The Diagnosis of Iron Deficiency Anemia*

DOROTHY FORD BAINTON, M.D.? and CLEMENT A. FINCH, M.D.

Seattle, Washington

T
HERE is a need for accurate methods and binding capacity determinations, a bone marrow
precise criteria in the diagnosis of iron examination for reticuloendothelial iron and usually
evaluation of sideroblast counts by one of us (D. E.).
deficiency and its attendant anemia. In the past,
Patients were considered in the following categories:
the presence of hypochromia and microcytosis
Group A: One hundred and fifteen patients met the
of the circulating red cells generally has been usual criteria for iron-deficiency anemia in that their
considered essential for the diagnosis of iron red cells were hypochromic and microcytic, and all
deficiency anemia. However, an inadequate iron responded to iron therapy with an increase greater
supply may retard erythropoiesis for weeks or than 2 gm. in the concentration of circulating hemo-
months before these characteristic abnormalities globin. Furthermore, there was no demonstrable
of the red cells are recognizable. Furthermore, hemosiderin in particles of aspirated marrow. The
reduced cell size is associated with a number of etiology of the iron deficiency anemia was determined
other conditions in which hemoglobin synthesis to be gastrointestinal bleeding in fifty-three patients
and vaginal blood loss in five. In five patients the
is also depressed, including thalassemia, lead
anemia was associated with pregnancy and in one
poisoning and pyridoxine responsive anemia. It
child with dietary iron deficiency. Three patients had
is apparent that recognition of iron deficiency sprue, and in ten patients the anemia occurred three
as a cause of anemia should depend on findings to sixteen years after partial gastrect~my. In thirty-
more immediate and specific than morphologic eight patients, including twenty-six women and
changes of the red cells. Other means of assessing twelve male subjects, the cause of the iron deficiency
the status of iron metabolism include the state could not be demonstrated despite intensive
determination of plasma iron and iron-binding investigation for blood 10~s.
capacity, the amount of hemosiderin within Grmp B: Seventeen patients, assumed to represent
reticuloendothelial cells and the quantity of recent iron deficiency, were selected on the basis of a
normochromic, normocytic anemia associated with
iron granules within the developing red cells.
absent marrow hemosiderin. By histories, fourteen
This paper summarizes these data obtained
of the seventeen had suffered recent blood loss.
from a large number of patients with varying
Group C: There were 122 patients who had anemia
degrees of iron depletion as well as conditions associated with inflammation or neoplasm. This
mimicking this deficiency state. Since the group was further subdivided into group C-l, those
important consequence of iron deficiency is with a decreased mean corpuscular hemoglobin
anemia, our prime purpose was to establish (thirty-four patients) and group C-2, those with a
laboratory criteria whereby the impairment of normal mean corpuscular hemoglobin (eighty-eight
erythropoiesis by deficient iron supply can be patients).
recognized. Group D: This group was composed of five patients
with polycythemia vera and evidence of iron de-
MATERIAL AND METHODS ficiency as indicated by absent marrow hemosiderin
and hypochromic microcytic erythrocytes. Hemato-
Patients Studied. Laboratory data and clinical crit levels ranged from 52 to 62, and red cell masses,
records of approximately 300 patients seen on the measured by chromium 51 (Cr6t), varied from 48 to
hematology consultation services of the University 62 ml. per kg. (normal values 25 to 30 ml. per kg.).
of Washington, King County and Veterans Adminis- Group E: There were six patients with combined
tration Hospitals in Seattle were reviewed. These megaloblastic anemia and depletion of marrow
patients were selected because in each, standard hemosiderin who were compared with eleven
hematobgic studies had been performed by our patients with megaloblastic anemia and abundant
research technicians, as well as plasma iron and iron- marrow iron.
* From the Department of Medicine, University of Washington School of Medicine, Seattle, Washington. This
investigation was supported by U. S. Public Health Service Research Grant No. HE-06242. Manuscript received June
10, 1963.
7 U. S. Public Health Service Fellowship No. HF-I 1, 902 and Training Grant No. 2A-5130. Present address: 131
Behr Avenue, San Francisco, California.

62 AMERICAN JOURNAL OF MEDICINE

 Iron Deficiency Anemia--B&ton, Finch 63
TABLE I
AVERAGE HEMATOLOGIC VALUES IN GROUPS OF PATIENTS STUDIED
-
Mean Cell
Mean Cell
No. of Reticulocyte Mean Cell Hemoglobin
Group Hematocrit (sl,) Hemoglobin
Patients Count* (%) Volume (cu. M) Concentration
(JJ@.) (gm. /lOO ml.)

115 1.3 28
(103-040) (0.1-4.7) (597ZO) (I ?26) (22-31)
17 1.2 33
(203_42) (0.1-3.1) (87% 3) (282234) (31.-34)
34 0.7 29.5 33
(203_40) (0.1-5.2) (86::5) (27-31) (30 -36)
88 0.7 30
(203_340) (0.1-5.2) (707i3) (212_325) (26 -33)
5 1.3 28
(525862) (0.6-l .9) (677S3) (27 -31)
-
NOTE: Total ranges appear in parentheses.
* Reticulocyte counts were corrected according to the degree of anemia (observed per cent reticulocytes multiplied
by 5, divided by observed red cell count in millions).

‘Table I summarizes red cell indices of patients in binding capacity was carried out according to the
groups A, B, C and D. method of Resslar and Zak [5]. The per cent satura-
Methods. Marrow hemosiderin was examined in tion of transferrin was determined by dividing plasma
aspirated marrow particles smeared on cover slips. iron by the total binding capacity times 100. The
The amounts present in these unstained preparations normal range in our laboratory is 80 to 150 pg. of iron
were graded as previously described [I]. For this per 100 ml. of plasma and the total iron binding
evaluation, particles of marrow must be present to capacity, 280 to 360. Normal range for the per cent
assure adequate representation of reticuloendothelial saturation is between 25 and 50 per cent.
cells. Specimens in which normal cells are replaced by The red cell concentration was determined by
neoplastic tissue are unsatisfactory. loading at least two pipettes and enumerating 1,000
The sideroblast count was performed according or more red cells in a counting chamber. The con-
to the method of Douglas and Dacie [2], using centration of hemoglobin was measured by the
Prussian blue as an iron stain and safranin as a cyanomethemoglobin technic in a photoelectric
counterstain. It is essential that the staining procedure calorimeter, and blood for hematocrit determinations
be carried out at 56%. In this preparation, the was spun in Wintrobe tubes at 2,200 g for thirty
nucleated erythroid cells are recognized by their minutes. The red cell mass was measured by the
dense, red, central nucleus and pink homogenous Cr5t technic [6].
cytoplasm. The dark blue iron granules within the
cytoplasm vary from 0.2 to 3 ~1in size. RESULTS
Individual sideroblast counts were performed by
The Iron Dejciency States. In this section the
one of us (D. B.). Some 300 cells were counted from
at least two separate preparations. Repeated counts results of measurements of reticuloendothelial,
on unmarked slides suggested that there was a count- plasma and normoblast iron obtained in patients
ing error of about 20 per cent. Thus absolute values with classical iron deficiency anemia (group A)
at the 10 per cent level might be expected to vary by are presented. From these data it was hoped to
ir 2 per cent and at the 80 per cent level by & 16 per establish laboratory criteria for the diagnosis
cent. Considerable experience is required before of this deficiency state. Observations were
much reproducibility is achieved. In our experience, further extended to patients who had impaired
30 to 50 per cent of the developing red cells in the
erythropoiesis due to lack of iron but whose red
marrow of normal subjects contain one to four fine
cell indices were normal (group R), patients
iron granules, while in the remainder there was no
with infection who demonstrated hypochromia
visible iron.
The iron concentration of either serum or heparin- and microcytosis (group C), patients without
ized plasma was determined by the method of Both- anemia but with evidence of iron deficiency
well et al. [3], with substitution of bathophenanthroline (group D) and finally patients with. dimorphic
as a color indicator [d]. Determination of total iron anemia (group E).
VOL. 37, JULY 1964
 64 Iron Deficiency
Classical iron dejciency anemia (Group A): In the
group of 115 patients with the typical iron
deficiency anemia previously described, the
results of the various laboratory determinations
are shown in Figure 1. The serum iron values
ranged from 10 to 61 pg. per cent, with a median
of 30 pg. per cent (mean, 28). The total iron-
binding capacity ranged from 170 to 460 pg.
per cent, with a median of 365 pg. per cent
(mean, 346). The per cent saturation ranged
from 2 to 16, with a median of 7 (mean, 7.3).
Sideroblast counts ranged from 0 to 10 per cent,
with a median of 2 per cent (mean, 2.5). In all
patients the amount of hemosiderin within
reticuloendothelial cells was markedly decreased
or absent. (This latter finding has been neces-
sary since it was the criterion for patient
selection.) The values obtained were as expected
with the possible exception of the total iron-
binding capacity. The fact that some patients
did not have an elevation in total iron-binding
capacity was probably due to protein depletion.
When the group of twenty-four patients with
serum albumin levels of less than 3 gm. per
100 ml. of plasma were compared with fifty-
one patients with albumin levels of 3 gm.
or above, the total iron-binding capacity
the former was found to have a median value
of 240 and that of the latter 360 (averages,
270 and 338).
Iron dejiciency anemia with normochromic, normo-
cytic cells (Group B): This group of seventeen
patients had normochromic, normocytic anemia
despite the absence of demonstrable iron stores.
On careful examination of the peripheral
smear, rare hypochromic, microcytic cells could
be found, although most of the cells appeared
normal. Morphologic evidence in the marrow
of a block in hemoglobin synthesis, as manifest
by collapsed cytoplasm of the developing red
cells, was equivocal or normal. As shown in
Figure 2, the serum iron levels ranged from 16
to 48 pg. per cent with a median of 32 kg. per
cent (mean, 29). The total iron-binding capacity
ranged from 210 to 350, with a median of 280
(mean, 265). The per cent saturation varied
from 5 to 16, with a median of 10 (mean, lo),
and sideroblasts varied from 2 to 10 per cent,
with a median of 4 per cent (mean, 4.5). Except
for the somewhat lower iron-binding capacity,
these measurements are similar to those found
in classic iron deficiency anemia. It seems likely
that the lower transferrin level was related to
hypoalbuminemia (average 2.6 gm. per 100 ml.
Anemia-B&ton, Finch
plasma) which was more prevalent in this group
than in group A.
Hyfiochromic, microcytic anemia of injammation and
malignang (Group C): Among 122 patients whose
anemia was associated with chronic inflamma-
tion and/or tumor, eighty-eight had normocytic
and normochromic red cell measurements, while
thirty-four showed significant hypochromia and
microcytosis. In the latter group of patients
(Fig. 3), the serum iron values ranged from 18
to 48 pg. per cent, with a median of 31 pg. per
cent (mean, 29). The total iron-binding capacity
ranged from 200 to 358, with a median of 260
(mean, 271). The per cent saturation ranged
from 7 to 19, with a median of 13 and the sidero-
blasts from 6 to 20 per cent, with a median of
12 per cent (mean, 13). These measurements are
again similar to those seen in iron deficiency.
However, in these patients the amount of iron
within the reticuloendothelial cells of the
marrow was usually elevated. The other patients
with normocytic, normochromic anemia asso-
ciated with inflammation or tumor, had plasma
iron levels ranging from 20 to 155 pg. per cent,
with a median of 50 pg. per cent (mean, 64).
Total iron-binding capacity ranged from 10 to
of 62 per cent, with a median of 28 per cent (mean,
26). Sideroblast counts had a median value of
32 per cent.
Hypochromic, mycrocytic erythrocytes in poly-
cythemia vera (Group D): A group of five patients
with polycythemia were studied because of the
presence of hypochromic, microcytic erythro-
cytes and absence of marrow hemosiderin. Their
serum iron values ranged from 21 to 38 Mg. per
cent, with an average of 26 pg. per cent. The
total iron-binding capacity averaged 303, with a
range of 270 to 410. The average per cent
saturation was 9, with a range of 5 to 14, and
the sideroblast count averaged 2 per cent, with
a range of 0 to 5 per cent.
Iron dejciency anemia and megaloblastic anemia
(Group E): Six patients had untreated megalo-
blastic anemia with no demonstrable iron
within the reticuloendothelial cells of the mar-
row. Their serum iron values ranged from 22
to 54 wg. per cent, with an average of 35 pg. per
cent. The total iron-binding capacity ranged
from 259 to 407, with an average of 302, and
the per cent saturation from 8 to 15, with an
average of 11. Sideroblast number ranged from
3 to 11 per cent, with an average of 8 per cent.
These measurements are consistent with the
diagnosis of iron deficiency anemia and are
AMERICAN JOURNAL OF MEDICINE
 Iron Deficiency Anemia-B&ton, Finch 65
r
*
t’
I6( )

*I

14c

+,

20

15’
1~=
12oi +
6C

40
.z
.... IO g IO

=
5= i

;;/:0
FIG. 1. Group A, chronic iron deficiency anemia. The
0s
-_

2 0 :1-
FIG. 3. Group C, chronic infection with microcytic hypo-
values of 115 patients with chronic iron deficiency chromic anemia. Individual determinations on thirty-
anemia (microcytic hypochromic anemia and absent four patients who gave evidence by red cell indices of a
marrow hemosiderin) are summarized. The normal block in hemoglobin synthesis are plotted. While marrow
range for each determination is indicated by the trans- hemosiderin was increased, other measurements were
verse shaded bar. In this group plasma iron is 60 rg. per depressed far below normal. Plasma iron values were
cent or less, the per cent saturation of transferrin is 16 similar to those seen in chronic iron deficiency anemia,
or less, and the sideroblast count is below 10 per cent. but the per cent saturation of transferrin and per cent
Transferrin levels (total iron-binding capacities) vary sideroblast levels were somewhat higher.
widely.

different from those seen in eleven patients with

uncomplicated megaloblastic anemia in whom
per cent saturation averaged 78 and sideroblasts
85 per cent.
Trr
s-ah

6C Observations Concerning Individual Measurements

of Iron Metabolism. In the course of these
5c
studies on iron deficiency anemia there was an
, 5C
4: opportunity to assess the significance of changes
40
in the various measurements employed. In
this section such pertinent observations are
35
summarized.
30 Reticuloendothelial iron of the marrow: The
morphologic characteristics of the hemosiderin
25
deposits in the bone marrow varied in respect
20 to size of deposits, from extremely fine granules
to particles of several microns in diameter. Large
15
aggregates appeared to correlate with slow
IO turnover of excess iron, as would be seen in
5 infection or chronic iron overload. On occasion,
in unstained preparations, large pale chunks are
-_ 0
found in the absence of fine granular iron, when
FIG. 2. Group B, blood loss anemia with depletion of most of the iron has been mobilized from the
hemosiderin stores. This group differs from group A in that marrow stores, as following hemorrhage. A
the red cell volume was normal or slightly increased.
comparison of the amount of marrow hemo-
However, measurements of the reticuloendothelial,
serum and sideroblast iron showed a depletion similar to siderin in relation to the transferrin saturation
that observed in chronic iron deficiency anemia. is shown in Figure 4. It is apparent that no
VOL. 37, JULY 1964
 Iron Deficiency Anemia-&z&on, Fzkch
. correlation exists in conditions other than iron
: deficiency anemia.
. Per cent saturation of transferrin: Correlations
.
l ‘. . were examined between the plasma iron supply
. .* as represented by either the plasma iron alone
:
or the per cent saturation of transferrin. and the
_L condition of the red cell as evidenced by changes
.
. in red cell size and sideroblast count. In infec-
tion, those patients with microcytosis showed
; per cent saturations depressed to levels seen in
iron deficiency anemia. (Fig. 3.) Also to be noted
. . in Figure 5 are a few patients (seven) with
. A )
.::. .*
normocytic normochromic red blood cells in
.l
f : . whom per cent saturation was below 15 per cent.
l: ::.
. :. l* .
.. These patients, in general, had experienced a
lr
.
1 :” .
recent onset of inflammation and may have had
.
insufficient time for changes in red cell mor-
I I I 1 I I ,
phology to develop. While in many, plasma
a +I +2 t3 +4 +5 t6 iron levels were similar to those seen in iron
R-E Iron Storer
deficiency anemia, hypochromia was not a
FIG. 4. Group D, lack of correlation between per cent consistent finding until the plasma iron level fell
saturation of transferrin and reticuloendothelial iron.
below 20 pg. per cent. On the other hand, in
When hemosiderin iron is found within the reticulo-
endothelial cells, no correlation exists between the fourteen of 127 patients with tumor and chronic
amount present and the per cent saturation of transferrin infection with anemia who had serum iron
(a similar lack of correlation exists between reticulo- values between 34 and 44 pg. per cent, with
endothelial iron and the plasma iron value). Only when proportionate decreases in total iron-binding
the reticuloendothelial iron is virtually absent does the
capacity (117 to 229), there was a normal per
per cent saturation fall.
cent saturation associated with normal red cell
indices. The correlation between per cent
saturation of transferrin and sideroblast count
was better than that between plasma iron and
sideroblast count as is illustrated in Figures 6
and 7.
Sideroblasts: Ample data have already been
presented to indicate the decrease in sidero-
blast count, which is associated with a decrease
in iron supply in iron deficiency and infection.
Increased numbers of sideroblasts, as well as an
increase in the number of intracellular iron
granules, are seen with increased transferrin
saturation. Thus in eleven patients with
megaloblastic anemia, the sideroblast percentage
0 ranged from 70 to 90, and there were usually
0 5 IO 15 20 25 30 35 40 45 50 55
seven to twenty granules of intermediate size
% saturation of tronsferrin
distributed diffusely through the cytoplasm,
FIG. 5. Group E, relationship between transferrin predominately in the late normoblasts. In ten
saturation and red cell hypochromia. The 122 patients
cases of refractory anemia, 70 to 100 per cent
with anemia associated with inflammation are grouped
according to per cent saturation and total iron-binding of the developing red cells were heavily laden
capacity. Patients with normal red cell indices are indi- with large granules usually ringing the nucleus.
cated by the shaded areas and patients with microcytic, A blockage in hemoglobin synthesis, other
hypochromic erythrocytes by the clear areas. There is a than that due to iron deficiency, was associated
segregation of patients, those above 20 per cent satura-
tion total iron-binding capacity have normal red cells,
with sideroblast counts elevated beyond that
most of those below 15 per cent have hypochromic red expected from the per cent saturation of
cells. transferrin. In three cases of thalassemia minor,
AMERICAN JOURNAL OF MEDICINE
 Iron Deficiency Anernia-Bainton, Finch 67
with saturation of 35 to 50 per cent, the sidero- 350

blast counts varied between 65 and 85 per cent,

325
both fine and large granules being present in the
I
cytoplasm. Of particular interest was a group 30
of fourteen patients with the anemia of infection "1

who had taken in excess of 2 gm. chloromycetin 2501

daily for between three and twenty-eight days. 225

i
* .
Seven of these patients showed an increase in .
the number of sideroblasts beyond that antici- 200 .
pated from the per cent saturation of transferrin, 1 . *
.
as shown in Figure 8. These observations indi-
175- . - .
:
k
cate that the sideroblast count is affected not ; 150.
. .
. *
only by the per cent transferrin saturation but

*-.
.
1 : .
also by abnormalities in hemoglobin synthesis Q 125- .

within the developing red cell.

It is recognized that the method of reporting,
that is, the per cent of nucleated red cells con-
taining iron granules, does not take into account
variations which might occur in a portion of cells
100

75 I - -*
:
.* *.
:'!:..
. :’
.
- .. .
.

present. Thus in one patient with pyridoxine

responsive anemia, a sideroblast count of 65 per
cent was found, consistent with a per cent
saturation of 77. On the other hand, the Sideroblasls X

normoblasts involved contained fifteen to thirty FIG. 6. Relation between sideroblasts and plasma iron.
fine granules of iron, an amount of iron far in Patients are included with a variety of diseases except
excess of that seen when no defect in hemoglobin for conditions affecting porphyrin or globin synthesis.
synthesis occurred.

COMMENTS

It seems appropriate to begin by defining the

two terms employed in this paper. Iron dejiciency
is taken to mean a reduction in total body iron 100 . * :
and iron deficient erythrofioiesis an inadequate
supply of iron to meet the needs of the erythroid
marrow resulting in the production of anemia.
90
I . -*
While these terms in themselves seem clear, .
they are only meaningful if they can be evalu-
ated clinically. In this sense, iron deficiency may
refer to an absolute decrease in red cell iron
plus storage iron, which may be measured by
determining blood hemoglobin concentration $ . .
2 40. . .
and hemosiderin within the reticuloendothelial : .*. - . *.
cells of the marrow. Since circulating red cells $30. . .::':'.
and reticuloendothelial cells represent about 95 20. -:: c..
ye; .,. . j
per cent of total body iron, other iron fractions
may be ignored. If both measurements show a ‘J

decrease in iron, there is little question but that

there is a decrease in body iron. If, in the
presence of anemia there is an increase in
marrow iron, it is assumed that the iron balance
is normal or increased.
The second condition, iron deficient erythro-
poiesis, refers to the limitation of hemoglobin
synthesis in the erythroid marrow due to an
Slderoblastr W
FIG. 7. Relation between sideroblasts and per cent
saturation of transferrin. It is apparent that the correla-
tion that exists between sideroblasts and per cent
saturation of transferrin is better than that with serum
iron alone.

VOL. 37, JULY 1964

 Iron Deficiency Anemia-Bainton, Finch
saturation with the per cent sideroblasts of the
marrow. (Fig. 6 and 7.) Better correlation is
found when per cent saturation is used as the
expression of available iron supply. This is
further reinforced by individual examples
among our own patients. Transferrin is de-
creased when there are factors limiting its
production (protein deficiency) or increasing its
loss (nephrosis). In such hypotransferrinemic
states one observes a corresponding fall in
serum iron, often to levels consistent with iron
deficiency, but with normal per cent saturation
and a normal sideroblast count and normal red
cell indices. For these several reasons the
expression, per cent saturation of transferrin, is
considered to be the best index of iron supply
to the marrow, and a decrease to below 16 is
0
0 IO 20 30 40 50 60 70 60 90 100 taken to indicate iron deficiency anemia. The
Sidrroblorts 1%) only apparent exception to this would appear
FIG. 8. Effect of chloromycetin on the sideroblasts. In the to be the presence of such low levels of serum
group of patients included in this study, there were iron that, regardless of transferrin saturation,
fourteen who had been taking chloromycetin for two to
blood flow itself to the marrow will limit supply.
thirteen days, in dosage not exceeding 40 mg. per kg. It
will be seen that six of these patients fell outside of the This level is probably approximately 25 pg.
expected area when the number of sideroblasts was per cent.
related to the per cent saturation of transferrin. A deficient supply of iron to the individual
immature erythrocyte depends on a discrepancy
inadequate supply of iron. This bears no neces- between the total amount of iron supplied and
sary relationship to marrow hemosiderin, but the number of erythroid cells using it; the rela-
rather to the iron supply present in the plasma. tionship does not relate to the absolute amount
The question arises as to the most meaningful of blood produced. For example, extreme
expression of the plasma iron supply. Jandl hypochromia and microcytosis is observed in
showed that iron uptake by reticulocytes was patients with polycythemia vera who are
not only a function of the amount of iron present making a greater than normal amount of blood,
in the plasma but also of its relation to the iron- and, on the other hand, little or no cell deformity
binding protein or transferrin [7]. In this clinical may be present in a patient with hypocellular
study, a better relationship was found between marrow and iron deficiency. Thus, either an
the expression, per cent saturation of transferrin, increase in the erythron or decrease in total
and decrease in hemoglobin synthesis in infec- body iron may produce the same deficiency
tion, than was shown with plasma iron alone. in the individual cell. The degree of marrow
For example, the group of fourteen patients with proliferation determines the severity of hypo-
a plasma iron depressed to levels of iron de- chromia and microcytosis in the iron-deficient
ficiency (less than 45 pg. per cent) who also had subject. It is of interest that proliferation is not
a depressed transferrin sufficient to result in a as marked in iron deficiency as with other
per cent saturation above levels in iron de- disorders of hemoglobin synthesis. Beutler [8],
ficiency (more than j16 per cent), had normal Giblett et al. [9] and Layrisse et al. [7U] have
cell indices. The obvious difficulty in using estimated the number of erythroid cells of the
infection to demonstrate the relationship be- marrow on the basis of the erythroid myeloid
tween decreased erythrocyte hemoglobin and ration to be one and a half to two times normal.
depressed plasma iron supply is the latent This may be contrasted with values of eight or
period required for changes in mean corpuscular ten times normal in thalassemia [77]. This cur-
hemoglobin values. tailed proliferation in iron deficiency may
A better approach to the relationship between represent a direct effect of iron on the mitosis
iron supply and erythroid demand is made by of cells rather than an indirect effect mediated
comparing the serum iron level and per cent through the erythropoietin level [72]. At any
AMERICAN JOURNAL OF MEDICINE
 Iron Deficiency Anemia-B&ton, Finch
rate, the limited proliferation is fortunate, for marrow. However, when the per cent saturation
if the amount of iron available were distributed is sufficiently depressed, the individual erythroid
among a greater number of cells, oxygen trans- cells of the marrow obtain insufficient iron to
port would be less effective, and the process of develop normally. Coincidental with the de-
cell production would have greater wastage. crease in plasma iron values and per cent
There is another aspect of interest concerning saturation of transferrin there is a decrease in
plasma iron supply and the intrinsic iron number of iron-staining granules in developing
metabolism of the developing red cell. We have red cells. This becomes critical when the per
shown that usually a predictable relationship cent saturation is below 16, and sideroblasts are
exists between iron supply and the nonhemo- less than 10 per cent; there follows a reduction
globin iron of the developing red cell, so that in rate of erythrocyte production and a decrease
usually both of these measurements in concert in the size and hemoglobin concentration of
reflect changes of iron supply. However, the erythrocytes. Only after the population of these
developing red cell also reflects the adequacy defective cells becomes significant in relation
of its internal machinery of hemoglobin syn- to the total circulating red cell mass will changes
thesis. If hemoglobin production is decreased in erythrocyte indices occur. Thus, in sequence,
for reasons other than iron deficiency, the changes of iron deficiency include the following:
frequency of sideroblasts would then increase (1) decrease in marrow hemosiderin; (2) fall in
above that expected from the per cent saturation transferrin,[saturation and per cent of sidero-
of transferrin. Such a disparity was found in blasts; and (3) change of a normocytic anemia
thalassemia minor, but even more interestingly to a hypochromic microcytic anemia.
was demonstrated after chloromycetin therapy. In the data presented in this paper the occur-
In half of the patients on ordinary therapeutic rence of a normocytic anemia with impairment
doses of the drug there was an increase beyond of erythropoiesis due to deficient iron supply is
the anticipated number of sideroblasts. It may be illustrated. Indeed, iron deficiency of the
speculated that the action of the drug is on marrow, despite adequate reticuloendothelial
globin synthesis, analogous to that observed in iron, is described in a number of anemic patients
bacterial systems in which there has been a with infection. This is explained by the block in
decrease in protein synthesis [73]. Since the iron release from the reticuloendothelial cell in
patients did not show elevation in plasma iron infection [76]. Another example of inadequate
levels or other hematologic changes, the increase iron supply with excess body iron is found in
in number of sideroblasts would appear to be a studies on a patient with little or no circulating
sensitive index of drug effect [74]. These transferrin [ 771. Thus, both external and internal
observations point out the potential utility of the causes may result in a failure in iron supply
sideroblasts in detecting abnormalities in hemo- to the erythron. A relative deficiency of iron has
globin production. been illustrated in polycythemia Vera, a condi-
Having defined the significance of iron stores, tion in which body iron may be increased yet
of plasma iron supply and of normoblast ferritin, erythropoiesis be impaired by inadequate iron
it seems appropriate to reconstruct the develop- supply. The term, iron deficient erythropoiesis,
ment of iron deficiency and iron deficiency embraces all of these conditions since it repre-
anemia in respect to both time and mechanism sents a deficient supply of iron in relation to
of production [75]. Iron depletion is reflected marrow requirements, whatever the specific
first in the utilization of existent iron stores as cause.
evidenced by a reduction in marrow (R-E)
SUMMARk
hemosiderin. If this occurs gradually, stores may
be nearly exhausted before plasma iron or Studies in a group of patients with iron
transferrin levels are significantly altered. When deficiency anemia indicate that 16 per cent
mobilization of reticuloendothelial iron and saturation of plasma transferrin or less implies an
enhanced absorption of iron are inadequate to inadequate supply of iron to the erythroid
meet the needs of the erythroid marrow, plasma marrow and is associated in time with hypo-
iron levels fall, and the amount of transferrin chromic, microcytic anemia. In some patients
usually increases. The fall in per cent saturation with infection similar depressions in transferrin
of transferrin serves the purpose of more com- saturation were observed, and these were also
pletely directing all available iron to the associated with a decrease in red cell hemo-
VOL. 37, JULY 1964
 Iron Deficiency Anemia-B&ton, Finch
globin. It is further documented that decreased tion of iron in plasma or serum. Biochem. J., 59:
erythropoiesis, due to an inadequate iron 599,1955.
4. SCHADE, A. L., OYAMA, J., REINHART, R. W. and
supply, is not immediately associated with MILLAR, J. R. Bound iron and unsaturated iron-
changes in cell indices and that an inadequate binding capacity of serum: rapid and reliable
supply of iron to the individual cell has no quantitative determination. Proc. Sot. Exfer. Biol.
relation to the total amount of blood being G? Med., 87: 443, 1954,
5. RESSLER, N. and ZAK, B. Serum unsaturated iron-
produced.
binding capacity. Am. J. Clin. Path., 30: 87, 1958.
Marrow hemosiderin has been shown, to- 6. DONOHUE, D. M., MOTULSKY, A. G., GIBLETT,
gether with the circulating hemoglobin level, E. R., PIRZIO-BIROLI, G., VIRANUVATTI, V. and
to be the best criterion for determination of total FINCH, C. A. The use of chromium as a red cell
tag. Brit. J. Haemat., 1: 249, 1955.
body iron, whereas it does not indicate the
7. JANDL, J. H., INMAN, J. K., SIMMONS,R. L. and
adequacy of iron supply to the marrow. ALLEN, D. W. Transfer of iron from serum iron-
Iron deficient erythropoiesis is defined as a binding protein to human reticulocytes. J. Clin.
state in which the supply of iron is inadequate Invest., 38: 161, 1959.
to support optimal erythropoiesis in the de- 8. BEUTLER,E. The red cell indices in the diagnosis of
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veloping red cell mass. This may occur as a
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result of depletion in total body iron or through 9. GIBLETT, E. R., COLEMAN,D. H., PIRZIO-BIROLI,G.,
an inadequate supply of plasma iron, which may DONOHUE,D. M., MOTULSKY, A. G. and FINCH,
be due either to a block in discharge of iron C. A. Erythrokinetics. Quantitative measurements
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poiesis in this sense is the per cent saturation of M. Hookworm anemia: iron metabolism and
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Sideroblast count has been shown to reflect
Cooley’s anemia. Blood, 12: 64, 1957.
not only iron supply, but hemoglobin synthesis 12. FINCH, C. A. Unpublished observations.
by the red cells. A discrepancy in sideroblast 13. BROCK, T. D. Chloramphenicol. Bact. Rev., 25: 32,
count from that predicted by the iron supply 1961.
14. BOWMAN, W. D., JR. Abnormal (“ringed”) sidero-
(per cent saturation of transferrin) is a sensitive
blasts in various hematologic and non-hematologic
indication of a block in hemoglobin synthesis. disorders. Blood, 18: 662, 1961.
15. BOTHWELL,T. H. and FINCH,C. A. Iron Metabolism,
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AMERICAN JOURNAL OF MEDICINE