The Role of Reticulocyte Hemoglobin Content (CHr)

to Early Diagnosis Iron Deficiency Anemia

Delita Prihatni
SMF/Dept Patologi Klinik
RSUP Dr. Hasan Sadikin/ FK UNPAD
BANDUNG
Introduction
• Iron Deficiensy Anemia (IDA) occurs due to an
imbalance between intake, absorption and iron
secretion in the body

• WHO prevalence (Anemia) : 5-19,9%

Male (>15 yo) : Hb <13 g/dL
Female (>15 yo) : Hb <12 g/dL
Pregnant women : Hb 11 g/dL

• Sudikno, Sandjaya (Pusat Penelitian dan

Pengembangan Upaya Kesehatan Masyarakat, Badan
Litbangkes) :
Tasikmalaya & Ciamis : reproductive female 9,6 %.
Michelle P. Zeller and Madeleine Verhovsek
CMAJ March 13, 2017 189 (10)
High Risk of Iron Def Anemia
The American
Academy of Pediatricians (AAP)

. The 2005 : breastfeeding.

The Centers for Disease
Control and Prevention
(CDC) High risk infant-
Reproductive woman & children
iron supplementation to (12yo)
pregnancy woman
10% pddk (2016)

The earliest prenatal visit

and early in the third Iron def anemia
trimester
The American Academy of Family
Physicians (AAFP)
The American College of
Obstetricians and
Gynecologists (ACOG)
.
Assesment of Body Iron Status

Rodak BF, Fritsma GA, M.Keohane E, Hematology, Clinical

Principles and application (2016)
1. MCV and MCH values are useful at diagnosis and in assessing trends over periods
of weeks or months.
2. % hypochromic red cells (%HRC) is the best-established variable for the identification
of functional iron deficiency (FID), CHr is the next most established option.
3. CHr value <29 pg predicts FID in patients receiving ESA therapy.
4. CHR <25 pg is suggestive of classical ID
5. CHR : 30-36 pg as best predictive value for likelihood of response to intravenous
iron therapy in CKD patients on haemodialysis
6. CHr is the best predictive value for likelihood of response to intravenous iron therapy
7. Serum ferritin concentration is not useful in predicting ESA responsiveness
in cancer-related anaemia.
8. Ferritin <12 lg/l indicate absent iron stores.
9. sTfR + the ferritin assay, if automated measures such as %HRC, CHr or Ret-He
are unavailable

British Journal of Haematology, 2013

Development of iron deficiency anemia

Rodak BF, Fritsma GA, M.Keohane E, Hematology, Clinical

Principles and application (2016)
 Screening for iron deficiency anemia
Primary care
CBC and assessment of the hematological
parameters: Hb/Ht or Eritr

Secondary
Tertiary care indicators of iron metabolism
iron levels, transferrin saturation,
serum circulating transferrin receptor,
ferritin

Reticulocyte Hemoglobin content (CHr)

(early indicator of iron deficiency)
Journal of Adolescent Health 36 (2005)
 Reticulocyte Hemoglobin content (CHr)
• The CHR is a measure to amount of Hb in the reticulocyte
• The CHR is a reasonably good reflection of how much iron was available to
the bone marrow for incorporation into new red blood cells a few days
before.
• Reticulocyte released into circulation about 2 days prior to maturation
into new red blood cells.
• The CHR compares favorably with serum ferritin in predicting a response
to intravenous iron
• Strongest predictor of iron deficiency and iron deficiency anemia
• highest sensitivity and specificity
• early indicator of response to iron treatment
• inexpensive test
Limitation : Sample stability
Study Comparison
Author CHr Results

Mast AE, Blinder MA, Lu Q, CHr <28 pg vs Prussiian sensitivity (74%)

Flax S, Dietzen DJ. Blue (bone marrow) specificity (73%)
(Blood 2002)
Thomas C, Thomas L. CHr < 28 pg functional iron deficiency-
(Clin Chem 2002) dialysis patients.

Mustafa K, Eren G, Fezan CHR: 29pg – predict IDA sensitivity (90,6%)

ŞM, Meltem O specificity (66,7%)
(Turk J Hematol 2013) hemoglobin, MCV, MCH,
and TS ( r>0.7 )
Riadi Wirawan, Ailinda T. CHR : 29,2 pg - CKD sensitivity (95,5 %)
Tedja, Fify Henrika, Aida specificity (94 %)
Lydia
(Acta Med Indonesia 2017)
 Thomas Plot
True iron deficiency : the sTfR  and the ferritin 
(the sTfR/log ferritin will be high and the will be low)

Functional iron deficiency

Ferritin may be falsely elevated by inflammation :
the sTfR/ log ferritin will be normal , CHR will be low

Latent iron deficiency :

the body’s need iron : sTfR production  ferritin 
(the sTfR/log ferritin value: high)
- Combination of RET-He (<32 pg) and anemia (Hb <11 g/dL) were used to rule out iron deficiency
anemia
- RET- He and its CHr equivalent are routinely available with automated reticulocyte analysis

CHr, can clearly separate patients with a higher likelihood of needing a transfusion from those with a
lower likelihood. In addition, these “functionally” iron deficient patients might conceivably be
a suitable target for preemptive treatment options such as intravenous iron therapy.
Anesthesiology 2010; 112:1211–5
Screening Algorithm using CHr for Iron Deficiency

Journal of Adolescent Health 36 (2005)

529.e1–529.e6
Sample Preparation

• Obtain samples before the initiation of dialysis.

• Avoid contaminating blood with heparin or saline.
• Use luer adapter to collect specimen directly into
lavender top tube avoid using syringes.
• Be sure to mix samples by gently inverting 5 times
after collection.
• Refrigerate specimens promptly while awaiting
shipment. Do not freeze.
Summary
- CHr Test to screen for iron deficiency anemia
may increase the accuracy of diagnosis,
enabling early detection and treatment of iron
deficiency
- The measurement is not affected by
physiologic interferences