Iron deficiency


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Iron deficiency

  1. 1. Disorders of iron metabolism and hem synthesis <ul><li>I ron deficiency and iron deficiency anemia </li></ul><ul><li>T he anemia of chronic disorders </li></ul><ul><li>S ideroblastic anemias </li></ul><ul><li>M ethemoglobinemia and other disorders with cyanosis </li></ul><ul><li>H emochromatosis </li></ul><ul><li>P orphyria </li></ul>
  2. 2. Iron metabolism <ul><li>Most body iron is present in haemoglobin in circulating red cells </li></ul><ul><li>The macrophages of the reticuloendotelial system store iron released from haemoglobin as ferritin and haemosiderin </li></ul><ul><li>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 </li></ul><ul><li>There is a small loss of iron each day in urine, faeces , skin and nails and in menstrua ting females as blood (1-2 mg daily) is replaced by iron absorbed from the diet. </li></ul>
  3. 3. Stages in the development of iron deficiency <ul><li>Prelatent </li></ul><ul><ul><li>reduction in iron stores without reduced serum iron levels </li></ul></ul><ul><ul><ul><li>Hb (N), MCV (N), iron absorption (  ), transferin saturation (N), serum ferritin (  ), marrow iron (  ) </li></ul></ul></ul><ul><li>Latent </li></ul><ul><ul><li>iron stores are exhausted, but the blood haemoglobin level remains normal </li></ul></ul><ul><ul><ul><li>Hb (N), MCV (N), TIBC (  ), serum ferritin (  ), transferin saturation (  ), marrow iron (absent) </li></ul></ul></ul><ul><li>Iron deficiency anemia </li></ul><ul><ul><li>blood haemoglobin concentration falls below the lower limit of normal </li></ul></ul><ul><ul><ul><li>Hb (  ), MCV (  ), TIBC (  ), serum ferritin (  ), transferin saturation (  ), marrow iron (absent) </li></ul></ul></ul>
  4. 4. Iron deficiency and iron deficiency anemia <ul><li>The characteristic sequence of events ensues when the total body iron level begins to fall: </li></ul><ul><li> 1. decreases the iron stores in the macrophages of the liver, spleen and bone marrow </li></ul><ul><li> 2. increases the amount of free erythrocyte </li></ul><ul><li> protoporphiryn (FEP) </li></ul><ul><li> 3. begins the production of microcytic erythrocytes </li></ul><ul><li> 4. decreases the blood haemoglobin concentration </li></ul>
  5. 5. Iron deficiency anemia Definition and etiologic factors <ul><li>T he end result of a long period of negative iron balance </li></ul><ul><ul><li>d ecreased iron intake </li></ul></ul><ul><ul><ul><li>inadequate diet, impaired absorption, gastric surgery, celiac disease </li></ul></ul></ul><ul><ul><li>i ncreased iron loss </li></ul></ul><ul><ul><ul><li>gastrointestinal bleeding ( haemorrhoids , salicylate ingestion , peptic ulcer , neoplasm , ulcerative colitis ) </li></ul></ul></ul><ul><ul><ul><li>excessive menstrual flow , blood donation , disorders of hemostasis </li></ul></ul></ul><ul><ul><li>i ncreased physiologic requirements for iron </li></ul></ul><ul><ul><ul><li>infancy, pregnancy, lactation </li></ul></ul></ul><ul><ul><li>cause unknown (idiopathic hypochromic anemia) </li></ul></ul>
  6. 6. Iron deficiency anemia Clinical manifestation <ul><li>P resentation of </li></ul><ul><ul><li>underlying disease 37% </li></ul></ul><ul><ul><li>anemia symptoms 63% </li></ul></ul>
  7. 7. Symptoms of anemia <ul><li>Fatigue </li></ul><ul><li>Dizziness </li></ul><ul><li>Headache </li></ul><ul><li>Palpitation </li></ul><ul><li>Dyspnea </li></ul><ul><li>Lethargy </li></ul><ul><li>Disturbances in menstruation </li></ul><ul><li>Impaired growth in infancy </li></ul>
  8. 8. Symptoms of iron deficiency <ul><li>Irritability </li></ul><ul><li>Poor attention span </li></ul><ul><li>Lack interest in surroundings </li></ul><ul><li>Poor work performance </li></ul><ul><li>Behavioural disturbances </li></ul><ul><li>Pica </li></ul><ul><li>Defective structure and function of epithelial tissue </li></ul><ul><ul><li>especially affected are the hair, the skin, the nails, the tongue, the mouth, the hypopharynx and the stomach </li></ul></ul><ul><li>Increased frequency of infection </li></ul>
  9. 9. Pica <ul><li>The habitual ingestion of unusual substances </li></ul><ul><ul><li>earth, clay (geophagia) </li></ul></ul><ul><ul><li>laundry starch (amylophagia) </li></ul></ul><ul><ul><li>ice (pagophagia) </li></ul></ul><ul><li>Usually is a manifestation of iron deficiency and is relieved when the deficiency is treated </li></ul>
  10. 10. Abnormalities in physical examination <ul><li>P allor of skin, lips, nail beds and conjunctival mucosa </li></ul><ul><li>N ails - flattened, fragile, brittle, koilonychia, spoon-shaped </li></ul><ul><li>T ongue and mouth </li></ul><ul><ul><li>glossitis, angular cheliosis, stomatitis </li></ul></ul><ul><ul><li>dysphagia ( Peterson-Kelly or Plummer-Vinson syndrome (carcinoma in situ) </li></ul></ul><ul><li>S tomach </li></ul><ul><ul><li>atrophic gastritis, (reduction in gastric secretion, malabsorbtion) </li></ul></ul><ul><li>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 </li></ul>
  11. 11. Laboratory findings (1) <ul><li>Blood tests </li></ul><ul><ul><li>erythrocytes </li></ul></ul><ul><ul><ul><li>hemoglobin level  </li></ul></ul></ul><ul><ul><ul><li>the volume of packed red cells (VPRC)  </li></ul></ul></ul><ul><ul><ul><li>RBC  </li></ul></ul></ul><ul><ul><ul><li>MCV and MCH  </li></ul></ul></ul><ul><ul><ul><li>anisocytosis </li></ul></ul></ul><ul><ul><ul><li>poikilocytosis </li></ul></ul></ul><ul><ul><ul><li>hypochromia </li></ul></ul></ul><ul><ul><li>leukocytes </li></ul></ul><ul><ul><ul><li>normal </li></ul></ul></ul><ul><ul><li>platelets </li></ul></ul><ul><ul><ul><li>usually thrombocytosis </li></ul></ul></ul>
  12. 12. Laboratory findings (2) <ul><li>Iron metabolism tests </li></ul><ul><ul><li>serum iron concentration  </li></ul></ul><ul><ul><li>total iron-binding capacity  </li></ul></ul><ul><ul><li>saturation of transferrin  </li></ul></ul><ul><ul><li>serum ferritin levels  </li></ul></ul><ul><ul><li>sideroblasts  </li></ul></ul><ul><ul><li>serum transferrin receptors  </li></ul></ul><ul><ul><li>FEP  </li></ul></ul>
  13. 13. Laboratory findings (3) <ul><li>Bone marrow test </li></ul><ul><ul><li>high cellularity </li></ul></ul><ul><ul><li>mild to moderate erythroid hyperplasia ( 25-35%; N 16 – 18% ) </li></ul></ul><ul><ul><li>the cytoplasm of polychromatic and pyknotic erythroblasts is scanty, vacuolated and irregular in outline. This type of erythropoiesis has been described as micronormoblastic </li></ul></ul><ul><ul><li>bone marrow showing absence of stainable iron </li></ul></ul>
  14. 14. Management of iron deficiency anemia <ul><li>Correction of the iron deficiency </li></ul><ul><ul><li>orally </li></ul></ul><ul><ul><li>intramuscularly </li></ul></ul><ul><ul><li>intravenously </li></ul></ul><ul><li>Treatment of the underlying disease </li></ul>
  15. 15. Oral iron therapy <ul><li>The optimal daily dose - 200 mg of elemental iron </li></ul><ul><ul><li>Ferrous </li></ul></ul><ul><ul><ul><li>Gluconate 5 tablets/day </li></ul></ul></ul><ul><ul><ul><li>Fumarate 3 tablets/day </li></ul></ul></ul><ul><ul><ul><li>sulphate 3 tablets/day </li></ul></ul></ul><ul><ul><ul><ul><li>iron is absorbed more completely when the stomach is empty </li></ul></ul></ul></ul><ul><ul><ul><ul><li>it is necessary to continue treatment for 3 - 6 months after the anemia is relived </li></ul></ul></ul></ul><ul><ul><ul><ul><li>iron absorption </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>is enhanced: vitC, meat, orange juice, fish </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>is inhibited: cereals, tea, milk </li></ul></ul></ul></ul></ul><ul><ul><ul><li>side effects </li></ul></ul></ul><ul><ul><ul><ul><li>heartburn, nausea, abdominal cramps, diarrhoea </li></ul></ul></ul></ul>
  16. 16. Failure of oral iron therapy <ul><li>I ncorrect diagnosis </li></ul><ul><li>C omplicating illness </li></ul><ul><li>F ailure of the patient to take prescribed medication </li></ul><ul><li>I nadequate prescription (dose or form) </li></ul><ul><li>C ontinuing iron loss in excess of intake </li></ul><ul><li>M alabsorbtion of iron </li></ul>
  17. 17. Parenteral iron therapy (1) <ul><li>Is indicated when the patient </li></ul><ul><ul><li>demonstrated intolerance to oral iron </li></ul></ul><ul><ul><li>loses iron (blood) at a rate to rapid for the oral intake </li></ul></ul><ul><ul><li>has a disorder of gastrointestinal tract </li></ul></ul><ul><ul><li>is unable to absorb iron from gastrointestinal tract </li></ul></ul>
  18. 18. Parenteral iron therapy (2) <ul><li>Preparations and administration </li></ul><ul><ul><li>iron - dextran complex (50mg iron /ml) </li></ul></ul><ul><ul><ul><li>intramuscularly or intravenously </li></ul></ul></ul><ul><ul><ul><li>necessary is the test for hypersensitivity </li></ul></ul></ul><ul><ul><ul><li>the maximal recommended daily dose - 100mg (2ml) </li></ul></ul></ul><ul><ul><li>total dose is calculated from the amount of iron needed to restore the haemoglobin deficit and to replenish stores </li></ul></ul><ul><ul><ul><li>iron to be injected (mg) = (15-pts Hb/g%/) x body weight (kg) x 3 </li></ul></ul></ul>
  19. 19. Parenteral iron therapy (3) <ul><li>Side effects </li></ul><ul><ul><ul><li>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 </li></ul></ul></ul><ul><ul><ul><li>systemic: </li></ul></ul></ul><ul><ul><ul><ul><li>immediate: hypotension, headache, malaise, urticaria, nausea, anphylactoid reactions </li></ul></ul></ul></ul><ul><ul><ul><ul><li>delayed: lymphadenophaty, myalgia, artralgia, fever </li></ul></ul></ul></ul>