The Importance of Iron Study in

Patients with Anemia

By
Khulood Abdulmuttaleb Al-Saeedi
Hi. Dip. In Medical laboratories

Lecture 2
Anemia describes the condition in which the number of RBCs
in the blood is low, or the blood cells have less than the normal
amount of hemoglobin (for age and sex). A person who has
anemia is called anemic.
♠ Although normal values can vary between laboratories,
typical values of hemoglobin level in patients with anemia:

- less than 13.5 g/dL in adult males

- less than 11.5 g/dL in adult females
- From the age of 2 years to puberty, less than 11.0 g/dL
- As newborn infants have a high haemoglobin level, 14.0
g/dL is taken as the lower limit at birth.
 Morphological Classification of anemia
MCV (Mean corpuscular volume)

<80 fl 80-95 fl >95 fl

Microcytosis Normocytosis Macrocytosis
 Morphological Classification of anemia
MCH & MCHC

MCH <27 g/dl MCH >27 g/dl

MCHC <32g/dl MCHC 32-36 g/dl

Hypochromic Normochromic

MCH (Mean corpuscular hemoglobin)

MCHC (Mean corpuscular hemoglobin concentration)
Microcytic, hypochromic Normocytic, Macrocytic
normochromic
MCV <80 fL MCV 80–95 fL MCV >95 fL
MCH <27 pg MCH ≥27 pg Megaloblastic: vitamin B12
or folate deficiency
Iron deficiency Many haemolytic anaemias
Thalassaemia Anaemia of chronic disease Non‐megaloblastic: alcohol,
Anaemia of chronic disease (some cases) liver disease, aplastic
(some cases) After acute blood loss anaemia
Renal disease
Mixed deficiencies
Bone marrow failure (e.g.
post chemotherapy,
infiltration by
carcinoma, etc.)
Iron deficiency anemia
Iron deficiency is the major cause of a microcytic,
hypochromic anaemia, in which the two red cell indices, mean
corpuscular volume (MCV) and mean corpuscular
haemoglobin (MCH), are reduced and the blood film shows
small (microcytic) and pale (hypochromic) red cells.

♠ Iron deficiency can exist with or without anemia. When iron

stores are depleted and insufficient iron is available for
erythropoiesis, hemoglobin synthesis in erythrocyte precursors
become impaired and hematologic signs of iron deficiency
anemia appear.
Groups At High Risk
The highest probability of suffering iron deficiency is found
in those parts of a population that have inadequate access to
foods rich in absorbable iron during stages of high iron
demand. These groups correspond to children, adolescents,
and women of reproductive age, in particular during
pregnancy.
Causes of Iron deficiency anemia
The primary causes of iron deficiency include:
1. Inadequate dietary intake. Low intake of bioavailable
iron.
2. Impaired absorption of iron
3. Blood loss (chronic blood loss).
4. Increased iron requirements (pregnancy, infancy).
5. Impaired iron recycling (hemolysis).
6. Medical conditions such as chronic kidney diseases.
Anemia of chronic disease
Any long-term medical condition can lead to anemia (each
anemia developed after chronic disease longer than 3 months).
♠ This type of anemia is the second most prevalent after
anemia caused by iron deficiency and develops in patients
with acute or chronic systemic illness or inflammation.
Such as infections, diabetes, autoimmune disorders,
malignancy.
The condition has thus been termed “anemia of inflammation”
due to:
1. Reduce in RBCs life span: direct cell distraction via toxin
from cancer cell, viruses, bacteria, etc.
1. Reduce RBCs production: by several mechanisms:
a. Production of erythropoietin blunted or inadequate despite
the presence of anemia.
b. Impaired release of iron from storage sites.
c. Reduce iron absorption from the gut.

♠ NOTE: Hepcidin elevated which blocks both the recycling

of iron from the macrophages and iron absorption.
Anemia related to kidney disease
The kidneys releases a hormone called the erythropoietin that
helps the bone marrow make RBCs.
In people with chronic (long-standing) kidney disease, the
production of this hormone is diminished, and this in turn
diminishes the production of RBCs, causing anemia.

In addition to increase urea and serum creatinine as toxic

products.
Anemia from active bleeding
Loss of blood through heavy menstrual bleeding or wounds
can cause anemia. Gastrointestinal ulcers or cancers such as
cancer of the colon may slowly lose blood and can also cause
anemia.
Anemia related to pregnancy
A gain in plasma volume during pregnancy dilutes the RBCs
and may be reflected as anemia.
Anemia during pregnancy is relatively common and can be
attributed to several factors
1. Iron deficiency due to increased demand for iron to
support the growing fetus and placenta. (Iron deficiency
anemia accounts for 75% of all anemia in pregnancy).
2. Folate or vitamin B12 deficiencies, especially if the mother
has an inadequate diet or absorption issue.
Anemia related to poor nutrition
Vitamins (vitamin B12 and folate) and minerals (iron) are
required for the proper production of hemoglobin and RBCs.
Deficiency in any of these micronutrients may cause anemia
because of inadequate production of RBCs.
Megalobalstic anemia an example of anemia related to
poor nutrition: The deficiency of vitamin B12 or folate
caused by:
1. Lack intake foods rich with vitamin B12 or folic acid.
2. Increase of demands (growth, pregnancy, chemotherapy).
3. Post infectious diseases or parasitic infection.
Thalassemia
This is another group of hemoglobin-related causes of anemia,
which involves the absence of or errors in genes responsible
for production of hemoglobin.
A hemoglobin molecule has subunits commonly referred to as
alpha and beta globin chains. A lack of a particular subunit
determines the type of alpha or beta thalassemia.
There are many types of thalassemia, which vary in severity
from mild (thalassemia minor) to severe (thalassemia major).
These are also hereditary, but they cause quantitative
hemoglobin abnormalities, meaning an insufficient amount of
the correct hemoglobin type molecules is made.
Sickle cell anemia
Sickle cell anemia is one of the most common inherited
diseases. Sickle cell disease caused by several mutations in the
β-globin gene.
The resultant hemoglobin (called HbS) has abnormal
physiochemical properties, and is prone to polymerization
with other hemoglobin molecules under conditions of low
oxygen tension. This has a number of adverse affects on
erythrocytes.
Abnormal hemoglobin molecules may cause problems in the
integrity of the RBC structure, RBC change shape under
stressed conditions and they may become crescent-shaped
(sickle cells).
Aplastic anemia
Aplastic anemia is a disease in which the bone marrow is
destructed and the production of blood cells is diminished.
This causes a deficiency of all three types of blood cells
(pancytopenia) including RBCs (anemia), white blood cells
(leukopenia), and platelets (thrombocytopenia).

Many common medications can occasionally cause this type

of anemia as a side effect in some individuals.
Hemolytic anemia
Hemolytic anemia is a type of anemia in which the RBCs
rupture, known as hemolysis, and are destroyed faster than the
bone marrow can replace them.
Hemolytic anemia could happen due to a variety of reasons
and is often categorized as acquired or hereditary.
Common acquired causes of hemolytic anemia are
autoimmunity and infection.
Disorders of RBC enzymes, membranes, and hemoglobin
cause hereditary hemolytic anemia.
Iron over load
Iron overload refers to the accumulation of excess iron in the
tissues. One of the forms in which this excess iron is stored is
hemosiderin. As iron continues to accumulate, ferritin
complexes can undergo changes, leading to the formation of
hemosiderin.
There is no physiological mechanism for eliminating excess
iron from the body, so iron absorption is normally regulated to
avoid accumulation.

Excessive iron deposition in tissues may result in serious

damage to organs, particularly the heart, liver and endocrine
organs.
Causes of Iron over load
1. Increased iron absorption
a. Hereditary (primary) haemochromatosis
b. Ineffective erythropoiesis, e.g. thalassaemia intermedia
c. Chronic liver disease
2. Increased iron intake
3. Repeated red cell transfusions