Free Erythrocyte Protoporphyrin for Diagnosis of Iron Deficiency and Iron Deficiency Anemia in Adolescent Female Athletes

Dong Hyun Kim; Sung Jin Kim; Soon Ki Kim; Byong Kwan Son; Han Ik Cho

doi:10.5045/kjh.2007.42.4.367

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Kim, Kim, Kim, Son, and Cho: Free Erythrocyte Protoporphyrin for Diagnosis of Iron Deficiency and Iron Deficiency Anemia in Adolescent Female Athletes

Original Article

Korean J Hematol 2007;42(4):367-374.

Published online: 19 January 2007

DOI: https://doi.org/10.5045/kjh.2007.42.4.367

Free Erythrocyte Protoporphyrin for Diagnosis of Iron Deficiency and Iron Deficiency Anemia in Adolescent Female Athletes

Dong Hyun Kim, M.D.¹, Sung Jin Kim, M.D.¹, Soon Ki Kim, M.D.^1,, Byong Kwan Son, M.D.², Han Ik Cho, M.D.²

¹Department of Pediatrics, College of Medicine, Inha University, Incheon, Korea

²Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea

Correspondence to： Soon Ki Kim, M.D. Department of Pediatrics, College of Medicine, Inha University 7-206, Sinheung-dong 3-ga, Jung-gu, Incheon 400-711, Korea Tel: +82-32-890-2843, 3518, Fax: +82-32-810-2844 E-mail: pedkim@inha.ac.kr

Received 27 August 2007 Revised 11 September 2007 Accepted 20 September 2007

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background:

If hemoglobin (Hb) synthesis is impaired by factors other than a deficiency in free erythrocyte protoporphyrin (FEP) synthesis, the amount of FEP might be increased. In this study, we analyzed the statistical values and contribution of FEP for the monitoring and diagnosis of iron deficient anemia in adolescent female athletes according to various sports.

Methods:

We collected whole blood from 64 adolescent female athletes 13 to 19 years of age. The FEP was measured fluorometrically. After other hematological indices were evaluated, statistical analysis was performed to compare the data among various athletes.

Results:

The mean age was 14.8±1.7 (13∼19) years old. The number of runners, badminton players and shooting athletes were 46.9% (n=30), 12.5% (n=8) and 40.6% (n=26), respectively. The prevalence of anemia, iron deficiency and iron deficiency anemia were 23.4%, 23.4% and 14.0%, respectively. The measured concentration of FEP was 48.7±21.1μg/dL (12∼125). A moderately negative correlation of Hb and FEP was noted and was found to be statistically significant (r=?0.571, P＜0.001). Among serum ferritin, TS and FEP, there was no statistically significant correlation. For the diagnosis of iron deficiency anemia, FEP was the most statistically significant index (P＜0.001). For iron deficiency, sensitivity, specificity, positive predictive value, and negative predictive value were 88.9%, 30.4%, 33.3%, and 87.5%, respectively. The receiver operating characteristic curves, showed that FEP had excellent diagnostic power to detect iron deficiency. There was a significant difference in the prevalence of iron deficiency among the three athletes, with runners and badminton players tending to be affected more frequently with iron deficiency than static athletes such as the shooters (runners and badminton vs. shooting athletes, 33.3% and 25.0% vs. 19.2%).

Conclusion:

Our results confirmed FEP to be the most significant factor for the diagnosis of iron deficiency in athletes. Proper nutritional counseling and monitoring need to be tailored to various sports, especially in terms of static versus nonstatic sports such as runners and badminton players versus shooting athletes.

Keywords: Anemia, Iron deficiency, Adolescents, Free erythrocyte protoporphyrin

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Fig. 1

Negative correlation between hemoglobin and free erythrocyte protoporphyrin. ∗ r is a Pearson correlation coefficient, P<0.001. ^†Hb, hemoglobin; ^‡FEP, free erythrocyte protoporphyrin.

Fig. 2

Dot matrix plot of free erythrocyte protoporphrin, ferritin, and tranferrin saturation.

Fig. 3

The receiver operating characteristic (ROC) curves of free erythrocyte protoporphyrin and ferritin in adolescent female athletes with lron deficienty. ∗AUROC, the area under an receiver operating characteric curve; ^†FEP, free erythrocyte protoporphyrin.

Table 1.

Age and hematologic characteristics in adolescent female athletes

	Runners (n=30)	Badminton players (n=8)	Shooting players (n=26)	P-value
Age (years)	14.9±1.7	16.3±2.5	14.4±1.0	0.064
Hb∗ (g/dL)	12.3±1.2	13.1±1.6	13.4±0.8	0.002
Ferritin (ng/dL)	18.3±10.5	18.6±8.8	21.1±1.8	0.061
TS^† (%)	26.1±14.3	26.3±15.3	25.5±13.1	0.097
FEP^‡(μg/dL)	54.8±25.3	50.8±19.4	41.1±12.7	0.048

Data are mean±standard deviation. Abbreviations: ∗Hb, hemoglobin;

^† TS, transferrin saturation;

^‡ FEP, free erythrocyte protoporphyrin.

Table 2.

Iron status in adolescent female athletes

	Criteria	Prevalence % (n)
Anemia	Hb∗＜12g/dL	23.4 (15)
Iron deficiency	Ferritin＜12ng/dL	23.4 (15)
IDA^†		14.0 (9)
NHANES III^‡		26.6 (17)
FEP^§ (μg/dL)	FEP≥36μg/dL	73.4 (47)

Abbreviations: ∗Hb, hemoglobin;

^† IDA, iron deficiency anemia: anemia and (1) ferritin ＜12ng/dL, or (2) TS＜16%;

^‡ NHANES III, National Health and Nutrition Examination Survey III: Two or more indices should be required for diagnosis of ID among serum ferritin, TS, and FEP;

^§ FEP, agnosis of ID among serum ferritin, TS, and FEP; free erythrocyte protoporphyrin.

Table 3.

Summary of the multiple regression model with contribution for the diagnosis of iron deficiency anemia

Model	Unstandardized coefficients		Standardized coefficients	t	Sig.	Collinearity statistics
Model	B	Sth. error	Beta	t	Sig.	Tol.∗	VIF^†
Constant	14.325	0.545		26.297	0.000
FEP	?0.033	0.007	?0.558	?4.989	0.000	0.894	1.118
Ferritin	0.001	0.013	0.010	0.088	0.930	0.902	1.108
TS	0.004	0.010	0.046	0.421	0.675	0.938	1.067
R²=0.328	Adjusted R²=0.294		F=9.763	P≒0.000

Abbreviations: ∗Tol., tolerance;

^† VIF, variance information factor.

Table 4.

NHANES III-based iron status according to the groups

FEP	Runners (n=30)		Badminton players (n=8)		Shooting players (n=26)
	ID∗	IDA^†	ID	IDA	ID	IDA
	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)
≥36mg/dL	9 (30.0)	6 (20.0)	2 (25.0)	2 (25.0)	4 (15.4)	1 (3.8)
<36mg/dL	1 (3.3)	0 (0)	0 (0)	0 (0)	1 (3.8)	0 (0)
Total	10 (33.3)	6 (20.0)	2 (25.0)	2 (25.0)	5 (19.2)	1 (3.8)

Abbreviations: ∗ID, iron deficiency;

^† IDA, iron deficiency anemia. P≒0.045

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