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A step toward an expanded iron toolkit: Hepcidin values in healthy Dutch children

Despite the tight regulation of iron for its essential roles in erythropoeisis, oxygen transport, and energymetabolism, iron deficiency anemia (IDA) remains themost common hematologic conditionworldwide and a common referral to the pediatric hematologist oncologist. Our task as the specialist is not only to ensure that a child’s IDA diagnosis is correct, but also to improve the patient’s treatment outcomes. Often, this step involves uncovering why a child is not responding to oral iron therapy. Nonadherence to iron is considered the primary reason for treatment failure in the majority of IDA patients, and indeed, this is a common problem.1 However, most hematologists have treated IDA patients who are truly adherent yet do not fully recover. The ability to better predict which patients will or will not respond to oral iron therapy would therefore be of tremendous value. Beyond those patients with classic IDA, we are increasingly consulted on children with chronic comorbid conditions that result in mixed presentations of iron deficiency and anemia of inflammation, in whom current iron laboratory parameters are difficult to interpret. Understanding the degree of inflammation present, and how such inflammation impacts the ability to successfully give iron therapy, or whether it is even necessary, are other ways in which an expanded iron toolkit would be of benefit. The discovery of hepcidin as a key iron regulator, which occurred less than two decades ago, has heightened our ability to understand the complex processes that affect iron metabolism.2 We now understand that hepcidin performs this function by acting on ferroportin, the only known iron exporter. Ferroportin permits the movement of intracellular iron from enterocytes, macrophages, and hepatocytes into the plasma for transport to the bone marrow and other tissues.2 In states of iron sufficiency, hepcidin binds to ferroportin, downregulating both iron absorption and release.3,4 In contrast, during states of iron defi-