Parenteral iron therapy in children with iron deficiency anemia

Iron deficiency anemia (IDA) continues to be a global public health problem. Oral iron is the universally accepted first-line therapy, and most children have a prompt and favorable response to oral formulations. In subsets of children who fail to respond due to intolerance, poor adherence, or inadequate intestinal absorption, parenteral iron is indicated. Despite numerous studies in adults with IDA of diverse etiologies, pediatric studies on parenteral iron use are very limited. Although mostly retrospective and small, these studies have documented the efficacy and safety profile of intravenous iron formulations. In this editorial the author comments on the most important published data and underscores the need to seriously consider parenteral iron use in children unresponsive to oral therapy.

Exploring progress in iron supplement formulation approaches for treating iron deficiency anemia through bibliometric and thematic analysis

Anemia is a severe health issue that affects around one-third of the global population. Therefore, the present study aims to conduct a bibliometric analysis to investigate the research trends regarding advancements on iron formulations in treating iron deficiency anemia via oral or parenteral route. This study adopts thematic and bibliometric methods on existing research on novel iron formulations. It also provides perspective into the existing understanding on treatment strategies for iron deficiency anemia. This study is conducted on 543 papers on various ferrous and ferric formulations used in the treatment of iron deficiency anemia. The study period is from 1977 to 2022, and the papers are identified from the Scopus database. The bibliometric analysis was carried out using the R tool's Bibliometrix package. The study discusses performance analysis, including annual publications, geographic analysis, relevant affiliations, journal analysis, and citation analysis. In addition, the conceptual structure, including the co-occurrence network, thematic map, thematic evolution, intellectual structure highlighting co-citation analysis, and social structure depicting the collaboration network and collaboration world map, are presented. The results showed increased research on formulation strategies for the treatment of iron deficiency anemia from 2010 onwards. The top 5 contributing countries are the USA, Italy, India, Germany, and the UK, and peer-reviewed journals from the area of nutrition. The most trending areas of study are iron deficiency anemia in pregnancy, chronic kidney diseases, inflammatory bowel diseases, and various intravenous formulations used in its treatment. The authors from Europe collaborate the most with authors from other countries. The study concludes that a safer and more effective iron formulation is needed to reduce the prevalence of anemia. The findings of the study are helpful in advancing research on innovative formulations for treating iron deficiency anemia. The insights from the study are helpful to policymakers in designing specific health policies and investing more in research and development of novel formulations for the treatment of iron deficiency anemia.

Outcomes and complications of heart failure with iron deficiency anemia: a nationwide analysis

INTRODUCTION

Heart failure is a pressing public health concern, affecting millions in the United States and projected to rise significantly by 2030. Iron deficiency, prevalent in nearly half of ambulatory heart failure patients, contributes to anemia and diminishes patient outcomes. In this study, we aim to evaluate the impact of iron deficiency anemia on acute heart failure hospitalizations outcomes.

METHODS

Utilizing the 2019 National Inpatient Sample (NIS) database, a retrospective observational study assessed 112,864 adult patients hospitalized with heart failure and 7,865 cases also had a concomitant diagnosis of iron deficiency anemia (IDA).

RESULTS

Among 112,864 heart failure hospitalizations in 2019, approximately 7% had concomitant iron deficiency anemia (IDA). Heart failure patients with IDA exhibited distinct demographic characteristics, with females comprising 51.1% (p < 0.01) and higher rates of complicated hypertension (p < 0.01), complicated diabetes (p < 0.01), and peripheral vascular disease (p < 0.01). Adjusted mean LOS for patients with IDA was significantly longer at 1.31 days (95% CI 0.71-1.47; p < 0.01), persisting in both HFpEF and HFrEF subgroups. While total hospital charges were comparable in HFpEF, HFrEF patients with IDA incurred significantly higher charges ($13427.32, 95% CI: 1463.35-$25391.29, p = 0.03) than those without IDA. Complications such as atrial fibrillation and acute kidney injury were notably more prevalent in HFpEF and HFrEF patients with IDA.

CONCLUSION

The study highlighted that iron deficiency in heart failure patients leads to extended hospital stays, increased costs, and heightened risks of specific complications, particularly in HFrEF. Our study emphasized the implications of IDA in patients with heart failure ranging from prolonged hospitalizations and increased costs. Addressing iron deficiency is crucial, given its substantial impact on heart failure hospitalizations and outcomes, emphasizing the need for proactive diagnosis and management.

Diagnosis of Occult and Obscure Gastrointestinal Bleeding

Occult and obscure bleeding are challenging conditions to manage; however, recent advances in gastroenterology and endoscopy have improved our diagnostic and therapeutic capabilities. Obscure gastrointestinal (GI) bleeding is an umbrella category of bleeding of unknown origin that persists or recurs after endoscopic evaluation of the entire bowel fails to reveal a bleeding source. This review details the evaluation of patients with occult and obscure GI bleeding and offers diagnostic algorithms. The treatment of GI bleeding depends on the type and location of the bleeding lesion and an overview of how to manage these conditions is presented.

Role of Endoscopy in the Diagnosis, Grading, and Treatment of Portal Hypertensive Gastropathy and Gastric Antral Vascular Ectasia

Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are 2 distinct gastric vascular abnormalities that may present with acute or chronic blood loss. PHG requires the presence of portal hypertension and is typically associated with chronic liver disease, whereas there is controversy about the association of GAVE with chronic liver disease and/or portal hypertension. Distinguishing between GAVE and PHG is crucial because their treatment strategies differ. This review highlights characteristic endoscopic appearances and the clinical features of PHG and GAVE, which, in turn, aid in their appropriate management.

A Single-group, Clinical Interventional Study on the Effect of Iron Deficiency Anemia on Blood Glucose and Insulin Resistance in Women with Type II Diabetes

AIMS

Iron deficiency anemia (IDA) is one of the disorders recently associated with an increase in insulin resistance (IR) and, consequently, diabetes mellitus (DM) affection by causing oxidative stress. In this study, we look at how IDA may contribute to developing type II diabetes mellitus (T2DM), controlling diabetes, and reducing IR in women with T2DM.

METHODS

In this single group, clinical interventional study, we enrolled 40 women with T2DM and IDA. Before and after intervention with ferrous sulfate tablets, their blood glucose (BG) levels and IR levels were evaluated. This study was approved by the Ethics Committee of Qom University of Medical Sciences (ethics code: IR.MUQ.REC.1397.031) and registered at the Iranian Center for Clinical Trials (No. IRCT20170215032587N3). A significant level was considered p <0.05.

RESULT

The mean age of patients was 48.18 ± 4.6 years, with 5.3-5.8 years duration of T2DM. After the intervention, the mean fasting blood glucose (FBG) level reached 198.53 ± 48.11 to 170.93 ± 37.41, which was significant (p <0.0001). Also, hemoglobin A1C level reached from 8.49 ± 0.9 to 7.96 ± 0.58, which was significant (p <0.0001). Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) demonstrating a significant reduction of IR levels after intervention with ferrous sulfate tablets (p <0.018).

CONCLUSIONS

IDA treatment in patients with T2DM can significantly reduce the BG and IR levels. To better control BG, checking iron status and its correction may provide better clinical outcomes in these patients.

CLINICAL TRIAL REGISTRATION NUMBER

IRCT20170215032587N3.

Capsule endoscopy for obscure gastrointestinal bleed in the tropics: A single-center experience on 350 patients

BACKGROUND

Obscure gastrointestinal bleed (OGIB), now called small bowel bleed (SBB), comprises 5% to 10% of all gastrointestinal (GI) bleed episodes and capsule endoscopy (CE) is a tool for its evaluation. Studies on CE in a large sample of SBB patients from the tropics are limited.

METHODS

We did a retrospective analysis of a prospectively maintained database of patients with SBB undergoing CE using PillCam or MiroCam CE.

RESULTS

Of 350 patients (age 52.4 ± 17.4 years; 248 [70.9%] male) undergoing CE, 243 (69.4%) and 107 (30.6%) had overt and occult SBB, respectively. CE detected lesions in 244 (69.7%) patients (single lesion in 172 [49.1%]; multiple in 72 [20.6%]). The single lesions included vascular malformations (52, 14.9%), ulcer/erosion (47, 13.4%), tumor (24, 6.9%), hookworm (19, 5.4%), stricture (15, 4.3%), hemobilia (1, 0.3%) and blood without identifiable lesion (9, 2.6%). Of 72 with multiple lesions, ulcer with stricture was the commonest finding (n = 43, 12.3%). No abnormality was detected in 106 (30.3%) patients. The frequency of lesion detection was comparable among patients with overt and occult SBB (173/243, 71.2% vs. 71/107, 66.3%, respectively; p = 0.4). Younger patients (0 to 39 years) more often had multiple lesions on CE than the older (≥ 40 years) ones (26/76, 34.2% vs. 46/228, 20.2%, respectively; p = 0.001).

CONCLUSION

CE has a high diagnostic yield in SBB in the tropics, regardless of the type of bleed or of CE brand and the duration of recording. Multiple lesions associated with SBB are commoner among younger (< 40 years) patients.

Identification and prediction of association patterns between nutrient intake and anemia using machine learning techniques: results from a cross-sectional study with university female students from Palestine

PURPOSE

This study utilized data mining and machine learning (ML) techniques to identify new patterns and classifications of the associations between nutrient intake and anemia among university students.

METHODS

We employed K-means clustering analysis algorithm and Decision Tree (DT) technique to identify the association between anemia and vitamin and mineral intakes. We normalized and balanced the data based on anemia weighted clusters for improving ML models' accuracy. In addition, t-tests and Analysis of Variance (ANOVA) were performed to identify significant differences between the clusters. We evaluated the models on a balanced dataset of 755 female participants from the Hebron district in Palestine.

RESULTS

Our study found that 34.8% of the participants were anemic. The intake of various micronutrients (i.e., folate, Vit A, B5, B6, B12, C, E, Ca, Fe, and Mg) was below RDA/AI values, which indicated an overall unbalanced malnutrition in the present cohort. Anemia was significantly associated with intakes of energy, protein, fat, Vit B1, B5, B6, C, Mg, Cu and Zn. On the other hand, intakes of protein, Vit B2, B5, B6, C, E, choline, folate, phosphorus, Mn and Zn were significantly lower in anemic than in non-anemic subjects. DT classification models for vitamins and minerals (accuracy rate: 82.1%) identified an inverse association between intakes of Vit B2, B3, B5, B6, B12, E, folate, Zn, Mg, Fe and Mn and prevalence of anemia.

CONCLUSIONS

Besides the nutrients commonly known to be linked to anemia-like folate, Vit B6, C, B12, or Fe-the cluster analyses in the present cohort of young female university students have also found choline, Vit E, B2, Zn, Mg, Mn, and phosphorus as additional nutrients that might relate to the development of anemia. Further research is needed to elucidate if the intake of these nutrients might influence the risk of anemia.

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Anemia tolerance

Anemia is a pathological condition in which the hemoglobin and red blood cell mass decrease; it is mainly defined by the concentration of hemoglobin in the blood. The World Health Organization guidelines establish specific values to define anemia in different population groups. Early detection of anemia can also be a valuable indicator of underlying medical conditions. Clinical studies have explored the relationship between perioperative anemia and morbidity, highlighting the need for more judicious therapeutic strategies, such as the use of Patient Blood Management, which aims to prevent and treat anemia in a personalized and effective way. Patient Blood Management emerges as a promising approach to dealing with anemia, recognizing that its correction through transfusion always carries risks and that personalized prevention and treatment can offer better outcomes for patients.

Inpatient management of iron deficiency anemia in pediatric patients with inflammatory bowel disease: A single center experience

BACKGROUND

Screening for iron deficiency anemia (IDA) is important in managing pediatric patients with inflammatory bowel disease (IBD). Concerns related to adverse reactions may contribute to a reluctance to prescribe intravenous (IV) iron to treat IDA in this population.

AIM

To track the efficacy and safety of IV iron therapy in treating IDA in pediatric IBD patients admitted to our center.

METHODS

A longitudinal observational cohort study was performed on 236 consecutive pediatric patients admitted to our tertiary IBD care center between September 2017 and December 2019. 92 patients met study criteria for IDA, of which 57 received IV iron, 17 received oral iron, and 18 were discharged prior to receiving iron therapy.

RESULTS

Patients treated with IV iron during their hospitalization experienced a significant increase of 1.9 (± 0.2) g/dL in mean (± SE) hemoglobin (Hb) concentration by the first ambulatory follow-up, compared to patients who received oral iron 0.8 (± 0.3) g/dL or no iron 0.8 (± 0.3) g/dL (P = 0.03). One out of 57 (1.8%) patients that received IV iron therapy experienced an adverse reaction.

CONCLUSION

Our findings demonstrate that treatment with IV iron therapy is safe and efficacious in improving Hb and iron levels in pediatric patients with IDA and active IBD.

The Association Between Hormonal Contraceptive Use and Anemia Among Adolescent Girls and Young Women: An Analysis of Data From 51 Low- and Middle-Income Countries

PURPOSE

This study explores whether adolescent girls and young women aged 15-24 who use hormonal methods of contraception are more or less likely to be anemic than their peers. We further examine whether the association between anemia and hormonal contraception varies based on the severity of anemia or the duration of method use.

METHODS

We conducted secondary analysis of data available for 51 low- and middle-income countries from the Demographic and Health Surveys. For each country, we used logistic regression models to explore the odds of being anemic (mildly, moderately, or severely) for those using hormonal methods of contraception. We also explored the odds of being moderately or severely anemic based on hormonal method use. Drawing on country-level effect estimates, we conducted meta-regression analyses to produce overall estimates of the association between anemia and hormonal contraception.

RESULTS

Overall, adolescent girls and young women using hormonal methods had lower odds of being mildly, moderately, or severely anemic (adjusted odds ratio 0.68; p < .001) and lower odds of being moderately or severely anemic (adjusted odds ratio 0.57; p < .001) compared to those not using any contraception. Both short- and long-term users of hormonal methods had lower odds of being anemic and lower odds of being moderately or severely anemic compared to those not using hormonal methods.

DISCUSSION

This study furthers our understanding of the association between anemia and use of hormonal contraception among adolescent girls and young women. More research is needed to assess causality and whether hormonal methods mediate the effects of heavy menstrual bleeding or other risk factors of anemia.

Impact of litter size on the hematological and iron status of gilts, sows and newborn piglets: a comparative study of domestic pigs and wild boars

BACKGROUND

The critically low hepatic iron stores of newborn piglets are considered to be a major cause of neonatal iron deficiency in modern breeds of domestic pig (Sus domestica). The main factor believed to contribute to this phenomenon is large litter size, which has been an objective of selective breeding of pigs for decades. As consequence, iron transferred from the pregnant sow has to be distributed among a greater number of fetuses.

RESULTS

Here, we investigated whether litter size influences red blood cell (RBC) indices and iron parameters in Polish Large White (PLW) piglets and gilts. Small and large litters were produced by the transfer of different numbers of embryos, derived from the same superovulated donor females, to recipient gilts. Piglets from large litters obtained following routine artificial insemination were also examined. Our results clearly demonstrated that varying the number of piglets in a litter did not affect the RBC and iron status of 1-day-old piglets, with all showing iron deficiency anemia. In contrast, gilts with small litters displayed higher RBC and iron parameters compared to mothers with large litters. A comparative analysis of the RBC status of wild boars (having less than half as many piglets per litter as domestic pigs) and PLW pigs, demonstrated higher RBC count, hemoglobin level and hematocrit value of both wild boar sows and piglets, even compared to small-litter PLW animals.

CONCLUSIONS

These findings provide evidence that RBC and iron status in newborn PLW piglets are not primarily determined by litter size, and indicate the need to study the efficiency of iron transport across the placenta in domestic pig and wild boar females.

Reticulocyte hemoglobin content associated with the risk of iron deficiency anemia

Background/Objective

Reticulocyte hemoglobin content (MCHr) was recognized as a rapid and reliable marker for investigating iron deficiency (ID). We hypothesized that MCHr was associated with the risk of iron deficiency anemia in adults.

Methods

This is a dual-center case-control study. A total of 806 patients and healthy individuals were recruited from Ruijin Hospital and Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine between January 2021 and December 2021. The participants were categorized into iron deficiency anemia (IDA) group (n = 302), non-IDA group (n = 366), and healthy control group (n = 138). According to the MCHr level, the participants were divided into two groups, i.e. normal MCHr (≥25 pg) and decreased MCHr (<25 pg) group. Multivariate logistic regression analysis and adjusted subgroup analysis were conducted to estimate the relative risk between MCHr and IDA, with confounding factors including age, sex, hemoglobin (Hb), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), Hematocrit (HCT), serum iron (Fe), ferritin (Ferrit), and total iron binding capacity (TIBC).

Results

Compared with the non-IDA, the MCHr level with IDA decreased significantly. ROC curve analysis showed that MCHr had the largest area under the AUC curve. After comprehensive adjustment for confounding factors, individuals with normal level of MCHr exhibited a decreased risk of IDA (OR = 0.68 [0.60, 0.77], P < 0.01), while the risk of IDA was up to 5 times higher for those with decreased MCHr.

Conclusion

Our findings supported the hypothesis that MCHr was associated with the risk of IDA in adults and could serve as an indicator of IDA severity. MCHr holds clinical value as an auxiliary diagnostic indicator, providing valuable insights into whether invasive examinations are warranted in the assessment of IDA.

[Evaluation of the efficacy and safety of intravenous infusion of ferric derisomaltose in the treatment of iron deficiency anemia: a single-center retrospective analysis]

Objective: To investigate the clinical efficacy and safety of ferric derisomaltose injection versus iron sucrose injection in the treatment of iron deficiency anemia (IDA) . Methods: A total of 120 patients with iron deficiency anemia admitted from June 2021 to March 2023 were given intravenous iron supplementation with ferric derisomaltose to assess the efficacy and safety of hemoglobin (HGB) elevation before and after treatment. Simultaneously, the clinical effects of iron supplementation with iron sucrose were compared to those of inpatient patients during the same period. Results: Baseline values were comparable in both groups. Within 12 weeks of treatment, the elevated HGB level in the ferric derisomaltose group was higher than that of the iron sucrose group, with a statistical difference at all time points, and the proportion of HGB increased over 20 g/L in the patients treated for 4 weeks was higher (98.7%, 75.9% ). During the treatment with ferric derisomaltose and iron sucrose, the proportion of mild adverse reactions in the ferric derisomaltose group was slightly lower than that of the iron sucrose group, and neither group experienced any serious adverse reactions. The patients responded well to the infusion treatment, with no reports of pain or pigmentation at the injection site. Conclusion: The treatment of IDA patients with ferric derisomaltose has a satisfactory curative effect, with the advantages of rapidity, accuracy, and safety. Therefore, it is worthy of widespread clinical use.

HIF-PHD inhibitor desidustat ameliorates iron deficiency anemia

Iron deficiency anemia is caused by many pathological conditions like chronic kidney disease (CKD), inflammation, malnutrition and gastrointestinal abnormality. Current treatments that are erythropoiesis stimulating agents (ESAs) and iron supplementation are inadequate and often lead to tolerance and/or toxicity. Desidustat, a prolyl hydroxylase (PHD) inhibitor, is clinically used for the treatment of anemia with CKD. In this study, we investigated the effect of desidustat on iron deficiency anemia (IDA). IDA was induced in C57BL6/J mice by iron deficient diet feeding. These mice were then treated with desidustat (15 mg/kg, PO) and FeSO4 (20 mg/kg) for five weeks and effect of the treatment on hematology, iron homeostasis, and bone marrow histology was observed. Effect of desidustat on iron metabolism in inflammation (LPS)-induced iron deficiency was also assessed. Both, Desidustat and FeSO4, increased MCV (mean corpuscular volume), MCH (mean corpuscular hemoglobin), hemoglobin, and HCT (hematocrit) in blood and increased iron in serum, liver, and spleen. Desidustat increased MCHC (mean corpuscular hemoglobin concentration) while FeSO4 treatment did not alter it. FeSO4 treatment significantly increased iron deposition in liver, and spleen, while desidustat increased iron in circulation and demonstrated efficient iron utilization. Desidustat increased iron absorption, serum iron and decreased hepcidin without altering tissue iron, while FeSO4 increased serum and tissue iron by increasing hepcidin in LPS-induced iron deficiency. Desidustat increased erythroid population, especially iron-dependent polychromatic normoblasts and orthochromatic normoblasts, while FeSO4 did not improve cell architecture. PHD inhibition by desidustat improved iron utilization in iron deficiency anemia, by efficient erythropoiesis.

The effectiveness of oral bovine lactoferrin compared to iron supplementation in patients with a low hemoglobin profile: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Patients with a low serum blood hemoglobin concentration suffer from a pathologic state that contributes significantly to morbidity and mortality figures worldwide. Oral iron supplementation, the most common method of treatment, is reported to have poor patient adherence, due to its unwanted side effects. Lactoferrin is a globular glycoprotein of the transferrin family that has shown promising results in patients with a low hemoglobin profile. This systematic review and meta-analysis of randomized clinical trials explore its effect on blood hemoglobin compared to conventional iron preparations.

METHODS

We followed the PRISMA Guidelines for reporting systematic reviews and meta-analyses. A systematic search was conducted in electronic databases (PubMed, CINAHL, Scopus, and Cochrane) from inception to June 2022. Meta-analysis was performed on studies where the primary outcome was the mean Hb concentration, comparing lactoferrin to ferrous sulfate subgroups. We assessed the methodological quality of the trials using the Jadad scoring scale.

RESULTS

Nineteen trials published between 2006 and 2022 met the eligibility criteria. It has been found that the levels of Hb concentration in different populations with varying health conditions undergo a moderate to significant change after treatment with all types of trialed interventions, including both iron and lactoferrin treatment, in both the intervention group and the comparison group. Most of the studies report that LF showed a statistically significant increase in Hb concentration levels, compared to those in the iron group. The meta-analysis included seven trials comparing the effectiveness of lactoferrin to ferrous sulfate for patients with low Hb concentration. The analysis showed a statistically significant increase in Hb levels in the oral bovine lactoferrin group compared to ferrous sulfate (SMD -0.81, 95% CI: -1.21, -0.42, p < 0.0001, I2 = 95.8%, P heterogeneity < 0.001).

CONCLUSIONS

Lactoferrin is an effective intervention at doses of 100-250 ng/day, for patients with a low Hb concentration. As a safer option and with high compliance evidence, lactoferrin can serve as an iron replacement treatment for patients who may be experiencing adverse side effects due to iron intake.

Association between iron deficiency anemia and subsequent stomach and colorectal cancer diagnosis in Germany

PURPOSE

Iron deficiency anemia (IDA) is the most common form of anemia worldwide, resulting in a high burden of disease. Accumulating evidence suggests that IDA is associated with the development of gastrointestinal (GI) cancers.

METHODS

Data from the IDA database (IQVIA) of primary care practices in Germany of adult patients first diagnosed with IDA between January 2005 and December 2021 were retrospectively analyzed and compared with a 1:1 propensity score-adjusted cohort without IDA. Study outcomes were first stomach cancer or colorectal cancer (CRC) diagnosis up to 10 years after the index date as a function of IDA.

RESULTS

A total of 122,502 individuals with IDA and 122,502 individuals without IDA were included. The 10-year cumulative incidence of CRC was 1.4% in the IDA patients compared to 0.8% in the cohort without IDA (p < 0.001). Regression analysis revealed a significant association between IDA and subsequent CRC (HR 2.05; 95% CI 1.83-2.30). Stomach cancer was diagnosed in 0.3% of IDA patients compared to 0.2% in the non-IDA cohort during the 10-year follow-up period (p = 0.002). However, this was significant only in the age group > 80 years (HR 2.73; 95% CI 1.60-4.67) and in men (HR 1.90; 95% CI 1.38-2.61).

CONCLUSION

These findings add to the literature and suggest an association between IDA and GI cancers. The extent to which this association is due to GI bleeding or other pathophysiological processes that may be caused by IDA requires further investigation, particularly experimental studies.

Reported outcomes in patients with iron deficiency or iron deficiency anemia undergoing major surgery: a systematic review of outcomes

BACKGROUND

Iron deficiency (ID) is the leading cause of anemia worldwide. The prevalence of preoperative ID ranges from 23 to 33%. Preoperative anemia is associated with worse outcomes, making it important to diagnose and treat ID before elective surgery. Several studies indicated the effectiveness of intravenous iron supplementation in iron deficiency with or without anemia (ID(A)). However, it remains challenging to establish reliable evidence due to heterogeneity in utilized study outcomes. The development of a core outcome set (COS) can help to reduce this heterogeneity by proposing a minimal set of meaningful and standardized outcomes. The aim of our systematic review was to identify and assess outcomes reported in randomized controlled trials (RCTs) and observational studies investigating iron supplementation in iron-deficient patients with or without anemia.

METHODS

We searched MEDLINE, CENTRAL, and ClinicalTrials.gov systematically from 2000 to April 1, 2022. RCTs and observational studies investigating iron supplementation in patients with a preoperative diagnosis of ID(A), were included. Study characteristics and reported outcomes were extracted. Outcomes were categorized according to an established outcome taxonomy. Quality of outcome reporting was assessed with a pre-specified tool. Reported clinically relevant differences for sample size calculation were extracted.

RESULTS

Out of 2898 records, 346 underwent full-text screening and 13 studies (five RCTs, eight observational studies) with sufficient diagnostic inclusion criteria for iron deficiency with or without anemia (ID(A)) were eligible. It is noteworthy to mention that 49 studies were excluded due to no confirmed diagnosis of ID(A). Overall, 111 outcomes were structured into five core areas including nine domains. Most studies (92%) reported outcomes within the 'blood and lymphatic system' domain, followed by "adverse event" (77%) and "need for further resources" (77%). All of the latter reported on the need for blood transfusion. Reported outcomes were heterogeneous in measures and timing. Merely, two (33%) of six prospective studies were registered prospectively of which one (17%) showed no signs of selective outcome reporting.

CONCLUSION

This systematic review comprehensively depicts the heterogeneity of reported outcomes in studies investigating iron supplementation in ID(A) patients regarding exact definitions and timing. Our analysis provides a systematic base for consenting to a minimal COS.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020214247.

Dietary intakes of iron, folate, and vitamin B12 during pregnancy and correlation with maternal hemoglobin and fetal growth: findings from the ROLO longitudinal birth cohort study

PURPOSE

Dietary micronutrient intakes of iron, folate and vitamin B12 are known to influence hemoglobin. Low maternal hemoglobin (maternal anemia) has been linked to low birthweight and other adverse health outcomes in the fetus and infant. Our primary aim was to explore relationships between maternal dietary micronutrient intakes, maternal full blood count (FBC) parameters and fetal abdominal circumference (AC) and estimated fetal weight (EFW) growth trajectories. Secondarily, we aimed to assess relationships between maternal dietary micronutrient intakes, maternal hemoglobin values and placental weight and birthweight.

METHODS

Mother-child pairs (n = 759) recruited for the ROLO study were included in this analysis. Maternal dietary micronutrient intakes were calculated from food diaries completed during each trimester of pregnancy. FBC samples were collected at 13- and 28-weeks' gestation. Fetal ultrasound measurements were recorded at 20- and 34-weeks' gestation. Growth trajectories for AC and EFW were estimated using latent class trajectory mixture models.

RESULTS

Dietary intakes of iron and folate were deficient for all trimesters. Mean maternal hemoglobin levels were replete at 13- and 28-weeks' gestation. Dietary iron, folate and vitamin B12 intakes showed no associations with fetal growth trajectories, placental weight or birthweight. Lower maternal hemoglobin concentrations at 28 weeks' gestation were associated with faster rates of fetal growth and larger placental weights and birthweights.

CONCLUSION

The negative association between maternal hemoglobin at 28 weeks' gestation and accelerated fetal and placental growth may be due to greater consumption of maternal iron and hemoglobin by fetuses' on faster growth trajectories in addition to placental biochemical responses to lower oxygen states.

Helicobacter pylori infection in pregnant women: Gastrointestinal symptoms and pregnancy- related disorders

Helicobacter pylori (H. Pylori) is a gram-negative, flagellated and spiral-shaped bacterial pathogen that impacts approximately 46% among pregnant women globally and has been associated with various maternal-fetal complications. Iron deficiency anemia, fetal growth restriction, cardiovascular diseases, and insufficient nutrient absorption can be observed in pregnant women, as well as miscarriages and pregnancy-specific hypertensive disease, such as pre-eclampsia. Thus, the evidence supports the influence of H. pylori infection on fetal implantation/placentation failure, and positive strains of the cytotoxin-associated gene A of H. Pylori were reported as the most prevalent in these conditions. However, current knowledge indicates a relationship between this infection and the occurrence of hyperemesis gravidarum, characterized by frequent nausea and vomiting. Regarding the diagnosis of this bacterial infection, non-invasive approaches such as stool antigen test, urea breath test, and serological tests are more accepted during pregnancy, as they are easy to carry out and cost-effective. Finally, the bacteria eradication therapy should consider the risks and benefits for the pregnant woman and her child, with pharmacological intervention depending on the clinical presentation.

RAPIDIRON Trial follow-up study - the RAPIDIRON-KIDS Study: protocol of a prospective observational follow-up study

BACKGROUND

Anemia is a worldwide problem with iron deficiency being the most common cause. When anemia occurs in pregnancy, it increases the risk of adverse maternal, fetal, and postnatal outcomes. It induces preterm births and low birth weight (LBW) deliveries, long-term neurodevelopmental sequelae, and an increased risk of earlier onset of postnatal iron deficiency. Anemia rates are among the highest in South Asia, and India's National Family Health Survey (NFHS-5) for 2019-2021 indicated that over half of pregnant women, and more than 65% of children, in the country are classified as anemic (Sciences IIfP, National Family Health Survey-5, 2019-21, India Fact Sheet). In 2021, the parent RAPIDIRON Trial (Derman et al., Trials 22:649, 2021) was initiated in two states in India, with the goal of assessing whether a dose of intravenous (IV) iron given to anemic women during early pregnancy results in a greater proportion of participants with normal hemoglobin concentrations in the third trimester and a lower proportion of participants with LBW deliveries compared to oral iron. As a follow-up to the RAPIDIRON Trial, the RAPIDIRON-KIDS Study will follow the offspring of previously randomized mothers to assess, neurobehavioral, hematological, and health outcomes.

METHODS

This prospective observational cohort study will follow a subset of participants previously randomized as part of the RAPIDIRON Trial and their newborns. Study visits occur at birth, 6 weeks, 4 months, 12 months, 24 months, and 36 months and include blood sample collection with both maternal and infant participants and specific neurobehavioral assessments conducted with the infants (depending on the study visit). The primary outcomes of interest are (1) infant iron status as indicated by both hemoglobin and ferritin (a) at birth and (b) at 4 months of age and (2) the developmental quotient (DQ) for the cognitive domain of the Bayley Scales of Infant Development Version IV (BSID-IV) at 24 months of age.

DISCUSSION

This RAPIDIRON-KIDS Study builds upon its parent RAPIDIRON Trial by following a subset of the previously randomized participants and their offspring through the first 3 years of life to assess neurodevelopmental and neurobehavioral (infants, children), hematological, and health outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05504863 , Registered on 17 August 2022. Clinical Trials Registry - India CTRI/2022/05/042933 . Registered on 31 May 2022.

Ratio of hemoglobin to mean corpuscular volume: A new index for discriminating between iron deficiency anemia and thalassemia trait

BACKGROUND

Iron deficiency anemia (IDA) and thalassemia trait (TT) are the most common microcytic and hypochromic anemias. Differentiation between mild TT and early IDA is still a clinical challenge.

AIM

To develop and validate a new index for discriminating between IDA and TT.

METHODS

Blood count data from 126 patients, consisting of 43 TT patients and 83 IDA patients, was retrospectively analyzed to develop a new index formula. This formula was further validated in another 61 patients, consisting of 48 TT patients and 13 IDA patients.

RESULTS

The new index is the ratio of hemoglobin to mean corpuscular volume. Its sensitivity, specificity, accuracy, Youden's Index, area under the receiver operating characteristic curve, and Kappa coefficient in discriminating between IDA and TT were 93.5%, 78.4%, 83.3%, 0.72, 0.97, and 0.65, respectively.

CONCLUSION

This new index has good diagnostic performance in discriminating between mild TT and early IDA. It requires only two results of complete blood count, which can be a very desirable feature in under-resourced scenarios.

Effect of Iron Polymaltose Complex Prophylaxis on Frequency of Iron Deficiency and Iron Deficiency Anemia

OBJECTIVES

To evaluate the effectiveness of national iron prophylaxis policy in 9-12 mo-old infants in Turkey.

METHODS

This study was planned as a cross-sectional study, and it included healthy infants aged 9 to 12 mo who presented to the pediatric outpatient clinic for routine check-ups. Parents were interviewed to identify risk factors for iron deficiency (ID) and gather information on Fe+3 - iron polymaltose complex (IPC) prophylaxis usage. Blood samples were collected for hemogram and ferritin analysis. Multiple logistic regression analyses were conducted to determine risk factors for ID and iron deficiency anemia (IDA).

RESULTS

The study included 317 infants. In the non-prophylaxis group, the frequency of IDA was 31.1%, compared to 13.4% in the regular prophylaxis group. Iron deficiency was detected in 25% of individuals receiving regular prophylaxis and 13.1% of those without prophylaxis. The risk factors for IDA were insufficient iron diets (OR 2.45, 95% CI: 1.35-4.45) and not receiving Fe+3 - IPC prophylaxis (OR 2.57, 95% CI: 1.24-5.31). The relationship between Fe+3 - IPC prophylaxis and ID did not reach statistical significance (p = 0.253).

CONCLUSIONS

Fe+3 - IPC prophylaxis is associated with a lower risk of iron deficiency anemia, but not iron deficiency.

Management of collagenous gastritis in children: Case series and literature review

Collagenous gastritis (CG) is a rare histopathological finding on gastric biopsies in children. It is associated with abdominal pain and iron deficiency anemia, usually not respondent to oral iron supplements. The aim of this study was to describe our experience in the management of pediatric patients with CG. Moreover, we propose to review the literature on this topic. We retrospectively reviewed all pediatric patients diagnosed with CG at our centre from January 2014 to January 2019. Three pediatric patients (2 F, mean age 12.3) were diagnosed with CG during the study period. Two presented with moderate and one with severe anemia. Symptoms were abdominal pain, asthenia and headache in two and asthenia and abdominal pain in one. All underwent upper and lower gastrointestinal endoscopy. All were firstly started with oral iron supplements with no benefit, principally due to poor compliance secondary to the worsening of the epigastric pain and proton pump inhibitor resistance. Therefore, they underwent ferric carboxymaltose (FCM) infusion with good clinical and laboratory response. Patients received a mean of two infusions/year, with stable hemoglobin levels and no adverse outcomes. Our review failed to identify a consistent response to specific treatments. Considering the apparent benign nature of the disease, symptomatic and supportive treatments are advisable. Iron deficiency anemia is largely present and therapy with oral iron supplements is not always successful. In our study, FCM infusion was effective in increasing the key blood indices in patients who poorly tolerated oral supplements.

Proton Pump Inhibitor Use and Iron Deficiency Anemia in Celiac Patients

INTRODUCTION

We sought to evaluate the effect of proton pump inhibitor (PPI) use on the development and severity of iron deficiency anemia (IDA) in celiac disease (CD).

METHODS

We conducted a retrospective chart review of patients older than 18 years of age at Milton S. Hershey Medical Center who were diagnosed with CD. We analyzed four cohorts of celiac patients: (1) IDA diagnosis with PPI usage, (2) no IDA diagnosis with PPI usage, (3) IDA diagnosis with no PPI usage, and (4) no IDA diagnosis with no PPI usage. We also stratified celiac patients with IDA by anemia severity.

RESULTS

Of 366 celiac patients, 92 (25.1%) were diagnosed with IDA, of which 60 (65.2%) were on a PPI. The mean Hgb of celiac patients with IDA on a PPI was 11.1 g/dL and 12.1 g/dL for those without PPI (p = 0.04). For all celiac patients on a PPI without IDA, the mean was 13.3 g/dL and 13.7 g/dL for those without PPI (p = 0.02). PPI use occurred in 12 (70.6%) of the 17 patients with low severity anemia, 11 (64.7%) of the 17 patients with medium severity and 6 (85.7%) of the 7 patients with severe (p = 0.55).

CONCLUSIONS

There is significant association between PPI use and IDA in celiac patients (p < 0.0001). Of those with IDA on PPIs, the distribution of the severity of anemia is not statistically different compared to those not on PPI. Discontinuation of PPIs or usage of alternative acid suppressive treatments may be indicated in patients with CD and iron deficiency anemia.

Iron Deficiency Anemia Is Associated with Proprioceptive Deficit in Adult Women: a Cross-Sectional Case-Control Study

Proprioception is essential to several conscious and unconscious sensations and automatic control of movement in daily life activities. Iron deficiency anemia (IDA) may alter proprioception as it could induce fatigue, and affect neural processes such as myelination, and neurotransmitters synthesis and degradation. This study aimed to explore the effect of IDA on proprioception in adult women. Thirty adult women with IDA and 30 controls participated in this study. The weight discrimination test was performed to assess proprioceptive acuity. Attentional capacity and fatigue were evaluated, too. Women with IDA had a significantly (P < 0.001) lower ability to discriminate weights compared to controls in the two difficult increments, and for the second easy weight (P < 0.01). For the heaviest weight, no significant difference was found. Attentional capacity and fatigue values were significantly (P < 0.001) higher in patients with IDA compared to controls. Moreover, moderate positive correlations between the representative proprioceptive acuity values and Hb (r = 0.68) and ferritin (r = 0.69) concentrations were found. Moderate negative correlations were found between the proprioceptive acuity values and general (r =  - 0.52), physical (r =  - 0.65) and mental (r =  - 0.46) fatigue scores, and attentional capacity (r =  - 0.52). Women with IDA had impaired proprioception compared to their healthy peers. This impairment may be related to neurological deficits due to the disruption of iron bioavailability in IDA. In addition, fatigue resulting from IDA due to the poor muscle oxygenation could also explain the proprioceptive acuity decrease in women suffering from IDA.

Justification of Universal Iron Supplementation for Infants 6-12 months in Regions with a High Prevalence of Thalassemia

Introduction

Many clinicians hesitate to adopt a universal infant iron supplementation program due to the risk of increased iron absorption for those with thalassemia. We aimed to determine thalassemia prevalence in 6- to 12-month-old infants, along with the iron status of those with and without thalassemia.

Methods

We performed a cross-sectional descriptive study of infants attending the Well Baby Clinic at Thammasat University Hospital for routine checkups. Complete blood count, hemoglobin electrophoresis, iron parameters, and molecular genetics for common α- and β-thalassemia were evaluated.

Results

Overall, 97 of 206 (47%) participants had thalassemia minor, the majority having Hb E traits. None had thalassemia intermedia or major. Familial history of anemia or thalassemia presented an increased risk of detecting thalassemia minor in offspring (OR 5.18; 95% CI 2.60-10.33, p=0.001). There were no statistical differences in transferrin saturation, serum ferritin and hepcidin between iron-replete infants with thalassemia minor and those without. However, one-third of infants with thalassemia minor (31/97) also had iron deficiency anemia (IDA), with a similar risk of having iron deficiency to infants without thalassemia. There was no hepcidin suppression in our infants with thalassemia minor as compared to controls.

Conclusions

Both thalassemia and IDA are endemic to Southeast Asia. Infants with thalassemia minor, particularly with Hb E and α-thalassemia traits, are at risk of IDA. Our short-term universal iron supplementation program for 6- to 12-month-old infants does not appear to increase the risk of those with thalassemia minor developing iron overload in the future.

Colorectal Cancer Screening and Iron Deficiency Anemia

In the United States, colorectal cancer has the fourth highest amount of annual new cancer cases per year between 2014 and 2018. In this article, the authors review the data and guidelines supporting effective direct visualization and stool-based testing methods of colon cancer screening along with work-up and management of Iron Deficiency Anemia.

[Analysis on the iron status and associated factors during the first trimester of pregnancy]

OBJECTIVE

To investigate the impact of dietary and underlying factors on the iron status of women in early pregnancy and to provide evidence for preventing iron deficiency and iron deficiency anemia, thereby reducing the incidence of associated adverse outcomes.

METHODS

From November to December 2018, women in the first trimester of pregnancy (< 12 weeks gestation) who established prenatal records at the Shunyi District Maternal and Child Health Hospital, Beijing, were enrolled in this study, in which 388 participants were accessed for data including demographic characteristics, anthropometric measurements, parity, biomarkers reflecting iron status, and food-frequency questionnaire. SPSS 26.0 were used for statistical analysis. Dietary patterns were extracted using principal component analysis, and factor scores of each dietary pattern were calculated. Two-sided Fisher exact probability test and one-way ANOVA were conducted to access differences in iron status among the groups, and the differences were significant if P < 0.05. Iron deficiency was defined as serum ferritin(SF) < 30 μg/L. To analyze the potential role of dietary factors on iron deficiency during the first trimester, the collected data listed above were adopted as independent factors for the cross-sectional Logistic regression. We used Logistic regression to analyze the potential effects of baseline characteristics and dietary factors on iron status.

RESULTS

Among the 388 participants included in the analysis, 121 (32.2%) were iron deficient, in which 107 (27.6%) were iron depletion (ID), 8 (2.1%) were iron deficiency erythropoiesis (IDA), 6(1.5%) were iron deficiency anemia. The mean SF concentration was (50.4±35.3) μg/L. Multiparity(OR=3.9, 95%CI: 1.81-8.42, P=0.001)was a risk factor for iron deficiency during early pregnancy. No significant iron status differences were found among the participants with different educational levels and anthropometric measurements. In contrast, age (OR =0.96, 95%CI: 0.94-0.97, P < 0.001) was a protective factor. For multiparas, taking iron-containing supplements might have a protective effect for iron deficiency (OR=0.27, 95%CI: 0.09-0.83, P=0.022). The balance-diet pattern (OR=0.81, 95%CI: 0.66-1.00, P=0.054) only showed a marginally significant effect.

CONCLUSION

Increasing attention should be paid to the iron status of pregnant multiparas and young pregnant women. For those women of reproductive age with the risk factors listed above, especially for multiparas, iron-containing supplements should be recommended to prevent gestational iron deficiency. The effect of the "balance" dietary pattern on iron status in the first trimester and following requires further research and discussion.

Evaluation of the barriers and facilitators of iron supplementation program among adolescent females

BACKGROUND & AIMS

Iron deficiency anemia is a major health problem in female adolescents; so, the iron supplementation program has been implemented in Iranian female high school students for nearly two decades. This study aimed to assess the barriers and facilitators of the program.

METHODS

This cross-sectional study was conducted by cluster random sampling with a sample size of 399 high school girls from the northern, southern, eastern, western and central regions of Iran. To collect data, we applied valid and reliable researcher-made questionnaires. Data were analyzed by SPSS version 22 software using the chi-squared test.

RESULTS

From the students' point of view, the most important reasons for not taking iron supplements were the bad taste of iron supplements, nausea after consumption, and not prescription of the iron supplement by physicians. Most the students believed that inviting health care professionals and movies or clips had the greatest impact on encouraging students to take supplements. About 45% of students reported that educational programs were not held for them, and only 28% of students received educational content/educational media about iron supplement. Also, 71% of students reported that there are not enough glasses for the consumption of supplement iron. There were significant relationships between iron supplements distributors (deputy assistant: 22.6% vs. 14.1%, P = 0.045), allocated enough time to intake iron supplements (72.0% vs. 37.1%, P < 0.001), implemented the educational program in schools (61.8% vs. 33%, P < 0.001), and the educator person of the program (health teachers: 42.7% vs. 35.7%, P = 0.039) with consumption of iron supplement by the students.

CONCLUSION

To achieve the goals of the program, it is necessary paying attention to various aspects of the program such as providing better quality iron supplements, providing more appropriate environmental conditions, designing more attractive training programs, strengthening general announcement, and employing more experienced executive staff.

CONCLUSION

Impact of iron supplementation on patient outcomes for women with abnormal uterine bleeding: a protocol for a systematic review and meta-analysis

BACKGROUND

Abnormal uterine bleeding (AUB), which includes heavy menstrual bleeding (HMB), is a common condition placing women at increased risk for developing iron deficiency and iron deficiency anemia (IDA). Depletion of iron stores has negative implications on physical, social, and emotional health, as well as quality of life. Iron supplements are safe, effective, and readily available, while red blood cell (RBC) transfusions have inherent risks including infectious and immune reactions. Despite high prevalence of IDA among women with AUB, there are limited studies on the impact of iron therapies on patient outcomes. This systematic review and meta-analysis will evaluate the impact of iron supplementation on patient outcomes for women with AUB, when compared to combination therapy, no intervention, placebo, or standard of care.

METHODS

We will conduct a systematic review and meta-analysis of randomized controlled trials and observational studies evaluating the impact of iron interventions on patient outcomes for women with AUB. Systematic literature searches will be conducted in major databases including MEDLINE, EMBASE, CENTRAL, CINAHL, and Web of Science. Studies assessing the impact of iron interventions on patient outcomes in women experiencing AUB, in comparison to combination therapy, no intervention, placebo, or standard of care, will be included in the review. Independent reviewers will screen for eligibility, assess risk of bias, and abstract data. Overall certainty of evidence for each outcome will be assessed using the GRADE approach. We will meta-analyze outcomes which are sufficiently homogeneous to summarize intervention effects and narratively synthesize nonhomogeneous outcomes. The main outcomes of interest are hemoglobin levels immediately prior to surgery and post-operatively, number of RBC transfusions, and adverse effects. Secondary outcomes will include length of hospital stay, intraoperative blood loss, adverse and side effects, quality of life, and iron indices.

DISCUSSION

This review will evaluate the impact of iron interventions on patient outcomes in women with IDA secondary to AUB with focus on changes in hematological and iron indices, red blood cell utilization, quality of life, cost of treatment, and adverse events. The results will inform evidence-based clinical practice for the management of iron deficiency and IDA secondary to AUB.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019137282.

Predictive Model for Positive Video Capsule Endoscopy in Iron Deficiency Anemia

BACKGROUND AND AIMS

Bleeding from the gastrointestinal tract can contribute to the development of iron deficiency anemia (IDA) among individuals without another obvious source of bleeding. In order to identify patients most likely to benefit from examination of the small bowel, our aim was to create a risk score for positive video capsule endoscopy (VCE) in IDA utilizing a multicenter collection of studies.

METHODS

We performed a retrospective multicenter study utilizing VCE studies performed for an indication of IDA between 1/1/2005 and 7/31/2018. VCE findings were graded based on the P0-P2 grading system. The primary outcome of interest was a positive (P2) VCE. Data were analyzed with Student's t test for continuous variables and the Fisher's exact test for categorical variables. Logistic regression was used to identify independent associations with positive VCE.

RESULTS

In total, 765 VCE procedures were included with 355 (46.5%) male subjects and a median age of 63.2 (SD 15.3) years. One hundred ninety studies (24.8%) were positive (P2) for small bowel bleeding. Four variables associated with positive VCE which were incorporated into a point scoring system: (+) 1 for age ≥ 66 years, active smoking and cardiac arrythmia and (-) 1 for preceding hemoglobin level ≥ 8.5. The risk probabilities for positive VCE-assigned scores - 1, 0, 1, and 2 + were 12.3% (95% CI 7.3-17.3%), 20% (14.9-25.1%), 34.8% (28.6-41%), and 39% (30-47.8%).

CONCLUSION

In order to improve the diagnostic yield of capsule examinations, risk factors should be applied to clinical decision-making. We created a risk score for positive VCE in IDA, including the risk factors of age, smoking, history of cardiac arrythmia, and preceding hemoglobin level.

Reticulocyte Hemoglobin Equivalent (Ret-He) as a Potential Diagnostic Marker of Iron Deficiency Anemia among Bangladeshi Adults

Anemia involving a variety of etiological sources constitutes a common side effect of long-term liver diseases. Anemia caused by an iron deficiency (IDA) is a prominent kind of anemia among various other types. Blood ferritin levels and other iron-related indicators can be used to identify anemia. On the other hand, it is now possible to quantify reticulocyte hemoglobin equivalent (Ret-He), which indicates the reticulocyte iron concentration. It would be useful to diagnose IDA immediately if Ret-He could evaluate the ID. The effectiveness of Ret-He to diagnose ID in Bangladeshi patients was investigated in an ongoing study. Whole bloodstream numbers, blood ferritin phases, and Ret-He concentrations were measured in a cohort of 215 Bangladeshi people. Hemoglobin (Hb) values less than 12 gm/dL were considered anemia. An individual was classified as iron deficient if their blood ferritin concentration was below 12 ng/mL. Participants were split into four groups for this study: non-ID groups with anemia, IDA, ID, and control groups. In comparison to patients with IDA and ID, the concentrations of Ret-He showed a downward tendency. Serum Ret-He levels were correlated with ferritin levels in the subjects. The measurement of the area around the intercept (AUC) for Ret-He on the ROC curve was 0.906, suggesting a correlation with diagnosis. The study's results provide optimism for the therapeutic use of Ret-He value as an indicator for identification in Bangladeshi patients.

How to cite this article

Miah MMZ, Pramanik MEA, Rafi MA, et al. Reticulocyte Hemoglobin Equivalent (Ret-He) as a Potential Diagnostic Marker of Iron Deficiency Anemia among Bangladeshi Adults. Euroasian J Hepato-Gastroenterol 2023;13(2):128-132.

Antenatal Optimization of Maternal Anemia Leads to Decreased Risks of Maternal Morbidity

Purpose of Review

Our review focuses on the appropriate use of intravenous iron to increase the likelihood of achieving target hemoglobin levels prior to delivery to reduce maternal morbidity.

Recent Findings

Iron deficiency anemia (IDA) is a leading contributor to severe maternal morbidity and mortality. Prenatal treatment of IDA has been demonstrated to reduce the likelihood of adverse maternal outcomes. Recent investigations of intravenous iron supplementation have demonstrated superior efficacy and high tolerability for the treatment of IDA in the third trimester, compared against oral regimens. However, it is unknown whether this treatment is cost-effective, available to clinicians, or acceptable to patients.

Summary

Intravenous iron is superior to the oral treatment of IDA; however, its use is limited by the lack of implementation data.

An atypical presentation of endometrial cancer as angina secondary to critically low hemoglobin and iron deficiency associated pancytopenia: A case report

Endometrial cancer is the most common type of gynaecological cancer in high-income countries. Abnormal uterine bleeding (AUB) is the most common symptom of endometrial cancer; however, patients can often present in an atypical fashion. This case is an example of an atypical presentation of endometrial cancer, with angina secondary to severe iron deficiency anemia, and a rare example of pancytopenia secondary to iron deficiency. A 46-year-old nulliparous woman with no past medical history presented to the emergency department with acute chest pain. All her vitals were normal. The ECG showed T-wave inversion with a negative serum troponin. She had obvious pallor but appeared well. She had a critical hemoglobin of 1.9 g/dL and severe iron deficiency with a plasma iron level of <2 μg/L. In the 6 months leading up to her presentation, she had heavy and prolonged menstruation of up to 10 days. She received a total of 6 units of packed red blood cells and an iron infusion. Her chest pain resolved, and her pancytopenia corrected following replenishment of iron stores. She underwent a laparoscopic total hysterectomy, bilateral salpingo-oophorectomy for stage 1b, grade 2 endometroid adenocarcinoma. This is one of the lowest hemoglobin levels recorded in a hemodynamically stable patient with endometrial cancer, and the only case report of iron deficiency induced pancytopenia secondary to abnormal uterine bleeding. This case is a reminder that female patients with angina should have their hemoglobin checked, and patients with anemia should have a thorough review of their gynaecological history.

Methodology and Baseline Data of a Comparative Exploratory Double-Blinded Randomized Study of Intravenous Iron on Fibroblast Growth Factor 23 and Phosphate in Chronic Kidney Disease

Modern intravenous iron compounds (e.g., ferric carboxymaltose [FCM] and ferric derisomaltose [FDI]) are utilized in the treatment of iron deficiency anemia in non-dialysis-dependent chronic kidney disease (ND-CKD). Product-specific alterations in the metabolism of fibroblast growth factor 23 (FGF-23) leading to hypophosphatemia have been described for certain intravenous iron compounds, such as FCM, with potential effects on bone and cardiovascular health and quality of life. No prior head-to-head comparison between FCM and FDI exists in ND-CKD. This single-center exploratory double-blind randomized controlled trial primarily aimed to investigate the differential impact of FCM and FDI on FGF-23 and phosphate in patients with iron deficiency +/- anemia and ND-CKD (stages 3a-5 - serum ferritin <200 μg/L or serum ferritin 200-299 μg/L and transferrin saturation <20%). Patients were randomized (1:1) to receive either FCM or FDI over two infusions (1 month apart). Follow-up was 3 months. Measurements of serum intact FGF-23, phosphate, vitamin D metabolites, parathyroid hormone, other bone metabolism, cardiovascular, and quality of life markers were monitored. 168 patients were prescreened. Thirty-five patients were screened; 26 patients were randomized. The mean (standard deviation) age was 67.9 (12.4) years and 17 participants were male. Most participants had stage 4 CKD (median [interquartile range] estimated glomerular filtration rate [eGFR]: 18.0 [11.3] mL/min/1.73 m2). A higher than normal median (interquartile range) level of intact FGF-23 (212.1 [116.4] pg/mL) was noted. Serum phosphate was within normal range, while parathyroid hormone was higher and 1,25 (OH)2 vitamin D lower than the normal range. The "Iron and Phosphaturia - ExplorIRON-CKD" trial will provide important information regarding the differential effect of intravenous iron products in terms of FGF-23, phosphate, and other markers of bone and cardiovascular metabolism, alongside patient-reported outcome measures in patients with ND-CKD.

TT@MHA: A Machine Learning-based Webpage Tool for Discriminating Thalassemia Trait from Microcytic Hypochromic Anemia Patients

BACKGROUND

Iron deficiency anemia (IDA) and thalassemia trait (TT) are the most common causes of microcytic hypochromic anemia (MHA) and are endemic in lower resource settings and rural areas with poor medical infrastructure. Accurate discrimination between IDA and TT is an essential issue for MHA patients. Although various discriminant formulas have been reported, distinguishing between IDA and TT is still a challenging problem due to the diversity of anemic populations.

METHODS

We retrospectively collected laboratory data from 798 MHA patients. High proportions of α-TT (43.33%) and TT concomitant with IDA (TT&IDA) patients (14.04%) were found among TT patients. Five machine learning (ML) approaches, including Liner SVC (L-SVC), support vector machine learning (SVM), Extreme gradient boosting (XGB), Logistic Regression (LR), and Random Forest (RF), were applied to develop a discriminant model. Performance was assessed and compared with six existing discriminant formulas.

RESULTS

The RF model was chosen as the discriminant algorithm, namely TT@MHA. TT@MHA was tested in an interlaboratory cohort with a sensitivity, specificity, accuracy, and AUC of 91.91%, 91.00%, 91.53%, and 0.942, respectively. A webpage tool of TT@MHA (https://dxonline.deepwise.com/prediction/index.html?baseUrl=%2Fapi%2F&id=26408&topicName=undefined&from=share&platformType=wisdom) was developed to facilitate the healthcare providers in rural areas.

CONCLUSION

The ML-based TT@MHA algorithm, with high sensitivity and specificity, could help discriminate TT patients from MHA patients, especially in populations with high proportions of α-TT patients and TT&IDA patients. Moreover, a user-friendly webpage tool for TT@MHA could facilitate healthcare providers in rural areas where advanced technologies are not accessible.

Ferric carboxymaltose for anemia in Crohn’s disease patients at a tertiary center: A retrospective observational cohort study

BACKGROUND

Although the gastrointestinal tract is the most affected by Crohn’s disease (CD), the condition triggers other consequent manifestations, and iron deficiency anemia (IDA) is one of the most common. Intravenous (IV) iron replacement is currently available through several drugs, such as ferric hydroxide sucrose and ferric carboxymaltose (FCM). However, the clinical management of these conditions can be challenging.

AIM

To elucidate the drug’s effectiveness, the present study analyzed, through medical records, the clinical and epidemiological data of a cohort of patients with active CD who received IV FCM for the IDA treatment.

METHODS

This retrospective observational study included 25 patients with active CD, severe anemia, and refractory to previous conventional treatments. Patients were evaluated two times: During the last treatment with ferric hydroxide sucrose and treatment with FCM.

RESULTS

After treatment with FCM, parameters of IDA assessment significantly improved, serum hemoglobin (Hb) levels increased in 93% of patients (P < 0.0001), and in 44%, there was an increase of ≥ 2 g/dL in a single application. In addition, 86% of the patients showed an increase in serum iron (P < 0.0001) and ferritin (P = 0.0008) and 50% in transferrin saturation (P = 0.01). The serum iron levels at baseline showed a negative association with the ileal and colonic CD and use of biologics and a positive association with patients who developed CD later in life after the age of 40 (A3) and with a stenosing (B2) and fistulizing (B3) phenotype. The values of Hb and hematocrit after ferric hydroxide sucrose treatment remained similar to those found before treatment.

CONCLUSION

This study demonstrated that FCM is an important therapeutic strategy for treating IDA in CD patients, achieving satisfactory results in refractory cases.

Successful management of cerebral venous sinus thrombosis due to adenomyosis: Case reports and literature review

OBJECTIVES

Cerebral venous sinus thrombosis (CVST) due to adenomyosis, though rare, threaten women with severe morbidity. Adenomyosis is easily overlooked in the etiological assessment of CVST. Etiological under-recognization has considerable prognostic, and therapeutic implications. The current study reports two cases of successful management of cerebral venous sinus thrombosis due to adenomyosis.

MATERIALS AND METHODS

We present two young women with cerebral venous sinus thrombosis due to adenomyosis. We additionally review the literature to identify previously reported cases of stroke associated with adenomyosis.

RESULTS

Except for this report, a total of 25 cases of stroke related to adenomyosis have been reported in the literature, of which only three cases are related to CVST. Through their diagnosis and treatment, we believe that early diagnosis and treatment are important for these patients with long-term illnesses. In addition, through literature review, for female stroke patients with heavy menstruation combined with anemia or carbohydrate antigen (CA) 125 elevation, the existence of adenomyosis should be vigilant and the etiological treatment should be timely targeted.

CONCLUSION

Our cases illustrate the significance of the etiological identification of CVST for women with adenomyosis and serve to increase clinicians' awareness of this disabling, but sometimes treatable, condition. In CVST due to adenomyosis associated with iron deficiency anemia and/or high serum CA125 level, antithrombotic therapy and treatment for the anemia may improve the hypercoagulable state. The long-term monitoring of D-dimer levels is required.

An active new formulation of iron carried by aspartyl casein for iron-deficiency anemia: results of the ACCESS trial

Oral iron supplementation is the cornerstone for the management of iron-deficiency anemia. A new oral formulation of iron conjugated with N-aspartyl-casein (Fe-ASP) (Omalin®, Uni-Pharma) is studied in the ACCESS double-blind, double-dummy randomized clinical trial; 60 patients were randomized to 12-week oral treatment twice every day either with oral ferrous sulfate (FeSO₄) delivering 47 mg elementary iron or oral Fe-ASP delivering 40 mg elementary iron. Participants had hemoglobin less than 10 g/dl, decreased red blood cell (RBC) count, and ferritin lower than 30 ng/ml; patients with a medical history of malignancy were excluded. The primary endpoint was the increase of Hb in the first 4 weeks of treatment, and the study was powered for non-inferiority. A new score of global improvement was introduced where all participants were given one point for any at least 10% increase of Hb, RBC, and reticulocytes. At week 4, the mean (SE) change of Hb was 0.76 g/dl in the FeSO₄ group and 0.83 g/dl in the Fe-ASP group (p: 0.876). The odds for worse allocation of the global score were 0.35 in the Fe-ASP group compared to the FeSO₄ group. Patients in the Fe-ASP group experienced a significant decrease in the number of IDA-related physical signs by week 4. No differences were found between the two groups in any of the patient-reported outcomes of fatigue and of gastrointestinal adverse events either at week 4 or at week 12. ACCESS is the most recent clinical trial showing the non-inferiority of Fe-ASP to FeSO₄ for the primary endpoint of the Hb change.

A randomized controlled trial of thrice-weekly versus thrice-daily oral ferrous fumarate treatment in adult patients with iron-deficiency anemia

Iron deficiency anemia (IDA) is a common health problem in developing countries. Many studies have shown that low-dose oral iron could have similar efficacy and less gastrointestinal effects in iron deficiency without anemia. This prospective open-labeled randomized controlled study was designed to compare the response of 200 mg ferrous fumarate thrice-weekly (TIW) as not inferior to the thrice-daily (TID) regimen and to assess the incidence of adverse events (AEs) between two regimens in treating adult patients with IDA. The primary endpoint was either an increase in Hb ≥ 3 g/dL, having Hb of 12 g/dL in females or 13 g/dL in males at the 12th week of treatment. Secondary outcomes included adverse events (AEs), red blood cell indices, iron profiles, and patient compliance. Sixty-four patients were randomized: 32 in the TIW arm and the other 32 in the TID arm. The response rates were not different between two arms either with intention to treat analysis (72.0%, 95%CI 56.6-88.5 vs. 71.9%, 95%CI 53.3-86.3, p = 0.777); or per-protocol analysis (88.9%, 95%CI 70.8-97.6 vs. 88.5%, 95%CI 69.8-97.6, p = 1.0), respectively. The trial demonstrated non-inferiority at a margin of 23%. Although the iron profile response of the TID arm was earlier than the TIW arm, almost all patients recovered from anemic symptoms at week 4, and hematologic responses were not different at week 12. There were more gastrointestinal AEs in the TID arm. In conclusion, this study showed that the TIW was non-inferior to the TID iron treatment of IDA patients but less AEs and costs.

A systematic literature review and meta-analysis of the incidence of serious or severe hypersensitivity reactions after administration of ferric derisomaltose or ferric carboxymaltose

BACKGROUND

Intravenous iron is the preferred treatment for patients with iron deficiency anemia in a variety of clinical situations. Although uncommon, administration of modern IV iron formulations can result in hypersensitivity reactions (HSRs) and, rarely, anaphylactic or anaphylactoid reactions.

AIM

The objective of the present study was to systematically review the literature to identify and analyze data on the incidence of HSRs after administration of ferric derisomaltose (FDI) or ferric carboxymaltose (FCM).

METHOD

A prospectively-registered systematic literature review was conducted to identify prospective randomized controlled trials comparing FDI and FCM with other intravenous iron formulations or oral iron. Searches were conducted in PubMed (including MEDLINE), EMBASE, and the Cochrane Library in November 2020. The relative incidence of serious or severe HSRs occurring on the day or day after dosing of intravenous iron, recorded under the standardized Medical Dictionary for Regulatory Activities query for anaphylactic reaction.

RESULTS

Data were obtained from seven randomized controlled trials of FCM (N = 2683) and ten of FDI (N = 3474) enrolling 10,467 patients in total. The number of patients experiencing any serious or severe HSR event was 29/2683 (1.08%) with FCM versus 5/3474 with FDI (0.14%). Bayesian inference of proportions showed the event rates to be significantly lower with FDI relative to FCM.

CONCLUSION

HSR events were uncommon with both intravenous iron formulations; however, the present study showed a significantly lower incidence of HSRs with FDI relative to FCM. Further large-scale, head-to-head trials of the iron formulations would be required to confirm this finding.

Tobacco smoking-related risk for iron deficiency anemia: A case-control study

BACKGROUND

Globally, iron deficiency anemia (IDA) is a significant public health problem. Tobacco smoking as a risk factor for anemia is often ignored.

AIMS

To study the tobacco smoking-associated risk for IDA.

This study was conducted in a tertiary care hospital in Dehradun, India from January 2019 to December 2020. One hundred ten patients having IDA (serum ferritin < 15 mcg/l) and an equal number of controls were randomly selected and assessed regarding their tobacco smoking status and type, quantity, and duration of tobacco used.

RESULTS

Seventy-six (69.1%) patients with IDA were tobacco smokers and were predominantly males (51cases, 67.1%) and beedi smokers (52 cases, 68.4%). The odds ratios (ORs) for the association of smoking tobacco (cigarette and beedi collectively), cigarette, and beedi with IDA were 7.60 (p < 0.0001), 2.79 (p = 0.01), and 5.68 (p < 0.0001), respectively. OR for developing IDA was more among light smokers (OR = 7.72, p < 0.0001) and increased with duration of smoking (p < 0.0001). IDA was not significantly associated with confounding risk factors like malnutrition (OR = 1.00, p = 1.00), low socioeconomic status (OR = 0.64, p = 0.21), dietary habits (OR = 1.43, p = 0.45), and place of residence (OR = 0.93, p = 0.88).

CONCLUSIONS

Tobacco smoking has a strong association with IDA. Both beedi smoking and cigarette smoking have a significant association with IDA. The risk of IDA is more among light smokers and is duration-dependent.

Causal association between iron deficiency anemia and chronic obstructive pulmonary disease: A bidirectional two-sample Mendelian randomization study

BACKGROUND

Observational studies have found an association between iron deficiency anemia (IDA) and chronic obstructive pulmonary disease (COPD) risk. However, whether IDA plays a role in COPD development remains unclear.

OBJECTIVES

This study was performed to explore the causal association between IDA and COPD.

METHODS

We obtained summary statistics for IDA from 6087 cases and 211,115 controls of European ancestry in an open genome-wide association study (GWAS) to select strongly associated single nucleotide polymorphisms that could serve as instrumental variables for IDA (P < 5 × 10-8). Additional summary statistics for COPD were obtained from 6915 COPD cases and 186,723 controls of European ancestry from a publicly available GWAS. A bidirectional Mendelian randomization analysis was performed using inverse variance weighting as the primary method of analysis. The reliability of the results was verified by heterogeneity and sensitivity analysis.

RESULTS

IDA increased the risk of COPD, with an odds ratio (OR) of 1.15 (95% confidence interval (CI: 1.04-1.25, p = 0.002). There was no evidence of a causal effect of COPD on IDA risk, with an OR of 0.99 (95% CI: 0.87-1.13, p = 0.91). The sensitivity analysis showed no evidence of heterogeneity or horizontal pleiotropy.

CONCLUSIONS

We found that IDA increases the risk of COPD. Additionally, there was no evidence that COPD increases the risk of IDA. Therefore, IDA should be considered in future COPD risk studies and reintroduced as a potential therapeutic target. The relationship between COPD and IDA risk requires further study using indirect mechanisms.

Effects of chronic Helicobacter pylori strain PMSS1 infection on whole brain and gastric iron homeostasis in male INS-GAS mice

Iron deficiency, the most common micronutrient deficiency in humans, is associated with long-term deficits in cognition and memory if left untreated. Infection with the gastric pathogen Helicobacter pylori has been linked to iron deficiency anemia (IDA). The H. pylori virulence factor cytotoxin-associated gene A (cagA) is proposed to be especially pertinent in iron deficiency. Male INS-GAS/FVB mice were infected with the CagA⁺ strain pre-murine Sydney strain 1 (PMSS1) for 12-13 or 27-29 weeks to investigate the role of chronic H. pylori infection in iron deficiency and neurological sequelae. Mice at both timepoints demonstrated significantly elevated gastric histopathology scores and inflammatory cytokines compared to sham-dosed controls. However, only mice at 27-29 weeks post infection had changes in hematological parameters, with significantly decreased erythrocyte count, hematocrit, serum hemoglobin, and increased serum total iron binding capacity. Gastric transcription of iron-regulatory genes Hamp and Bmp4 were significantly downregulated at both timepoints. In the brain, iron-dependent myelingergic and synaptic markers were significantly downregulated at 27-29 weeks. These results indicated that long-term infection of the CagA ⁺ PMSS1 strain of H. pylori in this study caused anemia, altered gastric iron homeostasis, and neurological changes similar to those reported in other rodent H. pylori CagA^- strain infection models.

Impact of maternal iron deficiency anemia on fetal iron status and placental iron transporters in human pregnancy

Iron deficiency anemia is associated with maternal morbidity and poor pregnancy outcomes. Heme and non-heme iron transport proteins expressed in the placenta help in adequate iron supply from anemic mother to fetus. Here we examined the expression of placental iron trafficking molecules and their association with maternal and neonatal iron status in pregnant women with iron deficiency anemia (IDA). Pregnant women who received prenatal care at Christian Medical College, Vellore, India for childbirth were recruited. Pregnant women who were 18-35 years old with gestational age (GA) of ≥36 weeks were eligible to participate in the study. In a prospective cohort of pregnant women, 22 % were iron deficiency anemia and 42 % were iron replete. Samples were collected (Maternal blood, placental tissue, and cord blood) from pregnant women with a gestational age of ≥38 weeks at the time of delivery. The mean gestational age at the first visit and delivery was 12.8 ± 2.72 weeks and 39 ± 1.65 weeks, respectively. Hemoglobin (9.3 ± 0.9 g/dl) and ferritin (15.4(0.8-28.3) ng/ml) levels at delivery were significantly decreased in IDA as compared to controls. The fetal hemoglobin and ferritin levels were in the normal range in both groups. There was no correlation between maternal and cord blood hepcidin with fetal iron status in IDA. We further analyzed the expression of iron transport genes in the placenta of controls and the IDA group. Under maternal iron insufficiency, the expression of placental iron transporters DMT1, FPN1, and GDF15 was upregulated at the protein level. In IDA, placental GDF15 and ferroportin protein had an association with fetal iron status. These findings confirm that placental iron traffickers respond to maternal iron deficiency by increasing their expression and allowing sufficient iron to pass to the fetus.

Iron Deficiency Anemia in Colorectal Cancer Patients: Is Preoperative Intravenous Iron Infusion Indicated? A Narrative Review of the Literature

Iron deficiency anemia is the most common extraintestinal symptom in patients with colorectal cancer (CRC). Inflammation associated with malignancy leads to functional iron deficiency via the hepcidin pathway, whereas chronic blood loss causes absolute iron deficiency and depletion of iron stores. The assessment and treatment of preoperative anemia is of great importance in patients with CRC, since published data have consistently shown that preoperative anemia is associated with increased need for perioperative blood transfusions and more postoperative complications. Recent studies have documented mixed results regarding the preoperative intravenous iron administration in anemic CRC patients in terms of efficacy for anemia correction, cost-effectiveness, need for transfusions and risk for postoperative complications.

New logarithm-based discrimination formula for differentiating thalassemia trait from iron deficiency anemia in pregnancy

BACKGROUND

Thalassemia trait (TT) and iron deficiency anemia (IDA) are the most common conditions of microcytic hypochromic anemia (MHA) in pregnant women. Accurate discrimination between TT and IDA is an important issue, and better methods are urgently needed. Although considerable RBC formulas and indices have been developed since 1973, distinguishing between IDA and TT is still a challenging problem due to the diversity of various anemic populations. To address this problem, we assessed the diagnostic function of 43 different differential formulas in patients with microcytic anemia by using accuracy measures and recommending a new log-based differential formula.

METHODS

The data of 430 pregnant women (229 with TT and 201 with IDA) were enrolled, and 44 formula performances were evaluated with receiver operating characteristic (ROC) analysis.

RESULTS

The newly introduced logarithm-based formula XS-1 performs better than the general discriminant index with sensitivity and specificity of 82.10 and 89.05, which are better than other formulas. In the pregnant population, the Shine and Lal and Roth..SVM. formulas have shown excellent performance, while other formulas showed poorer discriminative abilities in our study than in the original authors.

CONCLUSION

The logarithm-based formula XS-1 can be used to screen thalassemia and iron deficiency anemia during the first trimester. Considering the particularity of pregnancy, medical personnel in different regions should choose a screening formula similar to that of the local region and population when identifying thalassemia in pregnancy. Any formula should be independently verified locally before use. For the convenience of the health care team and experimental scientists, a web-based tool has been established at http://yyy.yiyiy.top/XS-1/ by which users can easily get their desired screening test result without going through the underlying mathematical and computational details.