iron deficiency

Disorders of iron metabolism and hem synthesis : 

Disorders of iron metabolism and hem synthesis I ron deficiency and iron deficiency anemia T he anemia of chronic disorders S ideroblastic anemias M ethemoglobinemia and other disorders with cyanosis H emochromatosis P orphyria

Iron metabolism: 

Iron metabolism 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 menstrua ting females as blood (1-2 mg daily) is replaced by iron absorbed from the diet.

Stages in the development of iron deficiency: 

Stages in the development of iron deficiency Prelatent reduction in iron stores without reduced serum iron levels Hb (N), MCV (N), iron absorption ( ), transferin saturation (N), serum ferritin ( ), marrow iron ( ) Latent iron stores are exhausted, but the blood haemoglobin level remains normal Hb (N), MCV (N), TIBC (), serum ferritin ( ), transferin saturation ( ), marrow iron (absent) Iron deficiency anemia blood haemoglobin concentration falls below the lower limit of normal Hb ( ), MCV ( ), TIBC (), serum ferritin ( ), transferin saturation ( ), marrow iron (absent)

Iron deficiency and iron deficiency anemia: 

Iron deficiency and iron deficiency anemia The characteristic sequence of events ensues when the total body iron level begins to fall: 1. decreases the iron stores in the macrophages of the liver, spleen and bone marrow 2. increases the amount of free erythrocyte protoporphiryn (FEP) 3. begins the production of microcytic erythrocytes 4. decreases the blood haemoglobin concentration

Iron deficiency anemia Definition and etiologic factors: 

Iron deficiency anemia Definition and etiologic factors T he end result of a long period of negative iron balance d ecreased iron intake inadequate diet, impaired absorption, gastric surgery, celiac disease i ncreased iron loss gastrointestinal bleeding ( haemorrhoids , salicylate ingestion , peptic ulcer , neoplasm , ulcerative colitis ) excessive menstrual flow , blood donation , disorders of hemostasis i ncreased physiologic requirements for iron infancy, pregnancy, lactation cause unknown (idiopathic hypochromic anemia)

Iron deficiency anemia Clinical manifestation: 

Iron deficiency anemia Clinical manifestation P resentation of underlying disease 37% anemia symptoms 63%

Symptoms of anemia: 

Symptoms of anemia Fatigue Dizziness Headache Palpitation Dyspnea Lethargy Disturbances in menstruation Impaired growth in infancy

Symptoms of iron deficiency: 

Symptoms of iron deficiency Irritability Poor attention span Lack interest in surroundings Poor work performance Behavioural disturbances Pica 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

Pica: 

Pica 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

Abnormalities in physical examination: 

Abnormalities in physical examination P allor of skin, lips, nail beds and conjunctival mucosa N ails - flattened, fragile, brittle, koilonychia, spoon-shaped T ongue and mouth glossitis, angular cheliosis, stomatitis dysphagia ( Peterson-Kelly or Plummer-Vinson syndrome (carcinoma in situ) S tomach atrophic gastritis, (reduction in gastric secretion, malabsorbtion) 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

Laboratory findings (1): 

Laboratory findings (1) Blood tests erythrocytes hemoglobin level  the volume of packed red cells (VPRC)  RBC  MCV and MCH  anisocytosis poikilocytosis hypochromia leukocytes normal platelets usually thrombocytosis

Laboratory findings (2): 

Laboratory findings (2) Iron metabolism tests serum iron concentration  total iron-binding capacity  saturation of transferrin  serum ferritin levels  sideroblasts  serum transferrin receptors  FEP 

Laboratory findings (3): 

Laboratory findings (3) Bone marrow test high cellularity mild to moderate erythroid hyperplasia ( 25-35%; N 16 – 18% ) the cytoplasm of polychromatic and pyknotic erythroblasts is scanty, vacuolated and irregular in outline. This type of erythropoiesis has been described as micronormoblastic bone marrow showing absence of stainable iron

Management of iron deficiency anemia: 

Management of iron deficiency anemia Correction of the iron deficiency orally intramuscularly intravenously Treatment of the underlying disease

Oral iron therapy : 

Oral iron therapy The optimal daily dose - 200 mg of elemental iron Ferrous Gluconate 5 tablets/day Fumarate 3 tablets/day sulphate 3 tablets/day iron is absorbed more completely when the stomach is empty it is necessary to continue treatment for 3 - 6 months after the anemia is relived iron absorption is enhanced: vitC, meat, orange juice, fish is inhibited: cereals, tea, milk side effects heartburn, nausea, abdominal cramps, diarrhoea

Failure of oral iron therapy: 

Failure of oral iron therapy I ncorrect diagnosis C omplicating illness F ailure of the patient to take prescribed medication I nadequate prescription (dose or form) C ontinuing iron loss in excess of intake M alabsorbtion of iron

Parenteral iron therapy (1): 

Parenteral iron therapy (1) Is indicated when the patient demonstrated intolerance to oral iron loses iron (blood) at a rate to rapid for the oral intake has a disorder of gastrointestinal tract is unable to absorb iron from gastrointestinal tract

Parenteral iron therapy (2): 

Parenteral iron therapy (2) Preparations and administration iron - dextran complex (50mg iron /ml) intramuscularly or intravenously necessary is the test for hypersensitivity the maximal recommended daily dose - 100mg (2ml) total dose is calculated from the amount of iron needed to restore the haemoglobin deficit and to replenish stores iron to be injected (mg) = (15-pts Hb/g%/) x body weight (kg) x 3

Parenteral iron therapy (3): 

Parenteral iron therapy (3) 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, anphylactoid reactions delayed: lymphadenophaty, myalgia, artralgia, fever