Anemia of Inflammation in Patients with Intestinal Failure on Home Parenteral Nutrition

Abstract

Anemia is common in intestinal failure (IF), but it is unknown if anemia in IF is due to iron deficiency or another etiology. Understanding iron status is important, as deficiency and overload are both associated with multisystem morbidity and mortality. The objective was to determine the etiology of anemia in a cohort of patients with IF and characterize iron status with respect to multisystem outcomes. This was a single center retrospective cohort analysis of iron parameters from August 1998 to March 2018 in 54 IF patients (355 person years). Thirty-eight percent of measurements showed iron deficiency, 36% anemia of inflammation, 21% indeterminate iron status, and 5% suggested iron overload. Mean direct and total bilirubin were elevated when ferritin was > 200 ng/mL and in inflamed and overloaded patients compared with iron-deficient patients. For every 10% increase in Tsat, bilirubin increased by 0.58 mg/dL from baseline (p = 0.003). Tsat > 50% had a mean positive culture probability of 60%. The probability of renal disease increased over time and average GFR decreased over time (−3.14 ± 1.37 mL/min per 1.73 m 2), and nearly one in five patients in this study had chronic kidney disease (CKD). Patients with IF are at risk for both iron deficiency anemia as well as anemia of inflammation, with at a portion of patients with anemia of inflammation and overload having elevated risk of cholestasis, CKD, and infection compared to their peers. Careful assessment of inflammation, risk of infection, and renal function should be performed prior to dosing iron to ensure safe and effective delivery of this essential micronutrient. Future directions include determination of extra-renal sources of inflammation in IF.

Inflammation and micronutrient deficiency as major risk factors for anemia in children with intestinal failure: A longitudinal cohort study

“…Few studies have focused on anemia in pediatric patients with IF. In a retrospective mixed cohort of 54 adults and children, 38% of the laboratory measurements suggested iron deficiency, and 36% suggested anemia of inflammation 6 . In an elegant cross‐sectional study, Thomassen et al assessed micronutrient provision and status in 19 pediatric patients with IF.…”

“…In addition, patients with chronic or acute diseases may develop inflammation anemia, a disorder of iron distribution, in which blockage of intestinal absorption and iron retention in reticuloendothelial cells of the medulla, spleen, and liver results in decreased erythropoiesis. 4,5 Little information is available in the literature regarding anemia in children with IF 6,7 and most are based on studies in which data were collected at a single point in time. In this study, we aimed to identify the frequency of anemia and the factors associated with Hb levels in children with IF during their course of HPN.…”

“…Little information is available in the literature regarding anemia in children with IF 6,7 and most are based on studies in which data were collected at a single point in time. In this study, we aimed to identify the frequency of anemia and the factors associated with Hb levels in children with IF during their course of HPN.…”

A comparison of health‐related quality of life in chronic intestinal failure and end‐stage kidney disease: A cross‐sectional study

“…CKD, but the underlying pathophysiologic mechanisms differ. [37][38][39][40] Lastly, people undergoing both treatments may experience emotional and psychological stress due to their medical condition and treatment. 41,42 It has previously been established that both people with CIF and receiving HD have significantly poorer HRQOL compared with the general population.…”

Evaluation and Management of Iron Deficiency in Children Undergoing Intestinal Rehabilitation—A Position Paper From the NASPGHAN Intestinal Rehabilitation Special Interest Group

“…In iron-sufficient individuals, roughly two thirds of total body iron is in red blood cells (RBC) and marrow, almost one third is stored in the hepatocytes and splenic and hepatic macrophages with relatively smaller but functionally important amounts of iron distributed in other tissues (21,(23)(24)(25). The hepatic reserve is of interest to IR specialists as there is a correlation between iron overload and hepatic fibrosis, infection, and liver transplant waitlist mortality and other liverrelated complications (26)(27)(28)(29)(30)(31)(32)(33).…”