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Iron Metabolism Altered in Kids with HIV

"We don't really know in the post-HAART era what is actually going on with iron metabolism and kids with HIV."

CHORI clinical scientist Ellen Butensky James, PNP, PhD, has just published a study in Pediatric Hematology Oncology that examines iron status in children with human immunodeficiency virus (HIV) disease for the first time since the introduction of highly active antiretroviral therapies (HAART) in the mid-nineties.

"Older studies conducted before HAART became common found that anemia was the most common of all blood problems kids with HIV had, but we don't really know in the post-HAART era what is actually going on," says Dr. James.

Prior to the availability of HAART, children with HIV had very few options in terms of treatment, suffered very high mortality rates, and had many HIV-associated complications, including anemia, which was linked with HIV disease progression, higher mortality and poor quality of life. However, with the advent of HAART, all of that changed.

“Before kids were being treated so well with these more powerful HAART drugs, overall they were sicker, and anemia was very common. Now that kids are being treated better, you can’t necessarily assume that the prevalence of anemia is the same,” Dr. James explains.

As a result, Dr. James undertook this latest study in order to find out how common anemia is in children with HIV in the post-HAART era, and what different types of anemia were present. While in general the study found that most people’s assumptions that anemia in children with HIV is much less of a problem now than prior to HAART, the study found that 50 percent of the children presented with an altered iron metabolism.

"Measuring iron is very complex, which is why it's not so easy to just say it's high or low," says Dr. James.
"There are a whole variety of tests because iron exists in the body in many different forms, and different levels of all those different forms can all indicate a different iron status."
While only 4 patients had actual anemia, a majority of the patients had iron deficiency. Iron deficiency, regardless of its cause, is a pre-anemic iron status in which iron levels are lower than normal and could become anemic in the future.

"If you had a lot of kids with HIV presenting with iron deficiency, you'd want to monitor them so they don't become anemic, but iron deficiency without anemia isn't actually looked at very often in the clinical setting because it requires testing that is less routine," says Dr. James.

The study also identified a number of patients with both iron deficiency and hyperferritenemia - high levels of stored iron, which has the potential to make HIV worse. Having both conditions at once presents a challenge, given that iron deficiency is treated with iron but giving iron to someone with high storage iron and HIV may make them sicker, and underscores the need to considering routine monitoring of iron metabolism in kids with HIV, even in the post-HAART era.
“While the study is very preliminary, it does suggest the need to conduct a multicenter study to see if this is happening to everybody, as well as a longitudinal study of the kids with iron deficiency to follow them over time, “ says Dr. James.

A longitudinal study would be able to look at when these patients become deficient, investigate whether it has to do with HIV or other HIV-associated illnesses, and determine whether or not the deficiency corrects itself or turns into anemia – all critical questions which Dr. James’ study raises.

“It’s too small study to suggest that everyone now needs to monitor iron deficiency in kids with HIV,” Dr. James says,  “but it certainly puts it in people’s heads that  alterations in iron metabolism are  happening even post-HAART and that we need to keep this in mind  when providing care to these patients. 

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Tuesday, May 17, 2011 8:19 AM

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