Iron Fortification Practices and Implications for Iron Addition to Salt.

This introductory article provides an in-depth technical background for iron fortification, and thus introduces a series of articles in this supplement designed to present the current evidence on the fortification of salt with both iodine and iron, that is, double-fortified salt (DFS). This article reviews our current knowledge of the causes and consequences of iron deficiency and anemia and then, with the aim of assisting the comparison between DFS and other common iron-fortified staple foods, discusses the factors influencing the efficacy of iron-fortified foods. This includes the dietary and physiological factors influencing iron absorption; the choice of an iron compound and the fortification technology that will ensure the necessary iron absorption with no sensory changes; encapsulation of iron fortification compounds to prevent unacceptable sensory changes; the addition of iron absorption enhancers; the estimation of the iron fortification level for each vehicle based on iron requirements and consumption patterns; and the iron status biomarkers that are needed to demonstrate improved iron status in populations regularly consuming the iron-fortified food. The supplement is designed to provide a summary of evidence to date that can help advise policy makers considering DFS as an intervention to address the difficult public health issue of iron deficiency anemia, while at the same time using DFS to target iodine deficiency.

Key Considerations for Policymakers-Iodized Salt as a Vehicle for Iron Fortification: Current Evidence, Challenges, and Knowledge Gaps.

Could DFS help prevent iron deficiency and anemia? Studies in controlled settings (efficacy) demonstrate that double-fortified salt (DFS; iron added to iodized salt) reduces the prevalence of anemia and iron deficiency anemia. Studies in program settings (effectiveness) are limited and reported differing levels of DFS coverage, resulting in mixed evidence of impact on anemia. What iron formulations are available and how do they affect iodized salt? Ferrous sulfate and encapsulated ferrous fumarate (both with various enhancers and/or coating materials) are the main iron formulations currently in use for DFS. Adding iron to iodized salt may lead to adverse changes in the product, specifically discoloration and losses in iodine content. These changes are greatest when the iodized salt used in DFS production is of low quality (e.g., contain impurities, has high moisture, and is of large crystal size). DFS requires iodized salt of the highest quality and a high-quality iron formulation in order to minimize adverse sensory changes and iodine losses. Appropriate packaging of iodized salt is also important to prevent losses. What is known about the minimum requirements to manufacture DFS? DFS producers must use high-quality refined iodized salt meeting the minimum standards for DFS production (which is higher than standards for salt intended for iodization alone), and an iron formulation for which there are rigid quality-assurance measures to ensure consistent quality and blending techniques. The actual proportion of iodized salt meeting the stringent requirements necessary for DFS production is unclear, but likely to be low in many countries, especially those with fragmented salt industries and a low proportion of industrially produced salt. What are the financial implications of adding iron to iodized salt? As a result of higher input costs both for input salt and the iron compound, DFS is more expensive to produce than iodized salt and thus has a higher production cost. Various grades of iodized salt are produced and consumed in different sectors of the market. Experience in India indicates that, on average, producing DFS costs 31-40 US dollars/metric ton or 0.03-0.04 US dollars/kg more than high-quality refined iodized salt. The exact impact of this production-level cost difference on profit margins and consumer price is specific to the conditions of different salt markets. Factors such as transport costs, customary wholesale and retail mark-ups, and taxes all vary greatly and need to be assessed on a case by case basis. Is DFS in alignment with salt-reduction efforts? The WHO has long recognized that salt iodization is an important public health intervention to achieve optimal iodine nutrition and is compatible with salt-reduction goals. Fortification of salt (with any nutrient) should not be used to justify or encourage an increase in salt intake to the public. Any effort to expand salt fortification to other nutrients should be done in close consultation with WHO and those working on salt reduction. What has been the experience with DFS delivery under different platforms? To date, DFS has been introduced into the retail market and in social safety net (primarily in India) programs, but sensory changes in DFS have been raised as concerns. The higher price for DFS has limited expansion in the retail market. In social safety net programs where the cost of DFS is subsidized for beneficiaries, programs must consider long-term resourcing for sustainability. Overall: The optimal production and delivery of DFS are still under development, as many challenges need to be overcome. There is a beneficial impact on hemoglobin in efficacy trials. Thus, if those conditions can be replicated in programs or the technology can be adapted to better fit current production and delivery realities, DFS may provide an effective contribution in countries that need additional food-fortification vehicles to improve iron intake.

Safety and efficacy of intravenous iron administration for uterine bleeding or postpartum anaemia: a narrative review.

The management of iron deficiency anaemia (IDA) consists of oral or intravenous administration of iron supplements. The aim of this narrative review is to summarise information regarding the treatment of IDA in women who have postpartum anaemia or uterine bleeding with intravenous (IV) or oral iron supplements. Fourteen randomised control studies comparing IV to oral iron treatment for IDA in 2913 women with uterine bleeding or postpartum haemorrhage are included. All reviewed studies suggest that IV iron administration is important in treating the IDA in such women and in improving their physical performance and quality of life. Comparisons among intravenous iron supplements show advantages of ferric carboxymaltose over others in time of reaching desired haemoglobin and ferritin values and in adverse reactions. Despite the limitation that the above evidence emerges from not systematically collected data, our review highlights that new forms of IV iron supplements seem safe and efficient in treating IDA.

Mobility and chemical fate of arsenic and antimony in water and sediments of Sarouq River catchment, Takab geothermal field, northwest Iran.

Arsenic (As) and antimony (Sb) concentrations in water and sediments were determined along flow paths in the Sarouq River, Zarshuran and Agh Darreh streams. The results indicate high As and Sb concentrations in water and sediment samples. Raman spectroscopy shows hematite (α-Fe2O3), goethite [α-FeO(OH)] and lepidocrocite [γ-FeO(OH)] in sediment samples. Calculated saturation indices (SI) indicate oversaturation with respect to amorphous Fe(OH)3 for all samples, but undersaturation with respect to Al and Mn mineral and amorphous phases. Therefore, ferric oxides and hydroxides are assumed to be principal mineral phases for arsenic and antimony attenuation by adsorption/co-precipitation processes. The considerable difference between As and Sb concentration in sediment is due to strong adsorption of As(V) into the solid phase. Also, lower affinity of Sb(V) for mineral surfaces suggests a greater potential for aqueous transport. The adsorption of arsenic and antimony was examined using the Freundlich adsorption isotherm to determine their distribution model in water-sediment system and its compatibility with the existing theoretical model. The results showed that the adsorption behavior of both elements complies with the Freundlich adsorption isotherm.

Iron dosing in kidney disease: inconsistency of evidence and clinical practice.

The management of anemia in patients with chronic kidney disease (CKD) is difficult. The availability of erythropoiesis-stimulating agents (ESAs) has increased treatment options for previously transfusion-requiring patients, but the recent evidence of ESA side effects has prompted the search for complementary or alternative approaches. Next to ESA, parenteral iron supplementation is the second main form of anemia treatment. However, as of now, no systematic approach has been proposed to balance the concurrent administration of both agents according to individual patient's needs. Furthermore, the potential risks of excessive iron dosing remain a topic of controversy. How, when and whether to monitor CKD patients for potential iron overload remain to be elucidated. This review addresses the question of risk and benefit of iron administration in CKD, highlights the evidence supporting current practice, provides an overview of standard and potential new markers of iron status and outlines a new pharmacometric approach to physiologically compatible individualized dosing of ESA and iron in CKD patients.

Effect of administration of antihelminthics for soil-transmitted helminths during pregnancy.

BACKGROUND: Helminthiasis is infestation of the human body with parasitic worms and it is estimated to affect 44 million pregnancies, globally, each year. Intestinal helminthiasis (hook worm) is associated with blood loss and decreased supply of nutrients for erythropoiesis, resulting in iron-deficiency anaemia. Over 50% of the pregnant women in low- and middle-income countries suffer from iron-deficiency anaemia. Though iron-deficiency anaemia is multifactorial, hook worm infestation is a major contributory cause in women of reproductive age in endemic areas. Antihelminthics are highly efficacious in treating hook worm but evidence of their beneficial effect and safety, when given during pregnancy, has not been established. OBJECTIVES: To determine the effects of administration of antihelminthics for soil-transmitted helminths during the second or third trimester of pregnancy on maternal anaemia and pregnancy outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015) and reference lists of retrieved studies. SELECTION CRITERIA: All prospective randomised controlled trials evaluating the effect of administration of antihelminthics during the second or third trimester of pregnancy. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS: A total of four trials including 4265 participants were included in this review. Two of the included trials were of high quality, while two were of relatively low quality with limitations and biases in design and conduct.Analysis showed that administration of a single dose of antihelminthic in the second trimester of pregnancy is not associated with any impact on maternal anaemia in the third trimester (risk ratio (RR) 0.94; 95% confidence interval (CI) 0.81 to 1.10; 3266 participants; four trials; low quality evidence). Subgroup analysis on the basis of co-interventions other than antihelminthic, which included iron supplementation given to both groups was also not associated with any impact on maternal anaemia (RR 0.76; 95% CI 0.47 to 1.23; 1290 participants; three trials; moderate quality evidence). No impact was found for the outcomes of low birthweight (RR 1.00; 95% CI 0.79 to 1.27; 3255 participants; three trials; moderate quality evidence), preterm birth (RR 0.88; 95% CI 0.43 to 1.78; 1318 participants; two trials, moderate quality evidence) and perinatal mortality (RR 1.09; 95% CI 0.71 to 1.67; 3385 participants; two trials; moderate quality evidence). None of the included studies reported impact on infant survival at six months of age. AUTHORS' CONCLUSIONS: The evidence to date is insufficient to recommend use of antihelminthic for pregnant women after the first trimester of pregnancy. More well-designed, large scale randomised controlled trials are needed to establish the benefit of antihelminthic treatment during pregnancy.

Arsenic removal using natural biomaterial-based sorbents.

Arsenic contamination of water is a major problem worldwide. A possible solution can be approached through developing new sorbents based on cost-effective and environmentally friendly natural biomaterials. We have developed new sorbents based on biomaterial impregnation with iron oxyhydroxide. In this study, raw peat material, iron-modified peat, iron-modified biomass (shingles, straw, sands, cane and moss) as well as iron humate were used for the removal of arsenate from contaminated water. The highest sorption capacity was observed in iron-modified peat, and kinetic studies indicated that the amount of arsenic sorbed on this material exceeds 90 % in 5 h. Arsenate sorption on iron-modified peat is characterised by the pseudo-second-order mechanism. The results of arsenic sorption in the presence of competing substances indicated that sulphate, nitrate, chloride and tartrate anions have practically no influence on As(V) sorption onto Fe-modified peat, whereas the presence of phosphate ions and humic acid significantly lowers the arsenic removal efficiency.

Pot evaluation of synthetic nanosiderite for the prevention of iron chlorosis.

BACKGROUND: Iron chlorosis is a problem that affects crops grown on calcareous soils. In this work, we assessed the effectiveness of nanosized siderite (FeCO3) to prevent iron chlorosis, the underlying hypothesis being that the oxidation products of siderite in soil are poorly crystalline, and hence plant-available, iron oxides. RESULTS: Nanosized siderite was prepared by mixing FeSO4 and K2CO3 solutions, either pure or doped with phosphate (siderite SID and SIDP, respectively). The average specific surface area was ∼140 m² g⁻¹ for SID and ∼220 m² g⁻¹ for SIDP. Experimental oxidation in a calcite suspension yielded goethite for SID and a mixture of lepidocrocite and goethite for SIDP. Two pot experiments in which a SID or SIDP suspension was applied to a calcareous soil at a rate of ∼2 g Fe kg⁻¹ showed nanosiderite to prevent iron chlorosis in chickpea. In a pot experiment with five successive crops, one initial application of ∼0.7 g Fe kg⁻¹ soil in the form of SID or SIDP was as effective as FeEDDHA in preventing Fe chlorosis. The residual effect of nanosiderite when applied to the first crop alone clearly exceeded that of FeEDDHA. CONCLUSION: Nanosiderite suspensions applied at rates of ∼0.7 g Fe kg⁻¹ soil were highly effective in preventing iron chlorosis and have a great residual effect.

"Functional food" for acceleration of growth in short children born small for gestational age.

OBJECTIVE: To assess the effect of nutritional supplementation on growth in short children born small for gestational age (SGA). PATIENTS: Fifty four short but otherwise healthy children (26 boys), 6.4 +/- 1.8 years of age, were referred for growth retardation. METHODS: Following a 6 month observation period the participants were randomly allocated to receive growth hormone therapy (GH) 1.26 IU/kg/day (0.042 mg/kg/day) or nutritional program (NUT) or passive observation (OBS). Patients in the nutritional program received 10 mg/day iron, 11 mg zinc-three times a week and 10000 IU/week of vitamin A. The following parameters were obtained 3 monthly: height, weight, dietary intake and serum IGF-1. RESULTS: Six months of nutritional supplement induced growth acceleration somewhat lower than that seen in the growth hormone treated children, but significantly greater than noted in the observation group (OBS 4.6 +/- 1.3, NUT 7.9 +/- 1.7, GH 9.1 +/- 1.8 cm/yr, P<0.001). CONCLUSIONS: Six months of vitamin A, iron and zinc supplementation induces growth acceleration in short children born SGA with subnormal nutrients intake similar to growth hormone therapy.

Iron replacement therapy: assessing today's options to prepare for bundling.

New Medicare rules that set forth a revised reimbursement scheme for dialysis services will introduce significant changes for providers. The new rules will abandon the current system of separate reimbursement for drugs associated with the hemodialysis services, including erythropoiesis-stimulating agents (ESAs) and intravenous (i.v.) iron. These rules will "bundle" these agents and related laboratory tests into a single, case-mix adjusted composite rate. These bundling rules will be gradually phased-in, beginning in 2011. One of the primary effects of the new reimbursement policy will be to discourage over-utilization of ESAs that comprise nearly one-quarter of hemodialysis-related Medicare expenditures. As a result, hemodialysis providers will be challenged to make hemodialysis services more cost-effective, while ensuring that Medicare clinical performance measures are met and patient care is not compromised. i.v. iron has an integral role in making anemia care more cost-effective in the hemodialysis setting by improving measures of iron-deficiency anemia, maintaining necessary iron balance, and reducing the utilization of ESAs. This review discusses the potential benefits of i.v. iron in the management of hemodialysis patients with iron-deficiency anemia. It also focuses on the available i.v. iron options, particularly the established efficacy and safety profile of i.v. iron dextran compared with other i.v. iron formulations as well as cost considerations.

A randomized controlled trial comparing oral and intravenous iron supplementation after Roux-en-Y gastric bypass surgery.

BACKGROUND: Iron deficiency (ID) is one of the most common postoperative deficiencies that may develop after Roux-en-Y gastric bypass (RYGB). The optimal mode of treatment is uncertain. AIM: To compare the efficacy of oral ferrous fumarate (FF), oral ferrous gluconate (FG), and a single intravenous infusion of ferric carboxymaltose (FCM) in women with ID after RYGB. METHODS: Multicenter randomized controlled trial including 120 women with a serum ferritin <20 µg/l during follow-up after RYGB. They were randomized into three groups: 41 patients were treated with FF 200 mg three times a day (total daily dose: 195 mg elemental iron), 39 received FG 695 mg twice a day (total daily dose: 160 mg elemental iron) for three months, and 39 patients were treated with a single intravenous dose of FCM (1000 mg elemental iron). Serum ferritin levels were measured at six weeks, and three, six and twelve months after the start of supplementation. RESULTS: At three months, persistence of ID was observed in 29.4% and 42.4% of the patients treated with FF and FG, respectively, but in none of those treated with FCM (p < 0.001). Over the next nine months, recurrence of ID was observed in 56.5% of patients treated with FF, in 52.9% treated with FG, and in 27.8% of those treated with FCM. Adverse effects were most common during oral treatment. CONCLUSION: In women developing ID after RYGB, a single dose of intravenous FCM is more effective and better tolerated than the standard treatment with either FF or FG. CLINICAL TRIAL REGISTRY NUMBER AND WEBSITE: The study was registered at clinicaltrials.gov under number NCT02271997.

Hemoglobin control, ESA resistance, and regular low-dose IV iron therapy: a review of the evidence.

Anemia management in hemodialysis patients has progressed following the introduction of erythropoiesis-stimulating agents (ESAs) and intravenous (IV) iron. However, maintaining a stable hemoglobin (Hb) level can be challenging. Patient comorbidities and variable dosage administrations of ESA therapy can lead to great variability in Hb concentrations over time. Fluctuating Hb levels is associated with increased complications. This article reviews factors that affect Hb control, with a focus on management practices (e.g., regular low-dose administration of IV iron) that can help improve anemia management.

Effect of administration of antihelminthics for soil transmitted helminths during pregnancy.

BACKGROUND: Helminthiasis is infestation of the human body with parasitic worms and it is estimated to affect 44 million pregnancies, globally, each year. Intestinal helminthiasis is associated with blood loss and decreased supply of nutrients for erythropoiesis, resulting in iron deficiency anaemia. Over 50% of the pregnant women in low- and middle-income countries suffer from iron deficiency anaemia. Though iron deficiency anaemia is multifactorial, hook worm infestation is a major contributory cause in women of reproductive age in endemic areas. Antihelminthics are highly efficacious in treating hook worm but evidence of their beneficial effect and safety, when given during pregnancy, has not been established. OBJECTIVES: To determine the effects of administration of antihelminthics for soil transmitted helminths during the second or third trimester of pregnancy on maternal anaemia and pregnancy outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2008). SELECTION CRITERIA: All prospective randomised controlled trials evaluating the effect of administration of antihelminthics during the second or third trimester of pregnancy. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted the data. MAIN RESULTS: Three studies (1329 women) were included in this review. Analysis showed that administration of a single dose of antihelminth in the second trimester of pregnancy is not associated with any impact on maternal anaemia in the third trimester (risk ratio (RR) 0.90; 95% confidence interval (CI) 0.68 to 1.19, random effects (2 studies, n = 1075)). Subgroup analysis on the basis of co-interventions other than antihelminthics which included iron supplementation given to both groups in the study by Larocque et al, and a subset of the study by Torlesse et al, showed that a single dose of antihelminth along with iron supplementation throughout the second and third trimester of pregnancy was not associated with any impact on maternal anaemia in the third trimester as compared to iron supplementation alone (RR 0.76; 95% CI 0.39 to 1.45, random-effects (2 studies, n = 1017)). No impact was found for the outcomes of low birthweight (RR 0.94; 95% CI 0.61 to 1.42 (1study; n = 950)), perinatal mortality (RR 1.10; 95% CI 0.55 to 2.22 (2 studies, n = 1089)) and preterm birth (RR 0.85; 95% CI 0.38 to 1.87 (1 study, n = 984)). Impact on infant survival at six months of age could not be evaluated because no data were available. AUTHORS' CONCLUSIONS: The evidence to date is insufficient to recommend use of antihelminthics for pregnant women after the first trimester of pregnancy. More well-designed, large scale randomised controlled trials are needed to establish the benefit of antihelminthic treatment during pregnancy.

Structural characteristics of humic-like acid from microbial utilization of lignin involving different mineral types.

This paper determines the impact of two clay minerals (kaolinite and montmorillonite) and three oxides (goethite, δ-MnO2, and bayerite) on the elemental composition and FTIR spectra of humic-like acid (HLA) extracted from microbial-mineral residue formed from the microbial utilization of lignin in liquid shake flask cultivation. Goethite, bayerite, and δ-MnO2 showed higher enrichment capabilities of C and O + S in the HLA than kaolinite and montmorillonite. Goethite showed the highest retention of organic C, followed by bayerite, but kaolinite exhibited the least exchangeability. Kaolinite and montmorillonite enhanced microbial consumption of N, resulting in the absence of N in HLA. A few aliphatic fractions were preferentially gathered on the surfaces of kaolinite and montmorillonite, making the H/C ratios of HLA from the clay mineral treatments higher than those of HLA from the oxide treatments. δ-MnO2 was considered the most effective catalyst for abiotic humification, and goethite and bayerite ranked second and third in this regard. This trend was proportional to their specific surface areas (SSAs). However, comparing the effects of different treatments on the promotion of HLA condensation by relying solely on the SSA of minerals was not sufficient, and other influencing mechanisms had to be considered as well. Additionally, Si-O-Al and Si-O of kaolinite participated in HLA formation, and Si-OH, Si-O, and Si-O-Al of montmorillonite also contributed to this biological process. Fe-O and phenolic -OH of goethite, Mn-O of δ-MnO2, and Al-O of bayerite were all involved in HLA formation through ligand exchange and cation bridges. Lignin was better protected from microbial decomposition by the kaolinite, bayerite, and δ-MnO2 treatments, which caused lignin-like humus (HS) formation. Under the treatments of δ-MnO2, goethite, and bayerite, HLA showed a greater degree of condensation compared to HLA precipitated by kaolinite and montmorillonite. Contributions from Si-O, and Si-O-Al of clay minerals, and Fe-O, Mn-O, and Al-O of oxides were the mechanisms by which minerals catalyzed the formation of HS from lignin.

Common misconceptions in the diagnosis and management of anemia in inflammatory bowel disease.

Anemia is the most common systemic complication of inflammatory bowel disease (IBD); so common that it is almost invariably not investigated and rarely treated. Several misconceptions are the reason for these clinical errors, and our goal will be to review them. The most common misconceptions are: anemia is uncommon in IBD; iron deficiency is also uncommon; just by treating the intestinal disease, anemia will be corrected; iron deficiency is the only cause for anemia in IBD; ferritin is an accurate parameter for the diagnosis of iron deficiency in IBD; the impact of anemia on the quality of life of IBD patients is limited; iron supplementation is rarely needed in IBD; high-dose oral iron solves the problem of iron malabsorption in IBD; intravenous (IV) iron is dangerous and of no proven benefit in IBD; IV iron is useful only for severe anemia; and erythropoietin has no role in the treatment of IBD anemia. These misconceptions are not evidence-based. On the contrary, there is enough evidence to support the following statements: (a) anemia is very common in IBD, (b) anemia should be investigated with care because many factors can be responsible, (c) treatment of anemia results in clear improvement in the objective parameters of well-being, especially in the quality of life, (d) IV iron is safe and effective in the treatment of iron deficiency anemia in IBD patients, and (e) erythropoietin is useful in a subset of patients with refractory anemia. Anemia diagnosis and treatment must not be neglected in IBD patients, and several misconceptions should be promptly abandoned.

Reducing phosphorus (P) losses from drained agricultural fields with iron coated sand (- glauconite) filters.

In north-west Europe, agricultural diffuse P losses are a major cause of eutrophication problems in surface waters. Given that the Water Framework Directive (WFD) demands fast water quality improvements and most of the actual P mitigation strategies tend to work on the long run, new short-term mitigation measures are urgently needed. We here report on the entire process of developing small scale field filters to remove P at the end of tile drains, starting from the screening of potential P sorbing materials (PSM): iron coated sand (ICS), acid pre-treated natural minerals (biotite, glauconite and olivine) and bauxite. Initial batch (ad)sorption experiments revealed following order in both, P sorption capacity and speed: ICS > bauxite > glauconite > olivine = biotite. Because of the presence of significant amounts of lead and/or nickel, we excluded bauxite and olivine from further experiments. Subsequent lab scale flow through systems were conducted with P filters containing mixtures of ICS and glauconite (100/0, 90/10, 80/20, 70/30 and 60/40%, respectively, on weight basis). We found a significant relationship between Ksat and the filter mixtures particle size distribution and bulk density, and a significant effect of the filter mixture composition on P removal efficiency and stability of Ksat. During the 10 week field trials, the pure ICS filters were capable of processing all drainage discharge rates (up to 6 m3 day-1) with a P removal efficiency of ≥74%. The 90/10 ICS/glauconite filters could process up to 4 m3 water day-1 with a P removal efficiency of 57%. As saturated ICS filters can easily be replaced and recycled for other applications, this is a promising sustainable technique to drastically cut back diffuse P losses and to tremendously improve surface water quality in the short term.

Treatment of Posttransplantation Anemia.

Kidney transplantation represents a renal replacement therapy for end-stage renal failure, with outcomes improving from year to year. With the improved survival prognosis, treatment of complications of chronic kidney disease after transplantation is becoming increasingly important. In particular, posttransplantation anemia (PTA) is often protracted, which could be related to a variety of factors, including the renal function status, graft rejection episodes, and infectious causes. PTA occurs in about 30-40% of transplant recipients, and is known to affect the function of the transplanted kidney as well as patient survival. Early PTA is associated with a risk of death and cardiovascular disorders, however, during this phase, priority is given to the appropriate maintenance of immunosuppression rather than to the treatment of anemia. Maintenance-phase PTA exerts a strong influence on the survival, prognosis of the transplanted kidney, quality of life, etc. Unlike the disease state and treatment of usual renal anemia, it has been suggested that PTA may possibly reflect the functional state of the transplanted kidney. Therefore, it has been suggested that proper renal function may be maintained by ensuring a normal hemoglobin level in kidney transplant recipients. Proper management of PTA could be expected to be associated with an improved prognosis of the transplanted kidney and improved patient survival in kidney transplant recipients. It is advisable to provide appropriate treatment by setting target levels in accordance with the dialysis vintage, primary disease, cardiovascular complications, and kidney transplant function and delineation of the transplant recipient characteristics.

Acute iron poisoning in adult female.

We report a case of a 27-year-old female with anemia, treated with high dose oral and parenteral iron therapy (within 20 days, the patient received a total dose of 4 g Fe+2 orally and 700 mg Fe+2 iv and im), and developed clinical manifestations characteristic of acute iron poisoning. Initial gastrointestinal symptoms and hypotension were followed by signs of mitochondrial toxicity: high leucocytosis, shock, multi-organ failure and disseminated intravascular coagulation. We discuss the difficulties in diagnosing acute iron poisoning. The initial low total iron blood capacity and high ferritin level, as well as the typical sequence of symptoms, supported the diagnosis. The patient avoided fatal consequences, probably due to the administration of iron doses over an extended period of time. However, cumulative effects led to the apparent iron toxicity. After 2 weeks of treatment, the patient was discharged from hospital in good condition. Human & Experimental Toxicology (2007) 26, 663-666.