List of Contributors xiii
Preface xvii
About the Companion Website xix
Part 1 Introduction to Iron 1
1 An Introduction to Iron in the Body 3
Sue Pavord and Noemi Roy
Introduction 3
Iron in the Body 3
Essential Functions of Iron in the Body 6
Iron Deficiency 6
Iron Overload 6
Bibliography 9
2 Regulation of Iron Trafficking in the Body 11
Megan Teh and Hal Drakesmith
Introduction 11
Hepcidin and Systemic Iron Homeostasis 11
Regulation of Hepcidin 12
Sensing Iron Concentrations 12
Erythropoietic Demand 14
Inflammation 14
Cellular Iron Homeostasis: Ferritin and Transferrin Receptor 14
Assessing Iron Status – How the Markers Used Relate to Underlying Biology 15
Bibliography 16
3 Iron and Immunity 17
Fabiana Busti and Domenico Girelli
Introduction 17
The Battle for Iron and the Concept of ‘Nutritional Immunity’ 17
Therapeutic Interventions Harnessing Nutritional Immunity 18
Iron Status and Susceptibility to Infections 19
Iron Deficiency and Health of Populations 19
Iron Overload and Risk of Infection 20
Iron Status and Response to Vaccines 20
Bibliography 22
Part 2 Iron Deficiency 23
Part 2a Assessment and Management of Iron Deficiency 25
4 Impact of Iron Deficiency on the Individual 27
Patrick Kyei-Mensah
Introduction 27
Symptoms and Signs of Iron Deficiency 28
Impact of Iron Deficiency on Specific At-risk Groups 28
Pregnancy, Parturition and Lactation 30
Paediatric Population 30
Non-pregnant Premenopausal Women 31
Individuals from Resource-poor Settings 31
Other Clinical Situations Associated with Iron Deficiency 31
Gastrointestinal Bleeding 31
Heart Failure 31
Chronic Obstructive Airway Disease 32
Renal Disease 32
Conclusion 32
Bibliography 32
5 Assessment of Iron Deficiency 33
Hanke L. Matlung and Dorine W. Swinkels
Introduction 33
Definitions 33
Ferritin Thresholds 33
Inflammation and Liver Disease 36
Additional Biomarkers 36
Red Cell Indices 36
Hepcidin Levels 37
Conclusion 38
Bibliography 38
6 Available Treatments for Iron Deficiency 39
Paolo Polzella
Introduction 39
Oral Iron Supplementation 39
Administration of Oral Iron 39
Intravenous Iron Therapy 40
Potential Adverse Effects of Intravenous Iron 41
Individualising Treatment 42
Bibliography 43
Part 2b Causes, Impact, Management and Prevention of Iron Deficiency in Clinical Specialties 45
7 Iron Deficiency in Primary Care 47
David McCartney
Introduction 47
Presentation of Iron Deficiency in Primary Care 47
The Main Causes of Iron Deficiency in Primary Care 48
Pre-menopausal Women 48
Post-menopausal Women and Men 49
Older Adults 49
The Diagnosis of Iron Deficiency in Primary Care 49
Haemoglobin 49
Iron Studies 49
Further Investigations 50
Treatment of Iron Deficiency in Primary Care 50
Dietary Advice and Prevention of Future Iron Deficiency 51
Bibliography 51
8 Iron Deficiency in the Preoperative Patient 53
Caroline R. Evans
Introduction 53
Haemoglobin Thresholds 53
Causes of Iron Deficiency in the Surgical Setting 54
Laboratory Tests 54
Management of Preoperative Iron Deficiency 55
Iron Treatment 55
Postoperative Management 56
Conclusion 56
Bibliography 56
9 Iron Deficiency in Gastroenterology 57
Mohmmed Tauseef Sharip and Nurulamin M. Noor
Introduction 57
Gastrointestinal Causes of Iron Deficiency 57
Assessment of Iron Deficiency in Patients with Gastrointestinal Disease 59
Specific Gastrointestinal Investigations 59
Angiodysplasia 62
Treatment of Iron Deficiency in Patients with Gastrointestinal Disease 62
Bibliography 64
10 Iron Deficiency in Renal Medicine 65
Philip A. Kalra
Introduction 65
Types of Iron Used in Nephrology and Safety Considerations 65
Iron Use in Haemodialysis Patients 66
Iron Use in Non-Dialysis-Dependent Chronic Kidney Disease 68
Iron Use in Peritoneal Dialysis 68
Bibliography 69
11 Iron Deficiency in Cardiology 71
Samira Lakhal-Littleton
Introduction 71
Causes of Iron Deficiency in Heart Failure 71
Impact of Iron Deficiency in Heart Failure 72
Management of Iron Deficiency in Heart Failure 72
Diagnostic and Management Uncertainties in Individuals with Cardiac Disease 73
Current Definitions of Iron Deficiency 73
Current Iron Replacement Therapies 74
Bibliography 75
12 Iron Deficiency in Neurology 77
Carmen Jacob and Ian Galea
Introduction 77
Iron Utilisation in the Central Nervous System 77
Iron and Neurocognitive Development 79
Neurological Associations in Iron Deficiency 79
Recommendations for Management of Iron Deficiency with Neurological Symptoms 80
Conclusion 80
Bibliography 80
13 Iron Deficiency in Obstetrics 83
Sue Pavord
Introduction 83
The Maternal Effects of Iron Deficiency 83
Fetal Effects of Iron Deficiency 85
Defining Anaemia in Pregnancy 85
How Is Iron Deficiency Diagnosed in Pregnancy? 86
Indications for Intravenous Iron 86
Management of Postpartum Anaemia 87
Bibliography 87
14 Iron Deficiency in Gynaecology 89
Imo J. Akpan
Introduction 89
Causes of Heavy Menstrual Bleeding 89
Definition of Heavy Menstrual Bleeding 89
Prevention of Iron Deficiency in Gynaecology 89
Investigation of Heavy Menstrual Bleeding 90
Management of Heavy Menstrual Bleeding 91
Hormonal Preparations 91
Anticoagulation Modification 91
Haemostatic Agents 92
Surgical Management 92
Iron Deficiency and Iron Deficiency Anaemia in Gynaecology 92
Impact of Iron Deficiency in Gynaecology 92
Management of Iron Deficiency in Women with Gynaecological Bleeding 94
Oral Iron Supplementation 94
Parenteral Iron Supplementation 95
Blood Transfusion 95
Bibliography 95
15 Iron Deficiency in Orthopaedics 97
Antony Palmer
Introduction 97
Diagnosis 97
Aetiology of Iron Deficiency 98
Preoperative Treatment of Iron Deficiency Anaemia 98
Patient Outcomes 98
Iron Deficiency Without Anaemia 100
Bibliography 100
16 Iron Deficiency in Intensive Care 101
Akshay Shah
Introduction 101
Iron Homeostasis in Critical Illness 101
Diagnosing Iron Deficiency in Critical Illness 103
Clinical Implications of Iron Deficiency in Intensive Care Unit 103
Patient Blood Management in Intensive Care 104
Intravenous Iron in Intensive Care 104
Concomitant Therapies for Anaemia Management in Intensive Care 104
Bibliography 105
17 Iron Deficiency in Medical Oncology 107
Sue Pavord
Introduction 107
Causes of Anaemia in Patients with Cancer 107
Diagnosis of Iron Deficiency in Patients with Cancer 108
Management of Anaemia in Patients with Cancer 108
Erythropoiesis Stimulating Agents 108
Blood Transfusion in Oncology 109
Prevention of Anaemia in Patients with Cancer 109
Implementation of Local Policy 109
Novel Anti-anaemia Agents 110
Conclusion 110
Bibliography 111
Part 3 Iron Overload 113
Part 3a Causes of Iron Overload 115
18 Transfusional Iron Overload 117
Samah Babiker and John Porter
Introduction 117
The Causes of Iron Overload and Influencing Factors 117
Pathophysiology and Effects of Transfusional Iron Loading on Body Iron Distribution 117
Rates of Transfusional Iron Overloading and Distribution in Different Diseases 119
Consequences of Transfusional Iron Overload 119
Prevention of Transfusional Iron Overload 121
Bibliography 121
19 Haemochromatosis 123
Graca Porto
Introduction 123
Pathogenesis 123
Frequency and Penetrance of HFE-Related Haemochromatosis 124
Diagnosis 125
Treatment and Prevention 127
Bibliography 127
20 Ineffective Erythropoiesis 129
Noemi Roy
Introduction 129
Erythropoiesis 129
The Role of Erythropoietin and Iron 130
Ferrokinetic Studies 131
Erythroferrone 131
Bibliography 132
Part 3b Effects of Iron Overload on Body Organs 133
21 Iron Overload in the Heart 135
Malcolm Walker
Iron and the Heart 135
Cardiac Iron Regulation 135
Iron Overload 135
Clinical Presentations and Their Management 136
Ventricular Dysfunction and Heart Failure 136
Arrhythmia 137
Assessment of Cardiac Iron 137
Magnetic Resonance Imaging 137
Other Heart Tests 138
Long-Term Management and Prevention 138
Bibliography 140
22 Iron Overload and the Liver 141
Emma Saunsbury and Jeremy Cobbold
Introduction 141
Histological Patterns of Hepatic Iron Overload 141
Pathophysiology of Hepatic Damage Secondary to Iron Overload 141
Assessment of Hepatic Iron Overload 143
Bibliography 144
23 Impact of Iron Overload on the Endocrine System 147
Amy Morrison and Miles Levy
Introduction 147
Diabetes Mellitus 147
Reproductive Endocrinology 148
Growth and Bone Health 150
Adrenal Function 150
Summary 151
Bibliography 152
24 Iron Overload and the Musculoskeletal System 153
Kassim Javaid
Introduction 153
Osteoporosis and Fracture Risk 153
Osteoarthritis 154
Calcium Pyrophosphate Deposition Disease 155
Management of Iron Overload in the Joints 155
Bibliography 156
Part 3c Assessment and Management of Iron Overload 157
25 Assessment of Iron Overload 159
Subarna Chakravorty
Introduction 159
Awareness of Potential Causes 159
Assessment of Transfusional Iron Overload 159
Role of Serum Ferritin and Iron Studies in Assessing Iron Overload 160
Imaging in Iron Overload 161
Monitoring Requirements for At-risk Patients 162
Bibliography 163
26 Management of Iron Overload 165
Nandini Sadasivam
Introduction 165
Iron Chelation Therapy 165
Indications for Iron Chelation Therapy 165
Administration of Iron Chelation Therapy 166
Combination Chelation Therapy 166
When to Start Iron Chelation Therapy 168
Practical Tips for Clinicians 168
Desferrioxamine 168
Deferasirox 169
Deferiprone 169
Calculation of ROIL Adults 169
Calculation of ROIL in Paediatric 169
Practical Prescribing Tips 170
Dose Adjustments for Comorbidities 171
Renal Disease 171
Desferrioxamine 171
Deferasirox 171
Established Dialysis 171
Liver Disease 171
Deferasirox 171
Pregnancy 171
Emerging Novel Therapies 171
Bibliography 172
Index 173
