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Lakhal-Littleton S, Cleland JGF. Iron deficiency and supplementation in heart failure. Nat Rev Cardiol 2024; 21:463-486. [PMID: 38326440 DOI: 10.1038/s41569-024-00988-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 02/09/2024]
Abstract
Non-anaemic iron deficiency (NAID) is a strategic target in cardiovascular medicine because of its association with a range of adverse effects in various conditions. Endeavours to tackle NAID in heart failure have yielded mixed results, exposing knowledge gaps in how best to define 'iron deficiency' and the handling of iron therapies by the body. To address these gaps, we harness the latest understanding of the mechanisms of iron homeostasis outside the erythron and integrate clinical and preclinical lines of evidence. The emerging picture is that current definitions of iron deficiency do not assimilate the multiple influences at play in patients with heart failure and, consequently, fail to identify those with a truly unmet need for iron. Additionally, current iron supplementation therapies benefit only certain patients with heart failure, reflecting differences in the nature of the unmet need for iron and the modifying effects of anaemia and inflammation on the handling of iron therapies by the body. Building on these insights, we identify untapped opportunities in the management of NAID, including the refinement of current approaches and the development of novel strategies. Lessons learned from NAID in cardiovascular disease could ultimately translate into benefits for patients with other chronic conditions such as chronic kidney disease, chronic obstructive pulmonary disease and cancer.
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Affiliation(s)
| | - John G F Cleland
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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Packer M, Anker SD, Butler J, Cleland JGF, Kalra PR, Mentz RJ, Ponikowski P. Identification of three mechanistic pathways for iron-deficient heart failure. Eur Heart J 2024:ehae284. [PMID: 38733250 DOI: 10.1093/eurheartj/ehae284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/29/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Current understanding of iron-deficient heart failure is based on blood tests that are thought to reflect systemic iron stores, but the available evidence suggests greater complexity. The entry and egress of circulating iron is controlled by erythroblasts, which (in severe iron deficiency) will sacrifice erythropoiesis to supply iron to other organs, e.g. the heart. Marked hypoferraemia (typically with anaemia) can drive the depletion of cardiomyocyte iron, impairing contractile performance and explaining why a transferrin saturation < ≈15%-16% predicts the ability of intravenous iron to reduce the risk of major heart failure events in long-term trials (Type 1 iron-deficient heart failure). However, heart failure may be accompanied by intracellular iron depletion within skeletal muscle and cardiomyocytes, which is disproportionate to the findings of systemic iron biomarkers. Inflammation- and deconditioning-mediated skeletal muscle dysfunction-a primary cause of dyspnoea and exercise intolerance in patients with heart failure-is accompanied by intracellular skeletal myocyte iron depletion, which can be exacerbated by even mild hypoferraemia, explaining why symptoms and functional capacity improve following intravenous iron, regardless of baseline haemoglobin or changes in haemoglobin (Type 2 iron-deficient heart failure). Additionally, patients with advanced heart failure show myocardial iron depletion due to both diminished entry into and enhanced egress of iron from the myocardium; the changes in iron proteins in the cardiomyocytes of these patients are opposite to those expected from systemic iron deficiency. Nevertheless, iron supplementation can prevent ventricular remodelling and cardiomyopathy produced by experimental injury in the absence of systemic iron deficiency (Type 3 iron-deficient heart failure). These observations, taken collectively, support the possibility of three different mechanistic pathways for the development of iron-deficient heart failure: one that is driven through systemic iron depletion and impaired erythropoiesis and two that are characterized by disproportionate depletion of intracellular iron in skeletal and cardiac muscle. These mechanisms are not mutually exclusive, and all pathways may be operative at the same time or may occur sequentially in the same patients.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, 621 North Hall Street, Dallas, TX 75226, USA
- Imperial College, London, UK
| | - Stefan D Anker
- Department of Cardiology of German Heart Center Charité, Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research, partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Javed Butler
- Baylor Scott and White Research Institute, Baylor University Medical Center, Dallas, TX, USA
- University of Mississippi Medical Center, Jackson, MS, USA
| | - John G F Cleland
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
- College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK
- Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
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Heefner A, Simovic T, Mize K, Rodriguez-Miguelez P. The Role of Nutrition in the Development and Management of Chronic Obstructive Pulmonary Disease. Nutrients 2024; 16:1136. [PMID: 38674827 PMCID: PMC11053888 DOI: 10.3390/nu16081136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/05/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a prevalent lung condition associated with significant morbidity and mortality. The management of COPD classically involves pulmonary rehabilitation, bronchodilators, and corticosteroids. An aspect of COPD management that is currently lacking in the literature is nutritional management, despite the prevalence of inadequate nutritional status in patients with COPD. In addition, certain nutritional imbalances have been reported to increase the risk of COPD development. This review summarizes the current literature on the role diet and nutrients may play in the risk and management of COPD development.
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Affiliation(s)
- Allison Heefner
- Department of Kinesiology and Health Sciences, Virginia Commonwealth University, Richmond, VA 23284, USA
- School of Medicine, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Tijana Simovic
- Department of Kinesiology and Health Sciences, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Kasey Mize
- Department of Kinesiology and Health Sciences, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Paula Rodriguez-Miguelez
- Department of Kinesiology and Health Sciences, Virginia Commonwealth University, Richmond, VA 23284, USA
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA 23284, USA
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Kim TH, Heo IR, Kim NY, Park JH, Yoon HY, Jung JY, Ra SW, Jung KS, Yoo KH, Kim HC. Factors Associated with the Discrepancy between Exercise Capacity and Airflow Limitation in Patients with Chronic Obstructive Pulmonary Disease. Tuberc Respir Dis (Seoul) 2024; 87:155-164. [PMID: 38225687 PMCID: PMC10990613 DOI: 10.4046/trd.2023.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 10/22/2023] [Accepted: 12/26/2023] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Exercise capacity is associated with lung function decline in chronic obstructive pulmonary disease (COPD) patients, but a discrepancy between exercise capacity and airflow limitation exists. This study aimed to explore factors contributing to this discrepancy in COPD patients. METHODS Data for this prospective study were obtained from the Korean COPD Subgroup Study. The exercise capacity and airflow limitation were assessed using the 6-minute walk distance (6-MWD; m) and forced expiratory volume in 1 second (FEV1). Participants were divided into four groups: FEV1 >50%+6-MWD >350, FEV1 >50%+6- MWD ≤350, FEV1 ≤50%+6-MWD >350, and FEV1 ≤50%+6-MWD ≤350 and their clinical characteristics were compared. RESULTS A total of 883 patients (male:female, 822:61; mean age, 68.3±7.97 years) were enrolled. Among 591 patients with FEV1 >50%, 242 were in the 6-MWD ≤350 group, and among 292 patients with FEV1 ≤50%, 185 were in the 6-MWD >350 group. The multiple regression analyses revealed that male sex (odds ratio [OR], 8.779; 95% confidence interval [CI], 1.539 to 50.087; p=0.014), current smoking status (OR, 0.355; 95% CI, 0.178 to 0.709; p=0.003), and hemoglobin levels (OR, 1.332; 95% CI, 1.077 to 1.648; p=0.008) were significantly associated with discrepancies in exercise capacity and airflow limitation in patients with FEV1 >50%. Meanwhile, in patients with FEV1 ≤50%, diffusion capacity of carbon monoxide (OR, 0.945; 95% CI, 0.912 to 0.979; p=0.002) was significantly associated with discrepancies between exercise capacity and airflow limitation. CONCLUSION The exercise capacity of COPD patients may be influenced by factors other than airflow limitation, so these aspects should be considered when assessing and treating patients.
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Affiliation(s)
- Tae Hoon Kim
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| | - I Re Heo
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| | - Na Young Kim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Joo Hun Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Hee-Young Yoon
- Division of Allergy and Respiratory Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Ji Ye Jung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Won Ra
- Department of Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Ki-Suck Jung
- Division of Pulmonary Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, College of Medicine, Hallym University, Anyang, Republic of Korea
| | - Kwang Ha Yoo
- Division of Pulmonary and Allergy Medicine, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Ho Cheol Kim
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
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Talbot NP, Cheng H, Hanstock H, Smith TG, Dorrington KL, Robbins PA. Hypoxic pulmonary vasoconstriction does not limit maximal exercise capacity in healthy volunteers breathing 12% oxygen at sea level. Physiol Rep 2024; 12:e15944. [PMID: 38366054 PMCID: PMC10873163 DOI: 10.14814/phy2.15944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 02/18/2024] Open
Abstract
Maximal exercise capacity is reduced at altitude or during hypoxia at sea level. It has been suggested that this might reflect increased right ventricular afterload due to hypoxic pulmonary vasoconstriction. We have shown previously that the pulmonary vascular sensitivity to hypoxia is enhanced by sustained isocapnic hypoxia, and inhibited by intravenous iron. In this study, we tested the hypothesis that elevated pulmonary artery pressure contributes to exercise limitation during acute hypoxia. Twelve healthy volunteers performed incremental exercise tests to exhaustion breathing 12% oxygen, before and after sustained (8-h) isocapnic hypoxia at sea level. Intravenous iron sucrose (n = 6) or saline placebo (n = 6) was administered immediately before the sustained hypoxia. In the placebo group, there was a substantial (12.6 ± 1.5 mmHg) rise in systolic pulmonary artery pressure (SPAP) during sustained hypoxia, but no associated fall in maximal exercise capacity breathing 12% oxygen. In the iron group, the rise in SPAP during sustained hypoxia was markedly reduced (3.4 ± 1.0 mmHg). There was a small rise in maximal exercise capacity following sustained hypoxia within the iron group, but no overall effect of iron, compared with saline. These results do not support the hypothesis that elevated SPAP inhibits maximal exercise capacity during acute hypoxia in healthy volunteers.
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Affiliation(s)
- Nick P. Talbot
- Department of Physiology, Anatomy and GeneticsUniversity of OxfordOxfordUK
| | - Hung‐Yuan Cheng
- Translational Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Helen Hanstock
- Swedish Winter Sports Research Centre, Department of Health SciencesMid Sweden UniversityÖstersundSweden
| | - Thomas G. Smith
- Centre for Human and Applied Physiological SciencesKing's College LondonLondonUK
- Guy's and St Thomas' NHS Foundation TrustLondonUK
| | | | - Peter A. Robbins
- Department of Physiology, Anatomy and GeneticsUniversity of OxfordOxfordUK
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Cleland JGF, Pellicori P, Graham FJ. Redefining both iron deficiency and anaemia in cardiovascular disease. Eur Heart J 2023; 44:1992-1994. [PMID: 36879446 PMCID: PMC10256186 DOI: 10.1093/eurheartj/ehad154] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Affiliation(s)
- John G F Cleland
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, University Avenue, Glasgow, UK. G12 8QQ, UK
| | - Pierpaolo Pellicori
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, University Avenue, Glasgow, UK. G12 8QQ, UK
| | - Fraser J Graham
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, University Avenue, Glasgow, UK. G12 8QQ, UK
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Vinke JS, Eisenga MF, Sanders JSF, Berger SP, Spikman JM, Abdulahad WH, Bakker SJ, Gaillard CAJM, van Zuilen AD, van der Meer P, de Borst MH. Effect of Intravenous Ferric Carboxymaltose on Exercise Capacity After Kidney Transplantation (EFFECT-KTx): rationale and study protocol for a double-blind, randomised, placebo-controlled trial. BMJ Open 2023; 13:e065423. [PMID: 36948568 PMCID: PMC10040026 DOI: 10.1136/bmjopen-2022-065423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
Abstract
INTRODUCTION Iron deficiency (ID) is common and has been associated with an excess mortality risk in kidney transplant recipients (KTRs). In patients with chronic heart failure and ID, intravenous iron improves exercise capacity and quality of life. Whether these beneficial effects also occur in KTRs is unknown. The main objective of this trial is to address whether intravenous iron improves exercise tolerance in iron-deficient KTRs. METHODS AND ANALYSIS The Effect of Ferric Carboxymaltose on Exercise Capacity after Kidney Transplantation study is a multicentre, double-blind, randomised, placebo-controlled clinical trial that will include 158 iron-deficient KTRs. ID is defined as plasma ferritin <100 µg/L or plasma ferritin 100-299 µg/L with transferrin saturation <20%. Patients are randomised to receive 10 mL of ferric carboxymaltose (50 mg Fe3+/mL, intravenously) or placebo (0.9% sodium chloride solution) every 6 weeks, four dosages in total. The primary endpoint is change in exercise capacity, as quantified by the 6 min walk test, between the first study visit and the end of follow-up, 24 weeks later. Secondary endpoints include changes in haemoglobin levels and iron status, quality of life, systolic and diastolic heart function, skeletal muscle strength, bone and mineral parameters, neurocognitive function and safety endpoints. Tertiary (explorative) outcomes are changes in gut microbiota and lymphocyte proliferation and function. ETHICS AND DISSEMINATION The protocol of this study has been approved by the medical ethical committee of the University Medical Centre Groningen (METc 2018/482;) and is being conducted in accordance with the principles of the Declaration of Helsinki, the Standard Protocol Items: Recommendations for Interventional Trials checklist and the Good Clinical Practice guidelines provided by the International Council for Harmonization of Technical Requirements for Pharmaceuticals for Human Use. Study results will be disseminated through publications in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER NCT03769441.
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Affiliation(s)
- Joanna Sj Vinke
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Michele F Eisenga
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Jan-Stephan F Sanders
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Stefan P Berger
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Jacoba M Spikman
- Department of Neuropsychology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Wayel H Abdulahad
- Department of Immunology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Stephan Jl Bakker
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Carlo A J M Gaillard
- Department of Nephrology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Arjan D van Zuilen
- Department of Nephrology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - P van der Meer
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Martin H de Borst
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
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Causal association between iron deficiency anemia and chronic obstructive pulmonary disease: A bidirectional two-sample Mendelian randomization study. Heart Lung 2023; 58:217-222. [PMID: 36623443 DOI: 10.1016/j.hrtlng.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 12/29/2022] [Accepted: 01/03/2023] [Indexed: 01/09/2023]
Abstract
BACKGROUND Observational studies have found an association between iron deficiency anemia (IDA) and chronic obstructive pulmonary disease (COPD) risk. However, whether IDA plays a role in COPD development remains unclear. OBJECTIVES This study was performed to explore the causal association between IDA and COPD. METHODS We obtained summary statistics for IDA from 6087 cases and 211,115 controls of European ancestry in an open genome-wide association study (GWAS) to select strongly associated single nucleotide polymorphisms that could serve as instrumental variables for IDA (P < 5 × 10-8). Additional summary statistics for COPD were obtained from 6915 COPD cases and 186,723 controls of European ancestry from a publicly available GWAS. A bidirectional Mendelian randomization analysis was performed using inverse variance weighting as the primary method of analysis. The reliability of the results was verified by heterogeneity and sensitivity analysis. RESULTS IDA increased the risk of COPD, with an odds ratio (OR) of 1.15 (95% confidence interval (CI: 1.04-1.25, p = 0.002). There was no evidence of a causal effect of COPD on IDA risk, with an OR of 0.99 (95% CI: 0.87-1.13, p = 0.91). The sensitivity analysis showed no evidence of heterogeneity or horizontal pleiotropy. CONCLUSIONS We found that IDA increases the risk of COPD. Additionally, there was no evidence that COPD increases the risk of IDA. Therefore, IDA should be considered in future COPD risk studies and reintroduced as a potential therapeutic target. The relationship between COPD and IDA risk requires further study using indirect mechanisms.
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Effect of intravenous ferric carboxymaltose on exercise capacity and quality of life in patients with COPD : A pilot study. Wien Klin Wochenschr 2023; 135:35-44. [PMID: 36044093 DOI: 10.1007/s00508-022-02073-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 07/22/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND OBJECTIVE Chronic obstructive pulmonary disease (COPD) is associated with reduced exercise capacity. In COPD iron deficiency is found in up to 50% of patients and may impair exercise capacity, the potential therapeutic effect is yet unknown. We aimed to estimate the beneficial effect of intravenous ferric carboxymaltose on exercise capacity and quality of life in patients with COPD. METHODS In this non-randomized, interrupted time series pilot trial we enrolled outpatients with stable COPD (GOLD II and III) and nonanemic iron deficiency (i.e., ferritin level < 100 μg/l or ferritin level 100-300 μg/l if transferrin saturation < 20%). Patients with cardiovascular-or inflammatory diseases were excluded. Participants performed 6‑minute walking test (6-MWT) and cardiopulmonary exercise testing (CPET) and completed the St. George's Respiratory Questionnaire (SGRQ). RESULTS From 35 screened patients, 11 (72% male, 63 ± 8 years, FEV1%predicted 44 ± 14) were included. Mean ferritin and hemoglobin were 70 ± 41 µg/l and 13.8 ± 1.7 g/dl, respectively. Four weeks after iron administration the 6‑MWT distance increased by 34.7 ± 34.4 m (95% CI, 10.0-59.3); p = 0.011. The VO2max increased by 1.87 ± 1.2 ml/kg/min (95% CI, 0.76-3); p = 0.006. Mean score of SGRQ was reduced by 7.56 ± 6.12 units (95% CI, 3 to 11); p = 0.004. The insignificant alteration in hemoglobin did not correlate with increase in exercise capacity. CONCLUSION Administration of intravenous iron was associated with improved exercise capacity and quality of life in stable COPD patients independent of hemoglobin. Our data provide a basis to calculate a statistically sufficient sample size for a randomized controlled follow-up study.
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Dugan C, Cabolis K, Miles LF, Richards T. Systematic review and meta-analysis of intravenous iron therapy for adults with non-anaemic iron deficiency: An abridged Cochrane review. J Cachexia Sarcopenia Muscle 2022; 13:2637-2649. [PMID: 36321348 PMCID: PMC9745472 DOI: 10.1002/jcsm.13114] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 09/04/2022] [Accepted: 09/21/2022] [Indexed: 12/14/2022] Open
Abstract
Iron is an essential nutrient for oxygen supply and aerobic metabolism. Iron deficiency impacts cellular respiration and mitochondrial energy metabolism, which can lead to reduced skeletal muscle function and muscle mass, causing sarcopenia. Intravenous iron offers the ability to rapidly correct iron deficiency, but the functional impact on patient mental and physical health is unclear. We assessed the effects of intravenous iron therapy on physical function and quality of life in the treatment of adults with non-anaemic iron deficiency. An update and reanalysis of a previously published Cochrane systematic review was performed to assess randomized controlled trials that compared any intravenous iron preparation with placebo in adults. The primary functional outcome measure was physical performance as defined by the trial authors. Secondary outcome measures included fatigue and quality-of-life scores, and adverse effects at the end of follow-up. Biochemical efficacy was assessed by change in serum ferritin and haemoglobin concentration levels. Twenty-one randomized controlled trials, comprising 3514 participants, were included. Intravenous iron compared with placebo resulted in significantly increased physical function measured by mean peak oxygen consumption (mean difference [MD] 1.77 mL/kg/min, 95% confidence interval [CI] 0.57 to 2.97). An overall improvement in fatigue was seen (standardized MD 0.30, 95% CI -0.52 to -0.09) but no overall difference in quality of life (MD 0.15, 95% CI -0.01 to 0.31). Biochemically, intravenous iron resulted in improved serum ferritin (MD 245.52 μg/L, 95% CI 152.1 to 338.9) and haemoglobin levels (MD 4.65 g/L, 95% CI 2.53 to 6.78). There was a higher risk of developing mild adverse events in the intravenous iron group compared with the placebo group (risk ratio 1.77, 95% CI 1.10 to 2.83); however, no differences were seen in serious adverse events (risk difference 0, 95% CI -0.01 to 0.01). The quality of evidence was rated 'low' and 'very low' for all outcome variables, except for fatigue, mainly due to most studies being judged as having a high risk of bias. In non-anaemic iron-deficient adults, the use of intravenous iron compared with placebo improved physical function and reduced fatigue scores. However, we remain uncertain about the efficacy in this population due to low-quality evidence, and there is a need for further studies to address potential impact on overall quality of life.
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Affiliation(s)
- Cory Dugan
- Division of Surgery, Faculty of Health and Medical ScienceThe University of Western AustraliaPerthAustralia
| | - Katerina Cabolis
- Department of Neuroinflammation, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Lachlan F. Miles
- Department of Critical Care, Faculty of Medicine, Dentistry and Health SciencesThe University of MelbourneMelbourneAustralia
| | - Toby Richards
- Division of Surgery, Faculty of Health and Medical ScienceThe University of Western AustraliaPerthAustralia
- Department of Neuroinflammation, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
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Martín-Ontiyuelo C, Rodó-Pin A, Echeverría-Esnal D, Admetlló M, Duran-Jordà X, Alvarado M, Gea J, Barreiro E, Rodríguez-Chiaradía DA. Intravenous Iron Replacement Improves Exercise Tolerance in COPD: A Single-Blind Randomized Trial. Arch Bronconeumol 2022; 58:689-698. [PMID: 35312562 DOI: 10.1016/j.arbres.2021.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/25/2021] [Accepted: 08/08/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Iron deficiency affects exercise capacity because of the critical role iron plays in the optimal functioning of skeletal muscle metabolism. We hypothesized that intravenous iron may improve exercise tolerance, quality of life (QoL), and daily physical activity (DPA) in patients with chronic obstructive pulmonary disease (COPD). METHODS This was a placebo-controlled, single-blind, parallel-group, randomized clinical trial. Iron deficiency was defined as a ferritin level<100ng/mL or a ferritin level between 100 and 299ng/mL with a transferrin saturation<20%, with or without mild anaemia. Patients were randomized at a 2:1 ratio to receive intravenous ferric carboxymaltose or placebo. The primary objective was to investigate whether intravenous iron replacement improved endurance time from baseline by at least 33%. The secondary objectives were to evaluate impact on QoL using the COPD Assessment Test (CAT) and on DPA by accelerometry. RESULTS We included 66 patients, 44 (66.7%) in the intervention group and 22 (33.3%) in the placebo group. Among patients receiving ferric carboxymaltose, 23 (52.3%) achieved the primary endpoint compared to 4 (18.2%) in the placebo group [p=0.009; relative risk 3.12, (95% CI, 1.19-8.12)]. CAT score decreased -3 (-6.0-1.3) points from baseline in the intervention group (p=0.007), in contrast to placebo group [-1 (-4.0-2.3) points, p=0.236] with no differences in DPA and adverse events in both groups. CONCLUSIONS Iron replacement improved exercise capacity and QoL in stable COPD patients with iron deficiency. The treatment was well tolerated. CLINICAL TRIAL REGISTRATION EudraCT 2016-001238-89.
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Affiliation(s)
- Clara Martín-Ontiyuelo
- Pulmonology Department-Muscle Wasting and Cachexia in Chronic Respiratory Diseases and Lung Cancer Research Group, Hospital del Mar-IMIM (Parc de Salut Mar), Health and Experimental Sciences Department (DCEXS), Universitat Pompeu Fabra (UPF), Barcelona Biomedical Research Park (PRBB), Barcelona, Spain; Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos-III (ISCIII), Barcelona, Spain
| | - Anna Rodó-Pin
- Pulmonology Department-Muscle Wasting and Cachexia in Chronic Respiratory Diseases and Lung Cancer Research Group, Hospital del Mar-IMIM (Parc de Salut Mar), Health and Experimental Sciences Department (DCEXS), Universitat Pompeu Fabra (UPF), Barcelona Biomedical Research Park (PRBB), Barcelona, Spain
| | - Daniel Echeverría-Esnal
- Pharmacy Department, Hospital del Mar (Parc de Salut Mar), Barcelona, Spain; Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Mireia Admetlló
- Pulmonology Department-Muscle Wasting and Cachexia in Chronic Respiratory Diseases and Lung Cancer Research Group, Hospital del Mar-IMIM (Parc de Salut Mar), Health and Experimental Sciences Department (DCEXS), Universitat Pompeu Fabra (UPF), Barcelona Biomedical Research Park (PRBB), Barcelona, Spain
| | - Xavier Duran-Jordà
- Methodology & Biostatistics Support Unit, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Mariela Alvarado
- Pulmonology Department-Muscle Wasting and Cachexia in Chronic Respiratory Diseases and Lung Cancer Research Group, Hospital del Mar-IMIM (Parc de Salut Mar), Health and Experimental Sciences Department (DCEXS), Universitat Pompeu Fabra (UPF), Barcelona Biomedical Research Park (PRBB), Barcelona, Spain
| | - Joaquim Gea
- Pulmonology Department-Muscle Wasting and Cachexia in Chronic Respiratory Diseases and Lung Cancer Research Group, Hospital del Mar-IMIM (Parc de Salut Mar), Health and Experimental Sciences Department (DCEXS), Universitat Pompeu Fabra (UPF), Barcelona Biomedical Research Park (PRBB), Barcelona, Spain; Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos-III (ISCIII), Barcelona, Spain
| | - Esther Barreiro
- Pulmonology Department-Muscle Wasting and Cachexia in Chronic Respiratory Diseases and Lung Cancer Research Group, Hospital del Mar-IMIM (Parc de Salut Mar), Health and Experimental Sciences Department (DCEXS), Universitat Pompeu Fabra (UPF), Barcelona Biomedical Research Park (PRBB), Barcelona, Spain; Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos-III (ISCIII), Barcelona, Spain
| | - Diego A Rodríguez-Chiaradía
- Pulmonology Department-Muscle Wasting and Cachexia in Chronic Respiratory Diseases and Lung Cancer Research Group, Hospital del Mar-IMIM (Parc de Salut Mar), Health and Experimental Sciences Department (DCEXS), Universitat Pompeu Fabra (UPF), Barcelona Biomedical Research Park (PRBB), Barcelona, Spain; Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos-III (ISCIII), Barcelona, Spain.
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12
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Wanderley Xavier AC, Koch R, Steinhorst Goelzer L, Muller PT. Pulmonary Arterial Pressure Changes Under Dobutamine Stress Echocardiography in Non-Anemic Iron Deficient COPD Subjects. Int J Chron Obstruct Pulmon Dis 2022; 17:1943-1949. [PMID: 36043204 PMCID: PMC9420441 DOI: 10.2147/copd.s365461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/25/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Non-anemic iron deficiency (NAID) is common in COPD, and could induce functional/structural changes in the pulmonary vascular bed. Thus, we aimed to study, during resting and ambient oxygen conditions, the systolic pulmonary arterial pressure (sPAP) changes during dobutamine stress echocardiography (DSE) for NAID+ compared to NAID- subjects with COPD. Patients and Methods We analyzed 24 patients with COPD and evaluated their clinical parameters, including lung function and serum iron profile, followed by the changes in the sPAP under DSE. Results Ten subjects with NAID+ were compared with fourteen NAID- subjects for sPAP measurement. At baseline, only left atrial volume was significantly different between groups (30±4 vs 23±5 mL*m2), respectively (p-value=0.002). For the right side, tricuspid annular plane systolic excursion (TAPSE) was similar between-groups (22±2 vs 20±4, p-value >0.05), at baseline. The sPAP (mmHg) changes were also not significantly different between groups (pre 32±14 vs peak 48±14 for NAID+ and pre 29±7 vs peak 43±10 for NAID-, Group p-value=0.400, Time p-value <0.0001, and Interaction p-value=0.606). Conclusion COPD subjects with NAID do not show increased sPAP responses during DSE, compared with iron-replete subjects.
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Affiliation(s)
- Ana Christina Wanderley Xavier
- Federal University of Mato Grosso do Sul (UFMS)/Maria Aparecida Pedrossian Hospital (HUMAP), Laboratory of Respiratory Pathophysiology (LAFIR), Campo Grande, Mato Grosso do Sul, MS, Brazil.,Echocardiography Unit, Maria Aparecida Pedrossian Hospital (HUMAP), Campo Grande, Mato Grosso do Sul, MS, Brazil
| | - Rodrigo Koch
- Federal University of Mato Grosso do Sul (UFMS)/Maria Aparecida Pedrossian Hospital (HUMAP), Laboratory of Respiratory Pathophysiology (LAFIR), Campo Grande, Mato Grosso do Sul, MS, Brazil
| | - Leandro Steinhorst Goelzer
- Federal University of Mato Grosso do Sul (UFMS)/Maria Aparecida Pedrossian Hospital (HUMAP), Laboratory of Respiratory Pathophysiology (LAFIR), Campo Grande, Mato Grosso do Sul, MS, Brazil
| | - Paulo T Muller
- Federal University of Mato Grosso do Sul (UFMS)/Maria Aparecida Pedrossian Hospital (HUMAP), Laboratory of Respiratory Pathophysiology (LAFIR), Campo Grande, Mato Grosso do Sul, MS, Brazil
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13
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Frise MC, Holdsworth DA, Johnson AW, Chung YJ, Curtis MK, Cox PJ, Clarke K, Tyler DJ, Roberts DJ, Ratcliffe PJ, Dorrington KL, Robbins PA. Abnormal whole-body energy metabolism in iron-deficient humans despite preserved skeletal muscle oxidative phosphorylation. Sci Rep 2022; 12:998. [PMID: 35046429 PMCID: PMC8770476 DOI: 10.1038/s41598-021-03968-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 12/10/2021] [Indexed: 01/01/2023] Open
Abstract
Iron deficiency impairs skeletal muscle metabolism. The underlying mechanisms are incompletely characterised, but animal and human experiments suggest the involvement of signalling pathways co-dependent upon oxygen and iron availability, including the pathway associated with hypoxia-inducible factor (HIF). We performed a prospective, case-control, clinical physiology study to explore the effects of iron deficiency on human metabolism, using exercise as a stressor. Thirteen iron-deficient (ID) individuals and thirteen iron-replete (IR) control participants each underwent 31P-magnetic resonance spectroscopy of exercising calf muscle to investigate differences in oxidative phosphorylation, followed by whole-body cardiopulmonary exercise testing. Thereafter, individuals were given an intravenous (IV) infusion, randomised to either iron or saline, and the assessments repeated ~ 1 week later. Neither baseline iron status nor IV iron significantly influenced high-energy phosphate metabolism. During submaximal cardiopulmonary exercise, the rate of decline in blood lactate concentration was diminished in the ID group (P = 0.005). Intravenous iron corrected this abnormality. Furthermore, IV iron increased lactate threshold during maximal cardiopulmonary exercise by ~ 10%, regardless of baseline iron status. These findings demonstrate abnormal whole-body energy metabolism in iron-deficient but otherwise healthy humans. Iron deficiency promotes a more glycolytic phenotype without having a detectable effect on mitochondrial bioenergetics.
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Affiliation(s)
- Matthew C Frise
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK
| | - David A Holdsworth
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK
| | - Andrew W Johnson
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Yu Jin Chung
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK
| | - M Kate Curtis
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK
| | - Pete J Cox
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK
| | - Kieran Clarke
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK
| | - Damian J Tyler
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK
| | - David J Roberts
- Nuffield Department of Clinical Laboratory Sciences, National Blood Service Oxford Centre, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9BQ, UK
| | - Peter J Ratcliffe
- Nuffield Department of Medicine, University of Oxford, NDM Research Building, Old Road Campus, Headington, Oxford, OX3 7FZ, UK
- Francis Crick Institute, London, NW1 1AT, UK
| | - Keith L Dorrington
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK
| | - Peter A Robbins
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK.
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14
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Shah AA, Donovan K, Seeley C, Dickson EA, Palmer AJR, Doree C, Brunskill S, Reid J, Acheson AG, Sugavanam A, Litton E, Stanworth SJ. Risk of Infection Associated With Administration of Intravenous Iron: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2133935. [PMID: 34767026 PMCID: PMC8590171 DOI: 10.1001/jamanetworkopen.2021.33935] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Intravenous iron is recommended by many clinical guidelines based largely on its effectiveness in reducing anemia. However, the association with important safety outcomes, such as infection, remains uncertain. OBJECTIVE To examine the risk of infection associated with intravenous iron compared with oral iron or no iron. DATA SOURCES Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomized clinical trials (RCTs) from 1966 to January 31, 2021. Ongoing trials were sought from ClinicalTrials.gov, CENTRAL, and the World Health Organization International Clinical Trials Search Registry Platform. STUDY SELECTION Pairs of reviewers identified RCTs that compared intravenous iron with oral iron or no iron across all patient populations, excluding healthy volunteers. Nonrandomized studies published since January 1, 2007, were also included. A total of 312 full-text articles were assessed for eligibility. DATA EXTRACTION AND SYNTHESIS Data extraction and risk of bias assessments were performed according to the Preferred Reporting Items of Systematic Reviews and Meta-analyses (PRISMA) and Cochrane recommendations, and the quality of evidence was assessed using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) approach. Two reviewers extracted data independently. A random-effects model was used to synthesize data from RCTs. A narrative synthesis was performed to characterize the reporting of infection. MAIN OUTCOMES AND MEASURES The primary outcome was risk of infection. Secondary outcomes included mortality, hospital length of stay, and changes in hemoglobin and red blood cell transfusion requirements. Measures of association were reported as risk ratios (RRs) or mean differences. RESULTS A total of 154 RCTs (32 920 participants) were included in the main analysis. Intravenous iron was associated with an increased risk of infection when compared with oral iron or no iron (RR, 1.17; 95% CI, 1.04-1.31; I2 = 37%; moderate certainty of evidence). Intravenous iron also was associated with an increase in hemoglobin (mean difference, 0.57 g/dL; 95% CI, 0.50-0.64 g/dL; I2 = 94%) and a reduction in the risk of requiring a red blood cell transfusion (RR, 0.93; 95% CI, 0.76-0.89; I2 = 15%) when compared with oral iron or no iron. There was no evidence of an effect on mortality or hospital length of stay. CONCLUSIONS AND RELEVANCE In this large systematic review and meta-analysis, intravenous iron was associated with an increased risk of infection. Well-designed studies, using standardized definitions of infection, are required to understand the balance between this risk and the potential benefits.
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Affiliation(s)
- Akshay A. Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Biomedical Research Centre Haematology Theme, Oxford, United Kingdom
- Adult Intensive Care Unit, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Killian Donovan
- Adult Intensive Care Unit, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Claire Seeley
- Department of Anaesthesia, Royal Berkshire Hospitals NHS Foundation Trust, Reading, United Kingdom
| | - Edward A. Dickson
- National Institute for Health Research Biomedical Research Centre in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | - Antony J. R. Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
| | - Susan Brunskill
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
| | - Jack Reid
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Austin G. Acheson
- National Institute for Health Research Biomedical Research Centre in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | - Anita Sugavanam
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Australia
| | - Simon J. Stanworth
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Biomedical Research Centre Haematology Theme, Oxford, United Kingdom
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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15
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Balasubramanian A, Henderson RJ, Putcha N, Fawzy A, Raju S, Hansel NN, MacIntyre NR, Jensen RL, Kinney GL, Stringer WW, Hersh CP, Bowler RP, Casaburi R, Han MK, Porszasz J, Make BJ, McCormack MC, Wise RA. Haemoglobin as a biomarker for clinical outcomes in chronic obstructive pulmonary disease. ERJ Open Res 2021; 7:00068-2021. [PMID: 34322549 PMCID: PMC8311135 DOI: 10.1183/23120541.00068-2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/11/2021] [Indexed: 12/01/2022] Open
Abstract
In COPD, anaemia is associated with increased morbidity, but the relationship between haemoglobin over its entire observed range and morbidity is poorly understood. Such an understanding could guide future therapeutic targeting of haemoglobin in COPD management. Leveraging the COPDGene study, we conducted a cross-sectional analysis of haemoglobin from COPD participants, examining symptoms, quality of life, functional performance, and acute exacerbations of COPD (AECOPD). Haemoglobin was analysed both as a continuous variable and categorised into anaemia, normal haemoglobin, and polycythaemia groups. Fractional polynomial modelling was used for continuous analyses; categorical models were multivariable linear or negative binomial regressions. Covariates included demographics, comorbidities, emphysema, diffusing capacity, and airflow obstruction. From 2539 participants, 366 (14%) were identified as anaemic and 125 (5%) as polycythaemic. Compared with normal haemoglobin, anaemia was significantly associated with increased symptoms (COPD Assessment Test score: p=0.006, modified Medical Research Council (mMRC) Dyspnoea Score: p=0.001); worse quality of life (St. George's Respiratory Questionnaire (SGRQ) score: p<0.001; Medical Outcomes Study Short Form 36-item Questionnaire (SF-36) General Health: p=0.002; SF-36 Physical Health: p<0.001), decreased functional performance (6-min walk distance (6MWD): p<0.001), and severe AECOPD (p=0.01), while polycythaemia was not. Continuous models, however, demonstrated increased morbidity at both ends of the haemoglobin distribution (p<0.01 for mMRC, SGRQ, SF-36 Physical Health, 6MWD, and severe AECOPD). Evaluating interactions, both diffusing capacity and haemoglobin were independently associated with morbidity. We present novel findings that haemoglobin derangements towards either extreme of the observed range are associated with increased morbidity in COPD. Further investigation is necessary to determine whether haemoglobin derangement drives morbidity or merely reflects systemic inflammation, and whether correcting haemoglobin towards the normal range improves morbidity.
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Affiliation(s)
- Aparna Balasubramanian
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Robert J. Henderson
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Nirupama Putcha
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ashraf Fawzy
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Sarath Raju
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Nadia N. Hansel
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Neil R. MacIntyre
- Division of Pulmonary and Critical Care Medicine, Duke University, Durham, NC, USA
| | - Robert L. Jensen
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
| | - Gregory L. Kinney
- Dept of Epidemiology, Colorado School of Public Health, University of Colorado, Denver, CO, USA
| | - William W. Stringer
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Craig P. Hersh
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Russell P. Bowler
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA
| | - Richard Casaburi
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - MeiLan K. Han
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Janos Porszasz
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Barry J. Make
- Dept of Epidemiology, Colorado School of Public Health, University of Colorado, Denver, CO, USA
| | - Meredith C. McCormack
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Robert A. Wise
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
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16
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Nutritional immunity: the impact of metals on lung immune cells and the airway microbiome during chronic respiratory disease. Respir Res 2021; 22:133. [PMID: 33926483 PMCID: PMC8082489 DOI: 10.1186/s12931-021-01722-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 04/15/2021] [Indexed: 12/15/2022] Open
Abstract
Nutritional immunity is the sequestration of bioavailable trace metals such as iron, zinc and copper by the host to limit pathogenicity by invading microorganisms. As one of the most conserved activities of the innate immune system, limiting the availability of free trace metals by cells of the immune system serves not only to conceal these vital nutrients from invading bacteria but also operates to tightly regulate host immune cell responses and function. In the setting of chronic lung disease, the regulation of trace metals by the host is often disrupted, leading to the altered availability of these nutrients to commensal and invading opportunistic pathogenic microbes. Similarly, alterations in the uptake, secretion, turnover and redox activity of these vitally important metals has significant repercussions for immune cell function including the response to and resolution of infection. This review will discuss the intricate role of nutritional immunity in host immune cells of the lung and how changes in this fundamental process as a result of chronic lung disease may alter the airway microbiome, disease progression and the response to infection.
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