Renal anemia mkb 10. Iron deficiency, chronic and hemolytic anemia
Anemia - this is the discrepancy between the proportion of hemoglobin in human blood and the criteria adopted by the World Health Organization for a specific age and gender. The term "anemia" is not a diagnosis of a disease, but only indicates abnormal changes in the blood test.
Code by international classification diseases ICD-10: iron deficiency anemia - D50.
The most common are anemia due to blood loss and iron deficiency anemia:
- Anemia due to blood loss can be caused by prolonged periods, bleeding in the digestive tract, and urinary tract, injuries, operations, oncological diseases.
- Iron-deficiency anemia formed as a result of a deficiency in the production of red blood cells
Causes and factors
Among the factors that increase the risk of developing anemia, doctors identify:
- insufficient intake of iron, vitamins and minerals;
- poor nutrition;
- loss of blood due to injury or surgery;
- kidney disease;
- diabetes;
- rheumatoid arthritis;
- HIV AIDS;
- inflammatory bowel disease (including Crohn's disease);
- liver disease;
- heart failure;
- diseases thyroid gland;
- anemia after an illness caused by an infection.
It is a misconception that anemia occurs only after an illness.
There are many more reasons:
Degrees and types of anemia
- lungs- the amount of hemoglobin is 90 g / l and above;
- average severity - hemoglobin 70-90 g / l;
- heavy anemia - hemoglobin below 70 g / l, while the norm for women is 120-140 g / l, for men - 130-160 g / l.
- Anemia due to iron deficiency... Women during pregnancy, menstruation and lactation need several times more iron than usual. Therefore, iron deficiency anemia often occurs during this period.
Likewise the baby body requires a lot of iron. This anemia can be treated with iron tablets or syrups. - Megaloblastic anemia occurs as a result of a deficiency of thyroid hormones, liver disease and tuberculosis. This type of anemia is caused by a lack of vitamin B12 and folic acid. Early diagnosis and treatment is very important for patients with megaloblastic anemia.
Weakness, tiredness, numbness of the hands, pain and burning of the tongue, shortness of breath are common complaints of this type of disease. - Chronic infectious anemia occurs due to a lack of bone marrow, with tuberculosis, leukemia and as a result of taking certain medications that contain toxic substances.
- Mediterranean anemia (a disease also known as thalassemia) is hereditary disease blood. The high incidence of this type is observed in Italians and Greeks. Initially, the symptoms are the same as for anemia due to iron deficiency.
As the disease progresses jaundice is observed, anemia is added as a result of kidney disease and spleen growth. Thalassemia is treated with blood transfusions. - Sickle cell anemia it is too hereditary disease in which the structure of hemoglobin in the blood differs from normal values. The erythrocyte takes the shape of a crescent, its life time is very short. This type is observed in representatives of the black race. The gene for this anemia is carried by women.
- Aplastic anemia it is a disruption in the production of red blood cells in the bone marrow. Vapors of harmful substances such as benzene, arsenic, radiation exposure can be the reason. The level of blood platelet cells also decreases.
The opposite of aplastic anemia is polycythemia., during which the usual number of red blood cells increases more than 2 times. The patient's skin turns red and an increase in blood pressure may be observed. The reason for this is lack of oxygen. This disease is treated by removing blood from the human body.
Who can get anemia?
Anemia is a disease that affects all age groups and races.
- Some children in the first year of life are at risk of anemia due to iron deficiency. These are premature births and children who were fed breast milk with a lack of iron. These babies develop anemia within the first 6 months.
- Children from one to two years of age are prone to developing anemia... Especially if they drink a lot of cow's milk and don't eat food with enough iron. Cow's milk does not contain enough iron for a baby's growth. Instead of milk a baby under 3 years old should be fed foods rich in iron. Cow's milk can also prevent the body from absorbing iron.
- Researchers continue to study how anemia affects adults. More than ten percent of adults are constantly mildly anemic. Most of these people have other medical conditions.
Signs and symptoms
Most frequent symptom anemia is fatigue. People feel tired and exhausted.
Other signs and symptoms of anemia include:
- difficulty breathing;
- dizziness;
- headaches;
- cold feet and palms;
- chest pain.
These symptoms may appear because it has become harder for the heart to pump oxygen-rich blood into the body.
In light and medium anemia (iron deficiency type) symptoms are:
- desire to eat foreign object: earth, ice, limestone, starch;
- cracks in the corners of the mouth;
- irritated tongue.
Signs of folate deficiency:
- diarrhea;
- depression;
- swollen and red tongue;
Symptoms of anemia due to vitamin B12 deficiency:
- tingling and numbness in the upper and lower extremities;
- difficulty in distinguishing between yellow and blue;
- swelling and pain in the larynx;
- weight loss;
- blackening of the skin;
- diarrhea;
- depression;
- decreased intellectual function.
Complications
The doctor, when announcing the diagnosis, must warn of the danger of anemia:
- Patients may experience arrhythmia- a problem with the speed and rhythm of the heart. Arrhythmia can lead to heart damage and heart failure.
- Anemia can also lead to damage to other organs in the body: the blood cannot provide the organs with sufficient oxygen.
- When oncological diseases and HIV / AIDS, the disease can weaken the body, and reduce the result of treatment.
- Increased risk the occurrence of anemia in kidney disease, in patients with heart problems.
- Some types of anemia occur with insufficient fluid intake or excessive water loss in the body. Severe dehydration is the cause of blood disorders.
Diagnostics
The physician must take a family history of the disease to determine whether the disease is inherited or acquired. He can ask the patient about common features anemia, whether he is on a diet.
The physical examination is:
- listening to the heart rate and breathing regularity;
- measuring the size of the spleen;
- the presence of pelvic or rectal bleeding.
- laboratory tests will help determine the type of anemia:
- general blood analysis;
- hemograms.
The hemogram test measures the value of hemoglobin and hematocrit in the blood. Low hemoglobin and low hematocrit are signs of anemia. Normal values \u200b\u200bvary by race and population.
Other tests and procedures:
- Hemoglobin electrophoresis determines the amount of different types of hemoglobin in the blood.
- Measurement of reticulocytes Is a count of young red blood cells in the blood. This test measures the rate of production of red blood cells by the bone marrow.
- Blood Iron Measurement Tests - This is the determination of the level and total content of iron, transmission, binding capacity of blood.
- If the doctor suspects anemia due to blood loss, he can offer an analysis to determine the source of bleeding. He will offer to take a stool test to determine blood in the stool.
If blood is present, endoscopy is necessary: examination of the inside of the digestive system with a small camera. - You may need also bone marrow analysis.
How is anemia treated?
Treatment for anemia depends on the cause, severity, and type of ailment. The goal of treatment is to increase blood oxygen by multiplying red cells and increasing hemoglobin levels.
Hemoglobin is a protein that transports oxygen to the body using iron.
Changes and additions to the diet
Iron
The body needs iron to form hemoglobin. The body absorbs iron more easily from meat than from vegetables and other foods. To treat anemia, eat more meat, especially red meat (beef or liver), as well as chicken, turkey and seafood.
In addition to meat, iron is found in:
Vitamin B12
Low vitamin B12 levels can lead to pernicious anemia.
Sources of vitamin B12 are:
- cereals;
- red meat, liver, poultry, fish;
- eggs and dairy products (milk, yogurt and cheese);
- iron-based soy drinks and vegetarian foods fortified with vitamin B12.
Folic acid
The body needs folic acid to produce new cells and protect them. Folic acid is essential for pregnant women. It protects against anemia and helps the healthy development of the fetus.
Good source food products folic acid are:
- bread, pasta, rice;
- spinach, dark green leafy vegetables;
- dry beans;
- liver;
- eggs;
- bananas, oranges, orange juice and some other fruits and juices.
Vitamin C
It helps the body absorb iron. Fruits and vegetables, especially citrus fruits, are a good source of vitamin C. Fresh and frozen fruits and vegetables contain more vitamin C than canned foods.
Vitamin C is rich in kiwi, strawberries, melons, broccoli, peppers, Brussels sprouts, tomatoes, potatoes, spinach, radishes.
Medication
Your doctor may prescribe medications to treat the underlying cause of anemia and increase the number of red blood cells in your body.
It can be:
- antibiotics to treat infections;
- hormones to prevent excessive menstrual bleeding in young girls and women;
- artificial erythropoietin to stimulate the production of red blood cells.
Operations
If the anemia has developed into a severe stage, surgery may be required: transplantation of stem cells of blood and bone marrow, blood transfusion.
Stem cell transplantation is performed to replace damaged ones in a patient from another healthy donor. Stem cells are found in the bone marrow. The transfer of cells is done through a tube inserted into a vein in the breast. The process is similar to a blood transfusion.
Surgical interventions
For life-threatening bleeding in the body that causes anemia, surgery is necessary.
For example, anemia in gastric ulcer or colon cancer requires surgical intervention to prevent bleeding.
Prevention
Some types of anemia can be prevented by eating iron-rich and vitamins. It is good to take nutritional supplements during a diet.
Important! For women who are fond of losing weight and various diets, taking additional iron supplements and vitamin complexes is a must!
After the main treatment for anemia, you need to keep in touch with your doctor and regularly check the blood count.
If the patient has inherited a malignant type of anemia, treatment and prevention should last for years. You need to be prepared for this.
Anemia in children and youth
Chronic illness, iron deficiency, and poor nutrition can lead to anemia. The disease is often accompanied by other health problems. Thus, the signs and symptoms of anemia are often less obvious.
You should definitely see a doctor if you have symptoms of anemia or if you are on a diet. You may need a blood transfusion or hormone therapy... If anemia is diagnosed in time, it can be completely cured.
Hypochromic anemia is a whole group of blood diseases that are united by a common symptom: a decrease in the value of the color index is less than 0.8. This indicates an insufficient concentration of hemoglobin in the erythrocyte. It plays a key role in the transport of oxygen to all cells, and its lack causes the development of hypoxia and its attendant symptoms.
Classification
Depending on the reason for the decrease in the color index, several types of hypotchromic anemias are distinguished, these are:
- Iron deficiency or hypochromic microcytic anemia is the most common cause of hemoglobin deficiency.
- Iron-saturated anemia, it is also called sideroachrestic. With this type of disease, iron enters the body in sufficient quantities, but due to a violation of its absorption, the concentration of hemoglobin decreases.
- Iron redistribution anemia occurs due to increased breakdown of red blood cells and the accumulation of iron in the form of ferrites. In this form, it is not included in the process of erythropoiesis.
- Anemia of mixed genesis.
According to the generally accepted international classification, hypochromic anemias are referred to as iron deficiency. They were assigned a code according to ICD 10 D.50
Causes
The causes of hypochromic anemia differ depending on the type. So, the factors that contribute to the development of anemia with a lack of iron are:
- Chronic blood loss associated with menstrual bleeding in women, gastric ulcer, rectal lesions with hemorrhoids, etc.
- Increased iron intake, for example, due to pregnancy, lactation, and growth during adolescence.
- Insufficient intake of iron from food.
- Impaired absorption of iron in the gastrointestinal tract due to diseases of the digestive system, surgery for resection of the stomach or intestines.
Iron-rich anemias are uncommon. They can develop under the influence of hereditary congenital pathologies, such as porphyria, and can also be acquired. The reasons for this type of hypochromic anemia can be the intake of certain medications, poisoning with poisons, heavy metals, and alcohol. It should be noted that very often these diseases are referred to as hemolytic diseases blood.
Iron-redistributing anemia is a companion of acute and chronic inflammatory processes, suppurations, abscesses, diseases of a non-infectious nature, for example, tumors.
Diagnosis and determination of the type of anemia
In the study of blood, signs are revealed that are characteristic of most of these diseases - a decrease in the level of hemoglobin, the number of red blood cells. As mentioned above, a decrease in the value of the color index is characteristic of hypochromic anemia.
To determine the treatment regimen, it is necessary to diagnose the type of hypochromic anemia. Additional diagnostic criteria are the following parameters:
- Determination of the level of iron in the blood serum.
- Determination of serum iron binding capacity.
- Measurement of the level of iron-containing protein ferritin.
- It is possible to determine the total level of iron in the body by counting sideroblasts and siderocytes. What it is? These are eritoid cells in the bone marrow that contain iron.
A summary table of these indicators for various types of hypochromic anemia is presented below.
Symptoms
Doctors note that clinical picture the disease depends on the severity of its course. Depending on the concentration of hemoglobin, a mild degree is isolated (the Hb content is in the range of 90 - 110 g / l), hypochromic anemia moderate (the concentration of hemoglobin is 70 - 90 g / l) and severe. As the amount of hemoglobin decreases, the severity of the symptoms increases.
Hypochromic anemia is accompanied by:
- Dizziness, flashing "flies" before the eyes.
- Digestive disorders, which are manifested by constipation, diarrhea or nausea.
- Changes in taste and perception of odors, lack of appetite.
- Dry and peeling skin, painful cracks in the corners of the mouth, on the feet and between the toes.
- Inflammation of the oral mucosa.
- Rapidly developing carious processes.
- Deterioration of the condition of hair and nails.
- The onset of shortness of breath, even with minimal physical activity.
Hypochromic anemia in children is manifested by tearfulness, increased fatigue, and moodiness. Pediatricians say that a severe degree is characterized by a delay in psycho-emotional and physical development. Congenital forms of the disease are detected very quickly and require immediate treatment.
With a small but chronic iron loss, chronic mild hypochromic anemia develops, which is characterized by constant fatigue, lethargy, shortness of breath, decreased performance.
Treatment for iron deficiency anemia
Treatment of any type of hypochromic anemia begins with determining its type and etiology. Timely elimination of the cause of a decrease in hemoglobin concentration plays a key role in successful therapy. Then drugs are prescribed that help restore normal blood counts and alleviate the patient's condition.
For the treatment of iron deficiency anemia, iron preparations are used in the form of syrups, tablets or injections (in case of impaired absorption of iron in the digestive tract). These are ferrum lek, sorbifer durules, maltofer, sorbifer, etc. For adults, the dosage is 200 mg of iron per day, for children it is calculated depending on weight and is 1.5 - 2 mg / kg. To increase the absorption of iron, ascorbic acid is prescribed at a dose of 200 mg for every 30 mg of iron. In severe cases, red blood cell transfusion is indicated, taking into account the blood group and Rh factor. However, this is used only as a last resort.
So, with thalassemia, children are given periodic blood transfusions from an early age, and in severe cases, bone marrow transplants are performed. Often, such forms of the disease are accompanied by an increase in the concentration of iron in the blood, therefore, the appointment of drugs containing this trace element leads to a deterioration in the patient's condition.
Such patients are shown the use of the drug desferal, which helps to remove excess iron from the body. The dosage is calculated based on age and blood counts. Desferal is usually given along with ascorbic acid, which increases its effectiveness.
In general with development modern methods treatment and diagnosis therapy of any form of hypochromic anemia, even hereditary, is quite possible. A person can undergo supportive treatments with certain drugs and lead a completely normal life.
Treatment of IDA includes treatment of the pathology that led to iron deficiency, and the use of iron-containing drugs to restore iron stores in the body. Identifying and correcting pathological conditions that cause iron deficiency are essential elements comprehensive treatment... Routine administration of iron-containing drugs to all patients with IDA is unacceptable, since it is insufficiently effective, expensive and, more importantly, is often accompanied by diagnostic errors (non-detection of neoplasms).
The diet of patients with IDA should include meat products containing iron in the composition of the heme, which is absorbed better than from other foods. It must be remembered that it is impossible to compensate for a pronounced iron deficiency only by prescribing a diet.
Treatment of iron deficiency is carried out mainly with oral iron-containing drugs, parenteral drugs are used if there are special indications. It should be noted that the use of iron-containing oral preparations is effective in most patients, whose body is able to adsorb a sufficient amount of pharmacological iron to correct the deficiency. Currently, a large number of preparations containing iron salts are produced (ferroplex, orferon. Tardiferon). The most convenient and cheapest are preparations containing 200 mg of ferrous sulfate, i.e. 50 mg of elemental iron in one tablet (ferrocal, ferroplex). The usual dose for adults is 1-2 tablets. 3 times a day. An adult patient should receive at least 3 mg of elemental iron per kg of body weight per day, i.e. 200 mg per day. The usual dosage for children is 2-3 mg of elemental iron per kg of body weight per day.
The effectiveness of preparations containing lactate, succinate or ferrous fumarate does not exceed the effectiveness of tablets containing ferrous sulfate or gluconate. The combination of iron salts and vitamins in one preparation, with the exception of the combination of iron and folic acid during pregnancy, as a rule, does not increase the absorption of iron. Although this effect can be achieved with high doses of ascorbic acid, the undesirable effects occurring make the therapeutic use of such a combination impractical. The effectiveness of slow-acting (retard) drugs is usually lower than that of conventional drugs, since they enter the lower intestines, where iron is not absorbed, but it can be higher than that of fast-acting drugs taken with food.
It is not recommended to take a break between taking pills for less than 6 hours, because within a few hours after using the drug enterocytes duodenum refractory to iron absorption. The maximum absorption of iron occurs when taking tablets on an empty stomach, taking it during or after meals reduces it by 50-60%. You should not drink iron preparations with tea or coffee, which inhibit the absorption of iron.
Most of the adverse events when using iron-containing drugs are associated with irritation of the gastrointestinal tract. In this case, adverse events associated with irritation of the lower gastrointestinal tract (moderate constipation, diarrhea) usually do not depend on the dose of the drug, while the severity of irritation upper divisions (nausea, discomfort, pain in the epigastric region) is determined by the dose. Adverse events are less common in children, although the use of iron-containing liquid mixtures for them can lead to temporary darkening of the teeth. To avoid this, you should give the drug to the root of the tongue, drink the medicine with liquid and brush your teeth more often.
In the presence of pronounced adverse events associated with irritation of the upper gastrointestinal tract, you can take the drug after meals or reduce a single dose. If adverse events persist, preparations containing less iron can be prescribed, for example, as part of iron gluconate (37 mg of elemental iron per tablet). If, in this case, the undesirable effects do not stop, then you should switch to slow-acting drugs.
Improvement of patients' well-being usually begins on the 4th-6th day of adequate therapy, on the 10th-11th day the number of reticulocytes increases, on the 16th -18th day the concentration of hemoglobin begins to increase, microcytosis and hypochromia gradually disappear. The average rate of increase in hemoglobin concentration with adequate therapy is 20 g / l over 3 weeks. After 1 -1.5 months successful treatment with iron preparations, their dose can be reduced.
The main reasons for the lack of the expected effect when using iron-containing drugs are presented below. It should be emphasized that the main reason for the ineffectiveness of such treatment is ongoing bleeding, therefore, identifying the source and stopping bleeding is the key to successful therapy.
The main reasons for the ineffectiveness of the treatment of iron deficiency anemia: continuing blood loss; incorrect drug intake:
- misdiagnosis (anemia in chronic diseases, thalassemia, sideroblastic anemia);
- combined deficiency (iron and vitamin B12 or folic acid);
- taking slow-acting preparations containing iron: impaired absorption of iron preparations (rare).
It is important to remember that in order to restore iron stores in the body with a pronounced deficiency of iron, the duration of taking iron-containing drugs should be at least 4-6 months or at least 3 months after the normalization of hemoglobin levels in the peripheral blood. The use of oral iron preparations does not lead to iron overload, since absorption decreases sharply when its reserves are restored.
The prophylactic use of oral iron-containing preparations is indicated during pregnancy, patients receiving continuous hemodialysis, and blood donors. Premature babies are shown the use of nutritional mixtures containing iron salts.
Patients with IDA rarely need use parenteral drugscontaining iron (ferrum-lek, imferon, fercoven and), since they usually respond quickly to treatment with oral drugs. Moreover, even patients with gastrointestinal tract pathology (peptic ulcer disease, enterocolitis, ulcerative colitis) are generally well tolerated by adequate therapy with oral drugs. The main indications for their use are the need to quickly compensate for iron deficiency (significant blood loss, forthcoming surgery, etc.), pronounced side effects of oral medications or impaired iron absorption due to damage small intestine... Parenteral administration of iron preparations may be accompanied by severe adverse events, as well as lead to excessive accumulation of iron in the body. Parenteral iron preparations do not differ from oral preparations in terms of the rate of normalization of hematological parameters, although the rate of recovery of iron stores in the body with the use of parenteral drugs is much higher. In any case, the use of parenteral iron preparations can be recommended only if the doctor is convinced that treatment with oral preparations is ineffective or intolerant.
Iron preparations for parenteral administration are usually administered intravenously or intramuscularly, with the intravenous route of administration being preferred. They contain 20 to 50 mg of elemental iron per ml. The total dose of the drug is calculated by the formula:
Iron dose (mg) \u003d (Hemoglobin deficiency (g / L)) / 1000 (Circulating blood volume) x 3.4.
The circulating blood volume in adults is approximately 7% of body weight. To restore iron stores, 500 mg is usually added to the calculated dose. Before starting therapy, 0.5 ml of the drug is administered to exclude anaphylactic reaction. If there are no signs of anaphylaxis within 1 hour, then the drug is administered so that the total dose is 100 mg. After that, 100 mg is injected daily until the total dose of the drug is reached. All injections are done slowly (1 ml per minute).
An alternative method is the simultaneous intravenous administration of the entire total dose of iron. The drug is dissolved in 0.9% sodium chloride solution so that its concentration is less than 5%. Infusion begins at a rate of 10 drops per minute, in the absence of adverse events within 10 minutes, the rate of administration is increased so that the total duration of the infusion is 4-6 hours.
The most severe side effect parenteral iron preparations is an anaphylactic reaction that can occur both with intravenous and intramuscular injection... Although such reactions are relatively rare, the use of parenteral iron preparations should be carried out only in hospitalsequipped to provide emergency care in full. Other undesirable effects include facial flushing, fever, urticaria, arthralgia and myalgia, phlebitis (if the drug is administered too quickly). Preparations should not come under the skin. The use of parenteral iron preparations can lead to the activation of rheumatoid arthritis.
Erythrocyte transfusions are carried out only in case of severe IDA, accompanied by pronounced signs of circulatory failure, or the forthcoming surgical treatment.
Among the various anemic conditions iron deficiency anemiaare the most common and account for about 80% of all anemias.
Iron-deficiency anemia- hypochromic microcytic anemia, which develops as a result of an absolute decrease in iron stores in the body. Iron deficiency anemia usually occurs with chronic blood loss or insufficient iron intake.
According to the World Health Organization, every third woman and every sixth man in the world (200 million people) suffer from iron deficiency anemia.
Iron exchange
Iron is an irreplaceable biometal that plays an important role in the functioning of cells in many body systems. The biological significance of iron is determined by its ability to be reversibly oxidized and reduced. This property ensures the participation of iron in the processes of tissue respiration. Iron makes up only 0.0065% of body weight. The body of a man weighing 70 kg contains approximately 3.5 g (50 mg / kg of body weight) iron. The iron content in the body of a woman weighing 60 kg is approximately 2.1 g (35 mg / kg body weight). Iron compounds have different structures, have functional activity characteristic only of them, and play an important biological role. The most important iron-containing compounds include: hemoproteins, the structural component of which is heme (hemoglobin, myoglobin, cytochromes, catalase, peroxidase), non-heme group enzymes (succinate dehydrogenase, acetyl-CoA dehydrogenase, xanthine oxidase. Iron is part of complex compounds and is distributed in the body as follows:
- heme iron - 70%;
- iron depot - 18% (intracellular accumulation in the form of ferritin and hemosiderin);
- functioning iron - 12% (myoglobin and enzymes containing iron);
- transported iron - 0.1% (iron associated with transferrin).
There are two types of iron: heme and non-heme. Heme iron is part of hemoglobin. It is contained only in a small part of the diet (meat products), is well absorbed (by 20-30%), other food components practically do not affect its absorption. Non-heme iron is found in free ionic form - ferrous (Fe II) or trivalent iron (Fe III). Most of the dietary iron is non-heme (found mainly in vegetables). The degree of its assimilation is lower than that of heme and depends on a number of factors. Only ferrous non-heme iron is absorbed from food. To "convert" ferric iron into ferrous, a reducing agent is needed, the role of which is played in most cases vitamin C (vitamin C). In the process of absorption in the cells of the intestinal mucosa, ferrous iron Fe2 + turns into oxide Fe3 + and binds to a special carrier protein - transferrin, which transports iron to hematopoietic tissues and places of iron deposition.
The accumulation of iron is carried out by the proteins ferritin and hemosiderin. If necessary, iron can be actively released from ferritin and used for erythropoiesis. Hemosiderin is a ferritin derivative with a higher iron content. Iron is released slowly from hemosiderin. The incipient (pre-latent) iron deficiency can be determined by the reduced concentration of ferritin even before the depletion of iron stores, while the concentration of iron and transferrin in the blood serum is still normal.
What causes iron deficiency anemia:
The main etiopathogenetic factor in the development of iron deficiency anemia is iron deficiency. The most common causes of iron deficiency are:
1.the loss of iron in chronic bleeding (most common reasonreaching 80%):
- bleeding from the gastrointestinal tract: peptic ulcer, erosive gastritis, varicose veins esophageal veins, colon diverticula, hookworm invasions, tumors, NUC, hemorrhoids;
- long and heavy menstruation, endometriosis, fibroids;
- macro- and microhematuria: chronic glomerulo- and pyelonephritis, urolithiasis disease, polycystic kidney disease, kidney and bladder tumors;
- nose, pulmonary bleeding;
- blood loss during hemodialysis;
- uncontrolled donation;
2.insufficient absorption of iron:
- resection of the small intestine;
- chronic enteritis;
- malabsorption syndrome;
- intestinal amyloidosis;
3.increased need for iron:
- intensive growth;
- pregnancy;
- the period of breastfeeding;
- sports activities;
4.insufficient intake of iron from food:
- newborns;
-- Small children;
- vegetarianism.
Pathogenesis (what happens?) During Iron Deficiency Anemia:
Pathogenetically, the development of an iron deficiency state can be conditionally divided into several stages:
1.prelatent iron deficiency (insufficient accumulation) - there is a decrease in the level of ferritin and a decrease in the content of iron in the bone marrow, increased absorption of iron;
2. latent iron deficiency (iron deficiency erythropoiesis) - additionally decreases serum iron, increases the concentration of transferrin, decreases the content of sideroblasts in the bone marrow;
3. Severe iron deficiency \u003d iron deficiency anemia - the concentration of hemoglobin, erythrocytes and hematocrit is further reduced.
Iron deficiency anemia symptoms:
During the period of latent iron deficiency, many subjective complaints and clinical signscharacteristic of iron deficiency anemias. Patients report general weakness, malaise, decreased performance. Already during this period, a perversion of taste, dryness and tingling of the tongue, impaired swallowing with sensation foreign body throat, palpitations, shortness of breath.
An objective examination of patients reveals "minor symptoms of iron deficiency": atrophy of the papillae of the tongue, cheilitis, dry skin and hair, brittle nails, burning and itching of the vulva. All these signs of a violation of the trophism of epithelial tissues are associated with tissue sideropenia and hypoxia.
Patients with iron deficiency anemia note general weakness, rapid fatigue, difficulty concentrating, and sometimes drowsiness. Appear headache, dizziness. Fainting may occur in severe anemia. These complaints, as a rule, depend not on the degree of decrease in hemoglobin, but on the duration of the disease and the age of the patients.
Iron deficiency anemia is also characterized by changes in the skin, nails and hair. The skin is usually pale, sometimes with a slight greenish tinge (chlorosis) and with an easily developing blush on the cheeks, it becomes dry, flabby, flakes, cracks form easily. Hair loses its shine, turns gray, becomes thinner, breaks easily, thinns and turns gray early. Changes in nails are specific: they become thin, dull, flattened, easily exfoliate and break, striation appears. With pronounced changes, the nails acquire a concave, spoon-shaped shape (koilonychia). In patients with iron deficiency anemia, muscle weakness occurs, which is not observed in other types of anemia. It is referred to as a manifestation of tissue sideropenia. Atrophic changes occur in the mucous membranes of the alimentary canal, respiratory organs, and genitals. The defeat of the mucous membrane of the alimentary canal is a typical sign of iron deficiency.
There is a decrease in appetite. There is a need for sour, spicy, salty food. In more severe cases, there are perversions of smell, taste (pica chlorotica): eating chalk, lime, raw cereals, pogophagia (craving for ice). Signs of tissue sideropenia quickly disappear after taking iron supplements.
Diagnostics of the iron deficiency anemia:
The main landmarks in laboratory diagnostics iron deficiency anemiathe following:
1. The average content of hemoglobin in the erythrocyte in picograms (norm 27-35 pg) is reduced. To calculate it, the color index is multiplied by 33.3. For example, with a color index of 0.7 x 33.3, the hemoglobin content is 23.3 pg.
2. The average concentration of hemoglobin in the erythrocyte is reduced; normally it is 31-36 g / dl.
3. Hypochromia of erythrocytes is determined by microscopy of a smear of peripheral blood and is characterized by an increase in the zone of central enlightenment in the erythrocyte; normally, the ratio of central illumination to peripheral darkening is 1: 1; with iron deficiency anemia - 2 + 3: 1.
4. Microcytosis of erythrocytes - a decrease in their size.
5. Coloring of erythrocytes of different intensity - anisochromia; the presence of both hypo- and normochromium erythrocytes.
6. Different form of erythrocytes - poikilocytosis.
7. The number of reticulocytes (in the absence of blood loss and the period of ferrotherapy) with iron deficiency anemia remains normal.
8. The content of leukocytes is also within the normal range (except in cases of blood loss or oncopathology).
9. The platelet count often remains within the normal range; moderate thrombocytosis is possible with blood loss at the time of examination, and the platelet count decreases when iron-deficiency anemia is based on blood loss due to thrombocytopenia (for example, with disseminated intravascular coagulation syndrome, Werlhof's disease).
10. Decrease in the number of siderocytes up to their disappearance (siderocyte is an erythrocyte containing iron granules). In order to standardize the production of peripheral blood smears, it is recommended to use special automatic devices; the resulting monolayer of cells increases the quality of their identification.
Blood chemistry:
1. Decrease in the content of iron in blood serum (normal for men 13-30 μmol / l, for women 12-25 μmol / l).
2. TIBC is increased (reflects the amount of iron that can be associated with free transferrin; TIBC is normal - 30-86 μmol / l).
3. Research of transferrin receptors by enzyme immunoassay; their level is increased in patients with iron deficiency anemia (in patients with anemia chronic diseases - normal or reduced, despite similar indicators of iron metabolism.
4. The latent iron-binding capacity of blood serum is increased (determined by subtracting the content of serum iron).
5. The percentage of transferrin saturation with iron (the ratio of the serum iron index to the TIBS; normally 16-50%) is reduced.
6. The level of serum ferritin is also reduced (normally 15-150 µg / l).
At the same time, in patients with iron deficiency anemia, the number of transferrin receptors is increased and the level of erythropoietin in the blood serum is increased (compensatory reactions of hematopoiesis). The volume of erythropoietin secretion is inversely proportional to the value of the oxygen transport capacity of the blood and is directly proportional to the oxygen demand of the blood. It should be borne in mind that the level of serum iron is higher in the morning; it is higher before and during menstruation than after menstruation. The iron content in the blood serum in the first weeks of pregnancy is higher than in the last trimester. Serum iron levels rise 2-4 days after treatment with iron supplements and then decrease. A significant consumption of meat products on the eve of the study is accompanied by hypersideremia. These data should be considered when evaluating serum iron test results. It is equally important to follow the technique laboratory research, blood sampling rules. So, the test tubes into which the blood is collected must first be washed with hydrochloric acid and bidistilled water.
Myelogram studyreveals a moderate normoblastic reaction and a sharp decrease in the content of sideroblasts (erythrokaryocytes containing iron granules).
Iron reserves in the body are judged by the results of the desferal test. Have healthy person after intravenous administration, 500 mg of desferal is excreted in the urine from 0.8 to 1.2 mg of iron, while in a patient with iron deficiency anemia, the excretion of iron is reduced to 0.2 mg. The new domestic drug defericolixam is identical to desferal, but it circulates in the blood longer and therefore more accurately reflects the level of iron stores in the body.
Taking into account the level of hemoglobin, iron deficiency anemia, like other forms of anemia, is divided into severe, moderate and mild anemia. With mild iron deficiency anemia, the hemoglobin concentration is below normal, but more than 90 g / l; with moderate iron deficiency anemia, the hemoglobin content is less than 90 g / l, but more than 70 g / l; with a severe degree of iron deficiency anemia, the hemoglobin concentration is less than 70 g / l. At the same time, clinical signs of the severity of anemia (symptoms of a hypoxic nature) do not always correspond to the severity of anemia according to laboratory criteria. Therefore, the proposed classification of anemias according to the severity of clinical symptoms.
According to clinical manifestations, 5 degrees of severity of anemia are distinguished:
1. anemia without clinical manifestations;
2. anemic syndrome of moderate severity;
3. severe anemic syndrome;
4. anemic precoma;
5. anemic coma.
Moderate anemia is characterized by general weakness, specific signs (for example, sideropenic or signs of vitamin B12 deficiency); with a pronounced severity of anemia, palpitations, shortness of breath, dizziness, etc. appear. Precomatous and coma can develop in a matter of hours, which is especially characteristic of megaloblastic anemia.
Modern clinical studies show that laboratory and clinical heterogeneity is observed among patients with iron deficiency anemia. So, in some patients with signs of iron deficiency anemia and concomitant inflammatory and infectious diseases the level of serum and erythrocyte ferritin does not decrease, however, after the exacerbation of the underlying disease is eliminated, their content decreases, which indicates the activation of macrophages in the processes of iron consumption. In some patients, the level of erythrocyte ferritin even increases, especially in patients with a long course of iron deficiency anemia, which leads to ineffective erythropoiesis. Sometimes there is an increase in the level of serum iron and erythrocyte ferritin, a decrease in serum transferrin. It is assumed that in these cases, the process of transfer of iron to gemsynthetic cells is impaired. In some cases, a deficiency of iron, vitamin B12 and folic acid is simultaneously determined.
Thus, even the level of serum iron does not always reflect the degree of iron deficiency in the body in the presence of other signs of iron deficiency anemia. Only the level of TIBC in iron deficiency anemia is always elevated. Therefore, not a single biochemical indicator, incl. OZhSS, cannot be considered as absolute diagnostic criterion with iron deficiency anemia. At the same time, the morphological characteristics of peripheral blood erythrocytes and computer analysis of the main parameters of erythrocytes are decisive in the screening diagnosis of iron deficiency anemia.
Diagnosis of iron deficiency is difficult in cases where the hemoglobin content remains normal. Iron deficiency anemia develops in the presence of the same risk factors as in iron deficiency anemia, as well as in persons with an increased physiological need for iron, especially in premature infants. early age, in adolescents with a rapid increase in height and body weight, in blood donors, with alimentary dystrophy. In the first stage of iron deficiency clinical manifestations are absent, and iron deficiency is determined by the content of hemosiderin in the macrophages of the bone marrow and by the absorption of radioactive iron in the gastrointestinal tract. At the second stage (latent iron deficiency), an increase in the concentration of protoporphyrin in erythrocytes is observed, the number of sideroblasts decreases, morphological signs appear (microcytosis, hypochromia of erythrocytes), the average content and concentration of hemoglobin in erythrocytes decreases, the level of serum and erythrocyte ferritin decreases, and transferrin saturation with iron. The hemoglobin level at this stage remains quite high, and the clinical signs are characterized by a decrease in exercise tolerance. The third stage is manifested by obvious clinical and laboratory signs anemia.
Examination of patients with iron deficiency anemia
To exclude anemias that have common features with iron deficiency anemia, and to identify the cause of iron deficiency, complete clinical examination sick:
General blood analysiswith the obligatory determination of the number of platelets, reticulocytes, the study of the morphology of erythrocytes.
Blood chemistry:determination of the level of iron, TIBC, ferritin, bilirubin (bound and free), hemoglobin.
In all cases it is necessary examine bone marrow punctatebefore prescribing vitamin B12 (primarily for differential diagnosis with megaloblastic anemia).
To identify the cause of iron deficiency anemia in women, a preliminary consultation with a gynecologist is required in order to exclude diseases of the uterus and its appendages, and in men, an examination by a proctologist to exclude bleeding hemorrhoids and a urologist to exclude pathology of the prostate gland.
Cases of extragenital endometriosis are known, for example in the respiratory tract. In these cases, hemoptysis is observed; fibrobronchoscopy with histological examination of a biopsy specimen of the bronchial mucosa allows to establish a diagnosis.
The examination plan also includes X-ray and endoscopic examination stomach and intestines in order to exclude ulcers, tumors, incl. glomic, as well as polyps, diverticulum, Crohn's disease, ulcerative colitis, etc. If pulmonary siderosis is suspected, X-ray and tomography of the lungs, sputum examination for alveolar macrophages containing hemosiderin are performed; in rare cases it is necessary histological examination lung biopsy. If kidney pathology is suspected, a general urine test, a blood serum test for urea and creatinine, and ultrasound and x-ray examination kidneys. In some cases, it is necessary to exclude endocrine pathology: myxedema, in which iron deficiency can develop a second time due to damage to the small intestine; polymyalgia rheumatica, a rare condition connective tissue in older women (less often in men), it is characterized by pain in the muscles of the shoulder or pelvic girdle without any objective changes in them, and in the blood test - anemia and an increase in ESR.
Differential diagnosis of iron deficiency anemias
When making a diagnosis of iron deficiency anemia, it is necessary to carry out differential diagnosis with other hypochromic anemias.
Iron-redistributive anemia is a fairly common pathology and in terms of the frequency of development it ranks second among all anemias (after iron deficiency anemia). It develops in acute and chronic infectious and inflammatory diseases, sepsis, tuberculosis, rheumatoid arthritis, liver diseases, oncological diseases, ischemic heart disease, etc. The mechanism of development of hypochromic anemia in these conditions is associated with the redistribution of iron in the body (it is located mainly in the depot) and the violation of the mechanism of iron reutilization from the depot. With the above diseases, the macrophage system is activated, when macrophages, under conditions of activation, firmly hold iron, thereby disrupting the process of its reutilization. IN general analysis blood, there is a moderate decrease in hemoglobin (<80 г/л).
The main differences from iron deficiency anemia are:
- an increased level of serum ferritin, which indicates an increased content of iron in the depot;
- the level of serum iron may remain within the normal range or be moderately reduced;
- TIBC remains within the normal range or decreases, which indicates the absence of Fe-starvation of serum.
Iron-saturated anemias develop as a result of a violation of heme synthesis, which is due to heredity or can be acquired. Heme is formed from protoporphyrin and iron in erythrokaryocytes. With iron-saturated anemia, there is a violation of the activity of enzymes involved in the synthesis of protoporphyrin. The consequence of this is a violation of heme synthesis. Iron, which was not used for the synthesis of heme, is deposited in the form of ferritin in the macrophages of the bone marrow, as well as in the form of hemosiderin in the skin, liver, pancreas, myocardium, as a result of which secondary hemosiderosis develops. In a general blood test, anemia, erythropenia, and a decrease in the color index will be recorded.
The indicators of iron metabolism in the body are characterized by an increase in the concentration of ferritin and the level of serum iron, normal indicators of TIBC, an increase in the saturation of transferrin with iron (in some cases it reaches 100%). Thus, the main biochemical indicators that allow assessing the state of iron metabolism in the body are ferritin, serum iron, TIBC and% saturation of transferrin with iron.
The use of indicators of iron metabolism in the body enables the clinician to:
- to identify the presence and nature of disorders of iron metabolism in the body;
- to identify the presence of iron deficiency in the body at the preclinical stage;
- to carry out differential diagnosis of hypochromic anemias;
- evaluate the effectiveness of the therapy.
Treatment for Iron Deficiency Anemia:
In all cases of iron deficiency anemia, it is necessary to establish the immediate cause of this condition and, if possible, eliminate it (most often, eliminate the source of blood loss or conduct therapy for the underlying disease, complicated by sideropenia).
Treatment of iron deficiency anemia should be pathogenetically grounded, complex and aimed not only at eliminating anemia as a symptom, but also at eliminating iron deficiency and replenishing its reserves in the body.
Iron deficiency anemia treatment program:
- elimination of the cause of iron deficiency anemia;
- medical nutrition;
- ferrotherapy;
- prevention of relapse.
For patients with iron deficiency anemia, a varied diet is recommended, including meat products (veal, liver) and plant products (beans, soy, parsley, peas, spinach, dried apricots, prunes, pomegranates, raisins, rice, buckwheat, bread). However, it is impossible to achieve an anti-anemic effect by diet alone. Even if the patient eats high-calorie foods containing animal protein, iron salts, vitamins, microelements, iron absorption of no more than 3-5 mg per day can be achieved. The use of iron preparations is necessary. Currently, a doctor has at his disposal a large arsenal of iron medications, characterized by different composition and properties, the amount of iron they contain, the presence of additional components that affect the pharmacokinetics of the drug, and various dosage forms.
According to the recommendations developed by WHO, when prescribing iron preparations, preference is given to preparations containing bivalent iron. The daily dose in adults should reach 2 mg / kg of elemental iron. The total duration of treatment is at least three months (sometimes up to 4-6 months). The ideal iron-containing preparation should have a minimum number of side effects, have a simple scheme of use, the best efficiency / price ratio, optimal iron content, preferably the presence of factors that enhance absorption and stimulate hematopoiesis.
Indications for parenteral administration of iron preparations arise with intolerance to all oral preparations, malabsorption (ulcerative colitis, enteritis), gastric ulcer and duodenal ulcer during an exacerbation, with severe anemia and the vital need to quickly replenish iron deficiency. The effectiveness of iron preparations is judged by changes in laboratory parameters over time. By the 5-7th day of treatment, the number of reticulocytes increases by 1.5-2 times compared with the initial data. Starting from the 10th day of therapy, the hemoglobin content increases.
Considering the prooxidant and lysosomotropic effect of iron preparations, their parenteral administration can be combined with intravenous drip administration of rheopolyglucin (400 ml - once a week), which protects the cell and avoids iron overload of macrophages. Considering significant changes in the functional state of the erythrocyte membrane, activation of lipid peroxidation and a decrease in the antioxidant protection of erythrocytes in iron deficiency anemia, it is necessary to introduce antioxidants, membrane stabilizers, cytoprotectors, antihypoxants, such as a-tocopherol up to 100-150 mg per day (or ascorutin, vitamin A, vitamin C, lipostabil, methionine, mildronate, etc.), as well as combine with vitamins B1, B2, B6, B15, lipoic acid. In some cases, it is advisable to use ceruloplasmin.
The list of drugs that are used in the treatment of iron deficiency anemia:
D50- D53- nutritional anemias:
D50 - iron deficiency;
D51 - vitamin B 12 - deficient;
D52 - folate deficiency;
D53 - Other nutritional anemias.
D55- D59- hemolytic anemias:
D55 - associated with enzymatic disorders;
D56 - thalassemia;
D57 - sickle cell;
D58-other hereditary hemolytic anemias;
D59-acute acquired hemolytic.
D60- D64- aplastic and other anemias:
D60 - acquired red cell aplasia (erythroblastopenia);
D61-other aplastic anemias;
D62 - acute aplastic anemia;
D63-anemia of chronic diseases;
D64-other anemias.
Pathogenesis
The supply of oxygen to tissues is provided by erythrocytes - blood cells that do not contain a nucleus, the main volume of an erythrocyte is occupied by hemoglobin - a protein that binds oxygen. The life span of erythrocytes is about 100 days. When the hemoglobin concentration is below 100-120 g / l, oxygen delivery to the kidneys decreases, this is a stimulus for the production of erythropoietin by the interstitial cells of the kidneys, this leads to the proliferation of cells of the erythroid lineage of the bone marrow. For normal erythropoiesis it is necessary:
healthy bone marrow
healthy kidneys that produce enough erythropoietin
a sufficient content of substrate elements necessary for hematopoiesis (primarily iron).
Violation of one of these conditions leads to the development of anemia.
Figure 1. Scheme of erythrocyte formation. (T.R. Harrison).
Clinical picture
The clinical manifestations of anemia are determined by its severity, the rate of development, and the patient's age. Under normal conditions, oxyhemoglobin gives up to tissues only a small part of the oxygen bound to it, the possibilities of this compensatory mechanism are great, and with a decrease in Hb by 20-30 g / l, the release of oxygen to the tissues increases and there may be no clinical occurrence of anemia, anemia is often detected by a random blood test.
At a concentration of Hb below 70-80 g / l, fatigue, shortness of breath during exercise, palpitations, and a throbbing headache appear.
In elderly patients with cardiovascular diseases, there is an increase in pain in the heart, an increase in signs of heart failure.
Acute blood loss leads to a rapid decrease in the number of erythrocytes and BCC. It is necessary, first of all, to assess the state of hemodynamics. Redistribution of blood flow and venous spasm cannot compensate for acute blood loss of more than 30%. Such patients lie, there is a pronounced orthostatic hypotension, tachycardia. The loss of more than 40% of blood (2000 ml) leads to shock, the signs of which are tachypnea and tachycardia at rest, stunnedness, cold clammy sweat, and a decrease in blood pressure. An urgent restoration of the bcc is necessary.
With chronic bleeding, the BCC manages to recover on its own, a compensatory increase in the BCC and cardiac output develops. As a result, an increased apical impulse, a high pulse appear, pulse pressure increases, due to the accelerated flow of blood through the valve, systolic murmur is heard during auscultation.
The pallor of the skin and mucous membranes becomes noticeable when the concentration of Hb decreases to 80-100 g / l. The appearance of jaundice can also be a sign of anemia. When examining the patient, attention is paid to the state of the lymphatic system, the size of the spleen and liver is determined, ossalgia is detected (pain when beating bones, especially the sternum), attention should be drawn to petechiae, ecchymosis and other signs of impaired coagulation or bleeding.
Severity of anemia(by Hb level):
slight reduction of Hb 90-120 g / l
average Hb 70-90 g / l
severe Hb<70 г/л
extremely severe Нb<40 г/л
When starting a diagnosis of anemia, you need to answer the following questions:
Are there signs of bleeding or has it already taken place?
Are there signs of excessive hemolysis?
Are there any signs of suppression of bone marrow hematopoiesis?
Are there signs of iron metabolism disorders?
Are there signs of vitamin B 12 or folate deficiency?