Iron deficiency Pasricha, Sant-Rayn; Tye-Din, Jason; Muckenthaler, Martina U ...
The Lancet (British edition),
01/2021, Letnik:
397, Številka:
10270
Journal Article
Recenzirano
Iron deficiency is one of the leading contributors to the global burden of disease, and particularly affects children, premenopausal women, and people in low-income and middle-income countries. ...Anaemia is one of many consequences of iron deficiency, and clinical and functional impairments can occur in the absence of anaemia. Iron deprivation from erythroblasts and other tissues occurs when total body stores of iron are low or when inflammation causes withholding of iron from the plasma, particularly through the action of hepcidin, the main regulator of systemic iron homoeostasis. Oral iron therapy is the first line of treatment in most cases. Hepcidin upregulation by oral iron supplementation limits the absorption efficiency of high-dose oral iron supplementation, and of oral iron during inflammation. Modern parenteral iron formulations have substantially altered iron treatment and enable rapid, safe total-dose iron replacement. An underlying cause should be sought in all patients presenting with iron deficiency: screening for coeliac disease should be considered routinely, and endoscopic investigation to exclude bleeding gastrointestinal lesions is warranted in men and postmenopausal women presenting with iron deficiency anaemia. Iron supplementation programmes in low-income countries comprise part of the solution to meeting WHO Global Nutrition Targets.
Accurate and affordable tools for diagnosing anemia and its main determinants are essential for understanding the magnitude and distribution of the problem and the appropriate interventions needed ...for its timely prevention and treatment. The objective of this review is to address methods, equipment, and sample‐related and quality control aspects of hemoglobin measurement for anemia diagnosis. Also, other iron‐, infectious‐, and genetic‐related causes of anemia are addressed in individuals and populations. The best practice for hemoglobin determination is the use of venous blood, analyzed on automated hematology analyzers, with high‐quality control measures in place. The importance of a correct anemia diagnosis is highlighted by the cost of a misdiagnosis. A false‐negative diagnosis may result in missing out and not treating anemia, its causes, and its adverse effects. On the other hand, a false‐positive diagnosis may result in the provision of unneeded treatment or referral for expensive laboratory tests to determine a cause of anemia, wasting valuable resources and risking causing harm. At the individual level, clinicians must understand the causes of absolute and functional anemia to diagnose and treat anemia at the clinical level. Actions toward anemia diagnosis and control at public health levels require global, regional, and country actions that should cover general and context‐specific characteristics.
Anemia is an important public health problem that negatively affects health of individuals and economic potential of populations. An accurate case definition is critical for understanding burden and ...epidemiology of anemia, for planning public health interventions, and for clinical investigation and treatment of patients. The current threshold hemoglobin concentrations for diagnosis of anemia were proposed in 1968 and based on studies predominantly of Caucasian adult populations in Europe and North America. The World Health Organization is undertaking a project to review global guidelines for anemia. We describe the process of obtaining input from technical experts, researchers, blood bank experts, policy makers, and program implementers to identify key information or knowledge gaps for anemia diagnosis. From this scoping exercise, six priority areas were identified on diverse topics related to the use and interpretation of hemoglobin concentrations to diagnose anemia in individuals and populations. A call for authors was conducted to produce background, review, and research papers across priority topics. This paper summarizes the first technical meeting, which included commissioned papers as well as case studies, describes key data gaps identified, and describes the next steps in the guideline development process to assess available evidence and define knowledge gaps to improve anemia characterization.
Iron deficiency, pregnancy, and neonatal development Ataide, Ricardo; Fielding, Katherine; Pasricha, Sant‐Rayn ...
International journal of gynecology and obstetrics,
August 2023, 2023-Aug, 2023-08-00, 20230801, Letnik:
162, Številka:
S2
Journal Article
Recenzirano
Odprti dostop
Anemia affects 36% of pregnant women worldwide. Of those affected, around 40% is due to iron deficiency (ID). Iron is an essential micronutrient involved in vital processes such as erythropoiesis, ...immune responses, and importantly—during pregnancy—placental and fetal development. Although menstrual bleeding can impact the incidence of ID even before the onset of pregnancy, this narrative review is pregnancy focused and will explore the impact of ID on placental development and iron uptake, fetal development and immunity, and maternal and infant susceptibility to infection. Although there have been advances in this area of research, much is needed to understand the regulation of iron and the effects of ID during pregnancy. Notably, more human studies are essential to generate the best evidence to advance strategies to reduce the incidence of ID during pregnancy to improve maternal, neonatal, and infant health.
Synopsis
Good‐quality studies of human maternal iron deficiency are needed to understand its impact on placental and fetal growth/development and maternal and infant susceptibility to infection.
Stay-at-home orders (lockdowns) have been deployed globally to control COVID-19 transmission, and might impair economic conditions and mental health, and exacerbate risk of food insecurity and ...intimate partner violence. The effect of lockdowns in low-income and middle-income countries must be understood to ensure safe deployment of these interventions in less affluent settings. We aimed to determine the immediate impact of COVID-19 lockdown orders on women and their families in rural Bangladesh.
An interrupted time series was used to compare data collected from families in Rupganj upazila, rural Bangladesh (randomly selected from participants in a randomised controlled trial), on income, food security, and mental health a median of 1 year and 2 years before the COVID-19 pandemic to data collected during the lockdown. We also assessed women's experiences of intimate partner violence during the pandemic.
Between May 19 and June 18, 2020, we randomly selected and invited the mothers of 3016 children to participate in the study, 2424 of whom provided consent. 2414 (99·9%, 95% CI 99·6–99·9) of 2417 mothers were aware of, and adhering to, the stay-at-home advice. 2321 (96·0%, 95·2–96·7) of 2417 mothers reported a reduction in paid work for the family. Median monthly family income fell from US$212 at baseline to $59 during lockdown, and the proportion of families earning less than $1·90 per day rose from five (0·2%, 0·0–0·5) of 2422 to 992 (47·3%, 45·2–49·5) of 2096 (p<0·0001 comparing baseline with lockdown period). Before the pandemic, 136 (5·6%, 4·7–6·6) of 2420 and 65 (2·7%, 2·1–3·4) of 2420 families experienced moderate and severe food insecurity, respectively. This increased to 881 (36·5%, 34·5–38·4) of 2417 and 371 (15·3%, 13·9–16·8) of 2417 during the lockdown; the number of families experiencing any level of food insecurity increased by 51·7% (48·1–55·4; p<0·0001). Mothers' depression and anxiety symptoms increased during the lockdown. Among women experiencing emotional or moderate physical violence, over half reported it had increased since the lockdown.
COVID-19 lockdowns present significant economic, psychosocial, and physical risks to the wellbeing of women and their families across economic strata in rural Bangladesh. Beyond supporting only the most socioeconomically deprived, support is needed for all affected families.
National Health and Medical Research Council, Australia.
Despite worldwide economic and scientific development, more than a quarter of the world's population remains anemic, and about half of this burden is a result of iron deficiency anemia (IDA). IDA is ...most prevalent among preschool children and women. Among women, iron supplementation improves physical and cognitive performance, work productivity, and well-being, and iron during pregnancy improves maternal, neonatal, infant, and even long-term child outcomes. Among children, iron may improve cognitive, psychomotor, and physical development, but the evidence for this is more limited. Strategies to control IDA include daily and intermittent iron supplementation, home fortification with micronutrient powders, fortification of staple foods and condiments, and activities to improve food security and dietary diversity. The safety of routine iron supplementation in settings where infectious diseases, particularly malaria, are endemic remains uncertain. The World Health Organization is revising global guidelines for controlling IDA. Implementation of anemia control programs in developing countries requires careful baseline epidemiologic evaluation, selection of appropriate interventions that suit the population, and ongoing monitoring to ensure safety and effectiveness. This review provides an overview and an approach for the implementation of public health interventions for controlling IDA in low- and middle-income countries, with an emphasis on current evidence-based recommendations.
Use of the Ganzoni formula would generally have resulted in higher dosing (eg, up to 1500 mg, given over two doses).2 We recognise this concern but emphasise that the trial was specifically designed ...to test a pragmatic single-dose intravenous strategy of iron replacement in a resource-constrained setting; treatment with a second dose would require spacing by 7 days, adding complexity to the implementation of a health programme and adding further costs for drugs and infusion. The results of our trial indicate that the single dose was successful in reducing the prevalence of iron deficiency at 36 weeks’ gestation from approximately 42% in the standard-of-care group to 18% in the intervention group (a prevalence ratio of 0·4).1 Whether further doses of iron to reduce the residual iron deficiency in the active group are warranted would depend on an analysis of the efficacy as well as the feasibility and cost of this approach. S-RP reports grants to his institution from the Australian National Health and Medical Research Council and the Bill & Melinda Gates Foundation, providing salary and research support.
Determination of iron status in pregnancy and in young children is essential for both clinical and public health practice. Clinical diagnosis of iron deficiency (ID) through sampling of bone marrow ...to identify the absence of body iron stores is impractical in most cases. Serum ferritin (SF) concentrations are the most commonly deployed indicator for determining ID, and low SF concentrations reflect a state of iron depletion. However, there is considerable variation in SF cutoffs recommended by different expert groups to diagnose ID. Moreover, the cutoffs used in different clinical laboratories are heterogeneous. There are few studies of diagnostic test accuracy to establish the sensitivity and specificity of SF compared with key gold standards (such as absent bone marrow iron stores, increased intestinal iron absorption, and hemoglobin response to SF) among noninflamed, outpatient populations. The limited data available suggest the commonly recommended SF cutoff of <15 μg/L is a specific but not sensitive cutoff, although evidence is limited. Data from women during pregnancy or from young children are especially uncommon. Most data are from studies conducted >30 y ago, do not reflect ethnic or geographic diversity, and were performed in an era for which laboratory methods no longer reflect present practice. Future studies to define the appropriate SF cutoffs are urgently needed and would also provide an opportunity to compare this indicator with other established and emerging iron indexes. In addition, future work would benefit from a focus on elucidating cutoffs and indexes relevant to iron adequacy.
In settings with high infection burdens, iron interventions for anaemia may be neither safe nor effective. Strategies to tackle the global burden of anaemia must take this into account, argue ...Sant-Rayn Pasricha and colleagues
Decreased hepcidin mobilizes iron, which facilitates erythropoiesis, but excess iron is pathogenic in β-thalassemia. Erythropoietin (EPO) enhances erythroferrone (ERFE) synthesis by erythroblasts, ...and ERFE suppresses hepatic hepcidin production through an unknown mechanism. The BMP/SMAD pathway in the liver is critical for hepcidin control, and we show that EPO suppressed hepcidin and other BMP target genes in vivo in a partially ERFE-dependent manner. Furthermore, recombinant ERFE suppressed the hepatic BMP/SMAD pathway independently of changes in serum and liver iron. In vitro, ERFE decreased SMAD1, SMAD5, and SMAD8 phosphorylation and inhibited expression of BMP target genes. ERFE specifically abrogated the induction of hepcidin by BMP5, BMP6, and BMP7 but had little or no effect on hepcidin induction by BMP2, BMP4, BMP9, or activin B. A neutralizing anti-ERFE antibody prevented ERFE from inhibiting hepcidin induction by BMP5, BMP6, and BMP7. Cell-free homogeneous time-resolved fluorescence assays showed that BMP5, BMP6, and BMP7 competed with anti-ERFE for binding to ERFE. We conclude that ERFE suppresses hepcidin by inhibiting hepatic BMP/SMAD signaling via preferentially impairing an evolutionarily closely related BMP subgroup of BMP5, BMP6, and BMP7. ERFE can act as a natural ligand trap generated by stimulated erythropoiesis to regulate the availability of iron.
•ERFE suppresses BMP/SMAD signaling in vitro and in vivo.•ERFE inhibits hepcidin induction by BMP5, BMP6, and BMP7.
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