donors

PURPOSE OF REVIEW

This review examines recent research on the prevalence and importance of iron deficiency in blood donors, and on efforts to mitigate it.

RECENT FINDINGS

Premenopausal females, teenagers, and high-frequency donors are at the highest risk for donation-induced iron deficiency, in both high-resource and low-resource settings. The physiology relating iron stores to hemoglobin levels and low hemoglobin deferral is well elucidated in blood donor populations, yet the clinical effects attributable to iron loss in the absence of anemia are challenging to identify. Expanded adoption of ferritin testing is improving donor management but may cause decreases in the blood supply from temporary donor loss. The potential for personalized donor management is emerging with development of computational models that predict individual interdonation intervals that aim to optimize blood collected from each donor while minimizing low hemoglobin deferrals.

SUMMARY

Measures to reduce iron deficiency are available that can be deployed on a standardized or, increasingly, personalized basis. Blood centers, regulators, and donors should continue to evaluate different tactics for addressing this problem, to obtain a balanced approach that is optimal for maintaining adequate collections while safeguarding donor health.

Ferritin Trajectories over Repeated Whole Blood Donations: Results from the FIND+ Study

BACKGROUND

Depending on post-donation erythropoiesis, available iron stores, and iron absorption rates, optimal donation intervals may differ between donors. This project aims to define subpopulations of donors with different ferritin trajectories over repeated donations.

METHODS

Ferritin levels of 300 new whole blood donors were measured from stored (lookback) samples from each donation over two years in an observational cohort study. Latent classes of ferritin level trajectories were investigated separately using growth mixture models for male and female donors. General linear mixed models assessed associations of ferritin levels with subsequent iron deficiency and/or low hemoglobin.

RESULTS

Two groups of donors were identified using group-based trajectory modeling in both genders. Ferritin levels showed rather linear reductions among 42.9% of male donors and 87.7% of female donors. For the remaining groups of donors, steeper declines in ferritin levels were observed. Ferritin levels at baseline and the end of follow-up varied greatly between groups.

CONCLUSIONS

Repeated ferritin measurements show depleting iron stores in all-new whole blood donors, the level at which mainly depends on baseline ferritin levels. Tailored, less intensive donation strategies might help to prevent low iron in donors, and could be supported with ferritin monitoring and/or iron supplementation.

Daily versus every other day oral iron supplementation in patients with iron deficiency anemia (DEODO): study protocol for a phase 3 multicentered, pragmatic, open-label, pilot randomized controlled trial

BACKGROUND

Iron deficiency anemia (IDA) accounts for the majority of anemia cases across the globe and can lead to impairments in both physical and cognitive functioning. Oral iron supplementation is the first line of treatment to improve the hemoglobin level for IDA patients. However, gaps still exist in understanding the appropriate dosing regimen of oral iron. The current trial proposes to evaluate the feasibility of performing this study to examine the effectiveness and side-effect profile of oral iron once daily versus every other day.

METHODS

In this open-label, pilot, feasibility, randomized controlled trial, 52 outpatients over 16 years of age with IDA (defined as hemoglobin < 12.0 g/dL in females and < 13.0 g/dL in males and ferritin < 30 mcg/L) will be enrolled across two large academic hospitals. Participants are randomized in a 1:1 ratio to receive 300 mg oral ferrous sulfate (60 mg of elemental iron) either every day or every other day for 12 weeks. Participants are excluded if they are as follows: (1) pregnant and/or currently breastfeeding, (2) have a disease history that would impair response to oral iron (e.g., thalassemia, celiac disease), (3) intolerant and/or have an allergy to oral iron or vitamin C, (4) on new anticoagulants in the past 6 months, (5) received IV iron therapy in the past 12 weeks, (6) have surgery, chemotherapy, or blood donation planned in upcoming 12 weeks, (7) a creatinine clearance < 30 mL/min, or (8) hemoglobin less than 8.0 g/dL with active bleeding. The primary outcome is feasibility to enroll 52 participants in this trial over a 2-year period to determine the effectiveness of daily versus every other day oral iron supplementation on hemoglobin at 12 weeks post-initiation and side-effect profile.

DISCUSSION

The results of this trial will provide additional evidence for an appropriate dosing schedule for treating patients with IDA with oral iron supplementation. Additional knowledge will be gained on how the dosing regimen of oral iron impacts quality of life and hemoglobin repletion in IDA patients. If this trial is deemed feasible, it will inform the development and implementation of a larger multicenter definitive trial.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03725384 . Registered 31 October 2018.

The prevalence and clinical characteristics of restless legs syndrome in patients with iron deficiency anemia in Korea

STUDY OBJECTIVES

While the prevalence and clinical characteristics of restless legs syndrome (RLS) are known to vary according to ethnicity, a detailed evaluation of this condition among patients with iron deficiency anemia (IDA) has not yet been reported in an Asian population. We investigated the prevalence and clinical characteristics of RLS in patients with IDA in Korea compared with age- and sex-matched patients diagnosed with idiopathic RLS.

METHODS

This prospective single-center study was performed at a regional university hospital. Consecutive patients with IDA were enrolled over a 4-year period. Clinical interviews and laboratory tests were conducted at the first visit. RLS diagnosis was confirmed through face-to-face interviews. We randomly selected patients with idiopathic RLS without comorbid medical disorders from our sleep center dataset as control patients. The clinical characteristics of both groups were compared.

RESULTS

We enrolled 124 patients with IDA. Fifty (40.3%) patients were diagnosed with RLS, with 82% exhibiting severe to very severe symptoms. Patients with IDA and RLS were older and reported more sleep deterioration than patients with IDA without RLS. Patients with IDA and RLS also had a more depressed mood and higher periodic limb movement index scores than patients with idiopathic RLS.

CONCLUSIONS

The prevalence of RLS among patients with IDA in Korea was high, with the majority having severe to very severe symptoms. Patients with IDA and RLS had poorer sleep quality and more emotional problems than patients with IDA without RLS. Therefore, patients with IDA should be screened for RLS to prevent adverse effects on the quality of sleep and life.

Association of proton pump inhibitor and histamine H2-receptor antagonists with restless legs syndrome

Restless legs syndrome (RLS) is a common sensorimotor disorder, which can disrupt sleep and is thought to be caused in part by low cellular iron stores. Proton pump inhibitors (PPI) and histamine H₂-receptor antagonists (H₂A) are among the most commonly used drugs worldwide and show evidence of causing iron deficiency. We conducted a case/non-case observational study of blood donors in the United States (N = 13,403; REDS-III) and Denmark (N = 50,323; Danish Blood Donor Study, DBDS), both of which had complete blood count measures and a completed RLS assessment via the Cambridge–Hopkins RLS questionnaire. After adjusting for age, sex, race, BMI, blood donation frequency, smoking, hormone use, and iron supplement use, PPI/H₂A use was associated with RLS (odds ratio [OR] = 1.41; 95% confidence interval [CI], 1.13–1.76; p = 0.002) in REDS-III for both PPI (OR = 1.43; CI, 1.03–1.95; p = 0.03) and H₂A (OR = 1.56; CI, 1.10–2.16; p = 0.01). DBDS exhibited a similar association with PPIs/H₂As (OR = 1.29; CI, 1.20–1.40; p < 0.001), and for PPIs alone (OR = 1.27; CI, 1.17–1.38; p < 0.001), but not H₂As alone (OR = 1.18; CI, 0.92–1.53; p = 0.2). We found no evidence of blood iron stores mediating this association. The association of PPI, and possibly H₂A, consumption with RLS independent of blood iron status and other factors which contribute to RLS risk suggest the need to re-evaluate use of PPI/H₂A in populations at particular risk for RLS.

The benefits of iron supplementation following blood donation vary with baseline iron status

Whole blood donation rapidly removes approximately 10% of a donor's blood volume and stimulates substantial changes in iron metabolism and erythropoiesis. We sought to identify donors who benefit from iron supplementation, describe the nature of the benefit, and define the time course for recovery from donation. Blood samples were collected over 24 weeks following whole blood donation from 193 participants, with 96 participants randomized to 37.5 mg daily oral iron. Changes in total body, red blood cell (RBC), and storage iron, hepcidin, erythropoietin, and reticulocyte count were modeled using semiparametric curves in a mixed model. and the changes were compared among six groups defined by baseline ferritin (<12; 12-50; ≥50 ng/mL) and iron supplementation. The effect of oral iron on storage and RBC iron recovery was minimal in donors with baseline ferritin ≥50 ng/mL, but sizeable when ferritin was <50 ng/mL. Iron initially absorbed went to RBC and storage iron pools when ferritin was <12 ng/mL but went mostly to RBCs when ferritin was ≥12 ng/mL. Donors with ferritin ≥12 ng/mL had a "ripple" increase in reticulocytes ~100 days after donation indicating physiological responses occur months following donation. Thus, iron supplements markedly enhance recovery from whole blood donation in donors with ferritin <50 ng/mL. However, full recovery from donation requires over 100 days when taking iron. The findings also highlight the value of the study of blood donors for understanding human hemoglobin and iron metabolism and their usefulness for future studies as additional biomarkers are discovered.

The Effect of Parenteral or Oral Iron Supplementation on Fatigue, Sleep, Quality of Life and Restless Legs Syndrome in Iron-Deficient Blood Donors: A Secondary Analysis of the IronWoMan RCT

Background: Besides anemia, iron deficiency may cause more subtle symptoms, including the restless legs syndrome (RLS), the chronic fatigue syndrome (CFS) or sleeping disorders. Objective: The aim of this pre-planned secondary analysis of the IronWoMan randomized controlled trial (RCT) was to compare the frequency and severity of symptoms associated with iron deficiency before and after (intravenous or oral) iron supplementation in iron deficient blood donors. Methods/Design: Prospective, randomized, controlled, single-centre trial. (ClinicalTrials.gov: NCT01787526). Setting: Tertiary care center in Graz, Austria. Participants: 176 (138 female and 38 male) whole-blood and platelet apheresis donors aged ≥ 18 and ≤ 65 years with iron deficiency (ferritin ≤ 30ng/mL at the time of blood donation). Interventions: Intravenous iron (1 g ferric carboxymaltose, n = 86) or oral iron supplementation (10 g iron fumarate, 100 capsules, n = 90). Measurements: Clinical symptoms were evaluated by a survey before iron therapy (visit 0, V0) and after 8–12 weeks (visit 1, V1), including questions about symptoms of restless legs syndrome (RLS), chronic fatigue syndrome (CFS), sleeping disorders, quality of life and symptoms like headaches, dyspnoea, dizziness, palpitations, pica and trophic changes in fingernails or hair. Results: We found a significant improvement in the severity of symptoms for RLS, fatigue and sleep quality (p < 0.001). Furthermore, a significant decrease in headaches, dyspnoea, dizziness and palpitations was reported (p < 0.05). There was no difference between the type of iron supplementation (intravenous versus oral) and clinical outcome data. Conclusion: Iron supplementation in iron-deficient blood donors may be an effective strategy to improve symptoms related to iron deficiency and the wellbeing of blood donors.

Iron Depletion in Adult and Teenage Blood Donors: Prevalence, Clinical Impact, and Options for Mitigation

Iron depletion is a known risk for adult blood donors, but recent studies indicate the prevalence of iron depletion is higher in teenage blood donors. Teenage donors account for more than 10% of the blood collected in the United States and are important for maintaining component availability. Evidence of harm from iron depletion has not been demonstrated, but the area would benefit from further scientific inquiry. Options to protect against iron depletion exist, but each has limitations including cost, logistics, and potential negative impact on blood supply. Blood centers should communicate with donors and make efforts to mitigate these risks.

Association of blood donation with iron deficiency among adolescent and adult females in the United States: a nationally representative study

BACKGROUND

Blood donation results in a loss of iron stores, which is particularly concerning for young female blood donors. This study examines the association of blood donation and iron deficiency among adolescent and adult females in the United States.

STUDY DESIGN AND METHODS

A cross-sectional analysis was performed using data from the 1999-2010 National Health and Nutrition Examination Survey (NHANES). Females who reported their blood donation history in the preceding year and had serum ferritin (SF) measurements were included. Analyses were weighted and stratified by adolescents (16-19 years; n = 2419) and adults (20-49 years; n = 7228). Adjusted prevalence ratios (aPRs) were estimated by multivariable Poisson regression. Standard errors were estimated by Taylor series linearization.

RESULTS

Geometric mean SF levels (ng/mL) were lower in blood donors compared to nondonors among adolescents (21.2 vs. 31.4; p < 0.001) and among adults (26.2 vs. 43.7; p < 0.001). The prevalence of absent iron stores (SF < 12 ng/mL) was higher in blood donors compared to nondonors among adolescents (22.6% vs. 12.2%; aPR = 2.03 [95% confidence interval (CI) = 1.45-2.85]) and among adults (18.3% vs. 9.8%; aPR = 2.06 [95% CI = 1.48-2.88]). Additionally, the prevalence of iron deficiency anemia (SF < 26 ng/mL and hemoglobin < 12.0 g/dL) was also higher in blood donors compared to nondonors among adolescents (9.5% vs. 6.1%; aPR = 2.10 [95% CI = 1.13-3.90]) and among adults (7.9% vs. 6.1%; aPR = 1.74 [95% CI = 1.06-2.85]). Similar results were observed in a sensitivity analysis restricted to adolescents aged 16 to 18 years.

CONCLUSIONS

Blood donation is associated with iron deficiency among adolescent and adult females in the United States. These national data call for further development and implementation of blood donation practices aimed toward mitigating iron deficiency.

Circulating plasma microRNAs as biomarkers for iron status in blood donors

OBJECTIVES

To investigate whether microRNAs can serve as biomarkers for iron status in blood donors.

BACKGROUND

Serum ferritin is a widely used biochemical test for detecting iron deficiency, but it has its limitations. Certain microRNAs (miRNAs) reportedly have a role in regulating iron homeostasis. Circulating miRNAs have been reported as potential biomarkers for various conditions but have not yet been studied in iron deficiency.

METHODS

Participating blood donors were divided into two groups: high ferritin (HF) (>150 µg L^-1 ) and low ferritin (LF) (<15 µg L^-1 ). MiRNA analysis was performed by an miRNA profiling service (Exiqon) using commercial qPCR assays. The study had two phases: (i) a pilot study (20 participants) where 179 miRNAs were analysed and (ii) a confirmation study (50 participants) of 13 selected miRNAs.

RESULTS

Mean serum ferritin was 13·8 µg L^-1 in the LF arm compared to 231 µg L^-1 in the HF group (P < 0·001). Hepcidin plasma levels were higher in the HF arm (P < 0·001), whereas soluble transferrin receptor 1 was higher in the LF group (P < 0·001). In the pilot study, samples did not separate according to study group on unsupervised analysis. When directly comparing HF vs LF groups, 17 miRNAs were differentially expressed (P < 0·05, t-test) but did not pass correction for multiple testing. The confirmation study of 13 selected miRNAs verified these findings as no miRNA was significantly different between the study groups.

CONCLUSION

In this study, circulating plasma miRNAs did not emerge as promising biomarkers for iron status in healthy individuals. However, in the future, alternative detection methods such as next-generation sequencing might indicate miRNAs that correlate with iron stores.

A Different Kind of Craving: Incidence and Treatment of Pica After Laparoscopic Roux-en-Y Gastric Bypass

BACKGROUND

Iron deficiency can occur in patients after Roux-en-y gastric bypass due to altered absorption. Pica, the compulsive craving and intake of non-nutritive substances, is a rare and poorly understood presentation of iron deficiency. To our knowledge, the rate of pica after RYGB has never been reported.

METHODS

The medical records of patients who underwent laparoscopic RYGB from 2001 to 2011 were reviewed. Patients with pica or other abnormal cravings were identified.

RESULTS

Pica was identified in 16/959 (1.7%) patients who underwent RYGB during the study period. The most common presenting sign was pagophagia. All patients with pica were female and had multiple risk factors for iron deficiency with 13/16 being premenopausal and 7/16 non-compliant with oral iron supplementation. Pica symptoms presented at a mean of 3.9 ± 1.9 years after RYGB. Iron deficiency was identified in all 16 patients, with a median ferritin level of 5.0 ng/mL (range 2-27). All 16 patients received intravenous iron and pica symptoms resolved.

CONCLUSIONS

Pica is a rare phenomenon associated with iron deficiency and can occur despite oral iron supplementation. In our experience, intravenous iron can relieve symptoms. Patients considering bariatric surgery should be counseled on pica. Patients with unusual cravings should be evaluated for iron deficiency.

Qualitative assessment of pica experienced by frequent blood donors

BACKGROUND

Pica, the compulsive consumption of ice or other nonnutritious substances, is associated with iron deficiency, a common negative consequence of frequent blood donation. Because of this, blood donors, such as those participating in the Strategies to Reduce Iron Deficiency (STRIDE) study, are an ideal population to explore pica and iron deficiency.

STUDY DESIGN AND METHODS

STRIDE was a 2-year intervention trial to assess the effectiveness of iron supplementation for mitigating iron deficiency in frequent blood donors. Subjects completed baseline and follow-up questionnaires that included questions about pica symptoms. In-depth telephone interviews were conducted with 14 of these subjects reporting pica symptoms and eight presumed controls (casual ice chewers) to gain a deeper understanding of pica symptoms and their impact on daily life and to make a final determination on the presence of pica.

RESULTS

Pica was confirmed in five of the 14 subjects reporting symptoms and in two of eight controls. Outcome misclassification based on the questionnaire was attributed to inadequate assessment of several pica symptoms identified during the interview. Comparison of subjects' repeated quantitative iron measurements taken throughout STRIDE with subjects' final adjudicated pica status revealed a positive relationship between development of pica and worsening iron status; the opposite was found in those whose pica symptoms resolved.

CONCLUSION

Continued refinement of pica symptom questions will allow for rapid and accurate detection of pica in frequent blood donors and confirmation of successful treatment with iron supplements.

Pica as a manifestation of iron deficiency

INTRODUCTION

Pica is the compulsive eating of non-nutritive substances. It is often associated with iron deficiency but its pathophysiology is unknown. Areas covered: We searched the literature using the keywords listed below. Our aim was to describe the phenomenon in its various aspects, to touch briefly on the historical and cultural background, and to examine in more detail the studies that tried to analyze the relative roles of iron deficiency and pica. Expert commentary: Pica is an intriguing symptom known for centuries. Pregnant women and preadolescents are at the highest risk of pica. Iron absorption is reduced in the presence of non-nutritive substances. Iron therapy usually cures the pica behavior. There are different forms of pica, one caused directly by iron deficiency probably due to the lack of iron in some areas of the brain and one more culturally driven and including mostly geophagy.

Restless legs syndrome associated with major diseases: A systematic review and new concept

Recent publications on both the genetics and environmental factors of restless legs syndrome (RLS) defined as a clinical disorder suggest that overlapping genetic risk factors may play a role in primary (idiopathic) and secondary (symptomatic) RLS. Following a systematic literature search of RLS associated with comorbidities, we identified an increased prevalence of RLS only in iron deficiency and kidney disease. In cardiovascular disease, arterial hypertension, diabetes, migraine, and Parkinson disease, the methodology of studies was poor, but an association might be possible. There is insufficient evidence for conditions such as anemia (without iron deficiency), chronic obstructive pulmonary disease, multiple sclerosis, headache, stroke, narcolepsy, and ataxias. Based on possible gene-microenvironmental interaction, the classifications primary and secondary RLS may suggest an inappropriate causal relation. We recognize that in some conditions, treatment of the underlying disease should be achieved as far as possible to reduce or eliminate RLS symptoms. RLS might be seen as a continuous spectrum with a major genetic contribution at one end and a major environmental or comorbid disease contribution at the other.

Pica for Uncooked Basmati Rice in Two Women with Iron Deficiency and a Review of Ryzophagia

Reports of pica for uncooked rice (ryzophagia) in adults who reside in European and derivative countries are uncommon. We evaluated and treated two nonpregnant women with pica for uncooked basmati rice. Both women reported fatigue, abdominal discomfort after consuming large quantities of uncooked basmati rice, and hair loss. One woman was from India and the other was from Pakistan. Both women were vegetarians. Basmati was the local rice in their native countries and their usual rice in the USA. Both women had tooth damage due to eating uncooked rice and iron deficiency with microcytic anemia attributed to menorrhagia and multiparity. Ryzophagia and other manifestations (except tooth damage) resolved after iron dextran therapy. We review and discuss other reports of ryzophagia associated with iron deficiency, pregnancy, race/ethnicity, geographic origin, and local traditions. We conclude that adults with ryzophagia in European and derivative countries are likely to be non-Europeans.

A randomized, blinded, placebo-controlled trial of education and iron supplementation for mitigation of iron deficiency in regular blood donors

BACKGROUND

The historical approach of offering dietary advice to donors with low hemoglobin (Hb) is ineffective for preventing iron deficiency in frequent donors. Alternative approaches to maintaining donor iron status were explored.

STUDY DESIGN AND METHODS

Frequent blood donors were randomly assigned into five arms for 2 years of follow-up. Three double-blinded arms provided 60 once-daily pills after each donation (38, 19, or 0 mg of iron). Two single-blinded arms provided iron status (ferritin) or no information letters after each donation. Ferritin, soluble transferrin receptor, and complete blood count were measured at each donation.

RESULTS

There were 692 subjects enrolled and 393 completed the study. Subjects in pill groups deenrolled more than those in letter groups (39% vs. 7%). Adverse events occurred equally in subjects receiving iron or placebo pills. Of those completing the study, the prevalence of ferritin of less than 12 or less than 26 ng/mL declined by more than 50% and was statistically indistinguishable in the three intervention groups (19 or 38 mg of iron; iron status letter). Longitudinal analyses of all subjects showed improved iron status in iron pill groups and worsening iron status in control groups (placebo; no information letter). The iron pill groups experienced a net increase of approximately 0.6 g/dL Hb compared to control groups. The iron status letter group had little change in Hb.

CONCLUSION

Providing 19 or 38 mg of daily iron or iron status information were effective and mostly equivalent interventions for mitigating iron deficiency in regular donors when compared at the end of the 2-year longitudinal phase of the study. Donors without intervention had worsened iron deficiency with continued donation.

Ask about ice, then consider iron

BACKGROUND AND PURPOSE

The study aims to review a condition defined by the desire to consume ice in order to satisfy an addictive-like compulsion, rather than for purposes of hydration or pain relief. This condition is called ice pica, or pagophagia. Associations between ice pica and iron deficiency, suggestions for clinical screening of at risk populations, and recommendations for treatment and follow-up care are provided.

DATA SOURCES

An extensive literature review of original research articles, reviews, clinical practice manuscripts, and scientific publications on pica and pagophagia.

CONCLUSIONS

A compulsion or craving for the consumption of ice is often overlooked in clinical practice. It is therefore important for clinicians to include ice pica as part of the review of systems for certain patient populations. Ice pica is frequently associated with iron deficiency, and iron supplementation is an effective therapy in most cases.

IMPLICATIONS FOR PRACTICE

Knowledge gained from screening for ice pica can generate valuable patient information and lead to the diagnosis and treatment of iron deficiency. The populations at risk include young women and blood donors of either sex.

Intravenous iron administration and hypophosphatemia in clinical practice

Introduction. Parenteral iron formulations are frequently used to correct iron deficiency anemia (IDA) and iron deficiency (ID). Intravenous formulation efficacy on ferritin and hemoglobin level improvement is greater than that of oral formulations while they are associated with lower gastrointestinal side effects. Ferric carboxymaltose- (FCM-) related hypophosphatemia is frequent and appears without clinical significance. The aim of this study was to assess the prevalence, duration, and potential consequences of hypophosphatemia after iron injection. Patients and Methods. The medical records of all patients who underwent parenteral iron injection between 2012 and 2014 were retrospectively reviewed. Pre- and postinjection hemoglobin, ferritin, plasma phosphate, creatinine, and vitamin D levels were assessed. Patients who developed moderate (range: 0.32–0.80 mmol/L) or severe (<0.32 mmol/L) hypophosphatemia were questioned for symptoms. Results. During the study period, 234 patients received iron preparations but 104 were excluded because of missing data. Among the 130 patients included, 52 received iron sucrose (FS) and 78 FCM formulations. Among FS-treated patients, 22% developed hypophosphatemia versus 51% of FCM-treated patients, including 13% who developed profound hypophosphatemia. Hypophosphatemia severity correlated with the dose of FCM (p = 0.04) but not with the initial ferritin, hemoglobin, or vitamin D level. Mean hypophosphatemia duration was 6 months. No immediate clinical consequence was found except for persistent fatigue despite anemia correction in some patients. Conclusions. Hypophosphatemia is frequent after parenteral FCM injection and may have clinical consequences, including persistent fatigue. Further studies of chronic hypophosphatemia long-term consequences, especially bone assessments, are needed.

Laboratory and genetic assessment of iron deficiency in blood donors

More than 9 million individuals donate blood annually in the United States. Between 200 and 250 mg of iron is removed with each whole blood donation, reflecting losses from the hemoglobin in red blood cells. Replenishment of iron stores takes many months, leading to a high rate of iron depletion. In an effort to better identify and prevent iron deficiency, blood collection centers are now considering various strategies to manage donor iron loss. This article highlights laboratory and genetic tests to assess the iron status of blood donors and their applicability as screening tests for blood donation.

Oral iron supplementation after blood donation: a randomized clinical trial

IMPORTANCE

Although blood donation is allowed every 8 weeks in the United States, recovery of hemoglobin to the currently accepted standard (12.5 g/dL) is frequently delayed, and some donors become anemic.

OBJECTIVE

To determine the effect of oral iron supplementation on hemoglobin recovery time (days to recovery of 80% of hemoglobin removed) and recovery of iron stores in iron-depleted ("low ferritin," ≤26 ng/mL) and iron-replete ("higher ferritin," >26 ng/mL) blood donors.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, nonblinded clinical trial of blood donors stratified by ferritin level, sex, and age conducted in 4 regional blood centers in the United States in 2012. Included were 215 eligible participants aged 18 to 79 years who had not donated whole blood or red blood cells within 4 months.

INTERVENTIONS

One tablet of ferrous gluconate (37.5 mg of elemental iron) daily or no iron for 24 weeks (168 days) after donating a unit of whole blood (500 mL).

MAIN OUTCOMES AND MEASURES

Time to recovery of 80% of the postdonation decrease in hemoglobin and recovery of ferritin level to baseline as a measure of iron stores.

RESULTS

The mean baseline hemoglobin levels were comparable in the iron and no-iron groups and declined from a mean (SD) of 13.4 (1.1) g/dL to 12.0 (1.2) g/dL after donation in the low-ferritin group and from 14.2 (1.1) g/dL to 12.9 (1.2) g/dL in the higher-ferritin group. Compared with participants who did not receive iron supplementation, those who received iron supplementation had shortened time to 80% hemoglobin recovery in both the low-ferritin (mean, 32 days, interquartile range [IQR], 30-34, vs 158 days, IQR, 126->168) and higher-ferritin groups (31 days, IQR, 29-33, vs 78 days, IQR, 66-95). Median time to recovery to baseline ferritin levels in the low-ferritin group taking iron was 21 days (IQR, 12-84). For participants not taking iron, recovery to baseline was longer than 168 days (IQR, 128->168). Median time to recovery to baseline in the higher-ferritin group taking iron was 107 days (IQR, 75-141), and for participants not taking iron, recovery to baseline was longer than 168 days (IQR, >168->168). Recovery of iron stores in all participants who received supplements took a median of 76 days (IQR, 20-126); for participants not taking iron, median recovery time was longer than 168 days (IQR, 147->168 days; P < .001). Without iron supplements, 67% of participants did not recover iron stores by 168 days.

CONCLUSIONS AND RELEVANCE

Among blood donors with normal hemoglobin levels, low-dose iron supplementation, compared with no supplementation, reduced time to 80% recovery of the postdonation decrease in hemoglobin concentration in donors with low ferritin (≤26 ng/mL) or higher ferritin (>26 ng/mL).

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01555060.

The strategies to reduce iron deficiency in blood donors randomized trial: design, enrolment and early retention

BACKGROUND AND OBJECTIVES

Repeated blood donation produces iron deficiency. Changes in dietary iron intake do not prevent donation-induced iron deficiency. Prolonging the interdonation interval or using oral iron supplements can mitigate donation-induced iron deficiency. The most effective operational methods for reducing iron deficiency in donors are unknown.

MATERIALS AND METHODS

'Strategies To Reduce Iron Deficiency' (STRIDE) was a two-year, randomized, placebo-controlled study in blood donors. 692 donors were randomized into one of two educational groups or one of three interventional groups. Donors randomized to educational groups either received letters thanking them for donating, or, suggesting iron supplements or delayed donation if they had low ferritin. Donors randomized to interventional groups either received placebo, 19-mg or 38-mg iron pills.

RESULTS

Iron deficient erythropoiesis was present in 52·7% of males and 74·6% of females at enrolment. Adverse events within 60 days of enrolment were primarily mild gastrointestinal symptoms (64%). The incidence of de-enrolment within 60 days was more common in the interventional groups than in the educational groups (P = 0·002), but not more common in those receiving iron than placebo (P = 0·68).

CONCLUSION

The prevalence of iron deficient erythropoiesis in donors enrolled in the STRIDE study is comparable to previously described cohorts of regular blood donors. De-enrolment within 60 days was higher for donors receiving tablets, although no more common in donors receiving iron than placebo.

Treatment of iron deficiency with intravenous ferric carboxymaltose in general practice: a retrospective database study

Background

Iron deficiency is a frequent problem in general practice. Oral supplementation may in some cases not be well tolerated or not be efficient. Intravenous ferric carboxymaltose may be an alternative for iron supplementation in general practice. The aim of the present study was to analyze the indications for and the efficacy of intravenous ferric carboxymaltose in a primary care center.

Methods

We retropectively analyzed electronic data from 173 patients given intravenous ferric carboxymaltose between 2011 and 2013 in primary care center with 18 GPs in Bern, Switzerland.

Results

Of all patients, 34% were treated intravenously due to an inappropriate increase in ferritin levels after oral therapy, 24% had side effects from oral treatment, 10% were treated intravenously due to the patients explicit wish, and in 39% of all cases, no obvious reason of intravenous instead of oral treatment could be found. Intravenous ferric carboxymaltose led to a significant increase in hemoglobin and serum ferritin levels. Side effects of intravenous treatment were found in 2% of all cases.

Conclusion

We conclude that treatment with intravenous ferric carboxymaltose is an efficient alternative for patients with iron deficiency in general practice, when oral products are not well tolarated or effective. As treatment with iron carboxymaltose is more expensive and potentially dangerous due to side effects, the indication should be placed with (more) care.

Response to intravenous iron in patients with iron deficiency anemia (IDA) and restless leg syndrome (Willis-Ekbom disease)

OBJECTIVES

Iron deficiency anemia (IDA) engenders restless legs syndrome (RLS, aka Willis-Ekbom disease). Intravenous (IV) iron can rapidly reverse IDA and would be expected to similarly reverse RLS caused by IDA. This is the first consecutive case series evaluating the effects of IV iron therapy on RLS occurring with IDA (RLS-IDA).

METHODS

RLS-IDA patients were evaluated before and 7-12 months after a 1000-mg IV infusion of low-molecular-weight iron dextran (INFeD(@)) using validated questionnaires and standardized telephone interview. Patients were classified as respondent versus nonrespondent for RLS improvement.

RESULTS

Follow-up data were obtained on 42 (70%) of 60 consecutive RLS-IDA patients. The symptoms of RLS were reduced in 76% (32/42) with 47% (20/42) showing an extended response lasting >6 months. The response did not relate to age or gender, but tended to be less among African-Americans than Whites (40% (2/5) vs. 81% (30/37), p = 0.078). White respondents versus nonrespondents had higher hemoglobin levels after treatment (12.1 vs. 11.3 g/dl, p = 0.03).

CONCLUSIONS

RLS-IDA is reduced after administration of IV iron in most cases, but the 24% failing to respond was higher than expected. The nonrespondents all showed below-normal hemoglobin levels (<12.5 g/dl) suggesting a failure of adequate treatment of the iron deficiency. IV iron treatment of the RLS with IDA likely requires ensuring more than minimally adequate body iron stores to support iron delivery to the brain. For some, this may require a dose higher than the customary 1000-mg IV iron used for the treatment of either IDA or RLS alone.

A meta-analysis of pica and micronutrient status

OBJECTIVES

Pica is the craving for and consumption of nonfood items, including the ingestion of earth (geophagy), raw starch (amylophagy), and ice (pagophagy). Pica has long been associated with micronutrient deficiencies, but the strength of this relationship is unclear. We aimed to evaluate the association between pica behavior and the risk of being anemic or having low hemoglobin (Hb), hematocrit (Hct), or plasma zinc (Zn) concentrations.

METHODS

We systematically reviewed studies in which micronutrient levels were reported by pica status. We calculated the pooled odds ratio for anemia or weighted mean difference in Hb, Hct, or Zn concentrations between groups practicing or not practicing pica behaviors.

RESULTS

Forty-three studies including 6,407 individuals with pica behaviors and 10,277 controls were identified. Pica was associated with 2.35 times greater odds of anemia (95% CI: 1.94-2.85, P < 0.001), lower Hb concentration (-0.65 g/dl, 95% CI: -0.83 to -0.48 g/dl, P < 0.001), lower Hct concentration (-1.15%, 95% CI: -1.61 to -0.70%, P < 0.001), and lower Zn concentration (-34.3 μg/dl, 95% CI: -59.58 to -9.02 μg/dl, P = 0.008). Statistical significance persisted after excluding outliers and in subgroup analyses by pica type and life stage.

CONCLUSION

Pica is significantly associated with increased risk for anemia and low Hb, Hct, and plasma Zn. Although the direction of the causal relationship between pica and micronutrient deficiency is unknown, the magnitude of these relationships is comparable to other well-recognized causes of micronutrient deficiencies. Pica warrants greater public health attention; specifically the potential physiological mechanisms underpinning the relationship between pica and micronutrient deficiencies merit further study.

How do we design, implement, and manage an ongoing program to provide iron supplements to women blood donors?

Here we describe the design and management of Indiana Blood Center's 10-year Iron For Women program, an ongoing community blood center-based program with continual program and donor management providing iron supplements to healthy women blood donors. Donor iron supplementation has typically been limited to research study protocols, for a defined period, with the associated resources and funding. The results of studies have supported the utility of iron supplementation: iron supplementation will enhance dietary iron for increased gastrointestinal absorption triggered as a normal homeostatic response to blood loss, thereby providing a suitable dietary iron source in the event the donor's usual diet lacks sufficient iron. Despite proven results, blood centers have been reluctant to adopt the practice due to barriers such as donor selection, ensuring the appropriateness of iron supplementation relative to the health of the donor, supplement costs, provision logistics, and program management costs. We present here how we designed our program and why it is in the Blood Center's interest to help willing women participate in volunteer blood donation by attempting to mitigate associated iron loss.

Diagnosis, comorbidities, and management of restless legs syndrome

OBJECTIVE

This narrative review describes the differential diagnosis of restless legs syndrome, and provides an overview of the evidence for the associations between RLS and potential comorbidities. Secondary causes of RLS and the characteristics of pediatric RLS are also discussed. Finally, management strategies for RLS are summarized.

METHODS

The review began with a comprehensive PubMed search for 'restless legs syndrome/Willis-Ekbom disease' in combination with the following: anxiety, arthritis, attention-deficit hyperactivity disorder, cardiac, cardiovascular disease, comorbidities, depression, end-stage renal disease, erectile dysfunction, fibromyalgia, insomnia, kidney disease, liver disease, migraine, mood disorder, multiple sclerosis, narcolepsy, neuropathy, obesity, pain, Parkinson's disease, polyneuropathy, pregnancy, psychiatric disorder, sleep disorder, somatoform pain disorder, and uremia. Additional papers were identified by reviewing the reference lists of retrieved publications.

RESULTS AND CONCLUSIONS

Although clinical diagnosis of RLS can be straightforward, diagnostic challenges may arise when patients present with comorbid conditions. Comorbidities of RLS include insomnia, depressive and anxiety disorders, and pain disorders. Differential diagnosis is particularly important, as some of the medications used to treat insomnia and depression may exacerbate RLS symptoms. Appropriate diagnosis and management of RLS symptoms may benefit patient well-being and, in some cases, may lessen comorbid disease burden. Therefore, it is important that physicians are aware of the presence of RLS when treating patients with conditions that commonly co-occur with the disorder.