Iron Studies

Iron deficiency is the most common type of anemia worldwide and therefore a significant cause of human morbidity. Other than menstrual blood losses, negligible iron is lost in a healthy person. Normally, regulation of iron absorption in the proximal small intestine controls iron balance. Iron deficiency results from increased need (growth of infancy or childhood, pregnancy), excessive loss (menstruation, hemorrhage, GI loss), inadequate intake (iron-deficient diet), or defective absorption (gastrectomy or sprue). In adult men or postmeno-pausal women with adequate iron stores, it takes 3 to 4 years for these stores to be depleted once negative iron balance starts.

During early iron deficiency anemia, the erythrocytes may be normochromic normocytic, and later the peripheral blood smear may show microcytosis, anisocytosis, poikilocytosis, and hypochromia. The reticulocyte count is low, and RDW is high (>16). Bone marrow stores of iron are decreased or absent. Serum iron has marked diurnal variation (higher in morning, lower later in day) and is increased transiently after meals. Because morning levels determine the reference range, iron levels should be performed on a fasting morning specimen. Obtaining a serum iron level without determining the level of transferrin (total iron-binding capacity, TIBC) is of limited value. Serum iron is decreased with inflammation, infection, and ascorbate deficiency and increased with iron ingestion, transfusions, liver disease, aplastic anemia, and ineffective erythro-poiesis. TIBC is an approximation of transferrin and can be calculated when the transferrin is known, as follows:

The total iron-binding capacity or transferrin is not subject to diurnal fluctuation, but it is reduced in chronic inflammation and malnutrition. Iron deficiency is the only micro-cytic hypochromic anemia associated with absent iron stores (Brittenham, 2005). The serum ferritin is the best indirect marker for the assessment of iron stores. However, serum ferritin is an acute-phase reactant and can be elevated in some patients with liver disease, malignancy, or inflammatory or infectious diseases. Therefore, although a low ferritin (<12 pg/L) is highly specific for iron deficiency, elevated ferritin levels do not rule out iron deficiency. Hemolysis may cause falsely high levels of serum iron. Table 15-17 lists results of iron studies in common anemias.

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