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Background: Many countries in the nutrition transition have high rates of iron deficiency (ID) and overweight (OW). ID is more common in OW children; this may be due to adiposity-related inflammation reducing iron absorption. Objective: We investigated whether weight status predicts response to oral iron supplementation in ID South African children. Design: A placebo-controlled trial of oral iron supplementation (50 mg, 4 × weeks for 8.5 months) was done in ID 6- to 11-year-old children ( n =321); 28% were OW or obese. BMI-for-age z -scores (BAZ), hepcidin (in a sub-sample), hemoglobin, serum ferritin (SF), transferrin receptor (TfR), zinc protoporphyrin (ZnPP) and C-reactive protein (CRP) were measured; body iron was calculated from the SF to TfR ratio. Results: At baseline, BAZ correlated with CRP ( r =0.201, P <0.001) and CRP correlated with hepcidin ( r =0.384, P <0.001). Normal weight children supplemented with iron had significantly lower TfR concentrations at endpoint than the OW children supplemented with iron and the children receiving placebo. Higher BAZ predicted higher TfR ( β =0.232, P <0.001) and lower body iron ( β =−0.090, P =0.016) at endpoint, and increased the odds ratio (OR) for remaining ID at endpoint in both the iron and placebo groups (iron: OR 2.31, 95% CI: 1.13, 4.73; placebo: OR 1.78, 95% CI: 1.09, 2.91). In the children supplemented with iron, baseline hepcidin and BAZ were significant predictors of endpoint TfR, with a trend towards a hepcidin × BAZ interaction ( P =0.058). Conclusion: South African children with high BAZ have a two-fold higher risk of remaining ID after iron supplementation. This may be due to their higher hepcidin concentrations reducing iron absorption. Thus, the current surge in OW in rapidly developing countries may undercut efforts to control anemia in vulnerable groups. The trial is registered at clinicaltrials.gov as NCT01092377.

A randomized controlled trial was conducted to assess the effect of African leafy vegetable (ALV) consumption on Fe, Zn and vitamin A status in children. Children were randomly allocated to receive either a 300 g cooked ALV dish and school meal starch (n 86) or the normal school meal (n 81) five times per week for three months. ALV in the dish consisted mainly of Amaranthus cruentus (at least 80 %) and the remainder of Cleome gynandra, Cucurbita maxima or Vigna unguiculata. Nutrient content and consumer acceptance of the ALV dish were also determined. North West Province, South Africa. Grade R to grade 4 children (6-12 years old) of two farm schools. The ALV dish contributed 11·6-15·8 mg Fe and 1·4-3·7 mg Zn. At baseline, prevalence of deficiencies in the intervention group was 16·0 %, 16·3 %, 7·0 % and 75·6 %, respectively, for anaemia (Hb<11·5 g/dl), Fe (serum ferritin<15 µg/l), vitamin A (serum retinol<20 μg/dl) and Zn (serum Zn<65 μg/dl); and in the control group 10·5 %, 18·5 %, 2·5 % and 75·3 %, respectively. No significant estimated intervention effect was found. This randomized controlled trial showed that ALV were unable to improve serum retinol, serum ferritin or Hb if there are only mild deficiencies present. Furthermore, despite the low Zn status in the study population, ALV consumption did not improve serum Zn concentrations either.

Objective: The objective of this study was to determine the effect of incrementally higher doses of iron on the zinc protoporphyrin to heme ratio (ZnPP/H) and serum ferritin, and developmental outcomes in premature infants at risk for iron deficiency. Study Design: Infants eligible for this prospective, randomized blinded trial were between 27 and 30 completed weeks of gestation, older than 1 week of age and tolerating 100 ml kg −1 per day of enteral feedings. The control group was treated with 2.2 mg kg −1 per day of ferrous sulfate and the treatment group was treated with 3 to 12 mg kg −1 per day based on the ZnPP/H. Infants had follow-up with Bayley exams at 6 and 24 months corrected age. Statistical evaluation included Student’s t -tests and Fisher’s exact test. Result: Eighty-one infants were enrolled (40 control, 41 treatment). The average total iron dose for the control group was 2.2 mg kg −1 per day and for the treatment group was 10.4 mg kg −1 per day ( P <0.05). The ZnPP/H was not different between the two groups. The ferritin at the end of the study was decreased in the control group but remained stable in the treatment group (control initial 202±109 ng ml −1 , final 168±141 ng ml −1 ( P <0.05); treatment initial 187±131 ng ml −1 , final 176±118 ng ml −1 ). At 24 months, infants with psychomotor development index <85 occurred in 25% of the subjects in the control group and in 7% of subjects in the treatment group in a post hoc analysis (odds ratio, 4.2; 95% confidence interval, 0.7 to 43, P =0.07). Conclusion: The ZnPP/H may not be a reliable marker of iron status when used in a short period of time during iron supplementation. Infants treated with a lower dose of ferrous sulfate had a decreasing serum ferritin and a trend toward increased motor delays at 24 months.

Community‑acquired pneumonia (CAP) still carries a high long‑term mortality. Free protoporphyrin in erythrocytes (FPP) is a well-recognized biomarker of erythropoietic porphyrias. However, it also reflects impaired heme synthesis, disturbances in iron metabolism, and inflammation-driven erythropoietic alterations, mechanisms particularly relevant in pneumonia. This pilot study aimed to evaluate, for the first time, the prognostic value of FPP and zinc protoporphyrin (ZnPP), measured in acetone extracts of erythrocytes using fluorescence analysis with 405 nm excitation, in predicting 100-day mortality among 66 patients hospitalized with CAP. The area under the ROC curve for FPP fluorescence in predicting mortality was 0.793 (95% CI 0.657–0.928; p  < 0.0001), with 63% sensitivity and 94% specificity. Elevated FPP fluorescence was associated with a tenfold higher mortality risk and over fifteenfold greater odds of death, even after adjustment for age and the Charlson Comorbidity Index (CCI). A single fluorescence measurement at 632 nm (F632) demonstrated identical prognostic accuracy to spectral deconvolution-derived FPP intensity. Furthermore, significant correlations were observed between F632 or FPP fluorescence intensities and multiple clinical parameters reflecting disease severity, systemic inflammation, and erythropoietic stress. Given its accessibility and prognostic potential, prospective studies should further validate the method presented to guide individualized clinical management in CAP.

Iron deficiency anaemia (IDA) is uncommon in individuals with sickle cell disease (SCD) because of availability of an adequate iron source potentially from increased red cell turnover and from blood transfusions. Also, iron deficiency anaemia can often go unnoticed because the sickle cell disease patients are already anaemic. Iron deficiency in sickle cell patients may result in lowering the intracellular haemoglobin concentration and this may ameliorate sickling. The present study was undertaken to determine the prevalence of iron deficiency anaemia and the response of iron supplementation in sickle cell disorders in tribal population of the four States viz. Maharashtra, Gujarat, Orissa and Tamil Nadu. A total of 8434 individuals (7105 AA, 1267 AS and 62 SS) were tested for zinc protoporphyrin/haem (ZPP/H) ratio and haemoglobin levels. Twenty two sickle cell anaemia (SS), 47 sickle cell trait (AS) and 150 normal control (AA) individuals who were iron deficient, were given iron therapy for a period of 12 wk and the laboratory investigations were repeated at the 13th wk. Sixty seven per cent of subjects with sickle cell anaemia and 26 per cent with sickle cell trait had elevated ZPP/H ratios (>80 micromol/mol) as against 22.8 per cent of normal individuals. The elevated ZPP/H ratios is an indicator of microcytic anaemia of iron deficiency. Following iron therapy, an improvement in the Hb levels and ZPP/H ratios was observed in both sickle cell disorders and normal individual cases. This study suggests that iron deficiency anaemia is an important problem in Indian sickle cell anaemia patients and iron supplementation should be given only in proven cases of iron deficiency anaemia.

Protoporphyrin IX (PPIX) is a fluorescent metabolite in the heme biosynthesis pathway, and cancer cells accumulate it when 5-aminolevulinic acid (5-ALA), a precursor, is administered. In the U.S., 5-ALA is approved for visualizing high-grade gliomas (HGG) during fluorescence-guided surgery. PPIX is also central to experimental photodynamic and sonodynamic therapies for HGG. Additionally, PPIX measurement is critical for diagnosing and monitoring porphyrias. Despite the need for a sensitive and rapid bioanalytical method for accurate quantification of PPIX in biospecimens, no reliable validation of an LC–MS/MS method is available due to challenges related to its chemical instability, poor solubility, and tendency to aggregate. This work is the first to present a fully validated, sensitive, and rapid LC–MS/MS method for determining PPIX levels in human plasma, blood, and brain tumors. The method overcomes stability concerns, achieving a 3.5-min total run-time with a concentration range of 1–2000 nmol/L for plasma and tumors, and 10–2000 nmol/L for blood. Application of the method in a clinical trial, which assesses sonodynamic therapy for HGG patients, shows significant PPIX production, peaking in plasma and blood six hours post-5-ALA administration. In recurrent HGG patients, PPIX levels were notably higher in gadolinium-enhancing tumor regions compared to non-enhancing areas, indicating preferential accumulation in tumors.

Iron deficiency assessment in myeloproliferative neoplasms is complicated by chronic inflammation, disease-related anemia, and treatment-induced changes in iron handling. We retrospectively analyzed 445 patients with MPN, including 158 with polycythemia vera, 97 with essential thrombocythemia, 44 with prefibrotic primary myelofibrosis, 127 with overt myelofibrosis, and 19 with MPN-unclassifiable, and compared conventional iron parameters with a population-based SHIP cohort of 4420 participants. ZPP was measured in the MPN cohort using quantitative fluorescence spectroscopy. Compared with SHIP, MPN patients had lower hemoglobin and higher ferritin, and the physiological positive correlation between ferritin and hemoglobin observed in SHIP was reversed in MPN patients, with R  = 0.27, 95% CI 0.24 to 0.30, p  < 0.001 in SHIP versus R  = − 0.45, 95% CI − 0.52 to − 0.36, p  < 0.001 in MPN. Median ZPP in the MPN cohort was 43.0 µmol/mol heme, with 123 of 445 patients (27.6%) showing ZPP values > 65 µmol/mol heme and 59 of 445 patients (13.3%) showing values > 100 µmol/mol heme. ZPP differed significantly between MPN entities, with median values of 35.0 µmol/mol heme in ET, 49.4 µmol/mol heme in PV, 36.5 µmol/mol heme in pre-PMF, 54.7 µmol/mol heme in overt MF, and 46.0 µmol/mol heme in MPN-U ( p  < 0.001). ZPP correlated inversely with hemoglobin in MPN patients ( R  = − 0.26, 95% CI − 0.35 to − 0.16, p  < 0.001), whereas its association with ferritin was weak ( R  = − 0.10, 95% CI − 0.20 to − 0.00, p  = 0.045). Among 80 patients with CTCAE grade ≥ 2 anemia, 58 (73%) had ZPP values above the upper limit of normal. In exploratory multivariable analysis, PV, overt MF, and phlebotomy were independently associated with higher ZPP, whereas CRP and time from diagnosis were not. In JAK2-mutated PV versus ET, ZPP was significantly higher in PV (48.5 versus 37.5 µmol/mol heme, p  = 0.010), complementing lower transferrin saturation and higher JAK2 variant allele frequency. These data indicate that ZPP provides a functional readout of iron-restricted heme synthesis in MPN, adds information beyond ferritin and transferrin saturation, and may refine diagnostic reassessment and therapeutic monitoring, particularly in PV and overt MF.

Specific recommendations for anemic individuals consist in increasing red meat intake, but the population at large is advised to reduce consumption of red meat and increase that of fish, in order to prevent the risk of developing cardiovascular disease. This study aimed to determine the effects of consuming an oily fish compared to a red meat diet on iron status in women with low iron stores. The study was designed attending the Consolidated Standards of Reporting Trials (CONSORT) statement guidelines. It was a randomised crossover dietary intervention study of two 8-week periods. Twenty-five young women with low iron stores completed the study. Two diets containing a total of 8 portions of fish, meat and poultry per week were designed differing only in their oily fish or red meat content (5 portions per week). At the beginning and the end of each period blood samples were taken and hemoglobin, hematocrit, serum ferritin, serum iron, serum transferrin, serum transferrin receptor-2 and the Zn-protoporphyrin/free-protoporphyrin ratio were determined. Food intake and body weight were monitored. During the oily fish diet, PUFA intake was significantly higher (p=0.010) and iron intake lower (mean±SD, 11.5±3.4 mg/day vs . 13.9±0.1 mg/day, p=0.008), both diets providing lower mean daily iron intake than recommended for menstruating women. Although there were no significant differences after 16 weeks, serum ferritin moderately decreased and soluble transferrin receptor increased with the oily fish, while changes with the red meat diet were the opposite. In conclusion, an oily fish diet compared to a red meat diet does not decrease iron status after 8 weeks in iron deficient women.

OBJECTIVE: Iron deficiency has been reported to elevate A1C levels apart from glycemia. We examined the influence of iron deficiency on A1C distribution among adults without diabetes. RESEARCH DESIGN AND METHODS: Participants included adults without self-reported diabetes or chronic kidney disease in the National Health and Nutrition Examination Survey 1999-2006 who were aged ≥18 years of age and had complete blood counts, iron studies, and A1C levels. Iron deficiency was defined as at least two abnormalities including free erythrocyte protoporphyrin >70 μg/dl erythrocytes, transferrin saturation <16%, or serum ferritin [less-than or equal to]15 μg/l. Anemia was defined as hemoglobin <13.5 g/dl in men and <12.0 g/dl in women. RESULTS: Among women (n = 6,666), 13.7% had iron deficiency and 4.0% had iron deficiency anemia. Whereas 316 women with iron deficiency had A1C ≥5.5%, only 32 women with iron deficiency had A1C ≥6.5%. Among men (n = 3,869), only 13 had iron deficiency and A1C ≥5.5%, and only 1 had iron deficiency and A1C ≥6.5%. Among women, iron deficiency was associated with a greater odds of A1C ≥5.5% (odds ratio 1.39 [95% CI 1.11-1.73]) after adjustment for age, race/ethnicity, and waist circumference but not with a greater odds of A1C ≥6.5% (0.79 [0.33-1.85]). CONCLUSIONS: Iron deficiency is common among women and is associated with shifts in A1C distribution from <5.5 to ≥5.5%. Further research is needed to examine whether iron deficiency is associated with shifts at higher A1C levels.

Coronavirus disease (COVID-19) has a severe impact on all aspects of patient care. Among the numerous biomarkers of potential validity for diagnostic and clinical management of COVID-19 are biomarkers at the interface of iron metabolism and inflammation. The follow-up study included 54 hospitalized patients with laboratory-confirmed COVID-19 with a moderate and severe/critical form of the disease. Iron deficiency specific biomarkers such as iron, ferritin, transferrin receptor, hepcidin, and zinc protoporphyrin (ZnPP) as well as relevant markers of inflammation were evaluated twice: in the first five days when the patient was admitted to the hospital and during five to 15 days; and their validity to diagnose iron deficiency was further assessed. The regression and Receiver Operating Characteristics (ROC) analyses were performed to evaluate the prognosis and determine the probability for predicting the severity of the disease in the first five days of COVID-19. Based on hemoglobin values, anemia was observed in 21 of 54 patients. Of all iron deficiency anemia-related markers, only ZnPP was significantly elevated (P<0.001) in the anemic group. When patients were grouped according to the severity of disease, slight differences in hemoglobin or other anemia-related parameters could be observed. However, the levels of ZnPP were significantly increased in the severely ill group of patients. The ratio of ZnPP to lymphocyte count (ZnPP/L) had a discrimination power stronger than the neutrophil to lymphocyte count ratio (N/L) to determine disease severity. Additionally, only two markers were independently associated with the severity of COVID-19 in logistic regression analysis; D-dimer (OR (5.606)(95% CI 1.019-30.867)) and ZnPP/L ratio (OR (74.313) (95% CI 1.081-5108.103)). For the first time ZnPP in COVID-19 patients were reported in this study. Among all iron-related markers tested, ZnPP was the only one that was associated with anemia as based on hemoglobin. The increase in ZnPP might indicate that the underlying cause of anemia in COVID-19 patients is not only due to the inflammation but also of nutritional origin. Additionally, the ZnPP/L ratio might be a valid prognostic marker for the severity of COVID-19.