SSRG International Journal of Medical Science ( SSRG-IJMS ) – Volume 6 Issue 12 – Dec 2019

Assessment of Iron Deficiency Anemia

Among Patients Attending Kigali University
Teaching Hospital
Izere Cedrick 1*, Dr. Lakshmi Agarwal2, Dr. Mucumbitsi Joseph3
*1
Research scholar, Department of Medical Laboratory Technology, Faculty of Health Sciences, Career Point
University, Kota, Rajasthan state, India.
2
Assistant professor, Department of Medical Laboratory Technology, Faculty of Health Sciences, Career Point
University, Kota, Rajasthan state, India.
3
Lecturer, Department of Biomedical Laboratory Sciences, Faculty of Applied Fundamental Sciences, INES-
Ruhengeri-Institute of Applied Sciences, Ruhengeri, Rwanda.

Abstract Conclusion: The factors associated with IDA that are

presented here should be taken into consideration in
Anemia in general is characterized by a decrease in planning effective measures for its control.
number of red blood cells or less the normal quantity
of haemoglobin. Iron deficiency is defined as a Keywords: Blood Count, Blood Smear, Iron
condition in which there are no mobilization iron Deficiency Anaemia.
stores, resulting from a long-term negative iron
balance and leading to a compromised supply of iron I. INTRODUCTION
to the tissue.
Iron deficiency anemia (IDA) is the most common
Objectives: The objective of this study was to assess micronutrient disorder in the world, affecting the
iron deficiency anemia and to estimate its prevalence health and socio-economic wellbeing of millions of
compared to other types of anemia in patients men, women, and children. It is highly prevalent in
attending Kigali University Teaching Hospital from developing countries but also remains a problem in
1st September to 31st October 2017. developed countries where other forms of
malnutrition have already been virtually eliminated.
Methods: This was a cross section study on data It is common in children under five years in eastern
from the clinical laboratory of this hospital located in Africa. [1] IDA result from a long term negative iron
Kigali city, with a representative sample of 68 balance, culminating in decreased or exhausted iron
patients from urban and rural areas. Anemia was stores. Iron, a component of every living cell, is
diagnosed by means of hemoglobin assays (from intrinsically involved in numerous biochemical
CBC test). Further tests were performed for reactions in the body and is associated with oxygen
diagnosis of iron deficiency anemia (IDA) though red transport and storage, energy production, DNA
blood cells indices (MCV, MCH and MCHC), synthesis, and electron transport. [2] It is a
peripheral blood smear (PBS), reticulocytes count pathological process in which hemoglobin (Hb)
and ferritin test. concentration in red cells is abnormally low,
considering variations as to age, gender, sea-level
altitude, as a result of several situations such as
Results: The results showed that 33 patients had iron chronic infections, hereditary blood conditions,
deficiency anemia with a prevalence of 51.5%.
deficiency of one or more essential nutrients that are
Among 33 IDA patients, 32 were female whereas 1 necessary for the formation of hemoglobin. Therefore,
was male (97% and 3% respectively). All three red there is no doubt that iron deficiency is the cause of
cell indices, and haematocrits count were reduced
most anemias. [3] According to a recent region and
with the mean and standard deviation of 68.98±6.79,
country summary, iron deficiency anemia is
20.73±3.00, 29.98±2.11 and 68.98±6.79 respectively; widespread among children under five years of age.
all PBS showed anisocytosis sometimes poikilocytosis
Children in south Asia and Africa are particularly
with hypochromic RBCs. Thrombocytosis was
affected, with over half of preschool aged children
observed in most of IDA patients. IDA was
having IDA in most countries. The prevalence of
significantly associated with age and sex with the P- IDA ranges from 22 to 66% worlwide. [4] Iron
value of 0.006 and 0.016 respectively. deficiency is considered to be one of most prevalent
forms of malnutrition. Iron deficiency is considered
to contribute to death and disability as a risk factor

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 SSRG International Journal of Medical Science ( SSRG-IJMS ) – Volume 6 Issue 12 – Dec 2019

for maternal and perinatal mortality, and also through Analyzer area and placed on the roll mixer, for at
its direct contributions to cognitive impairment, least five minutes. Patients’ blood were then run
decreased work productivity, and death from severe through the Hematology Analyzer. It means, all
anemia. However, even more important than anemia, information of the patient are written in a machine
itself, is the indication that the more common ID connected to the analyzer and after click OK and
without anemia may also adversely affect long-term dispose the sample to the needle of a sysmex and
neurodevelopment and behaviour and that some of press the button behind the needle, then the sample is
these effects may be irreversible [5] Few studies have aspirated by a needle. After the specimens have been
been conducted in Rwanda and their results are run, the results are printed out from a printer
limited to a group of persons or a specific region and connected to the analyzer. The results recorded were
they lack the factors that can be involved in such type hemoglobin, RBC, MCV, MCH, MCHC, Hct and
of anemia. According to this, there is an urgent need platelets.
to develop effective and sustainable interventions to
control iron deficiency anemia. Reticulocyte count
MATERIAL & METHODS Whole blood that is anticoagulated with EDTA were
used for this test. 5 drops of cresyl blue solution were
Study design put in a test tube labeled with a patient name and ID,
and 5 drops of well mixed EDTA anticoagulated
The study was a cross-sectional study which was blood were added in the labeled test tube. The
most appropriate to assess iron deficiency anemia. It contents were mixed by gently shaking and incubated
was concerned with patients whom anemia was at room temperature for 10 minutes. The smears were
suspected in internal medicine department and out- done using a wedge smear technique. The slides were
patient department for confirming if they present IDA. labeled and allowed to air dry. Reticulocytes were
This was done from 1st September to 31st October visualized under microscope on an oil immersion
2017. objective. This stain causes the ribosomal and
residual RNA to precipitate with the few remaining
Sampling area and study population mitochondria and ferritin mosses in living young
erythrocytes to form microscopically visible dark-
The target population in this research was all patients blue dusters and filaments (reticulum). An
with anemia attended KUTH from 1st September to erythrocyte still possessing RNA is referred to as a
31st October 2017. Data were collected on field reticulocyte.
during the research period, and it was conducted on
64 patients with anemia. For IDA patients, essential
tests were performed. Peripheral blood smear (PBS)

Sample collection PBS are made by placing a drop of blood on one end
of a slide, by the help of another slide to disperse the
blood over the slide's length. The aim is to get a
Patient samples were collected in EDTA and dry
region, called a monolayer, where the cells are
tubes for each study participant, at phlebotomy
spaced far enough apart to be counted and
service and in internal medicine department. The
differentiated. The monolayer is found in the
blood collected in EDTA tubes were directly
"feathered edge" created by the spreader slide as it
transported in hemetology department for complete
draws the blood forward. The slide is left to air dry,
blood count analysis and that in dry tubes were
after which the blood is fixed to the slide by
transported in biochemistry department for ferritin
immersing it briefly in methanol. The fixative is
study. The samples were analyzed using the
essential for good staining and presentation of
automated machines for haematological (Sysmex
cellular detail. After fixation, the slide is stained 20
500i) and biochemical (Coobas e411) studies.
minutes with Wright-Giemsa to distinguish the cells
from each other. Slides were allowed to air dry.
Essential tests for iron deficiency anemia
Helped by haematologist, the monolayer slides were
viewed under a microscope using oil immersion
These tests were done according to KUTH laboratory
objective. Individual cells are examined and their
SOPs
morphology is characterized and recorded.
Complete Blood Count
Serum ferritin
The hemetology section in this laboratory provide
automated CBC analyses each day using a XS- Blood sample collected in dry tubes were centrifuged
sysmex 800i and 500i analyzers. Blood in EDTA at 3,000 rpm for 5min to separate serum from blood
tube for CBC were brought to the Hematology cells. Serum of all patients were pipetted in the

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 SSRG International Journal of Medical Science ( SSRG-IJMS ) – Volume 6 Issue 12 – Dec 2019

sample cups to be tested for ferritin and analyzed by respectively. Anemia is dominant in females than in
Cobas e411 full automated analyzer. The results were males and is most frequent in adolescent and adults
printed, recorded and interpreted according to the people compared to younger and seniors. This study
normal ranges. agrees with that conducted in India, saying that the
prevalence of anemia was more than 60% among
Ethical consideration adolescent girls and young women, [6] and another of
one conducted in Atlanta, where the high prevalence
The application letter for data collection permission of anemia was observed in pre-menopausal women.
was written to KUTH research department for being This may be due to the increased loss of blood during
analyzed by KUTH research committee. Data were this period of age. [7]
collected after getting the approval letter from KUTH
research department. Data was recorded Prevalence of iron deficiency anemia among other
anonymously manipulated and information of types of anemia
patients was kept with high confidentiality and results
were used for academic purpose only. Table and figure below show how prevalent is iron
deficiency anemia among other types of anemia, of
Data analysis all 64 participants of this study. This classification is
based on hemoglobin and ferritin findings.
Results to assess iron deficiency anemia patients
Table 2: Prevalence of iron deficiency among all
were analyzed by using Excel and Data was coded,
patients
and analyzed in statistical package for social sciences
(SPSS) software for window 10. The assessment of Numbers Hb Ferritin
iron deficiency anemia patients was analyzed of patients (g/dl) (µg/l)
statistically and presented as percentage.
Iron deficiency 33 <12 <15
RESULTS & DISCUSSION anemia
Demographic and characteristics of study particip Other causes of 31 <12 >15
ants anemia

In this study, the demographic characteristics of the Based on ferritin and hemoglobin, anemia was
population were established to characterize the classified into 2 categories: iron deficiency without
population. Table 1 summarizes demographic anemia, and other kinds of anemia were classified
characteristics of population which was in into the 2nd category of other cause of anemia. In this
consideration. study, among 64 anemia patients, 33(51.5%) had iron
deficiency anemia, and 31(48.5%) had other types of
Table 1: Demographic characteristics of study anemia. This study agree with the study conducted,
participants (N=64). said that iron deficiency anemia occupy
Total Percentages approximately 50% of all anemias and that iron
Age- Below 17 7 10.9% deficiency is the main micronutrient disorder that
group [17-37[ 25 39.1% cause anemia. [8] In this study also, iron deficiency
anemia is dominant compared to other types of
[37-57[ 24 37.5%
anemia.
57 and 8 12.5%
above
Sex Male 9 14.1%
Distribution of iron deficiency anemia according to
Female 55 85.9%
age and sex
Mean Age: 36.53±20.36 years
Range: 92.8 During this study the distribution of iron deficiency
anemia patients was determined. The table 5 shows
As shown in table 1, in the present study, the total
the distribution of iron deficiency anemia patients
number of participants was 64 anemia patients and
according to the sex-age group.
from them the demographic characteristics of the
population were determined where the population
was categorized into 4 groups of ages (<17, 17-37,
37-57 and 57 years and above). The participants
below 17 years were 7(10.9%), 17-37 were
25(39.1%), 37-57 were 24(37.5) and in patients of 57
and above were 8(14.1%). Basing on gender,
9(14.1%) and 55(85.9%) were males and females

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 SSRG International Journal of Medical Science ( SSRG-IJMS ) – Volume 6 Issue 12 – Dec 2019

Table 3: Distribution of iron deficiency anemia Table 4: Level of main blood cells function for
according to age and sex IDA patients. SD stand for standard deviation.

Number of Iron- Tests

participants deficiency X2 Degree P RBCs parameters Value Normal Range
anemia of value (unit) (Mean±SD) of
freedom RBCs parameter
Age- Below 7 0(0%) 12.539 3 0.006* RBC counts 4.21±0.75 Men: 4.5-6.2×106/mm3
group 17 Women: 4.0-5.5×106/mm3
[17- 25 15(23.43%) Reticulocytes 0.64±0.57 Men and women 0.5-2.5%
37[ counts
[37- 24 16(25%) Hemoglobin 8.76±1.94 Men: 13-18 g/dl
57[ Women: 12-15 g/dl
57 and 8 2(3.12%) Haematocrit 28.95±5.29 Men: 40%-54%
above Women: 36%-46%
Total 64 33(51.5%) MCV 68.98±6.79 Men and women:80-100fl
Sex Male 9 1(1.56%) 5.814 1 0.016* MCH 20.73±3.00 Men and women: 28-32pg
Female 55 32(50%) MCHC 29.98±2.11 Men and women: 32-37g/dl
Serum Ferritin 7.22±2.75 Men: 15-300 µg/l
Total 64 33(51.5%) Women: 15-200 µg/l
Platelets count 521.03±174.7 Men and women:150-
450×106/mm3

P value <0.05 is statistically significant (*) As shown in table 4, hemoglobin level were
significantly decreased in iron deficiency anemia, of
The overall prevalence of iron deficiency anemia course as said the definition of anemia, being
patients observed in the present study was 51.5%. In 8.76±1.94 as compared to the reference range. This is
the age group of 17-37 and 37-57 was where iron due to the reduction of iron supply in hemoglobin
deficiency anemia is mostly prevalent compared to synthesis. [10] The same results have been reported
other age with the prevalence of 23.43% and 25% where red blood cell indices; MCV, MCH, MCHC
respectively. Among them, 50% were female and and haematocrit were significantly decreased in
1.56% was male. This is due to the fact that, as a patients with iron deficiency anemia, being
woman is in reproductive age, there is the increase of 68.98±6.79, 20.73±3.00, 29.98±2.11 and 68.98±6.79
blood loss. This occurs during menstruation, respectively. Red blood cells and reticulocyte were
pregnancy, breast feeding and pre-menopause period. normal, being 4.21±0.75 and 0.64±0.57. [11] Iron
This finding agrees with a study conducted; reported deficiency, survival of circulating erythrocytes and
that menstruation, pregnancy, breast feeding and pre- reticulocytes are normal or somewhat shortened due
menopause period are the causes of iron deficiency to that anemia is not severe. The table continues
anemia due to the incresed blood loss during this showing that the platelets levels were raised in some
period. The association between iron deficiency iron deficiency anemia patients as the mean and
anemia with age and sex, is likely to be the cause in standard deviation being 521.03±174.7, to mean that
this study with the P-value of 0.006 and 0.016 iron deficiency anemia can cause thrombocytosis in
respectively. [9] some patients. It is said that in IDA, the most
important factor affecting platelet counts is iron
saturation. These changes in the platelet parameter
Level of main blood cells function parameters may be due to low levels of tissue iron. They suggest
among IDA patients that decreased iron saturation might stimulate
megakaryopoiesis. Moreover, iron may have an
During this study the level of main blood function inhibitor effect on platelet counts. [12]
test for iron deficiency anemia patients were
determined. The table below summarizes those
parameters.

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 SSRG International Journal of Medical Science ( SSRG-IJMS ) – Volume 6 Issue 12 – Dec 2019

The Ministry of Health should help people to

emphasize on sensitizations about IDA prevention to
Morphological types of anemia prevent disabilities and death. We recommend
researchers to investigate about other types of anemia
that are more frequent, and search for how people
could manage for not being IDA victims. Further
studies are needed also to identify factors to address
this issue.

REFERENCES

[1] Lanzkowsky, P.(2016). iron-deficienc yanemia.

Lanzkowsky,s Manual of Pediatric Hematology and
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[2] Christopher V. Charles. (2012). Iron Deficiency
[3] Anemia. canada: InTech.
[4] Lopez, A., Cacoub, P., Macdougall, I. C., & Peyrin-
Biroulet, L. (2016). Iron deficiency anaemia. The Lancet,
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[5] Lozoff, B., Corapci, F., Burden, M. J., Kaciroti, N.,
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that iron depletion is the main factor responsible for Ahmed, F. U., Singh, R. P., & Sarma, U. C. (2006).
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[12] Lanzkowsky, P.(2016). iron-deficienc yanemia.
Conclusion [13] Lanzkowsky,s Manual of Pediatric Hematology and
Oncology (Sixth Edition), 69-83.
In the present study, iron deficiency anemia among [14] Streja, E., Kovesdy, C. P., Greenland, S., Kopple, J. D.,
McAllister, C. J., Nissenson, A.R., & Kalantar Zadeh, K.
patients attending KUTH was assessed. The high (2008). Erythropoietin, iron depletion, and relative
frequency of anemia was observed in females than in thrombocytosis: a possible explanation for hemoglobin-
males with the prevalence of 85.9% and 14.1% survival paradox in hemodialysis. American Journal of
respectively. Among all types of anemia, iron Kidney Diseases, 52(4), 727-736
[15] John P. Greer, John Foerster, John N. Lukens George M.
deficiency anemia was found to occupy 51.5% which Rodgers, Frixos Paraskevas, Bertil Glader. (2004).
make it more prevalent. According to age, Wintrobe's Clinical Hematology (11th edition ed.). New
adolescents and adults were significantly observed to York: Lippincott Williams & Wilkins Publishers.
have iron deficiency anemia in this study. [16] Simbauranga, R. H., Kamugisha, E., Hokororo,A., Kidenya,
B. R., & Makani, J. (2015). Prevalence and factors
associated with severe anaemia amongst under-five children
Recommendations hospitalized at Bugando Medical Centre, Mwanza,
Tanzania. BMC hematology, 15(1), 13.
We recommend routine screening for iron deficiency
anemia patients for all gender and .
age, for control and preventing IDA complications, to
sensitize IDA patients for improving their lifestyle
such as taking a complete daily dietary food, and
continuous hospital follow up.

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