Inflammatory Anemia Associated Parameters in Septic Patients
Inflammatory Anemia Associated Parameters in Septic Patients
1. To observe the changes in the inflammatory anemiaassociated parameters of patients with
 sepsis in the early stage of intensive care unit (ICU) admission.

 2. To evaluate their association with 28-days mortality

 3. To evaluate the effect of blood transfusion on these parameters and the survival of the
 studied patients
Anemia is one of the most common complications in patients with sepsis in the intensive care
 unit (ICU), as well as sepsis is a major cause of high mortality in ICU. Studies demonstrated
 that sepsis-related anemia can be caused by fluid loading related hemodilution, iatrogenic
 blood loss, decreases in iron supply, erythropoietin (EPO) production and erythrocyte
 lifespan .

 However, sepsis related anemia has been demonstrated to be associated mainly with
 inflammation (i.e., "anemia of inflammation"). Anemia of inflammation is usually a mild to
 moderately severe anemia (hemoglobin rarely < 8 g/dL) . It develops in the setting of
 infection, inflammatory disease or malignancy, together with low serum iron despite adequate
 systemic iron stores, decreased serum transferrin, normal size of erythrocytes and hemoglobin
 content or mildly decreased size and hemoglobin content of erythrocytes if the inflammatory
 disease is longstanding .

 Impaired iron homeostasis and the suppressive effects of proinflammatory cytokines on
 erythropoiesis, together with alterations in the erythrocyte membrane that impair its
 survival may result, ultimately, in inflammation-associated anemia .

 Hepcidin is a key regulator of inflammation-associated anemia. Hepcidin reduces the iron
 level in plasma through:

 1. direct inhibition of intestinal absorption of iron.

 2. promotion of iron storage in macrophages by down regulating expression of ferroprotein
 in intestinal mucosae and macrophages.

 Increased interleukin-6 (IL-6) in patients with sepsis can induce an abruptly increased
 synthesis of hepcidin, causing decreased plasma iron. Plasma iron can be depressed by
 inflammation markedly (more than 50%) and rapidly ( with in 24 hrs). Also, the interaction
 between inflammation and iron metabolism may interfere with other inflammatory anemia
 associated parameters and complicate iron metabolism in patients with sepsis.

 Typically, plasma ferritin (which stores iron) is reduced in iron deficiency anemia but can
 increase in the acute phase of sepsis. Anemia usually results in an increased synthesis of
 EPO in kidneys in minutes to hours, but the response to EPO is blunted in patients with
 sepsis . The soluble transferrin receptor (sTfR), an early and sensitive biomarker for
 diagnosing iron deficiency , is particularly useful for identification of concomitant iron
 deficiency in patients with inflammation. The sTfR is not affected by inflammation, which is
 a significant advantage over other biomarkers. Plasma sTfR reflects the degree of iron
 availability for cells, whereas plasma ferritin reflects iron storage. Hence, the ratio of
 sTfR to log ferritin (hereafter termed "sTfR/log ferritin") provides the efficacy of sTfR
 alone or ferritin alone in the diagnosis of iron deficiency. These cytokines have the
 propensity to promote iron restricted erythropoiesis, characterized by functional rather than
 absolute iron deficiency, occurring secondary to dysregulation of iron metabolism.

 Associations among inflammatory cytokines, EPO, and anemia in critically ill septic patients
 remain unclear.

 The inflammatory anemia-associated parameters mentioned above may change with the severity of
 inflammation in patients with sepsis. The sensitivity and specificity of these parameters can
 be modified if inflammation and iron deficiency are present concomitantly. This may
 complicate the diagnosis, evaluation, and treatment of inflammatory anemia.

 Hence, a better understanding of changes in the inflammatory anemia and associated parameters
 in patients with sepsis at the early stage of ICU admission is needed urgently. In addition,
 although severe anemia is associated with adverse outcomes in critical illness, a lowered
 plasma iron is part of the natural defense against pathogens.

 EPO has also been demonstrated to exert protective effects in the kidneys and lungs of mice
 with sepsis, but EPO deficiency contributes to anemia development in patients with sepsis. As
 a result of these effects, inflammatory anemia-associated parameters have been speculated to
 be associated with the prognosis of patients with sepsis , but relevant studies are lacking
Inclusion Criteria:

 1-patients meeting diagnostic criteria of sepsis and hemoglobin level less than 10 g/dl
 2-patients admitted to the intensive care unit Exclusion Criteria

 1. patients less than18 years of age.

 2. patients have chronic liver dysfunctions or chronic kidney disease resulting from
 different causes.

 3. patients with known iron related diseases (e.g., hemochromatosis), immunologic
 diseases or malignancies upon hospital admission; all types of anemia (aplastic, iron
 deficiency, hemolytic, megaloblastic).

 4. patients with overt blood loss (e.g., gastrointestinal bleeding) upon admission and
 during the ICU stay.