Anemia is defined as a deficiency in oxygen-carrying capacity of the blood due to diminished red blood cells. It is classified as regenerative or non-regenerative based on bone marrow response. Anemia is measured by hemoglobin, hematocrit, red blood cell count, mean corpuscular volume, and red cell distribution width. Symptoms include fatigue, dizziness, and shortness of breath. Causes include blood loss, increased destruction, or decreased production. Chronic ulcers like venous and diabetic ulcers account for most cases and result from prolonged pressure or reduced blood flow to tissues.

2. Anemia
Clinical Pharmacy
Submitted to: Ma’am Sobia Jawed
Group: 09

3. Definition of Anemia
 Deficiency in the oxygen-carrying capacity
of the blood due to a diminished
erythrocyte mass.
 Anemia is classified as:
 Regenerative: In a regenerative anemia, the bone
marrow responds appropriately to the decreased red cell
mass by increasing RBC production and releasing
reticulocytes.
 Non regenerative: In a non-regenerative anemia, the
bone marrow responds inadequately to the increased need
for RBC.

4. Measurements of Anemia
 Hemoglobin = grams of hemoglobin per 100 mL of whole
blood (g/dL)
 Hematocrit = percent of a sample of whole blood occupied by
intact red blood cells
 RBC = millions of red blood cells per microL of whole blood
 MCV = Mean corpuscular volume
 If > 100 → Macrocytic anemia
 If 80 – 100 → Normocytic anemia
 If < 80 → Microcytic anemia
 RDW = Red blood cell distribution width
 = (Standard deviation of red cell volume ÷ mean
cell volume) × 100
 Normal value is 11-15%
 If elevated, suggests large variability in sizes of
RBCs

5. Laboratory Definition of Anemia
 Hgb:
 Women: <12.0
 Men: < 13.5
 Hct:
 Women: < 36
 Men: <41

6. Symptoms of Anemia
 Decreased oxygenation
 Exertional dyspnea
 Dyspnea at rest
 Fatigue
 Bounding pulses
 Lethargy, confusion
 Decreased volume
 Fatigue
 Muscle cramps
 Postural dizziness
 syncope

7. Classification on Etiology
 Decrease in the total circulating red cell mass
 (hematocrit, hemoglobin concentration)
 Classification:
 A. Underlying mechanism
 blood loss
 increased destruction
 decreased production
 B. Morphology of erythrocytes
 size (micro-, macro-, normocytic)
 shape (spherocytosis, stomato-,...)
 color (degree of hemoglobinization: normo- hypo-,
hyperchromic)

8. Special Considerations in
Determining Anemia
 Acute Bleed
 Drop in Hgb or Hct may not be shown until 36
to 48 hours after acute bleed (even though
patient may be hypotensive)
 Acute Blood Loss – non-regenerative,
then moderately regenerative 3-7 days
later
 Chronic Blood Loss – marked
regeneration

9. Symptoms of Anemia
Acute Blood loss
 Clinical signs depend on the
degree of anemia, the duration
(acute or chronic), and the
underlying cause. In acute
blood loss, the patient usually
presents with tachycardia, pale
mucous membranes, bounding
or weak pulses, and
hypotension.
Chronic Blood loss
 Patients with chronic anemia
have had time to adjust, and
their clinical presentation is
usually more indolent with
vague signs of lethargy,
weakness, and anorexia.
 These patients will have similar
physical examination findings,
pale mucous membranes,
tachycardia, and possibly
splenomegaly or a new heart
murmur, or both.

10. Causes of Anemia -- Erythrocyte Loss
 May be due to:
 Erythrocyte loss (bleeding)
 Decreased Erythrocyte production
 low erythropoietin
 Decreased marrow response to erythropoietin
 Increased Erythrocyte destruction (hemolysis)
 The cause of the blood loss may be obvious, eg, trauma. If no evidence of external bleeding is
found, a source of internal or occult blood loss must be sought, eg, a ruptured splenic tumor,
other neoplasia, coagulopathy, GI ulceration, or parasites.
 Chronic bleeding (long-term bleeding) is often undetected for a long time. The patient
gradually loses blood, which means a loss of red blood cells and hemoglobin.
 Acute bleeding (not long term), can also reduce red blood cell count. Excessive blood loss can
be caused by:
 Stomach ulcers.
 Hemorrhoids.
 Inflammation of the stomach (gastritis).
 NSAIDS (nonsteroidal anti-inflammatory drugs)
 Menstruation - women who have very heavy periods (menorrhagia) have a higher
risk of developing anemia.
 Surgery and Trauma which results in bleeding, such as a car accident.
 Blood donations - some regular blood donors may develop anemia.

11. Anemia Due to Excessive Bleeding
or Trauma
• Excessive bleeding is the most common cause of anemia. When blood is lost,
the body quickly pulls water from tissues outside the bloodstream in an
attempt to keep the blood vessels filled. As a result, the blood is diluted, and
the hematocrit (the percentage of red blood cells in the total blood volume) is
reduced. Eventually, increased production of red blood cells by the bone
marrow may correct the anemia. However, over time, bleeding reduces the
amount of iron in the body, so that the bone marrow is not able to increase
production of new red blood cells to replace those lost.
• The symptoms may be severe initially, especially if anemia develops rapidly
from a sudden loss of blood, such as from an injury, surgery, childbirth, or a
ruptured blood vessel. Losing large amounts of blood suddenly can create
two problems:
• Blood pressure falls because the amount of fluid left in the blood
vessels is insufficient.
• The body's oxygen supply is drastically reduced because the
number of oxygen-carrying red blood cells has decreased so quickly.
• Either problem may lead to a heart attack, stroke, or death.

12. Acute Blood Loss
Acute Ulcer
Non-steroidal anti-inflammatory drugs (NSAIDs)
Non-steroidal anti-inflammatory drugs (NSAIDs) can cause bleeding in the
stomach. Ibuprofen and aspirin are two commonly prescribed NSAIDs.
Stomach ulcers
The acid in your stomach (which helps your body to digest food) can sometimes eat
into your stomach lining. When this happens, the acid forms an ulcer (an open sore).
This is also known as a stomach ulcer (or a peptic ulcer). Stomach ulcers can cause
your stomach lining to bleed, which leads to anaemia. In some cases, this blood
loss can cause you to vomit blood or pass blood in your stools faeces
Angio-dysplasia
Gastrointestinal bleeding can also be caused by a condition called angiodysplasia.
This is due to abnormal blood vessels in the gastrointestinal tract, which can cause
bleeding.

13. Less common acute ulcers
Bleeding ulcer
Internal bleeding is caused by a peptic ulcer which has been left untreated. When
this happens, it is now referred to as a bleeding ulcer - this is the most dangerous
type of ulcer.
Esophageal ulcer
This type of ulcer occurs in the lower end of your esophagus. Esophageal ulcers are
often associated with a bad case of acid reflux, or GERD as it is commonly called
(short for gastro esophageal reflux disease).
Stress ulcer
Stress ulcers are a group of lesions (or lacerations) found in the esophagus,
stomach or duodenum. These are normally only found in critically ill or severely
stressed patients.
Refractory ulcer
Refractory ulcers are simply peptic ulcers that have not healed after at least 3
months of treatment.

14. Chronic Ulcers
 A chronic ulcer is an ulcer that does not heal in an orderly set of stages and in a
predictable amount of time the way most ulcer do; ulcer that do not heal within
three months are often considered chronic.
Chronic ulcer seem to be detained in
one or more of the phases of wound healing. For example, chronic ulcer often
remain in the inflammatory stage for too long. In acute ulcer, there is a precise
balance between production and degradation of molecules such as collagen; in
chronic ulcer this balancee is lost and degradation plays too large a role
Classification
 The vast majority of chronic ulcer can be classified into three categories: venous
ulcers, diabetic, and pressure ulcers. A small number of ulcer that do not fall into
these categories may be due to causes such as radiation poisoning or ischemia.

15. Venous and arterial ulcers
Venous ulcers, which usually occur in the legs, account for about 70% to 90% of chronic ulcer and
mostly affect the elderly. They are thought to be due to venous hypertension caused by improper
function of valves that exist in the veins to prevent blood from flowing backward. Ischemia results
from the dysfunction and, combined with reperfusion injury, causes the tissue damage that leads to
the ulcer.
Diabetic ulcers
Another major cause of chronic ulcer, diabetes, is increasing in prevalence. Diabetics have a 15%
higher risk for amputation than the general population due to chronic ulcers. Diabetes
causes neuropathy, which inhibits nociception and the perception of pain. Thus patients may not
initially notice small ulcer to legs and feet, and may therefore fail to prevent infection or
repeated injury. Further, diabetes causes immune compromise and damage to small blood vessels,
preventing adequate oxygenation of tissue, which can cause chronic ulcer. Pressure also plays a role
in the formation of diabetic ulcers.
Pressure ulcers
Another leading type of chronic ulcer is pressure ulcers, which usually occur in people with
conditions such as paralysis that inhibit movement of body parts that are commonly subjected to
pressure such as the heels, shoulder blades, and sacrum. Pressure ulcers are caused by ischemia
that occurs when pressure on the tissue is greater than the pressure in capillaries, and thus restricts
blood flow into the area. Muscle tissue, which needs more oxygen and nutrients than skin does,
shows the worst effects from prolonged pressure. As in other chronic ulcers, reperfusion
injury damages tissue.
Diagnosis

16.  Chronic ulcer may affect only the epidermis and dermis, or they may affect tissues all
the way to the fascia. They may be formed originally by the same things that cause acute
ones, such as surgery or accidental trauma, or they may form as the result of systemic
infection, vascular, immune, or nerve insufficiency, or comorbidities such
as neoplasias or metabolic disorders. The reason a wound becomes chronic is that the
body’s ability to deal with the damage is overwhelmed by factors such as repeated
trauma, continued pressure, ischemia, or illness.
Ischemia
 Ischemia is an important factor in the formation and persistence of ulcer, especially
when it occurs repetitively (as it usually does) or when combined with a patient’s old
age. Ischemia causes tissue to become inflamed and cells to release factors that
attract neutrophils such as interleukins, chemokines, leukotrienes, and complement
factors.
Pathophysiology

17. Bacterial colonization
Since more oxygen in the wound environment allows white blood cells to
produce ROS to kill bacteria, patients with inadequate tissue oxygenation, for
example those who suffered hypothermia during surgery, are at higher risk
for infection. The host’s immune response to the presence of bacteria
prolongs inflammation, delays healing, and damages tissue. Infection can
lead not only to chronic ulcer but also to gangrene, loss of the infected limb,
and death of the patient.
Growth factors and proteolytic enzymes
Chronic ulcer also differ in makeup from acute ulcer in that their levels
of proteolytic enzymes such as elastase and matrix metalloproteinases (MMPs)
are higher,
while their concentrations of growth factors such as Platelet-derived
growth factor and Keratinocyte Growth Factor are lower.
Pathophysiology

18. Hemorrhoides
Hemorrhoids also called piles, are swollen and inflamed veins
in anus and lower rectum. Hemorrhoids may be located inside
the rectum (internal hemorrhoids), or they may develop under
the skin around the anus (external hemorrhoids).
Causes
• Pressure
• Constipation
• Diarrhea
• Sitting or standing for long periods of time
• Obesity
• Heavy Lifting
• Pregnancy

19. pathophysiology
Pile mass descends –
gripped by the sphincters –
more engorgement.
Mucosal gathering in relation
to the three branches of
superior rectal arteries –
called anal cushions –
necessary for completer
continence.
 They slide down and
internal haemorrhoids develop
in the prolapsing tissues.
 Dilated capillaries beneath
epithelium.
Symptoms
• Rectal Bleeding
• Bright red blood in stool
• Pain during bowel
movements
• Anal Itching
• Rectal Prolapse
• Thrombus

20. Chronic Vaginal Bleeding
 vaginal bleeding is abnormal bleeding from the vagina
that is due to changes in hormone levels or abnormal
bleeding in the absence of intracavitary or uterine
pathology.
 Most menstrual cycles occur every 22 to 35 days.
Normal menstrual flow lasts 3 to 7 days, with most blood
loss occurring within the first 3 days.
 The menstrual flow amounts to 35 mL and consists of
effluent debris and blood. Patients with menorrhagia lose
more than 80 mL of blood with each menstrual cycle and
often develop anemia.
 Although approximately 16 mg of iron are lost with each
menstrual cycle, this rarely results in anemia in women
with adequate intake of dietary iron.

21. Prevalence and symptoms
 Approximately 9% to 30% of reproductive-age women have menstrual
irregularities requiring medical evaluation. 20% of cases occur in
adolescent girls, and more than 50% occur in women older than 45.
 Involve more blood loss (loss of more than about 3 ounces of blood or
periods that last more than 7 days) but occur at regular intervals
(menorrhagia)
 Involve more blood loss and occur frequently and irregularly between
menses (menometrorrhagia)
 A woman may feel tired or have fatigue if she loses too much blood
over time. This is a symptom of anemia.
 If bleeding continues, women may develop iron deficiency and anemia.

22. Diagnosis:
During the general examination, clinicians should look for signs of anemia (eg,
conjunctival pallor).
Blood tests include CBC if bleeding is unusually heavy or has lasted at least several
days or if findings suggest anemia or hypovolemia. If anemia is identified and is not
obviously due to iron deficiency (e.g, based on microcytic, hypochromic RBC indices),
iron studies are done.
 TSH, prolactin , and progesterone levels are also measured.
 The serum ferritin level, which reflects body iron stores, is measured if
women have chronic, heavy bleeding.
Review of systems should seek symptoms of possible causes, including missed
menses, breast swelling, and nausea (pregnancy-related bleeding); abdominal pain,
light-headedness, and syncope (ectopic pregnancy or ruptured ovarian cyst); chronic
pain and weight loss (cancer); and easy bruising and excessive bleeding due to tooth
brushing or venipuncture (a bleeding disorder).
Imaging includes transvaginal ultrasonography if women have any of the following:
 Age > 35
 Risk factors for endometrial cancer
 Bleeding that continues despite use of empiric hormone therapy

23. Treatment for Anemia caused
by Vaginal bleeding
 Folic acid dose: 400 to 800 mcg
orally, intramuscularly,
subcutaneously or IV once a day
 Vitamin C dose: 75-150 mg per day
 Vitamin B-12 dose: 2-10
micrograms of vitamin B12 daily
combined with iron and/or folic acid
for up to 16 weeks and other
vitamins that help build red blood
cells.

24. Lab Findings
 Serum Iron
 LOW (< 60 micrograms/dL)
 Total Iron Binding Capacity (TIBC)
 HIGH ( > 360 micrograms/dL)
 Serum Ferritin
 LOW (< 20 nanograms/mL)
 Can be “falsely”normal in inflammatory
states

25. Diagnosis
Medical and Family Histories
Let your doctor know about any medicines you take, what you typically
eat (your diet), and whether you have family members who have anemia or
a history of it.
Physical Exam
Listen to your heart for a rapid or irregular heartbeat
Listen to your lungs for rapid or uneven breathing
Feel your abdomen to check the size of your liver and spleen
Your doctor also may do a pelvic or rectal exam to check for common
sources of blood loss.
Diagnostic Tests and Procedures
You may have various blood tests and other tests or procedures to find out
what type of anemia you have and how severe it is.

26. Complete Blood Count(CBC)
 CBC results include measurements of hemoglobin, hematocrit,
and mean corpuscular volume.
 Hematocrit. Hematocrit is the percentage of blood composed
of red blood cells. People with a high volume of plasma (the
liquid portion of blood) may be anemic even if their blood
count is normal because the blood cells have become diluted.
 33% for children 6 months - 5 years
 35% for children 5 - 12 years
 36% for children 12 - 15 years
 39% for adult men
 36% for adult non-pregnant women
 33% for adult pregnant women

27.  Hemoglobin. Anemia is generally considered when hemoglobin
concentrations fall below 11 g/dL for pregnant women, 12 g/dL for
non-pregnant women, and 13 g/dL for men.
 Mild anemia is considered when hemoglobin is between 9.5 - 13.0
g/dL
 Moderate anemia is considered when hemoglobin is between 8.0 -
9.5 g/dL
 Severe anemia is considered for hemoglobin concentrations below
8.0 g/dL
 Mean Corpuscular Volume. Mean corpuscular volume (MCV) is a
measurement of the average size of red blood cells. The MCV increases
when red blood cells are larger than normal (macrocytic) and
decreases when red blood cells are smaller than normal (microcytic).
Macrocytic cells can be a sign of anemia caused by vitamin B12
deficiency, while microcytic cells are a sign of iron-deficiency anemia.

28. Other Tests
 Serum Iron. Serum iron measures the amount of iron in the blood. A normal
serum iron is 60 - 170 mcg/dL. Lower levels may indicate iron-deficiency anemia
or anemia of chronic disease, while higher levels may indicate hemolytic anemia
or vitamin B12 deficiency.
 Total Iron Binding Capacity. Total iron binding capacity (TIBC) measures the
level of transferrin in the blood. Transferrin is a protein that carries iron in the
blood. TIBC calculates how much or how little the transferrin in the body is
carrying iron. A higher than normal TIBC is a sign of iron-deficiency anemia. A
lower than normal level may indicate anemia of chronic disease, sickle cell,
pernicious anemia, or hemolytic anemia.
 Reticulocyte Count. Reticulocytes are young red blood cells, and their count
reflects the rate of red blood cell production. The upper normal limit is about
100,000/mL. A low count, when bleeding isn't the cause, suggests production
problems in the bone marrow. An abnormally high count indicates that red blood
cells are being destroyed in high numbers and indicates hemolytic anemia.
Recent research suggests that the reticulocyte hemoglobin content (CHr) test
may be more accurate than a standard hemoglobin test for detecting iron
deficiency in infants.

29. Complications of Anemia
 Pregnancy: Pregnant women who are severely anemic have a significant risk of
complications, especially when they give birth and afterwards. Giving birth often
involves losing blood; being anemic already and then losing blood can result in
serious complications. If a mother is severely anemic her baby is much more
likely to be born prematurely and underweight. Babies born to mothers with
anemia are much more likely to have problems with anemia themselves later on
in infancy.
 Fatigue: Fatigue may have a considerable impact on the quality of life of the
patient. If the anemia is severe the patient may feel too tired to work, or carry
out essential daily tasks. Long-term fatigue may eventually lead to clinical
depression.
 Susceptibility to illness and infection: People with untreated anemia are
more susceptible to illness and infection, compared to healthy people.
 Heart Problems: The heart needs to pump more blood to make up for the lack
of oxygen and nutrients if you are anemic. This can eventually lead to
congestive heart failure.

30. Treating Acute Blood LossTreating Acute Blood Loss
 Stop the Bleeding
 Replace fluid loss
 Oxygen support
 Treat underlying disorder

31. Stop the Bleeding
1. Assess coagulation status
2. External arterial bleeder
 Temporary
 Cautery - silver nitrate, Kwik Stop,
electrocautery
 Epinephrine
 Permanent
 Excise abnormal tissue for biopsy
 Reveal normal artery and ligate

32. Stop the Bleeding
3. Abdominal bleeder
 exploratory surgery as soon as vascular volume and
oxygen carrying capacity restored
4. GI bleeder
 Sucralfate PO – 1-3g in a slurry
 Barium PO – 3-5 ml/lb
 Endoscopic cautery
 surgery

33. Replace fluid loss
 crystalloids
 10 ml/lb bolus and then reassess
 1-2 ml/lb/hr when hypovolemia replaced
 Colloids
 Hetastarch
 10 ml/kg over 5-15 minutes
 repeat once if needed
 Oxyglobin
 3-5 ml/kg added to fluids running at 0.5-2ml/lb/hr
 Or 10 ml/kg/hr for up to 3 hours
 If IV access is difficult, try intraosseous

34. Oxygen support
 Transfusion – RBC or whole
blood
 Oxyglobin
 Oxygen – nasal, flow-by, mask,
intubate

35.  Oral iron salts
 Ferrous sulfate – 325 mg po Q Day
 Side effects: constipation, black stools,
positive hemmoccult test
 Vitamin C can facilitate iron absorption.
Treat underlying disorder

36. Transfusion
 PCV threshold higher for acute blood loss
 20-25% with signs of hypoxia
 Or if going to surgery
 Improves oxygen carrying capacity
 May improve hemostasis
 Normally, transfusion of 10 ml/lb whole blood is given
over a minimum of 2 hours
 Pretreat with dexamethasone
 Give as fast as is tolerated
 Collect blood from the abdomen, pass through filter
and re-administer (use anticoagulant)
 No limitation on administration rate

37. Chronic Blood Loss Anemia
The chronic diseases that are associated with this process include:
Certain cancers. Examples include lymphomas and Hodgkin's disease.
Autoimmune diseases. Examples include rheumatoid arthritis, systemic lupus
erythematosus, inflammatory bowel disease, and polymyalgia rheumatica.
Long-term infections. Examples include chronic or recurrent urinary tract
infections, osteomyelitis, HIV/AIDS, hepatitis C.
Liver disease. Cirrhosis can reduce the production of red blood cells.
Gastrointestinal bleeding may also contribute to blood loss.
Heart failure. Many patients with heart failure also have anemia. Anemia is
associated with a higher risk of death in patients with heart failure. However, it is
unclear whether anemia actually causes or worsens heart failure. Recent research
suggests it may actually be a sign (marker) of heart failure. Iron deficiency in heart
failure can be due to a number of factors
Chronic kidney disease. The hormone erythropoietin (EPO) is produced in the
kidneys and stimulates the bone marrow production of red blood cells. Diseased
kidneys do not release sufficient amounts of EPO. Anemia can result and is universal
in end-stage renal disease (kidney failure). Chronic kidney disease is a common
complication of diabetes.

38. Chronic Blood Loss Anemia
Certain chronic diseases
ulcerative colitis
Cancer, including lymphoma
Hodgkin disease
Breast cancer
Chronic kidney disease
Long-term infections, such as bacterial endocarditis, osteomyelitis (bone
infection)
HIV/AIDS, hepatitis B or hepatitis C.

39. 39
Pathogenesis
 Shortened red cell life span, moderately 20-30%
(from 120 to 60-90 days)
 Relative bone marrow(erythropoiesis) failure
- Cytokines released from inflammatory cells (TNF-α,
IL-1, IFN-γ) affects erythropoiesis by inhibiting the
growth of erythroid progenitors
- Serum erythropoietin levels in patiens with ACD are
normal when compared to healthy subjects but much
lower than levels in non-ACD anemic patients

40. 40
Pathogenesis
ABNORMAL IRON METABOLISM
• Activation of the reticuloendothelial system with increased
iron retention and storage within it
• impaired release of iron from macrophages to circulating
transferrin (impaired reutilization of iron)
• Reduced concentration of transferrin
(decreased production, increase sequestration in the spleen
and in the foci of inflammation, increase loss )

41. 41
Anemia of chronic disease (ACD)
- symptoms
 Symptoms of the underlying disease
( malignancy or chronic inflammatory
disease)
 Symptoms of the anemia

42. 42
Laboratory features
 The anemia is usually mild or moderate ( Hb 7-
11g/dl)
- lower values are observed in 20-30% of patients
 The anemia is most often normochromic and
normocytic (MCHC and MCV are normal)
- MCV 70-80 fl in 5-40% of patients with ACD
- MCHC 26-32 g/dl in 40-70%
 Erythrocyte sedimentation rate (ESR) - usually
rapid
 Retikulocytes - most often normal or slightly
decreased number, increased count is rarely

43. 43
Laboratory features
 Iron metabolism
1. Serum Iron - decreased (it is necessary for the
diagnosis of ACD)
2. TIBC - reduced or low-normal (N)
3. Transferrin saturation(TS) - moderately decreased
( higher than in iron-deficiency anemia), usually > 10%
4. Serum Ferritin-increased or normal
5. Serum Transferrin Receptor (sTR)-Normal
6. Sideroblasts in the bone marrow-reduced (5-20%)

44. Treating Chronic Blood LossTreating Chronic Blood Loss
 Correct Anemia - Transfusion
 Treat underlying disorder
 Correct Iron Deficiency

45. Correct Anemia – Transfusion
 Anemia severe enough to cause clinical signs (PCV
<15-20%)
 Or preparing for corrective surgery
 Conservative transfusion volume to avoid
precipitating CHF
 Volume overload more of a problem in cats than
in dogs
 Use packed cells
 Correction of anemia results in resolution of
cardiomegaly within several weeks

46. Treat Underlying Disorder
 Deworm/deflea after patient is stabilized
 If GI Bleeding confirmed
 Abdominal US
 Endoscopy
 Exploratory Laparotomy
 Confirm blood loss has resolved by monitoring
reticulocyte count
 < 40,0000/ul
 Retics more sensitive than anemia for chronic
blood loss

47. Correct Iron Deficiency
 Ferrous sulfate 5 mg/lb/day PO
 Give with a meal
 Continue for weeks to months
 Serology to confirm iron stores are replete
 TIBC – falls back to normal
 Transferrin – 20-60% saturated
 Iron – 60-230 ug/dl