Ironically unwell: anaemia and iron deficiency among health-aware adults in the UK

Bone Marrow Iron in CKD: Correlation With Functional Iron Deficiency

Anemia After Renal Transplantation

Rethinking anaemia surveillance

Iron deficiency (ID) in children with inflammatory bowel disease (IBD) is either an absolute (depleted iron stores) or a functional deficiency (caused by chronic inflammation). Differentiating between these 2 types of ID is important because they require a different therapeutic approach. Zinc protoporphyrin (ZPP) and red blood cell distribution width (RDW) are parameters of functional ID. Studies using these parameters to differentiate are nonexistent. We aimed to evaluate the prevalence of and risk factors for absolute and functional ID in paediatric IBD patients while using ZPP and RDW. We evaluated the iron status and medical charts of 59 paediatric IBD patients in a secondary hospital in the Netherlands. Absolute ID was defined as serum ferritin <15 μg/L in the absence of infection and/or acute inflammation (C-reactive protein <10 mg/L). Iron deficiency anaemia (IDA) was defined as absolute ID in combination with anaemia. Functional ID, in patients without absolute ID, was defined as ZPP >70 μmol/mol haem and/or an RDW >14%. Anaemia of chronic disease (ACD) was defined as functional ID in combination with anaemia. Absolute and functional ID were found in 19/59 (32.2%) and 32/40 (80%) patients, respectively. The prevalence of IDA and ACD was 27.1% (16/59) and 20% (8/40), respectively. Multivariate analyses showed that absolute ID and IDA were both associated with a more recent IBD-diagnosis (both P < 0.05). Absolute and functional ID are common in paediatric IBD patients, and this differentiation is important because of therapeutic consequences. Furthermore, absolute ID and IDA are associated with a more recent IBD-diagnosis.

Background and Aims Iron deficiency is common in chronic kidney disease (CKD) and may result from either functional or absolute iron deficiency. We postulated that the presence of functional iron deficiency in patients with non-dialysis CKD (NDCKD) is associated with poorer outcomes including increased cardiovascular events and mortality. Method CKD patients who received their first dose of an iron infusion in our organisation between January 2017 and December 2019 were included, with follow-up through to December 2023. Demographic, comorbidity, treatment, laboratory, and outcome data were extracted from the organisation's electronic patient record. Of 852 patient records reviewed, 831 had the required data on iron indices and treatments and were included in the study. Patients were categorised into three groups based on iron deficiency status generated by one year time-averaged ferritin and transferrin saturation (TSAT) 12 months before their iron infusion: functional iron deficiency (FID) with transferrin saturation (TSAT) &amp;lt;20% and ferritin &amp;gt;100 µg/ml, absolute iron deficiency (AID) with TSAT &amp;lt;20% and ferritin ≤100 µg /ml, and standard iron parameters (no iron deficiency - NID). Analyses were performed using SPSS software. Results Of the 831 patients included, 298 (35.8%) had FID, 321 (38.6%) AID, and 212 (26.0%) NID. Baseline characteristics and outcomes are compared across the groups in Table 1. Patients with FID were older with a median age of 72 (IQR 61–81; P = 0.001) years. 51% of patients with FID, and 45.3% of patients with AID had a history of diabetes mellitus, compared to 36.8% of those with NID (P = 0.024). Median time-averaged ferritin was highest in those with FID (234 µg/ml), and lowest in those with AID (39 µg/ml), (P &amp;lt; 0.001). Median time-averaged TSAT was 13% in those with AID, 15% in those with FID, and 24% in those with NID (P &amp;lt; 0.001). A higher proportion of patients with NID had CKD stages 4 and 5 (FID: 77% vs AID: 64% vs NID: 88%; P &amp;lt; 0.001) as reflected by their lower median baseline estimated glomerular filtration rate (eGFR) (FID: 22 vs AID: 26 vs NID: 17 ml/min/1.73 m2; P &amp;lt; 0.001). Over a median follow-up of 38.5 months, a higher proportion of patients in the FID group died (FID: 62% vs AID: 49.5% vs NID: 46.2%; P = 0.001), and a lower proportion reached renal replacement therapy (FID: 31.9% vs AID: 22.7% vs NID: 45.8; P &amp;lt; 0.001). There were no significant differences between the groups with regard to cardiovascular events, hospitalisations, and erythropoietin stimulating agents or blood transfusion requirements. (Table 1). Multivariate Cox regression models showed factors including a higher age [HR:1.03; CI: 1.02–1.04; P &amp;lt; 0.001], any cardiovascular event history [HR:1.54; CI: 1.11–2.13; P = 0.009], cancer history, lower eGFR at baseline and FID status [HR:1.46; CI: 1.07–2.01; P = 0.017] to have a significant association with all-cause mortality. The Kaplan-Meir chart demonstrates the cumulative survival being significantly lower in patients with FID (Log-rank P &amp;lt; 0.001) (Fig. 1). Conclusion Both FID and AID were common in this cohort with NDCKD. No differences in cardiovascular events or hospitalisation episodes were found between the groups. In this cohort, those with NID had more advanced CKD (median eGFR 17 ml/min/1.73 m2) and were more likely to progress to renal replacement therapy. Functional iron deficiency status was found to have strong and independent association with all-cause mortality.

The prevalence of absolute and functional iron deficiency among adults in the US is unknown. To estimate the prevalence of absolute and iron deficiency and iron supplement use in the US across age, sex, and comorbidity categories. This cross-sectional study analyzed data from the National Health and Nutritional Examination Survey (NHANES) 2017 to 2020 prepandemic cycle. Participants included noninstitutionalized, civilian women and men aged 18 years or older who had available serum ferritin, iron, and unsaturated iron binding capacity measurements. Data analysis was performed from March 21, 2023, to July 5, 2024. Absolute iron deficiency and functional iron deficiency. Absolute iron deficiency was defined as serum ferritin less than 30 ng/mL regardless of transferrin saturation. Functional iron deficiency was defined as serum ferritin greater than or equal to 30 ng/mL with transferrin saturation less than 20%. The prevalence of absolute and functional iron deficiency was estimated among all adults in the US and separately among women and men according to age category (>18 years to <50 years, 50-65 years, and ≥65 years) using recommended sample weights and sampling design factors to provide estimates representative of the national, noninstitutionalized civilian population. The 95% CIs were calculated using the Korn-Graubard method. A total of 8021 US adults (mean age, 48 years; 95% CI, 47-49 years; 52% [95% CI, 50%-53%] female) were included in this analysis. An estimated 14% (95% CI, 13%-15%) of adults in the US met the criteria for absolute iron deficiency, and an estimated 15% (95% CI, 14%-17%) met the criteria for functional iron deficiency. Among US adults without anemia, heart failure, chronic kidney disease, or current pregnancy, the estimated prevalence of absolute iron deficiency was 11% (95% CI, 10%-11%), and that of functional iron deficiency was 15% (95% CI, 14%-17%). The prevalence of functional iron deficiency exceeded that of absolute iron deficiency in all US adults except women younger than 50 years. Iron supplement use ranged from 22% (95% CI, 12%-37%) to 35% (95% CI, 29%-42%) of women with iron deficiency and 12% (95% CI, 5%-21%) to 18% (95% CI, 8%-32%) of men with iron deficiency depending on age. These findings suggest that absolute and functional iron deficiency affect a large proportion of American adults even in the absence of anemia, heart failure, or chronic kidney disease. Further research on the role of functional iron deficiency in adverse health outcomes and on iron deficiency screening strategies is needed.

The aim – to compare patients with chronic heart failure and reduced left ventricular ejection fraction (LVEF) with absolute and functional iron deficiency (ID) state according to the main clinical, hemodynamic, laboratory parameters and clinical prognosis indicators. Material and methods. In January – February, 2018, 128 stable patients with chronic heart failure (111 of men and 17 of women), 18–75 years old, NYHA class II–IV, with left ventricular ejection fraction &lt; 40 % were screened. Patients were included in a clinical compensation phase. Quality of life was assessed by the Minnesota living with heart failure questionnaire (MLHFQ), physical activity was estimated by the Duke University index, functional status – by assessing the 6-minute walking test and a standardized lower limb extension test.Results. ID was observed in 61 % of patients, 65 % had absolute ID. Patients with both types of ID were in higher functional class, had a poorer quality of life and worse clinical and laboratory indices than patients without ID. Regardless of the difference in the functional and absolute ID formation mechanisms, no significant distinctions in the clinical and functional parameters, quality of life, as well as the parameters of intracardiac hemodynamics were found. Contrary to expectations, elevated levels of hepcidin were not detected in patients with functional ID compared to the absolute ID group. The reliable differences in survival/hospitalization rate between patients without ID and both groups of patients with ID allow us to recommend the screening of iron deficiency in all patients with chronic heart failure and reduced LVEF.Conclusions. ID is found in 61 % patients. Functional ID was found in 27 patients (21 %), absolute ID – in 51 patients (39.6 %). There were no differences between groups of patients with absolute and functional ID by age, functional class, LVEF, percentage of aneamic patients, 6-minute walking distance, thigh quadriceps endurance, quality of life, physical activity index, NT-proBNP, citrulline and hepcidin levels. Compared to patients with absolute ID, patients with functional ID had higher levels of hemoglobin, MCV, MCH, interleukin-6. Presence of both ID types was associated with worse survival and more frequent hospitalization.

Background Anaemia and iron deficiency are frequent following major surgery. The present study aims to identify the iron deficiency patterns in cardiac surgery patients at their admission to a cardiac rehabilitation programme, and to determine which perioperative risk factor(s) may be associated with functional and absolute iron deficiency. Design This was a retrospective study on prospectively collected data. Methods The patient population included 339 patients. Functional iron deficiency was defined in the presence of transferrin saturation <20% and serum ferritin ≥100 µg/l. Absolute iron deficiency was defined in the presence of serum ferritin values <100 µg/l. Results Functional iron deficiency was found in 62.9% of patients and absolute iron deficiency in 10% of the patients. At a multivariable analysis, absolute iron deficiency was significantly ( p = 0.001) associated with mechanical prosthesis mitral valve replacement (odds ratio 5.4, 95% confidence interval 1.9-15) and tissue valve aortic valve replacement (odds ratio 4.5, 95% confidence interval 1.9-11). In mitral valve surgery, mitral repair carried a significant ( p = 0.013) lower risk of absolute iron deficiency (4.4%) than mitral valve replacement with tissue valves (8.3%) or mechanical prostheses (22.5%). Postoperative outcome did not differ between patients with functional iron deficiency and patients without iron deficiency; patients with absolute iron deficiency had a significantly ( p = 0.017) longer postoperative hospital stay (median 11 days) than patients without iron deficiency (median nine days) or with functional iron deficiency (median eight days). Conclusions Absolute iron deficiency following cardiac surgery is more frequent in heart valve surgery and is associated with a prolonged hospital stay. Routine screening for iron deficiency at admission in the cardiac rehabilitation unit is suggested.

A number of factors have been shown to limit the response to recombinant human erythropoietin (r-HuEPO). One major factor appears to be an inadequate iron supply to the bone marrow. Erythropoiesis is dependent upon a continuous supply of iron to the bone marrow. The rate at which iron can be drawn from existing stores may easily limit the rate of delivery for haemoglobin synthesis. This results in 'functional iron deficiency' which is distinct from 'absolute iron deficiency' caused by depletion of iron stores. At present there are three main parameters available to clinicians wishing to monitor iron status in their patients: serum ferritin and transferrin saturation (TFS), which are indirect measurements, and the percentage of hypochromic red cells, which directly reflects marrow iron status. Ferritin levels should be measured before starting r-HuEPO therapy to ensure adequate iron stores (>200 microg/l), and when patients move from the correction phase to the maintenance phase of therapy (have stores become depleted during the correction phase?). In addition, ferritin levels can give an indication of iron overload following excess parenteral iron administration. The TFS represents a balance between iron supply by stores and demand by bone marrow. A saturation below 20% probably indicates iron-deficient erythropoiesis. However, this is an indirect measure of marrow iron supply and wide fluctuations have been observed when determined at different time points. The percentage of hypochromic red blood cells is measured by flow cytometry and a hypochromic subpopulation of more than 10% (normal percentage <2.5%) indicates iron-deficient erythropoiesis. However, not all departments may have access to the required equipment. The aim of iron supplementation is to provide sufficient iron for the correction phase and to replace iron losses (1500-2000 mg/year in haemodialysis patients) during the maintenance phase of r-HuEPO therapy. This amounts to a daily iron need in the range of 5 7 mg, which is well above the normal dietary intake and absorptive capacity of the human intestine. Therefore, there is a need for intravenous iron, in particular when the patient has absolute or functional iron deficiency, is intolerant of oral iron, or is not complying well with the oral regimen.

Anemia is a common complication of chronic kidney disease (CKD) and is associated with adverse patient outcomes. However, data on the prevalence of anemia in CKD patients is sparse, particularly in resource-limited settings. Therefore, this study aimed to assess the prevalence of anemia and its predictors among patients with CKD admitted to the Jimma medical center, southwest Ethiopia. A hospital-based prospective cross-sectional study was conducted from September 1 to November 30, 2020. All adult patients with CKD aged ≥18 years who fulfilled the inclusion criteria were consecutively recruited into the study. Data were entered into the Epi data manager version 4.4.1 and then exported to SPSS version 22 (IBM Corp., Armonk, NY) for analysis. The predictors of anemia were determined using multivariable logistic regression analysis. Statistical significance was set at P < .05. A total of 150 patients were included in this study. Of these, 64.67% were male, 56.67% had stage 5 CKD, 78% had a CKD duration of less than 1 year, and 74% had proteinuria. Hypertension (40.7%) and diabetes (14.7%) were the common causes of CKD. The prevalence of anemia was 85.33%. Of the patients, 28.67%, 40.67%, and 16% had mild, moderate, and severe anemia, respectively. On multivariate logistic regression, stage 4 CKD (adjusted odds ratio [AOR] 3.2, confidence interval [CI]: 1.78-12.91, P = .025), stage 5 CKD (AOR 4.03, CI: 1.17-13.73, P = .016), and CKD duration of less than 1 year (AOR 3, CI: 1.19-9.11, P = .007) were significantly associated with anemia. The prevalence of anemia among stage 3 to 5 CKD patients was very high. Anemia was significantly associated with the severity and duration of CKD. Therefore, serial follow-up of patients with a long duration and advanced stages of CKD may help prevent anemia and its adverse consequences.

Background and Aim: Iron deficiency is a common and clinically significant complication in non-dialysis dependent chronic kidney disease (CKD) patients, manifesting as either absolute or functional iron deficiency. This study aimed to assess the frequency and distribution of these subtypes of iron deficiency anemia (IDA) across different CKD stages and to identify their independent predictors. Materials and Methods: A cross-sectional study was conducted at the Nephrology Outpatient Department of Nishtar Hospital, Multan over a period of 6 months from July 2024 to December 2024, enrolling 451 adult patients with CKD stages 3a to 5 (non-dialysis dependent). Hemoglobin, serum ferritin, transferrin saturation, and serum iron were evaluated to classify iron deficiency. Results: Anemia was observed in 346 patients (76.7%). Of these, 133 (29.5%) had absolute iron deficiency (AID), and 213 (47.2%) had functional iron deficiency (FID). Anemia prevalence increased significantly with advancing CKD stage (p = 0.002). AID was highest in stage 5 (49.1%), while FID peaked in stage 4 (58.2%) (p &lt; 0.05 for both). Hemoglobin was significantly lower in AID (9.2 ± 1.1 g/dL) and FID (9.7 ± 1.3 g/dL) groups versus non-anemic patients (12.9 ± 0.8 g/dL; p &lt; 0.001). Serum ferritin was lowest in AID (51.2 ± 15.7 ng/mL) and highest in FID (173.6 ± 42.5 ng/mL). Transferrin saturation and serum iron levels were significantly reduced in both deficiency groups (p &lt; 0.001). Multivariate analysis revealed age &lt;60 years (aOR: 1.79; p = 0.027) and CKD stage 5 (aOR: 2.23; p = 0.024) as independent predictors of AID, while CKD stage 4 was significantly associated with FID (aOR: 2.93; p &lt; 0.001). Conclusion: Anemia, particularly functional iron deficiency, is prevalent in non-dialysis dependent CKD patients. Disease stage and age significantly influence the type of iron deficiency, highlighting the need for stage-specific evaluation and management.

1. Ann Chen Wu, MD* 2. Leann Lesperance, MD, PhD* 3. Henry Bernstein, DO*† 1. *Pediatric Health Associates, Hunnewell Ground Children’s Hospital 2. †Associate Professor of Pediatrics, Harvard Medical School, Boston, MA After completing this article, readers should be able to: 1. Determine the most common cause of iron deficiency in the United States. 2. Describe the pathogenesis of iron deficiency. 3. List populations at high risk for iron deficiency. 4. Outline the common signs and symptoms of iron deficiency. 5. Specify the American Academy of Pediatrics recommendations for screening for iron deficiency. In the March and April issues of Pediatrics in Review, we published a two-part article on managing anemia in a pediatric office practice. This article expands on the various tests for iron deficiency, including some relatively new ones. These articles should be read as complementary.—RJH Iron deficiency is the most common nutritional deficiency in the world, responsible for a staggering amount of ill health, lost productivity, and premature death. Although its prevalence in the United States has declined since the late 1960s, iron deficiency with or without anemia still is seen frequently in infants, toddlers, adolescent females, and women of childbearing age. In fact, iron deficiency anemia remains the most common hematologic disease of infants and children. Anemia is defined as a low hemoglobin (Hgb) concentration or red blood cell (RBC) mass compared with age-specific norms. Anemia may be caused by decreased RBC production, increased RBC destruction, or blood loss. Based on the size of the RBC, hematologists categorize anemia as macrocytic, normocytic, or microcytic. Iron is found in different compartments within the body. Total body iron (measured by ferritin), transport iron (measured by transferrin saturation), serum iron, and other hematologic and biochemical markers are used to describe the degrees of iron deficiency. Iron depletion refers to the earliest stage of diminishing iron stores in the setting of insufficient iron supply. Iron deficiency (without anemia) develops as these iron stores are depleted further and begin to impair Hgb synthesis. Finally, iron deficiency anemia results …

Background: Current evidence suggests an increased prevalence of iron deficiency (ID) and anemia in chronic obstructive pulmonary disease (COPD). ID and subsequent anemia can be due to iron losses via bleeding resulting in absolute ID or inflammation-driven retention of iron within macrophages resulting in functional ID and anemia of inflammation.Methods: This is a retrospective analysis of 204 non-exacerbated COPD patients in outpatient care. Current definitions of absolute and functional ID were applied to determine the prevalence of ID and to analyze associations to disease severity in terms of lung function parameters and clinical symptoms.Results: The studied cohort of COPD patients demonstrated a high prevalence of ID, ranging from 30 to 40% during the observation time. At the initial presentation, absolute or functional ID was found in 9.3% to 12.3% of COPD individuals, whereas combined forms of absolute and functional ID were most prevalent (25.9% of all individuals). The prevalence of ID increased during longitudinal follow-up (37 ± 15 months), and especially combined forms of ID were significantly related to anemia. Anemia prevalence ranged between 14.2% and 20.8% during the observation period and anemia was associated with lower FEV1, DLCOc, and CRP elevation. Accordingly, ID was associated with decreased FEV1, DLCOc, and an elevation in CRP.Conclusion: ID is common in COPD patients, but a uniform definition for accurate diagnosis does not exist. Prevalence of functional ID and anemia increased during follow-up. The associations of ID and anemia with reduced functional lung capacity and elevated inflammation may reflect a more severe COPD phenotype.

BackgroundAnemia in later life is associated with increased morbidity and mortality. The purpose of this study was to evaluate the prevalence and possible causes of anemia in the elderly in a well defined hospital cohort.MethodsParticipants in this cross-sectional, retrospective analysis included all inpatients and outpatients aged ≥64 years with complete blood counts treated at Innsbruck Medical University Hospital between October 1, 2004 and September 29, 2005 (n=19,758, median age 73 years).ResultsAccording to World Health Organization criteria, 21.1% of these patients were anemic, ie, 30.7% and 37.0% at 80+ years and 90+ years, respectively. The prevalence of anemia was significantly correlated with advanced age (r=0.21; P<0.001) and male sex (P<0.001). In anemic patients, renal insufficiency with a glomerular filtration rate <30 mL/min/1.73 m2 (11.3% versus 2.1%), hyperinflammation (62.1% versus 31.4%), absolute (14.4% versus 6.9%) or functional (28.2% versus 11.8%) iron deficiency, and folate deficiency (6.7% versus 3.0%) were observed significantly more often than in nonanemic subjects (P<0.001). The pathogenesis of anemia was multifactorial, with decreased renal function (glomerular filtration rate <60 mL/min/1.73 m2), signs of inflammation, and functional iron deficiency detected in 11.4% of anemic patients. Hemoglobin was significantly correlated with elevated C-reactive protein (r= −0.296; P<0.001) and low transferrin saturation (r=0.313; P<0.001). Mean corpuscular volume correlated only weakly with the various anemia subtypes. Cytopenias and morphologic alterations suggestive of underlying myelodysplastic syndromes were found in a substantial proportion of anemic patients, including thrombocytopenia (5.4%), leukopenia (8.26%), and macrocytic alterations (18.4%).ConclusionAnemia was frequently diagnosed in this series of elderly patients. Partly treatable nutritional deficiencies, such as iron or folate deficiency, were identified as possible causes. A complex and heterogeneous interplay of chronic inflammation, functional iron deficiency, and renal impairment was identified in a large proportion of patients. A hitherto undiagnosed myelodysplastic syndrome can be assumed in a relevant proportion of patients. Morphologic classification based on mean corpuscular volume is inadequate from the standpoint of pathogenesis. New parameters are needed to differentiate the multifactorial pathogenesis of anemia in the elderly.

Introduction. Quality of life (QoL) indicators in case of chronic heart failure (CHF) are associated with a number of clinical and instrumental indicators, which makes it possible to consider its assessment as one of the leading indicators of its severity. From a practical point of view, the identification of QoL indicators as the markers of CHF severity in patients with concomitant iron metabolism disorders, including different variants of latent and manifest iron deficiency (ID)is rather interesting. Purpose. To compare QoL parameters by means of MOS SF-36 and MLHFQ questionnaires in patients with CHF with reduced left ventricular ejection fraction with different iron deficiency types. Materials and Methods. 152 patients with CHF functional class (FC) II-III according to NYHA with reduced left ventricular (LV) ejection fraction (EF) of hypertensive and ischemic etiology with/and without iron deficiency (ID) were examined. All patients were divided into three clinical groups: the first clinical group (which is presented as a comparison group) amounted to 30 (19.7 %) patients with CHF with reduced LV EF without ID, the second one amounted to 60 (39.5 %) patients with CHF with reduced LV EF and latent ID, which included a number of patients with functional and absolute ID and the third clinical group amounted to 62 (40.79 %) patients with I-II severity degree of concomitant iron deficiency anemia (IDA). In order to assess QoL, all patients were interviewed using MOS SF-36 and MLHFQ. The comparison of the obtained findings was carried out among groups of patients with CHF with reduced LV EF without iron metabolism disorders, with functional ID and absolute ID, and among groups of patients with CHF with reduced LV EF without iron metabolism disorders, with I degree of IDA and II degree of IDA. Research findings. It was detected that in comparison with the group of patients without ID, QoL indicators according to MLHFQ questionnaire in patients with functional ID and absolute ID were significantly worse – 49.5 versus 53.5 (p = 0.05) and 60 points (p = 0.009), respectively. Physical health (PH) in these groups was 37.9 (p = 0.033) and 37.2 (p = 0.0068), respectively, which significantly differed from PH value in the comparison group – 41.2 points. In patients with functional ID and absolute ID lower PH values were detected due to significantly worse indicators of physical functioning (PF), role-physical functioning (RP) resulting from physical condition and general health (GH). Similar results were obtained during the analysis of QoL in patients with IDA of different degrees. In patients with mild IDA and moderate IDA as compared to the group of patients without ID, QoL indicators, according to MLHFQ questionnaire, were significantly worse (p = 0.007) and (p < 0.00001) 57 and 62 versus 49.5 points, respectively. In addition, it was detected that PH value according to SF-36 questionnaire results in the groups with IDA was also significantly lower than PH value in the group without ID due to low values of PF, RP and GH and amounted to 36.8 (p = 0.01) and 33.6 (p < 0.00001) versus 41.2 points, respectively. According to the conducted analysis, mental health (MH) decreased with the presence of functional and absolute ID and with an increase of IDA from mild to moderate degree, however significantly lower value was detected only in the group with moderate IDA as compared to the group of patients without ID (p = 0.02). In addition, a number of significant relations between QoL indicators according to MLHFQ, PH and MH scale SF-36 and hematological parameters and a number of iron metabolism indicators were detected during the study. This confirms the dependence of the patients’ QoL on existing iron metabolism disorders. Conclusions. Patients with CHF with reduced left ventricular ejection fraction and concomitant ID, regardless of the presence of anemia, are characterized by the worse QoL level as compared to the patient without ID. Whereas, latent functional and absolute ID has the same clinical relevance in terms of deterioration of QoL of patients with CHF. Reduction of iron metabolism levels can be considered as predictors of deterioration of patients' QoL and severe CHF.