Causes of anemia
- Microcytic:
- Nutritional deficiencies- Iron, copper or zinc
- Anemia of chronic inflammation
- Hemaglobinopathy - thalassemias
- Sideroblastic anemias
- Normocytic:
- Acute GI bleeding
- Hemolytic - Hypersplenism, infection, trauma, G6PD, sickle cell, spherocytosis
- Chronic renal insufficiency
-
Macrocytic:
-
Liver disease
-
Drug related - sulfasalazine, methotrexate, 6-mercaptopurine
-
B12 deficiency
-
Folate deficiency
-
Hypothyroidism
-
Alcoholism
-
Myelodysplastic syndromes
-
Clark SF. Iron deficiency anemia. Nutr Clin Pract. 2008 Apr-May;23(2:128-41. doi: 10.1177/0884533608314536. Review. PubMed PMID: 18390780.
Namjoshi SS, Muradian S, Bechtold H, Reyen L, Venick RS, Marcus EA, Vargas JH,Wozniak LJ. Nutrition Deficiencies in Children With Intestinal Failure Receiving Chronic Parenteral Nutrition. JPEN J Parenter Enteral Nutr. 2017 Feb 1:148607117690528. doi: 10.1177/0148607117690528. [Epub ahead of print] PubMed PMID: 29187063.
Young B, Zaritsky J. Hepcidin for clinicians. Clin J Am Soc Nephrol. 2009 Aug;4(8):1384-7. doi: 10.2215/CJN.02190309. Epub 2009 Jun 2. Review. PubMed PMID: 19556376.
Weiss. Anemia of Chronic Disease. N Engl J Med 2005; 352:1011-1023
Social Media
From Home Parenteral Nutrition Program at Boston Children's Hospital on October 24, 2016
"Oral iron supplements are commonly prescribed for HPN families. Temporary tooth staining common. To prevent tooth discoloration, place iron drops on tongue or take liquid in fruit/tomato juice via straw. Easily removed w/ tooth brushing after meds. Thanks to BCH HPN mom for sharing this photo."
Packed Red Blood Cells
- Each 1 ml of packed red blood contains elemental iron 1 mg.
- Often patients remain iron deficient after receiving a single blood transfusion, so iron supplementation is indicated.
Wintrobe, MM, Greer, JP (2009). Wintrobe's clinical hematology. Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 871.
Intravenous iron therapy
|
|
Ferric Gluconate |
Iron Sucrose |
Iron Dextran |
Ferumoxytol |
|
Concentration per vial |
62.5 mg/5 mL |
100 mg/5 mL |
100 mg/2 mL |
510 mg/17 mL |
|
Compatible with Parenteral Nutrition |
No |
No |
Yes |
No |
|
# of doses for 1000 mg replacement (FDA approved) |
8 |
5 |
10 |
2 |
|
# of doses for 1000 mg replacement (reported) |
4 |
2-3 |
1 |
2 |
|
FDA approved in pediatrics |
Age >6 |
>2 years |
Weight > 5 kg |
No |
|
Test dose required |
No |
No |
Yes |
No |
*None of available IV iron products are compatible w/ IV lipids. Iron dextran may be added to PN non-lipid bag.
Social Media
From Home Parenteral Nutrition Program at Boston Children's Hospital on September 4, 2015
"Iron dextran is the only kind of IV form of iron that can be added into your PN bag safely. It will make the bag turn a brownish color after it is added. Iron dextran should ONLY be added to a clear 2-in-1 bag (NOT a 3-in-1 bag with lipids). It's not compatible with Omegaven."
Other IV iron products approved in adults:
- Ferric carboxymaltose (Injectafer)
- Ferumoxytol (Feraheme)
With test dose of IV iron, monitor for the following side-effects:
- Anaphylaxis
- Skin rash
- Hives
- Chills
- Headache
- Hypotension
- Tachycardia
Repletion dosing of Intravenous Iron therapy
Iron Dextran Repletion Dosing Calculator
Total replacement dosage for iron deficiency anemia is calculated as follows:
0.0442 x LBW (kg) x (Hbn - Hbo) + [0.26 x LBW (kg)] = _____ mL x 50 mg/mL = ______mg
LBW = lean body weight, For patients weighing 5 to 15 kg, use actual body weight
Hbn = desired hemoglobin (g/dL) = 12 if 15 kg
Hbo = measured hemoglobin (g/dL)
Burns DL, Mascioli EA, Bistrian BR. Parenteral iron dextran therapy: a review. Nutrition. 1995 Mar-Apr;11(2):163-8. Review. PubMed PMID: 7647482.
Okam MM, Mandell E, Hevelone N, Wentz R, Ross A, Abel GA. Comparative rates of adverse events with different formulations of intravenous iron. Am J Hematol. 2012 Nov;87(11):E123-4. doi: 10.1002/ajh.23322. Epub 2012 Sep 11. PubMed PMID: 22965928.
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Maintenance dosing of Intravenous Iron therapy
- Typical dose: 0.5-1 mg/kg/week IV
- Maintenance dose depends the following factors:
- Dietary iron intake and anticipated absorption
- Body weight
- Blood loss -- venipuncture, GI blood loss, menses,
- Recommendation: Good history, guaiac stools, monitor labs closely, be ready to titrate dose
Hwa YL, Rashtak S, Kelly DG, Murray JA. Iron Deficiency in Long-Term Parenteral Nutrition Therapy. JPEN J Parenter Enteral Nutr. 2016 Aug;40(6):869-76. doi: 10.1177/0148607115587329. Epub 2015 May 13. PubMed PMID: 25972429.
Khaodhiar L, Keane-Ellison M, Tawa NE, Thibault A, Burke PA, Bistrian BR. Iron deficiency anemia in patients receiving home total parenteral nutrition. JPEN J Parenter Enteral Nutr. 2002 Mar-Apr;26(2):114-9. PubMed PMID: 11871735.
Monitoring of Intravenous Iron therapy
- Check CBC with reticulocyte count monthly.
- Check transferrin saturation monthly.
- Check liver panel monthly.
- Consider liver biopsy for iron content.
- Consider MRI of liver, pancreas and heart for iron overload
Ben Hariz M, Goulet O, De Potter S, Girot R, Rambaud C, Colomb V, Corriol O, Ricour C. Iron overload in children receiving prolonged parenteral nutrition. J Pediatr. 1993 Aug;123(2):238-41. PubMed PMID: 8345419.
Hernando D, Levin YS, Sirlin CB, Reeder SB. Quantification of liver iron with MRI: state of the art and remaining challenges. J Magn Reson Imaging. 2014 Nov;40(5):1003-21. doi: 10.1002/jmri.24584. Epub 2014 Mar 3. Review. PubMed PMID: 24585403; PubMed Central PMCID: PMC4308740.
Pfeiffer CM, Looker AC. Laboratory methodologies for indicators of iron status: strengths, limitations, and analytical challenges. Am J Clin Nutr. 2017 Dec;106(Suppl 6):1606S-1614S. doi: 10.3945/ajcn.117.155887. Epub 2017 Oct 25. Review. PubMed PMID: 29070545; PubMed Central PMCID: PMC5701713.