IRON DEFICIENCY ANEMIA

Dr Zaimah Z Tala, MS, SpGK Nutrition Dept Faculty of Medicine, University of Sumatera Utara

Definition
Deficit of circulating RBC associated with diminished oxygen-carrying capacity of the blood Most common hematologic disorder by far Hb < 12 g/dL Hb < 13 or 13.5 g/dL

classification
Microcytic (small cell) - Major nutritional cause is iron deficiency - Minor pirydoxin & copper deficiency Normocytic anemia - PEM & various chronic disease Macrocytic - Vit B12 & folic acid deficiency

Iron-deficiency anemia is the most common nutritional anemia and perhaps the most common nutritional deficiency disorder in the world.

 Characterized by the production of small erythrocytes and diminished level of circulating hemoglobin Last stage of iron deficiency Represent the end point of a long period of iron deprivation

 The greatest risk : - between 6 mo 4 yrs - early adolescent - during the menstruating years - during pregnancy

Causes of Iron Deficiency

Dietary inadequacy the most common cause Inadequate absorption
Pregnancy Infancy Adolescence lactation - poor diet (vegetarian)
Diarrhea ; intestinal disease ; atrophic gastritis ; Achlorhydria ; partial or total gastrectomy ; drug interference

Increased Iron requirement

Increased excretion

- excessive menstrual blood - hemorrhage from injury - chronic blood loss

Pathophysiology
Iron in the body : - functional form : heme, myoglobin, part of many enzyme - storage : ferritin & hemosiderine

Dietary Iron
Heme Fe (meat, fish and poultry) best absorbed. Non-heme Fe (cereal, vegetables) taken up less avidly. Heme Fe 20% bioavailable, nonheme only 3% Ionic Fe (Fe++) also well absorbed. >1/3 of Fe from fortification of flour. Tea inhibits Fe absorption.

Iron Absorption
Proximal small bowel, esp duodenum Enhanced by gastric acid (Fe+2 is valance absorbed) Heme Fe > non-heme Fe Reciprocal relationship to iron stores Direct relationship to erythropoiesis; with ineffective erythropoiesis Inhibited by inflammation, phytates

Fe
Plasma
16%
15%

4%

65%

 The great majority of iron in the body is found in red cells where it is incorporated into hemoglobin to function as an oxygen carrier. Smaller amounts are incorporated into myoglobin (muscle) and cytochromes (all tissues). As red cells turnover in the spleen, iron is recycled back to the bone marrow where it is re-incorporated into hemoglobin. Iron is transported through the plasma bound to transferrin and taken up by cells via the transferrin receptor. Iron is concentrated and stored within the cell encased by ferritin. Excess iron is stored primarily in the macrophages of the liver, spleen and bone marrow Very little iron is lost except through bleeding and menstruation. Therefore, homeostasis of total body iron is maintained by regulating intestinal iron absorption.

IRON
Body Compartments - 75 kg man
Stores 1000mg
Absorption < 1 mg/day

Tissue 500 mg

30 mg

Excretion < 1 mg/day

Red Cells 2300 mg

IRON STORES
Iron Deficiency Anemia
Stores 0 mg
Absorption 2-10 mg/day

Tissue 500 mg

3 mg

Excretion Dependent on Cause

Red Cells 1500 mg

Mechanisms for maintaining iron balance :

- continuous reutilization of iron - regulation of the absorption of iron - access to specific storage protein (ferritin)

Progression of Findings
Bone Marrow iron Serum Iron drops Total Iron Binding Capacity Increases MCV & Hb Blood Smear - Microcytic, Hypochromic

 Typical diet; formerly ~10-15 mg/d, now ~24 mg/d 10-15% comes from heme sources (meats & seafood) 85-90% comes from non heme sources (dried beans, peas, leafy green vegetable) >1/3 of Fe from fortification of flour.

Iron-deficiency anemia is usually discovered during a medical examination through a routine blood test. In addition to a complete medical history and physical exam, diagnostic procedures for iron-deficiency anemia may include additional blood tests and other evaluation procedures.

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Symptoms
Fatigue - Sometimes out of proportion to anemia Atrophic glossitis Pica, esp chew ice Koilonychia (Nail spooning)

Clinical Presentation
Asymptomatic Pallor fatigue, tachycardia Blue sclera Koilonychia

Lab Findings
Plasma ferritin measure of iron stores Transferrin saturation < 16% inadeq for eryhtropoiesis Ratio erythrocyte protoporphyrin to heme sensitive indicator of the iron supply to the developing RBC Hb or Ht

Hb concentration is unsuitable as a diagnostic tool of IDA, because : - it is affected only late in the disease - it does not indicate the type of anemia that exist - there is a wide variation in values in normal subjects

Anemia: Lab Evaluation

Normal Periperhal Smear

Iron Deficiency Anemia

IRON DEFICIENCY
Serum Iron Transferrin Ferritin

Iron Deficiency

Medical Management
Treatment should focus on the underlying disease, although this is often difficult Repletion of iron stores, not merely alleviation of the anemia should be the goal

Therapy
Oral ferrous form - ferrous sulfate most widely used - 50 - 200 mg elemental Fe/d (60 mg, 1-3 x / d - 6.0 mg elemental Fe/kg per day in children - Duration- 6 months Parenteral- Fe dextran 50 mg/ml, 100 mg/d im/iv
- more expensive & not as safe

IRON THERAPY
Response
Initial response takes 7-14 days Modest reticulocytosis (7-10%) Correction of anemia requires 2-3 months 6 months of therapy beyond correction of anemia needed to replete stores, assuming no further loss of blood/iron Parenteral iron possible, but problematic

If supplementation fails, maybe that : 1. The patients may not be taking the medication, most likely because of unpleasant side effect 2. Bleeding may be continuing 3. The supplemental iron is not being absorbed

parenteral route

Medical nutrition therapy

In addition to supplementation, attention should be given to the amount of absorbable dietary iron Liver, kidney, beef, egg yolk, dried fruit, dried peas and beans, nuts, green leafy vegetables, whole grain breads and cereals, and fortified food.

Factors affecting absorption

Enhancing factors : - ascorbic acid - MFP Inhibiting factors : carbonates oxalates phytates tanin

Prevention
Iron supplementation, i.e. giving iron tablets to certain target groups Iron fortification of certain foods Education about food in order to improve the absorption

Recommendations :
Improve food choices to increase amount of total dietary iron Include a source of vitamine C at every meal Include MFP at every meal if possible Avoid drinking a large amounts of tea or coffee with meals

Confusing Chart