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 Manfred Wick
Wulf Pinggera
Paul Lehmann

Clinical Aspects and Laboratory –

Iron Metabolism, Anemias
Concepts in the anemias of malignancies
and renal and rheumatoid diseases
Sixth, revised and updated edition

With contributions by
Volker Ehrhardt
 Dr. Manfred Wick
Institute of Clinical Chemistry, Klinikum Grosshadern,
University of Munich, Germany

Univ.-Prof. Dr. Wulf Pinggera

Maria Taferl, Austria

Dr. Paul Lehmann

Mainz, Germany

With contributions by
Dr. Volker Ehrhardt
Roche Diagnostics GmbH, Mannheim, Germany

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 Foreword
Anemias are a worldwide problem. Severe anemia affects mainly older
women and men. The WHO defines anemia as a hemoglobin concen-
tration of less than 12 g/dL in women and less than 13 g/dL in men
(World Health Organization. Nutritional Anemias. Technical Reports
Series 1992; 503). According to these criteria, 10–20% of women and
6–30% of men above the age of 65 years are anemic. In this book, we
place a new emphasis on the diagnosis and treatment of anemias of
chronic disease (ACD) and renal anemias. Nevertheless, iron deficiency
remains globally the most important cause of anemia.

There have been so many advances in the diagnosis and, in particu-

lar, the therapy of the anemias in recent years that it appeared necessary
to extend the spectrum of therapies and diagnostic methods described.
Apart from renal and inflammatory anemias, new insights regarding the
role of transferrin receptor, the physiology of erythropoietin produc-
tion, and the genetic defect as well as the pathogenesis of hemochroma-
tosis demanded a major update of the book.

The authors are grateful to Annett Fahle and Ralf Röddiger of Roche
Diagnostics GmbH for their committed cooperation and their support in
the publication of this book.

November 2010 M. Wick

W. Pinggera
P. Lehmann
 Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Iron Metabolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Absorption of Iron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Iron Transport in the Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Transferrin, Iron-Binding Capacity and Transferrin Saturation . . . . . . . . . . . 5
Iron Storage – Ferritins, Isoferritins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Distribution of Iron in the Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Iron Requirement and Iron Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Transferrin Receptor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Soluble Transferrin Receptor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Hepcidin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Fundamentals
Erythropoiesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Physiological Cell Maturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Hemoglobin Synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Erythropoietin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Erythrocyte Degradation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Phagocytosis of Old Erythrocytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Hemoglobin Degradation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Disturbances of Iron Metabolism/Disturbances

of Erythropoiesis and Hemolysis. . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Disturbances of Iron Balance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Iron Deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Disturbances of Iron Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Anemias of Malignancies and Anemias of Chronic Diseases. . . . . . . . . . . . 28
Differentiation between Shortage of Depot Iron
and Functional Iron Deficiency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
 VIII Table of Contents

Disturbances of Iron Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Renal Anemias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Pathophysiology of Erythropoietin Synthesis. . . . . . . . . . . . . . . . . . . . . . . 34
Iron Overload. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Fundamentals

Primary Hemochromatosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Other Hereditary States of Iron Overload . . . . . . . . . . . . . . . . . . . . . . . . . 39
Other Disturbances of Erythropoiesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Disturbances of Stem Cell Proliferation. . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Vitamin B12 and Folic Acid Deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Hemoglobinopathies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Disturbances of Porphyrin Synthesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Pathologically Increased Hemolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Haptoglobin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Features of Severe Hemolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Causes of Hemolysis (Corpuscular/Extracorpuscular). . . . . . . . . . . . . . . . . 48

Diagnosis of Disturbances of Iron Metabolism . . . . . . . . . . . . . . . . 50

Iron Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Case History and Clinical Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Ferritin, Transferrin, Transferrin Saturation, Soluble Transferrin
Receptor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Laboratory Diagnostics of Suspected Disturbances of Iron
Metabolism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Clinical Aspects

Most Frequent Disturbances of Iron Metabolism and Erythropoiesis . . . . . 66

Hypochromic, Microcytic Anemias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Iron Deficiency – Diagnosis and Therapy . . . . . . . . . . . . . . . . . . . . 68

Laboratory Diagnostics in Cases of Suspected Iron Deficiency. . . . . . . . . . . . 68
Clinical Pictures of Iron Deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Oral Administration of Iron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Parenteral Administration of Iron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Side-Effects and Hazards of Iron Parenteral Therapy. . . . . . . . . . . . . . . . . 78

Disturbances of Iron Distribution and Hypochromic Anemias . . . . . . 80

Iron and Cellular Immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Activation of the Immunological and Inflammatory Systems . . . . . . . . . . . 85
Therapy with Erythropoietin and i.v. Iron Administration . . . . . . . . . . . . . . 88
 Table of Contents IX

Anemias of Infection and Malignancy . . . . . . . . . . . . . . . . . . . . . . . 91

Biological Activity of Tumor Necrosis Factor. . . . . . . . . . . . . . . . . . . . . . . 92
Hemoglobin in Therapies with Cytostatic Drugs . . . . . . . . . . . . . . . . . . . . 93
Erythropoietin and Iron Replacement in Tumor Anemias . . . . . . . . . . . . . . 95
Anemias of Chronic Inflammatory Processes . . . . . . . . . . . . . . . . . 101
Anemias of Rheumatoid Arthritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Erythropoietin and Iron Therapy of Rheumatoid Arthritis . . . . . . . . . . . . . 104

Disturbances of Iron Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . 106

Clinical Aspects
Uremic Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Therapy of Uremic Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Iron Overload . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Primary Hematochromatosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Secondary Hematochromatosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

Non-Iron-Induced Disturbances of Erythropoiesis . . . . . . . . . . . . . 117

Macrocytic, Hyperchromic Anemia . . . . . . . . . . . . . . . . . . . . . . . . 118

Folic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Vitamin B12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Normochromic, Normocytic Anemia . . . . . . . . . . . . . . . . . . . . . . . . 126
Extracorpuscular Hemolytic Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Corpuscular Anemias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Erythropoietin Therapy of Other Diseases . . . . . . . . . . . . . . . . . . . . . . . . 130

Methods of Determination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 3 2

Serum/Plasma Parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

Laboratory

Iron. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Iron Saturation (Total Iron-Binding Capacity and Latent
Iron-Binding Capacity). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Iron-Binding Proteins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Ferritin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Transferrin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Transferrin Saturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Soluble Transferrin Receptor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Haptoglobin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
 X Table of Contents

Ceruloplasmin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Vitamin B12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Holotranscobalamin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Folic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Homocysteine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Erythropoietin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Blood Count . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Automated Cell Counting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Laboratory

Flow Cytometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

Impedance-Based Cell Counters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Hemoglobin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Hematocrit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Red Blood Cell Count . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Red Blood Cell Indices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Reticulocyte Count . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Hemoglobin Content of Erythrocytes. . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Erythrocyte Ferritin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Zinc Protoporphyrin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Tests for the Diagnosis of Chronic Inflammation . . . . . . . . . . . . . . 171
Erythrocyte Sedimentation Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
C-Reactive Protein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Interleukin-6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Interleukin-8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Tumor Necrosis Factor-α . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
 Introduction
Disturbances of iron metabolism, particularly iron deficiency and iron
redistribution are among the most commonly overlooked or misinter-
preted diseases. This is due to the fact that the determination of trans-
port iron in serum or plasma, which used to be the conventional
diagnostic test, does not allow a representative estimate of the body’ s
total iron reserves. In the past, a proper estimate was possible only by
the costly and invasive determination of storage iron in the bone mar-
row. However, sensitive, well-standardized immunochemical methods
for the precise determination of the iron storage protein ferritin in plas-
ma are now available. Since the secretion of this protein correctly re-
flects the iron stores in the majority of cases, these methods permit fast
and reliable diagnoses, particularly of iron deficiency status. In view of
the high incidence of iron deficiency and its usual simple treatment, this
fact should be common knowledge in the medical world.
Even non-iron-related causes of anemia can now be identified rap-
idly by highly sensitive, well-standardized methods. We hope that this
book will contribute to a better understanding of the main pathophysi-
ologic relationships and diagnostic principles (Fig. 1) of iron metabo-

Absorption Blood loss Hb synthesis

Excretion Transport Storage

Fig. 1: Physiological principles of iron metabolism

M. Wick et al., Clinical Aspects and Laboratory - Iron Metabolism, Anemias

© Springer-Verlag/Wien 2011
2 Introduction

lism and anemias. However, the diagnosis of bone marrow diseases in

the strict sense of the word, particularly if granulopoiesis or throm-
bopoiesis is involved, should remain the responsibility of hematologi-
cally experienced experts.
 Fundamentals
Iron Metabolism
Absorption of Iron

Iron, as a constituent of hemoglobin and cytochromes, is one of the

most important biocatalysts in the human body. The absorption of iron
by the human body is limited by the physico-chemical and physiologic
properties of iron ions, and is possible only through protein binding of
the Fe2+ ion (Fig. 2).

Fig. 2: Intestinal iron absorption

DMT1: Divalent Metal Transporter; DCT1: Divalent Cation Transporter;
Tf: Transferrin; HFE: Hemo-Iron; sTfR: soluble Transferrin Receptor; Hep: Hepcidin

M. Wick et al., Clinical Aspects and Laboratory - Iron Metabolism, Anemias

© Springer-Verlag/Wien 2011
 4 Iron Metabolism
Fundamentals

Iron is absorbed as Fe2+ in the duodenum and in the upper jejunum.

Since iron in food occurs predominantly in the trivalent form it must
(apart from the heme-bound Fe2+ component) first be reduced e.g. by
ascorbic acid (vitamin C). This explains why only about 10% of the iron
in food, corresponding to about 1 mg per day, is generally absorbed. This
daily iron intake represents only about 0.25‰ of the body’ s average total
iron pool, which is approximately 4 g; this means that it takes some time
to build up adequate reserves of iron. The actual iron uptake fluctuates
considerably, depending on the absorption-inhibiting and absorption-
promoting influences in the upper part of the small intestine. The follow-
ing factors inhibit absorption in clinically healthy individuals: reduced
production of gastric acid, a low level of divalent iron as a result of an
unbalanced diet (e.g., in vegetarians), a low level of reducing substances
(e.g., ascorbic acid) in the food, or complex formation due to high con-
sumption of coffee or tea. Conversely, absorption is promoted by a com-
bination of a meat-rich diet with a plentiful supply of heme-bound iron
and an acidic, reducing environment due to a high consumption of fruit
and vegetables. Dietary iron is mostly present either as Fe3+ or as heme.
Whereas the absorption of heme is less completely characterized by the
mechanism of Fe3+ absorption has become clearer. It is assumed that it
proceeds in two stages. At first, Fe3+ is reduced by ferric reductase (duo-
denal cytochrome b) to Fe2+ which is then transported across the cell
membrane by a ferrous iron transporter (divalent metal transporter 1,
DMT1 or DCT1). In the cells, Fe2+ is stored bound to ferritin. Before
export into the blood plasma by ferroportin, Fe2+ is oxidized to Fe3+ by an
endooxidase (ceruloplasmin in macrophages, hephaestin in enterocytes).
In the plasma, Fe3+ is bound to transferrin [62].
The transport protein for iron, DTC1, is mainly localized in the
duodenum within the enterocytic membrane and increases in con-
centration during alimentary iron deficiency. DTC1 is also expressed
in the kidneys, liver, brain, and heart [62].
Within certain limits, the absorption of iron can be adjusted to meet
the organism’ s iron requirement. Iron deficiency, anemia, and hypoxia
lead via increased transferrin and DCT1 synthesis to an increase in the
absorption and transport capacity.
Two models were postulated for the regulation of iron absorption. In
the so-called “crypt programming” model, immature crypt cells serve as
iron sensors by uptake of Fe3+ bound to transferrin via the basolateral
 Iron Metabolism 5

Fundamentals
membrane with the aid of the transferrin receptor. Essential for the normal
function of the transferrin receptor is a protein encoded by the HFE gene.
The amount of iron taken up by the immature enterocytes regulates the
expression of the iron transporters described above. In case of iron defi-
ciency, more transporters are exprimed; in case of iron overload, the ex-
pression of iron transporters is decreased. Consequently, after translocation
of the matured enterocytes to the villi, iron absorption depends on the
number of iron transporters exprimed in the immature cells.
In the second model, the “iron hormone” hepcidin plays a central role
in the regulation of iron recycling and iron balance. Hepcidin is a peptide
sythesized by the liver. It inhibits iron uptake in the duodenum and the
release of iron from intracellular storage pools. It is assumed that the inhi-
bition of hepcidin is caused by binding to and inducing the degradation of
ferroportin, the sole iron exporter in iron-transporting cells. The expres-
sion of hepcidin is regulated in response to anemia and hypoxia, and iron
load. When oxygen delivery is inadequate, the hepcidin levels decrease
and more iron is absorbed in the duodenum, and made available from
intracellular iron stores. The opposite occurs with iron load. For the nor-
mal regulation of hepcidin levels, the intact HFE gene is required [10].

Iron Transport in the Circulation

Iron is normally transported via the specific binding of Fe3+ by transferrin

in blood plasma [42]. The Fe3+-transferrin complex in turn is bound by
transferrin receptors to cells of the target organs which allow specific iron
uptake according to the individual needs of the various cells. Pronounced
non-specific binding to other transport proteins, such as albumin, occurs
in conditions of iron overload with high levels of transferrin saturation.
When there is an excess supply of heme-bound iron, part of the Fe2+-
heme complex may escape oxidation in the cells of the mucosa and be
transported to the liver after being bound by haptoglobin or hemopexin.

Transferrin, Iron-Binding Capacity, and Transferrin Saturation

Transferrin (Fig. 3) is the most important and specific iron transport

protein in the circulation. It is synthesized in the liver, and has a half-life
 6 Iron Metabolism
Fundamentals

Fig. 3: Transferrin crystals [64]

of 8–12 days in the blood. Transferrin is a glycoprotein with a molecular

weight of 79.6 kD, and β1 electrophoretic mobility. Its synthesis in the
liver may be increased as a corrective measure, depending on iron re-
quirements and iron reserves. At present little is known about the de-
tails of the regulatory mechanisms involved. Transferrin is detectable
not only in blood plasma, but also in many interstitial fluids, and a lo-
cally synthesized variant with a low neuraminic acid content (β2- or
τ-transferrin) is found in the cerebrospinal fluid. The functional and im-
munologic properties of the many isoforms are substantially the same,
the only important difference being the isoelectric point [42]. These
forms are therefore of no practical interest with regard either to analyti-
cal technique or to the assessment of the iron metabolism (except CDT:
diagnosis of alcoholism and β2-transferrin: CSF diagnostics). Each
transferrin molecule can bind a maximum of 2 Fe3+ ions, corresponding
to about 1.41 μg of iron per mg of transferrin.
By measurements of iron and transferrin concentrations, the total
specific iron-binding capacity in plasma can be determined. Owing to
its practicability, its low susceptibility to interference, and its high spec-
ificity, this method should be used to determine the iron transport by
 Iron Metabolism 7

Fundamentals
transferrin. It has made the determination of the iron saturation = total
iron-binding capacity (TIBC) and of the latent iron-binding capacity
(LIBC) largely redundant.
Under physiologic conditions, transferrin is present in concentra-
tions which exceed the iron-binding capacity normally necessary. The
fraction of transferrin-binding sites that are not occupied by iron is
known as the latent iron-binding capacity (LIBC). It is calculated from
the difference between the total iron-binding capacity and the serum
iron concentration.
This procedure has been replaced by the determination of the
percentage saturation of transferrin (TfS), which does not include
non-specific binding of iron by other proteins, so that only the physio-
logically active iron binding is measured. Fluctuations of the transfer-
rin concentration that are not due to the regulatory variations of the
iron metabolism can also be eliminated from the assessment in this
manner.
Approximately one third of the total iron-binding capacity is nor-
mally saturated with iron. Whereas the transferrin concentration re-
mains constant in the range from 2.0 to 4.0 g/L, without any appreciable
short-term fluctuations, the transferrin saturation changes quickly with
the iron concentration depending on the time of day, the current iron
requirement, and the intake of dietary iron. The total quantity of trans-
ferrin-bound iron in the blood plasma of a healthy adult is only about
4 mg, i.e. only 1‰ of the body’ s total iron pool of about 4 g.
It is clear from the very low plasma iron concentration and its short-
term fluctuations that neither the plasma iron concentration nor the
transferrin saturation can provide a true picture of the body’ s total iron
reserves. Assessment of the body’ s iron reserves is only possible by de-
termination of the storage protein ferritin.
The plasma iron concentration and the transferrin saturation only be-
come relevant in the second stage of diagnosis for differentiation of condi-
tions with high plasma ferritin concentrations (see “Disturbances of Iron
Distribution and Iron Overload”). The determination of the transferrin
saturation is preferable to the determination of iron alone, since this elim-
inates the effects of different blood sampling techniques, different states of
hydration of the patient, and different transferrin concentrations. Addi-
tionally, the determination of the soluble transferrin receptor (sTfR) has
gained importance.
 8 Iron Metabolism
Fundamentals

Iron Storage – Ferritins, Isoferritins

Because of the very limited iron absorption capacity, the average iron
requirement can be met only by extremely economical recycling of ac-
tive iron. Iron is stored in the form of ferritin or its semi-crystalline
condensation product hemosiderin in the liver, spleen, and bone mar-
row. In principle, every cell has the ability to store an excess of iron
through ferritin synthesis. The fundamental mechanisms are identical
for all types of cells (Fig. 4).
Iron directly induces the synthesis of apoferritin, the iron-free pro-
tein shell of ferritin, on the cytoplasmic ribosomes. In the majority of
metabolic situations, a representative fraction of the ferritin synthe-
sized is released into the blood plasma. The ferritin concentration
correctly reflects the amount of storage iron available (exception: dis-
turbances of iron distribution). This has been verified experimentally
by comparison with iron determinations in bone-marrow aspirates and
by monitoring serum ferritin after serial blood donations. In clinical
diagnosis, ferritin should be determined as the parameter of first choice
for the assessment of iron reserves, e.g. in the identification of the cause
of an anemia.

Fig. 4: Scheme of cellular iron storage and ferritin synthesis