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Anemia of Inflammation in Patients with Intestinal Failure on Home Parenteral Nutrition

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Abstract

Anemia is common in intestinal failure (IF), but it is unknown if anemia in IF is due to iron deficiency or another etiology. Understanding iron status is important, as deficiency and overload are both associated with multisystem morbidity and mortality. The objective was to determine the etiology of anemia in a cohort of patients with IF and characterize iron status with respect to multisystem outcomes. This was a single center retrospective cohort analysis of iron parameters from August 1998 to March 2018 in 54 IF patients (355 person years). Thirty-eight percent of measurements showed iron deficiency, 36% anemia of inflammation, 21% indeterminate iron status, and 5% suggested iron overload. Mean direct and total bilirubin were elevated when ferritin was > 200 ng/mL and in inflamed and overloaded patients compared with iron-deficient patients. For every 10% increase in Tsat, bilirubin increased by 0.58 mg/dL from baseline (p = 0.003). Tsat > 50% had a mean positive culture probability of 60%. The probability of renal disease increased over time and average GFR decreased over time (−3.14 ± 1.37 mL/min per 1.73 m2), and nearly one in five patients in this study had chronic kidney disease (CKD). Patients with IF are at risk for both iron deficiency anemia as well as anemia of inflammation, with at a portion of patients with anemia of inflammation and overload having elevated risk of cholestasis, CKD, and infection compared to their peers. Careful assessment of inflammation, risk of infection, and renal function should be performed prior to dosing iron to ensure safe and effective delivery of this essential micronutrient. Future directions include determination of extra-renal sources of inflammation in IF.

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Abbreviations

IF:

Intestinal failure

PN:

Parenteral nutrition

IBD:

Inflammatory bowel disease

Tsat:

Transferrin saturation

IFALD:

Intestinal failure-associated liver disease

CKD:

Chronic kidney disease

IBC:

Iron-binding capacity

EMR:

Electronic medical record

GFR:

Glomerular filtration rate

KDIGO:

Kidney Disease Improving Global Outcomes

SBS:

Short bowel syndrome

MCV:

Mean corpuscular volume

GGT:

Gamma-glutamyltransferase

ALT:

Alanine aminotransferase

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Sources of Support

NIH T32 Training Grant DK07180, UCLA Children’s Discovery and Innovation Institute Fellows Support Award.

Data

Data described in the manuscript will be made available upon request.

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Authors and Affiliations

  1. Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

    Cristina Farkas, Jorge H. Vargas, Robert S. Venick, Patricia L. Weng, Mark R. Hanudel, Tomas Ganz & Laura J. Wozniak

  2. Division of Pediatric Gastroenterology, Hepatology, & Nutrition, 650 Welch Road, Palo Alto, CA, 94304, USA

    Shweta S. Namjoshi

  3. Division of Pediatric Nephrology, Los Angeles, CA, USA

    Cristina Farkas, Patricia L. Weng & Mark R. Hanudel

  4. Department of Biostatistics and Medicine, UCLA, Los Angeles, CA, USA

    Nicholas J. Jackson

  5. Department of Nursing, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA

    Laurie E. Reyen & Pamela S. Baldivia

  6. Department of Medicine and Pathology, David Geffen School of Medicine, Los Angeles, CA, USA

    Tomas Ganz

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  1. Shweta S. Namjoshi
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Correspondence to Shweta S. Namjoshi.

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Conflict of Interest

T.G is a scientific founder and shareholder of Intrinsic Sciences, LLC and Silarus Pharma, and a consultant for Keryx/Akebia, Global Blood Therapeutics, La Jolla Pharmaceutical Company, Gilead Sciences, Sierra Oncology, Ironis, and Ambys.

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Research was conducted in accordance with the ethical standards of the responsible institutional or regional committee on human experimentation in accordance with the Helsinki Declaration of 1975 as revised in 1983 and was approved by the UCLA Institutional Review Board. For this type of study, formal consent is not required.

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Namjoshi, S.S., Farkas, C., Jackson, N.J. et al. Anemia of Inflammation in Patients with Intestinal Failure on Home Parenteral Nutrition. SN Compr. Clin. Med. 2, 1505–1513 (2020). https://doi.org/10.1007/s42399-020-00404-y

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