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Diagnosis of iron deficiency anemia in renal failure patients during the post-erythropoietin era

  • Kamyar Kalantar-Zadeh
    Affiliations
    Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY, USA

    Fourth Medical Clinic, University of Erlangen-Nürnberg, Nürnberg, Germany

    Department of Pathology, Nürnberg Municipal Hospitals, Nürnberg, Germany

    Franz Volhard Clinic, Rudolf Virchow University Hospitals, Free University of Berlin, Berlin, Germany
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  • Bernd Höffken
    Affiliations
    Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY, USA

    Fourth Medical Clinic, University of Erlangen-Nürnberg, Nürnberg, Germany

    Department of Pathology, Nürnberg Municipal Hospitals, Nürnberg, Germany

    Franz Volhard Clinic, Rudolf Virchow University Hospitals, Free University of Berlin, Berlin, Germany
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  • Helmut Wünsch
    Affiliations
    Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY, USA

    Fourth Medical Clinic, University of Erlangen-Nürnberg, Nürnberg, Germany

    Department of Pathology, Nürnberg Municipal Hospitals, Nürnberg, Germany

    Franz Volhard Clinic, Rudolf Virchow University Hospitals, Free University of Berlin, Berlin, Germany
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  • Heribert Fink
    Affiliations
    Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY, USA

    Fourth Medical Clinic, University of Erlangen-Nürnberg, Nürnberg, Germany

    Department of Pathology, Nürnberg Municipal Hospitals, Nürnberg, Germany

    Franz Volhard Clinic, Rudolf Virchow University Hospitals, Free University of Berlin, Berlin, Germany
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  • Morton Kleiner
    Affiliations
    Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY, USA

    Fourth Medical Clinic, University of Erlangen-Nürnberg, Nürnberg, Germany

    Department of Pathology, Nürnberg Municipal Hospitals, Nürnberg, Germany

    Franz Volhard Clinic, Rudolf Virchow University Hospitals, Free University of Berlin, Berlin, Germany
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  • Friedrich C. Luft
    Correspondence
    Address reprint requests to Friedrich C. Luft, MD, Franz Volhard Clinic, Wiltberg Strasse 50, 13122 Berlin, Germany.
    Affiliations
    Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY, USA

    Fourth Medical Clinic, University of Erlangen-Nürnberg, Nürnberg, Germany

    Department of Pathology, Nürnberg Municipal Hospitals, Nürnberg, Germany

    Franz Volhard Clinic, Rudolf Virchow University Hospitals, Free University of Berlin, Berlin, Germany
    Search for articles by this author
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      Abstract

      The purpose of this study was to evaluate the sensitivity and specificity of laboratory methods in the diagnosis of posterythropoietin-era, iron-deficient, chronic renal failure patients. The patient population comprised 25 anemic (hemoglobin <11 g/dL) patients with creatinine greater than 3 mg/dL; 20 were dialysis patients, two were transplant patients, and three patients had renal failure from other causes. Criteria for study inclusion were as follows: bone marrow iron was the reference standard and was graded 0 to +4, ranging from absent to diffuse homogeneous iron staining; serum ferritin concentration and serum transferrin saturation were tested in terms of sensitivity and specificity. The reference standard indicated that iron deficiency existed in 40% of patients. Neither serum ferritin nor transferrin saturation were completely adequate diagnostic tools. Serum ferritin levels less than 200 ng/dL were 100% specific for the diagnosis but only 41% sensitive. Transferrin saturation of less than 20% was 88% sensitive, but only 63% specific. By excluding patients with hypoproteinemia (transferrin values of <150 mg/dL), the sensitivity of the test increased to 100% and the specificity to 80%. We conclude that transferrin saturation is an adequate screening tool in anemic chronic renal failure patients, provided that hypoproteinemia is not present. By determining both the serum ferritin concentration and the transferrin saturation, a high sensitivity and specificity can be achieved, even in patients with hypoproteinemia. Furthermore, we believe that on this basis, iron therapy in patients with renal insufficiency can be improved.

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      References

        • Rosenblatt SG
        • Drake S
        • Fadem S
        • Welch R
        • Lifschitz MD
        Gastrointestinal blood loss in patients with chronic renal insufficiency.
        Am J Kidney Dis. 1982; 1: 170-174
        • Segal GM
        • Eschbach JW
        • Egrie JC
        • Stueve T
        • Adamson JW
        The anemia of end-stage renal disease: Hematopoietic progenitor cell response.
        Kidney Int. 1988; 33: 983-988
        • Oliveira C
        • Boquinhas H
        • Gaspar A
        • Adragao T
        • Boquinhas JM
        • Junior EC
        • Simoes J
        Assessment of iron requirements during treatment of anemia with recombinant human erythropoietin in patients with chronic renal insufficiency under hemodialysis.
        Acta Med Port. 1992; 5: 351-357
        • Nikolaev AI
        • Klepikov PV
        • Lashutin SV
        • Kondakhchan MA
        • Rogov VA
        • Trofimova EL
        Individual differences in the efficacy of Recormon in patients with terminal kidney failure: The role of iron deficiency.
        Ter Arkh. 1993; 65: 45-48
        • Barosi G
        • Merlo C
        • Palestra P
        • Liberato NL
        • Guarnone R
        • DiDio F
        • Piazza V
        • Salvadea A
        Variations in erythropoiesis and serum ferritin during erythropoietin therapy for anaemia of end-stage renal disease.
        Acta Haematol. 1993; 90: 13-18
        • Ohe Y
        • Akasaka K
        • Ohno Y
        • Kawagoe H
        • Kishimoto T
        • Sakai R
        • Tsujino T
        • Hara H
        • Fujita Y
        • Yoshida Y
        Part 1: Assay of erythropoietin in serum with short term enzyme linked immunosorbent assay method—The clinical significance. Part 2: Relation to serum iron, iron binding capacity, and ferritin in renal failure and hematological disorders.
        Rinsho Byori. 1993; 41: 463-467
        • Rosenberg ME
        Role of transferrin measurement in monitoring iron status during recombinant human erythropoietin therapy.
        Dial Transplant. 1992; 21: 81-90
        • Garrett S
        • Wormwood M
        Zinc protoporphyrin and iron deficient erythropoiesis.
        Acta Haematol. 1994; 91: 21-25
        • Beguin Y
        • Loo M
        • R'Zik S
        • Sautois B
        • Lejeune F
        • Rorive G
        • Fillet G
        Early prediction of response to recombinant human erythropoietin in patients with the anemia of renal failure by serum transferrin receptor and fibrinogen.
        Blood. 1993; 82: 2010-2016
        • Humphries JE
        Anemia of renal failure.
        in: Use of erythropoietin. ed 8. Med Clin North Am. 76. 1992: 711-725
        • Hotta T
        • Ogawa H
        • Saito A
        • Itoa A
        Iron balance following recombinant human erythropoietin therapy for anemia associated with chronic renal failure.
        Int J Hematol. 1991; 54: 195-200
        • Drueke TB
        Resistance to recombinant human erythropoietin in hemodialysis patients.
        Am J Nephrol. 1990; 10: 34-39
        • Van Wyck DB
        • Stivelman JC
        • Ruiz J
        • Kirlin LF
        • Katy MA
        • Ogden DA
        Iron status in patients receiving erythropoietin for dialysis associated anemia.
        Kidney Int. 1989; 35: 712-716
        • Van Wyck DB
        Iron management during recombinant human erythropoietin therapy.
        Am J Kidney Dis. 1989; 14: 9-13
        • Warschaw BL
        • Check IJ
        • Hymes LC
        • DiRusso SC
        Decreased serum transferrin concentration in children with the nephrotic syndrome.
        Clin Immunol Immunopathol. 1984; 32: 210-219
        • Guyatt GH
        • Oxman AD
        • Ali M
        Laboratory diagnosis of iron deficiency anemia: An overview.
        J Gen Intern Med. 1992; 7: 145-153
        • Doube A
        • Davis M
        • Smith JG
        • Maddison PJ
        • Collins AJ
        Structured approach to the investigation of anaemia in patients with rheumatoid arthritis.
        Ann Rheum Dis. 1992; 51: 469-472
        • Massey AC
        Microcytic anemia.
        in: Differential diagnosis and management of iron deficiency anemia. ed 8. Med Clin North Am. 76. 1992: 549-566
        • Nielsen OJ
        • Andersen LS
        • Ludwigsen E
        • Bouchelouche P
        • Hansen TM
        • Birgens H
        • Hansen NE
        Anemia of rheumatoid arthritis: Serum erythropoietin concentrations and red cell distribution width in relation to iron status.
        Ann Rheum Dis. 1990; 49: 349-353
        • Shroff K
        • Gaiha M
        • Singh T
        • Sharma SK
        Iron status in patients with rheumatoid arthritis with special reference to serum ferritin levels.
        J Assoc Phys India. 1991; 39: 675-677
        • Campos A
        • Garin EH
        Therapy of renal anemia in children and adolescents with recombinant human erythropoietin (rHuEPO).
        Clin Pediatr (Phila). 1992; 31: 94-99
        • Thompson WG
        • Meola T
        • Lipkin Jr, M
        • Freedman ML
        Red cell distribution width, mean corpuscular volume and transferrin saturation in the diagnosis of iron deficiency.
        Arch Intern Med. 1988; 148: 2128-2130
        • Witte DL
        • Angstadt DS
        • Davis SH
        • Schrantz RD
        Predicting bone marrow iron stores in anemic patients in a community hospital using ferritin and erythrocyte sedimentation rate.
        Am J Clin Pathol. 1988; 90: 85-87
        • Sears DA
        Anemia of chronic disease.
        Med Clin North Am. 1992; 76: 567-579
        • Paris M
        • Benoit MO
        • Bied A
        • Charlier C
        • Pressac M
        • Revenant MC
        • Vernet M
        Hemodialyse et ferritinemie.
        Ann Biol Clin (Paris). 1992; 50: 251-258
        • MacDougall IC
        • Cavill I
        • Hulme B
        • Bain B
        • McGregor E
        • McKay D
        • Sanders E
        • Coles GA
        • Williams JD
        Detection of functional iron deficiency during erythropoietin treatment: A new approach.
        BMJ. 1992; 304: 225-226
        • John GT
        • Chandy M
        • Thomas PP
        • Shatry JC
        • Jacob CK
        Iron stores in patients on haemodialysis after renal transplantation.
        Natl Med J India. 1993; 6: 108-110
        • Pela I
        • Lavoratti GC
        • Materassi M
        • Burgio G
        • Bartolozzi G
        Influence of iron metabolism on the efficacy of r-HuEPO treatment of anemia in children on hemodialysis.
        Pediatr Med Chir. 1991; 13: 474-477
        • Burns ER
        • Goldberg SN
        • Lawrence C
        • Wenz B
        Clinical utility of serum tests for iron deficiency in hospitalized patients.
        Am J Clin Pathol. 1990; 93: 240-253
        • Zadrazil J
        • Papajik T
        • Scudla V
        • Jezakova J
        • Budikova M
        • Slavicek J
        The iron reserve status in patients on regular hemodialysis treatment.
        Vnitr Lek. 1991; 37: 369-375
        • Allegra V
        • Mengozzi G
        • Vasile A
        Iron deficiency in maintenance hemodialysis patients: Assessment of diagnosis criteria and of three different iron treatments.
        Nephron. 1991; 57: 175-182
        • Brunati C
        • Piperna A
        • Guastoni C
        • Perrino ML
        • Civati G
        • Testini U
        • Perego A
        • Fiorelli G
        • Minetti L
        Erythrocyte ferritin in patients on chronic hemodialysis treatment.
        Nephron. 1990; 54: 219-223
        • Diaz-Tejeiro R
        • Maduell F
        • Diez J
        • Esparza N
        • Errasti P
        • Purroy A
        Red cell distribution width: A method that improves detection of iron deficiency in chronic hemodialysis patients.
        Nephron. 1989; 53: 379-380
        • Wulfhekel U
        • Dullmann J
        The diagnostic value of bone marrow iron.
        Folia Haematol (Leipz). 1990; 117: 419-434