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Annals of Clinical & Laboratory Science 37:57-62 (2007)
© 2007 Association of Clinical Scientists

Serum Transferrin Receptor Status of Healthy Adult Arabs

Huxley Knox-Macaulay1, David Gravell2 and Frances Elender3
1 Department of Haematology, College of Medicine and 2 University Hospital, Sultan Qaboos University, Muscat, Sultanate of Oman; 3 Research & Development Department, West Suffolk Hospital, Bury St. Edmunds, Suffolk, United Kingdom

Address correspondence to Huxley Knox-Macaulay, M.D., 7, The Green, Stanstead, Sudbury, Suffolk, CO10 9AS, UK; tel & fax 01787 280991; e-mail knox.macaulay{at}virgin.net.


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Acknowledgements
 References
 
Several studies have provided reference ranges for the concentration of serum transferrin receptor (sTfR) in various white populations, but there is a dearth of relevant reference sTfR data in non-whites. The aim of this investigation was to establish sTfR reference ranges and mean values for a healthy non-white Arab population that could be used also for Arabs worldwide. sTfR and serum ferritin concentrations were estimated by immunoassays and blood counts were determined by conventional methods. Analysis of the data of 114 volunteer Arab blood donors (91 male, 23 female) revealed a higher mean sTfR concentration in males of 22.6 ± 8.1 nmol/L (range 10.9–38.7 nmol/L) compared to that in females of 18.7 ± 4.4 nmol/L (range 10.7–25.8 nmol/L, p = 0.001). There was no significant correlation of sTfR concentration with age, serum ferritin level, or blood haemoglobin level, but a strong inverse correlation was demonstrated with mean cell volume and mean cell haemoglobin of red cells. Iron-replete volunteer subjects with {alpha}–thalassaemia trait appear to have relatively high mean sTfR concentration. We recommend the use of gender-dependent sTfR reference values for Arabs.

Keywords: serum transferrin receptor, serum ferritin, erythrocyte indices, Arab population


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Acknowledgements
 References
 
Estimation of soluble serum transferrin receptor (sTfR) concentration is a useful parameter for differentiating iron deficiency anaemia from the anaemia of chronic disease and for diagnosing iron deficiency anaemia in patients with a concomitant chronic inflammatory, infectious, or malignant disorder [1–8]. Lack of standardisation of the available immunoassays, coupled with their inter- and intra-assay imprecision [9–11], has made it obligatory to establish means and reference ranges for various populations. The dearth of relevant reference data for Arabs and other non-whites prompted this study in the Sultanate of Oman, a country that lies in the southeastern corner of the Arabian Peninsula. The populace of the Sultanate of Oman comprises individuals of various ethnic groups, including Arabs, Baluchis, Zanzibaris, and Bantu Africans. The Arabs who form the largest ethnic group are a non-white Semitic people whose ancestors were the original inhabitants of the Arabian peninsula. Their descendants migrated to other regions of the Middle East, North Africa, Europe, and the New World.

The relationships of sTfR levels with age, serum ferritin level, and various red cell indices were explored. Moreover, the effect on sTfR concentration of {alpha}–thalassaemia trait, sickle cell trait, and red cell glucose 6-phosphate dehydrogenase (G6-PD) deficiency (which are prevalent erythrocytopathies in Oman [12–14]) was also examined.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Acknowledgements
 References
 
Subjects.  The study protocol was approved by the Research & Ethics Committee of the College of Medicine, Sultan Qaboos University (SQU) and Sultan Qaboos University Hospital (SQUH). Both male and female Arab subjects were non-smoking, non-fasting, asymptomatic volunteer blood donors with unremarkable present, past, and family histories. Physical examination was essentially negative; in particular there were no signs of pallor and jaundice, nor was there any evidence of an infection, inflammatory process, or malignancy. All donors confirmed the absence of any febrile illness during a period of 4 weeks prior to the start of this study. Eighty percent of the volunteers were first-time donors, while the remaining 20% were regular repeat donors. The most recent blood donations by the repeat donors were not within the preceding 6 months of this investigation. None of the first-time or repeat donors had been treated with iron or other haematinics within 3 months of starting this study. No female donor was pregnant, nor was any receiving oral contraceptives or hormone replacement therapy. All donors resided in towns and villages at sea level.

Before the inception of this project, written explanation and verbal clarification of its objectives, nature, and potential problems were offered to all the volunteers and questions raised by them were answered as thoroughly as possible. Arab ethnicity was confirmed by responses to questions of a multidimensional nature with emphasis on ancestral origins, tribal and family relationships, residential location (particularly with respect to specific villages), and self identity; language and religion were regarded as far less significant. Oral or written consent for participation in the study was obtained from each volunteer. Blood samples were collected from all participants over a period of 4 consecutive weeks without prior knowledge of their haemoglobin (Hb) levels and other blood cell counts. The first-time and repeat blood donors were regarded as a single group for the purpose of data analysis and are henceforth referred to simply as ‘donors.’

Laboratory methods.  Serum samples were obtained after centrifugation of 10 ml of clotted blood within 4 hr of specimen collection. The sera were then stored in 1 ml aliquots at –70°C for an average period of 8 weeks prior to sTfR assays and at –20°C for no longer than 1 week prior to determination of the concentration of serum ferritin. Estimation of the sTfR level of each sample was carried out in duplicate and in parallel with appropriate quality control sera supplied with each kit at 3 different sTfR concentrations: low, 5.1–8.2 nmol/L; medium, 13.1–19.6 nmol/L; and high, 35.9–50.8 nmol/L. The procedure for sTfR determination was an enzyme immunoassay (EIA) monoclonal antibody technique using the Quantikine IVD human sTfR immunoassay kit (R&D Systems Europe, Ltd., Abingdon, Oxford, UK). ‘Internal’ (our laboratory) quality assurance intra-assay precision experiments on 10 samples (each sample was tested 3 times) produced CVs ranging from 4.0–6.5%; inter-assay precision measurements on 20 samples (each sample was also tested 3 times) yielded CVs of 5.5–6.7%. Serum ferritin concentration was estimated in duplicate by a Microparticle Enzyme Immunoassay (MEIA) using an Imx Ferritin commercial kit (Abbott Laboratories, Abbott Park, IL, USA). Appropriate quality controls supplied with each commercial kit at 3 different ferritin concentrations (low, 16–24 µg/L; medium, 140–180 µg/L; high, 320–480 µg/L) were included in the estimation of donor samples. Precision assays resulted in CVs of 3.8–7.5% for intra-assay determinations on 10 samples (each sample was tested thrice) and in CVs of 6.1–8.2% for inter-assay determinations on 20 samples (each sample was tested thrice). Our laboratory’s internal quality assurance procedures were buttressed by participation in an external quality assurance programme of the Royal College of Pathologists of Australia.

Complete blood cell counts were determined on potassium EDTA-anticoagulated samples using an electronic autoanalyser, Cell–Dyn 4000 (Abbott Laboratories, Abbott Park, IL, USA); the erythrocyte sedimentation rate (ESR) of each subject was estimated by the standard Westergren method using trisodium citrated blood. Other investigations included (i) a Sickledex HbS screening test (Ortho Clinical Diagnostics, Raritan, NJ, USA), (ii) high performance liquid chromatographic (HPLC) separation of normal and abnormal haemoglobins and estimation of HbA2 levels for the diagnosis of ß-thalassaemia trait using the automated Bio-Rad Variant ß-thalassemia Short Program (Bio-Rad Laboratories, Hercules, CA, USA), and (iii) a filter paper fluorescence screening test for red cell G-6-PD deficiency [15]. Molecular genetic techniques were not used in this project to determine the {alpha} and ß globin gene status of donors.

Statistical analysis.  All statistical functions were performed using the statistical software package SPSS, version 12.01 (SPSS, UK Ltd). Statistical distributions of sTfR levels, serum ferritin concentrations, and other variables were examined and where appropriate, natural logarithmic (loge, ln) transformations were made to produce relatively normal distributions and thereby reduce the influence of any persisting outlying values. Obvious outliers were excluded after identifying them by inspecting the raw numerical data as well as the histograms and/or scattergrams (not shown) of relevant variables. Differences between mean values of samples were assessed by applying two-sample t-tests assuming unequal variances. Relationships of loge sTfR to loge serum ferritin, and to certain untransformed haematological variables were explored by calculating Pearson’s product moment correlation coefficient (r) and its non-parametric equivalents, Spearman’s rank order rho, and Kendall’s tau correlation coefficients. The results of Kendall’s tau are not presented as their significance is similar to those of Spearman’s rho; loge(sTfR/serum ferritin) ratios were also determined.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Acknowledgements
 References
 
Blood samples were collected from 145 (103 male, 42 female) volunteer blood donors, but complete data for statistical analyses were available for 133 volunteers (93 male, 40 female) with an age range of 18–53 yr (median 21, mean 24.5 ± 7.9 yr). This cohort of 133 subjects was termed the pre-exclusion group; 19 donors (2 male, 17 female) were found to have either a low Hb concentration (<120 g/L in males, <115 g/L in females) and/or a low serum ferritin concentration (<15 µg/L in males and females). After excluding these 19 male and female volunteers, data of the residual group of 114 donors (91 male, 23 female) with an age range of 18–53 yr (median 22, mean 25.5 ± 8.4 yr) were reanalysed using the same statistical methods. These 114 subjects with normal Hb and serum ferritin concentrations formed the post-exclusion group. The ESR of each of the donors of both the pre- and post-exclusion groups was <15mm/hr.

The mean sTfR concentration of the combined male and female cohort is 21.8 ± 7.7 nmol/L, range 10.7–38.7 nmol/L (5 outliers excluded). Reference means and ranges of sTfR and serum ferritin concentrations as well as loge(sTfR/ferritin) ratios for males and females are presented in Table 1Go; loge(sTfR/ferritin) ratios enhance diagnostic discrimination [16,17] as values of sTfR and serum ferritin concentrations are of limited diagnostic sensitivity and specificity [4,8,18]. The distribution curves (not shown) of sTfR and serum ferritin concentrations of the pre- and post-exclusion male and female groups are unimodal. There are no statistically significant differences between the mean values of the following variables: sTfR, ferritin, Hb, reticulocyte count (retics) % and retics x109/L, of the whole (combined male and female) pre-exclusion and post-exclusion cohorts. Similarly, no significant differences between the means of these same variables of the pre- and post-exclusion cohorts of males are observed. However, among females, the mean sTfR concentration of the pre-exclusion group (24.8 ± 11.8 nmol/L) is significantly greater than that of the post-exclusion group (18.7 ± 4.4 nmol/L; p = 0.006), but the mean values of the other variables (ferritin, retics %, retics x109/L) of the females do not show any significant difference between the pre- and post-exclusion groups. The emphasis in this presentation is placed on the non-anaemic normoferritinaemic post-exclusion males and females (Table 1Go).


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  		Table 1. Means and ranges of serum transferrin receptor (sTfR) and serum ferritin (sf) concentrations of male [a] and female [b] blood donors of the post-exclusion donor group.
 
Mean sTfR and serum ferritin levels are significantly higher in post-exclusion males than females while mean sTfR concentrations of the constituent low MCV/MCH donor subsets are also significantly greater than the mean sTfR concentrations of the normal MCV/MCH donor subsets (Table 2Go); on the other hand, the mean serum ferritin concentrations of the respective low and normal MCV/MCH donor subsets are not significantly different from each other (Table 2Go). Conventional measurements (ie, blood cell counts including MCV and MCH, blood film examination, and HbA2 estimation) did not detect any ß–thalassaemia heterozygotes among the 114 donors. Mean sTfR level of the 29 X-linked red cell G6-PD deficient hemizygotes in the steady state was not significantly different from that of the much larger number of non-G6-PD deficient volunteers. Sickle cell trait (HbAS) was detected in only 8 individuals of whom 1 was iron-deficient (serum ferritin 11 µg/ L). Among the remaining 7 normoferritinaemic AS subjects, only 1 with a HbS level of 27% and sTfR concentration of 26.1 nmol/L appeared to have {alpha}-thalassaemia trait (hypochromic microcytic blood film, HbA2 2.8%, MCV 70.8 fl, MCH 23.1 pg). The mean sTfR of the remaining 6 AS individuals without {alpha}-thalassaemia (mean HbS 33.2%) was 21.7 nmol/L.


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  		Table 2. A comparative analysis of the mean concentrations of serum transferrin receptor (sTfR) and serum ferritin (sf) with reference to certain subsets of the *post-exclusion donor group.
 
No significant relationship was demonstrated between sTfR concentration and age, serum ferritin concentration, or Hb level. However, sTfR levels were negatively correlated with MCV (r = –0.342, p = 0.01) and MCH (r = –0.405, p = 0.01), but did not show any significant correlation with RDW. A positive correlation of sTfR concentration with red cell (r = 0.389, p = 0.01), retics x109/L (r = 0.318, p = 0.001) and retics % counts (r = 0.224, p = 0.017) was noted.


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Acknowledgements
 References
 
Separate sTfR reference ranges have been reported for non-white populations in various countries including Zaire (Democratic Republic of Congo) [2], Taiwan [7], Turkey [8], and white populations in Europe and Canada [11,16,18–28], as well as for nationals of Japan [29] and various racial groups in the United States [30]. However, this present study is the first in which sTfR reference values have been established for Arabs.

Many studies have not revealed any significant differences between the mean sTfR concentrations of white male and female adults [11,16,22,25,31]. In contrast, sTfR means and reference ranges are significantly different for male and female Arabs (Table 2Go); our gender-dependent findings are similar to those of Kolbe-Busch et al [26], who recommend sex-dependent reference sTfR values based on a study in European whites. Almost 43% (17/40) of the Arab female subjects were excluded from our investigation because of anaemia or hypoferritinaemia. Such high incidence of anaemia and/or iron deficiency among this sector of the Omani Arab population is not surprising in view of the significant prevalence of anaemia in this group. The results of a national survey published in 2000 by Al-Riyami and co-workers [32] revealed that out of a total of 1741 women aged 20–49 yr, about 30% were anaemic, while among 1677 adolescent girls and young women aged 12–19 yr, 41% were anaemic; the anaemia was mild (90–119 g/L) and due to iron deficiency in most of those tested. An expansion of our project to involve a larger number of healthy iron-replete, non-anaemic, Arab females is needed to confirm these sTfR gender differences in Arabs.

The non-anaemic normoferritinaemic donors with normal HbA2 levels (<3.5%), low MCV (≤75 fl), low MCH (<25 pg), blood films showing hypochromic microcytic red cells, few target cells, and mild anisopoikilocytosis, satisfy the haematological criteria for the diagnosis of {alpha}–thalassaemia trait. The high incidence of {alpha}–thalassaemia trait among the donors is not unexpected since there is marked community prevalence (45%) of this trait in the Omani population [14]. Though the use of molecular biological techniques would have clearly defined the specific type of {alpha}–thalassaemia (ie, deletional or non-deletional) and characterised the {alpha} globin haplotypes and genotype, the lack of such molecular data does not negate the non-molecular haematological diagnosis of {alpha}–thalassaemia trait in several of the volunteers.

The Arab {alpha}–thalassaemia heterozygotes with reduced MCV/MCH have higher mean sTfR concentrations than non-{alpha}–thalassaemia subjects with normal MCV and MCH in this investigation (Table 2Go). It is noteworthy that in 9 anaemic Taiwanese patients with {alpha}– or ß–thalassaemia trait, Ho [7] found a much elevated mean sTfR concentration of more than twice that of 50 healthy controls. We propose that in the low MCV/MCH red cells of {alpha}–thalassaemia trait, membrane damage by a slight excess of ßA globin chains may lead to mildly increased shedding of membrane cTfR (CD71) and consequently a small rise in sTfR concentration (Table 2Go). Moreover, the results obtained in the HbAS volunteers also suggest a possible enhancing effect of {alpha}–thalassaemia on sTfR levels though the extreme paucity of the relevant data (only 1 AS subject has {alpha}–thalassaemia trait) militates against a reliable conclusion. However, steady-state red cell G6-PD deficiency does not seem to affect sTfR concentrations.

The lack of a significant relationship of sTfR with age in our investigation has also been reported for other populations [16,22,24,25,30,31]. Also, our results and those of a number of non-Arab studies that do not show a significant relationship of sTfR with serum ferritin levels [2,3,16] contrast with other data that demonstrate a negative correlation between sTfR and serum ferritin in non-anaemic normoferritinaemic [11,21,22,24,26, 31] individuals. Ethnicity, variation in age-structures, and varying reference ranges for Hb and serum ferritin concentrations may account for these conflicting results in the studies cited.

In conclusion, we recommend separate gender-dependent reference mean values and ranges of sTfR concentration for Arab males and females, though further investigation involving a much larger cohort of healthy non-anaemic iron-sufficient Arab females is obligatory. Secondly, the relatively higher sTfR levels obtained in this population are to a large extent influenced by the presence of {alpha}-thalassaemia trait. A comparative study of the concentrations of membrane CD71 (cTfR) in {alpha}–thalassaemic and non-{alpha}–thalassaemic Arabs ({alpha}–thalassaemia haplotypes determined by molecular techniques) combined with an investigation of the correlation between cTfR and sTfR concentrations should prove illuminating. Finally, though sTfR concentrations are usually raised in iron deficiency, we could not demonstrate any relationship between sTfR and serum ferritin concentrations in healthy non-anaemic iron-sufficient Arabs.


   Acknowledgements
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Acknowledgements
References
 
The authors are grateful to Sultan Qaboos University and Sultan Qaboos University Hospital for generous financial and moral support. They also thank the Blood Bank nurses, Brigit Binny Sam and Beena Johnny, for their considerable help. The helpful cooperation of the participating volunteers is much appreciated.


   Footnotes
 
Present affliations of authors: 1currently retired; 3 School of Health & Social Studies, University of East Anglia, Norwich, Norfolk, United Kingdom.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Acknowledgements
 References
 

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