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In adults with vitamin B12 deficiency, an inverse correlation between the severity of megaloblastic anemia and the degree of neurological dysfunction has been reported. We aimed to evaluate the association between hematological findings and the results of neurodevelopmental assessment in infants. Denver-II developmental screening test (DDST II) was performed in vitamin B12-deficient infants (n = 122), and its relationship with hematological findings was evaluated. DDST II was abnormal in 15 (12.3%), suspect in 20 (16.4%) and normal in 87 (71.3%) cases. Among the infants aged ≥ 4 months (n = 89), cases with an abnormal DDST II had lower levels of hemoglobin (7.49 ± 3.13 vs. 9.87 ± 1.77 g/dL; P = 0.015), whereas they had higher levels of mean corpuscular volume (MCV) (90.05 ± 19.31 vs. 69.90 ± 10.51 fL; P = 0.002), mean corpuscular hemoglobin (MCH) (28.96 ± 7.50 vs. 22.03 ± 4.58 pg; P = 0.001), homocysteine (44.31 ± 11.51 vs. 21.05 ± 9.23 µmol/L; P < 0.001), transferrin saturation index (25.84 ± 17.72 vs. 9.55 ± 6.38%; P = 0.004) and ferritin (87.28 ± 82.21 vs. 26.59 ± 31.67 ng/mL; P = 0.040) than those with a normal DDST II. The receiver operator characteristic analysis could distinguish infants with an abnormal DDST II from those with a normal DDST II by using a hemoglobin level < 8.75 g/dL [sensitivity: 71.4%, specificity: 76.4%; area under curve (AUC): 0.744], an MCV > 88.4 fL (sensitivity: 76.9%, specificity: 98.2%; AUC 0.813), an MCH > 28.5 pg (sensitivity: 76.9%, specificity: 96.4%; AUC: 0.822), and a homocysteine level > 27.35 µmol/L (sensitivity: 92.9%, specificity: 85.5%; AUC: 0.907). Even mild abnormalities of some commonly evaluated laboratory variables (such as MCV and MCH) in an infant should alert the physicians for the possibility of an underlying vitamin B12 deficiency with some degree of neurological impairment.

Anaemia is a severe public health problem amongst all vulnerable age groups in India. The National Nutritional Anaemia Prophylaxis Programme initiated in 1970, was revised and expanded to include beneficiaries from all age groups namely children aged 6-59 months, 5-10 yr, adolescents aged 10-19 yr, pregnant and lactating women and women in reproductive age group under the National Iron Plus Initiative (NIPI) programme in 2011. The dose of iron, frequency and duration of iron supplementation and roles and responsibilities of the functionaries were described. At present, the coverage of beneficiaries with iron and folic acid has been poor at the national level. The prevalence of anaemia has continued to remain high during the last 60 years, and there has been no significant change in the scenario due to various reasons. The constraints in implementation and measures to improve the NIPI programme are discussed in the current article., Competing Interests: None

The current vaccine against tuberculosis, live attenuated Mycobacterium bovis BCG, has variable efficacy, but development of an effective alternative is severely hampered by the lack of an immune correlate of protection. There has been a recent resurgence of interest in functional in vitro mycobacterial growth inhibition assays (MGIAs), which provide a measure of a range of different immune mechanisms and their interactions. We identified a positive correlation between mean corpuscular haemoglobin and in vitro growth of BCG in whole blood from healthy UK human volunteers. Mycobacterial growth in peripheral blood mononuclear cells (PBMC) from both humans and macaques was increased following the experimental addition of haemoglobin (Hb) or ferric iron, and reduced following addition of the iron chelator deferoxamine (DFO). Expression of Hb genes correlated positively with mycobacterial growth in whole blood from UK/Asian adults and, to a lesser extent, in PBMC from South African infants. Taken together our data indicate an association between Hb/iron levels and BCG growth in vitro, which may in part explain differences in findings between whole blood and PBMC MGIAs and should be considered when using such assays.

Background: Our objective was to compare the capacity of iron (Fe) biofortified and standard pearl millet (Pennisetum glaucum L.) to deliver Fe for hemoglobin (Hb)-synthesis. Pearl millet (PM) is common in West-Africa and India, and is well adapted to growing areas characterized by drought, low-soil fertility, and high-temperature. Because of its tolerance to difficult growing conditions, it can be grown in areas where other cereal crops, such as maize, would not survive. It accounts for approximately 50% of the total world-production of millet. Given the widespread use of PM in areas of the world affected by Fe-deficiency, it is important to establish whether biofortified-PM can improve Fe-nutriture., Methods: Two isolines of PM, a low-Fe-control ("DG-9444", Low-Fe) and biofortified ("ICTP-8203 Fe",High-Fe) in Fe (26 μg and 85 μg-Fe/g, respectively) were used. PM-based diets were formulated to meet the nutrient requirements for the broiler (Gallus-gallus) except for Fe (Fe concentrations were 22.1±0.52 and 78.6±0.51 μg-Fe/g for the Low-Fe and High-Fe diets, respectively). For 6-weeks, Hb, feed-consumption and body-weight were measured (n = 12)., Results: Improved Fe-status was observed in the High-Fe group, as suggested by total-Hb-Fe values (15.5±0.8 and 26.7±1.4 mg, Low-Fe and High-Fe respectively, P<0.05). DMT-1, DcytB, and ferroportin mRNA-expression was higher (P<0.05) and liver-ferritin was lower (P>0.05) in the Low-Fe group versus High-Fe group. In-vitro comparisons indicated that the High-Fe PM should provide more absorbable-Fe; however, the cell-ferritin values of the in-vitro bioassay were very low. Such low in-vitro values, and as previously demonstrated, indicate the presence of high-levels of polyphenolic-compounds or/and phytic-acid that inhibit Fe-absorption. LC/MS-analysis yielded 15 unique parent aglycone polyphenolic-compounds elevated in the High-Fe line, corresponding to m/z = 431.09., Conclusions: The High-Fe diet appeared to deliver more absorbable-Fe as evidenced by the increased Hb and Hb-Fe status. Results suggest that some PM varieties with higher Fe contents also contain elevated polyphenolic concentrations, which inhibit Fe-bioavailability. Our observations are important as these polyphenols-compounds represent potential targets which can perhaps be manipulated during the breeding process to yield improved dietary Fe-bioavailability. Therefore, the polyphenolic and phytate profiles of PM must be carefully evaluated in order to further improve the nutritional benefit of this crop.

Background: Our objective was to determine if a biofortified variety of black bean can provide more bioavailable-iron (Fe) than a standard variety. Two lines of black beans (Phaseolus-vulgaris L.), a standard (DOR500; 59μg Fe/g) and biofortified (MIB465; 88μg Fe/g) were used. The DOR500 is a common commercial variety, and the MIB465 is a line developed for higher-Fe content. Given the high prevalence of Fe-deficiency anemia worldwide, it is important to determine if Fe-biofortified black beans can provide more absorbable-Fe., Methods: Black bean based diets were formulated to meet the nutrient requirements for the broiler (Gallus-gallus) except for Fe (dietary Fe-concentrations were 39.4±0.2 and 52.9±0.9 mg/kg diet, standard vs. biofortified, respectively). Birds (n=14) were fed the diets for 6-weeks. Hemoglobin-(Hb), liver-ferritin and Fe-related transporter/enzyme gene-expression were measured. Hemoglobin-maintenance-efficiency and total-body-Hb-Fe values were used to estimate Fe-bioavailability., Results: Hemoglobin-maintenance-efficiency values were higher (P<0.05) in the group consuming the standard-Fe beans on days 14, 21 and 28; indicating a compensatory response to lower dietary-Fe. Final total-Hb-Fe body content was higher in the biofortified vs. the standard group (26.6±0.9 and 24.4±0.8 mg, respectively; P<0.05). There were no differences in liver-ferritin or in expression of DMT-1, Dcyt-B, and ferroportin. In-vitro Fe-bioavailability assessment indicated very low Fe-bioavailability from both diets and between the two bean varieties (P>0.05). Such extremely-low in-vitro Fe-bioavailability measurement is indicative of the presence of high levels of polyphenolic-compounds that may inhibit Fe-absorption. High levels of these compounds would be expected in the black bean seed-coats., Conclusions: The parameters of Fe-status measured in this study indicate that only a minor increase in absorbable-Fe was achieved with the higher-Fe beans. The results also raise the possibility that breeding for increased Fe-concentration elevated the levels of polyphenolic-compounds that can reduce bean Fe-bioavailability, although the higher levels of polyphenolics in the higher-Fe beans may simply be coincidental or an environmental effect. Regardless, Fe-biofortified beans remain a promising vehicle for increasing intakes of bioavailable-Fe in human populations that consume high levels of these beans as a dietary staple, and the bean polyphenol profile must be further evaluated and modified if possible in order to improve the nutritional quality of higher-Fe beans.

In this issue of Blood, Cooke et al demonstrate the potential of a fully human anti-hepcidin antibody as a novel therapeutic for iron-restricted anemias such as anemia of inflammation, cancer, or chronic kidney disease (formerly known as “anemia of chronic diseases”).

Iron maldistribution has been implicated in the etiology of many diseases including the anemia of inflammation (AI), atherosclerosis, diabetes, and neurodegenerative disorders. Iron metabolism is controlled by hepcidin, a 25-amino-acid peptide. Hepcidin is induced by inflammation and causes iron to be sequestered within cells of the reticuloendothelial system, suppressing erythropoiesis and blunting the activity of erythropoiesis stimulating agents (ESAs). For this reason, neutralization of hepcidin has been proposed as a therapeutic treatment of AI. The aim of the current work was to generate fully human anti-hepcidin antibodies (Abs) as a potential human therapeutic for the treatment of AI and other iron maldistribution disorders. An enzyme-linked immunosorbent assay was established using these Abs to identify patients likely to benefit from either ESAs or anti-hepcidin agents. Using human hepcidin knock-in mice, the mechanism of action of the Abs was shown to be due to an increase in available serum iron leading to enhanced red cell hemoglobinization. One of the Abs, 12B9m, was validated in a mouse model of AI and demonstrated to modulate serum iron in cynomolgus monkeys. The 12B9m Ab was deemed to be an appropriate candidate for use as a potential therapeutic to treat AI in patients with kidney disease or cancer.

Testosterone administration increases hemoglobin levels and has been used to treat anemia of chronic disease. Erythrocytosis is the most frequent adverse event associated with testosterone therapy of hypogonadal men, especially older men. However, the mechanisms by which testosterone increases hemoglobin remain unknown. Testosterone administration in male and female mice was associated with a greater increase in hemoglobin and hematocrit, reticulocyte count, reticulocyte hemoglobin concentration, and serum iron and transferrin saturation than placebo. Testosterone downregulated hepatic hepcidin mRNA expression, upregulated renal erythropoietin mRNA expression, and increased erythropoietin levels. Testosterone-induced suppression of hepcidin expression was independent of its effects on erythropoietin or hypoxia-sensing mechanisms. Transgenic mice with liver-specific constitutive hepcidin over-expression failed to exhibit the expected increase in hemoglobin in response to testosterone administration. Testosterone upregulated splenic ferroportin expression and reduced iron retention in spleen. After intravenous administration of transferrin-bound (58) Fe, the amount of (58) Fe incorporated into red blood cells was significantly greater in testosterone-treated mice than in placebo-treated mice. Serum from testosterone-treated mice stimulated hemoglobin synthesis in K562 erythroleukemia cells more than that from vehicle-treated mice. Testosterone administration promoted the association of androgen receptor (AR) with Smad1 and Smad4 to reduce their binding to bone morphogenetic protein (BMP)-response elements in hepcidin promoter in the liver. Ectopic expression of AR in hepatocytes suppressed hepcidin transcription; this effect was blocked dose-dependently by AR antagonist flutamide. Testosterone did not affect hepcidin mRNA stability. In conclusion, testosterone inhibits hepcidin transcription through its interaction with BMP/Smad signaling. Testosterone administration is associated with increased iron incorporation into red blood cells., (© 2013 The Authors Aging Cell © 2013 Blackwell Publishing Ltd/Anatomical Society of Great Britain and Ireland.)

Resistance exercise increases heme synthesis in the bone marrow and the hemoglobin in iron-deficient rats. Post-exercise early nutrient provision facilitates skeletal muscle protein synthesis compared to late provision. However, the effects of post-exercise nutrition timing on hemoglobin synthesis are unclear. The current study investigated the effect of post-exercise meal timing on the activity of the key enzyme involved in hemoglobin synthesis, δ-aminolevulinic acid dehydratase (ALAD), in the bone marrow and examined the hemoglobin concentration in iron-deficient rats. Male 4-week-old Sprague-Dawley rats were fed an iron-deficient diet containing 12 mg iron/kg and performed climbing exercise (5 min × 6 sets/day, 3 days/week) for 3 weeks. The rats were divided into a group fed a post-exercise meal early after exercise (E) or a group fed the meal 4 h after exercise (L). A single bout of exercise performed after the 3-week training period increased the bone marrow ALAD activity, plasma iron concentration, and transferrin saturation. Although the plasma iron concentration and transferrin saturation were lower in the E group than the L group after a single bout of exercise, the basal hematocrit, hemoglobin, and TIBC after 3 weeks did not differ between the groups. Therefore, resistance exercise increases the bone marrow ALAD activity, while the post-exercise meal timing has no effect on the hemoglobin concentration in iron-deficient rats.

Erythropoiesis is a coordinated process by which RBCs are produced. Erythropoietin, a kidney-derived hormone, and iron are critical for the production of oxygen-carrying mature RBCs. To meet the high demands of iron during erythropoiesis, small intestinal iron absorption is increased through an undefined mechanism. In this study, erythropoietic induction of iron absorption was further investigated. Hypoxia-inducible factor-2α (HIF-2α) signaling was activated in the small intestine during erythropoiesis. Genetic disruption of HIF-2α in the intestine abolished the increase in iron absorption genes as assessed by quantitative real-time reverse transcription-PCR and Western blot analyses. Moreover, the increase in serum iron following induction of erythropoiesis was entirely dependent on intestinal HIF-2α expression. Complete blood count analysis demonstrated that disruption of intestinal HIF-2α inhibited efficient erythropoiesis; mice disrupted for HIF-2α demonstrated lower hematocrit, RBCs, and Hb compared with wild-type mice. These data further cement the essential role of HIF-2α in regulating iron absorption and also demonstrate that hypoxia sensing in the intestine, as well as in the kidney, is essential for regulation of erythropoiesis by HIF-2α.

Anemia of inflammation in patients with acute or chronic acute-phase activation is a common clinical problem. Hepcidin is a peptide shown to be the principal regulator of the absorption and systemic distribution of iron. Main inducers of hepcidin are iron overload, hypoxia and inflammation, where the latter has been linked to hepcidin via increased interleukin-6 (IL-6). This article addresses the impact and time course of postoperative acute-phase reaction in humans following heart surgery on prohepcidin, hepcidin, hematological markers and IL-6 concentrations. Serum concentrations of prohepcidin, hepcidin, IL-6 and hematological iron parameters were studied in five male patients without infection before and after heart surgery. This study, which is the first to report the impact on serum hepcidin and serum prohepcidin concentrations in patients following surgery, clearly demonstrates the induction of hypoferremia due to the postoperative acute-phase reaction. Significant changes were seen for serum iron concentration, transferrin saturation, total iron binding capacity and hemoglobin concentration. A significant increase in ferritin concentration was seen 96-144 h postoperatively. Additionally, there were significant alterations in both serum hepcidin after 96-144 h and serum prohepcidin after 48 h compared with preoperative values. Serum prohepcidin decreased, whereas serum hepcidin increased. In conclusion, changes in serum prohepcidin were followed by an increase in serum hepcidin. This speaks in favor of a chain of action where proteolytic trimming of serum prohepcidin results in increased serum hepcidin. However, hypoferremia appeared prior to the changes in serum prohepcidin and serum hepcidin.

Many investigators found that iron deficiency anemia (IDA) had a great influence on cognitive functions in infants and children. However, studies of such topic in adults are few and controversial. We prospectively assessed the possible influence of IDA and iron supplementation (for 3 months) on cognitive function and intelligence of 28 young adults with IDA. We used group of hematological, cognitive, neurophysiological tests for assessment including: mini-mental state examination (MMSE), Wechsler memory scale-revised (WMS-R), Wechsler adult intelligence scale-revised (WAIS-R), event-related potentials (ERPs), and electroencephalography (EEG). Compared to controls, patients demonstrated lower scores of different cognitive tests (MMSE, WMS-R, and WAIS-R), which showed significant improvement after treatment. Prolongation of ERPs latencies (N200 and P300) and reduction in their amplitudes (P200 and P300) were identified with significant increase in amplitude occurred after treatment. EEG abnormalities were observed in 55% of patients which showed improvement in 35% after treatment. Positive correlation was identified before and after treatment between hemoglobin levels and MMSE (P=0.01, 0.05), total verbal (P=0.04) and performance (P=0.05, 0.04) IQ scores. Negative correlation was identified between before and after treatment between P300 latency and total IQ of WAIS-R (P=0.03, 0.008) and hemoglobin level (P=0.4, 0.01). Positive correlation was found before and after treatment between P300 amplitude and total IQ (P=0.028, 0.01) and serum iron (P=0.01, 0.001). In conclusion, IDA is a significant factor in cognitive performance in adult population, which can be partially reversed by treatment.

Hemoglobin production during erythropoiesis is mechanistically coupled to the acquisition and metabolism of iron. We discovered that iron regulates the expression of alpha-hemoglobin-stabilizing protein (AHSP), a molecular chaperone that binds and stabilizes free alpha-globin during hemoglobin synthesis. In primates, the 3'-untranslated region (UTR) of AHSP mRNA contains a nucleotide sequence resembling iron responsive elements (IREs), stem-loop structures that regulate gene expression post-transcriptionally by binding iron regulatory proteins (IRPs). The AHSP IRE-like stem-loop deviates from classical consensus sequences and binds IRPs poorly in electrophoretic mobility shift assays. However, in cytoplasmic extracts, AHSP mRNA co-immunoprecipitates with IRPs in a fashion that is dependent on the stem-loop structure and inhibited by iron. Moreover, this interaction enhances AHSP mRNA stability in erythroid and heterologous cells. Our findings demonstrate that IRPs can regulate mRNA expression through non-canonical IREs and extend the repertoire of known iron-regulated genes. In addition, we illustrate a new mechanism through which hemoglobin may be modulated according to iron status.

Various pathologies are characterized by the accumulation of toxic iron in cell compartments. In anemia of chronic disease, iron is withheld by macrophages, leaving extracellular fluids iron-depleted. In Friedreich ataxia, iron levels rise in the mitochondria of excitable cells but decrease in the cytosol. We explored the possibility of using deferiprone, a membrane-permeant iron chelator in clinical use, to capture labile iron accumulated in specific organelles of cardiomyocytes and macrophages and convey it to other locations for physiologic reuse. Deferiprone's capacity for shuttling iron between cellular organelles was assessed with organelle-targeted fluorescent iron sensors in conjunction with time-lapse fluorescence microscopy imaging. Deferiprone facilitated transfer of iron from extracellular media into nuclei and mitochondria, from nuclei to mitochondria, from endosomes to nuclei, and from intracellular compartments to extracellular apotransferrin. Furthermore, it mobilized iron from iron-loaded cells and donated it to preerythroid cells for hemoglobin synthesis, both in the presence and in the absence of transferrin. These unique properties of deferiprone underlie mechanistically its capacity to alleviate iron accumulation in dentate nuclei of Friedreich ataxia patients and to donate tissue-chelated iron to plasma transferrin in thalassemia intermedia patients. Deferiprone's shuttling properties could be exploited clinically for treating diseases involving regional iron accumulation.

Developing erythroid cells are dependent on transferrin (Tf) to acquire iron in amounts sufficient for hemoglobin production. Previously, we showed that although these cells cannot grow in culture in the absence of Tf, ferritin (Ft) can substitute Tf to some extent and support the development of hemoglobin-containing cells. In the current study, we investigated the ability of various iron sources to replace Tf in cultures of normal human erythroid precursors. The results showed that whereas Ft and hemin supported erythroid cell proliferation and hemoglobinization in Tf-free cultures to some extent, ferric amonium citrate and iron complexed with several chelators had little or no effect. Although salicylaldehyde-isonicotinoyl-hydrazone, which is a tridentate lipid-soluble chelator, complexed with iron increased both cytosolic and mitochondrial labile iron pools, it failed to support heme synthesis and did not decrease the surface Tf receptors, suggesting that its iron is not recognized by the cells. Moreover, this iron-chelator complex did not support erythroid precursor proliferation and hemoglobinization. Thus, although under normal conditions, Tf is the major route of iron uptake, Ft and hemin, but not iron-chelator complexes, may serve as alternative iron sources under Tf-poor conditions.

Low iron status is known to increase the uptake of dietary cadmium in both adolescents and adults and there are indications that cadmium is absorbed from the intestine by the two major iron transporters divalent metal transporter 1 (DMT1) and ferroportin 1 (FPN1). In addition, it has been suggested that duodenal metallothionein (MT) may limit the transport of cadmium across the intestinal epithelium. The present investigation was undertaken to examine whether iron status influences cadmium absorption in newborns by applying a model of suckling piglets and the possible roles of duodenal DMT1, FPN1 and MT. An oral cadmium dose (20 microg/kg body weight) was given daily for 6 consecutive days on postnatal days (PNDs) 10-15 to iron-deficient or iron-supplemented piglets. The cadmium dose was chosen to keep the cadmium level at a realistically low but still detectable level, and without inducing any adverse health effects in the piglets. As indicators of cadmium uptake, cadmium levels in blood and kidneys were measured on PND 16 by inductively coupled plasma-mass spectrometry (ICP-MS). Cadmium levels in blood were statistically significantly correlated with cadmium levels in kidneys. The cadmium uptake was not higher in iron-deficient suckling piglets; rather, we detected a higher cadmium uptake in the iron-supplemented ones. The expression and localisation of DMT1, FPN1 and MT were not affected by iron status and could therefore not explain the findings. Our results suggest that there are developmental differences in the handling of both iron and cadmium in newborns as compared to adults.

Huntington's disease (HD) is one of nine neurodegenerative disorders caused by expansion of CAG repeats encoding polyglutamine in their respective, otherwise apparently unrelated proteins. Despite these proteins having widespread and overlapping expression patterns in the brain, a specific and unique subset of neurons exhibits particular vulnerability in each disease. It has been hypothesized that perturbation of normal protein function contributes to the specificity of neuronal vulnerability; however, the normal biological functions of many of these proteins including the HD gene product, Huntingtin (Htt), are unclear. To explore the roles of Htt, we have used antisense morpholino oligonucleotides to observe the effects of Htt deficiency in early zebrafish development. Knockdown of Htt expression resulted in a variety of developmental defects. Most notably, Htt-deficient zebrafish had hypochromic blood due to decreased hemoglobin production, despite the presence of iron within blood cells. Furthermore, transferrin receptor 1 transcripts were increased, suggesting cellular iron starvation. Provision of iron to the cytoplasm in a bio-available form restored hemoglobin production in Htt-deficient embryos. Since erythroid cells acquire iron via receptor-mediated endocytosis of transferrin, these results suggest a role for Htt in making endocytosed iron accessible for cellular utilization. Iron is required for oxidative energy production, and defects in iron homeostasis and energy metabolism are features of HD pathogenesis that are most pronounced in the major region of neurodegeneration. It is therefore plausible that perturbation of Htt's normal role in the iron pathway (by polyglutamine tract expansion) contributes to HD pathology, and particularly to its neuronal specificity.

Microcytic erythropoiesis in case of anemia is frequently due to iron deficiency or may be due to alpha- and beta- thalassemia trait as a result of increased activity of erythropoiesis. The aim of the present study was to evaluate alterations with regard to the degree of hemoglobinization in reticulocytes in comparison with mature erythrocytes. Iron availability in subjects with anemia resulting from iron deficiency and alpha- or beta- thalassemia was studied by application of conventional as well hemocytometric parameters that have recently become available. Participants of the study were reference subjects (n=75), subjects with iron deficiency anemia (IDA, n=52) and alpha- (n=26) or beta-thalassemia trait (n=24). If compared with the reference group obviously increased RBC counts together with decreased values for RDW-sd and MCHC were established in case of alpha- and beta- thalassemia subjects. Deviations were demonstrated to be more pronounced in case of beta- thalassemia. Accelerated erythropoiesis in the case of subjects with IDA and beta-thalassemia is manifested by detection of increased results for immature reticulocyte counts. In particular in case of beta- thalassemia, elevated reticulocyte counts combined with slightly increased values for ZPP/heme ratio reflect increased activity of erythropoiesis. In the case of subjects with beta-thalassemia serum transferrin concentrations revealed slightly decreased results, whereas serum ferritin and iron concentrations demonstrated a tendency towards higher values if compared with the group of reference subjects. At a definitive MCV level, the hemoglobin content of reticulocytes is decreased in the case of IDA if compared with the alpha- or beta- thalassemia trait. For the ratio of hemoglobin content of reticulocytes and erythrocytes, obviously decreased results are demonstrated in the case of subjects with iron deficiency anemia (1.02 +/- 0.08, mean +/- SD) and in the case of beta-thalassemia (1.06 +/- 0.04) if compared with the group of reference subjects (1.11 +/- 0.02) and a-thalassemia (1.11 +/- 0.07). Evaluation of the hemoglobinization state should be performed by means of pattern recognition in concordance with characteristic profiles for parameters reflecting the actual iron state. In case of therapy the result of intervention can be appropriately monitored by longitudinal follow-up.

Iron deficiency remains a public health challenge. The neurocognitive deficits that are associated with iron deficiency are most worrisome. Moreover, iron deficiency-associated elevated blood lead levels magnify the problem. Pediatricians must strive to prevent iron deficiency.

Cardiac T2* (magnetic resonance imaging relaxation parameter) is abnormally low in approximately 40% of adults with thalassemia major (TM), suggesting myocardial iron deposition, but it is unknown at what age this occurs. To address this question, we measured cardiac T2* and function in 19 young patients (aged 7-26 years) with TM as well as 17 patients receiving long-term transfusions for sickle cell anemia (SCA) matched for age, sex, and liver iron content. Cardiac T2* was normal in all of the SCA patients but was low (high iron) in 8 of 19 TM patients. Abnormal T2* was observed only in the TM patients receiving transfusions for 13 years or longer and was correlated with ferritin but not liver iron levels. Cardiac dysfunction was present in 3 of the 8 patients with low T2*. Cardiac T2* changes have a long latency relative to liver iron accumulation. Total transfusional burden is a significant independent risk factor for low cardiac T2* and may partially account for differences observed between patients with SCA and TM.

Our knowledge of erythropoiesis and iron in renal disease is limited. The accepted view of the control of erythropoiesis was founded on observations made in a variety of disorders, but the control mechanism in healthy individuals may not be quite the same. Evidence suggests that mechanisms other than erythropoietic stimulation may play a role in increased red blood cell production. Measuring erythropoiesis is complex. The quantitative reticulocyte count is probably the closest practical assessment of erythropoietic activity we can achieve, yet there is very little correlation between circulating erythropoietin level and reticulocyte count in normal and near normal subjects. Oxygen transport in humans depends entirely upon iron. In renal disease, the failure of the erythropoietin positive feedback mechanism can be readily and directly remedied; recombinant human erythropoietin therapy can replace the missing erythropoietin, but this will be negated if iron supply to the erythroid marrow falls short of demand. Measurement of iron stores is also complex. The use of serum ferritin concentration as a direct quantitative estimate of iron in the stores is not advisable, and in practice we have not found the transferrin receptor assay to be useful in identifying patients who require iron therapy. Use of percentage hypochromia as a measure of iron deficiency is complicated by the fact that hypochromic cells are not exclusively a consequence of functional iron deficiency. There are clearly lessons still to be learned in this field and there is much that we do not yet understand about the control of erythropoiesis and iron metabolism in humans.

The bioavailability of iron from a new commercial source containing ferric gluconate stabilized with glycine sold under the trade name Bioferrico was studied in this work by means of the prophylactic-preventive test in rats. NaFeEDTA was also studied by the same methodology for comparative purposes and ferrous sulfate was used as the reference standard. The test was conducted for 4 wk with male weaned rats, which were randomized into four groups of at least eight animals each. A control group received a basal diet of low-iron content, whereas the other groups received the same diet with iron added at a dose of 20 mg/kg as FeSO4.7H2O, NaFeEDTA, and Bioferrico, respectively. Individual hemoglobin concentrations (HbC) and weights were determined at the beginning and at the end of the study and food intake was daily registered. The iron bioavailability (BioFe) of each source was calculated as the ratio between the amount of iron incorporated into hemoglobin during the treatment (HbFe) and the total iron intake per animal (ToFeIn). A relative biological value (RBV) was obtained for each iron source under study as the ratio between the BioFe of the tested compound and that of the reference standard. The RBVs were 98% and 86% for Bioferrico and NaFeEDTA, respectively. Bioferrico showed a high bioavailability and behaved inertly in relation to the sensorial properties of the fortified food when it was added to flour. These qualities emphasize Bioferrico as a promising source for iron fortification.

In the present study 67 non-anaemic women were randomly allocated to either 100 mg or 15 mg iron daily at about the 10. week of pregnancy. At about week 18, 30 and 36 of pregnancy, as well as 6 weeks after delivery, hemoglobin and the serum concentrations of ferritin, vitamin B12, folates, Zn, Cu and Se were monitored. Dietary allowances of other minerals and vitamins are also increased in pregnancy, and the 15 mg iron tablet was enriched with Zn (10 mg), Cu (2 mg), Se (50 microg), vitamin B12 (3 microg), and folate (0.1 mg). Neither ferritin, nor Cu, Zn or Se concentrations differed statistically significantly between the treatment groups during pregnancy. Ferritin and Zn appeared to decrease approximately parallel to the hemodilution, whereas Cu concentrations increased from a non-pregnant reference mean of 18 micromol Cu/L to a maximum mean of nearly 33 micromol Cu/L during pregnancy. Se decreased concomitantly to about 1.0 micromol Se/L. Serum folate (around 15 micromol/L) was essentially unaffected by pregnancy in the group given multivitamin/mineral supplementation, whereas the mean concentration fell below 10 micromol/L in the group supplemented with 100 mg iron daily. Our results indicate that supplementation of 15 mg Fe daily during pregnancy results in a small reduction of hemoglobin. It is suggested that additional supplementation with folate might be of importance to maintain the serum folate concentration during pregnancy.

To compare two modalities of iron supplementation for the preoperative stimulation of erythropoiesis using recombinant human erythropoietin (rhEPO), 12 adults in normal hemoglobin and iron status due for elective surgery were randomized to rhEPO 200 U/kg body weight subcutaneously twice weekly combined with either iron sucrose 200 mg intravenously twice weekly or iron sulfate 160 mg/day orally, for 3 weeks preoperatively. Efficacy was measured by the increases over baseline in hemoglobin, reticulocyte count, and ferritin determined 3 days before surgery; preoperative reticulocyte count and ferritin were significantly higher with intravenous iron, whereas the only significant intragroup increases in hemoglobin between time points also occurred in this group. Intravenous iron significantly boosts the hematopoietic response to rhEPO and prevents iatrogenic iron depletion in otherwise healthy candidates for elective surgery.

Laver belongs to the genius of Porphyra and is the most valuable seaweed in the aqua-culture industry. It contains higher iron than many other plant foods. The bioavailability of iron from laver was evaluated in a rat hemoglobin regeneration assay. Reagent-grade ferrous sulfate was used as the reference standard, and the relative biological value (RBV) for laver was expressed as a percentage of the response to ferrous sulfate. RBV was calculated by two methods: slope-ratio and ratio of hemoglobin regeneration efficiency, and both yielded RBV of 26 for laver. Amount of available iron from laver estimated from RBV was comparable to many iron-fortified foods.

Dietary phytase supplementation improves bioavailabilities of phytate-bound minerals such as P, Ca, and Zn to pigs, but its effect on Fe utilization is not clear. The efficacy of phytase in releasing phytate-bound Fe and P from soybean meal in vitro and in improving dietary Fe bioavailability for hemoglobin repletion in young, anemic pigs was examined. In Exp. 1, soybean meal was incubated at 37 degrees C for 4 h with either 0, 400, 800, or 1,200 units (U) of phytase/kg, and the released Fe and P concentrations were determined. In Exp. 2, 12 anemic, 21-d-old pigs were fed either a strict vegetarian, high-phytate (1.34%) basal diet alone, or the diet supplemented with 50 mg Fe/kg diet (ferrous sulfate) or phytase at 1,200 U/kg diet (Natuphos, BASF, Mt. Olive, NJ) for 4 wk. In Exp. 3, 20 anemic, 28-d-old pigs were fed either a basal diet with a moderately high phytate concentration (1.18%) and some animal protein or the diet supplemented with 70 mg Fe/kg diet, or with one of two types of phytase (Natuphos or a new phytase developed in our laboratory, 1,200 U/kg diet) for 5 wk. In Exp. 2 and 3, diets supplemented with phytase contained no inorganic P. In Exp. 1, free P concentrations in the supernatant increased in a phytase dose-dependent fashion (P<.05), whereas free Fe concentrations only increased at the dose of 1,200 U/kg (P<.10). In Exp. 2 and 3, dietary phytase increased hemoglobin concentrations and packed cell volumes over the unsupplemented group; these two measures, including growth performance, were not significantly different than those obtained with dietary supplemental Fe. In conclusion, both sources of phytase effectively degraded phytate in corn-soy diets and subsequently released phytate-bound Fe from the diets for hemoglobin repletion in young, anemic pigs.

Iron uptake for hemoglobin synthesis was apparently increased in the reticulocytes of severely iron deficient anemic women, but was actually decreased significantly when expressed in terms of number of reticulocytes. The decreased synthesis could be restored to more than normal by supplementing with ferric iron or transferrin iron (normal plasma), but not with ferrous iron, which rather further reduced the already impaired hemoglobin synthesis.

Background: The study compared the efficacy of oral iron combined with intravenous iron supplementation to that of oral iron supplementation alone in increasing the preoperative production of hemoglobin (Hb) in autologous blood donors with normal iron stores., Study Design and Methods: One hundred eight iron-replete patients who were scheduled for donation of 3 units of autologous blood at weekly intervals were randomly assigned to receive, in a double-blind fashion, no iron supplementation (placebo, Group 1), oral iron supplementation (285.6 mg of elemental iron/day, Group 2), or oral iron plus intravenous iron supplementation (285.6 mg of elemental iron/day orally plus 102.5 mg of elemental iron/week intravenously, Group 3). The amount of Hb produced during the 21-day study period was determined by the total amount of Hb donated minus the change in the amount of circulating Hb between the first donation (Day 0) and the poststudy examination (Day 21)., Results: Hb production did not differ significantly in the two iron-supplemented groups (oral iron, 85 +/- 36 g; oral plus intravenous iron, 74 +/- 43 g). The patients in the oral iron group produced a significantly greater amount of Hb than those in the placebo group (85 +/- 36 g vs. 52 +/- 41 g, p < 0.01)., Conclusion: Oral iron supplementation increased the production of Hb in autologous blood donors more than placebo did. Additional intravenous iron did not lead to a further increase in preoperative Hb production.

We have demonstrated that iron controls hemoglobin (Hb) synthesis in erythroid differentiating K562 cells by enhancing the activity of a key enzyme of the Hb synthesis, delta-aminolevulinate synthase (ALAS). In the present study, we studied iron mobilization and the role of iron in erythroid differentiating cells by measuring the level of iron by means of high-performance liquid chromatography using electrochemical detection (HPLC-ED). After treatment of K562 cells with sodium butyrate, the expression of transferrin receptor (TfR) increased initially, followed by an increase in the levels of both total iron and Hb as well as the ALAS activity. However, no increase could be found in the levels of non-heme iron, low-molecular-mass iron (LMMFe) and ferritin. Addition of diferric transferrin (FeTf) enhanced both delta-aminolevulinic acid (ALA) and Hb synthesis. In contrast, addition of hemin elevated the levels of all iron species as well as the Hb synthesis but reduced the TfR expression and ALA contents in both butyrate treated and untreated cells. These results suggest that Hb synthesis is controlled by TfR expression, and that the ALA synthesis is suppressed by iron released from heme and/or Hb due to lowered expression of TfR.

Ferritin (Ft) plays an important role in cellular iron metabolism. It can store substantial amounts of iron in a nontoxic soluble form. However, its ability to donate iron for cellular needs, in particular for hemoglobin (Hb) synthesis in human erythroid cells, is still controversial. We studied the role of intracellular Ft-iron in Hb synthesis and the involvement of lysosomal proteolysis in iron release from Ft. Ft-iron release and its subsequent incorporation into heme was investigated in normal human erythroid precursors developing in culture. Dual staining flow cytometry with antibody (Ab)-specific for Ft and for Hb showed a decrease in cellular Ft content in erythroid cells during their maturation. Cellular Ft-iron participation in heme synthesis was studied by labeling cells with 59Fe. Cells were incubated with 59Fe-labeled human diferric transferrin (Tf), then chased, and intracellular radioiron distribution between Ft and Hb was determined on subsequent days by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and/or Ft immunoprecipitation and heme extraction. On day 6, most of the 59Fe accumulated in Ft. Thereafter, a progressive decrease of radioiron in Ft and a corresponding increase of the label in Hb was observed. Inhibition of heme synthesis with succinylacetone caused radioiron to remain in Ft and prevented its redistribution. Addition of unlabeled diferric Tf to the culture medium did not prevent radioiron from appearing in Hb. Chloroquine repression of lysosomal function prevented radio-iron redistribution between Ft and Hb. Inhibition of proteolysis by chymostatin and/or leupeptin led to Ft-protein accumulation in the cells and also prevented radioiron transfer from Ft to Hb. The results of the present study suggest that intracellular Ft donates iron for heme synthesis and that proteolytic Ft degradation in a lysosomal-like compartment is necessary for iron release and its transfer to heme.

Succinylacetone (SA) is an inhibitor of heme synthesis that acts on the enzyme delta-aminolevulinic acid dehydratase. When reticulocytes are incubated with 59Fe-transferrin (59Fe-Tf) in the presence of SA, there is an accumulation of 59Fe in the mitochondrion and in a cytosolic non-heme intermediate that has been described as a putative Fe transporter (Adams et al, Biochim Biophys Acta 1012:243, 1989). Considering these observations, the present study was designed to examine the intermediates of Fe metabolism in control and SA-treated reticulocytes. This investigation showed that in the cytosol of control cells, most 59Fe was incorporated into hemoglobin (Hb) with a minor amount entering ferritin. In addition, a previously unrecognized cytosolic intermediate was identified (band X) that was absent when heme synthesis was inhibited with SA. Upon reincubation of SA-treated reticulocytes with protoporphyrin IX, band X initially increased in intensity and then decreased later in the incubation. In contrast, when 59Fe-labeled control cells were reincubated in the presence of SA and unlabeled diferric Tf, there was a marked decrease in the intensity of band X. These experiments suggest that component X may be an intermediate involved in the transfer of heme in the cytosol. Alternatively, these data could also be interpreted as indicating that band X may be a short-lived hemoprotein. We have confirmed the presence of an 59Fe-containing molecule in the cytosol of SA-treated reticulocytes (band Y) that is not present in control cells. However, when cells were incubated with 59Fe-Tf plus SA and then chased in the presence of SA and unlabeled diferric Tf, there was no decrease in this cytosolic pool of Fe, suggesting that it was not a intermediate supplying Fe for either ferritin or heme synthesis. Finally, there is little low molecular weight (Mr) Fe in reticulocytes, and our studies suggest that the low-Mr Fe present does not behave as an intermediate. Moreover, after inhibition of heme synthesis with SA, 59Fe in the low-Mr compartment was markedly decreased, suggesting that this component may be heme or a low-Mr heme-containing molecule. Considering the apparent lack of a cytosolic Fe transporter in rabbit reticulocytes, an alternative model of intracellular Fe transport is proposed that does not implicate a potentially toxic intermediate pool of low-Mr Fe complexes.

Erythropoietin (EPO) plays a central role in the regulation of red blood cell (RBC) production. Since iron is an essential element for erythropoiesis and hemoglobin (Hb) synthesis, its importance is heightened in patients treated with epoetin alfa. Stimulation of erythropoiesis following the administration of epoetin alfa is associated with several changes in iron metabolism; indeed, plasma ferritin levels fall as a result of increased utilization of iron by the expanding erythroid marrow. The administration of epoetin alfa can therefore lead to a state of relative iron deficiency. Thus, iron supplementation is essential to maximize the effect of epoetin alfa-induced erythropoiesis.

To test the hypothesis that variations in H- and L-subunit composition in the ferritin shell affect intracellular iron metabolism, we established stable transfectants of mouse erythroleukemia cells overexpressing the H-ferritin subunit. Analyses were performed on individual clones of transfected cells induced to differentiate with hexamethylenbisacetamide (HMBA). The results showed that there was a reduction in the amount of hemoglobin produced, in inverse relationship with the level of H-subunit overexpression. Incorporation of [2-14C]glycine into heme was reduced by 20% t0 30% in the clones overexpressing H-ferritin subunit compared with control clone. However, the reduction in hemoglobin production was not reversed by addition of heme precursors (delta-aminolevulinic acid or iron) or by hemin itself. A reduced accumulation of beta-globin mRNA was also observed, which could account for the impaired hemoglobin synthesis. Furthermore, synthesis of the endogenous L-ferritin subunit was greatly repressed. Gel retardation assays performed on cytoplasmic extracts of transfected cells using an iron-responsive element (IRE) as a probe revealed that in overexpressing cells, the iron-regulatory protein (IRP) had a conformation with a high RNA-binding affinity, thus leading to translational repression of the endogenous L-ferritin synthesis. These data suggest that an increased formation of H-rich isoferritins leads to a rapid chelation of the regulatory iron pool. While the mechanism underlying the reduction in beta-globin mRNA remains to be elucidated, this study provides direct evidence for the role of IRP-mediated regulation of ferritin expression in erythroid cell metabolism.

Erythropoietin (EPO) is the primary regulator of day-to-day red blood cell production. Secreted by peritubular capillary lining cells in the kidney, EPO circulates in the plasma to interact with target cells in the bone marrow to maintain or stimulate erythropoiesis. The primary target of EPO action is the intermediate-stage erythroid burst-forming unit and the erythroid colony-forming unit (CFU-E). The CFU-E is estimated to have 300 to 400 high-affinity EPO receptors per cell and, in healthy individuals, is the cell with the highest number of receptors in the body. There is some controversy as to whether EPO provides a mitogenic signal to the CFU-E or, rather, prevents programmed cell death (apoptosis). Iron is an essential element for hemoglobin synthesis and its importance has been emphasized in individuals receiving recombinant human erythropoietin (rHuEPO). The administration of rHuEPO to patients with chronic renal failure has resulted in a number of changes in iron metabolism, including the reversal of iron overload as iron is mobilized from storage sites for hemoglobin synthesis. In addition, higher doses of rHuEPO create a state of functional (or relative) iron deficiency that is characterized by a low percent transferrin saturation in the face of adequate iron stores. The value of aggressive iron supplementation in patients receiving rHuEPO has been demonstrated in clinical trials of rHuEPO administration in individuals storing blood for autologous use at the time of surgery.

Aluminum (Al) overload in dialysis patients and experimental animals is associated with the development of anemia. However, the precise mechanisms of erythrocyte Al uptake and toxicity are poorly understood. Al accumulation, hemoglobin (Hb) synthesis and cell growth were evaluated in dimethylsulfoxide (DMSO)-induced Friend erythroleukemia cells (FEC), a model system for erythroid differentiation. FEC were grown in media containing either Al citrate, transferrin-aluminum (Tf-Al), Tf or no additions. Al accumulation occurring only in cells grown in Tf-Al containing media was detected at 24 hours and increased linearly up to 96 hours after induction. By 96 hours, 200 +/- 36 micrograms Al/liter lysed cells were detected in Tf-Al grown cells versus 5 +/- 1 micrograms Al/liter lysed cells in cells grown in Al citrate (P less than 0.001). Tf-Al inhibited Hb synthesis at 72 hours after induction. At 96 hours 50 +/- 15% cells were benzidine positive when grown in Tf-Al compared to 76 +/- 15% in Al citrate (P less than 0.001). FEC grown in increasing concentrations of Tf-Al (100 to 500 micrograms/ml) showed inhibition of Hb synthesis at lower concentrations of Tf-Al at 100 micrograms/ml than for cell growth at 300 micrograms/ml. Higher concentrations of Tf-Al (greater than 300 micrograms/ml) did not further inhibit Hb synthesis or cell growth. Iron (Fe) and Tf uptake were increased in Al loaded FEC compared to control cells. The increased Tf uptake was probably the result of increased Tf receptor expression on FES since Tf cell cycling time was unchanged. These data indicate that Al utilizes the Tf uptake pathway for entry into erythrocyte precursors. Al is toxic at sites distal to Fe uptake, possibly at the heme and/or globin synthetic pathways, resulting in decreased Hb synthesis and cell growth.

The bioavailability of iron from ferrous sulfate sources that had been stored for unknown periods was evaluated by using iron-deficient rats in experiment 1. The efficiency of converting dietary iron from these sources into hemoglobin varied from 60 to 84%. This variability was not explained on the basis of percent of iron in the ferrous state nor on the percent of iron in the source. The one fresh source used was reevaluated 3 months later, and its bioavailability had been reduced from 84 to 65%. The bioavailability of six fresh ferrous sulfate samples varied from 50 to 59% in experiment 2. It was concluded that, whenever ferrous sulfate is to be used as a reference source, fresh salt should be obtained to reduce variability among experiments.

Iron incorporation (59Fe) into erythropoietic cells from adult and foetal (11- to 15-day) peripheral blood and from foetal (12- to 15-day) livers has been investigated. Ion-exchange chromatography of haemolysates from such cells revealed two groups of 59Fe-containing proteins. The first group (X-fraction) was eluted from CMC-columns in the void volume and was highest in lysates of immature erythropoietic cells. This fraction contained a radiolabelled haemprotein of high molecular weight as well as other 59Fe-containing proteins. The haemprotein does not appear to be related to haemoglobin. The second group consisted of haemoglobins. One major (A1) and two minor (A2 and A3) haemoglobins were found in adult peripheral blood. In foetal liver lysates two major (F1 and A1) and two minor (F2 and A3) haemoglobins were present. The relative proportion of the major haemoglobins changed during development. Haemoglobin F1 was highest in the more mature livers. F1 proved to be different from A1 by chromatographic behaviour, in polypeptide chain composition and in fingerprints. A unique foetal polypeptide chain, intermediate in electrophoretic behaviour between the adult alpha- and beta-chain, was identified. In young foetal peripheral blood (11-day), in which 95% of the cells are of yolk-sac origin, one major (E1), two intermediate (E2 and E3) and one minor (F1) haemoglobin were demonstrable. Haemolysates of the peripheral blood of older embryos contain haemoglobins from erythroid cells of both yolk-sac and foetal liver origin. The haemoglobin pattern of such lysates is explicable in terms of the decreasing amount of embryonic haemoglobins (E1, E2 and E3) and the increasing amount of foetal haemoglobins (F1 and A1). Since A1 and E1 are the most prominent haemoglobins of livers from young embryos and yolk-sac erythrocytes respectively, and since they are very similar in chromatographic behaviour, foetal peripheral blood at all stages contain one dominant haemoglobin peak in the A1-E1 region. Most authors have neglected the relatively slight elevation of the foetal haemoglobin peak (F1) in front of A1-E1, the more because the F1-A1 region has been suspected sometimes to contain artificial haemoglobin components (Riggs, 1965). This probably explains why no foetal haemoglobin (F1) has been reported previously in the peripheral blood of foetal mice.

Iron incorporation into Friend virus infected leukemic murine spleen cells was studied using the two fungal iron trihydroxamates, fusigen and ferricrocin. Incorporation of 55Fe was measured by isolation of hemoglobin after dimethylsulfoxide-induced hemoglobin synthesis and compared with iron incorporation from 55Fe-labeled ferric citrate.

Avian vitellogenin has been studied as an iron carrier for hemoglobin synthesis by reticulocytes. The Fe-vitellogenin uptake by the immature red cells is progressive with time, following an unspecific iron uptake process. The iron uptake from Fe-vitellogenin was in proportion to the immature red cells present and the radioactive iron was found in the hemoglobin synthesized by these cells. These results open up the possibility of assigning a secondary role to the Fe-vitellogenin in the avian erythropoiesis, added to the classical iron transport function for egg production.

Studies were conducted to determine the iron requirements of laying and breeding hens (Gallus domesticus). Single Comb White Leghorn hens fed a purified diet containing 15 ppm iron exhibited a rapid decline in hematocrit, blood hemoglobin, egg iron concentrations and hatchability of fertile eggs. No effects of the low iron diet on body weight, feed consumption, or fertility were observed. When hens were fed graded levels of iron from 15 to 65 ppm at 10 ppm increments, a dose response was observed for hematocrit and hatchability. The iron requirement for maintenance of hematocrit was between 35 and 45 ppm iron. Fifty-five parts per million iron were required for maximum hatchability of fertile eggs.