Received 2014 Oct 9; Accepted 2014 Nov 21. The treatment of absolute IDA has been extensively reviewed elsewhere,26,27 but the mainstay of the recommendations for ID in patients with CIC must include investigating underlying causes and implementing appropriate iron supplementation. Bregman DB, Morris D, Koch TA, He A, Goodnough LT. Hepcidin levels predict nonresponsiveness to oral iron therapy in patients with iron deficiency anemia. Can iron deficiency cause high CRP? Study record managers: refer to the Data Element Definitions if submitting registration or results information.. Search for terms Adequate iron stores are expected in the green areas, but caution is recommended for patients in the dark green area (TSAT >20% and ferritin >500 g/L) if they are receiving parenteral iron, because they may be at risk of iatrogenic iron overload. Data include patients with HF, dialytic CKD or ndCKD, HIV infection, IBDs,36 and data from a systematic review of 38 studies in nonhealthy patients, including blood disorders, liver conditions, rheumatoid arthritis, among others.19 The area in red represents the thresholds for absolute ID recommended by WHO (ferritin >30 g/L and TSAT >16%). The .gov means its official. ? In line with these results, standardized AUC showed no statistically significant differences between high- and low-CRP groups in i.v. 1a, p<0.05). TSAT <25% yielded maximum sensitivity of 71%.24 In another study, BMID was identified in only 50% of patients with both TSAT <20% and ferritin <100 g/L, but TSAT <20% alone had a sensitivity of 85% and specificity of 48%.25 Those data suggest that underlying ID can still be considered in patients with CKD with TSAT of 20% to 25%, whereas for other CICs, TSAT <20% along with judicious evaluation of ferritin to diagnose ID seems appropriate. A growing portfolio is currently available in the United States: low-molecular-weight iron dextran, iron sucrose, ferric gluconate, ferumoxytol, ferric carboxymaltose (FCM), and ferric derisomaltose (previously known as iron isomaltoside; Table 3). Of note, the efficacy data presented here are not confounded by compliance issues since adherence was monitored in the trial and was excellent (99.2%) [15]. Iron saturation in ACD is typically >5% but <15%, and reduced TIBC is also suggestive of ACD. Can anemia cause high CRP and ESR? Following an inflammatory stimulus, causing, for example, IL6 expression which can directly induce CRP expression in the liver, CRP levels rise rapidly to peak levels of 350400mg/L. The Biomarkers Reflecting Inflammation and Nutrition Determinants of Anemia (BRINDA) research group found that a regression correction of ferritin using CRP >5 mg/L and AGP >1 g/L increased the prevalence of ID by 3% to 7%, even in countries with a low burden of infection, such as the United States,15,16 and a different regression correction using CRP and albumin increased the prevalence of ID from 7% to 24% in another study.17 Therefore, in areas of widespread inflammation or infection, the 2020 WHO guidelines18 strongly endorse the measurement of CRP and AGP, but make a conditional recommendation to use a ferritin threshold of 70 g/L to define iron deficiency in patients with CRP >5 mg/L or AGP >1 g/L or to implement arithmetic or regression correction of ferritin levels based on those markers. Correlations were estimated with Pearsons product-moment method. Figure 3 shows TSAT and ferritin levels found in patients with different CICs, with and without BMID. If you have a Best Practice personal account, your own subscription or have registered for a free trial, log in here: If your hospital, university, trust or other institution provides access to BMJ Best Practice through services such as OpenAthens or Shibboleth, log in via this button: If you have been provided an access code, you can register it here: For any urgent enquiries please contact our customer services team who are ready to help with any problems. There was no imputation of missing data; analyses are based on the observed data. Anemia can have many different causes. A systematic review19 examined 38 studies of BM iron in nonhealthy adults with rheumatoid arthritis, liver disease, hematologic disorders, and other CICs. Before The guideline may not apply to all patients with chronic inflammatory conditions (CICs), such as obesity, chronic kidney disease (CKD), liver disease, and heart failure (HF), in whom an increase in CRP is frequently absent, or where AGP measurements are not routinely available. Before starting parenteral iron, patients should be informed about potential adverse events. Yellow striped areas represent areas in which iron supplementation may be considered, depending on the CIC; only patients with CKD are likely to benefit from iron supplementation with ferritin <200 g/L and TSAT of 20% to 25%, whereas patients with HF or CKD treated with erythropoiesis-stimulating agents (ESAs) and/or hemodialysis may be considered for iron supplementation if TSAT is <20% and ferritin is up to 500 g/L. Severe hypophosphatemia (below 1.0 mg/dL or 0.3 mmol/L) is exceedingly rare but requires parenteral phosphate infusion to prevent seizures and arrhythmias. Beate Rzychon (Vifor Pharma Ltd, Switzerland) reviewed and commented on the manuscript. Patients with an underlying condition that causes iron deficiency anemia should be treated or referred to a subspecialist (e.g., gynecologist, gastroenterologist) for definitive treatment. Ferritin is an acute-phase protein and its serum levels are elevated during inflammation, reflecting the inflammatory state rather than iron stores. Fillet G, Beguin Y, Baldelli L. Model of reticuloendothelial iron metabolism in humans: abnormal behavior in idiopathic hemochromatosis and in inflammation. Another common symptom is restless leg syndrome (RLS), which is an unpleasant urge to move the legs during periods of inactivity. The study design has been reported previously [15]. SKD received speaker honoraria from Vifor International. These effects may be reduced when iron is taken with meals, but absorption may decrease by 40 percent.1 Medications such as proton pump inhibitors and factors that induce gastric acid hyposecretion (e.g., chronic atrophic gastritis, recent gastrectomy or vagotomy) are associated with reduced absorption of dietary iron and iron tablets.31, Parenteral therapy may be used in patients who cannot tolerate or absorb oral preparations, such as those who have undergone gastrectomy, gastrojejunostomy, bariatric surgery, or other small bowel surgeries. The dosage of elemental iron required to treat iron deficiency anemia in adults is 120 mg per day for three months; the dosage for children is 3 mg per kg per day, up to 60 mg per day.1 An increase in hemoglobin of 1 g per dL after one month of treatment shows an adequate response to treatment and confirms the diagnosis.16 In adults, therapy should be continued for three months after the anemia is corrected to allow iron stores to become replenished7 (Figure 36,28,31 ). In patients with chronic diarrhea, high epithelial turnover impairs absorption and mucosal inflammation can cause bleeding. Both ID and FID have hypoferremia but low TIBC, and high ferritin characterizes FID. Low red cell mass occurs secondary to chronic reduction in iron availability, impairing the incorporation of the metal into the porphyrin ring to form heme, making hemoglobinization of erythroid precursors in the bone marrow (BM) incomplete.2 In IDA, mature erythrocytes are typically hypochromic (with low mean corpuscular hemoglobin [MCH; <28 pg]) and microcytic (with low mean corpuscular volume [MCV; <80 fL]). Our results suggest that CRP may be useful to identify IBD patients who can benefit from first-line treatment with i.v. Background: Iron deficiency anemia (IDA) is a common complication of inflammatory bowel disease (IBD). Poor management of anemia can significantly affect the quality of life and lead to an increase in hospitalization rates and associated medical costs [2, 3]. In young children iron-deficiency anemia can cause significant motor, mental, and behavior abnormalities that are long-lasting. Van Assche G, Dignass A, Bokemeyer B, Danese S, et al. All adult men and postmenopausal women with iron deficiency anemia should be screened for gastrointestinal malignancy. CRP is a readily available laboratory value that is usually included in the routine assessment of IBD patients. This hepcidin block during inflammation leads to diminished amounts of free iron available for erythropoiesis [5]. Patients can also call 8-1-1 to speak . Normal values for CRP range between 0.20 and 6.10mg/L [8]. A significant difference was observed in the overall population at week 8 only (Fig. Most patients with CICs in association with true ID are found to have TSAT<20% and ferritin <200 g/L (red). Patients were stratified by baseline IL-6 levels into a high-IL-6 (>6pg/mL; n=95) and a low-IL-6 (6pg/mL; n=95) groups, and responsiveness to iron supplementation (Hb change from baseline) was compared. Iron-deficiency anemia can also cause you to feel dizzy or lightheaded. Free Online Library: Ready-to-Use Therapeutic Foods Fail to Improve Vitamin A and Iron Status Meaningfully during Treatment for Severe Acute Malnutrition in 6-59-Month-old Cambodian Children. This study investigated whether systemic inflammation at initiation of treatment (assessed by C-reactive protein [CRP] and interleukin-6 [IL-6] measurements) predicts response to iron therapy. Overall, validation of the current findings in a larger patient sample is needed, including the investigation of potential differences in the predictive power for CD and UC patients, before clinical recommendations can be made. In patients with CD, the risk of folate deficiency is high, reaching up to 20-30% at CD diagnosis [13,18,19]. Iron deficiency (ID) is the most common nutritional deficiency affecting children undergoing intestinal rehabilitation (IR). Oral treatment is cost effective, easily available, and should always be considered. iron therapy was retrospectively analyzed in an IBD patient population from a previously reported phase III clinical trial [15]. Serum ferritin concentrations for the assessment of iron status and iron deficiency in populations, Laboratory diagnosis of iron-deficiency anemia: an overview, New diagnostic tools for delineating iron status, Discordance between erythrocyte sedimentation rate and C-reactive protein measurements: clinical significance, Properties of four acute phase proteins: C-reactive protein, serum amyloid A protein, alpha 1-acid glycoprotein, and fibrinogen, Quantitative data on the magnitude of the systemic inflammatory response and its relationship with serum measures of iron status, Assessment of iron status in settings of inflammation: challenges and potential approaches, Adjusting ferritin concentrations for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project, Regression correction equation to adjust serum iron and ferritin concentrations based on C-reactive protein and albumin in patients receiving primary and secondary care, Are current serum and plasma ferritin cut-offs for iron deficiency and overload accurate and reflecting iron status? In the CKD population, ferritin values vary more broadly. Data Sources: A PubMed search was completed in Clinical Queries using the key terms iron deficiency and anemia. She asked whether she could take iron tablets or should receive iron injections, which she had heard carry a risk for allergic reactions. iron group are small, they may be important in clinical practice, where response to oral iron is often compromised by adherence problems. This cutoff is very close to the 5mg/L cutoff which is commonly used in clinical practice to identify the presence of inflammation. Impaired intestinal iron absorption in Crohns disease correlates with disease activity and markers of inflammation. Clinical Significance of C-Reactive Protein Levels in Predicting A ferritin test helps your doctor understand how much iron your body stores. Ferritin test - Mayo Clinic Nevertheless, ESR varies with hematocrit and is driven mostly by the production of fibrinogen and immunoglobulins, which last for several days in the circulation, whereas CRP is mainly produced by the liver in response to cytokines, particularly IL-6, and has a much shorter half-life; discrepancies between ESR and CRP are unsurprisingly common.12 CRP >50 mg/L is frequent in bacterial infections, making it an excellent marker of acute inflammation, whereas the less-noted -1-acid glycoprotein (AGP) increases later in the inflammatory process and is more suitable for confirming chronic inflammation.13 Because ferritin increases >5 times in patients with CRP >80 mg/L than in those with CRP <10 mg/L,14 studies have examined the possibility of correcting ferritin for inflammatory activity. Conflict-of-interest disclosure: The author declares no competing financial interests. AUC was also statistically significantly different in the subgroup of UC patients (high vs. low CRP, LS means: 22.7 vs. 31.2; p=0.031) but did not reach statistical significance in CD patients despite a large numerical difference (high vs. low CRP, LS means: 18.3 vs. 25.6; p=0.250). The history should focus on potential etiologies and may include questions about diet, gastrointestinal (GI) symptoms, history of pica or pagophagia (i.e., compulsive consumption of ice), signs of blood loss (e.g., epistaxis, menorrhagia, melena, hematuria, hematemesis), surgical history (e.g., gastric bypass), and family history of GI malignancy. Iron deficiency anemia was confirmed by percent transferrin saturation < 20 %. Anemia of chronic disease/anemia of inflammation - UpToDate CRP is routinely measured in IBD patients and forms part of the recommended diagnostic workup in patients with anemia (hemoglobin [Hb]<12g/dL in non-pregnant women, <13g/dL in men) [3, 9]. For both markers, there was no significant relationship with baseline Hb levels (CRP: R=0.0191, p=0.791; IL-6: R=0.0393, p=0.590). CRP . Because the anemia is mild and the history and laboratory values are consistent with iron. Skin discoloration from extravasation is also a possible complication and patients should be informed of that particular risk. One of the functions of an acute-phase reaction is to prevent iron from being scavenged by pathogens. She received an infusion of FCM uneventfully. Elevated CRP 10 mg/L occurred in 3.3% (95% CI: 2.5 to 4.2). iron (ferric carboxymaltose). FOIA SV is an employee of Vifor Pharma Ltd. CG has received grant and consultancy honoraria from Vifor Pharma Ltd, Pharmacosmos A/S, Fresenius Medical Care, and Renapharma Sweden. The results of this study suggest that patients with IBD and IDA, who have elevated CRP at initiation of treatment, may benefit from first-line treatment with i.v. Elevated hepcidin in inflammation is . Hematology Am Soc Hematol Educ Program 2020; 2020 (1): 478486. IBD patients with ACD had impaired oral iron absorption which correlated with disease activity and inflammatory markers but was independent of disease location and type of IBD (UC or CD). 3 Animal models of hyperthyroidism demonstrate decreased circulating plasma iron and increased hepatic iron and ferritin. Hb response to i.v. Iron deficiency anemia (IDA) is a common complication of inflammatory bowel disease (IBD). IV iron preparations: test dose, dosage, side effects, and average wholesale pricing. Most IBD patients become iron deficient at some stages of the disease [3, 4]. Ferritin and TSAT ranges reported by studies that evaluated BM iron in patients with CICs. Iron metabolism in patients with Graves' hyperthyroidism Recent data suggest that there are also other pro-inflammatory pathways modulating duodenal iron absorption. Tumour necrosis factor alpha causes hypoferraemia and reduced intestinal iron absorption in mice. A newer formulation, ferumoxytol, can be given over five minutes and supplies 510 mg of elemental iron per infusion, allowing for greater amounts of iron in fewer infusions compared with iron sucrose.2, There are no standard recommendations for follow-up after initiating therapy for iron deficiency anemia; however, one suggested course is to recheck complete blood counts every three months for one year. Diagnosis of iron deficiency anemia requires laboratory-confirmed evidence of anemia, as well as evidence of low iron stores.4 Anemia is defined as a hemoglobin level two standard deviations below normal for age and sex (Table 1).5, A complete blood count can be helpful to determine the mean corpuscular volume or red blood cell size. Iron deficiency is the most common nutritional disorder worldwide and accounts for approximately one-half of anemia cases. Shortness of breath and nausea. Intravenous iron can for the most part overcome the hepcidin block [24] and is therefore advisable in IBD patients with pronounced disease activity [3, 9]. Hepcidin-mediated ferroportin blockade traps iron inside cells, such as hepatocytes and macrophages, which in turn produce ferritin to store iron safely. Iron Deficiency Anemia in Chronic Kidney Disease - FullText - Acta High levels of 40-200 mg/L ?will occur in active inflammation or chronic bacterial infection. Jrgen Stein, Email: ed.trufknarf-inu.me@niets.j. Enterocytes are prevented from exporting absorbed iron (Fe) to transferrin (T) in the bloodstream. National Library of Medicine Other indications for parenteral iron include GI tract resection (including bariatric surgery), prolonged use of inhibitors of iron absorption (eg, proton pump inhibitors), and GI intolerance to oral iron (reported in 30% to 70% of patients). Overlap of ID and other disorders, such as chronic liver or kidney disease, may prevent the MCH and MCV from decreasing, and such indices also become unreliable for use in screening for ID in the presence of thalassemia trait, a frequent hereditary anemia. sharing sensitive information, make sure youre on a federal Iron Status in Infants in Ethiopia. - Full Text View - ClinicalTrials.gov Confusion or changes in speech. Schematic representation of the regulation of iron metabolism in FID in CICs. Hepcidin immunoassays may detect inactive forms as well as the biologically active form, hepcidin-25, and measurements can vary up to tenfold between different assays, making it difficult to determine reference values [22]. See permissionsforcopyrightquestions and/or permission requests. the contents by NLM or the National Institutes of Health. Patients with high baseline CRP achieved a lower Hb response with oral iron therapy. iron treatment appears to be independent of inflammatory status in IBD patients. Hematuria and epistaxis should be included in the inquiry because patients frequently fail to mention them. Hepcidin binds to the iron exporter ferroportin located on the basolateral surface of gut enterocytes and causes its internalization and degradation. Among iron tablet-treated patients, Hb increase was significantly smaller in the high- versus low-CRP subgroup (1.1 vs. 2.0, 2.3 vs. 3.1, and 3.0 vs. 4.0g/dL at weeks 2, 4, and 8, respectively; all p<0.05). The correlation between the degree of inflammation and response to oral or i.v. Men and postmenopausal women should not be screened, but should be evaluated with gastrointestinal endoscopy if diagnosed with iron deficiency anemia. Iron restriction eventually leads to the anemia of inflammation. Iron deficiency anemia (IDA) is the most common cause of anemia worldwide. Stefanie Kulnigg-Dabsch, Email: ta.ca.neiwinudem@hcsbad.einafets. Iron deficiency anemia signs and symptoms may include: Extreme fatigue Weakness Pale skin Chest pain, fast heartbeat or shortness of breath Headache, dizziness or lightheadedness Cold hands and feet Inflammation or soreness of your tongue Brittle nails Unusual cravings for non-nutritive substances, such as ice, dirt or starch Insufficient dietary intake of iron . >20%: hypotension and muscle cramps in hemodialysis patients; Incidence unknown: hypotension, flushing, headache, urticaria, GI symptoms, anaphylaxis, injection site reaction, myalgia, dyspnea, wheezing, fever. Haematologica 2011; 96:1761. Fe, elemental iron; LR, label recommendation. CD Crohns disease, Hb hemoglobin, IL-6 interleukin-6, i.v. In patients with chronic inflammation, iron deficiency anemia is likely when the ferritin level is less than 50 ng per mL (112.35 pmol per L).7 Ferritin values greater than or equal to 100 ng per mL (224.70 pmol per L) generally exclude iron deficiency anemia.9,10, In patients with no inflammatory states and in whom the ferritin level is indeterminate (31 to 99 ng per mL [69.66 to 222.45 pmol per L]), further tests can be performed to ascertain iron status. Supplemental iron may be given initially, followed by further workup if the patient is not responsive to therapy. 1b, p<0.05) and tended to be smaller until week 8 compared to the low-CRP group. The entered sign-in details are incorrect. Low serum iron is associated with anemia in CKD stage 1-4 - Nature by "Nutrients"; Food/cooking/nutrition C-reactive protein Health aspects EDTA Ethylenediaminetetraacetic acid Ferritin Functional foods Hemoglobin Hemoglobins Iron deficiency anemia Care and treatment . I have iron-deficiency anemia, and recently my lymphocyte along with Such symptoms include fatigue, loss of stamina, shortness of breath, weakness, dizziness, and pallor. In addition, gut luminal iron may induce oxidative stress [13] and increase local disease activity in IBD [3, 14]. With progressive iron depletion, the intracellular store of ferritin (iron-rich) is depleted, and serum ferritin (iron-poor) release by macrophages decreases proportionately, along with a progressive decrease in circulating transferrin-bound iron. Subpopulation analysis showed a significantly smaller Hb increase (p<0.05) in the high- versus low-CRP group at weeks 2, 4, and 8 among UC patients treated with oral iron (n=44; Fig. In addition, both markers proved to be independent of baseline TSAT (CRP: R=0.0337, p=0.657; IL-6: R=0.0708, p=0.358) and serum ferritin (CRP: R=0.1313, p=0.074; IL-6: R=0.0443, p=0.554). Stein J, Hartmann F, Dignass AU. A systematic review, Failure of serum ferritin levels to predict bone-marrow iron content after intravenous iron-dextran therapy, Serum ferritin level remains a reliable marker of bone marrow iron stores evaluated by histomorphometry in hemodialysis patients, A possible role for hepcidin in the detection of iron deficiency in severely anaemic HIV-infected patients in Malawi, Definition of iron deficiency based on the gold standard of bone marrow iron staining in heart failure patients, Bone marrow iron, iron indices, and the response to intravenous iron in patients with non-dialysis-dependent CKD, Bone marrow iron distribution, hepcidin, and ferroportin expression in renal anemia, Iron absorption from supplements is greater with alternate day than with consecutive day dosing in iron-deficient anemic women, Iron absorption from oral iron supplements given on consecutive versus alternate days and as single morning doses versus twice-daily split dosing in iron-depleted women: two open-label, randomised controlled trials, Novel oral iron therapies for iron deficiency anemia in chronic kidney disease, Hypophosphatemia: an evidence-based approach to its clinical consequences and management, Iatrogenic iron overload in dialysis patients at the beginning of the 21st century, Chapter 2: Use of iron to treat anemia in CKD, Intravenous iron in patients undergoing maintenance hemodialysis [published correction appears in, Safety and efficacy of rapidly administered (one hour) one gram of low molecular weight iron dextran (INFeD) for the treatment of iron deficient anemia, Iron absorption and serum ferritin in chronic inflammatory bowel disease, Serum ferritin and bone marrow iron stores. Bone marrow iron deficiency (BMID) is ID confirmed by the absence of granules of hemosiderin in macrophages and erythroblasts and requires an invasive procedure to obtain an adequate BM sample stained with Prussian blue (or Perls stain). Normal values for CRP range between 0.20 and 6.10 mg/L [8]. It is the most common nutritional disorder worldwide and accounts for approximately one-half of anemia cases.1,2 Iron deficiency anemia can result from inadequate iron intake, decreased iron absorption, increased iron demand, and increased iron loss.3 Identifying the underlying etiology and administering the appropriate therapy are keys to the evaluation and management of this condition. The study lacked longer follow-up with prolonged iron administration and assessment of hematological response. Patients in the yellow region may be considered for iron supplementation if TSAT is 20% to 25% in CKD, or if TSAT is <20% and ferritin is up to 500 g/L in HF, if they are receiving dialysis, and/or if they are using ESAs. While iron deficiency remains the most common cause of anemia worldwide, low iron stores are associated with symptoms regardless of the presence of typical microcytic, hypochromic anemia and may be hard to recognize in patients with concurrent inflammation. Kleber Yotsumoto Fertrin; Diagnosis and management of iron deficiency in chronic inflammatory conditions (CIC): is too little iron making your patient sick?. 1-10%: fecal discoloration, constipation, diarrhea, abdominal pain, nausea, vomiting. Infused iron is captured by Kupffer cells, which become overloaded and gradually shuttle the iron to hepatocytes. A complete iron panel showed low serum iron (54 mg/dL), normal TIBC (300 mg/dL), and low TSAT (18%). The median baseline CRP value of the study population was applied as the cutoff value. I. Iron-deficiency anemia is usually discovered during a medical examination through a blood test that measures . In patients with HF, TSAT >20% essentially excluded the possibility of BMID, regardless of ferritin levels.23 In patients with nondialysis CKD (ndCKD) who underwent BM evaluation, TSAT below 20% had only 50% sensitivity but 83% specificity to detect BMID, and the specificity for BMID improved to 98% if associated with a ferritin level <100 g/L, with a reduction in sensitivity to 33%. Iron-Deficiency Anemia: Symptoms, Treatments & Causes - Cleveland Clinic High intracellular iron also downregulates transferrin production, lowering TIBC. in a patient without chronic disease, active inflammation, or malignancy, C-reactive protein (CRP) can help support the diagnosis of an inflammatory process. The patient underwent an upper endoscopy and colonoscopy, and a bleeding gastric ulcer was detected, for which omeprazole was prescribed. Subjects: Community Pediatrics, Preventive Medicine As the test subjects were not anemic, only a single dose of oral iron was administered. Transferrin saturation (TSAT) <6% in combination with low ferritin is diagnostic of ID, but in the presence of inflammation, a seemingly arbitrary TSAT <20% is often used to diagnose ID. However, the predictive power of IL-6 was weak compared to CRP. There is no specific iron-containing preparation recommended to treat ID (Table 2), and evidence in pure ID/IDA supports that a single minimum dose of 60 mg of elemental iron administered on alternate days can be adequate and maximize tolerability,26,28,29 but studies in patients with CIC who are following such a regimen are lacking. A randomized, open-label, non-inferiority study of intravenous iron isomaltoside 1,000 (Monofer) compared with oral iron for treatment of anemia in IBD (PROCEED). Low iron also upregulates hepatic production of transferrin, resulting in high TIBC, contributing to low TSAT. The sensitivity of computed tomographic colonography for lesions larger than 1 cm is greater than 90 percent.7 The use of barium enema is less reliable, but may be of use if colonoscopy or computed tomographic colonography is not available. and transmitted securely. is of special relevance to Fe biofortifcation as it provides the population with a regular high consumption of contaminant soil Fe due to the traditional threshing procedure under the hooves of the cattle. CKD patients suffer from both absolute and functional iron deficiency. iron: n=136). iron was mainly independent of baseline CRP. In patients with HF who undergo coronary artery bypass graft, TSAT <19.8% and serum iron <13 mol/L were independently associated with mortality and were most accurate for BMID. By contrast, an iron saturation <5% and an elevated . 001) and IL-6 levels (mean difference in change: 1.33 ng/L, 95%CI 0.87-1.79, P < .