anemia & iron metabolism hossein piri hossein piri department of biochemistry and genetics,...
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ANEMIA & IRON METABOLISMHossein PiriHossein PiriDepartment of Biochemistry and Genetics, School of Medicine, Qazvin University of Medical Sciences, Qazvin, Iran
September 2014September 2014
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Classification of anemiaClassification of anemia
MorphologicMorphologic Normocytic: MCV= 80-100fLNormocytic: MCV= 80-100fL Macrocytic: MCV > 100 fLMacrocytic: MCV > 100 fL Microcytic : MCV < 80 fLMicrocytic : MCV < 80 fL
PathogenicPathogenic (underlying mechanism) (underlying mechanism) Blood loss (bleeding)Blood loss (bleeding) Decreased RBC productionDecreased RBC production Increased RBC destruction/poolingIncreased RBC destruction/pooling
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Normocytic AnemiasNormocytic Anemias
Acute post-Acute post-hemorrhagic anemiahemorrhagic anemia
Hemolytic anemia Hemolytic anemia (except thalassemia (except thalassemia and some other Hb and some other Hb disorders)disorders)
Endocrin diseasesEndocrin diseases Renal failureRenal failure Liver diseaseLiver disease Chronic disease Chronic disease
anemiaanemia Protein malnutritionProtein malnutrition Hypovitaminosis CHypovitaminosis C
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Microcytic anemiasMicrocytic anemias
Iron deficiency anemiaIron deficiency anemia ThalassemiaThalassemia Sideroblastic anemiaSideroblastic anemia
HereditaryHereditary
Chronic lead poisoningChronic lead poisoning
Anemia of chronic diseases Anemia of chronic diseases
(some cases)(some cases)
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Megaloblastic Macrocytic Megaloblastic Macrocytic AnemiasAnemias
Vit BVit B1212 deficiency deficiency Folic acid deficiencyFolic acid deficiency Other.Other.
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Pathogenic classificationPathogenic classification(Causes of anemia)(Causes of anemia)
Relative (increased plasma volume)Relative (increased plasma volume) Decreased RBC productionDecreased RBC production Blood lossBlood loss
Anemia due to acute bleedingAnemia due to acute bleeding Increased RBC destructionIncreased RBC destruction
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Pathogenic classificationPathogenic classification(Causes of anemia)(Causes of anemia)
Decreased RBC productionDecreased RBC production– Decreased Hb productionDecreased Hb production– Defective DNA synthesisDefective DNA synthesis– Stem cell defectsStem cell defects
Blood lossBlood loss– Anemia due to acute bleedingAnemia due to acute bleeding
Increased RBC destructionIncreased RBC destruction Relative(increased plasma volume)Relative(increased plasma volume)
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Decreased Hb productionDecreased Hb production
Iron deficiency anemiaIron deficiency anemia ThalassemiaThalassemia Sideroblastic anemiaSideroblastic anemia Lead poisoningLead poisoning
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Defective DNA synthesisDefective DNA synthesis
Vit BVit B1212 deficiency deficiency Folic acid deficiencyFolic acid deficiency Other.Other.
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Anemias caused by increased Anemias caused by increased RBC destruction RBC destruction (hemolytic (hemolytic anemias)anemias)
Can be classified as;Can be classified as; Hereditary hemolytic diseasesHereditary hemolytic diseases Acquired hem. DiseasesAcquired hem. Diseases
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IronIron & & (TIBC)(TIBC)
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:عملکرد:عملکردانتقال اکسیژنانتقال اکسیژنتنفستنفس ،متابولیسم اسیدهای آمینه و رادیکال آزاد، متابولیسم اسیدهای آمینه و رادیکال آزاد
لیپیدها، فسفریالسیون اکسیداتیولیپیدها، فسفریالسیون اکسیداتیو جزئی از جزئی ازHbHbو متالوآنزیم ها و متالوآنزیم ها
آهنآهن
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تركيبات آهن دار بدنتركيبات آهن دار بدن(آهن هم(آهن همHeme IronHeme Iron))
ترانسفرينترانسفرين هموسيدرين هموسيدرين
فريتين فريتين
آهن غير همآهن غير هم((None heme IronNone heme Iron)) ))HbHb((هموگلوبينهموگلوبين
ميوگلوبين ميوگلوبين آهن بافتي آهن بافتي
)آنزيمهاي تنفسي()آنزيمهاي تنفسي(
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Iron Transport into Plasma
Ferroportin 1
Macrophages
Fe+2
Ferro-portin 1
Macrophage
Fe+2
SenescentRBC
Hb
Fe
Fe+3 TfCerulo-plasminFerroportin 1
Duodenal cytochrome b
Ferroportin 1
Duodenal cytochrome b
Adapted frlm Andrews, NEJM 1999;341:1986
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Andrews N, NEJM 1999;341:1986
Receptor-Mediated Endocytosis
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Food iron is predominantly in the ferric state.In the stomach, where the pH is less than 4, Fe3+
can dissociate and react with low-molecular weight compounds such fructose, ascorbic acid, citric acid,
amino acids to form ferric complexes soluble in neutral pH of intestine fluid.
A protein DMT1 (divalent metal transporter 1), which transports all kinds of divalent metals, then
transports the iron across the cell membrane of intestinal cells. These intestinal lining cells can
then store the iron as ferritin.
The transfer of iron from the storage ferritin (as Fe3+ ) involves reduction to ferrous state – Fe2+ in
order for it to be released from ferritine.
The Fe2+ is subsequently again oxidized by ferroxidase ceruloplasmin and transported bound to
plasma transferrin to storage sites in the bone marrow, liver muscle, other tissues.
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اريتروپوئز و سنتز هماريتروپوئز و سنتز همBone marrowBone marrow
جذب ، انتقال و دفع آهن)متابوليسم آهن(جذب ، انتقال و دفع آهن)متابوليسم آهن(
RBC(blood)RBC(blood) اريتروپوئز اريتروپوئزغيرموثرغيرموثر
Plasma &Plasma & ECFECF
PhagocytesPhagocytes , RBC , RBC تخريبتخريب
HbHb
جذب روده جذب روده اياي
ذخيره سازي به ذخيره سازي به صورت فريتين صورت فريتين و هموسيدرينو هموسيدرين
خون ريزي و خون ريزي و دفع از طرق دفع از طرق
ديگرديگر
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04/19/23 Plasma Proteins 19
Transferrin (TRF)Transferrin (TRF) TRF (sidrophilin) is a plasma transport protein for iron (TRF (sidrophilin) is a plasma transport protein for iron (ββ1)1) Single polypeptide chain ,79.6 kDa, 5.5% carbohydrate. Single polypeptide chain ,79.6 kDa, 5.5% carbohydrate. Reversibly bind to divalent cations, Reversibly bind to divalent cations, TRF accounts for TIBC of plasmaTRF accounts for TIBC of plasma One TRF binds two Fe+3, TRF- Fe+3 complex transports iron One TRF binds two Fe+3, TRF- Fe+3 complex transports iron
to cellsto cells Every cell type has surface receptors of TRF Every cell type has surface receptors of TRF TRF is synthesized by liverTRF is synthesized by liver Plasma levels are regulated by iron availability (iron↓, TRF↑)Plasma levels are regulated by iron availability (iron↓, TRF↑) One-half of TRF exists in extravascular spacesOne-half of TRF exists in extravascular spaces
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04/19/23 Plasma Proteins 20
Receptors for TRFReceptors for TRF
After binding the TRF - Fe+3 -receptor complex is After binding the TRF - Fe+3 -receptor complex is internalized, resulting in release of iron from TRFinternalized, resulting in release of iron from TRF
Free Fe+3, is cytotoxic, is reduced and incorporated into Free Fe+3, is cytotoxic, is reduced and incorporated into ferritinferritin and and hemosiderinhemosiderin, for synthesis of compounds, , for synthesis of compounds, such as Hb, myoglobin, and cytochromessuch as Hb, myoglobin, and cytochromes
The receptor-apo TRF complex is recycled to the cell The receptor-apo TRF complex is recycled to the cell surface where the apo TRF is released and recycled, surface where the apo TRF is released and recycled, making the receptor available again for bindingmaking the receptor available again for binding
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04/19/23 Plasma Proteins 21
Clinical SignificanceClinical Significance
Differential diagnosis of anemia:Differential diagnosis of anemia: In hypochromic microcytic anemia: In hypochromic microcytic anemia: Elevated TRF & less saturated : Iron deficiencyElevated TRF & less saturated : Iron deficiency (saturation normally 30% to 38%)(saturation normally 30% to 38%) Low or normal TRF & highly saturated: Iron non-Low or normal TRF & highly saturated: Iron non-
dependencydependency
Estrogen increases TRF synthesis, Estrogen increases TRF synthesis,
TRF is a TRF is a negativenegative APP APP
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Iron Iron((كمبود آهن كمبود آهن deficiencydeficiency((
Iron Iron((افزايش آهن افزايش آهن overloadoverload((
- هموسيدروز- هموسيدروز
- هموكروماتوز)اوليه، - هموكروماتوز)اوليه، ثانويه(ثانويه(
ناهنجاريهاي متابوليسم آهنناهنجاريهاي متابوليسم آهن
آرتريتآرتريت
آريتمي قلبيآريتمي قلبي
نارسايي قلبينارسايي قلبي
سيروز كبديسيروز كبدي
هيپوتيروئيديسمهيپوتيروئيديسم
سرطان كبدسرطان كبد
ديابت مليتوسديابت مليتوس
هيپرپيگمانتاسيونهيپرپيگمانتاسيون
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:اثرات کمبود:اثرات کمبودآنمی هیپوکرومیک میکروسیتآنمی هیپوکرومیک میکروسیتالتهاب دهانیالتهاب دهانیدیستروفی ناخن دستدیستروفی ناخن دست
:اثرات سمیت:اثرات سمیتهموکروماتوز اولیههموکروماتوز اولیه
آهنآهن
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افزايش تخريب افزايش تخريبRBCRBCيا هموليز يا هموليز افزايش رها سازي آهن و يا فريتين از بافتها )نكروز افزايش رها سازي آهن و يا فريتين از بافتها )نكروز
حاد كبد(حاد كبد( كاهش توليد كاهش توليدHbHb مسموميت با )مسموميت با( pbpb كمبود ، كمبود ،
پيريدوكسين(پيريدوكسين(اريتروپوئز غير موثراريتروپوئز غير موثر((IneffectiveIneffective erythropoesiserythropoesis))افزايش جذب آهنافزايش جذب آهن((IronIron overloadoverload)) مصرف قرصهاي آهنمصرف قرصهاي آهنترانسفوزيون مكررترانسفوزيون مكررمصرف داروهاي ضد حاملگي پروژسترونيمصرف داروهاي ضد حاملگي پروژسترونيآلودگي سرنگ يا ظرف نمونهآلودگي سرنگ يا ظرف نمونه
FeFeعلل عمده افزايش علل عمده افزايش
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سندرم سوءتغذيه و سوءجذبسندرم سوءتغذيه و سوءجذبخونريزي مزمن و مكررخونريزي مزمن و مكرر(عفونت و عفونت و اختالل در رهاسازي آهن از سيستم رتيكولواندوتليال)اختالل در رهاسازي آهن از سيستم رتيكولواندوتليال
اختالالت التهابي مزمن(اختالالت التهابي مزمن()بيماريهاي مزمن)عفونت و بدخيمي(بيماريهاي مزمن)عفونت و بدخيمي)بيماريهاي حاد)عفونت(بيماريهاي حاد)عفونتكواشيوركوركواشيوركور)نفروز )سندرم نفروتيك(نفروز )سندرم نفروتيك
FeFeعلل عمده كاهش علل عمده كاهش
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PorphyrinesPorphyrines
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Heme BiosynthesisHeme Biosynthesis
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نقش ویتامین نقش ویتامین B12B12و و B9B9های های
در اریتروپوئزدر اریتروپوئز
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ها از مسير توليد ها از مسير توليد بيوسنتز پورينبيوسنتز پورينداخليداخلي
AspAsp
Formyl-Formyl-THFTHF
CO2CO2 GlyGly
Amide Nitrogen of Amide Nitrogen of GlnGln
Methenyl-Methenyl-THFTHF
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dTMPdTMPسنتز سنتز
تیمیدیالت سنتاز
AminopterinTrimethoprim
suicide inhibitor Breast and colon cancer
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Essential Nutrients for Erythropoiesis
Folic Acid Cobalamin Iron
Enzyme
Function
Source
Absorp.
Storage
Thymidylate synthetase
Methionine synthetase
Ferro-chelatase
DNA synth. DNA synth. Hb synth.
Vegetables, fruit, liver
Meats, milk,eggs
Meats, fortification
Prox. Intest. Prox. Intest.Term. Ileum
Liver Liver, kidney Macrophages