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Iron Deficiency Anemia

Iron Deficiency Anemia. Prof.Dr .Teoman SOYSAL. Iron Deficiency Anemia. One of the most common medical problems Most common cause of anemia Iron deficiency anemia is the last step ; Iron depletion : absent or decreased iron stores

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Iron Deficiency Anemia

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  1. Iron Deficiency Anemia Prof.Dr.Teoman SOYSAL

  2. Iron Deficiency Anemia • One of themostcommonmedicalproblems • Mostcommoncause of anemia • Irondeficiencyanemia is thelast step ; • Irondepletion: absentordecreasedironstores • Irondeficiency: depletion of stores + low serum ironandferritin • Irondeficiencyanemia: Anemiadeveloping in an irondeficientpatient

  3. Total amount of body iron:3-5 g

  4. IronMetabolism • Iron is located at thecenter of Hem molecules of Hb (amount:1.5-2 gr) and it is also; • Part of themyoglobin • Takesplace in thetissueenzymes • Storageformsare(1gr in men,0.5gr in women): • Ferritin • Hemosiderin • Location: Bone Marrow, Liver, Spleen • Transport ironis about 7 mg andboundtotransferrin.

  5. Iron Metabolism • Transferrinpicksupironfrom ; • The GI cellsto deliver it toHbformingcells • Storageparts as a step of ironrecyclingprocess • Absorbtion + recyclingprovidestheconstantironsupply of 20 mg/day(upto 35 mg)necessaryforHbsynthesis

  6. Daily Iron Demands Male1 mg Adolesc. 2-3 mg Women in repr.age 2-3 mg Pregnant 3-4 mg

  7. Iron Metabolism • Ironabsorbtion is restrictedtotheneeds of the body • 1mg of iron is losteachday • Sweating • Epidermalshedding • Menstruationandpregnancy/lactationareothermajorcauses of ironlossandincreseddemand in women

  8. Iron Metabolism • Normal dietcontainsabout 15 mg of iron/day • 6mg elementaliron/1000 cal • 1/10 of ingestediron is absorbed • Gastricacidreleasesironfromfood • Iron is absorbed in thereduced form • Ascorbateincreasesabsorbtion (byreducing) • Phytates,tannates,antacidsdecreaseabsorbtionbymakingcomplexeswithiron

  9. Iron Metabolism • Main sites of absorbtion are; • Duodenum • Upper jejunum • Malabsorbtive states or gastrojejunostomy prevent absorbtion.

  10. Iron Metabolism Transport of iron • Transferrin is the main iron carrier in plasma • It is produced in liver cells with increased synthesis in iron deficiency • Transferrin binds 1-2 ferric iron molecules • Transferrin-iron complex is endocytosed by Hb producing cells after linking to receptors.

  11. Iron Metabolism • Total iron binding capacity and iron • Transferrin is measured by quantifying the iron binding sites available • This is also called “Total iron binding capacity” • TIBC is 1/3 saturated under normal conditions • Plasma Transferrin : 300 μg/dL • Plasma Iron: 60-180 μg/dL

  12. Causes of iron deficiency • Chronicbloodloss • Increaseddemand • Malabsorbtion of iron • Inadequateironintake • Intravascularhemolysisandhemoglobinuria-hemosiderinuria • Combinations

  13. Increased demands • Pregnancy • Lactation • Rapid growth

  14. Decreased intake • Decreased iron in the diet • Vegetarianism • Tea-tost type feeding (old age) • Decreased absorbtion • Gastric surgery • Achlorhydria • Sprue • Pica

  15. Increased iron loss • Menorrhagia • GIS hemorrhagia • P.Ulcer • Oesophagitis • Varices • Hiatal hernia • Malignancy • Angiodysplasia • Diverticulosis • Meckel diverticula • Colitis or imf. Bovel disease • Hemorrhoids • NSAID use • Parasites

  16. Increased iron loss • Bleedingdisorder • Pulmonarylesionswithbleeding • Hemoglobinuria – hemosiderinuria (chronicintravascularhemolysis) • Hemodialysis • Hematuria (chronic) • Frequentdonation • 250 mg iron /unit-blood

  17. Clinical features • General symptoms of anemia • Fatiguemay be disproportionaltothedegree of anemiaduetodeficiency of tissueenzymeswhichalsoneediron • Chlorosis • Glossitis • Angularstomatitis • Paterson-Kelly (PlummerVinson) syndrome (oesephageal web leadingtodisphagia)

  18. Clinicalfeatures • Gastric atrophy • Ozena-anosmia • Nail changes • Brittle/fragility • Koilonchia/spooning • Hair loss • Splenomegaly

  19. Clinical features • Pica:Appetiteforbizzarefood/substances • Geophagy (earth,clay) • Pagophagia(ice) • Amylophagia(starch) • Developmentalproblems • Splenomegaly • Tayanc-Prasadsyndrome (growthretardation, hypogonadism, hepatosplenomegaly, zincandirondeficiency, geophagia) • Immun-deficiency

  20. Lab. Features • Hb,Htc,RBC:Low • MCV,MCH,MCHC:Low • RDW: High • Retics: Normal/Low • Plt:Normal/Low/High • WBC:Normal/Low • Smear: Hypochromia,anisocytosis,microcytosis, poikilocytosis

  21. Lab.Features • Serum Iron: (N: 60 – 180 μg/dL) • TIBC: (250 - 430 μg/dL) • Serum Ferritin (N:Female;10-150 μg/L, Male;29-248 μg/L) Malesandpost menopausalwomen<10 μg/L Premenopausalwomen <5 μg/L Iron def+Chr.Disease< 60 μg/L

  22. Lab.Features • Transferrinsaturation (Fe/TIBC):(<15%)<5%:definitelyindicatesirondeficiency • Serum Transferrin Receptor: • FreeErythrocyteProtoporphyrin(17 – 27 μg/dL) • Bone marrow : • Erythroid hyperplasia, • Absence ofhemosiderin

  23. Differential diagnosis • Microcyticanemias • Irondeficiencyanemia • Thalassemia ,HbC,HbEetc • Sideroblasticanemia • Leadpoisoning • Anemia of chronicdiseases (sometimes)

  24. Diff.Diagnostic Tests Iron deficiency Chronic disease Siderobl.anemia Thalasse-mia. Lead poisoning aminolaevulinic acid porphobilinogen

  25. Important !!!!!!! • The diagnostic procedure is not complete until the underlying pathology is disclosed.

  26. Treatment • Replaceironandtreatunderlyingdisease. • Oral route is preferredforreplacement. • Response can be followedbyretic. increase in 1-2 weeks (5-7 days) • Hbresponsetotreatment • half normal by a month • returnsto normal by 2-4 months • Replacementtherapy is prolongedby 6-12 monthstoreplenishstores of iron. • Ongoingbleedingmaycauseindefinitetherapy.

  27. Treatment Oral iron therapy: dose (mg) elemental iron(mg) Fe fumarate 200 65 Fe gluconate300 35 Fe sulphate 200 65

  28. Treatment Oral iron therapy: Total daily dose:150-200 mg elemental iron Give in 3-4 divided doses, Each one hour before meals. Do not prefer enteric coated forms. In case of GIS intolerance; • Change the route of administration or • Change the preparation or • Reduce dose

  29. Treatment Nonrespondingpatient: • possiblecauses • Misdiagnosis • Patientdoes not takethemedicine • Continuingbloodloss • Malabsorbtion • Changethedrug • Changetheroute of administration • Underlyingdisease /comorbidity • Combineddeficiency

  30. Treatment • Parenteral iron therapy: Routine use is not justified, Response is not faster than oral replacement. Indications • Malabsorbtion • Intolerance to oral replacement • Colitis/enteritis • Needs in excess of amount that can be given orally • Patient uncooperative/poor compliance • Autologous blood donation setting • Hemodialysis

  31. Treatment Parenteralirontherapy: Total irondose:(15-patientHb) x bw x 3 • IronDextran: 50 mg/ml (iv/im) • Maxdailydose is 100 mg im • Ferricgluconate: • A test dose of 25 mg elementaliron (2 mL) must be given in 50 mL salineover 60 minutes • Ferric-hydroxy-sucrose(100 mg/5mL) • 2.5 ml firstday • 5ml thirdday • 2x5 ml/week

  32. Parenteralreplacementtherapymaycause allergicreactions, localpainorinduration, serum sicknesslikedisease, lymphadenomegaly, arthralgia, myalgiaetc. Treatment

  33. preventiveironsupplementation • Pregnants ( at 20-24 weeks Hb< 11 g/dL, Ferritin ). • Lactation. • Frequent blood donation. • Autologous blood donation settings. • Gastrectomised patients. • High dose asprin treatment.

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