Hematocrite as a Screening Test of Iron Deficiency Occurrence in Tetralogy Of Fallot (Bagus Setyoboedi et al.

HEMATOCRITE AS A SCREENING TEST OF IRON DEFICIENCY OCCURRENCE

IN TETRALOGY OF FALLOT

Bagus Setyoboedi, Utamayasa A, Rahman MA, Ontoseno T

Department of Child Health
Faculty of Medicine, Airlangga University
Dr. Soetomo Teaching Hospital
Surabaya Indonesia

ABSTRACT

Tetralogy of Fallot (TF) is a cyanotic congenital heart disease, characterized by a shunt from right to left and a
decrease in blood flow to the lungs. Erythropoiesis as compensation for chronic hypoxia in TF patients often cannot be
balanced with adequate reserves of iron, causing iron deficiency and the "relative anemia". Parameters for determining
iron deficiency in patients with cyanotic congenital heart disease still in debate. The purpose was to study the use of
hematocrite as a screening test incidence of iron deficiency in patients with TF. This was a cross sectional study in
patients with Tetralogy of Fallot in Children Cardiac Outpatient Clinic Dr. Soetomo hospital Surabaya during July and
August 2004. Samples were taken in consecutive. Result was analyzed with McNemar test and cut-off point was
determined with receiver operator characteristic (ROC) curve and contingency C test. Of the 33 patients who were
found 14 (42.4%) patients with a hematocrite (HCT) less than or equal to 45% and 19 (57.6%) more than 45%. There
was significant positive relationship (r = -0.401, p = 0.021) between the hematocrite with the presence or absence of
iron deficiency (transferrine saturation < 11.5%) and MCV < 80 fl). The optimum value of hematocrite in predicting
iron deficiency ranged 40% to 45%, with highest sensitivity at 40% hematocrite (94.4%). Conclusion: Hematocrite
levels < 40% can be used as screening tests incidence of iron deficiency in patients with TF.

Keywords: hematocrite, iron deficiency, Tetralogy of Fallot, screening test

Correspondence: Bagus Setyoboedi, Department of Child Health, Faculty of Medicine, Airlangga University, Dr.
Soetomo Teaching Hospital, Surabaya, Indonesia

INTRODUCTION generated, it is necessary for us to know whether the

Tetralogy of Fallot (TF) is a cyanotic congenital heart
disease that most often found, the prevalence of 10-12%
of all congenital heart disease (Behrman 2000). As a
cyanotic congenital heart disease, it can lead to chronic
hypoxia in all tissues of the body. State of
erythropoiesis in compensation of chronic hypoxia on
TF patients often can not be balanced with adequate
rseserves of iron, causing iron deficiency and the
"relative anemia", in which the hemoglobine and
hematocrite levels are "normal" can be the same as in
the blood picture of iron deficiency anemia (Dallman
PR, 1987). The prevalence of iron deficiency in patients
with TF obtained at 55.4% (Ontoseno 2001).
Parameters that can be used to determine iron deficiency
in patients with cyanotic congenital heart disease still in
debate. Yet many writers who can still receive MCV
(Mean Corpuscular Volume) as a parameter determining
iron deficiency in patients with cyanotic congenital
heart disease simple and inexpensive (Olcay et al. 1996,
Onur et al. 2003). On the basis of the description above,
prior to either palliative or definitive surgery in patients
with TF and considering the impact that can be
hematocrite to describe the incidence of iron deficiency
in patients with TF for early detection can be done in a
way that is easy and simple, so that it can reduce
morbidity and mortality resulting from it.
MATERIALS AND METHODS
This study was an observational cross sectional study, in
patients with Tetralogy of Fallot in cardiac outpatient
clinic children of Dr. Soetomo hospital Surabaya. The
study was conducted July and August 2004, samples
taken in consecutive. Patients with post operative
definitive/palliative care, chronic infection, severe
malnutrition, iron therapy before, and TF with
complications were excluded. Each sample examination
hematocrite, transferrin saturation, and MCV. Result
was analyzed with McNemar test and Kappa agreement.
The value of cut off point was determined with receiver
operator characteristic (ROC) curve and contingency C
test.

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Folia Medica Indonesiana Vol. 46 No. 4 October - December 2010 : 279-281

RESULT patients (57.9%) and 8 female patients (42.1%), the

ratio is almost similar to the sex ratio of patients with
Of the 33 patients who were found as many as 14 TF in general is 60:40. (Guntherorth et al. 1983). Age of
(42.4%) patients with a hematocrite (HCT) less than or patients in general no effect on hematocrite in this
equal to 45% and a total of 19 (57.6%) patients with a study. Age of the patient also had no effect on the value
hematocrite more than 45%. of MCV and transferrin saturation. This is consistent
with previous studies in which iron deficiency in
Table 1. The basic characteristic of patients patients with TF obtained by 55.4% and there is no
difference between age, sex, weight, reticulocyte,
Hematocrite P erythrocyte sedimentation rate, C reactive protein and
≤ 45% > 45% blood albumin (Ontoseno 2002).
Gender N (%)
Male 11 (57.9%) 7 (50%) 0.923 Table 2. Hematocrite test in predicting iron deficiency
Female 8 (42.1%) 7 (50%)
Age (years old) 0.496 Statistic test
<1 yr - 4 (28.6%) Hct Se Sp NPP NPN
(%) (%) (%) (%) (%)
1-5 yrs 17 (89.5%) 6 (42.9%) McNemar kappa
> 50-10 yrs 1 (5.3%) 2 (14.3%)
> 10 yrs 1 (5.3%) 2 (14.3%) >40 94.4 53.3 70.8 88.9 0.108 0.002

Distribution of hematocrite based on the presence or

absence of iron deficiency shown in a scatter >41 83.3 66.7 75.0 76.9 0.424 0.003
diagram. Presence or absence of iron deficiency found
by doing a factor analysis of transferrin saturation (Cutt
of points 11.5%) and MCV (80 fl Cutt of points). From >42 66.7 66.7 70.6 62.5 0.832 0.056
the results of statistical analysis found a significant
positive relationship with r = -0.401, p = 0,021. ROC >43 61.1 66.7 68.8 58.8 1.000 0.112
curve shows the picture of the optimum hematocrite
value in predicting iron deficiency (transferrin
saturation < 11.5% and MCV < 80 fl) range from 40% >44 61.1 66.7 68.8 58.8 1.000 0.112
to 45%, with highest sensitivity at 40% hematocrite
(94.4%).
>45 55.6 73.3 71.4 57.9 1.000 0.095
2.0
Se: sensitivity, Sp: specificity, PPV: Positive Predictive Value, NPN:
1.5 Negative Predictive Value
Factor score MCV + Sat Transferin

1.0
As the parameters of the incidence of iron deficiency in
.5
TF we use indicators to Cutt of transferrin
0.0 saturation point of 11.5% and MCV with Cutt of
-.5
point 80 fl. In previous studies Lany 1997 get a
combination of MCV and transferrin saturation is a
-1.0
good screening test for detection of iron deficiency in
-1.5 patients with congenital heart disease including TF blue,
-2.0 with a value sensitivity 100% and a specificity of
30 40 50 60 70 80 87.5%. Cutt of points for MCV was 80 fl and for
Hct transferrin saturation 11.5% (Lany 1997).
Figure 1. Distribution of hematocrite based on iron
deficiency (transferrin saturation + MCV) Distribution of hematocrite based on the presence or
absence of iron deficiency in the statistical analysis
showed significant negative relationships but weak (r =
DISCUSSION -0.401, p = 0.021). Iron deficiency was obtained by
performing factor analysis of transferrin saturation (Cutt
In this study, male patients slightly more than women, of points 11.5%) and MCV (Cutt of points 80 fl ). The
but on statistical analysis, gender did not affect the combination of transferrin saturation (Cutt of
levels of hematocrite. In HCT < 45% obtained 11 male points 11.5%) and MCV (80 fl Cutt of points) in the
study by Lany 1997 further illustrate the relative effect

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 Hematocrite as a Screening Test of Iron Deficiency Occurrence in Tetralogy Of Fallot (Bagus Setyoboedi et al.)
of iron deficiency anemia in patients with TF sensitivity
value of 100% and specificity 87.5%. MCV values
better reflect the conditions of microcytic anemia that
has a high sensitivity (100%) but low specificity
(64.3%). While the transferrin saturation is even more
specifically describe the condition of iron deficiency
with sensitivity 81.8% and specificity 100% (Lany
1997).
To determine the ability of hematocrite in predicting
iron deficiency using ROC curves to determine
sensitivity and specificity. From the results, hematocrite
can only be used in predicting the saturation of
transferrin < 11.5% (p = 0.033; 95% CI 0.532 to 0.905),
whereas to predict MCV fl < 80 (p = 0.580 CI 95%) or a
combination of both (p = 0.055, CI 95%) are not
eligible. This is consistent with the objectives of this
research, because as we discussed earlier that further
describe the condition of transferrin saturation
deficiency of the second stage which has not happened
yet clinical signs of iron deficiency anemia (Hoffbrand
et al. 2001, Kazal 2002). In addition, < 11.5%
transferrin saturation have good specificity in describing
the condition of iron deficiency in patients with TF
(Ontoseno 2002). Therefore in this study hematocrite is
used as screening tests, then look for hematocrite values
that have the highest sensitivity and qualify McNemar
statistical tests obtained p> 0.05 and kappa<0.05. Based
on the results, the best hematocrite in predicting iron
deficiency conditions in patients with hematocrite levels
of TF that is at 40%.
The result of such research was in contrast to what was
obtained by previous researchers. But the sovereign,
when we examine further this research in fact both have
different viewpoints. Onur (2003) in the study divided
patients into two groups cyanotic SPA is iron
deficient and iron sufficient based on serum ferritin and
transferrin saturation. Then in both groups were given
iron supplements and the result is a non-significant
differences in hematocrite values in iron
sufficient group but significantly deficient in iron so it
does not recommend the use of hematocrite as a
parameter in diagnosing iron deficiency in patients with
cyanotic PJB. In this research we try to find the
hematocrite value that can describe the state of iron
deficiency in patients with TF (Onur et al. 2003). The
use of transferrin saturation describing the condition of
the second stage of iron deficiency would be better if
enhanced by using the serum ferritin or even tissue
ferritin a more sensitive and specific in determining the
condition of iron deficiency.
281
CONCLUSION
Hematocrite less than or equal to 45% have a fairly
significant negative relationship of transferrin saturation
with r = -0575, p = 0.01. In contrast to the hematocrite
above 45% it occurred positive relationship is also quite
significant that it is with r = 0.670, p = 0,021. By using
ROC curve is obtained to predict hematocrite < 11.5%
transferrin saturation as a picture of the second phase
deficiency with the results of analysis of statistical
significance (p = 0.033; 95% CI 0.532 to 0.905). From
further analysis concluded hematocrite can be used as
screening tests of iron deficiency in patients with
tetralogy of Fallot with a threshold of 40% (sensitivity
93%).
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