2. Anaemia: Definition of anaemia and prevalence of IDD
Anaemia is defined as ‘a reduction of the
haemoglobin concentration, red-cell count, or packed
cell volume to below normal levels’.
Some 2 billion people worldwide are affected by iron-
deficiency anaemia (IDD).
IDD is widely prevalent in India, with
20% of adult males,
40% of children and adult non-pregnant females
80% of pregnant females being affected.
3. Classification
The main groups of anaemias classified according to the
underlying cause
Reduced red-cell production:
• Defective precursor proliferation
• Defective precursor maturation
• Defective proliferation and maturation
Increased rate of red-cell destruction:
• Haemolysis
Loss of red cells from the circulation:
• Bleeding
4. Distribution and loss of iron
1.The total amount of iron in the adult body is between 3 and 4 gm as haem
2. Haem is found as haemoglobin and myoglobin, although appreciable
quantities are found the liver, kidney and intestine
3. In a normal individual, the average red cell life span is 120 days. Thus,
0.8–1% of red cells turn over each day. Because each milliliter of red cells
contains 1 mg of elemental iron, the amount of iron needed to replace
those red cells lost through senescence amounts to 20 mg/d (assuming an
adult with a red cell mass of 2 L
Adult male 80 kg (mg) Adult female 60 kg (mg)
Haemoglobin 2500 1700
Myoglobin/ enzymes 500 300
Transferrin iron 3 3
Stores 600 to 1000 0 to 300
5. Recommended daily allowance for iron.
Current recommended dietary allowances of iron for
Indians:
Boy 16-18yrs 50 (mg of iron/day)
Girl 16-18 30
Men >18 28
Women >18 30
Pregnant women 38
*Computed based on absorption rates of 3 per cent for males,5 percent for females
6. Causes of iron deficiency
Increased Demand for Iron
Rapid growth in infancy or adolescence
Pregnancy
Erythropoietin therapy
Increased Iron Loss
Chronic blood loss
Menses
Acute blood loss
Blood donation
Phlebotomy as treatment for polycythemia vera
Decreased Iron Intake or Absorption
Inadequate diet
Malabsorption from disease (sprue, Crohn's disease)
Malabsorption from surgery (postgastrectomy)
Acute or chronic inflammation
7. Absorption of iron from gut and homeostasis
Iron absorption—this occurs in the duodenum and upper jejunum and
the following complex processes are involved:
(1) divalent metal transporter protein (DMT1)—essential for
uptake of ferrous ions by gut cells and erythron
(2) ferrireductase—reduces ferric form to ferrous
(3) uptake of haem by enterocytes—mediated by an unknown
membrane protein;
(4) ferroportin—mediates egress of ferric ions from enterocytes.
Iron homeostasis—this is maintained by rigorous control of absorption
from the diet orchestrated by the peptide hormone, hepcidin, which is
synthesized by the liver and regulates the process by inhibiting efflux
of iron from enterocytes.
8. Iron metabolism and Haem synthesis
Most body iron is present in haemoglobin in circulating
red cells
The macrophages of the reticuloendotelial system store
iron released from haemoglobin as ferritin and
haemosiderin
They release iron to plasma, where it attaches to transferrin
which takes it to tissues with transferrin receptors –
especially the bone marrow – where the iron is
incorporated by erythroid cells into haemoglobin
There is a small loss of iron each day in urine, faeces, skin
and nails and in menstruating females as blood (1-2 mg
daily) is replaced by iron absorbed from the diet.
10. Stages in the development of iron deficiency*
Prelatent :- the stage of negative iron balance
reduction in iron stores without reduced serum iron
levels
Latent:- stage of iron-deficient erythropoiesis
iron stores are exhausted, but the blood haemoglobin
level remains normal
Stage of Iron deficiency anemia
blood haemoglobin concentration falls below the lower
limit of normal
*discussed in detail later
11. Approach to IDD will be considered under the
following heads:
History
Clinical features: general and specific
Examination
Blood tests
Bone marrow picture
Differential diagnosis
Treatment
12. History
In slowly developing anaemia, even at very low
haemoglobin levels, symptoms of anaemia may be absent.
History of a sore tongue, dysphagia, dyspepsia, bleeding
from any site, and of symptoms suggestive of
malabsorption is important in cases of anaemia.
Family history is important mainly in haemolytic anaemias
eg. thalassaemias in Sindhis, Kutchhis
Sickle cell disease in Patels
G-6-PD deficiency in Parsis
13. Symptoms of anaemias in general
Can be classified as per each system:
Fatigue
Dizziness, light headedness
Headache
Insomnia
Tinnitus
Palpitation
Dyspnoea
Lethargy
Disturbances in menstruation, reduced libido
Impaired growth in infancy
14. Symptoms of IDD
Irritability
Poor attention span with lack of interest in
surroundings
Poor work performance
Behavioural disturbances
Pica (geophagia. pagophagia, abnormal food cravings)
Defective structure and function of epithelial tissue
especially affected are the hair, the skin, the nails, the tongue,
the mouth, the hypopharynx and the stomach
Increased frequency of infection.
15. Pica (perverted eating habits)
The habitual ingestion of unusual substances
earth, clay (geophagia)
laundry starch (amylophagia)
ice (pagophagia)
Usually is a manifestation of iron deficiency and is
relieved when the deficiency is treated
It is dangerous because it can lead to helmenthiasis
(hookworm)
16. Abnormalities in physical examination
Pallor - of skin, lips, nail beds and conjunctival mucosa
Nails - flattened, fragile, brittle,
-koilonychia( hollow nail) due to retarded growth of nail plate.
3 stages: brittleness, platynychia and spooning
Tongue and mouth
Atrophic glossitis, angular cheiliosis, stomatitis
Dysphagia
Stomach
atrophic gastritis, (reduction in gastric secretion,
malabsorption)
The cause of these changes in iron deficiency is uncertain,
but may be related to the iron requirement of many
enzymes present in epithelial and other cells
19. Laboratory investigations
The single most important investigation is a careful examination of a
good-quality Romanowsky-stained peripheral smear (PS).
Some common morphologic abnormalities of the red cells seen on PBS
in IDD are as follows :
Abnormality Significance
Hypochromia (Defective haemoglobinisation) iron-deficiency anaemia,
thalassaemias
Microcytosis (Defective haemoglobinisation) iron-deficiency anaemia,
thalassaemias
Anisocytosis (Variation in size of cells) iron-deficiency anaemia,
thalassaemias
haemoglobinopathies
Pencil cells and target cells are amongst others to be seen and both are the
result of defective haemoglobinisation and/or excess membrane
21. Pencil cells: Oval to elongated, ellipsoid shape with central
area of pallor and hemoglobin at both ends of cell
Significance: Iron deficiency anaemia (Elongated cells)
Vitamin B12 deficiency anaemia (Oval Cells)
23. Target Cells:
Characterised by thin “bulls-eye” shape and an increase in the surface
membrane area to volume ratio due to a decrease in Hb
Significance: Iron Deficiency Anaemia,
Vit B12 deficiency Anaemia and
other disorders (eg Liver Disorders, Thalassemia)
24. Reticulocyte count: (N= upto 2%)
This gives an estimate of the adequacy of the marrow
response to the anaemia.
Reticulocytes are young red cells with presence of
nuclear remnants in the cytoplasm
Reticulocytopenia occurs in nutritional deficiency
anaemias and aplastic anaemia
25. Laboratory findings (1)
Blood tests
erythrocytes
hemoglobin level
packed cell volume (PCV)
RBC
MCV and MCH
Retic count
anisocytosis
poikilocytosis
Hypochromia
leukocytes
normal
platelets
usually normal or thrombocytosis
26. Iron studies
Serum Iron - the amount of circulating iron bound to
transferrin(normal range is 50–150 g/dL)
Total Iron-Binding Capacity(TIBC) - an indirect measure of the
circulating transferrin (normal range is 300–360 g/dL)
the serum ferritin level correlates with total body iron stores; thus,
is the most convenient laboratory test to estimate iron stores. The
normal value for ferritin in Adult males 100 g/L, while adult females
30 g/L.
Red cell protoporphyrin : reflects an inadequate iron supply to
erythroid precursors to support hemoglobin synthesis. Normal
values are <30 g/dL of red cells. In iron deficiency, values in excess
of 100 g/dL are seen.
Serum Levels of Transferrin Receptor Protein: because transferrin
receptor protein (TRP) is released by cells into the circulation,
serum levels of TRP reflect the total erythroid marrow mass.
Normal values are 4–9 g/L
27. Laboratory findings (2)
Iron metabolism tests
serum iron concentration
total iron-binding capacity
saturation of transferrin
serum ferritin levels
sideroblasts
serum transferrin receptors
28. Bone marrow examination
Staining of iron stores in the bone marrow with Perls’s
reagent where it appears blue.
Examination of the amount of iron provides useful
information as to the appropriateness of iron therapy for
hypochromic anaemia eg. In CKD, Chronic inflammation.
29. Laboratory findings (3)
Bone marrow examination
high cellularity
mild to moderate erythroid hyperplasia
bone marrow shows absence of stainable iron
30. Stages in the development of iron deficiency
Prelatent :- the stage of negative iron balance
reduction in iron stores without reduced serum iron levels
Hb (N), MCV (N), iron absorption (), transferin saturation (N),
serum ferritin (), marrow iron ()
Latent:- stage of iron-deficient erythropoiesis
iron stores are exhausted, but the blood haemoglobin level
remains normal
Hb (N), MCV (N), TIBC (), serum ferritin (), transferin saturation
(), marrow iron (absent)
Stage of Iron deficiency anemia
blood haemoglobin concentration falls below the lower limit
of normal
Hb (), MCV (), TIBC (), serum ferritin (), transferin saturation
(), marrow iron (absent)
31. Differential diagnosis
Tests Iron Deficiency Inflammation Thalassemia Sideroblastic
Anemia
Smear Micro/hypo Normal
micro/hypo
Micro/hypo with
targeting
Variable
Sr.Iron <30 <50 Normal to high Normal to high
TIBC >360 <300 Normal Normal
Percent
saturation
<10 10–20 30–80 30–80
Ferritin (g/L) <15 30–200 50–300 50–300
Hemoglobin
pattern on
electrophoresis
Normal Normal Abnormal with
thalassemia; can
be normal with
thalassemia
Normal
32. Management of iron deficiency anemia
Correction of the iron deficiency
Orally
Blood transfusion
intravenously
Treatment of the underlying disease
33. Blood tranfusion (PRC’s)
Indications:
Symptoms of anemia
Cardiovascular instability
Continued and excessive blood loss from whatever source
Advantages:
1. Transfusions correct the anemia acutely
2. Transfused red cells provide a source of iron for
reutilization (assuming they are not lost through
continued bleeding.)
34. Oral iron therapy
The optimal daily dose - 300 mg of elemental ironOral iron preparations
Generic Name Tablet (Iron Content) in mg
and % of absorption
Ferrous sulfate 325 (65) 20% ( Fefol, Fesovit, Orofer)
Ferrous fumarate 325 (107) 33% (Vitcofol. Livogen, Enzofer)
Ferrous gluconate 325 (39) 12%
Polysaccharide iron 150 (150) 100%
35. Oral iron: additional points
continue treatment for 3 - 6 months after the anemia is
relived
side effects
heartburn, nausea, abdominal cramps, diarrhoea
iron absorption
is enhanced: vitC, meat, orange juice, fish
is inhibited: cereals, tea, milk (tannin, phylates and
phosphates)
36. Failure of oral therapy
Incorrect diagnosis
Complicating illness
Failure of the patient to take prescribed medication
Inadequate prescription (dose or form)
Continuing iron loss in excess of intake
Malabsorption of iron
37. Parenteral iron therapy (1)
Is indicated when the patient
intolerance to oral iron
loses iron (blood) at a rate to rapid for the oral
intake
is unable to absorb iron from gastrointestinal
tract
38. Parenteral iron therapy (ii)
Preparations and administration
iron - dextran complex (50mg iron /ml)
intramuscularly or intravenously
necessary is the test for hypersensitivity, no longer
used
newer iron complexes such as sodium ferric gluconate
(Ferrlecit) and iron sucrose (Venofer) have lower rates
of adverse effects.
iron to be injected (mg) = (15-pts Hb/gm%) x body weight
(kg) x2.3 + 1000(for stores)
39. Side effects
Local:
pain at the injection site, discoloration of the skin,
lymph nodes become tender for several weeks, pain in
the vein injected, flushing, metallic taste
Systemic:
Immediate: hypotension, headache, malaise,
urticaria, nausea, anaphylactoid reactions
Delayed: lymphadenopathy, myalgia, arthralgia,
fever