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Diagnostic Aids to Qualify and Quantify Iron Various aids are available to diagnose, manage disease and reach a prognosis for patients with an iron disorder. Blood & Urine Chemistries Panels: blood tests can measure basic hormone function, immune function, liver—kidney—bone—heart—pituitary—pancreas—gall bladder— function, mineral levels (iron, copper, zinc, etc); electrolytes, blood cell morphology (size and shape) and performance. Some of these tests are listed on the Iron Disorders Institute Personal Health Profile for Iron Overload form.
Biopsies: are invasive, which means that the procedure involves penetrating an internal organ. This medical procedure is used to determine the extent of organ damage or to confirm disease. Patient with an iron disorder may undergo biopsy of the any vital organ, but the two most frequent biopsies performed on people with too much or too little iron include the liver biopsy and the bone marrow biopsy (also called bone marrow aspiration). Liver Biopsy Described The liver biopsy procedure is performed by a surgeon in a hospital setting. A person may be given a general anesthetic or a local anesthetic and a drug to relax them. A needle is used to draw out a specimen of liver tissue to be examined by a pathologist. The pathologist dries and weighs the specimen, which provides the information needed to calculate the hepatic index. The index is derived from a calculation of the amount of iron concentration (expressed in micromoles of iron per gram of dry liver) in the liver, divided by the age of the patient in years. Hepatic iron greater than 80 mol/g or a hepatic index greater than 1.9 confirms iron overload. Pathologists can see iron by staining a sample of the tissue obtained from liver biopsy with either Perl’s stain or Prussian blue. The sample is examined under a microscope, where iron appears as dark spots on the pathologist’s slide. Without stain, iron cannot be seen. Staining the tissue sample confirms the presence of iron, whereas drying and weighing the tissue sample, and then analyzing it for iron content, confirms the amount of iron contained in the biopsied organ. NOTE: with the availability of the genetic test, the liver biopsy is not longer used to diagnosis hereditary hemochromatosis although liver biopsy remains the gold standard for determining liver damage or disease (cirrhosis, cancer) Bone marrow aspiration: the procedure is similar to liver biopsy in that a needle is used to penetrate the bone marrow. The needle gathers a small amount of tissue from the marrow, which is stained for iron in the same way as a liver biopsy. Bone marrow tissue reveals the blood cell health and activity. This procedure is performed most often on patients with blood cancers, unexplained iron deficiency anemia or who are preparing for bone marrow transplantation.
heart and anterior pituitary. iron. The speed (velocity) with which the pulse moves and reaches its target is measured with ultrasound. In general. Scans & Imaging Magnetic Resonance Imaging (MRI): can qualify and quantify iron in the liver. If iron is present in the liver. or (R2)) which yield the relaxation time (recovery time) of the signal/pulse. In quantitative phlebotomy.co.excessiron.the stiffer the liver is the greater the degree of fibrosis. which contains approximately 200 to 250 milligrams of iron. For more about the procedure visit: . A radiologist must have additional training to perform this specialized imaging technique. When the signal is interrupted by a tumor or in this case.com/hcp/diagnosis/imaging_studies/magnetic. A reading is taken of these rates (proton transverse relaxation rates. the relaxation time is ―shortened‖. the relaxation time is normal and the output or reading of the organ scanned demonstrates no abnormalities. This is presently the only noninvasive approach to qualify iron deposits in the heart. MRI uses a powerful magnet and radio-frequencies (signals. or tissue sample for certain mutations. the output reading shows a ―black‖ area where the signal/pulse recovery time was abbreviated. patients who are pregnant or patients under the age of 18 years of age. This type of test examines DNA from a blood. The velocity of the pulse is directly correlated to the stiffness of the liver. The procedure is expensive. For more about Ferriscan® visit .http://www. FerriScan and SQUID are two aids that use the T2* relaxation approach. Genetic information does not provide information about iron levels. Using a specialized technique a trained radiologist can demonstrate differences in the rate at which a signal/pulse transverses (passes through) the body. A mechanical pulse goes through the skin to the liver.jsp http://www. but it does expose the potential risk of developing iron disorders. Fibroscan® should not be used on patients with ascites (fluid in the abdomen). Read more about this type of technology http://www.Quantitative Phlebotomy is an indirect way of diagnosing hemochromatosis.com/ SQUID: Superconducting Quantum Interference Device (SQUID) uses a low-power magnetic field with sensitive detectors that measure the interference of iron within the field. pulses) which are sent through the person’s body producing a reading that is sent to a computer. 4 grams of iron are found in about 16 to 20 pints of blood.com/screening-and-diagnosis4. Fibroscan® Noninvasive way to determine the rigidity (hardness) of the liver. Individuals who have 4 grams or more of mobilizable iron by quantitative phlebotomy may be diagnosed with iron overload. experimental with limited locations in the world providing this technology. In a very simplistic description. but requires special technique called T2* MRI.
. Fibroscan is available mostly in Canada and Europe.irontoxicity. The technology works with standard magnetic resonance imaging (MRI) equipment. In standard phlebotomy. about one pint of blood is removed.ferriscan.jsp Genetic testing examines DNA for mutations in genes that define a particular disease.uk/ FerriScan® is software that allows for a non-invasive (does not puncture the skin) way to measure the amount of iron in the liver (hepatic iron concentrations). . which in turn reflects the degree of fibrosis.http://www.fibroscan. the total amount of iron ultimately removed is calculated to determine whether the total body iron load is increased. If nothing stands in the way of the signal/pulse. saliva.
5 g/dL Severe anemia is considered for hemoglobin concentrations below 8. and pale skin and nail color. A detailed medical. 12 g/dL for non-pregnant women. or people with chronic diseases.5 . hematocrit. or enlarged spleen Heavy menstrual bleeding in women Any occurrence of blood in the stool or other signs of internal bleeding. People with a high volume of plasma (the liquid portion of blood) may be anemic even if their blood count is normal because the blood cells have become diluted. and shape of red blood cells (erythrocytes). and platelets. For diagnosis of anemia.9.13. Hemoglobin. determining its cause is very important. Anemia is generally considered when hemoglobin concentrations fall below 11 g/dL for pregnant women. Other iron status blood tests are also used.Alternative Names
Iron deficiency. This may be difficult.0 . so a rectal exam and stool test are essential. (Even if the patient has not observed any bleeding. a normal hematocrit percentage depends on age and gender. Pernicious anemia
The first step in any diagnosis is a physical examination to determine if the patient has symptoms of anemia and any complications. The severity of anemia is categorized by the following hemoglobin concentration ranges:
Mild anemia is considered when hemoglobin is between 9.
Complete Blood Count (CBC)
A complete blood count (CBC) is a panel of tests that measures red blood cells. personal. volume. the CBC provides critical information on the size.0 g/dL Moderate anemia is considered when hemoglobin is between 8. white blood cells. an enlarged spleen. nonvisible blood may be present. A complete blood count (CBC) blood test is performed to determine the presence of anemia. particularly in people who are elderly. poor. Anemic ranges for hematocrit generally fall below:
Hematocrit. or both
The doctor should examine the patient carefully. CBC results include measurements of hemoglobin. and mean corpuscular volume. Hemoglobin is the iron-bearing and oxygen-carrying component of red blood cells. Like hemoglobin. The normal value for hemoglobin varies by age and gender. especially checking for swollen lymph nodes. Hematocrit is the percentage of blood composed of red blood cells. and dietary history should report:
Any family or personal history of anemia A history of gallbladder disease.) Any dietary history. whose anemia may be caused by one or more factors. Because anemia may be the first symptom of a serious illness. and 13 g/dL for men. malnourished. particularly in the elderly. jaundice.
Other Iron Status Blood Tests
Serum Ferritin. while higher than normal levels may indicate hemolytic anemia. Ferritin is a protein that binds to iron and helps to store iron in the body. Recent research suggests that the reticulocyte hemoglobin content (CHr) test may be more accurate than a standard hemoglobin test for detecting iron deficiency in infants. An abnormally high count indicates that the red blood cells are being destroyed in high numbers and indicates hemolytic anemia. while microcytic cells are a sign of iron-deficiency anemia or thalassemias. and their count reflects the rate of red blood cell production. A diagnosis in these cases can often be made if the patient has noticed blood in the stools. Vitamin Deficiencies.150 ng/mL for women. Serum iron measures the amount of iron in the blood. Mean Corpuscular Volume.12 years: Below 35% Children ages 12 years . suggests problems in production in the bone marrow. Mean corpuscular volume (MCV) is a measurement of the average size of red blood cells. The upper normal limit is about 100. If so. Tests for vitamin B12 and folate levels.
Children ages 6 months . stool tests for this hidden (occult) blood are
.15 years: Below 36% Adult men: Below 39% Adult non-pregnant women: Below 36% Adult pregnant women: Below 33%
Other hemoglobin measurements such as mean corpuscular hemoglobin (MCH) and mean corpuscular hemoglobin concentration (MCHC) may also be calculated. Macrocytic cells can be a sign of anemia caused by vitamin B12 deficiency. The MCV increases when red blood cells are larger than normal (macrocytic) and decreases when red blood cells are smaller than normal (microcytic). or hemolytic anemia.5 years: Below 33% Children ages 5 years . Reticulocytes are immature red blood cells. Total Iron Binding Capacity. Serum Iron. Low levels typically mean reduced iron stores. Reticulocyte Count. however. sickle cell. megaloblastic anemia. pernicious anemia.170 mcg/dL. A higher than normal TIBC is a sign of iron-deficiency anemia. Normal values are generally 12 . Lower levels may indicate iron-deficiency anemia or anemia of chronic disease.300 ng/mL for men and 12 . A low count. which can be black and tarry or red-streaked.
Other Diagnostic Tests
If internal bleeding is suspected as the cause of anemia. the gastrointestinal tract is usually the first suspect as the source. TIBC calculates how much or how little the transferrin in the body is carrying iron. Lower than normal levels of ferritin are a sign of irondeficiency anemia. A normal serum iron is 60 . Often.000/mL. or anemia of chronic disease. Total iron binding capacity (TIBC) measures the level of transferrin in the blood. A lower than normal level may indicate anemia of chronic disease. Transferrin is a protein that carries iron in the blood. while higher levels may indicate hemolytic anemia or vitamin B12 deficiency. when bleeding isn't the cause. bleeding may be present but not visible.
org/751. sideroblastic anemias.P.D.
Read more: http://www. Serum ferritin is the preferred initial diagnostic test. M.H. Kentucky Am Fam Physician. Total iron-binding capacity. If there is not a 1 to 2 g per dL (10 to 20 g per L) increase in the hemoglobin level in that time. Routine iron supplementation is recommended for high-risk infants six to 12 months of age. M. and serum transferrin receptor levels may be helpful if the ferritin level is between 46 and 99 ng per mL (46 and 99 mcg per L). continued bleeding. In children. or unknown lesion. Preventive Services Task Force currently recommends screening for iron deficiency anemia in pregnant women but not in other groups.. Nine percent of patients older than 65 years with iron deficiency anemia have a gastrointestinal cancer when evaluated. however.H. M. Additional tests may then be needed to diagnose the precipitating condition. then the patient may simply be given a monthly trial of iron supplements.. 2007 Mar 1.P. If the patient's diet suggests low iron intake and other causes cannot be established using inexpensive or noninvasive techniques.xml. For other patients. The U. and women of reproductive age. is helpful in many patients. and lead poisoning. M. Iron deficiency anemia (IDA) is the most common nutritional deficiency worldwide.umm.4 IDA may affect visual and auditory functioning3 and is weakly associated with poor cognitive development in children. BENNETT. possibilities include malabsorption of oral iron. serum iron.edu/patiented/articles/how_anemia_prevented_000057_6. A colonoscopy may also be recommended to rule out colorectal cancer. and nearly 20 percent in black and Mexican-American women. transferrin saturation.75(5):671-678. the hemoglobin should be checked at one month.. Iron deficiency anemia is classically described as a microcytic anemia.D. If the patient fails to respond.2 There is some evidence that iron deficiency without anemia affects cognition in adolescent girls3 and causes fatigue in adult women. 9 to 12 percent in nonHispanic white women. CHAMBERS.D.htm#ixzz1vMGK29Qq
Iron Deficiency Anemia SHERSTEN KILLIP. a trial of iron is a reasonable approach if the review of symptoms. The differential diagnosis includes thalassemia. and MARA D.. Endoscopy. some types of anemia of chronic disease. It can cause reduced work capacity in adults1 and impact motor and mental development in children and adolescents. in which a fiber optic tube is used to view into the gastrointestinal tract. Lexington. University of Kentucky.. an endoscopic evaluation is recommended beginning with colonoscopy if the patient is older than 50. adolescents. and physical examination are negative. M. further evaluation is needed.S. bone marrow biopsy may be necessary in these patients for a definitive diagnosis.4 SORT: KEY RECOMMENDATIONS FOR PRACTICE
. JOHN M. particularly when the source of bleeding is unclear.required. The prevalence of iron deficiency anemia is 2 percent in adult men. Patient information: See a related handouts on this topic at http://familydoctor. history.
are black. Clinical recommendation High-risk infants six to 12 months of age should be given routine iron supplementation. Patients of either sex who are B 30 In a population-based cohort.01 to 0. usual practice. are preterm or low birth weight. sex.Evidence rating ReferencesComment B 14 Infants are considered high risk if they are living in poverty. percent of adults with anemia (95% screening for occult CI. 0. For information about the SORT evidence rating system.
CI = confidence interval. In men and nonmenstruating B 30 In a population-based cohort.5 The Healthy People 2010 goals are to reduce the occurrence of IDA to less than 5 percent in toddlers. the best for diagnosing iron deficiency anemia. or if their primary dietary intake is unfortified cow's milk. constipation or gastroesophageal reflux disease. and older gastrointestinal cancers.25) had screened for occult gastrointestinal cancer. see page 603 or http://www. 6 women younger than 65 years.18 Blood donors lose iron. adults with anemia had gastrointestinal cancer 31 times as often as adults without anemia.6 [corrected]
.org/afpsort. and 7 percent in women of reproductive age. undertaken in the absence of another explanation for iron deficiency. or case series.02 to 0. Prevalence The prevalence of IDA in the United States varies widely by age. Blood donors should take 20 mg C 13. or Alaskan Native. 0. Native American. and race (Table 1).17. Hemoglobin and ferritin tests are C 25–27. expert opinion. 1 percent in preschool-age children. C = consensus. are immigrants from developing countries. 9 older than 65 and have iron percent of adults older than 65 years deficiency anemia should be (95% CI.16) had gastrointestinal gastrointestinal cancer should be cancer on investigation. disease-oriented evidence. good-quality patient-oriented evidence.xml. regardless of race. vitamin C potentiates iron absorption.29 See Table 4 for likelihood ratios. A = consistent. 20 mg per elemental iron daily with vitamin day replaces lost iron with minimal C.aafp. B = inconsistent or limited-quality patient-oriented evidence.
†—Unreliable. Absorption of heme iron is minimally affected by dietary factors.TABLE 1 Prevalence of Iron Deficiency Anemia in Selected Populations in the United States Group/age (years)*1988 to 1994 (%)1999 to 2000 (%) Both Sexes One to two 3 2 Women (nonpregnant) 12 to 49 4 3 50 to 69 2 3 70 and older 2 1†
*—Data for all racial/ethnic groups. fiber. It also could be a sign of blood loss. tea. In states of overload. Iron absorption. The bioavailability of non-heme iron requires acid digestion and varies by an order of magnitude depending on the concentration of enhancers (e.51(40):899. IDA is never an end diagnosis. standard error/prevalence estimate) is greater than 30 percent. is only 5 to 10 percent of dietary intake in persons in homeostasis. Thus. Dietary iron is available in two forms: heme iron. Men and nonmenstruating women lose about 1 mg of iron per day.6 to 2. wine) found in the diet.5 percent more per day.. which is found in plant and dairy foods. Menstruating women lose from 0. and nonheme iron.g.. ascorbate. MMWR Morb Mortal Wkly Rep. Absorption can increase three. which is found in meat. hampered absorption.e. 2002. Etiology Iron metabolism is unusual in that it is controlled by absorption rather than excretion. which occurs mostly in the jejunum.7 A pregnancy takes about 700 mg of iron. patients with IDA presenting in primary care may have inadequate dietary intake. calcium. but it is a risk factor when coupled with the
. or physiologic losses in a woman of reproductive age. but the loss could be more than 42 mg per cycle depending on how heavily she menstruates. known or occult. Risk factors Table 28–13 lists risk factors associated with IDA. Adapted from the Centers for Disease Control and Prevention.to fivefold in states of depletion.g. Iron deficiency—United States.7 Iron deficiency results when iron demand by the body is not met by iron absorption from the diet. coffee. and a whole blood donation of 500 cc contains 250 mg of iron. meat) and inhibitors (e.. 1999–2000. the work-up is not complete until the reason for IDA is known. absorption decreases. relative standard error (i. An average 132-lb (60-kg) woman might lose an extra 10 mg of iron per menstruation cycle. Iron is only lost through blood loss or loss of cells as they slough. Low socioeconomic status is not a risk factor for IDA in women who never get pregnant. whereas nonheme iron makes up the bulk of consumed iron.
are preterm or low birth weight. are black.8 Child and adolescent obesity12 BMI ≥ 85% and < 95% percentile OR. status10 seven to 12 months postpartum: OR.S.2 to 3. but found insufficient evidence to recommend for or against routine screening in other asymptomatic persons. the guidelines did recommend routine iron supplementation in asymptomatic infants six to 12 months of age who are at high risk of IDA. and 16 mg per day for vegetarians because of their differential
. 2. However. 4.1.3 (95% CI. including iron. or Alaskan Native. Although the USPSTF found insufficient evidence to recommend for or against the routine use of iron supplements in healthy infants or pregnant women. suggesting there may be an unidentified.1 percent Blood donation more than two units per year in No statistics given women and three units per year in men9 Low socioeconomic status and postpartum Zero to six months postpartum: OR. are immigrants from a developing country. Screening and Primary Prevention The U. Infants are considered to be at high risk if they are living in poverty.15 a recent study showed a significant decline in the number of newborns weighing less than 5 lbs 8 oz (2. 2.8 There is a high rate of IDA among Mexican women living in the United States that is not accounted for by dietary intake or parity. which is the current standard of care in the United States.0 (95% CI.11 TABLE 2 Risk Factors for Iron Deficiency Anemia in the United States Risk factor Black8 Statistics Prevalence in white women: 7. Food and Nutrition Board publishes Dietary Reference Intakes (DRI) for many vitamins and minerals. Black women have a lower mean hemoglobin and a wider standard deviation than white women. or if their primary dietary intake is unfortified cow's milk.14 Encouraging mothers to breastfeed their infants and to include iron-enriched foods in the diet of infants and young children also is recommended. 1.5) BMI ≥ 95% percentile OR. BMI = body mass index. The U. Native American. possibly racial factor predisposing these women to iron deficiency. 1.increased iron demands imposed by pregnancy.1 Mexican ethnicity living in the United States11 OR. 1. 3. CI = confidence interval Information from references 8 through 13.S. nonmenstruating adults.5 kg) (number needed to treat = 7) when the mothers used routine prenatal iron supplementation. The DRI for iron is 8 mg per day for healthy. DRI replaced Recommended Daily Allowance. prevalence in black women: 25. even after adjustment for iron status.9) Vegetarian diet13 40 percent of vegans 19 to 50 years of age were iron deficient
OR = odds ratio. 18 mg per day for menstruating women. Preventive Services Task Force (USPSTF) recommends screening pregnant women for IDA.1 percent.4 to 3.16 This supports prescribing prenatal vitamins with iron to all pregnant women.
sideroblastic anemias.9 years — Children 5.21 In a hospital setting. However. and lead poisoning (rare in adults). absence of pallor was less helpful at ruling out anemia. Patients with lead poisoning will have characteristic signs and symptoms of lead poisoning. The differential diagnosis for microcytic anemia includes iron deficiency.22 Other classic symptoms such as koilonychia (spoon nails). was caused by anemia in only one out of 52 patients in a primary care practice. or dysphagia are not common in the developed world.6 even when anemia was defined as less than 9 g per dL (90 g per L). giving an LR of 0.18 Diagnosis The definition of anemia varies by sex and age. The most commonly used definitions of anemia come from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) (Table 315). some types of anemia of chronic disease.5 g per dL (115 g per L) — <11 g per dL <10. TABLE 3 Definition of Anemia by Hemoglobin Value Hemoglobin level World Health Population Organization Infants 0.absorption of nonheme iron.23
. a daily dose of 20 mg of elemental iron is recommended. pallor predicted anemia with a likelihood ratio (LR) of 4.5 to 4. Differentiating between iron deficiency and anemia of chronic disease can sometimes be difficult. especially in early iron deficiency or when the conditions coexist.0 to 11.5. the most common reason to check hemoglobin. a lower diagnostic level than that of the WHO or CDC. DIFFERENTIAL DIAGNOSIS IDA is classically described as a microcytic anemia. CLINICAL PRESENTATION Anemia cannot be reliably diagnosed by clinical presentation.5 g per dL (105 g per L) —
Information from reference 15. glossitis. Fatigue.20 which can differentiate them from patients with iron deficiency.17 For blood donors.9 years — Menstruating women <12 g per dL (120 g per L) Pregnant women in first or third <11 g per dL trimester Pregnant women in second <11 g per dL trimester Men <13 g per dL (130 g per L)
Centers for Disease Control and Prevention <11 g per dL (110 g per L) <11.19 Patients with sideroblastic anemia will have almost complete saturation of the serum transfer-rin. thalassemia.
41.0 0.64 0.82 1.76 0.08 10.54 0. Serum ferritin values greater than 100 ng per mL (100 mcg per L) indicate adequate iron stores and a low likelihood of IDA (Table 425.29 51.34 0.8 2.43 0.5 1.8 8.57 0.25 In some populations.8 0.26).91 0. Red blood cells in IDA are usually described as being microcytic (i.0 3. however the manifestation of iron deficiency occurs in several stages.5 0.3 1. Cutoffs for abnormality in these patients generally are higher. such as those with inflammatory disease or cirrhosis.1 0.15 Transferrin saturation Less than 5 percent 5 to 8 percent More than 8 to 21 percent More than 21 percent 16.e.5 3.81 0. mean corpuscular volume less than 80 μm3 [80 fL]) and hypochromic.51 1.43 0.52 0.46 0.28 Adults older than 65 Test Mean corpuscular volume Less than 75 μm3 75 to 85 μm3 86 to 91 μm3 (86 to 91 fL) 92 to 95 μm3 (92 to 95 fL) More than 95 fL Ferritin Less than 19 ng per mL (19 mcg per L) 19 to 45 ng per mL (19 to 45 mcg per L) 46 to 100 ng per mL (46 to 100 mcg per L) More than 100 ng per mL Likelihood ratio 8.DIAGNOSTIC TESTS The diagnosis of IDA requires that a patient be anemic and show laboratory evidence of iron deficiency. The most accurate initial diagnostic test for IDA is the serum ferritin measurement.24 Patients with a serum ferritin concentration less than 25 ng per mL (25 mcg per L) have a very high probability of being iron deficient.35 0.27 TABLE 4 Diagnosis of Iron Deficiency Adults with anemia* Test Mean corpuscular volume Less than 70 μm3 (70 fL) 70 to 74 μm3 (74 fL) 75 to 79 μm3 (75 to 79 fL) 80 to 84 μm3 (80 to 84 fL) 85 to 89 μm3 (85 to 89 fL) 90 μm3 (90 fL) or more Ferritin Less than 15 ng per mL (15 mcg per L) 15 to 24 ng per mL (15 to 24 mcg per L) 25 to 34 ng per mL (25 to 34 mcg per L) 35 to 44 ng per mL (35 to 44 mcg per L) 45 to 100 ng per mL (45 to 100 mcg per L) More than 100 ng per mL Transferrin saturation Less than 5 percent 5 to 9 percent 10 to 19 percent 20 to 29 percent 30 to 49 percent 50 percent or more Likelihood ratio 12. these tests must be interpreted slightly differently because ferritin is an acute-phase reactant..13
*Hemoglobin less than 13 g per dL [130 g per L] for men and less than 12 g per dL [120 g per L] for women
and normal levels are found in patients with anemia of chronic disease. The serum transferrin receptor assay is a newer approach to measuring iron status at the cellular level.7:145–53. Increased levels are found in patients with IDA. Ali M. McIlroy W. The choice of a ferritin level of less than 45 ng per mL (45 mcg per L) is to allow for a higher sensitivity. Oxman AD.28 RECOMMENDED DIAGNOSTIC STRATEGY Figure 129 shows a suggested diagnostic algorithm to determine if a patient has IDA. Laboratory diagnosis of iron-deficiency anemia: an overview. Patterson C. with the primary modification that serum iron. despite the fact that most laboratories' normal range for ferritin includes 45 ng per mL. Another laboratory change that occurs in patients with IDA is an increase in the iron-carrying protein transferrin. total iron-binding capacity. This algorithm is adapted from a clinical guideline. causing a decrease in the transferrin saturation and an increase in the total iron-binding capacity. with additional information from reference 26.Adapted with permission from Guyatt GH. Willan A.
Diagnosis of Iron Deficiency Anemia
. J Gen Intern Med 1992. The amount of iron available to bind to this molecule is reduced.29 If these blood tests are indeterminate. and transferrin saturation are recommended as follow-up tests in patients with an intermediate ferritin level as a strategy to reduce the need for bone marrow biopsy. an elevated serum transferrin receptor level is recommended to distinguish IDA from anemia of chronic disease.
92 of whom also were anemic. Patients with a high risk of underlying disease (e. FE = serum iron.30 Figure 24. 6 percent were diagnosed with a gastrointestinal malignancy. a cause for IDA must be established or serious disease may be overlooked. The general approach is to separate groups by risk of underlying disease.113:281–7. men of all ages and postmenopausal women) should be evaluated endoscopically for occult bleeding unless the history and physical examination strongly indicate a known benign cause for IDA. LR+ = positive likelihood ratio. Diagnostic algorithm for iron deficiency anemia. (MCV = mean corpuscular volume.
.31. None of the 442 premenopausal women with iron deficiency. Am J Med 2002. TfR = serum transferrin receptor. Rockey DC. TIBC = total iron-binding capacity. Because IDA has physiologic and pathophysiologic causes. In a population-based study of more than 700 adults with IDA.32 shows the authors' suggested evaluation for underlying causes of IDA. Prospective evaluation of a clinical guideline for the diagnosis and management of iron deficiency anemia.) Adapted with permission from Ioannou GN.29. Scott K.Figure 1.. Spector J. The risk of malignancy was 9 percent in patients older than 65 years with IDA.g.21. had a gastrointestinal malignancy detected.
Whether to begin with endoscopy or colonoscopy should be indicated by symptoms or age.35 Ferrous sulfate in a dose of 325 mg provides 65 mg of elemental iron. Information from references 4. Algorithm for evaluation and treatment of iron deficiency anemia. and 32. oral iron therapy is usually the first-line therapy for patients with IDA. In a patient older than 50 years who lacks symptoms. whereas
.33 However.31. a therapeutic trial of oral iron therapy is the recommended initial approach.29. it may take up to four months for the iron stores to return to normal after the hemoglobin has corrected. however.31 Some disease-oriented evidence by specialty researchers suggests that esophagogastroduodenoscopy may be valuable in women of reproductive age.21. in the absence of symptoms. Bone marrow response to iron is limited to 20 mg per day of elemental iron. An increase in the hemoglobin level of 1 g per dL (10 g per L) should occur every two to three weeks on iron therapy. Treatment Transfusion should be considered for patients of any age with IDA complaining of symptoms such as fatigue or dyspnea on exertion.34 As noted in the etiology section.29
Evaluation and Treatment of Iron Deficiency Anemia
Figure 2. the diagnostic work-up should begin with colonoscopy. However. It also should be considered for asymptomatic cardiac patients with hemoglobin less than 10 g per dL (100 g per L). iron absorption varies widely based on type of diet and other factors.
tea)37 or phytates (e.534 patients on hemodialysis. intolerance to oral iron. and adequate intake of liquids can alleviate the constipating effects of oral iron therapy.. Food and Drug Administration in 1999. Gastrointestinal absorption of elemental iron is enhanced in the presence of an acidic gastric environment.42 One major drawback of iron dextran is the risk of anaphylactic reactions that can be fatal.g.61 percent receiving iron dextran.e. was approved by the U. asam folat. 0. vitamin B12. The advantage of iron dextran is the ability to administer large doses (200 to 500 mg) at one time. intestinal malabsorption.43 Sodium ferric gluconate is usually administered intravenously in eight weekly doses of 125 mg for a total dosage of 1.. nonadherence. approved for use in the United States in 2000. which consists of myalgias. Anemia defisiensi dapat diklasifikasikan menurut morfologi dan etiologi menjadi 3 golongan :
. bran.g. proton pump inhibitors. This can be accomplished through simultaneous intake of ascorbic acid (i. this increases the likelihood of stomach upset because of iron therapy.36 Although iron absorption occurs more readily when taken on an empty stomach. histamine H2 blockers)39 reduce absorption and should be avoided if possible. Laxatives.325 mg of ferrous gluconate provides 38 mg of elemental iron. Safety profiles are similar to sodium ferric gluconate.g. stool softeners. piridoksin dan sebagainya.28
The Authors I. a safer form of parenteral iron.. but they may be prolonged in patients with chronic inflammatory joint disease.40 A liquid iron preparation would be a better choice for these patients.41 Until recently. Anemia Defisiensi
Adalah anemia yang terjadi akibat kekurangan satu atau beberapa bahan yang diperlukan untuk pematangan eritrosit.38 or medications that raise the gastric pH (e. 200 mg is administered intravenously five times over a two-week period. antacids. There also is a delayed reaction. is iron sucrose (Venofer). Foods rich in tannates (e.04 percent receiving sodium ferric gluconate had life-threatening reactions compared with 0. protein. headache.S.000 mg. Another intravenous preparation. No test dose is required. cereal). In a study of 2. seperti defisiensi besi. iron dextran (Dexferrum) has been the only parenteral iron preparation available in the United States. Sodium ferric gluconate (Ferrlecit).. Indications for the use of intravenous iron include chronic uncorrectable bleeding.. those who have religious objections). Increased patient adherence should be weighed against the inferior absorption. Nonsteroidal anti-inflammatory drugs will usually relieve these symptoms. Sustained-release formulations of iron are not recommended as initial therapy because they reduce the amount of iron that is presented for absorption to the duodenal villi. or a hemoglobin level less than 6 g per dL (60 g per L) with signs of poor perfusion in patients who would otherwise receive transfusion (e. although published experience is more limited. The risk of anaphylaxis is drastically reduced using sodium ferric gluconate. and arthralgias. vitamin C).g. that can occur 24 to 48 hours after infusion. In iron deficiency not associated with hemodialysis. Some persons have difficulty absorbing the iron because of poor dissolution of the coating.
terkadang untuk menghindari anemia defisiensi besi kedalam susu buatan atau tepung untuk makanan
. susu. Dari semua itu defisiensi besi merupakan penyebab utama anemia didunia. besi plasma 0.1. Kemudian masuk ke usus halus dirubah menjadi ion fero dengan pengaruh alkali. Hipokrom berarti mengandung hemoglobin dalam jumlah yang kurang dari normal (MCHC kurang).1 %. Anemia Defisiensi Besi merupakan penyakit yang sering pada bayi dan anak yang sedang dalam proses pertumbuhan dan pada wanita hamil yang keperluan besinya lebih besar dari orang normal. a. antasid. dibawah ukuran normal (MCV<80 fL). sebagian disimpan sebagai senyawa feritin dan sebagian lagi masuk keperedaran darah berikatan dengan protein (transferin) yang akan digunakan kembali untuk sintesa hemoglobin. buah. hemenzim 1 %. keadaan sideroblastik dan kehilangan darah kronik atau gangguan sintesis globin seperti pada penderita talasemia. Besi yang terkandung dalam makanan ketika dalam lambung dibebaskan menjadi ion fero dengan bantuan asam lambung (HCL). Mikrositik Hipokrom
Mikrositik berarti sel darah merah berukuran kecil. yang terdiri dari : masa eritrosit 60 %. kemudian ion fero diabsorpsi. dengan kebutuhan rata-rata 5 mg/hari tetapi bila terdapat infeksi meningkat sampai 10 mg/hari. sayuran yang mengandung klorofil. Hal ini umumnya menggambarkan defisiensi besi. Penyerapan ion fero dipermudah dengan adanya vitamin atau fruktosa. mioglobin 5-10 %. Berikut bagan metabolisme besi :
Adapun sumber besi dapat diperoleh dari
makanan seperti : hati. Besi diabsorsi dalam usus halus (duodenum dan yeyenum) proksimal. oksalat. Jumlah besi dalam badan orang dewasa adalah 4-5 gr sedang pada bayi 400 mg. tetapi akan terhambat dengan fosfat. daging telur. Sebagian dari transferin yang tidak terpakai disimpan sebagai labile iron pool. feritin dan hemosiderin 30 %. Kebutuhan besi pada bayi dan anak lebih besar dari pengelurannya karena pemakaiannya untuk proses pertumbuhan.
3 – 0. Cadangan besi dalam tubuh
Bayi normal/sehat cadangan besi cukup untuk 6 bulan Bayi prematur cadangan besi cukup untuk 3 bulan Ekskresi besi dari tubuh sangat sedikit bisa melalui urin. anemi selama kehamilan anak 1-2 tahun : masukan besi kurang. Remaja-dewasa: mentruasi berlebihan
Lemas. Sedangkan besi yang dilepaskan pada pemecahan hemoglobin dari eritrosit yang sudah mati akan masuk kembali ke dalam iron pool dan digunakan lagi untuk sintesa hemoglobin.5 mg/hari Wanita hamil 2.7 mg/hari
menurut patogenesisnya :
Masukan kurang : MEP. Absorpsi kurang : MEP.hari Anak 4-12 tahun Laki-laki dewasa 0. Anak 5-remaja : perdarahan karena infeksi parasit dan polip. diet tidak adekuat. sel kulit yang terkelupas dan karena perdarahan (mens) sangat sedikit. keringat. susu formula rendah besi.5 mg/hari
Wanita dewasa 1 – 2. pertumbuhan cepat.BP). kebutuhan yang meningkat karena infeksi berulang (enteritis. tinja. kebutuhan meningkat.
bayi ditambahkan kandungan besi namun terkadang dapat menimbulkan terjadinya hemokromatosis.4 – 1 mg/hari 1 – 1. diare kronis Sintesis kurang : transferin kurang Kebutuhan meningkat : infeksi dan pertumbuhan cepat Pengeluaran bertambah: kehilangan darah karena infeksi parasit dan polip
berdasarkan umur penderita penyebab dari defisiensi besi dapat dibedakan:
bayi < 1tahun : persediaan besi kurang karena BBLR. pucat dan cepat lelah Sering berdebar-debar
. lahir kembar. Pengeluaran besi dari tubuh yang normal : Bayi 0. defisiensi diet.4 mg. kehilangan darah karena divertikulum meckeli. ASI eklusif tanpa suplemen besi. pertumbuhan cepat. absorpsi kurang anak 2-5 tahun : masukan besi kurang.
licin. mengkilat. Jantung dapat takikardi Jika karena infeksi parasit cacing akan tampak pot belly
Penderita defisiensi besi berat mempunyai rambut rapuh.-
Sakit kepala dan iritabel Pucat pada mukosa bibir dan faring. telapak tangan dan dasar kuku Konjungtiva okuler berwarna kebiruan atau putih mutiara (pearly white) Papil lidah atrofi : lidah tampak pucat. Ht menurun MCV <80. Diharapkan kenaikan Hb 1 g. poikilositosis. MCHC <32 % Mikrositik hipokrom.
Kadar Hb <10 g/dL.dL setiap 1-2 minggu Transfusi darah bila kadar Hb <5 g/dL dan keadaan umum tidak baik Antelmintik jika ada infeksi parasit Antibiotik jika ada infeksi
. meradang dan sakit. IBC meningkat
Pengobatan kausal Makanan adekuat Sulfas ferosus 3X10 mg /KgBB/hari. merah. halus serta kuku tipis. mudah patah dan berbentuk seperti sendok. sel target SSTL sistem eritropoetik hiperaktif SI menurun. rata.