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IRON LAB ASSESSMENT Week 6 - PROBLEM SET Note: Clinical values are reported to one decimal place; please

report your final calculations accordingly (HgB, Hct, MCV, MCH, MCHC). Must show calculations and units for full credit.

(1) During iron deficiency, what happens (relative to normal) to the values for: (6 points) TIBC increases / decreases / no change Serum Iron increases / decreases / no change % Transferrin saturation increases / decreases / no change Serum Ferritin increases / decreases / no change Zn PP increases / decreases / no change Serum TfR increases / decreases / no change

(2) During iron overload, what happens (relative to normal) to the values for: (6 points) TIBC increases / decreases / no change Serum Iron increases / decreases / no change % Transferrin saturation increases / decreases / no change Serum Ferritin increases / decreases / no change Zn PP increases / decreases / no change Serum TfR increases / decreases / no change

(3) With respect to the test (assay) to determine serum iron concentration: a) It utilizes ferrozine to form a colored complex with the iron in the sample

b) The serum iron concentration is proportional to the difference in absorbance before versus after ferrozine addition c) A reducing agent at a basic pH causes transferrin-bound iron to dissociate to free Fe2+ d) All of the above e) a and b only

(4) Given two patients with identical RBC#s., one with normocytic, the other with macrocytic cells.... a) The patient with macrocytic cells has an MCV greater than the patient with normocytic cells b) The patient with macrocytic cells has a smaller hematocrit than the patient with normocytic cells c) The patient with macrocytic cells has an MCV smaller than the patient with normocytic cells d) a and b only e) b and c only

(5) Which of the following conditions can present with low MCV and low MCHC values? a) Iron deficiency b) Porphyrin defects c) Copper deficiency d) all of the above e) a and b only 2013 LAB 6

(6) An ongoing study of an isolated rural, tribal community living at in a rain forest yielded the data below. Based on these average values for all the individuals in the tribe, answer the questions below. (Data are from all 103 adult members of the tribe and are presented as the Mean Std.Dev.) (15 points) 2006 90 6 30 6 363 18 2007 90 5 31 4 346 19 2008 91 7 32 5 332 18 2009 88 9 32 6 321 20 2010 91 11 32 4 313 18 2011 90 10 33 5 308 14 2012 91 9 34 5 302 11

MCV (fL) MCHC (g/dL) TIBC (g/dL) serum Iron (g/dL)

139 15

140 12

142 17

151 19

159 15

168 16

171 18

a) What is your overall assessment of the tribes current iron status? You must comment on indicators and conclude about current status

The current tribes current iron status seems to be normal overall. Their MCV, MCHC, and TIBC cutoffs are all within the normal range. Their serum iron is more than adequate, but is not excessive. However, the decrease of TIBC and increase in Fe increases the risk of toxicity.

b) Comment/Discuss whether the data indicate any causes for concern in the future with respect to iron status of individuals in the tribe. Since the indicators show a gradual increase in iron levels, the population may be at risk for iron overload if the pattern continues.

(7) Regarding RBC and Iron indice values, which of the following could present the situation of chronic, inflammatory disease-driven Anemia? (2 pts) a) serum Iron = 36 g/dL together with a TIBC = 278 g/dL b) serum Iron = 38 g/dL together with Transferrin sat. = 25%

c) serum Iron = 37 g/dL together with serum Ferritin = 173 g/ml d) all of the above e) a and b only 2013 LAB 6

(8) The following were values obtained in a test to measure a male subjects serum iron: (22 points) _________________________________________________ INITIAL READINGS FINAL READINGS SAMPLE Abs. 560nm Abs. 560nm Iron STD 0.012 0.387 SUBJECT 0.093 0.134 _________________________________________________

The following were values obtained in a test to measure the same subjects UIBC: _________________________________________________ INITIAL READINGS FINAL READINGS SAMPLE Abs. 560nm Abs. 560nm Iron STD 0.010 0.385 SUBJECT 0.114 0.301 _________________________________________________

Using the above test results, calculate the following (show calculations): a) Subjects serum iron concentration =

(0.134 0.093 / 0.387 0.012) x 500 micrograms/dL = 54.7 micrograms/dL (stage 2)

b) Subjects UIBC = 500 [(0.301 0.114 / 0.385 0.010) x 500] = 250.1 micrograms/dL

c) Subjects TIBC = 54.7 + 250.1 micrograms/dL = 305.4 micrograms/dL (stage 3) d) Subjects Transferrin saturation (%) = (54.7 / 304.8) x 100% = 17.9%

e) Based on these values, what is your assessment of the subjects iron status? (COMMENT ON EACH INDICE) The patients TIBC indicates that his iron status is within normal range. His serum iron concentration indicates that he has iron deficient erythropoiesis. (Stage 2). He also has a low transferrin saturated % that is not normal, but not deficient either. So he is iron deficient, but it is unclear to what stage.

f) What (if any) additional subject data/test information would you need (and what would it mean) for you to make a definitive assessment? (YOU NEED TO LIST TWO AND COMMENT ABOUT STAGE) If the subject has an increase in ZnPP, and an increase in sTfR, but normal HgB, Hct, MCV, and MCHC, then the subject would definitely be in stage 2 of iron deficiency.

(9) A female patient presents with complaints suggestive of anemia. The following blood data and iron lab test results were obtained: (26 points)

MCV = 72.3fL RBC# = 3.88 x 1012/L HgB = 7.9 g/dL

Ferritin = 38

g/ml

For serum iron: For UIBC: ____________________________________ __ ___________________________________ INITIAL READ FINAL READ SAMPLE Abs. 560nm Abs. 560nm Iron STD 0.011 0.372 PATIENT 0.092 0.177 INITIAL READ FINAL READ SAMPLE Abs. 560nm Abs. 560nm Iron STD 0.004 0.369 PATIENT 0.104 0.284

____________________________________ ____________________________________

a) What is the patients Hct? 28.1% Hct, b) MCHC? 28.2g/dL MCHC

c) Describe the patients RBC Morphology: ( microcytic / normocytic / macrocytic ) ( hypochromic / normochromic / hyperchromic )

d) Is the patient is anemic? Yes / No Based on: low Hct / low HgB / both normal Severity: Mild / Moderate / Severe / very Severe

e) What is the patients Serum iron concentration 117.7 micrograms /dL f) What is the patients UIBC value 253.4 micrograms /dL g) What is the patients TIBC value

371.1 micrograms/dL

h) What is the patients Transferrin saturation (%) 31.7%

i) Is iron status a likely contributor to the blood indice values (YES or NO) and your diagnosis (why / how) (COMMENT ON ALL INDICES AND INFORMATION PROVIDED IN THE QUESTION) No. Her serum iron concentration, UIBC, and TIBC (Stage 1) values are all normal. Ferritin levels are below normal range, and MCV is also below average. So therefore, she has anemia because of abnormal iron stores and small red blood cell sizes.

(10) Joe is a 47 yr old male iron foundry worker (he works in an iron and steel beam manufacturing plant) who presents with fatigue, weakness and aching joints. (26 points) His RBC indices are as follows: HgB = 16.6 g/dL Hct = 46.3% RBC count = 5.11 x 1012/L Iron status lab test values are: Serum iron = 177 g/dL UIBC = 103 g/dL Ferritin = 323 g/ml Calculate Joes MCV, MCH and MCHC values (show calculations)

a) MCV = 463/5.11 = 90.6 fL

b) MCH = 166/5.11 = 32.5 rg

c) MCHC = 16.6 / .463 = 35.9 g/dL

d) Is Joe anemic? Yes / No Based on: low Hct / low HgB / both normal

e) Describe Joes RBC Morphology: ( microcytic / normocytic / macrocytic ) ( hypochromic / normochromic / hyperchromic )

f) Calculate Joes TIBC value: 177 plus 103 = 280 micrograms/dL

g) Calculate Joes Transferrin saturation (%): 177/280 x 100 = 63.2%

h) Taking into account all the available data and Iron status indicators, what are your conclusions with respect to Joes iron status? Iron overload, because his transferrin sat. percentage is higher than normal, his TIBC value is lower than normal, and his serum iron is higher than normal.

i) Given the above data, what would you predict his serum Transferrin receptor (sTfR) value to be? High Normal Low insuffient data

k) Given the above data, what would you predict his Zn protoporphyrin (ZnPP) value to be? High Normal Low insuffient data

(11) Ethel is a 73 yr old subject who has been participating in a double-blind study for a new arthritis treatment for the past 6 months. Though she was still relatively active, she now presents with fatigue, muscle aches and marked joint swelling and soreness, which now makes it extremely difficult and painful to go for the long walks she used to take. (24 points) Her current lab test results are: HgB = 9.7 g/dL Hct = 34.5% RBC count = 4.39 x 1012/L MCV std.dev. = 17 fL Calculate her MCV, MCHC and RDW values (show calculations)

a) MCV = 78.6 fL

b) MCHC = 28.1 g/dL

c) RDW = 21.6%

d) What is her RBC Morphology: ( microcytic / normocytic / macrocytic ) ( hypochromic / normochromic / hyperchromic )

e) Is she anemic? Yes / No based on: low Hct / low HgB / both normal

Tests to evaluate her Iron status yielded the following results: Serum Iron = 104 g/dL UIBC = 172.7 g/dL Ferritin = 189.4 g/ml ZnPP = 47 mol:mol

f) Calculate Ethels TIBC value: 104 micrograms/dL + 172.7 micrograms/dL = 276.7 micrograms/dL

g) Calculate Ethels Transferrin saturation: (104/276.7) x 100% = 37.6%

h) What are your conclusions on Ethels iron status? Evaluate all markers and give conclusion Ethel is anemic. Her serum iron is normal. Her TIBI is low, and her transferrin saturation is normal. However, she is likely anemic, and also positive in iron balance because her TIBC is less than 300 micrograms/L

i) What (if any) interventional or treatment strategy would you recommend? Decrease iron intake, and figure out the underlying cause. People with excess iron may suffer from anemia due to inflammation or chronic disease (bone marrow disorders), and see if there is a relationship between the two.

(12) A non-pregnant female patient has blood indices of MCV = 77 fL, and MCHC = 28.2 g/dL. Based on these values... a) her RBCs are macrocytic, normochromic b) her RBCs are microcytic, hypochromic c) her RBCs are normocytic, hyperchromic d) her RBCs are macrocytic, hyperchromic e) her RBCs are microcytic, hyperchromic

(13) In an effort to lose weight, a female patient started on a highly restrictive diet 3 months ago. She now presents with signs of anemia and had the following blood cell indice values: Hct =

27.8% HgB = 9.2 g/dL RBC# = 3.22 1012 cell/L. Based on these data, which of the following is/are true? a) She is not anemic b) She has normocytic, normochromic RBCs c) She has macrocytic, hyperchromic RBCs d) a and b only e) none of the above

(13) continued Follow-up test results provided the following values: Homocysteine = 15.3 mol/L RBC Folate = 197 nmol/L ser. Folate = 4 nmol/L total ser. B12 = 130 pmol/L. Based on these data (and the previous blood cell data above), which of the following is/are true? a) She is Folate deficient b) She is vitamin B12 deficient c) She is not deficient in either Folate or vitamin B12 d) a and b only e) none of the above

(13) continued Further test data are: ser Fe = 36 g/dL ser Ferritin = 9.2g/L TIBC = 413 g/dL TfR = normal (but at high end of range) Based on these data, which of the following is/are true? a) Her transferrin saturation (T-sat) = 8.7% b) Her UIBC = 377g/dL c) She is in at least stage 2 (or even early stage 3) of Iron deficiency d) all of the above

e) a and b only

(13) continued Final results provided the following: Red cell Distribution Width (RDW) = 22.6%, and ser. MMA = 273 nmol/L. Based on ALL of the aggregate data above, which of the following is/are true? a) Blood smear analysis and examination of the RDW histogram would indicate anisocytosis b) She has a folate deficiency secondary to a B12 deficiency c) She has an Iron deficiency d) all of the above e) a and b only