Iron Deficiency Anemia

IDA
Shen Yan
The Second Affiliated Hospital of CQMU

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 What is IDA?
• IDA is a microcytic (smaller than the
nucleus of the normal lymphocyte)
and hypochromic (with central areas
of pallor that exceed half the
diameter of the cells) anemia.

• Resulted from low stores of iron.

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Epidemiology
• Iron deficiency is by far the most common cause of anemia
worldwide.

• Up to 10% of the world population is affected.

• The prevalence rates are especially high in developing

countries where dietary insufficiency and intestinal parasites
are prevalent.

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 Pathophysiology
• Hemoglobin molecule
• Globin protein consists of 4 polypeptide chains. One heme
pigment attaches to each polypeptide chain. Each heme contains
porphyrin and Fe2+ that can combine reversibly with one oxygen
molecule

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Iron homeostasis in normal humans

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Pathophysiology
• Metabolisms of iron

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 Negative iron
metabolism
impact on iron metablism:
ferritin, hemosiderin
serum iron, TFR saturation
Iron deficiency total iron binding capacity,TIBC
(total serum transferrin concentration)

Impact on tissue and cell Impact on RBC

decreased activity of
iron-containing enzyme Hb falls

Skin,mucosa,etc. microcytic, hypochromic anemia

each system
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Causes
• More iron requirement

Increased physiologic requirements for iron：infants,

teenagers, pregnant women or lactating women

• less iron intake

Malabsorption of iron：subtotal gastrectomy, GI tract disease

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Causes
• More iron loss

Chronic blood loss: GI tract bleeding in males，excessive

menstrual flow in females, haematuria, overt haemoptysis

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Clinical manifestations

• anemia
• iron deficiency
• underlying disease

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Symptoms of anemia
• Fatigue

• Dizziness

• Headache

• Palpitation

• Dyspnea

• Lethargy

• Disturbances in menstruation
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Symptoms of iron deficiency
• Irritability

• Poor attention

• Poor work performance

• Increased frequency of infection

• Defect of epithelial tissue

• Pica

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Pica
• The habitual ingestion of unusual

substances

• soil, chalk, hair, paper

• Usually is a manifestation of iron deficiency especially after

hookworm infestation and is relieved when the deficiency is
treated
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Symptoms of iron deficiency

• In infants: developmental delays;

behavioral disturbances

• In pregnant women: an increase in preterm delivery ; an

increase in delivering a low-birth-weight child

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 Symptoms of iron deficiency

• Glossitis
Refers to inflammation of the tongue.

Causes the tongue to swell in size,

change in color, and develop a
different appearance on the surface.

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 Symptoms of iron deficiency
• Koilonychia

Nails that become concave in

shape, like a spoon.

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 Laboratory examinations

• Blood test

hemoglobin 

MCV(Mean Corpuscular Volume)<80 fl 

microcytic, hypochromic anemia

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Blood routine count

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Laboratory examinations
• Bone marrow smear

• mild to moderate erythroid hyperplasia (25-35%; N 16 –

18%)

• stainable iron decrease or absence.

• normal granulocytosis

• increased thrombocytosis

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Bone marrow smear
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Bone marrow stainable iron

Iron outside of RBC

a normal bone marrow a patient with IDA

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Bone marrow stainable iron

Iron inside of RBC

a normal bone marrow a patient with IDA

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Laboratory examinations
• Iron metabolism markers

• serum iron concentration 

• serum ferritin levels  (<12ug/l)

• total iron-binding capacity TIBC 

• saturation of transferrin  (<15%)

• serum transferrin receptors (sTFR) 

• Porphyrin metabolism marker

• free erythrocyte protoporphyrin (FEP) increased
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Stages of iron deficiency
• Iron depletion: Hb and serum iron remain normal, but the serum
ferritin level falls to < 20 ng/mL. The compensatory increase in
iron absorption causes an increase in iron-binding capacity
(transferrin level).

• Iron deficiency erythropoiesis: erythropoiesis is impaired. HB is

normal. Although the transferrin level is increased, the serum
iron level decreases; transferrin saturation decreases.

• Iron deficiency anemia: microcytosis and hypochromia develop.

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Diagnosis
• To confirm IDA
CBC + serum ferritin
• To confirm the possible causes (important)
gastrointestinal endoscopes
urine test
gynaecological check-up
……

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Differential diagnosis
• Sideroblastic anemia

SA is a diverse group of anemias characterized by the presence

of ringed sideroblasts (erythroblasts with perinuclear iron-engorged
mitochondria).

SA are iron-utilization anemias, which are characterized by

inadequate marrow utilization of iron for heme synthesis despite the
presence of adequate or increased amounts of iron.

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 Differential diagnosis
• Sideroblastic anemia

SA may be acquired or congenital.

Acquired SA is frequently associated with myelodysplastic syndrome (but may be

produced by drugs or toxins) and causes a macrocytic anemia.

Congenital SA is caused by one of numerous X-linked or autosomal mutations and is

usually a microcytic-hypochromic anemia with increased serum iron and ferritin and
transferrin saturation.

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 Differential diagnosis
• Thalassemia
It is a hemoglobinopathy that is among the most common inherited disorders of
hemoglobin production.
It is a microcytic and hemolytic anemia characterized by defective hemoglobin
synthesis, leading to symptomatic hemolytic anemia and splenomegaly.
Two subtypes: Alpha-thalassemia, Beta-thalassemia
Diagnosis is based on genetic tests and quantitative hemoglobin analysis.
Treatment for severe forms may include transfusion, splenectomy and stem cell
transplantation.

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 Differential diagnosis
• Anemia of chronic disease

Anemia of chronic disease is a multifactorial anemia.

It is characterized by a microcytic or normocytic anemia and low reticulocyte

count.

Diagnosis generally requires the presence of a chronic inflammatory condition,

such as infection, autoimmune disease, kidney disease, or cancer.

Values for serum iron transferrin are typically low to normal, while ferritin can
be normal or elevated.

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 Differential diagnosis
• Anemia of chronic disease

The mechanism includes: Slightly shortened RBC survival, due to release of

inflammatory cytokines, occurs in patients with cancer or chronic granulomatous
infections. Erythropoiesis is impaired because of decreases in both erythropoietin (EPO)
production and marrow responsiveness to EPO. Iron metabolism is altered due to an
increase in hepcidin, which inhibits iron absorption and recycling, leading to iron
sequestration.

Treatment: reverse the underlying disorder, give EPO.

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 Treatment

• Regardless of the presence of symptoms, all patients with iron

deficiency anemia and most with iron deficiency without anemia
should be treated.

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Treatment
• Blood transfusion
• Treatment of the underlying disease
• Iron supplement therapy
Oral iron therapy
Parenteral iron therapy

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Treatment
• Treatment of the underlying disease
Treatment of iron deficiency and iron deficiency anemia involves more
than simply replacing iron. In all patients, the cause of iron deficiency must be
identified and addressed. This is especially true for men and non-
menstruating women, in whom new onset iron deficiency is strongly
suggestive of blood loss from an occult gastrointestinal malignancy or other
bleeding lesion.

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 Treatment
• Iron supplement therapy
• Oral iron therapy
Inorganic iron: ferrous sulfate
organic iron: ferrous gluconate, polyferose
• iron absorption
enhanced: vitC, meat, orange juice, fish
inhibited: spinach, tea, milk, coffee
• Duration of treatment: 4 - 6 months
• Expected response: reticulocyte count increase in 5 to 10 days. HB
increase in 2 weeks.
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 Treatment
• Parenteral iron therapy
Indication: intolerance to oral iron or disorder of GI tract
Agent：iron dextran, iron isomaltoside injection
iron to be injected (mg) = (150- Hb) x 0.33 x weight (kg)
Adverse effects: pain at the injection site, anaphylactic reaction

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 Treatment
• Iron isomaltoside is a new intravenous iron preparation, licensed since 2009
in the UK and Europe. The iron is tightly bound within a nonionic
isomaltoside carbohydrate matrix, as opposed to most other iv. iron
preparations that use branched polymers to form a carbohydrate shell. This
conformation produces a low immunogenic potential, which allows high
single-dose infusions to adequately replenish stores.

• Iron Isomaltoside has the advantage of fewer hospital/ clinic visits and less
number of doses per course as the maximum dose per infusion is 1500 mg of
iron.

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Case
• A 50 year old man comes to see you because of
fatigue ,abdominal pain and a change in bowel habit for 3
month. He is found to have a hemoglobin of 60 g/L and MCV of
76 fl . Stool : O.B. (+). Marrow stainable iron test (-).He is
healthy previously.
• Question 1: Next ,which one is the most important examination ?

A. Serum ferritin B. Bone marrow smear

C. Colonoscopy D. abdominal CT scan

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Case
• Question 2: As to iron supplement, which one is optimal？

A. ferrous sulfate

B. ferrous gluconate

C. injection iron – dextran

• Question 3: How long will iron dextran be injected ?

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