{"id":40659,"date":"2021-09-30T11:14:30","date_gmt":"2021-09-30T11:14:30","guid":{"rendered":"https:\/\/biomedpharmajournal.org\/?p=40659"},"modified":"2021-10-11T08:26:31","modified_gmt":"2021-10-11T08:26:31","slug":"reticulocyte-hemoglobin-content-as-a-best-indicator-of-iron-deficiency-in-female-patients-with-diffuse-non-scarring-hair-loss","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol14no3\/reticulocyte-hemoglobin-content-as-a-best-indicator-of-iron-deficiency-in-female-patients-with-diffuse-non-scarring-hair-loss\/","title":{"rendered":"Reticulocyte Hemoglobin Content as a Best Indicator of Iron Deficiency in Female Patients with Diffuse Non-Scarring Hair Loss"},"content":{"rendered":"

Introduction<\/strong><\/p>\n

Iron deficiency is a well-known cause of diffuse non-scarring hair loss in women1<\/sup>. One of the rapidly diving cells in the body is the hair follicle matrix cells and iron is a cofactor for the ribonucleotide reductase which is the rate-limiting enzyme for DNA synthesis and, also is a regulator for multiple genes in the hair follicles 2<\/sup>. Iron deficiency without anemia is far more prevalent and\u00a0about two-folds higher than iron deficiency anemia and iron deficiency is more prevalent in women than men\u00a03<\/sup>. Iron deficiency with or without anemia is more common in menstruating women, black race, athletes, vegetarians and obese or\u00a0overweight 4-8<\/sup>. The most common cause of iron deficiency in premenopausal women is menstrual blood loss and in postmenopausal women is gastrointestinal blood loss 9, 10<\/sup>. Laboratory markers for iron deficiency anemia include low\u00a0hemoglobin levels, low mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH), increase red cell distribution width, decrease serum ferritin, decrease transferrin saturation (TSAT) and low reticulocyte hemoglobin content\u00a011<\/sup><\/p>\n

The purpose of the study is to evaluate the best laboratory markers of iron deficiency among women with diffuse non-scarring hair loss which was attributed to iron deficiency.<\/p>\n

Methods<\/strong><\/p>\n

This was a cross-sectional descriptive study conducted on patients with diffuse hair loss consulted outpatient dermatology clinic at Al-Sader Teaching Hospital from November 1, 2020, to May 1, 2021. The study was approved by the Institutional\u00a0Review Board of the University of Basrah and Ministry of Health. Patients more than 18 years old with diffuse hair loss and iron deficiency were included in the study. Iron deficiency state was confirmed by any one of the following parameters\u00a0(serum ferritin below 30 ng\/ml,transferrin saturation below 20% or reticulocyte hemoglobin content below 29 pg). Patients with coexistent vitamin D and zinc deficiency and other medical causes of hair loss such as thyroid disease were\u00a0excluded from the study. Data were collected on patients\u2019 age, gender, body mass index and history of chronic medical diseases. Patients were examined for types of hair loss. Investigations were sent including complete blood count, serum ferritin,\u00a0transferrin saturation (TSAT) and reticulocyte hemoglobin content (CHr). The CHr was reported from the CBC by using Siemens ADVIA 2120 (Siemens, Tarrytown, NY). Statistical analysis was descriptive in term of frequencies and percentages using SPSS version 25.<\/p>\n

Results<\/strong><\/p>\n

From November 1, 2020, to May 1, 2021, 51 patients with diffuse hair loss and iron deficiency were studied. Table 1 shows the baseline characteristics of the patients. The mean ages were 28 \u00b1 10.5 years, all were females, the BMI were 26.5\u00a0\u00b1 5 and all have no medical diseases. Table 2 shows the percentages of iron deficiency parameters in patients with iron deficiency state. Low reticulocyte hemoglobin content was reported in 98%, low transferrin saturation in 84.3% and low ferritin in 54.9%.<\/p>\n

Table 1: Baseline characteristics of the patients with diffuse hair lossand iron deficiency state (n = 51)<\/strong><\/p>\n\n\n\n\n\n\n\n\n
Characteristics<\/td>\nValues<\/td>\n<\/tr>\n
Age (years)<\/td>\n28 \u00b1 10.5<\/td>\n<\/tr>\n
Females<\/td>\n51 (100)<\/td>\n<\/tr>\n
Body mass index (BMI)<\/td>\n26.5 \u00b1 5<\/td>\n<\/tr>\n
Medical diseases<\/td>\n0 (0)<\/td>\n<\/tr>\n
Iron deficiency state<\/td>\n51 (100)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Values are expressed as Mean \u00b1 SD, n (%). Iron deficiency state defined as serum ferritin below 30 ng\/ml, transferrin saturation below 20% or reticulocyte hemoglobin content below 29 pg.<\/p>\n

Table 2: Percentages of iron deficiency parameters in patients with iron deficiency state& hair loss \u00a0(n = 51)<\/strong><\/p>\n\n\n\n\n\n\n
Iron deficiency parameters<\/td>\nValues<\/td>\n<\/tr>\n
Low reticulocyte hemoglobin content (CHr)<\/td>\n50 (98)<\/td>\n<\/tr>\n
Low transferrin saturation (TSAT)<\/td>\n43 (84.3)<\/td>\n<\/tr>\n
Low serum ferritin<\/td>\n28 (54.9)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Values are expressed as n (%). Iron deficiency state defined as serum ferritin below 30 ng\/ml, transferrin saturation below 20% or reticulocyte hemoglobin content below 29 pg.<\/p>\n

Discussion<\/strong><\/p>\n

Of total 51 patients with hair loss and iron deficiency, reticulocyte hemoglobin content (CHr) showed the highest frequency of iron deficiency, followed by TSAT whereas serum ferritin showed the lowest.<\/p>\n

Hemoglobin may be normal because iron deficiency state may occur without anemia. Both MCV and MCH reflect iron availability for erythropoiesis but they have certain limitations for diagnosis of iron deficiency state include the\u00a0followings: they are a late finding, slow to change, not reflect iron availability for erythropoiesis and not helpful in assessing response to therapy 12-14<\/sup>. Also, MCV may be normal in cases of iron deficiency during pregnancy, in an elderly with\u00a0coexistent nutritional deficiency such as folic acid and B12 and in patients with medical diseases that already increase the MCV such as liver disease 15-17<\/sup>. So, in our study because of these limitations and inaccuracy of both MCV and MCH,\u00a0we don\u2019t use these parameters for assessment of iron deficiency state. Serum ferritin is required for diagnosis of iron deficiency, and it reflect iron store (15). It is a stable glycoprotein and not affected by recent iron ingestion (18). Itis an acute phase\u00a0reactant and increased in inflammatory conditions making it invaluable for diagnosis of iron deficiency (19). In our study, more than 50% of cases with proved iron deficiency state have normal or even higher serum ferritin so normal\u00a0serum ferritin is not helpful to rule out iron deficiency state. Serum iron has many limitations for diagnosis of iron deficiency: it is affected by recent iron ingestion and has diurnal variation 20, 21<\/sup>. The TSAT indicate iron deficient erythropoiesis\u00a0rather than iron depletion state 13<\/sup>. It is also reduced in inflammation 22<\/sup>. The CHr measures the hemoglobin content of the newest RBCs thus indicating the iron availability over the previous 3-4 days so it reflect a real-time assessment of iron\u00a0availability over the previous 3-4 days so it reflect a real-time assessment of iron deficient erythropoiesis and assess response to iron therapy 23<\/sup>. Its levels are only slightly reduced in inflammation 24<\/sup>. It is helpful in diagnosis of both absolute\u00a0\u00a0and functional iron deficiency state when serum ferritin and TSAT are unhelpful.<\/p>\n

The study has many limitations. First, it is a cross-sectional descriptive study and not a prospective study or randomized controlled trial. Second, no control groups\u00a0were taken so we can\u2019t determine the positive and negative predictive value of the tests studied. Third, no follow up measurement of these parameters to assess response to iron therapy.<\/p>\n

Conclusion<\/strong><\/p>\n

The reticulocyte hemoglobin content (CHr)shows the highest frequency of iron deficiency in patients with diffuse hair loss and iron deficiency state.<\/p>\n

References<\/strong><\/p>\n

    \n
  1. Trost LB, Bergfeld WF, Calogeras E. The diagnosis and treatment of iron deficiency and its potential relationship to hair loss. J Am Acad Dermatol. 2006;54(5):824-44.
    \nCrossRef<\/a><\/li>\n
  2. Guo EL, Katta R. Diet and hair loss: effects of nutrient deficiency and supplement use. Dermatol Pract Concept. 2017;7(1):1-10.
    \n    CrossRef<\/a><\/li>\n
  3. Petry N, Olofin I, Hurrell RF, Boy E, Wirth JP, Moursi M, et al. The Proportion of Anemia Associated with Iron Deficiency in Low, Medium, and High Human Development Index Countries: A Systematic Analysis of National Surveys. Nutrients. 2016;8(11).
    \n    CrossRef<\/a><\/li>\n
  4. Siu AL. Screening for Iron Deficiency Anemia and Iron Supplementation in Pregnant Women to Improve Maternal Health and Birth Outcomes: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2015;163(7):529-36.
    \n    CrossRef<\/a><\/li>\n
  5. Haider LM, Schwingshackl L, Hoffmann G, Ekmekcioglu C. The effect of vegetarian diets on iron status in adults: A systematic review and meta-analysis. Crit Rev Food Sci Nutr. 2018;58(8):1359-74.
    \n    CrossRef<\/a><\/li>\n
  6. Sekhar DL, Murray-Kolb LE, Kunselman AR, Weisman CS, Paul IM. Differences in Risk Factors for Anemia Between Adolescent and Adult Women. J Womens Health (Larchmt). 2016;25(5):505-13.
    \n    CrossRef<\/a><\/li>\n
  7. Cepeda-Lopez AC, Melse-Boonstra A, Zimmermann MB, Herter-Aeberli I. In overweight and obese women, dietary iron absorption is reduced and the enhancement of iron absorption by ascorbic acid is one-half that in normal-weight women. Am J Clin Nutr. 2015;102(6):1389-97.
    \n    CrossRef<\/a><\/li>\n
  8. Reinke S, Taylor WR, Duda GN, von Haehling S, Reinke P, Volk HD, et al. Absolute and functional iron deficiency in professional athletes during training and recovery. Int J Cardiol. 2012;156(2):186-91.
    \n    CrossRef<\/a><\/li>\n
  9. Short MW, Domagalski JE. Iron deficiency anemia: evaluation and management. Am Fam Physician. 2013;87(2):98-104.<\/li>\n
  10. Percy L, Mansour D, Fraser I. Iron deficiency and iron deficiency anaemia in women. Best Pract Res Clin Obstet Gynaecol. 2017;40:55-67.
    \n    CrossRef<\/a><\/li>\n
  11. Guyatt GH, Oxman AD, Ali M, Willan A, McIlroy W, Patterson C. Laboratory diagnosis of iron-deficiency anemia: an overview. J Gen Intern Med. 1992;7(2):145-53.
    \n    CrossRef<\/a><\/li>\n
  12. Thomas DW, Hinchliffe RF, Briggs C, Macdougall IC, Littlewood T, Cavill I. Guideline for the laboratory diagnosis of functional iron deficiency. Br J Haematol. 2013;161(5):639-48.
    \n    CrossRef<\/a><\/li>\n
  13. Mikhail A, Brown C, Williams JA, Mathrani V, Shrivastava R, Evans J, et al. Renal association clinical practice guideline on Anaemia of Chronic Kidney Disease. BMC Nephrol. 2017;18(1):345.
    \n    CrossRef<\/a><\/li>\n
  14. Clark SF. Iron deficiency anemia. Nutr Clin Pract. 2008;23(2):128-41.
    \n    CrossRef<\/a><\/li>\n
  15. Pavord S, Daru J, Prasannan N, Robinson S, Stanworth S, Girling J. UK guidelines on the management of iron deficiency in pregnancy. Br J Haematol. 2020;188(6):819-30.
    \n    CrossRef<\/a><\/li>\n
  16. Busti F, Campostrini N, Martinelli N, Girelli D. Iron deficiency in the elderly population, revisited in the hepcidin era. Front Pharmacol. 2014;5:83.
    \n    CrossRef<\/a><\/li>\n
  17. Intragumtornchai T, Rojnukkarin P, Swasdikul D, Israsena S. The role of serum ferritin in the diagnosis of iron deficiency anaemia in patients with liver cirrhosis. J Intern Med. 1998;243(3):233-41.
    \n    CrossRef<\/a><\/li>\n
  18. Pavord S, Myers B, Robinson S, Allard S, Strong J, Oppenheimer C. UK guidelines on the management of iron deficiency in pregnancy. Br J Haematol. 2012;156(5):588-600.
    \n    CrossRef<\/a><\/li>\n
  19. Thurnham DI, McCabe LD, Haldar S, Wieringa FT, Northrop-Clewes CA, McCabe GP. Adjusting plasma ferritin concentrations to remove the effects of subclinical inflammation in the assessment of iron deficiency: a meta-analysis. Am J Clin Nutr. 2010;92(3):546-55.
    \n    CrossRef<\/a><\/li>\n
  20. Fisher AL, Nemeth E. Iron homeostasis during pregnancy. Am J Clin Nutr. 2017;106(Suppl 6):1567s-74s.
    \n    CrossRef<\/a><\/li>\n
  21. Pfeiffer CM, Looker AC. Laboratory methodologies for indicators of iron status: strengths, limitations, and analytical challenges. Am J Clin Nutr. 2017;106(Suppl 6):1606s-14s.
    \n    CrossRef<\/a><\/li>\n
  22. Peyrin-Biroulet L, Williet N, Cacoub P. Guidelines on the diagnosis and treatment of iron deficiency across indications: a systematic review. Am J Clin Nutr. 2015;102(6):1585-94.
    \n    CrossRef<\/a><\/li>\n
  23. Goodnough LT, Nemeth E, Ganz T. Detection, evaluation, and management of iron-restricted erythropoiesis. Blood. 2010;116(23):4754-61.
    \n    CrossRef<\/a><\/li>\n
  24. Canals C, Remacha AF, Sard\u00e1 MP, Piazuelo JM, Royo MT, Romero MA. Clinical utility of the new Sysmex XE 2100 parameter – reticulocyte hemoglobin equivalent – in the diagnosis of anemia. Haematologica. 2005;90(8):1133-4<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

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