PFAS Effects on Hematopoiesis
Red blood cell production (erythropoiesis) occurs in the bone marrow, driven by erythropoietin (EPO) — a hormone produced primarily by the kidneys. PFAS-induced kidney dysfunction can reduce EPO production, impair the hormonal drive for red blood cell formation, and contribute to normochromic normocytic anemia similar to the anemia of chronic kidney disease.
Beyond EPO effects, PFAS directly affect bone marrow progenitor cells. Animal studies demonstrate that PFAS exposure reduces erythroid colony-forming units — the progenitor cells that differentiate into red blood cells — and increases red blood cell turnover. These effects combine to reduce circulating red blood cell counts and hemoglobin levels.
Iron Metabolism Disruption
PFAS interfere with iron absorption and metabolism through multiple pathways. PFAS reduce expression of the duodenal iron transporter DMT1, impairing intestinal iron absorption. PFAS also affect hepcidin — the liver-produced hormone that regulates iron homeostasis — potentially causing iron sequestration that reduces iron availability for hemoglobin synthesis even when total body iron is adequate.
Studies of children in PFAS-contaminated communities have found higher rates of iron deficiency anemia compared to uncontaminated areas, even after controlling for dietary iron intake and socioeconomic factors. This observation is consistent with PFAS-induced impairment of iron absorption and utilization.
Clinical Recognition
Physicians evaluating patients with unexplained anemia — particularly in PFAS-contaminated communities — should consider PFAS exposure as a contributing factor alongside the standard anemia workup. An underlying PFAS contribution to anemia may explain cases that are partially but inadequately responsive to iron supplementation or EPO therapy.
PFAS-free filtered water reduces ongoing PFAS intake through the gastrointestinal tract, which may partially improve intestinal iron absorption over time. Adequate dietary iron combined with exposure reduction represents a comprehensive approach to managing PFAS-associated iron deficiency anemia.