Iron deficiency anemia in the emergency department: over-utilization of red blood cell transfusion and infrequent use of iron supplementation

AbstractObjectivesThree are no clinical practice guidelines that specifically address the management of patients with iron deficiency anemia (IDA) in the emergency department (ED). The goal of this study was to describe the characteristics of IDA patients who present to the ED, documentation of IDA by emergency physicians, utilization of iron supplementation, and the appropriateness of red blood cell (RBC) transfusions ordered in the ED.MethodsA retrospective medical chart review was performed of IDA patients who visited the ED of a large tertiary center over a three-month period. Appropriateness of RBC transfusion was determined using a novel algorithm developed by our institution.ResultsOver the study period, there was a 0.3% (49/14,394) prevalence of IDA in the ED. In thirty (30/49; 61%) patients, IDA was documented by an emergency physician. RBC transfusions were administered to 19 patients; 10 transfusions (53%) were appropriate, 3 (16%) were appropriate for indication, but more than the required number of units were ordered, and 6 (32%) were inappropriate. Of the patients discharged, one (1/25; 4%) patient received intravenous iron in the ED and 6 of the 11 patients (55%) that were not already taking oral iron received a prescription at discharge from the ED.ConclusionsThis assessment demonstrated that management of IDA patients presenting to the ED may represent an important knowledge-to-practice gap. It revealed that RBC transfusion may be over-utilized and could be replaced by safer, lower-cost alternatives such as intravenous and oral iron. Guidelines for management of IDA in the ED may be necessary to achieve consistent IDA management and avoid inappropriate use of RBC transfusion.

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Red Blood Cell Transfusion and the Use of Intravenous Iron in Iron Deficient Patients Presenting to the Emergency Department

Blood ◽

10.1182/blood-2020-141154 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 1-2

Author(s):

Arvand Barghi ◽

Robert Balshaw ◽

Emily Rimmer ◽

Murdoch Leeies ◽

Allan Garland ◽

...

Keyword(s):

Emergency Department ◽

Logistic Regression ◽

Iron Deficiency ◽

Blood Cell ◽

Red Blood Cell ◽

Hemoglobin Concentration ◽

Factors Associated ◽

Iv Iron ◽

Iron Parameters ◽

Rbc Transfusion

Background: Red blood cell (RBC) transfusions are often used to treat patients with iron deficiency who present to the emergency department (ED) with symptomatic anemia. Intravenous (IV) iron is the preferred treatment in this setting, as it has been shown to increase hemoglobin concentration rapidly and durably. We aim to determine the incidence of iron deficiency anemia (IDA) and the management of these patients in the ED setting. Objectives: To evaluate the incidence of IDA, the frequency of RBC transfusion and iron supplementation, and factors associated with RBC transfusion. Study Design: Retrospective cohort study of all adult patients presenting to the St Boniface Hospital (Winnipeg, CAN) ED from January 2014 to January 2019. Methods: We used electronic data from the Emergency Department Information System (EDIS) and Laboratory Information Services (LIS) databases to identify patients presenting with IDA, defined as anemia (hemoglobin <120 g/L) with either a transferrin saturation less than 20% or ferritin less than 30 umol/L, or mean corpuscular volume (MCV) of < 75 fL. A ferritin greater than 100 umol was used to exclude IDA, regardless of MCV. We extracted patient demographics, diagnoses, markers of iron storage, RBC transfusion and use of IV iron. Multivariate logistic regression analysis was used to evaluate factors associated with RBC transfusion. Results: Of 39222 patients, 17945 (45%) were anemic. Of the anemic patients, iron parameters were ordered in 1848 (10.3%) patients, and IDA was present in 910 (5.1 %). In the IDA population, 95 patients (10.4 %) received 1 RBC unit, and 197 patients (21.6 %) received 2 or more units. Oral iron and IV iron were prescribed for 64 (7 %) and 14 (1.5 %) patients, respectively. Our logistic regression model demonstrated that hemoglobin concentration was the main determinant of whether patients received RBC transfusion. Other variables including patient age, cardiac symptoms, heart rate, blood pressure, and CTAS score were not associated with increased likelihood of receiving RBC transfusion. Conclusion: Iron parameters were infrequently ordered in the evaluation of anemia in the ED, with limited use of oral and IV iron. The decision to transfuse RBCs was primarily influenced by hemoglobin concentration, but not other surrogates of hemodynamic instability. An interventional study to improve education and access to oral and IV iron is planned to reduce unnecessary RBC transfusions and their associated risks in patients with IDA. Disclosures No relevant conflicts of interest to declare.

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Iron supplementation in goitrous, iron-deficient children improves their response to oral iodized oil

Acta Endocrinologica ◽

10.1530/eje.0.1420217 ◽

2000 ◽

pp. 217-223 ◽

Cited By ~ 33

Author(s):

M Zimmermann ◽

P Adou ◽

T Torresani ◽

C Zeder ◽

R Hurrell

Keyword(s):

Iron Deficiency ◽

Iron Deficiency Anemia ◽

Iron Supplementation ◽

Thyroid Volume ◽

Oral Iron ◽

Deficiency Anemia ◽

Urinary Iodine Concentration ◽

Iodized Oil ◽

Iron Deficient ◽

Group 2

OBJECTIVE: In developing countries, many children are at high risk for both goiter and iron-deficiency anemia. Because iron deficiency may impair thyroid metabolism, the aim of this study was to determine if iron supplementation improves the response to oral iodine in goitrous, iron-deficient anemic children. DESIGN: A trial of oral iodized oil followed by oral iron supplementation in an area of endemic goiter in the western Ivory Coast. METHODS: Goitrous, iodine-deficient children (aged 6-12 years; n=109) were divided into two groups: Group 1 consisted of goitrous children who were not anemic; Group 2 consisted of goitrous children who were iron-deficient anemic. Both groups were given 200mg oral iodine as iodized oil. Thyroid gland volume using ultrasound, urinary iodine concentration (UI), serum thyroxine (T(4)) and whole blood TSH were measured at baseline, and at 1, 5, 10, 15 and 30 weeks post intervention. Beginning at 30 weeks, the anemic group was given 60mg oral iron as ferrous sulfate four times/week for 12 weeks. At 50 and 65 weeks after oral iodine (8 and 23 weeks after completing iron supplementation), UI, TSH, T(4) and thyroid volume were remeasured. RESULTS: The prevalence of goiter at 30 weeks after oral iodine in Groups 1 and 2 was 12% and 64% respectively. Mean percent change in thyroid volume compared with baseline at 30 weeks in Groups 1 and 2 was -45.1% and -21.8% respectively (P<0.001 between groups). After iron supplementation in Group 2, there was a further decrease in mean thyroid volume from baseline in the anemic children (-34.8% and -38.4% at 50 and 65 weeks) and goiter prevalence fell to 31% and 20% at 50 and 65 weeks. CONCLUSION: Iron supplementation may improve the efficacy of oral iodized oil in goitrous children with iron-deficiency anemia.

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Distinguishing iron deficiency anemia from thalassemia by the red blood cell lifespan with a simple CO breath test: a pilot study

Journal of Breath Research ◽

10.1088/1752-7163/aafe4f ◽

2019 ◽

Vol 13 (2) ◽

pp. 026007

Author(s):

Mei-qing Lei ◽

Ling-feng Sun ◽

Xian-sheng Luo ◽

Xiao-yang Yang ◽

Feng Yu ◽

...

Keyword(s):

Pilot Study ◽

Iron Deficiency ◽

Blood Cell ◽

Iron Deficiency Anemia ◽

Red Blood Cell ◽

Breath Test ◽

Deficiency Anemia ◽

Cell Lifespan

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Cerebral Venous Thrombosis after Red Blood Cell Transfusion for the Treatment of Iron Deficiency Anemia

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2019.104338 ◽

2019 ◽

Vol 28 (11) ◽

pp. 104338

Author(s):

Taku Inada ◽

Nobutake Sadamasa ◽

Ryota Motoie ◽

Norikazu Yamana ◽

Waro Taki

Keyword(s):

Iron Deficiency ◽

Blood Cell ◽

Venous Thrombosis ◽

Iron Deficiency Anemia ◽

Red Blood Cell ◽

Cerebral Venous Thrombosis ◽

Red Blood Cell Transfusion ◽

Deficiency Anemia

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Investigation of ischemia modified albumin levels in iron deficiency anemia

Turkish Journal of Biochemistry ◽

10.1515/tjb-2016-0315 ◽

2017 ◽

Vol 42 (3) ◽

Cited By ~ 1

Author(s):

Sibel Bilgili ◽

Giray Bozkaya ◽

Funda Kırtay Tütüncüler ◽

Murat Akşit ◽

Mehmet Yavuz

Keyword(s):

Iron Deficiency ◽

Iron Deficiency Anemia ◽

Iron Supplementation ◽

Binding Capacity ◽

Oral Iron ◽

Deficiency Anemia ◽

Control Group ◽

Ischemia Modified Albumin ◽

Before And After ◽

Anemia Group

AbstractObjective:The aim of this study was to evaluate the levels of ischemia-modified albumin (IMA), before and after oral iron supplementation in iron deficiency anemia and to determine the correlations between IMA and hemoglobin values.Study design:IMA, hemoglobin, hematocrit, mean corpuscular volume, ferritin, iron, total iron binding capacity and albumin levels were measured in 140 female patients with newly established as iron deficiency anemia before and after treatment and in 84 female healthy controls.Results:IMA levels were higher in the anemia group [0.340±0.082 absorbance units (ABSU)] compared to control group (0.291±0.077 ABSU). After oral iron therapy we saw that IMA values (0.392±0.080 ABSU) were higher than the IMA levels of the anemia group and the control group (p<0.05). Only in the anemia group there were negative correlations between IMA and hemoglobin, hematocrit.Conclusion:We conclude that the high levels of IMA in the anemia group might be attributed to hypoxia due to low hemoglobin levels. Iron is an oxidant element and oral iron supplementation may be associated with oxidative stress and may increase IMA levels by changing the albumin molecule. We thought that, IMA can be demonstrative of the severity of anemia since it was correlated with hemoglobin in the anemia group.

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Analysis Of TMPRSS6 Polymorphisms In Patients With Iron Deficiency Anemia Partially Responsive To Oral Iron Treatment

Blood ◽

10.1182/blood.v122.21.3438.3438 ◽

2013 ◽

Vol 122 (21) ◽

pp. 3438-3438 ◽

Cited By ~ 1

Author(s):

Erika Poggiali ◽

Fabio Andreozzi ◽

Isabella Nava ◽

Paola Delbini ◽

Lorena Duca ◽

...

Keyword(s):

Iron Deficiency ◽

Iron Deficiency Anemia ◽

Iron Supplementation ◽

Rare Variants ◽

Hematological Parameters ◽

Oral Iron ◽

Deficiency Anemia ◽

Healthy Donors ◽

New Variant ◽

Parenteral Iron

Abstract Introduction Iron Refractory Iron Deficiency Anemia (IRIDA) is an autosomal recessive form of iron deficiency anemia (IDA) caused by mutations in TMPRSS6 gene, and characterized by unresponsiveness to oral iron supplementation and low effectiveness of parenteral iron administration (Finberg 2009). So far 50 cases from 32 families have been reported and 40 mutations have been identified (De Falco 2013). Although mutations are extremely rare, recent insights have revealed that highly frequent polymorphisms of TMPRSS6 gene may influence iron absorption, being associated with increased risk of IDA (An 2012). Patients and Methods Between January 2009 and May 2013, 88 subjects (11 males, 77 females) with mean age 39+/-14 years were referred to the Hereditary Anemia Centre of “Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano” for persistent IDA poorly responsive to oral iron. All the patients (pts) were investigated for celiac disease, gastrointestinal bleeding, and HP infection. Hematological parameters, iron status, inflammatory markers, and thyroid function were tested. Sequence variation in TMPRSS6 gene was evaluated by PCR and direct sequencing in genomic DNA isolated from peripheral lymphocytes. Thalassemia trait was suspected and investigated in 27/88 (31%) pts (3 males, 24 females) using HPLC and genetic analysis of globin chains. Fifty healthy donors (15 females, 35 males) with mean age 28±9 yrs were used as control group. Results Frequency of SNP-120, SNP-113, P33P, K253E, Y418Y, D521D, Δ15accc and V739Y results significantly different between pts and controls. Association study revealed that in pts homozygosis for V736A is frequently associated with homozygosis for D521D and Y739Y, while polymorphic alleles F5F, P33P, K253E, S361S, Δ15accc are linked to V736A trans-allele. Based on the observation that homozygosis for V736A is not present in healthy control, we analyzed the hematological parameters in anemic pts homozygotes, heterozygotes, and wild type for V736A. No significant differences were found (table 1). Considering only the thalassemia pts, the combination of thalassemia trait and V736A is associated with a more severe anemia (Hb 10.3±1.4 g/dL, MCV 62.9±6.7 fL median ferritin 30 ng/mL), requiring blood transfusion in particular circumstances (pregnancy, surgery). Moreover, one new variant (H448R) was identified in a pt with IDA requiring parenteral iron supplementation. Two rare variants, A719T and V795I (estimated frequency 0.000/1 and 0.004/9), were detected respectively in two sisters, causing the IRIDA phenotype only in one, and in two patients, who require parenteral iron therapy. Discussion and Conclusion Several TMPRSS6 polymorphisms are more frequent in anemic pts than in healthy donors, suggesting their role in the refractoriness to oral iron. No significant differences were observed in hematological data related to V736A genotype. This is not surprising because all the pts were previously treated with iron therapy, which contribute to partially reduce the degree of anemia. In this study we found peculiar haplotypes, a new variant (H448R) and two rare variants (A719T and V795I), which may account for impairment in TMPRSS6 activity. Further studies are necessary to clarify the role of TMPRSS6 polymorphysms, which will allow identifying individuals at risk for more severe IDA, particularly in thalassemia pts, driving to correct diagnosis and management of iron supplementation, sparing to the patient inadequate therapeutic choices and diagnostic procedures. Disclosures: Cappellini: NOVARTIS: Membership on an entity’s Board of Directors or advisory committees.

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