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array:24 [ "pii" => "S2254887419302565" "issn" => "22548874" "doi" => "10.1016/j.rceng.2019.09.010" "estado" => "S300" "fechaPublicacion" => "2020-01-01" "aid" => "1736" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "copyrightAnyo" => "2019" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2020;220:31-42" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0014256519302358" "issn" => "00142565" "doi" => "10.1016/j.rce.2019.09.004" "estado" => "S300" "fechaPublicacion" => "2020-01-01" "aid" => "1736" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2020;220:31-42" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 149 "formatos" => array:2 [ "HTML" => 70 "PDF" => 79 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Artículo especial</span>" "titulo" => "Manejo del déficit de hierro en distintas situaciones clínicas y papel del hierro intravenoso: recomendaciones del Grupo Español de Eritropatología de la SEHH" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "31" "paginaFinal" => "42" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Management of iron deficiency in various clinical conditions and the role of intravenous iron: Recommendations of the Spanish Erythropathology Group of the Spanish Society of Haematology and Haemotherapy" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2807 "Ancho" => 2500 "Tamanyo" => 387636 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Algoritmos de diagnóstico y tratamiento de la AFR (A) y del tratamiento con FEIV y su control (B). AEE: agentes estimulantes de la eritropoyetina; AF: anemia ferropénica; AFR: anemia ferropénica refractaria; AI: anemia inflamatoria; Fe: hierro; FEEV: hierro intravenoso; Ft: ferritina; IRC: insuficiencia renal crónica; IST: índice de saturación de la transferrina; OMS: Organización Mundial de la Salud.</p>" ] ] ] "autores" => array:2 [ 0 => array:2 [ "autoresLista" => "J.A. García Erce, A. Altés, M. López Rubio, A.F. Remacha" "autores" => array:5 [ 0 => array:2 [ "nombre" => "J.A." "apellidos" => "García Erce" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Altés" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "López Rubio" ] 3 => array:2 [ "nombre" => "A.F." "apellidos" => "Remacha" ] 4 => array:1 [ "colaborador" => "en representación del Grupo Español de Eritropatología de la Sociedad Española de Hematología y Hemoterapia" ] ] ] 1 => array:2 [ "autoresLista" => "" "autores" => array:1 [ 0 => array:1 [ "colaborador" => "Otros componentes del Grupo Español de Eritropatología de la Sociedad Española de Hematología y Hemoterapia" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2254887419302565" "doi" => "10.1016/j.rceng.2019.09.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887419302565?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256519302358?idApp=WRCEE" "url" => "/00142565/0000022000000001/v1_202001221235/S0014256519302358/v1_202001221235/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2254887419302152" "issn" => "22548874" "doi" => "10.1016/j.rceng.2019.06.010" "estado" => "S300" "fechaPublicacion" => "2020-01-01" "aid" => "1735" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2020;220:43-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Iron and heart failure" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "43" "paginaFinal" => "48" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hierro e insuficiencia cardiaca" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1782 "Ancho" => 2167 "Tamanyo" => 167018 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Selection and identification of patients who would benefit the most from intravenous iron according to the meta-analysis by Anker et al.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">36</span></a> Results related to readmissions for cardiovascular cause and mortality of patients with irony deficiency treated with intravenous iron.</p> <p id="spar0045" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: Ferrit, ferritin (expressed in ng/mL); TSAT, transferrin saturation.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.Á. de las Nieves López" "autores" => array:1 [ 0 => array:2 [ "nombre" => "M.Á." "apellidos" => "de las Nieves López" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256519302346" "doi" => "10.1016/j.rce.2019.06.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256519302346?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887419302152?idApp=WRCEE" "url" => "/22548874/0000022000000001/v1_202002130124/S2254887419302152/v1_202002130124/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2254887420300011" "issn" => "22548874" "doi" => "10.1016/j.rceng.2019.11.001" "estado" => "S300" "fechaPublicacion" => "2020-01-01" "aid" => "1777" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "edi" "cita" => "Rev Clin Esp. 2020;220:29-30" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:9 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">EDITORIAL</span>" "titulo" => "Improving the care of people with chronic conditions in Spain. Common Position Statement of the Spanish Society of Internal Medicine and the Spanish Society of Family and Community Medicine" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "29" "paginaFinal" => "30" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Mejoras en la atención a personas con enfermedades crónicas en España. Declaración de posición común de la Sociedad Española de Medicina Interna y la Sociedad Española de Medicina Familiar y Comunitaria" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256519303054" "doi" => "10.1016/j.rce.2019.11.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256519303054?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887420300011?idApp=WRCEE" "url" => "/22548874/0000022000000001/v1_202002130124/S2254887420300011/v1_202002130124/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Management of iron deficiency in various clinical conditions and the role of intravenous iron: Recommendations of the Spanish erythropathology group of the Spanish society of hematology and hemotherapy" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "31" "paginaFinal" => "42" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.A. García Erce, A. Altés, M. López Rubio, Á.F. Remacha" "autores" => array:5 [ 0 => array:4 [ "nombre" => "J.A." "apellidos" => "García Erce" "email" => array:2 [ 0 => "jagarciaerce@gmail.com" 1 => "ja.garcia.erce@navarra.es" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:4 [ "nombre" => "A." "apellidos" => "Altés" "email" => array:1 [ 0 => "aaltesh@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 2 => array:4 [ "nombre" => "M." "apellidos" => "López Rubio" "email" => array:1 [ 0 => "montserratlr@outlook.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 3 => array:4 [ "nombre" => "Á.F." "apellidos" => "Remacha" "email" => array:1 [ 0 => "aremachas@ono.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] 4 => array:1 [ "colaborador" => "en representación del Grupo Español de Eritropatología de la Sociedad Española de Hematología y Hemoterapia" ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Banco de Sangre y Tejidos de Navarra, Servicio Navarro de Salud-Osasunbidea, Pamplona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Grupo de Trabajo de la Sociedad Española de Transfusión Sanguínea «Hemoterapia basada en sentido común», Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Grupo Español de Rehabilitación Multimodal (GERM), Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Hospital Sant Joan de Dèu, Manresa, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo del déficit de hierro en distintas situaciones clínicas y papel del hierro intravenoso: recomendaciones del Grupo Español de Eritropatología de la SEHH" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2840 "Ancho" => 2500 "Tamanyo" => 376598 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0425" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Algorithms for the diagnosis and treatment of iron-refractory iron-deficiency anemia (A) and for treatment with intravenous iron and its control (B). CRF: chronic renal failure; ESA: erythropoiesis-stimulating agents; Fe: iron; Ft: ferritin; IA: inflammatory anemia; IDA: iron-deficiency anemia; IRIDA: iron-refractory iron-deficiency anemia; IVFe: intravenous iron; TSAT: transferrin saturation index; WHO: World Health Organization.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Iron deficiency (ID) due to blood loss, absorption disorders and dietary deficiencies causes iron-deficiency anemia (IDA), whose treatment seeks to eliminate the underlying cause and restore hemoglobin levels and iron deposits. Typically, the latter 2 of these objectives can be achieved through oral iron therapy. The administration of intravenous iron (IVFe) should be limited to patients who are refractory or intolerant to oral preparations or who are undergoing treatment with erythropoiesis-stimulating agents (ESA). The use of IVFe beyond its indication can increase morbidity and mortality due to hypersensitivity and, especially, iatrogenic overload. Recent data from a Spanish study estimated a prevalence of approximately 9 % for anemia.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This estimate, coupled with the growing popularity of IVFe and the lack of reference guidelines in Spanish, prompted the Spanish Erythropathology Group (<span class="elsevierStyleItalic">Grupo Español de Eritropatología</span>, GEE) of the Spanish Society of Hematology and Hemotherapy to develop this project to list the main recommendations on the optimal use of IVFe in ID. Throughout this project, we based our work on the maximum scientific evidence available to reach the broadest consensus possible, thereby succeeding in creating a reference guide for good practices for the clinical management of most situations in ID.</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methodology</span><p id="par0010" class="elsevierStylePara elsevierViewall">An expert group of the GEE decided to provide other specialists and societies with the working guidelines to follow with their patients with ID, thereby avoiding practices based on misconceptions. The expert group reviewed all clinical and surgical scenarios with a major prevalence of IDA as well as a number of populations that deserve special attention (pregnant women, athletes, Jehovah’s Witnesses), each expert in their area of greatest experience. The experts then proposed contents regarding the diagnosis, treatment and follow-up of ID, with their contributions backed by the best scientific evidence available. For each topic, we proposed “good practices” and “key points”. Four coordinators supervised a separate section of distinct issues. The final version of each section was studied by the other 3 reviewers, and the final version was agreed upon by all authors.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This document condenses the conclusions extracted from this process.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Diagnosis of iron deficiency and iron-deficiency Anemia</span><p id="par0015" class="elsevierStylePara elsevierViewall">Diagnosing anemia is complex and should be conducted in coordination with hematology departments. In addition to defining a series of basic concepts for understanding this document, <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> synthesizes the key points and recommendations.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Treatment of iron deficiency and iron-deficiency Anemia</span><p id="par0020" class="elsevierStylePara elsevierViewall">The treatment should be dual: treatment of the cause (etiopathogenic and etiological) and replenishment of the lacking or missing iron. There are 2 treatment options for patients with iron deficiency: oral and intravenous iron. The first is the treatment of choice for IDA (Appendix BTable 1S, See Supplemental Material). Intolerance/refractoriness to oral iron and the need for rapid replenishment are indications for the use of IVFe (Appendix BTable 2S, See Supplemental Material), whose objective is to normalize hemoglobin and ferritin levels (without ferritin levels exceeding 500<span class="elsevierStyleHsp" style=""></span>μg/L). To calculate the dosage, there is the modified Ganzoni formula:</p><p id="par0025" class="elsevierStylePara elsevierViewall">Dose necessary<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>Weight (kg)<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>(15<span class="elsevierStyleHsp" style=""></span>―<span class="elsevierStyleHsp" style=""></span>patient’s hemoglobin level [g/dL])<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2.4<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>500</p><p id="par0030" class="elsevierStylePara elsevierViewall">Nevertheless, this formula should be used with caution in mixed IDA, because it can overestimate the dose and induce iatrogenic overload (special caution is advised for kidney failure) and can underestimate the dose in cases of active bleeding.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the key points regarding the use of oral iron or intravenous preparations. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the recommendations for treating ID or IDA according to the patient’s clinical condition.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Iron-refractory iron-deficiency anemia and iron-deficiency anemia intolerant to oral iron</span><p id="par0035" class="elsevierStylePara elsevierViewall">IDA is “refractory” (IRIDA) when it does not respond to oral ferrous salts at a daily dose ≥100<span class="elsevierStyleHsp" style=""></span>mg of elemental iron for 4–8<span class="elsevierStyleHsp" style=""></span>weeks. IRIDA is produced by gastrointestinal causes (<span class="elsevierStyleItalic">Helicobacter pylori</span>, celiac disease and other malabsorptive syndromes, autoimmune gastritis, gastric surgery), in the context of mixed IDA or by increased hepcidin production. To diagnose IRIDA, an algorithm should be applied that helps differentiate it from other clinical conditions such as thalassemia and chronic anemia (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). The treatment of choice is IVFe for restoring normal hemoglobin levels and a ferritin level of 100<span class="elsevierStyleHsp" style=""></span>μg/L.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Oral iron intolerance is dose-dependent and gastric (associated with <span class="elsevierStyleItalic">H. pylori</span>) or intestinal and is frequently resolved by reducing the dose. If there is an underlying cause, however, it should be treated. If the intolerance persists after decreasing the dose or administering delayed-release ferrous salts or liposomal iron on alternate days, IVFe should be administered.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Complex chronic disease</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Chronic renal failure</span><p id="par0045" class="elsevierStylePara elsevierViewall">The prevalence of IDA in nondialysis-dependent chronic renal failure (CRF) is approximately 60 %.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The diagnosis of IDA is guided by the transferrin saturation index (TSAT) and ferritin levels. The standard therapy consists of ESA and iron supplements (APPENDIX BTable 3S, See Supplemental Material). IVFe is essential for patients with anemia and chronic kidney disease undergoing dialysis and/or taking ESA. There is controversy, however, regarding the ferritin and TSAT thresholds for starting and/or discontinuing the supply of iron, given the high risk of iatrogenic overload.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Chronic heart failure</span><p id="par0050" class="elsevierStylePara elsevierViewall">More than 30 % of patients with chronic heart failure (CHF) can present ID, which contributes to cardiac muscle dysfunction and myocardial metabolism disorders.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> To diagnose CHF, the most widely used criterion is a ferritin level<span class="elsevierStyleHsp" style=""></span><100<span class="elsevierStyleHsp" style=""></span>μg/L or a ferritin level 100–300<span class="elsevierStyleHsp" style=""></span>μg/L with TSAT<span class="elsevierStyleHsp" style=""></span><20 %. The European Society of Cardiology established the criterion of when to treat ID in CHF. Although frequently employed, oral iron has marked limitations. The European and Spanish guidelines for heart failure therefore recommend the use of IVFe (with the maximum evidence).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> A recent study that analyzed up to 10<span class="elsevierStyleHsp" style=""></span>randomized studies showed that IVFe improves the cardiovascular prognosis of patients with CHF.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Inflammatory disease</span><p id="par0055" class="elsevierStylePara elsevierViewall">Anemia in chronic disease or associated with inflammation varies depending on the entity, reaching a prevalence of 50 % in patients with systemic lupus erythematosus. The condition is produced by an overexpression of hepcidin and cytokines, which alter erythropoiesis and the absorption of duodenal iron. The sTfR/log ferritin index is the most reliable laboratory test for diagnosing anemia. After more than 15<span class="elsevierStyleHsp" style=""></span>years, there is still no inexpensive and standardized technique for measuring hepcidin in clinical practice. The treatment is aimed at remission of the underlying disease. Specific treatments should only be administered if the underlying disease is not controlled. IVFe is the first choice when faced with true ID, but other options include ESA.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Neoplasia</span><p id="par0060" class="elsevierStylePara elsevierViewall">More than 40 % of patients with cancer present hemoglobin levels <12<span class="elsevierStyleHsp" style=""></span>g/dL at diagnosis, and anemia is associated with a poor prognosis.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The pathogenesis is multifactorial, with the participation of the immune system, iron metabolism, erythropoiesis and the neoplastic process itself. ID caused by abnormal hepcidin induction plays an important role.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Classical parameters are employed for the diagnosis, although with the known limitations inherent in the acute-phase reactant state of ferritin and in the reduction in serum transferrin in inflammation.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The ideal treatment would be to eradicate the neoplasm. To avoid transfusions, IVFe and ESA may be employed, especially in combination.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Iron should be provided intravenously. The efficacy of IVFe decreases in metastatic cancer, a chronic inflammatory scenario prone to releasing cytokines. The efficacy of ESA can be limited by ID or by other reasons, and the response can be delayed for weeks or months. ESA have also been related to a possible risk of carcinogenesis or angiogenesis in some neoplasias untreated with chemotherapy and have been associated with cardiovascular mortality in uses beyond the indication in patients who have not undergone chemotherapy. The use of ESA is therefore strictly limited to the indications of its datasheet.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">There is no full consensus among the various societies regarding the use of iron supplements in terms of therapeutic objectives. However, there is consensus on the use of IVFe in ID in patients with inflammation and/or who are undergoing chemotherapy and/or treatment with erythropoietin (Appendix BTable 4S, See Supplemental Material). IVFe is particularly useful for treating true ID in patients awaiting surgery, with the main contraindications for IVFe being active infections and intolerance.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Gastrointestinal disease</span><p id="par0070" class="elsevierStylePara elsevierViewall">More than 80 % of patients discharged after a gastrointestinal hemorrhage have anemia, which, however, is treated in less than 20 % of cases.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Bariatric surgery is an emerging cause of ID due to its growing implementation in patients with morbid obesity. These patients present underlying moderate iron deficiency associated with their inflammatory condition. The prevalence of anemia can approach 74 % in patients with inflammatory bowel disease (IBD), in which ID occurs due to blood loss through the mucosa, malnutrition, deficient absorption and hepcidin induction.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The guidelines recommend treating the anemia in IBD as part of the management of the disease itself. Oral iron can be effective for mild anemia (Hb<span class="elsevierStyleHsp" style=""></span>>11<span class="elsevierStyleHsp" style=""></span>g/dL), quiescent phases of IBD and if the IDA is trivial. IVFe is the choice for moderate-severe anemia (Hb<span class="elsevierStyleHsp" style=""></span><10<span class="elsevierStyleHsp" style=""></span>g/dL) associated with iron-deficiency IBD, for refractoriness/intolerance to oral iron and for active disease, given that inflammation blocks iron absorption. The recommended maximum thresholds for TSAT and ferritin are 50 % and 500<span class="elsevierStyleHsp" style=""></span>μg/L, respectively, although the risk of overload is low.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> ESA, frequently in combination with IVFe, constitute an effective alternative for situations with a lack of response to the therapy of the underlying disease and to IVFe in monotherapy and for when immunosuppressants do not control the inflammation. Allogenic blood transfusion (ABT) should be reserved for life-threatening conditions.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Critical patients and patients with sepsis</span><p id="par0075" class="elsevierStylePara elsevierViewall">Anemia is the most common laboratory finding in critical patients. With its multifactorial origin (hemorrhaging, numerous extractions [vampirism], functional iron deficiency [FID]), anemia has been related to increased morbidity and mortality, although anemia does not severely jeopardize the supply of oxygen.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Also, the underlying disease can be responsible for many of the unfavorable consequences attributed to anemia, whose follow-up recommendations are listed in Appendix BTable 5S (See Supplemental Material). The treatment of anemia needs to be individualized according to the clinical moment in time, the underlying disease and the comorbidities.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,19</span></a> In terms of ABT, the Spanish Society of Hematology and Hemotherapy recommends not transfusing more packed red blood cells than necessary to relieve the symptoms of anemia or to return the patient to a safe hemoglobin range (7 to 8<span class="elsevierStyleHsp" style=""></span>g/dL for stable noncardiac patients).<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The Consensus Document of Seville on the Alternatives to ABT and other guidelines state that hemoglobin levels >7<span class="elsevierStyleHsp" style=""></span>g/dL should be maintained except when faced with central nervous system damage or acute heart disease, which can require at least 8<span class="elsevierStyleHsp" style=""></span>g/dL, and that, in any case, the decision to transfuse should be made individually based on the anemia’s etiology, patient comorbidity, symptoms and hemoglobin concentration. Focusing this practice on the clinical context in question, it is important to remember that ABT has been associated with increased morbidity and mortality in critical patients and patients with sepsis. The recommendation is therefore to apply a “restrictive” transfusion criterion.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Oral iron was not associated with reduced mortality, and IVFe was unable to reduce either the risk of transfusion or mortality in a series of clinical trials in critically ill patients and patients with sepsis. The risk of infection is increased not only by the iron deficiency but also by the iron overload, an important observation for patients with sepsis.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In short, the use of iron (preferably IVFe) would only be recommended in cases of absolutely demonstrated ID, as an adjuvant to ESA or for patients undergoing the patient blood management (PBM) protocol.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The use of ESA is not recommended. In addition, critically ill patients and patients with sepsis are particularly vulnerable, and caution should be exercised when making any therapeutic decision.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,18</span></a> Various societies have therefore developed a number of action recommendations, especially “do not do” recommendations” (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Treatment for iron deficiency and iron-deficiency Anemia in specific populations</span><p id="par0085" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> synthesizes the key points and recommendations regarding this section.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Pregnant women</span><p id="par0090" class="elsevierStylePara elsevierViewall">During pregnancy, anemia is produced by hemodilution, and the iron requirements increase over the course of the pregnancy. ID is the most common cause of anemia. Hemoglobin levels<span class="elsevierStyleHsp" style=""></span><8–9<span class="elsevierStyleHsp" style=""></span>g/dL increase the maternal mortality risk, and ID increases this risk in the first months of life for the child. Hemoglobin, TSAT, ferritin and the variables provided by the hemogram are important for the diagnosis. Prevention is important for reducing the need for transfusion. The World Health Organization (WHO) and the US Centers for Disease Control and Prevention recommend oral iron supplements from the first prenatal visit, although other guidelines do not consider these supplements. In any case, pregnant women who do not take these supplements present iron-deficient erythropoiesis.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Once ID has started, it should be treated. Appendix B <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>S (See Supplemental Material) proposes a therapeutic algorithm. Oral iron constitutes the first option. IVFe should be limited to women with malabsorption, IBD, intolerance or poor response to oral iron and for cases of IDA with hemoglobin levels<span class="elsevierStyleHsp" style=""></span><9<span class="elsevierStyleHsp" style=""></span>g/dL, starting from the second trimester and in postpartum. The dose is calculated using the Ganzoni formula, with the weight prior to pregnancy and a hemoglobin objective of 11–13<span class="elsevierStyleHsp" style=""></span>g/dL. A check-up should be performed at 4–6<span class="elsevierStyleHsp" style=""></span>weeks to assess the need for a new dose. For postpartum, oral iron is also the first option, reserving IVFe for the assumptions listed earlier. Erythropoietin can be considered for cases with infections, inflammatory disorder or kidney failure. Transfusion should be considered for hemoglobin levels<span class="elsevierStyleHsp" style=""></span><7<span class="elsevierStyleHsp" style=""></span>g/dL, symptoms, massive obstetric hemorrhaging, continuous bleeding and additional hemorrhage risk.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Pediatric patients</span><p id="par0100" class="elsevierStylePara elsevierViewall">The WHO considers anemia in childhood for hemoglobin levels<span class="elsevierStyleHsp" style=""></span><10.9<span class="elsevierStyleHsp" style=""></span>g/dL for those aged 6–59<span class="elsevierStyleHsp" style=""></span>months,<span class="elsevierStyleHsp" style=""></span><11.5<span class="elsevierStyleHsp" style=""></span>g/dL for those aged 6–11<span class="elsevierStyleHsp" style=""></span>years and<span class="elsevierStyleHsp" style=""></span><12<span class="elsevierStyleHsp" style=""></span>g/dL for those aged 12–14<span class="elsevierStyleHsp" style=""></span>years. Worldwide, half of children younger than 5<span class="elsevierStyleHsp" style=""></span>years have anemia (with ID the main cause), caused mainly by a deficient diet, although malabsorption (<span class="elsevierStyleItalic">H.</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">pylori</span>, intestinal diseases) and blood loss associated with infections are also responsible. IDA affects physical and neurological growth and is diagnosed when hyporegenerative anemia, generally microcytic, and reduced iron deposits coexist. Given that 40 % of cases of IDA are not microcytic, it is worth determining ferritin levels to assess iron deposits in all children with anemia, regardless of the mean corpuscular volume. In inflammatory conditions, it is worth assessing TSAT and ferritin, given the limited validity of ferritin (being an acute-phase reactant). Oral iron is the first choice for pediatric IDA, reserving IVFe for conditions of intolerance, malabsorption and IBD, in which the dose is calculated with the Ganzoni formula. Transfusions should be limited to highly severe symptomatic cases. Transfusion might be necessary for infants with associated respiratory impairment.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Athletes</span><p id="par0105" class="elsevierStylePara elsevierViewall">ID is common, especially in endurance sports, due to the increased demand, loss due to intestinal microischemia and malabsorption due to temporary increases in hepcidin, in a context of increased erythropoietic activity. Runners can also experience anemia by traumatic hemolysis and dilutional anemia. ID is common in women due to recurrent menorrhagia. For the diagnosis, it is worth remembering that ferritin is an acute-phase reactant and increases during exercise. Measurements should therefore be made at least 24<span class="elsevierStyleHsp" style=""></span>h after the completion of the exercise. Treatment rests on nutritional counseling, but if this is insufficient, the treatment can include iron supplements (generally oral), although IVFe may be considered in specific cases (intolerance, need for rapid replenishment). Treatment response should be checked 6–8<span class="elsevierStyleHsp" style=""></span>weeks after starting the treatment, and laboratory check-ups should be performed twice a year.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Other populations (Jehovah’s witnesses, donors)</span><p id="par0110" class="elsevierStylePara elsevierViewall">Managing anemia in adult Jehovah’s Witnesses should be conducted according to Law 41/2002, respecting the patient’s autonomy. For minors, the duty judge should be notified so that they can authorize (or not) transfusion measures. These patients accept iron therapy and ESA and might accept treatments with recombinant coagulation factors (web address at the end of the article).</p><p id="par0115" class="elsevierStylePara elsevierViewall">Anemia or reduced hemoglobin levels are the main cause for rejecting donors (web address at the end of the article). ID is present in up to 3 % of “new” or “known” male donors and in 42 % of the “regulars”. These rates increase dramatically in women (32 % and 65 %, respectively).<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> In May 2013, the Spanish Ministry of Health, Consumer Affairs and Social Welfare issued 13 recommendations on managing female donors (APPENDIX BTable 6S, See Supplemental Material). IVFe is being considered as an option for managing female donors.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26,27</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Perioperative iron deficiency and Anemia</span><p id="par0120" class="elsevierStylePara elsevierViewall">Preoperative anemia is associated with increased postoperative morbidity and mortality. The WHO seeks to reduce the need for ABT in this context through their PBM programs, which aim to stimulate erythropoiesis, restore hemostasis, reduce bleeding, optimize tolerance to normovolemic anemia and promote the optimal use of transfusions.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> IDA is the main cause of inappropriate or inadequate ABT.</p><p id="par0125" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> synthesizes the key points and recommendations regarding this section. Appendix BTable 7S (See Supplemental Material) lists the recommendations of the Enhanced Recovery for Abdominal Surgery Clinical Pathway Workgroup (RICA) on the behavior to observe when faced with perioperative anemia.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Approximately 30 % of patients have anemia prior to surgery.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> The preoperative hemoglobin level is the most important independent transfusion risk factor, given that hemoglobin and anemia are the only transfusion and morbidity risk factors that we can modify.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28,30</span></a> With its generally multifactorial origin, preoperative anemia has a prevalence that varies depending on the underlying disease.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Perioperative bleeding and inflammation cause a mixed or inflammatory pattern of anemia associated with FID, with a prevalence exceeding 75 % in some types of cancer and a origin frequently associated with the underlying disease.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Postoperative anemia is the consequence of inflammation and, especially, surgical bleeding, which also involves the loss of iron from hemoglobin. The prevalence of postoperative anemia can exceed 80 % after surgical procedures such as hip fracture repair. Perioperative ID can slow postbleeding recovery.</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Diagnosis of preoperative anemia</span><p id="par0140" class="elsevierStylePara elsevierViewall">The differential diagnosis should be performed at least 30<span class="elsevierStyleHsp" style=""></span>days before the surgery for patients scheduled for major surgery to establish the appropriate treatment if necessary.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> For patients undergoing nonelective surgery, the detection should be performed as soon as possible. The Spanish Ministry of Health recommends not scheduling elective surgery with a risk of bleeding in patients with anemia until an adequate diagnosis and treatment analysis has been conducted.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,28,31</span></a></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Treatment for preoperative and postoperative anemia</span><p id="par0145" class="elsevierStylePara elsevierViewall">Appendix BTable 8S (See Supplemental Material) lists the recommendations of the Document of Seville on the use of iron to treat preoperative and postoperative anemia.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The objective in the first case is to achieve normal hemoglobin levels, although for procedures associated with medium-high bleeding, hemoglobin levels ≥14<span class="elsevierStyleHsp" style=""></span>g/dL are recommended to minimize the transfusion risk, postponing the surgery if necessary.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Many surgical patients can benefit from preoperative iron therapy. If possible, oral preparations should be employed,<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,28</span></a> although IVFe is justified when faced with malabsorption, intolerance, moderate-severe anemia or urgent replenishment.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> IVFe preparations have been shown effective and safe in correcting postoperative anemia and reducing the transfusion rate and volume.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Consensus documents on the alternatives to ABT and on the management of perioperative hemorrhaging recommend (with the maximum level of evidence) the administration of preoperative recombinant human erythropoietin (rHuEPO) for scheduled orthopedic surgery.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Appendix BTable 9S (See Supplemental Material) lists the recommendations of the Document of Seville on the use of rHuEPO for surgical and critically ill patients. The perioperative administration of rHuEPO should be accompanied by IVFe (optimizing its efficiency and safety).<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,32</span></a></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Controlling the treatment with intravenous iron</span><p id="par0155" class="elsevierStylePara elsevierViewall">Given there is no excretion mechanism for eliminating excess iron, control is important to prevent iatrogenic overload. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B proposes a treatment algorithm for IVFe and its control. Appendix BTable 10S (See Supplemental Material) shows the red blood cell variables whose progression should be considered during treatment with IVFe. Reticulocytes and hemogram variables regarding hemoglobin, although important, are not the only ones to assess. Ferritin and TSAT should also be considered because once these have returned to normal values, the iron deposits may be considered to have recovered.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Pure iron-deficiency anemia</span><p id="par0160" class="elsevierStylePara elsevierViewall">With ID the only cause, we can calculate the dose with the Ganzoni formula, with the limitation of not considering the losses that might occur during treatment. A hematologic response of 0.8–1<span class="elsevierStyleHsp" style=""></span>g/dL a week is expected. By 6–8<span class="elsevierStyleHsp" style=""></span>weeks, anemia and the remaining signs caused by ID should have receded. Otherwise, a new treatment should be performed. When the cause is chronic, maintenance treatment with oral iron or IVFe should be considered (without exceeding 500<span class="elsevierStyleHsp" style=""></span>μg/L of ferritin), depending on the circumstances.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Mixed iron-deficiency anemia</span><p id="par0165" class="elsevierStylePara elsevierViewall">When there are other causes in addition to ID, the tools for calculating the dosage have limitations. Caution is therefore advised to prevent the risk of iron overload.</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Mixed iron-deficiency anemia associated with other deficiencies</span><p id="par0170" class="elsevierStylePara elsevierViewall">It is worth identifying the cause and treating it in conjunction with iron replenishment therapy, whose efficacy should be analyzed at 6–8<span class="elsevierStyleHsp" style=""></span>weeks. If the cause is chronic, maintenance therapy with oral iron or IVFe should be assessed, in addition to the other deficient factors.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Mixed iron-deficiency anemia associated with other types of anemia</span><p id="par0175" class="elsevierStylePara elsevierViewall">The association occurs especially with chronic inflammatory anemia and anemia due to kidney failure. The underlying disease should be treated. For the previously mentioned reasons, dose calculation formulas should not be used to treat the anemia in the first case. Lower doses should be employed, and check-ups at 6–8<span class="elsevierStyleHsp" style=""></span>weeks should be performed to consider whether, if necessary, the therapy with IVFe should be discontinued. If the anemia is severe, the concomitant use of ESA may be assessed. In anemia due to CRF, the disease situation is similar, and we should proceed in a similar manner, considering additional doses of IVFe if the check-ups, which in this case should be conducted every 4–6<span class="elsevierStyleHsp" style=""></span>weeks, do not indicate adequate replenishment. Once the ID has been resolved, the use of ESA may be considered if the hemoglobin level recommends it.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> In this case, there is a risk of FID if the iron deposits are insufficient. It is therefore advisable to determine the TSAT and ferritin levels to, if necessary, postpone the treatment with ESA, supplement with IVFe and perform a check-up at 6–8<span class="elsevierStyleHsp" style=""></span>weeks to assess starting the ESA therapy. The onset of FID should be checked once therapy with ESA has started. It is therefore advisable to assess the patient’s iron metabolism every 4–6<span class="elsevierStyleHsp" style=""></span>weeks until the hemoglobin objective has been achieved. Once the hemoglobin objective has been achieved, the patient’s iron metabolism should be checked every 3–6<span class="elsevierStyleHsp" style=""></span>months to adjust the IVFe therapy with the TSAT and ferritin objectives of<span class="elsevierStyleHsp" style=""></span><20 % and<span class="elsevierStyleHsp" style=""></span>>100<span class="elsevierStyleHsp" style=""></span>μg/L (never exceeding<span class="elsevierStyleHsp" style=""></span>500<span class="elsevierStyleHsp" style=""></span>μg/L), respectively.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p></span></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conclusions</span><p id="par0180" class="elsevierStylePara elsevierViewall">IVFe is a tool of considerable value for managing ID and IDA. The correct management of perioperative anemia is essential in PBM programs. Nevertheless, the lack of excretion mechanisms that ensure the elimination of iron increases the risk of iatrogenic overload and requires the strict observation of certain action plans, especially when faced with comorbidities or risk scenarios. This document seeks to serve as a practical reference for any situation that requires managing patients with ID or anemia with a component of iron deficiency.</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Web addresses</span><p id="par0185" class="elsevierStylePara elsevierViewall">Approach for Jehovah’s Witnesses [consulted 17 Jan 2019]. Available at <a href="https://www.jw.org/es/medical-library/">https://www.jw.org/es/medical-library/</a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Resolutions and Recommendations of the Scientific Committee for Transfusion Safety (CCST). Blood Donation and Iron deficiency [consulted 14 Feb 2019]. Available at <a href="http://www.mscbs.gob.es/profesionales/saludPublica/medicinaTransfusional/acuerdos/docs/DonacionSangre">http://www.mscbs.gob.es/profesionales/saludPublica/medicinaTransfusional/acuerdos/docs/DonacionSangre</a>_Ferropenia.pdf</p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Funding</span><p id="par0195" class="elsevierStylePara elsevierViewall">The present project was conducted under the authors’ own initiative and received no external financial assistance.</p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conflicts of interest</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors received financial assistance from Vifor Pharma for conducting a meeting from which emerged the initiative for developing the manual “The Management of Iron Deficiency in Various Clinical Conditions”, upon which this article is inspired. This preparation also counted on the collaboration of the aforementioned company. Nevertheless, the present project was conducted under the authors’ own initiative and received no external financial assistance.</p><p id="par0205" class="elsevierStylePara elsevierViewall">The GEE of the Spanish Society of Hematology and Hemotherapy would like to thank Vifor Pharma for their cooperation in preparing this manual on the correct use of IVFe in iron deficiencies<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and a vademecum with the main recommendations of the previous document,<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> given that these texts constitute the basis of this work.</p><p id="par0210" class="elsevierStylePara elsevierViewall">The authors would also like to thank Professor Ana Villegas for writing the prologue of the previously mentioned work.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1306139" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1206265" "titulo" => "Palabras claves" ] 2 => array:2 [ "identificador" => "xpalclavsec1206264" "titulo" => "Keywords" ] 3 => array:3 [ "identificador" => "xres1306138" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Background" "secciones" => array:18 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Methodology" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Diagnosis of iron deficiency and iron-deficiency Anemia" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Treatment of iron deficiency and iron-deficiency Anemia" ] 3 => array:2 [ "identificador" => "sec0025" "titulo" => "Iron-refractory iron-deficiency anemia and iron-deficiency anemia intolerant to oral iron" ] 4 => array:3 [ "identificador" => "sec0030" "titulo" => "Complex chronic disease" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Chronic renal failure" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Chronic heart failure" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Inflammatory disease" ] 3 => array:2 [ "identificador" => "sec0050" "titulo" => "Neoplasia" ] 4 => array:2 [ "identificador" => "sec0055" "titulo" => "Gastrointestinal disease" ] 5 => array:2 [ "identificador" => "sec0060" "titulo" => "Critical patients and patients with sepsis" ] ] ] 5 => array:2 [ "identificador" => "sec0065" "titulo" => "Treatment for iron deficiency and iron-deficiency Anemia in specific populations" ] 6 => array:2 [ "identificador" => "sec0070" "titulo" => "Pregnant women" ] 7 => array:2 [ "identificador" => "sec0075" "titulo" => "Pediatric patients" ] 8 => array:2 [ "identificador" => "sec0080" "titulo" => "Athletes" ] 9 => array:2 [ "identificador" => "sec0085" "titulo" => "Other populations (Jehovah’s witnesses, donors)" ] 10 => array:2 [ "identificador" => "sec0090" "titulo" => "Perioperative iron deficiency and Anemia" ] 11 => array:2 [ "identificador" => "sec0095" "titulo" => "Diagnosis of preoperative anemia" ] 12 => array:2 [ "identificador" => "sec0100" "titulo" => "Treatment for preoperative and postoperative anemia" ] 13 => array:2 [ "identificador" => "sec0105" "titulo" => "Controlling the treatment with intravenous iron" ] 14 => array:2 [ "identificador" => "sec0110" "titulo" => "Pure iron-deficiency anemia" ] 15 => array:2 [ "identificador" => "sec0115" "titulo" => "Mixed iron-deficiency anemia" ] 16 => array:2 [ "identificador" => "sec0120" "titulo" => "Mixed iron-deficiency anemia associated with other deficiencies" ] 17 => array:2 [ "identificador" => "sec0125" "titulo" => "Mixed iron-deficiency anemia associated with other types of anemia" ] ] ] 5 => array:2 [ "identificador" => "sec0130" "titulo" => "Conclusions" ] 6 => array:2 [ "identificador" => "sec0135" "titulo" => "Web addresses" ] 7 => array:2 [ "identificador" => "sec0140" "titulo" => "Funding" ] 8 => array:2 [ "identificador" => "sec0145" "titulo" => "Conflicts of interest" ] 9 => array:2 [ "identificador" => "xack449688" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-03-02" "fechaAceptado" => "2019-09-05" "PalabrasClave" => array:1 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1206264" "palabras" => array:10 [ 0 => "Iron" 1 => "Anaemia" 2 => "Iron-deficiency anaemia" 3 => "Functional iron deficiency" 4 => "Iron overload" 5 => "Oral iron" 6 => "Intravenous iron" 7 => "Mixed anaemia" 8 => "Guidelines" 9 => "Manual of good practices." ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras claves" "identificador" => "xpalclavsec1206265" "palabras" => array:10 [ 0 => "Hierro" 1 => "Anemia" 2 => "Anemia ferropénica" 3 => "Déficit funcional de hierro" 4 => "Sobrecarga de hierro" 5 => "Hierro oral" 6 => "Hierro endovenoso" 7 => "Anemia mixta" 8 => "Guía" 9 => "Manual de buenas prácticas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Iron deficiency (ID) due to blood loss, absorption disorders and dietary deficiencies causes iron-deficiency anaemia, whose treatment seeks to eliminate the underlying cause and restore haemoglobin and iron deposits. Typically, the latter 2 of these objectives can be achieved through oral iron therapy. Intravenous iron administration (IIA) should be limited to those patients refractory or intolerant to oral preparations or who require rapid repletion. The indiscriminate use of IIA can increase morbidity and mortality due to iatrogenic overload. This fact, coupled with the growing popularity of IIA and the lack of reference guidelines in Spanish, led the Spanish Erythropathology Group of the Spanish Society of Haematology and Haemotherapy to develop this study, which presents the main recommendations on the optimal use of IIA in ID and attempts to constitute reference guidelines on good practices for the clinical management of these conditions.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">El déficit de hierro (DH) a consecuencia de pérdidas de sangre, trastornos de absorción y/o carencias dietéticas, originan anemia ferropénica (AF), cuyo tratamiento persigue eliminar la causa subyacente, y restaurar la hemoglobina (Hb) y los depósitos de hierro. Habitualmente, los dos últimos objetivos pueden conseguirse mediante ferroterapia oral. El hierro de administración endovenosa (FEEV) debe limitarse a aquellos sujetos refractarios o intolerantes a los preparados orales, o que requieran una repleción rápida. Su utilización indiscriminada podría incrementar la morbimortalidad por sobrecarga iatrogénica. Este hecho, unido a la creciente popularidad del FEEV y a la carencia de guías de referencia en nuestro idioma, condujo al Grupo Español de Eritropatología de la Sociedad Española de Hematología y Hemoterapia a elaborar este trabajo que recoge las principales recomendaciones acerca del uso óptimo del FEEV en los DH, y pretende constituir una guía de referencia de buenas prácticas para el manejo clínico de estas situaciones.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García Erce JA et al. Manejo del déficit de hierro en distintas situaciones clínicas y papel del hierro intravenoso: recomendaciones del Grupo Español de Eritropatología de la SEHH. Rev Clin Esp. 2020;220:31–42.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">El resto de los componentes del Grupo Español de Eritropatología de la Sociedad Española de Hematología y Hemoterapia están relacionados en el anexo.</p>" ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2840 "Ancho" => 2500 "Tamanyo" => 376598 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0425" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Algorithms for the diagnosis and treatment of iron-refractory iron-deficiency anemia (A) and for treatment with intravenous iron and its control (B). CRF: chronic renal failure; ESA: erythropoiesis-stimulating agents; Fe: iron; Ft: ferritin; IA: inflammatory anemia; IDA: iron-deficiency anemia; IRIDA: iron-refractory iron-deficiency anemia; IVFe: intravenous iron; TSAT: transferrin saturation index; WHO: World Health Organization.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0430" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">AID, absolute iron deficiency; CHr, reticulocyte hemoglobin content; CRF, chronic renal failure; EPO, erythropoietin; ESA, erythropoiesis-stimulating agents; FID, functional iron deficiency; Ft, ferritin; Hb, hemoglobin; %Hypo, percentage of hypochromic cells; IDA, iron-deficiency anemia; IRIDA, iron-refractory iron-deficiency anemia; IV, intravenous; MCH, mean corpuscular hemoglobin; MCV, mean corpuscular volume; RDW, red cell distribution width; sTfR, soluble transferrin receptor; Tf, transferrin; TSAT, transferrin saturation index.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">Basic concepts</span><a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• <span class="elsevierStyleItalic">Protagonists in iron metabolism</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">◦ <span class="elsevierStyleItalic">Ferritin</span> (Ft). An intracellular protein that stores iron. An important acute-phase reactant. Low ferritin levels are synonymous with ID, but ferritin levels can be falsely high in cases of inflammation and/or cell destruction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">◦ <span class="elsevierStyleItalic">Ferroportin</span>. A membrane transporter that allows iron to exit to the cell’s exterior. An essential protein in enterocytes and macrophages and sensitive to hepcidin action. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">◦ <span class="elsevierStyleItalic">Transferrin</span> (Tf). The protein in charge of transporting iron to the erythroid progenitors of bone marrow. Transferrin is an inverse acute-phase reactant: Transferrin levels increase in ID but decrease in cases of inflammation. Decreased transferrin levels also reflect malnutrition. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">◦ <span class="elsevierStyleItalic">Hepcidin</span>. A hormonal peptide of hepatic origin that reduces iron absorption at the intestinal level. Hepcidin is an essential regulator whose levels increase in conditions of iron overload and in high interleukin-6 levels in cases of inflammation and decrease in hypoxia and anemia. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• <span class="elsevierStyleItalic">Iron deficiency.</span> The reduction in organic iron mass, which leads to a persistent negative iron balance. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• <span class="elsevierStyleItalic">Iron-deficient erythropoiesis.</span> Erythropoiesis in which the iron supply to erythropoietic progenitors is restricted, a condition that induces a state of anemia. There are 3 types: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">◦ <span class="elsevierStyleItalic">Absolute iron deficiency</span> (AID). Typical in children, pregnant women, women of childbearing age and the elderly. AID is characterized by very low iron reserve levels (15<span class="elsevierStyleHsp" style=""></span>μg/L or 30<span class="elsevierStyleHsp" style=""></span>μg/L in cases of inflammation), ferritin levels<span class="elsevierStyleHsp" style=""></span><15<span class="elsevierStyleHsp" style=""></span>μg/L and a transferrin saturation index (TSAT) <16%. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">◦ <span class="elsevierStyleItalic">Functional iron deficiency</span> (FID). A situation in which the increased iron requirements by erythron exceed the ability to supply iron to erythropoietic tissue. FID can appear even with high iron reserve levels. FID manifests especially in patients treated with ESA, which induces a reduction in TSAT followed by a reduction in ferritin associated with an ineffective transfer of reserve iron to the intramedular synthesis of Hb. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">◦ <span class="elsevierStyleItalic">Iron block</span>. Caused when there is an overproduction of hepcidin in inflammatory, infectious or neoplastic processes, which induce hypoferremia and low iron availability for erythropoietic tissue. TSAT<span class="elsevierStyleHsp" style=""></span><20% and normal or high ferritin levels are detected in these cases.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• <span class="elsevierStyleItalic">Iron-deficiency anemia.</span> Anemia produced as the end result of any of the 3 types of iron-deficient erythropoiesis. IDA is considered to be present when Hb levels are <12 and <13<span class="elsevierStyleHsp" style=""></span>g/dL in women and men, respectively, although this definition is valid only for pure IDA, i.e., in which iron deficiency is its only cause. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• <span class="elsevierStyleItalic">Mixed iron-deficiency anemia.</span> Anemia in which iron deficiency (although partly responsible) does not constitute the only cause, given that other deficiencies (e.g., folate and vitamin B12) and other types of anemia (due to kidney failure or chronic inflammation) play a role. Therefore, additional variables should be employed in mixed IDA for its diagnosis.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Diagnosis of anemia and its causes</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• At the start of ID, patients can present a normal hemogram. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• The first red blood cell indices to be affected are RDW, MCH and MCV. Hemoglobin levels and red blood cell counts are subsequently affected. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• This process occurs in reverse when iron is replenished, with the biochemical parameters of this replenishment the last to recover. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• In addition to the biochemical parameters, hematimetric data such as the number of hypochromic reticulocytes, CHr and %Hypo help provide a proper evaluation of the additional iron state. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• These parameters serve to differentiate ID from a chronic process and to follow the treatment with erythropoietin in patients with CRF. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Although all the parameters have limitations, the most widely employed biochemical parameter is ferritin. Interpretation using all the parameters can therefore facilitate the assessment. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• sTfR and RsTf/logFt are highly useful for assessing states of ID associated with iron block. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• When faced with a poorer than expected iron response, clinicians should assess hemoglobinopathies and other less frequent congenital iron metabolism disorders (among them IRIDA), once AID and FID have been ruled out. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Types of therapeutic iron preparations</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• The first treatment option for IDA is oral ferrous salts at dosages of 60–200<span class="elsevierStyleHsp" style=""></span>mg/day. If gastric intolerance occurs, the compounds should be changed, the dosage should be decreased, and/or they should be administered with food. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• The iron preparations for intravenous administration are indicated for treating IDA when oral preparations are not appropriate or when a rapid supply of iron is clinically necessary. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• The selection of intravenous compound will depend on the center’s experience and the compound’s availability. However, the ideal formulations are those that enable a hemoglobin recovery and replacement of iron reserves in 1–2 administrations, given its cost-effectiveness. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Ferritin levels should be monitored for patients undergoing long-term intravenous therapy, especially for those with mixed IDA, with a target ferritin level of 100<span class="elsevierStyleHsp" style=""></span>μg/L and never exceeding 500<span class="elsevierStyleHsp" style=""></span>μg/L. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2237766.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Iron Deficiency: Basic Concepts, Diagnosis and Therapeutic Options. Key points and Recommendations.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0435" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">ASCO, American Society of Clinical Oncology; ASH, American Society of Hematology; BCSH, British Committee for Standards in Haematology; CHF, chronic heart failure; CKD, chronic kidney disease; CNS, central nervous system; EPO, erythropoietin; ESA, erythropoiesis-stimulating agents; ESC, European Society of Cardiology; ESMO, European Society for Medical Oncology; Ft, ferritin; Hb, hemoglobin; IBD, inflammatory bowel disease; ICU, intensive care unit; ID, iron deficiency; IDA, iron-deficiency anemia; IRIDA, refractory IDA; IVFe, iron intravenous; KDIGO, Kidney Disease Improving Global Outcomes; LVEF, left ventricular ejection fraction; rHuEPO, recombinant human erythropoietin; SEMICYUC, Spanish Society of Intensive Medicine Critical and Units Coronary arteries; SSC, Surviving Sepsis Campaign; TSAT, transferrin saturation index.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IRIDA and IDA intolerant to oral iron \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• To reach the diagnosis of IRIDA, other presentations of IDA need to be ruled out, and IRIDA must be differentiated from other diseases. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• The main causes of IRIDA are malabsorption associated with Helicobacter pylori, celiac disease, gastric surgery and autoimmune atrophic gastritis, mixed IDA and IRIDA caused by inadequate hepcidin production. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• The causes of IRIDA and the possible associated deficiencies need to be investigated and treated. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• The treatment of choice for IRIDA is IVFe; oral ferrous salts with delayed-release at the intestinal level may be used as an alternative. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• IDA intolerant to oral iron is dose-dependent and has been associated with H.<span class="elsevierStyleHsp" style=""></span>pylori infection. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• When treating IDA intolerant to oral iron, dose reduction for the ferrous salt should be assessed or its replacement with oral ferrous salts with delayed release in the intestine versus IVFe. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Treatment with IVFe should always be tailored and monitored through a serial study of the iron metabolism to prevent iron overload. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• If the cause of the IRIDA or intolerance is chronic or recurrent, appropriate maintenance therapy should be administered to prevent the recurrence of anemia or ID. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complex chronic disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic kidney disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• ID is a frequent cause of anemia in CKD; however, caution is advised when prescribing IVFe and not to address only the TSAT (its change could be due simply to inflammation and not ID) due to the risk of iron overload, especially in patients undergoing dialysis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• In CKD, ferritin levels should not be ≥500<span class="elsevierStyleHsp" style=""></span>μg/L, even though they are affected by inflammation and malnutrition. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• KDIGO: IVFe should be administered to patients undergoing dialysis only if TSAT and serum ferritin levels are <30 % and <500<span class="elsevierStyleHsp" style=""></span>μg/L, respectively.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic heart failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• ESC: ID should be treated in CHF with reduced ejection fraction (evidence IIa, grade A).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• In CHF, iron should be prescribed with prudence, moderating the dosages and monitoring to prevent iron overload, without ever approaching ferritin levels<span class="elsevierStyleHsp" style=""></span>>500<span class="elsevierStyleHsp" style=""></span>μg/L. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inflammation, neoplasia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Patients with inflammatory processes can benefit from IVFe and/or ESA, respecting a hemoglobin objective<span class="elsevierStyleHsp" style=""></span><12<span class="elsevierStyleHsp" style=""></span>g/dL. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• ASCO/ASH, ESMO: ESA should only be employed to treat anemia with chemotherapy-induced hemoglobin levels<span class="elsevierStyleHsp" style=""></span><10<span class="elsevierStyleHsp" style=""></span>g/dL, with the lowest possible dosage and a hemoglobin objective of 10–12<span class="elsevierStyleHsp" style=""></span>g/dL. ESA should be discontinued during the 4<span class="elsevierStyleHsp" style=""></span>weeks following the completion of chemotherapy. Given that it has no benefit at 6–8<span class="elsevierStyleHsp" style=""></span>weeks, the treatment provides no clinical advantage. ESA are not indicated for anemia not associated with chemotherapy or for preventing anemia.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Oral iron can be an option for patients with iron deficiency but no neoplasia or inflammation, for those with cancer in remission and for those with IBD with mild anemia and/or inactive disease, with few symptoms and no urgency to correct the anemia. The daily dose of elemental iron should not exceed<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mg. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• IVFe is the treatment of choice for patients with iron deficiency and chronic inflammation, those with active neoplastic disease and symptomatic ID, those with clinically active IBD, those with oral iron intolerance, hemoglobin levels<span class="elsevierStyleHsp" style=""></span><10<span class="elsevierStyleHsp" style=""></span>g/dL and for those who require ESA. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Treating true ID with IVFe is important for patients with cancer awaiting surgery, where correcting the deficiency prior to surgery is appropriate. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• The recommendation is to treat all patients who have iron deficiency and IBD with iron to normalize and maintain hemoglobin levels and iron deposits. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Critical patients and patients with sepsis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Anemia occurs almost consistently during ICU stays, maintaining mean hemoglobin levels of approximately 10<span class="elsevierStyleHsp" style=""></span>g/dL. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• The main causes of anemia are iron block produced by inflammation, blood loss and reduced red blood cell half-life. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• The deficiency etiology should be ruled out, the blood volume extracted for diagnosis minimized, the hemostasis optimized and gastroprotective agents employed. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Transfusions should be performed with a restrictive criterion (7<span class="elsevierStyleHsp" style=""></span>g/dL), except for brain disease, coronary disease, massive hemorrhaging and signs of tissue hypoxia. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• SEMICYUC: Red blood cell concentrates should not be transfused in critical but hemodynamically stable patients who are not bleeding, have no cardiac or central nervous system impairment and a hemoglobin concentration >7<span class="elsevierStyleHsp" style=""></span>g/dL.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• BCSH: In the absence of clear ID, routine iron administration is not recommended during critical disease (evidence 2D).<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Erythropoietin is generally not recommended, except for patients with a previous indication or who will undergo surgery with expected blood loss. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• BCSH: Do not employ rHuEPO for treating anemia in critical patients until there is more information on its safety and efficacy (evidence 1B).<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• SSC: Do not employ erythropoietin for anemia associated with sepsis (strong recommendation, evidence of moderate quality).<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2237768.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Treatment of Iron Deficiency and Iron Deficiency Anemia by Correcting the Patient’s Clinical Condition. Key points and recommendations.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0440" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Ft, ferritin; Hb, hemoglobin; IV, intravenous; IVFe, intravenous iron; WHO, World Health Organization.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pregnant women \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Anemia is defined in pregnancy as hemoglobin levels<span class="elsevierStyleHsp" style=""></span><11<span class="elsevierStyleHsp" style=""></span>g/dL or hematocrit levels <33 % in the first and third trimester and hemoglobin levels <10.5<span class="elsevierStyleHsp" style=""></span>g/dL or hematocrit levels <32 % in the second trimester. Anemia in postpartum is defined as a hemoglobin level<span class="elsevierStyleHsp" style=""></span><10<span class="elsevierStyleHsp" style=""></span>g/dL. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• A laboratory check-up is recommended for detecting the presence of anemia and ID at the start of pregnancy and at 28 weeks. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• A maternal hemoglobin level <9<span class="elsevierStyleHsp" style=""></span>g/dL increases the risk of premature delivery, intrauterine growth retardation and intrauterine fetal death. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Women should be counseled on their diet during the pregnancy, recommending iron-rich food and advising on the factors that promote or decrease iron absorption. Taking iron supplements when there is no anemia or ID is not necessary, except when ferritin levels are<span class="elsevierStyleHsp" style=""></span><70<span class="elsevierStyleHsp" style=""></span>μg/L, where the recommendation is for 40–60<span class="elsevierStyleHsp" style=""></span>mg daily orally to prevent iron-deficient erythropoiesis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Oral iron supplementation in women who do not have anemia should be discontinued if the hemoglobin level is >13<span class="elsevierStyleHsp" style=""></span>g/dL. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Once ID has started, treatment should be started with 100–200<span class="elsevierStyleHsp" style=""></span>mg daily of oral elemental iron in the form of ferrous salts. In the event of intolerance, poor response or moderate-severe anemia starting the second trimester, treatment with IVFe should be assessed. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• The treatment objective should be hemoglobin level normalization and replenishment of iron reserves. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pediatric patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• ID is the most common nutritional deficiency in childhood and the main cause of anemia in the pediatric population. ID can jeopardize physical and neurological development and should therefore be identified and treated promptly. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Breastfeeding infants and small children are especially susceptible due to their negative iron balance, which in turn is due to the high requirements of growth and because breastfeeding is a poor source of iron. Adolescents are another risk population, whose high iron needs are compounded by factors such as sports, dietary transgressions, obesity and menstrual losses. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• The best parameter for assessing ID is ferritin. According to the WHO, the threshold in childhood should be set at <12<span class="elsevierStyleHsp" style=""></span>μg/L for children<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>years or younger, <15<span class="elsevierStyleHsp" style=""></span>μg/L for children older than<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>years and at <30<span class="elsevierStyleHsp" style=""></span>μg/L when there is a concomitant infection. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• The treatment should be performed with oral iron, preferably ferrous salt, at dosages of 3–6<span class="elsevierStyleHsp" style=""></span>mg/kg/day of elemental iron, until the anemia is corrected and the iron deposits return to normal. For premature infants or those with extended breastfeeding, the recommendation is prophylaxis with supplements at lower dosages (1–2<span class="elsevierStyleHsp" style=""></span>mg/kg/day) for the first year of life. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• IVFe is safe and effective when the oral pathway is contraindicated or fails. Adverse effects are highly uncommon and self-limiting. Cost-effectiveness studies are needed to compare the available intravenous products. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Athletes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Iron deficiency is common among athletes, especially children and menstruating women, in those who participate in high-resistance sports and in disciplines with an incidence of eating disorders. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• All types of iron deficiency can affect physical performance and should be treated. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Regarding diagnostic tests, ferritin is an acute-phase reactant and increases during exercise. Therefore, to properly measure ferritin, at least 24<span class="elsevierStyleHsp" style=""></span>h should be allowed to pass after the exercise or even 6<span class="elsevierStyleHsp" style=""></span>days in the case of a marathon. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• For athletes older than 15<span class="elsevierStyleHsp" style=""></span>years, ferritin levels <30<span class="elsevierStyleHsp" style=""></span>μg/L are considered low. For altitude training, the objective is to maintain ferritin levels ≥50<span class="elsevierStyleHsp" style=""></span>μg/L before the training. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Iron deficiency should be treated with oral iron, reserving intravenous iron for when oral iron fails or immediate replenishment is needed. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Long-term daily oral iron and intravenous iron are not recommended for normal or high ferritin levels because the iron can be damaging. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2237769.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Treatment of Iron Deficiency and Iron-Deficiency Anemia in Specific Populations. Key points and recommendations.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0445" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">ABT, allogenic blood transfusion; BCSH, British Committee for Standards in Haematology; Hb, hemoglobin; ID, iron deficiency; IV, intravenous; PBM, Patient Blood Management; RICA, Enhanced Recovery for Abdominal Surgery Clinical Pathway Workgroup; SEDAR, Spanish Society of Anesthesiology, Resuscitation and Pain Relief.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">• SEDAR: Elective surgery with a risk of hemorrhaging should not be scheduled for patients with anemia until a diagnostic study has been performed and, if necessary, the appropriate treatment has been started.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• RICA: The recommendation is to detect preoperative anemia, given that it is associated with increased perioperative mortality (strong, high level of evidence).<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• According to the recent BCSH guidelines, patients should be counseled regarding the relationship between anemia, morbidity and mortality and should be given the opportunity to postpone non-urgent surgery until the anemia has been investigated and treated. Therefore, the importance of incorporating the principles of the first pillar of PBM has been proposed, including… \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">◦ The objective of preoperative drug treatment should be to normalize the levels. For patients who will undergo surgical procedures with medium-high bleeding, a hemoglobin level ≥13<span class="elsevierStyleHsp" style=""></span>g/dL would therefore be recommendable. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">◦ The possible presence of nutrient deficiencies (iron, B12 and folic acid) without anemia should be considered. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">◦ The drug treatment objective for postoperative anemia should be to prevent the risks of anemia and those of ABT exposure. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">◦ Patients with anemia who will undergo major surgery can benefit from iron administration, preferably intravenously, during the preoperative, perioperative and immediate postoperative periods. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">◦ Elective surgery with a risk of bleeding should not be scheduled for patients with anemia until a diagnostic study and appropriate treatment for the anemia have been conducted. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2237767.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Perioperative Iron Deficiency and Anemia. 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