Anemia and Iron Deficiency in Cancer Patients: Role of Iron Replacement Therapy.
Anemia and Iron Deficiency in Cancer Patients: Role of Iron Replacement Therapy.
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DOI：
10.3390/ph11040094
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发表时间：
2018-09-30
期刊：
影响因子：
--
通讯作者：
Girelli D
中科院分区：
文献类型：
--
作者：
Busti F;Marchi G;Ugolini S;Castagna A;Girelli D
贫血在癌症患者中相当常见，对生活质量和总体预后具有显著的负面影响。发病机制是复杂的，通常是多因素的，缺铁（ID）往往是一个主要的和潜在的可治疗的贡献者。反过来，癌症患者的ID可能是由于多种并发机制，包括出血（例如，在胃肠癌中或手术后）、营养不良、药物和铁调素驱动的铁螯合到巨噬细胞中，随后是铁限制性红细胞生成。事实上，绝对或功能性缺铁（AID或FID）都可能发生。虽然对于绝对ID，关于实验室定义（即铁蛋白水平<100 ng/mL ±转铁蛋白饱和度（TSAT）<20%）存在普遍共识，但仍然缺乏功能ID的共享定义。目前癌症贫血的治疗选择包括铁替代，红细胞生成刺激剂（ESA）和输血。由于对风险、费用和有限资源的关切，后者应保持在最低限度。铁疗法已被证明是一种有效的方法，以提高疗效的ESA和减少输血的需要。现有的指南主要关注化疗相关性贫血患者，当存在AID或FID时，通常建议静脉注射（IV）铁剂。然而，在FID的情况下，与TSAT <20%相关的铁蛋白的上限（铁应被规定为800 ng/mL）是一个有争议的问题。越来越多的认识到，癌症患者静脉注射铁剂的适应症是择期肿瘤手术中的术前贫血。在这种情况下，治疗的主要目标是减少围手术期输血的需要，而不是改善化疗相关贫血的贫血相关症状。方案主要基于非肿瘤手术中患者血液管理（PBM）的经验，但没有针对肿瘤手术的具体指南。在这里，我们讨论了一些可能的方法来管理ID的癌症患者在不同的临床环境中，根据目前的指南和建议，强调需要在该领域进行进一步的研究。
Anemia in cancer patients is quite common, with remarkable negative impacts on quality of life and overall prognosis. The pathogenesis is complex and typically multifactorial, with iron deficiency (ID) often being a major and potentially treatable contributor. In turn, ID in cancer patients can be due to multiple concurring mechanisms, including bleeding (e.g., in gastrointestinal cancers or after surgery), malnutrition, medications, and hepcidin-driven iron sequestration into macrophages with subsequent iron-restricted erythropoiesis. Indeed, either absolute or functional iron deficiency (AID or FID) can occur. While for absolute ID there is a general consensus regarding the laboratory definition (that is ferritin levels <100 ng/mL ± transferrin saturation (TSAT) <20%), a shared definition of functional ID is still lacking. Current therapeutic options in cancer anemia include iron replacement, erythropoietic stimulating agents (ESAs), and blood transfusions. The latter should be kept to a minimum, because of concerns regarding risks, costs, and limited resources. Iron therapy has proved to be a valid approach to enhance efficacy of ESAs and to reduce transfusion need. Available guidelines focus mainly on patients with chemotherapy-associated anemia, and generally suggest intravenous (IV) iron when AID or FID is present. However, in the case of FID, the upper limit of ferritin in association with TSAT <20% at which iron should be prescribed is a matter of controversy, ranging up to 800 ng/mL. An increasingly recognized indication to IV iron in cancer patients is represented by preoperative anemia in elective oncologic surgery. In this setting, the primary goal of treatment is to decrease the need of blood transfusions in the perioperative period, rather than improving anemia-related symptoms as in chemotherapy-associated anemia. Protocols are mainly based on experiences of Patient Blood Management (PBM) in non-oncologic surgery, but no specific guidelines are available for oncologic surgery. Here we discuss some possible approaches to the management of ID in cancer patients in different clinical settings, based on current guidelines and recommendations, emphasizing the need for further research in the field.
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