iron deficiency vs chronic disease anemia

[arkroyal]

hi everyone

had a quick question, if you have a patient who has a normocytic anemia with an iron panel of low serum iron, TIBC that is low-normal, and low iron saturation (like 7%) and normal ferritin level, would you consider this AoCD vs iron deficiency. i guess i'm thrown off by the low iron sat but i would expect a higher TIBC if iron deficient. of note, this particular patient has a history of chronic pancreatitis and no liver history that I know of.

thanks

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[jdh71]

Hard to make the case for iron deficiency with a normal ferritin and normal albeit a bit low TIBC

 

[gutonc]

Assuming you've ruled out other things like rare nutritional deficiencies (copper is one that is often overlooked) and primary bone marrow pathology like MDS then...

ACD...The End.

 

[jdh71]

and primary bone marrow pathology like MDS then...

This is how you pay for your boat, isn't it?

 

[surge55]

...that's anemia of chronic disease by definition. it has a bajillion causes, but that's not iron deficiency, unless you want to argue that it's a small combination. some people have both but have mainly an anemia of chronic inflammation (the new title for it) picture.

 

[jdh71]

Had a real motivated 4th year sub-I during my last year of residency. Man this kid was all over the place. He's always wanting to work up the anemia is the gomer population on my service and I'm always telling him to find something else to do. And one day he just kind of blows up at me in the righteous indignation that only 4th years with their lack of experience and still remaining optimism and hope for life and medicine can bring to any conversation and pretty much tells me he thinks I'm a bad doctor because I'm letting all these patients go undiagnosed. I fugure, hey, this kid has ballz and this is a teachable moment. So I tell him that he can order any anemia lab on any patient he is currently seeing with me going forward. After a week of working up anemias, I could see the defeated look in his eyes, and a bit of grudging respect for his senior resident. I asked him what was up, what did he find out and he says to me . . . "chronic disease. they are ALL anemia of chronic disease, but you already knew that didn't you??" He seemed a bit impressed, and I just said, "My friend, this is america, and not getting enough iron isn't our problem. Our problem is sick old gomers. Good luck in the match."

 

[gutonc]

This is how you pay for your boat, isn't it?

You have no idea...or perhaps you do.

I marrow everybody with a heme issue. It's like being a cardiologist...I rarely get a clinically relevant result but I always get mad RVUs.

 

[jdh71]

You have no idea...or perhaps you do.

I marrow everybody with a heme issue. It's like being a cardiologist...I rarely get a clinically relevant result but I always get mad RVUs.

You got hustle son!

In 7 months I plan to bronch EVERYONE (because you never know)

 

[arkroyal]

...that's anemia of chronic disease by definition. it has a bajillion causes, but that's not iron deficiency, unless you want to argue that it's a small combination. some people have both but have mainly an anemia of chronic inflammation (the new title for it) picture.

you says it ACD by definition b/c the ferritin is not low and TIBC isn't high? what if the patient comes in to the hospital for something and we think the ferritin is not low b/c of phase reactant

 

[NewYorkDoctors]

Had a real motivated 4th year sub-I during my last year of residency. Man this kid was all over the place. He's always wanting to work up the anemia is the gomer population on my service and I'm always telling him to find something else to do. And one day he just kind of blows up at me in the righteous indignation that only 4th years with their lack of experience and still remaining optimism and hope for life and medicine can bring to any conversation and pretty much tells me he thinks I'm a bad doctor because I'm letting all these patients go undiagnosed. I fugure, hey, this kid has ballz and this is a teachable moment. So I tell him that he can order any anemia lab on any patient he is currently seeing with me going forward. After a week of working up anemias, I could see the defeated look in his eyes, and a bit of grudging respect for his senior resident. I asked him what was up, what did he find out and he says to me . . . "chronic disease. they are ALL anemia of chronic disease, but you already knew that didn't you??" He seemed a bit impressed, and I just said, "My friend, this is america, and not getting enough iron isn't our problem. Our problem is sick old gomers. Good luck in the match."

I convinced a 4th year Sub I (who wanted to ultimately do GI) to do all of the fecal disimpactions because it would give him a useful skill that will look good on his resume.

He took it with great enthusiasm. Little did he know, I had already ordered tap water enemas for the patient so his job was mainly to clean up what remained.

 

[HelpPleaseMD]

I convinced a 4th year Sub I (who wanted to ultimately do GI) to do all of the fecal disimpactions because it would give him a useful skill that will look good on his resume.

He took it with great enthusiasm. Little did he know, I had already ordered tap water enemas for the patient so his job was mainly to clean up what remained.

.

 

[jdh71]

.

Agreed. My comment was NOT a hate on 4th years comment it was that I think you NEED TO HAVE A REASON to work up anemia in the american patient population.

For instance, I saw a 30 y/o male who is telling me he has a history of mild hemoptysis. The problem is out usual hemoptysis work-up just isn't panning out any details, but I noticed he was anemic, not profoundly so, but a Hgb of 11.7 in a 30 y/o male without any other issues is odd, and when my work-up showed iron deficiency, it made his story that much more believable. He ultimately ended up getting an open lung biospy and diagnosed with a smoldering vasculitis which is currently being treated.

 

[Instatewaiter]

Agreed. My comment was NOT a hate on 4th years comment it was that I think you NEED TO HAVE A REASON to work up anemia in the american patient population.

For instance, I saw a 30 y/o male who is telling me he has a history of mild hemoptysis. The problem is out usual hemoptysis work-up just isn't panning out any details, but I noticed he was anemic, not profoundly so, but a Hgb of 11.7 in a 30 y/o male without any other issues is odd, and when my work-up showed iron deficiency, it made his story that much more believable. He ultimately ended up getting an open lung biospy and diagnosed with a smoldering vasculitis which is currently being treated.

Was this the same guy with a small PFO?

 

[jdh71]

Was this the same guy with a small PFO?

Yup. PFO was NOT his problem. I knew it wasn't but when you're a fellow and the attending gives you marching orders.

 

[Instatewaiter]

Yup. PFO was NOT his problem. I knew it wasn't but when you're a fellow and the attending gives you marching orders.

I know that feeling.

 

[Gastrapathy]

Can't make a normal ferritin as an acute phase reactant when truly iron deficient. That said, he probably needs an egd, colonoscopy and capsule. Get that ms4 back here to do the 2 hr review of systems I'm going to need to extract an indication.


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[Ivancica]

Hi.

Please, could you be so kind and explain me this issue?

I have read that the tibc and iron have high values in case of hepatitis but low values in case of liver cirrhosis. Could you please explain me why?

And what about ferritin in that cases?

Thank you very much in advance!

 

[Instatewaiter]

So to put a fly in the ointment, in heart failure there is a good amt of literature of people with low iron, low percent sat but normalish ferritin (<100) who have BMBx-verified iron deficiency anemia... sooooo normal ferritin isn't the end-all-be-all.