Ferritin in the Non-Anemic Pregnant Patient as a Predictor of Anemia at Delivery
Anna FuchsCassandra HeiselmanRichelle FasslerChaitali Korgaonkar-CheralaOmar AbuzeidDiana GarrettoJennifer ChoiCecilia AvilaKimberly HerreraDavid Garry
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Abstract We assessed the accuracy and precision of seven commercial kits for serum ferritin. The concentration of ferritin as determined by these assays for a liver ferritin reference standard, a human heart ferritin standard, and normal sera correlated highly, but the absolute values varied widely. Use of an international reference standard for ferritin to prepare the standard curve greatly diminished the variability, but did not eliminate it. Although the seven kits differed in specificity for various human isoferritins, this did not appear substantially to affect accuracy. Six of the seven kits appeared sufficiently precise for clinical use over a wide range of ferritin concentrations.
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To the Editor.— We are indebted to Oski et al1 and to the 38 children who received injections of iron dextran for demonstrating the importance of determining not only which children had iron deficiency anemia but also those with iron deficiency without anemia. However, the primary physician needs a screening test that is efficient and not costly. Unfortunately, the history and physical examination are not effective screens for the identification of children at risk—with the exception of those children drinking in excess of one quart of milk a day.2
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Iron deficiency (ID) without anaemia frequently remains undiagnosed when symptoms are attributed to ID with anaemia. Serum ferritin is the primary diagnostic parameter, whereas <10 microg/l represent depleted iron stores, 10-30 microg/l can confirm ID without anaemia and 30-50 microg/l might indicate functional ID. In case of increased CRP or ALT, normal/elevated ferritin should be interpreted with caution. IV iron is indicated if oral iron is not effective or tolerated. At ferritin <10 microg/l, a cumulative dose of 1000 mg iron and at ferritin 10-30 microg/l, a cumulative dose of 500 mg is advised. At ferritin 30-50 microg/l a first dose of 200 mg might be considered. Ferritin shall be reassessed not sooner than 2 weeks after the last oral or 8-12 weeks after the last IV iron administration.
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Iron supplementation for the iron-depleted nonanemic athlete is a controversial issue. Athletes may be iron deficient due to poor dietary intake, significant or obligatory blood loss, or deficiency via increased need secondary to intense physical activity. Athletes who are found to be anemic secondary to iron deficiency do benefit and show improved performance with appropriate iron supplementation. There is contradictory evidence for iron supplementation and improving performance in the iron-depleted nonanemic athlete. An athlete’s iron status is usually monitored via serum ferritin. Currently, there is no standardized ferritin level at which supplementation is recommended, nor is there a consensus as to the appropriate maintenance of ferritin. Screening endurance athletes or female athletes in general for iron deficiency and also educating these athletes regarding the importance of a balanced diet to maximize performance would seem prudent and beneficial. Based on the literature, supplementation for the iron-depleted nonanemic athlete does not appear to be justified to solely improve performance.
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Abstract Iron deficiency is a very common and treatable disorder. Of all the tests available to diagnose iron deficiency, the serum ferritin is the most able to discriminate iron deficiency from other disorders. However, the reference range for ferritin in many laboratories will lead to underdiagnosis of iron deficiency in women. Studies have shown that 30%-50% of healthy women will have no marrow iron stores, so basing ferritin cutoffs on the lowest 2.5% of sampled ferritins is not appropriate. In addition, several lines of evidence suggest the body physiologic ferritin “cutoff” is 50 ng/mL. Work is needed to establish more realistic ferritin ranges to avoid underdiagnosing a readily treatable disorder.
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Blood donors were examined for serum ferritin values and concentration of ferritin in the erythrocytes. The group of male and female donors without previous donations showed average values of 102.27 ng and 51.75 ng of ferritin per one ml of serum, respectively. Males with over 20 donations had 68.04 ng ferritin per one ml, females 37.14 ng of ferritin per one ml. The reduced serum ferritin values in multiple male and female donors is statistically significant. Serum ferritin values in women of the two groups are lower than those of males, the difference also being statistically significant. In male and female blood donors, irrespective of the number of donations, average values of 13.74 ag and 12.07 ag of ferritin per erythrocyte, respectively, were established. The difference in ferritin concentration in the erythrocytes between males and females is statistically insignificant. The correlation coefficient failed to demonstrate any dependence between erythrocyte ferritin concentration and concentration of ferritin in the serum. The object of serum ferritin determination in blood donors is to detect the earliest stage of storage iron deficiency in the organism. For the latter purpose, the determination of erythrocyte ferritin is ineffective.
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Two hundred and seventy school children between 13 to 20 years were investigated for iron deficiency. Overall iron deficiency (assessed by serum ferritin assay) was 39% in adolescents; 30% boys and 54% girls were iron depleted, anemia was found in 17% boys (Hb 13g/dl) and in 18% girls (Hb 12g/dl). Iron deficiency was more frequent than anemia in adolescent girls than boys. Iron deficient children had significantly lower mean Hb levels (p 0.001) compared to children with adequate iron stores. A significant correlation was found between serum ferritin concentration and Hb levels in iron deficient children (r = 0.49, p 0.001). A high prevalence of iron deficiency in adolescents reported here reflects the limited availability of dietary iron in children belonging to lower socio-economic group and the importance of screening for iron deficiency and the treatment of these children with iron preparation. Iron status in this age group warrants further evaluation and research.
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We assessed the accuracy and precision of seven commercial kits for serum ferritin. The concentration of ferritin as determined by these assays for a liver ferritin reference standard, a human heart ferritin standard, and normal sera correlated highly, but the absolute values varied widely. Use of an international reference standard for ferritin to prepare the standard curve greatly diminished the variability, but did not eliminate it. Although the seven kits differed in specificity for various human isoferritins, this did not appear substantially to affect accuracy. Six of the seven kits appeared sufficiently precise for clinical use over a wide range of ferritin concentrations.
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