1. Iron Deficiency Anaemia
H.A MWAKYOMA, MD

2. 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

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

4. 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)

5. 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

6. 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

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

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

9. 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

10. 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)

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

12. 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, …)

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

14. 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

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

16. 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

17. 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

18. 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)

19. 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

20. 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

21. 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

22. 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.

23. 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.

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

25. 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

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

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