The Role of Reticulocyte Hemoglobin Content (CHr) to Early Diagnosis Iron Deficiency Anemia

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1 The Role of Reticulocyte Hemoglobin Content (CHr) to Early Diagnosis Iron Deficiency Anemia Delita Prihatni SMF/Dept Patologi Klinik RSUP Dr. Hasan Sadikin/ FK UNPAD BANDUNG

2 Introduction Iron Deficiensy Anemia (IDA) occurs due to an imbalance between intake, absorption and iron secretion in the body WHO prevalence (Anemia) : 5-19,9% Male (>15 yo) : Hb <13 g/dl Female (>15 yo) : Hb <12 g/dl Pregnant women : Hb 11 g/dl Sudikno, Sandjaya (Pusat Penelitian dan Pengembangan Upaya Kesehatan Masyarakat, Badan Litbangkes) : Tasikmalaya & Ciamis : reproductive female 9,6 %.

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4 Michelle P. Zeller and Madeleine Verhovsek CMAJ March 13, (10)

5 High Risk of Iron Def Anemia The Centers for Disease Control and Prevention (CDC) Reproductive woman & iron supplementation to pregnancy woman The American Academy of Pediatricians (AAP). The 2005 : breastfeeding. High risk infantchildren (12yo) 10% pddk (2016) The earliest prenatal visit and early in the third trimester The American College of Obstetricians and Gynecologists (ACOG). Iron def anemia The American Academy of Family Physicians (AAFP)

6 Assesment of Body Iron Status Rodak BF, Fritsma GA, M.Keohane E, Hematology, Clinical Principles and application (2016)

7 1. MCV and MCH values are useful at diagnosis and in assessing trends over periods of weeks or months. 2. % hypochromic red cells (%HRC) is the best-established variable for the identification of functional iron deficiency (FID), CHr is the next most established option. 3. CHr value <29 pg predicts FID in patients receiving ESA therapy. 4. CHR <25 pg is suggestive of classical ID 5. CHR : pg as best predictive value for likelihood of response to intravenous iron therapy in CKD patients on haemodialysis 6. CHr is the best predictive value for likelihood of response to intravenous iron therapy 7. Serum ferritin concentration is not useful in predicting ESA responsiveness in cancer-related anaemia. 8. Ferritin <12 lg/l indicate absent iron stores. 9. stfr + the ferritin assay, if automated measures such as %HRC, CHr or Ret-He are unavailable British Journal of Haematology, 2013

8 Development of iron deficiency anemia Rodak BF, Fritsma GA, M.Keohane E, Hematology, Clinical Principles and application (2016)

9 Screening for iron deficiency anemia Primary care CBC and assessment of the hematological parameters: Hb/Ht or Eritr Secondary Tertiary care indicators of iron metabolism iron levels, transferrin saturation, serum circulating transferrin receptor, ferritin Reticulocyte Hemoglobin content (CHr) (early indicator of iron deficiency) Journal of Adolescent Health 36 (2005)

10 Reticulocyte Hemoglobin content (CHr) The CHR is a measure to amount of Hb in the reticulocyte The CHR is a reasonably good reflection of how much iron was available to the bone marrow for incorporation into new red blood cells a few days before. Reticulocyte released into circulation about 2 days prior to maturation into new red blood cells. The CHR compares favorably with serum ferritin in predicting a response to intravenous iron Strongest predictor of iron deficiency and iron deficiency anemia highest sensitivity and specificity early indicator of response to iron treatment inexpensive test Limitation : Sample stability

11 Study Comparison Author CHr Results Mast AE, Blinder MA, Lu Q, Flax S, Dietzen DJ. (Blood 2002) Thomas C, Thomas L. (Clin Chem 2002) CHr <28 pg vs Prussiian Blue (bone marrow) CHr < 28 pg sensitivity (74%) specificity (73%) functional iron deficiencydialysis patients. Mustafa K, Eren G, Fezan S M, Meltem O (Turk J Hematol 2013) Riadi Wirawan, Ailinda T. Tedja, Fify Henrika, Aida Lydia (Acta Med Indonesia 2017) CHR: 29pg predict IDA sensitivity (90,6%) specificity (66,7%) hemoglobin, MCV, MCH, and TS ( r>0.7 ) CHR : 29,2 pg - CKD sensitivity (95,5 %) specificity (94 %)

12 Thomas Plot True iron deficiency : the stfr and the ferritin (the stfr/log ferritin will be high and the will be low) Functional iron deficiency Ferritin may be falsely elevated by inflammation : the stfr/ log ferritin will be normal, CHR will be low Latent iron deficiency : the body s need iron : stfr production ferritin (the stfr/log ferritin value: high)

13 - Combination of RET-He (<32 pg) and anemia (Hb <11 g/dl) were used to rule out iron deficiency anemia - RET- He and its CHr equivalent are routinely available with automated reticulocyte analysis CHr, can clearly separate patients with a higher likelihood of needing a transfusion from those with a lower likelihood. In addition, these functionally iron deficient patients might conceivably be a suitable target for preemptive treatment options such as intravenous iron therapy. Anesthesiology 2010; 112:1211 5

14 Screening Algorithm using CHr for Iron Deficiency Journal of Adolescent Health 36 (2005) 529.e1 529.e6

15 Sample Preparation Obtain samples before the initiation of dialysis. Avoid contaminating blood with heparin or saline. Use luer adapter to collect specimen directly into lavender top tube avoid using syringes. Be sure to mix samples by gently inverting 5 times after collection. Refrigerate specimens promptly while awaiting shipment. Do not freeze.

16 Summary - CHr Test to screen for iron deficiency anemia may increase the accuracy of diagnosis, enabling early detection and treatment of iron deficiency - The measurement is not affected by physiologic interferences

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