Железодефицитные новости

[Dr.Vad]

Обзор рекомендаций по диагностике и лечению ЖД:

A literature search was conducted in PubMed, Cochrane, and EMBASE and in main professional association websites, limited to documents published between 1 January 2004 and 30 June 2014.

RESULTS: Of 127 guidelines identified, 29 were selected, involving 29 professional associations and issued from the United States (n = 8), Europe (n = 6), Britain (n = 4), Canada (n = 3), international organizations (n = 2), France (n = 2), Poland (n = 1), Australia (n = 1), Mexico (n = 1), and Japan (n = 1). A total of 22 and 27 guidelines provided recommendations on diagnosis and treatment of ID, respectively. To define ID, all guidelines recommended a concentration for serum ferritin. One-half of them (10 of 22) proposed transferrin saturation (TSAT) as an alternative or complementary diagnostic test. To treat ID, most of the guidelines (18 of 27) recommended preferentially the oral route if possible, particularly in children and in women in the pre- or postpregnancy period. Iron supplementation should be administered intravenously according to 13 of 27 guidelines, particularly in patients with chronic kidney disease (CKD) (n = 7) and chemotherapy-induced anemia (n = 5). Treatment targets for ID included an increase in hemoglobin concentrations to 10-12 g/dL or normalization (n = 8) and serum ferritin >100 μg/L (n = 7) or 200 μg/L (n = 4). For the latter, in some situations, such as CKD, ferritin concentrations should not exceed 500 μg/L (n = 5) or 800 μg/L (n = 5). Only 9 guidelines recommended TSAT as a target, proposing various thresholds ranging from 20% to 50%.

CONCLUSIONS: It appears that for the diagnosis of ID, a cutoff of 100 μg/L for serum ferritin concentration should be considered in most conditions and 20% for TSAT, except in particular situations, including young healthy women with heavy menstrual flow. New indications of intravenous iron supplementation are emerging.

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Peyrin-Biroulet L и соавт. Guidelines on the diagnosis and treatment of iron deficiency across indications: a systematic review. Am J Clin Nutr. 2015 Nov 11

[Dr.Vad]

Послеродовая депрессия снижается на фоне назначения препаратов железа, у тех, у кого она сохранялась, цифры ферритина на фоне приема железа были ниже (плохое усвоение, плохой комплайенс?):

This randomized, double-blind, placebo-controlled trial evaluated 70 mothers with PPD. One week after delivery, the mothers were randomly allocated in the iron-treated (50 mg elemental iron/daily) and placebo-treated groups. After 6 weeks, the improvement of PPD symptoms was compared between the groups.
Ferritin significantly increased in the iron-treated group (p < 0.001), but not in the placebo group (p = 0.09). After intervention, ferritin was higher in the iron-treated group (medians: 78.2 vs. 37 mg/dl, p = 0.01). The rate of iron deficiency significantly decreased in the iron-treated group (p = 0.009), but not in the placebo group (p = 0.4). After intervention, the rate of iron deficiency was higher in the placebo group (31.4 vs. 8.5 %, p = 0.01). The Edinburgh Postnatal Depression Scale (EPDS) score significantly decreased in the iron-treated group (p < 0.001), but not in the placebo group (p = 0.13). After intervention, the EPDS score was lower in the iron-treated group (medians 9 vs. 12, p = 0.01). The improvement rate for PPD was significantly higher in the iron-treated group (42.8 vs. 20 %, p = 0.03). After intervention, mothers with continued PPD had lower ferritin than the improved mothers (41.8 vs. 67 mg/dl, p = 0.03). Mothers with continued depression had higher rate of iron deficiency compared to the improved mothers (27.1 vs. 4.5 %, p = 0.02).
[Ссылки доступны только зарегистрированным пользователям ]

[Dr.Vad]

Интересное чтиво в октрытом доступе:

The reproductive ecology of iron in women [Ссылки доступны только зарегистрированным пользователям ]

фрагмент, который вызвал особенный интерес раздел - железо и способность к зачатию IRON AND FECUNDITY: вначале публикация о том, как у 7 женщин с выпадением волос и ферритином ниже 40 на фоне коррекции дефицита железа и повышением ферритина "вдруг" случилась беременность - интересно, что 3 из них лечились/собирались лечиться/ от бесплодия, а у 4-х других беременность длительно не наступала несмотря на регулярный цикл и интенсивную половую жизнь без предохранения; затем результаты длительного 8 летнего наблюдения за 18.5 тыс женщин, у котпрых постоянный прием железа ассоциировался с более низким риском бесплодия, по сравнению с теми, кто не принимал...

[Dr.Vad]

Еще одна работа, на этот раз из Индии, указывающая что ЖД анемия может быть ассоциирована с выраженным кариесом у детей 2-6 лет:

children with severe early childhood caries (S-ECC) were more likely to have iron deficiency anemia (IDA) odds ratio (95% confidence interval): 10.77 (2.0, 104.9), (P = 0.001). In addition to this, S-ECC children were significantly more likely to have low Hb, MCV, and PCV levels (P < 0.001) which imply that S-ECC may be a risk marker for the development of anemia. More children (93%) with severe caries were found to have less body weight than ICMR standard weight for age as compared to children with low caries (P < 0.05%).
[Ссылки доступны только зарегистрированным пользователям ]

[Dr.Vad]

Дефицит железа как новый фактор риска редицива ТГВ:

ID was observed in 47 patients (21%). In a multivariate regression model, the presence of ID was associated with female sex, elevated C-reactive protein (CRP), anemia and reduced hemoglobin levels (all P <0.05). In a multivariate model, the presence of ID (or low serum ferritin levels) and elevated CRP levels, but not anemia, predicted VTE recurrence during 24 months. The hazard ratio adjusted for CRP and the presence of anemia was 3.17 for ID (95% confidence interval [CI], 1.20–8.38; P = 0.02) and 0.64 for serum ferritin levels (95% CI, 0.43–0.94; P = 0.02).

Iron deficiency: a novel risk factor of recurrence in patients after unprovoked venous thromboembolism
[Ссылки доступны только зарегистрированным пользователям ]

[Dr.Vad]

Почти у половины пациентов с ЖДА имеется и сопутствуюшее снижение/дефицит цинка (менее 0.99 мкг/мл), у таких пациентов более выражены умственные проблемы, со стороны серд. сосудистой системы, проявления синдрома беспокойных ног и др. симптомы:

Serum zinc levels were lower in anemic patients (103.51 ± 34.64 μg/dL) than in the control subjects (256.92 ± 88.54 μg/dL; <0.001). Patients with zinc level <99 μg/dL had significantly more frequent mental manifestations (p < 0.001), cardiopulmonary symptoms (p = 0.004), restless leg syndrome (p = 0.016), and epithelial manifestations (p < 0.001) than patients with zinc level > 100 μg/dL. When the serum zinc level was compared with pica, no statistically significant correlation was found (p = 0.742). Zinc is a trace element that functions in several processes in the body, and zinc deficiency aggravates IDA symptoms.
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Serum zinc levels in patients with iron deficiency anemia and its association with symptoms of iron deficiency anemia.//Ann Hematol. 2016 Mar 2.

[Dr.Vad]

Переносимость различных пероральных препаратов железа:

For this review 111 studies were included, with data on 10,695 patients. Ferrous sulfate with mucoproteose had the lowest incidence of AEs (4.1% for overall AEs, 3.7% for gastrointestinal AEs [GAEs]) and was used as the reference supplement in the regression model. Incidence rates of overall AEs for the other supplements were 7.3% for iron protein succinylate [GAEs: 7%; OR for AE compared to the reference supplement, 1.96], 23.5% for ferrous glycine sulfate [GAEs: 18.5%; OR: 5.90], 30.9% for ferrous gluconate [GAEs: 29.9%; OR: 11.06], 32.3% for ferrous sulfate without mucoproteose [GAEs: 30.2%; OR: 11.21], and 47.0% for ferrous fumarate [GAEs: 43.4%; OR: 19.87].
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Curr Med Res Opin. 2013 Apr;29(4):291-303.
Tolerability of different oral iron supplements: a systematic review.
Cancelo-Hidalgo MJ, и соавторы

[Dr.Vad]

Кокэйновский обзор по приему железа у менструирующих женщин:

We included 67 trials (from 76 reports), recruiting 8506 women; the number of women included in analyses varied greatly between outcomes, with endpoint haemoglobin concentration being the outcome with the largest number of participants analysed (6861 women). Only 10 studies were considered at low overall risk of bias, with most studies presenting insufficient details about trial quality.Women receiving iron were significantly less likely to be anaemic at the end of intervention compared to women receiving control (risk ratio (RR) 0.39 (95% confidence interval (CI) 0.25 to 0.60, 10 studies, 3273 women, moderate quality evidence). Women receiving iron had a higher haemoglobin concentration at the end of intervention compared to women receiving control (mean difference (MD) 5.30, 95% CI 4.14 to 6.45, 51 studies, 6861 women, high quality evidence). Women receiving iron had a reduced risk of iron deficiency compared to women receiving control (RR 0.62, 95% CI 0.50 to 0.76, 7 studies, 1088 women, moderate quality evidence). Only one study specifically reported iron-deficiency anaemia and no studies reported mortality. Seven trials recruiting 901 women reported on 'any side effect' and did not identify an overall increased prevalence of side effects from iron supplements (RR 2.14, 95% CI 0.94 to 4.86, low quality evidence). Five studies recruiting 521 women identified an increased prevalence of gastrointestinal side effects in women taking iron (RR 1.99, 95% CI 1.26 to 3.12, low quality evidence). Eight studies recruiting 1036 women identified an increased prevalence of hard stools/constipation (RR 2.07, 95% CI 1.35 to 3.17, high quality evidence); six studies recruiting 604 women identified an increased prevalence of loose stool (RR 2.13, 95% CI 1.10, 4.11, high quality evidence). Seven studies recruiting 1190 women identified evidence of an increased prevalence of abdominal pain among women randomised to iron (RR 1.55, 95% CI 0.99 to 2.41, low quality evidence). Eight studies recruiting 1214 women did not find any evidence of an increased prevalence of nausea among women randomised to iron (RR 1.19, 95% CI 0.78 to 1.82). Evidence that iron supplementation improves cognitive performance in women is uncertain, as studies could not be meta-analysed and individual studies reported conflicting results. Iron supplementation improved maximal and submaximal exercise performance, and appears to reduce symptomatic fatigue.

[Ссылки доступны только зарегистрированным пользователям ]

[Dr.Vad]

У женщин с ЖДА очень часто (почти всегда - менее 70 мг/дл у 90%) сопутствует и дефицит цинка согласно недавней публикации из Турции:
Turk J Haematol. 2016 Jun 5;33(2):156-158.
Serum Zinc Levels in Iron Deficient Women: A Case-Control Study.
[Ссылки доступны только зарегистрированным пользователям ]

[Dr.Vad]

A strong body of evidence demonstrates altered metabolism of iron and other metals modifies emotional behaviors. Conversely, people with psychological disorders appear to have reduced iron status; for example, serum iron levels are lower in schizophrenics than in controls [135]. Subjects with major depression have lower hematocrit and serum transferrin [136]. Interestingly, these patients also display lower zinc levels [137]. Moreover, the amount of selenium in the diet is inversely associated with reports of anxiety, depression, and tiredness, which are improved by selenium supplementation [113]. These findings suggest a possibility that individuals with mood symptoms may have insufficient vitamins and minerals [113] and therefore may need more micronutrient supplementation than healthy subjects [138].
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Iron and Mechanisms of Emotional Behavior. [Ссылки доступны только зарегистрированным пользователям ]

[Dr.Vad]

У девочек-подростков с обильными месячными очень часто имеется железодефицит, у половины из них ферритин менее 20, причем только у четверти анемия или микроцитоз, избыточный вес или ожирение было трехкратным фактором риска наличия ЖД у таких детей:

114 young women ages 9-19 years consecutively referred to a Young Women's Hematology Clinic with a complaint of heavy menstrual bleeding; 58 (50.9%) patients had ferritin <20 ng/mL indicating iron deficiency. Of the fifty-eight patients with iron deficiency, only 24 (41.4%) were anemic and 25 (46.3%) were microcytic... Patients had significantly higher odds of having iron deficiency if they were overweight or obese [2.81, 95% CI: (1.25, 6.29)] when compared with patients with normal BMI.

Iron Deficiency without Anemia: a Common yet Under-Recognized Diagnosis in Young Women with Heavy Menstrual Bleeding.
J Pediatr Adolesc Gynecol. 2016 Jun 1

[Dr.Vad]

Интересное наблюдение за молодыми мужчинами с ЖД без анемии из Израиля - за полтора года ЖДА развилась только в 10% случаев, а причина ЖД была установлена у менее 2%:

The study population included 2061 young men (mean age 20.7±1.8). During follow-up of 3150 person years, significant GI pathologies were diagnosed in 39 patients: inflammatory bowel disease in 25 (1.2%), celiac disease in 8 (0.4%), and peptic disease in 4 (0.1%). No cases of GI-related cancer were diagnosed. ID anemia developed during follow-up in 203 (9.8%). Lower baseline hemoglobin levels, lower ferritin levels, and younger age at diagnosis were more common among those who developed anemia. The development of anemia was a predisposing factor for the diagnosis of GI pathology (risk ratio=3.60, 95% confidence interval 1.34-8.32, P=0.012).

[Ссылки доступны только зарегистрированным пользователям ]

[Dr.Vad]

В полтора раза возрастает обнаружение железодефицита у дошкольников, если уровень ферритина оценивается вкупе с Ц-реактивным белком (где ЖД - ферритин менее 50, если ЦРБ более 5) по сравнению с просто сниженным ферритином менее 15, похожие цифры обнаружения ЖД можно увидеть, если определять рецепторы к трансферрину с децизионной цифрой более 1.95:

Using Soluble Transferrin Receptor and Taking Inflammation into Account When Defining Serum Ferritin Cutoffs Improved the Diagnosis of Iron Deficiency in a Group of Canadian Preschool Inuit Children from Nunavik [Ссылки доступны только зарегистрированным пользователям ]

[Dr.Vad]

Hypersensitivity reactions to intravenous iron: guidance for risk minimization and management
[Ссылки доступны только зарегистрированным пользователям ]

[Dr.Vad]

Публикация от турецких врачей показала, что выявление и коррекция железодефицита у детей с цианотичными пороками сердца приводит к увеличению гематокрита и гемоглобина, но общая вязкость крови даже несколько снижается, сатурация крови кислорода повышается и жалобы на головные боли, зрительную нечеткость и др. снижались:

A total of 39 patients with cyanotic congenital heart disease including 20 (51%) females, 19 (49%) males and whose mean age was 9.9 ± 6.2 years, average weight was 33 ± 18.4 kg were evaluated. Patients were categorized into two groups as having iron deficiency and no iron deficiency with respect to their ferritin levels. 4 mg/kg/day iron treatment with two valences was applied to the groups with iron deficiency for 3 months. Clinical and laboratory findings of both groups were assessed at the outset and 3 months later and viscosity measurements were carried out.

Iron deficiency was identified in 21 (53.8%) out of 39 patients. Average Hb and Hct values following 3-month iron treatment increased from 14.8 ± 2.4 g/dl to 16.0 ± 2.0 (P = 0.003) and from %45.8 ± 7.5 to %47.6 ± 7.2 (P = 0.052), respectively. Average viscosity value, however, was 5.6 ± 1.0 cP, it reduced to 5.5 ± 1.0 cP value by demonstrating very little reduction (P = 0.741). Nevertheless, O2 sat value increased from 71.7 to 75% and complaints such as headache, visual blurriness, having frequent sinusitis decreased.

Terlemez S и соавт. The effects of iron treatment on viscosity in children with cyanotic congenital heart disease. Hematology. 2016 Jul 19:1-6.