Iron Deficiency Aneamia

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Iron Deficiency Aneamia:

Iron Deficiency Aneamia

IDA:

IDA Commonest anaemia in india Defination--- Any anaemia which respond to adequate dose of Iron is called IDA

Causes Of Iron deficiency:

Causes Of Iron deficiency Deficient diet Decreased absorption Increased requirements Pregnancy Lactation Blood loss Gastrointestinal Menstrual Blood donation Hemoglobinuria

IDA - Etiology:

IDA - Etiology Blood loss Bleeding – Parasites, Gynecologic, ulcers… Increased need Pregnancy, Lactaion,Growing children Poor diet / poor absorption Malnutrition , malabsorption, intestinal surgery, gastric atrophy.

Iron metabolism:

Iron metabolism Iron is important for formation of Hb,myoglobin and other substances such as the cytochromes,cytochrome oxidase,peroxidase and catalases

Total iron-@3-4 Gm in body:

Total iron-@3-4 Gm in body Functional form 70% HB= 65% Myoglobin-4% Cytocrome oxidase- 1% Transferin-0.1% Storage form 30% 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 as haemoglobin (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 is stored as ferritin and one-third as haemosiderin in normal individuals. Small amounts of iron are also found in plasma (about 4 mg bound to transferrin), with some in myoglobin and enzymes.

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Daily Iron Loss Male: 1mg/day Females: 2mg/day Daily Iron Requirement Male: 1mg/day Females: 2mg/day

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Requirements Each day 0.5–1.0 mg of iron is lost in the faeces, urine and sweat. Menstruating women lose 30–40 mL of blood per month, an average of about 0.5–0.7 mg of iron per day. Blood loss through menstruation in excess of 100 mL will usually result in iron deficiency as increased iron absorption from the gut cannot compensate for such losses of iron. The demand for iron also increases during growth (about 0.6 mg per day) and pregnancy (1–2 mg per day). In the normal adult the iron content of the body remains relatively fixed

Dietary intake :

Dietary intake The average daily diet contains 15–20 mg of iron, although normally only 10% of this is absorbed. Absorption may be increased to 20–30% in iron deficiency and pregnancy.

Sources of Iron:

Sources of Iron Liver,egg Leafy vegitables Whole wheat Jaggery Razma cereals Heam iron(animal origin) Non Heam Iron

PowerPoint Presentation:

Non- haem iron is mainly derived from cereals, vegitables and grains . it forms the main part of dietary iron. Haem iron is derived from haemoglobin and myoglobin in organ meats. Haem iron is better absorbed than non- haem iron,

Absorption of Iron: :

Absorption of Iron: Mainly from Duodenum. Heme-Fe +2 from Meat (Myoglobin, hemoglobin) Non heme iron (Fe +3 reduced by Vit C & ferrireductase (FR) to Fe +2 for absorption)

Factors affecting Iron Absorption:

Factors affecting Iron Absorption Haem iron is absorbed better than non-haem iron Ferrous iron is absorbed better than ferric iron Gastric acidity helps to keep iron in the ferrous state and soluble in the upper gut Formation of insoluble complexes with phytate or phosphate decreases iron absorption Iron absorption is increased with low iron stores and increased erythropoietic activity, e.g. bleeding, haemolysis, high altitude There is a decreased absorption in iron overload , except in hereditary haemochromatosis, where it is increased

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Heam transporter Divalent metal transporter Apoferritin apotransferritin

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Dietary haem iron is more rapidly absorbed than nonhaem iron 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 to be 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 stomach and reduced from the ferric to the ferrous form by a brush border ferrireductase . Enterocytes are able to sense the body’s iron requirements 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 as Ferritin. the body’s iron status is probably the crucial deciding factor. Iron stored as ferritin will be lost into the gut lumen when the mucosal cells are shed; this regulates iron balance Iron Absorption

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Transport in the blood The normal serum iron level is about 13–32 μmol/L Iron is transported in the plasma bound to transferrin, a β-globulin that is synthesized in the liver. Each transferrin molecule binds two atoms of ferric iron and is normally one-third saturated.

Mucosal block theory:

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

PowerPoint Presentation:

Views to explain mucosal block theory (1) saturation of apoferritin and apotransferrin (2) Rate of apotransferrin synthesis in liver ,in iron overload so less iron will be absobed Rate of apotransferrin synthesis in liver ,in iron deficiency so more iron will be absorbed (3)Receptors on brush borders of Enterocytes in ID and in iron overload

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Most of the iron bound to transferrin comes from macrophages in the reticuloendothelial system and not from iron absorbed by the intestine. Transferrin-bound iron becomes attached by specific receptors 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 the reticuloendothelial system, is incorporated into Hb every day.

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

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Ferritin is a water-soluble complex of iron and protein. It is more easily mobilized than haemosiderin for Hb formation. It is present in small amounts in plasma. Haemosiderin is an insoluble iron–protein complex found in macrophages in the bone marrow, liver and spleen. Unlike ferritin, it is visible by light microscopy in tissue sections and bone marrow films after staining by Perls’ reaction.

Iron metabolism:

Iron metabolism Iron = 4-5g Per person Hb  65 % of total iron Reticuloendothelial 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 taken up by endocytosis into erythroblasts and cells of the liver, placenta, etc. with the aid of transferrin receptors. Storage & Recycling: Ferritin  one of the chief forms in which iron is stored in the body, storage occurs 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) slow release. 97 % recycled by phagocytes of liver, spleen and bone marrow 26 Ferritin

IDA - Pathogenesis::

IDA - Pathogenesis: Decreased Iron stores Decreased Hb Synthesis Delayed maturation of erythroblasts ( cytoplasmic ) Decreased cytoplasm, more division ( microcytes ) Decreased hb content ( hypochromia ) Iron Def.Anemia .

Microcytic Anemia (IDA):

Microcytic Anemia (IDA)

Hypochromic Microcytic RBC:

Hypochromic Microcytic RBC

Transferrin:

Transferrin Transport Protein For Iron In Blood Fully Saturated Transferrin = TIBC 300 - 350ug/dl Fe Normal Transferrin - 1/3 Filled With Iron 100 - 120ug/dl Fe (Serum Iron)

PowerPoint Presentation:

Normal IDA Serum iron 50-150 microgram/dl Decreased <30 µ g/dl Serum ferritin 30-100 microgram/dl Decreased <15 TIBC 300-360 microgram/dl Increased >360 % transferrin saturation 25-50% Decreased <10% Red cell protoporphyrin microgram/dl <30 microgram/dl Increased >100 MCV 100 fl Decreased <50 MCH 32 pg Decreased <15 MCHC 34% Decreased < 20 BM iron store 2-3++ depleted PBF normal Microcytic Hypochromic

Clinical Features::

Clinical Features: General features of Anemia Pallor, Weakness, Lethargy, Breathlessness on exertion Palpitations  heart failure  pedal edema Special features in IDA: Angular cheilitis, atrophic glossitis, Oesophageal atrophy/web  dysphagia, Koilonychia, brittle nails, gastric atrophy.

Angular cheilitis:

Angular cheilitis

Angular cheilitis & Glossitis:

Angular cheilitis & Glossitis

Koilonychia in Iron def.:

Koilonychia in Iron def.

Koilonychia in Iron def.:

Koilonychia in Iron def.

PowerPoint Presentation:

Low Hb=Anemia MCV Low microcytic Normal normocytic High macrocytic Measure Ferritin Low Normal/high Iron def Anemia Anemia of chronic disease/ Congenital Hb dis. Reticulocyte count high low Anemia of chronic disease Renal failure Marrow failure Hemolytic anemia or blood loss Measure B 12 + folate Low Megaloblastic anemia Normal

Anemia with Low MCV and Low Retics:

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.

Anemia with High MCV:

Anemia with High MCV Differential diagnosis Megaloblastic anemia – B12, Folate Nonmegaloblastic anemia – No def. High retics – bleeding, hemolysis * Laboratory evaluation Serum B12, RBC folate levels. Blood film – macroovalocytes, pancytopenia Bone marrow – dysplasia, neoplasia.

Anemia with Normal MCV:

Anemia with Normal MCV Differential diagnosis Primary bone marrow failure Aplastic anemia, drugs, chemotherapy Secondary bone marrow failure Uremia, Endocrine disorders, AIDS, Anemia of chronic disease Laboratory evaluation Blood smear & Iron, TIBC, Ferritin. Bone marrow smear and iron stores Kidney, Thyroid & liver function tests, Cortisol levels Erythropoietin level

Anemia with high Retics:

Anemia with high Retics Differential diagnosis: Bleeding – blood loss internal/external Hemolysis – immune, mechanical, toxic, inf. Laboratory evaluation Blood film, nRBC, spherocytes, Parasites, Retics. Hemolysis – indirect Bilirubin, Haptoglobin, Direct and indirect Coombs test Hemoglobin electrophoresis, G6PD screen etc.

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