Iron Deficiency Aneamia

8/4/2019 Iron Deficiency Aneamia

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Iron Deficiency Aneamia


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IDA

Commonest anaemia in indiaDefination--- Any anaemia which respondto adequate dose of Iron is called IDA


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Causes Of Iron deficiencyDeficient dietDecreased absorptionIncreased requirements

PregnancyLactation

Blood loss

GastrointestinalMenstrualBlood donation

Hemoglobinuria


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IDA - Etiology

Blood loss Bleeding Parasites, Gynecologic, ulcers

Increased need Pregnancy, Lactaion,Growing children

Poor diet / poor absorption Malnutrition , malabsorption, intestinal

surgery, gastric atrophy.


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Iron metabolism

Iron is important for formation of Hb,myoglobin and other substances such asthe cytochromes,cytochromeoxidase,peroxidase and catalases


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Total iron-@3-4 Gm in body

Functional form70%

HB= 65%Myoglobin-4%Cytocrome oxidase- 1%

Transferin-0.1%

Storage form30%Ferritin 2/3 rd Haemosiderin 1/3 rd


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Iron stores About two-thirds of the total body iron is in the circulation ashaemoglobin (2.5 3 g in a normal adult man).

Iron is stored in reticuloendothelial cells, hepatocytes and

skeletal musclecells (500 1500 mg). About two-thirds of this isstored as ferritin and one-third as haemosiderin in normalindividuals.

Small amounts of iron are also found in plasma (about 4 mgbound to transferrin), with some in myoglobin andenzymes.


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Daily Iron LossMale: 1mg/day

Females: 2mg/day

Daily IronRequirementMale: 1mg/dayFemales: 2mg/day


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Requirements Each day 0.5 1.0 mg of iron is lost in the faeces, urine andsweat.

Menstruating women lose 30 40 mL of blood permonth, an average of about 0.5 0.7 mg of iron per day.

Blood loss through menstruation in excess of 100 mL willusually result in iron deficiency as increased iron absorptionfrom the gut cannot compensate for such losses of iron.

The demand for iron also increases during growth (about0.6 mg per day) and pregnancy (1 2 mg per day).

In the normal adult the iron content of the body remainsrelatively fixed


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Dietary intake

The average daily dietcontains 15 20 mg of iron,although normally only10% of this is absorbed.Absorption may beincreased to 20 30% iniron deficiency andpregnancy.


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Sources of Iron

Liver,eggLeafy vegitables

Whole wheatJaggeryRazma

cereals

Heam iron(animalorigin)

Non Heam Iron


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Non-haem iron is mainly derived fromcereals, vegitables and grains . it forms

the main part of dietary iron.Haem iron is derived from haemoglobinand myoglobin in organ meats.

Haem iron is better absorbed thannon-haem iron,


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Absorption of Iron:

Mainly from Duodenum.Heme-Fe +2 from Meat (Myoglobin,hemoglobin)

Non heme iron (Fe +3 reduced by VitC & ferrireductase (FR) to Fe +2 forabsorption)


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Factors affecting Iron Absorption

Haem iron is absorbed better than non-haem iron

Ferrous iron is absorbed better than ferric ironGastric acidity helps to keep iron in the ferrous state and

soluble in the upper gut

Formation of insoluble complexes with phytate orphosphate decreases iron absorptionIron absorption is increased with low iron stores and

increased erythropoietic activity, e.g. bleeding,

haemolysis, high altitudeThere is a decreased absorption in iron overload , except in

hereditary haemochromatosis, where it is increased


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Heamtransporter

Divalent metal

transporter

Apoferritin

apotransferritin


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Dietary haem iron is more rapidly absorbed than nonhaemiron derived from vegetables and grain.

Most haem is absorbed in the proximal intestine.

The intestinal haem transporter(haem carrier protein 1) has been identified and found tobe highly expressed in the duodenum. It is upregulated by

hypoxia and iron deficiency.

Iron Absorption


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Non-haem iron absorption occurs primarily in the duodenum.

Non-haem iron is dissolved in the low pH of the stomachand reduced from the ferric to the ferrous form by a brushborder ferrireductase .

Enterocytes are able to sense the bodys ironrequirements

Iron Absorption


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Once inside the mucosal cell, iron may be transferred

across the cell to reach the plasma, or be stored asFerritin.the bodys iron status is probably the crucial

deciding factor.

Iron stored as ferritin will be lost into thegut lumen when the mucosal cells are shed; thisregulates iron balance

Iron Absorption


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Transport in the blood

The normal serum iron level is about 13 32 mol/L Iron is transported in the plasma bound to transferrin, a -globulin that is synthesized in the liver.

Each transferrin molecule binds two atoms of ferriciron and is normally one-third saturated.


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Mucosal block theory

Iron absorption in Iron deficiency(more TF less Ferritin is formed)Iron absorption in iron overload(More Ferritin shed with stool)


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Most of the iron bound to transferrin comes frommacrophages in the reticuloendothelial system and not fromiron absorbed by the intestine.

Transferrin-bound iron becomes attached by specificreceptors to erythroblasts and reticulocytes in the

marrow and the iron is removed

In an average adult male, 20 mg of iron, chiefly obtained

from red cell breakdown in the macrophages of thereticuloendothelial system, is incorporated into Hb every day.


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Iron is stored in reticuloendothelial cells,hepatocytes and skeletal musclecells (500 1500mg). About two-thirds of this is stored as ferritinand one-third as haemosiderin in normalindividuals.


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Ferritin is a water-soluble complex of iron and protein. Itis more easily mobilized than haemosiderin for Hbformation.It is present in small amounts in plasma.

Haemosiderin is an insoluble iron protein complexfound in macrophages in the bone marrow, liver andspleen.Unlike ferritin, it is visible by light microscopy in tissuesections and bone marrow films after staining by Perls reaction.


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Iron metabolism


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Iron metabolismIron = 4-5g Per personHb 65 % of total ironReticuloendothelial system + liver = 15-30 %

Myoglobin = 4%Intracellular oxidating heme compounds = 1%Transferrin = 0.1 %Absorption of Iron:

Mianly from Duodenum.

Heme-Fe+2

from Meat (Myoglobin, hemoglobin)Fe+2 from small intestine (Fe +3 reduced by Vit C & ferrireductase (FR) to Fe +2 for absorption)

Transport of Iron:Iron + Apotransferrin [protein from liver] Transferrin (Bound) is takenup by endocytosis into erythroblasts and cells of the liver, placenta, etc. withthe aid of transferrin receptors.

Storage & Recycling:Ferritin one of the chief forms in which iron is stored in the body, storageoccurs mainly in the intestinal mucosa, liver, bone marrow, red blood cells,and plasma. (4500 Fe +3 ions i.e. 600mg as readily available store).

Hemosidrin In marcophages of liver and bone marrow (250mg) slowrelease.

97 % recycled by phagocytes of liver, spleen and bone marrow 26

Ferritin


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IDA - Pathogenesis:Decreased Iron storesDecreased Hb Synthesis

Delayed maturation of erythroblasts(cytoplasmic)Decreased cytoplasm, more division(microcytes)Decreased hb content (hypochromia)Iron Def.Anemia.


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Microcytic Anemia (IDA)


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Hypochromic Microcytic RBC


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Transferrin

Transport Protein For Iron In Blood

Fully Saturated Transferrin = TIBC300 - 350ug/dl Fe

Normal Transferrin - 1/3 Filled With Iron100 - 120ug/dl Fe (Serum Iron)


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Normal IDA

Serum iron 50-150 microgram/dl Decreased


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Clinical Features:

General features of AnemiaPallor, Weakness, Lethargy,Breathlessness on exertion

Palpitations heart failure pedal edemaSpecial features in IDA:

Angular cheilitis, atrophic glossitis,

Oesophageal atrophy/web dysphagia,Koilonychia, brittle nails, gastric atrophy.


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Angular cheilitis


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Angular cheilitis & Glossitis


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Koilonychia in Iron def.


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Koilonychia in Iron def.


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Low Hb=AnemiaMCV

Lowmicrocytic

Normalnormocytic

Highmacrocytic

Measure Ferritin

Low Normal/high

Iron defAnemia

Anemia ofchronic disease/ Congenital Hb dis.

Reticulocyte count

high low Anemia of chronic diseaseRenal failureMarrow failure

Hemolytic anemia orblood loss

Measure B 12 + folate

LowMegaloblasticanemia

Normal


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Anemia with Low MCV and Low Retics

Differential diagnosis Iron deficiency (Micro Hypo - severe)

Anemia of chronic disease (mild micro/hypo)Laboratory evaluation Iron, iron-binding capacity, and ferritin

Blood smear Micro/hypo, Pencil cells.


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Anemia with High MCV

Differential diagnosis Megaloblastic anemia B12, FolateNonmegaloblastic anemia No def.High retics bleeding, hemolysis *Laboratory evaluation Serum B12, RBC folate levels.Blood film macroovalocytes, pancytopeniaBone marrow dysplasia, neoplasia.


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Anemia with Normal MCV

Differential diagnosis Primary bone marrow failure Aplastic anemia, drugs, chemotherapySecondary bone marrow failure Uremia, Endocrine disorders, AIDS, Anemia of chronic diseaseLaboratory evaluation

Blood smear & Iron, TIBC, Ferritin.Bone marrow smear and iron storesKidney, Thyroid & liver function tests, Cortisol levelsErythropoietin level


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Anemia with high Retics

Differential diagnosis: Bleeding blood loss internal/external Hemolysis immune, mechanical, toxic, inf.

Laboratory evaluationBlood film, nRBC, spherocytes, Parasites, Retics.Hemolysis indirect Bilirubin, Haptoglobin,Direct and indirect Coombs testHemoglobin electrophoresis, G6PD screen etc.


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and studying much are thethree pillars of learning.

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Iron Deficiency Aneamia

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