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Iron Deficiency Anemia

(Anemia of Chronic Blood Loss; Chlorosis)

By Evan M. Braunstein, MD, PhD, Johns Hopkins School of Medicine

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Iron deficiency is the most common cause of anemia and usually results from blood loss; malabsorption is a much less common cause. Symptoms are usually nonspecific. RBCs tend to be microcytic and hypochromic, and iron stores are low, as shown by low serum ferritin and low serum iron levels with high serum total iron-binding capacity. If the diagnosis is made, occult blood loss should be suspected until proven otherwise. Treatment involves iron replacement and treatment of the cause of blood loss.


Iron is distributed in active metabolic and storage pools. Total body iron is about 3.5 g in healthy men and 2.5 g in women; the difference relates to women's smaller body size, and dearth of stored iron because of iron loss due to menses. The distribution of body iron is

  • Hemoglobin 2 g (men), 1.5 g (women)

  • Ferritin 1 g (men), 0.6 g (women)

  • Hemosiderin 300 mg

  • Myoglobin 200 mg

  • Tissue enzymes (heme and nonheme), 150 mg

  • Transport-iron compartment, 3 mg

Iron absorption

Iron is absorbed in the duodenum and upper jejunum. Absorption of iron is determined by the type of iron molecule and by what other substances are ingested. Iron absorption is best when food contains heme iron (meat). Dietary nonheme iron is usually in the ferric state and must be reduced to the ferrous state and released from food binders by gastric secretions. Nonheme iron absorption is reduced by other food items (eg, vegetable fiber phytates and polyphenols; tea tannates, including phosphoproteins; bran) and certain antibiotics (eg, tetracycline). Ascorbic acid is the only common food element known to increase nonheme iron absorption.

The average American diet, which contains 6 mg of elemental iron/1000 kcal of food, is adequate for iron homeostasis. Of about 15 mg/day of dietary iron, adults absorb only 1 mg, which is the approximate amount lost daily by cell desquamation from the skin and intestines. In iron depletion, absorption increases due to the suppression of hepcidin, a key regulator of iron metabolism; however, absorption rarely increases to > 6 mg/day unless supplemental iron is added (1). Children have a greater need for iron and appear to absorb more to meet this need.

Iron transport and usage

Iron from intestinal mucosal cells is transferred to transferrin, an iron-transport protein synthesized in the liver; transferrin can transport iron from cells (intestinal, macrophages) to specific receptors on erythroblasts, placental cells, and liver cells. For heme synthesis, transferrin transports iron to the erythroblast mitochondria, which insert the iron into protoporphyrin for it to become heme. Transferrin (plasma half-life, 8 days) is extruded for reutilization. Synthesis of transferrin increases with iron deficiency but decreases with any type of chronic disease.

Iron storage and recycling

Iron not used for erythropoiesis is transferred by transferrin, an iron-transporting protein, to the storage pool; iron is stored in 2 forms, ferritin and hemosiderin. The most important is ferritin (a heterogeneous group of proteins surrounding an iron core), which is a soluble and active storage fraction located in the liver (in hepatocytes), bone marrow, and spleen (in macrophages); in RBCs; and in serum. Iron stored in ferritin is readily available for any body requirement. Circulating (serum) ferritin level parallels the size of the body stores (1 ng/mL = 8 mg of iron in the storage pool). The 2nd storage pool of iron is in hemosiderin, which is relatively insoluble and is stored primarily in the liver (in Kupffer cells) and in bone marrow (in macrophages).

Because iron absorption is so limited, the body recycles and conserves iron. Transferrin grasps and recycles available iron from aging RBCs undergoing phagocytosis by mononuclear phagocytes. This mechanism provides about 97% of the daily iron needed (about 25 mg of iron). With aging, iron stores tend to increase because iron elimination is slow.

Iron deficiency

Deficiency develops in stages. In the first stage, iron requirement exceeds intake, causing progressive depletion of bone marrow iron stores. As stores decrease, absorption of dietary iron increases in compensation. During later stages, deficiency impairs RBC synthesis, ultimately causing anemia.

Severe and prolonged iron deficiency also may cause dysfunction of iron-containing cellular enzymes.

Pathophysiology reference


Because iron is poorly absorbed, dietary iron barely meets the daily requirement for most people. Even so, people who eat a typical Western diet are unlikely to become iron deficient solely as a result of dietary deficiency. However, even modest losses, increased requirements, or decreased intake readily causes iron deficiency.

Blood loss is almost always the cause. In men and postmenopausal women, the most frequent cause is chronic occult bleeding, usually from the GI tract (eg, from peptic ulcer disease, malignancy, hemorrhoids). In premenopausal women, cumulative menstrual blood loss (mean, 0.5 mg iron/day) is a common cause. Intestinal bleeding due to hookworm infection is a common cause in developing countries. Less common causes include recurrent pulmonary hemorrhage (see Diffuse Alveolar Hemorrhage) and chronic intravascular hemolysis when the amount of iron released during hemolysis exceeds the haptoglobin-binding capacity.

Increased iron requirement may contribute to iron deficiency. From birth to age 2 and during adolescence, when rapid growth requires a large iron intake, dietary iron often is inadequate. During pregnancy, the fetal iron requirement increases the maternal iron requirement (mean, 0.5 to 0.8 mg/day—see Anemia in Pregnancy) despite the absence of menses. Lactation also increases the iron requirement (mean, 0.4 mg/day).

Decreased iron absorption can result from gastrectomy or malabsorption syndromes such as celiac disease, atrophic gastritis, and achlorhydria. Rarely, absorption is decreased by dietary deprivation from undernutrition.

Symptoms and Signs

Most symptoms of iron deficiency are due to anemia. Such symptoms include fatigue, loss of stamina, shortness of breath, weakness, dizziness, and pallor.

In addition to the usual manifestations of anemia, some uncommon symptoms occur in severe iron deficiency. Patients may have pica, an abnormal craving to eat substances (eg, ice, dirt, paint). Other symptoms of severe deficiency include glossitis, cheilosis, and concave nails (koilonychia).


  • CBC, serum iron, iron-binding capacity, serum ferritin, transferrin saturation, reticulocyte count, red cell distribution width (RDW), and peripheral blood smear

  • Rarely bone marrow examination

Iron deficiency anemia is suspected in patients with chronic blood loss or microcytic anemia, particularly if pica is present. In such patients, CBC, serum iron and iron-binding capacity, and serum ferritin and reticulocyte count are obtained.

Iron and iron-binding capacity (or transferrin) are measured because their relationship is important. Various tests exist; the range of normal values relates to the test used. In general, normal serum iron is 75 to 150 μg/dL (13 to 27 μmol/L) for men and 60 to 140 μg/dL (11 to 25 μmol/L) for women; total iron-binding capacity is 250 to 450 μg/dL (45 to 81 μmol/L). Serum iron level is low in iron deficiency and in many chronic diseases and is elevated in hemolytic disorders and in iron-overload syndromes. The iron-binding capacity increases in iron deficiency, while the transferrin saturation decreases.

Serum ferritin levels closely correlate with total body iron stores. The range of normal in most laboratories is 30 to 300 ng/mL, and the mean is 88 ng/mL in men and 49 ng/mL in women. Low levels (<12 ng/mL) are specific for iron deficiency. However, ferritin is an acute-phase reactant, and levels increase in inflammatory and infectious disorders (eg, hepatitis), and neoplastic disorders (especially acute leukemia, Hodgkin lymphoma, and GI tract tumors). In these settings, a serum ferritin up to 100 ng/mL remains compatible with iron deficiency.

The reticulocyte count is low in iron deficiency. The peripheral smear generally reveals hypochromic red cells with significant anisopoikilocytosis, which is reflected in a high red cell distribution width (RDW).

The most sensitive and specific criterion for iron-deficient erythropoiesis is absent bone marrow stores of iron, although a bone marrow examination is rarely needed.

Stages of iron deficiency

Laboratory test results help stage iron deficiency anemia.

Stage 1 is characterized by decreased bone marrow iron stores; Hb and serum iron remain normal, but serum ferritin level falls to < 20 ng/mL. The compensatory increase in iron absorption causes an increase in iron-binding capacity (transferrin level).

During stage 2, erythropoiesis is impaired. Although the transferrin level is increased, the serum iron level decreases; transferrin saturation decreases. Erythropoiesis is impaired when serum iron falls to < 50 μg/dL (< 9 μmol/L) and transferrin saturation to < 16%. The serum transferrin receptor level rises (> 8.5 mg/L).

During stage 3, anemia with normal-appearing RBCs and indices develops.

During stage 4, microcytosis and then hypochromia develop.

During stage 5, iron deficiency affects tissues, resulting in symptoms and signs.

Diagnosis of iron deficiency anemia prompts consideration of its cause, usually bleeding. Patients with obvious blood loss (eg, women with menorrhagia) may require no further testing. Men and postmenopausal women without obvious blood loss should undergo evaluation of the GI tract, because anemia may be the only indication of an occult GI cancer. Rarely, chronic epistaxis or GU bleeding is underestimated by the patient and requires evaluation in patients with normal GI study results.

Other microcytic anemias

Iron deficiency anemia must be differentiated from other microcytic anemias (see Table: Differential Diagnosis of Microcytic Anemia Due to Decreased RBC Production). If tests exclude iron deficiency in patients with microcytic anemia, then anemia of chronic disease, structural Hb abnormalities (eg, hemoglobinopathies), are considered. Clinical features, Hb studies (eg, Hb electrophoresis and Hb A2), and genetic testing (eg, for alpha-thalassemia) may help distinguish these entities.

Differential Diagnosis of Microcytic Anemia Due to Decreased RBC Production

Diagnostic Criteria

Iron Deficiency

Iron-Transport Deficiency

Sideroblastic Iron Utilization

Chronic disease/inflammation

Peripheral smear

Microcytosis (M) vs hypochromia (H)

M > H

M > H

M > H, may be normocytic

Frequently normocytic

Polychromatophilic targeted cells





Stippled RBCs






RBC distribution width (RDW)


Serum iron

Serum iron

Normal or decreased(↓)

Iron-binding capacity


Normal or decreased (↓)

% Saturation of transferrin

< 10


> 50

Normal or decreased (0–50)

Serum ferritin

(Normal, 30–300 ng/mL)

< 12 ng/mL

Usually normal

> 400 ng/mL

30–400 ng/mL

Bone marrow

RBC:granulocyte ratio (normal, 1:3–1:5)





Marrow iron




Ringed sideroblasts





>= more common than;= increased; = decreased.


  • Oral supplemental iron

  • Rarely parenteral iron

Iron therapy without pursuit of the cause is poor practice; the bleeding site should be sought even in cases of mild anemia.

Iron can be provided by various iron salts (eg, ferrous sulfate, gluconate, fumarate) or saccharated iron po 30 min before meals (food or antacids may reduce absorption). A typical initial dose is 60 mg of elemental iron (eg, as 325 mg of ferrous sulfate) given once/day (1). Larger doses are largely unabsorbed but increase adverse effects especially. Ascorbic acid either as a pill (500 mg) or as orange juice when taken with iron enhances iron absorption without increasing gastric distress.

Parenteral iron causes the same therapeutic response as oral iron but can cause adverse effects, such as anaphylactoid reactions, serum sickness, thrombophlebitis, and pain. It is reserved for patients who do not tolerate or who will not take oral iron or for patients who steadily lose large amounts of blood because of capillary or vascular disorders (eg, hereditary hemorrhagic telangiectasia). The dose of parenteral iron is determined by a hematologist. Oral or parenteral iron therapy should continue for 6 mo after correction of Hb levels to replenish tissue stores.

The response to treatment is assessed by serial Hb measurements until normal RBC values are achieved. Hb rises little for 2 wk but then rises 0.7 to 1 g/wk until near normal, at which time rate of increase tapers. Anemia should be corrected within 2 mo. A subnormal response suggests continued hemorrhage, underlying infection or cancer, insufficient iron intake, or malabsorption of oral iron.

Treatment reference

  • Moretti D, Goede JS, Zeder C, et al: Oral iron supplements increase hepcidin and decrease iron absorption from daily or twice-daily doses in iron-depleted young women. Blood 126(17):1981-1989, 2015. doi: 10.1182/blood-2015-05-642223.

Key Points

  • Iron deficiency anemia is usually caused by blood loss (eg, GI, menstrual) but may be due to hemolysis, malabsorption or increased demand for iron (eg, in pregnancy, lactation, periods of rapid growth in children).

  • Differentiate iron deficiency anemia from other microcytic anemias (eg, anemia of chronic disease, hemoglobinopathies).

  • Measure serum iron, iron-binding capacity, and serum ferritin levels.

  • Iron deficiency typically causes low serum iron, high iron-binding capacity, and low serum ferritin levels.

  • Always seek a cause of iron deficiency, even when anemia is mild.

  • Oral iron supplements are usually adequate; reserve use of parenteral iron for hematologists because of risks of adverse effects (eg, anaphylactoid reactions, serum sickness, thrombophlebitis).

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