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Guidelines for the management of iron deficiency anaemia
  1. Department of Medicine for the Elderly
  2. Tameside General Hospital, Fountain St
  3. Ashton under Lyne OL6 9RW, UK
  4. andrea.hirst{at}

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Editor,—In reply to Dr Scott's letter (), I would add that when iron deficiency coexists with the anaemia of chronic disorders (ACD) such as rheumatoid arthritis, a low transferrin saturation loses its diagnostic specificity due to the fact that comparable degrees of transferrin saturation occur in patients with the sole diagnosis of ACD.1 The corollary, in this context, is that the behaviour of ferritin as an acute phase reactant negates the expected fall in serum ferritin, with consequent loss of sensitivity in this parameter.1 Even so, in a comparison of bone marrow findings with tests such as transferrin saturation and serum ferritin in a study comprising patients with a variety of haematological disorders, “the most useful single variable to discriminate patients with iron deficiency from all other patients was serum ferritin”.2 Since then, the most promising test for identifying iron deficiency when it coexists with chronic inflammation has been the ratio of serum transferrin receptor/log serum ferritin (so-called TfR-F index), which achieves an unequivocal separation between iron deficient patients with coexisting chronic inflammation compared with those with the sole diagnosis of chronic inflammation.3 Even in that study, the receiver operating characteristic curve for serum ferritin, on its own, was diagnostically superior to the one generated by transferrin saturation.3