Many disorders of iron homeostasis (e.g., iron overload) are associated with the dynamic kinetic profiles of multiple non-transferrin bound iron (NTBI) species, chronic exposure to which is associated with deleterious end-organ effects. Here we discuss the chemical nature of NTBI species, challenges with measuring NTBI in plasma, and the clinical relevance of NTBI exposure based on source (iron overload disorder vs. intravenous iron-carbohydrate complex administration). NTBI is not a single entity but consists of multiple, often poorly characterized species, some of which are kinetically non-exchangeable while others are relatively exchangeable.Prolonged presence of plasma NTBI is associated with excessive tissue iron accumulation in susceptible tissues, with consequences, such as endocrinopathy and heart failure. In contrast, intravenous iron-carbohydrate nanomedicines administration leads only to transient NTBI appearance and lacks evidence for association with adverse clinical outcomes. Assays to measure plasma NTBI are typically technically complex and remain chiefly a research tool. There have been two general approaches to estimating NTBI: capture assays and redox-activity assays. Early assays could not avoid capturing some iron from transferrin, thus overestimating NTBI. By contrast, some later assays may have promoted the donation of NTBI species to transferrin during the assay procedure, potentially underestimating NTBI levels. The levels of transferrin saturation at which NTBI species have been detectable have varied between different methodologies and between patient populations studied.
| INTRODUCTIONThe biological importance of iron is well-described and the negative impact of iron deficiency on clinical outcomes is widely recognized, being typically associated with low transferrin saturations. 1 In contrast, iron overload conditions are typically associated with increased transferrin saturations, which when exceeding 70% to 75%, 2 lead to the appearance of loosely bound, kinetically dynamic, heterogeneous plasma iron species, that have been generally classified as nontransferrin bound iron (NTBI). This term typically refers to those plasma iron species that appear when sufficient iron binding sites on transferrin are not available kinetically, and which may be partially removed by excess iron-free transferrin or exogenous chelators. Therefore, operationally, as explained later, NTBI excludes plasma