Iron deficiency anemia diagnostic study of choice

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Diagnostic Study of Choice

Study of choice

• Iron stain (Prussian blue stain) of bone marrow macrophages and erythroid precursors (sideroblasts) on marrow spicules is the gold standard test for the diagnosis of iron deficiency anemia.
• Serum ferittin is the most widely used test for the diagnosis of iron deficiency anemia as it is non invasive. However, ferritin also acts as an acute phase reactant and can be unreliable in inflammatory illness.
• Iron studies are performed to look for the cause of iron deficiency.
• Iron deficency studies are performed if anemia is found on CBC and microcytic or normocytic anemia found on peripheral blood film.

Diagnostic results

The findings of various test results that confirm iron deficiency are:

• Iron stain (prussian blue staining) of erythroid precursors (sideroblasts) on marrow spicules shows ack of stainable iron in erythroid precursors.
• Serum ferittin levels < 30ng/ml, and serum ferritin <41 ng/mL in a patient with anemia and comorbidities (chronic diseases/inflammation)
• Serum iron <60 mcg/dL.
• Total iron binding capacity/ serum transferrin- TIBC is calculated by multiplying serum transferrin by 1.389. It is increased in iron deficiency anemia and decreased in anemia of chronic disease. TIBC>350 to 400 mcg/dL is diagnostic of iron deficiency.
• Transferrin saturation (TSAT) is the ratio of serum iron to TIBC: (serum iron  ÷  TIBC  x  100). It is <15% in iron deficiency (normal is 25-40%).
• Elevated erythrocyte (RBC) zinc protoporphyrin (eg, >80 mcg/dL).
• Decreased iron stain on eryhtroid precursors.

Sequence of Diagnostic Studies

The various investigations must be performed in the following order:

• Complete blood count
• Peripheral blood film
• Iron studies:
  • Serum ferittin
  • Serum iron
  • Serum transferrin/ total iron binding capacity
  • Transferrin saturation
• Serum eryrthrocyte zinc protoporphyrin
• Iron stain (prussian blue stain) on bone marrow aspirate

Diagnostic Criteria

Hb<10 mg/dl, MCV <95fL

Serum ferritin

Ferritin <30mg/ml

Ferritin 31-99mg/ml

Ferritin >100mg/ml

• TIBC >350mcg/dl OR • Serum iron <60mcg/dl OR • Transferrin saturation <15%

• TIBC-300-350mcg/dl OR • Serum iron-60 to 150 mcg/dL OR • Transferrin saturation 25-40%

• TIBC <300mcg/dl OR • Serum iron >150mcg/dl OR • Transferrin saturation >40%

Erythrocyte zinc protoporphyrin >100ng/ml RBC

Erythrocyte zinc protoporphyrin-30-70ng/ml

Increased iron staining on erythroid precursors

Decreased/Normal iron staining on erythroid precursors

Iron deficiency anemia

Evaluate for other causes of anemia