Evaluation of various discrimination indices in differentiating Iron deficiency anemia and Beta Thalassemia trait: A practical low cost solution.
Keywords:
Iron deficiency anemia, Beta Thalassemia trait, Microcytosis, Discrimination Indices
Abstract
Background: Mild microcytic hypochromic anemias due to Iron deficiency (IDA) and beta thalassemia trait(𝛽-TT) continue to be a cause of significant burden to the society, particularly in the poorer developing countries. The objective of the present study was to evaluate the validity of 12 different discrimination indices to distinguish 𝛽-TT from IDA.Methods: A total of 225 patients diagnosed with mild microcytic hypochromic anemia on complete blood count and peripheral blood film were included in the study. HB, RBC count, MCV, MCH and RDW obtained from the electronic cell counter were used to calculate 12 discrimination indices by various mathematical formulae. Sensitivity, specificity, positive predictive value(PPV), negative predictive value(NPV) and Youden’s index(YI) were calculated.Result: The Shine & Lal and Ricerca et al indices exhibited the highest sensitivity of 100% each while the England & Fraser index demonstrated the lowest sensitivity of 61.1%. The England & Fraser and Mentzer indices demonstrated the highest specificities of 90.2% and 86.9% respectively. The highest and the lowest PPV were found for Mentzer index (77.3%) and MCHD (32.71%) respectively. The Ricerca et al. and Shine & Lal indices demonstrated the highest NPV of 100% each and the lowest NPV was exhibited by MCHD (69.8%). The highest and the lowest values for Youden’s index were shown by Mentzer index (81.3%) and MCHD (2.36%) respectively.Conclusion: Though HBA2 estimation is the gold standard for diagnosing 𝛽-TT, in developing countries, Mentzer index followed by Ehsani et al. index can be used to screen mild microcytic hypochromic anemia cases to eliminate as many false positive cases as possible to reduce the financial cost.References
1) Brittenham GM. Disorders of iron metabolism: iron deficiency and overload. In: Hoffman R, Benz EJ Jr, Shattil SJ et al (eds) Hematology basic principles and practice, 2nd edn. 1995. Churchill Livingstone, New York.
2) RathodD A, Kaur A, Patel V. Patel K, Kabrawala R, Patel V, Patel M and Shah P. Usefulness of cell counterbased parameters and formulas in detection of 𝛽-thalassemia trait in areas of high prevalence. American Journal of Clinical Pathology. 2007;128(4):585–589.
3) Angastiniotis M, Modell B. Global epidemiology of hemoglobin disorders. Ann N Y Acad Sci. 1998;850:251-269.
4) Weatherall DJ, Clegg JB. Inherited haemoglobin disorders: An increasing global health problem. Bull World Health Organ. 2001;79:704-712.
5) Milman N. Anemia–still a major health problem in many parts of the world! Ann Hematol 2011;90:369 – 77.
6) Lokeshwar MR, Shah N, Kanakhiya S, Manglani M. Thalassemia. In: IAP Textbook of Paediatrics. 4th edition . Parthasarthy A, Menon PSN, Agarwal Rk, et al (eds): Jay Pee Brothers Medical Publishers Pvt Limited, New Delhi; 2009; 794-815.
7) Hallberg L. Iron requirements: comments on methods and some crucial concepts in iron nutrition. Biol Trace Elem Res. 1992;35:25-45.
8) Hoffmann J JML, EloĂsa Urrechaga E, Aguirre U. Discriminant indices for distinguishing thalassemia and iron deficiency in patients with microcytic anemia: A meta-analysis. Clin Chem Lab Med. 2015; 53(12): 1883–1894.
9) Thomas C, Thomas L. Biochemical markers and hematologic indices in the diagnosis of functional iron deficiency. Clinical Chemistry. 2002;48(7):1066–1076.
10) Ntaios G, Chatzinikolaou A, Saouli Z, et al. Discrimination indices as screening tests for β-thalassemic trait. Ann Hematol. 2007 86:487–491.
11) Turpelnen U. Liquid-chromatographic determination of hemoglobin A2. Clin Chem 1986;3216:999-1002.
12) Mentzer JWC. Differentiation of iron deficiency from thalassaemia trait. The Lancet 1973;1(7808):882.
13) England JM, Fraser P M. Differentiation of iron deficiency from thalassaemia trait by routine blood-count. The Lancet. 1973;1(7801):449–452.
14) Srivastava PC. Differentiation of thalassemia minor fromiron deficiency. The Lancet. 1973;2:154–155.
15) Shine I, Lal S. A strategy to detect 𝛽 thalassaemia minor. The Lancet. 1977;1(8013):692–694.
16) Ricerca BM, Storti S, d’Onofrio G, et al. Differentiation of iron deficiency from thalassaemia trait: A new approach.,” Haematologica. 1987;72(5):409–413.
17) Green R, King R. A new red cell discriminant incorporating volume dispersion for differentiating iron deficiency anemia from thalassemia minor. Blood Cells. 1989;15(3):481–495.
18) Telmissani OA, Khalil S, George T R. Mean density of hemoglobin per liter of blood: a new hematologic parameter with an inherent discriminant function. Laboratory Haematology. 1999;5:149–152.
19) Sirdah M, Tarazi I, Najjar EA, Haddad RA. Evaluation of the diagnostic reliability of different RBC indices and formulas in the differentiation of the 𝛽-thalassaemia minor from iron deficiency in Palestinian population. International Journal of Laboratory Hematology. 2008;30(4):324–330.
20) Ehsani M A, Shahgholi E, Rahiminejad M S, Seighali F, and Rashidi A. A new index for discrimination between iron deficiency anemia and beta-thalassemia minor: Results in 284 patients. Pakistan Journal of Biological Sciences. 2009;12(5):473–475.
21) Piplani1 S, Manan R, Lalit M, Manjari M, Bhasin T, Bawa J. NESTROFT - A Valuable, Cost Effective Screening Test for Beta Thalassemia Trait in North Indian Punjabi Population. JCDR. 20137(12):2784-2787.
22) Klee GG, Fairbanks VF, Pierre RV, Virgh D, O’Sullivan MB. Routine erythrocyte measurements in diagnosis of irondeficiency anemia and thalassemia minor. Am J Clin Pathol. 1976; 66:870–8777.
23) Bessman JD, Feinstein DI. Quantitative anisocytosis as a discriminant between iron deficiency and thalassemia minor. Blood. 1979;53:288–293.
24) England JM, Fraser P. Discrimination between iron deficiency and heterozygous-thalassaemia syndromes in differential diagnosis of microcytosis. Lancet. 1979;1:145–148.
25) Marti HR, Fischer S, Killer D, Bürgi W. Can automated haematology analysers discriminate thalassaemia from iron deficiency? Acta Haematol.1987;78:180–183.
26) Jayabose S, Giavanelli J, Levendoglu-Tugal O, Sandoval C, Ă–zkaynak F, Visintainer P. Differentiating iron deficiency anemia from Thalassemia minor by using an RDW-based index. J Pediatr Hematol. 1999;21:314.
27) Flynn MM, Reppun TS, Bhagavan NV. Limitations of red blood cell distribution width (RDW) in evaluation of microcytosis. Am J Clin Pathol. 1986;85:445–449.
28) Miguel A, Linares M, Miguel A, Miguel-Borja JM. Red blood cell distribution width analysis in differentiation between iron deficiency and thalassemia minor. Acta Haematol. 1988;80:59.
29) Bentley SA, Ayscue LH, Watson JM, Ross DW. The clinical utility of discriminant functions for the differential diagnosis of microcytic anemias. Blood Cells. 1989;15:575–584.
30) Perutelli P. Red blood cell distribution width in microcytosis. Haematologica. 1989;74:221–222.
31) Van Zeben D, Bieger R, Van Wermeskerken RK, Castel A, Hermans J. Evaluation of microcytosis using serum ferritin and red blood cell distribution width. Eur J Haematol. 1990;44:106–109.
32) Demir, Yaralı N, Fısgın T, Duru F and Kara A. Most reliable indices in differentiation between thalassemia trait and iron deficiency anemia. Pediatrics International. 2002; 44(6):612–616..
33) Novak RW. Red blood cell distribution width in pediatric microcytic anemias. Pediatrics. 1987;80:251–4.
34) Junca J, Flores A, Roy C, Alberti R and Milla F. Red cell distribution width, free erythrocyte protoporphyrin, and England–Fraser index in the differential diagnosis of microcytosis due to iron deficiency or beta-thalassemia trait: A study of 200 cases of microcytic anemia. Hematol Pathol. 1991;5:33–6.
35) Yermiahu T, Ben-Shalom M, Porath A. Quantitative determinations of microcytic–hypochromic red blood cell population and glycerol permeability in iron-deficiency anemia and b-thalassemia minor. Ann Hematol 1999;78:468–71.
36) Clarke G, Higgins T. Laboratory investigation of hemoglobinopathies and thalassemia: review and update. Clin Chem. 2000;46:1284–90.
37) Roberts GT, El-Badawi SB. Red cell distribution widths index in some hematologic diseases. Am J Clin Pathol. 1987;83:222–6.
38) Marsh WL, Jr, Bishop JW, Darcy TP. Evaluation of red cell volume distribution width (RDW). Hematol Pathol.1987;1:117–23.
39) Burk M, Arenz J, Giagounidis AA, et al. Erythrocyte indices as screening tests for the differentiation of microcytic anemias. Eur J Med Res. 1995;1:33–7.
40) Rahim F, Keikhaei B. Better differential diagnosis of iron deficiency anemia from beta-thalassemia trait. Turkish Journal of Hematology. 2009;26(3):138–145.
41) Ghafouri M, Sefat LM, Sharifi L. Comparison of cell counter indices in differention of beta thalassemia trait and iron deficiency anemia. The Scientific Journal of Iranian Blood Transfusion Organization. 2006;2(7):385–389.
42) AlFadhli S M, Al-Awadhi A M and AlKhaldi D. Validity assessment of nine discriminant functions used for the differentiation between Iron deficiency anemia and thalassemia minor. Journal of Tropical Pediatrics. 2007;53(2):93–97.
43) Ferrara M, Capozzi L, Russo R, Bertocco F and Ferrara D. Reliability of red blood cell indices and formulas to discriminate between 𝛽 thalassemia trait and iron deficiency in children. Hematology. 2010;15(2):112–115.
44) Vehapoglu A, Ozgurhan G, Demir A D, Uzuner S, Nursoy M A, Turkmen S and Kacan A. Hematological Indices for Differential Diagnosis of Beta Thalassemia Trait and Iron Deficiency Anemia. Hindawi Publishing Corporation Anemia. 2014, Article ID 576738, 7 pages http://dx.doi.org/10.1155/2014/576738
45) Urrechaga E, Borque L, and Escanero J F. The role of automated measurement of RBC subpopulations in differential diagnosis of microcytic anemia and 𝛽-thalassemia screening. American Journal of Clinical Pathology. 2011;135(3):374– 379.
46) Cao A, Galanello R. GeneTest Review: Beta-thalassemia. Genetics in Medicine. 2010;12:61–76
2) RathodD A, Kaur A, Patel V. Patel K, Kabrawala R, Patel V, Patel M and Shah P. Usefulness of cell counterbased parameters and formulas in detection of 𝛽-thalassemia trait in areas of high prevalence. American Journal of Clinical Pathology. 2007;128(4):585–589.
3) Angastiniotis M, Modell B. Global epidemiology of hemoglobin disorders. Ann N Y Acad Sci. 1998;850:251-269.
4) Weatherall DJ, Clegg JB. Inherited haemoglobin disorders: An increasing global health problem. Bull World Health Organ. 2001;79:704-712.
5) Milman N. Anemia–still a major health problem in many parts of the world! Ann Hematol 2011;90:369 – 77.
6) Lokeshwar MR, Shah N, Kanakhiya S, Manglani M. Thalassemia. In: IAP Textbook of Paediatrics. 4th edition . Parthasarthy A, Menon PSN, Agarwal Rk, et al (eds): Jay Pee Brothers Medical Publishers Pvt Limited, New Delhi; 2009; 794-815.
7) Hallberg L. Iron requirements: comments on methods and some crucial concepts in iron nutrition. Biol Trace Elem Res. 1992;35:25-45.
8) Hoffmann J JML, EloĂsa Urrechaga E, Aguirre U. Discriminant indices for distinguishing thalassemia and iron deficiency in patients with microcytic anemia: A meta-analysis. Clin Chem Lab Med. 2015; 53(12): 1883–1894.
9) Thomas C, Thomas L. Biochemical markers and hematologic indices in the diagnosis of functional iron deficiency. Clinical Chemistry. 2002;48(7):1066–1076.
10) Ntaios G, Chatzinikolaou A, Saouli Z, et al. Discrimination indices as screening tests for β-thalassemic trait. Ann Hematol. 2007 86:487–491.
11) Turpelnen U. Liquid-chromatographic determination of hemoglobin A2. Clin Chem 1986;3216:999-1002.
12) Mentzer JWC. Differentiation of iron deficiency from thalassaemia trait. The Lancet 1973;1(7808):882.
13) England JM, Fraser P M. Differentiation of iron deficiency from thalassaemia trait by routine blood-count. The Lancet. 1973;1(7801):449–452.
14) Srivastava PC. Differentiation of thalassemia minor fromiron deficiency. The Lancet. 1973;2:154–155.
15) Shine I, Lal S. A strategy to detect 𝛽 thalassaemia minor. The Lancet. 1977;1(8013):692–694.
16) Ricerca BM, Storti S, d’Onofrio G, et al. Differentiation of iron deficiency from thalassaemia trait: A new approach.,” Haematologica. 1987;72(5):409–413.
17) Green R, King R. A new red cell discriminant incorporating volume dispersion for differentiating iron deficiency anemia from thalassemia minor. Blood Cells. 1989;15(3):481–495.
18) Telmissani OA, Khalil S, George T R. Mean density of hemoglobin per liter of blood: a new hematologic parameter with an inherent discriminant function. Laboratory Haematology. 1999;5:149–152.
19) Sirdah M, Tarazi I, Najjar EA, Haddad RA. Evaluation of the diagnostic reliability of different RBC indices and formulas in the differentiation of the 𝛽-thalassaemia minor from iron deficiency in Palestinian population. International Journal of Laboratory Hematology. 2008;30(4):324–330.
20) Ehsani M A, Shahgholi E, Rahiminejad M S, Seighali F, and Rashidi A. A new index for discrimination between iron deficiency anemia and beta-thalassemia minor: Results in 284 patients. Pakistan Journal of Biological Sciences. 2009;12(5):473–475.
21) Piplani1 S, Manan R, Lalit M, Manjari M, Bhasin T, Bawa J. NESTROFT - A Valuable, Cost Effective Screening Test for Beta Thalassemia Trait in North Indian Punjabi Population. JCDR. 20137(12):2784-2787.
22) Klee GG, Fairbanks VF, Pierre RV, Virgh D, O’Sullivan MB. Routine erythrocyte measurements in diagnosis of irondeficiency anemia and thalassemia minor. Am J Clin Pathol. 1976; 66:870–8777.
23) Bessman JD, Feinstein DI. Quantitative anisocytosis as a discriminant between iron deficiency and thalassemia minor. Blood. 1979;53:288–293.
24) England JM, Fraser P. Discrimination between iron deficiency and heterozygous-thalassaemia syndromes in differential diagnosis of microcytosis. Lancet. 1979;1:145–148.
25) Marti HR, Fischer S, Killer D, Bürgi W. Can automated haematology analysers discriminate thalassaemia from iron deficiency? Acta Haematol.1987;78:180–183.
26) Jayabose S, Giavanelli J, Levendoglu-Tugal O, Sandoval C, Ă–zkaynak F, Visintainer P. Differentiating iron deficiency anemia from Thalassemia minor by using an RDW-based index. J Pediatr Hematol. 1999;21:314.
27) Flynn MM, Reppun TS, Bhagavan NV. Limitations of red blood cell distribution width (RDW) in evaluation of microcytosis. Am J Clin Pathol. 1986;85:445–449.
28) Miguel A, Linares M, Miguel A, Miguel-Borja JM. Red blood cell distribution width analysis in differentiation between iron deficiency and thalassemia minor. Acta Haematol. 1988;80:59.
29) Bentley SA, Ayscue LH, Watson JM, Ross DW. The clinical utility of discriminant functions for the differential diagnosis of microcytic anemias. Blood Cells. 1989;15:575–584.
30) Perutelli P. Red blood cell distribution width in microcytosis. Haematologica. 1989;74:221–222.
31) Van Zeben D, Bieger R, Van Wermeskerken RK, Castel A, Hermans J. Evaluation of microcytosis using serum ferritin and red blood cell distribution width. Eur J Haematol. 1990;44:106–109.
32) Demir, Yaralı N, Fısgın T, Duru F and Kara A. Most reliable indices in differentiation between thalassemia trait and iron deficiency anemia. Pediatrics International. 2002; 44(6):612–616..
33) Novak RW. Red blood cell distribution width in pediatric microcytic anemias. Pediatrics. 1987;80:251–4.
34) Junca J, Flores A, Roy C, Alberti R and Milla F. Red cell distribution width, free erythrocyte protoporphyrin, and England–Fraser index in the differential diagnosis of microcytosis due to iron deficiency or beta-thalassemia trait: A study of 200 cases of microcytic anemia. Hematol Pathol. 1991;5:33–6.
35) Yermiahu T, Ben-Shalom M, Porath A. Quantitative determinations of microcytic–hypochromic red blood cell population and glycerol permeability in iron-deficiency anemia and b-thalassemia minor. Ann Hematol 1999;78:468–71.
36) Clarke G, Higgins T. Laboratory investigation of hemoglobinopathies and thalassemia: review and update. Clin Chem. 2000;46:1284–90.
37) Roberts GT, El-Badawi SB. Red cell distribution widths index in some hematologic diseases. Am J Clin Pathol. 1987;83:222–6.
38) Marsh WL, Jr, Bishop JW, Darcy TP. Evaluation of red cell volume distribution width (RDW). Hematol Pathol.1987;1:117–23.
39) Burk M, Arenz J, Giagounidis AA, et al. Erythrocyte indices as screening tests for the differentiation of microcytic anemias. Eur J Med Res. 1995;1:33–7.
40) Rahim F, Keikhaei B. Better differential diagnosis of iron deficiency anemia from beta-thalassemia trait. Turkish Journal of Hematology. 2009;26(3):138–145.
41) Ghafouri M, Sefat LM, Sharifi L. Comparison of cell counter indices in differention of beta thalassemia trait and iron deficiency anemia. The Scientific Journal of Iranian Blood Transfusion Organization. 2006;2(7):385–389.
42) AlFadhli S M, Al-Awadhi A M and AlKhaldi D. Validity assessment of nine discriminant functions used for the differentiation between Iron deficiency anemia and thalassemia minor. Journal of Tropical Pediatrics. 2007;53(2):93–97.
43) Ferrara M, Capozzi L, Russo R, Bertocco F and Ferrara D. Reliability of red blood cell indices and formulas to discriminate between 𝛽 thalassemia trait and iron deficiency in children. Hematology. 2010;15(2):112–115.
44) Vehapoglu A, Ozgurhan G, Demir A D, Uzuner S, Nursoy M A, Turkmen S and Kacan A. Hematological Indices for Differential Diagnosis of Beta Thalassemia Trait and Iron Deficiency Anemia. Hindawi Publishing Corporation Anemia. 2014, Article ID 576738, 7 pages http://dx.doi.org/10.1155/2014/576738
45) Urrechaga E, Borque L, and Escanero J F. The role of automated measurement of RBC subpopulations in differential diagnosis of microcytic anemia and 𝛽-thalassemia screening. American Journal of Clinical Pathology. 2011;135(3):374– 379.
46) Cao A, Galanello R. GeneTest Review: Beta-thalassemia. Genetics in Medicine. 2010;12:61–76
Published
2016-12-13
Section
Original Article
Authors who publish with this journal agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access at http://opcit.eprints.org/oacitation-biblio.html).
