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Iron deficiency anemia

Iron deficiency anemia

What is it?

Anemia from lack of iron, also known as iron-deficiency anemia, is the reduction of hemoglobin values (iron-containing protein, with respiratory function, able to reversibly combine with molecular oxygen, specified with the initials Hb), under 13 g/gL in men and 12 g/dl in women, caused by the decrease of iron availability in the organism.

Iron-deficiency anemia represents the most common form of anemia in clinical practice, especially in women in fertile age and in subjects with an insufficient diet. Those who suffer from it: 30% in worldwide population, 8% in developing countries and up to 25% in women in fertile age, 51% in children in developing countries, 13% in developed countries.

The World Health Organization (WHO) has estimated that 600-700 million people in the world suffer from lack of iron, making it the most widespread nutritional problem, especially in developing countries.

Groups of people that are most at risk:

  • Children in play and development age: scarce iron deposits and high metal needs for body growth.
  • Women in fertile age: scarce corporeal deposits and constant loss for menstrual flows, pregnancies and breastfeeding.
  • Elderly: iron loss due to chronic dripping of blood in the digestive system (but also hemorrhoids, peptic ulcer disease, hiatal hernia, neoplasias).
  • People who follow reduced high-iron food diets (especially meat) because of health problems or choice.

Iron-deficiency symptoms

Anemia doesn’t show visible symptoms until the hemoglobin levels in the bloodstream are steady above 9-10 grams per deciliter (g/dl), as the organisms are capable of a series of adjustment mechanisms like increasing the quantity of blood pumped from the heart and the rise of the affinity between red blood cells and oxygen. These adjustment mechanisms allow for, regardless of the lack of hemoglobin in the bloodstream, the quantity of oxygen released to different tissues stays the same. Only when even these adjustment mechanisms are unable to assure an adequate amount of oxygen to the various body areas anemia symptoms and signs appear.

The most common symptoms associated to iron-deficiency anemia are: weariness, pallor, easy fatigue, irritability, increase of heart frequency, insomnia, headache, difficulty in concentrating, dizziness, especially when changing position from lying to standing up, nail fragility, dryness, weakening and loss of hair, thinning of the mouth mucosa linked to burning sensation, higher sensitivity to cold. Commonly in iron-deficiency anemia the devolpment of anemia is very slow and this allows the organism for the capability of progressively adapting to the decrease of circulating hemoglobin. Therefore the medical case, in most cases, is blurred and hardly noticeable. Only blood tests allow for diagnosing anemia and its cause.

Diagnosis

The diagnosis for sideropenic anemia is done through lab measurements after taking a venous blood sample. The first sign of iron-deficiency anemia is the decrease in hemoglobin (anemia) and reduced content of hemoglobin in red blood cells (MCV value on analysis) that may result of inferior dimensions compared to the normal ones (MCH value on analysis). Sometimes it is possible to observe red blood cells of different shapes amongst them (RDW on analysis).

Hemoglobin is measured in grams per deciliter of blood. Normal levels of hemoglobins are:

  • Women: 12,1 to 15,1 g/dl
  • Men: 13,8 to 17,2 g/dl
  • Children: 11 to 6 g/dl
  • Pregnant women: 11 to 12 g/dl

ACV means Average Cell Volume or average corpuscular volume. It’s a form of measurement of red blood cells average dimension (RBC), also called erythrocytes. The regular value of ACV is between 80 and 97-100 fL (= femtoliters: a unit of measure of average cell volume and it is equal to 0,000000000000001 liters). When the ACV number is higher than what it should be we talk about macrocytic anemia (or macrocytosis): that means the cell is larger than normal and it doesn’t work properly. When the ACV number is lower than normal we talk about microcytic anemia (or microcytosis): that means the cell is too small compared to the normal size and the hemoglobin quantity is obviously lower.

ACH means Average Corpuscular Hemoglobin. Therefore, the blood sample analysis of ACH is a test used to know how much hemoglobin is present in our body’s red blood cells. The ACH standard is between 30 and 37 grams per deciliter of blood. Any level above the normal range for ACH is considered as a symptom for a condition known as Macrocytic anemia. The opposite result is a condition where the results falls below the standard ACH result. In this situation, the patient is diagnosed with a condition known as Microcytic anemia. The ACH blood semple analysis is performed on people who show symptoms of acute anemia.

RDW (Red Cell Distribution Width) width of erythrocytary distribution is an indicator commonly supplied by any hemocrhome, able to estimate the dimension variability of red blood cells, thus their hetereogenity degree, also defined anisocytosis. It is increased during nutritional deficit (iron, folates, B12 vit). Blood transfusions, haemolysis and along with other indicators such as MCV, MCH, MCHC and it's useful for diagonising anemias differential. The standard RDW values are between 11,5% and 14,5%.

In order to verify if the anemia is caused by a lack of iron, the hematochemical parameters to be taken into account are:

Serum iron (iron analysis): this analysis is useful to observe the quantity of iron present in the bloodstream, meaning to verify that its absorption happens correctly. Standard iron values: women 37-147 ug/dl iron; men 59-158 ug/dl. If the result is higher than the maximum value, that means that there is an excessive amount of iron in the bloodstram (also callsed hypersideraemia) that may be caused by diseases, such as those of the liver, or genetic causes such as, for instance, hemocrhomatosis, which causes the person to inherit an abnormal ability to absorb iron that gets ingested through foods and that, if untreated, may lead to a specific form of diabetes and cirrhosis. If the result is lower than the standard (also called hyposideremia), it could be anemia that may be caused by, for example, copious menstruation or gastrointestinal hemorrhages.

Transferrinemia: measures the quantity of iron present in the bloodstream in the form of transferrin, a protein whose function is transferring iron. If transferrin has unusual values it means that iron absorption is not working properly. Standard Ferritin values: premenopause women 11-193 ng/ml – postmenopause women 18-280 ng/ml ferritin; men 25-300 ng/ml. If the result is higher than the normal values it may be the symptom of a hereditary disease like hemochromatosis (which causes iron to be excessively absorbed) or it may even be caused by thalassemia, leukemia or other tumoral diseases. If the result is lower than the normal value, in the organism there's a loss of iron and if there are no reserves, therefore, the reason must be examined in order to restore standard values.. If the iron values are very low, but ferritin is normal, it means that there are still sufficient iron reserves and you should not be alarmed.

Ferritinemia: doses the ferritin and thus allows to evaluate the existent iron deposit in the organism, in a very precise way this analysis indicates if there is an iron loss. Low levels of ferritin in the blood indicate indeed an abscence of iron in the deposits, condition that precedes anemia development. High levels of ferritin, however, indicate the possible exsistence of an iron overload. Standard Transferrin values: 0,20-0,37 g/dl. If the result is higher than the normal, it is possible to diagnose a hereditary disease that causes an excessive absorption of ingested iron through foods (hemocrhamotosis). If the result is lower than the standard, it is probably a liver disease and the doctor will recommend further analysis.

A correct diagnosis must always take into account the iron-deficiency's origin. It is necessary to investigate the incorrect dietary habits, excessive blood loss during menstrual cycles and research for the possible presence of hidden blood in feces. The differential diagnosis is realized with all the other forms of anemia (chronic diseases anemia, talassemia minor, chronic kidney diseases, myxedema) that show the same characteristics at the hematochemical exams (decrease of hemoglobin, decrease of ACV average corpuscular volume of red blood cells – and AHC average hemoglobin cell content).

Treatment

In order to treat efficiently an iron-deficiency anemia the first step is to identify what may be the cause that has determined the disease's development. The possible causes of iron-deficinency anemia are reduced to three kinds:

  • insufficient food intake,
  • intestinal absorption deficit,
  • chronic or acute blood loss.

The first cause is generally linked, in children, to an excessively prolonged milky nutrition and, in adults, to a vegetarian diet or malnutrition. The second cause is common amongst subject who underwent surgical treatments with the removal of part of the stomach or the first tract of the intestines. The third cause is the most commonly found and it is frequent in women in fertile age and in patients suffering from hemorrhoids, (stomach), hiatal hernias (a peculiar anatomical condition distinguised by the rising of a portion of the stomach from the abdomen to the thorax), diverticula (diverticula are pockets that develop in the colon's walls, usually in the sigmoid or left colon, but may affect all of the colon. Diverticulosis describes the presence of these pockets. Diverticulitis represents the inflammation or the complication of these pockets), ulcerative colitis (a chronic inflammatory disease that primarly affects the rectum and may affect part of or all of the colon), Crohn's disease (chronic inflammatory diseases of the intestines), colon or gastric carcinoma , abuse of anti-inflammatory medications, chronic inflammation of the kidney parenchyma, kidney, vescicle, urethral neoplasms.

The therapy consists firstly in correcting, wherever it's possible, the triggering cause of the anemia (for instance, correcting the diet, specific cure of the basic pathology) and in correcting the iron deficiency with specific supplements.

The iron supplements therapy, if well managed, is indeed able to quickly correct the anemia. Products for oral use or intravenous injection are available. This therapy is often burdened by bothersome side effects such as heartburn, abdominal cramps and diarrhea, that may be alleviated by temporarily reducing the medication/supplement dosage, so that the organism is allowed to some sort of adaptation to the therapy. Liposomal technology, used in some iron-based supplements, however allows to avoid these annoying side effects.

The good results of the therapy are highlighted by a correction of the anemia of about 50% within three weeks from the start.

Prevention

In clinical practice, at the moment, there is no indication of pharmacological use of iron supplements in the prevention of sideropenic anemia. Useful suggestions may be an appropriate diet and the screening of substantial hematic loss or morbid conditions, as previously mentioned, that may compromise the intestinal iron absorption or reduce its bioavailability. Certainly among the correctable causes of sideropenic anemia insurgency there is an incorrect diet. In sideropenic anemia prevention an iron-rich diet is essential. Even if it is difficult to acquire through diet only a sufficient iron intake to restore the reserves, whenever an iron-deficiency diagnosis has already been proven, once the reserves are restored through pharmacological supplementation, it will be easier to keep an adequate diet.

The minimum recommended intake of iron in adults (in normal conditions) is 10 mg daily in males and women in menopause and 18 mg daily in women in fertile age.

Iron that is found in foods of animal origin (red meat, turkey, chicken, fish like tuna or cod, salmon etc) it is eme iron that is absorbed more easily by our intestine. In foods of vegetable origin we find non eme iron (cereals, legumes, vegetables) of harder absorption. During pregnancy and breastfeeding these dietary reccomendations are of even greater importance and, even in this case, pharmacological prevention of sideropenic anemia insurgency is not indicated until the laboratory evidence of hematochemical analysis. Therefore in these cases the importance of an adequate and balanced iron intake is even greater.

Text from

  • http://www.allianceanemia.org
  • http://www.lammlab.it
  • http://www.emocromatosi.it
  • http://www.humanitas.it
  • LARN IV revisione 2014

Bibliography

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