Iron Deficiency Anaemia H.A MWAKYOMA, MD

Iron Deficiency Anaemia- Definition As the name implies, iron deficiency anemia is due to insufficient iron. Without enough iron, the body can't produce enough hemoglobin, a substance in red blood cells that enables them to carry oxygen. As a result, iron deficiency anemia may leave an individual tired and short of breath

Iron Deficiency —Aetiology Increased demand  for iron and/or haematopoiesis Iron loss Decreased iron intake Decreased iron absorption

Iron Deficiency anaemia Increased Demand for Iron and/or  Haematopoiesis  Infancy and adolescence Pregnancy and lactation Low socioeconomic status and poverty greatly increase the prevalence of iron deficiency in this category of populations In patients receiving erythropoietin therapy (= functional iron deficiency)

Iron Deficiency —Iron loss In  physiologic conditions Menstruation In pathologic conditions Surgery, delivery Haemoglobinuria ,haemoptysis Gastrointestinal tract pathology In therapeutic procedures Phlebotomy In blood donation

Iron Deficiency—Decreased Iron Intake or Absorption Vegetarians or malnutrition  (low-cost diet)1 Malabsorption syndromes Sprue, UHC, and Crohn’s disease After gastric and intestinal surgery Intestinal parasitosis (ancylostomiasis) Helicobacter pylori infection Autoimmune atrophic gastritis

Iron Deficiency Clinical Manifestations (I) Fatigue Decreased exercise tolerance Tachycardia Dermatologic manifestations Decreased intellectual performance Dysphasia Depression, increased incidence of infections Restless legs syndrome

Iron Deficiency Clinical Manifestations (II) Skin and conjuctival   pallor  Koilonychia Angular cheilosis Burning tongue Glossitis Hair loss (alopecia areata)

Iron Deficiency Iron deficiency anemia symptoms may include: Extreme fatigue Pale skin Weakness Shortness of breath Headache Dizziness or lightheadedness Cold hands and feet Irritability

Iron deficiency anemia symptoms may include: Inflammation or soreness of the tongue Brittle nails Fast heartbeat - tachycardia Unusual cravings for non-nutritive substances, such as ice, dirt or starch Poor appetite, especially in infants and children with iron deficiency anemia An uncomfortable tingling or crawling feeling in the legs (restless legs syndrome)

Iron Deficiency Diagnosis Laboratory tests for Iron depletion in the body Iron-deficient erythropoiesis (functional iron deficiency)

Diagnosis of Iron Depletion in the Body—Haematology Peripheral blood smear  of a patient with severe iron deficient  anaemia.  Note the important microcytosis (compare  red blood cells with lymphocyte) as well  as  hypochromia,  target cells, and poikilocytosis Iron deficiency Thalassaemia syndromes Haemoglobinopathies (E,C,CS, …)

Iron deficiency Anaemia of chronic diseases Familial sideroblastic anaemia Miscellaneous (lead intoxication…) Hypochromic, microcytic  anaemia usually with high platelets

Diagnosis of Iron Depletion in the Body— Clinical Chemistry Serum iron Transferrin (iron binding capacity) Transferrin saturation These  parameters are modified  by inflammation and  by fasting state. They  are thus of limited  value

Serum ferritin,  soluble  transferrin receptors (sTfR) and sTfR/log ferritin are excellent tools for screening iron stores

Iron Deficiency—Diagnosis Bone marrow examination  for stainable iron was regarded in the  past as the gold standard for diagnosing  iron deficiency No longer recommended for routine evaluation High inter- and intra-observer variability in evaluation Discomfort associated with procedure

Iron-Deficient Erythropoiesis (Functional Iron Deficiency)—Diagnosis Normal or increased  ferritin Laboratory signs of iron-deficient erythropoiesis Serum iron <60 μg/dL Transferrin saturation <20% Hypochromic RBC >5% Reticulocyte Hb content (CHr) <29 pg Soluble transferrin receptor > 7 mg/L

Main Conditions Characterized by Functional Iron Deficiency EPOstimulated red  cell production (anaemia of chronic kidney  disease) Insufficient mobilization of iron from macrophages (anaemia in rheumatoid arthritis and in cancer)

Refractory Iron Deficiency Anaemia In recent years,  Helicobacter pylori has been implicated in several studies as a cause of iron deficiency anaemia (IDA) refractory to oral iron treatment, with a favorable response to H. pylori eradication Another nonbleeding gastrointestinal condition that may result in IDA refractory to oral iron treatment is coeliac disease

Refractory Iron Deficiency Anaemia Autoimmune atrophic gastritis  or atrophic body gastritis has been associated  with chronic idiopathic iron deficiency with  no evidence of gastrointestinal blood loss  and thus is another cause that leads  to refractory IDA

IDA—Conclusions Iron deficiency  causes not only anaemia but also extraerythroid  symptoms Diagnosis of iron deficiency may be difficult in the presence of a concommitant inflammatory state Patients should be assessed for functional iron deficiency when erythropoietin is used to correct anaemia IDA refractory to oral iron treatment is a new entity justifying a particular diagnostic work-up

Diagnosis Anemia is typically diagnosed on a complete blood count. Apart from reporting the number of red blood cells and the hemoglobin level, the automatic counters also measure the size of the red blood cells by flow cytometry, which is an important tool in distinguishing between the causes of anemia. Examination of a stained blood smear using a microscope can also be helpful, and is sometimes a necessity in regions of the world where automated analysis is less accessible.

Diagnosis In modern counters, four parameters (RBC count, hemoglobin concentration, MCV and RDW) are measured, allowing others (hematocrit, MCH and MCHC) to be calculated, and compared to values adjusted for age and sex. Some counters estimate hematocrit from direct measurements.

Microcytic Hypochromic Anemia MCV <80 Reduced iron availability Reduced heme synthesis Reduced globin production

Microcytic Anemia REDUCED IRON AVAILABILTY Iron Deficiency Deficient Diet/Absorption Increased Requirements Blood Loss Iron Sequestration Anemia of Chronic Disease Low serum iron, low TIBC, normal serum ferritin MANY!! Chronic infection, inflammation, cancer, liver disease

Microcytic Anemia REDUCED HEME SYNTHESIS Lead poisoning Acquired or congenital sideroblastic anemia Characteristic smear finding: Basophylic stippling

Microcytic Anemia REDUCED GLOBIN PRODUCTION Thalassemias Smear Characteristics Hypochromia Microcytosis Target Cells Tear Drops