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Diagnostic Aids

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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.

This type of test examines DNA from a blood. the relaxation time is ―shortened‖. The procedure is expensive.excessiron. 4 grams of iron are found in about 16 to 20 pints of blood. Genetic information does not provide information about iron levels. Scans & Imaging Magnetic Resonance Imaging (MRI): can qualify and quantify iron in the liver. Using a specialized technique a trained radiologist can demonstrate differences in the rate at which a signal/pulse transverses (passes through) the body. or tissue sample for certain mutations.fibroscan. but requires special technique called T2* MRI.jsp http://www. In quantitative phlebotomy. or (R2)) which yield the relaxation time (recovery time) of the signal/pulse.http://www. about one pint of blood is removed. If iron is present in the liver.ferriscan. heart and anterior pituitary. .com/screening-and-diagnosis4. For more about Ferriscan® visit . the output reading shows a ―black‖ area where the signal/pulse recovery time was abbreviated. For more about the procedure visit: .irontoxicity.http://www. In standard phlebotomy. If nothing stands in the way of the signal/pulse. The speed (velocity) with which the pulse moves and reaches its target is measured with ultrasound. MRI uses a powerful magnet and radio-frequencies (signals. In a very simplistic description. Individuals who have 4 grams or more of mobilizable iron by quantitative phlebotomy may be diagnosed with iron overload. patients who are pregnant or patients under the age of 18 years of age. When the signal is interrupted by a tumor or in this case. .jsp Genetic testing examines DNA for mutations in genes that define a particular disease. which contains approximately 200 to 250 milligrams of iron. The velocity of the pulse is directly correlated to the stiffness of the liver.the stiffer the liver is the greater the degree of fibrosis. Fibroscan® Noninvasive way to determine the rigidity (hardness) of the liver. In general. A reading is taken of these rates (proton transverse relaxation Fibroscan® should not be used on patients with ascites (fluid in the abdomen). but it does expose the potential risk of developing iron disorders.Quantitative Phlebotomy is an indirect way of diagnosing hemochromatosis. FerriScan and SQUID are two aids that use the T2* relaxation approach. the relaxation time is normal and the output or reading of the organ scanned demonstrates no SQUID: Superconducting Quantum Interference Device (SQUID) uses a low-power magnetic field with sensitive detectors that measure the interference of iron within the field. This is presently the only noninvasive approach to qualify iron deposits in the heart. pulses) which are sent through the person’s body producing a reading that is sent to a computer. A mechanical pulse goes through the skin to the iron. experimental with limited locations in the world providing this 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. The technology works with standard magnetic resonance imaging (MRI) equipment. A radiologist must have additional training to perform this specialized imaging technique. Read more about this type of technology http://www. the total amount of iron ultimately removed is calculated to determine whether the total body iron load is increased. Fibroscan is available mostly in Canada and Europe. saliva.

determining its cause is very important. an enlarged spleen. or enlarged spleen Heavy menstrual bleeding in women Any occurrence of blood in the stool or other signs of internal bleeding. Complete Blood Count (CBC) A complete blood count (CBC) is a panel of tests that measures red blood cells. Anemia is generally considered when hemoglobin concentrations fall below 11 g/dL for pregnant women.) Any dietary history. and mean corpuscular volume. A detailed medical. 12 g/dL for non-pregnant women. poor.0 g/dL Hematocrit. volume. and 13 g/dL for men. (Even if the patient has not observed any bleeding. a normal hematocrit percentage depends on age and gender. or both The doctor should examine the patient carefully. white blood cells. Anemic ranges for hematocrit generally fall below: .Alternative Names Iron deficiency.0 . Hemoglobin is the iron-bearing and oxygen-carrying component of red blood cells.0 g/dL Moderate anemia is considered when hemoglobin is between 8. malnourished. and pale skin and nail color. CBC results include measurements of hemoglobin. hematocrit. For diagnosis of anemia. and platelets. 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. Hematocrit is the percentage of blood composed of red blood cells. Like hemoglobin. and dietary history should report:      Any family or personal history of anemia A history of gallbladder disease.5 . Pernicious anemia Diagnosis: The first step in any diagnosis is a physical examination to determine if the patient has symptoms of anemia and any complications. especially checking for swollen lymph nodes. personal. particularly in people who are elderly. or people with chronic diseases. This may be difficult. nonvisible blood may be present. the CBC provides critical information on the size. jaundice. particularly in the elderly.9. The normal value for hemoglobin varies by age and gender. Because anemia may be the first symptom of a serious illness. Hemoglobin. A complete blood count (CBC) blood test is performed to determine the presence of anemia.5 g/dL Severe anemia is considered for hemoglobin concentrations below 8. so a rectal exam and stool test are essential. whose anemia may be caused by one or more factors.13. The severity of anemia is categorized by the following hemoglobin concentration ranges:    Mild anemia is considered when hemoglobin is between 9. and shape of red blood cells (erythrocytes). Other iron status blood tests are also used.

Total iron binding capacity (TIBC) measures the level of transferrin in the blood. which can be black and tarry or red-streaked. Total Iron Binding Capacity. A lower than normal level may indicate anemia of chronic disease.150 ng/mL for women.      Children ages 6 months . while higher than normal levels may indicate hemolytic anemia. Mean Corpuscular Volume.12 years: Below 35% Children ages 12 years . while higher levels may indicate hemolytic anemia or vitamin B12 deficiency.300 ng/mL for men and 12 . bleeding may be present but not visible. Serum iron measures the amount of iron in the blood. Reticulocyte Count. Other Diagnostic Tests If internal bleeding is suspected as the cause of anemia. A normal serum iron is 60 . stool tests for this hidden (occult) blood are . pernicious anemia. If so.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. while microcytic cells are a sign of iron-deficiency anemia or thalassemias. Macrocytic cells can be a sign of anemia caused by vitamin B12 deficiency. or anemia of chronic disease.170 mcg/dL. Low levels typically mean reduced iron stores. An abnormally high count indicates that the red blood cells are being destroyed in high numbers and indicates hemolytic anemia. Tests for vitamin B12 and folate levels. Vitamin Deficiencies. A low count. Lower levels may indicate iron-deficiency anemia or anemia of chronic disease. Often. however. A higher than normal TIBC is a sign of iron-deficiency anemia. Other Iron Status Blood Tests Serum Ferritin. suggests problems in production in the bone marrow. or hemolytic anemia. A diagnosis in these cases can often be made if the patient has noticed blood in the stools. 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.000/mL. Transferrin is a protein that carries iron in the blood. TIBC calculates how much or how little the transferrin in the body is carrying iron. The upper normal limit is about 100. Ferritin is a protein that binds to iron and helps to store iron in the body. sickle cell. The MCV increases when red blood cells are larger than normal (macrocytic) and decreases when red blood cells are smaller than normal (microcytic). when bleeding isn't the cause. Mean corpuscular volume (MCV) is a measurement of the average size of red blood cells. the gastrointestinal tract is usually the first suspect as the source.5 years: Below 33% Children ages 5 years . megaloblastic anemia. Normal values are generally 12 . Serum Iron. and their count reflects the rate of red blood cell production. Lower than normal levels of ferritin are a sign of irondeficiency anemia. Reticulocytes are immature red blood cells.

University of Routine iron supplementation is recommended for high-risk infants six to 12 months of age.umm. and nearly 20 percent in black and Mexican-American women. The prevalence of iron deficiency anemia is 2 percent in adult men.H.htm#ixzz1vMGK29Qq Iron Deficiency Anemia SHERSTEN KILLIP. 9 to 12 percent in nonHispanic white women. and MARA D. M. It can cause reduced work capacity in adults1 and impact motor and mental development in children and adolescents. the hemoglobin should be checked at one month. possibilities include malabsorption of oral iron. further evaluation is needed. adolescents. 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. JOHN M. Nine percent of patients older than 65 years with iron deficiency anemia have a gastrointestinal cancer when evaluated. Kentucky Am Fam Physician. and women of reproductive age.D. Lexington. A colonoscopy may also be recommended to rule out colorectal cancer.... Read more: http://www.4 IDA may affect visual and auditory functioning3 and is weakly associated with poor cognitive development in children.. particularly when the source of bleeding is unclear.D..2 There is some evidence that iron deficiency without anemia affects cognition in adolescent girls3 and causes fatigue in adult women. then the patient may simply be given a monthly trial of iron supplements.required. in which a fiber optic tube is used to view into the gastrointestinal tract. 2007 Mar 1. an endoscopic evaluation is recommended beginning with colonoscopy if the patient is older than 50.4 SORT: KEY RECOMMENDATIONS FOR PRACTICE . Endoscopy. Iron deficiency anemia is classically described as a microcytic anemia. 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). M. however.75(5):671-678. BENNETT. or unknown lesion.S. some types of anemia of chronic disease. Total iron-binding capacity. and physical examination are negative.xml. a trial of iron is a reasonable approach if the review of symptoms. is helpful in many patients. Preventive Services Task Force currently recommends screening for iron deficiency anemia in pregnant women but not in other groups. sideroblastic anemias.P. history.D. bone marrow biopsy may be necessary in these patients for a definitive Serum ferritin is the preferred initial diagnostic test. If the patient fails to respond.P. Patient information: See a related handouts on this topic at http://familydoctor. serum iron. continued bleeding. For other patients. The differential diagnosis includes thalassemia. The U. CHAMBERS. M. Iron deficiency anemia (IDA) is the most common nutritional deficiency worldwide. and lead poisoning. In children. transferrin saturation. If the patient's diet suggests low iron intake and other causes cannot be established using inexpensive or noninvasive techniques. Additional tests may then be needed to diagnose the precipitating condition. M. M.

9 older than 65 and have iron percent of adults older than 65 years deficiency anemia should be (95% CI. see page 603 or http://www. expert opinion.aafp. or case series. adults with anemia had gastrointestinal cancer 31 times as often as adults without anemia. B = inconsistent or limited-quality patient-oriented evidence.01 to 0. C = consensus. usual practice. percent of adults with anemia (95% screening for occult CI. 0. 20 mg per elemental iron daily with vitamin day replaces lost iron with minimal C. or if their primary dietary intake is unfortified cow's milk. and older gastrointestinal cancers. sex. For information about the SORT evidence rating system. Blood donors should take 20 mg C 13. 0. Clinical recommendation High-risk infants six to 12 months of age should be given routine iron supplementation. CI = confidence interval.16) had gastrointestinal gastrointestinal cancer should be cancer on investigation. are black.xml. are preterm or low birth weight. the best for diagnosing iron deficiency anemia. Prevalence The prevalence of IDA in the United States varies widely by age. regardless of race.5 The Healthy People 2010 goals are to reduce the occurrence of IDA to less than 5 percent in toddlers. good-quality patient-oriented evidence. Hemoglobin and ferritin tests are C 25–27.25) had screened for occult gastrointestinal cancer.02 to 0. are immigrants from developing countries.Evidence rating ReferencesComment B 14 Infants are considered high risk if they are living in poverty.17. In men and nonmenstruating B 30 In a population-based cohort.18 Blood donors lose iron. or Alaskan Native. undertaken in the absence of another explanation for iron deficiency.29 See Table 4 for likelihood ratios. Patients of either sex who are B 30 In a population-based cohort. 6 women younger than 65 years. A = consistent. and 7 percent in women of reproductive age.6 [corrected] . and race (Table 1). vitamin C potentiates iron absorption. Native American. disease-oriented evidence. constipation or gastroesophageal reflux 1 percent in preschool-age children.

Low socioeconomic status is not a risk factor for IDA in women who never get pregnant.51(40):899. †—Unreliable. hampered absorption.g. MMWR Morb Mortal Wkly Rep. but the loss could be more than 42 mg per cycle depending on how heavily she menstruates. the work-up is not complete until the reason for IDA is known. In states of overload. Menstruating women lose from 0. Iron is only lost through blood loss or loss of cells as they slough.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. The bioavailability of non-heme iron requires acid digestion and varies by an order of magnitude depending on the concentration of enhancers (e. relative standard error (i. It also could be a sign of blood loss. which is found in plant and dairy foods. fivefold in states of depletion. patients with IDA presenting in primary care may have inadequate dietary intake. which is found in meat. An average 132-lb (60-kg) woman might lose an extra 10 mg of iron per menstruation cycle. 2002.e.. 1999–2000.7 Iron deficiency results when iron demand by the body is not met by iron absorption from the diet. tea.. meat) and inhibitors (e. Thus. fiber. calcium.5 percent more per day. Risk factors Table 28–13 lists risk factors associated with IDA. whereas nonheme iron makes up the bulk of consumed iron. and a whole blood donation of 500 cc contains 250 mg of iron. which occurs mostly in the jejunum. wine) found in the diet. or physiologic losses in a woman of reproductive age. Etiology Iron metabolism is unusual in that it is controlled by absorption rather than excretion. Adapted from the Centers for Disease Control and Prevention. known or occult.6 to 2..7 A pregnancy takes about 700 mg of iron. and nonheme iron. Absorption of heme iron is minimally affected by dietary factors. but it is a risk factor when coupled with the . Iron deficiency—United States. Dietary iron is available in two forms: heme iron. standard error/prevalence estimate) is greater than 30 percent. ascorbate. Iron absorption. Men and nonmenstruating women lose about 1 mg of iron per day. is only 5 to 10 percent of dietary intake in persons in homeostasis. IDA is never an end diagnosis.g. Absorption can increase three. absorption decreases.

1.8 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. status10 seven to 12 months postpartum: OR.S.8 Child and adolescent obesity12 BMI ≥ 85% and < 95% percentile OR. which is the current standard of care in the United States. Screening and Primary Prevention The U.S.16 This supports prescribing prenatal vitamins with iron to all pregnant women. 1.14 Encouraging mothers to breastfeed their infants and to include iron-enriched foods in the diet of infants and young children also is recommended.3 (95% CI. The DRI for iron is 8 mg per day for healthy. and 16 mg per day for vegetarians because of their differential .1. Infants are considered to be at high risk if they are living in poverty. DRI replaced Recommended Daily Allowance. including iron. are preterm or low birth weight. nonmenstruating adults.2 to 3.11 TABLE 2 Risk Factors for Iron Deficiency Anemia in the United States Risk factor Black8 Statistics Prevalence in white women: 7. Black women have a lower mean hemoglobin and a wider standard deviation than white women. even after adjustment for iron status. or Alaskan Native.9) Vegetarian diet13 40 percent of vegans 19 to 50 years of age were iron deficient OR = odds ratio. are immigrants from a developing country.4 to 3.1 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.15 a recent study showed a significant decline in the number of newborns weighing less than 5 lbs 8 oz (2.0 (95% CI. 4.increased iron demands imposed by pregnancy. but found insufficient evidence to recommend for or against routine screening in other asymptomatic persons. BMI = body mass index. prevalence in black women: 25. CI = confidence interval Information from references 8 through 13. The U. possibly racial factor predisposing these women to iron deficiency.5) BMI ≥ 95% percentile OR. 18 mg per day for menstruating women. Although the USPSTF found insufficient evidence to recommend for or against the routine use of iron supplements in healthy infants or pregnant women. 3. Food and Nutrition Board publishes Dietary Reference Intakes (DRI) for many vitamins and minerals. 2. or if their primary dietary intake is unfortified cow's milk.5 kg) (number needed to treat = 7) when the mothers used routine prenatal iron supplementation. the guidelines did recommend routine iron supplementation in asymptomatic infants six to 12 months of age who are at high risk of IDA. However. are black. 1.1 Mexican ethnicity living in the United States11 OR. Native American. Preventive Services Task Force (USPSTF) recommends screening pregnant women for IDA. suggesting there may be an unidentified.1 percent. 2.

or dysphagia are not common in the developed world.absorption of nonheme iron.0 to 11. Differentiating between iron deficiency and anemia of chronic disease can sometimes be difficult. a lower diagnostic level than that of the WHO or CDC.19 Patients with sideroblastic anemia will have almost complete saturation of the serum transfer-rin. a daily dose of 20 mg of elemental iron is recommended.5 to 4.17 For blood donors. Fatigue. some types of anemia of chronic disease.9 years — Children 5.22 Other classic symptoms such as koilonychia (spoon nails).5. was caused by anemia in only one out of 52 patients in a primary care practice. and lead poisoning (rare in adults). thalassemia.5 g per dL (115 g per L) — <11 g per dL <10. giving an LR of 0. Patients with lead poisoning will have characteristic signs and symptoms of lead poisoning.18 Diagnosis The definition of anemia varies by sex and age.6 even when anemia was defined as less than 9 g per dL (90 g per L).5 g per dL (105 g per L) — Information from reference 15. 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).23 . TABLE 3 Definition of Anemia by Hemoglobin Value Hemoglobin level World Health Population Organization Infants 0. CLINICAL PRESENTATION Anemia cannot be reliably diagnosed by clinical presentation.20 which can differentiate them from patients with iron deficiency. DIFFERENTIAL DIAGNOSIS IDA is classically described as a microcytic anemia. sideroblastic anemias. the most common reason to check hemoglobin. pallor predicted anemia with a likelihood ratio (LR) of 4. absence of pallor was less helpful at ruling out anemia. especially in early iron deficiency or when the conditions coexist.21 In a hospital setting. glossitis. The differential diagnosis for microcytic anemia includes iron deficiency. However.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.

5 3.8 0.1 0.43 0.11 41.8 8.57 0.25 In some populations.8 2. Serum ferritin values greater than 100 ng per mL (100 mcg per L) indicate adequate iron stores and a low likelihood of IDA (Table 425.0 3.35 0.43 0.0 0.DIAGNOSTIC TESTS The diagnosis of IDA requires that a patient be anemic and show laboratory evidence of iron deficiency.54 0.81 0.91 0. Cutoffs for abnormality in these patients generally are higher.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.52 0.29 51. however the manifestation of iron deficiency occurs in several stages.e.34 0.51 1.46 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 8.5 2.3 1. The most accurate initial diagnostic test for IDA is the serum ferritin measurement.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 12.15 Transferrin saturation Less than 5 percent 5 to 8 percent More than 8 to 21 percent More than 21 percent 16.08 10.82 1. Red blood cells in IDA are usually described as being microcytic (i.76 0.5 1. these tests must be interpreted slightly differently because ferritin is an acute-phase reactant.5 0. such as those with inflammatory disease or cirrhosis..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 .26). mean corpuscular volume less than 80 μm3 [80 fL]) and hypochromic.64 0.

29 If these blood tests are indeterminate. The amount of iron available to bind to this molecule is reduced. causing a decrease in the transferrin saturation and an increase in the total iron-binding capacity. Another laboratory change that occurs in patients with IDA is an increase in the iron-carrying protein transferrin. Patterson C. McIlroy W. Increased levels are found in patients with IDA. an elevated serum transferrin receptor level is recommended to distinguish IDA from anemia of chronic disease. with the primary modification that serum iron. Laboratory diagnosis of iron-deficiency anemia: an overview.7:145–53. This algorithm is adapted from a clinical guideline. total iron-binding capacity.Adapted with permission from Guyatt GH. Willan A. Diagnosis of Iron Deficiency Anemia . J Gen Intern Med 1992. The choice of a ferritin level of less than 45 ng per mL (45 mcg per L) is to allow for a higher sensitivity. 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. The serum transferrin receptor assay is a newer approach to measuring iron status at the cellular level. despite the fact that most laboratories' normal range for ferritin includes 45 ng per mL. with additional information from reference 26. and normal levels are found in patients with anemia of chronic disease. Oxman AD.28 RECOMMENDED DIAGNOSTIC STRATEGY Figure 129 shows a suggested diagnostic algorithm to determine if a patient has IDA. Ali M.

None of the 442 premenopausal women with iron deficiency.30 Figure 24. (MCV = mean corpuscular volume.29. In a population-based study of more than 700 adults with IDA. The risk of malignancy was 9 percent in patients older than 65 years with IDA. Diagnostic algorithm for iron deficiency anemia. TfR = serum transferrin receptor. 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. 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. Patients with a high risk of underlying disease (e. had a gastrointestinal malignancy detected.Figure 1. TIBC = total iron-binding capacity. 6 percent were diagnosed with a gastrointestinal malignancy. FE = serum iron. . Prospective evaluation of a clinical guideline for the diagnosis and management of iron deficiency anemia. LR+ = positive likelihood ratio. Because IDA has physiologic and pathophysiologic causes.21. Rockey DC. 92 of whom also were anemic. Scott K..32 shows the authors' suggested evaluation for underlying causes of IDA. Spector J. Am J Med 2002.31.) Adapted with permission from Ioannou GN.g.

it may take up to four months for the iron stores to return to normal after the hemoglobin has corrected. oral iron therapy is usually the first-line therapy for patients with IDA. in the absence of symptoms.31 Some disease-oriented evidence by specialty researchers suggests that esophagogastroduodenoscopy may be valuable in women of reproductive age.21.29 Evaluation and Treatment of Iron Deficiency Anemia Figure 2.29. It also should be considered for asymptomatic cardiac patients with hemoglobin less than 10 g per dL (100 g per L). Bone marrow response to iron is limited to 20 mg per day of elemental iron. In a patient older than 50 years who lacks symptoms. However. a therapeutic trial of oral iron therapy is the recommended initial approach. however. and 32.35 Ferrous sulfate in a dose of 325 mg provides 65 mg of elemental iron. whereas . Information from references 4. 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.31. 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.Whether to begin with endoscopy or colonoscopy should be indicated by symptoms or age. iron absorption varies widely based on type of diet and other factors.33 However. the diagnostic work-up should begin with colonoscopy. Algorithm for evaluation and treatment of iron deficiency anemia.

g. 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. bran..g. a safer form of parenteral iron. The advantage of iron dextran is the ability to administer large doses (200 to 500 mg) at one time. protein. There also is a delayed reaction. In a study of 2. Some persons have difficulty absorbing the iron because of poor dissolution of the coating. iron dextran (Dexferrum) has been the only parenteral iron preparation available in the United States.41 Until recently. 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. nonadherence. proton pump inhibitors. tea)37 or phytates (e. Anemia defisiensi dapat diklasifikasikan menurut morfologi dan etiologi menjadi 3 golongan : . which consists of myalgias. and adequate intake of liquids can alleviate the constipating effects of oral iron therapy.43 Sodium ferric gluconate is usually administered intravenously in eight weekly doses of 125 mg for a total dosage of 1. Gastrointestinal absorption of elemental iron is enhanced in the presence of an acidic gastric environment.40 A liquid iron preparation would be a better choice for these patients. Foods rich in tannates (e. approved for use in the United States in 2000. intolerance to oral iron. Anemia Defisiensi Adalah anemia yang terjadi akibat kekurangan satu atau beberapa bahan yang diperlukan untuk pematangan eritrosit. although published experience is more limited. piridoksin dan sebagainya. 0. Indications for the use of intravenous iron include chronic uncorrectable bleeding.28 The Authors I. cereal). Sodium ferric gluconate (Ferrlecit). was approved by the U.38 or medications that raise the gastric pH (e. and arthralgias.g. Laxatives. This can be accomplished through simultaneous intake of ascorbic acid (i. headache.S.e. Nonsteroidal anti-inflammatory drugs will usually relieve these symptoms. vitamin B12. Another intravenous preparation. that can occur 24 to 48 hours after infusion.04 percent receiving sodium ferric gluconate had life-threatening reactions compared with 0.36 Although iron absorption occurs more readily when taken on an empty stomach. seperti defisiensi besi. antacids..42 One major drawback of iron dextran is the risk of anaphylactic reactions that can be fatal. 200 mg is administered intravenously five times over a two-week period.. In iron deficiency not associated with hemodialysis.. asam folat.. Safety profiles are similar to sodium ferric gluconate. The risk of anaphylaxis is drastically reduced using sodium ferric gluconate. this increases the likelihood of stomach upset because of iron therapy. but they may be prolonged in patients with chronic inflammatory joint disease. No test dose is required. Increased patient adherence should be weighed against the inferior absorption. stool softeners.000 mg. histamine H2 blockers)39 reduce absorption and should be avoided if possible.325 mg of ferrous gluconate provides 38 mg of elemental iron. Food and Drug Administration in 1999.g. intestinal malabsorption.61 percent receiving iron dextran.534 patients on hemodialysis. vitamin C). those who have religious objections). is iron sucrose (Venofer).

Dari semua itu defisiensi besi merupakan penyebab utama anemia didunia.1 %. Kemudian masuk ke usus halus dirubah menjadi ion fero dengan pengaruh alkali. Jumlah besi dalam badan orang dewasa adalah 4-5 gr sedang pada bayi 400 mg. Hipokrom berarti mengandung hemoglobin dalam jumlah yang kurang dari normal (MCHC kurang). Mikrositik Hipokrom Mikrositik berarti sel darah merah berukuran kecil. tetapi akan terhambat dengan fosfat. Kebutuhan besi pada bayi dan anak lebih besar dari pengelurannya karena pemakaiannya untuk proses pertumbuhan. sebagian disimpan sebagai senyawa feritin dan sebagian lagi masuk keperedaran darah berikatan dengan protein (transferin) yang akan digunakan kembali untuk sintesa hemoglobin. Hal ini umumnya menggambarkan defisiensi besi. mioglobin 5-10 %. sayuran yang mengandung klorofil. 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. yang terdiri dari : masa eritrosit 60 %. daging telur. besi plasma 0. Besi diabsorsi dalam usus halus (duodenum dan yeyenum) proksimal. dibawah ukuran normal (MCV<80 fL). kemudian ion fero diabsorpsi. terkadang untuk menghindari anemia defisiensi besi kedalam susu buatan atau tepung untuk makanan . feritin dan hemosiderin 30 %. Sebagian dari transferin yang tidak terpakai disimpan sebagai labile iron pool. Berikut bagan metabolisme besi : Adapun sumber besi dapat diperoleh dari  makanan seperti : hati. hemenzim 1 %. antasid. Besi yang terkandung dalam makanan ketika dalam lambung dibebaskan menjadi ion fero dengan bantuan asam lambung (HCL). buah. oksalat.1. a. susu. dengan kebutuhan rata-rata 5 mg/hari tetapi bila terdapat infeksi meningkat sampai 10 mg/hari. keadaan sideroblastik dan kehilangan darah kronik atau gangguan sintesis globin seperti pada penderita talasemia. Penyerapan ion fero dipermudah dengan adanya vitamin atau fruktosa.

Absorpsi kurang : MEP.4 – 1 mg/hari 1 – 1. Remaja-dewasa: mentruasi berlebihan Gejala klinis Lemas.3 – 0. kebutuhan yang meningkat karena infeksi berulang (enteritis. kehilangan darah karena divertikulum meckeli. diet tidak adekuat. absorpsi kurang anak 2-5 tahun : masukan besi kurang.5 mg/hari Wanita hamil 2. defisiensi diet. ASI eklusif tanpa suplemen besi.7 mg/hari Etiologi menurut patogenesisnya :      Masukan kurang : MEP. sel kulit yang terkelupas dan karena perdarahan (mens) sangat sedikit. bayi ditambahkan kandungan besi namun terkadang dapat menimbulkan terjadinya hemokromatosis. Anak 5-remaja : perdarahan karena infeksi parasit dan polip. susu formula rendah besi. keringat.5 mg/hari Wanita dewasa 1 – 2. tinja. anemi selama kehamilan anak 1-2 tahun : masukan besi kurang. 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.BP).4 mg. 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. Pengeluaran besi dari tubuh yang normal : Bayi 0. 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. lahir kembar. pertumbuhan cepat. kebutuhan meningkat. pertumbuhan cepat. pucat dan cepat lelah Sering berdebar-debar .hari Anak 4-12 tahun Laki-laki dewasa 0.

mengkilat. Jantung dapat takikardi Jika karena infeksi parasit cacing akan tampak pot belly Penderita defisiensi besi berat mempunyai rambut rapuh. licin. merah. poikilositosis. Diharapkan kenaikan Hb 1 g.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 . IBC meningkat Terapi       Pengobatan kausal Makanan adekuat Sulfas ferosus 3X10 mg /KgBB/hari. mudah patah dan berbentuk seperti sendok. telapak tangan dan dasar kuku Konjungtiva okuler berwarna kebiruan atau putih mutiara (pearly white) Papil lidah atrofi : lidah tampak pucat.- Sakit kepala dan iritabel Pucat pada mukosa bibir dan faring. Ht menurun MCV <80. halus serta kuku tipis. rata. meradang dan sakit. Laboratorium      Kadar Hb <10 g/dL. MCHC <32 % Mikrositik hipokrom. sel target SSTL sistem eritropoetik hiperaktif SI menurun.