Latent Iron Deficiency and Iron Deficiency Anaemia in Hypoferritinemic Patients
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Journal of Rawalpindi Medical College (JRMC); 2014;18(1):139-141 Original Article Latent Iron Deficiency and Iron Deficiency Anaemia in Hypoferritinemic Patients Masooma Raza*,Samina T.Amanat **, Tariq Hussain**, Huma Abdul Shakoor*, Muhammad Asghar*. *Department of Pathology, Pakistan Atomic Energy Commission General Hospital, Islamabad;** Department of Medicine, Pakistan Atomic Energy Commission General Hospital, Islamabad Abstract of anemia. Ferritin levels must be assayed for assessing body iron stores. Background : To find out the frequency of iron Hypoferritinemia, Iron deficiency deficiency anaemia (IDA) and latent iron deficiency Key Words: (LID) amongst hypoferritinemic individuals anemia, Latent iron deficiency, Haemoglobin, Iron Methods : In this descriptive study individuals (n=1821) who were referred for serum ferritin Introduction estimation, for a period of one year were included. Iron deficiency anemia (IDA) is widely prevalent Ferritin levels were assayed by enhanced in Pakistan. IDA is preceded by a stage of latent iron chemiluminisence method. Haemoglibin levels were deficiency (LID) where serum ferritin is reduced but also estimated in all these subjects.Those hemoglobin and red cell indices are normal. Iron hypoferritinemic subjects were excluded from the depletion may be three times as common as iron study whose haemoglobin levels were not performed deficiency anaemia (IDA), which has a prevalence of 2- on the same day as serum ferritin assay, with raised 5% of adult men and postmenopausal women in the C-reactive proteins or had leukocytosis. Male developed world. Iron depletion is more common in patients having haemoglobin <13g/dl and female the developing world like Pakistan especially amongst patients with haemoglobin <12 g/dl were considered women because of menstruation, as a result, some anaemic. Children from 2-12 years were included in workers consider haemoglobin level of 10-11 g/dl as this study and children having haemoglobin below normal. 1,2 10 g/dl were considered anaemic. Patients with Iron depletion is a reduced content of total body normal haemoglobin, but with low serum ferritin iron. Iron deficiency anaemia(IDA) occurs when the were considered as suffering from latent iron iron deficiency is sufficient to reduce erythropoiesis deficiency anaemia Normal range of serum ferritin and therefore the haemoglobin (Hb) level falls. for adult male subjects was 12-300 ng/ml, for adult However, problems related to iron depletion can female subjects is 10-150 ng/ml and for children develop before this stage diagnosed by serum ferritin of 17-464 ng/ml was considered hypoferritinemia. This stage is occasionally detected normal. by a routine check of the serum ferritin or transferrin Results: Total number 1821 samples of serum saturation. Iron deficiency, with or without ferritin were assayed by enhanced concomitant anemia also has serious implications and chemiluminesence method out of which 458 (25.15 need to be treated. In children this leads to impairment %) number of patients had low serum ferritin. of growth and intellectual development. 981(53.87%) subjects had normal ferritin levels and Iron is the most abundant element on earth, with 382(20.97%) patients had high ferritin levels. In potential of high toxicity to living cells. Therefore, hypoferritinemic patients gender distribution complex regulatory mechanisms are present in human included total of adult males 88 (19.21%) adult to insure adequate intestinal absorption, females 222 (48.47 %) and 148 (32.31 %) children transportation, utilization, and elimination. Iron greater than 2 years.Subjects with low serum ferritin balance is regulated by absorption of iron rather than were divided into two groups latent iron deficient by excretion, because humans cannot actively excrete group and iron deficiency anaemic patients. Latent iron. Iron is absorbed from the small intestine.Iron is iron deficiency (LID) was seen in 19.43% . Mean lost from the body through sloughed skin cells and serum ferritin was low in IDA as compared to LID . sloughed enterocytes from the gut, and through any Conclusions: Latent iron deficiency may be form of blood loss. Males contain about 4,000 mg of missed if hemoglobin levels are taken as sole marker iron, of which 2,500 mg is within erythrocytes; 1,000 139 Journal of Rawalpindi Medical College (JRMC); 2014;18(1):139-141 mg is stored in splenic and hepatic macrophages, and period of one year (June 2012 to June 2013) were the rest is distributed in various proteins such as included. Ferritin levels were assayed by enhanced myoglobin, cytochromes or other ferroproteins. About chemiluminisence method. Haemoglobin levels were 1–2 mg of iron is lost every day, through skin and also estimated in all these subjects.Those enteric desquamation and minor blood losses. This hypoferritinemic subjects were excluded from the loss is balanced by intestinal absorption. Therefore, study whose haemoglobin levels were not performed iron recycling accounts for most of the iron on the same day as serum ferritin assay, with raised C- homeostasis in human. reactive proteins or had leukocytosis. Male patients For detection of body iron status several tests are having haemoglobin <13g/dl and female patients with available. Nowadays bone marrow examination has haemoglobin <12 g/dl are considered anaemic. been replaced by the measurement of blood ferritin. Children from 2-12 years were included in this study Other tests, like measurements of transferrin (Tf), of and children having haemoglobin below 10 g/dl soluble transferrin receptor (sTfr) or of hepcidin, are considered anaemic. Patients with normal also available reflecting dynamics of iron metabolism. haemoglobin, but with low serum ferritin were Hepcidin, is a 25 amino acid peptide hormone, mainly considered as suffering from latent iron deficiency produced by hepatocytes, plays very important role in anaemia .Normal range of serum ferritin for adult iron metabolism. Many mechanisms involved in the male subjects is 12-300 ng/ml, for adult female regulation of hepcidin may therefore regulate subjects is 10-150 ng/ml and for children, serum availability of iron to erythropoiesis by adaptation of ferritin of 17-464 ng/ml is considered normal. iron absorption and recirculation. Erythrocyte precursors take up iron through transferrin Results receptors,Tfr. Thus, the Tf cycle is dependent on the Total 1821 samples of serum ferritin were assayed by Tf-Tfr complex trafficking, involving internalization of enhanced chemiluminesence method out of which 458 the complex within endosome, followed by iron (25.15 %) number of patients had low serum ferritin. release upon acidification of the endosome and 981(53.87%) subjects had normal ferritin levels and recycling of the Tf-Tfr complex to the cell surface 382(20.97%) patients had high ferritin levels. where, Tf dissociates from Tfr, and is used to repeat the iron cycle. Ferrous is reduced to ferric by Table 1: Hypoferritinemia- Subjects distribution ferrireductase , as only ferric iron is transported to the Latent Iron Iron Total no of cytoplasm or to mitochondria. Due to its toxicity, iron deficiency(LID) Deficiency patients within the cytoplasm is associated with proteins such Anemia(IDA) as poly(RC)-binding protein 1 , functioning as Males 13(2.83%) 75(16.37%) 88(19.21%) Females 21(4.58%) 201(43.88%) 222(48.47%) cytosolic iron chaperone in the delivery of iron to Children 55(12%) 93(20.30%) 148(32.31%) ferritin. Within the ferritin molecule, iron is stored in Total 89(19.43%) 369(80.56%) 458(100%) the ferric form associated with hydroxide and phosphate anions. Each ferritin molecule can sequester Table 2: Comparison of mean levels of Hemoglobin up to approximately 4,500 iron atoms. Ferritin also has and Ferritin in hypoferritinemic patients (n= 458) enzymatic properties, converting ferric to ferrous iron, IDA (n=201) LID (n=21) as iron is internalized and sequestered in the ferritin Adult Hb(g/dl) 8.79±1.57 12.54±0.71 mineral core. 3 females Ferritin (ng/ml) 4.62±1.1 5.84±2.93 (n=222) IDA is an end stage of negative iron balance. It is Adult Hb(g/dl) 9.20±2.35 13.67±0.93 preceded by a stage of latent iron deficiency (ID) males Ferritin (ng/ml) 6.82±3.88 10.59±3.56 where serum ferritin is below 15.0 ng/ml with normal (n=88) Hb level. 4 It would be interesting to see the prevalence Children Hb(g/dl) 7.89±1.52 11.37±1.08 of latent ID in addition to IDA. Mild anemia is (n=148) Ferritin (ng/ml) 6.09±3.69 8.62±4.60 asymptomatic or cause non-specific symptoms. It would be of interest to find out latent iron deficiency In hypoferritinemic patients, gender distribution and this treatable disease should be treated simply by included total of adult males 88 (19.21%) adult females taking oral iron supplements. 222 (48.47 %) and 148 (32.31 %) children older than 2 years.Subjects with low serum ferritin were divided Patients and Methods into two groups latent iron deficient group and iron In this descriptive study individuals (n=1821) who deficiency anaemic patients. Latent iron deficiency were referred for serum ferritin estimation, for a 140 Journal of Rawalpindi Medical College (JRMC); 2014;18(1):139-141 (LID) was seen in 19.43% (Table 1). Mean serum hypoferritinemic individuals noted higher frequency ferritin was low in IDA as compared to LID (Table 2). of anemia in females, (48.47 %). This result is comparable to other studies.13-16 Discussion Iron is an important micronutrient required for Conclusion multiple functions in body.5- 8 Iron deficiency is a Latent iron deficiency has clinical implications and it major health issue in developing countries like may be missed if hemoglobin levels are taken as sole Pakistan where its rates have been reported to vary marker of anemia. Ferritin levels must be assayed for between 30-69%.8 Approximately 39% of adolescents, assessing body iron stores.