rev bras hematol hemoter. 2017;39(3):191–192
w w w . r b h h . o r g
Revista
Brasileira
de
Hematologia
e
Hemoterapia
Brazilian
Journal
of
Hematology
and
Hemotherapy
Scientific
Comment
Challenges
in
the
diagnosis
of
iron
deficiency
anemia
in
aged
people
夽
Niele
Silva
de
Moraes
a,b,
Maria
Stella
Figueiredo
a,∗aUniversidadeFederaldeSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil
bUniversidadedoEstadodoPará(UEPA),Belém,PA,Brazil
In this issue of the Brazilian Journal of Hematology and
Hemotherapy,Babaeietal.1investigatedthecut-offlevelfor
serumferritinthatwouldbetterdiscriminatebetweenelderly
patientswithandwithoutirondeficiencyanemia(IDA).
IDAisacommonmanifestationamongtheelderly
popula-tion.Ithasoftenbeenassociatedtogastrointestinalbleeding
caused by esophagitis, gastritis, peptic ulcer, cancer, and
intestinalpolyps.2–5Althoughabonemarrowexaminationis
thegoldstandardtesttoassessironstores,itisaninvasive
methodwithnopracticalapplicability.6,7Arecentsystematic
reviewshowedthatallguidelinesrecommendthe
measure-ment ofserum ferritin todiagnose IDA.8 Serumferritin is
consideredafirst-linediagnostictoolnotonlyduetoits
avail-ability,butalsobecauseitsplasmaticlevelsaccuratelyreflect
overall ironstorage,with 1ngofferritin per mLindicating
approximately10mgoftotalironstores.1,9
Whileserumferritinunder10–15ng/mLhas99%of
speci-ficityinthediagnosisofIDA,normalorelevatedferritinlevels
do not exclude IDA, since ferritin is an acute phase
pro-teinandmayincreaseduringinflammation,cancer,andwith
aging.8,10 Hence,somestudies providedata supportingthe
useofhigherferritinthresholdsfordiagnosis,suchas30or
100ng/mL.11,12
Elderlypeopleoftenhavemanymorbiditiessomeofwhich
canpotentiallyleadtoanemia,makingthediagnosisofIDA
particularly challenging in this population.13 Moreover, in
individuals withchronic diseases,anemia ofinflammation
DOIoforiginalarticle:http://dx.doi.org/10.1016/j.bjhh.2017.02.002.
夽
SeepaperbyFlávioAugustoNaoumetal.onpages223–8.
∗ Correspondingauthorat:DisciplinadeHematologiaeHemoterapia,EscolaPaulistadeMedicinadaUniversidadeFederaldeSãoPaulo
(EPM/UNIFESP),RDr.DiogodeFarias,824,04037-002VilaClementino,SãoPaulo,SP,Brazil.
E-mailaddress:[email protected](M.S.Figueiredo).
(AI)canbeassociatedwithanabsoluteirondeficiency,
espe-ciallyincaseswherethereisbleeding.14
Itisrecommendedtoexpandtherepertoireof
biochem-ical markers to differentiate between AI and AI with iron
deficiency (AI+IDA). These markers include red cell
vari-ables(suchashypochromicredcellsandreticulocyte-specific
indicesofvolumeandhemoglobincontent),transferrin
satu-ration,solubletransferrinreceptor(sTfR),andhepcidin.13–17
Amongthe redcell variables,hypochromicred cellsare
used to identify absolute iron deficiency in patients with
chronicrenalfailure,whereasreticulocyte-specificindicesare
usedtoassesstheironstatusofthesecells.8However,the
dif-ficultiesinthediagnosisofAI+IDAusingtheseparameters
remain.14
Transferrinsaturationischeapandavailableinmost
lab-oratories, and isquite suggestive ofIDA when below16%.
However, inflammatory illnesses affect transferrin
satura-tion andconclusionsmaybemisleadingifusedasthesole
marker.8,10,16
sTfRisanindicatorofironstatusandiselevatedinIDA.
It can beuseful inthe diagnosis ofAI+IDA although it is
relatively expensiveandnotwidelyavailable.3,10,18 TheTfR
index,aratiobetweensTfRandlogofferritin,isconsidereda
goodindicatorofIDAinpatientswithchronicdiseases,butit
dependsontheviabilityofthesTfRmeasurement.7,18
Hepcidin,a25amino-acidpeptidediscoveredatthe
begin-ningofthiscentury,isaregulatorofironmetabolism.This
http://dx.doi.org/10.1016/j.bjhh.2017.03.005
1516-8484/©2017Associac¸ ˜aoBrasileiradeHematologia,HemoterapiaeTerapiaCelular.PublishedbyElsevierEditoraLtda.Thisisan
192
rev bras hematol hemoter. 2017;39(3):191–192molecule induces the degradation of ferroportin, a
mem-brane proteinresponsible forirontransport.19,20 Lowlevels
ofhepcidin are seen in IDA anemia, while the opposite is
trueinAI.However,thistestismostoftenusedinresearch
institutions.19–21
ThediagnosisofIDAisnotalwayssimple.Serumferritin
aloneisnolongerrecommendedastheonlydiagnostictestto
assessIDAintheelderly.8,13Furthermore,theother
laborato-rialexamshavelowsensitivityorarenotwidelyavailable.21
Thechallengeremainsandanystudiesthatidentify
parame-tersofvalueduringclinicaldecision-makingarewelcome.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Acknowledgements
This work was supported by research grant from FAPESP
(13/12161-9).
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