Nutritional Aspects of Iron in Health and Disease

AGA Clinical Practice Update on Management of Iron Deficiency Anemia: Expert Review

DESCRIPTION

In this Clinical Practice Update (CPU), we will Best Practice Advice (BPA) guidance on the appropriate management of iron deficiency anemia.

METHODS

This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPUC and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. These Best Practice Advice (BPA) statements were drawn from a review of the published literature and from expert opinion. Since systematic reviews were not performed, these BPA statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE 1: No single formulation of oral iron has any advantages over any other. Ferrous sulfate is preferred as the least expensive iron formulation. BEST PRACTICE ADVICE 2: Give oral iron once a day at most. Every-other-day iron dosing may be better tolerated for some patients with similar or equal rates of iron absorption as daily dosing. BEST PRACTICE ADVICE 3: Add vitamin C to oral iron supplementation to improve absorption. BEST PRACTICE ADVICE 4: Intravenous iron should be used if the patient does not tolerate oral iron, ferritin levels do not improve with a trial of oral iron, or the patient has a condition in which oral iron is not likely to be absorbed. BEST PRACTICE ADVICE 5: Intravenous iron formulations that can replace iron deficits with 1 or 2 infusions are preferred over those that require more than 2 infusions. BEST PRACTICE ADVICE 6: All intravenous iron formulations have similar risks; true anaphylaxis is very rare. The vast majority of reactions to intravenous iron are complement activation-related pseudo-allergy (infusion reactions) and should be treated as such. BEST PRACTICE ADVICE 7: Intravenous iron therapy should be used in individuals who have undergone bariatric procedures, particularly those that are likely to disrupt normal duodenal iron absorption, and have iron-deficiency anemia with no identifiable source of chronic gastrointestinal blood loss. BEST PRACTICE ADVICE 8: In individuals with inflammatory bowel disease and iron-deficiency anemia, clinicians first should determine whether iron-deficiency anemia is owing to inadequate intake or absorption, or loss of iron, typically from gastrointestinal bleeding. Active inflammation should be treated effectively to enhance iron absorption or reduce iron depletion. BEST PRACTICE ADVICE 9: Intravenous iron therapy should be given in individuals with inflammatory bowel disease, iron-deficiency anemia, and active inflammation with compromised absorption. BEST PRACTICE ADVICE 10: In individuals with portal hypertensive gastropathy and iron-deficiency anemia, oral iron supplements initially should be used to replenish iron stores. Intravenous iron therapy should be used in patients with ongoing bleeding who do not respond to oral iron therapy. BEST PRACTICE ADVICE 11: In individuals with portal hypertensive gastropathy and iron-deficiency anemia without another identified source of chronic blood loss, treatment of portal hypertension with nonselective β-blockers can be considered. BEST PRACTICE ADVICE 12: In individuals with iron-deficiency anemia secondary to gastric antral vascular ectasia who have an inadequate response to iron replacement, consider endoscopic therapy with endoscopic band ligation or thermal methods such as argon plasma coagulation. BEST PRACTICE ADVICE 13: In patients with iron-deficiency anemia and celiac disease, ensure adherence to a gluten-free diet to improve iron absorption. Consider oral iron supplementation based on the severity of iron deficiency and patient tolerance, followed by intravenous iron therapy if iron stores do not improve. BEST PRACTICE ADVICE 14: Deep enteroscopy performed in patients with iron-deficiency anemia suspected to have small-bowel bleeding angioectasias should be performed with a distal attachment to improve detection and facilitate treatment. Small-bowel angioectasias may be treated with ablative thermal therapies such as argon plasma coagulation or with mechanical methods such as hemostatic clips. BEST PRACTICE ADVICE 15: Endoscopic treatment of angioectasias should be accompanied with iron replacement. Medical therapy for small-bowel angioectasias should be reserved for compassionate treatment in refractory cases when iron replacement and endoscopic therapy are ineffective.

Enriched-Fe maize kernels to prevent dietary Fe deficiency in humans

Iron (Fe) biofortification of edible organs without influencing crop yield is challenging, and potential solutions are largely unknown. Recently, Yan et al. identified a key regulator NAC78 (NAM/ATAF/CUC DOMAIN TRANSCRIPTION FACTOR 78) that enriches Fe in maize kernels without compromising crop yield. This may provide new crop yield management strategies for Fe acquisition and nutritional security.

The roles of essential trace elements in T cell biology

T cells are crucial for adaptive immunity to regulate proper immune response and immune homeostasis. T cell development occurs in the thymus and mainly differentiates into CD4+ and CD8+ T cell subsets. Upon stimulation, naive T cells differentiate into distinct CD4+ helper and CD8+ cytotoxic T cells, which mediate immunity homeostasis and defend against pathogens or tumours. Trace elements are minimal yet essential components of human body that cannot be overlooked, and they participate in enzyme activation, DNA synthesis, antioxidant defence, hormone production, etc. Moreover, trace elements are particularly involved in immune regulations. Here, we have summarized the roles of eight essential trace elements (iron, zinc, selenium, copper, iodine, chromium, molybdenum, cobalt) in T cell development, activation and differentiation, and immune response, which provides significant insights into developing novel approaches to modulate immunoregulation and immunotherapy.

Iron Absorption: Molecular and Pathophysiological Aspects

Iron is an essential nutrient for growth among all branches of life, but while iron is among the most common elements, bioavailable iron is a relatively scarce nutrient. Since iron is fundamental for several biological processes, iron deficiency can be deleterious. On the other hand, excess iron may lead to cell and tissue damage. Consequently, iron balance is strictly regulated. As iron excretion is not physiologically controlled, systemic iron homeostasis is maintained at the level of absorption, which is mainly influenced by the amount of iron stores and the level of erythropoietic activity, the major iron consumer. Here, we outline recent advances that increased our understanding of the molecular aspects of iron absorption. Moreover, we examine the impact of these recent insights on dietary strategies for maintaining iron balance.

Poly-β-cyclodextrin strengthen Pr6O11 porous oxidase mimic for dual-channel visual recognition of bioactive cysteine and Fe2

To conveniently monitor bioactive cysteine (Cys) and Fe2+ in practice, a kind of poly-β-cyclodextrin strengthen praseodymium oxide (Pr6O11) porous oxidase mimic (p-β-CD@Pr6O11) was constructed by virtue of the strong coordination between nano Pr6O11 and poly-β-cyclodextrin substrate. After its microstructure and physicochemical property were characterized in detail, it was noted that porous p-β-CD@Pr6O11 exhibited excellent enzyme-like catalytic activity to accelerate the oxidation of 3,3',5,5,'-tetramethylbanzidine (TMB) and 2,2'-azinobis (3-ethylbenzo-thiazoline-6-sulfonic acid) ammonium salt (ABTS) with significant color-enhancement effect in the air. Based on the signal amplification, trace Cys could exclusively deteriorate the UV-vis absorbance at 653 nm of p-β-CD@Pr6O11-TMB and Fe2+ alter the one at 729 nm of p-β-CD@Pr6O11-ABTS with visual color changes. Under the optimized conditions, the proposed p-β-CD@Pr6O11-TMB and p-β-CD@Pr6O11-ABTS systems were successfully applied for dual-channel monitoring of Cys in Cys capsules and fetal bovine serum and Fe2+ in agricultural products with quite low detection limits, i.e., 7.8×10-9 mol·L-1 for Cys and 6.93×10-8 mol·L-1 (S/N=3) for Fe2+, respectively. The synergetic-enhancement detection mechanisms to Cys and Fe2+ were also proposed.

Long-term iron supplementation combined with vitamin B6 enhances maximal oxygen uptake and promotes skeletal muscle-specific mitochondrial biogenesis in rats

Introduction

Iron is an essential micronutrient that plays a crucial role in various biological processes. Previous studies have shown that iron supplementation is related to exercise performance and endurance capacity improvements. However, the underlying mechanisms responsible for these effects are not well understood. Recent studies have suggested the beneficial impact of iron supplementation on mitochondrial function and its ability to rescue mitochondrial function under adverse stress in vitro and rodents. Based on current knowledge, our study aimed to investigate whether the changes in exercise performance resulting from iron supplementation are associated with its effect on mitochondrial function.

Methods

In this study, we orally administered an iron-based supplement to rats for 30 consecutive days at a dosage of 0.66 mg iron/kg body weight and vitamin B6 at a dosage of 0.46 mg/kg.

Results

Our findings reveal that long-term iron supplementation, in combination with vitamin B6, led to less body weight gained and increased VO2 max in rats. Besides, the treatment substantially increased Complex I- and Complex II-driven ATP production in intact mitochondria isolated from gastrocnemius and cerebellum. However, the treatment did not change basal and succinate-induced ROS production in mitochondria from the cerebellum and skeletal muscle. Furthermore, the iron intervention significantly upregulated several skeletal muscle mitochondrial biogenesis and metabolism-related biomarkers, including PGC-1α, SIRT1, NRF-2, SDHA, HSL, MTOR, and LON-P. However, it did not affect the muscular protein expression of SIRT3, FNDC5, LDH, FIS1, MFN1, eNOS, and nNOS. Interestingly, the iron intervention did not exert similar effects on the hippocampus of rats.

Discussion

In conclusion, our study demonstrates that long-term iron supplementation, in combination with vitamin B6, increases VO2 max, possibly through its positive role in regulating skeletal muscle-specific mitochondrial biogenesis and energy production in rats.

One advantageous reflection of iron metabolism in context of normal physiology and pathological phases

PURPOSE (BACKGROUND)

The presented review is an updating of Iron metabolism in context of normal physiology and pathological phases. Iron is one of the vital elements in humans and associated into proteins as a component of heme (e.g. hemoglobin, myoglobin, cytochromes proteins, myeloperoxidase, nitric oxide synthetases), iron sulfur clusters (e.g. respiratory complexes I-III, coenzyme Q10, mitochondrial aconitase, DNA primase), or other functional groups (e.g. hypoxia inducible factor prolyl hydroxylases). All these entire iron-containing proteins ar e needed for vital cellular and organismal functions together with oxygen transport, mitochondrial respiration, intermediary and xenobiotic metabolism, nucleic acid replication and repair, host defense, and cell signaling.

METHODS (METABOLIC STRATEGIES)

Cells have developed metabolic strategies to import and employ iron safely. Regulatory process of iron uptake, storage, intracellular trafficking and utilization is vital for the maintenance of cellular iron homeostasis. Cellular iron utilization and intracellular iron trafficking pathways are not well established and very little knowledge about this. The predominant organs, which are associated in the metabolism of iron, are intestine, liver, bone marrow and spleen. Iron is conserved, recycled and stored. The reduced bioavailability of iron in humans has developed extremely efficient mechanisms for iron conservation. Prominently, the losses of iron cannot considerably enhance through physiologic mechanisms, even if iron intake and stores become excessive. Loss of iron is balanced or maintained from dietary sources.

RESULTS (OUTCOMES)

Numerous physiological abnormalities are associated with impaired iron metabolism. These abnormalities are appeared in the form of several diseases. There are duodenal ulcer, inflammatory bowel disease, sideroblastic anaemia, congenital dyserythropoietic anemias and low-grade myelodysplastic syndromes. Hereditary hemochromatosis and anaemia are two chronic diseases, which are responsible for disturbing the iron metabolism in various tissues, including the spleen and the intestine. Impairment in hepatic hepcidin synthesis is responsible for chronic liver disease, which is grounding from alcoholism or viral hepatitis. This condition directs to iron overload that can cause further hepatic damage. Iron has important role in several infectious diseases are tuberculosis, malaria trypanosomatid diseases and acquired immunodeficiency syndrome (AIDS). Iron is also associated with Systemic lupus erythematosus [SLE], cancer, Alzheimer's disease (AD) and post-traumatic epilepsy.

CONCLUSION

Recently, numerous research studies are gradually more dedicated in the field of iron metabolism, but a number of burning questions are still waiting for answer. Cellular iron utilization and intracellular iron trafficking pathways are not well established and very little knowledge about this. Increased information of the physiology of iron homeostasis will support considerate of the pathology of iron disorders and also make available the support to advance treatment.