Question on anemia

[marly]

---

Members don't see this ad.

Does anyone know if high ferritin levels are used to differentiate between Iron deficiency anemia vs anemia of CD.

I used to believe only when ferritin is below 20 it confirms iron deficiency anemia, I was just told that Ferritin above 100 will rule out iron deficieny anemia.

thanks.

 

[ChildNeuro]

Does anyone know if high ferritin levels are used to differentiate between Iron deficiency anemia vs anemia of CD.

I used to believe only when ferritin is below 20 it confirms iron deficiency anemia, I was just told that Ferritin above 100 will rule out iron deficieny anemia.

thanks.

Ferritin is also an acute phase reactant, so a high ferritin does not necessarily rule out an iron deficiency anemia, a low ferritin would lead you down the road of iron deficiency anemia. I would look at other clinical info, i.e. bowel resection? i.e. did patient lose duodenum, look at a smear the RBCs should by microcytic and hypochromic, and you would expect the reticulocyte count to be low. Also, look at nutrition, is the patient malnourished? Also, is this a female patient who might have heavy menstrual periods i.e. blood loss, or perhaps an elderly patient who is recovering from colon CA and was chronically losing alot of blood? Look also at TIBC, and other causes of anemia i.e. anemia of chronic disease . . .

 

[marly]

He had microcytic, hypochromic anemia which can be found both in iron deficiency and in anemia of CD. However, the TIBC was also low ( not typical for iron deficiency 😕 ; serum iron low, iron sat low.

Regarding ferritin being an acute reactant, the information I got was that if it iron deficiency anemia is present with chronic inflamation then it will still be below 100 😕 😕

 

[ChildNeuro]

He had microcytic, hypochromic anemia which can be found both in iron deficiency and in anemia of CD. However, the TIBC was also low ( not typical for iron deficiency 😕 ; serum iron low, iron sat low.

Regarding ferritin being an acute reactant, the information I got was that if it iron deficiency anemia is present with chronic inflamation then it will still be below 100 😕 😕

OK, so TIBC should be high in a patient who has soley iron deficiency, because the body is producing more transferrin to bind iron to bring it to where it is needed. In anemia of chronic disease (or anemia of chronic inflammation as it is becoming known), the TIBC is low/normal in anemia of chronic disease. I have heard it mentioned by more than one attending that if the ferritin is high, the patient could still have iron-deficiency anemia, because ferritin is an acute phase reactant cells are releasing excess ferritin in response to inflammation, i.e. a patient with appendicitis. So, you get a C-reactive protein, which is also an acute phase reactant, then if this is normal, then you can conclude that your high ferritin rules out iron deficiency anemia. You need to look at the whole set of lab values as no one lab value rules out iron deficiency anemia. A patient who has a disease severe enough to get anemia of chronic disease, may as well have iron deficiency anemia. Low serum iron levels are not very helpful, as they can occur in infection, bacteria like to eat iron, and part of telogical explanation of ACD includes decreases serum iron so that bacteria can't grow as well, obviously this can work against a patient with chronic inflammation. Iron saturation can be low in iron deficiency and ACD.

Bottom-Line: A low ferritin is more helpful (iron deficiency), a normal/high ferritin doesn't tell you a whole lot, maybe iron deficient, maybe not, and you may need to order more tests i.e. CRP, TIBC, look at the whole picture of what is going on with your patient.

 

[marly]

Never heard of this theory, but makes sense..

 

[souljah1]

If a Pt is iron deficient, why would their cells have a lot of ferritin to release in the setting of inflammation? Ferritin is the body's iron storage. If you are iron deficient, you don't have storage. If you don't have storage, you don't have the ability to hold on to your storage and sequester it from bacteria. A high ferritin is indicative a "high body total iron", which doesn't make a whole lot of sense in iron deficiency. You can't take a ferritin of less than 20, mix it with a chronic inflammatory state, and make a ferritin of 300. You can sometimes see a NORMAL ferritin with iron deficiency, but will rarely ever see a high ferritin. The current thinking suggests that if you add an inflammatory process to someone with iron deficiency you can see up to a tripling in their serum ferritin. This is mainly mediated by interleukins and TNF-like agents and speaks to the teleological explanation you mentioned above.

 

[QuinnB]

I've seen very elevated ferritin in patients with BM biopsy confirmed iron deficiency anemia. I've also seen it in patient's with colon cancer and hematocrit of 25 from chronic bleeding (another iron deficiency anemia). It is well established that ferritin is an acute phase reactant, even in the context of iron deficiency anemia.

I've also seen normal values for ferritin in iron deficiency. I think a previous poster was correct in that a ferritin of 15-20 is very helpful in diagnosing iron deficiency anemia - otherwise I don't really make too much of it.

TIBC is frequently difficult to use, especially in nutritionally depleted patients (cancer, end stage organ disease, etc...).

Generally I use a combination of total iron, MCV, RDW, thalassemia index and TIBC +/- ferritin. Ultimately there is not too much harm in prescribing iron supplementation and evaluating for resolution of the anemia over time (probably the most practical choice as an outpatient).

 

[core0]

He had microcytic, hypochromic anemia which can be found both in iron deficiency and in anemia of CD. However, the TIBC was also low ( not typical for iron deficiency 😕 ; serum iron low, iron sat low.

Regarding ferritin being an acute reactant, the information I got was that if it iron deficiency anemia is present with chronic inflamation then it will still be below 100 😕 😕

Nope we see Ferritins in the 1000's in patients with anemia and low TIBC. This is seen in the setting of liver injury (usually Tylenol).

David Carpenter, PA-C

 

[core0]

I've seen very elevated ferritin in patients with BM biopsy confirmed iron deficiency anemia. I've also seen it in patient's with colon cancer and hematocrit of 25 from chronic bleeding (another iron deficiency anemia). It is well established that ferritin is an acute phase reactant, even in the context of iron deficiency anemia.

I've also seen normal values for ferritin in iron deficiency. I think a previous poster was correct in that a ferritin of 15-20 is very helpful in diagnosing iron deficiency anemia - otherwise I don't really make too much of it.

TIBC is frequently difficult to use, especially in nutritionally depleted patients (cancer, end stage organ disease, etc...).

Generally I use a combination of total iron, MCV, RDW, thalassemia index and TIBC +/- ferritin. Ultimately there is not too much harm in prescribing iron supplementation and evaluating for resolution of the anemia over time (probably the most practical choice as an outpatient).

The other issue is the low ferritin and older individual = think colon cancer:
http://www.amjgastro.com/showConten...9B-56BA2F2EE688&id=ajg_90812007&type=abstract
For those who don't have red journal access this is a pretty good review of the article:
http://www.labtestsonline.org/news/ferritin070413.html

David Carpenter, PA-C

 

[carrigallen]

You can sometimes see a NORMAL ferritin with iron deficiency, but will rarely ever see a high ferritin. The current thinking suggests that if you add an inflammatory process to someone with iron deficiency you can see up to a tripling in their serum ferritin.

Yep. This is my understanding as well, especially the 3x. That said, I think there have been entire review articles written on this subject.

The key distinction I have been taught is the difference between iron deficiency anemia and an iron deficiency state. You can have a BM Bx that stains for inadequate iron stores, this does NOT automatically mean the patient has iron deficiency anemia.