Detecting iron deficiency in anemic patients with concomitant medical problems Authors
Cite this article as: Kis, A.M. & Carnes, M. J GEN INTERN MED (1998) 13: 455. doi:10.1046/j.1525-1497.1998.00134.x Abstract OBJECTIVE: To determine the sensitivity and specificity of mean corpuscular volume, transferrin saturation, total iron-binding capacity, and ferritin level in determining iron deficiency in a population of anemic veterans with a wide variety of general medical diagnoses. DESIGN: Retrospective chart review. SETTING: Hospitals of the Department of Veterans Affairs in Madison and Milwaukee, Wisconsin. PARTICIPANTS: One hundred one anemic veterans with any medical condition who underwent bone marrow aspiration and serum iron studies. MEASUREMENTS AND MAIN RESULTS: Using the presence or absence of bone marrow hemosiderin as the reference standard, the sensitivity and specificity of the following serum iron indicators were calculated: mean corpuscular volume, transferrin saturation, total iron-binding capacity, and ferritin level. Of these patients, 41 (40.6%) were categorized as iron deficient, with no stainable bone marrow hemosiderin. A serum ferritin level ≤ 100 µg/L provided the best sensitivity (64.9%) and specificity (96.1%) for evaluating iron stores in this patient population. When performed within 24 hours of bone marrow examination, a serum ferritin level ≤ 100 µg/L was 100% accurate in separating iron-deficient from iron-sufficient patients. None of the other serum iron indicators alone or in combination performed better than ferritin level alone. CONCLUSIONS: In a population of anemic veterans with a wide variety of concomitant medical problems, a serum ferritin level ≤ 100 µg/L was optimal for determining iron deficiency. This is higher than the ferritin level of ≤ 50 µg/L cited in standard textbooks as evidence of iron deficiency in patients with inflammation, infection, or malignancy. Key words iron deficiency anemia feritin total iron-binding capacity transferrin saturation
Received from the University of Wisconsin Department of Medicine, Section of Geriatrics and Gerontology, and the Department of Veterans Affairs Geriatric Research, Education, and Clinical Center, Madison, Wis.
Dr. Carnes is a professor in the Department of Medicine and Director of Women’s Health at the William S. Middleton Veterans Hospital, and Dr. Kis was an internal medicine resident at the University of Wisconsin at the time this work was performed.
This work was supported by the Madison Geriatric Research Education and Clinical Center (GRECC) and the University of Wisconsin Department of Medicine.
Bunn HF. Anemia associated with chronic disorders. In: Isselbacher KJ, Martin JB, Braunwald E, Kauci AS, Wilson JD, Kasper DL, eds. Harrison’s Principles of Internal Medicine. 13th ed. New York, NY: McGraw-Hill; 1994:1732–4.
Erslev AJ. Anemia of chronic disease. In: Beutler E, Lichtman MA, Caller BS, Kipps TS, eds. Williams Hematology. 5th ed. New York, NY: McGraw-Hill; 1995:518–24.
Sears DA. Anemia of chronic disease. Med Clin North Am. 1992;76:567–79.
Kraus JR, Stolc V. Serum ferritin and bone marrow iron stores. Am J Clin Pathol. 1979;72:817–20.
Bell JD, Kincaid WR, Morgan RG, et al. Serum ferritin assay and bone-marrow iron stores in patients on maintenance hemodialysis. Kidney Int. 1980;17:237–41.
Milman N, Christensen TE, Pedersen NS, Visfeldt J. Pertoneal dialysis and hemodialysis patients with chronic renal failure. Acta Med Scand. 1980;207:201–5.
Milman N, Christensen TE, Visfelt J. Diagnostic efficacy of various laboratory tests in the assessment of bone marrow iron stores in patients with chronic uraemia. Scand J Haematol. 1981;26:257–64.
Milman N, Bangsboll S, Pedersen NS, Visfeldt J. Serum ferritin in non-dialysis patients with chronic renal failure: relation to bone marrow iron stores. Scand J Haematol. 1983;30:337–44.
Mirahmadi KS, Paul WL, Winer RL, et al. Serum ferritin level: determinant of iron requirement in hemodialysis patients. JAMA. 1977;238:601–3.
Blumberg AB, Marti HRM, Graber CG. Serum ferritin and bone marrow iron in patients undergoing continuous ambulatory peritoneal dialysis. JAMA. 1983;250:3317–9.
Beallo R, Dallman PR, Schoenfeld PY, Humphreys MH. Serum ferritin and iron deficiency in patients on chronic hemodialysis. Trans Am Soc Artif Intern Organs. 1976;22:73–9.
Hussein S, Prieto J, O’Shea M, Hoffbrand AV, Baillod RA, Moorhead JF. Serum ferritin assay and iron status in chronic renal failure and haemodialysis. BMJ. 1975;1:546–8.
Bentley DP, Williams P. Serum ferritin as an index of storage iron in rheumatoid arthritis. J Clin Pathol. 1974;27:786–8.
Bartels U, Pedersen NS, Jarnum S. Iron absorption and serum ferritin in chronic inflammatory bowel disease. Scand J Gastroenterol. 1978;13:649–56.
Vreugdenhil G, Baltus CAM, van Eijk HG, Swaak AJG. Anemia of chronic disease: diagnostic significance of erythrocyte and serological parameters in iron deficient rheumatoid arthritis patients. Br J Rheumatol. 1990;29:105–10.
Bezwoda WR, Derman DP, Bothwell TH, Baynes R, Hesdorffer C, MacPhail AP. Serum ferritin and Hodgkin’s disease. Scand J Haematol. 1985;35:505–10.
Hansen TM, Hansen NE, Birgens HS, Holund B, Lorenzen I. Serum ferritin and the assessment of iron deficiency in rheumatoid arthritis. Scand J Rheumatol. 1983;12:353–9.
Jakobsen E, Engeset A, Sandstad B, Aas M. Serum ferritin and bone marrow haemosiderin in patients with malignancies and healthy controls. Scand J Haematol. 1982;28:264–71.
Thomson ABR, Brust R, Ali MAM, Mant MJ, Valberg LS. Iron deficiency in inflammatory bowel disease: diagnostic efficacy of serum ferritin. Dig Dis. 1978;23:705–9.
Smith RJ, Davis P, Thomson ABR, Wadsworth LD, Fackre P. Serum ferritin levels in the anemia of rheumatoid arthritis. J Rheumatol. 1977;4:389–92.
Baynes RD, Bothwell TH, Bezwoda WR, Gear AJ, Atkinson P. Hematologic and iron-related measurements in rheumatoid arthritis. Am J Clin Pathol. 1987;87:196–200.
Blake DR, Waterworth RF, Bacon PA. Assessment of iron stores in inflammation by assay of serum ferritin concentrations. BMJ. 1981;283:1147–8.
Davidson A, van der Weyden MB, Fong H, Breidahl MJ, Ryan PF. Red cell ferritin content: a re-evaluation of indices for iron deficiency in the anaemia of rheumatoid arthritis. BMJ. 1984;289:648–50.
Mulherin D, Skelly M, Saunders A, et al. The diagnosis of iron deficiency in patients with rheumatoid arthritis and anemia: an algorithm using simple laboratory measures. J Rheumatol. 1996;23:237–40.
Baumann KS, Seifert B, Michel B, Ruegg R, Fehr J. Prediction of iron deficiency in chronic inflammatory rheumatic disease anemia. Br J Haematol. 1995;91:820–6.
Kurer SB, Seifert B, Michel B, Ruegg R, Fehr J. Prediction of iron in chronic inflammatory rheumatic disease anaemia. Br J Haematol. 1995;91:820–6.
Coenen JLLM, van Dieijen-Visser MP, van Pelt J, et al. Measurements of serum ferritin used to predict concentrations of bone marrow in anemia of chronic disease. Clin Chem. 1991;37:560–2.
Ali MAM, Luxton AW, Walker WHC. Serum ferritin concentration and bone marrow iron stores: a prospective study. Can Med Assoc J. 1978;118:945–6.
Mazza J, Barr RM, McDonald JWD, Valberg VS. Usefulness of the serum ferritin concentration in the detection of iron deficiency in a general hospital. Can Med Assoc J. 1978;119:884–6.
Psaty BM, Tierney WM, Martin DK, McDonald CJ. The value of serum iron studies as a test for iron-deficiency anemia in a county hospital. J Gen Intern Med. 1987;2:160–7.
Burns ER, Goldberg SN, Lawrence C, Venz B. Clinical utility of serum tests for iron deficiency in hospitalized patients. Am J Clin Pathol. 1990;93:240–5.
Punnonen K, Irjala K, Rajamaki A. Serum transferrin receptor and its ratio to serum ferritin in the diagnosis of iron deficiency. Blood. 1997;89:1052–7.
Beutler E, Robson MJ, Buttenwieser E. A comparison of the plasma iron, iron-binding capacity, sternal marrow iron, and other methods in the clinical evaluation of iron stores. Ann Intern Med. 1958;48:60–82.
Galen PS, Gambino SR. Beyond Normality: The Predictive Value and Efficiency of Medical Diagnosis. New York, NY: Wiley; 1975.
Lipschitz DA. Iron deficiency anemia, the anemia of chronic disease, sideroblastic anemia and iron overload. In: Stein JH, ed. Internal Medicine. 4th ed. Chicago, Ill: Mosby-Year Book; 1994:835–45.
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;90:85–7.
Cash JM, Sears DA. The anemia of chronic disease: spectrum of associated diseases in a series of unselected hospitalized patients. Am J Med. 1989;87:638–44.
PubMed CrossRef Copyright information
© Society of General Internal Medicine 1998